Tip of the week – Repeated Extensions

by David Pope

Most Physios are aware of the McKenzie MDT approach. Here is a quick tip when treating low back pain and referred leg pain which may help your results when incorporating the McKenzie approach.

From my clinical experience using repeated extensions, they seem to work best with patients that have referred pain into the hip or down the leg, they may or may not have neuro signs (pins & needles and/or numbness), get pain with sitting or flexion, and their pain is eased with standing and walking. These are generally classified as Posterior Derangement in the McKenzie system.

You can check their response to EIS (extensions in standing), but to be honest, this rarely gets a good response initially, so I generally skip it now. You can check how far down the leg their pain is in supine, then perform a few repeated FIL (flexion in lying – supine), knees to chest. I only generally do up to 5, as anymore stirs them right up, then check how far down the leg the pain is now. Once again, this isn’t much of a test, and I often skip it, as you can get false positives for improvements – they improve temporarily, then feel a lot worse after. I rarely use flexions as a treatment, as most times it makes symptoms worse. I can only recall 3 or 4 people in my entire treatment career that have benefited from repeated FIL, and needed this as their HEP.

Onto the money – repeated EIL (extensions in lying). The first thing you need to do is take a baseline of how far down the leg EXACTLY their pain reaches to at that point in time. The patient then puts their hands under their shoulders, like they are doing a pushup, and using their arms to do all of the work ie keeping their back extensors and glutes relaxed, push up as high as they can go, keeping their hips on the bed. Get them to do 10, even if it is a bit sore in their back, let them relax for a few seconds, then ask them exactly how far down the leg their pain reaches to now.

If the extensions of being successful, the pain will be less far down the leg. They may even have some increased discomfort in their back, but as long as the pain is not as far down the leg this may be a good treatment for them. You can follow this up with two more lots of ten extensions, and once again reassess how far down the leg pain reaches to now.

If their pain is more centralised, you can send them home with 3 lots of 10, 5 times per day. As they keep going with their extensions, their pain should become more centralised ie less far down their leg. I generally use EIL as their home program, and don’t use repeated extensions in standing for a while, or until their pain has mostly gone.

If their pain is unchanged, or further down the leg, definitely avoid giving them repeated extensions as a treatment or home program, and move onto something else. This is a quick summary of repeated EIL, and you can learn more about it in “Treat Your Own Back” by Robin McKenzie and on McKenzie courses.

So in summary, give extensions in standing (EIS) a miss initially, get a baseline of how far down the leg pain is in prone, use repeated EIL, then reassess how far down the leg their pain goes now. Let me know below if you love EIS and FIL…

I tend to consider MDT as treating their symptoms, rather than the cause of their back pain, and once their symptoms are settling, continue their extensions while moving onto treatment of the area loading up their lumbar spine eg the pelvis, thorax, foot, or hip etc, using the Integrated Systems Model, do some dry needling, and teach them how to move better. I also tend to tie in pelvic torsion or thoracic ring corrections while they are performing their EIL, once I have figured out their driver – this seems to help them improve quicker, and starts to treat the underlying cause of the problem.

How do you tend to use repeated extensions?

  • Lisa Coleman

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