Spinal Stenosis: Getting Results

The pain of lumbar spinal stenosis is not like that of a “typical,” uncomplicated episode of acute back pain. For one thing, it lasts a lot longer. Some of my patients tell me at their initial visits that it’s been a year or two since they could walk a city block without resting somewhere. Or that they have spent miserable months unable to sit comfortably during their sedentary workday. Also, the pain may not be restricted to the back; it may involve pain down one leg, or even into both legs.

These are common experiences and symptoms of one of the most challenging back problems. Challenging probably in part because the structural changes that create spinal stenosis are typically widespread. A signature feature is extensive degeneration in spinal discs, joints, spinal bones and ligaments. There are often multiple sites of nerve impingement, and multiple spinal structures that generate pain. In addition, just like every person’s spine is different, every person’s spinal degeneration is different. It seems that the combination of this (between-person) variability and extent of the chronic changes in the spine is what makes the pain of stenosis so stubborn.

Because of the uniqueness of each case of stenosis, many people who have it have needed to consult many health care professionals to find out what will help them. Will the problem respond to painkillers? Physical therapy? Spinal manipulation, like chiropractors do? Steroid injections into the spine? Surgery? It’s hard to predict, so success tends to be through trial and error; everyone responds differently to each form of treatment. As with other kids of chronic back pain, there’s no single, simple answer as to how this sort of pain should be treated. The only real, sensible consensus has been that one attempts the more conservative treatments first (e.g. exercise, acupuncture) long before considering the more invasive, surgical options.

In my practice, when treating someone with spinal stenosis, I often begin with hands-on therapies. While most people expect to receive high-speed “cracking”-style manipulation when they see a chiropractor, I typically take a different approach. Disc problems and potential instability between spinal bones are common in this disorder; I treat such structures gently! This means avoiding high-force or “cracking” adjustments. Instead, where I find restrictions in movement, I work gradually, patiently. Imagine unraveling something tangled; you don’t try to yank the tangles out. One by one, I identify movements that decrease limb pain or numbness; I guide the spine through those movements. Frequently one can sense the lower spine expanding out of chronic constriction, and assuming a stronger, more relaxed posture. We start to notice fuller spinal ranges of motion and freedom of movement.

Exercise is also a crucial part of treatment. I select exercises one by one, and instruct the patient in those exercises. Some of them are meant to reinforce the improvements in mobility we gained through the manual therapies. In fact, the manual therapies often lead into, or are seamless with, the exercise training; the hands-on treatment is also the basis for gently guided movement sequences. Therefore the exercise training really begins during the manual therapy component of treatment, enhancing the efficacy and power patients can rediscover during the course of treatment.

Other exercises are intended to foster greater trunk strength or stamina. We often think of these as stabilizing exercises; once we’ve restored freedom of movement, we want to reinforce that openness with greater stamina or coordination in the muscles around the spine. I’ve noticed many of my patients have been trained already, at least briefly, in some stability exercises; but they’re usually those that are performed lying down, or perhaps in an “all-fours” posture. That’s fine, but in my opinion it’s crucial to transition as well to exercises performed in upright postures. After all, you live your life mostly standing and sitting. Exercising only when lying on your back won’t train your muscles sufficiently for standing and walking through a shopping center, or around your favorite pond. So I make a point of introducing a variety of standing exercises early on.

Spinal stenosis is indeed a complex problem, with pain that is often chronic and stubborn. But I’ve found that with this combination of manual and exercise therapies, we can reduce that pain, allowing those with stenosis to do more of what they want.