What’s Your Bias? Either Way, Your Back Probably Hurts

A TON has happened since I actually finished writing this post. I wrote this back before I left for my first semester of PT school - A new update post is in the making. Until then, everyone’s back hurts sometimes and this topic is of particular interest to me.

If I haven’t mentioned it before, I was very fortunate to have been able to work at Comprehensive Physical Therapy with all of the great people and Physical Therapists it employs. Since it was in fact my last day yesterday (PT school starts in a week – time to get packin’), a topic inspired by PT Jackie would be the most appropriate. A huge thanks to Jackie for clarifying this topic for me. Jackie treats a lot of the back pain patients at Comprehensive and we had many discussions about lumbar bias. When I say bias, I mean which movement/posture do they move into/stand in most easily/often: Lumbar Extension (anterior pelvic tilt) or Lumbar Flexion (posterior pelvic tilt)?

Bias: Lumbar Extension vs. Lumbar Flexion

Anterior Pelvic Tilt results in Lumbar Extension. Posterior Pelvic Tilt results in Lumbar Flexion

A majority of the patients with back pain seen at Comprehensive were of the lumbar extension type. The key point in treating either case is to get them to move out of their bias. For example, if there was a patient who had a static posture of lumbar extension (APT) and their bias was to forward bend with a flat back and hinge from the hips, we would try and get them to go into lumbar flexion during a forward bend or a hip rock. On the opposite end, if they constantly move flexing at their spine and lumbar, we would want to teach them a forward bend with a proper hip hinge using a stick with three points of contact (back of the head, upper back, and tailbone), or hip rock in lumbar extension.

Whoa, whoa, whoa, Ms. Lippy. The part of the Post that I don’t like, is the Lumbar Flexion. Doesn’t Lumbar Flexion = El Diablo = Fighting Chicken?

I used to think Lumbar Flexion was so bad, that I made sure to move with a flat back as much as possible in all of my Activities of Daily Living (ADL) for fear of my nucleus pulposus herniating (which can still happen in extension, just directed anteriorly), even though I am of the Lumbar Extension bias:

 

Aside from my esoteric attempts at humor, a person with lumbar extension tendencies (ie: me/other lower crossed individuals) would do better to move with a flexed lumbar so that the paraspinals can lengthen and still maintain the ability to flex at the spine; however, someone with lumbar flexion tendencies, might want to learn a proper hip hinge when greeting your own fluffy puppies and performing your other ADLs. Below is a table outlining the quantifiable range of motion an individual should possess between each spinal articulation. The longer the bar, the more range of motion should be maintained at that segment. The first column pertains to this post, being flexion and extension, the middle column is lateral bending, and the last column is rotation.

Kinematics of the Spine. In White AA, Panjabi MM, eds: Clinical Biomechanics of the Spine, 1990

Collectively, the most flexion and extension occurs in the lumbar and cervical spine. Going back to Sahrmann’s concept of movement occurs in the path of least resistance, it seems to make sense that the spinal segments with the most room for movement in the sagittal plane are the ones where we see the most problems: anterior pelvic tilt, posterior pelvic tilt, and lower cervical flexion paired with upper cervical extension, resulting in forward head. This only reinforces how to train the segments that have tendencies towards ancillary movement: to train stability in a neutral posture. So, concurrently pursue lumbar neutral in static and dynamic posture and torso stability with appendicular motion.

Keep in mind: The goal isn’t to transform a Lumbar Extension bias into a Lumbar Flexion bias. It is to bring the individual from one side of the spectrum more towards the middle (Normal/Neutral).

I purposely left out mechanical causes of APT such as tight/short hip flexors, tight/short hamstrings, and weak/long abdominals. Sure these can be addressed in the clinic by means of low load prolonged static stretching, PNF hamstring stretching, and plank variations. These strategies can definitely help take someone below symptom threshold; with that being said, I think the heart of the matter is addressing what movements are reinforced day in and day out. Educate the individual on how to perform purposeful movement during ADLs, not necessarily just the given exercise. An APT individual can get in an hour and a half at the clinic stretching their hip flexors like crazy and help allow the pelvis to return to a more neutral position; however, the following events most likely follow the visit: 

Sitting at their desk for 5 hours, sitting in the car, sitting at the dinner table, sitting in the bathroom, sitting on the couch for the rest of the evening, falling asleep, waking up to the newest episode of Real Housewifes of New Jersey, and then lie down in bed.

Of course there is movement from one place to the other; but the majority of time is spent sitting. This allows adaptive shortening to set in. If they aren’t sitting, they are most likely reinforcing flat backed movement patterns in ADLs, not to mention ambulating other times in the same APT posture. In this combined clinic/in vivo scenario, only the symptoms (tight/short/long muscles) will continue to be treated while the problem, poor movement patterns, will go by the wayside. Poor movement causes pathology, not vice versa. Correct the movement, and the mechanical shortening/lengthening should cease.

Again, we’re talkin’ ADL stuff, not weight room stuff.

The key is to have the ability to flex your lumbar, but not load it in flexion – which can result in being sidelined pretty quickly. Regardless of your lumbar bias, you always want to pick up something heavy, whether it a barbell, groceries, or a toddler, with a flat back, chalked up (toddlers love chalk), spreading the floor, big breath of air, neck packed, shoulders packed, and blaring your favorite Avenged Sevenfold album:

Avenged was the only thing missing when hitting 405 lbs last saturday. So, unloaded movement in lumbar flexion doesn’t necessarly equal the devil, or el diablo, or a fighting chicken, afterall.

Warm regards,

Eric Keene

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