Low back pain and sciatica: what is happening, when to worry and what really works

Lower back pain is one of the most common reasons someone walks through the clinic door. It usually arrives with fear: "my disc has slipped", "my back is wrecked", "I've been told not to do sport". Let me give you the good news first, because it is the most important part: the vast majority of low back pain gets better, and it gets better sooner the sooner you start moving again with good judgement.

In this article I explain the difference between low back pain and sciatica, which signs really are a reason to go to A&E, what current clinical guidelines say about what works, and how I treat these cases at the clinic.

Low back pain and sciatica are not the same thing

Low back pain is pain in the lower part of the back. It can be sharp or dull, appear suddenly as you bend or settle in gradually. In most cases no single "guilty" structure can be pointed to (a disc, a joint, a specific muscle). That is why we talk about non-specific low back pain. Not having a specific label does not mean it is imaginary or that it has no treatment.

Sciatica is pain that travels down the leg along the path of a nerve, usually down the back of the thigh and below the knee. It often comes with tingling, numbness or an electric sensation. The leg frequently hurts more than the back itself.

The difference matters because it changes the examination, the prognosis and the exercises that make sense at the start.

When it is NOT a case for physiotherapy: warning signs

Also see your doctor before starting physiotherapy if the pain appears after a significant blow or fall, if you have a fever, if you have lost weight without explanation, if you have a history of cancer, or if the pain does not change at all with movement or rest. These situations are uncommon, but they have to be ruled out first. At the initial assessment I always go through them with you.

What you can expect: the real prognosis

A systematic review published in the BMJ on acute low back pain found that, on average, pain and disability fell by around 58% in the first month, and that improvement continued, more slowly, until roughly three months.

The same review shows something worth knowing from the start: it is common for another episode to appear during the following year. It does not mean you have got worse or that "it has slipped out again". That is why a good plan does not end the day the pain stops: it ends when you have the strength, confidence and tools to manage a flare-up on your own.

In sciatica the course is usually slower. In a study of patients treated without surgery, most (around 8 in 10) became free of leg pain, taking an average of about six months to get there. Tingling and loss of sensation usually take longer to recover than the pain.

Do you need an MRI?

In most cases, no. The NICE guideline on low back pain and sciatica recommends not requesting imaging routinely and reserving it for when the result would change treatment: suspicion of a serious cause or assessment for surgery.

The reason is simple: many people with no pain at all have bulges, "worn" discs or arthritis on their MRI. These are very common findings, especially with age, and they do not explain your pain on their own. An image out of context usually creates more fear than solutions.

What works according to clinical guidelines

The two references I follow are the NICE guideline (UK, revised July 2026) and the 2023 World Health Organization guideline on chronic low back pain. They agree on the essentials:

• Stay active. NICE recommends informing the patient and encouraging them to continue their normal activities. Prolonged bed rest is not part of the recommended treatment.
• Therapeutic exercise. It is the foundation of treatment in both guidelines. There is no such thing as "the exercise for back pain": the one that works is the one adapted to your case that progresses with you.
• Manual therapy as a complement. Mobilisation, manipulation or massage can help, but NICE recommends them only as part of a plan that includes exercise, never as the sole treatment.

And as for what not NICE does NOT recommend: belts and corsets, traction, insoles, ultrasound therapy, TENS or interferential currents. If you have had months of passive sessions without exercise, that may be part of the reason you are not progressing.

What about dry needling or neuromodulation?

I use them when there is a clear muscular component limiting movement, always in support of exercise. Let me be honest about the evidence: a 2023 systematic review concluded that dry needling can reduce pain and disability in the short term in low back pain, but that the evidence is of low quality and does not show long-term benefit on its own. That is why, at my clinic, dry needling opens a window to move better, and exercise is what consolidates the result.

How I treat low back pain at the clinic

1. Assessment. I rule out warning signs, understand what aggravates and relieves it, what your day-to-day is like and, if there is sciatica, I do a neurological examination (strength, sensation and reflexes).
2. Explanation. I tell you what I think is happening and what is not, without jargon and without alarmism. Understanding the problem reduces fear, and fear is one of the factors that most prolongs pain.
3. Treatment. Adapted exercise from the first session, accompanied by manual therapy or dry needling if your case calls for it.
4. Home plan. You leave with a few exercises, well explained, and clear criteria for knowing when to progress and when to hold back.
5. Follow-up. At the assessment I give you a realistic estimate of sessions. If after 3 or 4 sessions we see no changes, we rethink it or I refer you to the appropriate specialist.

Three things you can do today

• Walk. Short, frequent walks, within what you can tolerate. Moving a little several times a day usually feels better than one big isolated effort.
• Don't stay in bed. Resting for a while when you need to is fine; spending days lying down is not.
• Return to your activities gradually. Some pain when you move does not mean you are harming yourself. If an activity flares it up a lot, reduce it a little, but don't cut it out altogether.