Piriformis Syndrome - What a pain in the butt!

Piriformis syndrome is referred to as sciatica resulting from compression of the sciatic nerve by the piriformis muscle.  Most patients state that they have buttock pain with numbness and tingling travelling down the thigh and upper leg, less reported is associated low back pain.  Other features include painful sitting; tenderness over the sciatic notch; pain with hip movements that stress the pirifomis (internal rotation) and relief with shortening of the piriformis (external rotation of hip, or walking with the toe pointing out).  The condition must be differentiated from lumbar disc herniation in younger people, and advanced degeneration or tumors that narrows the spinal or lateral canals in the older population. 

It is estimated that 15-20% of the population are predisposed to piriformis syndrome as the sciatic nerve passes through the piriformis muscle body rather than underneath, making it more susceptible to compression.  Other causes of piriformis syndrome include: muscle imbalance of weak hip extensors/abductors and tight hip flexors/adductors caused by prolonged sitting; overuse injuries in a sitting position, such as rowing or biking; stiff sacroiliac joints causing gait changes and shearing of the piriformis; and overpronation of the foot causing the knee to turn inward and piriformis to compensate. 

Conservative treatment will generally resolve the symptoms, and can include: ice, NSAIDS or acupuncture for inflammation and pain control; avoiding aggravating activities (uphill running, biking, rowing); stretching tight muscles and strengthening weak muscles; massage or using a tennis ball to target tight muscles; manipulation to restore SI joint function; gait correction with orthotics; and tissue healing with therapeutic laser. 

How Chiropractic Neurology helped Sidney Crosby

If you follow hockey at all, you would know that its star player, Sidney Crosby, has been sidelined with a concussion since early January 2011.  As with most head injuries, there is no predicting how long recovery would take or if full recovery is possible.  After eight frustrating months, and uncertain if he would ever again play the game he so excelled at, Sidney turned to Dr. Ted Carrick, the father of chiropractic neurology, in a desperate attempt to help with his ongoing balance and spatial orientation problems, caused by a disruption in his vestibular system. 

Dr. Carrick assessed Sidney, and determined that his injury caused him to not be able to tell where his body is in space or where other objects in relation to him were in space, skills which are essential for an elite hockey player.  After determining what his brain dysfunction was, a treatment protocol involving various proprioception exercises to reeducate his brain and develop a new spatial grid were given.   This included eye exercises, balance exercise, multitasking exercises and sessions in a unique device called a gyroscope, which spins you around like a fair ride. 

After a week with Dr. Carrick, Sidney was sent home.  A few weeks later, on September 7^th, a high profile press conference was held to update the public on Sidney’s progress, and Dr. Carrick was at his side, explaining his unique therapy.  On September 17^th Sidney practiced with his team mates on opening day of training camp, without contact and without symptoms.  Sid the kid played his first game on November 21^st, scoring 2 goals and 2 assists, announcing to the hockey public that he was back. 

Currently a 400 person research project is underway at Life University in Georgia to try and validate Dr. Carrick’s treatment protocol, but as many in the field of head injuries would point out, concussions are unique to the individual and as such, so is the treatment prescribed.  Many in mainstream medicine remain skeptical, as they have never heard of Dr. Carrick, chiropractic neurology or his holistic approach to treating brain injuries.  But Sidney and his support team would tell you that it made the difference with getting him back on the ice. 

Source:  http://www2.macleans.ca/2011/11/03/rebuilding-crosbys-brain/

Managing Arthritis Naturally

 Many people with arthritic conditions rely on non steroidal anti-inflammatory drugs (Aspirin, Advil) which can produce intestinal ulcers and bleeding or Acetaminophen based drugs which can produce liver damage in long term users, and hence should be used sparingly.  Clinical studies have shown that degenerative arthritis and joint inflammation can be treated effectively with specific dietary changes and supplementation. 

Inflammation occurs when the body makes a hormone like substance, prostaglandin-2 (PG2), whereas PG1 and PG3 make non inflammatory products.  In our body, prostaglandins are made from the polyunsaturated fats that we eat.  Diets from high fat meat and dairy products make PG2 whereas diets with omega 3s from fish oil and flaxseed oil make PG3 and fats from evening primrose oil, borage oil and black current make PG1.  Vitamin B6, vitamin E, vitamin C, niacin, zinc, selenium and magnesium are also required to convert these essential fats into PG1 and PG3. 

Research reveals that certain herbals provide effective anti-inflammatory relief by blocking the synthesis of PG2 and other inflammatory chemicals without causing side effects of damage to the intestinal tract, liver or kidneys.  Curcumin, Boswellia, White Willow Bark Extract, Ginger Root Extract, Bromelain and Quercetin are herbal agents that have shown to provide relief for arthritic patients and also for other muscle, tendon or joint inflammatory conditions.

After controlling the pain and inflammation of arthritis, the next step is to provide the building blocks for repair of joint cartilage.  After age 40, the body loses the ability to manufacture optimal levels of glucosamine, the raw material for proteoglycans, and a major component of cartilage.  Hence supplementation with glucosamine sulfate can provide the body with the material to help repair and regenerate cartilage and halt further destruction of the joint.  Sulfur also plays a role in maintaining cartilage and reducing inflammation, hence the addition of MSM (methylsufonylmenthane) is often used in combination with glucosamine sulfate. 

The final step in managing arthritic conditions is to encourage movement of the joints.  This can involve both an exercise program to stabilize the joints, as well specific biomechanical manipulation to the joint to improve joint function and increase nutrition to the cartilage, thereby slowing the effects of degeneration.

How long will I need to come for treatment?

Frequency and duration of care are issues which the chiropractic profession has established formal guidelines in Canada since 1993.  This evidence based practice covers three areas: acute, uncomplicated pain; acute, complicated or chronic pain; and supportive or maintenance care.

Acute, uncomplicated pain applies to patients with pain of less than 3 weeks duration and with a common diagnosis of mechanical back pain (strain/dysfunction).  The protocol for these patients is to provide up to 3 treatments per week for 4 weeks.  If there is no improvement after 2 weeks, treatment should be modified.  If there is no improvement by 4 weeks or symptoms are progressive, treatment should stop and the patient be referred out to another health professional.  Typically, if the patient is showing improvement, there is an encouragement to return to modified activities and an exercise component is introduced with a decrease in visit frequency (e.g. to weekly) for another 4 weeks, for a total time of 8 weeks.  When maximum medical recovery is reached, the patient may either be discharged or maintenance care may be recommended.

Acute, complicated or chronic pain applies to patients with complications (significant trauma,   significant underlying spinal degeneration, a disc problem with neurological referral, etc) or chronic pain (recurrent, disabling attacks of spinal pain or pain for 12 weeks or more duration).  Treatment may be slightly more frequent (e.g. 3 times a week for 4-6 weeks, than 2 times a week for another 4-6 weeks) and for a longer duration (e.g. up to a total of 16 weeks).  Patients would be typically reassessed every 2-4 weeks to determine if there is improvement in symptoms and function, and whether to continue treatment or to refer to another health professional.  Advice on return to modified activities and specific exercise would be accompanied with a discussion on pain behavior.  If the patient has not returned to pre-episode status, a period of treatment withdrawal may determine if they have reached maximum medical recovery and whether they should be discharged or recommendations of supportive  care be given.  If maximum medical recovery has been reached, either discharge or maintenance care may be recommended.

Guidelines define two different forms of longer term chiropractic treatment.  Supportive care is for patients who have reached maximum improvement, but fail to sustain this improvement and who progressively deteriorate when treatment is withdrawn.  This treatment is determined to be therapeutically necessary, but must be determined on an individual basis.  Maintenance or preventative care is treatment for a patient who has no present symptoms but may seek to prevent recurrent episodes of back pain and promote health.  Typically, chiropractors have recommended monthly maintenance care.

Laser Therapy for Chronic Achilles Tendinopathy

Achilles Tendinopathy is common in many athletes following injury, and can lead to tendon degeneration, pain, loss of performance and eventual tendon rupture.  A study published in the American Journal of Sports Medicine investigated whether the addition of low level laser therapy (LLLT) for 8 weeks in addition to an eccentric exercise (EE) program would speed recovery and improve outcomes in recreational athletes with chronic Achilles Tendinopathy.

52 athletes with symptoms of at least 6 months of unilateral, activity limiting pain in the Achilles tendon were included.  They were randomized into two groups, the first group having EE and LLLT and the second group having EE with placebo LLLT.  LLLT and placebo LLLT were administered twice a week for 4 weeks, than weekly for 4 weeks.  EE were performed 4 times a week, consisting of unilateral calf raises performed on a step which started with body weight only, and progressed with weight in a back pack, beginning with 1 set of 15 reps and progressing to 12 sets of 12 reps.  Static stretching of the Achilles tendon was included.

 Outcomes were measured at 4, 8 and 12 weeks.  Pain intensity during physical activity was significantly better in the true LLLT group at every stage of assessment, and all secondary outcomes were also significantly better.  This study provides evidence that adding LLLT to an EE program may speed recovery and improve outcomes, up to 4 weeks following treatment.

Citation: American Journal of Sports Medicine 2008; 36(5):881-887.

Spinal Manipulation for Chronic Cervicogenic Headaches

Headache symptoms are very common, effecting approximately 16% of the population, and can be divided into three main categories:  migraine, tension and cervicogenic headaches.  Cervicogenic headaches are associated with neck pain and mechanical dysfunction of the cervical spine and therefore in theory should respond to spinal manipulation therapy (SMT) to restore normal neck movement. 

A 2010 pilot study looked at patients with chronic cervicogenic headaches.  The criteria included: at least 5 headaches a month for over 3 months; pain which started at the base of the skull and radiated over the top of the head to the front: and pain/reduced range of motion in the cervical spine.  The patients were randomly assigned to 4 treatment groups for the 8 week study:

·         High dose SMT (manipulation twice a week, totally 16 treatments)

·          Low dose SMT (manipulation once a week, with the second session per week for information only, totally 8 treatments)

·          High dose light massage (twice a week treatments, totally 16 treatments)

·         Low dose light massage (weekly treatments with a second session per week for information only, totally 8 treatments)

The results of the study were:

• There was no difference in the high or low dose SMT groups, but SMT was more effective than light massage.  At 8 weeks, the number of weekly headaches had decreased by 50% in the patients who received SMT.
• This difference was both statistically and clinically significant.  Overall there was a decrease in intensity/pain of the cervicogenic headaches, decrease in headache frequency; and decrease in medication intake which was sustained with the SMT groups.

This study supports that SMT can work as an additional intervention with cervicogenic headaches, best  in combination with soft tissue treatment, exercise and education.

Citation:  The Spine Journal 2010; 10:117-128

Maintenance Care for Chronic Low Back Pain

A landmark study which was accepted in January, 2011 to be published in Spine looked at maintenance spinal manipulation therapy (SMT) for chronic, non specific low back pain (LBP) and whether there was a reduction of pain and disability levels over an extended period of time.  About 85 % of LBP patients who seek treatment are of a non specific variety, where there is a lack of underlying pathology (bone or nerve).  LBP is considered chronic when it has been present for over 12 weeks. 

The study was divided into three groups:  control (sham manipulation), SMT for one month, SMT for 10 months.  Treatment was given three times a week for the first month of the study, with patients in both the SMT groups reporting significantly lower pain and disability than the control group.  Following the second phase of treatment (10 months), patients who received bi weekly maintenance SMT had significantly lower pain and disability scores than those patients who did not have maintenance SMT.  Although the outcome measures for both the SMT groups were similar after one month, the non maintenance SMT group gradually returned to pre treatment levels (similar to the control group) by the end of 10 months. 

Not only did the maintenance SMT group who received care over 10 months have better results regarding their pain and disability levels than those patients who stopped care after one month, they also had improved lumbar mobility and better perceptions of general health.  This study supports what chiropractors have been saying to their patients for years.  Once the initial phase of treatment has been completed to stabilize your back condition, it is beneficial to consider monthly maintenance care to keep your spine functional and hopefully avoid acute episodes of back pain.