Corrective Exercise

Corrective Strategies for Lumbo-Pelvic-Hip Complex Impairments (LPHC).

The client has problem with lower back pain. She has pelvic tilt and one leg shorter, which means that side is stronger, because it works harder to manage every movement. LPHC is an area of the body which is very important. It has a huge impact on the structures of both upper and lower body. This part of our body contains twenty-nine to thirty-five different muscles that are attached to the lumbar spine or pelvis (Clark et al.,2014). The most important muscles which are associated with the LPHC are: gastrocnemius/soleus, adductor complex, hamstring complex, hip flexor, abdominal complex, erector spinae, intrinsic core stabilizers, latissimus dorsi, tensor fascia latae/ IT band and gluteus medius and maximus. LPHC dysfunction can lead to dysfunctions in the other parts of the body (Powers, 2003).  Her upper body has some dysfunction as well which can lead to shoulder and upper – extremity injuries, cervical- thoracic spine and rib cage. Overactivity or tightness of the latissimus dorsi can have unwanted impact on the shoulder. The injury associated with LPHC impairment are lower back pain which the client has already got, sacroiliac joint dysfunction, hamstring complex and groin strains. Injuries which can be on under LPHC are as follows: patellar tendonsitis – ‘jumper’s knee’, IT-band tendonitis- ‘runner’s knee’, medial, lateral, and anterior knee pain, chondromalacia patellae, plantar fasciitis, Achilles’ tendonitis and posterior tibialis tendonitis ‘shin splints’ (Clark et al., 2014). Stress inflicted on the low back can increase hip and spinal flexion. It can also lead to increased stress in the hamstring complex and adductor magnus which can try counterbalance impair gluteus maximus and erector spinae complex to stabilize the LPHC. This leads to hamstring complex and groin strains (Sahrmann, 2002). Overactive can be primary hip flexor as a rectus femoris, which can have impact on ability to lengthen during functional movements and in consequence quadriceps strain and knee pain (Neumann, 2002).

To improve spine stability, the client should do specific exercises that are used in rehabilitation and prevention programs. There is a lot of evidence that exercises are very good for low back pain, however, there are still discussions about which muscle groups or muscles which are situated closer (local) or further (global) to also direct  exercise aims during spine stability training (Richardson, 1995).

The spine stability training is divided into two different approaches, as an exercise for local muscles contrary to global musculature (Richardson, 1995) and type of training as improving strength and power (abdominal bracing) contrary to improving neuromuscular control (abdominal drawing-in maneuver).

The most popular training uses exercises which concentrated on the global stabilizers. One study suggests that for spine stability the most important muscles are global (Grieve, 1982), however, this study presumes that intervertebral stability is accomplished. There was a discussion about which muscles local or global, are more helpful in spine stability. The conclusion is that both of muscles are engaged in spine stability, both of them bracing and drawing-in, which has an impact on intervertebral stability and lumbopelvic stability. The lumbopelvic stability relies on intervertebral stability. To train the local muscles and improve intervertebral stability basis is to the drawing-in movement. It can be a start in spine stability training program and it can progress to abdominal bracing (Richardson, 1995).

The client has got static posture assessment and she has lower crossed syndrome, because she has anterior pelvic tilt. The pelvis and lumbar spine are in position where there is excessive stress on the muscles and connective tissue related to LPHC during dynamic movement. She did single-leg squats and her torso has rotated inwards and hip has hiked.  After dynamic Postural Assessment, Gait: Treadmill Walking is known that she has excessive pelvic rotation. Suggested training program:   

Self-Myofascial Release

Here are exercises which the client should to: inhabit by foam rolling. Both sides: side toward shift (adductor and TFL/IT-band and opposite side away from shift piriformis and biceps femoris. In this situation gastrocnemius and soleus are big factor as well. The client did squat, and while she was down here ankle joints lacks sagittal plane dorsiflexion, this pushes the body to shift away from the limited side and shift to the other side. Suggested: hold on for thirty seconds.  

 

Figure 1: Same side TFL/IT-Band

 (Google.com, 2019)

Figure 2: Opposite side Piriformis

(Google.com, 2019)

Figure 3: Same Side Adductors

(Google.com, 2019)

Figure 4: Opposite Side Biceps Femoris

(Google.com, 2019)

Figure 5: Opposite Side Biceps Femoris

(Google.com, 2019)

Static Stretches

Next very important part is lengthening by static and neuromuscular stretches. The same side adductors and opposite gastrocnemius/soleus, TFL/IT-band, biceps femoris, and piriformis. Suggested: hold on for thirty seconds or can be for seven to ten seconds isometric contraction, and hold on for thirty seconds again.

Figure 6: Same Side Adductors

 (Google.com, 2019)

Figure 7: Opposite Side Gastrocnemius/Soleus

 (Google.com, 2019)

Figure 8: Same Side TFL

 (Google.com, 2019)

Figures 9: Opposite Side Piriformis

 (Google.com, 2019)

 (Google.com, 2019)

Figure 10: Opposite Side Biceps Femoris

(Google.com, 2019)

Neuromuscular Stretches: a second person is needed

Figure 11: Opposite Side Piriformis Same Side Adductors

(Google.com, 2019)

Figure 12 Piriformis: Same Side Adductors

 (Google.com, 2019)

Figure 13: Opposite Side Biceps Femoris

 (Google.com, 2019)

Isolated Strengthening Exercises they will activate body by isolated strengthening exercises and positional isometrics. The same side gluteus medius and the opposite side adductor complex. The client can make 4 repetition of increasing intensity 25, 50, 75 and 100% or 10-15 repetition with 2 seconds isomeric hold and 4 seconds eccentric contraction.

Figure 14: Opposite side adductor complex

 (Google.com, 2019)

Figure 15: Same side Gluteus Medius

 (Google.com, 2019)

Positional Isometric Techniques - second person needed

Figure 16: Same Side Gluteus Medius

 (Google.com, 2019)

Figure 17: Opposite Side Adductor Complex

 (Google.com, 2019)

Integrate exercise, dynamic movement. The client can use ball and make wall squats with dumbbells 10-15 repetition. Hold proper position to control exercise.

Figure 18: Wall Squat             

                                                                                

(Google.com, 2019)

For flat feet’s, she should walk on her toes, heels and inner side of the feet for a few minutes daily. She should use orthopaedical shoe insoles to be on the same level as the right part on her body. The left shorter leg will have support and this can be helpful for LPHC impairment.

References

·         Google.com. (2019). ball wall squats to overhead press - Google Search. [online] Available at: https://www.google.com/search?safe=strict&tbm=isch&source=hp&biw=1242&bih=592&ei=koDhXKK_CYfYaaeVr8gF&q=ball+wall+squats+to+overhead+press&oq=ball+wall+squats+to+overhead+press&gs_l=img.3...4994.23559..23789...0.0..0.207.2154.30j3j1......3....1..gws-wiz-img.....0..0j0i5i30j0i8i30j0i24j0i30.qeqFlFHAVzw#imgrc=MZUqupNSPxa2aM: [Accessed 19 May 2019].

·         Michael A. Clark, Scott C. Luccet, Brian G. Sutton (2014). Corrective Exercise Training Knee. 28(5), pp309-337.

·         Neuman DA (2002). Kinesiology of the Musculoskeletal System: Foundations for Physical Rehabilitation. St Louis: Mosby.

·         Powers CM, (2003). The influence of altered- lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. J Orthop Sports Phys Ther . 2003;33(11):639-646.

·         Richardson C, Jull G, Hodges P, Hides, (1999).  Therapeutic Exercise for Spinal Segmental Stabilization in Low Back Pain. London: Churchill Livingstone.

·         Sahramann SA (2002). Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis: Mosby, Inc;