Mid and Lower Thoracic and Lumbar Regions:
Stretching Techniques
Techniques to Increase Lumbar Flexion
PRECAUTION: If flexion of the spine causes a
change in sensation or causes pain to radiate down
an extremity, reassess the patient’s condition to
determine if flexion is contraindicated
SELF-STRETCHING
Method 1:
- pt position: hook-lying
- bring one knee and then the other toward
the chest, clasp the hands around the
thighs, and pull them to the chest, elevating
the sacrum off the mat (don’t grasp around
tibia)
Method 2:Quadruped (on hands and knees)
- Have the patient perform a posterior pelvic
tilt without rounding the thorax (concentrate
on flexing the lumbar spine, not the thoracic
spine)
- hold the position
- relax
- Repeat; this time bring the hips back to the
feet, hold, and then return to the hands and
knees position
- Stretch: gluteus maximus,
quadriceps femoris, and shoulder
extensor muscles
TECHNIQUES TO INCREASE LUMBAR
EXTENSION
PRECAUTION: Do not perform if extension causes
a change in sensation or causes pain to radiate
down an extremity
Self-stretching
Method 1: prone
- Prone with hands placed under the
shoulders.
- Have the patient extend the elbows and
push the thorax up off the mat but keep the
pelvis down on the mat. This is a prone
press-up
- To increase the stretch force, the pelvis can
be strapped to the treatment table.
- This exercise also places the hip flexor
muscles and soft tissue anterior to the hips
in an elongated position, although it does
not selectively stretch these tissues.
Method 2: standing
- Standing, with the hands placed in the low-
back area.
- patient leans backward
Method 3: Quadruped (hands and knees).
- Instruct the patient to allow the spine to sag,
creating lumbar extension.
- Alternating between this motion and a
posterior pelvic tilt can be used to teach the
patient how to control pelvic motion.
Techniques to Increase Lateral Flexibility of the
Spine

Traction as a Stretching Technique

Manual Traction: Lumbar Spine
● To stretch into extension, extend the hips.
● To stretch into flexion, flex the hips.
● To stretch into side bending, move the lower
extremities to one side.
STABILIZATION TRAINING
Positional Traction: Lumbar Spine
TRANSVERSE ABDOMINIS ACTIVATION
Patient position: Side-lying, with the side to be
stretched uppermost. A rolled blanket or thick towel
1. Drawing-In Maneuver (Abdominal
is placed under the spine at the level where the
Hollowing Exercise) for Transverse
traction force is desired; this causes side bending
Abdominis Activation
away from the side to be treated and, therefore, an
- pt: quadruped position in order to use the
upward gliding of the facets (Fig. 16.21 A).
effects of gravity on the abdominal wall.
Therapist position: Standing, at the side of the
Hook-lying, prone-lying, or semireclined
treatment table facing the patient. Determine the
positions
segment that is to receive most of the traction force
- progress to sitting and standing
and palpate the spinous processes at that level and
ASAP
the level above. Procedure: The patient relaxes in
- PT:
the side-bent position. Rotation is added to isolate
- palpate TrA distal to ASIS and lateral to
a distraction force to the desired level. Rotate the
rectus abdominis
upper trunk by gently pulling on the arm on which
- TrA: flat tension is felt
the patient is lying while simultaneously palpating
- IO: bulge of the mm is felt
the spinous processes with your other hand to
- Goal is min or no contraction
determine when rotation has arrived at the level just
of the IO
above the joint to be distracted. Then flex the
- patient assume a neutral spinal position and
patient’s uppermost thigh, again palpating the
attempt to maintain it while gently drawing in
spinous processes until flexion of the lower portion
and hollowing the abdominal muscles
of the spine occurs at the desired level. The
- patient to breathe in, breath out, then gently
segment at which these two opposing forces meet
draw the belly button in toward the spine to
now has maximum positional distraction force
hollow out the abdominal region
- When done properly: no substitute patterns;
- minimal to no movement of the
pelvis (posterior pelvic tilting)
- no flaring or depression of the lower
ribs
- no inspiration or lifting of the rib cage
 - no bulging out of the abdominal wall,
- no increased pressure through the POSTERIOR PELVIC TILT
feet. - Activates rectus abdominis mm used for
dynamic trunk flexion activity

MULTIFIDUS ACTIVATION AND TRAINING

- Prone or side-lying
- Place your palpating digits (thumbs or index
fingers) immediately lateral to the spinous
processes of the lumbar spine
- Palpate each spinal level so comparisons in
the activation of the multifidus (Mf) muscle
can be made between each segment as
well as from side-to-side.
- Instruct the patient to “swell the muscle” out
against your digits. Palpate for consistency
of muscle contraction at each level.
- Facilitation techniques include using the
drawing in maneuver and gently contracting
the pelvic floor muscles (as in Kegel
exercises)
- In the side-lying position, facilitate by gently
applying manual resistance to the thorax or
pelvis to activate the rotation function of the
Mf.
- The patient may be taught to self-palpate a
Mf contraction in the following manner. Sit
and rock the pelvis to find the neutral
position; with the fingers or thumbs placed
along the lumbar spinous processes, lean
forward a couple degrees. The Mf is thus
activated. Differentiate a Mf contraction from
tension in the aponeurosis of the global
erector spinae.

ABDOMINAL BRACING
- abdominal bracing occurs by setting the
abdominals and actively flaring out laterally
around the waist
- Should be:
- no head or trunk flexion
- no elevation of the lower ribs
- no protrusion of the abdomen
- no pressure through the feet
- hold the braced position while breathing in
a relaxed manner
- activate the oblique abdominal muscles
consistent with their global stabilization
function
 Variations and Progressions in the Stabilization
Exercise Program
STEPS
1. Find the neutral spine performing the
drawing-in maneuver, and then maintaining
the neutral spine while superimposing any
extremity motions
2. It is critical to instruct the patient to stop the
exercises (or decrease the intensity) as
soon as loss of control of the stable spinal
position is sensed.
a. Emphasis on mm endurance →
repetitions → add weights → dec reps
→ emphasize on strength
b. Use of external props
i. Use stabilizer pressure
ii. Use of dowel rod placed
GLOBAL MUSCLE STABILIZATION EXERCISE along the spine
iii. Extremity loading

QUADRATUS LUMBORUM STABILIZATION

- Strongest occur in side-plank
- Pt side lying
- prop up on the elbow and then lift the pelvis
off the mat, supporting the lower body with
the lateral side of the knee on the downward
side. The position can be maintained for an
isometric hold or performed intermittently
- Progress by having the patient support the
upper body with the hand (with the elbow
extended) and lateral aspect of the foot on
the downward side
- Arm and leg movements (without then with
weights) are added to increase the
challenge.

ISOMETRIC AND DYNAMIC EXERCISES

Alternating Isometric Contractions and Rhythmic
Stabilization
DYNAMIC STRENGTHENING: ABDOMINAL Pulleys or elastic material are secured at shoulder
MUSCLES level behind the patient. Progress the resistance as
● Curl-ups (various types) recruit primarily the patient’s abdominal strength increases.
the rectus abdominis, with low activity in
the obliques, transversus abdominis, and
psoas.
● Sit-ups (straight-leg and bent-knee) show
high rectus and external oblique activity,
high psoas activity, and high low-back
compression. Heel press sit-ups increase
psoas activity.
● Hanging-leg raises show high external
oblique and high spinal compression.Supine
single-leg lifts show negligible global
abdominal muscle activity (opposite lower
extremity provides stability). Primarily, these
exercises are used early in the stabilization
exercise routines to train the deep
stabilizing muscles under progressive
extremity loading.
● Supine-bilateral leg lifts show increased
activity in the RA, EO, and IO during the first
part of the range of hip flexion and
increased load on the spine.
● Curl-ups on a labile surface doubled the
activity of the rectus abdominis and
increased the activity of the external
obliques fourfold compared with curl-ups on
a stable surface
● Rectus abdominis - contract strongly in all
trunk curl type and leg lift exercises
● External obliques - contract strongest in sit-
ups and diagonal sit-ups to the opposite
side.
● Internal obliques - contract strongest in
diagonal sit-ups to the same side and
horizontal side propping
● Transversus Abdominis - Use of the
drawing-in maneuver prior to the abdominal
crunch, abdominal sit-back, and lateral side
propping activates increased muscle
thickness in the transversus abdominis
(demonstrated with ultrasound imaging)

Trunk Flexion (Abdominals): Supine

Trunk Flexion (Abdominals): Sitting or Standing

Patient position and procedures: Sitting or standing.