Neuro-dynamic Mobilisations in Clinical Practice and the Experience of Radicular Symptoms

Part 1 of this Blog presented literature on the efficacy of NDM, with some supporting its use in painful radiculopathy. In discussing NDM use in clinical practice, it is worth noting that although natural history and conservative treatment like NDM can be favourable for these conditions, at 12 months post onset, at least 33% of people have on-going symptoms (Vroomen et al, 2000). Konstantinou et al (2018) looked at conservative management and found that only 55% of patients had an improvement in symptoms at 12 months. This is significant as the symptoms experienced are often significant and difficult to live with (Ong et al, 2011). Boote et al (2017) found that radicular symptoms affected all areas of people’s lives including their relationships, work and sleep. During MSc education, I have not only been asked to explain why I am using techniques but also to attempt to understand a person’s experiences and listen to them as an expert in their lifeworld. A simplified, bio-medical approach is tempting but this neglects the complex, embodied nature of human beings (Cassell, 2010). The Department of Health (2014) indicates that for effective management, it is important that it aligns with a person’s perception of what matters to them about the condition and the impact on their lives. When utilising the efficacy literature on NDM in clinical practice, I feel that aspects of ‘what matters’ to people with the conditions also needs to be taken into account.

Ryan and Roberts (2019) identified three key themes in a large qualitative study in relation to ‘what matters’ to people experiencing radicular symptoms. These were; “Radicular symptoms”, “Impact of Radicular symptoms” and “Facing the future”.

Radicular Symptoms and NDM
Ryan and Roberts (2019) found radicular symptoms themselves often included incapacitating pain, altered sensation and weakness. Goldsmith et al (2019) participants reported these as mentally and physically draining and highlighted that people need explanations of their symptoms. The NDM literature in part 1 all used pain as an outcome, often with favourable results.  So, NDM management may have a positive effect on this aspect of ‘what matters’ to people but it would appear useful to couple it with explanations of symptoms. Other radicular symptoms including altered sensation and weakness were not investigated in the literature within part 1, so it remains unclear if NDM benefited them and more research is required.

Impact of Radicular Symptoms
Qualitative studies have indicated that radicular symptoms significantly impact people’s lives and relationships (Boote et al, 2017). Participants described increased anxiety, becoming low in mood, less able to participate in social activities and mourned their symptom free ‘self’ (Ryan and Roberts, 2019). 

Disability outcomes were common in the research evaluated in part 1. The most common being Modified Oswestry Disability Questionnaire (Basson et al 2017; Ferreira et al, 2016). These measures do assess function and mood, however, use set questions, which does not allow a person to address areas that are most important to ‘them’. It is not clear whether NDM intervention influenced individual’s experiences of the impact of symptoms. Aspects of living with radicular pain may require approaches to help people re-connect with their symptom free self and make sense of their experience, alongside NDM techniques.

Facing the Future 
Participants with radicular symptoms in both Ryan and Roberts (2019) and Goldstone et al (2019) perceived uncertainty about the future, loss of hope, worry about their potential to work, support themselves and return to activities that gave them purpose. Participants in both studies reported this had led to suicidal thoughts. This highlights the severity of impact on people and significance of a holistic approach. It requires listening to them, legitimising their symptoms and the effects of living with the condition (Verbeek et al 2014).

The ‘Place’ for NDM
Keeping these reported experiences of living with radicular symptoms in mind has helped me with reasoning the ‘place’ for NDM in management of these conditions. NICE (2016) recommends people with radicular symptoms are treated conservatively for the first 6-8 weeks. Having completed the evidence review in part 1 and in the absence of strong evidence on what conservative management should consist of, I feel it is reasonable to offer NDM as a part of physiotherapy intervention.  However, for those with severe and enduring symptoms, surgery, nerve root injections, +/- psychological support is recommended. When compared with prolonged conservative treatment, surgery has been shown to offer faster relief (Lewis et al, 2011). Early identification of people who may require injection or surgery could be achieved with a focus on individual impact of symptoms and their lived experience (Ryan and Roberts, 2019). Being aware of the limitations of the evidence presented in part 1, listening to the impact on people and ‘what matters’ to them could help guide decisions around this.

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Images 

Copyright Laura Jazwinski 2020 : All images were commissioned for the sole purpose of use within this project and were produced, with permission for their use, by Laura Jazwinski- Illustrator