(Note: If there is any fracture of the vertebrae or anterior disc protrusions, please do not follow this protocol)
Goal of Treatment: Optimize Spinal alignment, decrease disc space compression throughout entire lumbar spine, increase mobility in Sacral-Iliac (SI) Joint, increase hip mobility, increase core stability (more specifically transverse abdominis), decrease spasms and over activity of Quadratus Lumborum (QL) and Multifidi and Paraspinals in lumbar spine, decrease spasms and over activity of all hip flexor muscles, improve overall posture, stabilize pelvis, retrain proper biomechanics of activity of daily living (ADLs) and any fitness movements (ie. Squat, lunge, abdominal exercises, etc)
Setting Neutral Spine and Posterior Pelvis
In order to get the pelvis shift from an anterior rotation to a posterior rotation or neutral rotation, these factors have to be addressed. Hip flexors have to be lengthened via soft tissue methods and stretching. The Spinal Erectors have to be lengthened via soft tissue methods and core strengthening. It is essential that core strengthening is done properly and the hip flexors do not work as a synergistic muscle during these specific core strengthening exercises, or this will defeat the purpose of lengthening hip flexors. After those muscles are lengthened, and core is activated, then the fourth important component is to get full hip extension by strengthening the glute muscles. When strengthening the glutes, posterior pelvic positioning must be maintained by synchronizing transverse abdominis activation with glute activation. If glutes fire and hip extension is occurring without full activation and stabilization of transverse abdominis, there will be a false sense of hip extension and actually spinal erectors will be activating, defeating the purpose of lengthening spinal erectors.
Therefore, to effectively shift pelvis posterior, all these components must be done in same treatment session.
Treatment Plan and progression:
Specific Manual Therapy Techniques that are essential for effective neutral spine and posterior pelvis positioning
Spinal Erectors lengthened
1. Soft Tissue Massage – spasms and scar tissue of paraspinals and multifidi
2. Soft Tissue Massage – Quadratus Lumborum
3. Fascia Release using Cupping – spinal erectors
Hip Flexors lengthened
1. Psoas Release
2. Rect Fem Release – massage and foam roll
3. TFL Release – Tennis ball sidelying release
1. SI Mobilization – mobilize SI joint fully until both sides of equal movement
2. Muscle Energy Techniques for any unilateral anterior pelvic rotation cases
3. Sidelying manual posterior rotation of illium
4. Prone Glute Squeeze
Stabilize Sacrum and client activates glute and goes into hip extension without using back extensors. This allows for reciprocal inhibition of hip flexors.
Specific Techniques that are essential for exercises to be effective in setting neutral spine and posterior pelvis:
1. Activating Transverse Abdominis
Proper Activation of Transverse Abdominis is obtained with the biofeedback from Abs Done Right belt. Practice posterior rotation of pelvis, activation of transverse abdominis and breathing with the diaphragm.
Isometrically hold transverse abdominis for 1-3 minutes
2. Maintaining Posterior Pelvis and Neutral Spine throughout lower leg movement (Deadbugs)
To replicate how our pelvis will rotate as we walk, you want to be sure to learn in a supine position, with limited hip movement, how to maintain posterior pelvic positioning and neutral spine as the legs start moving into hip extension. Key is to not allow any hip flexors to activate during this movement and use the abdominals instead. Just alter legs and maintain Green Zone and a steady needle on the dial while legs move.
Goal is to progress from 10 sec to 1 minute continually without needle dropping out of Green Zone
3. Advance Deadbugs
Adding arm movements and longer leg movements challenges the ability of the spine to stay neutral, pelvis to stay posterior, and transverse abdominis to continue to stay activated throughout progressive movements.
Goal is to add arm movement first and leg movement second and then arms and legs alternating (like a supine bird dog)
4. Bird Dog
Next challenge is to be able to do bird dog in prone and be able to maintain core stability and posterior pelvis position when you don’t have the feedback of the Abs Done Right belt or the floor. Key is the ability to not lose any posterior pelvis or neutral spine positioning while alternating arms and legs. Legs lift due to glute squeeze only and no back muscle activation.
Using a wooden dowel along head, back, and hips helps give feedback if needed.
Goal is to feel abdominals and glute working and not activating any spinal erectors.
4a. Bird Dog over stability ball
Adding stability ball allows for more tactile feedback for maintaining neutral spine, but also causes more muscle recruitment due to being more unstable
Goal would be able to do 3 sets of 15 on each side and feeling glutes squeeze more to lift leg and more stability in general with movement patterns. (if a glass of boiling hot water could be on your low back, you would not spill it with movements)
4b. Bird Dog with ½ foam rolls under knees and hands
Advance all techniques and specifics of Bird Dog on ½ foam rolls under knees and hands
4c. Bird Dog with Arm and Leg resistance
This is the ultimate level of bird dog to get to. Ideally, this exercise should “burn” the abs and glutes, due to perfect pelvic and spinal positioning and core strength.
5. Glute Bridges w/ band around thighs
Glute bridges are excellent to do to work on the synchronizing of core and glute activation at same time. Again, neutral spine and posterior pelvis position needs to be optimized during glute bridge to ensure spinal erectors are not being activated and true hip extension is occurring. By adding the band around the thighs and pulling knees wide throughout exercise, it allows the glute meds to also work.
Green Zone abs and full glute pinches are held for 3 sec each rep. Complete 3 sets of 10 reps. (This is not easy to do. If it seems easy, its probably being done ineffectively)
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