CPS II By James Luker

Presentation Objectives Introduce my patient Present my clinical question centered around my patient’s needs Examine the base of literature regarding my clinical question Retrospectively determine if my patient’s treatment was appropriate Provide evidence-based insight for treatment of future patients

Patient Demographics 47 years old Caucasian female Lives with husband Physically active (exercise classes 5x/week) Sedentary job Drives to/from clinic and work

Patient History Performed an extensive exercise routine including lumbar extension exercises 3-4 weeks prior to admission, all symptoms began the day after this Shooting pain from L buttocks to L knee, occasionally L foot 9/10 High 2/10 Low Constant Transient Coccyx pain Numbness and tingling associated with her pain Aggravating factors include prolonged sitting and biking Relief from pain when supine or R sidelying No history of back pain of this nature

PT Exam Findings ODI: 20% Lordotic posture Lumbar ROM Flexion - 60% w/buttock pain Extension - 100% w/slight buttock pain L Rotation - 100% w/buttock pain R Rotation - 100% L Sidebend - 100% w/slight buttock pain R Sidebend - 100% Strength 5/5 Throughout Hip ROM Flexion - WNL BIL Extension - WNL with early ilium rotation BIL External Rotation – 30 deg BIL Internal Rotation – 40 deg BIL, buttock pain with left IR Strength 5/5 raises no red flags about serious neurological conditions. Early ilium rotation follows hyperlordotic posture and could point to tight rectus.

PT Exam Findings Special Tests Slump: N/A SLR: Negative, however increase in buttock pain w/SLR+DF FADIR: Negative FABER: Negative Ely’s: Positive BIL, L>R 90-90 Hamstring: Positive on L SI Test Cluster Distraction: Negative Compression: Negative Thigh Thrust: N/A Gaeslen’s: N/A Sacral Thrust: Negative Inconsistency in SLR results, but I didn’t perform the initial Evaluation so message is unclear. 100% on ODI is full function, 20% is pretty low.

PT Exam Findings Functional Tests SLS: WNL, slight lateral hip pain Anterior Heel-down: Dynamic genu valgus WNL Reduced L glute max activation w/volitional contraction Other Tests Joint Dysfunction: Hypomobility of Left Transverse Process of L5 w/slight buttock pain Palpation: Left Transverse Process of L5 TTP w/slight buttock pain Tissue Turgor: L glutes, rectus femoris BIL L>R

Patient Diagnosis Lumbar Radiculopathy MRI confirmed hyperlordosis at L5/S1, left lateral protrusion of L5/S1 disc causing impingement on the neural foramen

Prognosis Rehab potential considered to be fair-good Conservative treatment initially Corticosteroid injections Surgical intervention a possibility down the road

PT Goals Short Term: 4-6 weeks Full lumbar flexion without increase in pain Ambulate 30 minutes without increase in symptoms Independence with HEP Long Term: 6-8 weeks Reduce score on ODI by 10-12% (MCID) to reduce general disability related to back pain Return to sitting >/= 25 minutes without exacerbation of symptoms Demonstrate no increase in symptoms with SLR+DF in order to show reduced neural tension

Interventions McKenzie Extension exercises Core Strengthening Hip Strengthening STM to glute/piriformis Superficial Heat

Treatment Outcomes Some relief of symptoms during and immediately after treatment, but no maintenance between sessions McKenzie Extension exercises reduced intensity of pain and centralized pain when performed rigorously in clinic Ultimately surgery

Clinical Question For my 47 year old female patient with lumbar radiculopathy, does surgical intervention have better pain and/or disability outcomes compared to PT intervention?

Surgery versus Prolonged Conservative Treatment for Sciatica – Peul et al. The New England Journal of Medicine, 2007

Peul et al. Multicenter randomized trial 283 subjects assigned to early surgery OR conservative treatment My Patient Study Subjects Age 47 18-65 (mean 42) Duration of Symptoms 4 weeks 6-12 weeks (mean 9) Outcome Measure(s) ODI, NPRS RDQS, 100mm VAS, GPE Outcome Measure Timeline N/A Weeks 2, 4, 8, 12, 26, 38, 52 Severity of Symptoms 9/10 NPRS at worst “Severe” We used ODI and NPRS, the study used the Roland Disability Questionnaire for Sciatica, the 100-mm visual-analog scale for leg pain, and a 7-point Likert self-rating scale of Global Perceived Effect. Early Surgery was scheduled within 2 weeks after assignment to the group. 10% of patients assigned spontaneously recovered in that time period. Conservative care provided by GPs, included patient education on favorable prognosis, return to daily activities, pain meds if needed, and PT if patients exhibited fear-avoidant beliefs about movement. Surgery offered to patients after 6 months if symptoms persisted, or earlier than 6 months if progressive symptoms.

Median time to recovery: 4 weeks in surgery group, 12 weeks in conservative group. Recovery defined as “complete or nearly complete according to the 7-point Likert GPE. Not shown are the graphs for RDQ scores, VAS for Leg pain, and VAS for Back pain. Scores on the RDQ were not significantly different across the 52 weeks. VAS for leg pain was significantly different in favor of surgery across the 52 weeks, but equalized by the 1 year mark. VAS for Back pain was not significantly different across the 52 weeks, and equalized at the 24-28 week mark.

Limitations/Discussion Relief of symptoms 2x faster in early surgery group HOWEVER, no significant differences between groups for any measure at 1 year There is always cross-over between treatment groups Blinding to treatment group is not possible Conservative treatment described by the study may not reflect typical conservative treatment Measurement of time to recovery limited to scheduled intervals Cross-over: Most if not all studies addressing this diagnosis will have cross-over of patients from the alternative or conservative treatment group who elect to receive surgery during the study. This limitation is pretty difficult to get around unfortunately. Conservative treatment was guided by research nurses who participated with pain management support – may not get this in all clinics. Recovery – What this means is that between weeks 12-26 for example, a patient may have recovered at week 14 but would be lumped into the week 26 recovery group. This under-estimation of recovery time affected both groups though.

Effectiveness of conservative treatments for the lumbosacral radicular syndrome: a systematic review – Pim et al. European Spine Journal, 2007

Pim et al. Systematic review of 30 RCTs (764 database titles excluded by screening) Participant inclusion criteria were patients with acute, subacute, or chronic lumbosacral radicular symptoms Outcome measures included RDQ, ODI, SF-36 Treatment outcomes stratified to assessment at <3 months, 3-12 months, and 12+ months

Intervention Efficacy Short-term Efficacy Long-term Quality of Evidence # of studies Injections Conflicting vs. placebo/control No difference vs. placebo/control (ST)High (LT)High 14 Traction No difference vs. placebo N/A (ST)Moderate 9 Physical Therapy No difference vs. Surgery (LT)Low 4 Bed Rest No difference vs. control 2 Manipulation No difference vs. alternative care No difference vs. chemonucleolysis (ST)Low Medication Acupuncture No data presented = No evidence High 1

Limitations/Discussion Only 12/30 studies included had groups of n =/>30 Difficulty inherent in attempted blinding of treatment groups Geographically limited to regions publishing in French/Dutch/English/German Extremely high geographical variance in rates of surgical treatment

Summary Injections and traction are not recommended due to evidence of ineffectiveness PT, bed-rest, manipulation, and medication effects are inconclusive No evidence found for acupuncture whatsoever So…?

Clinical Carryover Patients should be educated thoroughly regarding both surgical and conservative treatment Surgery may have faster recovery in the short term (1-2 months), but long-term outcomes do not support it as the superior treatment There is a gap in the literature for specific PT interventions vs. surgical treatment for lumbar radiculopathy For my patient Conservative treatment reduced symptoms within PT sessions, but was not effective between sessions Pt elected surgery after 9 visits, literature supports this as valid More pain education may have increased efficacy of conservative treatment At the end of the day, every patient is going to be different and given the lack of strong evidence favoring one treatment vs. another, the most ethical path is to educate the patient faithfully so that they may make a personal informed decision.

References Delgado-López, Rodríguez-Salazar, Martín-Alonso, & Martín-Velasco. (2017). Lumbar disc herniation: Natural history, role of physical examination, timing of surgery, treatment options and conflicts of interests. Neurocirugía (English Edition), 28(3), 124-134. Peul, W., Van Houwelingen, H., Van den Hout, W., Brand, R., Eekhof, J., Tans, J., . . . Koes, B. (2007). Surgery versus Prolonged Conservative Treatment for Sciatica. The New England Journal of Medicine, 356(22), 2245-2256. Luijsterburg, P. A. J., Verhagen, A. P., Ostelo, R. W. J. G., van Os, T. A. G., Peul, W. C., & Koes, B. W. (2007). Effectiveness of conservative treatments for the lumbosacral radicular syndrome: a systematic review. European Spine Journal, 16(7), 881–899. http://doi.org/10.1007/s00586-007-0367-1

Questions?