Low back pain: Returning to flexion-based activities

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 ‘Rehabilitation of the Spine’ co-author Todd Hargrove summarised so eloquently in his Research Review on task-specific fear in chronic LBP, read the full Review HERE.

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 another.

Disclaimer number two – the title of the article is a bit of a misnomer (and a bit of clickbait!), as many activities generally involve some degree of flexion (1,2) – however, I’m referring to activities in which flexion is clearly visible to the naked eye.

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).

Refer to my Blog on osteoporosis for more detail on this!

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).

***The above populations are very specific and likely don’t apply to the vast majority of people seen with LBP.

Which clients should we do lumbar flexion training with?

Now we’ve spent a lot of time on exclusion criteria. As I’ve also said many times before, we do a great job telling people what not to do, and a terrible job of telling people what they can do.So let’s dive into who can and perhaps should train lumbar flexion.

The main inclusion criteria for lumbar flexion training are people who:

• Don’t fall into the above-mentioned groups
• Exhibited flexion as their main sensitizing activity (what some people would refer to somewhat haphazardly as discogenic back pain)
• Aren’t super irritable with respect to their symptoms
• Have no neurological deficits
• Need to get back to flexion activities

What about super irritable cases?

Some cases with a more centrally sensitized pain presentation may be highly sensitive to everything. This is a population in which most movements (not just flexion), and most body parts (not just the back) tend to start low and go slow. I picked this idea up from Greg Lehman – doing very small sets (1-5 reps) multiple times a day to help to slowly work on building mobility and fitness without being too aggressive can be a useful approach for the more irritable cases.

How should we progress clients through lumbar flexion training?

Step 1a: Belief change and reassurance

As Todd Hargrove described in the above-mentioned Research Review – a large number of people with chronic LBP exhibit a fear of bending; in some cases it requires a considerable amount of education and reassurance to get people to the point where they can start working into flexion comfortably. Notably, Mike Stewart outlines a useful approach in his Masterclass on persistent pain – he discusses the concept of utilising analogies, and highlights the value of enabling clients to come up with their own meaningful metaphors to make sense of their pain.

Additionally, utilising principles from the Cognitive Functional Therapy (CFT) approach may be useful – this is outlined in Sandy Hilton’s Research Reviews on CFT and the RESTORE trial. To summarise the summaries (see what I did there!) – people may need help to make sense of their pain and manage maladaptive behaviours. Additionally, exposure with control can be a valuable tool (described in detail in the CFT Review), and is a principle which overlaps with the progressive approach I have outlined below.

NOTE: one mistake I’ve made in my career in general is pushing people with activities which are safe, but beyond their confidence level. Mike Stewart recommends asking people their confidence with activity on a scale (zero = no confidence at all, five = full confidence); if the client’s confidence is less than three, the activity needs to be dialed back.

Step 1b: Lifestyle factors

Healthy lifestyle behaviours are another key component of the CFT approach described by Sandy Hilton; factors such as poor sleep, comorbid mental illness, obesity, smoking and/or poor diet can contribute to sensitivity and may represent a considerable roadblock to progress.

Once you have addressed these factors, you can begin to work on the lumbar flexion progressions 👇

Step 2: Cat camel or childs pose

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.

Step 3: Flexion in sitting

This takes two phases – 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.

Step 4: 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.

What about flexion-related sports?

My approach is generally similar, although there is limited research on disc adaptation in the sporting context so I do proceed more cautiously than with other activities. Two considerations I take when training for flexion-based sports are:

• Keeping activity volumes below a painful threshold (e.g. if 30 minutes of cycling in a flexed position is uncomfortable, I advise 15-20 minute sessions)
• Increasing volume methodically – in this situation I’m guided by Tim Gabbett’s research (even though his research isn’t on the specific topic) – I do not increase the weekly volume by more than 20% of the average volume from the previous month (e.g. if biking average of 20 minutes per session last month, I wouldn’t increase above 24 minutes per session)

Wrapping up

As with other topics I’ve written about, I understand these recommendations are very likely to change over time with the ever-evolving nature of research, but I hope this gives you some guidance on how to progress your clients into flexion-based activities safely and comfortably. As always – thanks for reading!

If you’d like to learn more about the research on task-specific fears in chronic low back pain, check out Todd Hargrove’s full Research Review HERE.