Joined: December 18, 2006
I'd say both SIJs subluxated and rotated anteriorly. Is there more lordosis than normal? Are her knees rotated more inwards when she walks? How is her posture? How about feet position when sitting (on floor) with legs straigth?
Just mobilise and correct possible SIJ subluxations... check also if sacrum is aligned, it might not be. And she might have hip subluxation too because of all those other dysfunctions...
Provocation tests are not for examing SIJ problems but only finding pain in that area. And pain is usually not there where the problem is.
SI belt can help to handle pain but it will not correct SIJ subluxation(s).
Joined: October 27, 2002
From: New York, NY
How exactly are we figuring out that this SIJ is subluxed and/or rotated. Are you all aware of how much the healthy and LBP SIJs actually move? Not enough to detect motion and position reliably. It also doesn't necessarily move in the patterns spelled out by the osteopathoic disciples. Studies have born this out. I think our profession needs to prove motion and palpation testing or finally move beyond it.
No one is saying the SIJ isn't a pain generator. There is ample evidence it does cause LBP. Some estimates have been as high as 30% in chronic cases. However, ruling it in or out is tricky. Laslett, as previously mentioned has developed the most fully tested system available for clinical use. Unfortunately, the movement, palpation tests are simply ignoring the research.
Joined: December 18, 2006
Healthy SIJ is not moving much. But when it is subluxated it is more loose (hypermobile). According to medical studies many people have asymmetry in pelvic mechanics...
Some estimations about SIJ as a pain generator is much higher than 30%. But when talking only about pain in SIJ it is much less. It generates pain to muscles and wear & tear to joints on hips, knees and ankles when pelvis is not working correctly... It changes the mechanics of walking. it causes sterss to discs and joints. There are many medical studies about those...
If one of 14 tests is positive you should consider SIJ subluxation. When they tested me with 4 tests they diagnosed it wrong: I had pain on right side, right leg was longer. They diagnosed SIJD to right side. That was wrong side. Table 3: http://www.ptjournal.org/cgi/reprint/82/8/772
Standing and sitting flexion tests are enough. It is a mistake to follow the pain. And that is what provocation tests will do.
Here one PT, who has been 10 years in Advisory board, World Congress on Low Back Pain and the Pelvis is telling a great text: "Here is the mind blower. In 1982 the American Academy of Orthopaedic Surgeons met in Toronto specifically to address LBP. They established criteria for testing and for the interpretation of those tests. They assumed that the SIJ was so strong as to be immune to injury through minor trauma and paid scant attention to it. They also reported that 'in spite of thorough examination they could establish a firm diagnosis less than 15% of the time. What they did not seem to realize is that when you use their recommended tests and interpret those test in the recommended manner that you will be compelled to miss the diagnosis over 85% of the time! It's not that they are not an intelligent group, but they just have not considered all of the evidence." http://www.kalindra.com/critical.pdf
DonTigny has a lot of experience and education. And he is a PT. Why is he not right about that?
Joined: April 26, 2002
The older I get the more amused I get with these discussions. Usually some fairly recent grad (in this case not even a PT) with very strong opinions on how things are. It amazes me how strong these opinions are even though they are almost completely based on conjecture. The following study for all intents and purposes puts a nail in the subluxed sij coffin.
1: Spine. 1998 May 15;23(10):1124-8; discussion 1129.Click here to read Links Manipulation does not alter the position of the sacroiliac joint. A roentgen stereophotogrammetric analysis.
Department of Orthopaedics, St. Goran's Hospital, Stockholm, Sweden.
STUDY DESIGN: A roentgen stereophotogrammetric analysis study of patients with sacroiliac joint dysfunction. OBJECTIVES: To investigate whether manipulation can influence the position between the ilium and the sacrum, and whether positional tests for the sacroiliac joint are valid. SUMMARY OF BACKGROUND DATA: Sacroiliac joint dysfunction is a subject of controversy. The validity of different sacroiliac joint tests is unknown. Long-standing therapeutic tradition is to manipulate supposed dysfunctions of the sacroiliac joint. Many manual therapists claim that their good clinical results are a consequence of a reduction of subluxation. METHODS: Ten patients with symptoms and sacroiliac joint tests results indicating unilateral sacroiliac joint dysfunction were recruited. Twelve sacroiliac joint tests were chosen. The results of most of these tests were required to be positive before manipulation and normalized after manipulation. Roentgen stereophotogrammetric analysis was performed with the patient in the standing position, before and after treatment. RESULTS: In none of the 10 patients did manipulation alter the position of the sacrum in relation to the ilium, defined by roentgen stereophotogrammetric analysis. Positional test results changed from positive before manipulation to normal after. CONCLUSIONS: Manipulation of the sacroiliac joint normalized different types of clinical test results but was not accompanied by altered position of the sacroiliac joint, according to roentgen stereophotogrammetric analysis. Therefore, the positional test results were not valid. However, the current results neither disprove nor prove possible beneficial clinical effects achieved by manipulation of the sacroiliac joint. Because the supposed positive effects are not a result of a reduction of subluxation, further studies of the effects of manipulation should focus on the soft tissue response.
Joined: March 15, 2006
Question: How powerful is a study that looks at 10 patients? When I was in PT school, I had about 50 subjects in our study on electrical stimulation and its effect on strength gains. I learned that I could prove just about anything that I wanted because the low n was just not very powerful at all.
He who is wise in the ways of science The Omniscient One
Joined: December 22, 2006
I think a lot of physical therapists confuse evidence-based medicine with Science-Based medicine. Just because we haven't figured out a way to measure objectively what we feel doesn't mean it doesn't work. Not only that, sackett himself said that evidence based medicine meant looking at all levels of evidence - level 4 clinical opinion is still evidence, just not "strong" in light of RCTs and reviews etc.
How many really good studies are there out there that don't have methodological problems with them?? I would wager that we rush too eagerly to do studies on things that we don't understand properly. I still trust my hands more than some scientist who has done a review of studies.
I agree with FLA that most problems are control issues and not subluxations. And i specialise in the SIJ. As for those who scoff at the small movements achieved in the SIJ, i would argue that mere milimeters are signficant - i have a shower screen door that slides on rollers. If the screw holding the roller onto the door moves only a few mm, the door scrapes with a nasty noise. We are all PTs - i am sure no one will argue with me that the human body is an amazing machine that we simply don't understand well.
As for the patient in this discussion, compression of ASIS on ASLRT simply means start transversus abdominus training...