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.
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.
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.