Williams Back Exercises

Issues of Concern

The main issue of concern is whether the William back exercises were superior or inferior to the McKenzie protocol. Researchers have compared the Williams and McKenzie protocols for back pain. Decreasing pain and return of lumbar motion were the variables examined. In the comparison of the two groups, patients who underwent the McKenzie protocol improved function to a significantly greater extent than patients in the Williams protocol group, as well as achieved this results in a significantly decreased period. EMG activity at four lumbar vertebrae was examined in patients performing posterior and anterior pelvic tilt exercises of the Williams protocol. The results showed the positions of pelvic tilt, curl up, knees to chest, and hamstring stretch, when completed with posterior tilt, minimized the electromyographic activity in both the lumbar and sacral regions. Furthermore, the use of anterior tilt positions should be avoided to minimize electromyographic activity in the lumbar and sacral regions. Lastly, the electromyographic activity the four lumbar vertebral levels respond independently of each other while the performance of Williams' flexion exercises.[7]

Generally speaking, patients with acute mechanical low back pain do not get referred to physical therapy or a home exercise program, but select populations at increased risk for developing chronic back pain could benefit.[8] Some studies have shown there to be modest efficacy to starting exercise therapy for back pain less than four weeks in duration, while multiple systematic reviews have not shown them to be superior to conservative therapy. 

Although some studies do prove that there is a significant efficacy of exercise therapy in selected cases of acute low back pain (less than four weeks).[9][10] However, systematic reviews have not demonstrated a treatment benefit of exercise therapy compared with conservative management.[11] Separately the evidence does support the use of exercise therapy for patients with subacute and chronic low back pain.[9][10][11]

Clinical Significance

Before the availability of more advanced treatment modalities for low back pain, the Williams exercises were the standard of care for this problem. The exercises can be performed in the supine position on any flat surface. The first maneuver of importance is to grab the legs and pull the knees to the chest and hold them for several seconds. Williams felt that this helped open the intervertebral foramen, stretched the ligaments, and distracted the apophyseal joints. 

Williams originally designed these exercises for chronic low back pain secondary to low-grade lumbar disc disease seen on X-ray. The theory was that when pressure is placed on the posterior aspect of the lumbar vertebral with extension, disc herniation can occur. In theory, this is due to increased lumbar lordosis; lumbar lordosis would decrease by limiting the pressure placed on the posterior aspect of the lumbar vertebra. The decrease in pressure would improve by improving the flexion of the vertebral disc, leading to decreased disc herniation, thus reducing the incidence of chronic low back pain. The exercises proposed to open the intervertebral foramen to provide additional lumbar stability. The McKenzie exercises have their basis on the belief that humans are constantly in a flexed position; this, in turn, causes the nucleus of the lumbar disc to move posteriorly. The posterior motion of the lumbar disc then causes back pain.

When patients perform the exercises regularly, they reduce pain, improve the stability of the lower pelvis, and increase the range of motion. The seven variations of Williams’s exercises include: 1) the pelvic tilt, 2) the single knee to chest, 3) double knee to chest, 4) partial sit-up, 5) hamstring stretch, 6) hip flexor stretch, and 7) squatting.

The Williams back pain exercises are repeatable as well as done for various lengths of time. The recommended duration for the exercise is every day for 10 to 20 minutes. Exercises are done with the patient lying supine on a flat surface and completed at home. Then the patient would flex their legs by pulling their knees to their chest and holding this position. The patient would relax and repeat the motion. An example of the various exercises appears below.

• The posterior pelvic tilt position is performed with the patient lying on their back with their hands at their side and their knees bent. The patient is then told to tighten the muscles of their abdomen, as well as their buttock muscles, flattening their back against the floor.
• The single knee to chest motion is done with the patient lying on a table or bed. They are then instructed to let a leg fall off the table or bed, bend their other leg and wrap their hands around the bent knee, and pull the bent leg toward their chest.
• The double knee to chest stretch is also done with the patient lying on their back. The patient is instructed to bring both their knees, one at a time, to their chest. With their hands held together, the patient pulls their knees towards their chest and curls their head forward. While performing the motion, the patient is instructed to keep their knees together and to have their shoulders flat on the floor. The patient then lowers one leg at a time.
• The lumbar flexion position with rotation is completed with the patient lying on their back with their hands at their sides and their knees bent. The patient is then instructed to rotate their knees towards the direction of pain.
• The seated lumbar flexion exercise starts with the patient sitting upright in a chair. The patient is urged to slowly bend forward until they feel the tension in their back. In contrast, the standing lumbar flexion exercise starts with the patient standing upright with their feet spread shoulder-width apart. The patient slowly bends forward, sliding their hands down to their legs until they feel the tension in their back.
• The partial sit-up exercise is completed with the patient lying on their back with their hands at their sides and their knees bent. The patient is instructed to use their abdominal muscles to raise their upper back off the floor while exhaling. The patient is supposed to rise only enough to get their shoulder blades off the floor. Furthermore, the patient is not supposed to thrust themselves off the floor or to lift their heads with their arms. While performing this motion, the patient is supposed to keep their knees bent and their feet flat on the floor. The patient should feel the muscle contraction only in their abdominal muscles. The patient is then instructed to gently lower their upper body in a smooth and relaxed motion.
• The partial diagonal sit-up is completed with the patient lying on their back with their hands at their sides and their knees bent. The patient is instructed to use their abdominal muscles to raise their upper back off the floor while exhaling. The patient raises their upper body off the floor with one shoulder higher than the other. The patient is not supposed to thrust themselves off the floor or to lift their heads with their arms but to keep their knees bent and their feet flat on the floor. The patient should feel the contraction only in their abdominal muscles. This motion is supposed to move smooth and relaxed while gentle lowing their upper body.

Mechanical back pain is one of the most common complaints seen in a primary care clinic. It often resolves with conservative management and time. Home exercise programs such as the William flexion exercises and the McKenzie extension exercises are two of the most common home exercises used. The William flexion exercises are designed to improve flexion of the lumbar vertebra while limiting lumbar extension. Performing these exercises, we aim to strengthen the gluteus and abdominal muscles. These exercises have been recommended for patients with a variety of low back pain complaints since the 1930s.

Most of the evidence is either level III or IV. Few recent studies have been completed on the Williams back exercises despite being the standard of care previously.  Health care professionals, which include physicians, therapists, and nurses, must have active conversations regarding home exercise programs with patients experiencing mechanical back pain. Home exercise programs can be considered part of the standard of care for mechanical back pain, along with other conservative treatment options.