Delve into Lumbar Spinal Stenosis (LSS), prevalent in those over 65. LSS results from the narrowing of the spinal canal or its recesses, leading to compression of the spine's neurovascular structures (1). Furthermore, LSS poses a significant societal challenge, ranking above conditions like congestive heart failure or COPD in causing disability in the aging population (2,9).
The good news is LSS often responds well to exercise and manual therapy. While some cases necessitate surgery, many can be managed non-invasively. Given its slow progression, there's time for effective treatment, paving the way for better control over LSS.
Article Index
Introduction
Examination & Diagnosis
Treatment
Exercise & General Recommendations
Conclusion & References
Symptoms of Lumbar Spinal Stenosis (LSS)
Lumbar Spinal Stenosis can be a chameleon, its symptoms changing and varying based on the condition's severity. Here's what to look out for: (3,9)
Lower Back, Buttock, or Leg Discomfort: This can range from a dull ache to a sharp pain, refusing to leave your side.
Weakness or Cramping in the Legs: Either unilateral (one side) or bilateral (both sides), this symptom is typically the handiwork of neurogenic claudication, which originates from the nervous system.
Difficulty Standing Up Straight or Standing Prolonged: A straight posture becomes a challenge, and standing for extended periods feels like running a marathon.
Decreased Pain When Bending Forward: A paradoxical symptom, the 'shopping cart sign', where bending forward in a flexed position, usually uncomfortable with ordinary back pain, actually provides some relief.
Impaired Balance: Like walking on a tightrope, maintaining balance becomes an arduous task.
Sitting Reduces Back Pain: Unlike ordinary back pain which intensifies with sitting, Lumbar Spinal Stenosis kindly dials down the discomfort when you take a seat.
Increased Back or Leg Pain with Standing: Stand up, and the pain levels rise, another departure from ordinary back pain which usually subsides upon standing.
Increased Leg Strength When Sitting or Lying Down: A surprising boost in leg strength with a change in position, a phenomenon you won't experience with regular back pain.
Red Flag - Loss of Bladder or Bowel Control: If you notice this, it's an urgent sign to consult your medical practitioner immediately. This symptom is a bright red flag waving for immediate attention
Unraveling the Causes of Lumbar Spinal Stenosis (LSS)
Lumbar Spinal Stenosis is a fascinating puzzle, with pieces like osteoarthritis, spinal disc damage, ligament thickening, inflammation, and even congenital factors fitting together to complete the picture. (4)
Spondylosis: Osteoarthritis of the spine can initiate disc and joint degeneration and spur bone growth. As these changes intensify, the spinal canal contracts, compressing the spinal cord and nerve roots, and leading to pain. However, strengthening spinal muscles can help slow down this process.
Spinal Disc Damage: Aging and injury can stiffen our once supple spinal discs, leading to neurovascular compression. The solution? Regular exercise to boost disc hydration, enhance shock absorption and maintain disc health.
Ligament Thickening: Healthy ligaments stretch and retract easily, but when they lose their elasticity, they contribute to Lumbar Spinal Stenosis. Maintaining a healthy lifestyle can promote ligament health and prevent this condition.
Inflammation: Swelling due to inflammation can restrict movement and make ligaments thicker and less elastic, upping the risk of Lumbar Spinal Stenosis.
Congenital Factors: A naturally narrower spinal canal can predispose individuals to spinal stenosis.
By understanding these factors, we can better navigate Lumbar Spinal Stenosis and develop effective strategies to combat this condition.
Detective Work: Diagnosing Lumbar Spinal Stenosis (LSS)
Hunting down the cause of back pain is no small task, and diagnosing Lumbar Spinal Stenosis is a mission that usually involves the trinity of physical examination, medical history, and imaging tests.
During the physical exam, your healthcare provider will turn detective, probing about your symptoms and conducting a neurological examination to evaluate your leg reflexes, strength, and sensation. The objective? To gather as much evidence as possible.
To supplement these clues, your healthcare provider may order imaging tests like X-rays, MRIs, or CT scans, offering a detailed glimpse into the architecture of your spine and potentially confirming the presence of Lumbar Spinal Stenosis. In certain cases, nerve conduction studies or electromyography (EMG) might be used to further evaluate the state of your nerves and muscles.
The International Delphi study has given us a valuable checklist of 7 diagnostic questions to help identify Lumbar Spinal Stenosis. (5,9)
Do leg or buttock pain accompany walking?
Does bending forward alleviate symptoms?
Does pain decrease when using a shopping cart or bicycle?
Are there any motor or sensory disturbances while walking?
Are the foot 'pulses' present and symmetric?
Is there lower extremity weakness?
Does the patient experience low back pain?
Deciphering Lumbar Spinal Stenosis: The Differential Diagnosis
Identifying Lumbar Spinal Stenosis isn't just about recognizing its presence, but also differentiating it from conditions with similar symptoms, such as Osteoarthritis, Herniated Disc, Trochanteric Bursitis, Peripheral Neuropathy, or Vascular Claudication. (6,9)
Hip Osteoarthritis (OA): Symptoms of Lumbar Spinal Stenosis and Hip OA can overlap significantly, as OA also presents with gluteal, groin, lateral hip, and leg pain when weight-bearing. OA can cause cartilage breakdown in the spine's joints, leading to bone spurs and narrowing of the spinal canal. Both conditions can even occur simultaneously, adding to the complexity.
Herniated Disc: This happens when a spinal disc's soft inner material pushes through the outer layer and presses on a nerve, leading to back and leg pain and numbness.
Trochanteric Bursitis: Here, the patient often experiences lateral leg pain, which increases when lying on the affected side—a symptom not associated with Lumbar Spinal Stenosis, thus providing a distinguishing factor.
Peripheral Neuropathy: This condition involves damage to the peripheral nerves, resulting in leg and feet pain, numbness, and weakness.
Vascular Claudication: Caused by Peripheral Arterial Disease (PAD), this condition is marked by leg pain due to decreased blood flow. Similar to Lumbar Spinal Stenosis, it causes increased pain with walking, which subsides with rest. But there's a twist—unlike Lumbar Spinal Stenosis, the pain from vascular claudication isn't relieved by forward flexion (the 'shopping cart sign') or cycling. This key difference helps in differentiating the two conditions.
As you can see, diagnosing Lumbar Spinal Stenosis is a fascinating journey of exploration, requiring careful evaluation, and a keen eye for detail.
Physical Examination
The video content below showcases some typical orthopedic and neurological examination techniques we employ to identify Lumbar Spinal Stenosis. Let's unravel the mystery of this condition together!
Low Back Examination - Effective Orthopaedic Testing - This video covers some common causes of low back pain and how to diagnose them using orthopedic examination procedures.
Hip Examination - Orthopaedic Testing This video goes through inspection and observation, palpation, Active and Passive Ranges of motion, and orthopedic examination of the Hip region.
Lower Limb Neuro Examination - The lower limb neurological examination is part of the overall neurological examination process. It assesses the motor and sensory neurons that supply the lower limbs.
Peripheral Vascular Examination - Key Points
A peripheral vascular examination is valuable for ruling out signs of vascular-related pathology. The detection and subsequent treatment of PVD can potentially mitigate cardiovascular and cerebrovascular complications. In this video, we review some common procedures we perform in daily clinical practice.
Unlocking the Treatment Path for Lumbar Spinal Stenosis
Lumbar Spinal Stenosis is commonly the cause for spinal surgeries among those over 65. But, it's crucial to remember that frequent doesn't necessarily mean first or inevitable.
Evidence leans towards a powerful pairing—manual therapy combined with exercise—as the initial line of defense. Even if surgery becomes a must, this dynamic duo can significantly enhance the results, both before and after the procedure.
Let's explore some of the manual therapy techniques for Lumbar Spinal Stenosis:
Spinal Mobilization: These are slow, rhythmic spine movements aimed at enhancing joint mobility and easing pain.
Soft Tissue Therapy: This involves manipulating soft tissues like muscles and ligaments to relieve tension and improve blood circulation.
Stretching: Your healthcare provider may guide you through specific stretches to boost flexibility and alleviate symptoms.
Myofascial Release: This method targets specific areas, applying pressure to alleviate tension and pain.
What's the outcome? A return to basics can yield dramatic improvements. Studies reveal that 33%-50% of patients with mild to moderate symptoms who receive traditional therapy report significant functional improvement. This includes reduced pain, enhanced daily function, and better walking ability. For some, this might just be enough to sidestep surgery entirely. (1, 7, 8,9)"
However, let's take a moment to reflect on what research does not endorse. Interestingly, the use of Tylenol, NSAIDs, opioids, neurogenic pain medications, muscle relaxants, and epidural steroidal injections aren't recommended for Lumbar Spinal Stenosis treatment. Despite this, these treatments often become the first line of defense. (9)
This doesn't imply that medication should be entirely discarded. If a patient is battling severe pain, experiencing sleep disturbances, or finding it impossible to exercise due to pain, medication can offer much-needed relief. But the ultimate goal remains the same—aid in sleep, enable the execution of prescribed exercises, and facilitate manual therapy. (1, 7, 8,9)
Manipulation & Mobilization
Spinal Manipulation or Mobilization can be highly beneficial for those struggling with Lumbar Spinal Stenosis. Consider the spine, from neck to lumbar, as a unified functional entity that requires optimal mobility for effective load distribution. When your neck and upper back are mobile, flexible, and robust, any action you perform distributes force across the entire spine.
For this reason, we suggest patients concentrate not only on the symptomatic area (lumbar spine) but also on any other regions of spinal tension. The following videos demonstrate examples of both manipulation and mobilization procedures. Each of these methods can be highly effective, and we tailor our suggestions and treatments according to the specific needs of each patient. (1)
Joint Mobilization - Lumbar Spine
Many aspects need to be addressed when eliminating low back pain. One of the key aspects is joint mobility. Basically, our capacity to produce an unlimited variety of movements requires good joint integrity. No joint ever works in isolation. An injury in one joint often results in bio-mechanical compensations in adjacent and distant joints.
Soft Tissue Therapy
The following videos are examples of common MSR procedures we often use with our Stenosis patients. The quality of your soft tissues will directly affect the level of pain experienced and your ability to function.
Lumbar and Thoracic Spine Fascial Release - In many cases, the thoracolumbar fascia can be an important key to resolving chronic low back pain. The Thoracolumbar Fascia [TLF] is a large region of connective tissue.
Resolve Chronic Low Back Pain - One of the structures that must be addressed is the deep paraspinal muscles. The Deep Para-Spinals (transversospinalis) muscles often atrophy in chronic low back pain cases.
Treatment Frequency Recommendations
When performing manual therapy for Lumbar Spinal Stenosis, some patients may experience initial relief or improvement within the first few weeks, especially in terms of pain. However, structural and functional changes, can take much longer and may require consistent therapy combined with exercises. The exact timeline for results can vary based on the severity of the condition, patient adherence to home exercises, and individual differences in healing. Regular assessments and feedback are essential to gauge progress and adjust the treatment plan as needed.
Initial Treatment Phase:
MSR Manual Therapy: 2 sessions per week for three weeks.
Home Exercises: Daily functional exercise programs as prescribed by the MSR practitioner.
Response Assessment:
Evaluate the patient's response to therapy during follow-up appointments, typically after three weeks of treatment.
Positive Response:
A positive response to manual therapy for the treatment of Lumbar Spinal Stenosis would be a noticeable reduction in pain and discomfort, coupled with improved function.
MSR Manual Therapy: Reduce to 1 session per week.
Home Exercises: Continue daily routines; adjust as necessary based on professional advice.
Persistent Symptoms:
MSR Manual Therapy: Maintain frequency of two weekly sessions, reassessing the treatment approach weekly.
Home Exercises: Re-evaluate and modify exercises under professional guidance, ensuring correct technique and adherence.
When performing manual therapy for Lumbar Spinal Stenosis, treatment should continue as long as there's an improvement in symptoms and function. If progress is noted and functional goals aren't yet met, ongoing therapy can be beneficial. If there are no noticeable results, only marginal improvements, or if progress plateaus, then treatment should be reconsidered or halted.
You should transition to maintenance care once the patient has achieved consistent symptom relief and optimal functional levels, ensuring that the achieved progress is sustained and potential recurrences are minimized. All decisions should be based on regular assessments and patient feedback.
Maintenance Phase:
MSR Manual Therapy: Monthly sessions or as needed.
Home Exercises: Daily routines to maintain benefits and prevent symptom recurrence, with periodic reviews by healthcare professionals.
When considering treatment for Lumbar Spinal Stenosis using MSR protocols, the primary focus is on achieving optimal results. The treatment plan is tailored, starting with six sessions in the initial phase. Based on the patient's response, sessions may be adjusted. The number of required visits is based on achieving the best possible outcome for the patient.
The Essential Role of Exercise
Studies indicate that individuals who maintain a regular exercise routine are less prone to spinal stenosis. Although it may seem counterproductive to exercise while experiencing pain, this is not the case.
Consider exercise as an anti-inflammatory strategy. Exercise enhances circulatory function, eliminates waste products, delivers oxygen to the site of injury, and helps in reducing pain levels. The equation is simple. The greater the inflammation, the higher the pain experienced. Therefore, reducing inflammation leads to a corresponding reduction in pain.
In addition to its anti-inflammatory effects, exercise renders ligaments and fascia more flexible, less stiff, and less likely to exert pressure on neurological structures. Furthermore, exercise decreases swelling, which in turn reduces the amount of neurovascular compression. (1)
Aerobic Exercise: The Heart of the Matter
Activities like walking, swimming, or cycling can enhance cardiovascular health and boost endurance, all while minimizing stress on the spine.
The crux of aerobic or cardiovascular exercise lies in increasing aerobic capacity, circulatory function, and energy production. By enhancing the density of capillaries in the muscles and upscaling mitochondrial function in cells, aerobic exercise aids in faster nutrient absorption for repair and more efficient waste product removal.
In the context of Lumbar Spinal Stenosis, aerobic exercise isn't just beneficial—it's essential. It could be the game-changer that tips the scales from constant pain to a symptom-free existence. (10)
Navigating Your Aerobic Zone Aerobic exercise should be performed within your aerobic zone, which is the optimal heart rate range for rehabilitation purposes.
To calculate your aerobic zone, follow these steps: (11)
Deduct your age from 220. For instance, if you're 40, the result would be 220 - 40 = 180.
Find the lower limit of your aerobic range by multiplying the result of step 1 by 0.6. In our example: 180 * 0.6 = 108.
Calculate the upper limit of your aerobic range by multiplying the result of step 1 by 0.7. In our example: 180 * 0.7 = 126. Your aerobic heart rate zone lies between these two numbers. This zone is pivotal for your recovery. Pushing beyond this zone may increase the risk of injury, while falling short of it may deprive you of maximum benefits.
We advise our patients to adopt a phased approach to aerobic exercise. In phase 1, aim for 5 to 10 minutes of aerobic exercise, 3 to 5 days per week (preferably cycling or swimming). In phase 2, scale up to 15 to 20 minutes of aerobic exercise, 4 to 7 days per week (again, cycling or swimming). In phase 3, target 30 to 60 minutes of aerobic exercise, 5 to 7 days per week (cycling or swimming).
Tip: Consider investing in a heart monitor/watch to keep track of your aerobic activity. Not only will you progress faster, but you'll also be better equipped to spot any potential cardiovascular issues.
Walking
Lumbar spinal stenosis can turn simple walking into a challenge riddled with discomfort. For many suffering from this condition, walking might not be the optimal form of exercise. Moreover, achieving your aerobic zone with walking could be a tall order; alternatives like biking and swimming could serve you better.
However, don't write off walking just yet! It's crucial to maintain your walking habit. Consider walking as a 'baseline test' to gradually extend your pain-free walking distance.
Walking, being a low-impact activity, can enhance cardiovascular health, augment endurance, and mitigate pain and other symptoms linked to Lumbar Spinal Stenosis in several cases.
A crucial point to remember: if your legs are weak, avoid pushing your limits with extended walking distances. Overstepping these boundaries could potentially exacerbate damage and weakness.
Daily Exercise Routine
The video below showcases a selection of exercises we typically recommend for those grappling with Lumbar Spinal Stenosis. You'll observe a significant emphasis on enhancing hip mobility. By cultivating hip mobility through targeted exercises and manual therapy, we can often strike a balance between a pain-free stride and extreme discomfort with each step.
5 Best Exercises For Spinal Stenosis
These are some common exercises we prescribe to patients suffering from Lumbar Spinal Stenosis.
General Recommendations
Alongside exercise and therapeutic interventions, incorporating the following strategies can help manage Lumbar Spinal Stenosis. These tactics primarily focus on avoiding pain triggers. It's important to note that activities that exacerbate lumbar spinal stenosis may result in lingering discomfort for several hours after the activity is completed.
Steering Clear of Activities That Induce Pain
Often, patients share how certain actions trigger their pain. However, they repeatedly engage in these activities, thereby worsening their condition and extending their pain duration. A prime example is the continuous effort to maintain an upright posture, which, for many with Lumbar Spinal Stenosis (LSS), is a significant pain inducer.
Individuals with LSS typically display a stooped, forward-bending posture. Despite the persistent discomfort, these patients frequently strive to stand up straight, which only further exacerbates their condition. I consistently advise my patients not to force an upright posture. Instead, I encourage them to straighten only when their inflammation and swelling have subsided, reducing pressure on the neurological structures and enabling a pain-free transition to an upright position. Forcing an upright posture amidst LSS can increase pressure on the spinal cord and diminish leg strength.
Extension Intolerance and LSS
Extension-intolerant Lumbar Spinal Stenosis is a subtype of LSS where symptoms like pain and numbness arise when the lower back is extended. This condition is more common in older adults, often resulting from degenerative changes in the spine. Patients with extension-intolerant LSS may find exercises and treatments that focus on forward bending (flexion) of the spine more beneficial than those involving extension.
The cornerstone of LSS recovery is avoiding any activity that necessitates backward bending, as this position narrows the foramina and reduces space in the spinal canal. For instance, reaching overhead to retrieve an item from a cupboard could instigate hours of pain.
Pro tip: It's advisable to reintroduce activities only when you can engage in them painlessly.
Use Braces, Canes and Walkers
Braces: A Supportive Aid for Lumbar Spinal Stenosis
Braces, akin to elastic corsets, can be highly beneficial for patients suffering from Lumbar Spinal Stenosis, particularly during symptom flare-ups. The brace restricts side-to-side bending and repetitive motion frequency, thereby reducing nerve root irritation, a potential source of radiating pain. In addition to aiding the patient in staying active while minimizing re-injury risks, braces can improve sleep quality by maintaining the spine in a neutral position.
Walking Aids: Temporary Support, Not a Permanent Crutch
Many patients hesitate to use walking aids such as walkers or canes, apprehensive about developing a dependency. However, this concern is largely unfounded. A temporary need does not equate to permanent reliance.
Utilizing a walker or cane during severe symptom flare-ups or for a few days could significantly alleviate pain. Moreover, using these aids early in the morning or late at night could prevent falls and potential hip or spinal fractures. Once you regain your strength and feel better, you can set aside the walker or cane.
Optimizing Sleep Positions for Lumbar Spinal Stenosis
Achieving a restful sleep when suffering from Lumbar Spinal Stenosis could be aided by choosing the right sleeping position to minimize pain and enhance sleep quality. Here are some recommended positions:
Side sleeping with a knee-supporting pillow: Aligning the spine and relieving lower back stress can be achieved by sleeping on your side with a pillow nestled between your knees.
Back sleeping with a knee-supporting pillow: This can alleviate lower back pressure and encourage proper spinal alignment.
Reclined sleeping: This position can lessen lower back pressure and can be especially beneficial for those who experience discomfort when lying flat.
Sleeping on the stomach should be avoided as it can intensify lower back stress and exacerbate Lumbar Spinal Stenosis symptoms.
Conclusion: Navigating Lumbar Spinal Stenosis
Lumbar Spinal Stenosis, an often debilitating condition, can significantly impact an individual's quality of life. However, understanding its underlying causes, recognizing symptoms, and adopting effective management strategies can dramatically change the course of the condition.
While surgery may seem like a quick fix, it is not always the best or only solution. An integrative approach, harnessing the power of manual therapy, targeted exercise, and strategic lifestyle changes, can alleviate symptoms and improve daily function. Remember, patient participation is crucial - it's about embracing a proactive role in your health journey.
The journey with Lumbar Spinal Stenosis may be challenging, but it is not insurmountable. With the right tools, knowledge, and guidance, you can navigate this path and reclaim your life. As you venture forward, keep in mind that every step you take towards better health is a victory, no matter how small it may seem. Here's to your strength, resilience, and the journey ahead!
DR. BRIAN ABELSON DC. - The Author
Dr. Abelson's approach in musculoskeletal health care reflects a deep commitment to evidence-based practices and continuous learning. In his work at Kinetic Health in Calgary, Alberta, he focuses on integrating the latest research with a compassionate understanding of each patient's unique needs. As the developer of the Motion Specific Release (MSR) Treatment Systems, he views his role as both a practitioner and an educator, dedicated to sharing knowledge and techniques that can benefit the wider healthcare community. His ongoing efforts in teaching and practice aim to contribute positively to the field of musculoskeletal health, with a constant emphasis on patient-centered care and the collective advancement of treatment methods.
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