What are the best management options for radiculopathy, including physical therapy and pharmacological interventions like steroids?

Management of Radiculopathy: Physical Therapy and Pharmacological Interventions

For radiculopathy, a structured physical therapy program focusing on core strengthening exercises combined with NSAIDs as first-line pharmacological treatment is the most effective approach for reducing pain and improving function. 1

Initial Assessment and Conservative Management

First-Line Interventions

• Physical Therapy Interventions:

  • Core strengthening exercises (most effective component)
  • Flexion-based exercises for spinal mobility
  • Supervised exercise programs (superior to passive therapy)
  • Structured program for 6-8 weeks 1

• First-Line Medications:

  • NSAIDs for pain and inflammation (monitor for cardiovascular, GI, and renal risks)
  • Acetaminophen as an alternative for those who cannot tolerate NSAIDs 2
  • Consider muscle relaxants for acute pain with muscle spasm if inadequate response to NSAIDs 1

Second-Line Interventions

• For persistent symptoms after 4-6 weeks:
  • Consider duloxetine for chronic pain 1
  • Spinal manipulation may be beneficial for radicular pain (shown to provide greater improvement in leg and back pain at 12 weeks compared to home exercise alone) 2
  • Manual therapy combined with exercise therapy 3

Steroid Use in Radiculopathy

Oral Steroids

• Prednisone may be considered for short-term use in severe radicular pain
• Caution: Prolonged use increases risk of:
  • Osteoporosis (particularly concerning with doses ≥5 mg for ≥3 months) 4
  • Adrenal suppression
  • Muscle weakness
  • Psychiatric effects ranging from mood swings to psychosis 4

Epidural Steroid Injections

• Consider only after failure of conservative management (4-6 weeks)
• Most beneficial for confirmed radiculopathy with corresponding imaging findings 5
• Higher risk of serious complications compared to other interventions 6
• Should be reserved for patients with moderate to severe symptoms who are potential candidates for surgery 2

Imaging Considerations

• Do not routinely obtain imaging for uncomplicated radiculopathy 2
• Imaging indicated only when:
  • Severe or progressive neurological deficits present
  • Red flags suggesting serious underlying condition
  • Persistent symptoms after 6 weeks of conservative management 2
• MRI is preferred for evaluating suspected radiculopathy in surgical candidates or those being considered for epidural steroid injection 2

Common Pitfalls to Avoid

1. Premature imaging: Routine imaging provides no clinical benefit in uncomplicated cases and can lead to increased healthcare utilization 2

2. Overreliance on passive therapies: Active physical therapy with core strengthening is more effective than passive modalities 1

3. Prolonged steroid use: Long-term steroid therapy carries significant risks including osteoporosis, adrenal suppression, and psychiatric effects 4

4. Neglecting self-care education: Patient education about expected course and self-management strategies is essential 2

5. Inappropriate surgical referral: Most cases of radiculopathy resolve with conservative management; surgery should be considered only after failure of comprehensive non-operative treatment 1

Follow-up and Monitoring

• Regular assessment using validated tools every 4-6 weeks initially
• If symptoms persist beyond 6 weeks despite conservative management, consider:
  • Imaging to identify pathology amenable to intervention
  • Referral to specialist for consideration of epidural injections or surgical options 6
• Approximately 80% of patients experience symptom resolution with appropriate conservative treatment 1