Physical Therapy for Thoracolumbar Spine – Therapeutic Exercise

General Exercise Guideline

⚫ Kinesthetic awareness
1. To develop patient awareness of (1) safe spinal positions, (2) safe spinal movement.
2. Consider the effects of prone, side-lying, sitting, and standing position have on the spine.
3. Teach the patient to move his/her pelvis into anterior/posterior tilt.
4. Teach the patient passive positioning (placing the leg in specific position).
⚫ Mobility / flexibility
1. Stretching and flexibility exercise.
2. To increase mobility of restricting tissue.
3. Stretching is contraindicated in the region of acute inflamed tissue.
4. Decreased mobility in structures in the lower extremities that restrict normal postural alignment
may be stretched.
⚫ Muscle performance
1. Muscle performance involves strength, power, endurance and stability.
2. Activation (exercise) of the core-stabilizing muscle are fundamental for developing spinal stability.
3. Dynamic strengthening-abdominal muscles
 Dynamic exercise of the trunk musculature are not initiated until
A. Late during the rehabilitation process.
B. After the patient has learned to stabilization in all functional activities.
 Common methods: curl-up, knee-to-chest, straight*leg raising.
 Precautions:
A. Intervertebral disc lesions or osteoporosis.
B. Experience pain with trunk flexion.
C. Strong muscle contraction, especial on psoas major could cause shear forces on the lumbar
vertebrae, which may not for spinal instability.
 Performed commonly at the end of the ROM in spinal extension.
 Common methods: thoracic elevation, leg lifts, superman.
 Precautions:
A. May not be appropriate for patients with arthritis or nerve root compression, spondylosis or
spondylolisthesis.
B. Modified the positioning toward more neutral spinal positions – such as the quadruped
position.
⚫ Evidence base suggestion for overload
1. 1 to 3 sessions/wk are recommended for most resistance training programs.
2. High-intensity, short-duration exercises are prescribed to strengthen muscles.
3. Low-intensity, long-duration exercises are used to improve muscular endurance.
4. 6 to 25 repetitions per set of exercise at intensities of 30% to 85% of the one repetition maximum
intensity can be used.
5. The achieve physiological changes in skeletal muscle, a minimum of 10 to 12 weeks of resistance
exercise is needed.
⚫ Cardiopulmonary endurance
 1. To develop cardiopulmonary fitness for overall endurance and well-being.
2. Aerobic exercise may be initiated once signs of inflammation no longer exist.
3. Begin with low to moderate intensity.
4. To choose activities that do not place added stress on the recovering spinal structure.
5. Common aerobic exercise: cycling, walking, running, stair climbing, swimming.
⚫ Functional activities training
Specific Exercise
⚫ Exercise for scoliosis
⚫ William’s flexion exercise
1. Introduction:
 The primary source of LBP is from paravertebral muscle spasm and loading of the facet joint.
 Stretching the paravertebral muscle, strengthen the gluteal and abdominal muscles.
 Opening intervertebral foramen, distracting the facet joint → relieve compression of nerve root.
 These exercises were introduced to teach the patient how to avoid lumbar extension, which
worsens low back pain and help improve lumbar flexion.
 Reduce pain, improve the stability of the lower pelvis, and increase the range of motion.
2. Procedure:
 Flatten back exercise (pelvic posterior tilt).
A. The patient lying with their hands at their side and their knees bent (then extension).
B. The patient is then told to tighten the muscles of their abdomen, as well as their buttock
muscles, flattening their back against the floor.

 Low back stretching exercise.

A. Patient are instructed to bend their single leg and wrap their hands, and pull the bent leg
toward their chest.
B. The double knee to chest stretch is also done with the patient lying on their back.
C. 若要增加 stretch 的力量時，治療師的手可以放在尾椎的地方帶屁股起來
 Abdominal strengthening exercise.
A. The patient lying on their back with their hands at their sides and their knees bent.
B. The patient is instructed to use their abdominal muscles to raise their upper back (scapula)
off the floor while exhaling.
C. Not supposed to thrust themselves off the floor or to lift their heads with their arms.
D. 可以先請病人雙手打直試著觸碰膝蓋，如果訓練得宜時可以請他雙手交叉或抱頭
  Hamstring stretching exercise.
A. Long sitting with toes directed toward the ceiling and knees fully extended.
B. Slowly lower the trunk forward over the legs, keeping knees extended, arms outstretched
over the legs.
 Hip flexor stretching exercise.
A. 病人呈現弓箭步，身體保持直立
 Achilles tendon stretching exercise.
⚫ McKenzie exercise
1. Concept:
 Exercise in centralizing direction.
 Extension principle for posterior derangement (most common type), flexion principle for anterior
derangement.
2. Indications:
 Posterior disc derangement syndrome.
 Limited lumbar extension.
3. Procedures:
 Correction of lateral shift.
 Self correction of lateral shift.
 Lying prone → Lying prone in extension of elbow → Lying prone in extension of hands.
A. Moves from the prone position to raise the upper half body off the table while maintaining
the pelvis and thighs on the table.
B. Slowly lowering the body.
C. Repeat and progressively increase the extension and repetition to the full.
D. May extension in lying with belt fixation.
 Sustained extension.
 Extension in standing.
 Extension mobilization, manipulation, rotation…

⚫ Stabilization training exercise

1. Muscles:
 Global muscles: rectus abdominis, external and internal obliques, quadratum lumborum, erector
spinae, iliopsoas.
 Core muscles: transversus abdominis, multifidus, quadratus lumborum, deep rotator.
 Coordination contraction of the transversus abdominis, multifidus, diaphragm, and pelvic floor
musculature provides stability.
 Proper core muscles contraction effect of limb motion on spinal stability, and of breathing on
posture and stability.
 2. Definition: a series of exercise that emphasize on placing the diseased spinal segment in its most
anatomic, pain-free, and balanced position and holding it there with muscular forces while
accomplishing tasks of living.
3. Concept of neutral zone:
 The neutral zone is the area that is mid-range in the ROM of a spinal segment where no stress is
placed on the passive osteoligamentous structures.
 When the condition is not acute, most people find the mid-range (the neutral position) to be their
functional position.
 Not static, same for everyone, and it may change as the symptom improves and tissue heals.
4. Purposes:
 To attain adequate dynamic control of lumbar spine forces to eliminate repetitive injury to the
intervertebral disc, facet joints, and related structures.
 To decrease repetitive torsional stresses and microtrauma to the lumbar spine by enhancing the
supportive nature of the musculature and the kinesthetic awareness of the lumbar spine.
5. Guidelines for stabilization training
 Kinesthetic training for awareness of safe motion and position must before stabilization training.
 Activation of the deep (core) stabilizing muscles.
 Supine → Bridging → Prone → Quadruped → Kneeling → Sitting → Standing → Walking…
Basic → Advance → Sport specific, ADL specific.
⚫ Pilatus exercise
1. Joseph Pilates (1880 - 1967) created a system of fitness exercise.
2. Contrology as a balance or complete coordination of body, mind, and spirit.
3. Progressively enhance breath, core, shoulder girdle, and limb control.
4. Movements are slow and conscious, with few repetition.
5. Exercise are done on floor mats and equipment.
6. Exercise are done from lying, sitting, kneeling, standing and other postures.