Slip Disc Treatment

Physiotherapy Treatment of Sciatica
by Jonathan Blood Smyth

Sciatica results from a structure impinging on a lumbar nerve root, causing compression and/or inflammation enough to cause neurological changes in the skin, reflexes and muscles served by the affected nerve. Not a common syndrome, it is estimated that 3-5% of the population suffer this kind of problem at some time. It affects men and women equally with men most susceptible in their forties and women in their fifties.  Up to a quarter have symptoms which last more than six weeks and referral to physiotherapists for acute management is routine.

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 great forces which we impose on the low back mean the lumbar intervertebral discs suffer structural changes and prolapses. Many activities involve a significant level of leverage, such as flexing over, performing movements in an upright position and lifting with the arms away from the body. This greatly magnifies the forces on the discs and due to their fluid mechanics they suffer 3-5 times the loads on the skeleton. This can cause the disc walls to degenerate, giving weak areas and predisposing to prolapse at some time.

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.

Physiotherapists use a variety of therapies to treat sciatica, with McKenzie technique being a mainstream technique for discogenic pains. Mobilisation and manipulation techniques, core stability work, myofascial release, specific exercises, manual techniques, soft tissue work and massage, analgesia, patient education, rest, the best position to relieve extreme sciatica pain and advice are all used as treatments. Most sufferers settle without investigation or surgery and a long term exercise programme is useful once the problem has settled.

Jonathan Blood-smyth

Technorati Tags: Acute Management, Back Pain, Buttock, Fifties, Fluid Mechanics, Forties, Inflammation, Intervertebral Discs, Leg Pain, Lumbar Nerve, Message Transmission, Nearby Structures, Nerve Root, Neurological Changes, Nuclear Material, Physiotherapy Treatment, Posture, Reflexes, sciatica treatment, Six Weeks