By Steve Young.
Last week I wrote about why physiotherapy should be a first line treatment for spinal stenosis (read it here). Classically, physiotherapy has focused on flexion based exercises to help relieve leg pain for the patient with spinal stenosis, but is there more that we can do for these patients and is there evidence to support the use of these interventions?
Here, in no particular order, are three important things to include in your treatment of Lumbar Spinal Stenosis patients:
1) Cardiovascular exercise.
There are a couple of reasons this is beneficial for the stenosis patient. Firstly, the vast majority of spinal stenosis patients are older and typically use walking as a form of cardiovascular exercise. As stenosis typically limits walking, many of these patients are generally deconditioned and would benefit from cardiovascular exercise. Secondly, it may be that spinal stenosis compresses the arterial blood supply to the nerves and this contributes to the condition. Cardiovascular exercise improves this aspect of the condition.
As walking ability is often limited, Whitman and colleagues included unweighted walking in their trial for the treatment of spinal stenosis and this was found to be effective in conjunction with multimodal physical therapy (ref). Unweighted walking is typically not widely available so it is worth noting that stationary cycling was equally efficacious for the treatment of spinal stenosis in a trial that was conducted by Pau (ref). Another potential option is pool based exercise.
2) Manual Therapy and Exercise.
The “Choosing Wisely” campaign suggests that we should not under dose older adults with respect to exercise interventions (ref). In fact, there is significant evidence that older adults in general improve from a conditioning program and lead longer lives with less disability. I would also suggest that we often under dose manual therapy interventions for older individuals and that they can, when appropriate, benefit from manual therapy. In the Whitman trial, all patients received manual therapy to the spine and demonstrated superior outcomes to those who were treated with a flexion only based treatment program.
3) Use a regional interdependence model.
Treat more than just the lumbar spine. The Whitman trial also included manual therapy and exercise to help improve the mobility of the thoracic spine, hips, knees and ankle joints as determined by the treating therapists. In my experience, the typical spinal stenosis patient lacks thoracic, hip, and knee extension. Improving mobility in these areas can improve a stenotic patient's overall mobility and decrease their leg symptoms.
Come see us speak at the Canadian Physiotherapy Congress in beautiful Victoria, BC next week! (Click here for more info)