The Influence of Exercise on Perceived Pain and Disability in Patients With Lumbar Spinal Stenosis: A Systematic Review of Randomized Controlled Trials

Multicentre investigation on the effect of decompressive surgery on Balance and physical ActiviTy Levels amongst patients with lumbar Spinal stenosis (B-ATLAS): protocol for a prospective cohort study

INTRODUCTION

Patients with lumbar spinal stenosis may have poor balance, decreased physical function and problems maintaining physical activity levels due to radiculopathy. Decompressive surgery is often indicated if conservative management fails to achieve a satisfactory clinical outcome. While surgical management has proven effective at treating radiculopathy, and patients report increased physical function postoperatively, objective measures of postural control and physical activity remain sparse. This study aims to investigate the effects of decompressive surgery on postural control and activity levels of elderly patients with lumbar spinal stenosis using objective measurements.

METHODS AND ANALYSIS

This is a 24-month, multicentre, prospective cohort study. Patients ≥65 years of age with MRI-verified symptomatic lumbar central canal stenosis will be recruited from two separate inclusion centres, and all participants will undergo decompressive surgery. Preoperative data are collected up to 3 months before surgery, with follow-up data collected at 3, 6, 12 and 24 months postoperatively. Postural control measurements are performed using the Wii Balance Board, mini Balance Evaluation Systems Test and Tandem test, and data concerning physical activity levels are collected using ActiGraph wGT3X-BT accelerometers. Patient-reported outcomes regarding quality-of-life and physical function are collected from the EuroQol-5D, 36-Item Short Form Health Survey and Zurich Claudication Questionnaire. Primary outcomes are the change in the sway area of centre of pressure and total activity counts per day from baseline to follow-up at 24 months. A sample size of 80 participants has been calculated.

ETHICS AND DISSEMINATION

The study has been approved by the Regional Ethics Committee of Region Zealand (ID EMN-2022-08110) and the Danish Data Protection Agency (ID REG-100-2022). Written informed consent will be required from all participants before enrolment. All results from the study, whether positive, negative or inconclusive, will be published in international peer-reviewed journals and presented at national and international scientific meetings. Study findings will be further disseminated through national patient associations.

TRIAL REGISTRATION NUMBERS

NCT06075862 and NCT06057428.

Beyond the Back: The Science of Lumbar Epidural Steroid Injections

Chronic low back pain causes significant morbidity and increases the global burden of disability. It has been shown to increase psychological, physical, and monetary load on the world population, In the USA alone, it causes an economic burden of 100 billion dollars/year [1]. Low back pain has been referred to as sciatica pain, lumbar radiculopathy, lumbar nerve entrapment, and neurogenic claudication. It is basically pain arising from the lower back region and radiating like a current to the lower limbs. The two prime causes of this low back pain with radiculopathy are intervertebral disc disease and facet joint arthritis [2]. The pathological aging changes happening in intervertebral disk cause disk herniation and other degenerative diseases such as lumbar canal stenosis and chronic instability. Lumbar radiculopathy or sciatica is mainly caused by compression of the nerve by protruded nucleus pulposus, which is the jelly like material of intervertebral disk [3,4]. Most of the patients with intervertebral disk disease and sciatica can be managed with conservative measures. These include anti-inflammatory analgesics, neuropathic medications such as pregabalin and gabapentin, regular exercises, and epidural steroid injections [5-7]. These measures help to prevent surgery. Significant compression of nerves with no relief from conservative measures qualifies to surgical intervention [2]. ESI, which has been used since 1952, is mainly used for lumbar and neck pain with radicular pain. It has shown excellent and quick results with minimal adverse effects. The ESI consists of injecting the steroids with or without local anesthetic medication in the epidural space to decrease the discogenic source of pain [8-11]. LSEI can be divided according to the needle route (interlaminar, transforaminal, or caudal). In this article, we will go over the various approaches for intralaminar (between the 2 adjacent laminae of lumbar vertebrae), transforaminal (through the intervertebral foramen), and caudal (through the sacral hiatus) epidural steroid injections [12-14].

Effectiveness of non-surgical treatment combined with supervised exercise for lumbar spinal stenosis: A systematic review and meta-analysis

BACKGROUND

The benefits of combining supervised exercise in the non-surgical treatment of lumbar spinal stenosis (LSS) is unclear.

OBJECTIVE

To compare the effectiveness of non-surgical treatments with and without supervised exercise for pain intensity, symptom severity, functional impairment/disability, walking distance, and quality of life (QOL) in LSS patients.

METHODS

Randomized controlled trials (RCTs) evaluating combinations of supervised exercises were searched using four electronic databases up to August 13, 2020. Meta-analysis was conducted for immediate and long-term results.

RESULTS

Three studies were identified, including 244 participants. Immediate-term results showed that leg pain intensity (mean distance [MD]: -0.94, 95% confidence intervals [95% CI]: -1.60 to -0.29, p< 0.01) and symptom severity (MD: -0.29, 95% CI: -0.50 to -0.08, p< 0.01) were lower in the study group than in the control group, and walking distance (MD: 415.83, 95% CI: 298.15-533.50, p< 0.001) and QOL were higher in the study group. Long-term results showed that functional disability/impairment (MD: 0.27, 95% CI: -0.49 to -0.04, p< 0.05) was lower in the study group than in the control group, and walking distance and QOL were higher in the study group.

CONCLUSION

The number of studies on this topic was small and limited. Combinations of non-surgical treatment and supervised exercise may not provide significant benefits.

Case-matched radiological and clinical outcome evaluation of interlaminar versus microsurgical decompression of lumbar spinal stenosis

PURPOSE

Endoscopic spine surgery is a globally expanding technique advocated as less invasive for spinal stenosis treatment compared to the microsurgical approach. However, evidence on the efficiency of interlaminar full-endoscopic decompression (FED) vs. conventional microsurgical decompression (MSD) in patients with lumbar spinal stenosis is still scarce. We conducted a case-matched comparison for treatment success with consideration of clinical, laboratory, and radiologic predictors.

METHODS

We included 88 consecutive patients (FED: 36/88, 40.9%; MSD: 52/88, 59.1%) presenting with lumbar central spinal stenosis. Surgery-related (operation time, complications, length of stay (LOS), American Society of Anesthesiologists physical status (ASA) score, C-reactive protein (CRP), white blood cell count, side of approach (unilateral/bilateral), patient-related outcome measures (PROMs) (Oswestry disability index (ODI), numeric rating scale of pain (NRS; leg-, back pain), EuroQol questionnaire (eQ-5D), core outcome measures index (COMI)), and radiological (dural sack cross-sectional area, Schizas score (SC), left and right lateral recess heights, and facet angles, respectively) parameters were extracted at different time points up to 1-year follow-up. The relationship of PROMs was analyzed using Spearman's rank correlation. Surgery-related outcome parameters were correlated with patient-centered and radiological outcomes utilizing a regression model to determine predictors for propensity score matching.

RESULTS

Complication (most often residual sensorimotor deficits and restenosis due to hematoma) rates were higher in the FED (33.3%) than MSD (13.5%) group (p < 0.05), while all complications in the FED group were observed within the first 20 FED patients. Operation time was higher in the FED, whereas LOS was higher in the MSD group. Age, SC, CRP revealed significant associations with PROMs. We did not observe significant differences in the endoscopic vs. microsurgical group in PROMs. The correlation between ODI and COMI was significantly high, and both were inversely correlated with eQ-5D, whereas the correlations of these PROMs with NRS findings were less pronounced.

CONCLUSIONS

Endoscopic treatment of lumbar spinal stenosis was similarly successful as the conventional microsurgical approach. Although FED was associated with higher complication rates in our single-center study experience, the distribution of complications indicated surgical learning curves to be the main factor of these findings. Future long-term prospective studies considering the surgical learning curve are warranted for reliable comparisons of these techniques.

Management of lumbar spinal stenosis: a systematic review and meta-analysis of rehabilitation, surgical, injection, and medication interventions

BACKGROUND

Lumbar spinal stenosis (LSS) has a substantial impact on mobility, autonomy, and quality of life. Previous reviews have demonstrated inconsistent results and/or have not delineated between specific nonsurgical interventions.

OBJECTIVE

The purpose of this systematic review is to assess the effectiveness of interventions in the management of LSS.

METHODS

Eligible studies were randomized controlled trials (RCTs) or prospective studies, included patients with LSS, assessed the effectiveness of any interventions (rehabilitation, surgical, injection, medication), included at least two intervention groups, and included at least one measure of pain, disability, ambulation assessment, or LSS-specific symptoms. Eighty-five articles met inclusion criteria. Meta-analyses were conducted across outcomes. Effect sizes were calculated using Hedge's g and reported descriptively. Formal grading of evidence was conducted.

RESULTS

Meta-analysis comparing rehabilitation to no treatment/placebo demonstrated significant effects on pain favoring rehabilitation (mean difference, MD -1.63; 95% CI: -2.68, -0.57; I² = 71%; p = .002). All other comparisons to no treatment/placebo revealed nonsignificant findings. The level of evidence ranged from very low to high for rehabilitation and medication versus no treatment/placebo for pain, disability, ambulation ability, and LSS symptoms.

CONCLUSIONS

Although the findings of this review are inconclusive regarding superiority of interventions, this accentuates the value of multimodal patient-centered care in the management of patients with LSS.

Efficacy and characteristics of physiotherapy interventions in patients with lumbar spinal stenosis: a systematic review

PURPOSE

To determine the efficacy of physiotherapy approaches used in the treatment of LSS and compare their delivery characteristics.

METHODS

A systematic search was conducted using MEDLINE/PubMed, EMBASE, Scopus, PEDro, CINAHL and Web of Science databases, from inception until March 2021. Inclusion criteria were clinical diagnosis of LSS confirmed through imaging techniques, RCTs written in English comparing physiotherapy interventions among them or versus placebo or usual care without restrictions on treatment and follow-up duration, outcomes related to pain, physical function, disability and quality of life. Two independent reviewers assessed records for eligibility and methodological quality (PEDro scale) and extracted participants' characteristics, interventions details and outcome measures at each timepoint. Pooled or un-pooled findings were reported as mean difference with 95% confidence interval, depending on heterogeneity. Evidence quality was rated using the GRADE approach.

RESULTS

Twelve studies (944 patients, mean PEDro score 7.6, range 5-9) were included. Three weeks of weight-supported walking improved pain and disability, while 8 weeks of aquatic exercises improved pain and walking tolerance (very low evidence). Six weeks of cycling reduced disability compared to weight-supported walking (low evidence). Six weeks of manual therapy plus exercise was not superior to supervised exercises (low evidence), but improved pain, walking tolerance, disability and quality of life compared to home/group exercises (moderate to very low evidence). Very low evidence supported 2 weeks of electromagnetic fields, whereas TENS (low evidence) and ultrasounds (very low evidence) revealed no effects.

CONCLUSIONS

These findings may assist clinicians in delivering effective physiotherapy interventions in LSS patients.

Effectiveness of additional deep-water running for disability, lumbar pain intensity, and functional capacity in patients with chronic low back pain: A randomised controlled trial with 3-month follow-up

BACKGROUND

Aquatic exercise (AQE) programme is commonly used as an alternative to the chronic low back pain (CLBP) treatment. The addition of aquatic aerobic exercises to AQE may be beneficial to patients with CLBP.

DESIGN

Randomised controlled trial.

OBJECTIVES

To assess the effectiveness of AQE with the addition of aerobic exercise - deep-water running (DWR) - compared to exclusive AQE in improving disability, lumbar pain intensity, and functional capacity in patients with CLBP.

METHODS

Fifty-four adult patients with CLBP were randomised either to the experimental group (AQE + DWR) or the control group (AQE). An assessor who was blinded to the group allocation performed both pre- and post-interventions assessments. Both treatments lasted 9 weeks, with a 3-month follow-up. The primary outcome was disability, as evaluated using the Roland Morris Disability Questionnaire. The secondary outcomes were pain and functional capacity; pain was assessed using a visual analogue scale (VAS), and functional capacity (travelled distance) was measured using the 6-min walk test (6WT).

RESULTS

A significant difference in pain was observed between groups after intervention in favour of DWR (mean difference -1.3 cm [95% confidence interval (CI) -2.17 to -0.45], d‾ = 0.80 [95% CI 0.22 to 1.33]).

CONCLUSION

Treatment with DWR was effective in the short term for achieving the desired outcome of pain reduction when compared with AQE only but not for disability and functional capacity.

An Algorithmic Approach to Treating Lumbar Spinal Stenosis: An Evidenced-Based Approach

OBJECTIVE

Lumbar spinal stenosis (LSS) can lead to compression of the neural and vascular elements and is becoming more common due to degenerative changes that occur because of aging processes. Symptoms may manifest as pain and discomfort that radiates to the lower leg, thigh, and/or buttocks. The traditional treatment algorithm for LSS consists of conservative management (physical therapy, medication, education, exercise), often followed by epidural steroid injections (ESIs), and when nonsurgical treatment has failed, open decompression surgery with or without fusion is considered. In this review, the variables that should be considered during the management of patients with LSS are discussed, and the role of each treatment option to provide optimal care is evaluated.

RESULTS

This review leads to the creation of an evidence-based practical algorithm to aid clinicians in the management of patients with LSS. Special emphasis is directed at minimally invasive surgery, which should be taken into consideration when conservative management and ESI have failed.

Is Pilates an effective rehabilitation tool? A systematic review

BACKGROUND

Pilates is a system of exercise focusing upon controlled movement, stretching and breathing. Pilates is popular today not only for physical fitness but also for rehabilitation programs. This paper is a review of the literature on the effectiveness of Pilates as a rehabilitation tool in a wide range of conditions in an adult population.

METHODS

A systematic literature review was carried out according to the PRISMA guidelines. Electronic databases were searched for cohort studies or randomised controlled trials (RCTs), and inclusion and exclusion criteria were applied. The final RCTs were assessed using the PEDro and CONSORT 2010 checklists.

RESULTS

Twenty-three studies, published between 2005 and 2016, met the inclusion criteria. These papers assessed the efficacy of Pilates in the rehabilitation of low back pain, ankylosing spondylitis, multiple sclerosis, post-menopausal osteoporosis, non-structural scoliosis, hypertension and chronic neck pain. Nineteen papers found Pilates to be more effective than the control or comparator group at improving outcomes including pain and disability levels. When assessed using the CONSORT and PEDro scales, the quality of the papers varied, with more falling toward the upper end of the scale.

CONCLUSION

The majority of the clinical trials in the last five years into the use of Pilates as a rehabilitation tool have found it to be effective in achieving desired outcomes, particularly in the area of reducing pain and disability. It indicates the need for further research in these many areas, and especially into the benefits of particular Pilates exercises in the rehabilitation of specific conditions.