Lumbar spinal stenosis-diagnosis and management of the aging spine.

Low back pain and lumbar spinal stenosis (LSS) is an extensive problem in the elderly presenting with pain, disability, fall risk and depression. The incidence of LSS is projected to continue to grow as the population ages. In light of the risks, costs and lack of long-term results associated with surgery, and the positive outcomes in studies utilizing physical therapy interventions for the LSS patient, a non-invasive approach is recommended as a first line of intervention. This Masterclass presents an overview of LSS in terms of clinical examination, diagnosis, and intervention. A focused management approach to the patient with LSS is put forward that emphasizes a defined four-fold approach of patient education, manual physical therapy, mobility and strengthening exercises, and aerobic conditioning.

Functional movement training for recurrent low back pain: lessons from a pilot randomized controlled trial.

OBJECTIVE: Despite considerable effort to reduce low back pain (LBP), approximately 60% of patients have recurrence after their first episode. The high rate of recurrence suggests that more effective intervention approaches are needed. This randomized, controlled feasibility trial was designed to compare disability, physical functional capacity, and pain outcomes at 2, 6, and 12 months for 2 conventional and 1 novel physical therapy (functional movement training) intervention for recurrent LBP. DESIGN: Randomized, controlled feasibility trial. SETTING: University hospital outpatient physical therapy clinic. PARTICIPANTS: Sixty-one participants (60% female) with recurrent LBP. INTERVENTIONS: Subjects were randomized to 1 of 3 intervention groups: group 1 had a single session consisting of standard back pain education; group 2 had 6 sessions in 8 weeks of conventional physical therapy; and group 3 had 6 sessions in 8 weeks of a novel method of functional movement training. Change from baseline was used to determine within-group changes and between-group differences for participants who finished each time point (2, 6, and 12 months). Changes were evaluated using analysis of variance and Newman-Keuls post hoc analysis. MAIN OUTCOME MEASURES: The primary outcome measure was the novel Continuous Scale Physical Functional Performance test (CS-PFP), a measure of actual physical functional capacity. Secondary measures included the revised Oswestry Disability Index, a measure of pain-related disability, the Roland Morris Disability Questionnaire, and a standard visual analogue pain scale. RESULTS: Of the participants, 67% provided data at 2 months and 44% provided information at 12 months. Raw change scores were evaluated at 2, 6, and 12 months. While no statistical significance was reached with any outcome measure, the trends suggested little change for group 1 (education) and suggested that greatest improvement in function may occur in group 3 (functional movement training). In particular, at 2 months, the CS-PFP change scores revealed a trend (P=.072) toward greater improvement in groups 2 (conventional physical therapy) and 3 (functional movement training) compared with group 1. At 12 months, Oswestry Disability Index and CS-PFP scores also trended toward significance for groups 2 and 3 (P=.7 and .9, respectively). Mean change scores were also calculated and revealed groups 2 and 3 had improved by 2 months and this improvement remained stable at the 1-year mark. Trends in the direction of best improvement occurred for those in the functional movement training group. CONCLUSION: A large-scale randomized, controlled trial is warranted to determine whether an intervention based on functional movement training is superior to conventional, impairment-based intervention for individuals with recurrent LBP.

Mobilization with movement as an adjunct intervention in a patient with complicated de Quervain's tenosynovitis: a case report.

STUDY DESIGN: Case study. OBJECTIVES: To describe the use of conventional physical therapy interventions together with Mobilization With Movement (MWM) techniques in the treatment of an individual with a complicated scenario of de Quervain's tenosynovitis. BACKGROUND: The patient was a 61-year-old woman who presented with signs and symptoms consistent with de Quervain's tenosynovitis of the right hand. Range limitations in all motions of the right wrist and first carpometacarpal joint complicated her presentation. METHODS AND MEASURES: Physical therapy included conventional intervention with superficial heat, ice, iontophoresis, and transverse friction massage directed to the first dorsal tunnel. Conventional joint mobilization techniques addressed the motion limitations of the first carpometacarpal, radiocarpal, and midcarpal joints. In addition, MWM techniques were utilized to promote pain-free wrist and thumb mobility. The specific MWM techniques used with this patient involved active movements of the thumb and wrist superimposed on a passive radial glide of the proximal row of carpal bones. RESULTS: The described treatment regime, which involved conventional physical therapy interventions, along with MWM, aided in the complete resolution of this patient's impairments and functional limitations. CONCLUSION: The combination of conventional physical agents, exercise, and manual therapy, and the less conventional MWM techniques, proved successful with this patient. MWM involving the correction of minutejoint malalignments, coupled with active motion of the wrist and first carpometacarpal joints, was an effective and efficient adjunct physical therapy intervention. Because subtle changes injoint alignment may contribute to painful syndromes in the tendon complexes that cross a malaligned joint, use of MWM as a treatment technique warrants continued research.