12

BACK

Strong and flexible back muscles are essential specific muscles in either the upper or lower back.
for maintaining good posture and an adequate range Although the major muscles are located in the same
of motion, and can reduce the risk of injuries that region of the body, they are exercised with distinctly
may occur from everyday activities . Certain exer- different body movements to isolate either the upper
cises are also beneficial in easing the backaches and or lower back.
pain that are often associated with a chronic "bad The major muscle groups of the upper back are
back ." Many people with AK and BK amputation teres major and minor, trapezius, and latissimus
experience back pain . Although no proven scientific dorsi . The muscles emphasized in the exercises that
data can pinpoint the exact cause, it is believed that follow are the trapezius muscles (commonly referred
a discrepancy in leg length, poor gait habits, and to as "traps") and the latissimus dorsi muscles
improper alignment are contributing factors. (commonly referred to as "lats") . The main lower
In a 1985 study at the Bioengineering Centre at back muscle emphasized in the exercises is the
the University College London, 80 percent of a erector spinae (sacrospinalis), a large and deep
study group of people with AK amputation reported three-part muscle.
that they had back pain . The group recorded a The correct techniques for lifting weights, or
statistically greater level of leg length difference and for lifting any heavy or bulky items encountered in a
scoliosis compared with a nonamputation control normal work day, are essential in protecting the
group . The results of the study suggest that there back from injury . Some general rules are:
may be some relationship between the leg length
1. Whenever picking up a weight, the back should
difference recorded in the group with amputations be straight and the head up . Bend by flexing
and the degree of incapacity due to lower back the knees before beginning to lift . This permits
pain . ' you to lift the weight primarily with the legs
An earlier study conducted by the Veterans and not the back.
Administration included several categories affecting 2. Hold the weight or object close to your body
the veteran with a lower limb amputation . One for added support and balance . In this way,
category that was surveyed among a cross-section of there is less risk of injury through losing your
veterans with amputations, both traumatic and balance or dropping the object.
dysvascular, was back pain . Fifty-four percent of 3. Get help or use a dolly to lift or move heavy
the 81 veterans with amputation surveyed in this objects.
category complained of back pain . 2
Exercises for the back usually concentrate on
2F .T . Hoaglund, et al., "Elevation of Problems and Needs of Veteran
'A . Middleditch and P . Jarman, Assessment of the Spine in Above- Lower-Limb Amputees in the San Francisco Bay Area During the
Knee Amputees, Bioengineering Centre Report. London : University Period 1977-1980 ." Journal of Rehabilitation Research and Develop-
College London, 1985, pp . 123-128 . ment, Vol . 20, No . 1, 1983, pp . 57-71.

165
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RRDS Clinical Guide . Physical Fitness : A Guide for Individuals with Lower Limb Loss

UPPER-BACK EXERCISE ROUTINE

Muscle Exercise Title

Latissimus Dorsi 77 Bent-over Rowing

Latissimus DorsilElbow Flexors 78 Seated Rowing

Latissimus Dorsi 81 Wide-grip Front Chin-up

Latissimus Dorsi/Elbow Flexors 82 Reverse Close-grip Front Chin-up
Latissimus Dorsi/Biceps 83 Reverse Medium-grip Front Chin-up
Trapezius 84 Seated Shoulder Shrug
Trapezius 85 Standing Shoulder Shrug

LOWER-BACK EXERCISE ROUTINE

Muscle Exercise Title

Erector Spinae 86 Hyperextension

Abdominals/Hip Flexors 87 Reversed Hyperextension (Interme-
diate)
Erector Spinae/Abdominals 88 Reversed Hyperextension (Ad-
vanced)
Erector Spinae 89 Stiff-legged Barbell Dead Lift

INCREASING Always do warm-up exercises before lifting weights.

THE
Start with a minimum of 8 repetitions with a given weight . If a minimum of 8
NUMBER
repetitions cannot be completed, the weight is too heavy for you and the
OF resistance should be lowered until 8 repetitions can be completed.
REPETITIONS
When 12 repetitions can be successfully completed, the weight should be
increased by 5-10 pounds . When 12 repetitions can be completed with the
increase in pounds, the weight may be increased again.
Work up to 15-20 repetitions per set for muscle maintenance, endurance, and
tone.
When performing exercises with free weights, it is recommended that 2-6
sets for each particular muscle group be used.

CAUTION
Beginners are encouraged to use free weights with a spotter present . Certain
exercises will require a spotter regardless of skill level (e .g., squats).
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Conditioning Exercises : Back

EXERCISE 77 . BENT-OVER ROWING

PURPOSE
Develops the latissimus dorsi muscles.

PROCEDURE
n Roll the bar close to your toes.
n Keep your feet about shoulder-width apart.
n Bend over and take hold of the bar . It is best for beginners to use the grip width that is
most comfortable and then vary it with practice.
n Keep your back straight and approximately parallel with the floor . With your knees
bent slightly, inhale and lift the bar until it nearly touches the lower portion of your
chest . This exercises all portions of the lat muscle.
n Keep your head up throughout and do not flex your wrists as you pull up the bar.
Exhale as you lower the bar . Do not let the bar touch the floor during the repetitions of
the exercise.

MODIFICATION
If balance is a problem, try Seated Rowing (Exercise 78).

SKILL LEVEL
Intermediate.

Richard Hughes wears an Endolite Multiflex Ankle, which

allows the prosthetic foot to remain flat on the floor for
better stability .
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RRDS Clinical Guide . Physical Fitness : A Guide for Individuals with Lower Limb Loss

EXERCISE 78 . SEATED ROWING (SEATED TWO-ARM LAT PULL-IN)

PURPOSE
Primarily strengthens latissimus dorsi and, to a lesser degree, the elbow flexor muscles.

PROCEDURE
n Sit on the platform seat in front of the pulley.
n Bend your knees slightly, keeping your feet firmly against the foot plate.
n Grasp the pulley handles with both hands and remain in a bent-forward position.
n With arms outstretched, knees bent, and upper trunk bent forward, pull the cables in
toward the chest just below the pectorals . Inhale as you pull . To keep strict form, keep
torso erect or lean slightly forward . Lean back only on your last repetitions and only if
you would not otherwise be able to complete them.
n Exhale as you slowly lower the weights back to the starting position.
n Minimize back movements.

VARIATION
For greater muscle stretch, lean forward . This variation will also use the lower back
muscles for stabilization when bringing the torso to an upright position.

SKILL LEVEL
Intermediate.

John Everett completes the final repetitions of a demanding

set .
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Conditioning Exercises : Back

EXERCISE 79 . NAUTILUS LAT PULL-DOWN

PURPOSE
Develops the latissimus dorsi muscles.

PROCEDURE
n Adjust the height of the seat so that the weights are slightly raised off the rack when
your arms are fully extended overhead.
n Secure yourself with the seat belt . Lean forward and keep your feet on the ground for
support.
n Take hold of the bar with both hands in a firm grip. Begin by pulling the bar down
until it touches the back of your neck at a level slightly above the shoulders.
n Inhale while pulling the bar down to a count of two.
n Exhale as you slowly let the bar back up to a count of four.

SKILL LEVEL
Intermediate.

Linda Pedersen uses her feet for support as she begins to

pull the bar down .
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RRDS Clinical Guide . Physical Fitness : A Guide for Individuals with Lower Limb Loss

EXERCISE 80 . WIDE-GRIP LAT PULL-DOWN

PURPOSE
Develops the latissimus dorsi muscles.

PROCEDURE
MI Adjust the seat so that when your arms are fully extended above your head the weights
are slightly raised off the rack . (The adjustable padded section positioned across the
front of your thighs helps to hold you down when lifting heavy weights . In addition, a
spotter can exert downward force on your shoulders to keep you from coming up off
the seat .)
▪ Grasp the bar as near to its end as is comfortable.
II Pull the bar down behind your neck to a level just above your shoulders with a count
of two.
▪ Inhale while pulling the bar down and exhale while letting the bar back up to the
starting position with a count of four.

SKILL LEVEL
Intermediate .

NOTE
This is essentially the same as Exercise 79 but
on a different apparatus.

Note the use of the padded section to help hold the legs
down .
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Conditioning Exercises : Back

EXERCISE 81 . WIDE-GRIP FRONT CHIN-UP

PURPOSE
Develops the latissimus dorsi muscles.

PROCEDURE
n The overhead bar should be at least 6 inches higher than you can reach from a standing
position with your arms fully extended . Stand on a stool to reach the bar and take hold
of it with your palms facing away from you . Use a wide grip outside the width of the
shoulders.
n Hang with your arms extended at full length . Flex at the knees if necessary to keep
your feet off the platform.
n Inhale as you pull yourself up to the bar, attempting to touch it with your chin . It is
acceptable to have the back slightly hyperextended, but try to keep your body from
swinging back and forth.
n Exhale as you lower yourself back down until your arms are fully extended.

SKILL LEVEL NOTE

Advanced . If this exercise is too difficult, the Reverse
Close-Grip Front Chin-Up (Exercise 82) may be
substituted.

The AK prosthesis can be supported by the sound leg in a

flexed position, as shown by Mike Nitz .
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EXERCISE 82 . REVERSE CLOSE-GRIP FRONT CHIN-UP

PURPOSE
Develops and strengthens the latissimus dorsi and, to a lesser degree, the elbow flexors.

PROCEDURE
▪ The overhead bar should be at least 6 inches higher than you can reach from a standing
position with your arms fully extended . If this is not possible, keep your knees flexed
while lifting your body to prevent your feet from touching the platform.
• Grasp the bar with your hands about 6 to 8 inches apart and palms facing you.
▪ Inhale as you pull yourself up, attempting to touch your chin to the bar . Do not swing
or sway your body.
II Exhale as you lower yourself to the hanging position.

MODIFICATION
Use a step stool to reach the bar.

SKILL LEVEL
Advanced .

John Everett's knees are flexed to keep his feet from

touching the platform .
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Conditioning Exercises : Back

EXERCISE 83 . REVERSE MEDIUM-GRIP FRONT CHIN-UP

PURPOSE
Develops the latissimus dorsi muscles and, to a lesser degree, the biceps.

PROCEDURE
n Adjust the bar so that you must stretch to reach it . Your feet should not touch the
floor when you hang with your arms fully extended.
n Grasp the bar ; grip with palms facing you . (Your hands should be about 10-12 inches
apart, not wider than your shoulders .) Raise up at least until your chin touches the bar.
n Flexing at the hips helps to maintain the body position.
n Pause momentarily in the top position and then lower yourself slowly to the floor.
Inhale as you pull yourself up and exhale as you return to the starting position.

MODIFICATION
In order to reach the bar, some individuals may need to use a step stool or have a spotter
help them.

SKILL LEVEL
Advanced .

Samantha Ellis flexes slightly at the

hips as she rests momentarily at the
top position .
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RnooClinical Guide . Physical Fitness : A Guide for Individuals with Lower Limb Loss

EXERCISE 84 . SEATED SHOULDER SHRUG

PURPOSE
Develops the trapezius muscles.

PROCEDURE
El Grasp the dumbbells in each hand with your palms facing your body, and take a seated
position at the end of the bench.
N~ Keep your back straight, head up, feet approximately 8-10 inches apart, with your arms
hanging at your sides . As you begin each repetition, allow your shoulders to drop as
low as possible with the weight of the dumbbells.
• Inhale and raise your shoulders as high as you can ; bring your shoulders up to your
ears . Keep your arms fully extended and down at your sides.
• Exhale as you lower your shoulders and arms to the starting position.

VARIATION
Roll the shoulders in a circular motion front to back and then back to front.

MODIFICATION
Keep the prosthesis slightly forward with
pressure on the heel to help you push against
the floor and stabilize your balance when
lifting weights from the seated position.

SKILL LEVEL
Intermediate.

Mike Nitz demonstrates a Seated Shoulder Shrug position

with 100-pound dumbbells .
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Conditioning Exercises : Back

EXERCISE 85 . STANDING SHOULDER SHRUG

PURPOSE
Develops the trapezius muscles.

PROCEDURE
n Bend your knees and pick up the dumbbells from the floor, using your legs to lift the
weight.
n Stand erect and hold the dumbbells by your sides with arms extended at full length,
back straight, and feet about shoulder-width apart.
n Allow your shoulders to drop as low as possible with the weight of the dumbbells.
n Inhale as you raise your shoulders in an attempt to touch your ears . Do not bend the
elbows.
n Exhale as you lower your shoulders to the starting position.
n When the desired number of exercise sets is completed, keep your head up, your back
straight, and bend at the knees as you lower the weights to the floor.

VARIATION
Roll the shoulders in a circular motion front to back and then back to front.

MODIFICATION
If standing balance is a problem,
choose the Seated Shoulder Shrug
(Exercise 84).

SKILL LEVEL
Intermediate.

John Everett demonstrates the exercise .

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RRDS Clinical Guide . Physical Fitness : A Guide for Individuals with Lower Limb Loss

EXERCISE 86 . HYPEREXTENSION

PURPOSE
Develops lower back strength.

PROCEDURE
n Climb onto the hyperextension bench in a face-down position, with your lower
abdomen and hips resting on the support above the hand bars . Grasp the hand bars for
balance while getting into position.
n Your legs should be outstretched between the two leg support bars . To help maintain
body position, the legs are held down by the upper padded bar.
n Lower your torso, let go of the hand bars, and fold your arms across your chest, as
demonstrated by Linda Pedersen in the photo.
n Raise your trunk up until your body is about parallel with the floor . The arms may be
folded across the chest, outstretched toward the feet, or out to the side.
n Arch your back and raise your body beyond the parallel position ; then lower yourself
down slowly as in the photo and repeat the sequence.
n As you advance in your physical conditioning, you may raise your back slightly beyond
the parallel position, as shown in the photo.
n Inhale while raising your body and exhale while lowering it.

VARIATIONS
For an enhanced workout, perform one or more of the following steps : 1) hold the body
in the up position for a few seconds, then lower yourself down slowly ; 2) hold a weight
behind the head or against the chest (whichever is more comfortable) ; 3) twist to each side
(left, center, then right), alternating on each repetition ; 4) hold the hands behind the head
during the entire exercise . The hands may be held against the chest when starting and out
to the sides as the exercise is completed (this may be easier for the beginner) . The
important thing is not to let the arms swing back and forth during the exercise.

SKILL LEVEL
Intermediate .

NOTE
Beginners should be instructed on how to get into the proper position on the hyperextension
bench without the danger of falling or straining . Start with the position demonstrated and
work up to the position shown as the back muscles are strengthened . Assistance may be
needed in positioning an AK or BK prosthesis between the support bars . To rest between
sets, turn over and sit up on the bench, support your weight with your arms, or step
completely out of the apparatus .
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Conditioning Exercises: Back

CAUTION
This exercise should be performed at each
individual's tolerance level, starting with a
limited range of motion . This exercise is not
recommended for people with previous back
injury.

Linda Pedersen demonstrates the Hyperextension

Exercise .
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RHOS Clinical Guide . Physical Fitness : A Guide for Individuals with Lower Limb Loss

EXERCISE 87 . REVERSED HYPEREXTENSION (INTERMEDIATE)

PURPOSE
Strengthens and stretches the abdominal muscles and hip flexors.

PROCEDURE
D~ Sit on top of the hyperextension bench and place your feet underneath the leg supports.
01 Balance yourself by holding the side bars . Make sure your feet are securely positioned
under the support bar.
U~ Slowly lower yourself backward and down until your hands reach the floor.
Ol Hold this position to stretch the abdominals . Bring yourself back to an upright position
by doing a sit-up or by having a spotter help you.

MODIFICATION
Use auxiliary suspension such as a cuff strap with a waistbelt or a latex suspension sleeve
to hold the prosthetic leg on.

SKILL LEVEL
Intermediate .

CAUTION
This exercise is not recommended for people with previous back injury . Beginners should
have an assistant to help them lower and raise the torso mndl they can do it by themselves
without risk.

John Everett demonstrates the reverse of the position shown in Exercise 86 . He can
stretch the low back and also perform sit-ups from this position . (You may not want
to drop down this far in order to do sit-ups .)
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Conditioning Exercises : Back

EXERCISE 88 . REVERSED HYPEREXTENSION (ADVANCED)

PURPOSE
Strengthens and stretches the lower back and, to a lesser degree, the abdominal muscles.
Attempt only after noting carefully the caution statement below.

PROCEDURE
n Perform the first three steps from Exercise 87 (Intermediate Reversed Hyperextension).
When your hands reach the floor, walk your fingers across the floor until you reach the
center post (or as close as possible).
n For each 6-12 inches of finger-walking, hold the position 10-20 seconds . This slow
development of the stretch will allow you to progress in a safe manner.
n Make sure to keep your head back . Make sure you have positioned yourself so that the
coccyx or lumbosacral spine are not impinged by the bench . Breathe naturally while
extending.

MODIFICATION
Use auxiliary suspension if necessary to hold the prosthetic leg on.

SKILL LEVEL
Advanced .

CAUTION
This exercise is not recommended for people with previous back injury . It is recommended
only for those who have had previous conditioning in lower back exercises.

Albert Rappoport demonstrates the advanced position . He uses the ActivSleeve

Suspension System for this exercise because the inner ribs prevent the sleeve from
slipping on the thigh . Its rubber material stretches so that a full range of motion can
be achieved .
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RRDS Clinical Guide . Physical Fitness : A Guide for Individuals with Lower Limb Loss

EXERCISE 89 . STIFF-LEGGED BARBELL DEAD LIFT

PURPOSE
Strengthens the muscles of the lower back.

PROCEDURE
n Roll the barbell to nearly touch your shins so that your feet are under the bar.
n Position your feet about shoulder-width apart . Do not bend your knees while doing the
exercise.
n Bend from the waist and grasp the bar with an alternated hand grip (i .e., one palm
facing toward you, the other away from you) . The alternated hand grip is safest,
especially when using heavier weights, because the bar is balanced and it is more
difficult for the barbell to slip out of your hands . Hold the bar with your hands about
shoulder-width apart, just outside the width of your feet.
n With legs and back straight, hands in position, and head up, inhale and lift the weight
until you are standing erect.
n Pause momentarily, keeping your arms straight with no bend at your elbows . (Flexing
the elbows decreases the strengthening effect on the back muscles .)
n Exhale as you lower the weight back to the floor, maintaining the straight-legged
position . It is acceptable for your arms to slightly touch the sides of your legs while
lifting and lowering the weight.

VARIATIONS
— If lifting straight-legged is too difficult, use the bent-knee technique for dead lifts,
keeping the back straight, the knees slightly bent, and lifting with the thighs and back.
— For a more intense workout, do not rest the weight on the floor—only touch it down
before lifting it back up.
— Another form of the Straight-Legged Dead Lift requires the person to stand on top of
a weight bench or low platform in order to lower the weight to a level below the feet for a
greater range of motion.

SKILL LEVEL
Intermediate to Advanced .

NOTE
Whenever lifting heavy weights, it is advisable to use a weight belt to prevent injury and to
take some of the stress off the lower back . However, in the photographed demonstration no
weight belt is used because the lifter is trying to emphasize his back muscles to a greater
extent . Only experienced lifters should use this technique and do so with caution . The
weights should be increased gradually and only if one trains on a regular basis . Remember,
even experienced lifters can injure themselves by not warming up, by not following strict
form, by not using a spotter, and by increasing the weight beyond their known capabilities .
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Conditioning Exercises : Back

CAUTION
This exercise is not recommended for those with previous back injury . Beginners should start
with bent knees when lifting the barbell.

Albert Rappoport is working out with 305 pounds .

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RRDS Clinical Guide . Physical Fitness : A Guide for Individuals with Lower Limb Loss

STEVE WILBER/SEATTLE, WA
Opponents face off in a game of crutch soccer .