Physiotherapy Treatment of Sciatica

Published: 24th November 2008
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The Treatment of Sciatica by Physiotherapists
by Jonathan Blood Smyth

The lumbar nerve roots emerge from the spine and at this point they are vulnerable to impingement from a disc prolapse, causing inflammation and/or compression of the nerve and the symptoms of sciatica. Sciatic leg pain is not common, affecting 3 to 5% of adults and both sexes equally. Men are more likely to get it in their 40s and women in their 50s, with pain symptoms lasting over six weeks in up to a quarter of cases. Physiotherapists are routinely asked to supervise the management of sciatica.

When the intervertebral disc material prolapses it causes injury by two mechanisms: direct mechanical compression of the nerve and chemical irritation. The disc material should not be outside the disc and its toxic chemicals help swelling both of the nerve and its surrounding structures, resulting in blockage of the circulation and of the nerve's normal message conduction. While the prolapse is responsible for the sciatica it has not been shown that the bigger the prolapse the more severe the person's pain.

The lumbar discs are more likely to have prolapses due to the high levels of force they have to endure. When we lift things away from the body, bend over at the waist or perform standing activities the back has to cope with the leverage involved. When stresses are loaded onto the discs the hydraulic mechanism magnifies the forces on the outer walls by three to five times that which the skeleton has to cope with. With time these stresses cause failure of the outer disc material and allow prolapses to occur.

Sciatica usually comes on quickly after an aggravating activity or posture, along with some back pain but this can go off when the leg pain starts. Sciatica is worsened by sneezing, sitting and coughing and is better lying down or standing. The pain is in the buttock and either down the back of the leg or the side and down into the foot. In 5% of cases the affected nerves are the first, second or third lumbar, which give front of thigh pain not beyond the knee. The full picture may sometimes not be present, with individuals describing discrete areas of pain such as the foot only.

The physiotherapist will take the patient's history with particular attention to "red flags" which are indicators of a serious medical reason for the back pain and the patient will not be appropriate for physio. Weight loss, fever, night sweats, age (under 20 or over 55), problems with bladder and bowel control, serious past medical history and night pain will be noted. Any uncertainty means referral to a doctor for investigation. The physio will note any postural abnormalities and the nature, position and activity response of the pain symptoms.

Severe nerve root pain commonly causes postural abnormality such as a bent forward position or a shift of the trunk to one side. The physio tests the movements of the spine and notes the pattern of movement loss and whether the pain centralises on repeated actions in one direction. The sensation, muscle strength and reflex reactions are all tested as part of the examination of the nervous system, with the straight leg raise helping to locate the problem to a particular spinal nerve.

Discogenic pain may change with repeated movements, spreading more towards the leg or in towards the back, the latter being called centralisation. Physiotherapists use this phenomenon to diagnose and treat disc related back pain and examine the joints of the lower limb as thigh and knee pain can be referred from an osteoarthritic hip joint. A full history and examination both eliminates patients who need medical referral for investigation and allow the physio to form a treatment strategy.

Treatments for sciatica due to disc prolapse are many and physiotherapists can choose to use mobilisations and manipulations, lumbar stabilising exercises, the McKenzie treatment path, soft tissue mobilisations such as massage and myofascial release, using analgesics, education about the condition, advice on resting and the best position to relieve extreme sciatica pain. Sciatica naturally settles in time in the vast majority of cases and physios would encourage patients to establish an exercise regime over the long term.

Jonathan Blood Smyth is a Superintendent Physiotherapist at an NHS hospital in the South-West of the UK. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in Manchester.

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