Journal of Physiotherapy 66 (2020) 83–88

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / j p hy s

Invited Topical Review

Physiotherapy management of sciatica

Raymond WJG Ostelo a,b
a
Department of Health Sciences, Faculty of Science, Vrije University Amsterdam; b Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam,
Amsterdam Movement Sciences Research Institute, the Netherlands

K E Y W O R D S

Physical therapy [Ostelo RWJG (2020) Physiotherapy management of sciatica. Journal of Physiotherapy 66:83–88]
Low back pain © 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under
Sciatica
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Radiculopathy

Introduction Diagnosis

A relationship between pathology of the lumbar spine and leg
pain was already suspected by the ancient Greeks and Egyptians.
Hippocrates was allegedly the first to use the term sciatica, from the
Greek word for hip ‘ischios’.1 Although sciatica is a commonly used
term, it may also cause confusion because it has been used to describe
any type of back or leg pain.2 But in most cases, and also in this paper,
sciatica is used to describe pain that radiates downwards from the
buttock along the course of the lumbosacral nerve roots.3 An alter-
native term for sciatica that is often used is lumbar radiculopathy.4,5
The prevalence and incidence of sciatica, as reported in the literature,
vary widely. Important reasons for that variation, among others, are
differences in definitions and methods of data collection. Cherkin
estimated the incidence to be 5 per 1000 in Western countries.6 In
the Netherlands, there were 117,200 new cases of sciatica in 2017.7 In
a recently published Danish study, the prevalence of sciatica among
patients with low back pain in the primary care setting ranged from 2
to 11% in chiropractic clinics and general practices, respectively.8
Although the economic burden of low back pain is enormous,9 the
economic burden of sciatica has not been studied as extensively. In
the Netherlands, it has been estimated that the direct and indirect
costs of patients suffering from sciatica approximate V1.2 billion per
year.10 In the United Kingdom it has been suggested that the
healthcare costs are £500 million and £3.8 billion in indirect costs.11
What is sciatica?
In most cases sciatica is caused by a herniated lumbar disc where
the nerve root is compressed by disc material that has ruptured
through its surrounding annulus.12 Rarer causes include spondylo-
listhesis, lumbar stenosis, foraminal stenosis and malignancy. The
common denominator of all these causes is the fact that the lumbar
nerve root is compressed, which may result in inflammation.12,13
Evidence suggests that it is not so much the pressure on the nerve
root that causes sciatica, but a combination of pressure-related, in-
flammatory and immunological processes.14
The diagnostic procedures are mainly based on the patient’s
symptoms (history taking) and the findings on physical examination.
As there is no single symptom reported during history taking or
result on a physical test that has a sensitivity or specificity large enough
to definitively diagnose sciatica, clinical guidelines recommend a
combination of history taking and physical tests in order to arrive at a
conclusion.4,5 Signs and symptoms that are indicative of sciatica and
should be addressed during history taking are: the dominance of leg
pain (more than back pain); the location of the leg pain (ie, to assess
whether it radiates down below the knee and whether it aligns with one
or more dermatomes); paraesthesia and/or sensory loss (roughly) in
line with the dermatomes of the affected spinal root (Figure 1); weak-
ness and/or reflex changes in a myotomal distribution; and an increase
in leg pain with coughing, sneezing and/or taking a deep breath.
The likelihood that sciatica is present is further increased if there
is no sudden onset but a gradual increase in complaints,4 although
sometimes the complaints can occur rapidly and be intense and
constant. A number of physical tests have a small added diagnostic
value: loss of muscle strength, particularly loss of dorsiflexion of the
foot when L5 is affected (often this loss is too subtle to cause foot
drop); increased finger-floor distance (. 25 cm); absence of tendon
reflexes; and a straight leg raise test (in particular, a negative test is
informative because it indicates decreased likelihood of sciatica); and
a positive crossed straight leg raise test (increased likelihood of
sciatica).4,15,16 When several signs, symptoms and physical tests are
all positive, a diagnosis of sciatica is considered to be more likely,
especially when the results of the history taking and physical tests
can be attributed to one nerve root.4 In the diagnostic process, it is
also very important to exclude serious underlying pathology such as
trauma, cancer or serious infections. In case of saddle anaesthesia,
disturbances of the bladder, loss of tone in the anal sphincter and
decreased sexual function, a cauda equina syndrome17 may be pre-
sent and patients should be referred for immediate medical attention.
The routine use of imaging in patients with sciatica as a further
diagnostic procedure is not recommended in the clinical

https://doi.org/10.1016/j.jphys.2020.03.005
1836-9553/© 2020 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
84 Ostelo: Physiotherapy management of sciatica

L3 inconsistent but mainly negative results regarding the prognostic

value of baseline pain severity, neurological deficit, nerve root tension
L4 signs, duration of symptoms, and radiological findings.22
L5
T10
T11 S1 S3 Conservative management
S4
T12 The first line of care for patients with sciatica is conservative,
S5
including information about sciatica and the role of imaging, and
S2 L1 C advice to stay active.4,5
L5 S2
S3
Information
L2
L1 Information to the patient should include an explanation of the
nature and prognosis of sciatica. Additionally, it should be discussed
with the patient that imaging is not recommended unless there are
good reasons to do so (eg, suspicion of cauda equina syndrome or
S2 fracture).4,5 This is an important topic to discuss because imaging
L3 L2 tests are often performed in order to reassure the patient or because
the patient expects that imaging should be done. One reason to
advise against routine imaging is that no clear role has yet been
established for imaging in determining either the conservative
management or prognosis. A telling illustration is described in the
study by Herzog et al.23 A 63-year-old woman with a history of low
back pain and right L5 radicular symptoms was sent to 10 different
S2 regional imaging centres within a 3-week period. All study centres
S1 had valid accreditation from the American College of Radiology,
including the spine magnetic resonance imaging (MRI) module, and
L3
L4 each participating centre was blinded to participation in the study
and evaluated the subject as a routine patient. No single interpretive
L5 finding was reported unanimously by the radiologist at all centres
and one-third of all reported findings appeared only once across all
10 imaging reports. The authors concluded that this indicates that
L4 there is at best a substantial difference in the standards employed by
radiologists when deciding what to include in diagnostic reports, and
at worst high prevalence of interpretive errors.23 A systematic review
S2 of 14 high-quality case-control studies (involving . 3000 participants
in total) demonstrated that although MRI evidence of disc bulge, disc
S2 S1 L4 degeneration, disc extrusions, disc protrusions, Modic 1 changes, and
S1
spondylolysis were significantly associated with back pain, the cau-
L5 sality of these findings was unclear.24 Furthermore, spontaneous
regression of lumbar disc herniation is likely to occur.25
Another reason to advise against routine imaging is that imaging
Figure 1. Dermatomes of the lower limb.
might have a negative psychological impact on patients. A rando-
mised trial assessed the effect of knowledge of diagnostic findings on
clinical outcome in patients with acute low back pain and/or radi-
guidelines.4,5 This is in line with the recommendation for non-specific
culopathy.26 A total of 246 participants (39% of whom had radicul-
low back pain, where international guidelines also recommend not
opathy) were randomised to the ‘blinded’ treatment arm (both
using routine imaging for patients with non-specific low back pain for
patient and physician were blinded to MRI results) or the ‘unblinded’
identifying specific causes of low back pain.18 Despite the guidelines,
treatment arm (MRI results provided within 48 hours). There were no
patients have often undergone an imaging procedure and brought the
differences between ‘blinded’ and ‘unblinded’ participants on the
results to their physiotherapy consultation. It is prudent to at least
primary clinical outcomes (disability, pain and number of sick days).
check whether the symptoms are concordant with the imaging
However, participants in the ‘blinded’ treatment arm showed more
findings.
improvement in general health (subscale of the Short Form 36 quality
of life questionnaire) compared with those who were ‘unblinded’.26
Prognosis
Advice to stay active
Although the general consensus is that the prognosis is usually
favourable because most cases of sciatica are self-limiting with pain For people with complaints of , 6 to 8 weeks, advice to stay active
decreasing over time,19 the evidence is less straightforward. The is considered to be an important element of conservative manage-
course of sciatica in primary care is often not studied in isolation, as ment. Clinical guidelines recommend the provision of ‘encourage-
most studies of low back pain include patients with and without leg ment to stay physically active’. Moreover, bed rest is not
symptoms/sciatica.20 A recently published UK-based study of patients recommended.4,5 A systematic review that compared ‘advice to stay
seeking primary care for back-related leg pain, including sciatica, of active’ with ‘structured exercises’ concluded that there is low-quality
any duration and severity, showed that only 55% of the patients with evidence according to the Grading of Recommendations, Assessment,
sciatica met the criterion for improvement in disability (ie,  30% Development and Evaluations (GRADE) framework that exercise
reduction in disability 1 year later).21 Because all of these studies provides small, superior effects compared with advice to stay active
included some type of (conservative) treatment the real (untreated) on leg pain in the short term.27 This was based on a meta-analysis
prognosis is, as yet, unknown. A review that assessed prognostic that included five randomised trials, demonstrating that there was
variables in patients with sciatica seeking conservative care found an 11-point difference (95% CI 1 to 22) on the 0 to 100 pain score
 Invited Topical Review 85

(Figure 2; for a detailed forest plot, see Figure 3 on the eAddenda). WMD (95% CI)
The exercise interventions studied in the trials included in that sys- Study Random
tematic review ranged from 4 to 8 weeks in duration and included
various types of exercise regimens (eg, specific postural instruction, Albert (2012) 51
static and dynamic lumbar stabilising exercises, motor control exer-
cises, muscle strengthening exercises, and directional preference Bakhtiary (2005) 52
exercises). However, there was no difference in short-term
disability.27 Moreover, moderate-quality evidence (according to Hofstee (2002) 53
GRADE) showed similar results between advice to stay active and
exercise for leg pain (MD 23, 95% CI 29 to 3) and disability (MD 22, Huber (2011) 54
95% CI 28 to 5) on the 0 to 100 scale in the long term. Overall, it could
be concluded that both approaches might be equally beneficial but Luijsterberg (2008) 55
exercises could be considered if leg pain is the dominant symptom.
Pooled
Exercise therapy

Recommendations regarding exercise therapy vary among the –40 –20 0 20 40

clinical guidelines because the evidence is inconclusive. The Danish
multidisciplinary guidelines recommend considering supervised ex- Favours advice Favours exercise
ercises as an addition to usual care.5 Supervised exercise therapy
includes directional exercises, motor control exercise, nerve mobi- Figure 2. Weighted mean difference (95% CI) of the effect of advice to stay active
compared with structured exercise on leg pain on the 0 to 100 visual analogue scale in
lisation, or strength exercises. But no specific recommendation for a
the short term.27,51–55
specific type of exercise treatment was made.5 For clinical practice,
that means that the type of exercise should be aligned with the
specific complaints and wishes of the patient and the specific training guidelines for general practitioners recommends that people with
of the physiotherapist. In contrast, the Dutch guidelines for general sciatica should not be referred for SMT in addition to general prac-
practitioners,4 which specifically focus on sciatica in the primary care titioner care because the evidence was considered to be too indirect.4
setting, recommend exercise therapy when patients have complaints There is ongoing debate about adverse events due to SMT. Based on a
for . 6 to 8 weeks and these complaints have not considerably recently published systematic review that included data on 9211
improved over this period. Another indication for exercise therapy is participants in 47 randomised trials (23 of which reported on adverse
when patients need more intensive supervision in their exercises events), it was concluded that the majority of the observed adverse
because their required level of physical functioning in daily life re- events were musculoskeletal, transient in nature, and of mild to
quires a more intensive exercise program and/or supervision. A final moderate severity.28 Although this systematic review included
indication for exercise therapy is when a patient has high levels of studies with chronic low back pain with or without referred pain into
kinesiophobia.4 the leg, it is unlikely that the results for sciatica would be substan-
tially different.
Spinal manual therapy
Medication
Physiotherapists and manual therapists often offer spinal manual
therapy (SMT) to their patients. The term SMT is used to describe a
Patients might take medication for their pain and might ask their
variety of techniques that encompass any manual technique that
physiotherapist about this. Therefore, it is advisable that physio-
moves one or more joints within normal ranges of motion with the
therapists have knowledge about the evidence regarding medication.
aim of improving spinal joint motion or function.5 A distinction is
In a systematic review, 23 randomised trials were included to assess
often made between mobilisation techniques and manipulation
the effectiveness of various types of medication for sciatica: non-
techniques.28 Mobilisation includes low-grade velocity, small or large
steroidal anti-inflammatory drugs, corticosteroids, antidepressants,
amplitude passive movement techniques within the patient’s range
anticonvulsants, muscle relaxants, and opioid analgesics. This review
of motion and control. Manipulation consists of a high-velocity im-
showed that in most of the pooled estimates, medication was not
pulse or thrust applied to a synovial joint over a short amplitude at or
substantially more effective than placebo or the difference in effect
near the end of the passive or physiological range of motion. In
was uncertain because the available data only permitted imprecise
general, the effects of SMT are small and short-term only. To illustrate,
the recently published Danish guideline was able to identify three
randomised trials that assessed the added value of SMT when added WMD (95% CI)
to usual care.5 The included populations were heterogonous (people Study Random
with disc protrusion but intact annulus verified by MRI; people with
radiating leg pain of mixed duration (mean 24 months) with or Bronfort (2014) 56
without neurological symptoms; and people with or without radi-
ating leg pain of mixed duration). Also, the interventions varied be- Paatelma (2008) 57
tween studies (manipulation versus a combination of manipulation,
mobilisation and muscle stretching techniques). The pooled mean
Santilli (2006) 58
difference was 21.07 (95% CI from 22.00 to 20.14) in favour of Pooled
manipulation on back pain (0 to 10 numerical rating scale) at the 12-
week follow up (Figure 4; for a detailed forest plot, see Figure 5 on the
eAddenda).5
–3.0 –1.5 0 1.5 3.0
This evidence was labelled as indirect evidence, but because of
this small and statistically significant effect, the recommendation is
Favours spinal manual Favours usual care
that physiotherapists or manual therapists could consider offering
therapy and usual care
SMT to patients with recent-onset sciatica in addition to usual
treatment.5 However, as the evidence is not very convincing, differ- Figure 4. Weighted mean difference (95% CI) of the effect of adding spinal manual
ences in recommendations between guidelines can be observed. In therapy to usual care on pain at 12 weeks to stay active compared with structured
contrast to the Danish multidisciplinary guideline, the Dutch exercise on leg pain on the 0 to 10 numerical rating scale at 12 weeks.5,56–58
86 Ostelo: Physiotherapy management of sciatica
estimates.29 In acute sciatica, corticosteroids improved pain in the
short term (MD 212 on a 0 to 100 scale, 95% CI 221 to 23) based on
moderate-quality evidence (according to GRADE). Some of the indi-
vidual trials in acute sciatica estimated a small benefit from non-
steroidal anti-inflammatory drugs; however, this evidence was low
quality (according to GRADE). Overall the quality of the evidence was
low (according to GRADE), so it is unclear which pain medication is
most effective for treating people with sciatica. Moreover, medica-
tions used for the treatment of sciatica can have considerable side
effects.30 As a consequence, the Dutch GP guideline only cautiously
recommended the use of pain medication, mainly for patients with
severe pain.4 The Danish guideline did not include any recommen-
dations regarding pain medication for sciatica because this was
outside its scope.5 Recently, a systematic review of 27 studies
assessed whether combining medicines gives greater pain relief. For
most combinations, there were no or only small effects on pain and
disability, and these results were only supported by low-quality
evidence.31
Surgical management
If complaints persist and no relevant improvement occurs despite
conservative treatment, guidelines recommend referral to a spine
surgeon to evaluate if there is an indication for lumbar surgery.4,5 The
surgeon carefully assesses the correspondence between the clinical
findings and the findings on imaging in order to select patients who
may benefit from surgery. The fact that patients should be carefully
selected for surgery is also supported by a recently published sys-
tematic review that assessed if surgery was more effective compared
to non-surgical treatment.32 Seven randomised trials involving 1158
participants were included. The results show that surgery had a
modest effect: 6 to 26 points greater pain reduction than nonsurgical
interventions as measured on a 0 to 100 visual analogue scale of pain
at up to 26 weeks follow-up, although the between-group difference
did not persist to one year. For physical functioning there were only
small between-group differences. Furthermore, the incidence of
reoperations ranged from 0 to 10%.
Postoperative physiotherapy
Recovery rates after conventional microdiscectomy were found to
be 66% at 4 weeks and 75% at 8 weeks33 and the return to work rate
was 15% at 2 months.34 At 2 years, 71% of patients who underwent
tubular discectomy and 77% who underwent conventional micro-
discectomy reported good recovery. A systematic review of 39 cohort
studies (13,883 participants with sciatica) reported that patients still
have moderate levels of pain and disability at the 5-year follow-up:
the mean pain score on a 0 to 100 scale was 21 (95% CI 13 to 30)
and the mean disability score was 13 (95% CI 11 to 16).35 Post-
operative management aims to speed up return to daily activities
and/or work and prevent the development of chronic symptoms;
however, the exact content of this postoperative management varies.
Early postoperative management: One important difference between
various postoperative programs is their starting point. A randomised
trial assessed whether referral for early rehabilitation (starting
immediately after lumbar disc surgery) is effective and cost-effective
compared with no referral.36 During hospitalisation (usually 1 to 2
days), all patients received usual postoperative care (ie, during one or
two sessions a physiotherapist or nurse provided advice and in-
structions for transfers and activities of daily living, and patients
received a booklet providing advice (mainly regarding activities of
daily living) and suggestions for exercises focusing on muscle
strengthening, core stability and mobilisation). Patients in the
experimental group were referred for early rehabilitation in primary
care starting the first week after discharge. Over 6 to 8 weeks the
physiotherapist aimed to gradually increase the intensity of the ex-
ercises and the activities that were important to the patient. The
control group received no referral. The results showed no clinically
important overall mean differences between early rehabilitation and
the no-referral control group for any of the main outcomes (global
perceived recovery, physical functioning or pain). To summarise: the
evidence suggests that early rehabilitation has no added value in
comparison with no treatment.
Postoperative management starting 4 to 6 weeks after surgery: A sys-
tematic review that assessed effectiveness of rehabilitation after
lumbar disc surgery included 22 randomised trials involving 2503
participants.37 The programs in the included studies were rather
heterogeneous and consequently there was one trial for most pro-
grams. Looking at programs that start 4 to 6 weeks after surgery, no
differences were observed when various types of rehabilitation (ie,
multidisciplinary programs, behavioural graded activity, strength and
stretching programs) were compared with some other form of exer-
cise. These results come with uncertainty because they were drawn
from low-quality to very-low-quality evidence, so a strong recom-
mendation for one type of rehabilitation program was not possible.
In the same systematic review,37 when physiotherapy was
compared with no treatment or education only, the results showed
that physiotherapy was associated with better outcomes for pain and
physical functioning immediately after treatment. Very low-quality
evidence (five trials, 272 participants) showed that exercises were
more effective than no treatment for pain at short-term follow-up
(SMD 20.90, 95% CI 21.55 to 20.24), and low-quality evidence (four
trials, six comparisons and 252 participants) suggested that exercises
were more effective for functional status on short-term follow-up
(SMD 20.67, 95% CI 21.22 to 20.12), although the estimated effect on
functional status from three trials (226 participants) was unclear on
long-term follow-up (SMD 20.22, 95% CI 20.49 to 0.04). The results
for functional status are presented in Figure 6. (For a detailed forest
plot, see Figure 7 on the eAddenda.37) An interesting observation was
that one trial showed that a multidisciplinary rehabilitation program,
specifically focused on return to work and coordinated by a medical
advisor, led to faster return to work than usual care.37
Future directions for research and practice
Sciatica is considered to have different pathogenic components. It
has been hypothesised that inflammation may play an aetiological
role. Various inflammatory proteins have been identified in patients
with sciatica (eg, interleukin (IL)-1b, IL-6, IL-8 and tumour necrosis
factor-a) but the pathogenic mechanisms that initiate these processes
in vivo are not well understood.38 A systematic review that aimed to
assess the association between the level of inflammatory activity and
clinical symptoms concluded that the clinical heterogeneity in the
SMD (95% CI)
Study Random
Erdogomus (2007) 59
Filiz (2005) 60
Filiz (2005) 60
McGregor (2011) 61
Yilmaz (2003) 62
Yilmaz (2003) 62
Pooled
–4 –2 0 2 4
Favours exercise Favours control
Figure 6. Standardised mean difference (95% CI) of the effect of exercise commencing 4
to 6 weeks after surgery for lumbar disc herniation, compared with no treatment or
education only, on functional status at the post-treatment follow-up.40,59–62
 Invited Topical Review
studies was too substantial to draw any firm conclusions.39 An
important question to be answered is to what extent inflammation
plays a role in sciatica and if there is a certain stage in the course of
(developing) sciatica at which this mechanism may be more promi-
nent. The ultimate aim would be to explore whether inflammatory
biomarkers could be used in predicting the clinical course of sciatica
and to identify subsets of patients that respond best to anti-
inflammatory treatment or surgery.
A related direction for future research concerns the classification
of patients with sciatica. As already mentioned, sciatica is a symptom
rather than a specific diagnosis. Leg pain is the common denomi-
nator, but the leg pain could be due to spinal nerve root involvement
or be referred (non-specific) pain due to back pain that spreads down
the leg from structures such as ligament, joint or disc but not
involving a spinal nerve root.40 In a recently published systematic
review aiming to identify classification systems for sciatica, 22 clas-
sification systems were identified.41 The definitions and diagnostic
criteria for ‘leg pain’ varied widely among these classification sys-
tems. A previous overview aimed to assess the consistency of ter-
minology used to describe sciatica in randomised trials; it concluded
that the terminology was used inconsistently.42 Moreover, they found
that the terms used to define leg pain in a given trial did not
correspond with the eligibility criteria used in that trial.42 There is
therefore an urgent need to reach consensus on definitions for leg
(and back) pain in a unambiguous manner so that the current
confusion regarding descriptors for radiating leg pain can be over-
come. The fact that there is so much confusion in the use of termi-
nology also reflects the gap in knowledge regarding mechanisms that
may cause this radiating pain. One of the big challenges in this field is
how to integrate clinical findings, results from physical tests, and
biomarkers into one classification system, with a specific focus on
primary care, where the majority of sciatica patients are screened
and treated.
As the effects of exercise therapy are generally rather small, an
important question is how to optimise the treatment. One potential
avenue to optimise treatment effects of exercise programs, including
home exercises, is to improve treatment adherence. However, exer-
cising happens to be the most common behaviour patients with pain
fail to adhere to.43 Non-adherence to home exercises is a well
established problem,44 as is non-adherence to advice regarding life-
style and physical activity.45 A qualitative study aimed to elicit the
experiences of people who underwent lumbar discectomy with per-
forming home exercises and following advice, and which factors
played a role in adherence to these exercises and advice.46 The main
factors that influenced adherence to exercise programs and advice
regarding daily activities differed widely between patients and
included: the perceived impact of surgery; recovery and treatment
expectations; and the type of patient and therapist involvement in
the rehabilitation process. Taking these factors into account enables
physiotherapists to tailor the exercise program to the specific char-
acteristics and needs of the patient. Future research in this field
should focus on how physiotherapists can elicit patient preference
and what practical skills physiotherapists need to incorporate these
preferences into patient-centred exercise programs. The role of
‘blended behaviour change interventions’, which combine therapeu-
tic guidance with online care, should be further explored.47
Finally, it is important to develop methods and approaches that
facilitate the implementation of clinical guidelines into daily practice.
There are many published guidelines on back pain and sciatica, and
there are many challenges when attempting to use these guidelines
in clinical practice.48 For the optimal use of guidelines in clinical
practice, mere distribution of the guideline and information materials
among healthcare professionals is not enough and active imple-
mentation is a necessity.49 Multifaceted or multicomponent ap-
proaches to implementation have been suggested to be the most
effective in successfully implementing guidelines and thus changing
practice.49 However, a recently published systematic review that
included nine individual studies, including three cost-effectiveness
analyses, showed that there were no differences in effect between
multifaceted strategies and control implementation of back and neck
87
pain guidelines.50 More research into how to optimise the uptake of
evidence in clinical practice is warranted.
eAddenda: Figures 3, 5 and 7 can be found online at https://doi.
org/10.1016/j.jphys.2020.03.005.
Ethics approval: Nil.
Competing interests: Nil.
Source of support: Nil.
Acknowledgements: Nil.
Provenance: Invited. Peer reviewed.
Correspondence: Raymond W J G Ostelo, Department of Health
Sciences, Faculty of Science, Vrije University Amsterdam, the
Netherlands. Email: r.ostelo@vu.nl
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