Physical therapy and surgery produce the same results for stenosis in older patients


Symptoms from lumbar spinal stenosis were relieved and function improved in as many patients utilising physical therapy as those undergoing surgical treatment, University of Pittsburgh researchers have shown in a two-year study published in Annals of Internal Medicine.

The researchers believe that this is the first study that clearly compared outcomes between surgery and an evidence-based, standardised physical therapy approach for lumbar spinal stenosis. The condition has seen decompression surgery become one of the fastest-growing interventions in older populations.

A total of 169 patients aged 50-plus set to undergo decompression surgery agreed to be randomly assigned into two groups—those who would have the procedure, and those who would go through two standardised, evidence-based physical therapy sessions per week for six weeks. After both groups were re-examined at intervals of six months, one year and two years, the patient outcomes appeared to be equal. There were no detectable differences between the groups in how their pain abated and the degree to which function was restored in their backs, buttocks and legs.

“Probably the biggest point to put across to physicians, patients and practitioners is: patients do not exhaust all of their non-surgical options before they consent to surgery. And physical therapy is one of their non-surgical options,” said principal investigator Anthony Delitto, chair of the Department of Physical Therapy, Pitt School of Health and Rehabilitation Sciences, as well as a member of Pitt’s Health Policy Institute and a consultant to University of Pittsburgh Medical Center.

“The idea we had was to really test the two approaches head to head,” he said. “Both groups improved, and they improved to the same degree. Now, embedded in that, there are patients who did well in surgery, and patients who failed in surgery. There are patients who did well in physical therapy, and there are patients who failed with physical therapy. But when we looked across the board at all of those groups, their success and failure rates were about the same.”

The research project also revealed issues surrounding physical therapy appointments in the USA and the cost of co-payments. Most patients did not finish the physical therapy regimen allowed them under Medicare and prescribed by the researchers, and one-third of the patients failed to complete even half of the regimen. Another 16% did not show for a single treatment, even though they had agreed to consider physical therapy.

“One of the big things that we know held patients back from physical therapy were co-payments,” Delitto explained. “Patients were on Medicare, and a lot of them were on fixed incomes. Some of those co-payments had to come out of pocket at US$25–35 per visit. That adds up, and some of the patients just could not afford it.”