Chiropractic and Sciatica

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:   Frankp@chiro.org

	The McKenzie Method Page A Chiro.Org article collection The McKenzie Method is grounded in finding a cause and effect relationship between the positions the patient usually assumes while sitting, standing, or moving, and the generation of pain as a result of those positions or activities. The therapeutic approach requires a patient to move through a series of activities and test movements to gauge the patient's pain response. The approach then uses that information to develop an exercise protocol designed to first “centralize” and then alleviate the pain.
	Low Back Pain Guidelines from Around the World A Chiro.Org collection A new addition is the NICE Guideline, NG 59 titled: “Low Back Pain and Sciatica in Over 16s: Assessment and Management”, and many other recent guidlines. This section also includes p;der recommendations from the California Industrial Medical Council, the Royal College of General Practitioners, the 1994 AHCPR guides, the "Mercy Conference Document", and the New Zealand "Psychosocial Yellow Flags" Page
	Diagnosis and Treatment of Sciatica British Medical Journal 2019 (Nov 19); 367: l6273 ~ FULL TEXT Sciatica is commonly used to describe radiating leg pain. It is caused by inflammation or compression of the lumbosacral nerve roots (L4–S1) forming the sciatic nerve. [1] Sciatica can cause severe discomfort and functional limitation. Recently updated clinical guidelines in Denmark, the US, and the UK highlight the role of conservative treatment for sciatica. [2–4] In this Clinical Update, we provide an overview for non-specialists on diagnosing sciatica and key principles in its management. The term “sciatica” is not clearly defined and it is often used inconsistently by clinicians and patients. [5] Radicular pain and lumbosacral radicular syndrome have been suggested as alternatives. [6] In this article, we use sciatica and radicular pain synonymously. Radiculopathy describes involvement of the nerve root, which causes neurological deficit including weakness or numbness.
	Clinical Diagnostic Model for Sciatica Developed in Primary Care Patients with Low back-related Leg Pain PLoS One. 2018 (Apr 5); 13 (4): e0191852 ~ FULL TEXT This study used information from clinical assessment to estimate the likelihood of sciatica in patients with LBLP presenting in the primary care setting. It is the first study to explore the considerable challenges, implications and sources of bias inherent with reference standard selection in identifying sciatica, and to compare models with different reference standards. A clear cluster of items was found which consistently identified sciatica: pain below the knee, leg pain worse than back pain, positive neural tension and neurological deficit. A simple scoring tool was developed which could prove useful to clinicians and researchers wishing to support their clinical judgement regarding the probability of whether a patient’s leg pain is sciatica. In research settings, the tool could enable more optimum identification of a homogenous group.
	Leg Pain Location and Neurological Signs Relate to Outcomes in Primary Care Patients with Low Back Pain BMC Musculoskelet Disord. 2017 (Mar 31); 18 (1): 133 ~ FULL TEXT The Quebec Task Force categories (QTFC) identify different LBP subgroups at baseline and there is a consistent ranking of the four categories with respect to outcomes. The differences between outcomes appear to be large enough for the QTFC to be useful for clinicians in the communication with patients. However, due to variation of outcomes within each category individuals' outcome cannot be precisely predicted from the QTFC alone. It warrants further investigation to find out if the QTFC can improve existing prediction tools and guide treatment decisions.
	What Do Patients Value About Spinal Manipulation and Exercise for Back-related Leg Pain? A Qualitative Study Within a Controlled Clinical Trial Manual Therapy 2016 (Dec); 26: 183–191 ~ FULL TEXT This qualitative study illustrates that patient satisfaction is rooted in the quality of the patienteprovider relationship, although perceived symptom improvements, relevant clinical information about sciatica and its treatment, and the distinct qualities of those treatments are important drivers of satisfaction for patients who received non-pharmacological treatments for their back-related leg pain. Global measures of satisfaction may not adequately represent the range of patients' experiences and perceptions of spinal manipulative therapy or home exercise. In addition to providing insight to the quantitative results of the parent trial, these findings suggest that tailored interventions to enhance patienteprovider relationships may facilitate compliance and enhance satisfaction with care.
	Symptomatic, Magnetic Resonance Imaging-Confirmed Cervical Disk Herniation Patients: A Comparative-Effectiveness Prospective Observational Study of 2 Age- and Sex-Matched Cohorts Treated With Either Imaging-Guided Indirect Cervical Nerve Root Injections or Spinal Manipulative Therapy J Manipulative Physiol Ther. 2016 (Mar); 39 (3): 210–217 ~ FULL TEXT "Improvement" was reported in 86.5% of SMT patients and 49.0% of CNRI patients (P = .0001). Significantly more CNRI patients were in the subacute/chronic category (77%) compared with SMT patients (46%). A significant difference between the proportion of subacute/chronic CNRI patients (37.5%) and SMT patients (78.3%) reporting "improvement" was noted (P = .002).
	Characteristics of Patients with Low Back and Leg Pain Seeking Treatment in Primary Care: Line Results from the ATLAS Cohort Study BMC Musculoskelet Disord. 2015 (Nov 4); 16: 332 ~ FULL TEXT In summary, in this unselected primary care cohort of patients seeking care for back and leg pain, disability levels are higher as compared with cohorts including mixed populations of LBP patients with and without pain in the leg(s) and similar for both sciatica and referred leg pain presentations. Nearly three quarters of the participants were clinically diagnosed as having sciatica. Approximately half of this cohort was likely to have pain of neuropathic nature as measured with self-reported scales. In contrast to non-specific LBP, minimal treatment was applicable to only a very small number of patients in this cohort. MRI findings of nerve root compression were present in just over half of the participants. There were differences between the sciatica and referred leg pain groups in terms of leg pain levels, neuropathic pain, bothersomeness due to the sciatic symptoms and MRI findings. Follow-up of this cohort will investigate the prognostic value of their baseline characteristics and explore the clinical relevance of the differences between those with sciatica and referred leg pain for the course of the low back and leg pain episode.
	Pain Location Matters: The Impact of Leg Pain on Health Care Use, Disability and Quality of Life in Patients with Low Back Pain European Spine Journal 2015 (Mar); 24 (3): 444–451 ~ FULL TEXT Patients with self-reported leg pain below the knee utilise more health care are more likely to be unemployed and have poorer quality of life than those with LBP only 12 months following primary care consultation. The presence of leg pain warrants early identification in primary care to explore if targeted interventions can reduce the impact and consequences of leg pain.
	The Effect of Adding Forward Head Posture Corrective Exercises in the Management of Lumbosacral Radiculopathy: A Randomized Controlled Study J Manipulative Physiol Ther. 2015 (Mar); 38 (3): 167–178 ~ FULL TEXT The addition of forward head posture correction to a functional restoration program seemed to positively affect disability, 3-dimensional spinal posture parameters, back and leg pain, and S1 nerve root function of patients with chronic discogenic lumbosacral radiculopathy.
	Spinal Manipulation and Home Exercise With Advice for Subacute and Chronic Back-related Leg Pain: A Trial With Adaptive Allocation   NCT00494065 Annals of Internal Medicine 2014 (Sep 16); 161 (6): 381–391 Of the 192 enrolled patients, 191 (99%) provided follow-up data at 12 weeks and 179 (93%) at 52 weeks. For leg pain, SMT plus HEA had a clinically important advantage over home exercise and advice (HEA) (difference, 10 percentage points [95% CI, 2 to 19]; P=0.008) at 12 weeks but not at 52 weeks (difference, 7 percentage points [CI, -2 to 15]; P=0.146). Nearly all secondary outcomes improved more with SMT plus HEA at 12 weeks, but only global improvement, satisfaction, and medication use had sustained improvements at 52 weeks. No serious treatment-related adverse events or deaths occurred.
	Prognostic Implications of the Quebec Task Force Classification of Back-related Leg Pain: An Analysis of Longitudinal Routine Clinical Data BMC Musculoskelet Disord. 2013 (May 24); 14: 171 ~ FULL TEXT A total of 1,752 patients were included, with a 76% 3-month and 70% 12-month follow-up. Subgroups were associated with activity limitation in all models (p < 0.001). Local LBP had the least and LBP + neurological signs the most severe limitations at all time-points, although patients with neurological signs improved the most. Associations with GPE after 3 months were only significant in Model I. Subgroups were associated with sick leave after 3 months in model I and II, with sick leave being most frequent in the subgroup with neurological signs. No significant differences were found in any pairwise comparisons of patients with leg pain above or below the knee.
	Conservative Management of a 31 Year Old Male With Left Sided Low Back and Leg Pain: A Case Report J Can Chiropr Assoc. 2012 (Sep); 56 (3): 225–232 ~ FULL TEXT This case demonstrates positive results for the treatment of a sub-acute lumbar disc injury with conservative care. It should be noted that results cannot be extrapolated to other cases, since this is only a single case report and the rapid resolution of this patient’s symptoms could be due to the natural history of the condition or the use of multiple interventions. Sitting and slouching have been shown to aggravate low back pain, especially when a disc injury is involved. Standing and extension exercises have been shown to help combat this. There are many reports of asymptomatic disc herniations and spontaneous resolutions, as well as muscular atrophy associated with this type of injury. The prognosis of disc herniation related low back pain relates to the extent of radiation, duration of pain and other psychosocial factors. Recommended conservative care includes spinal stabilization exercises, McKenzie assessment and treatment, neural mobilizations and chiropractic modalities, including spinal manipulative therapy. Conservative management may decrease pain and increase function for the treatment of lumbar disc injuries. Active patient participation in rehabilitative care is recommended before surgical referral.
	Predictors of Improvement in Patients With Acute and Chronic Low Back Pain Undergoing Chiropractic Treatment J Manipulative Physiol Ther. 2012 (Sep); 35 (7): 525–533 ~ FULL TEXT An important and unique finding in this current study is that although 123 (23%) of the patients with acute LBP and 71 (24%) of the patients with chronic LBP were diagnosed by their chiropractors as having radiculopathy, this finding was not a negative predictor of improvement. Radiculopathy was not simply defined as leg pain but required clinical signs of nerve root compression as determined by the examining chiropractor. Previous studies investigating outcomes from patients with LBP undergoing spinal manipulation have purposely excluded patients with radiculopathy, [2, 10, 29] and others have found that the presence of leg pain is a negative predictor of improvement. [12, 24, 30] This study purposely included these patients to evaluate this subgroup. It is quite common for patients with LBP experiencing radiculopathy to seek chiropractic care in Switzerland and to receive spinal manipulative therapy as one of the treatment options.
	Chiropractic and Self-care for Back-related Leg Pain: Design of a Randomized Clinical Trial   NCT00494065 Chiropractic & Manual Therapies 2011 (Mar 22); 19: 8 ~ FULL TEXT Back-related leg pain (BRLP) is a costly and often disabling variation of the ubiquitous back pain conditions. As health care costs continue to climb, the search for effective treatments with few side-effects is critical. While SMT is the most commonly sought CAM treatment for LBP sufferers, there is only a small, albeit promising, body of research to support its use for patients with BRLP.This study seeks to fill a critical gap in the LBP literature by performing the first full scale RCT assessing chiropractic SMT for patients with sub-acute or chronic BRLP using important patient-oriented and objective biomechanical outcome measures.
	Manipulation or Microdiskectomy for Sciatica? A Prospective Randomized Clinical Study J Manipulative Physiol Ther. 2010 (Oct); 33 (8): 576–584 ~ FULL TEXT One hundred twenty patients presenting through elective referral by primary care physicians to neurosurgical spine surgeons were consecutively screened for symptoms of unilateral lumbar radiculopathy secondary to LDH at L3–4, L4–5, or L5–S1. Forty consecutive consenting patients who met inclusion criteria (patients must have failed at least 3 months of nonoperative management including treatment with analgesics, lifestyle modification, physiotherapy, massage therapy, and/or acupuncture) were randomized to either surgical microdiskectomy or standardized chiropractic spinal manipulation. Crossover to the alternate treatment was allowed after 3 months.   Sixty percent of patients with sciatica who had failed other medical management benefited from spinal manipulation to the same degree as if they underwent surgical intervention. Of 40% left unsatisfied, subsequent surgical intervention confers excellent outcome. Patients with symptomatic LDH failing medical management should consider spinal manipulation followed by surgery if warranted.
	The Nordic Back Pain Subpopulation Program: Can Low Back Pain Patterns Be Predicted From the First Consultation With a Chiropractor? A Longitudinal Pilot Study Chiropractic & Osteopathy 2010 (Apr 29); 18: 8 ~ FULL TEXT A total of 110 patients were included and 76 (69%) completed follow-up. Thirty-five patients were examined by two chiropractors. The agreement regarding diagnostic classes was 83% (95% CI: 70 – 96). The diagnostic classes were associated with the pain course patterns and number of LBP days. Patients with disc pain had the highest number of LBP days and patients with muscular pain reported the fewest (35 vs. 12 days, p < 0.01). Men had better outcome than women (17 vs. 29 days, p < 0.01) and patients without leg pain tended to have fewer LBP days than those with leg pain (21 vs.31 days, p = 0.06). Duration of LBP at the first visit was not associated with outcome.
	Effectiveness of Manual Therapies: The UK Evidence Report Chiropractic & Manual Therapies 2010 (Feb 25); 18 (1): 3 ~ FULL TEXT Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain. The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration, and for manipulation/mobilization for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults. Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation, or for Stage 1 hypertension when added to an antihypertensive diet. In children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation.
	A Nonsurgical Approach to the Management of Patients With Lumbar Radiculopathy Secondary to Herniated Disk: A Prospective Observational Cohort Study With Follow-Up J Manipulative Physiol Ther 2009 (Nov); 32 (9): 723–733 ~ FULL TEXT A randomized trial by researchers at an outpatient rehabilitation department in Italy involving 210 patients with chronic, nonspecific low back pain compared the effects of spinal manipulation, physiotherapy and back school. The participants were 210 patients (140 women and 70 men) with chronic, non-specific low back pain, average age 59. Back school and individual physiotherapy were scheduled as 15 1-hour-sessions for 3 weeks. Back school included group exercise and education/ergonomics. Individual physiotherapy included exercise, passive mobilization and soft-tissue treatment. Spinal manipulation included 4–6 20-minute sessions once-a-week. Spinal manipulation provided better short and long-term functional improvement, and more pain relief in the follow-up than either back school or individual physiotherapy.
	Pain Patterns and Descriptions in Patients with Radicular Pain: Does the Pain Necessarily Follow a Specific Dermatome? Chiropractic & Osteopathy 2009 (Sep 21); 17 (1): 9 ~ FULL TEXT Two hundred twenty-six nerve roots in 169 patients were assessed. Overall, pain related to cervical nerve roots was non-dermatomal in over two-thirds (69.7%) of cases. In the lumbar spine, the pain was non-dermatomal in just under two-thirds (64.1%) of cases. The majority of nerve root levels involved non-dermatomal pain patterns except C4 (60.0% dermatomal) and S1 (64.9% dermatomal). The sensitivity (SE) and specificity (SP) for dermatomal pattern of pain are low for all nerve root levels with the exception of the C4 level (Se 0.60, Sp 0.72) and S1 level (Se 0.65, Sp 0.80), although in the case of the C4 level, the number of subjects was small (n=5). In most cases nerve root pain should not be expected to follow along a specific dermatome, and a dermatomal distribution of pain is not a useful historical factor in the diagnosis of radicular pain. The possible exception to this is the S1 nerve root, in which the pain does commonly follow the S1 dermatome.
	Chiropractic Management of Low Back Pain and Low Back-Related Leg Complaints: A Literature Synthesis J Manipulative Physiol Ther 2008 (Nov); 31 (9): 659–674 ~ FULL TEXT As much or more evidence exists for the use of spinal manipulation to reduce symptoms and improve function in patients with chronic LBP as for use in acute and subacute LBP. Use of exercise in conjunction with manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence. There was less evidence for the use of manipulation for patients with LBP and radiating leg pain, sciatica, or radiculopathy.
	Physical Assessment of Lower Extremity Radiculopathy and Sciatica J Chiropractic Medicine 2007 (Jun); 6 (2): 75–82 ~ FULL TEXT Several physical maneuvers are provocative to lumbosacral nerve roots or the sciatic nerve. Provocative maneuvers are intended to reproduce signs and symptoms of lower extremity radiculopathy/sciatica. Other maneuvers counter to the provocative maneuvers (palliative maneuvers) decrease nerve root and sciatic irritation and the related signs and symptoms (Figure 1).
	Chiropractic Manipulation in the Treatment of Acute Back Pain and Sciatica with Disc Protrusion: A Randomized Double-blind Clinical Trial of Active and Simulated Spinal Manipulations Spine J. 2006 (Mar); 6 (2): 131–137 ~ FULL TEXT A total of 64 men and 38 women aged 19-63 years were randomized to manipulations (53) or simulated manipulations (49). Manipulations appeared more effective on the basis of the percentage of pain-free cases (local pain 28 vs. 6%; p<.005; radiating pain 55 vs. 20%; p<.0001), number of days with pain (23.6 vs. 27.4; p<.005), and number of days with moderate or severe pain (13.9 vs. 17.9; p<.05). Patients receiving manipulations had lower mean VAS1 (p<.0001) and VAS2 scores (p<.001). A significant interaction was found between therapeutic arm and time. There were no significant differences in quality of life and psychosocial scores. There were only two treatment failures (manipulation 1; simulated manipulation 1) and no adverse events.
	The Nordic Back Pain Subpopulation Program: Validation and Improvement of a Predictive Model for Treatment Outcome in Patients With Low Back Pain Receiving Chiropractic Treatment J Manipulative Physiol Ther. 2005 (Jul); 28 (6): 381–385 ~ FULL TEXT In this study, patients with LBP who also had leg pain and LBP occurring sufficiently frequently or having lasted sufficiently long to add up to at least 30 days in the past year, and who did not report definite general improvement by the second treatment were not good candidates for short-term recovery. It is suggested that patients who fit the criteria of potential nonresponders should be carefully monitored to allow a selective approach of care.
	Spinal Manipulation, Epidural Injections, and Self-care for Sciatica: A Pilot Study for a Randomized Clinical Trial J Manipulative Physiol Ther. 2004 (Oct); 27 (8): 503–508 ~ FULL TEXT At week 12 (the end of the treatment phase), the outcome measures indicating the most improvement/change were the Oswestry disability score (mean, 22.9; SD, 19.9; effect size [ES], 1.8), leg pain severity (mean, 2.9; SD, 1.7; ES, 1.7), and if the symptoms were bothersome (mean, 25.2; SD, 16.0; ES, 1.6). Twenty-four patients were either "very satisfied" or "completely satisfied," and 22 of 32 patients reported 75% or 100% improvement. After 52 weeks, the outcome measure showing the most improvement/change was leg pain severity (mean, 2.3; SD, 2.6; ES, 1.35), followed by the Oswestry disability score (mean, 15.6; SD, 20; ES, 1.2) and if symptoms were bothersome (mean, 18.1; SD, 22.6; ES, 1.1). Eighteen patients were either "very satisfied" or "completely satisfied," and 15 of 32 patients reported 75% or 100% improvement.
	What Do Patients Think? Results of a Mixed Methods Pilot Study Assessing Sciatica Patients' Interpretations of Satisfaction and Improvement J Manipulative Physiol Ther. 2003 (Oct); 26 (8): 502–509 ~ FULL TEXT This study demonstrated that a "mixed methods" approach using qualitative research methods within a clinical trial is not only feasible but can provide interesting and useful information for trial interpretation and future study design. By providing insight to the multidimensional nature of patients' beliefs and perceptions, this technique may not only shape but also redefine the focus of patient-oriented research and health care for low back pain conditions.
	The Centralization Phenomenon in Chiropractic Spinal Manipulation of Discogenic Low Back Pain and Sciatica J Manipulative Physiol Ther. 2001 (Nov); 24 (9): 596–602 ~ FULL TEXT Assessment of the centralization phenomenon provided valuable diagnostic and prognostic information regarding chiropractic side-posture manipulation in this case series.
	Pain, Disability, and Satisfaction Outcomes and Predictors of Outcomes: A Practice-based Study Cronic Low Back Pain Patients Attending Primary Care and Chiropractic Physicians J Manipulative Physiol Ther. 2001 (Sep); 24 (7): 433–439 Overall, long-term pain and disability outcomes were generally equivalent for patients seeking care from medical or chiropractic physicians. Medical and chiropractic care were comparable for patients without leg pain and for patients with leg pain above the knee. However, an advantage was noted for chronic chiropractic patients with radiating pain below the knee after adjusting for baseline differences in patient and complaint characteristics between MD and DC cohorts (adjusted differences = 8.0 to 15.2; P <.002). A greater proportion of chiropractic patients were satisfied with all aspects of their care (P =.0000). The strongest predictors of primary outcomes included an interaction of radiating pain below the knee with provider type and baseline values of the outcomes. Income, smoking, comorbidity, and chronic depression were also identified as predictors of outcomes in this study.
	Nonoperative Treatments for Sciatica: A Pilot Study for a Randomized Clinical Trial J Manipulative Physiol Ther. 2000 (Oct); 23 (8): 536–544 A total of 706 persons were screened by phone to determine initial eligibility. Of these, over 90% of those persons contacted did not meet the entrance criteria. The most common reason for disqualification was that the duration of the complaint was longer than 3 months. Twenty patients were randomized into the study. All 3 groups showed substantial improvements in the main patient-rated outcomes at the end of the 12-week intervention phase. For leg pain, back pain, frequency and bothersomeness of leg symptoms, and Roland-Morris disability score, the percent improvement varied from 50% to 84%, and the corresponding effect sizes ranged from 0.8 to 2.2. Bothersomeness of leg symptoms was the most responsive outcome associated with the largest magnitude of effect size. All within-group changes from baseline were statistically significant (P <.01). No between-group comparisons were planned or performed because of the insufficient sample size and high risk of committing type I and type II errors.
	Manipulative Therapy in Lower Back Pain With Leg Pain and Neurological Deficit J Manipulative Physiol Ther 1998 (May); 21 (4): 288–294 The patient was initially treated with ice followed by flexion-distraction therapy. This was used over the course of her first three visits. Once she was in less pain, side posture manipulation was added to her care. Nine treatments were required before she was released from care.

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