Patients seeking relief from lumbar spinal stenosis — a common chronic back problem — felt the same improvement at the two-year mark whether they had physical therapy or surgery, a recent study found.
LSS commonly occurs in adults ages 60 and older, according to the American Academy of Orthopaedic Surgeons. Spinal wear and tear can narrow the space around the spinal cord, according to the AAOS. This narrowing puts pressure on the cord and its nerve roots, which can cause numbness, pain or weakness of the lower back, legs and thighs.
Researchers for the study, which appeared in the April issue of the Annals of Internal Medicine, compared the physical functions of 169 patients with LSS who randomly were assigned to receive either surgery or the conservative approach of physical therapy. No long-term differences were found between the groups.
The study’s finding that PT is just as effective as surgery in terms of functional improvement and relief should help patients consider their treatment options, physical therapists said.
“Research has shown repeatedly that a proper therapeutic exercise program which involves activation of the deep abdominal muscles and gluteals is effective at reducing many lumbar conditions including stenosis,” said Darwin Fogt, MPT, PT, president of Evolution Physical Therapy and Fitness in Culver City, Calif.
Marketing physical therapy
In the study, researchers focused on patients with LSS who had not undergone surgery for the condition. Most of the participants were older than 50 and experiencing pain and impaired mobility. The study, which took place from November 2000 to September 2007, assigned 87 of the participants to decompression surgery and 82 patients to PT. Of the physical therapy group, 57% changed their minds and opted for surgery.
The patients in the physical therapy group did not face the risk of surgery complications, which include infection, delayed healing and more surgery. The possible complication for patients receiving physical therapy was more symptoms.
Patients participated in physical therapy twice weekly for six weeks. The PT group also learned about proper posture and exercises to increase their flexibility. To gauge improvement for both patient groups, researchers measured their physical function at 10 weeks, six months, 12 months, and then two years.
Physical therapy does not cure LSS, but it helps to manage symptoms with stretching exercises, massage and abdominal and lumbar strengthening, experts said. Physical therapy’s effectiveness in managing the short-term and long-term pain and other symptoms of LSS also might bolster marketing efforts, Fogt said.
“It is my personal philosophy that PTs need to educate the community even more that the medical community about what we do,” he said. “Community involvement, including presence at local events, hosting educational seminars, and social media are all strategies that we employ to get the word out.”
Vivian Eisenstadt, MAPT, CPT, MASP, owner and chief PT at Vivie Therapy in Los Angeles, agreed PTs must help the public understand their vital role in healthcare.
“There is not a common knowledge about the chief abilities of physical therapists, and that’s because we were never confident about how to market to the public,” said Eisenstadt, who credits Yelp reviews and word-of-mouth, among doctor recommendations, for new clients.
Physicians should encourage their patients to try nonsurgical treatments when appropriate, said Amisha Klawonn, DPT, PT, OCS, FAAOMPT, an assistant professor in the DPT program at A.T. Still University School of Health Sciences in Mesa, Ariz.
“Healthcare is an interactive field, and physical therapy may need to be a recommendation of [their] spinal surgeon,” she said. In recent months, it has become possible for more patients to see a PT without their doctor’s approval.
“As of Jan. 1, 2015, all 50 states allow patients to seek some level of treatment from a PT without a physician referral,” said Klawonn, who owns Oneness Physical Therapy and Pilates in Phoenix.
Only 18 states grant unrestricted access to PTs’ services for evaluation and treatment, according to the American Physical Therapy Association.
Physical therapy treatment is conservative for most injuries, so it often should be the first line of defense, said Benjamin Butts, DPT, PT, OCS, SCS, director of rehabilitation services and performance therapy at Providence Saint John’s Health Center in Santa Monica, Calif.
“We now have a greater ability to do this with direct access in most states,” he said.
Patients might shy away from PT for another reason besides lack of awareness or a doctor’s recommendation, said Taylor Moore, DPT, a physical therapist practicing in Westchase, Fla.
Physical therapy “is not an easy fix and takes long-term commitment in order to achieve desirable results,” Moore said. “At some point in a patient’s past, a doctor has recommended surgery … and the patient has taken that advice without doing additional research.”
Physical therapy for LSS incorporates therapeutic exercises to open the spinal canal, said Klawonn, who regularly treats spinal stenosis with a blend of manual therapy and Pilates.
“A comprehensive exercise program will also include exercises that address neurodynamics, core strength and include lower extremity flexibility exercises such as stretches for the hip external rotators, hamstrings and calves,” Klawonn said. “Pilates-based exercises are an excellent way to improve spinal articulation, core control and incorporate breathing. Breathing, specifically diaphragmatic breathing has been shown to decrease chronic pain and assist with pain management very quickly.”
The latest therapies and techniques to treat LSS include an infrared sauna, “which heats from the inside out, so you are increasing circulation and relaxing muscles and tendons,” Eisenstadt said.
For patients with chronic low back pain, moderate- to high-intensity exercise can include walking “on a treadmill with a harness that helps unweight your spine to make walking more tolerable,” Butts said. “Also, you can look into bicycling to preserve cardiovascular fitness instead of walking if walking is irritating.”
Sometimes, surgery is the best option.
Issues with bowel and bladder functions, nerve damage, tingling and numbness in the saddle region or significant changes in reflexes are among the reasons to consult a surgeon, the PTs said.
Patients who decide surgery is the best option should consider physical therapy after their operation to improve healing, Fogt said.
“Even if a patient is unsuccessful at reducing symptoms,” he said, “they will still benefit from the strength increases from the exercises, help improve prognosis and reduce recovery time following the surgery.”