Sciatica Case Study: Bringing Research Into Practice
Patient with pain in the lower back travelling down the leg. Tingling sensations.
Treatment: Bed rest. Traction. Piriformis stretch. Back extensions. Repeat.
This was basically my management process for anyone walking into my office claiming that they have sciatica for an alarmingly long time. This approach was insufficiently person-centered and it resulted in poor therapeutic alliances and suboptimal management.
I got over it.
I pushed myself to explore the concept of sciatica, my patients beliefs about their diagnosis and treatments, improving my assessment and management skills and not seeing every patient with a single lens and galvanising my clinical practice above the uninspired cookie-cutter method of management.
Now, in this case study blog, I’m here to tell you how Physio Network’s reviews on sciatica helped me navigate this common yet complex condition.
Sciatica: A ‘Nothing Term’ for us or a ‘Something Term’ for them?
For physios, sciatica is characterised by pain radiating down the knee from the lumbar spine associated with altered sensation and/or weakness in the leg. Sciatica is common, with 60% of patients with low back pain presenting with leg pain features (1). It’s challenging for physios to find a structural cause as it could happen from disc herniations, compression, inflammation or tumors. At times, sciatica is wrongly mixed with the term ‘lumbar radiculopathy’. By now, physios should know that sciatica is a symptom and not a specific diagnosis (2).
For patients, sciatica can be an ‘all-encompassing’ experience with ‘physically and mentally draining’ symptoms with many feeling underappreciated in their consultations with the lack of clear explanations about treatment and prognosis. This failure of understanding the patient’s whole story leads to lack of trust and poor therapeutic alliance.
The Physio Network review written by Dr. Tom Walters prepared me to understand my patient’s perspective of living with sciatica. This review advocates the importance of patient’s beliefs about their illness and the role they can play in how well they respond to treatment. One of the reasons for physios not being able to get the desired clinical outcomes could be the inability to interpret their patients’ understanding of sciatica.
The patient was a 30 year old female corporate worker referred by a consultant spine surgeon with the diagnosis of low back pain with right leg sciatica. She mentioned that a month ago she was just picking up a suitcase from her bedroom floor when she felt a catch in her lower back accompanied with excruciating pain. She collapsed to the floor and was unable to get up. She called her friend to help her out and take her to the ER.
She mentioned that she has had a similar episode of back injury two years ago where she had debilitating pain and was not able to stand up for 2 weeks. She was given pain medications at the time and was advised bed rest. She didn’t have another such episode until this one.
She didn’t have any pain in her leg at the time. After hospital admission, an MRI was done and she was advised to undergo microdiscectomy the very next day. She mentioned that the words used by the radiologists and the surgeon were “ your back is screwed up” & “you won’t be able to deal with the pain”. She was prescribed heavy doses of painkillers and physio in the form of IFT and TENS. Her surgeon kept ‘persisting’ on her getting the surgery with words like “you will get paralysed”.
Eventually, her parents intervened and they decided to not undergo the operation. After a week of bed rest, gentle physio stretches and medications, she was able to slowly move around and her back pain started to get better. She was advised to wear a lumbar belt by her physio as she returned to her work. She presented with sharp, throbbing pain down her right leg till the foot which was worse than the pain in her back. It developed after 3 weeks from the episode and she has now started to limp because of it.
‘Understanding’ the Person (Not Just the Case)
Before we go into the physical assessment of this case, I want to point out how Tom Walter’s Physio Network review helped me to navigate this clinical encounter by exploring the patient’s understanding of sciatica. I further explored my patient’s beliefs as per the four main themes stated in the review.
She mentioned her illness experience as “crippling & debilitating”. She felt “isolated” as she was not able to do the things she liked and the surgeon’s words created a lot of fear in her. She had nightmares and she would wake up in pain. She noticed that her mood became more irritable and she felt depressed. Her concept of sciatica was majorly formed by what she read on Google and she believed that the ‘nerve is getting compressed’ and ‘it can’t shrink back’. She believed if compression stops, her pain would go away.
Her treatment beliefs included that eventually she would have to undergo surgery as exercises might not help with the compression and surgery will fix it. She stopped walking and jogging and she felt Ayurvedic massage and herbal medicine was helpful. She did not want to continue with the medications. She desired credible information and valued clear explanations about her prognosis. She mentioned that what her doctor told her was exactly what she had read on Google and was concerned over its credibility.
All this information helped me navigate this clinical encounter by better understanding how to approach and manage this ‘person with sciatica’. The review states that:
“In many cases, radicular pain is not related to mechanical nerve compression and can improve without a mechanical intervention, like surgery.”
Along with this, I took the time to explain to her about the potential role inflammation/neural sensitization can have on her experience of pain. I validated her experience of pain and she was grateful for the credible explanations. She mentioned that she “felt heard and taken seriously” and it “put her mind at ease”. She believed that feeling heard was part of her healing process. This helped set the right tone from the start before beginning any physical assessments or interventions.
Assessment and Diagnosis: No More Guesswork
Differentiating sciatica from other radicular symptoms makes it challenging as clinical features are highly variable in practice (3). Dr. Mary O’ Keeffe’s research review focused on distinguishing three subsets of nerve root involvement: sciatica (radicular pain); radiculopathy, spinal stenosis. It made the differential diagnosis much less complex.
The patient complained of leg pain which was significantly greater than her back pain. Repeated extension in standing increased her symptoms. She reported a gradual increase in symptoms over the last 3 weeks with the pain being 9/10 at its worst and 3/10 at its best. Aggravating activities included sitting for long hours, lifting heavy things and twisting. Relieving activities included crook lying and forward bending stretches.
She reported pain till the right foot with right SLR of 40° and a stretch in the left posterior thigh at 70°. Upper motor neuron testing (Babinski, ankle clonus test, Hoffmann’s sign) indicated nothing abnormal. Serious pathologies (cancer, cauda equina ) were ruled out. There was no numbness present. The pain intensified with a cough or a sneeze and the pain location aligned with the dermatomal concentration along with decreased Achilles tendon reflex in the right lateral foot. Prone knee bend test and crossed lasegue test were positive and finger to floor distance was 30cm. On palpation over the right piriformis region and PSIS, she reported mild tenderness. Her Oswestry Disability Index (ODI) score was 42% indicating severe disability.
Dr. Sarah Haag’s review made me aware about the clinical guidelines which recommend a combination of history taking, a cluster of physical tests, and the StEP screening tool as being helpful clinically to identify neuropathic pain in low back related leg pain (LBLP). The 8 patient history/clinical examination signs are (4):
- Duration of disease
- Paroxysmal pain
- Pain worse in leg than back
- Typical dermatomal distribution
- Worse on coughing/sneezing/straining
- Finger to floor distance
Considering the above information, I was able to identify neuropathic pain with LBLP in my patient which directly allowed me to provide more efficient care.
Role of Imaging
The patient asked if she really needed to get another MRI done as she was scared she would be needing surgery soon to “remove the compression”. Mary O’Keeffe’s review mentions that most patients with radicular syndromes do not require immediate diagnostic imaging. Even after this clinical update, she was recommended to get an MRI done. It was important for me to match the imaging findings with the symptoms before moving forward.
This was a difficult case to manage from the start considering the high intensity of pain, its psychological impact along with levels of functional disability, and the harmful beliefs propagated by healthcare professionals. Reading the aforementioned Research Reviews set up a great foundation for me and provided me with a useful understanding of the current evidence base to optimally manage this patient.
Tom Walter’s review helped me understand the value of seeking to understand the patient’s lived ‘illness experience’ and aided in building a strong therapeutic alliance and trust (5). Listening, educating, validating, understanding her beliefs combined with a thorough physical examination assisted in better clinical outcomes.
For context – sessions were done twice a week for six weeks.
In Mary O’Keeffe’s review, she mentioned how prognosis is normally favourable in most cases of sciatica. The pain subsides over time on its own. The first line of care should consist of reassurance, advice to stay active and resume activities as possible as well as exercise therapy.
Following reading this review, I was able to explain the nature and prognosis of sciatica and discussed the need for imaging and its ineffectiveness in determining either the conservative care or the prognosis, and was able to remove some fear. I was able to advise her regarding sciatica as a symptom, her treatment options and reducing modifiable risk factors (smoking & lack of movement). Realistic expectations were set after discussing the prognosis. It took time to convince her that surgery was not her only option.
She wanted to get active again and to be able to do her job. Therefore, staying active was considered the main goal. Rather than generic exercises, I advised her to slowly get into the things she likes doing the most as a physical activity. Walking was her favourite thing to do and we decided to try that slowly along with exercise therapy. We set little targets in terms of minutes walked and slowly changed the intensity as she felt better and more confident. Painting was something that relaxed her so we slowly incorporated that in her plan for stress relief.
Dr Sarah Haag’s review states that there is no one “best” intervention for low back pain with radiculopathy. Exercises targeted towards improving motor control, dynamic muscle strengthening and directional preference exercises along with neurodynamic mobilisation were included in the rehab program. This study also states that there’s no benefit of traction either alone or in combination with other treatment on pain intensity, functional status, or return to work.
This review showed that the addition of neurodynamic mobilization to motor control exercises may lead to a greater decrease in symptoms (6). The patient realised that exercises were safe for her as she started to enjoy ‘staying active’. She mentioned that the neurodynamic sliders “worked well for her” towards being self-sufficient in managing the pain.
The patient reported a decrease in pain to 5/10 by visit 3 and appreciated the fact that she was walking more. She stopped taking medications and was able to sit down and paint for 20 min by visit 4. By visit 7, she reported 2/10 pain in the leg and being self-sufficient with her exercises. She mentioned that even though the symptoms didn’t resolve completely, she could see she had made a lot of progress and found the rehab plan very meaningful.
By visit 15, she had pain free active range of motion in her back and her right SLR improved to 70°. She was able to walk for 5km without pain by visit 16 and was able to sit at work without pain. Her ODI score changed significantly from severe disability (42%) to no disability (0%). At 6 months follow up, she still did not have any leg pain and she was still staying physically active, working and travelling.
Sciatica can be challenging to treat in the clinic. After one year, only 55% of primary care patients reported greater than 30% improvement (7). The complexity of low back pain, lack of understanding of patients’ beliefs, limited knowledge of diagnosis, no ‘best’ intervention, no effective subgrouping of patients, confusion in the use of terminology, and failure of implementation of clinical guidelines often leave physiotherapists feeling unsure about how to navigate such clinical encounters (8). This leads to tensions in the dialogues between physios and patients. Patients are also left with higher degrees of hopelessness when physios fail to understand the impact of sciatica on their lives and identity (9).
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