Understanding Sciatica 2 CE Hours Course # 20-417865 Class Objectives 

Develop a better understanding of what sciatica is, how it happens, and how it’s treated  Gain a deeper understanding of the conditions commonly confused with sciatica  Learn the “red flags” to be aware of when someone has sciatica-like symptoms

Instructor Michael Ames, LMT www.AdvFundamentals.com 407-913-9755

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Advanced Fundamentals Education, LLC Advanced Fundamentals Education, LLC is an approved continuing education provider for massage therapists. We are approved through the National Certification Board for Therapeutic Massage & Bodywork (NCBTMB) and the State of Florida to offer continuing education credits to massage therapists. NCBTMB Provider #:

451911-12

State of Florida Provider #:

50-13930

Advanced Fundamentals Education, LLC Phone: 407-913-9755 Email: [email protected] Website: www.AdvFundamentals.com Disclaimers: The information in this course is generally accepted as factual at the time of publication. The information has been gathered through research or practical experience. Advanced Fundamentals Education, LLC holds no responsibility for any information later found or claimed to be inaccurate. It is the responsibility of individual practitioners to determine what is right for themselves and their clients. It is also the responsibility of individual practitioners to work within their scope of practice, laws and limitations. This course is for informational and CEU credit purposes only. There is no certification of any kind involved. Advanced Fundamentals Education, LLC does not advocate or condone any illegal, unethical or immoral activity, and no such advocacy or condonation should be implied from anything herein. Any discussion points throughout this course are merely used as a tool to facilitate thought and encourage creativity, while still abiding by the laws and ethics of your location and organization. The information contained in this course does not necessarily reflect the views of Advanced Fundamentals Education, LLC. Any similarity to any people or organizations is coincidental. The original content of this course is copyright protected. You may use the information provided for your personal use only as it is related to your continuing education or informational needs as a massage therapist. You may not reproduce this material in any way without written notice from Advanced Fundamentals Education, LLC. © www.AdvFundamentals.com

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Directions: You can download this PDF file to your computer or review the material online while you take the exam. The reading material and exam are NOT timed. thoroughly.

Read through the material presented

Once you are ready to take the exam: 1) If you are not on the password protected page, go to it. This is the same page where you downloaded your course material. A password was emailed to you when you purchased your online CEU course(s). The link to the Course Material and quiz can also be found on the “Access Courses” Page. 2) Complete the quiz. A passing grade is 70% or higher. You have unlimited attempts to pass your exam. 3) The quiz is graded automatically and you are shown whether you pass or fail the quiz along with your percentage score. You are not shown what questions you answered incorrectly. However, upon passing, you are shown all the correct answers so you can compare them to your answers (if you have them written down.) 4) Make sure you have saved our email to your contacts to ensure proper delivery of your certificate of completion. [email protected] 5) For Florida Massage Therapists, Course Completions are reported daily to Cebroker.com. 6) If you have any questions not answered here or in the FAQ section of the website, please contact us. We’re here to help any way we can. * Note: It is highly recommended that you print out any course material you wish to keep, as well as your certificate of completion. Your certificate of completion is your proof you completed this course. * Note: If you are submitting credit for your NCBTMB re-certification, you are responsible for submission of all your hours along with course information and any certificates needed as proof of completion.

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TABLE OF CONTENTS

-5- Getting started with sciatica: an introduction to the course -7- A closer look at sciatica a. What is sciatica? b. Who gets sciatica? c. What are the common symptoms of sciatica? -8- What are the major causes of sciatica? -10- How is sciatica diagnosed? -11- What are the treatments for sciatica? -12- Are there surgical treatments for sciatica? -12- How is massage therapy used in the treatment of sciatica? -14- Are there any ways to prevent sciatica? -14- Is there self-care for my clients with sciatica? -17- What sciatica is not: A presentation of the ailments that are commonly confused with sciatica -17- Sacroiliac joint dysfunction -18- Joint problems in the spine -18- Trigger points and referral patterns - the gluteus minimus -19- Piriformis syndrome -19- Ankylosing spondylitis -20- Critical conditions that require immediate medical attention -20- Red flags -20- Cauda equina syndrome -21- Spinal tumor -21- Spinal infection -23- Summary -24- Appendix – assessing red flags -26- Content bibliography -26- Image bibliography -27- Directions -28- Quiz

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GETTING STARTED WITH SCIATICA

Let’s begin with low back pain in general. It is among the most common reasons people seek medical attention. The occurrence of low back pain for an individual is estimated at 5% per year. The lifetime occurrence of low back pain has been estimated to be as high as 60-90%. According to these numbers, low back pain is second only to the common cold as a reason for visiting a doctor. Low back pain costs billions of dollars in lost productivity and healthcare expenses every year. Low back pain comes in many forms. Acute injuries from falls can cause serious and immediate low back pain. Old injuries from contact sports and accidents, thought to have been resolved years ago, can cause back pain later in life. Repetitive work that uses the lower back can lead to problems over the course of a worker’s life. Later still, osteoporosis causes micro-fractures in the lower spine that develop into back pain for millions of elderly people. Other chronic degenerative conditions can also cause debilitating back pain that is hard to treat. Sometimes pain is felt only in the back. But, very often, symptoms go beyond the lower back, through the leg, and as far down as the foot. The symptoms are usually felt in one leg only. The most common symptom is pain that is described as shooting and burning as far down as the toes. Alternately, there can be numbness or loss of sensation. There may even be muscle weakness. When this occurs, the client may be presenting with a condition known as sciatica. Sciatica comes in many degrees. The degree of symptoms can range from mild and uncomfortable to severe and debilitating. In general, sciatic pain is more severe and persistent than low back pain without sciatica. It is also responsible for more lost productivity and it is even more demanding on healthcare resources. Consider the experience of Roger, a 42-year-old construction worker, who suffered a fall at work: “I have always been an active person and I enjoyed working in the construction field. After my accident, I was put on bed rest for two weeks. The pain in my back was serious but not nearly as bad as the feeling in my left leg. I feel the burning, tingling and numbness all the way down into my foot. My doctor gave me medication for the pain but it doesn’t really help. It’s worse when I sit down and it makes it very difficult to sleep. After I had an MRI, I was told that I have a herniated disc in my lower back causing sciatica.” Sciatica is a specific pain syndrome that arises when the sciatic nerve is impinged upon or otherwise aggravated. People suffering from low back pain and symptoms that spread into the leg on the side of the body where the nerve is involved may have sciatica. Unfortunately, though, © www.AdvFundamentals.com

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as we will see, sciatica has become a catch-all term for anyone living with lower back pain and a wide and vague range of symptoms. These symptoms begin in the back but can affect the leg as much or more than the source. Jane, a 73-year-old woman and retired bookkeeper, had been living with back pain for years. When she began to have pain down the back of her right leg, she knew it was time to seek medical attention: “I began having back pain a few years ago. It wasn’t too bad at first and it would go away with a bit of rest and maybe a Tylenol. I assumed it was just part of getting older. A few weeks ago, though, I began feeling pain in my right leg. It is different from my back pain, which is aching. This pain is a shooting pain that I feel all the way down my leg. Sometimes it burns like a hot iron running along the back of my leg. Ouch! I went to see my doctor and he ordered x-rays and a CT scan. They showed a narrowing of the spinal canal that can irritate the nerves as they exit the spine. That is called spinal stenosis, and the burning, shooting pain is called sciatica.” One of the biggest challenges when meeting clients who are living with low back pain and related symptoms is to understand if they have true sciatica or a related pain syndrome. This is vitally important because the best treatment should be chosen based on the specific cause. The purpose of this course is to provide you with information you need in order to understand and manage sciatica. You will learn what sciatica is – and what it is not – and about the many treatments available. The goal is to help you manage this common yet challenging condition to the best of your ability and to the greatest benefit of your clients.

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A CLOSER LOOK AT SCIATICA

What is sciatica? Sciatica gets its name from the longest and largest nerve in the body – the sciatic nerve. This nerve starts in the lumbosacral region of the spine – specifically the L4 through S3 vertebrae. It travels through the buttocks and back of the leg. It ultimately gives rise to the nerves that reach all the way to the sole of the foot. Midway through the back of the leg, the sciatic nerve divides into the tibial nerve and the common peroneal nerve. The sciatic nerve is responsible for sensation throughout most of the leg. It also controls the muscles of the back of the thigh and those of the leg and foot. It is helpful to consider another name for sciatica that describes the condition quite well: “Lumbosacral Radiculopathy”.  Lumbosacral is the region of the spine where sciatica begins.  A radiculopathy is an ailment characterized by pain that radiates from the spine, extending outward, to cause symptoms beyond the source of the spinal nerve root irritation. Given the anatomy of the sciatic nerve, it is easy to see how aggravation or compression of the nerve roots at the spine can cause symptoms not just in the back but throughout the leg. There are many other ailments, however, that can produce symptoms very similar to sciatica. It is often difficult to distinguish true sciatica from these other conditions. Understanding this distinction is one of the main focuses of the course. This goal will be achieved by presenting detailed discussions of some of the main conditions that can be confused with sciatica. Another main focus is on the specific causes of true sciatica. The third main focus is on choosing the appropriate management for each particular case of sciatica.

Who gets sciatica? Almost anyone can get sciatica, and there are a wide range of causes. It is very rare in children and adolescents, except where there is an abnormality of the spine from birth. An example is spina bifida. The most common age group that experiences sciatica is between 30-50 years old. In this demographic, a herniated disc is by far the most common cause. This leads to the fact that people in jobs that require heavy lifting, turning and twisting are at the highest risk. But be aware that there are conditions other than sciatica that are common in this young to middle age group. It is important to keep in mind that older people can also get sciatica. In older people, the cause is usually a degenerative disorder of the spine such as spinal stenosis. As for gender, the changes of pregnancy can cause some women to experience pain that mimics sciatica.

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What are the symptoms of sciatica? The classic symptoms of sciatica are pain, numbness, burning and tingling that begin in the lower back but are felt coursing through the leg. True sciatica almost always occurs on only one side – the side where the nerve root irritation is occurring. The symptoms may sometimes be constant and aching but are more often intermittent and shooting. There may also be weakness of the muscles controlled by the sciatic nerve. These are the muscles in the back of the leg (via the tibial nerve) and the front and side of the leg (via the common fibular nerve). Many people describe the symptoms of sciatica as being at their worst in certain situations. Most people say that the pain is at its worst when they are seated for any period of time. Other people have the worst symptoms after a period of exercise or exertion. While not the case for everyone, some people find their symptoms improve after they lie down. Prolonged time lying down, however, may cause symptoms to get worse.

WHAT ARE THE MAJOR CAUSES OF SCIATICA?

Sciatica arises from a wide range of conditions that affect the nerve at its origin with the spinal column. They can be organized in several ways. One way is in terms of rate of onset. Some causes, such as an injury affecting the back, cause symptoms immediately. On the other hand, spinal stenosis and degenerative spondylolisthesis cause symptoms gradually over a long period of time. In a similar way, the age of the client is related to the cause. As noted above, most people with sciatica are 30-50 years old and herniated disc accounts for the majority of cases in this age range. Older people presenting with sciatica are more likely to have degenerative diseases of the spine. Again, these would be spinal stenosis and degenerative spondylolistheses, as well as bone spurs. It is important to note, though, that osteoarthritis of the spine can cause referred pain and similar symptoms. This is not technically sciatica, and will be discussed further in the section on conditions that can be confused with sciatica. Lumbar Disc Herniation The most common cause of sciatica is herniation of a disc in the lumbar spine. The spinal column consists of bony vertebrae that are separated by soft tissue “discs”. These discs are made up of a thick and firm outer ring called the annulus fibrosus. Within the ring is a softer, gel-like material called the nucleus pulposus. This structure provides excellent cushioning against the stresses that are placed on the back, and especially the lumbar spine.

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While the vertebral discs are very important for cushioning the burden on the spine, they are prone to damage and herniation. Damage can occur gradually from repeated stress or can occur in a moment as a result of an accident. When the annular ring is damaged, some of the nucleus pulposus can extrude posteriorly and pinch the nerve roots exiting the spine. This is a classic cause of sciatica. Degenerative disc disease Another common cause of sciatica is chronic degeneration of the disc. This condition is different from a herniated disc because it is a condition that develops over many years. As we age, we will all have some degeneration of the vertebral discs, but only a small number of us will develop symptoms. The same changes in the cervical vertebrae are a common cause of nerve irritation in the neck. This can cause symptoms of pain and weakness in the arms. In the lumbosacral spine, such degeneration presents with the classic symptoms of sciatica, as the irritation is at the level of the nerve root. The symptoms are pain and sometimes weakness or numbness due to a degenerated disc in the spine. This diagnosis can be very worrying for people because the word “degenerative” sounds as if their condition will get worse. This is not always the case. Symptoms often stabilize with time and sometimes get better. An important point about degenerative disc disease is that it can lead to other conditions that can also cause sciatica. These are spinal stenosis and degenerative spondylolisthesis.

Lumbar Spinal Stenosis Stenosis of the lumbar spine is an important cause of sciatica, especially in the elderly. Over the lifespan, the chronic load placed on the lumbar spine causes small fractures in the vertebral bodies. As the vertebrae heal, they may encroach upon the spinal canal, causing irritation of the nerve roots and symptoms of sciatica. As can be seen in the image at right, even a small narrowing of the spinal canal can cause irritation of the nerve roots. Spinal surgeons are very cautious about operating on spinal stenosis. It can involve major surgery to alleviate the pressure on the nerve roots, and sometimes symptoms persist after the operation.

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Spondylolisthesis A less common yet still important cause of sciatica is spondylolisthesis. In this condition, one vertebra slips anteriorly relative to the vertebra below it. There are two types of spondylolisthesis:

Isthmic Spondylolisthesis A small stress fracture can occur in the bone that connects the two joints on the back side of the spinal segment. It is generally believed that the fracture occurs in childhood, but symptoms do not develop until later in life. In fact, it is estimated that only 5% of people with Isthmic spondylolisthesis will have symptoms requiring treatment. Of these, only very few will benefit from surgical treatment.

Degenerative Spondylolisthesis Unlike isthmic spondylolisthesis, there is no fracture in degenerative spondylolisthesis. It is, rather, a function of the general aging process. Over the lifespan, the bones, joints, and ligaments in the spine weaken. As a result, they are less able to hold the spinal column in alignment. It is much more common in people over 65 years old, and also in women by a 3:1 margin over men. A careful history and physical exam by a spine specialist is needed to evaluate the possibility of spondylolisthesis. If spondylolisthesis is suspected, x-rays may be performed to confirm the diagnosis and/or rule out other causes of the symptoms. Once x-rays confirm the presence of spondylolisthesis, an MRI is warranted to determine if there is encroachment on the nerve roots that is causing symptoms.

HOW IS SCIATICA DIAGNOSED?

Sciatica is usually diagnosed by a family doctor or general practitioner. The first step is to find out about the history of the person’s problem with respect to any inciting incident, length and degree of symptoms, and any particular limitations. An important part of the history is for the doctor to ask specific questions about “red flags”.

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Among the most critical conditions are infections, tumors, and “cauda equina syndrome”. Cauda equina syndrome is an urgent condition characterized by rapid loss of sensation in the “saddle region”, i.e., inner thighs. The loss of sensation may be accompanied by loss of bowel and bladder function. If not corrected right away, these changes can be permanent. Cauda equina syndrome will be discussed further in the section on critical conditions that can be confused with sciatica. Once a detailed history, including questions about red flags, is obtained, the doctor should perform a directed physical exam. The exam addresses motor function and sensory function. A specific test for sciatica is the “Straight Leg Test”. Sensory testing should be performed to assess which specific nerve roots are being compromised. While sensory loss with sciatica may cover a range of nerve roots, the effect upon certain nerve roots may produce a very distinct pattern of sensory loss. After the history and physical examination, the doctor may decide to arrange for additional testing. The first imaging technique would be x-rays. These can be helpful in identifying changes in the bony structure of the spine that can cause symptoms of sciatica. These include degenerative disc disease, lumbar spinal stenosis, and spondylolisthesis. An MRI may follow to identify soft tissue changes. This would be particularly valuable in investigating a possible disc herniation. If symptoms persist, and especially if they get worse, the family doctor may refer the patient to a specialist for further diagnosis and treatment. Neurologists and orthopedic surgeons have special training in the evaluation and management of sciatica. In particular, an orthopedic surgeon specializing in back problems can offer expertise in assessment, and if necessary, surgical options. WHAT ARE THE TREATMENTS FOR SCIATICA?

Treatment of sciatica is based on the cause and severity of the condition. For many people, patience is all that is needed, as the symptoms resolve with time. Symptoms can be reduced with some simple ideas; for example, instead of sitting for long periods of time, alternate lying down with short walks. Initial medical management is conservative, using over-the-counter pain medications. For some people, heating pads are helpful, while others find that ice works well. For more serious cases that are not getting better, physical therapy is advised. A qualified physiotherapist can design a progressive exercise program to alleviate symptoms over a period of time. The typical range would be four to six weeks of regular treatment followed by an extended period of maintenance exercises. Prevention of sciatica is discussed below, and anyone who has had sciatica should follow the advice to spare themselves from further problems. Massage therapy is another intervention that can be helpful when applied by a trained and registered therapist. The massage therapy treatment for sciatica depends on the specific cause of the symptoms in each client. A detailed discussion of massage therapy as a treatment option for sciatica will be given below. © www.AdvFundamentals.com

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Other specialty fields that offer choices for sciatica are occupational therapy, acupuncture, and chiropractic. Some chiropractors apply laser treatment to achieve decompression of the sciatic nerve, although there is considerable debate about the success rate of this procedure. If further medical management is required, stronger pain medications – typically opiates – may be tried. This treatment is accompanied by the side effects and addictive potential of this class of medications. A more invasive approach is direct injection of steroids.

ARE THERE SURGICAL TREATMENTS FOR SCIATICA?

For the most serious cases that do not respond to any of the above treatments, surgery is an option to consider. According to the Journal of the American Medical Association, surgery is needed in only 10-20% of patients. There are two common surgical procedures to treat sciatica, depending on the cause. The preferred surgery for sciatica caused by a herniated disc is a microdiscectomy. As the name implies, this is an operation through a small opening (micro) to remove the offending part of the disc (discectomy) that is pinching the nerve. When the cause is spinal stenosis, a full lumbar laminectomy is required. Another name for this is open decompression, because a larger incision is required. This is a more dramatic operation that requires disruption of the surrounding muscle to remove the offending portion of the disc and bone of the vertebrae. A note on laser spinal decompression: There is considerable controversy about the use of laser treatment for sciatica. There are both chiropractors and spinal surgeons who support the use of laser decompression as part of their skill set. The evidence for the effectiveness of laser decompression, however, is not strong. In fact, some specialists consider it to be a sham – no more than an advertising ploy. As a massage therapist who may be asked about laser decompression, it is best to advise caution.

MASSAGE THERAPY IN THE TREATMENT OF SCIATICA

Massage therapy for the treatment of sciatica is a great option for those who want to avoid the risks associated with pain medications. Many people do not want to take medications that do not treat the problem but only mask symptoms. A study conducted in 2003 indicated that massage therapy reduces the need for pain medications by up to a third. Massage therapy for sciatica pain may require multiple sessions. But, with successful treatment, relief can last for two to three months.

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Prior to starting treatment, one of the following is needed: 1. Assessment by a physician with a diagnosis and clearance to begin massage therapy. 2. If someone self-refers, there should be none of the above red flags, and the symptoms should have been present for less than six weeks and not be getting worse. The following steps are a generalized course of action: (Adapted from http://www.massagetherapy.com/) 1. Safety should be considered first. No dramatic interventions should be performed. People with sciatica often have been splinting or guarding, so initial therapy is to gently ease these effects. Work around the neck, shoulders and lateral hips is appropriate. While this may not directly work on the source of the pain, the emphasis is on calming and relaxation. Nothing more is advised for the initial session unless the client’s pain symptoms dictate it. 2. If the patient responds well to the calming and relaxation techniques and symptoms ease between sessions, careful use of deeper massage may be applied. Proceed with caution, and if symptoms get worse between sessions, return to the gentler approach of Step (1). Since symptoms of sciatica can vary depending on body position, ask the client to stand and sit for a few minutes in the middle of the session to guard against postural effects on symptoms. 3. Rather than manually stretching the client’s extremities, allow their own gentle movements to guide the treatment. Since sciatica is an inflammatory condition, deep work that elicits pain is not suitable. The level of depth and pressure should not be so much that the client is unable to relax. 4. Treatment should not focus on the site of greatest pain. Deep work at the site may increase symptoms and prevent the client from relaxing into the treatment. 5. Advanced techniques that apply lateral compression or shearing forces to the spine (listhesis) should be avoided. These include some seated techniques. Therapy that involves twisting should be approached with caution. While some twisting maneuvers can relieve compression, the risk of worsening the compression is a concern. These five steps may seem quite limiting for therapeutic options, but they are still beneficial. The calming and relaxing effects can have good results over time. Slight improvements in pain levels can reduce splinting and guarding, which can alleviate uneven stresses on the spine. Overall, the comfort offered by a caring therapist can have a positive impact for someone suffering with the chronic, painful symptoms of sciatica.

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CAN SCIATICA BE PREVENTED?

According to the Mayo Clinic, there are three measures to maintain a healthy back and minimize the risk of developing sciatica: 1. Regular exercise: The focus should be on the core muscles of the abdomen and lower back. Strong core muscles contribute to good posture. Weight bearing exercise, especially running, should be done within one’s limits to prevent undue stress on the spine. 2. Maintenance of good posture when sitting: In addition to core muscle exercise, good posture depends on choosing a chair with good lower back support and arm rests. The knees and hips should be kept level and the back as straight as possible. This image shows how poor posture while seated puts stress not only on the lumbar spine, but also the upper thoracic and cervical spine. 3. Good body mechanics: The most important point here is paying close attention when lifting heavy objects repetitively. The back should always remain straight and the lifting should be accomplished with the legs. The object should be held as close as possible to the body. An effort should be made to avoid twisting and lifting at the same time. When the object is particularly heavy and/or awkward, it is best to have a second person to assist.

IS THERE SELF-CARE FOR MY CLIENTS WITH SCIATICA? The role of the massage therapist working with clients who have sciatica extends beyond the doors of the clinic. The skilled massage therapist can guide the client to obtain all the other services that may be of benefit. Make sure you are working within your legal and ethical scope of practice when “guiding” your clients. There are several measures that the client can take between sessions, and after sessions are completed, to get the most benefit from treatment. This section looks at five key areas to be pursued:

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Analgesia and the Client’s Physician There is always a balance with pain medications. Many clients choose to avoid “pain pills” altogether because they are aware that the pills only mask symptoms without addressing the cause of the problem. On the other hand, adequate pain medication allows the client to participate more fully in treatment compared with those who are in so much pain that they can’t undergo therapy or follow through with self-care. Over-the-counter non-steroidal antiinflammatories allow most people to actively participate in treatment. For those clients requiring further medication, assessment by a physician is valuable to:

1.

Develop and maintain a cooperative treatment approach with the client’s physician

2.

Clarify the diagnosis and act on any red flags if they develop

3.

Prescribe other medications that will allow the client to take part in therapy and selfcare. The three main types of medications are muscle relaxants, non-opioid painmedications, and opioid-type pain medications such as Vicodin or Percocet. Contrary to some existing skepticism about the use of opiate-type pain medication, judicious use can help the client participate in treatment to the fullest effect with minimal risk of dependence.

Thermal Treatments While it may seem straightforward, the use of thermal treatments can really help to maintain gains made between massage therapy appointments. For clients who are keen on this area of treatment, a structured regimen should be explained. When possible, evenings should include one hour of hot water therapy followed by thirty minutes of ice cold therapy applied to the lower spine. Occupational Therapy The term ergonomic refers to the procedure and practice of techniques that render the job site as comfortable and safe as possible. In many cases, the symptoms of sciatica result from chronic abnormal stress on the spine. In today’s computer-based employment world, far too many people suffer symptoms that result from too much time spent at a desk, in improper anatomic positions. These people experience neck and lower back problems. When the problem reaches the point of clinical sciatica, it is well past time for an occupational therapist to evaluate the client’s work space and determine if there are any changes that can be made. Once these causes are fixed, the client can focus on improving the existing symptoms with the knowledge that the workspace is no longer the main causing new symptoms.

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Stretching techniques Yoga has become an extremely popular way of targeting a range of ailments while also offering general relaxation. This is an ideal combination for people living with sciatica. As discussed earlier, the best treatment a massage therapist can offer is in gently alleviating the pain caused by sciatica. Yoga can continue this process beyond the doors of the clinic. Some of the more advanced yoga techniques can directly target the spine and may be helpful for clients with sciatica. It is important, though, to instruct the client that any positions and postures that are painful, or even uncomfortable, should be avoided. In that way, the relaxation techniques of yoga can be achieved without causing any problems specific to those with sciatica. Exercise As discussed earlier in the section on ways to prevent sciatica, strengthening exercises are vitally important to maximize the benefits of therapy. The following are two specific exercises that are proven to help with the symptoms of sciatica: 1. Lie on your back with both legs in the air. Place your right ankle on your thigh above your left knee. See the shape of the number four? It is there, just upside down. 2. Reach your right hand through the open space created by your right leg and grab your left hand that is reaching around the outside of your left thigh. Slowly bend your left knee. You should feel a stretch on the outside of your right hip. Hold for 30 seconds. Repeat. General Exercise Two: 1. Lie on your back, bend your right knee and place your right foot on the floor. 2. Raise your left leg as high as you can, keeping your pelvis square (don't raise your left hip toward your ear). 3. Hold your lower left thigh or place a strap over the arch or ball of your left foot. Flex your foot to stretch your calf too. 4. Hold for 30 seconds, then switch legs. (exercises described from fitsugar.com) © www.AdvFundamentals.com

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WHAT SCIATICA IS NOT: A PRESENTATION OF THE AILMENTS THAT ARE COMMONLY CONFUSED WITH SCIATICA

There are many conditions that can present in a manner similar to sciatica. They share some of its symptoms but have a different cause. It is important to understand the cause of the symptoms that are being confused with sciatica in order to identify the appropriate treatment. We will look at four of the most common conditions that can seem like sciatica but are actually something else. Then, in a section entitled “Critical Conditions”, we will examine three serious conditions that need to be dealt with urgently to avoid permanent damage or neurologic dysfunction. Sacroiliac Joint Dysfunction The sacroiliac (SI) joint is the anatomic location where the sacral region of the spine connects with the ilium, one of the bones that make up the pelvis. It is a very sturdy joint that is heavily reinforced with ligaments. As such, there is normally very little motion. When there is too much movement in this joint, symptoms can arise that may mimic sciatica. Too little movement can also cause symptoms. Compared to arthritis of the spine, this pain can be similar to sciatica caused by a herniated disc. The diagnosis of SI joint dysfunction as the source of pain can be challenging. To be certain, anesthetic nerve blocks performed by a specialized anesthesiologist may be required. If the SI joint is the cause, there should be immediate relief from the injection. In general, the initial treatment of sacroiliac joint dysfunction is conservative. Heat, cold and rest may be tried first, along with pain medication if required. There are other specific treatments: 

A chiropractor may be considered, especially if the cause of the problem is a fixated joint – sometimes called a “stuck” joint.



If, on the other hand, there is too much movement in the joint, an orthotic device such as a brace can be helpful. The effect is to stabilize the joint while any inflammation resolves – with the plan being to wean the patient off the brace gradually.



There is another very effective way to treat SI joint dysfunction that is similar to how it is diagnosed. As mentioned above, the condition can be diagnosed by injecting anesthetics into the joint. A trained anesthesiologist may perform injections – as a treatment – of a local anesthetic for short-term pain relief along with a corticosteroid for pain relief that can last weeks. The relief can allow the patient to participate in exercises to prevent the pain from coming back. In some instances, the pain never returns, but in other cases, the patient may require repeated injections.

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

For patients with long-term symptoms that do not respond to any of these treatments, some surgeons will perform a fusion of one or both of the SI joints.

Joint Problems in the Spine Like all joints in the body, the articulating parts of the vertebrae are prone to wear and tear over the course of one’s life. Arthritis in the spine can cause pain at the site and may also cause some referred pain. The terminology can be confusing, but it is important to note that referred pain occurs relatively close to the source whereas pain that radiates can be felt much further. The back pain in this case is dull and aching rather than the shooting pain seen in sciatica. The pain may migrate to different sites in the spine, buttocks and groin. There may be some pain in the upper thigh but it typically does not go beyond the knee. The cause of the symptoms in this case is the extensive system of interconnected sensory nerves that supply many of the tissues of the low back, pelvis and thigh. It is difficult to pinpoint exactly what structure is causing the pain. A general rule is that if the pain wakes the person up at night, they should be seen by a specialist to rule out dangerous causes such as infection or cauda equina syndrome. The treatment for arthritis of the spine is conservative. It will often resolve gradually after a few weeks. When it is aggravated, it may require a brief period of bed rest for 24-48 hours. For some people, heating packs or ice packs applied to the site of pain provide short-term relief. To alleviate symptoms over time, stretching and exercise are usually helpful. Medication is helpful in the short term, but the goal should be to not become dependent. Surgery is not recommended for arthritis of the spine unless it is causing nerve root entrapment as seen in spinal stenosis. Trigger Points and Referral Patterns There is a segment of practitioners who emphasize common trigger points in the gluteal musculature as being responsible for most sciatica-type pain. Some use the term “pseudosciatica”. Trigger points and referral patterns in the gluteus minimus muscle are the most likely to be confused with sciatica. Unlike the referral patterns of the piriformis and gluteus medius, those of the gluteus minimus include the side of the thigh and below the knee into the calf. Since one of the hallmarks of true sciatica is pain below the knee, there can be considerable confusion.

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Knowing the trigger points and pain patterns of the gluteus minimus, and to a lesser degree the piriformis, can greatly improve the practitioner’s skill in alleviating the symptoms caused by trigger points and referral patterns. Piriformis Syndrome Piriformis syndrome is a rare condition among people experiencing sciatica-type pain. It occurs when the piriformis muscle is tight or having spasms, thereby compressing the sciatic nerve. In an estimated 15% of people, the sciatic nerve actually passes through the muscle, putting them at higher risk of this condition. It can be confused with sciatica, but is not technically sciatica because the site of nerve irritation occurs outside the lower back. The symptoms are typically described as tingling or burning in the buttocks. There may also be some numbness at the back of the thigh. Pain below the knee is rare, but can occur, which makes the distinction from true sciatica more difficult. Initial treatment of pirformis syndrome is with non-steroidal anti-inflammatory medications and muscle relaxant medications. These provide sufficient pain relief to allow the client to do stretching exercises that can help relax the piriformis and gluteal musculature. Massage therapy can play an important role in the treatment of piriformis syndrome. The following recommendations are adapted from the Pacific College of Oriental Medicine:  After assessing the piriformis and gluteal muscles, therapy can begin with the application of constant pressure to the piriformis and other gluteal muscles. The goal is to release the tightness in the muscles and reduce spasms.  Long strokes, which go deep into the muscle fibers, can then be applied. The amount of pressure should vary depending on the patient and the extent of the muscle tightness.  Another technique is gentle vibration of the buttocks and sacrum. The goal of alleviating the muscle tightness that is compressing the sciatic nerve may require several sessions.

Ankylosing Spondylitis Ankylosing spondylitis is a rare cause of symptoms that can resemble sciatica. It is included here because it is the classic inflammatory-arthritis condition that can cause symptoms similar to sciatica. It is also important to know about because it almost always affects a certain demographic – men between the ages of 15 and 30. Special attention should be paid to men in this demographic.

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Ankylosing spondylitis is an inflammatory/auto-immune condition that affects the ligaments and tendons of the spine. When these soft tissues are damaged, the body’s response is to replace them with bony structures. This leads to fusion of the vertebrae, and over time the spine becomes rigid and inflexible. Based on what we have been learning, bony structures in the spine can cause irritation of the nerve roots and symptoms that resemble sciatica. If there is any suspicion of ankylosing spondylitis, a referral to a doctor – specifically a rheumatologist – should be made. CRITICAL CONDITIONS THAT REQUIRE IMMEDIATE MEDICAL ATTENTION

Critical Conditions that can be confused with sciatica There are three rare but critical conditions to consider when a client presents with symptoms that resemble sciatica. These are tumors, infections, and cauda equina syndrome (discussed in detail below). These conditions highlight the importance of obtaining a diagnosis from a medical doctor when considering treatment for sciatica. Self-diagnosis can be very dangerous. A red flag is a symptom that may point to a very serious and urgent problem. The client’s doctor should always ask specific questions about the red flags. If a patient presents for massage therapy but has any of the “red flags”, they should be sent directly to a medical doctor to investigate the cause and begin definitive treatment. Some of the critical red flags to know about are: 1. 2. 3. 4. 5. 6. 7.

History of cancer Unexplained weight loss Significant pain at night Pain at rest Fever with no obvious cause Recent infection Immunocompromised state (use of corticosteroids like prednisone, immune suppressants for transplant recipients, and HIV/AIDS) 8. Urinary retention or loss of bladder control 9. Loss of bowel function 10. Weakness or numbness of the inner thighs (“saddle anesthesia”) 11. Weakness or numbness of both legs 12. History of osteoporosis Urgent diagnosis and specific treatment may be necessary to prevent permanent neurological damage. Cauda Equina Syndrome Cauda equina syndrome is a true neurological/surgical emergency. The presentation is so dramatic that a person is unlikely to present to a massage therapy clinic. Nevertheless, it is vital © www.AdvFundamentals.com

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to be aware of this condition to avoid serious outcomes that can include permanent bowel and bladder incontinence and paralysis of the legs. The hallmarks are saddle anesthesia and bowel and bladder dysfunction. The most common cause is an acute, massive disc rupture in the lumbar spine. Other causes include an injury such as a car crash or a fall. Two other causes are spinal tumor and spinal infection. These two will be discussed further below. Cauda equina syndrome is best remembered by the meaning of the name. “Cauda equina” is from the Latin for “horse’s tail”. This is because the cause is in the distal spinal cord, where the bundled nerves exiting the spine resemble a horse’s tail. From that, one may think of the saddle on a horse. It may seem simple, but anyone presenting with severe back pain and what is called “saddle anesthesia” – loss of sensation in the inner thighs – is at high risk. The numbness may be so severe that standing and walking becomes difficult. Urgent referral to a hospital is required. A CT scan and an MRI should be performed and referral to a spinal surgeon and/or neurosurgeon should be made. Without timely treatment, these symptoms can become permanent.

Spinal Tumor A spinal tumor that causes symptoms similar to sciatica is very rare. Nevertheless, it is important to consider whenever a client presents with acute sciatica-like symptoms and any of the red flags listed above. A spinal tumor can grow quite slowly, so the symptoms may develop in a way that is not obvious. Tumors can be of the spinal vertebrae or of the surface of the spinal nerves. In any case, if there are serious symptoms and red flags, referral to a hospital and spinal specialist should be made as soon as possible.

Spinal Infection A spinal infection is among the rarest causes of sciatica-type symptoms. The immune system is almost universally able to prevent infections from developing in this area of the body. Hence, the importance of the red flags. Is there unexplained fever? Has the pain come on rapidly and is it worse at night and at rest? Is there a reason to suspect that the immune system is not working properly? Once again, if there are any positive red flags, urgent referral for medical treatment is required.

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SUMMARY OF CONDITIONS THAT ARE COMMONLY CONFUSED WITH SCIATICA Sacroiliac Joint Dysfnctn.

Joint Problems in the Spine

Trigger Points and Referral Patterns

Piriformis Syndrome

Ankylosing spondylitis

Cauda Equina Syndrome

Source of problem

Sacroiliac joint

Arthritis of the lumbar vertebrae

Tightness and spasm of gluteus minimus

Tightness and spasm of piriformis

Arthritis of the lumbar vertebrae

Severe compression of lower lumbar nerves

Degree of pain

Moderate

Low

Can be severe

Severe, especially if inflamed

Moderate, coming and going

Can be severe but less when numbness

Loss of sensation

Not typical

Not typical

Not typical

May occur

Depends on course of action

In the saddle region

Pain below the knee

Can occur

Unusual

Not unusual

May occur

Not usual

Not usual

Other symptoms

Stiff gait

Stiff back

Burning Tingling in at points - buttock referral patterns

Other inflamat’ry conditions

Loss of bowel and bladder function

Treatmnt.

Injections

Massage may help

Releasing muscle tension and spasms

Releasing muscle tension and spasm

Referral to rheumatologist

Urgent referral to neurosurge’n or spinal surgeon

No

Distal spread of symptom

No

Fever may occur

Many are usually present

If severe, prolonged symptoms +red flags

If severe, prolong’d sympt’ms +red flags

If severe, prolonged symptoms +red flags

Referral to rheumatologist

Urgent referral to surgeon

Red Flags No

Referral to specialist

If severe, prolonged symptoms +red flags

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SUMMARY Sciatica is a specific syndrome of pain and other neurological symptoms that result from the compression of the sciatic nerve. Given the anatomy of the sciatic nerve, it makes sense that the symptoms, including burning, tingling and numbness, can be felt all the way from the buttocks down to the toes. Anyone can get sciatica. In younger people, it is usually caused by a herniated disc. In older people, it is usually caused by a chronic condition such as spinal stenosis. For the massage therapist, caution should always prevail whenever there are symptoms of sciatica. Ideally, any client arriving at the door should have a diagnosis from a physician. This includes a history and physical exam followed by x-rays, a CT scan, and/or an MRI. In some cases, massage therapy may be started prior to a physician’s assessment if: 1. The pain is not too severe and not getting worse 2. The symptoms are relatively new (less than six weeks) 3. There are no red flags Treatment of sciatica begins with conservative measures. Light stretching and the application of hot and cold compresses are often helpful. For certain conditions, massage therapy can be very helpful. Sometimes referral to a chiropractor or physiotherapist is warranted. Surgery is a last resort for those people who do not benefit from any of the more conservative measures. Massage therapy in the treatment of sciatica should always be approached with caution. Some conditions that mimic sciatica, especially piriformis syndrome, benefit greatly from massage therapy. Others, such as true disc herniation, do not improve with massage. Perhaps the best news is that sciatica can be prevented. The Mayo Clinic recommends regular exercises to strengthen the gluteal musculature and avoidance of unhealthy postures to reduce the risk of developing sciatica. The role of the massage therapist working with clients who have sciatica extends beyond the doors of the clinic. The skilled massage therapist can guide the client to obtain all the other services that may be of benefit. There are several measures that the client can take between sessions, and after sessions are completed, to get the most benefit from treatment. Five key areas are:     

Analgesia and the client’s physician Thermal Treatments Occupational/ergonomic therapy Stretching techniques, including yoga Exercise

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What Sciatica is Not Unfortunately, sciatica is a complicated condition, because there are several other ailments that can mimic it. Dysfunction of the sacroiliac joint is one of the most common of these ailments, and one of the most complicated to distinguish from true sciatica. Chronic arthritic problems of the spine are also difficult. Trigger points and referral patterns of the gluteal muscles (especially the gluteus minimus) can present in a very similar way. Piriformis syndrome is a rare yet important cause that depends highly on massage therapy for recovery. Ankylosing spondylitis is an inflammatory condition that requires referral to a rheumatologist. One of the most important take-home messages is about three critical conditions that require immediate medical attention. Cauda equina syndrome, spinal tumor, and spinal infection are true neurological emergencies that should be directed to medical treatment as soon as possible. The list of red flags is helpful in deciding whether a serious condition may be causing the symptoms. Above all, the combination of severe low back pain, saddle anesthesia, and loss of bowel and bladder function is a neurosurgical emergency that demands immediate attention. When appropriate, using massage therapy for sciatica will be rewarding for you as a therapist and for your clients. Massage may not “fix” sciatica or many of the associated conditions; what it can do is calm down guarding and holding tension patterns, allowing the body to have access to proper blood flow and begin to heal itself. We hope this course will help you achieve these goals!

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ASSESSMENT FOR RED FLAGS – 12 KEY QUESTIONS TO ASK YOUR CLIENTS Therapist Name: Client Name: Date: Please answer the following questions with yes or no: 1. Have you ever had any form of cancer?

Yes

No

2. Have you noticed any weight loss that you have not been working on?

Yes

No

3. Do you have pain at night that is worse than you would expect?

Yes

No

4. Do you have pain at rest?

Yes

No

5. Are you having fevers that you can’t explain?

Yes

No

6. Have you had any infections recently?

Yes

No

Are you taking corticosteroids such as prednisone?

Yes

No

Are you on treatment for a transplant?

Yes

No

Is it possible that you have HIV?

Yes

No

8. Are you having trouble voiding or not holding your urine?

Yes

No

9. Are you having any trouble with your bowel function?

Yes

No

10. Do you have any weakness or numbness of the inner thighs?

Yes

No

11. Do you have significant weakness or numbness of both legs?

Yes

No

12. Do you have a history of osteoporosis?

Yes

No

7. Is there any chance that your immune system is not working?

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BIBLIOGRAPHY CONTENT http://www.spine-health.com http://www.mayoclinic.org/diseases-conditions/sciatica/basics/prevention/con-20026478 Current Diagnosis and Treatment in Family Medicine – Third Edition. Copyright 2011, McGraw-Hill Companies, Inc. http://www.fitsugar.com/You-Asked-Stretch-Sciatica-5594960 http://www.massagetherapy.com/articles/index.php/article_id/2064/Assessing-Sciatic-Pain http://www.massagetoday.com/mpacms/mt/article.php?id=14414 http://www.pacificcollege.edu/acupuncture-massage-news/articles/875-massage-treatment-forsciatica-relief.html http://www.webmd.com/back-pain/guide/cauda-equina-syndrome-overview IMAGES All images were retrieved from the public domain using an advanced Google Search. The parameters specified by contributors were “free to use or share, even commercially”. Massage Therapist - http://pixabay.com/en/massage-spa-therapy-back-treatment-272822/ Sciatic Nerve Anatomy - http://en.wikipedia.org/wiki/Common_fibular_nerve Herniated Disc – http://commons.wikimedia.org/wiki/File:Blausen_0484_HerniatedLumbarDisc.png Spinal Stenosis – http://en.wikipedia.org/wiki/Spinal_stenosis#mediaviewer/File:Spinal_Stenosis.png Spondylolisthesis – http://commons.wikimedia.org/wiki/File:Normal_disc_v.s_Spondylolisthesis.jpg Seated Pain Image - http://en.wikipedia.org/wiki/Radiculopathy Sacroiliac Joint Dysfunction – http://ssop.com.au/blog/prolotherapy-an-option-for-chronic-sacro-iliac-instability/ Trigger Points and Referral Patterns in the gluteus minimus – http://www.lowerbackpain-help.com/lower_back_pain_trigger_points.html

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Directions: You can download this PDF file to your computer or review the material online while you take the exam. The reading material and exam are NOT timed. thoroughly.

Read through the material presented

Once you are ready to take the exam: 1) If you are not on the password protected page, go to it. This is the same page where you downloaded your course material. A password was emailed to you when you purchased your online CEU course(s). The link to the Course Material and quiz can also be found on the “Access Courses” Page. 2) Complete the quiz. A passing grade is 70% or higher. You have unlimited attempts to pass your exam. 3) The quiz is graded automatically and you are shown whether you pass or fail the quiz along with your percentage score. You are not shown what questions you answered incorrectly. However, upon passing, you are shown all the correct answers so you can compare them to your answers (if you have them written down.) 4) Make sure you have saved our email to your contacts to ensure proper delivery of your certificate of completion. [email protected] 5) For Florida Massage Therapists, Course Completions are reported daily to Cebroker.com. 6) If you have any questions not answered here or in the FAQ section of the website, please contact us. We’re here to help any way we can. * Note: It is highly recommended that you print out any course material you wish to keep, as well as your certificate of completion. Your certificate of completion is your proof you completed this course. * Note: If you are submitting credit for your NCBTMB re-certification, you are responsible for submission of all your hours along with course information and any certificates needed as proof of completion.

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Take your exam online at the password protected page where you downloaded the material  The 15 questions below are the exact questions in the exact order as the online quiz.  It is recommended that you prepare your answers here before taking the online quiz. 1) TRUE or FALSE: According to the statistics, low back pain is second only to the common cold as a reason for visiting a doctor. 2) TRUE or FALSE: In general, sciatic pain is more severe and persistent than low back pain without sciatica. 3) TRUE or FALSE: Sciatica is a specific pain syndrome that arises when the sciatic nerve is impinged upon or otherwise aggravated. 4) TRUE or FALSE: Another name for sciatica that describes the condition quite well is “Lumbosacral Radiculopathy”. 5) TRUE or FALSE: The most common age group that experiences sciatica is 30-50 years old. 6) TRUE or FALSE: Amongst the age group in which sciatica is most common, herniated disc is the most common cause. 7) The classic symptoms of sciatica are: a. Pain b. Numbness c. Burning d. Tingling e. All of the above 8) Some of the causes of true sciatica are: a. Lumbar Disc Herniation b. Degenerative Disc Disease c. Lumbar Spine Stenosis d. Spondylolisthesis e. All of the above 9) TRUE or FALSE: According to the Journal of the American Medical Association, surgery is needed in only 10-20% of patients suffering from sciatica.

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10) To treat someone who self-refers for massage: a. There should be none of the red flags b. The history of symptoms should be less than six weeks c. Symptoms should not get getting worse d. All of the above 11) According to the Mayo Clinic, the three measures to maintain a healthy back and minimize the risk of developing sciatica are: a. Regular exercise such as core strengthening b. Maintaining good posture when sitting c. Maintaining good body mechanics d. All of the above 12) Some of the conditions that are confused with sciatica are: a. SacroIliac joint dysfunction b. Trigger points & referral patterns c. Piriformis syndrome d. Ankylosing spondylitis e. All of the above 13) TRUE or FALSE: Cauda equina syndrome is a true neurological/surgical emergency that can sometimes be confused with sciatica. 14) TRUE or FALSE: A spinal infection is amongst the rarest causes of sciatica-type symptoms. 15) Some of the red flag questions to ask are: a. Have you noticed any weight loss that you have not been working on? b. Are you having fevers that you can’t explain? c. Are you having trouble voiding or not holding your urine? d. Do you have a history of osteoporosis? e. All of the above

Follow the link below to the Access the Quiz for this Course Online. You may need to enter your password again to access this page. Your password can be found with your Order Confirmation Email.

ACCESS COURSE & QUIZ © www.AdvFundamentals.com

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