Soft Tissue Techniques in Piriformis Syndrome
Condition: Piriformis Syndrome
MeSH terms: Piriformis Muscle Syndrome; Syndrome
Study type: Interventional

Summary: 
      The purpose of the study is to compare the effects of active release technique and post
      isometric relaxation in patients with piriformis syndrome on pain, hip internal rotation
      range of motion and functional disability. A randomized clinical trial was conducted at Shifa
      Intl. Hospital, Islamabad. The sample size was 26 calculated through open-epi tool but were
      recruited 30. The participants were divided into two interventional groups each having 15
      participants. The study duration was six months. Sampling technique applied was purposive
      sampling for recruitment and group randomization using sealed envelope method. Only 35 to 55
      years participants with diagnosed piriformis syndrome were included in this study. Tools used
      in this study are Goniometer, Visual Analogue Scale and lower extremity functional scale.
      Data was collected at baseline, 3 weeks after sessions and after one month follow up. Data
      was analyzed through SPSS version 20.
    

Detailed description: 
      Piriformis syndrome is caused by prolonged or excessive contraction of the piriformis muscle.
      Because of the close proximity to the sciatic nerve, piriformis syndrome is associated with
      pain in the buttocks, hips, and lower limbs. Yeoman was the first to describe pain in the
      sciatic distribution to piriformis syndrome. Many synonyms for the condition are used in the
      literature, such as ''deep gluteal syndrome'' and ''pelvic outlet syndrome''. It has been
      suggested that piriformis syndrome is responsible for 5-6% of cases of sciatica. In the
      majority of cases, piriformis syndrome occurs in middle-aged patients (mean age 38 year). The
      ratio of female to male patients with piriformis syndrome has been reported as 6:1.

      Three specific conditions may contribute to piriformis syndrome:

        1. myofascial referred pain from trigger points in the piriformis muscle

        2. adjacent muscles, nerve and vascular entrapment by the piriformis muscle at the greater
           sciatic foramen

        3. dysfunction of the sacroiliac joint. Myofascial pain syndrome in the piriformis muscle
           is well recognized. Gluteal pain is reported to be observed in 97.9% of cases, pain (and
           paresthesias) in the back, groin, perineum, buttocks, hip, back of the thigh
           (81.9%),calf (59%),foot, in the rectum (during defecation), and in the area of the
           coccyx. Low back pain is reported to be observed in 18.1% of cases. Intense pain will
           occur when the patient sits or squats. Nevertheless, true neurologic findings are not
           usually present in piriformis syndrome and sensory deficits may be completely absent.

      There is no gold standard in diagnosing piriformis syndrome. The physical examination may
      reveal several of the following well-described signs:

        -  The piriformis sign, (which presents as tonic external rotation of the affected lower
           extremity) is reported to be observed in 38.5% of the patients.

        -  Freiberg's sign involves pain on passive forced internal rotation of the hip in the
           supine position, thought to result from passive stretching of the piriformis muscle and
           pressure on the sciatic nerve at the sacrospinous ligament. This test is positive in
           56.2% of the patients.

        -  Pace's sign consists of pain and weakness on resisted abduction and external rotation of
           the thigh in a sitting position . A positive test is reported to occur in 46.5% of the
           patient.

        -  Lasegue's sign involves pain on the affected side on voluntary adduction, flexion, and
           internal rotation.

        -  Beatty's maneuver is an active test that involves elevation of the flexed leg on the
           painful side while the patient lies on the asymptomatic side. Abducting the thigh to
           raise the knee off the table elicits deep buttock pain in patients with piriformis
           muscle but back and leg pain in those with lumbar disk disease.

        -  The Hughes Test (external isometric rotation of the affected lower extremity following
           maximal internal rotation) may also be positive in piriformis syndrome.

        -  Gluteal atrophy may be present.Sacroiliac tenderness is reported to be observed in 38.5%
           of the patients.

      Piriformis syndrome causing sciatica usually responds to conservative treatments, including
      physical therapy, lifestyle modification, pharmacological agents (non-steroidal
      anti-inflammatory agents, muscle relaxants, and neuropathic pain medication) and
      psychotherapy. Physiotherapy management for piriformis syndrome includes application of heat
      therapy and ultrasound therapy in conjunction with stretching of piriformis muscle shows good
      effect on treatment. Also manual therapy approaches like myofascial release (MFR), muscle
      energy technique (MET), Active release technique shows beneficial effect on the treatment of
      soft tissue. The last option is surgical intervention which involves endoscopic decompression
      of sciatic nerve.

      The Active release technique (ART) is a manual therapy used to recover function of soft
      tissue and in many ways similar to traditional 'Pin and stretch' techniques. Technique works
      on a variety of muscle, tendon, ligament, fascia and nerve tissues. In this technique deep
      pressure is applied over the tender point in a shortened position of the muscle and then
      patient is asked to actively take it in an opposite lengthened position. This will break the
      adhesions and restores the proper texture, elasticity and functions of soft tissues. There
      are a variety of studies that imply the value of ART as a treatment method for soft tissue
      injuries. ART has been used to treat nerve entrapment, tendinopathy, muscle strain, snapping
      hip syndrome, lateral epicondylitis, impaired range of motion, overuse syndrome, and improve
      performance and contributed to faster return to activity and decreased treatment time.

      Muscle energy technique (MET) is an active muscle based treatment approach that involves the
      voluntary contraction of a subject's muscle(s) in a precisely controlled direction, against a
      counterforce provided by the therapist. The MET may be used to decrease pain, stretch tight
      muscles and fascia, reduce muscle tonus, improve local circulation, strengthen weak
      musculature and mobilize joint restrictions. The MET is used for achieving tonus release in a
      muscle before stretching via introduction of an isometric contraction to the affected muscle
      producing post isometric relaxation. Post isometric relaxation (PIR) is a MET used to relax
      and lengthen a hypertonic and shortened muscle. This gentle stretching technique is typically
      used on postural muscles. These muscles often become short and tight and can lead to muscle
      imbalances. This can limit range of motion and cause joint restrictions.

      The effects of ART on gluteus medius for chronic lower back pain and concluded that ART was
      effective in reducing lower back pain.

      ART for ITB syndrome and results showed that ART decreases pain and improves function.

      The effects of Neuromuscular therapy and ART on piriformis tightness and concluded that
      significant improvement was observed in the VAS score and ROM in ART group.

      Compared the effectiveness of ART with mulligan bent leg raise for hamstring tightness and
      concluded that ART was better in improving flexibility and ROM of hamstring.

      Compared post isometric relaxation with stretching on piriformis syndrome and concluded that
      PIR technique group significantly improved in all outcome measures (pain, ROM).

      The effects of PIR technique on myofascial tightness of lumbo-pelvic musculature in patients
      with chronic low back pain and concluded marked improvement in pain and functional
      disability.

      Compared PIR technique with high velocity low amplitude techniques and concluded that both of
      the techniques are equally effective in managing low back pain.

      Compared post isometric relaxation and reciprocal inhibition and concluded that post
      isometric relaxation is more effective in treating piriformis syndrome than reciprocal
      inhibition and proposed to follow further in chronic piriformis syndrome.

      Currently there is little evidence of relative effects of Active release technique and post
      isometric relaxation in piriformis syndrome. Both techniques are found to be effective
      individually in different conditions but no research has been done yet on comparison of
      active release technique with muscle energy techniques like PIR in piriformis syndrome.
      Studies of ART on hamstring tightness shows significant immediate effects but the study was
      on healthy subjects. Effectiveness of ART is evident by one another study but only immediate
      effects were analyzed. Thus, effective long term follow up is lacking in literature. This
      present research will fill the gaps by studying the effects of ART and PIR in chronic
      piriformis syndrome and will help the clinicians with an alternative treatment approach
    

Intervention name(s): Post isometric relaxation; Active release technique alongwith conventional treatment
Intervention type(s): Other; Other
Intervention description(s): Patients in group B will receive post isometric relaxation technique. Patient lying in supine position, with the treated leg is placed into flexion at the hip and knee, so that the foot rests on the table lateral to the contra lateral knee (the leg on the side to be treated is crossed over the other). Therapist places one hand on the contra lateral ASIS to prevent pelvic motion, while the other hand is placed against the lateral flexed knee as this is pushed into resisted abduction to contract piriformis (PIR MET). The starting position will be the 1st sign of resistance towards end range. Therapist Force will be same as patient's force. Initial effort is approximately 20% of patient's strength. Duration of contraction is 7-10 seconds with three repetitions; Patients in Group A will receive active release technique.ART will be applied with patient in prone lying, knee flexed at 90. The therapist will place his elbow tip on taut band of piriformisand direct pressure isapplied, patient is then asked to do internal rotation of hip, in order to achieve lengthening of the muscle. This will be repeated 5-7 times.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Comparison of Active Release Technique and Post Isometric Relaxation in patients with Piriformis Syndrome
Masking: None (Open Label)
Primary purpose: Treatment