Retrolisthesis

EXERCISE PROGRAM

A Self - Help Guide to Rehabilitation

Exercises to Support Healing, Fitness & Sports

Michael C. Remy, DC, DABCO, CCSP

Prepared exclusively for [email protected] Transaction: 0116883185

 Copyright 2022, North Shore Health & Fitness Associates, Inc.

All rights reserved.

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No part of this book or program may be reproduced or shared in any form or by any means,
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copyright owner.

North Shore Health & Fitness Associates Inc. , Publishers

333 Glen Head Rd. Suite 218, Glen Head, NY 11545

Disclaimer:
Please be advised that any exercise and nutritional advice given in this book is for general
information purposes only. There is no intent to diagnose, treat, or suggest personal advice
as per your individual health issues or status. Certain exercise and nutritional advice given
in this book may be harmful for your condition, and may cause injury or a worsening of your
condition, as well as other health problems. Always consult with your own doctor before
beginning this or any exercise routine, or changing your diet.
 Gratitude

To my Lord and Savior

Jesus Christ,
Through whom all good and healing comes.

Special Thanks to Our Models:

Carol Clark
Justin Miller
Dr. Peg Martinez
Connor Remy
Jeannie Remy
Shannon Remy
Michele Ricciardi
Peter Von Schoenermarck
Barrie Sue Zicherman

and to:

Power Fitness Health Club, Brookville, NY for additional photography location

Images used under license from Shutterstock.com, Pixels.com, Unsplash.com

 CONTENTS

Chapter 1- Intro ... 6

Chapter 2- Your Retrolisthesis Analysis…9
Chapter 3- The Mechanical “Themes” of Your Pain … 26
Chapter 4- Your Neutral Spine … 31
Chapter 5- Retrolisthesis Posture & Movement: Basic Training… 35
Chapter 6- Exercises for Pain with Flexion … 43
Chapter 7- Exercises for Pain with Extension … 71
Chapter 8- Exercises for Pain with Rotation (Twisting) …82
Chapter 9- Exercises for Pain with Side Tilting & Side Leaning… 89
Chapter 10- Exercises for Pain with Translation Postures … 95
Chapter 11- Designing Your Custom Retro Workout Program … 100
Chapter 12- Avoiding Dangerous Exercises & Sports …115
Chapter 13- Pain Relief Exercises and Techniques …121
Chapter 14- The Mind Set for Overcoming Chronic Back Pain…127
Chapter 15- Nutrition for Back Pain and Inflammation … 139
Chapter 16- Conditioning a Better Back Condition … 141
Chapter 17- Putting It ALL Together…147
Chapter 18- References and Suggested Reading … 150

Video Demonstration Links of Back Pain Posture, Body Mechanics

and Spinal Stability Self Analysis: Part One… 10, Part Two… 16
 1
Introduction

Retrolisthesis is much more complex than simply a vertebra that has “slipped” backwards out of
alignment with adjacent vertebrae. It typically presents as a real challenge to both the back pain
sufferer and the professionals trying to help. Most doctors find it difficult to treat, while rehab and
exercise specialists will usually agree that it is not easy to find appropriate exercises that are
generically successful. The patient finds it difficult to find accurate information that is truly helpful
amid the online searches and consultations with doctors and therapists concerning a back pain
diagnosis that is considered rare.
The paucity of scientific research on retrolisthesis further supports the notion that there is no one
type of generic retrolisthesis pain or condition. Besides generally agreeing that most retrolisthesis
is due to spinal degeneration and associated with a decreased lordotic arch (curve) in the lower
back with a lower angle of pelvic tilt, these research studies often have conflicting results that adds
to the enigma of retrolisthesis.
Some studies show that retrolisthesis occurs primarily at the lowest lower back segment of L5/S1
followed by L4/5 (Hamdan), while others show that rertrolisthesis is most common at the L3/4
spinal level followed by L2/3 (Jeon), and that L3/4 retrolisthesis is most associated with back pain
and impaired function (Vogt). Other studies show that retrolisthesis does not increase the risk of
pain 3 years after disc herniation surgery, while other studies find that is does (Shenoy vs Kang).
Research theorizes that retrolisthesis can be caused by a compensatory mechanism due to either
too much or too little pelvic inclination (Jeon). Vogt has demonstrated that the prevalence of
retrolisthesis was over 3 times greater in older white females than in older African American
females. While it is generally agreed that spinal disc degeneration and surgery are the most usual
causes of low back retrolisthesis, Shen and colleagues demonstrated that in patients with L5/S1
disc herniations who later underwent surgery, no significant changes were found in pre-operative
pain or disability between those with or without retrolisthesis. They also found that the prevalence
of retrolisthesis was not associated with spinal degeneration, sex, age, race, or smoking status.
When looking at patients 8 years after disc surgery, Shenoy and colleagues found that having
retrolisthesis did not make a difference in pain or re-operation rates when comparing retrolisthesis
patients to those without retrolisthesis.
The problem with analyzing retrolisthesis pain is that there is no one spinal soft tissue that is always
responsible for the pain. Depending on the individual, back pain may be the result of damage or
stressful irritation to any of several spinal soft tissues including discs, ligaments, muscles, tendons,
facet joint capsules, synovial linings, fascia and nerves. It has been known for several decades now
 7

that imaging study findings on MRI, CT scan and X-ray such as herniated discs and arthritic
degeneration are poor indicators of what soft tissue is truly causing the pain. The same holds true
for an imaging study showing that one or more spinal vertebrae have slipped backwards
(retrolisthesis), which only indicates that there is some instability of the supporting restraints at
that spinal level. There are millions of people with the worst imaging study findings who have no
pain, and millions of others with normal imaging studies, showing no overt structural damage or
slippage, who are in the most severe pain. To complicate matters worse, attempting to treat only
the painful anatomical soft tissue rarely addresses the true cause of retrolisthesis problems, which
is the mechanical stress imparted to the spine that causes damage, inflammation and pain.
As most modern back pain researchers agree that over 90% of all low back is mechanical in nature,
chronic retrolisthesis back pain relief is usually only realized once the sufferer removes the
offending physical mechanical stresses that are causing the irritation. These mechanical causes
include faulty posture, movement and spinal stability habits, complicated by poorly conditioned
back fitness levels, which leaves the retrolisthesis sufferer open to not being able to safely handle
the physical stresses that are placed on their spine during their daily activities.
Once the retrolisthesis sufferer learns how to spare their back soft tissues from offending
mechanical stresses, and conditions their spinal stability to be able to safely handle the imposed
loads of daily life, the repetitive damage cycle is eliminated and back pain improves as the body
begins to heal. This is accomplished through a tailored program (unique to each individual) that
removes the repetitive micro-stresses of daily life by improving one’s posture, movements and
spine stability.
This FAST TRACK RETROLISTHESIS PROGRAM TM customizes exercises designed to
improve spine stability based on an analysis of posture and movements that cause pain. The
exercises, posture, and movement changes will be different for each person. Because there is
nothing generic about retrolisthesis pain, there is nothing generic about the self-management skills
taught in this program, other than identifying nutritional and psycho-social factors that may be
complicating the mechanical damage to one’s spine. The entire program is based on what works
most of the time for retrolisthesis sufferers, and is based not only on what the current research has
shown to be successful, but includes what I have found to work with retrolisthesis patients in my
32 years of clinical practice.
I have enjoyed an over 90% success rate with back pain patients, including retrolisthesis cases,
because of one crucial aspect to my approach. I have found that SPECIFICITY is the key to most
back pain relief. Whether my patients have retrolisthesis pain associated with
anterolisthesis/spondylolisthesis, herniated and degenerative discs, facet arthritis, IVF/lateral
recess/ or central spinal stenosis, scoliosis, sacro-iliac pain, or any other “mechanical’ source of
retrolisthesis back pain (with or without radiation into the legs), and regardless of whether or not
they have had surgery, I have found that in most cases, determining which specific positions and
 8

directions of movement are painful, and relating that to their specific spinal stability faults, is the
key to recovery.
It all begins with an analysis to determine what positions and movements are painful, and how
these relate to one’s posture and movement patterns, muscle asymmetries, and back fitness
conditioning levels. Most of the time, the analysis determines exactly which direction I need to
go in for treatment and rehab. While the approach is unique for each patient, the concept is the
same- teach and condition the patient to avoid irritating their spinal soft tissues by strengthening
their ability to stabilize the spine, and avoid the postures, movements and loads (forces) that
cause retrolisthesis damage and pain.
Once the exercise and posture/movement habits have been strengthened to a certain degree
(varying per individual), the body can finally get its innate healing process going because healing
can finally outpace the repetitive cycle of damage. This approach helps the great majority of my
patients, and hopefully these same self- management skills will help your retrolisthesis condition
as well.
Remember that this exercise and self-management skill program can only address what is found
on your analysis. The more careful and precise you are in your analysis, the better outcomes will
be expected. If you have a rehab specialist or doctor to work with, your analysis can be more in-
depth than what you can achieve through this program, as there is no substitute for a professional
examination. This program is not designed to be a diagnosis or treatment of your back pain, and
it is possible that the exercises or self-management skills presented may not be safe for your
particular condition, so always check with your doctor before beginning this or any exercise
program. Enlisting the help of a local spinal rehab specialist to assist in the advice and exercises
given can also help you in getting the most out of this program.
Many back pain sufferers from around the world have contacted me for personal help with their
analysis and exercise programs because they cannot find a local spine rehab specialist in their area.
As with all of my back pain programs, I am always available for online consultations and analysis
help for those who feel they need a more one-on-one approach. This information is available online
at the painfreeandfit.com website.
I hope this FAST TRACK PROGRAM FOR RETROLISTHESIS TM helps you identify the
mechanical causes of your lower back pain, and helps guide you through the exercises as well as
the posture/movement habit changes and other self-management skills necessary to help with your
retrolisthesis condition.

Dr. Michael C Remy, DABCO, CCSP

Board Certified Chiropractic Orthopedist
Board Certified Chiropractic Sports Physician
 2
Your Retrolisthesis Analysis

An analysis is essential before retrolisthesis exercises can be tailor-designed for you. Key
components of your typical postures, movement habits, and spine stability tendencies must be
discovered and related to your pain if you want the best chances of improving your condition
through a corrective exercise program.
Because every case of retrolisthesis is slightly different, the choices of your exercises, and how
you will want to perform them, will be different from anyone else. If every case of lower back
(lumbar) retrolisthesis was the same, with the only problem being low back pain provoked when
bending forwards due to a backwards displaced vertebra, then constructing an exercise program
would be easy. It would consist of strengthening the avoidance of flexion (bending forwards on
the spine) because flexion increases disc compression and mechanically forces the backwards
vertebral displacement of retrolisthesis. Exercises which strengthened the extensors (backward
bending muscles) would help to resist the forward bending forces, and help to avoid the
aggravating flexion motion. Unfortunately, this simplistic scenario is not the full reality of most
cases of retrolisthesis.
Retrolisthesis sufferers commonly have varied degrees of disc herniation, bulging and
degeneration. Some also have facet joint (the spinal joints behind the disc) degeneration/arthritis,
or have canal or IVF stenosis. Some may have spondylolisthesis (a forward slipped vertebra) at
one spinal level and retrolisthesis (backwards slip) at another. Any of these associated conditions
may causes the sufferer to have pain both with bending forward (flexion) and backwards
(extension). Some may have a sacroiliac joint issue or a muscular/tendon component to their
retrolisthesis condition which causes pain while twisting or side leaning (spinal rotation and lateral
flexion respectively). Other retrolisthesis low back pain can be caused by a short leg, a rotated
pelvis, an arthritic hip, a bowed knee, or a flat foot that is mechanically stressing the lower spine.
Many are in pain because they have late firing or weak core stabilizing muscles in the pelvis,
abdomen and back which fail to hold the retrolisthesis vertebra in a safe (neutral) position or range
of motion when bending and moving, thus causing dangerous micro-motions of the spine which
pinch, pull and otherwise damage nearby soft tissues causing pain. Still others have asymmetric
posture habits or have developed asymmetric muscles in the legs, hips, and shoulders which cause
a repetitive stress to the lower back aggravating their retrolisthesis. Some lack the required
strength to properly stabilize their retrolisthesis when lifting or moving heavy items, while others
lack the endurance in their stabilizing muscles to meet the duration demands of smaller repetitive
stresses related to their job or daily activities.
The reality is that for every unique case of mechanical back pain related to retrolisthesis, there is
a uniquely different targeted approach to stabilizing the spine and avoiding damage and pain.
 10

Choosing the appropriate exercises to develop spine stability must therefore come from an analysis
of the unique issues causing the problem.
A thorough analysis of the mechanical causes of retrolisthesis back instability and pain can be
divided into several aspects including posture, movement, strength/coordination and endurance.
All of these components will be considered in the following four part self-analysis. Remember that
no one part or finding is more important than another at this initial stage. Later, you will combine
your findings from the analysis, which will allow you to discover the directional “themes” of spinal
instability that relate to your pain.
The following four part analysis is designed to help you discover the mechanical faults that
are most likely causing your back stress and pain. Some of these findings may be very slight
in degree, but nonetheless may be very important in your healing. Record even the minutest
findings.

If you feel that you have no posture, movement or stability findings on a particular
checkpoint while standing, it often helps to double check your posture under a more
challenging position such as while standing on one leg, or while squatting. Using these two
additional tests help reveal small findings which are often not apparent during the normal
standing evaluation.

Stand in front of a full length mirror for this analysis. Recruiting a friend or family member as an
extra pair of “analysis eyes” may also be helpful. Assume your most natural posture.

PART ONE- Postural Alignment

Video Link:
https://youtu.be/NGRhHdCxXCc

1. Foot Posture. Begin by examining your feet. Ideally, your feet should be pointing straight
ahead, with your body weight being equally distributed on the four corners of each foot (the big
and small ball of the forefoot, and the inner and outer corners of the heel). If your feet lean more
on the inner edges or inner heel (foot pronation), your Achilles tendon at the back of your heel
will bow inwards. Conversely, if you lean with more weight on the outer aspect of your feet (foot
supination), your Achilles tendon will bow outwards.

If you have trouble checking this, ask a friend to view you from behind. If your heel leans in or
out, your Achilles will not be vertically straight, and will easily be seen from behind to bow in or
out. A pronated foot will decrease the normal medial longitudinal arch on the inner edge of the
foot while standing. A supinated foot will elevated this arch. Be certain on this aspect of the
analysis- it is huge for helping back pain because the normal curve (arch) of the lower back will
be increased with pronation, and decreased with supination.
 11

Pronation Supination

Examine the top of each standing forefoot next, just behind

where your toes meet your foot. Normally, this region should
have a slight elevation or crown, indicating a healthy
transverse arch under the bottom of the forefoot. The
transverse arch is located just behind the balls of your forefoot.

If the top of the forefoot appears flattened, or sunken in

towards the floor, the transverse arch has fallen or decreased
in its vertical height. Compare your right foot to your left.
Often, the side of greater foot pronation will be the same side
as a fallen transverse arch. Both of these affect back pain while
walking. A fallen transverse arch is demonstrated here in the
photo to the right. Record all of your foot analysis findings.

Finally, try to correct your foot posture towards normal alignment while standing to determine if
the corrections affect your back pain. If you pronate and naturally lean more on your inner heel,
tilt your heel so that you lean a bit more towards your outer heel. If you naturally supinate, lean
your heel inwards slightly. The goal is to even out the weight bearing pressures on the bottom of
each foot against the floor, so that you stand with your body weight equally distributed on all four
corners of each foot. If you have a fallen transverse arch, attempt to narrow your forefoot by
tensing your inner and outer forefoot towards each other (trying to “bunch–up” the floor beneath
your forefoot). Keep your toes flat as you attempt this. You will rarely see a visible movement
with this correction, but may notice that your forefoot elevates slightly.

If any of these corrections change the way your back feels while standing, record your findings.
You are especially interested in changes that make your back feel less pain, less tight, or more at
ease. If any corrections aggravate your pain, try less of a correction. Often, a full correction towards
 12

ideal alignment is too much of a sudden change for your back to be comfortable with. Usually
however, a slight change, even very slight, will improve back pain while standing.

Record your findings. If there is no change in the way your back feels with the corrections, simply
remember your analysis findings for future use in the program.

2. Check for Side Tilting Posture.

Look at the levelness of your hips and torso. Your hips, ribcage, shoulders, and knees should be
level in height from right to left sides. If they are not, you will have compression stress on one
side of your spine, and tensile (stretching stress) on the opposite side. It helps to place your fingers
on the top of your hips (pelvis) and also at the bottom of your ribs in this side tilt analysis.
Determine if one hip is slightly higher, or if one side of your torso or ribcage is lower. Disc and
joint compression exists on the side of low ribs, or a high hip. If you see perfectly level hips,
shoulders and ribs, try the same test while standing on one leg, or while squatting down. Most
people will have one hip that has a tendency to swing up (hip hiking), often corresponding with
their ribcage leaning downwards (torso side tilting or leaning) on the same side. If your hip swings
up while standing on either leg, record the side that swings up more.

Now see if your back pain can be relieved or aggravated by either increasing or decreasing the side
tilt of your ribcage or hips (pelvis). Often, straightening your body out will alleviate some of your
pain. If you have no pain presently, determine if your back feels less of a pulling or uncomfortable
sensation with these changes. Record the position that feels the most comfortable.
 13

3. Check for Twisting Posture.

Next, determine if your hips or chest have a tendency to twist to one side. You may place your
fingers on the front of your hips, and see that one side is positioned slightly forward compared to
the other. You may also see that one side of your
chest, or lower ribcage, is held slightly more
forward than the other. If you do not see any natural
twist in your body, lie down on the floor face up
with your knees bent and your feet flat on the floor.
Allow your knees to fall to one side, allowing your
pelvis to twist to that same side. Compare the
stretch (or range of movement) with your knees
falling to the opposite side. Many people will have
one side that feels more flexible, and one side that
is tighter to twist towards. The side that is easier to
twist towards (or the side that your natural posture
twists towards while standing) is a rotational
posture tendency of your torso or hips (pelvis).
Record your findings.

Now see if your back pain is relieved or aggravated

with slightly twisting either your hips or torso to
one side in the standing position. Test this with a slight twist of your pelvis without moving your
torso, and then with a twist of your torso, without moving your pelvis. Use a slight twist (less than
½ inch) to either side. Try the same twist lying face up on the floor with your hips and knees bent.
Often, twisting towards a neutral alignment (opposite to your natural posture deviation) will
alleviate some of your pain. Record your findings of pain aggravation or relief.

4. Check for Pelvic Tilting Posture.

Next, stand sideways to the mirror. Place one index finger on your pubic bone, and the other on
the tip of your tail bone. Normally, your pubic bone should be level with the tip of your tailbone.
Compare the height of your fingers while viewing yourself standing sideways in a full length
mirror. If your tailbone is higher than your pubic bone, you have anterior pelvic tilt posture. This
will typically increase the curve (or arch) in your lower back known as lordosis. It will also cause
your belt or the waist of your pants to tilt forward. If your pubic bone is higher than your tail bone,
you have a posterior pelvic tilt posture. In this case, your natural lower back arch will be flattened.
This causes a decrease in lordosis, and a backwards tilt of your belt, or waist line.

Slowly tilt your pelvis back and forth into anterior and posterior pelvic tilting while standing to
see if this positional change affects your back pain. Raise your tailbone upwards to anterior tilt and
 14

increase the curve in your lower back, and tuck your tailbone down and under (raising your pubic
bone upwards) to posterior pelvic tilt and flatten the curve in your back.

If you have difficulty with this, imagine the movement occurring at your belt buckle. Lower your
belt buckle for an anterior pelvic tilt, and then raise your belt buckle for a posterior pelvic tilt.
Determine the amount it takes in either direction to begin to feel the slightest back discomfort.
Then position your pelvic tilt at the midpoint between these two painful ranges of motion. This
should be the neutral position that provides the most comfort to your back pain. Note your findings.

Sway Back Posture Anterior Pelvic Tilt

5. Check for Forward Head and Sway Back Posture.

Continue viewing yourself standing sideways to the mirror. Your ear, shoulder, hip and knee
should all be vertically aligned. The vertical line that connects these body points should pass just
in front of your ankle while standing. Forward head posture exists if the center of your ear is in
front of the center of your shoulder. This can increase neck and lower back joint and disc
compression, as well as ligament/ muscle tensile stress. If the center of your hips are positioned
more forward than the center of your shoulders, you have sway back posture, which is associated
with weak “core” and buttock muscles, negatively affecting back mechanics.

Check to see if changing your posture by either pulling your head or pelvis straight back in relation
to your torso alleviates your back pain. It helps to first practice this while standing with your back
against a wall. Push your head and/or your hips back into the wall without pushing your back into
the wall. Test different amounts of position change, ranging from a few millimeters to 2 inches of
head and pelvis repositioning. Try to get the right combination of head and pelvis repositioning
that feels the best on your back. Record your findings.
 15

6. Check for Rounded Shoulder and Extended Head Posture.

The front of your shoulders should be flat in contour, and not concave (scooped-out or hollow) in
shape (rounded shoulder posture). The bottom of your nose should be level with the bottom of
the back of your head (where your neck meets your head). If the bottom of your nose is higher,
extended head posture is indicated. This is associated with an increased neck and lower back
curve, forward head posture, and general slumped posture, all of which stress your spine.

Reposition your shoulders by moving your shoulder

blades together to flatten the front of your shoulder
contour. This will stretch apart the front of your shirt.
Lower your nose as you pull your face towards the
back of your head, lengthening the back of your neck.
Determine if either of these postural changes alleviate
your back discomfort. Record your findings as to how
much of a correction makes your back feel the best.
Remember that if you have no pain presently, simply
determine if these postural changes allow your back to
feel less tension, less pulling, or more “at ease” in the
new position.

7. Check for Lateral Translation Posture.

Return to facing the mirror straight ahead. Your pelvis, ribcage and head should all be stacked
vertically on one another in alignment. Note if one of these areas is positioned sideways and not
in vertical alignment with the other regions. This misalignment is known as lateral translation
posture. Note if repositioning your pelvis, head, or ribcage towards normal alignment by sliding
any of these regions sideways towards center, affects your back discomfort. If you have difficulty
straightening yourself out, try it standing sideways against a wall, pushing the needed correction
into the wall without allowing the other body regions to press against the wall. Record your
findings.

8. Knee Posture.

Knee posture can affect the mechanical stresses that are imparted to your back. Checking your
knee alignment while standing and sitting is an important part of your analysis that can be used
later with your walking program.

In normal standing posture, each knee should be vertically aligned between the center of the thigh
and ankle. The knees will deviate inwards in knock knee posture, and away from each other in
bowlegged posture. When viewed from the side, each knee should be able to straighten. If it does
not, a flexed knee posture is present. This can be due to knee injury, arthritis, or muscle imbalance.
 16

If the knee straightens past a vertical alignment, so that the back of the knee bows backwards, a
knee recurvatum posture is present. When sitting, the knee cap and foot should face the same
direction. If the foot points more outwards than the knee cap, an external rotation knee posture
tendency is likely. Less commonly, a foot that points inwards in relation to the knee cap while
seated is known as an internal rotation knee posture.

All of these knee postures can affect the levelness of the pelvis, and thus create a mechanical
irritation to back soft tissues such as discs, joints, nerves, muscles and ligaments. While some of
these postures are correctable, others may not be. If you have found any of the above findings in
your analysis, note if changing them towards normal alignment affects your back pain or tension
in the standing position. Any corrections that lessen back pain or tension will be used later in your
corrective exercise program.

PART TWO-
Supporting Muscle Problems, Body Mechanics, and Corrections

Video Link:
https://youtu.be/SCPxS-9zgZI

1. Transverse Abdominal and Internal Oblique Muscles.

Your abdominal muscles are arranged in four layers and play a major role in supporting your
neutral spine position. Unfortunately, many back pain sufferers lack proper coordination, strength
or endurance of the abdominal muscles, which causes undue spinal stress.

This test is done lying face up with your knees and hips bent. Your feet are flat on the floor. Begin
the first part of the test by placing your fingertips two inches to the sides and one inch below your
belly button. Do not press in deeply as you want the touch to remain soft to sense what you will
do next. Gently pull (suck in) your lower abdomen toward your spine. Feel your lower abdomen
move down and away from your fingers. Do both sides move away equally? Does one side move
less? Do one or both sides bulge out toward your fingers?
 17

The deepest of your abdominal muscles (known as your

transverse abdominus) will draw your lower abdomen away
from your fingers equally on both sides if you have proper
mechanics. If you feel one side drawing in less, or bulging
outward, it indicates a compensatory or over active internal
oblique abdominal muscle contraction. The abdominal
oblique muscles are more superficial to the transverse
abdominus and should not contract with this draw-in
maneuver under normal circumstances. Internal oblique
contraction causes a bulge outwards instead of a hollowing
inwards with this test. This is a sign of improper spinal
stability mechanics, and demonstrates incorrect abdominal
muscle stabilization of your lower back.

To correct this problem, practice slowing down the speed

of the draw-in tension away from your fingers, and
emphasize a deeper draw-in on the side that you felt bulge
forwards. Keep slowing down the speed, and pull in deeper, until you have mastered the ability to
pull the lower abdomen away from your fingers without any bulging outwards. Note: Avoid trying
to pull your entire abdomen inwards. Allow your upper abdomen (above your belly button) to relax
with this analysis and correction.

2. Gluteus Max Muscle.

The gluteus max or buttock muscle is imperative to decreasing stress on the lower back. Many
people with chronic back pain have weak buttock muscles, which result in a compensatory over-
contraction of their back muscles, and spinal compression during everyday movements. Use this
test to determine if your buttock muscles are weak.

From the previous position, lift your hips off the floor as high as is comfortable (Glute Bridge
Maneuver). Hold this top position and compare the “tightness” or “hardness” of your lower back
erector spinae muscles to your buttock muscles. Your lower back erector spinae muscles are
located 1-2 inches away from the midline of your spine on both sides of your lower back. Use
your fingers to judge the comparative “hardness” or “softness” of the erector spinae versus your
buttock muscles.

The buttock muscles should ideally feel slightly harder than (or at least equal to) the lower back
muscles in this test. If you feel more hardness or tension in your lower back, it indicates
compensatory “over working” lower back muscles for weak buttock muscles. This is a very
common reason for lower back pain, as the buttocks are used for every step you take, every stair
you climb, and every time you get up from a stooped or seated position. When the buttocks
(gluteus max muscles) are weak, the lower back will compensate and over-work in an attempt to
 18

help the weak buttocks do their mechanical job. The erector spinae are smaller muscles which
were never designed to work that hard, and as a result can strain, putting excessive stress on spinal
joints and discs.

Glute Bridge Test

To correct a weak gluteus max with compensatory over-contraction of the lower back muscles,
practice the following. Using a comfortable amount of posterior pelvic tilt tension (as if you are
tilting your tail bone under and between your legs), but not actually moving it far enough to cause
back discomfort or change your neutral spine position, attempt to slowly tighten (harden) your
buttock as you feel both your lower back and buttock muscles. Practice this one side at a time. The
goal is to feel much more buttock tension than lower back tension, and the key to relaxing the back
and tightening the buttock is in the tail-tuck under tension, which engages your abdominal and
buttock muscles, while relaxing the back muscles. If you still feel more lower back muscle tension
than buttock, you need more tail tuck-under tension (not movement).

It helps to imagine that the buttock is hardening and swelling up, like a hard ball, that as it inflates,
pushes your pants backwards from the pressure. Practice this lying face up with the legs straight,
while standing, and in the glute bridge movement explained above.

3. Muscle Stability in Hip Flexion.

This third mechanical test is also done lying face up, but with your legs straight out on the floor.
It has two parts. The first is done by feeling the hardest and most prominent aspect on the side of
your hip. This is your greater trochanter bone. Feel the front of this bone with your index finger
 19

and the back of it with your middle finger. Place your opposite hand under your lower back. As
you bend your knees (try one at a time and then both simultaneously), you will be checking for
two mechanical mistakes.

The first will be an increased arching of your lower back. This will be apparent if the lower back
moves away from, instead of into, the hand under your lower back. The low back should flatten or
maintain its natural arch (lordosis) against your hand with normal mechanics. If your spine
increases its arch, and moves away from your hand, it indicates poor abdominal control of your
lower back during hip flexion (bending your hip and knee up or forward). Overarching is corrected
by maintaining a comfortable amount of tail-under posterior pelvic tilt tension (not necessarily
movement) to push your lower back into your hand, and maintain your neutral spine, as your knee
and hip bends (flexes).

The second mechanical mistake with this test will be if your hip (greater trochanter) moves forward
into your index finger. It should normally move back into your middle finger, or stay centered
between your two fingers. Movement forward (anterior hip malposition tendency) indicates an
imbalance in hip muscle activity which contributes to tight hip flexors, weak buttock muscles,
anterior pelvic tilting, and an overarching of the lower back curve. Any one, or all of these, will
stress chronic back pain.

To correct an anterior hip malposition, use your buttock contraction (learned in the last test) to pull
the greater trochanter backwards in the hip socket to both initiate (and follow through) with the
forward knee bend. Sometimes, it is easier to just think about the side of the hip pushing
backwards into the middle finger without necessarily making a conscious effort to tense the
buttock. Practice this correction lying face up, sitting and standing. The goal in all positions is
to feel the hip bone moving backwards in the hip socket. Note: Avoid the mistake of twisting your
entire pelvis with this correction, as the backwards movement should be local to the hip socket.

4. Multifidus Muscle.

The multifidus muscles play a major role in

maintaining a neutral spine and avoiding spine
stress. They are located on the right and left sides
of each midline vertebral bone in your lower
back. The multifidus can become weak or lack
sufficient coordination in many chronic back
pain cases. Begin standing and place your
thumbs against the midline bones of your lower
spine. These bones feel like knobs, and are
located in the vertical crease of the lower back.
The exact location you want to feel is the
lower/outer tips of each of your vertebral bones. You have five of these in your lower back, so
 20

feel each one and try to determine if you feel any difference from side to side, or one vertebral
level to the next. Now feel the same areas as you draw your lower abdomen in towards your spine.
Normally you will feel a slight bulge coming out into your thumbs on both sides of the spine as
your multifidi muscles contract. Your multifidi muscles work with your transverse abdominus,
diaphragm, and pelvic floor muscles to support and protect your lower back. If you notice that one
side does not bulge out as much, or feels “hollow” either at rest, or during the abdominal draw in,
it indicates a weak multifidus muscle. Check several times from side to side, and from one bone
to the next. Record your findings.

A weak or inhibited multifidus is corrected by imagining the tension of the lower abdomen (as it
pulls in towards the spine) to cause a bulging out tension in the area of the “hollow”. It helps to
picture this tension as a funnel whose wide end is the lower abdomen, and whose narrow spout is
against the side of the vertebra bone. With practice, it will become easier to cause the “bulge out”
of the multifidus into your finger, as you pull your lower abdomen through the funnel and into
your finger at the needed spinal level.

Those with trouble feeling this correction may be helped by performing it at the end of extra
exhalation, as you force out the residual air left in your lungs after normal exhalation. This extra
exhalation strongly recruits multifidus contraction. Leaning slightly forward from the hips while
standing also helps beginners contract the multifidus. Raising the opposite arm forwards while
standing is another technique. Finally, standing with one leg forwards and the other backwards,
multifidus contraction can be helped by lifting the rear heel while moving the hips forward, as if
taking a step -the multifidus contracts on the same side as the rear leg . Because backwards walking
has been shown to activate the multifidus more than forwards walking, this reverse direction of
walking may be used to help activate an inhibited or weakened multifidus as well. Use the method
that works best for you, as you practice contracting this important muscle without holding your
breath.

5. Hip Rotation Muscle Imbalance.

Lying face up on the floor and allowing your legs to

relax, check to see if one foot turns (angles or flares)
out more than the other. Confirm this by lying face
down with your knees bent to 90 degree angles, and
allow your ankles to fall out away from each other as
your knees remain together. A friend can help you by
gently pushing your ankles outwards. Check to see if
the ankle which does not fall out as far is the same
side as the leg and foot that turned out more when
lying face up. If it is on the same side, it indicates an
external rotated hip, which is an imbalance of
muscular forces across your hip that will stress your
lower back.
 21

An external rotated hip causes you to stand and walk with that leg and foot angled outwards. This
is also the side which you will choose to cross over the opposite leg when sitting and crossing your
legs. An external rotated hip and leg causes the pelvis on that side to elevate (hip hike), which
promotes a side tilt of your pelvis and ribs. Often, you will find an external rotated leg on the same
side as you found a high hip and low ribcage on your side tilt posture analysis. This causes a
compression stress on the same side of your lower back. A tensile (stretch) stress will occur on the
opposite side of your lower back.

To correct an external rotated leg/hip and the resultant elevated hip and torso side lean, simply
straighten your knee caps and feet while standing, so that they are facing straight forwards as much
as is comfortable. Now stand as tall as possible on the involved side, meaning you will be pushing
the hip down towards the floor and lifting the bottom of the ribs up on the external rotated side.
Placing your thumb against the bottom of your ribs and your index finger on the top of your pelvis
(hip) can be helpful, as you try to separate your thumb and index finger. This can be done standing
on two legs, and then one leg at a time. Additional exercises are included in the exercise chapters
of the program to help re-align your hips.

*Occasionally, orthopedic conditions known as tibial torsion and hip anteversion/ retroversion
can cause the leg bones to “twist” and give false findings. It is advised that you check for these
with your own doctor, as the corrections stated above would not be indicated in these cases, and
could harm you.

6. Knee Cap Lateral Tracking

Lying face up, or sitting on the floor with your legs

out straight, place two fingers on either side of the top
of the knee cap. One finger will be contacting the
upper/inner border of the knee cap, while the other
contacts the upper/outer border of the knee cap. As
you slowly straighten your knee, feel the tension
against both of your fingers. Normally, the quadriceps
(front thigh) muscle tenses as the knee straightens,
and the knee cap will move straight up (towards the
hip) into both of your fingers equally, but a lateral
tracking knee cap (patella) will cause you to feel
more tension against your outside finger, as the knee
cap (patella) moves outward.

To correct this, tense the thigh inwards (towards the

other thigh) as you straighten the knee. As you do this, the knee cap will tense more equally from
both sides and produce a proper alignment. By tensing the entire thigh inwards, you will feel the
knee cap start to move inwards. It is important not to actually move the thigh inwards, but only
tense it toward that direction. Only use an amount of isometric tension (muscular tension without
 22

movement) that is comfortable, and does not cause pain. The amount of tension ideally should
create equal pressure and tension against your two fingers. With practice, you should progress to
locally tensing only the knee cap, instead of the entire thigh.

Correcting knee cap alignment is important as it relates to both hip and lower back function.
Anterior pelvic tilt postures, pelvic imbalances, and increased lower back lordotic curvatures can
all be related to lateral tracking patella tendencies. Learning this correction will have a positive
effect on lower back stress while walking, climbing stairs, lunging, squatting and bending
forwards.

7. Tight Latissimus Muscles.

If your shoulders are not rounded, the palms of your hands while standing should point towards
each other, and not backwards. Palms that point backwards are found with tight latissimus dorsi
muscles. These muscles attach your pelvis, mid and lower back to your shoulders. Tightness here
can negatively affect your back. Another test for latissimus dorsi tightness is to lie on your back
with your legs straight. If you cannot touch the floor while reaching overhead without increasing
the arch of your lower back, your latissimus muscles are likely tight.

The latissimus can be stretched standing by holding your tail

bone tucked under while you reach up and across the top of
your head. A passive stretch may also be used where you
hold on to a high chinning bar (or door top) as you keep your
tail bone tucked under. In either stretch, drop the hip
downwards on the side being stretched, and lean your torso
away from that side. These stretches can be held 15 seconds
up to two minutes until the stretch sensation fades away.
Perform them 2-3 times per day.

8. Breathing and Abdominal Bracing.

Place one hand on your upper abdomen (above your belly

button) and the other hand on your chest. As you breathe in,
determine which hand moves more. With normal breathing,
your upper abdomen should move, and your chest should
remain motionless. If your chest moves more, it indicates that your chest and neck muscles are
being used incorrectly (chest breathing), which can negatively affect your back pain. Unless you
are maximally breathing, such as with heavy exercise, your diaphragm muscle located under your
ribcage, should cause your abdomen to move alone with normal breathing. Your diaphragm a
 23

attaches to your spine, and is an integral part of your core muscle spinal stabilizing system. You
will need a properly working diaphragm for any exercise.

To correct chest breathing, simply practice holding your chest and neck motionless while you
allow your upper abdomen to “inflate” as you breathe inwards, and “deflate” as you breathe
outwards. As your upper abdomen (not your lower abdomen located under your belly button)
moves outwards, allow your lower rib cage to expand sideways. Focusing on an entire “girdle” of
movement expanding around your upper abdomen and lower ribcage with inhalation, and
narrowing during exhalation, will train you to properly use your diaphragm while breathing. It
helps to imagine a ball inflating and deflating in your upper abdomen with this practice. This is
essential to supporting proper spinal stability.

Finally, check to see if you can brace with your abdominal muscles without holding your breath.
Abdominal bracing is tightening your abdominal muscles in an effort to prepare for a “punch to
your stomach”. Bracing causes all of your core muscles to engage and helps to lock your neutral
spine position (discussed in upcoming chapters) in place. Unfortunately, many back pain sufferers
lack the ability to brace while they breathe. This causes a relaxation of the core muscles and a loss
of neutral spine stabilization when breathing demands are increased, such as with the physical
exertion of exercise and various activities. As a result, back injury is much more likely during
physical exertions.

If you have trouble breathing (especially using your diaphragm instead of your chest), as you
tighten your abdominal muscles, you will likely hold your breath while abdominal bracing.

The corrective exercise for this is to practice light amounts of abdominal bracing (10% of
maximum) as you focus on the upper abdomen and lower ribcage movement of diaphragmatic
breathing just described. As you become more proficient at allowing a tightened core to move with
breathing, additional abdominal tension can be gradually added.

PART THREE
Painful Movements and Ranges of Motion

The next aspect of your self-analysis is identifying which back movements and ranges of motion
are painful. This will teach you which specific movements to avoid, how much you can move
without aggravation, and ultimately how to move without pain. The following motions should be
done standing and then sitting. While sitting increases lower back disc pressure (often a problem
in retrolisthesis), standing compresses the back portion of the disc, facet joints, spondylolisthesis
and stenosis conditions, and uses more muscular activity to maintain upright posture.
 24

In all of the following motions, only move as far as it takes to begin to feel discomfort. The goal
of this analysis is to simply determine if a particular direction of bending or twisting is painful,
and how far into the motion you can move before you begin to feel discomfort. This is not a test
to see how flexible you are. You only need to feel a slight discomfort at a limited range of
movement to determine if a particular direction of movement is painful. Therefore, move slowly
and carefully. Go as far as it takes to either move pain free as far as possible (which would be a
negative test direction), or until you begin to feel pain. Note that a feeling of stretch is not what
you are looking for. Record only those directions of movement (and ranges of those motions) that
are painful.

Begin standing and lean forward from your waist, as if you were trying to touch your toes. Then
try bending forwards and slightly to the right and left from this position. Note which specific
directions are painful and how far into each direction it takes to feel pain. Bending forwards (spinal
flexion) will stretch tight muscles involved in many lower back conditions, and compress discs
while driving the retrolisthesis vertebrae further backwards.
This often aggravates retrolisthesis pain. Depending on your
particular retrolisthesis condition and complex, it is possible
that this may relieve or not change your pain. Remember that
each case is different, and the best exercises will be chosen
from an honest analysis. Do not assume that you should be
feeling worse with flexion just because you have been
diagnosed with retrolisthesis. Simply record what you
honestly feel.

Next, lean back from your waist (spinal extension). Make sure
that your arms hang free at your sides, and do not support your
back as you do this. Follow this by leaning sideways to your
right, and then left. Then lean back and to each side at 45
degrees. Is there pain on the same side as hip hiking or an
externally rotated hip? Finally, twist to your right and then left
sides. Twisting while seated allows the motion to come from
your spine, while immobilizing your pelvis, and may be a better test for determining pain
provocation. Note not only which directions and amount of motion are painful, but also which
direction is the most painful.

You have just learned which direction(s) of movement need to be avoided to decrease damaging
stress on your back. You will be learning how to use your neutral spine position with the stability
strength of your supporting muscle corrections to avoid these painful directions of movement in
upcoming chapters. This doesn’t mean that you can’t bend forwards, backwards, sideways, etc.,
but rather that you will avoid bending far enough in a particular direction to cause pain. Thus, you
will use your pain free range of motion in any direction of movement to move safely.
 25

PART FOUR
Conditioning Tolerances and “Breaking Points”

Strength and endurance demands of sports and daily physical activities often play a role in
retrolisthesis back pain. Even if you have perfectly symmetrical posture, flawless movement and
impeccable coordination using your core muscles to properly stabilize your spine, injury can occur
if you do not have the strength or endurance to maintain your spinal stability past a certain limit
of imposed load or length of time.

During this part of the analysis, you will need to do a little thinking about what activities have
aggravated your retrolisthesis back pain in the past. Has it been lifting a certain amount of weight,
maintaining a certain static position or posture for a period of time, performing too much of an
activity around the house or yard, or a certain number of repetitive motions? Break down your
injury history and look for offending lengths of time, amount of repetitions, amount of weight, or
exertion in terms of force or duration that has caused painful back episodes. You will want to
establish your “breaking point” at which going beyond that particular limit will cause pain. It may
be the length of time you can sit, walk or stand. It may be the time you can garden or perform
house or yard work. It may be the number of times in a row you can bend or twist, or the amount
of weight you can lift, drag, push etc. You may record several different breaking points or physical
limitations for as many different positions or activities you remember causing your previous back
pain episodes. Make a list and save it for later in the program, as we will use these breaking points
to help design your exercise program.
 3
The Mechanical “Themes” of Your Pain

Now that you have completed your body analysis and recorded your findings, it is time to look for
“themes” in postures, directions of movement, and muscular asymmetries as they relate to your
retrolisthesis pain. A mechanical theme is a specific direction (or plane) of posture and movement
in which your spine is not stable, where spinal soft tissues become irritated with damaging
mechanical forces. This is often the same direction of movement that causes pain. Once you
establish the mechanical themes of your pain, learning how to align and hold your back to avoid
that direction will help you avoid injury and pain. The safest position to stabilize your back (neutral
spine) will be built on avoiding the themes that cause your pain. Increasing your ability to hold
your unique neutral spine position will be the basis of your entire healing exercise program.

Begin with understanding how your posture relates to your pain. Look for pain that is aggravated
with certain postures. Sitting typically aggravates disc generated back pain as the seated position
can load the discs (located at the front of the spine) ten times or greater versus the standing position.
This is fairly typical with many retrolisthesis low back pains. Standing typically aggravates
retrolisthesis cases that are additionally associated with stenosis, spondylolisthesis and facet
syndrome. All of these associated conditions are worse when the rear portion of the spine becomes
compressed. Stenosis (both spinal central stenosis and IVF stenosis) involves a narrowing of the
available space for nerves to pass through, and the standing position mechanically closes this
space, thus worsening stenosis symptoms. Spondylolisthesis (a forward slipped vertebrae) is
mechanically forced into a more forward position when standing versus sitting, and the facet joints
(located at the rear portion of the spine) also become
more compressed in the standing position, thus
aggravating facet pain.

It is common for an individual retrolisthesis (backwards

slipped) vertebra in the lower back to be forced more
backwards with forward bending (spinal flexion). This
is demonstrated in the image to the left. However, not
all cases are necessarily more painful in this direction
of motion. Patients whose pains are more aggravated
with various other directions of posture and movement
often become confused when their doctor tells them that
retrolisthesis should typically be most aggravated with
forward bending and sitting. The answer to this
common confusion is explained by what specific spinal
soft tissue (disc, facet joint capsule/synovial lining, muscle, tendon, ligament, nerve or fascia) is
actually being irritated the most. Different directions of posture and movement will either
compress or stretch different spinal structures at different ranges of motion.
 27

Back pain that is aggravated with side leaning is often

related to a side tilted posture. If your torso or pelvis is
naturally tilted sideways, compression will occur in the
lower back on the side of a low ribcage and/or a high
pelvis (hip hike), while stretching will occur on the
opposite side. These are demonstrated in the image to
the right. Retrolisthesis back pain can be the result of
either excessive spinal soft tissue compression or
stretching.

Start relating your posture findings to your painful

directions of movement, as well as to the positions and
activities of your daily life which cause pain. Are there
any similar directions or planes of movement that exist
in your posture and movement habits that match the same directions of movement that cause pain?

If you have a side tilted posture or repetitive movement habit, does your back pain bother you with
side tilting motions? This would be a theme in a side to side (lateral plane) direction.

If your pelvis (hips) or torso twists to one side in relaxed posture, or is more flexible twisting to
one side, ask yourself if you have pain with twisting movements? If you do, a rotation (twisting)
theme has just been discovered.

Do you have a forward head, rounded (forward) shoulders, or a stooped posture associated with
pain in forward bending? This would be a flexion theme.

Is your pain worse with increasing the arch in your lower back either by raising your tail bone up
(anterior pelvic tilting) or leaning your upper back backwards? Do you have a history of back pain
with prolonged standing, walking, wearing high heels,
extending your leg behind you, walking or running
downhill, or leaning backwards? If so, do you also have
a natural anterior pelvic tilt posture, tight hip flexors,
anterior hip malposition, or extended head posture?
These are all parts of an extension theme.

Use the postural corrections that eased your pain in the

analysis chapter to help establish a theme, or
direction/position/posture pattern that is painful. If you
have pain in multiple directions, determine which is the
most painful, or has the greatest history associated with
your injuries.
 28

If you have back pain standing, figure out if a correction of your foot, knee, head, shoulder, pelvis,
torso, or leg/hip posture alignment eases your pain. Check all your analysis findings discovered in
the previous chapter, especially those that are in the same basic direction of your pain (front to
back, side to side, and twisting or rotation). Perhaps a correction of sway back posture or lateral
translation of the ribcage or pelvis, or a change in head/neck posture, makes a difference. Use these
relief positions to confirm your themes.

Look for a pain-relieving change of posture or movement in the opposite direction of that which
provokes pain. If you have back pain bending forward at your waist, think of those corrections
that are in a front-to-back plane of motion anywhere in your body. Rounded shoulders, forward or
extended head posture, sway back posture, genu recurvatum, and an anterior hip malposition all
fit this front-to-back direction or plane of motion. Try repositioning or moving any of these
findings in the opposite direction of the postural flaw (correcting the abnormal mechanics). In most
of these examples, the correction would be moving the involved body part backwards (into
extension) to see if this eases the pain. Try different amounts (degrees of correction, or specific
ranges of motion) to determine how much of any correction eases the pain the most. If you find
that bending the waist backwards or correcting any of these examples eases your pain, you have
confirmed a theme in that direction or plane of motion.

The correction may be in the same local body region as your pain (lower back) or a different body
region. Check them all. Sometimes back pain that is aggravated by flexion (leaning forward) of
the lower back is relieved with extension not only of the lower back, but possibly a backwards
movement of the ribcage, head or knees. Always relate pain relief direction to the direction of
your abnormal posture and painful movement findings. Relief will usually be in the opposite
direction of the postural distortion or pain provoking motion. You are looking to establish which
posture or movement directions are mechanically causing your pain, and which correction of
posture or movement into the opposite direction relieve it. Remember that moving too far into the
direction of correction may also aggravate pain, therefore try different ranges (amounts or degrees)
of corrective motion to determine how much is needed to best relieve your pain.

You will find that there are only a limited number of directional themes related to provoking and
relieving your pain. They are as follows:

1. Flexion Pain Theme. Pain that is aggravated with bending forward at the waist can also be
associated with other forward (flexed) movements and postures such as a forward and extended
head posture, sway back posture, rounded shoulders, genu recurvatum knee posture, general
slumped posture, weak gluteus max (buttock) and multifidus muscles. Pains that are worse while
sitting and better while standing also typically fit this theme. Pains that are aggravated with flexion
are relieved by avoiding forward motion, usually by moving into some degree of extension
(backwards movement). Increasing the arch in the lower back (extension) will usually relieve the
pain.
 29

2. Extension Pain Theme. Pain that is aggravated with extension (backwards bending) is often
worse with standing posture, prolonged standing and walking, wearing high heels, running and
walking downhill, and relieved with sitting. Extension pain is associated with anterior pelvic
tilting, extended head posture, tight latissimus and hip flexor muscles, anterior and external rotated
hip malpositions, genu recurvatum knee posture, foot pronation, and weak gluteus max (buttock)
muscles. Correcting these mechanical dysfunctions to some degree will typically ease the back
pain. Tucking the tail bone under to flatten the arch of the lower back (posterior pelvic tilting), or
leaning slightly forward from the waist, will usually relieve the pain.

3. Twisting Pain Theme. Back pains that are

aggravated with twisting (rotation) are often
associated with rotational postures that have
asymmetrical tightness when twisting either the
pelvis or torso, and comparing the relative flexibility
twisting right to left. Relaxed postures that reveal one
shoulder or hip positioned more forward than the
opposite side fit this theme. Other typical findings
include external hip rotation (causing one foot to flare
outwards more than the opposite side), over-active
internal oblique muscles, internal or external knee
rotation posture, and one-sided tight latissimus
muscles. Correcting these mechanical flaws will
often relieve the pain, as well as twisting in the
opposite direction (away from the painful side of
twist).

4. Side Tilting/ Side Leaning Pain Theme. Low back pains that are aggravated with side leaning
are typically associated with hip hiking (elevating one hip or side of the pelvis more than the other),
postures in which the hips, shoulders or lower aspect of the ribs are higher or lower on one side
(side tilting postures), lateral translation postures of the ribcage or pelvis, asymmetrical tight
latissimus muscles, foot pronation, lateral tracking knee caps, one sided external rotated hip
postures, over-active internal oblique muscles, and leg length asymmetries. Side tilting away from
the side of pain provocation will relieve the pain, as well as correcting any mechanical issue
described above that includes a side-to-side direction of postural distortion or asymmetry.

5. Translation Posture Pain Themes. If pain is worse with generalized vertical compression of
the back (collapsing into a slump), then vertically lengthening the spine will typically relieve it.
This would be a vertical translational theme. Alternatively, a sway back posture (front-to-back
translation theme) requires a front-to-back correction similar to a flexion theme, where
repositioning the pelvis and head slightly backwards in relation to the ribcage will relieve the back
pain. A lateral translation theme would be present if sliding either the torso or pelvis straight
sideways (without side tilting) relieves the pain and straightens out body alignment.
 30

Once you have established which themes are related to your retrolisthesis back pain, you will be
ready to custom-design your neutral spine position, which will be the basis of protecting your
retrolisthesis from further injury and allow your healing process to flourish.
 4
Your Neutral Spine (Safe Zone)

Being able to move pain-free will be the result of maintaining a neutral (safe) spine position,
supported by correctly engaged supporting muscle tensions (RPI), and learning to move from other
parts of your body to limit your back from moving into a painful range of movement in any specific
aggravating direction. You will also have to respect the limits of your back conditioning, and avoid
pushing yourself past the threshold of “breaking points”, as discussed in chapter 2.

4 KEY POINTS TO MOVING PAIN FREE

Maintain Neutral Spine

Correctly Engaged Supporting Muscle Tension
Pain Free Range of Motion
Avoiding Conditioning Breaking Points

Now that you have an idea of how you will move without pain, it’s time to start putting this all
together and practicing it with your unique body. This will be done by learning how to engage
your RPI (Reverse Posture Isometric), which is the exact muscle tension required to keep your
back in a neutral spine position, and avoid moving or positioning yourself in one or more of the
painful directions (themes), or painful ranges of motion, that you have identified.

The term isometric means that you will use muscular tension (without movement) to hold your
most comfortable re-alignment positions (neutral spine) and avoid the painful movements learned
in the previous chapter. This is basically holding the opposite posture of your posture fault and
avoiding the themes or directions of pain.

As you practice holding your RPI and neutral spine position in various daily activities, remember
that this is the beginning of allowing your body’s healing process to finally outpace your injury
process. As you improve your neutral spine stability with additional exercises that strengthen your
RPI, you will be avoiding the mechanical stresses that cause most retrolisthesis pain. As you
decrease stress on your back, your body’s healing process can finally begin to work without
interruption (re-injury).

The exercises described in upcoming chapters will amplify your healing by providing a progressive
exercise strengthening stimulus to the soft tissues of your spine. This causes your body to
progressively turn-on its healing mechanism after each workout to greater and greater degrees, and
reconditions your back from pain and weakness to relief and strength.
 32

Finding Your Neutral Spine

Now it’s time to learn how to place your spine in a neutral (safe) position to avoid pain and injury.
This will be the position that you place your back in while performing any movement. The neutral
spine position protects your back from pain by avoiding the painful themes and ranges of motion
you have discovered. It assists in the body’s healing
process by avoiding the aggravating mechanical
stresses that cause mechanical back injury. This
concept is by far the MOST IMPORTANT
CONCEPT TO OVERCOMING YOUR BACK
PAIN. It is most likely the ANSWER you have
been searching for.

To discover your unique neutral spine, you will use a

combination of corrections to your posture alignment
findings. Go through each of the previous analysis
findings and focus on the corrections that best bring
you towards normal posture alignment and alleviate your pain. Use side tilting and twisting of your
head/neck, torso and pelvis, anterior or posterior pelvic tilting, forward head, sway back, extended
head, and lateral translation corrections to find the best alignment that makes your back feel the
most comfortable while standing and sitting. In any of these corrections, you will have a certain
range of motion (or distance) of correction that feels the best on your back. If you have no pain at
the time of testing, try to position yourself as close to ideal alignment as possible. Another method
to find your neutral spine is to use the amount of correction that best eases any excess muscle
tension that you can feel in your back.

If your hips normally twist to the right, your RPI would be to twist them to the left (toward neutral
alignment) as much as is needed to provide the maximal relief of pain or muscle tension in your
back. If your multifidus muscle is weak on the right side of your lowest vertebrae, your RPI would
be to bulge (tense or contract) it outwards. If your tailbone is higher than your pubic bone (anterior
pelvic tilt with increased lordosis), your RPI would be to tuck your tailbone down and under,
flattening the arch in your lower back, to the point of maximal back pain relief or minimal back
tension. If your back pain is aggravated by leaning your torso or head to the right, your RPI would
be to resist that direction of movement.

The key here is finding the exact position that best protects you from pain by combining your
posture corrections. The amount of each correction should be the most comfortable range of
motion in the particular corrective movement. For example, if you side tilt, experiment with how
much side tilt realignment correction feels best or eases excess muscle tension. Do the same with
each posture finding until you have combined all of your corrections into one single body position.
 33

You may have to try different sequences of corrections to determine what feels the best on your
back, or best eases excess muscle tension. For instance, the forward head correction may make
your back feel better if done after, as opposed to before, an anterior pelvic tilt correction. Once
you have determined the amount and sequence of your corrections that feel the best, remember
this unique position as your neutral spine. This will be the basis of all exercise to come, and help
you establish a “safe zone” for your back movement.

In the end, your body alignment should straighten out compared to your natural flawed posture.
Do not over correct alignment or RPI muscle tension past that which feels the most comfortable.
Focus on those corrections that make the most difference in pain relief and/or excess muscle
tension.

Your First Exercise

Your first exercise trains your RPI coordination and neutral spine position
by adding a slight balance challenge in the standing position. Begin by

#1
assuming your neutral spine position, engaging all of your RPI corrections
identified in your self-analysis, while standing with your feet facing straight
ahead (or as straight as comfort allows). Maintain equal body weight
balance on the four corners of each foot. Remember that this full-body
position should be the exact combination and sequence of posture and
muscle corrections that make your back feel the most comfortable.

Engage additional core muscular tensions by keeping your spine as tall as comfortably possible.
You will notice that your lower abdomen naturally pulls inwards as you elongate your spine, but
be sure to maintain any internal oblique or multifidus corrections (as previously explained in
chapter 2) as you do this. Your pelvic floor muscles, which connect your tailbone to your pubic
bone, should be recruited by consciously tensing this area at the bottom of your pelvis up towards
your head. This will assist in the vertical elongation of your spine. Enhance this slight tension by
hardening your superficial abdominal muscles by pretending that you are getting ready to receive
a punch to your stomach (abdominal bracing). Tensing your shoulder blades slightly down
towards your hips will help contract the latissimus dorsi muscles which will further solidify your
neutral spine. Use less tension on the side of a previously identified tight latissimus. All of these
added tensions will contract your abdominal and back muscles more. Avoid using too much
muscular tension or effort as you do this, using only 10% of your maximal effort. Be sure that each
tension is pain-free. Although there should be some effort and tension, it is more of an awareness
of tension (as opposed to a great physical exertion) that you are seeking.

As you lengthen your spine vertically, your collarbones will lift, your head will move straight
backwards, and your chin will slightly tuck under your jaw. This enhances the avoidance of
forward head posture. Be sure that you are not holding your breath as you do this, and allow your
upper abdomen and lower ribs to expand and contract with each inhale and exhale of your
 34

breathing cycle. Avoid moving your chest or neck as you breathe this way to emphasize the
diaphragm tension at the upper aspect of your abdominal cavity.

You now have all of your core muscles supporting your RPI neutral spine position, causing your
back to be in its safest alignment, guarded by the associated muscular tensions at 10% of your
maximal strength. As long as this neutral spine RPI position is maintained, your back is safe.

You will now challenge this neutral spine position by

lifting one heel (or entire foot) off the floor. The goal
is to provide just enough instability so that your body
sways no more than ¼ inch in any direction as you
maintain your RPI. If lifting only your heel provides
this slight instability, then that is where you will begin.
If lifting one heel provides no balance challenge, lift
your entire foot.

You may use your hand to tap onto a wall or other

stable structure to avoid swaying more than ¼ inch as you practice this balance challenge to your
RPI. The focus of this exercise is maintaining your neutral spine position and RPI tensions despite
the balance challenge.

Maintain your neutral spine position and RPI protective tensions for 10- 15 seconds before
switching legs. Remember that the goal of this exercise is to maintain your unique RPI neutral
spine position despite the balance challenge of standing on one leg. Do not be surprised if your
first wobble direction is in the same direction as one of your previously identified themes. Resist
the tendency to move into this direction by emphasizing the maintenance of your neutral spine and
RPI muscular tensions. Perform 3 repetitions of 10-15 seconds per leg. You can do this exercise
2-4 times per day.

Progression of Your First Exercise

Once you have the ability to hold your neutral spine and RPI while standing on one foot for a
minute, it will be time to progress your first exercise. You will do this by performing the same
exercise with your eyes closed. Do this while tapping onto a stable surface such as a chair back or
wall with your hand to again limit your body sway to ¼ inch or less. Remember that the goal here
is the same- to hold your RPI neutral spine without changing it, as you are strengthening your
coordination and endurance in maintaining a safe neutral spine position.

Practice this a few times daily until you can hold your RPI neutral spine on one leg with your eyes
closed for a minute. Further progression in this exercise can be made by standing on a sofa cushion
or pillow to enhance the balance challenge, beginning with the eyes open, and eventually
advancing to an eyes-closed challenge.
 5

Retrolisthesis Posture & Movement: Basic Training

Regardless of your unique neutral spine position and RPI tensions needed to stabilize your spine,
and the specific exercises required to address your themes of pain in upcoming chapters, this
chapter in Retrolisthesis Basic Training will provide you with the general knowledge of how to
move, lift, sit, stand, walk and sleep without aggravating your retrolisthesis condition. The premise
behind basic training is to learn the basics of maintaining a neutral spine with daily activities.

1. Move from the hips and not the lower back. To maintain your neutral spine during typical
daily bending movements, it is essential to begin to understand the relationship between the hips
and the lower back. Although both the hips and the lower back are designed to move, the hips are
designed to move much more and to bear much greater stresses. Most low back pain sufferers have
unfortunately reversed this relationship in their body, learning to move more from their low back
and less from their hips, thus causing undue lower back stress and injury.

To help decrease lower back stress, learning to move from the hips more while the lower back is
held stable (decreased or no movement) is a basic requirement of many daily activities. This is
especially so while bending forwards (flexion). Not only is flexion the most common direction of
movement for most daily activities, but it also is typically the most offending motion to
retrolisthesis low back pain sufferers.
 36

Maintaining the natural arch position (lordosis) in the lower back that
is set with neutral spine is the focus of this concept. Because disc
pressure is increased and vertebrae have a tendency to slide backwards
with flexion (changing lordosis), learning to bend forward from the
hips instead of the lower back is an essential starting exercise for most
retrolisthesis cases. The hip hinge and squat are the two most valuable
exercises to train this proper forward bending motion.

Hip Hinge

The hip hinge consists of rotating the pelvis around the hip joints
resulting in a forward tilt of the upper body. To practice this, begin
with your feet positioned directly under the center of your thighs and
engage your neutral spine position and RPI tensions. Allow your knees
to bend slightly. Rotate your pelvis and upper body as one solid unit around your hip joints as
shown in the example to the right. The key with this exercise is avoiding any motion at the waist
(lower back) or knees. Keeping one hand on your
lower back while you hip hinge will help you check
that it does not move (change lordosis). Only hinge
forward a few inches when first learning this essential
movement. The hip hinge trains low back stability (no
motion) while emphasizing hip motion. As you
become more proficient at the movement, greater
ranges of forward motion may be attempted. At any
range of motion, it helps to keep one hand on the lower
back to monitor stability (no motion should occur in
the lower back as it is held solid with the neutral spine
and RPI).

Hip hinging develops the gluteus max (buttock)

muscles and the extensor muscles of the back, both of
which are critical to those cases of retrolisthesis that are aggravated with flexion, as both hip and
spinal extensor strength checks (prevents) the spinal flexion pain theme.

This exercise can first be practiced for 1-3 reps several times per day to build coordination in the
movement, and then done 2-3 times per week for progressively greater repetitions to build
endurance strength. Start at 5-10 reps and add 2-3 per workout (never on consecutive days) until
you have reached 50-100 reps.
 37

Squat

The squat is the basic movement of getting in and out

of the seated position. It is used to get up from a
chair, a bed, or the floor, to bend forward, to pick
items up, and to move in many daily activities.
Besides breathing and walking, squatting is the most
common of all daily motions. Since most low back
pain sufferers fail to squat properly, and weakness
and dysfunctional movement in the squat is a
contributing factor in daily low back stress. This is an
essential exercise for everyone.

Squatting is a great back extensor (the ability to bend

the spine back or resist forward movement) conditioning exercise if performed correctly. The squat
can help strengthen and re-coordinate proper extensor function of the spine, hips and legs. As the
lower back is a part of the integrated body, and extension occurs across the entire body in most
daily demands, squatting is essential for decreasing most retrolisthesis lower back stress and
relieving pain.

There are many varieties of the squat. The safest squat is known as the sumo squat. It emphasizes
hip and knee flexion, and produces the minimal amount of extension stress on the lower back when
compared to other forms of squatting. It is a natural progression from the hip hinge. The sumo
squat is performed by widening your stance to allow a 2-3 foot distance between your feet. You
will need to point your feet outwards (at least 30-45 degrees) in this wider stance. This is
demonstrated in the example above.

Engage your lower back stability (neutral spine with RPI) and be sure that all four corners of each
foot bears equal bodyweight. Allow your knees to bend, but not move forward as you move your
hips back and down. This is essentially a hip hinge motion with the addition of knee bending.
Inhale diaphragmatically as you descend as far as is comfortable. Do not squat lower than allowing
your thighs to become parallel with the floor. Pause for a moment at the lowest position and then
return to the standing position by squeezing your buttocks together. Your lower back lordosis
should be held stable as your pelvis, torso and head all move slightly forward around the hip
joints as one solid unit. This is a key point in squatting. All the motion is in your hips and knees.
Even though your upper body tilts forward, it is because of the motion in your hip joints. There is
no motion occurring in the spine from your tailbone through your head. The spine is simply “going
for a ride” on the pelvis, which is rotating forward about the ball and socket of the hip joints.

Focusing your eyes on a point straight ahead or slightly higher will maintain the lordotic curve of
your neck and lower back. This is especially important if your lower back pain is aggravated by
bending forward (spinal flexion).
 38

In other types of lower back pain themes, such as those which are aggravated by spinal extension
(backwards bending) including stenosis, spondylolisthesis, and arthritis, it is usually better to
follow an arc with your eyes and chest (from straight ahead to a point 24-36 inches in front of your
feet). This will cause your hips to travel back and down at a 45 degree angle, which will decrease
the tendency to increase lordosis by looking upwards. Maintaining posterior pelvic tilt (tail under)
tension will assist this.

Descend as far as is comfortable. Your hips, knees and torso should all move together, and stop
simultaneously at the bottom of the squat. Pause for a moment before tensing the buttocks together
in order to reverse direction and stand up again. As you ascend in the squat, exhale and keep
tensing the buttocks (gluteus max) until you are standing erect in the starting position again. You
will be traveling along the same path that you descended along, only in the reverse direction during
the ascent.

Your spinal stability will be challenged the most as you change directions from descent to ascent.
This is true for any exercise. This is why it is imperative to pause for a moment before ascent.
This slight pause will make it easier to maintain spinal stability (neutral spine) during the change
in motion direction. As you practice, and become more proficient in squatting, you can change
direction more quickly, which will condition your lower back to maintain better stability.

The typical mistakes made during squatting are as follows:

1- Using the erector spinae lower back muscles more than the gluteus max buttock muscles.
If your self-analysis revealed weak buttocks, be sure to maintain tail-under tension during
the squat, especially at the transition phase from descent to ascent.

*NOTE: Tension here does not mean additional movement of tail under (posterior pelvic
tilting). Once you have set your exact neutral spine stability position and tension, you only
need to emphasize tensioning towards tail under, but not moving more into a tail under
motion during the squat. By tensing tail under without movement, the erector spinae will
be slightly inhibited by abdominal muscle recruitment, thus assisting the buttocks to tense
harder. This is extremely important to understand and do, because more tail-under
movement will change your stability position which can easily cause lower back injury.
This is a common mistake that even competitive weight lifters make, often causing low
back injury. Remember that with any exercise or movement, spinal stability means no
spinal motion outside of the set stability (neutral spine RPI with abdominal bracing)
position. To be sure that you have tension, but not movement, it helps to keep one hand on
your lower back while learning to squat. If your lower back lordotic arch decreases, you
are moving the tailbone. Ideally, the arch should remain constant throughout the squat.
 39

2- Hip Hiking. If you have a hip external rotation posture, it is highly likely that you will hip
hike while squatting. This is also common if you have a tendency to lean your ribcage and
mid back to one side (hip hiking will occur on the same side). Regardless of cause, hip
hiking is very common while squatting and can be avoided by placing your hands on the
top of your hips while learning the movement. You should feel for equal tension and
position (height) of your hips when comparing the right to left sides as you squat. Again,
like most corrections, you will be more greatly challenged the deeper you squat, and
especially during the transition from descent to ascent.

3- Pronation of the heels and ankles. The inner edge of your heel and feet will be more prone
to bear more weight than the outer edge as you go deeper in the squat. This should be
avoided as your knee will follow the inward motion, and ultimately cause hip hiking and
hyperlordosis of the lower back.

4- Inward tilting of the knees. This can occur with heel tilting or independently. Poor knee
stability causes hip and lower back instability. Make sure your knees point in the same
directions as your toes do, but do not allow your knees to move forward past your toes
while squatting.

5- Pelvic and torso rotation. Avoid your twisting tendencies by squatting in front of a mirror
at first. The typical mistake is twisting the pelvis away from the side of the externally
rotated hip.

6- Forward head posture. Squatting sideways to a mirror or having a friend check your form
can help to correct this.

Use a 3-5 second cadence to descend and to ascend in the squat. Begin with 10-12 reps and
progress by 2-3 reps each workout until you reach 50- 100 reps. If your hips, buttocks and thighs
are screaming after your high- rep squat sets, you are doing them correctly. If your lower back is
sore, you are progressing too quickly, or need more tail-under tension.

Parallel Hip Squat

The parallel hip squat places more stress on the lower back extensor muscles than the sumo squat.
It is advisable to incorporate it after a month or two of sumo squatting. It is a great way to
strengthen the lower back extensor muscles as they learn to work harmoniously with the powerful
hip extensor muscles.

The foot position and movement here is distinctly different than the sumo squat. Begin with your
feet pointing straight ahead and positioned directly underneath the center of each thigh.
 40

Most people will have approximately 4-6 inches between their feet in this position. Maintain all
four corners of each foot with equal body weight as you engage your back stability.

The movement of the parallel hip squat is more pronounced

with forward hip rolling. The buttocks will travel
backwards and downwards at a 45 degree angle. This is
more backwards than a typical sumo squat. The entire
spine and head all follow the pelvis as in a sumo squat, but
because the hips roll forward more, so does the entire rest
of the upper body. As a result, the upper body appears to
be leaning more forward, but is simply following the pelvis
as it rolls forward on the hip joints.

Your eyes and chest will initially be pointing straight ahead

at the top position, but will follow an arc from straight
ahead to a point 24-36 inches in front of your feet to get to
the bottom position. . There should be less of a tendency
to over arch the lower back with this technique. Therefore,
it is a better beginning squatting motion than the sumo
squat for those with lower back pain that is aggravated by
backwards bending (extension). This is common in such
retrolisthesis associated problems such as spondylolisthesis, stenosis, and facet syndromes.

Watch for the same mistakes as in the sumo squat during the parallel hip squat. It is normal for
the lower back to feel more fatigued (but not painful) after parallel hip squatting until the erector
spinae muscles become better conditioned over a few weeks. Use the same rep range and
progression as stated in the sumo squat description.

2. Daily Movements. Learning to squat and hip hinge is essential for bending forward in daily
activities. Either of these two motions should be used for all forward activities to protect your
lower back from injury. This includes brushing your teeth, washing dishes, leaning forward to
open a drawer, or when picking an item up off the floor. When lifting heavier items, it is important
to straddle your feet around the item, or position yourself as close to the item (hugging it) as
possible, and then use the sumo squat to lift.

Twisting movements are always safer for retrolisthesis if the hips and shoulders twist together at
the same rate and distance. When the shoulders twist farther than the hips (or vice versa), a
rotational stress is applied to the lower back which can cause injury. Start practicing twisting while
keeping your nose and belly button in vertical alignment with each other, avoiding the tendency
to allow either of them to lead the twisting motion.
 41

Side leaning (side tilting or lateral flexion) should be done with the help of bending both knees.
This will allow you to maintain equal distance between the pelvis (hips) and lower ribs on both
the right and left sides as you lean in either direction. This is especially important for those side
tilting pain themes where either compression or stretch in the lower back is dangerous.

Extension is often problematic for back pain that is exacerbated with reaching overhead, walking
downhill, or leaning backwards. Maintaining your neutral spine with tail under (posterior pelvic
tilt) tension can help reduce this stress. Increasing your abdominal muscle tension by “crunching”
the front of your lower ribcage downwards (as in an abdominal crunch exercise) can add to this
stability.

3. Sitting. Retrolisthesis typically involves some degree of disc degeneration, herniation or

bulging. Because sitting can load the discs with more than ten times the standing bodyweight,
learning to sit properly is essential to avoid back pain aggravation. Most people have a tendency
to slump down in seated positions, which decreases the lordotic arch of the lower back. This
increases disc compression and worsens the backwards slide of the retrolisthesis vertebrae. To
prevent this, practicing amore upright posture is often helpful.

To improve sitting posture, focus on sitting as tall as possible, lengthening your spine from your
lower back through the top of your head. This will help center your body weight on your “sit
bones” located at the crease between the back of your thighs and buttocks. Once you are tall, you
can fine tune the exact position by rocking slightly forward or backwards on the sit bones to find
the position that feels the most comfortable.

Sitting more upright will cause your lower abdomen to naturally pull inwards, as your core muscles
become more active. Using these muscles for longer periods of time than they are used to can be
tiring at first, so don’t try to maintain this position for too long when first practicing this new seated
posture. Take frequent breaks from it, and gradually increase the amount of time in upright posture
over several weeks to months before you can eventually sit in this new way permanently.

Additional tips to keep in mind while sitting include keeping the feet and knees pointed straight
ahead (avoid crossing the legs), and using a cushion or lumbar support pillow behind the lower
back to make sitting upright less active and more passive. This will help you to maintain better
posture over a longer period of time, which inevitably will decrease low back stress and most
retrolisthesis pain.

4. Standing. It is important to avoid leaning more on one leg or one hip compared to the opposite
side while standing. Likewise, standing with one leg/foot angled outwards more than the other
invites asymmetrical forces across the lower back. The feet should ideally be placed under the
center of the thighs and pointed straight forwards for optimal mechanical spinal support. All of
these corrections however, may take time to accommodate to. Never assume a position for longer
than it is comfortable for.
 42

Over time, with repeated practice, perfect alignment becomes quite comfortable. Typical postural
errors retrolisthesis sufferers should avoid while standing include anterior pelvic tilt, sway back
posture, general slumped (compressed spine) posture,
and forward head posture. Maintaining a vertically tall
spine while standing prevents many of these from
occurring.

5. Walking. Keeping the spine as vertically tall as

comfortable while walking helps to avoid many of the
same postural errors found in the standing position.
Emphasizing tightening the buttock just before the foot
strikes the ground and maintaining a tall waist (anti-hip
hiking) as the hip travels over the weight bearing foot
will help to prevent lateral pelvic movement and
excessive back muscle stress during walking. This is
especially important for those with side tilting/leaning
pain themes. Learning additional exercises to
strengthen your ability to contract the buttock without excessive back tension will be discussed in
upcoming chapters. Avoiding painful pelvic and torso rotational themes is also an important focus
for those with such mechanical issues. Backwards walking can be used for those with flexion pain
themes to accentuate extensor muscle development, which is commonly needed in retrolisthesis.

6. Sleeping. Maintaining postural alignment during sleep and recumbency during the day is an
important aspect of protecting your back from asymmetrical stress. While lying face up, pillows
placed at the sides of the lower legs can help prevent leg and foot outward rotation. Using a thin
pillow under the head while lying face up will help to prevent the deleterious effects of forward
head posture on the lower back. A pillow under the knees will often relieve low back pain and
sciatica caused by an excessive lordosis or extension pain themes when lying face up.

When lying on the side, proper pillow height should support the head and neck so that they are
level (parallel) with the bed to avoid side tilting posture habits. Using a pillow between the knees
and lower legs to keep the top thigh level with the bed can also reduce back strain while resting or
sleeping. Avoid bending the knees excessively (fetal position) as this can lead to tight hip flexor
and weak gluteus max (buttock) muscles which is a common mechanical stress to retrolisthesis
back pain. It is usually much wiser to keep the legs as straight as comfortable and avoid placing
one leg in front of the other when side sleeping and resting. Lying face down can occasionally
provide temporary relief for acute flexion based low back pain, but is not recommended long term
as a viable sleeping position.
 6

Exercises for Pain with Flexion

Flexion pain theme exercises are all designed to strengthen your ability to resist painful bending
forward motions. You will choose these exercises because you have identified that your back pain
is worse when bending forward from the waist, or with prolonged sitting and slumping. This
chapter will address the typical needs of most retrolisthesis sufferers.

Because the discs of the lower back are compressed when bending forward, slumping and sitting,
these exercises center around building up the endurance and strength of the extensor muscles
(those that help you sit and stand upright, and bend the spine backwards). Research has shown that
extensor muscles are often weak with chronic disc problems and strengthening the extensors are
often helpful. Extensor muscles also help to increase the lordotic arch of the lower back and the
forward (anterior) tilt of the pelvis, both of which are typically decreased in retrolisthesis.

Other exercises in this chapter help flexion pain themes by changing ribcage forward and backward
translation, improving the thoraco-lumbar fascia stability, increasing the activation of the deepest
core muscles, modifying walking mechanics, and further support anterior pelvic tilt and the
lordotic arch of the lower back. All of the exercises in this chapter are helpful in decreasing the
typical backwards sliding forces on low back vertebrae that is the hallmark of retrolisthesis.

While most of these exercises are appropriate for those whose pain is worse with flexion, some
exercises may be more indicated or contra-indicated than others. Never perform an exercise if it
aggravates your back pain. Emphasize those exercises that address your analysis findings. You
will not need to do each exercise every workout, but rather use those you feel most comfortable
with at the start. You can alternate exercises that are similar (in the same group, ex; multifidus
exercises) every other workout, or change to a new one within the same group each month to
ensure training variety and progression. These concepts will be further explained in the chapter on
your workout design.

Remember that progression in all of these exercises is the key to increasing spinal stability and
helping your body heal. This is accomplished by adding a few seconds of time each successive
workout to those endurance time based isometric exercises, and adding 1-3 repetitions (reps) each
successive workout to those exercises that use repeat repetitions. Always leave at least one day
rest between workouts of the same muscle groups (same directions of movement or tension) to
allow for proper post- workout recuperation and continual progress.
 44

Multifidus Exercises

Multifidus muscle endurance conditioning is important for all pain themes associated with
retrolisthesis. The deep multifidus muscle fibers prevent sliding (shearing or translation) of
vertebrae through their compression effect, while superficial multifidus fibers help extend (arch)
the lower back to prevent the excess flexion that is detrimental for so many retrolisthesis cases.

1. Hip Hinge with Isometric Holds. This is the same exact exercise presented in the last chapter,
except now as opposed to performing so many repetitions you will build up the length of time you
can hold yourself tilted forward in the hinge position. Begin holding for 10-15 continuous seconds
and build up by a few seconds each workout. Perform this exercise 2-3 times per week. Only repeat
for 2-3 “sets” per workout, resting a minute between each set of isometric hold. Remember to hold
your neutral spine position and RPI throughout the entire exercise, as this is paramount to
protecting your back from flexion based challenges. Always use a range of motion that is within
your flexibility limits, avoiding losing your neutral spine position.

2. Hip Hinge with Band Resistance at Chest. You

may also advance the hip hinge exercise by performing
it using a resistance band at your chest. Loop one end
of the band around an anchor point approximately 12
inches off the floor. Hold the opposite end of the band
against your chest and step away from the anchor point
until the band loses its slack. Step back an additional
foot or two so that as you move forward in the hinge
motion, tension is maintained in the band. As you
ascend in the movement, the band will offer resistance
as it stretches. Do not pull the band with your hands,
but keep it against your chest at all times, allowing
your multifidus and other extensor muscles to do the
work. You will feel several muscles working in your
back, buttocks and rear thighs. Build up 2-3 reps per
workout from 10 to 100 repetitions before stepping backwards another foot for added resistance.
Each time a new level of resistance begins, start over again at 10-20 repetitions. Remember the
key to the exercise is maintaining your neutral spine and RPI.

3. One Arm Front Shoulder Raise with Resistance. Holding a dumbbell or resistance band for
resistance in one hand, monitor your weak or inhibited multifidus with your opposite thumb. Focus
on the multifidus contraction as you slowly raise your straight arm forwards against resistance.
Only raise your arm to chest level. The key to this exercise is maintaining multifidus contraction
both while raising and lowering your opposite arm slowly, and maintaining your neutral spine and
RPI tensions. Add 2-3 repetitions per workout and build to 50-100 reps before adding more
resistance. When adding resistance, be sure to only increase by 1-5 pounds if using a dumbbell, or
step back a few inches when using a band.
 45

4. Standing Forward Weight Shift with Band.

Stand with one foot forward and the other backward.
Loop a resistance band around your waist with the
other end of the band anchored to a point behind you.
The band should be tense and not slack. Monitor your
multifidus weakness with your thumbs as you shift
your weight from your rear foot to your front foot by
lifting your rear heel and moving your chest straight
forwards. The band will stretch and offer resistance to
the forward movement. Be sure to keep your hips from
twisting and lead the forward weight shift with your
chest (not your hips). Move forward slowly and then
return slowly to the starting position. Repeat for
repetitions (adding 2-3 reps per workout) or hold for
longer extended isometric endurance hold times
(adding 2-3 seconds per workout). As in all exercises,
maintain your RPI and neutral spine.

Anterior Pelvic Tilt Exercises

Anterior pelvic tilt exercises are helpful in retrolisthesis because they help move the gravity axis
backwards, inducing more of an arch (lordosis) in the lower back. Many cases of retrolisthesis
suffer from a posterior pelvic tilt posture and a decreased lordotic arch. By increasing anterior
pelvic tilt and the arch of the lower back, the retrolisthesis vertebra is encouraged to move in a
forward direction. This relieves stress on the painful spinal soft tissues and prevents additional
backwards slide. Anterior pelvic tilting thus helps retrolisthesis healing to outpace injury.

1. Seated Anterior Pelvic Tilt Ball Rolls. Begin

sitting on a Swiss ball with your feet pointed straight
ahead and your neutral spine and RPIs engaged. Roll
the ball slightly forwards by raising your tail bone and
lowering your pubic bone (anterior pelvic tilting). Only
tilt as far as comfort allows. Hold this forward position
for 2-5 seconds before rolling the ball backwards to the
starting position by using a posterior tilting (reverse)
motion. Repeat for repetitions or for increased hold
times. Perform only 1-3 “sets”. Progression in this
exercise is the standard increase of 2-3 reps or 2-5
seconds per workout, building to eventually 100-200
reps or a single 3-20 minute hold time in this anterior
pelvic tilt posture.
 46

2. Standing Band Anterior Pelvic Tilts. Engage your

neutral spine position and RPI while standing with a
resistance band looped around your upper thighs (just
below your buttocks) and the other end anchored in
front of you. Step backwards until the tension of the
band eliminates any slack. Tilt your pelvis into an
anterior tilt (lowering your pubic bone and raising your
tailbone) against the resistance of the band. Only use
a range of pelvic tilting motion that is comfortable. Be
sure to hold the rest of your body perfectly still,
limiting the motion to your pelvis only. After holding
the position for 1-2 seconds, tilt your pelvis back to the
starting position and repeat for repetitions, building
from 10 to 100 by adding 2-3 reps per workout. Once
100 reps is reached, stand back an additional six inches
from the anchor and build again from 20 to 100 reps.

3. Prone Anterior Pelvic Tilts. Lying face down on the floor, engage your neutral spine and RPI.
Gently anterior pelvic tilt by pushing your pubic bone down into the floor and raising your tail
bone up towards the ceiling. Use a range of motion that is comfortable. This exercise can be
repeated for repetitions holding each anterior tilt for a few seconds, or can be done for extended
times to build isometric endurance. 2-3 reps can be added each workout eventually building to
100-300 reps, and isometric hold times can increase by 2-5 seconds per workout building to
eventually a 3-20 minute single hold.

4. Supine Anterior Pelvic Tilts with Dumbbell.

Lying face up on the floor or an exercise bench with
your legs straight, hold a light (5-10 pound) dumbbell
across the front of your hips (between your belly button
and pubic bone). Anterior pelvic tilt by raising your
tailbone towards your lower back and dropping your
pubic bone towards the floor. Hold for 2-3 seconds
before tilting your pelvis back to the starting position
and repeating for repetitions. Use a comfortable range
of motion, avoiding any degree of pelvic tilting that
causes back pain. Add 2-3 reps per workout building
from 10 to 300 reps before graduating to the next
heavier dumbbell (5 pound increments), and again
building from 20 to 100 plus reps.
 47

Tranversus Abdominis (TrA) Muscle Exercises

The transversis abdominis (TrA) muscle is the deepest of the abdominals and a key component of
spinal stability. Many back pain sufferers have a delayed TrA activation, meaning that although
the TrA should contract to stabilize the spine prior to moving the arms or legs, it activates after
limb movement. This common problem opens the risk of improper spinal movement as the arms
and legs move causing mechanical trauma to the retrolisthesis spinal segment. The following
exercises will help to quicken the activation time of the TrA so that it properly stabilizes the spine
before limb movement. Only move on to the next progressive exercise once you have mastered
perfect form and progressed in reps and hold time in the previous exercise.

1. Hook Lying TrA Contraction Progressions.

STAGE1. Lying face up on the floor with the hips and

knees bent and the feet flat on the floor, pull in your
lower abdomen (between your belly button and pubic
bone) towards your spine near the end of maximal
exhalation. Use your hands on your lower abdomen to
monitor this movement. If you have identified an over
active internal oblique muscle in your analysis, use the
correction already taught to make sure both sides of
your lower abdomen pull inwards equally (there should
be no bulging outwards while drawing inwards). Hold
your lower abdomen inwards as you breathe normally
for 10-15 seconds. Then release the draw in tension and
relax for 15 seconds before repeating the exercise. Build
up to 3 sets of 10 reps before progressing to stage 2.

STAGE 2. From the same position in Stage 1, hold the lower abdomen inwards as you alternatively
raise your right and left arms overhead. Use your neutral spine and RPI to avoid any lower back
motion as you do this. Build up to 3 sets of 10 reps as described in stage 1. If you have identified
tight latissimus muscles in your analysis, be sure to stretch them prior to this exercise.

STAGE 3. From the same position in Stage 1 and 2, hold the lower abdomen inwards as you
alternatively raise your right and left knee 12-18 inches. Your arms should rest at your sides as
you do this. Use your neutral spine and RPI to avoid any lower back motion as your legs move.
If you have identified anterior hip malposition/glide, be sure to use the correct motion described
in the analysis chapter. Build up to 3 sets of 10 reps as described in the previous stages.
 48

STAGE 4. From the same position, alternatively raise your opposite arms and legs. Be sure to
maintain a motionless lower back with your neutral spine and RPI tensions as you breathe normally
during this last stage. Build up to 3 sets of 10 reps as described in the previous stages.

STAGE 2 STAGE 3 STAGE 4

2. Transverse Abdominis with Standing Arm and Leg Motions.

Practice drawing in your lower abdomen (engaging the TrA muscle) in the standing position just
prior to haphazard arm and leg motions. Use forward, sideways, backwards and crossing motions
of both the arms and legs. The key to this or any TrA exercise is to engage the TrA just prior to
limb movement to ensure that spinal stability and core muscle contractions always precede limb
movements. Maintain the TrA pull-in during the motion of the limbs as well. Start with slow arm
and leg motions, and gradually increase speed over several weeks to months to improve this skill.
3. Transverse Abdominis with Balance Challenge. Engage your TrA muscle (lower abdomen
pulled in with vertically tall lower back maintaining proper lordotic arch and neutral spine pelvic
tilt position) as you stand on a sofa cushion or wobble board. As your balance is challenged by the
uneven or wobbling surface, the goal is to make sure to engage (or hold) the TrA just prior to any
change in directional sway. Once you have mastered this with the eyes held open, increase the
challenge with a closed-eye standing position on the wobbling surface. Limit your body sway to
no more than ¼ inch by holding or tapping onto a support with your hand.
 49

Extensor Muscle Strengthening Exercises

The extensor muscles of the back lift the spine up and backwards. They also hold the arch (lordosis)
of the lower back in position. This function is key to preventing forward bending (flexion)
movement on the lower back, and most importantly resists the tendency for retrolisthesis vertebrae
to slide backwards. The extensor muscles include the erector spinae, latissimus dorsi and
multifidus muscles. The following exercises include some that work all of these muscles as an
integrated group, as well as some that work these muscles in isolation.

1. Full Spine Extension.

This exercise strengthens the muscles that bend you backwards, hold you upright, and prevent disc
compression while standing, sitting and bending. This is important for all lower back disc
conditions, but caution must be taken in certain cases, such as when your disc degeneration is
associated with stenosis, spondylolisthesis, facet
syndrome, or pain that is worsened by bending
backwards. The key with this exercise is to tense the
extensor muscles of the entire spine, without
necessarily bending the spine backwards into painful
extension.

Begin lying face down on the floor or on an exercise

bench. Place your hands under your thighs. Engage
your RPI and associated core tensions. Emphasize tail-
under tension as you squeeze your buttocks and
shoulder blades together. Slowly raise your collar bone off the floor or bench causing muscular
tension to be felt from your head through your lower back region. Only raise high enough to feel
the tension, avoiding overarching the lower back by maintaining tail-under tension.

Your eyes should be looking towards the surface you are lying on throughout the motion. Hold
this position for 2-3 seconds, and then slowly lower your collarbone down to the starting position
before releasing your buttock, shoulder blade, tail-under, and stability tensions.

Repeat for 5-8 reps and add 1-2 reps per week until you have reached 100. Perform 1-2 sets. You
may advance this exercise by holding the top position for progressively longer hold times (5-30
seconds). Remember to start the reps over at 20 when increasing hold time.

If your lower back pain is relieved by leaning backwards (spinal extension), and you do not have
one of the above mentioned conditions, then you may raise your chest upwards with this exercise
and allow a tolerable amount of arch in your lower back. All others should maintain the exact
 50

amount of lower back curve (lordosis) that they normally have while lying face down with their
neutral spine position and tension.

Beginners may keep their hands tucked under their

thighs during this exercise. As you progress you may
hold your hands out to your sides in a “W” shape as
pictured to engage more upper back muscles and make
the exercise more challenging.

This aim of this exercise is to slightly lift the entire

upper body off the floor from the hips, avoiding
arching the lower back past your neutral spine degree
of arch. Extension (bending backwards) is a multi-joint
full body action in most daily activities and therefore
should be trained as such. The key therefore is to try to maintain your head, torso and hips in
alignment as your entire spine elevates slightly from the pubic bone, which is pressured into the
bench or floor in an effort to elevate the collarbone. Unless arching your back relieves your pain,
always emphasize tail-under tension to avoid arching your back. This tension strengthens
abdominal muscles, which as previously described, work with your back muscles to stabilize and
protect your lower back.

.
2. Reverse Hypers. This exercise highlights the
buttock, lower back and hamstring muscles as an
integrated extensor group. Engage your neutral spine
with RPI and associated core tensions. Position
yourself face down on an exercise bench or similar
support with your pubic bone on the bench, but one
inch from the edge of the bench. Your hands should be
holding the sides or top of the bench. If you have tight
latissimus muscles, it is advisable to hold as far
overhead as is comfortable. Your legs will be off the
bench with your feet touching the floor.
Emphasize tail under tension to prevent your lower back from increasing its arch past your neutral
spine amount as you tighten your buttocks together to raise both legs as far as is comfortable
without losing your RPI. Your knees should be relatively straight. Your legs should never be raised
past the level of the bench or support surface. Hold the top position for a second or two before
slowly lowering your feet back to the floor. All the motion should be occurring in your hip joints
as you stabilize your lower back with muscular tension throughout this exercise. Done correctly,
you will feel your buttocks and rear thigh muscles (hamstrings) working hard as your extensors
(posterior chain) are used in a different way than most daily movements.
 51

Typical mistakes include loss of (or insufficient) tail under tension, insufficient multifidus and
buttock recruitment, torso or pelvic rotation or side tilting, external hip rotation, and hip hiking.

Those with weak gluteus max muscles and tight hamstrings may feel this exercise more strongly
in the back of the thighs rather than the buttocks. This is a mistake and could lead to hamstring
injury. The correction for this dysfunction is to lock the knees straighter with more tension. This
will recruit more quadriceps muscle activity on the front of the thighs, thus relieving hamstring
overuse and helping to better target the buttocks, which should be the major muscle working in
the Reverse Hyper.

Those with tight latissimus muscles and increased lordosis will want to stretch the latissimus by
holding the bench with the hands as far overhead as possible. This will only be effective if the
proper amount of tail under tension is simultaneously applied to prevent the lower back from
excessively arching as the latissimus is stretched.

Begin with a range of motion that is extremely comfortable, perhaps only lifting the feet one inch
off the floor. Use 5-10 reps to begin and add 1-2 reps per workout, building to 100-200 reps. You
may advance the exercise by slowing the cadence of each rep, increasing isometric hold time at
the top of each rep, or adding a light resistance to your ankles in the form of a dumbbell or
resistance tubing attached to the foot of the exercise bench. Remember that all progression should
be slight and gradual from workout to workout.

3. Hip Hinge with Arms Held Over Head. Using the same Hip Hinge movement that has been
described previously, this exercise is modified by holding the arms overhead. As the hinge is
performed, the overhead position creates a longer lever (moment arm) that makes the extensor
muscles work much harder. This exercise should first be used only after the previous hip hinge
varieties have been progressed to several hundred reps. The Hip Hinge with Arms Held Overhead
should first be done using only the body weight of the arms, but can be further progressed over
months to include holding a resistance band overhead for a greater training effect.
4. Inverted Plank. The inverted plank strengthens
the extensor muscles of the spine, hips and legs. It
also challenges forward head stability, pelvic and
torso rotation tendencies, sway back posture and is
excellent for weak gluteus max muscles. For most
people with chronic lower back pain and weak core
muscles, it is a very challenging exercise.

Sit on the floor with your legs out straight. Engage

your lower back stability and tighten your buttocks.
Lift your hips up as high as comfortable, keeping your
head back and in alignment with your torso. The top
position is shown in the photo presented. Beginners may only lift their hips up a few inches.
 52

With progressive training practice over several months, your goal is to lift your hips to the full top
position (aligning the ear, shoulder, hip, knee and ankle) as shown in the photo.

The key to this exercise is to recruit more buttock tension than lower back erector spinae tension.
Emphasizing tail-under tension is the only way to do this. You will need more tail under tension
the higher the hips are raised. As in previous exercises, remember that this is tension and not extra
movement. Also be mindful to hold your stability preventing the common mistakes of pelvic and
torso rotation, as well as hip hiking.

Begin by holding the inverted plank position for 5-10 seconds, and add 1-2 seconds per workout.
Build up to 2-3 minutes.

5. Inverted Plank with Plate. This is the next

progression from the basic inverted plank
exercise described as the beginner/ intermediate
version. Begin with a light dumbbell or weight
plate (5 pounds) positioned at the front of your
hips in the seated floor position. A towel placed
between the weight and your hips is
recommended to avoid the weight from slipping
from the original position. Hold times can
progress from 15 seconds to 3 minutes. Progress
no more than 5 seconds per workout, and add
only 5 pound weight increments after building up
to at least one minute of hold time. Weight plates
will be easier than dumbbells to use in this exercise once weight increases. Remember to
emphasize gluteus max contraction, tail-under tension and knee- straightening tension to ensure
proper form as resistance builds.

6. Glute Bridges (1 and 2 Leg). Glute bridges are

designed to emphasize the gluteus max muscles
(buttocks) as a priority over the hamstrings and back
muscles during the backward movement of the leg
from the hip joint (hip extension). This is a “posterior
chain” exercise to strengthen the gluteus max muscles
with lesser contributions from the lower back
extensors and hamstrings. It is an excellent choice for
training more buttock contribution rather than back or
hamstring. Corrections of these two mistakes and
others need to be emphasized the higher your hips are
raised.
 53

Begin lying face up on the floor with your knees bent, and feet flat on the floor. Make sure your
hips, knees and ankles are all vertically aligned. Engage your lower back stability. Tense your tail
bone under slightly more as you squeeze both buttocks. This will decrease the participation of
lower back muscles during this exercise. Push your feet against the floor in an effort to slide them
away from your hips. Do not move them; only tense them in this direction. This will engage your
quadriceps on the front of your thigh and release excess tension from your hamstrings. Now
squeeze your buttocks harder as you emphasize your tail-under and feet-slide tension. Continue
doing so to lift your hips as high as you can comfortably. You will need more tail-under and feet-
slide tension the higher you lift.

The goal is to get your hips high enough so that your chest, hip and knee are in a straight line.
Hold fort a few seconds before lowering and repeating for reps. Start with 3-10 reps and add 1-3
per workout, building up to 50 reps. You can progress to a 1 legged glute bridge (pictured) once
you can perform 50 reps. This is the same exercise as a glute bridge, but is performed on one leg
by holding one knee toward your chest. This challenges hip hiking, torso and pelvic rotation much
more than the two- legged variety, and as such is good for those with these tendencies. Build up
from 5 to 50 reps as above in the two-legged version.

7. Straight Leg Glute Bridges (+ Bells). This is the

progression from the bent knee Glute Bridge
described previously. Your heels will be elevated
above the rest of your body on an exercise bench or
sofa. Your knees will be held straight throughout the
exercise. This exercise uses a greater amount of
hamstring and gluteus max contraction as the front
thigh muscles (quadriceps) are used much less.
Always emphasize gluteus max contraction over
lower back muscular contraction by emphasizing tail-
bone under tension. Maximize diaphragmatic
breathing during the lift.

Straightening the knees by tensing your front thigh muscles will alleviate any cramping in the
hamstrings. Begin with no additional weight and build reps from 10-100 adding 2-3 per workout.
Additional weight may be added by holding dumbbells at the front of your hips, emphasizing
strength by using rep ranges from 6-20. One-legged straight leg glute bridges are an even more
advanced version of this same exercise with challenges rotational and lateral stability greater than
the two- legged version.

8. Horizontal Squat. The horizontal squat is the same exact motion as a squat, except you will
hold the lowest position for progressively increased lengths of isometric time. This exercise has a
different (endurance) conditioning effect on your lower extremities and extensor core muscles than
normal squats, which is beneficial for prolonged stooped or bending activities.
 54

Hold your arms out to your sides, shoulder blades

pinched together, and use a squat depth that is
comfortable, and does not change the lordotic low back
arch of your neutral spine position. This may be only a
few inches of knee and hip bend, but do not squat lower
than having your thighs parallel with the floor
(horizontal). Maintain your unique lower back stability
position and tension as you breathe slowly with your
diaphragm (emphasizing using your upper abdomen to
inhale and exhale).

Build up to 3 minutes by increasing your isometric time by a few seconds each workout. Advanced
versions include performing this exercise while standing on sofa cushions to introduce a balance
challenge to holding your neutral spine in this position.
9. Bar Thigh Squats. This exercise may be performed using
the sumo or parallel style method of squatting previously
described. By allowing the weight of a barbell to rest on the
upper thighs, the lower back is spared significant stress, while
still providing an excellent strength workout for the hips and
legs. This follows our general theme of lower back stability
strength, with hip and leg mobility strength.

It is important to use a power weight rack or bench to rest the

weighted bar on before attempting this exercise. This will
prevent lower back stress in attempting to lift the barbell from
the floor. Alternatively, dumbbells may be used and held on
the upper thighs in place of a barbell.

Engage your lower back stability and position yourself under

the bar in the bottom of your squat position. The bar should be resting on the upper half of the
front of your thighs. Hold onto the bar with only enough pressure against it to prevent it from
slipping down your thighs as you squeeze your buttocks together and stand up straight. As you
ascend in the squat, be sure to emphasize pushing the bar into your thighs, without pulling it
upwards. Your thighs will be bearing the weight of the barbell, and only slight to moderate hand
pressure into your thighs will be needed to keep the bar from slipping down. A rolled up towel
placed between the bar and your thighs will assist in keeping the bar stable and add comfort.

This exercise not only strengthens the hips, legs, and lower back muscles, but also trains you in
how to lift household and yard items safely by using your thighs to bear the load. This type of
conditioning is imperative to reduce lower back stress in the unforeseen challenges of real life.
 55

The stronger you become in this exercise, the more ability you will develop in lifting multiple
items without aggravating your back by using your thighs to bear the majority of the stress.

Reps can vary from 10 to 100 in this exercise, using 1-5 sets per workout. As always, increase
reps, number of sets, and resistance gradually (2-5 reps per workout, 5 pounds per weight increase,
and 1 additional set per week to month).
10. Bar Thigh Rows. From the same lowest position of a Bar Thigh Squat, maintain your neutral
spine as you pull (slide) the bar up your thighs from just above your knees to your hips. Be careful
not to lift the bar off your thighs as this may increase spinal stress and injure your back. Begin
with a weight that allows an easy 20 reps and build your reps up to 100 by adding 2-3 reps per
workout. Once 100 reps is reached, add 5-10 pounds to the bar and begin the progression again.
11. Prone Rows. Lying face down on an exercise bench with your neutral spine engaged, tighten
your buttocks and pull a barbell or dumbbells up from the floor to the bottom of the bench. This
exercise allows the spine to be safely supported as the extensors (particularly the latissimus) work
hard to raise the weight. Keeping your elbows close to your sides during the Prone Row will
maximally activate the tension in your latissimus, which will be beneficial for retrolisthesis
stability training. Reps should be progressed from 5 to 30, and heavy weights can be used as you
build up your strength. This exercise typically avoids the increased risk of lower back injury
common to many other rowing exercises.
12. Reverse Flyes. Lying face down on an exercise
bench with your neutral spine engaged, tighten your
buttocks and raise hand-held dumbbells from below
the bench outwards and upwards in a circular motion
by squeezing your shoulder blades together. Keep
your elbows bent during the entire motion and limit the
range of elevation so that you are moving in a
comfortable range. This exercise targets the mid back
extensors which will help in upright posture and serve
to correct rounded shoulders. Use a weight that allows
at least 10 reps when starting and build to 30 -50 reps
before increasing dumbbell weight by five pounds and starting the progression over again.
13. Chin- Ups/ Pull-Ups. Chin-Ups and Pull-Ups can be used as advanced supportive back
exercises to train the latissimus, shoulders and abdominals. One of the advantages of these
exercises is that they pose no compressive threat to back problems, and actually provide a de-
compressive benefit as the spine elongates during the non-weight bearing motion. Keeping your
elbows close to your sides during these exercises will help to maximally activate your latissimus
dorsi (lat) muscles, which will enhance your spinal stability.
 56

Good form during these body weight exercises includes maintaining the neutral spine RPI with
different points of focus at different times in the range of motion. At the bottom of the motion, it
is common to lose the RPI tension and neutral spine position when changing directions from
lowering to raising. This often causes a jarring across the back that may cause injury. Slowing
down this transition phase to avoid loss of the neutral spine is of key importance to train proper
stability during this directional transition.
Tight latissimus muscles are stretched at the bottom range of motion
as well. This can cause an extension arch in the lower back, as the
latissimus stretches at the bottom of the motion and pulls on the
lower back. If you suffer with tight latissimus muscles, or back pain
that is aggravated with extension, use additional abdominal tension
to prevent overarching the back at this point in the exercise. A palms
facing away grip on the bar (pull-up grip) will shorten the
latissimus, which will help decrease this pull on the back. A palms
facing back towards you grip (chin-up grip) will stretch the
latissimus in this bottom position and accentuate the pull on your
back.
At the top of the motion, it is common to poke the head forward
over the bar, which may also cause an extension effect in the lower
back. This practice also ingrains forward head posture, which has
already been discussed as a detriment to many lower back problems. Maintain a stable neck and
back by tucking the head backwards as the top of the chin-up or pull-up is reached.
Extension or overarching in the back may also be decreased by allowing the hips and legs to swing
forward slightly, which will increase abdominal muscle activity during these pulling exercises.
Keep your body alignment rather straight as you do this, and avoid trying to excessively bend the
hip or knee joints, which can over-activate hip flexors and cause excessive anterior pelvic tilting,
lower back arching, and anterior hip malposition tendencies.
If your body weight is too heavy to perform at least 5 reps in this exercise, standing on a box and
using partial leg support is an option. As you become stronger, less leg support will be needed.
Slowing the cadence of pull-ups and chin-ups is a great way to advance the exercises once you can
perform 15-20 reps with full body weight. Bands looped across each shoulder and attached to the
bottom of the chinning apparatus is a very advanced progression option for these exercises, which
avoids the stretching stress on the back caused by holding a dumbbell between the ankles.
 57

14. Push-Ups and Dive Bombers

While push-ups are classically thought of as an upper body pushing exercise, they can also be used
to train the spinal extensors as the latissimus muscles contract strongly during this exercise. Pull-
ups, chins and rows condition neutral spine stability for pulling motions in real life, and push-ups
can condition back stability for the pushing motions that various tasks demand.
Daily and sports activities often require pushing, and as such rely on a coordinated effort of both
upper body strength coupled with core stability of the back. If your upper body is not strong enough
to push in the various tasks that your daily activities require, it is likely that you will use additional
momentum generated with your hips or back to assist in pushing whatever you need to push. This
compensatory movement usually results in added force transferring through your back. If you do
not train and condition your back to be stable during effortful pushing, your risk of losing proper
spinal stability increases as does the risk of back injury.
To use this supportive exercise properly, engage your neutral spine position and RPI tensions with
slight to moderate abdominal bracing at the top of the push-up position. If you are not strong
enough to perform a regular push-up against the floor, you may place your hands against a wall or
high counter top for an easier modification of this classic exercise. Focus on avoiding an
excessively increased arch in the lower back as well as rounded shoulders in this top position. Tail-
bone tuck under abdominal tension and pinching the shoulder blades slightly together will assist
in maintaining your neutral spine position. The latissimus muscle is quite active during pushups,
and thus, should be countered with buttock (gluteus max) tension to help stabilize the lower back
before descending in the motion.
As you inhale and bend your elbows to lower yourself, maintain a straight vertical alignment
between your knee, hip, shoulder and ear. Avoid the tendency to poke the head forward, increase
the arch in the lower back, and drop the torso between the shoulder blades (the shoulder blades
should remain flat against the ribcage). Slow your speed down at the bottom of the pushup motion
to maintain your neutral spine as you transition from a downward motion to an upward motion
while exhaling.
While your shoulders, chest and arms might seem like the major targeted areas during your push-
up, keeping focus on your core back corrections will expand the training stimulus of this exercise.
If your upper body is already strong, you may commonly feel this exercise is more core demanding
than upper body demanding when performed in this fashion.
Dive bombers are an advanced push-up exercise, which also include other extensor muscle
participation during the two phase motion. As opposed to training the pushing muscles on a
horizontal plane of motion to the body only, they offer varying angles of pushing and pulling
motions, which leads to a fuller development of the upper body muscles, including the extensors,
and supports the lower back lordosis at varying angles as well.
 58

They are performed by beginning on your hands and knees with your hips and knees bent so that
your hips are higher than your shoulders. The descent of the movement upon inhalation follows a
down-hill motion of the chest through the bottom push-up position and then up-hill to a point
where the shoulders are higher than the hips. These three phases of the dive bomber motion are
demonstrated in the following photos.

There is a natural tendency for the lower back to increase its arch as the dive bomber movement
is performed (especially as the torso begins to move up-hill). This arching should be limited to a
pain-free range of motion that was found in your initial body analysis, or checked by anterior and
posterior pelvic tilting on your hands and knees before the dive bomber exercise is performed each
workout. Posterior pelvic tilting and abdominal tension are the solutions to controlling excess
arching during this exercise. This exercise is helpful in allowing you to train and condition your
safe range of spinal extension.
Those with extension induced back pains associated with retrolisthesis such as spondylolisthesis,
stenosis, facet syndromes, etc. may find this very challenging and should be careful when
attempting this exercise- it may not be suitable for all of these types of cases. Conversely, those
back pains that are aggravated with flexion (many retrolisthesis disc problems) and relieved with
extension may find the dive bomber to be an excellent source of pain relief and full body
conditioning.
Once you have reached the last position demonstrated in the photos, exhale and return along the
same arc to the starting position to continue your next rep. Holding your neutral spine position (or
pain free range of spinal extension), as well as the points mentioned in the push-up explanation, is
paramount when performing this exercise. As with push-ups, if you are not yet strong enough to
perform this exercise against the floor, you may try it against a wall or counter top. The closer your
feet are to your hands, the easier the exercise will be, and progression is made over time by moving
your feet farther away from the wall or counter top.
 59

As reps increase to 20-50, the cadence of the exercise may be slowed for further strength
progressions. Additional progression can be made by performing the dive bomber holding a
resistance band in your hands, with the band wrapped behind your shoulder blades.
15. Single Straight Legged Deadlifting (SSLD) is an
extensor exercise that also challenges your ability to
resist twisting and lateral (sideways) bending. If your
analysis revealed that your back pain is worse not only
with flexion, but also with side bending or twisting as
well, this is an excellent extensor strengthening
exercise choice.

Maintain a slightly bent knee on your standing leg

while you pick the other foot off the floor by bending
your opposite knee. Engage your neutral spine and RPI.
Bend your entire upper body forward by rotating your pelvis around your standing hip as you
maintain your neutral spine. A straight line should be maintained between your ear, shoulder, hip
and non-standing knee throughout the movement. The same theme of safe bending and lifting is
used here- hip mobility with no spinal motion. Rotate your pelvis and entire body around your hip
as far as your flexibility comfort allows before reversing the motion and standing up straight again
by contracting your buttock on the side of the standing leg. Repeat for repetitions building from 5-
100, adding 2-3 reps each workout before adding resistance by holding a light dumbbell and
building again.

The common mistakes to avoid include rotating your pelvis away from the standing leg, hip hiking
and torso side leaning on the side of the standing leg, and changing your lordotic arch as you move
forward and backward. This exercise is an advanced extensor strengthening exercise which
challenges multiple planes of stability. Only begin this exercise after building up your extensor,
lateral, and twisting stability strength in other preliminary exercises.

Hip Joint Extension Exercises

As the thigh moves backwards in the hip socket (hip extension), there is a natural tendency for the
pelvis to roll forwards and for the lordosis (arch) in the lower back to increase. This is typically
helpful for retrolisthesis pain that is aggravated with spinal flexion as increasing the lordotic arch
of the lower back decreases the compressive forces on the front of discs, and the vertebral bodies
between discs, while encouraging forward movement of the retrolisthesis vertebra. While several
of the extensor exercises previously mentioned will help to develop the strength of the hip extensor
muscles, the following exercises are specifically designed to improve hip extension range of
motion to accentuate the lordotic arch of the lower back.
 60

1. Prone One Leg Hip Extension. Lying face up on an

exercise bench with your neutral spine and RPIs engaged,
bend your right knee to a 90 degree angle and lift your right
thigh as high as comfort allows. Allow your lower back to
arch, but not exceed your neutral spine range of comfortable
low back extension motion previously discovered in your
analysis. Hold for a second or two at the top position before
lowering and repeating for repetitions. Build reps from 10 to
100 by adding 2-5 per workout on non-consecutive days. It
is possible that your range of hip extension motion and
neutral spine arch will improve over the course of workouts,
and occasionally over the duration of a high rep set. Raising
one leg at a time emphasizes pelvic rotation on the same side
and is less of an extension stress to the lower back than both legs simultaneously extending. This
one sided hip extension will help your spinal soft tissue adaptation to extension with less chance
of injury.

Typical mistakes to avoid with this exercise include pelvic twisting (rotation) and hip hiking. If
hamstring cramping occurs at the back of the thigh, straightening the bent knee is often palliative.
Once 100 reps is attained, a resistance band can be used around the thigh or foot to provide extra
resistance as the rep progression starts over again from 10 or 20 reps and again builds to 100.

2. Standing One Leg Hip Extension with Resistance Band. Looping a resistance band or low
cable from a weight machine around your ankle, hip extension is performed by pulling your looped
leg backwards away from the band or cable attachment point. This exercise can significantly
challenge balance, and therefore should be done while holding onto a support. This will allow you
to better emphasize both hip and lower back extension while avoiding the typical mistakes of hip
hiking, torso/pelvic rotation, and bending forwards with the torso, thus encouraging both hip and
lower back extension. Respect your neutral spine range of motion with this exercise, which may
improve in its ability to extend or arch in the lower back over time. Reps should build from 10-
100 by adding 2-5 per workout before adding resistance and progressing again.

Psoas Stabilizing Exercises

The psoas muscle attaches the lower back vertebrae and discs to the thigh bone at the hip. When
the thigh is positioned at a right angle to the torso (such as in the seated position), maximal
contraction is possible in this lower back and hip stabilizing muscle. A strong psoas helps to
stabilize the lower back vertebrae more through compression (vertical force) than shear (horizontal
force). Because many retrolisthesis sufferers who have flexion based pain cannot safely handle
large vertical compressive forces on their damaged discs, the following psoas exercises are
typically performed with only the weight of the leg, avoiding extra resistance to decrease disc
stress.
 61

1. Seated Psoas Stabilizing Exercise. In the seated position

with the thighs positioned horizontal to the floor (seat height
adjustments may be needed), engage your neutral spine
position and RPIs. Without moving your pelvis, simply tense
your knee backwards through your thigh and into your hip
socket. The motion is very small, perhaps only 1/8 of an inch,
but will cause a tightness in the crease of your groin when
performed correctly. You can feel for this tightness with
your hand monitoring the crease of your groin when first
coordinating the exercise. Hold the backwards tension for 1-
10 seconds before slowly releasing and repeating for reps.
Rep speed should be slower during the release of the tension
than during the initial backwards pull to develop both the concentric (shortening) and eccentric
(lengthening) function of this important stabilizing muscle. Be careful not to change your neutral
spine position during this exercise. Build your reps and/or isometric hold time by 2-3 reps or
seconds per workout. This is an endurance exercise, not a strength exercise, and reps should
therefore be built up to 100-300, or isometric hold times can be built up to 3-7 minutes. Concentric
and eccentric rep cadences (the time it takes to pull the thigh back and to release it) should be
varied as conditioning advances.
2. Prone Psoas Stabilizing Exercise. The same exercise just
described can also be performed lying face down (prone) on
an exercise bench or bed with one thigh vertically hanging
off the bed with a bent knee. This is illustrated in the
accompanying photo. The exercise is performed by
maintaining your neutral spine and tensing your bent knee
through your thigh and into your hip socket. Avoid lifting
your buttock or twisting your pelvis as you do this exercise.
Your hanging thigh should be positioned 90 degrees
(vertically straight) to both the floor and your torso. Follow
the same progression and rep/ hold time range as described
in the seated version of this exercise.

Ribcage and Pelvic Translation Exercises

The following exercises take advantage of the mechanical changes in lower back spinal alignment
and movement as the result of moving the ribcage straight forwards and backwards in relation to
the pelvis. Depending on the retrolisthesis location (upper or lower aspect of the low back) and
direction or theme of pain (flexion vs. extension), one direction of ribcage/pelvic movement will
typically be more helpful than the opposite.
 62

Choosing the correct direction of movement for your unique retrolisthesis condition and
strengthening that direction to improve postural stress on the lower back is the aim of both ribcage
and pelvic translation exercises.

TYPE A
Exercises for Upper aspect of Lower Back (L1, L2, L3 and T12) Retrolisthesis
Pain Worse with Flexion.

If your retrolisthesis is located in the upper half of the lower back at the T12, L1, L2 or L3 spinal
levels, and the pain is worse with bending forwards (flexion), then the following exercises may be
helpful. As the ribcage moves straight forwards (anterior translation) in relation to the pelvis, the
upper vertebrae of the lower back move forward and extend, helping to reverse the typical
backwards movement of retrolisthesis in this area of the spine. Any exercise that moves the ribcage
forwards in relation to the pelvis (or the pelvis backwards in relation to the ribcage) will assist this
corrective motion.
A1. Prone Pelvic Posterior Translation. Lying face down on the floor or exercise bench, engage
your neutral spine and RPI. Keeping your ribcage, legs and
head flat on the bench or floor, raise your pelvis (hips)
straight up so that your pubic bone is no longer resting on the
bench or floor. Only raise your hips as far as comfortable.
Avoid changing the arch in your lower back by mistakenly
tilting (rotating) your pelvis forwards or backwards. Hold the
top position for 1-5 seconds before lowering and repeating
for repetitions. Build up from 10-100 by adding 2-3 reps per
workout, performing the exercise 2-3 times per week on non-
consecutive days. This exercise may also be used for just a
few reps (5-10) several times per day to reduce postural low
back stress and relieve retrolisthesis pain.
 63

A2. Seated Ribcage Anterior Translation with and without Resistance Band. Sitting on an
exercise bench or chair, engage your neutral spine and RPI. Move your ribcage straight forwards
(anterior translation) while your hips remain stable
(motionless) against the bench or chair. Only move your
ribcage forward as far as comfortable. Hold the forward
position for 1-5 seconds before returning to the starting
position and repeating for repetitions. Build up from 10-100
by adding 2-3 reps per workout, performing the exercise 2-
3 times per week on non-consecutive days. After 100 reps is
achieved, use a resistance band either wrapped around your
chest or held at the sides of your ribcage for additional
resistance for further progression. Always start the rep
progression over again beginning with 20- 30 reps when
adding resistance.
A3. Standing Ribcage Anterior Translation with and without Resistance Band. Perform the
same exercise as A2 above except in the standing position. Standing will be much more
challenging because you will have to avoid forward pelvic movement as your ribcage moves
forward. Using a split stance with one leg forwards and the other backwards will help this.
Remember the key to these exercises is the relative movement between the ribcage and pelvis. Use
the same rep scheme and resistance band options as described above.
A4. Standing Pelvic Posterior Translation with and
without Resistance Band. Engage your neutral spine and
RPI in the standing position. Without moving your ribcage
(holding onto a support with your hands may be helpful),
move your pelvis (hips) straight backwards without raising or
lowering your tailbone. Only move backwards as far as
comfortable. Hold the backward pelvic position for 1-5
seconds before returning to the starting position and repeating
for repetitions. Build up from 10-100 by adding 2-3 reps per
workout, performing the exercise 2-3 times per week on non-
consecutive days. After 100 reps is achieved, use a resistance
band wrapped around your hips, and anchored in front of you,
for additional resistance and further progression. As in previous exercises, always start the rep
progression over again beginning with 20- 30 reps when adding resistance.
 64

A5. Standing Double Band Pelvic and Ribcage Translation. This advanced exercise uses both
pelvic and ribcage translation to accentuate the spinal effect described for Type A retrolisthesis
cases. The first band is wrapped around the hips and
anchored in front of you as you pull your hips straight
backwards. The second band is wrapped or held around your
chest and anchored behind as you move your ribcage
straight forwards. Because both pelvic and torso are moving
simultaneously, you will typically need less overall range of
motion in this exercise compared to those previously
described. Be careful to avoid the common mistakes of
flexing or extending either the pelvis or torso (the motions
should be straight forwards and backwards- as if sliding two
stacked boxes on the floor in opposite directions). Use the
same rep scheme and resistance band progressions as
previously described.

TYPE B
Exercises for Lower aspect of Lower Back (L4, L5 and S1) Retrolisthesis
Pain Worse with Flexion.

If your retrolisthesis is located in the lower half of the lower back at the L4, L5 or S1 spinal levels,
and the pain is worse with bending forwards (flexion), then the following exercises may be helpful.
As the ribcage moves straight backwards (posterior translation) in relation to the pelvis, the lower
vertebrae of the lower back extend, helping to reverse the typical backwards movement of
retrolisthesis in this area of the spine. Any exercise that moves the ribcage backwards in relation
to the pelvis (or the pelvis forwards in relation to the ribcage)
will assist this corrective motion. However, if your analysis
revealed sway back posture, these exercises are not
recommended.
B1. Supine Pelvic Anterior Translation. Lying face up on
the floor or exercise bench, engage your neutral spine and
RPI. Keeping your ribcage, lower legs and head flat on the
bench or floor, raise your pelvis (hips) straight up so that
your buttocks either leave or lighten their pressure against
the bench or floor. Only raise your hips as far as comfortable.
Avoid changing the arch in your lower back by mistakenly
tilting (rotating) your pelvis forwards or backwards. Hold
 65

the top position for 1-5 seconds before lowering and repeating for repetitions. Build up from 10-
100 by adding 2-3 reps per workout, performing the exercise 2-3 times per week on non-
consecutive days. This exercise may also be used for just a few reps (5-10) several times per day
to reduce postural low back stress and relieve retrolisthesis pain.
B2. Seated Ribcage Posterior Translation with and
without Resistance Band. Sitting on an exercise bench or
chair, engage your neutral spine and RPI. Move your ribcage
straight backwards (posterior translation) while your hips
remain stable (motionless) against the bench or chair. Only
move your ribcage backwards as far as comfortable. Hold the
backward position for 1-5 seconds before returning to the
starting position and repeating for repetitions. Build up from
10-100 by adding 2-3 reps per workout, performing the
exercise 2-3 times per week on non-consecutive days. After
100 reps is achieved, use a resistance band either wrapped
around your chest or held at the center of your chest
(anchored in front of you) for additional resistance and further progression. Always start the rep
progression over again beginning with 20- 30 reps when adding resistance.
B3. Standing Ribcage Posterior Translation with and
without Resistance Band. Perform the same exercise as B2
above except in the standing position. Standing will be much
more challenging because you will have to avoid backward
pelvic movement as your ribcage moves backward. Using a
split stance with one leg forward and one leg backward will
make this exercise easier. Remember the key to these
exercises is the relative movement between the ribcage and
pelvis. Use the same rep scheme and resistance band options
as described above.
B4. Standing Pelvic
Anterior Translation
with and without Resistance Band. Engage your neutral
spine and RPI in the standing position. Without moving your
ribcage (holding onto a support with your hands may be
helpful), move your pelvis (hips) straight forward without
raising or lowering your tailbone. Only move forward as far
as comfortable. Hold the forward pelvic position for 1-5
seconds before returning to the starting position and
repeating for repetitions. Build up from 10-100 by adding 2-
 66

3 reps per workout, performing the exercise 2-3 times per week on non-consecutive days. After
100 reps is achieved, use a resistance band wrapped around your hips, and anchored behind you,
for additional resistance and further progression. As in previous exercises, always start the rep
progression over again beginning with 20- 30 reps when adding resistance.
B5. Standing Double Band Pelvic and Ribcage
Translation. This advanced exercise uses both pelvic and
ribcage translation to accentuate the spinal effect described
for Type B retrolisthesis cases. The first band is wrapped
around or held at the chest and anchored in front of you as
you pull your ribcage straight backwards. The second band is
wrapped around your hips and anchored behind as you move
your pelvis straight forwards. Because both pelvic and torso
are moving simultaneously, you will typically need less
overall range of motion in this exercise compared to those
previously described. Be careful to avoid the common
mistakes of flexing or extending either the pelvis or torso (the
motions should be straight forwards and backwards- as if sliding two stacked boxes on the floor
in opposite directions). Use the same rep scheme and resistance band progressions as previously
described.

Lordosis Accentuating Exercises

The following exercises are designed to further accentuate the arch (lordosis) of the lower back in
addition to exercises already presented in this chapter. Increasing lordosis will mechanically
alleviate the backwards spinal stresses of most retrolisthesis pain that is aggravated during flexion.
As with all of the exercises recommended in this program, always use a comfortable range of
movement, a gradual progression in reps, resistance, and
duration of hold time which does not aggravate your lower
back pain.
1. Spinal Extension Molding. Lying face up on the floor,
place a small rolled towel under the arch of the lower back
and relax passively for a few minutes. Use a rolled thickness
that is comfortable enough to initially allow a 3 minute
“molding” time. Gradually add 30 seconds to a minute over
weeks and months to build up to 20 minutes. This passive
“exercise” can be done on non-consecutive days 3 times per
week. Increase the thickness of the roll gradually over
several months to assist in the lordotic arch building effect.
 67

2. Lordotic Stretches. If found to be tight, stretching the following muscles will help restore the
lordotic arch of the lower back by accentuating an anterior tilt of the pelvis. If during these
stretches, you notice no tightness (no stretch sensation), then
they are not indicated as part of your retrolisthesis program.
Stretches can be done daily from 2-5 times per day.
Hamstrings. To stretch the hamstrings on the back of the
thigh, lie face up on the floor or exercise bench and hold your
bent knee so your thigh is perpendicular (straight up) from
the floor or bench. Slowly straighten the knee until a stretch
is felt at the back of the thigh. Hold the stretch position for at
least 15 seconds, but preferably until the sensation of stretch
resolves. Follow this with a slight increase of straightening
the knee and repeat for a second stretch.
Abdominals (Rectus Abdominus and External Oblique).
In the standing position, lower your pubic bone (within a
comfortable range) and tilt your chest up and backwards until
you feel a stretch in
your abdominal
region. This can also
be accentuated by
twisting slightly to one
side and then the other
for two additional
stretches. Hold the
stretch position for at
least 15 seconds, but preferably until the sensation of stretch
resolves. Follow this with a slight increase of chest lift,
pubic bone lowering,
or torso twist, and repeat for a second stretch.
Gluteus Max (Buttock). Lying face up, pull one bent knee
across your chest towards your opposite shoulder until a
stretch is felt in the buttock region. Hold the stretch position
for at least 15 seconds, but preferably until the sensation of
stretch resolves. Follow this with a slight increase of knee to
shoulder motion and repeat for a second stretch.
3. Hip Flexor Shortening. Shortening the hip flexors will
also help to accentuate the anterior tilt of the pelvis, thus
helping the lordotic arch. Spending prolonged times in the
 68

seated position with an accentuated anterior pelvic tilt (pubic bone down and tail bone up) that
allows comfort in the lower back will help to shorten the hip flexors over time. Another option is
to use hip flexor shortening exercises.
Frequent high repetition exercises using the hip flexors will over time lead to hip flexor tightness,
however it is important to avoid disc compression and shearing stress with hip flexor exercises, so
the following modified hip flexor exercise is recommended as opposed to the many found in
typical fitness routines.
Lying face up on an
exercise bench or
floor, engage your
neutral spine position
and RPI tensions.
Bend your left knee a
few inches so that your
left thigh is at about a
15 degree angle to the
bench or floor (photo
on left). Both of your
heels should remain
touching the bench or floor. Slowly bend your left knee to about a 45 degree thigh-to-bench/floor
angle, allowing your left heel to slide across the bench or floor as you do so (photo on right).
Reverse the motion to return to the starting position (15 degree angle). Repeat for repetitions and
then switch to exercising your right leg in the same manner. Gradually build up to 300-500 reps,
performed initially 3 times per week, and eventually multiple times daily over several months.

Walking Arm Swing Exercises

Increasing the distance or range of your arm swing while walking can impact spinal motion and
may help with retrolisthesis pain. The lowest aspect of the lower back (L4 and L5 spine levels)
will move forwards with an increased arm swing distance or range of arm swing motion. This may
help with retrolisthesis pain as it encourages a corrective forward motion to the backwards
retrolisthesis vertebral segment. Conversely, the upper aspect of the lower back (T12, L1 and L2
spine levels) will have a tendency to move forwards with a decreased range of motion or distance
of arm swing.
As with changing any posture or movement pattern, it is always recommended that these changes
be done gradually to allow a pain-free adaptation. This includes the actual range of arm swing
motion (distance of swing), as well as the time spent practicing your new arm swing.
 69

If your retrolisthesis is lower in spine position, gradually increase the amount of arm swing
distance over several weeks until it becomes your new walking form. If your retrolisthesis is
located more towards the top of your lower back, do the opposite and decrease the amount of arm
swing distance. Initially, this may only need to be done for a minute or two at a time, and practiced
3-5 times per day. Eventually, by adding slightly more time, distance, and practice sessions each
day, it should become your new walking standard.

Thoraco- Lumbar Fascia Stability Training to Resist Flexion

The Thoraco-Lumbar Fascia (TLF) is a complex webbing that envelops many muscles and spinal
structures of the lower back. It can be used to help stabilize your neutral spine and avoid flexion
motion in the lower back by tensing the various muscles that attach to it while avoiding a flexion
motion challenge.
You will need a wobble board to perform this exercise which can be purchased through an exercise
or rehab supplier, or made at home out of a small piece of plywood and a cross strip of wood
underneath. In either case, you will
want a board that you can stand on
that wobbles front to back. If
constructing your own wobble board,
simply nail a 1 inch or 1.5 inch thick
wood strip across the bottom of a
piece of plywood that is big enough
to stand on.
Engage your neutral spine position
and add the following muscular
tensions to tense your TLF:
Tense your shoulder blades down towards your hips and in towards your spine. Tense your tail
bone up towards your mid back. Squeeze your buttocks together and slightly bend your knees to
help tense the back of your thighs. Pull your lower abdomen in towards your spine as you elongate
your entire spine. Do not change your neutral spine position with any of these TLF tensions.
Stand on the wobble board with your neutral spine position and TLF tensions so that the strip of
wood underneath the board is aligned across the middle of each foot. The board will wobble
slightly forwards and backwards as you stand and balance on it.
The exercise is performed by holding onto a support with one or two hands with just enough
support to allow a ¼ inch wobble of your body from front to back. Your TLF will be working
especially hard to maintain your neutral spine position and avoid losing the lordotic arch in your
 70

lower back as the board wobbles backwards (heels moving into the floor). Increase your time
gradually over several weeks to months building to 5-10 minutes of continuous wobble board
training. Emphasize maintaining your neutral spine position and resisting the tendency to decrease
the arch of your lower back as the board wobbles from front to back. Avoid holding your breath
during this exercise. As you progress, you may increase the challenge by closing your eyes or
using less hand support. This exercise begins to make your neutral spine position more reflexive
and less conscious by integrating TLF tension to avoid flexion of your lower back.
Other TLF Exercises
The strength of the TLF can be increased by strengthening any of the muscles that attach to it. By
increasing the tension being able to be generated in the latissimus dorsi, trapezius, rhomboids, back
extensors and quadratus lumborum (QL), the stabilizing force of the lower back becomes enhanced
through the TLF. This includes training these muscles with very heavy weight over only partial
ranges of motion (being careful to avoid lower back disc compression and shear). One of the best
exercises to use heavy weight safely is the Prone Row exercise described on page 55. Because the
lower back is supported on the exercise bench, more weight can be used with less danger to the
lower back. Using heavy barbell or dumbbell weight, TLF tension and strength can be increased
using only an inch to two range of motion in pulling the weight up from the floor. As with all
exercises, gradually build up and progress in weight to allow injury-free adaptation, and always
emphasize holding your neutral spine position as the top priority during the lift. This style of
training can use the 1-3 rep range before the inability to perform additional reps. Perform 1-3 sets
per workout once weekly.
 7

Exercises for Pain with Extension

This chapter is for those retrolisthesis cases where back and/or leg pain is worsened when bending
backwards at the waist (spine extension). Although not nearly as common for retrolisthesis
sufferers compared to pain with flexion, some people with retrolisthesis have more pain with
extension because of associated spine conditions such as spondylolisthesis, spinal stenosis (central
or lateral/ IVF), postero-lateral disc herniation/bulging, facet syndrome, ligament instability, and
spine arthritis. Typically, these cases are also aggravated standing or walking for prolonged periods
of time, wearing high heels, and when walking downhill. If you exhibit no extension theme
analysis findings, these exercises are not needed in your program.

As opposed to those exercises presented in the previous chapter dealing with the flexion pain
theme, the exercises in this chapter will be designed to avoid extension, and will use movements
and muscles that are the exact opposite of those taught in the previous chapter. While developing
flexor muscle strength will help avoid extension movement, it is important for the retrolisthesis
sufferer to avoid too much flexion movement while developing their flexor muscles. Too much
flexion movement (bending forward at the waist and decreasing the lordotic arch of the lower
back) will have a tendency to push the retrolisthesis vertebra further backwards. With this in mind,
the following exercises emphasize maintaining your neutral spine position during abdominal
(flexor) exercises and avoid exaggerated flexion movement.
In those cases that need to strengthen their ability to avoid both flexion and extension (because
both directions of movement are painful), the exercises in this chapter should be added to those in
the previous chapter. Remember that the key to avoiding spinal soft tissue aggravation and allow
the body to heal is to strengthen your ability to avoid any movement direction that is painful and
maintain your unique neutral spine position.

Posterior Pelvic Tilt Exercises

To begin to learn how much posterior pelvic tilt motion is tolerable, assume a face up position on
the floor with your knees bent and feet flat on the floor. Gently roll your pelvis by tucking your
tail bone under and pubic bone towards your chest. This will flatten the lordotic arch in your lower
back and slightly flex your lower spine. Practice this with the legs bent, straight and while standing
to determine what range of motion (how much posterior pelvic tilt) is comfortable. This will be
used in all of the following abdominal exercises as a guide to limiting the amount of flexion
movement you should use. Because this range of movement can change from day to day and from
hour to hour it is important to check this before any abdominal exercise workout in order to avoid
flexing your lower back into a painful range of flexion.
 72

1. Posterior Pelvic Dumbbell Tilt. This exercise can be

advanced by placing a light dumbbell across your upper
thighs, just below your hips. As you posterior pelvic tilt in
the face up position with your legs straight on the floor or
exercise bench, the dumbbell will provide extra resistance to
the tilt and strengthen your posterior tilting ability. This will
improve your neutral spine holding ability to resist painful
extension movement. Begin with a 10 pound dumbbell and
perform 5- 10 reps. Increase 2-3 reps per workout 2-3 times
per week on non-consecutive days, building to 100 reps
before adding an extra 5-10 pounds and starting the
progression over again at 20 reps.
2. Posterior Pelvic Tilt Standing with Band. Engage you
neutral spine and RPI in the standing position with a
resistance band looped around the top of your thighs, just
below your groin, and anchored behind you at waist level.
Perform the posterior pelvic tilt motion to stretch the band,
and hold the stretched position for 2-3 seconds before
releasing and repeating for repetitions. Increase 2-3 reps per
workout 2-3 times per week on non-consecutive days,
building to 100 reps before stepping forward a few inches to
increase the resistance and starting the progression over
again at 20 reps.

Abdominal Exercises to Prevent Extension

The following abdominal (ab) exercises are designed to improve both abdominal strength and
endurance which will help you hold your neutral spine and resist extension movement. Endurance
exercises should be built up to at least 3 minute hold times, increasing 2-3 seconds per workout,
performed 2-4 times per week on non-consecutive training days. Strength exercises should be built
up from 5 reps to 30 reps by adding 1-2 reps per workout, performing strength exercises 1- 2 times
per week. Reps, hold times, and resistance levels should eventually meet or exceed those needed
for individual sports and daily activities to ensure your greatest ability to resist extension in your
everyday needs. Always prioritize holding your neutral spine position and RPI during abdominal
exercises.
 73

1. Straight Leg Ab Curl Up. Engage your RPI and

core tensions while lying face up with your legs
straight. If your lower back is uncomfortable in
this position, place a towel or pillow under your
knees. Look past your cheek bones towards your
collar bone to lock your head into proper
alignment. This will help you avoid lifting your
head more than your ribcage as you curl upwards.
Tilt your pelvis posteriorly by tucking your tail
bone under to a comfortable degree and raise your
lower rib cage towards your pubic bone. The
overall motion of the “sit up” is less than one inch as your pubic bone and lower ribs move towards
each other. Hold for 1-3 seconds at the top before lowering and repeating for additional lifts “reps”.
Start at 5 -10 reps and add 1-2 per week until you have built up to 100 reps for endurance
conditioning. Add dumbbells for strength training by holding one across the upper thighs as in the
Posterior Pelvic Dumbbell Tilt exercise described on the previous page, and another across the
chest (padded with a towel for comfort).
Emphasizing the tail bone under tension (posterior pelvic tilt) with this exercise more than the
ribcage raise is paramount to its effectiveness. Too often, abdominal training focuses on the sit up
aspect of motion, which is already quite developed from the usual postural habits of slumping
forward while seated. Extension pain relief due to conditions such as spondylolisthesis, facet
syndrome and stenosis relies on the ability to tuck the tail under with the abdominals, and not
slump forward, in order to decrease the extension stress of overarching the lower back curve. Thus,
the entire fascial system of interconnecting webbing on the front of the body (encasing the
abdominal muscles) must be trained to lift the pubic bone upwards much more than slumping the
ribs downwards. This is accomplished by focusing 90% of the effort on lifting the pubic bone
(posterior pelvic tilting), and only 10% on raising the ribcage. Allowing the legs to remain straight
during this exercise, as opposed to being bent, creates a longer lever force on the pelvis which
encourages anterior pelvic tilting and overarching of the lower back curve. This is desirable for
training purposes, as a greater challenge (and thus training effect) is placed on the abdominals to
resist this tendency by posterior pelvic tilting through tail under tension.
Avoid the common mistakes of leading the upper body motion with your head rather than your
lower ribcage. Your head should only raise because your ribcage is raising. Be sure to maintain
any internal oblique and multifidus corrections with this exercise, as they may be commonly lost
from rep to rep. Other common mistakes include hip hiking, torso side leaning, rotation of the
pelvis, thigh or torso, head side leaning, shoulder rounding and shrugging.
 74

2. Front Plank. From the top of a classic push-up position,

this exercise is performed by simply emphasizing tail under
(posterior pelvic tilt) tension while slightly “crunching” the
chest towards the pubic bone. This causes a slight elevation
of the lower back and hips compared to the straight body
contour in the top of a classic pushup. This exercise is perfect
for those with extension back pains because it emphasizes
abdominal control in an effort to resist the gravitational pull
on the abdomen and the tendency to over arch (extend) the
lower back. If you lack sufficient upper body strength to
assume this position, it can be performed by placing your
hands against a wall and moving your feet 6 inches to 3 feet
away from the wall. The farther your feet are from the wall,
the harder the exercise becomes. This is an isometric endurance exercise, which can begin with
3-10 second hold times, and progress by adding 1-3 seconds per week until you have built up to
1-3 minutes of holding the static position.

3. In- Line Plank. This exercise is a simple

modification of the front plank that can be used
after a few months of front plank progression. It
increases rotational instability, requiring more
abdominal oblique muscle activity, and is thus a
perfect selection for those with pelvic, hip, and
torso rotation tendencies associated with their
retrolisthesis.

Assume a front plank position as described above

and then move one hand in front of the other, and
one foot in front of the other. If your right hand
is placed forward of your left, then your right foot should be forward of your left as well. By
keeping your hands and feet “in line’, you will immediately feel the natural tendency to twist your
body as balance and your RPI corrections are challenged. Progress from 10 -15 seconds up to 3
minutes of hold time. In-line planks can also be performed against a wall or table edge as described
above for those without sufficient upper body strength.

If you have an externally rotated hip, or a tendency to hip hike, the foot of that side should be on
top, and the hand of the same side should be the bottom hand. For example, a right side hip hiker
or external hip rotation should keep their right foot on top of their left, and right hand below their
left. If you do not have these postural issues, alternate lead hand and foot positions every other set
or workout.

Besides losing the tail under and chest crunch-down position, common mistakes to avoid in either
the front or in-line plank include hip hiking and pelvic rotation on the rear leg side. This can be
helped by slightly bending the rear knee. Torso rotation and side leaning is more common on the
 75

front leg side. The rear leg is also more likely to externally rotate causing the heel to move inwards,
across the “in line” alignment. Enlisting a friend to monitor your alignment by watching from
above can be very helpful in establishing proper exercise form.

4. Bird Dog. From the on-hands-and-knees position,

raise one arm and the opposite leg as you avoid
overarching the lower back by posterior pelvic tilting
and “crunching” the lower front of your ribcage
towards your pubic bone (maintaining RPI neutral
spine stability). This is an isometric exercise that you
will build up the endurance time by 2-3 seconds with
each progressive workout. Avoid the common
mistakes of arching the lower back as your leg and arm
elevate, hip hiking on the kneeling leg, shoulder blade shrugging, external hip rotation on the raised
leg, head and torso side leaning, forward head posture, and torso/pelvic rotation. Advanced
versions include kneeling on (and holding onto) wobble discs or sofa cushions, or having a training
partner try to “tap” you out of balance at various points on your body, emphasizing your natural
mechanical and posture faults.

5. Stir The Pot. From a front plank position with your

RPI engaged, rest your chest and forearms on an
exercise Swiss ball. Using tail under and ribs
crunching down abdominal tension, press your chest
and forearms into the ball while making small circular
(stirring) motions with your forearms. Your lower back
will elevate slightly as you maintain abdominal
tension. Switch directions of the circular motion after
each 5-10 reps. Avoid the mistakes of hip hiking, torso
and pelvic rotation, torso side leaning, pelvic and torso
lateral translation, shoulder shrugging, extended head
posture, anterior hip malposition, and loss of the
abdominal tension leading to arching of the lower back. This exercise is a powerful
multidirectional abdominal endurance conditioning exercise that really heightens abdominal
stability of extension induced back pains. Advanced versions include making wider circular
motions, and using a sofa cushion or wobble disc under your feet to increase the stability challenge.

6. Standing Pullovers. Engage your RPI neutral spine stability in the standing position while
holding a gym cable machine bar or resistance band. Assume a slightly squatted position. Keeping
a slight bend to your elbows, push your hands from in front of your chest to your thighs. Repeat
for repetitions. Avoid the typical mistakes of arching the lower back as you raise your hands
upwards, rounded shoulders, forward head posture, as well as torso and pelvic misalignment. This
 76

is an excellent abdominal and upper body strengthening exercise that challenges your stability to
avoid anterior pelvic tilting and arching your lower back while your arms are raising. Work up to
20-30 reps before increasing resistance and beginning the progression over again at 5-10 reps.

7. Rolling Ball Sit Ups. Sitting on a Swiss exercise

style ball, engage your RPI neutral spine stability.
Avoiding any motion in your lower back, roll your
hips forward and lean your upper body backwards as
you sit back to a comfortable degree. Then reverse the
motion to sit back up. Begin with 5-10 reps. All of the
motion comes from your hip joints (not your low
back), as your body sits back and up, with the ball
rolling underneath you as you do so. This exercise
trains abdominal control of your lower back to avoid
overarching, and your neck to avoid forward head
posture. All of the motion is performed by your hip flexors, with complete immobile stability of
your spine. Avoid the common mistakes of changing the arch in your lower back, forward head
posture, torso and pelvic rotation, hip hiking, torso side tilting, and lateral torso translation.
Beginners and intermediates to this exercise should keep their hips
(buttocks) on the ball throughout the exercise. An advanced
version is performed with the hips rolling down far enough to leave
the ball, as is pictured in the photo. Gradually progress and work
up to high reps (100—300) for this endurance exercise.

8. Chops. This is a strength ab exercise. Engage your RPI neutral

spine stability in the standing position, holding a resistance band
or high cable rope above your right shoulder with your hands. As
you squat down and rotate to the left with your hips and torso
twisting as one unit, finish the motion by pressing your hands to
your left knee. Return to the starting position through the same arc
of motion, and repeat for repetitions. Work up to 20-30 reps before
increasing resistance and beginning the progression over again at
5-10 reps. Switch sides after your set. When choosing which side
to do first, be sure to finish with turning into the side of an external rotated hip, if you have one.
Avoid the mistakes of rotating the torso more than the hips, loss of spinal stability, hip hiking and
torso side leaning, forward head posture, foot pronation, rounded and elevated shoulders, and
sideways knee motion. Those with anterior hip malpositions need to focus on rearward upper thigh
motion in the hip sockets during the squat descent. Chops integrate lower, upper, and mid body
motion and stability.
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9. T/L–Hip Rotations. Begin this advanced abdominal

strengthening exercise in a standing sumo position. Engage your
RPI neutral spine and emphasize tail under tension with lower rib
abdominal ‘crunch down” tension. Keep your knees slightly bent
as you hold a resistance band against your chest.

Rotate your hips and torso as one solid unit to one side. Do not
allow your knees to move inwards or outwards more than an inch
as you do this.

Hold the end position for a moment before returning to the start
position and repeating for reps. Build from 5-30 and then increase
resistance by standing farther from the resistance band’s anchor
point, or using a heavier gauge band. Wobble discs or sofa
cushions under your feet can be used to add a balance challenge.

Leg Exercises for Extension Pain

The Split Squat and Lunge style exercises are an excellent choice for those retrolisthesis sufferers
who have pain with spinal extension because they both train the abdominal muscles to resist the
tendency to arch the lower back as one leg is stretched behind the body (hip extension). They also
provide the necessary hip and leg strength for bending and lifting activities needed to spare the
lower back excessive stress during many daily tasks and sports requirements. Begin with a simple
Stationary Lunge (Split Squat) and advance through
Stepping Lunges and Bulgarian Split Squats to enhance your
spinal stability while at the same time getting a great leg and
hip workout.

1. Stationary Lunge (Split Squat). Engage your RPI and

associated core tensions to hold your neutral spine in the
standing position. Maintain tail under tension (but no
additional posterior pelvic tilt movement, other than what
your RPI allows) as you step back with one leg as far as is
comfortable. Raise your rear heel and bend both knees,
allowing your body to descend straight downwards to a
comfortable degree. Only descend as far as you can to avoid
arching your lower back, and as far as the stretch in your rear
thigh comfortably allows. Avoid the tendency to lose the tail
under position as you descend, and keep your hips and the bottom of your ribcage level. Be sure
that each knee remains in line with its corresponding foot. If possible, descend fully so that your
rear knee almost touches the floor. This will be very difficult for most with anterior pelvic tilt
postures, so realize that descending only an inch or two will still be effective at the beginning.
 78

As time progresses, you will gain flexibility in your tight hip flexors, and your range of motion
will improve. Hold the bottom position for a moment, and then tighten your buttocks to stand
back up. Leave your feet in the same position and repeat the descent and ascent for repetitions.
Repeat for 3-10 repetitions before switching legs. Add 1-2 repetitions per week and build up to at
least 50 reps before switching sides. You should be near a support surface to tap (or hold) onto
with your hand for balance if you waver more than ¼ inch in this exercise.

Avoid the typical mistakes of losing the tail under posterior pelvic tilt position and arching your
lower back, elevating your front hip (hip hiking), leaning your torso sideways and downwards into
the front hip, leaning your front heel inwards (pronation), twisting your pubic bone and pelvis
away from the front hip (especially on the side of an externally rotated hip), forward head posture,
rounded shoulders, and turning the rear leg into external rotation (avoid turning the heel inwards,
keeping it straight instead). This exercise targets many of the issues associated with extension
induced back pain, as it stretches tight hip flexors, trains the RPI to avoid arching the lower back
as the hip flexors exert an anterior tilting pelvic force, strengthens the legs and glute max muscles
(sparing the tight and over-used lower back erector spinae muscles), improves hip mobility,
enhances coordinated balance, trains head and shoulder stability. Remember to emphasize form
and the maintenance of your RPI for the best results with this and any exercise.

As you advance, this exercise can be made more challenging by closing your eyes. Only attempt
this after you can maintain perfect form with your eyes open and not holding on for balance. Upon
closing your eyes, you may need to tap or hold lightly again on a support to limit the wobbling of
your body to no more than ¼ inch. Additional progression may be made by standing on a pillow
or sofa cushion with your eyes closed, or having a friend try to gently tap you off balance while
you hold the RPI position and perform the exercise. Once 50 reps has been attained, you may also
advance by holding dumbbells at your sides as you perform the stationary lunge. Remember that
when adding weight (no more than 5-10 pounds at a time), to decrease the reps by at least 50%
and then gradually build up again to 50 reps over successive workouts. Never combine additional
weight with balance challenges. In all varieties of the exercise, remember that holding your RPI
neutral spine position is the priority.

2. Stepping Lunges. This is the same exercise as just described, except that you will be stepping
forward with one leg into the lunge position from a normal standing position, then descending and
ascending, and finally stepping back into a normal standing position before repeating each rep.
You may alternate legs with each rep or complete all reps with one leg stepping forward before
switching sides.

3. Bulgarian Split Squats. This is the same exercise as the stationary lunge, except that you will
perform it with the rear leg elevated by placing the rear foot on an elevated surface, such as an
exercise bench. This causes more of a challenge to avoid arching the lower back, as the elevated
leg induces extension at the hip and lower back. The key to performing this exercise correctly is
to increase tail under tension the farther you descend in the movement. This will counter the
tendency to arch the lower back as the rear thigh hip flexor muscles stretch and exert a pull on
 79

your pelvis. Limit your motion so that you feel only a mild and comfortable pull in the front thigh
muscles of the rear leg. Your range of movement will also be limited by your ability to maintain
your RPI- specifically tail under position. This may mean that the overall motion of the exercise
may only be an inch at the beginning, which is acceptable. As time advances and you add a rep or
two each week (begin at 3-10 reps), you will improve your
flexibility and RPI holding strength, which will increase your
range of motion over time.

Besides overarching the lower back, avoid the common

mistakes of forward head posture, foot pronation, hip hiking
and torso side leaning on the side of the front leg, external hip
rotation on the rear leg, twisting of the pelvis (pubic bone)
away from the front leg, and excessive forward hip movement
as you descend.

Build reps up by 1-2 per week until you have reached 50 –

100. Further progression can be made by slowing the cadence
of each rep, standing on a sofa cushion with the front leg, or
holding weights in your hands. Remember to initially decrease
reps by at least 50% whenever adding weight, slowing
cadence, or introducing balance challenges to the exercise.

Perform all of your reps with one leg forward, before switching sides. If you have an external hip
rotation, or anterior hip malposition, be sure to position that leg forward first, and after switching
sides, finish the exercise with that leg behind you. The RPI will be most difficult to hold at the
bottom of the movement, when you are changing directions from descending to ascending in the
exercise. Performing the reps slowly and avoiding any quick, or bouncing motions, will help to
train proper form and avoid loss of your neutral spine stability.

Over Head Exercise to Resist Low Back Extension

Reaching overhead with your arms is associated with extension of the lower back as the upper
body leans back to assist the shoulder muscles. This can be used as part of your
healing/rehabilitative exercise program by maintaining an abdominal muscle “crunch down” of
your ribcage to prevent low back extension.
Begin standing and engage your RPI neutral spine. Emphasize “crunching” the front of your lower
ribcage down towards your pubic bone to help lock your lower back in position. Maintain your
neutral spine as you raise your arms overhead. The higher you reach, the more challenging it will
be to avoid arching your lower back.
 80

At the beginning, you may wish to keep one hand on your lower back to monitor the arch as the
other hand reaches overhead. As you progress in your ability to maintain the arch in your lower
back and avoid increasing it, you may increase the difficulty of the exercise by reaching higher, or
by holding dumbbells to perform a standing shoulder press motion.

Thoraco- Lumbar Fascia Stability Training to Resist Extension

The Thoraco-Lumbar Fascia (TLF) is a complex webbing that envelops many muscles and spinal
structures of the lower back. This was discussed in detail on page 69, but as opposed to the exercise
presented there to prevent flexion, we will use it in this chapter to prevent low back extension.
Engage your neutral spine position and add the TFL muscular tensions described on page 69 before
stepping onto a wobble board. Similar to the set up on page 69, the wobble board should be
positioned so that it will wobble slightly forwards and backwards as you stand and balance on it.
The exercise is performed by holding onto a support with one or two hands with just enough
support to allow a ¼ inch wobble of your body from front to back. Your TLF and abdominal
muscles will be working especially hard to maintain your neutral spine position and avoid
increasing the lordotic arch in your lower back during every wobble that tilts the board forward
(toes moving into the floor). Emphasizing your posterior pelvic tilt and abdominal “crunch down”
tensions will help you avoid arching your lower back during this balance challenge.
Increase your time gradually over several weeks to months building to 5-10 minutes of continuous
wobble board training. Emphasize maintaining your neutral spine position and resisting the
tendency to increase the arch of your lower back as the board wobbles from back to front. It is
common for your abdominal muscles to be sore for the first few weeks of training with this exercise
if you wobble for too long per session. Build your time up slowly to prevent this. Avoid holding
your breath during this exercise. As you progress, you may increase the challenge by closing your
eyes or using less hand support. This exercise begins to make your neutral spine position more
reflexive and less conscious by integrating TLF tension to avoid extension of your lower back.

Down Hill Walking

Another effective and more advanced abdominal exercise to prevent extension of the lower back
is progressive downhill walking while holding a posterior pelvic tilt and ab “crunch”. Typically,
walking downhill will cause the pelvis to tilt forward and the upper torso to lean backwards. This
will extend the spine and increase the lordotic arch in the lower back, typically aggravating
extension theme low back pain.
 81

To prevent this, a posterior pelvic tilt and abdominal “crunch down” position is held while walking
on progressively more challenging downhill slopes. This should first be practiced on flat terrain,
and once you feel comfortable with it, should be attempted on a very slight downhill grade. As
your endurance time builds on a slight downhill slope, further progression can be made by
increasing the downhill angle. At no time should the exercise cause an aggravation of pain, nor be
so difficult that your neutral spine position cannot be maintained.
 8

Exercises for Pain with Rotation (Twisting)

If your retrolisthesis pain is aggravated while twisting (rotating) either your torso or hips, this
chapter will present exercises to help you avoid the range of twist motion that provokes your pain.
It will also teach you how to twist from your mid back and lower body to avoid rotational theme
pains. Finally, a few corrective exercises will be taught to correct the typical rotational postures
that affect this type of mechanical back pain. If you exhibit no rotation analysis findings, these
exercises are not needed in your program.

Exercises to Prevent Painful Rotational Ranges of Motion

Learning to prevent a certain amount (or range) of twisting in the lower back is essential to avoid
further retrolisthesis aggravation. This will be unique for each individual, and may apply to
twisting either to only one or both sides of the body. From your analysis, you will have determined
which direction of twist causes your pain, and just how much motion it takes to feel pain. Review
this part of your analysis before attempting the following exercises as the range of motion may
change from day to day, or over the course of your healing response from your last injury. Be sure
to determine if it is pelvic (hip) twisting or torso (upper body or shoulder twisting) that is painful,
and if it occurs in the standing, seated, or both positions.

If your pain occurs while twisting your torso in the seated position, you will want to strengthen
your ability to resist twisting in this direction by holding a resistance band at your chest with the
other end of the band anchored at chest height on the side that causes pain. Be sure that you have
a decent amount of tension in the band so that it does not become slack twisting in either direction.

For example, if twisting your torso to the right causes pain, anchor the band 2-3 feet to your right
side while you hold the other end of the band at your chest. Practice holding your RPI neutral spine
as you twist your torso (chest and shoulders) away from the painful side (to the left) as far as is
comfortable. Do not pull with your hands during this twist, but only press the band into your chest
as your torso twists and stretches the band. You be strengthening the muscles that twist you away
from the direction of pain.

As you release the stretched band’s tension and return to the normal (neutral) seated position, allow
your body to twist past this neutral position into the direction of pain (to the right in our example),
but only twisting as far as is comfortable, stopping before the amount of twist becomes
uncomfortable or painful. You will be resisting the band’s recoil of twisting you towards your
direction of pain. Pause for a second or two as you twist both to the right and left sides. Repeating
the twists for repetitions which should increase by 2-3 reps per workout, performed 2-3 times per
week on non-consecutive days. Build from 10 reps up to 100-200 reps before increasing the band
resistance by sitting a few inches farther away from the anchor point and beginning the
progressions over again at 30 reps.
 83

This same exercise can be done standing if pain is aggravated with standing torso twisting motions.
If pain is noticed with pelvic (hip) twisting, then the exercise is modified by looping the band
around your hips in the standing position, and twisting to both directions as previously described,
strengthening the muscles that twist your pelvis away from pain, and avoiding the recoiling band’s
effort to twist you into a range of motion (distance of twist) that provokes pain.

All of these exercises help you to both strengthen the muscles that twist you away from the painful
side (if pain is noticed twisting to one side only), and teaches you how far you can safely twist
while avoiding back pain. These exercises scan be trained for very high reps (100-200) using light
resistance, and eventually for low reps (5-10) using heavy resistance depending on the twisting
needs of your daily activities and sports requirements.

Exercises to Twist from Mid Back and Lower Body

The following three exercises are designed to train you to twist from your lower body and mid
back to eliminate painful twisting in the lower back. In both of these exercises, you can start by
strictly moving with the legs and mid back, but eventually add a range of low back twisting to both
of them that is within a non-painful range of motion (taught
in the previous exercises).

1. Pivot Squat. Begin standing in a sumo squat position as

described on page 37. It will help to practice this exercise on
a wooden or tiled floor wearing socks to decrease friction.
Elevate your heels slightly, just enough so you can pivot on
the balls of your feet to one side. You should keep your feet,
knee caps, pelvis, chest and head all pointing in the same
direction (which will change) as you pivot, so that your entire
body is a solid unit pivoting (twisting) on the balls of your
feet. It helps to focus on the pivot point being the great ball
of each foot (just behind the great toes).

After you pivot to one side, practice pivoting to the opposite

side. Perform reps, pivoting back and forth to both sides. This
exercise will train you in a movement pattern that allows you
to twist to one side by pivoting on the balls of your feet with no spinal twisting at all. Increase reps
and speed as you progress in the exercise. To ingrain this movement into your nervous system as
a reflexive way of twisting, practice it with your eyes closed and while standing on sofa cushions
or other unstable surfaces.
 84

2. Isolated Mid Back Twisting. In the standing position with

your knees and hips slightly bent, engage your neutral spine
position. Twist your shoulders (mid back) to one side while
avoiding any twisting in your lower back or hips. You can
monitor this by keeping one hand on your lower back during
the exercise. Twist as far as comfort allows, and then repeat to
the opposite side. Repeat for repetitions, building from 10 -
200. This exercise trains you to twist your mid back in
isolation separate from lower back twisting. As workouts
progress and reps increase, it is typical for the flexibility in
your mid back to improve, which will provide you with a
greater range of upper body twisting that spares motion from
occurring at your low back retrolisthesis region.

3. Combined Pivot Squat and Mid Back Twisting.

Once you have become proficient in the first two exercises,
you can combine them into one exercise. Begin with a Pivot Squat, and after you have gained as
much twist with the pivot, add a mid back twist to increase your twisting range of motion (overall
distance of twisting reach). As you perform this combination exercise, be certain to avoid any
lower back twisting as your hand continues to monitor its motion. Vary the angle or height of your
hands as you twist in order to train all possible twisting needs.

Begin with just the weight of your body, but progress by performing this while holding dumbbells
or a resistance band. By combining the Pivot Squat with Mid Back Twisting, you are practicing a
safe twisting motion that eliminates dangerous rotation stress in the lower back. Eventually, you
may add a slight twist of the lower back to this combination exercise, but cautiously avoid ranges
of low back twisting motion that you have determined to be painful.

Strengthening Rotational Muscles without Rotation Motion

The following exercises are designed to strengthen your neutral spine RPI and resist rotation
(twisting) in your lower back. They can be used for endurance training (higher number of reps
with mild resistance) and/or strength training (lower number of reps with heavy resistance)
depending on your unique needs. Always emphasize all of your various mechanical corrections
(especially those involving rotational directions of movement, posture and stability) when
performing any of the following exercises. The top priority when performing any of these is to
resist any twisting motion in the lower back, as it should remain locked in solid to its neutral spine
position.
 85

1. Rotational Plank. The rotational plank has two

varieties- front and back. Engage your RPI neutral
spine position and assume the side plank position
as shown. You may option to perform this against
a wall as opposed to the floor if your upper body
strength is not sufficient, or side lying on the floor
and lifting only your hips off the floor. For the front
rotational plank, slowly twist your entire body
slightly forwards, lifting your heels and allowing
the balls of your feet to support your lower
bodyweight. Your face, belly button and kneecaps
should all be slightly facing the floor in front of
you. For the back rotational plank, lift your forefeet and allow your heels to bear your lower
bodyweight as you rotate your entire body backwards. Your face, belly button, and knee caps
should all be facing slightly up towards the ceiling. If using the wall variety or side lying floor
variety, slightly rotate your entire body in the same directions (forwards and backwards) as you
hold the side plank position.

Rotational planks strengthen your rotational

stability to avoid twisting stress on your lower back.
They strongly contract the abdominal oblique and
latissimus muscles, combining full body stability
from your legs through your shoulders and neck.
The latissimus muscles acting alone will overarch
the lower back and induce extension at the neck.
This exercise trains the abdominal obliques to
counteract this tendency which aids in retrolisthesis
stability in extension, flexion and twisting
activities. Common mistakes to avoid include
disproportionately twisting the pelvis more than the
torso or vice versa, loss of tail bone under tension (which will decrease the abdominal exertion
effect and negatively stress most cases of retrolisthesis), forward head posture, dropping the hips
out of alignment, and failure to rotate the feet as much as the upper body.

Hold the rotational plank for 5-10 seconds before repeating to the opposite side. 1-2 sets may be
performed. Add 1-2 seconds per week and build up to 3 minutes on each side. Advanced versions
include placing your feet farther from the wall in the standing variety, and placing a sofa cushion
under your hand and/or feet in the floor versions. Reps may be performed in lieu of isometric
holds.
 86

2. T/L–Hip Rotations. This (and the Bird Dog and In- Line
Plank) is the same exercise as presented last chapter to avoid
extension pain, but are done now with an emphasis on avoiding
rotation of the torso or pelvis. In a standing sumo position, engage
your RPI neutral spine and emphasize tail under tension with
lower rib abdominal crunch down tension. Keep your knees
slightly bent as you hold a resistance band against your chest.
Rotate your hips and torso as one solid unit to one side. Do not
allow your knees to move inwards or outwards much as you do
this. Hold the end position for a moment before returning to the
start position and repeating for reps.

This exercise is a powerful abdominal oblique strengthening

exercise that supports your spinal stability in twisting or rotational
planes of movement. Resistance can be increased by standing
further from the resistance band’s anchor point, or using a heavier gauge band. Wobble discs or
sofa cushions under your feet can be used to add a balance challenge.

3. Bird Dog. From the on hands and knees position, raise one arm and the opposite leg as you
avoid overarching the neck and lower back by maintaining RPI neutral spine stability. This is an
isometric exercise that you will build up the endurance time by 2-3 seconds with each progressive
workout. Avoid the common mistakes of hip hiking
on the kneeling hip, shoulder blade shrugging,
external hip rotation on the raised leg, head and torso
side leaning, forward head posture, and torso/pelvic
rotation.

Advanced versions include kneeling on (and holding

onto) wobble discs or sofa cushions, or having a
training partner try to “tap” you out of balance at
various points on your body, emphasizing your natural mechanical and posture faults. To challenge
rotational stability even greater, the Bird Dog can be performed using an ankle weight on the raised
leg and holding a light dumbbell in the raised hand.

4. In- Line Plank (as described on page 74). To exaggerate the rotational stability effect of this
exercise, it can be progressed to performing it on sofa cushions or wobble discs which will add
more of a balance challenge. As balance is maintained while avoiding rotation of the pelvis or
torso in relation to one another, rotation stability is maximized.
 87

Rotational Corrective Exercises

These are exercises that help to correct rotation postures and movement tendencies that lead to
rotational instability in the lower back. Progressing in these exercises 2-3 times per week in your
retrolisthesis workout program will assist you in decreasing the rotational mechanical stresses that
aggravate your retrolisthesis pain.

1. Correction of Pelvic Rotation with Resistance Band. Use

this exercise if you have identified that one side of your pelvis
is more forward than the opposite side in your standing
analysis. In the standing position, engage your RPI neutral
spine and loop a resistance band around your hips (pelvis).
The opposite end of the band should be anchored off to the
side of your pelvic twist (if your hips are twisted to the right
with your right hip more backward than your left hip, the band
should be anchored on your right side).

As you keep your torso facing straight ahead, twist your pelvis
away from the anchor point to stretch the band. Hold the end
position (as far as comfort allows) for 1-2 seconds before
returning to the starting position and repeating for repetitions. This is an endurance exercise,
therefore build up your reps from 10 to 100-200 before stepping farther away from the anchor
point and increasing resistance. Remember the key to this exercise is moving the pelvis in relation
to the torso, emphasizing a corrective direction.

2. Correction of Torso Rotation with Resistance Band.

Use this exercise if you have identified that one side of your
torso is more forward than the opposite side in your standing
analysis. In the standing position, engage your RPI neutral
spine and loop a resistance band around your chest or hold
one end of the band against the center of your chest. The
opposite end of the band should be anchored off to the side
of your torso twist (if your torso is twisted to the right with
your right shoulder more backward than your left shoulder,
the band should be anchored on your right side).

As you keep your hips (pelvis) facing straight ahead, twist

your torso away from the anchor point to stretch the band.
Hold the end position (as far as comfort allows) for 1-2 seconds before returning to the starting
position and repeating for repetitions. This is an endurance exercise, therefore build up your reps
from 10 to 100-200 before stepping farther away from the anchor point and increasing resistance.
Remember the key to this exercise is moving the torso in relation to the pelvis, emphasizing a
corrective direction.
 88

3. Hip Rotation Re-Alignment Squat. Use this exercise if you have identified an external rotated
hip (with or without an anterior hip malposition tendency) in your analysis. The parallel hip squat
(described on pages 39 and 40) can be modified to correct anterior and external hip rotation
postures. Performed over time, this exercise will re-develop the hip muscles to straighten out the
external hip rotation tendency, thus correcting the foot flare that is so common with stance and
walking.

When the flared foot tendency is corrected, the lower back is relieved of several mechanical insults,
including hip hiking, torso side leaning, weak gluteus max (buttock) muscles, and compensatory
over use of the lower back erector spinae muscles. Collectively, these corrections will reduce the
mechanical insults that often aggravate retrolisthesis pain.

Engage your neutral spine while standing with your feet

pointed straight ahead and under the center of each thigh.
Turn the foot of the anterior and/or externally rotated hip
slightly inwards (10-15 degrees) and place it one inch back
from the normal parallel hip squat position. The example
provided here demonstrates a right externally rotated hip
corrected by internally rotating it, and placing the right foot
one inch behind the normal parallel squat stance position.

The same technique is used as in parallel hip squatting, but

each knee cap must point in the same direction as its
corresponding foot. This is an excellent exercise for hip and
knee rotation instabilities, pronated feet, hip hiking and torso
and pelvic rotation problems.

As with all of the exercises, focus on maintaining your

unique low back neutral spine stability position and tensions
throughout the squat. Use the same cadence and progression as outlined in the basic parallel hip
squat exercise already described on pages 39-40. Maintain equal weight bearing balance on all
four corners of each foot throughout the movement, avoiding the tendency to pronate or supinate
the feet. Emphasize tightening the buttock on the side of the external rotated hip more than the
opposite side throughout the squat. Use any torso or pelvic rotation correction that is needed based
on your analysis. Typically, the pelvis (pubic bone) will need to twist slightly towards the side of
the external rotated hip during this exercise to avoid its natural tendency to twist away. Avoid the
common mistakes of hip hiking and torso side leaning on the side of the external rotated hip, and
be careful that as the knees bend, they do not travel forward or inward. If you have an anterior hip
malposition, focus on sliding the thigh back in the hip socket as you descend in the squatting
motion. Begin with 10-20 reps and increase by 2-3 reps each workout performed three times per
week on non-consecutive days. Build up to 200-300 reps in this endurance exercise to have the
greatest re-alignment results in your hip, while improving the mechanical stresses imparted to your
retrolisthesis from your legs. Hold dumbbells hanging at your sides to progress in strength.
 9

Exercises for Pain with Side Tilting & Side Leaning

The exercises in this chapter are designed to help prevent the side leaning/tilting movements that
cause your low back pain. They are also indicated if you have a lateral (sideways) posture or
movement tendency that has been identified in your analysis. If you exhibit no sideways/ lateral
analysis findings, these exercises are not needed in your program.

Exercises to Correct Torso or Head Side Tilting Postures

These exercises are used to help improve or re-balance the asymmetrical muscle forces that are
associated with side tilting postures of the torso (ribcage) and/or head. If you have identified that
your torso (rib cage) or head side tilts, the following exercises will typically be helpful.

1. Floor Side Lying Head/Torso Tilting. If you have

identified that your head or torso tilts to one side, lie down
sideways on the floor with the side you tilt towards facing
down. If your head tilts to the right, lie on your right side and
simply tilt your head upwards (left ear towards your left
shoulder) as far as comfortable.

If your torso tilts to the right, tilt it to the left by reaching

down the side of your top (left) leg with your hand as far as
comfortable to tilt your ribcage to the left. You are working
against gravity as your resistance with both of these
exercises. If your head or torso tilts to the left, perform these
exercises with your left side down. Hold this top position for
a second or two before lowering your head or torso to the
starting position and repeating the lift for repetitions. Start at
3-5 reps and add 1-2 per workout performed 2-3 times per
week on non-consecutive days. As with all corrective side
tilting exercises for asymmetry in the torso and pelvis, this is
only performed on one side to rebalance the muscular forces
on the neck and torso.

2. Standing Resistance Band Head/Torso Side Tilting. Either of the two exercises just described
can be performed standing using a resistance band. If your head tilts to the right, loop a resistance
band around your head and anchor the opposite end of the band off to your right side. As you tilt
your head to the left, the band will stretch as it provides resistance. If your torso tilts to the right,
loop the band around your chest or hold it at chest level as you lean to the left to stretch the band.
If your head or torso naturally tilts to the left, perform these exercises with the band anchored off
to your left side.
 90

Always use a comfortable range of motion and maintain equal pressure on both feet as you perform
these exercises. Use the same rep scheme and progression as described in the previous exercise.

Exercises to Correct Pelvic Hip Hiking

1. Standing Anti Hip Hike. To correct the tendency

to swing one hip upwards as you walk and move,
assume a one legged stance while standing on the
involved side. The exercise is performed by
swinging your standing hip downwards as you lift
the ribcage upwards on the same side. Your waist
will be vertically lengthening as you perform the
anti-hip hike maneuver. This will level your hips and
ribs. Hold the position for a few seconds before
relaxing and repeating for repetitions.

You may hold onto a support surface if balance is

needed. Increase reps by 2 per workout or isometric hold times by 2-3 seconds per workout.
Perform the Standing Anti-Hip Hike exercise 2-3 times per week on non-consecutive days. Build
up to 50 -100 reps or a 3 minute hold time in this endurance conditioning exercise. As you become
more proficient at the maneuver, practice it while walking as your hip travels above your weight
bearing foot with each step.

2. Anti- Hip Hike Lunge. Stand in a stationary lunge or split squat position (described on pages
77-78) with one foot forward and the other backward. Your heel should be raised off the floor on
the rear foot. This position will typically cause the common mistake of hip hiking on the side of
the lead foot. Practice swinging your front hip downwards to level your hips and pelvis. The
exercise can be performed for reps, holding each rep for a 2-3 second hold (building to 50-100
reps), or for endurance hold times building by 1-2 seconds per workout up to 3 minutes.

Exercises to Prevent Side Tilting/ Leaning

All of the exercises in this group are designed to challenge your ability to maintain your neutral
spine position and resist the exercise’s tendency to cause side tilting of either the torso or pelvis
(hip hiking). Be sure to make your top priority the maintenance of your neutral spine position and
strictly avoid any sideways movement in your torso, pelvis and lower back during any of the
following exercises.

1. Lying Side Plank. This exercise strengthens lateral stability which is the ability to resist side
tilting and translation (sideways shift of the torso or pelvis). This is important for those with side
 91

tilted (or translated) pelvic and torso postures. It is also a great exercise to assist in avoiding hip
hiking.

Lying on the floor, with your legs straight, and bottom shoulder shifted slightly forward so that the
back side of your bottom shoulder blade is contacting the floor, engage your lower back stability.
Tense your top buttock and raise your bottom hip off the floor as high as is comfortable.
Your bottom shoulder, lower leg and foot remain on the floor. Only the hips are elevated. Focus
on diaphragmatic breathing as you hold your hips off the floor for 3-10 seconds. Slowly lower
your hip back to the floor to complete the rep. Roll over, and repeat on the other side. Increase
your hold time by 1-2 seconds every workout until you can hold the position for three minutes.

It doesn’t matter which side you begin lying on, unless you have one of the following tendencies.
If your analysis revealed hip hiking, or tilting to one side with your torso, that side should be on
the floor first. If you translate your pelvis to one side, that side should be on the floor last.

2. Cliff Hangers. Lying on an exercise bench or bed, position your hips as close to the bottom
edge as possible, allowing your legs to hang off the edge. Maintain hand support and spinal
stability throughout the set up.

Move your legs up and down in a slow pulsing one inch

range of movement while spinal stability is
maintained. All motion comes from the legs moving
from the hips. The cadence of the pulsations should be
about one second to lower and raise the legs. That
means one half second to lower and one half second to
raise. This will be the most rapid rate of movement
introduced in the program thus far.

For symmetrical development, be sure to remain

directly on your side throughout the exercise to
stimulate both abdominal and back muscles equally. If
you roll slightly forward, you will be using more back muscles (better for back pains associated
with bending forwards), while rolling backward will recruit more abdominals (better for back pains
that are aggravated with bending backwards).

The side of your natural hip hike or torso sideways tilt should always be placed up first, followed
by lying at that side when turning over. If you are prone to one sided back or abdominal spasms
or cramps, that side should be positioned up first as well. This sequence will end the exercise with
a neurological relaxation of the tighter hip hiking and side tilting muscles, and a recruitment “wake
up” call to activate the weaker side, as that side is contracted last in the two sided sequence.
 92

Common mistakes include loss of posterior pelvic tilt position, pelvic and torso rotation, and
lowering the legs too far. The midline of your legs should be in the same horizontal alignment
(level) with your spine. Begin with 10-15 cliff hanger pulses (reps) on each side. Add 2-3 reps per
workout, building up to 100-200 reps.

3. Side Plank with Arm. This is the same

exercise that was described in the Lying Side
Plank, except your upper body will now be
supported by your straight arm. You will want to
protect your shoulder by tensing your upper arm
into your shoulder socket at a 30 degree angle
forward from your side. This engages your rotator
cuff muscles, supporting your shoulder joint and
improving your full body core stability.

Begin with a 5-10 second hold time and add 2-5

seconds per workout until you have reached 3
minutes. Remember to place your hip hiking,
external hip rotation, or torso leaning side down first before turning over and repeating the exercise
to the opposite side. Tense your bottom shoulder blade down and across towards the top tensed
buttock. To activate the latissimus muscle and opposite buttock through the thoraco-lumbar fascia
for added back stability to your neutral spine position.

Once you reach 3 minutes of hold time, additional strength may be gained by holding a
progressively heavier dumbbell on the top of your hip during the exercise. As with any advanced
exercise using additional weight or resistance, be sure to increase the amount of abdominal bracing
and RPI tensions proportionately to maintain your neutral spine against the additional challenge.
Progress from 30 seconds up to 3 minutes again with the additional resistance before adding the
next level of weight in 2-5 pound increments.

4. Wind Mill. The wind mill is a lateral stabilization

exercise that uses muscles throughout your entire body to
stabilize your back in a sideways direction. As opposed to
the other lateral stabilization exercises such as side planks
and cliff hangers, the wind mill adds great hip strength and
flexibility to lateral back stability, along with a much more
demanding balance challenge than other lateral stability
exercises.

Begin standing and engage your RPI neutral spine with

abdominal bracing. It helps to keep your index fingers on
your hips and your thumbs against the bottom of your ribs
 93

to monitor the levelness of your hips and lower ribs while you perform this exercise. Slowly tilt
your entire body sideways as it pivots on one standing hip joint. This motion is demonstrated in
the accompanying photo. Maintain strict alignment from your head through your leg, tilting only
as far as is comfortable. Reverse the motion to stand vertical again and repeat for repetitions. Avoid
hip hiking, forward or sideways head leaning, and torso side leaning in relationship to your pelvis.
You should maintain equal distance between your lower ribs and your pelvis on both sides
throughout the motion. Hip hiking is avoided on the standing hip by keeping the space between
the hip and ribs as “tall as comfortably possible”.

As you tilt farther from vertical, a stretch will occur on the inner thigh muscles of your standing
leg. The pull of these muscles may cause an anterior tilt of your pelvis if tight, so maintain a focus
on posterior pelvic tilting (tail bone under) if this is one of your mechanical issues. Avoid the
common mistake of rotating the pubic bone away from the standing leg. Besides lateral stability,
this exercise also trains rotational and forwards/backwards stability, but to lesser degrees.

The Wind Mill can be performed for progressive repetitions or isometric hold times. Feeling a
great muscular effort in your standing hip muscles is normal and is a perfect training stimulus for
those with hip hiking, external rotated hips, and lateral stability issues. The standing lower leg and
opposite back and abdominal muscles will be working hard as well during this exercise. Foot
pronators, supinators, and valgus knee issues will also be greatly challenged during the movement.

The wind mill is a perfect exercise for walkers who want to include supportive exercises in their
routine, but want to avoid recumbence on the floor or exercise bench. Advanced versions of this
exercise include performing it with your arms overhead (which will stretch tight latissimus muscles
and challenge anterior pelvic tilt tendencies), performing it while holding a dumbbell on the
leaning side, and closing your eyes to add an additional balance challenge (as demonstrated in the
photo).

5. One Leg Squat. The One Leg Squat is the next

progression in the squatting series. This is the same
exercise as the basic Parallel Hip Squat (pages 39-40),
except that it is performed on one leg at a time.
Squatting on one leg is not only more challenging
because of the balance demands, but the real challenge
is holding lateral (sideways) posture and stability points
as you squat on one leg. Hip hiking, torso side tilting,
and foot pronation/supination stability are intensely
challenged in this exercise.

To avoid hip hiking, tilt your standing hip down and across towards the opposite side as you get
deeper in the motion. At the same time, keep your rib cage leaning away from the standing leg to
avoid lateral tilting. Both of these are needed to maintain a level pelvis and ribcage. Avoid any
forward knee motion. Pelvic rotation will also easily occur toward the opposite side (pubic bone
 94

turns away from the standing leg) if not carefully monitored. Both hip hiking, ribcage side tilting,
and pelvic rotation will occur more readily on the same side as an externally rotated hip, and thus,
this is a great exercise for those with any of these problems. This exercise also strongly challenges
pronated/supinated feet and anterior pelvic tilt tendencies. Focus on maintaining four point foot
balance and pelvic tilt position the deeper you squat. Try to progress the depth of your squat to at
least a 45 degree thigh angle. With further practice, you may go as deep as having your thigh
become parallel with the floor.

This exercise is effective for developing control of side to side (lateral) low back stability like no
other. It helps to keep the hands on your hips (pelvis) and lower ribs to monitor their levelness.
Although it is somewhat challenging to maintain the anti-hip hike and ribcage lean alignment at a
few inches of squatting depth, it is extremely challenging the deeper you squat. If you are like
most, you will need more (ribcage leaning away and hip down and away) movement than you
think during this exercise.

Start with 5-10 reps, and add 1-3 per workout until you reach 50 reps. At 50 reps of one leg
squatting to a 45 degree thigh angle depth, you will have made a massive improvement in your
spinal lateral stability and hip/leg strength. This often translates into serious lower back pain relief.
 10

Exercises for Translation Postures

The exercises in this chapter are for those retrolisthesis sufferers whose posture analysis findings
revealed a translation theme, or whose pain is aggravated or relieved with vertical compression, or
sideways/forward/backward translation of either the head, torso or pelvis.

Forward Head Posture Correction

1. Prone Head Retraction. Lying face down on an

exercise bench or bed with your head hanging off the
edge, allow your head to fall towards the floor as far
as is comfortable to assume the starting position. The
exercise is performed by raising the head straight up
as high as comfortable without elevating your chest
off of the bench or bed. Hold the top position for a 2-
3 second count before lowering and repeating for
repetitions. Avoid rounded shoulders and tilting the
chin up or down as you do perform the exercise. Build
from 10 reps to 200 for this endurance exercise.

2. Standing Head Retraction. Loop a resistance band around

your head with the opposite end anchored in front of you. Allow
your head to assume a forward posture for a starting position. Pull
your head straight back without moving the rest of your body to
stretch the band. Your goal is to move your head back far enough
so that your ear is directly above your shoulder if comfort allows.
Otherwise, only pull back to the limit of your comfortable range
of movement. Avoid the common mistakes of elevating or
rounding your shoulders, side tilting your head, or losing
balanced weight distribution on all four corners of each foot.

Sway Back Posture Correction

1. Standing Sway Back Correction Exercise. Begin standing with your back against a wall.
Your heels may be between 1 and 6 inches away from the wall. Allow your buttocks, mid back
and head to all rest against the wall. Engage your lower back neutral spine stability and gently
press your buttocks and head straight back into the wall while lifting your shoulder blades away
from the wall. You only need to clear your shoulder blades enough off the wall so that a thin sheet
of paper could fit between the wall and your mid back.
 96

Avoid arching your lower back by tensing your tail under as you do this. Avoid lifting your chin
as you press your head straight backwards. Maintain all of your unique spinal stability points as
you maintain this position for 3-10 seconds. Repeat for 5-10 reps initially, and build up to 30 reps
over subsequent workouts by adding 1-2 reps per workout. You may also slowly extend your hold
time gradually over the workouts until you reach 1-3 minutes for 3-5 reps.

If you have severe forward head posture, you may need a

pillow between your head and the wall for comfort.
Depending on the severity of your sway back posture, you
may need to increase the distance of your heels from the wall
to permit this exercise. As you progress, move your heels
progressively closer, until they touch the wall.

2. Prone Sway Back Correction Exercise. Engage your

neutral spine in the face down position. Slowly lift your head
and hips straight up while your chest, knees and feet remain
on the floor or exercise bench. Only lift as high as is
comfortable. The overall motion of both the head and the
hips may be less than one inch. If you are not yet strong
enough to lift the hips fully off the bench or floor, simply raise them enough to lighten your pubic
bone’s pressure against the bench or floor. Hold the raised position for a 2-3 second count before
slowly returning to the starting position and repeating for repetitions. You may build up the reps
to 50-100 or increase the isometric hold time of one rep up to 3 minutes, adding 2-3 seconds per
workout performed 2-3 times per week on non-consecutive days.

Exercise for Vertical Translation (Pain with Compression)

1. Seated Chest Lifts with

and without Resistance
Band. This exercise targets
general slumped posture,
especially while seated. It is
indicated for those whose
back pain is worse when
sitting slumped and find relief
when sitting tall and erect.
This is common for many retrolisthesis sufferers. From the slumped seated position, the lower
abdomen is held in and up, shoulder blades drawn back, and the ribcage should elevate vertically
off of the pelvis. The end range of motion is when you are sitting as tall as comfortable possible.
Hold the top position for 5-15 seconds before releasing and repeating for subsequent repetitions.
 97

You can build up reps from 5-50 and/or increase the isometric hold time up to20 minutes by
gradually adding a few seconds each workout.
For extra resistance, the chest is tilted up against the resistance of bands or wraps. These bands or
wraps should be placed around the back of the thighs, and then encircle the tops of the shoulders.
In this way, resistance will be felt as you stretch the bands by sitting upright. Seated band chest
lifts can be performed for repetitions, or isometrically by holding the upright position for
progressively longer times. Key mistakes to watch for include: forward head posture, torso and
pelvic side tilting, rotation, and lateral translation, asymmetrical shoulder heights, shoulder
elevation (shrugging), shoulder rounding, excessive lower back extension (arching), pelvic tilting,
and loss of postural seated balance (the weight of the upper body should be centered over the
crease where the back of the thighs meet the buttocks).
2. Standing Chest Lift. The same exercise can be done in the standing position with or without
resistance bands. The standing version is indicated for those who find relief by standing tall and
pain while standing slumped. Begin without bands using only your bodyweight for resistance.
Perform 2-5 reps of 5-15 second holds while standing as tall as comfortable, and build by adding
2-3 reps per workout done 3 times per week on non-consecutive days. Add bands when you feel
you need more of a challenge by looping the bands around your shoulders and feet.

Exercises for Lateral Translation Postures of Torso

1. Side Lying Torso Lateral Translation Correction Exercise. Use this exercise if your analysis
revealed a torso lateral translation posture where your ribcage is set off to one side in relation to
your pelvis and legs, especially if realignment eases your back pain.

Lying on the side that your torso translates towards (example: lying on your right side if your
ribcage is positioned to the right of your pelvis and legs), lift your torso off the floor or exercise
bench as far as comfortable while your pelvis and legs remain on the floor or bench. It is not
necessary that your torso actually comes off the floor or
bench for this exercise to be effective, but only that it
becomes lighter in pressure against the floor or bench. Hold
this top position for 2-3 seconds before lowering your torso
and repeating for repetitions. Build up from 5-10 reps to 50-
100, or increase isometric hold time for one rep from a few
seconds to three minutes as you progress by adding 1-2 reps
or 1-3 seconds per workout done 2-3 times per week on non-
consecutive days.

2. Standing Band Torso Lateral Translation Correction

Exercise. The same exercise for torso lateral translation just
described can be advanced in difficulty by performing it in
 98

the standing position. Loop a band around your chest, or hold one end at your chest, with the
opposite end anchored off to the side that your torso translates towards (ex: band anchored off to
your right side if your torso is positioned to the right of your pelvis and legs). Without changing
the weight distribution on your feet, shift your torso away from the anchor point to straighten your
body alignment. You will need to use a counter tension of your pelvis in the opposite direction of
your torso movement to remain balanced on both feet during this exercise. Hold for 2-3 seconds
before returning to the starting position and repeating for repetitions. Use the same rep scheme
and progression as described in the previous exercise before advancing to a stronger level of band
resistance.

Exercises for Lateral Translation Postures of Pelvis (Hips)

1. Side Lying Pelvic Lateral Translation Correction

Exercise. Use this exercise if your analysis revealed a
pelvic lateral translation posture where your hips are set off
to one side in relation to your torso and feet, especially if
realignment eases your back pain.

Lying on the side that your pelvis translates towards

(example: lying on your left side if your hips are positioned
to the left of your torso and feet), lift your pelvis off the floor
or exercise bench as far as comfortable while your torso and
lower legs remain on the floor or bench. It is not necessary
that your pelvis actually comes off the floor or bench for this
exercise to be effective, but only that it becomes lighter in
pressure against the floor or bench. Hold this top position for 2-3 seconds before lowering your
pelvis and repeating for repetitions. Build up from 5-10 reps to 50-100, or increase isometric hold
time for one rep from a few seconds to three minutes as you progress by adding 1-2 reps or 1-3
seconds per workout done 2-3 times per week on non-consecutive days.

2. Standing Band Pelvic Lateral Translation Correction

Exercise. The same exercise for pelvic lateral translation
just described can be advanced in difficulty by performing it
in the standing position. Loop a band around your hips with
the opposite end anchored off to the side that your pelvis
translates towards (ex: band anchored off to your right side
if your pelvis is positioned to the right of your torso and feet).
Without changing the weight distribution on your feet, shift
your pelvis away from the anchor point to straighten your
body alignment. You will need to use a counter tension of
your torso in the opposite direction of your pelvic movement
 99

to remain balanced on both feet during this exercise. Hold for 2-3 seconds before returning to the
starting position and repeating for repetitions. Use the same rep scheme and progression as
described in the previous exercise before advancing to a stronger level of band resistance.
 11

Designing Your Custom

Retrolisthesis Workout Program
Designing a weekly program of exercise to improve retrolisthesis stability and support your
healing is based on the following principles. Regardless of how many days and hours you have
available for your retrolisthesis exercises, these principles are essential for your success. The more
closely you adhere to the guidelines suggested in this chapter, the greater your chances will be to
overcome your pain and return to a physical lifestyle without injury. Each principle will first be
discussed separately before blending them together to illustrate how to design your custom routine.
Finally, sample workouts are presented later in this chapter to help you build your actual workout
program.

Frequency and Duration of Workouts

Improving your spinal stability is based on slow and gradual

progression. This is imperative to both avoid re-injury and to
promote healing. If too much exercise is performed too quickly,
the result will be the same as participating in an activity that
your spine is not conditioned to safely handle, and injury will be
likely. Conversely, if steady progression is inadequate from
workout to workout, the strengthening stimulus that results in
healing and protects against future injury will not be triggered.

The perfect amount of exercise is thus enough to slightly stress

the body more than the last workout, but not enough to exceed
its ability to recuperate within a day or two. To accomplish this,
most workouts will need at least 1-2 rest days before the next similar workout (same theme
exercises) to allow for proper recuperation. This is essential for continued progression and healing.
If similar exercises using the same directions of motion (pain themes) are performed every day
without rest days between workouts, progression will quickly halt as the body’s recuperative
powers will fail to keep pace with the exercise stimulus. This will result in overtraining, increased
chances of re-injury, and a failure to progress. Without progression, your exercises become
meaningless as they do not stimulate healing and strengthening of spinal soft tissues.

With the exception of stretches and coordination exercises that are aimed at learning how to
assume a neutral spine position (which can be practiced multiple times each day), the vast majority
of your routine will be centered on building the strength, endurance or power of the stabilizing
muscles that hold your neutral spine position in place. These exercises, and any other
strengthening exercise that supports your pain theme avoidance, will need to be performed at least
2-3 times weekly to ensure progress. Depending on your life schedule and the available time for
 101

your retrolisthesis workouts, take at least 2 days off between workouts if you choose to exercise a
particular theme two times per week, and take 1-2 days rest between workouts of the same theme
if choosing to work out 3 times each week.

There is no problem working out every day, as long as you exercise different themes on different
days, making sure you do not repeat the same type of exercise two days in a row. For example, if
you have found in your analysis that you have a flexion, translation and rotation theme to your
pain, you could perform your flexion theme exercises on Mondays and Thursdays, your translation
theme exercises on Tuesdays and Fridays, and your rotation theme exercises on Wednesdays and
Saturdays. That schedule will allow at least 2 rest days between each muscle group worked in a
particular theme, yet cut down on overall daily workout time needed for your program. This is a
great way to split your exercises if you can only devote 5-15 minutes per day to your program.

If time is not an issue for you, you may wish to include all of your themes together in a single day
and workout three times per week on Mondays, Wednesdays and Fridays. If you still want to work
out each theme three times per week but are strapped for time, you may wish to break up your
workouts into multiple times each day with a 5 minute morning flexion workout, a 5 minute mid-
day translation workout, and a 5 minute evening rotation workout. The duration of each workout
and frequency are entirely flexible as per your preference, as long as you allow at least 48-72 hours
of recuperation between exercises for the same theme.

Some will find that they can make better progress with twice weekly workouts for a particular
theme, while others may find that they feel better in their back pain with three workouts per week.
You may have to experiment with which frequency works best for you.

Remember that more recuperation (rest days) between workouts will be needed as the workouts
become more intense, when you are under emotional or physical stress from other aspects of life,
and when your nutrition, hydration and sleep habits are poor. Missing a workout every once in a
while is inevitable, but try to be as consistent with the program as possible for your best results.
Try not to miss more than one workout in a row for the same pain theme.

Slow Gradual Progress

Remember that progression in your spinal stability exercises is the

key to both avoiding damaging back stresses and helping to
stimulate your body’s healing process. Injury is more likely if
progression is too fast, therefore the secret for continued progression
(and healing) is a slow and steady progression in your exercises
coupled with the avoidance of positions and activities that aggravate
your pain. Like the proverbial “turtle that won the race”, a slow and
continuous rate of progression will usually be your winning strategy.
 102

Progress comes in many forms including increasing the number of repetitions of an exercise,
lengthening the “hold” time of an endurance isometric exercise, adding more resistance via
increased band tension or dumbbell/barbell weight, making the exercise more challenging by
increasing the speed or balance requirements of the exercise, or increasing the range of motion of
an exercise. The key to steady and safe progress is to always use a range of motion, speed, hold
time, amount of resistance and balance that is comfortable (does not irritate your back or leg
symptoms), and above all allows you to maintain your neutral spine.

As a guideline, your rate of progress should add no more than 1-5 reps per workout if performing
the exercise for repeated movements (repetitions), no more than 1-5 seconds on isometric
endurance “hold times” from one workout to the next, and no more than a 2-5% increase in
resistance every 4-12 weeks. These rates of progression are typically safe for most, but may need
to be decreased if you experience an aggravation of your pain, or have an undue amount of muscle
soreness after a workout.

Choosing How to Perform Your Exercise

Spinal stability (neutral spine) training must meet the unique demands of your lifestyle to have the
greatest chances of promoting healing and protecting your back from further pain and injury. The
way you choose to perform any given exercise (type of conditioning) will be based on a number
of factors that all relate to what your specific back requires. Ideally, progress should build to the
point required by an individual’s unique physical demands of daily activities and sports. The whole
idea is to condition the neutral spine to be able to withstand the spinal forces that occur each day.

Someone who needs to maintain their neutral spine for long periods of time under low levels of
mechanical forces will need to train for endurance by using a high a number of repetitions or long
isometric hold times that eventually meet their daily activity or sports requirements. This may
require a slow progression of their exercises building from a few reps or seconds of hold time to
eventually performing hundreds of reps in a row and hold times of several continuous minutes.
Someone who needs to stand or sit in place, or perform a repetitive motion for prolonged periods
of time would fit this category.

Another person may need to develop strength more than endurance time because they need to lift,
push, or pull with more force during their daily activities. Here developing the strength to be able
to hold the neutral spine position for shorter periods of time against heavier resistance is needed.
This is conditioned over time using fewer reps and heavier weight or greater resistance with each
exercise.

Athletes and physical laborers often need to develop explosive strength (power) in their daily
activities, and would gear their training towards developing the ability to hold their neutral spine
position while lifting, throwing and moving resistance with great speed. Their exercises will
eventually need to be performed in a similar fashion.
 103

Building Your Program from the Bottom- Up

with Different Types of Conditioning Exercises

While different lifestyles will require different end goals, spinal stability training will need to
follow a general order. Everyone will need to start their training by first building a base of stability
with coordination and some degree of endurance before branching out into the specific types of
conditioning needed by an individual’s daily physical demands. Regardless of what unique type
of neutral spine training your retrolisthesis may eventually require, you will need to progress
through the various types and stages (spectrum) of spinal stability conditioning as follows:

1. Coordination Conditioning. You will need to master holding your neutral spine position or
range of neutral (pain free) motion in multiple positions such as standing, siting, lying down (face
up/down/sideways), squatting or while hip hinging, on all fours, and walking. This type of exercise
can be practiced multiple times each day and may take several weeks. Once you master the ability
to hold your neutral spine with RPI tensions in a variety of positions, it will be time to progress to
endurance training.

2. Endurance Conditioning. Regardless of your individual physical requirements, spend the first
few months building up reps and hold times to at least 50-100 reps and 3 minute hold times in the
exercises that apply to your pain theme. If you need more endurance conditioning of your neutral
spine to meet your daily physical demands, continue to build reps and hold times to meet your
requirements. If you need strength or power, move on to strength training next. Endurance training
can be done up to 3 times per week when progression is needed, and may increase to 5 times per
week to maintain a certain level of endurance once it is reached. Beginners may perform up to 3
sets of continuous reps, but as time and reps advance, only one set is needed as long as it is greater
than the previous workout. It is acceptable to take 5-10 second “mini breaks” during a high rep
set or long endurance hold, as long as the cumulative time and number of reps done is greater than
the last workout.

3. Strength Conditioning. Most people will need a combination of both endurance and strength
ability in holding their neutral spine for daily activities. When moving on to strength training, do
not forget to continue with some degree of endurance conditioning, especially the extension
exercises used to prevent flexion pain themes. Strength training can progress gradually with
increased resistance over several months to the point of doing the exercises for your pain themes
to failure. This means that one more additional rep is not possible after you have completed 5-15
continuous reps. Keep the speed of each rep controlled (no faster than 1-3 seconds on the
concentric or upwards lifting aspect of each rep, and 1-3 seconds on the eccentric or lowering
aspect of each rep). A slow controlled pace of exercise cadence using a total rep time of 2-6 seconds
from beginning to end of each rep allows greater development of strength and stability control.
Try to increase reps by 1-3 each workout. Strength training should be done 2-3 times per week to
progress, and may continue once per week after adequate strength has been reached for your
individual needs.
 104

Always maintain a perfect neutral spine as you near the end of each set of reps with strength
training, as the tendency to lose correct form increases as you become more tired and push to
complete the last few reps in the set. When using strength and endurance training in the same
workout, perform your strength sets (1-3 sets in total for each exercise) before your single
endurance set of any exercise. Your end goal is to build the strength of holding your neutral spine
in the exercises that apply to your pain theme slightly past the levels of strength needed in your
daily and sports activities. By exceeding the strength levels needed in your typical physical
demands, you will be building up added protection for any unexpected demands that may arise. If
your demands require explosive (fast bursts) of motions that require strength, move on to power
conditioning once your strength levels have exceeded your usual activity levels by an extra 20 %.

4. Power (Explosive Movement) Conditioning. Power training is needed by anyone who needs
to use a fast strength motion in their daily or sports activities. Exercises that fit your pain theme
should have already been built up to using heavy resistance for 5-15 reps before failure with your
strength training. To transition into spinal stability power conditioning, first add weight or
resistance to reach a 3 rep failure at a controlled speed of 2-6 seconds per rep. This will require
multiple sets that gradually increase the weight or resistance each set to serve as warm-up for the
heavier sets. Follow this by staying with that same 3 rep per set level of resistance, but gradually
increase the speed of performing each rep on subsequent workouts. Power training should
complete each rep in under 1 second time. Avoid the typical mistake of losing proper neutral spine
position as you switch directions of movement at the bottom or top of each rep. Progress by
gradually adding weight or resistance maintaining the same fast rep speed. Perform power training
once weekly per pain theme. Build to using a weight or level of resistance that is 20% greater than
that required by your daily activity or sports requirements.

5. Balance Challenge (Reflexive) Conditioning. Up to this

point, a lot of conscious mental focus has been needed to
maintain your neutral spine position in all of your exercises,
but the next step of progression in your training (regardless
of your individual goals) is to make your spinal stability less
conscious and more reflexive. As opposed to always thinking
through your neutral spine position in your physical activities
and postures, reflexive training makes these corrections more
automatic. This will allow you to enjoy the protection of a
neutral spine position during any activity, including those
slips and falls when you are not prepared to engage it.
Reflexive training uses balance challenges to make this
happen.

The concept is simple. The more you can hold your spine stable in unstable training environments,
the more automatic (reflexive) your holding ability will become.
 105

Begin progressing again through the spectrum of conditioning types already described, but this
time you will be using an unsteady surface to stand or lie on when performing your neutral spine
practice. This should begin by simply practicing your neutral spine position as you stand and walk
with your eyes closed. As your vision is eliminated, even though you are still mentally focusing
on your neutral spine position, you must depend more on the sensory nerves in the soft tissues of
your spine to reflexively cause your neutral spine position to be held. Initially you will have to
consciously focus very intently on maintaining your neutral spine and avoid the tendency to move
into your pain theme direction, but with practice, your neutral spine engagement will become more
automatic with less thought.

Progress this style of training by standing on one leg, or standing or lying on a sofa cushion while
performing your previous strength and endurance exercises. You may need to initially decrease
the amount of resistance as this will cause your entire body to wobble. You always want to limit
any body sway to no more than ¼ inch by holding onto a support with one hand while training
reflexively with a balance challenge. The goal is to always maintain a neutral spine and resist the
tendency to move into the direction of movement that typically causes your back pain or leg
symptoms.

Balance challenges can be used by performing any endurance or strength exercise already learned
in the last few chapters on slightly unstable surfaces such as foam padding, an exercise Swiss ball,
wobble boards, one-legged standing versions of exercises, or having a training partner attempt to
“tap” or push your body gently towards the direction of your pain theme as you resist. Progress
slowly through all of your exercises except power training exercises, which because of their
increased weight and explosiveness should only be trained reflexively under the supervision of a
professional.

6. Special SAID Exercise Conditioning. SAID exercises are special exercises that cause Specific
Adaptations to Imposed Demands. These are the final and most advanced type of exercises in the
conditioning spectrum. They are exercises you will need to create that are different than the ones
already presented in the last few chapters because they will be mimicking the exact daily or sports
activities that previously caused your retrolisthesis injuries or pain. SAID exercises are only
designed and implemented once all of the previous exercise types (coordination, endurance,
strength, power, and balance/reflexive training) are built up to exceed your unique requirements
by an additional 20%.

To design your SAID exercises, think about what previous movements and activities caused your
pain. This will include your physical conditioning tolerances and “breaking points” identified in
chapter 2. You will start your SAID routine by performing the movement or position that
previously caused pain using your neutral spine for a length of time, range of motion, amount of
resistance, speed, or level of balance requirement that is below your breaking point (amount that
previously or currently causes pain).
 106

Using dumbbells, barbells, resistance bands, pulley cables, or whatever resistance you have
available, create movements or positions (SAID exercises) that mimic those exact previously
painful movements. Remember that you are using your months (and in some instances years) of
neutral spine conditioning that you have built up to hold your neutral spine during the activity.
Your neutral spine conditioning progress is the difference between what you previously could not
do and what you will be capable of now. Because if this, focusing on holding your neutral spine
during your SAID exercise is of the utmost importance!

In some cases you will perform the exact activity using resistance to make it harder, while in other
cases, that activity will need to be modified slightly so as to spare your back from pain. Your
modifications will come from emphasizing the positions, motions, and tensions that support your
neutral spine and avoid your pain themes. Sometimes these modifications may be as simple as
using a single leg stance versus a double leg stance, replacing a bending motion with a squatting
or lunging motion, or reaching with one arm instead of two. Sometimes you will need to reposition
your body to face the task from a different angle. If you are having difficulty designing a SAID
exercise to meet your unique needs that avoids pain, a professional consultation with an
occupational or physical therapist, a movement coach, or a rehab specialist may be helpful.

As the weeks and months progress, you will slowly increase the activity by no more that 1-5% per
week in terms of activity length of time, range of motion, amount of resistance, speed, or level of
balance requirement, always avoiding any increase that causes you pain or a loss of neutral spine
holding ability. If you reach another breaking point that causes pain, stop and “peel back” to the
comfortable level that was below the pain or loss of neutral spine threshold. Stay at this sub-
threshold level for several workouts or weeks until you can then advance the activity progression
without pain or loss of the neutral spine position.

The end goal of using SAID exercises is to build them up to meet or exceed that which you need
in your daily activities or sports. SAID exercises should continue 2-3 times per week indefinitely
unless your daily or sports activities themselves can be used as spinal stability SAID exercise
training at least 2-3 times per week.

SAID Limitations

Because many retrolisthesis conditions are associated with disc degeneration and herniation/bulges
which can improve but never fully heal to pre-injury status, certain positions and levels of activity
forces may not be able to be comfortably surpassed because of permanent spinal soft tissue
degenerative limitations. If this is the case, and your SAID progressions reach a maximal
threshold, turn your training design and focus into strengthening an alternative pain-free movement
or position of activity that you will substitute for the limited one in real-life situations.
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Sample Programs

The following programs serve as examples using the principles taught in this chapter. When
designing your own retrolisthesis program, keep in mind the importance of matching your
frequency, duration, rate of progression, choice of exercises, and how you perform them with your
individual needs and goals.

Example 1.

Exercise Program for Pain with Bending Forward/ Slumping Forward (Flexion Theme).

Beginners Routine Months 1-2:

*One Set of Each Exercise Mon, Wed, Fri., Progress by 2-3 seconds or 2-3 reps each workout.

Multifidus Hip Hinge Isometric

Seated Anterior Pelvic Tilt Ball Rolls
Hook Lying TrA Stages 1-4
Prone Full Spine Extensions
Glute Bridges (2 Legged)
Reverse Flyes
Walking Arm Swings

Beginners Routine Months 3-4:

*One Set of Each Exercise Mon, Wed, Fri., Progress by 2-3 seconds or 2-3 reps each workout.
*3X/week Endurance Walks with Gradual Build Up of Time Holding Neutral Spine up to 15 min.

Multifidus 1 Arm Front Shoulder Raise

Standing Band Anterior Pelvic Tilts / Alternate with Standing TrA with Balance Challenge
Straight Leg Glute Bridges
Parallel Squats
Prone Rows

Beginners Routine Months 5-6:

*One Set of Each Exercise Mon, Wed, Fri., Progress by 2-3 seconds or 2-3 reps each workout.
Endurance Walks 20 min, 3X/week. Spinal Extension Molding Daily.

Reverse Hypers
Inverted Plank
Pushups
Parallel Squats with Balance Challenge
Supine Anterior Pelvic Tilt with Dumbbell
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Intermediates Routine Months 7-9:

*Progress by 2-3 seconds or 2-3 reps each workout.

Endurance Walks 25 min, 3X/week

Daily: Walking Arm Swings with Coordination Training Multifidus/TrA . Practice 1-2 minutes at
a time 2-3 times per day.

Mondays:

Prone Anterior Pelvic Tilts

Horizontal Squat
Straight Leg Glute Bridges with Bells
Chin Ups

Thursdays:

Hip Hinges with Arms Over Head

Prone Rows with Dumbbells
Pushups with 3 Second Pause at Bottom of Each Rep
Type A or B Seated Band Ribcage and Pelvic Translations

Intermediates Routine Months 10-12:

*Progress by 2-3 seconds or 2-3 reps each workout. Endurance Walks 30-40 min, 3X/week

Daily: Walking Arm Swings with Coordination Training Multifidus/TrA. Practice 2-4 minutes at
a time 2-3 times per day.

Mondays:
Bar Thigh Squats
Single Leg SLDs
Dive Bombers
Standing Band Anterior Pelvic Tilts with Increasing Band Tension Every 2 Weeks

Thursdays:
Bar Thigh Rows
One Legged Glute Bridges (Straight Leg) with Dumbbell on Front of Hip
Inverted Plank with Weight Plate
Standing Double Band Pelvic and Rib Translations
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Advanced Routine Months 13+:

Endurance Walks with Neutral Spine- Build Up to 45-60 Minutes, 3X /week

Rotate Different Exercises from the Flexion Pain Theme Chapter Every 2 Weeks. Add Resistance,
Reps, Speed, and Endurance Hold Times Progressively to the Point of Meeting Your Daily Needs
of Strength, Power, and Endurance etc. using the Stages of Spinal Stability Exercises Presented in
this Chapter.

Reflexive Balance Training

SAID Exercises

Example 2.

Exercise Program for Pain w/ Bending Backwards or Anterior Pelvic Tilting

(Extension Theme).

Beginners Routine Months 1-2:

*One Set of Each Exercise Mon, Wed, Fri., Progress by 2-3 seconds or 2-3 reps each workout.

Posterior Pelvic Tilts – Alternate Lying Face Up and Standing Positions Every Other Workout
Straight Leg Curl Ups
Bird Dogs
Stationary Lunges
Walking with Posterior Pelvic Tilts, Increasing Time Held Each Week

Beginners Routine Months 3-4:

*One Set of Each Exercise Mon, Wed, Fri., Progress by 2-3 seconds or 2-3 reps each workout.

Posterior Pelvic Tilts with Dumbbell

Stepping Lunge
Front Plank
Standing Pullovers
Bird Dogs
Walking with Posterior Pelvic Tilts, Increasing Time Held Each Week

Beginners Routine Months 5-6:

*Two Sets of Each Exercise Mon, Wed, Fri., Progress by 2-3 seconds or 2-3 reps each workout.
Stepping Lunge Holding Light to Moderate Dumbbells
In Line Plank
Rolling Ball Sit Ups
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Intermediates Routine Months 7-9:

*Two Sets of Each Exercise Mon, Wed, Fri., Progress by 2-3 seconds or 2-3 reps each workout.

Standing Posterior Pelvic Tilt with Band

Stir the Pot
T/L Hip Rotations
Bulgarian Spit Squat

Advanced Routine Months 10-12:

*Two Sets of Each Exercise Mon, Wed, Fri., Progress by 2-3 seconds or 2-3 reps each workout.

Chops
Stir the Pot on One Leg
Bulgarian Split Squat w/ Light to Moderate Dumbbells Held in Hands
Over Head Reaching w/ and w/out Dumbbells in Hands
Down Hill Walking with Posterior Pelvic Tilts, Increasing Time Held Each Week

Advanced Routine Months 13+:

Rotate Different Exercises from the Extension Pain Theme Chapter Every 2 Weeks. Add
Resistance, Reps, Speed, and Endurance Hold Times Progressively to the Point of Meeting Your
Daily Needs of Strength, Power, and Endurance etc. using the Stages of Spinal Stability Exercises
Presented in this Chapter.

Reflexive Balance Training

SAID Exercises

Example 3.

Exercise Program for 2 Themes (Pain with Rotation and Side Tilting).
Twisting and Side Tilting Pain Theme on 2 day/week Limited Time Schedule using AM and
PM workouts.

Beginners Routine Months 1-3:

*One Set of Each Exercise in AM and One Set in PM Workouts: Progress by 2-3 seconds or 2-3
reps each workout.
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Monday AM: Standing Anti Hip Hike, Bird Dog

Monday PM: Lying Side Plank, In-Line Plank

Thursday AM: Torso or Pelvic Corrective Band Rotations

Thursday PM: Cliffhangers

Beginners Routine Months 4-6:

*One Set of Each Exercise in AM and One Set in PM Workouts: Progress by 2-3 seconds or 2-3
reps each workout.

Monday AM: Anti Hip Hike Lunge

Monday PM: T/L Hip Band Rotations

Thursday AM: Pivot Squats

Thursday PM: Windmills

Intermediates Routine Months 7-9:

*Two Sets of Each Exercise in AM and One Set in PM Workouts: Progress by 2-3 seconds or 2-3
reps each workout.

Monday AM: Anti Hip Hike Lunges Holding Light to Moderate Dumbbells

Monday PM: T/L Hip Band Rotations Standing on Sofa Cushion

Thursday AM: One Legged Squats

Thursday PM: Side Plank with Arm

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Advanced Routine Months 10+:

Rotate Different Exercises from the Side Tilting/Leaning and Rotation Theme Chapters Every 2
Weeks. Add Resistance, Reps, Speed, and Endurance Hold Times Progressively to the Point of
Meeting Your Daily Needs of Strength, Power, and Endurance etc. using the Stages of Spinal
Stability Exercises Presented in this Chapter.

Reflexive Balance Training

SAID Exercises

Example 4.

Exercise Program for 4 Themes (Pain with Flexion, Rotation, Vertical Compression and Side
Translation). Flexion, Compression, Twisting and Side Translation Pain Themes on 3
day/week Limited Time Schedule using AM and PM workouts.

Beginners Routine Months 1-3:

*One Set of Each Exercise in AM and One Set in PM Workouts: Progress by 2-3 seconds or 2-3
reps each workout. Daily: Alternate Days of Spinal Extension Molding and Walking Arm Swings

Monday AM: Seated Chest Lifts using Body Weight, Bird Dog

Monday PM: Multifidus Hip Hinge

Wednesday AM: Torso or Pelvic Corrective Band Rotations and Side Translations

Wednesday PM: Prone Pelvic Anterior Tilts, Seated Chest Lifts using Body Weight

Friday AM: Isolated Mid Back Twisting, Side Lying Pelvic or Torso Lateral Translation
Correction

Friday PM: Horizontal Squat, Front Plank

Beginners Routine Months 4-6:

*One Set of Each Exercise in AM and One Set in PM Workouts: Progress by 2-3 seconds or 2-3
reps each workout.

Monday AM: Seated Chest Lifts using Bands, Bird Dog on Sofa Cushions
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Monday PM: Hip Rotation Realignment Squat, Reverse Hypers

Wednesday AM: Torso or Pelvic Corrective Band Rotations and Side Translations with Heavier
Band Resistance

Wednesday PM: Supine Anterior Pelvic Tilts with Dumbbell, In- Line Plank

Friday AM: Bar Thigh Squats, Prone Rows

Friday PM: Seated Chest Lifts with Band, Pull-ups

Intermediates Routine Months 7-9:

*Two Sets of Each Exercise in AM and One Set in PM Workouts: Progress by 2-3 seconds or 2-3
reps each workout.

Monday AM: T/L Hip Rotations with Band, Seated Chest Lifts Endurance Isometric During
Seated Work Station

Monday PM: Hip Rotation Realignment Squat with Dumbbells, Single Straight Leg Deadlifts

Wednesday AM: Side Lying Torso or Pelvic Corrective Side Translations, Rotational Plank

Wednesday PM: Standing Chest Lifts with Band, Reverse Hypers with Band at Ankles

Friday AM: Bar Thigh Rows, One Legged Squats

Friday PM: Combined Pivot Squat and Mid Back Twisting, Dive Bombers

Advanced Routine Months 10+:

Rotate Different Exercises from the Flexion, Rotation, Vertical Compression and Side Translation
Theme Chapters Every 2 Weeks. Add Resistance, Reps, Speed and Endurance Hold Times
Progressively to the Point of Meeting Your Daily Needs of Strength, Power, and Endurance etc.
using the Stages of Spinal Stability Exercises Presented in this Chapter.

Reflexive Balance Training

SAID Exercises
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Designing Your “Real Life” Workout

The Importance of Using Your Neutral Spine in Daily Activities

You can have the strongest core muscle holding ability of your neutral spine during your workouts,
but it will not do you a bit of good if you do not incorporate it into your daily activities. Using your
neutral spine to protect your retrolisthesis from aggravating forces and motions is what this entire
program is about. Without it, your healing will never outpace your aggravations, and you will
never strengthen your ability to enjoy a more physical lifestyle again. The whole point of your
exercises is to gain the strength and endurance to hold your neutral spine and avoid your pain
themes during all of your daily activates and positions.

This means that you must become conscious of your postures, movements, and time spent in
positions during the day. You must identify which daily activities are causing you to move into
your pain themes, and then practice using your newly developed neutral spine coordination,
strength and endurance to avoid those aggravating motions and positions. This means a constant
analysis of your body during the day. With practice, you will easily identify those offending
activities and learn to avoid them using your neutral spine.

If you have a flexion theme, practice engaging your neutral spine with all activates that are directly
in front of you. Using your exercise-developed new motion habits of squatting, lunging, hip
hinging and straight leg deadlifting, you now have new movement options that allow you to move
forward safely using your neutral spine. With an extension theme, stabilize your spine when
reaching up, overhead, leaning backwards, and getting up out of a squatted or seated position.
Many of these motions are similar to your exercises, therefore use your exercise form as much as
possible with daily activities. With a rotational theme, practice pivot squatting, mid back twisting,
or turning your entire body as a unit when turning to one side, and emphasize your neutral spine
RPI when pushing, lifting or pulling with one arm as this will have a tendency to twist your back.
If you have a side tilting theme, avoid hip hiking and side torso leaning when lifting or carrying to
one side, and practice turning your entire body straight ahead to directly face the intended object
to lift, push or pull. Side tilting and hip hiking should be avoided any time one leg is in front of
the other including lunging in daily activates, putting on socks and shoes, driving, and walking up
stairs. Translation themes need to emphasize avoidance of sway back posture while standing,
vertical slumping when sitting, forward head posture during forward activities, and lateral
translations when side lying, lifting, pushing or pulling to one side.

The more you incorporate your neutral spine use in daily activities, and correlate different
directions of your typical postures and movements with your themes, the more you will enjoy the
benefits of all your conditioning exercises as they help you avoid the dangerous mechanical
stresses that cause retrolisthesis back and leg pain.
 12

Avoiding Dangerous Exercises & Sports

You will use the same concepts discussed in the last chapter to help you avoid dangerous exercises
and sport motions that are likely to hurt your retrolisthesis condition. Whether you are working
out at your local gym or fitness class, playing at the tennis court, jogging or biking through town,
or participating in a team sport, taking some time to identify potential risks will be well worth your
effort.

Begin with the activities that have previously aggravated your condition. Look for motions and
positions of the exercises that cause you to move into your pain themes. Use limited ranges of
motion and your neutral spine position to correct the offending mechanics. Many sports
movements are actually repeats of the movements in the exercises you have included in your
program design. Practice emulating the correct form of the exercise you are familiar with already.

If your sport or exercise incudes bending forward and you have a flexion theme, use your squat,
lunge, hip hinge or straight leg deadlift neutral spine motion to replace the previous offending
motion. If the activity includes reaching over head or behind you, and you have an extension
theme, use the neutral spine based exercises learned in the extension theme chapter to avoid
extension in these movements. If the sport or activity uses a one-legged or one-armed motion,
watch for rotational tendencies of the torso or pelvis, as well as hip hiking and side leaning
tendencies. The same concept applies to any flexion, extension, side tilting, rotation or translation
based movement- use the corrections learned in your program exercises to avoid your pain themes.

Occasionally, you may have to be patient for your return to the sport or exercise that previously
aggravated your pain because you have not yet conditioned your neutral spine sufficiently enough
to perform the activity. At other times, certain sports or activities may simply not be a good choice
depending on your pain theme, level of degeneration, or conditioning ability. In these cases, it will
be wiser to choose a different sport or exercise and simply avoid the more dangerous option.

The following lists of exercises and sports are intended to make you aware of common dangerous
activities for your pain theme. While these lists are not exhaustive, and certainly do not totally
exclude you from participating, their purpose is to simply make you aware that they are the more
dangerous motions and sports for your particular pain theme.
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Dangerous Flexion Theme Exercises and Sports for Retrolisthesis

Deadlifting
Squatting with Bar on Shoulders
Full Sit Ups
Leg Raises
L Sits
Shoot Through
Toes to Rings
Toe Touches
Deep Leg Presses
Yoga Posture with Forward Bending (ex: Down Dog)
Pilates without Sufficient Hip and Back Extension Exercises Included
Bent Over Barbell Rows
Good Mornings
Burpees
Inverted Burpees
Kettle Bell Swings
Clean and Jerk
Snatches
Deep Pistol Squats
Biking/Cycling
Rowing Machines
Seated Cable Rows
Toes to Bar
Basket Rope Climbs
Wrapping Rope Climbs

Dangerous Extension Theme Exercises and Sports for Retrolisthesis

Over Head Pressing (especially with normal stance, extension is easier to control w/Split Stance)
Standing Barbell or 2 Arm Dumbbell Curls (less extension w/ Split Stance and 1 Arm Curls)
Sumo and Front Squats
Hyper Extensions
Kettle Bell Swings
Landmine
Snatch, Cleans, Jerks
Incline Chest Pressing
Cross Bench Pullovers
Flat Bench Pressing with Arched Back
Leaning Back Seated Cable Pulldowns
 117

Overhead Seated or Standing Tricep Extensions

2 Arm Lateral Raises
Leg Raises
Leg Extensions with Arched Back
Lying Leg Curls
Over Head and Behind Ball Throws
Kipping
Rope Climbs without Legs
Backwards bending Yoga Poses (ex: Cobra)
Reaching Overhead and Backwards Sport Motions (Volleyball, Basketball, Baseball etc.)
Twisting Sports Motions Associated with Extension (Golf, Racquet Sports, MMA)
Backwards Kicking Motions
Increasing Walking and Running Stride Length
High Jumping
Martial Arts Throws that Involve Leaning Backwards
Sled Work

Dangerous Rotation Theme Exercises and Sports for Retrolisthesis

1 Arm Pressing Motions (1 Arm Pushups, Chest, and Shoulder Presses)

1 Arm Pulling Motions (1 Arm Rowing, Pulldowns, Chins)
Racquet Sports
Golf
Baseball/ Softball
Bowling
Other Throwing Sports (Lacrosse, Hammer/ Discus, etc.)
Abdominal Twisting Exercises
Martial Arts 1 Arm Rotational Punches and Kicks
Lunges and Split Squats
Box Step Ups
One Legged Stance
One Legged Squats
Turkish Get Ups
Windshield Wipers
Yoga Twisting Postures (ex: Revolved Side Angle Pose)
Chopping Motions
1 Arm Snatch/ Clean/ Jerk
Side Stepping Exercises (Squats, Box Jumps, Karaoke Sports Drills)
1 Arm Cable Crossovers
1 Leg Hamstring Curls
1 Leg Extensions
1 Leg Presses
 118

1 Leg Squats
1 Leg Straight Leg Deadlifts
1 Leg Glute Bridges
Landmine
Elliptical Machine
Cross Country Ski

Dangerous Side Tilting /Leaning Theme Exercises and Sports for Retrolisthesis

Farmers Walks
Side Tilting and Twisting Abdominal Exercises
Bird Dog
Narrow or Staggered Grip Pull-ups
Leg Raises with Sideways (Lateral Motions)
1 Arm Pressing Motions (1 Arm Pushups, Chest, and Shoulder Presses)
1 Arm Pulling Motions (1 Arm Rowing, Pulldowns, Chins, Upright Rows, Lateral Raise)
Racquet Sports
Golf
Baseball/ Softball
Bowling
Other Throwing Sports (Lacrosse, Hammer/ Discus, etc.)
Martial Arts 1 Arm Rotational Punches and Kicks
Lunges and Split Squats
Running Stairs
Climbing Stairs with and without Added Weight
Box Step Ups
One Legged Stance
One Legged Squats
Turkish Get Ups
Windshield Wipers
Yoga Side Tilting Postures (ex: Triangle Pose)
Yoga Twisting Postures (ex: Revolved Side Angle Pose)
Landmine
Chopping Motions
1 Arm Snatch/ Clean/ Jerk
Side Stepping Exercises (Squats, Box Jumps, Karaoke Sports Drills)
Stair Master
Elliptical Machine
1 Arm Cable Crossovers
1 Leg Hamstring Curls
1 Leg Extensions
1 Leg Presses
 119

1 Leg Squats
1 Leg Straight Leg Deadlifts
1 Leg Glute Bridges

Dangerous Side Translation Theme Exercises and Sports for Retrolisthesis

Side Lying Presses and Pulls

Side Kicks and Strikes
Lateral Speed Drills
Reaching Sideways in Sports
Stair Master
Farmers Walks
Landmine
One Legged Stance Exercises
Opposite Limb Support Exercises (Bird Dogs, Crawls, etc.)
Knee to Opposite Shoulder Abdominal Exercises
Narrow or Staggered Grip Pull-ups
Chops
Diagonal Presses
Leg Raises with Sideways (Lateral Motions)
1 Arm Pressing Motions (1 Arm Pushups, Chest, and Shoulder Presses)
1 Arm Pulling Motions (1 Arm Rowing, Pulldowns, Chins, Upright Rows, Lateral Raise)
Racquet Sports
Golf
Baseball/ Softball
Bowling
Other Throwing Sports (Lacrosse, Hammer/ Discus, etc.)
Martial Arts 1 Arm Rotational Punches and Kicks
Lunges and Split Squats
Box Step Ups

Dangerous Front to Back Translation Theme (Sway Back and Forward Head Posture)
Exercises and Sports for Retrolisthesis

Reversing Directions of Movement in Front to Back Plane of Motion

(Lunges, Squats, Sudden Cuts & Changes of Directions in Sports)
MMA
Jumping
Over Head Pressing
Rope Climbs without Legs
Kipping
Bent Over and Seated Roes
 120

Rowing Machine
Elliptical Machine
Stair Master
Incline Treadmill
Uphill & Downhill Running
Standing Curls
Upright Rows
Snatch/Clean/Jerk
Sled Work

Dangerous Vertical Compression Translation Theme Exercises and Sports

for Retrolisthesis

Wrestling
MMA
Jumping Sports
Over Head Pressing
Deadlifts
Snatches
Cleans
Weighted Squats
Weighted Lunges & Split Squats
Standing Calf Machine
Squat Machine
Over Head Triceps Exercises
Seated Lat Pulldowns
Shrugs
Farmers Carry
Bent Over Rows
Heavy Upright Rows
Standing Barbell Curls
Log Carry
Landmine
 13
Pain Relief Exercises and Techniques

There are other exercises that can be used for immediate retrolisthesis back pain relief. There are
several mechanisms by which this occurs. These vary from (1) altering muscle tension in the
painful area, to (2) using gentle pain-free motion to stimulate certain types of nerves that have a
pain-dampening effect, to (3) breaking up scar tissue from a past inflammatory process that is
mechanically irritating local nerves, to (4) increasing local circulation that flushes noxious
substances out of the injured area, to (5) releasing of chemicals (endorphins, enkephalins) that
modulate pain. Any one (or a combination of these) is at play when exercise decreases pain. The
exact type, duration, intensity, and execution (form) of exercise is of more importance in some of
these mechanisms than others.

Realize that the following exercises are designed to relieve pain, not necessarily correct the root
cause of your pain or injury (body mechanics and back de-conditioning). However, these exercises
are very important in the comprehensive approach to your pain. These additional pain relief
exercises may be used from the very beginning of your exercise program. Once your pain subsides,
they do not need to be done on a daily basis, but may be used again for painful flare-ups of your
condition. Occasionally, these pain relief exercises may need to be a permanent part of your
program.

The following exercises relieve back pain by relaxing and de-stressing the typical target areas that
cause back pain. Try each one at least once to determine how you feel with it. Choose from the
following exercise(s) that seem to relieve your pain the most and focus on practicing those.

Low Back Positional Pain Release

Lay on the floor or on a firm mattress. Bend your

hips and knees as shown above. There are three
corrective maneuvers to this exercise. The first is
finding a position of greatest pain relief by either
arching or flattening the lower back. You will find
the right position by either gently tilting your
tailbone under (to flatten), or up toward your lower
back (to arch) the low back. Gently tilt back and
forth until you feel the greatest position of relief.
Next, without changing your low back arch, tilt
your pelvis from side to side, as if trying to push
one knee farther away from your hips than the
other.
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Do not move your feet as you perform this second correction. Try pushing the right hip long first,
then the left. Go back and forth until you feel the most comfortable position. It may be with your
hips level, or with one side longer. Lastly, while holding the first two positions of relief, gently
twist your hips to the right, and then to the left, to determine if twisting can provide additional
relief. This last correction will cause one side of your pelvis to be higher than the other. Hold the
combined 1, 2, or 3 corrective positions as one combined position for 90 seconds before very
slowly relaxing back to the starting position. Repeat as necessary, and stand up very slowly after
the pain has abated.

Spinal Mobilization Pain Relief Exercise

This exercise improves circulation, gently stretches and contracts lower back soft tissues, and
stimulates nerves which can all relieve local back pain. Engage a mild low back RPI tension in
your most comfortable position. That may be lying down, standing, sitting, or on your hands and
knees. You will gently move your spine through the three basic motions outlined in the last
exercise. The difference here is that you will be moving (mobilizing) your spine back and forth,
instead of just relaxing in a relieving position.

Begin by tilting your tailbone gently down and under, flattening the arch of your lower back. Move
only through a pain-free range of motion, holding the end position for two seconds, before tilting
your tailbone upwards (in the opposite direction to increase the arch). Only raise up as far as is
comfortable, and hold that position for two seconds. The mild RPI allows movement but not
enough to be painful. Then reverse the direction again and tuck down and under. Tilt gently back
and forth (alternating down and up), holding each comfortable end range position for two seconds
before tilting back in the opposite direction. Tilt back and forth in each direction 5-10 times as you
maintain a mild RPI of your lower back, pelvis and torso. End by relaxing for 10-30 seconds.

The next mobilization is tilting one side of your hip down, as the other tilts up. You will need to
bend your knees if doing this standing. Use the same pain-free range of motion, RPI, and two
second hold time as the first direction of mobilization. You will also tilt back and forth, alternating
right hip down and then the left, for 5-10 times.

The last mobilization is twisting your hips slightly to one side. The overall motion is less than an
inch. Begin by rotating your pelvis (pubic bone) to the right. This will cause your right hip to
move slightly backwards, while your left hip moves slightly forwards. Only move through a
comfortable distance (range of motion), and hold the end position for two seconds. Then rotate the
opposite direction (pubic bone twisting to the left). Hold for two seconds in the end range of
comfort. Alternate rotating right and left for 5-10 times.
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Vertical Spinal Decompression

Vertical decompression of spinal discs and joints can be accomplished in several easily accessible
home settings. You will need either an inside corner of a countertop, or two chair backs positioned
back-to-back with approximately two feet in-between them for your body to fit. A third option is
a gym style ‘dipping’ apparatus. Place your hands on the counter top, dip bars, or the tops of the
chairs. Support your full body weight on your arms, as you slowly bend your knees and allow
your feet to lift up from the floor. Let your spine slowly elongate and stretch, as it “hangs” from
your upper body support. Hold this position for 5-10 seconds before slowly allowing your feet to
support your body weight again. Rest 5-10 seconds and repeat. Do not stretch for more than 30
seconds to avoid over stretching and injury of ligaments and disc fibers. Repeat the decompression
stretch 3-10 times. Perform 1-3 times per day. Maintaining a mild RPI of your lower back, pelvis
and torso will be helpful during the stretch. Spinal decompression should be applied and released
very slowly to avoid aggravating spinal soft tissues. Let your feet both release and regain their
body weight support slower than you want to.

Performing gentle and small range of motion mobilizations (as in the previous exercise) while
vertically decompressing “hanging’ is another technique to relieve pain by mobilizing spinal joints,
discs and other soft tissues. If using this method, limit your mobilizations to 3-5 in any direction.
Avoid any direction that is painful. Spinal decompression with, or without mobilization, should
always feel good and never aggravate pain.

Spinal Decompression Spinal Decompression

Using Chairs at Countertop
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Hip Shift

The Hip Shift pain relief exercise can be performed in a variety of positions. This is particularly
helpful for those with weak gluteus max muscles, hip hiking, anterior hip malpositions, tight hip
flexors, and externally rotated hips. This pain relief exercise corrects several lower back and hip
alignment problems in one maneuver. It can easily become a “favorite” and “go to” pain relief
method for those who have any of these very common mechanical low back problems.

The Hip Shift can be done seated, standing, kneeling, lying down, or in any position. Using one
position over another is often a matter of preference, or based on your current body position when
back pain strikes. Becoming familiar with all of the different versions gives you pain relief options
in any circumstance.

Seated Hip Shift. Begin seated and engage your local core stability. On the same side as your
external rotated hip/ thigh, hip hiking, anterior hip, and/or weak gluteus max, tense your knee
straight back along your thigh bone into your hip socket. This will cause a shortening of your
thigh when compared to the opposite side. You will also feel your buttock (gluteus max muscle)
contract on that same side, as it moves slightly backwards. It is this gluteus max contraction that
pulls your thigh bone backwards in the hip socket, and is the correction for an anterior hip posture.
Only tense back as far as is comfortable. The overall motion is less than 1/4 of an inch. You may
also allow your pubic bone to turn slightly toward the same side as you do this.

As you hold this tension, tilt your hip down (anti-hip hike) on the same side. This will elevate
your hip on the opposite side. Tilt down as far as it takes for your lower back to feel the most
comfortable. Hold this position for 90 seconds and then release slowly. If you feel significant
relief, stop here. If your lower back pain is still bothersome, perform the exercise for repetitions,
instead of a 90 second hold time. Hold each rep for 3-5 seconds before repeating the shift for 10-
50 total reps.

This exercise resets the tension in your major hip

and lower back muscles, re-aligns the hip joint,
and decompresses the lower back joints and disc
spaces on the same side. It often is a powerful
relief maneuver for one-sided lower back pain
(on the same side) that is compressive in nature,
and less commonly relieves one-sided lower
back pain (on the opposite side) that is over-
stretched in nature.

The Hip Shift demonstrated here is addressing a

left sided external rotated hip and hip hiking.
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Lying Hip Shift. This is often the best position

for pain relief as all of the lower back and hip
muscles can totally relax in this non-weight
bearing position. Begin in the side lying
position, with the side of hip hiking, weak
buttock, tight hip flexor, anterior hip
malposition, external rotated hip, or
compressive back pain facing down. Bend
your top knee and place it on the floor or bed
in front of the bottom leg. Holding a slight
tailbone tuck-under posterior pelvic tilt, tense
your bottom buttock, and elongate the bottom
leg through the foot. This will cause your bottom hip to move away from your ribcage (anti-hip
hike). Emphasize turning your pubic bone into the floor or bed as you hold the position for 90
seconds before slowly releasing. As in the seated version, use repetitions if pain relief is not
satisfactory. Always use comfort and the degree of pain relief as your guide to overall motion and
number of repetitions.

Standing Hip Shift. The exercise can be done standing with both knees slightly bent. This
decreases disc pressure and may be preferable for those whose pain is aggravated with sitting.
Engage a posterior pelvic tilt, as you tense the buttock on the side of the external hip rotation, hip
hiking, anterior hip malposition, tight hip flexor or weak buttock. Shift your involved hip down by
moving that foot backwards 12-24 inches, and bending that knee more than the opposite side. Turn
your pubic bone towards the deeper knee bend. Lean your torso towards the side of the higher
knee. Keep the back leg and foot straight or slightly turned inwards. Slowly release after 90
seconds and repeat for repetitions if necessary.

This standing version may also be done using stairs or an elevated surface to step onto with the
opposite foot. In the case of a left sided external hip rotation, hip hiking, tight hip flexor, weak
buttock or compressive back pain, the right foot would be placed on a step or elevated surface. As
the left buttock is tensed with posterior pelvic tilt tension, the tight hip flexors will stretch as a
result of the left leg being positioned behind the right leg. The left hip is lower in this position, but
may be tilted down farther. The pubic bone should turn slightly to the left side. The left leg and
foot should be either straight or slightly turned in to complete the correction.

Prone Extension Pose. This is particularly suitable for flexion theme pain, and should be avoided
by those with extension pain. Lying face down on the floor, simply rest your forearms under your
chest to induce a slight arch in your lower back. Rest comfortably for 30-90 seconds. If
comfortable, increase the arch of your lower back successively by resting on your elbows with
your upper arms vertically under your chest (followed by an additional 30-90 second rest), and
finally with arms extended straight underneath your chest. Hold each increased arch position for
30-90 seconds before slowly returning to a normal face down position.
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Only increase the arch and amount of chest lift if

comfortable. This helps many flexion theme
retrolisthesis pains by changing the internal disc
pressures and helping to transiently bend the
retrolisthesis vertebrae towards a more forward
position.

Try each of these pain relief exercises and

determine which work for you. The ones that
provide immediate back pain relief are the best. It
may be all, some, one, or none. They may be used
several times each day to improve spinal soft
tissue stress and back pain. Remember that relief exercises can be used at any time during your
low back retrolisthesis exercise program. Whether you are just beginning, or have been
conditioning your back for years, these exercises are designed to provide immediate pain relief.
Use them any time your pain flares up, or as a preventative measure.
 14
The Mind-Set for Overcoming Chronic Back Pain

Back pain is much more than soft tissue damage and irritation. Over the past few decades,
scientific research has shown that many other factors play a significant role in the back pain
experience. Contemporary understanding of back pain includes not only the actual irritation of
back soft tissues and associated mechanical and physical conditioning factors, but also
encompasses the psychological and social factors that affect pain.
The bio-psycho-social view of back pain is the current
multi-dimensional model that is held by most experts, and
helps to explain how emotions, thoughts, beliefs, moods,
personalities, expectations, unresolved psychological
issues, an individual’s history, social constructs,
environments and attitudes all play a role in back pain. All
of these pieces often fit together like a puzzle, resulting in
the feeling of back pain. From a modern back pain
treatment perspective, this model is an inter-disciplinary
approach that tailors a comprehensive pain management
program addressing each back pain sufferer on an
individual basis.
Central to the bio-psycho-social model of pain is the concept of chronic pain. While at least 80%
of all people will experience back pain sometime in their life, most cases will resolve within a few
weeks, and not necessarily become an ongoing issue, or a repetitive one. Back pain that returns
frequently, extends past the normal healing time, or lasts greater than 3 months, is known as
chronic back pain.
The prevalence of chronic pain has been estimated to include 10-20% of all people, affecting 30
to 60 million Americans. Chronic back pain in particular increases as one ages, with estimates of
prevalence from as low as 4% in individuals between 24-39 years old, and up to 25% in older
individuals. All chronic pain is influenced by psychological processing and responses, making the
bio-psycho-social approach a valuable tool for treatment.
While it would be foolish to think that back pain is “all in your head”, the reality is that many
persistent retrolisthesis back pains are influenced by the bio-psycho-social complex.
Understanding how these various factors relate to pain, and what you can change to improve your
pain is a vital self-management tool for overcoming chronic back pain.
This chapter addresses some of the main psychological and other components of the bio-psycho-
social complex that affect back pain. Besides explaining how your particular chronic pain may be
related to some of these factors, mind-setting and other techniques are provided to help you break
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through this often overlooked component of back pain. It all begins with the realization that pain
does not necessarily equal damage, and an understanding of what the pain you feel truly is.

What is Pain?
Injury and pain are not the same. Pain is a complex process in the brain that is the ultimate result
of many factors, and is an unpleasant sensory or emotional experience associated with actual or
potential tissue damage. When someone feels pain in a missing arm or leg that no longer exists
(phantom limb pain), the pain is just as real as
someone who has just injured their arm or leg that is
still part of their body. Pain is a process that happens
in the brain, not in the rest of the body!
The brain is in a continual state of monitoring, and
deciding if something is a threat or not. It correlates
information from the rest of the body, including
incoming “alarm” or “danger” messages from soft
tissues, with past experiences, emotions, beliefs and
other factors in the bio-psycho-social complex.
After interpreting all of this information, the brain
must make a decision. If it decides that the threat
value of danger to the soft tissues is credible, then it
will construct pain.
Pain is more about sensitivity than actual damage. There are plenty of people who have severe
arthritic changes and disc herniations found on x-rays and MRIs who have absolutely no pain,
while other people who have completely normal imaging studies suffer from excruciating pain.
Nerve tissue sensitivity in the brain is influenced by multiple factors. While real damage can
definitely play a role in the sensory input to the brain, other factors of the bio-psycho-social
complex play a crucial role in the overall input to the brain as well, and thus help the brain to make
its decision to create pain.
Chronic pain is often associated with an increased sensitivity to pain. Changes in the spinal cord
and brain can occur which contribute to back pain being experienced out of proportion with actual
back damage. When back pain has been present for an extended period of time, the central nervous
system becomes hypersensitive to pain, and can even cause pain to be felt from non-irritating
stimuli such as normal touch or pressure. This is known as central sensitization and is part of
neuropathic pain.
While different types of chronic pain and different individual perceptions stimulate different brain
regions, they all have a tendency to shift away from actual tissue irritation (alarm or danger signals
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from back soft tissues), and instead shift toward emotional and motivational brain regions. Thus,
chronic pain is likely to result from other influences in addition to soft tissue damage. In fact, the
resting brain state actually becomes distorted in chronic pain.
The longer back pain is experienced, the more likely it is that the entire nervous system will
become extra sensitive to pain. Over time, it takes less and less “warning” signals from the back
to cause an over-protective pain response in the brain. Combined with the psychological variables
mentioned previously, the end result is pain being a composite of both real soft tissue irritation and
distorted brain decisions.

How Chronic Pain is Maintained

Back pain is often prolonged by several factors in the bio-psycho-social complex. Psychological
factors have been found to have a clear relationship to the development of persistent pain. Chronic
pain affects the immune system and shares the same biologic mechanisms as anxiety and
depression. The stress response of the body only occurs if stresses are appraised by the body as
being threatening, which is similar to the body’s pain response. Because the central nervous system
increases in activity during an injury or an emotional response, anxiety/stress and thoughts can
trigger a pain reaction in the brain.
Chronic pain can also be affected by other factors
such as other psychological issues and medication
use. Sensitivity to pain is influenced by fear,
worry, anger, past experience, sleep and beliefs.
Psychological distress and depression increase the
risk of chronic low back pain, and depression
tends to cause more severe and longer lasting pain.
Pain related fear-avoidance of activities appears to
be essential in developing chronic musculo-
skeletal pain problems, and even expectations are
related to low back pain outcomes. Anxiety is
frequent in many chronic pain conditions, which
often causes excess muscle tension that results in
more pain.
Medications that are prescribed in an effort to
relieve pain sometimes have the opposite effect. Many chronic pain sufferers have taken opioid
medications such as codeine, oxycodone, methadone, fentanyl, propoxyphene, Vicodin, Lorset,
Vicoprofen, Percocet, Percodan, Avinza, Kadian, etc to relieve pain. Some of these individuals
can develop opioid–induced hyperalgesia, which is an increased nerve sensitization to pain
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stimuli, resulting in more pain with less physical or psychological stimulus. This complicates the
chronic pain complex even further.
The way a person views pain and injury often plays a role in their level and duration of back pain.
This has to do with their personal history, experiences and social/cultural/environmental
influences. I can remember a Vietnam War Veteran early in my practice who actually laughed at
his sciatic pain every time he moved the wrong way. It baffled me at the time because I knew that
almost everyone else in his condition would be crying in the same circumstance, but he laughed at
his pain as he went about his daily activities. Obviously, despite the “alarm” or “danger” signals
coming into his brain from his sciatic nerve, other mental influences based on his personal history
and perspectives changed his brain’s decision about what was truly a threat and therefore what was
actually really painful. His sciatic condition did not last long.
While problems with spinal stabilization, faulty posture/movement habits, and lack of back fitness
(inadequate conditioning) affect back pain from a mechanical perspective, chronic pain is often
also maintained much longer and more intensely than necessary because the brain is negatively
influenced by these various psycho-social factors.

The Bottom Line

The bottom line for chronic back pain sufferers is that multiple factors in the bio-psycho-social
complex often need to be addressed to find lasting relief. While counseling and rehab programs
for addictions, and professional therapy for psychological issues such as depression, anxiety, and
underlying mental illness can play a pivotal
role in healing, other interventions such as
cognitive behavioral therapy, mindfulness
and positive self-talk have become viable
interventions for chronic back pain as well.
These therapies do not always need to be
administered through a professional to be
successful. Self-management for addressing
many aspects of the bio-psycho-social
complex is becoming increasingly more
popular and can be quite effective. This is
where personal psychology and setting your
mind comes into play. The good news is that despite emotions, social factors, beliefs, attitudes,
and many other factors that hyper-sensitize pain, you can reduce the perceived threat to your brain
and overcome chronic pain by taking an active role.
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It’s up to you to decide what input goes into your brain to help create or negate pain. You can
control the switch that turns on the pain in your brain!

The Mind-Set of Pain Relief

It all begins with a change in thinking or perspective. If there is a shift in thinking to a perspective
that you can adapt (be re-conditioned), then pain and function can be improved. There is a strong
link between negative beliefs and increased pain perception, and the general reassurance that you
can improve is associated with less pain.
When you understand why you hurt, and how the brain creates pain, you typically hurt less. If you
remember our description of pain being processed in the brain, you will recall that the brain makes
its decision about whether to produce pain based on what it deems as credible evidence. The same
holds true for pain relief. If the brain perceives the summation of all its input as credible evidence
of safety, as opposed to threat, the brain will construct less pain. It all depends on what input you
feed your brain!
The mind-set necessary for feeding your brain the pain relieving input you want consists of
multiple voluntary decisions and perspectives including: (1) overcoming your fears to movement
and gradually increasing your physical lifestyle, (2) making changes to your beliefs and attitudes
about pain based on the fact that pain is made in the brain and does not equal the amount of tissue
damage in your back, (3) changing your perspective from being a victim of pain towards viewing
pain as a challenge to acquire problem solving skills to self-manage your pain, (4) adapting a
healthier lifestyle, work and social environment to support your healing, (5) learning to relax and
accept what life hands you, (6) focusing on what you can still do despite your pain using
modifications of activities when necessary, (7) building a personal coping strategy to overcome
flare-ups and negative thoughts/emotions, and (8) improve your self-efficacy by believing that you
can get control over (and conquer) your back pain.
All of these factors help build faith and confidence in your ability to recover. The more of these
various thoughts and actions you persistently pursue, the more positive (safety) input will be fed
to your brain, and as a result, your pain sensitivity will begin to change. Your brain will have less
negative material to build pain with, and instead will build a pain-free decision of safety and well-
being.

How to Change Your Mind-Set

Once you understand and accept the fundamental concepts of mind-setting for pain relief, you can
then begin to put them into practice using specific methods. The following techniques will help
you change your mind-set (and thus brain input) step by step.
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1. Start Moving Again. Remember that pain

does not equal damage as you begin to carefully
explore movements and activities that you have
been avoiding. Begin with small ranges of motion
in any movements or activities that you have been
avoiding, and allow a mild discomfort if it occurs.
As long as pain is not significantly flared up 1-2
days after your movement, it is typically
considered safe, and a slight progression in
movement can be made the following day.
If pain becomes moderate to severe, the exposure
was too intense or too long in duration, and should
be decreased to an acceptable level after the pain
diminishes again. Choose activities and exercises
that you enjoy and have meaning to your life.
These are the most important and will fortify the positive sensory stimulation your brain requires,
helping to build the meaningful confidence you need in your back pain recovery.
Gradually build up small increases in range of motion, duration of time, and activity intensity of
your most feared movements. Use your RPI stability to help maintain a neutral spine position to
add to your back protection. This will help you realize that a gradual return to activities with correct
mechanics can be possible, helping to break the chronic pain cycle.
Use your back pain sensations during the day as a signal that you need movement. Pain means that
your back is requesting circulation, movement, and the pain relieving effects of motion.
Answering the call from your body with as little as a few minutes of movement can be one of the
best habits you can develop. It often doesn’t matter what the movement is at the time (spinal
mobilizations, walking, exploring a gradual return to your most feared movements), but only that
you start moving more frequently. These micro breaks of movement from static postures and
activities such as prolonged sitting, driving, standing, etc. can make a huge difference in your pain.
It helps to imagine yourself performing the activity or exercise pain-free before you attempt it. The
more stimulus to your brain concerning pain-free and healthy motion, whether real or imagined,
the more likely it is that the brain will create less pain while actually performing the activity.
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If you have trouble imagining your pain-free movement and life, try changing your perspective to
an outside view looking in. Imagine a view from high above the earth, watching you move and
live healthy and pain-free. This mental imagery
can be practiced at separate times during the day
for just a few minutes at a time, or when fitness
walking. By combining mental imagery with
physical corrections and the conditioning effects
of this retrolisthesis program, you will be
sending in multiple positive messages to the
brain, exponentially increasing your chances of
pain relief.
Remember to focus on the long term effects of
this type of graded exposure movement training.
Think more about where you want to be going
instead of where you are presently. It is
acceptable to have a slight discomfort with this
method, but not moderate or severe
exacerbation. Expect that slight flare-ups may occur with certain movements. When they do, it is
important not to interpret them as failures, but view them as stepping stones on your journey to
back pain recovery.
Retrolisthesis mechanical back pain is not so much about damaged structures as it is about back
fitness (conditioning) and function. Part of that function consists of the mechanics of movement
and back RPI stability, but the other part is the sensory information going into the brain that creates
pain. Using positive imagery with a gradual return to the activities and movements that you have
been avoiding will be the perfect complement to your exercises.
2. Mindfulness. As explained earlier in this chapter, one of the problems with chronic pain is that
it is complicated by negative thought and emotion. Chronic back pain sufferers are often not aware
of their tendencies towards these negative traits, and need to first objectively see themselves for
who they really are before changes can occur. Mindfulness opens this awareness by training you
to experience your back pain for what it truly is, uncomplicated by judgment, past experience, fear,
worry, catastrophizing, excessive focus on pain, magnification of symptoms, or attitudes of
helplessness.
Practicing mindfulness helps you to identify and separate the various components of your unique
bio-psycho-social complex. By identifying particular traits, you can then address and change them.
If you don’t know what the unique contributors to your pain are, you can never eliminate them.
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Mindfulness has been shown to improve chronic back pain and related function. By stripping
away as many of the peripherals to your pain experience as possible, you can often learn to control
your pain and hasten your progressive walk away from it.
Mindfulness is simply becoming aware of your body, emotions, thoughts and reactions as they
relate to your back pain. Because all of these change from moment to moment, and most people
spend little time focusing on the reality of the present moment, observing your pain and all its
related psychological factors without judgment or bias typically allows discovery of the hidden
psycho-social aspects of pain.
Focusing on the present moment may sound simple, but can be a real challenge for those with
chronic back pain who have a heap of practice mixing in past experiences, expectations, fears, and
other emotions in the brain, when in reality, the only thing that should really count is whether or
not there is a true danger to the body.
To begin practicing mindfulness, you will need to develop a new perspective of viewing yourself
for who you are, and what you really do in terms of thinking and reacting. You will need to focus
your attention on observing yourself with a sense of curiosity, like a scientist in a laboratory,
simply using his objective sense to note what is happening. This unbiased view may take some
time to develop, but will get easier the more you practice it.
To begin, close your eyes or gaze at one particular
object. This can be done standing, sitting or lying
down, but is most easily learned in a comfortable
position. If you are walking, you can focus on the
road ahead of you, or on an imaginary light.
Bring your attention to your breathing. Focus on
the air coming into your body, filling your
abdomen and chest. Become aware of the rising
and falling of these areas moment to moment
during the inhalation/exhalation cycle. Notice
how your nostrils will move slightly with each
breath as well. Note how these areas and your
entire body feels as the air enters and leaves you.
Become aware of how the breath you take moves
throughout your body. Notice any temperature
changes or sounds of the air as it comes into and leaves your body. Note how the air may change
sensations in any aspect of your body, including your back. Scan your body from head to toe,
observing how your breath affects each region. Don’t try to think, judge, or react to these
observations, just simply bring your awareness to how breathing affects you…it is all about just
observing the present moment, and how moments change with each breath.
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If any thought other than simple observation comes to you, gently re-focus your attention on your
breathing. Practice this for a few minutes.
Next, shift your attention away from your breathing and notice any thoughts or emotions you are
experiencing. Do not judge or analyze these thoughts, just simply observe where your mind goes.
Because thoughts are always changing, expect your observation to witness many thoughts and
possible emotions during this unbiased self-evaluation. Continue this for another few minutes, and
repeat your breathing, thought and emotion mindfulness practice a few times each day.
Once you begin to build your practice of this technique, begin to become mindful when you are in
pain, or when you think about your back pain and how it affects your life. Notice not only your
breath and body sensations when your back is bothering you, but also your thoughts and emotions
as they come to you during your pain episodes. Using a non-judgmental observation of your pain
experience will often reveal hidden factors in your brain’s pain generation process. Once you have
identified your reactions, thoughts and emotions to your back pain such as fear, anger, worry, self-
pity, disgust, indignation, hopelessness, etc., you can then begin to target these, and make some
changes for pain relief.
3. Positive Self-Talk and
Suggestions. Now that you have
identified the complicating reactive
thoughts and emotions you typically
use in your reaction to back pain, it’s
time to flip your attention to a
positive and healing perspective.
Positive self-talk is the practice of
using repetitive healing thoughts to
overcome your pain. It helps to
match a specific positive self-
suggestion or affirmation to a
specific negative thought or
emotion. For example, practicing replacing the emotion of fear with an affirmation such as “I am
going to be all right, the pain I am feeling does not equal the actual damage in my back, but is a
result of many other factors as well, all of which can be overcome”, can be said out loud or
contemplated in silence over and over whenever the negative thought of fear is revealed during
mindfulness.
This is where understanding chronic pain comes into play. When you know that chronic pain is
constructed in the brain based on many aspects of the bio-psycho-social complex, and that most
of them can be improved upon, it gives you hope and confidence that you too can overcome your
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back pain. Positive self-talk helps you to re-program the way your brain responds to the various
stimuli of this complex.
Changing your mind-set about your back pain is helpful both in the short term and the long term.
Once you have identified your specific negative reactions to pain, you can replace them and change
your pain experience. Using techniques such as distraction, you can find instant pain relief simply
by focusing on something other than your pain. The more intense the distraction, the more pain
relief is possible. While exercising, this may include a hyper-focus on your mechanical changes.
Setting your mind on another part of your body that is currently pain-free, or imagining a time
when your back did not bother you are additional techniques.
Reframing is another method that can offer mind-setting instant pain relief. Simply by imagining
your pain sensation changing from sharp or stabbing pain to a thermal sensation such as warmth
or coolness can reduce pain. This can be done initially with actual ice packs or heating applications,
and later can be practiced only with imagery. Another technique is changing the sensation of
tightness or spasm to gradual relaxation and calmness simply by imagining the change.
A powerful method of mind-setting pain relief can be activated by visualizing your pain being
controlled by a dial or volume control knob. Mentally turn the dial up to increase the pain slightly
when first practicing this technique, as increasing pain is typically much easier for the chronic pain
sufferer than decreasing it. Once you realize your mind has control over the intensity of your pain,
you can then practice moving the dial or control knob in the other direction, decreasing the level
of your pain.
Visualizing colors can also be helpful. Some
chronic pain sufferers find relief by imagining
their pain as an intense red color of paint,
localized in their back. Once this has been
mentally visualized, attention is shifted to another
part of the body that is not painful, imagining this
pain-free region to be a calm blue or green color
of paint. Pain relief is achieved by mentally
dipping a paintbrush into the blue/green paint, and
transferring the paint onto the intense red paint.
With enough applications of paint, it is possible
to “paint” the red hot back pain into a picture of
pain-free blue/green calmness.
Dissociation offers relief by imagining a
separation of the pain or yourself from your body.
Visualize yourself in another time, or high above the earth, or sitting across the room in a healthy
and pain-free body. This often works well while walking, as you visualize yourself in a new body
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full of strength and physical robustness, walking with a relaxed, yet strong and pain-free back.
Any of these mind-setting techniques can be used to formulate your own unique mental coping
strategy for pain. Based on your specific targets revealed during mindfulness training, you will
want to construct a personal self-talk script that affirms the positive corrections to your typical
negative responses to pain.
Here are some examples that cover many of the typical thoughts and emotions related to chronic
back pain. While you may find these generic affirmations helpful, it is more advantageous to use
them as an example or template to create your own personalized script to better address your
specific needs.
“Pain is only a warning (danger of threat) signal to my body, it is not a true sign of damage to my
back”
“Pain is a signal that it is time for me to start moving again”
“I can change many factors related to my pain, and I am in the process right now of overcoming
this pain and controlling it”
“I used to get worried about my pain, now I get
hopeful”
“The old me was angry about my back pain, the
new me realizes my back is peacefully getting
stronger every day”
“The abuse and pain that I suffered as a child was
then, it is not part of my current back fitness
issue”
“The social environment I used to belong to and
other peoples’ expectations do not dictate how my
back will heal, rather I (right now) dictate how my
back will heal”
“Just because my co-workers all have back pain
does not mean that I will because I am keeping my
back fit and in shape”
“My pain is beginning to change to a sensation of warmth, bringing circulation and healing
nutrients to the area”
“My back sensation is relaxing and not complicated by unrealistic responses such as fear, worry
and making a catastrophe out of something that is simply not that important in the overall meaning
to my life”
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“The pain is moving out of my body to another place, I feel it moving away from me’
“I have complete control over this pain and I am directing it out of my body”
“This pain is not actually in my body, I am only seeing it from afar, and because it is not really in
me, I can choose to focus on something else”
“Whatever this sensation is, it can’t be trusted due to various brain inputs, therefore I will only
trust that it is a sign that my body is healing and on the road to recovery”
“The pain I feel when moving is mild and not severe, therefore it has to mean that things are
healing in there and not actually being damaged”
“God loves me and has promised that if I asked to be healed, He will do it. I need only to have
faith in Him and stop thinking about the pain as it is now in the process of healing and leaving
me”
Practicing your unique affirmation(s) out loud and in your own head multiple times a day can go
a long way to helping reset the dysfunctional brain input related to negative psycho-social trends.
By alternating your mental focus between corrective body mechanics and your unique positive
affirmations while you exercise, you will be providing your brain and back with a more “full
spectrum” healing stimulus.
4. Professional Support. While movement therapy, mindfulness, and positive self-talk can often
make a significant change in back pain related to the bio-psycho-social complex, professional
therapy can be helpful in more resistant cases. Psychotherapy, spinal rehabilitation, occupational
therapy, cognitive behavioral therapy, acceptance and commitment therapy, mindfulness based
stress reduction, mindfulness based cognitive therapy, and various counseling services can all help
in reducing the peripheral elements that feed the brain’s pain generating process.
Finding a mind-set that works for you may take some exploring, learning, and practice, but in the
long run, addressing the various components of your unique psycho-social complex will offer you
the best chances of overcoming your unique chronic back pain.
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Nutrition for Back Pain and Inflammation

Nutrition is an important aspect of healing and pain relief. What you eat can have an effect on pain
and inflammation, as well as provide the nutrients that are needed to rebuild new healthy soft
tissue. Your selection of foods “sets the stage” in your body for pain perception and ongoing
inflammation. If you consume the “right” foods, and stay away from the “wrong” ones, you can
alter your body’s inner chemistry to subdue the pain and inflammation associated with mechanical
retrolisthesis back stress, while promoting healing.

Of course, any change in nutrition or diet should be undertaken with caution if you have a medical
or nutritional issue. Check with your doctor before changing your diet if this is the case, as
medications can be affected by dietary changes, and depending on your unique situation, some
changes may be dangerous for your condition. Generally however, the following tips hold true for
those who are looking to support spinal soft tissue health, and decrease back pain and inflammation
through better nutrition.

As you read the following recommendations, realize that your body’s inner chemistry is a
summation and balance of all the foods you eat. Promoting an anti-inflammatory and pain-free
state in your body is more about what you eat “most of the time”, and not about what you eat
“sometimes”. You do not have to eat “perfectly” to notice a difference in your back pain, but you
do need to eat better than you currently do, especially if you are like most typical back pain
sufferers living in the modern world of refined and processed foods, with an inadequate supply of
healthy nutrients.

From a nutritional perspective, the most common

foods that back pain sufferers will need to decrease
or nearly eliminate are refined sugars, refined
grains, some saturated fats and all
hydrogenated/trans-fats. This includes staying
away from most “bakery” products containing
flour and sugar, fast foods, cookies, chips, other
“sweets”, and most man-made (refined) packaged
foods. All of these foods lead to chemical changes
in your body that promote inflammation and pain.

On the other hand, back pain sufferers will be

better served by including a wide variety of fruits
(especially blueberries and apples) and vegetables (especially green leafy vegetables, cabbage,
broccoli, cauliflower, and brussels sprouts), grass fed meats, wild caught fish, chicken, shell fish,
omega 3 eggs and seeds (flax, hemp, chia), unprocessed nuts, olive and coconut oils, high fiber
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sprouted whole grains, oats, cheeses and spices. All of these foods alter your body chemistry to
protect against inflammation and pain.

Replacing bad foods with good ones is the best place to start
your nutritional make-over. To decrease pain and
inflammation, replace refined oils such as corn, safflower,
sunflower, cottonseed, soybean and peanut oil with olive oil
and/or coconut oil.

Replace sugar and flour based breads and cereals with

flourless sprouted breads, and whole grain unprocessed
cereals. Choose unprocessed nuts, fruits or veggies instead of
cookies and chips for snacks. Try to replace any refined
(white) sugar based food with a natural food that is less
sweet. Replace vegetable cooking oils with olive oil when
stir-frying or pan cooking, and avoid deep-fried foods.

Increase water intake as proper hydration can help to control

inflammation and promote healing. Add bromelain
(pineapples), ginger, garlic, flavinoids (citrus fruits), and
lycopene (cooked tomatoes) to decrease inflammation. Sea vegetables are also a great source of
many micro minerals and nutrients that may help.

Adding supplements to your diet may also be helpful. These include antioxidant vitamins,
minerals, and enzymes. Antioxidants neutralize the harmful effects of free radicals, which
promote inflammation. Antioxidant vitamins such as A, C, E, and the minerals zinc and selenium
are important. Antioxidant enzymes are found abundantly in sprouts (particularly wheat sprouts)
and stimulate your body's production of powerful anti-inflammatory chemical reactions. Other
anti-oxidants include alpha-lipoic acid and coenzyme Q10. Magnesium, probiotics, and vitamin
D can also be helpful, if you are deficient. Add anti-inflammatory omega 3 cold water fish oils,
which should have verification stating that they do not contain heavy metals or other pollutants.
Consider adding chondroitin sulfate, glucosamine sulfate, and MSM as supplements. A turmeric
supplement can also help control inflammation. Hyaluronic acid supplements may help support
joint and soft tissue health. Always be sure to check the purity of these commercial products as
many have additives or fillers that while decreasing price, may also decrease effectiveness because
there is less of the actual nutrients per serving.

While it is easy to feel over-whelmed by nutritional modifications, keep in mind that it is usually
a gradual process for most people. Radical nutritional changes of any type usually do not last, as
people are “used to’ eating a certain way, and usually do much better when they gradually shift
their tastes and preferences. Start with a few, small changes, add one or two supplements at a time,
and be patient. While changes in your body’s internal chemistry will start to occur within hours of
good eating, it can take a few weeks to months to really start to notice the shift in your symptoms.
 16
Conditioning a Better Back Condition

Back pain is usually a conditioned result

of how you live your life. Lasting pain
relief is only possible if the conditioned
habits that lead to back pain are re-
conditioned into healthier back habits.
Retrolisthesis, disc herniations, arthritis,
stenosis, spine degeneration, inadequate
back stability and fitness, posture and
movement errors, poor nutritional states
that promote pain, inflammation and poor
healing, central sensitization, and chronic
pain don’t just develop overnight, and back
pain typically is not the sole result of a
single episode of bending over the wrong way or lifting something heavy. Back pain usually
develops over time.
Whether pain comes on during a physical exertion, slip/fall, or out of “nowhere”, the underlying
issues that have left the back susceptible to injury or pain have usually been “growing” for a long
time due to habits that have trained the back to be in a certain level of health or “condition”.
Mechanical stress is only successful in causing back injury when that stress meets a back that is
not conditioned to safely handle the stress. If the back had been properly conditioned with adequate
endurance, strength, nutrition, rest, posture, movement and stability habits, it would in most cases
safely handle the imposed load without injury. In the more rare cases of major accidental traumas,
healing would occur more rapidly and completely if the back were in better condition. Regardless
of initial cause, chronic back pains could usually be avoided if the person had optimal bio-psycho-
social influences (conditioning) on their back and nervous system.
Either way, it is how you lead your life that ultimately conditions your back to be healthy and fit,
ready to safely handle the physical demands of life, or ill-conditioned and susceptible to injury and
pain.
Whether it is regular exercise that keeps your back strong for single exertions and conditioned for
repetitive endurance, nutrition that promotes healing and protects against systemic inflammation
and excess pain, proper posture, stability and movement that avoids compensatory mechanical
back stress, frequent micro-break habits and rest from long standing spine loads, reflexive spinal
stability that safely absorbs slips and falls, or even positive thoughts, emotional responses, and
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healthy social environments that maintain optimal brain and immune function, the reality is that
your daily lifestyle habits either set your back up for being fit, or being in pain.
The “big picture” of most back pain includes what you have been exposing your back and nervous
system to for many years. What you practice on a daily basis becomes your condition.
All of these bio-psycho-social factors are modifiable, as is your present back pain condition. It all
depends on how you live your life, what you choose to prioritize and practice on a routine basis
and let become your habits. Conditioning your back is like anything else in life that becomes
habitual. What is practiced over and over again becomes your habit and strength.
Back pain conditioning can be both bad and good. You are free to choose between them every day.
The “bad” conditioning habits that perpetuate back pain include practicing poor body mechanics
that support your pain themes, inappropriate posture and rest, inflammatory nutrition, negative
outlooks and beliefs, and a lack of adequate healthy back exercise. Choosing social contexts
(groups and individuals that support healthy or unhealthy living) and physical environments
(ergonomic work stations and home furniture) that either support or weaken your total back pain
experience can be your choice as well.
Good conditioning habits include being dedicated to modifying all of the above factors to support
a healthy back, enabling your body’s innate healing and conditioning mechanism to allow you a
pain-free and fit life. So much of your back pain experience is a direct result of what you choose
to condition, and is very much self-manageable.
These controllable habits are also usually
complicated by the involuntary habit of what your
nervous system has been practicing along the
entire length of your back pain journey.
Over time, as your central nervous system
receives a prolonged bombardment of either pain
or abnormal stability/posture/movement impulses
related to your back, it takes less and less of these
impulses to mechanically stress your back and for
you to experience pain. In fact, after a while, your
nervous system becomes so well practiced at
causing mechanical errors in movement and
stability or experiencing pain, that other normal
sensations that travel along nerves (pressure,
motion) can be mistaken for pain by your central
nervous system. In short, your nerves get so much practice at dysfunctional mechanics and pain,
that you become better conditioned to feel pain and mechanically insult your back.
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While all of these factors wind up in a vicious cycle of conditioning persistent mechanical stress,
pain and re-injury, the good news is that what has been conditioned in chronic back pain can be
changed, or re-conditioned, to a better and healthier state.
It all begins with a dedication to replacing the bad habits with new habits. Your back condition is
just like any other aspect of your life- it will become what you practice. Exercise is the perfect
activity to practice several good habits that will heal and protect your back. Focused exercise that
supports avoiding your pain theme allows re-conditioning of chronic back pain into a better
condition!
Relief and protection against back pain is a normal response of the body to proper physical and
mental input. It is up to you to take the active role in providing your back and nervous system with
the proper input that supports healing, back fitness, and lasting pain relief. This input is important
not only while exercising, but throughout your day as well. There are several factors that will assist
you in this re-conditioning quest. They are as follows:
1. Decide that you have had enough of your current back condition. This is the first step needed
for change. If you are comfortable with your present condition, there will be little impetus to
change.
2. Understand what mechanical, fitness, psychological, nutritional and social factors cause pain
and how to change them.
3. Learn the pain relief techniques, corrective exercises, neutral spine stability, exercise and sports
modifications, daily postures and movements, mind-sets, and nutrition that will support healing
and back fitness.
4. Use constant variety. Change static postures and types of movements to ensure continual
variety throughout the day. Staying in one position or repeating the same movement without
variation prevents the healthy physical stimulus and circulation within back soft tissues that keeps
your spine healthy. Using a micro-break every 15-30 minutes during the day to move or position
yourself differently, even for a few minutes at a time, can be of great benefit. Incorporating variety
in your exercises will also be helpful as the more variety you use, the better prepared (conditioned)
your back will be for those unexpected demands placed on your back.
5. Explore activities and motions that may initially feel stiff or mildly discomforting, but do not
cause a full-blown pain aggravation. This will help you to begin to learn the difference between
truly irritating movements and activities versus those that are simply mildly discomforting due to
neuropathic pain. This is a huge obstacle for many chronic back pain sufferers, that once explored
and learned, can have a significant impact on overcoming back pain. Because so much of lasting
back pain relief and returning to a physical lifestyle is based on movement, exploring what you
can actually do without truly aggravating your back is paramount.
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6. Choose supportive environments to help with your back fitness conditioning. Social
frameworks, relationships, groups and physical environments that support positive and uplifting
attitudes, good ergonomics, physical fitness, good nutrition, and a healthy lifestyle will all help
you reach your goals. Replacing negative environments (both physically and socially) with
supportive ones will make your positive changes in back conditioning much more likely.
7. Planning a Strategy is essential for reaching any goal, including conquering back pain. Using
the advice given in chapter 11 will assist you in planning your individual attack on your back pain,
and help you to zero in on your specific
needs and targets while allowing for your
personal preferences and life constraints.
8. Motivation to change and attempt
different habits begins with finding your
WHY. In other words, figure out why your
back pain (and associated life related to
your pain) needs to change based on your
personal values, your goals, and your life
meaning. You will need to develop a vision
of who you are without back pain, and what
you can do in life without it, which fulfills
your deeper sense of why you are alive, and
what you bring to others and the world. You need to realize how back pain is affecting these
deepest meanings of your personal life. Thinking of why overcoming back pain is essential to your
existence will fill you with a powerful internal motivation to change. Internal motivating reasons
that are frequently visualized will far outweigh and outlast any superficial external reason to
change. Any time you find yourself lacking motivation, just go back to your vision of why you
need to change your habits.
9. Consistency is the key to overcoming back pain. It is the deciding factor between success and
failure in establishing the new habits needed for a healthy and fit back. Regardless of things that
“get in the way”, a “lack of time”, forgetfulness, tiredness, being overwhelmed, unmotivated,
unfocused, “putting it off until tomorrow”, or any other excuse/reason you can think of, following
through with changing your unhealthy back habits into healthy ones always comes down to being
consistent. It is the difference between those who “try” and those who succeed.
It is not enough to identify your why and relate it to your values and personal meaning for change.
To be consistent, you must become dedicated to being consistent, or strive to be consistent about
consistency. This dedication means that you will purposefully seek out opportunities as they arise
each day to prove your values through consistent healthy actions.
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This includes posture, neutral spine stabilization before you move and lift, performing your back
exercises, identifying negative thoughts/emotions and flipping them to positive ones, choosing the
right foods that support healing and resist systemic inflammation, and opting for the right social
and environmental contexts that will aid in your healing.
Without being mindful of the daily opportunities to change, and getting into the “game” of flipping
old habits to new ones, your “auto pilot” will continue the same old habits that have conditioned
your back to be painful and out of shape.
Don’t become overwhelmed with how much has to change. Pick a top priority and just focus on
improving that one habit to begin. Become mindful throughout the day of the opportunities to
practice the new healthy back habit. Once you master it, you can move on to tackling your next
habit that needs improvement.
It helps to make a schedule for your new habit. Setting aside intermittent times during your day
for corrective exercise, stretches, healthy eating, micro rest breaks from static postures,
visualization, etc. will create the fertile ground needed to plant your seeds of change through
repetitive practice. Sometimes, creating a chart to monitor and track your progress will be helpful.
Include a review time at the end of your day to grade your performance. It takes only a minute or
two of self-evaluation to congratulate your achievements and identify areas that need
improvement. Making weekly goals and evaluating your success at the end of each week will help
with your consistency as well.
Expect and plan for those negative thoughts and
emotions that will arise and try to pull you away
from consistency. When they arise, meet them
with your motivating why visualization that
underscores your deeper meaning of staying
consistent with your back fitness and health.
Making a game out of your mini goals for the day,
week or month by setting a number to attain is
another consistency technique that can prove very
fruitful. Set a certain number of times each day
you want to practice or change a habit. This can
include the number of times you catch yourself
in poor posture, thinking negatively, performing
your stretches, eating something healthy,
avoiding a dangerous movement, practicing your
neutral spine RPI, etc. Try to not only meet your daily quotas, but break your previous records.
The more you challenge yourself and make it a game, the more you will become consistent.
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Finally, consistency is always easier with accountability. Find an accountability partner who you
can rely on to support your new healthy habits. When you have to answer to someone else, the
respect for your consistency becomes elevated.
Self- management of back pain is ultimately the only lasting solution for any chronic retrolisthesis
back pain sufferer. Realizing that back pain is a result of how you live your life is a major reality
check for many, but is necessary to identify the way out of chronic pain. By reconditioning your
present back condition, using these various factors and techniques that change your habits, you
can take control of not only your pain, but your overall health and well-being.
 17
Putting It ALL Together

Now it is time to start putting all that you have learned together, and actually use it to help your
retrolisthesis pain. Knowledge without action is worthless. When my patients do not progress, do
not find relief, or fail to enjoy lasting relief, it is usually because they have not been consistently
using what they have learned. Some have to learn the same lesson over multiple times before they
“get it” -meaning they actually have to commit to a permanent lifestyle of posture and movement
awareness and be consistent with their conditioning exercises and spinal stability to live
comfortably with spondylolisthesis.

So how do you make the information presented in this program a permanent part of your life, and
how do you use it to obtain the quickest and most lasting relief from your pain?

First, remember the mobilization and pain relief exercises presented can be used at any time to
reduce present pain. Even if you have the most conditioned spine and perfect body mechanics,
some accidents can happen that are beyond your conditioning. That’s just life- it is impossible to
prepare for everything and anything that can come your way.

Realizing this, remember to use the pain relief exercises, and 15-20 minute towel-wrapped ice
pack applications (every 1-2 hours), along with mobilization exercises if you do have an
exacerbation of your back pain or leg symptoms. The nutritional advice given is not only for when
you have a pain episode, but is intended to be a lifestyle to protect you from pain and inflammation,
as well as many other health problems.

You may also require professional health care treatments to assist in the healing and function of
your retrolisthesis condition such as chiropractic, flexion distraction, cranio-sacral, massage and
other soft tissue treatments. You can try several of them- both the self-treatments and those
provided by health care professionals. See which work best for you. Many cases of retrolisthesis
require a combination of treatment approaches for the greatest amount of pain relief and
prevention. Because we all respond differently, do not rely on what has worked for someone else,
but see which treatments work best for you. This goes for mobilization and conditioning exercises
as well.

Learn to correct your posture and movement faults as early as you can. This alone can provide
major pain relief and injury avoidance - especially if practiced consistently over your life time.
This takes practice. While awareness and correction of posture and movement may seem difficult
at first, it becomes easier and more automatic as you continue to practice it.

Strengthening/endurance and other conditioning exercises should be a permanent and consistent

part of your life if you wish to avoid pain. There is no way around this fact. You will avoid pain
by improving posture and body mechanics, but the stability of your unique neutral spine must be
 148

strengthened and conditioned to be able to handle the various stresses that will come your way.
Conditioning exercises based on your unique stability needs are the only way to prepare your body
to resist these stresses.

Strengthening exercises should be done 2-3 times per week indefinitely. They must be progressive
until they surpass your unique physical requirements by an extra 20%. Without a gradual increase
in endurance and strength, you will never realize your potential of pain relief and protection against
injuries and exacerbations. Remember that your endurance and strength should be built up past the
level of your daily physical demands to ensure protection against the unexpected stresses of life
when they occur.

Focus on the strengthening/ conditioning exercises that help you avoid your specific pain themes,
and seem to challenge your stability the most (these are the ones that you need the most). Also
include those exercises that emulate your daily and sports activities. The big picture is choosing
exercises that strengthen your stability for your unique lifestyle. A person who must avoid anterior
pelvic tilting and extension with increased lordosis will choose certain exercises that challenge
that aspect of posture and movement. Those exercises will be different from someone else who
must work on avoiding flexion and vertical compression in their daily activities.

Be sure your weekly program includes exercises that address all of your pain themes (directions
of movement that cause pain). Keep progressing in reps, hold times, balance and speed as the
months advance, changing exercises every 1-2 months to ensure exercise variety. The more variety
you have with your strengthening exercises, the better conditioned your lower back will be, and
the greater insurance you will have against pain. When you return to a certain exercise a few
months later, you may not be able to start where you left off previously, but your goal should be
to end the next cycle of that exercise stronger than the previous cycle. Remember to keep
progressing with the overall intent to meet and then exceed your SAID exercises by 20% as they
relate to your daily physical needs.

Don’t stress if you miss a workout. Simply follow up the next day, or on your next scheduled
workout day with one. Your spinal conditioning will not fall apart if you miss a workout here and
there, but if you start to miss multiple and especially consecutive scheduled workouts, you are
heading for trouble.

Check your mental attitude. Chronic pain can be worse than it has to be when you are focused on
the pain, disability, and all the negatives you can find. A positive mental outlook that there is hope
for your condition, and that it WILL improve is very important to the healing process. Prayer and
faith, as well practicing positive visualization and meditation can be extremely helpful to aiding
your healing and decreasing central pain sensitization. Modern science is finally proving that your
spirit and mind really can change the function of the body. Most long term sufferers need to address
this.
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Being consistent with good nutrition, posture, mechanics, and conditioning exercises will sell their
value to you. Once you notice the difference in the way you feel, you won’t want to give it up.
The added benefit is that a healing exercise program sets the stage for other exercise endeavors.
Building up your lower back to avoid pain with the program exercises often naturally leads to a
full-body fitness routine designed to keep your entire body in shape.

In spite of the depth of this program, remember that you may not be able to do it all on your own.
Professional help is needed to diagnose your pain, and many times is essential to guide you through
the best approaches to it. Manipulation and soft tissue therapy may be needed to help resolve
fibrosis/scar tissue, improve spinal joint mechanics, and restore normal nerve function. Some
people have difficulty learning new motor skills and exercises. If this is the case, a trainer can
help you learn the exercises so you can perform them correctly. Others may need a trainer to
motivate them into doing their workouts, while some may require a training partner to ensure
workout consistency.

If you are having difficulty with your analysis, choosing the right exercises, designing, or
advancing your retrolisthesis exercise program, feel free to contact me through the
painfreeandfit.com website. As my clinical practice hours and patient responsibilities permit, I
am available for online exercise consultations. Pricing and further info is available at the
painfreeandfit.com website.

Many people just like you have used the information provided in this FAST TRACK PROGRAM
for RETROLISTHESIS TM to obtain a pain free and fit lifestyle with their retrolisthesis low back
condition. While results may vary based on your individual condition, almost all patients and
students that I have shared this information with, and who have implemented it on a consistent
basis, have enjoyed some substantial degree of improvement.

I sincerely hope that you do as well.

Dr. Michael C Remy, DABCO, CCSP

Diplomate American Board of Chiropractic Orthopedists
Certified Chiropractic Sports Physician
 18
References and Suggested Reading

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Spine. J Korean Neurosurg Soc 57(3): 178-184
Jeon CH et al. (2013) Degenerative Retrolisthesis Is it a compensatory mechanism for sagittal
imbalance? The Bone & Joint Journal. Sep; 95-B (9): 1244-1249
Shen M et al. (2007) Retrolisthesis and Lumbar Disc Herniation: A Pre-operative Assessment of
Patient Function. Spine J. 7(4): 406-413
Shenoy K et al. (2019) Retrolisthesis and lumbar disc herniation: a postoperative assessment of
outcomes at 8-year follow-up. Spine J. Jun;19(6):995-1000
Kang KK et al. (2013) Retrolisthesis and lumbar disc herniation: a post-operative assessment of
patient function. Spine J. 2013 Apr;13(4):367-72
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