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.