General abstract
1.2 Riesgo cardiovascular en niños y adolescentes
A key factor in the successful outcome of treatment is the rehabilitative exercise necessary to restore normal muscle function. Getting patient compliance in this phase of treatment is likely to be difficult. Most patients are cooperative as long as they are in pain, but as pain subsides, their interest in rehabili
tative processes diminishes.
In some cases, the best way to ensure compliance is to refer the patient to a rehab facility with a prescription. A rehab cen
ter will be staffed with trained therapists who can monitor the patient, ensuring proper compliance. There is a growing inter
est among many practitioners in establishing in-house rehab centers. This is an excellent way to control the patient's exer
cise program.
Some patients are already members of health clubs with ad
equately equipped gyms. They can be educated in the office and released on their own recognizance. Those patients who cannot afford rehab or gyms can be given training in the office and provided with inexpensive resistance exercise tubing and can work out at home. These patients are the most difficult to control, however. To ensure the exercises are peIformed and performed correctly, the following must be done:
1. Give a careful explanation in lay terms of exactly what the problem is.
2. Test the muscle and demonstrate to the patient how weak it is and stress the importance of strengthening it.
3. Demonstrate the exercise.
4. Have the patient perform the exercise, making sure that cheating (recruitment of other muscles) does not occur.
5. Provide, where possible, a diagram of the exercise as a reminder.
6. Make available exercise tubing if it is to be used. Do not rely on the patient to obtain it on his or her own. of sessions to be completed per day.
9. Review the exercise and check muscles for improve
ment on subsequent visits.
When relying on the cooperation of the patient, the simpler the exercise process, the easier its execution, the more likely it will be followed. Instead of describing the number of sets and repetitions per set, I have found it easier, in some cases, to give the patient a time line. For instance, I will instruct the patient to start with a one or two minute set, or until the muscle
"burns," a few minutes of rest, then repeat again. The patient can gradually increase the time as the muscle responds. The extent of the program should be tailored to the patient's condi
tion and ability.
The exercise concepts described in this chapter are those developed over many years of clinical experience. They have proved to be the most successful exercises when relying on the patient to comply. The muscles considered are the most com
monly found to be weak or dysfunctional. There are numerous theories and methods of toning muscles. The exercise con
cepts described here can be modified to fit any program and should be an example of how to figure out creative ways to isolate and tone practically any muscle.
ABDOMINALS
There are countless "ab" exercise techniques. The evolution of the sit-up has progressed from the old straight legged full sit-up to the more correct current "cruncher." Dr. Logan de
vised his sit-up exercise to fully activate the total abdominal
168 THE Low BACK AND PELVIS
group. In many cases the rectus is the most emphasized, and the obliques and transverse groups get minimally worked, es
pecially the lower pelvic fibers. The full sit-up will enlist the psoas muscles in the second half of the movement. In more cases than not, the psoas muscles are already too tight, and a full sit-up will exaggerate the imbalance between these two antagonistic muscles.
A "half' sit-up that isolates the abdominals and deactivates the psoas is advantageous. By putting the legs up over a chair with the hips at 90°, the psoas muscles are unable to assist with any strength. By limiting the sit-up to the first half (raising up only to elevate the shoulder blades from the floor), the abdominals are used fully. At the same time, flattening the low back to the floor, which tilts the pelvis posteriorly, works the lower abdominal fibers.
With the arms outstretched, rise up to touch an imaginary point to the extreme left (Fig. 7-1), hold for a count of two, and slowly return to the floor. This is position one. With each successive sit-up, move the imaginary point to the right pass
ing the center point (over the knees) and ending with point six far to the right (Fig. 7-2). Then work back to the left. This six point radius of sit-ups works all the oblique and transverse fi
bers. The patient can be instructed to assess each position and add extra repetitions to those positions that seem weaker.
GLUTEUS MAXIMUS
Exercise 1
Instruct the patient to start on hands and knees. Raise one leg up and "push" the foot towards the ceiling (Fig. 7-3). Do not move the pelvis. The hip joint does not normally extend beyond neutral more than 10°. Further extension will be
ac-Fig. 7-1 Sit-up position I.
Fig. 7-2 Sit-up position 6.
Fig. 7-3 Gluteus maximus exercise I.
complished with pelvic rotation that defeats the purpose of the exercise. Start with 8 to 10 repetitions on each side and com
pare efforts. Add extra repetitions to the weaker side. As strength increases, ankle weights can be added as well as the number of repetitions increased.
Exercise 2
Using resistance tubing, a standing exercise can be done.
Stand next to a desk or table and rest the weight-bearing hip against the edge of the table. Flex the hip and knee of the side to be worked and secure the tubing around the heel. Secure the other end against the desk with both hands. Push the foot back against the resistance no more than eight inches past the other leg (Fig. 7-4).
Fig. 7-4 Gluteus maximus exercise 2.
Repeat 6 to 8 times and reverse to work the other side. Com
pare the efforts and work the weaker side a little more.
Exercise 3
This is a non-weight-bearing position that is easier to do if the patient is unable to perform the first two methods. The pa
tient lies supine with the hip and knee flexed to 90°. The resis
tance tubing is hooked around the heel, and the hip is extended to a 45° angle. This is actually the same as the standing exer
cise done supine. Repeat 6 to 8 times and switch to the oppo
site side. Compare and add repetitions to the weaker side.
GLUTEUS MEDIUS
Exercise 1
The most successful way to work the gluteus medius is to instruct the patient in side lifts (abduction with slight exten
sion) in the same position as the test, lying on one side, then the other (Fig. 7-5). Increase repetitions or add ankle weights or both.
Exercise 2
A standing exercise can be achieved by supporting the body by holding on to a wall or chair back. The leg is abducted and slightly extended while the pelvis remains level. This re
sembles a ballet exercise.
Fig.7-5 Gluteus medius exercise.
LA TERAL HIP ROT A TORS
Exercises 169
These exercises include the piriformis and gluteal muscles.
Exercise 1
Secure the resistance tubing to the leg of a heavy piece of furniture to the side being exercised. Sit in as reclined a posi
tion as possible, with the hip as extended toward neutral as is possible (about 30°-recall that the piriformis becomes an ab
ductor as the hip is flexed toward 90°). Hook the tubing around the foot and pull across toward the opposite leg, which rotates the hip laterally (Fig. 7-6).
Fig. 7-6 Piriformis exercise I.
170 THE Low BACK AND PELVIS
Repeat 8 to 10 times. If both sides are to be worked, com
pare and add repetitions to the weaker side.
Exercise 2
Sitting up straight, hook the tubing around the thigh near the knee. Secure the other end around the opposite knee. Abduct the thigh to exercise the piriformis, which, in thjs position, acts as an abductor (Fig. 7-7).
QUADRATUS LUMBORUM
Secure the tubing at chest level. Closing a knotted end in a door jamb is a convenient method for home use.
Extend and "lock" the knees. They should not bend during the exercise. All movement should be from the waist up. Make sure the pelvis does not shift. Lean toward the door and take tension on the tubing holding the end to the chest with both hands (Fig. 7-8).
Pull against the resistance and do a side bend to the opposite side (Fig. 7-9). Be sure the shoulders remain in line and do not rotate to recruit other muscles and "cheat." Repeat 8 to 10 times.
Repeat the above exercise first with one foot 6 to 8 inches behind and then 6 to 8 inches in front of the other foot. Com
pare the effort and add 8 to 10 additional repetitions to the weaker foot position. This positional change emphasizes dif
ferent portions of the muscles being worked.
Fig. 7-7 Piriformis exercise 2.
Fig. 7-8 Beginning position for Q-L exercise.
Fig. 7-9 Q-L exercise ending position.
TRANSVERSUSPERlNEI
This muscle is activated to stabilize the ischial tuberosities prior to the activation of the adductors in returning the thigh from an abducted state.
The best way to perform this exercise is to sit slumped in a chair with the legs extended out and clamped against the legs of a facing chair, in slight abduction. An isometric contraction to bring the legs together will activate and work the transver
sus perinei (Fig. 7-lO). Have the patient do a ten second iso
metric contraction 2 to 3 times a day.
A standing exercise can be done by standing with a wide stance and isometrically contract the adductors, which neces
sitates the initial action of the transversus perinei (Fig. 7- 1 1).
LOWER Q-L AND COCCYGEAL FIBERS OF THE GLUTEUS MAXI MUS
Exercise 1
The fourth Q-L segment and posterior abdominals are part of the system that pulls the iliac crest medially, countering the transversus perinei. When weak, they will allow a medial is
chium. The coccygeal fibers of the gluteus maximus are often weak with an anterior coccyx.
Fig. 7-10 Transversus perinei exercise.
Fig. 7-11 Standing exercise for transversus perinei.
Exercises 171
The patient is prone. Flex the knee to 90°. Abduct the hip as far as is comfortable. Then lift the foot toward the ceiling without rotating the leg (Fig. 7- 12). Repeat 8 to lO times.
Exercise 2
A sitting version can be done with tubing. The tubing is se
cured around the back of the neck and held tight on the oppo
site side. The other end is secured to the knee. Sit on the edge of the chair and abduct and flex the hip; take up all slack in the tubing and move the knee toward the floor, keeping the knee abducted (Fig. 7- 13).
FIFTH SEGMENT OF THE PSOAS
The lower psoas and iliacus can be isolated when found weak. The fifth segment of the psoas is often weak from lifting injuries that occur upon rising up.
Fig.7-12 Exercising the lower Q-L and coccygeal fibers of the glu
teus maxim us.
Fig. 7-13 Sitting exercise for lower Q-L and coccygeal fibers of the gluteus maxim LIS.
172 THE Low BACK AND PELVIS
[n the sitting position, secure the tubing over the knee and the other end under the opposite foot. Take up all slack, and lift the knee toward the chest. This will work the whole psoas.
By bending forward, further flexing the spine and hip, the lower psoas fibers and the iliacus can be isolated (Fig. 7- 14).
These last three exercises are the most important in the re
habilitation of the unstable pelvis.
HIP AND WAIST EXERCISES
Adductors
The pull is to and beyond the opposite leg into adduction (Fig. 7- 15). With each repetition, move the foot forward, and then reverse direction and move posteriorly, stepping over the tubing and progressing three or four increments into extension (Fig. 7- 16).
Abductors
Stand with the tube secured at foot level and secure firmly around the ankle. With the knee straight, abduct the hip to a comfortable end point (Fig. 7- 17). With each successive rep
etition, move the foot forward three or four increments and then back to a point three or four increments behind the oppo
site foot, stepping over the tubing as you pass neutral.
Repeat this sequence with the knee bent and the waist muscles more activated (Fig. 7- 18).
Fig. 7-14 Sitting exercise for lower psoas and iliacus.
Fig. 7-15 Adduction exercise-anterior starting position.
Fig. 7-16 Adduction exercise-posterior ending position.
These exercises should be done bilaterally. Any positions that seem weaker should be stressed with extra repetitions.
LORDOTIC LUMBAR EXERCISES
The lordotic lumbar syndrome (LLS) is a most common finding in chiropractic practice. The sedentary lifestyle of the modern age will weaken the support system of the erect body unless it is properly exercised.
Fig. 7-17 Abduction exercise.
Fig. 7-18 Abduction exercise with knee bent.
The patient with LLS has a chronic anteriorly rotated pelvis with stretched and weakened abdominals, gluteus maximus, and possibly the piriformis muscles. The iliacus and psoas will be hypertonic and in need of stretching.
Test for abdominal function in LLS patients by having them attempt a bilateral straight leg raise (SLR). If the pelvis tilts anteriorly before the legs lift off, it is a sign that the abdominals are not participating properly (Fig. 7- 19). They should be contracting and stabilizing the pelvis so the hip
flex-Exercises 1 73
Fig. 7-19 Active bilateral SLR. Note increased lordosis and pubic symphysis lower than anterior superior iliac spine indicative of weak abdominals.
ors can go to work properly. They are likely weak, and in most cases will be dysfunctioning proprioceptively.
When this finding is positive, press on the lower abdomen and support the abdominals. Then have the patient attempt a bilateral SLR (Fig. 7-20). The difference should be signifi
cant, which can be a good example for compliance.
The following exercise can tone the gluteals and abdominals as well as reestablish normal proprioceptive func
tion. Have the patient lie supine and place 5 to 10 Ibs of weight on the abdomen below the umbilicus. Bend one knee, and place the foot on the floor. Raise the pelvis off the floor with that leg (Fig. 7-21). At the same time, rotate the pelvis poste
riorly. Hold for 5 to 6 seconds. Repeat 6 to 8 times and reverse sides. Depending on the chronicity of the case, several ses
sions a day can be prescribed. This works both the gluteals and the abdominals.
When instructing the patient in this exercise, it may be nec
essary to consciously reeducate the patient to use the abdominals to posteriorly rotate the pelvis, rocking it back and
Fig. 7-20 Active bilateral SLR with abdominal support.
174 THE Low BACK AND PELVIS
Fig. 7-21 LLS exercise with weight.
forth. Place a hand on the supine patient's abdomen and the other under the lumbar spine. Actively work the pelvis and have the patient flatten the lumbar spine while attempting to pull the pubis toward the chin. This pelvic rocking exercise will help the patient understand what is necessary to normalize function. This condition is most common in women who have had children. The muscles are weak and often have not rees
tablished normal proprioceptive integration after being stretched and nonfunctional during pregnancy.