High-quality clinical guidelines are summaries of scientific literature designed to assist practitioner and patient decisions about health and healthcare.(1) These guidelines are developed through a systematic process of reviewing and consolidating scientific evidence. Because scientific knowledge evolves over time, guidelines are ideally updated every few years. Guidelines relevant to chiropractic care were once rare. Now, they are commonplace.
Challenges
The existence of guidelines, however, does not guarantee widespread adoption of evidence-based practices. One barrier is dissemination. Guidelines are published by numerous journals, some with subscription-only access. Even when practitioners are aware of guidelines, there is no guarantee they will be read, accurately interpreted, or adopted.
Translating recommendations into practice isn’t necessarily straightforward either, especially when tailoring care for individual patients. There are other challenges too, navigating the long and sometimes complicated articles isn’t naturally intuitive; and sometimes there are conflicting recommendations among different guidelines. But despite these challenges, high-quality guidelines can be a very useful resource. One example was authored by Bussières et al., on the topic of non-surgical care for neurogenic claudication.(2)
Neurogenic Claudication vs. Lumbar Spine Stenosis
Lumbar spine stenosis is most commonly caused by degenerative changes leading to a narrowed spinal canal, lateral recesses, and/or intervertebral foramen. Stenosis is typically benign and clinically unremarkable. However, if stenosis becomes severe enough, neurovascular structures can be compressed, leading to neurogenic claudication. Unfortunately, the scientific literature often equates stenosis (an imaging finding) with neurogenic claudication (a clinical syndrome). The lack of distinction causes confusion.
A key factor in accurately diagnosing neurogenic claudication is in recognizing the reversible nature of symptoms caused by transient compression and/or ischemia of neural structures. Symptoms of chronic pain, weakness, paresthesia, and numbness in the buttocks and lower extremities are exacerbated by standing and walking. Relief is usually noticed within a few minutes after sitting, lying, or other positions of lumbar flexion which tend to reduce neurovascular compression in stenotic areas.(3)
Surgical treatment is costly and it carries significant risk for complications.(4) Surgical outcomes are often similar to non-surgical care, suggesting chiropractic can play a meaningful role in management.(4) The clinical guidelines authored by Bussières et al., offer insight into effective non-surgical treatments.
Key Recommendations
Recommendations in the guideline include both pharmacological and non-pharmacological management. An abbreviated summary of major recommendations include:
- Offer a multimodal approach consisting of education and advice, manual therapy, and home exercise to improve walking capacity and other physical functions.
- Consider a trial of acupuncture to improve short term pain and physical function.
- For patients who recently underwent spinal fusion surgery, offer rehabilitation combined with cognitive behavioral therapy.
- Consider a trial of serotonin−norepinephrine reuptake inhibitors or tricyclic antidepressants.
- NSAIDS, Acetaminophen, Methylcobalamin, muscle relaxants, Pregabalin, Gabapentin, Calcitonin, and epidural steroid injections are not recommended.
- Opioids are not recommended as a first-line therapy.
Though the recommendations above are condensed slightly for the sake of brevity, there isn’t much more detail in the original statements. That generality is somewhat purposeful, for at least 3 reasons. 1) Guidelines are designed to inform rather than dictate clinical decision making; 2) Guidelines lose their broad applicability if recommendations target very specific clinical presentations; and 3) When research is inconclusive or unavailable to inform more specific statements, only general statements are feasible.
However, if practitioners are going to apply guideline-based care, broad statements demand answers to important follow up questions. For example, the first recommendation suggests practitioners include education and advice, manual therapy, and home exercises in care plans. Some logical questions that follow these kinds of recommendations are:
- What should be the focus of education and advice?
- What types of manual therapies should be used and where should they be applied?
- What is the best duration and frequency for manual therapies?
- What home exercises are most effective?
Clear, specific, and scientifically tested answers to some of these questions are not yet available. Fortunately, the guideline offers more detail for others. For example, nutritional and lifestyle education and advice are recommended for people who are overweight or obese with related comorbidities. Lifestyle education and activities to consider include physical activity promotion, pedometers, nutritional advice from dieticians, and exercise advice from an exercise physiologist.
Education appears crucial for effective care. It begins with helping people understand neurogenic claudication, in part so they reduce or eliminate fear-avoidance behaviors and remain active. Education should also include self-management techniques to maintain and enhance physical function. An educational approach used in at least one study supporting the guideline included:
- Advice about body positioning to reduce lordosis and build self-management capacity.
- Pacing advice to encourage physical activity and maintain physical function.
- Reassurance to build self-efficacy and avoid misconceptions about non-harmful pain.
- Goal setting, and graded physical activities to improve endurance while walking.(5)
Manual therapies referred to in the guideline included spinal mobilization, manipulation, and massage to thoracic, lumbar, pelvis, and lower extremity regions. Specific techniques are not further delineated. Home exercises include stretching and strength training, cycling, and treadmill walking with bodyweight support. Details about treatment and exercise frequency, duration, and strengthening exercises were not included.
Perhaps the most important message is that scientific evidence supports a multimodal (and likely multidisciplinary) approach for people with neurogenic claudication. Though this blog focuses on care offered by chiropractors, a good working knowledge of pharmaceutical and psychologically based therapies can be valuable. Being familiar all the types of therapies addressed in the guideline (recommended and not recommended) can help other management decisions such as referrals, collaborative care planning, and communication with patients and other providers.
Dr. Vining is associate dean of clinical research, as well as a professor, at the Palmer Center for Chiropractic Research, Palmer College of Chiropractic, in Davenport, Iowa.
References
1. Gatterman MI, Dobson TP, LeFevbre R. Chiropractic quality assurance: standards and guidelines. J Can Chiropr Assoc. 2001 Mar;45(1):11–7.
2. Bussières A, Cancelliere C, Ammendolia C, Comer CM, Zoubi FA, Châtillon CE, et al. Non-Surgical Interventions for Lumbar Spinal Stenosis Leading To Neurogenic Claudication: A Clinical Practice Guideline. J Pain. 2021 Sep;22(9):1015–39.
3. Nadeau M, Rosas-Arellano MP, Gurr KR, Bailey SI, Taylor DC, Grewal R, et al. The reliability of differentiating neurogenic claudication from vascular claudication based on symptomatic presentation. Can J Surg. 2013;56(6):372–7.
4. Zaina F, Tomkins-Lane C, Carragee E, Negrini S. Surgical versus nonsurgical treatment for lumbar spinal stenosis. Cochrane Database Syst Rev. 2016;(1):1–49.
5. Ammendolia C, Côté P, Southerst D, Schneider M, Budgell B, Bombardier C, et al. Comprehensive non-surgical treatment versus self-directed care to improve walking ability in lumbar spinal stenosis: A randomized trial. Arch Phys Med Rehabil [Internet]. 2018 Jun; Available from: https://linkinghub.elsevier.com/retrieve/pii/S0003999318303629
