In contrast, what most individuals view to be a neutral spine is this midpoint between maximum lumbar flexion and maximum extension where the lumbar spine has a small arch (lordosis). minimal lumbar spine motion), whereas the 300% condition was designed to bring isolated joints to end of natural physiological range.” Of the specimens, 23 (20%) experienced some form of injury related to either end plate fracture, avulsion fracture, or fracture of pars interarticularis. Interestingly, it was more likely that if one twin reported lower back pain, the other would as well; the frequency of lower back pain between twin groups was nearly identical. Currently, we have a number of papers that favor neutral while lifting; we do not have any favoring flexion. Rigidity provides an essential vertical bony axis, stability provides strong scaffolding for… With the lumbar spine in extension there is a decrease in the symptoms. This region generally shows 40-50° flexion, 15-20° extension, 5 … I agree with you that flexion of the spine is normal esp with certain lifting movements squat, dead lift or pulls. The side of the end plate facing the disc is composed of mostly fibrocartilage, making it very strong; in contrast, the side facing the vertebrae is mostly composed of calcified cartilage, which makes it structurally weaker. Fantastic. Instead, we will see individuals perform significantly fewer repetitions and allowing time to recover and adapt from that stress. Effects of load on good morning kinematics and EMG activity. We'll cover neutral vs. flexion, research on how dangerous (or not) flexion really is, and how to educate your clients on safe practices. Two questions were addressed with this study concerning the new SRSD: 1) whether spine movement was occurring with the methodology, and 2) where movement was taking place. Imaging should be primarily used to rule out sinister pathology such as cancer when there are signs pointing to it. The patient's knees should be bent towards their chest in mid lumbar flexion and rested on the therapist's hips. A sacral torsion occurs as a result of sacral rotation and side bending to the same side. You’re effectively making the arms longer. This paper helps to add depth to our understanding, as this mechanism is similar to what would be experienced in many sporting activities where an individual is compressed quickly – such as tripping and landing on their butt, or placing a heavy barbell on their back. Doing a final analogy: If your back is fucked, I won’t recommend you to lift with a flexed spine. Justin R Câmara, Joseph R. Keen, Farbod Asgarzadie. The phenomenon appears between 72.6 and 76.3% of maximal cervical flexion and disappears during the return to neutral position between 91.9 and 93.1% of maximal cervical flexion. Although some would consider driving a risk for disc herniation due to the commonly flexed posture and whole body vibration exposure, the researchers did not find driving exposure to be associated with lumbar degeneration, disc signal intensity, or any other “abnormalities.” Specifically, disc degeneration did not differ between twins, except in the case of the lower lumbar spine where non-drivers actually had more frequent herniations than the drivers. This. When examining many of the above papers looking at flexion, we should keep in mind the methods of the studies. Building on top of the bony structure, there is also a wide array of. In, flexion was comparable to neutral for low rate and in. When we look at the research, there seem to be factors that modify the inherent risk associated with lumbar flexion. This returns us to our previous discussion of hazard versus risk. There are various kinds of herniation classifications, some of which are focused on the nucleus pulposus, others on the whole unit. Extension Bias Impairments:-Disk lesions-flexion injuries. set up an experiment to compare three levels of compressive force (10, 20, and 40% of compressive tolerance) and three cycle rates (5, 10, and 30 cycles per minute) within two ranges – either the neutral zone, or 300% of the neutral zone – to a maximum of 5000 cycles. From the results, we can see that approximately 40% of individuals who are symptomatic will show some form of imaging finding, whereas approximately 20% of individuals who are asymptomatic will. […] Should You Fear Lumber Flexion? The cervical spine flexion and extension views demonstrate the seven vertebrae of the cervical spine when the patient is in a lateral position. Should you ask a range of professionals to define neutral spine and explain why it matters, you’d likely receive a range of answers. They say to just keep your spine in a safer position to deal with these levels of compression. ... Proprioception plays an important role in appropriate sensation of spine position, movement, and stability. Of these injured specimens, 14 came from the group that was exposed to 300% of the neutral zone, whereas 9 came from the regular neutral zone. In most studies examining flexion versus neutral, the stress is repeated motion to failure; in this study, though, it was comparing high rate internal pressure. Panjabi created these terms based on experiments looking at how much force was required to change the intervertebral motion of segments (load-displacement measures). Disc pressure and stress on the lumbar spine are at its lowest when lying in the supine position (25 kg). Read more information on low back pain. Is the chemistry of collagen in intervertebral discs an expression of Wolff’s Law? Usually you will then get annular tearing that may have no symptoms just stiffness in the low back from activation of the small nerves innervating the disc. This demonstrates lumbar flexion when combined with high compression as having an elevated risk over neutral. I would add a personal view; if you already have an injury this rules also change. Characterizing the combined effects of force, repetition and posture on injury pathways and micro-structural damage in isolated functional spinal units from sub-acute-failure magnitudes of cyclic compressive loading. I see value in both but can’t come to favor one side over the other. In Wade et al. These terms come from the Latin words with the same meaning.. Flexion describes a bending movement that decreases the angle between a segment and its proximal segment. In. If you’ve spent much time in the world of rehabilitation or fitness, you’ve likely been drilled by the “neutral” spine concept. We do need to note that there are data to support that symptomatic individuals are more likely to have MRI findings than asymptomatic individuals. Many of us have seen that one guy who can bust out rounded-back deadlifts without any issue, and most people have also known someone who seems to injure their back every other week. In fact if you believe the spine is best kept in a neutral position then I would highly suggest reevaluating your plans of recovery because you wont get through this life without eventually bending your spine. In addition, a flexed posture reduces the stress at the apophyseal joints, which may be irritable from excessive extension activities. Solomonow M. Neuromuscular manifestations of viscoelastic tissue degradation following high and low risk repetitive lumbar flexion. This list of possible “injuries” looks identical to that of the injuries resulting in a flexed spine. In the study, they exposed specimens to three different loads (260, 867, or 1,472 N) for a maximum of 86,400 cycles through lumbar flexion and extension within a “neutral zone.” In the low-force group, none of the specimens had a herniation. Those first two factors are very important, as discs are considered to be more at risk when dehydrated. But let’s -I’m making up numbers- say 1 second per cycle is spent in flexion => 5,000 seconds in flexion => 83 minutes in flexion. Building on top of the bony structure, there is also a wide array of ligamentum support for the spinal column. The concept of the neutral spine is that there is a specific position of the spine where it is safe from injury – particularly, from the dangers of lumbar flexion. Fluid flow is increased in flexed postures and helps to deliver nutrition better than a neutral position. I haven’t even finished the article yet, but thank you for writing this, Sam! in the lateral decubitus position, position the patient so that the humeri are extended 90 degrees to the thorax, with the elbows flexed so that the forearms are parallel to the thorax. What happens when “lumbar flexion” is maintained for hours (very commonly done by people who sit for hours)? PLAY. They had to accomplish a cervical flexion from a neutral seated position and from a 45 degrees forward leaning seated position. 6 ... leg side in flexion. But if you are healthy, it doesn’t mean that you will hurt your spine by lifting with a flexed spine. How healthy discs herniate: a biomechanical and microstructural study investigating the combined effects of compression rate and flexion. In both studies, we do see that with greater degrees of compression – either as rate or as load – flexion did have increased failure of the disc. about the spine and lumbar flexion. Its structure provides a remarkable combination of rigidity, stability, and flexibility. This elucidates the point of neutral spine being more a range than a specific position. Variability in Flexion Extension Radiographs of the Lumbar Spine: A Comparison of Uncontrolled and Controlled Bending. For example: if you have an injured knee, running activity is not a wise choice. Zhong M, Liu JT, Jiang H, Mo W, Yu PF, Li XC, Xue RR. In principle, any of the structures within the lumbar spine that receive innervation from the nervous system can be a source of back pain. You might have someone “hamstring curl the floor” and exhale to maintain the cylinder on a bench press for general pop, but if they’re powerlifter in competition, there’s a definitive advantage to extension. The stabilizing system of the spine. When an endplate fractures, it can allow for the nucleus pulposus to leak and become disrupted. This diverse structure of ligaments helps to provide an incredibly high amount of passive support to the spine. support for the spinal column. Adams MA, Hutton WC. Thre are sports with a light load and high repetition(row) and High load(Mas-wrestling), or strongman atlas stone lifting. Panjabi MM. This range approximately corresponds to the part of the population with the average and above the spine's average flexibility, without exceeding the 95 percentile borderline. Each vertebrae has a few major components: body, pedicle, lamina, spinous process, superior/inferior articular process, and transverse process. In neither of the above studies did lumbar flexion present as an inherent dangerous factor. conducted a study looking at the impact of compressive force with flexion and extension of the spine in porcine models. See Figure Figure5 5 for a representative subject's data for two positions, neutral (N) and full flexion (F) for the thoracic (T) and lumbar (L) measurements. phs taken in the standing position are most commonly used to evaluate spinal instability. A disc herniation is when the disc begins to push outward beyond its normal confines between the vertebrae. PLAY. This doesn’t mean that these findings are the cause of the pain and doesn’t dictate treatment. In most studies examining flexion versus neutral, the stress is repeated motion to failure; in this study, though, it was comparing high rate internal pressure. Their results demonstrated that the neutral spine is not safe from injury; in fact, the neutral segments experienced a higher percentage of disc failure during both impulse and gradual pressurization. If we were to take out the pars fracture specimens from the results to look at injuries less associated with extension, we see the results change to 9 for the neutral range and 12 for the 300% neutral zone. They say to just keep your spine in a safer position to deal with these levels of compression. Watch: Lumbar Spine Anatomy Video The L5-S1 motion segment has distinctive anatomy and receives a higher degree of mechanical stress and loads compared to the segments above. This structure helps to give a flexible but strong structure. Pull the chin in towards the chest. How to lift a box that is too large to fit between the knees. These reinforce a stronger correlation between genetics and pathoanatomical signs than other measures. For a left sacral torsion. – we see the spine deviate from a set position and undergo varying degrees of lumbar flexion and extension. You might have someone perform a “PRI squat” to assess these things, but you sure as hell wouldn’t load someone in that position. MRI findings of disc degeneration are more prevalent in adults with low back pain than in asymptomatic controls: a systematic review and meta-analysis. Or here’s a good angle (albeit at light weight): https://b-reddy.org/wp-content/uploads/2018/09/Konstantin-deadlift-lower-back.jpg. Most commonly, a disc herniation will occur posterior or posterior-lateral toward neural tissue, but it can occur in any direction. This is why it's the third movement in my 6 minute mobility drill. While I’m very hesitant to say that the latter person couldn’t get better, we do have a significant amount of information showing there is a genetic link to these conditions. This format was repeated until all segments failed either via disc failure or end plate fracture. Flexion of the Cervical Spine. Pos with sciatica, severe S/S. A familiar movement for most of us, spinal flexion is the act of bending forward. I’m currently obtaining my personal training qualifications, after leaving a career in medicine, and I’ve become very interested in the biomechanics of fitness. Magnetic resonance imaging of the lumbar spine in people without back pain. Is lumbar flexion better than neutral for anything? This lack of consistent terminology between clinicians, researchers, and the public leaves room for miscommunication and greater error in information sharing. : An in-vitro study using a porcine model. A typical lumbar vertebra . 1. This has been found to occur in normal aging (with many of these occurring before the age of 2). In particular, we are seeing more information showing that many of these “abnormalities” are more an aspect of aging than an association of pain. should be primarily used to rule out sinister pathology such as cancer when there are signs pointing to it. Most of the research was on cadaveric spines (mostly animal, but some with human cadaveric spines). Shark attacks are a hazard, but if you never enter water where sharks are, you are not exposed to them, leaving you with little risk of being exposed to a shark attack. Generally, getting your spine into a flexed position helps relieves the … These are not real research scientists, rather instead, greedy money-hungry unethical and immoral subhuman filth. I’m currently obtaining my personal training qualifications, after leaving a career in medicine, and I’ve become very interested in the biomechanics of fitness. In the quadruped position the lumbar spine is often flexed and the hips are in less than 90 degrees of flexion. Each side of the disc has a vertebral endplate which acts as a means to connect the disc to the bone. Film size use is 35 x 43 cm or 14 x 17 inches. It’s hard to see his lumbar in that older video, and dudes with those big of spinal erectors are hard to gauge, but with this better resolution you’re going to be hard pressed to find a great deal of lumbar flexion: https://www.youtube.com/watch?v=F25fhUGPQoE. Analogies can really help explain this concept. This structure helps to give a flexible but strong structure. In some cases, extraspinal flexion is desired. Shedding Some Light on Vitamin D Supplementation: Does It Increase Strength In Athletes? When discussing various sports, the recommendation will likely shift back and forth. Another aspect to discuss is the role of genetics. An important concept to understand as we go forward is the difference between hazard and risk. Incidence of spontaneous resorption of lumbar disc herniation: a meta-analysis. Indications These views are specialized projections often requested to assess for spinal stability. Patient position: Sidelying; spine in flexion and L SB, locking L5S1 into L rotation. It is pretty rare to find someone busting out 5,000 continuous reps of an exercise. This is the terminology that is most commonly applied to what we deem as the neutral spine. Brinjikji W, Diehn FE, Jarvik JG, Carr CM, Kallmes DF, Murad MH, Luetmer PH. Those first two factors are very important, as discs are considered to be more at risk when dehydrated. Beyond the need for it in activities of daily living and sports, lumbar flexion offers benefits to the spine that may not be achieved through a neutral position. compared vertebral disc failure and vertebral end plate failure between a neutral and flexed vertebral spine position with pressure impulse stress. Physical activity and the strength of the lumbar spine. Looking at that prior paragraph, we could be led to arguing that flexion with load is dangerous, but is that the whole story? It’s an opportunity to assess whether someone is stuck in a constantly extended state (a lot of the heavy lifter pop) and, with specific exercises, to train key sagittal and frontal plane muscles – hamstrings (L or bilateral), L adductor, obliques (extra focus on L). However, we can also see from the work of researchers like McGill, Wade, Gooyers, and others that there is more than just discs that can be compromised with flexion-based activities. can demonstrate four main types of motions: flexion, extension, rotation, and lateral flexion. Then, the disc was pressurized to a specific level (8MPa), allowed 12-14 seconds to settle and be observed for failure, and then more pressure was added progressively. Testing Motion: Push the patient's head gently on the the back of the head anteriorly. The Evidence for Myonuclear Muscle Memory May be Murkier Than Commonly Believed, Improbable Data Patterns in the Work of Barbalho et al: An Explainer, What I Learned About Injury Rates from Surveying 1,900 Powerlifters, https://www.youtube.com/watch?v=F25fhUGPQoE, https://b-reddy.org/wp-content/uploads/2018/09/Konstantin-deadlift-lower-back.jpg, TUESDAY GOOD READS – ISSUE #112 – AUGUST 28TH 2018 | Men's Fitness & Lifestyle, Stuff to Read While You're Pretending to Work: 11/2/18 - Tony Gentilcore, Stuff to Read While You're Pretending to Work: 11/2/18 | Fitness & Yoga, The 200 Amazing Fitness Articles You Need to Know About, How to Do The Jefferson Curl To Improve Low Back Pain | Seriously Strong Training, Basic Results • Stronger By Science - Gear Up To Fit. If there is tearing or strain of that tissue then vulnerability increases. So I agree, this topic is a very contentious one. Well, that’s not entirely true. The lateral in either extension or flexion is an alternative to the fan lateral for localization of foriegn bodies of the hand and fingers; it also demonstrate anterior and posterior displaced fracture of metacarpals. O’Sullivan K, O’Dea P, Dankaerts W, O’Sullivan P, Clifford A, O’Sullivan L. Neutral lumbar spine sitting posture in pain-free subjects. From the flexed back of a cyclist to an extended back of a gymnast, sporting demands require inherently different postures and capacities. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. When a person is leaning forward from … This is the most common sacral torsion dysfunction. Lumbar flexion is generally limited due to soft tissue tension, whereas the other motions may be limited by either soft tissue tension or bony approximation. Burnett A, O’Sullivan P, Ankarberg L, Gooding M, Nelis R, Offermann F, Persson J. This article is a complete guide to lumbar flexion in lifting. , we see that there was actually a higher incidence of endplate fractures than there was with disc failure with flexion. Each disc typically has 15-25 layers of annulus, which is made up of ~50% collagen and some elastin proteins. Does this indicate a better position? In yoga practice, spinal flexion is another way to refer to forward bends. This returns us to our previous discussion of hazard versus risk. In regards to the disc, from these studies, we can see where the argument that the disc is most at risk with lumbar flexion and elevated rates of compression comes from. That level of thoracic flexion can be a specific, high level, deadlift technique. Spondylolysis: a critical review. What is interesting to note is that one of the primary injuries that arose was a fracture of the pars interarticularis of the superior vertebrae (spondylolysis), which is most associated with hyperextension – not flexion. There are ligament structures that span along multiple segments of the spine, such as the posterior longitudinal ligament and ligament structures that connect individual segments, such as the interspinous ligament. A spondylolysis is where damage occurs to the pars interarticularis (in essence a fracture). Flexion. Most commonly, people associate lumbar flexion with disc injuries. These stresses slightly increase when you change from the supine position to lying on your side; this disc pressure is measured at 75 kg. . Methods: Previously taken lumbar spine x-rays of 103 patients in the neutral and full-flexed positions were reviewed. In all of these studies examining spinal flexion as a mechanism of injury, we are left with an unrealistic situation for the disc to be able to adapt. The load required for failure with disc herniation was lower than that of end-plate fracture. Assessment: Lumbar (Trunk) Flexion (MUSCLE Rectus Abdominus) Patient Position: Supine, no pillow under head Therapist Position: Standing STABILIZE None Method: PALPATION Anterior aspect of the trunk lateral to the midline ; RESISTANCE None ; Alternative Method: None. Prior research has also found pretty high rates of knee injuries, which we didn’t see in our […]. Pertaining to lifting, if we are looking at it from a perspective of low load or low rate activities such as picking up a pencil (and assuming the person does not have a high fear or belief that flexion is dangerous), it likely doesn’t matter whether they do so with a flexed or neutral spine. The cervical spine flexion and extension views demonstrate the seven vertebrae of the cervical spine when the patient is in a lateral position. This comes from varying perspectives of mechanisms associated with flexion – repetitive flexion, long duration stretch, low compression rate, high compression rate, etc. However, during activity – such as lifting something off the floor, squatting, etc. Does this indicate a better position? Second, we have information that shows the same injuries can occur in a, These injuries range from the tears within the, to the transition zone, tears at the inner annulus, tears at the mid annulus regions, micro-structural damage, disc herniation, and. paper, we can see that herniations in the lumbar spine had a correlation with the applied load – not necessarily the number of motion cycles. This study included 92 consecutive patients diagnosed with L4-5 degenerative lumbar spondylolisthesis. Cat pose and Child’s pose are postures where the spine is in flexion, and mostly rounded. If flexion does pose a hazard, the apparent exposure in order to induce much risk is appearing to be quite significant and is unlikely to arise. Or, browse all prehab and rehab articles on the site. Slowly rotate cervical spine to the right and left side. This leaves us to infer transfer (which is not always consistent) from animal models to humans. What is interesting to note is that one of the primary injuries that arose was a fracture of the pars interarticularis of the superior vertebrae (spondylolysis), which is most associated with hyperextension – not flexion. Subjects maintained the neutral position (phase 1) for approximately 2 s, fully flexed the neck with the goal of approximating their chin to their upper chest (manubrium) within 5 s (phase 2), maintained full flexion for 5 s (phase 3), and extended their neck to the neutral position within 5 s … Instead, we will see individuals perform significantly fewer repetitions and allowing time to recover and adapt from that stress. Because of this, many scientists have begun to examine human cadavers for a more accurate representation of our tissues. This is an incredibly important factor that has not been addressed, and the data ignoring it is extrapolated to the real world, which skews people’s beliefs on the topic. Pronation and Supination. Shark attacks are a hazard, but if you never enter water where sharks are, you are not exposed to them, leaving you with little risk of being exposed to a shark attack. Despite the strong convictions and assertive claims often made, the evidence is not quite as clear as people believe. Lower lumbar spine axial rotation is reduced in end-range sagittal postures when compared to a neutral spine posture. Testing Position: Sitting with thoracic spine and lumbar spine stabilized by a chair.. We need to consider the full spectrum of information and investigate other plausible mechanisms of injury. In essence, the vertebra were set to be either in a neutral zone or in 7° of physiological flexion (one segment). •Lateral flexion: Vertebral body needs to glide away from the direction of lateral flexion. See Exelby for success in MWMs in the lumbar spine. A sagittal plane spine reposition sense device (SRSD) has been developed. You forget to mention Konstantins Konstantinovs lifting experience with his uberly flexed back when deadlifting! First, as we discussed prior, it is inevitable to not have some degree of flexion in certain activities. Digging into the literature, we come to a number of discussion points on this topic: First thing: A quick summary of some important anatomy and terminology for this topic. Methods. We do need to note that there are data to support that symptomatic individuals are more likely to have. Muscles contract to produce movement at joints, and the subsequent movements can be precisely described using this terminology. These reinforce a stronger correlation between genetics and pathoanatomical signs than other measures. As we have discussed, even if an individual has some form of “abnormality” on imaging, it does not mean it is associated with flexion or their current pain experience. Intervertebral disc herniation: studies on a porcine model exposed to highly repetitive flexion/extension motion with compressive force. Was assessed using a kinematic capture device in order to assess onset and cessation angle of the PSIS ’ static. Question this idea, so thank you for writing this, Sam this us! 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Of annulus, which is made up of five bony vertebrae with a neutral seated position and undergo varying of! Without a second thought multiple studies article where he discussed this topic as well, Kallmes,... 2001, low-load flexion did not have any failure Faber GS, van Dieen JH deviate a! Outer parts of the lumbar spine Monday, September 29, 2014 of that then! A range of flexion during a, there seem to be factors that modify the inherent risk associated lumbar. That some people will have more resistant tissue to load and some elastin.... You ’ re interested feeling most of these studies were done on animals which is made up of %! Load required for failure with flexion but at the impact of compressive force the lumbar spine is often represented connection... Not inherently causative of pain or decreased function this article is a required position for many activities and may a... 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