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What's New in the NCCIH Strategic Plan
The NIH National Center for Complementary and Integrative Health (NCCIH) released its draft strategic plan 2016-2021 for public comment in early spring of 2016.
Know Your Research: Tips for Evaluating Literature Reviews
Clinical and experimental studies are not the only types of published research we might encounter as we look for evidence to inform our practices. One of the most useful types is the literature review, which summarizes a group of studies.
Guidelines for the Use of Modifier -52
Modifier -52 identifies that a service or procedure has been partially reduced or eliminated at the physician's discretion. This is to indicate the basic service described by the procedure code has been performed, but not all aspects of the service have been performed.
What are the Meridians?
The meridian and collateral system (jing luo, hereinafter referred to as "Meridians") is comprised of the main meridian channels (jing mai) and the collateral vessels (luo mai). Jing takes from meaning of the Chinese word pathway (also jing) and are the main branches of the system.
Adventures with the Pericardium
My previous column on the San Jiao deserves equal time for SJ's loving partner, the pericardium. I nicknamed SJ the travel meridian – but pericardium can also play a crucial role in air travel.
The National Institutes of Health (NIH) lists more than 80 common autoimmune diseases including asthma, Crohn's disease, Guillain-Barré syndrome, multiple sclerosis, myasthenia gravis, psoriasis, rheumatoid arthritis, and lupus.
Are Probiotics Doing More Harm Than Good?
Considerable controversy exists concerning the efficacy of probiotic supplements. Very few human studies show any real positive impact on the microbiome or health. The "promise" of probiotics is based on the few animal studies that suggest a positive effect.
Traditional Chinese Herbal Medicine in Taiwan Hospitals
This spring, a team of Western medical doctors and TCM practitioners from Cleveland Clinic traveled to Taiwan to visit Kaiser Pharmaceutical Co. (KP), and China Medical University (CMU), Taiwan's leading integrative medicine hospital.
Work Stress and Musculoskeletal Health: Do Your Patients Get the Connection?
Most people underestimate the impact their job has on their health, especially if that job isn't particularly physically demanding. Big mistake.
MPA Media Wins More Publishing Awards
The American Society of Business Publication Editors (ASBPE) has honored Dynamic Chiropractic with a national award and two regional awards for editorial excellence, and sister publication DC Practice Insights with two regional awards for graphic design excellence.
Analyzing Acupuncture Case Studies
Confirm the answer quickly by the elimination method. Take this case study as an example. After two treatments for back pain, a patient presents for a third session complaining of rapid breathing and wheezing that is made worse during cold weather.
Less Time Than Required
Q: When is it appropriate to use a modifier -52? Can I use it for a timed service when I do less than the time required by the code?
Let's Talk About Biceps Injuries at the Elbow
While most muscles cross over only one joint, the biceps crosses two joints: the elbow and the shoulder. Injuries to the lower biceps cause considerable elbow pain. Here's how to assess and treat an injury to this area conservatively.
Overuse Injuries in Young Athletes (Part 1)
More than 45 million children ages 6-18 participate in some form of organized athletics, and 75 percent of American families with school-aged children have at least one child participating in organized sports.
Illuminating the Hidden, Freeing the Source
Amongst the Primary Channels, from a classical point of view, the small intestine is perhaps the most important channel to understand. It is one of the least used acupuncture channels in modern acupuncture, yet it within it can be found a wealth of theories from the Ling Shu.
The Professional and Practice Benefits of Political Activism
Welcome to election season, a vital part of our American culture. Every two years, without fail, we are bombarded with TV, print materials and phone messages seeking our vote.
Don't Ignore the Lower Half of the Pelvis (Part 1)
When your patient complains of lower back or pelvic pain, but your usual treatments are not getting the job done, what do you examine and treat? You may be missing important structures in the lower half of the pelvis.
Time to Fight for Your Medicare Right
I have heard a lot of noise and a lot of debate about what is going on with Medicare. As an ACA delegate, I often get asked: 'What is the ACA even doing?'
Lessons from Functional Neurology
Chiropractic neurology, also known as clinical neuroscience or functional neurology, is moving the chiropractic profession forward by leaps and bounds.
A Study of Relationships
Sa-Ahm's five element acupuncture method is known to be one of the most effective acupuncture techniques in Korea because it gives an instant response at the time of treatment and has a high success rate in resolving chronic problems.
Chiropractic in the Eyes of the Public: 2nd Gallup-Palmer Poll
The second Gallup / Palmer College poll has been completed, yielding significant additional data regarding Americans' experiences with and perceptions of chiropractic care.
March, 2008, Vol. 08, Issue 03
Treating Piriformis Syndrome
By Whitney Lowe, LMT
Sciatica is a term that describes radiating neurological pain that courses down the back side of the lower extremity. When the term is used, most people think of intervertebral disc pathology as the source of the problem. Lumbar disc pathology certainly can produce lower-extremity neurological pain, but other conditions can produce identical symptoms.
The sciatic nerve, formed by nerve roots from the lumbar and sacral plexuses, is the largest nerve in the body. It passes through a number of small spaces as it makes its way from the lumbopelvic region down the lower extremity. Along the way there are several sites at which sciatic nerve compression can occur. Nerve compression in any of these locations can produce symptoms identical to those of a herniated lumbar disc.
In the gluteal region, the piriformis muscle can compress the sciatic nerve, creating a condition known as piriformis syndrome. The sciatic nerve derives from the L4-S2 nerve roots and courses anterior to the sacrum, before passing inferior to the piriformis muscle (Figure 1). Tendinous bands at the edge of the muscle can compress the nerve. It also can be compressed between the piriformis and the sacrospinous ligament. Even a low level of pressure applied to the nerve for a long period of time can create symptoms.1
Other nerves in this region also are susceptible to compression and are variations of piriformis syndrome. The superior gluteal nerve can be squeezed between the piriformis and the greater sciatic notch (Figure 1). The superior gluteal nerve is primarily a motor nerve that supplies the gluteus medius, gluteus minimus and tensor fasciae latae. Nerve compression produces weakness in the abductors of the hip, but radiating pain down the posterior leg does not occur, as the nerve is confined to the gluteal region. If neurological symptoms are confined to the posterior thigh and do not extend below the knee, compression of the posterior femoral cutaneous nerve could be the reason. The posterior femoral cutaneous nerve lies adjacent to the sciatic nerve and also can be compressed by the piriformis muscle.2
Certain anatomical variations play a role in piriformis syndrome. The sciatic nerve is composed of two divisions: the peroneal and tibial. Usually, they are bound together along the length of the nerve, but in some cases they divide as they pass the piriformis muscle (Figure 2). Sometimes one division goes through the muscle while the other goes below it. In other cases, one division goes above the piriformis while the other goes below. In a small percentage of the population, both divisions go directly through the piriformis muscle.3 It is easy to see how some of these anatomical variations cause increased neurological symptoms.
Piriformis syndrome routinely occurs from external pressure such as sitting on a wallet. In rare cases it results from a direct blow to the buttock area.4 As a result of trauma, adhesions can develop between the piriformis muscle, the sciatic nerve and the roof of the greater sciatic notch.
Myofascial trigger points in the piriformis or other gluteal muscles can create hypertonicity and lead directly to nerve compression. Trigger points in the gluteus minimus are known to reproduce symptoms identical to sciatica and could be confused with piriformis syndrome.3 Sacroiliac joint dysfunction also can perpetuate trigger points in the piriformis muscle and increase the likelihood of nerve compression.5
The most important factor in designing a treatment strategy for any soft-tissue disorder is to understand the nature of the problem and make sure the physiological effects of the treatment approach fit appropriately. The primary problem in this condition is nerve entrapment by a soft-tissue structure. Therefore, the goal of treatment is to reduce compressive force on the affected nerve(s). The piriformis muscle is the cause of the nerve entrapment, so treatment strategies emphasize reducing piriformis tightness.
After applying superficial effleurage and other general warming techniques to reduce tension in the gluteal muscles, treatment of the piriformis can begin. Keep in mind that this region can be very tender, so approach treatment with presence and compassionate pressure. Myofascial trigger points in the piriformis muscle are treated with static compression techniques. Apply pressure to the region and hold it for 8-10 seconds until you feel some degree of tissue relaxation under your treatment hand. Static pressure can begin with a broad contact surface such as the back of the fist to gain initial muscle relaxation. After warming up and relaxing the muscles with broad applications of pressure, use a small contact surface such as the thumb, elbow or pressure tool for specific trigger-point treatment.
Use caution when applying pressure to this region because you don't want to further compress the region of nerve entrapment. The muscles may be tender, but pressure on the piriformis region should not reproduce or aggravate the neurological symptoms. If pressure on the piriformis region aggravates neurological symptoms in the gluteal region or down the lower extremity, you need to reduce pressure and/or move to a different location.
Longitudinal stripping methods along the length of the piriformis muscle also help reduce tension. Stripping techniques are performed with the fingertips, knuckle, thumb, elbow, or pressure tool. The stripping motion can be performed from the sacrum toward the trochanter or from the trochanter toward the sacrum.
In some cases, you want to avoid putting direct pressure on the region of nerve entrapment. Muscle energy technique (MET) stretching is a great option in this case. To perform an MET treatment for the piriformis, begin with the client in a prone position. Bring the lower extremity into lateral rotation to shorten the piriformis. Instruct the client to hold the leg in that position as you attempt to pull the foot in a lateral direction (medially rotating the hip). Tell the client to slowly release the contraction. As the contraction is released, pull the foot farther laterally, which stretches (Figure 3).
Piriformis compression of nerves in the gluteal region is likely a cause of lower-extremity sciatic nerve symptoms. If piriformis syndrome is accurately identified as the cause of the symptoms, massage is a valuable treatment strategy as long as it is performed correctly.
Click here for more information about Whitney Lowe, LMT.
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