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Williams' Flexion Versus McKenzie
Extension Exercises For
Low Back Pain

In general, extension exercises may cause further damage in people with spondylolysis, spondylolisthesis and facet joint dysfunction (Harvey 1991), not to mention the possibility of crushing the interspinous ligament (McGill 1998).  While flexion exercises should be avoided in persons with acute disc herniation (Harvey 1991).

Brief History of Williams' Flexion Exercises
Dr. Paul Williams first published his exercise program in 1937 for patients with chronic low back pain in response to his clinical observation that the majority of patients who experienced low back pain had degenerative vertebrae secondary to degenerative disk disease (Williams 1937).  These exercises were developed for men under 50 and women under 40 years of age who had exaggerated lumbar lordosis, whose x-ray films showed decreased disc space between lumbar spine segments (L1-S1), and whose symptoms were chronic but low grade.  The goals of performing these exercises were to reduce pain and provide lower trunk stability by actively developing the "abdominal, gluteus maximus, and hamstring muscles as well as..." passively stretching the hip flexors and lower back (sacrospinalis) muscles.  Williams said: "The exercises outlined will accomplish a proper balance between the flexor and the extensor groups of postural muscles..." (Williams 1965, Williams 1937, Blackburn 1981, Ponte et al.).

Williams’ flexion exercises have been a cornerstone in the management of lower back pain for many years for treating a wide variety of back problems, regardless of diagnosis or chief complaint.  In many cases they are used when the disorder’s cause or characteristics were not fully understood by the physician or physical therapist.  Also, physical therapists often teach these exercises with their own modifications.  Williams suggested that a posterior pelvic-tilt position was necessary to obtain best results (Williams 1937).

Examples of Williams' Flexion Exercises
1. Pelvic tilt.  Lie on your back with knees bent, feet flat on floor.  Flatten the small of your back against the floor, without pushing down with the legs.  Hold for 5 to 10 seconds.

2. Single Knee to chest.  Lie on your back with knees bent and feet flat on the floor.  Slowly pull your right knee toward your shoulder and hold 5 to 10 seconds.  Lower the knee and repeat with the other knee.

3. Double knee to chest.  Begin as in the previous exercise.  After pulling right knee to chest, pull left knee to chest and hold both knees for 5 to 10 seconds.  Slowly lower one leg at a time.

4. Partial sit-up.  Do the pelvic tilt (exercise 1) and, while holding this position, slowly curl your head and shoulders off the floor.  Hold briefly.  Return slowly to the starting position.

5. Hamstring stretch.  Start in long sitting with toes directed toward the ceiling and knees fully extended.  Slowly lower the trunk forward over the legs, keeping knees extended, arms outstretched over the legs, and eyes focus ahead.

6. Hip Flexor stretch.  Place one foot in front of the other with the left (front) knee flexed and the right (back) knee held rigidly straight.  Flex forward through the trunk until the left knee contacts the axillary fold (arm pit region).  Repeat with right leg forward and left leg back.

7. Squat.  Stand with both feet parallel, about shoulder’s width apart.  Attempting to maintain the trunk as perpendicular as possible to the floor, eyes focused ahead, and feet flat on the floor, the subject slowly lowers his body by flexing his knees.  


Brief History of McKenzie Back Exercises
The McKenzie back extension exercises have been order by physicians and prescribed by physical therapists for at least two decades (
McKenzie 1981).  Robin McKenzie noted that some of his patients reported lower back pain relief while in an extended position.  This went against the predominant thinking of Williams Flexion biased exercises at this period of time.

Physical therapists can become "McKenzie certified", but the vast majority of physical therapists who treat low back pain are not.  McKenzie has developed diagnostic categories that assign patient to specific treatments.  Patients evaluated by McKenzie certified therapists are most likely to be placed into an extension biased exercise program.  This is probably why most people think of extension when talking about McKenzie exercises, or because the original exercises were in opposition to Williams' flexion exercises.

The goal of McKenzie exercises is to centralized pain.  If a patient has pain in the lower back, right buttock, right posterior thigh, and right calf, then the goal would be to "centralize" the pain to the lower back, buttock, and posterior thigh.  Then, "centralize" the pain to the lower back and buttock, and finally just the lower back.

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Typical McKenzie Back Extension Exercises
1.  Prone lying.  Lie on your stomach with arms along your sides and head turned to one side.  Maintain this position for 5 to 10 minutes.

2.  Prone lying on elbows.  Lie on your stomach with your weight on your elbows and forearms and your hips touching the floor or mat.  Relax your lower back.  Remain in this position 5 to 10 minutes.  If this causes pain, repeat exercise 1, then try again.

3.  Prone press-ups.  Lie on your stomach with palms near your shoulders, as if to do a standard push-up. Slowly push your shoulders up, keeping your hips on the surface and letting your back and stomach sag.  Slowly lower your shoulders.  Repeat 10 times.

4.  Progressive extension with pillows.  Lie on your stomach and place a pillow under your chest.  After several minutes, add a second pillow.  If this does not hurt, add a third pillow after a few more minutes.  Stay in this position up to 10 minutes.  Remove pillows one at a time over several minutes.

5.  Standing extension.  While standing, place your hands in the small of your back and lean backward.  Hold for 20 seconds and repeat. Use this exercise after normal activities during the day that place your back in a flexed position: lifting, forward bending, sitting, etc.

What Does Recent Research Suggest About William Flexion or McKenzie Back Exercises?
A.  Adams, et al. found that "extension can reduce stresses in the posterior annulus of those discs that are most protected by the neural arch.  This protection may be related to disc height loss, to the morphology of the neural arch, or both....

Discogenic pain is associated with stress concentrations in the posterior annulus.  That backward bending can reduce such stress peaks in some discs could explain pain relief in some back pain patients undergoing extension exercises...  Pain relief would be anticipated only in those patients whose painful discs can be stress shielded by the neural arch in extension, and this may depend on factors such as disc height, and the precise shape of the neural arch....  

Backward bending may also correct any posteriorly displaced intradiscal mass, which is presumably an embryonic stage of disc herniation.  This dynamic internal disc model may provide an explanation for the commonly noted phenomenon of "centralization", in which distal pain is abolished and symptoms move proximally, often in response to extension exercises (Adams 2000).

B.  When rehabilitating patients with back dysfunction, extension exercises that are presumably "passive" for the erector spinae muscles are frequently used.  The results of a study demonstrated that "passive" extension exercises were not truly passive for lumbar back extensor muscles.  From a clinical perspective, if the performance of passive back extension is important, extension in lying prone may not be the exercise of choice and having patients lying prone may be the most beneficial (Fiebert 1994 ).

C.  In one of the more carefully conducted randomized trials of nonsurgical back pain treatments undertaken in recent years, researchers conclude that McKenzie back exercises provide slightly greater pain relief than a placebo--the control group received a patient education booklet on low back pain.  Neither chiropractic manipulation nor McKenzie back exercises provided a significant functional benefit.

One of the most important tests of a therapy's efficacy is how it affects back problems over the long term.  McKenzie proponents have argued that their protocol reduces recurrences of back pain and decreases utilization of services.  This study showed evidence that McKenzie back exercises do not reduce low back pain recurrence.

"This casts doubt on the ability of the self-care-oriented McKenzie (back exercises) to reduce the utilization of services," suggest the researchers.  "There was no evidence that the higher initial costs of the physical treatments were offset by later savings," they add (Cherkin 1998).

D.  Nachemson arguably discredited Williams flexion back exercises when his study showed that these exercises may significantly increased the pressure within intervertebral discs of the lumbar spine (Nachemson 1963).

E.  Two studies have shown that lower back stiffness may only be a symptom of lower back pain and not the cause of it. (Johannsen 1995, Mellin 1985)  Johannsen, et al. conclude that "...increased spinal mobility does not necessarily lead to LBP (low back pain) improvement, and mobilizing exercises alone cannot be recommended to LBP patients (Johannsen 1995).

F.  Is there another explanation for symptom relief resulting from McKenzie?  What about tight iliopsoas muscles?  Isn't it more likely that the effectiveness of McKenzie extension exercises is associated with the elongation of the iliopsoas muscles secondary to the stretch positions.  The truth is that there is no reproducible data that shows that the exercise effect has anything to do with the nucleus pulposis "moving"... (Jorgensson 1993, Ingber 1989).

References
Adams MA, May S, Freeman BJ, Morrison HP, Dolan P. Effects of backward bending on lumbar intervertebral discs. Relevance to physical therapy treatments for low back pain. Spine 2000 Feb 15;25(4):431-7.

Blackburn SE, Portney LG. Electromyographic activity of back musculature during Williams' flexion exercises. Phys Ther  1981;61:878-885.

Cherkin DC et al., A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain, New England Journal of Medicine, 1998; 339:1021-9.

Fiebert I, Keller CD. Are "passive" extension exercises really passive?  J Orthop Sports Phys Ther 1994 Feb;19(2):111-6.

Harvey J, Tanner S. Low back pain in young athletes: a practical approach. Sports Med 1991;12:394-406.

Ingber R. Iliopsoas myofascial dysfunction: A treatable cause of "failed" low back syndrome. Arch Phys Med Rehab (70): 382-386 (1989).

Johannsen F, et al. Exercises for chronic low back pain:  A clinical trial. J Ortop Sports Phys Ther. 1995;22:52-59.

Jorgensson A. The iliopsoas muscle and the lumbar spine. Australian Physiotherapy 39(2): 125-132 (1993).

McGill SM. Low back exercises: evidence for improving exercise regimens. Phys Ther. 1998;78:754-765.

Mellin G: Physical therapy for chronic low back pain:  Correlations between spinal mobility and treatment outcome. Scand J Rehabil Med 1985;17:163-166.

Nachemson AL. the influence of spinal movements on the lumbar intradiscal pressure and on the tensile stresses in the annulus fibrosus.  Acta Orthop Scand 1963;33:183-207.

Ponte DJ, Jensen GJ, Kent BE. A preliminary report on the use of the McKenzie protocol versus Williams protocol in the treatment of low back pain.  J Orthop Sports Phys Ther 1984;6:130-9.

Williams PC: Lesions of the lumbosacral spine:  chronic traumatic (postural) destruction of the intervertebral disc, J Bone Joint Surg 1937;29: 690-703.

Williams PC: The Lumbosacral Spine.  New York, NY, McGraw-Hill Book Co, 1965, pp 80-98.