Therapeutic Advantages of Frequent Physical Therapy Sessions for Patients With Lumbar Spinal Stenosis

Masakazu Minetama, PT, PhD; Mamoru Kawakami, MD, PhD; Masatoshi Teraguchi, MD, PhD; Ryohei Kagotani, MD, PhD; Yoshimasa Mera, MD; Tadashi Sumiya, MD; Masafumi Nakagawa, PT, MS; Yoshio Yamamoto, PT; Sachika Matsuo, PT; Nana Sakon, PT; Tomohiro Nakatani, PT; Tomoko Kitano, CP, MS; Yukihiro Nakagawa, MD, PhD

Disclosures

Spine. 2020;45(11):E639-E646. 

In This Article

Abstract and Introduction

Abstract

Study Design: A retrospective study of a randomized clinical trial and a prospective study of patients with lumbar spinal stenosis (LSS).

Objective: The aim of this study was to identify the effects of the number of physical therapy (PT) sessions on clinical outcomes of patients with LSS.

Summary of Background Data: Supervised PT for patients with LSS has been reported to lead to better short-term outcomes in terms of disability and leg pain than unsupervised exercise. However, no studies have investigated the relationship between the number of PT sessions and the therapeutic effects in patients with LSS.

Methods: All patients received exercise therapy for 6 weeks. Included were 43 patients receiving supervised PT twice a week (P2 group), 38 patients receiving supervised PT once a week (P1 group), and 43 patients receiving a home exercise program alone (HE group). Clinical outcomes were measured using the Zurich Claudication Questionnaire (ZCQ), a numerical rating scale (NRS) of back pain and leg pain, the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ) at baseline and at 6 weeks.

Results: At 6 weeks, the P2 group showed significant improvements in ZCQ physical function, back and leg pain on the NRS compared with the P1 group (P < 0.05). Compared with the HE group, the P2 group showed significant improvements in ZCQ symptom severity and physical function, back and leg pain on the NRS, and JOABPEQ gait disturbance (P < 0.05). There were no significant differences in mean changes after 6 weeks between the P1 and HE groups.

Conclusion: Six weeks of supervised PT twice a week resulted in significant short-term improvements in symptom severity, physical function, back and leg pain, and gait disturbance compared with once a week and/or home exercise alone. Patients with LSS should be treated with intensive and supervised exercise programs to obtain maximum benefit of exercise therapy.

Level of Evidence: 3

Introduction

Lumbar spinal stenosis (LSS) is the most common indication for spine surgery in older adults, and its prevalence is likely to increase in aging population.[1] Surgery is generally performed to treat patients with LSS who do not improve with nonsurgical treatments because it is unlikely that LSS symptoms will worsen or that neurologic function will deteriorate rapidly.[2,3] Previous randomized controlled trial (RCT)s and prospective cohort studies indicate that decompression surgery offers an advantage over nonsurgical treatment for selected patients with persistent severe symptoms that include both back and leg pain.[4–7] A recent systematic review comparing surgery with nonsurgical treatment in LSS concluded that surgical groups showed better late clinical outcomes after 1 year, but surgical groups had higher complications rates than nonsurgical groups throughout follow-up.[8] However, in an RCT comparing surgical decompression with physical therapy (PT) in patients with LSS who were surgical candidates, PT yielded similar effects to surgical decompression, although 57% of the patients assigned to PT crossed over to surgery.[9] In the Spine Patient Outcomes Research Trial (SPORT), the largest RCT comparing surgical and nonsurgical treatment of LSS, patients who received PT in nonsurgical treatment group had higher self-ratings of improvement and were less likely to cross over to surgery than those who did not undergo PT.[10] Therefore, it is possible that adequate PT enables patients with LSS to avoid surgery.

Previous RCTs have been examined the efficacy of PT involving flexion exercises, strengthening exercises, aerobic conditioning such as body weight-supported treadmill walking and cycling, manual therapy, patient education, and PT regimens such as ultrasound, hot packs, and transcutaneous electrical nerve stimulation for patients with LSS.[11–15] A systematic review of PT for patients with LSS concluded that exercise therapy leads to better short-term outcomes than no exercise with respect to disability and back and leg pain, and modalities and manual therapy have no additional effect to exercise.[16] Recent RCTs reported that supervised and individualized exercise provides greater short-term improvement in symptoms and physical function and walking capacity than unsupervised or group exercise.[17,18] However, no reports have investigated the relationship between the number of PT sessions and the therapeutic effects in patients with LSS. The purpose of this study was to identify the effects of the number of PT sessions on clinical outcomes in patients with LSS.

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