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  • Physical Therapy's Effects Equal to Surgery for Spinal Stenosis Symptoms

    Physical therapy for spinal stenosis is as effective as surgery and should be fully considered as a first-choice treatment option, according to a new study that is the first to directly compare a single, evidence-based physical therapy regimen with decompression surgery among patients who agreed to be randomly assigned to either approach.

    The study focused on self-reported physical function among 169 participants diagnosed with lumbar spinal stenosis (LSS) after 2 years, but it also tracked function measurements along the way--at baseline, 10 weeks, 6 months, and 12 months. Researchers found that not only were 2-year effects similar for the 2 groups (87 who began with surgery and 82 who started with physical therapy), the increase in function followed similar trajectories from baseline on.

    Research was conducted between 2000 to 2007, and limited to patients 50 years and older who had no previous LSS surgery and had no additional conditions including dementia, vascular disease, metastatic cancer, or a recent history of heart attack.

    The study, which appears in the Annals of Internal Medicine (abstract only available for free), was led by Anthony Delitto, PT, PhD, FAPTA, with coauthors including Sara R. Pilva, PT, PhD, FAAOMP, OCS, Julie M. Fritz, PT, PhD, FAPTA, and Deborah A. Josbeno, PT, PhD, NCS. The findings have been reported in Reuters, the Pittsburgh Post-Gazette, Medpage Today, and other outlets.

    According to an editorial that accompanies the article (sample available for free), what makes this research important is that it restricted the nonsurgical approach to a single physical therapy regimen, and that participants—all of whom were prequalified for surgery—consented to a randomized treatment approach. Previous studies focused on surgical vs (mostly unspecified) "nonsurgical" approaches, and some allowed patients to self-select their treatment groups.

    Editorial author Jeffrey N. Katz, MD, MSc, writes that the current study more accurately represents practice, in which "clinicians and patients must choose between surgery and a particular nonoperative regimen, rather than an amalgam of regimens."

    Those particular nonoperative physical therapy treatments administered to the participants included "instruction on lumbar flexion exercises including posterior pelvic tilts and supine knee-to-chest and quadruped flexion exercises; general conditioning exercises, including stationary cycling or treadmill walking; lower extremity strengthening exercises … ; lower-extremity flexibility exercises deemed appropriate … ; and patient education to avoid postures involving hyperextension of the lumbar spine," authors write.

    Most participants in the physical therapy group attended at least 1 of the 12 prescribed sessions, with two-thirds participating in at least 6 sessions. However, over half (57%) of the physical therapy group elected to have surgery at some point within the 2-year study window. While authors write that this crossover presents "a challenge in interpretation," additional analysis revealed that even with this shift, "any differences between the groups were not significant."

    "From a clinical standpoint, Delitto and colleagues' trial suggests that a strategy of starting with an active, standardized [physical therapy] regimen results in similar outcomes to immediate decompressive surgery over the first several years," writes Katz in his editorial. "Taken together, these data suggest that patients with LSS should be offered a rigorous, standardized [physical therapy] regimen. Those who do not improve and ultimately consider surgery should be informed that the benefits are likely to diminish over time."

    Both the study's authors and Katz agree that health provider-patient communication is key.

    "Patients and health care providers should engage in shared decision-making conversations that include full disclosure of evidence involving surgical and nonsurgical treatments for LSS," authors write, with Katz's editorial arguing that "because long-term outcomes are similar for both treatments yet short-term risks may differ, patient preferences should weigh heavily in the decision of whether to have surgery for LSS."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Comments

    • Can't wait to read the study. Something to keep in mind for those LSS clients who are heavily considering surgical intervention.

      Posted by Steph on 4/8/2015 5:16 PM

    • I was most pleased to hear of the re-discovery of the posterior pelvic tilt. I have found it most helpful also, especially in the correction of the subluxation of the sacral axis. DonTigny, RL: Evaluation, manipulation and management of anterior dysfunction of the sacroiliac joint. The D.O. 14:215-226, 1973 DonTigny, RL: Letter to Editor: Sciatica and the Sacroiliac Joint. PT March 1977, p 143 DonTigny, RL: Dysfunction of the sacroiliac joint and its treatment. JOSPT 1:13-25, 1979 DonTigny, RL: Function and pathomechanics of the sacroiliac joint. Phys Ther 65:35-44, 1985 DonTigny, RL: Anterior dysfunction of the sacroiliac joint as a major factor in the etiology of idiopathic low back pain syndrome. Phys Ther 70:250-265, 1990 DonTigny, RL: Measuring PSIS movement. Clinical Management 10:43-44, 1990 DonTigny, RL: Sacroiliac joint as a major source of low back pain. Back Pain Monitor, April 1991, pp 55-58 DonTigny, RL: Sacroiliac joint dysfunction responds well to manual therapy. Back Pain Monitor, May 1991 DonTigny, RL: Mechanics and treatment of the sacroiliac joint. Journal of Manual & Manipulative Therapy, 1:3-12, 1993 DonTigny, RL: Function of the lumbosacroiliac complex as a self-compensating force couple with a variable, force-dependent transverse axis: A theoretical analysis. JMMT, 2:87-93, 1994 DonTigny, RL: The DonTigny low back pain management program. JMMT, 2:163-168, 1994 DonTigny, RL: Functional Biomechanics and Management of the Pathomechanics of the Sacroiliac Joint. In Dorman TA (ed): SPINE: State of the Art Reviews. Philadelphia, PA, Hanley & Belfus, Inc. 1995, Chpt 14 DonTigny, RL: Critical analysis of the sequence and extent of the result of the pathological release of self- bracing of the sacroiliac joint. Concurrently in JMMT 7:173-181, 1999 and J of Ortho Med (UK) 22:16-23,2000 DonTigny, RL: Critical analysis of the functional dynamics of the sacroiliac joints as they pertain to normal gait. J of Orthopaedic Medicine (UK) 27:3-10, 2005 . DonTigny, RL: Pathology of the sacroiliac joint, its effect on normal gait and its correction. J of Orthopaedic Medicine (UK) 27:61-69, 2005 DonTigny, RL: A detailed and critical biomechanical analysis of the sacroiliac joints and relevant kinesiology: the implications for lumbopelvic function and dysfunction. In Vleeming A, Mooney V, Stoeckart R (eds): Movement, Stability & Lumbopelvic Pain: Integration of research and therapy. Churchill Livingstone (Elsevier). Edinburgh, 2007, pp 265-279 DonTigny, RL: Sacroiliac 101; Form and Function; A biomechanical study. Journal of Prolotherapy 3:561-567, 2011 Available in full text from https://www.researchgate.net DonTigny, RL: Sacroiliac 201; Dysfunction and Management: A biomechanical solution. Journal of Prolotherapy 3:644-652, 2011 Available in full text from https://www.researchgate.net http://www.thelowback.com. How it works, why it hurts and how to fix it. http://www.greatseminarsonline.com Immediate relief of low back pain

      Posted by Richard DonTigny, PT on 4/8/2015 5:22 PM

    • I apologize, but I forgot to ask: What percentage of the general population has lumbar stenosis? What percentage of those treated whose pain was relieved still had any signs of lumbar stenosis? Timgren (Tingren J, Soinila S. Reversible pelvic asymmetry. J Manipulative Physiol Ther. 2006; 29(7):561-5.) described a reversible pelvic asymmetry corrected with treatment of the SI joint with posterior rotation. Did you notice any type of physical change in pelvic asymmetry with treatment of lumbar stenosis? Murakami (Murakami E. Tanaka Y, Aizawa T. Ishizuka M, Kokubun S. Effect of periarticular and intraarticular lidocaine injections for sacroiliac joint pain: Prospective comparative study. J of Orthopaedic Science.2007;May12(3):274-280.) reported 98% of back pain patients treated with periarticular injections of the sacroiliac joints were relieved. Were all cases of lumbar stenosis relieved with posterior pelvic rotation? I have measured changes in the position of the PSIS with correction of the sacral axis.(DonTigny, RL: Measuring PSIS movement. Clinical Management 10:43-44, 1990) and demonstrated reversible pelvic asymmetry on x-ray. (see previous) I have strong reservations about your hypothesis based on examination of about 8K (+ or - 1K) patients over 40 years)

      Posted by Richard L. DonTigny, PT on 4/12/2015 10:50 AM

    • I've always been glad to see the immense effect that physical therapy can have on patients. It's incredible to think that it can be used as an alternative to surgery, as you've pointed out by the study done here. Especially when it's a surgery that is so expensive and extensive.

      Posted by Lewis Remington on 4/16/2015 3:19 PM

    • It's really interesting how the study in the Annals of Internal Medicine that tested the effects of nonoperative physical therapy treatments showed that the short-term risks aren't as high compared with getting surgical treatment. There seems to be many benefits to getting physical therapy, other than the fact that it's a non-surgical approach to getting pain treatment. Even though the difference between the results between the group that had surgical treatment and the group that opted for physical therapy weren't that different, I think it goes to show that the fact that the benefits are more likely to diminish over time following surgery, opting for a non-surgical seems to be a better approach to treat pain.

      Posted by Deanna R. Jones on 5/5/2015 2:12 PM

    • Wow, that's incredible to me that physical therapy can do the same thing as spinal stenosis. Now that you mention it, it seems like physical therapy might be able to do that amount of good for me. I'm going to follow your tip about finding a therapist that knows exactly what they're doing.

      Posted by Mia Boyd on 5/13/2015 4:12 PM

    • As soon as I get the treatment sheet from my orthopaedic surgeon, I'll call you. Have been troubled with lumbar stenosis for 3.5 years and recently had a fall off a chair that exacerbated the works. I live a mile away.

      Posted by Charlie on 6/28/2015 11:54 AM

    • Non-surgical treatments are a great option when it comes to physical problems. I recently tore a ligament in my foot. After several doctors appointments, my parents and I decided not to have surgery. Instead, I went to physical therapy twice a week. It was the better option for me.

      Posted by Charlotte Eddington on 6/30/2015 12:08 PM

    • Have been diagnosed spinal stenosis and vertebrae slipped onto another vertebrae soon????? Opted out of surgery and have prescription for PT 27520 lots of nerve pain

      Posted by Doris lindsay on 9/11/2015 8:45 AM

    • I have had good luck with water aerobics 3x a week and Celebrex 2x a day for spinal stenosis and disc problems.

      Posted by Marty Holiman on 10/21/2015 2:09 PM

    • I was diagnosed with spinal stenosis in November. Sometimes the pain is nearly unbearable. I was dreading that I might need surgery to fix it, but it sounds like physical therapy can do exactly the same thing. I would much rather be healed through exercise than surgery. Thanks for sharing this article!

      Posted by Wendy Cartright on 1/7/2016 4:08 PM

    • I had no idea that physical therapy could replace surgery in some instances. I also think it is great that there are multiple ways to relieve back pain. Thank you for the great article about the effects of physical therapy!

      Posted by Wade Joel on 5/17/2016 5:57 PM

    • I had back surgery in 1990 and all has been well since that event. I re-injured my back three weeks ago and began to feel sciatica pain (7 out of 10) on right side (quads, hamstrings, hip area and down the right side of my shins) and across my belt line (both sides). When pain gets severe (9 out of 10) it enters my left quad and right groin area. MD put me on steroids and no improvement has been noted. He is now recommending PT. I am concerned that PT will delay surgery if needed and wonder if I can or should start PT while MRI, x-rays, etc. are being evaluated. The last time wasted/prolonged any surgical intervention/improvement to my sciatica pain for 6-8 weeks.

      Posted by fraank orlando on 5/24/2016 9:09 AM

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