Sciatica: Immediate Physiotherapy Improves Treatment Success Rates 60% at 1 Year

In our November bulletin, we described a study out of the U.K. that is reversing a decade’s old consensus opinion that sciatica has a good prognosis, with the majority of pain complaints resolving within four weeks.1,2 In the U.K. study, Kika Konstantinou et al. found that patients went from an average pain intensity of 5.2 on a 10-point scale to 2.4 after one year. Other measures of pain and disability showed strong persistence as well.

In October, the Annals of Internal Medicine published a study out of the U.S. which compared one-year sciatica outcomes based on treatment strategies.3 Consistent with the results found in the U.K. study, resolution of pain complaints proved unlikely throughout the year following the first primary care visit. Only 27.6% of patients receiving usual care selfreported treatment success at one-year followup.

Fortunately, in the current study, Dr. Fritz and colleagues measured an easy way to improve success rates for patients with sciatica. Patients who were referred to physiotherapy during their first primary care encounter had clinically and statistically significant improvements in disability measures after 4 weeks of treatment.

At one-year follow-up, those patients receiving immediate physiotherapy were 60% more likely to self-report treatment success. Dr. Fritz and colleagues randomised 220 patients presenting with sciatica less than 90 days old to either a usual care group or usual care plus immediate physiotherapy group. All patients received analgesics and imaging according to the discretion of the treating clinician.

All patients received patient education materials and a training session on home exercise and staying active. Patients randomised to physiotherapy additionally received six to eight physiotherapy sessions over four weeks. Physiotherapy included lumbar extension exercises and manual therapy such as spinal mobilization or manipulation.

Studies such as these typically find reduced use of other healthcare. In this scenario, Fritz and colleagues did not. Within a year, patients engaged in surgery (7.4%), injections (13.2%), advanced imaging (25%), and emergency department visits for sciatica (9.7%). Use of oral analgesics was not reported.

Despite the fact that immediate physiotherapy referrals greatly improved the likelihood of patient-reported success, there were no between-group differences in terms of other healthcare use. However, it may be likely that another episode of physiotherapy before surgery referral could reduce the need for surgery.

A study published in 2013 offered general aerobic exercises or physiotherapy to patients who qualified for surgery.4 Although patients reported having greater faith in the aerobics classes, patients receiving aerobic training proved five times more likely to elect surgery compared to patients receiving physiotherapy.

Research regarding the prognosis and conservative treatment of sciatica has been sparse over the years. However, a picture is emerging of a condition that is persistent but improved through immediate access to physiotherapy. Reducing the need for surgery may require repeated access to physiotherapy.

References 1. Konstantinou K, Dunn KM, Ogollah R, Lewis M, van der Windt D, Hay EM, ATLAS Study Team. Prognosis of sciatica and back-related leg pain in primary care: the ATLAS cohort. The Spine Journal. 2018 Jun 1;18(6):1030-40. 2. van Tulder M, Peul W, Koes B. Sciatica: what the rheumatologist needs to know. Rheumatology. 2010; 6: 139-145. 3. Fritz JM, Lane E, McFadden M, Brennan G, Magel JS, Thackeray A, Minick K, Meier W, Greene T. Physical Therapy Referral From Primary Care for Acute Back Pain With Sciatica: A Randomized Controlled Trial. Annals of Internal Medicine. 2020 Oct 6. 4. Nordin M, Belague F. Exercise may be beneficial for patients with chronic, severe sciatica who would normally qualify for surgery. Evid Based Med. 2013; 18 (2): 63-64

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