1. CPS II
By James Luker

2. 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

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

4. 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

5. 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.

6. 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.

7. 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

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

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

10. 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

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

12. 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

13. 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?

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

15. 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.

16. 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 week mark.

17. 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 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.

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

19. 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

20. 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

21. 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

22. 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…?

23. 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.

24. 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),
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),
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.

25. Questions?