5 Effective Exercises to Resolve Flexion Intolerant Back Pain
Reading time: 3 minutes
Flexion intolerant low back pain is a common presentation in chiropractic offices. And seasoned directional preference clinicians can attest that most LBP patients (especially younger patients) present with extension-biased back pain, meaning flexion aggravates their condition. (1)
However, restoring the ability to flex without the risk of injury is crucial for a complete return to activities of daily living, aka “life.” So ChiroUp asked ACA Rehab Council vice president and rehab sage Dr. Michael Braccio to give us the essentials for fixing flexion intolerance. This blog and video highlight five of his favorite flexion-intolerant back pain exercises to help your patients return to full action.
The Challenge Of Flexion Intolerance
Traditional rehab programs for flexion intolerance focused on strengthening the core muscles while maintaining a neutral spine. However, a systematic review found that subsequent improvements in strength and endurance did not correlate with a positive outcome. (2)
And while temporarily avoiding painful positions can be helpful at the beginning of rehab, exposing the spine to various movements is ultimately needed to help improve loading tolerance. This can improve self-efficacy and reduce the fear of bending forward, which are significant reasons exercise helps those with chronic low back pain. (3)
Check out this one-minute tutorial video detailing how to safely guide your patients back to full function with Dr. Baccio’s favorite flexion intolerant back pain exercises:
Here are the details of Dr. Braccio’s program to gradually and safely overcome flexion intolerance:
1. Quadruped rocking exercise
This exercise aims to start moving the spine into flexion by rocking the hips back into a child’s pose position with minimal load. If the spine is too sensitive to rock the hips to the feet, go where it is tolerated and slowly increase the range of motion.
2. Tall kneeling exercise
This exercise builds on the quadruped rock by increasing the load by using gravity. When the hips are on the feet, the spine is loaded under flexion. To further increase the load on this exercise, using a backpack or weight can increase the tolerance to loading under flexion.
3. Half-kneeling chop exercise
The next progression is to add variety to the flexion pattern by slowly flexing across the body. The exercise band is anchored high so that there is resistance when moving into spinal flexion.
4. Squats
The final loading progression is a squat. Starting with a bodyweight squat, the spine is loaded into flexion at the bottom of the position. Of course, the load can be added to this exercise again to increase tolerance to loading and build confidence with the movement.
5. Reactive challenge exercises
The last exercise is meant to increase confidence and reduce the fear of movement by challenging the spine more reactively. Many fun yet challenging games can be implemented here, including:
Balloon tosses with a partner
Movement mimes
Virtual bowling
The key is to introduce a variety of movements and minimize protective muscle guarding.
The goal of a gradual exercise progression is to find a tolerable movement, then slowly increase the load and complexity of the movement until the patient can return to full and pain-free ADLs.
Strength training is essential for chronic flexion intolerant low back pain rehabilitation; however, it is crucial to recognize that many other approaches and contributing factors also impact this condition.
Want to learn more about those other factors? Check out this ChiroUp on-demand webinar on LBP Directional Preference and Treatment Classifications.
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1. Donelson R, Silva GR, Murphy KE. Centralization phenomenon. Its usefulness in evaluating and treating referred pain. Spine. 1990 Mar;15(3):211-3. Link
2. Steiger, F. et al. "Is a positive clinical outcome after exercise therapy for chronic non-specific low back pain contingent upon a corresponding improvement in the targeted aspect (s) of performance? A systematic review." European Spine Journal 21 (2012): 575-598. Link
3. Costa, Luciola da C. Menezes, et al. "Self-efficacy is more important than fear of movement in mediating the relationship between pain and disability in chronic low back pain." European Journal of Pain 15.2 (2011): 213-219. Link
