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Three Part Question

IN [Adults with acute sciatica] IS [therapeutic ultrasound beneficial] AT [decreasing pain and improving function]?

Clinical Scenario

A 30 year old male gym enthusiast presents with a 3 week history of sudden onset of back pain, after lifting heavy weight, His pain radiates from the lumbar spine to the right posterior thigh lateral calf and foot and has associated mild paraesthesia. He has had treatment with Ultrasound (U/S) before for a different condition and he is asking if U/S could be useful in this case.

Search Strategy

National library for health web interface.
{[lumbar OR (low ADJ back)] AND [sciatica OR radicul* OR (nerve ADJ root ADJ pain) OR (extremity ADJ pain) OR (foot ADJ pain) OR (nerve ADJ root ADJ infammat*) OR (disc AND herniat*) OR (intervertebral ADJ disc) or (disc AND prolaps*)} AND {ultraso* OR (therapeutic ADJ ultraso*) OR (ultraso* ADJ therapy)}. All terms in TITLE and ABSTRACT , limited to HUMANS and ENGLISH language.
MEDLINE 1950 to 31/05/2011, CINAHL 1981 to 31/05/2001, AMED 1985 to 31/05/2011, EMBASE 1980 to 31/05/2011. SPORTDiscus 1830 to 31/06/2011. In addition the Cochrane and PEDro databases were also searched.

Search Outcome

After removing duplicates 251 papers were identified. Only three papers were relevant to the three part question. One was a systematic review of all conservative treatments of lumbar disc herniation with associated radiculopathy. Another was a comparison of mechanical traction, ultrasound and low –power LASER that was included in the systematic review. Finally there was a controlled trial published in 1983 which was not included in the systematic review. The two primary studies were included in the BET.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Nwuga, VC. 1983, Nigeria	N=73 men in 3 groups 1.Bed rest & active U/S 2.Bed rest and placebo U/S 3.Bed rest control Ruptured lumbar disk confirmed by myelogram Nerve root compression by electrodiagnositics Mean of 11 treatments per subject	2b pre-post double blinded controlled trial	Total ROM in Flexion –extension, side flexions and rotations.	Significant pre-post differences	No randomisation, no reporting of drop outs No power calculation, no report of statistical analysis
			4-point subjective scale of treatment response	Significantly higher rate of reported improvement reported by the US group.
UNLU et al, 2008, Turkey	N=60 (range 20-60years with > 12 weeks sciatica or femoral neuralgia and lumbar disc herniation confirmed by MRI scan, randomised in three equal groups: Traction; ultrasound; low power laser.	1b Randomised single blinded After treatment, 1 month and 3 months follow up	Lateral flexion	NSS between traction and LASER. U/S showed less improvement than traction after treatment and than LASER at 1 and 3 months	No control group
			Schober test	NSS between groups
			Muscular tenderness 4 point scale	NSS between groups long term.
			SLR	Significant improvement in the 3 groups at the 1st and 3ed month.

Comment(s)

Both studies had a high compliance although, for the study of (Nwuga, 1983) this is only assumed as the dropout rate is not reported. The study of (Unlu et al., 2008) is methodologically more robust (PEDro score =6 and clinical relevance score 2), but unfortunately it was not controlled.

Clinical Bottom Line

There is some weak evidence to suggest that ultrasound could be beneficial for the treatment of the acute sciatica. There is moderate evidence that ultrasound is no more effective than LASER or mechanical traction.

References

1. Nwuga, VC. Ultrasound in treatment of back pain resulting from prolapsed intervertebral disc. Arch Phys Med Rehabil 1983. 64, 88-89.
2. Unlu Z, Tasci S, Tarhan S, et al. Comparison of 3 Physical Therapy Modalities For Acute Pain in Lumbar Disc Herniation Measured by Clinical Evaluation and Magnetic Resonance Imaging. Journal of Manipulative and Physiological Therapeutics 2008. 31, 191-198.