Journal of Physiotherapy 66 (2020) 83–88

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s

Invited Topical Review

Physiotherapy management of sciatica

Raymond WJG Ostelo a,b
a
Department of Health Sciences, Faculty of Science, Vrije University Amsterdam; b Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam,
Amsterdam Movement Sciences Research Institute, the Netherlands

K E Y W O R D S

Physical therapy [Ostelo RWJG (2020) Physiotherapy management of sciatica. Journal of Physiotherapy 66:83–88]
Low back pain © 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under
Sciatica
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Radiculopathy

Introduction Diagnosis

A relationship between pathology of the lumbar spine and leg The diagnostic procedures are mainly based on the patient’s
pain was already suspected by the ancient Greeks and Egyptians. symptoms (history taking) and the findings on physical examination.
Hippocrates was allegedly the first to use the term sciatica, from the As there is no single symptom reported during history taking or
Greek word for hip ‘ischios’.1 Although sciatica is a commonly used result on a physical test that has a sensitivity or specificity large enough
term, it may also cause confusion because it has been used to describe to definitively diagnose sciatica, clinical guidelines recommend a
any type of back or leg pain.2 But in most cases, and also in this paper, combination of history taking and physical tests in order to arrive at a
sciatica is used to describe pain that radiates downwards from the conclusion.4,5 Signs and symptoms that are indicative of sciatica and
buttock along the course of the lumbosacral nerve roots.3 An alter- should be addressed during history taking are: the dominance of leg
native term for sciatica that is often used is lumbar radiculopathy.4,5 pain (more than back pain); the location of the leg pain (ie, to assess
The prevalence and incidence of sciatica, as reported in the literature, whether it radiates down below the knee and whether it aligns with one
vary widely. Important reasons for that variation, among others, are or more dermatomes); paraesthesia and/or sensory loss (roughly) in
differences in definitions and methods of data collection. Cherkin line with the dermatomes of the affected spinal root (Figure 1); weak-
estimated the incidence to be 5 per 1000 in Western countries.6 In ness and/or reflex changes in a myotomal distribution; and an increase
the Netherlands, there were 117,200 new cases of sciatica in 2017.7 In in leg pain with coughing, sneezing and/or taking a deep breath.
a recently published Danish study, the prevalence of sciatica among The likelihood that sciatica is present is further increased if there
patients with low back pain in the primary care setting ranged from 2 is no sudden onset but a gradual increase in complaints,4 although
to 11% in chiropractic clinics and general practices, respectively.8 sometimes the complaints can occur rapidly and be intense and
Although the economic burden of low back pain is enormous,9 the constant. A number of physical tests have a small added diagnostic
economic burden of sciatica has not been studied as extensively. In value: loss of muscle strength, particularly loss of dorsiflexion of the
the Netherlands, it has been estimated that the direct and indirect foot when L5 is affected (often this loss is too subtle to cause foot
costs of patients suffering from sciatica approximate V1.2 billion per drop); increased finger-floor distance (. 25 cm); absence of tendon
year.10 In the United Kingdom it has been suggested that the reflexes; and a straight leg raise test (in particular, a negative test is
healthcare costs are £500 million and £3.8 billion in indirect costs.11 informative because it indicates decreased likelihood of sciatica); and
a positive crossed straight leg raise test (increased likelihood of
What is sciatica? sciatica).4,15,16 When several signs, symptoms and physical tests are
all positive, a diagnosis of sciatica is considered to be more likely,
In most cases sciatica is caused by a herniated lumbar disc where especially when the results of the history taking and physical tests
the nerve root is compressed by disc material that has ruptured can be attributed to one nerve root.4 In the diagnostic process, it is
through its surrounding annulus.12 Rarer causes include spondylo- also very important to exclude serious underlying pathology such as
listhesis, lumbar stenosis, foraminal stenosis and malignancy. The trauma, cancer or serious infections. In case of saddle anaesthesia,
common denominator of all these causes is the fact that the lumbar disturbances of the bladder, loss of tone in the anal sphincter and
nerve root is compressed, which may result in inflammation.12,13 decreased sexual function, a cauda equina syndrome17 may be pre-
Evidence suggests that it is not so much the pressure on the nerve sent and patients should be referred for immediate medical attention.
root that causes sciatica, but a combination of pressure-related, in- The routine use of imaging in patients with sciatica as a further
flammatory and immunological processes.14 diagnostic procedure is not recommended in the clinical

https://doi.org/10.1016/j.jphys.2020.03.005
1836-9553/© 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
84 Ostelo: Physiotherapy management of sciatica

L3 inconsistent but mainly negative results regarding the prognostic

value of baseline pain severity, neurological deficit, nerve root tension
L4 signs, duration of symptoms, and radiological findings.22
L5
T10
T11 S1 S3 Conservative management
S4
T12 The first line of care for patients with sciatica is conservative,
S5
including information about sciatica and the role of imaging, and
S2 L1 C advice to stay active.4,5
L5 S2
S3
Information
L2
L1 Information to the patient should include an explanation of the
nature and prognosis of sciatica. Additionally, it should be discussed
with the patient that imaging is not recommended unless there are
good reasons to do so (eg, suspicion of cauda equina syndrome or
S2 fracture).4,5 This is an important topic to discuss because imaging
L3 L2 tests are often performed in order to reassure the patient or because
the patient expects that imaging should be done. One reason to
advise against routine imaging is that no clear role has yet been
established for imaging in determining either the conservative
management or prognosis. A telling illustration is described in the
study by Herzog et al.23 A 63-year-old woman with a history of low
back pain and right L5 radicular symptoms was sent to 10 different
S2 regional imaging centres within a 3-week period. All study centres
S1 had valid accreditation from the American College of Radiology,
including the spine magnetic resonance imaging (MRI) module, and
L3
L4 each participating centre was blinded to participation in the study
and evaluated the subject as a routine patient. No single interpretive
L5 finding was reported unanimously by the radiologist at all centres
and one-third of all reported findings appeared only once across all
10 imaging reports. The authors concluded that this indicates that
L4 there is at best a substantial difference in the standards employed by
radiologists when deciding what to include in diagnostic reports, and
at worst high prevalence of interpretive errors.23 A systematic review
S2 of 14 high-quality case-control studies (involving . 3000 participants
in total) demonstrated that although MRI evidence of disc bulge, disc
S2 S1 L4 degeneration, disc extrusions, disc protrusions, Modic 1 changes, and
S1
spondylolysis were significantly associated with back pain, the cau-
L5 sality of these findings was unclear.24 Furthermore, spontaneous
regression of lumbar disc herniation is likely to occur.25
Another reason to advise against routine imaging is that imaging
Figure 1. Dermatomes of the lower limb.
might have a negative psychological impact on patients. A rando-
mised trial assessed the effect of knowledge of diagnostic findings on
clinical outcome in patients with acute low back pain and/or radi-
guidelines.4,5 This is in line with the recommendation for non-specific
culopathy.26 A total of 246 participants (39% of whom had radicul-
low back pain, where international guidelines also recommend not
opathy) were randomised to the ‘blinded’ treatment arm (both
using routine imaging for patients with non-specific low back pain for
patient and physician were blinded to MRI results) or the ‘unblinded’
identifying specific causes of low back pain.18 Despite the guidelines,
treatment arm (MRI results provided within 48 hours). There were no
patients have often undergone an imaging procedure and brought the
differences between ‘blinded’ and ‘unblinded’ participants on the
results to their physiotherapy consultation. It is prudent to at least
primary clinical outcomes (disability, pain and number of sick days).
check whether the symptoms are concordant with the imaging
However, participants in the ‘blinded’ treatment arm showed more
findings.
improvement in general health (subscale of the Short Form 36 quality
of life questionnaire) compared with those who were ‘unblinded’.26
Prognosis
Advice to stay active
Although the general consensus is that the prognosis is usually
favourable because most cases of sciatica are self-limiting with pain For people with complaints of , 6 to 8 weeks, advice to stay active
decreasing over time,19 the evidence is less straightforward. The is considered to be an important element of conservative manage-
course of sciatica in primary care is often not studied in isolation, as ment. Clinical guidelines recommend the provision of ‘encourage-
most studies of low back pain include patients with and without leg ment to stay physically active’. Moreover, bed rest is not
symptoms/sciatica.20 A recently published UK-based study of patients recommended.4,5 A systematic review that compared ‘advice to stay
seeking primary care for back-related leg pain, including sciatica, of active’ with ‘structured exercises’ concluded that there is low-quality
any duration and severity, showed that only 55% of the patients with evidence according to the Grading of Recommendations, Assessment,
sciatica met the criterion for improvement in disability (ie,  30% Development and Evaluations (GRADE) framework that exercise
reduction in disability 1 year later).21 Because all of these studies provides small, superior effects compared with advice to stay active
included some type of (conservative) treatment the real (untreated) on leg pain in the short term.27 This was based on a meta-analysis
prognosis is, as yet, unknown. A review that assessed prognostic that included five randomised trials, demonstrating that there was
variables in patients with sciatica seeking conservative care found an 11-point difference (95% CI 1 to 22) on the 0 to 100 pain score
 Invited Topical Review 85

(Figure 2; for a detailed forest plot, see Figure 3 on the eAddenda). WMD (95% CI)
The exercise interventions studied in the trials included in that sys- Study Random
tematic review ranged from 4 to 8 weeks in duration and included
various types of exercise regimens (eg, specific postural instruction, Albert (2012) 51
static and dynamic lumbar stabilising exercises, motor control exer-
cises, muscle strengthening exercises, and directional preference Bakhtiary (2005) 52
exercises). However, there was no difference in short-term
disability.27 Moreover, moderate-quality evidence (according to Hofstee (2002) 53
GRADE) showed similar results between advice to stay active and
exercise for leg pain (MD 23, 95% CI 29 to 3) and disability (MD 22, Huber (2011) 54
95% CI 28 to 5) on the 0 to 100 scale in the long term. Overall, it could
be concluded that both approaches might be equally beneficial but Luijsterberg (2008) 55
exercises could be considered if leg pain is the dominant symptom.
Pooled
Exercise therapy

Recommendations regarding exercise therapy vary among the –40 –20 0 20 40

clinical guidelines because the evidence is inconclusive. The Danish
multidisciplinary guidelines recommend considering supervised ex- Favours advice Favours exercise
ercises as an addition to usual care.5 Supervised exercise therapy
includes directional exercises, motor control exercise, nerve mobi- Figure 2. Weighted mean difference (95% CI) of the effect of advice to stay active
compared with structured exercise on leg pain on the 0 to 100 visual analogue scale in
lisation, or strength exercises. But no specific recommendation for a
the short term.27,51–55
specific type of exercise treatment was made.5 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 guidelines for general practitioners recommends that people with
of the physiotherapist. In contrast, the Dutch guidelines for general sciatica should not be referred for SMT in addition to general prac-
practitioners,4 which specifically focus on sciatica in the primary care titioner care because the evidence was considered to be too indirect.4
setting, recommend exercise therapy when patients have complaints There is ongoing debate about adverse events due to SMT. Based on a
for . 6 to 8 weeks and these complaints have not considerably recently published systematic review that included data on 9211
improved over this period. Another indication for exercise therapy is participants in 47 randomised trials (23 of which reported on adverse
when patients need more intensive supervision in their exercises events), it was concluded that the majority of the observed adverse
because their required level of physical functioning in daily life re- events were musculoskeletal, transient in nature, and of mild to
quires a more intensive exercise program and/or supervision. A final moderate severity.28 Although this systematic review included
indication for exercise therapy is when a patient has high levels of studies with chronic low back pain with or without referred pain into
kinesiophobia.4 the leg, it is unlikely that the results for sciatica would be substan-
tially different.
Spinal manual therapy
Medication
Physiotherapists and manual therapists often offer spinal manual
therapy (SMT) to their patients. The term SMT is used to describe a
Patients might take medication for their pain and might ask their
variety of techniques that encompass any manual technique that
physiotherapist about this. Therefore, it is advisable that physio-
moves one or more joints within normal ranges of motion with the
therapists have knowledge about the evidence regarding medication.
aim of improving spinal joint motion or function.5 A distinction is
In a systematic review, 23 randomised trials were included to assess
often made between mobilisation techniques and manipulation
the effectiveness of various types of medication for sciatica: non-
techniques.28 Mobilisation includes low-grade velocity, small or large
steroidal anti-inflammatory drugs, corticosteroids, antidepressants,
amplitude passive movement techniques within the patient’s range
anticonvulsants, muscle relaxants, and opioid analgesics. This review
of motion and control. Manipulation consists of a high-velocity im-
showed that in most of the pooled estimates, medication was not
pulse or thrust applied to a synovial joint over a short amplitude at or
substantially more effective than placebo or the difference in effect
near the end of the passive or physiological range of motion. In
was uncertain because the available data only permitted imprecise
general, the effects of SMT are small and short-term only. To illustrate,
the recently published Danish guideline was able to identify three
randomised trials that assessed the added value of SMT when added WMD (95% CI)
to usual care.5 The included populations were heterogonous (people Study Random
with disc protrusion but intact annulus verified by MRI; people with
radiating leg pain of mixed duration (mean 24 months) with or Bronfort (2014) 56
without neurological symptoms; and people with or without radi-
ating leg pain of mixed duration). Also, the interventions varied be- Paatelma (2008) 57
tween studies (manipulation versus a combination of manipulation,
mobilisation and muscle stretching techniques). The pooled mean
Santilli (2006) 58
difference was 21.07 (95% CI from 22.00 to 20.14) in favour of Pooled
manipulation on back pain (0 to 10 numerical rating scale) at the 12-
week follow up (Figure 4; for a detailed forest plot, see Figure 5 on the
eAddenda).5
–3.0 –1.5 0 1.5 3.0
This evidence was labelled as indirect evidence, but because of
this small and statistically significant effect, the recommendation is
Favours spinal manual Favours usual care
that physiotherapists or manual therapists could consider offering
therapy and usual care
SMT to patients with recent-onset sciatica in addition to usual
treatment.5 However, as the evidence is not very convincing, differ- Figure 4. Weighted mean difference (95% CI) of the effect of adding spinal manual
ences in recommendations between guidelines can be observed. In therapy to usual care on pain at 12 weeks to stay active compared with structured
contrast to the Danish multidisciplinary guideline, the Dutch exercise on leg pain on the 0 to 10 numerical rating scale at 12 weeks.5,56–58
86 Ostelo: Physiotherapy management of sciatica

estimates.29 In acute sciatica, corticosteroids improved pain in the the no-referral control group for any of the main outcomes (global
short term (MD 212 on a 0 to 100 scale, 95% CI 221 to 23) based on perceived recovery, physical functioning or pain). To summarise: the
moderate-quality evidence (according to GRADE). Some of the indi- evidence suggests that early rehabilitation has no added value in
vidual trials in acute sciatica estimated a small benefit from non- comparison with no treatment.
steroidal anti-inflammatory drugs; however, this evidence was low
Postoperative management starting 4 to 6 weeks after surgery: A sys-
quality (according to GRADE). Overall the quality of the evidence was
tematic review that assessed effectiveness of rehabilitation after
low (according to GRADE), so it is unclear which pain medication is
lumbar disc surgery included 22 randomised trials involving 2503
most effective for treating people with sciatica. Moreover, medica-
participants.37 The programs in the included studies were rather
tions used for the treatment of sciatica can have considerable side
heterogeneous and consequently there was one trial for most pro-
effects.30 As a consequence, the Dutch GP guideline only cautiously
grams. Looking at programs that start 4 to 6 weeks after surgery, no
recommended the use of pain medication, mainly for patients with
differences were observed when various types of rehabilitation (ie,
severe pain.4 The Danish guideline did not include any recommen-
multidisciplinary programs, behavioural graded activity, strength and
dations regarding pain medication for sciatica because this was
stretching programs) were compared with some other form of exer-
outside its scope.5 Recently, a systematic review of 27 studies
cise. These results come with uncertainty because they were drawn
assessed whether combining medicines gives greater pain relief. For
from low-quality to very-low-quality evidence, so a strong recom-
most combinations, there were no or only small effects on pain and
mendation for one type of rehabilitation program was not possible.
disability, and these results were only supported by low-quality
In the same systematic review,37 when physiotherapy was
evidence.31
compared with no treatment or education only, the results showed
that physiotherapy was associated with better outcomes for pain and
Surgical management physical functioning immediately after treatment. Very low-quality
evidence (five trials, 272 participants) showed that exercises were
If complaints persist and no relevant improvement occurs despite more effective than no treatment for pain at short-term follow-up
conservative treatment, guidelines recommend referral to a spine (SMD 20.90, 95% CI 21.55 to 20.24), and low-quality evidence (four
surgeon to evaluate if there is an indication for lumbar surgery.4,5 The trials, six comparisons and 252 participants) suggested that exercises
surgeon carefully assesses the correspondence between the clinical were more effective for functional status on short-term follow-up
findings and the findings on imaging in order to select patients who (SMD 20.67, 95% CI 21.22 to 20.12), although the estimated effect on
may benefit from surgery. The fact that patients should be carefully functional status from three trials (226 participants) was unclear on
selected for surgery is also supported by a recently published sys- long-term follow-up (SMD 20.22, 95% CI 20.49 to 0.04). The results
tematic review that assessed if surgery was more effective compared for functional status are presented in Figure 6. (For a detailed forest
to non-surgical treatment.32 Seven randomised trials involving 1158 plot, see Figure 7 on the eAddenda.37) An interesting observation was
participants were included. The results show that surgery had a that one trial showed that a multidisciplinary rehabilitation program,
modest effect: 6 to 26 points greater pain reduction than nonsurgical specifically focused on return to work and coordinated by a medical
interventions as measured on a 0 to 100 visual analogue scale of pain advisor, led to faster return to work than usual care.37
at up to 26 weeks follow-up, although the between-group difference
did not persist to one year. For physical functioning there were only
Future directions for research and practice
small between-group differences. Furthermore, the incidence of
reoperations ranged from 0 to 10%.
Sciatica is considered to have different pathogenic components. It
has been hypothesised that inflammation may play an aetiological
Postoperative physiotherapy role. Various inflammatory proteins have been identified in patients
with sciatica (eg, interleukin (IL)-1b, IL-6, IL-8 and tumour necrosis
Recovery rates after conventional microdiscectomy were found to factor-a) but the pathogenic mechanisms that initiate these processes
be 66% at 4 weeks and 75% at 8 weeks33 and the return to work rate in vivo are not well understood.38 A systematic review that aimed to
was 15% at 2 months.34 At 2 years, 71% of patients who underwent assess the association between the level of inflammatory activity and
tubular discectomy and 77% who underwent conventional micro- clinical symptoms concluded that the clinical heterogeneity in the
discectomy reported good recovery. A systematic review of 39 cohort
studies (13,883 participants with sciatica) reported that patients still SMD (95% CI)
have moderate levels of pain and disability at the 5-year follow-up: Study Random
the mean pain score on a 0 to 100 scale was 21 (95% CI 13 to 30)
and the mean disability score was 13 (95% CI 11 to 16).35 Post- Erdogomus (2007) 59
operative management aims to speed up return to daily activities
and/or work and prevent the development of chronic symptoms; Filiz (2005) 60
however, the exact content of this postoperative management varies.
Filiz (2005) 60
Early postoperative management: One important difference between
various postoperative programs is their starting point. A randomised McGregor (2011) 61
trial assessed whether referral for early rehabilitation (starting
immediately after lumbar disc surgery) is effective and cost-effective Yilmaz (2003) 62
compared with no referral.36 During hospitalisation (usually 1 to 2
days), all patients received usual postoperative care (ie, during one or Yilmaz (2003) 62
two sessions a physiotherapist or nurse provided advice and in-
structions for transfers and activities of daily living, and patients Pooled
received a booklet providing advice (mainly regarding activities of
daily living) and suggestions for exercises focusing on muscle
strengthening, core stability and mobilisation). Patients in the –4 –2 0 2 4
experimental group were referred for early rehabilitation in primary
care starting the first week after discharge. Over 6 to 8 weeks the
Favours exercise Favours control
physiotherapist aimed to gradually increase the intensity of the ex-
ercises and the activities that were important to the patient. The Figure 6. Standardised mean difference (95% CI) of the effect of exercise commencing 4
control group received no referral. The results showed no clinically to 6 weeks after surgery for lumbar disc herniation, compared with no treatment or
important overall mean differences between early rehabilitation and education only, on functional status at the post-treatment follow-up.40,59–62
 Invited Topical Review 87

studies was too substantial to draw any firm conclusions.39 An pain guidelines.50 More research into how to optimise the uptake of
important question to be answered is to what extent inflammation evidence in clinical practice is warranted.
plays a role in sciatica and if there is a certain stage in the course of eAddenda: Figures 3, 5 and 7 can be found online at https://doi.
(developing) sciatica at which this mechanism may be more promi- org/10.1016/j.jphys.2020.03.005.
nent. The ultimate aim would be to explore whether inflammatory Ethics approval: Nil.
biomarkers could be used in predicting the clinical course of sciatica Competing interests: Nil.
and to identify subsets of patients that respond best to anti- Source of support: Nil.
inflammatory treatment or surgery. Acknowledgements: Nil.
A related direction for future research concerns the classification Provenance: Invited. Peer reviewed.
of patients with sciatica. As already mentioned, sciatica is a symptom Correspondence: Raymond W J G Ostelo, Department of Health
rather than a specific diagnosis. Leg pain is the common denomi- Sciences, Faculty of Science, Vrije University Amsterdam, the
nator, but the leg pain could be due to spinal nerve root involvement Netherlands. Email: [email protected]
or be referred (non-specific) pain due to back pain that spreads down
the leg from structures such as ligament, joint or disc but not
involving a spinal nerve root.40 In a recently published systematic References
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