Physiotherapy interventions are prescribed as first-line treatment for people with sciatica; however, their effectiveness remains controversial. The purpose of this systematic review was to establish the short-, medium- and long-term effectiveness of physiotherapy interventions compared to control interventions for people with clinically diagnosed sciatica.
This systematic review was registered on PROSPERO CRD42018103900. Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL (EBSCO), Embase, PEDro, PubMed, Scopus and grey literature were searched from inception to January 2021 without language restrictions. Inclusion criteria were randomised controlled trials evaluating physiotherapy interventions compared to a control intervention in people with clinical or imaging diagnosis of sciatica. Primary outcome measures were pain and disability. Study selection and data extraction were performed by two independent reviewers with consensus reached by discussion or third-party arbitration if required. Risk of bias was assessed independently by two reviewers using the Cochrane Risk of Bias tool with third-party consensus if required. Meta-analyses and sensitivity analyses were performed with random effects models using Revman v5.4. Subgroup analyses were undertaken to examine the effectiveness of physiotherapy interventions compared to minimal (e.g. advice only) or substantial control interventions (e.g. surgery).
Three thousand nine hundred and fifty eight records were identified, of which 18 trials were included, with a total number of 2699 participants. All trials had a high or unclear risk of bias. Meta-analysis of trials for the outcome of pain showed no difference in the short (SMD − 0.34 [95%CI − 1.05, 0.37] p = 0.34, I2 = 98%), medium (SMD 0.15 [95%CI − 0.09, 0.38], p = 0.22, I2 = 80%) or long term (SMD 0.09 [95%CI − 0.18, 0.36], p = 0.51, I2 = 82%). For disability there was no difference in the short (SMD − 0.00 [95%CI − 0.36, 0.35], p = 0.98, I2 = 92%, medium (SMD 0.25 [95%CI − 0.04, 0.55] p = 0.09, I2 = 87%), or long term (SMD 0.26 [95%CI − 0.16, 0.68] p = 0.22, I2 = 92%) between physiotherapy and control interventions. Subgroup analysis of studies comparing physiotherapy with minimal intervention favoured physiotherapy for pain at the long-term time points. Large confidence intervals and high heterogeneity indicate substantial uncertainly surrounding these estimates. Many trials evaluating physiotherapy intervention compared to substantial intervention did not use contemporary physiotherapy interventions.
Based on currently available, mostly high risk of bias and highly heterogeneous data, there is inadequate evidence to make clinical recommendations on the effectiveness of physiotherapy interventions for people with clinically diagnosed sciatica. Future studies should aim to reduce clinical heterogeneity and to use contemporary physiotherapy interventions.
‘Sciatica’ is a broad term describing spinally referred pain of neural origin that radiates into the leg. The reported prevalence of sciatica varies widely (1.2–43%) , probably due to different diagnostic criteria, reflecting a heterogeneous patient population. Sciatica is a significant burden to healthcare and the economy, as a neuropathic component in low back pain it is not only linked to poorer quality of life, but also increases the already high costs of back pain by a further 67% . Although prognosis is good for most patients, up to 45% continue to have symptoms for 12 months or longer .
Physiotherapy interventions such as exercise, manual therapy and psychological therapy are recommended in clinical guidelines for people with sciatica . However, the available systematic reviews examining the effectiveness of physiotherapy interventions are at least ten years old. For example, study selection in the most recent systematic review comparing surgery versus conservative care ended in 2009 . Their results could not be meta-analysed due to poor reporting and clinical heterogeneity. Similarly, a network-meta-analysis concluded its search in 2009 , finding no support for the effectiveness of exercise or traction while manipulation may be beneficial. However, the latter was based on a single study only. Prior to this, reviews specifically focusing on conservative management of sciatica were published in 2010  and 2007  and were unable to make strong conclusions on the superiority of any treatment. More recent reviews published in 2015 and 2016 were limited to a subset of physiotherapy interventions (e.g. physical activity versus surgery  and exercise versus advice to stay active ). A recent review  looked at a range of physiotherapy interventions, however the review did not include a meta-analysis.
Of note, sciatica is a heterogeneous condition with no agreed diagnostic criteria . Most reviews to date make no reference to the clinical diagnosis of included study participants rendering it unclear whether patients had confirmed nerve involvement. The objective of this systematic review was therefore to assess the up-to-date evidence on the effectiveness of physiotherapy interventions compared with control interventions in people with clinically diagnosed sciatica.
The protocol was prospectively registered on PROSPERO (CRD42018103900). We are reporting our findings according to the updated guidance for the PRISMA guidance .
We searched the following databases from inception to 29th January 2021: Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL (EBSCO), Embase, PEDro, PubMed and Scopus. We also searched grey literature including trial registries (OpenGrey and clinicaltrials.gov). The search strategy was developed in consultation with a medical librarian and included keywords relating to sciatica, physiotherapy and randomised controlled trials (Supplemental Table 1).
Included studies were randomised controlled trials evaluating physiotherapy interventions compared to a control intervention in people with ‘sciatica’. Trials were eligible if study participants were diagnosed with spinally referred leg pain of neural origin. This diagnosis required at least one of the following: positive sensory, myotomal or reflex tests on neurological examination; positive neurodynamic test (e.g. straight leg raise, slump); imaging confirming spinal nerve compromise correlating with symptoms; presence of neuropathic pain determined with neuropathic pain questionnaires; electrodiagnostic testing or quantitative sensory testing suggesting nerve root involvement. Studies which either did not specify how the sciatica diagnosis was made or were simply using pain referral into the leg without other clinical tests confirming a neural component were excluded. No restrictions were made on sciatica symptom duration or intensity. Eligible trials must evaluate physiotherapy interventions such as exercise, manual therapy, physiotherapy-led education, or a combination of these. The control intervention needed to be a non-physiotherapy intervention (e.g. surgery, GP care, other non-physiotherapy care). The control intervention could also be placebo, sham or no intervention. No restrictions were made on language.
Trials that included participants with serious pathology (e.g. cancer, fracture, cauda equina), pregnant women or participants aged below 18 were excluded. Studies evaluating post-surgical physiotherapy were excluded. As recent reviews address the effectiveness of acupuncture for people with sciatica [14, 15], and acupuncture is not core physiotherapy practice in many countries, trials evaluating acupuncture were excluded.
Two reviewers (LD, GJ) screened studies independently. In a first step, titles and abstracts were screened, followed by full texts. Discrepancies were resolved by discussion and arbitration by a third reviewer (AS) if required.
Two reviewers (LD, LK) independently used the Cochrane Risk of Bias tool to assess study quality and risk of bias . The tool was piloted on three excluded studies to test agreement of decision-making. Disagreements between reviewers were resolved by a third reviewer where required (GJ).
Two reviewers (LD, LK) independently extracted data using a standardised form; consensus was used to resolve any discrepancies. The following information was extracted: author, year, country, characteristics of participants (e.g. age, duration, severity of symptoms), diagnostic criteria, physiotherapy and control intervention (type, frequency and duration). Outcomes were extracted at baseline and follow-up time points. Primary outcomes of interest were pain (e.g. numerical pain rating scale) and disability (e.g. Oswestry disability index). Secondary outcomes were global perceived effect, quality of life, change in neurological function, psychological parameters, adverse events, and dropout rates. Means, standard deviations and sample sizes were extracted for each outcome. If alternative summary statistics were provided, we transformed the data using recommended calculations . If available, outcomes were extracted for different time points, and grouped according to time after randomisation as: short term (< 3 months); medium-term (> 3 months but < 12 months) or long-term (≥ 12 months). If multiple terms were reported within one period, the outcome closest to 7 weeks, 6 months and 12 months was used. When more than one body part was used to assess pain (e.g. leg and back pain), the highest score at baseline was used to reflect patients’ dominant symptoms. When more than one outcome measure was used within a trial for a specific outcome of interest, the outcome measure described by the trial authors as their primary measure was used.
Data synthesis and analysis
If data were available for the same outcome measure from at least two trials, meta-analysis was performed using Revman v5.4. We calculated standardised mean differences (SMD) and 95% confidence intervals (CI). Random effects models with inverse variance weighting were used to account for the variability of included studies. Heterogeneity was calculated with I2 statistics and interpreted as follows: ‘might not be important’ (0–40%), ‘moderate’ (30–60%), ‘substantial ‘(50–90%), and ‘considerable’ (75–100%) . We performed separate overall meta-analyses comparing physiotherapy interventions with control interventions for our primary outcomes of pain and disability.
We planned to perform a subgroup analysis according to type of physiotherapy interventions. However, this was impossible as interventions were too heterogeneous to pool. We performed a post hoc subgroup analysis comparing the effect of physiotherapy interventions according to the type of control intervention (minimal vs. substantial). Minimal intervention included advice/education only, GP care, or sham treatment. Substantial intervention included surgery, disc and epidural injections. Due to high risk of bias, we performed a post hoc sensitivity analysis, removing those studies where at least two parameters of risk of bias were rated as high. Results that could not be included in the meta-analysis were narratively described.
The electronic database searches returned 3958 records. Duplicates and studies deemed ineligible from titles/abstracts were removed, leaving 263 full-text articles. Of those, 245 were discarded as they did not meet the inclusion criteria. A total of 18 studies were included in this systematic review (Fig. 1) [18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35].
Risk of bias
Blinding of participants was understandably challenging to achieve in these trials, risk of performance bias was therefore high in 15 trials [18,19,20, 23, 25,26,27,28,29,30,31,32,33,34,35] and unclear in two trials [21, 24]. Detection bias was high or unclear in 11 [20, 21, 23, 25, 26, 29, 30, 32,33,34,35] of 18 studies (Fig. 2).
Table 1 contains details of study characteristics. A total of 2699 participants were included, 1198 (44.4%) of them were female. According to data available from 13 trials [18,19,20,21,22,23, 26, 28, 30,31,32,33, 35] participants’ age ranged from a mean of 36.0 (SD 5.8)  to 48.38 (SD 6.39) years . Baseline duration of sciatica was reported in eight trials, [18,19,20,21,22, 31,32,33], ranging from a mean of 1.8 (SD 1.3) weeks  to (median) 5.8 years (range 0.25–50) . Pain severity at baseline was reported by 16 trials [18,19,20,21,22,23,24, 26,27,28,29,30,31,32,33, 35], ranging from a mean of 4.8 (SD 1.9)  to 8.0 (SD 1.8)  on an 11-point scale. The diagnostic criteria for sciatica used in the included studies are listed in Supplemental Table 2.
Physiotherapy interventions varied considerably in the components included which prevented the preplanned subgroup analyses according to type of physiotherapy. Eleven trials included exercise [18, 19, 21, 23, 25, 29,30,31,32, 34, 35]. Type of exercise was most often unspecified or was at the discretion of the treating physiotherapist. Four studies made specific reference to neurodynamic exercise,  core stability , extension exercises  and isometric exercise . Eleven trials provided advice or education as part of the physiotherapy intervention [18, 21,22,23, 26,27,28,29, 32, 33, 35] with the most common advice to continue normal activity. Five studies used manual therapy or manipulations [19, 24, 27, 29, 31]. The frequency and duration of physiotherapy interventions were unreported in seven trials [23, 25, 29, 30, 33,34,35]. Where duration was reported, it ranged from 2 weeks  to 6 months . Further details on physiotherapy interventions are available in Tables 1 and 2.
Minimal intervention included advice to stay active  provision of a Back Book education booklet , bedrest or advice to continue normal activity , sham electrical nerve stimulation , sham laser therapy , GP care  or simulated manipulations . Substantial interventions involved surgery such as microdiscectomy or discectomy [26, 29, 32,33,34,35], or decompression [25, 28, 31]. One study compared epidural injection with extension exercises  and one compared chemonucleolysis disc injection  with physiotherapy.
Reporting of outcomes
Fifteen studies reported pain as a continuous outcome [18,19,20,21,22,23, 26,27,28,29,30,31,32,33, 35]. The three remaining studies reported a categorical outcome [24, 25, 34]. Fourteen studies reported a measure of disability [18,19,20,21,22,23, 26, 27, 29,30,31,32,33, 35]. Secondary outcome measures were not always reported (Supplemental Table 3). One trial reported treatment adherence . Adverse events were unreported in seven trials [20, 23,24,25, 28, 30, 34]. Of these, five [20, 23,24,25, 34] pre-date publication of Consort Guidelines  which includes reporting of adverse events. Supplemental Table 4 summarises details of the adverse events, which were less frequent with physiotherapy interventions than substantial control interventions. Dropout rates were unreported in three trials [20, 28, 29].
Overall meta-analysis on physiotherapy versus control intervention
For pain, 13 trials were included in the overall meta-analysis comparing physiotherapy versus all control interventions at short term, eight trials at medium term and nine trials at long-term time points. There was no difference in effectiveness of physiotherapy versus control interventions at short term (SMD − 0.34 [95%CI − 1.05, 0.37] p = 0.34, I2 = 98%, Fig. 3), medium term (SMD 0.15 [95%CI − 0.09, 0.38], p = 0.22, I2 = 80%, Fig. 4) and long term (SMD 0.09 [95%CI − 0.18, 0.36], p = 0.51, I2 = 82% Fig. 5).
For disability, 12 trials were included in the overall meta-analysis at short term, eight trials at medium term and eight trials at long term. There was no difference in effectiveness of physiotherapy versus control interventions at short (SMD − 0.00 [95%CI − 0.36, 0.35], p = 0.98, I2 = 92%, Fig. 6), medium (SMD 0.25 [95%CI − 0.04, 0.55] p = 0.09, I2 = 87%, Fig. 7) and long term (SMD 0.26 [95%CI − 0.16, 0.68] p = 0.22, I2 = 92%, Fig. 8).
Subgroup analysis on physiotherapy versus minimal intervention
For pain, six studies comparing physiotherapy with a minimal intervention were included in the subgroup analysis at short term, [18,19,20,21,22,23] three at medium [19, 21, 23] and two at long term [19, 23]. There were no group differences at short (SMD − 0.94 [95%CI − 2.11, 0.23] p = 0.11 I2 = 99%, Fig. 3) or medium-term (SMD − 0.14 [95% CI − 0.36, 0.09] p = 0.25, I2 = 40%, Fig. 4). However, there was a small effect (SMD − 0.38 [95% CI − 0.60, − 0.17, p = 0.0004, I2 = 3%], Fig. 5) in favour of physiotherapy interventions for pain reduction at the long-term time point.
One study  could not be meta-analysed due to insufficient data. Nonetheless, the results were broadly consistent with the meta-analysis. Santilli et al.  reported number of participants with reduction in radiating pain. At medium term, 48 participants (100%) of the physiotherapy group (spinal manipulation) reported reduction in radiating pain compared with 39 (81%) of those in the sham group. At long-term follow-up, 48 patients (100%) of the physiotherapy group continued to report reductions in radiating pain compared with 40 participants (83%) in the sham group.
For disability, six trials were meta-analysed comparing physiotherapy with minimal intervention at short term, [18,19,20,21,22,23] three at medium [19, 21, 23] and two trials at long term [19, 23]. No group differences were observed at short (SMD − 0.34 [95%CI − 0.70, − 0.01] p = 0.06, I2 = 87%, Fig. 6) medium, (SMD − 0.08 [95% CI − 0.39, 0.24] p = 0.63, I2 = 68%, Fig. 7) or long-term time points (SMD − 0.21 [95% CI − 0.45, 0.03] p = 0.09, I2 = 23%, Fig. 8). The Santilli  study did not report a measure of disability at any time point. Overall, these findings suggest that physiotherapy interventions are slightly more effective than minimal treatment for pain in the long term but not at short or medium term.
Subgroup analysis on physiotherapy versus substantial intervention
Eleven trials compared physiotherapy with substantial control intervention. Nine [26,27,28,29,30,31,32,33, 35] were included in the subgroup analysis for pain. There was no difference between physiotherapy and substantial intervention for the outcome of pain in the short (SMD 0.20 [95%CI − 0.27, 0.67] p = 0.39, I2 = 88%, Fig. 3) or long term (SMD 0.24 [95%CI − 0.05, 0.52], p = 0.10, I2 = 78%, Fig. 5). There was a small effect in favour of substantial intervention in the medium term (SMD 0.32 [95%CI 0.01, 0.63], p = 0.04, I2 = 81%, Fig. 4).
Two trials reported results that were not possible to incorporate in either meta-analysis [25, 34]. Amundsen  reported improvements in both the physiotherapy and surgical arms, however groups were not statistically compared. Weber  reported slightly higher rates of improvement in surgical compared to physiotherapy interventions at one year.
Seven trials were included in the meta-analysis for the outcome of disability [26, 27, 30,31,32,33, 35]. There was a small effect in favour of substantial interventions at short (SMD 0.40 [95%CI 0.09, 0.71] p = 0.01, I2 = 67%, Fig. 6) and medium term (SMD 0.46 [95%CI 0.08, 0.83], p = 0.02, I2 = 87%, Fig. 7) but no difference in the long term (SMD 0.42 [95%CI − 0.11, 0.94], p = 0.12, I2 = 93%, Fig. 8).
Four studies with high risk of bias in at least 2 parameters [28,29,30, 33] were removed from the meta-analysis. The sensitivity analyses revealed consistent results for all comparisons apart from the subgroup comparison of physiotherapy versus substantial control intervention (Supplemental Figs. 1–6). With the removal of high risk of bias studies, the effect on pain at medium term and on disability at short term favouring substantial interventions was no longer present (Supplemental Figs. 2 and 4).
This systematic review, including 18 studies and 2699 participants with a clinical diagnosis of sciatica suggests that physiotherapy interventions are only better than minimal interventions in reducing pain at long-term time points. Physiotherapy interventions are less effective than substantial interventions (e.g. surgery) in reducing pain at medium term and disability at short- and medium-term time points. However, heterogeneity was considerable in most meta-analyses, and confidence intervals were large, indicating substantial uncertainly surrounding the precision of these estimates. The favourable results for substantial intervention for pain in medium term and disability in short term did not persist following sensitivity analyses removing studies with high risk of bias. The currently available literature therefore provides insufficient evidence to support strong recommendations for physiotherapy interventions in the treatment of people with sciatica.
This systematic review reflects a wider collective inability to show significant benefit of non-surgical treatments for people with sciatica. Pharmacological options fail to demonstrate effects beyond placebo , including non-steroidal anti-inflammatories , anti-convulsants , anti-depressants  or opioids [4, 41]. Epidural cortisone injections have small effect sizes and short-term benefits . These findings are disappointing given the clear need for effective conservative interventions voiced by patients .
Apart from the possibility that physiotherapy is indeed not effective for patients with sciatica, there are multiple possible reasons for the lack of evidence. The physiotherapy interventions used in the 11 trials comparing physiotherapy with substantial interventions are not all considered contemporary in line with current clinical guidelines . This is a reflection of a lack of recent physiotherapy trials, with only four of the 11 studies published in the last decade [26, 28, 30, 31]. Current clinical guidelines recommend group exercise and continuation of normal activities; however, bedrest was a component of the conservative treatment arm in two trials [28, 34]. The UK NICE Guidelines  find no evidence supporting the use of corsets or belts, but these were a core component in another trial  conducted before publication of these guidelines. The physiotherapy interventions are highly heterogeneous and remain unclear in several studies. The Bailey study  leaves physiotherapy interventions at the discretion of the treating clinician, and the Peul study  refers people to physiotherapy only if they are fearful of movement, leaving uncertainty about how many participants in those trials had active physiotherapy treatment. It could also be argued that patients deemed suitable for surgery are likely to represent a specific subgroup that may be less amenable to physiotherapeutic interventions (e.g. with intractable pain or neurological deficit). Indeed, two trials comparing physiotherapy interventions with surgery included patients who had already failed conservative treatment [28, 29], raising serious concerns that physiotherapy interventions could possibly succeed in such a population.
A further challenge to progress in treatment is the diagnosis of sciatica itself . There is no agreed definition for sciatica, reflected in the wide range of definitions used in clinical trials , including our review. The broad term ‘sciatica’ comprises radiculopathy, radicular pain, or somatic referred pain. The differing patient populations bring clinical heterogeneity to most meta-analyses. Unfortunately, the high heterogeneity among studies reduces the confidence in our results. Together with previous systematic reviews with inconclusive findings, our results question the value of continuing to perform clinical trials in heterogeneous groups of patients. Although subgrouping according to risk stratification showed promise in the management of people with non-specific low back pain , this has failed in patients with sciatica . Subgrouping using a mechanism-based approach shows promising signals in patients with neuropathic pain of different aetiologies , but has yet to be examined in sciatica.
The risk of bias analysis highlights areas of improvement for future trials. Performance bias is the area with the highest risk of bias. Although recent studies have shown that blinding of participants is possible , it is not easy to eradicate this bias where the intervention is a physical one such as surgery or physiotherapy. The main area that could easily be addressed is detection bias. Blinding outcome assessment would have reduced overall risk of bias in four studies.
Strengths and limitations
The main strength of this review was the strict inclusion criteria based on clinical diagnosis confirming spinally referred leg pain of neural origin. A consequence of the tight inclusion criteria is the exclusion of 45 studies due to inadequate information on diagnosis of sciatica. As a result, our data reflect outcomes in patients with true nerve involvement. Insufficient reporting and low number of studies prevented a subgroup analysis according to type of physiotherapy intervention. Future trials with physiotherapy intervention should adhere to the TIDieR framework to fully describe the complexity of the intervention .
In summary, in patients with clinically diagnosed sciatica, physiotherapy interventions trialed to date provide inadequate evidence to make specific recommendations on their effectiveness in reducing pain or disability. The lack of convincing evidence may be due to several factors including incomplete trial reporting, clinical, methodological, and statistical heterogeneity, and trials lacking high methodological quality. Rather than continuing to perform trials in the heterogeneous population of ‘sciatica’, future studies should focus on reducing clinical heterogeneity, using contemporary physiotherapy interventions and high methodological quality to hopefully end the roadblock of discovery on the most effective physiotherapy interventions for these patient populations.
Konstantinou K, Dunn KM (2008) Sciatica: review of epidemiological studies and prevalence estimates. Spine (Phila Pa 1976) 33:2464–2472. https://doi.org/10.1097/BRS.0b013e318183a4a2
Schmidt CO, Schweikert B, Wenig CM, Schmidt U, Gockel U, Freynhagen R, Tölle TR, Baron R, Kohlmann T (2009) Modelling the prevalence and cost of back pain with neuropathic components in the general population. Eur J Pain (London, England) 13:1030–1035. https://doi.org/10.1016/j.ejpain.2008.12.003
Konstantinou K, Dunn KM, Ogollah R, Lewis M, Van Windt D, Hay EM, Team AS (2018) Prognosis of sciatica and back-related leg pain in primary care: the ATLAS cohort. Spine J 18:1030–1040. https://doi.org/10.1016/j.spinee.2017.10.071
NICE NIoHaCE (2016) Low back pain and sciatica in over 16s: assessment and management
Lewis RA, Williams NH, Sutton AJ, Burton K, Din NU, Matar HE, Hendry M, Phillips CJ, Nafees S, Fitzsimmons D, Rickard I, Wilkinson C (2015) Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. Spine J 15:1461–1477. https://doi.org/10.1016/j.spinee.2013.08.049
Jacobs WC, van Tulder M, Arts M, Rubinstein SM, van Middelkoop M, Ostelo R, Verhagen A, Koes B, Peul WC (2011) Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review. Eur Spine J 20:513–522. https://doi.org/10.1007/s00586-010-1603-7
Hahne AJ, Ford JJ, McMeeken JM (2010) Conservative management of lumbar disc herniation with associated radiculopathy: a systematic review. Spine (Phila Pa 1976) 35:E488-504. https://doi.org/10.1097/BRS.0b013e3181cc3f56
Luijsterburg PA, Verhagen AP, Ostelo RW, van Os TA, Peul WC, Koes BW (2007) Effectiveness of conservative treatments for the lumbosacral radicular syndrome: a systematic review. Eur Spine J 16:881–899. https://doi.org/10.1007/s00586-007-0367-1
Fernandez M, Ferreira ML, Refshauge KM, Hartvigsen J, Silva IR, Maher CG, Koes BW, Ferreira PH (2016) Surgery or physical activity in the management of sciatica: a systematic review and meta-analysis. Eur Spine J 25:3495–3512. https://doi.org/10.1007/s00586-015-4148-y
Fernandez M, Hartvigsen J, Ferreira ML, Refshauge KM, Machado AF, Lemes IR, Maher CG, Ferreira PH (2015) Advice to Stay Active or Structured Exercise in the Management of Sciatica: A Systematic Review and Meta-analysis. Spine (Phila Pa 1976) 40:1457–1466. https://doi.org/10.1097/BRS.0000000000001036
Lee JH, Choi KH, Kang S, Kim DH, Kim DH, Kim BR, Kim W, Kim JH, Do KH, Do JG, Ryu JS, Min K, Bahk SG, Park YH, Bang HJ, Shin KH, Yang S, Yang HS, Yoo SD, Yoo JS, Yoon KJ, Yoon SJ, Lee GJ, Lee SY, Lee SC, Lee SY, Lee IS, Lee JS, Lee CH, Lim JY, Han JY, Han SH, Sung DH, Cho KH, Kim SY, Kim HJ, Ju W (2019) Nonsurgical treatments for patients with radicular pain from lumbosacral disc herniation. Spine J 19:1478–1489. https://doi.org/10.1016/j.spinee.2019.06.004
Lin CW, Verwoerd AJ, Maher CG, Verhagen AP, Pinto RZ, Luijsterburg PA, Hancock MJ (2014) How is radiating leg pain defined in randomized controlled trials of conservative treatments in primary care? A systematic review. Eur J Pain (London, England) 18:455–464. https://doi.org/10.1002/j.1532-2149.2013.00384.x
Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE, Chou R, Glanville J, Grimshaw JM, Hróbjartsson A, Lalu MM, Li T, Loder EW, Mayo-Wilson E, McDonald S, McGuinness LA, Stewart LA, Thomas J, Tricco AC, Welch VA, Whiting P, Moher D (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 372:n71. https://doi.org/10.1136/bmj.n71
Qin Z, Liu X, Wu J, Zhai Y, Liu Z (2015) Effectiveness of acupuncture for treating sciatica: a systematic review and meta-analysis. Evid Based Complement Alternat Med 2015:425108. https://doi.org/10.1155/2015/425108
Ji M, Wang X, Chen M, Shen Y, Zhang X, Yang J (2015) The Efficacy of Acupuncture for the treatment of sciatica: a systematic review and meta-analysis. Evid Based Complement Alternat Med 2015:192808. https://doi.org/10.1155/2015/192808
Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, Savovic J, Schulz KF, Weeks L, Sterne JA, Cochrane Bias Methods G, Cochrane Statistical Methods G (2011) The Cochrane collaboration’s tool for assessing risk of bias in randomised trials. BMJ 343:d5928. https://doi.org/10.1136/bmj.d5928
Wan X, Wang W, Liu J, Tong T (2014) Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol 14:135. https://doi.org/10.1186/1471-2288-14-135
Ferreira G, Stieven F, Araujo F, Wiebusch M, Rosa C, Plentz R, Silva M (2016) Neurodynamic treatment did not improve pain and disability at two weeks in patients with chronic nerve-related leg pain: a randomised trial. J Physiother 62:197–202. https://doi.org/10.1016/j.jphys.2016.08.007
Fritz JM, Lane E, McFadden M, Brennan G, Magel JS, Thackeray A, Minick K, Meier W, Greene T (2021) Physical therapy referral from primary care for acute back pain with sciatica: a randomized controlled trial. Ann Intern Med 174:8–17. https://doi.org/10.7326/m20-4187
Ghoname E, White P, Ahmed H, Hamza M, Craig W, Noe C (1999) Percutaneous electrical nerve stimulation: an alternative to TENS in the management of sciatica. Pain 83:193–199
Hofstee DJ, Gijtenbeek JJM, Hoogland PH, Van Houwelingen JC, Kloet A, Lotters F, Tans JTJ (2003) Bed rest and physiotherapy are of no added value in the management of acute lumbosacral radicular pain: A randomised clinical study. Ned Tijdschr Geneeskd 147:249–254
Konstantinovic LM, Kanjuh ZM, Milovanovic AN, Cutovic MR, Djurovic AG, Savic VG, Dragin AS, Milovanovic ND (2010) Acute low back pain with radiculopathy: a double-blind, randomized, placebo-controlled study. Photomed Laser Surg 28:553–560. https://doi.org/10.1089/pho.2009.2576
Luijsterburg PA, Verhagen AP, Ostelo RW, van den Hoogen HJ, Peul WC, Avezaat CJ, Koes BW (2008) Physical therapy plus general practitioners’ care versus general practitioners’ care alone for sciatica: a randomised clinical trial with a 12-month follow-up. Eur Spine J 17:509–517
Santilli V, Beghi E, Finucci S (2006) Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations. Spine J 6:131–137. https://doi.org/10.1016/j.spinee.2005.08.001
Amundsen T, Weber H, Nordal HJ, Magnaes B, Abdelnoor M, Lilleås F (2000) Lumbar spinal stenosis: conservative or surgical management? A prospective 10-year study. Spine 25:1424–1436. https://doi.org/10.1097/00007632-200006010-00016
Bailey CS, Rasoulinejad P, Taylor D, Sequeira K, Miller T, Watson J, Rosedale R, Bailey SI, Gurr KR, Siddiqi F, Glennie A, Urquhart JC (2020) Surgery versus conservative care for persistent sciatica lasting 4 to 12 months. N Engl J Med 382:1093–1102. https://doi.org/10.1056/NEJMoa1912658
Burton A, Tillotson K, Cleary J (2000) Single-blind randomised controlled trial of chemonucleolysis and manipulation in the treatment of symptomatic lumbar disc herniation. Eur Spine J 9:202–207
Erginousakis D, Filippiadis D, Malagari A, Kostakos A, Brountzos E, Kelekis N, Kelekis A (2011) Comparative prospective randomized study comparing conservative treatment and percutaneous disk decompression for treatment of intervertebral disk herniation. Radiology 260:487–493
McMorland G, Suter E, Casha S, Du Plessis SJ, Hurlbert RJ (2010) Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study. J Manipulative Physiol Ther 33:576–584. https://doi.org/10.1016/j.jmpt.2010.08.013
Mondal P, Goswami S, Basak S (2017) Assessment of efficacy of transforaminal epidural steroid injection for management of low back pain with unilateral radiculopathy in industrial workers: A randomized control trial. J Clin Diagn Res 11:UC01–UC05. https://doi.org/10.7860/JCDR/2017/26400.10765
Nikoobakht M, Yekanineajd MS, Pakpour AH, Gerszten PC, Kasch R (2016) Plasma disc decompression compared to physiotherapy for symptomatic contained lumbar disc herniation: A prospective randomized controlled trial. Neurol Neurochir Pol 50:24–30. https://doi.org/10.1016/j.pjnns.2015.11.001
Osterman H, Seitsalo S, Karppinen J, Malmivaara A (2006) Effectiveness of microdiscectomy for lumbar disc herniation: a randomized controlled trial with 2 years of follow-up. Spine(Phila Pa 1976) 31:2409–2414. https://doi.org/10.1097/01.brs.0000239178.08796.52
Peul WC, van Houwelingen HC, van den Hout WB, Brand R, Eekhof JAH, Tans JTJ, Thomeer RTW, Koes BW (2007) Surgery versus prolonged conservative treatment for sciatica. N Engl J Med 356:2245–2256
Weber H (1983) Lumbar disc herniation: a controlled, prospective study with ten years of observation. Spine 8:131–140
Weinstein JN, Tosteson TD, Lurie JD, Tosteson ANA, Hanscom B, Skinner JS, Abdu WA, Hilibrand AS, Boden SD, Deyo RA, Weinstein JN, Tosteson TD, Lurie JD, Tosteson ANA, Hanscom B, Skinner JS, Abdu WA, Hilibrand AS, Boden SD, Deyo RA (2006) Surgical vs nonoperative treatment for lumbar disk herniation: the spine patient outcomes research trial (SPORT): a randomized trial. JAMA 296:2441–2450
Schulz KF, Altman DG, Moher D (2010) CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMJ 340:c332. https://doi.org/10.1136/bmj.c332
Pinto RZ, Maher CG, Ferreira ML, Hancock M, Oliveira VC, McLachlan AJ, Koes B, Ferreira PH (2012) Epidural corticosteroid injections in the management of sciatica: a systematic review and meta-analysis. Ann Intern Med 157:865–877. https://doi.org/10.7326/0003-4819-157-12-201212180-00564
Rasmussen-Barr E, Held U, Grooten WJ, Roelofs PD, Koes BW, Van Tulder MW, Wertli MM (2016) Non-steroidal anti-inflammatory drugs for sciatica. Cochrane Database Syst Rev 10:CD012382. https://doi.org/10.1002/14651858.CD012382
Enke O, New HA, New CH, Mathieson S, McLachlan AJ, Latimer J, Maher CG, Lin CC (2018) Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis. CMAJ 190:E786–E793. https://doi.org/10.1503/cmaj.171333
Ferreira GE, McLachlan AJ, Lin CC, Zadro JR, Abdel-Shaheed C, O’Keeffe M, Maher CG (2021) Efficacy and safety of antidepressants for the treatment of back pain and osteoarthritis: systematic review and meta-analysis. BMJ 372:m4825. https://doi.org/10.1136/bmj.m4825
Pinto RZ, Maher CG, Ferreira ML, Ferreira PH, Hancock M, Oliveira VC, McLachlan AJ, Koes B (2012) Drugs for relief of pain in patients with sciatica: systematic review and meta-analysis. BMJ 344:e497. https://doi.org/10.1136/bmj.e497
Oliveira CB, Maher CG, Ferreira ML, Hancock MJ, Oliveira VC, McLachlan AJ, Koes BW, Ferreira PH, Cohen SP, Pinto RZ (2020) Epidural corticosteroid injections for sciatica: an abridged Cochrane systematic review and meta-analysis. Spine 45:E1405–E1415. https://doi.org/10.1097/BRS.0000000000003651
Ryan C, Roberts L (2019) “Life on hold”: the lived experience of radicular symptoms. A qualitative, interpretative inquiry. Musculoskelet Sci Pract 39:51–57. https://doi.org/10.1016/j.msksp.2018.11.005
Jesson T, Runge N, Schmid AB (2020) Physiotherapy for people with painful peripheral neuropathies: a narrative review of its efficacy and safety. Pain Rep 5:e834. https://doi.org/10.1097/PR9.0000000000000834
Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, Konstantinou K, Main CJ, Mason E, Somerville S, Sowden G, Vohora K, Hay EM (2011) Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet 378(9802):1560–1571
Konstantinou K, Lewis M, Dunn KM, Ogollah R, Artus M, Hill JC, Hughes G, Robinson M, Saunders B, Bartlam B, Kigozi J, Jowett S, Mallen CD, Hay EM, van der Windt DA, Foster NE (2020) Stratified care versus usual care for management of patients presenting with sciatica in primary care (SCOPiC): a randomised controlled trial. Lancet Rheumatol 2:e401–e411. https://doi.org/10.1016/s2665-9913(20)30099-0
Baron R, Wasner G, Binder A (2012) Chronic pain: genes, plasticity, and phenotypes. Lancet Neurol 11:19–21. https://doi.org/10.1016/S1474-4422(11)70281-2
Beard DJ, Rees JL, Cook JA, Rombach I, Cooper C, Merritt N, Shirkey BA, Donovan JL, Gwilym S, Savulescu J, Moser J, Gray A, Jepson M, Tracey I, Judge A, Wartolowska K, Carr AJ (2018) Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet (London, England) 391:329–338. https://doi.org/10.1016/S0140-6736(17)32457-1
Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, Altman DG, Barbour V, Macdonald H, Johnston M, Lamb SE, Dixon-Woods M, McCulloch P, Wyatt JC, Chan AW, Michie S (2014) Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ 348:g1687. https://doi.org/10.1136/bmj.g1687
The authors would like to recognise the contribution of Neal Thurley, Outreach Librarian at the Bodleian Library, University of Oxford, in assisting with the search strategy for this systematic review. The authors would also like to thank Hubert van Griensven, Lecturer, University of Hertfordshire for assisting in translation from Dutch to English of one of the included studies.
The research and Lucy Dove were supported by the NIHR Biomedical Research Centre Oxford, based at Oxford University and Oxford University Hospitals NHS Trust. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. ABS is supported by a Clinical Research Career Development Fellowship from the Wellcome Trust (222101/Z/20/Z). For the purpose of Open Access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript arising from this submission.
Conflict of interest
The authors have no competing interests to declare that are relevant to the content of this article.
This is a secondary analysis of study data and therefore ethical approval was not required.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Dove, L., Jones, G., Kelsey, L. et al. How effective are physiotherapy interventions in treating people with sciatica? A systematic review and meta-analysis. Eur Spine J 32, 517–533 (2023). https://doi.org/10.1007/s00586-022-07356-y