I’m sure that you must have heard of sciatica but do you really know what it is or much about it? That is exactly what we are going to discuss in this article.
What is Sciatica?
Sciatica is nerve pain that travels symptomatically down the back of your leg via the sciatic nerve. It also can go by other names such as Lumbosacral radicular syndrome, nerve root pain, and nerve root entrapment but again these are broad terms (Koes et al 2007).
Is Sciatica a symptom rather than a diagnosis?
Short answer yes.
Many actual diagnoses can cause sciatica, which we will discuss later. The symptoms are pain, tingling, or numbness that follow the dermatome pattern of the nerve supply (see further down the page for reference). It is also possible to get muscle weakness in a corresponding myotomal distribution, which is the nerve supply to the muscles (Chou 2012).
If Sciatica is more of a symptom, then what can cause it?
Disc prolapse or herniation (slipped disc):
According to Koes et al (2007), 90% of cases of sciatica are caused by a Lumbar disc prolapse or herniation with nerve root compression, which is when a disc in the lower back protrudes and presses on the nerve root. The levels that this would have to press on to cause “Sciatic” symptoms would be S1 and S2, which are the Sacral levels number 1 and 2, as these nerves supply the back of the leg. Interestingly, if there was a disc prolapse on a different level then the symptoms would not be in the back of the leg and would not be called sciatica. For example if a disc pressed onto L1, which is Lumbar level 1 then the symptoms would be into the front of your groin. What is fascinating, is that this doesn’t have a fancy name like “groinyatica!” Yet the diagnosis would be the same, just a different level.
Spondylolisthesis:
This is when the vertebra above moves forward relative to the one below causing compression of nerves.
Spinal stenosis:
Stenosis means narrowing and in this case there are different types of spinal stenosis, which are caused by a spondylolisthesis, degeneration or can be genetic.
Central spinal stenosis: This is where the spinal canal is narrowed and this will typically cause pain down both legs and paraesthesia (abnormal sensation) or even numbness with activities such as walking and they are relived by bending the spine forwards. It is common for somebody to lean forwards onto something to alleviate symptoms.
Lateral recess stenosis and foraminal stenosis: These are narrowings to the nerve root and tend to cause sciatica down one leg rather than two (Van Tulder et al 2010).
Infection:
Most people wouldn’t realise that this can be a cause because luckily it is rare. Examples are discitis, vertebral osteomyelitis, or spinal epidural abscess and these would not be treated by physiotherapy but can be screened for in a physiotherapy assessment.
Cancer:
The dreaded ‘C’ word! Again rare but this can also be a cause of sciatica. Its tends to be Metastatic disease rather than than a primary tumour in the spine and so our assessment looks for what we call red flags, which could be a sign of this (Van Tulder et al 2010). This is a rather big reason why you should get assessed when you have sciatica. Our assessments at both physio clinics can assess you to determine the likelihood of this and therefore the need to get checked out medically and scanned.
What about more broad causes of sciatica?
Posture?
When I was at university I was taught that posture was very important and that if you had bad posture then it could cause back pain or sciatica or something else but more recent research has shown this to be inaccurate. For example, Pape et al (2018) found that slouching actually increased disc heights and disc hydration, which is a good thing. Another study by Korshoj et al (2018) found that prolonged sitting for manual workers actually helped then to recover faster from back problems. What this doesn’t mean though is slouching and sitting for ages isn’t always good. It boils down to variety, the body likes change and movement. There are even phrases that have been coined such as:
Your best posture is your next posture
and
Motion is lotion
This means don’t worry about perfect posture, think more about moving and have a variety of movement and this will be a better approach.
Bending the back?
People with bad backs and sciatica are often fearful of bending in the back as they believe that it is dangerous and that it will cause an injury. Even manual handling courses feed this believe with vilifying bending the back and only to lift with a straight back but I think this is wrong or at least mis-leading. For example, (Lagersted-Olsen et al 2016) found absolutely no association between forward bending and back pain.
Weak core?
Nope, check out the video below:
Age
Sciatica is most common between the ages of 45-64 years (Miranda et al 2002) and is Sciatica is uncommon in people younger than 20 years old according to NICE guidelines (2016).
Height:
Being tall has also been found to be a risk factor too (Miranda et al 2002).
Smoking:
We all know that smoking is bad for you but did you realise that it also increases you risk of developing sciatica?
Mental stress:
Stress gets blamed for a lot these days but it is true that having high levels of chronic mental stress affects inflammation in the body, affect pain thresholds and therefore sensitises you to pain and symptoms and this is why this is a definite risk factor (Miranda et al 2002).
Strenuous physical activity:
Frequent and repetitive lifting, especially while bending and twisting has also been found to increase the risk of sciatica but it is more about the frequent and repetitive than anything else.
Driving:
Again this is more about how much driving. People who drive for a living are more likely to get back pain and sciatica than people that don’t. The discussion is often raised about whether it is the posture, stress or the whole body vibration that is the cause.
How common is Sciatica?
5–10% of all people who have non-specific low back pain, have sciatica and this tends to be worse than the back pain (Koes et al 2007). Evidence suggests that between 13-40% of people will get sciatica in their life and every year 2-34% of people will suffer from sciatica (NICE 2016).
How do you diagnose Sciatica?
Diagnosis of the symptom is easy and obvious but you have to diagnose the real problem causing the sciatica, because the management of each one will be very different. This is why the most accurate way, is to be assessed by a Physiotherapist. We can work out what the cause of the sciatica is, from our subjective history, questions and our objective assessment and this is very accurate for diagnosis. We can assess your sciatica at either clinic in Stoke-on-Trent and it is very important to not bury your head in the sand because there is a definite risk of permanent nerve damage causing weakness and sensory loss. A common sign is foot drop, which is when you are unable to pick your foot up into dorsiflexion and you can trip from catching your foot and your foot slaps onto the floor due to lack of control.. In our assessment we test to see if there is significant muscle weakness or wasting, and can check your reflexes because loss of tendon reflexes is a more severe sign of nerve damage (University of Michigan Health System 2010).
Here are some examples of parts of a physio assessment for sciatica:
A positive straight leg raise test with leg pain between 30-75 degrees is 82% accurate diagnosing a lumbar disc prolapse according to Albeck et al (1996) and Kreiner et al (2014). Another test is the slump test, which is considered 84% accurate for diagnosing a disc prolapse & a negative test is 83% likely it’s not a disc prolapse (Cleland & Koppenhaver 2005).
For stenosis, if the person is over 65, back and pain is relieved by sitting & worsened with walking/standing then it’s 89% accurate for diagnosing stenosis (Cleleand & Koppenhaver 2005).
It could be something else:
our assessment will also rule out other problems that could be mimicking sciatica such as the Hip joint, Sacroiliitis, Greater Trochanter pain syndrome, Lumbar Facet joint pain, Piriformis syndrome, Neuropathy, Organ referral, Myelopathy and more (NICE 2016).
Scans?
Contrary to popular belief scan aren’t the best way to go here. They are only indicated in patients with “red flag” signs or symptoms or there is a potential need to inject or perform surgery.
In fact patients given an MRI early on didn’t recover any faster than those who didn’t (Modic et al 2005).
What are red flags?
These are signs of serious pathology such as cancer and infections as we mentioned earlier.
Here are a list of red flags for sciatica:
Cauda equina syndrome:
Sciatica in both legs
Severe or worsening neurological deficit in both legs (major motor weakness with knee extension, ankle eversion, or foot dorsiflexion).
Difficulty urinating or being unable to feel urination.
Urinary retention (being unable to go) with overflow urinary incontinence.
Faecal incontinence
Loss of sensation of rectal fullness.
Saddle anaesthesia or paraesthesia (perineal or genital sensory loss).
Laxity of the anal sphincter.
Cancer:
If the the person being 50 years of age of older.
Gradual onset of symptoms.
Severe unremitting constant pain that remains when the person is lying on their back, aching night pain that prevents or disturbs sleep, pain aggravated by straining and thoracic pain.
Localised spinal tenderness.
After four to six weeks of conservative treatment there is no symptomatic improvement.
Unexplained weight loss.
Past history of cancer, especially ones more likely to metastasize such as gastrointestinal, breast, lung, , prostate, renal and thyroid.
Spinal fracture:
Sudden and severe central spinal pain which is relieved by lying down.
There may be a history of major trauma, but not always sometimes even minor trauma, or even just lifting something innocuous can cause this in people with bone density issues such as osteoporosis or those who use corticosteroids.
Structural deformity of the spine on palpation may be present.
There may be point tenderness over the bone.
Infection:
As with many infections a fever will be present.
Known Tuberculosis, Diabetes or recent urinary tract infections.
Have a history of intravenous drug use.
Immune system issues: HIV infection, use of immunosuppressants, or any person who is immunocompromised.
It is very important to know that you should not base your diagnosis from these red flags from one single “red flag” question, you need several and even then it indicated the need to investigate rather than you have a problem listed above (Henschke et al 2013).
Other than these red flags indicating a scan then the biggest problem with scans is incidental findings, which is seeing things wrong on the scan that are not relevant. Amazingly this is rife. Just because a nerve is being compressed doesn’t mean that it will cause symptoms and this is key to understand when thinking about scans.
“Healthy nerves and nervous system can tolerate a lot of compression. This tolerance might be reduced in unhealthy population but lets not assume all nerve pain comes from impingement/compression. Sometimes nerves are just extra sensitive” – Dr. Annina Schmid, PT, PhD
Weiner et al (2008) found that 28% of people who had a disc prolapse on an MRI scan didn’t actually have one when they went in surgically and even more interestingly 33% of people that had a clear MRI did actually have one when they went in surgically. Not very accurate then hey?
Spinal problems are normal (sometimes)!
Brinjikji et al (2015) found the following things on normal non painful young people:
So why don’t these people have pain?
Pain is complex, things such as stress, anxiety, depression, lack of sleep, nutrition and more can sensitise your body to pain or symptoms.
How do you treat Sciatica?
As detailed earlier, you need to think broad as well as specific, so make sure that you consider things like, stress, anxiety , sleep etc. as these can be far more significant than you may think!
This being said, not all sciatica is treated in the same way at all. This is simply because each diagnosis causing the symptom is different. This is why when you are told that you have sciatica, it isn’t enough.
Physio reduces the need for scans by 34%, Injections by 42%, Opiods by 78% & surgery by 45% (Fritz et al 2012).
Advice and support:
All patients with sciatica need re-assurance and advice to not fear movement or avoid activity in general. This doesn’t mean to just carry on as normal but absolute rest is not the correct approach, so don’t just lie in bed! It is important to get back to normal daily activities and work as quickly as able as delaying this is not great for expected recovery. Heat is great to relive pain and spasm and enable movement. This can be as simple as a wheat bag or hot water bottle. When in bed on your side, it may be more comfortable to have a small firm cushion between the knees. For back sleeping, it may help to have several firm pillows under the knees.
This type of pain is over exaggerated by the body and pain is not a great indicator of harm so although painful it is not harmful to be in pain when moving and doing activities through the day.
Due to this overprotected response you don’t need to be pain-free before returning to normal activities or work. In fact getting back to work even with a phased return or modified duties get people back to normal faster than just staying off for longer. (Koes et al 2007).
Pain medication:
As we mentioned previously, pain is very over exaggerated and this is a limiter to recovery so pain is basically in the way and needs to be controlled to enable progress. Firstly paracetamol alone is not effective for managing sciatica so don’t go there. However, a good starting point is trying a nonsteroidal anti-inflammatory drug (NSAID) such as ibuprofen or naproxen as long as you are able to take this. The key is to use the least amount of medication to get the desired effect as there are negative side effects to any medication. Along with using an NSAID you should use a Gastroprotective medication due to the negative affect on the stomach commonly used here is Omeprazole.
The next level up is codeine with or without paracetamol. You should only use this if you can’t use nonsteroidal anti-inflammatory drugs or they are not effective or tolerated. Once again, use the least amount of medication to get the desired effect as there are negative side effects in this case constipation and opiod dependence.
As sciatica is nerve pain then it may be useful to try a neuropathic pain medication, such as amitriptyline, gabapentin, duloxetine or pregabalin.
Muscle spasm is very common with back pain and sciatica so if this is severe enough then up to 5 days of muscle relaxant medication can be useful, such as diazepam. Interestingly, Friedman et al (2017) found that diazepam combined with naproxen was no better than placebo but it still works.
Mckenzie treatment:
McKenzie techniques may have a good outcome for patients with a directional preference according to several authors: (Skytte et al 2005, Aina et al 2004). A directional preference is basically a movement that centralises the symptoms closer to the spine.
Machado et al (2010) found that the McKenzie method for acute low back pain was very cost effective due to it’s self sufficiency as it reduces healthcare utilisation.
Peterson et al (2015) compared Mckenzie treatment to spinal manipulation and found that Mckenzie treatment was better for nerve root sciatica pain and moved the symptoms out of the leg back towards the back, which is a good sign of improvement.
Here is an example of a Mckenzie exercise (Only for demo purposes in this instance):
Manipulation and mobilisation of the spine:
According to Kreiner et al (2014), spinal manipulation is an option for symptomatic relief in patients with lumbar disc herniation with radiculopathy. However this is a forceful technique so needs to be carefully considered before attempting. Mobilisations are not as forceful and are also recommended by NICE (2016) , especially in more difficult cases.
Neural and nerve mobilisation:
Evidence found positive therapeutic benefit from using neural mobilisations in neurodynamic dysfunctions such as sciatica (Ellis & Hing 2012). The key here is to apply these types of techniques when the nerve is less irritated and somewhat decompressed otherwise you may risk flaring the nerve up and making things worse.
Injection:
If conservative treatments are not working then an epidural corticosteroid or local anaesthetic injection may be attempted. Epidural steroid injection can be effective for 3 months pain relief in some lumbar disc prolapses. (Bhatia et al 2016). It is important to know that this is not a cure but can be used as a window of opportunity to rehab and get function back to normal.
Higher risk patients:
For people who are at higher risks of a bad outcome due to the higher risk factors mentioned further down, group exercise programmes may be beneficial, Physio with guidance on exercise and a combination of manual therapy such as spinal manipulation, mobilisation, or massage can be very useful and we offer these at both of our Stoke-on-Trent clinics.
Psychological interventions may be required, such as cognitive behavioural therapy to improve some of the barriers to recovery, such as negative thinking and fear etc.
Radiofrequency denervation:
This is a specialised injection, which uses heat to temporarily stop the nerve working in your back and therefore reduce pain. Once again this effect is not permanent so should be used as a window of opportunity.
Surgery:
Surgery is a last resort and is definitely not a guarantee! For example, there is even a medical term called: “Failed back surgery syndrome” This has been shown to occur in up to 50% of surgeries according to a systematic review done by Clancy (2017).
The most common surgery done is a spinal decompression, however the jury is out, Delitto et al (2015) found that surgical decompression has similar effects to Physiotherapy in Lumbar Spinal Stenosis surgical candidates.
Endoscopic percutaneous or open discectomy, which is where they remove some of the prolapsed disc pressing on the nerve either with keyhole or full open surgery. So this is an option if the sciatica is from a lumbar disc herniation (Ruan et al 2016).
After surgery you will need physiotherapy and Here at Hawkes Physiotherapy we will guide you through an exercise program for 4 to 6 weeks. This has been shown to cause a faster decrease in pain & disability after lumbar disc surgery (Ostelo et al 2009).
How long can Sciatica take to go away?
Good news!
Most people recover fully from an acute flare up but 20%-30% of sufferers can have long term problems even after one or two years (Koes et al 2007). What is also good is that 50% of people recover in 10 days and 75% will recover by 4 weeks (Van Tulder et al 2010).
However…
If you haven’t recovered within 12 weeks then there is a 71% chance that you may go onto need surgery after 1 year (University of Michigan Health System 2010). Another interesting finding is that women are more likely to recover slower and they are less likely to recover too according to (Peul et al 2008).
Other known factors that can affect your ability to recover are the following according to Toward Optimized Practice (2015):
Stress
Depression
Anxiety
Having been off work for a longer time
People who don’t enjoy their job
Lack of social or family support
Poor expectations of recovery (pessimism)
Physical work to get back to
Shift workers or anti-social working patterns
Incorrect beliefs about pain such as pain is harmful, movement is bad etc.
Having a compensation claim or applications for social benefits.
Does Sciatica reoccur?
Unfortunately it does, Mehlling et al (2012) found that 54% have least one recurrence within 6 months and 47% within 2 years.
How do you prevent Sciatica?
Prevention is difficult but minimising the risk is possible.
Physical activity:
Physical activity, particularly vigorous activity, is beneficial in helping maintain intervertebral disc health. (Bowden et al 2018) and is therefore an excellent ploy to prevent recurrence, not to mention the other benefits too!
Improving the factors that caused it in the first place:
For example improving things like Stress, Depression and Anxiety. Possibly improving how much driving you do or stopping smoking. The list will be different for everyone.
Strengthening:
To go along with physical activity, strength has been shown to be great at injury prevention and will make you back more tolerant in future. Lauersen et al (2014) found that strength training reduced overuse injury by one third!
Here is an example of a strengthening exercise for the lower back:
Overall:
Sciatica is a symptom not a diagnosis!
You need to get properly assessed to work out the real problem behind the symptom. Here at Hawkes Physiotherapy we do this all the time as sciatica is very common and you can book in at either clinic in Stoke-on-Trent.
Not all sciatica is caused by the same problem so treatments will vary immensely depending on this so don’t just follow a general guide for sciatica because you may make it worse.
We can diagnose, treat and develop a plan to minimise your future risk.
It is important to get the correct management early due to the chance of long term nerve damage and the chance of non recovery if problems persist beyond 12 weeks.
We can also work on how to prevent sciatica recurring too.
If you need any further information or would like to book an appointment then call Hawkes Physiotherapy on 01782 771861 or 07866 195914.
DISCLAIMER:
The content in this blog article is provided for general information purposes only and is not meant to replace a physiotherapy or medical consultation.
