: In the years that I have been practicing, I have treated many cases(and many variations), of back related challenges. Sciatica, Stenosis, mis-articulation by way of axial skeleton rotation, degenerative conditions …well, you could say, a lot of stuff.
Also, the general form of treatment has become all to repetitive for my liking. i.e. pain killers, muscle relaxing agents, hot baths( hardly any ice?), chiropractor, orthopedic surgeon …talk of surgery….hmmm.
My philosophy is that, when surgery is really…I should say actually needed, I am not against it if it means restoring the quality of life for those who truly have no other options……
Now before I get things hurled in my direction at a high velocity…I really love and totally support Chiropractics. I value it as a valid science and a healing agent of great magnitude.
Having said this, I feel that it, nor anything else is the one true stand alone, doesn’t require anything else kind of wonder treatment( aside from pure divine healings, which I also have witnessed). The physical body is a wonderfully complex machine!~
The significant thing about LBP / Sciatica , is the lack of understanding by practitioners about this condition, its many causes and the incomplete nature of treatment in each field of modality. So, let’s take a look at some relative facts about this human condition, shall we?
What it is: Sciatica is described generally as any situation which causes irritation and inflammation of the Sciatic Nerve. This can begin either inside or outside of the spinal chord itself and there are numerous situations which can be the initiator of this challenge, be it injury or illness.
The challenge then becomes that the para-spinal muscles which are also inflamed become hyper-contracted in a pain spasm and in their hyper contracted state, produce greater amounts of pressure upon the nerve roots (usually L-5, S-4 are the offending roots), which in turn causes functional complications and inflammation/fluid retention of the surrounding soft tissue.
It seems clear that L-5/S-1 being located at the apex of the lumbar spinal curve incurs an automatic antero-caudal instability. This is not the only mechanism involved in Sciatica.
This condition is further aggravated by the fact that quite often significant time passes and there are multiple sites of hyper-contraction. The muscle develops adhesions between itself, the fascia and the connective tissue,(tendons, ligaments). Biomechanical abnormalities occur in the gait, thusly perpetuating further injury ,hyper-contraction, pain spasm and adhesion.
A major contributor to the condition of Sciatica is the thora-columbar fascia which spreads from the lower thorax to the gluteal aponeurosis.
Once there is an abundance of adhesion built up between the para-spinals, quadratus lumborum and this particular fascia, there becomes a direct involvement of the gluteals and the deep six lateral rotators, (yes, the psoas is affected), which become hyper-contracted and inflamed. By now there is also lateral pelvic tilt and potentially axial skeleton A/P rotation with mis-articulation of the superior articular processes of the sacrum , resulting in pressure on nerve roots ! .
At this point there is beginning to be damage to the vertebrae as well as the acetabular fossa in the form of uneven wear due to mis-articulation. There is also the potential for the lateral rotators and gluteal muscles along with the piriformis to place severe pressure upon the Sciatic nerve owing to pain spasms,(hypercontraction). Recognizing this condition is not difficult and usually can be done without palpation. If in doubt, perform a 3D postural analysis with the proper charts. This should provide clear evidence of the structural abnormalities of the low back, pelvis and hips, allowing for a better understanding of the challenges.
Treatment: Ok…here we go! This condition usually comes with a lot of pain and immobility, making life difficult…It is not hard to understand why people gravitate to PAIN KILLERS, MUSCLE RELAXORS and HEATING PADS. Although, these things are the route of most physicians, I must say that this is only masking the symptoms and doing absolutely zippo el nunno for the condition itself(with the exception of muscle relaxors). I do see value in these types of treatment at the very onset of the condition, however, most of the time this ends up being the focus of treatment.
I would like to address pain. Basically, it is the nerves which alert us to the sensations associated with adverse conditions in our bodies. So, it stands to reason that if there is excessive pressure on the nerve root, the sensation of pain will also be present.
One of the major mechanisms of pain is INFLAMMATION. The condition of inflammation in the body also draws in excessive fluids to the inflamed area, creating pressure on the nerves, by way of edema,(swelling).In the Lumbar region of the spine, this can be extremely problematic.
Knowing this fact is helpful, as my first order of business in the treatment process is to the patient/client in the use of non-prescription anti-inflammatory agents, such as Motrin IB, Vitamin C and the local application of ICE. The rationale here is that if we can reduce inflammation…the incidence of pain will be lessened and restorative treatment can begin.
At the root of this challenge,(no pun intended), is what I consider to be the center of trouble in the condition of perceived Sciatica. Either there is a mis-articulation of L-5,S-1 or a condition of inflammation and edema in the soft tissue in this area of the body…or both! It must also be noted: The muscles of the gluteals and deep six lateral rotators of the hip can inflict great pressure on the Sciatic Nerve when in a hyper-contracted condition .
There are 2 forms of treatment that I recommend , unless there is significant injury,(meaning orthopedic), such as fresh vertebral disc herniation, vertebral fracture or other catastrophic spinal chord injury. These would be neuromuscular therapy and Chiropractic adjustment.
I placed these treatments on paper in the order they are most beneficial to the patient/client for total recovery.
So, after eliminating inflammation, it is time to deal with the muscles, tendons, fascia and any mis-articulations of joint structure which may be placing pressure on the nerve roots of the spine,(in this case the lumbar region).
I have a very strong belief in what I like to call the ABOVE & BELOW THEORY.
This is a very simple mindset which states : Every part of the musculo-skeletal system is connected to the other, from head to toe by either muscle, tendon, ligament or fascia and can be acted upon or otherwise influenced by another part of the anatomy above or below the injury site.
In the case of Sciatica, this means that AT THE VERY LEAST, EVERYTHING above and below the L-5, S-1 articulation should receive neuromuscular treatment. This means that all of the muscle origins/insertions, fascia and connective tissue need to be addressed with XFF, LFR, CFR, Passive ROM work and other clinical techniques so as to create a bilateral condition in the body. This is EXTREMELY IMPORTANT in the case of sciatica.
My rationale is simply facilitating a situation of neutrality in the position of the pelvis relative to the spine.The intention here is to relieve any Kyphotic or Lordotic positioning of the pelvis, allowing the foramen size to increase by decreasing the hyper-contraction of the gluteal, pelvic, spinal and para-spinal soft tissue….Please note: It is the articular surfaces of the laminae, pedicles and transverse processes which create the foramenal facilitation of the nerve roots of the spine. Thus, all of the musculature which have affect on the compression of the spinal column become increasingly important in consideration of sciatica.
I generally like to utilize hot towels / packs during the entire treatment as, this application facilitates deeper more effective friction work, allowing for fascial separation, stripping of yellow collagen fiber and breaking up of any scar tissue. Of course we know this should be followed up with cryotherapy to release the excess fluids and ease potential inflammation of the areas treated.
Once all of the necessary soft tissue has been treated and there is a condition of bilateralism above and below the pelvis,( this means posterior and anterior), with neutrality of the pelvis relative to the spine…it is time for the money shot!
At this time it is absolutely essential to correct any mis-articulations of the spinal column, pelvis and sacrum.
Above the pelvis this is usually a manual thrust with the patient in the prone position. At the L-5,S-1 articulation, this is generally a side lying ajustment,(I AM NOT A BIG FAN OF THE DROP TABLE ADJUSTMENT as L-5,S-1 usually have posterior compression with anterior or lateral transition.. A drop table at this point could be a disaster in the making!)
If you are not a Chiropractor, having a substantial amount of experience with this modality …leave it the hell alone and/or have it lined up with a Chiropractor immediately after your neuromuscular work!!!
My experience has been that, when all of these things have been accomplished the success of treatment relative to recovery from sciatic conditions has been about 99%. I feel very happy about that and so do my clients.
I have attempted to share not only food for thought, but also, treatment protocol that I have had great success with over the past 12 to 13 years, when other methods have been inefficient at best.
There needs to be continuity between modalities and clear communication between practitioners when treating this or any other pathology or condition, for the good of the patient…just a thought.
I hope this article is helpful and please feel free to ask questions and/or give feedback, so we might all learn more.
When all else fails…look to the feet,( another article).
Thanks, for following,
Steve Lynch, AAS/Holistic Health, LMT ,NMT CTE, Trainer