First World Spine Care Graduate: Hildah Molate
Hildah Molate, the first World Spine Care (WSC) scholarship student, graduated from Palmer College of Chiropractic earlier this year and is now working at the WSC community spine clinic in Shoshong, Botswana.
NBCE to Reinstitute Computer-Based Exams
The National Board of Chiropractic Examiners (NBCE) has announced it will reinstate computer-based testing in January 2019 courtesy of a partnership with testing and assessment solutions provider Prometric.
News in Brief
Parker University Launches New Open-Access Research Journal for Chiropractic; Western States, Cleveland-KC Name New Deans of Chiropractic Colleges; Sherman College Goes Tobacco-Free; Life University Wins 11 Awards.
Official NCCAOM Practice Tests
The National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) is excited to announce the launch of the new NCCAOM Exam Preparation Center.
A Novel Way to Prevent Elderly Falls: Toe Strength
In any given year, nearly 40 percent of senior citizens ages 70 and older will fall at least once. Each fall significantly increases the risk of not only sprains, strains and contusions, but also fractures.
Cyber Threat Checklist: Defend Your Business With These 10 Steps
Living in an internet connected society brings many conveniences and benefits. The power of the internet to connect us with customers, store data, and find information has opened the door for many small business owners to grow and flourish.
State by State: Chiropractic Leads Changes in Health Care
Monumental legislative bills in support of the chiropractic profession were passed recently in Washington, West Virginia and Oregon. Here is a review of this important legislation, state by state...
Missed Causes of LBP: It's the Syndrome, Not the Subluxation
When I read the chart notes of other chiropractors, I am usually disappointed. They list what vertebrae are fixated or misaligned. They may describe the involved fascia and muscles.
Is Primary Spine Care the Answer for Chiropractic?
Recently, we sat down with Mark Studin, DC, FASBE(C), DAAPM, DAAMLP, to discuss the state of chiropractic and why primary spine care may hold the key to chiropractic's future. Read what he had to share in this exclusive interview.
Catch the Workplace Wellness Wave
Do you offer workplace wellness services to local businesses? If not, you might want to consider this lucrative channel for expanding your practice. Workplace wellness programs and wellness-related benefits have grown in popularity over the past several decades.
Spring Allergies & The Spleen: Looking at Pattern Differentiation
As the season of Spring fades away and we shift into the warm summer months, many patients suffer from chronic allergies. This is by far one of the most common issues I see in the clinic as well as often mistreated and misdiagnosed.
Old Trend, New Risks: Heavy Weight Training
With more opportunities to exercise than ever, a greater selection of exercise options, and the subsequent opinions supporting and challenging their merits, it's easy to be confused as to which approach is best.
Dropping Insurance: 4 Steps
My office manager just got off the phone with the secretary of a long-standing patient. I have treated this woman and 10 members of her family for more than a decade. She has, as have all of my patients, paid my fee at the time of service since I dropped insurance in 1997.
Better With Chiropractic
While chiropractic care is receiving high levels of exposure these days, most pain patients who consult with a health provider still do so with their primary-care MD. And of course, that means in most cases, they're receiving standard medical care, not chiropractic.
Multi-Dimensional Acupuncture: 3D, 4D & 5D
Maggie is an intuitive healer and workshop leader who I met on a recent hike. While we were talking she told me how she had to take it easy because of her knees. She said that her doctor told her that she has the early signs of arthritis.
Paving the Way to Integrative Health & Wellness
Jared Polis (D-Colorado) and Mike Coffman (R-Colorado) launched the integrative health and wellness (IHW) caucus in October, 2018.
New Opportunities for DCs
For decades, the model chiropractic practice has been the single-doctor practice. Recent surveys have found that approximately two-thirds of U.S. doctors of chiropractic still practice this way, with another 20 percent practicing in multiple-chiropractor practices.
Diagnosing & Treating Aggressive Energy
Recently, there has been an article, and subsequent discussion, about the subject of Aggressive Energy (AKA "AE"), including ways to detect its presence and an alternative method of treating it.
Transforming Exam Delivery
The NBCE Board of Directors has never wavered on its promise to deliver an excellent, on-campus computerized testing experience to students. Likewise, there has never been a compromise to the delivery of fair, valid and legally defensible exams.
Reducing Allostatic Load & Stress Through Heightened Awareness
Your contemporary mental health and psychotherapy colleagues may often approach the treatment of allostatic load as a mental health condition and use prescription psycho-pharmaceutical medicine to affect general and specific central nervous system (CNS) pathways and brain neuro-chemistry medicine to alleviate the associated symptoms.
Chiropractic's Next Frontier: Adjusting the Microbiome
Restoring a healthy microbiome to help treat disease may be the next frontier in chiropractic offices around the country.
Practice Pearls: There's More to ROM Than Meets the Eye
As part of my neuromusculoskeletal examination, I perform range-of-motion (ROM) evaluations. I can "eyeball" the range and measure, I can use a goniometer and measure, I can use my phone app and measure, or I can use various other instruments to help determine degrees of motion.
Bastyr University: On the Front Lines of the Pain Epidemic
At University of Washington's Harborview Medical Center, the Seattle region's only Level I Trauma and Burn Center, the demands for in-patient care are dramatically different from a private clinic environment.
TCM Codes for the World
I just received an email concerning the ICD-TM11 codes. The World Health Organization (WHO) will be presenting the new ICD-11 codes to World Health Assembly very soon.
Prompting Memory: How to Stimulate Cognition
Recently I gave a talk titled, The Art of Memoir – Tapping the Past to Sharpen the Present at a senior lunch event in Austin, Texas.
Acupuncture's Standard of Care
Both a concern and critique of acupuncture, frequently espoused by the bio-medical community is, "there is no standard of care in acupuncture." The following is why I believe this statement is disingenuous at best.
Regenerative Medicine: How to Do It by the Books
The "lay of the land" for regenerative therapies, including but certainly not limited to adult stem-cell treatments, seems to change almost daily.
It's Time for a Functional Approach to Chronic Illness
It seems one of the more modern buzzwords is chronic, referring to diseases – that is to say, "ongoing and incurable." However, we can take a different perspective and recognize that, although the body may have been traumatized and injured, healing should always be viewed in the realm of possibility.
The Acupuncturist and the Opioid Crisis: Conquering Pain & Addiction in the U.S.
The current opioid epidemic dominates the discussion among national health leaders, recovery advocates and families nationwide. Opioids include heroin as well as prescription pain relievers such as oxycodone, hydrocodone, codeine, morphine, fentanyl, and others.
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 previous articles by Erik Dalton, PhD.
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