Therapy Considerations for the Flexion-Intolerant Low Back

Low back injuries are extremely prevalent amongst athletes who compete in powerlifting, weightlifting or Crossfit. As a performance therapist, I often treat athletes who are flexion intolerant and have difficulty bending forward due to pain. Common mechanisms for these types of injuries include:

  • Deadlifting
  • Squatting
  • KB Swings

Based on the assessment of a health care professional, the specific cause or diagnosis may differ from professional to professional. However, when treating a patient with low back pain, regardless of the specific diagnosis, it is important to provide the patient with pain education and movement re-training. Pain education and movement re-training set up the foundation for patients recovering from almost any injury. In this article, I will outline my approach to managing patients who are flexion intolerant using pain education and movement re-training.

Pain Education

Once you have performed a thorough assessment and provided your patient with a detailed report of findings as to what is causing or contributing to their pain, it is important to provide a brief explanation of what pain is.

Educating patients on the science of pain can help dispel myths they may believe and help manage expectations regarding recovery. I start by describing pain as experience or an output that is felt when a person is in danger. It is a decision that only the brain can make once it has processed all relevant information.  You can break a bone, sever a nerve or tear a muscle but you won’t experience pain if your brain does not think you are in danger. The primary purpose behind why pain exists is to motivate you to take action against threat, ultimately keeping you out of harms way. Several factors influence a patient’s experience of pain. Increased stress level, being labeled with a diagnosis, your beliefs about your pain, activity or fitness level and previous injuries all have an implication on your pain. This is in addition to local factors such as tissue trauma or inflammation. Tissue trauma or increased stress alone are often not enough to trigger pain. A multitude of factors are required to create a perception of threat high enough for the brain to signal a pain response.

Patients may come to your office with “thought viruses” or beliefs that are powerful enough to perpetuate their pain state. Examples are:

“I’m in pain so there must be something harmful happening to my body”
“I’m not doing anything until the pain goes away”
“The CT machine couldn’t find it so it must be bad”

It is important to address these concerns and educate your patients on the consequences of having a negative attitude towards their pain. It is only through education and awareness that therapists empower patients to take a positive approach to their rehabilitation and progress them in the right direction.

An excellent resource for patients and clinicians is the book Explain Pain by Lorimer Moseley. Check out my review of this book to learn more about the science of pain as described by Moseley by clicking this link.

Movement Re-Training

Now that the patient has a better understanding of the nature of their pain, providing them with strategies to move with greater confidence is important.

The way this can be accomplished is to perform the following:

  1. Teach the patient to move in a spine conserving way and how to achieve neutral spine
  2. Teach the patient how to limit micro movements in the spine by breathing and engaging an abdominal brace

A neutral spine posture has been proven to be the safest position for the spine to bear load when performing any type of lifting. A neutral spine helps maintain an optimal length for the muscles of the low back, allowing the muscles to stabilize the joints in the spine and limit their movement. In order to teach a patient how to achieve a neutral spine, awareness of pelvis position is important. Have the patient practice pelvic tilting in the supine position by moving the pelvis to either flatten (posterior pelvic tilt) or arch the low back (anterior pelvic tilt). Neutral spine exists in the middle of these extremes.

Posterior Pelvic Tilt (Back Flat)

Anterior Pelvic Tilt (Arched Back)

The cat/camel exercise is a great progression to the supine pelvic tilt. The patient may find that they feel pain at the extreme end ranges of motion. This feedback can help teach the patient to keep their back position within a neutral range (not too flexed or extended) which can keep them out of a painful posture.

Cat Camel – Flexed Spine

Cat Camel – Extended Spine

This can be further progressed to a standing position against a wall.

Standing Pelvic Tilt

Now that the patient knows how to manipulate their pelvic tilt, they will have greater awareness on how to find a neutral spine position. The next step is teaching the patient how to maintain a neutral spine through a dynamic movement. The hip hinge is a great way to teach your patient how to bend forward while maintaining a neutral spine and maximizing movement through their hips. Patients who are flexion intolerant can use the following drill to re-educate themselves to bend forward in a way that minimizes motion in their spine.

Hip Hinge Dowel Drill

Have the patient hold a dowel along their back with 3 points of contact (the head, mid back and low back).

Instruct the patient to reach their hips back without the dowel losing the 3 contacts and without bending the knees. If the dowel loses contact with the spine, the patient is using their spine to bend forward, which is incorrect. This feedback helps the patient maximize motion through their hips and limit motion through their spine.

The patient is maintaining a neutral spine while maximizing motion through the hips.

More mobility tools HERE

Dr. Ricky Singh BSc. Kin (Hons), DC, CSCS and Rocktape ambassador