Sciatic Pain Case Study and Active Isolated Stretching

I'm really excited about the upcoming Active Isolated Stretching (AIS) series! This technique is integral to my myofascial approach and instrumental in my assessment of which myofascial groups are involved in a specific pain pattern. As I describe below, AIS brings in a yang aspect to the yin nature of the myofascial work we teach. In other words, we are able to bring some movement into our treatments and assessments. If you are wanting a kinesthetic approach to deepening your understanding of joint dynamics and myofascial anatomy then this is definitely for you! My understanding in both of these areas increased exponentially once I started studying and doing this work.

I was fortunate to study with Aaron Mattes, the developer of AIS over 4 days. I also studied with Stuart Taws who was a student of Aaron’s and adapted his work to include a hands-on component. What I am presenting is my own take on their approach, honed over the last 10 plus years.

I always utilize multiple techniques in my approach to a specific case. Below is a case study example of a treatment involving acute sciatic pain utilizing cranial, myofascial release, acupuncture and active isolated stretching. I'm including my own thought process on the case in the bolded-italicized sections. I hope you find it helpful.

Acute Sciatic Pain

A new patient recently came in with acute sciatic pain. She was 69 years old, super spunky and hardly able to walk. She had been immobile for about a week. She said that the day of the appointment was the first day she was able to walk. She walked into the clinic favoring her right side and slightly bent forward. Walking up the stairs was quite difficult for her. She had nerve pain referring down to her foot following the gall bladder channel. 

The day before the onset (she woke up with it one morning) she lifted a 50-pound bag of mulch and turned to put it in her car. That will do it. Lifting with even subtle spinal rotation is enough to cause a significant pain cascade - even one that shows up a day or days later. 

There’s already a lot of important info here to sort out a treatment approach. Sciatica can mean lots of things. True sciatica is a lot different than sciatic nerve pain. True sciatica is nerve damage and it’s severe and less commonly seen in clinic. Sciatic nerve pain is super common and can also present in a severe manner.

Sciatic nerve pain can have two origins; one coming from the lumbar spine, referred to as axial sciatic nerve pain and the other coming from the hip, referred to as appendicular sciatic nerve pain. The terms aren’t as important as the concept. We want to know the origin of the pain pattern and not just the expression. If you’ve studied with me before you’ve probably heard my mantra (lovingly borrowed from Ida Rolf) “where it is, it isn’t.”   

Based on how this person walked in, lilting to the right, and the precipitating event, lifting a 50-lb bag and rotating a little, I was already thinking about her lower back and specifically the quadratus lumborum and its upper attachments at the thoracolumbar junction.

We started treatment with her face down. I began by utilizing a cranialsacral assessment and treatment technique to read  and release the pulls affecting the sacrum (By pull I mean where was there a myofascial drag on the sacrum? From the lumbar region? From the piriformi? s Or, even more inferior and from the hamstring attachment via the sacral ligaments?). Most of the pull on the sacrum was coming more from the lumbrosacral junction and higher. This led me to do myofascial release on her low back from sacrum to thoracolumbar junction. The myofascia was hypertonic with specific tension at both the ilolumbar ligament and the thoracolumbar junction. I treated these areas with specific myofascial release techniques. We achieved some positive tissue change from the work thus far. Not wanting to over treat I stopped working the low back there.

I checked in with the right hip next and the piriformis was tight - but not extremely so. At this point, I felt confident she had a spasm in the quadratus lumborum and that this was the origin of the sciatic nerve pain.

So, she had an axial origin to her sciatic nerve pain, the most specific symptom she had was pain and tightness in her right hip in the region of the piriformis – this could lead you to focus here if you were to direct treatment towards the site of loudest symptom. But, if we do this we can often miss an important causative area.

I felt comfortable that we had addressed the tension in the lower back with the myofascial work. I have learned over time that in acute cases less is much more. The body is feeling nervous about itself and over treating makes the body uncertain about what’s happening and primitive protective messages can arise causing more muscle spasm. If we do a little less I have come to believe this makes the body curious and able to explore releasing the protective pattern and exploring what it might be like to relax.  

I did acupuncture, choosing local points on the low back, gb 30 on the rt, yao yan bilateral, gb 34 bilateral, kd 3, and tb 6. Pretty simple really. She had good de qi response from the needles with gb 34 being particularly strong. I left the needles in for 15 minutes with stimulation 1/2 way through.

I often consider the liver and gall bladder from a Chinese medicine perspective in these cases, along with the bladder and kidney. I think in terms of both organ and channel, looking for how issues here may be involved in the case. In this instance, I was interested in the gall bladder channel especially. Palpating the channels confirmed this hypothesis.

After taking out the needles there was a decrease in tension and the piriformis was much more pliable. Now that the overlying reactivity and tension in her system was diminished I wanted to stretch her hip and low back gently. This is where Active Isolated Stretching is so helpful. There are amazing AIS techniques for the hip and low back muscles from either the prone or supine positions. Because she had been prone for a while already I had her turn to the supine position.

But wait, what the heck is Active Isolated Stretching?

Active Isolated Stretching (AIS) is a myofascial release technique applied in a different way than traditional myofascial work. AIS involves gentle and engaging movements of joints to address specific myofascial groups. In a way, it’s the more active yang approach that complements the receptive yin of cranial and typical myofascial release. (To check out more about it, consider looking into Aaron Mattes' book.)

We all know that the more we move the better we feel. And, the more different kinds of ways we move, the better yet. So, it makes sense that movement and treatment go together.

 The specific nature of the AIS stretches allows us to access deep myofascial and joint structures in a direct yet gentle way that is coherent with the Moving Mountain Institute approach. And, AIS adds the potency of movement to the work allowing the body to pay special attention to how it moves in space.

That's an example of integrating AIS into the other work I do and how it blends seamlessly into at home exercises (did I mention it's a billable code when you teach a patient how to do an at home exercise?).

Now back to our sciatic pain case:

My intent with doing the AIS at this juncture was 3-fold.

1)    The stretches would allow me to assess the work we had done thus far and find out how tight the piriformis and glutes were. This would further refine my assessment and prognosis following treatment.

2)    The stretches we were going to do would continue the treatment we had already done, allowing her body to experience safe and gentle movement though the myofascia that had been in protective mode. This kind of movement resets neuromuscular relationships. It’s so great to do at the end of a treatment for these reasons.

3)    The same stretches we would do are ones the patient can do at home for homework.

I spent about 10 minutes, maybe a bit longer going through a sequence of AIS stretches for the distal psoas attachment, fascia of the sacrum and lumbrosacral junction, and the internal and external rotators of the hip. While doing the hip rotator stretches I instructed her how to do the piriformis stretch at home. 

I used a few more minutes to show her a seated stretch for the QL and thoracolumbar aponeurosis (and obliques). This stretch is possibly the best "homework" I have in my toolbox. 

She walked out upright, in significantly less pain, and way more mobile. She had no problems going down the stairs while on the way in she struggled big time coming up. She felt super encouraged and was a lot lighter in spirit by the end of the session.

That's an example of integrating AIS into the other work I do and how it blends seamlessly into at home exercises (did I mention it's a billable code when you teach a patient how to do an at home exercise?).

Come check it out with us!

As I said at the beginning, I’m super excited about sharing these new techniques with you in our new Active Isolated Stretching course series! The first opportunity to learn some of the techniques and assessments described above is coming up on September 23rd, 2017, you can register here. And, a full course description can be found here.

Active Isolated Stretching I will be a one-day course and we will focus on treating cases just like the one discussed above. We will cover multiple approaches to address the hip and low back. In just one day you will learn a truly effective approach for these common and often acutely painful cases. 

If you’re curious to learn more about AIS, you can find a complete description here. I’m also attaching a couple articles about the technique by educator and sports medicine expert Ben E. Benjamin, Ph.D. He breaks down why, after 45 years of successful clinical practice, he was so excited to incorporate this approach into his practice. The articles are clear and give a great perspective on the technique (click here for Part I and Part II of these articles).

As always, let me know if you have any questions. Also, if you know anybody who you think may be interested in the work please feel free to forward this along or send them to our FB page to learn more about who we are what we're all about.

Thanks for doing what you do in this world,

Michael