September 5 th – 8 th 2013 Nottingham Conference Centre, United Kingdom nspine.co.uk

1. September 5th – 8th 2013 Nottingham Conference Centre, United Kingdom www.nspine.co.uk

2. Lumbar Spinal Stenosis (LSS)Conservative Management Ellen Hobbs Physiotherapist September 2013

3. What does the literature indicate? • Surgery is generally the gold standard. (Negrini et al 2010; Zaina et al 2012) • Only a few studies have compared surgical vs non-surgical treatment. (Negrini et al 2010) • Evidence regarding conservative management is limited and vague. (Atlas and Delitto 2006; Birkmeyer et al 2002; Goren et al 2009; Tomkins 2010 cited in Zaina et al 2012) However…..

4. What does the literature indicate? • Research non-specific / no current standard for conservative care. Therefore do positive results truly support surgery? (Backstrom et al 2011) • Long term effectiveness of surgery has been questioned. (Backstrom et al 2011; Fritz et al 1998) • Patient selection for surgery is ill-defined. (Backstrom et al 2011) • High risk and costly. (Fritz et al 1998)

5. What does the literature indicate? • Conservative / non-invasive = recommended first line intervention. (Negrini et al 2010; Fritz et al 1998) • The natural history of LSS is not necessarily a progressive decline. (Fritz et al 1998) • Patients with mild to moderate symptoms of lumbar stenosis have satisfactory outcomes following conservative management (Goren et al 2009)

6. Proposed Conservative Adjuncts

7. Patient Education and Manual Therapy Inform patient • Rationale for • Self management strategies (Backstrom et al 2011; Johnson et al 1991; Rademeyer 2003; Voet et al 2005) Manual Therapy • Use as a component of LSS is associated with improvements in pain and disability (Reiman et al 2009; Zaina et al 2012; Goren et al 2009) • Techniques used are varied / applied to different regions (Backstrom et al 2011) • Choice of procedure less important than the introduction of movement through manual therapy. (Backstrom et al 2011)

8. Exercise Prescription • Aerobic Training and Progressive strengthening: (supervised circuit / Spinal class / Home exercises) (Backstrom et al 2011; Goren et al 2009) • Core Stability Exercise: Done with a flexion bias emphasizing pelvic control e.g. shoulder bridge (Backstrom et al 2011; Fritz et al 1998) • Flexibility: Overall stiffness = common LSS presentation. (Fritz et al 1998; Whitman et al 2003, 2006; Creighton et al 2006; Murphy et al 2006 cited in Backstrom et al 2011; Zaina et al 2012). • Limited evidence directing exercise dosage in patients with LSS. DO WE UNDERTREAT? (Backstrom et al 2011)

9. Outcome Measures • Multi-dimensional • Objective markers • Patient Goals / Function • Roland Morris / ODI / EQ5D • VAS • Timed walk (15 minutes) • Sit to stand

10. Considerations and Onward Referral • Relies on correct differential diagnosis • Difficult due to similar coexisting symptoms (Fritz et al 1998) • NUH 4-6 sessions. If no change in symptomology the ? onward referral. • In reality there are no standard / set criteria for timeframes of conservative Mx

11. Summary • Patients with mild to moderate symptoms of lumbar stenosis may benefit from conservative management (Goren et al 2009) However: • Few existing RCTs (4/178) that specifically examine and report on patient with LSS receiving conservative treatment. (Agency for Healthcare Research and Quality 2001). • Studies do not evaluate applications alone. (Goran et al 2009) • Research fails to evaluate long term effectiveness of conservative management. (Agency for Healthcare Research and Quality 2001). • Lack of comparable patient groups and pre-treatment data for both surgical and conservatively managed patient groups (Agency for Healthcare Research and Quality 2001). • True comparisons are difficult as many patient treated conservatively end up having surgery. (Agency for Healthcare Research and Quality 2001).

12. Summary • However does this lack of evidence prove that these treatment are not effective? (Rockville 2001) • Need to consider each individual patient and their symptomology when deciding conservative vs surgical. • Need to establish set outcome measures for patient with LSS.

13. Appendix

14. Indications • Lower limb pain • Neurological symptoms exacerbated by walking • Neurogenic claudication • Reduced walking capacities

15. Injection • Epidural steroid injections used increasingly to relieve symptoms. (Delport et al 2004; Campbell et al 2007 cited in Backstrom et al 2011) • Low level evidence studies show some benefit in patients with spinal stenosis. One RCT indicates temporary relief for one month. Conclusions beyond three months cannot be made. (Agency for Healthcare Research and Quality 2001). • Systematic review concluded more strenuous studies need to be performed. (Nelemans et al 2005; Buenaventura et al 2009 cited in Backstrom et al 2011). • Often used in combination with physiotherapy.

16. Neurodynamics • Consider that pathoneurodynamics may be contributing to symptomology. • Neurodynamic testing and reproduction of symptoms using differentiation may indicate neurodynamics treatment. • Nerve gliding • Treatment of mechanical interface: • Trigger point / acupuncture • Taping to offload: Inhibitory across muscle fibres. Neural offloading: reduces nociceptor impulses

17. References Atlas SJ, Delitto A: Spinal stenosis: surgical versus nonsurgical treatment. Clin Orthop Rel Res 2006, 443 pp198 - 207 Backstrom KM, Whitman JM, Flynn TW: Lumbar spinal stenosis-diagnosis and management of the aging spine; Manual Therapy 2011, Vol 16 pp308-317. Birkmeyer NJO, Weinstein JM, Tosteson ANA, Skinner JS, Lurie JD, Deyo R, Wennberg JE: Design of the Spine Patient Outcomes Research Trial (SPORT); Spine 2002, June 15; 27 (12): 1361 – 1372. Fritz JM, Erhard RE, Vignovic M: Anonsurgical Treatment Approach for Patients With Lumbar Spinal Stenosis: Physical Therapy 1997, Vol 9 pp962-973.

18. References Fritz JM, Delitto A, Welch WC, Erhard, RE: Lumbar Spinal Stenosis: A Review of Current Concepts in Evaluation, Management, and Outcome Measurements. Arch Phys Med Rehabilitation 1998, Vol 79 pp 700-8. Goren A, Yildiz O, Findikoglu, G, Ardic F: Efficacy of exercise and ultrasound in patients with lumbar spinal stenosis: a prospective randomized controlled trial. Clinical Rehabilitation 2010, 24 pp 623-631. Johnsson K, Daglas M, Stucki G, Katz N, Bayley J, Fossel A. Degenerative lumbar spinal stenosis. A comparison of surgically treated and untreated patients. Spine 1991: 16: 615-9

19. References Negrini SZ, Zaina F, Romano M, Atanasio S, Fusco C, Trevisan C. Rehabilitation of lumbar spine disorders; an evidence-based clinical practice approach. De Lisa’s Physical 7 Rehabilitation-Principles and Practice 2010: 837 – 82. Treatment of Degenerative Lumbar Spinal Stenosis. Summary, Evidence Report/Technology Assessment: Number 32. AHRQ Publication No. 01-E047, March 2001. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/epcsums/stenosum.htm. Rademeyer I. Manual Therapy for lumbar spinal stenosis; a comprehensive physical therapy approach. Physical Medicine and Rehabilitation Clinics of North America 2003; 14: 103-10

20. References Reiman M, Harris J, Cleland J. Manual therapy interventions for patients with lumbar spinal stenosis: a systematic review. New Zealand Journal of Physiotherapy 2009; 37: 17 – 28. Zaina, F, Tomkins-Lane C, Carragee E, Negrini: Surgical versus non-surgical treatment for lumbar spinal stenosis (Protocal); The Cochrane Library 2012, Issue 12; pp 1-14.