Introduction

Lumbar spinal stenosis is a progressive, degenerative condition that affects nearly 11% of the geriatric population within the United States which is characterized by narrowing of the spinal canal, which may result in compression of the spinal cord and nerve roots.1 This narrowing commonly occurs due to intervertebral disc degeneration, hypertrophy of the facet joints, or thickening of the ligamentum flavum, all of which contribute to mechanical compression and reduced space for neural elements.2 LSS predominantly affects individuals over the age of 50, with a higher prevalence in females. By the age of 67, the prevalence of LSS reaches approximately 78%.2

The clinical presentation of LSS varies but often includes lower back pain, which may be localized or may radiate into the lower extremities, as well as neurogenic claudication. Neurogenic claudication is a hallmark symptom and is characterized by pain, numbness, or weakness in the legs that worsens with walking or prolonged standing and improves with lumbar flexion or sitting.2 In more advanced cases, LSS may lead to significant functional impairment, including balance difficulties, gait disturbances, and in severe cases, bowel, or bladder dysfunction.2 Without appropriate intervention, these complications may progress, underscoring the importance of early diagnosis and timely management to prevent deterioration and improve patient outcomes. This case report describes the successful treatment of a 67-year-old female patient with radicular pain. The multimodal treatment approach incorporated chiropractic adjustment, soft tissue modalities and neuromuscular training including DNS. DNS is a rehabilitative technique that is based on the foundations of developmental kinesiology and a focus on core control and stability using exercises performed in postural development positions that mimic those of early childhood. The goal of DNS is to reestablish spine and core stability through progressive load sharing exercises and an increase in Intra-abdominal Pressure (IAP).3 The structure of this case was based on a commentary by Malaya, Stuber, and Rose.4

CASE REPORT

Patient History

A 67-year-old female had a 4-month history of worsening right lower back pain, radiating to the right groin, hip, and down the right leg. She described the pain as “nerve pain” and reported associated right leg weakness. Her symptoms were worsened by walking (claudication) and relieved with rest and heat. She first noticed symptoms in late December 2023 to early January 2024. Her pain was described as stiff and tight, with a severity of 7/10, present 80% of the day, and worsened during provocative activities. Flexion and sitting provided relief, while extension and walking aggravate symptoms. The pain radiated to the right anterior hip, anterior thigh, right sacroiliac region, posterior hip, buttock, and posterior thigh on the right side. She previously underwent 3 months of conservative chiropractic and rehabilitation care, including manual therapy and spinal traction/decompression, without any resolution of symptoms.

Her medical history includes arthritis and dry eyes. She was taking RestasisTM (ophthalmic anti-inflammatory drops) for dry eyes, VenlafaxineTM (SNRI) for depression/anxiety, and DoxycyclineTM (antibiotic). She also took several supplements, including turmeric, magnesium, omega-3, vitamin D, vitamin C, bergamot, berberine, vitamin K, and collagen. She had a history of gastritis requiring hospitalization (date unknown). Her family history was significant for heart disease. Psychosocially, she reports difficulty sleeping due to pain. She had no known genetic conditions or relevant genetic testing results.

Physical Exam

We made a clinical diagnosis of lumbar spinal stenosis, based on the patient’s presentation, clinical assessment and results of clinical prediction guidelines. The patient is over the age of 60, has leg pain that is worse than low back pain, pain that is worse with walking and relieved by sitting, as well as associated neurogenic symptoms. On physical examination, right lower extremity nerve tension tests were positive, and hypoesthesia was noted in the right L4 and L5 dermatomes. She also demonstrated difficulty with heel and toe walking. Mechanical diagnosis and therapy (MDT) assessment revealed that 30 repetitions of seated flexion centralized pain and abolished distal symptoms, with improvement in walking tolerance as her claudication interval increased by one minute.

Her active range of motion (AROM) showed decreased thoracic and hip extension, with an inability to dissociate hip and lumbar extension. Motion palpation demonstrated multiple joint restrictions throughout her body, including the thoracic spine, lumbosacral junction, and femoroacetabular joints. Muscle tone assessment demonstrated hypertonicity in the bilateral cervicothoracic and thoracolumbar erector spinae, iliocostalis lumborum, and gluteal muscles, with mild tenderness on palpation. Conversely, hypoactivity of the diaphragm and abdominal wall was observed, confirmed through seated and supine breathing assessments and a DNS diaphragm test. There were no upper motor neuron (UMN) lesion signs, such as plantar response or clonus, and no red flag symptoms, including bowel or bladder incontinence, saddle paresthesia, syncope, fever, chills, and/or unexplained weight changes.

An MRI was ordered to assess the extent of lumbar stenosis. The MRI was completed with the patient in a neutral seated posture in an open upright scanner with sagittal/oblique T1/T2, sagittal STIR and coronal T2 imaging. MRI findings indicated moderate disc and severe bilateral facet joint degeneration with diffuse bulging and osteophyte formation at L4/L5. There was a right asymmetric degenerative spondylolisthesis measuring up to 4 mm at L4/L5. There was mild disc height loss and moderate facet arthropathy from L1 to S1, with the right side further progressed than the left at L2/L3. The MRI report found “no more than mild right foraminal stenosis” and that the findings of the report indicated “no significant stenosis.”

Intervention and Outcomes

Interventions

The patient received an initial 6-week trial of care, consisting of 2 visits per week. Treatment included spinal and extremity manipulation of joint restrictions, flexion-distraction therapy, soft tissue therapy, and therapeutic exercise. After 6 weeks, she transitioned to a maintenance care program of 1-4 visits per month.

Each visit began with an assessment of joint restrictions, determining the specific spinal and extremity segments requiring manipulation. This was followed by 5 minutes of flexion-distraction therapy, where the patient lay prone on a flexion-distraction table that passively mobilizes the lumbosacral region through slow, continuous motion. During this treatment, the clinician applied overpressure into counternutation and thoracic extension to alleviate extension restrictions in the affected spinal regions.

Following joint mobilization, soft tissue therapy was performed for approximately eight minutes per visit. The clinician assessed hypertonicity and pain on palpation, selecting specific muscles for treatment as needed. Techniques such as pin-and-stretch and fascial therapy targeted hypertonic musculature, which frequently included the bilateral cervicothoracic and thoracolumbar erector spinae, iliocostalis lumborum, and gluteal muscles.

The final 10 minutes of each session focused on therapeutic exercise, emphasizing intra-abdominal pressure training, core stabilization, and movement pattern restoration. The approach incorporated principles of DNS to address core dysfunction. Exercise progression was guided by the patient’s rate of perceived exhaustion (RPE) on a scale of 1-10. The initial phase focused on breathing mechanics and IAP regulation, starting with 3-month supine positioning, where the patient lay on their back with legs elevated at 90 degrees, supported on a chair or pad, and arms held perpendicular to the body.

Once respiratory function and IAP regulation were optimized, she progressed to 6-month supine positioning, introducing greater load to reinforce spinal flexion movements. This progression was particularly relevant for lumbar stenosis, as it actively opened the spinal canal and intervertebral foramina, facilitating self-decompression of the lumbar spine.

Next, therapeutic exercise advanced to 5-month side-lying positioning, which maintained the patient’s preferred palliative position of lumbar flexion while opening the posterior hip capsule and distracting the sacroiliac joints to alleviate radiating pain. This exercise also strengthened external hip rotators and reduced posterior hip capsule pinching. As the patient improved, she transitioned to 8-month modified low oblique sitting, integrating IAP control into global core strengthening and anti-extension strategies.

Additional therapeutic exercises included hip extension patterning to dissociate from lumbar extension, gait retraining with posterior pelvic tilt and core stabilization, functional movement training such as squat and hip hinge, and accessory muscle strengthening, including calf raises, toe activation drills, single-leg balance, and wobble board training. As treatment progressed, manual therapy techniques were gradually reduced in favor of increased time spent on therapeutic exercise.

Outcomes

Outcome measures focused on restoring global range of motion (ROM) and mobility in the thoracic spine, lumbar spine, and hips. Additional measures included gait analysis, pain intensity scales for leg and back pain, and functional assessments of activities of daily living (ADLs). At the conclusion of the 6-week trial of care, she reported greater than 50% improvement in pain and function. Notable improvements included increased thoracic extension and rotation ROM, enhanced hip extension and rotation mobility, and better lumbar flexion and extension mobility. She also demonstrated improved single-leg balance, longer stride length with reduced gait hesitation, and enhanced abdominal wall activation as measured by the Core 360 Belt + OhmTrak system. Functionally, she reported an increase in her claudication-free walking interval from one minute to ten minutes without right leg symptoms.

No adverse or unexpected events were reported throughout treatment, and no follow-up diagnostic testing was indicated.

DISCUSSION

This case study highlights the effectiveness of a multimodal approach to managing symptoms and functional deficits associated with moderate to severe neurogenic claudication in a 67-year-old patient. In a previous systematic review and intervention component analysis of randomized controlled trials on exercise treatments for lumbar spinal stenosis, tehinvestigators found that “exercise components featured more frequently in successful interventions included stretches, strength or trunk muscle exercises, fitness exercises, especially cycling, and psychologically informed approaches.”5 The treatment approach led to a decrease in the patient’s pain level from 7/10 to 2/10 and her pain-free walking duration increased from 1-minute intervals to 10-minute intervals. Additionally, she reported more than a 50% improvement in their ability to perform activities of daily living. Exercises primarily targeted the hip, lower leg, core, and foot musculature, while movement pattern modifications aimed to reduce compensatory extension in the hip and other areas.

After initial care opportunities did not provide relief, considerable progress was achieved through a combination of soft tissue therapy, therapeutic exercise, movement pattern modification, and passive treatments such as flexion-distraction and spinal manipulation. The inclusion of DNS is an important part of the treatment approach for lumbar canal stenosis in this case. Regulation of IAP through progressive incorporation of the diaphragm, abdominal wall and pelvic floor muscles helps create stabilization of the spine and evenly distributes load sharing decreasing stress on the spine in functional positions.3 The therapeutic exercises included functional movement training, loaded exercises, and DNS core progressions with trunk muscle exercises as a focus of treatment. This approach allowed for improvement in motor control that focused on functional movement, allowing the patient to see improvement in activities of daily living, and an overall decrease in daily pain level.

The MRI demonstrated no evidence of significant stenosis, a finding that contrasts with the clinical presentation described above. This discrepancy emphasizes the importance of integrating a comprehensive history and physical examination with imaging data. Given variability in test protocols and diagnostic accuracy, a multimodal testing approach is frequently more informative than reliance on a single investigation; individual test results should be interpreted in the context of the entire clinical picture.6–8 Consequently, management decisions should incorporate the patient’s history, physical examination, imaging findings, and, when indicated, supplementary investigations and should prioritize interventions directed at the patient’s symptoms and functional impairment rather than hinge on an isolated test result.

CONCLUSION

While this case report represents the positive effect a conservative care approach to treatment of lumbar spinal canal stenosis can have on patients, we acknowledge several limitations. The results from this single case study cannot be generalized without a need for future research that explores the long-term effects of multimodal treatment for lumbar spinal stenosis. There is currently no long-term assessment on whether improvements are sustained beyond one year and the likelihood of symptom relapse. Additionally, further investigation is needed to understand the impacts of Dynamic Neuromuscular Stabilization and core stabilization exercises on lumbar stenosis, particularly their benefits for lumbar stability and pain management. This case incorporates current research and knowledge about the use of DNS technique on core and spine stabilization and provides insight on the application of the combined multimodal approach to treating lumbar spinal canal stenosis.

Written consent for publication was obtained from the patient.

Author Contributions

Introduction: Jake Dahlke, Justin Decorey, Jazmine James, Janay Shuler
Case Presentation: Elizabeth Chadwick, Miranda Debrick, Derrick Vier
Intervention and Outcomes{ Grayson Howard, Chris Jumper, Tyler Landeros
Discussion and Summary: Tatiana Adejare, Tiffany Odgers, Alexander Walzel
Clinical Information / Compilation: Brett Winchester DC, Austin Parker DC, Pete Roy DC
Critical Interpretatio /Review of All Sections: Hillary Owen DC, Chris Malaya DC, PhD
Final Manuscript: All involved approved the final copy for submission