COGENT EVIDENCE
Folarin Babatunde PT PhD MScSEM MScPT BScPT
October 2024
Sciatica (also known as lumbosacral radicular syndrome, ischias, nerve root pain, nerve root entrapment) affects a lot of people and refers to the symptoms of buttock, thigh, and leg pain. Usually, sciatica is due to pain from irritation of the sciatic nerve which travels from the low back down the legs. Typically, sciatica occurs when a disc in the spine gets damaged or worn out and begins to press on the sciatic nerve. Lumbar spinal stenosis and tumors (to a lesser extent) are possible causes.
Anatomy
Sciatica gets its name from the sciatic nerve, the body's largest. There's a sciatic nerve on either side of the body. Each nerve extends through the buttock and down the leg into the foot and toes. However, the most common causes of sciatica does not involve direct injury to a sciatic nerve itself, but rather to the nerves higher in the spine that join to form the sciatic nerve.
Who gets sciatica?
Generally, 5%-10% of individuals with low back pain report sciatica, even though 49%-70% of all individuals report low back pain at some point in their lives. There appears to be no association between sciatica and sex or level of physical fitness.
Personal factors
Age with a peak between 45 and 64 years
Increasing risk with body height except in patients aged 50 to 60
Smoking
Mental stress
Genetic predisposition
Occupational factors
Strenuous physical activity that involves frequent lifting, bending and twisting increases the risk of developing sciatica, especially in those with prior sciatic symptoms
Jobs that causes vibration of the whole body such as machine operators and truck drivers
Jobs where workers are subject to continuous physically awkward positions
What Causes Sciatica?
Sciatica can happen due to any condition that affects the sciatic nerve or any of the five spinal nerves that bundle to form the sciatic nerve. Conditions that can cause sciatica include:
Disc herniation
Degenerative disc disease
Spinal stenosis
Foraminal stenosis
Spondylolisthesis
Osteoarthritis
Tumors, cysts or other growths.
Conus medullas syndrome
Cauda equina syndrome
Late pregnancy as ligaments get looser and the growing baby puts indirect pressure on the sciatic nerve.
What Are the Typical Symptoms of Sciatica?
Sciatica often feels like a bad leg cramp, and the pain is described as sharp ("knife-like"), achy or electrical in nature. The cramp can last for weeks before it goes away. Sometimes, pain occurs with moving, sneezing, or coughing. Sciatica is often accompanied by "pins and needles" numbness, or a burning or tingling sensation down your leg. In a worst case scenario, sciatica can lead to severe muscle weakness, with difficulty lifting the foot on the affected leg.
How Is Sciatica Diagnosed?
Physiotherapists can diagnose sciatica by asking about your symptoms and doing a physical examination. Most patients report radiating leg pain and may also have low back pain but this is less severe than the leg pain. Patients may be asked to report the pattern of the pain and whether it radiates below the knee using drawings of the human body. Sciatica is characterized by radiating pain that follows a dermatomal pattern. Patients may also report changes in sensation along the affected leg. This is followed by physical examination based on neurological testing such as positive response to the Straight Leg Raising (SLR) test (Lasègue’s sign) or the crossed straight leg raising test. The diagnosis of sciatica appears justified if a patient reports the typical radiating pain in one leg combined with a positive result on one or more neurological tests indicating nerve root tension or neurological deficit.
Physical Tests With a Diagnostic Value for Sciatica
Loss of muscle strength, especially loss of dorsiflexion of the foot when L5 nerve root is affected. Usually, this loss is too subtle to lead to a foot drop deformity.
Increased finger-floor distance (> 25 cm).
Straight leg raise test (a negative test is informative since it shows less likelihood of sciatica).
A positive crossed straight leg raise test (increased likelihood of sciatica)
Is Additional Investigation Required?
Blood tests and and diagnostic imaging such as x-ray, MRI or CT are usually not necessary for most people with sciatica except in specific circumstances. This is very important because evidence shows that disc herniations identified by CT or MRI are highly widespread in people without symptoms who do not have sciatica. Similarly, in many people with clinical symptoms of sciatica, lumbar disc herniations are not present on scans.
Furthermore, no one type of imaging method shows a clear advantage over others. The diagnosis of acute sciatica is based on taking a detailed history and physical examination and the treatment is conservative (non-surgical). Imaging may be indicated at the acute stage only if there are indications or “red flags” that the sciatica may be caused by underlying disease instead of a herniated disc. Diagnostic imaging may also be indicated in patients with severe symptoms who fail to respond to conservative care after 6 to 8 weeks.
Please, see your physician immediately if you are experiencing any of the following:
History of cancer, spine infections, or injection drug use
A new fever
Loss of feeling in the groin area
Trouble urinating or controlling the feelings of going to the bathroom
Significant leg weakness
Does Sciatica Get Better?
Sciatica is very unpredictable. Therefore, is hard to predict who will get better and who will still feel pain with or without any treatment. Some people with sciatica recover fully without any treatment. Most pain and related disability resolves within 2 weeks in about 1 in 3 people with acute sciatica and 75% of people reports improvement within 3 months. Unfortunately, about 30% of people with sciatica continue to have pain for one year or longer. It is generally advised that a qualified expert such a a physiotherapist specialized in musculoskeletal health be consulted if symptoms of sciatica lasts more than 12 weeks.
What Options Do I Have to Treat My Pain?
There are many ways to treat pain related to sciatica. However, the evidence is mixed and receiving treatment in a collaborative approach is the most suitable option for effective pain relief.
Anti-inflammatory medications such as ibuprofen or naproxen may provide modest, short-term relief. Acetaminophen (Tylenol) can also be helpful for pain.
Other prescribed medications such as muscle relaxers, steroids, opioids, and gabapentin are not proven to help, and some may have dangerous side effects.
Injections of steroid or numbing medications near the spine may help with short term pain relief but do not lead to a full recovery from sciatica.
Maintaining gentle physical activity (e.g., walking, light housework) as tolerated is important for recovery.
A physical therapist can help to educate you about specific exercises to speed up the recovery process.
There is no strong evidence that treatments like back adjustments, gentle spine stretching (called lumbar traction), or acupuncture are effective for managing sciatica.
How Can Physiotherapy Help?
The first line of care for anyone with sciatica is conservative and physiotherapists play a crucial role at this stage through different interventions.
EDUCATION
Physiotherapists provide clear, detailed and understandable explanation of the nature and prognosis of sciatica to patients. This interaction also offers guidelines on when there is a good reason to get diagnostic imaging.
STAYING PHYSICALLY ACTIVE
Clinical guidelines for management of back and leg pain recommends the provision of ‘encouragement to stay physically active’. Moreover, bed rest should be avoided. Advice to stay active is considered to be an important element of conservative management for people with complaints of sciatica less than 6 to 8 weeks. Effective physiotherapy intervention for sciatica often involves activities such as specific postural instruction, static and dynamic lumbar stabilizing exercises, motor control exercises, muscle strengthening exercises, and directional preference exercises.
THERAPEUTIC EXERCISES
Physiotherapists provide supervised exercise therapy including directional exercises, motor control exercise, nerve mobilization/gliding, or strength exercises for sciatica. In clinical practice, the type of exercise should recommended should be aligned with the specific complaints and desires of the patient and the current available evidence. It is not uncommon to develop a fear of movement called kinesiophobia following sciatica. Physiotherapists can help create a supervised exercise therapy program for anyone showing signs of kinesiophobia
SPINAL MANUAL THERAPY
Physiotherapists skilled in manual therapy usually offer spinal manual therapy (SMT) to their patients. SMT describes a variety of techniques that encompass any manual technique that moves one or more joints within normal ranges of motion with the goal of improving joint motion or function in the spine. Current recommendation is that physiotherapists could consider offering SMT to patients with recent-onset sciatica in addition to usual treatment.
I Am Still in Pain—Should I Consider Surgery?
Surgery has been recommended to improve symptoms in some people with sciatica when conservative treatments such as physiotherapy and pain medications fail to resolve symptoms significantly. Most surgeries for sciatica requires a small cut to the back and special tools to remove the damaged part of the disc in the spine to relieve the pressure on the sciatic nerve. However, there is always a chance that the pain may return even after surgical intervention. The recovery time from sciatica surgery varies among people and typically takes one and a half to three months. Like all types of surgery, there is always a risk of nerve damage and infection. If you are thinking about surgery, speak with a family doctor about deciding if surgery is right for you. We encourage you to use this Decision Aid to help you make up your mind. When surgery is indicated, a supervised physiotherapy and multidisciplinary rehabilitation program has been shown to yield the best results for patients.
MULTIDISCIPLINARY REHABLITATION
Available evidence n return to work showed that a multidisciplinary rehabilitation program that includes elements of back schools and ergonomics focused on, for example, motor control modification, resumption of activities of daily living including work and physical activity and enhancement of pain coping strategies, specifically focused on return to work and coordinated by a medical advisor, led to faster return to work than usual care after spinal surgery for sciatica.
POST OPERATIVE MANAGEMENT
Current evidence shows that when physiotherapy was compared with no treatment or education only after spinal surgery, physiotherapy was associated with better outcomes for pain and physical functioning immediately after treatment.
FOR MORE INFORMATION
Book an appointment with one of our physiotherapists at Cogent Physical Rehabilitation Center for an assessment and discussion on how physiotherapy can help you find relief from sciatica.
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