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By determining whether your client’s back pain is extension or flexion-related, you can more effectively drive their rehabilitation.

Having a client with low back pain (LBP) present for training can be very daunting for a fitness professional. However, it’s a situation that you will encounter, as up to 80 per cent of the population will have an episode of LBP at some stage. The cost to society in terms of lost working days and medical bills accounts for billions of dollars each year.

The aim of this article is to encourage PT’s to be more specific with their exercise prescription through classification of LBP, and to liaise with allied health professionals (AHPs) where required.

Assessing the risk

When a client presents with LBP the first conversation should be a subjective risk assessment. The aim of a risk assessment is simply to determine whether the issue is:

a) A low risk niggle that you can try and help with; or

b) An injury that needs to be immediately referred to a doctor or AHP.

If the client has any of the following then immediate referral is recommended:

  • Strong or severe pain: use a 1-10 scale and consider referral for anything above a 3/10
  • Constant pain regardless of position (indicating inflammatory pain)
  • Any signs of neurological compromise (a ‘pinched nerve’) which will be sharp referred leg pain, pins and needles, numbness or weakness
  • LBP that is unexplained (no obvious cause)
  • A history of cancer
  • Anything that is outside your sphere of competence.

Screening the client’s active range of motion (ROM) can help to determine the extent of the issue. Ask the client to bend forward as if touching their toes (flexion), bend backwards as far as they can (extension) and bend left and right, sliding their hand down the outside of their leg. If any of these movements are restricted or significantly limited by pain then, again, immediate referral is in order. If they can move comfortably through ROM then the issue is likely to be milder.

If the client has none of the above, they may have mild niggling LBP that seems mechanical in nature. However, as part of your duty of care, if the client has seen a physiotherapist or other AHP, you should make contact with that person in order to obtain advice about exercises you should and should not use with your client. If practical, attending the physio appointment with the client can be a great learning experience, engender loyalty in your client (as they can see you really care) and develop a new mutually beneficial referral source.

Classifying the pain

Once you’ve determined that the client’s low back pain is a low risk niggle that you can try and help with, you should attempt to classify whether their pain is flexion or extension-related. The aim of classification is to guide your intervention, and for this purpose we are going to keep it very simple – though bear in mind that LBP itself is seldom simple!

1. Flexion-related low back pain (FRLBP)

Clients in this category develop LBP through sudden flexion under load (such as lifting a bag of mulch in the garden) or repeated/sustained flexion (such as gardening all day or sitting on a long plane ride). Some structures in our lumbar spine are not sensitive to immediate pain signals (such as our discs) and often the pain is felt one or two days after the incident. It is important therefore to ask the client what they have done over the preceding few days.

Clients with FRLBP generally do not like to flex in the early stages – they will tend to bow or not want to bend at all. Extension, meanwhile, is often comfortable and pain relieving (think about what you want to do after a long car ride). They will not like sitting and the pain is often worse in the mornings.

These clients need to be protected from flexion, initially, to allow the injury to heal, and this will generally be guided by a physiotherapist. So, no squats, deadlifts or sit-ups. You should encourage gentle mobilisation such as walking and unloaded exercises such as knees rolling side-to-side (feet on the floor lying on your back with knees bent). The cobra stretch (a yoga position) is often helpful and pain relieving.

Once the injury is healing and the client is allowed to resume training, you need to teach them how to control their lumbar spine through hip flexion movements such as lifting. This is where teaching a well-controlled squat or deadlift becomes very important. However, the vast majority of trainers are not strict enough with maintaining ‘lumbar neutral’ in their clients. Obviously the topic of what constitutes the perfect squat opens a huge can of worms, but from a rehabilitation perspective we are looking for:

  • equal movement through the hips, knees and ankles
  • shins and trunk to be parallel at the bottom of the lift
  • the curve of the lower back to be maintained through the bottom of the lift (for this you must lift your client’s shirt and watch from the side – any posterior tilt, or tucking under of the pelvis, should be avoided – see image 1).

It is impossible to maintain strict lumbar control through a deep squat, so be conservative when training clients with FRLBP and don’t go deep. Deadlifts are also useful, but never to the floor. Use Olympic plates and start with the weights on a rack or platform.

The main muscle group you are trying to strengthen with FRLBP is multifidus, which provides segmental control when lifting or bending. Before commencing any squat or deadlift exercise, train your client to be able to ‘feel’ if they are maintaining a good lumbar position. This can be done by teaching them how to bow by using a stick (see image 2) and even through maintaining a better lumbar position in sitting with single leg extension (see image 3). Then progress onto exercises under load such as squats, but always stay conservative. Remember that they may not feel a re-injury during the workout, but can pull up sore the next day.

2. Extension-related low back pain (ERLBP)

Clients that fall into this category have pain that is generally non-traumatic in nature, unless they have had a hyper-extension injury playing sport. The pain will develop over time and is extremely common in both sway back postures and the hyper-lordotic clients (see images 4 & 5).

In both groups, the lumbar spine is in relative extension when upright. I explain to my patients that if I took their finger and bent it backwards towards end of range and held it for 30 minutes then that finger joint would get sore. The same happens to the facet joints in their lumbar spine. Individuals with ERLBP will experience pain with standing still and often with running when there is more extension loading. They will often get relief by flexing or sitting down.

Typically they will be tight in the hips (especially hip flexors) and have poor abdominal and gluteal control. This group is the most rewarding to work with as you can make a difference quite quickly. Obviously each case is different, but most clients will have a reduction in pain if you can:

  • correct their standing posture (this will takes months to become habitual)
  • loosen their hips, especially to gain more hip extension
  • loosen their thoracic spines
  • improve abdominal and gluteal control to reduce extension shear forces.

With the last point, you are aiming to improve control of the pelvis. In simplistic terms, choose exercises where the clients have to use their abs and glutes to avoid lumbar extension/anterior pelvic tilt. Push ups and bird-dog are good introductory exercises.

Next time you encounter a client with LBP, after determining that the client is low risk, see if you can classify them into FRLBP or ERLBP. This will allow you to guide your exercise prescription more specifically. If the client’s pain does not improve fairly quickly (within 4 to 6 weeks) or gets worse, then refer them to a physiotherapist or sports physician.


Adam Floyd B.Sc (Physio) B.PE (Hons) is a physiotherapist and exercise physiologist based in Perth. He is the owner of Regenerate Fitness and Rehabilitation which combines a large physiotherapy clinic with a full rehabilitation gym facility.

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