Transcript

When a patient tells me, “I can't stand up straight anymore,” I don't start with the X-ray. I start by watching them stand and walk.

Your body wants to keep your head stacked over your pelvis and your feet. When the lower back loses its natural inward curve, the upper body drifts forward.

So the body fights back. It tilts the pelvis backward, straightens the upper back, and, when those run out, bends the knees. That works for a while, but it takes muscle effort all day. That's why many people feel fine in the morning and exhausted after standing for an hour.

I also look at the hips. A stiff, arthritic hip can't extend enough to help, so hip pain and back pain often come together. Treating only one can miss the real problem.

That's why I order a standing X-ray from head to feet. It shows me the curve, and it shows me how hard your body is working to hold you upright.

Sometimes the answer is therapy. Sometimes it's the hip first. Sometimes it's rebuilding the spine's alignment. The first step is understanding why you're leaning.

Why do I lean forward when I walk?

Spinal imbalance (loss of lumbar curve)

As discs wear, the lower back can lose its inward curve. The trunk then drifts forward over the hips. Up to 60% of older adults have some form of adult spinal deformity. To stay upright, the body tilts the pelvis back and bends the knees. Those adjustments burn energy and cause fatigue, back pain, and short walking distances. See Flatback syndrome.

Spinal stenosis

With spinal stenosis, leaning forward opens up the spinal canal and relieves leg pain. People often feel better leaning on a shopping cart or sitting down. Their legs may feel heavy, numb, or painful after walking a short distance.

Parkinson's disease (camptocormia)

Some people with Parkinson's develop a severe forward bend of the trunk while standing or walking, called camptocormia. It affects roughly 3–18% of people with Parkinson's. A key clue is that the bend straightens out when the person lies down or leans against a wall.

Other causes

Weak back-extensor muscles: from muscle disease, aging-related muscle loss, or nerve conditions
Osteoporosis fractures: collapsed vertebrae that create a fixed rounded back
Normal-pressure hydrocephalus: a "magnetic," shuffling walk combined with memory problems and bladder urgency

A helpful clue: does it straighten when you lie flat?

A bend that disappears when you lie down points toward a muscle or nerve cause, such as Parkinson's or a myopathy. A bend that stays points toward a structural spine problem, such as fractures or degenerative deformity.

How is the cause found?

The evaluation usually includes:

A full-length standing X-ray that shows the spine, pelvis, hips, and knees in one image. Dr. Diebo's global sagittal axis measures whole-body posture from the knees to the neck. It correlates with patients' disability scores more closely than many standard measurements.
A neurological exam, with neurology referral if Parkinson's or a muscle disease is suspected
Bone density testing when fractures are possible

How is it treated?

Treatment depends on the cause. It may include physical therapy and strengthening, medication adjustment for Parkinson's, treatment of osteoporosis, decompression for stenosis, or surgical realignment for fixed spinal imbalance.

Get care urgently for:

Sudden leg weakness
Loss of bladder or bowel control
New numbness in the groin
A fall with new back pain

When to see a specialist. If you or a family member is bending forward more each year, request an appointment.

Sources

Diebo, Bassel G., et al. "Global Sagittal Axis: A Step Toward Full-Body Assessment of Sagittal Plane Deformity in the Human Body." Journal of Neurosurgery: Spine, 2016. PMID 27203811.
Diebo, Bassel G., et al. "Recruitment of Compensatory Mechanisms in Sagittal Spinal Malalignment Is Age and Regional Deformity Dependent." Spine, vol. 40, no. 9, 2015, pp. 642–649. PMID 25705962.
Srivanitchapoom, P., and M. Hallett. "Camptocormia in Parkinson's Disease: Definition, Epidemiology, Pathogenesis and Treatment Modalities." Journal of Neurology, Neurosurgery & Psychiatry, 2016. †

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