Research Report

Manual therapy interventions for patients with lumbar spinal

stenosis: a systematic review
Michael P Reiman, PT, DPT, OCS, ATC, CSCS
Assistant Professor, Wichita State University Physical Therapy Department, Wichita, KS, USA
Staff Physical Therapist, Via Christi Sports and Orthopedic Physical Therapy, Wichita, KS, USA

Jonathan Y Harris, PT, OCS

Staff Physical Therapist, Complete Joint and Spine Therapy, Wichita, KS, USA

Joshua A Cleland, PT, PhD

Associate Professor, Franklin Pierce University, Concord, NH, USA

ABSTRACT
Objective: The objective of this paper is twofold (1) determine the quality of current
available studies regarding the use of manual therapy intervention for the treatment
of lumbar spinal stenosis LSS and (2) determine the effectiveness of manual therapy
for the treatment of LSS.
Data sources: A literature search was conducted using the MEDLINE, CINAHL, PEDro
and Cochrane Controlled Trials databases. Clinical trials and observational studies
were also included.
Review methods: Abstracts of potentially relevant articles were reviewed and
screened for inclusion criteria. The quality of the relevant articles after abstract
screening was measured against the nineteen item Maastricht-Amsterdam criteria
list. Two reviewers independently assessed the relevant articles using these criteria.
Overall methodological quality scores and internal validity scores were determined
by adding the positive scores from their respective criteria.
Results: Thirty-one relevant studies were identified. Twenty of these studies were
excluded, leaving eleven studies meeting inclusion criteria for review. Overall
methodological quality of the eleven studies was poor. Only one high quality
randomized controlled trial (RCT) was identified.
Conclusion: Based on this systematic review, preliminary evidence indicates that
manual therapy combined with exercise demonstrates potential benefit in the
treatment of LSS, but further evidence of effectiveness is needed. Reiman MP, Harris
JY, Cleland JA (2009): Manual therapy interventions for patients with lumbar spinal
stenosis: a systematic review. New Zealand Journal of Physiotherapy 37(1) 17-28.
Key Words: spinal stenosis, lumbar spine, systematic review

INTRODUCTION despite the fact that the effectiveness of surgery

Lumbar spinal stenosis, a focal narrowing of the for LSS as compared with nonsurgical treatment
spinal canal, nerve root canals, or intervertebral has not been demonstrated in controlled trials
foramina (Arnoldi et al., 1976; Penning 1992) is a (Weinstein et al. 2008). There continues to exist
common and disabling condition in the older adult considerable controversy as to the most optimal
(Tomkins et al. 2007, Deyo et al. 2005; Weinstein management strategies for patients with LSS (Ciol
et al. 2006). High depression score has been et al., 1996; Gibson et al., 1999; Waddell and
associated with more severe symptoms, poorer Gibson 2000).
walking capacity and less treatment satisfaction In addition to the fact that the number of surgical
(Katz et al. 1995), as well as poorer postoperative interventions performed for the management of
treatment satisfaction (Katz et al.1999). These LSS has increased dramatically over the past
physical and mental impairments may continue few decades (Tomkins et al. 2007, Deyo et al.
to increase in prevalence as it has been estimated 2005; Weinstein et al. 2006), re-operation rates
that approximately 4% of patients visiting their for patients with LSS range from 5-23% (Chang
primary care physician and 14% of patients seeking et al. 2005; Jansson et al. 2005). Adverse events
assistance from a specialist for low back pain (LBP) associated with spinal surgery for the treatment
present with LSS (Fanuele et al., 2000; Hart et al., of LSS must also be considered and have been
1995; Long et al., 1996). reported to include myocardial infarction, wound
Increasing numbers of older adults may further infections, renal failure, congestive heart failure,
increase the financial and societal burden. Recently cerebrovascular accident, and dural tears (Carreon
it has been demonstrated that spending for lumbar et al. 2003; Malter et al. 1998; Ragab et al. 2003).
fusion increased more than 500%, from $75 million It has been proposed that better data on surgical
to $482 million over the decade from 1992 to 2003 effectiveness is needed as instrumented fusion
(Weinstein et al. 2006). Lumbar fusion represents was found to be very expensive compared with the
47% of total spending for back surgery in 2003, incremental gain in health outcome (Kuntz et al.
compared to 14% in 1992 (Weinstein et al. 2006) 2000). As a result of the aforementioned a trial of

NZ Journal of Physiotherapy – March 2009, Vol. 37 (1) 17

 conservative management has been recommended intensity scales, region specific disability scales
for patients with LSS prior to surgical intervention (Oswestry Disability Index [ODI] or the Roland
(Reindl et al. 2003). Morris disability scale), functional performance
Clinical trials specifically examining and reporting scales (6 minute walk test, treadmill walk test, etc.),
on patients with lumbar spinal stenosis who receive or a global rating of perceived outcome.
conservative measures are rare (AHRQ 2001). The
lack of evidence in support of commonly utilized Types of studies
conservative interventions continues to result in a Both randomized clinical trials (RCT) and
lack of clarity regarding what interventions should observational studies (non-randomized clinical
be utilized to manage patients with LSS. Manual trials, cohort studies, case series and case studies)
therapy is an intervention often used by physical were included due to the an expected low volume
therapists, and includes both thrust and non- of evidence available on this topic.
thrust manipulation. (Guide to Physical Therapist
Practice 2003). Despite the fact that manual therapy Search of literature
has been employed by skilled physical therapists Multiple bibliographic databases were searched
since the inception of the profession (Paris 2000), during October to November 2007. The following
its use for the management of LSS has begun to electronic databases were searched: MEDLINE using
gain attention in the literature. To date, the use PubMed (1966-2007), Cumulative Index to Nursing
of manual therapy has not been systematically and Allied Health Literature (CINAHL) (1983-2007),
reviewed in an attempt to determine its effectiveness Physiotherapy Evidence Database (PEDro), and the
in patients with LSS. The purpose of this study Cochrane Controlled Trials Register in the Cochrane
was to systematically review the evidence and Library (latest edition). This is the search strategy
make treatment recommendations regarding the recommended by the Cochrane Collaboration (van
use of manual therapy interventions for patients Tulder, et al. 1997). The MEDLINE search terms
with LSS. used in the search strategy are detailed in table 1.
We also hand searched the reference lists of articles
METHOD selected for this review to determine if other articles
Types of participants of relevance could be identified.
Studies were considered only if they included
patients diagnosed with LSS or symptoms consistent Study selection
with LSS. These symptoms would typically include One reviewer (MR) performed the database
postural dependent symptoms (e.g. pain worse with searches and reviewed the title and abstracts. If it
extension and ambulation, relieved with flexion was determined the article might meet the inclusion
and sitting), progressive aching pain in mid lower criteria from the description of the diagnosis, patient
back, possible unilateral or bilateral lower extremity symptoms, or manual therapy interventions utilized,
symptoms (including neurogenic claudication) and the full text articles were obtained and selection
potential lower extremity myotomal and dermatomal criteria applied. See Figure 1 for the flow chart
changes. Trials that included patients with acute, illustrating the reasoning for inclusion/exclusion of
chronic or general LBP of non-specific nature; as articles. Two authors of articles on this topic were
well as subjects with other diagnosis of LBP were contacted by e-mail to see if they were aware of any
excluded. other relevant sources of information. No other
studies of relevance to this review were identified.
Types of intervention
Table 1: MEDLINE search terms
Trials in which at least one of the treatments
administered was a type of manual therapy, Intervention terms: [physical therapy OR rehabilitation OR
including thrust and/or non-thrust manipulation, massage OR joint mobilization OR joint manipulation OR
massage or other manual treatments were included. manual therapy OR stretching OR conservative treatments
OR therapy]
Studies involving techniques were there was no Condition terms: [spinal stenosis OR lumbar spinal stenosis OR
manual contact between the clinician and the lumbar spine]
subject were excluded. Multi-modal interventions, Limiting terms: method of study [clinical trial, meta-analysis,
practice guideline, randomized controlled trial, review, case
including use of stretching and strengthening reports, journal article, multicenter study]; English language
exercises, ultrasound, and joint protection home only; All Adult: 19+ years; Humans
instructions, were included if the treatment
program involved a component of manual therapy.
Interventions including any form of manual Methodological quality
therapy that were used in a comparison between The methodological quality of each article was
conservative and surgical treatment of LSS were rated using the Maastricht-Amsterdam criteria
also included in the study. list (van Tulder et al., 1997). It consists of 19
items that can be rated individually using one of
Types of outcome measures three options: ‘yes/no/don’t know’ (Table 2). The
To be eligible for this review, outcome measures overall methodological quality score (overall QS) is
had to include at least one of the following: pain determined by adding up all of the ‘yes’ ratings, with

18 NZ Journal of Physiotherapy – March 2009, Vol. 37 (1)

 Figure 1: Flow chart illustrating the literature search.

Potentially relevant studies identified from search strategy (Table 1)

after screening abstracts (n=31)
Studies eliminated because they were
not an intervention study (n=7)

Studies eliminated because they were

not specific to lumbar spinal stenosis (n=6)

Studies eliminated because the intervention was not

adequately described (n=5)

Studies eliminated because manual therapy was not

utilized (n=2)

Additional potential studies found by hand-

searching references of articles retrieved (n=2)

Additional studies eliminated after review because they were

duplicate abstracts of included studies (n=2)
Studies meeting inclusion criteria (n=11)

a maximum score of nineteen. Items that refer to Table 2: The criteria list from the Cochrane Back Review
Group*
internal validity include criteria B, E, F, G, H, I, J,
L, N, P (van Tulder et al., 1997). External validity A Were the eligibility criteria specified?
is evaluated with the descriptive criteria (A, C, D, B. 1Was a method of randomization performed?
K, M), while the remaining two items (O, Q) are B. 2Was the treatment allocation concealed?
C. Were the groups similar at baseline?
statistical criteria. D. Were the experimental and control interventions
An internal validity score (IVS) was also given explicitly described?
by adding the positive scores for internal validity E. Was the care provider blinded to the intervention?
F. Were the co-interventions avoided or comparable?
items (van Tulder et al., 1997; Peeters et al., 2001; G. Was the compliance acceptable in all groups?
Verhagen et al., 2002). A score of greater than 50% H. Was the patient blinded to the intervention?
for the study on overall QS or IVS was considered I. Was the outcome assessor blinded to the
intervention?
of acceptable validity (Verhagen et al. 2002). J. Were outcome measures relevant?
K. Were adverse effects described?
DATA ABSTRACTION L. Was the withdrawal/drop-out rate described and
acceptable?
Two reviewers (MR and JH) independently read, M. 1 Was a short-term follow-up measurement performed?
examined, and extracted the necessary key data M. 2 Was a long-term follow-up measurement performed?
in the appropriate categories: characteristics of N. Was the timing of the outcome assessment in both
groups comparable?
patients (age, gender and diagnosis), treatments O. Was the sample size for each group described?
utilized, outcome measures assessed, and the P. Did the analysis include an intention-to-treat analysis?
! Q. Were point estimates and measures of variability
results of the respective studies. Any disagreements
presented for the primary outcome measures?
related to differences in interpretation of the criteria
were resolved with both authors reviewing the *van Tulder et al., 1997
article a second time and additional discussion.

NZ Journal of Physiotherapy – March 2009, Vol. 37 (1) 19

 Analysis Methodological quality
Qualitative analysis was achieved by attributing Table 4 details the methodological assessment of
levels that rate the scientific evidence (van Tulder the eleven included studies. The scores from the
et al., 2003). two reviewers (MR and JH) were within three points
• Level 1: Strong evidence – provided by for every article.
generally consistent findings in multiple The overall methodological quality of the
higher quality RCTs. eleven studies was poor (see Table 4). Insufficient
• Level 2: Moderate evidence – provided by information regarding methodological items, or
generally consistent findings in one higher non-randomized study design, result in lower
quality RCT and one or more lower quality scores for the majority of studies. Only one study
RCTs. (Whitman et al., 2006) scored 50% or more on the
• Level 3: Limited evidence – provided by overall methodological QS or IVS. This was the only
generally consistent findings in one or more study that included adequate information on the
lower quality RCTs. internal validity items (B1, B2, E, F, G, H and I).
• Level 4: No evidence – if there were no RCTs Therefore, Whitman et al (2006) was the only study
or if the results were conflicting. demonstrating acceptable validity (van Tulder et al
Higher quality trials were those scoring 50% or 1997; Peeters et al 2001; Verhagen et al 2002).
more for the IVS (van Tulder, et al. 1997; Verhagen The most common reasons for low internal
et al., 2002). validity scores were non-randomized study
Generally consistent findings were defined as design, groups non-equivalent at baseline, and
75% or more of the studies having statistically lack of information regarding contamination by
significant findings in the same direction (Verhagen co-interventions (table 4). Insufficient information
et al., 2002). was often provided about co-interventions (F) and
compliance with interventions (G). Blinding of the
RESULTS patient is often impossible in physical therapy
Thirty-one trials were identified using various trials, and for this reason was not commonly seen
MEDLINE search strategies. These were reviewed in the included studies.
and eleven articles satisfied the eligibility criteria. Intervention types (type of intervention, intensity,
Searching the reference lists of these articles and duration, number and frequency of sessions [D]
other databases did not identify any further trials. were generally not well described for most studies,
The reasons for ineligibility of articles are listed in except on those single and small cohort type studies
Figure 1, and the articles that were not eligible for and the trial by Whitman et al (2006). Initial
this systematic review are listed in the appendix. group characteristics (C) and adverse effects (K)
were also either not often described or difficult to
Study characteristics ascertain. This may affect the external validity of
Of the eleven included studies, one was a the studies.
randomized clinical trial, six were non-randomised Many of the studies used inadequate descriptions
cohort studies, two were case series and two were of manual therapy interventions. In the only RCT
single case studies. The only RCT (Whitman et identified (Whitman et al 2006) the specific manual
al., 2006) compared two groups with both groups therapy techniques utilized in this study were
treated conservatively. The group allocated to the not adequately described in the text; however,
manual therapy arm received exercises addressing accompanying video clips with audio descriptions
specified physical impairments and body weight were available on the publishing journal’s website
supported treadmill walking as well as manual describing some of the more commonly used
physical therapy techniques addressing the thoracic interventions in the study.
and lumbar spine, pelvis and lower extremities. Several studies that adequately described
The comparison group received lumbar flexion the manual therapy interventions implemented
exercises, treadmill walking, and sub-therapeutic (Creighton et al 2006; Whitman et al 2003;
ultrasound. Four studies compared surgical to Snow et al 2001; Dupriest et al 1993) were of
conservative interventions (Atlas et al., 1996, 2000, low level evidence due to study design. All of
2005, Athiviraham and Yen 2007); however, none the aforementioned studies recruited 6 or fewer
used a randomized design. These four studies subjects and did not include a comparison group.
found that surgical intervention results were The fact that there were multiple ‘don’t know’ scores
generally greater than conservative, but the degree was due to the fact that occasionally the studies
of difference between the two groups decreased over provided inadequate details to ascertain if the
time. At 8-10 years after intervention Atlas et al criteria were actually satisfied. Even after individual
(2005) reported the two groups had relatively equal and collaborative scoring and discussion by the two
outcomes (table 3). reviewers the study description was still not clear
enough to more definitively score.
Statistical information was also relatively poor.
Point estimates and measures of variability (Q)
were described for only six of the eleven studies

20 NZ Journal of Physiotherapy – March 2009, Vol. 37 (1)

 Table 3: Characteristics of studies meeting the review criteria.

Authors Participants Interventions Outcome measures Results Comments

Randomized clinical trails:
Whitman et al 58 patients with LSS; 29 Patients randomized Perceived A greater proportion RCT with
(2006) in flexion exercise and into two groups: flexion recovery with a of patients receiving multiple
walking group (mean exercise and walking global rating of MPTExWG reported objective
age 70.0 (7.2) years; 17 group (FExWG)(n=29) change, Modified recovery at 6 weeks measures.
females; 29 in manual and manual physical Oswestry Disability compared with Blinding
therapy group (mean therapy, exercise, and Index (OSW), those receiving to group
age 68.9 (8.7) years walking group (MPTExWG) treadmill walking FExWG (P=0.0015). allocation
(n=29). Treatment test, numeric Improvements in and
for the FExWG group pain rating scale, disability, satisfaction, treatment.
included lumbar flexion SSS satisfaction and treadmill Multi-modal
exercises, performance subscale walking tests favored approach.
of a progressive treadmill the MPTExWG at all Adequate
walking program, follow-ups (6 weeks sample size.
and sub-therapeutic and 1 year).
ultrasound. Treatment for
the MPTExWG received
manual physical therapy
to the thoracic and
lumbar spine, pelvis and
lower extremities, as well
as specific exercises to
address impairments in
mobility, strength, and/
or coordination, including
instruction in the same
flexion exercises as
prescribed for the FExWG
group
Observational or descriptive studies:
Atlas et al 148 patients recruited Surgical patients: 71 had Baseline interviews Surgical patients Prospective
(1996) from Orthopedic laminectomy, 7 had open and follow-up mail (77.4%) were cohort
surgeons and discectomy only and 3 had interviews at 3, 6, significantly better design with
Neurosurgeons from fusion and laminectomy. and 12 months. than nonsurgical objective
throughout Maine Therapy patients: bed rest Stenosis frequency (41.8%) of patients outcome
with diagnosed LSS. (28.6%), back exercises index, Roland scale, (P < 0.001). Surgical measures
81 patients treated (39.3%), traction (3.6%), SF-36, Quality of life patients were also comparing a
surgically (mean age corset or brace (14.3%), and satisfaction significantly better surgical and
67.6 (range 30-87) years; TENS (14.3%), physical surveys. on the Roland scale nonsurgical
67 nonsurgical patients therapy (23.2%), spinal and SF-36 (P<0.001). group. Not
(mean age 65.3 (range manipulation (23.2%), randomized.
22-89) years. other alternative therapies No blinding.
(5.4%), epidural steroids Multi-modal
(18.2%), and narcotic approach
analgesic use in past week surgical and
(20.7%) nonsurgical.
Large sample
size in both
groups.
Atlas et al 119 remaining patients See Atlas et al (1996) See Atlas et al 70% of the surgically See Atlas et
(2000) from original study; 67 (1996) treated and 52% of al (1996); less
surgically treated and the nonsurgically difference
52 treated nonsurgically treated patients between
(mean ages, etc. not reported that surgical
given). their predominant and
symptom, either nonsurgical
back or leg pain, groups
was better (P=0.04). compared to
Patient satisfaction initial study.
with quality of life
nonsignificantly
favored the surgical
group (P=0.16)
Atlas et al 105 patients alive after 10 See Atlas et al (1996) See Atlas et al A similar percentage See Atlas
(2005) years (67.7% survival rate); (1996) of surgical and et al (1996);
56 patients of the initially nonsurgical patients even less
treated surgically and reported that their difference
41 of the initially treated low back pain was between
nonsurgically. improved (53% surgical and
vs. 50%, P=0.8), nonsurgical
their predominant groups
symptom (either compared to
back or leg pain was initial study.
improved (54% vs.
42%, P=0.3), and they
were satisfied with
their current status
(55% vs. 49%, P=0.5).

NZ Journal of Physiotherapy – March 2009, Vol. 37 (1) 21

 Table 3: (continued)

Authors Participants Interventions Outcome measures Results Comments

Athiviraham et 125 consecutive patients Surgery with or without Roland-Morris At 2 years follow- Prognostic
al (2007) with clinical and fusion; nonsurgical Questionnaire (RM), up, the average cohort
radiographic LSS. Surgery treatments most frequently subjective outcome improvement in study. Not
without fusion patients used included physical analyses (patient Roland-Morris score randomized.
(n=49) average age of therapy, weight reduction, rating of worse, in decompression No blinding.
63 years; surgery with back braces, spinal same, or better). only, decompression Surgical vs.
fusion (n=39) average manipulation, analgesics, with fusion, and nonsurgical
age 70 years; nonsurgical muscle relaxants, anti- nonsurgical groups comparison
patients (n=24) average inflammatory medication, were 6.9, 6.1, and with large
age of 69 years. or epidural steroids. 1.2, respectively. sample sizes.
Percentage of No measures
patients who were of variability.
better, worse,
or the same:
decompression only
(63.3%, 4.1%, and
32.7% respectively);
decompression
with fusion (61.5%,
2.6%, and 35.9%
respectively); and
nonsurgical (25.0%,
12.5%, and 62.5%
respectively).
Creighton et 6 subjects diagnosed Low and high velocity Treadmill walking All 6 subjects Case series
al (2006) with LSS and neurogenic translatoric manipulations time, Oswestry demonstrated study design.
claudication (ages: 82, of T1-T9 and L1-L3, and two Disability Index improvements in Objective
71, 52, 64, 72, and 81 lumbar flexion exercises. (ODI), McGill Pain treadmill walking test measures. No
years). Questionnaire prior to neurogenic blinding.
scores, claudication No measures
thoracolumbar (range: 1 min 34 of variability.
flexion mobility. sec to 26 min); in
ODI (range: 7.5%
to 64.7%); and in
McGill questionnaire
scores (range: 25% to
57%). All 5 subjects
that were measured
demonstrated
improvement in
thoracolumbar
flexion mobility.
Murphy et al 55 patients (19 males and Distraction manipulation RM, numerical Mean patient- Observational
(2006) 36 females) with mean in prone on adjustable rating scale (NRS); rated percentage study
age of 65.2 (range 32 to table, neural mobilization, patients were also improvement from (consecutive
80) years. “cat and camel” exercises, asked to rater baseline to end patients). No
“nerve flossing” exercises, their perceived of treatment was blinding.
some patients also had percentage 65.1%. The mean Manual
mobilization and/or improvement improvement in therapy
stabilization exercises. disability from approach
baseline ot the end with
of treatment was supplemental
5.1 points. The mean exercises.
improvement in Objective
“on average” pain outcome
intensity was 1.6 measures.
points. The mean
improvement in “at
worst” pain was 3.1
points.
Simotas et al 49 patients meeting Surgical intervention was Global outcome Improvement and Descriptive
(2000) radiographic and clinical not specifically described. score, RM, function scores study with
criteria for LSS. Non- Non-surgical intervention overall rating for nonoperated disparity of
operative treatment consisted of bed rest of daily anxiety patients were numbers in
initiated on all patients; (6 patients), corset (9), and depression significantly each group
at 3 years following acupuncture (29), TENS (2), levels, motor improved (P<0.001 due to design
treatment, 9 of the 49 manipulation (2), physical score to assess for pain on average, of study.
patients had undergone therapy (47), and epidural motor strength of frequency of pain, Objective
surgical intervention. steroid injection (39). lower extremities, pain in back or measures
Nonoperative patients numerical pain buttocks, and used.
(n=40) average age rating scale, pain in leg or foot. No blinding
72 (range 53-87) years, functional survey. 32% improved in for outcome
operative patients walking distance assessment.
(n=9) average age 67 and frequency
(range 58-80) years. 13 (P<0.229 and P<0.259
nonoperative patients respectively.
were male and 2
operative patients were
male.

22 NZ Journal of Physiotherapy – March 2009, Vol. 37 (1)

 Table 3: (continued)

Authors Participants Interventions Outcome measures Results Comments

Whitman et al 3 retired military patients Supine iliopsoas stretch, Posture, SLR All 3 patients A case
(2003) all reporting LBP and prone hip posterior to and ROM demonstrated series of 3
lower extremity (LE) anterior mobilization, measurements, substantial positive patients with
symptoms aggravated prone rectus femoris reflexes and changes that were treatment
by standing upright stretch, lumbar rotation strength measures, sustained up to individualized
and walking; detailed mobilization/manipulation OSW, global rating 18 months. OSW plan of
information regarding in neutral, caudal glide to of change, patient score improvement care for
patient is listed; 81 year hip joint in flexion, unilateral assessment of ranged from 66% to each
old male suffering from posterior to anterior lumbar overall functional 95% of their baseline respective
worsening LBP and right spine mobilization. status, modified scores by discharge patient.
LE symptoms; 63 year Spinal Stenosis and 33% to 82% at 18 Detailed
old male with episodic, Scale. months. description of
worsening LBP of 45 year manual
duration and intermittent therapy
LE symptoms; 71 year interventions
old male with history of utilized.
worsening intermittent Objective
dull ache in left buttock outcome
and intermittent dull achy measures
symptoms into left LE. utilized.
No measures
of variability
(3 patients).
Snow et al A single 78 year old male Flexion-distraction 10 point verbal Decreased Single case
(2001) with low back pain and manipulation of the lumbar rating scale, frequency and study.
severe bilateral leg pains. spine. No other treatments verbal rating of intensity of leg Limited
Severe degenerative or modalities were used. improvement. symptoms and a objective
changes noted with resolution of LBP that measure.
magnetic resonance were maintained at No point
imaging. a 5 month follow up estimates or
visit. measures
of variability
(single case).
Dupriest et al A single 76 year old male Flexion-distraction Lumbar flexion and Visual analog Single case
(1993) with chief complaint of manipulation of the lumbar extension ROM and pain rating was 0, study.
LBP and left LE pain with spine to the L4-5 and L5-S1 visual analog pain improved lumbar Limited
MRI confirmed LSS. levels. Manual stretching scale. ROM for extension objective
of the thoracolumbar and flexion, resolved measure.
fascia, including tissue antalgia. No point
massage; exercises estimates or
consisting of double measures
knee to chest, iliopsoas of variability
stretches, quadriceps (single case).
stretches, hamstring
stretches, calf stretches,
pelvic tilt, bridging,
stationary bicycling and
progressive ambulation;
ultrasound, heel lift on the
right, and modification of
patients activities of daily
living.

(Whitman et al 2006; Atlas et al 1996, 2000, 2005; DISCUSSION

Murphy et al 2006; Simotas et al 2000). This systematic review demonstrates a lack of high
quality evidence regarding the utilization of manual
Treatment recommendation therapy in the treatment of LSS. We identified only
The varying levels of evidence relating to manual one RCT, comparing two physiotherapy treatment
therapy interventions for LSS are described in approaches with no control group. Due to the lack
table 5. It is our recommendation that there is of studies with acceptable validity, and because the
currently Level 2 evidence to support including quality of the available research regarding manual
manual therapy interventions in combination with therapy and its effectiveness on LSS patients is
other physiotherapy interventions for the treatment generally poor, it is difficult to make clear conclusions.
of LSS, on the basis of one high quality RCT and This review found preliminary evidence for the
several lower quality (non RCT) studies. We found utilization of manual therapy and exercise intervention
no RCT evidence directly comparing manual for patients with LSS, although it is apparent that
therapy with other interventions, placebo or no there is a need for future investigation on this topic.
treatment. Although some studies are of low (Level The findings of this review are consistent with a
4) quality and present high risk of bias, the evidence recent best-practice clinical guideline recommending
generally supports the utilization of various manual that use of physical therapy and exercise may be
therapy techniques in the management of patients potentially beneficial in certain subgroups of patients
with LSS. for controlling symptoms of LSS with neurogenic
claudication (Watters et al 2008).
NZ Journal of Physiotherapy – March 2009, Vol. 37 (1) 23
 Table 4: Methodological quality scores in decreasing order of overall quality score.

A B1 B2 C D E F G H I J K L M1 M2 N O P Q OQS IVS
Whitman et al Y Y Y Y Y N Y Y N Y Y N Y Y Y Y Y Y Y 16 9
(2006)
Atlas et al Y N N N N N DK Y N DK Y N Y Y Y Y Y N Y 9 4
(1996)
Atlas et al Y N N N N N DK Y N DK Y N Y Y Y Y Y N Y 9 4
(2000)
Atlas et al Y N N N N N DK Y N DK Y N Y Y Y Y Y N Y 9 4
(2005)
Athiviraham et Y N N N N N DK Y N N Y Y Y N Y Y Y N N 6 3
al (2007)
Creighton et al Y N N DK N N DK Y N N Y N N Y Y N N N N 5 2
(2006)
Murphy et al Y N N N N N DK DK N DK Y Y DK Y Y N N N Y 5 1
(2006)
Simotas et al Y N N N N N DK DK N DK Y N DK DK Y N Y N Y 5 1
(2000)
Whitman et al Y N N N N N Y DK N N Y N N Y Y N N N N 5 2
(2003)
Snow et al N N N N N N Y DK N N Y N N Y Y N N N N 4 2
(2001)
Dupriest et al N N N N N N DK DK N N Y N N Y Y N N N N 3 1
(1993)

D/K=don’t know; OQS=overall quality score; IVS=internal validity score

A few limitations exist in this systematic review. fact that only the first author selected the articles
Firstly, studies published in languages other than could also result in selection bias. A blinding
English were excluded for this review. This could mechanism of the articles was not implemented as
result in language bias and decrease precision. The the first author (MR) was also primarily involved
Table 5: Level of evidence levels for treatment comparisons identified in the review.

Treatment/Comparison Strength of Evidence Comments

Manual physical therapy as a Level 2* 1 RCT and multiple lower quality non-randomized studies.
component of conservative One RCT compared manual therapy, exercises and
intervention (compared with other bodyweight-supported treadmill walking to lumbar flexion
conservative interventions) exercises, treadmill walking, and sub-therapeutic ultrasound.
Manual therapy consisted of techniques to thoracic and lumbar
spine, pelvis and lower extremities. Superior improvement in
manual therapy group was significant at 6 week and 1 year
duration (Whitman et al 2006).

1 Non-randomized observational study (Simotas et al 2000):

Spinal manipulation was a component of a multi-modal
conservative therapy approach for 2 patients and other
conservative interventions for 47 subjects; 9 patients ended
up having surgery; remaining 40 patients all demonstrated
subjective and objective improvement

3 Case series and 2 single case reports: Spinal distraction

manipulation (Murphy et al 2006), spinal low and high
velocity translatoric manipulations (Creighton et al 2006) Hip
mobilization; spinal mobilization/manipulation (Whitman et
al 2003). Improvement in subjective and objective measures.
Decreased frequency and intensity of leg symptoms and
resolution of LBP maintained at 5 month follow-up in one case
following flexion-distraction manipulation on single subject (Snow
et al 2001). Spinal manipulation was a component of a multi-
modal conservative therapy approach in one case (Dupriest et
al 1993).
Spinal manipulation as a component Level 4 4 non-randomized observational studies of 2 cohorts. (Atlas et
of conservative intervention al1996, 2000, 2005) (Athiviraham et al 2007)
(compared with surgical intervention) Spinal manipulation was one of multiple conservative
interventions; Only 23.2% of subjects were treated with spinal
manipulation and the techniques were therapist dependent
(Atlas et al1996, 2000, 2005); 2 year follow-up favored surgical
intervention versus conservative intervention at 10 year follow-
up conservative intervention compared favorably with surgical
intervention (Athiviraham et al 2007).

*According to the criteria for the levels of evidence described by van Tulder et al (2003), Level 2 evidence requires one high quality
RCT and one or more lower quality RCTs. We awarded a Level 2 rating for the evidence, on the basis of one high quality RCT and
accepting generally consistent findings in several non-randomized studies in lieu of one or more lower quality RCTs. The criteria for the
levels of evidence described by van Tulder et al (2003) do not cover the situation of one high quality RCT alone.

24 NZ Journal of Physiotherapy – March 2009, Vol. 37 (1)

 in article selection and review. Due to minimal benefit of manual therapy in LSS patients. Although
and conflicting evidence on consistency of scores, RCT’s are considered the highest level of evidence
blinding is not seen as a mandatory step in of efficacy, it must also be taken into account that
performing a systematic review (van Tulder et al what is efficacious in randomized clinical trials is
1997; Jadad et al 1998; Reid and Rivett 2005). not always effective in a real world of day-to-day
We were unable to match the results of our practice (Westfall et al 2007). This can be relevant
literature review exactly to the criteria for the levels with interventions such as manual therapy, which
of evidence described by van Tulder et al (2003). has proven to be an effective intervention for various
Level 2 evidence requires one high quality RCT lumbar spine disorders in non RCT’s (Hough et al
and one or more lower quality RCTs, while Level 2007; Hsieh et al 2002), as well as in RCT’s (Aure
3 evidence requires generally consistent findings et al 2003; Lewis et al 2005; Goldby et al 2006).
in one or more lower quality RCTs (van Tulder While RCTs are important to confirm whether a
et al 2003). We identified one high quality RCT; new treatment causes an effect, they are unlikely to
however, all of the other studies identified were discover combinations of interventions or practices
non-randomized observational studies. We decided that are effective and efficient in routine care (Horn
to award a Level 2 rating for the evidence, due to and Gassaway 2007). It has also been argued that
finding one high quality RCT, accepting generally practice-based research provides the ‘laboratory’
consistent findings in several non-randomized that will help generate new knowledge and bridge
studies in lieu of one or more lower quality RCTs. the chasm between current recommended care
These included 3 case series (Simotas et al 2000; and future improved care (Westfall et al 2007).
Murphy et al 2006; Creighton et al 2006) and 2 Contributions via observational designs can
single case reports (Whitman et al 2003; Snow et al produce valuable clinical evidence that is practical
2001) in support of manual therapy. Although there and applicable, especially since the stringent nature
is no precedent in the literature to support the rating of RCT’s may limit some of this creative clinical
of Level 2 evidence for this specific combination of application.
evidence, we did this based on a similar reasoning Besides the lack of RCTs and low quality of
process as described by Reid and Rivett (2005). It methodology amongst these studies, another
should be recognized that different pooling rules problem that became apparent was the poor
could have resulted in a different level of evidence description of these trials. As can be seen by the
(Ferreira et al 2002). However, our results are high number of ‘don’t know’ scores in table 4, it was
consistent with a recent clinical practice guideline often difficult to surmise if a criterion had been met.
giving a rating of ‘Good” level of evidence and B level The lack of detailed description of the intervention
of recommendation for the utilization of both spinal employed in many of the studies makes it difficult
manipulation and exercise therapy as measures of not only to repeat the study, but also to implement
noninvasive interventions in patients with chronic the same techniques with similar patients.
or subacute LBP (Chou et al 2007). Therefore, based Several of the studies reviewed involved
on the results of this review, manual therapy could comparisons between surgical and nonsurgical
be considered a plausible treatment for LSS, in interventions, which can present tribulations.
combination with other physiotherapy interventions Comparison of surgical and nonsurgical treatment
including exercise therapies, although the small groups in non-randomized, observational study
number of studies available, as well as the poor designs is problematic because of a lack of
quality of such studies, does not allow for definitive comparable patient groups and pretreatment data
conclusions. (AHRQ, 2001). There is limited, contradictory
As we anticipated the paucity of RCTs on this evidence on whether patients with moderate pain
topic, we decided to include non-RCT studies in benefit more from surgery or from conservative
this systematic review. This inherently resulted in care for patients with LSS (AHRQ, 2001). There
an overall lower level of evidence in the hierarchy is a greater lack of comparable data with regards
of evidence based practice. Case series, single case to patients with severe stenosis, as such patients
studies and other studies without comparison typically receive surgery shortly after the diagnosis,
groups carry an uncontrollably high risk of bias making comparisons more difficult to ascertain
and therefore cannot test a hypothesis that the (AHRQ, 2001).
interventions studied result in better outcomes than
a comparison intervention or no treatment at all. It CONCLUSION
could be argued that the indirect evidence provided We conclude that there are an insufficient
by such studies should have been eliminated from number of high quality studies on this topic to
this review. The fact that this review was forced confidently determine the role of manual therapy
to rely on such low level evidence only further for patients with LSS. This systematic review
supports the position that the current lack of found that there is currently very limited clinical
studies is critical, in this group of patients that will research of adequate quality on the use of manual
only increase in number with time. therapy for these individuals. While this review
Greater numbers of well designed RCTs on this demonstrates the potential for manual therapy
subject will improve the understanding of the and exercise intervention in patients with LSS, we

NZ Journal of Physiotherapy – March 2009, Vol. 37 (1) 25

 suggest that future research more closely examine Chang Y, Singer DE, Wu YA, Keller R and Atlas SJ (2005): The
effect of surgical and nonsurgical treatment on longitudinal
not only potential benefits of manual therapy in outcomes of lumbar spinal stenosis over 10 years. Journal
this type of individual, but whether specific types of the American Geriatrics Society 53: 785-92.
of manual therapy or multimodal approaches are Chou R, Qaseem A, Snow V, Casey D, Cross Jr T, Shekelle P
et al (2007). Diagosis and treatment of low back pain: a
more beneficial. joint clinical practice guideline from the American college of
physicians and the American pain society. Annals of Internal
Key Points Medicine 147;478-491.
■ There is insufficient high-quality evidence Ciol MA, Deyo RA, Howell E and Krief S (1996): An assessment
of surgery fro spinal stenosis: time trends, geographic
regarding the effectiveness of manual therapy variations, complications and reoperations. Journal of the
for patients with LSS American Geriatrics Society 44: 285-290.
■ There is one high quality trial indicating Creighton DS, Krauss J and Marcoux B (2006): Management
of lumbar spinal stenosis through the use of translatoric
that manual therapy in combination with manipulation and lumbar flexion exercises: a case series.
exercise therapy and bodyweight-supported Journal of Manual and Manipulative Therapy 14:E1-E10.
treadmill walking is superior to lumbar flexion Deyo R, Gray D, Kreuter W, Mirza S and Martin BI (2005): United
States trends in lumbar fusion surgery for degenerative
exercises, treadmill walking and sub-therapeutic conditions. Spine 30: 1441-1445.
ultrasound DuPriest CM (1993): Nonoperative management of lumbar
■ There is some additional low-quality evidence spinal stenosis. Journal of Manipulative and Physiological
Therapeutics 16: 411-414.
indicating meaningful change in pain and Fanuele JC, Birkmeyer NJO, Abdu WA, Tosteson TD and
function with the use of manual therapy; Weinstein JN (2000): The impact of spinal problems on the
however, further research is required to health status of patients: have we underestimated the effect?
Spine 25: 1509-1514.
substantiate these results Ferreira MK, Ferreira ML, Maher CG, Refshauge K, Herbert RD
■ There is insufficient research comparing manual and Latimer J (2002): Effect of applying different ‘‘levels
therapy with other interventions such as exercise of evidence’’ criteria on conclusions of Cochrane reviews
of interventions for low back pain. Journal of Clinical
and/or surgical intervention Epidemiology 55: 1126–1129.
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specific patient population most likely to benefit of surgery for lumbar disc prolapse and degenerative lumbar
spondylosis. Spine 24: 1820-1832.
from a manual therapy approach. Gibson JNA and Waddell G (2005): Surgery for degenerative
lumbar spondylosis: updated Cochrane review. Spine 30:
ADDRESS FOR CORRESPONDENCE 2312-2320.
Goldby LJ, Moore AP, Doust J and Trew ME (2006): A randomized
Dr Michael Reiman, Department of Physical Therapy, Wichita
controlled trial investigating the efficacy of musculoskeletal
State University, 1845 N. Fairmount, Wichita, KS 67260-0043, United physiotherapy on chronic low back disorder. Spine 31:
States of America. E-mail: [email protected]. Phone: 1083-1093.
316-978-5649. Fax: 316-978-3025. American Physical Therapy Association (2003): Guide to Physical
Therapist Practice (Revised 2nd ed.) Alexandria, VA: American
Physical Therapy Association.
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NZ Journal of Physiotherapy – March 2009, Vol. 37 (1) 27

 Rittenberg JD and Ross AE (2003): Functional rehabilitation Whitman JM, Flynn TW and Wainner RS (2005): A comparison
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and Rehabilitation Clinics of North America 14: 111-120. subjects with lumbar spinal stenosis: A randomized clinical
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because not specific to LSS. surgical management of lumbar spinal stenosis. Instructional
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article was not an intervention; a descriptive study.

28 NZ Journal of Physiotherapy – March 2009, Vol. 37 (1)