Lumbar Protocol

Passive, Isolated Stretching Technique Guide:

• Mild Stretch – just starting to feel the stretch
• Moderate Stretch – strong, but comfortable
• Max Stretch – intense stretch that almost feels uncomfortable (tolerable)

Lumbar traction (2-4 minutes)

1. Secure the padded belt just superior to the pelvis. Grasping the ankles, use your body weight to pull on the lower extremities. Single leg pelvic tilt (same side)
2. Secure the non-stretching leg to the table with a belt mid-thigh.
3. Stand on the same side of the table as the leg that is being stretched, ask the client to inhale and then exhale as you bring the hip towards the same side shoulder with the knee in flexion. Provide gentle over pressure until the client states they are feeling a “MILD” stretch and bring the hip back to a neutral position. Repeat until the client states they are feeling a “MODERATE” stretch. Repeat once again, asking for a “MAX” stretch.

Single Leg Pelvic Tilt (same side)

1. Secure the non-stretching leg to the table with a belt mid-thigh.
2. Stand on the same side of the table as the leg that is being stretched, ask the client to inhale and then exhale as you bring the hip towards the same side shoulder with the knee in flexion. Provide gentle overpressure until the client states they are feeling a “MILD” stretch and bring the hip back to a neutral position.
3. Repeat until the client states they are feeling a “MODERATE” stretch. Repeat once again, asking for a “MAX” stretch.

Lumbar Roll (same side)

1. Leave the belts in the same positions but slightly adduct the non-stretching leg.
2. Place the foot of the leg you are stretching just medial to the opposite knee.
3. Ask the client to inhale then gently press the knee away from yourself, perpendicular to the trunk until the client reports a “MILD” stretch and asking them to exhale during the stretch. Repeat with a “MODERATE” stretch. Repeat with a “MAX” stretch.

3-way Hamstring (same side)

Knee Flexed

1. One belt should be placed just above the pelvis, with the non-stretching leg stabilized with the second belt, in a neutral position.
2. Allow the knee to remain in gentle flexion, ask the client to inhale then exhale as you flex the hip until they feel a “MILD” stretch. Repeat for a “MODERATE” stretch. Repeat for a “MAX” stretch.

Knee Extended in Neutral Position

1. Bring the hip into an adequate amount of flexion for the client to feel a mild stretch behind their leg, allowing the knee to remain in extension.
2. Have the client inhale, then exhale as you gently bring their hip into flexion until they feel a “MILD” stretch. Repeat these steps for a “MODERATE” stretch as well as a “MAX” stretch.

Knee Extended with Internal Rotation

1. Slightly internally rotate the hip.
2. Repeat the above steps from Knee Extended in Neutral Position.

Knee extended with External Rotation

1. Slightly externally rotate the hip.
2. Repeat the above steps from Knee Extended in Neutral Position.

Gastrocnemius Stretch

1. Hold the stretching leg in about 45-degrees of hip flexion, knee extended.
2. Place your hand over the calcaneus, gripping where the Achilles attaches to the calcaneus.
3. Use your forearm to draw the foot into dorsiflexion until a “MILD” stretch is felt in the calf. You may have to flex the hip slightly more if the client has more flexibility or you may have to allow the knee to gently flex if the stretch feels uncomfortable behind the knee.
4. Repeat for “MODERATE” and “MAX” stretches.
5. Repeat on the opposite leg.

Adductors (same side)

Flexed knee

1. The belts remain in the same position, secured above the pelvis and above the knee on the non-stretching leg.
2. Allow the knee to be flexed comfortably and without rotating the hip, ask the client to inhale, then exhale while you abduct and depress the hip with your compression happening on the medial aspect of the knee until the client reports a “MILD” stretch in the inner thigh.
3. Repeat for a “MODERATE” stretch. Repeat for a “MAX” stretch.

Extended knee

1. Extend the knee fully and allow the toes to point upwards, towards the ceiling. Stand between their leg and the table with the hand closest to the stretching leg placed at the medial aspect of the knee.
2. Gently abduct the hip, keeping the toes pointed towards the ceiling unless resistance is felt and the hip rotates externally. Do not force the hip to remain in a neutral position during this stretch. Allow the client to feel a “MILD” stretch and hold for desired time.
3. Repeat for “MODERATE” and “MAX” stretches in this position.

Piriformis – (opposite side)

1. Leave the belts in the same position, secured above the pelvis and above the knee on the non-stretching leg. Hyper adduct the non-stretching leg.
2. Bring the client’s stretching leg into a “Figure-4” position, keeping the knee directly in line with the same hip.
3. Gently draw their foot towards their opposite shoulder for a “MILD” stretch, holding for the desired time.
4. Inhale and repeat for a “MODERATE” stretch and then a “MAX” stretch.

Lateral glute roll (opposite side)

1. Slightly rotate the non-stretching leg inward.
2. With the stretching hip and knee flexed to 90-degrees each, place the foot on the opposite side of the non-stretching knee, the foot resting on the table. Place your hands on the lateral aspect of the stretching knee and apply downward pressure until a “MILD” stretch on the lateral hip is felt.
3. Hold for desired length of time. Repeat with a “MODERATE” stretch. Repeat with a “MAX” stretch.
   1. If the client feels “pinching” in the stretching groin area, gently circumduct the hip towards the same side shoulder and repeat the stretch, but with the foot in line with the client’s mid-calf on the non-stretching leg.

X stretch for the Tensor Fascia Latae and Quadratus Lumborum (opposite side)

1. Remove the strap from the non-stretching leg but leave the lumbar strap in place.
2. Place the non-stretching leg (which is closest to you) over top of the stretching leg.
3. Allow the non-stretching leg to rest on top of the stretching leg as you adduct the leg you want to stretch until a “MILD” stretch is felt at the lateral hip.
4. Repeat for “MODERATE” and “MAX” stretches.
5. Repeat this stretching series for the Quadratus Lumborum by raising the legs above the height of the table about 6 inches.
   1. ALTERNATE METHOD

1. Stabilize the pelvis more by placing the hand closest to the client’s trunk underneath their closest lateral hip.
2. Pull the legs towards yourself, sliding across the table until a stretch is felt. This may be necessary if the pelvis rolls towards you during the stretch.

Supine Thoracic Rotation

1. With the client lying supine, place the padded belt above the pelvis to secure the lumbo-pelvic area. The client will cross the leg closest to you over top of their other leg with the knee bent.
2. Stand to the side of the client and have the client take their opposite hand and grasp your hand (closest to their hip). Your opposite hand will give stabilizing pressure to the leg closest to you. and bring their trunk into forward flexion and rotation towards yourself while the client exhales. Hold for a “MILD” stretch and a “MODERATE” stretch.

REPEAT ALL SUPINE STRETCHES ON THE OPPOSITE SIDE AFTER GOING ALL THE WAY THROUGH THE LIST ABOVE (3-Way Hamstring, Gastrocnemius Stretch, Adductors, Hip Rotators, Lateral Glute Roll, X Stretch for Tensor Fascia Latae and Quadratus Lumborum, Thoracic Seat Belt Stretch)

Psoas – Thomas Stretch (Supine) OR Side Lying

SUPINE

1. Have the client stand directly in front of one end of the table, with the back of their hips touching the table. From this position, they will lay backwards so that their legs are hanging off the edge of the table.
2. Bring one hip and knee into flexion by placing the foot on the front of your shoulder as you stand directly in front of them.
3. Give gentle pressure to the non-stretching leg, flexing it further towards the client’s torso while you apply downward pressure to the opposite knee.
4. Perform “MILD”, “MODERATE”, and “MAX” stretches in this position.
5. Repeat on the opposite leg.

SIDE LYING

1. Remove all straps.
2. Have the client bring the bottom knee as far to their chest as possible. Maintain hips in a neutral position by applying pressure to the back of the hip you are stretching.
3. With your hand either cradling the medial aspect of their knee or your hand gently around their ankle/lower leg, extend the hip while you continue to provide stabilizing pressure on the posterior hip. You may have to adjust where your body is if the client has more flexibility.
4. Perform “MILD”, “MODERATE”, and “MAX” stretches in this position.

Quadriceps – From Thomas Stretch (Supine), Side Lying or Prone

SUPINE from Thomas Stretch

1. Immediately following the Thomas Stretch, remain in the same starting position but use your leg to gently flex the knee on the stretching leg.
2. Apply gentle downward pressure until a “MILD” stretch in the anterior thigh is felt and hold for desired time.
3. Repeat with “MODERATE” and “MAX” stretches.

PRONE

1. Position client prone on the table with the feet off the end of the table (to get ready for the posterior ankle stretch following). Place a bolster or your knee underneath their lower thigh.
2. Flex the knee until the client reports a “MILD” stretch. Repeat with a “MODERATE” stretch and again with a “MAX” stretch.

SIDE LYING

1. Leave straps removed and perform immediately following side lying psoas stretch.
2. Position the subject so that the thigh remains in a straight line with the upper body or the hip can be slightly extended. Position your body so that you are on the anterior aspect of the client’s lower leg.
3. Keep your hand on the medial aspect of the knee for comfort and gently flex the knee, using your body to move their lower leg, until a “MILD” stretch is felt. Hold for desired amount of time and repeat for “MODERATE” and “MAX” stretches.
4. Ensure throughout the stretch that the client is not feeling pressure or tension on the knee through communication.

Side lying Oblique

1. Leave straps removed and stand behind the client while they are in a side lying position, backed up to the very back edge of the table. Have the client comfortably flex the bottom knee and hip.
2. Allow the top leg to drop off the back of the table, top arm anchored by grasping the top of the table.
3. Stabilize the scapula by placing your closest hand at the inferior aspect of the scapula and applying superior pressure.
4. Have the client exhale while you apply gentle downward pressure with your free hand, placed above the knee joint to avoid pressure in the knee. Hold a “MILD” stretch and repeat for a “MODERATE” stretch and then a “MAX” stretch.
   1. ALTERNATIVE
      1. Have the client come to their side and laterally flex over a curved dome with their arms overhead. Give gentle overpressure at the shoulder while the client exhales.
      2. Repeat on the opposite side.

 

REPEAT ALL SIDE LYING STRETCHES ON THE OPPOSITE SIDE (S/L Psoas, S/L Quad, S/L Oblique) If performing the quad stretch prone, perform psoas and S/L oblique, followed by prone quad stretch and then switch to the opposite side psoas and S/L oblique. If performing the S/L quad stretch, perform psoas, quad then oblique before turning the client to their opposite side.

Seated Chest Opener

1. Have the client sit comfortably on the side of the table, facing away from you.
2. The client will clasp their hands behind their head and exhale while driving their elbows back.
3. You will be positioned behind the client, with your hands on the front of their elbows. Gently apply posterior pressure on the front of their elbows. Hold 2-3 seconds for a “MILD” stretch, a “MODERATE” stretch and a “MAX” stretch.

Seated Thoracic Rotation

1. Standing behind the client, allow their arms to rest at their sides. Placing one hand on the front of their shoulder and the other hand on the opposite side upper back, gently rotate the client towards you.
2. Hold for a “MILD” and “MODERATE” stretch and repeat in the opposite direction.

Seated Oblique Stretch

1. Remain behind the seated client and have them place their right hand on the side of the right side of their head and the other arm across the front of their stomach.
2. Use your right hand to grasp the client’s left hand and pull while your left hand will pull the client’s right elbow towards their head, which will side bend the client to the left.
3. Hold for a “MILD” and “MODERATE” stretch.
4. Repeat on the opposite side.

Upper Thoracic Extension

1. Begin with the client seated comfortably on the side of the table with their arms crossed and in front of their face, head down towards their elbows.
2. Stand directly in front of the client and loop your hands through the space near their elbows and place your hands on both sides of the upper thoracic spine.
3. Bring their trunk into slight forward flexion using your body and press down into their upper back with your hands, extending their upper thoracic spine. Perform 3-5 repetitions.