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Saturday, April 07, 2012
Do Symptom Guided Exercises Actually Help Sciatica?

While multiple studies have compared surgery to non-operative treatment for sciatica due to lumbar disk herniation, very few have compared different types of non-operative treatment. In the Spine Patient Outcomes Research Trial (SPORT), non-operative treatment was defined as “usual care” due to the fact that there was no evidence supporting an optimal non-operative regimen. In the April 1 issue, Dr. Albert and her colleagues from Denmark reported the results of their RCT comparing two non-operative regimens that differed only in the type of exercise therapy provided to the sciatica patients:  one included symptom guided exercises while the other suggested generic cardiovascular exercise. All 181 patients had radicular symptoms for at least two weeks with pain radiating below the knee, though there was no requirement for imaging to determine the underlying diagnosis. On the whole, the patients did well, with approximately 90% reporting that they were better or much better by one year. Their leg pain decreased from 4.4 on a 10 point scale to 1.4 over the course of a year. There were no clinically significant differences in outcomes between the two groups on the primary outcome measures (Roland-Morris Disability Questionnaire and a 10-point leg pain scale), though the symptom guided exercise group did have a higher level of general satisfaction and, interestingly, more improvement of their neurological findings. Given that the average age was 45, it can be assumed that most of these patients had disk herniations. Similar to SPORT, the vast majority made marked improvements over the course of the year, and none developed a major neurologic deficit or cauda equina syndrome. This is yet another paper that documents the generally good natural history of lumbar radiculopathy in younger patients and makes it clear that it is safe to treat these patients without surgery.

 

While this paper reinforces that younger patients with radiculopathy can make marked improvements without surgery, it is unclear how it should affect practice. The authors make some conclusions in their discussion about how symptom guided exercise should provide a similar outcome to surgery, but this trial did not compare surgery to symptom guided exercise. In comparing the outcomes to the surgical literature, one must remember that almost a quarter of the patients in the current study had symptoms for less than four weeks. The vast majority of these patients will get better with absolutely no treatment, so the patient population is somewhat different than the SPORT disk herniation study where all patients had symptoms for at least 6 weeks, neurological findings, and imaging demonstrating a herniated disk. The paper does suggest a benefit of symptom guided exercises, though the mechanism through which these exercises are beneficial remain unknown:  is the improvement related to core strengthening, decreased fear of movement or simply spending more time with a physical therapist? Regardless of the mechanism, this study should help clinicians inform their younger sciatica patients that they have a very high likelihood of improving without surgery. While SPORT showed a definite advantage to surgery in terms of a faster recovery and better outcomes for up to four years for disk herniation patients with symptoms for more than 6 weeks, patients with a short duration of symptoms should clearly consider symptom guided exercise before electing surgery. Future studies comparing surgery to specific non-operative treatment—i.e. injections or symptom guided exercises—would be very helpful, though it is unclear if such studies will ever be done.


Please read Dr. Albert’s article in the April 1 issue. Will this article change how you advise younger patients with sciatica about the benefits of exercise therapy? Let us know by leaving a comment on The Spine Blog.


Adam Pearson, MD, MS

Associate Web Editor

4/9/2012
Mark Schoene said:
The trial by Albert and Manniche doesn’t prove that “active conservative treatment” is efficacious. The usual way of interpreting efficacy studies is to base conclusions on the primary outcome measures. These are the most important outcomes, as predefined by the researchers. “Active conservative treatment” had no clinically important advantage in primary outcome measures in this RCT. A more standard interpretation of these data would be that “active conservative care” is not efficacious. It was no better than a sham intervention. Superiority in secondary outcomes might provide evidence that could be considered in further clinical trials—but not evidence that proves the efficacy of this intervention. At this point, there are no proven nonoperative treatment protocols for sciatica—weakening both nonsurgical and surgical care. (See Pinto, BMJ, 2012; Luijsterburg, Eur Spine J, 2007). There is an urgent need for further research in this area. Mark Schoene, Editor, The BackLetter
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Spine Journal
This Blog provides a forum for discussion about high impact articles published in Spine, including the bi-annual publication of "Evidenced-Based Recommendations for Spine Surgery." Website users can use this forum to discuss how the articles have affected their practice and query the authors about their findings and recommendations.

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