Movement Stability and Low Back Pain by sdfsb346f

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                             Movement Stability and Low Back Pain
                                                (Sacroiliac joint)
                                              Dr Andry Vleeming

                                   Friday 2nd Dec, University College Hospital,
                                           Archway Campus, London
                                             Organized by PhysioUK
                                  Janes notes taken during the conference.

 Anatomy & Physiology

 Internal pelvic movement occurs at the SIJ.

 Tiny movements occur at the SIJ and these are crucial. There is a 1-2mm movement between carpals in
 the wrist—the accessory movements. This may not seem like much but when this small movement is lost
 due to say, injury, the whole of the upper limb is affected as the wrist does not function optimally therefore
 the elbow and shoulder do not function optimally.

 The left and right SIJ are different in function.

 Motor control is influenced by what we think. This is especially true of cramping and splinting.

 Form closure refers to the principle form of a joint - how does everything “fit” together? The form closure
 in men and women is different. In men there is more force on the SIJ as the line of gravity is further away
 from it. In women, this means that the line of gravity is further away form the hip. If you have decreased
 form closer you need increased force closure.

 Force closure is the extra effort required to close the joint through e.g muscle action. Deeper structures
 have good force closure than superficial structures. E.g cruciates are excellent as they are close to the
 centre of rotation and are great at self bracing. Deep muscles are therefore better at bracing. In the SIJ,
 nutation leads to an increase in tension in ligaments and therefor force on the joint. Making movement
 using a big lever increases tension in the ligament. E.f when abducting the gh joint there is automatic
 external rotation of the arm due to increased tension in the anterior ligaments which are 20-30% thicker
 than the posterior ligaments (?)

 Continual self bracing with high forces blocks off the capillary bed leading to ischaemic changes and
 muscle pain. This occurs when a muscle contracts for 30% or more.

 Lordosis is completely related to function in the hips.

 Pelvic position alters according to our mood.

 Sway standing diminishes activity of multifidous by 50%; slump sitting diminishes it by 30%.

 Compare with the form and force closure of the glenohumeral and scapulothoracic joints:

 The glenohumeral joint has reasonable form closure but because it needs to be mobile this is not as good
 a form closure as the hip. Therefore we need increased force closure which we get from the rotator cuff.
 The scapulothoracic joint has poor form closure and consequently requires enormous force closure (in
 the form of serratus anterior).

 Before we can load a joint it must be compressed. In the pelvis we have nutation and counternutation.
 Counter nutation occurs when there is less than optimal movement. Counter nutation is the same as
 anterior rotation of the ilium.



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  You cannot increase muscle strength without also increasing tension in fascia. Transversus is related
to the thoracolumbar fascia which itself attaches to the transverse processes of the vertebrae: to self
brace this area the fascia must be taught. How do you tense the thoracolumbar fascia? Sit upright and
reduce the lordosis slightly.

In forward flexion it is impossible to keep the lumbar spine “hollow” as you get 85% flexion in forward
flexion and this tightens the thoracolumbarfascia.


Pathology
Pelvic Girdle Pain (PGP) is a sub-group of Low Back Pain which can be described as being specific.

There is a greater incidence of pelvic pain (lower than L5) in women than in men.

LBP can lead to head pain as you are unable to dissipate the force transferred through the body

Less than optimal stability in a joint may lead to increased motor units firing, increased muscle
contraction, which leads to hypoxia, chemical changes and pain.

The dorsal ligament may trap the dorsal rami S1-3



Diagnostic imaging
Conventional radiography is extremely poor sensitivity in detecting changes in the SIJ.

MRI discriminates SIJ changes but should only be used when “red flags” are present.


Assessing the SIJ
It is extremely difficult to assess the SIJ using manual testing methods.The SIJ is actually 3-4cm away
from our fingers when we palpate the area as we need to feel through skin, fat, fascia, and the multifidous
muscle.

Movements in the SIJ are extremely small.

Palpation of SIJ movements does not work. Injecting tantalum markers into the area we can be accurate
to 1/10th mm. When asked to identify movements and anatomical structures 60% of the top manual
therapists were inaccurate.


One of the main problems is that during testing, the patient will use any co-contraction possible to
stabilize a less than optimal joint. Therefore we do not have intra-patient reliability.

Always use pain referral maps.

Our emotional state alters the position of the spine. Ensuring the patient is emotionally comfortable
before assessment is crucial.

Manipulations do not alter the position of the SIJ as this has been tested by performing MRI before and
after manipulation.


Is not possible to palpate the Inferior Posterior Iliac Spine but we can palpate the long dorsal ligament.
This feels like bone and is only positive if one side is painful.

There are 6/7 tests for PGP (see below)


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 Patient must be able to locate the exact position of the pain for it to be PGP.

Use Short Form 36 before and after treatment. If your physical markers have improved (e.g increased
physical fitness) but the patient reports a similar pain level then intervention has failed.

If two tests positive no need for further testing if patient history confirms diagnosis

Tests
Posterior Pelvic Pain Provocation Test (P4)
Patrick’s Faber Test (fl, abduc, external rotation)
Palpation of the long dorsal SIJ ligament
Gaenslen’s Test
Symphysis Pain
Modified Trendelenburg’s Test
Active Straight Leg Raise (ASLR) Test

When performing the P4 test use only 1kg downward pressure. The test will not work if the patient is in
pain as co-contraction occurs. Use abdominal breathing to relax.

Gaenslen’s test is in supine with one leg in knee flexion and the other off the couch in extension, then
active flexion of the extended leg.

When using active SLR If pain decreases when more force closure applied this is positive for PGP.
Patients find ways of increasing force closure themselves. For example, by lifting alternate shoulder off
the couch (as in oblique curl) or rotating their leg before they lift it 20cm off the couch. Alternatively the
therapist can apply force closure by pressing 2kg approx above both trochanters.

Note that the ASLR test is not a pain provocation test but a test of function. E.g 0 is no problem: can raise
to 20cm and hold for 2-3 secs, 5 = impossible to raise at all.

In the Modified Trendelenburg Test, observe what the client does before lifting the leg…do they brace?

Treatment for PGP
You can start at any point on the Integrated Model of Function (ie with the patient’s emotional state and
body awareness, with force closer, with form closure or with motor control).

Body awareness is essential.

Integrated therapy is essential in treating pain.

changing from thoracic to abdominal breathing greatly influences force closure. Therefore, in order to
alter how a joint works, start with breathing.

Treat as for LBP but do not use levers which are too long during rehab. When there is non-optimal joint
stability.

Start with core control such as transversus.

Pelvic belts may be used in the short term only (as in long term they alter motor control).

Do not fuse SIJ as this decalcifies the joint.

Acupuncture is useful as it changes the neurophysiology in the body

Postural therapy is crucial

Contractions should be low level. Vleeming told the story of a therapist who misunderstood information


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 given in a lecture about pelvic floor training and got their patients to do maximal Pfloor contractions.
The result was distortion of the pelvic lymph nodes and abnormal pelvic pathologies.

Be careful not to prescribe avoidance of movement or you end up with a patient who is kinesiophobic.

Do straight leg distractions in supine for 20 secs to normalize the SIJ and check malleoli are equal.
Vleeming commented that he did this on a patient prior to an operation and normalized the SIJ. Prior to
the op the problem returned and only became normal under anaesthetic.

Lying prone relaxes the long ligament and decreases pain.

Typical four-point kneeling exercises train overall muscles including obliques, erector spinae, trans abs.


The importance of integrated therapy
The patient must love themselves and respect their role in the healing process. Patients who do not love
themselves often fail in rehab.
Patients with loss of motor control/body awareness, e.g stooped posture must train in body awareness
therapy.
Lacking elasticity. What about pendiculation? All animals stretch before they move. Patients must do
stretches, essential to proper functioning of the neural system.
Loading the system with splinting and cramping. Discover why a patient is co-contracting.
Low muscle force. Decreased strength leads to injury.
Locking and loading unilaterally. Share the weight.

220 LBP patients were x-rayed and given their results. 221 other LBP patients were not x rayed.
Those who had been x-rayed and given results had x2 more pain and work absence than those
who had not been x-rayed.



Comments on presentation
From a teaching point of view this was an interesting day as Dr Vleeming presented the same material in
a series of three lectures, each covering the same topics but in greater depth each time. So the second
lecture served as a review of the first. Unfortunately, we did not have time to receive the third lecture al-
though notes were provided.

Jane Johnson MCSP, MSc, BSc, BA(Hons)
Co-Director and esteemed author of Soft Tissue Release: Hands-on Guides for Therapists




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