resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
Managing Patient Expectations About Acupuncture
Last year, I attended the Pacific Symposium in San Diego for the first time in six or seven years. It was the 25th anniversary of this event, and on one evening there was a panel discussion with the title; "What is Qi?."
Lime Jello on Morphine
Taste is in the eyes... actually the mouth... of the beholder. My food preferences have changed, lightening from the food of my youth. My parents loved heavy eastern European cuisine and I loved it as a child. Now I enjoy leaner, healthier whole foods.
To The Finish Line With the Help of TCM
When acupuncturist Eddy De Smedt pursued a career in Traditional Chinese Medicine, he knew he wanted to make a difference.
Pulse Diagnosis: What We Know
I am still finding pearls of wisdom from the books and papers that I inherited from my pulse diagnosis mentor Jim Ramholz.
A Commonly Missed Spinal Fixation: The Upper Lumbar Spine (Part 2)
As mentioned in part 1, using a flexion-distraction table is a great way to unlock this particular fixation. You have found the stuck segment. You have determined whether it is unilateral, midline or bilateral.
Jingei Diagnosis: An Effective and Powerful Diagnostic
I graduated from the Kotatama Institute under the direction of Drs. Masahilo and Katsuharu Nakazono in 1984. As a student, I was exposed to the practice of most of the various theories and modalites of Oriental Medicine.
Essential Orthopedic Testing: Tests That Involve Standing on One Leg
Since these tests have a common mechanism of performance (standing on one leg), there are differential diagnostic concerns during testing. The tests cannot be completely isolated from each other for performance.
Uncle Sam Needs You (Part 2)
Where chiropractic care has been used in the military health services, it has been deemed very successful.
Simple Ways To Find True Happiness
Patients in our clinics are always seeking happiness. As their health advocate, we need to ensure we inform them that in order to find happiness, they have to make sure to identify what makes them happy in the first place.
The Heart Protector
On the physical level, the Pericardium is a double-layered sac of fibrous tissue that envelops the Heart. The space between the layers is filled with serous fluid that protects the Heart from external shock or trauma and lubricates to allow for normal Heart movement.
CMT & Stroke Risk: Myth vs. Fact
By now, most of you have probably heard that the American Heart Association recently published a statement regarding the association between cervical dissection (CD) and cervical manipulative therapy (CMT).
The Tao of Gender
If you think gender is as simple as having a new client check off the "male" or "female" box on your intake form, we hope this article will expand your understanding and thus the reach of your health care.
Healing With TCM at San Quentin State Prison
For the prisoners at San Quentin State Prison, life-sentences are the reality of every day life. It is not often that prisoners get the opportunity to use alternative medicine to deal with common ailments they encounter behind bars such as, depression, anxiety and pain.
Correcting Pelvic Rotation Around the Long Axis: Adjustment Protocol
The pelvis can be considered a ring that can misalign on the sacrum rotating around the long axis. The following is a description of an adjustment that helps to correct sacroiliac rotation around the long axis.
The Case for Immunization
As long as I have been a chiropractor, I have seen many in this profession oppose vaccinations. Indeed, it has often been taken as a "given" that to be a principled chiropractor requires a curmudgeon's willingness to hold aloft that banner of opposition.
Dr. George Goodman and His Legacy to Logan University
Those who knew him called him a revered leader, a visionary and one of chiropractic's biggest advocates. George A. Goodman, DC, Logan University's sixth and longest-serving president, passed away on Sept. 9. He was 70 years old.
The Wonders of Light Therapy: An Interview with Wes Burwell
I first met Wes Burwell in 2011 when he was teaching a class on light. Since then, every time I hear him speak, his understanding of the benefits, function and capacity of light has evolved.
Chiropractic Research in Review
Predicting Pain With Disability in Office Workers; Traction Approaches for Discogenic Cervical Radiculopathy; Intra-Articular Gas Bubbles Following Manipulation; Nonresponsive Chronic Ankle Sprains: Think Tendon Rupture.
Managing Today's Fertility Patient
I recently received an email from one of my fertility patients: "Got my lab results back. FSH is 11, AMH is 0.7. My doctor said these numbers aren't good. I guess I'm infertile. Just as a thought. Just set up an appointment to speak with an adoption agency."
Sports Science: What's in That Drink?
Athletes frequently ask me what the best liquid is to drink during exercise – water or a sports drink? Water provides the necessary hydration, but unfortunately, it lacks the key nutrients to aid in performance and recovery.
Commingling Money: 12 Questions for the ACA About the CHAMP / NCLAF Merger
The American Chiropractic Association recently announced it was merging the National Chiropractic Legal Action Fund and the Chiropractic Health Advocacy and Mobilization Project into a single entity that will support both legal and legislative actions.
AOMA Strengthens Leadership Team
AOMA Graduate School of Integrative Medicine, a leading college of acupuncture & herbal medicine, announced the appointment of Donna LaPoint Hurta, MBA as the new VP of Finance & Operations this Fall.
January, 2007, Vol. 07, Issue 01
A Case Report of the Treatment of Piriformis Syndrome
Applying Modalities of Therapeutic Bodywork
By Peggi Honig
Editor's Note: The following case study abstract received Honorable Mention Third Prize in the American Massage Therapy Association Massage Therapy Foundation 2006 Case Study Competition poster session at the national convention in Atlanta.
Objective: This study assessed the benefits of weekly therapeutic deep-tissue massage with the application of adjunct modalities, including somatic education and a stretching program to alleviate chronic pain caused by the compression of the sciatic nerve by the piriformis muscle.
Methods: A protocol of 10 weekly 90-minute massages applied deep-tissue techniques with adjunct modalities including: proprioception neuromuscular facilitation (PNF); positional release therapy (PRT) stretches; Feldenkrais method of awareness through movement exercises (ATM); Kripalu yoga; and myofascial work.Focus of the work centered on the muscles and bones of the lower back, posterior and anterior legs.
Results: After the first session, the subject was free of any sciatic pain for five days. When pain returned, the client was able to recognize what triggered the flare-up and shifted her patterns of movement to abate the discomfort. There was a recurrence of chronic pain in the fourth and fifth weeks due to habitual patterns and work-related stress that required massage to remedy. From the fifth week on, piriformis syndrome discomfort was rarely experienced.
Conclusion: This study demonstrates the application of therapeutic massage with a stretching program to ameliorate chronic piriformis syndrome. Rehabilitation is greatly improved with the addition of a daily stretching program and somatic education that improves the client's awareness of habitual patterns.
Key Words/Phrases: piriformis syndrome, pseudosciatica, sciatic nerve impingement, Positional Release Therapy (PRT) applications, chronic gluteal pain.
Background: Information regarding piriformis syndrome has, since its first description in 1928, proved problematic in diagnosing, due to the lack of supporting objective evidence. It is generally the client's described pain and the supporting medical process of elimination that leads to the diagnosis of this syndrome. At least 70% to 80% of the world population suffers from some form of lower back pain in their lifetime and of those, 50% experience piriformis syndrome.1
Etiology: Piriformis syndrome occurs from direct cause and effect incidents, e.g., blunt force trauma to the gluteal region, surgery, to the more common accumulative habitual patterns that create structural misalignment and functional compensation. Of the total world population experiencing piriformis syndrome, no more than 20% of cases are caused by anatomical nerve abnormalities.2
Causes: Fifty percent of piriformis syndrome cases are due to the spontaneous onset of sciatica symptoms, the most common cause being the result of vigorous physical activity. The remaining 50% are related to: contusions; concussive blow to the pelvic region; surgery; anatomical nerve abnormalities; hyperlordosis, muscle abnormalities and hypertrophy; fibrosis as a result of trauma; myositis ossificans, pseudoaneurysms of the inferior gluteal artery; cerebral palsy; and total hip arthroplasty.1
Morbidity: As of 2004, estimated costs related to piriformis syndrome were more than $16 billion. This was spent in both direct medical costs and indirect expenses to ameliorate pain.1 Piriformis syndrome has caused many sufferers to incur a loss of productivity because of pain, but due to the lack of agreement as to how to diagnosis this syndrome, time away from work is not fully documented. Reports suggest that there is a 6:1 female-to-male ratio of piriformis syndrome.1
Research: Standard allopathic protocols show less than a 50% reduction in chronic pain for up to three months, with full recurrence of symptoms with the application of either marcaine or botulinum neurotoxin B injection therapy.3 Botulinum toxin A proved even less effective.4 Limited physical therapy sessions are a part of the injection protocol. One surgery study of 239 patients showed a 58.5% excellent outcome, with the remaining patient statistics as follows: 22.6% good outcome; 13.2% limited; 3.8% no benefit; and 1.9% symptoms worsened.5 Sports medicine approaches reveal a greater reduction and elimination of piriformis syndrome with the application of regular stretching and manual therapy protocols. The greatest successes occur when the client commits to a daily regimen of a home stretching routine. In an acute flare-up of symptoms, the client must stretch every two to three hours when awake. This creates the beginning of somatic education in retraining tissues to learn to return to tonus and a relaxed state. After symptoms abate, it is necessary to continue the stretching exercises to reduce the return of habitual patterns that may have created this syndrome. Traditional Chinese acupuncture methods are another holistic approach used to ameliorate this syndrome.6
Assessment Tests: Medical doctors perform digital rectal exams to further reveal muscular tenderness and pinpoint the appropriate muscle for injection therapy application. Diagnostic imaging, also prescribed by doctors, is less effective in diagnosing this syndrome but helps to rule out other possible conditions.7 The assessment protocols I applied were: the Pace test to check for abduction and external rotation of pelvic muscles; Freiberg test to force internal rotation with the leg extended; Beatty maneuver to selectively contract the piriformis muscle with the client in side-lying position on the unaffected side; and functional assessment techniques, similar to the above muscle tests by Rolfing and massage therapists Art Riggs8 and Whitney Lowe.9
Therapeutic bodywork has presented promising applications for the reduction and remedy of pain associated with sciatic nerve impingement by gluteal muscles and at tenoperiostial junctions. Cataloging of therapies suggest a greater amelioration of symptoms with nonpharmacological approaches to reduce chronic pain.1 Emphasis on awareness of habitual patterns and movement, release of myofascial adhesions,10 deep transverse cross fiber friction and a daily stretching protocol show the greatest results in ameliorating piriformis syndrome.1
Profile of Client: The subject, a 43-year-old, active female, works in a corporate setting as an executive in human resources. Medical history includes the removal of her thyroid gland 13 years ago due to cancer. Client is clear of any recurrence of cancer and is under medical supervision including daily doses of synthroid. Client suffers from asthma and allergies. Weekly allergy shots are given in her right deltoid muscle. In addition to the allergy shots and thyroid medication, client takes 800 mg of ibuprofen for pain management as needed. A relative who is a physician's assistant concurred with the client's self-diagnosis of sciatic pain.
Subject has experienced chronic pain for the past few years. Pain is experienced in the right gluteal region; the pain travels inferior along the lateral side of the leg and down along the fibula. This is experienced with a verbal numerical rating scale at an intensity level of 10, often as a dull, throbbing ache that can travel distally to the hallux. Under stressful situations, pain moves contralateral. Ibuprofen for pain management is the only form of treatment prior to this case study. Client's desired outcome is to manage the pain with the hope to be pain-free. At the conclusion of the study, the client stated, "While the pain or discomfort may not completely go away, I can be more aware of how they get started and make adjustments early on to prevent or lessen it."
The symptoms of piriformis syndrome sciatic nerve impingement are treatable with massage, by addressing the muscles surrounding the sciatic nerve that are shorter and compressing the nerve. Application of deep transverse friction at tenoperiostial junctions and focus on softening and relaxing the piriformis and the other deep lateral rotators, as well as the gluteal muscles, greatly reduce symptoms of nerve impingement. Focus work on the surrounding hamstring muscles and proximal and distal bone attachments are also noteworthy to address, as they may further aid in compressing the sciatic nerve as it branches out and travels inferior dividing into the peroneal and tibial nerves. The most appropriate muscles and attachments to massage include: tensor fascia latae (TFL); iliotibial band; iliac crest; quadratus lumborum; quadriceps; hamstring group; the greater trochanter; and sacroiliac joint attachments. Special attention was given to the lateral side of the leg, including vastus lateralis, peroneus longus and brevis, and extensor hallucis longus muscles, as well as the psoas.
Assessment of the symptoms indicated impingement of the sciatic nerve in the gluteal region. Further research with colleagues and source literature confirmed my assessment of piriformis syndrome, and enabled me to review my plan of treatment.
Report of Clinical Visits and Treatment Plan
Subject entered case study treatment experiencing chronic sciatic pain in her right gluteal region on a daily basis. Range of pain was at the highest level, assessed with a verbal numeric rating scale, ranging from 1 to 10, and often transferred to her left side with a constant ache. Client experienced intermittent tingling down the lateral side of the right leg and calf. Assessment of client revealed a positional pattern of lateral rotation at the feet referring into the hips. Her left anterior superior iliac spine was elevated approximately 1 inch higher than her right side, and her right leg felt heavier and denser in passive movement. Both feet resisted medial rotation in passive testing. Client's range of motion was restricted at the coxofemoral joint where congested and contracted muscles were felt. In addition, her left shoulder was elevated due to habitual patterns of cradling the phone to her ear at work.
The subject received a series of 10 consecutive massages of 90 minutes in duration. The sessions were administered by a massage therapist in training as part of the graduation and certification protocol outlined by PMTI Core 600+ massage therapy program. The focus of each session was to ameliorate chronic sciatic pain radiating from the gluteal region. The weekly approach incorporated deep tissue with other bodywork modalities to address the softening of muscles and fibrous adhesions at muscle and tenoperiostial junctions of the pelvic girdle, the leg and lower leg affected by sciatic pain.
Each session began with a verbal intake and visual assessment. Generally, sessions began with the client in supine position beginning with a series of range of motion (ROM) movements at the feet, assessment of where movement was impeded, then palpating for the impingement of the sciatic nerve by the piriformis muscle.
As the session progressed the subject was moved into at least two positions (supine/prone, supine/side-lying). The protocol of each massage alternated with deep-tissue massage and adjunct modalities including CranioSacral Therapy (CST), PNF and PRT stretches, somatic awareness, Trager rocking and myofascial work.
The 15-minute conclusion of each session included a review of lengthening exercises and awareness of habitual patterns and movements for at-home focus. The last portion of closure included a verbal and visual review of client's state and postural alignment.
Focus work addressed the softening of hypertonic muscles, especially of the rectus femoris, vastus lateralis, tensor fascia latae, piriformis and gluteus maximus and medius. These muscles were most benefited by applying cross-fiber friction at tenoperiostial junctions. The frictions were applied for up to five minutes. No compressions or glides were ever used over the piriformis to reduce any further possibility of compressing the nerve. Cross-fiber glides, as well as glides along the grain of the muscle, were applied to aid in the softening of the quadratus lumborum. Cross-fiber friction from the posterior superior iliac spine along the iliac crest attachment was done with considerable gentleness, as client described a bruised sensation. This "bruised feeling" was most pronounced at all of the tenoperiostial junctions of the deep lateral rotator muscles, the gluteal area, as well as in the distal aspect of the iliotibial band. Intermittently, when the iliotibial band was most restricted, the patella tendon and ligament on the lateral side would cause discomfort. Assisted PNF stretches and PRT movements enabled the contracted muscles around the hips and knees to release, allowing for an increased range of motion. As needed, compressions of the iliopsoas were applied to balance work on the quadratus lumborum.
Deep-tissue compressions and cross-fiber friction of the piriformis muscle and tenoperiostial attachments at the sacrum and the greater trochanter gave the greatest softening and improvement of impingement of the sciatic nerve. In addition, cross-fiber friction of the iliac crest assisted in bringing slack to the gluteus maximus muscle overlaying the piriformis. The client was very sensitive in this area, so friction techniques were administered very gently. For congestion in the TFL and rectus femoris muscles, soft fist compressions and hand glides were the preferred strokes and tools to achieve reduction in tissue density. PNF-resisted stretches involved the client in her process, while PRT stretches and ROM movements brought awareness of what she does and how her body functions. This was especially useful when addressing the quadriceps muscle and iliotibial band. Somatic awareness education enabled the client to find other options of movement, looking for greater ease and comfort. This led her to catch herself as she moved into a habitual pattern that created pain. She was able to find options as to what she could do to improve the situation and reduce the discomfort. CST holds were applied to the occipital region to assess where along the spinal column movement of cerebrospinal fluid (CSF) was impeded. This directed my focus to where I could assist in releasing the compression of thoracic and lumbar muscles. As the client's constricted muscles began to release, the muscles of her lower trunk and gluteal area began to soften.
List of modalities applied: CranioSacral Therapy (CST), cross-fiber friction (XFF), deep-tissue massage (DT), Swedish and ancillary strokes, Kripalu yoga poses, myofascial release, proprioception neuromuscular facilitation (PNF), positional release therapy (PRT) and Trager rocking.
Massage appeared to ameliorate the symptoms of piriformis syndrome in the subject. Deep-tissue techniques proved an effective means to reduce compression of the sciatic nerve by surrounding muscles. Cross-fiber frictions were applied for several minutes at the tenoperiostial junctions, specifically at the greater trochanter and sacrum attachments of the piriformis, and the iliac crest moving lateral from the posterior superior iliac spine to address the iliolumbar ligament, as well as the gluteus maximus and minimus attachments. In conjunction with deep-tissue techniques, adjunct modalities that proved most effective were: resisted PNF stretches of the iliotibial band; PRT movements to increase range of motion at the hip and decompress client's coxofemoral joint; and somatic education to bring awareness to patterns of movement that create a dynamic which resulted in compression of joints and congestion in muscles. The 1-inch differential in the subjects anterior superior iliac spine leveled out to approximately a quarter-inch variable by the end of the first session. As the sessions progressed and her muscles began to relax more, the anterior hip imbalance disappeared.
Although massage did not alleviate symptoms all the time, the protocol did reduce the level of pain and the frequency of episodes of discomfort. Somatic education enabled the client to take control and recognize her movement patterns that participated in exacerbating this syndrome. Through the client's awareness of her habitual patterns and a daily stretching regimen, the compression that creates this chronic pain syndrome was greatly reduced. When the subject was not diligent in following her daily stretching exercises, her symptoms were more prone to reappear.
As the level of pain and the frequency of discomfort diminished, the client also was able to reduce the amount of NSAID taken on a daily basis to occasional use. This, as a secondary benefit, reduces the possibilities of gastric upset caused by NSAID.
This study demonstrates that the application of massage to reduce piriformis syndrome in general, especially during a flare-up, is possible with appropriate decompression at the joints involved, relaxation of muscles that surround the sciatic nerve and a daily stretching protocol. It would be beneficial to pursue a more comprehensive study, involving several clients over the duration of one year who live with this syndrome, to track the rate of improvement and the recurrence of symptoms. This could be further enhanced with observation of the long-lasting effects of massage and stretching in addressing this concern. The inclusion of somatic awareness to learn how and what patterns of movement may contribute to piriformis syndrome would be of great value in re-educating the individual. This would give the client some control over what they can do and how they can alleviate their discomfort.
Appendix of exercises for piriformis syndrome client:
Peggi Honig conducted this study at the Potomac Massage Training Institute. Her case report supervisor was Martha Brown Menard, PhD, CMT, director of research.
Peggi Honig currently practices massage at three different locations in Silver Spring and Rockville, Md. She can be reached at .
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