Physical therapy interventions for degenerative lumbar spinal stenosis: a systematic review

Abstract

Background: Physical therapy is commonly prescribed for patients with lumbar spinal stenosis (LSS); however, little is known about its effectiveness.

Purpose: The purpose of this study was to systematically review randomized controlled trials (RCTs), controlled trials, and cohort studies evaluating the effectiveness of physical therapy for LSS.

Data sources: Studies were searched on electronic databases to January 2012.

Study selection: Inclusion criteria were: clinical diagnosis of LSS with confirmatory imaging, evaluation of physical therapy treatment, presence of a comparison group, and outcomes of pain, disability, function, or quality of life.

Data extraction: Outcomes were extracted and, when possible, pooled using RevMan 5, a freely available review program from the Cochrane Library.

Data synthesis: Ten studies were included: 5 RCTs, 2 controlled trials, 2 mixed-design studies, and 1 longitudinal cohort study. Pooled effects of 2 studies revealed that the addition of a physical therapy modality to exercise had no statistically significant effect on outcome. Pooled effects results of RCTs evaluating surgery versus physical therapy demonstrated that surgery was better than physical therapy for pain and disability at long term (2 years) only. Other results suggested that exercise is significantly better than no exercise, that cycling and body-weight-supported treadmill walking have similar effects, and that corsets are better than no corsets.

Limitations: The limitations of this review include the low quality and small number of studies, as well as the heterogeneity in outcomes and treatments.

Conclusions: No conclusions could be drawn from the review regarding which physical therapy treatment is superior for LSS. There was low-quality evidence suggesting that modalities have no additional effect to exercise and that surgery leads to better long-term (2 years) outcomes for pain and disability, but not walking distance, than physical therapy in patients with LSS.

Figure 1.

Flowchart of systemic review inclusion and exclusion. Randomized controlled trials and cohort or clinical trials with comparison groups were considered.

Figure 2.

Forest plot of randomized controlled trials evaluating the addition of physical therapy modalities to an exercise program. Values represent weighted mean difference (95% confidence interval). The pooled effects were calculated using fixed-effect models (all I²=0%). Pain and disability outcomes are presented on a 0 to 100 scale, and walking ability measures are presented in seconds.

Figure 3.

Forest plot of randomized controlled trials (RCTs) comparing physical therapy and surgery. Values represent weighted mean difference (95% confidence interval). The pooled effects were calculated using fixed-effect models (all I²=0%) for pain at 6 months for the cohort studies and for disability at 2 years. All other pooled effects were calculated using random-effects models. Pain at 6 months RCTs I²=89%, pain at 1 year RCT I²=85%, pain at 2 years RCT I²=76%, disability at 6 months I²=63%, and disability at 1 year I²=76%. Pain and disability outcomes are presented on a 0 to 100 scale, and walking ability is presented in meters. Positive values favor surgery for the outcomes of pain and disability but favor physical therapy for ambulation time because high pain and disability are unfavorable outcomes, whereas high walking time is favorable.