Lomber spinal stenozun tedavisinde epidural steroid enjeksiyonu ile fizik tedavi yöntemlerinin etkinliğinin karşılaştırılması
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Date
2004
Authors
Koç, Zarife
Journal Title
Journal ISSN
Volume Title
Publisher
Uludağ Üniversitesi
Abstract
Lomber spinal stenoz (LSS), yaşlı popülasyonda en sık karşılaşılan ve spinal kanal, sinir kökü kanalı veya intervertebral foraminanın daralması sonucu oluşan dejeneratif spinal hastalıklardan biridir. Konservatif tedavi çoğu hastada semptomların giderilmesinde etkili olsa da, fizik tedavi yöntemleri, medikal tedavi ve epidural steroid enjeksiyonunun etkinliğini gösteren yeterli sayıda randomize kontrollü çalışma yoktur. Bu çalışma hastaların semptomları ile radyolojik bulgular arasında ilişki olup olmadığını göstermek ve LSS'un tedavisinde epidural steroid enjeksiyonu ile fizik tedavi yöntemlerinin etkinliğini karşılaştırmak üzere planlandı. Uludağ Üniversitesi Tıp Fakültesi Fiziksel Tıp ve Rehabilitasyon Polikliniği'ne başvuran, öykü, fizik muayene ve lomber MRG ile LSS tanısı koyulan 29 hasta çalışmaya alınarak üç gruba randomize edildi. Birinci gruba (n=10) 2 hafta süreyle lomber bölgeye ultrason, TENS, nemli sıcak paketten oluşan fizik tedavi programı ile germe ve güçlendirme egzersizlerinden oluşan egzersiz programı uygulandı, ikinci gruba (n=10) floroskopi eşliğinde, tek doz lomber epidural enjeksiyon yapıldı (60 mg triamsinolon asetonid ve 15 mg % 0.5 bupivakain HCI). Enjeksiyon sonrası birinci gruptaki hastalarla aynı terapötik egzersiz programı verildi. Üçüncü gruba ise (n=9) sadece diğer iki grup için tanımlanan egzersizlerden oluşan ev programı düzenlendi. Ayrıca tüm hastalara 2 hafta süreyle günde 2 kez 75 mg diklofenak sodyum verildi. Hastalar başlangıç, 2. hafta, 1., 3. ve 6. aylarda Schober testi, parmak-zemin mesafesi, spinal Phalen testi, düz bacak kaldırma testi, nörolojik muayene, ağrı için vizüel analog skala (VAS), treadmill testi (ağrının başlama süresi: ABS ve maksimum yürüme süresi: MYS), oturma-kalkma testi (OKT), ağırlıkla yürüme testi (AYT), Rolland Morris Disabilite İndeksi (RMDİ), Nottingham Sağlık Profili (NSP) parametreleri ile değerlendirildi. Birinci grupta ağrı (VAS), AYT, RMDİ, NSP ağrı alt grubunda tüm kontrollerde, NSP uyku alt grubunda 1., 3., 6. aylarda ve NSP emosyonel reaksiyon alt grubunda 2.hafta, 1., 3. aylarda anlamlı düzelme kaydedildi. İkinci grupta ağrı (VAS), treadmillde ağrının başlama süresi, RMDİ, NSP ağrı alt grubunda tüm kontrollerde, NSP fiziksel aktivite alt grubunda 2.hafta, 1., 3. aylarda anlamlı düzelme görüldü. Üçüncü grupta ise treadmillde ABS ve RMDi skorunda tüm kontrollerde, treadmillde MYS'nde 1., 3., 6. aylarda anlamlı düzelme saptandı. Gruplar arası karşılaştırmada, ikinci grupta ağrı (VAS), RMDi ve NSP fiziksel aktivite alt grubunda, sadece 2.haftada, üçüncü gruba göre daha fazla düzelme kaydedilirken, birinci ve ikinci grup arasında anlamlı fark yoktu. Ayrıca kas gücü kaybı hariç nörolojik muayene, ağrı (VAS), treadmill testi, OKT, AYT, RMDi, NSP parametreleri ile radyolojik bulgular arasında ilişki saptanmadı. Sonuç olarak, LSS'u olan hastalarda, hem fizik tedavi yöntemlerinin, hem de epidural steroid enjeksiyonunun ağrı ve fonksiyonel bozukluğu düzeltmede etkili olduğu, birinin diğerine üstünlüğü olmadığı ve etkinliğin uzun süreli olması için egzersiz tedavisiyle kombine edilmesi gerektiği kanısına varıldı.
Lumbar spinal stenosis (LSS) is one of the most frequent degenerative spinal diseases seen in elderly population which result from narrowing of the spinal canal, nerve root canal or the intervertebral foramen. Although conservative treatment is effective in relieving symptoms in most patients, there are not enough randomized controlled studies investigating the effectiveness of physical therapy methods, medical therapy and epidural steroid injection. This study was designed in order to evaluate the relationship between symptoms and radiological findings as well as to compare the effectiveness of epidural steroid injection and physical therapy methods in the treatment of LSS. Twenty-nine patients admitted to the Department of Physical Medicine & Rehabilitation, Uludag University School of Medicine who were diagnosed to have LSS according to history, physical examination and lumbar MRI were randomized to three groups. First group (n=10) was treated for 2 weeks with a physiotherapy program consisting of ultrasound, TENS, hot pack applied to lumbar region and an exercise program consisting of stretching and strengthening exercises. The second group (n=10) was treated with a single dose of epidural injection (60 mg triamcinolon acetonide and 15 mg % 0.5 bupivicaine HCI) under fluoroscopy and the same exercise program given to the first group. The third group (n=9) was treated only with a home exercise program consisting of the same exercises given to the first two groups. In addition, all patients received diclofenac sodium 75 mg bid for two weeks. The patients were evaluated by Schober test, finger to floor distance, spinal Phalen test, straight leg raising (SLR), neurological examination, pain 0JAS), treadmill test (time to first symptoms: TFS, total ambulation time: TAT), sit-to-stand test (SST), weight carrying test (WCT), Rolland Morris Disability Index (RMDI), Nottingham Health Profile (NHP) parameters at baseline, 2 weeks, 1,3 and 6 months. Significant improvement was observed in the first group in pain 0/AS), WCT, RMDI, NHP pain subgroup at all follow-up evaluations, in NHP sleep subgroup at 1, 3, 6 months and in NHP emotional reaction subgroup at 2 weeks, 1 and 3 months. In the second group, pain 0/AS), TFS in the treadmill test, RMDI and NHP pain subgroup were significantly improved at all follow-up evaluations, and in NHP physical activity subgroup at 2 weeks, 1 and 3 months. As for the third group, TFS and RMDI scores were significantly improved at all follow-up evaluations, as well as TAT in the treadmill test at 1, 3 and 6 months. The second group demonstrated a significantly more improvement in pain 0/AS), RMDI and NHP physical activity subgroup at 2 weeks compared to the third group, while no significant difference was noted between the first and the second treatment groups. Furthermore, no correlation was found between radiological findings and the study parameters except muscle weakness. In conclusion, both physiotherapy and epidural steroid injection was found to be effective in reducing pain and improving functional status in patients with LSS. While one method was not found to be superior to the other, it can be suggested that combination with exercise program might contribute to long-term effectiveness in both strategies.
Lumbar spinal stenosis (LSS) is one of the most frequent degenerative spinal diseases seen in elderly population which result from narrowing of the spinal canal, nerve root canal or the intervertebral foramen. Although conservative treatment is effective in relieving symptoms in most patients, there are not enough randomized controlled studies investigating the effectiveness of physical therapy methods, medical therapy and epidural steroid injection. This study was designed in order to evaluate the relationship between symptoms and radiological findings as well as to compare the effectiveness of epidural steroid injection and physical therapy methods in the treatment of LSS. Twenty-nine patients admitted to the Department of Physical Medicine & Rehabilitation, Uludag University School of Medicine who were diagnosed to have LSS according to history, physical examination and lumbar MRI were randomized to three groups. First group (n=10) was treated for 2 weeks with a physiotherapy program consisting of ultrasound, TENS, hot pack applied to lumbar region and an exercise program consisting of stretching and strengthening exercises. The second group (n=10) was treated with a single dose of epidural injection (60 mg triamcinolon acetonide and 15 mg % 0.5 bupivicaine HCI) under fluoroscopy and the same exercise program given to the first group. The third group (n=9) was treated only with a home exercise program consisting of the same exercises given to the first two groups. In addition, all patients received diclofenac sodium 75 mg bid for two weeks. The patients were evaluated by Schober test, finger to floor distance, spinal Phalen test, straight leg raising (SLR), neurological examination, pain 0JAS), treadmill test (time to first symptoms: TFS, total ambulation time: TAT), sit-to-stand test (SST), weight carrying test (WCT), Rolland Morris Disability Index (RMDI), Nottingham Health Profile (NHP) parameters at baseline, 2 weeks, 1,3 and 6 months. Significant improvement was observed in the first group in pain 0/AS), WCT, RMDI, NHP pain subgroup at all follow-up evaluations, in NHP sleep subgroup at 1, 3, 6 months and in NHP emotional reaction subgroup at 2 weeks, 1 and 3 months. In the second group, pain 0/AS), TFS in the treadmill test, RMDI and NHP pain subgroup were significantly improved at all follow-up evaluations, and in NHP physical activity subgroup at 2 weeks, 1 and 3 months. As for the third group, TFS and RMDI scores were significantly improved at all follow-up evaluations, as well as TAT in the treadmill test at 1, 3 and 6 months. The second group demonstrated a significantly more improvement in pain 0/AS), RMDI and NHP physical activity subgroup at 2 weeks compared to the third group, while no significant difference was noted between the first and the second treatment groups. Furthermore, no correlation was found between radiological findings and the study parameters except muscle weakness. In conclusion, both physiotherapy and epidural steroid injection was found to be effective in reducing pain and improving functional status in patients with LSS. While one method was not found to be superior to the other, it can be suggested that combination with exercise program might contribute to long-term effectiveness in both strategies.
Description
Keywords
Lomber spinal stenoz, Fizik tedavi, Epidural enjeksiyon, Terapotik egzersiz, Lumbar spinal stenosis, Physiotherapy, Epidural injection, Therapeutic exercise
Citation
Koç, Z. (2004). Lomber spinal stenozun tedavisinde epidural steroid enjeksiyonu ile fizik tedavi yöntemlerinin etkinliğinin karşılaştırılması. Yayınlanmamış tıpta uzmanlık tezi. Uludağ Üniversitesi Tıp Fakültesi.