Therapeutic Exercise And Manual Therapy For Persons With Lumbar Spinal .
Special ReportTherapeutic exercise and manual therapy for persons withlumbar spinal stenosisLumbar spinal stenosis (LSS) may produce disabling back and leg pain, and is the leading cause of surgeryin adults over 65 years old. No reviews have summarized the effects of manual therapy and therapeuticexercise for these patients. The objective of this article is to examine the design and effectiveness oftherapeutic exercise and manual therapy for patients with LSS, and to identify the state of evidence forthese interventions on pain, disability, function and impairments in patients with LSS. In the report, threephysical therapists each evaluated the methodological quality of 11 studies obtained from a systematicsearch of computerized databases. Patients involved in the studies were subjects aged 40–80 years withlow back and leg pain, and diagnosed with LSS for 1 month or more; with exercise or manual therapy asthe primary intervention; and any type of study design. Non-English articles, dissertations, unpublisheddata and studies using steroid injections, surgery or medications such as muscle relaxants, or studiescomparing modalities (i.e., ultrasound and electrical stimulation) with exercise were excluded. Interventionsincluded aerobic, strengthening, stabilization, flexibility, balance exercise and manual therapy. Themeasurements used were the MacDermid’s scale and the Sackett’s Level of Evidence. Results from thestudy indicated that two of seven studies (28.5%) were classified as high-quality trials; two (28.5%) asmoderate quality and three (43%) as low-quality studies. All studies demonstrated decreases in pain anddisability and improvement in overall function and participation. A limitation of the report was that thestudies were heterogeneous. Furthermore, only two studies were high-level randomized controlled trials.In conclusion, most studies assessed the benefits of mixed exercise interventions, rather than a single modeof exercise. Therapeutic exercises such as aerobic training, flexibility, strengthening exercise and manualtherapy produce small-to-modest effects for pain, disability and function in patients with mild-to-moderateLSS. Aerobic exercise in combination with flexibility, strengthening exercise and manipulation may bemore effective than aerobic, strengthening exercise, flexibility exercise or manual therapy alone.Keywords: degenerativen therapeutic exercisenlumbar spine n manipulation n stenosisLumbar spinal stenosis (LSS) is a slowly progressing disease effecting five in 1000 adults olderthan 50 years in the USA and is the leading causeof surgery in adults 65 years and older [1,2] . LSS,defined as a narrowing of the spinal canal, can beclassified based on its etiology as either congenital or acquired [2–4] . A congenitally narrowedspinal canal may result from shortened pedicles,thickened lamina and facets, or from congenitalscoliosis or lordosis. Acquired LSS most commonly results from degenerative changes suchas facet joint hypertrophy, spine osteoarthritis,intervertebral disc herniation, spondylolisthesisand degenerative disc disease [4–6] . LSS can alsobe classified based on anatomical location aseither central or lateral stenosis [3] .Narrowing of the spinal canal is associated with low back and leg pain, numbnessand fatigue in the legs [7,8] . This characteristicpattern of symptoms associated with LSS istermed ‘neurogenic claudication’. Symptomsare posture-dependent [3,7,8] , and pain is oftenaggravated by walking, prolonged standing orlying prone and relieved by sitting and lyingdown [1–3,7–10] . Patients with LSS frequentlyexperience low back pain, maintain a stoopedstanding posture, experience lumbar spine stiffness and lumbar and hip decreased range ofmotion and muscle tightness [1,4,7] . Sensory deficits, motor weakness and pathological reflexesappear with walking. Elderly patients withsevere stenosis have restricted walking capacityand exercise intolerance, leading to decreasedf unction and quality of life [5,6,7,11,12] .Interventions for LSS include surgical or conservative approaches. Studies have compared theeffects of surgical versus nonsurgical management [2,9,12–15] . Data indicate decompressive surgery is effective for 80% of patients with severesymptoms [9,11,13,15] . Although surgical treatmentsoffer early symptomatic relief, nonsurgical interventions are recommended owing to the risks10.2217/IJR.10.29 2010 Future Medicine LtdInt. J. Clin. Rheumatol. (2010) 5(4), 425–437Maura D Iversen†1,3,4,Vidhya R Choudhary2& Sandip C Patel2Northeastern University, Departmentof Physical Therapy, USA2MGH Institute of Health Professionals,Graduate Programs in PhysicalTherapy, USA3Division of Rheumatology, Immunology& Allergy, Section of Clinical Sciences,Brigham & Women’s Hospital, USA4Harvard Medical School, Boston,MA, USA†Author for Correspondence:Tel.: 1 617 373 5996Fax: 1 617 373 3161M.Iversen@neu.edu1ISSN 1758-4272425
Special ReportIversen, Choudhary & Patelassociated with surgery in the elderly and may bemore cost-effective [1,15] . In 1987, the total annualinpatient cost for surgery in LSS was estimatedto be approximately US 1 billion [2,9] . Therefore,nonoperative/conservative interventions are usedin the initial stages of LSS [1,5,9,10,16] and are a preferred alternative to surgery for mild-to-moderatesymptoms of LSS [2,3,7,17,18] .Nonoperative treatments include a combination of medications, bed-rest, epidural steroidinjections, physical therapy and therapeuticexercise (e.g., aerobic conditioning, strengthening, stretching, lumbar stabilization exercises,spinal manipulation and mobilization, posture and balance training, physical modalities,braces, traction, and transcutaneous electricalnerve stimulation). Although nonsurgical treatments cannot change the underlying pathology,some patients report improvement in symptomsfollowing treatment [18] .Therapeutic exercise is commonly prescribedfor patients with mild-to-moderate symptoms[15,17,18] . Exercises focus on modifying the position of the lumbar spine, hence reducing spinalcord narrowing and decreasing the chance ofnerve compression. As spinal extension causes a20% reduction in the intervertebral foraminalcross-sectional area in the normal and degenerative spine [2,3,8] , flexion-based lumbar stabilization exercises along with abdominal strengthening are encouraged [7,12,15,17] . Aerobic exercisessuch as treadmill walking with bodyweightsupport, cycling and swimming are prescribedin patients with back disorders [2,3,7,17,19–21] .Cycling places the lumbar spine in a flexedposition, thereby increasing the intervertebralcross sectional area, and is better tolerated thanwalking [17,22] .Manual therapy includes manipulationand mobilization of tight structures as wellas spinal stabilization to restore normalfunction [8] . Normal spinal mobility can beattained by stretching the tight structures suchas hip flexors, adductors and myofascial tissues[8,10,21] . Postural exercises encourage lumbarflexion and flatten the lordotic curve [9,10,16] .Aqua therapy or pool exercises are also recommended because the physical propertiesof water minimize stress on the spine [3,10] .In a study examining the natural history of32 untreated patients with LSS (mean age:60 years) Johnsson et al. noted that symptomsremained constant in 70% of patients andworsened in 15% of patients [23] . Thus, exercise and physical therapy are recommended tomanage symptoms. Simotas et al. suggest using426Int. J. Clin. Rheumatol. (2010) 5(4)epidural steroid injections prior to initiatingphysical therapy to reduce pain and enhancesubject participation in exercise [19,20] .The Maine Lumbar spine study is a large prospective study examining long-term outcomes (4and 8–10 years) of patients with LSS followingsurgical and nonsurgical interventions [14,21] . Itreported that patients treated nonsurgically havedecreased back and leg pain. Although nonsurgical treatment proved to be relatively effectivein this cohort, there is no indication of the typeof therapeutic exercise used. Also, the nonconservative group included interventions otherthan therapeutic exercise; therefore, the effectof therapeutic exercise alone on the improvementof symptoms cannot be determined.This article examines the state of the evidencefor therapeutic exercise and manual therapyfor the conservative management of LSS, anddescribes the effects of these interventions onselect outcomes. A few studies have comparedthe efficacy of surgical and nonsurgical treatments for LSS, but the exclusive effects oftherapeutic exercise or manual therapy have notbeen addressed widely. This systematic reviewaddresses the following guiding questions: What is the effect of strengthening, balance,postural and aerobic exercise on function, disability and impairments in patients withdegenerative LSS? Which mode of exercise is most beneficial tomanage the symptoms of LSS?Methods Definition of termsFor the purposes of this study, therapeutic exercise is defined as exercises that include aerobic,strengthening/stabilization and flexibility exercises, and endurance training, as well as manualtherapy including mobilization and manipulation and postural exercises. Manual therapyincludes manipulation and mobilization of thetight structures, and stabilization of the spine torestore normal function [8] . Search strategyWe searched medical literature publishedbetween January 1950 and March 2008.Specifically, we searched Medline 1950 to March2008, Cumulative Index to Nursing & AlliedHealth Literature (CINAHL) 1982 to Februaryweek 4 2008, EBM Reviews Cochrane Databaseof Systematic Review 4th Quarter 2008,EBM Reviews-American College of PhysicianJournal Club (ACP) 1991 to January/Februaryfuture science group
Therapeutic exercise & manual therapy for persons with lumbar spinal stenosisSpecial ReportLUMBARSpinal stenosisLumbar spinal stenosis (3204)Excluded 161 studiesNon EnglishEnglish (3043)Lumbar spinal stenosis AND low back pain AND degenerative AND exercise AND physical therapy AND physiotherapyAND aerobic exercise AND strengthening exercise AND mobilization exercise AND manipulation AND manual therapyAND flexibility exercise AND stabilization exercise AND therapeutic exercise (958)Excluded 612 studiesUsed surgical interventions onlyUsed only medications or nonsurgicaltreatment as the primary interventionExcluded 16 studies6 did not use manual therapy or therapeuticexercise as the primary intervention3 LSS not primary cause of LBP2 mixed CLBP and LSS patients4 used other therapies or other therapiesplus exerciseReviewed title and abstracts(346)Excluded 322 studiesUsed nonsurgical treatment other thanphysical therapyUsed braces, orthosis, electrotherapy as mainaspect of conservative treatment along with PTPhysical therapy treatment along with othermedical treatmentsSteroid injections along with PTReviewed studies (24)Included studies (7)Figure 1. Article selection process.CLBP: Chronic low back pain; LBP: Low back pain; LSS: Lumbar spinal stenosis; PT: Physical therapy.2008, Database of Abstracts of Reviews ofEffect (DARE) 1st Quarter 2008, PubMed toDecember 2009 and Physical therapy EvidenceDatabase (PEDro). In each database, we used thesearch term spinal stenosis together with combinations of the following terms: lumbar, lumbarspine, degenerative, physiotherapy, physical therapy, therapeutic exercise, aerobic exercise, endurance exercise, strengthening exercise and flexibilityexercise. We extended our search by reviewing thebibliographies of relevant publications. Study selectionPapers that met the following criteria were included: Evaluated therapeutic exercise or manualtherapy; Male and/or female subjects aged between 40to 80 years; Subjects had a history of low back pain withor without radiating symptoms for 1 monthor longer;future science group Subjects had evidence of lumbar LSS on MRIor radiograph or a diagnosis of LSS by anorthopedic specialist or physician; Pain, disability and function were assessed; Available in English.Any type of study design was accepted.Studies were excluded if they included surgical,orthopedic support devices or pharmacologicalinterventions, compared physical modalities(e.g., heat, electrical stimulation and traction)to exercise and or manual therapy, assessed postoperative exercise or merely described the naturalhistory of LSS.Three reviewers (VC, SP and MDI) independently read and scored the studies using astandardized data abstraction form based onthe MacDermid’s quality rating scale (developed by Joy MacDermid in 2004) [24] and theSackett’s level of evidence [102,103] . Informationextracted from the studies included: design, setting, sample demographics, intervention andwww.futuremedicine.com427
Special ReportIversen, Choudhary & PatelTable 1. Studies originally included based on review of abstract butexcluded from the review after more detailed review of the study.Study (year)Reason for exclusionOnel et al. (1993)Freburger et al. (2006)Iversen et al. (2003)Hurri H et al. (1998)Amundsen et al. (2000)Athiviraham et al. (2007)Tadokoro et al. (2005)Atlas et al. (2005)Atlas et al. (2000)Surgery versus conservative interventionsMixed diagnoses and use of injectionsMixed LSS and CLBP patientsSurgery and conservative interventionsSurgery versus conservative interventionsSurgery versus conservativeMixed conservative interventionsMixed conservative interventionsMixed conservative interventionsJoffe et al. (2002)Critchley et al. (2007)Badke et al. (2006)Simotas (2001)Single LBP not LSS patientCLBP patientsLBP patients and used cold or heat interventionReview – mixed conservative interventionsincludedOther conservative interventions includedOther conservative interventions includedProtocol – CLBP patientsMixed LSS and LBP patientsHurwitz et al. (2002)Shabat et al. (2007)Cleland et al. (2006)Sculco et al. [44][45][46][47][48][49][50]CLBP: Chronic low back pain; LBP: Low back pain; LSS: Lumbar spinal stenosis.control program features, data sources analysisand results. Discord between scoring aspects ofthe studies was resolved by further review ofthe studies and discussion among the reviewers. All the reviewers were trained in the use ofthese scales. The quality of the intervention andstudy design was evaluated and graded using theMacDermid Scale; this scale consists of 24 itemsand seven domains and is designed specificallyfor all study types [24] . The domains include:study description, study design, subject selection, intervention, outcomes, ana lysis and studyrecommendations. Each item was scored on ascale of 0, 1 or 2, yielding a maximum score of48. The higher the score, the better the methodological quality of the study. A study score of 35and above indicates high-quality studies, scoresof 25–34 were classified as moderate-level studies and the studies that were scored below 24were categorized as low-level studies. A 5‑pointgrading scale developed by Sackett was also usedto evaluate the e vidence of the studies.We inspected the results of each study todetermine whether the intervention improvedoutcomes. Unfortunately, outcome measures andstudy designs were too heterogeneous to combine studies in a meta-ana lysis. Thus, percentagechange in primary outcomes (pain, function anddisability) were calculated to allow for a crudecomparison across studies. Effect sizes werealso calculated for outcomes from randomizedc ontrolled trials using standard equations [101] .428Int. J. Clin. Rheumatol. (2010) 5(4)ResultsThe study selection process is summarized inF igure 1. The search strategy identified 3204articles with the term LSS. Of these, 958 werepotentially relevant studies assessing the impactof therapeutic exercise and manual therapy. Wereviewed all titles and abstracts, and subsequently excluded 934 studies that did not meetour inclusion criteria or were duplicates. Wethoroughly reviewed the 24 remaining studies.After reviewing the full text of 24 articles, sevenstudies met the inclusion criteria [17,25–30] . Ofthese seven, two studies used radiology reportsplus physician diagnosis to confirm LSS [17,25] .A total of 17 studies were excluded for the following reasons: the studies used surgery, medications and/or steroid injections in the design,assessed the impact of modalities as the primaryintervention, did not recruit patients with LSS,or recruited patients with LSS and chronic lowback pain, but did not report results separatelyfor persons with LSS. The excluded studies arelisted in Table 1. Study characteristicsThe general characteristics of the selected studies are summarized in Tables 2 & 3. Although ourdatabase search included articles published since1950, the publication dates of all included studieswere between the years 1993 and 2007. The methodological quality scores and the level of evidenceof the included studies are provided in Table 4 .Of seven included studies, two were randomized controlled trials [17,25] , one was a prospectivecohort [30] and four were case series/reports [26–29] .Study characteristics such as location, setting andsample size varied. Mean ages of subjects rangedfrom 58 to 72 years.A wide variety of therapeutic exercise interventions were assessed in the seven studies. Moststudies evaluated the effects of mixed interventions such as aerobic exercise in combinationwith flexibility exercise and manipulation/manual techniques [17,25–30] . One study assessed theimpact of two different aerobic exercise interventions [25] , one study provided an aerobic intervention in water [29] , three studies incorporatedmanual therapy with exercise [17,26,30] and threestudies assessed strengthening exercises as the primary mode of intervention [26–28] . The studieswere divided into three groups: comparison ofaerobic interventions, mixed interventions andindividual interventions.Two of seven studies (28.5%) were classified as high-quality trials using MacDermid’sscale (scores of 40/48) and Sackett’s level-1b;future science group
DesignSubjectsfuture science groupRCTn 6858www.futuremedicine.comn 587040/1bDuration: twice a week for 6 weeksRx 1: Flexion exercises, three repetitions for 30 splus weight-supported treadmill walking for amax of 45 min (FExWG)Rx 2: Manual physical therapy consisting ofthrust and nonthrust manipulation of the spineand lower extremity (three bouts of 30 s each),and manual stretching (three repetitions of 30 seach), flexion exercises plus treadmill walkingwith bodyweight support, as tolerated(MPTExWG)Mean improvement at 6 weeks:OSW: FExWG: 6.55; MPTExWG: 10.48SSS: FExWG: 2.03; MPTExWG: 1.57Walking: FExWG: 176.5 m; MPTExWG: 339.7 mNPRS: FExWG: 1.1; MPTExWG: 1.5Mean improvement at 1 year:OSW: FExWG: 5.03; MPTExWG: 7.14SSS: FExWG: 1.99; MPTExWG: 1.73Walking: FExWG: 130.4 m; MPTExWG: 209.8 mNPRS: FExWG: 1.2; MPTExWG: 1.0FExWG: 20% improvement in pain, 16% improvement indisability and 28% improvement in functionMPTExWG: 30% improvement in pain, 29%improvement in disability and 50% improvementin functionNo difference between two groups: OSW (p 0.44) andRMDQ (p 0.31)Overall reduction: significant (p 0.001)At week 3, test group perceive benefit two-thirds asoften as control groupTest group: 17% improvement in pain, 22% improvementin disabilityControl group: 16% improvement in pain,28% improvement in disabilityFExWG: Flexion exercise and walking group; FLE: Flexibility exercise; MPTExWG: Manual physical therapy exercise and walking group; NPRS: Numerical Pain Rating Scale; OSW: Modified Oswestry Disability Index;RCT: Randomized clinical trial; RMDQ: Roland–Morris Disability Questionnaire; SSS: Satisfaction Subscale of Spinal Stenosis.WhitmanRCTet al. (2006)Combined manual therapy and therapeutic exercise interventionsPua et al.(2007)MacDermid/ ResultsSackett’sscores40/1bBoth groups received heat, traction in Fowlerposition at 30:10‑s on/off cycle and 30–40% ofbodyweight and shortwave diathermy tomobilize spine, plus performed home flexionand neural mobilization exercises daily for6 weeksRx 1: Treadmill with bodyweight support at30–40% of bodyweight for 30 min, progressingfrom a gentle pace to pace at a BORG rating of11 to 15 twice a week for 6 weeksRx 2: Cycling on upright stationary bicycle at50–60 rpm for 30 min twice a week for 6 weeksMean age Primary intervention(years)Comparison of two modes of aerobic exerciseStudyTable 2. Characteristics and outcomes of studies of aerobic exercise alone or combined exercise and manual therapy for persons with lumbarspinal stenosis.[17][25]Ref.Therapeutic exercise & manual therapy for persons with lumbar spinal stenosisSpecial Report429
430DesignSubjectsInt. J. Clin. Rheumatol. (2010) 5(4)n 2CaseseriesCaseseriesFritz et al.(2006)Greenman(2006)70677218/4Balance, FLE, strengthening and aerobic exercise 15/4four times every weekFLE, strengthening and walking (three- tofour‑times per day for 6 weeks)20/4OSW score improved from ranges 66 to 95% and 33 to82% from baseline to discharge and at follow‑upModified SSS scored improved to range 1.0 to 2.6 and0.9 to 2.6 from baseline to discharge and at follow‑up,respectivelySymptom Severity Scale: improvement from 0.76 to 1.85at discharge and 0.14 to 1.29 at follow‑up33% improvement in pain, 76% improvement indisability and 56% improvement in functionBoth patients showed significant improvement in lumbarrange of motion and ambulationSignificant improvement in the muscle‑force productionof the gluteus maximus in the female and the quadricepsfemoris muscle in the male90% improvement in pain and 84% in disability Walking tolerance improved in all patients Initial evaluation: 40% of patients were at grade 1 and60% patients were at grade 2 Post-treatment: 20% were at grade 3 and 80% wereat grade 4 level Overall: 57% improvement in function was achieved Visual analog scale: 75% of patients reported goodimprovement 25–75% reported a fair amount of improvement and 25% reported poor amount of pain reliefMacDermid/ ResultsSackett’sscoresFExWG: Flexion exercise and walking group; FLE: Flexibility exercise; MPTExWG: Manual physical therapy exercise and walking group; NPRS: Numerical Pain Rating Scale; OSW: Modified Oswestry Disability Index;RCT: Randomized clinical trial; RMDQ: Roland–Morris Disability Questionnaire; SSS: Satisfaction Subscale of Spinal Stenosis.n 15n 3WhitmanCaseet al. (2003) seriesFLE, strengthening and walking (nine toten visits)Mean age Primary intervention(years)Comparison of two modes of aerobic exerciseStudyTable 2. Characteristics and outcomes of studies of aerobic exercise alone or combined exercise and manual therapy for persons with lumbarspinal stenosis.[28][27][26]Ref.Special ReportIversen, Choudhary & Patelfuture science group
Therapeutic exercise & manual therapy for persons with lumbar spinal stenosisSpecial ReportTable 3. Characteristics of studies assessing individual interventions for the conservative management ofsymptoms of lumbar spinal nterventionMurphy et al. Prospective n 57(2006)cohort6530/4Manual therapytwo- tothree‑times perweek for 3 weeks,then once or twiceper week after3 weeksKuck et al.(2005)63Lumbarstabilization inwater three‑timesper week for6 weeksCase series n 6MacDermid/ ResultsSackett’sscores27/4Statistically significant improvement frombaseline to end of treatment (p 0.0001)and from baseline to follow‑up(p 0.0002)RMDQ: improved by 5.1 points frombaseline to end of treatment (p 0.0001)RMDQ: improved by 5.2 points frombaseline to follow‑up (p 0.0001)30% improvement in pain and 40%improvement in disabilitySignificant improvement in pain anddisability levels (p 0.05)RMDQ: p 0.028RMPRS: p 0.04372% improvement in pain,50% improvement in disability and 66%improvement in functionRef.[30][29]RMDQ: Roland–Morris Disability Questionnaire; RMPRS: Roland–Morris Pain Rating Scale.two studies (28.5%) were moderate quality(MacDermid score: 27–33/ 48) and Sackett’slevel- 3b, 4 and three studies (43%) were rated aslow-quality studies (MacDermid score: 15–20)and a Sackett’s level of 4 (Figure 2) .Comparison of two modes ofaerobic exercisePua et al. (score: 40; level 1b) compared the effectsof two different aerobic exercise interventions forpatients with LSS using a randomized controlleddesign [25] . Patients were allocated to either30 min of treadmill walking with bodyweightsupport or cycling, twice a week for a 6-weekperiod. Both groups were prescribed a homeflexion-based exercise program to complete dailyfor 6 weeks and received mobilization techniquesand heat prior to the aerobic exercise sessions. Inweeks 1 and 2, patients walked/cycled at theirown comfortable pace. In weeks 3–6, the intensity of aerobic exercise increased to a moderatelevel. Disability was assessed using the OswestryDisability Index (OSW) [31] and the Roland–Morris Disability Questionnaire (RMQ) [32] .Both are well-validated and reliable measures.Back pain was measured on visual analog scale(VAS) [33] . The authors reported improvementsdisability in both groups at the 3‑ and 6‑weekassessments, although these differences were notstatistically significant. Reductions in pain anddisability were 17 and 22%, respectively, in thetreadmill group, and 18 and 28%, respectively,in the cycling group. When the results of thetwo aerobic intervention groups were combined,future science groupthere was a statistically significant improvementin disability (p 0.001). The authors concludedthat aerobic exercise can decrease disability, butthere is no significant difference between the useof 6 weeks of weight-supported treadmill walking or stationary cycling in outcomes. Figure 3illustrates effect sizes for specific outcomes.Studies combining manual therapy& exerciseOf the studies included in this category, onewas a randomized clinical trial [17] , one wasa prospective cohort study [30] and one was asmall case series [26] . In a high-quality randomized clinical trial by Whitman et al. (score: 40;level 1b) patients were randomly allocated toeither flexion exercises plus bodyweight-supported treadmill walking (treadmill group)or manual physical therapy, flexion exerciseand bodyweight-supported treadmill walking(manual group) [17] . Total treatment sessionslasted 45–60 min twice a week for 6 weeks.Outcomes assessed included: perceived recovery, self-reported pain, disability, satisfaction and function. At 6 weeks and 1 year, themanual therapy group demonstrated greaterimprovements in disability, walking toleranceand higher satisfaction compared with the flexion exercise group. The mean improvement indisability assessed with the OSW was 10.5 and6.5 at 6 weeks, and 7.1 and 5.0 at 1‑year followup [31] in the manual therapy and flexion exercisegroup, respectively [17] . The mean improvementin treadmill walking distance was reported towww.futuremedicine.com431
Special ReportIversen, Choudhary & PatelTable 4. Quality of studies based on the Joy MacDermid Scale†.StudyWhitman et al. Pua et al.(2006) [17](2007) [25]BackgroundComparisonPatient statusData collectionRandomizationPatient blindingProvider sion andexclusion ccording toprinciplesBiases of treatmentproviderInterventioncomparisonDefine primaryoutcomeAppropriatesecondary outcomeAppropriatefollow-up periodAppropriatestatistical test(s)Significant powerSize and effectreportAnalyses missingdataClinical andpracticalsignificance ndationTotal scoreLevel of evidence‡22222112222221122Murphyet al. (2006)Kuck et al.(2005) [29]Whitmanet al. (2003)Fritz et al.(2006) [27]Greenman(2006) 2222240lb40lb304274204184154[30]†‡[26]Score ranges from 0, 1 or 2; with 2 indicating highest value.Evidence criteria based on Sackett Scores [101,103].be 339.7 m in the manual therapy group compared with 176.5 m in flexion exercise group at6 weeks, and 209.8 m and 130.4 m at 1‑yearfollow-up in manual therapy and flexion exercisegroup, respectively. The manual therapy groupreported higher satisfaction rates compared with432Int. J. Clin. Rheumatol. (2010) 5(4)the flexion group (1.57 and 2.03, respectively, at6 weeks, and 1.7 and 2.0, respectively, at 1‑yearfollow-up). The authors reported overall reductions in pain of 20 and 30%, disability of 16and 29%, and function of 28 and 50% in theflexion exercise and treadmill walking group,future science group
Therapeutic exercise & manual therapy for persons with lumbar spinal stenosisCombined strengthening& aerobic exerciseFritz et al. (score: 18; level 4) conducted a casereport of two elderly patients diagnosed withdegenerative LSS to evaluate the effect of flexionexercise on pain and disability [27] . Both patientsreceived physical therapy treatment for 6 weeks,which included pelvic tilts, quadruped spinalflexion exercises and single knee-to-chest exercises for Patient 1, and quadruped spinal flexionfor Patient 2. Patients performed ten repetitionsof flexion exercises three- to four-times daily.Both patients performed treadmill walking aspart of their intervention. Patient 2 engagedmore in treadmill exercise as he was better tolerated to ambulation. Walking speed increasedfrom 0.7 to 0.8 mph and from 1.5 to 2.5 mphin Patients 1 and 2, respectively, after 6 weeks ofphysical therapy. The maximum walking timefuture science group483828188reeetnma[2 n8][2 al.7]GtmhiFritzanetet[2 al.6][2 al.9]ckWMWKuurphyet[3 al.0]et[2 al.5]aPuhitmanet[1 al.7]0Figure 2. Quality ranking scores of the included studies using theMacDermid Scale.Data taken from [17,25–30] .increased from 7 1/6 to 15 min and from 5 1/6to 15 min in Patients 1 and 2, respectively, at theend of therapy. Both patients reported no pain inthe low back or l
therapeutic exercise and manual therapy for patients with LSS, and to identify the state of evidence for these interventions on pain, disability, function and impairments in patients with LSS. In the report, three physical therapists each evaluated the methodological quality of 11 studies obtained from a systematic
INDEX PRESENTATION 5 THE THUMB 7 MECHANICAL EXERCISES 8 SECTION 1 THUMB Exercise 1 12 Exercise 2 13 Exercise 3 - 4 14 Exercise 5 15 Estudio 1 16 SECTION 2 THUMB WITH JUMPS Exercise 6 17 Exercise 7 - 8 18 Exercise 9 19 Exercise 10 20 Exercise 11 - 12 21 Estudio 6 22 SECTION 3 GOLPE Exercise 13 23 Exercise 14 24 Exercise 15 25 Exercise 16 - 17 26 Exercise 18 27 .
Chapter 1 Exercise Solutions Exercise 1.1 Exercise 1.2 Exercise 1.3 Exercise 1.4 Exercise 1.5 Exercise 1.6 Exercise 1.7 Exercise 1.8 Exercise 1.9 Exercise 1.10 Exercise 1.11 Exercise 1.12 Fawwaz T. Ulaby and Umberto Ravaioli, Fundamentals of Applied Electromagnetics c 2019 Prentice Hall
There is some degree of evidence of the use of therapeutic nursing interventions and general agreement on its meaning. Identified therapeutic instruments used by nurses in therapeutic interventions were: therapeutic letters, bathing and comforting care, humour, music, presence, mindfulness (cognitive therapy), therapeutic touch, .
Therapeutic Exercise Unlocked Contents Faculty ii Objectives v Program Committee vi What is the Role of Exercise in Low Back Pain? 1 Joel M. Press, MD, Christopher Visco, MD Corrective and Therapeutic Exercise for the Painful Lumbar Spine: Technique Matters! 7 Stuart M. McGill, PhD Writing a Therapeutic Exercise Prescription for Low Back Pain 15
1.1 Identify the principles of range of motion, resistive exercise and manual muscle testing. 1.2 State the general principles of exercise including endurance, power, cardiovascular effects, and psychomotor considerations. 1.3 State the indications and contraindications to therapeutic exercise. 1.4 Identify the effects of pain on therapeutic exercise. 1.5 Identify components of an exercise .
Interferential current therapy* Touch therapies* Yoga therapy* Interventions Acute and Subacute Low Back Pain and Practices Considered Diagnostic tests Laboratory testing Physical exercise Therapeutic exercise Therapeutic aquatic exercise* Yoga therapy* Active rehabilitation Self-management programs Massage therapy Acupuncture Acetaminophen and .
Occupational Therapy Occupational Therapy Information 29 Occupational Therapy Programs 30 Occupational Therapy Articulation Agreements 31 Occupational Therapy Prerequisites 33 Physical Therapy Physical Therapy Information 35 Physical Therapy Programs and Prerequisites 36 Physical Therapy Articulation Agreements 37 Physical Therapy vs .
exercise therapy by a well-trained exercise instructor who came to each child's home or school to conduct the exercise therapy sessions. The structured programme was implemented and conducted as after-school exercise sessions. The children underwent 6 months of exercise therapy at a frequency of twice a week, and duration of 1 h each session.
