Three-step treadmill test and McKenzie mechanical diagnosis and therapy to establish directional preference in a patient with lumbar spinal stenosis: a case report.

BACKGROUND: Lumbar spinal stenosis (LSS) is defined as narrowing of the spinal canal. LSS is commonly treated conservatively, primarily with flexion-based exercises. We present a patient diagnosed with LSS, refractory to a flexion-based protocol who ultimately responded to an extension-based protocol following establishment of directional preference with three-step treadmill testing. DESCRIPTION: A 64-year-old male was diagnosed with LSS with a 2-year history of bilateral neurogenic claudication unresponsive to flexion-based exercises. Initially, distinct directional preference or centralization was not demonstrated on repetitive movement testing. Ultimately, preference towards extension was established through a three-step treadmill test. An extension-based treatment plan was recommended, which provided significant relief despite focusing on exercises that are commonly avoided during traditional treatment for LSS. OUTCOMES: He began to centralize pain to his lower back after 2 weeks and denied neurogenic claudication on repeat three-step treadmill test at 3 weeks. His drastic improvements in pain levels and functional status continued throughout four sessions. DISCUSSION: Although the patient's initial diagnostic label may bias towards a spinal flexion protocol, further mechanical testing revealed an extension directional preference. The three-step treadmill test was crucial in establishing his directional preference and guiding his treatment. Treadmill testing may be useful in a subset of patients who do not demonstrate distinct directional preferences on mechanical testing.