[Year]

LOW BACK
PAIN
THERAPY
GUIDE

\
 APPENDIX
SR NO TOPICS PAGE NO

1 Sprain and Strain 3-6

2 Spondylolysthesis 7-13

3 Prolapsed Inter vertebral Disc 14 -19

4 Ankylosing Spondylitis 20 - 25

5 Sacroiliac dysfunction 26-31

6 Post surgical management 32-38

NOTE:

 Below mentioned is the guide to assess and treat various low back conditions the
PORTEA way.
 Assessment – It would provide you with the Key pointers of Assessment for the above
mentioned conditions and highlights a very important aspect of differential diagnosis
which is very commonly missed.
 Treatment – This document informs you about the various treatment techniques with
example of a few exercises you can use to treat the above mentioned condition. If you
know of other exercises (Which may not be mentioned on this document) which target
the same goal – You are free to use the same. Each physio can autonomously decide the
dosage of the exercises provided – but that should not affect the days of recovery of the
patient standardized by this Guideline unless medically required.
 Outcome measure and Service comprehensiveness - are the focus points of the
company this year. This document will also help you excel in the same.

2
 SPRAIN AND STRAIN
Sprain And strains
Sprains are caused by overstretching or tearing ligaments, and strains are tears in tendon or muscle. Both can occur
from twisting or lifting something improperly, lifting something too heavy, or overstretching. Such movements may
also trigger spasms in back muscles, which can also be painful.
Acute Chronic
3 months and more pain history, VAS is low,
0-1 months pain history , VAS is
pain is present mostly all day and
Ideal Symptoms high, Pain worsen with movement
movement/ activity is done using trick
and reduces with rest
movements.
Pain that worsens with movement, Muscle
Patients awaken with morning cramping or spasms, Decreased function
pain or develop pain after minor and/or range of motion of the joint
Clinical sign
forward bending, twisting, or (difficulty walking, bending forward or
lifting. sideways, or standing straight), Might have
pain radiating to buttocks and thigh.
Differential Diagnosis
Lumbar Muscle Strains/ Sprains Active ROM and MMT MRI, Passive and active ROM and MMT
To Rule SI Joint Dysfunction Gaenslen's Test, Gillet's Test, SI compression test, SI distraction test
Hamstring Tightness (With
SLR with Dorsiflexion, 90-90 straight leg raising test
Radiculopathy)
Hamstring Tightness (Without
SLR Without dorsiflexion
Radiculopathy)
Piriformis Tightness (With
Piriformis tightness test, SLR
Radiculopathy)
Piriformis Tightness (Without
Piriformis tightness test
Radiculopathy)
Herniated disc (With
X-ray, Valsalva Test, Slump, bow string test
Radiculopathy)
Herniated disc (Without X-ray, Valsalva Test,patient's symptoms are lessened in position of extension
Radiculopathy) (bending back) and provoked in flexion (bending forwards)
Facet joint syndrome (Without
Kemp's test and springing test
radiculopathy)
Facet joint syndrome (With Kemp's test , springing test and Lumbar quadrant test, Transverse process PA
radiculopathy) glide - relieve symptoms
Osteoporosis and Muscle
Blood test (Vitamin D and B12), BMI (Obesity), Bone density test
Weakness
Outcome measure Modified Oswestry disability Index
Diagnosis can be concluded only after any of the above mentioned tests comes positive.
3
Treatment
The duration of recovery in each phase may change from patient to patient, might take more or less time then
mentioned below. So treatment might take longer or shorter duration then mentioned.

Minimum number of required

sessions to be mentioned on
the case file. This can increase
7 days 15 days
to the below mentioned
number based on severity of
symptoms

Duration of treatment
6 Weeks 8 Weeks
(approximate minimum time)

1st (5 consecutive sessions in a

1st and 2nd Week (5 consecutive sessions in
week) and 2nd week (3 sessions
a week) 3rd and 4th week (3 alternate
Phase 1 alternate days in a week) (Use
Sessions in a week) (Use Combination of all
Combination of all Therapy
Therapy mentioned below)
mentioned below)
Ice/heat and Electrotherapy Ice/Heat Therapy and Electro therapy
Back pain Relief and Protection
(TENS/ IFT/Ultrasound) (TENS/IFT)

1st WEEK-Isometrics of involved 1st and 2nd week- Isometric contraction of

muscles(within pain limit) then Gluteus muscle transverse abdominals,
progress to maintaining static multifidus, pelvic tilts, single leg raise, single
Transversus abdominis contraction knee to chest, bridging, quadripod single leg
with SLR, Knee to chest, Bridging, raise. (Change to 3rd and 4th Week when
cat and camel and manipulation VAS is less by 1 count on scale and stiffness
Grade 1 or 2 based on intensity of is reduced/ activity based discomfort is
Strengthening pain. Figure of 4 stretch for glutei reduced)
(Change to Week 2 when VAS is 3rd and 4th Week- isometric contraction of
less by 1 count on scale) gluetei muscle, Isometric contraction,
2nd Week- 1st Week exercise+ activation of Transverse abdominals,
Hamstring Stretch, Quadriceps multifidus, 1/2 squat, lower trunk rotation
stretch, Side stretch and and prayer stretch. Figure of 4 stretch for
progression of strengthening and glutea, SLR of dorsiflexion, knee to chest (
core stability exercises. for sciatica)

Advance Treatment (Use one or Taping, Mckenzie, Mulligan, Pilates and Aqua therapy manual nerve
more therapy only if certified/ manual nerve mobilization (Use it mobilization (Use it from the beginning of
expertise) from the beginning of the phase) the phase)

4
 Take maximum rest and
Do's (Instruct the patient on Discontinue the activity that lead
Use posture while working/doing daily
the same on 1st Visit with to muscle sprain/strain until week
activity. Perform exercise in pain limit.
patient) 1 is cleared. Use back support/
Brace to avoid further injury

Don't (Instruct the patient on DO NOT start sports activity/

Avoid twisting and bending activity until
the same on 1st Visit with difficult exercise at this level. DO
phase 1 is cleared.
patient) NOT lift heavy objects

When Pain while activity has When pain during activity has reduced by 1
reduced 2 or more score on VAS or more score on VAS (e.g Initially patient is
Scale (e.g Initially patient had VAS on VAS 5, so when it reaches 4 Phase should
9, so when it reaches 7 Phase be changed), When frequency of muscle
When to change of Phase?
should be changed), Activity cramps/spasm has reduced by 10%. When
stiffness has reduced by 10%. Any stiffness is reduced by 20% in normal daily
one of above is achieved Phase activity. Any one of above is achieved phase
can be changed can be changed

3rd and 4th Week ( 3 sessions

5th and 6th Week (3 sessions alternate days
alternate days in a week) (Use
Phase 2 in a week) (Use Combination of all Therapy
Combination of all Therapy
mentioned below)
mentioned below)

Side lying Lumbar Thrust

Use hot pack/ cold pack for muscle
Manipulation grade 3 or 4 to
relaxation, pelvic tilts, back extension, knee
reduce stiffness, Knee to chest,
Restoring Normal ROM to chest, bridging, Lower trunk rotation,
low back rotation, extension in
prayer stretch, piriformis stretch and Back
prone, bridging, cat and camel,
extension.
piriformis stretch
Transverse abdominus retraining,
opposite arm leg raises, plank, Plank exercise, crunches, sit ups, trunk curls,
Strengthening superman, Side hold, resistance push up, prone leg raise, quadripod opposite
band rotation, hold relax leg and arm raise,
technique
Advance Treatment (Use one or
Mckenzie, Maitland, Mulligan, Taping, Mckenzie, Mulligan, Aqua therapy,
more therapy only if certified/
Pilates maitland
expertise)

5
 Start with basic daily activity, Use
Practice isometric contraction of abdominal
Do's (Instruction to be given back Support aid, Start stretching
muscles in daily activity, take breaks in-
when Patient enters Phase 2) exercise, Take Micro Breaks in-
between exercise
between work.
Do NOT hold breath while doing isometric or
Don't (Instruction to be given DO NOT Sit/stand for long
any strengthening exercises. DO NOT go
when Patient enters Phase 2) duration( 30 min)
above exhaustion limit.
When pain during activity has reduced by 2
When Pain while activity has
or more score on VAS, When frequency of
reduced 1 or more score on Vas
muscle cramps/spasm has reduced by 20%.
When to change of Phase? Scale, Activity stiffness has
When stiffness is reduced by 50% in normal
reduced by 30%. Any one of above
daily activity. Any one of above is achieved
is achieved Phase can be changed
phase can be changed
Phase 3 5th Week ( 2 times in a Week) 7th Week (2 Sessions in a week)

Knee to chest, low back rotation, Heat pack/ cold pack, Single leg raise plank,
extension in prone, bridging, cat bicycle crunch, Side plank, single leg lunge,
Restoring Full Function and camel, piriformis stretch, 1/3 squat, knee rolling, bridge with one leg
Crunches, Planks, cross leg raise, single leg squat, Dynamic Quadriceps
crunches, Lunges and Squats and Hamstring stretching.

Advance Treatment (Use one or

Aerobic Exercise, Pilates, Gym Mckenzie, Mulligan, Aqua therapy, maitland,
more therapy only if certified/
Training, Yoga aerobics, pilates
expertise)
Start doing all the daily activity, do Use home exercise program on days
Do's (Instruction to be given stretching and strengthening physiotherapist does not come, make
when Patient enters Phase 3) exercise at home. Start Walking/jogging/ aerobic exercise a part of
sports/fitness training/walking. daily routine

DO NOT slouch, DO NOT reach out for things

Don't (Instruction to be given DO NOT sit in wrong posture. DO
too far, DO not wear hard sole/ high heel
when Patient enters Phase 3) NOT use lumbar belt at this stage.
shoes
When to change of Phase? When patients Major treatment When patient no longer gets cramps/spasm
goals are achieved. So one patient in back, and all major treatment goals are
can be taken to next phase prior to achieved. So follow up visits should be done
discharge. in next phase prior to Discharge.

6
Phase 4 6th Week (1 Day in a week) 8th Week (2 Sessions in a week)
Exercises of 7th and 8th Week + theraband
General range of motion exercises strengthening trunk curl ups, trunk twist,
Preventing Recurrence
and strengthening exercise. back extension, lower abdominal crunch,
side bend,

Do's (Instruction to be given Maintain healthy weights, Use home exercise program/ aerobics exercise in daily
when Patient enters Phase 4) activity, Do eat healthy diet, Use firm mattress, wear flat shoes

Don't (Instruction to be given DO NOT smoke, DO NOT use support aids, DO NOT slouch in chair, Do NOT sleep
when Patient enters Phase 4) on stomach

All Short term goals are achieved and long term home exercise program is
Discharge
designed for the patient to avoid recurrence.

Service comprehensiveness
Value Added Services
Medical equipments Therabands, weights, exercise ball, Pull ups bar, Abs roller.
To suggest Anti inflammatory drugs, analgesics, For surgical intervention (For
Doctor Service
grade 3 strain in back muscles)
Diagnostic Bone density test, Blood test, x-ray, MRI,
Orthotics and prostatic For back support aids, for chair modifications, for any shoes modifications

7
 SPONDYLOLISTHESIS
Spondylolisthesis
Spondylolisthesis is a descriptive term referring to slippage (usually forward) of a vertebra and the spine above it
relative to the vertebra below it.
Anterolisthesis Retrolisthesis
Ideal Symptoms Anterolisthesis is a spinal disorder Retrolosthesis is the term used to define a
characterized by a dislocation of at least degenerative and an acute spine condition in
one vertebra relative to another, when an which a single vertebra gets displaced and
upper vertebral body, the main part of a moves backwards onto the vertebra lying
vertebra, slips forward relative to the below it. Include stiffness in the affected
vertebra below - Back or buttock pain. area, chronic back pain, extending to
Pain that runs from the lower back down buttocks and thighs or no pain and
one or both legs. numbness.
Numbness or weakness in one or both Results in narrowing of spinal canal leading
legs. Difficulty walking. to irritation of spinal nerves.
Leg, back, or buttock pain that gets worse
when you bend over or twist.
Loss of bladder or bowel control, in rare
cases.
Clinical sign Anterolisthesis is graded by measuring Retrolisthesis is graded by measuring how
how much of a vertebral body has slipped much of a vertebral body has displaced
forward,relative to the vertebrae below it. backward in relation to the vertebra below it.
Grade I — 1 percent to 25 percent slip Grade I — 1 percent to 25 percent slip
Grade II — 26 percent to 50 percent slip Grade II — 26 percent to 50 percent slip
Grade III — 51 percent to 75 percent slip Grade III — 51 percent to 75 percent slip
Grade IV — 76 percent to 100 percent slip Grade IV — 76 percent to 100 percent slip
Differential Diagnosis
Lumbar Muscle Strains/ Active ROM and MMT MRI, Passive and active ROM and MMT
Sprains
To Rule SI Joint Gaenslen's Test, Gillet's Test, SI compression test, SI distraction test
Dysfunction
Spondylolisthesis Spinal Instability Test- Painful Catch sign, Apprehension Test, Lumbar extension test
Piriformis Tightness Piriformis tightness test
Herniated disc X-ray, Valsalva Test
Iliopsoas tightness, Hip Fabers Test, Thomas Test
pathology, SIJ pathology
Osteoporosis and Muscle Blood test (Vitamin D and B12), BMI (Obesity), Bone density test
Weakness
Outcome measure Modified Oswestry disability Index
Diagnosis can be concluded only after any of the above mentioned test comes positive.
8
 Anterolosthesis Treatment
The duration of recovery in each phase may change from patient to patient, might take more or less time then
mentioned below. So treatment might take longer or shorter duration then mentioned.
Minimum number of 10 20
required sessions to be
mentioned on the case
file. This can increase to
the below mentioned
number based on
severity of symptoms

Anterolisthesis - Grade (I) - Acute Anterolisthesis( 6 Grade (I) -Chronic Anterolisthesis(8 Weeks )
Duration of weeks)
Treatment(Approximate)

Back pain Relief and Rest, Icing reduce pain, swelling from Ice/Heat Therapy and Electro therapy
Protection traumatized tissues and bleeding. (TENS/IFT).
Rest, Lumbar Belt, Static Abdominals, Core
Strengthening exercises

Strengthening 1st WEEK (5 consecutive sessions in a 1st and 2nd week (5 consecutive sessions in
week) -Isometrics (within pain limit) then a week) - Isometric contraction of Gluetus
progress to maintaining static Transversus muscle transverse abdominis, multifidus,
abdominis contraction with SLR, Knee to pelvic tilts, single leg raise, single knee to
chest, Bridging and manipulation Grade 1 chest, bridging, quadripod single leg raise.
or 2 based on intensity of pain. Figure of 4 Figure of 4 stretch glutea, SLR of
stretch glutea (Change to Week 2 when dorsiflexion, knee to chest (for
VAS is less by 1 count on scale) sciatica)(Change to 3rd and 4th Week when
2nd Week (3 sessions alternate days in a VAS is less by 1 count on scale and stiffness
week) - 1st Week exercise+ Hamstring is reduced/ activity based discomfort is
Stretch, Quadricepts stretch, Side stretch reduced).
and progression of strengthening and core 3rd and 4th Week (3 alternate Sessions in a
stability exercises, Bridging Flexion week)- isometric contraction of gluetus
exercises for the spine, for example: muscle, Isometric contraction, activation of
sitting on a chair with back resting, then Transverse abdmominis, multifidus, 1/2
gradually bending the trunk forward from squat, lower trunk rotation and prayer
the lumbar region Figure of 4 stretch, knee stretch, Figure of 4 stretch, knee to Chest and
to Chest and SLR. SLR ( for sciatica)

9
Strengthening 3rd to 6th Week (2 sessions in a week)- 5th week (3 sessions’ alternate days in a
Active posterior tilting is taught to the week)-Flexion exercises for the spine, for
patient to compensate the exaggerated example: sitting on a chair with back resting,
lumbar lordosis.The patient is given then gradually bending the trunk forward
guidelines for correction of posture and its from the lumbar region.
maintenance.Patient is adviced to lie 6th to 8th week ( 2 sessions in a week)- Side
prone to control the advancement of lying Lumbar Thrust Manipulation grade 3 or
lordosis. A thoraco-lumbar-sacral orthoses 4 to reduce stiffness, Knee to chest, low back
is given to prevent the lordosis. The brace rotation, bridging, cat and camel, piriformis
has to be worn continuously. stretch Back Stretches like-Knee to Chest

Advance Treatment (Use Taping, Mckenzie, Mulligan, manual nerve Pilates and Aqua therapy, manual nerve
one or more therapy mobilization (Use it from the beginning of mobilization (Use it from the beginning of
only if certified/ the phase) the phase)
expertise)

Do's (Instruct the patient Take maximum rest and Discontinue the Use posture while working/doing daily
on the same on 1st Visit activity that lead to muscle sprain/strain activity. Perform exercise in pain limit.
with patient) until week 1 is cleared. Use back support/
Brace to avoid further injury

Don't (Instruct the DO NOT start sports activity/ difficult Avoid twisting and bending activity until
patient on the same on exercise at this level. DO NOT lift heavy phase 1 is cleared.
1st Visit with patient) objects

Anterolisthesis - Grade (II) - Acute Anterolisthesis (6 Grade (II) -Chronic Anterolisthesis (8 Weeks
Duration of weeks) )
Treatment(Approximate)
Back pain Relief and Rest. Ice/Heat Therapy and Electro therapy
Protection Icing reduce pain,swelling from (TENS/IFT).Rest, Lumbar Belt .Core Muscle
traumatised tissues.Deep soft tissue Strenghtening Exercises to improve stability
mobilisation, Targets spasm and chronic Abdominal Strenghtening Exercises
muscle tension Gluteal Strengthening
TENS help relieve pain Lumbar Stretching Exercises
Postural Training / Functional Training

10
Strengthening 1st WEEK-Isometrics (within pain limit) 1st and 2nd week- Isometric contraction of
then progress to maintaining static Gluetus muscle transverse abdominis,
Transversus abdominis contraction with multifidus, pelvic tilts, single leg raise, single
SLR, Knee to chest, Bridging and knee to chest, bridging, quadripod single leg
manipulation Grade 1 or 2 based on raise. (Change to 3rd and 4th Week when
intensity of pain. (Change to Week 2 VAS is less by 1 count on scale and stiffness
when VAS is less by 1 count on scale) is reduced/ activity based discomfort is
2nd Week- 1st Week exercise+ Hamstring reduced)
Stretch, Quadriceps stretch, Side stretch 3rd and 4th Week- isometric contraction of
and progression of strengthening and core gluteus muscle, Isometric contraction,
stability exercises, Bridging Flexion activation of Transverse abdominals,
exercises for the spine, for example: multifidus, 1/2 squat, lower trunk rotation
sitting on a chair with back resting, then and prayer stretch
gradually bending the trunk forward from
the lumbar region
3rd to 6th Week- Active posterior tilting is
tought to the patient to compensate the
exaggerated lumbar lordosis.
The patient is given guidelines for
correction of posture and its maintenance.
Patient is adviced to lie prone to control
the advancement of lordosis.
A thoraco-lumbar-sacral orthoses is given
to prevent the lordosis. The brace has to
be worn continuously.
Advance Treatment (Use Taping, Mckenzie, Mulligan (Use it from Pilates and Aqua therapy (Use it from the
one or more therapy the beginning of the phase) beginning of the phase)
only if certified/
expertise)
Do's (Instruct the patient Take maximum rest and Discontinue the Use posture while working/doing daily
on the same on 1st Visit activity that lead to muscle sprain/strain activity. Perform exercise in pain limit.
with patient) until week 1 is cleared. Use back support/
Brace to avoid further injury

Don't (Instruct the DO NOT start sports activity/ difficult Avoid twisting and bending activity until
patient on the same on exercise at this level. DO NOT lift heavy phase 1 is cleared.
1st Visit with patient) object.

11
Anterolisthesis - Grade (III) - Acute Anterolisthesis Grade (III) - Chronic Anterolisthesis
Duration of
Treatment(Approximate)
Needs
surgical intervention

Anterolisthesis - Grade (IV) - Acute Anterolisthesis Grade (IV) - Chronic Anterolisthesis

Duration of
Treatment(Approximate)
Needs
surgical intervention

Retrolisthesis Treatment

The duration of recovery in each phase may change from patient to patient, might take more or less time then
mentioned below. So treatment might take longer or shorter duration then mentioned.
Minimum number of 10 20
required sessions to be
mentioned on the case
file. This can increase to
the below mentioned
number based on
severity of symptom.
Retrolisthesis - Duration Grade (I) - Acute Retrolisthesis ( 6 weeks) Grade (I) - Chronic Retrolisthesis (8 Weeks )
of
Treatment(Approximate)
Back pain Relief and Rest, Bracing Use hot pack/ cold pack for muscle
Protection relaxation, pelvic tilts, back extension, knee
to chest, bridging, Lower trunk rotation,
prayer stretch, piriformis stretch and Back
extension, Range of Motion Exercises for
lower back. Stretching with arms raised
above shoulders or in front of chest.
Spinal Flexibility Exs prove effective.
Strengthening Pelvic Tilts-Helps strengthen lower Lower Back Rolls- For providing a stretch for
muscles of abdominal wall and pelvis. lower back.Back extension Excersice.
Lying on floor with knees bend and
abdomen pulled in and slightly rock the
top of pelvis upward

Advance Treatment (Use Mckenzie, Maitland, Mulligan, Pilates Taping, Mckenzie, Mulligan, Aqua therapy,
one or more therapy maitland
only if certified/
12
expertise)

Do's (Instruction to be Start with basic daily activity, Use back Practice isometric contraction of abdominal
given when Patient Support aid, Start stretching exercise, Take muscles in daily activity, take breaks in-
enters Phase 2) Micro Breaks in-between work. between exercise
Don't (Instruction to be DO NOT Sit/stand for long duration( 30 Do Not hold breath while doing isometric or
given when Patient min) any strengthening exercises. DO NOT go
enters Phase 2) above exhaustion limit.
Retrolisthesis - Duration Grade (II) - Acute Retrolisthesis ( 6 weeks) Grade (II) - Chronic Retrolisthesis (8 Weeks )
of
Treatment(Approximate)
Back pain Relief and Icing reduce pain,swelling from Use hot pack/ cold pack for muscle
Protection traumatised tissues relaxation, pelvic tilts, back extension, knee
. Static back extension exercises. to chest, bridging, Lower trunk rotation,
piriformis stretch and Back extension, Range
of Motion Exercises for lower back.
Stretching with arms raised above shoulders
or in front of chest. Spinal Flexibility Exs
prove effective. Lying on floor with knees
bend and abdomen pulled in and slightly rock
the top of pelvis upward
Lower Back Rolls- For providing a stretch for
lower back.

Strengthening Pelvic Tilts-Helps strenghten lower HIP ROLLS- For maintaining strength and
muscles of abdominal wall and pelvis.Lying support of the pelvis and hip joits.
on floor with knees bend and abdomen Do this exercise standing or lying down,
pulled in and slightly rock the top of pelvis depending on your comfort level.
upward Hold onto a chair or wall for balance, with
one leg bearing most of your weight, the
other knee slightly bent with the ball of the
foot touching the floor. Keep the ball of the
working foot on the floor and slowly rotate
the knee outward, then inward.

Advance Treatment (Use Mckenzie, Maitland, Mulligan, Pilates Taping, Mckenzie, Mulligan, Aqua therapy,
one or more therapy maitland
only if certified/
expertise)

13
Do's (Instruction to be Always be sure of your footing; do not Go For Nutritious Diet- Includind vitamin A
given when Patient stand on a loose or moveable surface and C, copper and Zinc
enters Phase 2) while lifting Weight Reduction
Bend your knees as you squat down low Sitting in a proper posture
toward the object being moved, do not Exercise regularly
bend your back before or during the lift
Keep the low back relaxed and straight
while mopping, running the vacuum or
mowing the lawn
Hold object close to your body,
Lift objects only chest high; higher lifting
requires help to get above shoulder level
Get help with heavy objects, either
another person or equipment.
Don't (Instruction to be Don’t bend the back with the legs kept Don’t bend the back with the legs kept
given when Patient straight straight
enters Phase 2) Don’t twist while lifting, move the feet like Don’t twist while lifting, move the feet like a
a dancer by pivoting on the front part of dancer by pivoting on the front part of the
the foot foot
Don’t use a sudden jerking action to move Don’t use a sudden jerking action to move
anything since this will transfer that anything since this will transfer that impact
impact into your body into your body
Don’t lift above shoulder level Don’t lift above shoulder level
Retrolisthesis - Duration Grade (III) - Acute Retrolisthesis Grade (III) - Chronic Retrolisthesis
of
Treatment(Approximate)
Needs
surgical intervention

Retrolisthesis - Duration Grade (IV) - Acute Retrolisthesis Grade (IV) - Chronic Retrolisthesis
of
Treatment(Approximate)
Needs
surgical intervention
Service comprehensiveness
Value Added Services
Medical equipments Pelvic Rolls,Lumbar rolls, hip rolls , exercise ball, Abs roller.
Doctor Service To suggest Anti inflammatory drugs, analgesics, For surgical intervention (For grade 3 and
4) Lysthesis
Diagnostic Blood test, x-ray, MRI
Orthotics and prostatic For back support aids, for chair modifications, for any shoes modifications

14
 Prolapsed Inter Vertebral Disc

PIVD
The inner softer part of the disc (the nucleus pulposus) bulges out (herniates) through a weakness in the outer part of
the disc. A PIVD /prolapsed disc is sometimes called a Herniated disc.
Acute Subacute Chronic
Ideal Symptoms Sever pain, pain and Moderate pain, tingling Range of motion restricted,
Bending forward is very and numbness, difficulty decrease in muscle strength,
painful, sometimes in bending forward, difficulty in moving and
tingling and numbness, difficulty in changing changing postions sitting to
feel stiffness in the back, lying to sitting and standing and lying to sitting.
Movements are difficult, sitting to standing. Mild pain with movement.
difficulty in changing Weakness in back Difficluty in maintaing errect
sides in lying position, muscle. posture.
sometimes tingling and
numbness, Pain made
worse by couging,
sneezing, straining and
laughing.

Differential Diagnosis
Lumbar Muscle Strains/ Sprains Active ROM and MMT MRI, Passive and active ROM and MMT

To Rule SI Joint Dysfunction Gaenslen's Test, Gillet's Test, SI compression test, SI distraction test
Hamstring Tightness (Without SLR Without dorsiflexion
Radiculopathy)
Hamstring Tightness (With SLR with Dorsiflexion, 90-90 straight leg raising test
Radiculopathy)
Piriformis Tightness (Without Piriformis tightness test
Radiculopathy)
Piriformis Tightness (With Piriformis tightness test
Radiculopathy)

Herniated disc, PIVD (With Slump Test with dorsiflexion causes tingling and numbness, Bow string Test,
Radiculopathy)
Herniated disc, PIVD (Without X-ray, Valsalva Test, patient's symptoms are lessened in position of extension
Radiculopathy) (bending back) and provoked in flexion (bending forwards)

15
Iliopsoas tightness, Hip Fabers Test, Thomas Test
pathology, SIJ pathology

Osteoporosis and Muscle Blood test (Vitamin D and B12), BMI (Obesity), Bone density test
Weakness
Cauda Equina Red Flags rule out in hIstory, MRI, EMG, NCV.
Spinal stenosis, X-ray, Patient's symptoms are lessened in position of spinal flexion (bending
Spondylolisthesis. forwards) and provoked in spinal extension (bending backwards)
Outcome measure Modified Oswestry disability Index
Diagnosis can be concluded only after any of the above mentioned tests comes positive.
Treatment
The duration of recovery in each phase may change from patient to patient, might take more or less time then
mentioned below. So treatment might take longer or shorter duration then mentioned.

Minimum number of required 7 10 15

sessions to be mentioned on
the case file. This can increase
to the below mentioned
number based on severity of
symptoms

Duration of treatment Acute Stage (2 WEEKS) Subacute Stage (4 Chronic Stage (6 WEEKS)
(approximate minimum time) Weeks)

Phase 1 1st week (5 sessions in a 1st week (5 sessions in a 1st and 2nd Week (5
week) (Use week), 2nd Week (3 consecutive sessions in a
Combination of all sessions in a week) (Use week) 3rd week (3 alternate
Therapy mentioned Combination of all Sessions in a week) (Use
below) Therapy mentioned Combination of all Therapy
below) mentioned below)
Pain and Spasm reduction Cold therapy or heat Cold therapy or heat Cold therapy or heat therapy
therapy therapy TENS or IFT or Ultrasound
TENS or IFT or TENS or IFT or Soft tissue Manipulation
Ultrasound Ultrasound
Soft tissue Manipulation Soft tissue Manipulation
Exercises for muscle WEEK 1: Passive Week 1 : Passive 1st and 2nd week- Isometric
strengthening and flexibility Extension: Patient is Extension: Patient is contraction of Gluetus muscle
lying prone, If patient is lying prone, If patient is transverse abdominis,
within extreme pain, within extreme pain, multifidus,
place pillows place pillows

16
Exercises for muscle Underneath the Underneath the Pelvic tilts, single leg raise,
strengthening and flexibility abdomen for support, abdomen for support, single knee to chest, bridging,
gradually boost the gradually boost the quadripod single leg raise.
amount of extension by amount of extension by (Change to 3rd when VAS is
removing pillows. removing pillows. less by 1 count on scale and
Progress with the Progress with the stiffness is reduced/ activity
patient prop himself on patient prop himself on based discomfort is reduced)
the elbows, allowing the the elbows, allowing the 3rd week- isometric
pelvis to sag. Knee to pelvis to sag. contraction of gluetus muscle,
chest, ankle toe Knee to chest, ankle toe Isometric contraction,
movement,heel drag, movement,heel drag, activation of Transverse
hip hip abdmominis, multifidus, 1/2
abduction/adduction. abduction/adduction. squat, lower trunk rotation
Hamstring Stretch, Hamstring Stretch, and prayer stretch
Quadricepts stretch, Quadricepts stretch,
Side stretch and Side stretch and
progression of progression of
strengthening and core strengthening and core
stability exercises. stability exercises.
(Change to Week 2
when VAS is less by 1
count on scale)
Week 2: Week 1+ Side
lying Lumbar Thrust
Manipulation grade 3 or
4 to reduce stiffness,
extension in prone,
bridging, cat and camel,
piriformis
stretchTransverse
abdominus retraining,
opposite arm leg raises,
plank, superman, Side
hold, resistance band
rotation, hold relax
technique.
Additional therapy (Use one or Manual Traction or Manual Traction or Pilates and Aqua therapy (Use
more therapy only if certified/ Taping or Mckenzie, Taping or Mckenzie, it from the beginning of the
expertise) Mulligan (Use it from Mulligan (Use it from phase)
the beginning of the the beginning of the
phase) phase)

17
Do's (Instruct the patient on If symptoms are severe, Take maximum rest and Use posture while
the same on 1st Visit with DO take bed rest Discontinue the activity working/doing daily activity.
patient) (maximum for just two that lead to muscle Perform exercise in pain limit.
days) on a hard bed is sprain/strain until week
indicated with short 1 is cleared. Use back
periods of walking at support/ Brace to avoid
regular intervals (with further injury
corset). Walking
promotes lumbar
extension and
stimulates fluid
mechanics in lowering
swelling in the
disc/connective tissues.
Don't (Instruct the patient on Avoid flexed postures, Do not hold breath These are some movements
the same on 1st Visit with sitting for very long while doing exercises. you should try to avoid:
patient) duraton, bending or Do not sit in one posture bending over to lift very heavy
lifting activities, for a longer duration. items, performing squats with
asymmetric postures. too much weight, low back
DO NOT slouch, DO NOT extensions, as they put high
reach out for things too stress levels on discs, running:
far, DO not wear hard since it can place strains on the
sole/ high heel shoes. discs, any form of resistance
training

When to change Phase? Change to Week 2 when When Pain while activity When pain during activity has
VAS is less by 2 or more has reduced 1 or more reduced by 2 or more score on
count on scale score on Vas Scale, VAS
Activity stiffness has
reduced by 30%. Any
one of above is achieved
Phase can be changed

18
Phase 2 2nd week (3 sessions in 3rd week (3 sessions in a 4th and 5th Week (3 sessions
a week) (Use week), 4th Week (2 in a week) 6th week (2
Combination of all sessions in a week) (Use Sessions in a week) (Use
Therapy mentioned Combination of all Combination of all Therapy
below) Therapy mentioned mentioned below)
below)
Restoring Full Function Week 2:Knee to chest, Week 3: Knee to chest, Week 4th and 5th: Active
low back rotation, low back rotation, painfree range of motion
extension in prone, extension in prone, exercises side flexion and
Crunches, Planks, cross bridging, cat and camel, extension in standing, Knee to
leg crunches, Lunges piriformis stretch, chest, prone press ups,
and Squats Side lying Crunches, Planks, cross hamstring stretch,
Lumbar Thrust leg crunches, Lunges bridging,Plank, wall squat,
Manipulation grade 3 or and Squats prone press crunches,prone lying arms and
4 to reduce stiffness, ups, nerve mobility legs raise, sit ups, trunk curls,
Knee to chest, low back exercises, modalities. push up, prone leg raise,
rotation, extension in Simple spinal quadripod opposite leg and
prone, bridging, cat and movements in pain free arm raise. (Change week when
camel, piriformis stretch ranges using gentle patient does not find flexion
pelvic tilts. (Change difficult or is able to maintain
Week when difficulty in a plank posture for more than
flexion is reduced) 60 seconds)
Week 4: Week 3+ Pelvic Week 6: Week 4th and 5th
rocking can be done in +Active painfree range of
supine, sitting, prone motion exercises side flexion,
lying, side lying, and flexion and extension in
standing, quadripud (cat standing, Single leg raise plank,
and camel exercise). bicycle crunch, Side plank,
Emphasize on anterior single leg lunge, 1/3 squat,
pelvic tilt so that spine is knee rolling, bridge with one
in extension. Pelvic leg raise, single leg squat,
rolling can be added. Dynamic Quadriceps and
Hamstring stretching.

Advance Treatment (Use one or Aerobic Exercise, Pilates, Aerobic Exercise, Pilates, Mckenzie, Mulligan, Aqua
more therapy only if certified/ Gym Training, Yoga Gym Training, Yoga therapy, maitland, aerobics,
expertise) pilates

19
Do's Use relaxation Start with basic daily Use home exercise program on
techniques when pain activity, Use back days physiotherapist does not
increases while doing Support aid, Start come, make Walking/jogging/
activity. stretching exercise, Take aerobic exercise a part of daily
Micro Breaks in- routine Maintain good posture
between work. to avoid recurrence

Don't Do not sit in one posture DO NOT slouch, DO NOT DO NOT sit in wrong posture.
for a longer duration. Do reach out for things too DO NOT use lumbar belt at this
not hold breath while far, DO not wear hard stage.
doing exercises. sole/ high heel shoes.
Avoid flexed postures,
sitting for very long
duration, bending or
lifting activities,
asymmetric postures
Discharge All Short term goals are achieved and long term home exercise program is designed
for the patient to avoid recurrence.

Service comprehensiveness
Value Added Services
Medical equipments Therabands, weights, exercise ball. Pull ups bar.
Doctor Service To suggest Anti inflammatory drugs, analgesics, For surgical intervention (For
conditions like cauda Equina, Neurological deterioration, Persistant pain and signs
and symptoms of sciatic tension after 30 days of conservative treatment.)
Diagnostic Bone density test, Blood test, x-ray, MRI,
Orthotics and prostatic For back support aids, for chair modifications, for any shoes modifications

20
 ANKYLOSING SPONDYLITIS

Ankylosing Spondylitis
Ankylosing spondylitis is a chronic inflammatory autoimmune disease of the axial skeleton, with variable
involvement of peripheral joints and non articular structures. AS is one of the seronegative spondylo -
arthropathies and has a strong genetic predisposition.
Stage 1-Early Onset Stage 2-Progression Stage 3-Advanced Stage
Ideal Symptoms The early onset of Progressing stiffness and Advanced spondylitis is called as
spondylitis causes pain towards the spine and ankylosis, which signifies the fusion
stiffness and back pain other joints. of spinal joints because of
in the young Inflammation in spine, ribs, worsening inflammation.
adulthood. hips, legs or feet is an Pain starts debilitating and may
The pain starts slowly indication of condition cause immobility of spinal.
and advances towards worsening. Symptoms in advanced stage
the spine, worsens On worsening, causes eye include inflammation of bowels, low
due to inactivity pain, redness, blurred appetite level and tiredness.
during night. vision and sensitiveness to It may cause posture changes like
It is accompanied by light. stooping, haunching or any other
stiffness and pain in unerect postures.
the early morning and Advanced spondylitis may also
settles down gradually affect other parts of the body like
due to heat and heart or liver.
movement.
Clinical sign • Straight and stiff • Inability to breathe • Low fever
spine deeply (if AS affects the • Reduced appetite and weight loss
• Stooped posture joints between the ribs • Anemia
• Hip pain and and spine) • Skin rashes
stiffness • Pain and swelling in the • Gastrointestinal illness
shoulders, knees, ankles • Damage to heart and lungs
and feet
• Eye inflammation
Differential Diagnosis
To Rule SI Joint Gaenslen's Test, Gillet's Test, SI compression test, SI distraction test
Dysfunction
Hamstring Tightness SLR with Dorsiflexion, 90-90 straight leg raising test
Ankylosing Spondylitis Xray, MRI, Blood Tests for HLAB27 gene
Spondylolisthesis Spinal Instability Test- Painful Catch sign, Apprehension Test, Lumbar extension test
Herniated disc X-ray, Valsalva Test
Iliopsoas tightness, Fabers Test, Thomas Test
Hip pathology, SIJ
pathology
21
Cauda Equina Red Flags rule out in history, MRI, EMG, NCV
Osteoporosis and Blood test (Vitamin D and B12), BMI (Obesity), Bone density test
Muscle Weakness
Outcome measure Modified Oswestry disability Index
Diagnosis can be concluded only after any of the above mentioned test comes positive.
Treatment
Minimum number of 10 15 Minimum 10. Depending on
required sessions to patients condition it can be
be mentioned on the increased.
case file. This can
increase to the below
mentioned number
based on severity of
symptoms
Stage 1-Early Onset Stage 2-Progression 3 to 6 Stage 3-Advanced Stage exceeding
3 weeks (1st week weeks (3rd and 4th week 6 weeks (2 times a week for
continuous and the sessions 3 times a week. monitoring purposes)
2nd and third week 5th week and 6th week,
atleast 4 days a Sessions 2 times a week.)
week.
Back pain Relief and Rest Heat Therapy and Electro Heat Therapy and Electro therapy
Protection Heat therapy - therapy (TENS/IFT) (TENS/IFT)
assists alleviating Bracing Bracing
spasm and Static Abdominals, Core Static Abdominals, Core
stiffness. Strengthening exercises Strengthening exercises
Electrotherapy.
MFR and Soft tissue
mobilization.

22
Strenghtening 1st WEEK- Early Stage Exercises for 3 Comprise of Management Protocol
Isometrics (within weeks+ for Early Stage+ Advanced Stage+
pain limit) then Week 4 -General Exercises PHYSIOTHERAPY MONITORING
progress to Comprises stretching FOR CARDIOVASCULAR
maintaining static exercises during the warm- COMPLICATIONS
core Muscle up and cool-down periods: • Comprises resistance exercises at
Exercises, Bridging forward and backward a low intensity after finishing two to
and manipulation head stretch, sideways four weeks of an aerobic program.
Grade 1 or 2 based head stretch , chest and • Aerobic exercises include- 1.
on intensity of shoulders stretch , deltoid Warm-up: 10 minutes of step
pain. (Change to muscle stretch , triceps exercises (each motion repeated 10
Week 2 when VAS muscle stretch , overhead times) + 5 minutes of stretching
is less by 1 count stretch , lateral trunk exercises.
on scale) muscle stretch , 2. Main period: 20 minutes of step
2nd Week- 1st Abdominal stretch, leg exercises (each motion repeated 10
Week exercise+ extensor and pelvic flexor times).
Posture Correction stretch, spinal twist 3. Cool-down: 10 minutes of
Exercises by Means stretch, paravertebral pulmonary exercises + 5 minutes of
of Mirror Feedback muscle stretch and double stretching exercises Treadmill
Side stretch and knee-to-chest stretch. Exercises needs to be included at a
progression of Week 5- Week 4 exercises later stage when vitals normalize.
strengthening and -Aerobic Exercise- 1. PHYSIOTHERAPY MONITORING
core stability Warm-up: 10 minutes of FOR BONE INVOLVEMENT:
exercises, Bridging step exercises (each Osteoporosis: • Include Back
,Back extension motion repeated 10 times) Extension Exercises with Progressive
Exercises + 5 minutes of stretching Strengthening exercises along with
3rd Week- 1stweek exercises. Pain Relief Regime. Resistance
exercises+ 2nd 2. Main period: 20 minutes training and other interventions
week exercises+ of step exercises (each aimed at stimulating skeletal muscle
Restoring Normal motion repeated 10 growth can be included.
ROM & Posture times). Alternate between the two towels
Treatment may 3. Cool-down: 10 minutes as desired, making sure to end with
include joint of pulmonary exercises + 5 a cold compress. Alternating
mobilisation and minutes of stretching temperatures on your face will
alignment exercises Incentive cause vasoconstriction and
techniques, muscle Spirometry- This is a vasodilatation, physiological
stretching exercises session of breath holding changes that will stimulate your
Restore Normal and controlling breaths. face and the skin around your eyes.
Muscle Control & Patients should carry out •Do a full face massage: Soak a
Strength 3-5 second breath holds, towel in warm water. Rub your
Core Stabilisation combined with General neck, forehead and cheeks with the
Exercises to regain Exercises. Inspiratory towel. Then, use your fingertips to
normal muscle Muscle Training - include; gently massage your forehead and
control. closed eyes.
23
Strenghtening Restoring Function motion and flexibility •Do an eyelid massage: Wash your
and Return to exercises of the cervical, hands well. Then, close your eyes
Activity thoracic, and lumbar spine; and massage them with circular
Return to a labour- stretching of the hamstring movements of your fingers for 1-2
intensive activity. muscles, erector spine minutes. Make sure you press very
Tailor your muscle, and shoulder lightly on your eyes as you massage
rehabilitation to muscles; control them. Light pressure will help to
help achieve your abdominal and diaphragm stimulate your eyes.
own functional breathing exercises and PHYSIOTHERAPY MONITORING
goals. Chest expansion exercises. FOR LUNG INVOLVEMENT: Deep
Long Term Week 6- Week4+ Week 5+ Breathing Exercises
Management Manual Mobilization, Both Pulmonary Drainage to be
Ankylosing active angular and passive implemented as per the Lobes
spondylitis is a mobility exercises can be Affected.
condition that used in the physiological Spirometer needs to be educated
requires constant directions of the joints in and included to improve lung
management. the spinal column and the Endurance.
Sticking to a regular chest wall in flexion, PHYSIOTHERAPY CONSIDERATIONS
stretching plan extension, lateral flexion for skin involvement- • Frequent
specific to your and rotation and in Change Of positions
stiffness helps to different starting positions. Bed Sore Awareness needs to be
get the most out of Passive mobility exercises included.
your body. consist of general, angular PHYSIOTHERAPY MONITORING
The best advice is movements and specific FOR NEUROLOGICAL
to keep active. translator movements. COMPLICATIONS: For signs of
Regular physical serious spinal cord compression and
activity cauda equina syndrome e.g. urinary
regular stretching retention, increased frequency of
program every day. urination, loss of bowel control,
30 minutes of numbness/loss of sensation in the
moderate exercise saddle area, gait disturbance.
on most days of the Physiotherapy needs to include -
week. Guidelines Balancing exercises, Bowel
for correction of Retraining, Gait Retraining Needs to
posture and its be included in the Protocol
maintenance.

24
Advance Treatment Taping, Mckenzie, Pilates - Consists of a Taping, Mckenzie, Mulligan (Use it
(Use one or more Mulligan (Use it supervised Pilate’s session from the beginning of the phase)
therapy only if from the beginning which follows the accepted Pilates - Consists of a supervised
certified/ expertise) of the phase) Pilates method of Pilates session which follows the
movement. The difficulty accepted Pilates method of
of the movements should movement. The difficulty of the
be easy to moderate movements should be easy to
difficulty and not exceed moderate difficulty and not exceed
14 on the BORG scale 14 on the BORG scale
Do's (Instruct the Week 1- Take Week 4-Bend your knees Week 6-Sleep on a Firm Mattress
patient on the same maximum rest and as you squat down low Regular Back Strenghtening
on 1st Visit with Discontinue the toward the object being exercises
patient) activity that lead to moved, do not bend your Sitting in a proper posture, keeping
muscle back before or during the back erect while sitting long hours
sprain/strain until lift front of computer, standing
week 1 is cleared Week5-Keep the low back Exercise regularly, Relaxation
Week 2- Use back relaxed and straight while Techniques effective.
support/ Brace to mopping, running the Week 6-
avoid further injury vacuum or mowing the Avoid high intensity exercise at
Week3- Use lawn.Hold object close to present
posture while your body, • Take into account the results of
working/doing daily Week6-Lift objects only the exercise stress test, side effects
activity. Perform chest high; higher lifting of medication and the patients’
exercise in pain requires help to get above current activity level.
limit. shoulder level • If starting resistance exercise for
Always be sure of Get help with heavy the first time with a patient then
your footing; do objects, either another makes sure they begin at a low
not stand on a person or equipment. intensity after finishing two to four
loose or moveable Week 4-Don’t lift above weeks of an aerobic programme.
surface while shoulder level • Aerobic intensity needs to be
lifting. Week 5-Don’t use a below a level that does not induce
Week 1-Avoid sudden jerking action to abnormal responses but should be
twisting and move anything since this high enough so that there is an
bending activity will transfer that impact increase in heart rate.
until phase 1 is into your body. Sit-ups - Forward flexion of spine
cleared. Week 6-Avoid Running, with round back or straight legs.
Week 2-Don’t bend High Intensity Activities Lifting any moderate weight
the back with the that might aggravate or Rotation to point of strain (e.g.
legs kept straight worsen the condition. DO Tennis, Golf). - Sudden movements -
NOT start sports activity/ Activities which may increase risk of
difficult exercise at this falling
level. DO NOT lift heavy
objects

25
Don't (Instruct the Week 3-Don’t twist Avoid twisting and
patient on the same while lifting, move bending activity .
on 1st Visit with the feet like a Don’t bend the back with
patient) dancer by pivoting the legs kept straight.
on the front part of Avoid Using Thick pillows
the foot while sleeping.

Service comprehensiveness
Value Added Services
Medical equipments Pelvic Rolls,Lumbar rolls, Firm mattress , Exercise ball and spirometer
Doctor Service To suggest Anti inflammatory drugs, analgesics, Surgical intervention for hip
replacement
Diagnostic
Blood test, x-ray, MRI,Lab Tests for HLAB27, pulmonary function test, NCV test
Orthotics and For back support aids, for chair modifications, for any shoes modifications, Brace.
prostatic

26
 SACROILIAC JOINT DYSFUNCTION
Sacroiliac joint dysfunction
Sacroiliac joint dysfunction, also called sacroiliac joint disorder, sacroiliac joint disease, sacroiliac joint syndrome
or sacroiliac syndrome, or "sacroilliac dysfunction and instability", generally refers to pain in the sacroiliac joint
region that is caused by abnormal motion in the sacroiliac joint, either too much motion or too little motion.
Sacroiliac joint dysfunction
Ideal Symptoms Sacroiliac joint Dysfunction is characterized by Pain in the lower back, usually only on
one side.
Discomfort with bending over or standing after sitting for long periods.
Sacroiliac joint pain will be characterized by discomfort, a burning sensation, and pain
in the region of the lower back and hips. The pain will also be experienced in the
region of the thighs and groin.
Stiffness and burning sensation in the region of the pelvis
Clinical sign Inflammation, Altered Walking and Joint Mechanics, Leg Length Discrepancy,
Malalignment of pelvis, Muscle spasm
Differential Diagnosis

Lumbar Muscle Strains/

Active ROM and MMT
Sprains
To Rule SI Joint Gaenslen's Test, Gillet's Test, SI compression test, SI distraction test, Fabers test
Dysfunction
Ankylosing Spondylitis Xray, MRI, Blood Tests for HLAB27 gene
Spondylolisthesis Spinal Instability Test- Painful Catch sign, Apprehension Test, Lumbar extension test
Piriformis Tightness Piriformis tightness test
(Without
Radiculopathy)
Piriformis Tightness Piriformis tightness test, SLR
(With Radiculopathy)
Herniated disc X-ray, Valsalva Test
Iliopsoas tightness, Hip Fabers Test, Thomas Test
pathology, SIJ pathology
Osteoporosis and Blood test (Vitamin D and B12), BMI (Obesity), Bone density test
Muscle Weakness
Outcome measure Modified Oswestry disability Index And Borg Scale
Diagnosis can be concluded only after any of the above mentioned test comes positive.

27
 Treatment
Minimum number of 7 15 15
required sessions to be
mentioned on the case
file. This can increase to
the below mentioned
number based on
severity of symptoms
Acute Stage Week 1 To Sub-Acute Stage Week 3 Chronic Stage Exceeding 6
Week 3 - 1st Week to Week 6 - 3 times a Weeks
continuous sessions. 2nd week for the 3rd and the
week - 3 times a week. 4th week. Remaining 2
3rd week 2 times a times a week.
week.
Phase I- Pain Relief and Rest. Ice Therapy and Electro Ice Therapy and Electro
Protection Icing reduce pain, therapy (TENS/IFT) therapy (TENS/IFT)
swelling from Rest, Bracing Rest ,Bracing
traumatized tissues Static Abdominals, Core Static Abdominals, Core
Electrotherapy, soft Strengthening exercises Strengthening exercises
tissue massage are
effective.
Phase II- Restore 1st WEEK- Isometrics Acute Stage Exercises for Acute Stage+ Subacute
Function, Improve involved muscle (within 3 weeks+ stage + Week 6 Comprises of
Strength and Mobility pain limit) then progress Week 4 - Back Stretches Back Strengthening exercises
to maintaining static core like-Knee to Chest like Wall slides- Stand with
Muscle Exercises, Lie on your back with your back against a wall with
Bridging and knees bent and your feet your feet, shoulder width
manipulation Grade 1 or flat on the floor. Place apart, around 15 inches from
2 based on intensity of your hands behind your the wall.
pain. (Change to Week 2 knees, at the bottom of Slowly, slide down the wall
when VAS is less by 1 your hamstring muscle, into a sitting position, with
count on scale) and pull your knees up your knees at a 90 degree
2nd Week- 1st Week towards your chest. angle.
exercise+ Knee Rock, Knee Cross-Stretch Hold for five seconds and
While lying flat on the Lie on your back with one then slowly work your way
back bend both legs at leg flat and one knee back up the wall.
the knee. Keep the bent. Place your hand Planks-Lay on your stomach,
bottoms of the feet flat behind your bent knee, at placing elbows and forearms
on the mat and knees the bottom of your on the floor. In a push-up
touching each other. hamstring muscle, and position, balance on your
Without rotating the pull your knee up towards toes and elbows. Keep your
hips, slowly rock the your chest. Then gently back and legs straight. Hold
knees from side to side, ease your knee across for 5 seconds. Relax and

28
moving them off center your body towards your then repeat
by only a few inches. left shoulder, keeping Lower Back Strengthening
Side stretch and both shoulders flat. Exercise eg mentioned
progression of Week 5- Week 4 exercises below.
strengthening and core +Pelvic Tilts Lie on your back, feet flat on
stability exercises, Lie on your back with the floor with knees raised.
Bridging knees bent and feet flat Gently bend knees towards
3rd Week- 1st week on the floor. Keep your one side, bringing them as
exercises+ 2nd week feet hip width apart and close to the floor as possible.
exercises+ Restoring arms at your side. Flatten Hold for 5 seconds and then
Normal Range of motion your back to the floor return to the starting
Treatment may include- causing your hip to tilt position.
Leg flexion and Extension forward. Back and Side Arm Reach
excs. - With stomach Stretches. While standing On the floor, rest on your
muscle tightened, slowly stretch and arch one arm knees and the palms of your
raise the left leg a few over your head and bend hands. Raise one arm to
inches off the floor. Hold your upper body in the stretch it out in front of you.
for the count of 5. Lower direction of the arm which Keep your head and back
the leg and repeat with is NOT raised and Switch parallel to the floor. Hold for
the right leg. Same for sides 5 seconds and then return to
Extn. Week 6- Week4+ Week the starting position. Repeat
Sideways Leg Lift-This leg 5+ Lumbar stabilization 5 times, alternating sides.
exercise can help relieve exercises - One eg Cat Stretch
tension in the IT band, mentioned below. Begin with your knees on
and loosen up the area Knee Fold This exercise the floor and place your
surrounding the SI joint. can also be performed hands, palms down on the
Supine lying Raise the left using both knees at the floor, with your wrists in line
leg to a comfortable same time. Lie on your with your shoulders. Relax
height. Slowly swing the back with knees bent. the top of your feet to the
leg to medial, until a Exhale while lifting one floor.
slight pull is felt in the knee toward you chest. Arching your back round
outside leg muscles. (f Inhale returning your your spine, while at the
possible by the patient knee to the starting same time keeping your tail
you can also perform the position, keeping bone and the base of your
IT band stretch in abdominals flat, and navel neck in the starting position.
standing) to the spine. Repeat Lower your chin as though
several times and then pointing down towards your
repeat with the opposite navel. Relax with your spine
leg. in a neutral position.
Lumbar Vertebrae Stretch Cow Stretch
Lie on your back with Begin with your knees on
knees bent. Pull in and the floor and place your
tighten your stomach hands, palms down on the
muscles while flattening floor, with your wrists in line
29
 your lower back to the with your shoulders. Curl
floor. Hold for a few you toes under.Drop your
seconds. Repeat several abdomen towards the floor
times. and raise your eyes up
toward the ceiling, creating
an arch in your back.Let the
movement begin at your tail
bone and work its way up
toward your neck.
Advance Treatment Taping, Mckenzie, Pilates - Consists of a Taping, Mckenzie, Mulligan
(Use one or more Mulligan (Use it from the supervised Pilates session (Use it from the beginning of
therapy only if certified/ beginning of the phase) which follows the the phase)
expertise) accepted Pilates method Pilates - Consists of a
of movement. The supervised Pilates session
difficulty of the which follows the accepted
movements should be Pilates method of
easy to moderate movement. The difficulty of
difficulty and not exceed the movements should be
14 on the BORG scale easy to moderate difficulty
and not exceed 14 on the
BORG scale
Do's Week 1- Take maximum Week 4-Standing poses Week 6- To get the
rest and Discontinue the can help strengthen the additional benefit of muscle
activity that lead to area around the sacroiliac stretching and
muscle sprain/strain until joint. Focus on strengthening, you may want
week 1 is cleared Trikonasana (Triangle to use warm up and cool
Week 2- Use back Pose) and Utthita down exercises.
support/ Brace to avoid Parsvakonasana While standing in shoulder
further injury (Extended Side Angle depth water...
Week3- Use posture Pose), as these poses (Hydrotherapy)
while working/doing daily strengthen the rotator • Gently extend one leg
activity. Perform exercise and gluteal muscles that forward and then backward,
in pain limit. help to stabilize the area stretching the hip flexor,
Always be sure of your of the SI jointStanding quadriceps and hamstring
footing; do not stand on a poses can help strengthen muscles. Repeat with the
loose or moveable the area around the opposite leg.
surface while lifting. sacroiliac joint. Focus on
Trikonasana (Triangle
Pose) and Utthita
Parsvakonasana
(Extended Side Angle
Pose), as these poses
strengthen the rotator
and gluteal muscles that
30
 help to stabilize the area
of the SI joint
Week5-Sleep on a Firm
Mattress
Regular Back
Strenghtening exercises
Week 6-Sitting in a proper
posture, keeping back
erect while sitting long
hours front of computer,
standing
Exercise regularly,
Relaxation Techniques
effective

Don't wEek 1-Avoid twisting Week 4- As sacroiliac Week 6-

and bending activity joint dysfunction-freq is Avoid high intensity exercise
until phase 1 is cleared. likely to occur due to at present ?
Week 2-Don’t bend the excessive pressure on the • Follow the 90 Degree Rule.
back with the legs kept SI joints, it is advisable to The prohibited actions will
straight avoid all exercises that cause the sacral base to
Week 3-Don’t twist while increase the load and rotate forward and the ilia to
lifting, move the feet like strain that these joints rotate relatively backward,
a dancer by pivoting on would have to bear. opening the SI joint
the front part of the foot Contraindications in SI
joint dysfunction include:
Crunches, Sit Ups,
Twisting, Turning,
Weightlifting
Week 5-Doing Isolated
Exercises
Working Out With
Machines
Doing Long Bouts of
Cardio
Doing Crunches & Sit-Ups
To Get 6-Pack Abs
Repeating The Same
Workouts Over & Over
Doing Long Workouts

31
 Service comprehensiveness
Value Added Services
Medical equipments Pelvic Rolls,Lumbar rolls, Firm mattress , exercise ball, Abs roller.
Doctor Service To suggest Anti inflammatory drugs, analgesics
Diagnostic Blood test, x-ray, MRI, NCV testing
Orthotics and prostatic For back support aids, for chair modifications, for any shoes modifications

32
 SCOLIOSIS

Scoliosis
Scoliosis is a medical condition where your spine is curved from side to side. The spine of an individual with a typical
scoliosis may look more like an "S" than a straight line.

Symptoms Uneven hips,

Uneven shoulders,
One shoulder blade being more prominent than the other,
Listing (bending) to one side,
Pain around the areas above imbalanced areas.
Diagnosis Examine your spine, shoulders, rib cage, pelvis, legs and feet for abnormalities and
asymmetry. If a significant scoliosis suspected, arrange for X-rays to confirm cobb
angle - or severity of scoliosis.

Types of Scoliosis Structural (Idiopathic) scoliosis has genetic roots. A family history of scoliosis and
Idiopathic scoliosis usually develops in early adolescence between the ages of 11-14,
with a higher incidence occurring in females than males (10:1). If left undiagnosed and
untreated in adolescence, the curvature in the spine can progress.
Functional scoliosis can develop in adulthood, often in response to an injury or
repetitive practice of asymmetrical activities (i.e. tennis, golf swing etc). It is a
curvature in the spine that has formed from overuse of muscles on one side of the side
and under use of muscles on the reciprocal side. Since it is muscular based, it can
reverse with appropriate treatment and exercise.
Pathology-related scoliosis can arise in people with neuromuscular disease such as
muscular dystrophy or in response to a severe injury to the spinal cord such as
quadriplegia.

Outcome measure Modified Oswestry disability Index

The line of treatment in each would remain the same only time frame of recovery would change. Functional would need
postural assessment during activity. Structural would require patient to wear brace regularly.

33
 Minimum Therapy Duration of Do's Don't Additional
number of therapy therapy
required
sessions to be
mentioned on
the case file.
This can
increase to the
below
mentioned
number based
on severity of
symptoms
Pain reduction 15 Use Till VAS is Use the Do Not use Taping, Aqua
continue for 1st Ultrasound/ reduced 3 or therapy only modality in therapy
week and 2nd TENS/IFT , less than that. till patient who
week ( 3 sessions Isometric for inflammatio have
in a week) abdominal n and pain is undergone
muscles, back reduced. surgery and
muscles, have
gluteus fixatures. Do
muscles and Not use
knee, pelvic modality
tilts once pain is
reduced.
Rectifying Strengthening: If patient has Use Good Do not plat Taping Aqua
Imbalance Pelvic tilt, Cat mild to quality of on therapy
continue for 3rd, and camel, moderate mattress, trampolines,
4th and 5th single leg scoliosis, Keep DO not run
Week ( 3 balance with continue till moving, Do long
sessions in a support (Try to they fully return stretches distance, Do
week) get neutral to normal daily, regularly, not carry
back sporting and keep good heavy things,
curvature), pull recreational core Do not sleep
ups or activities the strength, on your
pushups, level can be Have good stomach,
diagonal curl changed. nutrition
ups, side shifts, If patient is with food
back extension more moderate
in prone lying, to severe spinal
Standing bend curvatures may
sideways and need to be
forward fitted for
bending. orthopedic
Stretching: braces in order
Hamstring to halt curve

34
 stretching, progression and
quadriceps change level
stretching, cat when patient
stretch, child's can perform all
pose, Dancer’s the exercise
stretch, chest mentioned with
stretch, brace
overhead comfortably.
triceps, knee to
chest
Breathing Excs:
Deep breathing
exercise,
pursed lip
breathing
exercise,
Diaphragmatic
breathing
Restoring Full 3rd, 4th, 5th Discharge Wear brace DO NOT Yoga, gym,
function 6th, 7th Week patient with a regularly if slouch, DO aerobics and
Week ( 5 exercise+ home exercise required, NOT reach aqua therapy
sessions in a Supine lying program. continue out for
week) cycling, Spine with daily things too
extension in activity and far, DO not
prone lying, keep active, wear hard
pushups with Wear sole/ high
pelvic tilt, proper foot heel shoes
Pelvic tilt in wear
standing, Side suggested
stretch in by orthotics.
standing, side
stretch sitting
on heels, Log
rolling, passive
back chest and
upper limb
stretches.
Service comprehensiveness
Value Added Services
Medical Therabands, weights, pulleys, exercise ball. Pull ups bar, Abs roller, Kettlebells, Abdominal
equipments carver
Doctor Service To suggest Anti inflammatory drugs, analgesics, For surgical intervention ( For scoliosis
correction).
Diagnostic Bone density test, Blood test, x-ray, MRI.
Orthotics and For back support aids, for chair modifications, for any shoes modifications.
prostatic
35
 POST SURGICAL MANAGEMENT
Post surgery Management

Types of Spinal Surgery:

Spinal Fusion: a surgeon joins spinal bones, called vertebrae, together. This restricts motion between the bones
of the spine. Fusion also limits the stretching of nerves.
Laminectomy: In it a surgeon removes parts of the bone, bone spurs, or ligaments in the back. This relieves
pressure on spinal nerves that may be causing pain or weakness.
Disc Replacement: a surgeon removes a damaged spinal disc and inserts an artificial disc between the vertebrae.
Discectomy: A bulging or "slipped" disc, the cushion that separates vertebrae, may press on a spinal nerve and
cause back pain. In a discectomy, the surgeon removes all or part of the disc.
Foraminotomy: a surgeon cuts away bone at the sides of vertebrae to widen the space where nerve roots exit
the spine. The enlarged space may relieve pressure on the nerves, thereby relieving pain.
Interlaminar Implant: It is alternative to spinal fusion is the implant of a U-shaped device. The device is placed
between two back bones in the lower back and helps maintain the space between.
Symptoms seen pre- Back pain, Leg pain, Weakness in Lower limb, Tingling and numbness in legs
operation, some might be difficulty in doing daily activity like bending, dressing up, sitting, difficulty lying to
present few weeks after sitting or standing, difficulty in walking, difficulty in driving, difficulty in ADL.
surgery.
Do's Exercise should be started as soon as possible post surgery. If a long journey is
unavoidable e.g. to get home from hospital the patient can recline as a passenger
and ensure breaks every 20-30 minutes to mobilize,
Don't Caution with prolonged standing for the first 4-6 weeks. Avoid any
twisting/bending movements. Aim to keep your back as straight as possible at all
times.
Outcome measure Modified Oswestry disability Index

Patient may feel some slight discomfort as the muscles begin working again. ‰If patient experience sudden or
increased pain, make them rest lying face down for few minutes until the pain settles.
Phase 1 1-3 Weeks (3 sessions in a week)

Exercise therapy ( In the Improve range of motion and strength: Isometric contraction of gluteal muscle,
Weeks introduce patient to abdominal muscle, pelvic tilt, single leg knee to chest, side bending, crook lying
exercises mentioned legs side to side.
gradually till patient's Pain Reduction: Ice application or TENS
muscle strength and Stretching: Hamstring stretrch, quadricepts stretch Back Stretch SLR
endurance) Walking: Pace up steadily, Should reach 30 minutes walk with or without break

36
Do's Sitting should be gradually built up during activities such as eating or relaxing and
should be guided by the development of symptoms. A limit of 15-20 minutes at
any one time is sensible for the first few days, and once this is comfortable it can
be increased gradually. Walking is unrestricted and should be increased day by
day as comfort allows. For the 1st few days only lift about 1kg (a ½ full kettle )
and then slowly increase .
Don't Avoid prolonged-sitting [>1 hour] for about 4 weeks until neural sensitivity has
settled and strength improved and can then try with care, e.g. in the bath

When to change the phase? When any one of the following is achieved: walking 30 minutes without break OR
Pain is relieved by VAS 2 or more OR when patient is comfortable performing
static exercises.

Phase 2 4-6 Weeks (5 sessions in a week)

Exercise therapy ( In the Week 4: Improve range of motion and strength: Isometric contraction of gluteal
Weeks introduce patient to muscle, abdominal muscle, pelvic tilt, single leg knee to chest, side bending,
exercises mentioned crook lying legs side to side. Quadripod position single arm raise, followed by
gradually till patient's single leg raise , bridging, crunches, planks.
muscle strength and Pain Reduction: Ice application or TENS
endurance) Stretching: Hamstring stretrch, quadricepts stretch Back Stretch SLR
Week 5 and 6 : Week 4+ Quadripod opposite arm and leg raise, bridging with
one leg raised,diagonal curl up, knees to chest, press ups, sit ups, wall squats,
piriformis muscle stretch, toe walking, heel walking, side planks, prone ball walk

Do's Continue to log-roll until neural sensitivity has settled and strength improved
which takes about 4-6 weeks, Continue home exercise program until normal
activity and function is achieved without discomfort, Normal gait pattern is
achieved and can go back to work.
Don't Avoid driving until about 4-6 weeks post-operation, or longer if there is a
significant loss of function or sensation in one or both legs/feet. The patient
should be able to sit comfortably in the driving position, drive, turn to look in the
mirror and have 100 % reaction times for an emergency stop.
Service comprehensiveness
Value Added Services
Medical equipments Therabands, weights, pulleys, exercise ball. Pull ups bar, Abs roller, Kettlebells,
Abdominal carver
Doctor Service To suggest Anti inflammatory drugs, analgesics
Diagnostic Bone density test, Blood test, x-ray, MRI,
Orthotics and prostatic For back support aids, for chair modifications, for any shoes modifications
37
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