Q&A Time: Lumbar Flexion Solution? | Modern Manual Therapy Blog

Q&A Time: Lumbar Flexion Solution?

Another great Q&A from a regular reader asked about lumbar flexion as a directional preference.

Remember, in The Eclectic Approach, the directional preference is not based on what is going on in a pathoanatomical disc model, but an updated neurophysiologic model. Despite the model, even most faculty members of the McKenzie Approach have rarely seen the Flexion Rapid Responder, or what they would call an Anterior Derangement Syndrome. The reasons for this most likely are
  • people flex thousands of times a day
  • a reset needs to be novel and non threatening, plus easier to get to end range
  • flexion in most cases is not novel, it's the norm
    • most patients initiate some form of stretching or unloading (and clincians that are not getting the desired results)
  • variants of, including the commonly used unilateral unloading (lumbar roll or gapping mobilzation/manipulation) are unloading thus more difficult to get to an end range
  • loading strategies are easier to get to end range, thus firing more joint mechanoreceptors, bombarding the CNS with novel, proprioceptive information
  • repetitive loading, rather than unloading eventually convinces the CNS that movement in all directions is ok

In my 16 year career, I have only really seen a handful of Flexion Rapid Responders they were
  • a hyperextension lumbar fall injury
  • 3 instances where my wife started doing repeated extension in lying after giving birth (and spending the entire 3rd trimester in an anterior tilt)
  • the recent Flexion Rapid Responder case I blogged about last year - sway back posture, intolerant to WB/loading

In all of these cases, you can see that extension or loading was the norm, but they are the exception and not the rule. In the SFMA, you often see MSF and it's breakouts as DP. My formal training in MDT allows me to take shortcuts in their system due to my clinical experience. I know when to use unilateral loading, and bilateral loading, and when to reintroduce flexion. These strategies work better for me because I have been at them for well over a decade. I have only taken SFMA part 1, and mainly use it to find other asymmetries distal to the proximal DP, but do not often prescribe 4x4 corrective exercise strategies as the resets I use combined with manual therapy are my go-tos. Your mileage may vary.

I know a lot of you have started looking for directional preference based on my posts, and that is great. Finding the directional preference empowers the patient with self treatment, that most passive forms of therapy do not offer. However, my pal Dr. Charlie Weingroff said it best when he tweeted, "Figuring out how to skip steps without missing anything starts with tediously honoring a systematic approach so you don’t miss anything." I can skip steps of a traditional repeated motion exam and The SFMA from experience (meaning learning from mistakes and adapting my approach).

What's the take home? Flexion Rapid Responders exist, but in my experience, and that of most MDT clinicians is that they are rare for a reason. Commonly things happen commonly, and people who are loading more than unloading are rare birds.

Keeping it Eclectic...


  1. Is someone in a rather large amount of ant pelvic tilt, whose symptoms immediately change with a PPT type activity and worsen with extension based activities, a rapid flexion responder or is this something else entirely?

  2. I've taken Part A and B over the past six months and have yet to see a flexion responder in this short amount of time, I think part of it is probably my patient demographics as well.

    I'm looking at MSF dysfunction differently now that I've gone through MDT coursework. Since I've been implementing MDT as my assessment and treatment process I've found quite a few MSF DN's and DP's goto FN immediately following some form of REIL. Most recent case being a late 20's female with right lower extremity radiculopathy since March (confirmed L5/S1 bulge) go from MSF to about her patella to full toe touch following multiple bouts of REIL.

  3. Depends on whether or not their symptoms stay improved with repeated or prolonged flexion. If so then yes.

  4. I had a few examples: elderly patient's with stenosis who benefited from some flexion and core strengthening. Weightlifters who hyperextend under load, spasm of the Psoas? Not classic rapid responders I will grant you.

  5. It's not the patient type that matters or what they have but how they respond to a repeated loading strategy.

  6. Yes! After the directional preference resets the CNS, all planes of movement should improve, not just the direction you're loading into repeatedly.

  7. I do like your approach and I am practising it actually. My question is regarding the Lights indications (and so the loading strategies and the EOR goal) . I have just a had 2 patients, "same situation" but different levels and I have tried your approach : patient A, an army fit guy, intermittent neck pain , 1 month, gradual develop, stable, pain on the left side (he has pointed and the fingers along the area C6-T2) . This is Sx 1 follow by an intermittent tingling/burning sensations along the arm , forearm, hand (C6-C8 areas) that is Sx 2. SFMA: Cx F FN, E DP (Sx1+sx2) Retraction DP ++, RR FN, LR DP - , SB right FN, SB Left DN. So he doesn't/can't load the left side. He likes and feels better doing unload (a mild discomfort sometimes but it is ok for him) so "opening the left side". RNT +ve . A kind of "regular class-room pattern". I did IASTM and we got a very small increase in LR, SB left but no in Retraction. The more Retraction I do, the more Sx1 + Sx2 go up BUT movement seems to get better after 10 reps and the symptoms subsides in 3-5 minutes anyway. He doesn't like to feel Sx1 + Sx2 during the Retraction. I had him educated about pain a little but he is one of those want to get fix soon. I gave him hvla and gained a little increase in Retraction and LR but still painful when I move to EOR. At the end of the visit, the little increase in movemnt seemed to get reduced. I mean I got something after the techniques - 30% better - but then it looked like 10% and patterns remained DP. So for you, is that a Yellow light anyway and I should go further? Not getting proper EOR can be the problem? O because he doesn't like it, I would rather change strategy and do some unload/opening stuff (the standard I was thaught and that I would have done) to try to "de-sensitize" and get RNT -ve. And only then try to load the left side.
    Patient B is same stuff (kind of regular pattern) . Student guy, cross fit superman wanna-be but Nature thought differently, sudden onset after power squat set, 3 weeks getting worse, buttock pain with intermittent pulling/burning sensations down to the leg posterolateral. He is MSF DP, SGIS right DN, SGIS left DP, MSE DP. In this case I only tried SGIS left few times and because I did not feel I was well managing the correction , I stopped. He was complaining too much. The pain was reproduced during the correction but didn't stay and subsided in 10 min walking. He was upset and worried. I did some TNE and did some IASTM on gluts and tigh and leg but I the SGIS didn't improve so much: still the same pain and maybe little increase in AROM. But as th patient A, I could see some little better movement but he could not feel it. I will work the other side next time and go for SGIL. Anyway, I consider it still a yellow light, am I wrong? or I should go for the "classic approach" (unload, open etc). In your opinion, intermittent symptoms and symptoms subsiding in a time window of 5-10 maybe 20 min can be the power indicators that the patient is a rapid responder and we can go "harder" to EOR anyway? This is the main difficult point if you are used too much to a standard way. Thank you.