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A 67-year-old male with coronary artery disease and chronic low back pain went to the neurologist complaining of 4 months of disabling leg pain when walking. The pain was located in the buttocks and posterior thighs in a symmetric distribution, and began after 10 minutes of walking on a level surface. The pain would ease after sitting for several minutes, and then he was able to continue walking. He reported being able to climb stairs to his home and to ride his bicycle without pain. The neurologist ruled out vascular claudication with Doppler ultrasound (i.e., no evidence of vascular insufficiency in his legs). Neurologic examination showed limited mobility of the lumbar spine, but no local tenderness or deformity. Right straight leg raise to 55° elicited pain in the back and right buttock. Muscle bulk, tone, and strength in the lower limbs were normal. Tendon reflexes were symmetrical at the knees and depressed at the right ankle. Proprioception and vibration sensation were slightly diminished at the toes. Magnetic resonance imaging of the lumbosacral spine showed widespread degenerative spine disease, central disc bulges at L3-L4 and L4-L5, and a focal, right-sided, posterolateral disc protrusion at L5-S1. Deformation of the thecal sac at the lower lumbar levels and multilevel neuroforaminal narrowing were also present. Needle electromyography (EMG) revealed mild chronic partial denervation with reinnervation in the medial head of the right gastrocnemius muscle. A diagnosis of neurogenic claudication secondary to lumbar spinal stenosis (LSS) associated with a mild right-sided S1 radiculopathy was made. The neurologist referred the patient to the physical therapist for evaluation and treatment.

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What are possible complications interfering with physical therapy?

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What are the most appropriate physical therapy outcome measures for pain and functional change?

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What is his rehabilitation prognosis?

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What are the most appropriate examination tests?

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What examination signs may be associated with this diagnosis?

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  • CAUDA EQUINA SYNDROME: Loss of function of the lumbar plexus neurologic elements (nerve roots) of the spinal canal below the conus medullaris of the spinal cord
  • NEUROGENIC CLAUDICATION: Pain or discomfort in the low back, buttocks, and legs that is initiated or intensified with walking and is relieved by sitting
  • RADICULOPATHY: Neurologic condition characterized by dysfunction of a spinal nerve, its roots, or both; usually presents with unilateral pain, paresthesia, weakness, and/or reflex changes in the affected nerve root distribution
  • SPINAL STENOSIS: Narrowing of the spinal canal with encroachment on the neural structures by surrounding bone and soft tissue

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  1. Describe lumbar spinal stenosis (LSS).

  2. Identify the classic signs and symptoms of neurogenic claudication.

  3. Discuss appropriate components of the examination.

  4. Identify key components in the treatment of LSS.

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PT considerations during management of the individual with chronic progressive low back pain, lower extremity pain, weakness, and neurogenic claudication ...

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