Graston Technique in Deep Gluteal Syndrome
Condition: Deep Gluteal Syndrome; Piriformis Syndrome
MeSH terms: Piriformis Muscle Syndrome; Sciatica; Syndrome
Study type: Interventional

Summary: 
      Deep gluteal syndrome describes the presence of pain in the buttock caused from
      non-discogenic and extrapelvic entrapment of the sciatic nerve. The Graston Technique (GT) is
      a kind of manual therapy technique known as soft-tissue instrument-assisted mobilization.
      Instruments help to perform massage/scraping of the skin and miyofascia gently. The aim of
      this study is to investigate additive effect of GT applied to the lateral and posterior
      fascia to the exercise program in patients with deep gluteal syndrome on pain and disability.
    

Detailed description: 
      Deep gluteal syndrome describes the presence of pain in the buttock caused from
      non-discogenic and extrapelvic entrapment of the sciatic nerve. Several structures can be
      involved in sciatic nerve entrapment within the gluteal space [1]. There are many anatomical
      variations between the sciatic nerve and piriformis muscle (PM) [2]. Some authors have
      associated deep gluteal pain syndrome with piriformis syndrome (PS) [3]. Chronic buttock pain
      caused by the musculoskeletal pathologies of the PM such as myofascial pain or pinching of
      the sciatic nerve by the PM during certain leg and hip maneuvers [4]. In most cases, PS is
      widely believed to be myofascial in origin [5].

      Treatment of PS starts with conservative pharmacotherapy with nonsteroidal anti-inflammatory
      drugs, muscle relaxants, and neuropathic pain agents and continues with physical therapy,
      which includes stretching of the PM to correct the underlying pathology [6]. If the
      conservative regimen fails, then more aggressive therapy, such as local injection of PM,
      which may reconfirm the diagnosis through therapeutic success, should be performed [7].

      Myofascial release is a specific manual therapy method claimed to be useful for treating
      skeletal muscle immobility and pain by relaxing contracted muscles, improving blood, oxygen,
      and lymphatic circulation, and stimulating the stretch reflex in muscles [8]. The Graston
      Technique (GT) is a form of manual therapy known as soft-tissue instrument-assisted
      mobilization. It is one of a number of manual therapy approaches that uses instruments with a
      specialized form of massage/scraping the skin and miyofascia gently [9]. This technique seems
      to have the therapeutic effects of inhibiting the adhesion of tissue, increasing the number
      of fibroblasts, and promoting collagen synthesis [10].

      Gait analysis has been widely used in the diagnosis of locomotors pathology and the
      assessment of treatment. But study of gait on deep gluteal syndrome remain unclear. 3-D
      motion analysis can be used to measure the kinematic and kinetic together with
      temporal-spatial parameters data of patients with deep gluteal syndrome during walking.
      Patients with deep gluteal syndrome show significant increase gait speed and cadence, and
      peak extensor moments with increased flexion, abduction and internal rotation at the hip
      during the whole gait cycle [11].

      Shear Wave elastography is an imaging technique which quantifies tissue stiffness by
      measuring the speed of shear waves in tissue. It is a new advanced dynamic ultrasound
      technique that provides information about the stiffness / consistency of the tissue by
      measuring the degree of strain in the tissue without external force [12].

      The aim of this study is to investigate the additive effect of GT to the exercise program in
      patients with deep gluteal syndrome on pain and disability.
    

Intervention name(s): Graston; Sham
Intervention type(s): Device; Other
Intervention description(s): Graston technique will be applied on the lateral and posterior fascia (tensor fascia lata, gluteus medius, gluteus minimus, gluteus maximus, hamstring, gastrocnemius and soleus muscles) in 15 minutes.
For the first 2 weeks; dorsolumbar stabilization, straight and side leg lifting, gluteal setting, side walking exercises For the second 2 weeks; dorsolumbar stabilization counting on spot, straight and side leg lifting, gluteal setting, side walking exercises with 0.5 kg weight on the ankle, piriformis, tensor fascia lata and hamstring stretching exercises; Sham graston technique will be applied on lateral and posterior fascia (tensor fascia lata, gluteus medius, gluteus minimus, gluteus maximus, hamstring, gastrocnemius and soleus muscles) in 15 minutes.
(Sham graston technique will be applied by partially touching the skin overlying the muscle or fascia region via ultrasound gel with the flat part of the Graston instrument so as not to provide any activity of the fascia) For the first 2 weeks; dorsolumbar stabilization, counting on spot, straight and side leg lifting, gluteal setting, side walking exercises For the second 2 weeks; dorsolumbar stabilization counting on spot, straight and side leg lifting, gluteal setting, side walking exercises with 0.5 kg weight on the ankle, piriformis, tensor fascia lata and hamstring stretching exercises
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Treatment
Keywords: deep gluteal syndrome; graston; elastography; piriformis syndrome; miyofascial release