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Dr. Brian Abelson

Are You Prescribing the Right Exercises? Flexion and Extension Intolerance

Updated: Aug 5


Yoga Pose

Back pain is a complex issue affecting millions of people worldwide. For many, the symptoms of this prevalent condition are often influenced, for better or worse, by phenomena known as flexion and extension intolerance. These terms depict the intensification of pain when the spine moves in specific ways—forward (flexion) or backward (extension).


The significance of flexion and extension intolerance arises from repeated clinical observations suggesting that exercise regimens often fail to address the distinct pain characteristics of individuals with back pain.


When correctly identified and managed, this intolerance can, in many instances, considerably expedite the recovery process. For some patients, the cornerstone of effective treatment lies in crafting suitable exercise routines and advising on postures to avoid, all customized according to the individual's unique intolerance pattern.


Article Index:

 

Flexed Position

Flexion Intolerance


Individuals grappling with flexion-intolerant back pain characteristically experience discomfort during anteriorly directed spinal flexion or while maintaining postures that enforce continuous spinal flexion, such as prolonged sitting. The lumbar lordosis is habitually diminished or even reversed in such a state, subjecting the intervertebral discs to altered biomechanical stressors.


A typical pathology implicated in flexion-intolerant back pain includes discogenic disorders, most notably, disc herniation or disc bulges. The nucleus pulposus protrudes through annular tears into the spinal canal or intervertebral foramen. This pathologic state is often precipitated by heightened anterior hydrostatic pressure within the disc, commonly provoked by spinal flexion.


The dynamics of spinal flexion increase compressive forces on the anterior aspect of the intervertebral discs, leading to further herniation of the nucleus pulposus through the compromised annulus fibrosus. This herniated disc material may then irritate or compress adjacent neural structures, including spinal nerve roots or, in severe cases, the spinal cord itself, instigating radicular pain or even neurologic deficits.


 

Extended Position

Extension Intolerance


Individuals dealing with extension intolerance encounter difficulties with pain during activities or postures that involve spinal extension or require maintaining extended spinal positions for prolonged periods. Activities that require an upright stance, walking for extended periods, or tasks that require a consistent upward gaze can escalate their discomfort.


Several pathologies associated with extension-intolerant back pain include spinal stenosis, spondylolisthesis, and facet syndrome. Spinal stenosis is characterized by a narrowing of the spinal canal that can increase mechanical pressure on neural structures due to limited space. Similarly, spondylolisthesis involves the forward slippage of one vertebral body over another, resulting in uneven weight distribution and potential compression of neural elements. Facet syndrome, characterized by irritation or damage to the facet joints between vertebrae, can also cause extension intolerance, as extending the spine can increase strain and pressure on these joints.


In these conditions, the posterior structures of the spine are subjected to heightened biomechanical stress. Spinal extension aggravates these conditions by further diminishing the posterior intervertebral space, increasing neural structure pressure. This intensifies the nociceptive response, leading to a magnified pain experience.


 


Ask Sign

History: The Cornerstone of Diagnosis


The importance of a comprehensive history cannot be understated—it serves as the bedrock of diagnosis, paving the way for effective management, especially when interwoven with meticulous physical examination and judicious use of imaging studies. When navigating the complexities of back pain, these questions can aid in honing your clinical acumen to discern the right exercise prescription for your patients:


Flexion Intolerant Questions:


[ ] Pain when the patient engages in full forward flexion (touching toes or during a seated reach):

  • Indicates possible flexion intolerance; may be associated with discogenic pain due to increased intradiscal pressure.

 

[ ] Pain relief when transitioning from a seated to a standing position:

  • Suggests flexion intolerance relief upon spinal unloading; consider discogenic issues where disc pressure is relieved by spinal extension.


[ ] Pain when lying flat on the back without a pillow under the knees:

  • Indicates potential flexion intolerance; flattening of lumbar lordosis may stress the posterior disc and soft tissues.


[ ] Pain on returning to an upright position after forward flexion:

  • Suggests flexion intolerance; may be associated with disc derangements or instabilities.


[ ] Pain with sustained sitting, especially in a slouched posture:

  • Indicates flexion intolerance; postural stress may exacerbate disc pathology or ligamentous strain.


Extension Intolerant Questions:


[ ] Pain during or after extension-based movements (arching the back, walking, or standing):

  • Indicates possible extension intolerance; consider facet joint syndrome or spinal stenosis.


[ ] Pain relief with sitting or flexed postures (sitting with knees higher than hips):

  • Suggests extension intolerance relief; flexion may decompress the neural elements in cases of stenosis or unload facet joints.


[ ] Pain when the patient extends the spine while lying prone (prone press-up test):

  • Indicates potential extension intolerance; may implicate facet joint irritation or nerve root impingement in stenosis.


Other Possibilities


[ ] Pain with rotational activities or when lifting an object:

  • May suggest facet joint irritation (extension intolerance) or compounded flexion-extension intolerance if disc pathology is present.


[ ] Increase in leg pain or paresthesia with either flexion or extension movements:

  • Indicates nerve root involvement; consider herniated disc for flexion and spinal stenosis or foraminal stenosis for extension.


[ ] No change in symptoms with movement:

  • May suggest non-mechanical pain sources; further investigation required.



Remember, the patient's response to these questions is just one aspect of the overall evaluation. Physical examination and imaging studies may also be necessary to confirm a diagnosis and develop an appropriate treatment plan.


 

Physical Examination Processes


Beyond obtaining a comprehensive history, conducting thorough orthopedic, neurological, and vascular examinations is critical when dealing with conditions like flexion and extension intolerance. This is particularly significant as these tests help in the differential diagnosis and enable the clinician to understand the source of pain, whether it is musculoskeletal, neural, or vascular.


Orthopedic tests help to identify structural or mechanical issues, neurological tests assess nerve function and health, and vascular tests evaluate blood flow. These examinations paint a clearer picture of the patient's health and specific pain patterns. This detailed understanding is crucial for developing an effective, personalized treatment plan for flexion or extension intolerance conditions.


Low Back Examination - Effective Orthopaedic Testing

This educational YouTube video is an excellent resource for healthcare practitioners, students, and anyone seeking to deepen their understanding of the common causes of low back pain and how to diagnose them using orthopaedic examination procedures.


Lower Limb Neuro Examination

The lower limb neurological examination is part of the overall neurological examination process and is used to assess the motor and sensory neurons which supply the lower limbs. This assessment helps to detect any impairment of the nervous system. It is used both as a screening and an investigative tool.


Peripheral Vascular Examination - Key Points

A peripheral vascular examination is valuable for ruling out signs of vascular-related pathology. The detection and subsequent treatment of PVD can potentially mitigate cardiovascular and cerebrovascular complications. This video reviews some common procedures we perform in daily clinical practice.


 

Bird Dog Exercise

Flexion Intolerant Exercises


A tailored exercise regimen that encourages extension or a neutral spinal position is often beneficial in cases of back pain that's intolerant to flexion. Additionally, core stabilization and strength exercises can help support the back by enhancing muscle endurance and reducing the load on the spinal structures.


Here are some exercises frequently suggested for those with flexion-intolerant back pain:

  1. Prone Press-ups: This exercise encourages spinal extension. Start by lying face down on the ground, then prop your upper body up on your elbows. If comfortable, place your hands flat on the ground beside your shoulders and push your upper body up, extending your arms fully and keeping your hips against the floor. Be careful not to hyperextend or strain your back.

  2. Bird Dogs: This exercise strengthens the core and promotes a neutral spine. Start on your hands and knees in a tabletop position. Raise your right arm and left leg simultaneously, extending them fully. Switch and repeat with the left arm and right leg.

  3. Glute Bridges: This exercise helps to engage the posterior chain (glutes and hamstrings) while maintaining a neutral spine. Caution should be observed to avoid overarching the back at the top of the movement.

  4. Planks: This core stabilization exercise strengthens the abdominal muscles and promotes a neutral spine. Lie on your stomach and prop yourself up on your elbows. Lift your body off the ground, so you're balanced on your elbows and toes. Try to maintain a straight body line and remember to breathe.

  5. Pelvic Tilts: This exercise promotes awareness of neutral spine and abdominal control. Lie on your back with your knees bent and feet flat on the floor. Tilt your pelvis to flatten your back against the floor, hold, and then relax.

  6. Side Planks: This variation of the plank targets the obliques and promotes lateral stability. Ensure your body alignment is correct and avoid twisting at the spine.

  7. Abdominal Bracing: This exercise trains the deep core muscles and can help improve spinal stability. While lying on your back with your knees bent and feet flat on the floor, contract your abdominal muscles as if preparing for a punch to the stomach. Try to breathe normally while holding this contraction.


Flexion Intolerance Exercise Video

7 Effective Exercises For Flexion Intolerant Back Pain - The significance of flexion and extension intolerance arises from repeated clinical observations suggesting that exercise regimens often fail to address the distinct pain characteristics of individuals with back pain. The following exercises are designed for individuals who are flexion intolerant (the back pain gets worse with positions of flexion).


 


Child's Pose

Extension Intolerant Exercises


In instances of back pain that's intolerant to extension, where discomfort or pain occurs when the spine extends or bends backward, exercises favoring a neutral or gently flexed spinal position often provide relief. Below are some exercises typically suggested for individuals with extension-intolerant back pain:

  1. Knee-to-Chest Stretch: While lying on your back, gently pull one knee at a time towards your chest. This exercise encourages lumbar flexion, which can alleviate discomfort associated with extension intolerance. Take care not to pull too forcefully, and keep movements controlled and smooth.

  2. Pelvic Tilts: This exercise promotes the awareness and control of a neutral spinal position. Lying on your back with your knees bent and feet flat on the floor, gently tilt your pelvis upward, pressing your lower back against the floor.

  3. Child's Pose: A yoga posture that provides gentle spinal flexion. It involves sitting back on your heels and extending your arms forward while bending at the waist. Be mindful of your body's limits and only stretch as far as is comfortable.

  4. Seated Forward Bend: In a seated position with your legs extended in front of you, gently bend at the waist and reach towards your toes. This provides a gentle stretch but caution should be taken not to overstretch or strain the back.

  5. Cat-Camel Stretch: This exercise, performed on all fours, involves alternation between arching your back upwards (like a cat) and dropping your belly down while lifting your chest and tailbone (like a camel). This exercise promotes spinal mobility and control but avoid forcing the spine into extremes of flexion or extension.

  6. Partial Curl-Ups: This exercise strengthens the abdominals while minimizing spinal movement. Lying on your back with your knees bent and feet flat on the floor, gently lift your head and shoulders off the floor. Placing your hands under the small of your back helps to maintain a neutral spine position.

  7. Dead Bug Exercise: This core stabilization exercise promotes a neutral spine. Start lying on your back with your arms extended towards the ceiling and hips and knees bent at 90 degrees. Carefully lower your right arm and left leg simultaneously without touching the floor, then return to the starting position. Repeat on the other side, maintaining control throughout the movement.


When executed properly, these exercises can provide relief and improve function in individuals with extension intolerance. However, it's crucial to always heed your body's feedback and consult with a healthcare provider before initiating a new exercise regimen.



Extension Intolerance Exercise Video

7 Effective Exercises For Extension Intolerant Back Pain - The significance of flexion and extension intolerance arises from repeated clinical observations suggesting that exercise regimens often fail to address the distinct pain characteristics of individuals with back pain. The following exercises are designed for extension-intolerant individuals (the back pain worsens with positions of extension).


 

Woman Stretching

Conclusion - Flexion and Extension Intolerance


Understanding flexion and extension intolerance is critical in the effective management of back pain. Identifying these patterns allows for the customization of exercise programs and lifestyle modifications that can significantly improve patient outcomes. While the approach does not guarantee complete relief for all, many patients benefit from a regimen tailored to their specific intolerance, enhancing their recovery and daily function.


A comprehensive diagnostic approach, integrating a patient's history with a physical examination, and if necessary, imaging, is essential to accurately identify the presence of flexion or extension intolerance. This enables practitioners to devise safe, effective treatment strategies that address the individual's unique spinal mechanics, offering a more targeted and sustainable resolution to back pain.


 

DR. BRIAN ABELSON, DC. - The Author


Photo of Dr. Brian Abelson

With over 30 years of clinical practice and experience in treating over 25,000 patients with a success rate of over 85%, Dr. Abelson created the powerful and effective Motion Specific Release (MSR) Treatment Systems.


As an internationally best-selling author, he aims to educate and share techniques to benefit the broader healthcare community.


A perpetual student himself, Dr. Abelson continually integrates leading-edge techniques into the MSR programs, with a strong emphasis on multidisciplinary care. His work constantly emphasizes patient-centred care and advancing treatment methods. His practice, Kinetic Health, is located in Calgary, Alberta, Canada.


 


MSR Instructor Mike Burton Smiling

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Enroll in our courses to master innovative soft-tissue and osseous techniques that seamlessly fit into your current clinical practice, providing your patients with substantial relief from pain and a renewed sense of functionality. Our curriculum masterfully integrates rigorous medical science with creative therapeutic paradigms, comprehensively understanding musculoskeletal diagnosis and treatment protocols.


Join MSR Pro and start tapping into the power of Motion Specific Release. Have access to:

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  • Article Library: Our Article Index Library with over 45+ of the most common MSK conditions we all see in clinical practice. This is a great opportunity to educate your patients on our processes. Each article covers basic condition information, diagnostic procedures, treatment methodologies, timelines, and exercise recommendations. All of this is in an easy-to-prescribe PDF format you can directly send to your patients.

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Integrating MSR into your practice can significantly enhance your clinical practice. The benefits we mentioned are only a few reasons for joining our MSR team.


 

References


  1. Adams, M. A., & Dolan, P. (2005). Spine biomechanics. Journal of Biomechanics, 38(10), 1972–1983.

  2. Balagué, F., Mannion, A. F., Pellisé, F., & Cedraschi, C. (2012). Non-specific low back pain. The Lancet, 379(9814), 482-491.

  3. Cholewicki, J., & McGill, S. M. (1996). Mechanical stability of the in vivo lumbar spine: Implications for injury and chronic low back pain. Clinical Biomechanics, 11(1), 1-15.

  4. Cook, C., Brismee, J. M., & Sizer, P. S. (2007). Subjective and objective descriptors of clinical lumbar spine instability: a Delphi study. Manual Therapy, 12(1), 13–21.

  5. Hicks, G. E., Fritz, J. M., Delitto, A., & Mishock, J. (2005). Interrater reliability of clinical examination measures for identification of lumbar segmental instability. Archives of Physical Medicine and Rehabilitation, 86(12), 2257-2261.

  6. Hodges, P. W., & Richardson, C. A. (1996). Inefficient muscular stabilization of the lumbar spine associated with low back pain: A motor control evaluation of transversus abdominis. Spine, 21(22), 2640-2650.

  7. McGill, S. (2007). Low back disorders: Evidence-based prevention and rehabilitation (2nd ed.). Human Kinetics.

  8. Nachemson, A., & Jonsson, E. (2000). Neck and Back Pain: The scientific evidence of causes, diagnoses, and treatment. Lippincott Williams & Wilkins.

  9. Panjabi, M. M. (2006). A hypothesis of chronic back pain: Ligament subfailure injuries lead to muscle control dysfunction. European Spine Journal, 15(5), 668–676.

  10. Rainville, J., Hartigan, C., Martinez, E., Limke, J., Jouve, C., & Finno, M. (2004). Exercise as a treatment for chronic low back pain. The Spine Journal, 4(1), 106-115.

  11. Willson, J. D., Dougherty, C. P., Ireland, M. L., & Davis, I. M. (2005). Core stability and its relationship to lower extremity function and injury. The Journal of the American Academy of Orthopaedic Surgeons, 13(5), 316-325.

  12. Wong, A. Y., Parent, E. C., Funabashi, M., Kawchuk, G. N. (2014). Do changes in transversus abdominis and lumbar multifidus during conservative treatment explain changes in clinical outcomes related to nonspecific low back pain? A systematic review. The Journal of Pain, 15(4), 377.e1-35.


 

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