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Lumbar Spinal Stenosis

Original Editors - Stefanie Van De Vijver, Pauline Bouten, Astrid Lahousse, Roxane Roosens and Laure Lievens

Top Contributors - Donald John Auson, Astrid Lahousse, Stefanie Van De Vijver, Kim Jackson, Roxane Roosens, Pauline Bouten, Lucinda hampton, George Prudden, Laure Lievens, Manisha Shrestha, Rosie Swift, Khloud Shreif, Sai Kripa, Shreya Pavaskar, Ewa Jaraczewska, Mariam Hashem and Ahmed M Diab  

Introduction

Lumbar spinal stenosis (LSS) is a degenerative condition characterized by the narrowing of the spinal canal in the lower back. It typically affects individuals over 60 years of age and is a significant cause of disability in the elderly. The narrowing can occur in the central canal, lateral recess, or vertebral foramina, leading to compression of neural and vascular elements.

Key points about lumbar spinal stenosis include:

  1. It can cause radiating pain, numbness, and weakness in the buttocks, thighs, or legs, particularly during walking or standing for extended periods.
  2. Symptoms often improve when sitting, resting, or bending forward.
  3. The condition is usually related to aging and degenerative changes in the spine.
  4. Not all patients with spinal narrowing develop symptoms; a diagnosis is only made when symptoms are present.
  5. It is the most common reason for spinal surgery in patients over 65 years old.
  6. There is currently no universally accepted definition or radiologic diagnostic criteria for LSS.
  7. The differential diagnosis is broad, as LSS can mimic or coexist with other conditions, especially in older adults.
  8. Diagnosis typically involves a combination of clinical presentation, imaging findings, and sometimes electrodiagnostic tests.
  9. The condition can significantly impact a person's quality of life, particularly affecting their walking capacity and ability to perform daily activities.[1].[2][3][4]

[5]

Clinically Relevant Anatomy

See Lumbar Anatomy: This anatomy is crucial in understanding how narrowing in various parts of the spinal structure can lead to compression of neural elements, resulting in the symptoms associated with lumbar spinal stenosis.[6][7]

Epidemiology

The epidemiology of lumbar spinal stenosis (LSS) can be summarized as follows:

  • Prevalence: LSS is estimated to affect 4.9% of the general adult population.
  • Age: The prevalence increases with age, affecting 6.8% of individuals 50 years or older, and 9% of those 70 years or older.
  • Gender: Some studies suggest a higher prevalence among women, though this is not consistently reported across all research.
  • Leading cause: LSS is the most common reason for spinal surgery in patients over 65 years of age.
  • Degenerative nature: As a degenerative condition, its incidence increases with age, primarily affecting individuals over 60 years old.
  • Asymptomatic cases: Not all individuals with anatomical spinal stenosis develop symptoms, making it challenging to determine exact prevalence.
  • Global impact: While specific international frequencies are not provided, LSS is recognized as a significant cause of disability in older adults worldwide.
  • Comorbidities: LSS often coexists with other spinal conditions, particularly in elderly populations, which can complicate epidemiological studies.

It's important to note that due to variations in diagnostic criteria and the often asymptomatic nature of anatomical stenosis, precise epidemiological data can be challenging to establish.[8],[9][10][11]. [12][13][14][15][16][17]

Etiology

The etiology of lumbar spinal stenosis (LSS) can be broadly categorized into congenital and acquired causes:

Congenital:

  • Idiopathic
  • Achondroplasia
  • Short, thick pedicles leading to a stenotic central canal

Acquired (more common) include:

  1. Degenerative disc disease - most frequent cause
  2. Age-related changes:
    • Disc degeneration and bulging
    • Facet joint hypertrophy
    • Ligamentum flavum hypertrophy
    • Osteophyte formation
  3. Spondylolisthesis - forward slippage of one vertebra over another
  4. Osteoarthritis
  5. Others: Spinal injuries or trauma; Post-surgical changes; Tumors (rare); Paget's disease; Ankylosing spondylitis; Rheumatoid arthritis

LSS most commonly affects the L4-L5 level, followed by L3-L4, L5-S1, and L1-L2. The condition typically results from a combination of these factors, with degenerative changes being the primary cause in older adults.[18] [4] [2]

Characteristics/Clinical Presentation

The characteristics and clinical presentation of lumbar spinal stenosis (LSS) typically include:

  • Neurogenic claudication: Pain, numbness, or weakness in the buttocks, thighs, or legs that worsens with walking or standing for prolonged periods.
  • Positional relief: Symptoms often improve with sitting, resting, or bending forward (flexion).
  • Exacerbation with extension: Pain typically increases when the spine is extended.
  • Bilateral symptoms: Often affects both legs, though can be asymmetrical.
  • Gradual onset: Symptoms usually develop slowly over time.
  • Low back pain: May be present, but leg symptoms often dominate.
  • Reduced walking capacity: Patients may report difficulty walking long distances.
  • "Shopping cart sign": Patients often find relief by leaning forward on a shopping cart while walking.
  • Weakness: May occur in the legs, particularly after walking.
  • Sensory changes: Numbness or tingling in the legs or feet.
  • Normal or subtle neurological findings: Physical examination may reveal only mild abnormalities.
  • Rarely, bowel or bladder dysfunction in severe cases.
  • Pain relief with sitting or lying down.
  • Bicycle test: Patients may be able to ride a stationary bicycle longer in a flexed position compared to an upright position.

The presentation can vary among individuals, and symptoms typically worsen over time if left untreated.[19][20][11][21]

Differential Diagnosis

The differential diagnosis of spinal stenosis is broad and differentiation between several conditions may be complicated because of their frequent coexistence, certainly in the elderly. Pathologies/diseases that mimic lumbar spinal stenosis are numerous. [6]

Diagnostic Procedures

The diagnostic procedure for lumbar spinal stenosis (LSS) typically involves:

  1. Clinical history: Detailed patient history focusing on symptoms, their onset, progression, and factors that worsen or alleviate them.
  2. Physical examination: Assessment of gait, range of motion, neurological function, and specific tests like the bicycle stress test.
  3. Imaging studies:
  • X-rays: To evaluate bony structures and alignment
  • MRI: Primary imaging modality, showing soft tissue and neural structures
  • CT scan: Useful for detailed bony anatomy, especially if MRI is contraindicated

Other diagnostic tools include:

  1. Electrodiagnostic testing: Electromyography (EMG) and nerve conduction studies may be used in atypical cases or when other conditions are suspected.
  2. Functional assessments: Tests like the bicycle stress test or treadmill test to evaluate claudication.
  3. Questionnaires: Specific tools like the Swiss Spinal Stenosis Questionnaire or Oswestry Disability Index to assess symptom severity and functional impact.
  4. Differential diagnosis: Ruling out other conditions with similar symptoms.
  5. Correlation of clinical findings with imaging: Ensuring symptoms match radiological evidence, as asymptomatic stenosis is common.

It's important to note that diagnosis is based on a combination of clinical presentation and imaging findings, as radiological evidence alone is not sufficient for diagnosis. The lack of a universally accepted "gold standard" for LSS diagnosis means that a comprehensive approach using multiple diagnostic tools is often necessary.[8][22].[4] [23] [24].[10][25].[10]

Outcome Measures

Lumbar spinal stenosis is related to neurogenic claudication, which is a leading cause of pain and disability. Therefore, specific questionnaires can be used for the assessment of a patient with lumbar spinal stenosis (LSS)[26][27].

Examination

The physiotherapy examination is a comprehensive process that involves both subjective and objective assessments.

  1. Objective Assessment:
    • Observation: Assessing posture, gait, visible abnormalities, and patient movements
    • Palpation: Hands-on examination to detect tenderness, swelling, or abnormalities
    • Joint assessment: Evaluating range of motion, stability, and joint integrity
    • Muscle assessment: Examining strength, endurance, and flexibility
    • Neurological tests: Assessing sensation, reflexes, and nerve function

Specific tests include:

  1. Bicycle Stress Test
  2. Two-Stage Treadmill Test [36]
  3. Motor Examination: crucial component in assessing patients with suspected lumbar spinal stenosis (LSS)it's purpose being:
    • To detect weakness in specific muscle groups
    • To identify the involved spinal level
    • To assess neurological dysfunction
  1. Key components:
  • Testing strength of great toe extensors
  • Evaluating hip abductor strength (using Trendelenburg test)
  • Assessing ability to walk on toes (S1 root involvement)
  • Checking heel walking ability (L4 or L5 nerve dysfunction)
  1. Specific tests:
  • Trendelenburg test: Observes for hip abductor weakness
  • Toe walking: Difficulty suggests S1 root involvement
  • Heel walking: Difficulty indicates L4 or L5 nerve dysfunction
  1. Myotome testing: Helps identify the specific level of nerve root involvement and provides information about pathoanatomy in the lumbar spine. While motor examination is important, it's worth noting that some research suggests physical examination findings alone may not be definitive in determining the presence or absence of LSS. The motor examination should be considered alongside other clinical findings and imaging results for a comprehensive assessment.[37].[38][39][40]

Medical Management

Medical management for lumbar spinal stenosis:

  1. NSAIDs: First-line for short-term pain relief
  2. Acetaminophen: Alternative for pain management
  3. Opioids: Limited use, not more effective than NSAIDs
  4. Muscle relaxants: Not proven more effective than NSAIDs
  5. Gabapentin: May help with radicular symptoms
  6. Epidural steroid injections: Can provide short-term relief
  7. Calcitonin: Some evidence for symptom improvement
  8. Prostaglandin E1 derivatives: May improve walking distance

Note: Medications aim to manage symptoms and enable participation in physical therapy. Long-term effectiveness is limited, and potential side effects should be considered.[41]

Surgical Management

Surgical management for lumbar spinal stenosis:

  1. Considered when conservative treatment fails
  2. Most common procedure: Decompressive posterior laminectomy
  3. Goal: Relieve pressure on spinal nerves
  4. Other options: Bilateral laminotomy, unilateral laminotomy, partial facetectomy, split-spinous process laminotomy/laminoplasty
  5. Fusion may be added if instability is present
  6. Choice depends on location and type of stenosis
  7. Generally elective, except in emergencies like cauda equina syndrome
  8. Aim: Improve function rather than prevent neurologic impairment
  9. Evidence suggests benefit, at least in short term (Class 1b evidence)
  10. Outcomes generally better for patients with predominant leg pain

Surgical approach should be tailored to individual patient needs and anatomical considerations.[42][4]

Physical Therapy Management

Physiotherapy for lumbar spinal stenosis (LSS) typically involves a combination of approaches:

  1. Flexibility and stability training: Core strengthening exercises; Stability exercises; Flexibility training; Lumbar flexion exercises. Preferred over extension exercises. Helps increase the cross-sectional area of the spinal canal and lateral recesses
  2. Exercise programs: General conditioning using body weight-supported treadmill walking or stationary cycling; Strengthening exercises for trunk and lower extremities; Exercises to maintain back flexibility; Correction of lumbar lordosis
  3. Manual therapy: Techniques for the spine and hips; Joint mobilization and distraction for spine, sacroiliac joint, and hip
  4. Neural mobilization: Aims to improve nutrition to compressed nerve roots; Enhances nerve gliding to relieve radicular symptoms
  5. Hydrotherapy
  6. Pelvic/lumbar manual traction: Stretches para-spinal muscles; Temporarily widens joint spaces
  7. Postural education: Ergonomic advice; Techniques for proper lifting, pushing, and pulling
  8. Pain management: Heat therapy to improve blood circulation; TENS (Transcutaneous Electrical Nerve Stimulation)
  9. Functional training: Activities of Daily Living (ADL) training; Functional movement exercises
  10. Education: On condition management; Importance of frequent position changes

The physiotherapy program is typically individualized based on the patient's specific symptoms, functional limitations, and goals. Treatment aims to reduce pain, improve function, and prevent symptom progression.[43].[44] [45][46][8][47].[30]. The youtube below shows some good exercises to use in treating clients with LSS.

[48]

Patient Education

  1. An anatomical explanation for the patients symptoms may contribute to a fear avoidance of activity and an over medicalization of the problem[49]
  2. Helpful advice may include items such as: Temporary avoidance of prolonged overhead activities; Temporary avoidance of prolonged axial loading (standing, use of backpacks, prolonged overhead working postures);Methods of self lumbo-pelvic flexion and/or rotational stretching techniques for pain control in standing, sitting, and lying.
  3. Basic body mechanics are taught to the patient with LSS, and they should be advised: To change positions frequently; Know and respect their current limits; To pace activities such as housework and yard work[10][50]
  4. Finally, patients should be aware of the natural course of this condition and patients should know that the majority of those with LSS do quite well over time, their condition either remaining the same or improving over time with no intervention at all[51] and that long term results are often no different when comparing those who received surgery for LSS and those who were treated non-surgically[10][52][53][54]

Manual Therapy

A recent systematic review[55] concluded that the use of manual therapy in conjunction with exercise is of potential benefit for the LSS population.[56] including:

  • Flexion–distraction manipulations,
  • Sidelying lumbar rotation thrust,
  • Posterior-to-anterior mobilizations,
  • Sidelying translatoric side bending manipulations,
  • Thoracic thrusts,
  • Neural mobilizations[10][52][53][54][57][58]

Manual Therapy Interventions

The manual therapy interventions provided in the randomized controlled trial (RCT) by Whitman et al. for patients with lumbar spinal stenosis included:

  1. Flexion-distraction manipulations
  2. Sidelying lumbar rotation thrust
  3. Posterior-to-anterior mobilizations
  4. Sidelying translatoric side bending manipulations
  5. Thoracic thrusts
  6. Neural mobilizations

The study found that the combined use of these manual therapy techniques appears to be an effective intervention. [59]

Hip Mobility/ Strength Exercises

  1. Muscles around the hip, such as: the hamstrings, rectus femoris, piriformis and tensor fascia latae can become shortened and the patient may respond positively to manual and self-stretching of these muscles.[10]
  2. Weakness in the hip extensors and abductors complete the picture of typical muscle imbalances in the hip region of the patient with LSS, and should be addressed through a progressive resistive exercise program that is vigorous enough to affect strength change[60][10]

Core Strengthening

Core strengthening is a key component in the physiotherapy management of lumbar spinal stenosis. Core strengthening exercises focus on improving the strength and stability of the muscles that support the spine and pelvis. These exercises typically target the abdominals, obliques, transverse abdominis, and gluteal muscles.

For patients with lumbar spinal stenosis:

  1. Exercises are generally performed with a flexion bias to minimize symptoms.
  2. Patients are taught to control pelvic position and motion, often using a posterior pelvic tilt (PPT) to relieve symptoms while standing or walking.
  3. The program starts with basic exercises and progresses to more advanced ones as the patient's control and strength improve.
  4. Exercises should be performed while maintaining correct lumbopelvic posture and control of the deep muscles.
  5. The specific dosage of exercises may vary, but the focus is on maintaining good control throughout.
  6. Core strengthening is often combined with other interventions like manual therapy and body-weight supported treadmill walking for optimal outcomes.

The goal of core strengthening in this context is to improve spinal stability, enhance functional capacity, and reduce pain associated with lumbar spinal stenosis.[60][10][50][61][35] [62] [63]

Clinical Bottom Line

The clinical bottom line for lumbar spinal stenosis (LSS) can be summarized as follows:

  1. Definition: LSS is a condition where the spinal canal or one or more of the lumbar vertebral foramina becomes narrowed, potentially causing compression of the spinal cord or spinal nerves.
  2. Symptoms: Include low back pain, buttock pain, leg pain, and numbness. These symptoms are typically aggravated by walking and relieved by resting.
  3. Conservative Treatment: Should be the initial approach for most cases of LSS. This includes:
    • Patient education
    • Manual therapy
    • Aerobic training
    • Exercise interventions (strengthening, stretching, mobilization)
    • Pelvic tilts
    • Lower back stabilization
  4. Physical Therapy Timing: Patients who receive physical therapy treatment in the first six weeks are less likely to undergo surgery at one-year follow-up.
  5. Outcomes: Patients who had physical therapy during the first 6 weeks showed:
    • Higher levels of self-rated major improvements at 3-6 months and 1 year
    • Greater reduction in leg pain after 1 year
  6. Surgery Consideration: If non-operative treatment fails, surgical treatment may be considered. The decision for surgery is based on the degree of physical disability and disabling pain.
  7. Treatment Goals: Interventions aim to relieve symptoms of spinal stenosis and prevent progression of the condition.

This clinical bottom line emphasizes the importance of early conservative management, particularly physical therapy, in the treatment of lumbar spinal stenosis, with surgery being considered only after non-operative approaches have been exhausted.

References

  1. ↑ Kreiner DS, Shaffer WO, Baisden JL, Gilbert TJ, Summers JT, Toton JF, Hwang SW, Mendel RC, Reitman CA. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). The Spine Journal. 2013 Jul 1;13(7):734-43.
  2. ↑ 2.0 2.1 Mazanec DJ, Podichetty VK, Hsia A. Lumbar canal stenosis: start with nonsurgical therapy. Cleveland Clinic journal of medicine. 2002 Nov 1;69(11):909-17.
  3. ↑ Melancia JL, Francisco AF, Antunes JL. Spinal stenosis. Handbook of clinical neurology. 2014 Jan 1;119:541-9.
  4. ↑ 4.0 4.1 4.2 4.3 Wu L, Cruz R. Lumbar spinal stenosis. InStatPearls [Internet] 2018 Oct 27. StatPearls Publishing. Available from: Wu L, Cruz R. Lumbar spinal stenosis. InStatPearls [Internet] 2018 Oct 27. StatPearls Publishing.Last accessed 26.1.2020)
  5. ↑ Depuy Synthes Companies. What is Spinal Stenosis. Available from: https://www.youtube.com/watch?v=31RuBxzXhr0 (last accessed 8.3.2019)
  6. ↑ 6.0 6.1 Cohen MS, Wall EJ, Kerber CW, Abitbol JJ, Garfin SR. The anatomy of the cauda equina on CT scans and MRI. The Journal of bone and joint surgery. British volume. 1991 May;73(3):381-4.
  7. ↑ David G. Borenstein, James S. Panagis, Peter C. Gerszten, and James N. Weinstein, Questions and answers about spinal stenosis, National institute of health
  8. ↑ 8.0 8.1 8.2 Costandi S, Chopko B, Mekhail M, Dews T, Mekhail N. Lumbar spinal stenosis: therapeutic options review. Pain Practice. 2015 Jan;15(1):68-81.
  9. ↑ Kalichman L, Cole R, Kim DH, Li L, Suri P, Guermazi A, Hunter DJ. Spinal stenosis prevalence and association with symptoms: the Framingham Study. The Spine Journal. 2009 Jul 1;9(7):545-50.
  10. ↑ 10.0 10.1 10.2 10.3 10.4 10.5 10.6 10.7 10.8 Backstrom KM, Whitman JM, Flynn TW. Lumbar spinal stenosis-diagnosis and management of the aging spine. Manual therapy. 2011 Aug 1;16(4):308-17.
  11. ↑ 11.0 11.1 Skinner HB, McMahon PJ. Current Diagnosis& Treatment in Orthopedics. 5th Edition. U.S.A.: Mc Graw Hill Education; 2014.
  12. ↑ Melancia JL, Francisco AF, Antunes JL. Handbook of Clinical Neurology: Spinal Stenosis. Handb Clin Neurol. 2014;119:541-9. [LoE: 3A] [Abstract
  13. ↑ Meyer F, Börm W, Thomé C. Degenerative Cervical Spinal Stenosis. Dtsch Arztebl int. 2008 mey; 105(20): 366-372. [LoE: 3A]
  14. ↑ Genevay S, Atlas SJ. Lumbar Spinal Stenosis. Best Pract Res Clin Rheumatol. 2010 Apr;24(2):253-65. [LoE: 3A]
  15. ↑ Wise C., Spinal stenosis, American College of Rheumatology, 2013.
  16. ↑ Ogiela D., Spinal stenosis, National Library of Medecin, 2012.
  17. ↑ Cluett J., M.D, Spinal stenosis, Orthopedics, 2010.
  18. ↑ Fritz JM, Erhard RE, Vignovic M. A nonsurgical treatment approach for patients with lumbar spinal stenosis. Physical therapy. 1997 Sep 1;77(9):962-73.
  19. ↑ Barbaro K, Midgley J. Priapism, a symptom of claudication of the cauda equina in spinal stenosis. Musculoskeletal Science and Practice. 2021 Apr 1;52:102337.
  20. ↑ Gallucci M, Puglielli E, Splendiani A, Pistoia F, Spacca G. Degenerative Disorders of the spine. Eur Radiol. 2005 Mar;15(3):591-8. [LoE: 2C]
  21. ↑ De Graaf I, Prak A, Bierma-Zeinstra S, Thoma S, Peul W, Koes B. Diagnosis of lumbar spinal stenosis: a systematic review of the accuracy of diagnostic tests. Spine. 2006 May;31(10):1168–1176. [LoE: 3A]
  22. ↑ Wu AM, Zou F, Cao Y, Xia DD, He W, Zhu B, Chen D, Ni WF, Wang XY, Kwan KY. Lumbar spinal stenosis: an update on the epidemiology, diagnosis and treatment. AME Medical Journal. 2017.
  23. ↑ Lee SY, Kim TH, Oh JK, Lee SJ, Park MS. Lumbar Stenosis: A Recent Update by Review of Literature. Asian Spine J. 2015:9(5):818-828. [LoE: 3A
  24. ↑ 1.     Kalff R, Ewald C, Waschke A, Gobisch L, Hopf C. Degenerative lumbar spinal stenosis in older people – current treatment options. Dtsch Arzetbl Int 2013;110(37):613–24. [LoE: 1A]
  25. ↑ 1.     Goldman L, et al. Questions and answers about spinal stenosis. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Cecil Medicine. 24th ed. Philadelphia, Pa.: Saunders Elsevier; 2012.
  26. ↑ Pratt RK, Fairbank JC, Virr A. [The Reliability of the Shuttle Walking Test, the Swiss Spinal Stenosis Questionnaire, the Oxford Spinal Stenosis Score, and the Oswestry Disability Index in the Assessment of Patients With Lumbar Spinal Stenosis.] Spine. 2002 Jan 1;27(1):84–91.
  27. ↑ 1.     Ammendolia C et al. Nonoperative treatment for lumbar spinal stenosis with neurogenic claudication. Cochrane Database Syst Rev. 2013 Aug;30(8). [LoE: 1A]
  28. ↑ Pratt RK, Fairbank JC, Virr A. The Reliability of the Shuttle Walking Test, the Swiss Spinal Stenosis Questionnaire, the Oxford Spinal Stenosis Score, and the Oswestry Disability Index in the Assessment of Patients With Lumbar Spinal Stenosis. Spine. 2002 Jan 1;27(1):84–91. [LoE: 2C]
  29. ↑ 1.     Tomkins CC et al. Construct validity of the physical function scale of the Swiss Spinal Stenosis Questionnaire for the measurement of walking capacity. Spine. 2007 Aug;32(17):1896-1901. [LoE: 2B]
  30. ↑ 30.0 30.1 1.     Macedo LG et al. Physical therapy interventions for degenerative lumbar spinal stenosis: a systematic review. Phys Ther. 2013 Dec;93(12):1646-60. [LoE: 2A]
  31. ↑ 1.     Cleland JA et al. Psychometric properties of selected tests in patients with lumbar spinal stenosis. Spine J. 2012 Oct;12(10):921-931. [LoE: 2B]
  32. ↑ 32.0 32.1 Pratt RK, Fairbank JC, Virr A.[The reliability of the Shuttle Walking Test, the Swiss Spinal Stenosis Questionnaire, the Oxford Spinal Stenosis Score, and the Oswestry Disability Index in the assessment of patients with lumbar spinal stenosis.] Spine. 2002 Jan 1;27(1):84-91.
  33. ↑ Sinikallio S, Aalto T, Airaksinen O, Herno A, Kröger H, Savolainen S, Turunen V, Viinamäki H. Lumbar spinal stenosis patients are satisfied with short-term results of surgery–younger age, symptom severity, disability and depression decrease satisfaction. Disability and rehabilitation. 2007 Jan 1;29(7):537-44.
  34. ↑ Pua YH, Cai CC, Lim KC. Treadmill walking with body weight support is no more effective than cycling when added to an exercise program for lumbar spinal stenosis: a randomised controlled trial. Australian journal of physiotherapy. 2007 Jan 1;53(2):83-9.
  35. ↑ 35.0 35.1 Whitman JM, Flynn TW, Childs JD, Wainner RS, Gill HE, Ryder MG, Garber MB, Bennett AC, Fritz JM. A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis: a randomized clinical trial. Spine. 2006 Oct 15;31(22):2541-9.
  36. ↑ 1.     Whitman JM, Flynn TW, Fritz JM. Nonsurgical management of patients with lumbar spinal stenosis: a literature review and a case series of three patients managed with physical therapy. Phys Med Rehabil Clin N Am. 2003 Feb;14(1):77-101. [LoE: 4]
  37. ↑ Takahashi N, Kikuchi SI, Yabuki S, Otani K, Konno SI. Diagnostic value of the lumbar extension-loading test in patients with lumbar spinal stenosis: a cross-sectional study. BMC musculoskeletal disorders. 2014 Dec;15(1):259.
  38. ↑ Katz JN, Dalgas M, Stucki G, Katz NP, Bayley J, Fossel AH, Chang LC, Lipson SJ. Degenerative lumbar spinal stenosis Diagnostic value of the history and physical examination. Arthritis & Rheumatism: Official Journal of the American College of Rheumatology. 1995 Sep;38(9):1236-41.
  39. ↑ Fritz JM, Delitto A, Welch WC, Erhard RE. Lumbar spinal stenosis: a review of current concepts in evaluation, management, and outcome measurements. Archives of physical medicine and rehabilitation. 1998 Jun 1;79(6):700-8.
  40. ↑ Hsiang JK, Kishner S. Spinal Stenosis Clinical Presentation. Medscape, Updated Jul. 2015;9.
  41. ↑ Wu L, Munakomi S, Cruz R. Lumbar spinal stenosis. InStatPearls [Internet] 2024 Jan 30. StatPearls Publishing.Available:https://www.ncbi.nlm.nih.gov/books/NBK531493/ (accessed 28.3.2025)
  42. ↑ Moon MS, Kim SS, Sihn JC. Lumbar spinal stenosis–a current view. Orthopaedics and Trauma. 2014 Dec 1;28(6):396-408.
  43. ↑ Minamide A, Yoshida M, Maio K. The natural clinical course of lumbar spinal stenosis: a longitudinal cohort study over a minimum of 10 years. Journal of Orthopaedic Science. 2013 Sep 1;18(5):693-8.
  44. ↑ May S, Comer C. Is surgery more effective than non-surgical treatment for spinal stenosis, and which non-surgical treatment is more effective? A systematic review. Physiotherapy. 2013 Mar 1;99(1):12-20.
  45. ↑ McGregor AH, Probyn K, Cro S, Doré CJ, Burton AK, Balagué F, Pincus T, Fairbank J. Rehabilitation following surgery for lumbar spinal stenosis: a Cochrane review. Spine. 2014 Jun 1;39(13):1044-54.
  46. ↑ Macedo LG, Hum A, Kuleba L, Mo J, Truong L, Yeung M, Battié MC. Physical therapy interventions for degenerative lumbar spinal stenosis: a systematic review. Physical therapy. 2013 Dec 1;93(12):1646-60.
  47. ↑ 1.     Fritz JM et al. Associations between physical therapy and long-term outcomes for individuals with lumbar spinal stenosis in the SPORT study. The spine journal. 2014;14:1611-21. [LoE: 2C]
  48. ↑ Physical Therapy Video. Top 7 exercises to stop Lumbar stenosis pain. Available from: https://www.youtube.com/watch?v=V4YDcYS3dyo (last accessed 8.3.2019)
  49. ↑ Breslau J, Seidenwurm D. Socioeconomic aspects of spinal imaging: impact of radiological diagnosis on lumbar spine-related disability. Topics in Magnetic Resonance Imaging. 2000 Aug 1;11(4):218-23.
  50. ↑ 50.0 50.1 Vo AN, Kamen LB, Shih VC, Bitar AA, Stitik TP, Kaplan RJ. Rehabilitation of orthopedic and rheumatologic disorders. 5. Lumbar spinal stenosis. Archives of physical medicine and rehabilitation. 2005 Mar 1;86:69-76.
  51. ↑ Johnsson KE, Uden A, Rosén IN. The effect of decompression on the natural course of spinal stenosis. A comparison of surgically treated and untreated patients. Spine. 1991 Jun;16(6):615-9.
  52. ↑ 52.0 52.1 Atlas SJ, Deyo RA, Keller RB, Chapin AM, Patrick DL, Long JM, Singer DE. The Maine Lumbar Spine Study, Part III: 1-year outcomes of surgical and nonsurgical management of lumbar spinal stenosis. Spine. 1996 Aug 1;21(15):1787-94.
  53. ↑ 53.0 53.1 Atlas SJ, Keller RB, Robson D, Deyo RA, Singer DE. Surgical and nonsurgical management of lumbar spinal stenosis: four-year outcomes from the maine lumbar spine study. Spine. 2000 Mar 1;25(5):556-62.
  54. ↑ 54.0 54.1 Atlas SJ, Keller RB, Wu YA, Deyo RA, Singer DE. Long-term outcomes of surgical and nonsurgical management of lumbar spinal stenosis: 8 to 10 year results from the maine lumbar spine study. Spine. 2005 Apr 15;30(8):936-43.
  55. ↑ Reiman MP, Harris JY, Cleland JA. Manual therapy interventions for patients with lumbar spinal stenosis: a systematic review. InDatabase of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] 2009. Centre for Reviews and Dissemination (UK).
  56. ↑ Whitman JM, Flynn TW, Childs JD, Wainner RS, Gill HE, Ryder MG, Garber MB, Bennett AC, Fritz JM. A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis: a randomized clinical trial. Spine. 2006 Oct 15;31(22):2541-9.
  57. ↑ Snow GJ. Chiropractic management of a patient with lumbar spinal stenosis. Journal of manipulative and physiological therapeutics. 2001 May 1;24(4):300-4.
  58. ↑ DuPriest CM. Nonoperative management of lumbar spinal stenosis. Journal of Manipulative and Physiological Therapeutics. 1993;16(6):411-4.
  59. ↑ Hoeksma HL, Dekker J, Ronday HK, Heering A, Van Der Lubbe N, Vel C, Breedveld FC, Van Den Ende CH. Comparison of manual therapy and exercise therapy in osteoarthritis of the hip: a randomized clinical trial. Arthritis Care & Research: Official Journal of the American College of Rheumatology. 2004 Oct 15;51(5):722-9.
  60. ↑ 60.0 60.1 Fritz JM, Erhard RE, Delitto A, Welch WC, Nowakowski PE. Preliminary results of the use of a two-stage treadmill test as a clinical diagnostic tool in the differential diagnosis of lumbar spinal stenosis. Journal of spinal disorders. 1997 Oct;10(5):410-6.
  61. ↑ Whitman JM, Flynn TW, Fritz JM. Nonsurgical management of patients with lumbar spinal stenosis: a literature review and a case series of three patients managed with physical therapy. Physical Medicine and Rehabilitation Clinics. 2003 Feb 1;14(1):77-101.
  62. ↑ 1.     Whitman JM et al. A Comparison Between Two Physical Therapy Treatment Programs for Patients With Lumbar Spinal Stenosis. SPINE. 2006;31(22):2541-49. [LoE: 1B]
  63. ↑ 1.     Macedo LG et al. Physical therapy interventions for degenerative lumbar spinal stenosis: a systematic review. Phys Ther. 2013 Dec;93(12):1646-60. [LoE: 2A]
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