Q&A Time! Sacroiliac Joint vs Lumbar | Modern Manual Therapy Blog

Q&A Time! Sacroiliac Joint vs Lumbar

Today's Q&A Time is regarding an often asked question regarding SIJ vs lumbar assessment and treatment sequencing. It's a very good question, even if the pseudo science behind "SIJ" assessment and treatment is not.



Blame the osteopaths with their overly complex right on right, left on right, unilateral flexion/extension, upslips, downslips, METs etc... and the influence they've had on countless of orthopaedic PTs and PT instructors. Trust me, this stuff absolutely does not have to be this complex.

What used to go on in my head after fellowship

  • pt comes in with unilateral LBP, around the SIJ not below the knee
    • differential - could be disc, could be SIJ, could be facet, could be muscle imbalance
    • it's not below the knee, and it's unilateral, rule out SI?
    • supine to long sit - never "sat" well with me
    • look at PSIS, S2, levels - hated this
    • do the stupid stork/Gilet test - this always made me feel dumb
    • palpate all over the place - you get the hang of this after a while
    • try to rationalize it in your head that something is moving earlier, something else is higher or deeper or some other such you have to palpate it 1000 times to feel it (which is really just believing it)
    • then look at lumbar PIVM
      • believe that you can tell which vertebrae you're on, not to mention feeling whether or not something is gapping or approximating
    • after perhaps 10-15 minutes palpation and passive assessment, excuse yourself politely while you figure out what to do
    • it's no wonder the SIJ and palpation tests have some of the worth reliability in the history of special tests

What goes through my head now

  • pt comes in with unilateral LBP, around the SIJ not below the knee
    • what do they "have?" - low back pain
    • is pain intermittent? --> most likely lumbar rapid responder
    • check lumbar repeated motion for asymmetries and directional preference
    • if too painful to move repeatedly in WB, move to NWB
    • if too painful to move in NWB, try positioning in what you think will be the directional preference
      • for unilateral complaints - try prone modified hips offset position as in this post
      • lumbar rotation in flexion, loading (closing) the involved side in sidelying (painful side on the table)
    • go heavy on the pain science education, decrease fear avoidance
    • use OMPT techniques - IASTM, DN, Joint mob, manip, neurodynamics, functional mobilization, to get them to be able to move
    • instruct them how to do hopefully a WB repeated loading strategy by the time they leave, if not, they may have to take off of work if acute and do NWB loading strategies for 1-2 days
  • after putting out the fire, use the SFMA to look for other head to toe asymmetries in movement and motor control, clean those up
As you can see, the more modern way of forgetting about SI, IS, AF, FA, positional faults, intervertebral motion, stabilization, etc, is much easier. On the occasion that repeated motions are ruled out, thoracic and hip motions are also symmetrical and normal, and they patient is a very lax female, possibly either a dancer/gymnast younger than 18 yo or pregnant or recently pregnant, they may need some stabilization. An SI stabilization belt works best to calm down the peripheral sensitizaiton as well as stabilization exercises or those for motor control as needed.

I hope this answered your question. You are struggling at the point where I was were you were given TOO MUCH INFORMATION. A simple and thus more reliable and systematic way of assessment that dictates treatment is needed for not only the lumbar spine but any area. Once you let go of pathoanatomy and look at movement and pain science education it is very liberating, but it can be a tough change. 

In summary
  1. eliminate the threat
    • pain science education
    • repeated motions exam for directional preference or position of relief
    • OMPT to get them moving
    • HEP keeps them better
  2. use a system like the SFMA to clear the movement
    • clear up asymmetries in motor control to help prevent future injury
    • get their capacity up to speed - ROM and pain free sometimes not enough to prevent recurrence
Keeping it Eclectic...

21 comments:

  1. Great blog about decreasing the technicality of patient complaints especially in a large area of complaint where true dysfunction is never completely understood. As a recent DPT grad (2013), and resident Ortho Residency Grad with Evidence in Motion (Aug 2014) the transition in your two thought processes described above is dead on. And with the guidance of a residency/fellowship this treatment/decision making scheme transition from the standard anatomical/biomechanical utilize every specialty test in the book format promoted in DPT programs. What you described actually allows you to understand the patient's complaints and treat based on their presentation and not what we think is going. Great work!

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  2. Thanks AJ! That is why EIM is my most recommended residency/fellowship program! Glad you're making the change much faster than I did!

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  3. Very good article. It definitely can get confusing and sometimes overcomplicated. Repeated movement/directional preference is huge and manipulation/manual therapies work well also.

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  4. Interesting article but can't follow everything ... too many abbreviations (?!) for me (Dutch guy)... PIVM, WB, NWB, OMPT, DN.

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  5. I have a terms/abbreviations page right at the top of my site just for that. http://goo.gl/9Cwsox

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  6. Yes, the manual therapies definitely work, it's just a matter of getting to the treatment sooner without all the traditional assessment prior. Move it and move on!

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  7. Another great post! I've always had issues with this very subject and appreciate your thoughts. I've also been seriously considering EIM for my tDPT and your endorsement pretty much locks it in for me...

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  8. Great Max and good for you! Let me know what you think of their program.

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  9. Just keeping it simple, such a great approach which only benefits the patient in the long term. Find that movement in WB/NWB that feels good, then just do more of that!

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  10. Thanks Sean, many times the assessment and treatment can both be simple on paper and in reality. That's not a bad thing, it's a great thing!

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  11. Dr. E,
    I just go finished the EIM Sports PT Certificate Program and want to next get my Manual Therapy Certificate. I have narrowed it down to EIM's program and the International Spine and Pain Institute's Certified Spinal Manual Therapists programs. Which one would you recommend between those two programs or would you recommend either of them?
    Josh

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  12. You probably can't go wrong with either. ISPI is very up to date with their Pain Science and manual therapy approaches.

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  13. Still doesn't address the "why" of why they have a SI dysfunction. If you treat they underlying why, you'll solve the SI problem. Otherwise you might as well have DC after your name.

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  14. You missed the point. No one can conclusively say why anyone has the pain they have, especially something as vague as "SIJ" dysfunction, which occurs in less than 10% of all lower back pain condition. Most of the "whys" just lead to patient beliefs that passive care is needed, like posterior rotation of ilium, or something being rotated. It's simply not needed in modern practice.

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  15. Can you refer me to physio pics, video or previous blog that explains the following two :
    for unilateral complaints - try prone modified hips offset position as in this post

    lumbar rotation in flexion, loading (closing) the involved side in sidelying (painful side on the table)
    Thanks!

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  16. First pic, modified hips offset http://www.physiopics.com/2014/04/lumbar-modified-hips-offset.html

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  17. http://www.csmc.sg/images/exercises/BE/BE_lumbar_rotation_stretch_01.png is a good example, but manual overpressure can be applied to the shoulders and hips by a clinician. It's your basic lumbar roll manipulation position, only the involved side is on the side down on the ground as opposed to the gapping side being involved on top

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  18. Great Thank you for your always prompt replies!

    Karine

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  19. No problem Karine, about to tackle your email's question for Wednesday's blog post!

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  20. Great post! I was laughing at the beginning about all of the tests we learned. It was so complicated. I still use anatomy/biomechanics as the base with great success, but I mobilize (first few visits only) and STABILIZE!! Very exercise based. Clinically, I have found most people have difficulty dissociating their movement in that area. Trunk moves with pelvis moves with leg. Dissociation with stabilization leads to normal movement in that area and then they are out the door! Thanks for the discussion.

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  21. Thanks Lori! Most people do have trouble with dissociation of the hip and pelvis. Many approaches work, and assessment can be simple and systematic, unlike what we learn in school and traditional manual therapy courses.

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