September 5th – 8th 2013
Nottingham Conference Centre, United Kingdom
www.nspine.co.uk
Lumbar Spinal Stenosis (LSS)
Conservative Management
Ellen Hobbs
Physiotherapist
September 2013
What does the literature indicate?
• Surgery is generally the gold standard.
(Negrini et al 2010; Zaina et al 2012)
• Only a few studies have compared surgical vs
non-surgical treatment. (Negrini et al 2010)
• Evidence regarding conservative management is
limited and vague.
(Atlas and Delitto 2006; Birkmeyer et al 2002; Goren et al 2009; Tomkins 2010 cited in Zaina et al
2012)
However…..
What does the literature indicate?
• Research non-specific / no current standard for
conservative care. Therefore do positive results truly
support surgery? (Backstrom et al 2011)
• Long term effectiveness of surgery has been
questioned. (Backstrom et al 2011; Fritz et al 1998)
• Patient selection for surgery is ill-defined.
(Backstrom et al 2011)
• High risk and costly. (Fritz et al 1998)
What does the literature indicate?
• Conservative / non-invasive = recommended first line
intervention. (Negrini et al 2010; Fritz et al 1998)
• The natural history of LSS is not necessarily a
progressive decline. (Fritz et al 1998)
• Patients with mild to moderate symptoms of lumbar
stenosis have satisfactory outcomes following
conservative management (Goren et al 2009)
Proposed Conservative Adjuncts
Patient
Education
Pain clinic
Manual
Therapy
Functional
restoration
Core Stability
Exercise
Conservative
Acupuncture
Flexibility
Aerobic training
/ Progressive
strengthening
Injection
Analgesia
Neurodynamics
Patient Education and Manual Therapy
Inform patient
• Rationale for
• Self management strategies
(Backstrom et al 2011; Johnson et al 1991; Rademeyer 2003; Voet et al 2005)
Manual Therapy
• Use as a component of LSS is associated with improvements
in pain and disability (Reiman et al 2009; Zaina et al 2012; Goren et al 2009)
• Techniques used are varied / applied to different regions
(Backstrom et al 2011)
• Choice of procedure less important than the introduction of
movement through manual therapy. (Backstrom et al 2011)
Exercise Prescription
• Aerobic Training and Progressive strengthening: (supervised
circuit / Spinal class / Home exercises) (Backstrom et al 2011; Goren et al 2009)
• Core Stability Exercise: Done with a flexion bias emphasizing
pelvic control e.g. shoulder bridge (Backstrom et al 2011; Fritz et al 1998)
• Flexibility: Overall stiffness = common LSS presentation.
(Fritz et al 1998; Whitman et al 2003, 2006; Creighton et al 2006; Murphy et al 2006 cited in
Backstrom et al 2011; Zaina et al 2012).
• Limited evidence directing exercise dosage in patients with
LSS. DO WE UNDERTREAT? (Backstrom et al 2011)
Outcome Measures
• Multi-dimensional
–
–
–
–
–
–
Objective markers
Patient Goals / Function
Roland Morris / ODI / EQ5D
VAS
Timed walk (15 minutes)
Sit to stand
Considerations and Onward Referral
• Relies on correct differential diagnosis
– Difficult due to similar coexisting symptoms
(Fritz et al 1998)
• NUH 4-6 sessions. If no change in
symptomology the ? onward referral.
• In reality there are no standard / set criteria
for timeframes of conservative Mx
Summary
• Patients with mild to moderate symptoms of lumbar stenosis
may benefit from conservative management (Goren et al 2009)
However:
•
Few existing RCTs (4/178) that specifically examine and report on patient with LSS
receiving conservative treatment. (Agency for Healthcare Research and Quality 2001).
•
Studies do not evaluate applications alone. (Goran et al 2009)
•
Research fails to evaluate long term effectiveness of conservative management.
(Agency for Healthcare Research and Quality 2001).
•
Lack of comparable patient groups and pre-treatment data for both surgical and
conservatively managed patient groups (Agency for Healthcare Research and Quality 2001).
•
True comparisons are difficult as many patient treated conservatively end up
having surgery. (Agency for Healthcare Research and Quality 2001).
Summary
• However does this lack of evidence prove that these
treatment are not effective? (Rockville 2001)
• Need to consider each individual patient and their
symptomology when deciding conservative vs surgical.
• Need to establish set outcome measures for patient with LSS.
Appendix
Indications
• Lower limb pain
• Neurological symptoms exacerbated by
walking
• Neurogenic claudication
• Reduced walking capacities
Injection
• Epidural steroid injections used increasingly to relieve
symptoms. (Delport et al 2004; Campbell et al 2007 cited in Backstrom et al 2011)
• Low level evidence studies show some benefit in patients with
spinal stenosis. One RCT indicates temporary relief for one
month. Conclusions beyond three months cannot be made.
(Agency for Healthcare Research and Quality 2001).
• Systematic review concluded more strenuous studies need to
be performed. (Nelemans et al 2005; Buenaventura et al 2009 cited in Backstrom et al 2011).
• Often used in combination with physiotherapy.
Neurodynamics
• Consider that pathoneurodynamics may be contributing to
symptomology.
• Neurodynamic testing and reproduction of symptoms using
differentiation may indicate neurodynamics treatment.
• Nerve gliding
• Treatment of mechanical interface:
• Trigger point / acupuncture
• Taping to offload: Inhibitory across muscle fibres. Neural
offloading: reduces nociceptor impulses
References
Atlas SJ, Delitto A: Spinal stenosis: surgical versus nonsurgical treatment. Clin
Orthop Rel Res 2006, 443 pp198 - 207
Backstrom KM, Whitman JM, Flynn TW: Lumbar spinal stenosis-diagnosis and
management of the aging spine; Manual Therapy 2011, Vol 16 pp308-317.
Birkmeyer NJO, Weinstein JM, Tosteson ANA, Skinner JS, Lurie JD, Deyo R,
Wennberg JE: Design of the Spine Patient Outcomes Research Trial (SPORT);
Spine 2002, June 15; 27 (12): 1361 – 1372.
Fritz JM, Erhard RE, Vignovic M: Anonsurgical Treatment Approach for
Patients With Lumbar Spinal Stenosis: Physical Therapy 1997, Vol 9 pp962973.
References
Fritz JM, Delitto A, Welch WC, Erhard, RE: Lumbar Spinal Stenosis: A Review
of Current Concepts in Evaluation, Management, and Outcome
Measurements. Arch Phys Med Rehabilitation 1998, Vol 79 pp 700-8.
Goren A, Yildiz O, Findikoglu, G, Ardic F: Efficacy of exercise and ultrasound in
patients with lumbar spinal stenosis: a prospective randomized controlled
trial. Clinical Rehabilitation 2010, 24 pp 623-631.
Johnsson K, Daglas M, Stucki G, Katz N, Bayley J, Fossel A. Degenerative
lumbar spinal stenosis. A comparison of surgically treated and untreated
patients. Spine 1991: 16: 615-9
References
Negrini SZ, Zaina F, Romano M, Atanasio S, Fusco C, Trevisan C. Rehabilitation
of lumbar spine disorders; an evidence-based clinical practice approach. De
Lisa’s Physical 7 Rehabilitation-Principles and Practice 2010: 837 – 82.
Treatment of Degenerative Lumbar Spinal Stenosis. Summary, Evidence
Report/Technology Assessment: Number 32. AHRQ Publication No. 01-E047,
March 2001. Agency for Healthcare Research and Quality, Rockville, MD.
http://www.ahrq.gov/clinic/epcsums/stenosum.htm.
Rademeyer I. Manual Therapy for lumbar spinal stenosis; a comprehensive
physical therapy approach. Physical Medicine and Rehabilitation Clinics of
North America 2003; 14: 103-10
References
Reiman M, Harris J, Cleland J. Manual therapy interventions for patients with
lumbar spinal stenosis: a systematic review. New Zealand Journal of
Physiotherapy 2009; 37: 17 – 28.
Zaina, F, Tomkins-Lane C, Carragee E, Negrini: Surgical versus non-surgical
treatment for lumbar spinal stenosis (Protocal); The Cochrane Library 2012,
Issue 12; pp 1-14.