Can you offer pain relief for the patient who limps in with sciatica from lumbar radiculopathy? Here's how you can.
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Learn how to give your patient with acute severe radiculopathy pain relief with scientifically validated mechanisms.
Course description. REGISTER NOW! 
NEW YORK, NY
Lower Quarter 1 - Hybrid Nov 10: open online In-Person Dec 10: 1 day in-person Dec 11: open practical videos Online: 3 months access, all theory and practical techniques. |
WATCH HOW TO DO THE STRAIGHT LEG RAISE - IN DETAIL
Next in-person course: Lower Quarter 1, Melbourne, July 30-31, 2022
Hosts: Ben Lustig Physiotherapy, Geelong Physical Therapy Instructor: Michael Shacklock, MAppSc, FACP |
SCIATICA: MISCONCEPTION
Neural mobilisation the treatment of choice for lumbar radiculopathy." Background We have for a long time been mobilizing nerves for neural pain. This may be helpful for some but it often provokes patients with acute severe sciatica, so many clinicians stopped doing it - rightfully so. This could be because there is a problem with the logic: The nerve problem is caused by excessive force - compression - and we apply more force with neural mobilization. So it's not surprising that neural mobilization often provokes. |
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So, instead, let's consider UNLOADING the nerve root for pain relief.
Emerging Strategies - Unloading Nerves
One of NDS' emerging strategies for severe nerve pain is to UNLOAD nerves for pain relief and recovery. Our research group has validated certain mechanisms for unloading the lumbar nerve root for acute severe sciatica and lumbar radiculopathy.
What Has Been Validated?
It was often assumed that applying tension to the nerve roots on one side also applies tension to those on the other side. THIS IS INCORRECT!
We have studied this in a range of samples and subjects: cadavers, in vivo, asymptomatic subjects, invasively and non-invasively (e.g. MRI). We showed that the nerve roots on the side CONTRALATERAL to the neurodynamic test undergo a REDUCTION IN TENSION and this is through spinal cord movement (Rade et al 2014a, 2014b, Shacklock et al 2016).
This is GOLD for giving patients relief of their nerve root pain, especially when it is severe and disabling. But there are inclusion and exclusion criteria because you could provoke the sciatica if you get this wrong.
You can learn these inclusion, exclusion and selection criteria on the lower quarter 1 hybrid course in New York (Nov 10, 2022-Feb 10, 2023).
We have also completed a clinical pilot study in which we found that unloading the nerve root using the intervertebral foramen in patients with acute severe lumbar radiculopathy in the emergency hospital setting was safe and provided greater relief than the control group.
The outcomes were:
- better functional outcomes and pain
- reduced medication consumption: 79% overall, opioids by 50% (Shacklock et al 2022).
But it's not a case of just applying the research. There are also inclusion and exclusion criteria for these foramen techniques as they relate to diagnostic categories.
You learn these things in detail on the course:
- research into the newly validated mechanisms
- inclusion exclusion criteria
- manual technique with precision.
Joseph Gravino (DPT, CMDT) will be doing the in-person part in New York in Dec (online component opens Nov 10 and you have 3 months access until Feb 10).
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REFERENCES
Rade M, Könönen M, Vanninen R, Marttila J, Shacklock M, Kankaanpää M, Airaksinen O 2014a Young investigator award winner: In vivo magnetic resonance imaging measurement of spinal cord displacement in the thoracolumbar region of asymptomatic subjects: part 1: Straight leg raise test. Spine 39 (16): 1288-1293
Rade M, Könönen M, Vanninen R, Marttila J, Shacklock M, Kankaanpää M, Airaksinen O 2014b Young investigator award winner: In Vivo MRI measurement of spinal cord displacement in the thoracolumbar region of asymptomatic subjects: part 2 - comparison between unilateral and bilateral straight leg raise tests. Spine 39 (16): 1294-1300
Shacklock M, Rade M, Poznic S, Marčinko A, Fredericson M, Kröger H, Kankaanpää M, Olavi Airaksinen O 2022 Treatment of sciatica and lumbar radiculopathy with an intervertebral foramen opening protocol: pilot study in a hospital emergency and in-patient setting. Physiotherapy Theory and Practice: February 2022, PMID: 35253599, DOI: 10.1080/09593985.2022.2037797
Shacklock M, Yee B, Van Hoof T, Foley R, Boddie K, Lacey E, Poley JB, Rade M, Kankaanpää M, Kröger M, Airaksinen O 2016 Slump Test: Effect of contralateral knee extension on response sensations in asymptomatic subjects and cadaver study. Spine 41 (4): E205–E210
Emerging Strategies - Unloading Nerves
One of NDS' emerging strategies for severe nerve pain is to UNLOAD nerves for pain relief and recovery. Our research group has validated certain mechanisms for unloading the lumbar nerve root for acute severe sciatica and lumbar radiculopathy.
What Has Been Validated?
It was often assumed that applying tension to the nerve roots on one side also applies tension to those on the other side. THIS IS INCORRECT!
We have studied this in a range of samples and subjects: cadavers, in vivo, asymptomatic subjects, invasively and non-invasively (e.g. MRI). We showed that the nerve roots on the side CONTRALATERAL to the neurodynamic test undergo a REDUCTION IN TENSION and this is through spinal cord movement (Rade et al 2014a, 2014b, Shacklock et al 2016).
This is GOLD for giving patients relief of their nerve root pain, especially when it is severe and disabling. But there are inclusion and exclusion criteria because you could provoke the sciatica if you get this wrong.
You can learn these inclusion, exclusion and selection criteria on the lower quarter 1 hybrid course in New York (Nov 10, 2022-Feb 10, 2023).
We have also completed a clinical pilot study in which we found that unloading the nerve root using the intervertebral foramen in patients with acute severe lumbar radiculopathy in the emergency hospital setting was safe and provided greater relief than the control group.
The outcomes were:
- better functional outcomes and pain
- reduced medication consumption: 79% overall, opioids by 50% (Shacklock et al 2022).
But it's not a case of just applying the research. There are also inclusion and exclusion criteria for these foramen techniques as they relate to diagnostic categories.
You learn these things in detail on the course:
- research into the newly validated mechanisms
- inclusion exclusion criteria
- manual technique with precision.
Joseph Gravino (DPT, CMDT) will be doing the in-person part in New York in Dec (online component opens Nov 10 and you have 3 months access until Feb 10).
--
REFERENCES
Rade M, Könönen M, Vanninen R, Marttila J, Shacklock M, Kankaanpää M, Airaksinen O 2014a Young investigator award winner: In vivo magnetic resonance imaging measurement of spinal cord displacement in the thoracolumbar region of asymptomatic subjects: part 1: Straight leg raise test. Spine 39 (16): 1288-1293
Rade M, Könönen M, Vanninen R, Marttila J, Shacklock M, Kankaanpää M, Airaksinen O 2014b Young investigator award winner: In Vivo MRI measurement of spinal cord displacement in the thoracolumbar region of asymptomatic subjects: part 2 - comparison between unilateral and bilateral straight leg raise tests. Spine 39 (16): 1294-1300
Shacklock M, Rade M, Poznic S, Marčinko A, Fredericson M, Kröger H, Kankaanpää M, Olavi Airaksinen O 2022 Treatment of sciatica and lumbar radiculopathy with an intervertebral foramen opening protocol: pilot study in a hospital emergency and in-patient setting. Physiotherapy Theory and Practice: February 2022, PMID: 35253599, DOI: 10.1080/09593985.2022.2037797
Shacklock M, Yee B, Van Hoof T, Foley R, Boddie K, Lacey E, Poley JB, Rade M, Kankaanpää M, Kröger M, Airaksinen O 2016 Slump Test: Effect of contralateral knee extension on response sensations in asymptomatic subjects and cadaver study. Spine 41 (4): E205–E210
ARTICLE - Our Recent Research: Reliability of the Extended Straight Leg Raise - Applicable to Athletes
Are you missing the neural aspect to the athlete's problem?
False negatives.
RELIABILITY OF THE EXTENDED STRAIGHT LEG RAISE
Introduction The straight leg raise (SLR) is the world's most performed neurodynamic test. It has existed for more than 4,000 years with the Egyptian physician Imhotep using it on patients with back pain injured during the pyramid era. These days, the manoeuvre is typically rated against MRI evidence of lumbar disc hernia and/or nerve root compression, producing the following sensitivity and specificity (Majlesi et al 2008) for nerve root compression: Sensitivity - 0.84. Specificity - 0.88. |
Key issue - reliability is key to all physical tests. Some studies do not test it, or they do it in asymptomatic subjects but not in a clinical sample with a recognized diagnosis.
So we wanted to test reliability of the straight leg raise in patients with nerve root compression on MRI. Another part was to see if movements that increase tension in the sciatic nerve above the usual SLR can be reliable. We think these extra movements might be a way of changing diagnostic efficacy and improving our understanding of its mechanisms. |
Definitions
SLR - only hip flexion with the extended knee.
Extended (E)SLR - added ankle dorsiflexion and internal hip rotation. These movements increase tension in the lumbosacral nerve roots and sciatic nerve.
Abnormal (positive) SLR - reproduction of clinical symptoms that change with dorsiflexion and/or internal rotation.
Differentiation - when movement of the neural structures in the problem area occurs by movement from another area whilst not moving the musculoskeletal structures in the area of the problem, e.g. dorsiflexion moves the lumbosacral nerve roots during the SLR but it does not move the spine.
SLR - only hip flexion with the extended knee.
Extended (E)SLR - added ankle dorsiflexion and internal hip rotation. These movements increase tension in the lumbosacral nerve roots and sciatic nerve.
Abnormal (positive) SLR - reproduction of clinical symptoms that change with dorsiflexion and/or internal rotation.
Differentiation - when movement of the neural structures in the problem area occurs by movement from another area whilst not moving the musculoskeletal structures in the area of the problem, e.g. dorsiflexion moves the lumbosacral nerve roots during the SLR but it does not move the spine.
We tested the reliability of responses of the extended SLR (dorsiflexion and internal hip rotation) in a low back pain population.
Methods
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Control group (n=20)
- pain in low back and/or pelvis - no pain below knee - normal ESLR: no reproduction of clinical symptoms, no change in response with dorsiflexion or hip rotation. |
Sciatica group (n=20)
- pain in low back and/or pelvis and sciatica - pain below knee - abnormal ESLR: reproduction of clinical pain, change in clinical pain with dorsiflexion and hip rotation. |
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Results
Inter-rater agreement between Examiner 1 and Examiner 2: 0.85 (p < 0.001, 95%CI: 0.71–0.99). Extremely good agreement in Cohen’s Kappa (Figure 1). |
Figure 1.
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Discussion and Conclusions - When To Extend the SLR and When Not To
Adding dorsiflexion and internal rotation to the usual straight leg raise was highly reliable in this population of lumbar nerve root compression from disc hernia.
That's all very well but how is this relevant to clinical practice and how can we apply this?
Even though found to be reliable, we must remember that hip rotation and dorsiflexion increase tension in the sciatic nerve. CHOICE of movement would therefore be determined by the PURPOSE of the movement and would be based on patient features.
Back pain could be differentiated with dorsiflexion, but internal rotation may not be necessary (or safe) in the patient with severe reproducible pain. If differentiation of clinical symptoms failed with the usual SLR (no hip rotation) and the problem were only mild, dorsiflexion would still be used for DIFFERENTIATION and internal rotation to INCREASE FORCE (a higher progression) and likelihood of detecting an abnormal response (more sensitive).
So internal rotation may be used as a reliable progression for patients in whom 'exclusion' is important at higher levels of function where their standard SLR is normal.
If then the extended SLR (internal rotation) reproduces clinical pain when the standard test did not, the test fails the exclusion test and would then change the response from normal to abnormal. The patient may then become a candidate for neurodynamic treatment when originally they were MISSED BY A FALSE NEGATIVE. You can avoid false negatives with appropriate progressions.
We think this progression may reduce the number of false negatives, particularly in higher functioning patients such as athletes in whom the standard SLR is not a high enough test.
Adding dorsiflexion and internal rotation to the usual straight leg raise was highly reliable in this population of lumbar nerve root compression from disc hernia.
That's all very well but how is this relevant to clinical practice and how can we apply this?
Even though found to be reliable, we must remember that hip rotation and dorsiflexion increase tension in the sciatic nerve. CHOICE of movement would therefore be determined by the PURPOSE of the movement and would be based on patient features.
Back pain could be differentiated with dorsiflexion, but internal rotation may not be necessary (or safe) in the patient with severe reproducible pain. If differentiation of clinical symptoms failed with the usual SLR (no hip rotation) and the problem were only mild, dorsiflexion would still be used for DIFFERENTIATION and internal rotation to INCREASE FORCE (a higher progression) and likelihood of detecting an abnormal response (more sensitive).
So internal rotation may be used as a reliable progression for patients in whom 'exclusion' is important at higher levels of function where their standard SLR is normal.
If then the extended SLR (internal rotation) reproduces clinical pain when the standard test did not, the test fails the exclusion test and would then change the response from normal to abnormal. The patient may then become a candidate for neurodynamic treatment when originally they were MISSED BY A FALSE NEGATIVE. You can avoid false negatives with appropriate progressions.
We think this progression may reduce the number of false negatives, particularly in higher functioning patients such as athletes in whom the standard SLR is not a high enough test.
References
Majlesi J, Togay H, Ünalan H, Toprak S 2008 The sensitivity and specificity of the slump and the straight leg raising tests in patients with lumbar disc herniation. Journal of Clinical Rheumatology (2): 87-91. DOI: 10.1097/RHU.0b013e31816b2f99
Majlesi J, Togay H, Ünalan H, Toprak S 2008 The sensitivity and specificity of the slump and the straight leg raising tests in patients with lumbar disc herniation. Journal of Clinical Rheumatology (2): 87-91. DOI: 10.1097/RHU.0b013e31816b2f99
Pesonen J, Shacklock M, Rantanen P, Mäki J, Karttunen L, Kankaanpää M, Airaksinen O, Rade M 2021 Extending the straight leg raise test for improved clinical evaluation of sciatica: reliability of hip internal rotation or ankle dorsiflexion. BMC Musculoskeletal Disorders (2021) 22:303. DOI: 10.1186/s12891-021-04159-y