Sciatica

Causes and Treatments for Sciatica
One of the harsh realities of the frail human condition is the fact that most people will suffer from some degree of low back pain at some point in their lives. Even people with relatively sedentary lifestyle can experience debilitating injuries to their lower back, and the potential for such injuries is exacerbated further when individuals engage in various sports activities. One such lower back and hip problem is sciatica, which is caused by spinal nerve root compression. Fortunately, there are a number of evidence-based interventions available for treating this condition, including both pharmacological and psychotherapeutic modalities. The purpose of this paper was to provide a review of the relevant peer-reviewed and scholarly literature concerning the common mechanisms of injury, anatomy of the injury (which structures are involved), presenting signs/symptoms, diagnostic procedures and/or special tests, and the basic healing process, rehabilitation, or surgery that needs to be done in order for the athlete to return to play. Finally, a summary of the research and important findings concerning the implications of sciatic injuries for individuals and sports medicine practitioners are provided in the paper’s conclusion.
Detailed description of anatomy and mechanism of injury, including common sports associated with the injury
The anatomy and mechanism of injuries that can result in sciatica include herniated lumbar discs which are implicated in chronic back pain and often severe disabilities. The research to date indicates that the prevalence rate for sciatica ranges from 13% to 43% of the general global population for this disorder (Onac & Moldovan, 2012). The term for the condition is based on the fact that the pain caused by sciatica originates and radiates along the sciatic nerve path (see graphics at Appendix A and B) that travels through the lower back to the hips and buttocks and then down both legs (Sciatica overview, 2018). Although every case of sciatica is unique in some fashion and both sides can be involved, the disorder typically only affects one side of the body (Sciatica overview, 2018).
The actual causes of sciatica vary but include bone spurs on the spine, the narrowing of the spine termed spinal stenosis which compresses a portion of the sciatica nerve or herniated disks (Sciatica overview, 2018). While these types of injuries can occur during any type of physical activity, they are especially pronounced during strenuous exercises and sports, particularly contact sports such as football. In this regard, Abitbot (2018) reports that, “Sciatica can result from direct nerve compression caused by external forces to the lumbar or sacral spinal nerve roots [from] football and other sports. The impact may injure the nerves or, occasionally, fragments of broken bone may compress the nerves” (para. 2). The specific adverse effects of sciatica also vary depending on the precise cause of and the severity of the injuries that are involved, pain, numbness and inflammation of the affected areas are common (Sciatica overview,2018).
Regardless of the specific cause of the injury or sports activity involved, a growing body of evidence confirms that the costs that are associated with treating sciatica are staggering, with some estimates indicating that $50 billion is spent each year in the United States alone (Onac & Moldovan, 2012). Furthermore, this enormous amount of health care resources does not take into account the comorbidities that are typically associated with chronic lower back pain. For instance, Onac and Moldovan (2012) emphasize that, “Patients with chronic back pain not only have a much higher emotional distress, but also a higher probability of developing psychiatric symptoms, of which the most common are depression, substance abuse and anxiety disorders” (p. 24). Moreover, left untreated, sciatica can cause or further exacerbate various existing psychological disorders, making early diagnosis and treatment all the more important as discussed below.
The presenting signs/symptoms, diagnostic procedures, and or special tests are relevant to making a diagnosis
Because occasional low back pain and numbness in the extremities are fairly commonplace among the general population, diagnosing sciatica may represent an especially challenging enterprise. It is important to note that the diagnosis of sciatica may include individuals with lower back pain that radiates on one leg or even both legs that involves the sciatic nerve (Sciatica overview, 2018). Two of the main diagnostic criteria for sciatica include (a) burning, lancinating (“piercing pain”), or stabbing pain radiates along the course of the sciatic nerve, most often down the buttocks and posterior aspect of the leg to below the knee; and (b) the loss of sensation, weakness, and reflex deficits (Sciatica, 2018).
In any context, of course, the sensation of pain is a highly subjective experience and the accurate diagnosis of sciatica requires a careful analysis of the type, location and severity of the pain, numbness, tingling and other symptoms that are reported (Sciatica overview, 2018). Since these types of symptoms can be caused by a wide range of disorders, the special tests that are used to diagnosis sciatica typically proceed in a step-wise fashion in order to rule out other potential causes as follows:
1. The distribution of numbness is used to localize the part of the nervous system that is involved;
2. Next, other clinical features—particularly rate of onset, associated neurologic symptoms and signs, and symmetry—further narrow the differential diagnosis and thus guide further questions and tests to diagnose specific causative disorders; and,
3. Electrodiagnostic studies (Sciatica, 2018).
Once a diagnosis of sciatica is confirmed, the next step involved is to identify the optimal course of action for treatment as discussed further below.
The basic healing process, rehabilitation, or surgery that needs to be done in order for the athlete to return to play is clearly described
Although mild cases of sciatica may resolve on their own in a few weeks if rest and appropriate palliative measures such as physical rehabilitation as well as cold or hot packs and rest are used, more severe cases of sciatica may require more aggressive clinical interventions including surgical, pharmacological and psychotherapeutic, or a combination of these modalities. While surgery is indicated for some individuals, the procedures involve a number of risks and are prohibitively expensive for many health care consumers (Singh & Singh, 2012). Nevertheless, despite the costs and risks that are involved, individuals whose sciatica causes them significant weaknesses in the leg or bladder or bowel changes may require surgical interventions in order to return them to their normal state of living (Sciatica overview, 2018).
Pharmacotherapeutic interventions are also widely used for treating sciatica. These interventions, however, also have their respective strengths and weaknesses in terms of their efficacy in resolving the symptoms that are associated with sciatica. Generally, pharmacological interventions for sciatica begin with drugs that tend to cause the fewest number of side effects for patients, including most especially the use of narcotics which carry the added risk of addiction. For instance, according to Lau and Han (2010), “Acetaminophen or nonsteroidal antiinflammatory drugs are typical first-line options. Other medications have moderate, mostly short-term benefits. Opioid analgesics or tramadol should be used occasionally and intermittently” (p. 39). In some cases, though, even the sustained use of powerful opioid analgesics will fail to produce the desired results. In these cases, the patients’ symptoms should be reevaluated and alternative therapeutic approaches considered. For example, according to Lau and Han (2010), “Muscle relaxants such as cyclobenzaprine offer short-term relief but are associated with [central nervous system] side effects, most commonly drowsiness and dizziness but also fatigue, somnolence, confusion, and irritability. Tricyclic antidepressants are [also] options to relieve chronic low back pain” (p. 40)
Besides surgical interventions, there are some other nonpharmacological strategies available for treating the symptoms of sciatica that have demonstrated, albeit relatively limited effectiveness, especially in those cases where the symptoms have been experienced for fewer than 4 to 8 weeks. In this regard, Lau and Han (2010) report that, “Spinal manipulation often is useful. Subacute low back pain may improve with intensive interdisciplinary rehabilitation, including cognitive-behavioral therapy (CBT), and can increase functional status” (p. 40). Likewise, for chronic cases of lower back pain caused by sciatica, progressive relaxation techniques combined with CBT therapy has been shown to have modest effectiveness in treating the painful symptoms associated with the disorder (Lau & Han, 2010).
Irrespective of which treatment modality or combination of modalities is used for treating sciatica, patient education and counseling represent essential components of the treatment plan (Lau & Han, 2010). While the treatments described above have some demonstrated efficacy in treating sciatica symptoms, the optimal course of action is to provide individuals with the information they need for self care strategies when injured and to prevent the recurrence of such injuries in the future. Recommended self-care strategies for sciatica include using the pain symptoms to avoid reinjuring the same areas, using heating pads and cold packs on affected areas, progressive relaxation techniques, as well as using appropriate exercise and stretching regimens (Lau & Han, 2010). It is also important to encourage sciatica sufferers to remain as active as possible since studies have shown that extended bed rest is less effective than limited physical activity in promoting healing (Lau & Han, 2010).
Regardless of the modality that is used, in most cases, the symptoms that are associated with sciatica tend to improve within the first month of treatment provided patients adhere to the prescribed interventions (Lau & Han, 2010). Determining the point at which athletes can return to active play is a fairly straightforward process. For example, according to one sports medicine practitioner, “Your doctor may use the same test to tell when each injury has recovered by having you lie on your back while the affected leg is lifted with a flexed foot. If it's no longer painful, it's healed!” (Hamilton, 2012, p. 24).
Conclusion
Bipedalism has numerous advantages for humans, of course, and the ability stand upright as well as to walk, jump and run has contributed to the survival of the species in virtually every hostile environment on earth through the millennia. This ability, however, is countered by the fact that the human spine is vulnerable to all types of insults, including sports-related injuries that can cause sciatica. In fact, the research was consistent in showing that almost any type of physical activity can either cause or exacerbate spinal nerve compression injuries. Although there are a number of evidence-based interventions available for the treatment of sciatica, the best medicine for both athletes and health care practitioners is to place a high priority on prevention.
References
Abitbol, J. J. (2018). Six leading causes of sciatica. Spine Universe. Retrieved from https://www.spineuniverse.com/conditions/sciatica/6-leading-causes-sciatica.
Hamilton, L. (2012, May). Q & A. Dance Magazine, 86(5), 24.
Lau, A. & Han, J. (2010, July). The truth about treating low back pain. Current Psychiatry, 9(7), 38-44.
Onac, I. A. & Moldovan, A. R. (2012, March). Medication, physiotherapy and cognitive behavior therapy for the treatment of chronic back pain: A clinical trial. Journal of Evidence-Based Psychotherapies, 12(1), 23-27.
Sciatica. (2018). Merck Manual. Retrieved from https://www.merckmanuals.com/professional/ musculoskeletal-and-connective-tissue-disorders/neck-and-back-pain/sciatica.
Sciatica overview. (2018). Mayo Clinic. Retrieved from https://www.mayoclinicorg/diseases-conditions/sciatica/symptoms-causes/syc-20377435.
Singh, A. & Singh, O. (2013, January-June). A preliminary clinical evaluation of external snehan and asanas in the patients of sciatica. International Journal of Yoga, 6(1), 71-74.



Appendix A


Source: https://www.mayoclinic.org/-/media/kcms/gbs/patient-consumer/images/2013/08/26/10/53/ds00516_im02917_mcdc_sciaticathu_jpg.jpg




Appendix B

Source: https://www.spineuniverse.com/sites/default/files/imagecache/gallery-large/wysiwyg_imageupload/3998/2017/10/11/sciatica23117022_m.jpg