Lumbar Stenosis

Spinal Stenosis

Do you get increasing back and leg pain with walking or standing? Is the pain quickly relieved by sitting?  Does your tolerance to walking GREATLY improve with you leaning on a shopping cart? Are you over 40?  A yes to most or all of the questions can STRONGLY suggest you might be suffering from spinal stenosis.

There can be stenotic changes in the neck, but the purpose of this article is understanding and home care for lumbar stenosis. Spinal stenosis is not only debilitating, but it affects millions of people each year and is one of the top reason people over 45 years old have surgery. Not only is surgery risky, but it’s effectiveness has continued to be questioned.

The research supports conservative care first.

With the combination of chiropractic care, rehabilitation, soft tissue therapy and home care, all working to affect the whole person and body, it’s time we became the first option.  Stenosis is one of the toughest things that I treat, and not all cases respond, but an aggressive course of conservative care should be the first line treatment.

You may (or may not) be surprised to learn that manipulation is one of the best care options for people suffering from spinal stenosis.

“Improvement was self-described as “good” or “excellent” in 80% of patients.” – JMPT, 2009

Stenosis patho-anatomy

To “stenose” is to narrow.  Stenosis can happen in our blood vessels, or any ‘tunnel’ in our body.  Spinal Stenosis is a narrowing of space affecting the nerves.  There are several kinds, but their presentation, and conservative treatment might be similar.  Spinal Stenosis is generally an advanced arthritic changes.  A narrowing of the spinal canal, will cause symptoms bilaterally into both legs.  When it affects the neural foramen, where the nerve exits the spine, symptoms can be more unilateral.

An astronaut who is in space for a year will experiences bone loss and bone demineralization or ligamentous thinning from extended periods not dealing with gravity.  A stenotic back is the polar opposite.  Their joints have adapted to stress by thickening.  The facet joint might be enlarged causing nerve root encroachment, or the big ligament that runs down the inside of our spinal canal might be enlarged (or hypertrophic) narrowing the spinal canal.

The symptoms of stenosis often starts with simple lower back pain. Over time, the pain may progress; numbness, tingling and weakness into the legs. Usually stenotic patients have a long history of back pain, but this isn’t always the case.  The hallmark complaint is the increasing leg pain/weakness with walking.  This is called Neurological Claudication.  It is always important to rule out to rule out Vascular Claudication.  It’s the reason a lot of individuals have had stents put in their leg arteries.  They can look awful similar, but a thorough exam can differentiate.

Stenosis - Treatment

Chiropractic adjustments can open up stenotic regions, taking the pressure off the nerve. Theses stenotic canals, are “opened” when a gentle adjustment is given, and proper motion to the vertebrae is restored. This helps takes the pressure off of the nerve, allows the pain to cool off, and the function to increase.

There’s a Coldplay song that I have always loved.  The line in it that resonates with me is:  “Nobody said it was easy, but no one ever said it would be this hard, oh take me back to the start”  Anyone that tells you they can ‘fix’ stenosis in X number of visits either doesn’t understand the biology, or is a shyster sales guru (aka lying). It’s not an easy fix. Stenosis is about getting some degree of relief, and then long term management.

Stenosis - Rehab and Management

Given the degenerative nature of Spinal Stenosis, addressing the rest of the musculoskeletal system can help ‘unload’ the stenotic area of the spine.  Typically, stenotic spines do better in flexion; hence the improved walking tolerance when pushing the grocery cart.  Manipulation is usually flexion biased.  To further compliment that, we might prescribe flexion based home exercises, and try to improve extension elsewhere.

Two adjoining areas where extension can, and should be, improved is the hips and the thoracic spine.  If we can improve extension here, we can effectively ‘ask less’ of the spine in standing and walking.  We’d continue with this “Joint by Joint” approach and work to improve lumbar stabilization.

Stenosis - Walking Program

Home exercise cannot stop there though. What I often say is that “a better back cannot be given to you, you will have to take it for yourself.” I want to help you take control and guide you on this process. Since walking is the most common painful factor, let’s address it.  Through gradually increasing walking times you can desensitize your back, and start to improve your walking tolerance.  Walking is a particularly good choice for seniors.  Walking for exercise isn’t just linked to better cardiovascular health, its linked to decreased rates of dementia and Alzheimer’s.

Here is my standard walking prescription.

  1. Figure out how long you can walk before symptoms start to increase.  Let’s say that at the 90 second mark, you get increasing symptoms.  At that point, you could keep walking, but don’t.  Sit down.
  2. How long does it take for symptoms to abide?  Typically, its near instant, but if we walked again right away symptoms would return right away.

We will want to train walking, but we also want the back to desensitize and calm down.  Therefore, we have to establish a minimum rest period.  Figuring out how long you need to rest is difficult, and highly individualized.  A 1:1 ratio of work (walking) to rest, will usually do it. But when your tolerance is a higher amount, say ten minutes, you probably don’t need to rest as long.

The plan is to walk about 75% of your tolerance.  Our 90sec onset patient will walk for 60-75 seconds, then rest for (approximately) equal time.  During the rest period doing some of your prescribed exercises is ideal, but simply resting is fine too. Then repeat the process.  If symptoms start sooner during subsequent round, shorten your walking times and/or lengthen your rest times. In more severe cases, the rest periods will need to be longer, and that is fine.

Graded Exposure - Stenosis solution for walking intolerance

This is graded exposure.  Doing a non-threatening amount, and gradually increasing the amount over a longer period of time.  It is time consuming and often difficult logistically. “Nobody said it was easy.”  I’d want you doing this 2-5 days a week depending on your condition and current fitness levels.

This is logistically possible and I would highly recommend my Branson crowd consider joining First Baptist Church Life Fitness Center.  They have a 1/16-mile walking track that is perfect for this.

Each week, add 10% to your time on 1-2 of the days. So if you’re willing to do this three days a week, week 1 would be all the same, 60-75seconds.  Week 2, one of the days you’d do a touch longer, pushing your limits more, 70-85 seconds walking.  Again, peeling back in subsequent rounds as needed.  The third week, it’d be all at the higher mark of 70-85sec, the fourth you’d add a touch to one day, the fifth, all at that higher mark and so on.  Over time, gradually, you can improve your walking tolerance.

How long do you do this?  Ideally wed get a solid 40+ minutes of walking time, but I know that is a daunting amount of time, so work up gradually.  Its common for stenotic patients to be coming from a point of very low fitness, so even starting at 5-10 minutes is a significant improvement.  Just get moving, and progressively increase.

Stenosis - quick and dirty

Stenosis is a difficult to treat, but an easy to understand condition.  The nerves are being pinched at various locations by arthritic changes.  An initial conservative approach is almost always warranted.  This should include manipulation/mobilization to the affected joints, and strategies to improve global movements in the adjoining hip and thoracic spine as well as abdominal and core strength.  Progress is always gradual, and increasing general fitness with the aforementioned walking program is an excellent way to improve your tolerance.

So if you have been suffering from a pinched nerve due to arthritis, bone spurs or ligament overgrowth; do not hesitate to reach out to see if our model of chiropractic care may be the best solution to get you on track and feeling great as quickly as possible.

I hope this information and video helps

Thanks

Dr. Zach

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