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Arch Phys Med Rehabil. 2018 Dec;99(12):2408-2419.e2. doi: 10.1016/j.apmr.2018.05.014. Epub 2018 Jun 20.

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

Author information

1
Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Rebecca MacDonald Centre for Arthritis & Autoimmune Disease, Mount Sinai Hospital, Toronto, Ontario, Canada. Electronic address: cammendolia@mtsinai.on.ca.
2
Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Faculty of Health Sciences, University of Ontario Institute of Technology and UOIT-CMCC Centre for Disability Prevention and Rehabilitation, Toronto, Ontario, Canada.
3
Occupational and Industrial Orthopaedic Centre, Department of Orthopaedic Surgery, NYU Langone Health, New York, NY.
4
Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA.
5
Canadian Memorial Chiropractic College, Toronto, Ontario, Canada.
6
Department of Medicine, Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
7
Department of Orthopedics, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.

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:

Back; Conservative treatment; Randomized controlled trial; Rehabilitation; Spinal stenosis

PMID:
29935152
DOI:
10.1016/j.apmr.2018.05.014

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