Williams' Flexion Versus McKenzie

Extension Exercises For

Low Back Pain
In general, extension exercises may cause further damage in people with
spondylolysis, spondylolisthesis and facet joint dysfunction (Harvey 1991),
not to mention the possibility of crushing the interspinous ligament (McGill
1998). While flexion exercises should be avoided in persons with acute disc
herniation (Harvey 1991).
Brief History of Williams' Flexion Exercises
Dr. Paul Williams first published his exercise program in 1937 for patients
with chronic low back pain in response to his clinical observation that the
majority of patients who experienced low back pain had degenerative
vertebrae secondary to degenerative disk disease (Williams 1937). These
exercises were developed for men under 50 and women under 40 years of
age who had exaggerated lumbar lordosis, whose x-ray films showed
decreased disc space between lumbar spine segments (L1-S1), and whose
symptoms were chronic but low grade. The goals of performing
these exercises were to reduce pain and provide lower trunk stability by
actively developing the "abdominal, gluteus maximus, and hamstring muscles
as well as..." passively stretching the hip flexors and lower back
(sacrospinalis) muscles. Williams said: "The exercises outlined will
accomplish a proper balance between the flexor and the extensor groups of
postural muscles..." (Williams 1965, Williams 1937, Blackburn 1981, Ponte et
al.).
Williams flexion exercises have been a cornerstone in the management of
lower back pain for many years for treating a wide variety of back problems,
regardless of diagnosis or chief complaint. In many cases they are used
when the disorders cause or characteristics were not fully understood by the
physician or physical therapist. Also, physical therapists often teach these
exercises with their own modifications. Williams suggested that a posterior
pelvic-tilt position was necessary to obtain best results (Williams 1937).
Examples of Williams' Flexion Exercises
1. Pelvic tilt. Lie on your back with knees bent, feet flat
on floor. Flatten the small of your back against the floor,
without pushing down with the legs. Hold for 5 to 10
seconds.
. $ingle Knee to chest. Lie on your back with knees bent and feet flat on
the floor. Slowly pull your right knee toward your shoulder and hold 5 to 10
seconds. Lower the knee and repeat with the other knee.
3. ouble knee to chest. Begin as in the previous
exercise. After pulling right knee to chest, pull left knee to chest and hold
both knees for 5 to 10 seconds. Slowly lower one leg at a
time.
4. Partial sit-up. Do the pelvic tilt (exercise 1) and, while
holding this position, slowly curl your head and shoulders off
the floor. Hold briefly. Return slowly to the starting position.
5. Hamstring stretch. Start in long sitting with toes directed
toward the ceiling and knees fully extended. Slowly lower the
trunk forward over the legs, keeping knees extended, arms
outstretched over the legs, and eyes focus ahead.
6. Hip Flexor stretch. Place one foot in front of the other
with the left (front) knee flexed and the right (back) knee
held rigidly straight. Flex forward through the trunk until
the left knee contacts the axillary fold (arm pit
region). Repeat with right leg forward and left leg back.
7. $6uat. Stand with both feet parallel, about shoulders width
apart. Attempting to maintain the trunk as perpendicular as possible
to the floor, eyes focused ahead, and feet flat on the floor, the subject
slowly lowers his body by flexing his knees.

Brief History of McKenzie Back Exercises

The McKenzie back extension exercises have been order by physicians and
prescribed by physical therapists for at least two decades (McKenzie
1981). Robin McKenzie noted that some of his patients reported lower back
pain relief while in an extended position. This went against the predominant
thinking of Williams Flexion biased exercises at this period of time.
Physical therapists can become "McKenzie certified", but the vast majority of
physical therapists who treat low back pain are not. McKenzie has developed
diagnostic categories that assign patient to specific treatments. Patients
evaluated by McKenzie certified therapists are most likely to be placed into
an extension biased exercise program. This is probably why most people
think of extension when talking about McKenzie exercises, or because the
original exercises were in opposition to Williams' flexion exercises.
The goal of McKenzie exercises is to centralized pain. If a patient has pain in
the lower back, right buttock, right posterior thigh, and right calf, then the
goal would be to "centralize" the pain to the lower back, buttock, and
posterior thigh. Then, "centralize" the pain to the lower back and buttock,
and finally just the lower back.

by Robin McKenzie
%ypical McKenzie Back Extension Exercises
1. Prone lying. Lie on your stomach with arms along
your sides and head turned to one side. Maintain this
position for 5 to 10 minutes.
. Prone lying on elbows. Lie on your stomach with
your weight on your elbows and forearms and your hips
touching the floor or mat. Relax your lower
back. Remain in this position 5 to 10 minutes. If this causes pain, repeat
exercise 1, then try again.
3. Prone press-ups. Lie on your stomach with palms near
your shoulders, as if to do a standard push-up. Slowly push
your shoulders up, keeping your hips on the surface and
letting your back and stomach sag. Slowly lower your
shoulders. Repeat 10 times.
4. Progressive extension with pillows. Lie on your
stomach and place a pillow under your chest. After
several minutes, add a second pillow. If this does not
hurt, add a third pillow after a few more minutes. Stay in this position up to
10 minutes. Remove pillows one at a time over several minutes.
. $tanding extension. While standing, place your hands in the
small of your back and lean backward. Hold for 0 seconds and
repeat. Use this exercise after normal activities during the day that
place your back in a flexed position: lifting, forward bending, sitting,
etc.