Fear of Flexion

This week we were thinking about the idea of spinal flexion and the fear of flexion in exercise and movement. There are certain contraindications for flexion, but we must think about how to appropriately teach flexion and when it is truly contraindicated versus it becoming a fear in the fitness industry.

Immediately, there are a few incidents that come to mind when I think of contraindications around flexion.

I remember taking a workshop one year for my continuing education credits to renew my teaching credentials and being surprised by something the presenter mentioned. This class I was in was about neurological conditions with Pilates clients. The presenter said she preferred working in neuro and never wanted to work in ortho because she was afraid of breaking someone. I was surprised that she felt it was possible to break someone from doing the work that we do, especially because I naturally feel very comfortable working with clients with orthopedic conditions to address. Neither practitioners nor clients should feel that they are going to break from working with orthopedic pathologies.

Similarly, as a student teacher in my Pilates program, I remember hearing that the classical Pilates system is too flexion focused, that there are many more exercises of flexion than there are of extension in the method, and that as teachers we must always be cautious to plan in extension exercises. However, there are always more flexion movements in all practices because the body moves through flexion in order to do any movement, and then the spine and joints extend back out of that amount of flexion to return to a "neutral" stance.

There are many contraindications presented to student teachers when they're learning in order to properly and most safely address various common pathologies. One of the most common is osteoporosis, and the general guideline is to avoid all spinal flexion for a client with this condition. However, as a teacher becomes more familiar with working with clients and managing pathologies, we realize there are many more nuances than this strict no-flexion policy. The primary contraindication that is generally advisable to limit or avoid specifically with osteoporosis of the spine is loaded flexion, and flexion with a twist.

So is flexion good or bad? There is no short answer to that.

Overall, we need to teach people to move fully as best they can, in ways that they don't tend to move on a daily basis in order to increase the overall strength and movement capacity of the body as a whole. Teachers should not teach clients to be afraid of certain positions or movements. Large fitness and physiotherapy organizations have basic guidelines to follow for liability reasons and they give a generalized overview since they can't assist everyone with their specific cases. We should follow the guidelines as a baseline, and then incorporate more movement and push the client as we see what they can do and what they feel comfortable doing in their body. While Pilates does not create enough force to break our clients, we need to work in evidence-based practice, pay attention to the individual, and be conscientious of what the client needs. We do have to be aware of how deep flexion, especially when loaded and/or paired with rotation can impact orthopedic conditions, but we cannot be afraid of flexion. Teachers need to be both educated in the anatomy and contraindications of the client's pathology while at the same time understanding everyone is different and might not follow the general guidelines.

While there are necessary contraindications and precautions for various pathologies, clients leave the studio and create flexion in their spine all day every day. When someone bends down to tie their shoes, reaches over to pick something up from the floor, weeds the garden, gets out of their car, or sits up in bed, the spine is moving into flexion. Depending on the individual it may or may not be comfortable or pain-free, but normal movements in daily life create varying degrees of spinal flexion and people need to be able to do that movement. In the studio, teachers can instill fear of flexion in the client if teachers are afraid of teaching flexion. When teaching clients we must ask ourselves how we can help support our clients doing these activities instead of creating a sense of rigidity and fear around certain movements.

Instead of creating fear of flexion, we can teach the client what flexion actually means, and how to better support that necessary daily movement. Just because an exercise has spinal flexion does not mean the spine has to be compressed or overloaded. We need to teach how to lift, build space, and lengthen first up and then over into the spinal flexion. A client can also be taught about reducing or limiting the range of a movement (ROM), being able to control the amount of flexion produced instead of bearing down or dumping into the maximum amount of flexion capable in the spine. Since movement heals and strengthens we shouldn't take movement away from clients, but rather add to them, teaching the body to load better and more efficiently, and building up the tissue tolerance necessary for the movements in the day outside of the studio. Avoiding certain positions can create more issues, tissue tension, and physical stressors. We need the spine to be able to move in all directions, within the range that is appropriate for the individual.

We were wondering when this idea that flexion is bad became perpetuated in the fitness industry. There are pop-fitness articles over the years that have said crunches compress the spine and are bad at strengthening the core musculature. There is research that shows how the action of flexion in a crunch is not as effective as planks in terms of muscle hypertrophy and muscle output and activation of the deepest layer of abdominals, but that doesn’t mean there isn't a place for exercises including crunches and flexion in fitness and rehab routines, and that definitely doesn’t mean it is a dangerous exercise.

In Pilates cues in crunches of "don't feel the neck", "don't feel your hip flexors", and "don't move the back", have become popular cues and have been taken out of context. It's true we want the movement to be initiated from the abdominals, not the neck, and we don't want the primary sensation to be in the low back or hips, however, in spinal flexion, the cervical flexors, hip flexors, and spinal flexors including in the lumbar region are all active. We don’t have to be afraid of sensation in those regions, but again depending on the individual client we can modify and adjust as needed.

As we've mentioned, Pilates doesn't generate enough force or extreme load to injure or severely exacerbate a preexisting condition, but we do want to be smart about the choices we give our clients and listen to how they feel throughout their sessions. Teachers should be aware of the guidelines, but be skeptical about following generalizations that are extremely rigid. Instead, we should ask what is right for this client. However, for newer or less experienced instructors, or even for experienced instructors who don't feel comfortable teaching certain pathologies, it is perfectly alright, and highly advisable to follow the generalized safety rules and to refer out as needed. If a teacher doesn't feel comfortable working with a specific condition, it's preferable to work more safely and it is fine to not build flexion into the program of someone with those pathologies.

For all movements, we should be trying to create length to find the lift, length to find the curl, and length in flexion, creating length in anything we do in Pilates, even in and especially in flexion. We must choose for the specific client what the best options are for them, the appropriate range, working with them and guiding them, but also letting the client guide us as well. Depending on how the client responds to something can guide what we choose for them and how we develop their programming. If we are unsure if an exercise is unsafe for a client for whatever reason, we can find a different exercise or a variation of it that can support the same movement for the same goal that might be better for that individual.

We must know what we are choosing for the body in front of us.

Don't be afraid of flexion as it does need to be incorporated in order to support daily movements and the full function of how the spine moves, but take all the factors into consideration such as range of motion, where the injury is if the client has a condition they're working with, and the nuances of the injury and the individual. It is not clearly delineated; it is very multifaceted.

Generalized Safety Guidelines:

Osteoporosis of the spine:

flexion is generally contraindicated as loaded flexion and/or twisting with flexion. However, there are physical therapy exercises such as modified partial roll-downs with the roll-down bar on the Cadillac. If someone says they have osteoporosis or osteopenia, we should know what level of the spine is diagnosed, because if they have osteoporosis in the hips but it's not seen in the spine in their imaging, that's different precautions. For osteoporosis in the hips, the Pilates Tree on the short box is contraindicated. For osteoporosis in the spine, Tower on the cadi is not advised.

Disc herniations:

Deep flexion at the level of the spine with the herniation is generally contraindication. We should ask which level of the spine and which direction the disc is herniated, though many clients won't know. The most common disc herniations are in the lumbar spine, the next common is in the cervical spine, and usually, the discs are protruding posteriorly.

Other common pathologies:

Stenosis, spondylolysis, and spondylolisthesis are all slightly different and everyone will be slightly differently affected.

Stenosis: Avoid excessive end-range extension

Spondylolysis, Spondylolisthesis: Avoid repeated bending, extending, or twisting motions, including sitting slumped or hunched over for long periods of time.

Different spinal levels impact the client's movements differently: If a client has Spondy in the lumbar spine they can do cervical and thoracic extension but should work on maintaining their version of neutral in the lumbar level with extensions and limit the ROM, but flexion-based movements will generally be pain-free.

As always, refer out as needed and listen to the client’s concerns and sensations.

Associated Podcast at 2 Pilates Chicks, Season 4 Episode 5