GRAND ROUNDS JANUARY 19, 2011 Duke Medicine Jessie Mathers, PT, OCS, FAAOMPT

Duke Medicine
Department of Physical Therapy & Occupational Therapy
GRAND ROUNDS
JANUARY 19, 2011
Jessie Mathers, PT, OCS, FAAOMPT
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
Needle
Transforaminal Injection
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 flexionbias 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
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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?