Rehabilitation following surgery for lumbar spinal stenosis

Abstract
Background
Lumbar spinal stenosis is a common cause of back pain among older people that can also give rise to pain in the buttock, thigh or leg, particularly when walking. There are several possible treatments, of which surgery appears to be best at restoring function and reducing pain. The outcome of surgery however falls well short of ideal and a sizeable proportion of patients do not regain good function. Importantly, there is no accepted evidence-based approach to post-operative care, which is what has prompted this review.
Objectives
This Cochrane Review was designed, to establish whether the outcome of surgery for lumbar stenosis can be improved by active rehabilitation programmes and if such programmes are superior to usual post-operative care. Active rehabilitation includes any group or therapist led intervention to improve functional status through a programme of exercises or educational material encouraging activity.
Search methods
A comprehensive search of CENTRAL (The Cochrane Library, most recent issue), the Cochrane Back Review Group Trials Register, MEDLINE, EMBASE, CINAHL, and PEDRO since their first issues was conducted on 12 January 2012.
Selection criteria
Only RCTs that compared the effectiveness of active rehabilitation with usual care in adults (>18 year olds) with confirmed lumbar spinal stenosis, who had undergone spinal decompressive surgery (with or without fusion) for the first time, were considered in this review.
Data collection and analysis
Two review authors independently extracted data for the included trials using a pre-developed form. Where necessary the authors of the original trials were contacted to request additional unpublished data. The outcome measures and interventions of the trials were assessed to ensure the baseline characteristics of participants were clinically homogeneous. The clinical relevance of each study was independently assessed, using the five questions recommended by the Cochrane Back Review Group (CBRG), and the risk of bias within the studies was assessed using the CBRG criteria.
The results of the individual studies were pooled in a meta-analysis where appropriate. For continuous outcomes, the mean difference (MD) was calculated when the same measurement scales were used in all studies and the standardised mean difference (SMD) when different measurement scales were used. Where the outcome data were skewed meta-analysis was performed on the log-scale and results were converted back to the original scale. A fixed-effect model was used to measure the treatment effect where there was no substantial evidence of statistical heterogeneity. If substantial statistical heterogeneity was detected, a random-effects model was used.

The primary outcome measure was functional status measured by a back-specific functional scale. Secondary outcomes included measures of leg pain and low back pain, and global improvement / general health. These were reported and analysed separately for short- and long-term outcomes. Statistical significance as well as clinical relevance of outcomes was considered. The GRADE approach was used to determine the overall quality of evidence for each outcome using five criteria, where evidence is ranked from high to very low quality, depending on the number of criteria met.
Results
The searches yielded 1726 results, and in total three studies were included in the review and meta-analysis.
Outcomes in the short-term (within 6 months post-operative):
In the short-term there is moderate quality evidence from three RCTs (N= 340) that active rehabilitation is more effective than usual care for functional status and low quality evidence that rehabilitation is more effective for reported low back pain. In contrast, low quality evidence suggests rehabilitation is no more effective than usual care for leg pain (N=340). Low quality evidence from two RCTs (N=238) indicates that rehabilitation is no more effective than usual care for general health.
Outcomes in the long-term (at 12 months post-operative):
In the long-term there is moderate quality evidence from three RCTs (N= 373 that rehabilitation is more effective than usual care for functional status and reported low back pain. Moderate quality evidence suggests that rehabilitation is more effective than usual care for leg pain (N=373). In contrast low quality evidence suggests that rehabilitation is no more effective than usual care for general health (evidence from two studies, N=273).
Authors' conclusions
The evidence suggests that active rehabilitation is more effective than usual care for improving both short and long term (back-related) functional status. Similar findings were noted for other secondary outcomes including; short-term improvements in low back pain and long-term improvement in both low back pain and leg pain. The clinical relevance of these statistically significant effects is medium to small. Our evaluation is limited by the small number of relevant studies identified. Further research is required to provide higher quality evidence, and to consider other relevant outcomes such as work participation.
Plain language summary
Can active rehabilitation improve the outcome of surgery for spinal stenosis?

Spinal stenosis is a common age-related condition of the spine (back) that leads to back and leg pain. Surgery is the treatment of choice for many patients, but we know that their ability to carry out everyday tasks (functional recovery) following surgery is not ideal, although leg pain does improve for most patients. This review wished to find out whether active rehabilitation after surgery could improve the ability of patients to carry out everyday tasks when compared to the usual post-operative care.
We found that very little work had been done in this area; only 3 studies were suitable for inclusion. Each involved a rehabilitation programme between 30 to 90 minutes long, either once or twice weekly, starting 6 to 12 weeks after surgery. We found that active rehabilitation is helpful following surgery, providing modest improvements in both function and low back pain in both the short-term (within 6 months of surgery), and long-term (at 12 months).