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Dutton's Orthopaedic Examination, Evaluation, and Intervention, 4e

CHAPTER 28: Lumbar Spine

WILLIAMS FLEXION EXERCISES

Dr. Paul Williams first published his exercise program in 1937 for patients with chronic LBP, in response to his
clinical observation that the majority of patients who experienced LBP had degenerative vertebrae
secondary to degenerative disk disease. According to Williams, “Man, in forcing his body to stand erect,
severely deforms the spine, redistributing body weight to the back edges of the IVDs in both the low back and
neck.”488

Conceptually, Williams believed that the goal of exercise was to reduce the lumbar lordosis or to flatten the
back through strengthening exercises for the abdominal muscles (to li the pelvis from the front) and
strengthening exercises for the gluteal muscles (to pull the back of the pelvis down). Williams designed a
group of six exercises to address these issues:

1. Trunk flexion or sit-up. Although the instructions that Williams gave to perform this exercise were
erroneous, a variation of this exercise, the crunch, forms the cornerstone of many modern exercise
protocols.

2. Posterior pelvic tilt. With the exception of patients with IVD lesions,494 the posterior pelvic tilt exercise,
outlined later, is still widely recommended. However, due to the fact that they can cause increased
compression loads on the lumbar spine,495 they should be prescribed with caution.

3. Trunk flexion or bilateral knees to chest. Like the posterior pelvic tilt exercise, this exercise is not
recommended for patients with IVD lesions. However, it may provide comfort to patients with spinal
lateral recess stenosis.

4. Long sit and reach. This exercise is no longer recommended because of the stress it places on the so
tissues of the low back. Williams himself acknowledged that this exercise would not be appropriate for
patients with sciatica.

5. Iliotibial band stretch in the front lunge position. Although adaptive shortening of the iliotibial band may
be a contributing factor in LBP, as suggested by Williams, better stretches for this structure exist.

6. Stand to squat or stand to sit. This exercise was recommended because of its ability to strengthen the
gluteal muscles. This exercise has since been incorporated into many spinal stabilization protocols.

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Although the use of William's exercises has decreased over the years, the exercises are still indicated for
those patients who experience an increase in symptoms when moving into spinal extension, and in those
cases where the goal is to widen the intervertebral foramina (lumbar spinal lateral recess stenosis) and gap
the zygapophyseal (facet) joints temporarily, thereby reducing nerve root compression.

McKenzie Approach

In many respects, the McKenzie approach (see also Chapter 22) contradicts Williams basic assertions that the
lumbar lordosis is harmful. McKenzie initially theorized that the development of LBP is primarily due to three
predisposing factors: prolonged sitting in the flexed position, the frequency of flexion, and a lack of extension
range.282 As a result, the early versions of the McKenzie approach focused on regaining spinal extension. The
McKenzie approach has since developed into a system that uses physical signs, symptom behavior, and their
relation to end-range lumbar test movements to determine appropriate classification and intervention.

The physical examination component of the McKenzie method involves a comprehensive assessment of the
patient, performed in a series of active and passive movements performed in the beginning, middle, and end
ranges of trunk flexion, extension, and combinations of side bending and rotation called side gliding.282 The
same maneuvers are repeated with the trunk in the neutral position, shi ed toward the side of pathology,
and away from pathology. The intent is to gauge the responses, reactions, or e ects of spinal loading, and for
the presence of the centralization phenomenon. The patient's response to the examination determines a
classification and the direction of preference for therapeutic exercise, with the direction chosen being based
on the ability of the position or movement to centralize the patient's symptoms. The end-range exercises
theoretically move the NP away from the side of compression loading, with flexion exercises moving the NP
posteriorly and extension exercises moving the NP anteriorly.282,496–501 The midrange exercises are better
suited for patients with symptoms of neural compression.502 Postural correction and maintenance of a
normal lordosis are also integral parts of the McKenzie program.

Long et al.503 investigated whether a McKenzie examination and follow-up on 312 patients with acute,
subacute, and chronic LBP would elicit a directional preference in these patients. Of the 312 patients, 230
participants (74%) had a directional preference, and these patients were randomized into groups of
directional exercises matching the patient's directional preference, directional exercises opposite the
patient's directional preference, or nondirectional exercises. Significant reductions in pain, pain medication
use, and disability occurred in the directional exercise group that was matched by their directional
preference.

The three major classifications or syndromes are postural, dysfunction, and derangement. Strategically
speaking, when utilizing McKenzie protocols, one should rule out a derangement first before treating
anything else.

Postural Syndrome

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The key characteristics of the postural syndrome are490

intermittent pain;

the time factor;

pain produced by the maintenance of posture/position;

symptoms provoked by position, but not by movement;

no deformity (relevant to pain);

no loss of movement;

no provocative signs/no pathology;

aged 30 years and under (usually);

sedentary workers (underexercised);

o en have cervical and thoracic pain also;

o en have days at a time without pain;

no pain while active and moving; and

pain is local to the spine (not referred).

As the postural syndrome is not generally a ected by mechanical maneuvers performed by the clinician or
the patient, the focus of the intervention is to isolate and subsequently instruct the patient to avoid the
o ending position(s). The “slouch/overcorrect” maneuver is taught to the patient. The patient should sit on
the edge of the chair and allow the lumbar spine to slouch into a fully flexed position and allow the head and
chin to protrude. He or she must then smoothly move into a fully erect sitting position, achieving a maximal
lumbar lordosis, with the head held directly over the spine and with a retracted chin.490 This postural motion
should be repeatedly performed from the position of “poor” (slouch) posture to the overcorrect position
VIDEO.

Dysfunction Syndrome

The key characteristics of the dysfunction syndrome include490

intermittent pain;

no time factor;

pain produced at end position or movement of shortened structures;

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pain relief with relief of stress/unloading shortened tissue;

always a loss of function/movement;

no deformity (not rapidly reversible);

test movements reproduce pain but pain does not worsen as a result;

over 30 years old except where trauma or derangement is a causative factor; and

poor posture o en underexercised.

The symptoms related to the dysfunction syndrome tend to be related to movement and become evident in
the di iculty or inability of the patient to accomplish end range of movement, most frequently in the
extremes of flexion and extension. The intervention goal for the dysfunction syndrome is the restoration of
function or movement of the adaptively shortened tissue using frequent repetition of restricted end-range
exercises. The stretches need to be performed daily every 2–3 hours to achieve the lengthening of adaptively
shortened so tissues. This usually needs to be continued for a 4–6-week period or until the patient can fully
stretch without any end-range pain. The following instructions must be given to the patient490:

Stretch in the direction of movement loss and end-range pain.

Allow elongation without microtrauma.

Pain produced by stretching must stop shortly a er the release of stress (persisting pain a erward indicates
overstretching).

Peripheralization of symptoms should never occur.

Stretching must be strong enough to reproduce discomfort or some pain.

Must regularly be performed during the day (15 times/2 hr).

Derangement Syndrome

The key characteristics of the various derangement syndromes are

o en constant pain;

time factors (diurnal cycle);

pain brought on or increased by certain movements/positions (repetition/sustaining usually worsens pain);

pain decreased or abolished by other movements/positions (repetition/sustaining usually improves the

condition);

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always a loss of movement/function;

deformity of kyphosis/scoliosis is common (derangements 2 and 4, respectively—see Chapter 22); and

deformity of accentuated lordosis uncommon (derangement 7—see Chapter 22).

McKenzie classifies derangement of the lumbar spine into seven categories on the basis of the location of
symptoms and the presentation of fixed antalgias responsive to end-range loading in directions other than
that within which complaints are caused.282,504 Derangements that are considered to be anterior require
strategies containing a flexion component, whereas those that are considered to be posterior involve
strategies incorporating an extension component. In most cases, these may be conducted within the sagittal
plane, but flexion and extension strategies may, in other cases, be combined with coronal or transverse
motions for the best mechanical and symptomatic responses.490 The theoretical model of the derangement
syndrome involves the concept of displacement of the NP/annulus.

The intervention goal for the derangement syndrome is to reduce the derangement by altering the
position/shape of the NP/annulus using restricted end-range loading for a prolonged period of time and then
to maintain the reduction and aid recovery of function.490 Mechanical treatment is dependent on the
mechanical diagnosis for derangements. The interventions for derangements 1–7 are outlined in Table 28-20.
The sequential extension progression advocated by McKenzie, initiated once the patient is able to tolerate
prone lying (Fig. 28-17), involves prone on elbows (Fig. 28-52), prone push-up (Fig. 28-53) VIDEO, and
extension in standing (Fig. 28-54) VIDEO.

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TABLE 28-20
Intervention of Derangements 1–7

Derangement Description Intervention

1 Central or symmetrical pain across L4–5, with rarely 1. Reduction by application of

buttock or thigh pain and no deformity extension principle
This indicates a minor posterior disk disturbance 2. Maintenance of reduction
by
maintenance of lordosis
sitting with lumbar support
frequent performance of
extension exercises
3. Recovery of function by
flexion procedures (lying
first), followed by extension
procedures: prone lying
(Fig. 25-20), prone on
elbows (Fig. 28-52), prone
push-up (Fig. 28-53), and
extension in standing (Fig.
28-54).
4. Prophylaxis:
Continuation of exercises
as directed. Patients can
self-treat
Follow advice (especially
regarding the avoidance of,
or proper mechanics
associated with, prolonged
bending and sitting)

2 Central or symmetric pain across L4–5, with or without 1. Reduction of deformity

buttock and or thigh pain, with deformity of lumbar until the prone position can
kyphosis be obtained easily
Indicates a major posterior-central disk disturbance. 2. Further treatment as for
A progression of derangement 1 and can easily worsen derangement 1
to a derangement 4 or 6

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Derangement Description Intervention

3 Unilateral or asymmetrical pain across L4–5 with or 1. Reduction as for

without buttock or thigh pain and no deformity derangement 1
A minor posterolateral disk disturbance 2. If no centralization or
A progression of derangement 1 reduction of pain occurs,
the application of unilateral
procedures is indicated.
3. Once centralization or
reduction of pain is
achieved, further treatment
as for derangement 1

4 Unilateral or asymmetrical pain across L4–5 with or 1. Reduction of derangement:

without buttock or thigh pain and with deformity of Lateral shi correction for
lumbar scoliosis lateral component of
Typically a major posterolateral disk disturbance and derangement
can be considered a progression of derangement 2 or 3 Extension procedures for
reduction of posterior
component
Maintenance of lordosis for
stabilization of reduction
2. If following reduction of
deformity no centralization
occurs the application of
unilateral technique is
necessary
3. Once centralization is
achieved, further treatment
as for derangement 1

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Derangement Description Intervention

5 Unilateral or asymmetrical pain across L4–5 with or Treatment of an adherent nerve

without buttock or thigh pain. There is leg pain root:
extending below the knee 1. Stretching by flexion
The pathogenesis is a posterolateral disk disturbance procedures
with impingement on nerve root and dural sleeve 2. Followed by extension
Progression of derangement 3 or 4 procedures to prevent
Intermittent sciatica may be caused by a disk bulge. recurrence of derangement
Flexion in both standing and lying enhance pain;
repetition worsens symptoms. It may be caused by an
Treatment of disk bulge:
adhesive or tethered nerve root. This is labeled as an
reduction of derangement as
adherent nerve root and flexion in standing enhances
treatment of derangements 1 or
pain but repetition does not necessarily worsen the
3
symptoms

6 Unilateral or asymmetrical pain across L4–5 with or If movement or

without buttock or thigh pain. There is leg pain postures/positions does not
extending below the knee and a deformity of sciatic reduce sciatica: no treatment
scoliosis utilizing movement or positions
The most frequent cause is a major posterolateral disk is possible at this stage
disturbance with impingement on the nerve root and If sciatica is reduced by
dural sleeve movement or positions then
proceed with a reduction of
deformity as with derangement
2 or further reduction as for
derangements 3 and 1

7 A symmetrical or asymmetrical pain across L4–5 with or Reduction of derangement

without buttock and/or thigh pain and a deformity of utilizing flexion procedures
accentuated lordosis
Involves an anterior or anterolateral disk disturbance

The aim of the intervention in derangement syndrome is to reverse derangement 2–6 by shi correction or extension
principle to resemble derangement 1 (centralization).

Data from He ner SL, McKenzie R, Jacob G. McKenzie protocols for mechanical treatment of the low back. In: Morris C,
ed. Low Back Syndromes: Integrated Clinical Management. New York, NY: McGraw-Hill; 2006:611–622.

FIGURE 28-52
Prone on elbows.
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FIGURE 28-53
Prone push-up.

FIGURE 28-54
Extension in standing.

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The McKenzie method has been tested for intraobserver variability, with di ering results.293,324,505 In a
recent study by Long et al.,503 the McKenzie approach using exercise prescription based on a directional
preference demonstrated significantly better outcomes than comparison groups performing exercise away
from a directional preference.

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Several outcome studies have examined the e ectiveness of the McKenzie method compared with that of
other approaches.506–509 Ponte et al.506 compared the e ectiveness of the McKenzie method with that of the
Williams approach and found that the McKenzie method demonstrated greater improvements in pain
intensity and lumbar ROM than the Williams protocol. However, this study had a small sample size (22
subjects), and subjects were not randomly assigned but rather assigned by the referring physician to a
treatment group.

Nwuga and Nwuga507 also compared the e ectiveness of the McKenzie method with that of the Williams
approach. Sixty-two females, aged 20–40 years and all diagnosed with a prolapsed IVD in the lumbar spine,
were assigned to either the McKenzie group or the Williams group. Similar conclusions were drawn from this
study as from the Ponte study, namely that the McKenzie method demonstrated greater improvements in
pain intensity and lumbar ROM than the Williams protocol.507

Stankovic and Johnell performed two separate outcome studies (1989 and 1994) that compared long-term
patient outcomes following treatment with either the McKenzie approach or with patient education alone in
a mini back school.508,509 A mini back school involves education of the patient in the mechanics of the spine,
proper posture, and safe li ing techniques. The 1989 study assessed six variables in 100 employed patients
with acute LBP: return to work, sick leave during recurrences, recurrences of pain during the year of
observation, pain, movement, and the patient's ability to self-help. The McKenzie method was found to be
superior in four of the six variables. The two variables that showed no significant di erence were sick leave
during recurrences and patient's ability to self-help.509 The 1994 study was a continuation of the 1989 study
and used the same subjects. The later study showed that subjects who received McKenzie treatment had
significantly fewer recurrences of pain and recurrent episodes of sick leave compared with the subjects who
received mini back school education.508

A randomized controlled comparative trial with an 8-month follow-up period was conducted by Petersen et
al.,483 which compared the e ect of the McKenzie treatment method with that of intensive dynamic
strengthening training in patients with subacute or chronic LBP. Two-hundred and sixty consecutive patients
with LBP and at least 8 weeks duration of symptoms (85% of the patients had more than 3 months duration
of symptoms) were randomized into two groups: Group A was treated with the McKenzie method (n = 132)
and Group B was treated with intensive dynamic strengthening training (n = 128). The treatment period for
both groups was 8 weeks at an outpatient clinic, followed by 2 months of self-training at home. Treatment
results were recorded at the end of the treatment period at the clinic, then 2 and 8 months a er. The study
concluded that the McKenzie method and intensive dynamic strengthening training seem to be equally
e ective in the treatment of patients with subacute or chronic LBP.

The reasons for the positive measure changes observed in the McKenzie treatments remain unclear.510
Schnebel et al.502 suggested that the positive results might be related to activation of the gate control
mechanisms or relaxation and/or decompression of neural tissues. Porterfield and De Rosa511 believed that

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the application of controlled forces to the spine through active exercise or manual techniques might
temporarily reduce pain levels by altering the fluid dynamics of injured tissue.

Spinal Stabilization Exercises

The core, which includes the muscles and joints of the abdomen spine, pelvis, and hips, is the kinetic link
that facilitates the sequential transfer of torques and angular momentum between the lower and upper
extremities.512 The boundaries of the core include the diaphragm (superior), abdominal and oblique muscles
(anterior-lateral), paraspinal and gluteal muscles (posterior), and the pelvic floor and hip girdle (inferior).513
The inherent nature of these muscular boundaries produces a corset-like stabilization e ect on the trunk and
spine.514 Stabilization is the process of decreasing abnormal or excessive symptomatic translations about
articulating joint surfaces.515 Through mechanical modeling, various studies have described the
requirements for a stable spine to be a combination of energy wells (potential energy state and the
relationship between spinal segments), whole body stability (factors that respond to loads or perturbations),
elastic energy and sti ness (joint sti ness as a result of muscular activation), and su icient stability
(adequate activation for functional movement).213,515 Although a definitive description of lumbar instability
has yet to be agreed upon, there is general agreement that it involves a loss of the spine's ability to maintain
its pattern of displacement under normal physiological loads.516 Thus, the basic premise of spinal
stabilization (core strengthening, dynamic stabilization, trunk stabilization, and lumbopelvic stabilization)
exercises is to teach the patient with LBP how to maintain functional levels by dynamically stabilizing the
involved segments (increasing the segmental sti ness) with increased muscular support. This increased
muscular support can then be used to help maintain the neutral zone.

There is evidence suggesting that therapeutic exercise is e ective in the treatment of nonspecific back
pain,517–520 although there is insu icient evidence to conclude with absolute certainty which theoretical
mechanism of lumbar stabilization would be most beneficial in the management of patients with lumbar
segmental instability.88 Until recently, there have been two popular core stabilization rehabilitation
strategies201,515,521:

1. The motor control exercises approach, which emphasizes specific training exercises for local muscles.

2. The general exercise approach, which include exercises for global muscles.

A third strategy has been introduced by Behm et al.,522 which proposes a functional model that maintains
the local stabilizers and separates the global muscles into mobilizers and transfer load categories. The
transfer load group represents those muscles with axial-appendicular attachments (i.e., gluteus maximus,
gluteus medius, hip adductors, rectus femoris, iliopsoas, trapezius, latissimus dorsi, deltoid, and pectoralis
major) that transfer force and momentum between extremities and core along the kinetic chain.522

Theoretically, local muscles are superior to global muscles in controlling shear loads and are thus
strengthened first as the inclusion of global muscle strengthening too early in the program may be
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deleterious. Before the stabilization progression can begin, the involved structures must be permitted to heal
beyond the acute stage of healing. This can be achieved with patient education about the anatomy and
function of the core muscles, and with exercises that involve only lower and/or upper extremity motion,
while avoiding specific trunk exercises and excessive trunk motion (see “Clinical Instability of the Lumbar
Spine” section).

Stretching Exercises

Muscle flexibility should be addressed according to patient tolerance. In individuals suspected to have
instability, stretching exercises should be used with caution, particularly ones encouraging end-range lumbar
flexion.420 Poor flexibility may cause excessive stresses to be borne by the lumbar motion segments. For
example, adaptively shortened hip flexors and rectus femoris muscles can cause an extension and rotation
hypermobility in the lumbar spine. Occasionally, stretching both the anterior and the posterior thigh muscles
is beneficial. However, most of the time, only one should be stretched, and the decision is based on the
diagnosis:

The patient with spinal lateral recess stenosis or a painful extension hypomobility, and who responds well to
lumbar flexion exercises, should be taught how to stretch the hip flexors and rectus femoris while protecting
the lumbar spine from excessive lordosis.

The patient with a painful flexion hypomobility or IVD herniation, and who responds well to lumbar extension
exercises, should be taught how to stretch the hamstrings while protecting the lumbar spine from flexing.

Stretches should be applied and then taught. The goal of stretching is to perform the technique, while
maintaining the pelvis in its neutral zone, to avoid excessive anterior or posterior pelvic tilting.

Aerobic Exercise

The importance of aerobic exercise cannot be overemphasized, both in reducing the incidence of LBP523 and
in the intervention for patients who have LBP.524 Aerobic fitness should be maintained. The following aerobic
exercises may be used as tolerated:

walking and jogging on so , even ground;

upper body ergometer;

indoor cross-country skiing machines; and

water aerobics.

Proprioceptive Neuromuscular Facilitation

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Two of the more commonly used forms of proprioceptive neuromuscular facilitation (PNF) exercises in
lumbar spine rehabilitation are rhythmic stabilization training (RST) and combination of isotonic (COI)
exercises525:

RST technique. Uses isometric contraction of antagonist pattern resulting in cocontraction of the antagonist
if the isometric contraction is not broken by the clinician. It is used mainly to manage conditions in which
weakness is a primary factor and in which stabilization provides stimulation of the agonistic pattern.526

COI technique. Used to evaluate and develop the ability to perform controlled purposeful movements. It
involves the performance of alternating concentric, eccentric, and isometric contractions and is used to treat
deficiencies in strength and ROM.527

Although previous studies have shown that isometric training can have positive e ects on back pain,525,528
information on the e ectiveness of dynamic and combined dynamic–static contraction exercises for trunk
muscle stabilization and strength is scarce. Kofotolis and Kellis525 examined the e ects of RST and COI on
trunk muscle endurance, flexibility, and functional performance in subjects with chronic LBP. Eighty-six
women (40.2 ± 11.9 [mean ± SD] years of age) who had complaints of chronic LBP were randomly assigned to
three groups: RST, COI exercises, and control. Subjects were trained with each program for 4 weeks, with the
aim of improving trunk stability and strength. The exercises were performed with the patient in sitting over
the edge of the treatment table and consisted of the subject flexing and then extending the trunk against the
clinician's variable manual resistance and maintaining static positions for 5 seconds. Multivariate analysis of
variance indicated that both training groups demonstrated significant improvements in lumbar mobility
(8.6–24.1%), static and dynamic muscle endurance (23.6–81%), and Oswestry Index (29.3–31.8%)
measurements, suggesting that static and dynamic PNF programs may be appropriate for improving short-
term trunk muscle endurance and trunk mobility in patients with chronic LBP.

Back School

Several back schools and back rehabilitation programs have been developed to teach people proper li ing
technique and body mechanics. These programs are aimed at groups of patients. They include the provision
of general information on the spine, recommended postures and activities, preventative measures, and
exercises for the back.

The e icacy of back schools, however, remains controversial.529,530 Cohen et al.531 concluded that there is
insu icient evidence to recommend group education for people with LBP.

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