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SIJ motion
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SIJ motion - February 23, 2002 11:22:00 AM
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mcap
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Group:
Perhaps our SIJ hypermobility/hypomobility conundrum is solved - a little.
Did anyone see the latest article by Richardson and company in Spine? They used a very interesting technique. They were evaluating the effect of TA and lateral abd. contraction on SIJ stiffness. They found that the TA contraction produced significantly more stiffness.
What was really interesting was the technique they used. They detected the vibration across the SIJ while the patient was in prone. The vibration was produced by small devices placed under the ASISs. The stiffer the joint, the more vibration will occur. Interesting..........
mcap
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Re: SIJ motion - February 26, 2002 11:44:00 PM
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henryryry
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From: Brisbane, Australia.
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mcap,
I was reviewing Bogduk's "Clinical Anatomy of the Lumbar Spine and sacrum" in preparation for my Master's this year. It is interesting that despite the number of tests that are available and the amount of courses and interesting hypothesis regarding the SIJ, it is only a joint that moves no more than 2-3 degrees. How someone can abnormal hypomobility or hypermobility, and consider this to be either abnormal or normal is beyond me? Any thoughts on this??
Henry***
ps - I have read that article by Richardson.. it is interesting that they hypothesis TA and multifidus as able to control hypermobile SIJ (which I see mostly in females after pregnancies). Definitely an interesting pathway to head towards.
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Re: SIJ motion - February 27, 2002 1:18:00 AM
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Sebastian Asselbergs
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Hi folks. I happened to be lucky enough to hear the presentation of this research by Richardson herself - a chance to hear her say that this test (elegant set-up BTW) and study only indicated a difference between SI joint stiffness, but not an indicator of actual ROM. That does not take away from the validity and sound theoretical basis of their study - I keep suggesting to post-grad students to try and study manual "pelvic" tests - intertester reliability, test vs. test, etc etc. Now this protocol should be a great help as monitoring tool...
Sebastian
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Re: SIJ motion - February 27, 2002 2:10:00 AM
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Andrew M. Ball MS MBA PT
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From: Chapel Hill
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I'm curious, as I don't typically follow the Ortho research and don't track articles in Spine. Is this Jan Richardson that we're talking about?
Drew
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Re: SIJ motion - February 27, 2002 2:23:00 AM
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henryryry
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From: Brisbane, Australia.
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Drew,
It is actually Carolyn Richardson. Here is the abstract:
The Relation Between the Transversus Abdominis Muscles, Sacroiliac Joint Mechanics, and Low Back Pain
Carolyn A. Richardson, PhD*; Chris J. Snijders, PhD†; Julie A. Hides, PhD‡; Léonie Damen, MSc†§; Martijn S. Pas, MSc†; Joop Storm, BSc†
From the *Department of Physiotherapy, University of Queensland, Australia, the
†Department of Biomedical Physics and Technology, Erasmus University Rotterdam, the Netherlands, the
‡Department of Physiotherapy, Mater Misericordiae Hospital, Brisbane, Australia, and the
§Institute of Rehabilitation, University Hospital Rotterdam, the Netherlands.
SPINE 2002;27:399-405
--------------------------------------------------------------------------------
Study Design. Two abdominal muscle patterns were tested in the same group of individuals, and their effects were compared in relation to sacroiliac joint laxity. One pattern was contraction of the transversus abdominis, independently of the other abdominals; the other was a bracing action that used all the lateral abdominal muscles.
Objectives. To demonstrate the biomechanical effect of the exercise for the transversus abdominis known to be effective in low back pain.
Summary of Background Data. Drawing in the abdominal wall is a specific exercise for the transversus abdominis muscle (in cocontraction with the multifidus), which is used in the treatment of back pain. Clinical effectiveness has been demonstrated to be a reduction of 3-year recurrence from 75% to 35%. To the authors’ best knowledge, there is not yet in vivo proof of the biomechanical effect of this specific exercise. This study of a biomechanical model on the mechanics of the sacroiliac joint, however, predicted a significant effect of transversus abdominis muscle force.
Methods. Thirteen healthy individuals who could perform the test patterns were included. Sacroiliac joint laxity values were recorded with study participants in the prone position during the two abdominal muscle patterns. The values were recorded by means of Doppler imaging of vibrations. Simultaneous electromyographic recordings and ultrasound imaging were used to verify the two muscle patterns.
Results. The range of sacroiliac joint laxity values observed in this study was comparable with levels found in earlier studies of healthy individuals. These values decreased significantly in all individuals during both muscle patterns (P < 0.001). The independent transversus abdominis contraction decreased sacroiliac joint laxity (or rather increased sacroiliac joint stiffness) to a significantly greater degree than the general abdominal exercise pattern (P < 0.0260).
Conclusions. Contraction of the transversus abdominis significantly decreases the laxity of the sacroiliac joint. This decrease in laxity is larger than that caused by a bracing action using all the lateral abdominal muscles. These findings are in line with the authors’ biomechanical model predictions and support the use of independent transversus abdominis contractions for the treatment of low back pain.
Key words: exercise; biomechanics; low back pain; sacroiliac joints; abdominal muscles] Spine 2002;27:399–405
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Re: SIJ motion - February 27, 2002 7:24:00 AM
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Sebastian Asselbergs
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birdie: as far as I understood the presentation - with slides, it helps... - vibration was applied to the ileum and measured at both the ileum and sacrum. With increased stiffness, and the measurements were more synchronous; with more laxity, the sacrum motion was less ("dampened") and slightly delayed. The transfer of vibration energy (sounds almost new-agey...) was less efficient over a space between the bone partners - when in full contact, the partners tested almost as one bone.
i hope this helps - haven't had lunch yet.
Thanks for the abstract henryry - my copy of the study is in a book (conference publication - kinda hard to scan and paste...
Sebastian
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Re: SIJ motion - February 27, 2002 11:17:00 AM
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pablo
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mcap and all,
The study by Richardson et al. was the study I mentioned a while back during the debate on the SIJ, and wether we can actually detect changes in ROM. What we can detect are changes in stiffness. If the stiffness of the SIJ is decreased, the way I understand it what actually happens is that there is a loss of ability of the SIJ to transfer loads across it. I believe this means that the energy is being absorbed at the SIJ instead of being spread out over the tissues of the pelvis.
I believe this decrease in stiffness has been measured in symptomatic subjects. It occurs on the symptomatic side. If we can detect changes in stiffness (not ROM) maybe we can then use what Vleeming describes as the force closure mechanism (using multifidus and transversus abdominis) to restore some stiffness to the SIJ. The research by Richardson spports this hypothesis. It is interesting to note that a transversus abdominis contraction is better at incresing energy transfer across the SIJ than a global abdominal contraction.
Sorry I don't have any referneces, I have lent the relevant sources to my supervisor. Some of this work was presented at IFOMT 2000 in Perth, Australia. More can be found in publications by A. Vleeming, Diane Lee, Paul Hodges, Julie Hides, and Carolyn Richardson.
The question still is, can we detect changes of stiffnes at the SIJ with manual tests? I think we can.
Pablo
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Re: SIJ motion - February 27, 2002 5:15:00 PM
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mcap
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Pablo:
I actually don't think you could assess the stiffness manually, but the study would be a great one, and I could certainly be wrong.
The point you raise brings up an interesting question. Is a less stiff joint worse because it is absorbing more load? Or is that the role of the SIJ, to absorb load and reduce stress on the hip and other structures. It is a load bearing joint. How much is too stiff?
I guess by looking at the stiffness of + SIJs decided by injection, we may get some loose parameters.
What do you think?
mcap
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Re: SIJ motion - February 28, 2002 12:15:00 AM
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henryryry
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To all:
I guess the other thought I had was does stiffness in the SIJ lead automatically to pain of SIJ pattern (or hypermobility for that matter)? If so, how does it lead to pain? Perhaps this leads to the basis of neurophysiology in manual therapy.
I have seen people who believe they can feel changes in stiffness in SIJ comparing both sides, but whether this is just within the realms of "normality" I don't know. I think more in-depth research definitely needs to be done.
Henry***
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Re: SIJ motion - February 28, 2002 1:58:00 AM
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Andrew M. Ball MS MBA PT
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From: Chapel Hill
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This was a pretty good study, and some of ya'll are missing the point. The questions that many of you are asking in terms of clinical application are good questions, and excellent ideas for future study, but that was not the intent of this study.
Mcap expecially raises some great points, to date, the stiffness of the SIJ can't be accurately assessed manually, and about a year ago we on this forum demonstrated quite clearly that there is significant disagreement among physical therapy professionals (all opinion mind you) about how much the SIJ moves.
Through vibration and Doppler imaging, this study begins to look at that question . . . how much play is there at the SIJ? Once we know that (in terms of an average population), we can then begin to determine the effects of too much, or too little play . . . but to date, we just didn't know how much optimal play was supposed to be.
This leads to two "clinical artists" using diametrically opposed techniques on similar patients because one believes movement to be too much, and the other believes it to be too little --- they can't both be right.
I can see a future where clinical scientists begin using this kind of technology to objectively determine SIJ play and, knowing what optimal should be, begin to enhance outcomes by applying the most effective, evidence-based techniques --- not the shotgun soloution that currently exists wrt this condition.
SJ's questions bear answering too. The vibration allows very detailed measurement of SIJ movement. Think of it as a very precise PROM test, far more precise than a goniomiter, and light years more precise than subjective clinical opinion (e.g. what you feel). The difference now, between the hip joint and the SIJ is that we think, for example, that about 30degrees of passive extension is normal at the hip, and that only about 20 degrees or so, is critically necessary for normal ambulation.
At the SIJ, not only do we not know what is necessary for active movement (as Mcap points out), but we're unclear on how much passive movement we should have. The vibration test used in the Richardson study should give us some insight into passive ROM norms at the SIJ.
Given this, I'm not sure that I understand your question about why the test wasn't done in weight bearing . . . unless you think that to do so would give a better approximation of how much muscles actively restrict play at the SIJ during static standing. Good question perhaps, but not the point of this study.
Drew
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Re: SIJ motion - February 28, 2002 6:32:00 AM
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mcap
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SJSJSJSJSJSJSJSJSJ:
You are correct. One can only extrapolate as to whether the SIJ is hyper or hypomobile according to the stiffness.
In functional activities the amount of motion may depend on several other factors such as muscle control (TA) and the length and motor control of the hip muscles that exert tourque on the joint. But you need to test with these factors eliminated if you want to see what's going on in the joint only.
This study was a simple, elegant way of determining joint stiffness. The stiffness of the joint does play a role in the functional motion. Further research will be needed to tell us what the relationship between stiffness and symptoms is.
mcap
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Re: SIJ motion - February 28, 2002 12:38:00 PM
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pablo
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From: ACT, Australia
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I don't think that what they were trying to measure was the position of the SIJ, or even its range of motion. Whether the joint is hyper or hypomobile may not have anything to do with this. Maybe the total range of motion doesn't change, but the amount of energy it takes to move the joint withing its "neutral zone" does. Not the best example, but if you look at a knee with a lax ACL, the total range of motion will be the same, but the amount of joint play will be greater, requiring greater muscular activity to control the movement. Maybe this is what happens at the SIJ.
I think joint stiffness as measured in the study is a great way of determining the joint's ability to transfer loads/energy. One of the main functions of the pelvis/SIJ complex is to enable transfer of energy between the ground and the upper body, and if this transfer of energy is impaired it leads to a dysfunctional pattern of use and compensatory strategies. Just as a deficient/lax ACL can accelerate the onset of osteoarthritis at the knee, it is possible that a dysfunctional SIJ can accelerate degenerative changes in the spine.
Pablo
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Re: SIJ motion - February 28, 2002 6:04:00 PM
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Bobcat
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Your rototiller model of vibration is intriguing but I think it is more applicable to macroscopic phenomena with infrasound. The Australian researchers likely used low-megahertz ultrasound, which is seen in industrial applications to test newly designed laminate materials or bio-replicate materials in a non-destructive fashion (NDT). You probably had to do some of this in biomech lab because its usually one of the first things they do to torture undergrad engineers with. The testing transducers are often adjusted to send out and receive frequencies over a wide bandwidth and you would want to also intentionally damp out the frequency bands natural to the material to be tested so as to avoid the "roto-tiller shaking your body apart at its naturally-resonant frequency" problem. It's almost like a hundred thousand really really small and zealous chiropractors applying adjustment thrusts in unison over an equally tiny surface area, and then waiting for the feedback stress waves to bounce back and direct them to where the flaws in the mechanical medium exist, er, sort of.
What the testers look for are as you suggested the velocity of the waves and the latency of the arbitrary single wave to go through the sample or reflect off some interface boundary. And the thicker it is, the longer it takes, and also, the stiffer it is, if the material is homogeneous, the velocity is proportional to the density of the material and the stiffness (ie more stiff and/or more dense then faster wave transmission). Bone, muscle and soft tissues are evidently not too homogeneous and have lots of intervening layers of fluid, tubules, fat and other crud resulting in much refraction, reflection, recombination of propagated waves and cancellation effects resulting in a muddy picture. I'd question the validity of the researchers' conclusions based on an examination of their instrumentation set up and an examination of their theoretical simulation as it relates to how they modeled their data. If you use a different algorithm to process the signal data, and a different theoretical interpretation of the data, you can come up with substantially different results. And what they are testing for may change simply depending on how and where you point the incident acoustic beam. See: [URL=http://www.cnrs.fr/cw/en/pres/compress/transversales/vivant/pages/04_new.htm]http://www.cnrs.fr/cw/en/pres/compress/transversales/vivant/pages/04_new.htm[/URL]
--and--
(needs Acrobat plug-in): [URL=http://www-elmape.rug.ac.be/www/staff/jozef/s/papers/paper27.pdf]http://www-elmape.rug.ac.be/www/staff/jozef/s/papers/paper27.pdf[/URL]
It would have been interesting to have a control with subjects just lying prone not doing anything and not having had any exercise training. And another baseline control on the wave signals from transducers placed at different orientations to the alignment of the trabeculae of each of the bony parts.
The other bothersome thing is this whole murky "laxity" concept which is not well defined being paired off with the mechanical concept of material stiffness as a relatively specific mathematical/mechanical construct occupying three dimensions. I mean, when I hear "joint laxity" the first thing I think of is loose ligaments and tendons, not how sound velocity and orientation changes within a mechanical array of simultaneous equations propagated into three dimensions. To get one from the other requires a bit more work that the simple blindfolded inference that one is certainly related to the other. You'd think you were talking about the action of the innominate load inciting protective recruitment of diaphramatic crurae or something.
What might be really interesting is using this approach on the adult cranial sutures. Those are supposedly "lax" at times.
It's good to see the use of objective instrumention because the output can be re-evaluated.
Aussies rule.
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Re: SIJ motion - March 2, 2002 4:39:00 AM
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Bobcat
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Maybe. They need to improve their model IMO. Notwithstanding, it beats "feels like I had an effect with my fingertips" anyday.
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