Non-Specific Low Back Pain Flexion Control Dysfunction

Where is Non-Specific Low Back Pain Flexion Control Dysfunction painful? (Body Chart)

Low Back Pain Flexion Control Dysfunction

What are the classical features of Non-Specific Low Back Pain Flexion Control Dysfunction?

Age: Can be all ages however thought to have greater prevalence in young active population adults

Gender: No variation was documented  

Sport: Active individuals, flexion biased sports (hockey, horse riding, AFL, motorsports)

Where is Non-Specific Low Back Pain Flexion Control Dysfunction painful?

– Localised back pain

– Well defined 

– More commonly central but can be ipsilateral/bilateral 

– Can refer in the buttock and leg but uncommon

– If persistent pain and bilateral may provide evidence for Spondylysthesis and require further investigation 

Characteristics of symptoms for Non-Specific Low Back Pain Flexion Control Dysfunction

– Sharp, catching pain with movement

– Aching pain when aggravated or sedentary for long periods 

– Episodic in nature 

– High intensity (5-8/10 VAS)

– Low frequency

– No neurological symptoms

Typical activity capability/restriction for clients with Non-Specific Low Back Pain Flexion Control Dysfunction

– Patient is often still highly active as symptoms resolve quickly

– Patients may describe completing regular activities by requiring rests to enable to pain to reduce 

– Will worsen if continually provoked (ie repeated flexion – hockey)

– Reduced fluency of movements due to guarding (ie picking something up on the ground)

Behaviour of symptoms for Non-Specific Low Back Pain Flexion Control Dysfunction


– Avoidance of flexion based activities, NSAIDs, extension-based activities, lumbar support in sitting, postural correction  


– Lumbar flexion, sitting, flexion biased combined movements, repeated movements into flexion, fast movements especially if at the end of range flexion 

24-hour pattern: 

– Activity dependant, likely to get better at night secondary to a prolonged period of extension

Typical history of a client with Non-Specific Low Back Pain Flexion Control Dysfunction

– Participation in activities with flexion moment (ie sitting for long periods of time)

– Previous episodes of similar lower back pain 

– Often report an insidious onset // likely to be related to prolonged flexion (sitting) 

– If acute onset will report a flexion biased mechanism of injury ie bending over to lift up something heavy off the group 

– Will get worse with activity when aggravated (no warm-up effect)

– Enquire about activity preceding incident if no clear mechanism

Pathobiological mechanisms behind Non-Specific Low Back Pain Flexion Control Dysfunction

– Need to triage and rule out specific pathology prior to using movement patterns 

– If clear then evidence supports the category of non-specific lower back pain

– Movement patterns are considered as a subcategory of non-specific lower back pain

– Only use as a pattern if nociceptive dominant 

– If chronic then considers it as an impairment however inadequate to use as a primary diagnostic label. Management should then be implemented as a nociplastic dominant presentation

Proposed pathology underlying Non-Specific Low Back Pain Flexion Control Dysfunction

– Triage completed and specific pathology excluded (non-specific lower back pain)

– Compressive load on the anterior tissues of the spine (ie disc pathology)

– Tensile load on the posterior tissues of the spine (ie PIV) 

– The lower back is considered to be insufficiently actively constrained 


Note: Evidence supports that pathology observed on imaging does not necessarily correlate to pain/disability

Physical impairments & associated structure/tissue sources (ie P/E findings)


– Hypermobility into lumbar flexion // with PPIVM

– Increased pain with lumbar movements (flexion + unilateral bias)

– Pain limited range into flexion, hypermobile if not pain limited 

– Hypomobility into extension 

– Stiffness with PA and unilateral PA PAIVM

– Worse with repeated movements into flexion 

– Reduced lumbar lordosis in sitting 

– Reduced motor control into extension // unable to get out of the aggravating position  

– Reduced lumbar body schema 

– Reduced local two-point discrimination 


– Glute weakness

– Hip flexor weakness 

– Reduced flexion range in thoracic spine and/or hips

– Reduced motor control into flexion in spine and hips


– Deconditioning 

– Reduced muscular endurance 

– Slouched posture 

– Bracing and breath-holding with flexion movement 


– Oswestry Low Back Pain Disability Questionnaire validated measurement tool

Typical contributing factors to Non-Specific Low Back Pain Flexion Control Dysfunction

– Weight

– Genetics

– Physical fitness 

– Hypermobility in the lumbar spine

– Participation in high-risk activities 

– Sporting Technique 

– History of low back pain 

– Smoking 

– Stress/anxiety

Relevant precautions/ contraindications to P/E and treatment

– Severity and irritability 

– Need to exclude specific pathology when considering a non-specific diagnostic umbrella

– Cordea equina 

– Clear neurological signs/symptoms if clinically indicated

Relevant diagnostic imaging for Non-Specific Low Back Pain Flexion Control Dysfunction

– Can be used to rule out serious pathology when indicated // note that referral for lower back pain in itself is insufficient, need to have evidence of specific pathology or neurological symptoms to consider. If non-specific back pain evidence to support patients do better without the scan 

– Presence of pathology is normal and not indicative of pain/disability if the patient comes with imaging // always conduct an unbiased assessment and then compare patient presentation to the clinical findings 

– MRI goal standard

Typical prognosis for Non-Specific Low Back Pain Flexion Control Dysfunction

– Often resolved within weeks

– Favourable if the first incident, with recurrence the prognosis worsens

– With the increase in psychosocial flags the prognosis worsens 

High-level evidence 

– Quicker return to work when positive outcome expectation

Management/treatment selection for Non-Specific Low Back Pain Flexion Control Dysfunction

Phases of rehabilitation

– Stage 1: Symptom management 

– Stage 2: Reloading phase

– Stage 3: Return to full function and sport


– Joint play techniques (high-level evidence) 

– Mobilise into extension

– Muscle control into extension in stage 1 // start with extension bias and progress to a flexion biased position 

– Muscle control into extension in stage 2 

– Muscle control translation into functional/dynamic activities stage 3  

– Pacing to progressively increase loading 

– Taping (box tap to limit flexion)



– Abdominal strengthening/control (mid-level evidence for TA activation)

– Increase mobility into flexion at hips/thoracic

– Muscle control into flexion at hips/thoracic



– Rest contraindicated (high-level evidence) 

– Increase physical activity (high-level evidence) 

– Consider biomechanics and technique // are we able to redistribute the load somewhere else

– Postural correction into lumbar extension (ie sitting posture) 

– Address contributing factors and cardiovascular fitness

– Equipment // patient population respond well to lumbar support 

– Consider work set up

– Ergonomic optomisation 


Pharmacological (high-level evidence) (refer as required) 


– Analgesics

– Muscle relaxant

Differential diagnosis for Non-Specific Low Back Pain Flexion Control Dysfunction

Spondylolisthesis // bilateral pain, neurological symptoms 

Disc pathology (especially if herniation) // flexion pattern and pain that crosses the midline

Spinal cord injuries // positive neurological or neurological symptoms 

Cord equina // B&B, saddle anesthesia, bilateral symptoms

Muscle strains // dynamic assessment

Central canal stenosis // neurological symptoms, bilateral symptoms

Nerve root // positive neurological or neurodynamic findings 

Cancer // subjective special questions 

Ankylosing spondylitis // inflammatory special questions


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