Physical Therapy for Sciatica—The Earlier, The Better

Early referral to a 4-week treatment course of physical therapy (PT) for recent-onset sciatica improved function and back pain intensity compared with usual care, a randomized controlled clinical trial showed.

“Our results were more favorable than those of past studies toward the benefits of physical therapy,” noted Julie Fritz, PT, PhD, of the University of Utah in Salt Lake City, and coauthors in Annals of Internal Medicine.

“Benefits of early PT in this study may be attributable to the focus on evidence-based interventions, specifically exercise and manual therapy, as core treatment components,” they wrote. “The early PT protocol used a repeated directional exercise program to centralize symptoms. This type of exercise has been found to be beneficial for sciatica and is commonly used by physical therapists.”

The trial’s primary outcome was the 6-month Oswestry Disability Index (OSW), which includes 10 functional sections and reports up to 100 points, indicating maximal disability. Minimum important difference is 6 to 8 points for acute low back pain and sciatica.

Baseline mean OSW scores were 35.8 and 38.9 points for the PT and usual care groups, respectively. Compared with the usual care group, the PT group had greater mean change in 6-month OSW (relative difference −5.4 points, 95% CI −9.4 to −1.3 points; P = 0.009), with significant differences also seen at 4 weeks and 1 year.

Back pain intensity after 4 weeks, 6 months, and 1 year also favored the early PT referral, as did self-rated treatment success at 1 year (45.2% in the PT group versus 27.6% with usual care). Leg pain intensity did not differ between groups.

No between-group differences were seen in 1-year follow-up for use of health care (surgery, injections, advanced imaging, and emergency department visits) or missed work.

“The results will be of interest to many, including the patients who feel their sciatica is not taken seriously by their primary care providers, the primary care providers making decisions about onward referral, and the growing group of physiotherapists working in first-contact roles in primary care,” noted Nadine Foster, DPhil, of Keele University, and Michael Reddington, PhD, of the University of Sheffield, both in England, in an accompanying editorial.

Some patients with low back pain and sciatica recover without much treatment; others have persistent difficulties with pain and disability and could benefit from physical therapy, injections, or surgery.

“One of the few factors shown to independently predict poor outcome in sciatica in primary care is leg pain duration — patients with longer durations of leg pain have worse pain and disability outcomes over time — thus underlining the importance of early decision making,” the editorialists said.

How and when to choose patients for referral, along with what treatments are effective, remains challenging in a context of mixed or negative results of earlier research. For example, prior work suggests imaging does not reliably identify who will benefit from more evaluation and invasive treatment, and evidence of clinical effectiveness of various treatments remains mixed. Primary care clinical guidelines recommend counseling patients to avoid bed rest and remain active, with use of nonsteroidal anti-inflammatory analgesics and, if needed corticosteroids or opioids.

For the present study, Fritz and colleagues enrolled 220 adults age 18-60 from February 2015 to October 2018. All had a first primary care visit for low back pain or sciatica within the previous 6 months, an OSW score of 20 or more, and primary care-directed treatment and workup. Symptoms were present for less than 90 days and symptoms below the knee were present in the last 72 hours. Examination supported lumbar nerve root involvement. Mean age was 39, mean symptom duration was 35.8 days, and about 49% were women.

Following education and counseling, patients randomized to a 4-week course of PT (n=110) began therapy, while the usual care group (n=110) had no further study intervention. The PT protocol recommended 6 to 8 sessions during the 4-week treatment period. Participants were assigned exercises at home every 4 to 5 hours on days between sessions. Assessments were conducted at baseline, 4 weeks, 6 months, and 1 year.

Mean physical therapy sessions attended was 5.5. Of all sessions, 96.4% included exercise, 67.6% included manual therapy, and 13.6% included traction. Off-protocol interventions in some sessions included massage, dry needling, a heating pad, and transcutaneous electrical nerve stimulation.

Of 37% of the PT group reporting adverse treatment related effects, most common were increased back pain (n = 24) and stiffness (n = 19).

“The benefit of early referral to physical therapy was, overall, rather modest,” the editorialists wrote.

“Although disability was, on average, better in the group referred early to physical therapy, the lack of effect on further health care use or days lost from work could mean that the additional cost of referring all patients with acute or subacute sciatica for early physical therapy would still be difficult to justify in many resource-constrained health care systems,” they pointed out. “We need to determine which patients need a course of physical therapy, what that should consist of, and when to instigate it, if we are to use health care resources wisely.”

“More important, fewer than half of all patients still could not self-rate their treatment as a success by 12 months, highlighting the need to continue to develop and test more effective approaches to sciatica management,” they added.

The study had several limitations: PT provider time was not balanced during the 4-week treatment period and the trial population was 83% white, limiting generalizability.

1. Early referral to a 4-week course of physical therapy (PT) for recent-onset sciatica improved 6-month disability and back pain scores in a randomized clinical trial.

2. At 1 year follow-up, self-rated treatment success favored PT, but no between-group differences were seen in health care use or missed work.

Paul Smyth, MD, Contributing Writer, BreakingMED™

Cat ID: 130

Topic ID: 82,130,438,130,394,192,48,925