The patient adopts the prone lying position with the arms alongside the trunk and the head turned to one side. In this position the lumbar spine falls automatically into some degree of lordosis.
Fig. Lying prone.
In derangement with some degree of posterior displacement of the nuclear content of the disc the adoption of procedure 1 may cause, or contribute to, the reduction of the derangement provided enough time is allowed for the fluid nucleus to alter its position anteriorly. A period of five to ten minutes of relaxed prone lying is usually sufficient. This procedure is essential and the first step to be taken in the treatment and self-treatment of derangement.
In patients with a major derangement, such as those presenting with an acute lumbar kyphosis, the natural lordosis of prone lying is unobtainable. These patients cannot tolerate the prone position unless they are lying over a few pillows, supporting their deformity in kyphosis.
In minor derangement situations the degree of posterior movement of the nucleus is relatively small. Prone lying may actually reduce the derangement without any other procedures being required in the treatment, provided sufficient time is allowed for the fluid mechanism to alter to a more anterior position. In these situations the prone position, though obtainable, may initially be painful. This does not indicate that the procedure is undesirable. The increase of pain in this position is nearly always felt centrally and is in fact desirable. If pain is produced or enhanced peripherally, the prone position must be considered harmful and should not be maintained.
A basic requirement for the self-treatment of derangement is that the prone position can be obtained and maintained. In this position the patient will commence the self-manipulative procedures, based on the extension principle.
In dysfunction there is a loss of extension movement or a reduced lordosis. In some patients with extension dysfunction the loss of movement may be enough to prevent lying prone for more than a few minutes. For these people lying prone in bed or while sunbathing has become impossible, because soft tissue shortening has reduced the available range of movement and prolonged extension stress produces pain.
The prone lying procedure by itself is not sufficient to resolve extension dysfunction. However, when adopted regularly and in conjunction with other procedures, prone lying should become painless as lengthening of shortened tissues takes place.
The prone lying position should be obtained by all patients attending for treatment of low back pain. It has been suggested that this position can be harmful because it increases and accentuates the lumbar lordosis. This applies only in a few situations: when we have failed to correct a relevant lateral shift prior to assuming the prone lying position; when extension produces or increases the compression on the sciatic nerve root; and in those rare derangements where nuclear material has accumulated anteriorly or antero-laterally, and prone lying increases the derangement. In all other instances the prone lying position is highly beneficial.
Patients with posterior derangement should after reduction be careful when arising from the prone position to standing. Every effort must be made to maintain the restored lordosis while moving from lying to standing in order to maintain the reduction of the derangement.