1. Lumbar Spinal Stenosis
Courtney Clark, PT, DPT, Cert. DN, Cert. MDT
Ivan Luna, PT, OCS, COMT, Cert DN
Raul Ramirez, SPT
Lumbar Spinal Stenosis

2. What is Lumbar Spinal Stenosis (LSS)?
Stenosis = Narrowing This narrowing can compress the spinal cord and nerves at the level of the lumbar vertebrae.

3. Causes Bony overgrowth Herniated disks Thickened ligaments Tumors
Spinal injuries
Age > 50
Congenital spinal diseases

4. 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

5. 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

6. Diagnosis Imaging X-ray MRI CT scan Ultrasound Myelography
Physical Examination
History
Symptom characteristics
Movement exam
Sensory-motor testing
Walking analysis

7. Treatment Physical Therapy Patient education Manual therapy
Aerobic training & exercise
Medical Management
Physical therapy
Pain medications
Epidural steroid injection
Decompression surgery

8. 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

9. 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.

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

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

12. 2D and 3D Axial Separation in Flexion

13. 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

14. 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

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

16. 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