Degenerative lumbar spinal stenosis (LSS) is defined as a narrowing of the spinal canal, resulting in compression of the spinal nerves [10, 11]. LSS is a primary cause of low back pain (LBP) and leg pain in people aged 65 years and older [12]. In fact, nearly 400,000 Americans, most over the age of 60 years, suffer from degenerative LSS [13]. Degenerative LSS can be caused by facet joint hypertrophy, osteoarthritis of the spine, intervertebral disc herniation, spondylolisthesis, degenerative disc disease [10] and from microinstability of the articular structures surrounding the canal and hypertro- phy of the cartilage [10]. Degenerative LSS commonly occurs at the L4-L5 and L5-S1 segments [10].
Lumbar spinal stenosis is classified by the location of the stenosis: central or lateral [13]. Central spinal stenosis refers to the narrowing of the central spinal canal, which com- presses the cauda equina and is mainly caused by disc bulg- ing and ligament hypertrophy. Lateral spinal stenosis, referred to as foraminal stenosis, refers to compression of the nerve root at the lateral foramen, caused mainly by osteo- phyte or bone spur formation [14].
Physical Examination Findings and Interventions
Patients typically present with LBP, lower extremity pain and fatigue, and neurogenic claudications, which are exacerbated by lumbar extension and relieved with lumbar flexion.
Sensory and proprioceptive changes due to lumbar nerve root involvement are believed to cause pain and balance problems;
leading to decreased walking capacity and function [15].
Fig. 12.1 International
Classification of Function (ICF) [4]
103 12 Physical Therapy Management of Select Rheumatic Conditions in Older Adults
Table 12.1 Dominant pathology, common impairments/functional limitations, physical therapy interventions and considerations for older adults with arthritis
Impairments and functional
limitations Physical therapy interventions Considerations in older adults Polymyalgia
rheumatica (PMR)
Muscle aching and stiffness of the neck, shoulder girdle, hips, thighs and buttocks which is worse in the morning; improves during the day and worsens at night. Joint swelling is atypical though distal hand joints and wrist may be tender.
Fatigue is prevalent
Active flare: Gentle stretching exercises, activity modification, patient education, assistive devices Stable disease: Incorporate strengthen-
ing exercises (8–10 repetitions) especially to shoulder and hip girdle muscles. Aerobic exercises using 60% of age predicted heart rate as standard or modify based on individual cardiovascular health.
Progress as tolerated
Weakness of shoulder and hip girdle muscles may be accentuated with general deconditioning and age-related changes, progress exercises slowly Monitor for signs of flare and avoid
dynamic exercise if flare occurs Assess dynamic balance, obtain data on
bone health from rheumatologist or primary physician, especially in presence of long-term steroid use Degenerative
lumbar spinal stenosis
Low back pain, lower extremity pain and fatigue and neurogenic claudica- tion, which are exacer- bated by lumbar extension and relieved with lumbar flexion. Sensory and proprioceptive changes, flexed standing posture, stiffness of the lumbar spine
Aerobic, strengthening, stretching, lumbar stabilization exercises, spinal manipulation and mobilization, posture and balance training, physical modalities, braces, traction and transcutaneous electrical nerve stimulation (TENS)
Recumbant bicycle exercise may be better tolerated due to flexed posture
Use of heat to increase extensibility of tissues prior to exercise recommended
Osteoporosis Diminished height, kyphosis, flatten lumbar curve, tight shoulder, hip and leg muscles, muscle weakness, reduced aerobic capacity and balance
Posture alignment and re-education, strength, flexibility, core stability, function, home safety and indepen- dence in activities of daily living and ambulation and are based on the patients’ physical examination findings
Use of heat to increase extensibility of tissues prior to exercise recommended
Gradual increase in resistance and repetitions for strengthening exercises, monitor of signs of stress fractures
Rheumatoid arthritis (RA)
Symmetrical and bilateral joint involvement, joint pain, swelling, stiffness, contracture muscle weakness and fatigue
Acute flare: Active ROM exercises to involved joints: 2 repetitions/joint/
day
Resting orthoses, assistive devices with built up handles or platform attachments
Subacute: Active ROM exercises: 8–10 repetitions/joint/day
Isometric exercises: 4–6 contractions of 6-s duration. Isotonic exercises with light resistance (avoid if joints are unstable, in presence of tense popliteal cysts or internal joint derangement). Aerobic training (15–20 min, 3×/week).
Stable Disease: Active ROM and flexibility exercises. Static and dynamic strength training [avoid dynamic exercises if joints are unstable or in presence of tense popliteal cyst(s)]. Aerobic training 15–20 min, 3×/week. Cardiac evaluation is recommended.
Establish heart rate parameters and use perceived rating of exertion scale. Orthoses and assistive devices, as needed
Monitor vital signs frequently during exercise to ensure safety (concern for asymptom- atic cardiovascular disease)
With use of isometric exercises, ensure proper breathing to reduce cardiovascular load Cardiac evaluation is recommended. Establish
heart rate parameters and use perceived rating of exertion scale (e.g. BORG) Can implement aerobic exercise in 3 U of
10 min/day
(continued)
Table 12.1 (continued)
Impairments and functional
limitations Physical therapy interventions Considerations in older adults Osteoarthritis
(OA)
Involves weightbearing joints, joint pain and malalignment, muscle weakness especially of quadriceps
Mild: Active ROM exercises with daily activities, 3–5 repetitions of flexibility exercise and 8–10 repetitions of static exercises of 6-s duration each. Dynamic exercises especially to quadriceps and hamstrings (8–10 repetitions). Low impact aerobic activities (pool, bicycling) 20 min, 3×/week Balance activities (BAPS and tilt
board), single limb stance Moderate: Static and dynamic
exercises – reduce to 5 repetitions;
3–5 repetitions of flexibility exercises. Low impact aerobic exercises (pool, bicycling – 20 min, 3×/week). Balance and propriocep- tion activities – bilateral
Use of cane or lateral heel wedge foot orthosis, neoprene knee sleeve Severe: Low to no impact aerobic exercises (pool) Note: advise functional activities to keep moving, Few to no repetitions of dynamic exercises. Patient education very important
Heat therapy to increase tissue extensibility prior to exercise
Use of pool and low impact exercise (elliptical machines) may be better tolerated
In patients with ligamentous laxity and malalignment, caution should be taken with prescribing quadriceps strengthening exercises. Orthoses, crutches or walker
Ankylosing spondylitis
Involves the axial skeleton, hip, shoulder and knee, Reduced spinal flexibility, decreased chest expan- sion, breathlessness, pain, limited lumbar range-of- motion, kyphosis, flatten lumbar lordosis, forward trunk flexion, aortic valve involvement
Passive range-of-motion exercises, strengthening exercises of the trunk, the back, the abdomen, the legs, inspiratory muscle training, aerobic conditioning, aquatic exercises and postural exercises and patient education
Monitor vital signs regularly, promote proper posture during exercise
Adapted from Iversen et al. [9]
Patients with LSS also have difficulty in detecting lumbar movements, potentially leading to increased postural sway and risk of falls [14, 15].
Intensity of LBP on physical examination varies. Patients with LSS often present with stooped standing posture, stiffness of the lumbar spine, decreased lumbar range of motion and hip joint motion, secondary to iliopsoas and rectus femoris tight- ness [15]. Symptoms of sensory deficits, motor weakness, and pathological reflexes appear with walking. Elderly patients with severe degenerative stenosis of the lumbar spine have restricted walking capacity and exercise intolerance, therefore, leading to decreased function and quality of life [14–16].
Physical therapy management of LSS can include: thera- peutic exercise such as aerobic conditioning, strengthening, stretching, lumbar stabilization exercises, spinal manipulation and mobilization, posture and balance training, physical modalities, braces, traction, and transcutaneous electrical nerve stimulation (TENS). Physical modalities are used as adjuncts
to therapy and are used in combination with therapeutic exer- cise, balance, and mobility training. Table 12.1 provides clini- cal features and physical therapy intervention for LSS [9].
Therapeutic exercise is effective in addressing impair- ments in patients with mild to moderate symptoms [17, 18].
Exercises are based on the pathoanatomic changes and patients’ physical examination findings [18]. Spinal exten- sion decreases the intervertebral foramina cross sectional area [15] therefore, flexion-based lumbar stabilization exer- cises such as William’s flexion and McKenzie’s exercise combined with abdominal strengthening are used to reduce pain and symptoms [19]. Placement of a blood pressure cuff under the lower back during performance of pelvic tilts can help quantify the muscle force generation of the trunk and provide feedback to patients during the exercise. Body weight supported treadmill walking, cycling and swimming frequently are used to enhance aerobic capacity and strength [18–20]. Body weight supported ambulation decreases the
105 12 Physical Therapy Management of Select Rheumatic Conditions in Older Adults
compressive forces on the spine; thereby increasing its cross- sectional diameter. Unfortunately, this mode of exercise is available only in the clinical setting. Stationary cycling (either recumbent or traditional seated posture) places the spine in a flexed position and is well tolerated and proven to enhance aerobic conditioning, strength and mood [18].
Manual therapy, in the form of manipulation or mobilization, can be used to restore normal range of motion and when fol- lowed by lumbar stabilization exercises, to enhance function [21]. Spine mobility can be improved by stretching tight structures such as hip flexors, adductors, and myofascial tis- sues. Postural education reinforces spinal alignment during exercise and with activities of daily living. Aquatic exercises minimize stress on the spine and the buoyancy of the water can facilitate motion [22]. Table 12.2 summarizes studies of physical therapy intervention for LSS [18, 23–27].
The Maine lumbar spine study [28] assessed the 4- and 8-to-10-year outcomes of surgical and nonsurgical treat- ments for patients with LSS and demonstrated that patients treated nonsurgically reported decreased back and leg pain.
There was no detailed description of therapeutic exercise included in the report. Published reviews of clinical trials of exercise interventions for nonsurgical management of LSS indicate variable effectiveness [20–22, 28].