3d - MDT & SI Joint Flashcards
what is the McKenzie Classification (MDT) system
system of assessment and classification of MSK disorders
- mechanical dx
- mechanical treatment based on mechanical dx
- prevention of recurrence
what does MDT place a strong emphasis on
patient ed and self treatment
what is the philosophical basis of MDT in the spine
the majority of LBP comes from the disc
- nucleus pulposis (disc itself)
- centralization
- peripheralization
what are the 2 main pain response subgroups? subgroups within these?
- centralized/directional preference
- non-centralization
- directional preference (sx feel better)
- no directional preference
what are components to a MDT exam
posture
mvmt in relation topain
repeated mvmts to reproduce
repeat mvmt 10-15xs then reassess sx
start in sagittal plane -> frontal –> transverse
- progress for what will be most provocative
MDT treatments
active and passive exercises
- trunk flex, ext, side gliding
NWB -> WBing based on centralization
- introduce mvmts opposite to preference
correction of lateral shift
how are pts classified per MDT and what are the classifications
uses pain behavior and its relationship to mvmts and positions
- postural syndrome
- dysfunction syndrome
- derangement syndrome
- other (no serious path, not severe sciatica w neuro deficits)
MDT postural syndrome: MOI
prolonged / sustained positioning
–> prolonged static loading of normal tissues
pain from mechanical deformation and sustained positioning
MDT postural syndrome: pain pattern
intermittent, midline & dull, never referred
gradual onset
MDT postural syndrome: aggravating and relieving factors
aggravating: standing, sitting, static positions
relieving: movement
MDT postural syndrome: clinical findings
no loss of motion
MDT postural syndrome: treatment
posture correction
interruption of end range stress at freq intervals
- get up and move!
MDT dysfunction syndrome: MOI
pain resulting from mechanical deformation of abnormal tissues
- contracted, fibrosed, adaptively shorted tissues, adherent nerve root (ANR)
MDT dysfunction syndrome: pain pattern
intermittent pain
local adjacent to midline
usually not referred, repeated mvmts don’t alter sx
MDT dysfunction syndrome: exam findings
restriction of end range motion
MDT dysfunction syndrome: emphasis of intervention
exercises at end range to remodel affected structures
MDT derangement syndrome: MOI
pain caused by internal disruption and displacement of tissue (primarily disc)
MDT derangement syndrome: pain pattern
sudden onset
constant, paresthesia or numbness down into leg
- peripheralization/centralization
central, unilateral, symmetric, or asymmetric
MDT derangement syndrome: aggravating factors
posterior derangement: flexion
anterior derangement: ext
MDT derangement syndrome: exam findings
lateral shift
loss of motion and function
MDT derangement syndrome: emphasis of intervention
perform mvmts to dec internal derangements and maintain stability
what is the guiding principle for treatment progressions in derangement syndrome and what are resulting categories
pt- controlled and generated mvmts that are assisted by clinician only when necessary
- static pt- generated force
- dynamic pt generated force
- clinician-generated forces
MDT category for pain during mvmt
derangement
MDT category for centralization of sx
derangement
MDT category for end range pain
dysfunction
MDT category for pain on prolonged static loading
postural syndrome
main intervention for postural syndrome
re-ed thru posture retraining
main intervention for dysfunction syndrome
remodel and stretch
main intervention for derangement syndrome
dec derangement
what does evidence say about the reliability and effectiveness of the MDT
good interrater reliability w/i therapists who are certified
not better than other rehab for dec pain and disability in acute LBP
however depending on comparative, better in dec pain and disability in chronic LBP
when can the dx of pelvic girdle pain be reached
AFTER EXCLUSION OF LUMBAR CAUSES and reproducible by specific clinical tests
what is pelvic girdle pain and common culprits
pain experienced between post iliac crest and gluteal fold
pregnancy, trauma, arthritis, OA
what is the function of the SIJ
multidirectional force transducer
what is controversial about the SIJ
some don’t agree that an injured SIJ can be cause of LBP
what composes the sacrum
5 fused vertebrae
interosseous ligs: location and main function
anterior
major SI stabilizer, creates pelvic ring
sacrotuberous ligs: location and main function
posterior
stabilize in sacral flex and taut in WB
long sacroiliac: location and main function
posterior
multifidi has some fibers which insert on the lig
sacral nutation vs counter nutation and their corresponding relative motions
nutation
- ant mvmt of base, post mvmt of apex
- post pelvic tilt
counter nutation
- post mvmt of base, ant mvmt of apex
- ant pelvic tilt
sacral nutation/flexion: motion resisted by ____, bilateral vs unilateral motion
resisted by sacrotuberous and interosseous ligs
(B) in initial stages of forward bending
unilateral during flex of LE
what position of the sacrum is more stable
nutation/flexion
sacral counter nutation/ext: motion resisted by ____, unilateral motion
resisted by long sacroiliac lig
(B) initial stage of backwards bending
what are the functional biomechanics of a forward bend
- ant pelvic tilt
- PSIS travel equally superiorly
- sacral nut inc relative to innominates for first 45-60deg of FB
- extensibility of tissues of sacrum reached so sacral counter nut w continued FB as pelvis cont to move forward
how and in what way specifically is torsion produced at pelvis
during climbing or walking
R innominate post rotates
L ant rotates
R sacrum nutated (relative to innominates)
L counter nutated (relative to innominates)
and vice versa
when is stability of pelvis achieved and what are contributing components
when active, passive, and NM controls work together to transfer loads
dynamic stability (intrinsic, extrinsic)
form closure
force closure
form vs force closure in the pelvis
form: passive stability
- ligs and bony attachments
force: active stability
- ms system, co-contraction
what are the 2 components to force closure and what specific structures are involved in each
inner unit = local/stabilizing ms
- levator ani, multifidi = control sacral position
- TrA, pelvic floor = inc intra-abdominal pressure
outer unit = gross/mvmt ms (adds compression)
- glut max, contralateral lats
- glut med and min, contralateral ADDs
what paths have a common pain referral over the SIJ
L3-4 facet
L4-5 nerve root
piriformis / sciatic nerve
why is SIJ path a dx of exclusion
most common sources of SI region pain are lumbar and hip dysfunction
SIJ pain: MOI
any trauma/fall/misstep
fall on glutes
quick upward force
SIJ pain: PMH
EDS (connective tissue disorder), RA, AS
hypermobility, pregnancy, PMS
med dx and hypermobility –> excessive mobility –> less form closure
SIJ pain: pain patterns
somatic pain referral rarely below knee
SIJ pain: goal of clinical exam
reproduce pain at SIJ w provocative tests
what is the order of the clinical exam for SIJ pain
palpation - static and dynamic
kinetics tests - type of dysfunction
ms length - confounding factors
leg length measurements
provocative tests - helps confirm SIJ dx
joint mobs
what is obliquity at the pelvis
rotation of 1 innominate vs the other
what is a significant finding of PSIS standing/supine alignment
~2.5cm difference
what are some dynamic/kinetic mvmt tests to do at the pelvis
forward bend
gillets
prone press up/ knee bend
long sitting
active SLR
what is a consideration before conducting a static palpatory non-WBing test
have them do a bridge up first to neutralize leg length
how would a R upslip present in palpatory testing
R ASIS/iliac crest higher in supine
R PSIS higher in prone
how would a R innominate ant rotation present in palpatory testing
R ASIS/iliac crest lower in supine
R PSIS higher in prone
how will a true innominate rotation present in static palpatory tests
in both NWB and WB
how will an upslip present in long sitting
leg length should change
- rotation will have femur pulled superior so malleoli won’t line up
what is a consideration of any objective measures used in the pelvis
lack a gold standard
what are the cluster of provocation tests used in the SIJ and how
- distraction
- post shear/thigh thrust
- Gaenslen L
- Gaenslen R
- compression
3/5 (+) indicates SIJ path
what are all the possible provocation tests that can be used at the SIJ
distraction*
post shear/thigh thrust*
FABER
gaenslen L* and R*
compression*
sacral thrust/spring test
cranial shear
when can a dx be achieved relating to an SIJ path
hx
r/o LBP and hip
3/5 provocative tests
once SIJ dysfunction dx, what guides treatment directions
positional tests
dynamic tests
confounding variables
- posture ms
- balance
- leg length
what are 6 classifications of pelvic girdle dysfunction
hypomobile
hypermobile
pain w normal mobility
pelvic girdle fx
coccyxadynia
ankylosing spondylitis
hypomobile: onset
trauma/lift/twist
insidious
positional stressors
compressive force
hypomobile: pain pattern and aggravating factors
pain over SIJ/into buttocks or post thigh
inc walking/stairs/rolling/STS
hypomobile: normal exam findings
neg LB scan
hip ROM WNL
hypomobile: abnormal exam findings
fixed palpatory obliquity
dec/fixed mobility w kinetic testing
dec arthrokinematics/mobs
(+) provocation tests
leg length discrepancy may be present
what are the 3 main possible obliquities
ant rotated innominate
post rotated innominate
up slip (inferior translation)
what are 3 ways to restore alignment when an obliquity is present
mobs
manips
MET
what are the 5 CPRs for mob or manip the SIJ (show banana manip as what would be done)
FABQ <19
sx <16days
no sx below knee
hyposegment LB
hip IR >35deg
acute hypomobile treatment
dec pain, inflammation, and MS spasm
sub acute hypomobile treatment
inc ROM and strength
promote good posture and body mechanics
chronic hypomobile treatment
ergonomics
dynamic stability
self management
hypermobile dysfunction: onset
repetitive micro trauma / major trauma
hormonal changes / pregnancy
hypermobile dysfunction: painpattern
pain location switches sides
- buttocks, thigh, pubic symphysis, groin
+/- clicking popping
hypermobile dysfunction: aggravating and relieving factors
aggravating:
- unilateral WB
- wt shift
relieving:
- rest
- positions that don’t stress joint
hypermobile dysfunction: exam findings
+/- positional faults
+/- gower sign
poor control (w wt shift)
poor isolation and endurance of stabilizing ms
antalgic gait (inc wt on one side)
change in dynamic/static palpatory tests
- difference in supine vs standing
inc joint glides
(+) active SLR
hypermobile dysfunction: medical intervention
if systemic
- sclerosing/prolotherapy/ pharm
fusion (after failed Rx)
hypermobile dysfunction: acute PT intervention
dec pain
inflammation and ms spasm
stabilization
SI belt
hypermobile dysfunction: sub acute PT intervention
correct obliquity
inc pain free ROM
strength
promote good posture & body mechanics
stabilization exercise
hypermobile dysfunction: chronic intervention
ergonomics
dynamic stabilization exercise
self-management (SI belt)
pain w normal mobility: onset
overuse articular and myofascial structures
dysfunction somewhere else - biomechanical (ie LBP)
pain w normal mobility: pain pattern and factors
same as hypo/hyper
pain over SIJ/buttocks/post thigh
inc w walking/stairs/STS
pain w normal mobility: exam findings
leg length/trendelenburg
- ms imbalance b/w gluts and lats, gluts and ADDs
- look down kinetic chain
pain w normal mobility: treatment
control aggravating factors
- ie running, walking, etc.
dec irritability
stability based exercise
- ie strengthen what is weak
sacrum dysfunction: onset
trauma / lift / twist
sacrum dysfunction: pain pattern and factors
same as hyper/hypo, normal mobility
pain over SIJ/buttocks/post thigh
inc w walking/stairs/STS
sacrum dysfunction: exam findings
positional fault
- upslip
- nutation, counternutation
—> when test flex/ext, not getting equal mvmt (B)
sacrum dysfunction: treatment
restore alignment
- MT
- METs
- repeated motions
pelvic girdle fx: onset
trauma
(+) radiographs
pelvic girdle fx: pain pattern and why
unable to WB
- fx anywhere on pelvic ring, WBing w any mvmt will cause pain bc of ligs that surround the ring and creates tension
pelvic girdle fx: exam findings
point tenderness over bony prominence
pelvic girdle fx: acute vs outpatient treatment
acute: external fixator
- compensate/mobility/fxn
outpatient: assess hypo/hyper mobility
- address impairements
coccyxadynia fx/sublux: onset
fall on buttocks
- missed chair/toilet seat
- fell down stairs
coccyxadynia fx/sublux: pain pattern and aggravating factors
localized over coccyx
strong/sharp pain w contact on coccyx
sitting worse than standing/walking
coccyxadynia fx/sublux: exam findings
sitting posture
pain palpation/mobs
coccyxadynia fx/sublux: treatment
mob or protect
function/strength
ankylosing spondylitis active vs late phase
active
- inflammatory process affecting ligs causing progressive fibrosis and low-grade fever
late
- bony ankyloses, bamboo spine risk for multiple stress fx
ankylosing spondylitis: demographics
young men
17-35yo
ankylosing spondylitis: sx
pain worse in AM, >3mo
- AM stiffness >3mo, >30min
LBP/ stiffness –> loss of motion
stiffness onset in SI region often
–> followed by progressive limit in mvmt
aggravated by inactivity
better w mvmt
ankylosing spondylitis: exam findings
dec ROM, general hypomobility
imaging
late stages:
- mobility
- gait
- breathing (rib cage)
- morbidity
ankylosing spondylitis: active stage interventions
medically managed
- NSAIDS
- corticosteroid injections
- PT not indicated**
ankylosing spondylitis: remission stage interventions
this is when they go to PT
posture
- promote ext sleeping
ext exercise
joint mob only in early non active stage
- contraindicated in late stages
aerobic
education
