Lumbar Radiculopathy Treatment: Difference between revisions

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== Introduction ==
== Introduction ==
[https://www.physio-pedia.com/Lumbar_Radiculopathy Lumbar radiculopathy] is recognized as a pain that radiates down the leg from the lumbar spine. It's commonly caused by a compression of the nerve root which leads to symtpoms such as altered sensation, decreased reflexes, and weakness along with descriptions of pain as sharp, shocks, numbness and/or tingling, etc. It affects approximately 3-5% of the population, with men often experiencing it in their 40's while women in their 50's and 60's<ref name=":3" />.  
[[Lumbar Radiculopathy|Lumbar radiculopathy]] is commonly caused by compression of a lumbar nerve root, resulting in symptoms which radiate down the legs. Symptoms include altered sensation, decreased reflexes, weakness, and pain, which may be described as sharp, shocks, burning, tingling, etc. Lumbar radiculopathy affects approximately 3-5% of the population. Males are more likely to experience lumbar radiculopathy when they are in their 40s, and females are more likely to experience it in their 50s and 60s.<ref name=":3" />   


There is controversy over the correct treatment for lumbar radiculopathy. Treatments include invasive procedures (surgery and injections), non-invasive procedures (education, manual therapy, exercise) and pharmacological (NSAIDs and oral steroids). Often the proper course of treatment may include a combination of  interventions.  
There are many different treatments utilised in the management of lumbar radiculopathy. It is still not clear which treatments are optimal, and treatment choice will depend on individual factors, including the cause of symptoms (e.g. venous congestion, disc impinging on the neural foramen, bony growth or disc degeneration).<ref name=":6">Rainey N. Lumbar Radiculopathy Treatment Course. Plus, 2024.</ref>


== Assessment ==
Current treatments include invasive procedures (e.g. surgery and injections), non-invasive procedures (e.g. education, manual therapy, exercise) and pharmacological management (e.g. non-steroidal anti-inflammatory drugs (NSAIDs) and oral steroids). Often, a combination of interventions may be required.  
The [https://www.physio-pedia.com/Lumbar_Radiculopathy_Assessment?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal assessment of a lumbar radiculopathy] is to determine if the person is appropriate for treatment. The assessment should include a subjective portion, which includes the history, aggravating/easing factors, and location of symptoms.  


Objective measures are included as well. These can include:
Remember, we can use the Treatment-based Classification System to guide our approach to managing individuals with low back pain with or without lumbar radiculopathy. For more information on this system, please see:  


* Myotome Testing ([https://www.physio-pedia.com/Assessing_Muscle_Strength#Measuring_Muscle_Strength manual muscle testing (MMT]))
* [[Treatment-based Classification System for Low Back Pain]]
* Sensation Testing
* [https://academic.oup.com/ptj/article/96/7/1057/2864925 Treatment-based classification system for low back pain: revision and update]<ref>Alrwaily M, Timko M, Schneider M, Stevans J, Bise C, Hariharan K, Delitto A. [https://academic.oup.com/ptj/article/96/7/1057/2864925 Treatment-based classification system for low back pain: revision and update]. Physical therapy. 2016 Jul 1;96(7):1057-66.</ref>
* Deep Tendon Reflexes
* [[Neurodynamics]]
* Lumbar Range of Motion
* Upper Motor Neuron Testing such as [[Hoffmann's Sign]], and [https://www.physio-pedia.com/Clonus_Reflex Ankle Clonus]


These test should not be performed in isolation but rather in combination to improve the diagnosis. You may also utilize these tests to show improvement or regression over time.  
== Assessment for Lumbar Radiculopathy ==
The assessment for lumbar radiculopathy should include a subjective evaluation, which covers the history, aggravating / easing factors, and location of symptoms, as well as an objective assessment.
 
Objective measures can include:
 
* myotome testing ([https://www.physio-pedia.com/Assessing_Muscle_Strength#Measuring_Muscle_Strength manual muscle testing])
* sensation testing
* deep tendon reflex testing
* [[neurodynamics]]
* lumbar range of motion
* upper motor neuron testing, such as [[Hoffmann's Sign|Hoffmann's sign]] and [[Clonus Reflex|ankle clonus]]
 
These tests should not be performed in isolation but in combination to improve the diagnosis. You may also utilise these tests to show improvement or regression over time.
 
For more information on the objective assessment, please see: [[Lumbar Radiculopathy Assessment]].  


== Red Flags ==
== Red Flags ==
The screening of [https://www.physio-pedia.com/Red_Flags_in_Spinal_Conditions?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal#cite_note-Koes-2 red flags] can be apart of the assessment process. With lumbar radiculopathy, there is a risk of a serious pathology such as [https://www.physio-pedia.com/Cauda_Equina_Syndrome 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<ref>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.
Screening for [[Red Flags in Spinal Conditions|red flags]] should be part of your assessment. With lumbar radiculopathy, there is a risk of serious pathology, such as [[Cauda Equina Syndrome|cauda equina syndrome]], cancer, or fractures. When considering prevalence, there are a few things to keep in mind:<ref>Galliker G, Scherer DE, Trippolini MA, Rasmussen-Barr E, LoMartire R, Wertli MM. Low back pain in the emergency department: prevalence of serious spinal pathologies and diagnostic accuracy of red flags. The American journal of medicine. 2020;133(1):60-72.
</ref>


</ref>.  
* red flags will often be more prevalent in certain areas of medicine (e.g. a spinal surgeon will see more individuals with red flags than a physiotherapist)
* emergency room physicians will see more individuals with serious spinal pathologies than primary care physicians


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<ref>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. <nowiki>https://doi.org/10.2106/JBJS.17.00134</nowiki>
Be aware that a single red flag symptom may not be due to a serious spinal pathology. Additionally, some symptoms will need further investigation, including:<ref>Premkumar A, Godfrey W, Gottschalk MB, Boden SD. 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. 2018;100(5):368-74.
</ref>:
</ref>


* Recent trauma (especially over 50 years of age) raises chance of vertebral fracture
* recent trauma, especially in individuals aged over 50 years: this raises the chance of a vertebral fracture
* History of cancer
* history of cancer
* Recent history of infection
* recent history of infection
* Loss of bladder and/or bowel control
* bladder or bowel dysfunction (including urinary retention, loss of bladder / bowel control)
* Pain that awakens someone from sleep (does, however, have a high false positive rate)
* pain that wakes the patient up from sleep (please note this does have a high false positive rate)


Based upon screening for red flags, there can be a level of concern<ref>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. <nowiki>https://doi.org/10.2519/jospt.2020.9971</nowiki></ref>:
A [[An Introduction to Red Flags in Serious Pathology|framework]] has been developed to help clinicians when screening for red flags.<ref name=":4" /> This framework encourages clinicians to not solely rely on a single red flag but to instead assess the patient's context alongside the red flag(s), taking into account factors such as symptom progression and co-existing conditions. Based on the findings, clinicians consider the level of concern and take appropriate action:<ref name=":4">Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL, et al. International Framework for Red Flags for Potential Serious Spinal Pathologies. The Journal of orthopaedic and sports physical therapy. 2020;50(7):350–72.</ref>


* Begin therapy (Can change the treatment if there is a change in the red flag symptoms)
* 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)
* 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)
* urgent referral (do not begin therapy and either investigate further or refer to a specialist)
* Emergency referral (Do not begin therapy and refer for emergency care)
* emergency referral (do not begin therapy and refer for emergency care)
This framework is described in detail here: [[An Introduction to Red Flags in Serious Pathology]].


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.  
== Key Interventions for Lumbar Radiculopathy ==
The management of lumbar radiculopathy often incorporates multiple interventions. The following sections outline the evidence for specific interventions for lumbar radiculopathy. Most of the evidence presented considers interventions utilised in conjunction with other interventions. All of the following treatments can be used alongside other interventions.  


=== Manual Therapy ===
=== Manual Therapy ===
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.
Manual therapy techniques include a range of hands-on approaches. Common manual therapy techniques for patients experiencing lumbar radiculopathy include mobilisation of the lumbar spine, mobilisation of the nerves, or manipulation. Always check for [[Spinal Manipulation#Contra-indications|contraindications]] and consider your skill level and the patient's level of comfort before selecting manual therapy interventions. Some patients are very irritable, and manual therapy techniques may intensify their pain symptoms.


==== Mobilization of the Lumbar Spine ====
==== Mobilisation of the Lumbar Spine ====
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<ref>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.</ref> <ref name=":0">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.</ref><ref>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. [[/doi.org/10.1515/jom-2020-0261|https://doi.org/10.1515/jom-2020-0261]]</ref><ref>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. <nowiki>https://doi.org/10.1016/j.jcm.2019.10.006</nowiki></ref>. 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.  
Spinal mobilisations are passive movements of a spinal segment that follow a grading scale (I-IV). The goal of mobilisations can be to decrease pain symptoms and improve spinal mobility. There is evidence to suggest that spinal mobilisation can be beneficial for lumbar radiculopathy. Several studies have found that spinal mobilisations combined with leg movement can help decrease pain.<ref>Kuligowski T, Skrzek A, Cieślik B. Manual therapy in cervical and lumbar radiculopathy: a systematic review of the literature. International journal of environmental research and public health. 2021;18(11):6176.</ref> <ref name=":0">Ashraf B, Ahmad S, Ashraf K, Kanwal, S, Ashraf, S, Khan N, et al. Effectiveness of spinal mobilization with leg movement versus McKenzie back extension exercises in lumbar radiculopathy. Pakistan J. Med. Heal. Sci. 2021;15(5):1436-40.</ref><ref>Danazumi M, Bello B, Yakasai A, Kaka B. Two manual therapy techniques for management of lumbar radiculopathy: a randomized clinical trial. Journal of Osteopathic Medicine. 2021;121(4):391-400. </ref><ref>Bello B, Danazumi MS, Kaka B. Comparative Effectiveness of 2 Manual Therapy Techniques in the Management of Lumbar Radiculopathy: A Randomized Clinical Trial. Journal of chiropractic medicine. 2019;18(4):253–60.</ref> In these studies, mobilisations were used alongside other treatments, including exercise and modalities. <blockquote>Therefore, mobilisations can ''make up part of the treatment'' for lumbar radiculopathy. </blockquote>


==== Mobilization of the Nerve ====
==== Mobilisation of the Nerve ====
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 [https://www.physio-pedia.com/Straight_Leg_Raise_Test?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal straight leg raise test], [https://www.physio-pedia.com/Slump_Test?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal slump test], or [https://www.physio-pedia.com/Femoral_Nerve_Tension_Test?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal femoral nerve test]. There is evidence that it can be useful in decreasing pain and improving function<ref>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. <nowiki>https://doi.org/10.3390/life13122255</nowiki></ref>. 
Mobilisation of the sciatic or femoral nerves involves tensioning or gliding the nerve. The technique is similar to the testing procedures of the [https://www.physio-pedia.com/Straight_Leg_Raise_Test?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal straight leg raise test], [https://www.physio-pedia.com/Slump_Test?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal slump test], or [https://www.physio-pedia.com/Femoral_Nerve_Tension_Test?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal femoral nerve test]. There is evidence that mobilising the nerve can help to decrease pain and improve function.<ref>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.</ref><blockquote>These techniques can be beneficial for patients experiencing acute symptoms as they can help decrease sensitivity. They can also be utilised with individuals with a possible entrapment. </blockquote>


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.  
The following videos demonstrate mobilisation techniques for the sciatic nerve and the femoral nerve.
 
<div class="row">
  <div class="col-md-4"> {{#ev:youtube|cZ-kEwWTmus|250}} <div class="text-right"><ref>Northern Lincolnshire and Goole NHS Foundation Trust. MSK Sciatic Nerve Glides. Available from: https://www.youtube.com/watch?v=cZ-kEwWTmus [last accessed 19/2/2024]</ref></div></div>
  <div class="col-md-4"> {{#ev:youtube|wDPjjPkJyEk|250}} <div class="text-right"><ref>INSYNC PHYSIO Vancouver. Anterior Hip Pain: Femoral Nerve Glides Sidelye. Available from: https://www.youtube.com/watch?v=wDPjjPkJyEk [last accessed 19/2/2024]</ref></div></div>
<div class="col-md-4"> {{#ev:youtube|Wo1JgMRGSlI|250}} <div class="text-right"><ref>Rehab My Patient. Femoral nerve glide floss 4. Available from: https://www.youtube.com/watch?v=Wo1JgMRGSlI [last accessed 4/2/2024]</ref></div></div>
</div>


==== Manipulation of the Lumbar spine ====
==== Manipulation of the Lumbar spine ====
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<ref>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.</ref>. Additionally, there is evidence to show that the use of manipulations can decrease the prescription of benzodiazepines<ref>Trager RJ, Cupler ZA, DeLano KJ'', et al''
High velocity, low amplitude (HVLA) thrust manipulations or manipulation techniques are quick, passive movements applied to a specific level of the spine or as a general technique. There is evidence demonstrating that manipulations can be beneficial for individuals with lumbar radiculopathy.<ref>Ghasabmahaleh SH, Rezasoltani Z, Dadarkhah A, Hamidipanah S, Mofrad RK, Najafi S. Spinal manipulation for subacute and chronic lumbar radiculopathy: a randomized controlled Trial. The American Journal of Medicine. 2021;134(1):135-41.</ref> Additionally, there is evidence suggesting that incorporating manipulation techniques into the care plan for lumbar radiculopathy can decrease the use of benzodiazepines<ref>Trager RJ, Cupler ZA, DeLano KJ, Perez JA, Dusek JA. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9196200/ 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 Jun 13;12(6):e058769. </ref> and the chance of discectomy.<ref>Trager RJ, Daniels CJ, Perez JA, Casselberry RM, Dusek JA. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9764600/ 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 Dec 16;12(12):e068262. </ref> <blockquote>The literature concludes that manipulation ''should be used as an adjunct'' to other treatments, including exercise. </blockquote>


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
=== Exercise ===
There is evidence to support the use of exercise in the treatment of lumbar radiculopathy.<ref name=":1" /> However, the literature does not always specify what "exercise" entails. The two most commonly researched areas of exercise with lumbar radiculopathy are stabilisation exercises and extension-based exercises.


''BMJ Open'' 2022;'''12:'''e058769. doi: 10.1136/bmjopen-2021-058769</ref> and chance of discectomy<ref>Trager RJ, Daniels CJ, Perez JA'', et al''
'''Stabilisation exercises''' aim to improve the motor control of the spine stabilisers. It has been suggested that if there is a disruption in the motor control in the spine, stabilisation activities can help restore motor control and decrease pain. Again, most research considers stabilisation exercises alongside other interventions, such as spinal manipulation and extension movements, such as cat-camel or a seated lumbar extension.<ref>Kostadinović S, Milovanović N, Jovanović J, Tomašević-Todorović S. 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. 2020;33(6):897-907.</ref><ref>Golonka W, Raschka C, Harandi VM, Domokos B, Alfredson H, Alfen FM, Spang C. 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.
</ref><ref>Danazumi MS. [https://journals.lww.com/necp/Fulltext/2019/07020/Physiotherapy_Management_of_Lumbar_Disc_Herniation.5.aspx Physiotherapy management of lumbar disc herniation with radiculopathy: a narrative review]. Nigerian Journal of Experimental and Clinical Biosciences. Jul-Dec 2019;7(2):93-100. </ref>


Association between chiropractic spinal manipulation and lumbar discectomy in adults with lumbar disc herniation and radiculopathy: retrospective cohort study using United States’ data
'''Repeated movements''' are a hallmark of the [[McKenzie Method]] or MDT (Mechanical Diagnosis and Therapy). When utilising repeated movements, the goal is to determine a [https://www.physio-pedia.com/Directional_Preference?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal directional preference], which is indicated by the [[centralization|centralisation]] of symptoms. It has been found that patients who can centralise their symptoms may have better outcomes.<ref>Albert HB, Hauge E, Manniche C. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3326129/ Centralization in patients with sciatica: are pain responses to repeated movement and positioning associated with outcome or types of disc lesions?] Eur Spine J. 2012 Apr;21(4):630-6.
</ref> 


''BMJ Open'' 2022;'''12:'''e068262. doi: 10.1136/bmjopen-2022-068262</ref> . The evidence does conclude that the use of manipulation should be used in adjunct with other treatments including exercise.  
The following videos demonstrate how repeated extensions can be performed in prone and standing.  


=== Exercise ===
<div class="row">
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<ref name=":1" />. 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.
  <div class="col-md-6"> {{#ev:youtube|kESRfUlaLP8|250}} <div class="text-right"><ref>joel laing. McKenzie Method: Extension in lying for relief of back pain and sciatica. Available from: https://www.youtube.com/watch?v=kESRfUlaLP8 [last accessed 4/2/2024]</ref></div></div>
  <div class="col-md-6"> {{#ev:youtube|zN8mpqLqB8o|250}} <div class="text-right"><ref>joel laing. McKenzie Method: Extension in Standing. Available from: https://www.youtube.com/watch?v=zN8mpqLqB8o [last accessed 4/3/2024]</ref></div></div>
</div>
 
Please note that while there is often a focus on extension-based movements, repeated movements may involve movements in the sagittal plane (flexion / extension), frontal plane (lateral), or a combination of movements, depending on the patient's directional preference.
 
'''General physical activity / cardiovascular exercise''' should also be considered. Thoomes et al.<ref>Thoomes E, Falla D, Cleland JA, Fernández-de-Las-Peñas C, Gallina A, de Graaf M. [https://www.tandfonline.com/doi/full/10.1080/09638288.2022.2130448 Conservative management for lumbar radiculopathy based on the stage of the disorder: a Delphi study]. Disabil Rehabil. 2023 Oct;45(21):3539-3548. </ref> note that individualised physical activity is beneficial in the acute phase of conservative management for lumbar radiculopathy. In the chronic phase, other types of exercise were recommended, including general aerobic exercise, general strength training, focused / targeted strength training, individualised physical activity, supervised exercise, etc. Options to consider include walking, biking, swimming, ski ergometer, etc.<ref name=":6" />


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<ref>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.</ref><ref>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.
=== Education ===
Education is a staple of treatment for many conditions, including lumbar radiculopathy.<ref name=":1">Khorami AK, Oliveira CB, Maher CG, Bindels PJ, Machado GC, Pinto RZ, et al. Recommendations for diagnosis and treatment of lumbosacral radicular pain: a systematic review of clinical practice guidelines. Journal of Clinical Medicine. 2021;10(11):2482.</ref> Patient education is recommended in clinical guidelines for treating back pain and lumbar radiculopathy.<ref name=":2">Stochkendahl MJ, Kjaer P, Hartvigsen J, Kongsted A, Aaboe J, Andersen M, et al. 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. 2018;27(1):60-75.</ref> It is important to note that "education" is a broad term; it could refer to many different things, including maintaining a healthy lifestyle (e.g. healthy diet and getting enough sleep), lifting mechanics, posture, and overall activity.


</ref><ref>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 </ref>.
When planning patient education, we must consider what information our patients want. A systematic review by Lim et al.<ref name=":5">Lim YZ, Chou L, Au RT, Seneviwickrama KMD, Cicuttini FM, Briggs AM, et al. 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. 2019;65(3):124-35.</ref> found that patients with low back pain, including lumbar radiculopathy, want to understand the following:<ref name=":5" />  


=== Repeated Movements ===
* their diagnosis and the cause of their symptoms (however, this may contribute "to expectations for and overuse of imaging"<ref name=":5" />)
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 [https://www.physio-pedia.com/Directional_Preference?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal 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 <ref>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. <nowiki>https://doi.org/10.1007/s00586-011-2018-9</nowiki>
* a personalised management strategy, including pharmacological and non-pharmacological management strategies
</ref>.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<ref name=":0" />, 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. 
* consistent information on the nature of low back pain, along with management strategies


=== Education ===
Moreover, they want this information to be presented so it is easily understood and is appropriate for their age, lifestyle, and occupational status.<ref name=":5" />
Education is a staple of helping people with not only lumbar radiculopathy, but also with rehabilitation any disorder or condition<ref name=":1">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.</ref>. Education has been included in clinical guidelines about treating back pain and lumbar radiculopathy<ref name=":2">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. <nowiki>https://doi.org/10.1007/s00586-017-5099-2</nowiki></ref>. 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<ref>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. <nowiki>https://doi.org/10.1016/j.jphys.2019.05.010</nowiki></ref>. 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 ===
=== Modalities ===
Modalities are commonly utilized interventions with rehabilitation of many conditions. For lumbar radiculopathy, the use of mechanical [https://www.physio-pedia.com/Lumbar_Traction?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal traction] and electrical stimulation, such as [https://www.physio-pedia.com/Transcutaneous_Electrical_Nerve_Stimulation_(TENS)?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal 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<ref>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. <nowiki>https://doi.org/10.5152/j.aott.2023.21323</nowiki></ref><ref>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. <nowiki>https://doi.org/10.1186/s12891-022-05196-x</nowiki></ref>. Often with research, traction or electrical stimulation is considered "physical therapy" instead of exercise or manual therapy approaches<ref>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. <nowiki>https://doi.org/10.12669/pjms.343.14345</nowiki></ref>. The use of modalities does seem to show some benefit when used in conjunction with additional interventions<ref>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.</ref><ref>Divyasree, S., Kumaresan, A., & Vishnuram, S. (2023). Effect of Mckenzie lumbar extension exercise with TENS on lumbar radiculopathy. ''Biomedicine'', ''43''(3), 1032-1035.
Different modalities are commonly utilised in rehabilitation settings. Two of the most common modalities for lumbar radiculopathy are mechanical [https://www.physio-pedia.com/Lumbar_Traction?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal traction] and electrical stimulation (e.g. [[Transcutaneous Electrical Nerve Stimulation (TENS)|transcutaneous electrical nerve stimulation (TENS)]]).


</ref>.  
Current evidence suggests that modalities are not as effective as manual therapy or exercise, but there is evidence they may have some benefit when used in conjunction with other interventions.<ref>Sanjana M, Yatish R. 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. 2021;8(1):08-13.</ref><ref>Divyasree S, Kumaresan A, Vishnuram S. Effect of Mckenzie lumbar extension exercise with TENS on lumbar radiculopathy. Biomedicine. 2023;43(3):1032-5.
</ref> There is also some evidence that traction can help reduce pain in individuals with lumbar radiculopathy in the short term.<ref>Vanti C, Saccardo K, Panizzolo A, Turone L, Guccione AA, Pillastrini P. 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. 2023;57(1):3-16.</ref>


=== Medication ===
=== Medication ===
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<ref name=":1" />. The most often prescribed medication is an non-steroidal anti-inflammatory drug (NSAID)<ref name=":3">Berry, J. A., Elia, C., Saini, H. S., & Miulli, D. E. (2019). A review of lumbar radiculopathy, diagnosis, and treatment. ''Cureus'', ''11''(10).</ref>. There is some evidence that it could help in the short term<ref>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. <nowiki>https://doi.org/10.1002/14651858.CD013581</nowiki></ref>, 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<ref>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.</ref>. Overall not been recommended in treatment guidelines that medications are effective<ref>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). <nowiki>https://doi.org/10.1007/s00586-017-5099-2</nowiki></ref>.
There is mixed evidence for the use of medication in the treatment of lumbar radiculopathy.<ref name=":1" /> The most often prescribed medications are non-steroidal anti-inflammatory drugs (NSAID).<ref name=":3">Berry JA, Elia C, Saini HS, Miulli DE. A review of lumbar radiculopathy, diagnosis, and treatment. Cureus. 2019;11(10).</ref> There is some evidence that NSAIDs could help in the short term,<ref>Van der Gaag WH, Roelofs PD, Enthoven WT, van Tulder MW, Koes BW. Non-steroidal anti-inflammatory drugs for acute low back pain. The Cochrane database of systematic reviews. 2020;4(4):CD013581.</ref> but have a limited benefit in the long term. Recent guidelines recommend against the use of NSAIDs and other opioids in the treatment of lumbar radiculopathy.<ref>Stochkendahl MJ, Kjaer P, Hartvigsen J, Kongsted A, Aaboe J, Andersen M, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2018 Jan;27(1):60-75. </ref> Anticonvulsants (such as gabapentin or pregabalin) are also sometimes prescribed for radicular symptoms, but there is evidence that these are largely ineffective for the treatment of lumbar radiculopathy.<ref>Enke O, New HA, New CH, Mathieson S, McLachlan AJ, Latimer J, et al. Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis. Cmaj. 2018;190(26):E786-E793.</ref>


=== Epidural Injection ===
=== Epidural Injection ===
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<ref name=":3" />. There is mixed evidence for the utilization of epidural injections<ref name=":1" /> <ref name=":2" />. 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<ref>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.</ref>. 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<ref>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. <nowiki>https://doi.org/10.1097/PHM.0000000000002021</nowiki></ref>.
An epidural injection may be suggested for individuals with lumbar radiculopathy who do not improve with conservative management.<ref name=":3" /> However, there is mixed evidence for their use,<ref name=":1" /> <ref name=":2" /><ref>Manchikanti L, Knezevic E, Latchaw RE, Knezevic NN, Abdi S, Sanapati MR, et al. Comparative Systematic Review and Meta-Analysis of Cochrane Review of Epidural Injections for Lumbar Radiculopathy or Sciatica. Pain physician. 2022;25(7):E889–E916.</ref> and other factors, such as socioeconomic status, may influence outcomes. For instance, Jayabalan et al. found that "Lower socioeconomic status was independently associated with higher pain alleviation after controlling for other potentially influential demographics."<ref>Jayabalan P, Bergman R, Huang K, Maas M, Welty L. Relationship Between Socioeconomic Status and the Outcome of Lumbar Epidural Steroid Injections for Lumbar Radiculopathy. American journal of physical medicine & rehabilitation. 2023;102(1):52-57.</ref>  


=== Surgery ===
=== Surgery ===
Surgery can be considered the final option for patients who do not do well with conservative treatment<ref name=":1" />. The outcomes on surgical and non-surgical are similar over a 2 year time period with surgical outcomes being slightly, but not significantly, better<ref name=":3" />.  Surgery should be withheld for only those patients with the most severe symptoms or that are showing red flag symptoms.  
Individuals with red flags or progressive neurologic loss will need to be reviewed by the relevant specialist (e.g. neurosurgeon / neurologist). Surgery may also be considered as an option for patients who do not improve with conservative treatment.<ref name=":1" /> The outcomes associated with surgical and non-surgical interventions are ''similar'' over a two-year period; surgical outcomes are slightly, but not significantly, better.<ref name=":3" />   
 
Rehab after a lumbar surgery is also recommended which should include education<ref>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.</ref>. 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<ref>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''.</ref>. 
 


Rehabilitation and patient education are recommended for individuals who have had lumbar surgery.<ref>George SZ, Fritz JM, Silfies SP, Schneider MJ, Beneciuk JM, Lentz TA. et al. 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. 2021;51(11):CPG1-CPG60.</ref> It is also beneficial to provide education prior to surgery. Pre-operative education has been found to help decrease fear of movement and improve function after surgery.<ref>Huysmans E, Goudman L, Coppieters I, Van Bogaert W, Moens M, Buyl R, et al. Effect of perioperative pain neuroscience education in people undergoing surgery for lumbar radiculopathy: a multicentre randomised controlled trial. British Journal of Anaesthesia. 2023.</ref> 
== References  ==
== References  ==


Latest revision as of 01:19, 3 April 2024

Original Editor - Matt Huey

Top Contributors - Matt Huey and Jess Bell  

Introduction[edit | edit source]

Lumbar radiculopathy is commonly caused by compression of a lumbar nerve root, resulting in symptoms which radiate down the legs. Symptoms include altered sensation, decreased reflexes, weakness, and pain, which may be described as sharp, shocks, burning, tingling, etc. Lumbar radiculopathy affects approximately 3-5% of the population. Males are more likely to experience lumbar radiculopathy when they are in their 40s, and females are more likely to experience it in their 50s and 60s.[1]

There are many different treatments utilised in the management of lumbar radiculopathy. It is still not clear which treatments are optimal, and treatment choice will depend on individual factors, including the cause of symptoms (e.g. venous congestion, disc impinging on the neural foramen, bony growth or disc degeneration).[2]

Current treatments include invasive procedures (e.g. surgery and injections), non-invasive procedures (e.g. education, manual therapy, exercise) and pharmacological management (e.g. non-steroidal anti-inflammatory drugs (NSAIDs) and oral steroids). Often, a combination of interventions may be required.

Remember, we can use the Treatment-based Classification System to guide our approach to managing individuals with low back pain with or without lumbar radiculopathy. For more information on this system, please see:

Assessment for Lumbar Radiculopathy[edit | edit source]

The assessment for lumbar radiculopathy should include a subjective evaluation, which covers the history, aggravating / easing factors, and location of symptoms, as well as an objective assessment.

Objective measures can include:

These tests should not be performed in isolation but in combination to improve the diagnosis. You may also utilise these tests to show improvement or regression over time.

For more information on the objective assessment, please see: Lumbar Radiculopathy Assessment.

Red Flags[edit | edit source]

Screening for red flags should be part of your assessment. With lumbar radiculopathy, there is a risk of serious pathology, such as cauda equina syndrome, cancer, or fractures. When considering prevalence, there are a few things to keep in mind:[4]

  • red flags will often be more prevalent in certain areas of medicine (e.g. a spinal surgeon will see more individuals with red flags than a physiotherapist)
  • emergency room physicians will see more individuals with serious spinal pathologies than primary care physicians

Be aware that a single red flag symptom may not be due to a serious spinal pathology. Additionally, some symptoms will need further investigation, including:[5]

  • recent trauma, especially in individuals aged over 50 years: this raises the chance of a vertebral fracture
  • history of cancer
  • recent history of infection
  • bladder or bowel dysfunction (including urinary retention, loss of bladder / bowel control)
  • pain that wakes the patient up from sleep (please note this does have a high false positive rate)

A framework has been developed to help clinicians when screening for red flags.[6] This framework encourages clinicians to not solely rely on a single red flag but to instead assess the patient's context alongside the red flag(s), taking into account factors such as symptom progression and co-existing conditions. Based on the findings, clinicians consider the level of concern and take appropriate action:[6]

  • 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 a specialist)
  • emergency referral (do not begin therapy and refer for emergency care)

This framework is described in detail here: An Introduction to Red Flags in Serious Pathology.

Key Interventions for Lumbar Radiculopathy[edit | edit source]

The management of lumbar radiculopathy often incorporates multiple interventions. The following sections outline the evidence for specific interventions for lumbar radiculopathy. Most of the evidence presented considers interventions utilised in conjunction with other interventions. All of the following treatments can be used alongside other interventions.

Manual Therapy[edit | edit source]

Manual therapy techniques include a range of hands-on approaches. Common manual therapy techniques for patients experiencing lumbar radiculopathy include mobilisation of the lumbar spine, mobilisation of the nerves, or manipulation. Always check for contraindications and consider your skill level and the patient's level of comfort before selecting manual therapy interventions. Some patients are very irritable, and manual therapy techniques may intensify their pain symptoms.

Mobilisation of the Lumbar Spine[edit | edit source]

Spinal mobilisations are passive movements of a spinal segment that follow a grading scale (I-IV). The goal of mobilisations can be to decrease pain symptoms and improve spinal mobility. There is evidence to suggest that spinal mobilisation can be beneficial for lumbar radiculopathy. Several studies have found that spinal mobilisations combined with leg movement can help decrease pain.[7] [8][9][10] In these studies, mobilisations were used alongside other treatments, including exercise and modalities.

Therefore, mobilisations can make up part of the treatment for lumbar radiculopathy.

Mobilisation of the Nerve[edit | edit source]

Mobilisation of the sciatic or femoral nerves involves tensioning or gliding the nerve. The technique is similar to the testing procedures of the straight leg raise test, slump test, or femoral nerve test. There is evidence that mobilising the nerve can help to decrease pain and improve function.[11]

These techniques can be beneficial for patients experiencing acute symptoms as they can help decrease sensitivity. They can also be utilised with individuals with a possible entrapment.

The following videos demonstrate mobilisation techniques for the sciatic nerve and the femoral nerve.

[12]
[13]
[14]

Manipulation of the Lumbar spine[edit | edit source]

High velocity, low amplitude (HVLA) thrust manipulations or manipulation techniques are quick, passive movements applied to a specific level of the spine or as a general technique. There is evidence demonstrating that manipulations can be beneficial for individuals with lumbar radiculopathy.[15] Additionally, there is evidence suggesting that incorporating manipulation techniques into the care plan for lumbar radiculopathy can decrease the use of benzodiazepines[16] and the chance of discectomy.[17]

The literature concludes that manipulation should be used as an adjunct to other treatments, including exercise.

Exercise[edit | edit source]

There is evidence to support the use of exercise in the treatment of lumbar radiculopathy.[18] However, the literature does not always specify what "exercise" entails. The two most commonly researched areas of exercise with lumbar radiculopathy are stabilisation exercises and extension-based exercises.

Stabilisation exercises aim to improve the motor control of the spine stabilisers. It has been suggested that if there is a disruption in the motor control in the spine, stabilisation activities can help restore motor control and decrease pain. Again, most research considers stabilisation exercises alongside other interventions, such as spinal manipulation and extension movements, such as cat-camel or a seated lumbar extension.[19][20][21]

Repeated movements are a hallmark of the McKenzie Method or MDT (Mechanical Diagnosis and Therapy). When utilising repeated movements, the goal is to determine a directional preference, which is indicated by the centralisation of symptoms. It has been found that patients who can centralise their symptoms may have better outcomes.[22]

The following videos demonstrate how repeated extensions can be performed in prone and standing.

[23]
[24]

Please note that while there is often a focus on extension-based movements, repeated movements may involve movements in the sagittal plane (flexion / extension), frontal plane (lateral), or a combination of movements, depending on the patient's directional preference.

General physical activity / cardiovascular exercise should also be considered. Thoomes et al.[25] note that individualised physical activity is beneficial in the acute phase of conservative management for lumbar radiculopathy. In the chronic phase, other types of exercise were recommended, including general aerobic exercise, general strength training, focused / targeted strength training, individualised physical activity, supervised exercise, etc. Options to consider include walking, biking, swimming, ski ergometer, etc.[2]

Education[edit | edit source]

Education is a staple of treatment for many conditions, including lumbar radiculopathy.[18] Patient education is recommended in clinical guidelines for treating back pain and lumbar radiculopathy.[26] It is important to note that "education" is a broad term; it could refer to many different things, including maintaining a healthy lifestyle (e.g. healthy diet and getting enough sleep), lifting mechanics, posture, and overall activity.

When planning patient education, we must consider what information our patients want. A systematic review by Lim et al.[27] found that patients with low back pain, including lumbar radiculopathy, want to understand the following:[27]

  • their diagnosis and the cause of their symptoms (however, this may contribute "to expectations for and overuse of imaging"[27])
  • a personalised management strategy, including pharmacological and non-pharmacological management strategies
  • consistent information on the nature of low back pain, along with management strategies

Moreover, they want this information to be presented so it is easily understood and is appropriate for their age, lifestyle, and occupational status.[27]

Modalities[edit | edit source]

Different modalities are commonly utilised in rehabilitation settings. Two of the most common modalities for lumbar radiculopathy are mechanical traction and electrical stimulation (e.g. transcutaneous electrical nerve stimulation (TENS)).

Current evidence suggests that modalities are not as effective as manual therapy or exercise, but there is evidence they may have some benefit when used in conjunction with other interventions.[28][29] There is also some evidence that traction can help reduce pain in individuals with lumbar radiculopathy in the short term.[30]

Medication[edit | edit source]

There is mixed evidence for the use of medication in the treatment of lumbar radiculopathy.[18] The most often prescribed medications are non-steroidal anti-inflammatory drugs (NSAID).[1] There is some evidence that NSAIDs could help in the short term,[31] but have a limited benefit in the long term. Recent guidelines recommend against the use of NSAIDs and other opioids in the treatment of lumbar radiculopathy.[32] Anticonvulsants (such as gabapentin or pregabalin) are also sometimes prescribed for radicular symptoms, but there is evidence that these are largely ineffective for the treatment of lumbar radiculopathy.[33]

Epidural Injection[edit | edit source]

An epidural injection may be suggested for individuals with lumbar radiculopathy who do not improve with conservative management.[1] However, there is mixed evidence for their use,[18] [26][34] and other factors, such as socioeconomic status, may influence outcomes. For instance, Jayabalan et al. found that "Lower socioeconomic status was independently associated with higher pain alleviation after controlling for other potentially influential demographics."[35]

Surgery[edit | edit source]

Individuals with red flags or progressive neurologic loss will need to be reviewed by the relevant specialist (e.g. neurosurgeon / neurologist). Surgery may also be considered as an option for patients who do not improve with conservative treatment.[18] The outcomes associated with surgical and non-surgical interventions are similar over a two-year period; surgical outcomes are slightly, but not significantly, better.[1]

Rehabilitation and patient education are recommended for individuals who have had lumbar surgery.[36] It is also beneficial to provide education prior to surgery. Pre-operative education has been found to help decrease fear of movement and improve function after surgery.[37]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 Berry JA, Elia C, Saini HS, Miulli DE. A review of lumbar radiculopathy, diagnosis, and treatment. Cureus. 2019;11(10).
  2. ↑ 2.0 2.1 Rainey N. Lumbar Radiculopathy Treatment Course. Plus, 2024.
  3. ↑ Alrwaily M, Timko M, Schneider M, Stevans J, Bise C, Hariharan K, Delitto A. Treatment-based classification system for low back pain: revision and update. Physical therapy. 2016 Jul 1;96(7):1057-66.
  4. ↑ Galliker G, Scherer DE, Trippolini MA, Rasmussen-Barr E, LoMartire R, Wertli MM. Low back pain in the emergency department: prevalence of serious spinal pathologies and diagnostic accuracy of red flags. The American journal of medicine. 2020;133(1):60-72.
  5. ↑ Premkumar A, Godfrey W, Gottschalk MB, Boden SD. 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. 2018;100(5):368-74.
  6. ↑ 6.0 6.1 Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL, et al. International Framework for Red Flags for Potential Serious Spinal Pathologies. The Journal of orthopaedic and sports physical therapy. 2020;50(7):350–72.
  7. ↑ Kuligowski T, Skrzek A, Cieślik B. Manual therapy in cervical and lumbar radiculopathy: a systematic review of the literature. International journal of environmental research and public health. 2021;18(11):6176.
  8. ↑ Ashraf B, Ahmad S, Ashraf K, Kanwal, S, Ashraf, S, Khan N, et al. Effectiveness of spinal mobilization with leg movement versus McKenzie back extension exercises in lumbar radiculopathy. Pakistan J. Med. Heal. Sci. 2021;15(5):1436-40.
  9. ↑ Danazumi M, Bello B, Yakasai A, Kaka B. Two manual therapy techniques for management of lumbar radiculopathy: a randomized clinical trial. Journal of Osteopathic Medicine. 2021;121(4):391-400.
  10. ↑ Bello B, Danazumi MS, Kaka B. Comparative Effectiveness of 2 Manual Therapy Techniques in the Management of Lumbar Radiculopathy: A Randomized Clinical Trial. Journal of chiropractic medicine. 2019;18(4):253–60.
  11. ↑ 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.
  12. ↑ Northern Lincolnshire and Goole NHS Foundation Trust. MSK Sciatic Nerve Glides. Available from: https://www.youtube.com/watch?v=cZ-kEwWTmus [last accessed 19/2/2024]
  13. ↑ INSYNC PHYSIO Vancouver. Anterior Hip Pain: Femoral Nerve Glides Sidelye. Available from: https://www.youtube.com/watch?v=wDPjjPkJyEk [last accessed 19/2/2024]
  14. ↑ Rehab My Patient. Femoral nerve glide floss 4. Available from: https://www.youtube.com/watch?v=Wo1JgMRGSlI [last accessed 4/2/2024]
  15. ↑ Ghasabmahaleh SH, Rezasoltani Z, Dadarkhah A, Hamidipanah S, Mofrad RK, Najafi S. Spinal manipulation for subacute and chronic lumbar radiculopathy: a randomized controlled Trial. The American Journal of Medicine. 2021;134(1):135-41.
  16. ↑ Trager RJ, Cupler ZA, DeLano KJ, Perez JA, Dusek JA. 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 Jun 13;12(6):e058769.
  17. ↑ Trager RJ, Daniels CJ, Perez JA, Casselberry RM, Dusek JA. 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 Dec 16;12(12):e068262.
  18. ↑ 18.0 18.1 18.2 18.3 18.4 Khorami AK, Oliveira CB, Maher CG, Bindels PJ, Machado GC, Pinto RZ, et al. Recommendations for diagnosis and treatment of lumbosacral radicular pain: a systematic review of clinical practice guidelines. Journal of Clinical Medicine. 2021;10(11):2482.
  19. ↑ Kostadinović S, Milovanović N, Jovanović J, Tomašević-Todorović S. 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. 2020;33(6):897-907.
  20. ↑ Golonka W, Raschka C, Harandi VM, Domokos B, Alfredson H, Alfen FM, Spang C. 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.
  21. ↑ Danazumi MS. Physiotherapy management of lumbar disc herniation with radiculopathy: a narrative review. Nigerian Journal of Experimental and Clinical Biosciences. Jul-Dec 2019;7(2):93-100.
  22. ↑ Albert HB, Hauge E, Manniche C. Centralization in patients with sciatica: are pain responses to repeated movement and positioning associated with outcome or types of disc lesions? Eur Spine J. 2012 Apr;21(4):630-6.
  23. ↑ joel laing. McKenzie Method: Extension in lying for relief of back pain and sciatica. Available from: https://www.youtube.com/watch?v=kESRfUlaLP8 [last accessed 4/2/2024]
  24. ↑ joel laing. McKenzie Method: Extension in Standing. Available from: https://www.youtube.com/watch?v=zN8mpqLqB8o [last accessed 4/3/2024]
  25. ↑ Thoomes E, Falla D, Cleland JA, Fernández-de-Las-Peñas C, Gallina A, de Graaf M. Conservative management for lumbar radiculopathy based on the stage of the disorder: a Delphi study. Disabil Rehabil. 2023 Oct;45(21):3539-3548.
  26. ↑ 26.0 26.1 Stochkendahl MJ, Kjaer P, Hartvigsen J, Kongsted A, Aaboe J, Andersen M, et al. 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. 2018;27(1):60-75.
  27. ↑ 27.0 27.1 27.2 27.3 Lim YZ, Chou L, Au RT, Seneviwickrama KMD, Cicuttini FM, Briggs AM, et al. 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. 2019;65(3):124-35.
  28. ↑ Sanjana M, Yatish R. 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. 2021;8(1):08-13.
  29. ↑ Divyasree S, Kumaresan A, Vishnuram S. Effect of Mckenzie lumbar extension exercise with TENS on lumbar radiculopathy. Biomedicine. 2023;43(3):1032-5.
  30. ↑ Vanti C, Saccardo K, Panizzolo A, Turone L, Guccione AA, Pillastrini P. 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. 2023;57(1):3-16.
  31. ↑ Van der Gaag WH, Roelofs PD, Enthoven WT, van Tulder MW, Koes BW. Non-steroidal anti-inflammatory drugs for acute low back pain. The Cochrane database of systematic reviews. 2020;4(4):CD013581.
  32. ↑ Stochkendahl MJ, Kjaer P, Hartvigsen J, Kongsted A, Aaboe J, Andersen M, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2018 Jan;27(1):60-75.
  33. ↑ Enke O, New HA, New CH, Mathieson S, McLachlan AJ, Latimer J, et al. Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis. Cmaj. 2018;190(26):E786-E793.
  34. ↑ Manchikanti L, Knezevic E, Latchaw RE, Knezevic NN, Abdi S, Sanapati MR, et al. Comparative Systematic Review and Meta-Analysis of Cochrane Review of Epidural Injections for Lumbar Radiculopathy or Sciatica. Pain physician. 2022;25(7):E889–E916.
  35. ↑ Jayabalan P, Bergman R, Huang K, Maas M, Welty L. Relationship Between Socioeconomic Status and the Outcome of Lumbar Epidural Steroid Injections for Lumbar Radiculopathy. American journal of physical medicine & rehabilitation. 2023;102(1):52-57.
  36. ↑ George SZ, Fritz JM, Silfies SP, Schneider MJ, Beneciuk JM, Lentz TA. et al. 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. 2021;51(11):CPG1-CPG60.
  37. ↑ Huysmans E, Goudman L, Coppieters I, Van Bogaert W, Moens M, Buyl R, et al. Effect of perioperative pain neuroscience education in people undergoing surgery for lumbar radiculopathy: a multicentre randomised controlled trial. British Journal of Anaesthesia. 2023.
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