title: Three-step treadmill test and McKenzie mechanical diagnosis and therapy to establish directional preference in a patient with lumbar spinal stenosis: a case report.
abstract: 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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: The GW Spine & Pain Center, The George Washington University Hospital, Washington DC.
authors.forename: G
authors.initials: G
authors.lastname: Padmanabhan
authors.forename: A
authors.initials: A
authors.lastname: Sambasivan
authors.forename: M J
authors.initials: MJ
authors.lastname: Desai