Sciatica Part 3 – Treatment - Logic & Recommendations
Updated: May 7
CONSERVATIVE TREATMENT OF SCIATICA
Whether you are trying to resolve sciatic pain caused by a Disc Herniation or caused by a Non-Discogenic Pain, a conservative treatment process will need to focus on, and include, the following three components to achieve optimal effects.
Joint function - By using Joint Manipulation/ Mobilization procedures.
Soft Tissue Intergritiy - By using Myofascial Release procedures.
Exercise - With a focus on three essential area: mobility, strength, and balance.
For patients who are suffering from back pain and sciatica caused by a disc herniation, research has shown that spinal manipulation can be an effective element that should be incorporated within an overall treatment strategy for relieving pain, increasing range of motion, and improving function. (1,2,3,4)
Research has shown that, after joint manipulation, there is an increase in what is known as the Pain-Pressure Threshold. (5) The Pressure Pain Threshold (PPT) is defined as the minimum force applied which induces pain. This measure has proven useful in evaluating tenderness symptoms (but not diagnosis).
This increase in tolerance could be caused by changes in b-endorphin and serotonin levels, an alteration in alpha motor neuron activity, or to changes in the response of the autonomic nervous system (ANS). The reality is that there is NO currently definitive consensus about why joint manipulation increases the PPT. However, we do know that the pain experienced by the patient is greatly reduced after joint manipulation. (6)
In addition to being effective in increasing the Pain Pressure Threshold, we have found that for cases of Disc Herniation, joint manipulation/mobilization has beneficial effects on both mechanical and neurophysiological components of the spine. (3)
Our capacity to produce an unlimited variety of movements requires good joint integrity. As practitioners, it is important for us to understand the complex interrelationships between the structure and function of multiple joints. No joint ever works in isolation. An injury in one joint often creates bio-mechanical compensations in both adjacent and distant joints.
Research has shown us that when joints become immobile (as in injury or osteoarthritis), they then become subject to several physiological changes. (6)
This includes a decrease in fluid content, which in turn can cause a decrease in the joint-fiber distance within the capsule surrounding the joint. This in turn causes the development of increased cross-fiber linkages, which can then cause adhesion formation in the synovial folds of the joints. These adhesions cause a decrease in the strength of collagenous tissue, which can then cascade into tissue failure, even with diminished tissue loading. (7,8)
Joint manipulation has been shown to partially reverse many of these changes. (7,8)
In the previous two blogs, we talked about all the ways the sciatic nerve can become entrapped - from fibrous entrapment of the sciatic nerve, to direct entrapment of the sciatic nerve by muscles and other anatomical structures (only 15% of the time). (16) Both of these are forms of myofascial restrictions that leading to entrapment, pain and dysfunction. To get an even better understanding of why the myofascial system is so important consider these factors.
Fascia as a Tensional Network
Fascia is often defined as “one interconnected tensional network that adapts its fiber arrangement and density according to local tensional demands.” (13)
When fascial tension is in good balance, fascia acts to distribute force throughout the body, and allows us to store and release energy for propulsion.
When fascial tension is NOT in balance, bio-mechanical compensations are created, with large areas in the body becoming dysfunctional.
Fascia's Role in Neural Communication
Research has shown that the body’s fascial network contains ten times the number of sensory nerve receptors as those that innervate muscle. This means there is 10 times the level of neuromuscular communication occurring through the fascia. (10)
This includes many different types of sensory receptors, including both myelinated proprioceptive endings (Golgi, Paccini, and Ruffini), as well as un-myelinated free nerve endings. (9,10,11) An alteration in the performance of this neurological network, as in cases of sciatica, can have systemic neurological implications.
Fascia - A Memory Repository
Let me explain what I mean by “Our fascia is the repository for our body’s history”. (12, 13)
Every injury or physical force that we experience causes changes within the body’s architecture through a process of mechanical compensation.
These compensations are a result of mechanical forces that induce transcriptional (RNA) changes in the body, which in turn produce changes in our fascial architecture. (12)
These changes can cause bio-mechanical imbalances, adhesion formation (fibrosis), thickening of tissues, and decreases in mobility. This is amazing! We are literally talking about how mechanical forces initiate transcription – the process of making an RNA copy of a gene sequence (12) – to then produce corresponding proteins – all based on the body’s physical history.
FINDING THE TREATMENT APPROACH THAT WORKS!
The reality is that not all treatment techniques work for all patients. What works great for one patient suffering from sciatica, does little or nothing for the next. That is why successful practitioners often use a multitude of procedures to address the needs of each individual patient.
In the programs we teach we often recommend practitioners invest time and effort to learn as much as they can from different perspectives. No one technique or procedure can meet the needs of every patient.
Albert Einstein is widely credited with saying, "The definition of insanity is doing the same thing over and over again, but expecting different results." If you want different results (or better results) than what you're getting, you have to take a different approach.
Below are some of the Motion Specific Release protocols that we commonly use in treating cases of Sciatic. Again what procedures we use will vary greatly with each patient, based on their history and physical examination findings. These procedures and always incorporated with joint manipulation/mobilization, and a functional exercise program.
Sciatic Nerve Release - Motion Specific Release: In this video Dr. Abelson demonstrates some of the Motion Specific Release (MSR) procedures we use to release the Sciatic Nerve. Symptoms of sciatica can be caused by disc herniation, foraminal stenosis, spinal stenosis, or entrapment of the sciatic nerve. The types of procedures we would use would vary with each case.
The Gluteus Maximus Release - Motion Specific Release (MSR): In this video Dr. Abelson demonstrates how to use Motion Specific Release (MSR) to release restrictions in the Gluteus Maximus muscle. Strong, flexible, engaged gluteal muscles are critical to optimum performance and injury prevention.
Thoracolumbar Fascial Release - Motion Specific Release: The thoracolumbar fascia (TLF) plays a critical role in both stabilization of the spine and in load transfer from the core. In this video Dr. Brian Abelson DC. demonstrates an extremely effective way of releasing the TFL. MSR videos are for demonstration purposes only. If you have a medical condition, please see your medical practitioner.
FOCUS ON THE OBJECTIVE
The objective of providing manual therapy is to decrease pain, increase range of motion, reduce hypertonicity, and improve function. These objectives are much easier to achieve when we use a combination of diverse interdisciplinary treatment modalities. Complex problems (such as sciatica) are much easier to solve when we look at them from diverse perspectives.
It is time to put aside the concept of 'singular' treatment modalities as a one-stop solution for all MSK conditions. As great as certain techniques are, no one technique can deliver everything. There is no such thing as a 'unified theory of everything' for health care.
By merging and using the best of the available methodologies, we are able to generate better results for our patients, and help them take control of their lives.
CONCLUSION - PART 3
When using conventional therapy - a combination Joint Mobilization, Myofascial Release procedures, and exercise often achievers the best results in addressing Sciatica. There is substantial research to support the use of manual therapy (conservative care) for pain reduction, increasing mobility, and improving overall function .
In part four, we will discuss "Exercise & Activities of Daily Living".
REFERENCES - PART 3
Snelling NJ. Spinal manipulation in patients with disc herniation: a critical review of risk and benefit. Int J Osteopath Med 2006;9:77–84.
Santilli V, Beghi E, Finucci S. Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations. Spine J 2006;6:131–137.
Oliphant D. Safety of spinal manipulation in the treatment of lumbar disk herniations: a systematic review and risk assessment. J Manipulative Physiol Ther 2004;27:197–210.
Lisi AJ, Holmes EJ, Ammendolia C. High-velocity low-amplitude spinal manipulation for symptomatic lumbar disk disease: a systematic review of the literature. J Manipulative Physiol Ther 2005;28:429–442.
Akeson WH, Amiel D, Abel JF, et al. (1987). Effects of immobilization on joints. , 219, pp. 28-37.
Woo SL, Matthews JV, Akeson WH, et al. (1975). Connective tissue response to immobility: correlative study of biomechanical and biochemical measurements of normal and immobilized rabbit knees. , 18(3), pp. 257-264.
Coronado RA, Gay CW, Bialosky JE, et al. (2012). Changes in pain sensitivity following spinal manipulation: a systematic review and meta-analysis. , 22(5), pp. 752-767.
Degenhardt BF, Darmani NA, Johnson JC, et al. (2007). Role of osteopathic manipulative treatment in altering pain biomarkers: a pilot study. , 107(9), pp. 387-400.
Mitchell JH, and Schmidt RF. (1977). Cardiovascular reflex control by afferent fibers from skeletal muscle receptors. In: Shepherd JT, et al, eds, Handbook of physiology, Section 2, Vol. III, Part 2. Bethesda: American Physiological Society, pp. 623-658.
Schleip R. (2003). Fascial plasticity— a new neurobiological explanation. Part 1. J Bodyw Mov Ther, 7(1), pp. 11-19.
Van der Wal J. (2009). The architecture of the connective tissue in the musculoskeletal system: An often-overlooked functional parameter as to proprioception in the locomotor apparatus. In: Huijing PA, et al, eds. Fascia research II: Basic science and implications for conventional and complementary health care. Munich: Elsevier GmbH.
Chen C, and Ingber D. (2007). Tensegrity and mechanoregulation: from skeleton to cytoskeleton. In: Findley T, and Schleip R, eds. Fascia research. Oxford: Elsevier, pp. 20-32.
Findley T, and Schleip R. (2009). Introduction. In: Huijing PA, Hollander P, Findley TW, and Schleip R, eds. Fascia research II. Basic science and implications for conventional and complementary health care. München: Urban and Fischer.
McGill, S.M. Ultimate back fitness and performance, Backfitpro Inc., Waterloo, Canada, 2004. ISBN 0-9736018-0-4. Fourth edition 2009.
McGill, S.M. Low back disorders: Evidence based prevention and rehabilitation, Human Kinetics Publishers, Champaign, IL, U.S.A., 2002. ISBN 0-7360-4241-5, Second Edition, 2007.
Lori A, Boyajian-O’ Neill, et al. Diagnosis and management of piriformis syndrome:an osteopathic approach. J Am Osteopath Assoc Nov 2008;108(11):657-664
DR. BRIAN ABELSON DC.
Dr. Abelson believes in running an Evidence Based Practice (EBP). EBP's strive to adhere to the best research evidence available, while combining their clinical expertise with the specific values of each patient.
Dr. Abelson is the developer of Motion Specific Release (MSR) Treatment Systems. His clinical practice in is located in Calgary, Alberta (Kinetic Health). He has recently authored his 10th publications which will be available later this year.
Dr. Abelson is the owner of Kinetic Health, a partner in BKAT Motion Specific Release, and a partner in Rowan Tree Books.
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