What are the best exercises for a patient with sciatica, considering potential underlying conditions such as herniated discs or spinal stenosis?

Best Exercises for Sciatica

For sciatica, the most effective approach is to remain active with supervised exercise therapy that includes stretching and strengthening, rather than bed rest, with the addition of neurodynamic exercises showing particular promise for improving quality of life. 1, 2

First-Line Exercise Approach

Stay active and avoid bed rest - this is the cornerstone recommendation from the American College of Physicians for managing sciatica, whether from herniated discs or spinal stenosis. 1, 2 Even when symptoms are severe, any necessary bed rest should be as brief as possible with rapid return to normal activities. 2

Specific Exercise Types by Symptom Duration

For Acute Sciatica (< 4 weeks):

• Remain active with normal daily activities as tolerated 1, 2
• Apply superficial heat using heating pads for short-term pain relief (effective at 4-5 days) 2
• Avoid passive rest - staying active is more effective than bed rest for both pain and function 3

For Subacute/Chronic Sciatica (> 4 weeks):

• Supervised exercise therapy with individual tailoring, stretching, and strengthening shows small to moderate effects with 10-point reduction on 100-point pain scales 2
• Motor Control Exercises (MCE) focusing on spinal stabilizing muscle coordination, control, and strength provide moderate pain reduction with functional improvements 2
• Neurodynamic exercises combined with conventional exercises significantly improve health-related quality of life and muscle activation compared to conventional exercises alone 4

Specific Exercise Components That Work

Muscle activation exercises targeting:

• Hamstrings (particularly contralateral side to pain) 5
• Hip adductors 5
• Gluteus medius and maximus 5
• Abdominal stabilizers 5

Stretching exercises for:

• Posterior hip capsule (particularly contralateral side) 5
• General flexibility work 2

Stabilization exercises focusing on core and spinal stability 5

The evidence shows that when initial stabilization and flexion exercises provide limited improvement, adding targeted muscle activation, inhibition, and hip capsule flexibility exercises can eliminate pain and restore function. 5

What NOT to Do

Avoid these common pitfalls:

• Do not prescribe bed rest - it leads to deconditioning and worse outcomes 1, 2
• Avoid passive modalities as standalone treatments - TENS, electrical stimulation, ultrasound, and taping lack evidence and should not be primary interventions 2
• Do not use unsupervised exercises initially - patients need proper instruction from a physical therapist before transitioning to home programs 6
• Avoid spinal manipulation with high-velocity thrusts if there is spinal fusion or advanced osteoporosis due to risk of fractures and spinal cord injury 6

Exercise Therapy Algorithm

1. Initial phase (Days 1-7): Stay active, apply heat, begin gentle movement 1, 2

2. If symptoms persist (Weeks 2-6): Initiate supervised exercise therapy with physical therapist focusing on motor control and stabilization 2

3. If limited improvement (Weeks 6+): Add neurodynamic exercises and targeted muscle activation/inhibition based on specific movement dysfunction patterns 4, 5

4. Chronic phase (> 12 weeks): Consider intensive interdisciplinary rehabilitation combining physical, vocational, and behavioral components 2

Additional Effective Adjuncts

While not strictly exercises, these can enhance exercise therapy outcomes:

• Spinal manipulation (by trained providers) shows small to moderate short-term benefits for acute sciatica 2
• Acupuncture as adjunct to exercise for chronic symptoms 2
• Cognitive-behavioral therapy combined with exercise for chronic pain 2
• Massage therapy alongside exercise programs 2

Important Clinical Considerations

Red flags requiring immediate evaluation rather than exercise therapy include: cauda equina syndrome, progressive neurological deficits, suspected infection, or malignancy. 2 These require urgent imaging and possible surgical consultation.

For patients with confirmed disc herniation and persistent symptoms beyond 6-8 weeks despite appropriate exercise therapy, consider epidural steroid injections or surgical consultation for discectomy. 1

The evidence consistently shows that exercise therapy must be supervised initially with individual tailoring to be effective - generic unsupervised back exercises alone show no benefit. 6 However, once properly instructed, patients can transition to home exercise programs for long-term management.