What is sciatica pain?
Listening to various patients this week complaining about the severe, sharp, tiring pain that sciatica pain brings inspired me to write a little piece on Sciatica.
Sciatica is something we as Physiotherapists see a lot of in clinic. Sciatica is pain caused by dysfunction of the sciatic nerve and the pain is felt anywhere from the buttock to the thigh, calf or foot. A lot of people also have low back pain, but not everyone who has sciatica pain has back pain.
The sciatic nerve pain can be severe, shooting, burning, electric-shock like and tingling. It can also have numbness and pins and needles into the buttock and leg. It is often aggravated by movement but can be present at rest. A herniated disc, inflamed soft tissue or degenerative vertebral joint can cause pressure on the sciatic nerve roots, resulting in sciatica. So too can infections, trauma, inflammatory disease or more serious pathology like cancer. The most common cause of sciatica is a herniated or bulging lumbar intervertebral disc. In older patients, lumbar spinal stenosis may cause these symptoms as well.
How common is sciatica pain?
Sciatica affects men and women equally but is more common in the 4th decade of life. Between 1-5% of the population will suffer from sciatica pain on an annual basis. Between 10-40% of people will experience sciatic pain at some point in their lifetime. It’s presentation means it usually only affects one side of the body.
It is a horrible pain, it is difficult to sleep and can be really draining, frustrating and tiring. Often it creates fear of movement. The thought of that sudden sharp shooting pain is often a concern with simple movements. So when you have a period of respite from the pain the temptation is to remain in that position. Complete rest is not the answer for long term recovery.
Sciatica is not the same as back pain. It is worth remembering that 8/10 people (perhaps more) will experience ‘simple’ low back pain in their lifetime. Although we term it ‘simple’, this does not dispute the fact back pain can be extremely painful and debilitating, however it is usually not cause for alarm (I could write another piece on this. There’s an idea, watch this space!).
Most cases of sciatica pain will improve within 6-8 weeks.
Every patient has a different story. Some described finding a miracle cure, some described real struggles with managing their pain despite medication and surgery. What really stood out though was that everyone’s story was different. We need to treat you as an individual and get to the root of your problem. As Physiotherapists, we look at pain from a Biopsychosocial perspective. Pain is influenced not just by the physical structures in the body but the effects our thoughts, experiences and beliefs. A good quote I saw recently was ‘The issue isn’t always the tissue” (I feel another blog coming on…).
Do you need a scan or X-ray to diagnose Sciatica?
No, investigations like MRI scans and x-rays are usually not indicated in back pain and sciatica. If your symptoms do not improve as expected or if you demonstrate any Red Flags, then you may be referred for Investigations.
We screen everyone for red flags. These are warning signs that suggest serious spinal pathology such as Cauda Equina Syndrome (CES), cancer or fracture. Your GP or Physiotherapist will ask you these sensitive questions, which you may feel are irrelevant or personal, however it is important that any red flags are identified early.
Serious spinal pathologies are rare and make up less than 2% of cases.
CES is compression of the sacral nerve roots and can lead to paralysis. This is rare, but serious. Symptoms include a loss of control of the bladder or bowel; tingling or numbness between the legs, genitals or anus; giving way or loss of control of the legs. If you have these symptoms this is a medical emergency and should be treated as such.
A first time onset of back pain aged less than 20 or over 55, feeling unwell, losing weight without trying and severe, unremitting back pain may be indicitive of a spinal tumour or metastases. It is important to disclose any history of cancer to your therapist. Further investigation may be required in the presence of these symptoms should be discussed with a GP in the first instance.
A spinal fracture can occur particularly in the presence of risk factors for osteoporosis. If you have experienced a trauma like a road traffic accident, slip or fall; even minor trauma with osteoporosis can cause a spinal fracture.
What is the best treatment for sciatica?
Sciatica Pain management is very important and drugs initially used for other disorders of the nervous system are often prescribed for sciatica. These include Gabapentin (an anti-epilepsy drug) and Amitryptiline (an anti-depressant). Your GP is not prescribing these because you are depressed or that they think the pain is ‘all in your head’ but because they work on reducing the chemical irritation that gives rise to sciatica.
Sciatica pain is a symptom and the cause widely varies. What works for one person may not for another. A thorough assessment with a Specialist Physiotherapist will help you to understand the causes of your pain and work out a management plan.
Recent research has shown that if your sciatica pain has not resolved by 6 weeks then it is unlikely to resolve with changing your approach and intervention. Physiotherapy has been shown to be the most evidence based approach to help you recover. The key though is finding out where the compression of the nerve originates. This does not mean you need an MRI. In fact only the patients heading fro surgery require imaging. Having a CT or MRI is not required and not indicated. This is aligned with the NICE guidelines for management of sciatica.
Sciatica pain can actually present differently based on individual physiology. In 50% of the population the sciatic nerve passes through a muscle in the buttock that can then spasm and contribute to further compression. This is a rare condition called piriformis syndrome. It is often incorrectly diagnosed. In the rest of the population the nerve may pass behind the muscle not causing it to react.
The nerve can be trapped in different places making the resulting in different sciatica symptoms and presentations. This is why sciatic pain or sciatica is really an umbrella term for lots of different conditions and is not actually a diagnosis in itself. A tailored, personalised approach is best. This way we can also deal with the psychological aspect such as fear of movement, beliefs around pain and education around healing times.
The severity of sciatica symptoms depends upon the amount of pressure and how long pressure is applied to the nerve. Even once pressure is released the nerve may be damaged and with low blood supply nerves can take some time to heal. We need to understand this and be patient.
The body will often adapt its movements to avoid pain and protect the affected area. Treatment must include exercises to restore normal movement patterns which stimulate the nerve and restore blood flow to the nerve.
There can be risk factors such as being over weight, loaded forward flexion, prolonged sitting and lifting heavy without the proper technique and support that will cause an injury that will in turn trap the sciatic nerve.
At Optimal Physio we ensure we are up to date with current management of Sciatica and low back pain. We use an evidence-based, individualised approach to your management to get you back to your best. Electrotherapy will not be used as it is not effective in treating this condition.
To learn more about sciatic and some frequently asked questions – go the sciatica page on our website
For a summary of the NICE guidelines the British Medical Journal published this infographic
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