Duke Medicine

Department of Physical Therapy & Occupational Therapy

GRAND ROUNDS
JANUARY 19, 2011

Jessie Mathers, PT, OCS, FAAOMPT

PHYSICAL THERAPYS 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 7782.

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

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;44:13991406.
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): 927935.
F. Tubach, J. Beaute, A Leclerc. Natural history and prognostic indicators of sciatica. J of
Clin Epidemiology 2004(57)174-179.

Questions?