LBP ec spondylosis

Current research points to exercise as the most effective noninvasive treatment for lumbar spondylosis
(38,46). Exercise should include cardiovascular activity, core muscle strengthening, extensibility
training, and education in body mechanics and ergonomics. The therapist’s main goal with exercise
prescription is to educate the patient on proper technique, ensuring appropriate muscle facilitation and
avoidance of compensatory patterns and helping the patient avoid fear of movement. Considering the
patient’s weight-bearing tolerance and comorbidities, cardiovascular exercise can be performed in the
weight-bearing or nonweight-bearing position and should be low impact. Depending on the patient’s
activity tolerance, strengthening and extensibility exercises can be performed in supine, side-lying,
prone, or quadruped position, progressing to sitting, then standing on even surfaces, and finally
standing on uneven surfaces. Emphasis is on controlled exercises through contraction of the core
muscles, such as the transversus abdominis (Figure 42.1), obliques, multifi dus (Figure 42.2), pelvic fl oor,
and hip musculature while completing movements of the upper and/or lower limbs (Figure 42.3). The
patient is educated on how to carry over the core muscle contraction while performing daily activities
such as during walking, transfers, lifting, and completing household chores (1,46,47). Patient education
should also include advice on maintaining a healthy lifestyle, which includes a healthy diet, good sleep
hygiene, and smoking cessation if this issue needs to be addressed, since nicotine and smoking have
been speculated as risk factors for degenerative disease of the spine.

Aquatic therapy can be useful for patients with poor weight-bearing tolerance or decreased land-
based exercise tolerance. Patients may benefi t from the buoyancy that the water provides enabling
them to perform cardiovascular, strengthening, and extensibility exercises in the pool without
increased pain (49,50). Taping techniques may also be useful in decreasing LBP associated with lumbar
spondylosis. The benefi ts of these taping techniques range from providing support, to decreasing
muscle tension, to acting as a reminder for postural correction. Qi Gong, a form of martial arts, is also
an effective program in reducing pain, increasing extensibility, and increasing strength. In addition, Qi
Gong promotes relaxation and improves concentration and circulation (51). Tai chi is also considered
to be an effective exercise program that can improve strength and balance. Recently a RCT of tai chi
exercise resulted in decreased pain and disability in patients with LBP, therefore, the authors
concluded that tai chi can be considered a safe and effective intervention for chronic LBP symptoms
(52). Since this is the fi rst RCT on tai chi for LBP, further research is necessary to confi rm their results.

Patient education is critical to ensuring a positive outcome. With the encouragement of a physical
therapist, patients need to take ownership of their pain and understand that their compliance with a
comprehensive HEP can determine the effectiveness of their treatment. Patients should be shown that
they are able to move without pain and to learn to not avoid movement because of fear of pain.
Patients should be instructed to perform their HEP daily and incorporate their body mechanic and
ergonomic training into their activities of daily living
LBP ec pathology

There are three main intervertebral lumbar disc pathologies that cause LBP: degenerative disc disease,
internal disc disruption, and disc herniation

MDT is an individualized program that is based on directional preference and will begin with movements
that patients can do with little pain, then progress to include additional planes of motion in order to
improve function and decrease pain. In general, extension based programs may be more appropriate
for central or para-central disc herniations, whereas neutral or flexion based programs may be more
effective for foraminal herniations. But this is a simplistic view of MDT, or the McKenzie method, which
requires advanced training to properly make a mechanical diagnosis and formulate a therapy program
to centralize and reduce symptoms. In addition to MDT, hip/trunk and lower limb mobility exercises
must be included and improvements should be made before transitioning to a core strengthening
program. Gentle trunk mobility exercises may be utilized, including flexion and extension cycles to
reduce joint stiffness and relax elastic structure resulting in lower joint loads during subsequent
movements (50). Careful attention needs to be paid to the patient’s gait and postural examination. A fl
at back posture (decreased lumbar lordosis) is often associated with short hamstrings, and increased
lumbar lordosis is often associated with tight hip fl exors (32). In these cases, exercises to correct these
postural and muscular imbalances can help reduce chronic strain on the spinal structures. Postural
control has repeatedly been found to be altered in patients with chronic LBP compared to healthy
controls (51). Patients should be instructed to develop improved core, biomechanical, and postural
awareness, and then incorporate this improved awareness into their daily activities. Flexible hips and
knees are required to adopt postures that protect the low back (23), thus it is imperative that hip and
knee mobility exercises (Figures 43.1 and 43.2) are included if ROM defi cits are present in order to
facilitate spine-conserving postures.

Core strengthening, lumbo-pelvic stability programs may be initiated early in the program for the
purpose of neuromuscular reeducation of the transverse abdominis and multifidus. Then patients
should learn to perform gentle limb movements during core muscle contraction (32) (Figure 43.3).
Exercises may be gradually advanced, with the goal of maintaining optimal spine stabilization during
increasing challenges to the body. The therapeutic program should aim to improve muscle strength
and endurance by incorporating exercises that limit compressive forces on the spine, which has been
demonstrated as a mechanism of injury (50). The patient will focus on training specific muscles,
beginning with anterior abdominal exercises while maintaining the spine in neutral posture, then lateral
muscle exercises for the quadratus lumborum and lateral abdominal wall muscles, and then a trunk
extensor program (50). The ultimate goal is for the patient to perform high-level activities without pain,
such as work and sports, while maintaining spinal stability (52). The strengthening and stability program
should be systematic, gradual, and progressive, and should emphasize endurance training (i.e., longer
duration and lower-effort) before strengthening. There is evidence indicating that endurance training
has more protective value than strength training alone, especially when considering that back injuries
can occur during activities with seemingly low-level demands, and that the risk of injury from motor
control error may occur (53). Thus strength gains should not be over-emphasized at the expense of
endurance (50).
Proprioceptive exercises that enhance neural and motor control have been recognized as an
important element of therapy for discogenic LBP (54). A sensorimotor stimulation program that
incorporates training on semi-unstable surfaces, such as an exercise ball, wobble, or rocking board,
can specifi cally activate the gluteal muscles and improve pelvic control by training the body to handle
unexpected perturbations. Activation of the gluteus maximus and gluteus medius helps to provide
improved stabilization of the pelvic girdle and in turn will help in the protection of the low back
against injury (54). The final phase of rehabilitation attempts to incorporate the gains made in postural
awareness, lower limb mobility, and spinal stability into functional exercises that may include weights,
pulleys, and advanced closed chain exercises such as lunges with a diagonal punch. If the patient is an
athlete, return to play criteria should be followed and sport-specifi c activities are added prior to return
to sport.

Specialized program,

Many consider the McKenzie method or MDT that was previously discussed in this chapter to be a
specialized technique. Dr. Shirley Sahrman teaches an approach that focuses on identification and
correction of movement impairment syndromes (55) and Dr. Vladimir Janda has emphasized a
neuromuscular reeducation approach to treating LBP (56), while both have recommended the
correction of muscular imbalances. Similar exercises that incorporate these concepts have been
discussed in the therapeutic exercise section of this chapter. In addition, there is mixed evidence
supporting the effi cacy of aquatic exercise for the treatment of discogenic LBP. One study suggests
that aquatic backward locomotion exercise is as benefi cial as progressive resistance exercise for
improving lumbar extension strength in patients after lumbar discectomy surgery (57). What is clear is
that patients with axial load sensitivity may be good candidates for aquatic therapy, which takes
advantage of water buoyancy to reduce axial load. In the acute phase, many patients are able to
tolerate exercise in warm water better than on land, in part due to the buoyancy effect of water, as
well as the relaxing effect from the proprioceptive input and support of the warm water. Aquatic
therapy facilitates low load and low impact exercise for the spine. Freestyle swimming may
exacerbate symptoms in the early stages of recovery due to the spinal extension and twisting that are
involved. If this is the case, a patient may better tolerate stationary aquatic exercises, such as standing
in a pool and performing abdominal sets, leg and arm movements, or treading water with a vest, all of
which are effective adjuncts to land based exercises.

Home program,

Patient adherence to a well-planned home exercise program (HEP) is an important component of an

effective rehabilitation program for discogenic LBP. Thorough patient education that includes an
explanation of the rationale behind the exercises will improve patient compliance and help to prevent
further injury. The early HEP focuses on core and postural awareness and proper spinal biomechanics.
Exercises to improve flexibility in the hips and knees are included to facilitate proper spinal
biomechanics. Core strengthening exercises are then incorporated, which may include isometric
flexion and extension cycles guided by directional preference, to achieve improved control throughout
the newly established ROM. The core strengthening regimen will then advance to incorporate gentle
limb movements while maintaining core muscle contraction with neutral spine alignment. The patient
may practice proprioceptive exercises with the goal of improving pelvic control and spine stabilization
during advanced activities. Patients should be instructed on a general conditioning program that
includes cardiovascular training or low impact aerobic exercise (e.g., walking), which has been shown
to improve outcomes in patients with LBP, and helps to prevent future injury (59). Although patients
may see a physical therapist three times per week, there is some evidence that low back exercises are
most benefi cial when performed daily (60). This underscores the importance of a HEP

LBP ec Radiculopathy

Therapeutic Exercise

Therapeutic exercise is the key to functional recovery. While medications, manual therapy, and
modalities can help to decrease pain and infl ammation, progression through the remaining phases of
rehabilitation is dependent on therapeutic exercise. As for ROM and lumbar radiculopathy, it has been
demonstrated that patients who achieved end range lumbar extension (12) and achieved it quickly
(13) had a better prognosis of avoiding surgery than patients who did not. Patients who are unable to
centralize their pain were six times more likely to have surgery (14). Prognostic factors such as leg pain
at onset are associated with poor outcomes and a greater likelihood of developing chronic symptoms, as
well (15,16,17,18,19,20). Therefore, once patients are able to centralize symptoms and their pain is
well controlled, a lower limb fl exibility and spinal mobility program should be initiated to restore
functional ROM. Postural training and proper spine biomechanics should also be taught and
awareness gradually improved during this period of decreased pain and improved ROM.

Core strengthening and lumbar stabilization programs are another key component of the therapeutic
exercise program for lumbar radiculopathy. Patients who are likely to respond to specifi c stabilization
programs have been identifi ed by Hicks et al (21). These patients tend to be younger (<40 years old),
have an average straight leg raise greater than 91 degrees, the presence of aberrant movements such as
a painful arc or catch with their movement on ascending from fl exion, positive prone instability test,
and the presence of a level of fear avoidance beliefs. In addition, it has been demonstrated that a
“specifi c exercise” treatment approach directed at the lumbar multifi dus and deep abdominal
stabilizers may be more effective in patients with chronically symptomatic spondylolysis or
spondylolisthesis, who may or may not present with lower extremity pain, when compared to general
strengthening and modalities (22). Therefore, neuromuscular reeducation exercises should be included
to retrain the transverse abdominis and multifi dus. With improved control of these muscles the patient
can gradually progress from basic to advanced core strengthening exercises in a neutral spine posture.
Please refer to the chapter on Lumbar Disc Pathology for further details.

Specialized Techniques

Mechanical diagnosis and therapy (MDT) is another specialized technique that has been shown to be an
effective assessment method for determining if certain patients will respond to treating themselves with
directionally specifi c exercises. Concepts such as centralization will help the clinician and patient
determine if their radiculopathy will respond to mechanical treatment. Centralization is defi ned as
when “pain is progressively abolished in a distal to proximal direction with each progressive abolition
being retained over time until all symptoms are abolished” (23).Movements in other directions or the
opposite direction can potentially cause symptoms or mechanics to worsen, as well. Centralization of leg
pain has been proven to be a predictor of good outcomes (20,24,25,26,27,28). Inability to centralize
symptoms is the strongest predictor of chronicity compared to a range of psychological, clinical, and
demographic factors (29). Other factors such as a signifi cantly higher percentage of leg to back pain may
have a high probability of harboring an extruded disc fragment (30).

Home Exercise Program

The patient’s home exercise program (HEP) begins as soon as the therapist or treating clinician assesses
the impact of posture on the patient’s radicular symptoms. If correction of the posture causes
symptoms to centralize or move proximally into the limb, the position should be strongly encouraged
and maintained throughout the day and at all times with assistance of devices such as a lumbar roll.
Patient education should focus on the critical concept of centralization and the idea that the pain may
increase closer to the spine or proximally in the limb as the patient improves. Education should focus on
the frequency of an exercise program that moves the pain proximally. Once a day may not be frequent
enough to counteract act the day-to-day postures of the patient. Repeating the HEP six to eight times a
day or every couple of hours may be required to keep a patient with a radiculopathy feeling good. Then
as the therapeutic exercise program progresses to lower limb fl exibility exercise and core strengthening,
these exercises are slowly incorporated into the HEP.

LBP ec Spondylisis + Spondylithesis

Therapeutic Exercise

Therapeutic exercise should focus on improving core control through dynamic lumbar stabilization,
maintaining or enhancing flexibility of the lower limbs (especially the hamstrings and hip flexor
muscles), and aerobic conditioning. In cases of acute spondylolysis, therapeutic exercise should only
begin after adequate rest has taken place and symptoms have resolved, although low impact aerobics
(e.g., aquatic exercise, cycling) may be utilized for athletes during the period of relative rest to prevent
further deconditioning. In the case of acute spondylolysis, a lengthy rehabilitation program is
required, with 3 months of rest and then at least 2 months of physical therapy before returning to
sport (8). Lumbar spinal extension and activities that increase pain should be avoided. One of the
most important techniques to teach the patient is abdominal bracing, or the abdominal draw-in
maneuver (12). The patient should be instructed to perform this in supine, in the hook lying position,
and in quadruped. The patient should be instructed to draw the umbilicus toward the spine to contract
the transverse abdominis muscle. Alternatively, abdominal bracing can also be obtained with slight
abdominal protrusion and activation of the transverse abdominis. This has been shown to have
increased stability of the lumbar spine in static positions (13). Cues for normal breathing and relaxing
the buttocks may be necessary to avoid over-recruiting the muscles of the hips, chest, and neck.
Research has also demonstrated atrophy of the lumbar multifi dus in patients with both acute and
chronic LBP (14). The lumbar multifidus can be trained either in isolation or as a co-contraction with the
transverse abdominis, and should be part of the neuromuscular reeducation component of the
therapeutic exercise program. Once control over these muscles has been mastered, the therapist can
gradually introduce dynamic core strengthening, which includes movement of the limbs to further
challenge the dynamic core stability with progression to more sport-specifi c training in athletes. As
progress is made, unstable surfaces should be utilized to further challenge the core muscles and
proprioception.

Specialized Techniques

A detailed postural assessment should be conducted during the initial evaluation by the physical
therapist and the patient should be viewed in both the sagittal and coronal planes. A detailed critique of
the entire kinetic chain is essential, but with lumbar spine conditions, it is important to focus on the
resting position of the pelvis. An anterior pelvic tilt can reveal tight hip fl exors and elongated
hamstrings, while a posterior pelvic tilt with a fl at back posture can expose tight hamstrings. A postural
assessment can help to guide your interventions for therapeutic exercise and manual therapy. Training
in posture and body mechanics is essential in the management of painful lumbar spine pathology.
Patients should evaluate their work station for ergonomic risk factors as outlined by the Occupational
Safety and Health Administration.

Patients should be instructed in the following techniques when lifting:

Carry the load close to your body

Do not twist your spine when moving objects between surfaces, turn your whole body instead

Bend at your knees, not at your back

Use the abdominal bracing technique described above

Home program

The home exercise program (HEP) should begin at the initiation of the rehabilitation program. It
should consist of dynamic lumbar stabilization and lower limb stretching. Compliance to the HEP is
essential to the overall success of physical therapy treatments.

LBP ec spinal stenosis

Therapeutic Exercise

Unfortunately, the evidence basis for the treatment of LSS with therapeutic exercise is poor. The NASS
guideline from 2008 states that there is insuffi cient evidence to support the effectiveness of physical
therapy for LSS (17). However, this gap in the literature is in part due to the paucity of studies on
rehabilitation for LSS, rather than a clear lack of effect of interventions. Thus, the treatment of LSS with
therapeutic exercise is based on some small studies which show effi cacy, and an understanding of
biomechanical principles which may contribute to worsened pain with impaired function. It is known
that the diameter of the spinal canal lessens with extension and increases with fl exion, thus a fl
exion-based program for the lumbar spine is often recommended, with avoidance of lumbar
hyperextension. In a study of patients with LSS and neurogenic claudication, treating physical
therapists reported in a survey that their preferred treatment plan included fl exion-based exercises
(82%), trunk muscle stabilizing exercises (70%), and general fi tness exercises (58%) (18). Williams’ fl
exion-biased exercises target and attempt to correct increased lumbar lordosis, paraspinal and
hamstring infl exibility, and abdominal muscle weakness. These exercises incorporate single and
double knee-to-chest maneuvers (Figure 46.1), hamstring and hip fl exor stretches (Figures 46.2a and
46.2b), stretches for the trunk and paraspinal muscles (Figure 46.3), pelvic tilts (Figures 46.4a and
46.4b), partial sit-ups, bridges in a neutral spine posture (Figure 46.5), and squats. Lumbar stabilizing
exercises are usually performed in a neutral spine position, or even with a fl exion bias to control
symptoms of LSS while progressing with these therapeutic exercises. Positional therapy is a technique
using a wheeled walker to promote lumbar fl exion with gait; this method has been shown in a case
series (n = 52) to improve ambulation and reduce neuropathic pain (19). Anecdotally, for those
patients who do not desire a wheeled walker, trialing bilateral walking sticks may also provide some
benefi ts for functional ambulation. Use of a treadmill for ambulation training, as part of the
therapeutic program for patients with LSS, has been shown to be helpful in several studies. Traction
harness-supported treadmill and aquatic ambulation to reduce compressive spine loading have been
shown to improve lumbar range of motion (ROM), straight leg raising, gluteal and quadriceps femoris
muscle force production, and maximal (up to 15 minutes) walking time (20). In a study comparing
patients doing manual therapy, exercises, and body-weight supported treadmill walking to patients
doing fl exion exercises and treadmill walking, more patients in the former group recovered at 6 weeks
compared with the latter group. These gains were maintained at 1 year by 62% of the manual therapy,
exercise, and walking group (body weight supported) and 41% of the fl exion exercise and walking group
(21). Because both groups had multiple interventions, it is diffi cult to generalize from this study.
Another study with 68 patients with LSS performed either treadmill with body weight support or cycling,
twice weekly for 6 weeks. Both groups also received an exercise program consisting of heat, lumbar
traction, and fl exion exercises. No signifi cant difference between the groups was found in terms of pain
or disability (22). Because of the ability to alter amount of spinal flexion with walking on a treadmill, a
two-stage treadmill test can be used to assess patients with LSS. This test uses a treadmill to control
walking posture, and assist in the diagnosis of LSS (23). It also has utility as an outcome measure to
assess progress with therapy, specifi cally ambulation distance and speed. Unloading using a traction
harness can also be part of the treatment of LSS; it allows for decompression of the spine, which
increases spinal diameter and unloads structures such as the discs and facet joints. Note that pool
therapy for initial ambulation may also be used for its offl oading effects (23). For patients who can’t
tolerate treadmill walking and don’t have access to a pool, cycling on a traditional stationary or
recumbent bicycle may be an excellent initial alternative for cardiovascular conditioning.

Specialized Techniques

Studies have also looked to see if determining a “directional preference” in patients with LBP can be
used to guide treatment (24). A directional preference is an immediate, lasting improvement in pain that
results from performing repeated lumbar flexion, extension, or side-gliding/ rotation tests. When
directionally based treatment was used in patients with a directional preference (74% of 312 patients),
this led to signifi cant improvement in all outcomes including a rapid decrease in pain and medication
use, but when the exercises given are “opposite” to directional preference (DP) or “nondirectional,”
then 1/3 of patients dropped out in 2 weeks (no matched subjects withdrew) (24). Note that these
studies were not specifi c for patients with spinal stenosis, but these techniques can be used in those
with LBP only and with sciatica, with exercises specifi cally used to decrease or eliminate lumbar midline
pain, or cause referred pain to centralize (or retreat in a proximal direction). The use of acupuncture as a
therapeutic modality is gaining in popularity, yet the evidence base for its effectiveness is lagging
behind. A recent review of studies on the effi cacy of acupuncture in both acute and chronic LBP was
performed, but the utility of acupuncture in patients with LSS was not specifi cally studied. The results of
this analysis were that there was no evidence showing acupuncture to be more effective than no
treatment. There was moderate evidence indicating that acupuncture is not more effective than trigger-
point injection or TENS, and there was limited evidence that acupuncture is not more effective than
placebo or sham acupuncture for the management of chronic LBP (25). Given the lack of effi cacy in a
chronic LBP population, and no way to know if thesetreatments are specifically useful for patients with
LSS, recommendations for patients to pursue acupuncture should be limited.

Home Exercise Program

Patient adherence to a home exercise program (HEP) is an important way to help them get relief with
the initial rehabilitation program, as well as to maintain improvements made in treatment over the long
term. Patient education regarding the postural etiologies underlying symptoms in LSS should be the fi rst
element to teach. This allows the patient to immediately begin altering their gait, maybe by using a
walker or walking sticks, or by stopping to rest and fl exing the spine for symptomatic relief. Reinforcing
the role of posture and the pelvic tilt, and giving exercises to do at home to work on lumbar stabilization
and pelvic position will allow the patient to continue to improve their strength, function, and hopefully
reduce pain. Finally, patients can be discharged from therapy with a set of exercises designed to stretch
chronically tight muscles and strengthen weak or over-lengthened muscles, while observing improved
posture and pelvic position throughout their daily tasks. The HEP can also encourage continuation of
conditioning and endurance activities.