Physiotherapy for Sciatica

Sciatica is usually caused by a herniated disc pressing on a nerve root as it leaves the spine, producing pain, pins and needles, numbness or sometimes weakness down the leg. The reassuring fact — well established in the evidence — is that most disc herniations shrink and settle over time, and most people recover without surgery. This natural tendency to improve is why patience and active management are the right first approach for the majority. A minority have severe or progressive weakness, or pain that does not settle, and for them surgery has a clear role — but even then, physiotherapy is part of the picture.

For sciatica, a physiotherapist typically advises staying as active as the pain allows, provides graded exercise and movements to ease nerve irritation and maintain mobility, and offers education and reassurance about the favourable natural history. The old advice of bed rest has been shown to be unhelpful. As with all physiotherapy, this is delivered by physiotherapists and tailored to the individual — it is their expertise, not mine — but it is what I most often recommend alongside simple pain relief in the early weeks.

This is where my role as a surgeon is clearest, and I try to be honest about it. Surgery for sciatica — usually a discectomy to remove the fragment pressing on the nerve — reliably and quickly relieves the leg pain, and it is the right choice when there is significant or progressive weakness, or when severe pain has not settled with time and non-operative care. But the important evidence is that, for most people, the final outcome a year or two later is similar whether they have surgery or continue with conservative care — surgery mainly gets there faster. So the decision is often about how much pain someone is in and how quickly they need relief, not about long-term damage. Explaining that honestly, and not rushing people into an operation they may not need, is central to how I practise.

The evidence supports both active, non-operative care and, in the right patient, timely surgery. Systematic reviews find that advice to stay active and structured exercise help in the management of sciatica, and that bed rest does not. Landmark randomised trials — the SPORT trial and the Dutch study by Peul and colleagues — show that surgery relieves leg pain faster than prolonged conservative treatment, while longer-term outcomes converge. This is exactly the balanced picture I set out for patients: physiotherapy and time for most, surgery for the minority who need faster relief or who have weakness.

With active, physiotherapy-supported care, sciatica usually eases over weeks to a few months, though it can fluctuate. A physiotherapist guides activity and exercise through that period. Where surgery is needed, physiotherapy supports recovery afterwards. If severe or worsening weakness, or any disturbance of bladder or bowel function, develops, that is an urgent situation and should prompt immediate medical assessment.

• —Fernandez M, et al. Advice to stay active or structured exercise in the management of sciatica: systematic review and meta-analysis. Spine 2015. (PMID 26165218)
• —Fernandez M, et al. Surgery or physical activity in the management of sciatica: systematic review and meta-analysis. Eur Spine J 2016. (PMID 26210309)
• —Peul WC, et al. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 2007. (PMID 17538084)
• —Weinstein JN, et al. Surgical versus nonoperative treatment for lumbar disc herniation (SPORT): randomized trial. JAMA 2006. (PMID 17119140)
• —Vroomen PC, et al. Lack of effectiveness of bed rest for sciatica. N Engl J Med 1999. (PMID 9971865)