Treatment Options for Sciatica: Neuromobilization and Low Back Pain

A title like this loses the attention of half of the people coming across this pain.  That’s okay.  I’m used to be being boring.   I did find this series of several articles to be interesting.

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Most everyone that comes into my office believes that they have sciatica or have been told by an acquaintance that their symptoms must be caused by “pinching off” the sciatic nerve.

While that is not always the case, sciatica or pain referred from the spine to the limbs is a very common Sciaticaissue.  There are a number of factors that can cause pain to be perceived in the leg, for example, as a consequence of an issue at the level of the lumbar spine.  Disc bulges, bone spurring, fibrosis/scarring or even entrapment/irritation in the piriformis muscle can be a cause of radiculopathy (or a pain that travels to the leg in a distribution consistent with “sciatica”).

Sciatica may affect as much as 43% of the population during the course of our lives.[i]  Treatment options for sciatica symptoms include:

• Physical therapy and exercise interventions
• Medications for management of symptoms
• Injections (e.g. epidural steroid injection) to address inflammatory processes at the level of the nerve root
• Surgery to decompress or alleviate pressure on a nerve root

Within the realm of conservative interventions is a technique called “neuromobilization.”  This technique is a method of conservative treatment of disorders of neural tissue.  The theory behind the technique is based on the idea that “essentially the entire nervous system is a continuous structure and it moves and slides in the body as we move and the movement is related to critical physiological processes such as blood flow to neurons.  This movement is quite dramatic and it is not hard to imagine that fluid such as blood in the nerve bed, a constricting scar, inflammation around the nerve or a nerve having to contend with arthritic changes or proximity to an unstable joint could have damaging effects, some of which could lead to pain."[ii]

The nuts and bolts of neuromobilization involve stretching techniques aimed at mobilizing nerve tissues (rather than the traditional aim of stretching out muscle tissues).  There is a lot of overlap between traditional seeming stretches and neuromobilization techniques.Neural Flossing

Neural flossing of the sciatic nerve, for example, involves something similar to a hamstring stretch with subtle changes to focus on mobilizing the length of neural tissues from the foot to the lumbar spine (pictured to the right).

A recent study in the Journal of Back and Musculoskeletal Rehabilitation looked at case studies of patients that did not respond to three “routine physical therapy sessions” and subsequently received neuromobilization techniques for 6 sessions.  The authors reported significant improvement in pain and function with the employment of these techniques.[iii]

A related study found that “neuromobilization therapy was superior to standard physiotherapy as regards eliminating or decreasing elevated resting muscle tone in response to pain in patients with low back pain.”[iv]

A study from more of a surgical perspective published in the October issue of Spine looked at patients undergoing microdiscectomy procedures had evidence on pathologic examination of “periradicular tissue consisted of the granulation with vascularization and many inflammatory cell infiltrations.”  They concluded that “The presence of periradicular fibrosis will compound the nerve root pain by fixing the nerve in one position, thereby increasing the susceptibility of the nerve root to tension or compression.”[v]

So, if you have an element of radicular-type pain or sciatica think about incorporating neuromobilization exercises in your program.  Or see a physical therapist trained in these techniques.  They may save you from the plague of sciatica that walks into my office.

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[i] Spine.  2008. Oct 15; 33(22):2464-72

[ii] http://noineurodynamics.blogspot.com/

[iii] Journal of Back and Musculoskeletal Rehabilitation. 2010. 23: 151-159

[iv] Ortop Traumatol Rehabil.  2009 Mar-Apr;11(2):164-76.

[v] Spine.  2010.  35(22): 2004-2014

Comments

[Alice Kahl, MA, PT, SCS, CFMT, ATC, TPI-CGFI-TP3]

Dr. Mangrum: I am pleased to see your appreciation of neuromobilization. The work of David Butler, et al, changed the way I, a manual therapist, treated patients and has made me a better, more successful therapist. PM&R docs would enjoy & learn a great deal from the NOI (Neuro Orhopedic Institute) courses (Mobilization of the Nervous System and Explain Pain) In the USA, NOI classes are taught by the International Spine & Pain Institute which includes proteges of David Butler.

[The Back Exercise Doctor]

Alice:

Thanks for the feedback. I agree that there is a lot I could learn from the folks at the ISPI. I have looked at taking courses from the ISPI group and would be very interested. Neuromobilization is a powerful tool and it can be very helpful to patients.

[Barry]

I'm sort of curious.... The neuromobilization example you use re sciata doesn't really state how the movement is accomplished. Do you have a link for more information? Thanks in advance.

[The Back Exercise Doctor]

Thanks for the follow-up. I knew when I put this together that the post was light on specifics of the technique. I anticipate doing a short video segment to demonstrate the technique, which would go a long ways to clarify exactly how to do these exercises.

The referenced studies involve some manual techniques (massage and even joint mobilization) to help facilitate the mobilization of nerual tissue. The primary take-home exercise is similar to a hamstring stretch. I did a quick search and found this youtube video, that while not the greatest quality highlights how to do the stretch.

http://www.youtube.com/watch?v=UoUqfOGuEOU

One thing to keep in mind if you try this exercise is that if you overdo it with this flossing you can really aggravate your pain in the short term. So be very modest with initial attempts at this (in terms of frequency, repetitions and degree of stretch).

Hope that helps. Let me know if you have questions or comments.

[Nack william A]

Thanks for taking this opportunity to talk about this, I feel fervently about it and I like learning about this subject will keep your new article. Thank you for your sharing!

[Sciatica]

Thanks for placing the post.it is very informative.This news is wonderful. The best news I have ever received. Great post & awesome site.