Sciatica

I’ve had a few sciatica patients in the last little while, so I thought it’d be a good time to talk briefly about it. Sciatica is pain brought about by impingement or irritation of the sciatic nerve. It can manifest as pain anywhere from the buttock (and even lower back) to the foot and may produce neural symptoms in the foot (pins and needles etc). While this can result from injuries or structural problems in the lower back, by far the most common cause in my clinic is from piriformis syndrome.

Briefly looking at the anatomy of the nerve and surrounding tissue, the sciatic nerve originates from several nerves of the lower lumbar and sacral spine joining together. This nerve then comes from under the sacrum and passes almost vertically down, deep in the buttock. It continues down the rear of the leg innervating the back of the thigh, the entire lower leg and most of the skin on your leg.

Impingement of the nerve can occur at the spinal outlets from disc compression (bulge/herniation/degeneration) or from conditions such as spondylolisthesis (backwards or forwards displacement of the vertebrae). Downwards pressure of a swollen uterus during pregnancy can also cause it. The cause I see most frequently is referred to as piriformis syndrome. While the sciatic nerve passes almost vertically, the piriformis runs almost horizontally from the sacrum to the greater trochanter (that lump on the side of your hip) of the femur. The muscle sits adjacent to the nerve and in some people the nerve actually passes through the muscle. These people are particularly prone to piriformis syndrome. The upshot is that a tight piriformis can easily compress the nerve producing pain and nerve-related symptoms like pins and needles. Over a period the compression can lead to inflammation that can take time to recede.

The piriformis is used by your body to laterally rotate the femur – that is, turn your foot out. This will give some idea of things that can cause tightness. Do you walk with your feet turning out? Do you do squats with the feet turned out? These sort of activities encourage the tighening and shortening of the muscle and increase pressure on the nerve. It pays to keep the gluteus maximus (the big outer bum muscle) strong to take pressure off the deeper muscles.

Remedial massage and Bowen Therapy are both great for this, although Bowen has the advantage of being non-inflammatory. If the body is non-responsive after one or two sessions then scans may be required to check the health of the intervertebral discs and refer on if there is a problem.

Is your fluid retention related to your gut?

I’ve noticed that quite a few patients coming in with fluid retention in the legs or bloating in the belly have a common factor of gastro-intestinal tract (GIT) problems. This can be anything from a food intolerance (often the usual suspects of wheat, dairy, yeast and fructose) to more serious conditions such as colitis and Crohn’s disease.

Why is this? Well, for those unfamiliar with the lymphatic system, the lymphatics empty back into your blood in the sub-clavian vein (in most people) near your clavicle or collar bone. This means that all lymphatic fluid in your body must make its way back to your neck. As the lymphatics have a large role in immune response and an allergic reaction or auto-immune problem is based in the immune system, this will lead to inflammation and various white blood cells and pro-inflammatory factors rushing to the gut. This clogs everything and water comes to surround the proteins in the immune reaction. The result is a bloated tummy and possible back-log right down to the ankles as the fluid from your legs must make its way through the abdomen to the thoracic duct under your sternum. You can think of it as trying to get out of a shopping centre car park at 5 when the shops shut. There are limited exits and all lanes feeding to them. The traffic jam eventually passes right back up to the other levels of car park.

Working with a naturopath or nutritionist can help you to understand food allergies and there are treatments, both medical and herbal, for inflammation of the bowel. Manual lymphatic work can help to clear out the old blockage and free the flow again. Obviously this isn’t the case with all lower body blockages – some are from surgery (C-section, appendicectomy, cancer, traumatic birth, varicose veins) and congenital causes, but it certainly makes a difference to a vast number of my patients.

How are you Standing?

With an increase in availability of sit-stand desks in the workplace, it's a good time to look at standing posture. This can have a huge impact on muscles and joints. It’s quite a common behaviour to adopt an ‘energy-saving’ stance when standing for long periods. Some people will throw their weight on to one hip or the other, and it common to see people lock their knees back. These postures “lock” the legs and save on using the muscles to keep you erect.

Unfortunately, they also greatly change the alignment of the body, increasing localised pressure on joints and setting up unnatural muscle usage patterns that can easily become ingrained and have an effect on exercise and movement. You can even experiment for yourself by standing with your feet about shoulder-width apart and straightening your knees until they lock back. Bend and straighten several times and feel the difference in your lower back and pelvis as your pelvis rotates and your belly is thrust forward. Also feel how it drives the weight straight down through your heel. Now try throwing your weight onto one hip and feel it in your heel, knee and lower back. Note how your shoulders now sit to the side of your hip.

Many people such as bouncers, chefs and retail staff stand for long periods on hard floors and end up adopting these patterns. Try to get in the habit of standing with your feet shoulder-width apart (maybe a little closer together for the ladies….) and your knees ever-so-slightly bent. Feel the natural position of your pelvis and note how the weight spreads evenly over the front and back of your feet. Try to make this your default position and also find some good supportive shoes. A formed foot-bed within the shoe will support your arches over those long days.

And if you feel yourself tiring and wanting to adopt an energy-saving posture, sit back down a while until you feel ready to stand well!

Can I Have a Treatment If I'm Sick?

Sometimes people come to their appointments sick with a cold or the ‘flu’. Sometimes I’m lucky enough to pick it up on the phone but sometimes they get sick between phoning and arriving. As a general rule, you shouldn’t have massage when you are sick.

Massage, and especially lymphatic drainage, stimulates the lymphatic system. This system forms a large part of your immune system and you need to give the white blood cells time to work their magic and kill the various viruses, bacteria and other pathogens that may have made it into your body. Stimulating the lymphatics during this time can pump an infection around before the various cells have a chance to do their thing. The same goes for exercise when sick. You should avoid strenuous exercise when you have a cold or the ‘flu’ as heavy exercise can pump it through your system. 

I can still perform Bowen Therapy when patients have an infection as it doesn’t manually stimulate the lymphatics but all massage styles are contra-indicated. If you find yourself ill, simply call or email to reschedule. Or let me know and we can do Bowen instead.

What's a Psoas?

I’ve had a bit of a run lately of people coming in with lower back pain that they can’t explain, often commenting that it’s worse when they go from sitting to standing. This frequently turns out to be the psoas muscle in spasm. The general response when I mention this is “Huh?” Most people don’t even know they have this muscle.

The psoas (with a silent “P”) runs from the inside of the transverse processes of your lumbar vertebrae (the attachment surfaces of the bones of your lower spine) internally to the lesser trochanter of your femur (an attachment point on the inside of the top of your thigh bone) and acts as a hip flexor (raises your knee towards your chest) and external rotator (turns your thigh out). When you are in a seated position it is in a shortened state, thus it often produces pain in the lower back when you stand and stretch it out.

The muscle also interacts with other muscles and it is important to address these when releasing the psoas. It is commonly associated with the iliacus muscle that runs from the inside of the iliac crest (the hip bone) and attaches at the same point on the femur, the two together being known as the iliopsoas. However, it also interacts with the quadratus lumborum (a deeper muscle of the lower back) and the diaphragm, which is the muscle that helps to inflate your chest when you breath. I’ve actually had patients come in with lower back back after a particularly violent sneeze as the diaphragm has set off both the QL and the psoas.

The psoas can also produce flow-on effects in the body if it is very tight or shortened. A tight psoas can impede the firing of the gluteus maximus (the large outer buttock muscle) and can in turn lead to overly tight hamstrings. The psoas can also put pressure on the femoral nerve that feeds the quadriceps, leading to weakness, pain and dysfunction.

For my money, the best treatment for this muscle is Bowen Therapy. There is a simple tweak to the attachment at the upper thigh that uses the stretch receptors in the muscle and fascia to release it. As it is largely an internal muscle, it is very hard to massage. It always works better if the accompanying muscles are also tweaked. There is also stretching to help release the muscle but it takes a little practice to get right. You need to stand in a straight-leg lunge with the leg of the side you are stretching, back. Then lift the chest up away from the groin and lean slightly to the opposite side. This should produce a slight pull at the inner, upper thigh.

And Pregnancy with Lymphatic Drainage?

This’ll be the last post about pregnancy for a while (unless you ask for more…) but I’ll just finish discussing my various modalities used during gestation.

Is lymphatic work safe during pregnancy? Yes, as long as there are no other complications and we avoid deep abdominal work. Again, you must tell your therapist you are pregnant. Lymphatic work is generally safe for most people and, before starting, your therapist will ask various questions about any problems with renal (kidney) function, thyroid function, history of tuberculosis, cardiac oedema and pregnancy. A positive answer on any of these will alter the treatment.

Why have a treatment during pregnancy? Well, some people have an existing oedema and may need help on an ongoing basis with returning fluid to the blood. This could be in an arm or leg. Pregnancy is the not the best time to consider a detox, so I wouldn’t advise a drainage during gestation for this purpose.

If you have swelling in your legs (cankles) that is purely linked to the pregnancy, drainage may help but it will most likely only bring temporary relief. The lymphatic vessels are fairly delicate and are quite easily compressed. The swollen uterus full of fluid and foetus pushes downwards into the bowl-shaped pelvis and compresses blood and lymphatic vessels and also nerves. This limits the amount of lymphatic fluid that can return to the blood. While I can drain this away, a short stint on your feet will likely see it return. If you are doing pregnancy yoga or Pilates, this can very useful as the exercises are often done on the floor, and if in a dog-pose, allows the weight of the uterus to fall forward and decompress the pelvic region. This is a little more like our four-legged ancestry!

What about Bowen Therapy in Pregnancy?

The obvious question to come off the recent post about massage during pregnancy is the implications for Bowen Therapy and Lymphatic Drainage in pregnancy. Today I’ll just deal with Bowen Therapy.

One of the wonderful things about Bowen Therapy is that it is safe to use on everyone from newborns to the elderly. Therefore Bowen is perfectly safe for use during pregnancy as long as we avoid the few procedures that engage the coccyx (tailbone). Procedures around the coccyx reflex to the uterus and can potentially cause miscarriage, so once again you must inform your therapist if you are pregnant, even if you aren’t up to the second trimester.

Bowen is otherwise fantastic during pregnancy as it helps to balance out the body and relieve tensions as things shift and move. The sacral procedure is fantastic for the lower back pain and pelvic instability that can arise and the procedure for the vagus nerve may be of use for morning sickness.

If you are considering pregnancy, it can even be useful to get your body balanced out before starting, particularly if you have a history of coccyx damage. I’ll discuss fertility protocols in a future post!

Massage in Pregnancy

I’m often asked by pregnant women (and their partners) if they can have massage during pregnancy. They are often told by doctors, nurses or great aunty Valmai that massage is dangerous. That isn’t entirely true.

If your doctor or obstetrician has given you a direct instruction to not have massage then you must follow that, but if you have just found it amongst some general advice then appropriate massage should be safe.

There are certain pressure and reflex points on the body that can link to the uterus and should be avoided during pregnancy. As long as you go to a qualified therapist (you can always ask to see qualifications and association membership) and tell that therapist that you are pregnant, then massage should be perfectly safe for you. For this reason, it’s probably best to go to a professional rather than get your partner to give you a rub. Also, only a qualified aromatherapist should use essential oils with you during pregnancy as many are contra-indicated.

If you are still concerned, then maybe avoid massage during the first and third trimesters as these are least stable periods of gestation. Wait until after your 13 week check. And if you are ever concerned, talk to your therapist and your doctor. That’s what they are there for.

Why massage during pregnancy? Well, your body is undergoing many changes during this time and there is a great deal of stress on it. As well as hormonal changes and the possibility of tiredness, there is a great change in the weight-bearing of the structure. Swelling breasts and belly both put new stresses on the spine and associated muscles and can create much new tension. Also, as the pregnancy progresses, ligaments can soften and structures can move, creating new tensions, especially around the pelvic area. Finally, the way you use your body can also change. As the belly grows, many women adopt something of a duck-walk which can tighten the deeper glute muscles and create sciatic pain. Of course, the world doesn’t stop just because you’re pregnant, so there is still a job, stress, exercise and housework to all take their toll.

Some practitioners work with a special table with a hole cut for the belly. I tend to start the massage seated in a special chair for back and neck and then progress to side-lying for glutes, legs and lower back. This will vary from therapist to therapist – some are pregnancy specialists.

Just remember to always inform all practitioners that you are pregnant, even when tradition dictates to keep it to yourselves, and if you are at all concerned, talk to your doctor!