“. . . according to the Yoga Sutra (3.1), the term [Bandha] refers to the ‘binding’ of consciousness to a particular object or locus (desha), which is the very essence of concentration.”
Georg Feuerstein



Tuesday, December 24, 2013

Healing with Yoga: Piriformis Syndrome

Years ago I developed sciatica as a consequence of a martial arts injury. I had seen a number of doctors who finally diagnosed it as an entrapment syndrome involving the piriformis muscle and the sciatic nerve. I tried, unsuccessfully, all of the conservative methods to treat it, including physical therapy, massage, manipulation—you name it. Finally, it looked like I would either have to live with the pain or have surgery—for which there was no guarantee of success. As it happened, one day I wandered into a yoga class at the Ann Arbor YMCA.

I remember being impressed by how different (and difficult) a yoga class was, even though I was used to hard physical training from playing sports; we were working with the body in ways I had never experienced and using precise movements and muscular engagements I hadn’t seen in other exercise methods. Not only did I feel great after my first class but also, to my surprise, the next day I noticed that my sciatic pain was greatly improved. Putting two and two together, I started going regularly to classes at YMCA (and later, the basement of a church). As long as I went to class, my sciatica no longer bothered me. With this in mind, let’s take a look at piriformis syndrome.

Piriformis Syndrome:

Piriformis syndrome is characterized by buttock and/or hip pain that may radiate into the leg as a form of sciatica. This syndrome is thought to result from spasm of the piriformis which causes irritation of the sciatic nerve as it passes across (or through) the muscle. Spasm in the piriformis can be precipitated by an athletic injury or other trauma. The mainstay of treatment involves stretching the piriformis and its neighboring external hip rotators, with surgery to release the muscle reserved for recalcitrant cases. Click here to review the anatomy and biomechanics of the piriformis muscle.

Tightness or asymmetries in the piriformis muscle can create rotational pelvic imbalances. This, in turn, can lead to imbalances further up the spinal column, through the process of "joint rhythm". Click here to learn more about lumbar pelvic rhythm in our previous blog post on Preventative Strategies for Lower Back Strains. Below in the links is a reference to an article from the Osteopathic literature addressing this subject in relation to the piriformis muscle.

Figure 1 is an illustration of the relationship of the sciatic nerve to the piriformis muscle. Approximately 80% of the time the nerve passes anterior to the muscle, exiting below the piriformis. The sciatic nerve can also divide above the muscle, with one branch passing through the piriformis and another branch passing anterior. This variation occurs about 14% of the time. Other variations include the undivided nerve passing through the muscle and the divisions passing both anterior and posterior to the piriformis (without penetrating the muscle). Note that the sciatic nerve can penetrate the muscle without ever causing pain or other symptoms (as is usually the case). Persons with this variation may, however, be predisposed to developing piriformis syndrome from an injury.

Various relationships of the sciatic nerve to the piriformis muscle.

Diagnosis of piriformis syndrome is accomplished through a careful history and physical examination as well as radiological studies. The physical exam includes the FAIR test (flexion, adduction, internal rotation of the hip). Click here for an example of this test.

Note that other causes of sciatica must be excluded before making the final diagnosis of piriformis syndrome. These include a herniated disc causing nerve root compression. Similarly, pathology affecting the hip joint must also be excluded. Accordingly, if you have sciatic type pain, be sure to consult a health care practitioner who is appropriately trained and qualified to diagnose and manage such conditions.

To review, when the hip is in a neutral position, the piriformis acts to externally rotate (turn outward), flex and abduct the hip joint. When the hip is flexed beyond about 60 degrees the piriformis becomes an internal rotator and extensor (and remains an abductor). Muscles stretch when we move a joint in the opposite direction of the action of the muscle. Click here for a review of the piriformis muscle, its attachments and action, and the mechanism of Reverse Pigeon Pose (video below).

Figures 2-5 illustrate several yoga poses that stretch the piriformis. Parvritta trikonasana and the rotating version of Supta padangustasana lengthen the muscle by adducting and flexing the hip. Similarly, Parsva bakasana and Marichyasana III adduct and flex the hip joint, thus stretching the muscle (which an extensor and abductor when the hip is flexing).

Figure 2. Piriformis stretching in supta padangusthasana.

Figure 3. Piriformis stretching in Parvritta trikonasana.

Figure 4. Piriformis stretching in Marichyasana III.

Figure 5. Piriformis stretching in Parsva bakasana.

Figure 6. Supported setu bandha - a recovery pose which maintains the piriformis in a relaxed position.

Video 1 demonstrates stretching of the piriformis in Reverse Pigeon Pose. This asana stretches the muscle by externally rotating and flexing the hip.



Video 2 illustrates the technique for using mysofascial connections to protect the knee joint in this pose. Click here for the details of this technique.



Now you're ready to take the Bandha Yoga QuickQuiz for the piriformis muscle! Click here to start.

Thanks for stopping by. If you would like to learn more about combining modern Western science and yoga, feel free to browse through The Key Muscles and Key Poses of Yoga, as well as the Yoga Mat Companion series by clicking here. Many thanks for your support in sharing us on Facebook, Twitter and Google Plus!


Namaste'


Ray and Chris (illustrations)


References:
  1. Pokorný D, Jahoda D, Veigl D, Pinskerová V, Sosna A. “Topographic variations of the relationship of the sciatic nerve and the piriformis muscle and its relevance to palsy after total hip arthroplasty.” Surg Radiol Anat. 2006 Mar;28(1):88-91.

  2. Boyajian-O'Neill LA, McClain RL, Coleman MK, Thomas PP “Diagnosis and management of piriformis syndrome: an osteopathic approach.” J Am Osteopath Assoc. 2008 Nov;108(11):657-64.

  3. Filler AG, Haynes J, Jordan SE, Prager J, Villablanca JP, Farahani K, McBride DQ, Tsuruda JS, Morisoli B, Batzdorf U, Johnson JP. “Sciatica of nondisc origin and piriformis syndrome: diagnosis by magnetic resonance neurography and interventional magnetic resonance imaging with outcome study of resulting treatment.” J Neurosurg Spine. 2005 Feb;2(2):99-115.
  4. Rodrigue T, Hardy RW. “Diagnosis and treatment of piriformis syndrome.” Neurosurg Clin N Am. 2001 Apr;12(2):311-9.

  5. Papadopoulos EC, Khan SN. “Piriformis syndrome and low back pain: a new classification and review of the literature.” Orthop Clin North Am. 2004 Jan;35(1):65-71.

Friday, December 13, 2013

Preventing Yoga Injuries vs Preventing Yoga, Part III: Joint Mobility, Stability and Proprioception

A central concept in all healing arts is that of correcting imbalances within the body. The principle of re-establishing balance can be found across all cultures from Navajo sand paintings, Ayurveda, Traditional Chinese Medicine to modern allopathy.  And anything with true healing power also has the capacity to cause injury when practiced without balance. For example, joint mobility is beneficial for a number of reasons--provided it is balanced with joint stability. In this blog post I discuss the concept of joint proprioception and its relationship to joint stability and yoga, concluding with a tip for “re-setting” muscular proprioception following hip openers. 

Proprioception refers to the sense of the relative position of neighboring body parts, such as the femoral head within the hip socket (acetabulum) as well as the muscular force utilized in movement of those parts. This is in contradistinction to exteroception, which is the perception of the outside world (like the feeling of the feet on the ground) and interoception, which is the perception of the inside of the body (pain, hunger etc). I look at proprioception as a type of “GPS” for the joints.

Joint position is detected by specialized nerve endings known as “proprioceptors” that are located within the muscles, ligaments and joint capsule and the periosteum (on the surface of the bones). These receptors communicate information about the joints to the brain via the sensory columns of the spinal cord.  Conscious sense of joint position is transmitted to the cerebrum of the brain; unconscious proprioception is communicated to the cerebellum. Figure 1 illustrates this pathway in a cross section of the spinal cord. 





Scientific studies have demonstrated that joint position sense is decreased in persons with osteoarthritis, with the consideration that reduced proprioception may play a role in the development of the disease. Indeed, exercises that improve proprioception have been demonstrated to be effective in the conservative management of osteoarthritis.  

Proprioception is also reduced in persons with joint hypermobility; exercises that improve joint position sense are also effective in reducing symptoms in this population. I suspect that proprioception may be also be a factor in those having joint pain associated with subtle instability (who do not have an identifiable cause for their pain such as arthritis, hypermobility or a structural lesion). Similarly, the diminished performance seen in certain athletes following stretching routines may be related to reduced joint position sense.

I bring this up in relation to yoga because certain individuals experience soreness in their hips following hip opening poses.  Understanding that this pain may be related to decreased proprioception, I have been using a simple technique to re-establish joint position sense following these poses. For example, I worked with several practitioners during the Blue Spirit Intensive who had this type of hip soreness. Following a sequence that led to Full Lotus, we applied the technique, which “resets” the joint position sense in the hips. After the “reset”, these folks noticed that the hip pain they typically felt was gone, with this benefit remaining throughout the day.

This leads me to believe that some of the hip pain experienced by practitioners may be related to a reduction in muscular proprioception after stretching, which persists as a subtle form of instability during other activities following practice. Furthermore, the soreness appears to be relieved by a technique to increase proprioception that involves co-activating the muscles surrounding the hip joint at a midpoint of the joint's range of motion.

Here’s the technique…

Following a hip opening sequence, and before Savasana, I utilize an intermediate version of Warrior II, where the forward knee and hip are not flexing deeply (figure 2). Then I “co-activate” the hip muscles in the forward leg (co-activation involves simultaneously contracting muscles that have opposite actions). The cue for this is to imagine pressing the inside of knee into an immoveable object while at the same time pressing the outside of the knee into a similar object (the knee remains centered and does not move). This engages both the hip adductors and abductors, as well as the internal and external rotators in a position where the joint is in the mid-range of motion. Done properly, this cue should give a feeling of stability in the hip joint.

Since it is a neurological process, this technique does not require strong muscular contraction; I only utilize just enough strength to feel the muscles engage and the hip stabilize. Furthermore, the cue only requires a short duration. I have been using 20 seconds, repeated twice on each side. The effect is a bit like “resetting” a GPS that has gone out of its normal range. Figures 3-5 illustrate the muscle groups involved with the arrows demonstrating the direction of force. Visualization of the muscles helps in this process.

Figure 2: Warrior II intermediate version. I use this for training proprioception.

Figure 3: Co-activating the hip adductors, abductors and rotators in Warrior  II.

Figure 4: Co-activating the hip adductors, abductors and rotators in Warrior  II.

Figure 5: Activating the deep external rotators of the hip in Warrior II.


Thanks for stopping by. We hope that you enjoy this tip on training proprioception of the hip joint. Note that if you have persistent hip pain or other symptoms, be sure to consult a health care provider who is appropriately trained and qualified to manage such conditions. 

If you would like to learn more about anatomy, biomechanics and yoga, feel free to browse through The Key Muscles and Key Poses of Yoga. Also, check out the Yoga Mat Companion series, which contains many examples of co-activation (including the one in this post). Many thanks for your support by sharing us on Facebook, Twitter and Google Plus as well.

Namaste'

Ray and Chris



References:
  1. Wolf JM, Cameron KL, Owens BD. “Impact of joint laxity and hypermobility on the musculoskeletal system.” J Am Acad Orthop Surg. 2011 Aug;19(8):463-71.
  2. Smith TO, Jerman E, Easton V, Bacon H, Armon K, Poland F, Macgregor AJ. “Do people with benign joint hypermobility syndrome (BJHS) have reduced joint proprioception? A systematic review and meta-analysis.” Rheumatol Int. 2013 Nov;33(11):2709-16.
  3. Smith TO, King JJ, Hing CB. “The effectiveness of proprioceptive-based exercise for osteoarthritis of the knee: a systematic review and meta-analysis.” Rheumatol Int. 2012 Nov;32(11):3339-51.
  4. Sahin N, Baskent A, Cakmak A, Salli A, Ugurlu H, Berker E. “Evaluation of knee proprioception and effects of proprioception exercise in patients with benign joint hypermobility syndrome.” Rheumatol Int. 2008 Aug;28(10):995-1000.
  5. Lund H, Juul-Kristensen B, Hansen K, Christensen R, Christensen H, Danneskiold-Samsoe B, Bliddal H. “Movement detection impaired in patients with knee osteoarthritis compared to healthy controls: a cross-sectional case-control study.” J Musculoskelet Neuronal Interact. 2008 Oct-Dec;8(4):391-400.
  6. Sharma L. “Proprioceptive impairment in knee osteoarthritis.” Rheum Dis Clin North Am. 1999 May;25(2):299-314, vi.
  7. Liikavainio T, Lyytinen T, Tyrväinen E, Sipilä S, Arokoski JP. “Physical function and properties of quadriceps femoris muscle in men with knee osteoarthritis.” Arch Phys Med Rehabil. 2008 Nov;89(11):2185-94.
  8. Lauersen JB, Bertelsen DM, Andersen LB. “The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials.” Br J Sports Med. 2013 Oct 7.
  9. Caplan N, Rogers R, Parr MK, Hayes PR. “The effect of proprioceptive neuromuscular facilitation and static stretch training on running mechanics.” J Strength Cond Res. 2009 Jul;23(4):1175-80.
  10. Higgs F, Winter SL. “The effect of a four-week proprioceptive neuromuscular facilitation stretching program on isokinetic torque production.” J Strength Cond Res. 2009 Aug;23(5):1442-7.
  11. Handrakis JP, Southard VN, Abreu JM, Aloisa M, Doyen MR, Echevarria LM, Hwang H, Samuels C, Venegas SA, Douris PC. “Static stretching does not impair performance in active middle-aged adults.” J Strength Cond Res. 2010 Mar;24(3):825-30.
  12. Wu Q, Henry JL. “Functional changes in muscle afferent neurones in an osteoarthritis model: implications for impaired proprioceptive performance.” PLoS One. 2012;7(5): Epub 2012 May 14.
  13. Shu B, Safran MR. “Hip instability: anatomic and clinical considerations of traumatic and atraumatic instability.” Clin Sports Med. 2011 Apr;30(2):349-67.
  14. Smith MV, Sekiya JK. “Hip instability.” Sports Med Arthrosc. 2010 Jun;18(2):108-12.
  15. Holla JF, van der Leeden M, Peter WF, Roorda LD, van der Esch M, Lems WF, Gerritsen M, Voorneman RE, Steultjens MP, Dekker J. “Proprioception, laxity, muscle strength and activity limitations in early symptomatic knee osteoarthritis: results from the CHECK cohort.” J Rehabil Med. 2012 Oct;44(10):862-8.