These techniques are used only if the test movements have shown that the postures and movements used decrease the symptoms. If no test movements decrease the symptoms, this mechanical approach to treatment should not be used.

Management of Acute Symptoms
If symptoms are severe, bed rest is indicated with short periods of walking at regular intervals. Walking usually promotes lumbar extension and stimulates fluid mechanics to help reduce swelling in the disk or connective tissues. If the patient cannot stand upright, he or she should use crutches to help relieve the increased pressure of the forward-bent posture.
If repeated flexion test movements increase the symptoms and if repeated extension test movements decrease or centralize the symptoms, all flexion activities should be avoided during the early phases of intervention. Treatment begins with the following maneuvers.

Passive Extension
• Patient position and procedure: Prone. If the flexion posture is severe, place pillows under the abdomen for support. Gradually increase the amount of extension by removing the pillows and then progress by having the patient prop himself or herself up on the elbows, allowing the pelvis to sag. When propping, pillows placed under the thorax help take strain off the shoulders. Wait 5 to 10 minutes between each increment of extension to allow reduction of the water content and the size of the bulge. There should be an accompanying centralization of or decrease in symptoms. Progress to having the patient prop himself or herself up on the hands, allowing the pelvis to sag.

• If the sustained position of prone propping is not well tolerated, have the patient perform passive lumbar extension intermittently by repeating the prone press-ups rather than just propping up.

PRECAUTION: Carefully monitor the patient’s symptoms. They should lessen peripherally (i.e., decreased foot and leg symptoms or decreased thigh and buttock symptoms) but may increase in the low back (centralize). If the symptoms progress down the lower extremity (peripheralize), immediately stop the exercises and reassess.

Lateral Shift Correction
If the patient has lateral shifting of the spine, extension alone cannot reduce a nuclear protrusion of the disk until the shift is corrected. Once the shift is corrected, the patient must extend to maintain the correction. Methods to correct the shift in various positions include the following. • Patient position and procedure: Standing with flexed elbow against the side of the deviated rib cage. Stand on the side to which the thorax is shifted and place your shoulder against the patient’s elbow. Then wrap your arms around the patient’s pelvis on the opposite side and simultaneously pull the pelvis toward you while pushing the patient’s thorax away. This is a gradual maneuver. Continue with the lateral shifting if centralization of the symptoms occurs. If there is overcorrection, the pain and lateral shift may move to the contralateral side, which is corrected by shifting the thorax back. The purpose is to centralize the pain and correct the lateral shift. Once the shift is corrected, immediately have the patient backward-bend. Again, allow time. Progress to passive extension with prone propping and prone press-ups.

• Patient position and procedure: Side-lying on the side to which the thorax is shifted. Place a small pillow or towel roll under the thorax. The patient remains in this position until the pain centralizes; he or she then rolls prone and begins passive extension with prone propping and prone press-ups.

• Patient position and procedure: Prone. Attempt to side-glide the thorax and pelvis toward the midline with manual pressure. The forces are in equal and opposite directions. Once the symptoms centralize, instruct the patient to begin passive extension with prone propping and prone press-ups.

Patient Education
• Help the patient recognize what positions and motions increase or decrease the pain or other symptoms by performing them under supervision.

• Instruct the patient to repeat the extension activities frequently, with lateral shift correction if necessary, during the first couple of days. For example:

• Teach self-correction of the lateral shift. The patient places the hand on the side of the shifted rib cage on the lateral aspect of the rib cage and places the other hand over the crest of the opposite ilium and then gradually pushes these regions toward the midline and holds.
• Instruct the patient to correct the shift by side-lying or prone-lying as previously described.

• Caution the patient to stop the activity immediately if the pain worsens or peripheralizes during exercises.

• Instruct the patient to maintain an extended posture with passive support while the lesion is healing. For example, have the patient use a towel roll or lumbar pillow while sitting. This is especially important when riding in a car or sitting in a soft chair. When going to bed, have the patient pin a towel, folded lengthwise four times, around the waist.

• Instruct the patient to avoid flexion activities, lifting, or any other functions that increase intradiskal pressure while symptoms are acute.

• Teach safe movement patterns to protect the back

Lumbar Traction
Traction may be tolerated by the patient during the acute stage and has the benefit of widening the disk space and possibly reducing the nuclear protrusion by decreasing the pressure on the disk or by placing tension on the posterior longitudinal ligament.

• Time of the traction should be short; osmotic forces soon equalize. However, upon release of the traction force, there could be an increase in disk pressure, leading to increased pain. Use less than 15 minutes of intermittent traction or less than 10 minutes of sustained traction.

• High poundage; more than half the patient’s body weight is necessary for separating the lumbar vertebrae.

• If there is complete relief initially, often there is an exacerbation of symptoms later.

Kinesthetic Training, Stabilization, and Basic Functional Activities
Once the patient learns to control the symptoms the following should be emphasized.

• Teach simple spinal movements in pain-free ranges using gentle pelvic tilts. The patient is taught to be aware of how far forward and backward he or she can rock the pelvis and move the spine without increasing the symptoms. The pelvic rocking is done in supine, sitting, hand-knee all-fours (quadruped), prone-lying, side-lying, and standing positions. It is important to stay within the patient’s ability to control the symptoms. Instruct the patient to finish all exercise routines with the pelvis tilted anteriorly and the spine in extension.

• Teach the patient basic stabilization techniques utilizing the core trunk muscles while maintaining control of the extended spinal position and performing simple extremity motions. It is important to caution against holding the breath and causing the Valsalva maneuver, which would excessively increase the intradiskal pressure.

• Encourage activities within the tolerance of the individual, such as walking or swimming.

• Initiate passive straight-leg raising with intermittent dorsiflexion and plantarflexion to maintain mobility in the nerve roots of the lumbar spine.

Management When Acute Symptoms Have Stabilized
Signs of Improvement
Improvement is noted with loss of spinal deformity, increased motion in the back, and negative dural mobility signs. Loss of back pain with an increase in true neurological signs is an indication of worsening. The patient is tested to determine that the symptoms have stabilized; this is accomplished by performing repeated flexion and extension tests with the patient standing and then lying supine and prone, as done initially. The tests may be positive for dysfunction (restricted motion, tension) but should not cause peripheralization of the symptoms, as when the condition was acute.

Emphasis of Intervention
The emphases during this stage are recovery of function, development of a healthy back care plan, and teaching the patient how to prevent recurrences. The pain from adaptive shortening decreases as normal flexibility, strength, and endurance are restored.

In addition, teach the patient these principles.

• Following any flexion exercises, perform extension exercises, such as prone press-ups or standing back extension.

• If being in a prolonged flexed posture is necessary, interrupt the flexion with backward bending at least once every hour. Also, perform intermittent pelvic tilts.

• If symptoms of a protrusion develop and are felt, immediately perform press-ups in the prone position, anterior pelvic tilts in the quadruped position, or backward bending while standing to prevent progression of the symptoms.

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