Spinal stenosis is a common cause of low back pain for many. In this article I want to touch upon the cause, symptoms, and treatments of spinal stenosis. I also want to show how spinal stenosis can be treated before jumping to surgery, injections, or medications with the powers of Physical Therapy.
While the purpose of this article is to provide you a comprehensive and easy to understand overview of spinal stenosis. I will include links throughout the article that will give more in depth information. Be sure to check them out if you would like to learn more!
Symptoms of Spinal Stenosis:
Before we dive into the meat of this article, I want to paint a picture for you.
Your low back back has been bothering and nagging you for around 4 months now. It has progressively gotten worse over time and now is to the point where it is affecting your everyday life.
Getting up in the morning your back is stiff and it hurts. Swinging your legs off the edge of the bed and standing up is a monumental task. You have to move around to “loosen up” your back. After around a half an hour it starts to feel better.
You go for your daily walk in the morning, you can walk for around 15 minutes before that all too familiar dull ache becomes an attention grabbing pain in your lower back.
Your kids, who live out of town have come to visit for the weekend. You're cooking their favorite homemade meal. Ten minutes into the meal you are done chopping the peppers and onions you're in pain. You have to sit down because you can literally “no longer stand the pain.” You have to sit down and rest for 15 minutes before you can finish cooking the rest of the meal.
All the above are common complaints of those with spinal stenosis. It can be a debilitating disease that affects people's ability to live their life to their fullest.
Visit With Your Doctor:
Your back pain is clearly affecting your everyday life activities. You are sick and fed up with it and decide it is time to do something about it.
You go to your primary care provider who orders x-rays. You get your imaging, and wait patiently for the doctor to read them.
The results are back. The doctor brings in the x-ray film and clips it into the light board. The image of your spine is illuminated by the background.
You study the picture intently, however, quickly realize you have no idea what you are looking at.
The doctor begins pointing at the bones on the x-ray and explaining what he sees. You try to make sense of what he is saying but very little sticks.
In the end the doctor concludes you have something called spinal stenosis and that you have a good amount of arthritis in your back.
Your Doctor states:
There is not much he can do to change the arthritis in your back. Arthritis is not reversible. I do have several treatment options for you including injections, medication, and surgery. He also mentions Physical Therapy.”
The doctor concludes he will leave it to you about what treatment option you would like to pursue.
Your Decision:
At this point you are confused and frustrated.
The doctor told you there is not much he can do for arthritis in your back. It is something that has formed due to age, and life's natural wears and tears.
Your thinking to yourself, “Why would I subject myself to taking medication, getting surgery, or a needle injected next to my spinal cord in my back. This risk does not seem sensible if there is not much that can be done for my condition?”.
We will leave this story here for the moment.
What is Spinal Stenosis:
I would like to now take the time to explain what spinal stenosis is. Spinal stenosis is much more than just arthritis. It is a very complex disease with multiple causes and multiple presentations.
If you can understand what is causing your pain, you are more likely to be able to fix it.
Joseph Armeli DPT, ATC, CSCS
Spine Anatomy:
To understand what spinal stenosis is you first have to have a bit of an understanding of the anatomy of the spine. Here I will give you a very brief run down of the anatomy of the spine.
Anatomy of The Spinal Vertebrae:
The spine is normally comprised of the following bones called vertebrae:
Purpose of the Spinal Column:
We are going to focus on the 7 lumbar or lower back vertebrae. The primary purpose of these bones is to protect the spinal cord. The bones also allow for movement including bending forward and back and side to side.
Lumbar Flexion
Lumbar Extension
Lumbar Sidebending
The Spinal Canal:
You can see the spinal cord running through the spinal canal inside the red circle above.
In the back of each of these 7 lumbar vertebrae there is a big hole that the spinal cord runs through.
This means the spinal cord is surrounded by bones from its starting point (your brain) all the way down to its ending point (your lower back).
Anatomy of the Intervertebral Foramen:
View of vertebrae as if looking down. Depicts spinal cord sending off nerve root through the tunnel called the intervetebral foramen
Overview of anatomy of spine. Inside red box is spinal nerve or nerve root exiting through intervertebral foramen.
The spinal cord sends little branches off of it to your limbs called nerve roots. These nerve roots exit the side of the spine through a tunnel called the intervertebral foramen. This is important and is an area that often causes a problem with spinal stenosis, I will get back to this later.
Spinal Cord Anatomy:
Now that we have covered the bony makeup of the spine we can discuss how the spinal cord works.
Everyone has heard of the spinal cord and knows it is not a structure they want to be injured as in serious injuries to the spinal cord it leads to paralysis.
Purpose of the Spinal Cord:
The spinal cord is basically the connector between your brain and the rest of the body. It helps with all the following:
How the Spinal Cord Works:
There are many pathways the spinal cord uses to send signals to the brain. I want you to understand the 2 most basic pathways the brain sends signals.
- 1The Motor Pathway
- 2The Pain Pathway
1. The Motor Pathway:
Let me describe the path a nerve impulse takes from the brain to the muscle to help you move:
Shows the sequencing of a nerve root as it travels from the brain to the muscle.
When you decide to stand up from a chair areas in the brain associated with this movement are activated. When these areas are activated your brain sends messages or nerve impulses to the spinal cord. These nerve impulses travel downward inside the spinal cord. Because they are traveling to the legs the nerve impulses travel all the way to the lumbar spine. The impulses then go out of the spinal cord via in the nerve root. The nerve impulses then continue along the nerve root until the it reaches its desired destination, being the muscle which helps you move.
2. The Pain Pathway:
Now let me describe how pain signals originate in the body and travel up to the brain. In this example we will use stepping on a nail:
Shows sequencing of pain nerves sending nerve impulses back to brain.
When you step on a nail you activate pain nerves located in your foot. These pain nerves send nerve impulses back through their associated nerve root to the spinal cord. It reaches the spinal cord in the lower back region because once again, this is where the nerve roots are located for your legs. From there it travels up the spinal cord to the brain. Your brain reads this message and expresses pain which is what you feel.
When you need to move your spinal cord acts as a connector carrying nerve impulses from the brain to the muscles.
When you feel pain your spinal cord acts as a connector carrying nerve impulses from pain nerves to the brain.
They are two different directions, muscle movement going down the spinal cord and pain perception going up the spinal cord.
Think of the spinal cord as a road system
The spinal cord itself as a busy 6 lane expressway.
Each nerve branch is the exit off the expressway.
The exit is a road leading to someone's home. The home is where the nerve branch ends. The home represents either the muscle, joint, or area of skin.
The cars on a expressway represent nerve impulses.
The cars travel on the busy expressway and get off at an exit. The exit leads to their home.
This is the same way nerve impulses travel through the spinal cord then exit through a nerve branch and reach a muscle that the nerve branch is connected to.
When everything on the expressway is functioning well cars go to and fro without an issue. This would mean your body is feeling normal sensations and is moving without flaws.
What is Spinal Stenosis:
So now that you have a little bit of an understanding about the spine itself and how the spinal cord works by sending off branches from within the spine I want to tell you what spinal stenosis is.
Spinal stenosis literally means the narrowing of the spine.
Remember how I talked about how the spinal cord has to run through the spinal canal. Due to natural wear and tear on the body this spinal canal becomes narrower. This means there is less room for the spinal cord to travel.
Think about our once 6 lane expressway turning into a 4 lane expressway but with the same amount of traffic. Cars would be backed up for sure. They can no longer get off the exit as well to their homes.
Your body responds to the cars being backed up by sending pain signals to your brain.
The pain can be located solely in your low back, but can sometimes travel down your leg. When the pain shoots down your legs your body is trying to tell you the cars on your expressway are having difficulty getting to their home.
Another Way to Think of Pain Traveling into Your Leg:
Think of a garden hose.
The water traveling through the hose is the electrical impulses from your brain to the spinal cord.
The hose is the nerve root branching off the spinal cord.
The head of the hose or the part the water comes out of, is the end goal, think of it as the nerve connecting to the muscle or area of skin.
If water comes out as a steady unimpeded stream you are happy, everything is working well. This means you have full sensation and the impulses are able to get to your muscles and skin to function correctly. You do not have pain
Now put a kink in the garden hose.
The water can no longer travel out of the water hose.
There is a problem in the system.
Your body is going signal to you something is wrong by sending back the sensation of pain.
One More Way to Think of Pain Traveling into Your Leg:
If that doesn't work think of the electrical set up for your TV.
To get the TV to turn on you connect a power cord to the outlet and the back of the TV. The purpose of the power cord is to bring electricity to the TV.
In this example the outlet is the spinal cord, and the power cord is the nerve exiting from the spinal cord to your legs.
The power cord carries electricity or in your body the nerve impulses.
If everything is functioning correctly the outlet supplies power through the power cord which connects to the TV which then turns the TV on. In your body this is analogous to the spinal cord sending unimpeded nerve impulses through the nerve root which then connects to the muscle.
When the TV is on and working this means there is no problem with the connection, everything is working. You feel no pain and you can move without any limitations.
Now let's say someone takes a pair of scissors and cuts this power cord. Electricity can no longer travel through the power cord and power the TV. In your body the nerve impulses can no longer reach their end destination.
Your body is going to alert you of this by causing you pain.
Okay, so I feel like I basically beat the concept of nerve impulses running form the spinal cord through the individual nerve to death.
Hopefully you understand this concept, and if you don’t please don’t hesitate to give me a call/text/email. I want to help guide you to understanding your pain. I truly believe in order to help fix your pain you have to understand what is causing your pain. I want to help you with this.
How Narrowing of the Spine Occurs:
Now you may be asking okay Joe I get that my spinal cord or nerves are being pinched off making it so that nerve impulses can not get to the rest of my body, but how do they get pinched off.
This is where the natural wear and tear comes in.
The Bodies Ability to Adapt to Stresses Placed Upon it:
To understand “natural wear and tear” and how it works on the human body we first have to understand one of the most fascinating things about the human body.
It’s ability to adapt to the stresses we place on it.
Think about a bodybuilder, they were not born with huge hypertrophied muscles. The bodybuilder forced his muscles with certain stresses to grow.
To get the muscle growth bodybuilders have they have to go to the gym for an amazing amount of hours and lifted progressively heavier weights.
Their muscles adapt to the progressively heavier weights by getting bigger.
On the contrary, think about someone who sits around all day.
The body adapts by gaining weight and losing muscle. They gain weight because their body does not need to use all the calories they consume.
Their muscles also go through a transformation called muscle atrophy. Muscle atrophy is the weakening of the muscles.
Our bodies are amazing machines and naturally built for survival.
If someone is not moving they are not using their muscles. The body assumes these muscles are not necessary to the person's life and delegates their energy or calories away from these muscles causing them to weaken.
The bodies ability to adapt can even be seen with something as little as a callus.
Let’s say you have been doing some edging around your house using a shovel for the past week. You notice the calluses that have formed on your hands.
Calllus build up is our body's way of adapting to the stresses placed on the hand so that a blister does not form.
How the Body Adapts to Stresses on the Spine From Aging:
Now that you have a grasp on the body’s ability to adapt to different stresses placed upon it, lets look at how our spine adapts to age.
As we get older our body’s spine structure changes.
The Intervertebral Disc (Not Labeled in the picture) is the blue structure. Remember the Jelly Donut.
The first adaptation that happens is a shrinking of the intervertebral discs.
Your intervertebral discs are basically fluid filled cushions in between each vertebra. The discs help cushion against the spine and even give the bones some nutrients.
Every medical professional you talk to will describe them as a “Jelly Filled Donut”, but if you have not heard this analogy yet I will give it to you here.
You can think of the intervertebral disc as a Jelly Filled Donut.
As a whole it is somewhat squishy. This property allows weight to be absorbed through the spine.
As you know the inside of a Jelly Donut is filled with a gel like substance (the jelly). The same can be said of your intervertebral discs except the jelly inside your discs is slightly more “watery” and filled with plenty of other nutrients that are necessary for spinal health.
The outside of the Jelly Donut is much harder and keeps the jelly contained inside. Once again, the same can be said about the intervertebral disc. The outside of the disc is a rubbery wall that holds the fluid inside.
When the rubbery outside has a leak it allows fluid to go outside. This is referred to as a herniated disc, however, that is for a different blog post.
So now that we have the “Jelly Donut” analogy out of the way let's talk about how the intervertebral disc adapts with age and its role in spinal stenosis.
As we get older the height of the intervertebral disc shrinks.
This is due to our friend gravity.
You are constantly being pulled downward towards the center of the earth which is what gives us our weight. Our weight sits on top of our spine. Over time this constant pressure towards the ground flattens these discs. While you can decrease the speed of this naturally occurring phenomenon by watching your weight, it will still occur.
I often see patients coming in after an X-ray saying they have Degenerative Disc Disease. They become very concerned about their “disease”.
I hate the term Degenerative Disc Disease. It causes unnecessary fear in patients. Degenerative Disc Disease is the phenomenon I have described above. It is the natural occurring process of being on our Earth. For further reading on degenerative disc disease see some of my other posts.
The reason I mention Degenerative Disc Disease is it is a part of the disease process of spinal stenosis. Often times it is Degenerative Disc Disease that leads to spinal stenosis.
The Natural Curves of the Spine:
So now our intervertebral discs have shrunk. Next, I want you to notice the natural curve of the lower spine. You'll notice in the diagram below the Lumbar curve naturally has a curve towards your belly button.
Medically this is called a lordotic curve. It is completely normal to have this curve. Some peoples are more pronounces than others.
Now think of the effect our shrunken intervertebral discs will have on this lordotic curve of the lumbar spine.
Not only is the shock absorbing property of the intervertebral disc going to be less placing more pressure on the spinal bones but also the angles of the curve are going to become more pronounced.
The result of the exaggerated angles of the lower spine is increased pressure placed on the bones and ligaments of the spine.
This is where the body’s amazing ability to adapt comes in, however, in this case it can backfire.
Bone begins to adapt to this increased pressure by building more bone. Think of the callus on your hand due to shoveling all day.
This adaptation causes a problem. There are 2 places the bone commonly "calluses" that cause problems.
- Generalized pain in the lower back
- Pain going down one leg
- Pain going down both legs
One is around the openings the spinal cord goes through called the spinal canal. The second is along with where the nerve branches exit called the spinal foramen. Both of these cause a pinching on the nerves.
As we’ve talked about in this article the pinching on the nerves is what causes pain. The pain typically presents in any combination of the following ways:
Treatments for Spinal Stenosis:
Hopefully you have a good understanding of what spinal stenosis is. If you do not, do not hesitate to reach out to me. I am available via text/call and email! I would love to hear from you, remember if you do not fully understand the cause of your pain, you can not make it go away.
Let’s talk about treatment.
There are multiple treatment options for you if you have spinal stenosis. They are:
Treatment Options for Spinal Stenosis:
Keep in mind I am a practicing Doctor of Physical Therapy, Certified Athletic Trainer, and Certified Strength and Conditioning Coach. All of which deal with treating this condition non-invasively (as compared to surgery, injections, and pain medication).
Non-invasive techniques use the body's ability to adapt to causing meaningful changes in your body.
I can not speak on the true effectiveness of each intervention as each situation being unique. Everyone reacts differently to each treatment method, and everyone has their own preferred preferences towards treatment.
I can tell you what I would do if it was me.
If I, myself, was diagnosed with spinal stenosis I would not want anyone performing surgery or injecting a needle close to my spine. The spine is a far too delicate structure and I know the substantial consequences if something were to go wrong.
As far as medications, I view them as a bandage, they do not fix the problem only cover it up.
If you cover up your pain you realistically are just going to make it worse.
Think about it, pain is your body's self defense mechanism. It tells you something wrong, and when it's painful enough will stop you from doing an activity.
The reason your pain gets bad enough to stop doing an activity is your body is shouting at you “HEY!! STOP IT YOU ARE CAUSING ME MORE DAMAGE!!
Pain is like your check engine light on your car.
When your check engine light comes on you don’t keep driving it! You bring it in to get it looked at and fix the problem!
Physical Therapy offers a non-invasive, low risk, approach towards curing or managing the pain of spinal stenosis.
Too often I see patients that have gone through other invasive procedures as the ones listed above first, only to come to Physical Therapy still in pain.
By the end of our time together it is often these people that say they wish they had tried PT first.
Treatment Approach of Physical Therapy for Spinal Stenosis:
While there are many ways to try and accomplish relieving your pain from spinal stenosis there are basic principles that a good Doctor of Physical Therapist should follow.
Get You Back to Your Previous Lifestyle:
It is unfortunate with today’s insurance based medical care everyone is focused on decreasing pain.
Don't get me wrong I do think decreasing pain is very important.
Unfortunately insurances have placed such an emphasis on pain levels it becomes over-emphasized.
In my virtual Physical Therapy visits I like to focus on function.
I want you to be able to move how you want to move. We do this by setting goals and working towards them.
If your goal is to be able to cook a full dinner without having to take a break due to pain that is what we are going to work towards.
When meet your functional goals with Physical Therapy pain takes care of itself.
Managing your Pain:
I know I just said I disagree with focusing on pain. However, it does play a crucial role in determining your current functional status and future decisions about creating an individualized treatment plan.
To do this, during our virtual Physical Therapy session, I need to figure out what activities you can not do due to your pain.
This allows me to determine how much pain is affecting you and your ability to perform activities.
I need to find a baseline of what activities are too painful to perform and what activities you can tolerate.
By asking questions and listening I begin to formulate a plan that will best work to manage your pain.
We can work together to figure out which activities are okay to be performing and which need to be modified or avoided until we have your pain under control.
Teaching Correct Movement Techniques:
There are movements that can place a lot of stress on the spine.
For example did you know sitting in a slumped position at a desk places 1.5 times more pressure through your spine versus sitting with good posture.
There are actual correct techniques, that place virtually no stress through the spine, when bending over to pick something up.
Also there is a correct way to set up your computer desk, car chair and so forth to allow for minimal pressures through the spine.
By talking to you during our first virtual Physical Therapy visit and throughout other visits we can make the appropriate changes to your movement and environmental set-up to allow for optimal health for your spine.
Strengthening the Core:
This is a staple of Physical Therapy. My goal after every virtual Physical Therapy visit is to have 3 exercises for you to perform.
The 3 exercises vary considerably due many factors.
For example an active person with good core strength will get different exercises than someone who has never done any exercise for your core.
Another reason I curtail exercises specific to you is...
Are you extremely flared up and can only tolerate simple movements or can you tolerate some more complex movements.
I believe that no case is the same and each treatment plan needs to be created to meet an individuals needs.
Work on Other Areas of Weakness:
The other thing I like to check is areas that are often forgotten. People overlook certain areas as being associated with back pain.
I will leave no stone uncovered.
Your back and your spine is basically the bridge between your torso and your limbs.
If you have weakness in your hips, legs, or shoulder muscles it can actually cause an increased load on your spine.
The increased load can hasten the wear and tear on your spine.
In Conclusion:
Hopefully you found this article very informative. I know it was long and lengthy.
You should have learned common symptoms of those with spinal stenosis. Gotten a better understanding of spinal anatomy. Learned what causes spinal stenosis. And last but not least learned how spinal stenosis can be treated.
My hope is with this article you have a better understanding of spinal stenosis and are willing to give physical therapy a try to cure your pain.
Once again if you have any questions or would like to set up a virtual Physical Therapy visit don't hesitate to reach out!. I want to hear from you!
Until next time,
Joe Armeli
