42 Sciatica

Sciatica

Sciatica is a condition characterized by symptoms of radiating pain in one leg with or without associated neurological deficits on examination. Lumbar disk herniations are a frequent cause of sciatica, for most of the population (70 to 90% of people) symptoms are generally self-limited and often resolve within 3 months (Schoenfeld & Weiner, 2010).

 

Sciatic Nerve
Sciatica is a condition characterized by symptoms of radiating pain in one leg.

Pathophysiology

Symptoms of sciatica radiates along the path of the sciatic nerve, which branches from your lower back through your hips and buttocks and down the leg. Neurovascular bundles may be exposed to mechanical irritation or a noxious biochemical environment at many different points. Prolonged irritation may result in a reduction of intraneural blood flow. In turn, local hypoxia of a peripheral nerve leads to a drop in tissue pH that triggers the release of inflammatory mediators, known as “inflammatory soup”. This noxious substance may contribute to ongoing nociception without overt nerve damage. The application of specific soft tissue treatments and neural mobilization may help to decrease sciatic nerve stiffness and diminish intraneural edema and/or pressure by mobilizing neural tubes (Gilbert et al., 2015; Neto et al., 2020).

Examination

A thorough health history intake can be done to gather information about patients’ limitations, course of pain, and prognostic factors for delayed recovery (e.g., low self-efficacy, fear of movement, ineffective coping strategies, fear-avoidance, pain catastrophizing) and answers to health-related questions. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions. Then undertake a physical examination: neurological screening test, assess mobility and/or muscle strength.

Red Flags for Serious Spinal Pathology

Red flags are signs and symptoms that raise suspicion of serious underlying pathology, for patients with low back pain there are a number of serious spinal pathologies to be aware of, these are cauda equina syndrome (0.08% of low back pain patients presenting to primary care), spinal fracture, malignancy, and spinal infection (Finucane et al., 2020Hoeritzauer et al., 2020).

Outcome Measurements

Incorporate one or more of the following outcome measurements when assessing and monitoring patient progress:

  • Self-Rated Recovery Question
  • Patient Specific Functional Scale
  • Oswestry Disability Index
  • Roland-Morris Disability Questionnaire
  • Brief Pain Inventory (BPI)
  • Visual Analog Scale (VAS)
  • Lower Extremity Functional Scale (LEFS)

Physical Examination

Incorporate one or more of the following physical examination tools and interpret examination results in the context of all clinical exam findings.

  • Kemp’s Test (Lower Quadrant Test)
  • Kernig/Brudzinski Test
  • Rebound Tenderness (McBurney’s Point)
  • Piriformis Test (FAIR Test)
  • Slump Test
  • Valsalva Maneuver
  • Well Leg Raise
  • Straight Leg Raise (Lasègue’s sign) or Braggard’s Test
  • Bowstring Maneuver
  • Prone Knee Bend Test/Femoral Nerve Stretch Test (Reversed Lasègue)

Treatment

Education

Provide reassurance and patient education on condition and management options and encourage the use of active approaches (lifestyle, physical activity) to help manage symptoms.

Manual Therapy

A treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. Structures to keep in mind while assessing and treating patients suffering from sciatica may include neurovascular structures and investing fascia of:

  • Gluteal Muscles (gluteus maximus, gluteus medius, gluteus minimus, and tensor fasciae latae)
  • Hamstring Muscle Group (biceps femoris, semitendinosus, and semimembranosus)
  • External Rotators of The Hip (piriformis, gemellus superior, externus and internus obturators, gemellus inferior, and quadratus femoris)
  • Erector Spinae (iliocostalis, longissimus, spinalis) & Multifidus
  • Quadratus Lumborum
  • Thoracolumbar Fascia & Latissimus Dorsi

Self-Management Strategies

Massage therapists not only provide hands-on treatment they can also develop self-management programs to help patients manage symptoms. Simple home-care recommendations such as hydrotherapy and stretching may be useful for people with sciatica.

Prognosis

Most patients improve over time with conservative treatment including exercise, manual therapy, and pain management (Stochkendahl et al., 2018; Jensen et al., 2019).


Sciatic Nerve Mobilization Technique with Erik Dalton


Key Takeaways

Contemporary multimodal massage therapists are uniquely suited to incorporate a number of rehabilitation strategies for sciatica based on patient-specific assessment findings including, but not limited to:

  • Manual Therapy (soft tissue massage, neural mobilization, joint mobilization)
  • Education that is Person-Centered (e.g., biopsychosocial model of health and disease, self-efficacy beliefs, active coping strategies)
  • Stretching & Loading Programs (e.g., concentric, eccentric, isometric exercises)
  • Hydrotherapy (hot & cold)
  • Self-Management Strategies (e.g., engaging in physical activity and exercise, social activities, and healthy sleep habits)

References and Sources

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Bailey, C. S., Rasoulinejad, P., Taylor, D., Sequeira, K., Miller, T., Watson, J., Rosedale, R., Bailey, S. I., Gurr, K. R., Siddiqi, F., Glennie, A., & Urquhart, J. C. (2020). Surgery versus Conservative Care for Persistent Sciatica Lasting 4 to 12 Months. The New England journal of medicine, 382(12), 1093–1102. https://doi.org/10.1056/NEJMoa1912658

Basson, A., Olivier, B., Ellis, R., Coppieters, M., Stewart, A., & Mudzi, W. (2017). The Effectiveness of Neural Mobilization for Neuromusculoskeletal Conditions: A Systematic Review and Meta-analysis. The Journal of orthopaedic and sports physical therapy, 47(9), 593–615. doi:10.2519/jospt.2017.7117

Bueno-Gracia, E., Pérez-Bellmunt, A., Estébanez-de-Miguel, E., López-de-Celis, C., Shacklock, M., Caudevilla-Polo, S., & González-Rueda, V. (2019). Differential movement of the sciatic nerve and hamstrings during the straight leg raise with ankle dorsiflexion: Implications for diagnosis of neural aspect to hamstring disorders. Musculoskeletal science & practice, 43, 91–95. https://doi.org/10.1016/j.msksp.2019.07.011

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Fritz, J. M., Lane, E., McFadden, M., Brennan, G., Magel, J. S., Thackeray, A., Minick, K., Meier, W., & Greene, T. (2020). Physical Therapy Referral From Primary Care for Acute Back Pain With Sciatica: A Randomized Controlled Trial. Annals of internal medicine, 10.7326/M20-4187. Advance online publication. https://doi.org/10.7326/M20-4187

Gilbert, K. K., Smith, M. P., Sobczak, S., James, C. R., Sizer, P. S., & Brismée, J. M. (2015). Effects of lower limb neurodynamic mobilization on intraneural fluid dispersion of the fourth lumbar nerve root: an unembalmed cadaveric investigation. The Journal of manual & manipulative therapy, 23(5), 239–245. doi:10.1179/2042618615Y.0000000009

Gilbert, K. K., Roger James, C., Apte, G., Brown, C., Sizer, P. S., Brismée, J. M., & Smith, M. P. (2015). Effects of simulated neural mobilization on fluid movement in cadaveric peripheral nerve sections: implications for the treatment of neuropathic pain and dysfunction. The Journal of manual & manipulative therapy, 23(4), 219–225. doi:10.1179/2042618614Y.0000000094

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Evidence-Based Massage Therapy by Richard Lebert is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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