Low back pain (LBP) is common. It is cited as affecting about 84% of all adults at some point in their lives. The most prevalent musculoskeletal cause of disability in adults is LBP. LBP is frequently recurrent, with about 60% of LBP cases suffering recurrent episodes. LBP is not always curable, and for some, it is a lifelong problem. The cost of LBP is enormous. In the US, the medical cost of LBP has been estimated at between 8 and 18 billion dollars annually. The majority of costs are spent on the chronic back pain population.

Improving Management of Low Back Pain

Medicine should be taking measures to improve the overall management of those with LBP. Classifying patients with non-specific LBP into sub-groups based on specific clinical characteristics and matching these sub-groups to specific therapeutic management strategies has been advocated to improve the management of those with LBP. One such clinical characteristic is called directional preference (DP).

What is Directional Preference?

DP is present when a person’s spinal and/or referred spinal pain gets better, goes away, or centers, and their spinal range of motion increases when they move or stand in the same way over and over (for example, bending, stretching, or moving laterally). When clinicians trained in the use of mechanical diagnosis and therapy (MDT) evaluate patients, DP is a common finding.

MDT is a system that utilizes the patient’s own movements and positions to identify specific subgroups of patients with mechanical pain syndromes that readily respond to mechanical therapy exercises and/or manual therapy techniques.

back pain direction preference

Research on Directional Preference

Long, Donelson, and Fung (2004) studied 312 patients with LBP and/or sciatica for the presence of DP during a structured physical examination. 230 (74%) of these patients exhibited a clear directional preference when examined (See pictures for the statistical breakdown of the directions preferred).

83% of the patients preferred extension.

10% of the patients preferred lateral movements.

7% of the patients preferred flexion.

The researchers divided these 230 patients into three treatment groups and recorded their outcomes:

Group 1

Performed exercises matching their individual directional preference.

Group 2

Performed exercises opposite their individual directional preference.

Group 3

Performed “non-directional” exercises. Performed 8 commonly used mid-range exercises not biased in any particular direction.

The outcomes measured were pain intensity, disability, medication use, degree of recovery, depression, and work interference before and after the treatment period.

The results of the study were impressive. 95% of the people in Group 1 (matching exercise) rated their pain or disability as better or resolved. Group 1 improved significantly more than both Group 2 and 3. Most dramatically, 35% of group 2 and 33% of group 3 withdrew from the study because of the worsening of their symptoms. In contrast, not one individual in Group 1 withdrew from the study due to worsening symptoms.

The authors concluded that exercises matching a person’s directional preference have the potential to significantly and rapidly decrease pain, disability, and medication use in people with LBP with or without sciatica.

Using Directional Preference in Treatment

At Stover Physical Therapy we use MDT to treat patients with LBP. Before administering any treatment we always complete a comprehensive history and evaluation based on MDT principles. Following the evaluation, we classify the patient’s disorder to aid in the development of an individualized treatment program that commonly includes directionally specific exercises and manual therapy procedures.

We use a validated health questionnaire called the Oswestry Low Back Disability Questionnaire to monitor our outcomes. The Oswestry is an instrument specifically developed to assess pain intensity and assess how LBP affects activities of daily living. Oswestry scores vary from 0% to 100%, with the lower number representing less pain and disability.

We have compiled the Oswestry results of 573 patients with LBP, with and without sciatica. 313 (55%) of these patients demonstrated DP at the initial evaluation. The average initial Oswestry score for this group of patients with DP was 31% (moderately disabled) and the average Oswestry score at discharge was 11% (minimally disabled) for this group of patients.


If you are among the many unfortunate sufferers of low back pain, undergoing a MDT examination by a qualified therapist would be a wise first step in learning how to effectively reduce your discomfort. Furthermore, the experience is a great way to learn the steps involved in the long-term management of these frequently recurrent problems. Many times, full recovery can be achieved within a few visits and without the need for expensive imaging studies.


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