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Chronic Low Back Pain: To Bend or Not To Bend?

Ahh, chronic low back pain!

You wake up in the morning barely able to roll in bed… much less get out of your bed! Your spouse blames your back pain on the fact that you sleep with your stomach faced down all night. In your head, you could also hear the unceasing reminder of your physical therapist, “You have to sleep in the right position!” 

Now, you are wondering, “Are they right in saying so?”

Dealing with back pain every day is difficult and a real challenge for so many people.

Low back pain is the single most common reason for medical visits in the United States. It’s also one of the leading causes of disability, as well as a major contributor to missed work and diminished quality of life.

Unfortunately, many people are afflicted with low back pain that keeps on recurring or lasts for over 12 weeks (3 months). If your back pain has lasted for more than 12 weeks, we classify it as chronic, meaning the pain is persistent or long-lasting.

If you are suffering from chronic low back pain, it would benefit you to know your back’s direction preference or bias. This article will explore what directional preference is and how you can find relief using direction-specific back exercises.

What is a directional preference?

Directional preference protocol is primarily based on the work pioneered by Robin McKenzie, a physical therapist who observed an accidental treatment breakthrough while treating one of his patients in New Zealand.

McKenzie, while busy attending to a patient, asked his next patient to wait in the next room. Not seeing a pillow on the treatment table, the patient proceeded to lie down on his stomach while waiting for his turn.

When McKenzie came into the room to see the patient, the patient got up and exclaimed that he didn’t need treatment; his back pain was gone!

How about you?

Have you noticed that your back pain symptoms are relieved when you lean forward to brush your teeth in the morning? Or does your back feel better when you lean back to gargle?

For some people, sitting upright makes their back pain worse. For others, sitting in a slouched posture aggravates their back.

So, which is which? And who is right?

Read on to learn some more…

Your back’s direction preference is the direction that:

  • Tends to relieve your pain symptoms.
  • Cause centralization (a positive indicator where the symptoms of pain, tingling, pins and needles, numbness, etc. recede from your buttocks and legs and go back closer to your spine).
  • Improve your function (e.g. increased tolerance in standing or sitting).

Almost all people that suffer from chronic low back pain will have a directional preference. The reason is that the direction preference of your back is movement-based and not based on any particular diagnosis, i.e. herniated disc, spinal stenosis, degenerative disc disease, etc.

This means that symptoms are much worse when you bend or move in a specific direction and are not as noticeable when bending or moving in the opposite direction. A directional preference is usually an indicator of the source of pain, which can assist with determining treatment options for chronic low back pain.

Why is directional preference important in treatment options for chronic low back pain?

The directional preference of chronic low back pain can be a difficult concept to grasp, so I often explain it in terms of examples…

For example, if someone has a forward bending directional preference, they may experience pain and discomfort when performing activities that require bending forward, like picking up a pencil or reaching for something off the floor.

However, once they bend backward to reach for the cupboard overhead or do an upward-facing dog pose in yoga class, these symptoms are usually relieved because of the change in direction of their movement.

This can also apply to your activities of daily living and in your job, which may include sitting all day, picking up or lifting objects from the floor, and then repeating the same movements over and over again. These are just some examples that show how situations can cause changes in back pain depending on different body positions throughout the course of the day.

So, why is it important to be aware of your back’s direction preference BEFORE treatment?

Imagine experiencing a worsening of your back pain symptoms whenever you bend forward and your physical therapist (or personal trainer, chiropractor, etc.), in his/her intent to strengthen your core muscles, asks you to perform abdominal crunches – 10 repetitions x 3 sets!

Ouch, you’re not helping your back; in fact, you’re making the symptoms worse!

How will you check for your back’s direction preference?

In my book, Back Pain Unlocked, I gave several scenarios you can monitor to observe and check to see how your back responds to the repetitive movements and loading you subject your back to throughout the day.

Here are a few examples…

Does your back feel better?

  • When you sleep on your stomach? Or when you sleep on your back with your knees or legs supported?
  • When you sit up tall? Or when you sit slouched forward?
  • When you lean forward on the sink to brush your teeth? Or when you lean back when gargling mouthwash?
  • When you lean forward on the grocery cart for support? Or when you stand up straight to push the grocery cart?
  • When you walk uphill? Or when you walk downhill?

How do you apply your back direction preference to your back exercises?

Once you have determined what your back direction preference is, follow the series of exercises I outline below to start improving your pain, your range of motion, and your overall function:


  1. Lie on your back.
  2. Bend both knees up and put your feet flat on the ground.
  3. Slowly bring both knees up towards your chest by grabbing your knees with your hands.
  4. Gently pull your knees up close to your chest. Hold this position for 5 seconds.
  5. Slowly allow your knees to lower back down to the starting position. Your feet should be flat on the floor and your knees should be bent.
  6. Perform 10 repetitions.

Alternative Position: When you have osteoarthritis or past injury to your knees, it might be difficult or even painful to pull on your knees in Step #4. If that is true with you, follow this alternative position below.

Place your hands to grab on your thighs underneath your knee.


  1. Sit in a chair with your knees open and your feet on the floor.
  2. Lean forward, bending at your low back.
  3. Reach your hands down towards the floor and hold this position for two to five seconds.
  4. Return to the starting position.
  5. Repeat 5 times.


  1. Stand with your feet about shoulder-width apart.
  2. Bend forward at the waist slowly.
  3. Reach your hands down towards your feet as far as possible and hold this position for five seconds.
  4. Return to the starting position.
  5. Repeat 5 times.


If your symptoms decrease or go away all together when you lean back or arch your back, your back condition likely has an extension bias. These exercises will help with your back pain:

  1. Lie down on your stomach with your arms under your shoulders or down at your side.
  2. Position your face down or turned to one side.
  3. Take slow, deep breaths and relax.
  4. Hold for 5 min.


  1. Lie down on your stomach and place your elbows under your shoulders so you are resting on your forearms.
  2. Take slow, deep breaths and relax.
  3. Hold for 1 minute, then return to the original position.
  4. Repeat 10 times


  1. Lie down on your stomach and place your hands under your shoulders.
  2. Slowly straighten elbows, keeping your lower body relaxed and your pelvis down on the floor while raising your back upwards as far as pain will allow.
  3. Take slow, deep breaths and relax.
  4. Hold for 1 minute.
  5. Repeat 10 times.

What can you expect if you follow a well-executed direction-preference-based treatment?

If you perform exercises that are designed for your back’s direction preference, you will see improvements that may take the form of the following:

  • Change in distribution of symptoms. You will notice that the symptoms you used to feel in your buttocks, thigh, or leg are reduced and centralize toward your spine.
  • Change in distribution of your chronic low back pain. If you don’t have symptoms running down your buttocks, thigh, or leg, but only in your low back, the area of pain shrinks and moves even closer to your midline.
  • Change in pain intensity or frequency. The intensity of leg symptoms may decrease, your chronic low back pain may become infrequent, or the intensity of your chronic low back pain may lessen.
  • Improved range of motion. Patients who have an obstruction resulting in decreased movement in a particular direction (e.g., extension) respond with an improved range of motion.
  • Improved function. You will experience an immediate improvement in activities that used to be particularly aggravating before. Use your usual activities as a gauge of how effective your back exercise program is.

Do you know what your back’s direction preference is? 

Dr. Lex Gonzales
Dr. Lex Gonzales, PT, DPT is an author and speaker who has been working as a licensed healthcare professional for over 24 years. On he provides quality information and practical solutions you can use to achieve the best version of your healthy self.

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