Lumbar Spinal Stenosis: Try PT first! Why it works without Surgery

By Dr. John Mishock, PT, DPT, DC 

 

Lumbar spinal stenosis is one of the most common drivers of back-and-leg pain in adults over 50, and it’s the top reason older Americans end up in spine surgery pipelines. But here’s the real talk: most people should not start with spinal surgery. A high-quality, physical therapy-first strategy is evidence-based, lower-risk, and often delivers meaningful functional gains—especially when the plan includes manual therapy, individualized exercise, progressive resistance training, and core motor control (Katz et al., JAMA, 2022).

As a PT and chiropractor, I’ll frame this the way we should in the clinic:

optimize function, reduce threat, build capacity, and keep surgery as the “strategic reserve”, not the opening move.

What is Lumbar Spinal Stenosis

Spinal stenosis is the narrowing of the spinal canal and/or foramina—most often from age-related changes (disc height loss, facet arthrosis, ligamentum flavum thickening, sometimes spondylolisthesis). The hallmark symptom pattern is neurogenic claudication, spinal nerve irritation leading to pain while standing and walking, that improves with sitting or bending forward. (Katz et al., JAMA, 2022).

That posture-dependent pattern matters because it tells us two things: 1. The movement pattern is often mechanically modifiable. 2. A well-designed rehab plan can “open space” functionally by improving movement strategies, tolerance, and trunk/hip strength, even if the spinal stenosis anatomy doesn’t magically reverse.

The “PT First vs Spinal Surgery

A major randomized trial compared decompressive surgery vs a structured PT program and found importantly—that both groups improved, and long-term differences weren’t the slam dunk many people expect. That 2-5years following surgery the functional outcomes were virtually the same.  (Delitto et al., Annals of Internal Medicine, 2015)

A large longitudinal research study showed that spinal surgery can provide faster symptom relief for some, but outcomes are complicated and improvements occur in nonoperative care groups equally as well. (Lurie et al., Spine, 2015) And here’s a key “prevention of surgery” signal, receiving PT first was associated with better self-reported outcomes and a reduced likelihood of short-term surgery (Fritz et al., The Spine Journal, 2014). Bottom line: PT isn’t “what you do while waiting for surgery.” PT is often the main event for avoiding surgery.

Manual therapy + individualized exercise: a high-leverage combination

A landmark randomized trial found that a program including manual physical therapy, exercise, and progressive walking produced superior outcomes compared with a more basic program in people with lumbar spinal stenosis. (Whitman et al., Spine, 2006) More recently, a large randomized clinical trial comparing several nonsurgical approaches found that manual therapy with individualized exercise produced greater improvements at 2 months than standard medical care or group exercise. (Schneider et al., JAMA Network Open, 2019).

The Clinical translation: manual therapy is best used as a force multiplier—to reduce pain, improve mobility, and create a “window” so the patient can load, train, and build capacity. Manual therapy without progressive exercise is usually a short-term play. Manual therapy with the right strength and motor control plan is a scalable strategy to prevent surgery in individuals with spinal stenosis.

Resistance training, core strength, and motor control: why they matter (and what the evidence says)

If spinal stenosis is partly a “space problem in the spinal canals,” why lift weights? Because in real life, stenosis is also a capacity problem: deconditioning, hip/trunk weakness, poor gait strategy, and fear-driven movement patterns amplify symptoms. Why do resistance exercise? 1) Progressive strengthening is a recurring ingredient in successful programs. A high-quality systematic review of exercise trials found that successful interventions commonly included strength/trunk muscle exercises, fitness work, and sometimes psychologically informed coaching (Comer et al., Clinical Rehabilitation, 2024). 2) Core stability work shows functional benefit in stenosis populations. In a randomized study, core stability exercise outperformed conventional exercise for functional outcomes and walking capacity in individuals with lumbar spinal stenosis. (Mu et al., Pakistan Journal of Medical Sciences, 2018)

A related study also reported that core stability exercises correlated with reduced stenosis severity and improved symptoms/function (Chen et al., Pakistan Journal of Medical Sciences, 2017). 3) Motor control is about “load distribution and the ability to control the spinal joints,” not just abs. Motor control training (deep trunk stabilizers, hip control, breathing/brace timing, hinge/squat mechanics) helps reduce repeated shear/compressive irritation and improves walking tolerance—especially relevant when stenosis overlaps with degenerative spondylolisthesis patterns (Katz et al., JAMA, 2022).

Practical takeaway: resistance exercise isn’t optional—it’s the long-term durability layer.

When surgery is the right call:

Let’s not be ideological. Surgery has a role.

Surgery should move up the priority list when:

• There’s a progressive neurologic deficit (worsening weakness)
• There are red flags (bowel/bladder changes, saddle anesthesia)
• There’s a failure of a well-executed conservative plan (not “two random visits”)
• Pain and walking limitations remain major quality-of-life blockers despite optimization (Katz et al., JAMA, 2022).

We can help!

If pain is limiting you from doing the activities you enjoy, give Mishock Physical Therapy a call: locations in Gilbertsville (610-327-2600), Skippack (610-584-1400), Phoenixville (610-933-3371), Boyertown (610- 845-5000), Limerick (484-948-2800)  at www.mishockpt.com or request your appointment by clicking here.

Dr. Mishock is one of only a few clinicians with doctorate-level degrees in both physical therapy and chiropractic in the state of Pennsylvania. He has also authored two books; “Fundamental Training Principles: Essential Knowledge for Building the Elite Athlete”, “The Rubber Arm; Using Science to Increase Pitch Control, Improve Velocity, and Prevent Elbow and Shoulder Injury” both can be bought on Amazon or train2playsports.com.