Starting in hands and knees with the hips positioned directly over the knees and the shoulders positioned directly over the hands, the patient is instructed to bend their elbows so that the shoulders are the same height as the hips.
The patient is instructed to find a neutral lumbar spine by rocking the pelvis from 12:00 to 6:00 and finding the midrange position.
The therapist monitors the PSISs to insure that they are level in the frontal plane before starting and during the performance of this exercise.
Instruct the patient to draw the belly up and in towards the spine without changing the lumbar neutral position. The therapist monitors the PSISs to insure that they remain stable and provides verbal feedback to the patient if any deviation should occur. The therapist should watch for any loss of the neutral lumbar spine position during the exercise.
The patient is instructed to hold for 10 seconds and repeat 3-5 times.
The patient is lying on their back with both knees bent up and the feet flat on the floor with their arms straight out in front and with palms together.
Instruct the patient to take their arms to the right and turn their head to the right as far as they can comfortably, then repeat to the left side to determine which side is easier to do.
Then if they found it was easier to turn to the right side, have them take their arms to the right while they turn their head to the left as far as they can comfortably and without straining, then have them bring the head and arms back to the midline starting position and repeat 5 times, rotating their head and arms in opposite directions.
Then ask them to recheck their ability to turn to the right while looking to the right and see if it’s even easier than before.
Then repeat these movements going the opposite way with their arms going to the left as they turn the head to the right, repeat 5 times, then they stop and recheck their ability to bring their arms to the left as they look to the left.
They patient is instructed to finish by bringing their arms to the right as they look to the right and arms to the left as they look to the left, back and forth 5 times each way.
Then have the patient recheck their ability to rotate the pelvis towards 3 and 9 o’clock to see if it’s easier to perform.
Unilateral bridging on the left side to re-educate 9 o’clock control:
The patient is lying flat on their back with their left knee bent and the left foot flat on the floor with their arms resting on the floor at the sides.
Instruct the patient to imagine that there is a string attached to their left knee that is pulling the knee forward over their left big toe as they slowly lift their left hip, then pelvis and finally the spine off the floor shifting their weight onto the right buttocks.
The patient should not lift any further than is comfortable while keeping their shoulders flat on the floor.
Then instruct the patient to slowly lower back to the floor initiating the movement from above down, first touching the middle back, then the lower back, then the pelvis and finally the hip to the floor.
Have them repeat this exercise slowly 6-8 times trying to get them to feel that their hip, pelvis and spine can move independently from each other rather than as a block.
Have them repeat the exercise on the right side to re-educate 3 o’clock control. Instruct the patient to always start with the easiest side first
Retraining Exercise to Restore Symmetrical 12 to 6 o’clock
Patient is positioned supine with hips and knees flexed and feet hip width apart.
The patient palpates the ASISs with their fingers or thumbs to assess for symmetry of the ASISs in the frontal plane before they initiate movement. The therapist observes the ASISs and gives the patient verbal cues if needed to level the ASISs before movement is initiated. The most common initial instruction to the patient is to bring the R ASIS up superiorly in order for the ASISs to start from a position of symmetry before movement begins.
The patient is then instructed to inhale as they roll the pelvis down towards 6 o’clock attempting to keep the ASISs level by continuing to monitor with their fingers. If during the initial movement assessment it was found that the R ASIS moved farther inferiorly than the L ASIS the therapist instructs the patient to focus on pushing the L ASIS a little further inferiorly to keep the ASISs level in the frontal plane.
The patient is then instructed to exhale and roll the pelvis up towards 12 o’clock while still maintaining contact at the ASISs. If during the initial movement assessment it was found that the L ASIS moved farther superiorly than the R ASIS, the therapist instructs the patient to focus on drawing the R ASIS up further superiorly in order to keep the ASISs level. The patient repeats the movements toward 6 and 12 o’clock 6 to 8 times trying to maintain symmetry by continuing to monitor at the ASISs and making any adjustments as needed.
The goal is for the patient to be able to roll the pelvis towards 6 and 12 o’clock with symmetry of the ASISs maintained throughout the full range of motion and eventually without the patient having “to think” about maintaining this symmetry.
Have the patient in long sitting with a belt or towel wrapped around the balls of the feet.
Instruct the patient to keep their toes pointing down and their head up as they bring their trunk forward as far as possible.
Instruct the patient to use the belt/towel to pull their toes up as they lower the head. This places maximum stretch on their nervous system. This position is held only momentarily.
Then have them release the stretch by letting the toes point down as they lift their head back up and they attempt to increase their trunk flexion.
They repeat these movements back and forth 8-10 times.
After this stretch, always remember to instruct the patient to lie on their back with the knees up and perform 12:00 to 6:00 pelvic rocking 10 times to release any tension across their lower back.
The patient is sitting with a belt or towel wrapped around the balls of the feet and is instructed to pull their trunk forward as far as they can while keeping their head up.
Then instruct the patient to drop their head down as they point their toes down and hold momentarily.
Then have the patient reverse these movements by raising their head up as they pull their toes up and hold momentarily.
Have the patient repeat these back and forth flossing movements of the nervous system 8-10 times.
When finished, always remember to instruct the patient to lie on their back with their knees up and feet flat on the table and rock the pelvis toward 12:00 and 6:00, 10-12 times to release any tension across the low back.
Counter Stretch for the Hamstrings (Neural Tension Self Mobilization)
The patient is standing with the feet approximately hip width apart and places both hands on top of a counter or table top with the hands shoulder width apart.
Have the patient bend their knees but have them keep their heels flat on the floor. The patient is instructed to lift their sit bones up and back, toward the ceiling to achieve a neutral spine.
Instruct the patient to push their hands against the table top to assist in extending and elongating the thoracic spine.
Instruct the patient to straighten their elbows and attempt to elongate the spine, dropping the chest towards the floor.
Finally, have the patient straighten the knees maintaining a neutral lumbar spine, while lifting the sit bones towards the ceiling.
They straighten and bend their knees on/off approximately 10-12 times. They should not feel pain in the low back with this stretch.
Do not allow the patient to hyperextend the knees or drop their head during the stretch.
Wall Stretch for the Hamstrings (Neural Tension Self Mobilization)
The patient is standing with the feet approximately hip width apart and places both hands against the wall with the hands shoulder width apart.
Have the patient bend their knees but have them keep their heels flat on the floor. The patient is then instructed to lift their sit bones up and back, toward the ceiling to achieve a neutral spine while lengthening the back of the leg.
Instruct the patient to push their hands against the wall to assist in elongating the thoracic spine.
Instruct the patient to straighten their elbows and attempt to elongate the spine, dropping the chest towards the floor.
Finally, have the patient straighten their knees while maintaining a neutral lumbar spine as they try to lift the sit bones towards the ceiling.
They straighten and bend their knees on/off approximately 10-12 times. They should not feel pain in the low back with this stretch.
Do not allow the patient to hyperextend the knees or drop their head during the stretch.
You may have to instruct the patient to begin this exercise with their hands much higher up the wall if they are not able to achieve and maintain a neutral lumbar spine while extending the knees.
As their flexibility improves the patient can slowly lower the placement of their hands on the wall.
The goal is for the patient’s hands to be placed on the wall at the same height as the hips, maintaining a neutral lumbar spine while fully straightening both knees.
Supine Left Hamstring Stretch with a Belt with Hip Adduction and Internal Rotation
The patient is lying supine and places a belt around the ball of the left foot.
Starting with the L knee flexed and with the left hip flexed to 90 degrees, instruct the patient to try to straighten the L knee as much as possible while maintaining dorsiflexion at the left ankle using the belt.
Then instruct the patient to keep the L knee as straight as possible as they bring the leg across the body into adduction and internal rotation to put an additional stretch on the sciatic nerve and lateral hamstrings.
The stretch is held for only 5 seconds and then released by bringing the left leg back to the midline while still maintaining a straight knee and dorsiflexion of the L ankle.
Instruct the patient to repeat this on/off stretch 10 times.
The patient is lying supine and places a belt around the ball of the left foot.
Starting with the L knee flexed and with the left hip flexed to 90 degrees, instruct the patient to try to straighten the L knee as much as possible while maintaining dorsiflexion at the left ankle using the belt.
The stretch is only held for 5 seconds and then released by bending the left knee.
Instruct the patient to repeat this on/off stretch 10 times while keeping the left knee pointing straight up towards the ceiling.