Physio Network

[Case Studies] Breaking down sciatica: a case study discussion with Charlie Clements

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In this episode with Charlie Clements we discuss his case study on sciatica that he has recently done for Physio Network. We explore: 

  • Key features of sciatica
  • Differential diagnosis
  • Management strategies 
  • Onward referral processes

This episode is closely tied to Charlie’s case study he did with us. With case studies, you can see how top clinicians manage real-world cases and apply their strategies to get better results with your patients.

👉🏻 Watch Charlie’s case study here with our 7-day free trial:
https://physio.network/casestudies-clements

Charlie Clements is a First Contact Physiotherapist for the NHS and based within the United Kingdom. He has a specialist interest towards spinal pathologies and sources of lower limb pain with a passion for delivering evidence-based content across his online platforms. He has published research looking at the influence of foam rolling on ankle injuries alongside previous experience working in professional cricket. 

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is @NoahMandelPhysio from Physio Network

SPEAKER_02:

On today's episode with Charlie Clements, we discuss sciatica. We dive into the diagnostic criteria for sciatica, important differential diagnoses, the treatment options and practice guiding principles when it comes to the management of this condition, and lastly, when to consider referring the patient to a spinal specialist. Charlie is a first contact physiotherapist working in the UK. He has a special interest in the low back, sciatica, and serious pathologies, and he teaches physios how to recognize and rule out red flags in his course. Charlie has done a case study with PhysioNetwork on this topic, where you can dive a lot deeper into this area than we were able to in today's episode. You can click the link in the show notes to watch Charlie's case study with a 7-day free trial. You're going to love this episode, as it will help you approach your sciatica cases with a lot more confidence. I'm Noah Mandel, and this is Case Studies. Welcome, Charlie. Thank you for joining us today on the podcast. So today we're going to talk about a very interesting patient that you've worked with and created a really great case study presentation on. But before we dive deeper into those really interesting details of the case, would you mind giving everyone a little bit of a background on this patient?

SPEAKER_01:

Yeah, so hi Noah. Thanks so much for having me on and thanks again for Physio Network for allowing me to do this really cool and interesting case study today that we're going to discuss about. So this was a case study of a gentleman, middle-aged, who presented to me in clinic. Clinically with something that I was suspicious of called sciatica. In the medical literature and stuff, we're looking now at something more like spine-related leg pain or lumbosacral radicular pain. And this was somebody that was in a lot of discomfort, had tried some self-management, hadn't really worked out and was coming for sort of their assessment and some advice and some guidance from somebody like myself. So for those listening, I work as a first contact physiotherapist in the UK. That's based in sort of primary care or general practice. And my role is more of an assessment. So I see people and provide sort of a specialist service and assessments. And from there, if we need to organize any test investigations or referrals elsewhere, then I can kind of do all of that really. So in

SPEAKER_02:

your role, assessment is key. And when it comes to assessing and diagnosing sciatica, or as you mentioned, it may be more appropriate to refer to it as lumbosacral radicular pain. What are some key things that you're looking for when it comes to a diagnosis? And how do you make sure you're not making any diagnoses for different conditions or for the wrong conditions?

SPEAKER_01:

Yeah, that's a really good point. And I think it's maybe something that basically as clinicians in the past, we've maybe sort of fallen short on. And if I had a penny for every time people come in and see me, and I'm sure you're the same, they were convinced they got sciatica and then it turns out to be something else. I'd probably be a slightly richer physio. For me, there's a really nice sort of like clinical tool that I refer to. So that was by a paper in 2018 by Steins and some colleagues, and that was based in the UK. So it was based in a general practice centre. They had patients coming in with back and leg symptoms, and they referred to sort of five key features that can help you with sort of, I guess, being a little bit more confident that this could be sciatica walking through the door. So that was pain in the leg, that's usually worse than the lower back, pain that's below the knee classically as well compared to sort of above the knee, some form of subjective sensory change, so tingling, pins and needles, numbness, as well as then some form of objective neurological deficit, so whether that's a sensory loss on physical exam, reflex changes, or perhaps a muscle weakness. And then finally, pain that's elicited with something like a neurodynamic test, though usually that's our passive straight leg raise. They scored that out of 10. A score of five or more increased the probability of somebody having it by over 80%, which I thought was quite interesting. And they compared that to a reference standard. So routinely, that's an MRI scan unless it's contraindicated. So that's something that in my head I'm thinking of as I'm going through some of these questions and asking patients in clinic. Some of the key things or differentials that it can be mistaken for, probably one of them is more like somatic referred leg pain. So pain that's coming from some of those somatic structures in the back and referring down into the leg. ways that can be quite useful to differentiate that is usually it's often more dull it's often more achy diffuse and it tends to be a little bit more proximal so rarely will it go below the knee so that's quite a key thing to to consider and usually it's comparable so it's on the same sort of spectrum and level in terms of pain severity compared to the lumbar spine probably the other thing is hip arthritis as well so certainly you know in the uk aging demographic of people that we're seeing. Probably also an increased prevalence of hip arthritis that I'm seeing in clinic in younger patients. It is quite key to try and differentiate that as well. So even today in clinic, I saw somebody with those types of features. Asking about a family history of arthritis is really key. Some of those subjective questions in the history that can tease it out. Normally, they've got some stiffness in the morning, takes them less than half an hour to get going, and often that can be the worst part of the day for them. Usually they've got discomfort going into the groin, the buttock, maybe down the thigh, but don't forget that it can go below the knee if it's really, really severe. And usually these people won't enjoy stuff like getting in and out of a car, standing up quickly from sitting for a while, or perhaps even putting on their shoes and socks. And then clinically, sort of from a physical assessment, they're more likely to limp. You're probably more likely to see a reduction in their movement compared to the opposite side when you're testing the hip passively. And you're probably going to get pain coming on when you're testing the hip passively as well. So flexing that hip, adducting it, and then internally rotating sort of for deer's test.

SPEAKER_00:

Ever wished you could see how experts treat real patients of theirs? With Case Studies by PhysioNetwork, now you can. Watch presentations where top clinicians break down real-life patient cases step by step, showing how they assess and treat even the trickiest conditions. It's the best way to improve your clinical reasoning and build confidence in the clinic. Click the link in the show notes to start your free trial today.

SPEAKER_02:

I think it's great to bring up those common culprits that can masquerade as this radicular pain. And it's so important for clinicians to know that just because there's pain in the back or near the hip area and it's radiating down the leg, that does not automatically mean that we're dealing with sciatica-like symptoms. So thank you for bringing that up. When it came to the management plan, when I was watching your case study, for me, this was one of the biggest takeaways. You didn't approach this patient's management plan very rigidly. You didn't say you have to do this one exercise in order to get better. Instead, you really worked with the patient. And I want to know if there are some general principles that you follow when managing a patient with a lumbosacral radicular pain or radiculopathy and how you applied that to this particular case.

SPEAKER_01:

Yeah, so I think in the absence of anything concerning or sinister, then certainly you would want to try conservative management. So that stepped approach certainly in the UK and probably across the world is recommended at the minute for the sciatica. So that's where we... look to trial some of those conservative interventions first before we then look at escalating care for imaging, injection, surgery. This gentleman for this chat, time was quite sensitive for them, so they were quite busy and they weren't too keen or receptive to being referred on to structured physiotherapy in an outpatient department. So together, we kind of came up with a bit of a program ourselves really. So There is some literature that suggests just general exercise can be comparable and just as effective for leg pain and disability at sort of three months, six months. So for us, he actually could tolerate walking quite well. So if possible, I quite like getting people just moving. So walking, a graded exposure to walking program can be a really nice way of encouraging some movement, encouraging some exercise. It's also quite distracting. So if you're out and about and you're you're outside, you're listening to a podcast, you're walking with friends or family, maybe you're taking the edge off of their leg pain a little bit. And if you want to be objective and you want to try and track things for a goal, everybody's got a smartphone nowadays or a smartwatch. So you could always look at tracking steps as well. That can just be quite a nice quick fix and easy win for the patient to look at some of those factors, I guess. Probably one of the key things though is getting their pain under control. So for me, I've got the luxury of working in a doctor's surgery. For those that perhaps don't medically prescribe, you want to be getting the patient on board with some form of medication, I would imagine. The caveat to that is if you look at the literature, we can't really say with a lot of confidence exactly what type of medication is the most effective. And I go into that in a bit more detail in the case study. But having a close working rapport with the GP or our prescribing colleagues can be really, really important. managing this. And then the same as I guess what ourselves and any other physio does is that we try to sort of calm things down and then slowly build it back up again. So that sort of graded exposure to movement for these like radicular pain syndrome, sciatica, however you want to call it. Flexion is normally quite a provocative movement pattern. And for this chap, it certainly was. So again, in the case study, I talked through just some basic sort of lumbar flexion exercises that can start from very, very easy and then gradually it progresses in its intensity and its movement. I love it.

SPEAKER_02:

So some really lovely themes there that you're bringing up. There's this patient-centered approach and this shared decision-making process. There's this idea that just a walking program can sometimes be helpful and that we have different options for for this type of population. So we don't need to feel so confined to one treatment plan. And you're also highlighting the importance of a collaborative approach with other healthcare practitioners so that analgesic medications can be prescribed to get their symptoms under control. So I really like all those points that you highlighted there, and it really helps to paint the bigger picture for this type of population. So In this case, unfortunately, it didn't all go according to plan, right? We needed to take another step. So can you walk us through the referral process that you experienced with this patient?

SPEAKER_01:

Yeah, so I think probably one of the key points for listeners is that sometimes with this condition, things don't progress and improve in the way that we think it would. And I'm certainly somebody that would want to really sort of have a good go at conservative efforts. But I guess one of the key features to make listeners aware of is that don't hang around too long with something like sciatica if it's not improving, or certainly if things get worse, have perhaps a slightly lower threshold for escalating their care and referring on when it's needed. So for myself, I work in that specialist role where I can kind of do that. So for this gentleman, the leg pain got worse and that was non-respondent to the medication and the treatment options that we were doing. So then I guess it's having a discussion with them about would they consider some of those more invasive options that are on the cards and might be available to them. So that could consist of something like injection therapies, essentially a corticosteroid that's injected into that sort of epidural space to try and calm the nerve down. Or if they've got weakness or if that's non-respondent to some of those interventions, then surgery could be an option as well. Probably in the UK and with the NICE guidance, that's normally after about a three-month window of rehab or conservative options. If we're looking at perhaps escalating that a little bit sooner, there are some mnemonics that I use and I've sort of borrowed and semi-stolen off of the likes of Adam Dobson, Tom Jetson, which I quite like and I've adapted myself as well in clinics. So They use the three Ps for myotomes, which is polyroutes, which is essentially multiple weakness at multiple spinal nerve root levels, progressive weakness. So it started at maybe sort of a strong four out of five, but it's gradually getting worse over time rather than better, or profound weakness. So less than three out of five on that Oxford grading scale. So, you know, classic example is a foot drop. That's where we want to be escalating care. And depending on where you work and what your setting is, that will be influenced by pathways. The other is pain. So I've sort of come up with my own little mnemonic. So the two Ps for pain. So again, progressive pain that's getting significantly worse despite all of the stuff that we've discussed or profound pains. You know, it's unremitting pain can't get better no matter what we do, impacting every aspect of that person's life. I think if you look at the literature, we look at the sort of prognostic factors, so certainly like the leg pain duration and the severity, they can influence how people get on conservatively or with some of those invasive procedures. So I think just have a slightly lower threshold for referring that on in that scenario. It

SPEAKER_02:

makes a lot of sense. So really, we just scraped the surface here when it comes to assessment and management and when you refer a patient on. But I think in just 15 minutes or so, you did an excellent job breaking all that down. So thank you for all that information, Charlie. Now, you go into all of these in a lot more detail in the full case study. And just a reminder that you can watch watch Charlie's full one hour presentation with a seven day free trial. And you can find the link to that trial in our show notes. Charlie, thank you so much for coming on today and sharing all of that information. I think that was excellent. And it was a pleasure to chat with you. Cheers Noah. Thanks so much.