Physiotherapy for Sciatica
What is Sciatica
It refers to the sensation of pain, numbness, tingling along the course of sciatic nerve from the lower back or buttocks radiating to one or both of the legs.
However,
It is the radiating pain can or can not present with the signs of neurological deficits like paresthesia or muscle weakness which commonly occur due to the direct pathology or trauma of sciatic nerve.
The common mistake is referring to any low back pain or radicular pain as sciatica.
Aggravating factors: Lumber spine flexion.
Twisting or bending
Aggressive coughing
CAUSES OF SCIATICA
This condition as the result of any condition that has either direct or indirect effect on the sciatic nerve.
Causes can be classified into spinal and non spinal causes:
Spinal causes:
Spinal stenosis (due to any degenerative or inflammatory condition)
Spondylolisthesis
Any spinal or paraspinal mass causing compression like malignancy
Disc herniation
Non spinal causes:
Piriformis syndrome
Pregnancy
Lumber radiculopathy
Pelvic tumor
Iatrogenic causes:
Direct surgical trauma
Faulty positioning during anesthesia
Injection of neurotoxic substances
Radiation
Tourniquets
SIGNS AND SYMPTOMS OF SCIATICA
Patient with sciatica presents with following signs and symptoms:
- Radicular pain along the distribution of lumbosacral region.
- Sensory impairment such as feeling of hot or cold or burning.
- Muscle weakness
- Reflex impairment 5- Gait dysfunction.
The distribution of signs and symptoms also depend upon the particular nerve root being injured.
L4: the symptoms appear in the thigh. Patient feels weakness in straightening the leg ans also has the diminished knee jerk.
L5: patients signs and symptoms extend up to the foot and big toe.
S1: patient experience symptoms in the outer part of the foot. Patient also feels weakness in elevating the heels off the ground and the knee jerk is diminished
DIAGNOSIS OF SCIATICA
The clinical diagnosis of the patient is done in following steps:
History:
The patient complains of the radiating pain following particular dermatological pattern.
Complain of pain in low back.
Sensory deficits in the lower limb.
Patient can also give the history of any trauma to spine.
Note: it is important to consider the red flags when dealing with sciatica. For example the patient presented with the urinary retention and decreased anal sphincter tone is most likely to be suffering with cauda equina syndrome and needs a referral
SPECIAL TESTS FOR SCIATICA
Lasegue’s test:
It Is the straight leg raise test performed for the diagnosis of sciatica and disc herniation. The test is considered positive when it evokes the pain during 30 to 70 degree of hip flexion.
Braggard test:
It is the modification of the above test. In this case dorsiflexion is performed along with straight leg raise. The angle of SLR is reduced. It is the indication of the positive sign.
Bowstring test:
It is also known as the popliteal compression test or posterior tibial nerve stretch test.
Test can be performed in both sitting and supine position. The knee is flexed and pressure is applied in the popliteal fossa evoking the symptoms.
The pain occurs due to quick snap on the posterior tibial nerve in popliteal fossa.
MEDICAL IMAGING FOR SCIATICA
Imaging is performed when the symptoms persist for more than 12 hours and the patient also present with neurological deficits. Following techniques can be used:
- Plain film:
It is used to evaluate the presence of any fracture or spondylolisthesis.
- Non contrast CT scan:
It has high performance than the plain film and is used to view the fracture when not viewed from the plain film.
- MRI:
It is used in case of presence of neurological deficits or patient is in extreme pain. It immediately gives the main cause of the symptoms.
TREATMENT FOR SCIATICA
Most of the patients show improvement over the time by the conservative treatment which include exercise, manual therapy and pain management.
There are mainly 3 regimens of the treatment:
- Pharmacological treatment:
With the help of medicines including NSAIDS, opioid and non opioid analgesics, muscle relaxants and anti-convulsants for the neurogenic pains and local corticosteroid injections at the affected area.
- surgical intervention:
It is used to address the structural abnormalities like disc herniation, any spinal or paraspinal tumor, epidural hematoma and abscess.
This regimen is adopted when the conservative treatment fails after 6 to 8 weeks of intervention.
- physical therapy management: to treat the patient with sciatica conservative management is really effective.
Self management techniques:
- use of hot pack or cold packs to reduce inflammation.
- Avoid prolong sitting or standing position.
- Try to change the position regularly from standing to sitting position.
- Use of proper lifting techniques.
- Use of proper erect posture.
Exercise:
- Core stabilization exercise
- Gentle stretching of lumber spine and hamstrings. Light exercise like walk
Manual therapy: it includes the mobilization of the spine or the soft tissue massage technique.
DIFFERENTIAL DIAGNOSIS OF SCIATICA
It is important to differentiate between sciatica and other conditions which has the common signs as that of sciatica but can have the worse condition.
Herniated lumbosacral disc:
The MRI gives the clear indication of the herniated disc. Also patient with herniated disc gives the history of trauma and gets the little benefit from physical symptoms. There can also be the presence of neurological deficits like limb weakness.
Cauda equina:
Patient presents with urinary retention and the abnormal anal sphincter tone. There is also numbness around the buttocks and genital region.
Piriformis syndrome:
Pain of piriformis syndrome normally arise from buttocks and can or cannot be radiating. But sciatica arises from lower back and is radiating.
Potts disease- spinal tuberculosis:
The patient presents with extreme weakness in its mobility along with raised temperature, fever, night sweats as well as neurological deficits.
Epidural hematoma:
There is the appearance of sudden localized and severe pain and the rapid neurological deficits.
And it does not depend upon any particular posture.
While sciatica grows slowly.
Nerve root impingement:
Impingement occur at any point along the spine and symptoms occur accordingly. While sciatica involves the compression of sciatic nerve at any point along it course
EXERCISES FOR SCIATICA
Following exercises can be adopted for the treatment of symptoms of sciatica. They can be taught at home or can be performed by the physiotherapist himself to avoid any shortcoming. Each exercise to be performed twice a day with the 20 sec hold, 3 repetitions per exercise.
- Single knee to chest stretch:
- Hamstring stretch:
- Piriformis stretch modified 3:
- Lower trunk rotation:
- Sciatic nerve glide in supine line:
- Double knee to chest:
- Bridging: