2.  Be familiar with the pathology of a typical nerve root pain.  Be familiar with the causes of nerve root symptoms.  Be familiar with the clinical presentation of nerve root irritation, nerve-root pressure, pressure on the spinal cord and pressure on the cauda equina.  Be familiar with the distinct characteristics of nerve root pain.

3.  Be familiar with the most widely used physiotherapy treatment protocol for a patient with a typical severe nerve root pain.  Be familiar with the most widely used physiotherapy treatment protocol for a patient with a cervical, lumbar, chronic and intermittent nerve root pain.  Be familiar with the clinical presentation of a typical patient with nerve root pain.

4.  Be familiar with the deep spinal muscles that can simulate nerve root symptoms.

5.  Pressure on the nerve-root causes pain  The pain does not come form the nerve-root itself, but develops as a results of venous congestion  The first sign is pins and needles in the distal region of the affected dermatome  The pain intensifies and the arterial blood circulation is restricted  The nerve’s conduction is suspended and signs of nerve-fall out develops

7.  Strength of the initial impulse  Duration of the abnormal pressure (the longer the worse it becomes)

8.  Disc prolapse  Disc protrusion  Osteophytes  Traction injuries  Swelling in the intervertebral canal and foramen  Relaxed ligamentum flavum  Hypertrophic capsule

9.  Stenosis  Adhesions  Deep-seated muscle spasm / trigger points  Instability of the movement segment

10.  Increased reflexes  Paraesthesia / abnormal sensation

11.  Decreased reflexes  Loss of sensation or no sensation  Muscle weakness – long-term muscle atrophy

12.  Gait disturbances / clumsiness  Bilateral pins and needles  Bladder dysfunction  Increased reflexes below the level of the lesion  + clonus  + Babinski

13.  Saddle anaesthesia  Urine retension

14.  Area  Nature  Movement  Deformities

15.  Well defined throughout the dermatome or  Dominates the distal part of the dermatome  Can occur in regions of the dermatome

16.  Severe pain – the patient appears to be experiencing a lot of pain, sometimes a total loss of function  Pain may be latent, often undulant and builds up  Sometimes a sharp, shooting pain that paralyses the patient  In acute phase the pain is constant and severe  In sub-acute and chronic phase the pain is intermittent

17.  Worsens after activities  Worse towards the end of the day  Worsens during sustained positions

18.  Imminent nerve-root pain of C7 refers to the medial border of the scapulae with cervical movements  S1 refers pain deep to the medial buttocks

19.  Examination will reveal that movements either causes distal pain or latent pain in the distal segment  The more distal pain is caused, the more carefully a patient needs to be managed

20.  Protective deformities occur  Patient stands on one leg with the other leg bent and toes resting on the floor

21.  Severe nerve root pain is difficult to treat  Patients respond slowly  Pain takes long to disappear  It takes about 2 weeks before any improvement can be observed

22.  Hospital or traction as an outpatient  Neurological examination is a ABSOLUTE PRE- REQUISITE for traction  Immediate TOTAL relief must not be achieved with traction under any circumstances  If total relief is obtained if may also cause severe sharpening of symptoms  Traction takes approximately 4 days to show an effect and the initial effect may be minimal  Palpation techniques are a contra-indication

23.  As soon as the symptoms improve mobilisation techniques namely Grade Gr IV- may be added to traction  Treated daily for 3 weeks  Thereafter intermittent for 6 weeks  Treatment is suspended after 85% improvement  If a plateau is reached after 2 weeks of treatment, the treatment must be suspended, in order to give the treatment pain time to subsided

24.  Cervical nerve root pain  Neurological evaluation  Constant traction  Collar for support to restrict movement – wean as soon as possible  Advice regarding sleeping position (mid position)  Later rotation and longitudinal  In the case of OA add central and unilateral PA’s

25.  Lumbar nerve root pain  Neurological evaluation  Total bed rest  Constant traction  Advice  Later rotation and direct mobilisations with OA  Takes longer to react to treatment

26.  History of prolonged pain in the back and leg  No specific incident

27.  Signs  Prolonged history  Slow progress  Reasonably stable condition  Symptoms vary very little  Activities make very little difference to the pain

28.  Objective  Sometimes no comparable sign  Make use of differentiation tests  Movements at end of range sometimes causes local back pain  No latent pain  Sustained positions (especially quadrant) sometimes positive

29.  Treatment  Treatment by means of strong techniques  Add one technique daily  Traction and SLR  Little reaction to traction  SLR works well  Manage in much the same manner as OA patients

30.  Deep spinal muscles: m quadratus lumborum m serratus post inf m piriformis m quadratus femoris can simulate nerve root pain symptoms – always give attention to these muscles during treatment

31.  Pain often occurs in only one dermatome  Long-term problem  Local hypertrophy and palpation tenderness of the interspinal ligament  Movements appear stiff  Quick active tests and palpation techniques do not reproduce the symptoms

32.  Treatment  Palpation techniques initially  Trigger points  Neural mobilisation  Cross-frictions  Ultrasound to treat the hypertrophic ligament  “Dry needling”