Lumbar Stenosis

[AJ Lievre]

Have a read. Nice to see PT’s as lead author’s in internal medicine journals.
Good supplement to this past weekend.
AJ

[Michael McMurray]

The article is attached

[Nick Law]

Thanks so much for posting AJ. I was fortunate to have ready this article a few months prior to starting residency, however I gleaned even more from it this go round. A few quick thoughts I had while reading the article:

– Was surprised to see that surgery for stenosis was the most common reason for lumbar surgery in the U.S.

– I thought a real strength of the study was that all of the patients included were deemed surgical candidates. If PT was beneficial to patients even with this level of impairment and pain, how much moreso is it appropriate for those with less disability.

– Lumbar flexion exercises received a grade of C in the practice guidelines, but were a core intervention in this study. Several PT interventions were used, and there was no control group, however I wonder if this study will contribute to increasing the grade of recommendation when the guidelines are updated.

– “Of the 481 patients who met eligibility criteria, 312 declined to participate, with most preferring not to risk randomly being assigned to the non surgical group and instead going straight to surgery.” Did anyone else cringe when they read this? I am assuming it was made known to the patients that they could transfer over to the surgical group at any time during the study. If so, this statement is quite condemning to our cultures attitudes and beliefs regarding surgical vs. skilled non surgical care.

– Along the same lines as the above statement, a very large percentage switched from PT to surgery. Misguided and erroneous beliefs (lower education levels noted in this group of patients)….

– An ODI of 27 at 26 and 104 week follow up for patients who were deemed appropriate for surgical intervention seemed quite satisfactory to me….go PT.

Other thoughts?

[Laura Thornton]

Really interesting article because I think it portrays a similar frustration that we face as providers of conservative treatment for this patient population.

The numbers of patients who declined participation in the trial based on the CHANCE of them receiving PT treatment as well as the number of cross-overs from PT to surgery and non-compliance with PT treatment shows the amount of obstacles we have to pass to show actual positive effects of conservative treatment only. In that sense, it is even more impressive that the results showed similar SF-32 outcomes, especially when you look at Appendix 2 with separating the crossovers from the patients who stayed with PT only.

Along with this, the intention to treat analysis is based on the number of patients who were offered initial PT treatment and includes the crossovers to the surgical group during the study. It’s somewhat difficult to take these results and conclude the similar effect of conservative treatment to surgical in all of the outcome measures. How are we to tell? Are the results from Appendix 2 a more important distinction then?

I’m having difficulty in understanding the importance of the CACE estimate. The difference in PT compliers vs. the number of patients in the surgical group who would have complied with PT if had been randomized to PT instead? Does anyone else think this is a bit hard to generalize?

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