Massage and Sciatica: An In-Depth Study - PDF Document

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  1. Chapter 4: Massage and Sciatica: An In-Depth Study 2 CE Hours By: Kerry Davis, LMT, CIMT, CPT Learning objectives Š Š Š Š Š Š Overview Š Š Š Š Define the characteristics of sciatica. Recognize the causes of sciatica. Compare sciatica with other conditions of the low back. Distinguish the muscle imbalance patterns attributing to sciatica. Understand the pattern of referred pain resulting from sciatica. Illustrate application of massage techniques to treat the client. Discuss how to construct a treatment plan. Discuss how to assess the client’s posture and gait. Describe the evaluation of the client’s pain patterns and symptoms. Demonstrate practice of test assessments to rule out other conditions of the low back. Low back pain affects more than three million people in the United States each year (Werner, 2002). According to a 2010 survey, low back pain was listed as the third most oppressive condition afflicting people. Low back pain does not discriminate between men and women and usually presents as early as the age of thirty; in fact, the prevalence increases in correlation with age (National Institute of Neurological Disorders and Stroke, 2015). It is likely that massage therapists will encounter multiple cases during the course of their practice due to the impact that low back pain has on society. This course will educate the massage therapist about how to identify sciatica. It will also familiarize the therapist with the most common causes of sciatica, discuss differences between sciatica from piriformis syndrome and sacroiliac joint dysfunctions, examine the proper evaluation of the condition, as well as develop the treatment protocols for sciatica. UNDERSTANDING SCIATICA Sciatica, or lumbar radiculopathy, is characterized as an inflammation of the sciatic nerve - causing pain in the low back, buttocks, hip, and posterior leg regions (Lowe, 1997). The symptoms are a result of compression of the sciatic nerve. “Sciatica” is often used as an umbrella term for any pain experienced in the low back; however, the pattern of pain that distinguishes sciatica from other low back conditions is a unilateral (one side) pain that originates from the low back, travels down the leg and - depending on severity - to the foot. Sciatica presents as a radiating, burning pain. It also is described as shooting pain with mild soreness, numbness in the leg, and/or tingling in the feet and toes. The degree of compression upon the nerve determines the range of symptoms that are experienced. In all cases, these symptoms can become aggravated during prolonged sitting, coughing, or bending (Werner, 2002). According to a clinical review, approximately 5-10 percent of patients with low back pain suffer from sciatica. It is the second most common reason for physician visits, the fifth most common reason for hospitalization, and the third most common cause for surgery (National Institute of Neurological Disorders and Stroke, 2015). Risk factors for sciatica Overweight Excess weight gain or quickly gaining weight translates to weak abdominal muscles and undue stress to the lumbar vertebrae. Sitting for long periods of time at a desk, especially with poor back support, is a factor for low back pain. Vibrations from a car - along with prolonged sitting - also contribute to the condition. Other occupational factors are jobs that require frequent heavy lifting. A risk factor is anything that increases the probability of developing a disease or injury. There are several components that place a person at risk for sciatica. Table 1 was compiled by the National Institute of Neurological Disorders and Stroke and identifies some of the risk factors for sciatica. Occupational Table 1: Risk factors for sciatica. Condition Age Description As people age, muscles lose elasticity, intervertebral discs lose flexibility, and bone density decreases. A lack of strengthening the abdominals and other muscles that support the spine leads to low back pain over time. “Weekend Warriors” (those who are sedentary throughout the week and engage in rigorous exercise on the weekend) are also at risk for low back pain. Pelvic adjustment for childbirth and excess anterior weight loading strains the lower back, which may result in sciatica that is generally resolved postpartum. There are several other conditions that create a predisposition to sciatica as shown in Table 2. Fitness level Table 2: Other risk factors for sciatica. Condition Postural deviations Description Janda’s Lower cross syndrome and scoliosis greatly increase the probability of nerve entrapment (The Janda Approach, 2016). Better known as osteoporosis of the spine, this degenerative condition progresses to create possible bone spurs, and involves muscle weakness (Werner, 2002). Pregnancy Spondylosis Massage.EliteCME.com Page 46

  2. Spondylolysis Disc herniation This condition involves the lumbar vertebrae - specifically L5 - and is marked by a defect resulting in an altered ability to bear weight (Litao, 2015). Involving the lumbosacral area, this disorder occurs when one vertebrae becomes anteriorly displaced over the vertebrae below (Werner, 2002). This condition transpires when the intervertebral disc becomes compressed, causing some of the jelly-like fluid to slip out (Werner, 2002). Spondylolisthesis Due to the various risk factors for sciatica, a thorough examination of the client’s medical history is essential in identifying which factors are contributing and which factors can be eliminated. This process will aid in a more proficient treatment plan. Signs and symptoms of sciatica Sciatica presents with various signs and symptoms - the severity of which depend on the cause. According to Physio Pedia (2016), pain in the buttocks is the main symptom. Pain caused by nerve entrapment is described as mild, sharp, or radiating; entrapment of the sciatic nerve will also cause these symptoms. The course of this pain begins in the gluteal region and refers down the leg - constantly or intermittently - depending on the cause for entrapment. 4. Referred pain directly correlates to the severity of the injury. In accordance with the above guidelines, sciatica symptoms depend on where the nerve is compressed. The following list, provided by Physio Pedia (2016), details the location of sciatic nerve entrapment and its corresponding symptoms: ● L4: Compression of the nerve at the L4 vertebrae results in pain, tingling, and numbness in the thigh of the affected side, and extends down to the big toe. ● L5: Compression at the L5 vertebrae will present as pain, tingling, and numbness traveling down to the top and inner portion of the foot and toes on the affected side. ● S1: Compression of the nerve at the S1 level will present as pain, tingling, and numbness traveling down the lateral portion of the leg and foot, including the outer half of the bottom of the foot. What is referred pain? Referred pain is defined as “pain felt in an area outside the location of the injury” (Werner, 2002). There are four basic guidelines inherent with referred pain. Dr. Ben Benjamin, the founder of the Muscular Therapy Institute in Cambridge, Massachusetts, classified these guidelines as: 1. Referred pain is always referred distally (from the axial skeleton towards the appendicular skeleton). 2. Referred pain is unilateral. If there is complaint of pain on both sides then the injury is present bilaterally (both sides). 3. Referred pain occurs within a pattern-able dermatome. A dermatome is the area of the body innervated by a single spinal root. For example, the sciatic nerve dermatome includes the buttocks and hamstrings. Since the sciatic nerve innervates several structures of the lower body, other symptoms include: impaired reflexes, burning sensation, limping on the affected side, and muscle weakness of the affected side. As stated previously, a thorough examination is imperative to create a treatment plan. Anatomy, physiology, and kinesiology of the low back The low back When discussing the low back, the lumbar spine and sacrum are generally referenced as one unit; however, these structures are indeed separate. The supraspinous ligament connects the spinous process (the posterior bony landmark of the vertebral body) of one vertebra to another. The interspinous ligament connects the spinous process from the bottom of one vertebral body to the top of another, or from the root to the apex. The supraspinous and interspinous ligaments work together to hinder excessive spinal flexion (Kishner, 2015). The lumbar spine is comprised of five vertebrae: L1, L2, L3, L4 and L5. The vertebrae are stocky in nature and are designed to support the head and thorax, yet offer considerable flexibility for flexion, extension, rotation, and lateral flexion (Stone & Stone 2003). Together, they create a lordotic curve - or convex anteriorly, and concave posteriorly. The normal curvature range for the lumbar spine is 40-60 degrees (Biel, 2001). The iliolumbar ligaments connect the transverse processes (bony protrusions to the left and right of the vertebral body) of the L4 and L5 vertebrae to the iliac crest (hip). This ligament acts to secure the sacroiliac joint (Kishner, 2015). Nerves The sciatic nerve is the largest nerve in the body and innervates all the muscles of the lower body. It is a combination of nerves emerging from the fourth lumbar vertebra down through S3 of the sacrum. This connected group of nerves is called the lumbosacral plexus. From S3, the sciatic nerve then passes through the gluteal region to the posterior thigh. It then branches off into two segments at the popliteal region (Biel, 2001). Distal to the L5 vertebra lays the sacrum. The sacrum is a triangular bone that consists of four to five vertebrae fused together that are also situated between the iliac bones of the hip and form the sacroiliac joint. Aside from linking the spine to the hips, the sacrum also acts to transfer weight to the pelvis and legs from the upper body. The sacrum forms a kyphotic curve, or concaves anteriorly, and is convex posteriorly (Biel, 2001). Ligaments Ligaments are dense connective tissue that link two bones together at a joint. Their primary function is to provide joint stability and to prevent movement that might cause damage. An important characteristic of ligaments is their limited ability to stretch. As a result, a ligament will not return to its original length if overstretched, and thus are more likely to tear (Werner, 2002). Should overstretching occur, additional movement of the bones develops and may result in a pattern of re- injury (Werner, 2002). The most frequently sprained ligaments that influence low back pain are: the supraspinous between L4-L5 and L5-S1, the interspinous between L4-L5 and L5-S1, and the iliolumbar (Benjamin, 2015). Muscles There are five muscles that have a major effect on the lumbar spine and/or the sacroiliac joint: the iliopsoas, the quadratus lumborum, the gluteus maximus (along with gluteus medius), and the piriformis (Neumann, 2010). Iliopsoas is a powerful hip flexor. It extends from the anterior surface of the lumbar vertebrae and ilium, deep into the abdominal contents which attach to the lesser trochanter of the femur. The lesser trochanter is the site of attachment of two muscles: the psoas and iliacus. The psoas muscle originates from the body and transverse processes of all lumber vertebrae, in addition to the twelfth thoracic. It also originates Massage.EliteCME.com Page 47

  3. from the intervertebral discs above each vertebra. The psoas muscle then passes under the inguinal ligament (the connecting ligament between the pubic tubercle of the pubis and the anterior superior iliac spine [ASIS] of the ilium) and inserts into the lesser trochanter of the femur. sacrotuberous ligament (which connects the sacrum and coccyx to the ischium at the ischial tuberosity), sacroiliac ligament, and the erector spinae aponeurosis (the common attachment point for the erector spinae muscles on the sacrum). It extends to the iliotibial band (IT band) and to the gluteal tuberosity of the femur. It is innervated by the inferior gluteal nerve (L5, S1, & S2). Although it is not a postural muscle, a weakness in the gluteal muscle usually results in low back pain - specifically weakness in gluteus medius. This muscle - located at the outer hip (ilium) and inserting to the greater trochanter - works in conjunction with the gluteus maximus to extend the hip. An important action that the gluteus medius has during walking is inhibiting the pelvis from dropping toward the opposite swinging leg (Neumann, 2010). Aside from being a major hip flexor, the psoas is crucial in providing vertical stability for the lumbar spine and directly affects the degree of the lordotic curve. The thick iliacus muscle arises from the iliac fossa (anterior portion of the ilium), as well as from the anterior inferior iliac spine (AIIS), to join with the psoas and insert at the lesser trochanter of the femur (Biel, 2001). Both muscles are innervated by nerves branching from L2 and L3 of the lumbar plexus (Stone & Stone, 2003). The final muscle that can affect low back pain - and perhaps the most commonly associated with low back pain - is the piriformis. Emerging from the sacrum and sacrotuberous ligament, the piriformis inserts into the greater trochanter of the femur - where it acts to laterally rotate the hip. There is one essential feature of the piriformis that gives it a central role in creating sciatic pain: the location of the muscle in relation to the sciatic nerve which can put it in a position to possibly entrap the nerve. As the sciatic nerve travels through the gluteal region, it passes under the piriformis muscle. Because of this, an over- contracted piriformis can place direct pressure upon the sciatic nerve (Neumann 2010). In addition, a small percentage of the population is born with the sciatic nerve passing through the actual muscle (Lowe, 1997). The quadratus lumborum (QL) is often mistaken as a muscle of the low back due to the accessibility of its lateral edge from the side of the trunk, beneath the erector spinae. In actuality, it is the deepest abdominal muscle and is perceived as a continuation of the transverse abdominis (Biel, 2001). The QL originates from the iliolumbar ligaments (L4 and L5) and the iliac crest to insert into the transverse processes of the first through fourth lumbar vertebrae - as well as the twelfth rib. Innervated by T12 and L1 nerves, the QL acts to laterally flex the trunk and elevate the hip (Stone & Stone, 2003). Gluteus maximus is the superficial muscle of the gluteal region and is the most influential lateral rotator of the hip. This large muscle arises from the posterior sacrum, coccyx, outer surface of the ilium, Differentiating sciatica from other pathologies Since the lower back is a complex anatomical area, there are other conditions that have symptoms that may mimic sciatica. Two such conditions are Piriformis syndrome and Sacroiliac joint dysfunction (Lowe, 1997). sciatica is that sciatica will present with weakness and diminution of the proximal and distal muscles; piriformis syndrome will exhibit weakness with shortening in the distal muscles only (O’Neill- Boyajian, McClain, Coleman & Thomas, 2008). Piriformis syndrome The piriformis muscle connects the femur to the sacrum. While walking, it contracts as the leg is brought forward (the swing phase). It then contracts a second time to provide postural stability while the opposite leg swings forward (the stance phase) (O’Neill-Boyajian, McClain, Coleman & Thomas, 2008). As a result, limping or difficulty walking are symptoms of piriformis syndrome. To diagnose piriformis syndrome, a thorough intake history must be conducted to rule out disc pathologies, trochanteric bursitis (inflammation of the bursa of the hip and femur joint), and sciatica. There are four diagnostic tests recommended: FAIR, Pace, Freiburg tests, and Beatty Maneuver (Lowe, 1997). FAIR stands for flexion, adduction, and internal rotation and is also known as the “Piriformis test.” To perform this test, the client will assume a side-lying position with the unaffected side resting on the edge of the massage table. From this position, the client will flex the hip and knee so that the knee drops off the table. Next, the therapist will ensure that the pelvis remains steady by placing one hand on the hip, and then will provide a gentle stretch of the piriformis by pressing the knee down with the other hand. Re-creation of symptoms indicates a positive test result (Lowe, 1997). According to Physio Pedia (2014), several other symptoms similar to sciatica may be shared with piriformis syndrome. These include: ● Pain with prolonged sitting (over 15-20 minutes). ● Pain with sitting cross-legged. ● Pain when rising from a seated position. ● Radiating pain felt at the sacrum, buttocks, hip, and/or groin. Piriformis syndrome pain radiates into the low back, as does sciatica pain. This condition is classified into two types: primary piriformis syndrome and secondary piriformis syndrome. The Pace test involves resisted hip abduction by the therapist at the knee while the client is seated. Again, re-creation of symptoms is a positive test result (Physio Pedia, 2016). Primary piriformis syndrome is rare and is caused by an anatomical anomaly. It is depicted as the sciatic nerve passing through the muscle belly of the piriformis. The majority of piriformis syndrome cases fall into the secondary piriformis syndrome category. Secondary piriformis syndrome occurs when the inflammation resulting from a microtrauma (overuse) or a macrotrauma (a car accident or fall) entraps the sciatic nerve. Fifty percent of secondary piriformis syndrome cases result from direct trauma to the buttocks (macrotrauma) and leads to muscle spasm, swelling, and nerve compression. An example of a microtrauma is “wallet neuritis,” which is a result of prolonged sitting on a hard surface. Clients test positive 56.2 percent of the time for the Freiburg sign test. This test is performed with the client laying supine on the massage table. The therapist will then bring the hip of the affected side into passive internal rotation. The result is positive if symptoms present (Physio Pedia, 2016). The final assessment indicated for piriformis syndrome is the Beatty Maneuver. For this test, the client will assume a side-lying position on the table with the affected side up. The client will then flex the leg, resting the knee on the table. A positive sign is achieved if symptoms are re-created when the client lifts and holds the knee off the table (Physio Pedia, 2016). In either case, pain from piriformis syndrome generally lessens when lying down: in this position, the excessive external rotational pull on the leg presents as splayfoot (the foot is turned away from the midline). A critical distinction between piriformis syndrome and A quick comparison of these tests shows that the FAIR and Freiburg tests administer stretching of the piriformis, whereas the Pace test and Beatty Maneuver utilize contraction of the piriformis. Massage.EliteCME.com Page 48

  4. Sacroiliac joint dysfunction Sacroiliac joint dysfunction (SI joint dysfunction) is considered to be a degenerative arthritic condition (Werner, 2002). The triangle shaped sacrum is tightly wedged between the iliac of the pelvis, causing limited mobility in the SI joint. resembles sciatica; a determining distinction between the two is that SI joint dysfunction develops over a long time, whereas sciatica can have a sudden onset (MedicineNet.com, 2016). There are two diagnostic procedures for SI joint dysfunction, in addition to a thorough history: the Gapping test and the FABER test. Several mechanical conditions contribute to the wearing down of the cartilage cushion within the joint. These conditions create an environment for inflammation to occur as the bones rub against one another. Low back pain associated with SI joint dysfunction develops gradually because of this friction. Sprains to the iliolumbar ligament are the main culprits. A sprain is a tear to a ligament; ligaments do not heal quickly due to poor blood supply and when they do heal, they never return to their original length. This sets the stage for instability and re- injury (Werner, 2002). Injury to the iliolumbar ligament of the SI joint can be caused by a motor vehicle accident, fall, chronic postural stress (anterior pelvic tilt), or running and lifting (Physio Pedia, 2016). To administer the Gapping test, the client will lay supine on the massage table. The therapist places one hand on each anterior superior iliac spine (ASIS), located anterior and medial from the trochanter. The therapist then places downward and lateral pressure, which stresses the SI joint. Pain as a result of this is a positive sign for SI joint dysfunction (Lowe, 1997). The FABER test is also referred to as “Patrick’s test” or the “Figure Four” test. FABER is an acronym for flexion, abduction, and external rotation. The client will place one leg in a flexed, abducted, and externally rotated position - while the therapist places one hand on the ASIS of the straight leg and the other hand on the knee of the flexed leg. Pain or discomfort when downward pressure is applied to the knee tests positive for SI joint dysfunction (Lowe, 1997). The pain associated with SI joint dysfunction is hard to pinpoint, but will be felt in the low back, hip, thigh, and/or groin unilaterally. Pain is aggravated by standing, walking, and forward flexion - yet it is relieved by lying down. Sacroliliac joint dysfunction pain closely Although these tests help differentiate SI joint dysfunction from other conditions, treatment depends heavily on the cause. Causes of sciatica Table 4: Muscles linked to sciatica. Postural/tonic muscles (tight) Iliopsoas. Piriformis. Erector spinae (thoracolumbar). Quadratus lumborum. Rectus femoris. The majority of sciatica causes are mechanical in nature. Tables 1 and 2 under the Risk Factors section reference the posture and an alteration of the vertebrae as reasons for sciatic occurrence. To best understand the role muscle tension plays in mechanical malfunction, an exploration into muscle imbalance will first be discussed. Phasic muscles (weak) Transverse abdominis. Gluteus maximus. Gluteus medius. Multifidus. Vastas medialis. Muscle imbalance Renowned physician Dr. Vladimir Janda, who spearheaded the combination of physical medicine with rehabilitation, found muscle imbalance to be influenced by the central nervous system (CNS) - more so than a result of structural change through his research. He also stated that when muscle tone changes, it is a reflection of the sensorimotor system. The sensorimotor system refers to the interdependence of the CNS with the muscular system. Muscles respond the same to dysfunction at the joint as they do to upper motor lesions (i.e. a stroke); the only variation being the degree of tightness to weakness. As a result, Janda classified muscles into two groups according to the way they mimicked the CNS pattern: the postural (tonic) and phasic systems. Table 3 illustrates the differences between each group (The Janda Approach, 2016). These patterned responses create postural deviations which lead to other conditions - such as sciatica through reciprocal inhibition (muscle weakness due to increased tension in the antagonist muscle), trigger point weakness (hyperirritable muscle causing overuse and weakness), and fatigue (muscle fatigue before pain is felt). Janda classified these postural deviations as Upper crossed syndrome, Lower crossed syndrome, and Layer syndrome. Upper crossed syndrome (UCS) involves muscles of the cervical region. Lower crossed syndrome (LCS) involves muscles of the pelvic region, and Layer syndrome (LS) is a combination of the two. Table 5 illustrates the characterizations for each syndrome (The Janda Approach, 2016). Table 3: Postural and tonic systems. Postural/tonic muscle characteristics Flexors. Balance against gravity. Phasic muscle characteristics Extensors. Work against gravity (movement oriented). Contract quickly and fatigue quickly. Weaken under stress. Can withstand sustained contraction. Shorten under stress. Postural muscles are prone to tightening, whereas phasic muscles are prone to weakening. Table 4 categorizes the muscles most relevant to sciatica in the postural and phasic systems. Massage.EliteCME.com Page 49

  5. Table 5: Janda’s syndromes. Structural scoliosis is a congenital condition; the spine has had a lateral curvature from birth. Functional scoliosis is a curvature that is created in response to stresses placed upon it. It is often a way that the spine deals with rapid growth during adolescence. Functional scoliosis affects girls more than boys (Werner, 2002). Upper crossed syndrome (UCS) Tight upper trapezius, levator scapula, and pectoralis major/ minor muscles. Lower crossed syndrome (LCS) Tight thoracolumbar extensors, iliopsoas, & rectus femoris. Layer syndrome (LS) Tight upper trapezius, levator scapula, pectoralis major/minor, thoracolumbar extensors, iliopsoas, & rectus femoris. Weak deep cervical flexors, middle & lower trapezius, abdominals, gluteus medius, & gluteus maximus. Joint dysfunction at the atlanto-occipital joint C4-5, cerivo- thoracic joint, glenohumeral joint, T4-5, L4-5, L5-S1, SI joint, & hip joint. Marked by: ● Forward head posture; ● Increased cervical lordosis; ● Thoracic kyphosis; ● Elevated & protracted shoulders; ● Winged scapulae; ● Increased activation of the levator scapula & upper trapezius to stabilize the glenohumeral joint; ● Anterior pelvic tilt; ● Increased lumbar lordosis; ● Lateral lumbar shift; ● External leg rotational; ● Knee hyperextension. Ligament sprains As seen in Table 5, muscle imbalance affects the joints resulting in dysfunction. Traumatic injuries – caused by motor vehicle accidents or falls - also impact ligaments. Ligaments have a tendency to become lax and refer pain, due to their inability to rebound. There are three ligaments of the lumbar spine most commonly sprained: the supraspinous and interspinous of L4-5 & L5-S1, and the iliolumbar ligament. Table 6 illustrates the different characteristics of each ligament. Weak deep cervical flexors, middle & lower trapezius. Weak abdominals, gluteus medius & gluteus maximus. Table 6: Ligaments. Supraspinous ligament Controls flexion of the spine. Interspinous ligament Prevents hyperextension of the spine. Pain is felt centralized in the upper glute region to the lateral leg. Discomfort with standing upright & balancing. Iliolumbar ligament Joint dysfunction at the atlanto-occipital joint C4-5, cervico- thoracic joint, glenohumeral joint & T4-5. Joint dysfunction at L4-5, L5-S1, SI joint & hip joint. Stabilizes the SI joint. Pain is felt centralized along the upper iliac crest. Pain is felt to one side of the low back, across the hip, to the groin area. Discomfort with lateral flexion away from the painful side. Marked by: ● Forward head posture; ● Increased cervical lordosis; ● Thoracic kyphosis; ● Elevated & protracted shoulders; ● Winged scapulae; ● Increased activation of the levator scapula & upper trapezius to stabilize the glenohumeral joint. Marked by: ● Anterior pelvic tilt; ● Increased lumbar lordosis; ● Lateral lumbar shift; ● External leg rotational; ● Knee hyperextension; ● Type A= imbalance at the hip; ● Type B= imbalance in low back. Discomfort with standing upright & balancing. Although laxity of ligaments can manifest as referred pain in the low back, it usually is a secondary condition of muscle imbalance and/or postural deviation (Benjamin, 2010). Spondylosis, spondylolysis & spondylolisthesis From muscle imbalance to ligament injury, instability of the joints brings about degeneration and other disorders. The first of which is spondylosis. Spondylosis is best understood as osteoarthritis of the vertebrae, and occurs with age. Chronic irritation within the structures of the vertebral body - due to misalignment - results in inflammation and a decrease in range of motion. This often leads to spondylolysis, as well as possible lumbar radiculopathy. In addition, the irritation triggers the growth of osteocytes (bone spurs), which can create a narrowing of the spinal canal, or stenosis (Vokshoo, 2014). Spondylolysis is marked by a stress fracture of the pars interarticularis. The pars interarticularis is a structure on the posterior vertebral body that connects the upper and lower vertebrae. This usually occurs at the L4-L5 junction, since it has the most movement. Some cases of spondylolysis present as a congenital condition; however, the majority of cases result from activities that chronically place excess stress on the spine - such as gymnastics or weight lifting. Weakness of the lumbar spine at the L4-L5 articulation eventually results in the anterior dislocation of the L5 vertebrae, or spondylolisthesis. In response to the slipped vertebrae, the surrounding muscles will attempt to stabilize the area. Another consequence is a compression of the sciatic nerve root (Vokshoo, 2014). These postural deviations can strain ligaments and cause degeneration of the joint. Lower crossed syndrome directly affects the SI joint, as well as the piriformis muscle - making it a precursor for both dysfunctions discussed earlier (Physio Pedia, 2016). Not mentioned here is scoliosis: a lateral curvature of the spine. Scoliosis manifests as an increased lateral curvature in the upper thoracic region (usually to the right) and in the lumbar regions. The degree of curvature varies; it is not considered severe unless it is above 34 degrees. This condition is divided into structural scoliosis and functional scoliosis. Massage.EliteCME.com Page 50

  6. Table 7 compares the different features of spondylosis, spondylolysis, and spondylolisthesis. vertebrae. As with many conditions, accruing compressive forces press down on the vertebral column, inhibiting the intervertebral discs. Combined with degeneration, this leads to protrusion of the jelly- like fluid of the disc. The most common herniation occurs at L4-L5 and L5-S1, where the disc will press onto the sciatic nerve and elicit lumbar radiculopathy. There are four degrees of herniation: 1. Bulging: The entire disc is herniated. 2. Protrusion: The inner nucleus pulposus herniates out the outer wall (annulus fibrosis). 3. Extrusion: A small piece of the inner nucleus protrudes with a small connection remaining, or separates completely. 4. Rupture: The inner nucleus erupts and leaks out. Table 7: Comparison of different vertebral pathologies. Spondylosis Spondylolysis Degeneration of the vertebrae. pars interarticularis. Irritation from chronic misalignment causes bone spurs to grow. a fracture. Spondylolisthesis Anterior dislocation of the L5 vertebrae. Any condition that weakens the structure of the vertebral joint (i.e. ligament injury, herniation, spondylosis, spondylolysis). Pain is felt in the low back and/or sciatica. Stress fracture of the Chronic excessive loading of the lumbar spine leads to Since intervertebral discs lack a nerve supply, pain can be intermittent depending on the degree of herniation - as well as the body position. The symptoms associated with lumbar disc herniation are: ● Localized low back pain that refers down the leg. ● Muscle weakness that occurs suddenly and only in the muscles of the innervating nerve. ● Tingling in the low back and down the leg. ● Numbness along the dermatome. ● Change in bowel and bladder control. Pain is felt in the low back & legs. Exacerbated by standing and walking; relieved by sitting or trunk flexion. Pain is felt in the low back. Exacerbated by activity - especially hyper-extension. Pain will worsen with prolonged sitting; conversely, it will decrease with activity (Werner, 2002). The Lasegue sign is used to assess disc herniation. To perform this test, the client will lay supine on the massage table. The therapist will then take the leg of the afflicted side into passive flexion until the pain is re-created. The therapist will next lower the leg two inches and have the client dorsiflex. If there is no increase in pain, the therapist will have the client flex the neck - in addition to dorsiflexion of the foot. If this pain is exacerbated, then the test is positive (Lowe, 1997). Spondylosis is common in the age group that is most afflicted with sciatica. Spondylolysis and spondylolisthesis, however, affect this group at such a low percentage rate that they are important only as a means for narrowing the cause of radiculopathy (Orthoinfo, 2016). Disc herniation Perhaps the most attributed condition for sciatica in the medical community is disc herniation. Discs are the spongy cushion between Evaluation and assessment A thorough evaluation is necessary to develop an effective treatment. The first step is a thorough health history intake, which will help narrow the possible causes. The therapist should then provide a postural assessment to implicate lower crossed syndrome or other muscular imbalances. Bony landmarks will provide a point of reference when assessing symmetry. It is important to evaluate gait and balance due to the interconnectedness of the muscular and central nervous systems. If the gait is disrupted, walking will present restrictions in the sacroiliac joint; this should produce a figure eight movement. During gait assessment, the therapist should look for similar areas with possible restricted movements and for areas that may have excess movement. Gait dysfunction will be produced as a result of the following: 1. Pain. 2. Muscle inhibition. 3. Decrease in muscle length. 4. Restrained joint movement. 5. Alterations in bone or soft tissue. If pain is felt during active and passive assessment for dysfunction, as well as during compression, this indicates a disruption in the joint - not the soft tissue. This extends beyond a massage therapist’s scope of practice, and must be referred to an appropriate health care professional. However, if pain is felt during active range of motion along with traction, it is connected to soft tissue dysfunction. Tables 8a & 8b compare the different causes of sciatica (Fritz, 2015). Massage.EliteCME.com Page 51

  7. Table 8a: Causes for sciatica. Muscle imbalance Piriformis syndrome. Hypertonicity of the piriformis muscle. Overuse (mirotrauma). Ligamentous Inter/supraspinous sprain. Condition Definition Lower cross syndrome. Postural deviation. Iliolumbar sprain Ligamentous tear. Traumatic injury/muscle imbalance. Cause Sensorimotor systems response. * Anterior pelvic tilt. Signs & symptoms * Splayfoot. * Centralized pain at the upper iliac crest in the gluteals to the lateral leg region. * Pain at one side of low back, across hip to the groin. * Pain & weakness in distal muscles. * Joint dysfunction at L4-5 & L5-S1. * Discomfort with lateral flexion away from the painful side. * Limping & difficulty walking. * Increased lumbar lordosis. * Discomfort with standing upright. * Radiating pain from sacrum to hips & down leg. * Weak abdominals & gluteus maximums & gluteus medius. * Discomfort with trunk extension. * Pain with prolonged sitting. * Tight iliopsoas. * Pain with sitting cross legged. * Pain relieved when lying down. FAIR, Pace, Freiburg, Beatty. Tests Postural assessment & gait assessment. Table 8b: Causes for sciatica. Joint Disorders Spondylosis. Disc Pathologies Herniation. Condition Sacroiliac joint dysfunction. Degeneration of the cartilage at the SI joint. Degenerative arthritis/ sprains. * Unilateral pain in the low back, hip and with standing, walking, & forward flexion. Spondylolisthesis. Definition Osteoarthritis of the vertebrae. Chronic misalignment and/ or bone spurs. * Pain in the low back & legs. Anterior dislocation of the L5 vertebrae. Sprains, herniation, spondylosis. * Low back pain. Protrusion of an intervertebral disc. Cumulative compressive forces. * Low back pain referring down to the legs. Cause Signs & symptoms * Sciatica: burning, radiating, sharp/shooting pain from the low back down the leg to the foot that is constant/ intermittent. X-ray. * Pain is worse with standing & walking. * Immediate muscle weakness. * Pain relieved by lying down. * Pain relieved with trunk flexion & standing. * Tingling in the low back. * Numbness. Test Gapping, FABER. X-ray. Lasegue. Treatment Massage is indicated for sciatica because the majority of the causes stem from a dysfunction of the musculoskeletal system. In the acute phase, however, direct massage to the piriformis and gluteal region may be contraindicated (Lowe, 1997). lymph flow to and from the area. In addition, friction can be used - helping to release restrictions in the muscle tissue. There are two ways to facilitate friction: ischemic/cross-fiber friction and ischemic/passive range of motion friction (Fritz, 2015). Massage The goal of massage is to bring balance back to the system. Once the mechanoreceptors of a muscle become chronically stimulated, they will respond to the least amount of stimuli - this leads to overuse and early fatigue. In order to increase the threshold, care must be taken to re-lengthen the shortened musculature. With this in mind, the therapist should begin by placing a pillow under the abdomen of the prone client - in order to alleviate any increased lordotic curve during the massage session. This will help the compensatory muscles to slacken. Other considerations for a client experiencing acute sciatica include having the client lie in a side position, the utilization of a massage chair, or performing a shortened treatment session (Fritz, 2015). Ischemic/cross-fiber friction refers to the therapist placing direct pressure on the muscle, then applying a deep, slow movement across the fibers to encourage release of tension; ischemic/passive range of motion friction involves direct pressure being applied to the muscle, and at the same time passively moving the client’s joint to create friction (Fritz, 2015). Focusing the friction on the postural (tonic) muscles would benefit the sciatica client, considering muscle imbalance and postural deviation are a root cause for all conditions that have been previously discussed. These include the iliopsoas, the rectus femoris, the thoracolumbar erector spinae, the quadratus lumborum, and the piriformis. Attention to the weakened, phasic muscles at the hip (gluteus maximus and gluteus medius) is also important (The Janda Approach, 2016). Applying effleurage to calm the affected area and to warm the tissue is recommended, and should also be performed to encourage blood and Massage.EliteCME.com Page 52

  8. Stretching is also an integral component of treatment since muscle contracture limits joint range of motion. During the session, post- isometric relaxation can be used to break the neural patterns limiting range of motion. This is done by passively placing the joint in its end range. The therapist then applies light resistance to the client’s contraction for ten seconds, increasing the stretch during the relaxation phase, and then repeating. This technique would work best for the muscles of the hip since they are phasic (Fritz, 2015). have a schedule of reassessment in order to determine adjustments to the treatment plan (Fritz, 2015). Self-therapy If the sciatica client does not take the necessary steps to alleviate the condition outside of the massage room, progress could be slow. It is important that the therapist encourages the application of ice to any areas of inflammation, followed by moist heat which will bring fresh nutrients from the blood to the area (heat) and take waste products away (ice) (Mayo Clinic, 2016). This may result in increased mobility. According to the National Institute of Neurological Disorders and Stroke, the best way to alleviate pain is through exercise that strengthens the core (back and abs). Therefore, referring the client to an exercise professional will help restore balance. It also may be beneficial to suggest that the client confer with a skilled practitioner who can identify any nutritional deficiencies in the diet, in order to expedite healing. Treatment plan A client in the acute phase of sciatica initially may need multiple sessions per week. The determination of frequency depends on the severity of the condition, the self-therapy plan, and complimentary therapies. Massage is generally safe to be administered more than once per week. The first variable to consider is deciding between either relaxation or deep friction therapy. Because of the versatility, mixing Swedish techniques with deep friction therapy for a combined session is one option for treatment - separating these techniques for contrast, with a focused session one day and then relaxation the next. Another option would be the length of the session. When a sciatica client initially receives treatment, sessions may need to be limited to thirty minutes - depending on the severity of symptoms. In the acute phase, a client may not wish to be on the table for a prolonged period of time. Offering side-lying or chair massage as an alternative will help the client receive the benefit of massage without aggravating the condition. Once in the subacute phase, sixty minute sessions should be tolerable (Fritz, 2015). Treatment for chronic sciatica Sometimes all avenues of therapy have been exhausted without much change in the amount of pain, possibly due to the degree of degeneration present. When this occurs, the referring physician may recommend epidural injections. As a last resort, surgery may be required to widen the spinal cord or remove a herniated disc (Physio Pedia, 2016). Prevention The best way to treat sciatica is through prevention: maintaining good posture (while both standing and sitting), employing safe lifting protocols, and engaging in exercises that strengthen the core (National Institute of Neurological Disorders and Stroke, 2015). Regular massage therapy factors in as well, and will help to relieve stress and encourage proper healing of soft tissue injury. Massage is an integral component to keeping the body balanced. In conjunction with massage, a client may also be taking anti- inflammatories, receiving chiropractic adjustments, and/or physical therapy. To provide the best level of treatment, the therapist should confer with the client’s health care team. The therapist should also Conclusion Sciatica is an umbrella term for several conditions affecting the low back. Since the sciatic nerve is the largest and main innervator for the lower body, it is understandable that many symptoms are shared with other dysfunctions. Radiating pain from the sacrum through the gluteal region down the posterior leg is one commonality among low back disorders. It is essential to note that sciatica is a secondary condition. Although there are instances of congenital disorders resulting in References structural change to the lumbar spine (spondylosis, primary piriformis syndrome, scoliosis), these instances are rare. The majority of precursors that give rise to sciatica occur from an imbalance to the musculoskeletal systems. These precursors either directly influence sciatica (secondary piriformis syndrome, ligament sprains, or joint dislocations) or indirectly impact sciatica (postural deviations). Regardless, massage therapy has a positive effect in treating and preventing sciatica. 1. Benjamin, B., MD. (2010). Pain caused by low back ligaments. Massage Today vol. 10 issue 04. Retrieved from the Massage Today website: http://www.massagetoday.com/mpacms/mt/article. php?id=14188 Benjamin, B., MD. (2010). Referred pain. Massage Today Vol.10 Issue 08. Retrieved from the Massage Today website: http://www.massagetoday.com/mpacms/mt/article.php?id=14269 Biel, A., LMP. (2001). Trail guide to the body: how to locate muscles, bones, and more/2nd ed. Boulder, CO: Books of Discovery. ChiroGeencbi.nlm.gov/pubmed/260006705k. (2015). Lumbar dermatomes. Retrieved from the ChiroGeek website: http://www.chirogeek.com/Sciatica/dermatomes.html EurSpine, J., PubMed (2016). Prevalence of gluteus medius weakness in people with chronic low back pain compared to healthy controls. Retrieved from the PubMed website: http://www.ncm.nlm.nih.gov/ pubmed/260006705 Family Doctor. (2014). Piriformis syndrome. Retrieved from the FamilyDoctor.org website: http:// www.familydoctor/en/diseases-conditions/piriformis-syndrome.html Fritz, S., MS, NCTMB. (2015). Mosby’s massage therapy review/4th ed. St. Louis, MO: Elsener, Inc. Gillott, C. (2015).Sciatica: causes, symptoms and treatments. Medical News Today. Retrieved from the Medical News Today website: http://medicalnewtoday.com/articles/7619.php?page=2 Google. (2016). Sciatica. Retrieved from the Google website: http://www.google.com/ search?q=Sciatica 10. The Janda Approach. (2016). About Dr. Janda. Retrieved from the Janda Approach website: http:// www.jandaapproach.com/about/ 11. The Janda Approach. (2016). Causes of muscle weakness. Retrieved from the Janda Approach website: http://www.jandacrossedsyndromes.com/about/causes-of-muscle-weakness/ 12. The Janda Approach. (2016). Jandas Evaluation. Retrieved from the Janda Approach website: http:// www.jandaapproach.com/the-janda-approach/janda-evaluation/ 13. The Janda Approach. (2016). Janda Syndromes. Retrieved from the Janda Approach website: http:// www.jandaapproach.com/the-janda-approach/jandas-syndromes/ 14. The Janda Approach. (2016). Jandas Treatment. Retrieved from the Janda Approach website: http:// www.jandaapproach.com/the-janda-approach/jandas-treatment/ 15. The Janda Approach. (2016). Philosophy. Retrieved from the Janda Approach website: http://www. jandaapproach.com/the-janda-approach/philosophy/ 16. The Janda Approach. (2016). Restoring muscle balance. Retrieved from the Janda Approach website: http://www.jandacrosssyndrome.com/about/restoring-muscle-balance/ 17. Kishner, S., MD, MHA. Medscape. (2015). Lumbar spine anatomy. Retrieved from the Medscape website: http://www.emedicine.medscape.com/article/1899031-overviewa#2 18. Koes, B.W., van Tudler, M.W. & Peul W.C. (2007). Diagnosis and treatment of sciatica. BMJ, 334(7607): 1313-1317. doi: 10.1136/bmj.39223. 19. Litao, A., MD, Medscape (2015). Lumbosacral Spondylolysis. Retrieved from the Medscape website: http://www.emedicine.medscape.com/article/95691-overview#a5 20. Litao, A., MD. Medscape. (2015). Lumbosacral spondylolysis: presentation. Retrieved from the Medscape website: http://www.emedicine.medscape.com/article/95691-clinical 21. Lowe, W., LMT (1997). Functional assessment in massage therapy/3rd ed. Bend, OR: Orthopedic Massage Education & Research Institute. 22. Mayo Clinic. (2016). Healthy lifestyle: stress management. Retrieved from the Mayo Clinic website: http://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/massage/art-20045743 23. MedicineNet.com. (2016). Sacroiliac joint dysfunction. Retrieved from the MedicineNet.com website: http://www.medicinenet.com/script/main/mobileart.asp?articlekey=84902&page=2 24. National Institute of Neurological Disorders and Stroke. (2015) Low back pain fact sheet. Retrieved from the National Institute of Neurological Disorders and Stroke website: http://www.nids.nih.gov/ disorders/backpain/detail_backpain.htm 25. Neumann, D. (2010). Kinesiology of the hip: a focus on muscular action. The Journal of the American Osteopathic Association, doi: 10.2519/jospt.2010.3825. http://www.jospt.org/doi/abs 26. O’Neill-Boyajian, L. DO, McClain, R.L., DO., Coleman M.K., DO., & Thomas, P.P., PhD. (2008). Diagnosis and management of piriformis syndrome: an osteopathic approach. The Journal of the American Osteopathic Association. Retrieved from the Journal of the American and Osteopathic Association website: http://www.jaoa.org/article.aspx?articleid=2093614 27. Ombregt, L. (2013). The ligamentous concept from a system of orthopaedic medicine/3rd ed. 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  9. MASSAGE AND SCIATICA: AN IN-DEpTH STUDy Final Examination Questions Select the best answer for each question and mark your answers online at Massage.EliteCME.com. 1. A distinguishing trait of sciatic pain from other low back conditions is: a. Sciatica is described as a sharp, shooting pain down the leg. b. Sciatica is a unilateral pain - originating from the low back and traveling down the leg. c. Pain that is felt in the low back, wrapping around the hip and is difficult to pinpoint. d. Centralized pain in the low back. 4. A client experiencing a burning, radiating pain down the leg to the bottom of the foot indicates entrapment of the sciatic nerve at which location? a. L3. b. L4. c. L5. d. S1. 5. Positive signs during administration of the Gapping and FABER tests indicate which of the following conditions? a. Piriformis syndrome. b. Disc herniation. c. Iliolumbar sprain. d. Sacroiliac joint dysfunction. 2. If pain presents with passive and active range of motion, where is the dysfunction? a. Joint. b. Tendon. c. Muscle. d. Fascia. 3. Spondylolisthesis is classified as which of the following? a. Degeneration of the vertebrae. b. A stress fracture of the pars interarticularis. c. Anterior dislocation of the L5 vertebrae. d. Osteoarthritis of the vertebrae. MFL02MSE17 Massage.EliteCME.com Page 54