Low back pain : returning to flexion - based activities.. Help's physiothearapy

Fear of flexion-based activities is a common theme in people with Low Back Pain (LBP); if you ask one hundred people with LBP which activities they’re concerned about, the most common response you’re going to get is bending forward or flexion. This is something my fellow

Now, most peoples’ day-to-day tasks don’t involve a tonne of end range lumbar flexion, and there are a few populations in which a heap of lumbar flexion is not appropriate (more on that below). However, there are certain sports and activities which require spinal flexion mobility and tolerance. This begs the question – how do we return people with LBP to these flexion-based activities safely? The below article aims to answer this question.

Major disclaimer to start with – as with all my works, this should not be considered individualised medical advice. Every person with back pain is different – an exercise that may help one person could be counterproductive for anoactivities

Which clients are NOT indicated for flexion-based activities?

I want to set the stage for this article by saying this does NOT apply to:

• Post surgical clients (e.g. laminectomies or spinal fusions, where specific rehab protocols are indicated)

• Acute low back pain (in most cases) – often more sensitive in nature

• Cases with specific conditions (i.e. ankylosing spondylitis) contributing to back pain

• Red flag conditions (i.e. fracture, tumor, infection)

• People who have a directional preference for lumbar flexion (they’re likely doing it already so we don’t have to worry about reintegrating it!)

There are also some other populations in which lumbar flexion training is not appropriate (at least in my anecdotal experience). These people may include:

1 – Powerlifters and olympic lifters

While weightlifting will always involve some lumbar flexion (2), the main aim is to keep as neutral a spine as possible. If you see a powerlifter keel over a lot with the bar during a maximal lift, chances are they’re not coming up with the weight.

The other factor to consider with athletes, and this is something I agree with Stu McGill on, is that these athletes push their spines to the limits; they’re lifting extremely heavy loads on a regular basis, so I believe it’s best to minimise lumbar flexion load during day-to-day life to enhance their capacity to perform when needed.

Similarly, I’m not a huge fan of back stretching (or excessive stretching in general) for powerlifters or olympic lifters beyond that which is needed for the sport.

2 – Osteoporosis

Some research has suggested that flexion loads expose osteoporotic vertebrae to a higher risk of failure (3).

Now, that doesn’t mean we need to avoid flexion altogether – however, I often limit flexion activities for people with moderate to high vertebral fracture risk unless they’ve already been doing them for a while… and even then, I’m very careful with load management!

Cases in which I am more supportive of continuing flexion-based activities include people with low-moderate fracture risk AND physically fit individuals who have participated in activities like yoga or pilates before; it may be appropriate to adjust the overall volume of lumbar flexion completed during cumulative exercise and Activities of Daily Living (ADLs).

3 – People with recurring LBP aggravated by flexion

As much as I’m a big believer in the body’s adaptive capabilities – we all know those clients that come back a couple of times a year because they “bent the wrong way” and hurt their back. Some clients just don’t adapt well to certain movements, so I tend to be more open to minimising spinal flexion for these clients (again, you can never eliminate fully).

How should we progress clients through lumbar flexion training?

The cat camel (sometimes referred to as cat cow) is a popular stretch for back pain and for good reason – many people with LBP tolerate it well. So this is the first place to start when implementing some flexion-based training with your client.

firstly, it’s best to start with partial flexion by instructing your client to bend their elbows to about 90-100 degrees, lower their arms until their forearms touch their legs, and then flex forward as far as they can comfortably. Once they can tolerate this, the next phase is encouraging the client to touch the floor with their hands from a sitting position.

NOTE: if there is discomfort during any step, simply adjust the activity by reducing the range of movement.

Flexion in standing

This is exactly what it sounds like! It may sound counterintuitive – but I find people who can do seated flexion usually don’t have problem with unloaded flexion in standing.