Thursday Thoughts: Painful Transitions from Sit to Stand: Stenosis or Extension Directional Preference? | Modern Manual Therapy Blog

Thursday Thoughts: Painful Transitions from Sit to Stand: Stenosis or Extension Directional Preference?

A recent fellowship mentoring session with a few older patients had a commonly asked question regarding lumbar stenosis and painful transitions from sitting to standing.

How do you know if the condition requires flexion or extension as a directional preference?

It's a common assumption that an older population would have narrowing in their spinal canal or intervertebral foramen that may be contributing to extension or WB sensitivity. However, as with many pathoanatomical conditions, what their spine looks like on an x-ray or MRI does not correlate with their movement or level of function
Extension Rapid Responders will have
  • prolonged sitting makes them worse or
  • prolonged sitting makes the transition from sitting to standing painful
  • however, even though initial standing may be painful, after walking for a while, they straighten up and their symptoms get better
  • typically have better hip ROM, especially in IR and extension
  • lumbar spine is a rapid responder in ROM, hips may be rapid or slower in responding
Flexion Rapid Responders
  • prolonged sitting makes their symptoms better
  • static standing and walking are both painful and relieved by sitting or bending
  • typically have a loss of hip extension, thoracic extension, and their lumbar spines may have increased anterior tilt
  • standing "upright" still has minimal hip flexion instead of neutral, and tend to walk hunched
  • hips and thoracic spine are probably slow responders for ROM
The variability in how these two hypothetical cases are throughout the day plus their structure adds up in summation what their CNS responds to as novel. In the first case, since they are able to get upright, it is prolonged flexion and repetitive flexion that is the norm, so extension ends up being the directional preference. They are able to obtain extension because they have it, like many rapid responders.

In the second case, despite being flexed in standing and walking, the hip flexion keeps them in an anterior pelvic tilt during many WB ADLs. This is continously giving an input of loading or extension to the CNS, so extension and WB become sensitized. They most likely respond to flexion as a directional preference but it is difficult to obtain because of an tendency for anterior pelvic tilt and slower responding hips, lumbar, and thoracic spines.

Hope this clears up some of the differences!

Keeping it Eclectic...


  1. Unrelated, but you answered my question last time so I'll try here with another question. Since reading pain science related information I now have the question, what is the indication for lumbar/ cervical surgery at the radio graphic level. Do these Dr.'s simply say we tried a few things and it didn't work so therefore lets fuse it. Is there anything I can read as far as what is a good surgical indication for degenerative back and neck pain. I understand worsening radicular symptoms, bowel bladder, and muscle atrophy would be one, but I am more so asking about the gray area where they just have a lot of pain and have tried various resources with minimal results.

    Again thanks for all you do! Always look forward to your posts.

  2. That's not clear to any of us. Depends on the doc, check out Tim Flynn's research that correlates some spinal fusion with geography.