Lower Back Pain

Amsterdam Clinics

 Lower Back Pain

Dia 2
KNGF Guideline Lower Back Pain
Non-specific
Specific
Normal course
Abnormal course
Screening
Present red flags
History-taking
Clinimetric
Lumbosacral Radicular Syndrome
(LRS)
Examination summary
Examination
Suspected radicular radiation

Non specific low back pain

Factors that may slow down
recovery of LBP
Treatment plan
Diagnosis
KNGF patient profiles
Profile 1.
Profile 2.
Profile 3.
Example
Example
Example
Conclude treatment
So how are we going to
implement this in our daily
work?

Treatment plan

KNGF Guideline Lower Back Pain

Specific
A-specific

Non-specific
Non-specific low back pain is defined as low back pain
for which no specific cause can be identified. This is the
case in about 90% of all patients with low back pain.
The most obvious symptom in these patients is pain in
the lumbosacral region. The pain may also radiate to the
gluteal region and the upper leg. It may be increased
when the patient adopts a particular position, makes
certain movements or lifts or moves heavy objects. The
patient has no general symptomsof disease, such as
fever or weight loss. The pain may be continuous or
occur in episodes.

Specific
- 1. the lumbosacral radicular syndrome, a form of
specific low back pain characterized by radicular pain in
one leg, which may or may not be associated with
neurological deficits;
- 2. back pain resulting from a possibly serious underlying
specific disorder, such as (osteoporotic) vertebral
fractures, malignities, ankylosing spondylitis, severe
forms of vertebral canal stenosis, or severe forms of
spondylolisthesis.

Normal course
A normal course means that the patients activity
level and degree of participation gradually increase
over time to the level present before the episode
of low back pain. In many cases, the pain will also
diminish. This does not mean that the low back pain
always disappears completely, but that it no longer
limits the patients activities and participation in
society.

Abnormal course
The course of back pain is considered abnormal if the
patients activity limitations and participation
restrictions do not decrease over time but remain
unchanged or even increase.
An abnormal course with delayed recovery is defined as
no clear increase in activity level and reduction in
participation restrictions after 3 weeks.

Screening
Malignity
Osteoporotic vertebral
1st episode >50
fracture
Continuous pain, non Recent fracture(<2y)
mechanic
Previous vertebral #
Noctural pain
>60 y
General malaise
History of malignancy Low body weight (<60 kg /
BMI <20)
Weight loss
Old with hip #
Elevated erythrocyte
sedimentation rate (ESR) Use of corticosteroids

Local percussion pain

Tenderness and axial
pressure pain in the spinal
colmn
Marked height reduction
Increased thoracic
kyphosis

Ankylosing spondylitis
Severe
1st episode <20
spondylolisthesis
Male
1st episode <20
iridocyclitis
Palpable
(history of) unexplained
misalignment of
peripheral arthritis or
the processus
inflammatory bowel
spinosi L4-5
disease
Pain mostly nocturnal
Morning stiffness > 1 h
Less pain when lying
down or exercising
Good response to
NSAIDs
Elevated ESR

Present red flags

Direct access physical therapy
Discus with Bahaa, Maartje,
Explain Red flags are patterns of signs or symptoms (warning signals) that may indicate more or less
serious pathology, requiring further medical diagnostics.
Advice guest to do additional diagnostics and make a follow up appointment*
Referral for physical therapy
Try to come in contact with the doctor in a smart way*
Inform guest that we want to make sure that physical therapy is indicated and dont want to miss
anything important.
Make appointment for a follow up and/or ask the guest if we can contact his/her doctor.
The diagnostics and treatment of patients with potentially serious specific disorders and the treatment
of the lumbosacral radicular syndrome are beyond the scope of the present KNGF guideline.
*We need to discus how we are going to do this

History-taking
With our examination (LOFTIH) sheet we collect the right information
according to the KNGF guideline.
Specific for lower back pain we can focus more on:
-cooping strategies
-presence possible psychological factors
-social history regarding occupational, home and family situation
-extra attention to changes in work load, experienced pressure, duration
of episode and pain free periods.
(The use of specific psychological questionnaires is not recommended
(KNGF) but may be considered)

Clinimetric
NRS (VAS)
PSC (PSK)
QBPDS (Quebec Pain Disability Scale)
At the beginning, evaluation (every 3-4 weeks) and end of treatment.
+Pay attention to the compliance with therapy (reasons for noncompliance)
Additional: describe health believes, cooping strategies, IPQ-K,

Lumbosacral Radicular Syndrome

(LRS)
LRS is a specific but non-severe low back pain problem.
radicular pain radiating to the leg (unilateral)
leg pain that is more prominent than low back pain.
Shooting pain, found in specific dermatome
Radicular pain (beyond the knee)
Numbness and paresthesia in the same dermatome
(radiculopathy)

Examination summary
Examination based on the impairment of;
-Body structure and function
-Limitations of activities (sitting, bending, standing up etc.)
-Restrictions of participation (reported during anamnesis)

Examining the joints (thoracic, lumbar, lumbosacral

vertebral column, pelvis, hips)
Muscle examination
(Paraspinal) skin examination
Performance of restricted activities

Examination
Based on the impairment of;
-Body structure and function
-Limitations of activities (sitting, bending, standing up etc.)
-Restrictions of participation (reported during anamnesis)
Examining the joints (thoracic, lumbar, lumbosacral vertebral column, pelvis, hips)
-ROM, direction of motion, resistance to movement and end feel.
-Evaluation of consistency and provocation of the pain and radiation.
Muscle examination:
-assessing muscle length, elasticity, end feel, tenderness on contraction and stretching, muscle
tone, coordination and strength.
(Paraspinal) skin examination:
- assessment of level of grasp, shift, pliability and end feel of the skin
Performance of restricted activities:
- (According to PSC)

Suspected radicular radiation

-Fingertip-to-floor distance (+ve > 25 cm)
-SLR -> Lasgues sign +ve/-ve
-Muscle strength

Non specific low back pain

If:
No red flags
No LRS
Profile 1: Normal recovery -> treatment
Profile 2: abnormal recovery, without dominant presence of psychosocial factors
Profile 3: abnormal recovery, with dominant presence of psychosocial factors
Delayed recovery
-factors that might explain the persistent nature of the episode.
(factors on next sheet)

Factors that may slow down recovery of

LBP
back pain-related
factors
-severe limitations of
activities
-radiating pain
-widespread pain

personal factors
-older age
-poor general health
status

occupational
factors

psychosocial
factors

-unsatisfactory
relationships with
colleagues

-psychological and
psychosocial stress

-physically heavy
tasks

-pain-related fears /
avoidance
behaviour
-somatization
-depressive
complaints

Treatment plan
In consultation with guest and other relevant parties.
The (SMART) treatment plan encompasses:
the final objectives plus the time schedule
the interventions to be applied
the schedule for evaluations and the form of
evaluation
the expected number of treatment sessions
(exceeding the expected number of sessions should
prompt an evaluation and a possible change of profile)

Diagnosis
A good treatment plan starts with a clear diagnosis:

Non-specific / specific
Acute/ sub-acute/ chronic/ recurrent
Trauma/ surmenage
Normal / abnormal course
Sustaining (perpetuating) factors / recovery limiting factors
(which)
Prognosis: reduction of complaints / full recovery / stabilization
For example:
/ favorable
orsub-acute
unfavorable
67 year
old man with
sucundair subacromial impingement with possible
bursitis due overload(surmenage). Abnormal course 6 weeks. Sustaining factors:
limited internal rotation and age. Prognosis is full recovery.

KNGF patient profiles

Profile 1 Normal course
Profile 2 Abnormal course
Profile 3 Abnormal course with psychological factors
-max 3 sessions
-provide education and advice and allow the patient to find that exercise has a
favorable effect.
Main points:
LBP is not harmfull
Increase of pain not associated with damage of body structures
Moderate and gradually increasing exercise promotes recovery

Profile 1.

Profile 1 Normal course

Profile 2 Abnormal course
Profile 3 Abnormal course with psychological factors
-till guest is satisfied or goal is accomplished
-provide with education and advise as profile 1.
-prescribe a program of exercise therapy*
-limit the use of manual techniques / massage (/ physical modalities)
-self-efficacy
Main points:
*exercise therapy program that fits in with the patients needs and the therapists
expertise and experience
The patient should be advised to exercise at home, increase their level of activity
and return to work, if necessary with temporarily adjusted workload.

Profile 2.

Profile 1 Normal course

Profile 2 Abnormal course
Profile 3 Abnormal course with psychosocial
-treatment
factorslike profiles 1 and 2 but more emphasis on:
a. information and advice
b. possibly a greater need for multidisciplinary consultation or collaboration
c. greater focus on behavioral principles in the exercise program

-inform the patient of the findings and explain the unfavorable influence of these
psychosocial factors
on the recovery process. The therapist should also reassure the patient.
Encourage the patient to engage in exercise, gradually increase their activity levels, and
continue or resume work.
Prescribe a graded activities program

Profile 3.

Example
Diagnose:
-40 year old man with non-specific low back pain since 2
weeks with motor control deficit. Favorable prognosis with full
recovery after 3 weeks.
(Profile 1, KNGF)
Treatment plan
Treatment goal (SMART):
Frequency:
Extra information:
- I&A:
- E&S:
- MT:

Example
Diagnose:
-
(Profile 2, KNGF)
Treatment plan
Treatment goal (SMART):
Frequency:
Extra information:
- I&A:
- E&S:
- MT:

Example
Diagnose:
-35 year old woman with recurrent non-specific low back pain with
abnormal course for 2 years. Perpetuating factors: widespread
pain, pain-related fears/avoidance behavior. Prognosis is reduction
of pain and self management.
(Profile 3, KNGF)
Treatment plan
Treatment goal (SMART):
Frequency:
Extra information:
- I&A:
- E&S:
- MT:

Conclude treatment
The treatment is concluded as soon as its agreed objectives have been achieved. (SMART GOAL(S))
Even if the objectives have not been achieved, however, the treatment will have to be concluded at
some stage.
It is not useful to continue the treatment if no progress has been made after 3-6 weeks, the chances
of achieving progress after this period are small. This must be discussed explicitly with the patient
before the final treatment session.
The patient should try to remain physically active
Physical activity promotes physical fitness and does not increase the risk of recurrence of the back
pain.
There is a risk of recurrent back pain but the patient should maintain an active lifestyle and
continuing to work.
Make agreements about when the guest should come back to us (changing/limiting complaints)
Report referring doctor about conclusion treatment.

So how are we going to implement

this in our daily work?
Diagnosis
Treatment plan
Treatments
Evaluation

Treatment plan
We aim for a approach in which the patient is (partly) responsible for the
results to be achieved. This can be done by actively involving the patient
in the design of the treatment plan and the implementation of treatment.
Herby we make sure we create the right expectations (expectation
management) and stimulate compliance.

SMART: Mister L.B.P. will be able to run 5K 3 times per week without back
pain in the first week in February.
Treatment profile 1
Treatment profile 2
Treatment profile 3

 Diagnose:
-40 year old man with non-specific low back pain since 2 weeks with
motor control deficit. Favorable prognosis with full recovery after 3
weeks.
(Profile 1, KNGF)
Treatment plan
Treatment goal (SMART): Mister L.B.P. will be able to run 5K 3 times per
week without (NRS 0) back pain in the first week of January.
Frequency: 2 x per week for 6 weeks, after that evaluate how many times
needed.
Extra information:
- I&A: provide education and advice that exercise has a favorable effect.
- E&S:
- MT:muscle release when considered necessary

After this sheet the information

is unrelated to the KNGF
guideline

Recommendations for Diagnosis of Low Back Pain

Diagnostic triage
History taking and physical examination to excludered
flags.
Physical examination for neurologic screening
Consider psychosocial factors
Radiographs not useful for nonspecific LBP.

The Quebec task force classification

system (Waddell Triage)
Non-specific

Radiculair
syndrome

-Acuut/chronisch
movement/contr
ol impairment

Specific
pathology
-bechtrew
-malignancy
-fractures
-infection
-cauda equine
-spinal stenosis

Observation
Localization of pain (pain mapping)
Posture; Flexion pattern etc , pelvis vorlauf
Finger-bottem distance
Physical examination
back: flexion-extension-rotation-lateroflexion
pelvis:
hips: flexion-extension-rotation

Specific tests
Neurologic examination (strength, sensation, reflexes, SLR)

Diagnostic imaging
sciatica/radicular syndrome
neurologic problems that require surgical assessment or
investigation:

Radiating pain explained

Radiating pain in:
-thight L2-L4
- sciatica, from pinching the sciatic nerve between L4 and the sacrum.

Shooting pains elsewhere in the leg, genital dysfunction, incontinence

and other urinary or bowel complications.
May result from radiculopathy of any of several other lumbar, sacral, or
lower thoracic nerves.
In very severe cases, partial paralysis or constant, intolerable pain may
occur.

SCEGS
Somatic
Cognition
Emotion
General Health
Social

Recommendations
Acute or Subacute Pain
Reassure patients
(favorable prognosis).
Advise to stay active.
Prescribe medication if
necessary
Discourage bed rest.
Consider spinal
manipulation for pain
relief.
Do not advise backspecific exercises. ?!

Chronic Pain
Refer for exercise
therapy

Acute phase
Back specific exercises not usefull in the first weeks (NL,
UK)
Low-stress aerobic exercises in acute LBP (USA)
McKenzie in acute (and chronic) (Den)
Spinal mobilization (NL, D, UK, Den)
beyond the acute stage all recommend exercise therapy

Treatment goals
-Improve posture and motor control on reflex / automatic basis
-Improve mobility / flexibility
-Joint mobilisations
muscle recorded relaxation / stretch
coordination, strength, UHV
-mucle facilitation
-functional exercise therapy (spinal stabilization)
-proprioseptie retraining
-cardiovasculaire training
relearning posture

Treatment Ten
1. Status praesens
-Actuality - the pain now? (VAS)
-Reactivity - which was in response to examination/treatment last time?
2. Repeat diagnosis and help question
-Let the guest bring up as much as possible.
3. Explain therapy goals
-Tell why
4. Movement preparation
-Active movements in all directions
5. Measure baseline
6. Mobilization exercises (passive when active is not effective)
-Good instruction and explanation (possible homework exercise)
-After mobilizations always stabilization exercises.
7. Stabilization exercises
-Good instruction and explanation (possible homework exercise)
8. Posture instruction / functional training => mostly sitting position (ergonomics)
9. Repeat baseline
10. Home Exercises repeat + conclude
Ask when the guest is going to do the home exercises.
Ask if the guest expects any difficulties this week/with exercises.
Motivation to do exercises
In all treatment should the help question be the starting point!

 Many ways of treating back pain exist, and the program

of treatment must be adapted to the particular
situation of each patient. Good posture is always
essential. Learning to sit up straight, perhaps with a
lumbar support roll, or a change of habits, such as
learning to lift with the legs rather than the back, may
be advised. Sometimes drug therapy with painkillers
or muscle relaxants, or physical therapy with
manipulation and exercises, is the only additional
treatment required.
As a last resort and in extreme cases, including
emergency cases of incontinence or paralysis, surgery

Ergonomics
People with desk-bound occupations and sedentary
habits are at great risk for developing low back pain,
especially if they slouch in their chairs or fail to protect
the natural lordosis of the lumbar spine.

Medication
1. Paracetamol/acetaminophen (lower incidence of gastrointestinal
side effects)
2. Nonsteroidal anti-inflammatory (in cases where paracetamol is
not sufficient)
(3.)muscle relaxants, opioids, local anesthetic, compound
medication
time-contingent prescription of the pain medication

Perspective and prospects

Since the late twentieth century they have understood it
as a natural degenerative condition that can usually be
delayed by good posture habits and managed by
physical therapy, strength-building exercises, painkilling
drugs, and lifestyle changes.

Definitions
Chronic low back pain (CLBP)
-back pain excisting for > 6 weeks
Acute low back pain
Non-specific low back pain
Specific low back pain

Classification of (Chronic) Low Back

Pain
Classification of LBP in homogeneous groups, and
implementation of specific interventions aimed at these
groups increases the chance for us to find effective
treatments.
LBP is a multi-dimensional problem: until now many
emphasis on psychosocial factors and less on pathoanatomical, neurophysiological and physical factors.

Models for diagnose and classification of non specific

low back pain.

Patho-anatomical model
Peripheral pain generator model
Neuro-physiological model
Psychosocial model
Mechanical load model
Clinical signs and symptoms Model
Muscle Control Model
Biopsychosocial Model

Patho-anatomical model
In finding intervertebral disc and facet degeneration,
annular tears, prolapse, protrusion, spondylolisthesis,
foraminele and spinal stenosis, etc. is often assumed that
these have a relationship with back pain.
Many "abnormal" findings are also present in a pain-free
population
There is a weak correlation between patho-anatomical
findinings and the level of pain and limitations.

Peripheral pain generator model

Focuses on the identification of the structure by means of painful
anamnesis, pain location, clinical findings and diagnostic blocks.
Has led to studies, which report that the majority of LBP has its
origin in the intervertebral disc (45%), facet joint (20%) and the
sacroiliac joint (15%).
Main limitation of this model is that the intervention itself
focuses on the symptom of pain (anesthetic blocks and
denervation of painful structure) and not the underlying treated
mechanism.

Neuro-physiological model
Research of the influence of the nervous system at pain
disorders, has led to registration of complex biochemical and
neuro-modulation changes at peripheral, spinal and cortical
level.
-Central sensitization in most Chronic LBP patients may develop
after secondary persistent peripheral nociceptive input.
- Focusses on the influence of frontal lobe in pain inhibition and
facilitation.
-Therapeutic focus on psychological and cognitive interventions.

Psychosocial model
Maladaptivecopingstrategiessuch as negativethinking about
pain,kinesiophobia,catastrophizingareassociated with high
painlevels, limitations andmuscle tension.
Financialcompensation, problems atwork,
family problemsand cultural influencescanhave influence on
sensitization ofpain.
These factors are onlydominant andnamedprimary in a small
sub-group.

Mechanical load model

Both high and low level of physical activity can be seen from as a risk factor
for LBP, while a moderate level of physical activity is considered to be
protective.
Risk factors:
-Sustained postures and movements, vibration and heavy loads, sudden and
repeated spinal rotations
Individual factors:
-decreased body strength, muscle control, and mobility are correlated with LBP.
Little evidence for ergonomic interventions.

Clinical signs and symptoms Model

Anamnestic data as the location and character of pain,
limitations in mobility and function, pain response on
mechanical loads and repetitive movements are the
fundament in LBP classification.
Evidence is limited for LBP classification (only 50% of
CLBP population is to classify according to the McKenzie
model)
Limitation of this model is that it ignores the complex
bio psychosocial factor.

Clinical signs and symptoms Model

McKenzie method
Maitland concept
Mulligan concept
Combined movement concept
Neurodynamic concept

Muscle Control Model

An increasing focus on the treatment of (C)LBP from a muscle
control perspective.
Although there is a high correlation between LBP and muscle
control disorders, it is not clear whether the disorder is
cause or consequence.
Mobility and muscle control disorders are common in the
presence of pain.
Motor control impairment / Movement impairment

Muscle Control Model

- Pathological processes as neurogenic, radicular pain,
neuropathic pain and rheumatic disorders result in an altered, or
protective movement pattern in response to pain. (adaptive vs
maladaptive)
- Psychological processes such as stress, anxiety, depression,
hysteria and somatization can disrupt "normal" physical activity.
- Attempts to "normalize" movement patterns in the above
group is ineffective by the non-mechanical cause of these
disorders.

Muscle Control Model

There is increasingly evidence of the utility of subgroups in
which maladaptive movements and decreased muscle control
result in a continuous abnormal load and mechanically
provoked pain in Chronic Low Back Pain.

BioPsychoSocial model
Literature and clinical practice indicate that a multidimensional approach to deal with LBP is necessary.
Relative contribution of the dimensions and their dominance
associated with LBP will be different for each patient.
The challenge for us is to consider all dimensions based on
anamnesis, examination and additional diagnostics and
questionnaires.

References
Borenstein, David G., Sam W. Wiesel, and Scott D. Boden. Low Back and Neck Pain: Comprehensive Diagnosis and
Management. 3rd ed. Philadelphia: Saunders, 2004. Print.
Brennan, Richard. Back in Balance: Use the Alexander Technique to Combat Neck, Shoulder, and Back Pain. London:
Watkins, 2013. Print.
Burn, Loic. Back and Neck Pain: The Facts. New York: Oxford UP, 2006. Print.
Cailliet, Rene. Low Back Pain Syndrome: A Medical Enigma. Philadelphia: Lippincott, 2003. Print.
Chevan, Julia, and Phyllis A. Clapis. Physical Therapy Management of Low Back Pain: A Case-Based Approach. Burlington:
Jones Bartlett Learning, 2013. Print.
Fishman, Loren, and Carol Ardman. Back Talk: How to Diagnose and Cure Low Back Pain and Sciatica. New York: Norton,
1997. Print.
Hasenbring, Monika I., Adina C. Rusu, and Dennis C. Turk, eds. From Acute to Chronic Back Pain: Risk Factors, Mechanisms,
and Clinical Implications. Oxford: Oxford UP, 2012. Print.
Hodges, Paul W., Jacek Cholewicki, and Jaap H. Van Dieen. Spinal Control: The Rehabilitation of Back PainState of the Art
and Science. New York: Churchill Livingstone/Elsevier, 2013. Print.
Hutson, Michael A. Back Pain: Recognition and Management. Boston: Butterworth-Heinemann, 1993. Print.
McGill, Stuart. Low Back Disorders: Evidence-Based Prevention and Rehabilitation. Champaign, Ill.: Human Kinetics, 2002.
Print.
Twomey, Lance T., and James R. Taylor, eds. Physical Therapy of the Low Back. New York: Churchill Livingstone, 2000. Print.
Waddell, Gordon The Back Pain Revolution. 2nd ed. New York: Churchill Livingstone/Elsevier, 2004. Print.
Derived from: "Back pain." Magill's Medical Guide, Sixth Edition. Salem Press. 2010.

McKenzie
derangement, dysfunction, and postural syndrome

Luomajoki

OSullivan

Maitland
Passive physiological intervertebral
movements(PPIVM) refers to a spinalphysical therapy
assessment and treatment technique developed by
Geoff Maitland used to assess intervertebral movement
at a single joint, and to mobilise neck stiffness
Also for back?

Manual therapy
Spinal mobilisation
effective in acute and chronic (NL guideline)
Pretzel technique

Indications for stability training

SLR together with hypermobility (Breighton)
PA / Rosettest
<40years
Aberant motions
Functional test : pelvic tilt, bridge

Concrete treatment examples

Amsterdam Clinics

1. Passive mobilisation exercises

Rotatie: multifidi MRT stretch
erector in zit
2. Stabalizing exercises to prevent destabilisation. (stabalize after mobaelize)
Train till exhaustion (Trainen tot vermoeidheid)
muscle soreness without back pain
Work on strenght, endurance, coordination, balance
Basics: Pelvic tilts, bridge, trunk curls, lunges
Patient education
Identificate functional range identificeren, which movements are painfree
Isometric stabilisation excersises met co-contractie van glute en abdomen
Posterior Pelvic tilt vasthouden en dan armen en benen bewegen (dead bug)
Bewustworden, coordinatie, kracht, uhv worden hier getraind
Trunk curl (crunch) (hip flexors)
Zelfvertrouwen, spierontspanning, circulation, mobiliteit bij meer acute klachten
Stabilisatie met McKenzie 3x per week (8weken)
Binnen functional range trainen, trainen zonder pijn, aanleren dat trainen geen kwaad doet
voorwaarden creeren; adaptieve verkorting
bruggetje maken, misschien eerst spierontspannen, rekken, joint mobilisaties
Patient moet vertrouwen krijgen in therapie en dus beginnen met lichte bekkenkantelingen, rekkingen en aerobe training
Functional range passive prepositioning active prepositioning dynamic stabilization facilitation labile surfaces functional tasks
Ipv 3x15 zegt Morgan herhalingen tot bepaalde vermoeidheid
Wanneer pt kwaliteit niet meer kan vasthouden, dan evt terugschakelen naar een makkelijkere oefening (scalen, mulligan)
Spier facilitatie of stretching
reprogramming
Van liggend, naar kruiphouding naar gewichtdragend (staan)
Liggende oefeningen begeleid met trackties zijn het lichtst
Liggen met knien gebogen en kussentje eronder houdt pelvic tilt vast
Oefening tot breakdown en dan peel back

Pelvic Tilt
Progressie:
liggen gebogen knien
liggen gestrekt
zittend
staand
handen-knieen
geknield, voeten onder billen
rechtop op de knieen zitten
zitten met voetzolen tegen elkaar
buiklig

Dead bug track

hook lying, armen strekken
hook lying, benen strekken
armen en benen
hoger etc

 Bridge track
brug maken
brug maken been heffen
been strekken
been strekken en dips

 Pronetrack
buiklig, met kussen onder de buik
arm heffen
arm en been heffen
onder kussen

 Quadruped track
juiste houding en 1 arm strekken
n been heffen
arm en been
op arm/been duwen
n arm omhoog heffen naar romprotatie

Kneelingtrack

Abdominals
Crunch
Trunk Curl
Sit Back
Hip Thrust
Obliques

Lunge (quadriceps)
Lunge
With weight
With pulley / exercise tubing
Backward lunge
Sideways Lunge

Squat
Squat
With forward bend (deadlift?)

Styrofoam, medicineball, stick,

exercise tubing stabilization
exercises.
1. On Styrofoam
-posterior pelvic tilt
-one knee to chest
-one knee to chest, arms overhead
-on circle wedge hands on chest 1 knee to chest
2. Isometric Abdoinals (with therapist)
-Crunch position with foam between knees, therapist pushes/pulls.
-Medicine ball between feet and therapist throws ball
-Ball between feet and gym ball on abdomen therapist pulls ball
-Medicine ball held between feet/sticks

Gymnastic ball exercises

1. Isometric stabilization
a. Seated:
-anterior and posterior pelvic tilt
-single leg raise
-single leg raise and roll back
b.Bridge (quads, glutes)
-seated and roll down ball to bridge
-return to sitting position
-1/2 sit up and march
-Bridge up/down

Training m. transversus abdominus, m. multifidus, m.

iliopsoas, (m. quadratus lumborum).