Journal of Back and Musculoskeletal Rehabilitation 36 (2023) 799–813 799

DOI 10.3233/BMR-220220
IOS Press

Review Article

Effectiveness of non-surgical treatment

combined with supervised exercise for
lumbar spinal stenosis: A systematic review
and meta-analysis
Ryunosuke Urataa,1 , Tatsuya Igawaa,b,c,1,∗ , Shomaru Itod and Akifumi Suzukie
a
Department of Rehabilitation, International University of Health and Welfare Mita Hospital, Tokyo, Japan
b
Department of Physical Therapy, School of Health Science, International University of Health and Welfare, Tochigi,
Japan
c
Department of Rehabilitation, International University of Health and Welfare Hospital, Tochigi, Japan
d
Department of Rehabilitation, International University of Health and Welfare Narita Hospital, Chiba, Japan
e
Toyota Tsusho All Life Corporation, Tokyo, Japan

Received 12 July 2022

Accepted 13 December 2022

Abstract.
BACKGROUND: The benefits of combining supervised exercise in the non-surgical treatment of lumbar spinal stenosis (LSS) is
unclear.
OBJECTIVE: To compare the effectiveness of non-surgical treatments with and without supervised exercise for pain intensity,
symptom severity, functional impairment/disability, walking distance, and quality of life (QOL) in LSS patients.
METHODS: Randomized controlled trials (RCTs) evaluating combinations of supervised exercises were searched using four
electronic databases up to August 13, 2020. Meta-analysis was conducted for immediate and long-term results.
RESULTS: Three studies were identified, including 244 participants. Immediate-term results showed that leg pain intensity
(mean distance [MD]: −0.94, 95% confidence intervals [95% CI]: −1.60 to −0.29, p < 0.01) and symptom severity (MD:
−0.29, 95% CI: −0.50 to −0.08, p < 0.01) were lower in the study group than in the control group, and walking distance (MD:
415.83, 95% CI: 298.15 to 533.50, p < 0.001) and QOL were higher in the study group. Long-term results showed that functional
disability/impairment (MD: −0.27, 95% CI: −0.49 to −0.04, p < 0.05) was lower in the study group than in the control group,
and walking distance and QOL were higher in the study group.
CONCLUSION: The number of studies on this topic was small and limited. Combinations of non-surgical treatment and
supervised exercise may not provide significant benefits.

Keywords: Spinal stenosis, exercise therapy, systematic review as topic, meta-analysis as topic

1 Tatsuya
Igawa and Ryunosuke Urata contributed equally to this Therapy, School of Health Science, International University of Health
work. and Welfare 2600-1, Kitakanemaru, Ohtawara, Tochigi, 323-8501,
∗ Corresponding author: Tatsuya Igawa, Department of Physical Japan. E-mail: igatatsu.7@gmail.com.

ISSN 1053-8127/$35.00 c 2023 – IOS Press. All rights reserved.

800 R. Urata et al. / Effectiveness of non-surgical treatment combined with supervised exercise for lumbar spinal stenosis

1. Introduction systematic review comparing non-surgical treatments

with and without supervised exercise to clarify the im-
Approximately 20% of adults over the age of 65 years mediate and long-term effectiveness of the combina-
suffer from lumbar spinal stenosis (LSS). Patients with tion.
LSS who have narrowed spinal canals or intervertebral
foramina have lower limb pain and numbness, neuro-
logical claudication, and severely restricted physical 2. Materials and methods
activity [1]. The number of people with LSS tends to
increase with age [2], and globally, it may increase fur- This systematic review was reported according to the
ther in the future, particularly in a rapidly aging com- PRISMA 2020 statement [14]. The revised flowchart
munity [3]. There is some evidence that exercise ther- in the PRISMA 2020 statement distinguishes between
apy for LSS is effective in improving pain and disabil- original and updated systematic reviews [13]. As our re-
ity [4–8]. Although exercise therapy is generally pre- view is not an update of a previous review, we chose the
scribed before surgery [9], effective means of provision search strategy of the original systematic review. The
have not been established. protocol of this systematic review was prospectively
Supervised exercise is effective for conditions such registered with PROSPERO (CRD42020199232) [14].
as intermittent claudication, cancer-related fatigue, The study included literature that had already been pub-
and hip osteoarthritis [10–12]. Supervision can prop- lished; thus, Institutional Review Board approval was
erly improve adherence and exercise intensity due to waived.
the encouragement from and confidence of healthcare
providers [11]. In recent reviews, supervised exercise 2.1. Eligibility criteria
has been suggested to be effective even in the non-
surgical treatment of LSS [7,8]. The LSS clinical guide- The eligibility criteria were as follows: (i) studies that
lines published by the Danish Health Authority in 2019 included patients with LSS who were above 50 years
state that “supervised exercise is one of the recom- of age and were diagnosed by medical history, physical
mended treatments” [7]. A previous review by Jacobi et and neurological examinations, and diagnostic imaging;
al. [8] shows low-to-moderate evidence that a combina- (ii) studies that compared the combination of super-
tion of supervised exercise and manual therapy was su- vised exercise and non-surgical treatment (e.g., medi-
perior to exercise performed by patients independently cations, injections, exercise instruction, and education)
in improving short-term walking capacity, pain intensity with the non-surgical treatment without supervised ex-
(leg and back pain), and symptom severity. Therefore, ercise; and (iii) Randomized controlled trials (RCTs)
supervised exercise may be an effective approach for that were published in English after 1990 until August
LSS patients. 13, 2020. A previous study defined supervised exercise
Treatment selection for LSS is usually based on a as treatment sessions that occur at least twice a week
combination of clinical evidence and individual patient and last for at least 6 weeks [15]. We included treat-
characteristics and preferences [9]. In some cases, the ments that met at least 80% of the required frequency
two treatments may be combined. Long-term evidence for supervised exercise (a total of at least 10 frequen-
for complex non-surgical treatments, including super- cies) in our review. Non-RCTs, cohorts, observational
vised exercise, is very important for clinicians and pa- studies, case-control studies, case reports, and studies
tients during treatment decisions. Although previous re- related to surgery were excluded.
views have focused on supervised exercise versus other
forms of exercise, the combination of supervised ex- 2.2. Search strategy and study selection process
ercise with other non-surgical treatments has not been
fully considered, and the synergistic effect of this com- Records were identified using multiple electronic
bination is not clear. search databases, including MEDLINE via PubMed,
We hypothesized that combining supervised exercise Cochrane Central Register of Controlled Trials, Phys-
with the non-surgical treatment of LSS would result in iotherapy Evidence Database, and CINAHL (the search
superior immediate and long-term clinical outcomes. was completed on August 13, 2020). The search for-
This is because the synergistic effects of supervised mula included words such as “spinal stenosis,” “exer-
exercise and other treatments may benefit patients with cise,” and “randomized controlled trial” (Table 1 and
LSS. Thus, the purpose of this study was to conduct a Appendix). The identified records were stored in End-
 R. Urata et al. / Effectiveness of non-surgical treatment combined with supervised exercise for lumbar spinal stenosis 801

Table 1
Search strategy in MEDLINE via PubMed
MEDLINE via PubMed
(("Spinal stenosis"[MeSH Terms] OR "spinal stenosis"[ALL Fields] OR "spinal stenoses"[ALL Fields]) OR (("lateral recess"[ALL Fields] OR
"foraminal"[ALL Fields]) AND ("pathologic constriction"[ALL Fields] OR "constriction, pathologic"[MeSH Terms] OR "stenosis"[ALL
Fields])) OR (("lumbar"[ALL Fields] OR "lumbo"[ALL Fields] OR "lateral"[ALL Fields] OR "central"[ALL Fields] OR "foraminal"[ALL
Fields]) AND ("spinal stenosis"[ALL Fields] OR "spinal stenoses"[ALL Fields] OR "canal stenosis"[ALL Fields] OR "canal stenoses"[ALL
Fields] OR "stenosis"[ALL Fields] OR "stenoses"[ALL Fields] ))) AND ("transcutaneous electric nerve stimulation"[MeSH Terms] OR "pain
management"[MeSH Terms] OR "rehabilitation"[MeSH Terms] OR "pain management"[ALL Fields] OR "rehabilitation"[ALL Fields] OR
"physical therap*"[ALL Fields] OR "physiotherap*"[ALL Fields] OR "exercise"[ MeSH Terms] OR "exercis*"[ALL Fields] OR "Physical
Fitness"[ALL Fields] OR "Physical Conditioning"[All Fields] OR "Physical Activit*"[All Fields] OR ("Physical"[All Fields] AND
("Conditioning"[All Fields] OR "activit*"[All Fields])) OR "Training"[ALL Fields] OR “Gymnastic*”[ALL] OR “Walking”[ALL Fields] OR
“Ambulation”[ALL Fields] OR "health education"[MeSH Terms] OR “Health education”[ALL Fields] OR (“Health”[ALL Fields] AND
"education"[ALL Fields]) OR “education”[ALL FIelds]) AND "English"[Language] AND ("randomized controlled trial"[Publication type]
OR "randomized controlled trial"[Title/Abstract] OR "randomized controlled trials"[Title/Abstract])

note Ver. X9 (USACO, Tokyo, Japan), and duplicate rated on a 3-point scale (“Low,” “Some concerns,” and
papers were deleted. “High”). Disagreements were first discussed by two
Two independent researchers performed a two-step researchers, and if not resolved, a third researcher was
screening process to rigorously assess the eligibility of invited to participate in the discussion.
the study. For the primary screening, the titles and ab-
stracts were evaluated, and for the secondary screening, 2.5. Data synthesis and analysis
the full texts were read in detail. Disagreements were Effective exercise modalities for LSS have not been
first discussed by two researchers, and if they were not established [9]. Supervised exercise programs were dif-
resolved, a third researcher was invited to participate in ferent across the studies; therefore, we performed a
the discussion. meta-analysis with a random-effects model. Mean dif-
ference (MD) or standardized MD (SMD) and 95%
2.3. Data collection process confidence interval (CI) were calculated for the pre-
specified outcomes. The significance levels were set at
Two independent researchers extracted data on study 5%. For statistical heterogeneity, the chi-square test and
characteristics, participants, interventions for study and the I2 value were calculated, and the significance level
comparator groups, outcomes, and methodology. We of the chi-square test was set at 10%. I2 values were
used pain intensity (numerical rating scale [NRS]), interpreted as follows: 0%, nonsignificant; 30%–60%,
symptom severity (symptom severity domain of the moderate heterogeneity; 50%–90%, substantial hetero-
Zurich claudication questionnaire and the Swiss spinal geneity; and 75%–100%, significant heterogeneity [17].
stenosis questionnaire [ZCQS]), and functional impair- If heterogeneity was detected, subgroup analyses based
ment/disability (Oswestry disability index [ODI], and on the number of exercises, duration of intervention, or
physical function domain of the Zurich claudication frequency of intervention were performed. Publication
questionnaire and the Swiss spinal stenosis [ZCQF]) bias was visually evaluated using a funnel plot. Statis-
as the primary outcomes of this review. Secondary tical analysis was performed using Review Manager
outcomes were self-reported questionnaires on health- Ver. 5.4 software (Cochrane Collaboration, Software
related quality of life (QOL), walking distance or speed, Update, Oxford, UK).
and adverse events. Each outcome was categorized as The certainty of evidence in each outcome was as-
immediate (less than 1 month after treatment) or long- sessed according to the Grading of Recommendations
term (> 1 year after randomization) outcome. Assessment, Development, and Evaluation (GRADE)
methodology framework [18]. Three researchers scruti-
2.4. Risk of bias assessment nized the following items: risk of bias, inconsistency,
indirectness, imprecision, and publication bias, and they
The Cochrane risk of bias tool version 2.0 was used then rated the certainty of the total evidence on a scale
to assess the risk of bias in each study [16]. Two inde- (“High,” “Moderate,” “Low,” and “Very low”). Down-
pendent researchers evaluated the randomization pro- grading criteria were defined as follows:
cess, deviations from intended interventions, missing Risk of bias: Downgrade was considered if “Some
outcome data, outcome measurement, and selection of concern” or “High” was included in the overall risk
the reported results, and the overall risk of bias was of bias integrated.
802 R. Urata et al. / Effectiveness of non-surgical treatment combined with supervised exercise for lumbar spinal stenosis

Fig. 1. The PRISMA flowchart of the study selection process.

Inconsistency: Downgrade was considered when tronic databases. Eventually, three studies were in-
the similarity of point estimates, overlapping con- cluded in this systematic review [20–22] (Fig. 1). De-
fidence intervals, χ2 test, and I2 values were eval- tailed characteristics of each study are presented in Ta-
uated, and there was heterogeneity for which no ble 2. The three included studies published in 2018 and
cause could be identified. 2019 were performed in Canada, the United States, and
Indirectness: Downgrade was considered if there Japan, respectively. A total of 244 participants (110 men
were substantial differences between what was con- and 134 women), with a high proportion of females, met
sidered in the systematic review and the population, the eligibility criteria for this study. The mean age of
interventions, outcomes, and controls measured in participants in all the studies was 70.2 years. In all the
the integrated study. studies, the participants were classified into two groups,
Imprecision: Downgrade was considered if the non-surgical treatment with and without supervised ex-
sample size was small and there was a wide range ercise. In all three studies, the supervised exercise for
of effect estimates. The sample size for complement the study group included manual therapy, stretching,
accuracy was based on an optimal information size muscle endurance and stabilization exercises, cycling,
(OIS) of 400 people. In addition, the downgrade and weight-supported treadmill training. These were
was considered if the lower limit of the 95% CI for provided individually by a physical therapist or chi-
the estimated effect was below the minimal clini- ropractor, and the frequency of treatment met the eli-
cally important difference (MCID). The outcomes gibility criteria (a total of 10–12 frequencies). In two
of MCID application were NRS leg pain, back pain, studies, a voluntary training program, including daily
ZCQS, and ZCQF, with thresholds of 1.5, 1.25, walking and home exercise, was provided to both the
0.36, and 0.1, respectively [19]. study and control groups [20,22]. In one study, epidural
Publication bias: Downgrade was considered when steroid injections (ESI) and patient education were pro-
publication bias was suspected. vided to both groups [21]. The included studies were
homogeneous; therefore, the meta-analysis included all
the studies.
3. Results
3.2. Risk of bias
3.1. Study selection and study characteristics
The overall risk of bias in all the studies was a con-
A total of 597 records were identified from the elec- cern (Fig. 2). They were rated as high risk in outcome
 Table 2
Characteristics of the included studies
Age Sex
Study Country Sample size Intervention Analyzable outcomes
mean (SD) male: female
All SG CG All SG CG SG CG SG CG
Ammendolia Canada 104 51 53 70.6 69.4 71.7 18: 33 27: 26 Comprehensive group Self-directed group ZCQS, ZCQF, ODI, and
et al., 2018 (7.7) (9.5) 1. Structured comprehensive con- 1. Self-directed training program (ev- NRS (leg and back pain),
servative training program (twice ery day): instructional videos, work- SF-36
a week): self-management strate- books, and pedometers on how to per- Follow-up: 8 weeks and
gies using a cognitive-behavioral ap- form the required exercises and self- 3, 6 and 12 months
proach; a standardized set of 18 exer- management strategies; 15- to a 30-
cises; manual therapy. minute training session with an expe-
2. Self-directed training program (ev- rienced independent licensed chiro-
ery day): same as the control group. practor (only once).
Duration of intervention: 6 weeks Duration of intervention: 6 weeks
Hammerich United 54 23 31 67.2 66.3 67.8 11: 12 15: 16 ESI + PT group ESI group ODI, NPRS, and SF-36
et al., 2019 States (9.7) (1.9) (1.8) 1. Evidence-based multimodal PT 1. One to 3 ESIs are performed ac- Follow-up: 10 weeks and
program (once a week): manual phys- cording to standardized algorithms. 6 and 12 months
ical therapy; mobility; aerobic exer- 2. Education by the Back Book.
cise; muscle endurance and stabiliza- Duration of intervention: 10 weeks
tion exercises.
2. One to 3 ESIs are performed ac-
cording to standardized algorithms.
3. Education by the Back Book.
Duration of intervention: 10 weeks
Minetama et Japan 86 43 43 72.7 72.3 73.2 20: 23 19: 24 PT group HE group ZCQS, ZCQF, SPWT,
al., 2019 (6.9) (8.2) 1. Supervised PT sessions (twice a 1. Daily walk NRS (leg and back pain),
week): manual therapy; individually 2. HE program (every day): three 30- and SF-36
tailored stretching and strengthening second bouts of both single and dou- Follow-up: 6 weeks
exercises; cycling and body weight- ble knee-to-chest exercises; ten 6-
supported treadmill walking. second bouts of trunk raise and bridg-
2. Daily walk ing in the supine position; a four-
3. HE program (every day) point kneeling exercise.
Duration of intervention: 6 weeks Duration of intervention: 6 weeks
Abbreviation. SG, study group; CG, control group; SD, standard deviation; ESI, epidural steroid injection; PT, physical therapy; HE, home exercise; ZCQS, symptom severity domain of the
Zurich claudication questionnaire; ZCQF, physical function domain of the Zurich claudication questionnaire; ODI, Oswestry Disability Index; NRS or NPRS, numerical (pain) rating scale;
SPWT, self-paced walking test; SF-36, MOS 36-Item Short-Form Health Survey.
R. Urata et al. / Effectiveness of non-surgical treatment combined with supervised exercise for lumbar spinal stenosis
803
804 R. Urata et al. / Effectiveness of non-surgical treatment combined with supervised exercise for lumbar spinal stenosis

mediate results showed that the study group improved

significantly compared to the control group (n = 188,
MD [95% CI] = −0.29 [−0.50 to −0.08], p = 0.006)
(Fig. 4). The study that combined supervised exercise
with a self-directed training program [20] showed no
significant difference between the study and control
groups in the long-term results (n = 104, MD [95%
CI] = −0.22 [−0.47 to 0.02], p = 0.08).

3.3.3. Functional impairment/disability

Of the studies that assessed functional impairmen-
t/disability, two used the ZCQF [20,22], and two used
the ODI [20,21]. Synthesis of results was performed
Fig. 2. Summary of risk of bias. separately for ZCQF and ODI. The two studies that
reported ZCQF reported immediate results [20,22], and
measurements because of inadequate blinding of thera- one reported long-term results [20]. The meta-analysis
pists or participants. performed to assess immediate effects showed no sig-
nificant difference between the study and control groups
3.3. Results of each predetermined outcome (n = 188, MD [95% CI] = −0.21 [−0.58 to 0.16],
p = 0.27) (Fig. 5). Regarding long-term results, the
3.3.1. Pain intensity group that was prescribed both supervised exercise and
The three included studies reported pain intensity as the self-directed training program improved signifi-
assessed by the NRS; two of them reported leg pain cantly compared to the group that was prescribed the
intensity [20,22], and the three studies reported back self-directed training program alone (n = 104, MD
pain intensity [20–22]. Synthesis of results was per- [95% CI] = −0.27 [−0.49 to −0.04], p = 0.02) [20].
formed separately for leg pain and low back pain. Of Regarding the ODI, immediate and long-term results
the two studies that reported leg pain intensity, one re- were reported in two studies [20,21]. The meta-analysis
ported only immediate results [22], and one reported showed no significant difference between the study and
both immediate and long-term results [20]. The meta- control groups (immediate: n = 158, SMD [95% CI]
analysis performed to assess immediate effects showed = −0.07 [−0.39 to 0.24], p = 0.65; long-term: n =
that the leg pain intensity of the study group improved 158, SMD [95% CI] = −0.05 [−0.47 to 0.36], p =
significantly compared to that of the control group (n = 0.80) (Fig. 5).
188, MD [95% CI] = −0.94 [−1.60 to −0.29], p =
0.005) (Fig. 3). One study that combined supervised ex- 3.3.4. Walking distance
ercise with a self-directed training program [20] found Walking distance, as assessed by the self-paced walk-
no significant difference between the study and control ing test (SPWT), was reported in two studies [20,22].
groups in long-term results (n = 104, MD [95% CI] Two of them reported immediate results [20,22], and
= −0.50 [−1.60 to 0.60], p = 0.37). All three stud- one reported long-term results [20]. The meta-analysis
ies that reported back pain intensity reported imme- performed to assess immediate results showed that
diate results [20–22], and two reported long-term re- the study group improved significantly compared to
sults [20,22]. Back pain intensity showed no significant the control group (n = 188, MD [95% CI] = 415.83
difference between the study and control groups in im- [298.15 to 533.50], p < 0.00001) (Fig. 6). Regarding
mediate (n = 242, MD [95% CI] = −0.34 [−2.08 to long-term results, the self-directed training program
1.40], p = 0.70) and long-term results (n = 158, MD with supervised exercise group improved significantly
[95%CI] = 0.97 [−1.81 to 3.75], p = 0.49) (Fig. 3). compared to the self-directed training program alone
group (n = 104, MD [95% CI] = 473.20 [203.90 to
3.3.2. Symptom severity 742.40], p < 0.0006) [21].
Symptom severity, as assessed by the ZCQS, was
reported in two studies [20,22]. The two reported im- 3.3.5. Quality of life
mediate results [20,22], and one reported long-term re- The QOL, as assessed by the 36-Item Short-Form
sults [20]. The meta-analysis performed to assess im- Health Survey (SF-36), was reported in three stud-
 R. Urata et al. / Effectiveness of non-surgical treatment combined with supervised exercise for lumbar spinal stenosis 805

Fig. 3. Forest plots of pain intensity. Abbreviation. NRS, numerical rating scale.

Fig. 4. Forest plot of symptom severity. Abbreviation. ZCQS, symptom severity domain of the Zurich claudication questionnaire.

ies [20–22]. We were able to pool the subscale results to 12.05], p = 0.02), SF (n = 188, MD [95% CI] =
for all the studies. However, the meta-analyses per- 6.02 [0.06 to 11.99], p < 0.05), role-emotional (RE)
formed to assess the long-term results of physical func- (n = 242, MD [95% CI] = 12. 03 [0.79 to 23.27], p =
tioning (PF), role-physical, bodily pain (BP), vitality 0.04), and mental health (MH) (n = 242, MD [95% CI]
(VT), and social functioning (SF) were not performed = 6.40 [1.76 to 11.04], p = 0.007) were significantly
because they were reported in only one study [20]. Re- improved in the study group than in the control group
garding immediate results, PF (n = 188, MD [95% CI] (Figs 7 and 8). Regarding long-term results, MH (n =
= 7.03 [1.69 to 12.37], p = 0.010), general health (GH) 158, MD [95% CI] = 4.98 [0.71 to 9.26], p = 0.02)
(n = 242, MD [95% CI] = 7.42 [4.07 to 10.78], p < was significantly improved in the study group than in
0.0001), VT (n = 188, MD [95% CI] = 6.61 [1.17 the control group (Fig. 8). In addition, for the long-term
806 R. Urata et al. / Effectiveness of non-surgical treatment combined with supervised exercise for lumbar spinal stenosis

Fig. 5. Forest plots of functional impairment/disability. Abbreviation. ZCQF, physical function domain of the Zurich claudication questionnaire;
ODI: Oswestry disability index.

Fig. 6. Forest plot of walking distance. Abbreviation. SPWT, self-paced walking test.

results of PF (n = 104, MD [95% CI] = 8.20 [0.20 to 21]. One of them reported adverse events related to
16.20], p = 0.04) and BP (n = 104, MD [95% CI] = supervised exercise therapy [20]. Specifically, back pain
10.00 [2.10 to 17.90], p = 0.01), the group that under- exacerbation (n = 5/51) and knee, hip, and ankle joint
went the self-directed training program combined with pain exacerbation (n = 4/51) were reported during the
supervised exercise improved significantly compared to 8-week intervention period.
the group that underwent self-directed training program
alone [20]. 3.4. Certainty of evidence

3.3.6. Adverse events Results of the certainty of evidence are presented in

Adverse events were reported in two studies [20, Tables 3 and 4. For the item of risk of bias, the patient-
R. Urata et al. / Effectiveness of non-surgical treatment combined with supervised exercise for lumbar spinal stenosis 807

Fig. 7. Forest plots of QOL. Abbreviation. SF-36, 36-Item Short-Form Health Survey.
808 R. Urata et al. / Effectiveness of non-surgical treatment combined with supervised exercise for lumbar spinal stenosis

Fig. 8. Continuation of Fig. 7.

 Table 3
Summary of findings of certainty of the evidence for each outcome (Immediate)
No. of studies No. of participants Risk of bias Inconsistency Indirectness Imprecision Publication bias Effect (95% CI) Certainty
Pain intensity
NRS leg pain 2 188 Seriousa Not serious Not serious Very seriousd,e Strongly suspectedg MD −0.94 VERY LOW
(−1.60 to −0.29)
NRS back pain 3 242 Seriousa Very seriousc Not serious Very seriousd,f Strongly suspectedg MD −0.34 VERY LOW
(−2.08 to 1.40)
Symptom severity
ZCQS 2 188 Seriousa Seriousb Not serious Very seriousd,e Strongly suspectedg MD −0.29 VERY LOW
(−0.50 to −0.08)
Functional impairment/disability
ZCQF 2 188 Seriousa Very seriousc Not serious Very seriousd,f Strongly suspectedg MD −0.21 VERY LOW
(−0.58 to 0.16)
ODI 2 158 Seriousa Not serious Not serious Very seriousd,f Strongly suspectedg SMD −0.07 VERY LOW
(−0.39 to 0.24)
Walking distance
SPWT 2 188 Not serious Not serious Not serious Seriousd Strongly suspectedg MD 415.83 LOW
(298.15 to 533.50)
Quality of life
SF-36
Physical function 2 188 Seriousa Not serious Not serious Very seriousd,f Strongly suspectedg MD 7.03 VERY LOW
(1.69 to 12.37)
Role physical 2 188 Seriousa Not serious Not serious Very seriousd,f Strongly suspectedg MD 7.28 VERY LOW
(−1.40 to 15.95)
Bodily pain 2 188 Seriousa Very seriousc Not serious Very seriousd,f strongly suspectedg MD 6.16 VERY LOW
(−2.07 to 14.39)
General health 3 242 Seriousa Not serious Not serious Very seriousd,f Strongly suspectedg MD 7.42 VERY LOW
(4.07 to 10.78)
Vitality 2 188 Seriousa Not serious Not serious Very seriousd,f Strongly suspectedg MD 6.61 VERY LOW
(1.17 to 12.05)
Social functioning 2 188 Seriousa Not serious Not serious Very seriousd,f Strongly suspectedg MD 6.02 VERY LOW
(0.06 to 11.99)
Role emotional 3 242 Seriousa Very seriousc Not serious Very seriousd,f Strongly suspectedg MD 12.03 VERY LOW
(0.79 to 23.27)
Mental health 3 242 Seriousa Not serious Not serious Very seriousd,f Strongly suspectedg MD 6.40 VERY LOW
(1.76 to 11.04)
a, Risk of bias of some concerns; b, Unexplained moderate heterogeneity (I2 = 30–60%); c, Unexplained substantive heterogeneity (I2 = 50–90%); d, Small sample size (n < 400); e, Lower
limit of 95% CI less than threshold (MCID); f, Confidence interval with no effect or very small effect estimated; g, Possibility of publication bias. Abbreviation. RCT, randomized controlled trial;
R. Urata et al. / Effectiveness of non-surgical treatment combined with supervised exercise for lumbar spinal stenosis

CI, confidence interval; MD, mean difference; SMD, standardized mean difference.
809
 810
Table 4
Summary of findings of certainty of the evidence for each outcome (long term)
No. of studies No. of participants Risk of bias Inconsistency Indirectness Imprecision Publication bias Effect (95% CI) Certainty
Pain intensity
NRS leg pain 1 104 Seriousa Not serious Not serious Very seriousd,e Strongly suspectedf MD −0.50 VERY LOW
(−1.60 to 0.60)
NRS back pain 2 158 Seriousa Very seriousc Not serious Very seriousd,e Strongly suspectedf MD 0.97 VERY LOW
(−1.81 to 3.75)
Symptom severity
ZCQS 1 104 Seriousa Not serious Not serious Very seriousd,e Strongly suspectedf MD −0.22 VERY LOW
(−0.47 to 0.02)
Functional impairment/disability
ZCQF 1 104 Seriousa Not serious Not serious Very seriousd,e Strongly suspectedf MD −0.27 VERY LOW
(−0.49 to −0.04)
ODI 2 158 Seriousa Seriousb Not serious Very seriousd,e Strongly suspectedf SMD −0.05 VERY LOW
(−0.47 to 0.36)
Walking distance
SPWT 1 104 Not serious Not serious Not serious Seriousd Strongly suspectedf MD 473.20 LOW
(203.90 to 742.40)
Quality of life
SF-36
Physical functioning 1 104 Seriousa Not serious Not serious Very seriousd,e Strongly suspectedf MD 8.20 VERY LOW
(0.20 to 16.20)
Role physical 1 104 Seriousa Not serious Not serious Very seriousd,e Strongly suspectedf MD 5.20 VERY LOW
(−4.90 to 15.40)
Bodily pain 1 104 Seriousa Not serious Not serious Very seriousd,e Strongly suspectedf MD 10.00 VERY LOW
(2.10 to 17.90)
General health 2 158 Seriousa Not serious Not serious Very seriousd,e Strongly suspectedf MD 3.14 VERY LOW
(−1.70 to 7.99)
Vitality 1 104 Seriousa Not serious Not serious Very seriousd,e Strongly suspectedf MD 1.20 VERY LOW
(−4.10 to 6.50)
Social functioning 1 104 Seriousa Not serious Not serious Very seriousd,e Strongly suspectedf MD 1.20 VERY LOW
(−5.90 to 8.40)
Role emotional 2 158 Seriousa Not serious Not serious Very seriousd,e Strongly suspectedf MD 0.87 VERY LOW
(−7.05 to 8.78)
Mental health 2 158 Seriousa Not serious Not serious Very seriousd,e Strongly suspectedf MD 4.98 VERY LOW
(0.71 to 9.26)
a, Risk of bias of some concerns; b, Unexplained moderate heterogeneity (I2 = 30–60%); c, Unexplainable significant heterogeneity (I2 = 75–100%); d, Small sample size (n < 400);
e, Confidence interval with no effect or very small effect estimated; f, Possibility of publication bias. Abbreviation. RCT, randomized controlled trial; CI, confidence interval; MD, mean
R. Urata et al. / Effectiveness of non-surgical treatment combined with supervised exercise for lumbar spinal stenosis

difference; SMD, standardized mean difference.

 R. Urata et al. / Effectiveness of non-surgical treatment combined with supervised exercise for lumbar spinal stenosis 811

reported outcomes were downgraded due to some con- stretching, abdominal muscle exercises, pelvic tilt ex-
cerns. For the imprecision, all evidence was down- ercises, and spinal manipulation [20–22]. These exer-
graded due to the sample size being less than the OIS. cises may have been unsuitable for some patients. Pad-
Furthermore, the immediate results of NRS leg pain and manabhan et al. [23] reported that low back pain and
ZCQS were further downgraded because their effect ODI scores improved when exercises that encouraged
estimates did not exceed the MCID. Regarding publi- lumbar extension in patients with LSS who had chal-
cation bias, the possibility could not be ruled out, and lenges with lumbar flexion were performed. It has been
thus all evidence was downgraded. Eventually, NRS leg suggested that the motor approach to LSS should focus
pain, NRS back pain, ZCQS, ZCQF, ODI, and SF-36 not only on radiological findings but on the direction of
showed very low evidence in both immediate and long- movement and posture in which symptoms disappear or
term results. In addition, SPWT showed low evidence are alleviated [24]. Therefore, clinicians and therapists
for both immediate and long-term results. may need to be cautious when introducing supervised
exercises that promote lumbar flexion.
Regarding functional impairment/disability as as-
4. Discussion sessed by the ZCQF, two studies compared the volun-
tary training programs alone versus a combination of
Our systematic review evaluated RCTs comparing the training program and supervised exercise. ZCQF
non-surgical treatment with and without supervised ex- score is a useful clinical index to determine the severity
ercise for LSS. To the best of our knowledge, this is the of lower extremity symptoms and neuropathic inter-
first systematic review evaluating the benefits of com- mittent claudication and reflects the subjective walking
bining supervised exercise therapy with non-surgical ability of patients [25]. Of the two studies that reported
treatment for LSS. According to our review, the com- immediate results, one supported the combination of
bination of supervised exercise had better immediate supervised exercise with the training program, while
results for NRS leg pain, ZCQS, ZCQF, SPWT, and the other showed no statistical difference. In the meta-
SF-36 (PF, GH, VT, SF, RE, and MH) and long-term analysis, no statistical differences were detected to sup-
results for ZCQF, SPWT, and SF-36 (PF, BP, and MH) port the superiority of the combination of supervised
than that had by non-combined treatment. However, the exercise and the training program. In one study that
certainty of all the evidence was low, and the strength examined long-term outcomes, beneficial results were
of the effect was small. This result was contrary to our observed after the combination of supervised exercise
hypothesis. and the training program [20]. However, the size of the
This review identified two studies that reported that effect was small. In addition, SPWT results, reflecting
a combination of supervised exercise and a voluntary objective walking ability, suggested that a combination
training program was superior to the voluntary train- of supervised exercise and voluntary training is signifi-
ing program alone in immediate leg pain intensity and cantly better than voluntary training alone in achieving
symptom severity results. However, a meta-analysis of both immediate and long-term results. Although there
the pooled data detected only small differences, and the are limitations in interpreting the effect size of SPWT,
certainty of the evidence was very low. Our findings the improvement in walking ability due to the combina-
were similar to those of previous studies in both effect tion of supervised exercise and voluntary training may
direction and magnitude. Two RCTs included in the differ between subjective and objective assessments.
meta-analysis were also included in a prior study [7], Regarding QOL assessed by the SF-36, two studies
and this could explain the similarity between the prior compared a voluntary training program alone and its
study and our study. combination with supervised exercise, and one study
Back pain intensity did not improve significantly in compared ESI alone and its combination with super-
both immediate and long-term results. Although the re- vised exercise. In the meta-analysis of the pooled data,
sults were heterogeneous (Fig. 3), due to the small num- improvements in several subcomponents were shown.
ber of studies identified, the causes could not be deter- The benefits of exercise and physical activity on well-
mined. These trends were similar for the ODI (Fig. 5). being have been reported from several neuroscientific
To explore this inconsistent result, there are factors to perspectives [26,27]. Increased exercise or physical ac-
consider. The three studies included in this review pre- tivity due to the combination of supervised exercise
scribed supervised exercises that promote lumbar flex- with other non-surgical treatments may have influenced
ion, including knee-holding lumbar paraspinal muscle these improvements.
812 R. Urata et al. / Effectiveness of non-surgical treatment combined with supervised exercise for lumbar spinal stenosis

According to the results of our review, there was no Funding

firm evidence that the combination of supervised exer-
cise notably improves clinical outcomes in LSS. In pre- The authors report no funding.
vious reviews, it has been emphasized that supervised
exercise (and/or a combination of manual therapy) im-
proves pain, symptom severity, and physical function Informed consent
in LSS more than medical, voluntary training, or group
exercise [7,8]. Although supervised exercise is superior Not applicable.
to other exercise modalities, the benefits of combining
it may be less. The review results suggest the need for
Conflict of interest
clinicians and therapists to consider which non-surgical
treatments and supervised exercise combinations are
The authors declare that they have no conflict of
optimal.
interest.
This systematic review has some limitations. First,
the number of included studies was limited, and the
sample size was small. The lack of an additional meta- Acknowledgments
analysis and the assessment of publication bias may
have affected the weak estimates of evidence. In ad- The authors have no acknowledgments.
dition, the number of studies that contributed to the
long-term results tended to be even smaller than that of
studies that contributed to the immediate results. Long- Author contributions
term outcomes of non-surgical treatment have also been
reported in previous large cohort studies [28]. In the All authors contributed to the conception and design
future, a systematic review that includes cohort studies of the study. Material preparation, data collection, and
in the eligibility criteria should be considered. Second, analysis were performed by RU, TI and AS. The first
all the studies that contributed evidence had a potential draft of the manuscript was written by RU, and all
risk of bias. For patient-reported outcomes, the risk of authors commented on the previous versions of the
bias is higher if patient-blinding is not ensured [16]. manuscript. All authors read and approved the final
Although double-blinding is difficult when comparing manuscript.
exercise therapies, the influence of implementation bias
and detection bias on the results cannot be ignored.
Third, our review included only conditions that com- Supplementary data
bine voluntary training and ESI with supervised ex-
ercise; therefore, the findings of this study cannot be The supplementary files are available to download
generalized to the combinations of supervised exercise from http://dx.doi.org/10.3233/BMR-220220.
with other non-surgical treatments.
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