Physical Therapy Referral From Primary Care for Acute Back Pain With Sciatica : A Randomized Controlled Trial.

BACKGROUND: Few studies have examined primary care management for acute sciatica, including referral to physical therapy. OBJECTIVE: To evaluate whether early referral to physical therapy reduced disability more than usual care (UC) alone for patients with acute sciatica. DESIGN: Randomized controlled clinical trial. (ClinicalTrials.gov: NCT02391350). SETTING: 2 health care systems in Salt Lake City, Utah. PATIENTS: 220 adults aged 18 to 60 years with sciatica of less than 90 days' duration who were making an initial primary care consultation. INTERVENTION: All participants received imaging and medication at the discretion of the primary care provider before enrollment. A total of 110 participants randomly assigned to UC were provided 1 session of education, and 110 participants randomly assigned to early physical therapy (EPT) were provided 1 education session and then referred for 4 weeks of physical therapy, including exercise and manual therapy. MEASUREMENTS: The primary outcome was the Oswestry Disability Index (OSW) score after 6 months. Secondary outcomes were pain intensity, patient-reported treatment success, health care use, and missed workdays. RESULTS: Participants in the EPT group had greater improvement from baseline to 6 months for the primary outcome (relative difference, -5.4 points [95% CI, -9.4 to -1.3 points]; P = 0.009). The OSW and several secondary outcomes favored EPT after 4 weeks. After 1 year, between-group differences favored EPT for the OSW (relative difference, -4.8 points [CI, -8.9 to -0.7 points]) and back pain intensity (relative difference, -1.0 points [CI, -1.6 to -0.4 points]). The EPT group was more likely to self-report treatment success after 1 year (45.2%) than the UC group (27.6%) (relative risk, 1.6 [CI, 1.1 to 2.4]). There were no significant differences in health care use or missed workdays. LIMITATION: The patients and providers were unblinded, and specific physical therapy interventions responsible for effects could not be determined. CONCLUSION: Referral from primary care to physical therapy for recent-onset sciatica improved disability and other outcomes compared with UC. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Systematic review of prognostic factors for work participation in patients with sciatica.

Sciatica impacts on the ability to work and may lead to a reduced return to work. This study reviewed and summarised prognostic factors of work participation in patients who received conservative or surgical treatment for clinically diagnosed sciatica. We searched MEDLINE, CINAHL, EMBASE and PsycINFO until January 2018. Cohort studies, using a measure of work participation as outcome, were included. Two independent reviewers performed study inclusion and used the Quality In Prognosis Studies tool for risk of bias assessment and GRADE to rate the quality of the evidence. Based on seven studies describing six cohorts (n=1408 patients) that assessed 21 potential prognostic factors, favourable factors for return to work (follow-up ranging from 3 months to 10 years) included younger age, better general health, less low back pain or sciatica bothersomeness, better physical function, negative straight leg raise-test, physician expecting surgery to be beneficial, better pain coping, less depression and mental stress, less fear of movement and low physical work load. Study results could not be pooled. Using GRADE, the quality of the evidence ranged from moderate to very low, with downgrading mainly for a high risk of bias and imprecision. Several prognostic factors like pain, disability and psychological factors were identified and reviewed, and these could be targeted using additional interventions to optimise return to work. PROSPERO registration number: CRD42016042497.

Usefulness of corset adoption after single-level lumbar discectomy: a randomized controlled trial.

OBJECTIVE In this paper, the authors sought to verify whether corset adoption could improve the short-term and midterm outcome scores of patients after single-level lumbar discectomy. METHODS A monocentric, randomized controlled trial of 54 consecutive patients who underwent single-level lumbar discectomy at the authors' institution was performed from September 2014 to August 2015. Patients were randomly assigned to use or not use a lumbar corset in the upright position. Patients with previous interventions for disc herniation or with concomitant canal or foraminal stenosis were excluded. The visual analog scale, Oswestry Disability Index, and Roland Morris Disability Questionnaire were used to compare groups at the 1- and 6-month follow-up time points. RESULTS No significant differences between the 2 groups were reported at either time point for any given outcome irrespective of the scale used. CONCLUSIONS Corset adoption does not improve the short-term and midterm outcomes of patients after single-level lumbar discectomy.

The clinical and cost-effectiveness of stratified care for patients with sciatica: the SCOPiC randomised controlled trial protocol (ISRCTN75449581).

BACKGROUND: Sciatica has a substantial impact on patients, and is associated with high healthcare and societal costs. Although there is variation in the clinical management of sciatica, the current model of care usually involves an initial period of 'wait and see' for most patients, with simple measures of advice and analgesia, followed by conservative and/or more invasive interventions if symptoms fail to resolve. A model of care is needed that does not over-treat those with a good prognosis yet identifies patients who do need more intensive treatment to help with symptoms, and return to everyday function including work. The aim of the SCOPiC trial (SCiatica Outcomes in Primary Care) is to establish whether stratified care based on subgrouping using a combination of prognostic and clinical information, with matched care pathways, is more effective than non-stratified care, for improving time to symptom resolution in patients consulting with sciatica in primary care. We will also assess the impact of stratified care on service delivery and evaluate its cost-effectiveness compared to non-stratified care. METHODS/DESIGN: Multicentre, pragmatic, parallel arm randomised trial, with internal pilot, cost-effectiveness analysis and embedded qualitative study. We will recruit 470 adult patients with sciatica from general practices in England and Wales, over 24 months. Patients will be randomised to stratified care or non-stratified care, and treated in physiotherapy and spinal specialist services, in participating NHS services. The primary outcome is time to first resolution of sciatica symptoms, measured on a 6-point ordered categorical scale, collected using text messaging. Secondary outcomes include physical function, pain intensity, quality of life, work loss, healthcare use and satisfaction with treatment, and will be collected using postal questionnaires at 4 and 12-month follow-up. Semi-structured qualitative interviews with a subsample of participants and clinicians will explore the acceptability of stratified care. DISCUSSION: This paper presents the details of the rationale, design and processes of the SCOPiC trial. Results from this trial will contribute to the evidence base for management of patients with sciatica consulting in primary care. TRIAL REGISTRATION: ISRCTN75449581 , date: 20.11.2014.

Physiotherapy for Patients with Sciatica Awaiting Lumbar Micro-discectomy Surgery: A Nested, Qualitative Study of Patients' Views and Experiences.

BACKGROUND AND PURPOSE: Sciatica is a common clinical condition that can be extremely painful, disabling and life-changing. Whether conservative or surgical treatment for sciatica secondary to an intervertebral disc prolapse is most effective is still much debated. An important component of conservative treatment is physiotherapy, which aims to promote physical and psychological health for the patient, whilst resorption of the disc takes place. This paper reports a qualitative study of patients' views and experiences of a bespoke physiotherapy intervention for the treatment of sciatica. METHODS: A qualitative study nested within a pilot randomized controlled trial of bespoke physiotherapy for the treatment of patients with sciatica awaiting lumbar microdiscectomy surgery. Patients randomized to receive bespoke physiotherapy in the intervention arm of the trial were invited to take part in semi-structured interviews. Twenty-one in-depth, semi-structured interviews took place. All interviews were recorded, fully transcribed and thematically analysed. RESULTS: Most patients in the sample found the physiotherapy valuable, appreciating the individual nature of the approach, the exercises to reduce pain and discomfort, techniques for improving functional spinal movement, walking and dynamic posture, and manual therapy and cardiovascular exercise. A small number did not find the physiotherapy of benefit. Sixteen patients in the sample went on to proceed with surgery, but most of these found value in having had the physiotherapy first. DISCUSSION: Many patients with sciatica appreciate the value of physiotherapy prior to surgery. Future research should examine patients' experiences of bespoke physiotherapy delivered within primary care. Copyright © 2016 The Authors Physiotherapy Research International published by John Wiley & Sons Ltd.

Individualised functional restoration plus guideline-based advice vs advice alone for non-reducible discogenic low back pain: a randomised controlled trial.

OBJECTIVES: To evaluate the effectiveness of individualised functional restoration plus guideline-based advice compared to advice alone in people with non-reducible discogenic pain (NRDP). DESIGN: Subgroup analysis within a multicentre, parallel group randomised controlled trial. SETTING: Fifteen primary care physiotherapy clinics. PARTICIPANTS: Ninety-six participants with clinical features indicative of NRDP (6 week to 6 month duration of injury). INTERVENTIONS: Over a 10 week period physiotherapists provided 10 sessions of individualised functional restoration plus guideline-based advice or two sessions of advice alone MAIN OUTCOME MEASURES: Primary outcomes were back and leg pain (separate numerical rating scales) and activity limitation (Oswestry Disability Index). RESULTS: Between-group differences favoured individualised functional restoration over advice for back pain (1.1, 95% CI 0.1 to 2.1), leg pain (1.5, 95% CI 0.4 to 2.6) and Oswestry (6.3, 95% CI 1.3 to 11.4) at 10 weeks as well as Oswestry at 26 weeks (6.6, 95% CI 1.4 to 11.8). Secondary outcomes and responder analyses also favoured physiotherapy functional restoration suggesting the differences were clinically important. CONCLUSIONS: In people with NRDP of ≥6 weeks and ≤6 months duration, individualised functional restoration was more effective than advice for all primary outcomes at 10 weeks and sustained at 26 weeks for activity limitation. Our results suggest that for people with NRDP not recovering after 6 weeks, an individualised physiotherapy functional restoration program should be considered. CONTRIBUTION OF PAPER: (1) A physiotherapist delivered functional restoration program individualised to pathoanatomical, psychosocial and neurophysiological barriers and incorporating guideline-based advice was more effective than advice alone in people with non-reducible discogenic low back pain of ≥6 weeks and ≤6 months duration. (2) This trial differs significantly from other studies on individualised physiotherapy, as it investigates a conservative management program that specifically targets the pathoanatomical subgroup non-reducible discogenic pain. ACTRN numbers: ACTRN12609000412235; ACTRN12609000834257.

Neurodynamic treatment for patients with nerve-related leg pain: Protocol for a randomized controlled trial.

OBJECTIVES: To investigate if neurodynamic treatment is more effective than advice to remain active in patients with nerve-related leg pain. DESIGN: Parallel-group randomized controlled trial blinded to the outcome assessor conducted in Porto Alegre, Brazil. PARTICIPANTS: Sixty patients recruited from the community and private practices. INTERVENTION: Patients will be randomly assigned to receive four sessions of neurodynamic treatment over two weeks comprising passive lumbar foramen opening and neurodynamic sliders plus home exercises or advice to remain active. MAIN OUTCOME MEASURES: Leg pain intensity, disability, low back pain intensity, functional ability, symptoms distribution and global impression of recovery will be assessed at two and four weeks after randomization. ANALYSIS: A linear mixed model will be employed for each outcome following intention to treat principles.

Onset and maximum values of electromyographic amplitude during prone hip extension after neurodynamic technique in patients with lumbosciatic pain: A pilot study.

OBJECTIVE: The mechanisms underlying the effects of neurodynamic techniques are still unknown. Therefore, the aim of this study was to provide a starting point for future research on explaining why neurodynamic techniques affect muscular activities in patients with sciatic pain. METHODS: A double-blind trial was conducted in 12 patients with lumbosciatica. Surface electromyography activity was assessed for different muscles during prone hip extension. Pre- and post-intervention values for muscle activity onset and maximal amplitude signals were determined. RESULTS: There was a significant reduction in the surface electromyography activity of maximal amplitude in the erector spinae and contralateral erector spinae (p < 0.05). Additionally, gluteus maximus (p < 0.05) activity onset was delayed post-intervention. CONCLUSIONS: Self-neurodynamic sliding techniques modify muscular activity and onset during prone hip extension, possibly reducing unnecessary adaptations for protecting injured components. Future work will analyze the effects of self-neurodynamic sliding techniques during other physical tasks.

Does Kinesiophobia Modify the Effects of Physical Therapy on Outcomes in Patients With Sciatica in Primary Care? Subgroup Analysis From a Randomized Controlled Trial.

BACKGROUND: A higher level of kinesiophobia appears to be associated with poor recovery in patients with sciatica. OBJECTIVE: The aim of this study was to investigate whether kinesiophobia modifies the effect of physical therapy on outcomes in patients with sciatica. DESIGN: This was a subgroup analysis from a randomized controlled trial. SETTING: The study was conducted in a primary care setting. PATIENTS: A total of 135 patients with acute sciatica participated. INTERVENTION: Patients were randomly assigned to groups that received (1) physical therapy plus general practitioners' care (intervention group) or (2) general practitioners' care alone (control group). MEASUREMENTS: Kinesiophobia at baseline was measured with the Tampa Scale for Kinesiophobia (TSK) and a single substitute question for kinesiophobia (SQK). Pain and recovery were assessed at 3- and 12-month follow-ups. Regression analysis was used to test for interaction between the level of kinesiophobia at baseline and treatment allocation. Subgroup results were calculated for patients classified with high fear of movement and for those classified with low fear of movement. RESULTS: Kinesiophobia at baseline interacted with physical therapy in the analysis with leg pain intensity at 12-month follow-up. Kinesiophobia at baseline did not interact with physical therapy regarding any outcome at 3-month follow-up or recovery at 12-month follow-up. When comparing both treatment groups in the subgroup of patients with high fear of movement (n=73), the only significant result was found for leg pain intensity difference from baseline at 12-month follow-up (intervention group: X̅=-5.0, SD=2.6; control group: X̅=-3.6, SD=2.7). LIMITATIONS: The post hoc study design and relatively small sample size were limitations of the study. CONCLUSIONS: In 135 patients with sciatica, evidence shows that patients with a higher level of kinesiophobia at baseline may particularly benefit from physical therapy with regard to decreasing leg pain intensity at 12-month follow-up.

Conservative treatments for lumbar radicular pain.

Lumbar radicular pain is a frequent medical pathology and represents a significant burden on society. The diagnosis of sciatica is largely clinical, in the setting of a combination of radicular pain and neurologic deficits (motor, reflexes, and/or sensation) or a positive straight leg raise test. Imaging is generally not necessary for sciatica, except in the presence of warning signs or in the setting of persisting or worsening pain. The recommended first-line treatment has not yet been clearly established. The choice of a conservative treatment approach combined with simple analgesics in the initial stages seems to be reasonable. A detailed discussion with the patient is important to explain the fact that surgery may only be necessary in the event of pain persisting in excess of 3 months or because of the development or worsening of a neurologic deficit. More high quality studies are clearly required to assist the medical practitioner in knowing how best to treat this group of patients.

Endometriosis ciática: una causa poco conocida de ciatalgia / Sciatic endometriosis: A little known cause of sciatica

La ciática cíclica debida a implantación de tejido endometrial en el nervio ciático es una causa muy rara de ciatalgia. Se presenta en mujeres en edad fértil, en forma de episodios de dolor del nervio ciático de presentación cíclica coincidentes con la menstruación. Son varias las teorías de la patogénesis, la más aceptada sería la del implante endometrial por menstruaciones retrógadas. El diagnóstico y tratamiento tempranos son fundamentales para prevenir una mononeuropatía sensitivomotora del nervio ciático y el daño irreversible. Se presenta el caso de una mujer joven con dolor ciático crónico recurrente resistente a tratamiento con medidas físicas rehabilitadoras y analgesia de tercer y cuarto escalón de la OMS. Una RM de pelvis demostró la presencia de endometriosis ciática. Tras la realización de doble anexectomía y bloqueo hormonal mejoró el cuadro clínico (AU)

Cyclic sciatica due to implantation of endometrial tissue into the sciatic nerve is a very rare cause of sciatic pain. This disorder occurs in women of childbearing age in the form of episodes of cyclic sciatic pain that coincide with menstruation. Several pathogenic theories have been proposed and the most widely accepted is probably endometrial implantation due to retrograde menstruation. Early diagnosis and treatment are essential to prevent sensorimotor mononeuropathy of the sciatic nerve and irreversible damage. We report the case of a young woman with recurrent chronic sciatic pain refractory to treatment with physical rehabilitative measures and third and fourth step analgesia in the World Health Organization’s analgesic ladder. Pelvic magnetic resonance imaging showed the presence of sciatic nerve endometriosis. The performance of double o ophorectomy and hormone blockade improved the clinical picture (AU)

Lumbociática como forma de presentación de una malformación vascular: síndrome de Foix-Alajouanine / Sciatica as a presentation form of a vascular malformation: Foix-Alajouanine syndrome

La lumbociática y la lumbalgia son el motivo más frecuente de consulta de origen musculoesquelético en atención primaria y especializada. Las malformaciones vasculares medulares y entre ellas las fístulas arteriovenosas son una rara entidad, pero una causa tratable de tetraplejía progresiva. Los síntomas de aparición pueden ser dolor radicular y lumbar, debilidad y alteración de esfínteres entre otros. La fisiopatología de estas malformaciones explica mediante las variaciones de presión venosa la forma de aparición relacionada con los esfuerzos y la clínica tan variable. Es imprescindible un diagnóstico diferencial con otras afecciones con sintomatología neurológica. El diagnóstico y tratamiento precoz puede evitar la progresión. Presentamos el caso de un varón de 40 años diagnosticado inicialmente de lumbociática, que evolucionó de manera aguda a una paraparesia y cuyo diagnóstico resultó ser una fístula arteriovenosa medular. Describimos los tipos de malformaciones arteriovenosas y su fisiopatología (AU)

Sciatica and low back pain are the most frequent reasons for skeletal muscle consultation in primary and specialized care. Spinal cord vascular malformations, among them arteriovenous fistulae, are a rare but a treatable condition of progressive paraplegia and tetraplegia. The initial symptoms may be radicular and lumbar pain, weakness and sphincters disorders, among others. The pathophysiology of these malformations explains the presentation form related to efforts and such variable clinical symptoms according to the variation of venous pressure. A differential diagnosis must be made in regards to other diseases that have neurological symptoms. Early diagnosis and treatment can prevent the disease-progression. We report the case of a 40-year old man initially diagnosed of sciatica that evolved to acute paraparesia. Finally, he was diagnosed of spinal arteriovenous fistula. We describe the different types of arteriovenous malformations and their pathophysiology (AU)

Predictors of patient-reported recovery from motor or sensory deficits two years after acute symptomatic lumbar disk herniation.

OBJECTIVE: To determine the prevalence of patient-reported recovery from motor or sensory deficits over 2 years of follow-up after acute symptomatic lumbar disk herniation and to identify predictors of perceived recovery. DESIGN: A prospective inception cohort. SETTING: An outpatient spine clinic. PATIENTS: Consecutive adults with lumbosacral radicular syndrome (onset ≤12 weeks) due to symptomatic lumbar disk herniation, confirmed by magnetic resonance imaging: 95 patients with a baseline motor deficit by physical examination and 59 patients with a baseline sensory deficit by physical examination. METHODS: The patients received individualized nonsurgical treatment or, in a minority of cases, surgical treatment. All of the patients underwent a standardized baseline neurologic examination, including motor and sensory testing. Patients with a motor or sensory deficit at the baseline examination reported on whether they perceived persisting weakness or sensory deficits at 1- and 2-year follow-up. We calculated the 1- and 2-year prevalence of patient-reported persisting weakness or sensory deficits. We examined factors associated with perceived recovery from motor or sensory deficits by using bivariate analyses and multivariate logistic regression. RESULTS: Among patients with a baseline motor deficit, the prevalence of patient-reported continuing weakness was 38% at 1 year and 25% at 2 years. Among patients with a baseline sensory deficit, the prevalence of patient-reported continuing sensory deficits was 53% at 1 year and 47% at 2 years. A positive straight leg raise test (odds ratio [OR] 0.26 [95% confidence interval (CI) 0.08-0.83]) and opioid use (OR 0.24 [95% CI 0.06-0.83]) were independently and negatively predictive of patient-reported motor recovery. Female gender was independently and negatively predictive of patient-reported sensory recovery (OR 0.20 [95% CI 0.04-0.99]). CONCLUSIONS: Patient-reported recovery from motor deficits after lumbar disk herniation occurs for 75% of patients over 2 years, but recovery from sensory deficits over this time frame occurs in only 53% of patients. A positive straight-leg raise test and female gender may predict poor recovery from motor and sensory deficits, respectively.

A single question was as predictive of outcome as the Tampa Scale for Kinesiophobia in people with sciatica: an observational study.

QUESTION: In people with sciatica in primary care, can a single question be used to predict outcome at 1 year followup as accurately as validated questionnaires on kinesiophobia, disability, and health-related quality of life? DESIGN: Observational study within a randomised cohort. PARTICIPANTS: 135 people with sciatica in primary care. OUTCOME MEASURES: Kinesiophobia was measured with the Tampa Scale for Kinesiophobia (TSK), disability with the Roland Morris Disability Questionnaire (RDQ), and health-related quality of life with the EQ-5D and the 36-item Short Form (SF-36) Physical Component Summary. Participants also answered a newly devised substitute question for each questionnaire on an 11-point numerical rating scale. Global perceived effect and severity of leg pain were recorded at 1 year follow-up. RESULTS: The correlation coefficient between the TSK and its substitute question was r=0.46 (p<0.001). The substitute question was better at predicting pain severity in the leg at 1 year follow-up than the TSK (addition of explained variation of 11% versus 4% in a logistic regression analysis). The TSK and its substitute question did not significantly differ in their prediction of global perceived effect at 1 year follow-up. The other substitute questions and both the RDQ and EQ-5D did not contribute significantly to one or both of their prediction models. CONCLUSION: It may be feasible to replace the TSK by a single substitute question for predicting outcome in people with sciatica in primary care. The other substitute questions did not consistently predict outcome at 1 year follow-up.

Influence of directional preference on two clinical dichotomies: acute versus chronic pain and axial low back pain versus sciatica.

OBJECTIVE: To determine whether outcomes from treatment determined by subjects' directional preference (ie, reduction in back and/or leg pain, by performing a single direction of repeated end-range lumbar movement) would vary based on pain duration, location, or neurologic status. DESIGN: A secondary analysis of data from a multicenter randomized clinical trial. SETTING: Eleven physical therapy departments or clinics in 5 countries, with referrals for both acute and chronic low back pain. SUBJECTS: Seventy-one of 80 subjects with acute to chronic low back pain, and with and without radicular leg pain, and with or without mild neurologic deficit, were found at baseline to have a directional preference and were then treated with directional exercises that matched their directional preference. METHODS: All of the subjects were treated for 2 weeks with directional exercises and compatible posture modifications. Independent variables were pain duration, pain location, and neurologic status. MAIN OUTCOME MEASUREMENTS: Primary measures were back and leg pain intensity and function (Roland Morris Disability Questionnare). Secondary measures were activity interference, medication use, depression (Beck Depression Inventory), and a self-report of improvement. RESULTS: The subjects significantly improved their back and leg pain intensity, disability, and all secondary outcome measures, but pain duration, location, and neurologic status classification did not predict treatment responsiveness. Across all pain duration categories, 91%-100% either improved or resolved completely. There also was significant improvement across all pain location and neurologic status categories, with no significant differences across the outcome variables. CONCLUSIONS: In subjects found to have a directional preference who then treated themselves with matching directional exercises, neither pain duration nor pain location and neurologic status predicted their uniformly good-to-excellent outcomes.

A pilot study of the prevalence of leg pain among women with endometriosis.

Radiating leg pain is a common symptom presenting in manual therapy practices. Although this symptom has been reported as a complication of endometriosis, its prevalence and characteristics have not been studied. We surveyed members of a national endometriosis support group with endometriosis using a self-administered, mailed questionnaire. The main outcome measures were the prevalence and characteristics of leg pain. Of 94 respondents, leg pain was reported by 48 women (51%), and was bilateral in 59% of these symptomatic women. The likelihood of experiencing leg pain was related to weight gain since age 18, age, and height. The most common treatments tried included exercise, over-the-counter medications, and massage therapy, all with variable results. These data support leg pain as a prevalent complication of endometriosis, and that the disease may affect multiple peripheral nerves. Manual therapists should remain aware to this possible etiology for radiating pain.

A pilot study examining the effectiveness of physical therapy as an adjunct to selective nerve root block in the treatment of lumbar radicular pain from disk herniation: a randomized controlled trial.

BACKGROUND: Therapeutic selective nerve root blocks (SNRBs) are a common intervention for patients with sciatica. Patients often are referred to physical therapy after SNRBs, although the effectiveness of this intervention sequence has not been investigated. OBJECTIVE: This study was a preliminary investigation of the effectiveness of SNRBs, with or without subsequent physical therapy, in people with low back pain and sciatica. DESIGN: This investigation was a pilot randomized controlled clinical trial. SETTING: The settings were spine specialty and physical therapy clinics. PARTICIPANTS: Forty-four participants (64% men; mean age=38.5 years, SD=11.6 years) with low back pain, with clinical and imaging findings consistent with lumbar disk herniation, and scheduled to receive SNRBs participated in the study. They were randomly assigned to receive either 4 weeks of physical therapy (SNRB+PT group) or no physical therapy (SNRB alone [SNRB group]) after the injections. INTERVENTION: All participants received at least 1 SNRB; 28 participants (64%) received multiple injections. Participants in the SNRB+PT group attended an average of 6.0 physical therapy sessions over an average of 23.9 days. MEASUREMENTS: Outcomes were assessed at baseline, 8 weeks, and 6 months with the Low Back Pain Disability Questionnaire, a numeric pain rating scale, and the Global Rating of Change. RESULTS: Significant reductions in pain and disability occurred over time in both groups, with no differences between groups at either follow-up for any outcome. Nine participants (5 in the SNRB group and 4 in the SNRB+PT group) underwent surgery during the follow-up period. LIMITATIONS: The limitations of this study were a relatively short-term follow-up period and a small sample size. CONCLUSIONS: A physical therapy intervention after SNRBs did not result in additional reductions in pain and disability or perceived improvements in participants with low back pain and sciatica.

Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica.

BACKGROUND: Acute low-back pain (LBP) is a common reason to consult a general practitioner. Debate continues on the comparative effectiveness of advice on bed rest and staying active as part of the primary care management. OBJECTIVES: To determine the effects of advice to rest in bed or stay active for patients with acute low-back pain or sciatica. SEARCH STRATEGY: We searched the Cochrane Back Review Group Trials Register, CENTRAL, MEDLINE, EMBASE, Sport, and SCISEARCH to May 2009, reference lists of relevant articles, and contacted authors of relevant articles. SELECTION CRITERIA: Randomised trials of the effectiveness of advice to stay active or rest in bed for patients with acute LBP or sciatica. The main outcomes were pain, functional status, recovery and return to work. DATA COLLECTION AND ANALYSIS: Two authors independently selected trials, assessed the risk of bias and extracted data. The trials were combined qualitatively or statistically, depending on data availability and presentation. MAIN RESULTS: We included ten RCTs with varying risk of bias. For patients with acute LBP, results from two trials (N = 401) suggest small improvements in pain relief (SMD 0.22 (95% CI: 0.02 to 0.41) and functional status (SMD 0.29 (95% CI: 0.09 to 0.49) in favour of advice to stay active. For patients with sciatica, there is moderate quality evidence of little or no difference in pain relief (SMD -0.03 (95% CI: -0.24 to 0.18)) or functional status (SMD 0.19 (95% CI: -0.02 to 0.41)), between advice to rest in bed or stay active.Low quality evidence (3 RCTs, N = 931) suggests little or no difference between exercises, advice to rest in bed or stay active for patients with acute LBP. Low quality evidence (1 RCT, N = 250) suggests little or no difference between physiotherapy, advice to rest in bed or stay active for patients with sciatica. No trials that compared different ways of delivering advice. AUTHORS' CONCLUSIONS: Moderate quality evidence shows that patients with acute LBP may experience small benefits in pain relief and functional improvement from advice to stay active compared to advice to rest in bed; patients with sciatica experience little or no difference between the two approaches. Low quality evidence suggests little or no difference between those who received advice to stay active, exercises or physiotherapy. Further research is very likely to have an important impact on the estimate of effect and is likely to change our confidence in it.