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        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?