Sciatica

Introduction

Sciatica is a relatively common form of pain in the legs that often misunderstood by the patients. Actually, it is a symptom more than a diagnosis. Sciatica means, “Any type of pain that is caused by the impingement or irritation of the sciatic nerve.” An impinged or compressed sciatic nerve (nerve root from L1 to L4) can cause pain with numbness and stinging sensation, which extends from the lower back to one or both the lower extremities, ending at the feet. It is also associated with the disc (lumbar disc) herniation.

According to the experts, not all the pain which radiates from the lower back, down to the legs is sciatica. Sometimes, it may be a referred pain of lower back pain, not originating from the herniated disc or nerve impingement.

As per the survey and information in the Journal of Best Practice and Research Clinical Rheumatology, it is said that the prevalence of Sciatica ranges from 1.6% to 43% worldwide. The studies also found that working populations with physically demanding jobs are more likely to have sciatica as compared to the general population.

Recent studies show that about 1 million MRI performed for the Sciatica cannot find a treatable cause. With a new imaging technique called Magnetic Resonance Neurography, about 69% patients are found to have compressed sciatic nerve, deep in the buttocks by the Piriformis muscle. The researchers say that about 25% of the general population is susceptible to have irritation and trapping of the Sciatica nerve and Piriformis muscle, particularly when they are overworked and tired. This can lead to Piriformis syndrome, which is the most common cause of Sciatica.

Usually, the Sciatica patients respond well to the conservative, cost-effective measures, especially physiotherapy. The physiotherapy should be tried first to get rid of the nerve entrapment and, to get relief of the symptoms.

Anatomy of sciatica

Sciatica can be caused by a number of possible causes. Any condition that puts pressure on the sciatic nerve can cause pain in the lower back, buttocks and back of the leg. The pressure may come from the spinal discs, bones or muscles. A traumatic event may also cause injury in the lower back or hip area, leading to dislocation of the bone, spasm, and injury of the muscle with the involvement of the sciatic nerve. There are four major conditions that can cause sciatica.

The piriformis syndrome is common cause of sciatica which irritates the sciatic nerve, causing pain, tingling sensation, and numbness in the back of the legs and the feet. It might be caused by misalignment of the pelvis and / or hip joint, which changes the position of the Piriformis muscle, putting pressure on the sciatic nerve.

The herniated discs in the spine can also put pressure on the nerve. A herniated or bulging of the disc may occur as a result of a traumatic event or from the pressure caused by the muscle imbalance.

Spinal stenosis or a decrease in the space between the vertebrae: It is a small and compact space, where the nerve exits the spine. The narrowing of space is often caused by the compression of the spine, due to the muscle imbalances.

Isthmic spondylolisthesis, a condition where the vertebra slips or moves out of position, pinching or putting pressure on the sciatic nerve. It may be caused by a traumatic event or chronic muscle imbalance.

Rare causes:

Any infection in the spine

Injury of the spine, and its surrounding muscles and ligaments

Any growth in the spine, like a tumor

Cauda equina syndrome

Cauda equina syndrome: Cauda equina is a bunch of nerves that exits from the end of the spinal cord. Cauda equina syndrome occurs when theses nerves are compressed and get damaged. It is rare, but serious condition, which can lead to paralysis if not treated at the right time.

Signs and symptoms of sciatica pain

Sciatica is defined as pain which occurs due to the compressed and irritated sciatic nerve. The pain can be sharp, dull or burning. It can be localized, or may irradiate to the entire length, traveling down to the buttocks and legs, including the feet and toes. It can affect one of the legs. Coughing, sneezing, squatting or prolonged periods of sitting can exacerbate the pain. The spasms or cramps of the muscles, innervated by the sciatic nerve may also cause additional pain. The pain in the lower back and hamstrings can also reduce the flexibility of the back and hips.

Common signs and symptoms of sciatica:

Pain

The pain can range from dull to burning type, anywhere along the nerve pathway.

Numbness

This can also occur anywhere along the nerve pathway. Pain can be experienced in an area with numbness.

Weakness

The muscles innervated by the sciatic nerve may become weak due to a reduced ability to send signals along the path.

Tingling or "pins and needles"

This can be felt in the legs and feet.

Cramps or spasms

The hamstrings or calves muscle spasm or cramp may occur as a result of incomplete signals that are sent through the nerve pathway.

Physiotherapy management

Objectives of physiotherapy:

Educate the patient about the correct movements and posture to reduce strain on the back

To control the symptoms

Maintain patient’s appropriate activity levels

Educate the patient about the correct movements and posture to reduce strain on the back

Maximize the flexibility and strength

Exercise for sciatica:

In some patients, the pain may limit the flexibility. The prescribed stretching exercises can improve the flexibility of the trunk muscles. Flexibility exercises can help expand the intervertebral foramen. The intervertebral (between the vertebrae) foramens are small channels through which the nerve roots are leaving the spinal cord. The intervertebral foramen is located on the left and right sides of the spine.

The extension exercises, such as McKenzie method, acts on the muscles and ligaments. The exercises help maintain the natural lordotic curve, which is important for good posture of the spine.

Aerobic (high / low impact) exercises also offer many benefits, including improved muscular endurance, coordination, strength, strong abdominal muscles and weight loss. Aerobic exercise increases core strength and Weight-bearing capacity (legs bear the body weight); such as brisk walking also improves bone density of the legs, and decreases hip and lower back pain. It can also relieve the stress, and improves sleep, which helps in reducing the chronic pain.

Hamstring stretch

Physiotherapy for pain relief

There are varieties of physiotherapy techniques and modalities that can help relieve the symptoms of Sciatica. Passive treatments provide relaxation and pain relief, and muscle and joint strength of the body. They may include massage, heat and cold therapy, hydrotherapy, TENS (transcutaneous electrical nerve stimulation) and ultrasound.

TENS (Transcutaneous Electrical Nerve Stimulation):

TENS therapy sounds intense but is not painful. The electrodes, attached to the skin, send a small electrical current to key points on the nerve pathway. TENS is generally believed to trigger the release of endorphins, which are natural painkillers in the body.

Ultrasound:

This therapy uses sound waves to create a gentle heat that increases circulation of blood to the deeper tissues. Ultrasound helps reduce swelling, stiffness and pain. This passive therapy also improves your range of motion, which is likely to be limited due to the pain of rheumatoid arthritis.

Heat Therapy:

Heat causes a natural healing process of the body by relaxing the joints and tired muscles and speed the blood flow to the painful area. Extra blood supplies oxygen and extra nutrients.

Heat cannot completely eliminate the source of your pain of RA, but can effectively reduce chronic pain. Heat therapy is used in a couple of ways: through dry heat (heating pad or hot, dry towel) or heat (steam heat or a hot damp cloth) wet.

When the heat therapy is used after finishing the physical therapy, never overheat painful areas if you are using a heating pad; set it to low or medium. When using a hot towel, touch it first to make sure that it is not too hot.

Spinal traction

Spinal traction therapy can be administered manually or mechanically, depending on patient’s needs.

Spinal traction Manual

In manual spinal traction, a physiotherapist uses his hands to put a patient in a state of tension. Then he or she uses the manual force on the joints and muscles to expand the spaces between the vertebrae.

Mechanical Traction

In mechanical spinal traction, the patient lies on a table that has special tools to stretch the spine. A physiotherapist will attach a series of ropes, slings and pulleys to the patient to relieve mechanical pressure.

Massage:

Therapeutic deep tissue massage can help relax joints and muscles. Your therapist may use heat and cold massage therapies to increase their profits.

NoteYou should not massage into or near the arthritic area because it may cause pain. But massage can relax muscles and tissues that affect tired joints, even if not directly with them.

Sciatica Pain Prevention

As the old saying goes, "An ounce of prevention is worth a pound of cure." In the case of Sciatica, this is very true. Prevention of the development problem in the first place will help you avoid weeks of pain and possible weakening as you try and rehabilitate the injury.

Although you cannot prevent every acute injury, you can take steps to make the area around the sciatic nerve, less susceptible to injury. Strengthening the Piriformis helps prevent the compression of the sciatic nerve. This muscle pulls the leg outward and causes an outward rotation of the foot. The exercises that require the leg to be outward forced against the resistance will help strengthen this muscle. Strengthening the lower back and hip muscles help support the prevention of spinal injury, there that could compress the nerve.

The correct posture, a good warm-up before physical activity, and healthy and flexible muscles around the lower back and hips will help reduce injuries in this area that could put pressure on the sciatic nerve.

The flexibility of the piriformis muscle is another common concern. Since this muscle rarely stretched in everyday activities that can remain shorter: so, when a person is forced into a stretched position and cannot have the flexibility to support the forced stretch, it can lead to damage the muscle. Increased flexibility in the muscle can reduce the risk of injury. The lower back and hamstrings are also common areas of inflexibility, which can lead to muscle imbalances and acute injuries.