Effect of physical therapy timing on patient-reported outcomes for individuals with acute low back pain: A systematic review with meta analysis of randomized controlled trials.

OBJECTIVE: The purpose of this systematic review with meta-analysis was to investigate the effect of early physical therapy (PT) for the management of acute low back pain (LBP) on patient-reported outcomes of pain and disability, compared to delayed PT or non-PT care. LITERATURE SURVEY: Randomized controlled trials in three electronic databases (MEDLINE, CINAHL, Embase) were searched from inception to June 12, 2020, and updated on September 23, 2021. METHODOLOGY: Eligible participants were individuals with acute low back pain. The intervention was early PT compared to delayed PT or non-PT care. Primary outcomes included the patient-reported outcomes of pain and disability. The following information was extracted from included articles: demographic data, sample size, selection criteria, PT interventions, and pain and disability outcomes. Data were extracted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) Scale. Random effects models were used for the meta-analysis. SYNTHESIS: Seven of 391 articles met the eligibility criteria and were included in the meta-analysis. Random effects meta-analysis comparing early PT to non-PT care for acute LBP indicated a significant reduction in pain (standard mean difference [SMD] = 0.43, 95% confidence interval [CI]: -0.69 to -0.17) and disability (SMD = 0.36, 95% CI: -0.57 to -0.16) in the short term. Early PT compared to delayed PT did not result in improvement in short-term pain (SMD = -0.24, 95% CI: -0.52 to 0.04) or disability (SMD = 0.28, 95% CI: -0.56 to 0.01), or long-term pain (SMD = 0.21, 95% CI: -0.15 to 0.57) or disability (SMD = 0.14, 95% CI: -0.15 to 0.42). CONCLUSIONS: This systematic review and meta-analysis suggest early PT versus non-PT care is associated with statistically significant reductions in short-term pain and disability (up to 6 weeks) with small effect sizes. The results indicate a nonsignificant trend favoring a small benefit of early PT over delayed PT for outcomes at short-term follow-up but no effect at long-term follow-up (6 months or greater).

Transient Hypokalemic Quadriplegia After a Lumbar Transforaminal Epidural Dexamethasone Injection: A Case Report.

A 30-year-old man with no significant medical history presented with hypokalemic quadriplegia 4 hours after he received a lumbar transforaminal epidural steroid injection (ESI) containing dexamethasone and lidocaine. A comprehensive workup ruled out acquired and hereditary causes of hypokalemic paralysis. Symptoms gradually resolved within hours after potassium restoration with no residual neurologic deficits. Paralysis after transforaminal ESI is uncommon but has been associated with particulate steroids that can coalesce into aggregates and occlude vessels. To our knowledge, there have been no case reports of paralysis after ESI with dexamethasone, a nonparticulate steroid. This transient paralysis is possibly caused by the effects of glucocorticoids on Na-K channels and insulin resistance resulting in hyperglycemia and subsequent hypokalemia. We reviewed the differential diagnosis of transient paralysis after epidural steroid injection in this report. LEVEL OF EVIDENCE: IV.