Treatment of Pelvic and Sacroiliac Pain

Question 1

Which type of interventions to treat the pain of SIJ dysfunction?

Answer 1

– Nonsteroidal anti-inflammatory drugs (NSAIDs)
– Physical therapy
– Corti costeroid injections
– Manipulation
– Radiofrequency denervation
– SIJ belts
– Surgery.

Question 2

Quais são as três grandes teorias associadas aos tratamentos por terapia manual?

Answer 2

• Biomechanical: structural change including distance or movement.
• Neurophysiological: stimulus response that allows corresponding muscle relaxation.
• Muscle reflexogenic: modulation or gating of pain secondary to response.

Question 3

Relativamente à teoria biomecânica, qual a evidência existente ao nível da manipulação?

Answer 3

• Thrust does not accurately target a specific joint;
• No change in joint position before and after manipulation (even after confirmation of change by the attending physiotherapist);
• No change in Hip ROM after SIJ manipulation.

Question 4

Em termos de efeitos neurofisiológicos, o que a evidência nos diz acerca da terapia manual pélvica?

Answer 4

• Pain (and disability) is reduced in symptomatic subjects.
• Pain is decreased in patients with related hip and SIJ symptoms.
• Decrease in Lower extremity symptoms.

Question 5

Em termos de efeitos musculo-reflexogénicos, o que a evidência nos diz acerca da terapia manual pélvica?

Answer 5

• SIJ functions to improve feed-forward mechanism of TrA.
• Soft tissue tension is decreased.
• Significant decrease in reflex excitability even after cutaneous stimulation.

Question 6

Quais são os parâmetros notáveis da manipulação?

Answer 6

• Effects do not alter joint position but likely affect soft tissue.
• Fast thrust have greater neurophysiological affects.
• Thrust only works if muscle or joint capsule is affected.
• Must be performed on symptomatic subjects.
• Must be performed on same side as dysfunction and are enhanced when directed at the area of pain.
• Variable results may likely be a reflection of complex innervation pattern (rami from L5-S3) and large joint.

(Atenção: estudos efetuados entre 1995 e 1999)

Question 7

Are the Manual Therapy Techniques Specific to the SIJ?

Answer 7

• No
• Lumbar spine also creates changes
• Even manipulation on cervical spine can create changes on SIJ.
• Audible may or may not be SIJ and is rarely at the targeted level (lembra-te que a fast thrust technique já é considerada manipulação, mesmo que não emita um estalo).

Question 8

O que poderá otimizar os benefícios da manipulação sacroilíaca?

Answer 8

• Cerca de 80% da população que tem dor pélvica ou sacroilíaca responde positivamente à manipulação.
• A single session of SIJ and lumbar manipulation was more effective for improving functional disability than SIJ manipulation alone in patients with SIJ syndrome.
• Spinal HVLA manipulation may be a beneficial addition to treatment for patients with SIJ syndrome.

Question 9

Which could be the best treatment of SIJ in patients with leg pain?

Answer 9

A RCT demonstrated that:
• Physiotherapy 20% of success;
• Manual therapy 72% of success;
• Intra-articular injection 50% of success.

Question 10

Quais são os fortes ligamentos da sacroilíaca? E como resulta a estabilização em form closure?

Answer 10

• Ventral sacroiliac ligament
• Interosseous sacroiliac ligament
• Sacrotuberous ligament
• Sacrospinous ligament
• Iliolumbar ligament
• Long Dorsal ligament.

Os interósseo, sacrotuberoso, sacro espinhoso e iliolombar apresentam uma direção horizontal, enquanto o longo dorsal se dispõe na vertical, originando a form closure no sacro.

Question 11

Quais são os músculos estabilizadores ativos primários da sacro-ilíaca? E secundários?

Answer 11

Primary:
• Multifidi
• Inferior Internal Oblique
• Transverse Abdominus

Secondary
• Gluteus Maximus
• Hamstrings
• Erector Spinae
• Latissimus Dorsi

Question 12

Em que medida o transverso do abdómen e o oblíquo interno inferior interferem com a estabilidade?

Answer 12

• The TA and IIO pull medially on the ASIS thus increasing the stiffness of the SIJ ligaments.

Question 13

Que achado clínico costumam apresentar indivíduos com dor SIJ?

Answer 13

• Generally individuals with SIJ pain demonstrate a delay in contraction of IO, multifidus and glut max in the support leg during standing hip flexion.
• Compensate with earlier activation of biceps femoris.

Question 14

Quais são os princípios de gestão clínica?

Answer 14

• Focus on local muscles, TrA and multifidus.
• Low load, tonic isometric contractions.
• Include contraction of pelvic floor.
• Breath normally during abdominal drawing in action.
• Maintain specificity of deep muscle action independent of global muscles.

Question 15

Como podemos gerir o exercício clínico específico?

Answer 15

• Focus on one particular muscle (of local system) at a time.
• Try different instruction, visual cues, or imagery.
• Try different postures and positions.
• Use various forms of facilitation and feedback.
• Use methods to decrease overactivity of global musculature.

Question 16

After control of pain and local stabs what should we do?

Answer 16

Devemos focar-nos em exercícios de estabilidade dirigidos a outros músculos regionais que podem estar envolvidos. Ex: eretor da espinha, glúteo máximo, hamstrings, etc.

Question 17

Os exercícios de estabilização resultam realmente?

Answer 17

There is moderate evidence to support the role of stabilization exercise in decreasing laxity of the sacroiliac joint, changing lumbopelvic kinematics, altering selective recruitment of stabilizing musculature, and reducing pain.

Question 18

E os pacientes que não respondem a terapia manual, respondem a exercícios de estabilidade, mas ainda têm dor?

Answer 18

• We can consider the use of an SIJ Belt.
• Application of a belt significantly decreases mobility of the SIJ.
• The decrease of mobility is larger with the belt positioned just caudal to the anterior superior iliac spines than at the level of the pubic symphysis.
• The findings are in line with the biomechanical predictions and might be the basis for clinical studies about the use of pelvic belts in pregnancy-related pelvic girdle pain.

Question 19

A utilização de cintas pélvicas ajuda mesmo?

Answer 19

• Application of SIJ belt decreased laxity by approximately 36% in women with pregnancy related pelvic girdle pain.
• Wearing a belt improved lifting strength by approximately 40%, while pain scores improved by 13%.
• A minimum tension of 50N is needed.

Question 20

How to perform nutation mobilization?

Answer 20

The patient assumes a sidelying position with the painful side up. The painful leg is flexed beyond 90 degrees to engage the pelvis and promote passive physiological flexion/nutation of the sacrum. The clinician places his/her hands on the ischial tuberosity and ASIS to promote physiological rotation. The patient’s pelvis is passively moved to the first sign of concordant pain.

Question 21

Describe the counternutation mobilization.

Answer 21

The patient assumes a sidelying position with the painful side up. The painful leg is extended and the table side leg flexed to 90 degrees to promote passive physiological extension/counternutation of the sacrum. The clinician cradles the leg with the caudal side hand further encouraging hip extension. The cranial sided hand is placed on the PSIS and promotes anterior rotation of the innominate. The patient’s pelvis is passively moved to the first sign of concordant pain.

Question 22

Como aplicar a posterior rotation of the innominate muscle energy technique?

Answer 22

The leg on the painful side is flexed at the knee and hip and raised into as much hip flexion as the patient can tolerate. The opposite extremity is placed in neutral. The patient is instructed to push downward with the knee and hip against the resistance of the clinician with the involved side and simultaneously flex the opposite hip against hand resistance.

Question 23

How it is performed the anterior rotation of the innominate muscle energy technique?

Answer 23

The leg on the painful side is placed in a position of flexion, abduction, and external rotation. The opposite extremity is placed in neutral. The patient is instructed to flex and adduct the affected lower extremity against resistance while in supine.

Question 24

Como manipular a sacroilíaca?

Answer 24

The patient assumes a supine position and interlocks his/her fingers behind the head with elbow pulled together. The clinician side-flexes the patient’s body away and rotates the patient’s body toward them. The patient is rolled until end range and the clinician then applies a quick thrust at end range to the patient’s ASIS.

Question 25

Como poderemos estimular a ativação do transverso do abdomen?

Answer 25

In the prone position, place the blood pressure cuff under the abdomen with navel in center and distal edge of pad in line with right and left ASIS. Inflate the pad to 70mmHg. The patient is asked to “draw in” their belly button. Successful muscle contraction is a reduction of pressure by 4-10mmHg and maintaining the hold for 10 seconds.

Question 26

During the clinical examination, Ms. B’s physical therapist was able to identify pain which reproduced the symptoms in her low back. Ms. B was positive on the thigh thrust test, sacral thrust, and compression pain provocation tests. Given the history and clinical presentation of Ms. B, what appear she suffers?

Answer 26

Given the history and clinical presentation of Ms. B, it would appear she suffers most likely from one-sided SIJ syndrome. Symptoms include both SIJ and pubic symphysis pain, so a mixed model will most likely present with both anterior and posterior pain.

Question 27

Based on Cook’s integrated approach of SIJ treatment, which treatment techniques would be considered the first line of treatment?

Answer 27

Mobilize into passive posterior physiological movement. A majority of patients respond favorably to posterior mobilizations of the innominate.

Question 28

Ms. B’s physical therapist has found good results with the passive physiological mobilizations and is ready to progress to stabilization exercises. Which of the following muscle groups is most appropriate to target?

Answer 28

Transverse abdominis. When first initiating stabilization exercises it is of primary importance to focus on local musculature including transverse abdominis, multifidus and internal oblique.

Question 29

Ms. B does not currently require an SIJ belt but for other patients presenting with pelvic girdle pain, it is extremely important to set the tension of the belt. A minimum of how much tension is needed with an SIJ belt?

Answer 29

A minimum of 50N is needed for an SIJ belt to be effective.

Question 30

What are the pelvic instability management strategies?

Answer 30

• Early referral to a physiotherapist specialising in women’s health;
• Pelvic floor exercises;
• No heavy lifting (this includes toddlers);
• Avoid climbing stairs;
• Keep knees together: When getting in and out of bed and the car, no breast stroke (bruços) if swimming;
• Consider strapping or belt;
• Paracetamol predelivery;
• Anti-inflammatories may be taken after delivery;
• May benefit from a mobility device such as crutches or a walking frame;
• Avoid prolonged legs apart positions during labour.

Question 31

Qual a evidência na utilização de injeções intra-articulares?

Answer 31

There is limited (or poor) evidence for the effectiveness of intraarticular steroid injections.

Question 32

Existe evidência de que que a fusão cirúrgica da sacro-ilíaca pode ser benéfica?

Answer 32

• There are some benefits.
• Mean pain score at the 12 month follow up interval was 2.3 (±3.1), resulting in an average improvement of 6.2 points from baseline, representing a clinically and statistically significant (p=0.000) improvement.
• Patient satisfaction was very high with 100% indicating that they would have the same surgery again for the same result.

Question 33

O que é prolotherapy? E seu uso neste tipo de condições demonstra resultados favoráveis?

Answer 33

• It involves injecting an otherwise nonpharmacological and non-active irritant solution into the body, generally in the targeted connective tissue region for the purpose of strengthening weakened connective tissue and alleviating pain.
• Use of prolotherapy in private practice has shown positive clinical outcomes for the 76% of patients who attended the 3-month follow-up visit (76% at 12 months and 32% at 24 months).
• Similar results were found in the questionnaires (Quebec Back Pain Disability Scale, Roland-Morris 24 and Roland-Morris 24 Multiform questionnaires) at 3, 12 and 24 months.

Question 34

O que constitui a Radiofrequency Ablation? É útil?

Answer 34

• Involves use of radiofrequency waves to disrupt nerve function.
• Nerve function comes back over time.
• Limited evidence (Poor),

Question 35

In the event that Ms. B did not respond to manual therapy or stabilization, other non-conservative management strategies are available. Which treatment could she consider next?

Answer 35

• A non-conservative treatment approach including prolotherapy has shown positive results in this patient population with positive effects lasting up to 2 years.
• Sacral fusion also does show favorable results, but surgery should always be considered the last option due to the number of complications.

Question 36

Refere alguns exercícios que podem ser feitos para corrigir o anterior pelvic tilt?

Answer 36

• Squats (squats strengthen the buttock muscles, hamstrings, and other leg muscles);
• Pelvic tilt (this exercise helps to strengthen the abdominal muscles);
• Kneeling rear leg raises (this exercise stretches the back and buttock muscles, while strengthening the stomach muscles);
• Kneeling hip flexor stretch (this stretch helps to loosen and lengthen tight hip flexor muscles);
• The glute bridge (this exercise targets the buttock muscles and the hamstrings);
• The plank (the plank exercise helps to target the stomach muscles and back).

Question 37

What tips may reduce the risk of anterior pelvic tilt?

Answer 37

• Avoid sitting for prolonged periods of time. Those who have desk jobs, and other roles that require sitting for long periods, should take regular breaks that involve walking around or stretching.
• Engage in regular physical activity. This should include both stretching and strengthening exercises.
• Ensure proper posture, especially when sitting. A comfortable and healthful workspace with correctly positioned desk, screen, and seating is important.