Low Back Pain - Flexion Intolerance | Part I
Author: Dr. Joey Glenn
Have you ever bent down to pick up your shoes and suddenly find yourself on the floor in crippling back spasm? I've heard this story too frequently. The scenario is scary and confusing to most people, especially my typical patient that is relatively active, lifting weights, running, etc and this two pound shoe just did them in. I get it, trust me. I've been there and have seen too many of you to think you're crazy. The bad news... this sucks! It hurts really bad. The good news... it is totally treatable, you're not broken and will be back very soon with proper treatment. So what is your normal course of action? Statistics show most people go to their primary physicians and wind up with pain control medication and muscle relaxers. Sound familiar? A smaller percentage of people go to a chiropractor and get frequent adjustments, often feeling great relief that seems to be transient and sometimes completely gone by the time you reach the car looking forward to that next visit. A third segment of suffering people will go straight to physical therapy often getting range of motion and baseline strength exercises to build up that core to protect your spine but again finding a long road to recovery and often transient relief. The fourth and final segment will do nothing, confining their situation to bad luck and either "walking it off" or becoming bed ridden for days, weeks or months on end, and in the worst of cases live life with "a bad back". None of these sound fun and we have created a model that defies these typical scenarios in favor of putting the responsibility and power back into the patient's hands. If the patient understands what happened, what is wrong, how to fix it, and most importantly how to avoid re-aggrevating the condition the vast majority will get better quickly and completely return to your normal activity with a perfectly healthy back. Check out our process and if you are struggling with back pain currently, desperately googling please try this out and give us a call if you can use help.
This is vital. Back pain can have many causes but statistically speaking most low back pain is discogenic, meaning the intervertebral discs between the bones in your spine could be causing the pain, in clinical terms we call this a space occupying lesion, or I'm sure you've heard of a bulged disc. We will focus on this type of pain today and more specifically flexion intolerance. If you have not been assessed and diagnosed this may not be for you. Please seek out a qualified clinician if any of these movements, exercises, or self care is painful.
- Lay down on your stomach with your chin resting on your hands. Attempt to relax as much as possible. Take 10 nice relaxed breaths in this position.
- Prop yourself up to your elbows, almost as if your reading a book on your stomach. Relaxing in this position, allowing your hips to sag to the floor, thinking of relaxing the back and only using your arms and chest to keep you up. In this position relax for 20 slow controlled breaths.
- Return your chest down to the floor and allow 10 breaths.
- Prop back up to the elbows and how for 20 slow controlled breaths. Again, reminding yourself to relax as much as possible and think of hanging your back on the bones and joints, not bracing your muscles whatsoever.
- Return your chest down to the floor and allow 10 breaths.
- Last time, prop yourself back up and take 20 slow controlled breaths.
So, what happened? Interpret your pain experience at this point. Did your back pain get worse? Then this is not a good starting point for you. We can help, but your back pain is not the typical flexion intolerance and would require a different assessment and treatment all together. However, if your back pain got slightly better, or maybe you had sciatica and shooting pain down your leg that now seems to be better, or at least not traveling as far down the leg (we call this centralization of pain) then this is for you.
Why flexion hurts
In most cases what is causing your flexion intolerance is a problem with your movement. Again speaking in assumptions, most likely you are hinging at your low back instead of your hips when you bend over. The S shaped curve of your spine helps evenly distribute load throughout your back with movement. When bending forward the discs in your spine are pushed backwards. This can become an issue with bulging which threatens the sciatic nerve and CNS. Protective muscle spasms issue and you may feel locking of your low back or chronic tightness of the low back as they attempt to protect your spine and maintain that curve. You can see why focusing solely on the muscle tightness, joint position, or core engagement is not a good idea. We have to piece the entire puzzle together and treat the body. We have to simultaneously remove the protective muscle tightness, heal the disc, and improve movement quality to truly find relief of the perceived threat and get you back into action.
I like to tell patients on the first visit that we need to "put a bandaid on the situation". You come to me because you're in pain, so my first priority is to remove that pain. We often begin with laser therapy (a blog post of it's own), to help speed healing, and prep the tissue for treatment. Other pain reliving modalities include ice, heat, rock tape, biofreeze, and manual therapy. All of which are utilized under indicated conditons but for you at home I would recommend trying biofreeze, ice or heat and using what seems to work best for you.
Treat the cause
Again, we are focusing on discogenic, flexion intolerant backs. In this case the method that has shown to be far superior in terms of treatment is the McKenzie Method. Robin McKenzie is a physical therapist that discovered the techniques and system used and it was entirely by accident. Follow me here... one day Dr. McKenzie was treating a patient when another walked into his clinic. As he was currently busy he asked the second patient (with discogenic, flexion intolerant pain) to go ahead into the second room and lay face down. Dr. McKenzie forgot that the table in room number 2 was in a position much like a dentists chair, so to lay face down the patient would be in a position of extension. When Dr. McKenzie finished with patient number 1 and walked into room number 2 the patient exclaimed "thanks doc, I feel so much better!". Baffled Dr. McKenzie went to work to understand the mechanism of which simply laying in extension helped to cure this patient's back pain. What he discovered is amazingly simply and effective and has been researched extensively since. Essentially when you find a directional preference (a direction of movement that causes the pain to either vanish or move out of the leg toward the low back) you then exercise and mobilize into that position, effectively pushing the disc centrally and removing the threat. The McKenzie Method is often bastardized by those that do not understand the system and simplified into an extension based system when it is actually any direction of movement as long as the pain is being centralized or abolished. Anecdotally I have seen one patient that required flexion, but this patient was post partum and had just spent 9 months leaning into extension. Anyway, back to your flexion intolerance... depending on severity and ability to perform the exercises I ask the patient to spend some time in extension, whether that means laying with a couple of pillows under the chest, on elbows, or even performing full press ups. This movement gets repeated throughout the day as often as possible. I like to tell my patients that their arms should be tired or sore the following day from performing the program.
Remove the insulting behavior
Education of what exactly is causing the pain is absolutely key to fixing the problem. At this acute stage flexion is not helping. So stop stretching your hamstrings, I know they feel tight but bending forward to grab your toes truly is aggravating the issue. Understanding new mechanisms to perform daily activities like tying your shoes and brushing your teeth without rounding your back may seem boring and fruitless, but if I were to do one thing with this patient this would be it! Once the healing has taken place you will tolerate some rounding of your low back, to put on your shoes of example, but moving forward we would like to optimize the quality of your movement, particularly while lifting or squatting to improve the reliance of the low back and reduce likelihood of future episodes of threat and spasm.
In Part II we will dive into what we do after you are out of pain but not out of the woods. This is where the magic happens. By training proper movement quality, strength, and endurance we can build a resilient low back to avoid reaggrevation of the injury and get back to the things you love to do!