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Payers https://www.instituteforchronicpain.org Tue, 31 Jan 2023 10:41:28 +0000 Joomla! - Open Source Content Management en-gb Sciatica https://www.instituteforchronicpain.org/common-conditions/sciatica https://www.instituteforchronicpain.org/common-conditions/sciatica

What is sciatica?

Sciatica is a common pain condition marked by pain, numbness and/or tingling beginning in the buttock and oftentimes extending down the leg, all the way to the foot.

Sciatica is the result of either inflammation or irritation of the sciatic nerve. The sciatic nerve is a nerve which starts at the spinal cord in the low back, extends through the piriformis muscle in the buttock, and branches down the back of the leg, and into the foot. Causes of sciatica are disc herniations or other degenerative changes in the lower part of the spine, piriformis syndrome, and, rarely, tumors along the spine. Stress can also play a role, particularly in exacerbations of sciatica.

The cause of sciatica is often difficult to identify in actual practice. The use of MRI’s to identify the cause is common, but problematic in many cases. While tumors are typically readily seen on an MRI, it is often difficult to identify degenerative changes of the spine that might cause sciatica. Some patients will have MRI’s that show, for example, a disc herniation and nerve root irritation that is consistent with their symptoms. Many patients, however, have sciatica without any objective findings on MRI. Still others commonly have findings on MRI that are inconsistent with their symptoms. For these reasons, providers often pursue epidural steroid injections and nerve blocks in an attempt to identify the cause of sciatica. However, these procedures can also provide unreliable results. As such, with the exception of tumor-related sciatica, healthcare providers typically presume the cause of the condition without ever obtaining definite confirmation.

Is there a cure for sciatica?

The vast majority of acute cases of sciatica resolve on their own within a few weeks to months.

However, sometimes it continues and becomes chronic. It’s considered chronic when lasting longer than six months. Typically, chronic sciatica has no cure and lasts indefinitely.

Chronic sciatica is likely to involve a secondary complication called central sensitization.1 Central sensitization isa highly reactive state of the nervous system, which amplifies pain. It can also sometimes cause sensitivity to touch, fatigue, poor sleep, anxiety, and depression.

Therapies & Procedures for sciatica

In the healthcare community, there is no conventional agreement as to what the best treatment is for sciatica. Treatment recommendations are often dependent on the type of provider that the patient sees. In part, it is due to the above-noted difficulties with confirming a cause of sciatica. In the absence of a definite confirmation, healthcare providers must base treatment recommendations on their presumptions of what is causing it. As such, the area of the healthcare provider’s expertise can sometimes influence these presumptions. Surgeons and interventional pain physicians can tend to presume a cause of degenerative changes of the spine. As such, patients who see these types of providers will tend to get recommendations for surgery or interventional procedures. Physical therapists can tend to presume either degenerative changes of the spine or piriformis syndrome. Patients who see physical therapists will tend to get recommendations for stretching and strengthening exercises. Health psychologists and other chronic pain rehabilitation providers focus on the nervous system, of which the sciatic nerve is a part. Patients who see such providers tend to get recommendations for ways to reduce the reactivity of the sciatic nerve, as well as the whole nervous system, if central sensitization is occurring.

Common therapies for sciatica are the following:

  • Surgeries: laminectomies, discectomies, and fusions
  • Interventional procedures: epidural steroid injections, nerve blocks, rhizotomies, and spinal cord stimulator implants
  • Physical therapies: stretching and strengthening exercises
  • Chronic pain rehabilitation programs

Surgeries

Despite how frequently surgical and interventional procedures are performed in the healthcare system, most of these procedures have limited benefit. Surgery for sciatica in the first few months after onset has been shown to provide more rapid relief than conservative approaches. However, by one-year follow-up, conservative approaches will catch up, so to speak, and the amount of pain relief will be the same.2 The long-term effectiveness of surgery for sciatica remains unclear as no studies to date have been published on its long-term effectiveness. Conventional wisdom is that pain reduction with surgery is typically not permanent. As a result, despite taking a little longer, most healthcare providers prefer to trial conservative approaches before surgery.

Interventional pain procedures

Research on the outcomes of epidural steroid injections, nerve blocks and rhizotomies show that they are all ineffective on average.3, 4, 5 

There is limited evidence to support the use of spinal cord stimulator implants. A number of poor quality studies show mildly positive results. The use of spinal cord stimulators seems somewhat more helpful with leg pain that results from failed back surgeries than true sciatica.6, 7 

Physical therapy

Physical therapy for acute sciatica is mildly to moderately effective.8 The quality of the effectiveness studies is moderate to good.

Chronic pain rehabilitation programs

For chronic sciatica, chronic pain rehabilitation programs are typically the most beneficial treatment. Effectiveness is measured by multiple criteria, including pain reduction, rates of returning to work, and reducing the need for further healthcare services.9, 10 The quality of studies is moderate.

References

1. O'Neill, S., Manniche, C., Graven-Nielsen, T., Arendt-Nielsen, L. (2007). Generalized deep-tissue hyperalgesia in patients with low-back pain. European Journal of Pain, 11, 415-420.

2. Peul, W. C., et al. (2007). Surgery versus prolonged conservative treatment for sciatica. New England Journal of Medicine, 356, 2245-2256.

3. van Tulder, M. W., Koes, B., Seitsalo, S., & Malmivaara, A. (2006). Outcomes of invasive treatment strategies in low back pain and sciatica: An evidence based review. European Spine Journal, 15, S82-S89.

4. Arden, N. K., Price, C., Reading, I., Stubbing, J., Hazelgrove, J., Dunne, C., Michel, M., Rogers, P., & Cooper C. (2005). A multicentre randomized controlled trial of epidural corticosteroid injections for sciatica: The WEST study. Rheumatology, 44, 1399-1406.

5. Ng, L., Chaudhary, N., & Sell, P. (2005). The efficacy of corticosteroids in periradicular infiltration in chronic radicular pain: A randomized, double-blind, controlled trial. Spine, 30, 857-862.

6. Chou, R., Atlas, S. J., Stanos, S. P., & Rosenquist, R. W. (2009). Nonsurgical interventional therapies for low back pain: A review of the evidence for the American Pain Society clinical practice guideline. Spine, 34, 1078-1093.

7. Taylor, R. S., Van Buyten, J., & Buchser, E. (2005). Spinal cord stimulation for chronic back and leg pain and failed back surgery syndrome: A systematic review and analysis of prognostic factors. Spine, 30, 152-160.

8. Hayden, J. A., van Tulder, M. W., Malmivaara, A. V., & Koes, B. W. (2005). Meta-analysis: Exercise therapy for non-specific low back pain. Annals of Internal Medicine, 142, 765-775.

9. Gatchel, R., J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793.

10. Turk, D. C. (2002). Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. Clinical Journal of Pain, 18, 355-365.

Date of publication: April 27, 2012

Date of last modification: October 8, 2018

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Common Conditions Fri, 27 Apr 2012 13:42:18 +0000
Piriformis Syndrome https://www.instituteforchronicpain.org/common-conditions/piriformis-syndrome https://www.instituteforchronicpain.org/common-conditions/piriformis-syndrome

What is piriformis syndrome?

Piriformis syndrome is a neuromuscular condition that occurs when the piriformis muscle in the buttocks pinches the sciatic nerve. The piriformis muscle is a large muscle on each side of the buttocks. The sciatic nerve is a nerve which starts at the spinal cord in the low back, extends through the piriformis muscle in the buttock, and branches down the back of the leg, all the way to the foot.

Symptoms of piriformis syndrome are pain, numbness and/or tingling in the buttock. Sometimes, these symptoms can extend down the leg and into the foot.

Piriformnis syndrome is one of the causes of pain the leg. It's sometimes mistakenly diagnosed as sciatica.

Is there a cure for piriformis syndrome?

Piriformis syndrome can often be relieved with physical therapy, mild low-impact aerobic exercise such as in a warm water pool, and relaxation therapies. However, on occasion, it can become chronic. In chronic cases, chronic pain rehabilitation programs are likely the most beneficial treatment strategy.

 

Date of publication: April 27, 2012

Date of last modification: October 23, 2015

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Common Conditions Fri, 27 Apr 2012 13:41:13 +0000
Foot & Leg Pain https://www.instituteforchronicpain.org/common-conditions/foot-leg-pain https://www.instituteforchronicpain.org/common-conditions/foot-leg-pain Foot & Leg Pain

What is foot and leg pain?

Pain in the feet or legs is common. It can be caused by a number of different conditions. The most common conditions that cause pain in the feet and/or legs are the following:

  • Plantar fasciitis
  • Arthritis
  • Neuropathy
  • Sciatica

Some of these conditions are commonly short-lived, while others are chronic.

If you have a new onset of pain in your legs or feet, it is important to have it evaluated by a healthcare provider. Many acute conditions, such as sprains, bone fractures, or blood clots, can be successfully treated. Some conditions, however, are chronic.

Plantar fasciitis

Plantar fasciitis causes pain in the heel and bottom of the foot. It is due to inflammation of the plantar fascia. The plantar fascia is a muscle-like connective tissue at the bottom of the foot.

Plantar fasciitis is associated with overuse, such as with runners, or in cases of obesity.

Treatments are anti-inflammatory medications, heel stretches, supportive footwear, and weight loss.

With treatment or on its own, plantar fasciitis usually improves within months to a year or two.

Arthritis

Arthritis is a common pain condition marked by inflammation of the joints. The inflammation causes pain, swelling, and stiffness. Arthritis can occur in any joint of the body.

There are different types of arthritis. The two most common are osteoarthritis and rheumatoid arthritis.

Osteoarthritis might best be considered the result of general wear and tear. It can occur from traumatic injuries, overuse, and age. It Photo by How Soon Ngu courtesy of Unsplashresults from a loss of cartilage, which ordinarily provides cushioning for the bones in the joints. With the loss of cartilage, the bones can rub together in the joints, causing inflammation. In turn, the inflammation leads to pain, swelling, stiffness, and tenderness. Osteoarthritis most commonly occurs in the hips, knees, ankles and feet.

Common treatments for osteoarthritis are anti-inflammatory medications, physical therapy, cortisone injections, arthroscopic and joint replacement surgeries, and chronic pain rehabilitation programs.

Rheumatoid arthritis is the result of the immune system mistaking healthy cartilage for being diseased, and consequently it attacks the cartilage of the joints. Over time, the immune system erodes the cartilage. The subsequent loss of cartilage causes inflammation when the joints are used. In turn, the inflammation causes pain, joint stiffness, and swelling. In advanced stages, the joints become deformed. Rheumatoid arthritis most commonly occurs in the hands and feet.

Common treatments for rheumatoid arthritis are anti-inflammatory medications, chemotherapies, physical therapy, and chronic pain rehabilitation programs.

Neuropathy

Neuropathy is damage to nerves and causes pain, numbness and/or tingling. While technically many conditions are a form of neuropathy, the term ‘neuropathy’ usually refers to peripheral neuropathy.

Peripheral neuropathy is nerve damage in the peripheral nerves. It usually starts in the hands or feet as numbness or tingling. Over time, these symptoms can progress to pain. Patients most often describe the pain as a burning type of pain.

The most common cause of peripheral neuropathy in the hands or feet is diabetes. It is then commonly referred to as ‘diabetic neuropathy.’ Other causes can be kidney disease, HIV, or alcohol dependence. It can also occur for unknown reasons. In the latter case, it is called ‘idiopathic peripheral neuropathy.’

If the cause of neuropathy is diabetes, therapy involves aggressive treatment of diabetes. In such cases, treatment consists of medications to control glucose, dietary changes, exercise, and weight loss.

In all cases of neuropathy, therapies also focus on symptom management. Common symptom management therapies include antidepressant medications, anticonvulsant medications, opioid medications, mild aerobic exercise, cognitive behavioral therapy, and chronic pain rehabilitation programs.

Sciatica

Sciatica is a common pain condition marked by pain, numbness and/or tingling, beginning in the buttock and oftentimes extending down the leg, all the way to the foot and toes.

The vast majority of acute cases of sciatica resolve on their own within a few weeks to months. Sometimes, it continues and becomes chronic. It’s considered chronic when lasting longer than six months.

Sciatica is the result of either inflammation or irritation of the sciatic nerve. The sciatic nerve is a nerve which starts at the spinal cord in the low back, extends through the piriformis muscle in the buttock, and branches down the back of the leg, and into the foot. Causes of sciatica are disc herniations or other forms of degenerative disc disease in the lower part of the spine, piriformis syndrome, and, rarely, tumors along the spine. Stress can also play a role, particularly in exacerbations of sciatica.

The cause of sciatica is often difficult to identify in actual practice. The use of MRI’s to identify the cause is common, but problematic in many cases. While tumors are typically readily seen on an MRI, it is often difficult to identify degenerative changes of the spine that might cause sciatica. Some patients will have MRI’s that show, for example, a disc herniation and nerve root irritation that is consistent with their symptoms. Many patients, however, have sciatica without any objective findings on MRI. Still others commonly have findings on MRI that are inconsistent with their symptoms. For these reasons, providers often pursue epidural steroid injections and nerve blocks in an attempt to identify the cause of sciatica. However, these procedures can also provide unreliable results. As such, with the exception of tumor-related sciatica, healthcare providers typically presume the cause of the condition without ever obtaining definite confirmation.

Common therapies for sciatica are the following:

  • Spine surgeries
  • Interventional procedures: epidural steroid injections, nerve blocks, rhizotomies, and spinal cord stimulator implants
  • Physical therapies: stretching and strengthening exercises, mild aerobic exercises
  • Chronic pain rehabilitation programs

Date of publication: April 27, 2012

Date of last modification: September 21, 2021

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Common Conditions Fri, 27 Apr 2012 13:37:41 +0000