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Research Review By Dr. Ceara Higgins©

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Date Posted:

March 2016

Study Title:

Clinical Outcomes for Neurogenic Claudication Using a Multimodal Program for Lumbar Spinal Stenosis: A Retrospective Study

Authors:

Ammendolia C & Chow N

Author's Affiliations:

University of Toronto; Mount Sinai Hospital, Toronto; Canadian Memorial Chiropractic College, Toronto, Canada.

Publication Information:

Journal of Manipulative & Physiological Therapeutics 2015; 38(3): 188-194.

Background Information:

Degenerative lumbar spinal stenosis (DLSS) is an age-related degenerative narrowing of the spinal canal, often leading to compression and ischemia of the spinal nerves (2). DLSS is a common cause of neurogenic claudication, leading to pain, disability, and loss of independence in older adults (1). Neurogenic claudication commonly presents as bilateral or unilateral buttock or lower extremity pain, heaviness, numbness, tingling, or weakness, brought on by walking and standing, and relieved by sitting and forward flexion. Functionally, this causes limitations in walking ability that are greater than those seen in individuals with knee or hip osteoarthritis (3) and functional limitations greater than those seen in individuals with congestive heart failure, chronic obstructive lung disease, or systemic lupus erythematosus (1). These limitations can lead to a sedentary lifestyle and declines in overall health. Neurogenic claudication due to DLSS is commonly treated with nonsurgical care and, due to the chronicity of the condition, self-management is also paramount.

This study aimed to assess the effectiveness of the 6-week Boot Camp Program for Lumbar Spinal Stenosis for improving patients’ symptoms and functional status.

Pertinent Results:

Medical records from 49 patients were included. The average age of patients was 70 years of age, 65% were female, and they had a mean duration of 11 years for back pain and 8.6 years for leg symptoms. Some variability existed in the number of patients included in different data points due to missing data and variability in symptoms. At baseline, the average Oswestry Disability Index (ODI) was 51/100 and the average walking item of the ODI was 3. This indicates that the patients included were severely disabled with moderate walking limitations. The baseline average pain score was 7/10 for both leg and back and Swiss Spinal Stenosis (SSS) questionnaire symptom and function scores were 3.22/5 and 2.27/4 respectively, indicating high levels of pain and functional limitations. At 6-week follow-up, all outcomes showed both statistically and clinically significant improvements.

The authors postulated that the improvements shown could be related to meeting the specific goals of the Boot Camp Program. These include:
  1. Improved intersegmental lumbar spine mobility as a result of side posture mobilization/manipulation and flexion-distraction combined with home flexion exercises;
  2. Increased ability to self-align the spine (reducing the lumbar lordosis and increasing the cross-sectional area of the spinal canals to reduce nerve compression) due to core strengthening exercises;
  3. Improved lower extremity strength and overall aerobic capacity without increased symptoms due to stationary biking; and
  4. Improved functional status (especially walking) due to the use of a cognitive behavioural approach combining goal setting and positive reinforcement to overcome fear avoidance behaviours.

Clinical Application & Conclusions:

This study provides preliminary evidence for the use of a multimodal program of care with an emphasis on self-management for symptom and functional improvements in patients with neurogenic claudication. The Boot Camp Program for Lumbar Spinal Stenosis showed both statistically significant and clinically important improvements in all outcomes. This ‘boot-camp’ type of program may best include a combination of manual therapy, home-based exercises, and cognitive-behavioural training. This is a very promising approach to Lumbar Spinal Stenosis – an often challenging clinical condition! The lead author of this study is planning to test this program further in a randomized trial, which we will certainly review once published!

Study Methods:

A retrospective medical record review of consecutive patients enrolled in the Boot Camp Program for Lumbar Spinal Stenosis from January 2010 to April 2013 was completed. Medical records were selected based on the following inclusion criteria:
  • 50 years of age or older
  • Clinical evidence of neurogenic claudication due to lumbar spinal stenosis
  • Symptoms for more than 3 months
  • Completed both the Boot Camp Program for Lumbar Spinal Stenosis and the pre- and post-treatment outcome measures and questionnaires
Exclusion criteria were as follows:
  • Spondylitis, neoplasm, infection, or metabolic disease
  • Radiculopathy due to lumbar disc herniation
  • Psychiatric and/or cognitive disorders
  • Not able to read or comprehend English sufficiently enough to complete self report
The Boot Camp Program for Lumbar Spinal Stenosis consisted of one-on-one treatment sessions with one of the authors (C.A.), 1-3 times per week for 15-20 minutes, and home care. Frequency of care was decided on a case by case basis depending on severity of symptoms and travel time to the clinic.

A typical treatment session began with education, reassurance, and positive reinforcement. This included: 1) instructions on self-management strategies using a cognitive behavioural approach (16); 2) information on causes of pain and disability due to DLSS, its natural history, and prognosis; and 3) instructions on managing symptoms and how to maintain their daily routines using problem solving, pacing, relaxation, and body positioning. This included instructions on reducing lumbar lordosis while standing and walking through the use of the pelvic tilt (body repositioning technique). Positive reinforcement, reassurance, goal setting, and graded activity were used to reduce pain-related fear and improve self-efficacy and function. The clinician emphasized maximizing function, especially walking ability.

Next, the patient was given 5 minutes of manually assisted mechanical flexion-distraction in a prone position with a push-relax technique used to progressively stretch the piriformis, gluteus medius, rectus femoris, adductors, and iliopsoas muscles. This is followed by side posture mobilization/manipulation of the lumbar spine while in a flexed position and supine neuromobilization of the sciatic nerve. This manual therapy was aimed at increasing flexibility of the lumbar spine and facilitating intersegmental lumbar flexion.

Finally, exercises from previous session were reviewed and 2-3 new exercises were given. Exercises included muscle stretching, strengthening, and conditioning exercises focused on improving back and lower extremity fitness and facilitation of lumbar flexion. Tight muscles that promote lumbar extension were stretched using supine knee to chest and knee to opposite chest stretches, side posture quadriceps stretches, and standing iliopsoas stretches. Muscles that promote and control lumbar flexion were strengthened using supine pelvic tilt, half sit ups, side posture lateral stabilizer exercises, and prone lumbar and gluteal extension exercises. As well, patients with limited walking ability were given a graduated cycling program using a stationary forward leaning bike and patients with no walking ability limitations were given a graduated walking program. Both of these aimed to improve lower extremity conditioning and overall fitness. Patients received a written exercise and conditioning program schedule outlining the type, frequency, and intensity of the exercises to be performed. Exercises were performed twice a day at home with increasing number, intensity, and frequency on a weekly basis over the course of the 6-week program.

Data Collection & Outcomes:
Baseline data and 6-week follow-up data was extracted from patients’ medical files. The Swiss Spinal Stenosis questionnaire (SSS) was used to assess physical function via the physical performance scale, symptom severity via the symptom severity scale, and treatment satisfaction via the treatment satisfaction scale. Functional disability was measured using the Oswestry Disability Index (ODI) and leg and back pain were independently measured at baseline and 6-week follow-up using the 11-point numerical rating scale (NRS).

Study Strengths / Weaknesses:

Strengths:
  • All manual therapy and information/exercises were prescribed by the same clinician, increasing the likelihood of consistency from patient to patient.
  • An emphasis was placed on self-management strategies in everyday life. This is very important as neurogenic claudication is a chronic condition.
  • All patients had clear clinical evidence of neurogenic claudication.
  • All outcome measures utilized have been validated.
  • Large improvements were seen both statistically and clinically in outcome measures.
Weaknesses
  • Retrospective studies are limited by the difficulty in controlling bias and cofounding factors, and the reliance on the accuracy of the records used.
  • There was no control group or randomization of treatment interventions.
  • Only patients who completed the program were included. Patients not improving may have left the program before completion leading to inflated rates of improvement.
  • Neither the patient or the practitioner were blinded which could have created bias.
  • No objective measures were used to assess walking capacity or performance.
  • Only short-term outcomes were used. Improvements may have diminished over time.

Additional References:

  1. Fanuele JC, Birkmeyer NJ, Abdu WA, et al. The impact of spinal problems on the health status of patients: have we underestimated the effect? Spine 2000; 25: 1509-1514.
  2. Takahashi K, Kagechika K, Takino T, et al. Changes in epidural pressure during walking in patients with lumbar spinal stenosis. Spine 1995; 20: 2746-2749.
  3. Winter CC, Brandes M, Muller C, et al. Walking ability during daily life I patients with osteoarthritis of the knee or the hip and lumbar spinal stenosis: a cross sectional study. BMC Musculoskelet Disord 2010; 11: 233.
  4. Linton SJ, 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.
  5. Bodack MP, Monteiro M. Therapeutic exercise in the treatment of patients with lumbar spinal stenosis. Clin Orthop Relat Res 2001: 144-152.
  6. Ammendolia C, Stuber KJ, Rok E, et al. Nonoperative treatment for lumbar spinal stenosis with neurogenic claudication. Cochrane Database Syst Rev 2013; 8: CD010712.

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