From the Guidelines
For a resident with increasing sciatica pain in the left leg, I strongly recommend a supervised exercise program, such as exercise therapy, to alleviate symptoms and improve quality of life. This approach is supported by the American College of Physicians and the American Pain Society, as outlined in their joint clinical practice guideline 1. The guideline suggests that exercise is a crucial component of managing low back pain and sciatica, as it can help reduce pain and improve function.
When it comes to exercise, it's essential to consider the type and intensity of the program. A supervised exercise program can include a range of activities, such as muscle strengthening, flexibility, stretching, or aerobic exercise. The goal is to improve overall physical fitness and reduce pressure on the sciatic nerve. For example, gentle stretching exercises like the seated piriformis stretch and the knee-to-chest stretch can help relieve pressure on the sciatic nerve.
In addition to exercise, other interventions like acupressure, acupuncture, and back school may be considered, but the evidence for these approaches is less clear 1. It's also important to note that a positive straight-leg-raise test can indicate nerve root tension, and reproduction of the patient's sciatica when the unaffected leg is lifted is referred to as a positive "crossed" straight-leg-raise test 1.
Overall, a multi-faceted approach that includes exercise, education, and lifestyle modifications is likely to be the most effective way to manage increasing sciatica pain in the left leg. By prioritizing exercise and physical therapy, residents can reduce their symptoms, improve their quality of life, and minimize the risk of long-term morbidity and mortality.
From the Research
Management of Sciatica Pain
- The management of sciatica pain, including the use of analgesic and adjuvant pain drugs, has been investigated in several studies 2, 3.
- A systematic review and meta-analysis published in 2012 found that the evidence for the efficacy of non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, antidepressants, anticonvulsants, muscle relaxants, and opioid analgesics in managing sciatica ranged from moderate to low quality 2.
- The review found that most of the pooled estimates did not favor the active treatment over placebo, except for corticosteroids and the anticonvulsant gabapentin, which showed some benefits in the short term 2.
Combination Drug Therapy
- A systematic review and meta-analysis published in 2019 investigated the effects of combination drug therapy in patients with low back pain and/or sciatica on pain, disability, and adverse events 3.
- The review found that most combinations had no or small effect on pain and disability, and there was no clear evidence to support any combination drug therapy for the management of low back pain and sciatica due to the limited number of studies and overall low quality of evidence 3.
- However, one combination, buprenorphine plus pregabalin, was found to have a clinically important difference in pain relief compared to buprenorphine alone, although the quality of evidence was low 3.
Adverse Events
- The studies found that the median rate of adverse events was 17% for active drugs and 11% for placebo 2.
- The 2019 review found that there was no statistically significant increased risk of serious adverse events with combination drug therapy, and when the risk of adverse events was statistically significant, it favored monotherapy or placebo 3.