The Monday Memo
February 25th, 2019 PITT DPT STUDENTS
Challenging the Treatment of Lumbar Spinal Stenosis
Lumbar spinal stenosis (LSS) is defined as a narrowing of the spinal canal that results in compression of the nerves traveling down the lower back and into the legs. Lumbar spinal stenosis is often a degenerative condition that affects people later in life usually after the age of 65. Patients with LSS typically present with pain/symptoms below the buttocks, feel relief of pain/symptoms when seated, present with a wide base of support during gait, and have pain/difficulty walking.
Currently, the most common reason for surgery in older adults is LSS; however, there is very little evidence comparing surgery to non-surgical treatment, or of the efficacy of non-surgical interventions for LSS. Recently, a team comprised of members from the University of Pittsburgh looked to improve the evidence gap by publishing an article in the Journal of the American Medical Association that compared three non-surgical interventions for LSS.
The randomized control trial study specifically compared medical care, group-based exercise, and manual therapy with individual exercise. The non-surgical treatments were completed across 6 weeks. The main outcomes of the study were between-group differences at 2 months in self-reported symptoms and physical function and a measure of walking capacity.
Medical care involved 3 visits to a physician and typically the prescription of oral medications including any combination of nonnarcotic analgesics, anticonvulsants, and antidepressants. The medical care arm also gave physicians the option of prescribing epidural steroid injections if the patient was not responding to oral medications or presented with more severe neurological symptoms.
The group exercise arm participated in a supervised exercise class for older adults at 2 local Pittsburgh community centers. The study participants went to 2 exercise classes per week totaling to 12 classes.
The manual therapy and individual exercise group included treatment provided by a chiropractor or physical therapist. Treatment included light aerobic exercise on a stationary bicycle, lumbar distraction manual therapy, neurodynamics, hip, sacroiliac, and lumbar facet mobilizations, soft tissue mobilizations, and home exercise programs. The programs were individualized and stressed flexion-based exercises.
According to the study, the manual therapy and individualized exercise group showed greater improvement of symptoms and physical function compares to the medical care or the group exercise arm. At 6 months the study found that there were no differences between the groups. While this study did not directly compare non-surgical and surgical treatment for LSS it did demonstrate that patients experiencing lumbar spinal stenosis can make clinically and statistically meaningful improvements in walking capacity without the significant costs, risks, complications, and rehospitalizations associated with surgery.
-Janet Mitchell, SPT
Schneider MJ, Ammendolia C, Murphy DR, et al. Comparative Clinical Effectiveness of Nonsurgical Treatment Methods in Patients With Lumbar Spinal Stenosis: A Randomized Clinical Trial. JAMA Netw Open.2019;2(1):e186828. doi:10.1001/jamanetworkopen.2018.6828