We’ve all had the patient walk in the door with acute low back pain. It’s awful. They’re in a ton of pain and can’t function.
In this episode, we discuss our strategies for working with people with acute lumbar radiculopathy to get them on the right path as soon as possible.
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#AskMikeReinold Episode 346: How to Treat Acute Lumbar Radiculopathy
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Show Notes
• Treating Low Back Pain with a Lateral Shift
Transcript
Ella Hauser:
All right, here we go. Tom from Massachusetts says, “One injury I tend to struggle with the most is someone with acute lumbar radiculopathy. They often have low back pain, poor movement, and a neurological zing down their leg. Some even have a shifted posture. What are your tips for getting them out of acute symptoms?”
Mike Reinold:
Great question, Tom. You know what? I actually like how Tom really focused this one too for us a little bit on getting them out of their acute symptoms because I’ve seen this range, right? I’ve seen this range from just moist heat and e-stim to doing too much activity and flaring it up more and more. So I think this will be a good episode just to get some tips on what we do. Who wants to start? Dave, I know Dave loves low backs. Exactly, none of us really like low backs. Neither does Tom from Massachusetts.
Dave Tilley:
Actually, no. I actually ironically was telling someone last week that I enjoy treating low backs because when you find something that’s really useful for someone, they’re extremely grateful, and I don’t know, we work with a lot of athletes. That’s great. I love that. But also not being able to pick your daughter up because your back hurts so bad has definitely got to suck. So it’s rewarding.
But yeah, I’ll try to make it brief and let other people jump in, but I don’t know. I find personally that a lot of times low back pain is a lot less things, but done consistently is really the key. So in my opinion, when we see people maybe given our settings is like we’re probably the first people to really listen to their entire story and try to understand how they got to us. I think a lot of times, they go to the ER or they go to a physician’s office, and no shade of course, but they get seven minutes and they get given drugs.
I think actually, ironically, someone I’m treating right now, she got like 30 oxys at the ER and then was told to go home and rest and then go to PT eventually, and she was like, “I have no idea why my back hurts.” She literally just got a ton of drugs. So yeah, I think taking the time to listen, what makes it better, worse… How’d it start? How’d it come on? Are there positions you know that if you do those for a long time, it makes them really bad?
I think that’s really important because trying to find a directional preference is really the key to this. There’s obviously more athletic people who have extension rotation based back pain, but the average person tends to have more flexion rotation or compression intolerant back pain. So you’re trying to tease out what are the things that make them worse and better, and some people I think it’s not worth diving down the rabbit holes of pain science versus biomechanics, but I’ve taken those courses and 80%, 85% of their concepts overlap, and it’s really about the delivery for the person in front of you.
You get someone who’s really high level, really athletic… The rapport and relationship with them is going to go better if you use more biomechanical stuff and you explain more about the physics of back pain. Whereas someone who is really terrified of their back and they’re really scared, they don’t really want to hear about their MRIs and the things that are going on. It’s better to avoid those terms. But you explain why their back hurts because there’s probably certain positions or postures that they do more often that are sensitizing things, and then there’s certain positions or postures they’re not doing throughout their daily life. Most people aren’t lying on their stomach a lot or back bending a lot or doing limbo contests, and so they don’t really have any extension in their back at all throughout their day. But they do sit a lot. They drive to work, they tend to deadlift in their workouts.
They have a lot of things that maybe do put flexion forces on their back. So you’re trying to educate them on like, “Hey, listen, you have some positions or postures that are maybe not as comfortable right now, and some that are really more. We want to essentially double down the things to help you.” And I think that’s honestly… Half the battle is listening to them and giving them education on the things that are in their daily life that are probably provocative. If they wake up and do a bunch of work at home, they drive to their office, they sit all day at meetings, they go home, they drive to the gym, they skip their warmup, and they do some dead lifting. That’s 80% of people I’ve treated in the adult population for flexion intolerant back pain. So let’s sit on a hard chair when we are at home.
Let’s avoid deep couches. Let’s sit with a lumbar roll when we’re driving or at meetings. Let’s try to get up and walk around and do some cat-cows or press-ups throughout the day. I think the 23 hours outside the PT is more important than the hour that we give them to educate them. But of course, manual therapy has a role to then maybe get them more comfortable to exercise more tolerably. If heat and some soft tissue work and dry needling helps their back feel better for a couple hours, they can do more press ups. They can get up on their feet and walk around. Then I think that’s our role, is the education and helping them exercise more comfortably. But yeah, so that’s the acute case for me mostly is four weeks of that just education and I see people once every two weeks with really bad sciatica and they’ve done just fine.
Mike Reinold:
So I love how you really centered that around, it’s almost patient education… And think about how many times people just come to you, they have no idea why they hurt. So if they don’t know why they hurt, they just know they have the sciatica thing that they’ve heard about on the internet. And if you don’t know why, then how are you supposed to have any hope that you’re going to get better? You don’t know why, so how are you going to fix it? If your sink’s leaking and you don’t know why, you’re just like, “Oh, my sink’s leaking,” I don’t know, right?
Dave Tilley:
Just to make the analogy, and I’ve said this in the podcast before, but me and cars. I know literally nothing about my car. I can’t change my oil. I literally know nothing. And I have one mechanic who’s local who I go to. Every time I ask him what’s wrong and do it, I feel like I’m at MIT getting the most complex engine like reverse coolant something. I have no idea what this person’s saying and I’m nervous about giving my money. We have a family friend who’s a mechanic, who knows that I know nothing about my car, and gives me a very simple explanation and why I need to get these parts and get it fixed. I’m like, “Okay, that makes sense, that goes over there.” But the same thing happens in PT. We just throw up tons of these terms on people and they have no idea what discs are and nerve roots and stuff. They have no clue and they get really overwhelmed.
Mike Reinold:
I feel like you’re the guy at Jiffy Lube or Express Oil that takes all the upsells. You get new windshield wipers…
Dave Tilley:
Yeah, I have like $1,600 worth of tires now from my oil filter. I have no idea why.
Mike Reinold:
Rear differential… But it’s funny you say that though, but you know that there’s some treatment styles out there within our profession and some of our similar base professions that you could argue are the same thing. They take advantage of you not understanding it, so they throw the kitchen sink at you and charge you for it to try to get that. So I love, love, love how this has to center around a bit of the why and it’s kind of funny because you’re right. I feel like there’s this… We have to reconcile this from what we’re learning online here with pain science stuff and biomechanics and how that goes together. But man, if you have a neurological thing going down your leg and you have some weakness and stuff, it’s definitely more than just oversensitized tissue. We’re not just talking about pain, we’re talking actually about some other things that are happening here.
You have to get down into the weeds a little bit about both, biomechanically, what that does, but then also what it does do for psychosocial. I think that’s important to put pain science together with biomechanics with that, otherwise, they’re never going to get better. So you have to say, “Look, this position, biomechanics, is not a good position for you. You need to get time out of that position, biomechanics. But it’s not the end of the world if you are in this position, but just realize it’s going to continue to keep your symptoms present. You’re not going to get better.” Pain science.
It’s just little ways how you put those two together. But I think just like everything else, I don’t think I’ve ever said in my career when somebody said, “Should we do A or B?” I say, “A or B, it’s always both.” With everything we’ve ever talked about on every episode of this podcast. So Dave, I think that’s great stuff. Does anybody else want to talk specifically about… So Dave talked about the thought about it. What are some of the things… Let’s actually get to the basics. What are some of the things somebody comes to you, what do you do with them in the clinic on the table, right? Dan, you want to jump in?
Dan Pope:
Yeah, for sure. And obviously, education is a big one, but if you kind of look globally through the research on radicular low back pain specifically, because that is a very specific type of low back pain, you’ve got a lot of options and I think it freaks people out. So I treat it similarly to other sorts of pain problems, meaning that there’s probably a wide variety of exercises that are beneficial for these folks with things like walking can be helpful, doing basic exercise like cat-cows, doing McKenzie exercises. You could do strength training and you pick whatever works the best and the patient really wants to do. I also find for these folks, early on, these are the guys that limp through the door or sometimes you see someone come in through a wheelchair and you’re like, “What is going on with this person?” But they literally hurt so bad that they can’t move in bed, they can’t stand up. Walking is a huge problem.
So I think early on, you’re trying your best to be creative about what they can do, and obviously the soft tissue stuff like the modalities, whatever else, can be beneficial early on. But I’m also just a big proponent of doing more exercise and positions that feel really good. And I actually have a list of exercises I’ll go through that are based in certain positions. So for instance, supine exercises, prone exercises, sideline exercises, quadruped exercises, standing exercises, seated exercises. If the person feels amazing sitting, but terrible standing, I’m not going to give them a ton of walking, right? I give them a bunch of sitting exercises, that’s fine. If they can’t roll around on the floor, I probably shouldn’t give a million core stability exercises because they’re going to go from a plank position, to side lying, to quadruped, and their back is just dying.
So what I tend to focus on early on is getting information about what positions feel terrible, just like Dave was saying. Sometimes it’ll be crystal clear: this person’s flexion tolerant or extension tolerant. I usually find that one position is a little worse than another, but we start with the positions that feel really good. So a lot of folks are just not going to be able to tolerate laying on their back, just kind of extends them a little bit too much. So maybe we focus more on quadruped exercises because they’re going to be in a little bit of a flex posture or seated exercises. If you’re looking for specifics, it’s the basics. It’s things like cat-cows, but maybe not pushing those end ranges that are really aggravated. I think McKenzie is something that can be really beneficial. I haven’t taken McKenzie courses, so just make sure that you know that when I say these things.
But if you look globally at the research about radicular pain, this goes for the neck and low back, McKenzie is not necessarily needed. It’s also not as well studied in this population, which is always interesting to me because what I learned in school is like, radiating pain, McKenzie, and it’s really not studied that well. So I don’t think you have to push that. And the other thing I will say is that these are interesting injuries for patients because they feel God awful and it feels like your life is over. And most of these folks go to the emergency room and think something is tremendously wrong and they just go home a lot of times with some medications and they’re confused. They don’t know what’s going on and they often will make a really fast reversal. So I think it’s also important to educate your patients, “As this resolves, don’t be afraid to do more. You may find, two weeks from now, you’re feeling very good. We’re much better for now.”
So that’s a patient education piece, but it also helps guide their own exercise progression. So let’s say they’re starting with super simple things, they’re feeling quite a bit better. The question becomes, “Hey, can I do more?” And the answer is “Yes, you should be doing more. That’s a good thing.” So just focus on the basic easy exercises. You may not feel like you’re doing the best job, maybe, because you’re giving them super simple stuff. But gentle motion of the spine, gentle core exercises, nerve glides is another one you can do, walking if they tolerate it well, focus on the positions that feel really good and I would do the exercises more frequently if they feel good. A lot of patients will feel better after their exercises, so do a couple times a day, right?
Mike Reinold:
Love it. What do you think, Len?
Lenny Macrina:
I think all great stuff. I’m going to quickly add, and people are going to probably come at me for this, but shocker, don’t be afraid. You guys alluded to medications and drugs. I think the right ones will benefit, so some kind of steroid pack or something. Not that we’re prescribing that, but I think having that in our back pocket, don’t be afraid to refer out if they’re not getting better in the time you think they should or they’re so acutely afraid and in pain that you need help to get them to be able to do PT better. So I think getting them to a doctor, a primary care doctor, and maybe coaching the patient on what the symptoms and what to ask for or just something of that nature, to get them some kind of dose pack or something to alleviate the symptoms, to take the edge off so they can do more. So drugs can be friendly if they’re the right ones prescribed in the right way. So don’t be afraid of that as well.
Mike Reinold:
Love it. This episode brought to you by Merck.
Lenny Macrina:
Yeah, Pfizer.
Mike Reinold:
I’m happy to jump in on probably the debatable one here a little bit here too. The one that people like talk about here, but Dave and Dan gave the right answers in line too, because Lenny likes drugs. So Lenny’s older, he’s looking for shortcuts. It is what it is, right? Dave didn’t give the right answers in terms of what we need to do. Here’s one thing I want to throw at you too. Do not be afraid to use moist heat, and e-stim, and soft tissue work, and manual therapy on these people to make them feel better. You just gave them a window of opportunity, like Dave said, to potentially now be able to have more movement variability and then that is going to help them get over this a little bit. But you also just let them get to their son’s baseball game and sit in the bleachers, which aren’t very comfortable. If you’re a parent, you know these things.
So you have to realize here that they’re coming to you for many reasons. It’s not just to solve their problem or for the only thing you can do as evidence-based practice. They’re coming to you to make them feel better and don’t forget that. If you just give them pain science and you just tell them to go walk because it’s the only thing in the literature that’s shown to be effective and that person leaves in pain, that’s not a good approach to their daily life. So just keep that in mind. You have to combine all these things together. But again, back to a couple episodes ago, people feel like shamed if they’re on social media and they say like, “Oh my God, you used moist heat on somebody? That’s crazy. What are you doing? You’re wasting time.” You got to realize that. You have to put these together and we have a job to do and sometimes our job is to help neuromodulate their pain, so we can get more and have them experience better life and hopefully get through these symptoms that we do know will be transient at some time, hopefully.
To me, I think, this is a big topic. We could go on and on and on with acute lumbar radiculopathy, but I think what we nailed today covered it fairly well. It’s a ton of education. It’s a ton of movement variability and then putting it all together. What I like about this is, is this is somebody that, I don’t want to say you know the diagnosis, but there’s a lot of low back pain. You don’t know why they have low back pain. It’s just pain and then there’s no radiculopathy. There’s no dermatome, myotome reflex stuff. There’s no rotational bias. You have a stress reaction, anything like that. They just have low back pain, those are the ones that are tricky.
When they actually have radiculopathy down the leg, to me, that’s almost a relief because I know what they’re dealing with a little bit more. So keep that in mind. So, awesome episode. Thanks so much, Tom. Appreciate it. If you have a question like that, head to mikereinold.com. Click on that podcast link and fill out the form. We will answer your questions, just keep them coming. We’ll keep answering them and please, rate and subscribe to us, Apple Podcasts and Spotify, so you get notifications when you have our next episode. Thank you so much.
