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Streamline Your Front Desk
Your front office can be your greatest source of efficiency or it can be a constant bottleneck. Increasing the productivity of this area, while not sacrificing the quality of patient interaction, can be a little tricky. However, with some focused effort and intention, your front desk can keep your practice running smoothly.
Parker University Embraces New Era
Change is in the air at Parker University, which recently announced the selection of both a new president and a new consultant for its seminar program.
One of the most common trends to see in clinical medical practice and public health is the cycles of health "buzzwords." These come and go depending upon the current cultural zeitgeist. One year, "parasites" are causing all the issues, and the next year it's "candida."
The Need for Standards
ISO-TC-249: You may look at these letters and numbers and wonder what they are and what they might mean. They turn into: International Standards Organization- Technical Committee – 249. There is a global organization called The International Organization for Standardization.
A Different Way of Looking at It
The way you and your chiropractic colleagues access information has changed over the past decade. According to a recent survey conducted by Dynamic Chiropractic, almost half (48 percent) of DCs read online articles on their personal computer or laptop daily.
How to Reach Your World With the Chiropractic Message
My latest effort to share chiropractic occurred in mid-May while I was sitting at an introductory parent information night for high schoolers. The IT instructor informed us that each student would be receiving a computer for all their studies.
Keeping Malpractice Allegations at Bay
It has been suggested that in the litigious environment in which we live, the practice of chiropractic should be defensive and practitioners should constantly be watching their backs. An element of defensive practice is a good idea.
Billing One-on-One, Direct Patient Contact
This is often misunderstood and leads to trepidation when documenting and subsequently billing timed services.
Billing Timed Services
Q: I do not always use physical medicine services but in my state I do have a scope of practice that allows me to provide many of these services. I am trying to understand what "direct one-on-one patient contact" means in relation to physical medicine services.
In This Current Age of Anxiety
Anxiety, also referred to angst or hysteria, goes by many names. One, popularized by the sagacious Zhang Zhong Jing, who many practitioners of Chinese Medicine may be familiar with, is known as Restless Zang/Fu disorder.
Discovery: Finding Insights and Each Other in Different Disciplines
Recently I've been thinking about all sorts of things which are hidden from our daily direct experience. That general category is what links nearly everything that catches my attention and then demands some kind of investigation.
Distal Style Treatment of Neurogenic Pain
Treat locally or distally? This question has frequented my thoughts for the treatment of pain throughout my acupuncture career. Each style has strengths and weaknesses, thus the versatile practitioner would do well to forgo dogmatic adherence to any one style in deference to the needs of the individual patient.
A Whole-Body Approach to Chronic Tension Headaches
Nearly every day in our practices, we see patients with chronic headaches that have not responded to traditional treatment. They present in our offices with a feeble hope that "maybe" a chiropractor can help.
Low Fat vs. Low Carb & the Power of Protein
A science-based website recently posted a nice summary of 23 randomized, controlled trials from peer-reviewed journals pitting low-carb diets against low-fat diets.
With Low-Back Pain, Sometimes Little Things Matter
Typical treatments for low back pain involve large muscles like the quadratus lumborum, iliopsoas, and piriformis. However, there are situations when a very small muscle, the multifidus, can play a significant role in the diagnosis and treatment of low back muscular or spinal injury.
Sleepless nights, anxiety, mood swings, euphoric energy bursts, obsessive thinking, and a strange feeling in his chest. That is what Matt was experiencing when he first entered my practice. Rather than being concerned, he was loving every minute of it.
Prostate Cancer Risk
A large study published in January 2016 in the American Journal of Clinical Nutrition showed that men who are vegans had a 35% lower risk of developing prostate cancer compared to non-vegan men. The study followed more than 26,346 men who are part of the Adventists Health Study-2.
Transforming Las Vegas
On a warm spring day in Las Vegas, Sonia Kim, clinic front desk staff, is busy preparing for a full day of intern shifts at Wongu Health Center. She greets patients, makes sure documents are properly signed, and lets the interns know that their patients have arrived.
News in Brief
NYCC Aggregates Degree Programs in New School; Palmer Chancellor Receives Education Award From ICA; Oklahaven Announces "Have a Heart" Winners.
Holistic Skin Care and Modern Technology
Anti-aging is a concept that we hear in reference to skin rejuvenation and growing older on a daily basis. Aging begins as soon as we are born; therefore "pro-aging" is embracing all stages of life gracefully, with vitality, wisdom, joy, and gratitude as the goal.
Hip Flexor Contractures & LBP in Above-the-Knee Amputations
Patients with above-the-knee amputations (AK or AKA) are particularly prone to developing hip flexor contractures. Not to be confused with muscle tightness, contractures are a permanent shortening of tissues which cause deformity or distortion.
Finger (Pad) Pointing: Repetitive-Use Injury Waiting to Happen
"My wrist and hand hurt. I spend all day working on computers and then I come home and spend more time on a computer, usually playing video games."
Building Bridges with Discipline
As practitioners of traditional Chinese herbal medicine, our role is to educate patients and medical practitioners about the various safety aspects of our medicine. Medical doctors that embrace Chinese medicine want to collaborate and include Chinese herbal medicine in more aspects of clinical care to support their patients.
Constructing Our Reality, Part 2
My last article discussed perception and its relationship to the primary channels. Before we get to the channels most commonly used to treat sensory disturbances, the small intestine and triple heater, we should first talk about the bladder channel.
Understanding Levels of Evidence
The concept of levels of evidence is a cornerstone of research literacy and a great starting point for understanding basic principles of how research works.
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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