I wrote a post several weeks ago giving readers history and objective findings of a difficult chronic low back pain case.  Revert back to it before reading on.

Patient was treated in physical therapy for 3 weeks with no expression of improvement per SANE scale, no change per GROC, only short term centralization phenomenon but no carry-over beyond 3 hours, and no changes in pain rating scale (still 6/10 currently, 6/10 at best and 6/10 at worse).  However, Oswestry score did decrease from 56% to 42%, a drop from 28 to 21 points, or 7 point difference.

Therefore, even though high construct of central sensitization, “ramped up CNS”…she was referred out as I wasn’t doing anything for her.

She returned to our office s/p 1 week ESI (epidural steroid injection) for further therapy with following results:

1. Her pain is significantly improved and highest pain has been in a week has been 2/10.

2. No leg symptoms (centralized)

3. Only has taken 1 pain pill in a week (initially took pain pills everyday).

Some insight/questions:

1. She did have a positive crossed SLR on initial evaluation (highly specific for IDH)…maybe she did need ESI based on this finding itself…or as my assumption…she was so ramped up that this gave a false positive finding.

2. Even though functionally improved, patient did not express changes at all with a multi-modal physical therapy treatment so don’t rely on functional scales.

3. It has been only a week s/p ESI, but was this the intervention needed for success?

What are your impressions for referring out for ESI? What signs/symptoms indicate success for this procedure, or is it just failure of PT intervention?



  1. Based on your initial evaluation she has an S1 radiculopathy on the right. (Diminished reflex, loss of strength and sensation all correlated to that spinal level.)

    Werneke has suggested that to term a response as centralization there should be progressive improvement between visits. That was not the case here.

    McKenzie has stated that failure to respond is common in people with a radiculopathy. Given her response to the ESI it suggests that she had a strong chemical/inflammatory component of her pain mechanism. It required a chemical response.

    Some conditions just don’t respond to PT. Some respond better to PT after an injection.

    Hopefully you can help her to keep her symptoms from recurring.

    1. Paul,
      Yes, absolutely agree with all your statements. I would have assumed how “hot” the area was if she didn’t have symptoms for 7+ years. I’ll keep track of her over next few weeks with hope she continues to improve.

  2. I think physiotherapy is one of the best options for radiculopathy. I’m saying this from my own experience. I was suffered from L5/s1 disk hernia for almost 5 years and had consulted an expert physiotherapist for treatment. He had suggested doing some stretching and pain relief modality, and cold therapy along with the medication. It really worked. Now, I got relieved from the pain, Still I’m continuing my exercises which include upper back extension, total back extension, curl ups and some stretching exercises.

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