Lumbar directional preference

Does your back pain worsen when you are sitting? Or rather when you are standing? The answer to this simple question could transform your recovery. Directional preference classifies your lower back pain according to how it behaves in response to movement and guides the choice of exercises that will truly relieve your pain.

Why is your pain behavior a better guide to treatment than an MRI?

MRI scans reveal abnormalities in 30% of 20-year-olds and 90% of 60-year-olds who have no pain.1 The behavior of your pain depending on your position is a more effective guide to treatment than radiological images, as the latter do not always reflect the clinical reality.

Only 5 to 10% of cases of low back pain have a diagnosis that can be identified through imaging.2 MRI does not explain the pain in the vast majority of cases. On the other hand, classification by movement allows 75% of mechanical low back pain to be categorized.3 This significant proportion demonstrates the effectiveness of the directional approach in understanding and treating your condition.

This clinical approach observes how your pain responds when you move in different directions. It accurately identifies the positions that relieve your pain versus those that worsen your symptoms. The McKenzie Method, based on directional preference, has strong scientific evidence for reducing pain and speeding up recovery. Many physical therapists use this approach to tailor your exercises to your specific pattern.

To better understand your lower back pain as a whole and discover the various possible causes, consult our comprehensive guide to lower back pain.

What is flexion pain and how can you recognize it?

The pain when bending worsens when sitting for long periods, driving your vehicle, or leaning forward to pick up an object. It accounts for approximately 70% of mechanical low back pain.3 An important distinguishing feature is that the transition from sitting to standing is achieved without major difficulty. This is precisely what distinguishes it from the disc pattern, where this transition poses a problem.

What are the typical symptoms of the flexion pattern?

The classic "back strain" generally falls into this flexion pattern. It often occurs after a sudden flexion movement such as lifting a box off the floor, tying your shoes, or picking up a fallen object. The pain may be immediate or appear a few hours after the triggering activity.

People who work long hours sitting in front of a computer frequently exhibit this pattern. Sitting for several hours increases intradiscal pressure and creates progressive tension in the posterior structures of your lumbar spine.

What exercises relieve flexion pattern?

Seated pelvic tilt: Sit on the edge of your chair with your feet flat on the floor. Gently tilt your pelvis forward and backward to find the neutral position for your back, where you feel the least tension. Consciously maintain this position during your daily seated activities, whether at work, in the car, or at home.

Standing hip flexion: When you need to bend forward, bend at the hips rather than at your lower back. Keep your back straight and bend by flexing your hips. This technique protects your back when you need to bend down to pick something up or work in a bent position.

Gentle lumbar extension: While standing, place your hands on your lower back and gently lean backward. This extension movement helps counterbalance the effects of prolonged flexion. Repeat this exercise several times a day, especially if you work in a seated position for long periods of time.

Avoid: The exercise that involves bringing your knees toward your chest. Although this stretch is popular, it increases the flexion load on your spine and can aggravate your symptoms if you have a flexion pattern.

What is extension pain and how can you recognize it?

The pain worsens when you stand still for long periods of time, when you walk slowly (such as in a shopping mall), or when you work with your arms raised (painting ceilings, putting things away on high shelves). It quickly subsides when you sit down or lean on a counter to reduce lumbar lordosis. Irritated facet joints and spinal stenosis are often involved in this pattern.

What are the typical symptoms of the extension pattern?

This pattern can be recognized by several distinctive characteristics:

• Pain that gradually develops when cooking while standing, especially when preparing meals that require standing still.
• Significant discomfort when grocery shopping, especially if you walk slowly while looking at the shelves
• Immediate relief when leaning on the kitchen counter or grocery cart
• Significant worsening when working with your arms raised, such as painting a ceiling or putting things away on high shelves
• Difficulty standing for extended periods of time at social events, with a need to sit down regularly

People withlumbar osteoarthritis often exhibit this extension pattern. Prolonged standing compresses the posterior structures of the spine, including the facet joints and the nerves that exit between the vertebrae. This compression causes the pain characteristic of the extension pattern.

People over the age of 60 are more likely to develop this pattern due to natural degenerative changes that affect the joints of the spine over time.

What exercises relieve the extension pattern?

Standing pelvic tilt: While standing, gently pull your navel toward your spine by slightly contracting your abdominal muscles. This position reduces excessive lumbar lordosis and decompresses the posterior facet joints, which are a source of pain. Maintain this corrected position during prolonged standing activities.

Psoas stretch: When the psoas muscle is tight, it accentuates lumbar lordosis. To stretch it, get into a lunge position with one knee on the ground. Move your pelvis forward while keeping your torso straight. You should feel a stretch at the front of the hip of your back leg.

Strengthening the deep abdominal muscles: Lying on your back with your knees bent, pull your navel toward your spine by contracting your deep abdominal muscles. Hold this contraction for 10 seconds while breathing normally. Strong abdominal muscles help control excessive lumbar lordosis.

Strengthening the glutes: Lying on your back with your knees bent and feet flat on the floor, squeeze your glutes and lift your pelvis slightly off the floor. Strong glutes stabilize the pelvis and reduce the tendency for excessive lumbar extension during standing activities.

Avoid at all costs: Repeated lumbar extensions (such as the "Superman" exercise or cobra sit-ups) and any exercises performed in a strongly arched position that increase compression of the posterior structures.

What is mixed pain or disc-related pain?

Mixed or disc pain can be recognized by one major distinguishing feature: marked difficulty in moving from a sitting to a standing position. You have to walk a few steps bent over, sometimes even holding onto furniture, before you can straighten up completely. This is the most important criterion for differentiating this pattern from others.

How can you distinguish the discal pattern from other patterns?

The key criterion for recognition is difficulty transitioning from sitting to standing. If you have trouble standing up after sitting for a while and have to walk a few steps in a bent position before you can stand up straight, you probably have a disc or mixed pattern.

Other important specific characteristics:

• Both flexion AND extension worsen your symptoms, unlike pure patterns.
• The pain varies considerably depending on the time of day (often worse in the morning upon waking up).
• Initial acute phase: lumbar extension is very limited and painful.
• Subacute phase (after a few days): walking gradually begins to relieve symptoms.
• Sudden movements or prolonged positions aggravate the condition.

This pattern often suggests disc damage where the nucleus of the intervertebral disc exerts pressure on the surrounding structures. Disc herniation is the classic example of this pattern, although not all cases of mixed patterns are necessarily disc herniations.

What is sacroiliac pain?

Sacroiliac pain differs from the three classic directional patterns in several distinctive ways:

• Pain localized on one side, often precisely at the dimple visible at the bottom of the back
• Rapid onset of pain regardless of position (sitting, standing, lying down)
• Walking does NOT relieve pain, unlike disc patterns in the subacute phase.
• Pain often triggered by asymmetrical movements or prolonged standing on one leg
• Marked local tenderness on palpation of the sacroiliac joint

This condition requires specific assessment and treatment techniques that differ from those used for classic lumbar directional patterns.

How to identify your pattern in 5 simple questions?

Three key questions will quickly guide your pattern: Is your pain worse when sitting or standing? Does it ease when you change position? Do you have difficulty standing up after sitting for a while?

• Is your pain worse when sitting for long periods or standing for long periods?
• Does your pain significantly improve when you change position?
• Do you have difficulty standing up completely after sitting down?
• Does walking relieve or worsen your pain?
• Is your pain localized on one specific side or is it more central and diffuse?

This classification allows you to quickly guide your initial self-treatment. However, a comprehensive professional assessment is still recommended to confirm your pattern and optimize your treatment plan.

When should you consult a professional?

Consult a physical therapist if your pain persists for more than 6 to 8 weeks without noticeable improvement, if this is your second episode of low back pain, or if the pain extends down your leg beyond the knee. Fortunately, red flags requiring urgent medical attention are present in less than 1% of cases.

Statistics show that approximately 90% of acute low back pain resolves naturally within 6 to 8 weeks with or without specific treatment. However, the recurrence rate reaches 40 to 70% in the following year.8 Identifying your pattern from the first episode and learning the appropriate exercises significantly reduces the risk of future relapse.

Early consultation also helps prevent the development of inadequate muscle compensation and avoidance behaviors that can unnecessarily prolong your episode of pain.

What are the red flags that require immediate consultation?

Consult a doctor immediately or go to the emergency room if you experience any of the following symptoms:

• Loss of bladder control (new urinary incontinence) or bowel control (fecal incontinence)
• Gradual numbness in the genital or perineal area (saddle anesthesia)
• Rapidly progressing muscle weakness in both legs simultaneously
• High fever accompanied by severe and unexplained lower back pain
• Significant unintentional weight loss associated with back pain
• History of cancer with new lumbar pain
• Pain that steadily worsens despite rest and appropriate treatment

These rare symptoms may indicate serious conditions such as cauda equina syndrome, spinal infection, or pathological fracture, which require urgent medical attention.

If your lower back pain radiates down your leg and causes numbness or tingling, check out our detailed article on lumbosciatica to better understand this specific condition.

How does Physioactif assess and treat your directional pattern?

Our specialized physical therapists systematically assess your movement pattern during the initial evaluation session. They validate your pattern using standardized repetitive movement tests and immediately customize your exercises based on your individual response to the various movements tested.

• Detailed questions about the specific behavior of your pain in various positions and activities
• Repeated movement tests in different directions to clearly identify your directional preference
• Careful observation of your transition from sitting to standing and your dynamic posture
• Identification of exercises and positions that provide immediate relief during the session
• Assessment of your range of motion and functional limitations
• Neurodynamic tests if pain radiates into the leg

Research shows that patients with a clearly identifiable directional preference achieve better clinical outcomes.4 Early and accurate identification of your pattern leads to significantly faster and more lasting recovery. Self-management strategies taught early on also greatly reduce the risk of future recurrence.

Our physical therapists also use specific manual techniques tailored to your pattern: joint mobilization, myofascial release, and neuromuscular techniques that effectively complement your personalized exercise program.

To learn more about the complete physical therapy evaluation process and the different treatment approaches available, check out our detailed guide to physical therapy for back pain.

References

• Brinjikji W, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816.
• Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001;344(5):363-370.
• Fritz JM, et al. Subgrouping patients with low back pain. Phys Ther. 2007;87(4):441-454.
• May S, Donelson R. Evidence-informed management of chronic low back pain with the McKenzie method. Spine. 2008;33(22):E887-E900.
• Delitto A, et al. Low back pain clinical practice guidelines. Phys Ther. 2012;92(4):e1-e51.
• Long A, et al. Does it matter which exercise? Spine. 2004;29(23):2593-2602.
• Henschke N, et al. Prevalence of and screening for serious spinal pathology. BMJ. 2009;339:b3829.
• da Silva T, et al. Risk of recurrence of low back pain. Spine. 2017;42(13):1003-1009.