Study Comparing 3 Different Treatments for Arthritis of the Lower Back (Lumbar Spinal Stenosis)

BACKGROUND: Lumbar spinal stenosis (LSS) is a condition that is highly prevalent in the senior citizen population. LSS is the most frequent indication for spinal surgery in patients over the age of 65 years. The fastest growth in lumbar surgery in the U.S. this past decade has occurred in older adults with LSS and the rate of complex fusion procedures has increased 15-fold. These surgical procedures are associated with significant health care costs, risks, complications, and re-hospitalization rates. Yet, evidence is lacking for the effectiveness of the various non-surgical treatments offered to patients with LSS. This knowledge gap has greatly hindered the development of clinical practice guidelines relevant to the non-surgical treatment approaches for LSS.

OBJECTIVES: This study will perform a comparison of three common approaches to the non-surgical management and treatment of patients with LSS. The specific research questions associated with this study are: (1) How do group exercise and manual therapy with rehabilitative exercise compare with medical care? (2) How do group exercise and manual therapy with rehabilitative exercise compare with each other? (3) Are there any baseline predictors associated with clinical improvement in any of these non-surgical treatment approaches? The long term objective of this study is to produce research evidence relevant to community stakeholders and to inform better decision making about non-surgical treatment options available to LSS patients.

METHODS: This will be a comparative effectiveness study utilizing the research design of a randomized controlled clinical trial (RCT). It will be a 3-group RCT that allows for pragmatic treatment approaches in each of the three study arms. The study sample will consist of 259 older adults (>60 years) who have symptoms consistent with a diagnosis of LSS, which will be confirmed by clinical examination and diagnostic imaging. Eligible subjects will be randomized into one of three pragmatic treatment approaches: 1) medical care; 2) group exercise; or 3) manual therapy with rehabilitative exercise.

All subjects will be treated for a 6-week course of care. Primary outcome measures are two validated research measurement tools; the Swiss Spinal Stenosis Questionnaire (self-reported pain/function) and the Self Paced Walking Test (performance-based measure). We will also employ a novel secondary outcome measure; the Sense Wear Armband which provides a real-time measure of physical activity during normal daily living.

• NSAIDs; adjunctive analgesics; adjunctive anti-depressants (Drug), also known as ibuprofen, celecoxib, diclofenac, misoprostol, acetaminophen, tramadol, gabapentin, nortriptyline, duloxetine, sertraline, trazodone, mirtazapine: Physician will administer these medications based upon the individual needs of each patient.
• Lumbar epidural injection (Procedure): The attending physician may refer subjects for epidural injections at a pain clinic that is affiliated with the University of Pittsburgh Medical Center. All epidural injections will be provided by licensed physicians who are board certified in physical medicine and rehabilitation or anesthesiology.
• Joint Mobilizations (spine, sacroiliac, hip) (Other): These joint mobilizations will be applied manually to the lumbar facet joints, sacroiliac joints, and/or hip joints by licensed physical therapists and chiropractors.
• Individualized exercises: clinical setting (Other): The treating physical therapist or chiropractor will work with each subject to develop a set of individualized exercises in the clinic setting. The goal is to have the subjects continue these exercises at home.
• Group Exercise: community setting (Other): The group exercise will take place at community centers that provide exercise classes for older adult. The exercises are taught by certified fitness instructors in a group setting at these community centers.

Primary outcomes

• Swiss Spinal Stenosis (SSS) Questionnaire Score [Primary End-Point was 8 weeks ( 2 weeks after completion of 6-week intervention).]: Our primary aim included a primary outcome measure of self-reported pain/function, which was the change in SSS total score between baseline and 8 weeks. The Swiss Spinal Stenosis Questionnaire (SSS) is a validated 12-item condition-specific instrument for patients with lumbar spinal stenosis. It provides a patient self-report measure of pain and physical function. Higher scores represent worse symptoms and less physical function. The 12-item SSS total score range is 12-55. For our analysis, we compared the change in the 12-item Total score from baseline to 8 weeks.

Secondary outcomes

• Self Paced Walking Test (SPWT) [Primary end-point was 8 weeks ( 2 weeks after 6 week intervention is completed).]: Our primary aim also included a performance-based outcome measure, which was the distance walked during the SPWT. The analysis was a comparison of between-group changes in SPWT between baseline and 8 weeks. The Self-Paced Walking Test (SPWT) is a validated objective measure of a patient's walking capacity, which is performed on a level walking surface. The patient is instructed to walk at their own pace and to stop when the symptoms are troublesome enough that s/he needs to sit down to rest. The total time and total distance walked are measured by the research assistant. Our unit of measure was the total distance walked, expressed in meters.

Other outcomes

• Sense Wear Armband [Primary End-Point was 8 weeks ( 2 weeks after completion of 6-week intervention).]: Our secondary aim was to measure the change in physical activity between baseline and 8 weeks using the Sense Wear armband (SWA). The outcome measure was the average number of minutes spent daily performing physical activities >1.5 metabolic equivalents (METs).The SWA is a small device that collects information from multiple sensors: a triaxial accelerometer, heat flux, skin temperature, and galvanic signal. The information is integrated and processed by software using proprietary algorithms utilizing subjects' demographic characteristics (gender, age, height, and weight) to provide minute-by-minute estimates of physical activity. The SWA has shown good reliability and validity. The research participants in our study will wear the SWA for a week before and after they complete the treatment interventions.

Sex: All, ages: 60 Years to any

Inclusion Criteria:

* Minimum age of 60 years
* Can read/write English and understand directions
* Diagnosis of lumbar spinal stenosis confirmed by CT or MRI scan
* Has limitation of standing and/or walking tolerance
* Willing to attend treatments 2 times per week for 6 weeks
* Ability to walk at least 50 feet without the need for a cane or walker

Exclusion Criteria:

* History of metastatic cancer
* Advised by a physician not to exercise
* History of lumbar surgery for spinal stenosis or previous lumbar fusion
* Presence of severe peripheral artery disease in legs
* Severe hypertension: Systolic > 200 mm/hg or Diastolic > 110 mm/hg
* Ankle brachial index < 0.8
* Neurologic or neurodegenerative disease other than stenosis that severly impairs the ability to walk
* Presence of cauda equina symptoms (saddle paresthesia, progressive loss of bladder/bowel function, etc)

Participant flow

Outcome results

• Swiss Spinal Stenosis (SSS) Questionnaire Score (Primary), Mean, units on a scale: Medical Care -2.0 +/- 5.5; Group Exercise -1.7 +/- 5.2; Manual Therapy and Exercise -4.1 +/- 5.9 (p 0.73)
• Self Paced Walking Test (SPWT) (Secondary), Mean, meters: Medical Care 130.5 +/- 478.7; Group Exercise 219.2 +/- 413.0; Manual Therapy and Exercise 267.8 +/- 507.8 (p 0.29)
• Sense Wear Armband (Other pre specified), Mean, minutes per day: Medical Care -23.1 +/- 85.3; Group Exercise 4.3 +/- 64.8; Manual Therapy and Exercise -6.0 +/- 76.0 (p 0.03)

Adverse events

Time frame: Assessed from beginning of treatment up to 2 month follow up assessment.

Other adverse events by term

Limitations and caveats: We realize in retrospect that our original choice of the term "usual medical care" may have been confusing, because there is great variation in the medical management of patients with stenosis. We suggest that "medical care" is a better term.

• Schneider M, Ammendolia C, Murphy D, Glick R, Piva S, Hile E, Tudorascu D, Morton SC. Comparison of non-surgical treatment methods for patients with lumbar spinal stenosis: protocol for a randomized controlled trial. Chiropr Man Therap. 2014 May 10;22:19. doi: 10.1186/2045-709X-22-19. eCollection 2014. PMID 24872875
• Results publication: Roseen EJ, Smith CN, Rahim A, Deal C, Fischer R, Morone NE, Flack A, Penza C, Suri P, Dougherty PE, Weiner DK, Schneider MJ. Which lumbar spinal stenosis patients will improve with nonsurgical treatment? A secondary analysis of a randomized controlled trial. Chiropr Man Therap. 2025 Dec 9;33(1):57. doi: 10.1186/s12998-025-00620-0. PMID 41366694
• Results publication: Schneider MJ, Ammendolia C, Murphy DR, Glick RM, Hile E, Tudorascu DL, Morton SC, Smith C, Patterson CG, Piva SR. Comparative Clinical Effectiveness of Nonsurgical Treatment Methods in Patients With Lumbar Spinal Stenosis: A Randomized Clinical Trial. JAMA Netw Open. 2019 Jan 4;2(1):e186828. doi: 10.1001/jamanetworkopen.2018.6828. PMID 30646197

• Michael J Schneider, PhD, DC, Principal investigator, University of Pittsburgh