Severe Sciatica: Solutions and your options
Finding a solution to your sciatica
A skilled practitioner in the McKenzie Method (Mechanical Diagnosis & Therapy or MDT) is the ideal person to assess you if you have sciatica.
It is your history, in combination with the effect that repeated movements and/or sustained positions (the main difference with the MDT assessment) that change your pain that helps to classify the source of your leg pain, and most importantly to identify if there are specific exercises that you can do that will reduce or Centralize the pain.
The MDT form of assessment is arguably the most researched form of assessment studied for back pain, and has been shown to be valid and reliable (Werneke et al 1999, Kilpikoski et al 2002, Razmjou et al 2000, Clare et al 2004, Gutke et al 2010, Werneke et al. 2010) at classifying the problem and determining if your pain can be Centralized (Long et al 2004, Hefford et al 2008, May and Aina, 2012).
Watch this short youtube video for an explanation about MDT and the assessment process
(https://youtu.be/vqzlbHsf5rw)
Relief of pain from bulging discs
Research shows that around 70% of low back problems, including those with sciatica and neurological signs will have a direction of movement that can Centralize or relieve their pain (Hefford et al 2008, May and Aina 2012). This direction of movement that causes pain to Centralize is called your direction preference, and regular exercises in the direction of preference will resolve your problem, restoring movement and function, and eliminating the pain.
Various models about how this may work have been proposed, including the disc model where these exercises reduce the amount of disc bulging and take pressure off the nerve (Wetzel and Donnelson, 2003).
Whether we can prove that this is truly what happens is debatable, but there are over 50 studies on the importance and prognostic power of Centralization (May and Aina, 2012), and so ultimately it is the change in pain and its location with the assessment that determines the management
What do I do if my problem is coming from a disc bulge?
If an MDT assessment can identify a direction of movement (your direction preference) that centralizes your pain, or rapidly eliminates it your prognosis is excellent. Regular performance of this direction specific exercise (usually every few hours in the short term), in combination with posture correction and temporary avoidance of prolonged or repeated movements in the opposite direction will resolve the problem (Long et al, 2004). This can occur within days, and commonly it takes a few weeks.
A skilled MDT practitioner can usually identify if you will be one of the majority whose leg pain falls in this group, and it can be established usually within 1-3 sessions if you will indeed respond, most often in the first session (Werneke and Hart, 2003)
Common exercises that give relief of sciatica (note these should always be prescribed by a qualified McKenzie Method practitioner based on your individual assessment):
- Extension in lying (https://youtu.be/kESRfUlaLP8 )
- Extension in lying with lateral modification ( https://youtu.be/N3LKrsQbnn8 )
- Side-glide in standing ( https://youtu.be/-WB8hdnkv1w )
What if I do not respond to repeated movements and I am not a ‘McKenzie Method responder?’
A recent study by Hans Van Helvoirt et al (2014) showed that in those with sciatica who unresponsive to a McKenzie Assessment that underwent an injection into the nerve root (transformenal epidural steroid injection):
- 16% had complete resolution of their sciatica following the injection
- 46% then showed centralisation with an MDT assessment 2 weeks after the injection, who had been non-responders prior to the injection
- 16% showed a decrease in sciatica but remained non-responders to MDT testing for centralisation
- 22% did not respond to the injection and received an operative intervention
These results show that a significant subgroup of those with severe sciatica can avoid surgery, either by relief of the injection or by becoming responders to an MDT assessment once the chemical irritation around the nerve is treated by an epidural injection.
Other people with chemical irritation of the nerve who may not want to have an injection, or who have failed to improve with an injection around the nerve root, will respond to anti-inflammatory medication in a similar way. For some people a trial of Voltaren for 7-10 days (under the guidance of their GP) or Prednisolone (a stronger steroid based anti-inflammatory drug) can resolve the chemical component, and bring relief and then the potential for specific direction based exercises to then have an effect.
Stayed tuned for part 3 – Severe pain from disc rupture and options for those that do not respond to the McKenzie Method
For an assessment of your low back pain or sciatica, come and see our McKenzie specialist physiotherapist Joel Laing at Absolute Health & Performance in Melbourne’s CBD.
# Melbourne physio
# Melbourne CBD physio
References:
Helvoirt, H., Apeldoorn, A.T., Ostelo, R.W., Knol, D.L., Arts, M.P., Kamper, S.J. and Tulder, M.W., 2014. Transforaminal epidural steroid injections followed by mechanical diagnosis and therapy to prevent surgery for lumbar disc herniation. Pain Medicine, 15(7), pp.1100-1108.
Werneke, Mark, Dennis L. Hart, and David Cook. “A Descriptive Study Of The Centralization Phenomenon”. Spine 24.7 (1999): 676-683. Web.
May, Stephen and Alessandro Aina. “Centralization And Directional Preference: A Systematic Review”. Manual Therapy 17.6 (2012): 497-506. Web.
Wetzel, F.Todd and Ronald Donelson. “The Role Of Repeated End-Range/Pain Response Assessment In The Management Of Symptomatic Lumbar Discs”. The Spine Journal 3.2 (2003): 146-154. Web.
Hefford, Cheryl. “Mckenzie Classification Of Mechanical Spinal Pain: Profile Of Syndromes And Directions Of Preference”. Manual Therapy 13.1 (2008): 75-81. Web.
Razmjou, Helen, John F. Kramer, and Riki Yamada. “Intertester Reliability Of The Mckenzie Evaluation In Assessing Patients With Mechanical Low Back Pain”. J Orthop Sports Phys Ther 30.7 (2000): 368-389. Web.
Werneke, Mark W. et al. “Prevalence Of Classification Methods For Patients With Lumbar Impairments Using The Mckenzie Syndromes, Pain Pattern, Manipulation, And Stabilization Clinical Prediction Rules”. Journal of Manual & Manipulative Therapy 18.4 (2010): 197-204. Web.
Clare, Helen A, Roger Adams, and Christopher G Maher. “A Systematic Review Of Efficacy Of Mckenzie Therapy For Spinal Pain”. Australian Journal of Physiotherapy 50.4 (2004): 209-216. Web.
Gutke, Annelie, Gunilla Kjellby-Wendt, and Birgitta Öberg. “The Inter-Rater Reliability Of A Standardised Classification System For Pregnancy-Related Lumbopelvic Pain”. Manual Therapy 15.1 (2010): 13-18. Web.
Long, Audrey, Ron Donelson, and Tak Fung. “Does It Matter Which Exercise?”. Spine 29.23 (2004): 2593-2602. Web.
