Conservative physiotherapy for lumbar spinal stenosis with neurogenic claudication: A structured narrative review

Abstract

Background: Lumbar spinal stenosis (LSS) is a major cause of pain, disability, walking limitation, and neurogenic claudication in older adults. Although conservative physiotherapy is widely recommended before surgical escalation, uncertainty remains regarding the most clinically useful nonoperative components, supervision requirements, and durability of benefit. Objective: To synthesize current evidence on conservative physiotherapy interventions for LSS with neurogenic claudication, compare major intervention categories, interpret methodological quality and certainty of evidence, and identify clinically relevant research gaps. Methods: A structured narrative review was conducted using a predefined PICO framework. Clinically relevant evidence was identified through a narrative-review-oriented search of PubMed/MEDLINE, EMBASE, Cochrane CENTRAL, PEDro, Web of Science, and CINAHL for January 2000 to April 2025, supplemented by reference-list screening of relevant reviews. Randomized controlled trials, RCT follow-up publications, systematic reviews, and meta-analyses involving adults with imaging-confirmed LSS receiving conservative physiotherapy were prioritized for clinical synthesis. Methodological quality was summarized using PEDro scores for RCTs and AMSTAR-2 domains for systematic reviews where available. Certainty was interpreted narratively using GRADE domains rather than assigned through a de novo systematic-review process. Because the work was designed as a structured narrative review rather than a prospectively registered systematic review, database-level search counts and a flow diagram are not reported. Results: Seventeen references were retained for synthesis, including individual randomized trials and follow-up studies, systematic reviews/meta-analyses, contextual clinical guidelines, and one small emerging-modality RCT. Because review-level and trial-level evidence may overlap, findings were synthesized narratively rather than cumulatively pooled. The most consistent evidence supported supervised multimodal physiotherapy combining individualized exercise, flexion-compatible aerobic conditioning, manual therapy, and education. Directed exercise plus manual therapy improved walking capacity in review-level evidence, while supervised physiotherapy showed superior short-term outcomes compared with home exercise and sustained benefit at 1 year in one RCT cohort. Active TENS did not demonstrate benefit over sham TENS; evidence for spinal manipulation, dry needling, neural mobilization, and transcranial direct current stimulation remains preliminary or adjunctive. Conclusion: Supervised multimodal physiotherapy is the most consistently supported conservative approach for adults with LSS and neurogenic claudication. The evidence favours structured, progressive, flexion-compatible, and professionally supervised rehabilitation rather than passive or standalone modalities. Future prospectively registered systematic reviews and adequately powered RCTs with standardized protocols, longer follow-up, and clinically meaningful outcomes are needed to refine conservative treatment pathways.