Effectiveness of conservative non-pharmacologic therapies for pain, disability, physical capacity, and physical activity behaviour in patients with degenerative lumbar spinal stenosis: a systematic review and meta-analysis.

Abstract

OBJECTIVE\nTo investigate the effectiveness of conservative non-pharmacologic therapies on pain-related, physical capacity, and physical activity outcomes in patients with degenerative lumbar spinal stenosis (LSS).\n\n\nDATA SOURCES\nSystematic search of MEDLINE, EMBASE, CENTRAL, and PsycINFO from inception to November 4, 2019 without language restrictions.\n\n\nSTUDY SELECTION\nPairs of review authors independently identified randomized clinical 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 1,718 records; data from 21 reports of 19 trials (1,432 patients) were included.\n\n\nDATA EXTRACTION\nReview 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.\n\n\nDATA SYNTHESIS\nWe pooled data using random-effects meta-analyses; treatment effects were reported as mean differences (MD) and 95% CI. Directed exercise and manual therapy was superior to self-directed or group exercise for improving short-term walking capacity (MD[95%CI]\u202f=\u202f293.3[61.7 to 524.9] meters; low-quality evidence), back pain (MD[95%CI]\u202f=\u202f-1.1[-1.8 to -.4; moderate quality evidence], leg pain (MD[95%CI]\u202f=\u202f-.9[-.2 to -1.5]; moderate-quality evidence), and symptom severity (MD[95%CI]\u202f=\u202f-.3[-.4 to -.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.\n\n\nCONCLUSIONS\nFor patients with LSS, there is low- to moderate-quality evidence that manual therapy with supervised exercises results in small improvements in short-term walking capacity, pain, and symptom severity compared to 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.