What are the facts? We can easily be overwhelmed due to information overload
There is so much information out there on Sciatica that it can leave a client/patient more confused, frustrated and overwhelmed than ever. For well-meaning professionals (trainers, coaches and clinicians alike) the overwhelming amount of data can lead to a lack of clear direction on how to help the person in front of them.
The Surprising High Magnitude of the Problem
According to Stynes S et al, approximately two thirds of patients with low back pain (LBP) also report leg pain. With such high occurrence, clinicians and coaches/trainers alike will likely have the opportunity to help guide someone through their recovery of this condition. It is the goal of this blog to provide some guidance on the common questions that we all have about Sciatica.
What is sciatica? – An ambiguous yet common term
The term Sciatica has been thrown around loosely and has confused the consumers to think that any pain that shoots behind the leg must be Sciatica. This is not the case. According to Jean-Pierre Valat et al “The majority of the time, this painful sensation is referred pain from the lower back and is neither related to a disc herniation nor does it relate to nerve-root compression.”
Jean-Pierre Valat and colleagues further state that sciatica for most researchers and clinicians, refers to a radiculopathy, involving one of the lower extremities, and usually related to disc herniation (DH). Furthermore, available evidence from basic science and clinical research indicates that both inflammation and/or compression (of the nerves exiting the spine) are important in order for the nerve root to be symptomatic.
The diagnostic challenge
Clinically, the challenge lies in making an educated guess whether your client/patient is in fact experiencing pain and suffering due to Sciatica as defined above. To help with this challenge, Stynes et al have provided a clinical model that can be useful to dictate the probability of Sciatica. Below are the criteria and associated probability of Sciatica based on how the client/patient describes their experience.
As you can see from this excellent list above sciatica is about leg symptoms arising from nerve irritation in the spine. Neurological tests/deficits are an important part of the assessment of the severity of the condition.
The patient’s perspective
A client or patient who is suffering from Sciatica has most likely been provided with a litany of information from their own research, from friends and family’s experiences or even previous professionals. Those suffering this condition will have difficult questions that we should be prepared to answer if we are to place ourselves in a position to help them understand what to expect and how to navigate the inevitable ups and downs of the recovery process.
Some of these difficult questions include “How long will this last? Do I need steroid medicine (eg. Medrol pack or prednisone), an injection or surgery? Will this go away? Is exercise safe for Sciatica?”
How long will this last?
According to Oosterhuis and van Tulder, “The natural course of sciatica is favourable in the majority of patients.
However, according others the prognosis of sciatica is more variable. Flare ups are probable and long lasting low grade discomfort possible. One recent study by Konstantinou stated that over half of the people experiencing sciatica reported only 30% improvement in their activities of daily living at 12 months. Therefore, suggesting a timeline of predictable, linear improvement is a promise that we cannot keep and one that may foster frustration and concern. It may be a better practice to inform a client that progress is not predicated on complete resolution of symptoms but rather a functional progress of increasing meaningful activities.
For example, if sciatica symptoms are still present but performing a daily task has become easier and less debilitating this can be celebrated and is worth memorializing. The more a practitioner can celebrate the small wins WITH the client, the more likely the client is to be encouraged to resume meaningful activities that will aid in the recovery process.
Do I need a scan & if so when?
A retrospective study of 2 years published in the Global Spine Journal by Gupta et al showed us that “there is no correlation between size of a lumbar disc herniation and the likelihood that a patient will require surgery after 6 weeks of nonoperative management.” This is a reminder for the clinicians and clients alike that patience and a respect of the recovery process for lumbar disc herniations is paramount.
So though the presence of a “large” herniation may seem like a logical anatomical rationale for surgical intervention, we know that this alone cannot be the tipping point for a decision on surgery. This being the case, early scans are often unnecessary barring there are no neurological deficits like mentioned before (especially measurable loss in motor function). However, certainly if disabling leg symptoms persist or worsen beyond 6 weeks and an epidural or surgical consultation is considered an MRI would be indicated. This may depend on the patient’s social situation or context. A professional athlete who stands to lose a great deal of money if they have a long delay in their Return to Sport may receive an MRI and more invasive treatments sooner rather than later.
Do I need an epidural or surgery?
In many cases Sciatica can be managed conservatively with self-management, exercise and manual therapy, but in those cases where the nerve symptoms are worsening after approximately 6 weeks (especially signs of motor weakness such as the ability to heel walk or toe walk), more invasive options should not be ignored. According to Oosterhuis and van Tulder, “international consensus is that surgical treatment should only be offered if the radiating leg pain persists despite a period of conservative management.
Epidurals or oral steroids can be used to manage disabling symptoms that don’t respond to patient education, self-management or other conservative therapies.
Phelopater Sedrak et al suggest that treatment consist of 6 to 8 weeks of nonoperative treatment prior to considering surgical intervention, assuming no significant or progressive neurological deficits. However, others report it makes more sense to wait longer.
What are the likely outcomes for surgery?
In a recent study involving patients with sciatica lasting more than 4 months and caused by lumbar disk herniation, microdiskectomy was superior to nonsurgical care with respect to pain intensity at 6 months of follow-up.
Raymond WJG Ostelo writes in publication via the Journal of physiotherapy, “Recovery rates after conventional microdiscectomy were found to be 66% at 4 weeks and 75% at 8 weeks and the return to work rate was 15% at 2 months. At 2 years, 71% of patients who underwent tubular discectomy and 77% who underwent conventional microdiscectomy reported good recovery.”
A systematic review of 39 cohort studies that included 13,883 participants with sciatica reported that patients will still have moderate/mild levels of pain and disability (2/10 pain and 13% disability) even at the 5-year follow-up after surgery. So though these levels are mild, it is common for those recovering from sciatica to be affected by it long term.
Is Surgery 100% Safe?
Out of 64 patients who underwent surgery 9 had adverse events and 1 had a repeat surgery for recurrent disc herniation. Even though at 6 months post-operatively those who elected for surgery may have superior outcomes, the Weinstein SPORT study showed no difference at 2 years between surgery & no surgery.
It is generally believed that surgery will lead to a faster resolution of symptoms. Yet, in a study published in Sports Health by Sedrak et al of NFL football players this was not the case. 83.0% of those operated on returned to play (RTP) whereas 81.5% in the nonoperative group also RTP. No statistically significant difference for RTP rate was found. Most importantly,” the mean time to RTP for patients undergoing lumbar discectomy was 5.19 months (range 1.00-8.70 months), and 4.11 months (range 3.60-5.70 months) for those treated conservatively.”
In this same study of NFL players it was mentioned that the most common complication of surgery is recurrence of LDH requiring a repeat surgery. This information allows us to understand that even when surgery is indicated it is not full proof and repeat surgery is a not out of the realm of possibility.
Long-term positive outcomes often reported with surgery for sciatica are questioned in this recent 2022 study which looked at results from over 500 patients who were operated on. This study included follow-up data 8 years post-operatively.
- Re-operation rates of 26%
- Unfavorable recovery for 35%
The study’s authors concluded that any softening of surgical criteria would increase the likelihood of negative outcomes.
Can My Disc Herniation Heal Even Without Surgery?
Disc herniations are a very common structural factor that drives sciatica symptoms. For someone who is experiencing relentless sciatica symptoms and worried sick that they are broken and won’t be able to get back to their normal self, hearing this foreign latin terminology as their diagnosis can be overwhelming.
When given this diagnosis, clients often feel they are doomed and the only option is surgery. As we have touched on above, we know that this is not always the case. In addition a systematic review by Chiu et al looked at 361 herniated discs over an average of 18.6 months below is a phenomenal summary of the findings.
These findings show that discs CAN and DO heal over time and that the bigger the disc herniation the better the odds that the disc herniation will at least get smaller.
Furthermore, we know from studies like J J Jarvik et al and W Brinjikji et al that disc bulges and herniations occur in people who have NEVER experienced low back pain. Below are two great summaries:
So to the person who is scared and overwhelmed who has been given a scan and told they have a disc herniation, just know that this herniation may get smaller over time, it just may take on average over a year to do so. Also, a third to over half of people with no pain have the same thing so you CAN do the things you love and achieve your goals with this diagnosis. Though the road to recovery is never as easy as we would like it to be. However with support and guidance getting back to normal life and in some cases even better should be possible.
Can Sciatica be Cured or DO I have to learn to live with it?
The likelihood of complete resolution of symptoms with or without surgery is something that cannot be promised but this does not mean that there is no hope. Data presented above shows a generally positive prognosis for sciatica treated both operatively and non-operatively. However, recurrences are common and complete resolution of all symptoms is not always possible.
Because sciatica is often persistent, it is crucial that we put the focus on gradual return to (home, occupational & recreational/sport) activities. To achieve this the process is simple – gradual exposure to basic rehab training elements and progressive overload. In effect, we are conditioning the body anew to handle normal stress and strain. By re-conditioning it the body’s tolerance rises and sensitivity falls.
Three of world’s top musculoskeletal pain rehabilitation experts, Mosely, O’Sullivan and Linton reported on the safety of activity resumption, and the role of positive health coaching and support during this process. They further emphasized how important this is to the patient’s mental outlook.
Shifting the focus from symptom amelioration to what one CAN physically do provides an achievable goal. Ones tolerance for valued activities can improve with reassurance and reactivation even if symptoms persist.
Is exercise safe for Sciatica?
Patients who engage in exercise before and after spine surgery have better mental health and spine-specific recovery trajectories than those who do not. All health care providers should encourage patients to exercise while they are waiting for surgery. Post-operatively as soon as the surgeon gives the go ahead it is important to begin a rehab (strength and conditioning) program.
Clinical guidelines recommend the provision of ‘encouragement to stay physically active’. Moreover, bed rest is not recommended.
Exercise and physical activity is not only safe for those suffering from Sciatica, it is highly encouraged early and often by the current literature. The role of the clinician here is crucial to reassure and reactivate the client/patient to resume activities that are tolerable as soon as possible.
Many people who seek medical advice are rightfully concerned and may be afraid to perform daily activities due to their experiences which cause pain and disability. However, physical activity is not as risky as we once thought and may be the key ingredient to kickstart a positive recovery.
To best recognize and manage Sciatica, an alliance between the client/patient and the clinician is critical. Traditional healthcare models that rely on the clinician to “fix” a problem are not robust enough to address this complicated condition. Collaboration, expectation of “Flare-ups”, and ongoing support are crucial (Alice Kongsted, Jan H).
Which Exercises are Best for Sciatica?
Clinically we know that exercise is valuable, but encouraging general physical activity may be even more so. Fernandez et al concluded “there was no difference at intermediate and long term follow ups between advice and exercise for patient relevant outcomes…leg pain and disability status”.
Recommendations regarding exercise therapy for sciatica vary among the clinical guidelines because the evidence is inconclusive. (Physiotherapy management of sciatica 2020 Ostelo) The Danish multidisciplinary guidelines recommend for sciatica considering supervised exercises as an addition to usual care. Supervised exercise therapy includes directional exercises, motor control exercise, nerve mobilization, or strength exercises. But no specific recommendation for a specific type of exercise treatment was made. For clinical practice, that means that the type of exercise should be aligned with the specific complaints and wishes of the patient and the specific training of the physiotherapist. (Mette Jensen Stochkendahl, Per Kjaer, Jan Hartvigsen, Alice Kongsted , et al).
Choosing an exercise to help someone become more confident and resilient is the goal and requires empirical trial and error. There are no recipes or “cookie cutter” protocols which work best. Certainly there are no “3 best exercises for Sciatica”. Creating a collaborative alliance anchored to regular communication and ongoing support will build more trust between client and practitioner.
Traditional healthcare approaches reliant on the clinician to “fix” or cure the problem are not appropriate for this complex condition. Collaboration, expectation of “Flare-ups”, and ongoing support are crucial (Alice Kongsted, Jan H).
For people dealing with sciatica we know there is a high probability of recurrence and there is a possibility of mild as well as persistent, lower grade symptoms. To provide the best possible care that is evidence-informed and person-centered, requires the clinician to support the patient by guiding and encouraging them along their journey. By supporting a client to become resilient both physically through physical activity as well as mentally through managing expectations and providing knowledge of normal recovery, self-efficacy becomes not only possible but achievable.