Comprehensive Nonsurgical Treatment Versus Self-directed Care to Improve Walking Ability in Lumbar Spinal Stenosis: A Randomized Trial


      • Effective nonsurgical treatments for lumbar spinal stenosis are unknown.
      • Limited walking ability is the dominant impairment in this population.
      • We conducted a randomized trial that tested a 6-week comprehensive training program.
      • The comprehensive program showed large and sustainable improvements in walking ability.
      • A total of 81% of comprehensive participants achieved the walking minimally clinically important difference at 12 months.



      To compare the effectiveness of a comprehensive nonsurgical training program to a self-directed approach in improving walking ability in lumbar spinal stenosis (LSS).


      Randomized controlled trial.


      Academic hospital outpatient clinic.


      Participants (N=104) with neurogenic claudication and imaging confirmed LSS were randomized. The mean age was 70.6 years, 57% were women, 84% had leg symptoms for >12 months, and the mean maximum walking capacity was 328.7 m.


      A 6-week structured comprehensive training program or a 6-week self-directed program.

      Main Outcome Measures

      Continuous walking distance in meters measured by the Self-Paced Walk Test (SPWT) and proportion of participants achieving at least 30% improvement (minimally clinically important difference [MCID]) in the SPWT at 6 months. Secondary outcomes included the Zurich Claudication Questionnaire (ZCQ), Oswestry Disability Index (ODI), ODI walk score, and the Short-Form General Health Survey subscales.


      A total of 48 versus 51 participants who were randomized to comprehensive (n=51) or self-directed (n=53) treatment, respectively, received the intervention and 89% of the total study sample completed the study. At 6 months, the adjusted mean difference in walking distance from baseline was 421.0 m (95% confidence interval [95% CI], 181.4-660.6), favoring the comprehensive program and 82% of participants in the comprehensive group and 63% in the self-directed group achieved the MCID (adjusted relative risk, 1.3; 95% CI, 1.0-1.7; P=.03). Both primary treatment effects persisted at 12 months favoring the comprehensive program. At 6 months, the ODI walk score and at 12 months the ZCQ, Medical Outcomes Study 36-Item Short-Form Health Survey-physical function and -bodily pain scores showed greater improvements favoring the comprehensive program.


      A comprehensive conservative program demonstrated superior, large, and sustained improvements in walking ability and can be a safe nonsurgical treatment option for patients with neurogenic claudication due to LSS.


      List of abbreviations:

      95% CI (95% confidence interval), LSS (lumbar spinal stenosis), MCID (minimally clinically important difference), ODI (Oswestry Disability Index), SF-36 (Medical Outcomes Study 36-Item Short-Form Health Survey), SPWT (Self-Paced Walk Test), ZCQ (Zurich Claudication Questionnaire)
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        • Fanuele J.C.
        • Birkmeyer N.J.
        • Abdu W.A.
        • Tosteson T.D.
        • Weinstein J.N.
        The impact of spinal problems on the health status of patients: have we underestimated the effect?.
        Spine. 2000; 25: 1509-1514
        • Kobayashi S.
        Pathophysiology, diagnosis and treatment of intermittent claudication in patients with lumbar canal stenosis.
        World World J Orthop. 2014; 5: 134-145
        • Jansson K.A.
        • Nemeth G.
        • Granath F.
        • Jonsson B.
        • Blomqvist P.
        Health-related quality of life (EQ-5D) before and one year after surgery for lumbar spinal stenosis.
        J Bone Joint Surg Br. 2009; 91: 210-216
        • Ammendolia C.
        • Schneider M.
        • Williams K.
        • et al.
        The physical and psychological impact of neurogenic claudication: the patients’ perspectives.
        J Can Chiropr Assoc. 2017; 61: 18-31
        • Fritz J.M.
        • Delitto A.
        • Welch W.C.
        • Erhard R.E.
        Lumbar spinal stenosis: a review of current concepts in evaluation, management, and outcome measurements.
        Arch Phys Med Rehabil. 1998; 79: 700-708
        • Sinikallio S.
        • Aalto T.
        • Airaksinen O.
        • et al.
        Depression and associated factors in patients with lumbar spinal stenosis.
        Disabil Rehabil. 2006; 28: 415-422
        • Chen E.
        • Tong K.B.
        • Laouri M.
        Surgical treatment patterns among Medicare beneficiaries newly diagnosed with lumbar spinal stenosis.
        Spine J. 2010; 10: 588-594
        • Ammendolia C.
        • Stuber K.J.
        • Rok E.
        • et al.
        Nonoperative treatment for lumbar spinal stenosis with neurogenic claudication.
        Cochrane Database Syst Rev. 2013; 8: CD010712
        • Ammendolia C.
        • Stuber K.
        • Tomkins-Lane C.
        • et al.
        What interventions improve walking ability in neurogenic claudication with lumbar spinal stenosis? A systematic review.
        Eur Spine J. 2014; 23: 1282-1301
        • Wessberg P.
        • Frennered K.
        Central lumbar spinal stenosis: natural history of non-surgical patients.
        Eur Spine J. 2017; 26: 2536-2542
        • Ammendolia C.
        • Chow N.
        Clinical outcomes for neurogenic claudication using a multimodal program for lumbar spinal stenosis: a retrospective study.
        J Manipulative Physiol Ther. 2015; 38: 188-194
        • Ammendolia C.
        • Côté P.
        • Rampersaud Y.R.
        • et al.
        The boot camp program for lumbar spinal stenosis: a protocol for a randomized controlled trial.
        Chiropr Man Therap. 2016; 24: 25
        • Linton S.J.
        • Andersson T.
        Can chronic disability be prevented? A randomized trial of a cognitive-behavior intervention and two forms of information for patients with spinal pain.
        Spine. 2000; 25: 2825-2831
        • Chung S.S.
        • Lee C.S.
        • Kim S.H.
        • Chung M.W.
        • Ahn J.M.
        Effect of low back posture on the morphology of the spinal canal.
        Skeletal Radiol. 2000; 29: 217-223
        • Tomkins C.C.
        • Battie M.C.
        • Rogers T.
        • Jiang H.
        • Petersen S.
        A criterion measure of walking capacity in lumbar spinal stenosis and its comparison with a treadmill protocol.
        Spine. 2009; 34: 2444-2449
        • Stucki G.
        • Daltroy L.
        • Liang M.H.
        • Lipson S.J.
        • Fossel A.H.
        • Katz J.N.
        Measurement properties of a self-administered outcome measure in lumbar spinal stenosis.
        Spine. 1996; 21: 796-803
        • Fairbank J.C.
        • Pynsent P.B.
        The Oswestry Disability Index.
        Spine (Phila Pa 1976). 2000; 25: 2940-2952
        • Wewers M.E.
        • Lowe N.K.
        A critical review of visual analogue scales in the measurement of clinical phenomena.
        Res Nurs Health. 1990; 13: 227-236
        • Tinetti M.E.
        • Richman D.
        • Powell L.
        Falls efficacy as a measure of fear of falling.
        J Gerontol. 1990; 45: P239-P243
        • Guralnik J.M.
        • Ferrucci L.
        • Pieper C.F.
        • et al.
        Lower extremity function and subsequent disability: consistency across studies, predictive models, and value of gait speed alone compared with the short physical performance battery.
        J Gerontol A Biol Sci Med Sci. 2000; 55: M221-M231
        • Haley S.M.
        • McHorney C.A.
        • Ware Jr., J.E.
        Evaluation of the MOS SF-36 physical functioning scale (PF-10): I. Unidimensionality and reproducibility of the Rasch item scale.
        J Clin Epidemiol. 1994; 47: 671-684
        • Radloff L.S.
        The CES-D scale. A self-report depression scale for research in the general population.
        Appl Psychol Meas. 1977; 1: 385-401
        • Cleland J.A.
        • Whitman J.M.
        • Houser J.L.
        • Wainner R.S.
        • Childs J.D.
        Psychometric properties of selected tests in patients with lumbar spinal stenosis.
        Spine J. 2012; 12: 921-931
        • Copay A.G.
        • Glassman S.D.
        • Subach B.R.
        • Berven S.
        • Schuler T.C.
        • Carreon L.Y.
        Minimum clinically important difference in lumbar spine surgery patients: a choice of methods using the Oswestry Disability Index, Medical Outcomes Study Questionnaire Short Form 36, and pain scales.
        Spine J. 2008; 8: 968-974
        • Whitman J.M.
        • Flynn T.W.
        • Childs J.D.
        • et al.
        A comparison between two physical therapy treatment programs for patients with lumbar spinal stenosis: a randomized clinical trial.
        Spine (Phila Pa 1976). 2006; 31: 2541-2549
        • Gignac M.A.
        • Cott C.
        • Badley E.M.
        Adaptation to disability: applying selective optimization with compensation to the behaviors of older adults with osteoarthritis.
        Psychol Aging. 2002; 17: 520-524
        • Qaseem A.
        • Wilt T.J.
        • McLean R.M.
        • Forciea M.A.
        Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians.
        Ann Intern Med. 2017; 166: 514-530
        • Comer C.
        • Redmond A.C.
        • Bird H.A.
        • Hensor E.M.
        • Conaghan P.G.
        A home exercise programme is no more beneficial than advice and education for people with neurogenic claudication: results from a randomised controlled trial.
        PLoS One. 2013; 8: e72878
        • Delitto A.
        • Piva S.R.
        • Moore C.G.
        • Welch W.C.
        Surgery versus nonsurgical treatment of lumbar spinal stenosis.
        Ann Intern Med. 2015; 163: 397-398
        • Weinstein J.N.
        • Tosteson T.D.
        • Lurie J.D.
        • et al.
        SPORT Investigators. Surgical versus nonsurgical therapy for lumbar spinal stenosis.
        N Engl J Med. 2008; 358: 794-810
        • Atlas S.J.
        • Deyo R.A.
        • Keller R.B.
        • et al.
        The Maine Lumbar Spine Study, Part III. 1-year outcomes of surgical and non-surgical management of lumbar spinal stenosis.
        Spine (Phila Pa 1976). 1996; 21: 1787-1794