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

      Highlights

      • 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.

      Abstract

      Objectives

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

      Design

      Randomized controlled trial.

      Setting

      Academic hospital outpatient clinic.

      Participants

      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.

      Interventions

      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.

      Results

      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.

      Conclusions

      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.

      Keywords

      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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