Issue link: https://www.massageandbodyworkdigital.com/i/82405
(3 out of 4 people who test negative, prove to have nerve root compression verifiable by other clinical means). I should mention that unless your training and licensing specifically permit you to diagnose conditions like disc issues, it is of course inappropriate to offer your client a diagnosis or even suggest an interpretation of the SLT, for a variety of good reasons. Even if you are a licensed physical therapist. chiropractor, or other professional whose scope of practice does include diagnosis, telling someone with a positive SLT that they have a 9 in 10 chance of having a disc issue is a loaded and potentially complex conversation, with the potential for inadvertent harm as well as good. For most massage and manual therapists, a positive SLT is reason to refer to a specialist for further evaluation, or to confirm that your client is already under a specialist's care. Even in these cases, knowing and using the SLT will allow you to strategize your own work appropriately. PIRIFORMIS TEST Whether or not the SLT indicates possible nerve root compression, you'll want to check for piriformis contributions to sciatic pain to further narrow down your choice of possible techniques. Although you will often see combined patterns of axial and appendicular entrapment, you'll approach each issue differently when you go to the table. Nerve entrapment by the piriformis muscle is probably the most common cause of appendicular sciatica (accounting for about 70 percent of all nonlumbar sciatic pain6 ), so this test will help identify the most likely cause of appendicular sciatic pain. To perform the test, ask your seated or supine client to pull the knee of the affected leg to their chest (Image 4). If actively bringing the knee across the midline of the body (adduction with flexion) increases sciatic pain, this indicates probable piriformis or hamstring entrapment of the sciatic nerve. Both the SLT and the Piriformis Test can be performed passively, or supine instead of sitting. Some sources suggest that including the passive and supine variations in assessment increases the accuracy of the Straight Leg and Piriformis Tests. Other sources purport that positional differences in results suggest "malingering" (purposeful feigning of symptoms for secondary gain, such as insurance benefits). In most of our practices, of course, it is a safe working assumption that we can wholeheartedly believe our clients when they report pain. WHAT YOU CAN DO Since they involve different entrapment sites and mechanisms, axial and appendicular sciatica are approached in different ways. Because many of the causes of axial sciatic pain involve instability, bone-to-bone, or whole- body patterns, direct myofascial work with axial sciatica can be quite tricky. Although there are very effective manual therapy approaches to the lumbar causes of axial sciatic pain, they often involve skilled discernment and judicious application by an experienced practitioner. While sometimes deep lumbar work can be quite helpful for someone with axial sciatic symptoms, if it is performed unskillfully, deep or overly-focused work (including active release, deep massage, direct myofascial release, structural work, or trigger point work) can in some cases worsen symptoms of lumber disc issues by inadvertently releasing the adaptations and compensations that are providing stability to an unstable spine. For this reason, many of the actual techniques for working with axial sciatica are probably beyond the scope of a journal article and are best learned in an in-person training The Straight Leg Test (SLT) can help you determine if there is likely cause for referral to a specialist. The test may indicate possible nerve root compression if: 1. Sciatic pain is reproduced between 30° and 70° of hip flexion (70° is pictured). 2. Pain worsens with ankle dorsiflexion, slumping, or neck flexion (dropping the head forward). 3. Pain is relieved by knee flexion of the raised leg. Images courtesy Advanced-Trainings.com. The Piriformis Test. An increase in sciatic symptoms when the flexed leg is brought across the body (adduction) indicates probable piriformis involvement. Boost your practice with ABMP's Website Builder—free for members on ABMP.com 113