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physiotherapy
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GRAND ROUNDS
JANUARY 19, 2011
Jessie Mathers, PT, OCS, FAAOMPT
Duke Medicine Department of Physical Therapy & Occupational Therapy
PHYSICAL THERAPY’S ROLE IN
TREATING LUMBAR RADICULOPATHY
IN CONJUNCTION WITH EPIDURAL
STEROID INJECTION
A case study
Objectives
Define lumbar radiculopathy
Demonstrate clinical decision making for patients
with lumbar radiculopathy
Describe the ESI procedure and efficacy as a
treatment
Examine the evidence for PT in conjunction with ESI
Examine evidence for treatment-based subgroups
for low back pain
The patient
48 year old male
PMH:
Chronic low back pain, GERD
Exercise 3x/wk, plays golf
Travels frequently for work
Diagnosed with lumbar radiculopathy
episode of severe back and bilateral leg pain and
numbness about 8 weeks prior
“back locked up and could not move”
Imaging
Magnetic Resonance Imaging (MRI)
Findings:
Herniated disc at L4-5 with mild foraminal stenosis and
facet arthritis
Mild disc bulging at L5-S1
Treatment received
Most recent episode was 10/22/10
10/23/10: Steroid dose pack x6 days, Percocet
(Oxycodone and acetaminophen)
10/27/10: Epidural steroid injection L4-5 (under
fluoroscopy)
PT referral for “core strengthening”
Initial Visit: Subjective
Pain 4/10
Exacerbating factors:
Sitting more than 30 minutes
Leaning over to restore boat
Alleviating factors:
Stretching
Lying down
Relevant history
Military background (carrying rucksack, jumping
from airplanes)
Related chronic, episodic bouts of back pain for
>20 years (since being in the military)
Becoming increasingly frequent with more subtle
triggers
Has history of successful PT
Initial Visit: Chief complaint
Low back pain and Right
more than Left lower
extremity pain
Numbness R dorsal foot
Denied: weakness,
bowel/bladder changes
+ cough/sneeze
PT evaluation
Posture: no lateral shift noted
Neurologic Screen
Deep Tendon Reflexes: normal
Clonus: negative
Myotomes: normal
Dermatomes: diminished light
touch Right L4 distribution
Straight Leg raise: + Right
Active range of motion
Single motions
All motions WNL
Flexion provoked Right lower extremity pain
Repeated motions:
Flexion: increased intensity of back and Right leg pain
Extension: decreased back pain, no change in leg pain
Passive accessory motions
Unilateral P-A (posterior-anterior/spring test)
Hypomobility L4-5 and L5-S1
Right L5-S1 increased R leg pain (to foot)
Repeated UPAs at L5-S1 continued to provoke pain
Irritability?
What is radiculopathy?
Typically unilateral
Symptoms in a specific nerve root distribution
(dermatomal pattern)
c/o pain, paresthesias, weakness
Often radiates to foot or toes
Straight leg raise testing worsens pain
Terms lumbar radiculopathy and sciatica often used
interchangeably
Multifactorial Causes
Herniated lumbar vertebral
disc causing compression of
the nerve root, leading to
neural ischemia, edema and
eventually to chronic
inflammation and scarring
Facet osteoarthritis leading
to nerve root compression.
Radiculopathy Facts
The lifetime prevalence is at least 5.3% in men and
3.7% in women, representing 6% of total work
disability
Often has high rate of recurrence
Risk Factors:
Age (peak 45-64 years), increasing risk with height,
smoking, stress
Driving at least 2 hrs/day, high score of psychosomatic
problems, previous episode of sciatica
Prognosis
Likely there will be improvement over a 2-6 month
period regardless of treatment received
Persistent/recurring sciatica in up to 53% of
patients
Various studies agree that 20% of those with
sciatica progress to surgery within 6 months
Epidural Steroid Injection
Can be performed by anesthesiologist, radiologist,
neurologist, physiatrist or surgeon
Injection includes anesthetic and steroid
Example: Betamethasone mixed with 1% lidocaine plus
normal saline
CT guided vs. fluoroscopy
Less radiation, more accurate, “game time” decisions
ESI Effects
Usually feel dramatically better immediately due to
anesthetic
Can take 2-7 days for steroid to take effect
There is no way to predict who will respond quickly,
slowly, or at all OR the duration of pain relief
There are no contraindications to exercise after ESI
PT TREATMENT
Treatment based subgroups of LBP
Subgrouping patients with LBP has been proposed
to improve outcomes
Groups:
Specific Exercise/Directional preference
Manipulation
Stabilization
An Examination of the Reliability of a
Classification Algorithm for Subgrouping
Patients With Low Back Pain
Julie M. Fritz, PhD, PT, ATC, Gerard P. Brennan, PhD, PT,
Shannon N. Clifford, MPT, Stephen J. Hunter, PT, OCS,
and Anne Thackeray, PT
SPINE. Volume 31, Number 1, pp 77–82.
Which subgroup for this patient?
Does not fit manipulation group
Symptoms below the knee
Duration of symptoms
Does not fit the specific exercises group due to no
clear directional preference
Stabilization?
3 or more previous episodes
Increasing episode frequency
Clinical decision making
History sounds like “hypermobility”
Multiple previous episodes
Increasing frequency of episodes with less traumatic
events
Manual therapy candidate?
Certain techniques may be indicated
PT Treatment
Considerations:
Stabilization category
Level of irritability: mild
Modify current stretching program to eliminate flexion-
bias stretches
Manual therapy
Neural glides, thoracic spine
Patient Follow-up
Travelled extensively out of the country
Followed up with PT 2 more visits
Pain 2/10 average
Able to perform hobby of restoring boats
Exercises daily (including core exercise program)
What does the evidence say?
Treatment-based subgroups
Fritz et al, 2006: classification decision-making algorithm
showed good interrater reliability, regardless of the
experience of the examiner
Kamper et al, 2010: “research has failed to demonstrate
the utility of any classification system with sufficient certainty
to recommend incorporation into clinical practice”
ESI and PT
A Pilot Study Examining the Effectiveness of Physical
Therapy as an Adjunct to Selective Nerve Root
Block in the Treatment of Lumbar Radicular Pain
From Disk Herniation: A Randomized Controlled
Trial
A. Thackeray, J. Fritz, G. Brennan, F. Zaman, S. Willick.
December 2010 (90) Physical Therapy
ESI and PT
Randomized control trial n=44
2 groups:
Injection followed by 4 weeks of PT
Injection with no PT after
Reductions in pain and disability in both groups
No differences between groups for any outcome
Limitations
Small sample size (n=44)
Follow up duration was short (2 months, 6 months)
Focus of the exercise was not on strengthening
Nearly half of the participants had been
nonresponsive to physical therapy treatment prior to
the injection, which may have created a bias
against the potential benefit of physical therapy
after injection
RCT comparing ESI to IM saline injection
Significant reduction in pain early on in those having
an epidural steroid injection but no difference in the
long term (2 years) between the two groups
The rate of subsequent operation in the groups was
35%
Other studies demonstrated 10-15% required eventual
surgery
Take home points
Lumbar radiculopathy is a complex, sometimes
frustrating diagnosis to treat
Numerous nonsurgical treatment options available,
yet current evidence is limited and conflicting
Treatment based subgroups may or may not be
helpful in treating patients with LBP
ESI can provide effective, mostly short term relief
for lumbar radiculopathy
References
N. K. Arden, C. Price, I. Reading, et al. A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: the WEST study. Rheumatology 2005;44:1399–1406.
J. Weinstein, T. Tosteson, J. Lurie, A. Tosteson, B Hanscom, et al. Surgical vs Nonoperative Treatment for Lumbar Disk Herniation: The Spine Patient Outcomes Research Trial (SPORT): A Randomized Trial. JAMA. 2006 November 22; 296(20): 2441–2450.
R. Buenaventura, S. Datta, S. Abdi, and H. Smith. Systematic Review of Therapeutic Lumbar Transforaminal Epidural Steroid Injections. Pain Physician 2009; 12:233-251.
B. Koes, M. van Tulder, W. Peul. Diagnosis and treatment of sciatica. BMJ 2007; 334:1313-1317.
J Wilson-MacDonald, G. Burt, D. Griffin, C. Glynn. Epidural steroid injection for nerve root compression. J Bone Joint Surg 2005; 87:352-355.
S. Atlas, R. Keller, Y. Wu, R. Deyo, and D. Singer. Long-Term Outcomes of Surgical and Nonsurgical Management of Sciatica Secondary to a Lumbar Disc Herniation: 10 Year Results from the Maine Lumbar Spine Study. Spine 2005; 30(8): 927–935.
F. Tubach, J. Beaute, A Leclerc. Natural history and prognostic indicators of sciatica. J of Clin Epidemiology 2004(57)174-179.
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