Feldenkrais and ‘sciatica’

I am often asked ‘can Feldenkrais help Sciatica?’ or ‘do you have experience with sciatica?’ And as it is around a lot I thought I would write something about it since it can also help illustrate more generally how a Feldenkrais Teacher might approach an issue like that. I am boringly likely to answer those first two questions by saying, ’well I have experience of people who have sciatic pain’ or ‘I have clients who experience/used to experience back pain and/or sciatic pain.’ It sounds like one of those annoying semantic quibbles but actually it is very to the point because while we can make some generalisations about sciatica and back pain – and argue about definitions – when you get down to the real nitty gritty of it no one has back pain or ‘sciatica’ in the same way or for exactly the same reasons/causes and people respond to their pain differently and have different lives that enable them to help themselves to different degrees – so are you ‘treating’ a condition called ’sciatica’ or simply  working with a person who has pain in which the sciatic nerve may be involved?

Making that difference is a significant  part of understanding the difference in a Feldenkrais Teacher’s approach which we will come back to, but firstly we should perhaps consider what sciatica actually is. There are arguments over definitions, but perhaps the simplest way is to say what it feels like: pain (or sometimes numbness) that radiates down the back of the buttock and leg and can even travel under the foot. It may or may not include back pain. The pain may just be occasional tingling or sudden shocks or it may be a dull ache or it may be a burning or even terrible grinding pain. It gets its name from the sciatic nerve which is the nerve that is formed by the nerves exiting the spinal column in the bottom of the lower back and sacrum and it runs down the through the pelvis, the big muscles in the buttock and down the back of the leg and under the foot (changing its name along the way but never mind.) There are actually specific diagnositic tests to differentiate sciatica form non specific kinds of back pain but we can take this as what people generally mean by ‘sciatica’.The generally given reason for the pain is that somewhere along that route the nerve is being compromised (squashed) or impinged on (touched) – most often (according to studies) at the root ie where it exits in the lower back (hence the link to lower back difficulty or pain) but it could be in the pelvis, or in the muscles around the pelvis/hip joint. It is often said that stubborn cases of sciatica are harder to shift than low back pain.

One approach (often very successful) is to look at the structure and to attempt to diagnose where the nerve is being impinged on/compressed and then to take steps to prevent that impingement/compression either through surgery or other ‘conservative’ treatments such as physiotherapy, osteopathy, chiropracy or perhaps structural integration. The diagnosis could be that damage to a disc or to vertebrae or some kind of calcification in the exit holes (foramina) of the sacrum is resulting in pressure on the nerve, or that one or other set of muscles in the lower back or within the pelvis are tightening or spasming and compressing the nerve and so either some kind of surgery to ’tidy up’or remove whatever is deemed to be pressing on the nerve is carried out and/or a treatment to work with the muscles in the area to rebalance them or re-align the vertebrae and release the stranglehold around the nerve. I would call these structural approaches with basically a mechanistic solution ie fix the structure to relieve the pain. Alangesics or steroid injections might also be used for symptomatic relief. A study in BMJ ‘Diagnosis and treatment of sciatica’ 2007;334;1313-1317 B W Koes, M W van Tulder and W C Peul covers a lot of the ground and shows that many cases of sciatica resolve themselves within a few months, but that for longer term cases many ‘conservative’ treatments (especially injections) do not fair well in trials. But it also quotes a large more recent trial which found both conservative treatments and surgery had a good rate of recovery and that while surgery had a quicker outcome, the results months and years later were much the same. Other studies favour surgery, but it is easy to find anecdotal evidence (some of which is also in the BMJ study) for much less successful outcomes where pain returns after initial relief.

However, there are also some interesting studies that cast doubt on whether impingement is the issue as often as thought. There is an interesting study in New England Journal of Medicine 1994 “Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain” (brought to my notice by Ralph Strauch GCFP) in which spinal MRIs were performed on approximately 100 active, symptom-free adults ranging in age from the mid-50s to the mid-80s, then sent to radiologists for blind interpretation. Roughly half showed sufficiently severe spinal abnormalities that, if the MRI had come from a patient complaining of back pain, the abnormality would have been identified as the source of the pain. (abstract: http://content.nejm.org/cgi/content/abstract/331/2/69) Given these people had no pain despite having the same kind of abnormalities that are usually given as the cause of pain, it could also suggest that we can’t be sure impingement of the sciatic nerveis the cause when there IS pain or that the surgery or physio works by reducing the impingement. The eminent pain specialist Patrick Wall points out in his book ‘The Science of Suffering’ (p122) that a placebo trial for a procedure that injected a fluid into the spine to dissolve a protruding disc showed a very high rate of recovery simply by injecting a totally innocuous fluid instead. Another trial for a procedure that was intended to burn away the bulging tissue showed that a needle wired up to produce just the right amount of heat to destroy the tip of tissues was no more effective than a needle without sufficient heat.  We are beginning to discover the dynamic nature of chronic pain, how it builds up and that it is not necessarily directly linked to tissue damage (increase of area sensitive to pain receptors, increase of the neuro-transmitters for pain and lowering of the threshold for triggering pain, longer term changes within the central nervous system for example) and so it may be that these approaches work by simply disturbing the tissues and interrupting the pain cycle in that way. (p123 and elsewhere in work of Melzak and Wall)

I don’t have the answer any more than anyone else but I hold these different possibilities in mind when I work.  In any case, from the evidence of who turns up in my studio it is clear that while these approaches are often successful for whatever reason, they don’t always work for everyone. Some come because they have tried one or more of these approaches and in their case it hasn’t worked; some are on a hunt because they have got to a point that surgery is suggested as the only possibility and they don’t want to go that route unless they really have to and some are simply looking for a different, more educational, less mechanistic kind of approach because that is what interests them.

So what do I, as a Feldenkrais Practitioner, do that is different? Well for a start I am not a medic and I am not trying to diagnose. If they want (or seem to need) that approach I will send them back to the medics. As a Feldenkrais Practitioner I am looking at how this person is, how they move, hold themselves and respond. I am looking (and feeling) to discover – and enable the person to discover – the way they function, the patterns they have developed and preferred on the assumption that while in many ways these patterns may have served them well in their lives, in some way these patterns also contain the reason for the pain. It may also be that there are layers of patterns that have built up around and in response to the initial pain which are not, in fact, helping and may well be part of producing more pain. In fact I have worked with someone where probably a good 50% of the pain could be attributed to these secondary patterns – although sciatica was just a side show in that particular case!.

I think in terms of ‘habits of pain,’ allowing in my mind for that to be habits of muscle activity that might be compressing the nerve or causing a vertebra to or disc to be disrupted and so impinge on the nerve, or for it to be a dynamic cycle of pain that has built up and needs re-calibrating or for it to be more a habit of expecting anticipating and possibly even setting up the trigger for pain at a different level (or, as is most likely, I think, a mixture). In general therefore I would like to work without triggering pain if I possibly can, both to offer relief and to remind the person that this is possible and that pain is not inevitable or necessary. This may seem obvious but actually it is not always how methods work: some can involve extremely painful palpitation of ‘tight’ muscles or ‘trigger points’ for release.

As I work I am looking, for example, at how the person’s weight drops down through the skeleton into the pelvis, and then through the hips, legs, feet to the ground. I am asking what is going on in the ribs upper spine that may affect how they weight-bear. I am even, and often very crucially, asking how they carry their head as this is a very significant part of which leg we carry our weight over (something the Alexander teachers know so well). Sometimes there is more weight and a more compacted feel on the side where they feel the pain and the job can be to enable them to learn how to stand and move with a more equal distribution and so I may spend quite a lot of time (surprisingly to the client) working with the pain free side to improve it so it does its share of the work better and relieves the other side. Sometimes the pain is on the looser side that cannot find its support so well. I will be looking at how the person uses their back as a whole to see if we can find a better organisation so that the lower back doesn’t need to hold so tight or do whatever it is doing that might compromise the root of the nerve or be part of a ‘habit of pain’. That may involve spending quite a lot of time with the ribs and chest so that it can learn to participate more fully in the movement of the back and allow the lower back to find a better place. In turn that may involve working with breathing so that the client can feel how the ribs and chest need to move with the breath –sometimes they have become a little stuck in the position of an in-breath and just feeling how the ribs can come down on the out breath and so not keep pulling on the upper lumber spine all the time can make a big difference to the level of ease and free up possibilities for movement. And of course I will be looking at clarifying how the leg and back work together both in the specific way the hip joint is working but also in how the lower leg bones and ankle are involved and the way the leg and back relate through the movement of the pelvis and lower back. I will be looking to help them find a different way of using themselves and using the support of the skeleton and the ground so that muscles that habitually – and unnecessarily – tighten to hold them up don’t feel the need to do so to keep them safe any more.

I can’t enumerate all the ways I would work as It really depends on what is going on with the person, and other Feldenkrais Teachers will have different takes and insights on how to work – but those are a few examples

 

Does it work? We have no studies as far as I am aware specifically for Feldenkrais and sciatica though there are two for back pain which are both positive (see my research list on the site). In my experience it depends, obviously, on the practitioner’s level of skill – but also very importantly on the client/student’s state of being and what is going on as part of their ‘sciatica’. If they can stick with the work and integrate it over time, if they can really feel and do what that may mean for their life and the way they respond to it, yes it can and does work. I hope some of those people get to read this and add their comments and experiences. Sometimes it doesn’t take a lot to shift a pattern enough to improve enough to be free of pain. Sometimes – and with stubborn cases of ‘sciatica’ this can be especially true –  it may take considerable time as there may be a deep investment in some of the physical and emotional patterns involved that is very difficult for the person to shift even with great application and diligence. Sometimes it is a case of finding ‘enough’ improvement to be better ‘enough’. The wonderful thing about Feldenkrais is that it is about learning and not fixing so time spent with it always brings discoveries and is never wasted.

However. There are some important caveats. I should add that one study I saw found that 16% of sciatica can be caused by gynaecological issues which is important to remember. Feldenkrais might be able to help with secondary muscular activity to help relieve pain from these kind of conditions but something like endometriosis for example is a condition that primarily needs a medical approach. There are also (rare) occasions when the pain is caused by a tumour so it is always important for persistent pain to be investigated medically as well.