Health & Exercise Forum

Treatment and Prevention

Last week, in part I on spinal stenosis, we discussed the definition and diagnosis of the problem and why people with the disease have difficulty walking and standing and preferred sitting.This week we discuss treatment options and prevention for this problem. If a diagnosis of lumbar spinal stenosis is confirmed, the physician may choose conservative treatment. While the condition affects approximately 8-11% of Americans, mostly over 50, surgery is only a viable option in advanced cases in which nerve damage and weakness in the muscles of the legs is evident. In these cases, it is purported that surgery is approximately 80% effective. The purpose of this column will be to present conservative, non-operative measures. While conservative measures will not reverse the degenerative spinal changes that have already occurred, they can make accommodations and allow for improved function and possibly retard progression of the disease. Conservative management includes:

Medications:

There are a wide variety of medications for the treatment of spinal stenosis which may be used according to the stage or seriousness of your problem.

1. anti-inflammatory medications (over-the-counter non-steroidal anti-inflammatory drugs (NSAID’s) or steroids.
2. analgesics-pain killers
3. anti-depressants-decreases nerve pain
4. Nerve pain medications and anticonvulsants (Neurontin – Gabapentin)
5. Steroid injections into the epidural space or facet joints

Posture/Position Retraining:

Most people with spinal stenosis have discovered through experience (cause and effect), that some positions and activities seem to aggravate their symptoms while others provide relief.

1. Patient education regarding posture, body mechanics, activity modification, and ergonomic training.
2. Avoid rounded shoulders.
3. Avoid excessive arching of the lower back.
4. Avoid overhead reaching – use your nose as a guide – if higher than your nose, use a step stool or a ladder.
5. Sleep with a pillow under knees.
6. Limit activities that increase symptoms.
   1. Prolonged weight bearing (standing and walking).
   2. Determine walking and lifting limits.

Physical Therapy:

Spinal stenosis is too complicated for the average person to establish an exercise or treatment program without professional help. In fact, many traditional exercises will aggravate the problem.

In addition to posture retraining and ergonomics, a comprehensive physical therapy program includes strengthening of the core and leg muscles, improving range of motion in the hips and lower back to increase the opening of the nerve canals, and increasing endurance to the leg muscles, all in a concerted effort to restore function.

1. Walking program: Walking on an inclined treadmill (15 degrees)
2. Aquatic therapy – used in early stages if land based walking cannot be tolerated. But, in time must advance from pool walking to land to improve function.
3. Walking program with a rollator walker or walking as tolerated. Level driveway, sidewalk or shopping mall.
4. Aerobic and cardiovascular exercises.
5. Stationary bike--With or without backrest
6. Swimming using side or backstroke. Avoid breast stroke and overhead crawl because it increases extension of the spine which further closes the canal.
7. Range of Motion Exercises: to restore spine mobility.
   1. Knees to Chest: lying in bed, use both hands to bring both knees up toward chest. Stop at 90 degrees and hold 10 seconds. Repeat 10 times. Advance to 95 – 100 –105 degrees weekly.
8. Leg Strengthening: Start exercises sitting for comfort. Perform slowly and repeat 10 times:
   1. Hip Hike: sit in chair, hike hip up 4-6 inches
   2. Hip Squeeze: sit in chair, squeeze pillow 5 seconds
   3. Leg Kick: sit in chair, kick leg out straight
   4. Gas Pedal: sit in chair, pump feet up and down
9. Lumbar stabilization (core) exercises: Tighten Abdominal Muscles-Lying in bed flatten back into bed using abdominal muscles. Hold for 5 seconds repeat 10 times
10. Balance training: Hold onto countertop, flatten back using abdominal muscles, Lift one leg, hold 5 seconds, repeat using other leg, perform 5 times
11.   Pain control (without meds) – Massage, moist heat, ice, home electrical stimulation device

Knees To Chest

Conclusion:

Since 25% to 50% of individuals treated non-surgically had satisfactory outcomes, conservative management is generally recommended for the elderly patients and those with mild to moderate symptoms.When conservative, non-operative management fails, when symptoms are severe, or in rare cases of rapid progression of leg weakness, and loss of function, surgery  may be recommended. Surgery is indicated for individuals who failed non-surgical therapy and who have advanced imaging studies (MRI, CT, etc.) that correspond to the existing symptoms. Generally, an individual with spinal stenosis will undergo a decompressive laminectomy and occasionally a fusion. Surgical success rates up to 90% have been reported and high percentages of patients express satisfaction with the results.

Spinal stenosis is not necessarily progressive deterioration! Some individuals do deteriorate over time and eventually require surgery. However, large percentages of people with spinal stenosis maintain or improve with time. Also, consultation with your primary care physician and possibly a physiatrist, neurologist, neurosurgeon or orthopedic surgeon may be required to eliminate other possible causes of your symptoms: vascular problems, hip osteoarthritis, unstable degeneration of the spine, herniated lumbar disc, or peripheral nerve problems.

Contributions: Janet Caputo PT, DPT, OCS

Visit your doctor regularly and listen to your body.

NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum”  in the Scranton Times-Tribune.

This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com.

Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at Gesisinger Commonwealth School of Medicine.