Low back pain patients can respond really well to some exercises or movements, but struggle with other movements that you may have found really successful or helpful with other patients.
In today's email I want to explore how you can identify exercises that will help the low back pain patient in front of you. And what you can do when patients have stopped some of their regular activities or exercises because it aggravated their low back pain.
Directional preference or "ambiturner"?
Directional preference can be a good starting point to help identify effective exercises for your patients, and give you specific clues on how to modify or adjust their current activities and exercises.
Before we dive into how to use it, what's “directional preference”?
"Directional preference" always makes me think of Derek Zoolander saying "I'm not an ambiturner. I can't turn left" in the classic movie Zoolander.
Derek had a "directional preference", but not the one we're talking about here.
When a repeated movement in one direction (e.g. lumbar extension) causes a patient’s pain to decrease or centralise, and movement in the opposite direction (e.g. lumbar flexion) increases or peripheralises low back pain, this is “directional preference”. It’s highly correlated with positive findings on discography, or in other words, their symptoms may have a discogenic driver (Deneuville et al. 2025).
This is a good prognostic indicator, and when someone consistently responds well to a particular movement direction (e.g. extension), that can help guide our exercise program, and build up our patient’s movement confidence.
This directional preference approach also helps us identify how to keep patients exercising, and how to modify exercises or activities that are aggravating their pain.
Low back pain with overhead pressing
Here’s a common example in your gym-going patients.
Your patient might have low back pain during or after overhead presses (OHP). Since it's an aggravating movement or activity, we might think it'll be best to take squats or overhead presses out of their program for the time being to let their back calm down.
Here’s another way of approaching it.
As Dr David Toomey (NZ Titled Musculoskeletal Physio, PhD) says in this week’s Clinical Edge member presentation....
"Rather than asking:
“Should the patient stop this exercise? or “What exercise should I replace this with?”
you can ask
“How can I modify this exercise so the patient can keep doing something they enjoy?”
You keep them exercising, while allowing things to calm down.
Overhead presses aren’t “bad” movements, and there’s no “right way” to do these movements, but when they're flaring up your patients pain, you can often find a different, less aggravating way to perform these movements.
During an OHP, it’s pretty common for people to drift into lumbar extension. In a patient with a flexion preference, this is often enough to aggravate their symptoms.
Instead of stopping OHP, you can teach them lumbo-pelvic positioning, how to move or stay in slight lumbar flexion during the movement, and soften their knees while they press.
These small adjustments to the setup and movement strategy during an exercise can keep your patient training comfortably.
That shift in thinking can be really powerful, giving your patients confidence, and keeping them engaged with the activities and sports they enjoy, rather than creating a growing list of things they should avoid.
How can you apply this approach to other movements and exercises?
Dave Toomey's presentation this week is full of practical examples and demonstrations on how to choose and modify your patients low back pain exercises using directional preference to guide you.
How can you confidently prescribe exercise for low back pain patients when either flexion or extension movements (“directional preference”) consistently aggravate their symptoms?
In this practical presentation, David Toomey explores how to identify and work with both flexion and extension directional preferences in low back pain patients, and reveals practical strategies to modify exercises, improve movement confidence and keep patients active without unnecessarily provoking symptoms.
You’ll discover how repeated movements, symptom centralisation and directional preference patterns can help guide exercise selection and clinical reasoning, while learning practical ways to translate concepts such as lumbar flexion, extension and pelvic tilting into patient-friendly cues and exercises.
Using real-world demonstrations and gym-based examples, David walks you through how to adapt common exercises including squats, deadlifts, glute bridges, bench press and overhead press variations for patients with either a flexion or extension preference.
In this presentation you’ll discover:
- What directional preference is and how it relates to symptom centralisation and discogenic low back pain.
- Why identifying a patient’s preferred movement direction can help guide exercise selection and progression.
- How to teach pelvic and lumbar movement concepts using simple, memorable cues and analogies.
- Practical cueing strategies to teach lumbar lordosis and kyphosis and pelvic tilt in standing, sitting, four-point kneeling and supine positions.
- How to adapt common exercises for patients with a flexion or extension preference.
- Exercise modifications for squats, deadlifts, glute bridges, bench press and overhead press variations.
- How to reduce symptom aggravation by modifying setup, range of motion, stance and movement strategy.
- Why limiting unnecessary lumbar extension or flexion during exercise can significantly improve exercise tolerance.
- How to use taping techniques to provide movement feedback and reduce aggravating movements during exercise.
- Strategies to help fearful patients re-engage with exercises such as squats and deadlifts.
- How reframing exercises and changing language can reduce fear avoidance and improve exercise participation.
- Practical ways to progress patients toward heavier lifting without reinforcing fear around load or movement.
You’ll finish this presentation with practical exercise modifications, adaptable movement strategies and patient-friendly cueing techniques that will help you confidently tailor exercises for low back pain patients with directional preferences while keeping them moving, training and progressing successfully.
Click here for your access, or login here if you're a Clinical Edge member.