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"Mature" adults and spinal stenosis
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"Mature" adults and spinal stenosis - April 19, 2008 8:30:11 PM
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KAK
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I did not want to detract from the “Extension… in geriatric…” discussion, but the thread reminded me of a question I’ve wanted to post re: spinal stenosis. I suspect that the patient population I am thinking of may have central canal stenosis as well. I am thinking of the ones who have minimal standing/walking tolerances and their symptoms are completely relieved with sitting- the ones that walk into your clinic quite flexed. Of course their symptoms are relieved with flexion positioning/exercises, but get them back on their feet and the symptoms return quite readily.
What specific manual techniques, exercise progression or education do you find clinically effective for these patients? By effective, I mean that they experience a significant improvement in their standing and walking tolerances.
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RE: "Mature" adults and spinal stenosis - April 20, 2008 11:18:01 AM
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kamryn
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Hi - this paper describes what I think are some very effective manual and exercise techniques for this population. Interestingly, the authors used thrust manupulation techniques (in additiona to other treatments) with a population that some may think manipulation may not be indicated. These authors also followed this case series up with a nice RCT in Spine showing the benefits of their treatment approach. I think the case series is a bit more helpful for the clnician as the treatment methods are explained in a more detail than in the RCT.
http://download.journals.elsevierhealth.com/pdfs/journals/1047-9651/PIIS1047965102000761.pdf
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RE: "Mature" adults and spinal stenosis - April 21, 2008 9:00:15 AM
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PTupdate.com
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KAK: Not really easy to put everything in a post regarding treatment of this patient population, but I will put down what I find works the majority of the time
First, I find that patients are pretty much "resolved" when I have them at the point where they can lie prone on elbows for 5-10 minutes, and quad flexibility is full to the point where their foot can touch their buttock.
I will make note to seperate those who have radicular or unilateral symptoms versus those with central pain. The ones with radicular symptoms are pretty much guaranteed success. Those with pain right where L5 is mashed down on the sacrum on radiographs, are obese, are much more difficult to fix.
My typical program will use modalities as needed. I utilize seated flexion, LE flexibility, pelvic stabilization, manual therapy to increase segmental motion to those hypomobile levels (my theory is that if L4 and/or 5 are degenerated and perhaps even unstable, the fact that L3 and above are all very stiff means these hypermobile levels have to do that much more). I may use manual or mechanical traction, based on relief provided. I utilize weight loss, reminding them that the fit and trim 20 year old gym chick has back pain when pregnant and carrying 20 xtra pounds, so their 75 year old degenerated back with a 40 lb gut isn't going to tolerate very much.
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: "Mature" adults and spinal stenosis - April 21, 2008 7:14:31 PM
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Kaden
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John,
What percent of your patients in this population can you get lying prone on elbows for 5-10 minutes. I agree that extension if able should be included in the program b/c walking around flexed all the time will cause problems as well.
However, I struggle putting this population intentionally into prone on elbows as this will often trigger "another event".
It is often some trivial movement that led to the inflammatory process and sent them to the clinic with complaints of stenotic type pain. I struggle putting them back in extension when I have someone feeling good, only to find out they don't tolerate extension and flare them up.
Again, I agree with the concept of trying to normalize some extension as ideally we would like things moving this direction as well but I struggle when to do this or whether or not to do it at all.
Food for thought.
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RE: "Mature" adults and spinal stenosis - April 21, 2008 8:37:50 PM
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PTupdate.com
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Kaden: I start based on what their symptoms are. If difficulty lying prone, I stuff pillows under their abdomen. After a few visits, I usually can get them prone, and then work from there, just monitoring symptoms. I may have to shift hips one way or another, but that's in the more extreme cases. Otherwise, if you listen to what they tell you, and they understand your plan, no problems will occur.
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: "Mature" adults and spinal stenosis - April 22, 2008 5:20:59 PM
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KAK
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Thanks Kamryn- that is a helpful article!
Thanks John! So that I understand, as I have some of the same concerns as Kaden- you use flexion (among other things) to relieve symptoms, in conjunction with a graded exposure (avoiding increased symptoms) to extension, to facilitate a better tolerance to loading. Is this an accurate description of part of your approach?
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RE: "Mature" adults and spinal stenosis - April 23, 2008 7:45:27 AM
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PTupdate.com
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KAK: Exactly. And, it's really no different than my approach to most joints in the body. Once normal mechanics, strength, motion are normalized, pain disappears and function returns. Patient's just need to be on your side regarding avoidance of agitating their symptoms and following your program.
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: "Mature" adults and spinal stenosis - April 23, 2008 1:01:15 PM
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TexasOrtho
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John. You and I seem to be on the same page with a lot of clinical issues (not that it should matter to you). Just thought I'd mention it. Good stuff.
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Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: "Mature" adults and spinal stenosis - April 23, 2008 8:29:21 PM
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PTupdate.com
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It matters a lot to me.... I'm flattered.
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: "Mature" adults and spinal stenosis - April 25, 2008 3:22:38 PM
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RSBMPT
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Does Fig. 1 F from the link Kamryn posted look like Ginger's CM technique?
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RE: "Mature" adults and spinal stenosis - April 25, 2008 4:10:54 PM
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Kaden
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It looks like a unilateral lumbar PA and unless anyone on this forum is really really really old I don't think we could claim this as our technique. There is no mention of continous mobilzation in the article.
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RE: "Mature" adults and spinal stenosis - April 25, 2008 7:03:41 PM
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RSBMPT
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Kaden, I don't really think my sarcasm came through on that post.
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RE: "Mature" adults and spinal stenosis - April 25, 2008 8:12:47 PM
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Kaden
Posts: 258
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now i get it - i'm working on limited caffeine today.
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