Phys Med Rehabil Clin N Am 14 (2003) 111120

Functional rehabilitation for degenerative lumbar spinal stenosis

Joshua D. Rittenberg, MDa,b,*, Amy E. Ross, MPTa
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
a

Nonoperative treatment for lumbar spinal stenosis must address anatomic and biomechanical factors. In addition to passive modalities, manual therapy, and patient education, an active program consisting of exionbased lumbar stabilization exercises, hip mobilization, proprioceptive training, and general conditioning should be initiated. There have been a paucity of studies looking at specic 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 nonspecic, 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 deterioration 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 surgical with conservative management. The conservatively treated patients were placed on bed rest for 1 week, tted 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 2003, Elsevier Science (USA). All rights reserved. PII: S 1 0 4 7 - 9 6 5 1 ( 0 2 ) 0 0 0 8 2 - 7

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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 maintain a kyphotic posture. After 4 years, almost half of the patients randomized to conservative care were improved, with improvements maintained at 10-year follow-up. An important nding in this study was that delaying surgery, even in the severe patients, had no eect 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 prospective study comparing outcomes of surgery with nonsurgical management. 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 follow-up period. Again, conservative treatment was nonspecic. The most common treatments were back exercises, bed rest, physical therapy, manipulation, 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 nonsurgically for an average of almost 3 years. Treatment was described in detail, consisting of a combination of oral nonsteroidal anti-inammatory drugs, oral steroids in some, epidural steroids in most, and physical therapy. Physical therapy consisted of exion-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 signicantly improved, compared with baseline. Walking scores improved or remained stable in 75% of subjects. Eighty percent of patients were satised with treatment. It is generally accepted that, without treatment, approximately 25% of subjects improve, 25% get worse, and 50% do not change. Those who initially 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 recommended, if possible, to avoid the deleterious eects of inactivity and deconditioning in the older patient [7]. Relative rest and activity modication are typically more appropriate, with education given to the patient to help avoid

J.D. Rittenberg, A.E. Ross / Phys Med Rehabil Clin N Am 14 (2003) 111120 Table 1 Passive treatments for degenerative lumbar spinal stenosis Treatment modality Oral analgesic medications When used

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Bed rest Epidural steroids TENS (transcutaneous electrical nerve stimulation) Cryotherapy Hot packs Orthoses (delordosing) Manual therapy (mobilization/manipulation) Biofeedback Trigger point injection Acupuncture

Acute or chronic phase, may include acetaminophen, nonsteroidal anti-inammatory drugs, opioids, calcitonin, TCAs (tricyclic antidepressant medications), gabapentin, etc. Acute phase (usually not necessary, limit <48 hr) Acute or subacute radicular pain Acute or chronic pain Acute pain Subacute or chronic pain Acute or chronic, limited role Acute or subacute phase, joint hypomobility Chronic pain Myofascial pain Acute or chronic pain

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 number of patients with lumbar spinal stenosis wearing delordosing orthoses [8]. In the authors experience, however, bracing is generally not necessary. Pharmacologic treatment typically consists of standard analgesic medications. Nonsteroidal anti-inammatory medications, acetaminophen, opioid analgesics, and other medications should be prescribed with caution and monitored closely to minimize complications. Calcitonin (in a randomized,
Table 2 Active treatments for degenerative lumbar spinal stenosis Activity modication/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-specic 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 conrm a pain generator. However, the signicant 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 specicity. The zygapophysial joint has been estimated to be a primary pain generator 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 anesthetic are used to conrm 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 therapeutically. In carefully selected patients conrmed to have z-jointmediated 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 patients 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 inammation and edema around nerve roots, alteration of local blood ow, and direct nociceptive eects. 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 presented elsewhere in this issue. In the authors opinion, physical therapy is the most eective treatment 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. Objective outcome measurement is an important element in documenting treatment ecacy. The following section describes a proposed strategy for functionally oriented physical therapy specic 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 specic needs of each patient. A therapeutic exercise program for the patient with spinal stenosis should include exion-based lumbar stabilization exercises, a exibility 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-functional 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 required functional activities [22]. Patients must be trained to move in the sagittal, coronal, and transverse planes. Exercises addressing all cardinal planes of motion will more closely prepare the patient for lifes daily activities and are the basis for a functional rehabilitation program [23]. Basic exion 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 exion 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 motionfrom decreased muscle length, hip capsular tightness, or degenerative joint diseaseis commonly present. Triplanar (multidirectional) functional stretches are an eective 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 exibility, while simultaneously increasing strength and proprioception. Hip exor and hamstring

Fig. 1. Seated forward bending.

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Fig. 2. Standing unilateral forward bending.

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 mobilization 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 exed position to promote opening of the lateral or central canal. Pillows

Fig. 3. (AC) Triplanar lunges. (D) Rotational hamstring stretch. (E) Rotational hip exor stretch.

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Fig. 3 (continued )

may be placed under the pelvis to increase lumbar exion if the mobilization position produces symptoms (see Fig. 4). The benets of a core strengthening program in decreasing the occurrence 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 segment [16]. Bilateral hip internal rotation (toeing-in) will help to emphasize rotational movement at the hips. Holding a medicine ball can help to stimulate abdominal muscle activity [17,18]. The transverse abdominis should be trained with a hollowing contraction, as described by McGill [16,18]. In addition to transverse plane

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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Fig. 5 (continued )

movement, frontal and sagittal core exercises may be introduced in a painfree 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 cardiovascular training eect may be dicult to achieve, because the primary complaint 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 exed position. Unweighted treadmill walking has been described by Fritz et al [1921]. 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 specic goals must be considered. In addition to passive modalities, manual therapy, and patient education, an active program consisting of exion-based lumbar stabilization exercises, hip mobilization, proprioceptive training, and general conditioning should be initiated. More studies are needed to establish the benet of a comprehensive, multifaceted treatment approach and to prove its clear benet over the natural history of lumbar spinal stenosis. References
[1] Johnsson KE, Uden A, Rosen I. The eect of decompression on the natural course of spinal stenosis. A comparison of surgically treated and untreated patients. Spine 1991; 16(6):6159.

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[2] Johnsson KE, Rosen I, Uden A. The natural course of lumbar spinal stenosis. Clin Orthop Related Res 1992;(279):826. [3] Amundsen T, Weber H, et al. Lumbar spinal stenosis: conservative or surgical management? A prospective 10-year study. Spine 2000;25(11):142436. [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):178794 [discussion: 17945]. [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):97203 [discussion: 2034]. [6] Stucki G, et al. Measurement properties of a self-administered outcome measure in lumbar spinal stenosis. Spine 1996;21(7):796803. [7] Bortz WM II. Disuse and aging. JAMA 1982;248(10):12038. [8] Willner S. Eect of a rigid brace on back pain. Acta Orthop Scand 1985;56(1):402. [9] Eskola A, et al. Calcitonin treatment in lumbar spinal stenosis: a randomized, placebocontrolled, double-blind, cross-over study with one-year follow-up. Calcif Tissue Int 1992; 50(5):4003. [10] Schwarzer AC, et al. The relative contributions of the disc and zygapophyseal joint in chronic low back pain. Spine 1994;19(7):8016. [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):55765. [14] Dreyfuss P, et al. Ecacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine 2000;25(10):12707. [15] Saal J, et al. High level of inammatory phospholipase A2 activity in lumbar disc herniations. Spine 1990;15:6748. [16] White A, Panjabi M. Clinical biomechanics of the spine. 2nd ed. Philadelphia: LippincottRaven; 1990. [17] McGill SM. Low back exercises: evidence for improving exercise regimens. Phys Ther 1998;78(7):75465. [18] McGill SM. Low back stability: from formal description to issues for performance and rehabilitation. Exerc Sport Sci Rev 2001;29(1):2631. [19] Fritz JM, Erhard RE, Vignovic M. A nonsurgical treatment approach for patients with lumbar spinal stenosis. Phys Ther 1997;77(9):96273. [20] Fritz JM, et al. Lumbar spinal stenosis: a review of current concepts in evaluation, management, and outcome measurements. Arch Phys Med Rehabil 1998;79(6):7008. [21] Fritz JM, et al. Preliminary results of the use of a two-stage treadmill test as a clinical diagnostic tool in the dierential diagnosis of lumbar spinal stenosis. J Spinal Disord 1997; 10(5):4106. [22] Liebenson C. Functional exercises. Journal of Bodywork and Movement Therapies 2002; 6(2):10816. [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: inuence of core strengthening. Medicine & Science in Sports & Exercise 2002;34(1):916.