Sciatica, Herniated Disc and Back Pain

Sciatica
Sciatica

Searching for help and the right treatment for sciatica, back pain or a pinched nerve? (Your nerve isn’t really pinched though it may be compressed from a herniated disc.)¬†Sciatica can be¬†an irritating, ¬†painful, sometimes scary,¬†condition. I want to reassure¬†you that¬†it is possible to find effective treatment to manage and heal your sciatica – at least I’ve found this to be true in my¬†20 plus¬†years working as a¬†NY physical therapist, specializing in neck pain, spine pain and sciatica.

Do you have the hallmark signs of sciatica: pain, numbness, burning or tingling anywhere from your low back to your hip or further down your leg, even all the way to your toes on one side of your body? Do you have trouble walking, sitting, or exercising because of it?

Since sciatic nerve pain is most often associated with back pain, and since the causes of low back pain are not crystal clear, neither is the cause of sciatica. If you have a history of back pain plus radiating leg pain, has your doctor performed an MRI and found you have a bulging disc or herniated disc? Were you diagnosed with lumbar radiculopathy?

Physical therapists and other medical professionals describe sciatica as a set of symptoms, not a clearly defined disorder. When a patient comes in for treatment of her sciatica, a number of questions run through my mind. Is her low back pain or sciatica caused by a bulging disc or herniated disc? Does the pain arise because of an irritated or stuck facet joint (other joints on each vertebrae)? Or is her sciatica caused by inflammation or irritation anywhere in the low back or along the sciatic nerve in that one leg? Does she have arthritis in the spine or osteophytes? Does the pain arise from a biochemical reaction to injury? Or did she develop sciatica and/or back pain after taking a fall or some other compression injury to the buttocks? Even a tense muscle can pull the spine in such a way that you experience nerve impingement. Did you know that stress and how you work with it can be a huge contributing cause to pain? Then might you want to choose a physical therapist who, in addition to giving you the best treatment possible in nyc, also gives you the time and gentle care you need so you can work through all of the factors contributing to your pain and stress?

Sciatic pain can also be because of a tight or injured piriformis. This is called piriformis syndrome. What this means is that the piriformis muscle, a muscle deep in the buttocks, may be pressing on the sciatic nerve because of your structural anatomy or because you slipped and fell on your buttocks, or because the piriformis is overworked and tight, as can happen with dancers with overworked turn out. Most of the time, both in my experience and in the medical literature, the sciatic pain in your leg originates in your low back. The piriformis muscle is likely to be tight or implicated at the same time and needs to be treated as well.

Maybe you and/or your health care providers have thought that the pain in your buttocks was a hamstring pull, or the pain in the back of your ankle was achilles tendonitis. The missing link in treating plantar fasciitis may be related to the lower branches of the sciatic nerve. Is it possible you have a hip, leg, ankle or foot issue AND the nerve somewhere in the leg is out of whack? Oh yes. I have encountered this so many times in my physical therapy practice.

If you are treated for any of these seemingly unrelated injuries Рa pulled hamstring, calf, achilles tendon, or plantar fasciitis Рand the problem still lingers, you might want to consider seeing a physical therapist who is knowledgeable and skilled at treatment of peripheral or, in this case specifically, sciatic nerve pain.

Again, stress can be a huge contributing factor in chronic pain. Huge. Most of us intuit this,¬†but we don’t know what to do about it. We also know that stress affects us physically, emotionally, mentally, or spiritually. Did you know that even your¬†beliefs about pain can affect its intensity and duration? The question is how do you work with the stress which may be exacerbating your low back pain, lumbar radiculopathy or sciatica?

This is where Yoga Physical Therapy in NYC comes in. In one-hour private  sessions, you learn to become aware of the stress in your body and then how to work with it. Your insights into your stress are gold. Here, you will be instructed in different strategies for relaxation and mindful breathing. A mashup of gentle, targeted exercises Рfrom yoga, Feldenkrais, dance, and physical therapy Рare prescribed for their healing effects. By learning to breathe with and into the pain during these gentle exercises, you are doubly empowered to decrease and manage your own stress and your pain.

What are other best¬†treatments for sciatica and back pain? Look for a physical therapist who knows neurodynamics, also known as nerve flossing or neural glides, who knows about¬†nerve massage, which together can be super effective in easing the sciatic pain. Gentle hip stretches are among the first exercises to do to soothe and open the body and mind. Maitland’s spinal mobilizations are hugely effective. So is myofascial release to the trunk, hips and leg. Often¬†yoga poses, like sphinx and cobra, are effective in the treatment of bulging and herniated discs. They don’t work for everybody. If they are the right treatment for you, they can help decrease¬†back pain and stiffness as well as relieve pressure on the sciatic nerve.

Each patient is unique and requires different treatment strategies. Therapeutic exercises need to be carefully chosen and monitored to see how they work for you at each stage of healing. I think of each exercise, carefully taught using a mindful breath, as a discreet dose of medicine. These exercises, knitted together with your ongoing feedback, are designed to ease and heal what hurts. Your feedback, questions and preferences are consulted at all stages of treatment. You set the tone and pace of your physical therapy, not the therapist. Not the insurance company.

As¬†most cases of sciatica, or lumbar radiculopathy,¬†arise¬†from the low back, the spine needs to be evaluated and treated. I find a gentle, thoughtful approach is best. Effective physical therapy treatment will work first to decrease the pain. There are stages of stretching and strengthening which come next. But first I’m concerned, as I imagine you are, too, with finding the¬†fastest and best ways to decrease your pain.

Sharon Gary, a NY physical therapist offering the best treatment practices in midtown Manhattan, will work with you one-on-one in private one hour sessions. Using these effective healing treatments, strategies and techniques, her approach with Yoga Physical Therapy has helped many people with herniated discs, low back pain, lumbar radiculopathy and sciatica.

 

The Best Way to Relax

When you are suffering from neck, back, hip or shoulder pain, even if you’re just plain tired, Constructive Rest, practiced just 10 minutes a day, is the way to go.

Constructive Rest, pictured below, is a resting position of the body, in which the arms and legs are supported rather than held by the muscles of the neck and spine. By relieving the spine of the weight of the legs at their articulation with the trunk, the pelvis, trunk muscles, fascia and internal organs are also given a chance to rest. As the weight of the arms across the chest presses into the articulation of the shoulders where they meet the trunk, chronically tight and overworked neck, shoulder and back muscles are given an opportunity to reset, too.

Basic Position: open your feet hip-width apart with the heels outside the toes in a slightly pigeon-toed position. Let your knees fall together so your legs support one another. Cross and drape your arms one over the other, resting them on your chest like empty coat sleeves. Your hands should be relaxed and open, falling off the arms.*

In The Thinking Body, Mabel Todd, who originated Constructive Rest, recommends it for “relieving the spine from strain of leg weights and favoring a return of blood to heart.”¬≤ She describes how, throughout nature, cycles of work are always followed by a dynamic pause, or rest. Different from sleep, these dynamic rest periods are intrinsic to life — from the tiniest cells to the heart, lungs, digestive and neuromuscular systems. The moment of rest and silence in the lub dub of the heart is when the heart’s atrial chambers fill with oxygenated blood in preparation for the next squeeze of the heart, which then sends newly oxygenated blood out to each and every cell in the body. It is a dynamic pause.

Lulu Sweigard, a student of Todd’s, wrote in the Human Movement Potential that “the distribution of its structural weight should balance the body so that no muscle work need be added to maintain equilibrium in the position.”¬≥ What we are seeking to accomplish with Constructive Rest, then, is to bring the body into effortless mechanical equilibrium.

Constructive Rest creates an opportunity for the spinal curves, from head to tailbone, from left to right, to relax and lengthen onto the even surface of a supportive ground. Tense muscles, tissues, joints and organs throughout the body can relax and literally unwind from the demands of maintaining an upright position against gravity.

Remember, the point is to be absolutely comfortable and use as little muscular effort as possible to maintain the position. If you don’t find this position comfortable, perhaps another variation on Constructive Rest might work better for you.

Practicing Constructive Rest only 10 minutes a day has delicious effects. By supporting your body in dynamic relaxation, you can unwind from pain and fatigue while you tune into your breath and your body, relax and let go.**

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NOTES AND REFERENCES

* Try not to forcefully bend your arms or hold your arms in place by gripping with your hands.

** Other benefits may be similar to those of meditation and yoga where lowered stress levels, decreased anxiety, lower blood pressure, decreased heart rate, improved mood and energy levels are well documented. However, to discuss these bonus effects is beyond the scope of this article.

¬Ļ Image provided by Ann F. Cowlin, Yale University, and Dancing Thru Pregnancy.

² Todd, Mabel Elsworth, The Thinking Body: A Study of the Balancing Forces of Dynamic Man,  Dance Horizons, Incorporated, 1937, p.290.

³ Sweigard, Lulu E., Human Movement Potential: Its Ideokinetic Facilitation, Harper & Row, Publishers, Inc., 1974, p. 216

Variations on Constructive Rest

In a previous blog post, The Best Way to Relax, I described the many benefits of Constructive Rest. Here, I wish to offer a few variations on the basic position, pictured at left. At different times, or because of your body type, you might find one of these variations more comfortable. And comfort is what we’re looking for here.

  • Try placing a small pillow under the head if you have a deep chest (thoracic kyphosis) or forward head. If you notice your chin is pointing towards the ceiling and your head is cocked back, you need a pillow. If you simply feel strain in your neck or back, try a pillow. It should be as small as possible to comfortably support your head and neck. The goal is to support your body’s neutral alignment in a comfortable, balanced way so that you can let go of all muscular holding.
  • If the backs of the hips are tight (this is true for many men), try lining up your knees with your hips and ankles rather than trying to force the knees together. Then cross the arms over your chest. If your legs stay in place on their own without drifting to the sides or falling open, this may be the optimal position for your body.
  • If you have a large chest, or if for any reason you are simply uncomfortable crossing your arms over the chest, try resting your arms about 45 degrees away from the trunk of your body with your palms facing up. Allow the weight of the arms to release into gravity.
  • You can loosely tie your thighs together with a scarf or theraband to keep legs from falling open.
  • If the floor feels hard or uncomfortable, try putting more padding down.
  • Sometimes a small pillow placed under the pelvis or low back may feel good.
  • Another approach to Constructive Rest is to prop the legs, bent 90 degrees at the hips and knees, onto a chair seat or sofa. Open the arms out to the sides, palms up, or cross your arms across your chest as in the basic position.

Whichever adaptation you choose, try lying in the same position for 10 minutes a day for a few days. Notice the difference in how you feel.

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* Image provided by Ann F. Cowlin, Yale University, and Dancing Thru Pregnancy.

Degenerative Disc Disease – Neck and Back Pain

Is Degenerative Disc Disease Causing My Neck & Back Pain?

At the age of 42, after an MRI, I was diagnosed with Degenerative Disc Disease. I also had two bulging and one herniated disk. I went home, crawled into bed and cried, convinced that my body was aging beyond repair, and it would be all downhill from there. That was fear. Not fact.

What I now¬†know and want to share with you is that degenerative disc disease may just be a normal part of aging, not a disease at all! “Consider the results of a major 2014 review by Brinjikji¬†et¬†al: signs of degeneration are present in very high percentages of healthy people with no problem at all. ‘Many imaging-based degenerative features are likely part of normal aging and unassociated with pain.*'”

The Bad News    

Yes, your neck or back hurts and your doctor just told you that you have a condition with the word¬†‚Äúdegenerative‚ÄĚ in it. You can‚Äôt even bend down to feed the cat in the morning because your back is so stiff and painful. Or¬†maybe your problem isn’t so much having¬†back pain, but your foot is numb. Or you have pain, numbness or tingling in your buttocks, knee or calf. It‚Äôs been going on longer than you care to admit and nothing seems to make it better.

The Good News

Remember:¬†that MRI is not the whole story. In fact studies show that there is a low correlation between a scary MRI and low back pain. “Low back pain experts have long understood that you simply cannot reliably diagnose low back pain either with MRI, or with X-ray.

Okay fine, you say, but¬†you still have¬†back pain, which is why you got the MRI in the first place. Here’s where the good news comes in.¬†You can get better. More likely than not, you can return to a completely pain-free life. With the right treatment and a few targeted exercises, you can restore¬†flexibility to your spine and become stronger than you‚Äôve ever been. You will probably need to learn a few postural adaptations, especially at your computer, along the way.

The other good news is that this is a wake-up call while you’re still fairly young. Treatment might include gentle back and hip flexibility exercises using¬†a gentle, healing¬†breath to ease your body and mind. You might learn¬†a few¬†postural tips¬†and¬†appropriate core strengthening exercises. Later your treatment might include yoga back strengthening with other exercises to make your hips and legs stronger. You might find that not only do these exercises¬†make your back feel better, you look better, too. And who doesn’t want that? With a stronger core, you might find you have more energy. (P.S. the core refers not only your belly muscles, but all of the muscles surrounding your pelvis – side hip muscles – glutei medii and minimi, the glutei maximii (your glutes), your pelvic floor and efficient, coordinated use of your breath with movement.) The strengthening usually comes after we’ve got a handle on your pain. (Beware treatments that load you up with weights for strengthening from the get go – I’ve had too many patients come to me after that kind of therapy. Their pain didn’t improve or sometimes it got worse.) Continue reading “Degenerative Disc Disease – Neck and Back Pain”

Tips to Prevent Back Injury

Tips to Prevent Back Injury – The Iliopsoas Muscle

 

You may wonder why it might be a good idea to avoid double leg lifts, whether your knees are bent or extended, if you have a history of back pain. In yogic terms, this would include boat (navasana) and its variations.

Q: Why would double leg lifts re-injure the back?

A: Because of an unequal and excessive pull on the spine and hips by the iliopsoas muscles, considered to be the primary hip flexors.

The psoas major has its origins on the spine at vertebrae T12 and throughout the lumbar spine on L1 through L5. The iliacus arises on the inside of the hip bone, the ilium. They both attach on the femur on the lesser trochanter. They also serve as important postural muscles.

Let‚Äôs look at this more closely. In almost every patient that I have treated for low back pain or injury, including sacro-iliac problems and sciatica, she also shows a curvature, or rotation, of her spine. This curvature may be an acquired scoliosis, from injury or unequal use of the body over time. Overuse of the right side of the body is common — we live in a right handed world. (Quickly, what hand are you holding your mouse with?) Or, she might have classic scoliosis, called idiopathic scoliosis, which develops in children, usually around adolesence and seems to run in families. This means that the psoas muscles, arising from your low back, are pulling unequally on either side of the curve or rotation in your spine.

Further, the legs have weight. Together, they are approximately 40% of your entire body weight. In a 150 lb. person, if one leg weighs 150 x .20 = 30 lbs., then both legs together weigh 60 lbs.

In a double leg lift, whether you are lying on your back or in the boat pose, whether your legs are bent or straight, the psoas have to move and hold 60 lbs. This is exerting a pull of at least 60 lbs. directly on your back.

Think about it. If you lift, or worse, hold in an isometric contraction as we do in navasana, that much weight on an unstable back — a back which is rotated and uneven on top of an unstable and rotated pelvis — then does it make sense that you might feel or develop pain in your back?

Remember, an unequal pull of the iliopsoas muscles will only exacerbate an already unstable situation, leading to back strain, reinjury and pain. And, we haven’t begun to mention that the different fibers of the psoas, at its multiple insertions on 5 vertebrae in the low back, pull unequally at different points in the movement cycle.

The Role of Posture in Back Pain

Part I – Coming to the Floor

Image from Gray’s Anatomy 1932

Yoga can be an excellent modality for managing and healing low back pain. Just as many poses in Yoga are ideal for healing certain kinds of back pain, other poses may make back pain worse. It depends on the nature and cause of your back pain.

I agree with Robin McKenzie, a New Zealand Physiotherapist, that poor postural habits play a big role in most back pain. McKenzie has developed a body of work that successfully treats back pain. Many of the exercises that are prescribed by the McKenzie are the same postures that can be found in many gentle or beginning Yoga classes. (Unfortunately, many of these same postures have been dropped from more advanced Yoga classes today.)

We live in a world in which we are sitting — at our desks, in front of the television, at our computers — for many hours of the day and night. We sit in slouched postures, with our spines rounded forward, our heads jutting forward (check out your posture right now). The position of the spine in this curved forward “C” position is called flexion. We have four natural spinal curves, at the neck, the thorax, the lumbar and the sacral spines which form a gentle S from the top down. However, with the demands placed on us from early childhood, when we begin to sit at uncomfortable desks, we begin to alter our natural spinal curves. We begin to lose our ability to find a neutral, or comfortable, position. We begin to slouch. We slouch when we’re sitting. We slouch when we’re standing up.

We slouch because we can’t find a comfortable position in which to counter gravity, a constant force pulling on our bodies. When we give into dysfunctional postural habits, then we end up fighting gravity, one of the strongest forces in the Newtonian universe. What happens next is that the anti-gravity/postural muscles in our necks, extending to the entire length of our spines begin to overwork. As they overwork, they fatigue. As they fatigue, they begin to hurt. It’s not that we don’t try to sit up straight, but we end up slouching because we don’t have the strength to maintain an upright position anymore. It becomes a vicious cycle.

These long muscles, the erector-spinae muscles, extend in series from the base of the skull to the sacrum. In a slouched posture, not only do they overwork and become tense, but at the same time they become over-lengthened, weak and painful. They are not able to do their jobs in holding the trunk upright against gravity. Once these muscles become weak and over-lengthened, other muscles in the hips try to compensate. The hip muscles, working to keep the body upright against gravity, depending on their placement and your anatomy, become short, tight, weak and painful.

At the same time, the Core muscles, the deep abdominal and pelvic stabilizing muscles surrounding the hips, become weak and flabby. Breathing is often shallow. With a slouched posture, the ribs are compressed in the anterior body and the diaphragm, the primary muscle in breathing, is placed in a disadvantageous position.

The body may feel tense and tired. Trying to sit or stand erectly becomes more and more difficult. Our bodies are out of balance and out of sync with gravitational pulls. The body ends up fighting gravity rather than working efficiently within the gravitational field.

How do we restore balance to our bodies?

The best way is to go to the mat, to the floor, where the body can rest into gravity, without having to fight it. The flat surface of the floor provides maximum support and feedback to a body out of sync. Once lying on the floor, you can begin to realign yourself, front-to-back, right-to-left, head-to-toe. The four spinal curves are supported. Where the spine is rotated, a common occurrence in people who suffer from back pain, it can begin to unwind.

The body craves balance. Coming into the floor, embracing gravity and relaxing into it, combined with breathing mindfully, is the beginning of healing your back pain.

 

How Yoga Physical Therapy Works With Pain

Day 2. I started this blog because I want to get the word out about NY Yoga Physical Therapy. Sometimes I come home after working with a patient who has chronic pain with a great idea that we discovered during our session, and I want to share it. So this is a way to get me started writing about the work, to explain what it is that we do in Yoga Physical Therapy.

First and foremost, I look at the body with the eyes of a Physical Therapist. The training was the best I could find for understanding the components of the human body and how it moves in space. From my background in dance and yoga, I became a Physical Therapist because I was hungry to know about muscles, joints, the nervous system, and how it all fits together. Then, by studying the pathology of injury and disease, I learned what happens when something goes wrong. My job as a Physical Therapist is to find a way to help the injured body in pain recover. These 20 plus years of working with injuries and disease have only increased my understanding and intuitive approach.

Yet as great as the Physical Therapy training was, it didn’t give me a way to deal with the whole person. Often I would find people were tense, upset and holding tension in their bodies, especially those with low back pain, upper back pain, neck pain and those with frozen and painful shoulders. (I also see people holding tension in their feet, knees and hips.) At first, I didn’t know what to do with this growing observation. I wasn’t trained in how to deal with stress and the psychological components of pain, disease and injury.

Once I consciously started practicing holistically, incorporating Yoga, mindful breath work and other holistic practices into the sessions, I began to be able to help people help themselves with the effects of stress held in their bodies Рphysically, emotionally and psychologically. The introduction of the breath, not only into the exercises, but as a separate activity in itself, began to transform the effectiveness of the therapy sessions, especially in those with chronic neck pain, upper back pain, middle back pain and low back pain.

By helping you learn how to breathe into area injury and pain, you become aware of your own experience of feelings, holding, tension and tightness in that area of the body. On a physical level, getting breath into a tight or tense area literally begins to open up the area. As the muscles relax, they loosen their hold on the bones. The affected bone(s), pulled out of line by an overactive muscle, can begin to relax back into place. When the muscle, then the bone(s), release back into a relaxed state, then the affected joint can begin to realign itself. Yes, you can learn to breathe into targeted areas of the body. As the body relaxes, or disinhibits from tension and pain, then the breath can freely move the trunk.

Secondly, blood does not flow freely through tense muscles. So another result of using a mindful breath is that it helps muscles to relax. Relaxed muscles allow blood to freely circulate through these affected muscles. With more blood flow, more oxygen gets into the area. More oxygen equals more healing. The molecules and chemicals for healing can now get to get to the injured, painful area. Not only that, but the byproducts and waste molecules from cellular respiration Рor cleaning up the debris from the injury Р is now able to move out of the area more quickly. This aids in decreased swelling, inflammation and therefore improved healing.

On the psychological level, mindful, meditative breathing is documented to lessen the effects of stress, including lowering blood pressure and decreasing heart rate. It lessens¬†the effects of cortisol, the stress hormone of the fight-or-flight reaction. As a person becomes more aware of ¬†bodily tension and learns to breathe into it, often the emotions or thinking that contributes to that tension begin to loosen their hold as well. As the mind begins to relax, so too does the body. Once the body begins to relax, so do the mind and emotions. It’s a dynamic, interactive process.

I’ve had patients thank me for helping them to identify and learn to work with the stress that is contributing to their pain and injury. Once they developed an awareness that they were holding tension in their backs, necks, feet or hips, they were able to begin working with, and begin lessening, that tension. Their pain started to go down, too.

For one patient with chronic back pain and neck pain, a sudden¬†awareness and acceptance¬†of how he held¬†tension in these areas was the turning point in his treatment. He said, “I thought about what you said last week about accepting the discomfort. And over the weekend, I got it. It was weird, but my experience of the pain changed.” He stopped therapy shortly after.

Awareness is key. So is acceptance. With aware breathing into an injury, combined with specifically targeted positioning or stretching of the body, the healing process is powerfully supported. Using a gentle and mindful breath also gives us an effective tool to support the entire healing process, body and mind. Paradoxically, acceptance of pain can reduce the anxiety and fear surrounding it, which then contributes to the relaxation of the tension that we hold because these feelings.

Sharon Gary of Yoga Physical Therapy in mid-town Manhattan can help you with this holistic, integrative approach to healing.