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Special RepoRt Special RepoRt
Therapeutic exercise and manual therapy for persons with
lumbar spinal stenosis
Lumbar spinal stenosis (LSS) may produce disabling back and leg pain, and is the leading cause of surgery
in adults over 65 years old. No revies have summaried the effects of manual therapy and therapeutic
eercise for these patients. he obective of this article is to eamine the design and effectiveness of
therapeutic eercise and manual therapy for patients ith LSS, and to identify the state of evidence for
these interventions on pain, disability, function and impairments in patients ith LSS. n the report, three
physical therapists each evaluated the methodological uality of studies obtained from a systematic
search of computeried databases. atients involved in the studies ere subects aged –
years ith
lo back and leg pain, and diagnosed ith LSS for month or more ith eercise or manual therapy as
the primary intervention and any type of study design. Nonnglish articles, dissertations, unpublished
data and studies using steroid inections, surgery or medications such as muscle relaants, or studies
comparing modalities (i.e., ultrasound and electrical stimulation) ith eercise ere ecluded. nterventions
included aerobic, strengthening, stabiliation, fleibility, balance eercise and manual therapy. he
measurements used ere the acermid’s scale and the Sackett’s Level of vidence. esults from the
study indicated that to of seven studies (
.5) ere classified as high uality trials to (
.5) as
moderate uality and three () as lo uality studies. ll studies demonstrated decreases in pain and
disability and improvement in overall function and participation. limitation of the report as that the
studies ere heterogeneous. urthermore, only to studies ere highlevel randomied controlled trials.
n conclusion, most studies assessed the benefits of mied eercise interventions, rather than a single mode
of eercise. herapeutic eercises such as aerobic training, fleibility, strengthening eercise and manual
therapy produce smalltomodest effects for pain, disability and function in patients ith mildtomoderate
LSS. erobic eercise in combination ith fleibility, strengthening eercise and manipulation may be
more effective than aerobic, strengthening eercise, fleibility eercise or manual therapy alone.
†1,3,4
n n n Maura D Iversen ,
Keywords: degenerative lumbar spine manipulation stenosis
n 2
therapeutic exercise Vidhya R Choudhary
2
& Sandip C Patel
Lumbar spinal stenosis (LSS) is a slowly progress- are posture-dependent [3,7,8] and pain is often 1
Northeastern University, Department
ing disease effecting five in 1 adults older aggravated by waling prolonged standing or of Physical Therapy, USA
2
than years in the S and is the leading cause lying prone and relieved by sitting and lying MGH Institute of Health Professionals,
Graduate Programs in Physical
of surgery in adults years and older [1,2] LSS down [1–3,7–10] atients with LSS freuently Therapy, USA
defined as a narrowing of the spinal canal can be experience low bac pain maintain a stooped 3Division of Rheumatology, Immunology
& Allergy, Section of Clinical Sciences,
classified based on its etiology as either congeni- standing posture experience lumbar spine stiff- Brigham & Women’s Hospital, USA
tal or acuired [2–4] congenitally narrowed ness and lumbar and hip decreased range of 4Harvard Medical School, Boston,
MA, USA
spinal canal may result from shortened pedicles motion and muscle tightness [1,4,7] Sensory defi- †
Author for Correspondence:
thicened lamina and facets or from congenital cits motor weaness and pathological reflexes Tel.: +1 617 373 5996
scoliosis or lordosis cuired LSS most com- appear with waling lderly patients with Fax: +1 617 373 3161
M.Iversen@neu.edu
monly results from degenerative changes such severe stenosis have restricted waling capacity
as facet oint hypertrophy spine osteoarthritis and exercise intolerance leading to decreased
intervertebral disc herniation spondylolisthesis f unction and uality of life [5,6,7,11,12]
and degenerative disc disease [4–6] LSS can also nterventions for LSS include surgical or con-
be classified based on anatomical location as servative approaches Studies have compared the
either central or lateral stenosis [3] effects of surgical versus nonsurgical manage-
arrowing of the spinal canal is associ- ment [2,9,12–15] ata indicate decompressive sur-
ated with low bac and leg pain numbness gery is effective for of patients with severe
and fatigue in the legs [7,8] This characteristic symptoms [9,11,13,15] lthough surgical treatments
pattern of symptoms associated with LSS is offer early symptomatic relief nonsurgical inter-
termed ‘neurogenic claudication’ Symptoms ventions are recommended owing to the riss
10.2217/IJR.10.29 © 2010 Future Medicine Ltd Int. J. Clin. Rheumatol. (2010) 5(4) 425–47 ISSN 1758-4272 425
SSppeecciiaall R ReeppooRRtt vveerrsesenn hhoouuddhhaarry y aattelel Therapeutic exercise manual therapy for persons with lumbar spinal stenosis Special RepoRt
associated with surgery in the elderly and may be epidural steroid inections prior to initiating
more cost-effective [1,15] n 1 the total annual physical therapy to reduce pain and enhance
inpatient cost for surgery in LSS was estimated subect participation in exercise [19,20]
to be approximately S1 billion [2,9] Therefore The aine Lumbar spine study is a large pro-
nonoperativeconservative interventions are used spective study examining long-term outcomes (
in the initial stages of LSS [1,5,9,10,16] and are a pre- and –1 years) of patients with LSS following
ferred alternative to surgery for mild-to-moderate surgical and nonsurgical interventions [14,21] t
symptoms of LSS [2,3,7,17,18] reported that patients treated nonsurgically have
onoperative treatments include a combina- decreased bac and leg pain lthough nonsur-
tion of medications bed-rest epidural steroid gical treatment proved to be relatively effective
inections physical therapy and therapeutic in this cohort there is no indication of the type
exercise (eg aerobic conditioning strengthen- of therapeutic exercise used lso the noncon-
ing stretching lumbar stabiliation exercises servative group included interventions other
spinal manipulation and mobiliation pos- than therapeutic exercise therefore the effect
ture and balance training physical modalities of therapeutic exercise alone on the improvement
braces traction and transcutaneous electrical of symptoms cannot be determined
nerve stimulation) lthough nonsurgical treat- This article examines the state of the evidence
ments cannot change the underlying pathology for therapeutic exercise and manual therapy
some patients report improvement in symptoms for the conservative management of LSS and
following treatment [18] describes the effects of these interventions on
Therapeutic exercise is commonly prescribed select outcomes few studies have compared
for patients with mild-to-moderate symptoms the efficacy of surgical and nonsurgical treat-
[15,17,18] xercises focus on modifying the posi- ments for LSS but the exclusive effects of
tion of the lumbar spine hence reducing spinal therapeutic exercise or manual therapy have not
cord narrowing and decreasing the chance of been addressed widely This systematic review
nerve compression s spinal extension causes a addresses the following guiding uestions
reduction in the intervertebral foraminal
¡hat is the effect of strengthening balance
cross-sectional area in the normal and degenera- postural and aerobic exercise on function dis-
tive spine [2,3,8] flexion-based lumbar stabilia- ability and impairments in patients with
tion exercises along with abdominal strengthen- degenerative LSS¢
ing are encouraged [7,12,15,17] erobic exercises
such as treadmill waling with bodyweight ¡hich mode of exercise is most beneficial to
support cycling and swimming are prescribed manage the symptoms of LSS¢
in patients with bac disorders [2,3,7,17,19–21]
ycling places the lumbar spine in a flexed Methods
position thereby increasing the intervertebral n efinition of terms
cross sectional area and is better tolerated than £or the purposes of this study therapeutic exer-
waling [17,22] cise is defined as exercises that include aerobic
anual therapy includes manipulation strengtheningstabiliation and flexibility exer-
and mobiliation of tight structures as well cises and endurance training as well as manual
as spinal stabiliation to restore normal therapy including mobiliation and manipula-
function [8] ormal spinal mobility can be tion and postural exercises anual therapy
attained by stretching the tight structures such includes manipulation and mobiliation of the
as hip flexors adductors and myofascial tissues tight structures and stabiliation of the spine to
[8,10,21] ostural exercises encourage lumbar restore normal function [8]
flexion and flatten the lordotic curve [9,10,16]
ua therapy or pool exercises are also rec- n Search strategy
ommended because the physical properties ¡e searched medical literature published
of water minimie stress on the spine [3,10] between anuary 1 and arch
n a study examining the natural history of Specifically we searched edline 1 to arch
untreated patients with LSS (mean age umulative ndex to ursing llied
years) ohnsson et al. noted that symptoms ¤ealth Literature (¤L) 1 to £ebruary
remained constant in of patients and wee ¥ ¦eviews ochrane atabase
worsened in 1 of patients [23] Thus exer- of Systematic ¦eview th §uarter
cise and physical therapy are recommended to ¥ ¦eviews-merican ollege of hysician
manage symptoms Simotas et al. suggest using ournal lub () 11 to anuary£ebruary
426 Int. J. Clin. Rheumatol. (2010) 5(4) future science group
SSppeecciiaall R ReeppooRRttvveerrsesenn hhoouuddhhaarry y aattelelTherapeutic exercise manual therapy for persons with lumbar spinal stenosisSpecial RepoRt
LUMBAR
Spinal stenosis
Lumbar spinal stenosis (3204)
Exlue stuies
on English
English (3043)
Lumbar spinal stenosis A lo ba pain A egeneratie A exerise A ph sial therap A ph siotherap
A aerobi exerise A strengthening exerise A mobiliation exerise A manipulation A manual therap
A lexibilit exerise A stabiliation exerise A therapeuti exerise ()
Exlue 2 stuies
Use surgial interentions onl Reiee title an abstrats
Use onl meiations or nonsurgial (34) Exlue 322 stuies
treatment as the primar interention Use nonsurgial treatment other than
ph sial therap
Use braes orthosis eletrotherap as main
aspet o onseratie treatment along ith
Exlue stuies h sial therap treatment along ith other
i not use manual therap or therapeuti meial treatments
exerise as the primar interention Steroi inetions along ith
3 LSS not primar ause o LB Reiee stuies (24)
2 mixe LB an LSS patients
4 use other therapies or other therapies
plus exerise nlue stuies ()
igure rticle selection process
CLBP: Chronic low back pain LBP: Low back pain L: Lumbar pinal tenoi P: Phical therap.
atabase of bstracts of ¦eviews of Subects had evidence of lumbar LSS on ¦
ffect (¦) 1st §uarter ubed to or radiograph or a diagnosis of LSS by an
ecember and hysical therapy vidence orthopedic specialist or physician
atabase (ro) n each database we used the
search term spinal stenosis together with combi- ain disability and function were assessed
nations of the following terms lumbar, lumbar vailable in nglish
spine, degenerative, physiotherapy, physical ther-
apy, therapeutic exercise, aerobic exercise, endur- ny type of study design was accepted
ance exercise, strengthening exercise and flexibility Studies were excluded if they included surgical
exercise ¡e extended our search by reviewing the orthopedic support devices or pharmacological
bibliographies of relevant publications interventions compared physical modalities
(eg heat electrical stimulation and traction)
n Study selection to exercise and or manual therapy assessed post-
apers that met the following criteria were included operative exercise or merely described the natural
history of LSS
valuated therapeutic exercise or manual Three reviewers (¨ S and ) inde-
therapy pendently read and scored the studies using a
standardied data abstraction form based on
ale andor female subects aged between
to years the acermid’s uality rating scale (devel-
oped by oy acermid in ) [24] and the
Subects had a history of low bac pain with Sacett’s level of evidence [102,103] nformation
or without radiating symptoms for 1 month extracted from the studies included design set-
or longer ting sample demographics intervention and
future science group www.futuremedicine.com 427
SSppeecciiaall R ReeppooRRtt vveerrsesenn hhoouuddhhaarry y aattelel Therapeutic exercise manual therapy for persons with lumbar spinal stenosis Special RepoRt
able studies originall included based on revie o abstract but results
excluded rom the revie ater more detailed revie o the stud The study selection process is summaried in
stud ear reason or exclusion re Figure 1 The search strategy identified
articles with the term LSS ©f these were
nel et al. (1 ) urer eru coneratie interention [36] potentially relevant studies assessing the impact
reburer et al. (200)
ied dianoe and ue of inection [37] of therapeutic exercise and manual therapy ¡e
eren et al. (200)
ied L and CLBP patient [38] reviewed all titles and abstracts and subse-
urri et al. (1 ) urer and coneratie interention [39] uently excluded studies that did not meet
munden et al. (2000) urer eru coneratie interention [40] our inclusion criteria or were duplicates ¡e
thiiraham et al. (200) urer eru coneratie [41] thoroughly reviewed the remaining studies
adokoro et al. (200)
ied coneratie interention [42] fter reviewing the full text of articles seven
tla et al. (200)
ied coneratie interention [21] studies met the inclusion criteria [17,25–30] ©f
tla et al. (2000)
ied coneratie interention [14] these seven two studies used radiology reports
offe et al. (2002) inle LBP not L patient [43] plus physician diagnosis to confirm LSS [17,25]
Critchle et al. (200) CLBP patient [44] total of 1 studies were excluded for the fol-
Badke et al. (200) LBP patient and ued cold or heat interention [45] lowing reasons the studies used surgery medi-
imota (2001) eiew – mied coneratie interention [46] cations andor steroid inections in the design
included assessed the impact of modalities as the primary
urwit et al. (2002) ther coneratie interention included [47] intervention did not recruit patients with LSS
habat et al. (200) ther coneratie interention included [48] or recruited patients with LSS and chronic low
Cleland et al. (200) Protocol – CLBP patient [49] bac pain but did not report results separately
culco et al. (2001)
ied L and LBP patient [50] for persons with LSS The excluded studies are
CLBP: Chronic low back pain; LBP: Low back pain; LSS: Lumbar spinal stenosis. listed in Table 1
control program features data sources analysis n Study characteristics
and results iscord between scoring aspects of The general characteristics of the selected stud-
the studies was resolved by further review of ies are summaried in Tables 2 & 3 lthough our
the studies and discussion among the review- database search included articles published since
ers ll the reviewers were trained in the use of 1 the publication dates of all included studies
these scales The uality of the intervention and were between the years 1 and The meth-
study design was evaluated and graded using the odological uality scores and the level of evidence
acermid Scale this scale consists of items of the included studies are provided in Table 4
and seven domains and is designed specifically ©f seven included studies two were random-
for all study types [24] The domains include ied controlled trials [17,25] one was a prospective
study description study design subect selec- cohort [30] and four were case seriesreports [26–29]
tion intervention outcomes ana lysis and study Study characteristics such as location setting and
recommendations ach item was scored on a sample sie varied ean ages of subects ranged
scale of 1 or yielding a maximum score of from to years
The higher the score the better the method- wide variety of therapeutic exercise inter-
ological uality of the study study score of ventions were assessed in the seven studies ost
and above indicates high-uality studies scores studies evaluated the effects of mixed interven-
of – were classified as moderate-level stud- tions such as aerobic exercise in combination
ies and the studies that were scored below with flexibility exercise and manipulationman-
were categoried as low-level studies -point ual techniues [17,25–30] ©ne study assessed the
grading scale developed by Sacett was also used impact of two different aerobic exercise interven-
to evaluate the e vidence of the studies tions [25] one study provided an aerobic inter-
¡e inspected the results of each study to vention in water [29] three studies incorporated
determine whether the intervention improved manual therapy with exercise [17,26,30] and three
outcomes nfortunately outcome measures and studies assessed strengthening exercises as the pri-
study designs were too heterogeneous to com- mary mode of intervention [26–28] The studies
bine studies in a meta-ana lysis Thus percentage were divided into three groups comparison of
change in primary outcomes (pain function and aerobic interventions mixed interventions and
disability) were calculated to allow for a crude individual interventions
comparison across studies ffect sies were Two of seven studies () were classi-
also calculated for outcomes from randomied fied as high-uality trials using acermid’s
c ontrolled trials using standard euations [101] scale (scores of ) and Sacett’s level-1b
428 Int. J. Clin. Rheumatol. (2010) 5(4) future science group
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