Piriformis Syndrome & Acupuncture
The symptoms of piriformis syndrome are mainly pain deep in the buttocks which may possibly refer along the sciatic nerve down to but rarely below the knee. This pain is typically worse when sitting, climbing stairs, walking, running, and doing squats. Pain is located in the middle of one side of the buttock and is often worse when getting up from bed. There is usually direct tenderness in the region of the piriformis tendon over the buttock region, and some women may experience labial pain or dyspareunia. The right leg is often affected after driving long distances when the foot has been externally rotated on the gas pedal. Similarly, the foot on the affected side is often externally rotated when relaxed. The Western medical diagnosis of this condition is mostly a diagnosis of exclusion. It is based on the symptoms and physical examination, with x-rays, MRIs, and nerve conduction tests used to exclude other diseases. The differential diagnosis of this condition includes hamstring injury, lumbar disk herniation, lumbosacral facet syndrome, lumbosacral radiculopathy, spondylolithiasis, spondylolysis, and sacroiliac joint injury or subluxation. It is estimated that six percent of all patients with sciatica have piriformis syndrome. In any case, this is a difficult condition to diagnose and it is resistant to treatment.
Western medical treatment of this condition consists of 2-3 weeks of rest from sports and activities which cause pain. Physical therapy may be used to strengthen the unaffected opposing muscles, and anesthetics, such as lidocaine and bupivacaine, may be injected locally at trigger points. Other therapies to consider include correction of any running flaws and stretching. Full return to activities may take 2-3 months. In some cases, cortisone is injected locally, and surgical exploration may be recommended in nonhealing cases.
Wu Han-yang of the Dong Tai Municipal People’s Hospital in Jiangsu published an article titled, “A Survey of the Treatment Efficacy of Treating 80 Cases of Piriformis Syndrome with Multidirectional Needling.” This article appeared in issue #9, 2002 of Ji Lin Zhong Yi Yao (Jilin Chinese Medicine & Medicinals) on page 47-48. Because Western medicine finds this condition recalcitrant to treatment, a precis of this article appears below.
Cohort description:
Altogether there were 160 patients in this study which was conducted from 1990-2001 in the outpatient ward of the Chinese author’s hospital. Among these, 113 were male and 47 were female. These patients were 16-68 years of age, with an average age of 39.5 years. The course of disease had lasted from as short as two days to as long as seven years. Ninety-six patients had a history of external injury, 53 patients had suffered from contraction of wind cold or cold dampness, eight had a history of chronic taxation detriment, and the original cause of this condition in three patients was unclear. All these patients had one-sided buttock pain. In 125 cases, it was right-sided, while in only 35 cases it was left-sided. these patients were randomly divided into two groups, a so-called usual or one-directional acupuncture group and a so-called multidirectional acupuncture group. In terms of sex, age, disease duration and condition, there was no marked statistical difference between these two groups.
Treatment method:
In the multidirectional acupuncture group, patients were mainly needled at Huan Tiao (GB 30), Zhi Bian (Bl 54), and a shi points on the buttocks. These were needled with three inch 28 gauge needles which were inserted and manipulated with both hands. The heads of these needles were directed toward the site of the pain. Then the needles were twisted causing relatively strong soreness, numbness, distention, and pain which radiated down the sciatic nerve and up into the back. Then these needles were withdrawn and reinserted into the muscle with the tip of the needle pointed successively up, down, right, left. After this, three cones of warm needle moxibustion were burned on the handles of the needles. At the same time, needles were inserted into Yang Ling Quan (GB 34), Wei Zhong (Bl 40), Cheng Shan (Bl 57), Fei Yang (Bl 58), and Kun Lun (Bl 60). These were manipulated with even supplementing-even draining or draining hand technique. These needles were retained for 20-30 minutes and then removed. Treatment was given once every other day or once per day in acute cases, and 10 treatments equaled one course of therapy. The members of the conventional or unidirectional acupuncture group received acupuncture at the same points for the same amount of time. However, the points on the buttock region were not needled with the multidirectional technique but were simply inserted perpendicularly.
Treatment outcomes:
After four courses of therapy, 63 members of the multidirectional acupuncture group were judged cured, 16 cases got a marked effect, and only one case got no effect. In the conventional or unidirectional acupuncture group, 50 cases were judged cured, 25 got a marked effect, and five got no effect. Therefore, the cure rates were 78.8% and 62.5% respectively. However, in terms of total effectiveness rates, there was no significant difference. Where there was a significant difference was in the number of acupuncture treatment necessary to achieve a cure. Of the 63 patients cured in the multidirectional needling group, six cases were cured with one course of treatment, 31 were cured in two courses, 21 were cured in three courses, and five required four courses. Among the 50 cases cured in the unidirectional needling group, only one case was cured in one course, 18 were cured in two courses, 25 were cured in three courses, and six were cured in four courses. Therefore, 58.7% of those who were cured in the multidirectional acupuncture group were cured in 1-2 courses of treatment, while only 38% of those cured in the conventional acupuncture group were cured in two courses. Thus the course of treatment necessary to affect a cure was statistically shorter using the multidirectional needling method.
Discussion:
According to Dr. Wu, needling a single acupoint in multiple directions is a technique which is found as early as the in the Nei Jing (Inner Classic). Dr. Wu quotes the Ling Shu (Spiritual Axis) chapter titled “Needling the Officials” as saying, “Waggling needling means first needling perpendicularly, [then] lifting [and needling] front and back, [then] waggling [side to side] sinew tension in order to treat sinew impediment.” This type of needle technique soothes the sinews and relaxes spasm, frees the flow of the network vessels and stops pain. It very pronouncedly transports and moves the qi and blood in the diseased area. In this case, this technique is used to relax spasm and contracture of the piriformis muscle, reduce relative hyperemia and edema, and to loosen and resolve adhesions. This is based on the idea that piriformis syndrome is a species of sinew vessel impediment obstruction due to qi stagnation and blood congelation. Because there is no free flow, there is pain.
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