Lumbar spinal stenosis bootcamp: New approaches for patients with complex back and leg pain
By Dirk Keenan
By Dirk Keenan
Throughout many years as a practising chiropractor, I have found myself frustrated with patients who have experienced long term back and leg pain, with no relief from my approach. I utilize various chiropractic techniques and include many mechanical and PEMF physical therapies that seemed to be beneficial in most spinal conditions, but not with the treatment of lumbar spinal stenosis.
It was my experience that older patients presenting with severe lumbar arthritic degeneration, the principal symptom being leg pain, would often experience disappointing clinical outcomes.
My first introduction to new research surrounding lumbar spinal stenosis (LSS) was through Dr. Carlo Ammendolia at the Canadian Memorial Chiropractic College. Shortly after our detailed discussion, I recognized that this approach was going to be an essential development for the chiropractic profession. Dr. Ammendolia is a world authority on the non-surgical management of LSS and has led a number of us through the very latest research available on the diagnosis and management of this condition, and its long-lasting effects such as neurogenic claudication.
Based on my experience with LSS patients, I concluded that by simply having the patients tilt forward, they experienced immediate and significant relief. As Dr. Ammendolia explained, the type of pain they are experiencing is not inflammatory, and therefore medications, herbals, anti-inflammatory diets, and corticosteroids are ineffective. The simple movement of the body bending forward allowed more room for the spinal cord and spinal nerves within the central and lateral canals. The instantaneous relief was due to the sudden improvement in the microvascular circulation to the spinal nerves. Once the patient regained their upright posture, the pain would soon return. This etiological sequence provided evidence as to how the condition should be treated. His research eventually led him to develop the “Lumbar Spinal Stenosis Bootcamp.”
I had always instructed my patients that reducing inflammation was key to reduce their pain, but I later discovered that strategy was ineffective in treating LSS. The pain originating from diminished circulation explained why typical chiropractic, physiotherapy, massage, and medications including anti-inflammatories, opioids and corticosteroids, did not provide significant relief (if any).
A professional program for chiropractors
During the program, I discovered patients may have various degrees of lumbar spinal stenosis, and not everyone would go on to develop neurogenic claudication. Those that did had very specific characteristics. They would go on to develop mostly hip or leg symptoms – the back pain was not typically predominant. They found pushing grocery carts more comfortable than walking upright and found sitting to be a pain-free activity. LSS patients even had the ability to ride a stationary bicycle pain-free, which was key to their success in the program. If fitness and conditioning were increased, they could combine the recommended exercises with daily physical activity and the outcome would take its course.
The course then summarized the conditions to be included in the differential diagnosis of lumbar spinal stenosis such as advanced hip osteoarthritis, which can cause leg pain, as well as vascular conditions. These conditions include intermittent claudication and deep venous thrombosis, which is known to produce leg pain without the tendency to forward bend while walking. In the senior age group, we were advised to consider another differential diagnosis including malignancy, hip bursitis, neuropathy, and fracture.
While patients and some physicians may continue to herald the MRI and CT scan as the method of the lumbar spinal stenosis diagnosis, the condition can also be diagnosed with plain film X-rays and a thorough examination in order to rule out other likely conditions. A diagnosis of LSS does not always rely on advanced imaging. Chiropractors who have acquired boot camp training can be central to the diagnosis and treatment of lumbar spinal stenosis and neurogenic claudication.
Previously, the only successful treatment documented was lumbar decompression surgeries, which is not generally advisable in an older adult due to the risk of complications. One of these surgeries involves anchoring spacers between the spinous processes, thereby mechanically opening the foramina. Results a few years post surgery were varied, with symptoms often returning two to three years later.
Not everyone with significant lumbar spinal degeneration goes on to develop neurogenic claudication however, it can occur frequently. On occasion, lumbar spinal stenosis patients are diagnosed by their family physician through MRI, but upon thorough examination, they are found to have a lumbar facet syndrome or a sacroiliac dysfunction as the main issue.
How it works
Patients who are referred to our clinic for the LSS bootcamp will undergo a thorough consultation and examination to determine whether or not they meet the criteria for a LSS diagnosis. Those that meet the diagnostic criteria will begin to learn about their diagnosis and the required 18 exercises through a DVD, workbook, and their twice-weekly appointments over a six-week time frame.
It is imperative the patient understands that the success of the program depends entirely on their ability to complete the exercises, not just for the six-week period, but for the rest of their lives. The term “bootcamp” is suitable, as it truly defines the patient’s obligation to fully participate in order to be successful.
The patient’s family physician or referring specialist is advised about our program through our PMP generated “medical doctor reports,” as well as at the beginning and at the end of care. Patients have appreciated the inclusion of their physician, and the report becomes an excellent clinical summary for the patient’s personal health records.
If the patient is pain focused, we redirect our bootcamp patients that our main outcome measure will be increased function. We explain that the outcome we focus on is mobility, as measured by the number of steps a patient can take at one go before they need to stop. Each week, the patient keeps a record of the number of steps taken. It is not unusual to see the numbers double throughout the week. Oftentimes by the end of the program patients find their walking is tremendously improved or completely restored. When this occurs, the pain is often significantly diminished. We emphasize with patients that although the pain may decrease dramatically, the main goal is to focus on increasing the number of steps that can be taken during their walks.
The six-week program is partly based upon eighteen exercises, which follow a gradually increasing intensity. New exercises are added during each appointment, once the previous weeks’ exercises have been reviewed. During the twice-weekly appointments, chiropractors deliver a variety of interventions including mobilizations, flexion-distraction adjustments, the Bonyon technique, proprioceptive neuromuscular facilitation and nerve flossing. All of these interventions work to support and enhance the impact of the patient’s daily at-home exercises. The sessions can be somewhat strenuous, but patients become excited as their strength quickly returns.
Recently, support for this approach was published in the Archives of Physical Medicine and Rehabilitation 2018;99;2408-19. In this randomized controlled study there was significant evidence that supports this approach over self-directed care. More research will be published in 2020.
As the baby boomer generation ages, degenerative conditions like lumbar spinal stenosis will become more common and many of those patients will be looking for a natural and effective approach to improve their quality of life while maintaining their independence. The lumbar spinal stenosis bootcamp is an excellent solution that afflicted seniors should consider.
Dirk Keenan is a second-generation chiropractor practising in Ottawa’s oldest clinic for the past 34 years. Dr. Keenan pursues an active interest in multi-disciplinary clinics, Interprofessional education, and chiropractic practices abroad. He is currently in the midst of establishing an international locum service. Interested parties in international locums, multi-disciplinary practices, or interprofessional education can contact him at firstname.lastname@example.org.