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Back Pain & Sciatica
Back pain is rarely as simple as the last movement that hurt.
At Montefiore Clinic in Tel Aviv, we assess low-back pain, recurrent flare-ups, leg pain and sciatica by looking at the individual presentation rather than applying the same treatment protocol to everyone.
The aim is to understand what is making your system vulnerable, which findings are actually relevant to your symptoms, and what needs to change for normal movement and function to return.
Evgeny Dizik, MPT, DO — Physiotherapist & Osteopath
60-minute, one-to-one assessment and treatment.
When Back Pain Keeps Coming Back
Low-back pain often changes over time. A person may have months when the back hardly bothers them, followed by an acute flare-up. Another episode may include pain travelling into the buttock or leg, numbness, tingling or weakness.
The movement that starts a flare-up is not necessarily the whole reason the flare occurred.
Someone may bend to pick something up, lift a couch, sit for several hours or return to training and suddenly develop pain. The obvious conclusion is: “That movement injured my back.”
Sometimes it did. But often the situation is more complicated.
One way I explain this to patients is to imagine a warehouse with an increasing fire risk.
Different problems can accumulate over time: reduced physical capacity, a previous injury, altered movement, neurological irritation, poor recovery, loss of strength, inadequate sleep, high stress, or other health and lifestyle factors. The system continues to function, but with progressively less reserve.
Eventually something provides the final spark.
The clinical question is therefore not only:
“What did you do when the pain started?”
It is also:
“Why was your system unable to tolerate that demand at that particular moment?”
Treatment is not about making the body perfect or finding one magical cause. It is about identifying the relevant vulnerabilities, reducing those we can change, and rebuilding enough capacity that normal life no longer repeatedly pushes the system into a flare.
Back Pain and Sciatica Are Not the Same Thing
“Sciatica” is often used to describe almost any pain travelling from the back or buttock into the leg.
Clinically, that is not enough.
Leg pain may involve a lumbar nerve root or other neural tissue, but referred pain from non-neural structures can sometimes produce a similar experience. Even when the neural system is involved, the reason may differ considerably between patients.
A disc protrusion, narrowing around a nerve root, altered neural mobility, local mechanical irritation and other contributing factors can all form part of the picture.
This is why two people whose pain follows a very similar path down the leg may need quite different treatment.
At Montefiore Clinic, neurological assessment may include myotomal strength testing, neurodynamic testing such as the straight-leg raise, movement testing and additional sensory or reflex examination when indicated. Neural-mobilization techniques have evidence of benefit in lumbar radicular presentations, but no single test or technique explains every case.
Sciatica describes what the patient feels. It does not yet tell us why the neural system is symptomatic.
Symptoms We Commonly Assess
Patients come to us with many different combinations of symptoms, including:
Local or recurrent low-back pain; painful or restricted bending, rotation or loading; pain into the buttock or leg; numbness, tingling or altered sensation; weakness or loss of confidence in the leg; symptoms aggravated by sitting, standing, walking or running; repeated flare-ups after previous treatment; and back or leg symptoms associated with returning to sport, work or normal activity.
The presence of one of these symptoms does not automatically identify its cause. The examination is designed to determine which findings actually matter in that individual case.
What We Assess
Whenever possible, we begin with what I call an asterisk: a movement, position or activity that reliably reproduces the patient's complaint.
It might be bending forward. Sitting and standing again. Rotating. Squatting. Raising the leg. Loading one side. Sometimes there is no immediate asterisk because symptoms only appear after five kilometres of running or several hours at work; in that case, the real-world activity becomes our test.
We then examine possible contributors.
That can include posture and movement under load, lumbar and hip mechanics, neurological function, myotomal strength, neural mobility, muscular control, previous injuries, scars and the way different parts of the movement system interact.
When the history gives us a reason to look further, the assessment may also include breathing mechanics, diaphragm or pelvic-floor function, or relevant digestive, pelvic and other health factors. These are not automatically assumed to cause back pain. They are investigated only when the history and examination make them relevant, and medical assessment is sought where appropriate.
The important principle is:
An abnormal finding is not automatically a relevant finding.
If we suspect that a particular structure or function matters, we may support it, unload it, change its position or otherwise facilitate it, and then repeat the patient's asterisk.
If the movement becomes easier, the range improves or the pain decreases, that finding moves higher on our list of priorities.
If nothing changes, the hypothesis becomes less important and we look elsewhere.
An immediate improvement does not prove that we have discovered a single biological “cause.” It tells us that the finding may be clinically relevant and is worth testing further through treatment and functional follow-up.
Our Approach to Back Pain & Sciatica
Treatment follows the assessment.
I work primarily as a manual physiotherapist and osteopath, so hands-on treatment is an important part of the session. But there is no standard manipulation, mobilisation or exercise that every patient with back pain receives.
Depending on the findings, treatment may involve joint or soft-tissue techniques, osteopathic manual treatment, neurodynamic work, treatment of relevant scars, dry needling, pelvic-floor treatment when indicated, movement modification or other approaches.
The question is never simply:
“Which technique treats back pain?”
The better question is:
“What are we trying to change in this patient, and what is the safest and most useful way of changing it?”
If the patient is in an acute flare, we do not force painful examination procedures simply because they are part of a standard test battery. An acutely painful back can still be assessed and treated, but the examination and treatment dose are adapted to what the patient can tolerate.
The first goal may be to reduce the overall irritability enough that a more complete assessment becomes possible.
Manual treatment is also not the final destination. Once useful movement and muscular function are restored, exercise is used to strengthen and reinforce that improvement.
Current guidelines likewise support individualized care, exercise and self-management, with manual treatment as one possible component of a broader treatment approach.
Exercise: The Right Load, Not Simply More Movement
Movement matters. But “keep moving” does not mean every movement, at every dose, is appropriate for every patient.
Exercise should challenge the system without repeatedly provoking it.
A small amount of discomfort during rehabilitation is not automatically harmful. If the discomfort settles as the movement continues, does not progressively spread, and leaves the patient functioning well afterwards, the load may be appropriate.
If an exercise progressively increases pain, aggravates neurological symptoms, decreases function or repeatedly leaves the patient worse afterwards, we modify it.
That might mean changing the load, range, angle, position, speed or movement chain—or starting with a very small dose and progressing gradually.
Current evidence does not demonstrate that exercises performed with some pain are universally better or worse than pain-free exercise; the important issue is how the individual responds and progresses.
So the choice is not between “exercise through the pain” and “stop moving.”
It is about finding the amount and type of movement that the patient can successfully adapt to.
Persistent Pain Is Not Always a Simple Structural Problem
When pain has continued for months or years, the nervous system itself can become more sensitive.
Sleep, repeated flare-ups, reduced activity, stress, fear of movement, unsuccessful treatment and repeated painful loading can all change the environment in which the patient experiences and responds to pain.
But identifying sensitization does not mean that the pain is imaginary, psychological, or that the search for modifiable physical contributors should stop.
In a highly sensitive presentation, treatment simply has to respect the system's current tolerance.
We may begin with very small movements or loads, use non-threatening patterns, work away from the most irritable region and gradually increase what the patient can do.
An important part of recovery is giving the patient back control.
Understanding which movements are tolerable, how to modify an aggravating task, how to exercise successfully and how to manage sleep, activity and everyday habits can substantially change the patient's relationship with the condition.
The goal is not for life to revolve around avoiding pain.
The goal is to restore enough capacity that the patient can return to work, family, sport, hobbies and whatever else makes their life worth getting back to.
When Further Medical Assessment May Be Needed
Physiotherapy and osteopathy are not appropriate substitutes for medical investigation when the clinical picture suggests serious or progressive disease.
New or rapidly progressing neurological weakness, new bladder or bowel dysfunction, new sexual dysfunction associated with severe radiating back pain, or new numbness around the perineal or “saddle” area require urgent medical assessment for conditions such as cauda equina syndrome.
Significant trauma, unexplained deterioration, systemic symptoms or a clinical course that does not behave as expected may also require imaging or medical referral.
This is also part of treatment.
If the patient is not progressing the way the working diagnosis predicts—or is becoming worse—we stop, reassess the hypothesis and involve the appropriate medical professional rather than repeatedly performing the same treatment.
When Is Treatment Finished?
The absence of pain during one session is encouraging, but it is not our only definition of recovery.
We want the relevant neurological and muscular function to improve, neural movement to normalize as far as clinically appropriate, the patient to tolerate the activities that previously caused problems, and the important functional findings to remain stable.
The patient should also know what to do independently: which exercises to continue, how to progress activity, what habits matter in their particular case, and how to respond if symptoms begin to return.
The goal is not simply to make the patient feel better on the treatment table.
It is to restore enough function, capacity and self-management that the patient no longer needs treatment.
About Your Practitioner
Evgeny Dizik, MPT, DO
Physiotherapist & Osteopath
Treatment at Montefiore Clinic combines detailed orthopedic and neurological assessment with physiotherapy, osteopathic manual treatment and individualized rehabilitation.
Sessions are 60 minutes, one-to-one, allowing time to examine the problem, treat what appears clinically relevant, retest the response and adjust the plan accordingly.
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