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...
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