What is Lumbar Spinal Stenosis?

Lumbar spinal stenosis is a condition where there is bony narrowing of the spinal canal or intervertebral foramen. This narrowing leads to decrease space for the neurovascular bundle, which may lead to symptoms of weakness in the lower limb(s) by putting pressure on the nerves that supply them. Other symptoms include tingling, numbness or pain in the lower limbs. It should be known that although signs of spinal stenosis may appear on diagnostic imaging (such as x-rays), that symptoms will not always be present.

Natural History of Lumbar Stenosis

Natural history refers to the natural progression of a condition if no treatment were to be rendered by a health care practitioner. The number of studies examining the natural history of lumbar stenosis are few and far in between, with one study by Johnsson et al reporting that 19 of their 27 subjects with moderate untreated spinal stenosis showed no changes after 4 years of observation. They also observed that 4 patients had shown an improvement, and 4 patients had progressed without serious sequelae.

In the short term (1-4 years) surgical outcomes were better than conservative management, however, long term (10 years follow up) had shown no significant difference between the two groups for lower back pain, but the surgical group had better outcomes for radicular pain. 

Conservative Treatments vs Surgery for Spinal Stenosis

Symptoms of spinal stenosis tend to respond well to non-invasive plan of managements and is recommended for initial treatment for those with mild-moderate pain. Two phases of conservative treatment have been identified, the first phase is pain reduction with passive modalities, the second phase is formal functional physical therapy (a.k.a. exercise rehabilitation).

Conservative management include NSAIDS, acetaminophen, muscle relaxants, exercise program, aerobic exercise, and epidural steroid injections, with 50% with pain have relief after 3 months.  Acupuncture, hot packs, ultrasound, TENS, and traction, and chiropractic treatment may also be included into conservative treatment with chiropractic manipulation showing to be the most effective at relieving posture-dependent symptoms.

Operative treatment is indicated for those with severe pain, constant neurological symptoms, and those who have failed to benefit from conservative treatment. Between operative treatment and conservative management, 60-90% of patients with lumbar stenosis will receive relief of their symptoms. Due to degenerative arthritic changes however, back pain may still exist.

Physical Therapy for Lumbar Stenosis

Physical therapy includes 4 approaches for the management of lumbar stenosis, they include education, manual therapy, exercise, and aerobic training. Patient education is composed of prognosis, natural history, self-management, home exercise programing, intent of therapy, and pain sciences information. Advice may include avoiding prolonged overhead activities, avoidance of prolonged axial loading, stretching techniques in standing, sitting, or lying positions, frequent postural changes, current limit identification, and activity pacing. 

Manual Therapy for Lumbar Stenosis

Manual therapy combined with exercise therapy was found to be effective for pain and disability in those suffering from lumbar spinal stenosis (LSS). Techniques included in manual therapy include joint mobilizations and joint manipulations. Studies examined in a review had seen benefits from manual therapy despite differences in treatment plans across different randomized controlled trials. Studies with successful results performed either flexion-distraction manipulations, sidelying lumbar rotation thrust, posterior-to-anterior mobilizations, thoracic thrusts, side lying translatoric side bending manipulation, and neural mobilizations.

Flexion-distraction manipulation has shown to decrease the severity and frequency of leg pain, to the point where there may be resolution of leg pain. Manual therapy may also be applied to the thoracic region, pelvis, hips, and lower extremities. It was also identified that normalization of hip motion is important for patients with LSS. Techniques such as hip distraction manipulation, anterior and inferior glide mobilization, postero-lateral and caudal glide mobilizations, and manual stretching of the iliopsoas and rectus femoris were effective at giving patients benefits. 

Who Can Do Manual Therapy for Lumbar Stenosis?

Manual therapy in the form of joint mobilizations can be applied by your massage therapist, physiotherapist, chiropractor or osteopathic manual practitioner. Joint mobilizations aim to restore normal kinematic motion in a joint or set of adjacent joints. Joint manipulations (also know as adjustments) can be applied by your chiropractor and some certified physiotherapists. To book in with a Rehab Hero clinician click the button below:

Exercises For Lumbar Stenosis

Aerobic training is beneficial for both LSS and neurogenic claudication. Exercise may include unweighted walking (parachute strap) or cycling, spinal mobility and flexion exercises, hip mobility exercises, hip strengthening, and core strengthening. Unweighted exercise involves unweighting until pain or symptoms are relieved, and then ambulating with quality movements for 30 minutes. As the patient progresses, the amount weight reduction is reduced slowly. If patient response does not occur within the first couple of sessions, it is recommended to switch to cycling, inclined treadmill walking, or pool walking.

Self-relieving exercises include stretching techniques, hip extension exercises (stretching the hip flexors), thoracic extension, lumbar flexion, and lumbar rotation, with side-lying lumbar rotation exercise being very effective at relieving lower limb symptoms. It is also hypothesized that thoracic and hip extension exercises should relieve the burden of extension that may be loaded unto the lumbar spine. 

An example of a hip extension exercise that also aims to flex the lumbar spine (to distract the lumbar facet joints) is the Split Squat Pelvic Tilt exercise:

An example of a thoracic extension exercise is the Kneeling Thoracic Extension exercise:

An example of a side-lying lumbar rotation exercise is the Xbox Stretch exercise:

For additional exercises specific to your experiences and symptoms it is recommended to consult your health care team. Exercises can be prescribed by your sports physiotherapist, massage therapist or chiropractor. To book in with a Rehab Hero therapist click the button below:

References

1. Lee S, Kim T, Oh J, Lee S, Park M. Lumbar Stenosis: A Recent Update by Review of Literature. Asian Spine Journal [serial on the Internet]. (2015, Oct), [cited November 8, 2017]; 9(5): 818-828. Available from: MEDLINE with Full Text.

2. Backstrom K, Whitman J, Flynn T. Masterclass: Lumbar spinal stenosis-diagnosis and management of the aging spine. Manual Therapy [serial on the Internet]. (2011, Jan 1), [cited November 8, 2017]; 16308-317. Available from: ScienceDirect.

3. Yuan P, Albert T. Nonsurgical and Surgical Management of Lumbar Spinal Stenosis. Journal Of Bone & Joint Surgery, American Volume [serial on the Internet]. (2004, Oct), [cited November 8, 2017]; 86(10): 2320-2330. Available from: SPORTDiscus with Full Text.

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