A Sudden Onset of Sciatica: A Case Study
Author: Deborah Kempel, R.M.T.
Abstract: This case study is on a patient with sciatica who complained of pain and numbness radiating down his right hip and leg. Patient presented with decreased range of motion and function of his right leg with gait deviations. He was treated for four sessions with Integrative Manual Therapy (IMT) with a focus on biomechanics. After treatment was completed, patient presented with normal gait, increased range of motion of his right leg, and a total elimination of pain and paresthesia in his right leg. The patient was now able to return to his normal daily routine.
Key Words: Sciatica, hip, paresthesia, numbness
Presentation
The patient came in for assessment and treatment of Integrative Manual Therapy (IMT)1 for (medical doctor diagnosed) sciatica. The patient stated that he awoke one morning four to five weeks previous in severe pain. His goals of treatment were to eliminate pain and numbness in the right hip and leg, to maintain normal function, to relax the muscles of the leg and to walk normally. He had several physio treatments including ultrasound, stretching and exercise in the previous two weeks without improvement.
According to the patient, all movement was difficult for his right hip and leg due to severe pain. There was also a complaint of numbness down the leg to the foot. He experienced problems working and had a couple of days where he could not get out of bed. Visually, I observed that he walked with a limp on the right side.
Evaluation
I used Hoppenfeld’s2 passive range of motion testing on this patient with the following results. The patient’s left leg was normal except for +10° of extension and -10° of flexion. The involved right leg range of motion tests were as follows:
There was pain during all movements of the right leg. My assessment of Myofascial Mapping3 for this patient indicated his involved area to be the primary one. I then assessed the biomechanics of his pelvis using Muscle Energy and ‘Beyond’ Techniques4. Initially, there was no movement of his iliums, his sacrum was stuck in a right vertical rotation, his right pubic bone would not move superior, L5 was extended rotated to the left and L4 was flexed rotated to the left.
Treatment Plan
Any Bone Bruises5 in the pelvic region that were affecting the biomechanics or the lumbosacral nerves were to be treated. Neural Tissue Tension Technique6 was to be used on any involved nerves. I planned to treat with Advanced Strain and Counterstrain Technique7 to improve the blood supply and perform disc therapy, where required.
Treatment
This patient underwent four treatments, totaling three and one-half hours over a two-week period. The treatment of the sacral Bone Bruise allowed glide of the iliums although greater on the left than the right. I proceeded to do Bone Bruises of the intervertebral spaces of L3 to S3 and performed a Type III Muscle Energy and ‘Beyond’ Technique8 at the coccyx. At the patient’s subsequent treatment, I did Neural Tissue Tension Technique of L4 and L5 nerve roots, sacral plexus and sciatic nerve. The L5 disc was treated with Disc Therapy.
Response was immediate. The patient stated that the pain and numbness had decreased approximately 80%. His movement out of bed was reported to be much better. Visually, I observed that he still had a substantial limp when he arrived for his third treatment. I found a very low immune response in the whole right hip and femur region. It was treated with Immune Deficiency Motility9. I then treated a large Bone Bruise 4 to 5 inches above his knee. The limp was resolved. The right ilium was still slightly superior and would not glide inferior. I treated the iliac artery, vein and the right leg with Muscle Rhythm from Advanced Strain and Counterstrain Technique. The ilium then had inferior glide. Using Muscle Energy and ‘Beyond’ Techniques, the Accessory Sacroiliac joint of the right side was treated. Neural Tissue Tension treatment of sensory nerve S1, common peroneal nerve and the deep peroneal nerve resolved the residual numbness and pain in the patient’s foot.
Final Evaluation
The patient’s range of motion test of his right leg was similar to the original test of the left leg. The biomechanics of his iliums, sacrum, pubic bone, L4 and L5 appeared to be good. Limited range of motion, pain and numbness were resolved. Gait appeared normal. The patient reported that he was able to carry out his normal routine comfortably which was his main goal.
Discussion
As per Taber’s, sciatica is defined as "severe pain in the leg along the course of the sciatic nerve felt at the back of thigh running down the inside of the leg"10. The etiology states "compression or trauma of the sciatic nerve or its roots, especially that resulting from ruptured intervertebral disk or osteoarthrosis of lumbosacral vertebrae; inflammation of sciatic nerve resulting from metabolic, toxic, or infectious disorders; pain referred to sciatic nerve from other parts of body"11. Between the third and fourth session, the patient remembered a fall on his buttocks that he had experienced approximately six weeks prior to the sudden onset of sciatica. He reported having had pain on his tailbone for one week at that time. It would appear that this fall had resulted in the bone bruising and the restriction of the biomechanics of the pelvis. Over time, this condition caused irritation to the nerve roots of the sciatic nerve. This patient’s etiology was a classic example of Taber’s first stated etiology. Integrative Manual Therapy brought effective and immediate improvement and resolved the patient’s complaints in a short period of time.
Notes
1 Service Marked
2 Hoppenfeld, Stanley. Physical Examination of the Spine and Extremities. Norwalk, Connecticut: Appleton-Century-Crofts, 1976. p. 143.
3 Myofascial Release 2 Seminar, Facilitated by Dialogues in Contemporary Rehabilitation.
4 Weiselfish, Sharon, Ph.D., P.T.. Manual Therapy with Muscle Energy Technique. West Hartford, Connecticut: ANA Publishing, 1994. pp. 71, 97, 135.
5 Cranial Therapy Series III Seminar. Facilitated by Dialogues in Contemporary Rehabilitation.
6 Neural Tissue Tension Seminar. Facilitated by Dialogues in Contemporary Rehabilitation.
7 Giammatteo, Thomas, D.C., P.T. and Sharon Weiselfish-Giammatteo, Ph.D., P.T. Integrative Manual Therapy for Autonomic Nervous System and Related Disorders. Berkeley, California: North Atlantic Books, 1997. pp. 71, 127.
8 Muscle Energy and ‘Beyond’ Level 4 Seminar. Facilitated by Dialogues in Contemporary Rehabilitation.
9 Diaphragm Compressions Seminar, Facilitated by Dialogues in Contemporary Rehabilitation.
10 Taber Cyclopedic Medical Dictionary. Philadelphia: F.A. Davis Company, 1986. Edition 15, p. 1529.
11 Ibid
Bibliography