Current Physical Medicine and Rehabilitation Reports

https://doi.org/10.1007/s40141-018-0171-3

MUSCULOSKELETAL REHABILITATION (J FRIEDLY, SECTION EDITOR)

The Role of Exercise in Treatment of Lumbar Spinal Stenosis Symptoms

Sean T. Matsuwaka 1 & Brian C. Liem 1

# Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Purpose of Review Lumbar spinal stenosis is a common condition that can cause significant disability due to low back or leg pain
and walking limitations. Initial non-surgical management usually involves exercise. This review examines available evidence for
various forms of exercise in managing symptoms of lumbar spinal stenosis (LSS).
Recent Findings Evidence for exercise in treating lumbar spinal stenosis symptoms is limited with a lack of robust, randomized-
controlled trials. Generally, combinations of stretching, core strengthening with emphasis on lumbar flexion, and well-tolerated
cardiovascular exercises are recommended.
Summary Based on current evidence, various forms of exercise seem reasonable to consider for LSS symptoms as no one
exercise has been shown to be superior. Engaging patients to exercise and addressing barriers is important to improve the
adherence to and effectiveness of treatment. Future research is needed to study exercises specifically for LSS and compare the
efficacy of different exercises in managing LSS.

Keywords Lumbar spinal stenosis . Exercise . Low back pain . Spine . Rehabilitation

Introduction
Lumbar spinal stenosis (LSS) is a common, often degenera-
tive condition in which changes in the discs, facet joints, and
ligamentum flavum lead to narrowing of the central canal,
lateral recess, and neural foramen [1–3]. This can result in
compression of the spinal cord, cauda equina, and spinal nerve
roots and can present as symptoms of back, buttock, and leg
pain [4]. Patients often describe “neurogenic claudication”
symptoms, which include worsening of pain with standing
and walking and improvement in symptoms with sitting, lean-
ing forward, and walking uphill [2]. Non-surgical manage-
ment is the initial recommendation for the majority of patients
without significant neurologic deficits [1, 5•, 6]. Treatments
This article is part of the Topical Collection on Musculoskeletal
Rehabilitation
* Sean T. Matsuwaka
smatsuwa@uw.edu
Brian C. Liem
bliem@uw.edu
1
University of Washington, Sports Medicine Center at Husky
Stadium, 3800 Montlake Blvd NE, Seattle, WA 98195, USA
that are frequently used include exercise and physical therapy,
medications, spinal manipulation, and epidural steroid injec-
tions for radicular pain [1, 4, 7]. However, the effectiveness of
these therapies is not well known. Non-surgical management
strategies have been compared to surgical intervention in
many studies, but protocols are heterogeneous and involve
various combinations of treatments and various types of exer-
cises [8–13]. A systematic review concluded that there was
insufficient evidence to determine whether surgical or conser-
vative management was superior for treatment of LSS [14].
In general, the majority of evidence supporting exercise for
treatment of LSS is low-quality. Recommendations are often
based on expert opinion given the limited number of relevant,
randomized controlled trials [15]. Most studies have limita-
tions that include small sample sizes, short durations, lack of
controls, and non-validated and variable outcome measures
[1, 15]. The North American Spine Society’s 2013 guidelines
on LSS state that there is insufficient evidence to recommend
for or against the use of physical therapy or exercise as stand-
alone treatments for LSS. However, their guidelines state that
a limited course of active physical therapy is a reasonable
option [5•]. Surgical intervention is not urgent in most cases
because the clinical course of LSS often does not progress
with time [8, 11, 16]. Several reviews conclude that based
on available evidence, exercise seems to be better than no

exercise, and insufficient evidence is available to conclude
what type of exercise is best [17–19, 20•]. Because of this
perceived benefit in LSS, despite limited data, examining the
various available exercises is clinically helpful to guide pa-
tients who want to try them before considering other options,
such as surgery.
Physical Therapy and Therapy-Based Exercise
Physical therapy can be divided into active exercise and pas-
sive modalities. Active therapies include stretching and flexi-
bility training, core strengthening and stabilization programs
with lumbar flexion, and cardiovascular conditioning [4, 12,
16, 21–25, 26•]. Within the active therapy group, there are
also specific methodologies that are utilized, including the
McKenzie Method or Mechanical Diagnosis and Therapy
and Proprioceptive Neuromuscular Facilitation. Passive or
manual therapy can be performed by a therapist and includes
spinal manipulation, joint mobilization, therapeutic ultra-
sound, massage, and other modalities.
Stretching and Flexibility Training
Increasing flexibility is important to improve spine and pelvic
alignment. Lower extremity stretching includes targeting hip
flexors and hamstrings with the goal of increasing hip exten-
sion and posterior pelvic tilt [21, 22]. Thoracic and lumbar
musculatures are also stretched to improve mobility [4, 16,
21]. Flexibility in these areas theoretically decreases the
amount of resting extension placed on the lumbar spine and
allows for an increased canal diameter for the spinal cord to
pass through [27]. Although stretching is a routine component
of most therapy programs that have been studied, no studies
have specifically examined the efficacy of stretching alone in
treating LSS symptoms.
Core Strengthening and Lumbar Stabilization
Exercises
Lumbar stabilization and core strengthening programs are fre-
quently used to treat LSS and low back pain (LBP) [28]. The
aims of these programs are to increase support of the spinal
column and reduce lumbar lordosis through strengthening of
transverse abdominis, multifidi, paraspinals, and gluteal mus-
cles. Core strengthening in LSS is accomplished primarily by
performing flexion-based exercises, which are derived from
McKenzie exercises and Williams’ flexion exercises as de-
scribed next. One randomized-controlled trial examined
whether a specific core strengthening exercise program could
improve pain and function more than general exercise in 44
patients with chronic LBP with spondylolisthesis, an align-
ment condition that can result in LSS [29]. Patients were
Curr Phys Med Rehabil Rep
randomized into either a core strengthening group, focused
on training of deep abdominals and lumbar multifidi, or a
control group that performed their normal level of exercise
directed by a general practitioner. After weekly sessions for
10 weeks, the core strengthening group had a greater reduc-
tion in LBP intensity measured by a Visual Analogue Scale
(VAS) with a mean difference of 35 points and improvement
in functional disability measured by Oswestry Disability
Index (ODI) with mean difference of 13 points. This signifi-
cant difference was maintained at 30 months. Although this
study suggests benefit of core strengthening for a related LBP
condition, it did not specifically study LSS.
Specific Physical Therapy Methodological Approaches
and Classification Schemes
Multiple physical therapy approaches and classification
schemes are used to treat a variety of LBP conditions
[30–32]. However, these methodologies are not designed spe-
cifically to target patients with LSS. Certain aspects of these
approaches, though, are often incorporated into therapy strat-
egies for LSS.
McKenzie Method/Mechanical Diagnosis and Therapy
and Flexion-Based Exercises
McKenzie Method or Mechanical Diagnosis and Therapy
(MDT) is a classification scheme that aims to categorize pa-
tients and guide treatment with a direction-specific set of
movements to counteract a “derangement” or “dysfunction.”
The goal is to produce a pain response called centralization,
which reduces distal referred symptoms [33]. An example
would be treating LBP due to a herniated disc and pain worse
with lumbar flexion by performing exercises that encourage
lumbar extension. These exercises, performed at end ranges,
are meant to directly alleviate symptoms. For LSS, extension
usually exacerbates low back and claudication pain, so
flexion-based exercises are encouraged to relieve symptoms
[30, 34, 35]. Flexion exercises also have a history derived
from Williams’ flexion exercises and have been used as part
of therapy programs in many studies for LSS [12, 16, 25,
36–39] and emphasized in multiple reviews [4, 19, 21, 24].
These exercises were originally used to manage generalized
LBP and involve core strengthening with the lumbar spine in
relative flexion and stretching of low back muscles to reduce
excess lumbar extension. Williams believed extension placed
stress on the posterior elements of the spine and resulted in
pain [40]. Examples of Williams’ flexion exercises are shown
in Fig. 1. In LSS, lumbar flexion is theorized to increase the
spinal canal diameter and prevent cord compression that can
result in neurogenic claudication symptoms [27].
Studies have not been performed to evaluate MDT or flex-
ion exercises specifically for LSS. A meta-analysis of 11
Curr Phys Med Rehabil Rep
Fig. 1 a–h Examples of
Williams’ flexion exercises.
Arrows show the direction of
movement. a Posterior pelvic tilt.
b Partial sit-up. c Single knee to
chest. d Seated trunk flexion. e
Double knee to chest. f hamstring
stretching. g Hip flexor stretch. h
Full squat
randomized-controlled trials aimed at evaluating the effec-
tiveness of MDT for LBP without defined pathologic entity,
with or without radiation, found MDT to be more effective in
reducing pain (weighted mean difference of 4.2 on a 100-
point scale) and disability (weighted mean difference of 5.2
on a 100-point scale) in acute LBP than passive therapy at
1 week [30]. However, compared to advice to stay active, it
was less effective at 12 weeks. There was not enough evi-
dence in these studies to draw conclusions about use of MDT
for chronic LBP, and the authors felt that its overall effective-
ness is still in question. Another systematic review included
six trials and showed MDT to be effective in the short term
for reducing pain (mean difference of 8.6 points on a 100-
point scale) and disability (mean difference of 5.4 points on a
100-point scale) in the neck and low back without defined
pathologic entity, with or without radiation, compared to oth-
er treatments, but did not have enough data to look at long-
term outcomes [41]. Based on these studies, the evidence for
MDT in non-specific chronic LBP as well as LSS is limited
and needs to be further studied.
Proprioceptive Neuromuscular Facilitation
Proprioceptive neuromuscular facilitation (PNF) is a form of
therapy that enhances response to proprioceptive inputs in
order to improve motor recruitment patterns and motor con-
trol. It involves stretching, resisted movement, traction, and
approximation or joint compression and is used in conditions
with either structural dysfunctions or neuromuscular control
dysfunctions. PNF is thought to improve flexibility, strength,
and range of motion [31, 42, 43]. There is no evidence for it
specifically in LSS, and a few low-quality studies have exam-
ined its effect in non-specific chronic LBP [31, 42]. One study
compared PNF against core stabilization exercises for 54 pa-
tients with chronic non-specific LBP [42]. After a program of
exercises 4 times per week for 6 weeks, no significant differ-
ences were found between the 2 groups in lumbar pain
intensity measured by VAS, although both groups improved
from baseline. Another study compared PNF with core stabi-
lization exercises for 60 patients with chronic non-specific
LBP and found after daily sessions for 1 month no difference

between the groups in pain by VAS, but PNF had greater
significant improvement in lumbar mobility by modified
Schober method and disability by modified ODI [31]. A re-
cent study looked at 42 patients with chronic LBP who
underwent PNF sessions 5 times per week for 1 month versus
a control group that received an educational booklet. At
3 months, it found significant and sustained improvements
in the primary outcome of pain intensity by 0–10 numerical
rating scale with mean difference of 2.3 and secondary out-
comes of disability, patient satisfaction, and health-related
quality of life in the PNF group [44].
Cardiovascular Conditioning
Cardiovascular conditioning is felt to be an essential compo-
nent of overall well-being and fitness in patients with LSS [2,
16, 21]. Some authors propose that exercise may improve
oxygenation of small vessels impacted by LSS [21]. Others
believe that conditioning can enhance soft tissue function and
strengthen muscles [16]. Examples of cardiovascular exer-
cises that are well tolerated in LSS include body-weight sup-
ported treadmill walking, stationary cycling, swimming, and
aqua walking/jogging.
Body-Weight Supported Treadmill Walking
Activities that unload the spine while providing exercise can
be beneficial in LSS because they theoretically do not induce
claudication symptoms that can occur with walking [39].
Progressive body-weight supported treadmill walking is one
method, and it is hypothesized to reduce the vertical compo-
nent of the ground reaction force during walking and to de-
crease compressive forces on the spine, resulting in increased
canal and neural foramina diameters [24, 25, 36, 37, 39, 45].
This reduces symptoms of pain from nerve root or cord com-
pression. The amount of support is gradually reduced over
time until walking can be performed without assistance.
Body-weight supported treadmill walking has been shown to
improve pain and function in patients with non-specific, non-
surgically corrected LBP [45], but no studies have investigat-
ed its direct benefit in LSS. Increasing the incline on a tread-
mill has been shown to reduce LSS claudication symptoms by
placing the lumbar spine in slight flexion [4, 21, 24, 46, 47].
A randomized clinical trial compared 2 groups with LSS
treated with non-surgical, exercise-based management [36].
One group included body-weight supported treadmill walk-
ing, manual therapies, and exercises for strength, mobility, and
coordination. The other group included unsupported treadmill
walking, flexion-based exercises, and sub-therapeutic ultra-
sound. The program included 58 patients and held twice
weekly sessions for 6 weeks, and the primary outcome was
a Global Rating of Change Scale measuring self-perceived
Curr Phys Med Rehabil Rep
recovery of their health status on a − 7 to + 7 scale. At the
end of 6 weeks, both groups had self-perceived recovery, but
the group that included body-weight supported treadmill
walking and manual therapy had a statistically significant
higher perceived recovery with 79% of patients meeting
threshold for perceived recovery (+ 3 on the Global Rating
of Change Scale) compared to 41% in the other group.
However, after 1 year, there was no significant difference be-
tween the groups in self-perceived recovery and in secondary
outcomes including modified ODI, Lumbar Spinal Stenosis
Scale, Numerical Pain Rating Scale for leg pain, or walking
distance. This study was limited by a high risk of bias due to
inadequately describing randomization procedures and lack of
blinding participants and providers. The variety of exercises
used in this study makes it difficult to make conclusions about
any particular exercise, but the use of body-weight supported
treadmill walking instead of unsupported treadmill walking
and addition of manual therapy did not seem to make a sig-
nificant difference in long-term outcomes.
Cycling
Stationary cycling is well tolerated in patients with LSS [48].
A randomized trial compared 68 patients with LSS divided
into 2 groups that performed either stationary cycling or body-
weight supported treadmill walking for 12 sessions over
6 weeks [39]. Both groups also received heat therapy, lumbar
traction, and a home exercise program with flexion exercises.
The primary outcome measured was disability using the mod-
ified ODI. Both groups had significant improvements in dis-
ability, and between the groups, there was no significant dif-
ference in disability reduction at 3 or 6 weeks. However, this
study compared 2 forms of exercise to one another and did not
include a non-exercise treatment comparator. The authors con-
cluded that both forms of exercise were equally effective and
appropriate to consider.
Another randomized-controlled study examined 45 people
with LSS and claudication symptoms divided into 3 groups:
ultrasound plus exercise, sham ultrasound plus exercise, and a
control that used neither ultrasound nor exercise [49]. The
exercise program included sessions 5 days per week for
3 weeks of low-intensity cycling, stretching, and core
strengthening. Ultrasound was performed 5 days per week
for 3 weeks. Primary outcome measures included pain in leg
and low back using VAS, disability using ODI, functional
capacity with exercise treadmill test, and consumption of an-
algesics (acetaminophen was provided as a rescue analgesic).
At 3 weeks, both groups that performed exercises had statis-
tically significant improvement in all measures except for leg
pain in the group with exercise plus ultrasound. No improve-
ment was seen in any measure in the control group. There
were no significant differences between the exercise plus ul-
trasound and the exercise plus sham ultrasound group except
Curr Phys Med Rehabil Rep
less analgesic consumption in the ultrasound group. This
study demonstrated that therapeutic exercise, which included
cycling, was beneficial in the short term in managing pain,
disability, and improving function. Long-term outcomes were
not examined. Given the number of other treatments included,
it is difficult to determine the exact impact that cycling alone
would have had on outcomes.
Swimming and Aqua Walking/Jogging
Water-based activities are also thought to provide spinal
unloading by reducing gravitational forces, and swimming
or aqua walking can be a vigorous cardiovascular workout
[22]. Swimming strokes that increase lumbar extension, such
as breast stroke and freestyle, are usually avoided as they are
anecdotally thought to exacerbate symptoms [4, 22]. There is
little to no evidence regarding the benefits of swimming for
LSS beyond these general considerations. One low-quality,
non-controlled study examined 6 people with LSS enrolled
in a 12-week aquatic walking and jogging program.
Participants performed aquatic walking and jogging 3 times
per week for 60 min and had significant improvement in bal-
ance on the Berg Balance Scale, muscle function on Janda’s
muscle function test, ankle range of motion, and improvement
on a fall efficacy scale [50].
Other Forms of Exercise
Yoga, tai chi, and Pilates are forms of exercise that have
gained popularity in treating various forms of LBP [51–54].
Studies have included patients with LSS but do not specifical-
ly target this population.
Yoga
Yoga is a mind-body exercise technique that originated in
India and includes physical poses, breathing techniques, and
meditation that are thought to improve flexibility, body aware-
ness, and physical and mental relaxation [51, 55]. Yoga has
been compared to both no treatment and other back-focused
exercises for a variety of chronic LBP conditions. A system-
atic review examined the evidence for yoga in the treatment of
chronic unspecified LBP, including LSS, and found 12 studies
that reported effects of yoga on back-related function or pain
[51]. This review found low-quality evidence in 7 trials that
yoga provided small-to-moderate improvements in back-
related function compared to no treatment at 3 and 12 months
and moderate evidence that it provided small-to-moderate im-
provements at 6 months. However, there was no statistically
significant improvement in pain at any time point with yoga
compared to no treatment. Compared to back-specific exer-
cises, there was very low-quality evidence of little or no
difference in functional improvement with yoga at 3 and
6 months and there was no data available at 1 year. For pain,
there was very low-quality evidence supporting improvement
with yoga at 7 months compared to back-specific exercises
but no data for other time frames. Trials assessed were con-
sidered low-quality due to high risk of performance and de-
tection bias as well as lack of blinding and self-assessed out-
comes. Another systematic review and 2 other recent clinical
guidelines also examined the evidence for yoga in chronic
LBP, which included both radicular and non-radicular symp-
toms as well as LSS. These reviews included similar studies
and came to similar conclusions [55, 56, 57•].
Tai Chi
Tai chi is a Chinese martial art and form of exercise that
utilizes slow movements to train balance, muscle strength
and flexibility, breath regulation, and body awareness [52,
58]. A few studies have demonstrated some benefit with tai
chi for non-specific chronic LBP, which may include LSS.
One study randomized 160 participants with non-specific
chronic LBP into a tai chi group or a waitlist control, which
included their usual exercise routines and examined
“bothersomeness of pain symptoms” measured from 0 to 10
on a numerical rating scale [52]. Non-specific chronic LBP
included patients with and without leg pain but excluded “se-
rious spinal pathology,” those scheduled for spinal surgery
and those with contraindications to exercise. After 18 sessions
in 10 weeks, the tai chi group had improvement in
“bothersomeness of pain symptoms” measured as a mean dif-
ference of 1.7 points compared to the waitlist group. A ran-
dom sample of participants, whose baseline characteristics
were statistically similar to the total study sample, was
interviewed, and 75% felt that this difference made participat-
ing in the 10-week course worthwhile. The authors also felt
this difference was clinically meaningful.
In another study, 320 retired athletes with non-specific
chronic LBP were randomized into a tai chi group or groups
that performed swimming, backward walking, jogging, or no
exercise for 6 months to compare improvement in the intensity
of LBP measured by VAS. All exercises and tai chi were
performed 5 days per week for 45 min, and all groups also
had manual therapy performed. At 3 and 6 months, all groups
had improvement in LBP intensity. The tai chi group had
statistically significant improvement in LBP intensity com-
pared to all groups with a mean difference of at least 5.8
points, except for no difference compared to the swimming
group [58].
Pilates
Pilates is a method of exercise that focuses on core strength-
ening, flexibility, postural alignment and control, and

endurance [59, 60]. These exercises have some evidence of
efficacy in treating LBP but have not been studied specifically
for patients with LSS. A systematic review examined the lit-
erature regarding Pilates for non-specific LBP, which could
include LSS, and looked at 10 studies comparing Pilates to
either no treatment or to other forms of exercise [59]. Six
studies compared Pilates to no treatment and found low-to-
moderate-quality evidence with moderate effect size that
Pilates is more effective in improving both pain and disability
in the short term (less than 3 months) and intermediate term
(between 3 months and 1 year). Low-quality evidence showed
a significant short-term effect with small effect size of Pilates
on improving function and global impression of recovery but
no significant intermediate-term effect. Four studies compared
Pilates with other exercises. There was low-quality evidence
showing mixed results for improvement in pain in the short
and intermediate term. For improving disability, there was
moderate-quality evidence showing no difference between
Pilates and other exercises in both the short and intermediate
term. And for measured functional improvements, there was
low-quality evidence showing no difference in the short term,
but in the intermediate term, other exercises had greater func-
tional improvements with small effect size than Pilates.
Evidence was deemed low-quality in these studies due to mul-
tiple factors, most often small sample sizes, but also included
high risk of bias, inconsistency of results across trials, and low
generalizability of findings.
Another review looked at the evidence for Pilates in LBP,
including LSS, and found 11 studies with low-quality evi-
dence showing small or no improvement in pain and no im-
provement in function compared to usual care with physical
activity [56]. Overall, Pilates may be slightly superior to no
treatment but not necessarily more beneficial than other exer-
cises for treating LBP, including LSS.
Engaging Patients to Exercise
Motivating patients to exercise can be a common and difficult
task that clinicians encounter [61, 62]. This has been shown to
be problematic in patients with LSS [63, 64•] and has also
been studied in depth in chronic LBP and in the elderly [62,
65, 66]. Patients express barriers to exercise, including a fear
of worsening symptoms, reinjury, or falling [36]. One quali-
tative study examined patients with LSS with neurogenic
claudication symptoms and compared them with patients with
vascular claudication symptoms and asymptomatic patient
controls. The study found 35 patients with neurogenic claudi-
cation to have a higher degree of fear of movement/reinjury
and activity avoidance measured by the Tampa Scale for
Kinesiophobia than the control group and similar fear of
movement/reinjury but higher activity avoidance than patients
with vascular claudication [63]. Other reasons described in the
Curr Phys Med Rehabil Rep
elderly include lack of time, lack of motivation, lack of an
exercise partner, inadequate facilities, and fatigue [61].
Psychosocial factors can also contribute to lack of engage-
ment, including depression, anxiety, and insomnia, all of
which can worsen symptoms of pain and avoidance behaviors
[16, 63]. Undertreating patients may occur as clinicians may
be overly cautious with prescribing exercise due to a patient’s
age and comorbidities, and this can prevent patients from
achieving their maximum recovery [21].
Another qualitative study derived from a larger randomized
trial for non-surgical LSS management used focus groups of
included patients with LSS to assess opinions and factors con-
tributing to intervention adherence. The study identified barriers
to accessing healthcare, which included comorbid health condi-
tions and multiple socioeconomic factors, such as lack of trans-
portation, time constraints, and financial barriers [64•].
Regarding facilitators to accessing healthcare, perceived treat-
ment benefit was the most important to continued participation.
Patients also preferred providers who listened to concerns and
clearly explained the disease process and interventions. In addi-
tion, group exercises provided social support and motivation to
attend all sessions. In order to engage patients in exercise, clini-
cians should understand the cause of patients’ barriers and en-
couraging patients to confront their fears [16, 63, 65].
Reassurance and close guidance by therapists through exercise
programs should be provided. For example, therapists should
start patients with an exercise program of body-weight support-
ed treadmill walking and gradually increase the amount of walk-
ing time and decrease the amount of weighted support as pa-
tients progress. This can decrease fears of pain and falling asso-
ciated with walking and motivate patients to eventually achieve
the goal of an independent walking program [21]. Finding ap-
propriate exercises for individual patients’ functional levels and
exercises that are of interest to each patient is also important [21].
Conclusions
Multiple exercises have been studied in managing LSS symp-
toms and are usually performed together in various combina-
tions. Therapies often incorporate stretching, flexion-based
exercises to strengthen core muscles and lumbar stabilizers,
and cardiovascular conditioning. Exercises should be tailored
to meet each patient’s specific condition and interests, espe-
cially given the current evidence, which has not shown one
form of exercise to be superior. The literature for exercise
specifically in LSS is sparse and comprised of low-quality
studies, and ongoing research is important because exercise
is recommended as a first-line treatment in most cases.
Engaging patients in exercise by addressing barriers, gradual-
ly introducing exercise programs while managing symptoms,
and developing patient buy-in through education and demon-
stration of the benefits of exercise is essential. Treating this
Curr Phys Med Rehabil Rep
condition that is prevalent among older individuals will be
important as the population ages [67], and exercise is a safe
and healthy option that should be promoted with guidance
from a qualified healthcare provider.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no competing
interests.
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
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