Massage Therapy

Continuing Education
SCIATICA AND MASSAGE

NCBTMB Provider #451897-12

www.nirvanamassagecenational.com
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SCIATICA AND MASSAGE

5 CEUs

Content copyright 2012, 2013 Nirvana Massage CE National, LLC

All rights reserved. All trademarks and/or copyrights are in effect.

This course is for informational and continuing education purposes

only.

All information in this course has been thoroughly researched and

referenced. It is accepted as factual at the time of publication. Nirvana
Massage CE National, LLC disclaims responsibility for any contradictory
information.

It is the responsibility of the massage therapist and/or medical professional to

determine what precautions to take in the particular field and to abide by
their scope of practice.
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COURSE OUTLINE
Chapter One: What is Sciatica?
Chapter Two: What Causes Sciatica?
Chapter Three: Symptoms of Sciatica
Chapter Four: How is it Diagnosed?
Chapter Five: Treatments: Physical Therapy
Chapter Six: Treatments: Medication, Injections, and Surgery
Chapter Seven: Acupressure and Acupuncture
Chapter Eight: Massage Techniques for Sciatica
Chapter Nine: Steps to Take at Home
Chapter Ten: Other Treatment Options
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COURSE BEGINS NOW

Chapter One

What is Sciatica?

Sciatica is “an irritation or compression of the sciatic nerve,”i or “pain,

tingling, or numbness produced by an irritation of the nerve roots that lead
to the sciatic nerve. The sciatic nerve is formed by the nerve roots coming
out of the spinal cord into the lower back.”ii

iii
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The sciatic nerve is actually a bundle of several spinal nerves that pass
through openings in the sacrum, which is the bony protuberance on the
bottom of the spine. It is the largest and longest nerve in the body, and the
primary nerve of the leg. The sciatic nerve starts in the low back, moves
through deep muscular layers of the buttocks, through the back of the thigh,
and divides into two branches above the knee.

Once the nerve splits, the shorter branch goes toward the outer leg and
ends below the kneecap. The long branch moves down the back of the leg
into the heel.

Compression or other irritation of the nerve can lead to “sharp, electrical

wave of pain, along with other symptoms, such as numbness, tingling,
weakness, achiness, and burning.”iv It can manifest as a bad leg cramp, or
can be severe enough that makes standing or sitting impossible. The pain
can be worsened when you cough or sneeze, and it can occur suddenly or
develop over time. Some people find that they can’t bend their knee in the
affected leg, or even move their toes.v

Sciatica often accompanies other lower back pain, and for 35 to 40 percent
of low back pain sufferers, sciatica is the worst part of the condition. Sciatica
is responsible for 95% of lower back pain surgeries.
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Chapter Two

What Causes Sciatica?

Despite the fact that lower back pain and sciatica often occur together,
they have separate causes and are usually two different issues. Lower back
pain is usually a muscular problem, while sciatica is a nerve problem.

In fact, sciatica “is almost without exception the result of a neurological

problem in the back, or an entrapped nerve in the pelvis or buttocks. Very
rarely, other neurological conditions, such as multiple sclerosis or stroke, may
account for it.”vi More than 5 percent of people in the United States suffer
from sciatica, and each individual has a 40 percent chance of developing it
at some point in his or her lifetime.vii

Seven common causes of sciatica include:

 “Compression of the sciatic nerve by a herniated disk in the back.

The disks in the lumbar spine are thick cushions of cartilage that
separate the vertebrae of the spine. The disks have a hard, fibrous
outer layer and a soft inner layer (it resembles gelatin). They are the
spine’s shock absorbers. Disks do not have individual blood supplies, so
they absorb nutrients from surrounding tissues.
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Over time, various factors like repetitive lifting, bad posture, and lost
flexibility can inhibit nutrient absorption and cause the disk to become
brittle. The gelatin-like inner layer can then protrude through the worn-
down, malnourished outer layer. This is a herniated disk.viii

ix

 Spinal stenosis (narrowing of the spinal column). This is most common in

seniors. The narrowing is “a result of the formation of bone spurs on the
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spine. This condition can cause the sciatic nerve to be compressed as it

passes through the narrowed canal. There is a gradual onset of pain in
the lumbar region. The pain may radiate into the buttocks and
occasionally down the legs.” x

 Spondylosis (degenerative spinal osteoarthritis, often associated with

aging).

 Nerve entrapment. The most common example is piriformis syndrome,

in which a muscle in the buttock is causing not only muscular pain but is
pressing against the sciatic nerve and causing sciatica. A recent article
found that two-thirds of non-disk sciatica was caused by nerve
entrapment in the buttock.
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Piriformis muscle in redxi

The piriformis muscles are responsible for outward rotation of the hip
when standing, and inward rotation when sitting. They can become
inflamed due to injury or overwork, and this inflammation will in turn
compress the nerve.
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People most likely to suffer from piriformis syndrome and its resulting
sciatica include those who sit for long periods of time (office workers,
truck drivers), especially when sitting with a thick wallet in one pocket. It
also includes those who stand for long periods of time. Other
candidates include those who fall onto the buttocks, those who do too
much aerobic exercise, and those with leg-length discrepancies.xii

 Inflammation and swelling from any other type of arthritis, sprains, joint
slippage, or possibly infection.

 Vascular problems. In the late stages of pregnancy, due to increased

blood volume in the spine, the fixed space inside the spinal cord may
narrow, compressing the nerves and causing sciatica; for those with a
condition called ‘pseudo sciatica,’ or intermittent claudication, poor
blood supply in the legs can mimic sciatica after short walks. The
compression, inflammation, reflex mechanism, or entrapment problems
briefly described above are associated with the nerve fibers that travel
though the spine, exit it, and pass down through the body to the lower
extremities. These fibers from the sciatic nerve and other fibers behind
the sacrum travel down the legs and into the feet. The referred pain
mechanisms include pathways going through the same points buy
originating above the spinal cord, often in the brain.
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 Central mechanisms. Stroke or cerebral hemorrhage or multiple

sclerosis can, on occasion, result in pain in the sciatic distribution.
Referred pain is an especially relevant central mechanism of pain. It is a
reaction by the central nervous system to a condition having nothing to
do with the sciatic nerve, but the nervous system reacts in such a way
as to cause pain to be felt along the sciatic nerve.”xiii

Other causes can include:

 Emotional stress, which can cause tightening of the muscles and

contraction around the sciatic nerve
 Sacroiliac Ligament Tear- these ligaments hold the hip bones to the
sacrum, and when injured the swelling can compress the sciatic nerve
 Weak muscles from a sedentary lifestyle and weight gain. When the
back muscles are weak, there is a greater likelihood of a pinched
sciatic nerve
 Endometrial cysts, which can engorge and compress the nerve in the
pelvisxiv
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Chapter Three

Symptoms of Sciatica

As stated in chapter one, the defining symptoms of sciatica are an

electrical-feeling pain or tingling in the lower back or buttocks that can
move down the leg as far as the toes. There might also be weakness or
numbness accompanying the pain, or weakness/numbness on its own
without the nerve pain.

These symptoms may worsen when you sit or stand for long periods of time,
or when you move in ways that cause the spine to flex (such as doing knee-
to-chest exercises). Walking, lying flat on your back, and spinal extension
exercises like push-ups might make the symptoms lessen.xv

The pain or tingling can be constant, or it can come and go. It can be
“sudden or progressive.” The pain might be described as “sharp, stabbing,
electrical, and burning.” The symptoms might show up in one leg or both
legs. The pain can be distributed uniformly along the nerve, but it is more
common for there to be specific spots of intense pain. The pain might feel
like “bugs crawling” or “pinching.”xvi
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For most patients, the pain is sharp, comes on suddenly in one spot, then
gradually fades. The burning sensation also tends to come on suddenly,
peak, and gradually fade. It returns and cycles.

There might also be reduced reflexes in people with sciatica. The Achilles
tendon reflex and knee reflex are the most commonly affected by sciatic
nerve issues, and will be the ones your doctor tests you for. Another less
common symptom is “footdrop,” or the inability to walk on your heels or
toes.xvii

Many people will experience achiness along the pathway, along with the
sharp pain/tingling. This is caused by strained or overworked muscles, which
in turn can be caused by sitting or standing in odd positions in an attempt to
alleviate the sciatica pain. Bending at the waist can also make it worse.xviii

Mimics of Sciatica

There are some conditions that can cause symptoms that appear to be
sciatica, but are not. A condition only qualifies as sciatica if it involves the
sciatic nerve. Pain in the lower back that travels down the leg and foot can
be caused by a number of things that have nothing to do with the nerve.
These conditions are mimics. Some examples of mimics of sciatica include:
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 Muscle issues- “pulled or sprained muscles or a muscle spasm can

cause pain that goes from the buttock down the back of the leg,
across the knee, and down to the ankle or foot.”xix

 Vascular issues- Claudication can cause pain that mimics sciatica. This
happens when there isn’t enough arterial blood feeding muscles in the
calves and removing toxic by-products of metabolism. The by-product
build-up causes the pain. Compartment Syndrome is another vascular
issue that mimics sciatica. This happens when you are injured and the
area swells beyond the limit of vascular supply, “endangering the
muscles and nerves.” Compartment Syndrome must be treated quickly
and with surgery.xx

 Edema (swelling)- Fluid that collects in the legs can create the same
feeling as sciatica. It can also lead to lower back pain, as the fluid
makes your legs heavier and harder to lift when you walk.

 Neuropathic conditions- “weak, uncoordinated, and ineffective

transmission of motor and sensory impulses in a single nerve, including
the sciatic nerve but also other single nerves, can mimic sciatica.”xxi
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Chapter Four

How is it Diagnosed?

While it might seem like it would be easy to self-diagnose sciatica, it is

important that your client see a medical doctor for confirmation, since
sciatica can itself be a symptom of a greater problem (and since some of
the mimic disorders are also serious). The doctor will go through a number of
steps to diagnose sciatica.

 Physical exam- this might include the doctor observing as the patient
walks and sits. A range of motion exam of your back might be done.
The doctor will palpate the legs and lower back, looking for areas of
pain and tenderness. You may be asked to walk on your heels and
toes, as well as test your reflexes.
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xxii

 Straight leg raise test- the patient lies on his back and the doctor raises
the legs one by one to see if pain occurs and at what angle. If pain
happens at an angle of 30 to 60 degrees and the pain is localized in
the back, that is an indication of irritation of the sciatic nerve root. If
bending the knee relieves the pain, the issue is the nerve. If it does not
relieve the pain, the issue is probably in the hip. If the pain is in the back
of the knee in both legs, the patient probably just has tight hamstrings.

 SSEP- Somatosensory evoked potential test, used to examine sensory

nerves.xxiii

 X-ray- spinal x-rays can reveal bone spurs or other bone issues that can
be affecting the nerve.
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 Magnetic Resonance Imaging (MRI)- a test that uses a powerful

magnet to produce cross-section images of the back area. It provides
detailed pictures of bone and the soft tissues (so is good for detecting
herniated disks and other tissue problems that can be causing the
sciatica).

An MRI showing an abscess that had been pressing on the sciatic

nerve, causing sciaticaxxiv

 Computerized tomography (CT) scan- a contrast dye is injected into

the spinal canal, where it circulates through the nerves and shows up
white on the imaging.xxv
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 Electromyogram (EMG)- an electrical current is passed through the

nerves to detect any disease of the nervexxvi

Chapter Five

Physical Therapy

Sciatica has a number of treatments, both traditional and natural. In this

chapter, we will be discussing physical therapy, one of the most common
treatments for sciatica in traditional Western medicine.

Sometimes, sciatica will go away on its own, especially if it is being caused

by a secondary injury. For example, when a pulled muscle in the hip swells
and presses on the sciatic nerve, the sciatica will go away once the swelling
of the pulled muscle goes down and stops pressing on the nerve.xxvii

Physical therapy is a common first treatment prescribed by doctors for lower

back pain and sciatica. It is often combined with “nonsteroidal anti-
inflammatories…to reduce spasticity, help restore function, improve mobility,
relieve pain, and prevent further episodes. In addition, physical therapy aims
to restore, maintain, and encourage overall fitness and health.”xxviii
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Physical therapy for sciatica often involves exercises that focus on “lumbo-
pelvic, or core, stabilization” that strengthens “muscles of the abdomen and
torso, or pelvic tilts.”xxix

Physical therapist doing core work with a patientxxx

Physical therapists may recommend the use of heat to relieve pain and
reduce muscle stiffness, or cold to reduce swelling or inflammation.

Electricity

Physical therapists can use electrical stimulation to make muscles contract.

This can tire out the muscles, reducing tightness or spasms, or aid in
contraction, which strengthens muscle weakness or imbalance. The use of
electricity by your PT is called functional electrical stimulation, or FES.

Transcutaneous Nerve Stimulation (TENS)

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This is the “application of electricity directly to nerves…used in the acute

state of an injury to decrease pain and allow for the use of passive, active
assisted, or active movement that will begin to correct the disorder. For
chronic problems, TENS keeps pain fibers occupied with the use of innocuous
stimuli, blocking the reception of impulses that relay actual pain so that an
individual gains a sense of well-being and loses nothing.”

Ultrasound

High-frequency sound waves are used to treat injuries. The sound waves
travel into the affected area, creating a gently heat that relaxes the muscles
and reduces spasm and pain.

Active Assisted Range of Motion

The therapists will help you lift and move for gentle strengthening/stretching.

Extension and Flexion

These are back exercises that improve muscle tone/strength, relieve pain,
and help prevent injury. They can be used to move a bulging disk back into
place and then strengthen surrounding muscles to prevent the disk from
slipping again.

Isometric/Isotonic Exercise
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Contracting muscles without moving and constant resistance to motion in

specific range of motion exercises, respectively.

Joint Mobilization

“The therapist stretches the joint until it reaches its limit, then helps it to go
further. This is usually followed by active exercises, so you can maintain the
mobility the therapist has helped achieve.”

Strain-Counterstrain

The PT puts the painful area into a relaxed position, then shortens the muscle
for 90 seconds to release it, then gently elongates through the muscle’s
range.

Myofascial Release

“The patient and therapist interact in the stretching process, the therapist
receiving feedback for deciding the strength, timing, and type of stretch to
effectively lower tension in the fascia, or connective tissue in the body.”
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A therapist performing myofascial releasexxxi

Gait Training

Analysis of bad habits associated with walking that can lead to back issues.

McKenzie Method

Exercises developed by a New Zealand PT named Robin McKenzie. It is used

to identify the movements that produce pain, then shift the pain to the
midline of the body through exercise, then reduce the pain, then eradicate
it.
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Traction

A treatment “designed to pull the vertebrae a safe distance apart from one
another so that nerves are no longer compressed as the exit the body.
Traction can also relieve muscle spasms and creates a vacuum between the
vertebrae, giving any bulging disks an opportunity to slide back into place.

A lower-back traction machinexxxii

VAX-D

A machine that controls and monitors back stretch with a programmable

controller.
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Lumbrosacral Corset

“This external source of stabilization for weak musculature is a thick belt used
for spondylolisthesis. It pulls in the abdomen, raising backward pressure in it.
This pushes the vertebrae back, or at least keeps them from slipping.”

Orthotics

Shoe inserts that can change the way you carry your weight or the angle at
which you stand. They can also provide arch support and leg discrepancies.

SIJ Belt

A Sacroiliac joint belt is a triangular padded belt that fits over the sacrum
and holds it together- helpful in SI joint derangement.xxxiii
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Chapter Six

Medication, Injections, and Surgery

Along with physical therapy, traditional Western medicine also offers

medications, injections, and surgical treatment options for patients suffering
from sciatica. Massage clients might be under any number of these
treatments when they come to you, so be sure to get a full medical history
before you begin treatment.

Oral Medications

Nonsteroidal Anti-Inflammatories

These can be either over-the-counter or prescription drugs. They are

prescribed to reduce swelling and pain, and are usually given when the
doctor thinks the issue will resolve itself. Examples include Ibuprofen and
Naproxen.

These drugs are generally safe, but can cause stomach trouble. Prescription
strength doses are actually safer than over-the-counter because the dissolve
slower and you need fewer pills.

Muscle Relaxants
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Doctors will prescribe muscle relaxers if they believe the sciatica is being
caused by muscle spasms or tightness. Common examples include Flexeril
and Soma. Once the muscles relax, they loosen their spasmatic grip on the
spinal column, widening the space where the nerves exit the spine and
reducing the sciatica. These drugs can also be prescribed in combination
with nonsteroidal anti-inflammatories.

There are problems with muscle relaxers- they do not treat the cause of the
problem. Their effects will be felt through the whole body, and not just at the
affected area. They can impede judgment and daily activities, and can
eventually be addictive.

Opioids

“This category of painkiller can be naturally derived from some form of

opium or be synthetically produced. Whereas other nonaddictive painkillers
are currently under development, opioids are the front line against severe
pain.” Examples include Percocet and Oxycontin. These drugs have some of
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the same issues as muscle relaxers- they can be addictive and impair daily
function.

Steroids

Steroids are generally given for herniated disks, spinal nerve compression
issues, and spinal stenosis (all contributing factors in sciatica). They reduce
internal inflammation and swelling, and are often used as an alternative to
surgery. They can reduce pain enough to make physical therapy an option.

Antidepressants

“It’s well known among physicians who treat back pain that low doses of
antidepressants can be helpful- doses so small that they could not help with
depression. Nobody seems to know why these medicines are so good for
some patients.”xxxiv

Injections

Injections are used when efficiency is needed in the sciatica treatment. The
medication is delivered directly to the affected area.
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Trigger Point Injections

These are usually give to treat back and neck pain, and can also be used in
the piriformis muscle when it is spasming and causing sciatica. The injection
uses a combination of Lidocaine (an anesthetic) and a low dose steroid.
Marcaine can be used in place of the Lidocaine- it’s longer acting and can
be more effective at dulling pain. Sarapin may also be in the injection, which
has anti-inflammatory properties.

Epidural Injections

An epidural of steroids can be an alternative to surgery when the sciatica

and low back pain is unresponsive to physical therapy. It can be effective in
treating herniated disks, spinal stenosis, and degenerative disk disease.

IDET

Intradiscal electrothermal therapy “is a procedure in which a needle is used

to introduce a wire into an injured disk, after which the wire is heated. The
extreme heat destroys some disk material and reduces the volume of the
disk. This procedure is meant to decompress nerves compromised by the
disk.”
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Radio Frequency Ablation

Using a Teflon needle and fluoroscope, the anesthesiologist puts the tip of
the needle at the damaged area. “The medial branch is a sensory nerve
that is part of the posterior primary division of the nerve root. It serves the
spinal muscles, the blood vessels…Once the needle is places, a type of
electrical current is emitted from the tip of the needle.” It current interrupts
nerve conduction, diminishing pain.

Surgery

Invasive procedures might be necessary in cases where physical therapy

and medications are not working. Surgery is an option for patients with
lumbar spinal issues, “especially those with nerve pain going down the leg, or
leg weakness. It can relieve pain as much as 70 percent of the time.”xxxv

However, surgery might not be a good option for those who have back pain
that does not involve nerves. “There are four basic surgical procedures to
relieve nerve compression at a specific spinal level:

 Laminectomy. Removal of a small section of the bone that covers the

nerve root and/or some of the disk material from beneath that root.
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 Disectomy. Removal of some of the disk material from beneath the

nerve root. After this operation, the nerve root has more space in which
to heal.
 Fusion. Joining one or more spinal vertebrae together so they no longer
move.
 Arthroplasty. Repair of the joints between facets of adjacent
vertebrae.”xxxvi

Surgeries will fall into one of two main categories:

 Conventional “open” surgery, done with a regular incision. The surgeon

makes and repairs a wound, and the patient needs recovery time and
narcotic pain relief. Some surgeons prefer this method because they
can see and feel what they’re doing.
 Minimally invasive surgery, done through tiny incisions, often with just
local anesthetic and in an out-patient basis. This utilizes mini cameras,
microscopes, and sometimes advanced imaging technology.

Patients with herniated disks will usually get one of two types of surgery:
removing material that compresses nerve roots, or taking out the center of
the disk to create space for the rest of the disk to “slip” back into place
between the vertebra.
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Patients with piriformis syndrome may consider surgery as a very last resort.
Some patients will require removal of the piriformis muscle entirely, others will
only require it to be thinned and cleaned of any adhesions. Around 80
percent of patients who undergo surgery for piriformis syndrome-related
sciatica will have a near complete recovery.xxxvii
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Chapter Seven

Acupressure and Acupuncture

Acupressure and acupuncture are related modalities of Traditional Chinese

Medicine (TCM). Both can be used to treat sciatica, and it is possible that
your client will use one or both in their search for relief.

The main concept behind both treatments is that life energy called chi
circulates through the body on meridians, which are energy pathways that
resemble blood vessels or the nervous system. Chi must move through the
meridians unobstructed for good health to be maintained. When the flow of
chi is blocked, health issues like back pain occur.

Acupressure
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xxxviii

“The goal of acupressure, which can be described as an ancient system of

massage, is to stimulate, disperse, and regulate the body’s healing energy.
Through the practitioner’s application of pressure, using fingers, palms,
thumbs, or elbows, chi is encouraged to circulate throughout the body.”xxxix

Sciatica occurs when the chi is obstructed along the bladder, gallbladder, or
kidney meridians. The obstruction occurs when the five elements are out of
balance- when cold, wind, or damp invade the body. The colder the
imbalance, the worse the sciatica pain.
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“As the practitioner applies pressure to the points, obstructions in the flow of
healing energy dissolves, muscles and ligaments relax, and the body returns
to a healthier state. By moving the stagnation and dispersing the wind, cold,
or damp, the kidney, gallbladder, and/or bladder meridians are
strengthened. As a result, the symptoms of sciatica decrease. Applicable
pressure points could be along the low back and legs, and/or at distal points
on other parts of the body. If points are used along the low back and legs,
some of these points may be tender and sore while being treated.”xl

Acupuncture

Acupuncture is similar to acupressure, but uses “the insertion of fine needles

at specific points on the meridians. The penetration of these points triggers
the flow of chi, resolves blockages, and allows recovery to begin. The
primary focus of acupuncture is to correct the cause of illness by stimulating
the body’s natural healing abilities.”xli

xlii
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The acupuncture therapist stimulates the circulation of chi by inserting the

needles and relieving blockages. The insertion of the needles us usually
painless, though some clients feel heat, tingling, or numbness in a fleeting
way at the acupuncture point.

Medical research also shows that acupuncture stimulates the body’s natural
healing reactions by stimulating the red and white blood cell regulation. It
triggers the release of endorphins, cortisol (natural anti-inflammatory), and
natural pain-killers. Acupuncture also helps regulate blood pressure, and
relieves depression and anxiety, which are commonly found in patients with
low back pain.

There are several adaptations of acupuncture, which function on the same

principles:

 “Cupping- specialized glass cups are placed upon specific

acupuncture points on the kidney meridian, located on the low back.
A process of removing the oxygen from the cup creates a vacuum like
pressure. This pressure draws chi and blood to the area of the lower
back, facilitating the flow of chi and opening the meridians.
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xliii

 Electro-acupuncture- After acupuncture needles have been inserted, a

low-intensity, pulsing, electric current is applied through the
acupuncture needle. Electro-acupuncture disperses a tingling
sensation around the acupuncture point and reaches a large number
of…points on the meridian.

 Laser Acupuncture- …an option for individuals who fear needles. Points
are stimulated by a fine, low-energy laser beam emitted from a laser
pen. The treatment is painless.

 Moxibustion- a form of heat therapy. It involves the burning of a cigar-

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shaped roll of the herb moxa- also known as mugwort…above the

acupuncture point. An additional technique includes laying a small
slice of fresh gingerroot directly on the treatment site, and then placing
a piece of dried moxa on top of the ginger…moxibustion results in a
deep, penetrating heat and subsequent pain relief. The heat not only
has a soothing effect, but also opens the pores of the skin, allowing the
healing properties of the ginger to penetrate the body.”xliv

Acupuncture with moxibustionxlv

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Chapter Eight

Massage Techniques For Sciatica

Since a client coming for massage most likely has muscular-related sciatica,
you will generally be focusing massage on the lower back (lumbar area)
and the glutes/hips to target the piriformis muscles.

Hips/Glutes

When dealing with the hips and glutes, you can warm up the area with
effleurage while the client is lying on his or her stomach. Move so that you
are standing behind the opposite hip from the one you are working on. So if
you want to work the left glute, stand on the client’s right side. Reach across
both buttocks and find the hip joint of the far leg, pressing into the point
where the piriformis attaches to the hip joint.

Do some cross-fiber friction across the tendon that connects the piriformis to
the hip joint. Be sure to cook your shoulders back and down away from your
ears. Lean back slightly so you can use your weight to put more pressure into
the spot where you are working without stressing your wrist or fingers.
Alternate this with stripping of the piriformis muscle, moving the cross-fiber
friction up the length of the muscle and across the buttock.
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Then locate the sacrum and work around the ridges of the sacrum, using
circular friction and finger pressure to work any adhesions of the
attachments along the sacral ridge. You can then move into petrissage of
the glutes and hips to increase blood flow to the nerve area.xlvi

You can also move into working the attachments of the hamstrings at the
bottom of the buttocks. Loosening the hamstrings will decrease pressure on
the pelvic bones, allowing the sacrum to remain in alignment.

Cranio-Sacral Element

If the sacrum is out of alignment, it can affect the cranio-sacral bones closest
to where the spine joins the skull. If you have experience in cranio-sacral
therapy, you can place one hand at the occipital and place another at the
sacrum, then begin applying pressure to the sacrum to re-align it, keeping
the occipital bones steady.

After work has been done to the piriformis/hip area, you can apply gentle
pressure to the L5/S1 region with one hand and then pull gently on the
muscles of the spine with the other hand, pulling them toward the head. This
is a sacral pull, a stretch which can help alleviate tightness around the base
of the spine. Hold this gentle stretch through any movement you feel, until
the muscles settle.
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You can then move so you are standing at the client’s hip, facing the head.
Place the closest hand over the sacrum so the heel of the palm is on the
coccyx and the fingers are at the L5/S1 junction. The heel of the palm exerts
gentle downward pressure (toward the feet) while the fingers rock side to
side slightly. It’s a very gentle and light technique, so you don’t stress the
hand. These sacral pulls will help realign the sacral bone, giving you even
deeper access to the piriformis and glutes.xlvii

When dealing with sciatica that involves compression of the nerve (axial
sciatica), you will need to keep the following in mind:

“1. The safest, most universally helpful intentions for massage therapists
dealing with axial sciatica are to gently ease the effects of unnecessary
splinting and guarding, and to relieve the overall tension and stress of
dealing with pain. Relaxation and calming approaches, as well as work
around the lateral hips, shoulders, and neck, are especially helpful.

2. Work slowly. If you do deep work, proceed very gradually, noting your
client's response between sessions. If there is a persistent increase in pain
after your session, work less deeply next session, and/or in different places.
What may feel good on the table may worsen the symptoms when upright,
so if possible, ask your client to sit or stand partway through your session to
check in about pain level, and adjust or redirect your work accordingly.
 41

3. Use your client's own gentle active movements, rather than passive
moving, stretching, or positioning. Use your client's comfort as a guide.
Painful work is not helpful with inflammatory conditions such as sciatica, so
your clients should be instructed not to push through their pain. Find a level
of depth and pressure that allows your client to relax into the work.

4. Especially in sciatica and other nerve issues, the point of greatest pain is
often the place that is least in need of direct, deep pressure. Because tissues
are already inflamed or unstable in the spot of pain, direct work may worsen
the symptom later. Instead, ease the body around the most painful areas.

5. Avoid any techniques that apply longitudinal compression or shearing

forces (listhesis) to the spine, such as some seated techniques or passive
stretches. Also, use caution with positions or techniques that twist the spine,
which can narrow the foremen around an already crowded nerve root
(twists can also relieve compression, but use them cautiously).

6. It is a good idea for your client with acute axial sciatic signs to be under
the care of a spine specialist such as an chiropractor, orthopedist, physical
therapist, or other rehabilitation specialist. If you suspect undiagnosed
lumbar disc issues (for example, if your client feels a worsening of sciatic
symptoms with the SLT), be sure to refer your client to a qualified medical
 42

specialist for an evaluation and possible rehabilitative work. Don't hesitate to

get supervision or advice from a mentor as well.”xlviii

Thai Massage

Thai massage is a combination of acupressure, traditional Swedish massage,

and guided yoga. The practitioner moves the client in and out of various
stretches while working pressure points and relaxing the muscles.

xlix

Thai massage can be very effective at loosening the muscles in the glutes
that can be compressing the sciatic nerve.
 43

Thai massage can also be a very active therapy, so you will want to take
care to be very gentle as you start the treatment. The client may be
experiencing pain in the exact muscles you need to work, so ease into the
work before you go after the tension with your thumbs or elbows.

A good starting technique is to have the client lie on his or her stomach on
the mat (Thai massage is done a special floor mat, not on a table). Begin by
kneading into the glute muscles with your closed fists. The kneading should
start at the outside of the hip joint, working up and across the piriformis and
up to the sacrum. This opening work will increase blood flow to the muscles
and allow them to relax so you can work more deeply later.

Once the muscles are warm, you can get on your knees and face the
client’s head, then lean into the glutes with your forearm, starting near the
leg and working up toward the hip. Work into the glutes with the forearm,
“walking” up and down the glutes. After the forearm work and the
kneading, you should be able to feel where the piriformis (or any other glute
muscle) is tight. You can then use the elbow gently to place firm pressure on
the tight spots, leaning into it while you stay on your knees on the mat.

Another effective way to work the piriformis in Thai massage is with your
heels. With the client lying face down on the mat, straddle his or her
 44

midsection so one foot is on either side of the hips. Lean over and place one
hand on either side of the ribs for balance. Lift each heel over the hip joint
(with the toes still on the mat) and drop the heels right into the hip joint,
where the piriformis attaches. Lean back off your hands slightly to use your
weight to press into the piriformis. This technique requires the practitioner to
have a good level of hip flexibility and upper body strength.

Once the glutes are loosened, you can begin working the IT band that runs
on the outside of each leg. With the client on his back, bend the knee and
bring it out to the side, so the foot touches (or comes near to) the knee of
the opposite leg. Walk your hands up and down the side of the IT band that
should now be easily accessible. If you encounter any areas of tightness,
increase the pressure until the muscle softens.

Have the client turn over onto his back. Bring the knee up, holding the ankle
with one hand and guiding the knee with the other. Bring the knee up and
press it back toward the opposite shoulder. Ground the hip down with one
hand and use the other that is holding the ankle to extend the foot,
stretching the IT band.

Bend the knee again and drop it across the other leg, performing a spinal
rotation. Press the knee away and ground the shoulder down to the floor,
 45

stretching the tops of the glutes and the low back. Repeat with the other
leg.

Thai massage spinal rotationl

Bring the soles of the feet together, allowing the knees to drop open toward
the floor. Gently press onto the knees to stretch the groin and front of the hip,
relaxing the glutes and the back of the hips. li

Foot Reflexology

Foot reflexology is a technique that applies pressure to specific reflex areas

on the feet in order to correct issues on other areas of the body.
 46

“Practitioners of foot reflexology believe that specific reflex points on the feet
correspond to particular areas and systems of the body…the practitioner
applies stroking and sustained pressure (mostly with the thumb) to specific
spots on the feet that reflect to the corresponding areas of the body…”lii

Foot reflexology chartliii

 47

The sciatic nerve reflex runs a specific path down the side of the ankle
behind the ankle’s bony prominence, down the heel and around the
bottom of the heel, then back up the inside of the ankle (like the bottom of
stirrup pants). To work the reflex, thumb-walk down the outside of the ankle
and around the heel. Thumb-walking involves pressing into the reflex with the
thumb and then moving it down slightly, pressing, moving, pressing. When
you get to the inside of the ankle, you can switch to finger walking. This can
result in intense sensation for clients with sciatica or even those with hip
issues, so be gentle.liv
 48

Chapter Nine

Steps to Take at Home

In addition to treatment from his or her doctor, physical therapy and

alternative treatments including massage, people with sciatica can also
help alleviate their symptoms at home. There are some exercises to be done
and habits that can be changed to help prevent the worsening of
symptoms.

Exercise

One of the most important ways to prevent back issues is to strengthen your
core. The weaker the abs are, the more likely the client is to have back
problems. Clients can do any core routine they like, from Pilates to yoga to
old-fashioned calisthenics, but they must do something. There are exercise
books available for free at the library, and videos of ab workouts available
online for every fitness level.

There are also simple stretches and strengthening exercises you can do at
home.

 Bends- “Try this if you have stenosis, spondylolisthesis, piriformis

syndrome, herniated disk, or arthritis. Sit comfortably in a wooden chair.
Your feet are on the floor, forearms on your thighs, and palms on your
 49

knees. Gradually slide your forearms forward. Your feet remain flat on
the floor. Keep your spine straight. Your arms, not your back, should be
holding you up, bearing your weight. Leaning forward stretches the
muscles of your buttocks and lower back without stretching the
nerves.”

 Twists- “This particular twist is good for arthritis, sacroiliac joint

derangement, piriformis syndrome, and stenosis…Sit toward the front of
the seat of an armchair, feet flat on the floor, knees together and
pointing straight ahead. Bring your right hand over to the left chair arm.
Your left hand reaches behind you toward the right chair arm or all the
way to it. Let your right chest move forward and your left arm pull your
left shoulder back. Sit up straight.”lv

 Legs Up- an exercise for pinched nerves because of stenosis. Lie on the
floor with the buttocks close to a wall. Put the legs straight up against
the wall parallel to each other. Let them rest there for as long as you
want. To come down, bend one knee, roll to that side, and bring that
leg and food to the floor. Repeat this exercise as often as you like. You
can lie on cushions if you want.

 Wall Dog- A variation of the yoga post upward-facing dog. It increases

the range of motion of the spine and stretches the back of the hip joint,
which can be helpful for those with piriformis syndrome. Stand a foot
 50

away from the wall, facing the wall. Distribute weight evenly on both
feet. Place both palms high on the wall, above eye level and more
than shoulder-width apart. Keep the fingers pointed up, knees and
elbows straight. Pull the hips back and bring the armpits forward and as
close to the wall as you can. Don’t do this if you have spondylolisthesis.

 Standing Lean- a stretch for the muscles between the pelvis and
thoracic spine, helps with sacroiliac joint derangement,
spondylolisthesis, segmental rigidity, and herniated disks. Stand facing
a table or counter with the feet apart. Face the palms away from the
body. Lean forward, digging the elbows into the lower ribs until the
heels of the hands rest on the table. Relax the abdominals. You’ll feel a
stretch in the low back. Lean for about 20 seconds as many times per
day as you can stand it.

 Barflies’ Trick- Perch one foot about six inches off the floor by resting it
on a ledge, staircase, a telephone book, or whatever is available. It
relieves pain and relaxes the lower back muscles.lvi

Routines

Backaches are often a precursor to sciatica, and backaches themselves are

often caused by habits. Examples include wearing the same pair of
unsupportive shoes every day for weeks, or sitting in the same spot on the
 51

couch slumped over while watching television every night. Some ideas for
switching up routines to help prevent back pain:

 Change your shoes

 Change the shoulder over which you carry your purse, or switch to a
backpack.
 Move the position of the driver’s seat in your car
 Change your exercise routine to prevent repetitive motion stress
 Replace your work chair and keyboard with ergonomic alternatives.
 Sleep in the fetal position- it’s ideal for sciatica because it relieves the
pain of herniated disks, SI joint issues, spondylolthesis, piriformis
syndrome, and arthritis.
 Lose weight. Carrying excess weight just places more pressure on the
spine and nerves. If you cannot exercise because of pain, try
swimming.
 Sleep with a pillow between the knees
 Check your mattress- replace it if it is more than ten years old
 Take regular soaks in a warm tub, about 20 minutes a day three or less
times per weeklvii

Posture

Posture- including the way you walk- can cause back pain. Yoga is an
effective way of becoming more aware of your posture. Your head, neck,
 52

torso, buttocks, and legs should be aligned when you stand. You can also
have your gait analyzed to determine if one leg is shorter than the other.

Tadasanalviii

The yoga pose tadasana, or standing mountain, is especially helpful for

those who need to work on their posture to prevent back pain. Those pose
looks deceptively simple, but involves spreading and grounding the toes,
keeping the pelvis tucked and the abs engaged, with the shoulders down
 53

and back away from the ears, and the head, neck, hips and heels all in
alignment.lix
 54

Chapter Ten

Other Treatment Options

There are a number of other treatment options available for clients with
sciatica. Your clients should report any other treatments they are undergoing
on the medical intake form they fill out when they come to see you. Here are
a few other treatments you might encounter with your clients:

Chiropractic

A chiropractor uses “manipulation of the spine in order to reestablish the

proper alignment of the spinal bones and to restore normal motion.
Manipulations are performed by hand, although some chiropractic doctors
may use special treatment tables to facilitate the outcome. Certain
treatment processes also include the application of heat and cold, or
ultrasound for muscle relaxation.”

The spinal adjustments are made using quick and precise thrusts to force the
joints just beyond their normal range of motion. A hand-held instrument can
be used for low-force treatments, called the Activator technique. This
technique is gentler.
 55

Chiropractic Activatorlx

Hydrotherapy

Also known as water therapy or aquatic therapy. It consists of exercises and

stretches performed in a warm, shallow pool. It is particularly effective at
treating muscle and joint-related sciatica, and for stress relief. The buoyancy
of the water takes stress and weight off the joints, which can cause pain
relief. Some hydrotherapy facilities also use cooling pools.

“The warm water used for aquatic therapy stimulates and then relaxes tired,
aching muscles. It increases blood flow to the skin and muscles, thus relieving
stiffness. By improving the circulation, a fresh supply of oxygen and nutrients
are carried to the tissue to repair damage. The cooler, more invigorating
water helps reduce muscle swelling and pain by constricting blood vessels.”lxi
 56

Osteopathy

Osteopathy is a type of medicine that is based on the following beliefs: the

entire body needs to be considered when treating a condition, and the
musculoskeletal system plays a key role in any dysfunction. This approach
addresses physical, psychological, and lifestyle factors when determining the
underlying cause of a condition.”

In osteopathy, sciatica is viewed as a disturbance in the musculoskeletal

system that can be caused by poor posture, unhealthy body mechanics, or
physical or emotional trauma. The goal of osteopathic treatment for sciatica
is to “increase mobility, improve circulation, decrease muscle and ligament
tension, and decrease pain in the low back region and along the sciatic
pathway. This is brought about through the manipulation of the joints and
soft tissue, and through exercise to improve poor posture and body
mechanics.”lxii

Rolfing

Rolfing is a form of “structural integration that involves deep manipulation of

the connective tissue in order to restore the body’s natural alignment. The
practitioner performs manipulations with the fingers, thumbs, forearms, and
elbows. Practitioners of Rolfing believe that the structure of the body affects
both physical and mental health.”
 57

Our posture, gait, and sleep position can all pull the body out of alignment.
The connective tissue can harden, bunch, and become inflexible after years
of bad habits. This restricts the body’s alignment.

Bad posture leads to restrictions, which leads to pain in Rolfing theorylxiii

Rolfing practitioners apply deep pressure to soften and lengthen restricted

connective tissue, restoring surrounding tissue to proper function. There are
usually ten sessions, with breath being a big focus during each session.
 58

Tai Chi

Tai chi is an ancient Chinese movement therapy that consists of a series of

slow, controlled movements that are intended to “unite the mind and body,
to build inner strength, and to create and develop a healthy flow of energy
(chi) within the body.” The practice combines movement with breathing
techniques and meditation. The smooth movements opens joints and
dissolves chi blockages, allowing energy to circulate throughout the body.

The practice also causes relaxation and the combination of stretching and
twisting exercises the body without high impact. According to Traditional
Chinese Medicine (TCM), once chi blockages are dissolved and energy flow
is restored, healing of sciatica and other disorders can begin.

i Larry P. Credit, Sharron G. Hartunian, Margaret J. Nowak, Relieving Sciatica, Avery Publishing
Group, 2000.
ii WebMD, “Sciatica Topic Overview,” http://www.webmd.com/back-pain/tc/sciatica-topic-
overview
iii Wikimedia Commons, “Gray1244,” http://commons.wikimedia.org/wiki/File:Gray1244.png
iv Ibid
v Cleveland Clinic, “Diseases and Conditions,”
http://my.clevelandclinic.org/disorders/sciatica/hic_what_is_sciatica.aspx
vi Ibid
vii Ibid
viii Credit, Harunian, Nowak
ix Wikimedia Commons, http://commons.wikimedia.org/wiki/File:HerniatedSpinalDisk-
 59

NarrowedNerveRoot.JPG
x Credit, Harunian, Nowak
xi Wikimedia Commons, “Piriformis Muscle,”
http://commons.wikimedia.org/wiki/File:Piriformis_muscle.PNG
xii Credit, Harunian, Nowak
xiii Fishman and Ardman
xiv Credit, Harturian, Nowak
xv WebMD
xvi Fishman and Ardman
xvii Ibid
xviii Credit, Harunian, Nowak
xix Fishman and Ardman
xx Ibid
xxi Ibid
xxii Wikimedia Commons, “Straight Leg Raise Test,”
http://commons.wikimedia.org/wiki/File:Straight-leg-test.gif
xxiii Ibid
xxiv Wikimedia Commons, “Pyomyositis MRI,”
http://commons.wikimedia.org/wiki/File:Pyomyositis_MRI.jpg
xxv Mayo Clinic, “Sciatica Tests and Diagnosis,”
http://www.mayoclinic.com/health/sciatica/DS00516/DSECTION=tests-and-diagnosis
xxvi Cleveland Clinic, “Sciatica,” http://my.clevelandclinic.org/disorders/sciatica/hic_sciatica.aspx
xxvii WebMD, Sciatica
xxviii Fishman and Ardman
xxix Ibid
xxx Wikimedia Commons,
http://commons.wikimedia.org/wiki/File:Personal_trainer_monitoring_a_client%27s_movement_dur
ing_a_fitball_exercise.JPG
xxxi Flickr, http://www.flickr.com/photos/wonderlane/3275189299/
xxxii Flicker, http://www.flickr.com/photos/gurms/6440130965/sizes/z/
xxxiii Fishman and Ardman
xxxiv Ibid
xxxv Ibid
xxxvi Ibid
xxxvii Ibid
xxxviii Flickr, http://www.flickr.com/photos/sportex/8076561722/sizes/m/in/photostream/
xxxix Credit, Hartunian, Nowak
xl Ibid
xli Ibid
xlii Wikimedia Commons, http://commons.wikimedia.org/wiki/File:Flickr_-
_Official_U.S._Navy_Imagery_-_Cmdr._Yevsey_Goldberg_conducts_an_acupuncture_procedure..jpg
xliii Wikimedia Commons, http://commons.wikimedia.org/wiki/File:Fire_Cupping.jpg
xliv Credit, Hartunian, Nowak
xlv Wikimedia Commons,
http://commons.wikimedia.org/wiki/File:Accupuncture_and_moxing.jpg
 60

xlvi YouTube, Specialty Massage Tips: Sciatica Treatment With Massage,

http://www.youtube.com/watch?v=s-m9A9DE_b8
xlvii YouTube, Back Massage Therapy How To For Sciatica Pain Relief Treatment,
http://www.youtube.com/watch?v=RWV2cSgE_2k
xlviii Til Luchau, Assessing Sciatic Pain,
http://www.massagetherapy.com/articles/index.php/article_id/2064/Assessing-Sciatic-Pain
xlix Flickr,
http://www.flickr.com/photos/taraangkorhotel/5918685202/sizes/m/in/photostream/
l Flickr, http://www.flickr.com/photos/wanhoff/208808605/sizes/m/in/photostream/
li PsycheTruth, “Thai Asian Body Massage Therapy How To, Low Back Pain Techniques Sciatica,”
http://psychetruth.blogspot.com/2011/11/thai-asian-body-massage-therapy-how-to.html
lii Credit, Hartunian, Nowak
liii Wikimedia Commons,
“http://commons.wikimedia.org/wiki/File:Foot_Vital_Point_Refrexology.jpg”
liv HowCast, How to Relieve Sciatica Using Foot Reflexology Techniques,
http://www.youtube.com/watch?v=qzMbmYCOkUY
lv Fishman and Ardman
lvi Ibid
lvii Ibid
lviii Flickr, http://www.flickr.com/photos/tarnalberry/2347257740/sizes/m/
lix Fishman and Ardman
lx Wikimedia Commons,
http://commons.wikimedia.org/wiki/File:Chiropractic_Activator_device.jpg
lxi Credit, Hartunian, and Nowak
lxii Ibid
lxiii Flickr, http://www.flickr.com/photos/bethscupham/7387111804/sizes/n/