Lumbar Stenosis Protocol

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fozzy40

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Just out of curiosity, is there a physical therapy protocol for leg and back pain secondary to lumbar stenosis? I did a quick pubmed search but was not able to come up with anything specific. Directional preference? Neutral stabilization? I'm sure there is a wide variety of treatment plans so if you could share your method I would greatly appreciate it.
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fozzy40 said:
Just out of curiosity, is there a physical therapy protocol for leg and back pain secondary to lumbar stenosis? I did a quick pubmed search but was not able to come up with anything specific. Directional preference? Neutral stabilization? I'm sure there is a wide variety of treatment plans so if you could share your method I would greatly appreciate it.
Click to expand...

I'll give a try

From my experience, most of people with LBP and significant stenosis/LE symptoms are relieved with sitting and aggravated with standing/walking. I've also noticed a lack of hip extension ROM/tight rectus and thoracic extension hypomobility. So, a lot of what I typically do is rectus/hip extension stretches/ROM exercises (while avoiding lordosis/lumbar extension) and thoracic mobilization manual treatments to improve extension ROM and flexibility as appropriate. Lots more treatment/rationale than above, but for me is dependent on each patient and tailored as such.

Whitman et al 2006 had positive outcomes with a flexion based routine plus a walking program, but better outcomes with manual treatment to the hip/lumbopelvic/thoracic spine in addition to above.

Protocol: improve hip extension/thoracic extension ROM while avoiding lumbar extension, improve lumbar flexion/posterior pelvic tilt strength/mobility, institute a walking program.
 
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Fiveoboy11 said:
I'll give a try

From my experience, most of people with LBP and significant stenosis/LE symptoms are relieved with sitting and aggravated with standing/walking. I've also noticed a lack of hip extension ROM/tight rectus and thoracic extension hypomobility. So, a lot of what I typically do is rectus/hip extension stretches/ROM exercises (while avoiding lordosis/lumbar extension) and thoracic mobilization manual treatments to improve extension ROM and flexibility as appropriate. Lots more treatment/rationale than above, but for me is dependent on each patient and tailored as such.

Whitman et al 2006 had positive outcomes with a flexion based routine plus a walking program, but better outcomes with manual treatment to the hip/lumbopelvic/thoracic spine in addition to above.

Protocol: improve hip extension/thoracic extension ROM while avoiding lumbar extension, improve lumbar flexion/posterior pelvic tilt strength/mobility, institute a walking program.
Click to expand...

Great response and thank you!

Do you find most of your patients have a neutral or posterior pelvic tilt when they initially present? Do you encourage a posterior pelvic tilt to maintain lumbar hypolordosis?
 
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What type of stenosis? Central, Lateral recess, or foraminal? It may explain what position they feel less discomfort in. I have an article from school (Rehabiltation for Patients with Lumbar Stenosis) that covers some of your questions. There are 2 downsides though 1) it was published in Sep 1993 by Ira Fiebert & Nathan Lebwohl, and 2) its not found online. I could try to scan the article and PM you with the info if you like.
 
fiveoboy11 said:
i'll give a try

from my experience, most of people with lbp and significant stenosis/le symptoms are relieved with sitting and aggravated with standing/walking. I've also noticed a lack of hip extension rom/tight rectus and thoracic extension hypomobility. So, a lot of what i typically do is rectus/hip extension stretches/rom exercises (while avoiding lordosis/lumbar extension) and thoracic mobilization manual treatments to improve extension rom and flexibility as appropriate. Lots more treatment/rationale than above, but for me is dependent on each patient and tailored as such.

Whitman et al 2006 had positive outcomes with a flexion based routine plus a walking program, but better outcomes with manual treatment to the hip/lumbopelvic/thoracic spine in addition to above.

Protocol: Improve hip extension/thoracic extension rom while avoiding lumbar extension, improve lumbar flexion/posterior pelvic tilt strength/mobility, institute a walking program.
Click to expand...

+1
 
A Burly Man said:
What type of stenosis? Central, Lateral recess, or foraminal? It may explain what position they feel less discomfort in. I have an article from school (Rehabiltation for Patients with Lumbar Stenosis) that covers some of your questions. There are 2 downsides though 1) it was published in Sep 1993 by Ira Fiebert & Nathan Lebwohl, and 2) its not found online. I could try to scan the article and PM you with the info if you like.
Click to expand...

All 3 types of stenosis. I don't have a patient in mind just a general question. Where was the article published?
 
fozzy40 said:
Great response and thank you!

Do you find most of your patients have a neutral or posterior pelvic tilt when they initially present? Do you encourage a posterior pelvic tilt to maintain lumbar hypolordosis?
Click to expand...

You're welcome. I think the majority probably have a flexed lumbar posture in sitting, but the tendency seems to be at least a fulcrum toward extension in standing (because of poor thoracic/hip extension flexibility/hypomobility causing the lumbar area to take up the slack). Perhaps I am imagining this. I don't really teach people standing with a posterior pelvic tilt held position, seems to be a waste of time and way too much effort for the patient to ever do it prolonged. What I do like to teach a lot of people for home exercises with these issues sometimes is thomas (leg off EOB) with contralateral single knee to chest, and supine hooklying on the floor (firm surface) with UE's behind head for thoracic extension ROM.
 
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