Chapter 4: Massage and Sciatica: An In-Depth Study 2 CE Hours By: Kerry Davis, LMT, CIMT, CPT Learning objectives Define the characteristics of sciatica. Discuss how to construct a treatment plan. Recognize the causes of sciatica. Discuss how to assess the client’s posture and gait. Compare sciatica with other conditions of the low back. Describe the evaluation of the client’s pain patterns and symptoms. Distinguish the muscle imbalance patterns attributing to sciatica. Demonstrate practice of test assessments to rule out other Understand the pattern of referred pain resulting from sciatica. conditions of the low back. Illustrate application of massage techniques to treat the client. Overview Low back pain affects more than three million people in the United encounter multiple cases during the course of their practice due to the States each year (Werner, 2002). According to a 2010 survey, low back impact that low back pain has on society. This course will educate the pain was listed as the third most oppressive condition afflicting people. massage therapist about how to identify sciatica. It will also familiarize Low back pain does not discriminate between men and women and the therapist with the most common causes of sciatica, discuss usually presents as early as the age of thirty; in fact, the prevalence differences between sciatica from piriformis syndrome and sacroiliac increases in correlation with age (National Institute of Neurological joint dysfunctions, examine the proper evaluation of the condition, as Disorders and Stroke, 2015). It is likely that massage therapists will well as develop the treatment protocols for sciatica. UNDERSTANDING SCIATICA Sciatica, or lumbar radiculopathy, is characterized as an inflammation in the feet and toes. The degree of compression upon the nerve of the sciatic nerve - causing pain in the low back, buttocks, hip, determines the range of symptoms that are experienced. In all cases, and posterior leg regions (Lowe, 1997). The symptoms are a result these symptoms can become aggravated during prolonged sitting, of compression of the sciatic nerve. “Sciatica” is often used as an coughing, or bending (Werner, 2002). According to a clinical review, umbrella term for any pain experienced in the low back; however, approximately 5-10 percent of patients with low back pain suffer the pattern of pain that distinguishes sciatica from other low back from sciatica. It is the second most common reason for physician conditions is a unilateral (one side) pain that originates from the low visits, the fifth most common reason for hospitalization, and the third back, travels down the leg and - depending on severity - to the foot. most common cause for surgery (National Institute of Neurological Sciatica presents as a radiating, burning pain. It also is described as Disorders and Stroke, 2015). shooting pain with mild soreness, numbness in the leg, and/or tingling Risk factors for sciatica A risk factor is anything that increases the probability of developing Overweight Excess weight gain or quickly gaining weight a disease or injury. There are several components that place a person translates to weak abdominal muscles and undue at risk for sciatica. Table 1 was compiled by the National Institute stress to the lumbar vertebrae. of Neurological Disorders and Stroke and identifies some of the risk Occupational Sitting for long periods of time at a desk, factors for sciatica. especially with poor back support, is a factor Table 1: Risk factors for sciatica. for low back pain. Vibrations from a car - along with prolonged sitting - also contribute to the Condition Description condition. Other occupational factors are jobs that Age As people age, muscles lose elasticity, require frequent heavy lifting. intervertebral discs lose flexibility, and bone density decreases. There are several other conditions that create a predisposition to sciatica as shown in Table 2. Fitness level A lack of strengthening the abdominals and other muscles that support the spine leads to low back Table 2: Other risk factors for sciatica. pain over time. “Weekend Warriors” (those who Condition Description are sedentary throughout the week and engage in Postural deviations Janda’s Lower cross syndrome and scoliosis rigorous exercise on the weekend) are also at risk greatly increase the probability of nerve for low back pain. entrapment (The Janda Approach, 2016). Pregnancy Pelvic adjustment for childbirth and excess Spondylosis Better known as osteoporosis of the spine, anterior weight loading strains the lower back, this degenerative condition progresses to which may result in sciatica that is generally create possible bone spurs, and involves resolved postpartum. muscle weakness (Werner, 2002). Massage.EliteCME.com Page 46 Spondylolysis This condition involves the lumbar vertebrae Disc herniation This condition transpires when the - specifically L5 - and is marked by a defect intervertebral disc becomes compressed, resulting in an altered ability to bear weight causing some of the jelly-like fluid to slip out (Litao, 2015). (Werner, 2002). Spondylolisthesis Involving the lumbosacral area, this disorder Due to the various risk factors for sciatica, a thorough examination of occurs when one vertebrae becomes the client’s medical history is essential in identifying which factors are anteriorly displaced over the vertebrae below contributing and which factors can be eliminated. This process will aid (Werner, 2002). in a more proficient treatment plan. Signs and symptoms of sciatica Sciatica presents with various signs and symptoms - the severity of 4. Referred pain directly correlates to the severity of the injury. which depend on the cause. According to Physio Pedia (2016), pain in In accordance with the above guidelines, sciatica symptoms depend on the buttocks is the main symptom. Pain caused by nerve entrapment is where the nerve is compressed. The following list, provided by Physio described as mild, sharp, or radiating; entrapment of the sciatic nerve Pedia (2016), details the location of sciatic nerve entrapment and its will also cause these symptoms. The course of this pain begins in the corresponding symptoms: gluteal region and refers down the leg - constantly or intermittently - ● L4: Compression of the nerve at the L4 vertebrae results in pain, depending on the cause for entrapment. tingling, and numbness in the thigh of the affected side, and What is referred pain? extends down to the big toe. Referred pain is defined as “pain felt in an area outside the location of ● L5: Compression at the L5 vertebrae will present as pain, tingling, the injury” (Werner, 2002). There are four basic guidelines inherent and numbness traveling down to the top and inner portion of the with referred pain. Dr. Ben Benjamin, the founder of the Muscular foot and toes on the affected side. Therapy Institute in Cambridge, Massachusetts, classified these ● S1: Compression of the nerve at the S1 level will present as pain, guidelines as: tingling, and numbness traveling down the lateral portion of the 1. Referred pain is always referred distally (from the axial skeleton leg and foot, including the outer half of the bottom of the foot. towards the appendicular skeleton). Since the sciatic nerve innervates several structures of the lower body, 2. Referred pain is unilateral. If there is complaint of pain on both other symptoms include: impaired reflexes, burning sensation, limping sides then the injury is present bilaterally (both sides). on the affected side, and muscle weakness of the affected side. As 3. Referred pain occurs within a pattern-able dermatome. A stated previously, a thorough examination is imperative to create a dermatome is the area of the body innervated by a single spinal treatment plan. root. For example, the sciatic nerve dermatome includes the buttocks and hamstrings. Anatomy, physiology, and kinesiology of the low back The low back The supraspinous ligament connects the spinous process (the posterior When discussing the low back, the lumbar spine and sacrum are bony landmark of the vertebral body) of one vertebra to another. The generally referenced as one unit; however, these structures are indeed interspinous ligament connects the spinous process from the bottom of separate. one vertebral body to the top of another, or from the root to the apex. The lumbar spine is comprised of five vertebrae: L1, L2, L3, L4 and The supraspinous and interspinous ligaments work together to hinder L5. The vertebrae are stocky in nature and are designed to support excessive spinal flexion (Kishner, 2015). the head and thorax, yet offer considerable flexibility for flexion, The iliolumbar ligaments connect the transverse processes (bony extension, rotation, and lateral flexion (Stone & Stone 2003). Together, protrusions to the left and right of the vertebral body) of the L4 and they create a lordotic curve - or convex anteriorly, and concave L5 vertebrae to the iliac crest (hip). This ligament acts to secure the posteriorly. The normal curvature range for the lumbar spine is 40-60 sacroiliac joint (Kishner, 2015). degrees (Biel, 2001). Nerves Distal to the L5 vertebra lays the sacrum. The sacrum is a triangular The sciatic nerve is the largest nerve in the body and innervates all bone that consists of four to five vertebrae fused together that are also the muscles of the lower body. It is a combination of nerves emerging situated between the iliac bones of the hip and form the sacroiliac from the fourth lumbar vertebra down through S3 of the sacrum. This joint. Aside from linking the spine to the hips, the sacrum also acts connected group of nerves is called the lumbosacral plexus. From S3, to transfer weight to the pelvis and legs from the upper body. The the sciatic nerve then passes through the gluteal region to the posterior sacrum forms a kyphotic curve, or concaves anteriorly, and is convex thigh. It then branches off into two segments at the popliteal region posteriorly (Biel, 2001). (Biel, 2001). Ligaments Muscles Ligaments are dense connective tissue that link two bones together at a There are five muscles that have a major effect on the lumbar spine joint.