Two-Stage Treadmill Test | Lumbar Stenosis | Neurogenic Claudication

The Two-Stage Treadmill Test assesses the difference in walking distance and symptom provocation between flat incline walking in patients who suffer from neurogenic claudication due to lumbar spinal stenosis.

De Schepper et al. (2013) performed a systematic review on the diagnostic accuracy of tests used to diagnose lumbar spinal stenosis. They concluded that the diagnosis should be mainly based on patient history taking, while physical examination tests have not been found to be useful. However, a more recent systematic review by Cook et al. (2019) found that a couple of physical tests can actually be useful to confirm the diagnosis. One of them is the two-stage treadmill test originally described by Fritz et al. ( 1997). With a sensitivity of 50% and a specificity of 92.3%, this test seems good to confirm, but not exclude lumbar spinal stenosis. However, the study used imaging as the reference standard, whereas stenosis is a clinical diagnosis.

As neurogenic claudication due to lumbar spinal stenosis is related to activity, it makes sense to use functional tests in order to provoke symptoms. To conduct the test, have a patient walk on a treadmill on a level plane for 10 minutes. After a 10-minute break, the patient is then instructed to walk on an inclined treadmill at a 15-degree plane for 10 minutes. This incline will decrease lumbar lordosis during walking and thus increase the cross-sectional area in the spinal canal. The test is considered positive for lumbar spinal stenosis if there is earlier onset of symptoms with level walking or prolonged recovery time after level walking or an increased total walking time on an inclined treadmill.

21 OF THE MOST USEFUL ORTHOPAEDIC TESTS IN CLINICAL PRACTICE

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Other common tests for lumbar spinal stenosis are:

• Clinical prediction rule of Cook
• Modified Romberg Sign
• Kemp’s Test/Quadrant Test.

References

De Schepper, E. I., Overdevest, G. M., Suri, P., Peul, W. C., Oei, E. H., Koes, B. W., … & Luijsterburg, P. A. (2013). Diagnosis of lumbar spinal stenosis: an updated systematic review of the accuracy of diagnostic tests. Spine, 38(8), E469-E481.

Cook, C. J., Cook, C. E., Reiman, M. P., Joshi, A. B., Richardson, W., & Garcia, A. N. (2020). Systematic review of diagnostic accuracy of patient history, clinical findings, and physical tests in the diagnosis of lumbar spinal stenosis. European Spine Journal, 29(1), 93-112.

Fritz, J. M., Erhard, R. E., Delitto, A., Welch, W. C., & Nowakowski, P. E. (1997). Preliminary results of the use of a two-stage treadmill test as a clinical diagnostic tool in the differential diagnosis of lumbar spinal stenosis. Journal of spinal disorders, 10(5), 410-416.