Pelvic Flashcards
Blue flag meaning
Component of yellow flags and often related to workplace demands, time pressure, and other features that could cause an increase in symptoms
Black flag meaning
Component of yellow flags and often related to policy and work conditions that are out of the patient’s control
What ligament is most commonly tender in peripartum females?
Long dorsal SIJ ligaments
Appropriate first line of PT tx for nonspecific SIJ pain may include:
Manual therapy and therapeutic exercise
Fortin finger sign
Patient points with one finger to PSIS (within 1cm)
Manual therapy: which is better - general thrust techniques vs specific techniques?
General is JUST AS effective as specific
T/F: there is evidence for use of TENS and manual therapy for facilitating descending inhibitory mechanisms?
True
Is palpation reliable for identification of a problem spot and for tx?
No
What intra-articular factors make the SIJ stable?
The grooves and ridges that increase the coefficient of friction
Form closure
Theory that the SIJ is stable due to the sacrum being WEDGED between the ilia and ligaments
Force closure
Theory that muscles and ligaments provide a compressive force across the SIJ
Can form and force closures be associated with functional activity limitations/improvements
No, lack of contemporary research to associate those theories
SIJ is relatively thin where (anterior/posterior)
Anterior, therefore is susceptible to leakage during intra-articular injection
Sacrotuberous ligament blends with what ligament?
Long dorsal SIJ ligament
The sacrotuberous ligament has been identified as connected directly to what muscle?
Biceps femoris (sometimes completely fused)
What is the only muscle that directly attaches to the SIJ?
Piriformis
Anterior SIJ innervation
L4-S2 branches
Posterior SIJ innervation
L5-S4
Is the SIJ capable of nociception
Yes
Vascular claudication of the pelvis can present like what?
Mechanical pain with movement, trophic changes, temperature changes, LE pulse abnormalities
Can SIJ motion be detected with palpation
No, SIJ motion appears to be sub-clinically detectable and not reliably palpated by PT’s
Nutation
PPT, anterior/inferior movement of sacrum, ASIS higher vs PSIS
Counternutation
APT, posterior/superior movement of sacrum, PSIS higher vs ASIS
T/F: SIJ movement increases as jt load increases
False, it decreases (becomes more stable)
What axis has been shown to have the most mobility in the SIJ?
Transverse axis (S2)
Has there been any association between decreased pressure pain thresholds (PPT) and SIJ issues?
Yes, lower PPTs in group with SIJ pain
Pain in Fortin’s area (with/without) pain in the ischial tuberosity is likely to be of SIJ origin
Without
Risk factors for NEGATIVE prognosis of antepartum population with PGP
Prior hx of pregnancy, orthopedic dysfunctions, high BMI, smoking, work dissatisfaction, lack of belief in improvement
What other structures should be screened prior to diagnosis of PGP or SIJ pain?
Lumbar spine and hips
T/F: clinicians can cautiously use pain provocation tests to invetigate the SIJ as potential pain source
True, it’s been found that the tests alone or in a cluster do not demonstrate diagnostic value
T/F: Pain referral to lumbopelvic region from visceral disorders are rare
False, it’s not uncommon = should abdominal screen
Pelvic floor is innervated by what nerve
Pudendal nerve
Questionnaire to determine neuropathic pain
Self-administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS)
OR
Pain Detect questionnaire
+ Babinski
DF of big toe = UMN lesion
DTR - Patella (levels)
L3-L4
DTR - Achilles (levels)
L5-S1
Upper motor neuron lesions (DTR, babinski, bladder actvitiy)
DTR: hyper-reflexive
Babinski: +
Bladder: overactivity
Lower motor neuron lesions (DTR, babinski, bladder actvitiy)
DTR: hypo-reflexive
Babinski: -
Bladder: hypoactive
Anal reflex
S2-S5, presence of voluntary sphincter contraction - intact pelvic floor innervation
Bulbocavernosus reflex
S2-S4, squeezing the penis gland or clitoris = reflex contraction of external anal sphincter
Absence = sacral nerve damage
2 types of sacral stress fractures
1) Insufficiency fx’s
2) Fatigue fx’s
Demographics/risk factors for insufficiency fractures
Think “OLD” and SUDDEN
- Mean age 70.5 y/o
Risk factors: post-menopausal, older, female w/hx of osteoporosis, hx of pelvic radiation, RA, and long-term corticosteroid use
Sudden onset and pain w/ walking
Demographics/risk factors for fatigue fractures
Think “YOUNG” and GRADUAL
- Mean age 21.5 y/o
Risk factors: Increased training, deficient diet
Sudden onset and pain w/ walking
What is the best imaging tool for diagnosis of sacral fractures?
MRI
Most concordant sign with sacral stress fractures?
Pain with palpation over sacrum or SIJ
Role of PT in management of sacral fractures?
Appropriate load management
Is non-radiographic (nr-axSpA) or radiographic (axSpA) commonly known as ankylosing spondylitis (AS)?
radiographic (axSpA)
T/F: damage from nr-axSpA can be visible when using magnetic resonance imaging (MRI)
True (most of the time)
Individuals with both types of axSpA typically present in what manner? And demographics?
<40 y/o, males (2/3)
Long duration of symptoms that include: morning stiffness (especially in buttock), stiffness of spine, fatigue
Other complaints may include tendon insertion pain, eye irritation, inflammatory bowel disease
T/F: vertebral fx is common with axSpA
True - d/t association with low bone mineral density
Best test that is most informative vs functional tests when identifying someone with nr-axSpA
FABER (moderate)
What antigen is commonly found in those with AS?
HLA-B27
Present in 85-90% of those with AS
Osteitis condensans ilii
Self-limiting condition marked by sclerosis of the iliac bone
Demographics of osteitis condensans ilii
Women who have had children, 40’s
Typically asymptomatic
Best tx of osteitis condensans ilii
Unknown, use impairment-based approach
Blood tests for AS
Increased levels of inflammatory markers:
C-reactive protein, erythrocyte sedimentation rate
Presence of HLA-B27
Best approach to management of AS: meds vs PT
A combo of both is best
(Flexion/extension) exercises have been shown to be beneficial for axSpA
Extension
Cardiovascular & strengthening exercises VS traditional tx (posture, stretching, breathing) for tx of AS?
Cardio and strength = better
(Low/high) intensity exercise best improves the overall quality of life and reducing disease progression of axSpA.
High intensity
5 types/classifications of PRPGP (pregnancy-related pelvic girdle pain)
1) Pelvic girdle syndrome
2) Symphysiolysis
3) One-sided sacroiliac syndrome
4) Double-sided sacroiliac syndrome
5) Misc
Pelvic girdle syndrome:
Pain location
+ tests
Pain in BOTH SIJ and pubic symphysis
FABER, thigh thrust
Symphysiolysis syndrome:
Pain location
+ tests
Pain in symphysis pubis
TTP over SP, pain w/ trendelenburg test
One-sided sacroiliac syndrome:
Pain location
+ tests
Pain in one SIJ
+ thigh thrust
Double-sided sacroiliac syndrome:
Pain location
+ tests
Pain in bilat SIJ
+ thigh thrust
Miscellaneous (PRPGP) category:
Pain location
+ tests
Daily pain in 1 or more pelvic jt’s
Inconsistent findings
IS PRPGP self-limiting
Overall yes
Being physically active during pregnancy (does/does not) reduce the odds of developing pain during pregnancy or post-pregnancy
Does not
HOWEVER, physical activity can be preventative for LBP
Education or a stabilization belt alone (are/are not) good as a stand alone tx’s for PRPGP
are not needs to be a combo
When selecting exercises for PRPGP, what is the best approach
Exercises should address the patient’s weakness and functional limitations
ALSO emphasize return to regular activity as able
Study for PRPGP: exercise with highest amount of gluteus medius activation
Side-plank (aka side-bridging)
Study for PRPGP: exercise with highest amount of gluteus maximus muscle activity
Bird-dog
Also good for TA activation
Study for PRPGP: exercise with highest amount of lumbar multifidus activation
Free-weight exercises
What level of evidence for manual therapy in PRPGP patients? (A-E)
Level C
Including HVLA
T/F: manual techniques are all equal when treating PRPGP population
True, one is not better vs the others
Still Level C evidence but no evidence to show harm
Is it reasonable to apply tx concepts for non-specific LBP to those with non-specific PGP?
Yes
Are core stabilization exercises better vs other forms during tx of PGP?
No
T/F: Is TENS is okay to use on someone with nociplastic pain
Yes, however the evidence is conflicting regarding the efficacy. TENS activates descending inhibitory systems in the CNS
Is manual therapy indicated in tx of central nociplastic pelvic girdle pain?
Some evidence, can increase both pressure and thermal pain thresholds
Many techniques have an isometric muscle contraction component
Is exercise indicated in tx of central nociplastic pelvic girdle pain?
Yes, but limited evidence in how much improvement it can really make
T/F: there is a significant relationship between poor sleep and pelvic pain?
Yes, in chronic pelvic pain
Should education re sleep hygiene
Does diet play a role in pelvic pain?
Yes, it appears that it does
Only outcome questionnaire developed specifically for PGP
Pelvic girdle questionnaire (PGQ)
What test was the strongest predictor of ODI score at 1yr post-partum
ASLR test
Oswestry disability index vs Roland Morris disability questionnaire for high/low disability
ODI = higher disability
RMDQ = lower disability
Tests are not better vs the other
Step count associated with lower all cause mortality
8,000 steps per day
