Can Physical Therapy be as Effective as Surgery for Lumbar Spinal Stenosis?
A recent study sought to answer this question, and found that physical
therapy achieved similar results to surgery in the treatment of lumbar
Lumbar spinal stenosis (LSS) is a condition characterized by pain in the
lower back and legs, and sometimes numbness and weakness of the legs.
People with LSS often have limited standing and walking tolerance due
to pressure on nerves as they exit the spine in the lower back. The condition
becomes more common with age.
The study, led by Anthony Delitto, PT, PhD, FAPTA and published in the
April 2015 issue of Annals of Internal Medicine, was the first to compare
a single, evidence based physical therapy regimen with decompression surgery
among patients with spinal stenosis who agreed to be randomly assigned
to either approach. In their research report, the authors state that LSS
is now the most often cited cause for lumbar surgery in the United States.
LSS also happens to be a very common diagnosis that we see in physical therapy.
In a Reuters article about this study, Dr. Delitto said, “Surgery
is a riskier procedure, with about a 15% complication rate, and half of
those are life threatening. It isn’t a life-threatening procedure
to do physical therapy.”
To show the effectiveness of physical therapy in easing the symptoms of
LSS, Delitto and colleagues asked 481 patients if they would be willing
to join a study where they would be randomly chosen to proceed with surgery,
or receive physical therapy. All of these patients had already been considered
to be surgical candidates by a spine surgeon, and had already consented
to surgery. Many patients declined to participate in this study to avoid
the possibility of being assigned to the non-surgical group. However,
169 patients did participate in the study.
The physical therapy regimen in this study emphasized stretching and general
conditioning exercises, as well as patient education in postures to avoid.
Patients had the option to crossover from the physical therapy group to
the surgery group at any time, or vice versa. Only 2 patients crossed
from the surgery group to the physical therapy group. In contrast, 47
patients crossed over from the physical therapy group to the surgery group.
In the end, however, no matter which group patients were assigned to,
surgery or physical therapy, they had a similar reduction of pain and
other symptoms two years after the start of the study.
So is physical therapy as effective as surgery for LSS? The actual answer
is, of course, “it depends.” All treatment decisions should
be made on a case-by-case basis and the results of any particular research
study should not be over-generalized. There are cases of LSS in which
compression of nerves or the spinal cord is too severe, and surgery may
be necessary to prevent or minimize permanent damage. More often, however,
surgery is not immediately imperative, and in these cases, the results
of this study suggest that it makes good sense to participate in an active
physical therapy program before considering invasive and higher risk interventions
such as surgery. If you are suffering with LSS, be sure to openly discuss
all your treatment options with your primary care doctor and specialists
to help make the best treatment decision for you.
David Kandel, PT, OCS, CSCS
PVHMC Physical Therapist