Foraminal and extraforaminal lumbar stenosis-radiculopathy, central stenosis, which causes pain, tingling, or cramps in the extremity lateral recess. Patients with central stenosis experience more symptoms when standing and walking and the pain is typically relieved by slouching or leaning forward. 3

The patient was 38 years old male by profession farmer, presented with paraparesis who was admitted at tertiary care centre. Patient reported with the history of laminectomy through D8-L1 for wedge compression fracture before six months from the time of reporting to physiotherapy. At the time of baseline assessment on observation patient was mesomorphic, wheel chair bound with abdomino - thoracic breathing and atrophy of lower limb muscles with an attitude of limb: ankle in slight plantar flexion and hip externally rotated. On examination the vitals were as follows, temperature was normal, pulse rate-85 beats per minute, respiratory rate-18 breaths per minute, blood pressure was 130/80 mm hg and Mini mental status examination was 30. All the deep tendon reflexes for upper limb were 2+ and for lower limb 4+ and there was no limb length discrepancy. Post operatively he felt weakness in both of his lower limbs and even noticed shaking of ankles. He also complained of weakness in bilateral lower limbs and further no control over bladder, he was bedridden for two months and was totally dependent for his daily living activities (ADLs). Patient was unable to walk with walker, for the preceding two months. Physical examination revealed severe bilateral ankle clonus with impaired sensation in lower limbs and sensation was normal in the upper limbs. The assessment included collection of demographic data, muscle strength of upper and lower limb assessed using Manual Muscle Testing (MMT), functional activities assessed by Barthel index, clonus assessed through spastic reflexes scores. (SCATS).

He had total score of ten on the modified Barthel index, for MMT grade of one for the bilateral lower limb muscles and three for bilateral upper limb muscles and SCATS score was three at baseline. Post evaluation exercises were designed specific to the symptoms and planned. The following exercises were progressively implemented Week wise for a period of three months. Initially patient was positioned in supine position for bilateral upper limb strengthening and weight cuff of half kg was tied at the wrist joint level and resistance was increased based on the patient’s capacity.4 Bed mobility training was initiated by the patient positioned in supine lying with the momentum of upper limb with the assistance of therapist. Bed mobility skills were taught to the patient: how to go for, side lying, prone, returning from prone to supine or side lying, long sitting in the bed.5, 6, 7, 8, 9 For clonus stretching exercises were given for bilateral lower limb muscles.10 After completing upper limb strengthening and bed mobility training wheel chair transfers training was started viz…folding the wheel chair and unfolding, educated how to overcome obstacles and ramps, ascending inclines, descending inclines and passing through doors etc. Wheelchair skills included activities of daily living according to his needs. Wheelchair should be angulated 45 degrees to the edge of the bed and wheels should be locked, by using his bed mobility skills he transferred himself from bed to the wheelchair by using his upper limb strength. 11

In Post laminectomy cases it is necessary to screen for sensory and motor impairment. Modified tailored protocol has shown improvement in functional scale to reduce clonus and to improve muscle power.

Patient followed up only for three months, if functional electrical stimulation, hydrotherapy and advanced physiotherapy management would have been included further for still better outcome.