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Spinal stenosis is a degenerative condition of the spine that causes narrowing of the openings of the vertebrae. These openings are either in the central spinal canal, where the spinal cord sits, or the foramen, small openings on the sides of each vertebra where spinal nerve roots branch off from the spinal cord.
Spinal stenosis is most common in the lumbar spine of the low back, affecting more than 200,000 adults in the United States. It can also occur in the cervical spine of the neck.
It is believed that the degenerative changes that cause spinal stenosis begin in the discs between the vertebrae of the spine. These discs help provide cushioning and shock absorption in the spine.
When they lose water content and the disc height decreases over time, they also lose their ability to provide cushioning and shock absorption. The vertebrae of the spine can then become compressed, causing friction.
Degenerative spinal stenosis can also develop from excess scar tissue and bone spurs that may form after injury or spinal surgery. A bone spur is a growth that develops on the edge of a bone.
A diagnosis of spinal stenosis will be made by your physician. Your doctor will take an X-ray of your lower back to determine the exact location of the degeneration and to measure how narrow the openings of your lumbar vertebrae have become.
Pain, stiffness, limited mobility, and loss of range of motion (the extent of movement) of your low back are often present. If spinal stenosis has caused nerve compression, you may also experience pain, numbness, tingling, or weakness in your buttocks, thighs, and lower legs.
A physical therapist will determine the degree of spinal stenosis by assessing the following:
A physical therapist will also check for nerve compression to determine if there are any symptoms in your legs that are being caused by your spine.
The most common symptom of spinal stenosis is increased pain with backward bending (extension of the lumbar spine). This includes positions that extend the spine, such as standing, walking, and lying on your stomach.
Symptoms usually get better when you bend forward and when your spine is positioned more into flexion (flexed or bent), such as while sitting and reclining. These positions open up the spaces in the central spinal canal.
With a more severe case of spinal stenosis, there may be significant pain, limited mobility, and nerve compression causing weakness of the legs. Milder cases of spinal stenosis usually do not involve nerve compression. Symptoms like back stiffness are more common.
While spinal stenosis is the most common reason for undergoing spinal surgery in adults 65 and older, surgery is almost always performed on an elective basis if pain, symptoms, and disability persist after trying other measures, including physical therapy, for several months or years. The severity of your symptoms and current state of health will determine whether your doctor will recommend surgery.
Conservative measures are always tried first. They are often safer and more effective than surgery. A 2018 systematic review (a study based on all available primary research) found that physical therapy and exercise yield similar outcomes to spinal stenosis surgery for improving pain and disability. Except for severe cases of spinal stenosis, surgery is often not necessary.
The goals of physical therapy for someone with spinal stenosis include:
Spinal stenosis is most often treated by an outpatient physical therapist.
Stretching of the low back muscles—including those running vertically along the spine and those running diagonally from the pelvis to the lumbar spine—can help relieve muscle tightness and pain, and it can improve overall mobility of the lumbar vertebrae and range of motion of the lumbar spine.
Stretching the muscles of the hips—including the hip flexors in the front of the hip, the piriformis in the back of the hip, and the hamstrings that run from the back of the hip down the leg to the knee—is also important since these muscles are attached to the pelvis, which directly connects to the lumbar spine. Restriction in hip muscles can directly affect the mobility of the lumbar spine.
Exercises for core strengthening will also play a key role. The abdominal muscles of the core—including the muscles in your trunk, pelvis, lower back, hips, and abdomen—help stabilize the lumbar spine and protect it from excessive movement and compressive forces.
Often with spinal stenosis, the core muscles are weak and inactive and are not doing their job to support the lumbar spine. Core exercises often begin by activating your deep abdominal muscles while lying flat on your back with your knees bent. Exercises will progress as you gain more strength and control as your lumbar spine stabilizes.
Because spinal stenosis often can cause leg weakness, physical therapy will also involve exercises for strengthening your leg muscles, especially your glutes, as well as balance training.
This exercise helps stretch the lower back muscles and brings your spine into flexion, a position that is often more comfortable for patients with spinal stenosis. It opens up the central spinal canal and can help relieve pressure in the lumbar spine.
This exercise helps activate and strengthen your transverse abdominis, a deep core muscle that helps stabilize and support your lumbar spine and improve your spinal alignment. When the transversus abdominis is not actively engaged when sitting, standing, or lying down, the pelvis will tilt forward, called an anterior pelvic tilt, which extends the lumbar spine too much (excess lordosis).
An anterior pelvic tilt and excess lumbar lordosis can increase pain in patients with spinal stenosis. This exercise aims to realign your spine and pelvis by bringing you into a posterior pelvic tilt. This involves tilting your pelvis under and maintaining a straighter, neutral spine.
This exercise helps strengthen the gluteus maximus, the large muscles that make up the buttocks and hip area. These muscles help provide stability to the pelvis and decrease strain on the lumbar spine.
If the glutes are weak, the lower back may compensate by activating the muscles that extend the lumbar spine (lumbar paraspinals), especially when standing up from a seated position. This can cause increased pain as the back is extended.
When there is leg weakness with spinal stenosis, the glutes are not activating properly. The glutes are a very important muscle group that aid in balance when walking and changing directions. Strengthening the glutes will help take the pressure off the lumbar spine and improve your leg strength and overall standing balance.
This exercise helps improve mobility of the lumbar spine and surrounding muscles. This position will improve your spinal mobility without causing increased pain by avoiding extension.
Working with a physical therapist can help prevent future problems from spinal stenosis by:
Often with spinal stenosis, the condition gets worse over time, with decreased activity and increased weakening of the core muscles that support the low back. Staying active and exercising to maintain good strength and stability of your lumbar spine and legs will help provide a stable foundation to support your lower back and prevent symptoms of spinal stenosis from getting worse.
Physical therapy can help improve your quality of life by decreasing your pain and providing you with the knowledge of how to correct your posture, avoid positions and movements that make your pain worse, and complete everyday activities in a way that avoids increased strain on your low back.
Physical therapy usually involves performing stretches for the low back, hips, and legs; mobility exercises; and core strengthening exercises to improve lumbar support and decrease pain.
Treatments such as moist heat or electrical stimulation may also be used on a case-by-case basis if there is significant pain or tightness in the muscles of the lumbar spine. However, there is insufficient clinical evidence to support that these have any additional benefit.
Aquatic physical therapy can help spinal stenosis by relieving pressure exerted on the spine. The buoyancy of the water can relieve pressure and pain, and movement in water helps increase blood flow to surrounding muscles and joints to improve flexibility and muscle activation.
A 2018 systematic review of available research suggests no significant differences in treatment outcomes for patients with spinal stenosis when comparing exercise therapy and surgery. Surgery alone cannot strengthen the muscles that stabilize the spine, increase mobility of the spine or flexibility of surrounding muscles, or improve postural alignment. For most patients that undergo spinal stenosis surgery, physical therapy and exercise are still required after the operation.
Physical therapy is an essential part of the treatment plan for spinal stenosis. Exercises performed during physical therapy can help strengthen your lower back muscles and restore mobility. While they are beneficial, check with your doctor or physical therapist before attempting these exercises at home to avoid additional injuries.
Spinal stenosis worsens over time. If you have been diagnosed with this condition or experience symptoms of spinal stenosis that are interfering with your ability to complete everyday activities, you should seek treatment from a physical therapist as soon as possible. Therapists can help get you back to being able to move and provide you with the necessary corrections to protect your back.
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By Kristen Gasnick, PT, DPT
Dr. Gasnick is a medical writer and physical therapist based out of northern New Jersey.
