Patients may present with a flexed posture and be unable to extend because of increased neurological symptoms and decreased mobility; these patients would benefit from early interventions that emphasize flexion of the involved segments to relieve symptoms. The patients may have a medical diagnosis of spondylosis or spinal stenosis, may have sustained an extension load injury, or may have swollen facet joints so symptoms increase with extension. The flexed position reduces or relieves the symptoms.

Principles of Management

Effect of position. Flexion widens the intervertebral foramina, whereas extension decreases the size of the foramina. Any compromise of the foraminal opening, such as encroachment from bony spurs or lipping or swollen tissue, reduces the space. The patient may describe intermittent nerve root symptoms (intermittent numbness or tingling) whenever the involved segment extends, indicating mechanical compression. Constant nerve root symptoms could be caused by inflammation and swollen tissue.

Effect of traction. Traction has been demonstrated to widen the intervertebral foramina. Positioning the spine in flexion prior to the application of traction provides the greatest increased space.

Effect of trauma and repetitive irritation. Swelling in the facet joints from macrotrauma or microtrauma leads to a compromised foraminal space. With degeneration and increased mobility in a spinal segment, instability could be the cause of repetitive microtrauma leading to swelling and pain.

Effect of meniscoid tissue.The meniscoid tissue of the joint capsule may become impinged with sudden movements. This blocks specific movements, such as extension and side bending to the involved side. Manipulation and traction usually relieve the symptoms.

Indications and Contraindications for Intervention—Flexion Approach

Indications. Flexion is used if neurological and/or pain symptoms are eased with flexion and worsened with extension positions or motions.

CONTRAINDICATIONS: Extension and extension with rotation positions, motions, and exercises are contraindicated if neurological symptoms or pain worsen with these motions. Flexion exercises are contraindicated if neurological or pain symptoms peripheralize with flexion or repeated flexion maneuvers.

Management of Acute Symptoms
Rest and Support

• With acute joint symptoms, a cervical collar or lumbar corset may help provide rest to the inflamed or swollen facet joints.
• Support is also beneficial in the management of patients with RA or other disorders associated with hypermobility or instability.
• It is important to discontinue the use of such devices as the acute symptoms decrease so the muscles can learn dynamic control and to avoid dependence.

Functional Position for Comfort
• For flexion bias in the lumbar spine, the position is usually with the hips and knees flexed so the lumbar spine flexes.
• In the cervical spine, the position is toward axial extension (upper cervical flexion) with some flexion also in the lower cervical region.
• If there are neurological signs, the position provides maximal opening of the intervertebral foramina to minimize impingement of the nerve root.

Cervical Traction
• Gentle intermittent joint distraction and gliding techniques may inhibit painful muscle responses and provide synovial fluid movement in the joint for healing.
• Dosages must be very gentle (grade I or II) to avoid stretching the capsules and are best applied with manual techniques during the acute stage.
• With spondylosis or stenosis, if a patient does not have signs of acute joint inflammation but does have signs of nerve root irritation, stronger traction forces may be beneficial to cause opening of the intervertebral foramina, which helps relieve the pressure.

Correction of Lateral Shift

If the patient has a lateral shift of the thoracic region along with symptom relief when in flexion, he or she may be taught self-correction.
Patient position and procedure Standing with the leg opposite the shift on a chair so the hip is in about 90° of flexion. The leg on the side of the lateral shift is kept extended. Have the patient then flex the trunk onto the raised thigh and apply pressure by pulling on the ankle.

Correction of Meniscoid Impingements

If there is entrapped synovial or meniscoid tissue in a facet joint that blocks motion into extension, release of the trapped meniscoid relieves the pain and the accompanying muscle guarding. The joint surfaces need to be separated and the joint capsules made taut.

Cervical Traction, Mobilization, Manipulation
Traction to the spine may be applied manually or mechanically. The patient can also be taught self-traction and positional traction techniques.

• Traction applied longitudinally along the axis of the spine has the effect of sliding the facets joint surfaces and thus places tension on the facet capsules.
• Traction with side bending and rotation of the spine has the effect of distracting the facet joint surfaces as well as placing tension on the capsules.

Management When Acute Symptoms Have Stabilized
Specific emphasis when treating patients with mobility impairments due to hypomobile or hypermobile facet joints include:

• Hypomobile joints require stretching but not if the techniques stress a hypermobile region. Traction techniques may be effective if the hypermobile region is stabilized during stretching. For those trained in joint manipulation techniques, they are effective for selective facet joint stretching and have been found to be an effective part of a total treatment approach when there is instability in specific areas and restricted mobility in neighboring facet joints.
• Emphasis is on developing dynamic stability through muscle control in the hypermobile regions while gaining mobility in the restricted regions.
• If there are bony changes and osteophytic spurs, the patient should avoid postures and activities of hyperextension, such as reaching or looking overhead for prolonged periods of time. Adaptations in the environment might include using a stepstool so reaching is at shoulder level. Postures and motions emphasizing flexion of the spine that increase the size of the intervertebral foramina are usually preferred.
• For patients with RA, emphasis is on stabilization and control. Because of the potential instabilities from necrotic tissue and bone erosion, subluxations and dislocations may cause damage to the spinal cord or vascular supply and be extremely debilitating or life-threatening.

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