I have covered the rationale and aims of performing routine exercises for the spinal joints in a previous article, now I will move on to the performance of the spinal exercises themselves. Patients should follow the exercise instructions and perform the exercises smoothly with even timing through the range, holding for a short period at the end of the joint ranges. A moderate degree of pain may well be acceptable as long as it is not too severe and does not last long after the performance of the exercise. Doing the exercises daily is key to managing a back pain problem.

Leg flexion to the chest In supine hold on to your knee and pull your thigh up to your chest, keeping it at the full extent for a few seconds, with the other leg remaining flat down. The lumbar spinal joints, ligaments and muscles, hip and sacroiliac joints are mobilised during this manoeuvre.

Bilateral knees to chest stretch Lying flat on the back, bend your knees and pull on your shins, pulling your thighs up to the trunk. This is less stretching for the sacroiliac and hip but gives a stronger stretch to the low back structures including the ligaments, muscles and joints.

The Pose of a Child Kneel on the floor and allow the trunk to curl forward to lie on the fronts of the thighs with the back stretching out into flexion. This flexes the whole of the spine because the bodyweight increases the force of the stretch.

Squatting down This movement involves a greater degree of force than previous ones and can be useful to counteract the effects of sitting for too long. Extension movements are often recommended to restore the lumbar curve after sitting too long but flexion can be just as helpful in relieving discomfort.

Squat right down until your thighs are against your calves, using a block under your heels if you need to maintain balance. Staying down in that position for half a minute, allowing the lumbar spine to flex out, can be performed at times or three times in a row with rests between.

Stretching out at the bottom of the movement, the back is kept in this position for half a minute or so at a time.

Lying on the front Sometimes the ability to extend the lumbar spine is restricted and then prone lying, lying on the front, is a useful starting exercise as even this can stress the joints when they are stiff. The back is more extended in this position that it appears on the surface.

Elbow supported prone lying A progression from lying on the front is to get the patient to support themselves up on their forearms to increase the extension stretch on the lumbar spine. The lumbar spine is placed in greater extension than prone in this position, stressing the tight structures and forcing them to give.

McKenzie Repeated Prone Extensions McKenzie technique is a form of manipulative treatment at affecting disc dysfunction and derangement. Lying on the front with the hands placed near shoulder level, the patient pushes until their arms are straight whilst leaving the pelvis down on the bed, involving a significant lumbar extension.

This exercise is known to be aggravating in certain patients as it forces the facet joints together so needs to be tested by a physiotherapist to ensure effectiveness.

Lumbar Rotations ” Knee Rolling Lying on the back, the knees are bent and both knees are rolled to one side and then another, allowing the movement to go as far as it comfortably can. Although there is little rotation in the lumbar joints some of the spinal structures can be tight into rotation.

Lumbar Rotation Mobilisation The patient lies on their back and leaves their shoulders on the ground as they bend one leg up so the opposite hand can get hold of the knee and pull the leg over the body, stretching out the back. This stretches the facet joints and soft tissue structures strongly so other stretches might be more appropriate before progression is made to this exercise.

Colles’ fractures, named after Abraham Colles who first described in 1814 the common fracture of the last inch of the radius and ulna near the wrist, is a very common consequence of a fall on the outstretched hand (FOOSH). Typical treatment is immobilisation in a plaster of Paris or similar material for five to six weeks to allow bony union, followed by a rehabilitation period of a month or more, a short period of which might involve a wrist brace for comfort during activity. Due to the functional importance of the hand, the period of immobilisation is kept to a minimum to prevent dysfunction of the hand and wrist.

Once the Plaster of Paris has been removed the physiotherapist will examine the wrist for appropriate healing by firmly palpating the area over the fracture, which should not show much more than mild tenderness. The hand should look a natural colour, have no tightness or swelling in the fingers and muscle wasting should not be severe. Movements of the wrist will be restricted in a few planes but should not be affected in all planes of motion, neither should there be severe pain on movement nor pain on all movements. If many problems are present the physiotherapist will take urgent steps to rehabilitate the patient.

Initial treatment is to instruct the patient in range of motion exercises to be performed every two hours. For many fractures this is all that is required as the movements are easily restored with a few days’ exercises, concentrating on the end ranges of movement. The shoulder and elbow are checked to make sure they are not limited as they may have been injured in the initial incident or kept very still by the patient whilst in plaster. The pronation and supination movements of forearm rotation are functionally very important, and the physiotherapist checks wrist extension and flexion and finger and thumb movements.

Patients often report that the wrist feels at risk after the plaster has been removed and this may be due to the early removal of the plaster to prevent functional loss from immobilisation. A futura brace, a fabric support stiffened with a metal piece under the wrist, is applied with Velcro straps to give support during normal activities of daily living. The brace should be taken off during rests or light activity and for regular performance of the exercises. Too much further immobilisation at this stage could be harmful so patients should understand the limited use of the splint for comfort during activity.

If the ranges of motion do not improve as they should then the physiotherapist will consider using joint mobilisations to ease the movements. Accessory movements can be performed to the inferior radio-ulnar joint to help pronation and supination, and to the radiocarpal (wrist) and midcarpal joints, with the physiotherapist fixing one side of the joint as he or she moves the other side of the joint passively. This can be done gently or more vigorously at the end of range to push against the restrictions within the joint. Mobilisations can also be performed with the joint at the end of its available movement to give it the sliding and gliding movements it requires.

Returning steadily to normal use of the wrist and hand is the easiest and often the most successful way to regain forearm strength. In some cases more must be done to return the hand to normal if it is very weak or the person needs to return to a heavy manual job or has particular upper limb strength requirements for a sport or hobby. Instruction in practicing all the different hand movements against resistance can be accomplished in a hand class, where patients can use equipment designed to strengthen particular movements such as gripping, pulling, twisting, turning and to improve fine hand function.

If the hand is very painful, swollen and restricted in motion then treatment may be urgently directed to preventing a pain syndrome developing, once the fracture has been reviewed by a doctor to make sure healing has progressed as it should. Hot and cold contrast bathing for the hand can be useful for the pain and swelling, with massage and sensory work to reduce the hypersensitivity which can be troublesome. Patients need to be very clear that they need to work hard through the pain in these cases to regain a normal hand.