The patient, already lying prone, places the hands (palms down) near the shoulders as for the traditional press-up exercise. He now presses the top half of his body up by straightening the arms, while the bottom half, from the pelvis down is allowed to sag with gravity. The top half of the body is then lowered and the exercise is repeated about ten times. The first two or three movements should be carried out with some caution, but once these are found to be safe the remaining extension stresses may become successively stronger until the last movement is made to the maximum possible extension range. If the first series of exercises appears beneficial, then a second series may be indicated. More vigour can be applied and a better effect will be obtained if the last two or three extension stresses are sustained for a few seconds.

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It is essential to obtain the maximum elevation by the tenth excursion and once obtained the lumbar spine should be permitted to relax into the most extreme ‘sagged’ position.

Fig. Extension in lying.


This procedure is a further progression of the previous two. Instead of a sustained extension stress on the contents and surrounding structures of the lumbar segments, there is now an intermittent extension stress, having a pumping as well as a stretching effect.

This procedure is the most important and effective in the treatment of derangement as well as extension dysfunction. The very maximum degree of extension possible without external assistance, is obtained with this exercise. An increase of central low back pain at maximum elevation can be expected and should not cause any concern as it will gradually wear off. It is usually described as a strain pain and differs from the pain which has caused initial consultation. In addition to the effects on the disc and periarticular structures there are two other physiologically related phenomena that could possibly result from the performance of this exercise.

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The self sealing phenomenon

Evidence gathered by Markolf and Morris suggests that a self sealing mechanism exists within the disc and appears shortly after injury. The initial injury weakens the annulus but appropriate stress applied subsequently results in restoration of near normal strength, suggesting that the disc has a remarkable recovery ability and that certain stresses may enhance rapid recovery. White and Panjabi conclude that the self sealing phenomena is mechanical in nature and is not dependent on the viscosity or softness of the disc, for the study was performed on degenerative as well as normal discs.

My question arising from this information is … Does the performance of repeated passive extension in lying cause a reversal of the posterior migration of the nucleus into the developing radial fissure? Does the movement then initiate the self sealing phenomena?


Cartilaginous repair

Following trauma articular surfaces are normally rested or immobilised to permit healing. It is well known that scar tissue is laid down under these circumstances and damaged articular cartilage is replaced with fibrous collagen. Recent investigations by Salter suggest that if passive continuous motion is applied to joints containing traumatised intra articular cartilage, the damaged cartilage is replaced by true cartilaginous cells instead of scar tissue, and further, these joints do not develop arthritic changes subsequently. The evidence has yet to be confirmed in human studies. We can now pose the question … Does the regular performance of passive extension following lumbar disc damage enhance the quality or improve the nature of the healing tissues of the posterior annulus?

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 prod...
Spine Health. PROCEDURE 11 — SUSTAINED ROTATION/MOBILISATION IN FLEXION The patient lies supine on the couch, and the therapist stands on the side to which the legs are to be drawn, facing the head end of the couch. The patient’s far shoulder is held firmly on the couch by the therapist’s near hand, providing fixation and stabilisation. With the other hand the therapist flexes the patient’s hips and knees to a rightangle and carries them towards himself, causing the lumbar spine to rotate. With the patient’s ankles resting on the therapist’s thigh the knees are allowed to sink as far as possible and the legs are permitted to rest in that extreme position. The lumbar spine is now hanging on its ligaments in a position which combines side bending and rotation. By pushing the knees further towards the floor the therapist applies overpressure to take up the remaining slack in the lumbar spine. Depending on the purpose for which the procedure is used, the position of extreme rotation is maintained for a shorter or longer period. Fig. Sustained rotation/mob...
Back Pain. Diagnosis THE THERAPIST’S RESPONSIBILITY The therapist is part of the team involved in the treatment and rehabilitation of patients suffering low back pain. In some countries manipulative therapists are primary contact practitioners. Consequently, their diagnostic skills have greatly improved, enabling them to define which mechanical conditions can be helped by mechanical therapy and to separate these conditions from the nonmechanical lesions which have no place in the therapy clinic. However, differential diagnosis is really not within the scope of manipulative therapy. It is my view that differential diagnosing by medical practitioners is necessary to exclude serious and unsuitable pathologies from being referred for mechanical therapy. In making diagnoses the manipulative therapist should confine himself to musculo-skeletal mechanical lesions. Specialised in this field, he is usually able to make far more accurate diagnoses than most medical practitioners. As the manipulative therapy prof...
GATE CONTROL THEORY OF PAIN What occurs at the cellular level when pain is experienced? The gate control theory of pain, by P. D. Wall and Ronald Melzack, offers a useful model of the physiological process of pain. Gate control is recognized as a major pain theory. According to the gate control theory, pain is a balance between information traveling into the spinal cord through large nerve fibers and information traveling into the spinal cord through small nerve fibers. Without any stimulation, both the large and small nerve fibers are quiet, and the substantia gelatinosa (SG) blocks the signal to the transmission cell (T cell) connected to the brain. The “gate is closed,” and there is no pain. With pain stimulation, small nerve fibers are active. They activate the T-cell neurons but block the SG neuron, making it impossible for the SG to block the T-cell transmission to the brain. The result is that the “gate is open”; therefore, there is pain. In other words, pain is experienced whenever the substances that ...
Spine Health. PROCEDURE 2 — LYING PRONE IN EXTENSION The patient, already lying prone, places the elbows under the shoulders and raises the top half of his body so that he comes to lean on elbows and forearms while pelvis and thighs remain on the couch. In this position the lumbar lordosis is automatically increased. Emphasis must be placed on allowing the low back to sag and the lordosis to increase. Fig. Lying prone in extension. Effects: Procedure 2 is a progression of procedure 1 and merely enhances its effects by increasing extension. Again, in derangement some time must be allowed to affect the contents of the disc and, if possible patients should remain in this position for five to ten minutes. In more acute patients sustained extension may not be well tolerated due to pain, and initially we must rely on the use of intermittent extension.