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Research Review By Dr. Robert Rodine©

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Date Posted:

July 2011

Study Title:

Lumbar spinal stenosis: diagnosis and management of the aging spine

Authors:

Backstrom K, Whitman JM & Flynn TW

Author's Affiliations:

University of Colorado Hospital Rehabilitation Department, Colorado, USA.

Publication Information:

Manual Therapy 2011; 16(4): 308-17.

Background Information:

Low back pain (LBP), even the non-specific mechanical variety, is a significant detriment to the health of society. While the prevalence of LBP in the adult population has been estimated at approximately 30% (1), the prevalence in those over the age of 65 years is estimated to be 50% (2).

This is significantly concerning as our population continues to age. To illustrate, a recent population analysis has shown that the proportion of adults over the age of 65 in developed regions of the world will almost double (growing from 8% to 14%) by 2040 (3).

For those over the age of 65, a specific form of low back pain which can also produce lower extremity symptoms and significantly affect quality of life is lumbar spinal stenosis (LSS). Patients with LSS typically present with LBP and lower extremity symptoms. Fatigue or heaviness in the legs, or outright vascular or neurogenic claudication often makes standing or walking for long periods of time very difficult. Lumbar flexion is often a relieving position, particularly sitting. These symptoms are thought to originate from one or a combination of: neural compression in the lumbar spine, vascular compromise, or altered pain sensation. Canal stenosis can be congenital, or result from degenerative changes of spinal tissues.

The purpose of this paper was to review the diagnostic process and management strategy for LSS from a manual therapy perspective. Information was presented in a narrative format and will be summarized below.

Pertinent Results:

The bulk of this paper was divided into three sections, labeled as Diagnosis, Physical Therapy Management and Medical Management.

Diagnosis:

Backstrom et al. initiated their discussion by tackling an important component of LSS, that being the importance and relevance of diagnostic imaging. As we know, the radiographic signs of spinal degeneration have little correlation to signs and symptoms experienced by patients. It is not surprising then, that during this review, the authors were unable to find research correlating imaging findings with the symptoms of LSS. Additionally, they quote research which found signs of canal narrowing, consistent with LSS, in 30% of asymptomatic subjects (4, 5). As such, the use of imaging may prove of little benefit when trying to categorize low back pain patients or determine their prognosis based on imaging findings.

Therefore, the use of physical/clinical examination and patient history is likely to be of far more benefit when trying to place patients into the LSS diagnostic category. (EDITOR’S NOTE: the same could be said for most spinal conditions.)

Within low back and leg pain patients in this age category, several conditions must be ruled out during the history and clinical exam. These include spinal tumors, peripheral and diabetic neuropathies, peripheral artery disease, etc. A recently developed Clinical Prediction Rule by Konno stressed the importance of ruling out the vascular system as a cause of claudication in these patients (6).

When leaning towards LSS as a diagnosis, a recently developed and validated CPR by Sugioka et al. recommended using a scoring system for patients based upon presentation:
  • 60-70 years of age = 2 points
  • > 70 years of age = 3 points
  • Onset over 6 months prior = 1 point
  • Relief with flexion = 2 points
  • Relief with extension = -2 points
  • Standing aggravates = 2 points
  • Intermittent claudication symptoms = 1 point
  • Urinary incontinence = 1 point
The higher the score, the more likely the patient has LSS. A total score of 7 or more creates a 1.70 likelihood ratio that the patient is suffering from LSS.

Most importantly however, the authors stress the importance of a functional exam of the spine and lower extremity. This is based on findings from Whitman et al. that LSS patients typically present with hypomobility of the thoracic, lumbar and hip region (7). In addition, faulty mechanics are often found throughout the entire lower extremity as well as weakness within the core musculature.

Physical Therapy Management:

This section began by addressing patient education, a pivotal component of therapy for any spinal condition. In brief, they highlighted that a complete education session consisting of the following, should be undertaken:
  • The definition/meaning of LSS
  • The intent and purpose of manual therapy
  • The course and expectations of therapy
  • The purpose of home based therapies, such as exercise
  • The natural and clinical history (using surgery as a comparison) for LSS and the patients prognosis
  • Self-management strategies such as modifying aggravating activities and positions
  • Information regarding current pain concepts
Manual Therapy:

Recently, a systematic review concluded that manual therapy and exercise may offer benefit to patients with LSS (8). However, as we have seen with other clinical topics, the therapy techniques reviewed were vast and diverse. As such, the authors of this review recommended that all elements of the MSK system which are involved in upright ambulation be addressed with manual therapy, using an impairment based approach.

A key element of this paper is the emphasis the authors place on addressing hip motion. Therefore, a treatment approach which emphasizes passive and active stretching to the rectus femoris and psoas, anterior glide mobilization and long axis distraction manipulation to the hip was recommended (there are other options and techniques, of course). Additionally, any manual therapy techniques aimed at increasing hip and knee extension as well as ankle dorsiflexion could be beneficial. Most notably, the authors state that ‘the choice of a particular procedure appears less important than the introduction of movement in these areas through manual techniques.’ It is worth noting that the authors did state the importance of both thrust and non-thrust techniques to the thoracic, lumbar and sacroiliac regions, further emphasizing the importance of a comprehensive approach to treating LSS.

This section is where the authors steal the show. Perfectly presented….maximizing thoracic extension will minimize lumbar extension during upright posture. This makes sense based on postural analysis and centre of gravity concepts. However, they take it a step further with hip range of motion. The inability to fully extend the hip and maintain a neutral pelvis results in increased extension from the lumbar spine during gait. As this is an aggravating component of LSS, patients are unable to walk for long distances or stand for long periods of time. By maximizing thoracic and hip extension, the lumbar spine is relieved. This is a very progressive and holistic view indeed! Core strengthening with a flexion bias is also recommended (as always, based on patient response to such loading and positions). (EDITOR’S NOTE: I typically start all patients with neutral spine core rehab and alter the positioning from there based on patient response and progression.)

Aerobic Training and Exercise:

With respect to aerobic training for LSS patients, two strategies are recommended. The first is cycling, as the flexed posture enables activity without symptoms of claudication. The second is treadmill walking, however with the assistance of an overhead vest-like traction device with ‘unweights’ the patient and minimizes axial loading. The authors stress a functional component however to aerobic training, rather than simply stating ‘get out and move.’ The key, they suggest, is lumbo-pelvic positioning. This means that patients are able to better control their lumbo-pelvic rhythm while walking and maintaining a proper pelvic tilt. This will help to minimize lumbar extension during ambulation, a position which would typically aggravate symptoms.

In LSS patients, the purposes of aerobic training are:
  • To improve cardiovascular fitness;
  • to allow an immediate use of gains in strength and flexibility to improve overall function;
  • to decrease fear-avoidance behaviors and beliefs; and
  • to improve pain modulation.
At home exercise is also highly important, with emphasis on individually identified impairments. Thoracic extension self-mobilization, lumbar rotation stretches and stretches aimed at improving hip extension are considered to be foundational.

Medical Management:

The mainstay of medical management should consist of the following:
  • Diagnose and monitor the patient
  • Help patient to initiate conservative therapy
  • Medicate with NSAIDs, opioids and epidural steroid injections as necessary – the complications and risks of these therapies should be continuously considered
  • Given the risks and long term results compared to conservatively treated patients, surgical procedures should likely be reserved for a subgroup of LSS patients. However, no research has been conducted to date to validate this theory or identify subgroups more likely to respond to surgery or conservative therapy.

Clinical Application & Conclusions:

Backstrom and colleagues have put together a well thought out and informative review on manual therapy treatment strategies for LSS patients. With an emphasis on impairment based treatment, rather than symptom based treatment, this piece stands above other reviews in how it guides clinicians to address functional limitations in this patient population.

In particular, the authors recommend aerobic training and home-based exercise, activity modification rather than avoidance, core strengthening and the realization of lumbo-pelvic positioning all compliment a manual therapy focus on improving thoracic extension, lumbar mobility and hip range of motion. Through these techniques, LSS patients may be better able to improve their function and enable them to not only continue, but also to increase daily activities such as walking. This will ultimately enhance a patient’s quality of life and ensure continued independence.

Study Methods:

This paper was a narrative review. As such, there was no formal search strategy or presentation of results. This paper was presented categorically according to sub-topic, with a presentation of research that supported the authors’ primary hypothesis.

Study Strengths/Weaknesses:

Obvious limitations to this study were its narrative reporting format and therefore bias presentation of research. Nonetheless, the paper is quite strong in its use of current evidence, balanced approach of medical and non-medical approaches, the presentation of CPR guidelines and emphasis of an impairment based treatment model rather than a symptom based model.

The paper also offers an extensive appendix section which visualizes many of the treatment techniques used in manual therapy for LSS patients. This will help readers better translate this research into practice.

Overall, this was a strong paper, despite its narrative format. It was well presented, particular the theory behind an impairment based model aimed at the thoracic spine and hip.

Additional References:

  1. Andersson GB. Epidemiology of low back pain. Acta Orthop Scand Suppl 1998;281:28-31
  2. Bressler H, Keyes W, Rochon P et al. The prevalence of low back pain in the elderly: a systematic review of the literature. Spine 1999;24:1813-9
  3. Population Reference Bureau. http://www.pSSrb.org/publications/graphicsbank/populationtrends.aspx;2010 [accessed 12.20.10]
  4. Weisel SW, Tsourmas N Feffer H et al. A study of computer assisted tomography; 1. The incidence of positive CAT scans in an asymptomatic group of patients. Spine 1984;9(6):549-51
  5. Boden S, Davis D, Dina T et al. Abnormal magnetic-resonance. JBJS 1990; 72:403-8
  6. Konno S, Hayashino Y, Kukuhara S et al. Development of a clinical diagnosis support tool to identify patients with lumbar spinal stenosis. European Spine Journal 2007;16:1951-7
  7. Whitman J, Flynn T, Fritz J. Nonsurgical management of patients with lumbar spinal stenosis: a literature review and a case series of three patients managed with physical therapy. Phys Med Rehab Clin N Amer 2003;14:77-101
  8. Reiman M, Harris J, Cleland J. Manual therapy interventions for patients with lumbar spinal stenosis: a systematic review. New Zealand Journal of Physiotherapy 2009; 37:17-28.

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