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?

Spine Health. PROCEDURE 4 — EXTENSION IN LYING WITH BELT FIXATION The patient’s position and the exercise are the same as in the third procedure, but now a fixating belt is placed at or just below the segments to be extended. The safety belt is the first simple external aid, used to enhance maximum extension. It does so by preventing the pelvis and lumbar spine lifting from the couch. Other methods of restraint may be used effectively, for example the body weight of a young son or daughter when exercising at home. Fig. Extension in lying with belt fixation. Effects: This procedure creates a greater and more localised passive extension stress than the previous ones. It is particularly suitable for stretching in the case of extension dysfunction, and is more often required in dysfunction than in derangement. In dysfunction some pain will be experienced in the small of the back while exercising, because contracted tissues are being stretched. In derangement the rules pertaining to the centralisation phenomenon must be observed, and the proce...
TREATMENT OF THE DERANGEMENT SYNDROME Of all patients with low back pain those having derangement of the intervertebral disc are the most interesting and rewarding to treat. As in dysfunction, it is essential in derangement that from the very first treatment correction of the sitting posture be achieved, but in the early and acute stages of derangement emphasis is placed on the maintenance of lordosis rather than the obtaining of the correct posture. Failure in this respect means failure of what otherwise might be a successful reduction of the derangement. So often it occurs that a patient describes a significant relief from pain and is visibly improved immediately following treatment, but later that same day after sitting for some time he is unable to straighten up on rising from sitting and the symptoms have returned just as they were before treatment. Usually the patient clearly understands the dangers of bending and stooping and carefully avoids these movements. But the hidden dangers of sustained flexion incurred in t...
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 th...
Back Pain History Taking an accurate history is the most important part of the initial consultation when one is dealing with any medical or surgical problem. Unfortunately, when the mechanical lesion is involved there is still lack of understanding regarding the nature of the questions that should be asked, the reasons for asking them, and the conclusions to be drawn from the answers. I will set out step by step the stages that should be developed in history taking, and the questions that should be asked at each stage. Practitioners will already have their own method of history taking, and I do not suggest at all that they should alter their routine. However, I believe that the following questions must be included, if one is to reach a conclusion following the examination of patients with mechanical low back pain. INTERROGATION As well as the usual questions regarding name, age and address, one should enquire as to the occupation of the patient, in particular his position at work which provides us ...
Spine Health. PROCEDURE 10 — ROTATION MANIPULATION IN EXTENSION The patient lies prone as for procedure 1. The therapist stands to one side of the patient and, having selected the correct segment, places the hands on either side of the spine as for the technique of rotation mobilisation in extension (procedure 9), which is always applied as a premanipulative testing procedure. The information obtained from the mobilisation is vital and determines on which side and in which direction the manipulation is to be performed. If following testing the manipulation is indicated, the therapist reinforces the one hand with the other on the appropriate transverse process. The manipulation is then performed as in procedure 8. Fig. Rotation manipulation in extension. Effects: The effects of the external force and the reasons for its use are the same as for procedure 9. When the desired result is not obtained with the mobilising technique, manipulation is indicated under certain circumstances. Regarding the direction in which the manipulation is to be...