Why Your Sciatica Keeps Coming Back Even After Chiropractic or Physical Therapy

You went in for your appointment, felt some relief for a few days, or only hours, and felt you were right back at square one by the time your next session rolled around. At Sembach Chiropractic, this often is the reported history of patients with chronic lower back pain or sciatica who have seen another provider before. But why are so many people left feeling this way? Why do so many people believe that their pain is a lost cause and this is just the "norm" of chiropractic care? There are a few ways this could be the case, but first let's review what true sciatica pain presents like.

Sciatica complaints are often complex in origin, but present with very common or classic symptoms. Sciatica pain does not always come from the peripheral nerve itself, and is very commonly irritated at the spinal level due to pressure from other structures. This pressure or irritation can create pain symptoms away from the root, down to where the nerve travels and innervates, classified as "sciatica". The pain feels like a sharp, shooting sensation down the posterior leg, varying in distance away from the lower back, often into the glute muscles or posterior knee. It can also be described as numb or tingling. This radiating pain varies from person to person clinically. Sciatica keeps coming back if not addressed correctly, especially if the treatment plan only addressed the peripheral symptoms.

Illustration of sciatic nerve pathway into the legs.

The Importance of Your First Visits

Knowing how intense back pain or sciatica can feel, we understand how important it is to have proper intervention early. When you first visit a chiropractor or a physical therapist for any injury, there are many things that need to be observed to come to a conclusion about diagnosis and care. If you have seen one of these providers previously, your exam may have included X-ray imaging, describing your pain and symptom history, and a few orthopedic tests. However, this standard procedural examination style may have fallen short when it comes to function. It may have made you feel rushed or unsure of what your care might look like. Your first visits set the tone for the rest of care, and may be a good indicator if you'll find success with the provider's plan.

An X-ray is a common first day process for many chiropractic offices. While you can gain some useful information from this type of imaging, it only shows the provider your bones, and the space between the bones. Any other diagnosis involving discs, nerves or soft tissues affected by bony structure is inconclusive as these parts of anatomy are not seen on X-ray. The correlation between findings on this type of imaging and sciatica pain is not strong due to this. This is when some providers then refer out for additional imaging. There are providers out there who do more harm than good with these, as they can often use terminology that creates fear or makes you feel like your body is more broken than it might actually be!

The next step in that process is an MRI to get further soft tissue diagnosis information. This is where you will see detailed information about the discs, the nerves, and the muscles at the spinal level. There's only one problem. Research tells us that MRI findings of disc herniations are also found in asymptomatic people (Brinjikji et al). Meaning these folks have a disc herniation visible on imaging, but no symptoms of sciatica or low back pain. With high incidence of these findings, it weakens the definitiveness of correlation between herniation present and sciatica pain or lower back pain. It also means that your provider may have sent you through this "hoop" when the treatment likely did not need to change or be altered based upon the MRI. Again, this type of imaging when not explained well to a patient can cause more harm than good, as we can catastrophize the results and create limiting beliefs about the body.

One of the most important things that a provider does during the exam is the orthopedic tests or movement based testing. These help the provider determine where the pain and symptoms are coming from, and if not done thoroughly, there's a lot to be missed. We also have very few orthopedic tests that are sensitive and specific to sciatica pain. Many orthopedic tests can create pain generated from additional structures as well as the chief complaint of sciatica. It is important for a provider to know which tests to use to formulate the treatment plan, as well as additional techniques to understand your lifestyle. If the exam stops at imaging and a few hands-on tests, it wouldn't be hard to miss a few details that could impact your success. At Sembach Chiropractic, we use several additional techniques during our Comprehensive Examination process to get specific about low back pain or sciatica. Our sciatica exams include nerve tensioners, Mckenzie Method, and a functional movement screen, we also look to find techniques that reduce pain during the exam and leave you feeling better than when you walked in.

Your first appointment with a chiropractor or physical therapist had an intake form, but did it explore what your lifestyle was like before sciatica or lower back pain? When time is spent digging into exercise activity, nutrition, sleep health, social activity, previous sport information, work, family conditions, and your goals - that's a lot of detail. These details paint a picture of what your physical demand is outside of the office setting. It also reveals the most important reason you may have sought help in the first place - you've got goals to accomplish! Being thorough in movement and information is critical to understanding the patient outside of the sciatica symptom presentation, which ultimately allows the provider to make a stellar treatment plan.

Why Office Flow Matters

It's important to audit your past chiropractic or physical therapy experiences before believing that your low back pain or sciatica is a lost cause. Every office is different to some capacity, but many have a very familiar flow!

Many people report that they had very quick visits, or did not see their clinician for very a long time during their visit. It is not uncommon for chiropractic offices or physical therapy offices to pass off patients to an assistant or a technician, and you may have had limited time to discuss your injury every session. Or worse, the details you shared did not get properly passed on to make adjustments in your care plan in a timely manner.

The office flow may not only have had you working with someone besides the doctor, but it may have required that several others are under the same supervision simultaneously. We can all agree it is easier to miss the small details that matter when our attention is divided. Another person in the office ecosystem is having to learn the way your body moves, what you have responded well to, and what your activity is going to look like when you leave your appointment. This may be further disrupted by higher volume offices, where there is a lot of emphasis on the steady flow of patients coming in and out quickly, and opportunities to learn more about the patient's condition can be missed in the hustle of the day. Sciatica and lower back pain could be coming back because your plan may have become too monotonous, and unchallenging due to the office flow and pass off between providers.

At Sembach Chiropractic, we dedicate ourselves to getting to know the patients on a deeper level. We aim to understand the drive behind each of their activity goals and we create treatment plans that support it. We also make sure that the individual appointments are always 1 on 1 with the doctor. We strongly believe that this individualized time allows us to intercept where changes should be made with treatment and when patients need to be further challenged to keep getting better in a timely manner. This session format has been very effective for minimizing the "I felt really good for about a day or two and then it came back" descriptions from our patients.

The Treatment Methods Make All the Difference

We have had many people in Crown Point, Indiana express that they have only ever received spinal adjustments from their chiropractor. They often shared that there were no other service provided, or that they would be encouraged to book massages in their chiropractic office as a part of the plan. With that being the bulk of the plan, it's no wonder sciatica pain or lower back pain kept coming back, because the treatment didn't address how your body functions outside of the office! At Sembach Chiropractic, spinal adjustments are only one of the many tools we utilize in patient care.

Spinal adjustments are useful in creating more mobility at the joint space, which signals to the brain that movement is occurring, then allowing the brain to temporarily shut down pain receptors at the region. This is why we can feel great leaving an appointment involving a spinal adjustment, even if nothing else was done that day, but may often feel exactly the same a few days later. The way our brain perceives and accomplishes movements throughout the day doesn't change much from an adjustment.

Soft tissue work may also have a similar, short-term effect. Massages, Theraguns, foam rolling, lacrosse ball rolling, cupping, dry needling or other methods stimulate the muscle tissue making it more pliable, while increasing blood flow. This is great for some general muscle aches, but for injuries like lower back pain and sciatica, this would not promote long-term change in the body to prevent re-occurring episodes of pain if used by itself. This is because muscles do what the brain and nervous systems tells them to do, not the other way around. No neurological or functional changes made, no long-term muscle tissue change! This is why we all have those knots we know feel better after a massage, but they never seem to fully disappear.

Here's the final piece of treatment plans with Sembach Chiropractic - functional therapeutic exercise. Now, many people have experienced some format of physical therapy before. The type of physical therapy you receive greatly varies based on the clinical setting and the degree of injury. Some offices are better suited for older populations, while some may be better suited for young athletes post-operation or surgery. However, the exercise material you are given should follow a simple format for you to achieve a long-term result no matter what type of population is favored. If the exercise routine does not follow this format, and your lower back pain keeps coming back, there were likely some missing componenets from your plan of care.

An exceptional therapeutic exercise routine should first lay a good foundation for the nervous system, especially in sciatica cases. During this phase of rehab, the exercises are still challenging, but do not have to be complex to perform. The second phase of therapies should be a progression from what is mastered in the first phase, and so on and so forth. It is also especially important for the end stages of care to closely model what activities the patient prefers or has goals to improve upon. Therefore, if a patient wants to be able to pick their kids up without sciatica pain, the rehab should include weight lifting that is close to their child's weight, with flexion of the lumbar spine and rotation. In order for your lower back and sciatica pain to minimized, your spine has to build back resilience to the activities that were extremely aggravating at the beginning of care, as well as be able to move in all directions!

Each of these treatment methods can be somewhat effective individually. Sembach Chiropractic seamlessly blends the spinal adjustment, soft tissue work, and therapeutic exercise together in an individualized setting. This allows us to address the mobility at the joint level and ease the muscles tension, creating space for the body to be pliable and adaptable, while implementing the nervous system and functional movement changes necessary to move stronger throughout day to day life. Our goal is that when you leave the office, you aren't dependent on the hands-on services to feel better and move better!

Stop The Pain Cycle

If we consider how different chiropractic and physical therapy offices are from one another, we can also see why treatment outcomes may not look the same. Sciatica pain and lower back pain does not have to be a debilitating condition, when managed properly and attentively. As the patient, you should feel that you are making continuous progress throughout each visit, with progression of your goals and a stronger sense of confidence in your body. It is the provider's responsibility to ensure that you feel this way with the treatment plan to the best of their ability! If you are still feeling stuck with your low back pain or sciatica, do not hesitate to book a complimentary Introductions call with Dr. Caitlin Sembach to hear how our methods could get you the results you have been seeking.

Resources:

Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., Halabi, S., Turner, J. A., Avins, A. L., James, K., Wald, J. T., Kallmes, D. F., & Jarvik, J. G. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR. American journal of neuroradiology, 36(4), 811–816. https://doi.org/10.3174/ajnr.A4173

Jensen MC, Brant-Zawadzki MN, Obuchowski N, Modic MT, Malkasian D, Ross JS. Magnetic Resonance Imaging of the Lumbar Spine in People Without Back Pain. The New England Journal of Medicine. 1994 Jul 14;331(2):69–73.

Stadnik TW, Lee RR, Coen HL, et al. Annular tears and disk herniation: prevalence and contrast enhancement on MR images in the absence of low back pain or sciatica. Radiology. 1998 Jan;206(1):49–55.