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Three Part Question

IN [patients presenting with signs and symptoms of spinal stenosis] IS [manual therapy and/or exercise better than injections] AT [reducing pain and improving walking].

Clinical Scenario

A 70 year old gentleman presents to the physiotherapy department with lower back pain and neurogenic claudication to bilateral lower limbs on walking. Your clinical diagnosis is of lumbar spinal stenosis. You wonder if evidence exists to support that physiotherapy (manual therapy and/or exercise) would be of benefit to this patient or if they should be referred for a spinal epidural injection.

Search Strategy

Medline 1950-Aug 2007, AMED 1985-Aug 2007, Cinahl 1982-Aug 2007, Embase 1974-Aug 2007 via Dialog Datastar; Cochrane viaNLH; PEDRO 1985-2007
[Spin$ adj stenos$.TI. or SPINAL-STENOSIS#.DE.] and [(PHYSICAL-THERAPY-MODALITIES#.DE. or EXERCISE-THERAPY#.DE. or physiotherapy.TI. or manual adj therap$.TI,AB. or physical adj therap$.TI,AB. or manipulat$ near therap$.TI,AB.) or (INJECTIONS-SPINAL#.DE. or INJECTIONS-EPIDURAL#.DE. or {injection$ near epidural} or {injection$ near corticosteroid} or {injection$ near nerve root})] Limit to humans and English language

Search Outcome

Altogether 290 papers were found of which 2 were relevant to the clinical question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Swezey 1996 USA	47 patients with neurogenic claudication due to spinal stenosis confirmed on MRI scan as moderate to marked. Group 1: all patients instructed in ergonomics, flexion exercises, use of cane, analgesic drugs (n=47). Group 2: as group 1 plus pelvic traction (n=11). Group 3: as group 1 plus epidural corticosteroid injections (n=13)	5 year folow up survey	Subjective patient rating of: improved, remained unchanged, worsened	Group 1: 56% improved, 39% unchanged, 5% worse. Group 2: 64% improved, 18% unchanged, 18% worse. Group 3: 46% improved, 54% unchanged, 0% worse	Small subject numbers. Not most appropriate design to compare interventions. Poor validity of outcome measures. No randomisation/ blinding to treatment groups. Lack of clarity of results.
Shabat 2007 Israel	36 patients diagnosed with spinal stenosis on CT/MRI scan over the age of 65 years. All 36 patients received 'Physiotherapy' of ultrasound and short wave electrotherapy plus flexion exercises. 12 sessions were given lasting 30-40 minutes each. 24 of the 36 patients also received an epidural steroid injection. Follow up was 6-10 months post diagnosis.	Case series	Oswestry Index	Patients who recieved 'Physiotherapy' alone and patients who received 'Physiotherpy' plus an epidural steroid injection showed no lasting improvement on the index	Small sample size. Classified as 'severe' stenotic patients yet the study attempts to relate the findings to all patients with stenosis. 'Physiotherapy' includes a very mixed array of interventions with little justification for the modalities used or detail of what was actually done. Not the most appropriate study design to assess the effectiveness of interventions.

Comment(s)

There is very little evidence available comparing the differing efficacy of conservative treatments for spinal stenosis. The evidence that is available is contradictory in that one study suggests both injections and physiotherapy are ineffective, whilst the other study reviewed suggests both are effective in certain patients but is limited in its ability to compare the two. Both studies are of poor methodological quality.

Clinical Bottom Line

At present the published literature is lacking in evidence as to the greater efficacy of manual therapy and exercise over injections, and vice versa in patients with spinal stenosis.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Swezey Outcomes for lumbar stenosis: a 5-year follow-up study Journal of Clinical Rheumatology, vol 2,3, June 1996
2. Shabat, S., Folman, Y., Leitner, Y., Fredman, B., Gepstein, R. Failure of conservative treatment for lumbar spinal stenosis in elderly patients Archives of Gerontology and Geriatrics 44 2007, 235-241