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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
copyright Stephen Janz 2017
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
copyright Stephen Janz 2017
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
copyright Stephen Janz 2017
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.
copyright Stephen Janz 2017
Disc bulge is the main cause of
sciatica
Sciatica from a bulging disc is the focus of this workshop.
copyright Stephen Janz 2017
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)
copyright Stephen Janz 2017
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
copyright Stephen Janz 2017
Pathology
http://www.bangalorespine
clinic.co.in/images/lumbar-
disc-herniation.jpg
copyright Stephen Janz 2017
Posterio-lateral disc bulge
http://www.espalda.org/divulgativa
/dolor/causas/comoaparece/comp
resion.asp
copyright Stephen Janz 2017
L5 disc bulge can affect traversing S1
nerve root
https://i.ytimg.com/vi/AWR1M
90NG5s/maxresdefault.jpg
copyright Stephen Janz 2017
https://www.chirobase.org/07Strateg
y/AHCPR/ahcprclinician.html
copyright Stephen Janz 2017
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
copyright Stephen Janz 2017
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/
copyright Stephen Janz 2017
Prognosis
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1895638/
‘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.
copyright Stephen Janz 2017
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
Acute Exercises
Can aggravate
Prone arch
Hamstring stretch
Knees to chest
http://www.spine-health.com/wellness/exercise/exercise-sciatica-a-
herniated-disc
copyright Stephen Janz 2017
copyright Stephen Janz 2017
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.
copyright Stephen Janz 2017
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
copyright Stephen Janz 2017
copyright Stephen Janz 2017
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.
copyright Stephen Janz 2017
Most important piece of equipment for
treating sciatica
copyright Stephen Janz 2017
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
copyright Stephen Janz 2017
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
copyright Stephen Janz 2017
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.
copyright Stephen Janz 2017
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
copyright Stephen Janz 2017
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
copyright Stephen Janz 2017
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
copyright Stephen Janz 2017
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
copyright Stephen Janz 2017
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
15 minutes retention
Outcome – No leg pain x 2 days
Repeat 5 days later
copyright Stephen Janz 2017
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
15 minutes retention
copyright Stephen Janz 2017
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
copyright Stephen Janz 2017
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
copyright Stephen Janz 2017
-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.
copyright Stephen Janz 2017
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
copyright Stephen Janz 2017
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.
copyright Stephen Janz 2017
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
copyright Stephen Janz 2017
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
copyright Stephen Janz 2017
Treatments 15-20
Alternate abdominal/ Local and PIT to patients preference treating around
7-14 days apart
Increased cycling activity
copyright Stephen Janz 2017
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
copyright Stephen Janz 2017
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).
copyright Stephen Janz 2017
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.
copyright Stephen Janz 2017
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
copyright Stephen Janz 2017
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/
copyright Stephen Janz 2017
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
copyright Stephen Janz 2017