Effect of integrated neuromuscular inhibition technique compared with positional release technique in the management of piriformis syndrome

Journal Club

Authors

Affiliations

Nate Yomogida, PT, DPT

Doctor of Physical Therapy

B.S. in Kinesiology

Chloë Kerstein, PT, DPT

Doctor of Physical Therapy

B.A. in Neuroscience

¹

In 2021 conducted a single-blind randomized clinical trial

Methods

• Ethics: Declaration of Helsinki Guidelines
• Date (DD-MM-YYYY)
  • 11-11-2019
  • 12-10-2020
• Location: ?Nguru, Yobe State, Nigeria?

Blinding

• “single blind”
  • Patients: Blinded
  • Investigators: Not blinded
  • Outcome assessors: Blinded

Sampling

• Calculated sample size: 40 total (20 per group)
  • Tail (1)
  • Probability level (α―0.05)
  • Power (p―0.8)
  • Effect size (d―0.82)
  • Allocation ratio (N2/N1―1) for t-test of difference between two independent means (two groups)
• Expected attrition rate: 20%
• Final sample: 48 participants
• Sampling method: Consecutive

Eligibility

• Age: ≥19 years old
• Diagnosis: Leg or buttock pain based on Physiotherapist diagnosis using the diagnostic criteria
• Chronic: ≥3 months

Diagnosis Criteria

1. Unilateral buttock pain and radiculopathy due to spasms of the piriformis muscle or sciatic nerve compression
2. Buttock pain aggravated when sitting
3. External tenderness near the greater sciatic notch and pain with any maneuver including: Freiberg sign, Beatty test, and FAIR Test
4. Limited straight leg raising ability

Exclusion Criteria

1. Psychiatric conditions that would have made it difficult to provide consent which was decide3d using using Mini-Mental State Examinations
2. Any pathology or recent injury around the hip, sacroiliac joint, or lumbar spine
3. Limb length discrepancy (LLD)
4. Recent buttock trauma and bladder/bowel dysfunction
5. Sciatica or lumbar radiculopathy for reasons other than the piriformis: Deep gluteal syndrome or Extrapelvic compression of the sciatic nerve or sacral plexus including sciatic neuritis due to gamelli-obturator internus syndrome, pudendal nerve compression, increased mechanical stress on the innominate bones, compression of the fibular branch of the sciatic nerve, bursitis, hip impingement, upper hamstrings tendinitis, or referred gastrointestinal pain, referred pelvic pain

Demographics

There was no official statement on ethnicity or race of the participants but they were all sampled from

• Age
  • <35yo n=34
  • ≥40yo n=7
• Gender
  • male n=39
  • female n=9

Outcomes assesment

• Pain
• Sciatica via sciatica bothersome index (SBI)
• Functional Mobility: TUG
• Quality of Life: SF-36
• Hip Abduction: Goniometry
• Hip Internal Rotation

Medication

Participants were asked to suspend all pain medication during the trial.

Compliance

Compliance was monitored via monthly phone calls.

Treatment

• 2x/wk for 8 weeks
• 2 physiotherapists
  • PT#1 6 years of experience
  • PT#2 10 years of experience
• PTs switch after 4 weeks
• Patients received stretching exercises at the clinic and given an HEP to take home

INIT Treatment

Positional Release Technique

Stretching Exercises

• Piriformis Stretching
• Hamstring/Calf Stretching

Statistical Analysis

• Shapiro-Wilk test was used to assess the normality of the data
• Levene test was used to assess the homogeneity of variances among groups
• Independent t-test was used to compare measurable outcomes at baseline
• A 2-way Repeated measures Analysis of Variance (ANOVA) was used to measure the effect of INIT and PRT on pain, sciatica, functional mobility, and quality of life
  • Between Subject Variable: the interventions (INIT and PRT)
  • Within-Subject variable: Time (baseline, immediately posttreatment, and 4 months posttreatment)
• Differences between the means were considered at a 5% probability level (p<0.05) and the confidence interval (CI) value was set at 95%

Results

Pain (VAS)

# Custom theme definition
theme_vas <- function() {
  theme_minimal(base_size = 14) +
    theme(
      legend.position = "top",
      plot.title = element_text(face = "bold", hjust = 0.5),
      axis.title.x = element_text(margin = margin(t = 10)),
      axis.title.y = element_text(margin = margin(r = 10))
    )
}

Figure 1

Sciatica Bothersome Index

Figure 2

Timed Up-and-Go

Figure 3

SF-36

Figure 4

References

1.

Danazumi MS, Yakasai AM, Ibrahim AA, Shehu UT, Ibrahim SU. Effect of integrated neuromuscular inhibition technique compared with positional release technique in the management of piriformis syndrome. Journal of Osteopathic Medicine. 2021;121(8):693-703. doi:10.1515/jom-2020-0327