Piriformis Syndrome & Sciatica in TCM

Definition

Piriformis syndrome it means '' Yaotuitong '', Pain in the waist & leg, in relation with ''Wei syndrome'' (flaccidity /atrophy of lower limbs with motor impairment

• Sciatica Symptoms is called “BiZheng 痹症” in Traditional Chinese Medicine (TCM).
• The Huang Di Nei Jin in 475-221 B.C. (The Yellow Emperor’s Internal Classic) discussed the syndrome of pain in the low back and leg.

Patients who present lumbago or sciatica symptoms in a TCM clinic are usually diagnosed as suffering from a type or a combination of the following Bi syndromes: 

• Wandering Bi(Wind) moving pain, aching in the limbs thin-white coating, superficial / tight pulse  
• Painful Bi(Cold) severe stabbing & fixed pain, limitation of movement , thin-white coating ,wiry / tight pulse  
• Fixed Bi(Dampness) numbness & heavy sensation, fixed pain & soreness , white sticky coating, soft moderate pulse 
• Febrile Bi(Heat) redness, swelling , pain & difficult movement , red body with yellow & sticky coating ,wiry / rapid pulse

TCM Aetiology & Pathology

*External traumatic history of hip or impairment of spinal cord by fracture /dislocation of vertebra
*Over strain history, Injury & inflammation of pisiform muscles
*Stimulation & compression of sciatic nerve
*Symmetric dysfunction of sensation motion & disturbance of peripheral nervous system, also have Wei syndrome (but is not from central nervous    system

1. Obstruction of Wind-cold-damp
2. Qi stagnation and Blood stasis obstructing the collaterals
3. Kidney essence & Jing deficiency
4. Qi and Blood deficiency

Syndrome Differentiations

1) Obstruction of wind-cold-damp

As a Bi syndrome, it is fixed, severe and cold pain in the lumbar region and legs. Movement is limited when bending forward and backward as well as turning. It is aggravated on cloudy, rainy and cold days.

Tongue: White, greasy coating

Pulse: Wiry and floating

2) Qi stagnation and Blood stasis obstructing the collaterals  

History of injury, Lower back pain occurs right after the injury, worse with movement, gradually radiating pain in lower limb, severe fixed prickling pain in the lumbar region and leg, aversion to pressure.

Tongue: Dark purplish, sometimes with purple spots.

Pulse: Deep, chopping, uneven 

 

3) Kidney essence & Jing deficiency

Lingering soreness and weakness of the loins and knees, lassitude and listlessness.

Tongue: Pale with white coating.

Pulse: Deep, thin, weak pulse.

4) Qi and Blood deficiency

Aging , Chronic pain on low back or leg , The pain worsen in the morning , Cold and wind or damp can made pain worsen

Tongue: white or light red

Pulse: weak and deep

Treatment Principle:

• Expel wind ,Warm cold & remove dampness , to release pain
• Dredge the channel , Activate the collateral's ,promote blood flow, remove stasis to release pain
• Tonify kidney, generate blood ,essence to strengthen tendons & nourish muscles
• Tonify qi and blood to Promote circulation of qi & blood , to strengthen tendons & nourish muscles

Acupuncture and Technique Prescription:

If the pain comes from wind-cold-damp, or blood stasis, then the points are reduced. If due to Kidney Jing Def., they receive even stimulation.

Lumbar level Hua Too Jia Ji points: These are local points located just above where the posterior branch of the spinal nerves exits the vertebrae.

·         GB 30 Huan Tiao: An extremely important point if the leg pain occurs along the GB channel. This point should be needled at least 2 cun deep, with the patient lying in a lateral recumbent position, the affected side facing up. The preferred needling sensation should radiate all the way down to the ankle.

·         BL 36 Cheng Fu: Activates the Channel, Relaxes the Tendons, With UB 36 and 37, the needling sensation should radiate down the leg.

·         BL 37 Yin Men: Moves Lumbar Region Qi and Blood Stagnation

·         BL 40 Wishing: He Sea Point, Tonifies Kidney Qi, Dispels Wind Damp

·         BL 57 Cheng Shan: Relaxes The Tendons Benefits The Leg Muscle

·         BL 60: Kun Lun: Jing River Point, Benefits The Lumbar Spine Relaxes The Tendons

·         GB 34 Yanglingquan: The Hui-converging point of tendons & muscles. The sciatica nerve is said to belong to the tendons.

·         GB 41 Zu Lin Qi: Shu stream point for heaviness and pain, especially useful for pain along the GB channel.

Evenly supplement technique, needle retaining 20 minutes, with moxibustion or heating lamp.

For Wind-cold-damp Bi, add:

·         Du14 Dazhui: (even) The crossing point of all the Yang channels, for dispelling Wind-cold-damp.

• Sp9 YinLingQuan: (reduce) He sea point. Belonging to the element of water, it is used to dispel damp.

For Blood stasis obstructing the collaterals, add:

·         Ashi points: (reduce) For Kidney Essence & Jing deficiency, add:

·         BL 17 Ge Shu: (reduce) The Hui-converging point of blood, removes blood stasis.

·    BL 23 ShenShu:(reinforce) Strengthens Essence Nourishes Kidney Yin, Strengthens The Lumbar Region

·         KI 3 Tai Xi: (reinforce) Tonifies Kidney Jing

·     KI 4 Da Zhong (reinforce) Luo point of the Kidney channel. tonifies the Kidneys and invigorates the channel

with cold compress 10 minutes apply aid if blood stasis cause pain and swelling, cold can stop pain prevent swelling aggravated then hot compress (it can regulate circulation to relieve blood stasis) for 20 minutes.

For deficiency of qi and blood, add:

• DU 20 Baihui: Meeting Point on the Du Vessel with the six yang channels. Raises Yang
• RN 6 Qihai : Mu Point for Sea of Qi, Strengthens Original Qi, Fortifies Yang, Harmonizes Blood
• RN 12 Zhongwan: Front Mu Point of the Stomach ,Regulates Qi
• SP 10 Xuehai : Invigorates Blood ,Dispels Stasis
• ST 36 Zusanli : Nourishes Blood ,Nourishes Yin ,Strengthens Original Qi
• BL  20 Pishu : backshu point,Tonifies Spleen Yang, Raises Spleen Qi

Evenly supplement technique, needle retaining 30 minutes, with moxibustion or heating lamp.

 

2. Electro-acupuncture

Prescription: Lumbar Jiaji (EX-B 2), Yanglingquan (GB 34) and Weizhong (BL 40).

Performance: After needling sensation is felt, impulse current is attached to the needles for 10 - 15 minutes; The frequency is
selected by mixed frequency-100/2; once a day to activate qi, A combination of electro-acupuncture and Tuina is the key to treat sciatica due to musculoskeletal conditions (Piriformis syndrome)

 

3. Ear Acupuncture

For additional assistance in treating the pain associated with sciatica. After the acupuncture treatment, seeds are taped into the ears to supply an on-going stimulation to these points. These seeds or even magnets are worn for a few days at a time. Ear acupuncture is an effective adjunct to acupuncture for treating sciatica pain.

   Ear point : waist, leg, kidney, sacral vertebrae, shenmen, liver ,sub cortex

4.Cupping
 The cupping therapy apply for promoting the circulation of Qi & blood , remove stasis dredge 

  the channels and collaterals to relieve pain
 using warm needle and cupping was more effective than the acupuncture alone

Others treatment added

Qi Gong (Chi Kung)

        These exercises direct the qi in the body toward the area of the body where the qi energy is either deficient or stagnant.
        Qi gong exercises are used in between acupuncture treatments.

Chinese Massage or “Tui Na”

       The massage therapy is given for twenty minutes, once per day. promoting circulation of qi 

       and blood, to reduce pain,
       Rolling, pressing/kneading and pushing were performed to relax muscles and open the    meridians.   Stretching the SI joint and hip joint

       follows the Tuina treatment duration per secession is 15 minutes.

Cautions and Contraindications

Piriformis syndrome

      * At the acute stage, Excess symptoms as follows

• severe pain in the buttock radiating to the lower limb
• difficult in walking

     
don’t use heavy manipulation (TuiNa) and traction, but you can do acupuncture and herbs.       

   

Herniated lumbar disc symptoms:

• severe low back pain
• pain radiating to buttocks, legs, and feet
• pain made worse with coughing , straining, or laughing
• tingling or numbness in legs or feet
• muscles weakness or atrophy in lateral stages
• muscle spasm

Surgery for herniated lumbar disc, if one of the following happens:

①If symptoms are very severe, if symptoms occur repeatedly for years, or if alternative treatment is not working.

②If there is central herniation, with compression to caudal equina nerves that causes sphincter dysfunction.

③If there is Nerve root compression with numbness and foot drop.

Life style Advice

1. Avoid living in humid area - save from external pathogenic factors(cold, dampness) invades into the body
2. Regular exercise - do proper physical motion such as Taichi, which activates the patient circulation of qi and blood
3. Completed and balance nutrition to sustain the functional vital organ to prevent rigidity and flaccidity of limbs
4. Be careful with daily care to keep warm for those with acute full paralysis and regular massage or others treatment
5. Balance emotion to Harmonize the spirit and stress or strain

 Case Analysis

Chief complains: Waist & Leg Pain

Asking:

She suffered from pain in the low back, the groin, into the hip, the buttocks down the back of the leg and down to the heel for 3 years , dull pain on the buttocks and radiated downward through the lateral side of leg when walk or stand up , Achilles tendinitis is a soreness and stiffness that comes on gradually ,sharp pain on the right dorsal foot ,dislike to pressure and worsen in midnight for 3 weeks ,she takes painkillers when pain coming ,Sore back , appetite is normal, prefer cold drinks if thirsty ,scanty urination , defecation still OK , no chill & fever , no headache, no trauma or injury ,She had Diabetes (type 2) under medication for 5 years history, pale tongue with thin white coating , corpulent , weak and thready pulse.

Past History: Diabetes for 5 years

Palpation: Dull pain on the buttocks and radiated downward through the lateral right side of leg and dorsal foot

Diagnosis: Piriformis syndrome

Syndrome Differentiation: Qi and blood stagnation underline spleen & kidney deficiency

Explanation:

She had Diabetes (type 2) under medication for 5 years, lower back pain for 3 years due to deficiency of the Kidney function; bones will be lack supplement and become weaker. Lumbar region is the house of kidney ,radiating pain downward to lateral side of foot due to deficiency of the Liver function, ligaments and tendons can't be maintained and will be lose strength according to the same source of Kidney and Liver in TCM theory, deficiency of  KI-essence which caused very old ages leads to KI function decline ,it fail to generate blood, she had chronic diseases it leads to deficiency of qi and blood , finally worse condition it will cause stagnation of qi and blood leads to waist and leg pain ,teeth mark , corpulent tongue body with thin white coating , week and thready pulse due to deficiency of the spleen function it fail to transport and transform blood and yin fluid.

                                                  

Treatment Principles:

• tonify KI , nourish yin , strengthen SP function
• dredge the meridians and collaterals
• promote circulation of Qi and Blood to stop pain

Select Acu-points and Manipulation:

1. reinforcing : yanglingquan, zusanli, taixi, pishu, shenshu 
2. reducing: huantiao, weizhong, chengshan

Points Explanation:

• yanglingquan: He-sea point(GB) reinforce the muscle and tendon
• huantiao: activate channel, promote circulation of qi and blood
• chengshan: Relaxes the tendons benefits the leg muscle
• taixi: yuan/shu point of KI channel to tonify Kidney Jing(essence)
• weizhong: release stasis & stagnation to stop the lumbar pain
• pishu: backshu point, Tonifies Spleen Yang, Raises Spleen Qi
• shenshu:Back Shu point of KI channel to strengthen KI and restore KI qi
• zusanli: to strengthen circulation of qi and blood, to relieve pain

Conclusion

Piriformis syndrome involves pain in the low back, the groin, into the hip, the buttocks down the back of the leg and down to the heel.

• Pain in the buttock that radiates down the leg is commonly called sciatica. The most common cause for sciatica is irritation of the spinal nerves in or near the lumbar spine. Sometimes the nerve irritation is not in the spine but further down the leg.  
• One possible cause of sciatica is Piriformis syndrome. Piriformis syndrome can be painful, but it is seldom dangerous and rarely leads to the need for surgery.

Effects of Acupuncture and TuiNa
    * Balance body energy.
    * Adjustment hormones.
    * Relieve pressure (decompression).
    * Reduce pain.
    * Increase blood circulation in particular areas.
    * Activate the acupuncture channels (meridians).
    * Alleviate muscle spasm, relax muscles.
    * Repair damaged soft tissue.
    * Adjust joints.

Rehabilitation and Prevention

   * During recovery from lumbar disc herniation, focus on muscle exercise of abdominal and 

      lower back that  can balance the vertebral column and prevent herniation.
   * Avoid carrying heavy things.
   * Periodic treatment (acupuncture or TuiNa or massage) for lower back.
   * Calcium oral supplement to prevent osteoporosis