Overcoming Barriers to Non-surgical Treatment for Lumbar Spinal Stenosis

Peer Reviewed

Many patients are willing to comply with non-surgical treatments for lumbar spinal stenosis, including exercise, but face various barriers to treatment compliance, according to a qualitative study in the April issue of The Spine Journal.
Hands on training during a physical therapy session"Patients with lumbar stenosis genuinely want to learn how to self-manage their condition"“Our findings indicate that patients with lumbar stenosis genuinely want to learn how to self-manage their condition,” said lead author Allyn M. Bove, PT, DPT, Assistant Professor in the Department of Physical Therapy at the University of Pittsburgh School of Health and Rehabilitation Sciences in Pittsburgh, PA. “As clinicians, it is imperative that we provide education on self-managing stenosis and connect our patients to other providers or community groups that can support them as they learn to manage the disease.”

“In addition, many patients with lumbar stenosis recognize the importance of committing to exercise and physical activity, but they want to participate in programs that are tailored to their abilities and interests,” Dr. Bove told SpineUniverse. “Therefore, it may be wise to refer these patients for a short course of formal rehabilitation to learn optimal exercise techniques that will help with their particular symptoms. Of course, the goal would be for these patients to become independent with exercises as quickly as possible and continue exercising long-term.”

“This study supports prior studies showing that patients typically benefit with exercise programs and should try all non-surgical options before considering surgery unless patients have progressive neurological issues (eg, weakness, bowel and bladder involvement, unsteady gait, unremitting pain),” commented Santhosh A. Thomas, DO, MBA, Medical Director of the Center for Spine Health and Associate Medical Director of the Richard E. Jacobs Medical Center at the Cleveland Clinic in Avon, OH. “Each patient has specific needs and ability, which should be strongly considered when planning an exercise program,” said Dr. Thomas, who is a SpineUniverse Editorial Board member.

Study Population and Interventions
The study included 50 patients with lumbar spinal stenosis (28 women; mean age 73-years) who were part of a larger randomized clinical trial of non-surgical treatments (n=180). The 50 patients participated in a qualitative focus group to discuss their treatments and experiences with lumbar spinal stenosis.

Interventions were conducted over a 6-week period and included:

  1. Medical care (n=18): Consult and two follow-up visits with a physical medicine and rehabilitation physician. Treatments included oral medications, epidural corticosteroid injections, and physical activity recommendations.
  2. Community-based group exercise classes (n=15): two sessions per week.
  3. Clinic-based manual therapy and individual exercise (n=17): two sessions per week.

Non-surgical Treatments Improved Pain and Functioning
The patients reported consistently positive feedback regarding all three study interventions, with most patients reporting at least some degree of reduced pain or improved functioning, particularly regarding walking ability. For many patients, the effect of the exercise intervention was temporary unless done on an ongoing basis beyond the 6-week study period.

Other modalities that provided temporary relief included corticosteroid injections and pain medications. In general, patients stated a preference for individualized health care tailored to their particular limitations and lifestyle.

Barriers to Non-surgical Treatments for Lumbar Spinal Stenosis
Transportation was the most common barrier to accessing non-surgical health care for lumbar spinal stenosis; time constraints and cost of continued care outside of the study were also common barriers to care. In addition, comorbidities (eg, chest pain and pulmonary disease) were frequently cited as barriers to exercise participation.

Few patients reported spinal stenosis symptoms and functional limitations as barriers to care.

Improving Access to Non-surgical Treatments for Lumbar Spinal Stenosis
“The patients in our study indicated that they place a high value on physicians with good communication skills,” Dr. Bove said. “It is important for spine care specialists to talk to their patients with lumbar stenosis and discuss the known benefits of exercise. If a patient seems interested but isn’t sure where to start, consider referring them to a rehabilitation provider and/or to a community-based exercise program.”

In addition, social support provided by group exercise classes was frequently cited by patients as a motivating factor to complying with treatment. The researchers suggested that healthcare providers should be aware of local exercise classes or support groups to refer patients to.

“Patients respond and prefer individualized treatments that address their specific limitations and impairments,” Dr. Thomas told SpineUniverse. “It is important to have patients buy-in to the individualized program and more importantly, once this is prescribed, they should participate in it actively and regularly so they can see and maintain the benefits of exercise.”

Dr. Thomas emphasized the importance of educating the public and patients about benefits of non-surgical options and timely referral to appropriate providers who can assess these patients before surgical referral. In addition, “patients should know the benefits of exercise, which are not limited to pain relief. Patients will notice improved mood, improved strength and coordination, and better ability to deal and recuperate from injuries,” Dr. Thomas said.

“There are a number of providers who specialize in various non-surgical treatments, including physical medicine and rehabilitation physicians (physiatrist), physical therapists, and chiropractors,” Dr. Thomas said. “Physical therapists should aim to have independence with an exercise program. Patients should exercise regularly and if gains are not noted within a few months (results are unlikely to be seen within hours, days or weeks from the start of a program), a reassessment with a physician would be helpful.”

“This study was performed with people who had willingly enrolled in a research study that involved exercise, so our results may not be generalizable to the overall population of individuals with lumbar spinal stenosis,” Dr. Bove noted. “However, research is clear that many individuals with chronic low back pain become fearful of exercise and movement because they think it will worsen their symptoms. As busy healthcare providers, we all need to find the time to have conversations with our patients with lumbar stenosis and address any concerns or fears they have about starting an exercise program.”

This study was funded by Patient-Centered Outcomes Research Institute.

Disclosures
Dr. Bove and Dr. Thomas have no relevant disclosures.

Updated on: 05/04/18
Continue Reading
Patient Characteristics Do Not Predict Benefit From Adding Corticosteroid to Lidocaine in Epidural Injections for Lumbar Spinal Stenosis Symptoms
Santhosh A. Thomas, DO, MBA
Medical Director
Center for Spine Health
Cleveland Clinic
Avon, OH
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