Rehab Protocol

Rehabilitation Program For Low Back Pain

Overview

One of the keys to improving your back pain condition is rehabilitating the core of your body. The core of your body is essentially everything from your hips up to your shoulders. As you have learned, when dealing with back injury and back pain, there are dramatic changes that occur to the tissues of your back and throughout your core. These changes include stiffness, weakness and deconditioning.

The purpose of the rehabilitation protocol outlined below is to address the issues of stiffness, weakness, and deconditioning that plague your core and contribute to your ongoing back pain. Through consistent and regular participation in a progressive rehabilitation program, you can restore the stretch and elasticity to your tissues and regain maximum strength in the muscles that support your spine. In this way, you can significantly raise the injury threshold of the tissues in your back and reduce, if not completely eliminate, your back pain condition.

This rehabilitation program is a 2-phase protocol that should be performed 3 days per week. It is designed to progress in its intensity and duration as your injury threshold increases. Everyone should start with the Phase 1 exercises and then progress through the protocol as your back becomes stronger and more flexible. The exercises in each phase should be performed 3 times a week. If you cannot complete all of the exercises and repetitions as you start each phase that is okay. Just do what you can and you will gradually progress in the exercises and in the repetitions until you can perform them all without difficulty. How long you continue to perform the exercises in each phase will depend upon your own unique situation. The key is to continue to perform the exercises in each phase until you can perform them easily and consistently with no increase in your back pain. For some this could mean you are performing a particular phase for a few weeks but for others it may be several months before you are ready to move on.

Keep in mind that over time you are making your back tissues healthier and slowly raising their injury threshold. The goal is to maximize your injury threshold by making the tissues as elastic and strong as possible. This way you can return to doing all the things you want to do with little or no back pain.

Phase 1

Goals: Stretching (Restore range of motion); Posture (Perform postural retraining); Strengthening (Perform anti-movement isometric holds)

I. Stretching (Restoring Range of Motion)

A. Double Leg Hamstring Wall Stretch

Lie on your back with your buttocks near the wall and your legs extended straight up with heels resting on the wall. How close your buttocks is to the wall will depend on how tight your hamstrings are. For those with tighter hamstrings your buttocks will be farther from the wall. The key is to be sure that your knees are completely straight.
Dorsiflex your feet and ankles by pulling your feet and toes towards your body while keeping the knees straight. Hold for 20-30 seconds, relax for 5 seconds, then repeat 2 more times.

B. Single Leg Hamstring Wall Stretch with rope or elastic band.

While lying on your back with buttocks near the wall, keep one leg extended straight up with your heel on the wall and your knee straight. Keep the other leg bent to 90 degrees resting the sole of your foot on the wall.
With the rope or elastic band around the ball of the foot of the extended leg, pull gently on the band or rope to feel an increased stretch of the hamstring on the back of the leg. Hold for 20-30 seconds, relax for 5 seconds, then repeat 2 more times.
Switch legs and repeat three similar stretches on the other leg as described above.

C. Child’s Pose (stretches your lower back and arms)

Start on your hands and knees with your hands placed slightly above your head level.
Drop your buttocks gently toward your heels as you stretch the rest of your body down and forward.
In the fully stretched position, rest your arms outstretched along the floor, rest your stomach comfortably on top of your thighs, and rest your forehead on the floor.
Hold this position for 20-30 seconds then rise up into kneeling position for 5 seconds and repeat 2 more times.

D. Prone Press Ups (Back extension stretch)

Lie on your stomach on the floor or a mat and relax your body.
With your elbows bent, place your hands flat on the ground under your shoulders.
Keep your back and hips relaxed and the tops of your feet on the floor and then use your arms to press your upper back and shoulders up with chin and eyes looking up.
Hold the press up for 15 seconds and then slowly return to the starting position. Repeat 2 more times.
If you are unable to do the full press up, then prop on your elbows instead. Once comfortable on your elbows, you can then progress to the full press up.

E. Cat Stretch

Start on your hands and knees with hands shoulder width apart knees hip-width apart and your back flat.
Engage your abdominal muscles as if pulling your belly button towards your spine. Round your back towards the ceiling. Allow your head and neck to fall naturally between your arms.
Hold for 15-20 seconds, relax for 5 seconds, then repeat 2 more times.

F. Kneeling Hip Flexor Stretch

Begin by kneeling on the floor or mat. Then bring your left foot forward with foot flat on the ground so that your heel is positioned directly beneath your knee.
You right leg should be extended behind you with the top of your foot touching the floor.
Keep your back straight, eyes looking straight ahead, and slowly shift forward, moving your weight forward until you can feel a stretch in the front of your right hip. Do not arch your back.
Hold this position for 20-30 seconds, relax for 5 seconds, then repeat 2 more times.
Then switch you legs and perform the same stretch on your left hip.

II. Postural Retraining

A. Assisted Squats

Find a railing, a door frame, or other suitably stable object to hold onto.
Stand erect with feet slightly wider than shoulder width holding on to the stable object. Brace your stomach and establish a straight spine with chest up and chin parallel to floor, looking forward.
Start the movement as if you were about to sit down, dropping your hips down and back. Descend as far as comfortable while maintaining a straight back. The goal is thighs parallel to the floor but you may not get there for some time. That’s okay, just do the best you can.
Use the support to ensure that you are maintaining proper posture throughout the movement and to assist in rising back up to starting position.
Perform 3 sets of 10 repetitions.

B. Dowel Hip Hinges (Requires the use of a wooden dowel. A broom handle works well for this exercise)

Stand tall with feet shoulder width apart. Keep your chest up, chin parallel to the floor and eyes looking forward.
Hold the wooden dowel with both hands behind your back with one hand above your head and the other down by your tailbone.
The wooden dowel should touch 3 areas. Your tailbone, between your shoulder blades, and directly behind your head.
Brace your stomach and focus on moving your hips back 10-12 inches as you bend forward, hinging at the hips. There should be a slight bend in the knees.
As you hinge forward the dowel should not lose contact with any of the 3 points (tailbone, between shoulder blades, back of head). If it does, there is a flaw in your hip hinge and it needs to be corrected. It usually means you are rounding and bending your spine. This is incorrect because the bending should take place only at the hips.

III. Gluteal (buttocks) Activation/Strengthening

A. Clam Shells

Lie on your side with your legs stacked and your knees bent at a 45 degree angle.
Rest your head on your lower arm and use your top arm to steady your body. It is important to keep your hips stacked one on top of the other and not tip them forward or backward.
Brace your abdominal (stomach) muscles to help stabilize your spine and your hips.
Keep your feet touching, raise your upper knee as high as you can without shifting your hips. Your lower leg should remain on the floor.
Pause briefly and then return your upper leg to the starting position on top of your lower leg. Perform 3 sets of 15-20 repetitions.
Turn on to your opposite side and repeat with the other leg.

B. Clam Shells With Resistance Band

Once you can perform the above Clam Shell exercise without difficulty you can add a resistance band to increase strength.
Place the resistance band around both legs just above the knees.
Repeat the same movements as described above for the Clam Shell exercise. Again, be certain that you stabilize your abdominal muscle and don’t tip your hips forward or backward.
Perform 3 sets of 10-15 repetitions each leg.

C. Pelvic Bridge Exercise

Lie down on your back on the floor or mat. Bend your knees and place the soles of your feet on the mat up near your buttocks. Your feet and knees should remain hip distance apart.
Keep your arms on the floor at your sides to help stabilize your core as you perform the pelvic bridge movement.
Brace your abdominal (stomach) muscles and gently lift your hips up towards the ceiling. Press your feet into the floor as you lift your hips as high as is comfortable.
As you lift, you should squeeze your buttocks muscles, keeping them firm throughout the movement.
Keep your shoulders on the floor as you lift to protect your neck. You should not be pressing your head or neck into the floor as you lift, only your shoulders and feet.
Pause briefly at the top and then return to the starting position.
Perform 3 sets of 10-15 repetitions.

IV. Trunk/Core Anti-movement Exercises

A. Front Plank

Begin on your hands and knees on a padded carpet or rubber mat. Place both elbows and forearms on the ground, shoulder width apart, directly beneath your shoulders.
Then extend both legs straight back and place the toes of your feet on the ground hip width apart. Keep your head relaxed and eyes looking down at the floor.
Brace your abdominal (stomach) muscles and keep your body straight and rigid in a straight line from your ears to toes with no sagging or bending at the waist.
Hold this position for 20 seconds, then relax for 10 seconds on hands and knees, then repeat 2 more times.
Over time work up to 30, 45, then 60 seconds

B. Side Plank

Lay on your side with your elbow on the floor under your shoulder. Keep your legs stacked one on top of the other and your knees extended fully straight.
Brace your abdominal (stomach) muscles and slowly lift up on your elbow raising your hips up towards the ceiling. Be certain not to let your hips tilt forward or backward.
Keep your body straight and rigid in a straight line from your chin to
your toes with no sagging at the hips. In the correct position the only thing touching the ground should be your elbow and forearm and the side of your bottom foot.
Hold this position for 10-15 seconds, relax for 10 seconds by lowering your hip to the ground, then repeat 2 more times. Turn onto your opposite side and repeat 3 sets of 10-15 seconds.
Over time work up to 30, 45, then 60 seconds.

C. Bird Dogs

Begin on your hands and knees on the carpeted floor or rubber mat. Keep you hands shoulder-width apart and your knees hip-width apart.
Brace your abdominal (stomach) muscles and start by lifting one hand and the opposite knee a couple of inches off the ground while balancing on the other hand and knee. Once you feel balanced and steady you can move on to the full range of motion.
Point the arm straight our in front of you and your opposite leg straight out behind you. You should form a straight line from your hand to your foot, keeping your hips square to the floor. Keep your back straight and don’t sag.
Pause in full extension and then return your hand and knee to the starting position, then repeat with the same arm and leg for a total of 10 repetitions. Repeat 2 more sets for total of 3 sets.
Then switch arms and legs and perform 3 sets of 10 repetitions on the opposite side.

Phase 2

Goals: Stretching (Continue to improve flexibility); Posture (Reinforce learned patterns); Strengthening (Continue to develop Strength and Work Capacity)

I. Stretching (Improving Flexibility)

A. Continue with the stretching program that you have learned in Phase 1 but add the following 2 stretches to your program.

B. Wall Figure 4 Stretch

Lie on your back with your buttocks near the wall. Bend your knees and place both feet on the wall creating a 90 degree angle with your knees.
Now cross your right ankle over the lower part of the left thigh just above your knee in a Figure 4 position.
Place your right hand on your right thigh and gently press it open.
Hold for 20-30 seconds, then relax for 5 seconds, then repeat 2 more times.
Switch legs and perform 3 sets of 20-30 seconds on left leg.

C. Camel Stretch

Begin on your hands and knees with hands shoulder-width apart knees hip-width apart, your back flat and your eyes looking to the floor.
Brace your abdominal (stomach) muscles drawing your belly button towards your spine as you drop your belly towards the floor.
Arch your back gently, lifting your chest and tilting your pelvis. Look towards the ceiling without straining your neck.
Hold for 15-20 seconds, then relax in neutral position for 5 seconds, then repeat 2 more times.

II. Gluteal (Buttocks) Strengthening

A. Bench Bridges

Lie down on your back on the floor or mat with your buttocks near the bench. Bend your knees and place your heels up on the bench with your knees bent to 90 degrees.
With your arms on the floor at your sides, brace your abdominal (stomach) muscles and gently lift your hips up towards the ceiling while pressing down into the bench with your heels.
Squeeze your buttocks and keep your core tight and lift until you form a straight line between your knees and your shoulders.
Keep your shoulder on the floor as you lift to protect your neck. You should not be pressing your head and neck into the floor, only your shoulders and your heels.
Pause briefly at the top and then slowly return to the starting position. Perform 3 sets of 10-12 repetitions.

B. Single-leg Cable/Elastic Band Abductions

Stand on one leg with the cable of the low pulley machine, or an elastic band, attached to your other ankle as pictured below. Stand so that you are facing perpendicular to the resistance. If using an elastic band make sure that it is securely attached to a stable, immovable object such as the leg of a large table.
Stabilize your body by placing your hand on the cable machine or the table. Keep your posture aligned and stand far enough from the machine or table to ensure tension on the cable or elastic band.
Slowly and with control, abduct the hip, moving the outer leg laterally away from your body and the machine or table. Keep your knee straight and push your leg away about 30-40 degrees. Pause briefly, then slowly lower your leg back to the starting position and repeat for a total of 10 repetitions. After completing 1 set of 10 repetitions, rest for 45-60 seconds then repeat a total of 2 more sets on that leg.
Switch sides, swapping the ankle cable or elastic band to the other leg and repeat 3 sets of 10 repetitions on the other leg.

C. Split Squats With Dumbbells

Stand initially with both feet underneath your shoulders and holding one dumbbell in each hand.
Step one foot forward as wide as you can while keeping both heels planted on the ground with toes pointing forward.
Brace your abdominal (stomach) muscles and maintain an upright torso, then bend both your knees, allowing your back heel to come off the ground as you shift your weight onto the heel of your front foot.
Lower your body until your front thigh is parallel to the ground and pause briefly. Then drive through your front heel to stand back up to starting position and repeat for a total of 10 repetitions. Rest for 45-60 seconds then repeat 2 more sets on that leg.
Switch legs and repeat 3 sets of 10 repetitions on that leg.
Start with very light dumbbells (3-5 pounds) and only increase the weight of the dumbbells when you can easily perform 3 sets without difficulty.

D. Bulgarian Split Squats

Once you have mastered the standard split squats with dumbbells you can progress to the Bulgarian Split Squat. This is similar to the standard split squat but the rear foot is elevated on a bench.
While holding a dumbbell in each hand with arms extended at your sides, place the top of your rear foot onto a bench. Your feet should be approximately 3 feet apart.
Brace your abdominal (stomach) muscles and maintain an upright torso. Then lower your hips toward the floor bending your front knee until your front thigh is parallel to the floor.
Pause briefly, then drive through your front heel to stand back up to starting position and repeat for total of 10 repetitions. Rest for 45-60 seconds then repeat 2 more sets on that leg.
Switch legs and repeat 3 sets of 10 repetitions on the other leg.
Again, start with light dumbbells and increase the weight as you get stronger.

E. Single Leg Roman Deadlift

Standing with your feet shoulder-width apart and knees slightly bent raise one leg off the floor.
Keeping the knee on the standing leg flexed about 15-20 degrees, brace your abdominal (stomach) muscles, keep your back straight, and bend (hinge) forward at your hips, lowering your torso until it is almost parallel to the floor.
Briefly pause, then while squeezing your buttocks, raise your torso back up to the starting position and repeat for total of 10 repetitions. Rest for 45-60 seconds then repeat 2 more sets on that leg.
Switch legs and repeat 3 sets of 10 repetitions on the other leg.
Initially perform this exercise without weights. Once you have perfected the technique you can begin to add weights. When using weights, hold the kettle bell or the dumbbell in the hand opposite the leg that remains on the ground.
Keep your head and neck in a neutral position when performing this exercise.

F. Anti-rotation Kneeling Cable/Elastic Band Chop

Kneel on one knee, perpendicular to the cable or elastic band. Kneel on the knee closest to the cable or elastic band with the opposite foot flat on the ground. Keep your back straight with your chest tall.
The cable or elastic band should be attached low to the ground. Reach across your chest and with both hands and grab the cable handle or elastic band. Position your body so that there is tension on the cable or elastic band.
Brace your abdominal (stomach) muscles, and while keeping your shoulders and hips square and head and eyes facing forward, rotate your arms across your body from low to high, keeping your arms and elbows straight.
Pause briefly, then rotate your arms back across your body and down to the starting position. Repeat for a total of 10 repetitions. Rest for 45-60 seconds then repeat 2 more sets.
Switch sides by turning around and facing the other direction and complete 3 sets of 10 repetitions on the other side.
Make sure your hips and shoulders stay square and do not rotate. If you are finding it difficult to stabilize your core then lower the weight.
You can vary this exercise by raising the cable or elastic band to a high position and performing a high-to-low chop, or positioning the cable or elastic band at chest level and performing the chop straight across.

G. Front Planks

Continue Front Planks as described in Phase 1 but increase the length of time you hold the plank.

H. Side Planks

Continue Side Planks as described in Phase 1 but increase the length of time you hold each plank.

**Disclaimer**

You should consult your physician or other health care professional before starting this or any other fitness program to determine if it is right for your needs. This is particularly true if you (or your family) have a history of high blood pressure or heart disease, or if you have ever experienced chest pain when exercising or have experienced chest pain in the past month when not engaged in physical activity, smoke, have high cholesterol, are obese, or have a bone or joint problem that could be made worse by a change in physical activity. Do not start this fitness program if your physician or health care provider advises against it. If you experience faintness, dizziness, pain or shortness of breath at any time while exercising you should stop immediately.

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