clinically effective strategies for sciatica

Clinically Effective

Strategies for SciaticaStephen Janz: Clinic Director Kenmore Centre for Health

Research tells us that Acupuncture is twice as effective as standard care

when treating sciatica:

Lewis RA, Williams NH, Sutton AJ, Burton K, Din NU, Matar HE, et al. Comparative

clinical effectiveness of management strategies for sciatica: systematic review

and network metaanalyses. The spine journal : official journal of the North

American Spine Society. 2015 Jun 1;15(6):1461-77.

But what works well?

Many approaches

copyright Stephen Janz 2017

Local treatment

Which points? Bladder, Jiajia, extra, Du, 1cun points

Distal points

Microsystem

Auricaular

Abdominal

‘Balance method’

Point Injection therapy

Massage?

Exercise Therapy ?

Acute

Rehab


This presentation will outline commonly effective strategies, as well as the

role of some adjunctive therapies

Demonstrate some techniques

Everything wont be new to everyone

Something will probably be new to everyone.

Goal is to give food for thought when treating patients, and give ideas for

patients who don’t respond adequately


Definition

Pain along course of sciatic nerve

May or may not have back pain as well

L4/5 and 5/S1 most often affected levels

Affects distribution of L4/5, L5/S1 and S1 traversing nerve roots.

Usually caused by degenerative joints and associated disc bulge


Other causes of sciatica can include:

Spinal stenosis

Spondylosis: a degenerative spinal osteoarthritis

Nerve entrapment: a muscle in the buttock may compress the sciatic nerve and cause pain. For example the

piriformis syndrome

Inflammation and swelling from arthritis, sprains, joint slippage or infection. Infections can be caused by iliopsoas,

pelvic and gluteal abscesses.

Vascular problems: due to increased blood volume in the spine during the late stages of pregnancy, the fixed

space Inside the spinal cord may narrow and cause compression on the nerves

Central mechanisms: stroke, cerebral hemorrhage or sclerosis can cause pain in the sciatic area

Traumatic pathologies:

o Proximal hamstring injuries/avulsions

o Compression of the adjacent sciatic nerve caused by edema, inflammation and haematoma formed

around the affected tendon.

Gynecological pathologies:

o Ectopic endometriosis, ovarian cysts and pregnancy may result in sciatica. The right side is more

commonly affected.


Disc bulge is the main cause of

sciatica

Sciatica from a bulging disc is the focus of this workshop.


Presentation

Pain (may be intense pain in the buttock)

Lumbosacral radicular leg pain

Numbness

Muscular weakness

Gait dysfunction (may be related to pain or motor impairment eg ‘drop foot’)

Sensory impairment

Sensory disturbance

Hot and cold or tingling or burning sensations in the legs

Reflex impairment

Paresthesias or dysesthesias and oedema in the lower extremity that can be caused by the irritation of the sciatic nerves (the lumbar nerve L4 and L5 and the sacral nerves S1,S2 and S3)


Examination

Often tender over L5/S1 and L4/5 Du points if disc bulge

Straight leg raise test may be +ve

Slump test may be +ve

Often restricted hip internal rotation on affected side.

Do not try manual release – may aggravate.

Note distribution of pain/numbness/paresthesia


Pathology

http://www.bangalorespine

clinic.co.in/images/lumbar-

disc-herniation.jpg


Posterio-lateral disc bulge

http://www.espalda.org/divulgativa

/dolor/causas/comoaparece/comp

resion.asp


L5 disc bulge can affect traversing S1

nerve root

https://i.ytimg.com/vi/AWR1M

90NG5s/maxresdefault.jpg


https://www.chirobase.org/07Strateg

y/AHCPR/ahcprclinician.html


Standard Care

Rest for no more than 2 days for initial pain management

Keep active

Adequate pain relief to maintain activity

Gentle exercise

>70% of people report improvement (not cure) in 4 weeks. 20-30% have problems after one to two years.

No Xray within first 6 weeks

Investigate if other neurological signs and symptoms

Bowel or bladder issues, poor gait or stability, bilateral leg symptoms, genital symptoms,

Investigate if systemic signs and symptoms

Weight loss, night sweats, chills, fevers, nausea/vomiting, unrelenting night pain.

http://www.sahealth.sa.gov.au/wps/wcm/connect/07edec8049e4dbbfb409fe3a89b74631/ManagingSciatica-RAH-AlliedHealth-120123.pdf?MOD=AJPERES&CACHEID=07edec8049e4dbbfb409fe3a89b74631


http://www.sahealth.sa.gov.au/wps/wcm/connect/07edec8049e4dbbfb409fe3a89b74631/ManagingSciatica-RAH-AlliedHealth-120123.pdf?MOD=AJPERES&CACHEID=07edec8049e4dbbfb409fe3a89b74631

Standard Treatment

The conservative treatment consisted of ergonomic instruction, active

physical therapy, education/counselling with instructions for home-based

exercise, and non-steroidal anti-inflammatory drugs if tolerated.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5223716/


Prognosis


‘In general the clinical course of acute sciatica is favourable and most pain and related disability resolves within two weeks.’

For example, in a randomised trial that compared non-steroidal anti-inflammatory drugs with placebo for acute sciatica in primary care 60% of the patients recovered within three months and 70% within 12 months.

About 50% of patients with acute sciatica included in placebo groups in randomised trials of non-surgical interventions reported improvement within 10 days and about 75% reported improvement after four weeks.

In most patients therefore the prognosis is good, but at the same time a substantial proportion (up to 30%) continues to have pain for one year or longer.



Acupuncture more effective

_Adapted from : Lewis RA, Williams NH, Sutton AJ, Burton K, Din NU, Matar HE, et al.

Comparative clinical effectiveness of management strategies for sciatica: systematic review and network metaanalyses. The spine journal : official journal of the North American Spine Society. 2015 Jun 1;15(6):1461-77. copyright Stephen Janz 2017

https://www.researchgate.net/publication/259698024_Comparative_clinical_effectiveness_of_management_strategies_for_sciatica_Systematic_review_and_network_meta-analyses

Acute Exercises

Can aggravate

Prone arch

Hamstring stretch

Knees to chest

http://www.spine-health.com/wellness/exercise/exercise-sciatica-a-

herniated-disc


Acupuncture: Acute 1

If acutely inflamed local treatment may be too strong initially and lead to aggravation

Avoid massage

Can use auricular points

Abdominal points

Analgesics

Anti-inflammatory herbs/medications

Tumeric

NSAID’s

Paracetamol

Antispasmodics

Diazepam

Magnesium

Sedative

Eg Mersyndol

Doxcylamine, paracetamol, codeine.


Acupuncture Acute 2

Treatment principle is to move stagnation in lower lumbar

Segmental approach.

Needle above and below

Points of choice – Jia ji points L3/4, 4/5 and 5/S1

Must needle to depth of the disease – usually 50 mm and touch bone

Supplementary points – usually trigger points in gluts Bl 54 and lateral in glut medius muscle. 75 mm pins.

Treat Du Mai SI3, Bl 62

St 36 – promote healing

Often use electro stim on jiaji points

Can use heat lamp

12-15 minutes retention only.

Treatment frequency


Acute Acupuncture 3

Above method sometimes doesn’t work

Sometimes patient is in worse pain afterwards

Why?

Impact of prone posture

Muscle spasm

Cant needle to correct depth due to posture

Cant needle optimum structure due to extension of spine.

For the above reasons a special piece of equipment should be used in

nearly all cases of sciatica and disc bulge.


Most important piece of equipment for

treating sciatica


What to do when the patient doesn’t

progress

Use alternative methods.

Auricular points

Abdominal points

Point Injection Therapy

May use as a course of treatment or alternate.

Patient will tell you what works best


54 Year Old Carpenter

History of Chronic Recurrent Low Back Pain

Current episode of 1 week duration following crawling through cramped

roof space.

Very painful in bed at night

‘S’ disc posture

Lumbar pain

Numb R anterior thigh

Tender du points lower lumber

SLR -ve


Treatment 1-3

Prone 50mm jiaji L5/4/4/ bilaterally

1cun points L5/4/3 with electro stim 4/100 Hz

Bl54 bilaterally

R SI 3 and L Bl 62

R ST 36

15 minutes retention

Treat 4 days apart x3 – progressive improvement with reduced area of

numberless but still very painful in bed at night.


Treatment 4

Repeat treatment will pillow under abdomen

Dramatic improvement – pain at night nearly resolved.

3 more treatments 4-5 days apart

No more night pain. No Back pain.

Whole episode resolved in 4 weeks.

Was able to work through episiode


17 year old Student

2 year history pain from R glut to calf.

No history of injury

Thin build

Many Rx’s

MRI inconclusive

Steroid Injections and local anaesthetic: un-remarkeable result

12 month physio – slow improvement but still pain down leg

Can’t sit at school

Aggravated to sit/carry a bag


Examination

SLR + ve at 70%

Tight lower erector

Tender over SIJ and Du L5/S1

Clinically looks like a disc problem but physio insists SIJ issue


Treatment 1

Plan – treat 4-5 days apart x 5 and review

50mm Bl 54 bilaterally – ashi on R (would use 75mm pins but thin build)

50mm SIJ with 1cun pt L4/5 electro stim 4/100 between Jia ji and SIJ points

1cun pt and Du point L5/S1

Outcome of first treatment– No change


Treatment 2

Pillow under abdomen

50 mm Bl 54 and Glut med bilaterally

SIJ bilat

50 mm jia ji L4/5 and L5/s1 to 40mm. Electrostim 4/100 Hz


Outcome – No leg pain x 2 days

Repeat 5 days later


Treatment 4

No pain since 2 day post treatment

SLR now 90 degrees (was 70)

For hamstring stretches

Pillow under abdomen

50 mm Bl 54 and Glut med bilaterally

No SIJ points

50 mm jia ji L4/5 and L5/s1 to 40mm. Electrostim 4/100 Hz



Treatment 5

Episode of pain which spontaneously resolved

Repeat treatment. No electro

Add reverse curls and Knees to chest exercise.

Treat twice more 1 week apart –

Pain free – can sit at school without pain

Refer back to referring physio for further rehab exercises


Cyclist

45 year old office worker and weekend cyclist

3 month history L side sciatica – uncertain trigger

Worse since chiropractic manipulation 3 months ago

Pain 5/10 and into left calf with tight glut and low lumbar

Dull ache into left lat malleolus


-ve SLR

-ve hip slump

Tender Du L4/5

Feels better on Mobic

MRI confirms large left paracentral disc extrusion L4/5 causing L5 nerve root

compression.


Treatment 1-8

Initial response to Jia Ji and Du points L3/4/5 with electro 4/100 hz on 1 cun

pts

TDP lamp

Si 3, Bl 62, St 36

Gradual improvement with 8 treatments over 6 weeks

Given Sarah Keys ‘Back in action’ book to read


Treatment 9

Add pillow under abdomen

Jia Ji and Du points L3/4/5 with elctro 4/100 hz on 1 cun pts

TDP lamp

75 mm Bl 54 and lateral glut med point

Si 3, Bl 62, St 36

Outcome – Pain free episodes.


Treatment 10-12

Saline Point Injection Therapy

1 ml Jia Jia L4/5 and L5/S bilaterally

½ ml Du L4/5 and L5/S1

Needle R SI3 and L Bl 62.

Outcome

Initially sore for a few days then 20 km bile ride.

3 weekly PIT treatment


Treatment 13-14

Left leg achy with bike ride

Use Abdominal Acupuncture

CV 12, 10, 6, 4 and granule points around CV4

Left Bl 26 x 3

R SI3 L Bl 62

Outcome: Sometimes almost pain free.

Ok after bike ride

Changed Panadol to turmeric


Treatments 15-20

Alternate abdominal/ Local and PIT to patients preference treating around

7-14 days apart

Increased cycling activity


Treatments 21-25

Occasional Twinges only in calf

Built up to 100 km rides

Follow up treatment stretched to 4 weekly then ceased

No treatment required for last 5 months

Entire course of treatment took 7 months


53 Year Old Office Worker

Sciatica since manual handling luggage several months prior to coming for treatment

Left leg intermittent shooting pain.

Numbness into left foot.

SLR-ve

Inconsistent results from usual local treatment (6 treatments)and sometimes aggravated

Given simple core exercises

Thoracic pain when pillow used under abdomen.

Treatment interrupted by focus on treating Trochanter bursitis

(balance pelvic imbalalce, IR laser around bursa 6 J/pt x 5 points).


Point Injection Therapy

3 months after initial presentation (at least 6 months of symptoms)

1ml saline per point jia ji and Du L4/5 and 5/S1

6 points in all

Roll over and use ear lumbar points, SI 3, Bl 62, St 36

Outcome ’Surprisingly Good’

Repeat weekly total of 3 sessions

Much better, only slight toe numbness left.


Long Term Rehabilitation

Exercise.

Strengthen core muscles

Can commence early in treatment as long as doesn’t aggravate too much

Many online resources

Pilates

Yoga

Walking


Common core exercises

Heel slide

Glut med

Reverse Curl

Four Point Kneeling

Resources for exercises:

Back in Action by Sarah Keys: http://www.simplebackpain.com/back-in-action.html

Summit health http://www.summitmedicalgroup.com/library/adult_health/sma_low_back_pain_exercises/

Physio Advisor pilates: https://www.physioadvisor.com.au/exercises/pilates/beginner-exercises/


How does sciatica differ to other forms

of back pain?

Muscular

More massage and bladder points

Facet joints

(often sacral oedema) – 1 cun points

Sacro-iliac

Massage and target SI joints

In each case add gluteal points


clinically effective strategies for sciatica

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