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September5th–8th2013NottinghamConferenceCentre,UnitedKingdomwww.nspine.co.ukSeptember5th–8th2013LumbarSpinalStenosis(LSS)

ConservativeManagementEllenHobbsPhysiotherapistSeptember2013

LumbarSpinalStenosis(LSS)

CWhatdoestheliteratureindicate?Surgeryisgenerallythegoldstandard.

(Negrinietal2010;Zainaetal2012)Onlyafewstudieshavecomparedsurgicalvsnon-surgicaltreatment.(Negrinietal2010)Evidenceregardingconservativemanagementislimitedandvague.

(AtlasandDelitto2006;Birkmeyeretal2002;Gorenetal2009;Tomkins2010citedinZainaetal2012)However…..WhatdoestheliteratureindicWhatdoestheliteratureindicate?Researchnon-specific/nocurrentstandardforconservativecare.Thereforedopositiveresultstrulysupportsurgery?(Backstrometal2011)Longtermeffectivenessofsurgeryhasbeenquestioned.(Backstrometal2011;Fritzetal1998)Patientselectionforsurgeryisill-defined.(Backstrometal2011)Highriskandcostly.(Fritzetal1998)WhatdoestheliteratureindicWhatdoestheliteratureindicate?Conservative/non-invasive=recommendedfirstlineintervention.(Negrinietal2010;Fritzetal1998)ThenaturalhistoryofLSSisnotnecessarilyaprogressivedecline.(Fritzetal1998)Patientswithmildtomoderatesymptomsoflumbarstenosishavesatisfactoryoutcomesfollowingconservativemanagement(Gorenetal2009)WhatdoestheliteratureindicProposedConservativeAdjunctsConservativePatientEducationManualTherapyCoreStabilityExerciseFlexibilityAerobictraining/ProgressivestrengtheningNeurodynamicsAnalgesiaInjectionAcupunctureFunctionalrestorationPainclinicProposedConservativeAdjunctsPatientEducationandManualTherapyInformpatientRationaleforSelfmanagementstrategies(Backstrometal2011;Johnsonetal1991;Rademeyer2003;Voetetal2005)ManualTherapyUseasacomponentofLSSisassociatedwithimprovementsinpainanddisability(Reimanetal2009;Zainaetal2012;Gorenetal2009)Techniquesusedarevaried/appliedtodifferentregions(Backstrometal2011)Choiceofprocedurelessimportantthantheintroductionofmovementthroughmanualtherapy.(Backstrometal2011)PatientEducationandManualTExercisePrescriptionAerobicTrainingandProgressivestrengthening:(supervisedcircuit/Spinalclass/Homeexercises)(Backstrometal2011;Gorenetal2009)CoreStabilityExercise:Donewithaflexionbiasemphasizingpelviccontrole.g.shoulderbridge(Backstrometal2011;Fritzetal1998)Flexibility:Overallstiffness=commonLSSpresentation.(Fritzetal1998;Whitmanetal2003,2006;Creightonetal2006;Murphyetal2006citedinBackstrometal2011;Zainaetal2012).LimitedevidencedirectingexercisedosageinpatientswithLSS.DOWEUNDERTREAT?(Backstrometal2011)ExercisePrescriptionAerobicTOutcomeMeasuresMulti-dimensionalObjectivemarkersPatientGoals/FunctionRolandMorris/ODI/EQ5DVASTimedwalk(15minutes)SittostandOutcomeMeasuresMulti-dimensioConsiderationsandOnwardReferralReliesoncorrectdifferentialdiagnosisDifficultduetosimilarcoexistingsymptoms(Fritzetal1998)NUH4-6sessions.Ifnochangeinsymptomologythe?onwardreferral.Inrealitytherearenostandard/setcriteriafortimeframesofconservativeMxConsiderationsandOnwardRefeSummaryPatientswithmildtomoderatesymptomsoflumbarstenosismaybenefitfromconservativemanagement(Gorenetal2009)However:FewexistingRCTs(4/178)thatspecificallyexamineandreportonpatientwithLSSreceivingconservativetreatment.(AgencyforHealthcareResearchandQuality2001).Studiesdonotevaluateapplicationsalone.(Goranetal2009)Researchfailstoevaluatelongtermeffectivenessofconservativemanagement.

(AgencyforHealthcareResearchandQuality2001).Lackofcomparablepatientgroupsandpre-treatmentdataforbothsurgicalandconservativelymanagedpatientgroups(AgencyforHealthcareResearchandQuality2001).Truecomparisonsaredifficultasmanypatienttreatedconservativelyenduphavingsurgery.(AgencyforHealthcareResearchandQuality2001).SummaryPatientswithmildtomSummaryHoweverdoesthislackofevidenceprovethatthesetreatmentarenoteffective?(Rockville2001)Needtoconsidereachindividualpatientandtheirsymptomologywhendecidingconservativevssurgical.NeedtoestablishsetoutcomemeasuresforpatientwithLSS.SummaryHoweverdoesthislackAppendixAppendixIndicationsLowerlimbpainNeurologicalsymptomsexacerbatedbywalkingNeurogenicclaudicationReducedwalkingcapacitiesIndicationsLowerlimbpainInjectionEpiduralsteroidinjectionsusedincreasinglytorelievesymptoms.(Delportetal2004;Campbelletal2007citedinBackstrometal2011)Lowlevelevidencestudiesshowsomebenefitinpatientswithspinalstenosis.OneRCTindicatestemporaryreliefforonemonth.Conclusionsbeyondthreemonthscannotbemade.(AgencyforHealthcareResearchandQuality2001).Systematicreviewconcludedmorestrenuousstudiesneedtobeperformed.(Nelemansetal2005;Buenaventuraetal2009citedinBackstrometal2011).Oftenusedincombinationwithphysiotherapy.InjectionEpiduralsteroidinjeNeurodynamicsConsiderthatpathoneurodynamicsmaybecontributingtosymptomology.Neurodynamictestingandreproductionofsymptomsusingdifferentiationmayindicateneurodynamicstreatment.NerveglidingTreatmentofmechanicalinterface:Triggerpoint/acupunctureTapingtooffload:Inhibitoryacrossmusclefibres.Neuraloffloading:reducesnociceptorimpulsesNeurodynamicsConsiderthatpatReferencesAtlasSJ,DelittoA:Spinalstenosis:surgicalversusnonsurgicaltreatment.ClinOrthopRelRes2006,443pp198-207BackstromKM,WhitmanJM,FlynnTW:Lumbarspinalstenosis-diagnosisandmanagementoftheagingspine;ManualTherapy2011,Vol16pp308-317.BirkmeyerNJO,WeinsteinJM,TostesonANA,SkinnerJS,LurieJD,DeyoR,WennbergJE:DesignoftheSpinePatientOutcomesResearchTrial(SPORT);Spine2002,June15;27(12):1361–1372.

FritzJM,ErhardRE,VignovicM:AnonsurgicalTreatmentApproachforPatientsWithLumbarSpinalStenosis:PhysicalTherapy1997,Vol9pp962-973.ReferencesReferencesFritzJM,DelittoA,WelchWC,Erhard,RE:LumbarSpinalStenosis:AReviewofCurrentConceptsinEvaluation,Management,andOutcomeMeasurements.ArchPhysMedRehabilitation1998,Vol79pp700-8.GorenA,YildizO,Findikoglu,G,ArdicF:Efficacyofexerciseandultrasoundinpatientswithlumbarspinalstenosis:aprospectiverandomizedcontrolledtrial.ClinicalRehabilitation2010,24pp623-631.JohnssonK,DaglasM,StuckiG,KatzN,BayleyJ,FosselA.Degenerativelumbarspinalstenosis.Acomparisonofsurgicallytreatedanduntreatedpatients.Spine1991:16:615-9ReferencesFritzJM,DelittoA,ReferencesNegriniSZ,ZainaF,RomanoM,AtanasioS,FuscoC,TrevisanC.Rehabilitationoflumbarspinedisorders;anevidence-basedclinicalpracticeapproach.DeLisa’sPhysical7Rehabilitation-PrinciplesandPractice2010:837–82.TreatmentofDegenerativeLumbarSpinalStenosis.Summary,EvidenceReport/TechnologyAssessment:Number32.AHRQPublicationNo.01-E047,March2001.AgencyforHealthcareResearchandQuality,Rockville,MD.http://www.ah/clinic/epcsums/stenosum.htm.RademeyerI.ManualTherapyforlumbarspinalstenosis;acomprehensivephysicaltherapyapproach.PhysicalMedicineandRehabilitationClinicsofNorthAmerica2003;14:103-10ReferencesNegriniSZ,ZainaF,ReferencesReimanM,HarrisJ,ClelandJ.Manualtherapyinterventionsforpatientswithlumbarspinalstenosis:asystematicreview.NewZealandJournalofPhysiotherapy2009;37:17–28.Zaina,F,Tomkins-LaneC,CarrageeE,Negrini:Surgicalversusnon-surgicaltreatmentforlumbarspinalstenosis(Protocal);TheCochraneLibrary2012,Issue12;pp1-14.ReferencesReimanM,HarrisJ,September5th–8th2013NottinghamConferenceCentre,UnitedKingdomwww.nspine.co.ukSeptember5th–8th2013LumbarSpinalStenosis(LSS)

ConservativeManagementEllenHobbsPhysiotherapistSeptember2013

LumbarSpinalStenosis(LSS)

CWhatdoestheliteratureindicate?Surgeryisgenerallythegoldstandard.

(Negrinietal2010;Zainaetal2012)Onlyafewstudieshavecomparedsurgicalvsnon-surgicaltreatment.(Negrinietal2010)Evidenceregardingconservativemanagementislimitedandvague.

(AtlasandDelitto2006;Birkmeyeretal2002;Gorenetal2009;Tomkins2010citedinZainaetal2012)However…..WhatdoestheliteratureindicWhatdoestheliteratureindicate?Researchnon-specific/nocurrentstandardforconservativecare.Thereforedopositiveresultstrulysupportsurgery?(Backstrometal2011)Longtermeffectivenessofsurgeryhasbeenquestioned.(Backstrometal2011;Fritzetal1998)Patientselectionforsurgeryisill-defined.(Backstrometal2011)Highriskandcostly.(Fritzetal1998)WhatdoestheliteratureindicWhatdoestheliteratureindicate?Conservative/non-invasive=recommendedfirstlineintervention.(Negrinietal2010;Fritzetal1998)ThenaturalhistoryofLSSisnotnecessarilyaprogressivedecline.(Fritzetal1998)Patientswithmildtomoderatesymptomsoflumbarstenosishavesatisfactoryoutcomesfollowingconservativemanagement(Gorenetal2009)WhatdoestheliteratureindicProposedConservativeAdjunctsConservativePatientEducationManualTherapyCoreStabilityExerciseFlexibilityAerobictraining/ProgressivestrengtheningNeurodynamicsAnalgesiaInjectionAcupunctureFunctionalrestorationPainclinicProposedConservativeAdjunctsPatientEducationandManualTherapyInformpatientRationaleforSelfmanagementstrategies(Backstrometal2011;Johnsonetal1991;Rademeyer2003;Voetetal2005)ManualTherapyUseasacomponentofLSSisassociatedwithimprovementsinpainanddisability(Reimanetal2009;Zainaetal2012;Gorenetal2009)Techniquesusedarevaried/appliedtodifferentregions(Backstrometal2011)Choiceofprocedurelessimportantthantheintroductionofmovementthroughmanualtherapy.(Backstrometal2011)PatientEducationandManualTExercisePrescriptionAerobicTrainingandProgressivestrengthening:(supervisedcircuit/Spinalclass/Homeexercises)(Backstrometal2011;Gorenetal2009)CoreStabilityExercise:Donewithaflexionbiasemphasizingpelviccontrole.g.shoulderbridge(Backstrometal2011;Fritzetal1998)Flexibility:Overallstiffness=commonLSSpresentation.(Fritzetal1998;Whitmanetal2003,2006;Creightonetal2006;Murphyetal2006citedinBackstrometal2011;Zainaetal2012).LimitedevidencedirectingexercisedosageinpatientswithLSS.DOWEUNDERTREAT?(Backstrometal2011)ExercisePrescriptionAerobicTOutcomeMeasuresMulti-dimensionalObjectivemarkersPatientGoals/FunctionRolandMorris/ODI/EQ5DVASTimedwalk(15minutes)SittostandOutcomeMeasuresMulti-dimensioConsiderationsandOnwardReferralReliesoncorrectdifferentialdiagnosisDifficultduetosimilarcoexistingsymptoms(Fritzetal1998)NUH4-6sessions.Ifnochangeinsymptomologythe?onwardreferral.Inrealitytherearenostandard/setcriteriafortimeframesofconservativeMxConsiderationsandOnwardRefeSummaryPatientswithmildtomoderatesymptomsoflumbarstenosismaybenefitfromconservativemanagement(Gorenetal2009)However:FewexistingRCTs(4/178)thatspecificallyexamineandreportonpatientwithLSSreceivingconservativetreatment.(AgencyforHealthcareResearchandQuality2001).Studiesdonotevaluateapplicationsalone.(Goranetal2009)Researchfailstoevaluatelongtermeffectivenessofconservativemanagement.

(AgencyforHealthcareResearchandQuality2001).Lackofcomparablepatientgroupsandpre-treatmentdataforbothsurgicalandconservativelymanagedpatientgroups(AgencyforHealthcareResearchandQuality2001).Truecomparisonsaredifficultasmanypatienttreatedconservativelyenduphavingsurgery.(AgencyforHealthcareResearchandQuality2001).SummaryPatientswithmildtomSummaryHoweverdoesthislackofevidenceprovethatthesetreatmentarenoteffective?(Rockville2001)Needtoconsidereachindividualpatientandtheirsymptomologywhendecidingconservativevssurgical.NeedtoestablishsetoutcomemeasuresforpatientwithLSS.SummaryHoweverdoesthislackAppendixAppendixIndicationsLowerlimbpainNeurologicalsymptomsexacerbatedbywalkingNeurogenicclaudicationReducedwalkingcapacitiesIndicationsLowerlimbpainInjectionEpiduralsteroidinjectionsusedincreasinglytorelievesymptoms.(Delportetal2004;Campbelletal2007citedinBackstrometal2011)Lowlevelevidencestudiesshowsomebenefitinpatientswithspinalstenosis.OneRCTindicatestemporaryreliefforonemonth.Conclusionsbeyondthreemonthscannotbemade.(AgencyforHealthcareResearchandQuality2001).Systematicreviewconcludedmorestrenuousstudiesneedtobeperformed.(Nelemansetal2005;Buenaventuraetal2009citedinBackstrometal2011).Oftenusedincombinationwithphysiotherapy.InjectionEpiduralsteroidinjeNeurodynamicsConsiderthatpathoneurodynamicsmaybecontributingtosymptomology.Neurodynamictestingandreproductionofsymptomsusingdifferentiationmayindicateneurodynamicstreatment.NerveglidingTreatmentofmechanicalinterface:Triggerpoint/acupunctureTapingtooffload:Inhibitoryacrossmusclefibres.Neuraloffloading:reducesnociceptorimpulsesNeurodynamicsConsiderthatpatReferencesAtlasSJ,DelittoA:Spinalstenosis:surgicalversusnonsurgicaltreatment.ClinOrthopRelRes2006,443pp198-207BackstromKM,WhitmanJM,FlynnTW:Lumbarspinalstenosis-diagnosisandmanagementoftheagingspine;ManualTherapy2011,Vol16pp308-317.BirkmeyerNJO,WeinsteinJM,TostesonANA,SkinnerJS,LurieJD,DeyoR,WennbergJE:DesignoftheSpinePatientOutcomesResearchTrial(SPORT);Spine2002,June15;27(12):1361–1372.

FritzJM,ErhardRE,VignovicM:AnonsurgicalTreatmentApproachforPatientsWithLumbarSpinalStenosis:PhysicalTherapy1997,Vol9pp962-973.ReferencesReferencesFritzJM,DelittoA,WelchWC,Erhard,RE:LumbarSpinalStenosis:AReviewofCurrentConce

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