Improving walking after lumbar spinal stenosis surgery: co-design and single-arm feasibility trial of the STructured Rehabilitation and InDividualised Exercise and Education (STRIDE) programme

This study demonstrates that the co-designed, theory-informed STRIDE rehabilitation programme is acceptable and feasible for improving walking outcomes in patients undergoing lumbar spinal stenosis surgery, showing promising signals of clinical benefit that support progression to a definitive trial.

The Gist

Imagine your spine is like the main support beam in an old house. Over time, that beam can get worn down, and the hallway around it (the spinal canal) gets too narrow. This is called Lumbar Spinal Stenosis (LSS). It's like trying to walk through a hallway that keeps getting smaller; your legs feel heavy, painful, or weak, and you just can't walk very far.

For many people, surgery is the "renovation" that clears the hallway. But here's the catch: even after the surgery fixes the beam, many people still can't walk much better than before. They stay stuck on the couch, afraid to move, or just don't know how to get back to their old active selves.

This paper is about a new project called STRIDE (which stands for STructured Rehabilitation and InDividualised Exercise and Education). Think of STRIDE not just as a medical treatment, but as a personalized "training camp" and "coaching journey" designed to help people walk better after their spinal surgery.

Here is the story of how they built it and tested it, explained simply:

1. Building the Plan: "Co-Designing the Map"

Before they built the program, the researchers didn't just sit in an office and guess what would work. They used a method called Co-Design.

• The Analogy: Imagine you are building a new video game level. Instead of the developers deciding what the obstacles are, they invited the players (patients), the parents (family), and the game masters (doctors) into the room to draw the map together.
• What happened: They held workshops with 39 people. They asked: "What stops you from walking?" and "What would help you?"
• The Result: They created STRIDE, a 24-week program (12 weeks before surgery, 12 weeks after). It's like a training manual that teaches you how to walk again, but it also teaches you how to think about walking again. It tackles fears, builds confidence, and gives you a plan that fits your life, not a generic one-size-fits-all.

2. The Program: A Two-Act Play

STRIDE is split into two acts, guided by a physiotherapist (a movement coach):

• Act 1: Pre-Surgery (The Warm-up): Before the operation, you meet with a coach. You learn about your condition, set goals, and start gentle exercises to get your legs ready. It's like a pilot training before a big flight. You get a pedometer (step counter) and a diary to track your progress.
• Act 2: Post-Surgery (The Flight): After the surgery, the coach helps you land safely. You review your progress, adjust your exercises, and learn how to keep walking as you recover. The goal is to make sure you don't just survive the surgery, but actually thrive afterward.

3. The Test Run: "The Pilot Flight"

The researchers wanted to see if this program was actually doable and if people liked it. They didn't test if it was "perfect" yet; they just wanted to see if the plane could fly.

• The Crew: They recruited 15 people waiting for spine surgery.
• The Journey: These people went through the 24-week STRIDE program.
• The Results:
  • Did they like it? Yes! The program was rated a perfect 5 out of 5 for acceptability. People felt supported, less afraid, and more confident.
  • Did it work? The numbers showed promise. After the program, people walked about 80 meters further in a 6-minute test and took about 1,400 more steps per day compared to when they started.
  • The Hurdle: The biggest complaint was travel. Since the program required in-person visits, some people found the trip to the hospital tiring and difficult. It's like having a great gym, but it's 45 minutes away, and you're already tired from your injury.

4. What Did They Learn?

The study concluded that STRIDE is a winning concept.

• The Good: It works well to get people ready for surgery and helps them recover faster. The "personal coach" approach was the secret sauce.
• The Fix: To make it even better for the next big test, they need to make it easier to access. Maybe offer more video calls or local clinics so people don't have to travel so far.

The Bottom Line

Think of spine surgery as fixing a broken leg. STRIDE is the rehabilitation boot camp that teaches you how to run again. This study proved that this specific boot camp is popular, safe, and effective. It gives patients the tools, the confidence, and the plan they need to go from "I can't walk" to "I'm walking again."

The researchers are now ready to take this program to a bigger stage to prove it works for everyone, not just a small group.

Technical Summary

1. Problem Statement

Clinical Context: Lumbar Spinal Stenosis (LSS) is a degenerative condition causing pain and severe walking limitations, particularly in older adults. While surgery is the standard intervention for those unresponsive to conservative management, 75–90% of patients fail to increase their walking activity post-operatively, remaining at risk for inactivity-related morbidity.
Research Gap: Existing rehabilitation programs for LSS are often inconsistent, lack robust theoretical underpinning, and focus primarily on younger populations or specific surgical types (e.g., discectomy/fusion) rather than the older demographic typical of LSS. Furthermore, walking recovery is frequently neglected as a primary outcome, and few interventions address the complex pre- and post-operative needs of this population using behavior change theories.
Objective: To co-design a theory-informed, physiotherapy-led rehabilitation program (STRIDE) to improve walking behavior after LSS surgery and evaluate its feasibility and acceptability for a future definitive trial.

2. Methodology

The study employed a multi-methods design consisting of two distinct phases:

Phase 1: Intervention Co-Design

• Approach: An adapted Experience-Based Co-Design (EBCD) approach integrated with the Behaviour Change Wheel (BCW) and the Theoretical Domains Framework (TDF).
• Participants: 39 stakeholders, including 9 patients (post-surgery), 4 family members, and 26 healthcare professionals (HCPs), recruited from three NHS hospitals.
• Process: Four workshops and small group meetings were held to identify barriers to walking, prioritize rehabilitation goals, and generate intervention ideas.
• Theoretical Mapping: Priorities were mapped to the COM-B model (Capability, Opportunity, Motivation – Behaviour). Intervention ideas were appraised using the APEASE framework (Acceptability, Practicality, Effectiveness, Affordability, Side effects, Equity).
• Outcome: Development of the STRIDE programme prototype, refined via a modified Delphi process.

Phase 2: Single-Arm Feasibility Study

• Setting: King's College Hospital, London.
• Participants: 15 adults (≥50 years) awaiting elective lumbar decompression surgery for LSS.
• Intervention (STRIDE): A 24-week, physiotherapy-led program delivered in two phases:
  • Pre-operative (12 weeks): 3 core sessions + 1 optional session.
  • Post-operative (12 weeks): 3 core sessions + up to 2 optional sessions.
  • Content: Individualized exercise, education, goal setting, and behavior change techniques (BCTs) targeting knowledge, perceived control, fears, and physical capability.
  • Delivery: Mix of in-person, virtual (telephone/video), and self-management tools (pedometers, workbooks).
• Measures:
  • Feasibility: Recruitment rates, retention, attendance, and fidelity.
  • Acceptability: Theoretical Framework of Acceptability (TFA) questionnaire (0–5 scale) and qualitative focus groups.
  • Clinical Outcomes: 6-Minute Walk Distance (6MWD), daily step count (ActivPal), lower-limb function, pain, disability (ODI), and psychological factors.
• Analysis: Descriptive statistics, effect sizes (Hedges' g), and thematic analysis of qualitative data.

3. Key Contributions

• Novel Intervention Design: STRIDE is the first program to combine pre-habilitation and post-rehabilitation specifically for LSS surgery, explicitly conceptualizing walking as a modifiable behavior grounded in the BCW and TDF.
• Co-Design Rigor: The study demonstrates a robust integration of EBCD (patient/carer lived experience) with BCW (theoretical behavior change mechanisms), ensuring the intervention is both theoretically sound and practically relevant.
• Comprehensive Framework: The program targets six joint priorities: knowledge/expectations, perceived control, pre-operative physical preparation, personalized post-op plans, fear reduction, and timely communication.
• Feasibility Data: Provides critical pilot data (recruitment, retention, adherence) and identifies specific barriers (travel burden) to inform the design of a future multi-site Randomized Controlled Trial (RCT).

4. Results

Feasibility and Recruitment

• Recruitment: 15 of 31 eligible patients (48%) were recruited. The primary barrier was travel distance (39% ineligible, 52% declined).
• Retention: 80% retention to study end. Four participants dropped out (2 decided against surgery, 1 unable to complete final assessment, 1 withdrew due to spouse's illness).
• Adherence: High attendance rates (82% pre-op, 94% post-op). Low uptake of optional sessions (20% pre-op, <10% post-op).
• Fidelity: 91% of core components were delivered as intended.

Acceptability

• Quantitative: Median overall acceptability score was 5/5 (IQR 0). The lowest scores were for "Burden" and "Opportunity Costs," driven primarily by travel requirements.
• Qualitative: Participants valued the personalized, supportive approach and the role of the physiotherapist in building confidence. While travel was burdensome, most deemed it "worth the effort."
• Refinements Suggested: Local delivery sites, flexible appointment formats, digital resources (replacing bulky manuals), and structured peer support.

Clinical Outcomes (Preliminary Signals)

• Walking Capacity (6MWD): Showed small pre-operative improvement (+49.9 m) and moderate-to-large post-operative improvement (+81.6 m) compared to baseline.
• Daily Step Count: Increased by +868 steps/day pre-op and +1,405 steps/day post-op.
• Function & Disability: Significant improvements in sit-to-stand time and Oswestry Disability Index (ODI) scores post-surgery.
• Note: Effect sizes were moderate to large but had wide confidence intervals due to the small sample size.

5. Significance and Conclusion

• Clinical Impact: The STRIDE program is highly acceptable to patients and demonstrates promising signals for improving walking behavior and physical function in older adults undergoing LSS surgery.
• Methodological Value: The study validates the utility of combining EBCD and BCW for developing complex rehabilitation interventions, ensuring they address both the "how" (mechanisms) and the "who/what" (user experience).
• Future Directions: The findings support progression to a multi-site Randomized Controlled Trial (RCT). Key modifications for the future trial include:
  • Decentralizing delivery to reduce travel burden.
  • Implementing remote monitoring for objective measures.
  • Incorporating peer support and nutritional/mental health content.
  • Addressing the challenge of variable waiting times for surgery.

In summary, the STRIDE programme represents a significant step forward in addressing the gap in post-LSS surgical recovery, offering a scalable, theory-driven model to restore walking independence in an aging population.