Back Pain and Exercise – What is my Directional Preference and why does it matter to me

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Taylor Sipos

Back pain is one of the leading causes of pain and disability in the world. Conditions and injuries such as spinal stenosis and disc herniations can interrupt your activities of daily life and recreation. Luckily, we know that physiotherapy and exercise help the majority of back pain sufferers. Physiotherapists have a recognized expertise in prescribing movement and strength-based exercises to help in your recovery. One of the frameworks physiotherapists use to help them decide which types of exercises will help you is directional preferences.

A directional preference is when a movement in a certain direction is associated with a reduction in low back pain. This means that when you exercise in your back’s “preferred position” the exercises should be more comfortable and effective.

When it comes to the low back, the 2 main movements that typically present as a directional preference are flexion and extension. Flexion is when you bend your low back forward, and occurs when you sit, bend over to tie your shoes or pick something up off the floor. Extension is when you bend your spine backwards and occurs when you stand, walk and lie on your stomach.

Additionally, some people with back pain do not experience significant improvement with either of these movements. We refer to these patients as having a neutral preference and recommend the use of neutral in exercises as this should be the most comfortable posture. Most people can exercise safely and comfortably in a neutral posture.

If you find that sitting and bending forward relieves your pain, you most likely have a flexion preference. Conversely, if you find that bending backwards or walking relieves your pain you most likely have an extension preference. If you find that there is no clear pattern on what relieves your pain or provokes it, you most likely should exercise in a neutral preference.

To summarize, most backs exhibit one of three Directional Preferences:

1 Flexion preference – your back prefers forward bending
2 Extension preference – your back prefers backward bending
3 Neutral preference – your back is best if you keep it in neutral. It irritates if you go into more flexion or more extension.

Why is it important to find my directional preference?

Our therapists use the designation of Directional Preference to choose exercise programs. This well-established format is used world-wide. It is successful at helping people become more active because it respects the fact that even two people with the same diagnosis can have completely different directional preferences!

For example, although most people with spinal stenosis will prefer flexion, there is a small group of people who will do better with extension. It is important to consider this instead of giving all spinal stenosis patients generic flexion exercises.

Additionally, a diagnosis of disc-related back pain gives limited insight into the type of exercise you need. Some backs will need flexion whereas others will do better with extension. These variabilities are why it is essential to know your Directional Preference to engage in safe exercise at this time in your recovery.

If you would like a therapist to help you determine your directional preference so that you can exercise more effectively, you can book an appointment with one of our physiotherapists, massage therapists, kinesiologist or chiropractor by calling the clinic at (416) 925-4687 or emailing us at

This service pro­vides gen­eral infor­ma­tion and dis­cus­sion about therapy, health and related sub­jects. It is not meant to replace advice and/or treatment from your health care professional.