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TREATMENT OF EXTENSION DYSFUNCTION

By far the most common form of dysfunction is that involving loss of extension. Having already explained and taught the postural requirements, we must now instruct the patient in the methods required to regain lost extension. We must explain to him the reasons for the need to recover the extension movement. The patient must realise that without an adequate range of extension it is not possible to sit with a lordosis, even when a lumbar support is used. For some patients it is imperative that the range of extension be improved, otherwise they will be unable to sit correctly. It is my experience that, following adequate explanation, patients will co-operate with the treatment and work hard at their recovery. They will perform exercises that cause discomfort or even pain, as long as they understand the reasons for doing so.

Fig. Recovery of loss of extension, using the procedure of extension in lying.

Exercises

In order to systematically stretch the lumbar spine in extension, I have adopted a system in which the patient is able to use gravity and his own body weight to apply enough force for adequate passive stretching of the joints of the lumbar spine. This procedure, a modified press-up exercise, is extension in lying. If with this exercise the desired result is not obtained quickly enough or if progress ceases, extension in lying with belt fixation must be commenced.

If due to circumstances it is absolutely impossible to perform extension exercises in lying, extension in standing must be performed instead. But it must be emphasised that a far better extension stretch is obtained with extension exercises in lying.

The patient should be instructed to perform the exercise ten times on each occasion, and to repeat the series ten times a day at intervals of approximately two hours. It is most important to ensure that stretching occurs very regularly and the patient does not let more than two to three hours pass by without doing so.

The exercise routine should result in an increase of localised central back pain which subsides within ten to twenty minutes. The patient should also develop some new pains higher up in the spine and across the shoulders. These are normally the result of performing new exercises and holding a new posture. It is necessary to explain that the combination of the new posture and exercises will result in discomfort felt in other places; that this new aching is unavoidable and indeed necessary, but will pass after a week or so. Patients who do not complain of these transitional pains are probably not exercising adequately.

Irrespective of the category in which they may fall, all patients should be warned of the significance of producing peripheral pain. If exercises are found to produce peripheral pain, the patient should stop and wait until the next treatment when further advice should be sought.

The loss of function in patients in this group is usually resolved gradually over a period of about four to six weeks. After this period the patient may reduce the number of times the exercises are performed to four sessions per day, maintaining the number of ten repetitions at each session. I instruct my extension dysfunction patients that they should continue the programme and perform ten exercises twice daily for the rest of their lives.

Often it is desirable to keep some record of progress and the therapist may choose to take photographs to evaluate the improvement in the lumbar extension curve. The improvement is most evident in the first week, and therefore the first photographs should be taken on the first day prior to the commencement of the self-treatment programme.

Special techniques

As soon as progress slows down or ceases it is time to add mobilisation techniques. If after three to four mobilisation treatments no change is evident, the patient should be manipulated. Special techniques of mobilisation and manipulation are indicated, when the patient is unable to fully restore lumbar extension himself. These procedures may ensure full recovery of extension provided the extension exercises in lying are continued as well.

The Dysfunction Syndrome

The word ‘dysfunction’ chosen by Mennell to describe the loss of movement commonly known as ‘joint play’ or ‘accessory movement’ seems infinitely preferable to the terms ‘osteopathic lesion’ and ‘chiropractic subluxation’, neither of which means anything and both of which mean everything.

‘Dysfunction’ or ‘not functioning correctly’ at least acknowledges that something is wrong without going through the sham procedure of pretending that only those who belong to the club really understand the terminology. For years osteopaths and chiropractors have claimed that only the people, properly trained in their particular calling, have the necessary knowledge to understand their terminology. There may be some truth in that.

Although I believe that the term ‘dysfunction’ as used by Mennel does not strictly cover the loss of movement caused by adaptive shortening, I have chosen to use this term instead of repeatedly referring to ‘adaptive shortening’. Essentially, the mechanism of pain production in dysfunction is the same as in normal tissues — that is, when overstretching of soft tissues causes sufficient mechanical deformation of the free nerve endings in these tissues, pain will arise. In dysfunction soft tissues in or around the segment involved are shortened or contain contracted scar tissue. When normal movement is attempted these structures are placed on full stretch somewhat prematurely. While normally movement in the joint would take place over a certain distance before being stopped by ligamentous tension, it is now brought to a halt after only part of that distance is completed. Attempts to move further towards end range will result in overstretching and produce pain. The pain is felt at the end of the existing range and ceases immediately after end range stretch is released. Repeated uncontrolled stretching of contracted soft tissues will lead to further micro-traumata and pain. The patient then avoids the movement which is painful, and adaptive shortening of the scar reduces the existing range of movement even more.

DEFINITION

Developed as a result of poor postural habit, spondylosis, trauma or derangement, the dysfunction syndrome is the condition in which adaptive shortening and resultant loss of mobility causes pain prematurely — that is, before achievement of full normal end range movement. Essentially, the condition arises because movement is performed inadequately at a time that contraction of soft tissues is taking place.

History

There are two possibilities regarding the cause of dysfunction. When dysfunction develops following trauma or derangement, the patient will be aware of the onset. He will describe the symptoms from the date of trauma or derangement, but the pain produced by trauma or derangement will no longer be present and the symptoms are now related to the resultant loss of mobility and function. When dysfunction is the result of poor posture or spondylosis the patient will be unaware of the onset. He will be unable to relate the cause of the pain to a particular incident and usually describes a gradual slow onset of pain commencing for no apparent reason.

Patients in the dysfunction category are likely to be over thirty years of age. However, younger patients may well present, who have had previous low back pain or trauma which resulted in loss of function that has not been detected or treated.

The pain is felt at the end range of certaincmovements, or before end range is achieved, and this may interfere with the performance of simple tasks. For example, loss of function in the neck is often first noticed when the motorist turns the head while reversing the car; in loss of function in the low back it is often difficult to put stockings on the feet or to get into the trousers.

Initially patients with dysfunction are stiff first thing in the morning, loosening as the day progresses. But as time passes flexion and extension become reduced and the morning stiffness does not pass. In extension dysfunction lying prone for any length of time — for example, on the beach — cannot be tolerated. Due to inadequate extension in the lumbar spine the ligamentous structures are placed on full stretch prematurely while lying prone and pain is produced.

Often the patient with dysfunction states that he feels better when he is active and moving about than when at rest. The reasons for this are obvious: during regular and not excessive activity end range of movement is seldom required and, if so, only momentarily; on the other hand, during resting end positions are readily assumed and as soon as they are maintained they may prove painful. In dysfunction the pain is intermittent, occurring only when periarticular structures are placed on full stretch. This happens much sooner in a patient with dysfunction than in a normal person, hence the much more frequent provocation of pain in dysfunction. The greater the loss of function, the more often will the pain occur.

Pain from dysfunction sometimes develops in an episodic manner and appears to resemble derangement. This episodic pain is triggered by excessive use, for example a vigorous afternoon in the garden. Overstretching of contracted soft tissues causes minor traumata and produces or increases pain. If the patient rests for a few days the pain subsides, but further scarring and healing contractures will increasingly limit the available range of movement. This becomes a vicious circle which will only be broken by treatment procedures as described for dysfunction.

Examination

Generally, the posture of the patient with dysfunction will be poor. In the absence of trauma or previous back pain episodes, often only poor posture is to be blamed for the development of dysfunction. This is confirmed by merely correcting the posture which relieves the patient of a significant amount of pain. Except in the elderly with dysfunction, deformity is not commonly seen.

However, there is always a loss of movement or function. Often the loss of movement is a capsular pattern type of restriction. This is clearly described by Cyriax for spinal as well as peripheral joints. When dysfunction in the spine is the result of poor posture or spondylosis, there tends to be a symmetrical movement loss in all directions and group lesions are commonly seen.

However, when dysfunction is the result of trauma and derangement there is more often an asymmetrical movement loss, some movements remaining full range and others being partially or completely lost. Group lesions may or may not develop following trauma depending on the extent of the damage sustained, and are hardly ever seen following derangement.

If there is a significant loss of extension, the lordosis may be reduced or the patient may be unable to produce the lordosis, even if he strains to do so. If there is a loss of flexion, the patient may have difficulty in reaching his toes and on bending forwards the lumbar spine may remain in slight lordosis. Alternatively, the loss of flexion may become apparent midway through the flexion excursion by a deviation of the body to one side or other of the midline. Many variables are possible and all must be noted in order to determine the pattern of movement restriction of each patient individually.

Fig. Loss of extension.

Fig. Loss of flexion.

Fig. Loss of flexion with deviation.

The test movements

It will not be difficult to reproduce the symptoms with the test movements. Due to the reduced end range of some movements pain is elicited readily as soon as stretching of these movements is performed, and each time the stress is released the pain subsides quickly.

Following the test movements the patient should be allowed to move about and perhaps have a short walk. The object of this is to determine the effect of the test movements on the general pain pattern. A patient with dysfunction may be slightly more aware of his pain after the examination, but he will never remain significantly worse, provided tissue damage due to overstretching of shortened structures has not taken place. Following the test movements the movement pattern will not have altered — that is, if we were to repeat the whole sequence the same movements would produce the same pain as in the first session.

Clinical example

Let us look at the example of a typical patient with dysfunction. In particular we must assess the effects of the test movements on the pain. In this patient pain is produced at the point of full stretch in flexion and extension, which are both restricted in range of movement. Repetition of the test movements does not make the symptoms better or worse, and on release of the stress the pain subsides leaving the patient no worse than before testing. Rapid changes of symptoms do not occur in dysfunction. It takes weeks for soft tissues to become contracted and adaptively shortened and, likewise, it will take a long time for them to lengthen again.

Treatment of the dysfunction syndrome

Patients who fall in the dysfunction category will still require postural instruction. When planning treatment we must include from the first day all the procedures laid down for the patient with postural pain. The patient with dysfunction can learn quickly to control those symptoms which are caused or enhanced by bad posture.

The symptoms of dysfunction are more related to movement and become evident in the difficulty or inability of the patient to accomplish end range of movement, most noticeable in the extremes of flexion and extension. These symptoms will remain present until the length of the shortened tissues is increased and the range of movement is improved. This will be achieved in about four to six weeks, provided the treatment procedures are used in a precise and clearly defined manner. The very nature of adaptive shortening of soft tissues adjacent to articular structures prohibits the rapid recovery of function in a few days.

Stretching must be performed in such a way that it allows elongation of ligamentous structures and scar tissue without causing micro-traumata. Pain produced by stretching should stop shortly after the stress is released. When pain persists long after stretching has occurred overstretching has taken place. To achieve lengthening of soft tissues it is not sufficient to perform stretching once a week, neither is it sufficient to do this once a day. Too many physiotherapy clinics make their patients return daily for ten minutes of mobilisation or, worse still, one minute of manipulation with the express purpose of restoring mobility. This concept of treatment may well be acceptable, if the patient is given adequate exercises to perform regularly in between treatment sessions. However, often enough this is not done; or else, when the patient is instructed in a self-treatment programme he is carefully warned not to do the exercises if they cause pain, thus defeating the purpose of the stretching.

If a patient receives manipulation in an attempt to lengthen contracted structures, minor trauma must follow and the dysfunction cycle will be perpetuated. If the patient receives only mobilisation procedures and does not perform exercises, the stretching that occurred during the ten minutes of treatment will be entirely lost by the contraction that is allowed to take place over the next twenty-three hours and fifty minutes, or whatever time period separates the treatment sessions. Even if exercises are given, no benefit will result unless the patient is instructed to move to the extreme range where some, but not great, discomfort or pain should be experienced. If no strain pain is produced during the performance of exercises for the recovery of lost movement, the contracted soft tissues are not being stretched enough to enhance elongation of the shortened structures. Furthermore, if the stretching procedures are not performed often enough, no benefit will result either. If the rest periods between the stretching procedures are too long, the length of time when no stretching takes place negates the effect of stretching.

We can have a significant influence on the remodelling of tissue expecially during the process of repair.

In all dysfunction situations exercises for the restoration of movement and function must be performed about ten times per day from first thing in the morning to last thing at night. On each of the ten occasions a minimum of ten movements will be performed. In other words, the patient will perform one hundred stretches per day in groups of ten. The following instructions must be given to the patient:

  • if the exercises do not produce some minor pain, the movement has not been performed far enough into the end range;
  • the type of discomfort aimed at is not unlike the pain felt when bending the finger backwards beyond the normal position;
  • the pain should have subsided within ten to twenty minutes after completion of the exercises;
  • when pain produced by the stretching procedures lasts continuouly and is still evident the next day, overstretching — that is, too much stretching;
  • has taken place; in this case the number of exercises in each sequence or the frequency of the sequences must be reduced.

It is accepted that due to circumstances many patients will be unable to strictly follow the recommended frequency of exercising. Where it is not possible to perform stretching as often as instructed, recovery of full function is likely to take a little longer.

During the course of one treatment session we should not use more than one new procedure; nor should that procedure, if it is a manipulative thrust technique, be performed more than once. Following the application of a new procedure or a manipulation we must wait, if necessary twenty-four hours, to assess the response of the patient.

TYPICAL TREATMENT PROGRESSION — THE POSTURAL SYNDROME

The days referred to in the treatment progression are related to treatment sessions which do not necessarily take place on consecutive days. This also applies for the treatment progressions of the dysfunction and derangement syndromes.

Day one

  • Assessment and conclusion/diagnosis.
  • Postural discussion ensuring adequate explanation of the nature of the problem. The patient must understand the cause of pain. I usually give the simple example of pain arising from the passively bent forefinger.
  • We must satisfy ourselves and the patient that the pain can be induced and abolished by positioning. If it is not possible to induce pain during the first treatment session, the patient must be instructed mow to abolish pain by postural correction when next it appears.
  • Commence with postural correction exercises and give postural advice; do not try to teach too much the first visit.
  • Discuss the importance of maintenance of the lordosis while sitting prolonged, and demonstrate the use of lumbar supports in sitting and lying.

Day two

  • Confirm diagnosis.
  • Check results. If the patient was unsuccessful in controlling the postural pain on his own, it is possible that we have not taught correction well enough. It also may be that the patient has not corrected his posture adequately or maintained the corrected posture long enough. When confronted with such a suggestion in an accusing manner, patients often feel offended and deny having slouched. We must be tactful when discussing these points.
  • If possible have the patient produce and abolish the pain; otherwise enquire as to his ability to abolish the pain during the preceeding twenty-four hours by correcting the posture whenever pain appeared.
  • Check the exercises. It is surprising how often patients alter the exercises without realising it.
  • Repeat the postural advice in full.
  • Inform the patient that ‘new pains’ are to be expected as a result of adjustment to different postural habits.

Day three

  • Treatment as for day two.
  • Once the patient is adequately controlling his postural stresses, treatment may be altered from a daily basis to every second or third day.
  • Once the pain occurs only occasionally and can be well controlled, the patient may stop the ‘slouch-overcorrect’ exercise.
  • Reassure regarding the onset of ‘new’ postural pains.

Day four and five

  • Check exercises and progress.
  • Deal with any other postural pain that may have become apparent.
  • Deal with other situations which may have previously been overlooked.

Further treatments

  • A few check-ups at greater intervals may be necessary to ensure the patient has full control of his postural pain.
  • We must ensure that the patient has adequately stressed the joints and is engaged in all normal activities.
  • Discuss the consequences of postural neglect.
  • Before discharge prophylaxis must be discussed in detail.

TREATMENT OF THE POSTURAL SYNDROME

Every patient must be examined and analysed individually, and educated for his own particular postural stress. Education is probably the most important part of the treatment for low back pain of postural origin. The patient must have a clear and unambiguous explanation of the mechanism that produces his pain. He must realise that, when he assumes the positions of stress causing pain, he is in fact pulling the ligaments apart; and all that is required to stop his postural pain, is to stop stressing the ligaments for about ten days. I also explain to the patient that once he commences the correction regime, he will and should develop some new pains which are commonly felt higher in the back. This is merely the consequence of adjustment to a new postural habit.

The more often pain is triggered, the more readily it will occur. And the less often pain is triggered, the more difficult it is to be produced. Thus, poor sitting positions maintained regularly will cause pain after the passage of less and less time. Conversely, good sitting postures will enable the patient to remain pain free for longer and longer periods, and when slouching next occurs it will take much more time for the pain to arise. After two weeks of correct sitting patients will be able to slouch for short periods without having pain. However, no one should be permitted to slouch for extended periods. For example, a patient who usually gets low back pain after ten minutes of slouched sitting, may after a couple of weeks of sitting correctly revert to the slouched position and only experience pain after twenty minutes in that position. This painfree slouched sitting period can be progressed up to a limit, so that at the end of ten weeks of correct sitting a patient may well be able to slouch for an hour or two. A possible explanation for this phenomenon is forthcoming from Professor P. D. Wall.

Correction of the sitting posture

All patients who have low back pain produced or enhanced by prolonged sitting, should receive an adequate explanation regarding the cause of pain and the need for maintenance of the correct sitting posture.

We must explain that when a person sits his spine will sooner or later take up a relaxed posture. Unless a special lumbar support is given or a conscious effort is made to maintain the lordosis, the lumbar spine will move into a fully flexed position placing various ligamentous structures on full stretch. The nucleus of the intervertebral discs is forced posteriorly, the intradiscal pressure rises, and the stresses on the posterior wall of the annulus are increased. At this stage there are many reasons for the spine to feel uncomfortable. If this position is maintained for a long period, the spine will become painful as well and in some cases derangement may occur. Few patients fail to comprehend our explanations, provided these are couched in terms understandable to the layman.

To convince the patient that our suspicions about his sitting posture are correct it is necessary to prove this to him. Pain of postural origin arising by sitting incorrectly will be abolished by sitting correctly. During the first treatment session we must reproduce the pain by positioning the patient and allowing enough time for postural stresses to build up. Once pain is felt the patient is easily convinced that it is posture-related, when on adopting the correct sitting posture the pain ceases. If we cannot reproduce the symptoms during the first treatment, we must instruct the patient to assess the relationship between posture and pain himself by correction of the sitting posture the next time pain is felt.

To achieve correction of the sitting posture the following is necessary:

  1. firstly the patient must be able to obtain the correct sitting posture;
  2. then he must know how to maintain it when sitting for prolonged periods.

To obtain the correct sitting posture

The patient must have a good understanding of the correct sitting posture, and his control of the muscles and joints involved in obtaining it must be restored. Therefore, it is necessary that he be acquainted with the extreme of the good and bad sitting positions before he is instructed regarding the correct sitting posture.

In order to achieve this we have to introduce the ‘slouch-overcorrect’ procedure. The patient must sit slouched on a backless chair or stool, allow the lumbar spine to rest on the ligaments in the fully flexed position, and permit head and chin to protrude. Then he must smoothly move into the erect sitting posture with the lordosis at its maximum and the head held directly over the spine with the chin pulled in. This sequence should be repeated in a flowing rhythmical manner, so that the patient moves from the extreme of the good to the extreme of the bad position.

Fig. a – Slouched sitting. b – Overcorrected sitting. c – Correct sitting. Figures a and b together form the ‘slouch-overcorrect’ procedure, and Figure c shows the ten percent release from the overcorrected position.

After some practise at this most patients are able to find the extreme of the good sitting position. They should become so good at it, that at the snap of the fingers they can assume the overcorrected sitting posture and hold it for a few minutes. Once this can be achieved patients are advised to follow this procedure whenever pain is felt and to maintain the extreme of the good sitting position for a few minutes. Pain induced by poor sitting is nearly always quickly abolished by this method. On discovering the relationship between sitting postures and pain by this simple exercise few patients fail to carry out our advice. Postural correction and exercises related to pain are easily understood and performed by most people.

Once the patient has a good understanding of the good and bad postures he can assume while sitting, he must be taught which position is the correct sitting posture. The extreme of the good position is of course closest to the desirable, but it is impossible to hold this position for any length of time because various structures are on full stretch and will become painful with time. Therefore, the patient is instructed to move into the extreme of lordosis and then release the last ten percent of the movement. After this release from fully strained erect sitting the position can easily be maintained if necessary. This is the position that must be adopted habitually in the future. It must be emphasised that in the correct sitting posture the lumbar spine always has a certain amount but not the maximum of lordosis. If postural pain arises in the sitting position, it is caused by an insufficient or lost lordosis and postural correction will abolish the pain. Thus, in order to leam how to assume the correct sitting posture with a lumbar lordosis patients must be instructed to carry out the ‘slouch-overcorrect’ procedure three times daily, fifteen to twenty times at each session. At the end of each session they must release the last ten percent of the extreme good sitting position. They have now found the correct sitting posture. This routine must be kept up for three to four days at least, longer if necessary, until the correct posture becomes automatic.

To maintain the correct sitting posture

When sitting for prolonged periods it is essential that a certain amount of lordosis be maintained at all times. From the very first day the patient must be shown how this can be achieved. The lumbar spine may be held in lordosis in two ways:

  • (a) actively by conscious control of the lordosis, when sitting on a seat without backrest.
  • (b) passively by the use of a lumbar support, when sitting on a seat with a backrest. The purpose of the lumbar supportive roll is to hold the lumbar spine in a good but not extreme lordosis in the sitting position while relaxing, working and driving the car. Without the support the lordosis will be lost as soon as a person leans back in a chair or concentrates on anything other than maintaining the lordosis.

The lumbar roll as sitting support:

A roll inserted in the small of the back provides adequate support for the lumbar spine in sitting, provided the apex of the support maintains the lordosis just short of its maximum. When placed at or just above the belt line, affecting approximately the area of the third and fourth lumbar vertebrae, it produces the optimum lordosis, provided one sits with the sacrum against the back of the chair. A cushion is not a suitable lumbar support because, when placed behind the low back, it merely pushes the whole spine a few centimeters away from the back of the chair without in any way influencing the angle of extension or degree of lordosis in the lumbar spine.

Fig. a – Use of lumbar roll in office chair. b – Use of lumbar roll in easy chair. This roll can also be used for support in a car seat.

Various rolls can be made for the different situations in which they may be required — for example, lounge chair, office chair and car seat. If a lounge chair or car seat is designed in such a way that the roll is absorbed by the upholstery, it may be necessary to place one or more cushions in the chair first and then add the lumbar roll.

Patients frequently complain about the effort they must expend to maintain the correct sitting posture, more so when this is done actively than with the help of a lumbar roll. In fact, many patients will describe a strain pain or say that the new position is a painful one. It is important that these pains are recognised as new postural stresses which should normally occur. If after a day or two of correct sitting a patient has not complained of ‘new pains’, it is likely that he has not maintained the corrected position often and long enough. Adjustment to a new posture results in shortlived transitional aching of a different quality and location than the pain which initially forced consultation. It should not last longer than five to six days.

It is reported that most people in North America sit with the lumbar lordosis accentuated. On several visits to the United States and Canada I have had the pleasure of treating some hundreds of patients, and I was relieved to notice that most of these, as well as most of the doctors and physiotherapists attending my courses, sat with the lumber spine held in flexion after about half an hour of sitting. I was relieved because I had been wondering whether patients in North America just might be different from those in Australasia and Europe, in which case the treatments I have developed would be most unsuitable in the North American continent. I mention this to draw attention to a fundamental error in the clinical observation of the basic mechanics of the sitting posture, which has led to the development of an inflexible concept of treatment for low back pain throughout North America based on the assumption that the lordosis is undesirable, extension harmful and flexion beneficial.

In that continent, the treatment of low back pain has been influenced by authors who argue that damage in the posterior compartment of the disc is the result of compressive forces exerted by the lordotic posture which they believe is a predominant feature of western cultures. The treatment recommended involves a combination of flexion exercises and postures all carefully calculated to reduce the lumbar lordosis. Supporters of the flexion philosophy argue that African and Asian cultures do not have as high an incidence of back pain as is found in western society and this is largely because of the flexed spinal postures adopted by these cultures. Other authorities, Armstrong, and more recently Hickey and Hukins, state that annular failure under compression is unlikely to be a significant cause of low back pain. White and Panjabi were not aware of any investigation in which cross cultural and racial comparisons had ever been satisfactorily studied and related to low back pain. They also state that Williams flexion exercises are based on the assumption that achieving and maintaining a flexed lumbar spine is preferable, but “this has not been proved and is contrary to evidence of studies in vivo of intradiscal pressure and electromyographic studies”.

Another widespread misconception, held by many doctors and therapists, suggests that postural correction can be achieved by strengthening the muscles of the spine. Strengthening of muscles has no effect on posture. No strengthening exercises will educate muscles to maintain the correct posture. Actively maintaining the correct posture is the only way to achieve postural correction. This has the added bonus that the muscles required to maintain this position are automatically strengthened merely by performing the task for which they were originally designed.

In postural retraining the problem does not lie in the inability to assume the correct posture, but in a loss of awareness of the correct posture, if indeed such an awareness existed. To restore this it is necessary to retrain postural concepts, which is essentially a matter of the will. Indeed, willpower motivated by pain must be our tool. We are able to show the patient what must be done to correct his posture, but only he himself can do it.

Correction of the standing posture

Prolonged standing is another position in which low back pain may be enhanced. Usually, the patient can be seen to stand with a protruding abdomen and the lordosis at its extreme, ‘hanging’ on the lumbo-sacral ligaments. To achieve postural correction in standing the patient must be shown how to move the lower part of the spine backwards by tightening the abdominal muscles and tilting the pelvis backwards, while at the same time moving the upper spine forwards and raising the chest.

Fig. a – Relaxed standing. b – Correct standing.

There are two common relaxed standing positions. One is achieved simply by folding one’s arms and allowing the chest to drop. Chest and thoracic spine move posteriorly and pelvis moves anteriorly. This places the lower lumbar and lumbo-sacral joints into full extension. You can try this for yourself and will find that, once having adopted this position further movement into extension is impossible. The best way to observe if this posture is the cause of the patient’s pain, is to talk with him for some time until he is standing relaxed. If pain is present due to this position, correction should reduce or abolish it.

To re-educate a patient with this stance, we must first place him in the relaxed standing position until pain is produced. Alteration of the angle of pelvic inclination will reduce the standing pain almost immediately. This is best achieved by lifting the chest and thoracic spine, simultaneously tilting the pelvis slightly backwards. The ability to control the pelvic inclination in standing must be mastered first; then the angle at which the pain is abolished must be established and maintained. If pain in standing can not be reproduced on the first examination the patient must be instructed to evaluate the relationship between posture and pain himself by postural correction the next time pain is felt.

The second relaxed standing position is obtained by taking all the body weight on one leg, while the knee of the other leg is allowed to bend causing the pelvis to droop at the same side. The lumbar spine moves into a full side gliding/rotation position. Again, you can try this for yourself and will find that having adopted this position no further movement into side gliding or extension is possible. If this position produces pain it is easily corrected and avoidance of the standing habit should suffice.

Correction of the lying posture

Pain in the lying position is common. It causes considerable distress when it interferes with sleep over a long enough period, and it requires attention when the patient regularly wakes up with pain in the morning, the pain abating as the day progresses. There are two factors to be investigated:

  • The lying posture itself. This is different for each person and must be dealt with individually. The lying posture during sleep is difficult to influence.
  • The surface on which one is lying. For the majority of people the mattress itself should not be too hard, whereas the base on which the mattress rests must be firm and unyielding. This allows adequate support for the contours of the body without placing stresses on the spine. Usually, the surface on which one is lying is easily corrected or modified.

When dealing with pain produced by lying in bed, I have three recommendations to make which may be worth considering:

Due to the natural contours of the body — that is, wider at shoulders and pelvis than at the waist — and due to the lordotic curvature of the lumbar spine, the lumbar area may be placed under stress in the prone, supine or side lying position. This is particularly so when a hard mattress is supported by a firm and unyielding base. If this is thought to be the cause of the problem, the patient should use a lumbar supportive roll. When lying prone the roll will prevent extreme extension in the lumbar spine. When lying supine with the legs outstretched the roll will fill the gap between the lumbar spine and the mattress and prevent sagging of the spine into flexion. When lying on the side it will fill the gap between pelvis and ribs and prevent sagging of the spine into side bending. This type of lumbar support in bed usually works quickly or not at all and should be tried for about three nights.

The lumbar roll as lying support

A beach towel folded end to end and then rolled cross-wise usually fits around the average middle. If this is too big a bath towel folded length-wise can be used instead. Each patient will have to experiment to find the correct size of lumbar roll required in his particular case. He should wrap the towel around the belt line and attach the two ends to each other. If left loose the roll will not remain in place and may, when positioned anywhere else than at the waist, further increase the stresses placed on the spine.

Fig. Use of lumbar roll in lying. The roll is not fastened in the picture in order to show the shape of the spine.

When the base of the mattress is not firm enough or the mattress itself is too soft, stresses may also be placed on the lumbar spine. Because of the costs involved in replacing a mattress or its base, I always recommend that the mattress be placed on the floor if it is felt that a firm flat base is required. If there is no improvement after sleeping three to four nights on a flat surface, it is unlikely that this is the answer to the patient’s problems.

There is a small number of people who require a sagging mattress. Usually these people fall under the flexion principle category. The sagging mattress can easily be created by placing pillows at both ends of the bed in between the mattress and its base to form a dish shape.

Conclusion

We should now have equipped the patient with sufficient information enabling him to sensibly control mechanical stresses and deal with symptoms himself. The essence of treatment of the postural syndrome is that, if it is possible for patients to stop their pain, it is also possible for them to prevent the onset of the pain. I feel that it is negligent of the medical and physiotherapy professions to continue giving relief for episodic pain without familiarising patients with the manner in which their pain arises and providing them with the means to prevent the onset of such pain. It is my experience that patients with postural pain, when properly instructed and advised, treat themselves ably and adequately. TTiey can well control their postural stresses, and only need assistance when excessive and sometimes unexpected external forces have been placed on their joints — for example, following lifting heavy weights, stepping unexpectedly from the pavement, being hit by a motor vehicle, a sudden bout of coughing or sneezing while sitting or bent forwards.

When treatment is completed successfully we must explain to the patient that, although the present pain has been relieved, recurrence of similar symptoms is possible whenever he forgets postural care for extended periods. The consequences of postural neglect should be discussed when appropriate.

Consequences of postural neglect

The effects of postural habits on the shape of man are obvious when we observe people around us. If head and chin are allowed to protrude long and often enough, the ability to glide the head dorsally will be lost which results in a permanently protruding head and a dowager’s hump. As age advances this once reversible situation will become irreversible. People with this type of posture have a flattened lumbar spine as well, and by the age of seventy the ability to stand erect is lost so that they walk with a slight stoop. Movement that was once easily obtained is lost forever. But this postural stoop is not the inevitable consequence of ageing. Loss of function can be prevented if movements in the desired direction are performed adequately and often enough.

Initially, poor postural habits will only produce pain without loss of function. If as a result of continuous slouched sitting, flexion is regularly performed but extension never, the anterior structures of the joints involved will shorten and the posterior structures will lengthen. In this way flexion remains readily obtainable, but extension becomes more and more difficult and will therefore be avoided. Thus, the consequences of postural neglect are adaptive shortening leading to dysfunction.

Adaptive shortening implies loss of function and movement. In addition to the production of pain whenever the shortened structures are placed on stress, this loss of movement and function must inevitably lead to impairment of nutrition in an avascular structure like the disc. This will become one of the contributing factors of disc degeneration.

We should point out to people engaged in sedentary occupations that adaptive shortening and dysfunction due to poor posture can be prevented by regular postural correction and adequate performance of the appropriate exercises before adaptive shortening is allowed to develop.

The Postural Syndrome

DEFINITION

I would define the postural syndrome as mechanical deformation of postural origin causing pain of a strictly intermittent nature, which appears when the soft tissues surrounding the lumbar segments are placed under prolonged stress. This occurs when a person performs activities which keep the lumbar spine in a relatively static position (as in vacuuming, gardening) or when they maintain end positions for any length of time (as in prolonged sitting).

History

Patients with postural pain are usually aged thirty or under. Frequently they have a sedentary occupation and in general they lack physical fitness. In addition to low back pain they often describe pains in the mid-thoracic and cervical areas. They state that the pain is produced by positions and not by movement, is intermittent and may sometimes disappear for two to three days at a time. It is often found that, when patients are more active at weekends — playing tennis and dancing — they have relatively little or no trouble. The reason is that, although activity places more stress on the lumbar spine than does the adoption of static postures, with movement the stresses are continually changing and pain does not occur. The stresses arising from static postures, although less than those occuring during activity, are sustained and will, if maintained, eventually cause pain.

Examination

On examination no deformity is evident, no loss of movement will be detected and the test movements prove to be painfree. X-rays are normal and laboratory tests are negative. The patient’s sitting and often the standing posture will be poor, and usually this is the only objective finding.

Clinical example

Let us look at the clinical example of a typical patient with the postural syndrome. The patient has a bad posture indeed, and the pain cannot be reproduced by the test movements. To reproduce the appropriate postural stress, the patient must assume and maintain the position that is stated to cause pain — that is, the sitting posture. Only after the passage of sufficient time will the symptoms appear in this position, and up to half an hour may be required before pain is felt. Once pain has been produced by adoption of a certain posture, it will be abolished by correction of that posture. Now our suspicions are confirmed and a diagnosis can be made. In short, the patient with the postural syndrome has no clinical or laboratory findings indicating a particular pathology and all functions appear perfectly normal.

Thousands of people are seeking treatment for pain resulting from bad postures; they consult doctors who often are unsuited to deal with the problem and, taking the easiest way out, prescribe pain relieving drugs instead of recommending postural correction; disillusioned with drug therapy patients attend a chiropractor, osteopath, physiotherapist or some fringe manipulator who, mainly out of ignorance, proceeds to manipulate joints in which there is no pathology and certainly nothing ‘out of place’.

I must emphasise that in many patients presenting with postural pain no pathology needs to exist. All patients with low back pain have an increase in pain when postural stresses are added. In derangement and dysfunction there is a pathological cause for the pain, and postural stresses may enhance the pathological state. But in the postural syndrome no pathology is present, and the only treatment that is required is postural correction and re-education and instruction in prophylaxis.

Postures involved

Every patient with pain of postural origin has a different description for the circumstances leading to the production of pain. Sitting, by no means the only postural situation causing and prolonging low back pain, is the most frequent cause of postural pain. Some patients will name the sitting position purely and simply as causative, and they complain that pain is produced as soon as they spend more than a certain amount of time, say ten minutes, in any sort of chair or car seat. Others will describe sitting at the typewriter as the only time that pain is felt. Bus, taxi, and car drivers all complain of being worse while seated for long periods in their vehicles; both pilots and passengers complain about the seating in airplanes.

Fig. Clinical example of a typical patient with the postural syndrome.

Fig. Sitting postures.

Working in prolonged standing positions also may cause postural pain, but the opportunity to move and change position is greater in standing than in sitting and the avenues for relief are more numerous. Consequently, there are less complaints of pain arising from the standing position than from sitting. People who work in cramped positions, be it standing or sitting, are also likely to complain of low back pain. The incidence of low back pain is very high in people who work in continuously stooped positions.

Fig. Standing postures.

The lying position may be an additional source of stress enhancing low back pain, and if pain predominantly occurs while lying it requires thorough investigation.

Fig. Lying posture.

Spine Health. PROCEDURE 17 – SELF-CORRECTION OF LATERAL SHIFT

Having corrected the lateral shift and the blockage to extension, it is now essential to teach the patient to perform self-correction by side gliding in standing followed by extension in standing. This must be done on the very first day, so that the patient is equipped with a means of reducing the derangement himself at first sign of regression. Failure to teach self-correction will lead to recurrence within hours, ruining the initial reduction, and the patient will return the next day with the same deformity as on his first visit.

I have discarded the technique of self-correction as described previously and instead I now teach patients to respond to pressures applied laterally against shoulder and pelvis. Initially, therapist’ assistance is required. Patient and therapist stand facing each other. The therapist places one hand on the patient’s shoulder on the side to which he deviates, and the other hand on the patient’s opposite iliac crest. The therapist applies pressure by squeezing the patient between his hands, ensuring that the patient’s shoulders remain parallel to the ground. When over correction has been achieved by the therapist, the mobility must be maintained by the patient who is therefore taught to actively respond to the pressures applied by the therapist. After some practise, remembering to keep the shoulders parallel to the ground, the heels on the ground and the knees straight, the patient can correct his own deformity. It is important to make the patient stand for a minute or two in the extreme over corrected position.

Immediately following correction of the lateral deformity full extension must be restored. In the corrected standing position the patient must perform about ten repetitions of extension in standing.

Fig. Self-correct ion of lateral shift.

It must be emphasised that as long as the lordosis is retained there is little chance of recurrence of the derangement. If the patient is unable to maintain the reduction, he must perform self-correction during the day at regular intervals. The patient is advised to perform a series of extension in lying exercises after each session of self-correction.

Effects and points to note:

It must be obvious that the last two procedures mainly influence the disc in derangement situations. In all instances time must be allowed for the reduction of the derangement to take place. Failure to correct the common lateral shift is usually the fault of the therapist, who has not taken enough time to allow a change in the contents of the disc to occur. The lateral shift correction including the restoration of extension must be an unhurried process and may take up to forty-five minutes in difficult patients. Constant repetition of the corrective procedures is necessary.

During the correction period there must be a continual reference to the patient’s symptoms. When there is any suggestion of the production or enhancement of limb pain, treatment must be applied with great caution and a change should be made to the angle of flexion or extension in which the lateral shift is being corrected.

Maintenance of the lordosis following the reduction of the derangement must be emphasised from the first day, and we must ensure that the patient has adequate knowledge to retain his lordosis while sitting. The most common cause of regression or recurrence of symptoms within a few hours of reduction is a poor sitting posture. For example, after a successful reduction a patient may drive home for twenty to thirty minutes and on leaving the car full derangement has recurred. This occurs commonly and must be anticipated. In order to cope with this problem the patient should be provided with a lumbar support — for example, a rolled towel or something similar — to accentuate and support the lordosis in sitting.

In acute cases patients should go home (and not back to work) after reduction has been achieved. On arrival home they should move directly to a mirror and check if derangement has recurred. If so, they should perform the self-correction procedures before it becomes too difficult to reduce the lateral shift without outside help. Then they must lie prone for a few minutes on a bed or on the floor prior to performing a series of extension in lying exercises. This pattern should be repeated each hour or whenever possible throughout the day, and between exercise sessions the patient must be lying and not sitting. On retiring for bed the patient must lie supine in the over corrected position, with a lumbar support in the small of the back to maintain the lordosis, for about thirty minutes before going to sleep. The next morning there is usually a significant reduction in the deformity and pain after the correction procedure has been performed once or twice, although when first awaking the pain may be quite noticeable on movement.

Spine Health. PROCEDURE 16 — CORRECTION OF LATERAL SHIFT

This procedure has two parts: first the deformity in scoliosis is corrected; then, if present, the deformity in kyphosis is reduced and full extension is restored. The patient, standing with the feet about thirty centimeters apart, is asked to clearly define the areas where pain is being felt at present. The therapist stands on the side to which the patient is deviating and places the patient’s near elbow at a right angle by his side. The elbow will be used to increase the lateral pressure against the patient’s rib cage.

The therapist’s arms encircle the patient’s trunk, clasping the hands about the rim of the pelvis. Now the therapist presses his shoulder against the patient’s elbow, pushing the patient’s rib cage, thoracic and upper lumbar spine away while at the same time drawing the patient’s pelvis towards himself. In this manner the deformity in scoliosis is reduced and, if possible slightly overcorrected.

Initially, there will be significant resistance to the procedure, which may actually cause an increase in pain. It is quite safe to continue with correction as long as centralisation of pain takes place, and therefore the patient must be questioned continually about the behaviour of his pain. Relaxation of the patient during the procedure is very important and we should always try to get the patient to ‘let it all go’. The first pressure in the series should be a gentle gradual squeeze which is held momentarily and then released. After this an accurate assessment of the patient’s reactions must be made. Experience has taught me that too much pressure or too fast a correction in the initial stages may result in fainting and collapse of the patient. If well tolerated the pressure is applied a little further each time. As correction progresses over ten to fifteen rhythmically applied pressures, the patient usually describes that the pain moves from a unilateral to a central position, and by the time over correction is achieved there will be a significant reduction in intensity of the pain or the pain may have moved slightly to the opposite side. If after a few rhythmical pressures no progress is made in the correction, it may be necessary to apply a longer and more sustained pressure.

Sometimes reduction may be felt clearly by the therapist and the patient’s trunk is felt to move slowly but surely from its previously held position. In lightly-built or tall and slender patients shift correction may occur quite easily, and only a few minutes of ten to fifteen pressures are required to reduce the derangement. On the other hand, some acute lateral shifts are extremely difficult to reduce and one may have to perform five or six series of corrective pressures.

Assuming that correction of the deformity in scoliosis has been achieved, we must now proceed with restoring the lumbar lordosis. This is preferably commenced in the standing position. The patient no longer exhibits a lumbar scoliosis but may still have a kyphosis. The therapist, holding the patient as for correction of the scoliosis, must maintain slight over correction while moving the low back of the patient into the beginning of extension. A few movements will indicate the ease with which the lordosis will be restored. If the extension range improves rapidly it is usually belter to recover as much extension as possible in the standing position. If extension does not increase rapidly, then it is better to change to extension in lying. This procedure should produce a steady and continuing reduction of central pain, and it should automatically follow for all patients with a postero-lateral derangement once the scoliosis has been corrected and the symptoms have centralised.

Fig. Correction of lateral shift.

Effects:

These will be discussed following the next procedure.

Spine Health. PROCEDURE 15 — FLEXION IN STEP STANDING

In this procedure the patient stands on one leg while the other leg rests with the foot on a stool so that hip and knee are about ninety degrees flexed. Keeping the weight bearing leg straight the patient draws himself into a flexed position, firmly approximating the shoulder and the already raised knee (both being on the same side). If possible the shoulder should be moved even lower than the knee. The patient may apply further pressure by pulling on the ankle of the raised foot. The pressure is then released and the patient returns to the upright position. The sequence is repeated about six to ten times. It is important that the patient returns to neutral standing and restores the lordosis in between each movement.

Fig. Flexion in step standing.

Effects:

This procedure causes an asymmetrical flexion stress on the affected segments. It is applied when there is a deviation in flexion, which may occur in dysfunction as well as derangement. Both in dysfunction and derangement the leg to be raised is that opposite to the side to which the deviation in flexion is taking place — for example, in deviation in flexion to the left the right leg has to be raised.

In dysfunction asymmetrically shortened structures are stretched by flexion in step standing, provided it is performed often enough with the application of sufficient stress.

In derangement the procedure will influence the off-center nucleus so that it moves to a more central position, thus allowing the normal pathway of flexion to be regained. Where deviation in flexion is due to derangement some patients will experience a reversal of the deviation if the procedure is performed too often. Thus the exercise must be repeated only five to six times before checking if flexion in standing has been reduced to normal.

Spine Health. PROCEDURE 14 — FLEXION IN STANDING

The simple toe touching exercise in standing does not need much elaboration. The patient, standing with the feet about thirty centimeters apart, bends forward sliding the hands down the front of the legs in order to have some support and to measure the degree of flexion achieved. On reaching the maximum flexion allowed by pain or range, the patient returns to the upright position. The sequence is repeated about ten times, should be performed rhythmically, and initially with caution and without vigour. It is important to ensure that in between each movement the patient returns to neutral standing.

Fig. Flexion in standing.

Effects:

Flexion in standing differs from flexion in lying in various ways. Naturally, the gravitational and compressive forces act differently in both situations. In flexion in standing the movement takes place from above downwards, and the lower lumbar and lumbo-sacral joints are placed on full stretch only at the end of the movement. In addition, the lumbo-sacral nerve roots are pulled through the intervertebral foramina.

Thus, flexion in standing can be used as a progression of flexion in lying and may affect dysfunction as well as derangement. It can also be used specifically to stretch the scarring in an adherent nerve root or in nerve root entrapment.

If, in attempts to recover function following derangement, flexion in standing is performed too soon, the patient may rapidly worsen. This will happen even when there is no nerve root involvement. The same patient may safely perform flexion in lying and experience no increase in pain. It would appear that the gravitational stresses during flexion in standing are sufficient to cause an increase in derangement by further bulging of the disc wall.

Flexion in standing is an important procedure in the treatment of anterior derangement situations (Derangement Seven), as it causes a posterior movement of the nucleus within the disc wall.

Spine Health. PROCEDURE 13 — FLEXION IN LYING

The patient lies supine with the knees and hips flexed to about forty-five degrees and the feet flat on the couch. He bends the knees up towards the chest, firmly clasps the hands about them and applies overpressure to achieve maximum stress. The knees are then released and the feet placed back on the couch. The sequence is repeated about ten times. The first two or three flexion stresses are applied cautiously, but when the procedure is found to be safe the remaining pressures may become successively stronger, the last two or three being applied to the maximum possible.

Fig. Flexion in lying.

Effects:

Flexion in lying causes a stretching of the posterior wall of the annulus, the posterior longitudinal ligament, the capsules of the facet joints, and other soft tissues. As the movement takes place from below upwards the lower lumbar and lumbo-sacral joints are placed on full stretch at the beginning of the exercise as soon as movement is initiated. Thus, the procedure is very important in flexion dysfunction when shortening of posterior soft tissues has occurred.

The procedure should always be performed following stabilisation of a reduced posterior derangement. This ensures that no flexion loss remains after the patient has become symptom free. By keeping the patient in extension and avoiding flexion as healing takes place, we permit scar formation with the joints in a shortened position. This shortened position will be held by the scar as it contracts, the patient remaining painfree but unable to flex. Any attempts to perform flexion beyond the limits imposed by the contracting scar, will produce pain. Therefore, further flexion will be avoided and adaptive shortening gradually worsens.

Flexion in lying performed regularly following reduction of posterior derangement allows the formation of an extensible scar in the midst of an elastic structure. Should we permit an inextensible scar to remain in the midst of an elastic structure, — the disc in this case — then sooner or later the patient will inadvertently move beyond the limitations of the scar, which results in further tearing of soft tissues and apparent recurrence of the derangement condition. This basic complication of healing exists throughout the muscular as well as the articular systems.

Flexion in lying also causes a posterior movement of the fluid nucleus and will be utilised in anterior derangement situations (Derangement seven) to reverse the excessive anterior position of the nucleus.