Symptoms linked to the cause radiologically. Spinal stenosis was confirmed by spinal imaging (magnetic resonance imaging or computed tomography scan) showing stenosis in areas corresponding to symptoms in the lower extremities. Patients without confirmatory spinal imaging were excluded from our study.
Peripheral neuropathy was diagnosed by changes in nerve conduction studies interpreted as being consistent with axonal or demyelinating peripheral neuropathy. Using these criteria, we assembled a case series of 52 patients with imaging-confirmed lumbar spinal stenosis and walking limitations. Of the 52 patients, 33 had received a previous diagnosis of spinal stenosis confirmed by spinal imaging, but only 10 considered that to be the cause of their lower extremity symptoms, with the remainder presenting with a primary diagnosis of peripheral neuropathy—with or without arterial claudication.
Using positional testing to confirm suitability of rollator walker
Patients with lower extremity symptoms of lumbar spinal stenosis underwent a therapeutic trial of “positional testing” involving full-time use of a 3- or 4-wheeled rollator walker (usually provided as a loan) set to induce lumbosacral flexion for 3 days. For patients no taller than 4’ 9” to 5’ 2”, a reduced-height walker (29” to 32”) was usually necessary; patients shorter than 4’ 9” usually needed a modified pediatric walker.
Patients returned for adjustment of the walker if it was uncomfortable or unhelpful. We recommended they also use a shower stool and kitchen stool to minimize erect posture. If they experienced nocturnal exacerbation of neuropathic symptoms, we encouraged them to try sleeping in a recliner. If patients with neuropathic symptoms wanted to continue sleeping in bed, we encouraged them to try sleeping with a pillow beneath their thighs (if sleeping on their back), or sleeping in a fetal position with a pillow between their thighs (if sleeping on their side).10
We usually reevaluated patients in 3 to 5 days, comparing current pain severity and walking capability with previous levels. Patients reporting improvement were encouraged to maintain this full-time positional testing for a total of 10 days. During the subsequent “positional therapy” phase, they gradually reduced their use of the walker, if possible, to an amount just needed to maintain improvement. The therapy phase lasted for 3 months, bringing the total time that patients used a walker to nearly 14 weeks.
Criteria for successful treatment
We gauged treatment success according to self-reported walking capabilities and subjective descriptions of uncomfortable symptoms, using criteria previously described.10
Walking distance. Patients reported uninterrupted walking distance before using the walker and after they had begun using the walker. We classified improvement in walking distance as excellent (over 400% increase), good (250%– 399%), moderate (100%–249%), or poor (≤99%). (The distance a patient can walk—before pain sets in—may vary from day to day. We therefore gauged improvement in this distance by contrasting consistent walking distances achieved and maintained with positional management to the shortest usual walking distance before the intervention.)
Pain reduction. To define a decrease in discomfort reported during the positional testing phase and maintained with positional therapy, we used a verbal analog pain scale (1–3 out of 10=mild pain; 4–7=moderate pain; 8–10=severe pain). We classified reduction in discomfort stemming from spinal stenosis as excellent (75%–100%), good (50%–74%), moderate (25%–49%), or poor (≤24%).
Results
Rapid and dramatic improvement for most patients
The 52 patients in our case series ranged in age from 67 to 90 years; 19 were men. Of the 52, improvement in ambulation was excellent for 30 (58%), good for 7 (13%), moderate for 8 (16%), and poor for 7 (13%) after 3 to 5 days.
Of 48 patients with neurogenic pain, grading with the verbal analog pain scale showed relief was excellent for 22 (46%), good for 11 (23%), moderate for 7 (14.5%), and poor for 8 (16.5%) after 3 to 5 days.
Of the 37 patients with excellent or good improvement in ambulation, 11 needed to keep using the walker extensively, 22 frequently, and 4 occasionally or not at all. Of the 6 patients who had undergone spinal stenosis surgery, improvement was excellent for 3, good for 1, and poor for 2.
A subgroup of 36 patients in our study had diabetes. Of these, 25 had concomitant peripheral neuropathy; 18 reported good to excellent improvement of ambulation or reduction of pain.
Conclusion
Patients deserve a trial of positional therapy with the wheeled walker
These descriptive data support the hypothesis that positional therapy with a wheeled walker set to induce lumbosacral flexion alleviates lower extremity symptoms of spinal stenosis. Limitations of this case series: