A Pilates Based Approach to Lumbar Spine Stenosis and Related Pain

Pain from LSS can be disabling. Here's how a few home-based exercises can help. Video demonstration included.



In my Pilates practice in San Francisco, I often work with older adults who suffer from pain related to lumbar stenosis, also called lumbar spinal stenosis (LSS). Lumbar stenosis is a narrowing of the spinal canal inside the five vertebrae of the lower back – you may hear your doctor call them L1 to L5. This narrowing can put pressure on the nerves of the low back, which can cause pain locally, or in the buttocks, groin, and even running down the legs.


Pain from LSS can be disabling. My clients often complain that walking or standing for long periods is quite painful. Pain from stenosis can interfere with basic activities such as going grocery shopping, cooking dinner, walking through a museum, or standing up at parties.


Karina Del Rosario, MD, a physiatrist and assistant clinical professor at the University of California San Francisco’s Department of Orthopedic Surgery, evaluates a number of patients with LSS and related pain. She confirms that LSS pain is typically “worse with standing, walking, and activity and can be alleviated with rest or sitting.”

Even though LSS refers to the lower back, she explains that leg pain is a common symptom and that in some patients, leg pain can be worse than the pain experienced in the back.“Pain severity varies (person to person) and can also be associated with numbness or weakness in the legs,” she adds. “If someone is experiencing significant numbness or weakness in the legs, they should notify their healthcare provider right away.”


Give Physical Therapy A Go Before Considering Surgery

To manage LSS pain,  patients often rely on pain medications or steroid injections. In more severe cases, or when conventional treatments don’t work, minimally invasive percutaneous image-guided lumbar decompression (PILD), implanted devices, or decompression surgery (ie, laminectomy) may be considered to correct the condition.

However, patients are typically encouraged to try physical therapy, osteopathic therapy, and exercise before resorting to any invasive procedure.

In fact, a randomized trial supported by the National Institutes of Health compared physical therapy to surgery as a treatment for LSS and found virtually no difference. The study followed 169 people, all aged 50 and older, who were diagnosed with lumbar spinal stenosis and who were considered surgical candidates, over the course of 7 years. They compared patients who underwent corrective surgery to those who took part in a physical therapy program. Both groups saw improvements in their pain as early as 10 weeks into the study, and there was no significant difference in pain level after 2 years. The researchers concluded that undergoing physical therapy before undergoing surgery may help avoid possible post-operative complications, and suggested doctors discuss the risks and benefits of both surgical and non-surgical interventions with their patients.


The researchers did note, however, that without a control group in the study, it’s impossible to judge the success attributable to either intervention. Hopefully, more studies will be conducted in the future.

In the meantime, Dr. Del Rosario shares that, “Physical therapy is a mainstay of conservative medical treatment [for LSS] and can be helpful for many patients.” While she agrees that more high-quality research is needed regarding the benefit of specific exercises in the management of LSS pain, she usually recommends the following:

  • lumbar spinal stabilization and strengthening
  • core strengthening
  • reduction of lumbar lordosis (the natural curve forward in the lower back), with a focus on lumbar flexion-based exercises*
  • proper posture techniques
  •  stretching especially of the hamstrings
  • light cardio, such as stationary bike riding.


*What is Lumbar Flexion? People with lumbar stenosis tend to feel more comfortable with their back in the “lumbar flexion” position, which can be achieved through sitting or lying down. Lumbar flexion is a flattening of the natural curve of the lower back. You move toward lumbar flexion, for example, if you lie down on a mat and press your lower back down into the floor, or if you sit down and relax your lower back backward. For some people, lying on one side with knees tucked in also puts the lumbar spine in flexion, and can be a comfortable resting position.

Everything Dr. Del Rosario suggests in terms of physical therapy for LSS corresponds to what has worked for my Pilates clients over the years, although some of my clients do better with strengthening in a neutral spinal position, as opposed to in lumbar flexion. Everyone is different – your body will tell you which position is best for you.


Try These Home-Based Pilates Exercises to Help Relieve Pain

There are three basic Pilates exercises that are easy to learn and practice at home. The exercises work by strengthening the core muscles of the pelvis and abdomen, noted by Dr. Del Rosario above, and by improving the alignment of the spine. I use these exercises with my LSS clients just about every day.

I’ll describe them below but you can also watch a video demonstration here. Follow along if you like, and pause the video when you need to, so you have enough time to explore the exercises on your own.

Remember to always consult with your doctor first to make sure these exercises right for you. You also may want a good physical therapist or Pilates teacher to help make sure you are doing them correctly. If your pain increases, even just a little, stop and find someone well trained to help you. In my experience, your body will tell you right away what works for you. If your pain decreases as you are working, the exercise is a good one for you. Take it slow and listen to your body’s clues.

The author demonstrates pelvic positioning to engage deep abdominal muscles.

#1: Pelvic Positioning with Abdominal Support

In this exercise, you’ll find the position that’s the most comfortable for your lower back and pelvis, and then engage your deep abdominal muscles to hold that position. As mentioned, many people are most comfortable in slight lumbar flexion – but some need a more neutral spine position. Here’s how to find your sweet spot:

Lie on your back with your knees up. Use a pillow for your head if it feels better. Place your palms flat on your lower belly. As you exhale, imagine you are zipping up a tight pair of pants from your pubic bone to your navel. The zipping pulls your belly closer to your spine, and you should feel this deepening under your hands. The zipping also tips your lower back flat into the mat (into flexion).

Go slowly, and pay close attention to how your lower back, hips, and legs feel. See if you can find a pelvic position where your pain decreases a bit. I usually have people give their pain a number level from 1 to 10, with 10 being really severe pain. If you can find a position that takes your pain down a few points, or even just one point, that’s your sweet spot.

Wherever that sweet spot is for you, hold your pelvis in place there with your abdominal muscles, breathing in and out for 30 seconds or so. You may need to ensure that your lower back is flat on the mat, or you may need to just connect to your abdominal muscles while remaining in the resting position you began with when you first lay down. The most important thing is that your pain continues to lessen and that you feel your deep zipper working. Relax and rest when you need to.


The author demonstrates gentle knee folds to help lumbar stenosis pain.

#2: Gentle Knee Folds

Once you’ve found your sweet spot and feel strong enough to hold your position with your deep abdominals, you can move on to this next exercise. Start by tilting your pelvis into your most comfortable position, using your deep zipper. Then, on your next exhale, practice gently lifting one foot up off the mat, without letting your pelvis or lower back change position. Set your foot down on an inhale, and alternate legs.

This exercise is harder than it sounds. Pay attention to the subtle tilting of your pelvis toward the leg that lifts. You’re trying to use your deep abdominals to eliminate this tilting and stay stable. I like keeping my hands lying on my belly, to reinforce the feeling of the deep zipper and the dropping of my navel toward my spine. If it’s too hard to lift your whole leg, it’s fine to just lift one heel, leaving your toes down. Again, let pain be your guide. You want to feel your pain decreasing, even slightly, as you do this exercise.

If your pain increases, stop and stick with exercise #1.


The author demonstrates standing pelvic tilts to ease pain from lumbar stenosis.

#3: Standing Pelvic Tilts

Standing pelvic tilts involve the same maneuvers as in exercise #1, but in a standing up position. These moves can be helpful while washing dishes or standing for long periods.

Stand comfortably and lay your hands over your low belly. Soften your knees just a little.

On an exhale, gently draw your deep belly zipper upward from your pubic bone to your navel, and tilt your pelvis under you as though you’re flattening your lower back against a wall behind you.

Again, pay attention to pain. Can you find a position where your pain decreases, even slightly? Wherever that is for you, stay there, and practice breathing for 30 seconds or so as you hold the position with your deep abdominals. (A tip on breathing – it’s easier to keep your low abs active if, as you inhale, you practice expanding your sides and back, instead of your stomach.)

Once you get used to it, you won’t need your hands to be sure your lower abdominals are working for you. Then you can experiment with this exercise in daily life.

Final Tidbits

If you have pain in your back, hips, or legs from lumbar spinal stenosis, it’s worth trying physical therapy before resorting to surgery. For many people, physical therapy exercises can alleviate pain just as effectively as surgery, and with far less recovery time!

The home exercises described here can help strengthen your deep abdominal muscles and align your spine—and may help decrease your pain. These exercises are just a start – there are hundreds of ways to strengthen the areas around the lower spine and pelvis and your daily practice can vary, especially with the help of a good therapist.

Always check with your doctor before starting a new exercise regimen, and remember, with perseverance, daily activities that involve standing and walking will become easier and more comfortable, which is well worth your effort.

Updated on: 01/15/21
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