Is there a role for physiotherapy (physical therapy) in the management of sciatica?

Role of Physiotherapy in Sciatica Management

Physiotherapy has a limited role in acute sciatica and should not be considered superior to simply continuing normal activities, but it may provide modest benefit in patients with severe disability at presentation. 1, 2

Evidence for Acute Sciatica (< 4 weeks duration)

The evidence for physiotherapy in acute sciatica is weak and does not support routine use:

• Bed rest and physiotherapy are not more effective than continuation of activities of daily living for acute sciatica. 2 In the Westeinde sciatica trial of 250 patients, no significant differences were found in pain scores or disability between physiotherapy, bed rest, or simply continuing normal activities at 1,2, or 6 months. 2

• The American College of Physicians/American Pain Society guidelines specifically state that supervised exercise therapy and home exercise regimens are not effective for acute low back pain, and spinal manipulation shows only small to moderate short-term benefits. 3

• For patients with acute sciatica, advising continuation of normal activities is as effective as formal physiotherapy and avoids unnecessary healthcare costs. 2

Evidence for Subacute and Chronic Sciatica (> 4 weeks duration)

The role of physiotherapy becomes more nuanced in longer-standing sciatica:

• At 12 months follow-up, 79% of patients receiving physiotherapy plus general practitioner care reported improvement versus 56% receiving general practitioner care alone (RR 1.4; 95% CI 1.1-1.8), but this benefit was only seen in global perceived effect, not in objective measures of leg pain, functional status, or disability. 1

• Physiotherapy appears most beneficial for patients presenting with severe disability at baseline, though the effect is primarily on patient-reported global improvement rather than measurable functional outcomes. 1

• A 2023 systematic review and meta-analysis found no significant difference between physiotherapy and control interventions for pain or disability at short-term (SMD -0.34, p=0.34), medium-term (SMD 0.15, p=0.22), or long-term (SMD 0.09, p=0.51) follow-up. 4

• The same systematic review noted that most included trials had high or unclear risk of bias and substantial heterogeneity (I² = 80-98%), indicating considerable uncertainty in these estimates. 4

Clinical Algorithm for Physiotherapy Referral

For acute sciatica (< 4 weeks):

• Do not routinely refer for physiotherapy 2
• Advise patients to continue normal activities as tolerated 2
• Reserve physiotherapy only for patients with severe functional impairment who specifically request intervention 1

For subacute/chronic sciatica (> 4 weeks):

• Consider physiotherapy referral if severe disability is present (e.g., Quebec Disability Scale score indicating major functional limitation) 1
• Set realistic expectations: patients may report feeling better globally, but objective pain and disability measures may not significantly improve 1, 4
• Physiotherapy should include active interventions (supervised exercise) rather than passive modalities (massage, ultrasound, heat) if used 3

For patients awaiting surgery:

• Many patients with sciatica awaiting lumbar microdiscectomy appreciate the value of bespoke physiotherapy while waiting, even if they ultimately proceed with surgery 5
• Physiotherapy can provide pain reduction techniques, functional spinal movement training, and cardiovascular exercise during the surgical waiting period 5

Important Caveats and Pitfalls

• The evidence base is of poor quality: Most trials have high risk of bias, and there is extreme heterogeneity between studies (I² values of 80-98%), making firm conclusions difficult. 4

• Physiotherapy is not cost-effective for routine sciatica management: At 12 months, physiotherapy added to general practitioner care was not more cost-effective than general practitioner care alone. 1

• Avoid passive modalities: Transcutaneous electrical nerve stimulation (TENS), intermittent or continuous traction, and other passive treatments have not been proven effective for sciatica. 3

• Contemporary physiotherapy interventions are understudied: Many trials evaluating physiotherapy used outdated approaches, and modern evidence-based physiotherapy techniques (such as neural mobilization) require further robust evaluation. 4, 6

• Patient expectations matter: Some patients derive psychological benefit from physiotherapy even without objective improvement, which may influence their decision to pursue or delay surgical intervention. 5