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.

READ:   Spine Health. PROCEDURE 2 — LYING PRONE IN EXTENSION

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.

READ:   Examination of Back Pain

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.

READ:   Spine Health. PROCEDURE 3 — EXTENSION IN LYING

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.

READ:   Spine Health. PROCEDURE 6 — EXTENSION IN STANDING

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.

READ:   Spine Health. PROCEDURE 9 — ROTATION MOBILISATION IN EXTENSION
Spine Health. PROCEDURE 7 — EXTENSION MOBILISATION The patient lies prone as for procedure 1. The therapist stands to one side of the patient, crosses the arms and places the heels of the hands on the transverse processes of the appropriate lumbar segment. A gentle pressure is applied symmetrically and immediately released, but the hands must not lose contact. This is repeated rhythmically to the same segment about ten times. Each pressure is a little stronger than the previous one, depending on the patient’s tolerance and the behaviour of the pain. The procedure should be applied to the adjacent segments, one at a time, until all the areas affected have been mobilised. Fig. Positioning of hands prior to extension mobilisation. Extension mobilisation. Effects: In this procedure the external force applied by the therapist enhances the effects on derangement and dysfunction as described for the previous extension procedures. In general, symmetrical pressures are used on patients with central and bilateral symptoms. Therapist-...
Intervertebral discs Figure. The adult vertebral column and typical vertebrae in each region, lateral views. There are at least 24 intervertebral discs interposed between the vertebral bodies: six in the cervical, twelve in the thoracic and five in the lumbar region, with one between the sacrum and coccyx. (Additional discs may be present between fused sacral segments.) The discs account for approximately one-quarter of the total length of the vertebral column, and are primarily responsible for the presence of the various curvatures. On descending the vertebral column, the discs increase in thickness, being thinnest in the upper cervical region and thickest in the lower lumbar. In the upper thoracic region, however, the discs appear to narrow slightly. In the cervical region the disc is about two-fifths the height of the vertebrae, being approx-imately 5 mm thick. In the thoracic region the discs average 7 mm in thickness, so that they are one-quarter of the height of the vertebral bodies. The discs in ...
Spine Health. PROCEDURE 6 — EXTENSION IN STANDING The patient stands with the feet well apart and places the hands (fingers pointing backwards) in the small of the back across the belt line. He leans backwards as far as possible, using the hands as a fulcrum, and then returns to neutral standing. The exercise is repeated about ten times. As with extension in lying it is necessary to move to the very maximum to obtain the desired result. Fig. Extension in standing. Effects: Extension in standing produces similar effects on derangement and dysfunction as extension in lying, but it is less effective in the earlier treatment stages of both syndromes. Whenever extension in lying is prevented by circumstances, an extension stress can be given by extension in standing. In derangement, extension in standing is designed to reduce accumulation of nuclear material in the posterior compartment of the intervertebral joint, provided this accumulation is not gross. In the latter case extension in lying will have to be performed first. Th...
Spinal manipulation techniques There are many differing philosophies and concepts surrounding the practise of spinal manipulation and its effects on the pathologies which may exist in the spine. To satisfy all these philosophies an equal number of institutions has developed, teaching those wishing to learn. No matter what school presents its case or which philosophy is adhered to, all manipulative specialists claim to have a high success rate. They all use techniques which vary in nature, application and intent; they proclaim that their own methods are superior to those used by others; and yet, somehow they all obtain uniformly good results. Self-limitation of low back pain plays, of course, a significant role in this happy situation. Apart from this there are definite benefits which are obtained quickly by using manipulative techniques. Throughout the years I have practised many forms of mobilisation and manipulation, including osteopathic and chiropractic techniques and those taught by Cyriax. I have come to be...
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 i...