Lumbar Side-Flexion

by Sam Ahmed

I. Description of Motion:

The vertebral column is capable of flexion, extension, lateral flexion (side-bending), and rotation. Bending of the vertebral column to the right or left from the neutral (erect) position is lumbar side flexion and returning to the erect position from a position of lumbar side flexion is lateral extension.¹

True lumbar side flexion is thought to be combination of side bending and rotation. Normally, side bending is attributed to one-sided contraction of the oblique, the transverse abdominus and the quadratus lumborum (QL) .²

Out of these three muscles, only unilateral contraction of the QL can bring on pure lateral flexion, and is thought to be the primary muscle.³ The QL originates from the lower portions of the last rib and is attached to the transverse process of the upper four lumbar vertebrae.⁴ It inserts at two locations, the illiolumbar ligament and iliac crest. It is innervated by the 12th thoracic and first through fourth ventral rami of lumbar nerves (T12, L1-L4).⁵

II. Mobilizing – Increasing Range of Motion:

The normal range of movements of the vertebral column for side flexion is 15-35 degrees however this can by limited by⁶:

• Thickness, elasticity, and compressibility of the IV disks¹
• Shape and orientation of the Zygapophysial joints¹
• Tensions of the joint capsules of the Zygapophysial joints¹
• Resistance of the back muscles and ligaments¹
• Attachments to the thoracic (rib cage)¹
• Bulk of surrounding tissue¹

The following three stretching techniques/positions can be effective in increasing the range of motion associated with lumbar side-flexion. Below each description is the length of time to hold the stretch, the feeling the patient should experience with the stretch and the frequency that the stretching should be performed.

A. Side-Bending with Chair⁷

1. Start by raising one arm directly over head and placing your second arm directly on the back support of a chair.
2. Slowly side shift your pelvis and hips to the right and away from the chair
3. While slowly sliding your pelvis, shift your pelvis and hips to the right and away from the chair
4. Stop when you feel a stretch down side of your body away from the chair.
5. Make sure to position your body for good balance and that the center of gravity falls evenly between both feet

i. Hold this position for 15-30 Seconds
ii. Exhale and return to the starting position
iii. Repeat this exercise 3 times for 30 seconds at least twice a day

B.Side-Bending Stretch with Wall⁷

1. Start by standing parallel to an open wall, roughly 1-2 feet away and place your entire forearm along the wall.
2. Slowly side shift your pelvis and hips toward the wall
3. Make sure to keep your elbow at a 90 degree angle
4. Stop when you feel a stretch down side of your body away from the chair.
5. A stretch should be felt on the lumbar spine that is on the same side of the wall
i. Hold this position for 15-30 Seconds
ii. Exhale and return to the starting position
iii. Repeat this exercise 3 times for 30 seconds at least twice a day

C.Side-Bending Childs Pose⁷

1. Start by having patients sit in the quadruped position.
2. Make sure patients have hand directly under shoulders and knees directly under hips
3. Slowly have the patients grab onto a corner of the table with both hands
4. Instruct the patients to slowly sit back and lean away from the corner
5. Patient should feel stretch on elongated side.
i. Hold this position for 15-30 Seconds
ii. Exhale and return to the starting position
iii. Repeat this exercise 3 times for 30 seconds at least twice a day

Targeted Tissue: The muscles which are primarily being stretched in the above video's are the lateral fibers of the erector spinae, the QL (quadratus lumborum), and the abdominal muscles.⁸

III. Indications for Stretching:

If a patient presents with a decrease in range of motion a number of stretching techniques, such as those described above, can be used to mobilize muscles, surrounding tissue and associated structures. A manual lumbar side flexion mobilization can also be performed by a trained Physical Therapist to improve lumbar side flexion range of motion, passive physiological movements, and passive accessory movements.

Refer to the following links under Potential Clinical Syndromes Related to Lumbar Spine for more information.

IV. Strengthening:

The following three strengthening techniques/activities can be effective in increasing strength in lumbar side-flexion. Below each description I have Identify how you might progress the activity from easy to harder to improve strengthening. The ideal frequency each technique should be performed is also listed below.

A.Side Plank

1. Lie on your right side, in a straight line from head to knees while resting on your forearms.
2. Make sure your elbow are placed directly under your shoulders
3. With your abdominals gently contracted, lift your hips off the floor, and maintaining the line between your head and knees.
4. Keep your hips square and your neck in line with your spine.
i. Hold this position for 20-40 Seconds
ii. Exhale and return to the starting position, Repeat two to three times alternating sides
iii. Complete 2-3 sets of 5 repetitions 2-3 times a day for optimal strengthening.

B.Hip-Up’s or Hip-Hikes

1. Lie on your right side, in a straight line from head to knees while resting on your forearms.
2. Make sure your elbow are placed directly under your shoulders
3. With your abdominals gently contracted, lift your hips off the floor, and maintaining the line between your head and knees.
4. Keep your hips square and your neck in line with your spine.
i. Hold this position for 1-2 Seconds
ii. Exhale and return to the starting position
iii. 1-2 sets of 10 repetition 2-3 times a day for optimal strengthening
iv. To increase intensity of this exercise, increase either the number of repetitions or the hold from 1-2 seconds to 3-4 seconds or more

C.Lateral Side-Bends

1. Stand up straight while placing your left hand on your left leg (palms facing the torso) and have the right hand holding your waist.
2. Your feet should be placed at shoulder width. Then while keeping you back straight and you head up, bend at the waist to the right as far as possible
3. Slowly breathe in as you bend to your side, then hold for a second and return to the starting position.
4. Instruct the patient to repeat the movement but bending to the left instead. Hold for a second and come back to the starting position
i. Have the patient complete 1-2 sets for 10 repetition 2-3 times a day for optimal strengthening.
ii. To increase intensity of exercise have patients complete this exercise with a dumb bell in hand as shown.

V.Potential Clinical Syndromes or Etiologies:

Potential Clinical Syndromes Related to Lumbar Spine:

Please refer to the following link to learn more about this

1) http://morphopedics.wikidot.com/lumbar-spine

2) http://morphopedics.wikidot.com/clinical-syndromes

3) https://www.princeton.edu/uhs/pdfs/Lumbar.pdf

VI. Additional Web Based Resources:

http://morphopedics.wdfiles.com/local--files/week-six/Core%20Stability%20Exercises.pdf
http://orthoinfo.aaos.org/topic.cfm?topic=a00302
http://www.spine-health.com/wellness/exercise/lumbar-spine-stabilization-exercises
http://www.safe-stretch.info/

Footnotes

1. Moore KL, Dalley AF, Agur AM. Clinically Oriented Anatomy. Lippincott Williams & Wilkins; 2013.

2. Available at: http://emedicine.medscape.com/article/1899031-overview#aw2aab6b3. Accessed December 3, 2014.

3. Hansen L, de Zee M, Rasmussen J, Andersen TB, Wong C, Simonsen EB. Anatomy and biomechanics of the back muscles in the lumbar spine with reference to biomechanical modeling. Spine (Phila Pa 1976). Aug 1 2006;31(17):1888-99

4. Moore KL, Dalley AF, Agur AM. Clinically Oriented Anatomy. Lippincott Williams & Wilkins; 2013.

5. Available at: http://www.meddean.luc.edu/lumen/MedEd/GrossAnatomy/dissector/mml/ql.htm. Accessed December 6, 2014.

6. Kendall FP, McCreary EK, Provance PG, Rodgers MM, Romani WA. Muscles Testing & Function with Posture & Pain. 5th ed. Baltimore, Maryland: Lippincott Williams and Wilkins; 2005

7. Available at: http://www.safe-stretch.info/chair-sidebend/. Accessed December 3, 2014.

8. Muscles. NYU Langone Medical Center Web Site. http://hjd.med.nyu.edu/spine/patient-education/spine-anatomy/muscles-and-ligaments/muscles. Accessed November 25, 2014.