Dr. Allan Horowitz, published newspaper article, Richmond Hill Liberal, Copyright March 07, 1990

Dear Dr. Horowitz:

Could you please explain the difference between a back flexion and a back extension program. I recently had a back problem that required treatment at a chiropractor’s office.

When I was almost finished with the treatments at his office he prescribed some back flexion exercises for me. He told me to do them every day, and that they were supposed to relieve the pressure on my back. Everything worked just fine and I’m now back to work feeling much better.

I have a friend who works as a physiotherapist at a rehabilitation hospital in Toronto. She was surprised to hear that I was prescribed a back flexion program instead of what she says is the newest way of thinking regarding back exercises, namely back extension.

Was the chiropractor wrong or are they talking about the same thing with different names, or are they both just trying to drive me crazy?

Answer:

Flexion exercises are designed to take the pressure off the back part of the disc, which is the cushion between the spinal bones.

Many, but not all, back problems originate in the back part of this disc when it becomes “pinched”.

Flexing the back, such as what would be done when you are lying on your back and you hold your knees and bring them up to your chest, will open up the space available to the disc, and will usually help relieve some of the pressure on the “pinched” disc.

Extension is the opposite movement, and will actually increase the pressure on the back part of the disc, thereby increasing the patient’s pain. Extension is the movement one associates with bending backwards, and this motion should be avoided if one has a disc problem.

What I just outlined is the usual rule. People are not machines and don’t always do what they are supposed to, or respond to exercises like they should. Theory is just that.

I think the problem in your case comes because of a lack of knowledge on your friend’s part. Your chiropractor had the luxury of examining you while you were in pain. He then was following your condition while he was administering the treatments. He then gave you the best exercise program for you at that time. It worked didn’t it?

Your friend means well, and I am sure she is well versed in back exercises. She is correct when she claims that a “new” theory of exercises dictates extension instead of flexion.

The problem still exists regarding when to prescribe each form of exercise. Many types of back pain caused by muscular weakness will eventually respond to a series of back extension exercises designed to increase the strength of the back muscles. Some disc problems will respond favorably to an extension routine and this should be tried if the flexion routine doesn’t work.

There is no golden rule when it comes to treating backs. Often I will prescribe something that I think will work for one patient’s problem and, after a week or two when it hasn’t worked, I will try something else. This might work within a day or two. The patient then asks the expected question; “Why didn’t you suggest that in the first place?”

The answer is that different techniques work differently on different patients, even if the diagnosis is the same on the two patients.

SUBJECTIVE TASK

I think the reason for this is that diagnosing the source of back pain is still a very subjective, tricky, task and it could be that what we think is a disc problem might very well be something else.

We give exercises which should help a disc, but they don’t. We then give exercises that usually don’t help the disc problems, but they do help in this case. Maybe the problem wasn’t really a disc to begin with.

There must be a better way to diagnose the source of pain other than a physical examination, correct?

Yes there is, but the problem is that many of these tests are only reserved for the patients where the thought of surgery has come into the picture. We will not perform a test which is very painful, risky, involves a hospital stay, or is very expensive (some cost over $1,000 per test) unless the results of these tests will help determine the best way to treat the patient, usually surgically.

Our health care system will not pay $1,000 for a test to determine whether a patient should bend forward or backward when doing his exercises. Sorry…