525- Optimizing Non-Surgical Stenosis Care

Welcome to the Evidence Based Chiropractor, where each week we deliver the latest chiropractic research and marketing strategies, all in the time it takes to get to your office. Now, here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. On today's episode, we are talking all about lumbar spinal stenosis. So if you take care of people with lumbar spinal stenosis, this episode is for you. We're gonna dive into a brand new piece of research before I get started. Big shout out to a couple sponsors and partners of this podcast. Number one being Leander Tables, they're gonna hook you up with $1,000 off their Series 950 table. You can check out more and connect with their team at the link down in the show notes as well as Shockwave centers of America. $500 off and a free cart. So thank you so much for being a part of this community and this audience. I'm always looking to bring some of the best tools and resources to you and really give you an opportunity to onboard these with some of the best discounts out there. Leander Table, Shockwave Centers of America. Thank you to you both. And if you're a listener and interested in a new table or shockwave, please check out their links down at the show notes or connect with their team and let them know you're a listener of this podcast. Now, as I said at the top on today's episode, this is all about lumbar spinal stenosis, who actually improves with non surgical care. So if you take care of lumbar stenosis patients in your practice, you've probably seen patients that have done some people do better than others. And the question starts to become why? And I'll lead this off with a question, which is how many lumbar spinal stenosis patients have you seen who feel like they're already halfway towards surgery before they even walked into your practice? They've been told advanced degenerative changes. They've been told, you know, severe narrowing, you probably need surgery eventually and just manage it until the point where you need to have surgery. And meanwhile, you and me, we're frustrated. And the patients are as well. They're frustrated, they're scared, they're not walking as much, they're starting to gain weight, they're losing confidence, and they're slowly but surely reducing their quality of life over time. And, you know, this is the part that really bugs me. We've known for a long period of Time that non surgical care works for a lot of patients that have stenosis. Manual therapy, movement based care, progressive exercise, lifestyle guidance. But we haven't been great at answering what I'll call the billion dollar question, which is who are the patients in that group that actually respond best? Because not every stenosis patient is exactly the same. Some get better really quickly, some stall out, some ebb and flow, some need more time, some need more or less of the various modalities and services that you offer in your practice. So this study, which came out in 2025, finally starts to give both of us some real answers. And what I love about this paper is that it doesn't just ask, hey, does non surgical care work? It more importantly asks who improves the most and why. And that's where this starts to get pretty fun clinically and I'm gonna say really powerful for how you educate your patients, how you set expectations, and how you position the care that you deliver each and every day. So this study was published in Chiropractic and manual therapies in 2025 and the title is basically which Lumbar Spinal Stenosis Patients Will improve with non Surgical treatment. So in plain English, they wanted to evaluate what types of patients get the biggest and best improvements, which when they receive conservative care, especially manual therapy plus individual exercise, which is probably a lot of what you're doing. And that's compared to things like group exercise or medical management. So this wasn't just like a tiny pilot study. They analyzed data from randomized controlled trial with over 215 older adults. Every single one of them had confirmed lumbar spinal stenosis on imaging and, and real symptomatology day in and day out. Leg pain, walking, limitations, neurogenic claudication, really the whole package. The average age of the individual in this study was 72 years old. Over half were female and most had moderate symptoms and limited walking capacity at baseline. So they broke out the participants of this study into three primary groups. Group number one was manual therapy plus individualized exercise. This was delivered by chiropractors or PTs. And it involved mobility work, soft tissue work, joint mobilization plus personalized exercises. This is really what I'll call chiropractic. This is what you're doing day in and day out with your patients. Group number two was group exercise, so general fitness classes for older adults. And then group number three was medical care, medications, activity, advice, and sometimes injections. So the researchers tracked two main outcomes over the course of two months. Symptoms and function. And they utilized the Swiss spinal stenosis Questionnaire addition, which we'll call the S sq. They also measured walking capacity using a self paced walking test. So quite literally how far the patients, the people could walk before symptoms stopped them. And then they asked two big questions. One, which patient characteristics predict improvement overall? Really important question question number two, which patient characteristics change how much benefit someone gets specifically from manual therapy and individualized exercise? So this is kind of really the exactly the type of data that I'm gonna say we need to sharpen clinical decision making and ultimately sharpen our patient conversations as well. And you probably are very well aware, but we'll do a quick recap. Neurogenic claudication spinal stenosis. Ultimately narrowing of the spinal canal causing pressure on the spinal cord that can take place centrally, it can take place lateral recess. Normally if it's foraminally, you're gonna see more radiculopathy more than spinal stenosis. So usually this is central stenosis and, and, or lateral recess stenosis, depending upon where. Now that compression can come from one of three things. Typically bone, ligament or fluid. Right. You can have osteophytic growth that causes that narrowing. Often these things are in concert. Of course. Often that comes with ligamentum flavor hypertrophy. That ligament taking up extra space can cause compression. Or of course there can be fluid as well. That could be a cystic or it could be fluid post surgically like a seroma or something that effect. Now there are the outliers of course, where somebody had a previous surgery and there's a screw in the way or something to that effect. But outside of the outliers we really look towards ligament bone and I should not forget about disc of course as well. So we look at ligament bone, disc herniation, protrusion, fragmentation, extrusion, whatever it might be. It's taking up space in the canal now that can, that canal should be ultimately it should be about 10 millimeters. Anytime that that gets crunched down, that's where you're going to see mild, moderate or severe stenosis. And the beautiful part is that when we're talking about really small and tight areas, a little bit of change can make a big difference. This is why people with advanced stenosis, neurogenic, claudication, just the classic example, they park their car to go grocery shopping. They make it to the front door of the grocery store and then if they're young enough, they get down into a squatted position with some flexion for 10, 15 seconds and then I can get up, get a grocery cart and then they can make it around they're leaning on a cart, you can go forever around the store. You take the cart away, you're looking for the chair, right? There's a very limited amount of time before pain and weakness are gonna bring things to a halt. So the, that is, you know, I'm gonna say with a symptomatology, and I think we all probably ask those questions to be able to, whether we have imaging or don't have imaging, understand exactly what's going on with those patients. I'm gonna say the benefit or the good news here is that little change can make big differences. In other words, as I described, somebody can get into a flexed position or put 10, 20 pounds of their body weight on a shopping cart and they can go forever, right? So these are tight spaces. So when you get somebody into, and you probably have had this happen, somebody lays down on a chiropractic t just put the table into flexion, just put the legs down. If it's a flexion extension type table, flexion distraction type table, you just get them into a flex position. It's like, oh, now I can feel my toes. Now this is instant relief, right? So the good news is, is that quite often, even with advanced or severe symptomatology, little changes can make massive differences. And that's great news for you and I because helping somebody reduce even the inflammation in that area can make a massive difference. You start to see improvements in the disc and reduction in disc herniation, massive improvement. And sometimes this can be like half a millimeter can make a massive difference between a ton of symptomatology and almost zero symptomatology. So movement based care, inflammation reduction, helping people, again, I'm gonna say systemically reduce inflammation while moving better, while also ensuring that, that I'm just going to utilize lumbar stenosis for this example, that there's support from the musculature around it because if somebody is, let's say hyperlordotic now they're carrying 20, 30 pounds up front. That's pulling that lordosis forward even farther. Again, just think about a half a millimeter, a millimeter, two millimeters of change. You put 20, 30 extra pounds in somebody's tummy, you're easily gonna pull a millimeter or two of extra lordosis. So long story short, we can make massive changes and that's really, really good news. So in this study, let's take a look at some of the headline statistics. So across the entire group, symptoms improved by two and a half points on the SSSQ scale over two months walking capacity improved by about 200 meters. So that's roughly two football fields. That's massive. So overall non surgical care helps. And that's the baseline from which we'll start. But here's where it gets really interesting, which is who. Who improved more on symptoms and function? Now let's just hit some of them. Younger patients, probably no surprise here. Younger patients under 70, non smokers, patients who started with worse symptoms and disability. Interesting. We'll come back to that. Patients who expected the treatment to help. So smokers improved less. That's not a shock clinically. But let's ask the second question here. Who improved more on walking ability? Bigger walking ability improvements or bigger walking improvements showed up in younger patients. Again, patients without knee osteoarthritis. So that wasn't a limiting factor if you didn't have it right. And patients who are more physically active at baseline. So this makes a lot of intuitive sense. If their knees are in good shape and the nervous system could tolerate movement, walking is going to rebound a heck of a lot faster. And then the question who benefited the most from manual therapy plus individualized exercise? Kind of what we do. And this is the real gold. Manual therapy plus individualized exercise produced larger benefits than than group exercise or medical care in a few subgroups. One, patients under 70 had significantly better symptom improvement than patients over 70 utilizing manual therapy plus individuals as exercise. And patients with hip osteoarthritis had massive walking improvements over 500 meters. More improvement compared to those without hip OA. Really interesting. So 500 meters. And that tells us something fascinating about how regional mobility, soft tissue work and joint mechanics can really influence functional walking in stenosis patients. So let's simplify what's happening here. Patients who started out worse tended to improve more. So that should be a good thing. It means if somebody comes in and they have pretty advanced symptomatology, as long as there's no red flags, get after it, get them moving, get them, get them going. And it's a classic regression towards the mean, but it's also clinically meaningful. If somebody walks in barely able to function, they often have more upside when you restore motion, reduce sensitivity and improve their confidence. Additionally, younger patients responded better. That's probably due to a few different things. Better tissue adaptability, better neuroplasticity, very real thing. Fewer comorbidity, morbidities and a higher activity tolerance. So smokers lagged behind, consistent with what we know. Slower healing, advanced inflammation, systemic and chronic and vascular issues. So this was, let's just talk about walking for a moment, let's shift, and then we'll go back. So walking, it's the functional holy grail for pretty much all stenosis patients. You don't need to have perfect pain scores. Many people just want functional ability, right? You need people walking, shopping, living, doing their activities, especially as they get older. So walking improved more in people without knee arthritis. So the mechanics mattered, who are already more active, momentum matters. And who are younger. Basically, reserve capacity matters. So the most fascinating finding, I think, and probably what took you back, was the hip osteoarthritis effect. Patients with hip OA responded dramatically better to manual therapy. Why? Well, hip stiffness can actually mimic stenosis symptoms. Hip restriction can limit stride, load transfer, and gait mechanics. And manual therapy addressed hip mobility directly. So restoring hip motion unlocked a ton of walking capacity. And that's exactly why individualized care matters. And I'm looking at this, and I'm just thinking, what else do you have in your tool belt in your practice? This paper did not go into what I'm about to suggest, but even the limitation of knee arthritis. Do you have a shockwave unit? Man, imagine getting that going with somebody who has concurrent stenosis hip oa. And again, good, Great opportunity with shockwave. Great opportunity with a Novopulse device. We'll drop a link down to Novopulse as well. OA pain recovery program can't recommend it enough. There's really a ton of opportunity when patients have more than one thing going on for you to dig deeper into your toolkit. And this can really dramatically change the outcome for these patients. So this study, in my opinion, gives us massive clinical leverage, and it helps you triage better. When a stenosis patient walks in, you can now think about, think about their age, think about, you know, are they a smoker or not smoker? What's their baseline function really? Is there hip and knee involvement? Checking that adjacent joint, as we often discuss, never leave your examination at the only at the joint or body region of challenge. Always check the one next door. Hip knee important here, activity levels and expectations. So those variables can help you predict what who will likely respond more quickly, who might need more Runway, and who needs layered care plans. Great opportunity to really refine your expectations and agreements, how you're discussing things during your report of findings directly up front. And this can go in, as you know, to your examination conversations, in your report of findings conversations in your marketing and reactivation conversations. So the big takeaway from this study is not all stenosis patients respond the same. Probably in your practice. Not no surprise there, but many will respond really, really well when their care is individualized, when it's movement focused and when I'm say it's regionally intelligent in terms of what are you taking care of, what are the expectations and how are you communicating that. So manual therapy plus personalized exercise. Absolutely the way to go in absence of red flags. This just stacks more knowledge to the benefits of who you are and what you do as a chiropractor. So get out there and get it. There is no shortage of individuals who have stenosis and this is a perfect opportunity, I'm going to say, to plug MD Connection by the evidence based chiropractor. Why am I plugging it? Because it's about getting out there to other healthcare providers. There are a ton of stenosis patients in your community who will not come in and see you unless they're referred by another healthcare provider. That's just the way it is. So what can you do about that? Well, you can continue to put out great content online. You should. You can continue to message through through email all of your existing patients, inactive patients with patient pilot, you should. But you definitely have a missed opportunity if you're not connecting with other healthcare providers in building referral relationships. And there is no better program than MD Connection to help you do that. I'll drop a link down in the show notes. Additionally, I mentioned Novopulse and their OA recovery program. It is a full scale program that helps you install a OA treatment protocol in your practice hardware and software. I will drop a link down to Novopulse. Be sure to check them out. Other than that, I just wanna say thank you so much for tuning into this podcast. I appreciate you being part of this community. I'm going to continue to try to bring fantastic research, great conversations and ultimately awesome deals from some of our partners as well. Each and every week. If you have not left a rating or review, I would appreciate it. If you take a moment and do so, just scroll down on your phone, tap how many stars, leave a line of text. That would be awesome. Other than that, I hope you have a fantastic week in practice and I will talk to you soon.

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