I once made a sciatica sufferer’s pain worse. After that experience, I would become nervous any time a client with sciatica walked through my door. But then, I injured my back, and, ironically, ended up in the same position as my client: the health practitioners I went to increased my sciatica pain. Eventually, I did get better, but I wondered what did we, as health practitioners, do wrong? Over the next decade, I talked to massage therapists, physical therapists, and chiropractors and tested out ways to keep acute sciatic pain from becoming worse during treatment.

Sciatica is Nasty Business
Sciatica—irritation of a lower-back spinal nerve—is nasty business. A person with sciatica may experience excruciating pain in the buttock and pain down the leg, along with numbness and muscular weakness. Pain can be constant or intermittent.
Depending on where the nerve compression or irritation is occurring—L4, L5, S1, S2, or S3—symptoms can manifest in different places. For example, L4 nerve compression causes pain/numbness in the thigh. L5 nerve compression can extend pain/numbness to the foot and big toes. S1 nerve compression can affect the outer part of the foot.1
The good news is that 90 percent of people recover from sciatica without surgery,2 which means there’s a significant chance we can help someone through sciatica if we’re careful not to increase sciatic pain.

Three strategies when addressing a client’s sciatica:
1. Determine the best body position on the table for the client.
2. Don’t try to do too much.
3. Identify perpetuating factors.

Body Position is Important
Body positions (e.g., sitting) can increase or reduce sciatic pain. Since sciatic nerve irritation can happen in different areas of the spine, no one position is going to produce the same effect for all. For instance, some sufferers can’t find a comfortable sleeping position and often wake up at night. Others can sleep, but have extreme pain when sitting. For one person, a foot on a chair while standing may be the ticket to getting through the day, while for another, sitting with a lumbar support may be the only way the pain is bearable. On the massage table, the importance of body position is just as important.

Not Face Down
In my experience, prone is the position that can most often aggravate a sciatica condition. In addition, a prone client leaves the door open for ratcheting up the pressure. More pressure in the lower back/sacrum area can further incite already angry nerves. I also found that even if an acute sciatica sufferer doesn’t feel an increase in pain when I kick up the pressure, they’re likely to feel more pain after the massage when they turn or stand up.

Pick a Side
So, for positioning an acute sciatica sufferer on the table, we’re left with supine or side. And if side-lying, which side? There is one sure way to find out which position on the table will be the best for your client. Ask them: “How do you sleep now?”
If it’s supine, which I find rarely to be the case with acute sciatica clients, then you’ll have a more challenging massage, having to work with your hands under the back. If they sleep on their side (the most common answer), ask which side.
Case closed? Not quite. Sometimes a client is not in tune with their sciatica pain. In other words, inadvertently, they could be giving you bad information. If you suspect this, do more digging. For one, make sure they are not giving you their “pre-sciatica pain” sleeping position. Also, is the client loading up on pain medication at night, which temporarily allows them to tolerate a bad sleeping position? Most of the time, I find that a sciatica client knows their best sleeping position. However, if in doubt, opt for side-lying and check in to see if the pain is increasing. If so, have your client carefully roll to the other side.

No aggressive techniques
During an acute phase of sciatica, even the sensation of clothing contacting one’s lower back can be painful. I’ve personally had clients reduced to tears when I was simply palpating to find the pain areas. With that tenderness in mind, it doesn’t make sense to use aggressive techniques (deep pressure and extreme stretching) in the lower-back area where the risk of doing bad outweighs the risk of doing good.
Wait until later, when the person is out of acute pain, to pursue a more aggressive treatment. If you increase the sciatica pain from the get-go, a new client may never come back, and you’ll never have the chance of helping that client manage or resolve their sciatica.

Avoid Deep Pressure When You Can
If you find yourself in a position where the client insists on deep pressure for their sciatica pain, consider your client’s familiarity with their sciatica pain. Do they have a long history of dealing with sciatica pain? If so, have they had success with deep pressure? If that is the case, have them guide you to only the areas where deep pressure was effective.
If your client hasn’t had a long history of dealing with sciatica, but simply likes deep pressure or believes deep pressure solves everything, try this strategy: light pressure in the acute sciatica area (lumbar and sacrum areas) and deep pressure in compensatory muscles (e.g., thoracic back) and areas of referred pain (e.g., hamstring and calf). This way you meet their psychological need for deep pressure without further contributing to an inflammatory response in the lumbar/sacral area.

Make Conservative Postmassage Recommendations
If you back off with pressure and stretching of the lumbar and sacrum areas, but go crazy with the postmassage suggestions, then you’re back to square one of potentially doing more harm than good. Providing a lot of postmassage suggestions can feel good because it seems like you’re empowering the client to help themselves. But you’ll serve your client far better if you carefully select stretches and self-massage tools that have a low probability of aggravating their sciatica. If the client has a regimen of protective stretches for their back, have them modify them until they get out of the acute phase.

Figure Out Perpetuating Factors
Lastly, be aware of perpetuating factors. A perpetuating factor can be defined as anything one does—from bad work posture to bad decision-making—that aggravates or prolongs a pain condition.
A starting point for identifying perpetuating factors is to ask the client if anything in their work, home, or recreational life changed before or at the onset of acute sciatica. Here are examples of work changes that could act as perpetuating factors: the client has been spending more hours in front of the computer or now has a longer commute to work. Home changes could be that the client has a new bed or has been sleeping on a different bed because of traveling. Trying a new exercise, changing a golf swing, or working in the garden are examples of recreational changes.  

Dig For Information
I often circle back to perpetuating factors a few times during the course of the massage because a client doesn’t necessarily make the connection between what they do and how it affects the lower back. Also, establishing solid perpetuating factors can take time because you have to figure out the right questions to ask. For example, Kishawn, a client of mine, came in with pain in his shoulder. He said he had injured the area years ago and that nothing changed in his CrossFit workout, which he had started six months ago.
After I started working on him, it became apparent that the area he injured years ago (clavicle) and the area that bothered him now (labrum/biceps tendon) were different. I went back to questioning him about his workout and found out that the new area of pain was also associated with a loss of strength in his shoulder. Eventually, I discovered that he recently injured his shoulder when working out with heavier weights and that he was still trying to work out with the same intensity.

Be Persistent
Here’s why I initially didn’t pick up that Kishawn’s workout was a perpetuating factor:
1. I assumed the new injury was an aggravation of an older injury.
2. I didn’t have enough accurate information to formulate the right question. As far as Kishawn was concerned, his CrossFit workouts hadn’t changed over the past six months—because he was always trying to add more weight and work harder.  
3. Kishawn loved CrossFit and didn’t want to stop. He was trying to ignore what he didn’t want to know—that his workout caused his injury and that working out while injured was continuing to aggravate the injury.
Once you have identified a potential perpetuating factor, you can make a suggestion to correct it. For instance, gardening, an activity that happens a few months a year and that can be demanding on the back, can aggravate sciatica. If you suspect gardening may be a perpetuating factor, have the client show you how they bend when working in the garden. My guess is that they’re bending in a way that puts tension in their lower-back area. If that’s the case, show them an alternative way to bend (e.g., take a knee when weeding).

Health Practitioners Can Be Perpetuating Factors
You can go out of your way as a massage therapist not to be a perpetuating factor, but that doesn’t mean other health or fitness practitioners are doing the same. For instance, a chiropractor once sent me an acute sciatica client, Emily. Both the chiropractor and I were treating Emily when her sciatica pain started to lessen. She had steady improvement for a few weeks and was only taking one half dose of a painkiller instead of four or more at a time. Then, suddenly, her sciatica came back in spades.
The next time I saw her, she reported that she had zero improvement after the chiropractor and I had worked on her. I drilled down on what might have changed in Emily’s life to put her back in the acute sciatica phase. Eventually, I discovered that the chiropractor had given her a heel lift for her shoe just before the onset of the latest round of acute pain. When she took the heel lift out, the pain started to go away.
Though they strive to do what’s best for their clients, fitness professionals can sometimes be perpetuating factors, too. Sarah was referred to me by a personal trainer. She was in constant sciatic pain, and whatever I did had little to no effect on her pain. Sarah’s trainer was doing very specific back exercises to help Sarah with her sciatica. I wondered if the exercises were actually exacerbating her condition, but Sarah was so invested in her trainer’s philosophy of correcting her back that I couldn’t get Sarah to stop doing the lower-back exercises. For the ensuing months, as I kept in contact with the trainer, Sarah’s sciatica never got better.

Doctors Make Mistakes, Too
Doctors are not exempt from being perpetuating factors, either. Michael has been my client for 20 years. He manages his sciatica through massage, chiropractic, and light exercise and stretching. For the most part, he only has acute episodes once or twice a year. One day, Michael went to his general practitioner for a physical. His doctor told him he had a surefire way to get rid of his back pain for good. It involved back exercises, including trunk rotation exercises. Michael trusted his doctor and earnestly tried his suggestions, but the experiment failed miserably and set Michael back for a while.
In retrospect, if Michael had asked his chiropractor or me what we thought of the doctor’s plan, we would have voiced major concerns. Though well-intentioned, the doctor didn’t have a historical understanding of Michael’s sciatica like the chiropractor and I did. He thought that Michael needed to be pushed, but we knew that over the years Michael had fine-tuned his exercises so they wouldn’t aggravate his sciatica.

First, Do No Harm
Sciatica clients benefit when we adopt the mind-set “first, do no harm.” Here’s how to “do no harm”: Help the client find the most comfortable position on the table. Back off from doing aggressive techniques (deep pressure and extreme stretching) in the lower-back area. Make conservative stretching recommendations and postmassage suggestions. Help a client identify perpetuating factors by asking if anything in their work, home, or recreational life has changed before or at the onset of acute sciatica.
As you strive not to be a perpetuating factor yourself, remember that other health/fitness practitioners working with your client can unknowingly be one. Be prepared to have that conversation with your client and/or other health/fitness practitioners if you think what they’re doing is contributing to the sciatic pain. And take a minute to pat yourself on the back for going the extra mile and carrying out the often unnoticed work that helps your client get out of pain faster.

Notes
1. Physiopedia, “Sciatica,” accessed September 2016, www.physio-pedia.com/Sciatica#Definition.2FDescription.
2. WebMD, “Slideshow: A Visual Guide to Sciatica,” accessed September 2016, www.webmd.com/back-pain/ss/slideshow-visual-guide-to-sciatica.

Mark Liskey is a massage therapist, continuing education teacher, business owner, and writer. He shows massage therapists how to stay out of pain, make more money, and find their way at www.makethemostofmassage.com.