Lumbar Radiculopathy Treatment

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Top Contributors - Matt Huey  

Introduction[edit | edit source]

Assessment[edit | edit source]

Red Flags[edit | edit source]

The screening of red flags can be apart of the assessment process. With lumbar radiculopathy, there is a risk of a serious pathology such as caudia equina, cancer, or fractures. A few things to keep in mind about the prevalence of red flags. They will often be more prevalent in certain areas of medicine. A spinal surgeon will see more red flags than a physiotherapist. Even with physicians there is a discrepancy in the prevalence. Emergency room physicians will see more cases of serious spinal pathologies than primary care physicians[1].

Be aware that a single red flag symptom may not be due to a serious spinal pathology. Additionally, some symptoms have been found to need further investigation[2]:

  • Recent trauma (especially over 50 years of age) raises chance of vertebral fracture
  • History of cancer
  • Recent history of infection
  • Loss of bladder and/or bowel control
  • Pain that awakens someone from sleep (does, however, have a high false positive rate)

Based upon screening for red flags, there can be a level of concern[3]:

  • Begin therapy (Can change the treatment if there is a change in the red flag symptoms)
  • Begin a trial of therapy with watchful waiting (Same as above but monitor progress closely)
  • Urgent referral (Do not begin therapy and either investigate further or refer to specialist)
  • Emergency referral (Do not begin therapy and refer for emergency care)

One aspect that must be kept in mind, is that treatment of lumbar radiculopathy often is not isolated to one specific intervention. Most of the evidence presented will include interventions that are utilized in conjunction with one another. Each one of the following areas can be utilized alongside one another with treatment.

Manual Therapy[edit | edit source]

Manual therapy techniques can include a number of different hands on approaches. Commonly used manual therapy techniques utilized with patients dealing with lumbar radiculopathy include mobilization of the lumbar spine, mobilization of the nerves, or manipulation. Aspects to keep in mind when deciding to use any hands on technique are contraindications, along with the skill level of the provider and comfort level of the patient. There are patients who's pain symptoms are very irritable to which manual therapy techniques may intensify the pain symptoms.

Mobilization of the Lumbar Spine[edit | edit source]

Spinal mobilizations are passive movement of a spinal segment that follows a grading scale (I-IV). The goal with mobilizations can be to decrease pain symptoms and improve spinal mobility. There is evidence to show that the use of spinal mobilization can be beneficial in the treatment of lumbar radiculopathy. Several studies have found the use of spinal mobilizations with leg movement show some benefit in decreasing pain[4] [5][6][7]. Do keep in mind that in the studies, mobilizations were used in adjunct to other treatments, including exercises and modalities. This can demonstrate that the use of mobilizations should be used as a portion of a possible treatment.

Mobilization of the Nerve[edit | edit source]

Mobilization of the sciatica or femoral nerve is either a tensioning or gliding of the nerve. These are performed similar to the testing procedures of the straight leg raise test, slump test, or femoral nerve test. There is evidence that it can be useful in decreasing pain and improving function[8].

When utilizing these as a treatment, this can be beneficial for patients dealing with acute symptoms to assist in decreasing the sensitivity. They can also be utilized with individuals with a possible entrapment.

Manipulation of the Lumbar spine[edit | edit source]

High velocity, low amplitude (HVLA) or manipulation techniques are often thought of as techniques performed by chiropractors, but also performed by physical therapists and osteopathic physicians. It is a quick, passive movement applied to either a specific level or as a general technique. There is evidence to show that the use of manipulations can be useful with lumbar radiculopathy[9]. Additionally, there is evidence to show that the use of manipulations can decrease the prescription of benzodiazepines[10] and chance of discectomy[11] . The evidence does conclude that the use of manipulation should be used in adjunct with other treatments including exercise.

Exercise[edit | edit source]

Exercise is a key component in the treatment of lumbar radiculopathy. It has been found that it could be added to patient's treatment plans[12]. It is often just expressed as "exercise" in research without much guidance from there. The two most commonly researched areas of exercise with lumbar radiculopathy are stabilization and extension based.

The use of stabilization exercises are to improve the motor control of the spine stabilizers. It is believed that there is a disruption in the motor control in the spine and the use of stabilization activities, restores this control and decreases pain. Most evidence utilizes stabilization exercises along with other interventions such as spinal manipulation and extension movements such as cat-camel or a seated lumbar extension[13][14][15].

Repeated Movements[edit | edit source]

The use of repeated movements is a hallmark of the McKenzie Method or MDT (Mechanical Diagnosis and Therapy). When utilizing repeated movements, the goal is to determine a directional preference, which is the centralization of the symptoms. It has been found that if a patient is able to centralize their symptoms, they do improve their outcomes [16].One aspect of utilizing repeated movements, is that it is not only the use of repeated extension. There are studies that do show utilizing repeated extension does help people with lumbar radiculopathy symptoms[5], however, the proper utilization of repeated movements may involve movements either in the sagittal plane (flexion/extension), frontal plane (lateral), or a combination of movements. Additionally, movements such as repeated extension are included in research that focus on extension based exercises.

Education[edit | edit source]

Education is a staple of helping people with not only lumbar radiculopathy, but also with rehabilitation any disorder or condition[12]. Education has been included in clinical guidelines about treating back pain and lumbar radiculopathy[17]. Within research, education is often a broad topic that may include things such as performing healthy habits such as diet and sleep, lifting mechanics, posture, and overall general activity. There is evidence that has broken this down into what patients have expressed what they want in terms of information on low back pain, which can include lumbar radiculopathy[18]. It was found that patients want a definite diagnosis to the cause of their symptoms along with a personalized management strategy. They also wanted consistent information on the nature of low back pain along with management strategies that were pharmacological and non-pharmacological. They wanted this presented to them in a manner that was appropriate for their age, lifestyle, and occupational status that was in an understandable language.

Modalities[edit | edit source]

Modalities are commonly utilized interventions with rehabilitation of many conditions. For lumbar radiculopathy, the use of mechanical traction and electrical stimulation, such as TENS, are two of the most common. In looking at current evidence, modalities are not as effective as manual therapy or exercise but some evidence for the short term[19][20]. Often with research, traction or electrical stimulation is considered "physical therapy" instead of exercise or manual therapy approaches[21]. The use of modalities does seem to show some benefit when used in conjunction with additional interventions[22][23].

Medication[edit | edit source]

The prescription of medications is limited within the physiotherapy profession, however, this may be a conversation to have with patients. There is mixed evidence for the use of medication in the treatment of lumbar radiculopathy[12]. The most often prescribed medication is an non-steroidal anti-inflammatory drug (NSAID)[24]. There is some evidence that it could help in the short term[25], however limited benefit in the long term. Anticonvulsants (such as gabapentin) are another medication that can be prescribed specifically due to the radicular symptoms. There is evidence that these are largely ineffective as well for the treatment of lumbar radiculopathy[26]. Overall not been recommended in treatment guidelines that medications are effective[27].

Epidural Injection[edit | edit source]

Epidural injections are another area that is outside the scope of some providers. It can be a possible intervention for people who fail conservative management[24]. There is mixed evidence for the utilization of epidural injections[12] [17]. In the evidence that supports epidural injections, it does not lay out things such as is it more effective at certain pain levels or at certain points during the course of dealing with radicular symptoms[28]. Something to keep in mind as well is that a person of a lower socioeconomic status may experience more relief with the use of an epidural[29].

Surgery[edit | edit source]

Surgery can be considered the final option for patients who do not do well with conservative treatment[12]. The outcomes on surgical and non-surgical are similar over a 2 year time period with surgical outcomes being slightly, but not significantly, better[24]. Surgery should be withheld for only those patients with the most severe symptoms or that are showing red flag symptoms.

Rehab after a lumbar surgery is also recommended which should include education[30]. It's also beneficial to provide education prior to surgery as well since it has been found to aid in decreasing fear of movement and improved function after surgery[31].

Resources[edit | edit source]

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References[edit | edit source]

  1. Galliker, G., Scherer, D. E., Trippolini, M. A., Rasmussen-Barr, E., LoMartire, R., & Wertli, M. M. (2020). Low back pain in the emergency department: prevalence of serious spinal pathologies and diagnostic accuracy of red flags. The American journal of medicine, 133(1), 60-72.
  2. Premkumar, A., Godfrey, W., Gottschalk, M. B., & Boden, S. D. (2018). Red Flags for Low Back Pain Are Not Always Really Red: A Prospective Evaluation of the Clinical Utility of Commonly Used Screening Questions for Low Back Pain. The Journal of bone and joint surgery. American volume, 100(5), 368–374.
  3. Finucane, L. M., Downie, A., Mercer, C., Greenhalgh, S. M., Boissonnault, W. G., Pool-Goudzwaard, A. L., Beneciuk, J. M., Leech, R. L., & Selfe, J. (2020). International Framework for Red Flags for Potential Serious Spinal Pathologies. The Journal of orthopaedic and sports physical therapy, 50(7), 350–372.
  4. Kuligowski, T., Skrzek, A., & Cieślik, B. (2021). Manual therapy in cervical and lumbar radiculopathy: a systematic review of the literature. International journal of environmental research and public health, 18(11), 6176.
  5. 5.0 5.1 Ashraf, B. U. S. H. R. A., Ahmad, S. H. A. K. E. E. L., Ashraf, K. A. S. H. I. F., Kanwal, S. U. M. A. I. R. A., Ashraf, S. H. A. Z. I. A., Khan, N. O. U. M. A. N., ... & SHAFIQUE, S. (2021). Effectiveness of spinal mobilization with leg movement versus McKenzie back extension exercises in lumbar radiculopathy. Pakistan J. Med. Heal. Sci, 15(5), 1436-1440.
  6. Danazumi, M., Bello, B., Yakasai, A. & Kaka, B. (2021). Two manual therapy techniques for management of lumbar radiculopathy: a randomized clinical trial. Journal of Osteopathic Medicine, 121(4), 391-400.
  7. Bello, B., Danazumi, M. S., & Kaka, B. (2019). Comparative Effectiveness of 2 Manual Therapy Techniques in the Management of Lumbar Radiculopathy: A Randomized Clinical Trial. Journal of chiropractic medicine, 18(4), 253–260.
  8. Lin L-H, Lin T-Y, Chang K-V, Wu W-T, Özçakar L. Neural Mobilization for Reducing Pain and Disability in Patients with Lumbar Radiculopathy: A Systematic Review and Meta-Analysis. Life. 2023; 13(12):2255.
  9. Ghasabmahaleh, S. H., Rezasoltani, Z., Dadarkhah, A., Hamidipanah, S., Mofrad, R. K., & Najafi, S. (2021). Spinal manipulation for subacute and chronic lumbar radiculopathy: a randomized controlled Trial. The American Journal of Medicine, 134(1), 135-141.
  10. Trager RJ, Cupler ZA, DeLano KJ, et al Association between chiropractic spinal manipulative therapy and benzodiazepine prescription in patients with radicular low back pain: a retrospective cohort study using real-world data from the USA BMJ Open 2022;12:e058769. doi: 10.1136/bmjopen-2021-058769
  11. Trager RJ, Daniels CJ, Perez JA, et al Association between chiropractic spinal manipulation and lumbar discectomy in adults with lumbar disc herniation and radiculopathy: retrospective cohort study using United States’ data BMJ Open 2022;12:e068262. doi: 10.1136/bmjopen-2022-068262
  12. 12.0 12.1 12.2 12.3 12.4 Khorami, A. K., Oliveira, C. B., Maher, C. G., Bindels, P. J., Machado, G. C., Pinto, R. Z., ... & Chiarotto, A. (2021). Recommendations for diagnosis and treatment of lumbosacral radicular pain: a systematic review of clinical practice guidelines. Journal of clinical medicine, 10(11), 2482.
  13. Kostadinović, S., Milovanović, N., Jovanović, J., & Tomašević-Todorović, S. (2020). Efficacy of the lumbar stabilization and thoracic mobilization exercise program on pain intensity and functional disability reduction in chronic low back pain patients with lumbar radiculopathy: A randomized controlled trial. Journal of Back and Musculoskeletal Rehabilitation, 33(6), 897-907.
  14. Golonka, W., Raschka, C., Harandi, V. M., Domokos, B., Alfredson, H., Alfen, F. M., & Spang, C. (2021). Isolated lumbar extension resistance exercise in limited range of motion for patients with lumbar radiculopathy and disk herniation—Clinical outcome and influencing factors. Journal of Clinical Medicine, 10(11), 2430.
  15. Danazumi, Musa Sani1,2,. Physiotherapy Management of Lumbar Disc Herniation with Radiculopathy: A Narrative Review. Nigerian Journal of Experimental and Clinical Biosciences 7(2):p 93-100, Jul–Dec 2019. | DOI: 10.4103/njecp.njecp_30_19
  16. Albert, H. B., Hauge, E., & Manniche, C. (2012). Centralization in patients with sciatica: are pain responses to repeated movement and positioning associated with outcome or types of disc lesions?. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 21(4), 630–636.
  17. 17.0 17.1 Stochkendahl, M. J., Kjaer, P., Hartvigsen, J., Kongsted, A., Aaboe, J., Andersen, M., Andersen, M. Ø., Fournier, G., Højgaard, B., Jensen, M. B., Jensen, L. D., Karbo, T., Kirkeskov, L., Melbye, M., Morsel-Carlsen, L., Nordsteen, J., Palsson, T. S., Rasti, Z., Silbye, P. F., Steiness, M. Z., … Vaagholt, M. (2018). National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 27(1), 60–75.
  18. Lim, Y. Z., Chou, L., Au, R. T., Seneviwickrama, K. M. D., Cicuttini, F. M., Briggs, A. M., Sullivan, K., Urquhart, D. M., & Wluka, A. E. (2019). People with low back pain want clear, consistent and personalised information on prognosis, treatment options and self-management strategies: a systematic review. Journal of physiotherapy, 65(3), 124–135.
  19. Vanti, C., Saccardo, K., Panizzolo, A., Turone, L., Guccione, A. A., & Pillastrini, P. (2023). The effects of the addition of mechanical traction to physical therapy on low back pain? A systematic review with meta-analysis. Acta orthopaedica et traumatologica turcica, 57(1), 3–16.
  20. Amjad, F., Mohseni-Bandpei, M. A., Gilani, S. A., Ahmad, A., & Hanif, A. (2022). Effects of non-surgical decompression therapy in addition to routine physical therapy on pain, range of motion, endurance, functional disability and quality of life versus routine physical therapy alone in patients with lumbar radiculopathy; a randomized controlled trial. BMC musculoskeletal disorders, 23(1), 255.
  21. Kolu, E., Buyukavci, R., Akturk, S., Eren, F., & Ersoy, Y. (2018). Comparison of high-intensity laser therapy and combination of transcutaneous nerve stimulation and ultrasound treatment in patients with chronic lumbar radiculopathy: A randomized single-blind study. Pakistan journal of medical sciences, 34(3), 530–534.
  22. Sanjana, M., & Yatish, R. (2021). Comparative study on the Mckenzie technique with tens versus neural mobilization with tens in chronic low back pain with radiculopathy. International Journal of Physical Education, Sports and Health, 8(1), 08-13.
  23. Divyasree, S., Kumaresan, A., & Vishnuram, S. (2023). Effect of Mckenzie lumbar extension exercise with TENS on lumbar radiculopathy. Biomedicine, 43(3), 1032-1035.
  24. 24.0 24.1 24.2 Berry, J. A., Elia, C., Saini, H. S., & Miulli, D. E. (2019). A review of lumbar radiculopathy, diagnosis, and treatment. Cureus, 11(10).
  25. van der Gaag, W. H., Roelofs, P. D., Enthoven, W. T., van Tulder, M. W., & Koes, B. W. (2020). Non-steroidal anti-inflammatory drugs for acute low back pain. The Cochrane database of systematic reviews, 4(4), CD013581.
  26. Enke, O., New, H. A., New, C. H., Mathieson, S., McLachlan, A. J., Latimer, J., ... & Lin, C. W. C. (2018). Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis. Cmaj, 190(26), E786-E793.
  27. Stochkendahl, M.J., Kjaer, P., Hartvigsen, J. et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J 27, 60–75 (2018).
  28. Manchikanti, L., Knezevic, E., Latchaw, R. E., Knezevic, N. N., Abdi, S., Sanapati, M. R., Staats, P. S., Gharibo, C. G., Simopoulos, T. T., Shah, S., Abd-Elsayed, A., Navani, A., Kaye, A. D., Albers, S. L., & Hirsch, J. A. (2022). Comparative Systematic Review and Meta-Analysis of Cochrane Review of Epidural Injections for Lumbar Radiculopathy or Sciatica. Pain physician, 25(7), E889–E916.
  29. Jayabalan, P., Bergman, R., Huang, K., Maas, M., & Welty, L. (2023). Relationship Between Socioeconomic Status and the Outcome of Lumbar Epidural Steroid Injections for Lumbar Radiculopathy. American journal of physical medicine & rehabilitation, 102(1), 52–57.
  30. George, S. Z., Fritz, J. M., Silfies, S. P., Schneider, M. J., Beneciuk, J. M., Lentz, T. A., ... & Vining, R. (2021). Interventions for the management of acute and chronic low back pain: revision 2021: clinical practice guidelines linked to the international classification of functioning, disability and health from the academy of orthopaedic physical therapy of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy, 51(11), CPG1-CPG60.
  31. Huysmans, E., Goudman, L., Coppieters, I., Van Bogaert, W., Moens, M., Buyl, R., ... & Ickmans, K. (2023). Effect of perioperative pain neuroscience education in people undergoing surgery for lumbar radiculopathy: a multicentre randomised controlled trial. British Journal of Anaesthesia.