SI Joint Notes

Question 1

Dreyfuss

Answer 1

(1996): No symptom or clinical test useful in diagnosis of SIJD. Convened panel of 14 experts to develop battery of clinical signs or maneuvers specific to SIJ dysfunction. None of the patient-reported symptoms or clinical tests predicted response to SIJ block. Used 12 clinical tests alone or in combination.

Question 2

“Position” innominate or sacrum stuck in?

Answer 2

Riddle and Freburger (2002) examined reliability of standing flexion, prone knee flexion, supine to sit, and sitting PSIS tests. Found reliability of measurements from these 4 tests is too low for clinical use with likelihood of proper treatment not being chosen and possibly applied to wrong side or in wrong direction.

Question 3

O’Sullivan

Answer 3

(1997): Supports specific stability training (TrA and LM co-contraction) in spondylolisthesis and spondylolysis

Question 4

Aim of HVLAT to dysfunctional articulation/SIJ?

Answer 4

1. Decrease pain
2. Increase ROM
3. Reduce disability
4. Increase muscle strength/force closure
5. Improve feed-forward activation times

Question 5

Stuge (2004,2006)?

Answer 5

Effective treatment of 4P best achieved when exercises for entire spinal musculature are included

Question 6

Richardson

Answer 6

(2002): Supports notion that co-contraction of TrA and LM significantly decrease laxity of SIJ. Looked at Doppler vibrations propogated to ASIS in 13 asymptomatics in prone (stiffness, not ROM) during abdominal draw in and bracing. Did simultaneous US and EMG but didn’t even look at LM. The draw-in decreased SIJ laxity significantly more than bracing, but they didn’t look at LM, so supports TrA contraction for SIJ dysfunction.

Question 7

Stuge

Answer 7

(2004): Looked at specific stabilizing exercises versus control and found less disability and evening pain for stabilizing group but joint mobs/manips were used PRM in both groups.

Question 8

Holm

Answer 8

(2002): Many muscles stabilize the spine (not just TrA, IO, and LM)

Question 9

Do you need to rule out disc first

Answer 9

Laslett (2006) says yes, Van der Wurff (2006) says no. Gutke (2009): the 4P test was still negative in patients with lumbar disc herniation as confirmed with CT scan, both before and after surgery.

Question 10

Kavcic

Answer 10

(2004): Lumbar stability depends on all the trunk muscles

Question 11

Reliability of SI joint provocation tests?

Answer 11

Kokmeyer (2002) used 3/5 pain provocation and both examiners found all asymptomatic subjects in the study (100% agreement). Concluded multi-test regimen for SI joint is reliable (Kapp 0.7) and thigh thrust was almost as good as multi-test regimen (Kappa 0.67)

Question 12

TrA Altered Timing: Cause or Effect

Answer 12

Cowan (2004) couldn’t determine cause or effect but from pain physiology literature:
Capra and Ro (2000), Matre (1998), Arendt-Neilsen (1996), Hodges and Moseley (2003), Holm (2002).
Marshall and Murphy (2006): Improved FFA timing of TrA following single HVLAT to SIJ.

Question 13

Hungerford (Muscle Finding)

Answer 13

(2003): Delayed onset of lumbopelvic muscles in presence of SI joint pain (IO, LM, and GMax)

Question 14

Laslett?

Answer 14

Laslett (2003, 2005) compared positive “gold standard” fluoroscopically guided injection (provocation of familiar pain followed by 80% pain relief with anesthetic block) to physical exam

1. Thigh thrust most sensitive single test, ASIS distraction most specific
2. Validity (using double diagnostic injection, 3/6 positive tests, and screen out discs)
   a. (2003): Sn = 91%, Sp = 87%
   b. (2005): Sn = 94%, Sp = 78%
3. Multi-test regimen for SIJ provocation improves diagnostic accuracy over single tests

Question 15

Does it matter which direction you manipulate?

Answer 15

Clements (2001) had 40 asymptomatics with >8 degrees AA rotation asymmetry. AA symmetry was restored regardless if HVLAT applied unilaterally towards, unilaterally away, or bilaterally.

Question 16

Sensory challenge of palpating SI joint?

Answer 16

McGrath (2006):
1. SI joint lies 5-7 cm deep to skin where you are touching
2. There are 7 discrete anatomical layers over SI joint
3. Medially facing position of innominate on sacrum
4. 1-2 degrees of rotation in flex/ext and 1 mm translation sup/inf and ant/post
Conclusion: SI joint is inaccessible to palpation and it’s unlikely you can manually detect motion through overlying tissue

Question 17

Van der wurff?

Answer 17

2006 (b): 3/5 (FABER, thigh thrust, Gaenslen’s, compression, distraction) had Sn = 85%, Sp = 79%

Question 18

Can we put SIJ back in place?

Answer 18

1. Tullberg (1998) - radiology study where HVLAT did not alter position of SIJ
2. Cibulka (1988) - found changes with innominate tilt during physical exam after Chicago HVLAT
3. Childs (2004) - 4 days after Chicago HVLAT found restoration of pelvic bony (iliac crest height) and improvements in WB symmetry on 2 scales that correlated with decreased pain but not function in acute and chronic LBP. Cohort study without control or placebo.

Question 19

Holmgren and Waling

Answer 19

(2007): Found “poor” inter-examiner reliability for static palpation tests of L5 transverse process, sacral sulci, and ILA. Agreement slightly better than that expected by chance (Kappa from 0.11 to 0.17). However, medial malleolus static palpation test in prone had “fair” inter-examiner reliability (Kapp 0.28).

Question 20

Childs (RCT)

Answer 20

(2007): 131 patients with LBP. Group 1 got manipulation and exercise. Group 2 got exercise only. Patients who complete exercise intervention without HVLAT were 8x more likely to experience worsening in disability than patients who received HVLAT.

Question 21

Gutke

Answer 21

(2009): RCT of 110 subjects. Posterior pelvic pain provocation test (4P test) was performed with 4 groups of patients.
1. Patients with CT verified disc herniations on wait list for surgery
2. 6 weeks post disc surgery
3. Pregnant women seeking care for pelvic girdle pain
4. Women with pelvic girdle pain after delivery
4P test had Sn=0.88, Sp=0.89. Gutke found the 4P test was negative in patients with lumbar disc herniation, as verified by CT, both before and after disc surgery. Therefore, not necessary to rule out disc prior to using 4P test.

Question 22

Dumas

Answer 22

(1995): Found no effect of exercise on prevention or treatment of pelvic pain during or after child birth

Question 23

Lack of reliability/validity of SIJ blocks

Answer 23

Berthelot (2006):

1. Effect of SIJ blocks are identical in only 60% of cases
2. Anesthetic diffuses out of SI joint in 61% of cases (Fortin 1999)
   a. Often coming in contact with lumbosacral trunk and L5 or S1 nerve roots
   b. Distance between anteroinferior 1/3 of SIJ and L4 root or lumbosacral plexus is less than 10 mm (Atlihan 2000)
3. Pain provocation tests and SIJ blocks are unreliable and not valid for diagnosing SIJ syndrome
4. Pain believed to come from inside SIJ may actually come from neighboring structures, sucah as man ligaments constraining SIJ

Question 24

Evidence based update of SIJ

Answer 24

Laslett (2010)

1. Generally accepted that 13% of patients with CLBP have origin at SIJ
2. Evidence that greater experience using symmetry and motion tests results in poorer inter-examiner reliability than novices
3. SIJ pain and discogenic pain rarely co-exist, the centralization phenomenon has been found highly specific to discogenic pain and is not observed in patients with confirmed SIJ or facet pain (SIJ tests that are positive in presence of centralization are likely false positives)
4. LR’s for 3/6 SIJ tests are +LR 4.16 and –LR 0.12
5. Steroid injections, phenol injections, and radiofrequency neurotomoy appear to be effective in a proportion of cases
6. Prolotherapy evidence is poor
7. Surgical fusion and debridement offer a moderate chance of pain reduction for those unresponsive to conservative interventions
8. SIJ injections not perfect but remain the best available reference standard
9. Laslett feels mob/manip to SIJ for those positive on CPR is unsuccessful or aggravating
10. Presently there are no studies examining treatment for those confirmed as having SIJ pain. Laslett feels exercises aimed at lumbopelvic stability and injections have the most potential.

Question 25

Hungerford (RCT)

Answer 25

(2004): Compared males with posterior pelvic pain to controls. Did camera motion analysis during Gillet’s test (markers on skin). In controls the WB innominate posteriorly rotated and translated superiorly with single leg stance, vs. subjects who anteriorly rotated and translated inferiorly. Study suggests aberrant motion and positional faults do exist in PGP.

Question 26

Strength and tone of PFM

Answer 26

Almedia (2010): 40 healthy females with no control group. Sacral HVLAT in lateral recumbent immediately increased intravaginal pressure after HVLAT, altering strength and tone of PFM.

Question 27

Best practice for SIJD clinical diagnosis?

Answer 27

1. Multi-test regimen of PP tests (3/6 or 3/5)
   a. Validity: Laslett (2003, 2005); Van der Wurff (2006)
   b. Reliability: Kokmeyer (2002)
2. Fortin’s area and lack of lumbar pain(Van der Wurff 2006)
3. ASLR (Mens 1999)
4. TrP’s
   a. BL 54 (piriformis) and BL 23 (QL)
   b. Level IV evidence…no empirical

Question 28

Robinson

Answer 28

(2007) : 1. Found SI joint motion palpation tests (joint play) to have “poor” inter-examiner reliability
2. Found clusters of 3/5 SI joint pain provocation tests to have “moderate to good” inter-examiner reliability

Question 29

Mob/manip or exercise 1st choice for SIJ/4P?

Answer 29

Richardson (1999) said we should stabilize all LBP no matter the pathology on day one (support from O’Sullivan 1997 with spondylolisthesis/spondylolysis and Hides 2001 for acute 1st episode LBP). Stuge (2004) adjusted asymmetrical motion of SIJ’s prior to exercise with joint mob to influence optimal form closure and enhance possibility to exercise without pain. Compare the outcomes of Stuge 2004 and Mens 2000.

Question 30

Nilsson-Wikmar

Answer 30

(1998): Compared effects of the following for 4P:
1. Exercises given by PT
2. HEP of strength and stretching
3. No exercise
Conclusion: No difference between groups

Question 31

Hides

Answer 31

(2001): Supports TrA and LM co-contraction training for acute 1st episode LBP only

Question 32

TrA altered timing?

Answer 32

Cowan (2004) wasn’t able to determine whether the delay in onset of EMG of TrA (after rectus femoris) with ASLR in the long-standing groin pain population was present before the onset of pain and thus was causative or if the timing alteration occurred as a result of pain and dysfunction.

Question 33

Manipulation for SIJ Conclusion?

Answer 33

1. No empirical evidence that supports use of mob or HVLAT in those diagnosed with SIJD, there is one cohort study though
2. No evidence whether HVLAT should proceed or follow exercise in SIJ and/or 4P syndromes

Question 34

Mens

Answer 34

(2000) : 44 women with 4P divided into 1. experimental group (diagonal trunk muscle exercises for force closure) 2. Longitudinal trunk muscle exercises 3. Instructions on how subjects could increase ADL’s but told to refrain from exercise
1. No difference in improvement for experimental and control groups
2. 25% of experimental group had to stop because exercise caused pain
3. Study didn’t support use of force closure stabilizing exercises for 4P
4. Mens conclusion was to reassure patient, await spontaneous resolution, educate, and give pelvic belt
5. Training diagonal trunk muscle system no more effective than light exercise or no exercise and gradually increasing ADL’s for 4P

Question 35

Stuge (2006)

Answer 35

Do subjects with vs. recovered from persistent PGP and disability differ with respect to the ability to voluntarily contract TrA and IO, and to strength of the PFM. Ability to voluntarily contract deep abdominals and strength of PFM not different between groups. Did not support hypothesis that PGP patients suffer from dysfunction of voluntary muscle contraction of TrA, IO, or PFM.

Question 36

ASLR Validity?

Answer 36

Mens (1999) looked at 21 non-pregnant peri-partum pelvic girdle pain patients

1. 20/21 had positive ASLR and this strongly correlates with mobility of pelvic joints in 4P
2. The pubic bone on the symptomatic side displaced caudally about 5 mm when standing on opposite leg or during ASLR on symptomatic side (caused by excessive anterior rotation of innominate near SI joint)
3. Test-retest reliability of 0.87, Sn = 87, Sp = 94.

Question 37

Timgren and Soinila

Answer 37

(2006): Analyzed 150 patients with LBP, 130 had asymmetric iliac crest heights and leg length difference on manual palpation. All patients with pelvic asymmetry had OA asymmetry. Did HVLAT or MET to SIJ, all patients had reestablishment of pelvic symmetry and this correlated significantly with diminishing symptoms. Study suggested pelvic asymmetry is common, often neglected cause of pain.

Question 38

Why do 94% of Australian Osteopaths still place high importance on static pelvic asymmetry tests for diagnosis of SI joint dysfunction?

Answer 38

Peace and Fryer (2004) referenced Dreyfus (1994). The symmetry and motion tests for determining SI joint dysfunction have become accepted not because of scientific clinical studies but because they have been continually propagated within orthopedic, medical, manual medicine, osteopathic, and chiropractic texts.

Question 39

SI joint pain patterns?

Answer 39

Van der Wurff 2006 took 60 subjects with pain below L5 over posterior SI joint with or without leg pain. Underwent 2 diagnostic SI joint injections and had to get greater than 50% pain reduction for at least 1 hour with lidocaine and 4 hours with bupivicane to be positive responder.

1. 45% were positive responders, 55% negative
2. No major difference in pain referral for positive/negative responders
3. In both groups pain was referred to buttock, posterior thigh, lateral/medial lower leg, and ventral side of medial/lateral leg to foot or ankle
4. All (100%) of responders felt pain in SI region (Fortin’s area)
5. All 100% of non-responders felt pain in an area just inferolateral to it overlying ischial tuberosity (Tuber’s area)
6. Only 10% of responders had pain in “tuber area”, positive Fortin area combined with negative Tuber area was discriminative

Question 40

Shearar

Answer 40

(2005): Cohort study of 60 patients diagnosed with SIJ syndrome. Group 1 got side-posture HVLAT to SIJ and group 2 got activator adjustments. Both had statistically significant improvements in pain and disability but no difference between groups. No control and didn’t use valid way to diagnose the SIJ though.

Question 41

SI joint symmetry and motion tests?

Answer 41

Freburger and Riddle (2001) did literature review of standing and sitting flexion; Gillet’s test; supine to sit; prone knee flexion; and sacral spring.

1. Symmetry/motion tests have poor inter-tester reliability
2. Low sensitivity (0.46 - 0.49) and low specificity (0.38 - 0.64)
3. Amount of motion extremely small (less than 2 mm or 2 degrees)