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Is There Anything Else You Can Do for My Leg Pain? 

How many times have you heard this from frustrated sciatica patients, or worse yet, felt this as a provider? If a patient presents with a problem amenable to your skillset, you beam with confidence in knowing that you hold the key to their recovery. But…when symptoms persist following treatment; patients and providers leave with differing levels of frustration and disappointment.

Symptom reduction depends on many variables; however, joint mobilization and nerve flossing are generally beneficial for the treatment of sciatica. This blog will review these skills and discuss a proven new technique that combines both. This procedure is called Spinal Mobilization with Leg Movement (SMWLM).

To learn more, check out this 3-minute tutorial.

Many evidence-based chiropractors employ the strategy of “calming things down before building them back up.” While the treatment of muscles, joints, tendons, or ligaments may follow this mantra – nerve symptoms don’t. Nerves may be a primary source of pain but are rarely the primary source of dysfunction. Prolonged nerve compression or irritation triggers a series of intraneural events that ultimately lead to impaired neurodynamics (nerve sliding) and increased pain. (1)

Successful management of neurogenic symptoms requires restoration of tissue mobility. SMWLM blends nerve mobilization and spinal mobilization to provide quick relief of sciatic lower back pain. Before we see how it works, let’s review the components. 

 

Technique #1. Neural Mobilization for Sciatica

Nerve mobilization incorporates combined movements of two or more joints to restore neuroplasticity and nerve length by mobilizing the entire nerve tract. Neural mobilization eprimarily aims to release adhesions along the course of the nerve, thereby reducing the likelihood of neural ischemia secondary to compression or traction. Check out the following demo of sciatic nerve mobilization or “nerve flossing.”

Sciatic Nerve Floss:

Compression of the sciatic nerve may result in radiating pain or paresthesia into the anterolateral leg and foot. Nerve release may help resolve adhesions and restore normal mechanical function by “flossing” the affected nerves. The patient should be supine with their affected leg extended. The clinician begins by flexing the patient’s hip (SLR) while the patient holds their neck in extension until symptoms are reproduced in the leg. The patient is instructed to flex their neck as the clinician lowers the patient’s leg. Alternately, sciatic nerve floss may be performed with the patient seated Flossing motions should not create or intensify any radicular complaints. The flossing pattern should be repeated ten times, from the starting position to the end position. The patients may benefit from continuing self-flossing exercises at home.

Technique #2: Mulligan Spinal Mobilization

Mulligan Spinal Mobilization involves the assessment and correction of “positional faults” within the spine.  Positional faults are the result of repetitive, traumatic, or postural strains that alter normal physiologic joint motion that may result in long-lasting biomechanical changes and irritation to nearby structures.

Spinal joints have specific articular surface angles, cartilage thicknesses, and orientation of ligaments or capsule fibers to allow for optimal load transfer through each joint. Any disruption to normal motion may perpetuate a cycle of joint dysfunction and symptom reproduction.

Hmm… Sounds like something we learned about in chiropractic school!

Abnormal lumbar joint mechanics can lead to irritation of pain-sensitive structures, including nerve roots—aka Sciatica. Spinal mobilization corrects joint positional faults—aka joint dysfunction, joint restrictions, malpositions, or sub!#+@tions 🙂.  When applied to a specific spinal level, spinal mobilization may result in an immediate reduction in pain and increases in mobility. (2) Spinal mobilization and manipulation also increase intervertebral foraminal space with subsequent nerve root decompression. (3)

Lumbar Rotation/ Lateral Flexion Mobilization (not Mulligan):

Begin facing the patient in a side-lying position—affected leg up. Place your superior hand on the spinous process of L5 and apply medial pressure.  Place your inferior hand on the PSIS of the affected side.  Passively flex the patient’s affected leg using your forearm or leg to provide overpressure until end range of motion (ROM).  Apply three sets of ten mobilizations using the inferior hand to rotate the lumbar spine into end ROM.  

Clinical Pearl: Apply a contract-relax phase at the end to further enhance ROM.  Perform this step by having the patient rotate against your inferior hand at end range.  Hold for seven seconds; then relax.  Upon relaxation, gently roll the patient further into rotational end range before the next contraction.

1 + 2 = Technique #3: Spinal Mobilization with Leg Movement (SMWLM):

Data has recently shown that combining joint mobilization and neural (flossing) provides significantly improved outcomes in leg and back pain, disability, SLR, ROM, and patient satisfaction in the short and long-term. (4,5) Here’s how that works:

SMWLM:

Begin facing the side-lying patient – affected leg up. Passively flex the patient’s affected straight leg until the point of reproduction of back or leg symptoms, then note the approximate degree of hip flexion. Next, apply sustained medial pressure to the patient’s L5 spinous process while repeating the initial side-lying SLR maneuver. This step may be augmented with the help of an assistant. 

Is the patient able to achieve a greater range of hip flexion with the applied pressure to the lumbar spine?

If NO, then move your contact up to apply medial pressure to L4 and repeat the side-lying SLR movement. Repeat at superior levels if needed. If medial does not alleviate symptoms at any level, this may not be an appropriate therapy for the patient.

If YES, then repeat three sets of 7-10 side-lying SLR’s with applied medial pressure to the affected level.

Pro Tips for Spinal Mobilization with Leg Movement

  • On the first visit, this technique should be only be repeated three times to minimize the potential for exacerbation. If the patient does not experience any latent exacerbation, perform three sets of 7-10 repetitions on subsequent visits. 
  • Maintaining knee extension and ankle dorsiflexion throughout this maneuver will increase nerve tension and may be considered as an escalation once symptoms have centralized.
  • An at-home Side-Lying Sciatic Nerve Floss may be considered as a supplement to your in-office treatment.  

Discussion

All of our clinical “toolboxes” have “drawers” that represent various skills and techniques. Some toolboxes have one drawer, while others have many. A “single drawer” D.C who pounds down the high spots will no doubt help a percentage of patients, but utilizing many well-honed skills in carefully crafted treatment plans will improve the odds significantly.

The need for MSK services will always thrive, but in the future, patients will choose providers more selectively based on effectiveness, value, and convenience. “Best practice” treatment plans that resolve problems quickly are paramount to value and cannot be replaced by less proficient options.

ChiroUp exists to help you to deliver exceptional treatment. We are much more than an exercise program. ChiroUp is a system that improves patient compliance, measures clinical outcomes, and allows you to build relationships with your patients.

Does your current system do that?

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References

1. Carroll M, Yau J, Rome K, Hing W. Measurement of tibial nerve excursion during ankle joint dorsiflexion in a weight-bearing position with ultrasound imaging. J Foot Ankle Res. 2012; 5(5):1–6.

2. Mulligan BR. Manual therapy. “nags”, “Snags”, “MWMs”, etc 4th edition. Pg:44-45.

3. Wilson, Ed. “The Mulligan concept: NAGS, SNAGS, and mobilizations with movement.” Journal of bodywork and movement therapies 5.2 (2001): 81-89.

4. Kiran Satpute, Toby Hall, Richa Bisen, Pramod Lokhande. Patients With Lumbar Radiculopathy—A Double-Blind Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation Volume 100, Issue 5, May 2019, Pages 828-836

5. Das SMS, Dowle P, Iyengar R. Effect of spinal mobilization with leg movement as an adjunct to neural mobilization and conventional therapy in patients with lumbar radiculopathy: Randomized controlled trial. J Med Sci Res. 2018; 6(1):11-19. 

About the Author

Dr. Brandon Steele

Dr. Brandon Steele

DC, DACO

Dr. Steele began his career at The Central Institute for Human Performance. Dr. Steele has trained with experts including Pavel Kolar, Stuart McGill, Brett Winchester, and Clayton Skaggs. He has been certified in Motion Palpation, DNS, ART, and McKenzie Therapy. Dr. Steele lectures extensively on clinical excellence and evidence-based musculoskeletal management. He currently practices in Swansea, IL and serves on the executive board of the ICS.

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