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Self-Management of Sciatic Nerve Pain

10/20/2014

5 Comments

 
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Practice what you preach. As physical therapists, we like to lecture about how our patients need to be compliant with their Home Exercise Program (HEP) if they want to get better or prevent injury. Yet we often are some of the worst patients when faced with an injury. Not only can this apply to consistency with HEP, but also with assessment patterns. Have you ever stressed to a co-worker or student the need to "look at the whole chain," then as soon as a friend asks you to look at their shoulder you get fixated on that shoulder? I recently had an awakening similar to this as I had been treating many patients with repeated motions, but treating myself with core stabilization.

About a year ago, a couple friends and I ran up and down the Grand Canyon. This was done with insufficient training as I was barely able to walk for a week afterwards and unable to run for 2 weeks. Once the initial delayed onset muscle soreness (DOMS) dissipated, I noticed I would consistently get a pain along my posterior thigh when running anything longer than 2 miles. Initially, I only noticed the pain with running at terminal swing on my left side, but I began to notice it with walking and any trunk twisting motions. I took a few weeks off running, thinking I just needed more rest. When I returned to running 3 weeks later, I continued to have pain with running (although with less severity) and with occasional trunk twisting motions. During one my of my residency lab practice sessions, I had my mentor evaluate me who initially diagnosed it as a HS strain based off subjective complaints since it was bothering me with terminal swing. He advised I shorten my stride length, which did help some, but the pain remained. Upon further examination, it was found that my exact pain was reproduced with slump sciatic nerve testing on the L side.

With my history of a hypermobile lumbar spine, I began treating myself with core stabilization exercises (a la Shirley Sahrmann) and sciatic nerve glides. This significantly reduced my symptoms and got me approximately 90% better. However, I would still occasionally notice the pain, especially with running and twisting. Every once in awhile, I would ask a co-worker to do a Thoraco-Lumbar (T-L) Junction manipulation which would eliminate my pain, but only temporarily. I would joke with my patients that when I am consistent with my HEP of core stabilization exercises and sciatic nerve glides, I forget about my pain and stop doing the HEP, which leads to the return of my pain. This seemed like an ongoing cycle. One day, I was on a long car drive and noticed the pain returned. However, I had just then had a realization with my patients how frequently repeated lumbar extension reduces pain, given how most patients spend too much time in lumbar flexion anyway. I quickly did about 10 standing lumbar extensions, which initially recreated my pain, but was eliminated at completion of the repetitions. I experimented and performed the repeated extensions before running and noticed I had no pain. Now I use repeated extension prophylactically in order to keep the pain away, especially with higher level activities.

Now, it is clear that the Sahrmann core stabilization method can be successful, as evidenced by the reduction of my symptoms. However, I found the repeated loading to get me over the hump and allow me to return to prior level of activity symptom-free. It's not that I choose one or the other. In practice, I actually utilize both theories, as once I have found the Directional Preference, I repeatedly load that movement and follow-that up with movement re-education to isolate movement in one region from another. The biggest issue of course is compliance. With both methods, the HEP should be performed consistently, whether symptomatic or asymptomatic.

-Chris

5 Comments
AJ Sobrilsky
10/26/2014 10:27:00 pm

Chris,

Couldn't agree more about ourselves being the worst patients's of all. You brought up an interesting treatment approach; one that I feel therapist in general need to be more adept in. The TBC for low back pain demonstrates that roughly 50% of patients can be categorized into one group and close to 20-25% can fall into two. You and I both know those patient's that fit the exact criteria ("home-run") are far and between and thus we need to be skilled in assessing the patient's subjective and objective presentation in order to match the most appropriate treatment plan. I think the bigger question still remains regarding the appropriate approach with the other 25% that don't "fit" - chronic pain, post surgical, etc.

As evidenced above sometimes a specific and evolving approach will improve patient status - your pain improved with motor control/stabilization exercises. Then, you included directional exercises and intermittently utilized manipulation. THIS IS A PERFECT example of the fluidity we have as therapist to manage musculoskeletal conditions.

Keep the good clinical inquiry coming. Cheers!

Reply
Chris link
10/27/2014 02:46:59 pm

Hi AJ,

Great link to some of the evidence that is being promoted by the APTA. I think the understanding of our need for an eclectic approach will only help patient outcomes as rarely does just one treatment work for the majority.

Reply
Clinton link
11/7/2014 12:44:19 am

This post couldn't have come at a more appropriate time for me. I'm experiencing pain that began locally in my right piriformis after performing a high volume of heavy kettlebell swings, which did not resolve with rest, foam rolling, stretching, etc. Later the pain manifested upon the distal lateral aspect of my right tibia with an increase in magnitude of the original piriformis pain. Later a positive slump test on my right side resulted in textbook reproduction of my * sign.

Briefly following the trend of being my own worst patient, I assumed the pain would go away on its own as I do not get injured often. For several days I was content with slightly limping on my commute to work and the pain would decrease as the day wore on, but would inevitably return the following morning.

After a couple of stubborn days like this, I decided enough was enough and started to consistently perform sciatic and peroneal nerve glides, prone extensions and gradually increasing my hip hinge and toe touch movements. I still included some dynamic and static hamstring and piriformis muscular stretching here and there but the neural tension exercises appear to give me the most relief.

As annoying as injuries can be, when I do encounter them I find them to be pretty educational experiences from a first-person perspective and makes me resonate with patients better. I feel like it also encourages me to be that much more emphatic on the importance of a daily, consistent HEP. Especially some that may seem awkward or annoying to do (neural glides/flossing), but their significance cannot be overstated.

Great post Chris and looking forward to reading more, thanks for sharing your experience!

Clinton

Reply
Christopher Fox link
11/15/2014 01:25:48 am

Hi Clinton,

I think we, as physical therapists, can best sympathize and educate our patients if we are unfortunate (or fortunate) enough to have an injury and experience rehab as well. Being able to relate to the patients can be key, because it can elevate the trust between patient and therapist. I hope your injury has been feeling much better and thank you for sharing your experience!

-Chris

Reply
Haven Painrelief link
7/26/2022 02:22:08 am

That’s really nice. I appreciate your skills. Thanks for sharing.

Reply



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