Transcript Sacroiliac Joint Dysfunction

Sacroiliac Joint Pain and
Dysfunction
Source of LBP
 SIJ source of LBP 15-38% of cases
 In a 2010 study the cause of subjects with SIJ was:
Idiopathic: 30%, Overload of work injury: 26% Fall:
24%, MVA: 9%, Other incidents: 11%
 Also includes Pelvic Girdle Pain. Approx 20% of
pregnant women in large cohort studies.
Integrated model of function
 SIJ dysfunction as a failure of load transfer causing
pain at joint.
 TrA, pelvic floor, posterior sling (force closure)
Differential Diagnosis
 SIJ pain can refer into buttock, iliac crest, groin,
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abdomen, leg and foot.
Possible dysfunction or pain from lumbar
intervertebral discs or facet joints.
Fortin et al (1994, 2003): potential pain distribution
along sciatic nerve mimics a herniated lumbar disc
Screen hip condtions, neuro, as required
Rule out other conditions if only mm trigger point
referring pain
International Association for Study of Pain
 For a complete Dx of pain of SIJ origin:
 Pain in SIJ region,
 Pain reproduced by clinical tests selectively stressing
the joint
 Pain completely relieved by selective delivery of local
anaesthetic.
History, characteristics of SIJ pain
 Pain maps: never above L5, may refer down leg
 Patients may describe as sciatica
 Pain is recurring, triggered by bending, lifting
 Commonly idiopathic
 Initial episodes and MOI: pregnancy, trauma from
fall or MVA, hard braking, transverse force on pelvis
 Worse when loaded, eg standing, walking
 Possible changes in bladder habits
Mitchell et al (2012) clinical review
 SIJ is more likely the source of pain if:
a) The patient points to the PSIS as the source of
pain.
b) Pain is predominantly below the L5 level
c) The sacral sulcus is tender.
SIJ as origin of pain
 (Diagnostic anaesthetic injection is reference standard)
 Van der Wurf (2006):
 All subjects that responded to the SI joint block had
symptoms located at the Fortin area (3cm medially by 10
cm vertically inferior to the PSIS)
 All subjects that did NOT respond to the SI joint block
had symptoms at the Tuber area (just inferolateral to the
ischial tuberosity)
 Pain in the Fortin area but not Tuber, patients may have
SIJ pain
 But if they have pain in the Tuber but not the Fortin area
it can rule out SIJ pain (sensitive)
Clinical tests for Dx pain and instability
 SIJ provocation tests:
 Sacral thrust
 Compression
 Distraction
 Thigh thrust
 Gaenslan’s test
 ASLR (has high sens and spec)
 Passive joint glide of ilium.
 Stork test
Laslett et al. (2005)
 3/6 +ve provocation tests had Sens: 94%, Spec: 78%
for diagnosing SIJ pain.
 If Gaenslan’s test is excluded, 2/4 +ve tests Sens:
88%, Spec 78%
 In order of highest individual sens and spec:
1.
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4.
Thigh thrust
Distraction
Compression
Sacral thrust
 Rule out SIJ if all tests do not provoke pain
Hancock et al. (2007)
 Tests for LBP as disc, facet joint or SIJ as source
 Changes and degeneration on MRI increased
probability of disc as source. (+LR approx 1-5 for
each feature on MRI)
 Centralisation of pain increases likelihood of disc as
source (+LR=2.8 (95% CI 1.4-5.3)
 Helps rule out disc in absence of these signs
 No tests for facet joint were informative
Laslett (2008). Clinical Prediction Rule
 SIJCPR: Chronic LBP populations with:
 3+ SIJ provocation tests +ve
 Symptoms that cannot be made to centralise
have a 77% probability for SIJ pain.
 If also pregnant, probability increased to 89%
Other common associated impairments
 Weak core
 Weak glutes
 Tight or previously injured hip and back muscles
 Malalignments
 Leg length discrepancies
Leg length discrepancies
 Causes pelvic obliquity
 Kiapour et al. (2012), relationship between LLD of 1,
2 and 3 cm.
 1cm increases load of SIJ up to 5x, 3cm up to 12x
Malalignments
 Innominate shears, sup and inferior
 Innominate rotations, anterior and post
 Innominate in flare and out flare
 Sacral torsions, flex and ext
 Unilateral sacral lesions, flex and ext.
Riddle and Freburger (2002)
Stork test – Muscle activity
 Barbara Hungerford (2003, 2004) hip flexion in
standing EMG acitvity:
 Subjects with no hx of pain (control): Feedfoward
activation of OI, lumbar multifidus.
Biceps fem, add longus, glutes, TFL after initiation of
motion.
 Subjects with PGP: Onset of OI, multifidus and
glute max significantly delayed on symptomatic side
Biceps fem activation significantly earlier
Stork test - Innominate motion
 Control subjects: Posterior rotation of innominate
(sacral nutation). Self bracing mechanism
 PGP group subjects: Anterior rotation of innominate
(sacral counternutation). Failure of self bracing
mechanism.
Stork test – Intratherapist reliability
 Hungerford et al. (2007)
 3pt scale: PSIS neutral/ cephalad/caudad direction
 2pt scale: -ve= neutral or caudad. +ve= cephalad
 33 subjects, 3 therapists
 Good inter-rater reliability for 2pt scale. Agreement
between therapists occurred: 91.9% (L), 89.9% (R)
 Moderate reliability for 3pt scale: 82.8%(L),
79.8%(R)
Physiotherapeutic treatments for SIJ pain
 Address entire abdomino-lumbo-sacro-pelvic-hip
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complex.
Correct malalignments of pelvis and spine + address any
deficiencies and restrictions found in PE
Muscle energy technique and taping
Myofascial release and dry needling of trigger points
Exs for stablisation, muscle activation and targeting weak
links + imbalances.
TrA and the multifidus may increase tension on posterior
SI ligaments and posterior layer of the thoracolumbar
fascia, hence causing a nutation force on the sacrum
Allison et al. (2008)
 Feedfoward responses of TrA are directionally
specific and act asymmetrically
 TrA is a feedfoward muscle and preactivates other
trunk mm during rapid arm raising.
 The ipsilateral TrA lagged behind that of the
contralateral side
 Contradicts earlier studies stating the bilateral
feedfoward responses are highly consistent in
healthy controls and how this isolated activation
contributes substantially to segmental stability of the
lumbar spine.
Gnat et al.(2012)
 An in vitro study found a simulated TrA muscle force
does not increase stiffness of the pubic symphisis or
innominate bone.
 Supports the notion that TrA’s role in stabilising the
SIJ is via tensioning of the thoracolumbar fascia
Cusi (2010) clinical review
 Differentiate primarily force closure and form
closure failure through exclusion
 Exs programs successful if adequate ligamentous
strength (form closure)
 Up to 3 months to yield results
Stuge et al. (2004) RCT
 Post partum women with PGP
 Physio with stabilisation exs vs. Physio alone with
basic strengthening/mob exs
 Exs 30-60min, 3x/week for 18-20 weeks.
 50% reduction in disability, 30mm reduction in pain
VAS scale, improvement in QoL at 1 year cf.
insignificant changes in control group.
 Maintained at 2 yr follow-up
3 Stages of Exercise Therapy
 Isolation
 Train motor control ability TrA, pelvic floor +downtrain global
mm. compensation
 Combination
 Progressively challenge, incorporate activation of global mm.
while maintaining control from prev stage.
 Function
 Progress to functional activities according to patient needs and
goals.
Fail to respond to exs program?
 Intrinsic factors:
 Poor design (exs not specific enough)
 Premature progression through stages
 Poor compliance
 Poor exs technique
 Extrinsic factor: failure of form closure if program
was executed correctly.
Prolotherapy
 Stimulate proliferation of collagen for tissue repair of
weak SI ligaments
 Poor evidence in earlier studies due to specific cause
of LBP unidentified.
Stiffness, laxity, mm weakness, SIJ, facet joint, disc?
Prolotherapy studies
 Cusi et al. (2008) SIJ Case series 25 patients not
responding to exs
 3 prolotherapy injections, 6wks apart into dorsal
interosseus lig
 Significant improvement in clinical exam paramters and
functional questionnaires at 3, 12, 24 months.
 Mitchell et al case series: prolotherapy on SIJ ligaments
resulted in 76% of patients satisfied.
 Kim et al. (2010) RCT: ““Intra-articular prolotherapy
provided significant relief of sacroiliac joint pain, and its
effects lasted longer than those of steroid injections.”
Pelvic Compression Belt
 Jung et al. (2012)
 Pelvic compression belt improved hip extension
muscle activation in SIJ patients during SLS.
 SIJ pain group with pelvic belt: sig decrease in biceps
fem activation when compared to control
+Premotor reaction time for glute max decreased and
increased for biceps fem.
Posterior pelvic tilt taping: Lee and Yoo (2011)
 Case report: 20 yr old female swimmer with anterior
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pelvic tilt and hyperlordosis. Chronic bilateral SIJ
pain.
PPTT performed 6x/week. Avg of 9hr each time for
2 weeks.
Cobb's angle (L1-S1) had decreased from 68° to
47° and that the sacral horizontal angle had
decreased from 45° to 31°.
Reductions in motion asymmetry, provocation test
pain and pain on palpation of medial buttock area.
No follow up
Spinal and SIJ HVLA Manipulations
 Kamali and Shokri (2011): single session HVLA to
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SIJ vs. HVLA to SIJ and Lumbar spine (rotational)
16 subjects each group, diagnosed with SIJ pain with
provocation tests
Both groups significant improvement in pain and
function immediately, 48hr and one month post
SIJ and lumbar manipulation more effective than
SIJ manipulation alone
Treat both as closely interrelated
Corticosteroid injections
 Limited evidence
 Case series report excellent pain relief with duration
up to 10 months
 77% of 155 patients positive responders over a mean:
followup of 44 months, 2.7 injections, duraction of
9.3 months
Hansen et al. (2012)
 Sys review on SIJ interventions for pain relief (11
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studies)
Evidence for cooled radiofrequency neurotomy
in managing sacroiliac joint pain is fair.
Evidence for effectiveness of intraarticular steroid
injections is limited (or poor).
Evidence for periarticular injections of local anesthetic
and steroid or botulinum toxin is limited (or poor).
Evidence for effectiveness of conventional
radiofrequency neurotomy is limited (or poor).
Evidence for pulsed radiofrequency is limited (or poor).
 THE END.