Are combined conservative interventions effective in reducing pain, disability and/or global rating of pain in people with sciatica with known neuropathic pain mechanisms?

Purpose: National Clinical Guidelines recommend an integrated combination of conservative management strategies for sciatica. However, the efficacy of such combinations have not been established. The purpose of this systemic review with meta-analysis was to determine the efficacy of combined conservative (non-pharmacological) compared to single interventions for people with sciatica with a confirmed neuropathic mechanism.

Methods: The systematic review was registered on PROSPERO CRD42023464011. The databases included were the Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL (EBSCO), Embase, PubMed, Scopus, APA PsycINFO, and grey literature sources from inception until January 2024. Inclusion criteria were randomized controlled trials that assessed the effectiveness of combined non-pharmacological interventions in comparison to a control intervention among individuals with sciatica of a neuropathic origin identified using diagnostic or clinical tests. Primary outcomes were back pain, leg pain, and disability. The secondary outcome was global rating of change. Study selection, data extraction and risk of bias assessment (using Cochrane ROB2) were assessed by two reviewers. Meta-analysis was performed with a random effects model with inverse variance weighting used for the metanalysis using SPSS v 29.

Results: 3,370 articles were identified, of which 6 were included. Risk of bias was high in one study and had some concerns in the remaining 5 studies for each outcome measure. There was evidence of efficacy for combined interventions for back pain in the short-and long-term (SMD - 0.56 (95% CI -0.91, -0.22, p = 0.01, I² = 0.2; SMD - 0.44 (95% CI -0.79, -0.1, p = 0.03, I² = 0.00), and for disability in the short term (SMD - 0.48 (95% CI -0.92, -0.04, p = 0.04, I² = 0.72). There was no evidence of efficacy for leg pain at any time point (( short term SMD - 0.45 (95% CI -0.91, 0.02, p = 0.06, I² = 0.65), medium term (SMD - 0.29 (95% CI -1.12, 0.54, p = 0.35, I² = 0.82), long term (SMD - 0.40 (95% CI -1.23, 0.44, p = 0.18, I² = 0.57).Certainty of evidence ranged from very low to moderate.

Conclusion: There are few studies that have combined conservative (non-pharmacological) interventions for the management of sciatica with a neuropathic component pain mechanism, as recommended by National Clinical Guidelines. This review indicates that combining conservative (no-pharmacological) management strategies appeared more effective than single interventions for the outcomes of low back pain in the short and long term, and for disability in the short term, but not for leg pain at any time point. The overall low certainty of evidence, suggests that future studies with more robust methodologies are needed.