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
- 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
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...