In the present study, we evaluated the low back and leg symptoms of patients with LSS, dichotomized into those who self-quarantined during the COVID-19 pandemic and those who did not. Our findings support our hypothesis that staying home accompanies short-term relief of low back pain, although it does not benefit HRQoL or ADL. We found that more female patients and more patients with severe low back and leg pain tended to self-quarantine. After case-control matching, the improvement in NRS score for low back pain in the SQ group was significant, while that in the non-SQ group was not. There was no significant difference between the groups regarding the NRS score for leg pain or numbness. Nevertheless, self-quarantine did not help to regain HRQoL or ADL. Per our knowledge, this is the first study to evaluate the short-term effects of limiting outings and exercise during the self-quarantine period on low back symptoms in patients with LSS.
From May to July 2020, the outpatient clinic of our hospital was closed to concentrate medical resources on the treatment of COVID-19. We continued follow-up on nearly all patients with lumbar degenerative disease via telemedicine; thus, participant baseline evaluation was performed telephonically. NRS was used to evaluate pain and numbness, and the daily life independence level was used for ADL estimation in order to determine the patient's symptoms. Reportedly, the NRS is more responsive and sensitive than the VAS and can be administered verbally14. While a self-administered VAS was used at follow-up to strengthen the data, 8 participants were not able to complete the form—this may have been due to vision-related issues or lack of understanding the contents.
Before case-control matching, the SQ group reported a significantly higher baseline NRS score for low back pain than that reported by the remaining patients. Walking ability in patients with lumbar degenerative disease has a reported inverse correlation with back pain severity15; thus, it is reasonable that patients with severe back pain limited outings and exercise after the order from the government. This difference led to failure in yielding 1:1 matching.
In the case-control analyses, low back pain improved more in the SQ group than in the non-SQ group. Notably, all patients received conservative treatment prior to and during quarantine. Approximately 90% of participants received a prescription, and the doctor provided pain relief via exercise guidance delivered through a scheduled telephonic call. There was only a minor difference in the prescribed medications between the groups. Therefore, our findings suggest that, as an adjunct to conservative treatment, self-quarantining was superior to not self-quarantining for improving low back pain and, thus, staying home may have contributed to a short-term improvement in symptoms in patients with LSS.
However, the SF-12 RCS score in the SQ group was significantly lower than that in the non-SQ-group, while no difference in the PCS or MCS scores were found at follow-up. Limiting outings and exercise likely diminishes social roles, at least temporarily; thus, this finding is reasonable as a side-effect of self-quarantine. It suggests that, despite self-quarantine helping to decrease the NRS score for low back pain, it is not a sufficient treatment option for LSS.
In the SQ group, we failed to find a relationship between an improvement in ADL and low back and leg pain relief. The abovementioned findings indicate that self-quarantine did not significantly contribute to relief of leg pain or numbness. Thus, a potential cause of ADL impairment could have been persistent neurogenic claudication, despite self-quarantining.
Our findings are consistent with those of other studies concerning the COVID-19 pandemic. Kuitunen et al. reported a 31% decrease in low back symptom–related emergency department visits during and after national lockdown16. Clinic visits and the surgical caseload for lumbar spinal diseases also decreased17,18. Although the pandemic forced medical providers and patients to concentrate resources, pain relief upon staying home may also be a potential cause of decreased hospital visits.
This study had several strengths. Since it was a single-centre study conducted at a general hospital, accurate information on medication and comorbidities were obtained from medical records—consideration of medication is important in the evaluation of changes in symptoms. Additionally, since the baseline evaluation was conducted telephonically, the associated ethical and social burden under the state of emergency was minimal. Treatment bias was avoided since physicians were not aware of the quarantine status of the patients until follow-up.
However, there were also several limitations. First, patients with severe symptoms who required referral to another spine centre and those who underwent early surgical intervention were excluded due to ethical reasons. Nonetheless, the findings suggest that self-quarantine may benefit low back pain relief, at least in mild cases that can be managed conservatively. Second, patients reported their self-quarantine status by answering a yes/no question and quantitative data regarding limitation of movement were not available. However, each patient had their own physical activity level and low back symptoms of LSS arise from own daily life activity. Findings suggest that patients who reported to having limited outings or exercise during lockdown were likely to experience a reduction in low back pain. Third, the mean period between baseline and follow-up was 2 months—we assessed the short-term effect of self-quarantine. Notably, quarantine has an adverse effect on anxiety, stress, and other psychological factors7; these aspects could worsen pain, numbness, and ADL deterioration. Moreover, consistent physical inactivity is a risk factor for osteoporosis in older adults19. Future studies should involve a longer follow-up period to assess these factors.
In conclusion, we found an improvement in low back pain in patients with LSS who performed self-quarantine from May to July 2020, during the early period of the COVID-19 pandemic in Japan. However, no significant improvement in leg pain or numbness was found, and self-quarantine did not benefit HRQoL or ADL. These results may help spine practitioners and surgeons to understand changes in patient symptoms during the COVID-19 pandemic period, and lead to optimizing the use of healthcare resources.