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:
- the lack of hip extension creates a larger extension moment at the lumbar spine in WB which typically increases their complaints
- psoas release
- QL release, especially for lateral stenosis
- prone knee bend anterior glide
- IASTM to ITB, rectus femoris
- 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
- IASTM/FR to ITB, lateral hamstring/gluteal junctional area
- hip long axis distraction, mobilization with movement hip IR with the belt ala Mulligan
- improving thoracic extension = less lumbar extension = less closing moments at the lumbar spine
- IASTM to the paraspinals, general P/As, nothing special here
- 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
- 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.
- 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.