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Counterstrain and Exercise: An Integrated Approach

A - Chin Nod Stretch

Muscles Principally Involved
Upper trapezius, semispinalis,
splenius
capitus,
deep
suboccipital muscles, and the
sternocleidomastoid.
Setup Position
This exercise can be performed
in the standing or seated
position.
Action
The chin is moved into the neck
while simultaneously tilting the
head forward to stretch the suboccipital region.
Monitoring
The stretch should be felt at the
base of the occiput.
Precautions
Do not hold the stretch in a painful
manner.
Discontinue
this
exercise
if
dizziness
or
numbness is experienced.
Duration
This stretch is held from 10 to
15 seconds.
Repetition
Repeat 2 to 3 times for up to 4
times per day or as otherwise
directed.

Chin Nod

Chapter H

B - Lateral Neck Stretch

Reinforcement Exercises

Lateral Neck

Muscles Principally Involved

Middle scalene, upper trapezius,
and deep cervical flexors.
Setup Position
This exercise is performed while
seated on a chair or stool. The
right arm grasps the bench or the
chair maintaining an erect truck.
Action
The neck is sidebent to the left
pivoting at the cervicothoracic
junction (not the occipitocervical
junction). The chin is tucked
toward the base of the neck. The
head is slightly rotated to the
right until mild non-painful
resistance is appreciated. The
monitoring hand should feel the
scalene muscle tension during
the stretch.
Monitoring
The opposite hand monitors the
scalene muscles between the
trapezius and clavicle.
Precautions
Do not hold the stretch in a painful
manner.
Discontinue
this
exercise
if
dizziness
or
numbness is experienced.
Duration
Hold this position for 10 to 1 5
seconds.
Repetition
The stretch should be repeated
1 to 3 times 2 to 3 times per
day or as otherwise directed.
Reverse the position to stretch
the other side of the neck.

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Chapter H

C - Anterior Neck Stretch

Reinforcement Exercises

Anteri or Neck

Muscles Principally Involved

Anterior scalene, platyssma, and
sternocleidomastoid.
Setup Position
This exercise is performed while
seated on a chair or stool. The
right arm grasps the bench or the
chair to keep the shoulder from
cephalward movement during
the stretch. Maintain an erect
trunk.
Action
The neck is sidebent to the left
pivoting at the cervicothoracic
junction (not the occipitocervical
junction). The chin is tucked toward the base of the neck. The
head is slightly rotated to the right
until mild non-painful resistance is
appreciated.
The
monitoring
hand should feel the scalene
muscle
tension
during
the
stretch.
Monitoring
Using the
opposite
hand,
monitor
the
right
anterior
scalene muscle
above
the
clavicle.
Precautions
Do not hold the stretch in a painful
manner. Back off if dizziness or
numbness is experienced.
Duration
Hold for 10 and 15 seconds.
Repetition
Repeat 2 to 3 times on each side
2 to 3 times per day or as otherwise directed.

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Chapter H

D - Posterior Neck Stretch

Reinforcement Exercises

Posterior Neck

Muscles Principally Involved

Levator scapulae and upper
trapezius group.
Setup Position
This exercise is performed while
seated on a chair or stool. Reach
behind the hip with the right arm
and grasp the bench maintaining the
shoulders slightly depressed. The
trunk is maintained erect while
seated.
Action
The neck is sidebent to the left
pivoting at the cervicothoracic
junction (not the occipitoatlantal
junction). The chin is tucked toward
the base of the neck. The head is
slightly rotated to the left until mild
non-painful
r esistance
is
appreciated. The monitoring hand
should feel the muscle tension
during the stretch. The trunk is
slightly flexed and turned to the left
as a unit allowing the right shoulder
to depress until the upper trapezius
is gradually engaged into the
stretch.
Monitoring
Left hand will monitor the right side
of the posterior neck and upper
trapezius.
Precautions
Do not hold the stretch in a painful
manner. Back off if dizziness or
numbness is experienced.
Duration
Hold for 10 and 15 seconds.
Repetition
Repeat 2 to 3 times on each side 2
to 3 times per day or as otherwise
directed.

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Chapter H

E - Pectoralis Upper Fiber

Stretch

Reinforcement Exercises

Pectoralis

Muscles Principally Involved

Pectoralis major and minor.
Setup Position
This exercise is performed
standing and facing a wall at a 45
degree angle. Face the wall
with the right shoulder abducted
and elbow flexed. With the elbow
4 to 5 inches below the shoulder
height, place the forearm and the
hand against wall.
Action
Rotate the trunk as a unit to the
left until the stretch can be felt
on the right anterior chest wall.
Gradually push the body forward
by the action of the torso.
Maintain the scapula on the
posterior rib cage (scapular
retraction) while maintaining
shoulder abduction, horizontal
flexion and external rotation. To
increase the stretching action,
the chest wall can be pushed
forward with a small degree
of
upper
thoracic
extension. Inhalation effort will
accentuate the stretch and
enhance relaxation (inhibition)
within the pectoral muscles.
Monitoring
Stretch should be felt over the
right upper chest.
Precautions
Shoulder girdle discomfort is
voided by gradually engaging the
shoulder into abduction and
horizontal flexion.
Duration
Hold for up to 20 seconds.
Repetition
Repeat 1 to 3 times on each
side 2 to 3 times per day or as
otherwise directed.
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Chapter H

E - Pectoralis Middle Fiber

Stretch
Variation from left page:
The elbow is placed at shoulder
height with the forearm and the
hand against the wall.

E - Pectoralis Lower Fiber

Stretch
Variation from left page:
The elbow is placed above
shoulder height with the forearm and the hand against the
wall.

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157

Chapter H

F - Rotator Cuff Stretch

Reinforcement Exercises

Rotator Cuff

Muscles Principally Involved

Subscapularis,
infraspinatus,
teres
minor,
teres
major,
supraspinatus, latissimus dorsi,
triceps brachii, deltoids, and
pectoralis.
Setup Position
This exercise is performed in the
standing or seated position.
Place a towel in the right hand
and raise the arm overhead as
illustrated. The left hand reaches
behind the back and grasps the
towel. The thoracic cage and
abdomen should remain in ideal
posture.
Action
Having a secured grip on the
towel with both hands, pull on
the towel with the left hand
bringing
the
right
hand
downwards behind the upper
back. Next, with the towel in the
same position, the right arm
pulls the towel upwards.
Monitoring
Stretch is felt over the posterior
proximal region of the right arm
and on the anterior proximal
region of left shoulder.
Precautions
Exaggerated discomfort felt in
either of the shoulders may
indicate excessive stretching of
the rotator cuff.
Duration
This
stretch
is
held
for
approximately 10 to 15 seconds
in each arm in each of the two
directions discussed.
Repetition
Repeat 2 to 3 times for each
shoulder up to 2 times per day
or as otherwise directed.

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Chapter H

G - Forearm Pronation &

Supination Stretch
Muscles Principally Involved
Forearm flexors, extensors,
pronators, and supinators.

Reinforcement Exercises

Forearm Pronation
& Supinati on

Setup Position
This exercise is performed in the
standing,
sea ted,
or
supine
positions. The elbow is straightened
with the opposite hand grasping
the other ha nd that is to be
stretched.
Action
The hand is stretched to the ceiling
with the palm facing downward in
order to extend the wrist. This is
maintained for approximately 10 to
15 seconds. Next, rotate the right
hand so the palm is facing the ceiling
and apply flexion to the wrist until it
is felt in the forearm. Again,
maintain the stretch for 10 to 15
seconds.
Monitoring
The stretch is felt in the anterior and
posterior forearm compartments.
Precautions
Avoid overstretching the wrist. If
numbing pa in is experienced,
discontinue the exercise.
Duration
As stated, each stretch is held
between 10 to 15 seconds.
Repetition
Repeat the above routines 2 to 3
times on each side of the forearm
for both the right and left arms up
to 2 times per day or as otherwise
directed.

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Chapter H

H - Illiopsoas Kneeling Stretch

Muscles Principally Involved
Iliopsoas and the rectus femoris.

Reinforcement Exercises

lliopsoas Kneeling
Stretch

Setup Position
This exercise is performed in the
kneeling position. Place the left knee
on the floor to stretch the above
muscle group. The right foot is
placed forward so that the knee will
be flexed by approximately 90
degrees and the right hip by
approximately 90 degrees. The
knees are maintained at a hip width
distance from each other. The left
hand is kept on a chair or a bench
for balance.
Action
The pelvis assumes a posterior tilt
by tightening the buttock and the
abdominal muscles during this
stretch. It is important to maintain
this orientation in orde r
to
adequately stretch the above muscle
groups. The upper body core is
moved forward as if pushing the hips
forward while maintaining the left
knee placed on the floor.
Monitoring
The stretch is felt into the front of
the thigh and groin. The back should
not be allowed to arch backward
(lordosis).
Precautions
Maintain balance through this
exercise by holding onto a stationary
object. Perform this exercise slowly
avoiding sudden movements. A
pillow or a cushion should be placed
underneath the knee if necessary.
Duration
This stretch is ideally held between
7 to 15 seconds allowing slow
stretching of this region.
Repetition
2 to 3 repetitions for each side up to
2 to 3 times per da y or as
otherwise directed.
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Chapter H

J - Prayer Stretch

Reinforcement Exercises

Prayer Stretch

Muscles Principally Involved

Erector spinae, latissimus dorsi,

and lateral fibers externa l
oblique muscle.
Setup Position

This exercise is performed in the

kneeling position with the elbows
placed over a bench or a chair. The
knees are placed hip width apart.
Adjust the distance from the bench
to allow the hips to be at a 90 degree
angle. The elbows should be near
the edge of the bench to allow the
head to move forward.
Action

First, tighten the buttocks and the

abdomen to maintain posterior
pelvic tilt, generating stretch to the
lower back. Next, the chest is
pushed slowly toward the floor with
the head and neck moving forward
between the arms. Inhalation can
further assist the stretch.
Monitoring

The stretch will be felt at the

posterior proximal aspect of the
arms and at the thoracolumbar
region.
Precautions

Do not extend the neck. Avoid

excessive strain on the shoulder
joints. The knees can be protected
by placing a cushion (i.e., pillow)
under them.
Duration

The stretch is typically held between

20 to 30 seconds.
Repetition

Repeat 3 to 5 times up to 2 times

per day or as otherwise directed.

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Chapter H

K - Kneeling Erector &

Latissimus Stretch
Muscles Principally Involved
Erector spinae, deep spinal erectors,
latissimus dorsi, and lateral external
oblique.

Reinforcement Exercises

Kneeling Erector &

Latissimus Stretch

Setup Position
This exercise is performed on the
hands and knees on the floor as
illustrated. First start with the hands
placed shoulder width apart and
knees slightly spread out for
stability. The first position illustrated
has the right hand placed with the
left while maintaining a slightly
arched back.
Action
The buttocks and abdomen are
tightened to maintain posterior
pelvic tilt during this exercise. The
buttock region then approximates
the ankles while the right shoulder
is moved toward the floor in order
to stretch the above muscle group.
Monitoring
The stretch should be felt at the
paraspinal and flank regions into the
above noted muscle groups.
Precautions
Avoid excessive pressure on the
wrist, elbow, and shoulder joints. Do
not allow the lower back to become
lordotic. Use a pillow or other
cushioning material to decrease
contact pressure with the floor.
Duration
Slowly
apply
this
stretch
maintaining for between 10 to 15
seconds.
Repetition
Repeat 2 to 3 times on each side up
to 2 times per day or as otherwise
directed.

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Chapter H

L - Seated Erector Stretch

Muscles Principally Involved
Erector spinae, deep short
erectors, qua dratus lumborum,
oblique abdominii group.

Reinforcement Exercises

Erector Spinae &

Deep Erectors

Setup Position
This exercise is performed seated
on a bench, stool, or chair. The
feet are placed on the floor at
shoulder width. The right hand
reaches behind the chair and
grasps the chair providing support for the body which will flex
forward towards the knees.
Action
The left arm crosses over the
right knee as the body flexes forward
stretching
the
back
sequentially from above to
below. The position becomes
forward flexion, rotation to the
right, and sidebending to the
right. Proceed until the stretch
becomes non-painfully limited
at the region of greatest
restriction. Stop when this
restriction is approached. Take
a deep breath in and hold for
a
few
seconds
while
maintaining
this
stretch.
Exhale and follow with further
non-painful stretch. Inhalation
should be coordinated with slow
return to the neutral position.
Monitoring
The stretch should be felt down
the mid-back and into the hips.
Precautions
Avoid sudden or painful stretch
Duration
This stretch is ideally held
between 10 to 20 seconds
allowing slow stretching of this
region.
Repetition
2 to 3 repetitions in each direction up to 2 to 3 times per day
or as otherwise directed.
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Chapter H

M - Quadratus Lumborum
Stretch
Muscles Principally Involved
Quadratus lumborum, latissimus
dorsi, and erector spinae.

Reinforcement Exercises

Ouadratus
Lumborum

Setup Position
This exercise is performed in the
sidelying
position
on
an
appropriate table that is secured
or a firm bed. The posterior
pelvis is placed at the edge of
the table sufficient to be safe but
also allowing the left leg to
extend off the table in order to
apply the stretch to the above
musculature. The hands should
also assist in stabilizing the
body on the table.
Action
The stretch is assisted with deep
inhalation while allowing the left
leg to continue to stretch downward with the assistance of
gravity. This is a slow exercise
requiring
several
cycles
of
inhalation and exhalation.
Monitoring
The stretch is felt above the left
hip.
Precautions
The
surface
where
this
exercise is performed must be
stable to avoid falling. If any
discomfort is felt during any
part of this exercise, it should
be discontinued.
Duration
This stretch is paced on slow
respiratory assistance. Typically
allow from 5 to 7 breathing cycles
for each side.
Repetition
This exercise can be repeated up
to 2 times per day to each side
or as otherwise directed.

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Chapter H

N - Piriformis Stretch

Reinforcement Exercises

Piriformis Stretch

Muscles Principally Involved

Piriformis, gemelli, obturator,
and quadratus femoris muscles
Setup Position
This exercise is performed in the
supine position. The left leg is
grasped at the knee and pulled
across the body to the right as
illustrated. A towel can be
wrapped around the knee
utilizing the ends to pull the leg
if it is difficult to reach the knee.
The left foot is placed to the
lateral aspect of the right leg to
maximize the stretch.
Action
Pull the knee to the right until a
stretch is felt in the left hip and
buttock region. The left hip is
maintained on the floor or table
so that the force is isolated to
the hip.
Monitoring
The stretch is felt in the hip and
buttock region.
Precautions
Once the exercise is completed,
do not return the leg to the neutral
position too suddenly.
Duration
The stretch should be held
between 15 to 20 seconds.
Active contraction of these hip
muscles against the hand will
provide isometric release of the
tightness.
In this case, the contraction is
held between 5 to 7 seconds.
Either approach is followed with
further stretch to the right.
Repetition
Repeat 2 to 3 times on each side
2 to 3 times a day or as otherwise directed.
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Chapter H

O - Rectus Femoris Stretch

Rectus Femor is

Muscles Principally Involved

Rectus femoris
Setup Position
This exercise is performed in the
sidelying position. The spine is
maintained
in
the
neutral
position. A pillow under the head
will help
to maintain this
neutrality. The hip is positioned
perpendicular to the table or
floor. The right hip and knee are
flexed to maintain stability. The
left hand grasps the dorsum o f
the left foot.
Action
Tighten
the
buttocks
and
abdomen to maintain posterior
pelvic tilt and to decrease the
tendency of creating lumbar
lordosis. The left leg is extended
by
lifting
the
left
foot
cephalward.
Monitoring
The stretch should be felt down
the anterior aspect of the leg
being stretched.
Precautions
Avoid backward
lumbar spine.

bending

Reinforcement Exercises

the

Duration
This stretch is maintained between from 15 t o 20 seconds.
Repetition
Repeat 2 to 3 times on each side
2 to 3 times per day or as otherwise directed.

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Chapter H

P - Hamstring Stretch with

Reciprocal Inhibition

Reinforcement Exercises

Hamstrings

Muscles Principally Involved

Biceps femoris, semimembranosus,
and semitendinosis.
Setup Position
This exercise is performed while
seated on a stool. The leg to be
stretched is extended at the knee
with the heel of the foot placed on
the floor and placed in a dorsiflexed
position. The other foot is placed
on the floor to support the body. The
hands maintain slight pressure on
the patella of the leg that is being
stretched.
Action
Pivot from the hips in order to place
a stretch to the hamstring muscles
until a very mild non-painful stretch
is felt. Next, attempt to push the
patella bone upward toward the
pelvis by tightening the quadriceps
muscle, crea ting a reciprocal
inhibition action on the hamstring
muscles. Maintain this isometric
contraction for 3 to 5 seconds.
Follow this with a further stretch as
the hips are flexed forward.
Monitoring
The stretch should be felt behind the
knees and behind the upper legs.
Precautions
Due to high leverage orientation with
this exercise, caution should be
taken not to over-stretch the
hamstring muscles into further
strain.
Duration
Maintain the stretch for 10 to 15
seconds.
Repetition
These stretch and contraction efforts
should be repeated up to 3 times for
each leg up to 2 times per day or as
otherwise directed.
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Chapter H

Q - Iliotibial Band/Latissimus
Stretch
Muscles Principally Involved
Tensor fascia lata, iliotibial band,
peroneii, oblique abdominal, and the
latissimus dorsi muscles.

Reinforcement Exercises

l l iotibia l Band
Stretch

Setup Position
This exercise is performed against a
wall in order to stabilize the body
yet affect the desired stretch. The
right foot and entire right side is first
placed against the wall. The right
leg is then crossed behind the left
leg. Maintain the hip secured
against the wall and the left hand
may also be placed on the wall to
add to this security. Additionally, be
sure that the floor is not slippery so
that the feet remain secured.
Action
A mild force is applied to the lower
right leg while stretching the right
arm overhead and to the left. The
hip remains secured and is the
non-moving pivot point.
Monitoring
The stretch is felt to the side of the
leg and behind the shoulder.
Precautions
Note the above setup position in
order to perform this exercise
securely. If this exercise cannot be
performed securely it should not be
performed.
Duration
Slowly apply this stretch maintaining
for between 10 to 15 seconds.
Repetition
Repeat 2 to 3 times on each side 2
to 3 times per day or as otherwise
directed.

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Chapter H

R - Hip Adductor Stretch

Muscles Principally Involved
Adductor
brevis,
adductor
longus,
adductor
magnus,
pectineus, and gracilis.

Reinforcement Exercises

Hip Adductor
Stretch

Setup Position
This exercise is performed in the
standing position with the feet
wide apart. The spine is
maintained straight with the
pivoting taking place in the hips.
The right leg is straightened
though the knee is not allowed
to be locked while the left hip
and knee are flexed. The hands
are placed on the opposite thigh
for stability.
Action
The body is allowed to decline to
the left by increasing the flexion
in the left hip and knee. The
right leg is allowed to abduct
during this stretch in order to
stretch the adductor muscle
groups.
Monitoring
The stretch is felt in the inner
medial thigh.
Precautions
Maintain balance throughout this
routine. Do not increase the
stretch if pain is experienced.
Duration
This stretch is held between15
to 20 seconds.
Repetition
Repeat 2 to 3 times on each side
up to twice a day or as otherwise directed.

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Chapter H

S - Tibialis Anterior Stretch

Muscles Principally Involved
Tibialis anterior, extensor hallucis
longus, extensor digitorum longus,
and extensor digitorum brevis.

Reinforcement Exercises

Anteri or Shin
Stretch

Setup Position
This exercise is performed in the
seated position with the leg and
ankle to be stretched off the side of
the chair. The dorsum of the right
leg is placed toward the floor.
Action
Bring the right knee downward and
slightly forward in order to stretch
these muscle groups.
Monitoring
The stretch should be felt to the
anterior shin and dorsum of the foot.
Precautions
There is high mechanical advantage
with this routine. Do not continue
the stretch if pain is experienced.
Maintain stability throughout this
exercise.
Duration
Slowly apply this stretch maintaining
for between 10 to 15 seconds.
Repetition
Repeat 2 to 3 times on each side up
to 2 times per day or as otherwise
directed.

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Chapter H

T - Calf Stretch

Reinforcement Exercises

Calf Stretch

Muscles Principally Involved

Gastrocnemius,
soleus,
popliteus,
tibialis
posterior,
flexor hallucis longus, flexor
digitorum longus, quadratus,
and flexor digitorum brevis.
Setup Position
This exercise is performed in the
standing position. The feet are
placed shoulder width apart. The
left foot is placed one long step
backward maintaining the heel
on the floor. The right knee is
slightly flexed and both feet
should be facing forward.
Action
Tighten
the
buttocks
and
abdomen. Extend the left knee
while maintaining the heel flat
on the floor. Bend the right
knee and lean forward to place
the stretch to the posterior left leg
and plantar aspect of the foot.
Monitoring
The stretch should be felt to the
calf, posterior knee, and ankle
regions.
Precautions
Do not apply excessive pressure
on the knee or ankle joints.
Discontinue this exercise if pain
is experienced.
Duration
Slowly
apply
this
stretch
maintaining for between 15 and
20 seconds.
Repetition
Repeat 2 to 3 times on each side
up to 2 times per day or as
otherwise directed.

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Chapter H

Re1 - Pelvic Tilt Retraining

Reinforcement Exercises

Pelvic Tilt

Muscles Principally Involved

Gluteii and abdominal muscle
groups. This exercise begins the
retraining and stabilization of the
pelvis necessary for postural
balance. This exercise is also a
component for many of the exercises
in this manual.
Setup Position
This exercise is first performed in the
supine position with the knees
bent and feet flat on the floor or
table at shoulder width apart.
Once this exercise is mastered, it
can be performed in the standing
position.
Action
The first stage is to tighten the gluteii
and abdominal muscles in order to
maintain posterior pelvic tilt. This
will also flatten the lumbar region
stretching the quadratus lumborum,
erector spinae, and the deep erector
muscles. Visualize a movement in
which the abdominal muscles draw
the xiphoid and pubic bone regions
together and downward toward the
lower back.
Monitoring
The contraction effort should be felt
in the buttocks and abdomen.
Precautions
Do not use the lumbar muscles to
flatten the back.
Duration
This exercise is held between 5 to
10 seconds.
Repetition
This routine can be repeated
frequently in either the supine or
standing position. Between 5 to 10
repetitions performed a few times a
day or as otherwise directed.

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Chapter H

Re2 - Pelvic Tilt Retraining

with Bridge
Muscles Principally Involved
This exercise is the next stage
to the pelvic tilt exercise. This
retraining exercise increases the
strength of the gluteii and
abdominaI muscle groups. The
goal is to lift the pelvis off the
floor or table 1 to 2 inches
while maintaining a posterior
rotation of the pelvis.

Reinforcement Exercises

Pelvic Tilt with

Bridge

Setup Position
The set up position is the same
as the pelvic tilt setup position.
Action
The initial action is to perform
the action described for the
pelvic
tilt
stretch.
While
maintaining the posterior tilt, the
hips are lifted upward without
arching the lumbar region. The
thoracic
cage
should
be
maintained on the table or floor
while the hips are raised and
the lower back is stretched.
Monitoring
The contraction effort should be
felt
in
the
buttocks
and
abdomen.
Precautions
Do not allow the lumbar spine to
become lordotic or the pelvis to
lift unequally from either side.
Duration
Once the hip has reached 1 to
2 inches off the floor or the
table,
this
position
is
maintained between 5 to 10
seconds.
Repetition
The number of repetitions will be
dictated by the ability to
maintain correct form.

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Chapter H

Re3 - Abdominal Breathing Retraining

Muscles Principally Involved

Thoracoabdominal diaphragm,
pelvic floor, and pelvic
diaphragms
Setup Position

This exercise is performed in the

supine position. The knees are
bent with the feet placed on the
table hip width apart. The back
remains flat on the table.
Action

Perform a forced inspiratory effort

feeling outward motion of the
abdominal wall. This action
results in an increased intraabdominal volume facilitating
abdominal
and
pelvic
diaphragmatic excursions. Next,
perform a forced expiratory effort
by depressing the abdominal wall
posteriorly.
Monitoring

Place one hand over the umbilicus

and the other hand over the lower
third of the sternum. The hand
over the abdomen should monitor
that motion occurs from the
abdomen and not from the
thoracic cage.
Precautions
If dizziness or light headedness

occurs, decrease the inspiratory

and expiratory excursion returning
to
normal
breathing
until
symptoms subside.
Duration

The exhalation phase should take 2

to 3 times as long as the Inhalation
phase.
Repetition

Between10 to 20 repetitions of
the above procedure performed
daily or as otherwise directed.

RennleMatrlx

Reinforcement Exercises

174