Is it possible to identify which low back pain patients might experience the most benefit from spinal manipulation combined with exercise? In a 2011 study, researchers identified which patients might respond best to this combination of care and which patients might need a more aggressive approach.

Directional preference (DP) describes a situation in which it feels better for the patient to move in one direction versus another. For example, if a patient feels worse bending forwards (which is quite common) and feels better bending backwards, then “extension-biased exercises” are preferred.

If leg pain is present, the DP that reduces or eliminates the leg pain (called centralization, or CEN) is the exercise-biased direction, and it’s important to avoid any exercise that increases leg pain (peripheralization).

In the study, which involved 584 patients with low back pain, the researchers found that 60% of the participants had a DP and of those patients, 60% had CEN. The researchers found that the patients with a DP that reduced CEN responded the best to care (in this case, spinal manipulation combined with exercise) in regards to improved pain and function. On the other hand, the patients who had no DP experienced the least overall improvement.

The value of using a classification system like this allows a doctor of chiropractic to determine which exercises will help each individual LBP patient the most. It also provides them with the ability to identify those most likely to respond favorably and those patients who may need a more comprehensive treatment.

So, if you feel best bending backwards and/or leg pain lessens, the preferred exercises include bending backwards (extension) from standing, prone press-ups (“saggy” push-ups) or hugging a gym ball, and/or extending your back over a gym ball or a stack of large pillows. Of course, there are many additional exercises but ANY position that reduces LBP and/or leg pain will help.