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...