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

Transforaminal Injection

Needle

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 Education

Posture

Ergonomics

Prevention

Prognosis

PT treatment

Core stabilization

Maintain walking daily

Stop doing flexion exercises

Manual therapy

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

Thanks!

Dr. Christopher Lascola and his team at

Southpoint

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.

Questions?