ORIGINAL ARTICLE

Effectiveness of William's flexion exercises in

management of low back pain
1 2 3
Muhammad Usman Khalid , Mahvish Rafiq , Nosheen Zehra

1
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

2
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
Pakistan Journal of Medicine and Dentistry 2013, Vol. 1 (01): 21-33 22
Muhammad Usman Khalid, Mahvish Rafiq and Nosheen Zehra
treatment. If this pain is not treated then become damage. So, due to these reasons non

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
5
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 MA in his study recommended

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 for the management of pain10.
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
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 gluteus
and chronic1 pain have some benefit, and are 12
musculature to manage low back pain.
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
various adverse effects. Certain medicines are
unsafe during pregnancy and may cause side
physical therapy treatment can improve the
13
patient ability to function .The effectiveness of
14
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 23
Effectiveness of William's flexion exercises in management of low back pain
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
included in the study.
effectiveness of Williams flexion exercises. As
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
pregnancy and anyone who would have been
conducted among patients of LBP. All those
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

Pakistan Journal of Medicine and Dentistry 2013, Vol. 1 (01): 21-33 24

Muhammad Usman Khalid, Mahvish Rafiq and Nosheen Zehra
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
17
and collect baseline data by means of health version . Frequencies and percentages were

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.

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
experienced. 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. Among them 96 (38.4%) had

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-
Pakistan Journal of Medicine and Dentistry 2013, Vol. 1 (01): 21-33 25
Effectiveness of William's flexion exercises in management of low back pain
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
Pakistan Journal of Medicine and Dentistry 2013, Vol. 1 (01): 21-33 26
Muhammad Usman Khalid, Mahvish Rafiq and Nosheen Zehra
(25.2%) had mild pain and 7 (2.8%) had exercise and post pain intensity P<0.00 (Table

moderate pain. There was significant 2).

association between sessions of William Flexion

Table 2: Association of William Flexion Exercise and Post Pain Intensity

Number of William Flexion

Intensity of Pain after Exercise
Exercise Sessions
Moderate P- Value
No Pain Mild Pain Total
Pain

n (%) n (%) n (%) n (%)

5 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) 0.037

More than 10 16 (6.4) 63 (25.2) 7 (2.8) 86 (34.4)

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
No Pain Mild Pain Moderate Pain Total P- Value
n (%) n (%) n (%) n (%)
Mild Pain 11 (4.4) 34 (13.6) 2 (0.8) 47 (18.8)
Moderate Pain 9 (3.6) 94 (37.6) 4 (1.6) 107(42.8)
Sever Pain 20 (8) 72 (28.8) 4 (1.6) 96 (38.4) 0.079
Total 40 (16) 200 (80) 10 (4) 250 (100)

At the start of physiotherapy of patients, flexion (52.8%) of patients which was improved

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
Pakistan Journal of Medicine and Dentistry 2013, Vol. 1 (01): 21-33 27
Effectiveness of William's flexion exercises in management of low back pain
(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)

Figure 1: Improvement in Spine Flexion and Extention after William's Flexion

Exercise
40
Spine Flexion and Extension after Exercise %

34.8
35

30 27.6

25

20 18
Completely Improved
15 Slightly Improved
9.6
10
6.4
5 3.6

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 were also inquired about 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%) replied that there was 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

average of 28.6 works day are lost per year due

DISCUSSION
19
to low back pain. 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
20,21
Nachemson A reported that about 80% people reported in literature.

Pakistan Journal of Medicine and Dentistry 2013, Vol. 1 (01): 21-33 28

Muhammad Usman Khalid, Mahvish Rafiq and Nosheen Zehra
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
21
received Williams flexion exercises. 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 and mild pain also showed

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

took more than 5 sessions. Various studies also

According to the Williams these exercises
reported improvement in LBP after Williams
reduce the pressure on the posterior element of
20, 21,24
flexion exercise.
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
20, 23
low back pain. Williams flexion exercises sit up, pelvic tilt, knee to chest, hamstring

also strengthen the back and abdominal stretch, hip flexor stretch and squat. Participants
Pakistan Journal of Medicine and Dentistry 2013, Vol. 1 (01): 21-33 29
Effectiveness of William's flexion exercises in management of low back pain
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
suggested that preventive strategies should be
working environment and daily living.25 In
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
flexion exercise was beneficial for most of the
Williams flexion exercise and it was performed
participants in the study. This exercise with more
on patients with LBP. Although results of this
than five sessions showed significant
study showed improvement in pain but there
improvement in pain intensity. Along with
was no comparison group so findings may not
improvement in pain intensity there was also
prove cause effect relationship. On the other
improvement in spine flexion ad extension after
hand, this study will open future avenues for
this exercise.
further research to do comparative analysis
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