Effects of Prone Spinal Extension Exercise on Passive Lumbar Extension Range of Motion Richard L Smith and David B Mell

PHYS THER. 1987; 67:1517-1521.

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4-6 we expected to observe an increase in passive extension ROM in both male and female subjects performing the exercises.8 McKenzie's extension principle for dysfunction is based on increasing ROM by stretching the shortened periarticular tissues and returning them to their original length. Eighteen healthy female and 18 healthy male volunteers were divided randomly into control groups (women. This article was submitted March 31. was to determine the effects of passive lumbar extension exercises. therefore. Lumbosacral region. fascia. Recent studies of reduced spinal motion1 and the long-term development of restricted ROM in patients with persistent low back trouble2 acknowledge the importance of lumbar mobility in the prognosis of patients' functional capacity.11 Flattening the lumbar spine. when this study was conducted. 1987. Adults who are not engaged actively in spinal stretching activities should show a gain in spinal ROM if they follow a specific stretching regimen.3 on passive lumbar extension ROM in healthy young adults. Although these exercises are administered to patients with lumbar dysfunction accompanied with pain. University of Montana. muscles. We used spondylometry to measure lumbar extension ROM. Spokane. He was a senior physical therapy student. correct the dysfunction syndrome. MT 59812. We suggest further studies to examine the effects of lumbar extension exercises on patients with restricted ROM and low back pain.9 McKenzie suggested passive lumbar extension exercises to accentuate momentarily the lordosis and. n = 10). whereas passive hyperextension exercises10 and maintenance of lordosis could move the disk away from these structures. men. MT 59801 (USA). Because reduced ROM may be the result of shortened soft tissue (ie. and was accepted February 3. Analysis of the data revealed no significant difference between the female groups. University of Montana. was with the authors for revision 21 weeks. Recovery of lumbar ROM is prognostic for patients with low back pain. in his study of the lumbar disk. Nachemson. we believe examining the effects of extension exercises on healthy adults is a logical first step toMr. thus. when this study was completed.3. October 1987 Downloaded from http://ptjournal. specifically McKenzie's extension-in-lying exercise.8 This habitual posture of lumbar flexion. McKenzie hypothesized. Maintenance of the lumbar lordosis may provide a prophylactic safeguard against intervertebral disk protrusion. ligaments. designated by Mennell as a loss of involuntary movement. Key Words: Exercise therapy. The experimental groups performed 20 repetitions of a prone extension exercise each day for four weeks. ward understanding this therapeutic intervention.Effects of Prone Spinal Extension Exercise on Passive Lumbar Extension Range of Motion RICHARD L. Sacred Heart Medical Center. Mr. 2013 .025) in the passive lumbar extension ROM between the male experimental and control groups preventing a loss of spinal mobility in the men who exercised.10 Posteriorly directed disks may exert pressure on pain-sensitive structures resulting in low back pain. Physical therapists routinely evaluate lumbar spinal mobility in patients with spinal disorders and often administer specific therapeutic regimens to increase lumbar extension range of motion in patients with restricted ROM and pain. we found no evidence in the literature that these exercises increase lumbar extension ROM in either patients or healthy individuals.7 Many individuals lead a sedentary life style and remain seated for long periods of time with the trunk held in lumbar flexion.org/ by guest on September 15. McKenzie described a resulting dysfunction syndrome characterized by adaptive shortening of soft tissue and a partial loss of movement of the lumbar spine. n = 8) and experimental groups (women. WA 99204. MELL The purpose of this study was to determine the effectiveness of prone spinal extension exercises for increasing passive lumbar extension range of motion in healthy young adults. joint capsules. The results are discussed in light of the clinical significance of lumbar extension ROM. Physical therapy. Lack of exercise and poor posture are two causes of dysfunction.apta. Spine. resulted in increased pressure on the disk. in the lumbar spine. found high tangential strains in the posterior part of the annulus fibrosus of lumbar disks in subjects who sit unsupported or lean forward during sitting and standing and less disk pressure the more the lumbar spine was moved toward lordosis. Missoula. 1986. 101 Eighth Ave W. Saunders described a similar lumbar flexion syndrome characterized by the reduction of lumbar extension. Physical Therapy Program. n = 8. n = 10. Smith is a self-employed physical therapist. The exercises produced a significant difference (p < . Missoula. men. Potential Conflict of Interest: 2. SMITH and DAVID B. 645 E Central Ave. He was Visiting Assistant Professor. and skin)4 and because stretching increases tissue mobility and results in increased ROM. the control groups did not. The purpose of this study.10 Cyriax postulated that the lumbar lordosis serves to protect the posterior longitudinal ligament from excessive strain and exerts anteriorly directed pressure on the intervertebral disk. or loss of the lumbar lordosis. Although the lumbar extension exercise regimen is used often by physical therapists.3. Physical Therapy Services. Mell is a physical therapist. results in reduced periarticular tissue length and elasticity and loss of mobility. The 1517 Volume 67 / Number 10.

1). to examine the reliability of measuring prone spinal extension ROM using the spondylometer.) took three separate measurements on each of 6 subjects on the same day. We considered the spondylometer to be an appropriate instrument for measuring lumbar spinal extension ROM because the design of the spondylometer allowed lumbar intervertebral joint movement to have a greater effect than thoracic joint movement on the measurement reading. these ROM data were considered to be ordinal and were analyzed accordingly.S. 2013 . Instrumentation We used a spondylometer to measure lumbar extension ROM. these orthopedic diseases and faulty postural positions result in muscular.4 Range 19-26 21-31 19-28 19-29 180 179 165 171 Height (cm) s 7 6 3 8 Range 170-193 170-188 160-170 163-191 78 81 63 67 Weight (kg) s 6 11 6 11 Range 68-86 68-104 54-73 53-87 Human Research. therefore.2 3.15 and active spinal extension exercises have been associated with reduced occurrence of vertebral wedging and compression fractures in patients with postmenopausal osteoporosis.1 21. The two rubber feet of the protractor straddled the PHYSICAL THERAPY *Camp International. Based on their medical histories.* a pelvic fixation pad.17 From a biomechanical standpoint.B.14 Lumbar extension therapy plays an adjunctive role in the management of arthritis and related rheumatic disorders. The study was approved by the university's Institutional Review Board for Fig.). TABLE 1 Characteristics of Groups Age (yr) Group Experimental men (n = 10) Control men (n = 8) Experimental women (n = 8) Control women (n = 10) s 21.9 22.apta. One tester (R. The subject group selection was known only by one of us (D.19 One of us (R. and related soft tissue disorders of the lumbar spine that may be helped by passive ROM exercises. ligamentous. 1. 1518 Downloaded from http://ptjournal. and the two control groups consisted of 8 men and 10 women. the angle between the arms of the spondylometer and the index of spinal mobility decreased slightly on extension. Jackson.4 3.18 The ROM measurement provided a measure of spinal mobility and did not represent the sum of the angles of movement occurring at each intervertebral joint. respectively.6 cm long and were bent 12. The two experimental groups consisted of 10 men and 8 women. was used to stabilize the subject's pelvis during spinal extension ROM measurement.8 cm apart. we assumed all subjects had normal ROM.L.M. so we replaced it with a seat belt (Fig. MI 49201.7 23. They were asked to maintain their current level of activity for the duration of the study. performance of passive extension exercises by healthy individuals possibly may maintain lumbar ROM and prevent low back dysfunction. indicating that the method is very reliable. 109 W Washington Ave.16 The "sway-back" and "flat-back" postures involve a loss of lumbar lordosis*.12 The ability to achieve lumbar extension in the acute phase has been shown to be predictive of resolution of low back pain syndrome. a cephalic foot and a caudal foot. Two rubber feet. The free end of one rod carried a pointer that moved over the scale of a protractor joined at the midpoint of its base.6 cm in diameter and connected at a central hinge joint. Inc. A modified Spinex Maxi®. All subjects were oriented to the study and gave their informed consent.results of a recent study documented the effects of the McKenzie protocol in decreasing low back pain and increasing lumbar flexion and lateral flexion ROM. We found that the METHOD Subjects Thirty-six male and female student volunteers at the University of Montana participated in this study. Procedure We conducted a pilot study of a group of 6 untrained subjects. The other rod terminated in a small rubber knob (Fig. The 180-degree protractor is marked in 1-degree increments.7 cm from their free ends through an angle of 35 degrees. 2).17 Kendall and McCreary defined sway-back posture as an increased flexion of the lumbar spine caused by a posterior deviation of the upper trunk. pad's standard stabilizing strap interfered with the measurement. 1). Eighteen men and 18 women without a history of back injuries or low back pain within the previous six months were divided randomly into control and experimental groups by the flip of a coin. different from the 36 subjects in the experimental and control groups.18 The spondylometer consisted of two steel rods that were 0. were fastened to the base of the protractor 6. Furthermore. All subjects lay prone on the Spinex Maxi® with their pelvis stabilized by the belt over their sacrum.5 1. Spondylometer used to measure prone thoracolumbar extension range of motion. Although differences may exist between normal ROM and ideal ROM.) measured all subjects between 1 PM and 5 PM using the same procedure for the duration of the study. respectively (Tab.L. we believe that healthy individuals not actively engaged in spinal stretching can increase their ROM with a specific stretching regimen.8 3.13 whereas marked limitation of extension reproducing lower extremity pain is considered to be a poor prognosis. The intraclass correlation coefficient was calculated to be 94.18 Because of the variable movement of the central hinge joint. The rods were 40.org/ by guest on September 15.S.

025).ROM Group s Experimental (n = 10) Control (n = 8) a Final ROM s 44.1 9. was completed in about two minutes.TABLE 2 Descriptive Data for Initial and Final Range of Motion and Range-of-Motion Differences for Male Subjectsa Initial.0 Absolute values measured in degrees. possibly preventing loss of lumbar extension ROM and re1519 Fig.apta. Their Mann-Whitney U test value was 35 (critical value = 21) and. Exercise compliance was not related to a change in ROM (Spearman's correlation coefficient r = . the ROM values were standardized according to the height of each subject and analyzed as with the absolute values. This group was measured an average of 28.3 These subjects were asked to perform the exercise 20 times at one setting each day for four weeks. In a few subjects.05 level of significance was attained for the men. moving the hands toward the hips ensured maximal passive lumbar extension. The level of significance was set at . The subjects were given charts to record their exercises and were contacted weekly to help ensure compliance with the exercises. although the men who exercised gained an average of 1.5 days (range = 28-30 days) after the initial measurement.0 -3. We did not specify a time of day to exercise. 2. These results suggest that prone extension exercises should be performed during periods of sedentary activity. all subjects were instructed to lie with their arms by their sides and the weight of their heads on their chin with their nose just touching the pad (Fig.4 43.8 degrees between the female groups. and the cephalic foot of the protractor was placed over the fifth lumbar intervertebral disk space. but not for the women. 2013 . belt. The subjects in the control groups were instructed to go about their normal daily activities. they were instructed to place their hands near their shoulders.35) and did not affect the outcome. After four weeks. to straighten their arms as if they were performing a Volume 67 / Number 10. 2).4 4.1 Change in ROM s 1. Data Analysis We used a one-tailed Mann-Whitney U test20 to determine whether the change in extension ROM in the experimental groups was significantly different than in the control groups. The Mann-Whitney U test value of 18 (critical value = 21) indicated that this difference was statistically significant (p < . RESULTS The ROM data obtained from the male experimental and control groups RESEARCH and the female experimental and control groups are presented in Tables 2 and 3. Further analysis of the mean change in ROM for the male groups revealed that. Two practice movements were performed.0 11. therefore. and to stretch back to their painless physiologic limit (Fig. The measurement at the end of the ROM was recorded. push-up. the subjects in all groups were measured again using the same procedure.9 days (range = 27-32 days) after the initial measurement.3 38. and then two ROM measurements were recorded and averaged. The knob at the other free end of the spondylometer was placed over the seventh cervical spinous process (Fig.4 degrees of ROM (Tab. spending much of the time in sitting positions during the day in class and at night studying.05.5 days (range = 26-39 days) after the initial measurement. Analysis of the data standardized for height revealed no significant difference in the results for either men or women. The subjects in the male control group were measured an average of 28. Data were analyzed using the absolute ROM values. The subjects in the experimental groups were instructed to perform McKenzie's passive spinal extension-inlying exercise. The study was conducted during the winter quarter at the University of Montana.2% (range = 57%100%) of the days of the exercise program. 2). The passive lumbar extension ROM increased in the male experimental group and decreased in the male control group. the control group actually lost 3. 3). October 1987 Downloaded from http://ptjournal.8 days (range = 28-31 days) after the initial measurement. The average difference in extension ROM was 0. The subjects in the male experimental group were compliant and performed the exercises for an average of 82. 3. Subject in extension position for end measurement of prone spinal extension range of motion. Subject in position for the initial measurement of prone spinal extension range of motion. to exhale. For the extension position measurement.0 degree of ROM.05 level. Fig. and the difference between this value and the initial measurement represented the spinal extension ROM.org/ by guest on September 15.8 10. They were instructed to complete and hold each repetition of the extension position for five seconds. respectively. therefore. 2). DISCUSSION The critical Mann-Whitney U test value at the . The subjects in the female experimental group had an average compliance rate of 90% (range = 82%-96%) and were measured an average of 29.8 2. and the student subjects thus may have entered a relatively sedentary period of time. For the initial measurement. no significant difference was found at the . Because extension ROM may be influenced by the length of the trunk.6 41. The exercise regimen. Subjects in the female control group were measured an average of 28.4 7.

3 43. restricted extension ROM has not been associated clearly with spinal dysfunction. University of Montana.1. We observed female extension ROM to slightly exceed male ROM (statistically insignificant) (Tabs. and variations in activity levels may have confounded the results. The results demonstrate that healthy men. Additional studies are needed to examine the relationship of spinal ROM and spinal dysfunction. male adults. in addition to consistent stabilization of the pelvis and standardized instructions to each subject. female adults performing the exercises.21 documented no significant extension ROM difference between sexes in 15. Restricted spinal mobility has been associated with degenerative joint changes4 and low back TABLE 3 Descriptive Data for Initial and Final Range of Motion and Range-of-Motion Differences for Female Subjects* Initial ROM Group Final ROM Change in ROM s s 47.6 5. Accurate monitoring of activities may be necessary to study this possibility. Our ROM data are consistent with ROM values reported for men and women in other studies. hyperextension of the lumbar segment may cause overriding and subluxation of the posterior joints. larger scale studies are needed to provide a clearer understanding of the effects of spinal stretching on spinal ROM. CONCLUSION Prone lumbar extension exercises performed for two minutes each day for four weeks may have prevented a decrease in passive lumbar extension ROM in healthy.6 43. for their valuable editorial suggestions and assistance with the statistical analysis. pain.3 An exercise routine including transient pain may be necessary for a gain in passive extension ROM. 3). University of Montana. We were surprised that the subjects in the experimental groups did not increase significantly their passive extension ROM.3 -0. We instructed the subjects to stretch to the maximum limit of extension without causing pain. 1520 Downloaded from http://ptjournal. We suggest that further studies be conducted of the effects of passive lumbar extension exercises on subjects of different ages and on patients with spinal dysfunction and restricted ROM. Movement patterns may be diag- nostic of ankylosing spondylitis18 and discogenic low back pain. The reasons why extension ROM in the women did not improve may include sex differences in soft tissue bulk and elasticity.18 and Moll et al.org/ by guest on September 15. Acknowledgments. young. and possibly patients with limited extension ROM. can maintain their extension ROM by performing this prone extension exercise. For example.0 16. We believe that patients with decreased ROM because of soft tissue shortening are more likely to demonstrate a change in ROM than healthy individuals.22 Soft tissue injuries often cause ROM restriction.0 8. PhD. precise palpation of bony landmarks and placement of the instrument. Abdominal or hip flexor muscle tightness may restrict lumbar extension ROM. Even though the belief is widespread that restricted spinal mobility develops in patients with low back pain.7 Absolute values measured in degrees.ducing the potential for low back pain. using spondylometry in the standing position. Furthermore. Although gravity may affect the passive extension ROM in both prone and standing positions.to 24-year-old adults. The accuracy of spondylometry depends on many variables and requires a skilled user to detect small differences in ROM. passive lumbar extension exercises seem to be appropriate for young adults with decreased range of this important motion. Although our subjects were healthy young adults with apparently normal ROM.7 5. Our observations indicated that the more active subjects did not demonstrate as much change in ROM as did the relatively inactive subjects.4 3.2 s 0. who are susceptible to losing spinal motion as a result of inactivity.5 Experimental (n = 8) Control (n = 10) a 47. Extension ROM did not significantly change in healthy. whereas McKenzie suggested that stretching should result in a brief increase of central back pain. our normative extension mobility data may serve as baseline data for determining appropriate extension treatment strategies for young patients with low back pain.0 13.apta. Sagittal lumbar mobility should be assessed carefully by the clinician to determine possible biomechanical problems. Sturrock et al. for typing the manuscript. young.10 Macnab warned that if degenerative disk changes cause a loss of elasticity in the anterior annular fibers.2 A regimen of spinal stretching exercises may help prevent these conditions. Typing/Word Processing Services. and the effects of lumbar extension exercises on lumbar spines with reduced ROM. The activity levels of the subjects in the experimental groups may have been different than the activity levels of the subjects in the control groups. The small number of subjects examined also may have influenced the results. 2013 PHYSICAL THERAPY . We also thank Neile Graham. contributed to accurate measurements in this study. Lumbar extension exercises also might result in significant change in ROM when performed by older persons or by those with pathological problems and decreased lumbar extension ROM. spondylometry had good reliability for measuring passive lumbar extension ROM in the prone position and thus should be considered for clinical use. This lack of an increase may be explained partially by our exercise guidelines or by the small sample size. Further research is necessary to explore these possibilities. 2. These findings also suggest that young women with a change in passive lumbar extension ROM may require a different exercise regimen than that of young men. using a tape measure method. We thank Richard Gajdosik and Kathleen Miller.

1984. vol 1. McKenzie RA: Prophylaxis in recurrent low back pain. Williams & Wilkins. pp 84-91 Volume 67 / Number 10. Munns K: Effects of exercise on the range of joint motion in elderly subjects. October 1987 Downloaded from http://ptjournal. Boston. vol 2. Swezey R: Joint stiffness: Effects of exercise on young and old men. John Wiley & Sons Inc. Butterworth Publishers. Wright V: An objective clinical method to measure spinal extension. Scand J Rehabil Med 17:1-4. New York. 1984. 407-413. Wojtulewski JA. MD. 57. 1981. Macnab I: Backache. Williams & Wilkins. pp 161-165 20.RESEARCH REFERENCES 1. Saunders HD: Evaluation. pp 192-195 16. Sinaki M. Little. Waikanae. 1984 17. Spinal Publications Ltd. Hamberg J: Muscle Stretching in Manual Therapy: The Spinal Column and the Temporo-Mandibular Joint. NJ. Enslow Publishers.1973 19. Jensen GJ. pp 284-285. 1972 22. p 172 15. 1984 13. pp 401-405 21. ed 3. Rheumatol Rehabil 14:129149. Alfta. 1985 2. deVries HA. 473-482. Mennell JM: Back Pain: Diagnosis and Treatment Using Manipulative Techniques. Rheumatol Rehabil 11:293-312. Hillside. Nachemson A: Towards a better understanding of low-back pain: A review of the mechanics of the lumbar disc.org/ by guest on September 15. MA. In Smith EL. 1984 3. Moll JMH. 1977. ed 3. Stadt RJ. Brown & Co. England. NZ Med J 89:22-23. Ponte DJ. Mikkelsen BA: Postmenopausal spinal osteoporosis: Flexion versus extension exercises. p 99 10. et al: Predictive value of the physical examination for patients with discogenic low back pain. 1983. ed 2. MD. ed 7. 1984. MD. Cyriax J: Textbook of Orthopaedic Medicine: Diagnosis of Soft Tissue Lesions. Minneapolis. McCreary EK: Muscles: Testing and Function. Daniel WW: Biostatistics: A Foundation for Analysis in the Health Sciences. 1978. Treatment and Prevention of Musculoskeletal Disorders. Surgical Forum 33:532-534. Rheumatol Rehabil 12:135142. pp 25. pp 7-13 5. Biering-Sorensen F: Physical measurements as risk indicators for low-back trouble over a oneyear period. Baltimore. Levrini MG. J Gerontol 27:218-221.apta. Journal of Orthopaedic and Sports Physical Therapy 6:130-139. MA. 288 18. Serfass RC (eds): Exercise and Aging: The Scientific Basis. 1960. 1979. Hart FD: Spondylometry in a normal population and in ankylosing spondylitis. NY. pp 345. Baltimore. ed 4. 1983. 103 4. MA. 535 11. London. New Zealand. 1984. Chapman EA. 1975 12. McKenzie RA: The Lumbar Spine: Mechanical Diagnosis and Therapy. 1972 6. Kendall FP. Gall EP (eds): Rheumatic Diseases: Rehabilitation and Management. The Viking Press. Spine 9:106-119. pp 167-178 7. 1985. Boston. Butterworth Publishers. pp 23-29 8. Baltimore. Sturrock RD. MN. Sweden. Riggs GK. 2013 1521 . 9. Kent BE: A preliminary report on the use of the McKenzie protocol versus Williams protocol in the treatment of low back pain. Arch Phys Med Rehabil 65:593596. Maitland GD: Vertebral Manipulation. Korst JK: The natural history of idiopathic low back pain. Williams & Wilkins. Turocy RH. Baillière Tindall. 1982 14. Liyanage SP. Boston. Kopp JR. Alfta Rehab Förlag. 1981. Evjenth O. Lankhorst GJ. Currier DP: Elements of Research in Physical Therapy.

Effects of Prone Spinal Extension Exercise on Passive Lumbar Extension Range of Motion Richard L Smith and David B Mell PHYS THER.xhtml Information for Authors http://ptjournal.apta.apta. Subscription Information http://ptjournal.org/site/misc/terms.org/ by guest on September 15.apta. 1987.org/subscriptions/ Permissions and Reprints http://ptjournal. 67:1517-1521.apta.xhtml Downloaded from http://ptjournal. 2013 .org/site/misc/ifora.

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