patient with disc bulge and spinal stenosis at L3-L4, L4-L5, L5-S1, spondylolithesis of L4 on L5

[nmarman]

Doing any extension exercise would be mad in my book there is clearly no mechanical advantage to this in a patient with stenosis. You need to make the foramina gap (flexion) not close (extension). Remember why this condition happened the disc bulged, then losest height, then caused rubbing of the facets; which went through a defensive osteophytic formation to stabilise.
By entering the facets you will make them worse!!! Before you make them better. By using flexion distraction method you should see results by forth treatment. This can also be by hunching them over a pillowed stool and genteelly pushing cephalad aspect of the spinous processes individually into flexion.
Also get them to sleep in fetal position at night. Assuming that offers relief - does it?

One thing of note from your discription: is pain when they bend forward is it when sitting, standing that cause pain?

Is it due to muscle spasm. Very likely to happen in a failed spine like this.
Or is it due to facet capsule aggravation very common to happen in grade 1 spondy.
Or is it just nerve tension.

Grade one spondylolisthesis is stable if that helps.

[GrantP]

agree no extensions as likely to make matters worse. especially given worse with walking (extension) and better in sitting (flexion). give flexion exercises to gap and open foramen to rleive nerve irritation, try some gentle neural flossing/gliding work, either in supine, or sitting to decrease the neural sensitivity. active support with core+++ in neutral. teach to maintain neutral. consider biomechanics at foot, either orthotic, barefoot science product etc. agree sometimes passive support necessary also in short term to relieve neural sensitivity.
if all fails surgical opinion to stabilise

good luck

[bluebear]

I didn't see a description of osteophyte formation or severe degeneration of the facets on what was described on CT.

The last two posts reaction to my suggesting extension has validity in that yes, it will close the foramen, however, they are clearly ignoring your description of pain with sitting too long and bending.

To me this suggests that, yes while the disc is likely compromised by the persons age, it is possibly still behaving dynamically, and indeed flexion, as described by your history, is an aggravating factor and could in all reality make him worse too.

I am not suggesting, as you may be picturing, a full prone McKenzie extension.

Just lay him prone. If things ease a little, then bring him into less than 5 deg extension. If the stenosis is still being contributed too by a dynamically acting disc this position will be tolerated, if, as suggested there is gross degenration then it won't be toleratedand of course you would cease.

To those that so strongly argue for flexion, in light of bending and sitting being aggravating factors, why would you only treat the stenosis and ignore its underlying cause?

[GrantP]

bluebear, you may be right, with limited extension being ok, but i would only stabilise in neutral. from my experience anyway, extensions may help if it is hydrated disc, but then you need force to 'reduce' any disc bulge, ie mckenzies. otherwise all you are doing is gradually improving an extension dysfunction. also with spondy extension tends to make it worse, regardless of any osteophyte or other degeneration, which there is likely to be anyway, as it exagerates the slip, further closing the foramen and irritating the nerve. there are other causes of pain with prolonged sitting than a disc, postural overload, muscular-ligamanetous tension etc which would be better suited to advice to avoid prolonged sitting rather than to do extensions. my opinion anyway and difficult without patient to assess and try out on

[bluebear]

These are difficult to treat, and you quite rightly point out other possible causes of pain in flexion and prolonged sitting.

The limited amount of extension I am proposing, unless the spondy was advanced, would cause minimal impact, and may just provide some relief.

I agree on the stabilisation front, but by the sounds of it that has been tried.

Good luck Pad, let us know how you get on.
BB