TriRehab: WFH Series

Sciatica Explained!

Beliefs about sciatica

We see clients reporting that they have 'sciatica' regularly in clinic, usually whilst wincing and desperately rubbing their symptom area to attempt to alleviate their often debilitating pain without much luck. I have family members, friends and colleagues that have complained of the effects of sciatica on and off for years, unpredictable in nature, that strikes without reason and usually makes itself scarce despite no huge shift in behaviour, leaving the sufferer with a combination of relief and frustration. Often, there is a feeling that their symptoms control them, rather than the other way round. Although sciatica and similar nerve root dysfunctional conditions are treated in large numbers every day in clinics globally (and now across computer screens and telephone lines), there still appears to be somewhat of a gap between the knowledge of practitioners and our client's understanding of what is actually causing these issues and more importantly, how they can help themselves.

Symptomatic clients have shown disturbing beliefs regarding the cause of their symptoms, such as being due to disc compressions, as well as having uncertainty around postural habits and feeling they have 'spinal malalignment'(Goldsmith et al 2019). Rather worryingly, people in the same study felt that their symptoms were not taken seriously and that their pains were underappreciated by their physiotherapist, possibly because the symptoms were not visible, despite the extreme intense pain. Moreover, surgery was seen to be the most powerful management tool to definitively take care of the issue, rather than non-invasive strategies.

Admittedly, the study size was small (13 people) and there was only one physiotherapist which could enhance the risk of reporter bias, but the information gathered certainly rings true for people I treat with recurrent episodes of sciatic like symptoms. I'll tackle the aforementioned beliefs, but let's just briefly drill down into finding out what sciatica actually is and differentiating it from other pesky nerve root botherers.

What is Sciatica?

60% of people with lower back pain report additional leg pain that is usually described as being the more debilitating symptom. Sciatica is often unilateral in nature (one sided), characterised by sharp pains along the path of the sciatic nerve. The sciatic nerve originates from the lower spine (L4-S3) and meanders down through the buttocks, down the back of the thigh and leg and finally ending in the foot. It holds the title of the longest and largest nerve in our body and when it's aggravated, it really knows how to throw a tantrum. Sudden movements such as coughs, sneezes or strains tend to be particularly uncomfortable, although as the symptom severity increases, so does the number of painful activities. Positive nerve tension tests help confirm the presence of sciatic nerve irritability, such as Straight Leg Raise (lower lumbar nerve roots) or Prone Knee Bend (upper lumbar nerve roots).

A radiculopathy is another nerve root dysfunction which is signified by dermatomal disturbances, including alterations or loss of sensation, muscle weakness, the sensation of muscle tightness and changes in reflex production on testing. This is often coupled with sciatica but can be considered a separate issue too.

Lastly, spinal stenosis is the term given to bilateral leg pain, caused by impingement of nerves leaving the spinal cord. In older adults, this is usually due to degenerative changes in the spine, though congenital changes can be the causal factor in younger people. These pains are usually relieved by activities in flexion (sitting or forward bending) and are worsened with extension movements (walking and standing).

Changing Beliefs

Although disc prolapse can cause sciatic nerve irritation, this does not necessarily mean this is the cause of the symptoms. Previous studies have shown that asymptomatic people have disc prolapses too, so there is no confirmed correlation between disc health and symptom production. Pain is a complex multidimensional emotional response that we feel, that rarely equates to tissue, bone or neural health.

Furthermore, imaging is not a totally reliable tool in terms of deciphering what might be causing nerve related symptoms as it cannot show neural sensitisation or inflammatory changes. In fact, people can often feel their symptoms have worsened or that they require surgery after receiving results of scans!

As mentioned earlier, surgical intervention is thought to be a definitive option to managing these symptoms and could improve in the short term, but there is no evidence that the improvement continues a year down the line (Jensen 2019) and so we champion conservative management with our clients, in accordance with the NICE Guidelines of lower back pain management (2018). But this is great news as everything points towards non-surgical approaches being the way forward!

In a nutshell, although mechanical changes can be responsible for our symptoms, it's highly likely there are other contributing factors that are affecting the severity of our symptoms, such as our beliefs, stresses and anxieties.

How Can Working From Home Affect This?

WFH poses a few threats to people with non-specific lower back pain and/or recurrent bouts of associated leg pains:

• Spending longer times sitting or lying down without getting up from the chair can put your spine in a compromised position, as well as causing global joint stiffness, muscular weakness and fatigue.
• Less than desirable work ergonomics- working in bed, lying on the sofa, leaning forward and working at the coffee table, sitting on a high breakfast stool...although these may all look aesthetically pleasing when you picked them out of the catalogue, these are all ergonomic villains if we spend any length of time in these positions and were not designed to work at for hours on end!
• High levels of stress and anxiety can increase the alertness of your pain receptors (nociceptors), meaning that the intensity of the pain is more likely to be higher and more difficult to manage, especially if over a longer period of time. This can typically be a case of 'chicken or egg' in terms of stress and pain and can be a tricky (but definitely achievable) puzzle to complete with the help of healthcare professionals.
• Poor sleep or a non-structured sleeping routine, especially if we are working until late. This has also been shown to increase the rate of injury in the general population by 1.7 times! Although sciatica can be physically and mentally draining, sleeping during the day can cause just as many issues too, in terms of developing good sleeping patterns.
• Sedentary lifestyles have become more prevalent as the world locked down, which meant that over time we may have lost motivation to exercise. Deconditioning can play a role in increasing our susceptibility to feeling these pains whilst we plunge further into Netflix holes. Moreover, our shopping lists may include more alcohol and less fruit and vegetables, which isn't fantastic for our health in the long run.

What Can I Do To Help Myself?

As explained previously, there are loads of strategies that you can implement to help take control of these symptoms:

• Moving regularly is key. You may no longer have a decent chair, or a suitable desk, but that just means that you have to be innovative. If you're on a work call, take the time to walk around. If you have a laptop, move from standing at the kitchen worktop, to sitting at the kitchen table. If you feel something is stiff or uncomfortable, that could be your body asking you to move a little more.
• Giving yourself a structured routine to allow for postural changes throughout the day. Try to work between emails, to calls, to zoom meetings, to making yourself a drink, to going on a walk etc. We spend a lot of time worrying about our posture and often people tell me they have the 'wrong posture'. There is non 'one size fits all'- the only wrong posture is the one you spend time in for longer than 30 minutes without moving!
• Exercising is a proven way to help combat stress, anxiety and therefore pain. A gradual increase in activity is a marvelous way to restore function and desensitise angry nerves. There is no exercise that is better than the other, just make sure you enjoy it! This should not feel like work, otherwise you won't necessarily get all the benefits that exercise can bring you. Light exercise can even include gardening, housework or doing the big shop.
• Identify a sleep routine that allows you to wind down for the evening to give yourself the best chance of catching 7-9 hours sleep. This should not revolve around looking at screens, but maybe a gentle walk of the dog, a stretching routine you're fond of, a decaffeinated night time tea or maybe some light reading (NOT WORK EMAILS!).
• Seeing family and/or friends, whilst adhering to social distancing of course, is a simple way of relieving stress too. It's amazing how quickly pain can subside once you've got your mind on something else a lot more interesting than the same old discomfort you've been feeling!
• Seeing your GP and discussing pain medications to hep to reduce the intensity of your pain and allow you to increase your activities is perfectly okay.
• Using heat or ice can be a effective way of managing sensitised pain too.
• Seeing a Physiotherapist or similiar for more guidance and clarification on symptoms, as well as a more tailored, individual approach.

Summary

Sciatica is a common injury that healthcare professionals have been treating for a long time and will continue to do so. If you begin to feel the rumblings of some leg pain and are fearing the worst (especially if these are recurrent symptoms), then don't panic and have a go at utilising some of the tips mentioned above.

As healthcare professionals, we have to take responsibility for not explaining conditions and for not offering reassurance when it is most needed. In a world where Google remains the internet king, symptoms can be searched and catastrophised quicker than you can say 'Argh the bloody sciatica is back', hopefully this provides a bit of clarity!

Like all musculoskeletal conditions, educating and exercise is key. For any further information, or if this has sparked more questions about your own symptoms, sciatica related or not, then please do send me a message via LinkedIn or an email at joe@triwellness.co.uk and I'd be happy to help. Happy Rehabbing!

Joe Mulligan is the Physiotherapy Manager at TriONLINE, a cost-effective multidisciplinary service that aims to provide excellent employee health and wellbeing services for SMEs using the 3 recognised pillars of health: mental health, physical health and nutrition.

References

• Hill JC, Konstantinou K, Egbewale BE et al (2011) Clinical Outome Among low back back pain consulters with referred leg pain in primary care. Spine 2011; 36: 2168-2175
• R Jensen, Kongsted A, Kjaer P, Koes B (2019) Diagnosis and Treatment of Sciatica. BMU. 19. 367
• Delitto A, Piva SR, Moore CG, et al (2015) Surgery versus non-surgical treatment for lumbar spinal stenosis: A randomized trial. Ann Intern Med; 162: 465-473
• Goldsmith R, Williams N & Wood F (2019). Understanding sciatica: illness and treatment beliefs in a lumbar radicular population. A qualitative interview study. BJGP Open, doi; 10.3399/bjgopen19x101654