Patient Case: SIJ dysfunction

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JLS_PT_OCS -> Patient Case: SIJ dysfunction (October 6, 2005 5:35:00 AM)
I had a couple patients today that I saw that I think are germane to the discussion of palpatory diagnosis and manipulative treatment. HISTORY: 49 y.o female with CLBP on the right pelvic area "They told me it's my SI joint" since JAN 2005. Insidious onset, localized pain, otherwise healthy. As soon as she told me that, I thought the same thing I think everytime a patient shares a "certain" diagnosis for nonspecific LBP, I think "Riiiiight...".She was in 4/10 pain today and oswestry scale was 46% (!!), though she was in no apparent distress. EXAM: Her Lx ROM was NL except for limitation into forward flexion, no change in sx's with repeated motion in standing into flex or ext. She localized the symptoms to her R SIJ area. She had a positive thigh thrust, Gaenslen, supine-sit, and Gillet. For the supine-sit test, she was equal leg length in supine, but involved R side was shorter in long sitting. Negative Patrick/FABER and pelvic rock. Positive Thomas markedly so on Right. I did not palpate her pelvic landmarks because I almost never do. No neurodynamic issues. Neuro screening NL. ASSESSMENT: I reluctantly admitted to myself that this might indeed be the "classic" SIJ of "Anterior Rotation". Her previous therapist had called this an anterior torsion (this was a followup from another PT). She had some good temporary relief with manipulation by a chiro, but then stated it would just get bad again and she would have to keep going back over and over, so she stopped going. Gee, never heard that one before. Her previous therapist did some MET for her with some relief and had her working on Lx stabilization exercises which were slowly helping. TREATMENT: After the supine Lumbosacral "chicago" technique ("old reliable" I call it) She improved 50% immediately in terms of pain, had increased forward bending, and a (!!) negative supine-sit test. Left the office with a big smile on her face. DISCUSSION: I thought of all those palpatory diagnosis people and how seeing this type of patient must be the thing that solidifies their beliefs. For all my sarcastic attitude about palpatory diagnosis and such, this patient seemed to actually have a biomechanical problem that was evidently improved by manipulation. (dangit!) Certainly I was mentally eating some crow about it, but I was glad I was able to help her feel better. PLAN: She left with self-mob exercises for her supposed anterior torsion and hip flexor stretches. She was instructed to continue her stabilization training as well. She will be gone on temporary military duty to an foreign land for the next 3 mos, and will followup when she comes back. Thoughts on this patient and her treatment? J

Shill -> Re: Patient Case: SIJ dysfunction (October 6, 2005 8:04:00 AM)
First, answering questions with more questions. Didja try UNLOADED spine repeated movements, or just standing? Could do you elaborate on her restriction into forward flexion. Was she stopped by pain, or something else? I also like to have more information on what they do during the daily routine, and how the symptoms behave with those activities. You know that what you intended to manipulate may not be the structure that moved, and that it may not matter what moved. It is great that you made her feel better, but until you follow up, you are in the temporary results boat with the other practitioners who have "helped" her in the past. So cautious optimism would need to be employed. Just some thoughts. Steve

JLS_PT_OCS -> Re: Patient Case: SIJ dysfunction (October 6, 2005 8:40:00 AM)
Steve- Repeated movements were in standing only. Pain was the limiting factor in her flexion, not her hamstring length. She was having difficulty with lifting her leg to get in and out of the car (how many times have we heard that?) and of pushing her foot down into her combat boots when getting dressed. Yes, my patients wear combat boots. :) I totally concur with everything you said in your second paragraph. It was the negative supine-sit test after the treatment that really threw me, as far as questioning whether some sort of biomechanical thing being "fixed", which you know I don't think I believe in anyway. I did do the original supine-sit test twice and got the same result. Thanks for your response. J

steve -> Re: Patient Case: SIJ dysfunction (October 6, 2005 8:41:00 AM)
Jason, Thanks for the taking the time to post an extensive case study, I always find this educational. I would be very interested to see how she is on follow-up and would also wonder about how she scored on the CPR for manip, more specifically the FABQ as her high ODQ score didn't sound like it correlated with her objective examination. This would suggest that there were some chronic pain components involved with her presentation. I agree with Steve's last paragraph explicity and often wonder how much of our manual treatments are simply a quick neurofascilitation that allows patients to reset and improve when they are acute and provides short lived relief and breeds dependency in the chronic pain population. Was there an educational component to your treatment as well? Any other thoughts? Steve

JLS_PT_OCS -> Re: Patient Case: SIJ dysfunction (October 6, 2005 8:46:00 AM)
Steve (Canada Steve)- Thanks for your input. I did not give her a FABQ, as she was late for her appt and I was running behind today. I agree that her high OSW score did not correlate to her emotional state/ presentation, as she was very calm, etc. I too think Steve is spot-on with his second paragraph and I agree with your assessment about the deal with manipulation, I also think it's merely a quick facilitation treatment, and wonder about it's long term potential. We did a bit of education, and I explicity told her how important the stability exercises (which probably are as much about neurofacilitation as any "stabilizing" action they may have) were, and how the goal of the manipultive therapy was simply to reduce pain and to get a "foot in the door" for the rehab, and it was not the primary intervention strategy. But I do tell this to all the folks I do manual therapy with as well. Thanks for your comments. J

steve -> Re: Patient Case: SIJ dysfunction (October 6, 2005 9:33:00 AM)
Jason, I kind of figured you did but I thought it was worth discussion. So what is your plan if she comes back in 3 months, is consistant with stability exercises and there was only short lived improvement with manipulation? Steve Steve

JLS_PT_OCS -> Re: Patient Case: SIJ dysfunction (October 6, 2005 10:20:00 AM)
Good question. If she comes back in 3 mos and is no better overall with only temporary relief from manipulation... I might try some different manual approaches if her SIJ cluster is still positive, like some sidelying mob/manip or MET. I will push the stability exercises pretty hard and enroll her in our regular stabilization training class. I might consider an SIJ belt for her (I don't think we have those in the clinic, but it might be worth it to order some). I might also consider working with her on ideomotor movement in the office (a la simple contact) before I take the next step... If she fails to improve with this after a couple months of dedicated therapy, I would refer her to the local PM&R/Physiatry clinic where they do some ESIs and Prolotherapy, as well as acupuncture. J

Shill -> Re: Patient Case: SIJ dysfunction (October 7, 2005 3:12:00 AM)
Jason, Im glad you said your patients wear combat boots, and not my mom. Not that there's anything wrong with that.....

JLS_PT_OCS -> Re: Patient Case: SIJ dysfunction (October 7, 2005 3:39:00 AM)
Hope not, I wear combat boots, too. It sure saves money on the work wardrobe. When I finally get out of the Army, I will have very little to wear to my civilian job.. I don't think jeans and my "Go Vegan" Tshirt will cut it... :) J

Yogi -> Re: Patient Case: SIJ dysfunction (October 7, 2005 5:22:00 AM)
Jason, cool, you found the typical anterior innominate. You also released it, which unfortunately, we do not know if her previous treatments had done, although they should have. However, I've had times when the straight anterior rotation MET treatment wouldn't do it, and when checking S/Cs tender points, I've found the point for flareout, rather than the one for straight rotation. I suspect the lumbar mob had the necessary oblique directional application to release the SI in this instance. I'll be suprised if she's not fine a followup. So, is manipulation going to end up being a neuro technique, after all.

JLS_PT_OCS -> Re: Patient Case: SIJ dysfunction (October 7, 2005 8:13:00 AM)
Yogi- Since all pain is neural in origin, then I think all techniques are neural techniques. (yes this is Jason still not Diane, Nari, or Barrett) :) I don't know about all that flareout/rotation stuff you mentioned, as you know I don't believe in that stuff anyway. You may believe the anterior innominate is typical (that's certainly what I learned in school also) but I do know other SIJ people (DonTigny maybe?) who say anterior innominate dysfunctions don't exist. What a whacky joint! If indeed it is a physical joint problem... While I appreciate your compliment about "releasing" it, I would be suprised if it turns out to be that easy. She had been seeing a chiropractor before, and from what I've seen those folks are pretty good manipulators, so I would think if it could have been corrected by manipulation alone, then I think the DC would have done it, and she never would have ended up seeing me. I have suspicion that the manip will only be temporary relief for her, and that I will have to investigate some of those other options I discussed earlier. But I am hopeful she will be completely better, and my peers will knight me as "Manipulatus, the God of Manipulation". However, I think this is unlikely. :) J

eam -> Re: Patient Case: SIJ dysfunction (October 8, 2005 5:16:00 AM)
Hi Jason, Nice topic. Couple of questions-(I don't mean to be difficult :) just curious as to the clinical reasoning and I think you probably answered this in your previous posts). If the manipulation provided only temporary relief from the DC, why did you initiate your treatment with that technique and how did you explain this to the patient? Also, interesting that her pelvic rotation cleared up after the tx. I'll bet her psoas is not just tight but constantly firing whipping that pelvis forward. The SIJ is indeed a whacky joint and I usually have good success with the MET but lingering sx's persist if the lumbar spine is left untreated. Keep us posted! Erica

Synergy -> Re: Patient Case: SIJ dysfunction (October 8, 2005 7:09:00 AM)
Erica (Jason, pardon my intrusion to her question to you), From what I can tell, it appears the aforementioned patient may have only received manipulation from the chiropractor when she was seeing him/her. The patient then went to a PT who began her on some stabilization training and METs. Jason, correct me if I'm wrong, performed the manipulation technique (Chicago Roll) and combined that with stabilization exercises. Manipulation and stabilization used together have shown promising results in the literature. There's a pretty good article in Evidence in Motion that just discussed this. Looks like Jason has engaged in EBP. :)

Diane -> Re: Patient Case: SIJ dysfunction (October 8, 2005 8:30:00 AM)
Jason, [QUOTE]Since all pain is neural in origin, then I think all techniques are neural techniques. (yes this is Jason still not Diane, Nari, or Barrett) :) [/QUOTE]What a fresh breeze blows.. :D Now, all that's left is for you to try light stuff on people before crunchy heavy stuff, and the numbers of patients who seem to 'benefit from manip' will dry to a trickle, then turn to dust. Course, it's not EBP officially , yet..

nari -> Re: Patient Case: SIJ dysfunction (October 8, 2005 1:29:00 PM)
Jason I'll echo Diane's post. A great breeze...don't let it whimper away to a mere puff. Nari

Randy Dixon -> Re: Patient Case: SIJ dysfunction (October 10, 2005 9:09:00 PM)
Jason, I think you've come across the problem of EBP and some things that just won't seem to go away. Too many times therapists find that fixing things like anterior inominate torsion takes care of the problem, which contradicts what they see the evidence pointing to. I think SIJ/pelvis is the #1 culprit in that regard. Personally I found this same problem in myself, corrected it as suggested by Don Tigny, actually as suggested in "The Malalignment Syndrome", and I noticed the results, my shoulders leveled when they had never been level, plantar fascitis and ITB problems cleared up, right foot pointed straight and didn't evert, and I had soreness in my back consistent with changes that were purportedly happening, that is the adaptive curves were noticable by their soreness and the stretching side felt stretched. Now it is going to be hard for me to doubt the evidence of my own experience. I think one of the CPR rules actually is evidence of this syndrome also. I had a similar experience with spinal manipulation, I could put my finger on the pain, could feel the stepoff of the disc and when I got manipulated both disappeared immediately and I felt the joint move precisely where I thought it should move. It had hurt for three months and hasn't hurt again in 20 years. So I was sold and just hoped the evidence would catch up.

JLS_PT_OCS -> Re: Patient Case: SIJ dysfunction (October 11, 2005 2:51:00 AM)
Erica- Good question you posed. Chris, my public relations man, has cleared that up for me. But seriously, I'm not sure what techniques the DC used. The "box of chocolates" idea comes up, in that I have no idea what kind of chiro she saw. (similar concerns could be leveled at PTs, of course). I explained to the patient that I thought SIJ dysf was over-diagnosed, but that I had seen a few folks with what I was convinced was a true biomechanical problem, and that I thought she was one of those people. I thought her best shot for acute pain relief was the manipulation, but that I expected it to be temporary as it had been with her chiropractor. I said if it was a problem that could have been fixed with a simple "pop" then she would not be in the office, the DC would have "fixed" her. I told her the stability exercises she had already been taught were likely her best route for long term relief. Also, I did explain why the combination of manipulative care and specific exercise rehabilitation was so important, and why PT was her best bet for that (had to give her a quick PT plug). :) Randy- I don't have an explanation for the apparent "biomechanical" problem/solution you describe. I think these true mechanical problems are pretty rare, but perhaps you are one example of the person who's body works the way the manual therapy books said it should. Ever seen the movie "Constantine"? Remember what the experienced Constantine tells his green-but-well-read apprentice about fighting demons? "It's not like it is in the books." I feel like I tell students that all the time. I guess it's sometimes helpful to see that it may indeed be just like the book...sometimes. J

Yogi -> Re: Patient Case: SIJ dysfunction (October 11, 2005 9:30:00 AM)
Jason, well you'd think if musicians can be Knighted,.... I wouldn't hold my breath for a Forum Knighting, even for a #1 poster. Randy, good post, I always love a reality injection. Thanks.

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