Exercise as it relates to Disease/Effects of physical therapy on the management of pain and symptoms associated with Sciatica

The following page is a critique of the following article: "Physical Therapy Plus General Practioner's Care Versus General Practitioner's Care Alone for Sciatica: a Randomised Clinical Trial with a 12-Month Follow-up.This article was written by: Pim A. J. Luijsterburg, Arienne P. Verhagen, Raymond W. J. G. Ostelo, Hans J. M. M. van den Hoogen, Wilco C. Peul, Cees J. J. Avezaat, and Bart W. Koes.

What is the Background to This Research?
Lumbosacral Radicular Syndrome (LRS) or Sciatica is a disorder where the sciatic nerve becomes impinged. The main symptoms associated with Sciatica are pain and numbness originating in the lower back and travelling down the leg. The sciatic nerve is a nerve that runs through the lower back and hip, in to the buttock and down the lower leg. Sciatica is cause by trauma of the spine resulting in added pressure on the lumbar spine and sacrum. This can include: age related changes to the spine, obesity, diabetes, and professions which include twisting of the spine or lifting heavy loads.

It is generally agreed on that treatment of Sciatica for the first 6-8 weeks should be conservative. However, there is not a clear rationale as to why this should be the case. In 2007 a systematic review of 30 independent studies was conducted by Luijsterburg et al. assessing the effectiveness of various treatment methods for sciatica. From this review they were able to conclude that conservative methods were not very effective, however they cold not conclude if physical therapy was effective.

The aim of this study is to determine whether physical therapy is effective in treating Sciatica

Where is the Research From?
This article was published on 3/1/2008 in volume 17, issue 4 of the European Spine Journal. The research was conducted in Rotterdam (Netherlands) and the surrounding area. The authors of this article have a history of research in this area and have worked together previously on multiple other research articles.

What Kind of Research was This?
The study was a randomised un-blinded trial held in a clinical setting. The patients were randomly allocated in to a group by a research assistant who was independent of the research, this was done through a computer based program. The patients, GPs, and physical therapists were not blinded for the purpose of this research.

What did This Research Involve?
135 patients were allocated in to 2 groups; GP care only, or GP and physical therapist care. Patients were selected based on a selection criteria. Patients were seen in a one-on-one setting, no group sessions were done throughout the research. During the first 6 weeks of the intervention the patients were allowed a maximum of 9 appointments All patients were assigned to see a GP who gave advice on managing symptoms of sciatica as well as prescribing pain medication if needed. The full guidelines GPs followed can be found here.

The patients seeing a physical therapist were given advice on sciatica as well as active treatment. The type of exercise was left up to the physical therapist to decide.

Passive treatments such as acupuncture, massage, and other manipulation treatments were not used at any point in this trial.

What Were the Basic Results?
Two different outcomes were measured: global perceived effectiveness (GPE)ranked from 1-7 which was the primary measure, and leg and back pain rated from 0-10 which was the secondary measure.

Over the 52 weeks there was a significant difference between the two groups in the primary outcome. More patients in the GP + PT group reported an improvement than in the GP only group (79% compared to 57%).

In the secondary measure there was no significant difference between the two groups, however there was a significant change in pain levels in the leg (−2.3;−1.9 decrease in pain after 3 weeks, and −4.4;−3.7 after 52 weeks). The changes in pain levels in the back were not very significant.

What Conclusions can we Take From This Research?
While physical therapy appears to have a significant effect on the patients perceived wellness and effectiveness of the treatment, it does not have a significant effect on leg and back pain. Further research should be done on how physical therapy can effect the symptoms associated with Sciatica. Further research should also be done pain management techniques as this seems to be the biggest problem in people suffering from Sciatica. Every patient is different and may not respond to the same treatment as someone else, it is important to keep this in mind when setting any guidelines GP's or physical therapists must use.

Practical Advice
If guidelines are put in place they need to be used by every professional involved. Having one group use guidelines and the other not may effect the accuracy of the results. Putting guidelines in place will help ensure that everyone receives the same treatment and the results will be more accurate. Guidelines should be agreed upon by all professionals involved, and if anyone goes outside of the guidelines it should be brought up with researchers who can record it down in case an outlier is present in the results.

Having self-evaluated responses can effect results, patients may lie and say they feel better as they think that is what the researchers want to hear. Implementing a questionnaire or something similar may be a more effective way of collecting perceived wellness as the researchers can decide whether the treatment is working, they may also ask questions which the patient did not think about when giving response.

Further Information/Resources?

 * General information on Sciatica
 * Meta-analysis done on effects of exercise on treatment of Sciatica