The Sciatica Explained (Part 2)

Éric-Olivier Sirois

Physiotherapist

September 22, 2022

This article aims to give you the tools and knowledge to enable you to take control of your pain.The goal is not only to help you manage and control your pain but to help you find a way (by yourself or with the help of a health professional) to resolve the cause of your problem (nerve pain/sciatica). As long as we don't fix the cause of your pain, the pain will keep coming back no matter how many painkillers you take. This is to help you regain control over your life!

This article is the second one of its series "Nerve pain Explained".  In this 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? 

If you are confused over specific topics of the second article, look at the first article of the series if you haven’t yet. 

What is Sciatica? (5)

Radicular sciatica (or, for simplicity, sciatica) is a fancy word to refer to symptoms associated with the compression of an irritated portion of the sciatic nerve (nerve root) as it comes out of your spine. (2-6) The sciatic nerve is a large nerve (roughly the size of your pinky) that is made of multiple nerve roots (L4-L5-S1-S2-S3) coming out from your spinal cord (visualize it as the roots of a tree merging to form the trunk). (2)  

It is a bundle of nerves that has the job of supplying your buttock region, back of your thigh, your calves and your feet for movements and sensations. (2) This is why many people with sciatica mention having knee pain, calf pain, and foot and toe pain. It is because the affected nerve is the one that gives sensation to these specific regions. If you find yourself having unusual weaknesses in those regions, it is likely again due to the nerve since the nerve controls the muscles there. The same is true if you are experiencing a loss of sensation in those regions. Usually, the segments involved are (L5-S1) (4-5). This is simply the name of the compressed nerve in your back. 

What are the Symptoms of a Sciatica?

Particular symptoms are associated with sciatica. It is essential to understand that no one has the same pain experience, even if the diagnosis is the same. Pain is unique to every one of us, just like our fingerprints. With this being said, in general, people tend to describe their pain as shooting(radiating), sharp (intense), stabbing (knife-like), tingling, burning or electric shocks. Some will have constant pain, while others will have intermittent episodes of pain, meaning that sometimes, they don’t feel any pain in their back or legs.

Where does a Sciatica usually Hurt?

The pain is more commonly reported to be only on one side, more intense in the leg than in the lower back. (2-3-4-7. However, it happens that people will experience the symptoms in both legs and even change from side to side. If this is you, know it isn’t just in your head; it happens to more people than you’d think.

Depending on which nerve level services , the pain in your leg will typically be in different regions. For instance, if it is the nerve L3 that is affected, you will most likely report pain in your front thigh and buttock. If the pain is usually more in your calf and posterior thigh, most likely, your nerves L5 and or S1 are involved. 

If you follow the black line, you can see the potential painful tracks associated with the different nerve levels involved. The red spots represent the regions the most likely to be painful and where you will experience the most flare-ups. Frequency of irritation of the different nerves: L3 = 0.5% L4 = 1% L5 = 44% S1 = 54% (5)

What is Causing My Sciatica? 

First, I would like to say that there are excellent chances that what you are experiencing is reversible and doesn’t require anything more than physical therapy to resolve. 

What could it be, you may be asking yourself? Well, there is a plethora of options. We will divide the possibilities into two groups. The first group can change with conservative care alone, such as physical therapy, and the second is the group that is not responsive to conservative treatments alone. Most individuals, close to 80% according to research, will fall in the first group, which has an excellent prognosis and tends to improve significantly within weeks.

The First Group: The Derangement (Responding)

There is this thing that we call a derangement in physical therapy, which pretty much means that something in your joint is altering the way it works. A good way to see it would be by imagining a piece of rubber stuck in the door joint. This can result in pain and movement loss the same way you will not be able to fully open and close the door if the rubber is in there. This can happen to all the joints in our body. 

A derangement is a non-specific diagnosis when discussing who’s to blame. This is because it has been shown multiple times that it is too often impossible to determine the exact source of the pain… which piece of tissue is the culprit. So, if you are looking for a specific name, I am sorry, but it is not something we can accurately do without poking needles in you and seeing which ones reproduce your symptoms. Many people will claim that they can accurately tell you the exact issue, but they are likely wrong. 

Multiple studies have shown there are as many people or almost with disc herniations and absolutely no pain as people with disc herniations and pain. Many healthy people don’t have any back pain and are diagnosed with herniated discs on their MRIs. It is possible to have a pain-free life with a herniated disc. (10)

From these studies was concluded that imagery (MRI/X-ray) cannot correctly determine the source of your symptoms. This is why we stopped diagnosing specific structures as the source of the pain and instead started grouping them according to their symptoms and the way they respond to different treatment approaches, i.e. (derangement). If you desire to read more on how with MRIs, we cannot determine the origin of most pains, I wrote an entire article on the topic. 

Furthermore, it has happened multiple times where I had patients walk into my offices with an MRI result showing that they have a disc herniation and therefore why their back hurts. They also usually ask me if they will need surgery or if it will ever get better. The vast majority are typically discharged by the 4th session as they have fully recovered. Now did undergoing physical therapy reduce their disc herniation? A small study looked at this. 

A study compared the MRIs of people with known disc herniation with sciatica symptoms before and after undergoing two to five physical therapy sessions with a trained physical therapist in the McKenzie Method. The study had 11 patients that presented with sciatica. The study looked for early changes in the location and size of the disc herniation on the MRI. In other words, can physical therapy change a disc herniation? They found that all patients experienced a decrease in signs and symptoms of their sciatica during and after these physical therapy sessions, but none showed any change on the MRI. 

If the disc herniation was the source of the pain, it should have followed the symptoms and disappeared in the second MRI, yet it didn’t. This suggests that their symptoms did not come from the disc herniation but something that maybe wasn’t even visible on the MRI. What was it exactly? We can’t tell for sure, but we know that all these patients with sciatica showed improvement with physical therapy.

Diagnoses Within the Derangement Group

1. Disc herniations 

2. Spinal Stenosis

3. Non-specific low back pain 

4. Osteoarthritis (regardless of its stage, from mild to multi-levelled facet osteoarthritis, they can all respond very well)

5. Degenerative disc disease

6. Chronic low back pain

How do we know it is this Derangement thing?

Derangements are also known as rapidly reversible mechanical problems showing a directional preference. Okay, that’s a mouthful, Éric-Olivier. What does that mean? Let’s break it down. 

Rapidly Reversible: When it is indeed a derangement, we expect to see at least moderate changes in the symptoms and how you can move within the first sessions. 

Mechanical problem: This refers to the source of your problem. It can be chemical, therefore, requiring a chemical solution to improve, for instance, drugs and injections, or it can be mechanical, thus, requiring a mechanical solution to improve such as movements/exercises. 

Directional preference: Directional preference is a type of movement (direction) that significantly improves the patient’s symptoms and way of moving when performed with the proper force and frequency.

How do I Know if I have a Directional Preference?

One if not the most essential thing with derangements is finding this last key point, “the Directional Preference (DP).” Here’s a question for you: does your leg pain flares up when you sit for a long time, bend forward to touch your toes, pick up boxes, or drive, or is it worse when walking and sitting upright? This simple question will help you tremendously. If you don’t know, I suggest you keep a little journal for the next two or three days and write down what triggers your symptoms. 

I ask what makes you worse since it is the human tendency to focus on what hurts rather than what decreases the pain. But the directional preference is almost always the opposite of the one making you worse. Thus, knowing what makes you worse, we can quite accurately assume the movements you need to improve your situation.

If you answered to sit for a long time, bending forward, touching your toes, picking up boxes, and driving worsens your symptoms, then we can say your symptoms are worsened by flexion. 

If you answered that walking and sitting upright, in general, makes your symptoms worse than sitting on the couch, in your case, your symptoms are made worse by what we call extension. 

Thus, if you said flexion movements make you worse, we can quite accurately assume your directional preference will be the extension and vice-versa.

Centralization/Peripheralization 

Another key sign to look for is Centralization/Peripheralization. What is that, you ask? These terms are associated with the location of your pain and how it behaves and is best explained through a picture. This is what peripheralization looks like: 

This picture shows the location of the pain experienced by someone. We can see that at first, it presents as a very local lower back pain. As it progresses, the pain starts feeling lower and lower down the leg. It is moving in the periphery (peripheralizing). If you’ve realized that during certain movements/positions, you feel your pain moving down; for instance, when walking, you only feel that nagging back pain, but after sitting for 30 minutes, you are experiencing pain on the side of your hip and down to your knee. The same happens when you are driving. Then it seems like flexion movements are peripheralizing your pain. 

Once again, I ask the question asking what makes you worse since it is the human tendency to focus on what hurts rather than what decreases the pain, but what we are looking for is if there are specific movements such as walking in the previous example that help your symptoms to move from down the leg up in the chain toward your knee and buttock as shown on the picture below. 

This is what we call centralization, which is another strong indicator that we are dealing with derangement and thus something rapidly reversible with adequate physical therapy.

Treatments for Sciatica 

It is important to note that it is not unusual sciatica symptoms to reduce on their own. Still, some people will need help from a health therapist to provide them with proper guidance, education/answers, and exercises to reduce and manage their symptoms. 

For this treatment section, we will only look at the physical therapy option as this is usually the first line of treatment for sciatica. In a third article, I go over all the other options if physical therapy fails to resolve your problem.

Physical Therapy

I would recommend you seek help from a physical therapist if you have insurance or can afford it. I would recommend physical therapy first for three reasons. First, they are often the best-qualified professional to help you with sciatica. The second is that they are much easier to get an appointment with and the last reason is that almost every single time, your physician will tell you to go to physical therapy and then return if it doesn’t work. 

So, as we can see, going through your doctor first will only have you wait for weeks to end up going into physical therapy. You might as well start immediately and regain your quality of life as soon as possible. If you don’t have insurance and can’t afford it, your family doctor would be the next best professional to see. It is also important to know that you do not need a doctor’s referral to go in physical therapy.

To ascertain the diagnosis of derangement and adequately find your directional preference, the direction that will help decrease your symptoms and regain your quality of life, a thorough assessment should be completed by a physical therapist with expertise in back pain. 

That said, I can still tell you what the treatment plan in physical therapy can look like according to which movements make you worse. It is important to remember that these are not professional advice but only examples. I will always suggest you seek help from a physical therapist instead of trying to fix it yourself. I do understand that it isn’t something that is accessible to all for various reasons, which is why I will show you examples, and you are free to do what you want with them. 

Flexion makes me worse

If this is you, and you likely are since this is the case for 78% of people, your directional preference is likely extension. This means that you will probably see improvements in your symptoms if you try to spend a bit more time in extension and a bit less in flexion for a bit. It also means that you could likely benefit from an exercise that promotes extension. Here are four regularly given exercises for people that need to move in extension.

1)    Sustained extension in lying on elbows

2)    Repeated extension in lying

3)    Repeated extension in standing over counter

4)    Repeated extension in standing

Extension makes me worse (6%)

If this is you, your directional preference is likely flexion. This means that you will likely see improvements in your symptoms if you try to spend a bit more time in flexion and a bit less in extension for a bit. It also means that you could likely benefit from an exercise that promotes flexion. Here are three regularly given exercises for people that need to move in flexion.

1)    Repeated Flexion in Lying

2)    Repeated Flexion in Sitting 

3)    Repeated Flexion in Standing

Both extension and flexion make me worse

If both flexion and extension make you worse, then I would certainly invite you to seek help from a professional and book an appointment with a physical therapist trained in the McKenzie method.

How Do I Know If My Sciatica is Getting Better?

The beauty of physical therapy with the McKenzie method is that within one or two sessions, the therapist will be able to tell you the likely prognosis. You will also be able to tell if you are getting better as significant improvements are expected during those initial sessions. Here are the changes you want to be attentive for: 

Location (centralization): Is the pain less present lower down in my leg? Am I experiencing this concept that we looked at earlier of centralization? Is my pain slowly migrating upward toward my buttock and back? If yes, you are likely on the right track, and everything indicates you are improving.

Function: do you find yourself able to do things you were unable to do because of your pain or from loss of movement? Are you more functional than before? If yes, then it appears that you are moving the right way. 

Intensity and frequency of your pain: You will know your sciatica is improving when you experience your symptoms less often, and when they are present, they aren’t as sharp or intense as they used to be.

Conclusion 

Hopefully, after reading all this, you are somewhat reassured and hopeful that maybe you are in that category of derangement. If it can reassure you, as I’ve mentioned before, roughly 80% of people with sciatica were found to belong in this fast-responding group.

If you want to know the next steps if physical therapy fails to provide you with the relief you are looking for, make sure to read the third and last article of this series. This article looks at more invasive treatments such as injections and surgeries. I also give more tools to help you control your symptoms and stay as active and functional as possible.

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.sirois@outlook.ca 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

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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.jpg

3.     https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcREchJNzcDuCt8nwSmRswPSBqmJVfE7nz78RFuaAJxfqtHRRzG6bqLA-iEE7fuJ31IyTn0&usqp=CAU

4.     https://i.ytimg.com/vi/1iaCrkupBxg/maxresdefault.jpg

https://img.emedihealth.com/wp-content/uploads/2019/12/4-repeated-lumbar-extension-600x400.jpg

6.     https://www.g4physio.co.uk/blog/common-stretches-advice/lumbar-spine-flexion-lying/

7.     https://www.thephysiocompany.com/blog/2019/12/9/5-amazing-low-back-stretches

8.     https://www.g4physio.co.uk/blog/common-stretches-advice/lumbar-spine-flexion-stretch-standing/

https://www.spine-health.com/video/cervical-selective-nerve-root-block-videohttps://lindywell.com/pilates-for-beginners-part-three-flexion-extension/

https://www.socalhip.com/wp-content/uploads/2021/10/Sciatica-Hip-Pain-Causes-Treatment.jpg