Loss of flexion is the second most common movement loss in the lumbar spine. It manifests itself in several ways, which interfere with either the amount of available flexion or the pathway taken to achieve flexion. This type of dysfunction is commonly seen in patients with an accentuated lordosis.
Patients with significant flexion dysfunction are usually unable to sit slouched with a convex lumbar spine. When giving postural instructions to these patients, we must explain that once sitting relaxed they place the lumbar spine on full stretch much sooner than patients with a normal flexion excursion.
Fig. Recovery of loss offlexion, using the procedure of flexion in standing.
Recovery of pure flexion loss
To regain flexion we must, just as in the case of extension dysfunction, explain to the patient the purpose of performing exercises. Again, we must stress the necessity of causing a moderate degree of discomfort or pain with the exercises. Pain produced by stretching of contracted structures involved in the loss of flexion should be felt across the low back. Often it resembles the pain of which the patient originally complained, and as in the recovery of extension it should be shortlived.
Recovery of pure flexion is commenced with exercises. The patient must perform flexion in lying (Proc. 13). This exercise should be performed ten times about every two hours. As said before, frequency and regularity of exercising are important factors in the treatment of dysfunction. When five to six days have passed the patient will describe that the knees can be bent fully onto the chest. All flexion that can possibly be restored in this position is now recovered, and the exercise no longer produces pain. In order to apply full passive stretch to regain the last few degrees of lumbar flexion it is necessary to perform flexion in standing (Proc. 14).
Up till now flexion has been performed in lying (Proc. 13) with elimination of gravitational forces. This rarely makes the patient significantly worse. In flexion in standing (Proc. 14) gravitational stresses are added.
When applied to dysfunction resulting from recent derangement, flexion in standing (Proc. 14) may sometimes exacerbate the condition. Therefore, when commencing flexion in standing (Proc. 14) the patient should reduce the number of exercises performed at each session as well as the frequency of the sessions per day — for example, five to six repetitions of the exercise should be done five to six times per day. This way there is little risk of exacerbation, and after four to five days the patient may progress to a full programme.
Eventually the patient will recover his flexion and will almost reach the ground before any strain pain is felt. No discomfort should be experienced on returning to the erect position.
If full flexion cannot be restored by the patient’s own efforts, the application of special procedures may be indicated, such as rotation mobilisation and manipulation in flexion (Proc. 11 and 12).
Occasionally, a patient with the derangement syndrome will mistakenly be placed in the dysfunction category. If this occurs the flexion procedures may immediately and significantly worsen the symptoms, and in this way the true nature of the condition will be revealed. Consequently, the treatment programme must be altered appropriately.
N.B. Remember that the recovery of function in flexion following recent derangement, is hazardous. Extension in lying (Proc. 3) should always follow flexion movements in order that any posterior disturbance is corrected immediately.
Treatment of flexion with deviation
There are two common types of deviation in flexion resulting from dysfunction. The first one occurs in the patient who is unable to reach full flexion via the normal sagittal pathway, no matter how hard he tries. Due to adaptively shortened structures within the intervertebral segment he is forced to deviate to one side during flexion.
Treatment for this type of flexion loss may follow the course recommended for recovery of pure flexion loss. Thus, treatment commences with flexion in lying (Proc. 13). Provided the initial twenty-four hour period of flexion in lying (Proc. 13) has not caused a lasting increase or peripheralisation of pain, the use of flexion in step standing (Proc. 15) is indicated at an early stage of treatment to correct the deviation in flexion. This is later followed by flexion in standing (Proc. 14) to ensure recovery of full flexion movement. When commencing flexion in step standing (Proc. 15) the same precautions should be taken as discussed previously (that is, when commencing flexion in standing (Proc. 14) in treatment recommended for recovery of pure flexion).
If the initial twenty-four hour period of flexion in lying (Proc. 13) causes a lasting increase or peripheralisation of symptoms, our diagnosis is incorrect and the most likely reason for the deviation is internal derangement of a lumbar disc. Consequently, we must alter our treatment approach.
The second type of deviation in flexion resulting from dysfunction is caused by an adherent nerve root, and its treatment will be discussed in conjunction with the treatment of sciatica.