I recently saw a social media post entitled “Prone Exercise Progression for Low Back Pain.” If only it were that simple! There is no "prone exercise progression" for low back pain. Prone exercises are used for certain diagnoses with certain patients. Pain, after all, is not a diagnosis. We don’t treat heart pain or lung pain - we treat the underlying diagnosis. Will I allow that there are rare cases in which we can’t establish a true cause? Sure. But in those cases you get there by ruling out a multitude of possibilities.
Not only can we do better than treating the symptom of pain, but we can be specific about what each individual needs. A prone exercise progression will help some people with some diagnoses. It will also do nothing for some people and will make some people worse. You can try whatever you find on the internet if you want. We all do it from time to time. But success is more likely when you have an individual diagnosis and plan. -- Laura
As I've written before: most orthopedic answers lie in moving people in directions they don’t usually move into. Top of that list? Yes: extension. How often do you bend your low back all the way back? Your neck? Your shoulder? Your hip?
But that doesn’t mean all problems are fixed with extension exercises. (Taking a step back, not all orthopedic problems are fixed with movement. Over 90% are, but that leaves room for conditions that require different interventions.) A person who responds to exercise, may need repeated rotation, side glide, side bend, flexion, or any combination of movements. I look for the exercise that positively affects a person’s symptoms, movement, and function. It really can be put that simply. While most need some form of extension, there are dozens of potentially therapeutic exercises.
Robin McKenzie did not invent the exercise of extension, but, as far as I know, he was the first to regularly explore if repeated extension (in its various forms) could be therapeutic. It’s really a shame that students (and others) have the notion that there are Williams flexion exercises and McKenzie extension exercises. It is not only an oversimplification - it is wrong. I am having one patient now perform lumbar flexion for her home program - and applying the McKenzie method to her problem is what got me there. -- Laura
I remember thinking years ago how odd it seemed that people’s joint pain (often occurring for no known reason) would be addressed by simultaneously stretching muscles, moving joints, strengthening other muscles, and changing posture (plus ice, heat, US, etc). It didn’t seem logical that all of those pieces fell perfectly into disarray, leading to pain.
Does it make more sense that joint immobility and muscle tightness and weakness led to the impingement, or that the impingement led to those findings? What I find more rational is that a joint impingement, a joint derangement, or, simply put, a joint that’s a bit stuck occurs because, well, joints are mobile things and these things happen. The most obvious example is you unknowingly sleep in a certain position and you wake up with stuck neck joints. Or your shoulder joint gets impinged because you repeatedly move in a new way starting tennis again. Or your low back gets deranged because you sit in the exact same position in your office chair for hours a day. These factors and others can easily lead to minor (fixable!) joint disruptions. In fact, most of these examples, especially the neck scenario, will resolve with daily movement (and possibly a little rest) on their own - no doctors or other help needed.
I deduce in the clinic if a joint is impinged/not moving optimally by repeatedly moving joints and gauging the effect. I don’t rely on “impingement tests.” I secondly don’t believe in the value of imaging except for a small minority of cases. It’s much more likely that the bony configuration of your joint (eg shoulder acromion or hip acetabulum) has been that way, if not your entire life, then most of your life, and therefore this new pain is due to new factors.
To address it, in contrast to the stretching, strengthening, and movement I alluded to above, we look for the specific joint movement that unpinches the joint. It’s typically one that is not regularly performed in the person’s daily life. The theory as to why these things occur is that it’s normal for joints to get a bit stuck if you don’t move them in a variety of directions or if you spend the majority of your time in one uninterrupted direction. They’re so common that most self resolve, but I see the stubborn ones. -- Laura
It’s easy to be misguided by immediate results from an intervention, whether the intervention is movement or something else like heat. For example, if we do 20 knee extensions in semi-loaded and you gain significant range in your obstructed knee flexion, that could be due to a few factors. One, I am just “warming up” the knee joint (or whatever structure(s)) so now we get more mobility. Meaning, if we do anything that moves the knee a lot, we’ll get more flexion. Or, two, extension in semi-loaded is truly the specific, necessary exercise for this knee to unlock flexion.
There are ways to answer this inquiry. For one, if we then wait several minutes with the knee resting, we can re-test flexion. After resting, if the gains remain, it’s less likely the factor was simply being “warmed up.” Similarly, if the person does that extension exercise over a few days at home, we should see improved flexion out of the gate (when “cold”) on the next visit. And, if we do a separate knee exercise 20 times and flexion does not improve or worsens, then we know there is something special about semi-loaded knee extension for this particular knee.
It’s not uncommon to see great changes in the clinic that don’t hold up over several days of repetition. That’s fine. It was prescribed as a home program to see the effect, not as a cure. That response tells us a lot of information regarding diagnosis and what to do next. But don’t persist if you see any type of positive change that, over time, just doesn’t stick. Sometimes that simply means the positive change that initially occurred was due to a general “warming up” phenomenon. Now look for the intervention that can create lasting positive change. --Laura
Once we find the direction a joint needs (its directional preference), we must establish the protocol. A rule of thumb is 10 repetitions every 2 hours, but it needs to be tailored to people’s specific situations. There are many parameters when it comes to the home protocol, mainly total volume, repetitions per set, sets per day, frequency, cadence, and time.
For me, frequency is the most significant - how regularly the exercise is performed throughout the day. Of course the other dimensions matter, but if I had to choose between 100 repetitions at 9:00am, 25 reps in the morning plus 25 reps in the evening, or 5 reps performed frequently (say every 3 hours), I would choose the final option. The reason is simply that in the intervening time people move their bodies, their joints, in all different directions. Doing the exercise regularly in effect “resets” the joint to the desired position. So if 6 hours or 3 days passes, when the exercise is revisited it’s more likely there’s more “resetting” to do. It’s as if the boulder rolled farther down from the top of the mountain and now there’s more to overcome. With high frequency, we want to keep the boulder from rolling down too far and eventually keep it set where it should be at the top of the mountain. This is not my exact mindset when I approach muscle, tendon, nerve, capsule, or other problems; however, for those I diagnose with joint derangements, frequency is almost always the number one priority for improvement. -- Laura
I look for direct cause and effect. In most cases, the cause. the intervention, is movement. Movement is usually generated by the patient, but I can use manual techniques if needed. Here’s a simple, common example of how I implement this in the office.
A patient presents with isolated pain on the right shoulder, lateral aspect. History: intermittent pain, pain usually with reaching, no pain at rest, can’t throw, present for 3 months, staying the same, no trauma, notices loss of flexion which can vary. Physical exam: no pain at rest and no cervical or thoracic loss of ROM or pain. Shoulder flexion: moderate loss with pain at end range. Shoulder internal rotation: minimal loss with pain during movement. Concordant pain with resisted abduction and pain-free weakness in external rotation (3+/5). All other shoulder baselines are normal. I don’t regularly do special tests.
Now I want to investigate if there is a particular movement (directional preference exercise) that has a positive effect on those baselines. I test 10 reps of cervical retraction and extension with overpressure: no effect on baselines. I test 10 reps of right lateral cervical flexion with overpressure: no effect. I test 10 reps of thoracic extension with ball overpressure: no effect. I test 10 right shoulder internal rotations (hand behind back): shoulder external rotation improves to 4+/5 and flexion is less painful. We do 20 more internal rotations and flexion is now only minimal loss and there’s no more pain with resisted abduction. We have found a significant positive effect with the exercise repeated shoulder internal rotation.
That will become the patient’s home program until the next visit. It’s about demonstrable cause and effect, not theories or guessing. It’s about being specific and not giving someone who needs one movement a program of seven things to stretch, strengthen, and retrain when it’s not needed. -- Laura
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