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.

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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.

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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.

Spine Health. PROCEDURE 9 — ROTATION MOBILISATION IN EXTENSION The position of patient and therapist is the same as for procedure 7. By modifying the technique of extension mobilisation so that the pressure is applied first to the transverse process on the one side and then on the other side of the appropriate segment a rocking effect is obtained. Each time the vertebra is rotated away from the side to which the pressure is applied — for example, pressure on the right transverse process of the fourth lumbar vertebra causes left rotation of the same vertebra. The technique should be repeated about ten times on the involved segment and, if indicated, adjacent segments should be treated as well. Fig. Rotation mobilisation in extension. Effects: Also here the external force applied by the therapist enhances the effects on derangement and dysfunction as described for the previous extension procedures. The reasons for adding therapist-technique are the same as for procedure 7. In general, unilateral techniques are likely to effect unilateral...
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...
Spine Health. PROCEDURE 12 — ROTATION MANIPULATION IN FLEXION The sequence of procedure 11 must be followed completely to perform the required pre-manipulative testing. If the manipulation is indicated a sudden thrust of high velocity and small amplitude is performed, moving the spine into extreme side bending and rotation. Fig. Rotation manipulation in flexion. Effects: There are many techniques devised for rotation manipulation of the lumbar spine. When rotation of the lumbar spine is achieved by using the legs of the patient as a lever or fulcrum of movement, confusion arises as to the direction in which the lumbar spine rotates. This is judged by the movement of the upper vertebrae in relation to the lower — for example, if the patient is lying supine and the legs are taken to the right, then the lumbar spine rotates to the left. It has become widely accepted that rotation manipulation of the spine should be performed by rotation away from the painful side. This has applied to derangement as well as dysfunction, because hitherto n...
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 ...
Examination of Back Pain Having digested the information supplied by the referring doctor, extracted as much relevant information as possible from the patient, and checked the radiologist’s report, we may proceed to the examination proper. If the patient is able to do so, we should make him sit on a straight backed chair while taking his history. During this lime he will reveal the true nature of his sitting posture. When the patient rises to undress after the interrogation we should observe the way he rises from sitting, his gait, the way he moves, and any deformity that may be obvious. We will record the following: I. POSTURE SITTING If the patient has been sitting during history taking, we already have a good impression of his posture. We now ask him to sit on the edge of the examination table with his back unsupported. In the majority of cases the patient will sit slouched with a flexed lumbar spine. Some patients are more aware of the relationship between their posture and pain. They have discover...