Effective Treatments for Sciatica
Exact data on the incidence and prevalence of sciatica are lacking. In general an estimated 5%-10% of patients with low back pain have sciatica, whereas the reported lifetime prevalence of low back pain ranges from 49% to 70%. The annual prevalence of disc related sciatica in the general population is estimated at 2.2% Most patients with acute sciatica have a favorable prognosis but about 20%-30% have persisting problems after one or two years. The diagnosis of sciatica and its management varies considerably within and between countries. Disc surgery may provide quicker relief of leg pain than conservative care but no clear differences have been found after one or two years.
Gluteal and Sciatic Nerves
Acland’s DVD Atlas of Human Anatomy The Lower Extremity Lippincott Williams and Wilkins
Most acute back problems are self- limiting: • Around 90% will be better within 6 weeks regardless of the treatment they receive. • Bed rest is almost never of value for non- specific pain. • Between 2% and 8 % will develop chronic symptoms. • Most people can point to a single event.
Carol Hartigan, MD Assistant Clinical Professor, Physical Medicine & Rehab, Harvard Medical School Fear-avoidance behavior and Reduced activity levels are common. 'Let's not guard it and protect it anymore, It's the opposite of what they have been told. If you have a bad back, it should be strong and flexible and fit."
Carol Hartigan , MD The Spine Center at New England Baptist Hospital SpineCenter@NEBH.org Rainville J, Hartigan C, et al. 2004. Exercise as a treatment for chronic low back pain. The Spine Jour 4: 106-115 .
Vladimir Janda, MD Key figure in the 20th Century rehabilitation movement Is best known for his identification of the upper crossed; and lower crossed syndromes. Each of these clinical scenarios described conditions in which the tone of antagonistic muscle groups became imbalanced and led to the predictable sequence of pain and dysfunction.
Dr. Ben Benjamin Founder of the Muscular Therapy Institute in Cambridge, MA. The low back is the most commonly injured part of the body. The most common low back injury is the Sacroiliac ligaments.
benbenjamin.com b enbenjamin.com.au Ligaments of the Sacrum: The Primary Cause of Low Back Pain benbenjamin.com/pdfs/08so.pdf
Prolotherapy
Ross A. Hauser M.D. drhauser@caringmedical.com www.caringmedical.com Oak Park, IL 60301
Contributing Factors If no violent falls or traumas have occurred, many contributing factors can play a large part in damaging the sacroiliac region and supporting ligaments. • Prolonged sitting - The single most stressful event in the low back which puts all of the weight of the upper body on the sacroiliac area. • This posture can lead to tight hip flexor muscles that encourage weakness in the low back.
Contributing Factors • Bending of the knees in this position will cause tight hamstrings muscles which pull the ischium downwards that further strains the low back. • Poor posture - Will magnify strain on the vertebral discs and sacral ligaments.
Contributing Factors Poor posture habits are sometimes ingrained from an early age. Many causes include: being tall in height as a child. Not being encouraged to stand up straight. Wearing shoes with unusually high heel heights.
Contributing Factors Inadequate support - Weak abdominal muscles do not allow the spine to stay balanced evenly on the pelvis causing more pronounced spinal curvature. Relaxing in soft furniture will eventually influence posture, which weakens supporting structures of the spine.
Contributing Factors Poor flexibility - The body responds to poor flexibility by altered or limited mobility. This change in mobility results in unnecessary stress on the joints, poor circulation, and weakness in other muscle groups.
Dissecting Low Back Pain Before the musculature of the low back can be examined we must look at the movements we should be capable of.
Assessment is the key In order the effectively treat sacroiliac joint dysfunction, or lower body pain assessment skills must be practiced and perfected. A series of question and answers: When did you first notice the problem? Can a certain movement reproduce any pain? If you used any previous treatment, was it helpful? Any muscle aches, tension, or problems sleeping? Be sure to address the list of contributing factors in the previous chapter. Encourage the person to make lifestyle changes if many of the factors are on their list.
Functional Assessment Protocol Resistance or pressure from the therapist is only 1 to 2 pounds. Direction of resistance follows black arrows on illustration. Test is performed for a maximum of 5 seconds.
Trunk Extension • Position of the Subject: Prone with head and upper trunk extending off the table from about the nipple line. Arms at sides. • Position of Therapist: Standing at side of table. Lower extremities are stabilized just above the ankles. • Test: Subject extends spine, raising body from the table so th at the umbilicus clears the table. • Instructions to Subject: “Raise your head, arms, and chest from the table as high as you can”.
Trunk Flexion • Position of Subject: Supine with hands clasped behind head. Grade 3, arms outstretched in full extension above plane of body. • Position of Therapist: Standing at side of table. Lower extremities are stabilized just above the ankles. • Test: Subject flexes trunk through range of motion. A curl up is emphasized, and trunk is curled until scapulae clear table. • Instructions to Subject: “Tuck your chin and bring your head, shoulders, and arms off the table, as in a sit- up”
Trunk Rotation • Position of Subject: Supine with hands clasped behind head. • Position of Therapist: Standing at side of table. Lower extremities are stabilized just above the ankles. • Test: Subject flexes trunk and rotates to one side. This movement is then repeated on the opposite side. • Instructions to Subject: “Lift your head and shoulders from the table, taking your right elbow toward your left knee.” Reverse.
Hip Extension • Position of Subject: Prone. • Position of Therapist: Standing next to limb. Hand to give 1 to 2 pounds of resistance is placed on the posterior leg just above the ankle. The opposite hand may be used to stabilize pelvis at the Sacrum. • Test: Subject extends hip. Resistance is given straight downward to the floor. • Instructions to Subject: “Lift your leg off the table without bending your knee and don’t let me push it down.”
Hip Flexion • Position of Subject: Sitting on table with thighs fully supported and lower legs hanging over the edge. • Position of Therapist: Standing next to limb. The contoured hand to give 1 to 2 pounds of resistance over distal thigh just proximal to the knee. • Test: Subject flexes hip, clearing the table. • Instructions to Subject: “Lift your leg off the table and don’t let me push it down.”
Hip External Rotation • Position of Subject : Sitting on table, supported by hands. • Position of Therapist : Kneels beside limb to be tested. The hand that gives resistance grasps the ankle. 1 to 2 pounds of resistance is applied as a laterally directed force at the ankle. The other hand which offers counter pressure is contoured over the lateral thigh just above the knee. Resistance of 1 to 2 pounds is given as a medially directed force at the knee. • Test : Subject externally rotates the hip. • Instructions to Subject: “Don’t let me turn your leg out.”
Hip Adduction • Position of Subject: Side-lying with test limb resting on the table. Uppermost limb is supported by therapist by cradling the leg with the forearm. • Position of Therapist: Standing behind subject. The hand giving resistance to the lowermost limb is placed on the medial distal part of the femur. • Test: Subject adducts hip until the lower limb contacts the upper one. Using 1 to 2 pounds of resistance. • Instructions to Subject: “Lift your bottom leg up to your top one. Hold it. Don’t let me push it down.”
Hip Abduction • Position of Subject: Side-lying with test leg uppermost. Lowermost leg is flexed for stability. • Position of Therapist: Standing behind subject. The hand giving resistance of 1 to 2 pounds is contoured across the lateral surface of the knee. The other hand is used to palpate Gluteus medius and minimus. • Test: Subject abducts hip without flexing the hip. • Instructions to Subject: “Lift your leg up in the air. Hold it. Don’t let me push it down.”
Assessment of Pelvic Girdle
Posterior legs – Gastrocnemius
Posterior legs – Hamstrings
Low back – Lateral rotator tendons
Low back – Lateral rotator tendons
Low back - Sacral ligaments
Low back - Sacral ligaments
Low back - Iliolumbar ligaments
Low back - Sacroiliac fascia
Low back - Sacroiliac fascia
Lateral Raffe – Quadratus Lumborum
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