SI instability (Full Version)

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FLAOrthoPT -> SI instability (September 15, 2004 1:11:00 PM)

what are your preferred methods of treatment for SI instability? Any specific belts you like? Any specific exercises? Any specific manual techniques? Just curious..



Bournephysio -> Re: SI instability (September 15, 2004 2:47:00 PM)

Belt: just a normal velcro si-belt. The ones with extra tightening straps are nice (Diane Lee's?).

Exercises: Multifidus/TA followed by slings ala Hodges/Lee/Vleeming + targeting specific deficits prn (e.g. post glut med)

Manual Techniques: if its not "locked": nothing if it is "locked": 1. sidelying si gap since it won't irritate any underlying Lsp pathology.
2. Shotgun m/e
3. upslip manip (not just for upslips)
4. other m/e

Other: acupuncture

Doug



j.avakian -> Re: SI instability (September 15, 2004 7:12:00 PM)

I like the principal of Diane Lee's belt but the last three ladies I have used them with didn't like wearing them because they were too bulky to fit under their cloths (and wouldn't wear them on the outside). Therefore they didn't wear them as long as I would have liked. (But while using them they had greater recruitment of muscles and less pain in standing/walking). Therfore I have gone back to simple velcro straps.



Alex Brenner PT MPT OCS -> Re: SI instability (September 15, 2004 10:17:00 PM)

I use the Serola Biomechanics SI belt (www.serola.net). They recently have an advertisement on the back of the latest copy of Orthopaedic Physical Therapy Practice magazine (the one that comes with your Ortho section dues). It is not very bulky and I get pretty good feedback from patients with it.

As far as exercises, I usually have the patient perform a lumbar stabilization program that focuses on multifidus and TA. I can send you a copy of it if you like. Good luck.



eam -> Re: SI instability (September 16, 2004 4:24:00 AM)

Hi!
I prefer the Active SI belt. More neoprene like-but with a good hold-able to be worn under clothes. I have a patient who has the Serola and the Active one-she uses both-but the active one, I think, is easier for her put on and take off. These patients, for me anyway, are in the "more challenging to treat" category. I put her on a stabilization program both open and closed chain exercises-very small movements, small ROM-multifidus, abds, glutes etc). THe open chain ones flared her up in a big way. In the prone position, even lifting her leg like 2 inches off the floor-increased her sx's. So, I am trying to think of strictly closed chain that will effectively do the job. Any ideas? I actully that maybe she had Ehler's Danos Syndrome-she was that bad. But I spoke with the physician and he wasn't so convinced.
Erica



Shill -> Re: SI instability (September 16, 2004 4:30:00 AM)

Well, in case you wanted another opinon that could generate some uproar, here is mine. I dont treat the SI joint. The last time I generated any treatment directed solely at the SI joint was years ago. Funny that my patients are still getting better without this. A belt that the patient will wear is the only thing that I find useful, if, in fact, SI instability exists. As we all know, though may not like to admit, our tests for SI mobility/stability, etc., are simply unreliable, and I dont like basing my treatment programs on unreliable tests. To me, its a lot like guessing.
I am open to change, but nothing I have seen or heard yet (11 years) changes my mind. I used to scoff at the approach I use now, (repeated movements, centralization, etc) but have since seen the light, through helpful research that validates this approach. SI approaches have not had this to bolster their following. Perhaps I will come around on this issue at some time in the future, but I am not holding my breath.



hmgross -> Re: SI instability (September 16, 2004 5:35:00 AM)

I agree with Shill. I really don't know that an SI belt does much, but it can provide some proprioceptive input, feels "good" because it hugs around the sore spots. I own the Serola belt Army described, and it serves me well(it stays put and can be worn under jeans). Unilateral press ups have helped in the past (on the opposite side if the symptomatic SI appears anterior). I do use muscle energy techniques at times but Mulligan in the L5-S1 works well too. I have noticed that I NEVER have SI sx when walking/jogging on a regular basis.



FLAOrthoPT -> Re: SI instability (September 16, 2004 1:53:00 PM)

yeah, shill and company, but do they actually get better for good when you ignore their sacrum, or are they the patients who seek other clinics and other docs because it keeps coming back. The same ones who show up at my clinic and say after treatment, wow it really is better and it has not come back, the same ones who said "they only did things for my low back and it got a little bit better but not all the way so I stopped going". I think the SI is actually WAY underrated as a source of pain. I find palpation skills combined with stress testing combined with the Active SLR test (DIanne Lee) are VERY reliable both inter- and intra- rater. My 2 cents...so far I tend to agree with everyone here on their SI Tx, just not sure if anyone had a magic pill...just takes time, especially if recently pregnant...



Augustine5I -> Re: SI instability (September 16, 2004 4:57:00 PM)

HI FLAOrthoPT,

This region of the body is a bit complex. Be careful with any "shotgun" technique. Try to be as specific as possible related to the cause of the instability.
If the instability is due to muscle weakness, proper training to gain back "stability" should be the focus of your treatment. I find weakness of the gluteus maximus and multifidus muscles to be a particular problem.
After all, if you somehow manipulate the hypomobile SI it will only be a temporary fix if the reason it got that way was poor lumbosacral stability. The patient/client would be forced to use muscle energy techniques as symptomatic management.
I have used manipulation or adjustments to this area depending on how the person presents. But if the sacrum is sidebending or upslide or outflare or whatever....you must know which side and in what way to perform the procedure.
As always, it is probably a combination of proper therex instruction coupled with good hands on treatment that will win the day.

I don't know if anyone has exact data, but I have always read that true S.I. joint problems only account for 15% of all back pain patients.

Just my limited knowledge on the subject,

Tom H.



j.avakian -> Re: SI instability (September 16, 2004 7:53:00 PM)

If you guys read Richard DonTignys articles one may be led to belive the SI is the only source of LBP and not the disc or facets. Which is a statement he makes in one article I have read of his. (Jounal of Manual and Manipulative Therapy Vol 2 No 4 1994) Also He puts 30 yrs of his own research and clinical experence against this belief too. (He has a web site with a lot of his own information on it but I can't seem to find it tonight).



Alex Brenner PT MPT OCS -> Re: SI instability (September 16, 2004 9:48:00 PM)

I actually read somewhere that SI joint problems account for less than 10% of all back pain, however, I have peer reviewed other therapists notes who would swear that 9 out of 10 backs they treated the SI joint was to blame.

Here is some interesting information from several experts on low back pain. You will recognize some of the practitioners who made these quotes...

[list]
  • "80% of back pain is caused by weak or tense muscles..."
  • "The majority of back pain originates in the Sacral ligaments."
  • "In 50% or more...the facet joint is the site of dysfunction.
  • "90-95% of back pain is due to disks"
  • "An extremely high percentage...have fascial problems"
  • "50-70% of chronic symptoms are psychosocial in origin"
    [/list]

    It is apparent from above that the experts do not agree. Remember, these are EXPERTS who made these quotes. Here is the bottom line.

    [list]
  • We can only diagnose definite pathology in about 15% of patients with LBP.
  • There is very little relationship between physical pathology & associated pain and disability.
  • We regard back pain as an injury, but most
    episodes occur spontaneously with normal everyday activities.
  • High-tech imaging tells us very little about simple backache.
    [/list]

    In my opinion, the diagnosis part of managing low back pain is not that important. What is important to me is improving Oswestry scores in a reasonable amount of time using an evidence based approach whether by manipulation, lumbar stabilization, pnt education, exercises, medication, or a combination of these above.

    Just my thoughts.

    Army



    • PTupdate.com -> Re: SI instability (September 17, 2004 4:40:00 AM)

    Sometimes I have more of a "shotgun" approach to instability...not so much the manipulative technique as just "blasting away". I don't want to spend time focusing on a group or two (musculature) that may not be the right ones. Therefore, if it crosses the joint or can influence the joint, I strengthen it (including lats, hip rotators, glut med/max, hip flexors, hamstrings). Seems to work quite well for me.

    Recently worked on a young girl with instability that drove from another state for me to treat her. I was the only one with success, and used the above approach. However, symptoms/signs returned when she stopped doing the whole routine...still performing some but perhaps not the right ones, or ones that need other exercises to augment the effects.

    John Duffy, PT OCS
    [URL=http://www.PTupdate.com]www.PTupdate.com[/URL]



    Shill -> Re: SI instability (September 17, 2004 9:20:00 AM)

    FLAOrthoPT,
    Do they get better for good you asked? Sure they do. How do I know? Outcome data and outcome surveys.
    Everyone has patients who stop coming, for a myriad of reasons. Improper care is not a reason I lose patients. I see quite a few folks who have seen the HUMMERS (Hotpack, Ultrasound, Massage) and arent better as well. I also get those who have had previous PT directed at the SI joint, who are equally unsatisfied.
    [QUOTE]I think the SI is actually WAY underrated as a source of pain. I find palpation skills combined with stress testing combined with the Active SLR test (DIanne Lee) are VERY reliable both inter- and intra- rater. [/QUOTE]Thanks for your opinion, but unless you are far better than all of the researchers, that is all it is, an opinion. The key word in your quote is think , but the research puts to rest any thoughts of reliability.

    There are so many misconceptions on back pain, as well as back pain management. Army's post outlines many of these. Fact is, we dont know that much. I try to use approaches/ techniques that not only have been validated through research, but make some biomechanical sense. SI treatment makes little to no sense to me. It is based on how malalignment = pain. I dont believe we are supposed to be perfectly symmetrical in all planes. Many studies have disproven that asymmetries lead to pain. You can throw all of the left on rights, right on left stuff at me all day, but I think it was dreamt up by someone who simply wanted to make it seem so much more technical than it needs to be, out of some insecurity regarding the thought that his or her skills demanded more respect. "Look at how complex this pelvis/innominate/sacral rotation problem is.... I must need to be a genius to fix it."
    Naah, no genius required.
    Bottom line - At the moment, there are many "accepted" ways to treat LBP. Few have been proven superior over others. Some have been completely refuted. If, in fact, your outcomes are superior, study it, write it up. Maybe you, FLAOrthoPT, could become the one who validates the approach.

    Have a nice weekend,
    Lets hope Jeanne stays away from y'all

    Steve



    Bournephysio -> Re: SI instability (September 17, 2004 11:01:00 AM)

    Shill, you do realize that all your comments go the other way around as well.

    Lumbar treatment makes little to no sense to me. It is based on how malalignment = pain
    You can throw all of the esrs and fsls, reil and ta dysfunction stuff at me all day,but I think it was dreamt up by someone who simply wanted to make it seem so much more technical than it needs to be, out of some insecurity regarding the thought that his or her skills demanded more respect. "Look at how complex this lumbar derangement/instability/rotation problem is.... I must need to be a genius to fix it."

    There is little doubt that the sij can be involved in low back pain. There is more mechanical evidence that an si belt can significantly effect si instability than there is that tranverse abs can significantly effect lumbar stability.

    If you only did treatment that there was reliable and valid assessment for and has been proven to be valid and effective you would probably be doing very little for your patients. Not mackenzie not manipulation not transverse abs/multifidus retraining not mcgills stability exercises.

    Doug



    FLAOrthoPT -> Re: SI instability (September 17, 2004 7:20:00 PM)

    i was talking purely SI lig instability, not malalignments. I mean ones in where the Ant and Post fibers are so strained that you can have like 1-2 inches of play in an A-P direction. Ones that when you physically hold the pelvic girdle together the patient can do a full single leg squat yet when you let go they cannot weight bear. I was only talking about that specific condition, that of instability/laxity.

    Anyway though, let's tear apart McKenzie some. I feel that M is "an idiots guide to backs." It is a cookbook approach as far as I am concerned that sometimes works not based on the principals of fixing derangements but by unintenionally doing neural glides and small amplitude self mobs. I truly doubt if you think long and hard about it that M approach is doing what it says it is doing, and results are fortuitous at best based merely upon happy coincidence that the true problem is being targeted without meaning to. I find that with good palpation and treating the entire Lower quadrant with combinations of whatever is necessary be it mult. re-ed, SI stabilization, manipulation, ROM, etc, you need to pick what is needed for what the dysfunction is. If you try to find a magic pill,..err...McKenzie, and use the cookbook with 2 pages..flex or ext. to try to treat every back patient you are hopefully
    either getting lucky that nature is healing these patients anyway or maybe taking advantage of secondary unintended treatments/gains such as neural glides/mobility. Most good ortho PTs do not use the same treatment for anyone never mind for "low back pain." You need to constantly assess and determine the dysfunction and treat accordingly. I think neural tension and instability as well as SI and DDD with neural impingement accounts for WAY more incidences of low back pain than muscle strain and disk HNP/protrusion.

    Once again, you'll be quick to point out this is my opinion, but no kidding, this is an opinion board....it is merely Mckenzie's opinion, or Paris' opinion, or MAitland's opinion, maybe we should take their theories and use them as theories but not as sacred text. It is unwise to hold only one tool in your tool belt, hope you see the light one day..



    FLAOrthoPT -> Re: SI instability (September 17, 2004 7:23:00 PM)

    ps, believe it or not I even have opinions about outcome surverys. Never have used them, never will. I mean, have you ever filled out an outcome survey for anything, like after taking a course, etc. Where you not in a rush to just be done, did you really take the time to fill it out to the best of your ability weighing each question and each answer..outcome surveys may be a gold standard, but 12 karat gold at best. I think if we could do a third party outcome measure then that may tell us a whole lot more, but until then I'd rather base my success on whether or not I see that patient being able to do everything they have potential to do without incidence....



    SJBird55 -> Re: SI instability (September 18, 2004 3:11:00 AM)

    What exactly do you mean by a third party outcome measure?



    FLAOrthoPT -> Re: SI instability (September 18, 2004 11:10:00 AM)

    well, if the PT does the outcome it is biased, if the patient does the outcome survey it is biased. If a non-biased person were to do the survey based on observation let's say, then it would be less biased, not that this can happen, but that would be 3rd party



    SJBird55 -> Re: SI instability (September 19, 2004 4:36:00 AM)

    Then why do studies indicate that the outcome tools are valid and reliable, even though they are self-reports?



    FLAOrthoPT -> Re: SI instability (September 19, 2004 6:41:00 AM)

    look at the bias though, valid and reliable for who, all i am saying is that patients will skew their answers either in attempt to please or displease the therapist. How many times do you see people who have great things to say, oh they were so nice at the other place, but then when it gets down to it they were not getting better. Or other way around, someone who got very better, not as good as they wanted, and will skew the results, will still be reliable, because they will be reproduced between raters i would guess, but valid to what. What is the validity measured against, i think it is being measured against either other scales (with more biases) or against observed functional improvement? I just do not get what the validity is measured against. For example, OASIS forms for medicare, I do about 7 a day, all outcomes check box format. Well i keep it correct, but when in doubt of course i will skew it to make it look like greater outcome has been achieved, same when they fill out the start of care oasis, you are going to naturally have a bias towards underestimating the patients ability to make your outcomes look better. I think this is true when either the PT or the patient fills out outcomes, they will be very skewed, but skewed consistantly so it shows good reliability. Isn;t it easier to just check your goals, if you wanted the patient to be able to jump 3 feet, and run and hop 5 times, and perform cutting maneuvers on grass and kick a ball 30 yards all without pain during or after, and the patient can now do that, then bingo, success. Or even better, goal:patient will return as starter on soccer field and play 2 full games without pain, instability, or swelling or compensation in 12 weeks. And the patient does just that, then success. Well of course I knoww ith backs it is sometimes harder, but I feel a lot of times it is because people give up to quick, or chalk up another "chronic back." I mean when properly rehabbed how many "chronic backs" are there really?I am very much rambling but I think if someone comes in and in your histiry they say i can no longer pick up my grandchildren, no longer drive for more than 1/2 hour at a time, and no longer carry boxes greater than 20 pounds, then great, here are your goals, why need 20 more pages of paperwork for them to fill out? Either you know youhave succeeded in your goals or not. I am rambling, I am done, obviously I feel that outcome measures are a waste of time and aggravate patients, and used merely to justify treatment to insurance companies, I still say the proof is in the pudding: that is if the patient is better, you'll know it, you wont need to say look mr.smith, it says here that really you ar bette, your scores have gone up 7 points, see you are better, but yet he still has limitations and pain. I know some patients are such the case where you cannot make chicken salad out of chicken ****, but maybe then and only then you'll need small improvements to justify treatment, but even then if no real improvement in functional outcomes is expected should you really attempt treatment per se or just do a bunch of education in one or two visits and d/c. Ok I am digging a hole, just wanted to respond that I do not like outcome surveys, i am out of breath.



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