Physiotherapy Management of Sciatica

Ancient Greeks and Egyptians suspected a link between lumbar spine pathology and leg pain. Hippocrates introduced the term “sciatica,” which describes pain radiating from the buttock along the lumbosacral nerve roots.

The prevalence and incidence of sciatica vary due to different definitions and data collection methods. The economic burden of sciatica has not been extensively studied, but in the Netherlands, it is estimated to cost around V1.2 billion per year, while in the United Kingdom, healthcare costs are estimated to be £500 million with £3.8 billion in indirect costs.

What Is Sciatica?

Research indicates that sciatica results from a combination of pressure-related, inflammatory, and immunological processes, rather than solely from nerve root pressure. Sciatica is mainly caused by a herniated lumbar disc, where the nerve root gets compressed by the ruptured disc material.

The underlying factor in all these causes is the compression of the lumbar nerve root, leading to inflammation. Other less common causes include spondylolisthesis, lumbar stenosis, foraminal stenosis, and malignancy.

Diagnosis

To diagnose sciatica, a combination of the patient’s symptoms and physical examination findings is relied upon. There is no single symptom or test that can definitively diagnose sciatica. Clinical guidelines recommend utilizing history taking and physical tests together for a conclusive diagnosis.

Specific signs and symptoms such as leg pain dominance, pain location, sensory changes, weakness, and reflex changes indicate sciatica. While the gradual onset of symptoms is typical, rapid and intense complaints can also occur.

Certain physical tests offer additional diagnostic value. It is crucial to exclude serious underlying conditions. Routine imaging is not recommended; however, if conducted, the symptoms should align with the imaging results.

Prognosis

While the prognosis for sciatica is commonly seen as positive, the evidence surrounding it is not entirely clear. Studies examining the progression of sciatica in primary care settings are scarce and often involve patients with both sciatica and low back pain.

A recent study found that only 55% of patients with sciatica showed improvement in disability after one year. Prognostic factors like pain severity, neurological deficit, and symptom duration have yielded inconsistent and mostly unfavorable outcomes.

Conservative Management

The initial approach in caring for patients with sciatica typically involves conservative measures, which include providing information about sciatica and the role of imaging, as well as advising patients to stay active

. This conservative approach aims to educate patients about sciatica, its causes, and potential treatment options. Additionally, emphasizing the importance of staying active and maintaining mobility can help alleviate symptoms and promote recovery.

By encouraging patients to remain physically active within their tolerance levels, healthcare providers aim to prevent the development of secondary complications associated with prolonged inactivity and to support the natural healing process.

Conservative management is often the first line of treatment before considering more invasive interventions, such as medications or surgical options.

Effective communication with patients about the nature and prognosis of sciatica is of utmost importance. In most cases, routine imaging is not recommended unless specific indications, such as suspected cauda equina syndrome or fracture, are present.

It is essential to acknowledge the potential variability among radiologists and the possibility of interpretive errors in imaging reports. Although MRI evidence of spinal changes is associated with back pain, the causality of these findings remains uncertain.

It is worth considering that spontaneous regression of lumbar disc herniation can occur.

Moreover, it is important to be aware that routine imaging may have adverse psychological effects on patients. In a randomized trial, no significant differences in clinical outcomes were observed between participants who received blinded treatment without knowledge of MRI results and those who received unblinded treatment with MRI results.

However, noteworthy improvements in general health were reported by participants in the blinded treatment group.

Advice to Stay Active

It is vital to motivate patients to stay physically active and discourage them from opting for bed rest as part of conservative management for sciatica. Findings from a systematic review suggest that exercise may provide slightly superior short-term relief for leg pain compared to simply staying active without engaging in specific exercises.

However, there is no significant difference in short-term disability between the two approaches. In the long term, both strategies, namely advising patients to stay active and incorporating exercise, appear to yield similar benefits. Exercise can be particularly beneficial when leg pain is the predominant symptom.

Exercise Therapy

Due to inconclusive evidence, there is variation in clinical guidelines concerning exercise therapy for sciatica. The Danish guidelines advocate for customized supervised exercises based on the patient’s specific complaints and the physiotherapist’s expertise.

On the other hand, the Dutch guidelines propose exercise therapy for patients with ongoing complaints, a requirement for intensive supervision, or significant kinesiophobia. When deciding on the appropriate exercise approach, individual factors and treatment goals should be taken into consideration.

Spinal Manual Therapy

Spinal manual therapy (SMT) is commonly utilized by physiotherapists and manual therapists for treating individuals with sciatica. SMT involves mobilization and manipulation techniques to enhance spinal joint movement. However, the effects of SMT are typically modest and short-lived.

While certain studies indicate a slight advantage of SMT in relieving back pain, the evidence remains inconclusive, leading to varying recommendations among guidelines. There are concerns regarding potential adverse events associated with SMT, but most reported events are temporary and of mild to moderate intensity.

Medication

Physiotherapists should be knowledgeable about the evidence regarding medication for sciatica, as patients often ask about it. A systematic review found that medication for sciatica, such as nonsteroidal anti-inflammatory drugs and corticosteroids, showed limited effectiveness compared to placebo.

The quality of evidence was generally low, making it unclear which medication is most effective. Additionally, medications for sciatica can have significant side effects. Combination medications also demonstrated minimal effects on pain and disability, supported by low-quality evidence.

Surgical Management

When conservative treatment fails to improve symptoms, guidelines recommend referring patients to a spine surgeon for evaluation of lumbar surgery. The surgeon carefully assesses clinical and imaging findings to select suitable candidates.

A recent systematic review found that surgery had a modest effect on pain reduction compared to non-surgical interventions, although the difference did not persist beyond one year. Reoperation rates ranged from 0 to 10%, and there were small differences in physical functioning.

Postoperative Physiotherapy

Recovery rates after microdiscectomy surgery for sciatica vary, with 66% at 4 weeks and 75% at 8 weeks. At 2 years, good recovery was reported by 71% of patients who underwent tubular discectomy and 77% who had conventional microdiscectomy.

However, at the 5-year follow-up, patients still experienced moderate levels of pain and disability. Early postoperative rehabilitation programs showed no additional benefits compared to no treatment.

Rehabilitation starting 4 to 6 weeks after surgery did not show significant differences between various types of programs. Physiotherapy had better outcomes for pain and physical functioning, but the evidence quality was generally low.

A multidisciplinary rehabilitation program focused on return to work showed promising results for faster return to work.