Using Directional Preference to Relieve Back pain

Do you ever wonder why doing one thing hurts your back, but doing another thing makes it feel better? Or why doing nothing makes it worse and being more active makes it feels better? or vise versa. This is because people are different and can have many different reasons for having back pain. One way physical therapists classify people and their treatment approaches is by directional preference. People will fall into one of three groups. These three groups are flexion preference, extension preference and no directional preference. 

Flexion Preference

Flexion refers to the motion of bending forward at the back, such as sitting. The flexion group tends to be people who have undergone more degenerative changes in their back. Bending forward opens up a hole in the back where nerves come out wider so that you create more space for the nerve that is continually being impinged. This is why this group tends to have more increase in pain with upright activities, that is relieved with sitting or slouching. If you fall in this group, don’t think you’re doomed for life for any prolonged upright activities and that you’re going to have to constantly be taking sitting breaks to function throughout the day. We just have to use this knowledge to assist us in creating more motion above and below the low back so that the low back doesn’t move excessively in to the ranges where it impinges on to the nerve. Here’s an example of a common treatment for most individuals in this group:

Stretching Tight Hip Flexors: Tight hip flexors cause the low back to move more in to an extended position causing the nerve to get impinged. If we stretch hip flexors the traditional way, not know what you know now you will put your back in to more pain. Here is the right and wrong way of stretching. 

Correct

Incorrect

The top picture shows stretching of the hip flexors where the back is flexed, but hips are extended=Good. The bottom picture shows the back and hips in extended position=Bad

Use this strategy for stretching any tight areas in your body that will ease excessive motion in back. 

Here’s one more motion that is very important for you to learn and perfect. Many stretches, exercises, functional tasks that’s painful can be made better by performing this move. It is called a posterior pelvic tilt. Learn to tilt the pelvis backward without moving anything else. ie. laying on back, small of back pushing down in to table. Look for video instruction on this, as a picture doesn’t do it justice.

Extension Preference 

Extension is the motion of doing a back bend or accentuating the curvature in your low back. This population of people tend to be younger, non-smoking, healthier individuals. Most commonly, these people have disc herniation and swelling small enough to be able to moved forward off of the nerve that’s irritated with extension motions or positions. A common issue for individuals with this preference is hamstring tightness. Here is an example of correct way and incorrect way of stretching hamstrings with someone who has an extension preference. 

Correct

Incorrect

The top picture shows stretching of the hamstrings where the back is extended=Good. The bottom picture shows stretching of the hamstrings with the back in a flexedposition=Bad

Use this strategy for stretching any tight areas in your body that will ease excessive motion in back. 

Here’s one more motion that is very important for you to learn and perfect. Many stretches, exercises, functional tasks that’s painful can be made better by performing this move. It is called a anterior pelvic tilt. Learn to tilt the pelvis forward without moving anything else. ie. Laying on bed arching the low back away from bed. Look for video instruction on this, as a picture doesn’t do it justice.

No Directional Preference

This category means there’s no helping you. Just kidding. This just means that this population feels better in a neutral position of the spine between the two ranges of motion. Usually this population is considered “double jointed” by the lay man, but it just means you have excessive motion in your joints. These people tend to be painful with prolonged positioning in to flexion and or extension. Here you have to master the posterior pelvic tilt and the anterior pelvic tilt talked about earlier. If you find yourself in a flexed position, tilting anteriorly will help you find a more neutral position and in an extended position, tilting your pelvis posterior will do the same. Rehabilitating starts with strengthening exercises of the core in a neutral position initially and then working further out toward the extremes away from the neutral position as your body tolerates it.

If you need an exam to figure out what directional preference you are, or need help finding what areas that are tight that will improve your back pain, or need program to get you on your way to rehabilitating yourself at home. Select the initial evaluation item on this page.