Journal of Back and Musculoskeletal Rehabilitation 33 (2020) 983–988 983

DOI 10.3233/BMR-181290
IOS Press

Effects of ELDOA and post-facilitation

stretching technique on pain and functional
performance in patients with piriformis
syndrome: A randomized controlled trial
Momena Shahzad, Nazish Rafique∗ , Syed Shakil-ur-Rehman and Syed Ali Hussain
Riphah College of Rehabilitation Sciences, Riphah International University, Islamabad, Pakistan

Received 30 May 2018

Accepted 31 January 2020

Abstract.
BACKGROUND: Piriformis syndrome (PS) is a neuro-muscular condition, which is often underdiagnosed in clinical settings.
This study will determine the effects of myofascial stretching Elongation Longitudinaux Avec Decoaption Osteo Articulaire
(ELDOA) and post-facilitation stretching of the piriformis muscle in patients with PS.
OBJECTIVE: We aimed to compare the effects of ELDOA and post-facilitation stretching of the piriformis muscle on pain,
muscle length and functional performance in patients with PS.
METHODS: A randomized clinical trial was conducted with 40 PS patients including both males and females, between the ages
of 30–70. Patients were randomly assigned to the ELDOA or post-facilitation group after assessments with the Numeric Pain
Rating Scale (NPRS), Lower Extremity Functional Scale (LEFS), Piriformis Length Test and Straight Leg Raise (SLR). The
assessments were done at baseline and at the end of the sixth week of treatment.
RESULTS: The patients treated with ELDOA demonstrated significant improvement in pain (pre = 7.00 ± 2.75, post = 3.00 ±
1.75), piriformis length (pre = 27.6 ± 5.54, post = 36.8 ± 3.13), SLR (pre = 36.40 ± 7.24, post = 67.5 ± 8.36) and LEFS (pre
= 26.90 ± 12.24, post = 58.10 ± 8.62), as compared with the group treated with post-facilitation stretching: pain: pre = 6.00 ±
1.00, post = 2.00 ± 1.50; piriformis length: pre = 28.55 ± 4.03, post = 38.8 ± 2.70; SLR: pre = 40.60 ± 7.48, post = 74.25 ±
5.19, and LEFS: pre = 25.20 ± 7.66, post = 66.30 ± 7.27).
CONCLUSION: It can be concluded that the post-facilitation stretching technique shows more improvement in pain, muscle
length, SLR, and LEFS in patients with PS as compared to ELDOA.

Keywords: Muscle energy technique, myofascial stretching, piriformis syndrome, functional performance, post-facilitation
stretching, Lower Extremity Functional Scale (LEFS)

1. Introduction foramen [1]. It results in gluteal region pain, numbness

and tenderness, which may radiate down to the ipsilat-
Piriformis syndrome (PS) is a neuromuscular dis- eral lower limb [2]. It is regarded as one of the most
order that causes sciatic nerve entrapment by the piri- common causes of non-discogenic or extra spinal sciat-
formis muscle, while exiting through the greater sciatic ica [3] and should be considered as a possible diagnosis
if sciatica occurs without any clear spinal pathology [4].
∗ Corresponding
Since keeping a wallet in the back pocket of jeans is
author: Nazish Rafique, Riphah College of Reha-
bilitation Sciences, Riphah International University, Islamabad, Pak- considered to be a predisposing factor, it is also known
istan. Tel.: +92 3002132436; E-mail: [email protected]. as wallet sciatica or back pocket sciatica [5].

ISSN 1053-8127/20/$35.00
c 2020 – IOS Press and the authors. All rights reserved
984 M. Shahzad et al. / Effects of ELDOA and post-facilitation stretching technique

PS has a prevalence of 6% in the general popula- In 2016, Marques et al. conducted a randomized con-
tion [6] and mostly affects women, with a female to trolled trial (RCT) that showed that MET results gained
male ratio of 6:1, possibly due to the wider Q angle in greater flexibility in comparison to self-stretching [15].
females [7]. PS commonly occurs during the fourth and In a quasi-experimental study conducted by Clement
fifth decades of the life span [5]. PS accounts for 6–8% (2016), ELDOA showed improvement in range of mo-
cases of sciatic pain [7] and is responsible for 5–6% tion and flexibility, and also decreased physical ten-
cases of chronic low back [8]. sion and anxiety [16], whereas in 2014 Talapalli and
Boyajian-O’Neill et al. reported two types of PS: Sandeep concluded that MET (PFS) is more effective
primary and secondary PS. In primary PS, PS occurs than PIR in reducing hamstring muscle tightness and
as a result of an intrinsic defect (anatomic cause) of improving popliteal angle range [17]. According to a
the muscle itself (e.g. split piriformis muscle) or sciatic systemic review by Joseph and Arthur, the muscle en-
nerve anatomical variations. Primary PS accounts for ergy technique seems to be more beneficial in decreas-
less than 15% of cases among PS patients. In secondary ing pain that lasts more than 24 hours and minimizing
PS, the piriformis muscle abnormality (e.g. inflamma- disability that lasts more than four weeks in low back
tion or hypertrophy) results from predisposing factors, pain patients [18].
which involve the local ischemia effect, ischemic mass All previous studies in which the post-facilitation
effect, micro or macro trauma, excessive exercise and stretching technique has been performed on different
altered biomechanics (e.g. leg length discrepancy) [9]. muscles, have shown greater improvement in compari-
In this study, we focused on treating piriformis muscle son to other techniques. However, the post-facilitation
tightness or hypertrophy due to which the sciatic nerve stretching technique and ELDOA have never been com-
is compressed. We have therefore selected patients with pared and performed to the piriformis muscle. There-
secondary PS. fore, the current study was designed to compare the
PS is characterized by the following symptoms: pain effects of myofascial stretching ELDOA and post-
during walking (e.g. antalgic gait, foot drop); pain that facilitation stretching on pain, muscle length and func-
lasts more than 15–20 minutes when lying, sitting and tional performance in patients with PS.
standing; pain that arises when standing up from a
seated or squatting position; pain that is not relieved
by change of position; pain in the abdomen, pelvis and 2. Methodology
inguinal region; and dyspareunia in females [10].
Three tests (when positive) are indicative of PS, This RCT study was conducted at Riphah Rehabili-
namely: the Beatty test, Freiberg test [11] and Pace tation and Research Center of Pakistan Railway Gen-
test [12]. The positive FAIR test (flexion, adduction and eral Hospital, Rawalpindi, from 1 August 2017 to 31
internal rotation) is also an indicator of PS. It has a January 2018. In total 46 PS patients were enrolled in
sensitivity of 0.88 and specificity of 0.83 [13]. the study. The sample size was calculated by the online
Conservative treatment of PS includes medication, OpenEpi tool. Out of 46 participants, 23 were included
physiotherapy, acupuncture and local anesthetic injec- in each group. Participants were randomly assigned to
tions [3]. Elongation Longitudinaux Avec Decoaption Group A (myofascial stretching ELDOA) or Group B
Osteo Articulaire (ELDOA) or Longitudinal Osteo- (post-facilitation stretching) by the toss and trial method
Articular Decoaptation Stretching (LOADS) in English, in which an unbiased coin was tossed with one side as
is a manual physical therapy tool and myofascial stretch A (Group A) and the other as B (Group B).
technique designed to produce active decompression Males and females, aged between 30–70, diagnosed
by creating a space in the targeted area and causes re- with PS with short piriformis length (< 40◦ ), a positive
alignment of the structure by correcting fascial tension. FAIR (flexion, adduction and internal rotation) test and
Locally, ELDOA improves muscle tone for posture cor- pain for more than one month were included in the
rection and generally, improves the kinetic sense of the study. Individuals with leg pain that was not related
myofascial chain and causes normalization of tension to the piriformis (e.g. disc herniation, sacroiliac joint
in the myofascial system [14]. dysfunction, degenerative joint disease) were excluded
The muscle energy technique (MET) is an active soft from the study. Three participants dropped out of both
tissue technique in physical therapy, in which a mus- groups, so the study was completed with a total of 40
cle lengthens itself by using its energy to relax. Post- patients: 20 in Group A and 20 in Group B.
facilitation stretching is one of the two MET techniques Treatment was given three days/week for six weeks.
and is used to treat chronically shortened muscles [14]. The Numeric Pain Rating Scale (NPRS), Lower Ex-
 M. Shahzad et al. / Effects of ELDOA and post-facilitation stretching technique 985

Fig. 1. CONSORT diagram for the data collection.

tremity Functional Scale (LEFS), Piriformis Length

Test and Straight Leg Raise ranges were used as assess-
ment tools. Assessments were done at baseline and at
the end of the sixth week of treatment. Informed con-
sent was collected from all participants in both Urdu
and English. The data collection procedure is outlined
in Fig. 1.

3. Procedure

Prior to the treatment, both groups were treated with

ultrasound (1 MHz frequency, constant mode, and 1.0
intensity) for three minutes at the piriformis muscle
tender or the trigger point.

3.1. Group A

Group A was treated with myofascial stretching (EL-

DOA) of the piriformis muscle. Each patient was seated
with the sound leg in a knee extended position with Fig. 2. ELDOA of the piriformis muscle.
supinated foot, while the affected leg was internally
rotated with knee flexion and the foot was in prona- 3.2. Group B
tion. Arms were straight, externally rotated and reach-
ing forward. The spine was erect moving towards the Group B was treated with post-facilitation stretching
ceiling. The pelvis was slightly posteriorly rotated and (PFS) of the piriformis muscle. Each patient was in the
the head was kept straight and in a neutral position. supine position with hip flexion greater than 60◦ , and
While this position was maintained, internal rotation a slight adduction and external rotation of the affected
of the affected leg was increased or decreased until the leg. The practitioner then wrapped the leg with the su-
patient felt a stretch in the piriformis muscle. This posi- perior arm and placed the inferior hand on the table
tion was held for one minute with 15 seconds rest. Five and moved the piriformis muscle in the midrange posi-
reps/sessions were done, as shown in Fig. 2. tion. The patient was asked to externally rotate the leg
986 M. Shahzad et al. / Effects of ELDOA and post-facilitation stretching technique

± 5.54, SLR ranges 36.40 ± 7.24 and LEFS 26.90

± 12.24. Post-treatment values were: sitting duration
90.00 ± 30.00, standing duration 45.00 ± 27.50, NPRS
3.00 ± 1.75, piriformis length 36.8 ± 3.13, SLR ranges
67.5 ± 8.36 and LEFS 58.10 ± 8.62.
In Group B, pre-treatment values were: sitting du-
ration 25.00 ± 17.50, standing duration 15.00 ± 8.75,
NPRS 6.00 ± 1.00, piriformis length 28.55 ± 4.03,
SLR ranges 40.60 ± 7.48 and LEFS 25.20 ± 7.66.
Post-treatment values were: sitting duration 80.00 ±
52.50, standing duration 52.50 ± 26.25, NPRS 2.00 ±
Fig. 3. PFS technique for the piriformis muscle. 1.50, piriformis length 38.8 ± 2.70, SLR ranges 74.25
± 5.19 and LEFS 66.30 ± 7.27, as shown in Table 2.
Table 1 There were no significant differences between the
Age, gender and trigger points of the participants
groups in post-sitting (p-value 0.978) and post-standing
Variables Mean ± S.D
(p-value 0.406) duration. After treatment, Group B
Age 50.42 ± 10.03
Gender Male 9 (22.5%)
showed significant improvements in the Numeric Pain
Female 31 (77.5%) Rating Scale (p-value 0.003), Straight Leg Raise ranges
Trigger point Positive 13 (32.5%) (p-value 0.004), Piriformis Length Test (p-value 0.037)
and Lower Extremity Functional Scale (p-value 0.002)
against the resistance. This isometric contraction was in comparison to Group A, as can be seen in Table 2.
held for 10 seconds and the stretch was applied for 15
seconds with a 30 seconds rest period. The leg was then
gently adducted and internally rotated, and moved to 5. Discussion
the new barrier. Five reps/sessions were done, as shown
in Fig. 3. Significant improvements were found in both groups.
After the treatment, both groups were given a hydro Participants in Group B, who were treated with post-
collateral pack for 10 minutes. A home plan, consisting facilitation stretching, showed more improvements in
of piriformis stretching, hamstring muscle stretching, pain, SLR range, piriformis length and lower extremity
hip abductors strengthening and prone hip extension ex- function, in comparison to Group A, who were treated
ercises, was provided. These exercises were performed with myofascial stretching ELDOA.
in three phases: phase I (first and second week), one set Redij et al. concluded in one of their RCTs that
of 10 reps/day; phase II (third and fourth week), two MET results in greater improvement in hip extension
sets of 10 reps/day; and phase III (fifth and sixth week), range and iliopsoas muscle flexibility than the PIR tech-
two sets of 10 reps/twice a day). nique [19]. Another RCT conducted by Marques et
Statistical analysis was done on SPSS software ver- al. showed the MET (PFS) and self-stretching effect
sion 21 (IBM, USA). The Wilcoxon test was used for on the posterior chain flexibility of different muscles.
within-group analysis and the Mann-Whitney U test They concluded that MET results in greater flexibil-
was used for between-group analysis. ity than self-stretching [15]. Jadav and Patel concluded
that post-facilitation stretching results in greater im-
provement in range and flexibility [20]. Talapalli and
4. Results Sandeep reported that MET is more effective than PIR
in reducing hamstring muscle tightness and improving
In the study, the mean age of the participants was popliteal angle range [17]. Joseph and Arthur reported
50.42 ± 10.03 years, nine (22.5%) patients were male in a systemic review that the muscle energy technique
and 31 (77.5%) were females. Thirteen (32.5%) patients was more beneficial in decreasing pain and minimizing
reported piriformis trigger points, as shown in Table 1. disability in low back pain patients [21].
Significant improvements were found in both groups In all previous studies, the PFS technique was applied
after treatment. In Group A, pre-treatment values were: to different muscles rather than the piriformis muscle,
sitting duration 20.00 ± 17.50, standing duration 12.50 but the PFS technique nevertheless showed greater re-
± 5.00, NPRS 7.00 ± 2.75, piriformis length 27.6 duction in pain, improvement in flexibility, range and
 M. Shahzad et al. / Effects of ELDOA and post-facilitation stretching technique 987

Table 2
Comparison of median, IQ and p-value
Pre-median Pre-median Post-median Post-median
Variables p-value p-value
± IQ (Group A) ± IQ (Group B) ± IQ (Group A) ± IQ (Group B)
Sitting duration 20.00 ± 17.50 25.00 ± 17.50 0.074 90.00 ± 30.00 80.00 ± 52.50 0.978
Standing duration 12.50 ± 5.00 15.00 ± 8.75 0.590 45.00 ± 27.50 52.50 ± 26.25 0.406
NPRS 7.00 ± 2.75 6.00 ± 1.00 0.491 3.00 ± 1.75 2.00 ± 1.50 0.003
SLR ranges 36.40 ± 7.24 40.60 ± 7.48 0.790 67.40 ± 8.36 74.25 ± 5.19 0.004
Piriformis length 27.65 ± 5.54 28.55 ± 4.03 0.561 36.80 ± 3.13 38.80 ± 2.70 0.037
LEFS 26.90 ± 12.24 25.20 ± 7.66 0.602 58.10 ± 8.62 66.30 ± 7.27 0.002

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