www.njchiropractors.com I 21 deficits that will follow a dermatomal pattern. Deep tendon reflexes of the lower extremities are often difficult to elicit in older patients although this is usually noted symmetrically. Supine straight leg raising is usually negative in DLSS because this maneuver introduces lumbar flexion and reduces nerve compression. Loss of muscle tone, and in more advanced cases muscle atrophy is noted due to nerve compression and disuse (as a result of a more sedentary lifestyle). It is important to assess the lower extremity pulses to ensure they are present and symmetrically equal. Imaging Neurogenic claudication is a clinical diagnosis based on the history and physical examination and imaging is not necessary. Imaging is needed when red flags are present that suggest other potential serious diseases or conditions such as cancer, infection or spine fracture. Imaging is also needed when the patient’s condition is not improving and there may be the need for surgery or other invasive treatments. When imaging is necessary an MRI is the imaging modality of choice. It is imper- ative to correlate the imaging finding to patient’s symptoms and physical findings since most people over the age of 65 will have degenerative changes in the spine, which may not be related to the patient symptoms. Treatment Only a small minority of patients receive surgery. The vast majority of individuals with DLSS receive non-surgical care. However, what constitutes effective non-surgical care is unknown (Ammen- dolia 2012). Most common non-surgical therapies include physical therapy, chiropractic, acupuncture, massage therapy, medication and epidural injec- tions. Anti-inflammatory medication and epidural cortisone injections tend not to be effective since the symptoms generally are due to neuro-ischemia and not inflammation. This is demon- strated by the immediate reduction in symptoms when flexing forward (which restores spinal blood flow). This would not likely be the case if the condition was due to an inflammatory process. The ability to reduce symptoms of DLSS by changing spinal posture/structural alignment and/or increasing blood flow to the spinal nerve provides potential mechanisms for interventions to improve symptoms and walking ability. We have designed and have imple- mented a six-week self-management training program (The Boot Camp Program) for DLSS at the Rebecca MacDonald Centre for Arthritis and Auto-immune Diseases (RMCAAD) at Mount Sinai Hospital (MSH). The goal of the training program is to provide patients with the knowledge, skills, self-confidence, and physical capacity to manage their symptoms and maxi- mize their function on their own. The program is multi-modal, tailored and directed to the structural, functional, physiological and psychosocial consequences of DLSS. It includes structured aerobic exer- cise (walking, cycling, or swimming) to build stamina, self-confi- dence, lower extremity strength, balance and overall fitness. There is instruction on specific exercises that help to build core strength aimed at enabling individuals to reduce the lordosis (body realignment using pelvic tilt) during standing and walking. Education is provided using a cognitive behavioral approach and is aimed at problem solving, goal setting and building self-confidence to self-manage and maximize mobility. Manual therapy is provided with the aim of improving inter-segmental lumbar spine flexion and overall flexibility with the goal of facilitating the ability to self-align the lumbar spine to a more functional position using the pelvic tilt while standing and walking. The program is delivered one-on-one over six weeks, and during this period a step-by-step home exercise program is designed and tailored to the individual with the goal of being maintained for life. We have completed a clinical trial evaluating the effectiveness of this approach at the University of Toronto that demonstrated excellent short and long-term results. Symptomatic DLSS is a common and rapidly growing problem and one that will likely present in your clinic. Having an understanding the etiology, pathophysiology and the dynamic nature if the condition will help with the diagnosis and treatment. DLSS is a chronic condition and not likely to go away, providing patients with self- management strategies to maximize walking and functional status are key to improved quality of life. Carlo Ammendolia, DC, PhD, is the Director of the Chiropractic Spine Clinic and the Spinal Stenosis Program at the Rebecca MacDonald Centre for Arthritis and Autoimmune Diseases at Mount Sinai Hospital. He is an assistant professor in the Department of Health Policy, Management and Evaluation at the University of Toronto. He has been in clinical practice for over 35 years and now combines clinical practice and research in the area of non-operative treatment of mechanical, degenerative and inflammatory spinal disorders with a special interest in lumbar spinal stenosis. For more information on the boot camp program, visit www. spinemobility.com.