Effective Treatments for Textbook Lumbar Stenosis | Modern Manual Therapy Blog

Effective Treatments for Textbook Lumbar Stenosis


Here are my go-to treatments for patients who have a textbook presentation of lumbar stenosis.

The ironic thing about stenosis is that patients need to walk forward bent to open up their spinal canal. This leads to a cascade of musculoskeletal changes that enchances their dysfunction and makes it harder for them to walk and perform upright ADLs.

Areas to focus on:
Hip Extension

  • the lack of hip extension creates a larger extension moment at the lumbar spine in WB which typically increases their complaints
  • treatments
    • psoas release
    • QL release, especially for lateral stenosis
    • prone knee bend anterior glide
    • IASTM to ITB, rectus femoris
Hip IR
  • I find many of my older population not only have a lack of hip IR, they often have 0 degrees or less
  • any WB movement would place increased stress on the lumbar spine, especially activities like golfing or tennis
  • treatments
    • IASTM/FR to ITB, lateral hamstring/gluteal junctional area
    • hip long axis distraction, mobilization with movement hip IR with the belt ala Mulligan
Thoracic extension
  • improving thoracic extension = less lumbar extension = less closing moments at the lumbar spine
  • IASTM to the paraspinals, general P/As, nothing special here
Neurodynamics
  • treating the neural container often increases lumbar and LE mobility
  • start with sciatic tensioners and progress to slump sliders/tensioners if needed
  • femoral nerve tensioners/sliders if there is anterior or anterolateral thigh complaints or significant limits to hip extension
Patient Education
  • educate on how research shows long term outcomes for surgery and injections show no lasting effects for leg complaints or walking tolerance
  • meds and injections normally just mask the complaints vs treating the cause and improving function through improving movement quality and quantity
  • decrease any anxiety by telling them when their lower back or LEs feel fine, their spine still has those "kisses of time" on the MRI
  • graded exercise with progressive longer periods of walking upright
  • general conditioning and exercise certainly does not hurt either
  • give them education on other options if therapy is not working
Patient ther ex
  • M's for repeated hip IR - one of my favorites!
  • self sciatic and femoral tensioners
  • glut strengthening as there is often atrophy of the gluteals from a lack of hip extension
  • bilateral lumbar rotation/gapping rotation with LEs over a theraball
I find the above treatments/education often works well, sometimes to increase function, others to completely abolish pain. This is by no means a cookbook for success on an often difficult caseload, with patients who have never exercised before, have poor body awareness, and just want a fix.

Timeframe
  • if you restore mobility to the affected joints, nervous system and surrounding tissues, and function and/or symptoms do not improve within 6-8 weeks, you are probably beating a dead horse so time to consider other options
It was the most heart breaking patient case ever, when I applied everything I could think of to my own father, who had progressively worsening LE weakness and paraesthesia that really affected his walking. I held it off for a few years, especially if he would visit for longer periods of time. 

He went to the Philippines for a few months and stopped doing his exercises and of course did not bring his home traction unit (which actually helped, one of the only ones I have used on a patient!). When he came back, there was nothing I could do to make the LE complaints stay away, and his walking worsened. The bottom line is, I gave it my best shot and he ended having about 80% improvement in function and Sx reduction with minimally invasive spinal surgery. The only thing I recommended. I have not done enough research on it, but I am glad he listened to me, and did not go with a laminectomy or fusion like most of the surgeons he had seen had suggested. He can now walk, golf, and lift his grandkids! I still do maintenance manual work and neurodynamics on him, because it also always makes him feel better.

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