Extension Related Back Pain with Hypermobility

If you’re an active adult or athlete with hypermobility, recovering from back pain can be especially frustrating. What works for most people—like stretching or simply “moving more”—can actually make things worse if your joints already move too much.

At Cohen Health and Performance, we often help hypermobile individuals recover from extension-related back injuries, which typically result from excessive compression of the spine during movement. You may have heard some of the more technical terms for these injuries—like spondylosis, spondylolisthesis, pars defects, or even stress fractures.

These types of injuries are common in athletes who spend a lot of time arching or extending through the low back—think gymnastics, dance, overhead lifting, and even running.

Why Hypermobility Needs a Different Approach

Hypermobility means your joints exceed normal range. While that can be an advantage in sports requiring flexibility, it places a higher demand on your muscles to create stability. This is especially important when it comes to the spine, where poor control can lead to repeated irritation or injury.

If you’re recovering from an extension-based back injury—one where backward bending has caused too much load through the joints in the spoine—your recovery needs to be just as specific as your condition.

How Physical Therapy Can Help

At Cohen Health and Performance, our physical therapists work directly with hypermobile patients to restore safe movement and prevent re-injury. Our approach focuses on:

Stabilizing the spine by improving deep core work
Distributing movement across the hips, shoulders, and thoracic spine rather than dumping into the low back
Progressively retraining lumbar extension, so it’s controlled and not reliant on end-range joint motion
Building strength to support hypermobile joints through all phases of movement

We don’t just chase flexibility or range—we build the foundation for controlled, purposeful movement that leads to long-term results.

Recovering Extension the Right Way

Extension is a normal and necessary part of athletic movement—but when it happens excessively or without control, it can lead to spinal compression and pain. Here’s how we approach it in the clinic:

Train Core Control First
Your core muscles are your spine’s best defense against compression. We teach you how to activate and coordinate these muscles—especially in positions of extension—so that your spine is protected, not overloaded.
Use the Hips and Shoulders
Movement should be shared—not isolated. Our physical therapists help you restore mobility and coordination in the hips and shoulders so that the lumbar spine isn’t forced to do all the work.
Control Mid-Range Before Deep Range
Hypermobility often comes with a tendency to hang out in end-range. We train you to control movement through more mid-range positions first, before carefully progressing to deeper extension with purpose and strength.
Build Strategic Strength
Strength is one of the most important tools in hypermobility rehab. We customize strength programs to support your spine and joints so you can move powerfully without pain.

Our Goal: Help You Stay Active, Pain-Free, and Performing

Whether you’re a gymnast, a weightlifter, or simply someone who likes to push yourself physically, we understand how important your activity is to you. At Cohen Health and Performance, we don’t just help you get out of pain—we help you move with confidence and longevity.

3 physical therapy exercises to keep your back healthy from home

I hope that you took full advantage of last week’s long holiday weekend.

My weekend was full of food, family, football, and plenty of time to relax.

In today’s constant, go-go-go society, we all can benefit from a little more time to relax and may help improve your outcomes in physical therapy. But for those of us who are used to moving constantly, this can result in back discomfort.

Research shows that decreased daily movement increases the risk of lower back pain.

Our spines are designed to move, and the structures in our lower backs (most notably, our discs) do not receive optimal nutrition and blood flow when we are sedentary.

The risk for lower back pain further increases if you have a history of lower back pain.

If the holidays are causing you to be less physically active than normal or you have a history of lower back pain, the activities below can make a huge difference!

The goals of these activities are to get the back moving and get the stabilizing mechanisms of the spine going!

Start by performing these activities a couple of times per day as a “movement break”.

Spinal Segmentation: 3 spinal waves in each direction
90/90 Hip Lift: 3 sets of 5 breathing cycles (each breathing cycle is in through the nose, followed by a full exhale, followed by a 5-second pause)
Physioball rollouts: 2-3 sets of 5 (try performing this with a breath at the top of each rep!)

P.S. If you are looking to solve your chronic back pain once and for all, contact us to set up an evaluation for back pain physical therapy in our McLean or new Bethesda location!

This is why your back pain isn’t going anywhere

Let me tell you about a past physical therapy patient who saw me in our Bethesda and McLean facilities. We’ll call him John. John is a hard-working guy that had been struggling with back pain for years. It started with pain while weight training and eventually prevented him from standing for more than 20 minutes at one time. His inability to stand was a major problem because his job required him to be on his feet constantly.

He had been to doctors, physical therapists, and chiropractors. He tried foam rolling, changing his desk setup, and even those strange massage gun-looking things.

That is when he came to see me for a more “sports approach” to physical therapy.

I began our session by asking him questions about his back; I could sense that he had heard them before. But my following questions grabbed his attention.

He had not received these questions before, and I asked about his sleep habits, use of technology, and stress. These questions created our “aha moment” as we realized the following areas needed to improve if he wanted to conquer his back pain in physical therapy.

A Poor Night’s Sleep

Sleep is the best recovery tool that we have. Research has shown that sleep quality improves outcomes in chronic pain patients, especially with back pain.

We first made sure that John had a high-quality mattress. A poor-quality bed can leave your back feeling worse due to a lack of support. Most people with back pain tolerate a firmer mattress best. Be sure to test multiple mattresses and determine the best and most comfortable ones.

John’s final sleeping recommendation was simple—no more sleeping on his stomach. Sleeping on your stomach increases the compression on your lower back. Sleeping on your side or back can be extremely challenging when you are not used to it. But it will become much easier over time.

Addiction to Technology

John was spending way too much time looking at screens.

According to recent research, the average person spends about nine hours per day using electronic devices, which increases tension in several areas, like the lower back.

We started by setting realistic limits on John’s use of technology. We gave him a technology curfew of 9 pm (he couldn’t use his phone after 9 pm). Phones, iPads, and TVs contain blue light, suppressing melatonin production, a hormone essential for quality sleep.

Reduce Stress

The body is resilient, but it can only handle so much physical and emotional stress. Research indicates that people struggling with anxiety and depression are more likely to experience a few orthopedic pains, including lower back pain.

After discussing this with John, he mentioned that he had enjoyed meditation but didn’t have enough time to keep it up. Because he enjoyed meditating, I suggested he try one of the many great apps with short, 5-minute meditations.

Suppose meditation doesn’t work for you. No big deal! Search for one thing you enjoy, which reduces your stress, and implement that into your daily routine. Walking outside does that for me. Rain or shine, I ensure I get at least a couple of walks in a day.

As John worked to address these issues, we created a comprehensive physical therapy plan to help his back. Combining all these factors allowed him to recover and return to work and his active lifestyle fully.

Back pain is a complex issue, influenced by many factors. But that is a good thing because that provides many ways that experts can help. If you have back pain that won’t go away, don’t hesitate to contact us so that we can help you find solutions.

The Best Sitting Posture

This is the best sitting posture.

Many physical therapy articles and rehab blogs discuss the importance of sitting posture and how perfect sitting posture is essential to avoid neck and back pain. Here are a few examples of what I found in several articles online.

Sit with your feet flat on the floor. This position helps to distribute your weight evenly and reduces pressure on your lower back.
Support your lower back. If your chair doesn’t provide enough support for your lower back, consider using a lumbar roll or cushion. This can help maintain the natural curve of your spine and prevent low back pain.
Sit up straight. Sitting up straight helps to maintain good posture and reduce strain on your back. Avoid slouching or leaning forward.

While these may be helpful recommendations as part of the physical therapy process, they miss the most important thing.

There is no perfect sitting posture, and the “best” posture is the one that is constantly changing.

When standing, we naturally sway and shift our weight forward and back or from one foot to another. Unfortunately, this goes away as we sit and concentrate on something…like this blog I’m writing!

The longer we concentrate on something, muscular tension increases. This keeps us still and helps us focus better on what is in front of us. Unfortunately, too much muscular tension leads to discomfort.

Does this mean you must get up every 10-15 minutes and move around? In a perfect world, sure, but there may be better solutions if you try to get stuff done.

As I am writing this article, I am fidgeting. My sitting posture is changing, and I am shifting my weight from one side to the other. I sometimes cross one leg under the other and raise or lower my chair.

But one more part of sitting posture may be most impactful.

Give your eyes a break.

Research shows a connection between high levels of focus on a screen and discomfort in the upper body.

Optometrists recommend the 20/20/20 rule to help with this. The 20/20/20 rule states that for every 20 minutes of focus-intensive work, you should take a 20-second break and look 20 feet away.

This helps to reduce your focus on a single point and, as a result, reduces tension in your upper body.

Our bodies typically don’t respond well when we ask them to be still for long periods. A more active approach to sitting helps us avoid the discomfort that may come with it.

If you are interested in learning other strategies that can be used to sit comfortably throughout your day, contact us!

What a Runny Nose and Your Pain Have in Common

Do you remember the last time that you caught a cold, the flu, or had Covid? If you are like me, you build a mountain of dirty tissues to keep your snot under control. Meanwhile, the little bug causing it runs around your body, creating chaos.

The pain you feel when exercising is a lot like your runny nose. Pain is a symptom of a larger issue and the key to finally fixing it is to correct that root cause.

Unfortunately, I find that most athletic physical therapy treatment for focuses on the symptoms, rather than the reasons the symptoms started in the first place. We wouldn’t blow our nose all day without taking medicine to kill the bug causing it, would we?!

At Cohen Health and Performance, the goal of every patient’s first performance physical therapy appointment at our Bethesda or McLean location is to discover the root cause of their symptoms. Once this has been identified, our physical therapists create a rehabilitation plan that is customized for every person that we see. Every person is different, with different reasons for an injury and different goals. If your physical therapist has a cookie cutter plan that they use for every patient with low back pain, for example, find another physical therapist!

How do you know if your physical therapy plan is a good one?

The end goals of the rehabilitation plan should be YOUR goals, not the goals of the physical therapist. The physical therapist should clearly describe how your plan is going to get you back to the activities that are most important to you, not what the insurance company wants to see.

For example, we help many runners overcome injury. Their first physical therapy appointment includes a running analysis if they are able to do so. Their rehabilitation plan then includes drills that will help them get back running ASAP. Below is an example of an exercise that we may give a runner with knee pain to prepare them for the stress of their training.

It is easy for physical therapy to become focused on outcomes that insurance companies want to see because that is what is required to get paid. This is why we advise our patients to look for a physical therapy clinic that works for their patients, not insurance companies!

Don’t Trust Your Pain

We have all experienced physical pain (in fact, my own history of low back pain is what interested me in sports physical therapy).

Maybe you injured your back lifting weights. Perhaps you hurt you shoulder playing catch with your kids. You may have irritated your knee when training for a marathon.

You decide to see your doctor, physical therapist, or medical provider of choice. They then prescribe the recommended treatment or “plan of care.”

Throughout the course of treatment, you determine if you are getting better by monitoring your pain. Is it decreasing? Is it staying the same or getting worse? If your pain is improving, the treatment is working. If not, it is failing. Pretty straight forward.

That is the way that standard physical therapy views treatment but is short sighted.

Modifying your daily activities or exercise routines will help pain quickly improve in the short term but the root causes of the pain remain. This is when many people stop going to physical therapy or performing their home exercise routine.

This pain-free period of time provides the body with an opportunity to address the root causes of pain. This is essential if you wish to prevent it from returning in the future while returning to full activity.

Pain is a prediction made by the brain. When pain continuously occurs during a movement or activity, the body learns to expect it. This expectation must lessen for pain to ultimately disappear during aggravating activities. If you really want to nerd out on pain science, check out this article by my friend and fellow physical therapist, Zac Cupples.

Imagine that you have lower back pain every time that you attempt to lift something off the floor such as deadlifting a barbell in the gym or emptying dishes out of the dishwasher.

The brain has an expectation that this bent over position will hurt. Therefore, similar positions must be experienced without pain. Does this mean that you should start deadlifting on day 1 of treatment. Absolutely not. The best solution is to start with something less threatening and build from there. Below is an example of a great activity that physical therapy patients with low back pain start with.

The brain will then determine that these positions are not threatening, ultimately reducing risk of pain in the future while facilitating a full return to active life.

If you are an active adult ready to solve chronic pain for good, contact us to receive a customized home exercise program today!