Lumbar spine pain on flexion

Lumbar pain on flexion is one of the commonest symptom reports clinicians hear when treating patients low back pain.  There are a number of clinical reasoning processes, which need to be considered.

Pathology

Much of the literature focuses on the changes in intra-discal pressure associated with spinal flexion implying that spinal flexion pain is associated with increased disc strain reproducing symptoms.  In order to strengthen the hypothesis of disc related flexion pain the clinician needs to establish other components of discogenic characteristics to support the hypothesis.

These can range from the overtly obvious…..

gross global movement restriction

spinal shift

radicular pain

positive neuro-provocation tests

neurological signs

to the other end of the spectrum where symptoms are only produced on flexion and only localised in the lumbar spine.  Of course acknowledging that any of the spinal elements may reproduce pain on flexion and this produces a list of potential targets to include:

zygapophyseal joints

supra-spinous ligaments,

intra-spinous ligaments

posterior longitudinal ligament

ligament flavum

local segmental musculature

Symptom Location – clues to aetiology

The ability to localise symptoms can give the clinician some clues as to the possible structures involved, but in cases of centralised pain this does not particularly enhance diagnostic accuracy other than to reduce the likelihood of facet joint involvement.

Treatment

Interestingly typical treatment approaches for flexion related pain is to use extension/McKenzie’s extension protocols, passive accessory intervertebral motion to facilitate extension (Maitland).  Undoubtedly this strategy is helpful for patients when improvements in tolerance for extension related treatments show simultaneous improvement in flexion capacity.  And for those that don’t?…….

What do we do for patients whose flexion does not improve with extension regimes?

The caseload of interest here are the patients who might be categorised as non-specific low back pain who have persistent problems with spinal flexion.  Here is a list of tips for things to evaluate when accessing this function:

1. Spinal segment flexion range.
2. Hamstring flexibility.
3. NeuroDynamic sensitivity.
4. Proximal trunk control.
5. Pelvic rotation on femoral heads.
6. Sacroiliac nutation.
7. Hip extensor muscle function on flexion (eccentric control).
8. Hip extensor muscle function on return to upright (concentric control)
9. Paraspinal / abdominal co-activation on return to upright.
10. Lumbal-pelvic rhythm on flexion.

PS

11. Lumbal-pelvic rhythm on return to upright.

Evaluating each of these components allows the clinician to determine mechanisms of breakdown and plan treatment strategies to facilitate recovery. Exploring these mechanisms is relevant for non-responders to extension regimes.

Enjoy the clinical challenge.
David