Effective Treatments for Sciatica

Transcription

1 Effective Treatments for Sciatica A one day manual therapy course to improve your treatment of sacroiliac, low back and sciatica pain. AdvancedMassageEducation.com

2 Effective Treatments for Sciatica Table of Contents Introduction... Dissecting Low Back Pain.. Contributing Factors. Moving the Lower Body Assessment is the key Doing it "to" or Doing it "With" Massage Treatment.. 24 Active isolated assisted-stretching Kinesiology tape treatment... Self-treatment Bibliography.. 47 Usage Rights

3 Introduction Sciatica (or sciatic neuritis) is a set of symptoms that may be caused by general compression and/or irritation of one of the five spinal nerve roots. Piriformis syndrome while related and many times confused with sciatica, points more to a specific origin of dysfunction. Sciatic nerve dysfunction affects nearly 40 percent of adults at some point during their lifetime. Among the many possible causes of nerve compression, spinal disc herniation leads the list of much research material, but according to Ben Benjamin, PhD of Cambridge, Massachusetts spinal disc herniation accounts for only 5 percent in sciatica cases. Other well known compressive causes include: Spinal stenosis, in which the spinal canal narrows because of bone spurs, spondylolisthesis, or inflammation or structural irregularities. Pregnancy, the uterus can press directly on the sciatica nerve, or as a result from muscular tension, laxity of ligament tightness, or postural imbalance. Spinal Tumors may form on the spinal cord, surrounding nerve or ganglia. Because of the position of the sciatic nerve it is also subject to trauma at the point at which it crosses over the ischial spine. In order to be truly successful in treating Sciatica the above possible causes may need to be addressed to rule them out first. Manual therapy focused on muscular and structural imbalance of the low back and pelvic region, sacroiliac joint dysfunction, scar tissue of the sacral ligaments of the pelvis, and addressing other contributing factors have been found to yield surprising results. The foundation of treating the lower body started for me many years ago with various mentors and instructors that shared their insight and opinions on how to alleviate pain and bring their patients body into a better balanced myofascial unit. Some of my greatest influences in bodywork of the lower region were specific modalities that would only focus on segments of the whole. Dr. Carol Hartigan, from the New England Baptist Hospital Spine Center and a professor at Harvard University. She feels back pain is part psychological and part of it is overcoming the fear that if you use your back it will hurt. It s natural and normal to think if we have pain, we shouldn't move. Dr. Ben Benjamin on addressing adhesive scar tissue of the sacral ligaments of the pelvis. John Barnes work bringing the fascial system to the forefront and how this system affects not only posture, but every organ in the body. Thomas Myers on mapping major fascial bands that increase tonus or inhibit movement. 3

4 Eric Dalton s work on Myoskeletal Alignment, his work opened my eyes. Not specifically to his techniques, even though ground breaking. It was his reference to a mentor of his, Vladimir Janda. Dr. Janda was a Czech neurologist and physiatrist. Dr. Janda has done extensive clinical research on the pathogenesis and treatment of chronic musculoskeletal pain. In 1979, he identified his specific upper and lower crossed syndromes of muscle imbalance and continued to be active in clinical practice, research, and lecturing until his death in November, Dr. Janda felt that tonus muscles were tight composed mostly of flexors and phasic muscles were weak composed mostly of extensors. In my own clinical practice, my focus has been of the imbalances seen in my patients in a front to back plane, as in Dr. Janda s work. I came to the conclusion that the muscular/fascial system is a series of levers and pulleys. When one side shortens the other side lengthens. It wasn t until I started to focus on working with elite athletes to improve their performance that I noticed in increasing number of athletes had a rotational imbalance originating from the pelvis. Volumes of clinical data had been written on front to back imbalances but you would be hard pressed to find much written on rotational imbalances. Once I started to apply the theory of levers and pulleys and the concepts of Dr. Janda to rotational imbalances my results were not only more positive, but conditions like Sciatica and chronic low back pain, I had previously been unable to affect were now improving. The question still remained, how did the person get to that point? Dissecting Low Back Pain Low back pain is felt by most of us at one time or another in our lives. If you think about the true mechanism of pain, its purpose is to tell us when we are doing something wrong. With any luck, this acute pain will subside quickly in a few days with no lasting effect. If this pain becomes chronic or a common occurrence, our posture and our emotional state will be compromised, which in turn can set up degeneration of the spinal structures over time. Treatment of low back pain is confusing for many therapists because once the structural integrity of the pelvis is compromised by injury every structure that inserts or is associated with the lower body is affected. It is not uncommon to find pain in one area, but the source is in another area. 4

5 To unravel this complicated region let us first look at the foundation of the spine. The pelvis itself is made up of the Ilium on both sides and the sacrum. Sacral ligaments hold these structures together. In most cases I have found that the sacral ligaments have developed scar tissue adhesions from violent falls, bike crashes, or the stress of prolonged sitting, which inhibit proper support and function of this region. This faithful reproduction of a lithograph plate from Gray's Anatomy, a two-dimensional work of art, is not copyrightable in the U.S. as per Bridgeman Art Library v. Corel Corp.; the same is also true in many other countries, including Germany. Unless stated otherwise, it is from the 20th U.S. edition of Gray's Anatomy of the Human Body, originally published in 1918 and therefore lapsed into the public domain. 5

6 The keystone of all of the structures in the low back is the sacroiliac joint. This joint is the connection point of the sacrum and the Ilium, and is held in place by the sacral ligaments. This faithful reproduction of a lithograph plate from Gray's Anatomy, a two-dimensional work of art, is not copyrightable in the U.S. as per Bridgeman Art Library v. Corel Corp.; the same is also true in many other countries, including Germany. Unless stated otherwise, it is from the 20th U.S. edition of Gray's Anatomy of the Human Body, originally published in 1918 and therefore lapsed into the public domain. It is this scar tissue formation of the ligaments that stabilizes the sacroiliac joint that is one of the main causes of low back pain. Ligament strain or traumatic stretching of these supporting structures will undermine the strength needed to hold the sacrum in place, thus providing strain up into the spine. You could treat the muscles of the low back effectively to ease discomfort, but eventually the pain will return someday without considering the damaged ligaments. 6

7 Contributing Factors If no violent falls or traumas have occurred in the low back, 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. 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. 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. 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. 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. Moving the Lower Body Before the musculature of the lower body can be examined we must look at the movements we should be capable of. Primary movement muscles are in bold type, synergistic muscles are italicized. Trunk extension Iliocostalis thoracis Iliocostalis lumborum Longissimus thoracis Spinalis thoracis Semispinalis thoracis Multifidus Rotatores 7

8 Trunk flexion Rectus abdominis Psoas major Iliacus Obliques Transversus abdominis Trunk rotation Obliques Rotatores Latissimus dorsi Rectus abdominis 8

9 Hip Extension Gluteus maximus Semimembranosus Semitendinosus Biceps femoris Hip flexion Psoas major Iliacus Rectus femoris Sartorius Tensor fasciae latae 9

10 Hip lateral rotation Piriformis Gemellus superior Obturator externus Gemellus inferior Obturator internus Quadratus femoris Hip adduction Pectineus Adductor brevis Adductor longus Adductor magnus Gracilis 10

11 Hip abduction/ medial rotation Gluteus medius Gluteus minimus Tensor fasciae latae Assessment is the key In order to effectively treat sacroiliac joint dysfunction, or lower body pain assessment skills must be practiced and perfected. These assessment tools will show us three things: 1. Are regions of the body compensating for structure instability? 2. Which specific muscle or tendon is affected? 3. Is it a muscle/tendon injury or ligament/joint injury? Systematic evaluation of muscular imbalance begins with static postural assessment, observing muscles for characteristic signs of hypertonicity or hypotonicity. As you inspect, compare each area bilaterally, noting any indications of pathology as well as the condition and general contour of the anatomy. This is followed by 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? 11

12 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. To assess joint range of motion I use passive tests to exclude muscle involvement (except for the first two). Pain often during these movements may point to ligament dysfunction. Trunk Flexion Have the subject bend at the waist and slowly lower their arms as far as they can to the floor. Trunk Extension Have the subject support their back and bend back at the waist as far as they can and slowly look up to the ceiling. 12

13 Trunk Rotation In the seated position have the subject grasp their shoulders and passively rotate the trunk to one side and to the other side. Hip Flexion Have the subject supine and passively bend the knee and push the knee superiorly to flex the hip. Hip Flexion (alternate) Passively raise the straight leg superiorly to flex the hip. 13

14 Hip Extension In the standing position with the hands at the table have the subject put all of their body weight on the opposite leg to be assessed. Passively lift the straight leg backwards in extension. Hip lateral rotation In the prone position passively bend the knee and drop the foot across the body. Hip Medial rotation In the prone position passively bend the knee and drop the foot away from the body. 14

15 Hip abduction In the supine position passively bring the straight leg out laterally from the body. Hip adduction In the supine position passively bring the straight leg in medially across the body. Next, characteristic movement patterns are assessed, and specific muscles are tested for tightness or shortness. This is referred to as Functional Assessment. There is such a wide variation of the grading scale with normal adults, for our purpose a much gentler version will be used. In most cases pain will point to muscle or tendon damage during these tests. 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 preformed for a maximum of 5 seconds. 15

16 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 that the umbilicus clears the table. Instructions to Subject: Raise your head, arms, and chest from the table as high as you can. 16

17 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 subject next to the chest. 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 17

18 Trunk Rotation 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 subject next to the waist. 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. Then, Lift your head and shoulders from the table, taking your left elbow toward your right knee. 18

19 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. 19

20 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. 20

21 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. 21

22 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. 22

23 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. 23

24 Doing it "to" or Doing it "With" There are two approaches applied by therapists: "working on the person" and "working with the person." Working on the person pre-supposes that the person cannot help themselves; working with the person pre-supposes that the person has some practical responsibility for, and ability to change, their own condition. Every massage stroke is one or the other: doing it to the person or doing it with them; it is either forcing them to relax or helping them discover that they are contracting and teaching them to relax when, until then, they had forgotten how. Done passively, tissue manipulation evokes (calls forward) a gradual deepening of the person s awareness and control of their muscular actions, but this deepening is greatly limited by the lack of sensory feedback that active movement provides. Tissue manipulation done with active participation by the person evokes more than relaxation and flexibility: Because the person has enhanced awareness of the connection between sensation and movement, their control of movement (e.g., strength, resting tension level, and coordination) improves much faster. Massage Treatment A combination of techniques and modalities are required to effectively treat the lower body. The goal is to lengthen short, hypertonic muscles with deep-tissue, myofascial release, friction massage, and active isolated assisted-stretching techniques which I have found to elongate this dysfunctional tissue. If your assessment skills are sound, you should have a good indication as to where you need to focus your work. Keeping in mind Janda s upper cross syndrome of predictable sequence of tightness and weakness. Through experience I have found most problems dealing with muscle tissue seem to come and go. With chronic complaints over years ligament damage and structural changes occur. One of my favorite techniques is a movement I like to call Dynamic Extension Release. It is commonly known as a massage concept called pin-and-stretch, which is applying pressure to a muscle as you elongate it. The first order of business is to position the person on the table in a supine position. In this manual, techniques described may only need to be performed on one side only. I have included stretches to re-educate the effected muscle and to restore healthy resting lengths. As we begin this work, assessment of the pelvic girdle is paramount because of the structural relationship as the foundation of the vertebral column and it could point to dysfunction. 24

25 Assessment of Pelvic Girdle With the person lying supine, gently pull the legs to center the person. While doing this, approximate the leg length. Rotate the feet left and right to determine flexibility of the internal and external rotators of the hip. This information may help later to explain hip problems. Facing the pelvis from the legs, place a finger on the crest of the anterior superior iliac spine. Determine if the left or right anterior superior iliac spine is more anterior. If one anterior superior iliac spine is more anterior this points to more tightness than the other side. More tightness on one anterior side usually means the opposite side is tighter on the posterior side. Being this structure is the foundation of the spine. Not only will the spine be rotated but the supporting muscles and connective tissue will be affected. Keep this information in mind as you start your work. 25

26 Posterior legs Gastrocnemius Starting with a small amount of oil or lotion stroke up the entire leg with a gentle flowing movement. This stroke not only gives you information as to the structure of the leg and muscle development, but also muscle tightness or dysfunction. With the calf muscle, using the fingers pull medial to lateral to treat the medial head of the muscle. As you pull up and around the medial head feel for any muscle fiber adhesions. If any adhesions are found, go against the grain and smooth out any restrictions. To release the outside head, push lateral to medial in the same fashion as the medial head. Dynamic Extension Release movement is performed by having the person start in plantar flexion and slowly moves into dorsi flexion while you stroke the Gastrocnemius. 26

27 Posterior legs Hamstrings Starting with a small amount of oil or lotion, use forearm strokes up the hamstrings to smooth out any superficial tightness. Generally dysfunctional tendons that insert around the knee are best treated by stroking with the tissue, not crossfiber. Dysfunctional tendons that insert at the ischial tuberosity are best treated by crossfiber friction. The hamstring muscles are notorious for adhesions. If any adhesions are found, go against the grain and smooth out any restrictions. Each hamstring muscle may have to be treated separately. Dynamic Extension Release movement is performed by having the person start in knee flexion and slowly moves into knee extension while you stroke the Hamstrings. 27

28 Low back - Sacral ligaments In the prone position, place a rolled up towel under the patient s hip (optional). Using finger tips gently crossfiber the length and width of the sacrum. Noting any sensitive tissue. Continue until a loosening is felt. From your anterior pelvic assessment, one side may require additional work. 28

29 Low back - Sacroiliac fascia In the prone position, place a rolled up towel under the person s hip (optional). Push straight down just above the sacrum to treat the iliolumbar ligament. With a series of fascial glides, push from the iliolumbar ligament out and down toward the greater trochanter, being sure to stay medial of the sacroiliac joint. Continue until a loosening is felt. From your anterior pelvic assessment, one side may require additional work. 29

30 Low back Lateral rotator tendons Bring the person s knee up (flexion) and hip flexion to produce lateral rotation. Push gently behind the great trochanter and crossfiber the rotator tendons. If any adhesions are found, go against the grain and smooth out any restrictions. Dynamic Extension Release movement is performed by having the person start in knee flexion and slowly moves into internal rotation of the hip while you stroke the lateral rotator tendons. *Hip flexion will expose the Sciatic Nerve from under the Gluteus Maximus muscle. 30

31 Low back Lateral rotators Bring the person s knee up (flexion) and hip flexion to produce lateral rotation. Begin superior to the greater trochanter, using the elbow or palm of the hand. Slowly stroke down toward the Ischium. If any adhesions are found, go against the grain and smooth out any restrictions. 31

32 Lateral Raffe Quadratus Lumborum Start where the lateral thorcolumbar fascial and the base of the 12 th rib meet. Compress medially at least 45 degrees to reach underneath the lateral side of the Erector Spinae, compress down until the Ilium bone is reached. If this area is tender to the touch or in a contracted state, hold static pressure until it releases. 32

33 Mid back Erector Spinae Start your forearm stroke up the back from the hip, just lateral from the spine, concentrating on the erector muscle area about T12 up to T6. (This area receives a lot of abuse and generally can withstand deep pressure). Continue laterally to reach the Lateral Raffe. Compress the lateral edge into the center of the spine to further release this muscle group. Dynamic Extension Release movement is performed by having the person start by arching their back (flexion) and slowly lowers to the table while you stroke the area from T-12 through T-6 lateral of the spinous processes in a superior and inferior direction. 33

34 Anterior legs Quadriceps In the supine position, using the fingers to push lateral to medial. If knee problems are present with tight quadriceps, hook around the lateral side of the patella with the thumb or fingers and push lateral to medial over the top edge of the patella to treat the vastus lateralis tendon. Continue diagonally up to the adductor muscles. To treat the medial quadriceps, hook around the medial hamstring tendons behind the knee and pull medial to lateral. With Dynamic Extension Release make sure the knee can bend by placing the lower leg off of the table. Straighten the knee and demonstrate the movement of bending the knee to the patient. Start by having the knee straight and instruct the person to slowly bend the knee while you stroke proximal to distal (or reverse) to release the quadriceps. 34

35 Anterior hip - Inguinal ligament Concentrate with earlier determined ASIS if it is more anterior. Place one hand inferior to the ASIS on the inguinal ligament. Slowly press into the ligament. With the other hand, flex the hip and the knee and rotate the leg, feeling the tendons tighten as you rotate the leg. Rotate clockwise and counter clockwise. Follow any restriction and hold until a release is felt. Continue the pressure medially one inch toward the pubic area searching for restrictions. With one hand on the ankle and the other hand on the knee. Rotate the flexed hip while applying a mild torque clockwise and counter clockwise. 35

36 Active isolated assisted-stretching These movements will not only elongate tight muscles and ligaments that you have just released, reeducate the injured tissue, but will also strengthen weaken areas without activating the stretch reflex. Posterior Calf stretch (prone) Bend the knee and place the hand on plantar side of the foot. Instruct the person to bring their foot downwards into dorsi flexion as far as possible, contracting the anterior shin muscles and exhale during movement. Therapist provides gentle assistive stretch at the end of the movement by using the hand to provide a gentle pushing effort. 10 repetitions. 36

37 Hamstring stretch (supine) Place one hand behind the bent knee; push the knee superior to flex the hip. Instruct the person to straighten the knee as far as possible, contracting the quadriceps muscles and exhale during movement. Therapist provides gentle assistive stretch at the end of the movement by using the hand to provide a gentle pushing effort of the foot to help straighten the knee. 10 repetitions. 37

38 Hamstring/Glutes (Additional) Lie on the floor with towel in both hands, place one foot in the middle of the towel. Pull towel toward the body, while contracting the quads to straighten the knee. 10 repetitions. Lie on the floor with knee bent, placing hands on the sole of the foot. Pull the foot toward the center of the body and to the floor, while contracting the hip flexors. 10 repetitions. 38

39 Sacroiliac fascia stretch (passive movement supine) Instruct the person to bring the knee to the opposite side as far as possible, contracting the adductor muscles and exhale during movement. Therapist provides gentle assistive stretch at the end of the movement by using the hand to provide a gentle pushing effort at the knee. Change the angle of rotation of the hip until the person feels the tension at the sacrum. Erector Spinae Stretch (passive movement standing) To stretch the right side, cross the elbows overhead. Bend laterally to stretch. Repeat on the opposite side. 39

40 Quadratus Lumborum stretch (passive movement supine) To stretch the right side, cross the left leg over the right. Place the fingers in between the two ankles and pull both legs to the left. Repeat on the opposite side. 40

41 Quadriceps stretch (prone) Stabilize the low back by placing the hand on the sacrum. With the other hand cradle the bent knee and lift to extend the hip. Instruct the person to bring their knee away from the table as far as possible, contracting the gluteal muscles and exhale during movement. Therapist provides gentle assistive stretch at the end of the movement by using the hand to provide a gentle lifting effort of the knee. 10 repetitions. 41

42 Inguinal ligament stretch (passive side lying) Facing the feet, place your hip into the person s sacrum. Grasp the bent knee and the ankle into hip flexion. Rotate your body outward from the table while holding the knee and ankle to stretch the hip into extension. 42

43 Quadriceps/Hip flexor stretch (additional) Isotonic Active stretching (seated on the edge of the table) is used to lengthen muscle by contracting against resistant and then relaxing into a further stretch. Have the person hold the bent knee of the opposite leg to be stretched, while supporting the head lower the person to the table. Place your hand on the knee of the straight leg, pushing the hip into extension. Instruct the patient to flex the hip and flex the knee while pushing against your hand using 20% of their effort for 5 seconds and repeat 5 times, then reverse. 43

44 Kinesiology tape treatment By using the addition of kinesiology tape after treatment it has accomplished 2 objectives. 1. Affects the sensory receptors to help the person to be aware of areas or positions they might have forgotten about. 2. Aids in mechanical correction by utilizing the stretching qualities of the tape with pulling where it is needed to stimulate a sensation which results in the body s adaptation to the stimulus. Application essentials Clean the area with alcohol before application to remove any oil residue. For overused or tightened muscles, the tape is applied from insertion to origin. For chronically weakened muscles or where increased contraction is desired, the tape is applied from origin to insertion. Spilt the 2 halves to make a V. Have the person flex their hip. Apply the anchor point with no tension at the Ischium. Attach the 2 ends with 25% tension around the center of the gluteus and posterior or behind the greater trochanter. 44

45 Self treatment Other than the treatment you have given, the person s best chance of success with their pain is realizing that the management of their lower body is their responsibility. Self treatment will be more effective in the long term management of their pain than any other form of treatment. Present the person with a stretching card on the following page. Demonstrate each movement for the person. Have the person perform these stretches daily as often as possible. Instruct the person to go to their end range with minimal discomfort. Encourage the person to be as active as possible even if they are experiencing pain. Awareness of improper posture and self stretches will reeducate the lower body, retard scar tissue formation and will continue to improve range of motion. 45

46 46

47 Bibliography Roger M Jawish-Anatomical, Clinical and Electrical Observations in Piriformis Syndrome, Journal of Orthopaedic Surgery and Research (2010 5:3) Peter Kent, Hanne Mjøsund, Petersen DHD-Does targeting manual therapy and/or exercise improve patient outcomes in nonspecific low back pain? A systematic review, BMC Medicine 2010, 8:22 (8 April 2010) Gert Bronfort -Effectiveness of manual therapies: the UK evidence report, Chiropractic & Osteopathy ( :3) Kingsley R. Chin -Interventional Spine: An Algorithmic Approach, Part 4 Section 2, Elsevier (2007) On the reliability and validity of manual muscle testing: a literature review-scott C Cuthbert, Chiropractic & Osteopathy (2007, 15:4) Vladimir Janda -Postural and phasic muscles in the pathogenesis of low back pain, Proceedings of the 11th Congress of International Society of Rehabilitation of the Disabled, Dublin, Ireland. Pages (1968) Erik Dalton-Low Back, Piriformis and SI Joint Pain, Massage Today May, 2007, Vol. 07, Issue 05 Lori A. Boyajian-O Neill-Diagnosis and Management of Piriformis Syndrome: An Osteopathic Approach, J AM Osteopath Association (2008)108 (11): 657 Dr. Myk Hungerford-Beyond Sports Medicine, SMTI (1993) Mel Cash-Sport & Remedial Massage Therapy, Ebury Press (1996) Leon Chaitow-Palpation and Assessment Skills, Churchill Livingstone (2003) Helen Hislop-Daniels and Worthingham s Muscle Testing, Saunders (2002) Carmine Clemente-Anatomy, Lea & Febiger (1986) Judith Orloff-Intuitive Healing, Times Books (2000) Laura Day-Practical Intuition, Broadway Books (1997) Robert Acland-The Video Atlas of Human Anatomy, Williams & Wilkins (2000) 47

48 Manual Page 1 and Slide 1 Effective Treatments for Sciatica Usage Rights "istock.com/ Eraxion." Stock photo ID: Unrestricted standard license to reproduce. Cover image Presentation Slide 2 Creative Commons Attribution-Share Alike 4.0 International license. - Author(s): KDS Sciatic nerve2.jpg from Wikimedia Commons - License: CC-BY-SA 4.0 Presentation Slide 4 Video shown with permission from Wolters Kluwer Health

49 Presentation Slide 5 Author(s): KDS4444 Sciatic nerve2.jpg from Wikimedia Commons - License: CC-BY-SA 4.0. Creative Commons Attribution-Share Alike 4.0 International license. Manual Page 4 Garry Adkins and advanced massage education. All future images not listed are owned by: Garry Adkins and advanced massage education. Manual Page 5 This faithful reproduction of a lithograph plate from Gray's Anatomy, a twodimensional work of art, is not copyrightable in the U.S. as per Bridgeman Art Library v. Corel Corp.; the same is also true in many other countries, including Germany. Unless stated otherwise, it is from the 20th U.S. edition of Gray's Anatomy of the Human Body, originally published in 1918 and therefore lapsed into the public domain. 49

50 Manual Page 6 This faithful reproduction of a lithograph plate from Gray's Anatomy, a twodimensional work of art, is not copyrightable in the U.S. as per Bridgeman Art Library v. Corel Corp.; the same is also true in many other countries, including Germany. Unless stated otherwise, it is from the 20th U.S. edition of Gray's Anatomy of the Human Body, originally published in 1918 and therefore lapsed into the public domain. Presentation Slide 8 "123RF.com/Mark Andersen;" Stock photo ID: Rear view of woman with hands on lower back with Pain written on it. Unrestricted standard license to reproduce. Manual Page 7 MassageNerd.com Used with permission

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53 Presentation Slide 14 Creative Commons Attribution-2.0 Generic Les mouvements du sacrum by Pathologies - Traumatologie 3D. Presentation Slide 15 What Causes Sacroiliac Joint Syndrome?]. Retrieved September 30, 2012 from: oiliac-joint-syndrome.htm. Used with permission Presentation Slide 16 This faithful reproduction of a lithograph plate from Gray's Anatomy, it is from the 20th U.S. edition of Gray's Anatomy of the Human Body, originally published in 1918 and therefore lapsed into the public domain. 53

54 Presentation Slide 17 This faithful reproduction of a lithograph plate from Gray's Anatomy, it is from the 20th U.S. edition of Gray's Anatomy of the Human Body, originally published in 1918 and therefore lapsed into the public domain. Presentation Slide 19 Video shown with permission from Caring Medical & Rehabilitation Services, S.C Presentation Slide 21/24/25 Photo Researchers, Inc. Used with permission

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59 Presentation Slide 59 Presentation Slide 62 Treatment of a Case of Subacute Lumbar Compartment Syndrome Using the Graston Technique. Warren I. Hammer, DC This faithful reproduction of a lithograph plate from Gray's Anatomy, a two-dimensional work of art, is not copyrightable in the U.S. as per Bridgeman Art Library v. Corel Corp.; the same is also true in many other countries, including Germany. Unless stated otherwise, it is from the 20th U.S. edition of Gray's Anatomy of the Human Body, originally published in 1918 and therefore lapsed into the public domain. [muscle_anterior_anatomy]. Retrieved with permission September 30, 2012 from: Presentation Slide 74 Creative Commons Attribution license (reuse allowed). KT Tape Kinesiology Taping Instructions for Gluteus Pain. Healthy Life. 59

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