William's Flexion Exercises Reduce Low Back Pain

ORIGINAL ARTICLE
Effectiveness of William's flexion exercises in

management of low back pain
1
Muhammad Usman Khalid , Mahvish Rafiq , Nosheen Zehra
Muhammad Usman Khalid
Student of Post Professional Doctor in Physical Therapy, Ziauddin University

Email: dr.usman_khalid@yahoo.com
Contact #: 0323-2097104
2
Mahvish Rafiq
Student of Post Professional Doctor in Physical Therapy, Ziauddin University

Email: mahvish_rafiq@hotmail.com
Contact #: 0322-2243384
3
Nosheen Zehra
Assistant Professor
Department of Community Health Sciences, Ziauddin University
Email: nosheen_zehra130@hotmail.com
Contact #: 0300-2427127
Corresponding Author
Nosheen Zehra
Assistant Professor
Department of Community Health Sciences, Ziauddin University
Email: nosheen_zehra130@hotmail.com
Contact #: 0300-2427127
Pakistan Journal of Medicine and Dentistry 2013, Vol. 1 (01): 21-33
21
Effectiveness of William's flexion exercises in management of low back pain
ABSTRACT
Background: Low back pain is a common musculoskeletal disorder affecting 84% people once in third life time. It
may be acute or chronic. Among various available options for management of low back pain, William's flexion
exercise is one of them. Williams flexion exercises the set of physical exercises use to enhance lumbar flexion to
avoid lumbar extension, and strengthen the abdominal and gluteus musculature to manage low back pain
Objective: To assess the effectiveness of William flexion exercise in management of patients with low back pain.
Methodology: A cross sectional study was conducted among 250 patients with low back pain from different hospitals
of Karachi. Sample was selected by convenience sampling technique and data was collected on structured
questionnaire. These patients were provided Williams Flexion Exercise and changes in pain and posture were
noticed before and after exercise. Data was analyzed by SPSS version 17and P value <0.05 was considered as
significant.
Result: Pain intensity was significantly (p value = 0.03) reduced in those who took more than 5 sessions of Williams
Flexion Exercise. Of total 96 (38.4%) patients with severe pain before exercise, no Pain was found in 20 (8%)
patients after exercise. From 107 (42.8%) and 47 (18.8%) patients with moderate and mild pain respectively, no pain
was found in 9 (3.6%) and 11 (4.4%) patients respectively. Spine flexion and extension was improved completely in
45 (18%) out of 132 (52.8%) patients with mild restrictions, in 24 (9.6%) out of 93 (37.2%) patients with moderate
restrictions and in 9 (3.6%) out of 25 (10%) patients with severe restrictions.
Conclusion: William flexion exercise provided benefits to most of the participants in the study, thus it may be an
effective technique to reduce the intensity of low back pain.
Key Words: Williams Flexion Exercise, Low Back Pain
INTRODUCTION
affect both the gender. Normally the pain is

divided on the basis of its duration3.The pain
Participants Low back pain (LBP) can be defined

lasting less than a week is called acute pain and
as the pain and stiffness in lower back. LBP is a
the pain which lasting more than a week to
common musculoskeletal disorder affecting 84%
months is called chronic low back pain. The
1
people at some point in their lives. LBP can

acute pain resolves within a week with specific
22
Muhammad Usman Khalid, Mahvish Rafiq and Nosheen Zehra

treatment. If this pain is not treated then become
damage.
chronic pain.4A chronic low back pain disturbs
pharmacological treatment may be treatment of
the individual during his working environment.
choice and beneficial for pain management.
Sometimes this pain becomes so severe that it
During the past two decades, the advice for LBP
So, due to these reasons non
will affect the daily activity. And for a while this
given by primary care physicians has changed.
pain becomes so extreme that person is unable
Adams
to move and outcome is complete bed rest.
minimizing bed rest or stays active and to avoid
There are numerous structures that surround the
bed rest.9
lumber supine like ligament and muscles. Spine
The rehabilitation program of chronic LBP is
when loses its stability by straining of these
beneficial
structures results in back pain.6The risk factors
MA
in
for
the
his
study
recommended
management
pain10.
of
Exercise therapy, can be effective after the
for straining are poor body posture, overweight
acute stage of LBP as well. The positive results
and weak back and abdominal muscle.
have been known with specific types of exercise
Various treatment options are available for
used by physical therapists.11
management of LBP.7Short term use of pain and
Among these specific exercises, one is Williams
anti-inflammatory medications may help relieve

flexion exercises (WFE) also called Williams
the symptoms of lower back pain. NSAIDs are
lumbar flexion exercises. These are the set of
slightly effective for short-term symptomatic
physical exercises use to enhance lumbar
relief in patients with acute and chronic low-back
flexion
to
avoid
lumbar
extension,
and
pain without sciatica. Muscle relaxants for acute

strengthen
the
abdominal
and
and chronic1 pain have some benefit, and are

musculature to manage low back pain.
gluteus
12
more effective in relieving pain and spasms

when used in combination with NSAIDs. 8
Scheermesser M, in his study found that
Chronic use of these medications may result into
physical therapy treatment can improve the
various adverse effects. Certain medicines are
patient ability to function .The effectiveness of
unsafe during pregnancy and may cause side
physical therapy can reduce the disability. The
effects including drowsiness, or may lead to liver
studies also showed that the patient totally
13
14
23

dependent on medication may lead mild to
were included in the study.
moderate disability which can effect on daily
Sample size was calculated by WHO sample
activity. So role of physical therapy is also
size estimation calculator. For sample size
important in low back pain. Manual therapy is
calculation prevalence of LBP was taken as
also more effective in low back pain. The aim of
80%, at 95% confidence level and keeping 0.05
physical therapy treatment is to improve pain
margin of error. The minimum number of
15
free activity of daily lining
participants required for inclusion in the sample

was calculated as 246 but 250 patients were
This
study
will
help
in
identifying
the
effectiveness of Williams flexion exercises. As
included in the study.

Non-probability convenient sampling technique
this maneuver is among available management

was used to enroll participants in the study.
plans for LBP so the results of this study will
Patients aged between 18 to 90 years having
help all health care providers to modify their
LBM for at least three to four months but less
practices. Most of the time doctors prescribed
than 9 months were included in the study. Only
medications for LBP management but with the
those patients of LBP were be the part of study
help of this research their knowledge regarding
where LBP was associated with nerve root
exercise based management of LBP will be
impingement at inter vertebral foramen, spinals
improved. So the aim of this study is to assess
tenosis and postural changes and they were
the effectiveness of William flexion exercise in
declared medically fit by their doctors to
management of patients with low back pain.
undertake the exercise. Patients with any
METHODOLOGY
potentially serious pathology, who have spinal

tumor, prior surgery back pain, and back pain
A cross sectional study, spanning over a year

start after road traffic accident, females with
from February 2011 to January 2012, was
conducted among patients of LBP. All those
pregnancy and anyone who would have been

unable to attend or participate in the exercise
patients taking physical therapy treatment from

program were excluded from the study.
different private and public hospitals of Karachi
24

A brief history of patients was taken via
taken before including these patients in the
interview and physically examination was done
study.
to exclude possible serious spinal pathology
Data was entered and analyzed by using SPSS
and collect baseline data by means of health
version
measures. Data was collected on structured
calculated for qualitative variables while mean
questionnaire enclosing questions targeting to
and standard deviation for quantitative variables.
assess the type, intensity, duration and pattern
Chi square test was used to find association for
of pain. There were questions on relieving
qualitative variables and p vale <0.05 was
factors, occurrence of pain and the worse time
considered as significant.
17
. Frequencies and percentages were
of pain. As this study was aimed to assess the
RESULTS
effectiveness of William's Flexion Exercises so
there were questions on before and after
Total n= 250 patients were included in the study
results of exercise. We use visual analogue
with mean age of 43 + 13 years. Out of them 90
pain scale to measure the intensity of pain
(36%) were male and 160 (64%) were females.
before and after the treatment, that is a simple
From the sample 124 (49.6%) patients were
assessment tool consisting of a 10 cm line with
from private clinics, 85 (34%) were from private
0 on one end, representing no pain, and 10 on
tertiary care hospitals and 41 (16.4%) were from
the other, representing the worst pain ever
government hospitals.
16
Location and type of pain was
These patients were inquired about the
marked using the provided key as (0000 = Pins
characteristics of pain and it was found that
and needles, /////// = Stabbing, XXXX =
80(32%) had pins and needles type pain,
Burning, ZZZZ = Deep Ache). In addition, we
79(31.6%) had deep ache, 78 (31.2%) had
also evaluate patients spine flexion and
burning pain, and 13 (5.2%) experienced
extension before and after the treatment and
stabbing pain.
also analyze pain intensity after William flexion
severe pain, 107 (42.8%) had moderate pain
exercise. Purpose of the study was explained
and 47 (18.8%) had mild pain. Duration of pain
to participants and informed consent was
was found from 3-4months in 102(40.8%), 4-
experienced.
Among them 96 (38.4%) had
25

6months in 92(36.8%) and 6-9months in 56
Most of the patient 189 (75.6%) used lying
(22.4%) patients. Those patients who had
position to relief their pain while 26 (10.4%)
localized back pain were 138 (55.2%), those
preferred standing, 20 (8%) sitting and 15 (6%)
whose pain radiate to leg were 96 (38.4%) and
used different posture to relief their pain.
others were 16(6.4%). Constant pain was found

Patients took different patterns of William
in 114 (45.6%) patients, intermittent pain in 90
Flexion Exercises as partial sit up by 30(12%)
(36%) and occasional pain in 35 (14%) patients.
patients, pelvic tilts by 70(28%), knee to chest
In 50 (20%) patients pain was worse at morning,
by
223(89.2%),
hamstring
stretch
by
in 46 (18.4%) patients at night, in 32 (12.8%)

153(61.2%),
hip flexor muscle
stretch
by
patients in evening, in 16(6.4%) patients in

118(47.2%), and squatting by 17(6.8%). (Table
afternoon and in 106 (42.4%) patients pain was
1)
not associated with any particular time of day.
Table 1: William flexion exercise component
Percentage
Frequency
(%)
(n= 250)
Partial sit up
12
30
Pelvic tilt
28
70
Knee to chest
89.2
223
Hamstring muscle stretch
61.2
153
Hip flexor muscle stretch
47.2
118
Squat
6.8
17
These patients in sample took various sessions
pain, 115 (46%) had mild pain and 1 (0.4%) had
of William flexion exercise as 5 sessions were
moderate pain after completion of treatment. Of
taken by 30(12%) patients, 6 to 10 sessions by
30 (12%) patient who had 5 sessions, among
134 (53.6%) patients and more than 10 sessions
them 6 (2.4%) had no pain, 22 (8.8%) had mild
were taken by 86 (34.4%) patients. It was found
pain and 2 (0.8%) had moderate pain. While 86
that those 134 (53. %) patients who took 6 to 10
(34.4%) patients who took more than 10
sessions of physiotherapy, 18 (7.2%) had no
sessions among them 16 (6.4%) had no pain, 63
26

(25.2%) had mild pain and 7 (2.8%) had
exercise and post pain intensity P<0.00 (Table
moderate
2).
pain.
There
was
significant
association between sessions of William Flexion
Table 2: Association of William Flexion Exercise and Post Pain Intensity

Number of William Flexion
Exercise Sessions
Intensity of Pain after Exercise

No Pain
Mild Pain
Moderate
Pain
Total
n (%)
n (%)
n (%)
n (%)
6 (2.4)
22 (8.8)
2 (0.8)
30 (12)
6 to 10
18 (7.2)
115 (46)
1 (0.4)
134(53.6)
More than 10
16 (6.4)
63 (25.2)
7 (2.8)
86 (34.4)
P- Value
0.037
To assess the effectiveness of Williams flexion
(1.6%) after exercise. In 107 (42.8%) patients
exercise for LBP, pain intensity was measured
pain was moderate before exercise which was
before and after the sessions of exercise. Before
reduced to mild pain in 94 (37.6%) patients and
exercise 96 (38.4%) patients had severe pain
in 47 (18.8%) patients pain was mild before
which was reduced to no pain in 20 (8%), mild
exercise that was reduced to no pain in 11
pain in 72 (28.8%) and moderate pain in 4
(4.4%) patients. (p > 0.000) (Table 3)
Table 3: Pain Intensity before and after William Flexion Exercise

Pain Before Exercise
Pain After Exercise
Mild Pain
Moderate Pain
Sever Pain
No Pain
n (%)
11 (4.4)
9 (3.6)
20 (8)
Mild Pain
n (%)
34 (13.6)
94 (37.6)
72 (28.8)
Moderate Pain
n (%)
2 (0.8)
4 (1.6)
4 (1.6)
Total
n (%)
47 (18.8)
107(42.8)
96 (38.4)
Total
40 (16)
200 (80)
10 (4)
250 (100)
of
which
0.079
At the start of physiotherapy of patients, flexion
(52.8%)
and extension of spine was measured to
completely in 45(18) and slightly in 87 (34.8%)
observe the effect of exercise after treatment.
patients. Moderate restriction was found in 93
Initially mild restrictions were seen in 132
(37.2%) that was completely improved in 24
patients
P- Value
was
improved
27

(9.6%) patients and similarly sever restriction
completely improved in 9 (3.6%) patients. (P-
was found in 25 (10%) patients that was
value=
0.360)
(Fig
2)
Spine Flexion and Extension after Exercise %
Figure 1: Improvement in Spine Flexion and Extention after William's Flexion

Exercise
40
34.8
35
30
27.6
25
20
18
Completely Improved
15
Slightly Improved
9.6
10
6.4
3.6
5
0
Severe
Moderate
Mild
Spine Flexion and Extension Restriction
From the sample of 250, only 70 (28%) patients
in their life experienced low back pain.17 Most of
returned with complain of pain reoccurrence.
the time LBP is of acute type and resolve
Patients
the
immediately or within few days but sometimes it
improvement in their life quality, and 121
is of recurrent type and in some individuals it
(48.4%)
complete
becomes chronic.18 LBP is an important cause
improvement while 129(51.6%) said there was
of activity limitation and according to Ponte DJ
partial improvement.
for every 100 subjects aged 25 to 44, an
were
also
replied
that
inquired
there
about
was
average of 28.6 works day are lost per year due
DISCUSSION
to low back pain.
19
Among various available
Low back pain is such a common problem that
options for management of LBP, Williams
every adult once in a life time affected by it.
flexion exercise may helps in improving LBP as
Nachemson A reported that about 80% people
reported in literature.
20,21
28

Therefore this study was focused in assessing
muscles which maintain the all structure alien
the effectiveness of Williams flexion exercise in
and prevent the over loading of the posterior
management of patients with low back pain.
element of the lumbar spine.
Recent management guidelines for chronic LBP
Results of our study showed that Williams
recommended exercise for returning to physical

flexion exercises had beneficial effect in chronic
22
activity.
Significant improvement in patients of

LBP which was measured by visual analogs
LBP was reported in literatures who have

scale (VAS) and spinal restriction observed
received Williams flexion exercises.
21
Results of
before and after the treatment. Pain intensity
our study also supported that Williams flexion

when measured before therapy, reflected that
exercise can lead to improvement in low back
38% patients had severe, 43% had moderate
pain.
and 19% had mild pain. Improvement in pain
Exercise intervention with patient education, are
after therapy was found in most of the case as of
first in the conservative approach to treat
those with severe pain, 8% had no pain and
musculoskeletal conditions of the lumbar spine.
29% had mild pain. Similarly patients with
By the exercise, body tissues adapt to the
moderate
stresses and demands of everyday living. In
improvement as shown in table 3. In our study,
most cases the back pain are mechanical in
patients were given number of Williams Flexion
nature so, a functional approach will produce the
exercise sessions and significant improvement
long-term benefit.
(p-0.03) in pain intensity was found in those who
According to the Williams these exercises
and
mild
pain
also
showed
took more than 5 sessions. Various studies also

reported improvement in LBP after Williams
reduce the pressure on the posterior element of

flexion exercise.
20, 21,24
the lumbar spine. These exercises restore

motion and strength of lower back is helpful in
Different patterns of Williams flexion exercises
relieving pain and preventing reoccurrence of
were performed by patients with LBP as partial
low back pain.

also
20, 23
strengthen
Williams flexion exercises
the
back
and
abdominal
sit up, pelvic tilt, knee to chest, hamstring

stretch, hip flexor stretch and squat. Participants
29

reported that pelvic tilt, knee to chest and
management of LBP as this exercise helped
hamstring stretching gave them more relaxation
patients effectively and not only reduce LBP
and reduction in pain and squatting was more
but also improved daily activities. It is,
difficult for more individuals.
therefore recommended to properly investigate

and diagnosed patients with LBP and for those
Along with exercise patient education is also

patients who require physiotherapy may be
very important. Posture is a vital component for
treated with Williams flexion exercise. It is also
the management of low back pain during the
working environment and daily living.25 In
suggested that preventive strategies should be

introduced for managing LBP that will in return
posture education we educated the patients

improve the daily pain free activities of
regarding activity of daily living and postural
individuals and reduce economic burden of
improvement in occupation. After the complete
society.
session of treatment we gave a home exercise
CONCLUSION
program with demonstration.
Results of our study highlighted that Williams

As this study was focused on effectiveness of
Williams flexion exercise and it was performed
on patients with LBP. Although results of this
study showed improvement in pain but there
was no comparison group so findings may not
prove cause effect relationship. On the other
hand, this study will open future avenues for
flexion exercise was beneficial for most of the

participants in the study. This exercise with more
than
five
sessions
showed
significant
improvement in pain intensity. Along with

improvement in pain intensity there was also
improvement in spine flexion ad extension after
this exercise.
further research to do comparative analysis
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ORIGINAL ARTICLE

Effectiveness of William's flexion exercises in

Muhammad Usman Khalid , Mahvish Rafiq , Nosheen Zehra

Muhammad Usman Khalid

Student of Post Professional Doctor in Physical Therapy, Ziauddin University

Student of Post Professional Doctor in Physical Therapy, Ziauddin University

Effectiveness of William's flexion exercises in management of low back pain

affect both the gender. Normally the pain is

Participants Low back pain (LBP) can be defined

people at some point in their lives. LBP can

Pakistan Journal of Medicine and Dentistry 2013, Vol. 1 (01): 21-33

Muhammad Usman Khalid, Mahvish Rafiq and Nosheen Zehra

chronic pain.4A chronic low back pain disturbs

pharmacological treatment may be treatment of

the individual during his working environment.

choice and beneficial for pain management.

Sometimes this pain becomes so severe that it

During the past two decades, the advice for LBP

So, due to these reasons non

will affect the daily activity. And for a while this

given by primary care physicians has changed.

pain becomes so extreme that person is unable

to move and outcome is complete bed rest.

minimizing bed rest or stays active and to avoid

There are numerous structures that surround the

lumber supine like ligament and muscles. Spine

The rehabilitation program of chronic LBP is

when loses its stability by straining of these

structures results in back pain.6The risk factors

Exercise therapy, can be effective after the

for straining are poor body posture, overweight

acute stage of LBP as well. The positive results

and weak back and abdominal muscle.

have been known with specific types of exercise

Various treatment options are available for

used by physical therapists.11

management of LBP.7Short term use of pain and

Among these specific exercises, one is Williams

anti-inflammatory medications may help relieve

pain without sciatica. Muscle relaxants for acute

and chronic1 pain have some benefit, and are

more effective in relieving pain and spasms

Scheermesser M, in his study found that

Chronic use of these medications may result into

physical therapy treatment can improve the

various adverse effects. Certain medicines are

patient ability to function .The effectiveness of

unsafe during pregnancy and may cause side

physical therapy can reduce the disability. The

effects including drowsiness, or may lead to liver

studies also showed that the patient totally

Pakistan Journal of Medicine and Dentistry 2013, Vol. 1 (01): 21-33

Effectiveness of William's flexion exercises in management of low back pain

were included in the study.

moderate disability which can effect on daily

Sample size was calculated by WHO sample

activity. So role of physical therapy is also

size estimation calculator. For sample size

important in low back pain. Manual therapy is

calculation prevalence of LBP was taken as

also more effective in low back pain. The aim of

80%, at 95% confidence level and keeping 0.05