resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
Treating GERD and Incontinence: Focus on Trigger Points
Gastroesophageal reflux disease (GERD) is defined as the regurgitation of stomach acid in the esophagus. Previously, it was thought that GERD was caused by a hiatal hernia, but recent trials suggest the cause is an inability of the hiatal sphincter to contract normally.
Older Patients, Stroke Risk and Manipulation
The first population-based study in the United States to evaluate stroke risk following spinal manipulation – and the first involving older adults – suggests that "[c]hiropractic cervical spine manipulation is unlikely to cause stroke in patients aged 66 to 99 years with neck pain.
Will You Be an Amplifer or a Mute?
These times are changing, and changing quickly. There have been many challenges to this profession throughout the past few years. The challenge is to talk, then talk and talk some more about this medicine.
How We Can Help the Injured Brain
The majority of patients with mild traumatic brain injuries recover within seven to 10 days. If concussion signs and symptoms continue beyond seven days, the diagnosis changes from acute concussion to post-concussion syndrome.
An Excerpt from TCM Case Studies: Pediatrics
This excerpt is reprinted with permission from Jamie Wu. TCM Case Studies: Pediatrics was released in 2014 by People's Medical Publishing House.
Joint Supplements for Athletes (Part 2)
A fairly recent discovery in nutrition supplemental medicine has proven to be a breakthrough in maintaining athletic joint health. Research suggests a combination of undenatured type-II collagen and tetrahydro-iso-alpha acids helps revitalize joint function and performance in athletes.
Striking a Blow to the Medical Monopoly
The U.S. Supreme Court has issued a landmark ruling in North Carolina State Board of Dental Examiners v Federal Trade Commission.
Keep Seniors Safe: Age-Proofing the Home
I want to give Dr. Claudia Anrig kudos for her Dec. 1, 2014 column, which highlighted safety issues youngsters might encounter in the home.
Converting More Patients to Your Practice
In 2013 and 2014, the theme was "the money is in the list." This meant that if you had a big email list, you were really making some "cha-ching." Unfortunately, having thousands of emails doesn't equate to thousands of dollars in profit.
There Really is No Room for Sexism
Recently, Matteo* (a transgender male) approached me during a break in an advanced shiatsu class in Berlin where he was one of two men in a group of 20 women. "Pamela. Don't forget to remind the translator to include male endings."
The Way We Are Designed: A Conversation with Gil Hedley, PhD
I was first introduced to the work of Gil Hedley by Tom DiFerdinando. He gifted me Gil's DVD series.
God and the Chiropractor
My wife went to church last Wednesday night and brought home a CD of the pastor's message. As she handed it to me, she said, "You should listen to this; you'll like it." Our family regularly goes to church and our faith plays a major role in our lives.
Treating Beyond Pain
More often than not, when a patient presents to the office, it is for a pain complaint. Headache, neck pain, low back pain, sciatica, carpal tunnel... The pain is often the focus of the patient's mindset, and they don't often have any thought of what comes after the pain.
Pain Is Only a Piece of the Puzzle
More often than not, when a patient presents to the office, it is for a pain complaint: headache, neck pain, low back pain, sciatica, carpal tunnel, etc.
News in Brief
ACA Exec. Vice President Out, Acting EVP In; F4CP Executive Director Retires; New ED Named.
Synergy Doesn't Happen in Silos: Acupuncture in Hospitals and Other Healthcare Settings
As acupuncture and traditional East Asian medicine continue to intersect and integrate with biomedical approaches, the conversation about integration expands and becomes richer.
The Need for a New Medical Model: A Challenge for Biopsychosocial and Ecopsychologica Medicine
Chinese medicine speaks of alignment between humans, heaven and earth. It is a complex view with a focus upon relationship. These are comprehensive ideas with no specific terms in contemporary medical practice.
Recreational Cannabis Use and TCM
Many people are drawn to cannabis for its effects physically, mentally and emotionally. Medically, cannabis has some legitimate uses, however the scope of this article is limited to the recreational use of cannabis.
A Well-Kept Secret: 5 Element Acupuncture, Part II
Supervising acupuncture interns at a TCM college, it has always struck me how funny it is to hear the clinic manager tell the patients that the Five Element clinic specializes in treating emotions, as if patients with physical pain have no emotions!
Managing Tibialis Posterior Tendon Injuries
The tibialis posterior is the deepest, strongest and most central muscle of the leg, with fibers originating from the tibia, fibula and interosseous membrane.
The Dietary Supplement Research Dilemma
I do not care what the truth is, one way or another; I just want to know it. And when it comes to dietary supplements, the truth can be hard to find for a number of reasons.
TCM Congress in Rothenburg is Largest in Western World
In the medieval town of Rothenburg, deep set within the Bavarian countryside in Southern Germany, the TCM Kongress Rothenburg each year draws around 1.200 participants from more than 40 different countries to attend the biggest TCM conference in the Western world.
What Do You Know About Physician Compare?
Physician Compare is a website that allows consumers to search for and obtain information about physicians and other health care professionals who provide Medicare services.
May, 2007, Vol. 07, Issue 05
Low Back, Piriformis and SI Joint Pain
By Erik Dalton, PhD
Following my February 2007 Massage Today column on sacroiliac joint syndrome, I received several e-mails from therapists asking how to differentiate low back, sacroiliac and piriformis syndrome pain.The first distinction needing clarification is that piriformis syndrome is considered a "functional entrapment syndrome." The word "functional" describes neurological compression disorders resulting from positional or kinesiological factors that are not solely linked to structural or inflammatory conditions. Therefore, clients presenting with piriformis syndrome typically only experience sciatic-like symptoms during certain movements or when pressure is applied to the affected area (Figure 1).
Sacroiliac and piriformis syndrome anatomy is comprised of many complicated elements involving bone, muscle, connective tissue and nerves. Understanding this anatomy helps reveal the difficulty that exists when developing a healing program for these often-debilitating conditions. Frequently, piriformis syndrome pain begins as the external femoral rotator balance that is distorted by pelvic obliquity, due to conditions such as backward sacral torsions, iliosacral inflares and foot hyperpronation. The most common and tormenting of the sciatic-like SI dysfunctions is called a right-on-left backward sacral torsion. It occurs when the sacrum gets stuck rotated right and side-bent left between the two innominates (Figure 2).
Typically, backward torsions involve a lifting incident, during which the person bends forward and side-bends left at the lumbosacral junction. Intervertebral discs, facet joints, sacroiliac ligaments and piriformis muscles are most vulnerable to injury in this position. However, the movement that precipitates the greatest long-term discomfort takes place when the person attempts to straighten up while L5 is side-bent left and rotated right. As L5 jams backward into the sacrum, sharp, burning sciatic pain shoots into the buttocks and down the leg. Unfortunately, backward torsions commonly are mistaken for disc pathology, causing many unneeded and unsuccessful surgical procedures. Prolonged ligament and joint capsule stress caused by an unstable (crooked) sacroiliac joint can sympathetically spasm the piriformis muscle, causing contracture, fibrosis and sciatic impingement (Figure 3), even though a torsional SI joint fixation may have been the culprit responsible for initiating the sciatic assault. Soon, the fibrotic piriformis escalates the symptoms by trapping the nerve between it and other muscles, ligaments or bone in the sciatic notch. The end result of this double-crush disorder is neural breakdown and interruption of the axoplasmatic flow of vital nutrients. Some researchers estimate that double-crush syndromes occur in as much as 40 percent of the sciatic population.1
Hamstrings and Piriformis Role in SI Dysfunction
Double-crush sciatic pain often originates from a piriformis injury brought on by lifting or overuse. As the L5 facet joints glide forward on the sacrum during trunk flexion, the piriformis and sacrotuberous ligaments must restrain the sacrum from moving forward (counternutation). Regrettably, tendon and ligament fibers are vulnerable to microtraumatic tearing during this bending/twisting maneuver. Because the piriformis partially originates from the sacrospinous ligament, which is fascially linked to the hamstrings, trauma or overuse can create adhesive scar tissue that shortens the piriformis and drags on the sacrum. Prolonged unilateral sacral drag leads to ligament hypermobility, inflammation and sacroiliac imbalance. When the hamstrings and piriformis destabilize the SI joint, other nerves (superior and inferior gluteal) become inflamed, causing symptoms resembling piriformis syndrome (Figure 4).
Since the nerve supply for the glutei, tensor fascia lata and piriformis muscles does not travel under or through the piriformis with the sciatic nerve, any signs of denervation (muscle weakness or atrophy) may indicate SI dysfunction, which might be co-present with piriformis syndrome. Often, only one piriformis will be short and tight, forcing the sacrum to shift laterally on its long axis. This sets the stage for yet another painful compensatory problem at the lumbosacral junction, known as an apex shift. According to Retzlaff, et al.,2 apex shifts cause the sacral base to rotate anteriorly, resulting in a deep sacral sulcus on the side of the tight/short piriformis. This unleveling of the sacral base creates a lumbar spine rotoscoliosis (corkscrew), which can compensate and twist all the way up to the O-A joint (Figure 5).
Since pelvic imbalances are a major contributing factor in all low back and piriformis dysfunctions, it makes sense for the manual therapist to first develop a therapeutic strategy for establishing iliosacral and sacroiliac alignment. Figure 6 demonstrates an effective elbow technique for correcting an upslipped left innominate. This iliosacral condition frequently is seen in people who bear weight on the left leg during prolonged standing. As the client gently pulls up on the therapy table while performing slow pelvic tilts, the therapist's elbow slowly releases fibrotic erector spinae, quadratus lumborum, latissimus dorsi and iliolumbar ligaments, allowing the innominate to drop inferiorly. The importance of the iliolumbar ligaments cannot be overlooked. Their primary function is preventing excessive lumbar side-bending, but they can become major sciatic pain generators when fibrotic. Because the iliolumbar ligaments form fascial hoods over the sciatic nerve when strained, they rub on the nerve's dural sheath, contributing to double (or triple) crush syndromes.
In summary, piriformis syndrome should not be treated as an isolated event, even if tests such as the Pace, Freiberg and Beatty are positive. A stable pelvis, derived through proper upper and lower quadrant balance, is essential for long-term correction of sciatic nerve conditions. All ligaments and muscles attaching to the pelvis from above and below should be tested and balanced. Once the low back and pelvis are functioning properly, piriformis techniques that address the muscle's origin and insertion, such as those shown in Figure 7 and Figure 8, usually are effective in relieving pressure on the sciatic nerve ... but not always.
Although sciatica is the most common condition treated by neurosurgeons, piriformis syndrome rarely is mentioned in the majority of neurology textbooks, with only a minimal number of U.S. surgeons trained to properly treat the condition. For the past 75 years, sciatica has been thought to be caused by a herniated disc and treated accordingly. Now, researchers at Cedars-Sinai Medical Center; the University of California, Los Angeles; and the Institute for Nerve Medicine in Los Angeles have developed a new nerve-imaging technology called magnetic resonance neurography. The technology has proven extremely effective in implicating piriformis syndrome as a causative factor for sciatic leg pain in the majority of patients who had failed diagnosis with traditional MRI scans and/or were not treated successfully with surgery. The researchers evaluated 239 patients whose symptoms had not improved after diagnosis or treatment for a herniated or damaged disc. All patients received a detailed neurological exam and had a thorough review of all previous scans and treatment history to rule out any condition that might have been missed.
Results of the study confirmed that 69 percent had piriformis syndrome, while the remaining 31 percent had a combination of other nerve, SI joint or muscle conditions. Researchers using these active diagnostic techniques found piriformis syndrome to be a more common cause of sciatica than the herniated disc.3 To treat piriformis syndrome, Dr. Filler, et al., injected a long-acting anesthetic into the spine, muscle or nerves. About 85 percent of the patients obtained some relief from the injections, which helped relax the piriformis muscle spasm. However, relief was not long-lasting and 62 patients required surgery to correct the syndrome. Of those, 82 percent had a good or excellent result during the six-year follow-up.
This groundbreaking study, published in the Journal of Neurosurgery: Spine, will surely help medical and manual therapists weed out complex diagnostic conditions such as sciatica - a condition that affects nearly 40 percent of adults at some point during their lifetime. Therefore, it behooves today's touch therapist to recognize the clinical signs of piriformis entrapment and all associated double-crush syndromes. Fortunately, now that reliable imaging tests and surgical treatments are available in most major hospitals, we must embrace one of our foremost fundamental therapeutic adages: If in doubt, refer them out!
Click here for more information about Erik Dalton, PhD.
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