Williams’ Flexion Program James F. Wyss MD, PT Assistant Attending Physiatrist Associate Fellowship Director Director of Education – Physiatry Dept. Hospital for Special Surgery

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Who was Williams? Dr. Paul C. Williams (1900-1978) Orthopedic surgeon from Dallas, TX Modified the Regen Exercises, AKA “squat exercises” in an attempt to treat CLBP due to lumbar DDD. Published his modified exercises in 1937 https://en.wikipedia.org/wiki/Williams_Flexion_Exercises

What was his theory? “The fifth lumbar disc has ruptured in the majority of all persons by the age of twenty..” He proposed the L5-S1 disc pathology led to NF stenosis at this level and nerve irritation and was made worse with spinal extension, therefore, flexion exercises were recommended. Encouraged posterior pelvic tilt position to decrease lumbar lordosis.

Additional theories Many with CLBP had DDD with evidence of decreased posterior IVD height and increased lordosis. Purpose was to train the trunk flexor muscles and teach posterior pelvic tilt to reduce lordosis and to “open up” the posterior IVD space (and posterior elements).

Effects of Flexion on the Spine Cadaveric study of the spine confirmed flexion increases the sagittal diameter of the canal and dural sac. (Dai et al Spine 1989) JD Reid showed similar findings in 1960 in Journal of Neuro Neurosurg and Psych. Central canal and neuroforamen increase in size, inter- spinous distance increases and decreases compression on facet joints (Adams & Hutton JBJS 1995)

Williams’ exercises Posterior pelvic tilt Single knee to chest (SKTC) Double knee to chest (DKTC) Partial sit up Hamstring stretch Hip flexor stretch Squat

Posterior Pelvic Tilt www.stretching-exercises-guide.com

SKTC & DKTC www.physio-pedia.com

Partial Sit Up mda.org Modified curl up is part of Dr. Stuart McGill’s Big 3 runwaterloo.com

Hamstring Stretch www.somastruct.com Active seated hamstring stretch is nice alternative or addition

Hip Flexor Stretch Only exercise that potentially positions the lumbar spine into lordosis. victoryfitnesscenter.net

Anatomy of the Psoas Older theories on being prime mover L-spine (flexion, side bending) somewhat disproven by Bogduk, then McGill. Produces predominantly compressive loads to maintain Lspine lordosis, and creates shear at L5- S1 (Bogduk 1992) ZENKIYOGA.COM

Squat www.keepyourdaydream.com community.tribesports.com

Advantages of this Exercise Program Easy to teach in 1-2 sessions by PT or physician Easy for patients to learn May improve hip and spine mobility (although not proven) in stiff/inflexible patient May be beneficial for posterior element spinal pain (e.g. facet OA) and possibly for spinal stenosis.

Studies on Effects of William’s flexion exercises EMG: paraspinal activity increased with anterior tilt, decreased with posterior tilt (Blackburn and Portney PT 1981) Motion of the spine and specific elements, such as increased canal diameter were discussed earlier and to my knowledge have not been assessed during performance of these specific exercises.

Any proof that it is effective? No differences b/w using spinal flexion or extension exercises along with postural training for acute LBP (Dettori et al Spine 1995) RCT manual therapy w/ BWST versus flexion exercise/treadmill walking and US (Whitman et al Spine 2006). Manual therapy group did better, but strange design/comparison. To the best of my knowledge, the full Williams’ flexion program has not been formally study

Summary Know your history: William’s flexion exercise have been utilized for nearly 80 years Clinically they are applied to different conditions than Dr. Williams initially intended, including LSS and facet mediated LBP In my opinion, they are easy to teach to patients and tend to help manage symptoms from LSS and/or facet mediated LBP They remain largely unproven as a superior or inferior exercise program for LSS and/or LBP Recently we began a pilot study at HSS comparing William’s flexion to individualized PT program for LSS.

REFERENCES https://en.wikipedia.org/wiki/Williams_Flexion_Exercises Santaguida PL, McGill SM. The Psoas Major Muscle: 3-D Geometric Study. J Biomechanics. 1995: 28(3):339-345. Bogduk N, Pearcy M, Hadfield G. Anatomy and Biomechanics of Psoas Major. Clin Biomech. 1992:7:109-119. Dai et. The effect of flexion-extension of the lumbar spine on the capacity of the spinal canal. Spine 1989:14(5):523-5. MA Adams and WC Hutton. The effect of posture on the lumbar spine. JBJS, British volume, 67(4): 625-629. Blackburn and Portney. PT 1981;61:878-885. Whitman et al. A comparison b/w 2 PT treatment programs for patients with LSS. Spine 2006:31(22):2541-2549.