Background & Etiology
The spine is a key component of the central nervous system. It houses and protects the spinal cord and nerves, which run from the brain throughout the body to transmit signals that control motion and function. The spinal canal is where the spinal cord runs from the brain to the sacrum. Narrowing of the canal can put pressure on the spinal cord effecting the transmission of nerve signals to the body. Spinal foramen are small holes, through which the nerves travel to reach the rest of the body. Foramen exist at each vertebral level of the spine, one on each side. These openings can become damaged, putting pressure on the nerves that run through them.
Spinal Stenosis is the narrowing of the spinal foramen, or the spinal cord. This puts pressure on the nerves in the spine, and can cause a range of symptoms depending on what nerves have their function disrupted.
Spinal stenosis can occur due to age related degeneration, or it can be the result of another injury or illness that damages the spine.
- Arthritis of the spine
- Bone disease like Paget’s disease or achondroplasia
- Congenital defects in the spine
- Herniated or slipped disc
- Nerve root entrapment
- Spinal tumors
When spinal stenosis affects a nerve the symptoms will vary based on which nerve is affected and which part of the body that nerve enervates. Symptoms can vary from mild to severe. Common symptoms include:
- Difficulty walking or balance
- Pain that gets worse over time
- Symptoms affect only one side of the body
Treatment of spinal stenosis will depend on the severity of the condition. Treatment recommendations for spinal stenosis include:
- Rest: avoid the activities that produce the pain (overhead activities, looking up, lifting, twisting, of the head and neck)
- Medication to reduce inflammation (anti-inflammatory drugs and pain medication)
- Ice: apply ice to the cervical spine to help reduce pain and associated muscle spasm. Apply ice right away and then at intervals for about 20 minutes at a time. Do not apply directly to the skin.
- An exercise regiment designed specifically to address the cause of the symptoms and facet joint irritation.
- Bracing or the use of supports may be necessary to reduce stress on the facet joints, muscles and cervical spine or neck.
- Steroidal medication to reduced inflammation in moderate to severe conditions.
- Physical therapy to reduce inflammation, restore joint function, improve motion, and help return to full function.
In mild cases rest, ice and medication may be enough to reduce the pain. Many patients will do well with this regiment. Physical therapy is recommended to develop a series of stretching and strengthening exercises to prevent reoccurrence of the injury. Return to activity should be gradual to prevent a flare up of symptoms.
Moderate to Severe
If the problem persists, consulting with your health care provider should be the next step. Your physician will perform a thorough evaluation to determine the possible cause of your symptoms, the structures involved, the severity of the condition, and the best course of treatment.
In addition to performing a thorough examination your physician may order the following tests to make a more concise diagnosis:
- X-ray to determine if there is any joint degeneration, fractures, bony malformations, arthritis, tumors or infection present.
- MRI to determine any soft tissue involvement including visualization of the discs, spinal cord and nerve roots.
- CT scans, which can give a cross section view of the spinal structures
Your physician may recommend several medication options individually or in combination to reduce the pain, inflammation and muscle spasms that may be associated with spinal stenosis.
- Over the counter medications for mild to moderate pain.
- If over the counter medications are not effective your physician may prescribe stronger pain medication.
- Anti-inflammatory drugs or prescription NSAIDS (non-steroidal anti-inflammatory drugs) to reduce inflammation following acute injury.
- Muscle relaxers to reduce acute muscle spasm.
- Injections such as facet injections, nerve blocks or epidural injections. These may involve the injection of corticosteroids to a specific structure to reduce local inflammation.
Severe or Non-Responsive Condition
In the case of conditions that do not respond to conservative care surgery may be indicated. If you continue to experience some of the following symptoms surgery may be necessary:
- An increase in radiating or radicular pain
- Pain or nerve irritation that gets worse
- Associated disc involvement
- Extremity weakness
- Incontinence or loss of balance and bladder involvement
- Abnormal tone or spasticity of the extremities
- Balance and gait disturbances
Surgery may be necessary to address the underlying condition causing the spinal stenosis. Surgery is usually not performed when there is only back pain, but may be recommended if symptoms are affecting the ability to walk or impeding severely on a patient’s life and function.
Physical Therapists are professionals, educated and trained to administer interventions. As defined by The Guide to Physical Therapist Practice, interventions are the skilled and purposeful use of physical therapy methods and techniques to produce changes consistent with the diagnosis, prognosis and the patient or client’s goals.
Your physical therapist will perform a thorough evaluation to assess and determine the following:
- Spinal examination where the patient is put through a series of movements and tests to determine the most probable cause of your current back condition.
- Strength: resisted testing is performed to determine if there is associated weakness or strength imbalances.
- Flexibility: tight muscles can contribute to poor mechanics and weakness creating imbalances and making one more susceptible to disc and back injuries.
- Posture Analysis, ADL’s and technique: discuss and observe the activity that may have started the problem. Examination of dynamic and static postures that may have cause or contributed to your current back problem. A review of your current activities at home and work that may or may not be causing or prolonging your present condition.
Physical therapy for spinal stenosis must remain conservative at the onset to avoid aggravating the condition. Emphasis will be on rest, reducing the inflammation and increasing the blood circulation for healing. Once the initial inflammation has been reduced, a program of stretching and strengthening will be initiated to restore flexibility to the joints and muscles involved while improving strength and stability to the spine. Your program design will be based on the structure and cause of your symptoms. A program not tailored to your problem could aggravate your symptoms.
Common Physical Therapy interventions in the treatment of spinal stenosis include:
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, stretching and joint mobilization by a physical therapist to improve alignment, mobility and range of motion of the spine. Use of mobilization techniques also help to modulate pain.
- Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen muscles of the back and abdominals to support, stabilize and decrease the stresses place on the spinal joints, discs, and neck.
- Neuromuscular Reeducation (NMR) to improve posture, restore stability, retrain the patient in proper sleeping, sitting and body mechanics to protect the injured spine.
- Modalities including the use of ultrasound, electrical stimulation, ice, cold laser, traction and others to decrease pain and inflammation spinal structures.
- Home programs including strengthening, stretching and stabilization exercises and instructions to help the person perform daily tasks and advance to the next functional level.
Most people with spinal stenosis can be active with their condition, if they seek treatment. Duration of treatment can range from 4 to 12 weeks depending on the severity of the symptoms. Patients requiring surgery may take longer to recover. Patients need to continue with a regiment of stretching, strengthening and stabilization exercises. Use of proper mechanics, proper posture, body mechanics and awareness of the do’s and don’ts for a healthy back is necessary for a good prognosis long term. Remember, “once you have a neck problem, you have a neck problem” goes a long way to preventing further injury.