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Re: SI instability
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Re: SI instability - September 20, 2004 4:35:00 AM
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Shill
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From: Madison WI USA
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Doug,
I agree with you on all of the "esrs and fsls, reil and ta dysfunction stuff". Thats why I dont use those methods either. Speculation based. Not for me. I like the idiots approach to back pain, despite FLAorthoPT's many opinions . Just look at how well all of those "idiot's guide to (insert anything here)" are selling.
Yours in idiocy (idiocrity?)
Steve
_____________________________
Steve Hill PT
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Re: SI instability - February 1, 2005 3:53:00 AM
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JLS_PT_OCS
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I would agree with posters that state much of back treatment is unnecessarily complex, and part of it may be to make the methods or skills of a practitioner appear better. Of course there is a whole profession based on this. (not mine)
I know there is some promising research and good outcome studies supporting TrA retraining and lumbar stabilization, manipulation, and even a newer study using the patient's directional preference in symptoms to select exercise therapy.
I know of no studies about the biomechanics of the SIJ that prove an SI belt can improve SI stability, much less that such evidence is greater than that for the previously posted interventions.
Doug, if you've got such evidence, please post it. Perhaps I am missing an essential element of care...though until I see some data, I am reluctant to buy any of these belts.
I agree they may be useful in the management of an individual patient, but lots of other interventions are like that...unproven, questionable, but occasionally helpful.
For example, I get good response from many patients with traction, but I would never state such a treatment is evidence-based. But it works sometimes, I don't know why. So I keep it in my toolbox (which perhaps should contain SIJ belts as well?) but I still always start with evidence based treatment first.
That way, most patients improve the way the literature says they will, and for others whom I incorporate traction, SI belts, or other approaches... I am glad they get better, but I also lie in bed at night wondering if it is just a placebo effect...
Thatis the inevitable result of using such treatments...until the data comes out to support them. Not being a researcher just yet, I guess I have to wait for that...
:)
Jason.
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: SI instability - February 1, 2005 6:40:00 AM
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TLB
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From: Arizona
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I to used to treat the SIJ and use belts for SI instability, but no more. There is just no proven intertester/intratester reliability and studies show the SIJ moves 3mm maximum. I thoughly agree with Shill and Jason on this to start where there has been proven research and go from there. If anyone has some research studies showing reliable palpation or treatment of the SIJ please post a link.
PS.
FLAOrtho have you actually been to a M course? If you have then may I be so bold to suggest that you ask for your money back. It sounds as though you haven't been or you would know it's not just Flex. or Ext. , but has many components including a significant lateral component, mobilization, stabilization and neural glides. It's great for the toolbelt as stated earlier.
_____________________________
Todd
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Re: SI instability - February 1, 2005 8:19:00 AM
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Bournephysio
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From: Calgary
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Jason, the only mechanical evidence that "supports" ta as a stabilizer is a study done in lying down anaesthetized pigs. They showed something like a 20% increase in stiffness with activation. 20% sounds like a lot until you consider that an osteoligamentous spine collapses with 90N of load. A 20% change won't improve that by much.
Vleeming has shown that a relatively small amount of pressure (5lbs I believe) is needed to improve SI stability.
I never said proved anywhere but if it decreases pain in a particular patient, I will use it.
TLB: can you let me know what 3mm has anything to do with whether or not the sij can become painful? As mentioned on another thread, there are validated SIJ tests. "start where there has been proven research and go from there" Where is your proven research for your neural glides?
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Re: SI instability - February 1, 2005 8:43:00 AM
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steve
Posts: 452
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From: victoria, bc Canada
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Jason,
"I know there is some promising research and good outcome studies supporting TrA retraining and lumbar stabilization, manipulation, and even a newer study using the patient's directional preference in symptoms to select exercise therapy."
Could you post the reference for the directional preference in symptoms to select exercise therapy?
Thanks
Steve
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Re: SI instability - February 1, 2005 10:48:00 AM
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FLAOrthoPT
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From: West Palm Beach
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enough with e.b. for a second. Take someone with SI area pain, have them try to do a unilateral squat, now hold there sacrum fixed with one hand and use firm pressure at the ASIS to close the posterior aspect of the SI jt and have them repeat, see if they can do it better or without pain, if not repeat but this time close the anterior aspect of the SI. Well, if this helps, then I have them do the Active straight leg raise test per Dianne LEe, and if I can decreae pain and increase performance by approximatin the ASIS or closing the ant aspect or by gapping closed the post aspect, then I say SI belt will totally help this patient. I have used it with way too god of results to even worry about E.B. And no, i have not done M course, but have worked with several PTs whom have, and read a bunch, and have many problems with the philosophy especially that he only beleives in like 3 caused for LBP. Anyway, I am in too much of a rush to argue M here, but would love to so soon...
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Re: SI instability - February 1, 2005 11:55:00 AM
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FLAOrthoPT
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ok, back...love the SIJ, so I do not mind healthy arguments, even if proven wrong, or even worse made to rethink my treatment approaches (sarcasm). I think the discussions are valuable. but just to throw your hands up and say show the evidence, I mean come on, did you lose all ability to rationally and critically think through a dysfunction and evaluation to find what treatment would be appopriate for the specific dysfunctions you find. You must be one of those people who get stumped when you see a new diagnosis you've never seen and rush to look up an evidence based protocol. i am not one for recreating the wheel, but treat the darn dsysfunction. Is it hypo or hyper mobile is it a neural tension issue, is it a repetitive stress issue, is it a neural impingement issue, etc etc etc...all I can say is I feel I am very successful in treating SI instability problems but do not do anything unusual that no other PT has learned. If it is unstable I work on stabilization, if it is hypomobile I work on mobs and manips, if it is a positional fault I look for the cause up and down the chain, like and L5 dysfunction with the Sacrum being in opposite positioning, etc. I just do not get why everyone has forgot how to treat dysfunctions and scream if there is no evidence I am not doing it? If I cannot at least hypothesize where and why the dysfunction is occurring I am not going to treat the symptoms..So when I have someone who has been aggressively stretching their piriformis (PErsonal trainer told her to) has been running aggressively the past 3 months with a 1/2 inch leg length discrpency and complains of pain in weightbearing right over her SI area then I am thinking SI. SO then when I do a posterior stress test a la NAIOMT and get about 5 times as much play ont he dysfunctional side, and have her do the whole A SLR and functional test with and without active (contract TA/Mult) or passive (me) stabilization and get my results, then I know if I am treating the problem. Of course I want to look at the whole lower chain and figure out if something at the foot is causing excess movement at the hip and SI and L-spine and treat accordingly, and of course I am going to look at the L-spine and see if hypo mobility has casue some excessive movement patterns in the SI...I think Dontigny, Richard Jackson, and Diane Lee are much more evidence based then the older schools of McKenzie. So if this is theoretical rhetorical arguments made in effort to dig up research and evidence for treatment fine, but if you really doubt the significance and role of the SIJ in pathology then yes it us my (in bold as you would like) opinion and many others that you are missing a big component of treatment for these patients.
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Re: SI instability - February 1, 2005 12:15:00 PM
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nari
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FLAOrthoPT
Ditto!!...
I also thought we treated dysfunctions according to our assessment and clinical reasoning!!!
Nari
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Re: SI instability - February 1, 2005 2:36:00 PM
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FLAOrthoPT
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i think this gets lost sometimes...
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Re: SI instability - February 2, 2005 1:33:00 AM
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JLS_PT_OCS
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Steve-
Here is the info on exercise selection and directional preference:
Spine, 2004 December. Long, Donelson, Fung. "Does it matter which exercise? A randomized controlled trial of exercise for low back pain."
FLA -
I don't think anyone espousing EBM (especially me) is arguing that we should not look for impairments in our patients and treat them empirically.
Please don't confuse a preference for evidence based methods as a rejection of all others. That is simply not the case.
Where evidence exists, we should use it. Where evidence does not exist, we should do the best we can to integrate our training and clinical experience to provide the best care we can to our patients. That was Sackett's original definition (paraphrased).
From your mini case study description there, it sounds like you are doing just that.
So it seems you and I actually have the same general approach, and are in agreement. It also sounds like I could learn a lot from your approach. :)
EBM does not equal protocol based therapy.
I think all these tests and biomechanical models you mention can be helpful in that they give us a way to use our clinical reasoning to puzzle out a solution to an individual patient's problem, when there is insignificant evidence to guide our treatment. A place to start, if you will.
No one is saying that does not have value. And no one is screaming that if there is no evidence, they won't use a given technique or procedure. Or if there are, they are out of my earshot. :)
Using EBM methods first, and falling back on impairments and biomechanics models second is not a rejection of methods. It is in prioritization of methods.
If you look at the research being done by some of the top names in EBM Physical Therapy, you will see them mention the term "impairment based approach" many, many times.
Bourne-
Are you really under the impression that there is no scientific proof for Lumbar Stabilization in a human model? Do you really think all of this new research and treatment is based on pigs?
(granted, they're cute, but they just can't seem to progress to the more difficult stability exercises) :)
Please do a PubMed search for these terms and check out the large number of studies demonstrating efficacy in humans. Stabilization exercise is one of the few proven interventions for chronic low back pain. And one we should all be using.
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: SI instability - February 2, 2005 2:47:00 AM
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FLAOrthoPT
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ok, understood, thanks for the clarification
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Re: SI instability - February 2, 2005 3:35:00 AM
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Bournephysio
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Jason, I am well aware of the evidence in this area. Besides being up to date in the literature, I've seen people like Hodges, McGill, Cholewicki, Solemenow, Stokes present at conferences such as ISSLS, World Congress of Biomechanics and IFOMT. Neither the motor control research nor the clinical trials can answer questions about mechanics. There are many reasons why these exercises may work besides mechanics. If you have seen Hodges speak you will have likely seen his slide that has a ton of different possible mechanisms. The pig study I mentioned is the only mechanical link. The only other mechanical study is McGill's stability model. They did not find that ta provided significant stability to the lumbar spine. The pig study is the only one used to support a mechanical role of transversus and it is quite underwhelming for the reasons I mentioned.
Doug
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Re: SI instability - February 2, 2005 4:14:00 AM
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Yogi
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I kind of wonder, if like the pigs, the humans don't have a lot of difficulty progressing to the more difficult stability exercises, and especially using them enough to create a new engram (habit). Seems to me it would take alot of personal dedication to overcome the effects of all the years of adaptations to the body you were born with. I'd like to see a longitudinal study, I just wonder if stabilization isn't another of those bandwagons that come along every few years. The theory sounds good, and logical, but how's it working in practice?
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Re: SI instability - February 3, 2005 12:48:00 AM
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JLS_PT_OCS
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Yogi-
An impressive bandwagon, then. It has shown results in outcome studies that no other treatments have in the conservative management of chronic low back pain.
I have found many people have great difficulty progressing in stabilization, but just about everyone learns enough to significantly decrease their disability and improve their function. I don't claim to be an expert, so perhaps with a better instructor, they would do better. :)
Doug-
Interesting perspective. I guess I am always more interested in results and less interested in the underlying theory and whether or not my results make sense according to that theory.
Perhaps I misinterpreted your statement to mean that you are not in favor of using this protocol because we can't explain biomechanically why it works. If so, I jumped the gun, sorry.
Theories are great and we need to continue to explore new paradigms and models of thought, that's where new innovations come from.
But I very often see people in our profession more interested in theories than in results for our patients, and that is frustrating.
I read a Buddhist writer who once said "get comfortable not knowing".
I think this applies well to stabilization training as well as other treatments we have -- I know they work, I've seem the data, I just don't know why. And to be honest, the more experience I get, the less I care about the 'why'.
I think all of us in the medical profession have spent god knows how much money trying to explain nonspecific spinal pain, and as far as I can work out, it has amounted to nothing. I think I have, as Gordon Waddell put it, abandoned the search for the causitive factors (and therefore, the explanations for why an intervention addressing that works).
Perhaps I have gone too far in questing for results to the exclusion of explanation?
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: SI instability - February 3, 2005 1:24:00 AM
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SJBird55
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An odd question that I'd like to toss out... one of the current exercise fads is pilates. I am definitely not an expert in pilates and I have only done a limited amount of reading on pilates. But... I wonder, if this exercise fad sticks around for a while and has a large population active with this form of exercise, I wonder if back pain may possibly be better controlled in the population as a whole? From the reading I have done, there is a kind of, sort of, parallel in thoughts that stabilization is needed from the core. So, if we as therapists work from a "stabilization" theory of sorts, then if that particular exercise is being done by a healthy population (with the same sort of philosophy behind the exercise) then can it potentially be extrapolated that maybe the population will have less back pain?
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Re: SI instability - February 3, 2005 4:52:00 AM
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JLS_PT_OCS
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I actually have some experience with Pilates and with several instructors of this method. Also my wife is a personal trainer and has done some of it as well.
Some pilates instructors teach their clients to 'stabilize" using their transversus abdominins and progress to harder stability exercises. So in that way, it is very similar.
However, some other instructors are not that picky and will accept the overuse of the external oblique and rectus abdominis to provide the base for the exercises. Obviously, this is not really a stabilization approach, and given current data would not think it would help back pain in the slightest.
Also pilates places a lot of emphasis on supine techniques, often to the exclusion of more "functional' positions. Holy Iliopsoas, Batman!!
So I do not recommend this exercise program for my chronic back patients, be they "SIJ" people or some other cause. But I can see why some PTs use it and integrate it into fitness / wellness practices, I assume they are teaching that program using TrAbd and Multifidus.
I haven't used an SIJ belt in about 6 years, but I guess if I saw a patient who had enough of the findings that FLA mentions, I would think that would be appropriate. I think the problem is more likely one of spectrum bias.
On one end, you've got those people like FLA mentioned who have tons of empiric findings that suggest SIJ problem. The other end contains people with buttock area pain but no findings like that.
There seems to be no evidence that would lead me to use a belt in one patient over another, so in that case we fall back on an impairment based approach and use it in the treatment, see what happens.
The question becomes how many of those findings do you need to see to try a belt, and if there are no assymetry/motion findings, then would you also consider it? There don't seem to be any predictive features about who will or won't improve from an SIJ belt. (that I am aware of).
So, if you use these belts in your practice, what or how many findings do you need, or do you just try them on everyone?
Not being sarcastic, honestly asking.
Thanks.
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: SI instability - February 3, 2005 9:04:00 AM
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Yogi
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Jason, good answer, I thought I was playing devil's advocate and would stir up alot of defensiveness and/or controversy, but nope, just a truthful incisive answer. Refreshing. I take your point, nothing's perfect. If it helps them, they'll do it, if not, they won't. When I used to use SI belts, I'd just try cinching a gait belt around first, to see if it felt better. If I was still in that type of clinic, I'd probably still do it that way. Again, appreciate your humility and clarity.
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Re: SI instability - February 3, 2005 9:18:00 AM
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steve
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From: victoria, bc Canada
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Jason,
Similar to you, I use the belt sparringly and will actually test them with a piece of theraband tied around the pelvis if I don't have one that fits them. The only time I use them is when I get 4/5 positive with provocation tests on the SI joint (FABers, thigh thrust, compression, distraction and sacral shear) and these tests are valid when compared against individuals who experience pain relief with nerve blocks of the sacroiliac joint. While doing the provocation tests, if they state that distraction, or pushing posterior/lateral bilaterally on the anterior pelvis relieves I will give the belt a try. Expectant mothers are also good candidates when the SI is implicated and there is a specific belt that forms to them anteriorly.
Lastly, I have used them on perhaps 3 individuals who truly felt unstable - ie. I glided the pelvis posteriorly (I know - no evidence that we can palapte this movement) and there was a very very lax end feel to the joint. Worked like a charm on these three but admittedly these cases were out of thousands of low backs.
Anyone else care to comment?
Steve
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Re: SI instability - February 6, 2005 10:16:00 AM
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srcase
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From: Michigan
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I have had much success using Pilates-based exercises for patients with chronic LBP and/or SI joint dysfunction. Pilates, if done correctly and modified for the individual patient is very intelligent, purposeful stabilization training that carries over into real-life function. I usually start to train the patient to stabilize in neutral position and then work into flexion and/or extension depending on the patient's deficits. The exercises do not have to be supine and can be taught in sitting, standing, prone, or quadruped. I use Swiss balls, theraband, BOSU, and the pressure biofeedback cuff to give feedback, resistance, and proprioceptive input.
I do agree with Jason that there are PT's out there who have taken a weekend course and are not truly utilizing the correct Pilates principles with their patients. If you are interested in Pilates, I suggest a much longer/intensive course of study such as Stott certification, McEntire Method, or the Physical Mind Institute.
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Re: SI instability - February 7, 2005 3:42:00 AM
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JLS_PT_OCS
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Or in lieu of an expensive certification you can just spend the 30 bucks and get 'Therapeutic Exercise for Segmental Spinal Stabilization in Low Back pain" and get all the priciples and treatment methods of stabilization exercise.
Use your knowledge of biomechanics and go from there. If your goal is to treat patients, and not instruct fitness classes, then go the non-certified route. Who needs it?
I don't think any of the major research studies proving the efficacy of this treatment method used the word "pilates" at all.
I am similarly not aware of any outcome studies using the "pilates method" for back patients.
I don't know what Case means by "correct pilates principles" (alas, I am not certified in this exercise class/marketing technique) but use Occam's Razor and stick with the proven stabilization techniques. None of which require the comical looking and shamelessly overpriced jungle gym equipment that pilates recommends and requires proficiency on for certification.
Case mentions above the treatment modalities discussed in detail in the book and proven in the research studies, which clearly do not require the "extra" stuff.
I am sure Case is very familiar with the dramatic improvement in back pain patients with the stabilization approach. Case's patients probably do extremely well, and that would be no surprise given the ample research support for the approach.
I think you should save your money for some actual medical rehab training, though...
I think there are several CEU programs out there, taught by Physical Therapists, that cover the lumbar stabilization exercise progression, proven successful. You are MUCH better off there than a pilates certification class. In my opinion.
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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