Oh, My Aching Back!

Why are patients and their physicians so often frustrated by back pain?

A common evolutionary belief is that erect posture is inherently stressful for the spine. The human lumbar spine has a forward curvature (lordosis), which is viewed as an imperfect adaptation in man’s supposed struggle to progress from four-footed stance to two-footed stance. With this evolutionary premise, a logical treatment for back pain would be to perform exercises which decrease or reverse the lordosis.

The work of Dr Paul Williams has been extremely influential in the American medical profession’s understanding of back pain. According to Dr Williams, ‘Man, in forcing his body to stand erect, severely deforms his spine.’

Dr Williams devised a series of exercises known as Williams Flexion Exercises, which have been widely used in back pain treatment, with a goal of decreasing or reversing the lordosis. The exercises include the pelvic tilt, partial sit-up, and drawing the knees to the chest. Patient education materials based on flexion exercises are widely disseminated from doctors’ offices, physical therapy clinics, and the general media. They frequently are illustrated with a caricature of a happy ape walking on all fours, contrasted with an unhappy cave-man trying to stand upright and holding his back in pain.

Despite widespread use of flexion (bending) exercise, back pain remains a severe problem. Patients entering a course of flexion exercises cannot be assured of the probability of a successful outcome. Physicians have no recognized way of predicting which patients will respond to conservative (non-surgical) treatment. Furthermore, there is a lack of controlled scientific study to support the use of flexion exercises over any other treatment, or no treatment.

About 25 years ago, a physical therapist in Wellington, New Zealand, made an accidental discovery. The therapist, Mr Robin McKenzie, found that postures or exercises which restored full lordosis would, in many cases, decrease or abolish pain, shortly after a temporary period of increased pain. Teaching patients to maintain the lordosis in daily activities continued to control pain. He developed a system of evaluating and classifying patients to identify which patients would benefit from restoration of lordosis by performing extension exercises.

Very gradually, the use of extension exercise has found some acceptance in the American medical community through the efforts of McKenzie and the therapists whom he has trained. In 1986, a controlled scientific study was performed in Dallas, Texas. This study clearly supported the extension exercise when compared to (1) lumbar flexion with a traction apparatus, and (2) ‘back school’ (general strengthening, flexibility, and body mechanics).

Mr McKenzie is no creationist, but his work supports the creationist view that the lumbar lordosis is not a deformity with inherent strain from past evolutionary development. The lumbar spine is, instead, a most efficient means of supporting weight and providing for movement in erect, bipedal posture.

If extension is healthful for the lumbar spine, what about flexion? If you are now sitting, your lumbar spine is probably flexed. Bending, stooping, lying curled up, and slouched standing also produce lumbar flexion. McKenzie’s view is that these flexion activities, when prolonged and unbalanced by extension, are responsible for most of the common recurrent back pain in modern cultures.

We live, work, and have recreation in a fallen world. The postures that our spine assume, in weariness, discouragement, and sloth, are not the postures that Adam and Eve enjoyed when they first walked the Earth and tended the uncorrupted garden.

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