ASSESSMENT OF DISABILITY AND FUNCTIONAL

ABILITY IN SPINAL STENOSIS NON-SURGICAL

PATIENTS

A RESEARCH REPORT SUBMITTED TO THE UNIVERSITY OF HEALTH

SCIENCES

PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE

DEGREE

OF

DOCTOR OF PHYSICAL THERAPY

BY

MARIA NOOR

DECEMBER, 2019

UNIVERSITY OF HEALTH SCIENCES

LAHORE, PAKISTAN

1
2
 DEDICATION

I dedicate this report to my parents, teachers, family, friends and faculty of Rashid
Latif College of Physical Therapy who raised to the person I am today. Their
luminous presence in my life is all what I live for. Their endless support, patience and
understanding give me courage to go on and I owe my motivation, knowledge and
success to them.

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 TO WHOM IT MAY CONCERN

It is hereby certified that this research report is based on results of study

carried out by Maria Noor (Roll no: 063158 ) She has fulfilled the entire
requirement and qualified to submit the accompanying research for the
degree of “Doctor of Physical Therapy”.

Supervisor Signature:

Supervisor Name: Dr.Abbas M.Jamil

Designation:
Rashid Latif College of Physical Therapy
(RLCPT) Lahore

4
 UNDERTAKING

I MARIA NOOR, UHS Registration No. 2014-RLMC-0243-UHS declare

that the content of my thesis titled ASSESMENT OF DISABILITY AND
FUNCTIONAL ABILITY IN SPINAL STENOSIS NON –SURGICAL
PATIENTS is based on my own research findings and have not been taken
from any other source except the references from search engines and has not
been published before. I also undertake that I will be responsible for any
plagiarism in this thesis.

Signature: __________________________

Name: Maria Noor (Roll no: 0)

Final Profession DPT

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 ACKNOWLEDGEMENT

In the name of Allah, the most Gracious and the most Merciful, all praises to Allah
for the strength and His blessings in completing this research and granting me
strength and courage thus far to complete my thesis. This report could have not been
accomplished without the support and assistance of numerous people to whom I will
be grateful.

I express my gratitude to Dr. Rehana Niazi, Principal Rashid Latif College of

Physical Therapy. Her advice and careful guidance were indispensable and
irreplaceable. I extend my deep appreciation to her for her kindheartedness, wisdom,
patience, encouragement, positive criticism and assistance in bringing this work to
completion.

I express my profound sense of reverence to my Research supervisor

Dr.M Abbas Jamil the skillful and professional ways in which he supported me
throughout this work. His extreme generosity will be remembered always.

Not forgotten, my appreciation to my teachers, Dr Nazeer Ahmad and

Dr.Muhammad Ehtisham, for giving me an exceptionally helpful
guideline,their encouragement and insightful comments are continuous source
of motivation for me. My sincere thanks to the entire faculty of Rashid Latif
College of Physical Therapy, my family and friends for their support and
encouragement.

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 List of Tables

Sr.No Tables Pg. No

1. Frequency of age of participants 26

2, Summary of pain intensity 27

3. Summary of lifting 28

4. Summary of walking 29

5. Summary of standing 30

6. Summary of social life 31

7. Summary of travelling 32

8. Summary of feeding 33

9. Summary of dressing (upper body) 34

10. Summary of grooming 35

11. Summary of respiration 36

12. Summary of sphincter management (bladder) 37

13. Summary of sphincter management (bowel) 38

14. Summary of mobility in bed 39

15. Summary of transfer bed 40

16. Summary of mobility indoors 41

17. Summary of mobility outdoors 42

18. Summary of stair management 43

19. Summary of Oswestry 45

20. Summary of SCIM 46

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Sr. No Figures Pg. No

Histogram

1. Mean age of participants 26

Bar charts

1. Figure of pain intensity 27

2. Figure of lifting 28

3. Figure of walking 29

4. Figure of standing 30

5. Figure of travelling 32

6. Figure of feeding 33

7. Figure of dressing ( upper body) 34

8. Figure of grooming 35

9. Figure of bladder 37

10. Figure of sphincter management (bowel) 38

11. Figure of mobility 39

12. Figure of transfer in bed 40

13. Figure of mobility indoor 41

14. Figure of mobility outdoor 42

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15. Figure of stair management 43

16. Figure of transfer wheel chair ground 44

17. Figure of oswestry 45

Cross tabs

Sr.No Tables Pg. No

1. Correlation of ODI and Self- Care 47

2. Correlation of 0DI and respiration 48

3. Correlation of ODI and mobility 49

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TABLE OF CONTENTS;

1.INTRODUCTION……………………………………………………………………………………………………………...13

2. LITERATURE REVIEW……………………………………………………………….17

3. OBJECTIVES .............................................................. 20Error! Bookmark not defined.

4. OPERATIONAL DEFINITIONS ................................ 21Error! Bookmark not defined.

5. MATERIALS AND METHODS ..................................................................................... 22

5.1. SETTING: ................................................................................................................ 22

5.2. STUDY POPULATION: ......................................................................................... 22

5.3. DURATION OF STUDY: ....................................................................................... 22

5.4. STUDY DESIGN: ............................................... 22Error! Bookmark not defined.

5.5. SAMPLE SIZE: ................................................... 22Error! Bookmark not defined.

5.6. SAMPLE SELECTION ............................................ 23Error! Bookmark not defined.

5.6.1. Inclusion criteria: ................................................... 23Error! Bookmark not defined.

5.6.2. Exclusion criteria: .................................................................................................. 23

5.7. SAMPLING TECHNIQUE ..................................................................................... 23

5.8. OUTCOME MEASUREMENT TOOL ............... 23Error! Bookmark not defined.

6. DATA COLLECTION PROCEDURE ........................ 23Error! Bookmark not defined.

7. DATA ANALYSIS .......................................................................................................... 23

8. ETHICAL CONSIDERATIONS ..................................................................................... 24

9. Results:............................................................................................................................. 25

10. DISCUSSION: ............................................................................................................. 50

11. CONCLUSION: ........................................................................................................... 53

12. LIMITATIONS: ........................................................................................................... 54

13. RECOMMENDATIONS: ............................................................................................ 54

14. REFERENCES ............................................................................................................ 55

15. APPENDIX 1 ..................................................................................................................... 58

15.1. Consent Form .............................................................................................................. 59

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16. APPENDIX 2 ............................................................................................................... 60

16.1. Questionnaire .............................................................................................................. 60

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 ABSTRACT
BACKGROUND:

Lumbar spinal stenosis is common spinal disorder comprising of buttock pain with or

without causing low back pain. The most common levels are L4 and L5 with 91 %

patients having neural compression. The most common complaint with stenosis is

pain. As lumbar spinal stenosis limits physical activities and lead to disability.

OBJECTIVE:

The aim of the study was to find assessment of disability and functional
ability in spinal stenosis non – surgical patients.

METHOD:

An observational cross sectional study was done.Using Oswestry Disability Index

(ODI) and Spinal Cord Independence Measure (SCIM) , data was collected from 35
spinal stenosis patients.

Results:

Pearson correlation was applied to find the assessment of disability and functional
ability in spinal stenosis non – surgical patients and results indicated that there is
strong negative correlation between disability and functional ability with probability
value was (P -.789).

Conclusions:

The study revealed that there is strong negative correlation between disability and
functional ability .There is need to aware the people about the pain and severity of
spinal stenosis.

Key Terms:

Spinal stenosis, Lumbar spinal stenosis,Functional ability and Disability.

12
1.INTRODUCTION :

Degeneration of intervertebral disc leads to instability or hypermobility of

superior facet joints. Hypertrophied articular process resulting in spinal canal
dimensions reduction and leads to compression of neural elements. Venous
congestion leads to hypertension of nerve roots responsible for complex symptoms
called as neurogenic intermittent claudication (NIC)(Lee. et al., 2015)

Stenosis means narrowing on basis of pathological findings stenosis is of two

types congenital and acquired. Congenital stenosis is due to achondroplasia or
idiopathic stenosis. Acquired stenosis is degenerative. Narrowing factors for stenosis
are disc herniation, hypertrophy of ligamentum flavum , osteophyte, ectopic fat tissue
, spondylolisthesis(Lee et al., 2015).

Lumbar spinal stenosis(LSS) most common spinal disorder that is comprising

of buttock pain with or without low back pain(Lafian and Torralba, 2018). The level
of spinal stenosis is at L4 and L5 with 91% of patients having neural compression. It
is degenerative process begins in intervertebral disc depending upon these factors ,no
of viable cells, water, proteoglycan content in nucleus pulposus(Schroeder et al.,
2016).

Nucleus pulposus degenerates, height of disc diminishes there will be buckling

or bulging of annulus fibrosis. Anterior column of spine has less ability for absorbing
stress. Transferring of abnormal force to posterior column lead to narrowing of spinal
canal through hypertrophy. Spinal stenosis classified on the of regions of spine
affected cervical, thoracic, lumbar(Lafian and Torralba, 2018).

Main symptopm of spinal stenosis is pain. Sites for pain are low back, thighs,
buttock, and legs. In LSS discomfort is describe as cramping or burning. Pain
aggravated by standing and walking and relieved by sitting or leaning forward. Spinal
stenosis may present as central or lateral. In central usually pain is bilateral and in
lateral recess foramina pain is unilateral radiculopathy(Lurie and Tomkins-Lane,
2016).

Diabetes is multiorgan disease weakens connective tissue, bone or cartilage.

Diabetes results in ossification of posterior longitudinal ligaments or bone which
leads to spinal stenosis and nerve pressure. Diabetes more prevalent in spinal surgical

13
patients. The prevalence of DM is 8%. Microangiopathy from diabetes affect nutrition
of spine results into disc degeneration(Asadian et al., 2016).

Obesity commonly defined as body mass index (BMI) of more than 30 kg .It is
associated with musculoskeletal disorders as chronic back pain and intervertebral disc
degeneration. As obesity associated with postoperative surgical complications as
blood loss and surgical site infections.

Obesity is major issue related to QOL leading spine to be stenosis and disk
degeneration it is life threatening(Cao et al., 2016).Degenerative lumbar spinal
stenosis (LSS) is a common spinal disease that occurs mostly in the elderly. This
disease can induce lumbocrural pain, intermittent claudication, and other symptoms;
limit physical activities of patients; accelerate decline of cardiopulmonary function;
and thus severely decrease the quality of patients’ life. However, many patients may
lose opportunities to undergo surgery due to the advanced age and poor constitution,
despite having clear surgical indications Therefore, early prevention and intervention
for LSS are particularly important. Paraspinal muscles have fatty infiltration and have
weak attachments to bone especially multifidus spinal muscles(Jiang et al., 2017).

Lumbar spinal stenosis can be identified by plain radiographics as narrowing

of height of intervertebral foramina, interlaminar window, hypertrophy of facet joints,
short pedicles thick lamina and posterior concavity. CT and MRI are also helpful but
CT is used where soft tissues ossified and MRI is contraindicated. The sedimentation
sign lack of sedimentation to nerve root to dorsal part of dural sac(positive
sedimentation sign) is reliable for diagnose to LSS(Wu et al., 2017).

With the “baby boomer” era getting more seasoned, 10,000 people cross the 65-
year-old check each day in Joined together States, hence, posturing a major healthcare
challenge. Whereas LSS isn't life debilitating, it contrarily impacts the quality of life
(QOL) due to considerable inability, with impediments in
performing schedule everyday life activities.2 It is judicious to survey the
pathophysiology and current treatment alternatives for LSS with accentuation on
evidence based treatment options(Costandi et al., 2015).

As LSS is causing significant physical inactivity, functional abilities limitations.

Physical fitness and performance decreased that contributes to decline in quality of
life(QOL). There is strong evidence between functional abilities and disability from

14
low back pain and fitness parameters in women at age of 65 years. As spinal stenosis
patients reported motor deicits in lower extremity and buttock , bowel and bladder
dysfunction that also provides evidence of poor QOL(Park et al., 2017).

Short stride length is also associated clinical symptom with spinal stenosis
patients. Short stride is major risk factor for fall. Associated factors with short stride
identified for prevention of spinal stenosis patients. As fall results in severe and many
traumatic injuries leading to disability as spine is already in degenerative states in
elderly. Two step test and Up and Go test are used to measure stride in elderly
population(Fujita et al., 2019a)

Locomotive syndrome is that in which activities of daily life restricted owing

to disability and problems in one or many parts of muscuoloskeletal system. Lumbar
spinal stenosis is the risk factor for locomotive syndrome. LSS was significantly
associated with locomotive syndrome with the TWO step test results. The level of risk
for locomotive syndrome is assessed by stand up test, two step test and 25 question
risk assessment(Fujita et al., 2019b)

Spinal stenosis leads to urinary incontinence that effects quality of life in

women and men. Women faces more urinary tract problems such as more leakage of
urine or more urge to urinate or more frequency of urine than healthy womens. Perner
et a.l conducted a study to check urinary incontinence in men with low back pain and
80% of spinal canal stenosis patients had disorders of urinary tract(Truszczyńska-
Baszak et al., 2018).

Pelvic rigidity is smaller pelvic acceleration during walking. Patients with

greater stenosis had greater pelvic rigidity and muscle atrophy. Stenosis lead to
intermittent claudication that results into inactivity. Inactivity leads to atrophy of
Paraspinal muscles and pelvic rigidity. Pelvic rigidity during walking may be a
sensitive parameter for early detection of compensation mechanism (Bumann et al.,
2019).

As lumbar spinal stenosis limits physical activities and lead to disability.

Limited physical activities may result to develop many chronic diseases as
cardiovascular disorders, type 2 diabetes mellitus, certain cancers and many
neurological conditions. There are two options for treating LSS non –conservative
treatment and conservative. Non –conservative includes physiotherapy like flexibility

15
exercises, strengthen exercises, treadmill walking training, modalities as
ultrasound,TENS,and heating(Minetama et al., 2019).

Fitts’s law undertaking accurately measures overall performance capacity

variations between healthy and LSS individuals. mainly, the planning, initiation, and
execution of lower limb practice capacity can be quantified with degenerative LSS.
The relationship to pain inside the assisting leg in the course of the preliminary stages
of movement is more essential than pain inside the working leg. In terms of overall
performance, movement execution extra adversely affected than motion
initiation(Passmore et al., 2015).

With the best of researcher knowledge there are many studies on surgical
treatments of spinal stenosis and related disabilities. There are very few studies on
non-surgical stenosis related disability. This study emphasis to be alarm the patients
in early stages to prevent permanent disability and enhance functional abilities by
introducing physical therapy clinical guidelines and life style modifications.

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2: LITERATURE REVIEW

A randomized control trials conducted in 2017 on lumbar spinal stenosis: an

update on the epidemiology, diagnosis and treatment concluded that One randomized
controlled study (RCT) (90) included a add up to of 94 patients with 50 agent and 44
non-operative patients found both agent and
nonoperative administrations appeared enhancement of torment and
Oswestry Inability List (ODI), but the contrast in favor of operation was 11.3
in incapacity (95% CI: 4.3–18.4), 1.7 in leg pain (95% CI: 0.4–3.0), and 2.3 (95% CI:
1.1–3.6) in back pain at one year take after up and 7.8 in inability (95% CI: 0.8–14.9)
1.5 in leg pain (95% CI: 0.3–2.8), and 2.1 in back torment (95% CI: 1.0–3.3) at two
year take after up. Walking capacity, either detailed or measured, did
not vary between the two diverse medications(Wu et al., 2017).

A study conducted in 2015 on lumbar Spinal Stenosis: Therapeutic Options

Review concluded that in age between 60 to 69, the prevalence of LSS is very high.
The percentage of mild to moderate stenosis in this age group is 40% and 19.7% have
severe stenosis. A little trial (N = 45)27 illustrated low-quality prove that
physical treatment works out are more beneficial, within the brief term ,than no
treatment in decreasing neurogenic claudication pain and progressing function. In
another little trial (N = 68)29, treadmill walking was not found to be superior to
stationary cycling within the brief term. The other 2 trials given exceptionally low-
quality prove for all outcomes.28,30 When compared with flexion-based works
out, strolling, and pretense ultrasound, manual treatment works out combined with
unweighted treadmill strolling illustrated short-term generally change (N =
68)(Costandi et al., 2015).

A randomized control clinical trials on spinal stenosis prevalence and association

with symptoms concluded that 92 patients were enlisted, with 36 SC and 35 UC
patients completing all follow-up visits : A randomized controlled trial paralleling full
clinical practice guidelines based treatment, counting spinal
manipulative treatment managed by chiropractors, to family physician-directed usual
care in the treatment of patients with ALBP. A full CPG-based
treatment counting CSMT is related with significantly more prominent change in

17
condition-specific working than compared to family physician directed usual care.
(Kalichman et al., 2010).

A study conducted in 2019 on effectiveness of physical therapy combined with

epidural steroid infection: randomized parallel group trial concluded that no
significant difference between epidural steroid injection and epidural steroid injection
plus physiotherapy in oswestry disability index at any time although sample show
improvements at 10 week. Epidural steroid injection plus physiotherapy was found
more beneficial relate to quality of life, factors of emotional function and emotional
well being(Hammerich et al., 2019).

A study conducted in 2019 on supervised physiotherapy versus home exercises

for patients with lumbar spinal stenosis :a randomized trial in which 86 patients were
enrolled in study thirty nine men and fourty seven women average age 72 years.
Fourty three were in physiotherapy group and fourty three were in home exercise
group concluded that supervised physical therapy resulted in significantly short term
outcomes as compared to home exercise therapy groups(Minetama et al., 2019).

A study conducted in 2019 on low impact exercise programm for patients with
symptomatic spinal stenosis awaiting surgery: controlled pilot study concluded that
low impact exercises were not beneficial and high impact interventions required to
improve symptoms. That study enrolled 26 participants in exercise group or non
execise group. Non-exercise group reported more lumbar pain, more severe
symptoms, higher use of analgesics and poorer QOL. Exercise groups reported
minimal difference in the pain and symptoms with low impact exercises(Thornes et
al., 2019).

A study conducted in 2018 on lumbar spinal stenosis in older adults:

randomized controlled trial concluded that 400 patients with moderate to severe leg
pain (self reported pain score of 4 or greater on a scale of 0-10) and disability score of
7 or higher on RMQD (range 0-24) there was no significant difference between
epidural steroid injection versus epidural lidocaine. There was another randomized
trial concluded that outcomes of decompression and physiotherapy at 6 months, 1
year follow up and 2 year follow up shows better results with decompression in
reducing pain(Lafian and Torralba, 2018).

18
 A study conducted in 2016 on diabetes mellitus a new risk factor for developing
spinal stenosis: case control study concluded that total of 50 patients (15.2%) were
diagnosed with diabetes which consist of 32 (29.1%) in the stenosis group and 11
(10%) in the control group. The prevalence of diabetes in women with spinal stenosis
was 35.9% whereas prevalence of diabetes in control group was 10.9% .This
difference was statistically significant in the spinal stenosis group in comparison with
the controls (P , 0.0001). The prevalence of pain in diabetes patients is more with
spinal stenosis(Asadian et al., 2016).

19
3: OBJECTIVES

To find out assessment of disability and functional ability in spinal stenosis non-
surgical patients.

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4: OPERATIONAL DEFINITIONS

Spinal stenosis:

A narrowing of spinal canal and foramen which results in choking of spinal

cord or nerve roots.

Lumbar spinal stenosis:

(LSS) is a common spinal disorder in the older population, and the clinical
syndrome consisting of pain in the buttock or lower extremity, with or without low
back pain and corresponding imaging findings of narrowing of spaces around neural
and vascular elements in the lumbar spine (Wu et al., 2017).

Disability:

An inability to perform or a limitation in the performance of actions ,tasks and

activities usually expected in specific social roles that are customary for the
individuals or expected in persons status or role specific socioculture context and
physical environment.

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5: MATERIALS AND METHODS

5.1 Setting:

1.Jinnah hospital

2.General hospital

5.2 Study population:

Spinal stenosis non-surgical patients

5.3 Duration:

This study was conducted within duration of 6 months after the

approval of synopsis.

5.4 Study design:

Descriptive cross-sectional was used.

5.5 Sample size:

35 patients admitted to Jinnah hospital Lahore and General hospital

Lahore were included in this study.

Sample size was calculated by using the following formula:

N= [(Za/2)2 x P(1-P)] / d2

d is margin of error = 5%

Z 1-ɑ ⁄2 is the desired level of significance =95%

P ₒ is the proposed portion of patients with spinal stenosis i.e. 2.4% .

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5.6: SAMPLING SLECTION:

5.6.1: Inclusion criteria:

 Diagnosed spinal stenosis non-surgical patients.

 Both male and female with age 55 – 75

5.6.2: Exclusion criteria:

 Subjects with recent spinal surgery past 6 months

 Patients who are amputated.
 Patients who have history of trauma.
 Severe disable patients with neurological deficits (stroke,Parkinson,epilepsy).
 Patients with any arthroplasty.

5.7: SAMPLING TECHNIQUE

Non-probability Convenience sampling was used in this study.

5.8 Outcome measures:

Oswestry Disability Index

Spinal Cord Independence Measure

6: DATA COLLECTION

The study protocol was approved by the local ethics committee. The participants
were duly informed, and written and oral consent were obtained. Questionnaire were
filled by face to face interview technique. Clinical information was obtained from
patients file records.

7: DATA ANALYSIS

The data was analyzed by IBM STATISTICS 25. The quantitative variables were
presented as mean, standard deviation ,range and histogram. Caregorical variables
were evaluated as percentage (%), frequencies , cross tabulation , bar chart . Pearson
correlation was used to assess disability and functional ability in spinal stenosis non –
surgical patients.

8: ETHICAL CONSIDERATIONS

23
Permission from ethical committee of Rashid Latif College of physical therapy
was obtained in order to carry out study. The religious and cultural considerations
were duly taken at the time of data collection.

9: KEY WORDS

Spinal stenosis, Lumbar spinal stenosis, Disability and Functional

ability.

24
Results:

In this study 35 patients with lumbar spinal stenosis were asked to fill
ODI(Oswestry Disability Low back Pain) and SCIM(Spinal cord
Independence Measure) with mean age of 65.7714±6.389.Out of 35
patients 5(14.3%) were with minimal disability ,10(28.6%) were with
moderate disability,20(57.1%) were with severe disability.

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Summary of age of patients

Descriptive Statistics
N Minimum Maximum Mean Std. Deviation
Age 35 55.00 75.00 65.7714 6.38972
Valid N (listwise) 35

Table 9.1

Figure 9.1:Mean age of participants

Results: Age group of participants was between the minimum limits of 55 years and

maximum limits of 75 years with mean age of 65.77±6.39 years.

26
Summary of pain intensity:

Frequency Percent

Valid I have no pain at the

2 5.7
moment

The pain is very mild st

3 8.6
the moment

The pain is moderate at

5 14.3
the moment

The pain is fairly severe at

4 11.4
the moment

The pain is very severe at

14 40.0
the moment

The pain is worst

7 20.0
imaginable at the moment

Total 35 100.0

Table 9.2 Pain Intensity

Figure 9.2 Pain Intensity

Results: Out of 35 participants 2(5.7%) were with no pain ,3(8.6%)were with mild

pain ,5(14.3%) were with moderate pain ,4(11.4%) were with fairly severe pain

,14(40%) were with very severe pain ,7(20%) were with worst pain .

27
Summary of Lifting:

Frequency Percent

Valid I can lift heavy weight

2 5.7
but it gives extra pain

Pain prevents me from

lifting heavy weights ,
2 5.7
but i can manage light to
medium weights

I can lift very light

9 25.7
weights

I cannot lift or carry

22 62.9
anything at all

Total 35 100.0

Table 9.3

Figure 9.3

Results: Out of 35 participants 2(5.7%) were lifting weights with

minimal pain,2,9(25.7%) were lifting very light weights ,22(62.9%) were

not lifting weights.

28
Summary of walking:

Frequency Percent

Valid Pain prevents me from

10 28.6
walking more than 1 mile

Pain prevents me from

2 5.7
walking more than ½ mile

Pain prevents me from

3 8.6
walking more than 100 yards

I can only walk using a stick

6 17.1
or crutches

I am in bed most of the time 14 40.0

Total 35 100.0

Table 9.4

Figure 9.4

Results: Out of 35 participants 10(28.6%) were with pain that prevented

walking from 1mile, 3(8.6%) pain prevented them from walking more
than100 yards,6(17.1%) were using stick for walking

29
Summary of standing;

Table 9.5

Figure 9.5

Results: Out of 35 patients 4(11.4%) were standing as long but with

pain,3(8.6%) were standing for more than one hour,6(17.1%)pain

prevented from standing more than half hour,9(25.7%) were standing for

more than 10 minutes,13(37.1%) were not standing.

30
Summary of social life:

Frequency Percent

Valid My social life is normal and

1 2.9
gives me no extra pain

My social life is normal but

9 25.7
increases the degree of pain

Pain has no significant effect

on my social life apart from
1 2.9
limiting my more energetic
interests eg , sport

Pain has restricted my social

3 8.6
life and i do not go out often

Pain has restricted my social

5 14.3
life to my home

I have no social life because

16 45.7
of pain

Total 35 100.0

Table 9.6

Results: Out of 35 participants 9(25.7%) were having normal social life

but it gives them extra pain,3(8.6%) were not go out often,5(14.3%) were

restricted their life to home,16(45.7%) were having no social life.

31
Summary of travelling:

Frequency Percent

Valid I can travel anywhere

7 20.0
but it gives me extra pain

Pain restricts me to
journeys of less than one 3 8.6
hour

Pain restricts me to short

necessary journeys 7 20.0
under 30 minutes

Pain prevents me from

travelling except to 18 51.4
recieve treatment

Total 35 100.0

Table 9.7

Figure 9.7
Results: Out of 35 patients 7(20.0%) were travelling anywhere but with extra pain
,3(8.6%) were travelling less than hour,7(20.%) pain restricted them to short journeys
under 30 minutes,18(51.4%) pain prevented them from travelling except to receive
treatment.

32
Summary of feeding:

Frequency Percent

Valid fully assisted oral feeding

6 17.1

Needs partial assistance

9 25.7
for eating

Eats independently;
needs adaptive devices
or assistance only for 11 31.4
cutting food and pouring
or opening

Eats and drinks

9 25.7
independently

Total 35 100.0

Table 9.8

Figure 9.8

Results: Out of 35 patients 6(17.1%) were needed fully assisted oral

feeding,9(25.7%) were needed partial assistance,11(31.4%) were eating
independently used adaptive devices for opening and
pouring,9(25.7%)were eating independently.

33
 Summary of dressing (upper body):

Frequency Percent

Valid Requires total assistance 10 28.6

Requires partial assistance 5 14.3

Independent with cwobzl;

5 14.3
requires adaptive devices

Independent with cwobzl;

doesnot require adss; needs
4 11.4
assistance or adss only for
bzl

Dresses any cloth

independently ; doesnot
10 28.6
require adaptive devices or
specific setting

44 1 2.9

Total 35 100.0

Table 9.9

Figure 9.9
Results: Out of 35 patients 10(28.6%) required total assistance,5(14.3%) required

partial assistance,5(14.3%) independent with cowbzl needed adaptive

devices,10(28.6%) dressed any cloth not required adaptive devices.

34
Summary of grooming:

Frequency Percent

Valid Requires total assistance 9 25.7

Requires partial assistance 12 34.3

Grooms independently with

5 14.3
adaptive devices

Grooms independently
9 25.7
without adaptive devices

Total 35 100.0

Table 9.10

Figure 9.10
Results: Out of 35 patients 9(25.7%) were required total assistance,12(34.3%) were

required partial assistance,5(14.3%) were groomed independently with adaptive

devices,9(25.7%) were groomed independently without devices.

35
Summary of respiration:

Frequency Percent

Valid Breathes independently with

TT; requires total assistance
10 28.6
in coughing or TT
management

Breathes independently
without TT; requires little
3 8.6
assistance or stimulation for
coughing

Breathes independently
22 62.9
without assistance or device

Total 35 100.0

Table 9.11

Results: Out of 35 patients 10(28.6%) were breathing independently with

TT required total assistance in coughing,3(8.6%)breathing independently
without TT required little assistance or stimulation for
coughing,22(62.9%)were breathing independently without assistance or
device.

36
Summary of sphincter management (Bladder):

Frequency Percent

Indwelling catheter 6 17.1

RUV less than 100cc;

continent ; doesnot use 29 82.9
external drainage instrument

Total 35 100.0
Table 9.12

Figure 9.12

Results: Out of 35 participants 6 (17.1%) were required indwelling

catheter,29(82.9%)RUV less than 100cc,continent does not need external
drainage.

37
Summary of sphincter management( Bowel):

Frequency Percent

Valid Irregular timing or very low

frequency (less than once in 21 60.0
3 days) of bowel movements

Regular timing , but requires

assistance (e.g,for applying
3 8.6
suppository); rare accidents
(less than twice a month )

Regular bowel movements

1 2.9
,without assistance

Regular bowel movements;

without assistance ; no 10 28.6
accidents
Total 35 100.0

Table 9.13

Figure 9.13
Results: Out of 35 patients 21(60%) were having irregular timing or low

frequency,3(8.6%) were having regular timing but required assistance,1(2.9%) regular

bowel movements rare accidents ,10(28.6%) were having regular bowel movements.

38
Summary of mobility in bed and action to prevent pressure sores:

Frequency Percent

Valid Needs assistance in all

12 34.3
activities

Performs one of the

5 14.3
activities without assistance

Performs two or three of the

6 17.1
activities without assistance

Performs all the bed mobility

and pressure release 12 34.3
activities independently

Total 35 100.0

Table 9.14

Figure 9.14
Results: Out of 35 patients 12(34.3%) were needed assistance in all

activities,5(14.3%) were performing one of the activities without assistance,6(17.1%)

were performing two or three activities,12(34.3%) were performing all the activities.

39
Summary of transfer ;bed wheel chiar :

Frequency Percent

Valid Requires total assistance 9 25.7

Needs partial assistance or

supervision or adaptive 11 31.4
devices (e.g,sliding board)

Independent (or doesnot

15 42.9
require wheelchair )

Total 35 100.0

Table 9.15

Figure 9.15
Results :Out of 35 patients 9 (25.7%) were required total assistance,11(31.4%)

required partial assistance or needed some supervision,15(42.%) were independent.

40
Summary of mobility indoor:

Frequency Percent

Valid Requires total assistance 10 28.6

Requires supervision while

walking ( with or without 10 28.6
devices)

Walks with crutches or two

3 8.6
canes (reciprocal walking )

Walks without walking aids 12 34.3

Total 35 100.0

Table 9.16

Figure 9.16
Results: Out of 35 patients 10(28.6%) were required total assistance,10(28.6%)

required partial supervision while walking,3(8.6%) walked with crutches or two

canes,12(34.3%) were walked independently without walking aids.

41
Summary of mobility outdoors:

Frequency Percent

Valid Requires total assistance 10 28.6

Requires supervision while

walking ( with or without 15 42.9
devices)

Walks with a walking frame

3 8.6
or crtuches (swing)

Walks with one cane 1 2.9

Needs leg orthosis only 1 2.9

Walks without walking aids 5 14.3

Total 35 100.0

Table 9.17

Figure 9.17
Results :Out of 35 participants 10 (28.6%) were required total assistance ,15(42.9%)

required partial assistance,3(8.6%) were using walking frame,1(2.9%) were required

one cane,1(2.9%) required leg orthosis,5(14.3%) were walked independently.

42
Summary of stair management:

Frequency Percent

Valid Unable to ascend or

23 65.7
descend stairs

Ascends and descends at

least 3 steps with support or
4 11.4
supervision of another
person

Ascends and descends at

least 3 steps with support of 6 17.1
handrail or crutch or cane

Ascends and descends at

least 3 steps without any 2 5.7
support or supervision

Total 35 100.0

Table 9.18

Figure 9.18
Results: Out of 35 participants 23(65.7%) were unable to ascend or descend the

satirs,4(11.4%) were able to ascend or descend at least 3 steps with support,6(17.%)

were able to ascend or descend the stairs at least 3 steps with handrail,2(5.7%) were

able to ascend or descend without support .

43
Summary of transfer ;ground wheelchair:

Figure 9.19
Results :Out of 35 participants 22(62.9%) were required assistance,13(37.1%) were

transferred independently with or without any supervision.

44
Summary of Oswestry disability index:

Frequency Percent

Valid Minimal Disability 5 14.3

Moderate Disability 10 28.6

Severe Disability 20 57.1

Total 35 100.0

Table 9.20

Figure 9.20

Results: Out of 35 patients 5(14.3%) were with minimal disability

,10(28.6%) were with moderate disability,20(57.1%) were with severe

disability.

45
Summary of SCIM (Spinal cord independence measure):

N Minimum Maximum

Self Care 35 .00 20.00

Respiration and Sphincter 35 4.00 40.00
Mobility 35 .00 40.00
Total Score 35 13.00 100.00
Valid N (listwise) 35

Table 9.21

Results:Out of 35 patients there was total dependence for self care score

was zero(0),respiration and sphincter score was 4.00 ,for mobility score

was .00,total score is 13.00 means fully dependent.

46
Summary of correlation of ODI and self care:

Correlations : Self-Care
Owestry LBP Pearson Correlation -.592
Sig.(1-tailed) .000
N 35
Correlation is significant at 0.01 level (1-tailed).

Table 9.22

Result:

There was strong negative correlation between oswestry disability index

and self care with the p value of -.592

47
Summary of correlation of ODI and respiration and sphincter:

Correlations; Respiration & Sphincter

Pearson correlation -.609

Owestry LBP Sig.(1-tailed) .000
N 35

.**correlation is significant at 0.01 level(1 –tailed)

Table 9.23

Result: There was strong negative correlation between oswestry low

back and respiration and sphincter with the p value of -.609.

48
Summary of correlation of ODI and mobility:

Correlations:
Mobility

Pearson’s correlation -.747

Sig.(1-tailed) .000
Osestry LBP N 35

Correlation is significant at 0.001 level (1-tailed).

Table 9.24

Result :There was strong negative correlation between Oswestry Disability low

back pain and mobility with p value of -.747.

49
10. Discussion:

A study conducted in 2019 on effectiveness of physical therapy combined with

epidural steroid infection: randomized parallel group trial concluded that no

significant difference between epidural steroid injection and epidural steroid injection

plus physiotherapy in oswestry disability index at any time although sample show

improvements at 10 week. Epidural steroid injection plus physiotherapy was found

more beneficial relate to quality of life, factors of emotional function and emotional

well being(Hammerich et al., 2019).

A study conducted in 2016 on diabetes mellitus a new risk factor for developing

spinal stenosis: case control study concluded that total of 50 patients (15.2%) were

diagnosed with diabetes which consist of 32 (29.1%) in the stenosis group and 11

(10%) in the control group. The prevalence of diabetes in women with spinal stenosis

was 35.9% whereas prevalence of diabetes in control group was 10.9% .This

difference was statistically significant in the spinal stenosis group in comparison with

the controls (P , 0.0001). The prevalence of pain in diabetes patients is more with

spinal stenosis(Asadian et al., 2016).

A study conducted in 2018 on lumbar spinal stenosis in older adults: randomized

controlled trial concluded that 400 patients with moderate to severe leg pain (self

reported pain score of 4 or greater on a scale of 0-10) and disability score of 7 or

higher on RMQD (range 0-24) there was no significant difference between epidural

steroid injection versus epidural lidocaine. There was another randomized trial

concluded that outcomes of decompression and physiotherapy at 6 months, 1 year

follow up and 2 year follow up shows better results with decompression in reducing

pain(Lafian and Torralba, 2018).

50
In this study, Age group of participants was between the minimum limits of 55 years

and maximum limits of 75 years with mean age of 65.77±6.39 years. Out of 35

participants 2(5.7%) were with no pain ,3(8.6%)were with mild pain ,5(14.3%) were

with moderate pain ,4(11.4%) were with fairly severe pain ,14(40%) were with very

severe pain ,7(20%) were with worst pain .

Out of 35 participants 2(5.7%) were lifting weights with minimal pain,2(5.7%) were

lifting weights and pain prevented them,9(25.7%) were lifting very light weights

,22(62.9%) were not lifting weights. Out of 35 participants 10(28.6%) were with pain

that prevented walking from 1mile,2(5.7%) pain prevented from walking more than

1\2 mile,3(8.6%) pain prevented them from walking more than 100 yards,6(17.1%)

were using stick for walking,14(40%) were in bed most of the time.

Out of 35 participants 9(25.7%) were having normal social life but it gives them extra

pain,3(8.6%) were not go out often,5(14.3%) were restricted their life to

home,16(45.7%) were having no social life. Out of 35 patients 7(20.0%) were

travelling anywhere but with extra pain ,3(8.6%) were travelling less than

hour,7(20.%) pain restricted them to short journeys under 30 minutes,18(51.4%) pain

prevented them from travelling except to receive treatment.

Out of 35 patients 6(17.1%) were needed fully assisted oral feeding,9(25.7%) were

needed partial assistance,11(31.4%) were eated independently used adaptive devices

for opening and pouring,9(25.7%)were eated independently:Out of 35 patients

10(28.6%) were breathing independently with TT required total assistance in

coughing,3(8.6%)breathing independently without TT required little assistance or

stimulation for coughing,22(62.9%)were breathing independently without assistance

or device.

51
Out of 35 patients 10(28.6%) were required total assistance,10(28.6%) required

partial supervision while walking,3(8.6%) walked with crutches or two

canes,12(34.3%) were walked independently without walking aids.

:Out of 35 paarticipants 10 (28.6%) were required total assistance ,15(42.9%) required

partial assistance,3(8.6%) were using walking frame,1(2.9%) were required one

cane,1(2.9%) required leg orthosis,5(14.3%) were walked independently.

Out of 35 participants 23(65.7%) were unable to ascend or descend the

satirs,4(11.4%) were able to ascend or descend atleast 3 steps with support,6(17.%)

Out of 35 participants 22(62.9%) were required assistance,13(37.1%) were transferred

independently with or without any supervision.

Out of 35 patients 5(14.3%) were with minimal disability ,10(28.6%) were with

moderate disability,20(57.1%) were with severe disability.

There was strong negative correlation between oswestry disability index and self care

with the p value of -.592. There was strong negative correlation between oswestry low

back and respiration and sphincter with the p value of -.609.There was strong negative

correlation between Oswestry Disability low back pain and mobility with p value of -

.747.

52
11. Conclusion:

Spinal stenosis negatively effects the functional ability and disability .there is need to

alarm the population to manage their physical abilities to prevent disability related to

stenosis by introducing different exercises and life style modifications. Physical

therapy guidelines must recommend to prevent age related disabilities.

53
12. Limitations

There were following limitations related to this study:

1. Data was not collected from private hospitals.

2. Designing and validating a set of classification criteria for LSS within a

multicenter, multidisciplinary framework.

13. Recommendations:

1. Future researchers to take larger samples.

2. Data should be collected from the private hospitals .

3. Health care providers should utilize their clinical expertise and design different

medicinal and exercise regimens to help improve symptoms and thus quality of life in

these patients.

54
14.REFRENCES:

Asadian, L., Haddadi, K., Aarabi, M. and Zare, A., 2016. Diabetes mellitus, a new

risk factor for lumbar spinal stenosis: a case–control study. Clinical Medicine

Insights: Endocrinology and Diabetes, 9, pp.CMED-S39035.

Bumann, H., Nüesch, C., Loske, S., Byrnes, S.K., Kovacs, B., Janssen, R., Schären,

S., Mündermann, A. and Netzer, C., 2020. Severity of degenerative lumbar spinal

stenosis affects pelvic rigidity during walking. The Spine Journal, 20(1), pp.112-120.

Cao, J., Kong, L., Meng, F., Zhang, Y. and Shen, Y., 2016. Impact of obesity on

lumbar spinal surgery outcomes. Journal of Clinical Neuroscience, 28, pp.1-6.

Costandi, S., Chopko, B., Mekhail, M., Dews, T. and Mekhail, N., 2015. Lumbar

spinal stenosis: therapeutic options review. Pain Practice, 15(1), pp.68-81.

Fujita, N., Sakurai, A., Miyamoto, A., Michikawa, T., Otaka, Y., Suzuki, S., Tsuji, O.,

Nagoshi, N., Okada, E., Yagi, M. and Tsuji, T., 2019. Stride length of elderly patients

with lumbar spinal stenosis: Multi-center study using the Two-Step test. Journal of

Orthopaedic Science, 24(5), pp.787-792.

Hammerich, A., Whitman, J., Mintken, P., Denninger, T., Akuthota, V., Sawyer, E.E.,

Hofmann, M., Childs, J.D. and Cleland, J., 2019. Effectiveness of physical therapy

combined with epidural steroid injection for individuals with lumbar spinal stenosis: a

randomized parallel-group trial. Archives of physical medicine and

rehabilitation, 100(5), pp.797-810.

55
Jiang, J., Wang, H., Wang, L., Zhang, B., Guo, Q., Yuan, W. and Lu, X., 2017.

Multifidus Degeneration, A New Risk Factor for Lumbar Spinal Stenosis: A Case–

Control Study. World neurosurgery, 99, pp.226-231.

Kalichman, L., Cole, R., Kim, D.H., Li, L., Suri, P., Guermazi, A. and Hunter, D.J.,

2009. Spinal stenosis prevalence and association with symptoms: the Framingham

Study. The spine journal, 9(7), pp.545-550.

Lee, S.Y., Kim, T.H., Oh, J.K., Lee, S.J. and Park, M.S., 2015. Lumbar stenosis: a

recent update by review of literature. Asian spine journal, 9(5), p.818.

Lurie, J. and Tomkins-Lane, C., 2016. Management of lumbar spinal

stenosis. Bmj, 352.

Minetama, M., Kawakami, M., Teraguchi, M., Kagotani, R., Mera, Y., Sumiya, T.,

Nakagawa, M., Yamamoto, Y., Matsuo, S., Koike, Y. and Sakon, N., 2019.

Supervised physical therapy vs. home exercise for patients with lumbar spinal

stenosis: a randomized controlled trial. The Spine Journal, 19(8), pp.1310-1318.

Park, S., Han, H.S., Kim, G.U., Kang, S.S., Kim, H.J., Lee, M., Park, S.H., Choi,

K.H., Kim, S.H. and Yeom, J.S., 2017. Relationships among disability, quality of life,

and physical fitness in lumbar spinal stenosis: an investigation of Elderly Korean

Women. Asian spine journal, 11(2), p.256.

Passmore, S.R., Johnson, M.G., Kriellaars, D.J., Pelleck, V., Enright, A. and

Glazebrook, C.M., 2015. Fitts’s Law using lower extremity movement: Performance

driven outcomes for degenerative lumbar spinal stenosis. Human movement

science, 44, pp.277-286.

56
Schroeder, G.D., Kurd, M.F. and Vaccaro, A.R., 2016. Lumbar spinal stenosis: how is

it classified?. Journal of the American Academy of Orthopaedic Surgeons, 24(12),

pp.843-852.

Thornes, E., Stendal Robinson, H., Moosmayer, S., Ekeland, A. and Vøllestad, N.K.,

2020. Low-impact exercise program for patients with symptomatic lumbar spinal

stenosis awaiting surgery: a controlled pilot study. European Journal of

Physiotherapy, 22(2), pp.97-105.

Truszczyńska-Baszak, A., Wysocka, E., Starzec, M., Drzał-Grabiec, J. and

Tarnowski, A., 2018. Urinary incontinence due to lumbar spinal stenosis causing

disability and lowering quality of life. Journal of back and musculoskeletal

rehabilitation, 31(4), pp.735-741.

Wu, A.M., Zou, F., Cao, Y., Xia, D.D., He, W., Zhu, B., Chen, D., Ni, W.F., Wang,

X.Y. and Kwan, K.Y.H., 2017. Lumbar spinal stenosis: an update on the

epidemiology, diagnosis and treatment. AME Medical Journal.

57
15. APPENDIX I

15.1. English Consent Form

The study you are about to participate is to ASSESMENT OF DISABILITY AND

FUNCTIONAL ABILITY IN NON-SURGICAL SPINAL STENOSIS PATIENTS

……………………………………………………………………………

The study has no potential harm to participants. All data collected from you will be coded in

order to protect your identity, and should not be disclosed to anyone. Following the study there

will be no way to connect your name with your data. Your answers to the questions will not

affect the quality of education given to you. Any additional information about the study results

will be provided to you at its conclusion, upon your request.

You are free to withdraw from the study at any time. You agree to participate, indicating that you

have read and understood the nature of the study, and that all your inquiries concerning the

activities have been answered to your satisfaction.

Name: Date:

Signature:

58
‫‪Urdu Consent Form‬‬

‫‪ -----------------------‬میں‬ ‫تصد یق کرتا ‪ /‬کرتی ہوں‬

‫کہ جناب ۔۔۔۔۔۔۔۔۔۔۔۔۔۔۔۔۔۔۔ نے‬

‫‪ :‬اپنی تحقیق بعنواى‬

‫‪‘ASSESSMENT OF DISABILITY AND FUNCTIONAL ABILITY IN NON-‬‬

‫”‪SURGICAL SPINAL STENOSIS PATIENTS‬‬

‫کے هتعلق بتا دیا ہے ۔ هجھے اس کی نو عیت ‪ ،‬هقا صذ‪ ،‬احذاف ‪ ،‬تو ____________________ سیز نگزانی‬

‫قعات‪ ،‬فوائذ اور خطزات کے هتعلق ساری هعلوهات فزاہن کز دی گئ ہیں۔‬

‫هیں رہیں گی اور هزیض کا نام اور دیگز هعلوهات صزف تحقیق‬ ‫اس تحقیق کے دوراى ساری هعلوه ات صیغہ راس‬

‫کے لیے استعوال ہوں گی۔ هجھے یہ بھی بتا دیا گیاہے کہ یہ تحقیق صزف ایک شخص کے هفاد هیں نہیں بلکہ‬

‫بحثیت هجووعی انسانیت کا هفاد اس سے وابستہ ہے۔ اگز هیں توام تفصیالت جاننے کے بعذ اس تحقیق هیں شاهل‬

‫ہونے سے هعذرت کزوں تو هجھ پز کوئی پابنذی نہیں ہو گی۔ هیں کسی وقت بھی اس تحقیق سے اپنے آپ کو‬

‫علیحذہ کز سکتا ‪ /‬سکتی ہوں اور هجھ پز کسی قسن کی کوئی بنذش نہیں ہو گی ۔ هیں بذات خود بقائوی ہوش و‬

‫حواس اپنی رضا هنذی سے اس تحقیقاتی عول هیں شاهل ہوتا‪ /‬ہوتی ہوں۔‬

‫۔۔۔۔۔۔۔۔۔۔۔۔۔۔۔۔۔۔۔۔‬ ‫هحقق‬ ‫دستخط‬

‫دستخط هزیض ۔۔۔۔۔۔۔۔۔۔۔۔۔۔۔۔۔۔‬

‫‪59‬‬
16. APPENDIX II

60
61
62
63