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.
Disc prolapse can result in the internal nuclear material being extruded past the outer disc wall, physically compressing the nerve root which runs nearby. The nuclear material is also chemically irritating to the nerve structure and these irritants make the nerve and nearby structures swell, partly blocking the local circulation and the nerve's message transmission. Disc prolapse is typically the cause of proper sciatica but the size of the prolapse is not closely related to the amount of pain the person suffers.
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.
A thorough history performed by the physio will uncover any red flags, an indication of a possibly serious underlying medical condition responsible for the pain. Loss of weight or appetite, severe pain at night, a history of cancer, unwellness or fever, bowel or bladder control difficulties, young or older patients, all these things ring warning bells and the physio will refer the patient on to a medical specialist for evaluation. The location, nature and response to activities and postures of the pain will be noted by the physiotherapist.
The physiotherapist begins with postural observation of the patient which can show an inability to stand up or a thoracic shift to one side. Spinal movements are performed and the pattern of movement limitation noted, with a full neurological examination of the lower limbs. The physio is looking for deficits in muscle power, reflexes or feeling which are related to the specific nerve root involved. The straight leg raise may be performed to check the stretch reaction of the spinal nerve.
The McKenzie technique works on pain centralisation, the tendency for pain to move towards the back from the legs, suggesting a disc problem, and many physios use this technique. Pain in the front of the thigh and over the knee can be referred from the hip joint, so the physiotherapist will assess the lower limb joints to check the diagnosis. A thorough examination informs the physiotherapist of the likely diagnosis and how they might treat the syndrome, or that the patient needs to be referred to a medical practitioner for a consultation and investigation.
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.
Disc prolapse can result in the internal nuclear material being extruded past the outer disc wall, physically compressing the nerve root which runs nearby. The nuclear material is also chemically irritating to the nerve structure and these irritants make the nerve and nearby structures swell, partly blocking the local circulation and the nerve's message transmission. Disc prolapse is typically the cause of proper sciatica but the size of the prolapse is not closely related to the amount of pain the person suffers.
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.
A thorough history performed by the physio will uncover any red flags, an indication of a possibly serious underlying medical condition responsible for the pain. Loss of weight or appetite, severe pain at night, a history of cancer, unwellness or fever, bowel or bladder control difficulties, young or older patients, all these things ring warning bells and the physio will refer the patient on to a medical specialist for evaluation. The location, nature and response to activities and postures of the pain will be noted by the physiotherapist.
The physiotherapist begins with postural observation of the patient which can show an inability to stand up or a thoracic shift to one side. Spinal movements are performed and the pattern of movement limitation noted, with a full neurological examination of the lower limbs. The physio is looking for deficits in muscle power, reflexes or feeling which are related to the specific nerve root involved. The straight leg raise may be performed to check the stretch reaction of the spinal nerve.
The McKenzie technique works on pain centralisation, the tendency for pain to move towards the back from the legs, suggesting a disc problem, and many physios use this technique. Pain in the front of the thigh and over the knee can be referred from the hip joint, so the physiotherapist will assess the lower limb joints to check the diagnosis. A thorough examination informs the physiotherapist of the likely diagnosis and how they might treat the syndrome, or that the patient needs to be referred to a medical practitioner for a consultation and investigation.
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.
About the Author:
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 London.
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