Assessing and managing radicular pain

Tom Jesson

C LAS S OV E RV I E W
Radicular pain is one of the most common conditions in clinical practice, and one of the most high-
stakes conditions, too. Despite this, there is still confusion about the best way to assess and manage
radicular pain. This course will clarify that confusion. By the end of the course, the learner should
not only know more about best practice for radicular pain, but also the evidence base and biological
principles that underpin best practice, allowing them to make high quality, nuanced decisions for the
patient in front of them.

1 Copyright © Physio Network

P RESENTER bi o

Tom Jesson is a physiotherapist with experience in musculoskeletal primary

care and as a chronic pain specialist. He has written extensively on the
topics of radicular pain, chronic pain and clinical reasoning.

Module Summaries from their spine, or is it something else? Does this

person have radicular or referred pain? And How
Module 1: “What are we talking about?” is this person’s nerve functioning?

This module starts with a brief overview of the

history of a condition that has long has confused
clinicians and scientists. We clear up some of the
common words used to describe different kinds
of back and leg pain, and the words used in MRI
reports. And we take a deep dive into what is
known about the pathology of the painful nerve
root.
Learning objectives:
• The often unappreciated masqueraders of
radicular pain
• How to differentiate radicular from referred
pain
• The theory behind basic nerve testing

Module 3: “Person-centred treatment”

Learning objectives:
This module draws from the qualitative research
• The different pathomechanisms that
and patients’ own accounts to understand the
contribute to radicular pain
condition from their perspective. It suggests
• The different types of disc lesion various ways we can talk with patients to help
• The terminology used to describe nerve root them understand and manage their pain.
pain
Learning objectives:
• Some of the most important things patients
Module 2: “Reasoning the assessment”
need to know
This module explains how to answer three key
• Some communication strategies to reassure
clinical questions. Is this person’s pain coming
and educate

2 Copyright © Physio Network

Module 4: “Evidence-based treatment”
This module gives an overview of what the
evidence base says for the most common
interventions for the condition: exercise,
injections, surgery and medications. It explains
what the indicators are for referring on, and when.
Learning objectives:
• The evidence base behind our treatments
• How to reason referral to other professions
SUGGESTED READING
1. Bogduk, N., 2009. On the definitions and
physiology of back pain, referred pain, and
radicular pain: Pain 147, 17–19. https://doi.
org/10.1016/j.pain.2009.08.020
Comment: essential reading, a clear descrip-
tion of the different kinds of back/leg pain
2. Calvo, M., Dawes, J.M., Bennett, D.L., 2012.
The role of the immune system in the gener-
ation of neuropathic pain. The Lancet Neurol-
ogy 11, 629–642. https://doi.org/10.1016/
S1474-4422(12)70134-5
Comment: a bit heavy going but a good in-
troduction to the way different body systems
get involved after a nerve injury
3. Deyo, R.A., Mirza, S.K., 2016. Herniated Lum-
bar Intervertebral Disk. New England Journal
of Medicine 374, 1763–1772. https://doi.
org/10.1056/NEJMcp1512658
Comment: good overview paper
4. Dower, A., Davies, M.A., Ghahreman, A.,
2019. Pathologic Basis of Lumbar Radicular
Pain. World Neurosurgery 128, 114–121.
https://doi.org/10.1016/j.wneu.2019.04.147
Comment: best review of pathomechanisms
3 Copyright © Physio Network
Progress Checklist
1. Review all learning objectives
2. Complete all Masterclass video lectures
3. Take the quiz to test your knowledge
4. Print or save your certificate to record your
professional development.
5. Fardon, D.F., Williams, A.L., Dohring, E.J.,
Murtagh, F.R., Gabriel Rothman, S.L.,
Sze, G.K., 2014. Lumbar disc nomencla-
ture: version 2.0. The Spine Journal 14,
2525–2545. https://doi.org/10.1016/j.
spinee.2014.04.022
Comment: easy and clear read on MRI
reports
6. Furman, M.B., Johnson, S.C., 2019. Induced
lumbosacral radicular symptom referral pat-
terns: a descriptive study. The Spine Journal
19, 163–170. https://doi.org/10.1016/j.
spinee.2018.05.029
Comment: nice study of variation in pain
patterns
7. Gifford, L., 2001. Acute low cervical nerve
root conditions: symptom presentations and
pathobiological reasoning. Manual Ther-
apy 6, 106–115. https://doi.org/10.1054/
math.2000.0386
Comment: insightful and readable clinical
review
 SUGGESTED READING
8. Goldsmith, R., Williams, N.H., Wood, F., 2019.
Understanding sciatica: illness and treatment
beliefs in a lumbar radicular pain population.
A qualitative interview study. BJGP Open bjg-
popen19X101654. https://doi.org/10.3399/
bjgpopen19X101654
Comment: insightful qualitative research
9. Grimm, B., Blessinger, B., Darden, B.,
Brigham, C., Kneisl, J., Laxer, E., 2015. Mim-
ickers of Lumbar Radiculopathy. Journal
of the American Academy of Orthopaedic
Surgeons 23, 7–17. https://doi.org/10.5435/
JAAOS-23-01-7
Comment: decent overview of some differ-
ential diagnoses
10. Mayer, J.D., 2019. “Pain Behavior”: What My
Pain Treatment Got Wrong. Health Aff (Mill-
wood) 38, 159–163. https://doi.org/10.1377/
hlthaff.2018.05323
Comment: evocative and very readable pa-
tient experience
11. Pinto, R.Z., Verwoerd, A.J.H., Koes, B.W.,
2017. Which pain medications are effective
for sciatica (radicular leg pain)? BMJ j4248.
https://doi.org/10.1136/bmj.j4248
Comment: summary of state of evidence for
pain meds
12. Robblee, J., Katzberg, H., 2016. Distinguish-
ing Radiculopathies from Mononeuropa-
thies. Frontiers in Neurology 7. https://doi.
org/10.3389/fneur.2016.00111
Comment: decent clinical summary
13. Ryan, C., Roberts, L., 2019. ‘Life on hold’: The
lived experience of radicular symptoms. A
qualitative, interpretative inquiry. Muscu-
loskeletal Science and Practice 39, 51–57.
https://doi.org/10.1016/j.msksp.2018.11.005
Comment: interesting qualitative research
4 Copyright © Physio Network
14. Schmid, A.B., Nee, R.J., Coppieters, M.W.,
2013. Reappraising entrapment neuropathies
– Mechanisms, diagnosis and management.
Manual Therapy 18, 449–457. https://doi.
org/10.1016/j.math.2013.07.006
Comment: excellent review paper helping
to understand entrapment neuropathies
beyond the entrapment
15. Schmid, A.B., Hailey, L., Tampin, B., 2018.
Entrapment Neuropathies: Challenging
Common Beliefs With Novel Evidence.
Journal of Orthopaedic & Sports Physical
Therapy 48, 58–62. https://doi.org/10.2519/
jospt.2018.0603
Comment: very clear and clinically useful
summary of most recent entrapment neu-
ropathy research
16. Smyth, M.J., Wright, V.J., 1977. The Clas-
sic: Sciatica and the Intervertebral Disk An
Experimental Study. Clinical Orthopaedics
and Related Research 129, 9. https://doi.
org/10.1097/00003086-197711000-00003
Comment: old but one of the most useful
and interesting studies on nerve root pain
17. Tawa, N., Rhoda, A., Diener, I., 2017. Accuracy
of clinical neurological examination in diag-
nosing lumbo-sacral radiculopathy: a system-
atic literature review. BMC Musculoskeletal
Disorders 18. https://doi.org/10.1186/
s12891-016-1383-2
Comment: helpful overview of value of ob-
jective examination
Finally, livingwellpain.net is a very useful and
readable website written by Tina, someone with
sciatica who has taken an interest in pain man-
agement and physio.
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MODULE 1
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5 Copyright © Physio Network
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org/10.1056/NEJMcp1512658
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10. Dower, A., Davies, M.A., Ghahreman, A.,
2019. Pathologic Basis of Lumbar Radicular
Pain. World Neurosurgery 128, 114–121.
https://doi.org/10.1016/j.wneu.2019.04.147
11. Fardon, D.F., Williams, A.L., Dohring, E.J.,
Murtagh, F.R., Gabriel Rothman, S.L.,
Sze, G.K., 2014. Lumbar disc nomencla-
ture: version 2.0. The Spine Journal 14,
2525–2545. https://doi.org/10.1016/j.
spinee.2014.04.022
12. Ji, R.-R., Nackley, A., Huh, Y., Terrando,
N., Maixner, W., 2018. Neuroinflamma-
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lips, A., Guo, J., Laing, R.J.C., Abdi, S., Decos-
terd, I., Woolf, C.J., 2009. A Novel Tool for the
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6 Copyright © Physio Network
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MODULE 2
1. Furman, M.B., Johnson, S.C., 2019. Induced
lumbosacral radicular symptom referral pat-
terns: a descriptive study. The Spine Journal
19, 163–170. https://doi.org/10.1016/j.
spinee.2018.05.029
2. Gifford, L., 2001. Acute low cervical nerve
root conditions: symptom presentations and
pathobiological reasoning. Manual Ther-
apy 6, 106–115. https://doi.org/10.1054/
math.2000.0386
3. Mahn, F., Hüllemann, P., Gockel, U., Brosz,
M., Freynhagen, R., Tölle, T.R., Baron, R.,
2011. Sensory Symptom Profiles and Co-
Morbidities in Painful Radiculopathy. PLoS
ONE 6, e18018. https://doi.org/10.1371/
journal.pone.0018018
4. Murphy, D.R., Hurwitz, E.L., Gerrard, J.K.,
Clary, R., 2009. Pain patterns and descriptions
in patients with radicular pain: Does the pain
necessarily follow a specific dermatome?
Chiropractic & Osteopathy 17. https://doi.
org/10.1186/1746-1340-17-9
5. Schmid, A.B., Nee, R.J., Coppieters, M.W.,
2013. Reappraising entrapment neuropathies
– Mechanisms, diagnosis and management.
Manual Therapy 18, 449–457. https://doi.
org/10.1016/j.math.2013.07.006
6. Scholz, J., Mannion, R.J., Hord, D.E., Griffin,
R.S., Rawal, B., Zheng, H., Scoffings, D., Phil-
lips, A., Guo, J., Laing, R.J.C., Abdi, S., Decos-
terd, I., Woolf, C.J., 2009. A Novel Tool for the
Assessment of Pain: Validation in Low Back
Pain. PLoS Medicine 6, e1000047. https://
doi.org/10.1371/journal.pmed.1000047
 REFERENCES
7. Stynes, S., Konstantinou, K., Ogollah, R., Hay,
E.M., Dunn, K.M., 2018. Clinical diagnostic
model for sciatica developed in primary care
patients with low back-related leg pain. PLOS
ONE 13, e0191852. https://doi.org/10.1371/
journal.pone.0191852
MODULE 3
1. Chiu, C.-C., Chuang, T.-Y., Chang, K.-H., Wu,
C.-H., Lin, P.-W., Hsu, W.-Y., 2015. The prob-
ability of spontaneous regression of lumbar
herniated disc: a systematic review. Clini-
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org/10.1177/0269215514540919
2. Goldsmith, R., Williams, N.H., Wood, F., 2019.
Understanding sciatica: illness and treatment
beliefs in a lumbar radicular pain population.
A qualitative interview study. BJGP Open bjg-
popen19X101654. https://doi.org/10.3399/
bjgpopen19X101654
3. Konstantinou, K., Dunn, K.M., Ogollah, R.,
Lewis, M., van der Windt, D., Hay, E.M., 2018.
Prognosis of sciatica and back-related leg
pain in primary care: the ATLAS cohort. The
Spine Journal 18, 1030–1040. https://doi.
org/10.1016/j.spinee.2017.10.071
4. Mayer, J.D., 2019. “Pain Behavior”: What My
Pain Treatment Got Wrong. Health Aff (Mill-
wood) 38, 159–163. https://doi.org/10.1377/
hlthaff.2018.05323
5. Ogollah, R.O., Konstantinou, K., Stynes, S.,
Dunn, K.M., 2018. Determining One‐Year
Trajectories of Low‐Back–Related Leg Pain in
Primary Care Patients: Growth Mixture Mod-
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org/10.1002/acr.23556
7 Copyright © Physio Network
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lived experience of radicular symptoms. A
qualitative, interpretative inquiry. Muscu-
loskeletal Science and Practice 39, 51–57.
https://doi.org/10.1016/j.msksp.2018.11.005
8. Saunders, B., Bartlam, B., Artus, M., Kon-
stantinou, K., 2018. Biographical suspension
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MODULE 4
1. Dedering, Å., Peolsson, A., Cleland, J.A.,
Halvorsen, M., Svensson, M.A., Kierkegaard,
M., 2018. The Effects of Neck-Specific Train-
ing Versus Prescribed Physical Activity on
Pain and Disability in Patients With Cervical
Radiculopathy: A Randomized Controlled
Trial. Archives of Physical Medicine and
Rehabilitation 99, 2447–2456. https://doi.
org/10.1016/j.apmr.2018.06.008
2. Fernandez, M., Ferreira, M.L., Refshauge,
K.M., Hartvigsen, J., Silva, I.R.C., Maher, C.G.,
Koes, B.W., Ferreira, P.H., 2016. Surgery or
physical activity in the management of sci-
atica: a systematic review and meta-analysis.
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https://doi.org/10.1007/s00586-015-4148-y
3. Fernandez, M., Hartvigsen, J., Ferreira, M.L.,
Refshauge, K.M., Machado, A.F., Lemes, Í.R.,
Maher, C.G., Ferreira, P.H., 2015. Advice to
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5. Langevin, P., Desmeules, F., Lamothe, M.,
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6. Peul, W.C., van den Hout, W.B., Brand, R.,
Thomeer, R.T.W.M., Koes, B.W., 2008. Pro-
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8 Copyright © Physio Network
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7. Peul, W.C., van Houwelingen, H.C., van den
Hout, W.B., Brand, R., Eekhof, J.A.H., Tans,
J.T.J., Thomeer, R.T.W.M., Koes, B.W., 2007.
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8. Pinto, R.Z., Verwoerd, A.J.H., Koes, B.W.,
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