#046 – Physical Therapy for Lumbar Spinal Stenosis Evidence in 2021

Lumbar spinal stenosis (LSS)

Lumbar spinal stenosis (LSS) is a degenerative process causing the narrowing of the central spinal canal, lateral recesses, or intervertebral foramen (or a combination thereof), progressively compressing the neurovascular structures in the spinal canal or foramen.

Physical therapy for the lumbar spinal stenosis (LSS), 2021 evidence (Non-Surgical Interventions).

1- Non-Surgical Interventions for Lumbar Spinal Stenosis Leading To Neurogenic Claudication: A Clinical practice guideline.

This guidleine sat out to answer 11 question related to the effectiveness of non-surgical interventions for lumbar spinal stenosis. 3 of which are related to physical therapy.

(If you’re interested in the in answers for the pharmaceutical questions click here)

Resutls (Answers)

Question 1. For patients with lumbar spinal stenosis, should multimodal rehabilitation interventions vs. another treatment be used to decrease pain, and improve function, quality of life, and return to function?

• Intervention: Multimodal Therapy
• Recommendation: For patients with LSS and neurogenic claudication with or without LBP, we suggest offering a combination of education and advice, manual therapy and home-based exercise for improvement in walking capacity and symptoms/physical function in the short and long term.
• Strength of Recommendation: Conditional/Weak
• Quality of evidence: Moderate.
• Definition: Multimodal rehabilitation interventions may include sedentary and nutrition lifestyle changes, behavioral change techniques in conjunction with manual therapy, exercise and/or rehabilitation, and ancillary non-pharmacological treatment.
• Intervention characteristics: Multimodal rehabilitation intervention was delivered twice weekly over 6 weeks. It included individualized instruction on exercise and self-management strategies using a cognitive-behavioral approach. At the end of the program, daily home exercise (30 minutes cycling plus 30 minutes of structured exercises) and self-care strategies should be maintained.

Question 2. For patients with lumbar spinal stenosis, should acupuncture vs. another treatment be used to decrease pain, and improve function, quality of life, and return to function?

• Intervention: Acupuncture
• Recommendation: For patients with LSS and neurogenic claudication with or without LBP, we suggest considering traditional acupuncture on a trial basis to improve pain and physical function in the short-term.
• Strength of Recommendation: Conditional/Weak
• Quality of evidence: Very low.
• Definition: Needle acupuncture (e.g., Hwato Acupuncture, Suzhou, China; 0.30×40 mm/0.30×75 mm) at various sites (e.g., Acupoints of Shenshu (BL23), Dachangshu (BL25), Weizhong (BL40), Chengshan (BL57), and Taixi (KI3)) or outward from the spinous process bilaterally at L2, L4, S2, and S4, middle of the popliteal fossa, inferior recess in the fibular head, lower end of the groove of the inner and outer head of the gastrocnemius).
• Remarks: There is very low quality evidence from two small trials that acupuncture provides marginal short-term improvement in pain and functional recovery for degenerative LSS. Current evidence provides borderline clinically important short-term improvement and is insufficient to suggest long-term benefit.

Question 3. In patients who underwent spinal fusion with or without decompression, should supervised training after surgery vs. another treatment be used to decrease pain, and improve function, quality of life, and return to function?

• Intervention: Supervised training after surgery.
• Recommendation: For patients with LSS and neurogenic claudication, we suggest offering post-operative rehabilitation with CBT to reduce pain and improve function at 1 month and 12 months post-surgery.
• Strength of Recommendation: Conditional/Weak
• Quality of evidence: Low.
• Definition: Post-operative rehabilitation was defined as a supervised program of exercises and/or educational materials encouraging activity 12 weeks after surgery. Supervised exercise may include active spinal mobilisation, strengthening of spinal deep muscles, stretching of lower limb and low back, functional exercise, walking, and ergonomic advice.
• Study included: A RCT compared individual 60-min sessions twice/week of cognitive-behavioral therapy (CBT) for 4 weeks combined with exercise (90-min session 5 times/week for 4 weeks) to exercise therapy alone in of patients with post-operatively following lumbar fusion due to LSS with NC.
• Result: At 1 month, CBT + exercise had significantly less disability and back pain compared to exercise alone. At 12 months, CBT + exercise had significantly less disability, back pain, and leg pain compared to exercise alone. A small proportion of participants in both groups reported minor transitory pain worsening and mood alterations.

See the Full Table of Benefits and Comparative Benefits of Nonpharmacological Therapies Here

Summary of Recommendations

• We suggest clinicians consider offering a multimodal rehabilitation intervention consisting of a combination of education, sedentary and nutrition lifestyle modification for patients with limited walking ability and overweight or obese individuals with related comorbidities, behavioral change techniques in conjunction with manual therapy (spinal mobilization, manipulation, massage) of the thoracic and lumbar spine, pelvis, and lower extremities, and individually tailored supervised and home exercise program (stretches and strength training, cycling, and body weight-supported treadmill walking).
• We cannot recommend the use of NSAIDs, analgesics (methylcobalamin, paracetamol, calcitonin), opioids as a first-line treatment, muscle relaxants, antiseizure neuropathic medication (pregabalin), or epidural steroidal injections.

2 – Effectiveness of conservative non-pharmacologic therapies for pain, disability, physical capacity, and physical activity behaviour in patients with degenerative lumbar spinal stenosis: a systematic review and meta-analysis

Results

• Directed exercise and manual therapy was superior to self-directed or group exercise for improving:

1. Short-term walking capacity (61.7 to 524.9 meters; low-quality evidence),
2. Back pain (moderate-quality evidence),
3. Leg pain (moderate-quality evidence),
4. Symptom severity (low-quality evidence).

• There is very low-quality evidence that rehabilitation is no better than surgery at improving intermediate- or long-term disability.
• Single trials provided conflicting evidence of effectiveness for a variety of therapies.

Conclusion

• For patients with LSS, there is low- to moderate-quality evidence that manual therapy with supervised exercises results in small improvements in short-term walking capacity, pain, and symptom severity compared to self-directed or group exercise.
• The choice between rehabilitation and surgery for LSS is very uncertain owing to the very low-quality of available evidence.

3 – Management for lumbar spinal stenosis: A network meta-analysis and systematic review

• A total of 34 trials (n = 4341) and nine interventions were included.

Interventions

• Decompression, decompression plus fusion, endoscopic decompression, interspinous process spacer device, laminectomy, laminotomy, minimally invasive decompression, non-surgery, split spinous process decompression.
  • Non-surgical interventions include drugs, physiotherapy, spinal injections, lifestyle modification, and multidisciplinary rehabilitation.

Results

• No significant difference in improving patients’ dysfunction among any of the investigated interventions.
• Surgical interventions were better than non-surgical interventions in relieving both short- and long-term pain.
• Endoscopic decompression had the lowest complication rate among all surgical interventions. Also, laminotomy had a lower reoperation rate than the interspinous process spacer device.
• Decompression plus fusion resulted in more blood loss than any other surgical intervention, and the interspinous process spacer device had the lowest operation time.
• Endoscopic decompression had the shortest hospitalization time.

Conclusion

• There were no significant differences among the interventions in improving patients’ functions.
• Surgical interventions were better than non-surgical interventions in relieving pain but had a higher incidence of complications.
• Decompression plus fusion is not necessary for LSS patients. In addition, endoscopic decompression as a less invasive surgical method is a good choice for LSS patients.

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Final conclusion

• Exercise and manual therapy are beneficial for LSS, in conjunction with education, nutrition, lifestyle modification and behavioral change techniques.
• Although the evidence of superiority is not clear, non-surgical interventions are worth trying before surgical interventions.

Note:

• I was only able to find these 3 articles on spinal stenosis in 2021, searched science direct, PubMed and PEDro (11/06/2021). If you know other articles send them my way here.

References

1. Non-Surgical Interventions for Lumbar Spinal Stenosis Leading To Neurogenic Claudication: A Clinical practice guideline. (Open Access)
2. Effectiveness of conservative non-pharmacologic therapies for pain, disability, physical capacity, and physical activity behaviour in patients with degenerative lumbar spinal stenosis: a systematic review and meta-analysis (Restricted Access)
3. Management for lumbar spinal stenosis: A network meta-analysis and systematic review (Restricted Access)