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EFFECTIVENESS OF WILLIAM’S FLEXION EXERCISE IN THE MANAGEMENT OF

LOW BACK PAIN

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TJPRC: International Journal of Physiotherapy &
Occupational Therapy (TJPRC: IJPOT)
Vol. 1, Issue 1, Jun 2015, 33-40
© TJPRC Pvt. Ltd.

EFFECTIVENESS OF WILLIAM’S FLEXION EXERCISE

IN THE MANAGEMENT OF LOW BACK PAIN

MOHAN KUMAR. G, REVATHI. R & RAMACHANDRAN. S

Faculty of Physiotherapy, Dr. MGR Educational & Research Institute University, Velappanchavadi,
Chennai, Tamil Nadu, India

ABSTRACT
Objective of the Study
To evaluate the effectiveness of William’s flexion exercise in the management of low back pain.

Background of the Study

As there is a trend towards an increase in the number of low back pain patient with growing stress in life globally
there is need of appropriate physical therapy treatment. Likewise strengthening of abdominal muscles and gluteus muscles
is effective or not will see in this study.

Methodology

30 patients of both male and female were selected from the ACS medical college and hospital Chennai -77 The
duration of study was four weeks. Visual analogue scale and Oswestry disability index questionnaire is used before and
after exercise for analyzing the pain and activities

Data Analysis

Comparing visual analogue scale on both pre[5.06] and post test[3.56] showed p[<0.001] highly significant with
subjects. Comparing oswestry disability index questionnaire on both pre [28.80] and post[17.6] showed p[<0.001] highly
significant with subjects.

Result

There is significant effects of William’s flexion exercise in low back pain management Pain intensity was
significantly reduced in those who took more than

Conclusions

William’s flexion exercise provided benefits to most of the participants in this study, thus it may be an effective
technique to reduce the intensity of pain and increase range of motions

KEYWORDS: William’s Flexion Exercise, Low Back Pain, Visual Analog Scale, Oswestry Disability Index
Questionnaire

INTRODUCTION

Low back pain is a painful clinical, bio psychosocial syndrome with multiple etiology, characterized by pain
between the twelfth rib and the sacrum, associated with or without radiation to the lowerlimbs, causing limitation of

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34 Mohan Kumar. G, Revathi. R & Ramachandran. S

activities and disability One would have thought by now that the problem of diagnosis and treatment would have been
solved, but the tissue remains mysterious and clouded with uncertainty..It is a challenge for the medical community. In the
view of mechanical the accentrated lumbar lordosis is associated with increase prevalence of low back pain1.Imbalancein
trunk muscle strength the lumbar curve is increased and might be one of risk factor for LBP2.LBP incidence is depend on
according to age.80% of the world population had at least one LPB episode and the 20% remaining have not paid attention
to it. While this pain becomes so extreme that person is unable to move and outcome is complete bed rest. Adams MA in
his study recommended that stays active and to avoid bed rest3.Ligament and muscles that surround the lumbar spine Strain
in these structures which results in backpain4. The factors which cause back pain are poor body posture, overweight and
weak back and abdominal muscle in lumbar spine. Variation in pelvic morphology may significantly influences measures
of pelvic tilt and in nominate rotational asymmentry5. Many treatments are effective for low back pain but they relieve only
for one or two hours. Using of these medication that results in liver damage and also drowsiness6.Physical therapist use
many exercise for back pain Among these specific exercise, one is ''Williams flexion exercise'' also called lumbar flexion
exercise. Williams flexion exercise program was developed in 1937 for patient with chronic lbp for men under 50 and
female under 40 years who had exaggerated lumbosacral lordosis7.The solution, Williams explained, was to have the
patient perform exercises and adhere to postural principles which serve to decrease the lumbar lordosis to a minimum,
thereby reducing the pressure on the posterior elements of the lumbar spine.8 Williams said: "The exercises outlined will
accomplish a proper balance between the flexor and the extensor groups of postural muscles..."9. Williams suggested that a
posterior pelvic-tilt position was necessary to obtain best results10.The WFEs stand in some opposition to another type of
back exercises, devised by Robin McKenzie (b. 1931) and known as the “McKenzie extension exercises”, which involve
the opposite motion of extending the spine backwards. (One review stated that “Perhaps no two methods of physical
therapy treatment for low back pain are so contradictory in both theory and practice”)8.There was no significant
relationship between lbp occurrence and concluded that the degree of lumbar lordosis did not differ between normal
patients and those with lbp10.These are the set of physical exercises use to enhance lumbar flexion to avoid lumbar
extension and strengthen the abdominal and gluteus musculature to manage low back pain 11.Physical therapy treatment can
improve the patient ability to function12.The physical therapy can reduce the disability13.So role of physical therapy is also
important in low back patients. Getting a neutral position depends upon stretching the extensor lumbar muscles
(paravertebral muscles and iliopsoas) and toning the abdominals (which pull the pube up) and the gluteus (which pull down
the posterior part of the pelvis) Extending across the anterior surface of the body from the superior border of the pelvis to
the inferior border of the ribcage are the muscles of the abdominal wall, including the transverse and rectus abdominis and
the internal and external obliques. Working as a team, these muscles contract to flex, laterally bend, and rotate the torso.
The abdominal muscles also play a major role in the posture and stability to the body and compress the organs of the
abdominal cavity during various activities such as breathing and defecation .In patients with normal abdominal
muscles, as trunk flexion is slowly initiated by raising the head and shoulder from a supine position, the pelvis tilts
posteriorly simultaneously. Exercise intervention with patient education, are first in the conservative approach to treat
musculoskeletal conditions of the lumbar spine. By the exercise, body tissues adapt to the stress and demands of everyday
living. In most cases the back pain are mechanical in nature so, a functional approach will produce the long-term benefit

Attached to the pelvis are muscles of the buttocks, the lower back, and the thighs. These muscles, including the
gluteus maximus and the hamstrings, extend the thigh at the hip in support of the body's weight and propulsion. Toddy and
colleagues [1994] preferred increasing hamstring flexibility by isokinetic training as an effective method to improve

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Effectiveness of William’s Flexion Exercise in the Management of Low Back Pain 35

performance in the hamstring muscle14. Other pelvic muscles, such as the psoas major and iliacus, serve as flexors of the
trunk and thigh at the hip joint and laterally rotate the hip as well. Press heel sit ups increase psoas major activity 15Mental
practice may prove to be a useful adjunct to traditional treatment option aimed at increasing muscle strength 16. They
17.
found no significant inn mean of lordosis after four weeks by using isometric flexion exercise . Very little quality
research and data seems to indicate that acupuncture was not effective for the treatment of back pain.So the aim of this
study is to assess the effectiveness of William flexion exercise in management of patients with low back pain.

METHODOLOGY

The design of this study was experimental study. This study done in outpatient department of Physiotherapy at
ACS Medical College and Hospital. The period of this study was twice in a day for four weeks. The study group included
30 patients, Patients were selected in simple random sampling method. The study includes only the 30 patients of both
male and female with the age group between 18 and 45 yrs, Mechanical low back pain, Muscle strain, Spondylolisthesis,
Exaggerated lumbar lordosis, Patients were excluded if they had Sciatica ,Spinal tumours, Low back pain due to road
traffic accidents, Pregnancy, Spinal stenosis, Recent spinal fracture. Lumbar spondylosis, Visual analogue scale and
Oswestry disability index questionnaire were used as a outcome measures

INTERVENTION

A brief history of patients will be taken via physical examination was done. Data will be collected on structured
questionnaire enclosing questions targeting to assess the type, intensity, duration and pattern of pain. These are the
questions on relieving factors. Occurrence of pain and the worse time of pain. As the study aim is to assess the
effectiveness of Williams flexion exercise in the management of low back pain. Information conveyed to the patient about
William flexion exercise. The pre treatment score will be taken before initiating the exercise by using oswestry
questionnaire and visual analogue scale

Williams' Flexion Exercises18: 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.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 1seconds.Lower the knee and repeat with the
other knee. 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.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. 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.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. 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

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36 Mohan Kumar. G, Revathi. R & Ramachandran. S

Figure 1: Hamstring Stretchz

Figure 2: Pelvic Tilt

Figure 3: Double knee to Chest

Figure 4: Partialsitups

Figure 5: Curlups

Figure 6: Quadriceps Stretch

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Effectiveness of William’s Flexion Exercise in the Management of Low Back Pain 37

After twice a day for four weeks the post treatment score will be taken by using oswestry questionnaire and visual
analogue scale. At last the score will be analyses between pre and post treatment. In addition to evaluate the spine flexion
and extension with pain intensity before and after exercise.

DATA ANALYSIS

Table 1: Pain Intensity and Physical Activity before Exercise

Visual Analogue Scale Oswestry Questionnarie
Pain Intensity
Mean SD Mean SD
Mild(53%)
Moderate(40%) 5.66 0.844 28.80 4.52
Severe(7%)

Table 2: Pain Intensity and Physical Activity after Exercise

Visual analogue Oswestry
Pain Intensity Scale Questionnarie
Mean S.D Mean S.D
Mild
Moderate 3.54 1.10 17.6 5.84
Severe

Figure 7: Improvement in Pain Intensity and Physical Activity

Statistically analysis of SPSS software the mean and standard deviation of this study shows that there is a
significant different in pre and post test score and the significant p value > 0.001

RESULTS

Total n= 30 patients were inquired about the characteristics of pain and functional activity. Duration of pain was
found at least 3 months.

The table 1 shows that the pre test score for VAS mean [5.66] and sd [0,844] and for ODI mean [28.80] and sd
[4.52].The table 2 shows that the post test score for VAS mean [3.54] and sd [1.10] and for ODI mean [17.6] anssd [5.84]

Graph represent that the pre test value of mean and standard deviation for VAS and ODI have a changes in the
values when compare to post test values of both VAS and ODI.The values are analyzed with SPSS software and placed in
data analysis

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38 Mohan Kumar. G, Revathi. R & Ramachandran. S

There was significant association between sessions of William Flexion exercise and post pain intensity<0.001

DISCUSSIONS

According to the William’s these exercises reduce the pressure on the posterior element of the lumbar spine.
These exercises restore motion and strength of lower back is helpful in relieving pain and preventing reoccurrence of low
back pain. It also strengthen the back and abdominal muscles which maintain the all structure alien and prevent the over
loading of the posterior element of the lumbar spine. William flexion exercises using valsalva maneuver were particularly
benificial for patient with lumbar lordosis19.It is effective to correct the accentrated lumbar lordosis and decrease low back
pain.(Ricci et al.2011)20During the situps exercise the pelvis was found to be tilted and put the spine in hypertension before
forward trunk displacement.(Rici et al.2011)20. The posterior pelvic tilt requires moderate activity of internal and external
oblique muscles their helps to generate the intra abdominal pressure.(Mark et al.2011) Curl ups exercise produce
21
lumbar flexion and provided maximum activity of external and rectus abdominals muscle . Along with exercise patient
education is also very important. Posture is a vital component for the management of low back pain during the working
22
environment and daily living .Pain intensity when measured before therapy, reflected that 7% patients had LBP which
was measured by visual analog scale (VAS) and spinal restriction observed severe, 40% had moderate and 53% had mild
pain.Improvement in pain after therapy was found in most of the case as of those with severe pain had slight pain,
moderate pain patients had partial pain and mild pain had complete reduced in pain. In my study, patients are given
number of William’s Flexion exercise sessions and significant improvement (p<0.001)) in pain intensity is found in these
who took more than sessions. Various studies also reported improvement in LBP after William’s exercise 23.

According to data analysisThe table 1 shows that the pre test score for VAS mean [5.66] and sd [0,844] and for
ODI mean [28.80] and sd [4.52].The table 2 shows that the post test score for VAS mean [3.54] and sd[1.10] and for ODI
mean [17.6] anssd [5.84].Graph represent that the pre test value of mean and standard deviation for VAS and ODI have a
changes in the values when compare to post test values of both VAS and ODI. The Results of our study highlighted that
William’s flexion exercise was beneficial for most of the participants in the study. This exercise with more than four
sessions showed significant improvement in pain intensity. Along with improvement in pain intensity there was also
improvement in spine flexion ad extension after this exercise.

CONCLUSIONS

A present study concluded that a four weeks Williams Flexion Exercise program yielded significance reduce of
pain and improvement in spinal range of motion in patients with low back pain. This study revealed that there is a
significant improvement in terms of pain and improvement in term of spine range of motion patients with low back pain

REFERENCES

1. Cillet R. low back pain syndrome.philadelphiapa.fadavisco,1978 pp.33-49, 16 2.Kim Hj, Chung S Kim S 2006
Influences of Trunk Muscles on lumbar lordosis and sacral angle. European Spine Journal;15 409-414

2. Adams, 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 J 2000; 25: 431-8

3. Tuchinsky D, Back pain: it’s all in your neck, pine lake road suite 100 USA. Writers Club Press 2000:5

4. PreeceSj, William P,Nester C J,Grham –Smith P,l 2008.variation in pelvic morphology may prevent the

www.tjprc.org [email protected]
Effectiveness of William’s Flexion Exercise in the Management of Low Back Pain 39

identification of anterior pelvic tilt. 16;113-117.

5. Malanga GA, Dunn KR. Low back pain management: approaches to treatment J Musculoskeletal Med 2010:27;
30515

6. Williams PC: The Lumbosacral Spine. New York, NY, McGraw-Hill Book Co, 1937,29.690-703.,

7. Ponte, David Joseph, et al (1984), “A Preliminary Report on the Use of the McKenzie Protocol versus
WilliamsProtocol in the Treatment of Low Back Pain”, JOSPT, Vol. 6, No. 2 (Sept-Oct), 6:130-9.

8. Blackburn SE and Portney LG (1981), “Electromyographic Activity of Back Musculature during Williams'
Flexion Exercises”, PhysTher; 61:878-885.

9. Williams P.C. (1937), “Lesions of the Lumbosacral Spine: 2. Chronic Traumatic (postural) Destruction of
theLumbosacral Intervertebral Disc”, J Bone Joint Surg; 29:690-703.

10. Matsudaira K, Hara N, Arisaka M, Isomura T. Comparison of Physician’s Advice for Non-specific Acute Low
BackPain in Japanese Workers: Advice to Rest Versus Advice to Stay Active. Industrial Health 2011; 49: 203-8

11. ScheermesserM, Bachmann S, Schämann A, Oesch P, Kool.J. A qualitative study on the role of cultural
backgroundin patients' perspectives on rehabilitation. BMC MusculoskeletDisord 2012: 13; 5

12. Kuczynski J, Schwieterman B, Columber K, Knupp D, Shaub L, Cook C. Effectiveness of physical

therapistadministered spinal manipulation for the treatment of low back pain: a systematic review of the literature.
Int J Sports PhysTher 2012; 7: 647-62.

13. Teddy W, Troy L, Lason W.effect of hamstring stretching on hamstring muscle performance,jospt.1994;20

14. Juker, D.1998. Quantative intramuscular myoelectric activity of lumbar portions of psoas and the
abdominal.medscisports exercise;30;301-310

15. Sidaway B And TrzaskaAr.2005.can mental practice increase ankle dorsiflexor torque physiotherapy;85;1053-
1060.

16. Giglio C A And VolponJb. 2007. Development and evaluation of thoracic kyposis and lumbar lordosis;1;187-
193Davise JB, physiotherapy 2011 766,271

17. http://www.backtrainer.com/Williams-Flexion-Versus-McKensie-Extension-Exercises-For-Low-Back-Pain.html

18. Davis E, Gibson T.1979.the value of exercise in the treatment of low back pain rheumatology and
rehabilitation;18;243 -247

19. Ricci B, Marchetti M And Figura F.1981.biomechanics of sit ups exercises.medsci sports exercise;113;54-59

20. Halpern and bleck.Wheeler G, Wipf E, Staiger O, Deyo R.Approach to the diagnosis and evaluation of
lowMuhammad Usman Khalid, MahvishRafiq and NosheenZehra Pakistan Journal of Medicine and Dentistry
2013, Vol.1 (01): 21-3.

21. Guccione et al.effectiveness of an ergonomic intervention on work related posture and low back pain.2010.

22. Williams P. Examination and conservative treatment for disc lesions of the lower spine. Clin Orthop1955; 528

www.tjprc.org [email protected]
 40 Mohan Kumar. G, Revathi. R & Ramachandran. S

23. Peterson T, Larsen K, Jacobsen S, Spine.2007, 32, 2948.

24. Richardson C, Jull G, Manual therapy, 1995, 1, 2.

25. May S, Johnson R, Physiotherapy2008, 94, 179.

26. Miller E, Schenck R, Karnes J, John R, Journal of Manual andManipulativeTherapy,2005 13, 103

27. Fairbank JCT, Couper J, Davies J B, O’brien JP, Physiotherapy1980 66, 271

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

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

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

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

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

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

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

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

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

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

38. 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 PhysTher 1984; 6:130-9.

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

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

41. www.mayoedu

42. www. Low back pain Wikipedia.com.

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