Practice recommendations
- Positional therapy with a wheeled walker may help patients with spinal stenosis to walk, as well as ease their pain. This conservative approach has minimum risks—and minimum costs.
Abstract
Methods: We analyzed a retrospective case series of 52 patients with spinal stenosis confirmed by spinal imaging and walking limitations treated with a wheeled walker set to induce lumbosacral flexion.
Results: Of the 52 patients, improvement in ambulation was classified as excellent for 30 (58%), good for 7 (13%), moderate for 8 (16%), and poor for 7 (13%). Among 48 patients with neurogenic pain, pain relief was classified as excellent for 22 (46%), good for 11 (23%), moderate for 7 (14.5%), and poor for 8 (16.5%).
Conclusions: These retrospective data from a case series support the hypothesis that positional therapy with a wheeled walker set to induce lumbosacral flexion relieves lower extremity symptoms of spinal stenosis. However, an adequate test of this hypothesis will require randomized trials of sufficient size and duration that include objective clinical endpoints such as quality-of-life measures, immobility complications and need for drugs, physical therapy, procedures including epidural injections, and spinal surgery.
In the meantime, this conservative strategy is an option for patients following the recommendations of the North American Spine Society, or for those who have contraindications (or aversions) to surgery or epidural injections, or who have found these options ineffective. Positional therapy with a wheeled walker offers the possibility of short-term benefits for ambulation and pain, with minimal risks and costs.
When shoppers at the grocery store are leaning forward on their carts, many of them could be trying to relieve the pain of lumbar spinal stenosis. This way of finding temporary relief is one we replicated with a wheeled walker for prolonged periods in a retrospective case series to see what further benefits might be gained.
Symptoms are affected by body position and activity level. For patients with lumbar spinal stenosis, lower extremity symptoms can be debilitating and include loss of sensation, paresthesias, burning, pain, weakness, claudication, difficulty standing or walking, or nocturnal neuropathic pain in the feet, legs, or thighs. Axial loading1 (as occurs during walking) and spinal extension2 (as occurs in an erect position) both decrease the diameter of the central spinal canal and lateral recesses, and may cause nerve compression and lower extremity symptoms. In contrast, lumbosacral flexion—facilitated, for example, by leaning forward on a grocery cart3—opens the spine and may reduce nerve compression and related symptoms.
Exhaust all medical options before turning to surgery. The North American Spine Society (NASS) has issued clinical guidelines for spinal stenosis that make recommendations regarding the value of pharmacologic interventions, manipulative techniques, behavioral therapies, and other conservative measures (www. guideline.gov).4 For patients with severe or unremitting symptoms requiring specialized care by spine specialists, NASS further outlines 3 phases of gradually intensifying medical therapy before turning to surgery, which is associated with increased morbidity and costs.5
A previously untested medical approach. Most patients may return to productivity within 2 to 4 months after starting conservative treatment, but some will still require treatment recommended for greater levels of severity.6 For these latter patients, no randomized trials have evaluated the efficacy of medical management with a wheeled walker. This new intervention, if effective, could avoid or delay the expense and side effects of surgery.7 In addition, a wheeled walker may decrease pain from spinal stenosis.8
To explore whether positional therapy with a wheeled walker relieves lower extremity symptoms of lumbar spinal stenosis, we conducted a retrospective case series of 52 patients with spinal imaging confirmed lumbar spinal stenosis and walking limitations.9
Methods
These observations were based on retrospective chart reviews of all patients in a podiatric private practice (SMG) over 1 year to identify those with lower extremity symptoms of lumbar spinal stenosis who were evaluated with positional testing.
Identifying possible stenosis by positional history
Patients were suspected of having spinal stenosis contributing to, or entirely responsible for, lower extremity neuropathic or claudication symptoms based on a positive positional history, including any of the following patterns:
- walking limitation in which the patient needed to sit or lean forward to get relief
- significant improvement in ambulation when pushing a grocery cart, walker, or baby stroller, or when on a treadmill that induced lumbosacral flexion
- constant, frequent, or occasional lower extremity symptoms of a neuropathic nature with an unclear cause that was exacerbated by walking or standing
- nocturnal exacerbation of neuropathic symptoms affected by sleep position.