Functional rehabilitation for degenerative lumbar spinal stenosis

Abstract

Nonoperative treatment for lumbar spinal stenosis must address anatomic and biomechanical factors. The entire functional kinetic chain and patient specific goals must be considered. In addition to passive modalities, manual therapy, and patient education, an active program consisting of flexion-based lumbar stabilization exercises, hip mobilization, proprioceptive training, and general conditioning should be initiated. More studies are needed to establish the benefit of a comprehensive, multifaceted treatment approach and to prove its clear benefit over the natural history of lumbar spinal stenosis.

Full text

Functional rehabilitation for
degenerative lumbar spinal stenosis
Joshua D. Rittenberg, MD
a,b,
*, Amy E. Ross, MPT
a
a
Center for Spine, Sports, and Occupational Rehabilitation,
Rehabilitation Institute of Chicago, 1030 North Clark Street,
Suite 500, Chicago, IL 60610, USA
b
Department of Physical Medicine and Rehabilitation,
Northwestern University Medical School, 345 E. Superior Street,
Chicago, IL 60611, USA
Nonoperative treatment for lumbar spinal stenosis must address ana-
tomic and biomechanical factors. In addition to passive modalities, manual
therapy, and patient education, an active program consisting of flexion-
based lumbar stabilization exercises, hip mobilization, proprioceptive train-
ing, and general conditioning should be initiated.
There have been a paucity of studies looking at specific nonoperative
treatment protocols, and controversy still exists in the community as to what
an appropriate course of nonoperative treatment entails. Several studies
have compared the outcome of surgery to ‘‘conservative treatment.’’ The
conservative treatment described has typically been nonspecific, with results
approximating the natural history of the disease. So, two questions remain.
(1) Can nonoperative treatment improve the quality of life, functional level,
and pain level of the patient? (2) Is conservative treatment better than the
natural history?
Johnsson et al [1,2] described the natural history of degenerative lumbar
spinal stenosis, following patients for up to 4 years. Neurologic deteriora-
tion was not seen. Thirty-three percent of patients had improvement in pain
level, 58% were unchanged, and only 10% worsened. Walking capacity
improved in 42% of patients, did not change in 32%, and decreased in 26%.
Amundsen et al [3], in a 10-year prospective study, compared surgi-
cal with conservative management. The conservatively treated patients
were placed on bed rest for 1 week, fitted with a 3-point hyperextension
* Corresponding author. Center for Spine, Sports, and Occupation Rehabilitation,
Rehabilitation Institute of Chicago, 1030 North Clark Street, Suite 500, Chicago, IL 60610.
E-mail address: jrittenber@rehabchicago.org (J.D. Rittenberg).
1047-9651/03/$ – see front matter Ó2003, Elsevier Science (USA). All rights reserved.
PII: S 1 0 4 7 - 9 6 5 1 ( 0 2 ) 0 0 0 8 2 - 7
Phys Med Rehabil Clin N Am
14 (2003) 111–120

thoracolumbar orthosis, admitted for inpatient rehabilitation for 1 month,
and encouraged to walk. The patients continued with the hyperextension
brace after discharge for 3 more months. Physical therapy was described
as ‘‘ambulation’’ and ‘‘stabilizing exercises,’’ along with instructions to main-
tain a kyphotic posture. After 4 years, almost half of the patients random-
ized to conservative care were improved, with improvements maintained at
10-year follow-up.
An important finding in this study was that delaying surgery, even in the
severe patients, had no effect on surgical outcome. Additionally, radiologic
data did not correlate with outcome.
Atlas et al [4], in the Maine Lumbar Spine Study, conducted a 1-year pro-
spective study comparing outcomes of surgery with nonsurgical manage-
ment. Those treated surgically had worse pain and functional measures at
baseline. Patients with mild-to- moderate symptoms received conservative
care. Only 4 of 67 nonsurgical patients went on to surgery during the fol-
low-up period. Again, conservative treatment was nonspecific. The most
common treatments were ‘‘back exercises,’’ bed rest, physical therapy, mani-
pulation, and narcotics. Less than 20% received epidural steroids. Greater
improvement was found in the surgically treated patients, although 36% of
nonsurgically treated patients reported improvement in symptoms and
worsening of symptoms was rare.
Simotas et al [5] conducted a study following 49 patients treated nonsur-
gically for an average of almost 3 years. Treatment was described in detail,
consisting of a combination of oral nonsteroidal anti-inflammatory drugs,
oral steroids in some, epidural steroids in most, and physical therapy. Phys-
ical therapy consisted of flexion-based lumbopelvic stabilization exercises.
Outcome was measured using the spinal stenosis scale, a validated outcome
measurement tool described by Stucki et al [6].
At follow-up, 42% of patients reported mild or no pain (56% had mild
or no leg pain), and 17% had severe pain. Overall, pain scores were signifi-
cantly improved, compared with baseline. Walking scores improved or re-
mained stable in 75% of subjects. Eighty percent of patients were satisfied
with treatment.
It is generally accepted that, without treatment, approximately 25% of
subjects improve, 25% get worse, and 50% do not change. Those who ini-
tially present with more severe symptoms are more likely to have surgery.
Treatment
Nonoperative treatment options are abundant and can be categorized
into passive and active treatments (Tables 1 and 2). Bed rest is not recom-
mended, if possible, to avoid the deleterious effects of inactivity and decon-
ditioning in the older patient [7]. Relative rest and activity modification are
typically more appropriate, with education given to the patient to help avoid
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aggravating activities. In particular, patients should be instructed to sleep
with a pillow under their knees to promote a posterior pelvic tilt and
decreased dural tension. Pain relief has been demonstrated in a small num-
ber of patients with lumbar spinal stenosis wearing delordosing orthoses [8].
In the author’s experience, however, bracing is generally not necessary.
Pharmacologic treatment typically consists of standard analgesic medica-
tions. Nonsteroidal anti-inflammatory medications, acetaminophen, opioid
analgesics, and other medications should be prescribed with caution and
monitored closely to minimize complications. Calcitonin (in a randomized,
Table 1
Passive treatments for degenerative lumbar spinal stenosis
Treatment modality When used
Oral analgesic medications Acute or chronic phase, may include acetaminophen,
nonsteroidal anti-inflammatory drugs, opioids,
calcitonin, TCAs (tricyclic antidepressant
medications), gabapentin, etc.
Bed rest Acute phase (usually not necessary, limit <48 hr)
Epidural steroids Acute or subacute radicular pain
TENS (transcutaneous electrical nerve
stimulation)
Acute or chronic pain
Cryotherapy Acute pain
Hot packs Subacute or chronic pain
Orthoses (delordosing) Acute or chronic, limited role
Manual therapy
(mobilization/manipulation)
Acute or subacute phase, joint hypomobility
Biofeedback Chronic pain
Trigger point injection Myofascial pain
Acupuncture Acute or chronic pain
Table 2
Active treatments for degenerative lumbar spinal stenosis
Activity modification/relative rest
Flexion-based lumbar stabilization
Triplanar core strengthening
Hip mobilization and stretching
Neural mobilization
Functional stretching
Postural training
Activity of daily living training to minimize hyperextension postures and axial loading
Ambulation
Unweighted with harness on treadmill
Pool-based
Outdoor or treadmill
Stationary bike
Aquatic-based exercise
Proprioceptive training
Sport-specific training (golf, tennis, and so forth)
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double-blind, placebo-controlled study) was shown to provide pain relief and
improve function, most likely by its action on central opioid receptors [9].
Diagnostic blocks with local anesthetic may be useful to help confirm a
pain generator. However, the significant rate of false-positive responses with
single blocks must be taken into consideration. The double-block paradigm,
in which responses to successive injections with long-acting and short-acting
agents are measured, is helpful to improve specificity.
The zygapophysial joint has been estimated to be a primary pain gener-
ator in 15% of chronic low-back pain patients [10]. Hypertrophy of the
z-joints develops as part of the the degenerative cascade [11] and leads to
an increase in axial weightbearing from 18% [12] in the young spine to as
high as 47% [13]. Therefore, the z-joint should be considered in the older
patient with axial pain.
Medial branch blocks or intra-articular z-joint blocks with local anes-
thetic are used to confirm the diagnosis of zygapophysial joint-mediated
pain obtained with the history and physical examination. Intra-articular
injection with corticosteroid and local anesthetic may be used therapeuti-
cally. In carefully selected patients confirmed to have z-joint–mediated pain,
medial branch neurotomy may provide prolonged relief of symptoms [14].
Intra-articular sacroiliac joint injection is considered the gold standard for
the diagnosis of sacroiliac joint-mediated pain; however, it should be
remembered also that the posterior ligamentous structures of the sacroiliac
joint are potential pain generators. Provocative testing with discography has
the potential to diagnose intrinsic disc-mediated pain; however, it remains
controversial.
Therapeutic injections with corticosteroid may be useful to reduce pain,
improve tolerance for rehabilitation, and thereby facilitate a patient’s timely
return to normal function. The basis for using epidural steroids for radicular
pain caused by disc-mediated pathology has been well established [15]. In
degenerative lumbar spinal stenosis, it is less clear. Proposed mechanisms
of action include reduction of inflammation and edema around nerve roots,
alteration of local blood flow, and direct nociceptive effects.
Epidural steroid injections should be performed for acute exacerbations
in symptoms or if the patient has failed to respond to conservative treatment
over a period of several weeks or more after initial presentation. A thorough
description of the role of epidural steroids in lumbar spinal stenosis is pre-
sented elsewhere in this issue.
In the author’s opinion, physical therapy is the most effective treat-
ment for degenerative lumbar spinal stenosis, and there are various
approaches, several of which are presented in this volume. Skilled manual
therapy can greatly enhance a functional rehabilitation program. Objec-
tive outcome measurement is an important element in documenting treat-
ment efficacy. The following section describes a proposed strategy for
functionally oriented physical therapy specific to the patient with lumbar
spinal stenosis.
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Functional exercises for the patient with spinal stenosis
One of the challenges of a successful rehabilitation program is designing
an exercise program that is functional, fun, and easy to comply with on a
daily basis. It should address the specific needs of each patient.
A therapeutic exercise program for the patient with spinal stenosis should
include flexion-based lumbar stabilization exercises, a flexibility program
aimed at improving hip mobility, strengthening of the core muscles
(abdominals, gluteals, etc.), and cardiovascular exercise.
When we think of lumbar stabilization exercises, most envision exercises
performed lying supine on a plinth or swiss ball. Isolated exercise in non-func-
tional positions may be a good starting point in some patients. However,
because most patients spend their days standing, walking, sitting, working,
or playing, a rehabilitation program should ultimately strive to mimic re-
quired functional activities [22]. Patients must be trained to move in the sag-
ittal, coronal, and transverse planes. Exercises addressing all cardinal planes
of motion will more closely prepare the patient for life’s daily activities and are
the basis for a functional rehabilitation program [23].
Basic flexion exercises may be done in supine by actively bringing one or
both knees to the chest or in sitting by simply instructing the patient to bend
forward and reach toward their toes (Fig. 1).
Standing flexion exercises can be used to alleviate neurogenic claudication
or radicular symptoms brought on by walking. The patient rests one foot on
a chair or park bench, then leans forward as though tying his/her shoes until
symptoms disappear or are reduced (Fig. 2).
Decreased hip range of motion—from decreased muscle length, hip cap-
sular tightness, or degenerative joint disease—is commonly present. Tripla-
nar (multidirectional) functional stretches are an effective method to
increase hip mobility, along with improving range of motion further down
the kinetic chain of the lower extremities. A multiplanar lunge program,
as described by Gray [23] is a useful tool to improve flexibility, while simul-
taneously increasing strength and proprioception. Hip flexor and hamstring
Fig. 1. Seated forward bending.
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muscle tightness may contribute to lordotic stresses on the lumbar spine and
should be addressed with a stretching program (Fig. 3).
Manual therapy can be performed to help address capsular tightness of
the hip. A basic passive accessory joint glide with the assistance of a mobi-
lization belt is pictured in Fig. 4. The half-prone rectus femoris stretch can
be used to mobilize the anterior hip capsule with passive hip internal or
external rotation. The pelvis and lumbar spine are placed in a neutral or
flexed position to promote opening of the lateral or central canal. Pillows
Fig. 3. (A–C) Triplanar lunges. (D) Rotational hamstring stretch. (E) Rotational hip flexor
stretch.
Fig. 2. Standing unilateral forward bending.
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may be placed under the pelvis to increase lumbar flexion if the mobilization
position produces symptoms (see Fig. 4).
The benefits of a core strengthening program in decreasing the occur-
rence of low back pain has been demonstrated in an athletic population
[24]. A standing core strengthening exercise program should be initiated
early. Examples of standing core exercises are pictured in Fig. 5. Transverse
plane exercises may be tolerated early because of minimal axial loading and
the presence of only one degree of rotation occurring at each vertebral seg-
ment [16]. Bilateral hip internal rotation (toeing-in) will help to emphasize
rotational movement at the hips. Holding a medicine ball can help to stim-
ulate abdominal muscle activity [17,18].
The transverse abdominis should be trained with a ‘‘hollowing con-
traction,’’ as described by McGill [16,18]. In addition to transverse plane
Fig. 3 (continued )
Fig. 4. (A) Standing anterior hip glide with belt. (B) Prone rectus femoris stretch with anterior
hip glide.
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Fig. 5. (A, B) Transverse core. (C, D) Sagittal core. (E) Frontal core. (F, G) Single leg stance
core.
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movement, frontal and sagittal core exercises may be introduced in a pain-
free range and progressed accordingly. Exercises performed on a single leg
will help to enhance proprioception.
Endurance, the ability to maintain core muscular performance over a
period of time, has been found to have a much greater protective role
against low back injury than strength alone [17]. General conditioning must
be integrated into any comprehensive rehabilitation program. A cardiovas-
cular training effect may be difficult to achieve, because the primary com-
plaint of most patients is pain with ambulation. Patients should be
encouraged to try a stationary bike or an inclined treadmill, both of which
place the lumbar spine in a more optimal flexed position. Unweighted tread-
mill walking has been described by Fritz et al [19–21]. Walking in a pool is
another alternative.
Summary
Nonoperative treatment for lumbar spinal stenosis must address anatomic
and biomechanical factors. The entire functional kinetic chain and patient
specific goals must be considered. In addition to passive modalities, manual
therapy, and patient education, an active program consisting of flexion-based
lumbar stabilization exercises, hip mobilization, proprioceptive training, and
general conditioning should be initiated. More studies are needed to establish
the benefit of a comprehensive, multifaceted treatment approach and to prove
its clear benefit over the natural history of lumbar spinal stenosis.
References
[1] Johnsson KE, Uden A, Rosen I. The effect of decompression on the natural course of
spinal stenosis. A comparison of surgically treated and untreated patients. Spine 1991;
16(6):615–9.
Fig. 5 (continued )
119J.D. Rittenberg, A.E. Ross / Phys Med Rehabil Clin N Am 14 (2003) 111–120

[2] Johnsson KE, Rosen I, Uden A. The natural course of lumbar spinal stenosis. Clin Orthop
Related Res 1992;(279):82–6.
[3] Amundsen T, Weber H, et al. Lumbar spinal stenosis: conservative or surgical man-
agement? A prospective 10-year study. Spine 2000;25(11):1424–36.
[4] Atlas SJ, et al. The Maine Lumbar Spine Study. Part III. 1-Year outcomes of surgical and
nonsurgical management of lumbar spinal stenosis. Spine 1996;21(15):1787–94 [discussion:
1794–5].
[5] Simotas AC, et al. Nonoperative treatment for lumbar spinal stenosis. Clinical and outcome
results and a 3-year survivorship analysis. Spine 2000;25(2):97–203 [discussion: 203–4].
[6] Stucki G, et al. Measurement properties of a self-administered outcome measure in lumbar
spinal stenosis. Spine 1996;21(7):796–803.
[7] Bortz WM II. Disuse and aging. JAMA 1982;248(10):1203–8.
[8] Willner S. Effect of a rigid brace on back pain. Acta Orthop Scand 1985;56(1):40–2.
[9] Eskola A, et al. Calcitonin treatment in lumbar spinal stenosis: a randomized, placebo-
controlled, double-blind, cross-over study with one-year follow-up. Calcif Tissue Int 1992;
50(5):400–3.
[10] Schwarzer AC, et al. The relative contributions of the disc and zygapophyseal joint in
chronic low back pain. Spine 1994;19(7):801–6.
[11] Kirkaldy-Willis WH, Burton CV. Managing low back pain. 3rd ed. New York: Churchill
Livingstone; 1992.
[12] Nachemson A. Lumbar interdiscal pressure. Acta Orthop Scand 1960;43.
[13] Yang K, King A. Mechanism of facet load transmission as a hypothesis for low-back pain.
Spine 1984;9(6):557–65.
[14] Dreyfuss P, et al. Efficacy and validity of radiofrequency neurotomy for chronic lumbar
zygapophysial joint pain. Spine 2000;25(10):1270–7.
[15] Saal J, et al. High level of inflammatory phospholipase A2 activity in lumbar disc herni-
ations. Spine 1990;15:674–8.
[16] White A, Panjabi M. Clinical biomechanics of the spine. 2nd ed. Philadelphia: Lippincott-
Raven; 1990.
[17] McGill SM. Low back exercises: evidence for improving exercise regimens. Phys Ther
1998;78(7):754–65.
[18] McGill SM. Low back stability: from formal description to issues for performance and
rehabilitation. Exerc Sport Sci Rev 2001;29(1):26–31.
[19] Fritz JM, Erhard RE, Vignovic M. A nonsurgical treatment approach for patients with
lumbar spinal stenosis. Phys Ther 1997;77(9):962–73.
[20] Fritz JM, et al. Lumbar spinal stenosis: a review of current concepts in evaluation, man-
agement, and outcome measurements. Arch Phys Med Rehabil 1998;79(6):700–8.
[21] Fritz JM, et al. Preliminary results of the use of a two-stage treadmill test as a clinical
diagnostic tool in the differential diagnosis of lumbar spinal stenosis. J Spinal Disord 1997;
10(5):410–6.
[22] Liebenson C. Functional exercises. Journal of Bodywork and Movement Therapies 2002;
6(2):108–16.
[23] Gray G. Functional approach to the musculoskeletal system. Chicago (IL): Rehabilitation
Institute of Chicago seminar; 2001.
[24] Nadler SF, Malanga GA, Bartoli LA, et al. Hip imbalance and low back pain in athletes:
influence of core strengthening. Medicine & Science in Sports & Exercise 2002;34(1):9–16.
120 J.D. Rittenberg, A.E. Ross / Phys Med Rehabil Clin N Am 14 (2003) 111–120