Lumbar Spinal Stenosis Courtney Clark, PT, DPT, Cert. DN, Cert. MDT Ivan Luna, PT, OCS, COMT, Cert DN Raul Ramirez, SPT Lumbar Spinal Stenosis https://images.medicinenet.com/images/appictures/sciatica-s2-sciatic-nerve.jpg

What is Lumbar Spinal Stenosis (LSS)? Stenosis = Narrowing This narrowing can compress the spinal cord and nerves at the level of the lumbar vertebrae. https://orthoinfo.aaos.org/globalassets/figures/a00053f01.jpg

Causes Bony overgrowth Herniated disks Thickened ligaments Tumors Spinal injuries Age > 50 Congenital spinal diseases https://www.spineuniverse.com/sites/default/files/legacy-images/vert_body-BB.jpg

Types of LSS Central Lateral Compression of part of spinal cord Compression of nerve roots exiting spinal cord Symptoms down both legs Symptoms typically down one leg (can be both) Worsens with lumbar extension Worsens with lumbar extension + side bending towards side of symptoms Eases with lumbar flexion Eases with lumbar flexion + side bending away from side of symptoms http://www.moveforwardpt.com/image.axd?id=cca2ef37-4e71-4afd-b75c-f761b11e97a9&t=634559298499830000

Symptoms Pain that begins in low back and can travel down the hip  backside of leg Numbness and/or tingling on leg or foot Weakness in leg or foot Positions of comfort: Bending forward Sitting Positions of discomfort: Bending backward Walking https://neupsykey.com/wp-content/uploads/2017/03/9781604060980_c017_f002.jpg

Diagnosis Imaging X-ray MRI CT scan Ultrasound Myelography Physical Examination History Symptom characteristics Movement exam Sensory-motor testing Walking analysis https://www.painmanagementsanantonio.com/wp-content/uploads/2013/10/stenosis6.png\ http://www.myrehabetc.com/wp-content/uploads/2014/11/Lower-Back-Exam2.jpg

Treatment Physical Therapy Patient education Manual therapy Aerobic training & exercise Medical Management Physical therapy Pain medications Epidural steroid injection Decompression surgery http://brooksidept.com/wp-content/uploads/2013/04/Orthopedic-Manual-Therapy-300x218.jpg http://www.fablabconnect.com/wp-content/uploads/2015/09/iStock_000008768191_Large.jpg

Physical Therapy – Education Definition of LSS Intent of treatment (next slides) Self management strategies Positions of comfort, pacing of activities, frequently change positions Home exercise program Natural course of condition: The majority of people with LLS do quite well over time Their condition either remains the same of improves over time Physical Therapy – Education

Physical Therapy – Manual Therapy Hands-on therapy aimed at improving joint mobility, tissue flexibility, & upright walking Techniques are applied based on patient impairment Typically focused on lumbar and thoracic regions, hips, pelvis, & lower extremities VS Thoracic spine extension and hip extension techniques are employed to provide more upright ambulation while preserving flexion bias of lumbar spine which brings pt relief -Whitman study – Manual therapy, flexion and impairment-based exercises, & BWS treadmill > flexion exercises, treadmill walking and sub-therapeutic US -Thrust & non-thrust mobilization/manipulation to lumbar and pelvic regions -Normalization of hip motion appears key for successful treatment – distraction mob/manipulation (valuable intervention technique for restoration of motion and function [Hoeksma et al]), hip ant glide mob + manual stretch of psoas & RF ---Also improvement of knee ext and ankle DF The choice of a particular procedure appears less important than the introduction of movement in these areas through manual techniques.

Examples of Manual Techniques Rotational lumbar manipulation Hip lateral glide mobilization Hip flexor stretch Hip distraction Examples of Manual Techniques

Examples of Manual Techniquesof Manual Techniques Hip inferior glide mobilization Thoracic manipulation Hip posterior-anterior mobilization Translatory lumbar manipulation

2D and 3D Axial Separation in Flexion

Aerobic training and exercise Improve overall fitness and function, induce vascular changes for improved blood flow to tissues, and self- management Unweighted treadmill walking Spinal mobility & lumbar flexion exercises Thoracic extension and lumbar rotation exercises Hip mobility and flexibility exercises Self-stretching Core and lower extremity strengthening Encouraging a walking program is theoretically helpful for Improving CV fitness allowing the pt to immediately use any gains in mobility and strength Decrease fear avoidance issues related to walking Improved pain modulation through stimulation of large motor pathways

Examples of Exercises Double knee to chest Thoracic self-extension Pts are unweighted to extent that pain is relieved so they may walk with good quality movement and pain-free ideally for 30 min Amount of unweighting is lessened over time. Researcher’s experience – pts have a fairly dramatic response to unweighting within the first couple of sessions for aerobic exercise Alternate – cycling, walk on inclined TM, pool walking Unweighted treadmill walking Rectus femoris self-stretch Hip abduction strengthening

Examples of Exercises Lower abdominal strengthening Single knee to chest Iliopsoas self-stretch Lumbar rotation stretch

Medical Management Epidural steroid injections Found to have some benefit in symptoms Complications – may increase low back or leg pain, headaches Surgery Long-term results do not differ from results of conservative care May be of benefit when symptoms are intractable Atlas et al – surgical group fared better in short term, ther wasn’t significant difference between the surgery and non-operative groups of patients over long term. Deyo et al – trend in surgery has risen dramatically with use of complex fusion surgerise with corresponding rise in life-threatening adverse events, length of stay, re-hospitalization, costs, and mortality 20% of those undergoing complex procedures have slow recoveries requiring discharge to skilled nursing facilities https://www.healthline.com/hlcmsresource/images/News/general-health/042017_surgeryopioid_THUMB_LARGE.jpg