Regular exercises to restore the strength of your back and a gradual return to everyday activities

Initial Exercise Program
Ankle Pumps
1. Lie on your back.
2. Move ankles up and down. Repeat 10 times.
3. Repeat 10 times.






Heel Slides
1. Lie on your back.
2. Slowly bend and straighten knee.
3. Repeat 10 times.






Abdominal Contraction
1. Lie on your back with knees bent and hands resting below ribs.
2. Tighten abdominal muscles to squeeze ribs down toward back.
3. Be sure not to hold breath.
4. Hold 5 seconds.
5. Relax.
6. Repeat 10 times.






Wall Squats
1. Stand with back leaning against wall.
2. Walk feet 12 inches in front of body.
3. Keep abdominal muscles tight while slowly bending both knees 45 degrees.
4. Hold 5 seconds.
5. Slowly return to upright position.
6. Repeat 10 times.





Heel Raises
1. Stand with weight even on both feet.
2. Slowly raise heels up and down.
3. Repeat 10 times.








Straight Leg Raises
1. Lie on your back with one leg straight and one knee bent.
2. Tighten abdominal muscles to stabilize low back.
3. Slowly lift leg straight up about 6 to 12 inches and hold 1 to 5 seconds.
4. Lower leg slowly.
5. Repeat 10 times.








Intermediate Exercise Program
Single Knee to Chest Stretch
1. Lie on your back with both knees bent.
2. Hold thigh behind knee and bring one knee up to chest.
3. Hold 20 seconds.
4. Relax.
5. Repeat 5 times on each side.






Hamstring Stretch
1. Lie on your back with legs bent.
2. Hold one thigh behind knee.
3. Slowly straighten knee until a stretch is felt in back of thigh.
4. Hold 20 seconds.
5. Relax.
6. Repeat 5 times on each side.








Lumbar Stabilization Exercises With Swiss Ball
Abdominal muscles must remain contracted during each exercise (see Abdominal
Contraction). Perform each exercise for 60 seconds. The farther the ball is from your
body, the harder the exercise.
Lying on Floor
1. Lie on your back with knees bent and calves resting on ball.
2. Slowly raise arm over head and lower arm, alternating right and left sides.
3. Slowly straighten one knee and relax, alternating right and left sides.
4. Slowly straighten one knee and raise opposite arm over head. Alternate opposite
arms and legs.
5. Slowly "walk" ball forward and backward with legs.

Sitting on Ball
1. Sit on ball with hips and knees bent 90°and feet resting on floor.
2. Slowly raise arm over head and lower arm, alternating right and left sides.
3. Slowly raise and lower heel, alternating right and left sides.
4. Slowly raise one heel and raise opposite arm over head. Alternate opposite arm
and heel.
5. Marching: Slowly raise one foot 2 inches from floor, alternating right and left
sides.


Standing
1. Stand with ball between your low back and wall.
2. Slowly bend knees 45 ° to 90 ° . Hold 5 seconds. Straighten knees.
3. Slowly bend knees 45 ° to 90 ° while raising both arms over head.








Lying on Ball
1. Lie on your stomach over ball
2. Slowly raise alternate arms over head.
3. Slowly raise alternate legs 2 to 4 inches from floor.
4. Combine 1 and 2, alternating opposite arms and legs.
5. Bend one knee. Slowly lift this leg up, alternating right and left legs.
NOTE: Be careful not to arch your low back


Advanced Exercise Program
Hip Flexor Stretch
1. Lie on your back near edge of bed, holding knees to chest.
2. Slowly lower one leg down, keeping knee bent, until a stretch is felt across top of
the hip/thigh.
3. Hold 20 seconds.
4. Relax.
5. Repeat 5 times on each side.

Piriformis Stretch
1. Lie on back with both knees bent.
2. Cross one leg on top of the other.
3. Pull opposite knee to chest until a stretch is felt in the buttock/hip area.
4. Hold 20 seconds.
5. Relax.
6. Repeat 5 times each side.


Lumbar Stabilization Exercise With Swiss Ball
Lie on stomach over ball.
1. " Walk " hands out in front of ball until ball is under legs. Reverse to starting
position.
2. " Walk " hands out in front of ball until ball is under legs and slowly raise
alternating arms over head.
3. " Walk " hands out in front of ball and slowly perform push-ups.

Core Muscle Activation For the Back

Over the last several years it seems that you cannot read a fitness magazine or online health article without being told that you need to strengthen your core. The problem is that most people do not know what the core really is. Many people believe that the core is simply your abdominal muscles, and that answer is partly correct, but there is much more to the core than just the abdominal muscles, and the core is much more difficult to get stronger than simply doing a bunch of crunches.
Why are the core muscles so important? The simple answer is that they provide support and stability around your midsection allowing you to perform all of your everyday activities such as walking, bending over or throwing a ball without increasing the stress on your lower back. However, when you have an injury or pain in your lower back these muscles will often get inhibited. When they get inhibited they do not work correctly which in turn can create more pain in the lower back, and you end up in a cycle that you are not able to break out of.
To learn how to activate the core you must first understand the anatomy that makes it up. There are three distinct muscles that form the core:
Pelvic floor: The pelvic floor is like a sling on the bottom of your pelvis traveling from the front to the back and its function is to hold all of your internal organs up and together; the most familiar function that we all use the pelvic floor for is stopping ourselves from going to the bathroom. So the next time you are stuck in your car or at a meeting and you have to go to the bathroom pay close attention to the muscles in your pelvis and you will have a better understanding of how these muscles work. These muscles can often become injured or inhibited and then they are not able to function optimally, a common injury to these muscles is pregnancy and childbirth. During the birthing process the muscles get stretched out and they do not always return to form. In order to strengthen these muscles we must selectively tighten them; many women are familiar with this by doing a Kegel exercise. In order to tighten the muscle specifically it is easiest to feel if you lie down on the ground and bend your knees so your feet are on the floor. Put your fingers on the front part of your pelvic bones and then slide them about an inch towards your bellybutton. Then tighten your pelvic floor by pulling up on the muscles; think of stopping yourself from going to the bathroom. This should be a very gentle pull! You should not be pulling so tight that you are having trouble breathing. With your fingers you are feeling for a slight tightening, and your stomach should stay flat. If you feel your muscles pushing into your fingers you are activating your outer abdominal muscles and you are doing too much.

Transverse abdominis: The best way to visualize your transverse abdominal muscle is like a corset or a back brace that you might wear if you are doing heavy lifting; next time you go to a big warehouse store notice that a lot of the employees wear a back brace. The muscle starts on your back and travels horizontally around towards your bellybutton. When this muscle tightens it pulls in and creates support around your midsection, exactly like the back brace. This muscle will often become dysfunctional when someone has experienced a back injury, and the way it acts when dysfunctional is by not contracting properly. When it does not contract properly you will loose a lot of support in your lower back and this will often perpetuate your lower back injury. To find and selectively activate these muscles assume the position you were in to activate the pelvic floor by lying on your back with your legs bent and your fingers just off of your hip bones. You will tighten this muscle by drawing your bellybutton in towards your spine; do not simply suck your gut in. Think of it as if you are trying to pull on a tight pair of jeans. With your fingers you should feel the muscles tightening, but again you should not feel the muscles pushing out and into your fingers. This is a gentle contraction and it should not be limiting your ability to breathe easily, and you should be able to hold a conversation while holding these muscles tight. Often people find it easier to first pull up on the pelvic floor and then draw in the bellybutton.

Multifidus: These muscles are often the most difficult for people to learn to isolate, but they may be the most important based on their location in terms of treatment for lower back injuries. They are positioned on the back of your spine and connect a single vertebra to the one above it, and it is this segmental stabilization that is necessary for proper lower back function. Just like the other muscles these will often get weak after a lower back injury because the pain and inflammation will inhibit these muscles from functioning properly. To isolate these muscles you will do best to co-contract them with your pelvic floor. Start by lying on the floor with your knees bent and gently pull up on your pelvic floor, you will then tighten your multifidus by pulling your tailbone up towards your spine. You should feel a tightening on your lower back, but do not let your back arch up, it should stay in its neutral position. Some people are able to feel the muscles tighten by putting their hand in the small of their back about one half an inch off of your spine; not everyone can feel these muscles tighten so do not get frustrated if you cannot feel them.

Once you have mastered contracting these muscles in isolation begin working on them together by tightening up your pelvic floor, then your transverse abdominals and finally your multifidus. As these become easier to activate you can begin to add resistance by performing leg movements such as sliding one leg down the floor, or lifting a leg up in the air; just make sure to keep the muscles tight while you are doing it. Finally, since most people do not hurt their back while lying on the ground you are going to have to start working on these muscles while standing, sitting and walking. So when you are out on your evening walk think about these muscles, when you are working around the house or driving into work tighten them up, even if you are at the gym performing a workout on a totally distant muscle group, like your biceps, think about activating your core so that when you lift a weight your back will be stable and protected.

All of these muscles are difficult to learn to contract properly, especially if you have had an injury to your back, as these muscles will often be dysfunctional and not working the way they should be.

Vertebral Column Anatomy

Vertebral Column Anatomy

Seven cervical, 12 thoracic, 5 lumbar, 5 fused sacral vertebra and the coccyx compose the vertebral column. The vertebral column has four characteristic curvatures: the anterior convexity of the sacrum, the lumbar lordosis, the thoracic kyphosis, and the cervical lordosis. In the supine patient, the lumbar spine has its highest point at L4 and the thoracic spine has its lowest point at T4. In the lumbar area, the spinous processes project directly posteriorly whereas in the thoracic area, the spinous processes project posteriorly and more inferiorly until they reach their steepest downward angulation at the midthoracic level where they overlap with the lamina of the vertebra immediately inferior. This overlap can make the midline approach to the epidural space difficult or impossible at the T5-T9 levels. At higher thoracic levels, the spinous processes become level again to become nearly horizontal at C7. The spinal canal is enclosed by the vertebral bodies anteriorly, the pedicles laterally, and the ligamenta flava and the laminae posteriorly. The canal ends superiorly in the foramen magnum and inferiorly in the sacral hiatus.

Ligaments

The supraspinous ligament runs along the tips of the spinous processes and blends with the ligamentum nuchae at its superior end. In elderly individuals and in persons who engage in heavy physical activity, the ligament can become ossified, making a midline approach to the epidural space impossible. The interspinous ligament stretches vertically from the inferior border of each spinous process to the superior border of the spinous process below, except in the cervical spine, where it is absent. Dorsally, the interspinous ligament blends with the supraspinous ligament. Ventrally, it fu

ses with the ligamenta flava and the laminae. The laminae slope posteriorly and inferiorly so that their ventral surfaces are in close contact with the dura. The ligamentum flavum is a tough elastic ligament that attaches to the ventral surface of the superior lamina and the dorsal surface of the inferior lamina. Laterally, the ligament thins as it blends with the joint capsu

le of the articular processes. Within the spinal canal, the posterior longitudinal ligament runs along the dorsal surface of the vertebral bodies and is adherent to the anterior dura. The anterior longitudinal ligament joins the vertebral bodies along their anterior surface.

The Dura Mater

The dura mater is a toug

h fibrous membrane that envelopes the arachnoid mater, cerebrospinal fluid, pia mater, spinal nerves, spinal cord and brain. Within the cranium, the dura is composed of an outer endosteal component that lies against the bone of the cranium and an inner meningeal component. These two layers are tightly adherent except where they divide to form the venous sinuses. At t

he foramen magnum, the endosteal layer divides from the meningeal layer and lines the spinal canal as the endosteum of the vertebral bodies. The meningeal layer continues caudally as the dural sac, and ends at the S2 level in adults. The attachment of the meningeal dura to the endosteal dural at the foramen magnum anatomically isolates the cranial vault from the epidural space of the spinal canal.

The Arachnoid Mater

The arachnoid mater is a thin metabolically active membrane that loosely adheres to the dural sac and contains the brain and spinal cord bathed in CSF. Between the arachnoid and the dura lies the subdural space, a potential space through which local anesthetics can distribute via a misplaced spinal needle or epidural catheter. Connective tissue trabeculae extend from the arachnoid to the pial surface of the spinal cord to secure the cord in the CSF. Arachnoid granulations ranging from microscopic to 3 mm in diameter cluster around the nerve roots in the dural cuff region. These granulations emerge through the dura and press into surrounding veins and epidural fat. By transcellular vacuolar transport, the granulations clear the CSF of foreign particulate material, likely by emptying directly into the epidural venous plexus or into the epidural connective tissue, for subsequent removal by lymphatic drainage.

The Pia Mater and Spinal Cord

The pia mater is a thin highly vascular membrane composed of flat ep

ithelial cells and tightly adherent to the spinal cord. A long filamentous extension of the pia, the filum terminale, pierces the caudal end of the dural sac and blends with the periosteum of the coccyx to secure the spinal cord within the sac. The spinal cord ends at the L1-2 level in adults. The spinal roots continue caudally to the intervertebral foramina of the lower lumbar and sacral levels as the cauda equina.