Directional Exercises

Ron Donelson

Updated 4/2015

Directional exercises are a unique treatment for those patients with neck (NP) or low back pain (LBP) found to have a “directional preference”. They can be reliably identified by a unique clinical evaluation described here at under “Assessment Tools/Repeated End-Range Spinal Testing”. These methods of evaluation and this treatment are collectively known as “Mechanical Diagnosis & Therapy” (MDT).1

Most spinal treatments are based principally on trial-and-error that typically require a lengthy trial that often leads to insufficient benefit and unnecessary expense while allowing symptoms and disability to persist. However, this form of mechanical assessment is capable of reliably and promptly assessing whether or not a specific direction of exercise treatment will be effective.2

The many patients whose pain-generator is found to have a “directional preference” during this assessment are given the mechanical diagnosis of a “reducible derangement”. That means the pain-generator acts like something that was painfully out-of-position and was able to be corrected or put back in place. These patients have a predictably good-to-excellent, and usually rapid, recovery using directional exercises and postural modifications.3-6, 11-18

This form of exercise treatment for this large subgroup of patients consists of performing 8-10 repeated end-range lumbar or cervical movements/exercises, initially every two hours at home or work, but only in the direction matching the “directional preference” identified in the baseline evaluation. Between exercise sessions, posture modifications are essential to minimize time spent with the spine bent in the opposite direction, usually flexion or forward bending. Again, these patterns of pain response are all identified during the baseline mechanical assessment.

Performing these directional strategies provides the underlying derangement with beneficial mechanical loads that correct the derangement while temporarily avoiding loading in its direction of vulnerability.

A directional preference is reported to exist in 70-89% of recent-onset back or neck pain, including those with pain radiating down the arm or leg.3-6 It is also elicited in 50% or more of chronic patients and similarly in those considered to be candidates for some form of disc surgery.7-10 These high percentages are found by examining clinicians that have completed an educational program and credentialing examination conducted by the McKenzie Institute. Directional exercises are not indicated in patients whose baseline evaluation does not reveal a directional preference.

There are five required stages to providing a lasting recovery for a reducible derangement.1 A well-trained MDT provider coaches each patient in directional self-treatment methods with most patients moving rapidly through all five recovery stages within 5-6 clinic visits. All stages focus on the progressive care of the pain generator’s directional character:

  1. Determine if the pain-generator has a directional preference that enables eliminating the pain.

  2. If so, teach the patient to implement matching directional strategies and posture modifications to eliminate the pain.

  3. Once eliminated, shift to the proactive use of these same directional self-treatment strategies to prevent the pain from returning, both short- and long-term.

  4. Gradually re-introduce movements, positions, and then activities that require the disorder’s direction of vulnerability - usually flexion. The overall goal is to achieve full range-of-motion and restore all activities without symptoms.

  5. Prevent recurrences. Recurrent episodes routinely have the same directional characteristics as the baseline episode. Continue either the proactive use of directional exercises and improved posture or implement them immediately with the first sign of any recurring pain.

There are currently eight published clinical trials that randomized LBP patients who were found at baseline to have a directional preference.11-18 All eight report superior outcomes using matching directional exercise compared with an assortment of commonly prescribed alternative lumbar pain treatments.

Recoveries using this from of care routinely take place without the need for medications, imaging, or any other form of treatment.


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