Effectiveness of Conservative Nonpharmacologic Therapies for Pain, Disability, Physical Capacity, and Physical Activity Behavior in Patients With Degenerative Lumbar Spinal Stenosis: A Systematic Review and Meta-Analysis.

OBJECTIVE: To investigate the effectiveness of conservative nonpharmacologic therapies on pain, disability, physical capacity, and physical activity outcomes in patients with degenerative lumbar spinal stenosis (LSS). DATA SOURCES: Systematic search of MEDLINE, EMBASE, CENTRAL, and PsycINFO from inception to November 4, 2019, without language restrictions. STUDY SELECTION: Pairs of review authors independently identified randomized controlled trials published in peer-reviewed scientific journals reporting on the effects of rehabilitation interventions on pain intensity (back or leg), disability, symptom severity, physical capacity, physical activity behavior, or adverse events (secondary outcome) in adults with LSS. The search identified 1718 records; data from 21 reports of 19 trials (1432 patients) were included. DATA EXTRACTION: Review author pairs independently extracted data and assessed included studies. We assessed risk of bias with the Cochrane tool, and overall study quality with the Grading of Recommendations Assessment, Development and Evaluation classification. DATA SYNTHESIS: We pooled data using random-effects meta-analyses; treatment effects were reported as mean differences (MD) and 95% confidence intervals (CI). Directed exercise and manual therapy was superior to self-directed or group exercise for improving short-term walking capacity (MD, 293.3 m; 95% CI, 61.7-524.9 m; low-quality evidence), back pain (MD, -1.1; 95% CI, -1.8 to -0.4; moderate quality evidence), leg pain (MD, -.9; 95% CI, -0.2 to -1.5; moderate-quality evidence), and symptom severity (MD, -0.3; 95% CI, -0.4 to -0.2; low quality evidence). There is very low quality evidence that rehabilitation is no better than surgery at improving intermediate- or long-term disability. Single trials provided conflicting evidence of effectiveness for a variety of therapies. CONCLUSIONS: For patients with LSS, there is low- to moderate-quality evidence that manual therapy with supervised exercises improves short-term walking capacity and results in small improvements in pain and symptom severity compared with self-directed or group exercise. The choice between rehabilitation and surgery for LSS is very uncertain owing to the very low quality of available evidence.

Effectiveness of an exercise-based prehabilitation program for patients awaiting surgery for lumbar spinal stenosis: a randomized clinical trial.

Lumbar spinal stenosis is the most common reason for spine surgery in older adults, but the effects of prehabilitation on perioperative outcomes among these patients have not been investigated. This study aims to evaluate the effectiveness of a preoperative exercise-based intervention program compared with usual care on the improvement of clinical status, physical capacities and postoperative recovery of patients awaiting surgery for lumbar spinal stenosis. Sixty-eight participants were randomised to receive either a 6-week supervised exercise-based prehabilitation program or hospital usual care. The outcomes included both clinical and physical measures. Data collection occurred at post-intervention, and 6 weeks, 3- and 6-months post-surgery. Significant but small improvements were found in favour of the experimental group at the post-intervention assessment for pain intensity, lumbar spinal stenosis-related disability, lumbar strength in flexion, low back extensor muscles endurance, total ambulation time, and sit to stand performance. A significant difference in favor of the intervention group was found starting at the 3-month postoperative follow-up for low back-related disability. No adverse events were reported. Exercise-based prehabilitation did not improve short-term postoperative recovery in patients with lumbar spinal stenosis.

Supervised physical therapy versus unsupervised exercise for patients with lumbar spinal stenosis: 1-year follow-up of a randomized controlled trial.

OBJECTIVE: To compare the 1-year outcomes of patients with lumbar spinal stenosis treated with supervised physical therapy or unsupervised exercise. DESIGN: A single-center randomized controlled trial with concealed allocation, blinded assessor and intention-to-treat analysis. SETTING: Spine care center. SUBJECTS: A total of 86 patients presenting with symptoms of neurogenic claudication caused by lumbar spinal stenosis. INTERVENTIONS: The physical therapy group received supervised physical therapy sessions twice a week for 6 weeks and home exercise program. The home exercise group received 6-week home exercise program only. MAIN MEASURES: The primary outcome was symptom severity on the Zurich claudication questionnaire at 1 year. Secondary outcomes included physical function, pain, health-related quality of life and the surgery rate after 1 year. RESULTS: At 1 year, more patients in the physical therapy group than in the home exercise group achieved minimum clinically important differences in Zurich claudication questionnaire symptom severity (60.5% vs 32.6%; adjusted odds ratio [AOR] 4.3, [95% CI [1.5-12.3], P = 0.01); Zurich claudication questionnaire physical function (55.8% vs 32.6%; AOR 3.0 [1.1-8.1], P = 0.03); SF-36 bodily pain (48.8% vs 25.6%; AOR 2.8 [1.1-7.3], P = 0.03), and SF-36 general health (20.9% vs 7.0%; AOR 6.1 [1.1-33.0], P = 0.04). The surgery rate at 1 year was lower in the physical therapy than in the home exercise group (7.0% vs 23.3%; AOR 0.2 [0.04-0.9] P = 0.04). CONCLUSIONS: Supervised physical therapy produced greater improvements in symptom severity and physical function than unsupervised exercise and was associated with lower likelihood of receiving surgery within 1 year.

A Qualitative Study of Preparation for Lumbar Spinal Stenosis Surgery: Perceptions of Patients and Physical Therapists.

OBJECTIVES: To gain the perspectives of patients who underwent lumbar spinal stenosis (LSS) surgery and physical therapists who treat spine-related disorders regarding rehabilitation and other care prior to LSS surgery. DESIGN: Qualitative focus group study. METHODS: Sixteen patients (4 female; average ± SD age, 64.3 ± 8.8 years; time since surgery, 9.9 ± 4.4 months) and 10 physical therapists (2 female; average ± SD age, 40.9 ± 6.6 years; time in practice, 17.2 ± 7.7 years) participated. Four groups were conducted: 2 with patients post LSS surgery and 2 with physical therapists who treat spine-related disorders. Participants were asked open-ended questions by a trained facilitator regarding their perceptions of preoperative LSS education and rehabilitation. Transcripts were coded and themes were identified. RESULTS: Analyses revealed 4 themes within the discussions: (1) desire for helpful information, (2) benefits of preoperative rehabilitation, (3) downfalls of preoperative rehabilitation, and (4) desire for coordinated care. Varying opinions on preoperative physical therapy between patients and physical therapists were discussed, revealing that similar numbers of participants held positive and negative perceptions of preoperative physical therapy. A desire for more thorough preoperative education and care was expressed by both groups. CONCLUSION: There is a clear need for standardized preoperative LSS care and education. This may decrease misunderstandings about LSS surgery and its treatments in the future as well as improve coordinated care between surgeons and physical therapists. J Orthop Sports Phys Ther 2020;50(4):198-205. Epub 30 Oct 2019. doi:10.2519/jospt.2020.8887.

Provocative Walking Test of Strength for Diagnosis, Management, and Outcome Assessment of Symptomatic Lumbar Spinal Stenosis.

Background. Clinical care and randomized trials of rehabilitation or surgery for symptomatic lumbar spinal stenosis with neurogenic claudication (LSS) are complicated by the lack of standard criteria for diagnosis and outcome measurement. Objective. To evaluate whether manual muscle testing (MMT) can detect transient lower-extremity weakness provoked by walking in patients with likely LSS. Methods. A total of 19 patients with symptoms and MRI findings suggestive of LSS were tested for a decline in lower-extremity strength, using the British Medical Council scale of MMT, by comparing strength at rest to a change in strength within 60 s of completing a 400-foot walk. They were retested after reclining supine for another 2 minutes. This examination was repeated following decompressive lumbar surgery. Results. All patients developed bilateral weakness in the distribution of their LSS, but always including the hip extensors and knee flexors, when tested immediately after the provocative walking test. Most patients were not aware of weakness or change in gait during the walking task. They recovered to baseline strength after resting supine. The patients did not improve with physical therapy. When examined within 8 weeks after decompressive laminectomy, no one developed weakness during the 400-foot walk, and daily lower-extremity pain had resolved. Conclusions. A careful repetitive motor examination can detect transient paraparesis in patients with definite LSS. This finding supports the diagnosis and the functional severity of LSS while providing an objective outcome measurement for physical therapy and surgical interventions that goes beyond symptoms of pain.

Feasibility of conducting an active exercise prehabilitation program in patients awaiting spinal stenosis surgery: a randomized pilot study.

Prehabilitation is defined as the process of augmenting functional capacity before surgery in preparation for the postoperative phase. This study intends to assess the feasibility of conducting a preoperative intervention program in patients with lumbar spinal stenosis and to report on the piloting of the proposed intervention. Patients were allocated to a 6-week supervised preoperative rehabilitation program or a control group. The intervention included supervised exercise sessions aimed to improve strength, muscular endurance, and spinal stabilization. Outcomes were measured at baseline, 6 weeks later and again 6 weeks, 3 months and 6 months after surgery. Sixty-five percent of admissible participants agreed to take part in the study, of which 5% dropped out before the end of the intervention period. Eighty-eight percent of potential training sessions were delivered without adverse event. Improvements were seen in favour of the experimental group at the preoperative assessment for active ranges of motion, leg pain intensity, lumbar extensor muscle endurance and walking capacities. Results show that slight modifications to the choice of outcome measures would increase feasibility of the main study. The absence of adverse events coupled with positive changes seen in dependant outcome measures warrant the conduct of a full-scale trial assessing the effectiveness of the intervention.

Altered postural timing and abnormally low use of proprioception in lumbar spinal stenosis pre- and post- surgical decompression.

BACKGROUND: Lumbar spinal stenosis (LSS) is frequently associated with postural instability. Although several studies evaluated patients' functional impairments, underlying sensorimotor mechanisms are still poorly understood. We aimed to assess the specific set of postural control deficits associated with LSS during spontaneous and externally perturbed stance and evaluated post-surgical changes in postural behavior. METHODS: We analyzed postural control in eleven LSS patients (age 69 ± 8 years) pre- and post-laminectomy, correlated experimental data with functional tests and patient-reported outcomes, and compared findings to 15 matched, healthy control subjects (age 70 ± 6 years). Postural control was characterized by spontaneous sway measures and measures of perturbed stance. Perturbations were induced by anterior-posterior pseudorandom tilts of the body support surface. We used an established postural control model to extract specific postural control parameters. RESULTS: Spontaneous sway amplitude, velocity and frequency were abnormally large in LSS patients. Furthermore, patients' postural reactions to platform tilts, represented by GAIN and PHASE were significantly altered. Based on simple feedback model simulations, we found that patients rely less on proprioceptive cues for stance regulation than healthy subjects. Moreover, their postural reactions' timing is altered. After surgery, patients' spontaneous sway amplitude was significantly reduced and their postural timing approximated the behavior of healthy subjects. CONCLUSION: The reduction in proprioceptive input for stance control due to stenosis-caused afferent dysfunction is a functional disadvantage for LSS patients - and may be the basis of increased spontaneous sway. This disadvantage may cause the timing of postural reactions to alter, with the intent of preventing rapid changes in stance regulation for safety reasons. After surgery, patients' postural timing approximated those of healthy subjects, while the abnormally low use of proprioception remained unchanged. We suggest the post-surgery rehabilitation of proprioception, eg through balance exercises on unstable surfaces and reduced visual input.

Development and delivery of the BOOST (Better Outcomes for Older adults with Spinal Trouble) intervention for older adults with neurogenic claudication.

Neurogenic claudication due to spinal stenosis is a common cause of disability in older adults. Conservative treatments are a favourable treatment option. This paper describes the development and delivery of the BOOST (Better Outcomes for Older adults with Spinal Trouble) intervention, a physiotherapist-delivered physical and psychological intervention for the management of neurogenic claudication in older adults. The BOOST intervention is being tested in a multi-centre, randomised controlled trial in UK National Health Service Trusts; delivered by physiotherapists registered with the Health and Care Professionals Council. Participants are aged 65 years or older, registered with a primary care practice, and report symptoms consistent with neurogenic claudication. Intervention content and delivery was initially informed by clinical and patient experts, research evidence, and behaviour change guidelines; and refined following an intervention development day attended by researchers, health professionals, and Patient and Public Involvement representatives. The BOOST intervention comprises 12 group sessions, promoting sustained adherence with a long term home and physical activity programme. Each session includes education and group discussion, individually tailored exercises, and walking. Initial exercise levels are set at a one-to-one assessment. Continued home exercise adherence and increased physical activity following completion of the sessions is facilitated through support telephone calls. Trial registration ISRCTN12698674.

Impact of Spinal Manipulation on Lower Extremity Motor Control in Lumbar Spinal Stenosis Patients: A Small-Scale Assessor-Blind Randomized Clinical Trial.

OBJECTIVE: The purpose of this study was to quantify the impact of a single lumbar spinal manipulation (SM) intervention on the leg movement performance of degenerative lumbar spinal stenosis (LSS) patients in a small-scale registered randomized clinical trial. METHODS: Participants with LSS (n = 14) were tested at baseline for pain, lumbar range of motion, and behavioral or kinematic motor performance (using an established Fitts' Law foot-pointing task), then underwent covariate adaptive randomization to receive SM or no intervention. Postintervention all dependent measures were repeated. Experimenters were blinded to patient group allocation. University ethics board approval was attained. RESULTS: For the primary outcome movement time, there was no significant difference between groups. As predicted by Fitts' Law, all participants had longer movement times as task difficulty increased. Secondary kinematic outcomes yielded no significant between-group differences. Consistent with Fitts' Law, kinematic measures changed significantly with task difficulty. Pairwise comparisons revealed the kinematic variables were more adversely affected by greater movement amplitudes than target size changes. No exploratory differences in pain or lumbar range of motion were observed. CONCLUSION: Changes in motor performance were not observed in this chronic pain population after a single SM intervention compared with a control group. Given the sample size, the study may have been underpowered to detect meaningful differences. Fitts' Law was observed for the lower extremity-pointing task for an LSS population and may provide an objective measure of motor performance.

Effectiveness of Physical Therapy Combined With Epidural Steroid Injection for Individuals With Lumbar Spinal Stenosis: A Randomized Parallel-Group Trial.

OBJECTIVE: To examine the effectiveness of epidural steroid injection (ESI) and back education with and without physical therapy (PT) in individuals with lumbar spinal stenosis (LSS). DESIGN: Randomized clinical trial. SETTING: Orthopedic spine clinics. PARTICIPANTS: A total of 390 individuals were screened with 60 eligible and randomly selected to receive ESI and education with or without PT (N=54). INTERVENTIONS: A total of 54 individuals received 1-3 injections and education in a 10-week intervention period, with 31 receiving injections and education only (ESI) and 23 additionally receiving 8-10 sessions of multimodal PT (ESI+PT). MAIN OUTCOME MEASURES: Disability, pain, quality of life, and global rating of change were collected at 10 weeks, 6 months, and 1 year and analyzed using linear mixed model analysis. RESULTS: No significant difference was found between ESI and ESI+PT in the Oswestry Disability Index at any time point, although the sample had significant improvements at 10 weeks (P<.001; 95% confidence interval [CI], -18.01 to -5.51) and 1 year (P=.01; 95% CI, -14.57 to -2.03) above minimal clinically important difference. Significant differences in the RAND 36-Item Short Form Health Survey 1.0 were found for ESI+PT at 10 weeks with higher emotional role function (P=.03; 95% CI, -49.05 to -8.01), emotional well-being (P=.02; 95% CI, -19.52 to -2.99), and general health perception (P=.05; 95% CI, -17.20 to -.78). CONCLUSIONS: Epidural steroid injection plus PT was not superior to ESI alone for reducing disability in individuals with LSS. Significant benefit was found for the addition of PT related to quality of life factors of emotional function, emotional well-being, and perception of general health.

Predicting clinical outcome and length of sick leave after surgery for lumbar spinal stenosis in Sweden: a multi-register evaluation.

PURPOSE: Lumbar spinal stenosis (LSS) can be surgically treated, with variable outcome. Studies have linked socioeconomic factors to outcome, but no nation-wide studies have been performed. This register-based study, including all patients surgically treated for LSS during 2008-2012 in Sweden, aimed to determine predictive factors for the outcome of surgery. METHODS: Clinical and socioeconomic factors with impact on outcome in LSS surgery were identified in several high-coverage registers, e.g., the national quality registry for spine surgery (Swespine, FU-rate 70-90%). Multivariate regression analyses were conducted to assess their effect on outcome. Two patient-reported outcome measures, Global Assessment of leg pain (GA) and the Oswestry Disability Index (ODI), as well as length of sick leave after surgery were analyzed. RESULTS: Clinical and socioeconomic factors significantly affected health outcome (both GA and ODI). Some predictors of a good outcome (ODI) were: being born in the EU, reporting no back pain at baseline, a high disposable income and a high educational level. Some factors predicting a worse outcome were previous surgery, having had back pain more than 2 years, having comorbidities, being a smoker, being on social welfare and being unemployed. CONCLUSIONS: The study highlights the relevance of adding socioeconomic factors to clinical factors for analysis of patient-reported outcomes, although the causal pathway of most predictors' impact is unknown. These findings should be further investigated in the perspective of treatment selection for individual LSS patients. The study also presents a foundation of case mix algorithms for predicting outcome of surgery for LSS. These slides can be retrieved under Electronic Supplementary Material.

Preoperative sense of coherence associated with the 10-year outcomes of lumbar spinal stenosis surgery.

A prospective 10-year follow-up study was conducted to determine the significance of the preoperative sense of coherence, with respect to the preoperative and 10-year clinical characteristics, among lumbar spinal stenosis patients ( N = 99). In addition, the predictive value of the preoperative sense of coherence regarding the 10-year surgery outcome was also evaluated. In a logistic regression analysis, a weak preoperative sense of coherence and low functional ability predicted the patients' functional ability 10 years after the surgery. Moreover, those patients with weak sense of coherence before surgery showed poorer functional ability 10 years after the surgery, but not preoperatively. A weak preoperative sense of coherence seems to associate with poorer long-term outcome after surgery; therefore, various rehabilitation strategies are discussed.

[Clinical study of exercise rehabilitation and gait analysis during the perioperative period of lumbar percutaneous transforaminal endoscopic discectomy].

OBJECTIVE: To explore the clinical effect of exercise rehabilitation during perioperative period on residual pain, gait and activities of daily living (ADL) in patients with lumbar spinal stenosis (LSS) after lumbar percutaneous transforaminal endoscopic discectomy(PTED). METHODS: The clinical data of 48 patients with LSS underwent PTED from December 2015 to December 2016 were retrospectively analyzed. Patients were divided into observation group and control group according to different rehabilitation patterns, being 24 cases in each group. The patients of observation group received exercise rehabilitation and the patients of control group received conventional rehabilitation. Visual analogue scale(VAS), Oswestry Disability Index (ODI) and the ratio of supporting phase were recorded before operation and 12 days, 6 months after operation. The correlation between the ratio of supporting phase and VAS, ODI was analyzed. RESULTS: The ratio of supporting phase of observation group was significantly higher than that of control group at 12 days after operation(P<0.05). The VAS and ODI in observation group were significantly lower than that of control group at 6 months after operation(P<0.01). There was no correlation between the ratio of supporting phase and ODI or VAS in two groups (P>0.05). CONCLUSIONS: Lumbar percutaneous transforaminal endoscopic discectomy combined with exercise rehabilitation during the perioperative period can release or eliminate postoperative residual pain, improve gait balance, enable activities of daily living, and has a positive effect in patients with lumbar spinal stenosis.

Which Neuromuscular Attributes Are Associated With Changes in Mobility Among Community-Dwelling Older Adults With Symptomatic Lumbar Spinal Stenosis?

OBJECTIVES: To identify neuromuscular attributes associated with mobility and changes in mobility over 2 years of follow-up among patients with and without symptomatic lumbar spinal stenosis (SLSS). DESIGN: Secondary analysis of a longitudinal cohort study. SETTING: Outpatient rehabilitation center. PARTICIPANTS: Community-dwelling older adults ≥65 years with self-reported mobility limitations (N=430). SLSS was determined using self-reported symptoms of neurogenic claudication and imaging-detected lumbar spinal stenosis. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Basic and advanced mobility as measured by the Late-Life Function and Disability Instrument (LLFDI). RESULTS: Among 430 community-dwelling older adults, 54 (13%) patients met criteria for SLSS, while 246 (57%) did not. On average LLFDI basic and advanced mobility scores decreased significantly from baseline through year 2 for participants with SLSS (basic: P=.04, 95% CI 0.18, 5.21; advanced P=.03, 95% CI 0.39, 7.84). Trunk extensor muscle endurance (trunk endurance) and leg strength were associated with baseline basic mobility (R2=0.27, P<.001) while leg strength and knee flexion range of motion (ROM) were associated with baseline advanced mobility among participants with SLSS (R2=0.47, P<.001). Among participants without SLSS trunk endurance, leg strength and ankle ROM were associated with baseline basic mobility (R2=0.38, P<.001), while trunk endurance, leg strength, leg strength asymmetry, and knee flexion ROM were associated with advanced mobility (R2=0.20, P<.001). Trunk endurance and leg strength were associated with change in basic mobility (R2=0.29, P<.001), while trunk endurance and knee flexion ROM were associated with change in advanced mobility (R2=0.42, P<.001) among participants with SLSS. Among participants without SLSS trunk endurance, leg strength, knee flexion ROM, and ankle ROM were associated with change in basic mobility (R2=0.22, P<.001), while trunk endurance, leg strength, and knee flexion ROM were associated with change in advanced mobility (R2=0.36, P<.001). CONCLUSIONS: Patients with SLSS experience greater impairment in the neuromuscular attributes: trunk endurance, leg strength, leg strength asymmetry, knee flexion and extension ROM, and ankle ROM compared to patients without SLSS. Differences exist in the neuromuscular attributes associated with mobility at baseline and decline in mobility over 2 years of follow-up for patients with and without SLSS. These findings may help guide rehabilitative care approaches for patients with SLSS.

Home-based cycling program tailored to older people with lumbar spinal stenosis: Barriers and facilitators.

BACKGROUND: Lumbar-flexion-based endurance training, namely cycling, could be effective in reducing pain and improving function and health-related quality of life in older people with chronic low back pain. OBJECTIVES: To assess barriers and facilitators to home-based cycling in older patients with lumbar spinal stenosis (LSS). METHODS: We conducted a retrospective mixed-method study. Patients≥50 years old followed up for LSS from November 2015 to June 2016 in a French tertiary care center were screened. The intervention consisted of a single supervised session followed by home-based sessions of cycling, with dose (number of sessions and duration, distance and power per session) self-determined by patient preference. The primary outcome was assessed by a qualitative approach using semi-structured interviews at baseline and 3 months and was the identification of barriers and facilitators to the intervention. Secondary outcomes were assessed by a quantitative approach and were adherence monitored by a USB stick connected to the bicycle, burden of treatment assessed by the Exercise Therapy Burden Questionnaire (ETBQ) and clinical efficacy assessed by change in lumbar pain, radicular pain, disability, spine-specific activity limitation and maximum walking distance at 3 months. RESULTS: Overall, 15 patients were included and data for 12 were analyzed at 3 months. At baseline, the mean age was 70.9 years (95% CI: 64.9-76.8) and 9/15 patients (60.0%) were women. Barriers to cycling were fear of pain and fatigue, a too large bicycle, burden of hospital follow-up and lack of time and motivation. Facilitators were clinical improvement, surveillance and ease-of-use of the bicycle. Adherence remained stable overtime. The burden of treatment was low [mean ETBQ score: 21.0 (95% confidence interval: 11.5-30.5)]. At 3 months, 7/12 patients (58.3%) self-reported clinical improvement, with reduced radicular pain and disability [mean absolute differences: -27.5 (-43.3 to -11.7), P<0.01 and -17.5 (-32.1 to -2.9), P=0.01, respectively]. CONCLUSIONS: For people with LSS, home-based cycling is a feasible intervention.

A comparative study of 2-year follow-up outcomes in lumbar spinal stenosis patients treated with physical therapy alone and those with surgical intervention after less successful physical therapy.

BACKGROUND: The efficacy of physical therapy for patients with lumbar spinal stenosis (LSS) has been reported only for the short term, and few reports have compared outcomes of surgical treatment with nonsurgical treatment after physical therapy. The purpose of this study was to assess 2-year outcomes of LSS patients treated with surgery or under follow-up observation after physical therapy for 6 weeks. METHODS: Patients presenting with neurogenic claudication, radiologically-confirmed central LSS affecting both legs and refractory symptoms to pharmacotherapy of more than 3 months were enrolled. Patients were treated with manual therapy, stretching and strengthening exercises, and body weight-supported treadmill walking once a week for 6 weeks. Clinical outcomes were measured using the Zurich Claudication Questionnaire (ZCQ), visual analog scale of low back pain, leg pain, and numbness, the Japanese Orthopedic Association Back Pain Evaluation Questionnaire and the SF-36. Two years after physical therapy, patients were classified into the observation group (Group I) or the surgery group (Group II), whose patients failed to respond to physical therapy and wanted to undergo surgery. RESULTS: Thirty-eight patients were enrolled; 28 had complete data at 2 years: 21 and 7 in Groups I and II, respectively. Group II had a higher body mass index (BMI) than Group I. There were no significant differences in clinical outcomes at baseline. Six weeks after physical therapy, Group I had significantly better outcomes for symptom severity and physical function on the ZCQ subscales, physical functioning and bodily pain on the SF-36 subscales. These outcomes in Group I were maintained or improved and did not differ significantly between groups at 2-years. However, the physical function on the ZCQ subscales was improved in Group II more than those in Group I (mean difference -0.6; 95% CI: -1.2 to -0.03, P < 0.05) at 2 years. CONCLUSIONS: At 2 years, the outcomes except for the change in physical function score in the ZCQ subscale did not differ significantly between patients who had undergone surgery and those who avoided surgery.

Telephone-Based Intervention to Improve Rehabilitation Engagement After Spinal Stenosis Surgery: A Prospective Lagged Controlled Trial.

BACKGROUND: Spine surgery outcomes are variable. Patients who participate in and take responsibility for their recovery have improved health outcomes. Interventions to increase patient involvement in their care may improve health outcomes after a surgical procedure. We conducted a prospective interventional trial to compare the effectiveness of health behavior change counseling with usual care to improve health outcomes after lumbar spine surgical procedures. METHODS: In this study, 122 patients with lumbar spinal stenosis undergoing a decompression surgical procedure from December 2009 through August 2012 were enrolled. Participants were assigned, according to enrollment date, to health behavior change counseling or usual care. Health behavior change counseling is a brief, telephone-based intervention intended to increase rehabilitation engagement through motivational interviewing strategies that elicit and strengthen motivation for change. Health behavior change counseling was designed to identify patients with low patient activation, to maximize postoperative rehabilitation engagement, to decrease pain and disability, and to improve functional recovery. Participants were assessed before the surgical procedure and for 3 years after the surgical procedure for pain intensity (Brief Pain Inventory), disability (Oswestry Disability Index), and physical health (12-Item Short-Form Health Survey, version 2). Differences in changes in health outcomes after the surgical procedure were compared between the health behavior change counseling group and the usual care group. RESULTS: By 12 months, health behavior change counseling participants reported significantly greater reductions in pain intensity (p = 0.008) and disability (p = 0.028) and significantly greater improvement in physical health compared with usual care participants (p = 0.025). These differences were attenuated by 24 and 36 months after the surgical procedure. Early improvements in health outcomes were mediated by improvements in physical therapist-rated engagement and self-reported attendance at physical therapy sessions in the health behavior change counseling group. CONCLUSIONS: Health behavior change counseling improved health outcomes during the first 12 months after the surgical procedure through changes in rehabilitation engagement. Wider use of health behavior change counseling may lead to improved outcomes not only after lumbar spine surgery but also in other conditions for which rehabilitation is key to recovery. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Spinal cord injury associated with cervical spinal canal stenosis: Outcomes and prognostic factors.

OBJECTIVES: To specify outcomes and identify prognostic factors of neurologic and functional recovery in patients with an acute traumatic spinal cord injury (SCI) associated with cervical spinal canal stenosis (SCS), without spinal instability. METHODS: A retrospective study was conducted using data from a Regional Department for SCI rehabilitation in France. A description of the population characteristics, clinical data and neurological and functional outcomes of all patients treated for acute SCI due to cervical trauma associated with SCS was performed. A statistical analysis provided insights into the prognostic factors associated with the outcomes. RESULTS: Sixty-three patients (mean age 60.1 years) were hospitalized for traumatic SCI with SCS and without instability between January 2000 and December 2012. Falls were the most frequent cause of trauma (77.8%). At admission, most patients had an American Spinal Injury Association Impairment Scale (AIS) grade of C (43.3%) or D (41.7%) and the most frequent neurological levels of injury were C4 (35.7%) and C5 (28.6%). Clinical syndromes were frequently identified (78.6%), with the most frequent being the Brown-Sequard plus syndrome (BSPS) (30.9%), followed by central cord syndrome (CCS, 23.8%). Almost 80% of survivors returned to the community, 60% were able to walk and 75% recovered complete voluntary control of bladder function. Identified prognostic factors of favourable functional outcomes were higher AIS at admission, age under 60 years and presence of BSPS or CCS. CONCLUSION: Traumatic SCI, associated with SCS results mostly in incomplete injuries, can cause various syndromes and is associated with favourable functional outcomes.