EFFECTIVENESS OF DEEP FRICTION MASSAGE & STRETCHING EXERCISES IN PIRIFORMIS SYNDROME

INTERDISCIPLINARY JOURNAL OF CONTEMPORARY RESEARCH IN BUSINESS VOL 3, NO 3 EFFECTIVENESS OF DEEP FRICTION MASSAGE & STRETCHING EXERCISES IN PIRIFORMIS SYNDROME Dr Waqar Ahmed Awan BSPT (Pak), PP-DPT (Pak) SENIOR LECTURER/ IN-CHARGE INDUSTRIAL LIASON & RESEARCH Isra School of Rehabilitation Sciences, Isra University, Islamabad Campus Dr. Muhammad Naveed Babur Associate Professor/ Principal Isra School of rehabilitation Sciences, Isra University Islamabad Campus) Abstract The purpose of the study was to evaluate the effectiveness of therapeutic deep soft tissue mobilization with stretching exercises program, along with patient education and home exercises. A case was selected from an outpatient clinic. A 41 years old supervisor male nurse had complaint of pain in the left gluteal region radiating to left lower extremity. Pain level on verbal numeric scale was 8/10 (0 to 10) and affected the clients ADLs & IADLs. The subject received ten consecutive session of 45 minutes in duration, 2 times per week for five week, during each session, deep soft tissue mobilization techniques with stretching exercises, focused on the muscles of the lower back, left posterior thigh and leg, along with patients education about habitual patterns adopted by the patient at home or in occupational setting were included. Subject was taking 400mg Tab. Ibuprofen for pain management before the physical therapy started. During treatment client was stopped to take medicine. After the 10th session of physical therapy and proper follow-up home exercises program, client was pain free on numerical scale 0 to 10. No radiation of pain to lower extremity. He was pain free during his ADLs and IADLs. This study shows the application of deep soft tissue mobilization techniques along with stretching exercises and clients awareness about habitual patterns greatly improved the piriformis syndrome, but to test the validity and reliability of the techniques and to find out the level of evidence for the techniques need more comprehensive study to be done like RCTs and cohort study. Keywords: Effectiveness; Deep Friction Massage ; Stretching Exercises ; Piriformis Syndrome Introduction Piriformis syndrome; In the gluteal region, the piriformis muscle can compress the sciatic nerve, creating a condition known as piriformis syndrome 1. The sciatic nerve derives from the L4- S2 nerve roots and courses anterior to the sacrum, before passing inferior to the piriformis muscle 2, 3. Certain anatomical variations play a role in piriformis syndrome. The two divisions of sciatic nerve: the peroneal and tibial. Usually, they are bound together, but in some cases they divide as they pass the piriformis muscle. Sometimes one division goes through the muscle while the other goes below it. In other cases, one division goes above the piriformis while the other goes below. In a small percentage of the population, both divisions go directly through the piriformis muscle. 4 COPY RIGHT 2011 Institute of Interdisciplinary Business Research 378

it is easy to see in Fig. I how some of these anatomical variations cause increased neurological symptoms. Fig. II Sciatic nerve variations (Mediclip image 1998 Williams & Wilkins. All Rights Reserved) Background; Information regarding Piriformis syndrome has been first describe in 1928, about its controversial diagnosis. Piriformis syndrome is also called pseudo sciatica, wallet sciatica, and hip socket neuropathy 5 Etiology: The total world population experiencing piriformis syndrome, not more than 20% are caused by anatomical nerve abnormalities. 6 in 50% of piriformis syndrome cases the onset of symptoms of sciatica may be spontaneous; the most common cause is due to vigorous physical activity. The remaining 50% are associated to contusions, concussive blow to the pelvic region, surgery, anatomical nerve abnormalities, hyperlordosis, muscle abnormalities and hypertrophy, fibrosis as a result of trauma and total hip arthroplasty. 5 pressure to the gluteal region, such as sitting on a wallet. It rarely results from a direct blow to the buttock area. 7 As a result of trauma; adhesions can develop between the piriformis muscle, the sciatic nerve and the roof of the greater sciatic notch. Myofascial trigger points in the performis muscle or other gluteal muscles can create hyper tonicity and that leads to nerve compression.4 Sacroiliac joint dysfunction also can disseminate trigger points in the piriformis muscle and increase the chance of nerve compression.8 Clinical features; of the piriformis syndrome may include, pain and/or parasthesia radiating from the sacrum through gluteal region, posterior aspect of the thigh and calf. Symptom precipitate when the patient sit or lie on affected side for more then 15-20 minutes. These symptoms may associate with numbness. Pain also worsens when patient rise from seated or squatted position, ambulation may improve the pain and worsen with no movement. Change in position does not affect the pain.19 there may be pain in contra-lateral sacroiliac joint. There is also weakness in the involve leg this may cause antalgic gait or drop foot. In piriformis syndrome, pain may be feels in abdomen; pelvis and inguinal region may be associated with bowel movements. In female piriformis syndrome may cause of dyspareunia. 5 Differential Diagnosis; Piriformis syndrome may mix other conditions. It may be a considered in a differential diagnosis. The differential diagnosis may be including any trauma to the buttocks and the presence of any bowel and bladder problems, lumbosacral radiculopathies, degenerative disc disease, compression fractures, and spinal stenosis. 22 sacroilliatis and sacroiliac joint dysfunction are also considered as a possible cause of piriformis syndrome. Diseases of the hip, including arthritis and bursitis, as well as fracture, should be considered in differential diagnoses. The obturator internus muscle, also an external rotator of hip, suggested as a contributing factor of sciatic neuritis in patient with possible piriformis syndrome. 19 COPY RIGHT 2011 Institute of Interdisciplinary Business Research 379

Results: Deep soft tissue mobilization techniques were appeared to improve the symptoms of piriformis syndrome in the subject. These techniques proved an effective means to reduce compression of the sciatic nerve by surrounding muscles. Transfer fiber frictions were applied for several minutes at the tenoperiostial junctions, especially at the greater trochanter and sacrum attachments of the piriformis, as well as the gluteus maximus and minimus attachments. In conjunction with deep soft tissue mobilization techniques, stretching exercises of the involved muscle proved their effectiveness and postural awareness education to bring awareness to patterns of movements and positions that resulted in compression of joints and congestion in muscles. During the case study clients pain was decreased from level 8 to 4 on verbal numeric scale. Frequency of pain also decreased between 1 to 3 times on weekly basis. Table I; Comments Made By Client during Treatment Sessions Session 1st & 2nd Reduced bruise feeling and become feeling of cool air blowing through leg Session 3rd; Mild tenderness over the piriformis muscle Session 5th Pain returned and gave compressed feeling Session 6th & 7th Completely Pain Free Session 8th Mild pinching in gluteal region while jerky movement occurs Session 10th Feeling great After the week of the case study client reported that while I stand, sit or walk I am more aware of it that how these contribute to my discomfort and now I can make adjustments quickly to prevent or reduce the pain. Stretching exercises help me to release the tension from muscles which I do on daily basis and after a week of last session I am completely pain free Discussion; Most of the time in sports medicine regular stretching and manual therapy, like soft tissue mobilization approaches, tell a greater decrease and elimination of piriformis syndrome. 9 Heat or cold therapy is usually most effectively applied before the physical therapy or home therapy sessions because it may decrease the discomfort associated with direct treatment applied to an 10, 11 irritated or tense piriformis muscle. Deep friction massage is also helpful for release of piriformis muscle with passive internal rotation of hip. 5 the ultimate goal of physical therapy is symptom elimination through a systematic program designed to increase the relaxation by of the mobilization of surrounding muscle groups and joints, as well as to increase the supporting strength of these muscle groups. In particular, the strengthening of the adductor muscles of the hip has been shown to be beneficial for patients with 12, 13, 14 piriformis syndrome. Application of deep transverse friction at tenoperiostial junctions is helpful and should be focus on softening and relaxing the piriformis and the other deep lateral 15, 16, 17 rotators, as well as the gluteal muscles. Physical Therapy Evaluation: History & Complaints; Subject was a 41years old male, works in a hospital setting as supervisor male nurse. Client suffers from hypertension from last 10 years and taking Capoten 25mg (Captopril ACE inhibitor) to manage hypertension. In addition to the hypertension, client takes Tab. Brufen 400mg/B.D for pain management. No radiological imaging has been done to rule out the actual cause of sciatica. Subject was entered in case study with the chronic sciatic pain in his left gluteal region for one year that runs inferiorly along the lateral side of thigh. Pain was experienced on daily basis. Pain felt at highest level assessed with verbal numeric scale 8/10, ranging from 1 to 10. Pain is experienced often as a sharp throbbing pain. In stressful situations, pain moved inferiorly along the fibula and to the big toe. Pain frequency was intermittent. Pain is COPY RIGHT 2011 Institute of Interdisciplinary Business Research 380

INTERDISCIPLINARY JOURNAL OF CONTEMPORARY RESEARCH IN BUSINESS aggravated by sitting, standing and stair climbing and driving a car for longer period of time (1-2 hours). Before the case study the only form of treatment was Tab. Brufen 400mg (Ibuprofen) for pain management. Physical examination; of the client indicated a positional pattern of lateral rotation at the feet, referring into the hips. While subject was in supine lying, his left leg was more rotated externally then the right leg. That shows the tightness of the external rotators of the left hip. During performing the passive movement, left leg felt heavier then the right leg. While palpating, the left piriformis muscle was felt contracted between the sacrum and greater trochanter of femur. Lasegue sign was positive when performed. 2nd test FAIR (flexion, adduction, and internal rotation) test was reliable test to diagnose the piriformis syndrome. 23 The FAIR test performed with the patient supine knee and hip flexed and hip medially rotated, while the client resisted therapist attempt to externally rotate and abduct the hip during this procedure symptoms reproduced. Clients history, complaint of pain and physical examination indicated that the symptoms of sciatica were produced due to nerve entrapment under the piriformis muscle and confirmed the diagnosis of piriformis syndrome. Intervention: The subject received series of ten consecutive sessions of 45 minutes in duration. The sessions were administered by a physical therapist. Each session was focused to decrease chronic sciatic pain radiating from the left gluteal region. The two sessions were given in a week, were included deep soft tissue mobilization (cross fiber friction, longitudinal fiber friction, positional release therapy) for five minutes, focused on individual muscle. Stretching exercises (five repetitions with 20 seconds hold) were performed to improve the elasticity of muscles and decrease the fibrous adhesions at muscle and teno-periostial junctions of the pelvic girdle, posterior, lateral thigh muscles and left calf muscle. Each session started by asking the patient and visual assessment of the posture and the movements. Sessions began with the client in supine position and perform ROM of the involved leg, to assess the movement limitation, then palpating the tender point in the region. After the assessment of the ROM patient then move into two more positions which are side lying and prone. After manual session last 10 minutes included a review of stretching exercises and awareness of habitual patterns and movements for at home focus. The last portion of session included a verbal and visual review of clients state and postural alignment. Hypertonic muscles especially of the gluteal muscles, piriformis, hamstrings, tensor fascia latae and calf were focused. The cross fiber friction at tenoperiostial was very beneficial. The cross fiber frictions were applied for up to five minutes. No prolong compressions or glides used over the piriformis to avoid further possibility of compressing the nerve. Cross fiber friction was applied to the posterior superior iliac spine, coxofemoral and the iliac crest attachments with considerable gentleness as client described a mild tenderness. This tenderness was most felt at all of the tenoperiostial junctions of the deep lateral rotator muscles, the gluteal area, as well as in the distal aspect of the iliotibial band and the calf muscles. Deep transverse fiber friction of the piriformis muscle and tenoperiostial attachments at the sacrum, iliac crest and the greater trochanter greatly reduced the tightness and impingement of the sciatic nerve. Transverse friction technique was applied very gently in this area because client was very sensitive in the location. Congestion in the illio tibial band and hamstrings were reduced by the longitudinal friction glide by using forearm were beneficial in this area. Gentle stretching exercises were also administered at that time which produced the relaxation. Postural awareness education enabled the client to discover other options of movements and positions which led the client to ease and comfort. This helped him to catch himself, as he moved into a habitual pattern VOL 3, NO 3 COPY RIGHT 2011 Institute of Interdisciplinary Business Research 381

that produced pain. He was able to discover movements and postures which improve the situation and reduce the discomfort. Table II; List of deep soft tissue mobilization techniques applied for treatment Cross fiber friction (XFF) Longitudinal fiber friction (LFF) Positional release therapy (PRT) Stretching exercises (SE) Conclusion; This study indicated that the application of deep soft tissue mobilization techniques to reduce the symptoms of piriformis syndrome in general, especially during a flare-up, is possible with a daily stretching protocol. During the literature review very little literature was found on the topic and that available literature was not comprehensive. Only the case studies and literature reviews about the piriformis syndrome were found. To find out the reliability and validity of the soft tissue mobilization techniques, it would be valuable to do a more comprehensive study involving several clients over the duration of one year that live with piriformis syndrome. The addition of client education about posture and movements awareness to learn how and what patterns of these may contribute to piriformis syndrome would be of great value in reeducating the individual. This would help the client to control or to reduce their discomfort. It is proved that deep soft tissue mobilization techniques significantly decrease the level of pain and discomfort during ADLs and IADLs. Education of the client about postures and movements enabled the client to take control and recognize his habitual pattern that contributed in worsening the condition. All these protocols along with daily stretching regimen greatly reduced the compression on sciatic nerve but if the subject is not careful to follow the daily stretching exercises his symptoms may reappear. COPY RIGHT 2011 Institute of Interdisciplinary Business Research 382

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