Over a quarter of the elderly population living at home complain of back pain. In a study using radiographic imaging to determine a cause of back pain symptoms, Boden2 found several changes in older persons during an examination of their spine, which include narrowing of the disc space, traction osteophytes, muscle degeneration and end plate sclerosis. Nevertheless, Boden reports that these common changes in older individuals correlate poorly with clinical symptoms. We need to examine the causes of low back pain in older persons. This article specifically investigates one of the common diagnoses seen in the older population, lumbar stenosis.

Spinal stenosis or lumbar stenosis is a narrowing of the foramen for the spinal nerves in the area of the lumbar canal. Three structures contribute to spinal stenosis, the ligamentum flavum, facet joints and disc spaces. As one ages there is a decrease in disc height which if pronounced can allow buckling of the ligamentum flavum into the spinal canal. It is interesting to note that the AP diameter of the dural sac is decreased by extension approximately 9 percent. If someone already has a lumbar stenosis, back extension will cause a further decrease of the AP diameter by 67 percent3. In contrast, there is widening of the lumbar canal with flexion causing a relief of symptoms. 

Symptoms associated with lumbar stenosis are wide based gait, thigh pain following 30 seconds of lumbar spine extension and decreased dermatomal sensation and reflexes in the area of the stenosis. Lateral and central stenosis have different symptoms. A patient with lateral stenosis will have increased pain at rest and at night while central stenosis causes an increased limitation when walking and reduced reflexes in the knee and ankle. Both lateral and central stenosis can cause the patient to stand and walk with a stooped posture. Iversen4 designed and performed a study to characterize patients with lumbar spinal stenosis. He found that 51% had lower extremity weakness as evidenced by weakness in the extensor hallucis longus, 81% had decreased neurosensory response and 66% were unable to walk farther than two blocks. 

There are two different types of tests that can be used to evaluate a patient with suspected lumbar stenosis in order to differentiate it from vascular symptoms. The first is the bicycle test. This test consists of having the person bicycle in both flexion and extension. If the person can bicycle longer in flexion without the symptoms occurring, the diagnosis would be considered lumbar stenosis. The second is the stoop test, which is similar. If walking with flexion relieves the symptoms then the diagnosis would be considered lumbar stenosis versus walking upright or with extension, which would exacerbate symptoms of lumbar stenosis. This is often times why patients with lumbar stenosis prefer to push a wheelchair or grocery cart; because the position gives them relief. Other activities that can be examined on the initial evaluation were determined in an article by Whitehurst5. It was found that patients with lumbar stenosis had more difficulty with sit→stand tests, treadmill tests, and weight carry tests.

Once information is gathered on flexion – extension parameters, muscle tightness of the hips, hamstrings and lumbar spine, the therapist can then determine what to expect for the patient. Not much as been published on the prognosis and very little has been published on prognosis with conservative means. However, in 1992 Johnson6 looked at the natural course of lumbar spine stenosis and found during a four-year follow-up that 70% of the cases were unchanged while 15% showed improvement and 15% were worse. In 19987, researches looked at the effects of epidural steroid injections on pain due to lumbar stenosis or herniated disc. They found that only 38% of lumbar stenosis patients reported improvement on pain scores while 61% of patients with herniated discs reported improvement. Therefore, it was concluded that steroid injections might not be efficacious for symptom improvement in patients with lumbar stenosis. Finally, Fritz8 found that a trial of conservative care is recommended but at the time there were not any good randomized controlled studies comparing surgical with conservative treatment. 

Fritz’s study led the way for a randomized controlled study on treatment that is now in the literature. In 1997, Fritz9 looked at a nonsurgical treatment approach for patients with lumbar spinal stenosis. Patients treated with flexion, unloaded ambulation, and strengthening exercises were found to have improvement in all outcome measures after 6 weeks of physical therapy, which continued at the one-month follow-up. We have taken this information and developed a protocol for the treatment of patients with lumbar stenosis and have gotten outstanding results. The protocol stresses flexion and lumbar stabilization. In working with the type I muscle fiber, numerous repetitions are needed. Patients are asked not to do 10 pelvic tilts once a day but 50 pelvic tilts three times a day. If patient can reach this exercise level, they will see results but if they continue to perform very few exercises, they will see little improvement if any. Below is the protocol.

Protocol Lumbar Stenosis
1. Modalities to stretch the low back muscles and soft tissue as needed (Moist Heat, Ultrasound, Electrical Stimulation)
2. Joint Mobilization to the low back to stretch into flexion as needed – rotation, distraction, posterior tilt, posterior stretch, rotation oscillation, and segmental rotation oscillation.
3. Soft tissue stretch to low back muscles – massage, passive pelvic tilt, posterior tilt contraction
4. Instruction in body mechanics
a. Sleeping in the fetal position
b. Sitting at least once a day for 20 minutes with knees higher than hips – preferable midday
c. Stand with tummy and buttocks tucked
d. Posteriorly tilt pelvis when walking
5. Therapeutic exercises:
a. Posterior Tilts 10 repetitions holding each 10 seconds. Increase to 50 repetitions in 5-10 minutes, three times per day
b. Partial Sit-ups – 10 repetitions holding 10 seconds. Increase to 50 repetitions three times a day
c. Single knee to chest – (if no osteoporosis), 3-5 repetitions holding 30 seconds, three times per day
d. Wall flats – 10 repetitions for 10 seconds, three times a day. Increase to 30 repetitions three times a day
e. Progress through dynamic lumbar stabilization exercises – supine, sitting, standing.

References:
1. Edmond SL, Felson DT. “Prevalence of Back Pain In Elders.” Journal of Rheumatology, 2000;27:220-225.
2. Boden SD. “The Use of Radiographic Imaging Studies in the Evaluation of Patients who have Degenerative Disorders of the Lumbar Spine.” Journal of Bone and Joint Surgery, 1996;78(1):114-124.
3. Nowakowski P, Delitto A, Erhard RE. “Lumbar Spinal Stenosis.” Physical Therapy, 1996;76(2):187-190.
4. Iversen MD, Katz JN. “Examination Findings and Self-Reported Walking Capacity in Patients with Lumbar Spinal Stenosis.” Physical Therapy, 2001;81(7):1296-1306.
5. Whitehurst M, Brown LE, Eidelson SG, D’Angelo A. “Functional Mobility Performance in an Elderly Population with Lumbar Spinal Stenosis” Arch Phys Med Rehabil, 2001;82:464-467.
6. Johnsson KE, Rosen I, Uden A. “The Natural Course of Lumbar Spinal Stenosis.” Journal of Clinical Orthopedics and Related Research, 1992;279: 82-86.
7. Rivest C, et al. “Effects of Epidural Steroid Injection on Pain due to Lumbar Spinal Stenosis or Herniated Discs: A Prospective Study.” Arthritis Care and Research, 1998;11(4):291-297.
8. Fritz JM, et al. “Lumbar Spinal Stenosis: A Review of Current Concepts in Evaluation, Management and Outcome Measures.” Arch of Phys Med and Rehabil, 1998;79:700-708.
9. Fritz JM, Erhard RE, Vignovic M. “A Nonsurgical Treatment Approach for Patients with Lumbar Spinal Stenosis.” Physical Therapy, 1997;77(9):962-973.