Back Pain Solutions I:
Posture-Movement Therapy

About Bruce I. Kodish

The year was 1981, the place a busy hospital in Pittsburgh. My first glimpse of Paul was of his being wheeled down the hallway of the physical therapy department towards the curtained booth where I would see him. Lying on his back on a gurney, a patient transport table on wheels, he looked nervous.

I felt a little nervous myself, as I often did just before meeting a new patient. I didn’t need to feel worried. As a young physical therapist working with people with back pain, I had begun to have a fair amount of success applying the activity-related approaches I had studied.

An New Old Approach to Back Pain
The ancient Chinese and Hindu civilizations both used therapeutic exercise (positions and movements) in their systems of medicine.1 Posture and movement as therapy also has a long history in the West. More than 2000 years ago, the Greek physician Hippocrates used manipulation and traction to treat people with back pain.2 Massage and exercise also played important parts in his general practice.3 In his book On Articulations he emphasized the importance of balancing rest with active movement. He wrote:
" ...all parts of the body which have a function, if used in moderation, and exercised in labors to which each is accustomed, become thereby healthy and well-developed, and age slowly; but if unused and left idle, they become liable to disease, defective in growth, and age quickly. This is especially the case with joints and ligaments, if one does not use them. In those who are neglected and never use the leg to walk with but keep it up in the air, the bones are more atrophied than in those who use the leg."4

As Erwin H. Ackerknecht noted in his Short History of Medicine, Hippocrates also “put great emphasis on the value of observation of the disease process, on the practical rather than the theoretical. This...relegates speculative theories to minor importance.”5

In later centuries, this activity-related and observation-based approach began to get neglected in relation to back pain. By about 200 years ago,Waddell notes, “restriction of activity, rest and even bed rest [had become] the traditional medical treatment.”6

Nonetheless, a small number of medical doctors and surgeons, osteopaths, chiropractors and physical therapists, among others, carried on the practice of various forms of activity-related (posture-movement) therapy for back pain with varying degrees of success.

In the twentieth century, James Cyriax, M.D., had a major influence on physical therapists interested in using activity-related therapy for back pain and other musculoskeletal problems. Cyriax promoted a precise method of testing and diagnosing mechanical disorders by observing the effects of postures and movements on symptoms. As he noted, “a change in symptoms corresponding to the stresses acting on the lesion is common to all disorders of the moving parts.”7 He taught simple, precise methods of treatment, particularly manipulation (passive movement), and promoted the use of these methods by physical therapists.

Physical therapists such as Freddy Kaltenborn, Geoffrey Maitland, Stanley Paris and others have carried forward this tradition of activity-related treatment, especially the use of passive movement (manipulative therapy). Maitland, for example, has greatly elaborated on the art of closely observing the relation of the “pain response (its quality and its behavior) to movements and positions.”8 He has taught therapists how to use this pain response as a guide to treatment by means of passive movement.

Physical therapist Robin McKenzie has also advanced activity-related treatment. He and his colleagues emphasize using exercises (movements and static postures carried out by the individual) as a form of self-treatment. As Jacob and McKenzie note, “ As with the rehabilitation tradition, the preference is for patient self-generated movements.”9

In this approach, self-treatment with posture and movement, guided as needed by a therapist, does not preclude the use of passive movements when necessary. However, as self-treatment often works successfully on its own, it seems better to apply it first before going on to manipulative treatment by the therapist. This provides the person with back pain more opportunity to learn how to manage his own symptoms.10 Paul’s story illustrates the usefulness of this approach.

Paul
Paul was a mechanic in his mid-thirties. While he was guiding a heavy engine being put into place with a hoisting device, the chain slipped. Before he had time to think, Paul tried to catch the engine to keep it from falling. He felt something give way in his back. Over a number of weeks the immediate low back pain had gradually spread into his right buttock and down the back of his leg into his calf.

After about two months and despite some physical therapy and chiropractic treatments, the pain was now constant and disturbing his sleep. Sitting and bending were agony, as were standing and walking any distance. He was unable to work. He had been admitted to the hospital for a workup, including a myelogram, prior to anticipated surgery for a herniated disc.
A myelogram is a special x-ray test wherein fluid is first injected into the spinal canal. This fluid makes it possible to see dents in the lower spinal cord and nerves which can indicate if and in what location a herniated disc may be pressing on nerve tissue. Paul’s myelogram was scheduled for the next day.

Paul was in the clinic this day for some ‘palliative’ treatment: heat, ultrasound, massage and flexion exercise. I got a history of his problem from him and carefully (he was in constant, severe pain) tested the reflexes, sensation and muscle strength in his legs. Although he had pain and tingling in his right calf, the results seemed normal.

To comply with the orthopedist’s orders to do flexion exercises, I asked Paul to pull his knees to his chest. Paul was willing to try. However, the pain in his calf increased and spread into his foot after only a few movements. I decided that flexion exercises were not for him right now. I asked him to stop and roll over onto his stomach (a static prone-lying posture). He moved slowly and carefully, in evident pain, and I went to get the heat pack.

Knowing how positions and movements can affect symptoms, when I returned I asked him how far the pain in his right leg extended. His foot had stopped hurting and tingling— however, he felt intense discomfort going down to his mid-calf.

I helped him to lift himself up while I placed a pillow under his belly to see if this might make a difference. He felt no worse. I helped him lift up again to place another pillow. This time the pain retreated up to the back of his knee. I was encouraged because the site of his pain had changed by changing his position. I placed the hotpack on his back and left the room for a few minutes.

When I returned, Paul reported that his knee felt better. He felt pain from his back and buttock down to his mid-thigh, a good sign. The pain was “centralizing,” a term McKenzie uses to describe symptoms moving out of the limb and towards the spine (see the section on Soft Tissue Changes in Chapter 9). So I left Paul with both pillows and the hot pack, which was basically there to distract him and keep him still.

After five minutes his symptoms had not significantly changed. I decided to see what would happen if I removed first one pillow and then the second. After he settled back down on the table, with his spine in a basically neutral position, he reported no pain in his thigh, only in his back and buttock.

An hour later, my supervisor was wondering why I was keeping my patient so long and Paul was doing press-ups, an exercise during which he repeatedly extended his spine —bent it backwards—by pushing up with his arms while lying on his stomach (Exercise #3 in Chapter 10). He had some difficulty doing this. The movement was limited. However, the pain in his leg and butt had vanished. Although the right-sided back pain was still present, it had shifted closer to the center of his back. It had taken more than an hour, with many gradual adjustments of pillows and body position on the table, but both Paul and I felt elated.

Paul’s orthopedic surgeon had his office next to the physical therapy clinic. I ran over to talk with him. I described what I had done with Paul and how he had responded. I requested that the order be changed to extension exercises and explained my rationale for doing so. At the time, flexion exercises were prescribed almost universally in the U.S. and this approach, using extension when appropriate, was not well known or accepted. He looked skeptical but agreed and I beat a hasty retreat.

Back in the clinic, Paul’s arms felt sore. He had done 40 press-ups while waiting for me to return. But although he felt moderate pain across his lower back, he felt much better overall, with no buttock or leg pain. I suggested he do the exercises every couple of hours, and sent him back to his room.

Paul returned to the clinic the next morning. He had a small amount of constant back pain which, with exercise and a brief use of passive movement (spinal manipulation) applied by me, he was able to get rid of by the afternoon’s session. His myelogram had been cancelled. He was discharged the following day and continued coming for about 3 weeks as an outpatient, until he had returned to full duty at work and was entirely pain-free. On his last visit he thanked me for helping him to avoid surgery.

Posture-Movement Therapy
As Paul discovered, the effectiveness for an individual of activity-related treatment does not depend on abstract theories or statistics. Neither a theory nor a statistic will indicate exactly how you as an individual will respond to a treatment. Rather, treating you as an individual requires an empirical, observational approach.

Taking the attitude of a personal scientist, you can determine what works for you. Applying some of the insights of Hippocrates, Cyriax, Maitland and others, you can become a better observer as you explore the possibilities of posture and movement to reduce your pain and improve your functioning. In this way, you can become a better consumer of the healthcare services that you receive. Using the insights of McKenzie, you especially can explore the role of self-treatment in posture-movement therapy. (Chapter 10 details a set of positions and movements that you may find useful.)

What positions and movements reduce your symptoms and improve your ability to move?

This chapter has introduced you to some of the background and application of posture-movement therapy. This approach to therapy solutions for back pain works together with educational solutions which I explore in the next chapter.

Chapter 3 Notes:
1. Licht, in Basmajian, p. 1

2. Cyriax, Textbook of Orthopaedic Medicine, Vol.1, p. 484

3. Kamenetz, in Rogoff, p. 8

4. Licht, p. 4

5. Ackerknecht, p. 58

6. Waddell, p. 241

7. Cyriax, op. cit., p. 348

8. Maitland, Vertebral Manipulation, p. 3

9. Jacob and McKenzie, p. 225

10. McKenzie, The Cervical and Thoracic Spine, p. 103

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