Chapter 4: Massage and : An In-Depth Study 2 CE Hours

By: Kerry Davis, LMT, CIMT, CPT

Learning objectives ŠŠ Define the characteristics of sciatica. ŠŠ Discuss how to construct a treatment plan. ŠŠ Recognize the causes of sciatica. ŠŠ Discuss how to assess the client’s posture and gait. ŠŠ Compare sciatica with other conditions of the low back. ŠŠ Describe the evaluation of the client’s patterns and symptoms. ŠŠ Distinguish the muscle imbalance patterns attributing to sciatica. ŠŠ Demonstrate practice of test assessments to rule out other ŠŠ Understand the pattern of referred pain resulting from sciatica. conditions of the low back. ŠŠ Illustrate application of massage techniques to treat the client. Overview Low 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 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 , is characterized as an inflammation in the feet and toes. The degree of compression upon the 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 . 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 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 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. (Werner, 2002).

Massage.EliteCME.com Page 46 This condition involves the lumbar vertebrae Disc herniation This condition transpires when the - specifically L5 - and is marked by a defect becomes compressed, resulting in an altered ability to bear weight causing some of the jelly-like fluid to slip out (Litao, 2015). (Werner, 2002). 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 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). 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. Their primary function is to provide joint stability and to prevent and/or the sacroiliac joint: the iliopsoas, the quadratus lumborum, movement that might cause damage. An important characteristic of the gluteus maximus (along with gluteus medius), and the piriformis ligaments is their limited ability to stretch. As a result, a ligament will (Neumann, 2010). not return to its original length if overstretched, and thus are more Iliopsoas is a powerful hip flexor. It extends from the anterior surface likely to tear (Werner, 2002). Should overstretching occur, additional of the lumbar vertebrae and ilium, deep into the abdominal contents movement of the bones develops and may result in a pattern of re- which attach to the lesser trochanter of the femur. The lesser trochanter injury (Werner, 2002). The most frequently sprained ligaments that is the site of attachment of two muscles: the psoas and iliacus. The influence low back pain are: the supraspinous between L4-L5 and psoas muscle originates from the body and transverse processes of all L5-S1, the interspinous between L4-L5 and L5-S1, and the iliolumbar lumber vertebrae, in addition to the twelfth thoracic. It also originates (Benjamin, 2015).

Page 47 Massage.EliteCME.com from the intervertebral discs above each vertebra. The psoas muscle sacrotuberous ligament (which connects the sacrum and coccyx to the then passes under the inguinal ligament (the connecting ligament ischium at the ischial tuberosity), sacroiliac ligament, and the erector between the pubic tubercle of the pubis and the anterior superior iliac spinae aponeurosis (the common attachment point for the erector spine [ASIS] of the ilium) and inserts into the lesser trochanter of the spinae muscles on the sacrum). It extends to the iliotibial band (IT femur. band) and to the gluteal tuberosity of the femur. It is innervated by Aside from being a major hip flexor, the psoas is crucial in providing the inferior gluteal nerve (L5, S1, & S2). Although it is not a postural vertical stability for the lumbar spine and directly affects the degree of muscle, a weakness in the gluteal muscle usually results in low back the lordotic curve. The thick iliacus muscle arises from the iliac fossa pain - specifically weakness in gluteus medius. This muscle - located at (anterior portion of the ilium), as well as from the anterior inferior iliac the outer hip (ilium) and inserting to the greater trochanter - works in spine (AIIS), to join with the psoas and insert at the lesser trochanter conjunction with the gluteus maximus to extend the hip. An important of the femur (Biel, 2001). Both muscles are innervated by nerves action that the gluteus medius has during walking is inhibiting the branching from L2 and L3 of the lumbar plexus (Stone & Stone, pelvis from dropping toward the opposite swinging leg (Neumann, 2003). 2010). The quadratus lumborum (QL) is often mistaken as a muscle of the The final muscle that can affect low back pain - and perhaps the most low back due to the accessibility of its lateral edge from the side of commonly associated with low back pain - is the piriformis. Emerging the trunk, beneath the erector spinae. In actuality, it is the deepest from the sacrum and sacrotuberous ligament, the piriformis inserts into abdominal muscle and is perceived as a continuation of the transverse the greater trochanter of the femur - where it acts to laterally rotate abdominis (Biel, 2001). The QL originates from the iliolumbar the hip. There is one essential feature of the piriformis that gives it ligaments (L4 and L5) and the iliac crest to insert into the transverse a central role in creating sciatic pain: the location of the muscle in processes of the first through fourth lumbar vertebrae - as well as the relation to the sciatic nerve which can put it in a position to possibly twelfth rib. Innervated by T12 and L1 nerves, the QL acts to laterally entrap the nerve. As the sciatic nerve travels through the gluteal flex the trunk and elevate the hip (Stone & Stone, 2003). region, it passes under the piriformis muscle. Because of this, an over- contracted piriformis can place direct pressure upon the sciatic nerve Gluteus maximus is the superficial muscle of the gluteal region and (Neumann 2010). In addition, a small percentage of the population is is the most influential lateral rotator of the hip. This large muscle born with the sciatic nerve passing through the actual muscle (Lowe, arises from the posterior sacrum, coccyx, outer surface of the ilium, 1997).

Differentiating sciatica from other pathologies Since the lower back is a complex anatomical area, there are other sciatica is that sciatica will present with weakness and diminution conditions that have symptoms that may mimic sciatica. Two such of the proximal and distal muscles; piriformis syndrome will exhibit conditions are Piriformis syndrome and Sacroiliac joint dysfunction weakness with shortening in the distal muscles only (O’Neill- (Lowe, 1997). Boyajian, McClain, Coleman & Thomas, 2008). Piriformis syndrome To diagnose piriformis syndrome, a thorough intake history must The piriformis muscle connects the femur to the sacrum. While be conducted to rule out disc pathologies, trochanteric bursitis walking, it contracts as the leg is brought forward (the swing phase). (inflammation of the bursa of the hip and femur joint), and sciatica. It then contracts a second time to provide postural stability while the There are four diagnostic tests recommended: FAIR, Pace, Freiburg opposite leg swings forward (the stance phase) (O’Neill-Boyajian, tests, and Beatty Maneuver (Lowe, 1997). McClain, Coleman & Thomas, 2008). As a result, limping or difficulty FAIR stands for flexion, adduction, and internal rotation and is also walking are symptoms of piriformis syndrome. known as the “Piriformis test.” To perform this test, the client will According to Physio Pedia (2014), several other symptoms similar to assume a side-lying position with the unaffected side resting on the sciatica may be shared with piriformis syndrome. These include: edge of the massage table. From this position, the client will flex the ●● Pain with prolonged sitting (over 15-20 minutes). hip and knee so that the knee drops off the table. Next, the therapist ●● Pain with sitting cross-legged. will ensure that the pelvis remains steady by placing one hand on the ●● Pain when rising from a seated position. hip, and then will provide a gentle stretch of the piriformis by pressing ●● Radiating pain felt at the sacrum, buttocks, hip, and/or groin. the knee down with the other hand. Re-creation of symptoms indicates Piriformis syndrome pain radiates into the low back, as does sciatica a positive test result (Lowe, 1997). pain. This condition is classified into two types: primary piriformis The Pace test involves resisted hip abduction by the therapist at the syndrome and secondary piriformis syndrome. knee while the client is seated. Again, re-creation of symptoms is a Primary piriformis syndrome is rare and is caused by an anatomical positive test result (Physio Pedia, 2016). anomaly. It is depicted as the sciatic nerve passing through the muscle Clients test positive 56.2 percent of the time for the Freiburg sign test. belly of the piriformis. The majority of piriformis syndrome cases fall This test is performed with the client laying supine on the massage into the secondary piriformis syndrome category. Secondary piriformis table. The therapist will then bring the hip of the affected side into syndrome occurs when the inflammation resulting from a microtrauma passive internal rotation. The result is positive if symptoms present (overuse) or a macrotrauma (a car accident or fall) entraps the (Physio Pedia, 2016). sciatic nerve. Fifty percent of secondary piriformis syndrome cases The final assessment indicated for piriformis syndrome is the Beatty result from direct trauma to the buttocks (macrotrauma) and leads Maneuver. For this test, the client will assume a side-lying position to muscle spasm, swelling, and nerve compression. An example of a on the table with the affected side up. The client will then flex the leg, microtrauma is “wallet neuritis,” which is a result of prolonged sitting resting the knee on the table. A positive sign is achieved if symptoms on a hard surface. are re-created when the client lifts and holds the knee off the table In either case, pain from piriformis syndrome generally lessens (Physio Pedia, 2016). when lying down: in this position, the excessive external rotational A quick comparison of these tests shows that the FAIR and Freiburg pull on the leg presents as splayfoot (the foot is turned away from tests administer stretching of the piriformis, whereas the Pace test and the midline). A critical distinction between piriformis syndrome and Beatty Maneuver utilize contraction of the piriformis.

Massage.EliteCME.com Page 48 Sacroiliac joint dysfunction resembles sciatica; a determining distinction between the two is that SI Sacroiliac joint dysfunction (SI joint dysfunction) is considered to be joint dysfunction develops over a long time, whereas sciatica can have a degenerative arthritic condition (Werner, 2002). The triangle shaped a sudden onset (MedicineNet.com, 2016). sacrum is tightly wedged between the iliac of the pelvis, causing There are two diagnostic procedures for SI joint dysfunction, in limited mobility in the SI joint. addition to a thorough history: the Gapping test and the FABER test. Several mechanical conditions contribute to the wearing down of To administer the Gapping test, the client will lay supine on the the cartilage cushion within the joint. These conditions create an massage table. The therapist places one hand on each anterior superior environment for inflammation to occur as the bones rub against one iliac spine (ASIS), located anterior and medial from the trochanter. another. Low back pain associated with SI joint dysfunction develops The therapist then places downward and lateral pressure, which gradually because of this friction. Sprains to the iliolumbar ligament are stresses the SI joint. Pain as a result of this is a positive sign for SI the main culprits. A sprain is a tear to a ligament; ligaments do not heal joint dysfunction (Lowe, 1997). quickly due to poor blood supply and when they do heal, they never return to their original length. This sets the stage for instability and re- The FABER test is also referred to as “Patrick’s test” or the “Figure injury (Werner, 2002). Injury to the iliolumbar ligament of the SI joint Four” test. FABER is an acronym for flexion, abduction, and external can be caused by a motor vehicle accident, fall, chronic postural stress rotation. The client will place one leg in a flexed, abducted, and (anterior pelvic tilt), or running and lifting (Physio Pedia, 2016). externally rotated position - while the therapist places one hand on the ASIS of the straight leg and the other hand on the knee of the flexed The pain associated with SI joint dysfunction is hard to pinpoint, leg. Pain or discomfort when downward pressure is applied to the knee but will be felt in the low back, hip, thigh, and/or groin unilaterally. tests positive for SI joint dysfunction (Lowe, 1997). Pain is aggravated by standing, walking, and forward flexion - yet it is relieved by lying down. Sacroliliac joint dysfunction pain closely Although these tests help differentiate SI joint dysfunction from other conditions, treatment depends heavily on the cause. Causes of sciatica The majority of sciatica causes are mechanical in nature. Tables 1 Table 4: Muscles linked to sciatica. and 2 under the Risk Factors section reference the posture and an Postural/tonic muscles (tight) Phasic muscles (weak) alteration of the vertebrae as reasons for sciatic occurrence. To best understand the role muscle tension plays in mechanical malfunction, Iliopsoas. Transverse abdominis. an exploration into muscle imbalance will first be discussed. Piriformis. Gluteus maximus. Muscle imbalance Erector spinae (thoracolumbar). Gluteus medius. Renowned physician Dr. Vladimir Janda, who spearheaded the Quadratus lumborum. Multifidus. combination of physical medicine with rehabilitation, found muscle Rectus femoris. Vastas medialis. imbalance to be influenced by the central nervous system (CNS) - more so than a result of structural change through his research. He also stated These patterned responses create postural deviations which lead that when muscle tone changes, it is a reflection of the sensorimotor to other conditions - such as sciatica through reciprocal inhibition system. The sensorimotor system refers to the interdependence of the (muscle weakness due to increased tension in the antagonist muscle), CNS with the muscular system. Muscles respond the same to dysfunction trigger point weakness (hyperirritable muscle causing overuse and at the joint as they do to upper motor lesions (i.e. a stroke); the only weakness), and fatigue (muscle fatigue before pain is felt). Janda variation being the degree of tightness to weakness. As a result, Janda classified these postural deviations as Upper crossed syndrome, Lower classified muscles into two groups according to the way they mimicked crossed syndrome, and Layer syndrome. Upper crossed syndrome the CNS pattern: the postural (tonic) and phasic systems. Table 3 (UCS) involves muscles of the cervical region. Lower crossed illustrates the differences between each group (The Janda Approach, syndrome (LCS) involves muscles of the pelvic region, and Layer 2016). syndrome (LS) is a combination of the two. Table 5 illustrates the Table 3: Postural and tonic systems. characterizations for each syndrome (The Janda Approach, 2016). Postural/tonic muscle Phasic muscle characteristics characteristics Flexors. Extensors. Balance against gravity. Work against gravity (movement oriented). Can withstand sustained Contract quickly and fatigue contraction. quickly. Shorten under stress. Weaken under stress. Postural muscles are prone to tightening, whereas phasic muscles are prone to weakening. Table 4 categorizes the muscles most relevant to sciatica in the postural and phasic systems.

Page 49 Massage.EliteCME.com Table 5: Janda’s syndromes. Structural scoliosis is a congenital condition; the spine has had a lateral curvature from birth. Functional scoliosis is a curvature that is Upper crossed Lower crossed Layer syndrome created in response to stresses placed upon it. It is often a way that the syndrome (UCS) syndrome (LCS) (LS) spine deals with rapid growth during adolescence. Functional scoliosis Tight upper Tight thoracolumbar Tight upper affects girls more than boys (Werner, 2002). trapezius, levator extensors, iliopsoas, trapezius, levator Ligament sprains scapula, and & rectus femoris. scapula, pectoralis As seen in Table 5, muscle imbalance affects the joints resulting in pectoralis major/ major/minor, dysfunction. Traumatic injuries – caused by motor vehicle accidents minor muscles. thoracolumbar or falls - also impact ligaments. Ligaments have a tendency to extensors, iliopsoas, become lax and refer pain, due to their inability to rebound. There & rectus femoris. are three ligaments of the lumbar spine most commonly sprained: the Weak deep cervical Weak abdominals, Weak deep cervical supraspinous and interspinous of L4-5 & L5-S1, and the iliolumbar flexors, middle & gluteus medius & flexors, middle & ligament. Table 6 illustrates the different characteristics of each lower trapezius. gluteus maximus. lower trapezius, ligament. abdominals, gluteus Table 6: Ligaments. medius, & gluteus maximus. Supraspinous Interspinous Iliolumbar ligament ligament ligament Joint dysfunction at Joint dysfunction at Joint dysfunction at the atlanto-occipital L4-5, L5-S1, SI joint the atlanto-occipital Controls flexion of Prevents Stabilizes the SI joint C4-5, cervico- & hip joint. joint C4-5, cerivo- the spine. hyperextension of joint. thoracic joint, thoracic joint, the spine. glenohumeral joint glenohumeral joint, Pain is felt Pain is felt Pain is felt to one & T4-5. T4-5, L4-5, L5-S1, centralized along the centralized in the side of the low back, SI joint, & hip joint. upper iliac crest. upper glute region to across the hip, to the Marked by: Marked by: Marked by: the lateral leg. groin area. ●● Forward head ●● Anterior pelvic ●● Forward head Discomfort with Discomfort with Discomfort with posture; tilt; posture; standing upright & standing upright & lateral flexion away ●● Increased ●● Increased lumbar ●● Increased balancing. balancing. from the painful cervical ; lordosis; cervical lordosis; side. ●● Thoracic ●● Lateral lumbar ●● Thoracic Although laxity of ligaments can manifest as referred pain in the low ; shift; kyphosis; back, it usually is a secondary condition of muscle imbalance and/or ●● Elevated & ●● External leg ●● Elevated & postural deviation (Benjamin, 2010). protracted rotational; protracted shoulders; ●● Knee shoulders; Spondylosis, spondylolysis & spondylolisthesis ●● Winged hyperextension; ●● Winged From muscle imbalance to ligament injury, instability of the joints scapulae; ●● Type A= scapulae; brings about degeneration and other disorders. The first of which is ●● Increased imbalance at the ●● Increased spondylosis. activation of hip; activation of Spondylosis is best understood as of the vertebrae, and the levator ●● Type B= the levator occurs with age. Chronic irritation within the structures of the vertebral scapula & upper imbalance in low scapula & upper body - due to misalignment - results in inflammation and a decrease in trapezius to back. trapezius to range of motion. This often leads to spondylolysis, as well as possible stabilize the stabilize the lumbar radiculopathy. In addition, the irritation triggers the growth of glenohumeral glenohumeral osteocytes (bone spurs), which can create a narrowing of the spinal joint. joint; canal, or stenosis (Vokshoo, 2014). ●● Anterior pelvic tilt; Spondylolysis is marked by a of the pars interarticularis. ●● Increased lumbar The pars interarticularis is a structure on the posterior vertebral body lordosis; that connects the upper and lower vertebrae. This usually occurs at ●● Lateral lumbar the L4-L5 junction, since it has the most movement. Some cases of shift; spondylolysis present as a congenital condition; however, the majority ●● External leg of cases result from activities that chronically place excess stress on rotational; the spine - such as gymnastics or weight lifting. ●● Knee Weakness of the lumbar spine at the L4-L5 articulation eventually hyperextension. results in the anterior dislocation of the L5 vertebrae, or These postural deviations can strain ligaments and cause degeneration spondylolisthesis. In response to the slipped vertebrae, the surrounding of the joint. Lower crossed syndrome directly affects the SI joint, muscles will attempt to stabilize the area. Another consequence is a as well as the piriformis muscle - making it a precursor for both compression of the sciatic nerve root (Vokshoo, 2014). dysfunctions discussed earlier (Physio Pedia, 2016). Not mentioned here is scoliosis: a lateral curvature of the spine. Scoliosis manifests as an increased lateral curvature in the upper thoracic region (usually to the right) and in the lumbar regions. The degree of curvature varies; it is not considered severe unless it is above 34 degrees. This condition is divided into structural scoliosis and functional scoliosis.

Massage.EliteCME.com Page 50 Table 7 compares the different features of spondylosis, spondylolysis, vertebrae. As with many conditions, accruing compressive forces and spondylolisthesis. press down on the , inhibiting the intervertebral discs. Table 7: Comparison of different vertebral pathologies. Combined with degeneration, this leads to protrusion of the jelly- like fluid of the disc. The most common herniation occurs at L4-L5 Spondylosis Spondylolysis Spondylolisthesis and L5-S1, where the disc will press onto the sciatic nerve and elicit Degeneration of the Stress fracture of the Anterior dislocation lumbar radiculopathy. There are four degrees of herniation: vertebrae. pars interarticularis. of the L5 vertebrae. 1. Bulging: The entire disc is herniated. Irritation Chronic excessive Any condition 2. Protrusion: The inner nucleus pulposus herniates out the outer from chronic loading of the that weakens the wall (annulus fibrosis). misalignment causes lumbar spine leads to structure of the 3. Extrusion: A small piece of the inner nucleus protrudes with a bone spurs to grow. a fracture. vertebral joint small connection remaining, or separates completely. (i.e. ligament 4. Rupture: The inner nucleus erupts and leaks out. injury, herniation, Since intervertebral discs lack a nerve supply, pain can be intermittent spondylosis, depending on the degree of herniation - as well as the body position. spondylolysis). The symptoms associated with lumbar disc herniation are: Pain is felt in Pain is felt in the low Pain is felt in the low ●● Localized low back pain that refers down the leg. the low back & back. Exacerbated by back and/or sciatica. ●● Muscle weakness that occurs suddenly and only in the muscles of legs. Exacerbated activity - especially the innervating nerve. by standing and hyper-extension. ●● Tingling in the low back and down the leg. walking; relieved ●● Numbness along the dermatome. by sitting or trunk ●● Change in bowel and bladder control. flexion. Pain will worsen with prolonged sitting; conversely, it will decrease with activity (Werner, 2002). The Lasegue sign is used to assess Spondylosis is common in the age group that is most afflicted with disc herniation. To perform this test, the client will lay supine on the sciatica. Spondylolysis and spondylolisthesis, however, affect this massage table. The therapist will then take the leg of the afflicted group at such a low percentage rate that they are important only as a side into passive flexion until the pain is re-created. The therapist will means for narrowing the cause of radiculopathy (Orthoinfo, 2016). next lower the leg two inches and have the client dorsiflex. If there is Disc herniation no increase in pain, the therapist will have the client flex the - in Perhaps the most attributed condition for sciatica in the medical addition to dorsiflexion of the foot. If this pain is exacerbated, then the community is disc herniation. Discs are the spongy cushion between test is positive (Lowe, 1997).

Evaluation and assessment A thorough evaluation is necessary to develop an effective treatment. 1. Pain. The first step is a thorough health history intake, which will help 2. Muscle inhibition. narrow the possible causes. The therapist should then provide a 3. Decrease in muscle length. postural assessment to implicate lower crossed syndrome or other 4. Restrained joint movement. muscular imbalances. Bony landmarks will provide a point of 5. Alterations in bone or soft tissue. reference when assessing symmetry. It is important to evaluate If pain is felt during active and passive assessment for dysfunction, gait and balance due to the interconnectedness of the muscular and as well as during compression, this indicates a disruption in the central nervous systems. If the gait is disrupted, walking will present joint - not the soft tissue. This extends beyond a massage therapist’s restrictions in the sacroiliac joint; this should produce a figure eight scope of practice, and must be referred to an appropriate health care movement. During gait assessment, the therapist should look for professional. However, if pain is felt during active range of motion similar areas with possible restricted movements and for areas that along with traction, it is connected to soft tissue dysfunction. Tables 8a may have excess movement. Gait dysfunction will be produced as a & 8b compare the different causes of sciatica (Fritz, 2015). result of the following:

Page 51 Massage.EliteCME.com Table 8a: Causes for sciatica. Muscle imbalance Ligamentous Condition Piriformis syndrome. Lower cross syndrome. Inter/supraspinous sprain. Iliolumbar sprain Definition Hypertonicity of the Postural deviation. Ligamentous tear. piriformis muscle. Traumatic injury/muscle imbalance. Cause Overuse (mirotrauma). Sensorimotor systems response. Signs & symptoms * Splayfoot. * Anterior pelvic tilt. * Centralized pain at the * Pain at one side of low * Pain & weakness in distal * Joint dysfunction at L4-5 upper iliac crest in the back, across hip to the muscles. & L5-S1. gluteals to the lateral leg groin. region. * Limping & difficulty * Increased lumbar * Discomfort with lateral walking. lordosis. * Discomfort with standing flexion away from the upright. painful side. * Radiating pain from * Weak abdominals & sacrum to hips & down leg. gluteus maximums & * Discomfort with trunk extension. * Pain with prolonged gluteus medius. sitting. * Tight iliopsoas. * Pain with sitting cross legged. * Pain relieved when lying down. Tests FAIR, Pace, Freiburg, Postural assessment & gait Beatty. assessment. Table 8b: Causes for sciatica. Joint Disorders Disc Pathologies Condition Sacroiliac joint Spondylosis. Spondylolisthesis. Herniation. dysfunction. Definition Degeneration of the Osteoarthritis of the Anterior dislocation of the Protrusion of an cartilage at the SI joint. vertebrae. L5 vertebrae. intervertebral disc. Cause Degenerative arthritis/ Chronic misalignment and/ Sprains, herniation, Cumulative compressive sprains. or bone spurs. spondylosis. forces. Signs & symptoms * Unilateral pain in the * Pain in the low back & * Low back pain. * Low back pain referring low back, hip and with legs. * Sciatica: burning, down to the legs. standing, walking, & * Pain is worse with radiating, sharp/shooting * Immediate muscle forward flexion. standing & walking. pain from the low back weakness. * Pain relieved by lying down the leg to the * Pain relieved with trunk * Tingling in the low back. down. flexion & standing. foot that is constant/ intermittent. * Numbness. Test Gapping, FABER. X-ray. X-ray. Lasegue. Treatment Massage is indicated for sciatica because the majority of the causes lymph flow to and from the area. In addition, friction can be used - stem from a dysfunction of the musculoskeletal system. In the acute helping to release restrictions in the muscle tissue. There are two ways phase, however, direct massage to the piriformis and gluteal region to facilitate friction: ischemic/cross-fiber friction and ischemic/passive may be contraindicated (Lowe, 1997). range of motion friction (Fritz, 2015). Massage Ischemic/cross-fiber friction refers to the therapist placing direct The goal of massage is to bring balance back to the system. Once the pressure on the muscle, then applying a deep, slow movement across mechanoreceptors of a muscle become chronically stimulated, they the fibers to encourage release of tension; ischemic/passive range of will respond to the least amount of stimuli - this leads to overuse and motion friction involves direct pressure being applied to the muscle, early fatigue. In order to increase the threshold, care must be taken to and at the same time passively moving the client’s joint to create re-lengthen the shortened musculature. With this in mind, the therapist friction (Fritz, 2015). should begin by placing a pillow under the abdomen of the prone Focusing the friction on the postural (tonic) muscles would benefit the client - in order to alleviate any increased lordotic curve during the sciatica client, considering muscle imbalance and postural deviation massage session. This will help the compensatory muscles to slacken. are a root cause for all conditions that have been previously discussed. Other considerations for a client experiencing acute sciatica include These include the iliopsoas, the rectus femoris, the thoracolumbar having the client lie in a side position, the utilization of a massage erector spinae, the quadratus lumborum, and the piriformis. Attention chair, or performing a shortened treatment session (Fritz, 2015). to the weakened, phasic muscles at the hip (gluteus maximus and Applying effleurage to calm the affected area and to warm the tissue is gluteus medius) is also important (The Janda Approach, 2016). recommended, and should also be performed to encourage blood and

Massage.EliteCME.com Page 52 Stretching is also an integral component of treatment since muscle have a schedule of reassessment in order to determine adjustments to contracture limits joint range of motion. During the session, post- the treatment plan (Fritz, 2015). isometric relaxation can be used to break the neural patterns limiting Self-therapy range of motion. This is done by passively placing the joint in its If the sciatica client does not take the necessary steps to alleviate the end range. The therapist then applies light resistance to the client’s condition outside of the massage room, progress could be slow. It is contraction for ten seconds, increasing the stretch during the relaxation important that the therapist encourages the application of ice to any areas phase, and then repeating. This technique would work best for the of inflammation, followed by moist heat which will bring fresh nutrients muscles of the hip since they are phasic (Fritz, 2015). from the blood to the area (heat) and take waste products away (ice) Treatment plan (Mayo Clinic, 2016). This may result in increased mobility. According to A client in the acute phase of sciatica initially may need multiple sessions the National Institute of Neurological Disorders and Stroke, the best way per week. The determination of frequency depends on the severity of the to alleviate pain is through exercise that strengthens the core (back and condition, the self-therapy plan, and complimentary therapies. Massage is abs). Therefore, referring the client to an exercise professional will help generally safe to be administered more than once per week. restore balance. It also may be beneficial to suggest that the client confer The first variable to consider is deciding between either relaxation with a skilled practitioner who can identify any nutritional deficiencies or deep friction therapy. Because of the versatility, mixing Swedish in the diet, in order to expedite healing. techniques with deep friction therapy for a combined session is one Treatment for chronic sciatica option for treatment - separating these techniques for contrast, with a Sometimes all avenues of therapy have been exhausted without much focused session one day and then relaxation the next. Another option change in the amount of pain, possibly due to the degree of degeneration would be the length of the session. When a sciatica client initially present. When this occurs, the referring physician may recommend receives treatment, sessions may need to be limited to thirty minutes epidural injections. As a last resort, surgery may be required to widen the - depending on the severity of symptoms. In the acute phase, a client or remove a herniated disc (Physio Pedia, 2016). may not wish to be on the table for a prolonged period of time. Offering Prevention side-lying or chair massage as an alternative will help the client receive The best way to treat sciatica is through prevention: maintaining the benefit of massage without aggravating the condition. Once in the good posture (while both standing and sitting), employing safe lifting subacute phase, sixty minute sessions should be tolerable (Fritz, 2015). protocols, and engaging in exercises that strengthen the core (National In conjunction with massage, a client may also be taking anti- Institute of Neurological Disorders and Stroke, 2015). Regular inflammatories, receiving chiropractic adjustments, and/or physical massage therapy factors in as well, and will help to relieve stress and therapy. To provide the best level of treatment, the therapist should encourage proper healing of soft tissue injury. Massage is an integral confer with the client’s health care team. The therapist should also component to keeping the body balanced.

Conclusion Sciatica is an umbrella term for several conditions affecting the low structural change to the lumbar spine (spondylosis, primary piriformis back. Since the sciatic nerve is the largest and main innervator for the syndrome, scoliosis), these instances are rare. The majority of precursors lower body, it is understandable that many symptoms are shared with that give rise to sciatica occur from an imbalance to the musculoskeletal other dysfunctions. Radiating pain from the sacrum through the gluteal systems. These precursors either directly influence sciatica (secondary region down the posterior leg is one commonality among low back piriformis syndrome, ligament sprains, or joint dislocations) or indirectly disorders. It is essential to note that sciatica is a secondary condition. impact sciatica (postural deviations). Regardless, massage therapy has a Although there are instances of congenital disorders resulting in positive effect in treating and preventing sciatica. 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Page 53 Massage.EliteCME.com massage and sciatica: an in-depth study Final Examination Questions Select the best answer for each question and mark your answers online at Massage.EliteCME.com. 1. A distinguishing trait of sciatic pain from other low back 4. A client experiencing a burning, radiating pain down the leg to conditions is: the bottom of the foot indicates entrapment of the sciatic nerve at a. Sciatica is described as a sharp, shooting pain down the leg. which location? b. Sciatica is a unilateral pain - originating from the low back and a. L3. traveling down the leg. b. L4. c. Pain that is felt in the low back, wrapping around the hip and c. L5. is difficult to pinpoint. d. S1. d. Centralized pain in the low back. 5. Positive signs during administration of the Gapping and FABER 2. If pain presents with passive and active range of motion, where is tests indicate which of the following conditions? the dysfunction? a. Piriformis syndrome. a. Joint. b. Disc herniation. b. Tendon. c. Iliolumbar sprain. c. Muscle. d. Sacroiliac joint dysfunction. d. Fascia.

3. Spondylolisthesis is classified as which of the following? a. Degeneration of the vertebrae. b. A stress fracture of the pars interarticularis. c. Anterior dislocation of the L5 vertebrae. d. Osteoarthritis of the vertebrae.

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