RU2846396C1 - Method for piriform muscle relaxation in treating lumbosacral spine dorsopathy - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: invention refers to medicine, namely to traumatology and orthopaedics, neurology, therapeutic exercises. Method for piriform muscle relaxation accompanying lumbosacral spine dorsopathy involves spasm relief of this muscle and pelvic floor muscles by doing physical exercises. Patient lies with his/her back on flat horizontal surface-support, wherein the lumbar region is adjacent to it, the legs are bent at the knee joints, the feet are on the horizontal support with the entire surface, the outer side of the ankle joint of the first-trained leg is brought above the patella region of the second-support leg, wherein area of knee joint of first leg is turned in same direction and rests with its inner side against vertical support. With both hands, the patient grasps the inner and outer thigh of the second leg so that the ankle of the first leg is above the arms in the patella. In this position, rhythmic arm movements are made to pull up the second leg, while the inner region of the knee joint of the first leg rests against the vertical support. Movement is carried out in the following directions: to the shoulder, of the same name with the trained leg; to middle of distance between similar shoulder and breast bone; to breast bone; to middle of distance between opposite shoulder and breast bone; to opposite shoulder. Each motion lasts for 3-5 seconds, its amplitude is adjusted to patient's discomfort. Exercise is repeated mirror-like for the second leg. Total time is 1-3 minutes for each leg during 3 daily exercise sessions, and starting from 4th session – 5-7 minutes; the therapeutic course is no less than 9 sessions.

EFFECT: method provides more effective medical rehabilitation of lumbosacral dorsopathy, ensured recovery and preventive maintenance of the piriform muscle function.

1 cl, 3 dwg, 2 ex

Description

The invention relates to medicine, traumatology and orthopedics, neurology, therapeutic physical training (TPT) and concerns the performance of therapeutic exercises for spasm of the piriformis muscle, including within the framework of therapeutic physical training during medical rehabilitation for dorsopathy of the lumbosacral spine (LSS), and at home in the event of spasm of this muscle in the presence of LSS dorsopathy.

Degenerative-dystrophic diseases of the spine occupy one of the leading places in the structure of all morbidity in terms of prevalence and social significance. They also account for approximately 50% of all diseases of the nervous system and about 70% of diseases of the peripheral nervous system. According to WHO, the DALY (disability-adjusted life expectancy) indicator due to back pain is constantly growing, which is facilitated by low levels of physical activity, excess body weight, constant static and vibration effects, professional overloads, etc. (WHO, 2004; Bendixen A. et al., 2007; Rubin D.I., 2007; Stovitz S.D. et al., 2008).

Diseases of the spine and joints affect both the older and younger generations. The most extensive group of diseases of the spine is degenerative-dystrophic (osteochondrosis, intervertebral hernias, disc protrusion). Vertebrogenic syndromes account for more than 65% of all diseases of the nervous system, among which the lumbar form of dorsalgia occupies 71-82%. The leading position in terms of the duration of disability among the working population is noted for back pain.

Recently, a pathogenetic focus has emerged in the treatment and rehabilitation of vertebrogenic syndromes, in which one of the main points is the need to improve blood circulation in the areas of interest. At the same time, complex conservative therapy, as a rule, does not significantly improve treatment results, even with long-term, 21-35 days, inpatient treatment.

Dorsopathy is the leading pathology among diseases of the peripheral nervous system, requiring periodic treatment and rehabilitation measures (Gurlenya A.M., Bagel G.E., Smychek V.B. Physiotherapy in neurology. - 2008). This disease has a wide clinical polymorphism, varied severity of the course, a high percentage of disability, affects the working population, which determines the special social significance of dorsopathies. However, the main complaint of patients with dorsopathies is pain in the trunk and / or limbs of non-visceral etiology associated with degenerative-dystrophic diseases of the spine and soft tissues. Recently, the term "nonspecific pain" in the back has entered clinical practice, when there is no clear cause-and-effect relationship between symptoms, physical data and visualization results. This pain is associated with musculoskeletal disorders without signs of root damage and "specific" spinal injuries. In 80-90% of cases, low back pain is nonspecific, that is, it does not have a clear pathological correlation (Casser H.R., Seddigh S., Rauschmann M. AcuteLumbar Back Pain. DtschArztebl Int. 2016 Apr 1; 113 (13): 223-34; Koes B.W., van Tulder M.W., Thomcaas S. Diagnosis and treatment of low back pain. BMJ. 2006; 332: 1430-1434). Currently, the generally accepted definition of low back pain (LBP) is pain localized between the XII pair of ribs and the gluteal folds. In the world literature, LBP is displayed as LBP (lowbackpain).

Lumbar radiculitis manifests itself not only by lumbago (pain) and lumbago (lumbago), but also by sensitivity disorders in the legs, decreased tendon reflexes and vegetative-trophic disorders. The patient may develop intermittent claudication, pain in the legs, which increases when walking, due to vasospastic ischemia of the leg when the tense piriformis muscle affects the sympathetic fibers of the inferior gluteal artery and sciatic nerve (Pukacher P.Ya. Neurological manifestations of osteochondrosis of the spine. Moscow, 1985).

In the treatment of pain syndromes in dorsopathies associated with degenerative-dystrophic diseases of the spine, various methods are used.

Traditional treatment of lumbar osteochondrosis of III-IV periods depends on the degree of neurological manifestations, symptoms and stage: remission or exacerbation. Usually doctors recommend immobilization of the lumbar region, taking painkillers, reflexology, physiotherapy and dosed physical exercises (in the remission stage) (Bogorodinsky D.K. Spondylogenic lumbosacral radiculitis. Chisinau, 1975; Shiman, A.G., Saikova L.A., Kiryanova V.V. Physiotherapy of diseases of the peripheral nervous system, 2001; Podchufarova, E.V. Treatment of acute pain syndromes of lumbosacral localization: pain syndromes in neurology, 2005; Naidin V.L. Treatment of spinal osteochondrosis using medicinal electrophoresis of caripazim, 2005).

A method for treating spinal osteochondrosis is known (RU 2164398, 27.03.2001), which involves vibrotraction on a device for vibratory traction of the spine with the patient in the prone and supine positions. In the prone position, manual action is performed with vertebrae spreading and compression on the intervertebral discs. After vibrotraction, pressure is applied to the paravertebral zones and vacuum massage is performed. Before fixing the PKOP, active traction is performed in a standing position with subsequent maximum forward bending. However, the muscular-fascial-ligamentous apparatus is in a tonic state, which forces the use of force and causes microtrauma to it, which are then reorganized into microcicatricial changes. Techniques aimed at distraction in the spinal motor segments (SMS) lead to their instability.

There are known methods of influencing with various types of physio- and mechanotherapy using devices, block trainers, acupuncture, manual therapy methods in areas of pain syndromes, PCOP, as well as directly spasmodic muscles, including piriformis (RU 2740268 C1, Nuvakhova M.B., Vygovskaya S.N., Eremushkin M.A., Vakulenko S.V., 12.01.2021; RU 2823234 C2, Stakin M.I., 22.07.2024; RU 2287317 C1, Kalabanov V.K., 20.11.2006; RU 2722936 C1, Muntyan A.M. et al., 05.06.2020; RU 2159606; RU 2356528; RU 2511650 C1, Yakusheva A.N. et al., 10.04.2014; Gavaa Luvsan. Traditional and modern aspects of reflexotherapy. Moscow: Nauka, 1990, pp. 374-376). However, the described known methods may be available only in medical institutions. Meanwhile, the patient may need to relieve pain and spasm "here and now", even at home.

Also known are methods of post-isometric relaxation (PIR) of spasmodic muscles, in particular piriformis, as part of complexes of various therapeutic effects in dorsopathies of the PKOP (RU 2367402 C1, Savin Yu.P., 20.09.2009). In this case, appropriate physical exercises are performed to stretch and relax the lumbar, gluteal muscles, the entire pelvic girdle, with the simultaneous use of breathing exercises. However, the presence of a medical specialist is usually required, and improvement is not achieved immediately.

Another well-known method of therapeutic action on spasmodic muscles in lumbar dorsopathies is post-activation stretching (PAR) of the muscular-ligamentous apparatus (RU 2237459 C2, Kalabanov V.K.). PAR is performed with an amplitude of 15-90°, using the patient's self-resistance and sports weights, starting from the peripheral parts of the patient's body and ending with the lumbar spine. However, such methods are long-term and require the participation of a medical specialist.

A method for treating intervertebral disc herniations is known (RU 2190384), which involves a relaxing massage of the back and abdominal muscles followed by longitudinal passive traction of the spine. However, this method carries a risk of injuring the nerve endings of the spinal cord, and the method requires long-term treatment.

The Kabat-Kaiser (PNF) method is known, aimed at restoring neural pathways with the restoration of feedback. This is the so-called "proprioceptive pacing" mechanism, the main principles of which are:

- performing complex movements in accordance with the natural work of muscles, for the most complete activation of the fibers of contracting muscles,

- counteraction to movement for maximum activation of proprioceptors,

- multiple repetition of movement processes, which, according to the principle of compensation, leads to the creation of new motor connections and the restoration of their conductivity,

- when performing specific types of movements, the patient must be fully focused and cooperate with the therapist.

The abbreviation PNF stands for Proprioceptive Neuromuscular Facilitation. PNF therapy helps immobilize limbs to prevent muscular dystrophy, and has been shown to be highly effective in developing contractures and eliminating joint stiffness.

The main idea of PNF is to maximally activate proprioceptors. The action potential accumulated in them eventually reaches such a value that it “frees” the nerve pathway along which the impulse transmission was disrupted, and the impulse reaches the central nervous system, which causes the inclusion of an adequate feedback mechanism.

Proprioceptive sensitivity is provided by receptors that are located in all muscles, joints and ligaments and react to stretching and compression. Information from these receptors goes to the brain, where a body diagram is formed. A healthy person in a conscious state can feel the position and movement of their arms and legs, resistance to their movement, the weight of things. Proprioception provides sensations of the position and pose of the body, the direction and speed of movement, muscle effort (muscle tone).

During PNF therapy, receptors are targeted using certain manipulations by the doctor and simultaneous movements of the patient. In this case, the brain relearns how to control the position, posture, balance and movements of the body, forms and consolidates new dynamic stereotypes, and motor activity improves (Susan S. Adler, Dominiek Beckers, MathBuck "PNF in Practice").

However, the Kabat-Kaiser (PNF) method requires multiple repetitions and, accordingly, a long time investment (months of work), which can be difficult to implement for both patients and medical professionals.

In case of PCO dorsopathy, a frequent manifestation is piriformis syndrome, the causes of which, along with PCO dorsopathy, can also be back injuries, muscle strain in the gluteal region, asymmetry of the pelvic bones with spinal curvatures, myositis, etc.

This syndrome is classified as a myofascial syndrome (MFS) - the most common pathology of the muscular-ligamentous apparatus, characterized by muscle dysfunction and the formation of local painful muscle seals in the affected muscles. According to literature, 12% of patients have experienced pain associated with MFS at least once in their lives. Musculoskeletal dysfunction was diagnosed in 5-36% of patients who sought medical help with complaints of back pain (Shostak N.A., Pravdyuk N.G. Myofascial syndrome (piriformis muscle syndrome) - approaches to diagnosis and treatment. // RMJ. 2014; 28:2022; https://www.rmj.ru/articles/revmatologiya/Miofascialynyy_sindrom_sindrom_grushevidnoy_myshcy_podhody_k_diagnostike_lecheniyu/).

There are a number of theories of the pathogenesis of MFS. The most widely accepted is the theory of ischemic muscle spasm, according to which the initial stimulus is considered to be acute or chronic muscle overload, accompanied by local blood flow disorders (arteriole spasm, venule dilation) and leading to microdamage to tissues and accumulation of inflammatory mediators that activate pain receptors, which in turn initiates a reflex contraction of the muscle, which is also maintained as a result of the release of intracellular calcium. Within the spasmodic muscle, sensitized areas of even greater muscle compaction are formed. This is how trigger points (TP) are formed, pathognomonic for MFS. In addition, long-term muscle spasm causes the formation of local fibrosis within the painful muscle. Active and latent TP are distinguished. An active TP is a direct source of pain, a latent TP is manifested by pain only upon palpation. Palpation of the TP causes pain in a distant but strictly defined place ("pain pattern"). The patient involuntarily tries to eliminate the stimulus that caused the pain - the "jump symptom", which is a characteristic sign of the MFS. The muscle in which at least one TP has formed becomes less extensible, which causes difficulty and limitation of movements involving it.

Diagnosis of MFS is based on the identification of typical signs and clinical manifestations, according to the diagnostic criteria of D.G. Simons:

I. “Big” criteria (5 criteria must be present):

1) complaints of local or regional pain;

2) limitation of range of motion;

3) a palpable “tight” band in the affected muscle;

4) an area of increased sensitivity within the “tight” cord (TT);

5) a zone of referred pain characteristic of the affected muscle.

II. “Minor” criteria (1 of 3 criteria must be present):

1) reproducibility of pain during TT stimulation;

2) tremor during palpation of the TT of the affected muscle;

3) reduction of pain when stretching the affected muscle.

The muscles most often subject to pathological changes are those that belong to the category of predominantly tonic muscles that regulate the static-kinetic function of the body: the muscle that lifts the scapula, the latissimus dorsi, the trapezius muscle, the muscle that straightens the spine, the quadratus lumborum, and the piriformis muscle.

The piriformis muscle originates on the pelvic surface of the sacrum, exits the pelvic cavity through the greater sciatic foramen, passes along the back of the hip joint, and attaches to the greater trochanter. It is responsible for external rotation of the thigh with slight abduction.

Piriformis syndrome most often accompanies degenerative diseases of the spine and sacroiliitis in inflammatory spondylopathy. In addition, it is one of the most common causes of non-vertebrogenic radiculopathy with compression of the sciatic nerve between the altered piriformis muscle and the sacrospinous ligament, as well as with the passage of the nerve through the muscle itself. This pathology is more common in women.

The clinical picture of piriformis syndrome consists of local symptoms and symptoms of sciatic nerve compression. Local symptoms include aching, pulling, "bruising" pain in the buttock, sacroiliac and hip joints, which intensifies when walking, standing, adducting the hip, and in a half-squat; it subsides somewhat when lying down and sitting with legs apart. Pain from sciatic nerve compression acquires a vegetative coloring (feelings of coldness, burning, numbness) with irradiation throughout the leg. In some patients, compression of the inferior gluteal artery and the vessels of the sciatic nerve itself leads to intermittent claudication (infrapiriform intermittent claudication). The skin of the leg turns pale. The patient is forced to stop walking, sit down or lie down.

The piriformis muscle should be palpated with the patient lying on his side or stomach. Areas of local tension can be palpated through the gluteus maximus. Spasmodic areas are most often located medial to the lateral two-thirds of the piriformis line and lateral to the medial third of the same line (an imaginary line running from the second sacral vertebra slightly medial to the posterior superior iliac spine to the greater trochanter of the femur; it corresponds to the superior border of the piriformis muscle and the posterior border of the gluteus medius muscle).

Piriformis syndrome is characterized by the presence of pain upon palpation of the upper inner region of the greater trochanter of the femur (the site of attachment of the piriformis muscle) and the sacroiliac joint (the projection of the site of attachment of the piriformis muscle).

Passive adduction of the patient's hip with simultaneous inward rotation causes pain (Bonnet-Bobrovnikova symptom). Pain spreading along the back of the leg may occur when tapping the buttock on the painful side. When affecting the lower lumbar or upper sacral spinous processes, the gluteal muscles contract (Grossman symptom). In addition, palpation reveals pain in the soleus and gastrocnemius muscles. Since painful tension of the piriformis muscle is most often associated with irritation of the first sacral root, it is suggested to perform a novocaine block of this root and novocainization of the piriformis muscle. A decrease or disappearance of pain along the sciatic nerve may indicate a compression effect of the spasmodic muscle (Shostak N.A., Pravdyuk N.G. Myofascial syndrome (piriformis muscle syndrome) - approaches to diagnosis and treatment. // RMJ. 2014; 28:2022; https://www.rmj.ru/articles/revmatologiya/Miofascialynyy_sindrom_sindrom_grushevidnoy_myshcy_podhody_k_diagnostike_lecheniyu/).

Sometimes surgical intervention is recommended, which is performed only when conservative therapy is ineffective (muscle relaxants, local anti-inflammatory and physiotherapy).

Preventive measures taken on a regular basis reduce the risk of recurrence of this syndrome.

Therapeutic exercise (TE) not only relieves the acute condition by stretching and relaxing the muscle, but also has a preventive effect. Exercises in complexes are selected taking into account the anatomy of the piriformis muscle, they also have a positive effect on the functions of the spinal muscles, legs, and overall flexibility.

Correctly performed exercises help relieve spasms, the piriformis muscle stretches, becomes more flexible and stronger. Blood circulation improves, which also improves the function of the gluteal muscles and upper thigh.

There is a set of exercises for performing at home with the syndrome of the piriformis muscle and sciatic nerve, suitable for stretching and relaxing the buttocks, helping with pain syndrome. It can be performed at any level of training, however, it is not advisable to independently choose exercises for stretching the piriformis muscle, a consultation with a medical specialist in exercise therapy is necessary.

In addition, when performing each movement, you must rely on your own feelings, monitor the absence of discomfort, pain, and not just the description of the technique. If you feel discomfort, you must stop exercising.

It is forbidden to perform more approaches than the patient's physical condition initially requires, even if the patient believes that he or she can do so many. It is forbidden to perform exercises during the acute phase of an attack due to pain. There is a high probability of causing even more harm.

Often, such exercises use the principle of isometrics, which is based on the use of muscle tension against stationary equipment without changing the position of the body. Since the muscles do not contract, the tendons take on the main load, thereby improving proprioception, since these receptors are located mainly in the tendons. With the help of isometric exercises, the muscles overcome maximum resistance and experience maximum tension in the most effective phase of movement. The duration of tension is from 5 seconds (short) to 10 seconds (long). Concentric exercises with weights can be performed in the complex, during which they stop for 5-10 seconds (isometric tension occurs).

Well-known exercises for the piriformis muscle include twisting movements (using diagonal muscle chains), flexion and extension, targeted static tension, a relaxing position of the whole body, etc. All movements should be performed smoothly, without jerking (Electronic resources: https://newneuro.ru/uprazhneniya-dlya-grushevidnoj-myshczy/; A set of exercises for stretching the piriformis muscle exercises for stretching the piriformis muscle: https://yandex.ru/video/preview/16284399713502480306, 09.27.2023; https://yandex.ru/video/preview/11559843980779718562, 11.25.2023; https://yandex.ru/video/preview/5252492698818562653, accessed 04.06.2025).

As a prototype (closest analogue) of the proposed method, we will consider a well-known method of performing exercises to stretch the piriformis muscle, disclosed in the video publication: Exercises to stretch the piriformis muscle - https://dzen.ru/video/watch/63d678a30d92eff0c10c0cd95, accessed 04.06.2025.

This well-known set of exercises includes an exercise in which the patient lies with his back on a flat horizontal support surface, with the lumbar region adjacent to the horizontal support.

The legs are bent at the knee joints, the feet are standing with their entire surface on a horizontal support. The patient brings the outer side of the ankle joint of the first - trained leg over the knee area of the second leg. In this case, the knee joint area of the first leg is turned in the same direction.

With both hands the patient grasps his shin, pulling it towards himself and remaining in this position for several seconds (or making rhythmic movements to pull the supporting leg towards himself).

However, in addition to this exercise, the complex according to the prototype method also includes a number of other exercises for more effective relaxation of the piriformis muscle.

At the same time, the patient may feel uncomfortable doing a whole series of exercises, memorizing the methods of their implementation. And the effectiveness of performing only one such exercise may be low.

In this regard, the technical task of the present invention was to create an effective method for performing stretching exercises, relaxing the piriformis muscle, aimed at obtaining an accelerated result, including in cases of dorsopathies of the piriformis muscle, causing chronic spasm of the piriformis muscle and, accordingly, chronic pain syndromes.

The technical result of the proposed invention is the restoration and prophylactic maintenance of the piriformis muscle function, including in cases of dorsopathies of the piriformis muscle, due to the smooth and dosed removal of muscle spasm, performing exercises in multidirectional vectors, even at home. In this case, a course of at least 9 proposed sessions serves as a therapeutic effect, and to consolidate the achieved result and prevent subsequent spasms of the piriformis muscle, we recommend doing the exercise regularly in the form of morning exercises. The use of different motion vectors in this one exercise allows increasing its effectiveness, even without resorting to other useful exercises. The use of additional emphasis on a vertical support enhances the effect of passive movement aimed at stretching the piriformis muscle along the proposed vectors, compared to the previously known exercises from the prototype.

To achieve this technical result, we have proposed a method for relaxing the piriformis muscle in dorsopathy of the lumbosacral spine, which includes relieving spasm of this muscle and the muscles of the pelvic floor by performing physical exercises.

To do this, the patient lies on his back on a flat horizontal support surface, with the lumbar region adjacent to the horizontal support,

the legs are bent at the knee joints, the feet are placed with their entire surface on a horizontal support,

the outer side of the ankle joint of the first leg - the one being trained - is brought over the knee area of the second (supporting) leg,

in this case, the area of the knee joint of the first leg is turned in the same direction and its inner side rests against the vertical support,

with the brushes of both hands the patient grasps the outer and inner sides of the thigh area of the second leg so that the ankle area of the first leg is above the hands, in the knee area,

in this position, make rhythmic movements with your hands to pull your second leg towards you, while resting the inner area of the knee joint of your first leg on a vertical support,

movements are performed in the following directions:

- to the shoulder of the same name as the trained leg,

- to the middle of the distance between the same shoulder and the sternum,

- to the sternum,

- to the middle of the distance between the opposite shoulder and the sternum,

- to the opposite shoulder,

and each movement is performed for 3-5 seconds,

the range of motion of pulling up the second leg with the hands - until the patient feels discomfort,

then the exercise is repeated in mirror image for the other leg,

total exercise time - 1-3 minutes for each leg during 3 daily exercise sessions, and starting from the 4th session - 5-7 minutes of exercise for each leg,

course - not less than 9 sessions.

One of the significant advantages of the proposed method of performing the exercise is also that it has a positive effect not only on the spasmodic piriformis muscle, but also on the pelvic floor muscles.

To perform the exercise, you can use a thick sports mat. If performing the exercise at home, the patient can spread the mat in the doorway and lie down on the mat so that the lumbar region is exactly at the level of the doorway. For convenience (from throwing the head back), you can additionally put a bolster under the neck.

The patient bends his legs at the knee joints, the feet are on the mat with their entire surface. Then the patient places the outer side of the ankle joint of the first - trained leg over the knee area of the second - supporting leg. In this case, the knee joint area of the trained leg is turned in the same direction and its inner side rests against the vertical support, which at home can be the vertical part of the doorway (door frame), and in a gym, for example, the horizontal bar stand.

With both hands the patient grasps the thigh area of the second (supporting) leg from the outside and inside, so that the ankle area of the first leg is above the hands. This distinguishes this exercise from the known one, in which the patient grasps the shin, during which there is a fairly strong bending of the supporting leg at the knee joint, which can cause additional discomfort to the patient. In cases where at the beginning of the exercises the pain syndrome exceeds 5 points on the VAS and the patient is elderly, it can be difficult for him to reach the popliteal area of the supporting leg with his hands. Then at the beginning of the exercises it is possible to use a wide belt or a sheet rolled into a tourniquet as a clamp, which with the help of a medical specialist is placed under the knee of the supporting leg, and the patient pulls the ends of such a clamp towards himself (Fig. 3, a, b), if necessary - a roller under the occipital region.

In piriformis syndrome, pain is observed on one side in the gluteal region (on the affected side). The patient must be tuned to the clarity and smoothness (without jerks) of movements during the exercise, as well as a sense of proportion when bringing the supporting lower limb to the patient's body and the force of impact on it. On the painful side, the adduction must be done more gently and with a smaller amplitude at the initial stage. As the pain decreases, the amplitude can be increased, monitoring the absence of pain. Thus, the patient then makes rhythmic movements with his hands to pull the second (supporting) leg by the thigh towards himself, thereby passively stretching the piriformis muscle and the pelvic girdle muscles due to the abduction and simultaneous rotation of the passive - trained leg - with an emphasis on the vertical part of the doorway or another vertical support post (Fig. 1, a-d). The amplitude of movements is until the patient begins to feel minimal pain, which corresponds to the criterion of them being uncomfortable. This corresponds to the force of performing the movement being approximately 30% of its maximum possible force. To understand and train this, the patient is offered to use a hand dynamometer - by squeezing it with his hand with increasing force, the patient learns to understand what its force of impact is from the maximum possible force. Breathing during the movements is free.

The movements are performed along the following vectors (directions):

- to the shoulder of the same name as the trained leg,

- to the middle of the distance between the same shoulder and the sternum,

- to the sternum,

- to the middle of the distance between the opposite shoulder and the sternum,

- to the opposite shoulder.

Each movement is performed smoothly, i.e. it is performed by stretching it for 3-5 seconds (bringing the leg closer to you and returning it to its previous position).

Repeating the exercise in a mirror image for the other leg, even if the piriformis muscle on the other side is not in spasm, has a preventive focus and also serves to restore the symmetry of the body's muscle chains. In addition, this helps to evaluate the effect of the exercises in dynamics, in a comparative aspect.

After performing the exercise for both sides, the lower limbs are raised up with half-bent knee joints and a light chaotic shaking of both legs is performed (Fig. 2), increasing their unloading, improving the relaxation of the muscles of the lower limbs as a whole.

At the initial stages - running in - the patient can start with a total exercise time of 1 minute for each leg. During the first 3 sessions, the total time is usually 1-3 minutes for each leg. From the 4th session, the time is gradually increased to 5-7 minutes for each leg (1-2 minutes per session).

In addition, at the beginning of the exercise (for example, during the first 30 seconds of performing the movements), especially in cases of severe pain syndrome of the patient, it is also possible to reduce the number of movement vectors of pulling up the supporting leg - to 3, namely: to the shoulder of the same name as the trained leg, to the sternum and to the opposite shoulder, with subsequent increase in the number of movement vectors to the required 5.

The course usually consists of 9 sessions. However, it can be continued - until the effect of a completely symmetrical muscle sensation is achieved when performing the exercise on the affected lower limb in comparison with the healthy side, and then - for preventive purposes on an ongoing basis. It is useful to include the exercise in the warm-up before therapeutic physical (physical therapy complexes) and sports loads on the pelvic girdle and lower limbs.

Brief description of the figures

Fig. 1 (a-d) - view of the exercise from different angles.

Fig. 2 - Performing leg shaking after performing the exercise to improve muscle relaxation of the lower limbs.

Fig. 3 (a, b) - a variant of performing the exercise with a “collar”.

Clinical examples

1. Patient E., 45 years old, male. Complaints of pain in the back (lumbosacral region) and buttocks, more on the right, when getting up in the morning after sleep or after a long stay in a static position (driving, at a desk).

On examination: lumbosacral hyperlordosis, compaction in the extensor muscles, decreased range of motion in the lumbar region, shortening of the lower leg flexors on the right (compensation of the synergist muscles to stabilize the pelvis), positive flexion test on the right, shift of the body's center of gravity to the left and anteriorly. Pain intensity on a 10-point VAS pain scale at rest is 5-6 points. Palpation of the right piriformis muscle - hypertonicity, increased pain syndrome.

Based on the results of a previously conducted MRI study, the patient was diagnosed with osteochondrosis of the lumbosacral spine, protrusion of the L4-5, L5-S1 discs.

The patient performed the proposed exercise (the first 3 sessions under the supervision of a medical exercise therapy specialist, then at home).

Each movement was performed smoothly - for 3-5 seconds (bringing the leg closer to you and returning it to its previous position).

In the first session, the patient performed the exercise for 1 minute for each leg, in the second - 2 minutes, in the 3rd - 3 minutes for each leg. From the 4th session - 5 minutes for each leg, from the 6th - 6 minutes, in the 8th-9th sessions - 7 minutes for each leg.

During the first session, due to severe pain, during the first 30 seconds for the sore and healthy leg, the patient performed movements only along 3 vectors: to the shoulder of the same name as the trained leg, to the sternum and to the opposite shoulder, with subsequent increase in the number of movement vectors to the required 5.

The pain syndrome decreased to 4 points on the VAS scale during the first session. After the 3rd session - 2 points. Completely relieved by the 9th session.

The course consisted of 9 sessions. However, the patient then continued to do the exercise at home for preventive purposes.

After 1 year - no complaints from the gluteal region, no function of the piriformis muscle. Repeated MRI examination - no deterioration in the dynamics of progression of degenerative-dystrophic manifestations of osteochondrosis and disc protrusions were detected.

Movements in the lumbosacral region and pelvic girdle are full and painless.

2. Patient E., 52 years old, female. Complaints of local pain in the lumbar region radiating to the left gluteal region and left thigh along the back surface, occurring after a long stay in a static sitting position, discomfort, tightness in the buttock, which pass after rubbing and after lying on the back on a hard surface.

On examination: lumbosacral hyperlordosis, tension, shortening of the extensor muscles, painful spasms of the gluteal muscles, VAS score - 6 points.

Palpation of the left piriformis muscle revealed localized hypertonic zones in the form of painful cords and nodules. There is a decrease in the range of motion in the lumbar region, shortening of the flexors of the left leg in the form of a compensatory reaction of the synergists stabilizing the position of the pelvis, the adductors (adductor muscles of the pelvic girdle) are spasmodically contracted; the flexion test is positive on the left, the center of gravity is shifted forward to the right.

Based on the results of an MRI study previously conducted on the patient, a conclusion was obtained about the presence of MP signs of retrospondylolisthesis L5-S1, degenerative-dystrophic manifestations of osteochondrosis of the lumbosacral spine.

Lumbosacral dorsopathy and piriformis syndrome were diagnosed.

The patient performed the proposed exercise: lying on her back on a flat horizontal support surface, the lumbar region adjacent to the horizontal support, legs bent at the knee joints, feet resting with their entire surface on the horizontal support.

At first, she placed the outer side of the ankle joint of the left leg over the knee area of the right leg, the knee area of the left leg was turned to the left and its inner side rested on a vertical support (the patient performed the first three sessions of the exercise in the exercise therapy room, using a horizontal bar as a vertical support, then the exercises were conducted at home, using a doorway).

With both hands, the patient grasped the outer and inner sides of the thigh area of the right leg, so that the ankle area of the left leg was above the hands, in the suprapatellite area of the right healthy leg.

The patient made rhythmic movements with her arms to pull her right leg towards herself while simultaneously pressing the inner area of the knee joint of her left leg against a vertical support.

The movements were performed in the following five directions:

- to the shoulder of the same name as the trained leg,

- to the middle of the distance between the same shoulder and the sternum,

- to the sternum,

- to the middle of the distance between the opposite shoulder and the sternum,

- to the opposite shoulder,

and each movement was performed smoothly - for 3-5 seconds (decreasing from movement to movement). The amplitude of movements for pulling up the trained left leg with the hands - until the patient began to feel discomfort.

Then the patient repeated the exercise in a mirror image for the right leg.

The total exercise time was 1-3 minutes for each leg during 3 daily exercise sessions, and starting from the 4th session - 5-7 minutes of exercise for each leg. A total of 9 sessions were conducted.

Already after the first session, the patient noted an improvement in her well-being, and the tension in the extensor and adductor muscles decreased. The pain score according to VAS before the sessions was 5 points. After the 4th session, it decreased to 3 points, and after the 7th, to 2 points. The pain was relieved by the 9th session.

After the 5th session, the tone of the abdominal muscles improved, the tension of the calf flexor muscles decreased, the flexion test became negative. The mood improved.

At the end of the course, the patient also noted a decrease in episodes of urinary incontinence associated with her existing climacteric syndrome (1-2 episodes per day with tension in the abdominal wall, coughing, sneezing, compared to 3-4 episodes before the course), which obviously indicates the effect of the exercise performed on strengthening the pelvic floor muscles.

The patient was advised to continue performing exercises for preventive purposes.

A year later - the achieved effects are maintained. According to MRI data, there is no deterioration.

It should be noted that the majority of patients with PKOP dorsopathy who underwent a course of the proposed exercise also noted an improvement in mood and a decrease in anxiety-depressive manifestations after the relief of pain syndrome.

Thus, the given examples show high efficiency, rapid achievement of therapeutic effect when performing the proposed exercise, demonstrate the convenience of performing the exercise for patients, since they can perform the main part of the course in normal home conditions, which also reduces the burden on medical institutions and specialists. Additionally, this exercise, according to our observations, can help strengthen the pelvic floor muscles, which is important for women with episodic urinary incontinence against the background of climacteric syndrome. The exercise is safe and does not cause any complications or negative side effects, does not worsen the condition of the PKOP.

Claims (18)

A method for relaxing the piriformis muscle in dorsopathy of the lumbosacral spine, including relieving spasm of this muscle and the muscles of the pelvic floor by performing physical exercises, characterized in that for this purpose the patient lies with his back on a flat horizontal support surface, with the lumbar region adjacent to the horizontal support, the legs are bent at the knee joints, the feet are placed with their entire surface on a horizontal support, the outer side of the ankle joint of the first leg being trained is brought over the knee area of the second leg, in this case, the area of the knee joint of the first leg is turned in the same direction and its inner side rests against the vertical support, with the brushes of both hands the patient grasps the outer and inner sides of the thigh area of the second leg so that the ankle area of the first leg is above the hands, in the knee area, in this position, make rhythmic movements with your hands to pull your second leg towards you, while resting the inner area of the knee joint of your first leg on a vertical support, movements are performed in the following directions: to the shoulder of the same name as the trained leg, midway between the shoulder of the same name and the sternum, to the sternum, to the middle of the distance between the opposite shoulder and the sternum, to the opposite shoulder, and each movement is performed for 3-5 seconds, the range of motion of pulling up the second leg with the hands - until the patient feels discomfort, then the exercise is repeated in mirror image for the other leg, total exercise time - 1-3 minutes for each leg during 3 daily exercise sessions, and starting from the 4th session - 5-7 minutes of exercise for each leg, course - not less than 9 sessions.