TREATMENT OF FLEXION DYSFUNCTION

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.

READ:   Spine Health. PROCEDURE 5 — SUSTAINED EXTENSION

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.

Exercises

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).

READ:   Spine Health. PROCEDURE 17 - SELF-CORRECTION OF LATERAL SHIFT

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.

READ:   Spine Health. PROCEDURE 16 — CORRECTION OF LATERAL SHIFT

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.

Special techniques

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.

READ:   Spine Health. PROCEDURE 12 — ROTATION MANIPULATION IN FLEXION

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).

READ:   Spine Health. PROCEDURE 4 — EXTENSION IN LYING WITH BELT FIXATION

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.

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...
Low Back Pain. Contraindications Although it has been accepted throughout that all patients have received adequate medical screening, occasionally patients with serious pathology or mechanical disorders unsuited to mechanical treatment are encountered during routine examination. If in the examination no position or movement can be found which reduces the presenting pain, the patient is unsuited for mechanical therapy, at least at this time. The existence of serious pathology should be considered when the history states that there has been no apparent reason for the onset of symptoms; that the symptoms have been present for many weeks or months, and have during that time increased in intensity; and that they are constant; and the patient feels that he is gradually getting worse. On examination the pain remains exactly the same, irrespective of positions assumed or movements performed. Usually there is little loss of function if any, and postural deformity is not often seen. In addition to the examination finding, th...
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...
The Derangement Syndrome Of all mechanical low back problems that are encountered in general medical practise, mechanical derangement of the intervertebral disc is potentially the most disabling. It is my belief that in the lumbar spine, if in no other area, disturbance of the intervertebral disc mechanism is responsible for the production of symptoms in as many as ninety-five percent of our patients. Twenty-five years of clinical observation and treatment of lumbar conditions have convinced me that certain phenomena and the various movements which affect them, can occur only because of the hydrostatic properties invested in the intervertebral disc. For thirty years Cyriax has attributed lumbar pain to internal derangement of the intervertebral disc mechanism. He has outlined the cause of lumbago, and proposed that pain of a slow onset is likely to be produced by a nuclear protrusion while that of a sudden onset is caused by a displaced annular fragment. Although at present we are unable to prove either of ...
Back pain Prevention The majority of patients responding to basic extension and flexion principles of treatment have been educated in the means of achieving pain relief and restoring function. They have carried out the self-treatment procedures and have to a large extent become independent of therapists. Following successful treatment it requires little emphasis to convince patients that if they were able to reduce and abolish pain already present, it should also be possible to prevent the onset of any significant future low back pain. Of all the factors predisposing to low back pain only postural stresses can be easily influenced and fully controlled. We must develop this potential ingredient of prophylaxis to the full. The patient must understand that the risks of incurring low back pain are particularly great when the lumbar spine is held in sustained flexed positions; and that when the lordosis is reduced or eliminated for prolonged periods, he must at regular intervals and before the onset of p...