Sciatica part 3: Treatments and useful tools

Eric-Olivier Sirois

Physiotherapist

November 21, 2022

Introduction 

This article is the third of its series "Nerve pain Explained". I strongly suggest you to read the previous 2 articles as this one builds on the different topics already covered.

In the first article, we covered the following topics: 

1.     Why do my nerves cause pain?

2.     Why does a pinched nerve in my back hurt down to my foot?

3.     What are the typical symptoms associated with nerve issues?

4.     What should I do if I have these symptoms?  

5.     What happens if my nerves are compressed/pinched or irritated for too long? 

In the second article, we covered the following topics about sciatica:

1.     What is sciatica

2.     What are the symptoms of sciatica?

3.     Where does a Sciatica usually Hurt?

4.     What is Causing My Sciatica? 

5.     The First Group: The Derangement (Responding)

6.     What is a derangement?

7.     Different diagnosis associated with sciatica?

8.     How do I Know if I have a Directional Preference?

9.     Centralization/Peripheralization 

10.  Treatments for Sciatica (physical therapy)

11.  How Do I Know If My Sciatica is Getting Better?

This third article aims to explain and present the steps after physical therapy, when it isn’t enough to provide you a complete resolution or the relief you were looking for. This article looks at injections and surgeries and additional resources. You will find additional tools to help you better manage your symptoms and to help you stay as active and positive as possible regardless of your condition at the end of this article.  

As we saw in the last article, roughly 80% of people with sciatica were found to fit in the fast-responding group, which we defined as the group to obtain complete resolution of their sciatica with conventional physical therapy. But what if I didn’t get full resolution with physical therapy? What are my next steps? Let’s look at it together. If this is you, you fall in this second sub-group that we will name non-responding. 

Non-responding  (Mechanically unresponsive radiculopathy) 

Who falls in this group? Those who did not respond to conservative care. There are no specific conditions that fall in this group from the get-go. We can only safely say your symptoms appear non-responsive to conservative care and may require more invasive interventions only once… conservative care has been thoroughly explored. It can take six weeks or more before concluding that you are in this group. This may seem long, but it is important to exhaust conservative options before going down the injections and surgeries path. 

In the non-responding group, we will find individuals that went through general physical therapy and didn't see any or only minimal improvement in their symptoms. 

Once the typical conservative route has been attempted, the next step should be to see a physical therapist trained in the McKenzie Approach (MDT) and then, if necessary, obtain a referral for an injection. 

STEP 1) The McKenzie approach

A study looked at patients who had gone through the general physical therapy protocol without any improvements. They were then assessed by neurosurgeons and orthopedists and determined to be candidates for lower back surgery, which means that every single patient in this study was on the waiting list for a herniated disc surgery and had consented to the surgery. 

All initial patients (132) were assessed by trained physical therapists in the McKenzie Method (MDT). Their job was to see if the patients truly couldn't benefit from physical therapy. The McKenzie approach is a different approach that is not yet commonly used but becoming more and more the gold standard, especially for lower back pain and sciatic-like pain in the physical therapy world. As mentioned, all 132 patients had already undergone the general physical therapy protocol according to national guidelines and failed to obtain any relief.

Amazingly, out of those 132 patients, 41 ended up never receiving an injection nor undergoing surgery, as they were found to respond and improve significantly or even completely with the McKenzie approach. That's 31% of the patients that failed to get better with the general physical therapy approach and yet clearly responded to McKenzie's physical therapy. 

This is why I believe it could be worth trying before going for injections if a McKenzie-trained therapist hasn't seen you. It isn't magical since 69% of the assessed patients did not respond to this approach. However, it still saved one out of three patients from receiving unnecessary injections or even undergoing serious surgeries.

Step 2) Injections 

I've tried the McKenzie approach and don't feel better. What's next? The next step usually is to get a referral for an injection. There are different types of injections, but we will generalize them into the same category for simplicity. The same study then looked at all the patients that showed no signs of further improvements with the McKenzie approach. From there, these patients (69) * received from one to four injections. Here are the results of the injections. 

They found for 16% of the patients, their symptoms completely resolved after the injection. In 46 % of them, it significantly reduced their symptoms and allowed them to start responding to the McKenzie physical therapy treatments. In 16% of the patients, it significantly reduced their symptoms, but they were still not gaining any improvements from physical therapy. Lastly, 22% of them obtained no relief from the injections, saw no improvements from further treatments in physical therapy, and underwent further invasive interventions. 

What is important to keep in mind is that 100% of the patients that participated in the study had already consented to herniated disc surgery and were waiting for surgery. Out of the sixty-nine patients that received injections, only one out of 5 (22%) truly required surgery.

As we can see, 95 out of the 132 patients ended up recovering greatly and even completely with either the McKenzie approach, injections, or the combination of the two.

In other words, majority of patients that were expected to require surgery did not and were able to recover with either McKenzie physical therapy treatments (31%), injections (17%), or the combination of injections followed and McKenzie physical therapy treatments (24%) significantly or even completely. This sure should bring at least some of hope to anyone currently dealing with sciatica. This shows that it is more likely than not (71%) to get significantly better without any surgery, even if at first it seemed like it was the only option. 

This goes to show that only a very small portion of individuals will need to undergo surgeries for sciatica if proper order of care is given. 

            Step 1) Physical Therapy with the McKenzie approach 

            Step 2) Injections + Physical Therapy

            Step 3) Surgery  

This is important to understand because maybe you are in this situation and are waiting to undergo a surgery. I am not a doctor and am not here to contradict another health professional’s opinion, but it is definitely worth asking if you haven’t tried physical therapy if it would be a possibility. And if you have tried physical but didn’t get any improvements from it, the same holds true for trying the McKenzie Method before injections and surgery. If there was a simple and inexpensive way for you to avoid a surgery and all the potential complications, wouldn’t you want to try it first?Maybe for your specific condition it is not recommended and your doctor will be able to tell you, but you have nothing to lose and everything to win by asking.

Step 3) After injections

Once you’ve received an injection, going back in physical therapy is your next step. You read this right. As we’ve seen above, 46% of the patients after receiving injections started seeing significant improvements with physical therapy treatments. After injections it is a 50/50 chance that you will get better with physical therapy, this is why it is so important to give it a second try. 

If you fall in the group that starts improving with physical therapy, great, you will improve without any further invasive interventions. Your path to recovery is clear and you have a great prognosis. 

If you fall in the group that still doesn’t improve with physical therapy combined with injections, don’t lose hope, there are more options and resources at your disposition.

I’m in that last group! What are my options?

For those with remaining symptoms and consequences from the sciatica after receiving injections and trying again physical therapy, there are more resources. It is important to not lose hope although you likely feel like you are stuck with it forever. 

1.     Medications

Certain drugs have been shown to significantly help decrease the symptoms of nerve pain as experienced with sciatica. For more information ask your doctor and your pharmacist as they are the experts in this field. 

2.     Surgery

When everything fails and the pain and limitations are too great to live with, surgeries can sometime provide the relief one hopes for. 

3.     Groups and Clinics 

Learning to cope with help of chronic pain groups and chronic pain clinics has been shown to have a significant positive impact on the reported pain and distress experienced by those living with painful conditions. 

Talking with other individuals living with similar pain as us can sometime help us feel understood which can have a profound impact on our well-being.

There are multiple accessible groups that have for mission to help individuals living with chronic pain. Their goal is to help you be as functional as possible and maximize your quality of life.

These groups and clinics have a wide range of tools and tricks to help you manage as best as possible your symptoms and help you be as active as you can. One of these tools which I teach to all my patients is the Traffic Lights Guide. 

Traffic Lights Guide

The traffic light guide is a very simple tool to not only guide the professional, but is also helpful for patients. It gives you a guide to know how much to do, how much pain is acceptable, what should happen afterwards and when you should “back off.” It will give you the tools and confidence to evaluate and respond to your own symptoms which is highly empowering! 

This guide is to be used the same way as if you were driving. This is a simple and useful tool to help you stay as active as possible. It is important to not stop all your activities as usually complete rest for more than 2-3 days can become detrimental and make the situation worse. Movement is almost always the best treatment. 

Continuing to do sports or to train can be something very stressful for many as no one wants to worsen their situation by doing something they shouldn’t have done. But how to know what I can and can’t do? This is where the traffic lights guide comes handy. If you are not sure about a certain activity, test it using these guidelines.

Green light

This is any activity or movement that, when you do it, either make you feel better or doesn't change your symptoms. You can do these activities as much as you want, and I would encourage you to do them regularly. Here is how you might feel about green light activities: 

1. The symptoms in your leg and back feel better during and after.
2. The symptoms in your leg feel better during and after.
3. My leg pain centralizes (meaning it's moving upward).
4. The symptoms in your back feel better, and your leg symptoms stay the same or improve during and after.
5. Your symptoms don't change during and after.
6. Your movements improve, and your symptoms stay the same during and after.
7. Your movements and symptoms stay the same during and after.

Yellow light

This is any activity or movement that, when you do it, you might feel a slight increase in your symptoms, but once you stop them, your symptoms settle down within 15 minutes to where they were before the activity. These are activities you can do, but I recommend you closely monitor how you feel during and after. These are activities I would usually recommend slowly increasing how much you do. Similar to if you were starting to train again after a long pause. Here is what you might experience with yellow activities: 

1. My pain increases slightly, but once I stop, it settles down to the same intensity.
2. My pain moves lower down in my leg (peripheralizing), but once I stop, it returns to the exact location as before.
3. As I do the exercise, I feel fine, but once I stop, my pain increases slightly for a few minutes before settling down.
4. As I do the activity, I feel fine, but once I stop, I feel stiffer for a few minutes but get back to my pre-activity state quickly.

Red light

This is any activity or movement in which you feel worse and stay worse even once you stop. These are activities that you might want to put on hold for now. This doesn't mean you will never do these activities again. It only means that it could be a good idea not to do them right now. These aren't inherently bad or dangerous; they are simply not the best as of today for you. They are worth retesting somewhat regularly to see if you are now able to do them. Don't ban them for life. Put them on hold if they clearly and significantly make you worse. Here is what you might experience with red activities: 

1. My pain is peripheralized (moving lower and lower in my leg) and stays down.
2. New symptoms are produced during the activity and remain even after I stop.
3. My pain increases during the activity and stays increased.

Here is a diagram to show the difference between a yellow activity and red activity 

Conclusion 

Although very painful and debilitating, nerve pain has good prognosis. As we saw, regardless of your symptoms and presentation, the odds are that you will either fully or significantly recover from nerve pain and that there are multiple professionals and resources at your disposition. Hopefully these articles helped keeping you hopeful and invested in your recovery.  

I hope these 3 articles were able to answer your questions and give you the tools and knowledge you need to help yourself and see as needed help from the right health professionals.

Seeking Guidance 

As always, If you feel like you would benefit from an evaluation to identify and treat your pain from a health professional, you are welcome to make an appointment with me. It will be my pleasure to guide and help you. 

If you’d like to discuss any of the points raised in this article in more detail, I would love to speak to you. You can contact me by email at ericolivier.physio@gmail.com or by phone at 514-692-3347. I currently offer free no-strings-attached 15-minute phone call consultations to discuss how I can best assist you, so if you are not sure if you want to book an appointment or if I can help you, make sure to call me. It will be my pleasure to answer and guide you. 

References

van Helvoirt, H., Apeldoorn, A. T., Ostelo, R. W., Knol, D. L., Arts, M. P., Kamper, S. J., & van Tulder, M. W. (2014). Transforaminal epidural steroid injections followed by mechanical diagnosis and therapy to prevent surgery for lumbar disc herniation. Pain medicine (Malden, Mass.), 15(7), 1100–1108. https://doi.org/10.1111/pme.12450 

Pictures

https://files.miamineurosciencecenter.com/media/filer_public_thumbnails/filer_public/04/05/040541cf-46b4-46d1-9117-4f596bb6b402/xsciatic_nerve_roots.jpg__1355x1042_q85_subject_location-678,P2C516_subsampling-2.jpg.pagespeed.ic.-zJPWajXma.jpghttps://painarthritisrelief.com/wp-content/uploads/2018/06/Sciatica-or-Back-Pain.jpghttps://www.caringmedical.com/wp-content/uploads/2017/02/types-of-spinal-stenosis-WEB.jpghttps://image.shutterstock.com/image-illustration/3d-illustration-showing-lumbar-vertebra-260nw-1681729558.jpghttps://sequencewiz.org/wp-content/uploads/2015/12/DiscPositionInfographic.pnghttps://c8.alamy.com/comp/2B93ABJ/3d-illustration-showing-painful-herniated-disc-or-slipped-disc-2B93ABJ.jpg

https://www.statology.org/wp-content/uploads/2020/04/bellCurve1.png