DESCRIPTION
SIGNS & SYMPTOMS
PT IMPLICATIONS
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- Constriction of the spinal canal that can affect multiple areas. Due to osteophyte growth and decrease in intervertebral disc space there can be possible forces on the spinal cord if it is center focused spinal stenosis, or lateral stenosis which can encroach on the nerves that exit the spinal cord.
SIGNS & SYMPTOMS
- Pain, especially in the lower back; pain, aching, cramping, and numbness in the buttock and/or lower extremities that radiate distally in a dermatomal distribution
- Patients may also complain of weakness or heaviness in the lower extremities
- Neurogenic claudication is present and is relieved with trunk flexion
- Patients often describe worsening pain with lumbar extension postures, including standing and walking
- Symptoms usually have an insidious onset and progress gradually over time
- Symptoms are variable because one or multiple nerve roots may be affected at one or multiple locations within the lumbar spine
- Narrowing can be localized to the central canal, the lateral recess, or the neural foramen resulting in different patterns of symptoms:
- Lateral spinal stenosis
- Typically occurs at L4-S1
- Generally presents as sciatica without low back discomfort
- Symptoms are worsened by rotation and extension and are typically intermittent
- Central spinal stenosis
- Multisegmental, with a typical range of 2–5 vertebral segments impacted
- The site most frequently affected is L3-L4
- The diagnosis is based on clinical examination and may be confirmed with CT scans or MRI. Not all patients with significant narrowing on imaging have symptoms and vice versa. X-rays can identify coexisting degenerative spondylolisthesis or degenerative scoliosis. CT scans and MRI can help to identify the exact location and severity of narrowing and identify impingement on the spinal cord or spinal nerve roots. CT is better for looking at bony detail and compression from osteophytes. Myelography and postmyelography CT can provide additional information on the extent of stenosis and are the test of choice when MRI cannot be performed. Electrodiagnostic tests such as needle electromyographic examination (NEE) may be performed. Their sensitivity to diagnose conduction abnormalities is greatest in patients with severe or advanced lumbar spinal stenosis.
- The correlation between clinical findings and radiological findings is weak) however, a high proportion of physical therapists (PTs) report that they regularly refer patients for radiologic investigations when neurogenic claudication is suspected. Unless a surgical opinion is being sought, such referral may be unnecessary
PT IMPLICATIONS
- The goals of physical therapy are to improve muscle strength and flexibility, functional mobility, and pain levels. Spinal stenosis is a progressive, degenerative condition, so the goal is to maximize functional ability. Physical therapy interventions include manual therapy, modalities, therapeutic exercise, body-weight-supported treadmill walking, cycling, stretching of lower extremity and trunk muscles, aquatic therapy, activity modification, and patient education. A need for research evidence to guide the choice of physical therapy treatments has been identified
- There is insufficient evidence regarding the effectiveness of physical therapy in lumbar spinal stenosis
- A systematic review found insufficient evidence to draw conclusions about the effectiveness of exercise as a standalone treatment for lumbar spinal stenosis
- There is a lack of randomized controlled trials (RCTs) comparing physical therapy outcomes to the natural history of lumbar spinal stenosis, and a lack of use of standardized techniques and validated outcomes
- In certain subgroups, physical therapy and exercise may be beneficial in controlling symptoms of neurogenic claudication
- Acute stage:
- Rest, Ice, NSAIDs, and Quadricep strengthening exercises
- Subacute/chronic stage:
- Strengthen Lower extremity musculature with the emphasis of eccentric strengthening
- Lengthen shorten muscles
- Patient education: Teach the patient how to land softly. Look at functional movements like step down and orientation of their knee.
- Orthotics
- If symptoms persist for more than 6 to 8 weeks with conservative treatment, an orthopedic consultation is recommended.
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