Functional rehabilitation for degenerative lumbar spinal stenosis

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Functional rehabilitation for degenerative lumbar spinal stenosis. Joshua D. Rittenberg, MDa,b,*, Amy E. Ross, MPTa. aCe
Phys Med Rehabil Clin N Am 14 (2003) 111–120

Functional rehabilitation for degenerative lumbar spinal stenosis Joshua D. Rittenberg, MDa,b,*, Amy E. Ross, MPTa a

Center for Spine, Sports, and Occupational Rehabilitation, Rehabilitation Institute of Chicago, 1030 North Clark Street, Suite 500, Chicago, IL 60610, USA b Department of Physical Medicine and Rehabilitation, Northwestern University Medical School, 345 E. Superior Street, Chicago, IL 60611, USA

Nonoperative treatment for lumbar spinal stenosis must address anatomic and biomechanical factors. In addition to passive modalities, manual therapy, and patient education, an active program consisting of flexionbased lumbar stabilization exercises, hip mobilization, proprioceptive training, and general conditioning should be initiated. There have been a paucity of studies looking at specific nonoperative treatment protocols, and controversy still exists in the community as to what an appropriate course of nonoperative treatment entails. Several studies have compared the outcome of surgery to ‘‘conservative treatment.’’ The conservative treatment described has typically been nonspecific, with results approximating the natural history of the disease. So, two questions remain. (1) Can nonoperative treatment improve the quality of life, functional level, and pain level of the patient? (2) Is conservative treatment better than the natural history? Johnsson et al [1,2] described the natural history of degenerative lumbar spinal stenosis, following patients for up to 4 years. Neurologic deterioration was not seen. Thirty-three percent of patients had improvement in pain level, 58% were unchanged, and only 10% worsened. Walking capacity improved in 42% of patients, did not change in 32%, and decreased in 26%. Amundsen et al [3], in a 10-year prospective study, compared surgical with conservative management. The conservatively treated patients were placed on bed rest for 1 week, fitted with a 3-point hyperextension * Corresponding author. Center for Spine, Sports, and Occupation Rehabilitation, Rehabilitation Institute of Chicago, 1030 North Clark Street, Suite 500, Chicago, IL 60610. E-mail address: [email protected] (J.D. Rittenberg). 1047-9651/03/$ – see front matter Ó 2003, Elsevier Science (USA). All rights reserved. PII: S 1 0 4 7 - 9 6 5 1 ( 0 2 ) 0 0 0 8 2 - 7

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thoracolumbar orthosis, admitted for inpatient rehabilitation for 1 month, and encouraged to walk. The patients continued with the hyperextension brace after discharge for 3 more months. Physical therapy was described as ‘‘ambulation’’ and ‘‘stabilizing exercises,’’ along with instructions to maintain a kyphotic posture. After 4 years, almost half of the patients randomized to conservative care were improved, with improvements maintained at 10-year follow-up. An important finding in this study was that delaying surgery, even in the severe patients, had no effect on surgical outcome. Additionally, radiologic data did not correlate with outcome. Atlas et al [4], in the Maine Lumbar Spine Study, conducted a 1-year prospective study comparing outcomes of surgery with nonsurgical management. Those treated surgically had worse pain and functional measures at baseline. Patients with mild-to- moderate symptoms received conservative care. Only 4 of 67 nonsurgical patients went on to surgery during the follow-up period. Again, conservative treatment was nonspecific. The most common treatments were ‘‘back exercises,’’ bed rest, physical therapy, manipulation, and narcotics. Less than 20% received epidural steroids. Greater improvement was found in the surgically treated patients, although 36% of nonsurgically treated patients reported improvement in symptoms and worsening of symptoms was rare. Simotas et al [5] conducted a study following 49 patients treated nonsurgically for an average of almost 3 years. Treatment was described in detail, consisting of a combination of oral nonsteroidal anti-inflammatory drugs, oral steroids in some, epidural steroids in most, and physical therapy. Physical therapy consisted of flexion-based lumbopelvic stabilization exercises. Outcome was measured using the spinal stenosis scale, a validated outcome measurement tool described by Stucki et al [6]. At follow-up, 42% of patients reported mild or no pain (56% had mild or no leg pain), and 17% had severe pain. Overall, pain scores were significantly improved, compared with baseline. Walking scores improved or remained stable in 75% of subjects. Eighty percent of patients were satisfied with treatment. It is generally accepted that, without treatment, approximately 25% of subjects improve, 25% get worse, and 50% do not change. Those who initially present with more severe symptoms are more likely to have surgery.

Treatment Nonoperative treatment options are abundant and can be categorized into passive and active treatments (Tables 1 and 2). Bed rest is not recommended, if possible, to avoid the deleterious effects of inactivity and deconditioning in the older patient [7]. Relative rest and activity modification are typically more appropriate, with education given to the patient to help avoid

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Table 1 Passive treatments for degenerative lumbar spinal stenosis Treatment modality

When used

Oral analgesic medications

Acute or chronic phase, may include acetaminophen, nonsteroidal anti-inflammatory drugs, opioids, calcitonin, TCAs (tricyclic antidepressant medications), gabapentin, etc. Acute phase (usually not necessary, limit