Why Your Patient Feels Worse After E-Stim (It's Not the E-Stim)

Dr. Lucas Marchand
4 days ago
6 min read

A patient walks into your clinic bent forward like a question mark, their torso shifted noticeably to one side. Every movement is deliberate, calculated to avoid some invisible tripwire of pain. You recognize the presentation immediately: acute lower back pain, the kind that makes standing upright feel like defying gravity itself.

You do what you've been trained to do. You place them prone on the treatment table, apply electrical stimulation or perform soft tissue work, and send them on their way. Fifteen minutes later, they stand up—and something is wrong. They're not better. They might even be worse.

The treatment gets blamed. The modality gets questioned. But what if you've been looking in the wrong direction all along?

The Body's Communication System

Think of pain-relieving postures as the body's native language. When someone adopts that characteristic flexed and shifted stance, they're not being dramatic or seeking attention. They're speaking volumes about what's happening beneath the surface. Extension—the backward bending of the spine—has become the enemy, and their nervous system has issued a company-wide memo: avoid it at all costs.

Yet standard prone positioning does exactly what the body is desperately trying to prevent. It creates lumbar extension, like forcing someone with a sprained ankle to walk on their toes for fifteen minutes straight. We wouldn't dream of doing that, yet we routinely position acute back pain patients in ways that directly contradict their protective mechanisms.

Understanding Antalgic Posturing in Acute Low Back Pain

What the Flexed Posture Tells You

When a patient presents in an antalgic (pain-relieving) posture—flexed forward with lateral shift—their body is running sophisticated damage control. This isn't random. The flexion creates space in the spinal canal, reduces compression on irritated structures, and minimizes shear forces across injured tissues.

This posture is like a biological splint, as purposeful as the swelling that protects a twisted ankle. Ignore it at your patient's peril.

Common Pathologies That Hate Extension

Several conditions share a common enemy: lumbar extension. These include:

Posterior or posterolateral disc bulges: Extension narrows the spinal canal and increases pressure on already-compromised discs
Inflamed facet joints: Extension loads these joints like closing a book too forcefully on swollen pages
Nerve root compression: Extension reduces foraminal space where nerves exit the spine
Ligamentous strain: Extension stretches already irritated posterior ligaments

Each of these conditions responds to extension the way your eyes respond to bright light after sitting in darkness—with immediate, protective withdrawal.

The Positioning Problem Nobody Talks About

Why Standard Prone Creates Extension

Place someone face-down on a flat table, and physics takes over. The natural lordotic curve of the lumbar spine creates extension, amplified by gravity pulling the abdomen downward. For a healthy spine, this is inconsequential. For an acutely injured spine, it's like pressing on a bruise for fifteen minutes.

The treatment modality—whether electrical stimulation, ultrasound, or manual therapy—becomes collateral damage in the patient's mind. "The e-stim made me worse," they report, when really the positioning held them hostage in a provocative position while the treatment was applied.

The Treatment Gets Blamed

Imagine you're cooking a perfect meal but serving it on a dirty plate. The food isn't the problem, but it gets sent back to the kitchen anyway. This is what happens when we apply sound therapeutic interventions in biomechanically disadvantageous positions.

Electrical stimulation doesn't inherently aggravate acute low back pain. Soft tissue work doesn't typically cause harm. But combined with forced extension for ten to fifteen minutes? Now you've created a scenario where the treatment can't succeed, regardless of its merits.

The Simple Solution: Pillow Placement for Prone Positioning

Creating Relative Flexion in Prone

The fix is elegantly simple: place a pillow under the anterior superior iliac spines (ASIS)—those bony prominences at the front of the hips. This single adjustment transforms the biomechanics of prone positioning.

Think of it like adjusting the angle of a ramp. Instead of creating downward pressure (extension), you're creating a more neutral or even slightly flexed position. The lumbar spine gets the message: "You're safe here. You can relax."

Biomechanical Benefits

This pillow placement accomplishes three critical objectives:

Reduces Compressive and Shear Forces: By creating relative flexion, you decrease the mechanical stress on discs, facet joints, and nerve roots. It's like reducing the weight on a scale—the structure can finally breathe.

Respects Protective Posturing: Instead of fighting the body's wisdom, you're working in concert with it. The nervous system can stand down from high alert because you're not forcing it into the danger zone.

Allows Muscular Relaxation: Paraspinal muscles that have been in protective spasm can finally release. They're no longer guarding against unwanted extension because extension isn't happening. It's like finally being able to unclench your fist after holding it tight for hours.

Clinical Application and Patient Outcomes

Reading the Patient's Presentation

Your patient is offering you a diagnostic roadmap from the moment they walk through the door. That flexed, shifted posture isn't an obstacle to work around—it's information to work with.

Consider two scenarios: In the first, you see the posture and immediately adjust your treatment positioning to accommodate it. In the second, you follow standard protocol regardless of presentation. Which patient is more likely to improve? Which is more likely to return for their next appointment?

Matching Position to Tissue Tolerance

Athletic coaches understand this principle intuitively. You don't ask a pitcher with a sore elbow to throw fastballs. You modify the activity to match what the tissue can tolerate, gradually progressing as healing allows.

The same principle applies to treatment positioning. Start where the patient is comfortable—often in relative flexion—and progress toward neutral positioning as their symptoms allow. Forcing someone into extension on day one is like asking them to run before they can walk.

Beyond E-Stim: When Positioning Matters Most

Other Modalities Affected by Poor Positioning

Electrical stimulation is hardly the only treatment that suffers from positioning problems. Ultrasound, heat therapy, manual therapy, and even dry needling can all be compromised by placing patients in biomechanically disadvantageous positions.

The modality is simply the messenger getting shot for delivering bad news. The real culprit is the positional stress we inadvertently created.

Alternative Positions for Acute Cases

For patients who can't tolerate prone positioning even with pillow modification, consider these alternatives:

Side-lying: Allows for complete control of spinal positioning and often feels safest to acutely injured patients
Supine with knees bent: Creates relative flexion and often reduces muscle guarding
Seated: Sometimes the best position is the one the patient naturally adopts

The goal isn't to force prone positioning because it's convenient for the clinician. The goal is therapeutic benefit for the patient.

Clinical Pearls and Troubleshooting

When to Suspect Positioning as the Problem

Red flags that positioning might be aggravating your patient:

They report increased symptoms during or immediately after treatment
They struggle to find a comfortable position on your table
Their muscles remain visibly tense throughout the treatment
They walk in flexed and leave flexed (or more flexed)

These signs are your clinical check-engine light. Don't ignore them.

H3: Communicating with Patients About Positioning

Transparency builds trust. When you place that pillow under their hips, explain why: "Your body is telling me that extension bothers you right now, so I'm positioning you in a way that respects that. This should feel more comfortable and help you respond better to treatment."

Patients appreciate being included in the clinical reasoning process. It transforms them from passive recipients to active participants in their recovery.

Listen to What the Body Is Telling You

The human body is remarkably articulate when we take time to listen. That antalgic posture isn't a problem to solve—it's a solution the body has already implemented. Our job as clinicians isn't to override that wisdom but to work within its parameters.

A pillow under the ASIS during prone treatment is more than a comfort measure. It's a recognition that positioning is as much a part of the intervention as the modality we're applying. It's an acknowledgment that sometimes the best thing we can do is get out of the body's way and let it heal in the position it knows is safest.

The next time a patient reports feeling worse after electrical stimulation or soft tissue work, don't automatically blame the treatment. Look at the position you held them in. Ask yourself: did I respect their protective posturing, or did I fight it?

Your patient's body is offering you free information with every shifted stance and guarded movement. The question is: are you listening?

When we match our treatment positioning to what the tissue will tolerate, we stop being the source of aggravation and become genuine facilitators of healing. And isn't that why we entered this profession in the first place?

Have a wonderful week,