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Functional rehabilitation for degenerative lumbar spinal stenosis

  • Kaiser Permanente, Oakland, CA

Abstract and Figures

Nonoperative treatment for lumbar spinal stenosis must address anatomic and biomechanical factors. The entire functional kinetic chain and patient specific goals must be considered. In addition to passive modalities, manual therapy, and patient education, an active program consisting of flexion-based lumbar stabilization exercises, hip mobilization, proprioceptive training, and general conditioning should be initiated. More studies are needed to establish the benefit of a comprehensive, multifaceted treatment approach and to prove its clear benefit over the natural history of lumbar spinal stenosis.
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Functional rehabilitation for
degenerative lumbar spinal stenosis
Joshua D. Rittenberg, MD
*, Amy E. Ross, MPT
Center for Spine, Sports, and Occupational Rehabilitation,
Rehabilitation Institute of Chicago, 1030 North Clark Street,
Suite 500, Chicago, IL 60610, USA
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 ana-
tomic and biomechanical factors. In addition to passive modalities, manual
therapy, and patient education, an active program consisting of flexion-
based lumbar stabilization exercises, hip mobilization, proprioceptive train-
ing, 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 deteriora-
tion 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 surgi-
cal 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: (J.D. Rittenberg).
1047-9651/03/$ – see front matter Ó2003, Elsevier Science (USA). All rights reserved.
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Phys Med Rehabil Clin N Am
14 (2003) 111–120
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 main-
tain a kyphotic posture. After 4 years, almost half of the patients random-
ized 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 pro-
spective study comparing outcomes of surgery with nonsurgical manage-
ment. 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 fol-
low-up period. Again, conservative treatment was nonspecific. The most
common treatments were ‘‘back exercises,’’ bed rest, physical therapy, mani-
pulation, 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 nonsur-
gically 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. Phys-
ical 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 signifi-
cantly improved, compared with baseline. Walking scores improved or re-
mained 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 ini-
tially present with more severe symptoms are more likely to have surgery.
Nonoperative treatment options are abundant and can be categorized
into passive and active treatments (Tables 1 and 2). Bed rest is not recom-
mended, if possible, to avoid the deleterious effects of inactivity and decon-
ditioning in the older patient [7]. Relative rest and activity modification are
typically more appropriate, with education given to the patient to help avoid
112 J.D. Rittenberg, A.E. Ross / Phys Med Rehabil Clin N Am 14 (2003) 111–120
aggravating activities. In particular, patients should be instructed to sleep
with a pillow under their knees to promote a posterior pelvic tilt and
decreased dural tension. Pain relief has been demonstrated in a small num-
ber of patients with lumbar spinal stenosis wearing delordosing orthoses [8].
In the author’s experience, however, bracing is generally not necessary.
Pharmacologic treatment typically consists of standard analgesic medica-
tions. Nonsteroidal anti-inflammatory medications, acetaminophen, opioid
analgesics, and other medications should be prescribed with caution and
monitored closely to minimize complications. Calcitonin (in a randomized,
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.
Bed rest Acute phase (usually not necessary, limit <48 hr)
Epidural steroids Acute or subacute radicular pain
TENS (transcutaneous electrical nerve
Acute or chronic pain
Cryotherapy Acute pain
Hot packs Subacute or chronic pain
Orthoses (delordosing) Acute or chronic, limited role
Manual therapy
Acute or subacute phase, joint hypomobility
Biofeedback Chronic pain
Trigger point injection Myofascial pain
Acupuncture Acute or chronic pain
Table 2
Active treatments for degenerative lumbar spinal stenosis
Activity modification/relative rest
Flexion-based lumbar stabilization
Triplanar core strengthening
Hip mobilization and stretching
Neural mobilization
Functional stretching
Postural training
Activity of daily living training to minimize hyperextension postures and axial loading
Unweighted with harness on treadmill
Outdoor or treadmill
Stationary bike
Aquatic-based exercise
Proprioceptive training
Sport-specific training (golf, tennis, and so forth)
113J.D. Rittenberg, A.E. Ross / Phys Med Rehabil Clin N Am 14 (2003) 111–120
double-blind, placebo-controlled study) was shown to provide pain relief and
improve function, most likely by its action on central opioid receptors [9].
Diagnostic blocks with local anesthetic may be useful to help confirm a
pain generator. However, the significant rate of false-positive responses with
single blocks must be taken into consideration. The double-block paradigm,
in which responses to successive injections with long-acting and short-acting
agents are measured, is helpful to improve specificity.
The zygapophysial joint has been estimated to be a primary pain gener-
ator in 15% of chronic low-back pain patients [10]. Hypertrophy of the
z-joints develops as part of the the degenerative cascade [11] and leads to
an increase in axial weightbearing from 18% [12] in the young spine to as
high as 47% [13]. Therefore, the z-joint should be considered in the older
patient with axial pain.
Medial branch blocks or intra-articular z-joint blocks with local anes-
thetic are used to confirm the diagnosis of zygapophysial joint-mediated
pain obtained with the history and physical examination. Intra-articular
injection with corticosteroid and local anesthetic may be used therapeuti-
cally. In carefully selected patients confirmed to have z-joint–mediated pain,
medial branch neurotomy may provide prolonged relief of symptoms [14].
Intra-articular sacroiliac joint injection is considered the gold standard for
the diagnosis of sacroiliac joint-mediated pain; however, it should be
remembered also that the posterior ligamentous structures of the sacroiliac
joint are potential pain generators. Provocative testing with discography has
the potential to diagnose intrinsic disc-mediated pain; however, it remains
Therapeutic injections with corticosteroid may be useful to reduce pain,
improve tolerance for rehabilitation, and thereby facilitate a patient’s timely
return to normal function. The basis for using epidural steroids for radicular
pain caused by disc-mediated pathology has been well established [15]. In
degenerative lumbar spinal stenosis, it is less clear. Proposed mechanisms
of action include reduction of inflammation and edema around nerve roots,
alteration of local blood flow, and direct nociceptive effects.
Epidural steroid injections should be performed for acute exacerbations
in symptoms or if the patient has failed to respond to conservative treatment
over a period of several weeks or more after initial presentation. A thorough
description of the role of epidural steroids in lumbar spinal stenosis is pre-
sented elsewhere in this issue.
In the author’s opinion, physical therapy is the most effective treat-
ment for degenerative lumbar spinal stenosis, and there are various
approaches, several of which are presented in this volume. Skilled manual
therapy can greatly enhance a functional rehabilitation program. Objec-
tive outcome measurement is an important element in documenting treat-
ment efficacy. The following section describes a proposed strategy for
functionally oriented physical therapy specific to the patient with lumbar
spinal stenosis.
114 J.D. Rittenberg, A.E. Ross / Phys Med Rehabil Clin N Am 14 (2003) 111–120
Functional exercises for the patient with spinal stenosis
One of the challenges of a successful rehabilitation program is designing
an exercise program that is functional, fun, and easy to comply with on a
daily basis. It should address the specific needs of each patient.
A therapeutic exercise program for the patient with spinal stenosis should
include flexion-based lumbar stabilization exercises, a flexibility program
aimed at improving hip mobility, strengthening of the core muscles
(abdominals, gluteals, etc.), and cardiovascular exercise.
When we think of lumbar stabilization exercises, most envision exercises
performed lying supine on a plinth or swiss ball. Isolated exercise in non-func-
tional positions may be a good starting point in some patients. However,
because most patients spend their days standing, walking, sitting, working,
or playing, a rehabilitation program should ultimately strive to mimic re-
quired functional activities [22]. Patients must be trained to move in the sag-
ittal, coronal, and transverse planes. Exercises addressing all cardinal planes
of motion will more closely prepare the patient for life’s daily activities and are
the basis for a functional rehabilitation program [23].
Basic flexion exercises may be done in supine by actively bringing one or
both knees to the chest or in sitting by simply instructing the patient to bend
forward and reach toward their toes (Fig. 1).
Standing flexion exercises can be used to alleviate neurogenic claudication
or radicular symptoms brought on by walking. The patient rests one foot on
a chair or park bench, then leans forward as though tying his/her shoes until
symptoms disappear or are reduced (Fig. 2).
Decreased hip range of motion—from decreased muscle length, hip cap-
sular tightness, or degenerative joint disease—is commonly present. Tripla-
nar (multidirectional) functional stretches are an effective method to
increase hip mobility, along with improving range of motion further down
the kinetic chain of the lower extremities. A multiplanar lunge program,
as described by Gray [23] is a useful tool to improve flexibility, while simul-
taneously increasing strength and proprioception. Hip flexor and hamstring
Fig. 1. Seated forward bending.
115J.D. Rittenberg, A.E. Ross / Phys Med Rehabil Clin N Am 14 (2003) 111–120
muscle tightness may contribute to lordotic stresses on the lumbar spine and
should be addressed with a stretching program (Fig. 3).
Manual therapy can be performed to help address capsular tightness of
the hip. A basic passive accessory joint glide with the assistance of a mobi-
lization belt is pictured in Fig. 4. The half-prone rectus femoris stretch can
be used to mobilize the anterior hip capsule with passive hip internal or
external rotation. The pelvis and lumbar spine are placed in a neutral or
flexed position to promote opening of the lateral or central canal. Pillows
Fig. 3. (A–C) Triplanar lunges. (D) Rotational hamstring stretch. (E) Rotational hip flexor
Fig. 2. Standing unilateral forward bending.
116 J.D. Rittenberg, A.E. Ross / Phys Med Rehabil Clin N Am 14 (2003) 111–120
may be placed under the pelvis to increase lumbar flexion if the mobilization
position produces symptoms (see Fig. 4).
The benefits of a core strengthening program in decreasing the occur-
rence of low back pain has been demonstrated in an athletic population
[24]. A standing core strengthening exercise program should be initiated
early. Examples of standing core exercises are pictured in Fig. 5. Transverse
plane exercises may be tolerated early because of minimal axial loading and
the presence of only one degree of rotation occurring at each vertebral seg-
ment [16]. Bilateral hip internal rotation (toeing-in) will help to emphasize
rotational movement at the hips. Holding a medicine ball can help to stim-
ulate abdominal muscle activity [17,18].
The transverse abdominis should be trained with a ‘‘hollowing con-
traction,’’ as described by McGill [16,18]. In addition to transverse plane
Fig. 3 (continued )
Fig. 4. (A) Standing anterior hip glide with belt. (B) Prone rectus femoris stretch with anterior
hip glide.
117J.D. Rittenberg, A.E. Ross / Phys Med Rehabil Clin N Am 14 (2003) 111–120
Fig. 5. (A, B) Transverse core. (C, D) Sagittal core. (E) Frontal core. (F, G) Single leg stance
118 J.D. Rittenberg, A.E. Ross / Phys Med Rehabil Clin N Am 14 (2003) 111–120
movement, frontal and sagittal core exercises may be introduced in a pain-
free range and progressed accordingly. Exercises performed on a single leg
will help to enhance proprioception.
Endurance, the ability to maintain core muscular performance over a
period of time, has been found to have a much greater protective role
against low back injury than strength alone [17]. General conditioning must
be integrated into any comprehensive rehabilitation program. A cardiovas-
cular training effect may be difficult to achieve, because the primary com-
plaint of most patients is pain with ambulation. Patients should be
encouraged to try a stationary bike or an inclined treadmill, both of which
place the lumbar spine in a more optimal flexed position. Unweighted tread-
mill walking has been described by Fritz et al [19–21]. Walking in a pool is
another alternative.
Nonoperative treatment for lumbar spinal stenosis must address anatomic
and biomechanical factors. The entire functional kinetic chain and patient
specific goals must be considered. In addition to passive modalities, manual
therapy, and patient education, an active program consisting of flexion-based
lumbar stabilization exercises, hip mobilization, proprioceptive training, and
general conditioning should be initiated. More studies are needed to establish
the benefit of a comprehensive, multifaceted treatment approach and to prove
its clear benefit over the natural history of lumbar spinal stenosis.
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... The ability to move the hip, especially into extension, without concomitant lumbar extension is frequently necessary for pain free ambulation in the patient with LSS. In addition to manual therapy at the hip, the patient can perform hip flexor stretching while maintaining a Posterior Pelvic Tilt (PPT) (Fritz et al., 1997a;Rademeyer, 2003;Rittenberg and Ross, 2003;Whitman et al., 2003;Yuan and Albert, 2004;Vo et al., 2005). Other muscles around the hip, such as the hamstrings, rectus femoris, piriformis and tensor fascia latae can become shortened and the patient may respond positively to manual and selfstretching of these muscles. ...
... Other muscles around the hip, such as the hamstrings, rectus femoris, piriformis and tensor fascia latae can become shortened and the patient may respond positively to manual and selfstretching of these muscles. Weakness in the hip extensors and abductors complete the picture of typical muscle imbalances in the hip region of the patient with LSS, and should be addressed through a progressive resistive exercise program that is vigorous enough to affect strength change (Fritz et al., 1997a;Rittenberg and Ross, 2003). ...
... Therefore, most patients with LSS are appropriate for some level of core strengthening, especially those with impaired strength or motor control of the abdominal and lumbar musculature. It is expected that most core strengthening will be done with a flexion bias and will attempt to allow the patient to control pelvic position and motion to minimize symptoms while standing and walking (Fritz et al., 1997a;Simotas et al., 2000;Rademeyer, 2003;Rittenberg and Ross, 2003;Whitman et al., 2003;Yuan and Albert, 2004;Vo et al., 2005). Specifically, patients can be taught to temporarily use a PPT to relieve symptoms, or even to maintain a slight PPT to lessen or avoid symptoms entirely while standing and/or walking. ...
Low back pain and lumbar spinal stenosis (LSS) is an extensive problem in the elderly presenting with pain, disability, fall risk and depression. The incidence of LSS is projected to continue to grow as the population ages. In light of the risks, costs and lack of long-term results associated with surgery, and the positive outcomes in studies utilizing physical therapy interventions for the LSS patient, a non-invasive approach is recommended as a first line of intervention. This Masterclass presents an overview of LSS in terms of clinical examination, diagnosis, and intervention. A focused management approach to the patient with LSS is put forward that emphasizes a defined four-fold approach of patient education, manual physical therapy, mobility and strengthening exercises, and aerobic conditioning.
... Electrical stimulation is an effective and noninvasive method to break pain cycles. It has no known adverse effects, nor does it have irreversible effects on the human body [4,5]. ...
... Oral analgesics, bed rest, epidural injections, cryotherapy, electrical stimulation therapies, hot pack, manual therapies, biofeedback therapies, and trigger point injections are used for treating pain in degenerative LSS [5]. In this study, instead of classical electrotherapy, a FREMS technique that can produce a wave with a stable wave length (40-75 msec) and frequency (50-100 Hz) using the Phyback device was used. ...
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A randomized prospective study. To assess postoperative analgesic requirements after Phyback therapy preemptively in patients undergoing lumbar stabilization. Frequency Rhythmic Electrical Modulation System is the latest method of preemptive analgesia. Forty patients were divided into two groups. Patients who were to receive tramadol were allocated to "group A" and those who were to receive Phyback therapy were allocated to "group B." In patients with a visual analog scale score of >4 or a verbal rating scale score of >2, 75 mg of diclofenac IM was administered. The amount of analgesic consumption, the bolus demand dosage, and the number of bolus doses administered were recorded. Patient satisfaction was evaluated using the visual analog patient satisfaction scale. There were statistically significant differences in the visual analog scale and verbal rating scale scores in the fourth, sixth, 12th, and 24th hours. The number of bolus infusions was significantly lower in group B. The amount of analgesic consumption was higher in group A. There was a significant difference between the two groups in the number of bolus infusions and the total amount of analgesic consumption, and this comparison showed better results for group B. Application of Phyback therapy reduced postoperative opioid consumption and analgesic demand, and it contributed to reducing patients' level of pain and increased patient satisfaction. Moreover, the application of preemptive Phyback therapy contributed to reducing preoperative pain which may have reduced patient anxiety.
... When patients with NC symptoms are referred for physiotherapy treatment, they are commonly prescribed home exercise programmes to include spinal flexion and stabilisation exercises in addition to aerobic fitness exercises [3]. These exercise choices reflect recommended programmes which are based on the theoretical benefits of modifying posture to reduce the lordotic curve and minimise the extension forces through the lumbar spine and thereby optimising the available space for the spinal nerves [4][5][6][7]. There is, however, little evidence from clinical trials regarding effectiveness. ...
... Participants randomised to the active treatment group received the same standardised advice and education as the control group and in addition, they were prescribed a condition-specific home exercise programme to be carried out twice daily at home over a six week period. The set of exercises was selected to reflect a combination of current physiotherapy practice as evidenced by recent practitioner survey data [3,12] and recommendations in the available literature [4][5][6][7]. The constituent exercises focussed on 1) flattening of the lumbar lordosis 2) lumbar flexion 3) abdominal muscle activation 4) trunk muscle strengthening and 5) aerobic fitness (see Appendix S2). ...
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Objective: To compare the effectiveness of a physiotherapy programme with a control treatment of advice and education in patients with neurogenic claudication symptoms. Design: Pragmatic randomised controlled clinical trial. Setting: Primary care-based musculoskeletal service. Patients: Adults aged 50 or over with neurogenic claudication symptoms causing limitation of walking. Interventions: Condition-specific home exercises combined with advice and education, or advice and education alone. Main outcome measures: The primary outcome was the difference in improvement of symptom severity scores on the Swiss Spinal Stenosis Scale at eight weeks. Secondary outcomes included measures of physical function, pain and general well-being at eight weeks and 12 months. Results: There was no significant difference between groups in the Swiss Spinal Stenosis symptom severity scale at eight weeks (t = 0.47, p = 0.643): mean change (SD) control group -0.18 (0.47), treatment group -0.10 (0.66), difference (95% CI) 0.08 (-0.19, 0.35); baseline-adjusted difference 0.06 (-0.19, 0.31)]. An unplanned subgroup analysis suggested that for patients with the top 25% of baseline symptom severity scores, the physiotherapy exercise programme resulted in an improvement in the primary outcome, and modest but consistently better secondary outcomes at both time-points compared to the control group. The effectiveness in different subgroups requires further direct evaluation. Conclusions: In the treatment of patients with neurogenic claudication symptoms, a physiotherapist-prescribed home exercise programme is no more effective than advice and education. Ethical approval: The study was approved by Leeds Central Ethics Committee and informed consent was given by all participating patients. Copyright: The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors, a worldwide licence to the Publishers and its licensees in perpetuity, in all forms, formats and media (whether known now or created in the future), to i) publish, reproduce, distribute, display and store the Contribution, ii) translate the Contribution into other languages, create adaptations, reprints, include within collections and create summaries, extracts and/or, abstracts of the Contribution, iii) create any other derivative work(s) based on the Contribution, iv) to exploit all subsidiary rights in the Contribution, v) the inclusion of electronic links from the Contribution to third party material where-ever it may be located; and, vi) licence any third party to do any or all of the above. Trial registration: ISRCTN 78288224 - doi10.1186/ISRCTN35836727; UKCRN 4814.
... Analgesics, NSAIDs, opioids and muscle relaxants are used but this poses a threat to the older population. A comprehensive rehabilitation program of manual therapy , stretching and strengthening exercises for the lumbar spine and hip region have been advocated to LSS patients (6). LSS accounts for 30% of all epidural injections; however the results for epidural corticosteroids have shown limited benefit (2). ...
... In general, a trial of conservative, nonsurgical treatment precedes surgical treatment. Nonsurgical treatments used for LSS include physical therapy [5][6][7] ; analgesic, anti-inflammatory and anticonvulsant medications [8,9] ; and epidural steroid injections. [10][11][12] Many patients suffer from the symptoms even while using all of the above mentioned treatments repeatedly. ...
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Background: Currently, there is some clinical evidence supporting the use of acupuncture in alleviating pain and dysfunction in patients with lumbar spinal stenosis (LSS). However, the question of whether acupuncture could be efficacious for ageing patients remains unanswered. We designed a randomized controlled study to evaluate the safety and feasibility of acupuncture for participants with symptomatic LSS. Methods: This study is a randomized, single-blind, noninferiority trial. This clinical trial was approved by the Linyi Cancer Hospital. We received informed consent from all patients before surgery. In preparing this report, we adhered to the Consolidated Standards of Reporting Trials guidelines. We randomized consented study participants on a 1:1 ratio to one of two study groups (acupuncture and control groups) using a computer-generated list of random numbers in varying block sizes. Three outcome measures were selected to evaluate the effectiveness and safety of the treatment: visual analogue score and Oswestry disability index, and complicatins. A P < .05 was regarded as statistically significant. Results: The hypothesis was that the acupuncture group would achieve acceptable clinical outcomes as compared to the control group in LSS. Trial registration: This study protocol was registered in Research Registry (researchregistry5744).
Study design: Retrospective cohort study. Objective: To assess readmission rates and risk factors for 30-day and 90-day readmission after elective lumbar decompression at a single institution. Summary of background data: Hospital readmission is an undesirable aspect of interventional treatment. Studies evaluating readmissions after elective lumbar decompression typically analyze national databases, and therefore have several drawbacks inherent to their macroscopic nature that limit their clinical utility. Methods: Patients undergoing primary one- to four-level lumbar decompression surgery were retrospectively identified. Demographic, surgical, and readmission data within "30-days" (0-30 days) and "90-days" (31-90 days) postoperatively were extracted from electronic medical records. Patients were categorized into four groups: (1) no readmission, (2) readmission during the 30-day or 90-day postoperative period, (3) complication related to surgery, and (4) Emergency Department (ED)/Observational (OBs)/Urgent (UC) care. Results: A total of 2635 patients were included. Seventy-six (2.9%) were readmitted at some point within the 30- (2.3%) or 90-day (0.3%) postoperative periods. Patients in the pooled readmitted group were older (63.1 yr, P < 0.001), had a higher American Society of Anesthesiologists (ASA) grade (31.2% with ASA of 3, P = 0.03), and more often had liver disease (8.1%, P = 0.004) or rheumatoid arthritis (12.0%, P = 0.02) than other cohorts. A greater proportion of 90-day readmissions and complications had surgical-related diagnoses or a diagnosis of recurrent disc herniation than 30-day readmissions and complications (66.7% vs. 44.5%, P = 0.04 and 33.3% vs. 5.5%, P < 0.001, respectively). Age (Odds ratio [OR]: 1.02, P = 0.01), current smoking status (OR: 2.38, P < 0.001), longer length of stay (OR: 1.14, P < 0.001), and a history of renal failure (OR: 2.59, P = 0.03) were independently associated with readmission or complication. Conclusion: Increased age, current smoking status, hospital length of stay, and a history of renal failure were found to be significant independent predictors of inpatient readmission or complication after lumbar decompression.
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Lumbar spinal stenosis (LSS) is a major cause of debilitation in adults, and acupuncture is a recommended treatment. We assessed the effect of acupuncture on pain and quality of life in patients with LSS. Twenty-four patients with LSS who had symptoms of neurogenic claudication were randomly selected and underwent 10 sessions of acupuncture. Pain and quality of life were evaluated before and immediately after the intervention and six weeks later by using the Visual Analogue Scale (VAS) and SF-36. Paired t-tests and repeated measure tests were used to analyze the data. p < 0.05 was considered significant. The mean age of the patients was 48.2 ± 10.8 years. The mean VAS scores before and immediately after intervention, 7.9±1.3 and 4.3±2.1, were statistically different (p < 0.001), as was the mean score, 3.08±2.3, six weeks later (p = 0.01). Five aspects of the SF-36 score were associated with significant improvements immediately after acupuncture (p < 0.05). Comparisons of the scores before and six weeks after intervention showed significant improvements in emotions, vitality, general health, bodily pain, and physical well-being. Therefore, acupuncture had a significant short-term effect on pain and quality of life in patients with LSS.
Purpose: The purpose of this case study is to describe the management of a female patient with chronic left low back pain and sacroiliac joint pain (LBP/SIJP) using unique unilateral exercises developed by the Postural Restoration Institute (PRI) to address pelvic asymmetry and left hip capsule restriction, which is consistent with a Right Handed and Left Anterior Interior Chain pattern of postural asymmetry. Client Description: The client was 65-year-old woman with a 10-month history of constant left LBP/SIJP and leg pain. Intervention: The patient was seen six times to correct pelvic position/posture and left hip posterior capsule restriction via (1) muscle activation (left hamstrings, adductor magnus, and anterior gluteus medius) and (2) left hip adduction to lengthen the left posterior capsule/ischiofemoral ligament. Stabilization exercises included bilateral hamstrings, gluteus maximus, adductors, and abdominals to maintain pelvic position/posture. Measures and Outcome: Left Ober's test (initially positive) was negative at discharge. Pain as measured on the Numeric Pain Rating Scale (initially 1/10 at best and 8/10 at worst) was 0/10–0/10 at discharge. Oswestry Disability Index score (initially 20%) was 0% at discharge. The patient no longer had numbness in her left leg, and sexual intercourse had become pain free. Implications: Interventions to restore and maintain the optimal position of pelvis and hip (femoral head in the acetabulum) may be beneficial for treating patients with chronic LBP/SIJP. The patient's pain was eliminated 13 days after she first performed three exercises to reposition the pelvis and restore left posterior hip capsule extensibility and internal rotation.
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Functional imaging, which provides information of how tissues function rather than structural information, is well established in neuro- and cardiac imaging. Many musculoskeletal structures, such as ligaments, fascia and mineralized bone, have by definition a mainly structural role and clearly don't have the same functional capacity as the brain, heart, liver or kidney. The main functionally responsive musculoskeletal tissues are the bone marrow, muscle and nerve and, as such, magnetic resonance (MR) functional imaging has primarily addressed these areas. Proton or phosphorus spectroscopy, other fat quantification techniques, perfusion imaging, BOLD imaging, diffusion and diffusion tensor imaging (DTI) are the main functional techniques applied. The application of these techniques in the musculoskeletal system has mainly been research orientated where they have already greatly enhanced our understanding of marrow physiology, muscle physiology and neural function. Going forwards, they will have a greater clinical impact helping to bridge the disconnect often seen between structural appearances and clinical symptoms, allowing a greater understanding of disease processes and earlier recognition of disease, improving prognostic prediction and optimizing the monitoring of treatment effect.
Combining orthopedic surgery with biomechanical engineering, this reference and teaching text reviews and analyzes the clinical and scientific data on the mechanics of the human spine. This edition adds new material on vibration (i.e. road driving) and its effect on the spine; anatomy and kinematics
The purpose of this case report is to describe a physical therapy approach to the evaluation, treatment, and outcome assessment of two patients diagnosed with lumbar spinal stenosis. Evaluation consisted of assessment of neurological status, spinal range of motion, and lower-extremity muscle force production and flexibility; administration of the Modified Oswestry Low Back Pain Questionnaire and the Roland-Morris Disability Questionnaire; assessment of pain using a visual analog scale; and performance of a two-stage treadmill test. The treatment program was designed to treat the impairments, and harness-supported treadmill ambulation (unloading) was used to address the limitation in ambulation identified by the treadmill test. Outcome assessment included measuring changes in the status of the impairments and assessing responses to the disability questionnaires and performance of the two-stage treadmill test. Improvements were noted on all outcome measures for both patients after 6 weeks of physical therapy and at the 4-week follow-up examination. Larger case series and randomized trials with long-term follow-ups are recommended.
The course of 32 untreated patients with spinal stenosis was studied. The mean patient age was 60 years, and the mean period of observation was 49 months. About 75% of the patients had spinal claudication. In the follow-up survey, the same number of patients had claudication, but the symptoms were milder. In estimation by visual analog scale, symptoms in 70% of the cases were unchanged, 15% showed improvement, and 15% worsened. No proof of severe deterioration was found after four years, and expectant observation may be an alternative to surgical treatment.
Study Design. A cohort of 100 patients with symptomatic lumbar spinal stenosis, characterized in a previous article, were given surgical or conservative treatment and followed for 10 years. Objectives. To identify the short- and long-term results after surgical and conservative treatment, and to determine whether clinical or radiologic predictors for the treatment result can be defined. Summary of Background Data. Surgical decompression has been considered the rational treatment. However, clinical experience indicates that many patients do well with conservative treatment. Methods. In this study, 19 patients with severe symptoms were selected for surgical treatment and 50 patients with moderate symptoms for conservative treatment, whereas 31 patients were randomized between the conservative (n = 18) and surgical (n = 13) treatment groups. Pain was decisive for the choice of treatment group. All patients were observed for 10 years by clinical evaluation and questionnaires. The results, evaluated by patient and physician, were rated as excellent, fair, unchanged, or worse. Results. After a period of 3 months,relief of pain had occurred in most patients. Some had relief earlier, whereas for others it took 1 year. After a period of 4 years, excellent or fair results were found in half of the patients selected for conservative treatment, and in four fifths of the patients selected for surgery. Patients with an unsatisfactory result from conservative treatment were offered delayed surgery after 3 to 27 months (median, 3.5 months). The treatment result of delayed surgery was essentially similar to that of the initial group. The treatment result for the patients randomized for surgical treatment was considerably better than for the patients randomized for conservative treatment. Clinically significant deterioration of symptoms during the final 6 years of the follow-up period was not observed. Patients with multilevel afflictions, surgically treated or not, did not have a poorer outcome than those with single-level afflictions. Clinical or radiologic predictors for the final outcome were not found. There were no dropouts, except for 14 deaths. Conclusions. The outcome was most favorable for surgical treatment. However, an initial conservative approach seems advisable for many patients because those with an unsatisfactory result can be treated surgically later with a good outcome.