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Palpation of the sacroiliac joint: An anatomical and sensory challenge

Authors:

Abstract

The sacroiliac joint (SIJ) is identified as one of many possible sources of non-specific low back pain and may be a target for diagnostic palpation. Putative diagnostic palpation of joint motion, tissue texture changes and pain form a routine aspect of practice in manual healthcare. However, the tactile tradition of diagnostic palpation is beset with anatomical and sensory confounding that may establish an upper ceiling for sensitivity and specificity. For illustrative purposes, this is highlighted by a review of the anatomy of the sacroiliac joint (SIJ). Increasing critical awareness of the inherent limitations in the tactile tradition of diagnostic palpation may lead to the development of a standardised and technologically based approach.
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Journal of Osteopathic Medicine 9 (2006)
103-107 www.elsevier.com/locate/ii osm
Commentary
Palpation
of the sacroiliac
joint: An anatomical
and sensory challenge
M. Christopher McGrath*
Dunedin Osteopathic
Clinic,483 George Street,900l Dunedin, New Zealand
Received 9 January 2006; received in revised form 8 February 2006; accepted
7 March 2006
Abstrsct
Backgrotmd: T"be sauoiliac joint (SIJ) is identified as one ofmany possible
sources of non-specific low back pain and may be a target
for diagnostic palpation. Putative diagnostic palpation ofjoint motion, tissue texture changes and pain form a routine aspect of
pmctice in manual healthcare.
However, the tactile tradition ofdiagdostic palpation is beset with anatomical and sensory confound-
ing that may establish
an upper ceiling for sensitivity and specificity. For illustmtive purposes,
this is highlighted by a r€view of the
anatomy of the sacroiliac joint (SU). Increasing critical awareness of the ilherent limitations in the tactile tradition of diagnostic
palpation may lead to the development of a standardised and technologically based approach.
Aims and objectives: T o highlight anatomical and sensory
difficulties that may b€ associated with tlle use of diagnostic palpation. To
promote wider critical consideration for the continuing role ofdiagnostic palpation as a tactile tradition in manual healthcare and to
speculate that a technological answer
may provide a more reliable and valid altemative.
Discussiot Reviewing the anatomy of tlle sacroiliac region demonstrates why diagnostic palpation of the SIJ may be more difficult
than may be commonly
perceived,
Furthermore, the somatosensory basis ofdiagnostic
palpation
is a confounding variable that may
not b€ possible
to cicumvent. In an era in which evidence for clinical practice is sought, it is timely that specific
elements of this
distinctive diagnostic tradition in rnanual healthcare
b€ c tically examined. It is speculated that the development ofa technological
solution may provide an alternative.
Conclusion: Review
of the relevant anatomy helps enhance critical thinking about th€ use of palpation in manual healthcare
practice.
The diagnostic examination of tle SIJ by palpation appears to be an accepted investigative approach of manual healthcare but is
coofounded by anatomical and sensory variables. Illustrative of systematic and possibly insurmountable anatomical and sensory
confounding, the continued use of non-standardised, manual diagnostic palpation as a basis for manipulative intervention is
questionable.
There is a need to develop a sophisticated, technologically based alternative that offers a reliable multimodal input,
standardizatiol of findings and comparative indexing of such findings to a reference data-base. Therein lies an opportunity for
a pan-disciplinary /mgua-franca in diagnostic
palpation.
@ 2006 Elsevier Ltd. All rights reserved.
rKelwo./Jr Osteopathy; Diagnosis; Palpation;
Sacroiliac region; Sacroiliac
joitrt; Healthcare; Non-specific low back
pain;
Tndition; Technology
:
-\-,
1. Introduction
Osteopaths and others in manual healthcare practice,
routinely manage'non-specific' low back pain,l of which
* Fax:
+64 3 477 7020.
E-mail address : office@osteopath.co.nz
1746-0689/$
- see front matter
O 2006
Elsevier Ltd. All rights reserved.
doi: I 0. I 0 I 6/j.ijosm.2006.03.00 I
the SIJ is believed to account for between 5-l5oh, al-
though some reports have suggested as much as 20o/o
or 30o .''' Inthis instance,
'non-specific'low back symp-
toms are defined to be symptoms occurring primarily in
the back that suggest
neither nerve root compromise nor
a serious underlying condition.4 Clinical tests that deter-
mine whether the SIJ is a contributing cause in an epi-
sode of 'non-specific' low back pain have recurrently
104 M.C. McGrath f International Journal of Osteopathic Medicine 9 (2006) 103-107
been shown to have poor reliability and validity.s'6 al-
though, more recently this has been contested.T'8
Palpation is a widely used diagnostic adjunct in med-
icine. For instance, it is an accepted
and routine practice
for the measurement of pulse rate, examination of the
cervical lymph nodes or examination of the abdomen.
Yet, it is recognized that diagnostic medical palpation
is limited by moderate sensitivity and specificity. For
example, both the sensitivity
and specificity of cervical
lymph node
palpation for the detection
of metastatic
dis-
ease have been reported to be moderate, in the 60%-
70oh range.e Another study of abdominal palpation for
the detection of aortic aneurysm demonstrated moderate
sensitivity and specificity of the 60%-80% range.tn
In manual healthcare, for which diagnostic
palpation
arguably occupies a routine and defining role in both
diagnosis and subsequent intervention, validity is weak
and a paucity of information exists that establishes
a link between diagnostic findings and therapeutic out-
comes. One systematic review
of the content validity for
palpation used in spinal examination highlights its
diagnostic weakness,ll with poor sensitivity and specific-
ity for segmental motion/non-motion detection and sim-
ilar results for pain provocation. Such findings are also
consistent with the evidence surrounding
osteopathic
pal-
patory diagnosis, which is acknowledged to be diffuse.l2
A need has been identified for the inter-disciplinary
harmonization of palpation protocols and the develop-
ment of reference standardsll that may go some way
to improving the situation. Arguably however, this
may not be the answer as a more recent study of cervical
spine
motion palpation, that included the reference'gold
standard' of non-mobile congenital block vertebrae,l3
demonstrated low sensitivity (detection of non-mobile
segments) ranging between 557o and 78oh and good
specificity
(detection of mobile segments) to range be-
tween 9lo/o and 98o .
Focusing critical attention on the anatomical chal-
lenge that confronts diagnostic
palpation highlights the
potential impact of this confounding variable, i.e.: 'rs
what is thought being
palpated, actually being
palpated?'
A rhetorical but incontrovertible fact remains that the
clinician is only touching the skin, a structure that is
well removed from the target of the examination by
interposing layers of connective tissue. With this in
mind therefore, the anatomy of the posterior sacroiliac
region is reviewed.
2. Anatomical considerations
of the posterior sacroiliac
region
Wide anatomical variations in the size,
shape, con-
tour, facing and location of the SIJ have been observ-
ed,14-to not only between different individuals but also
between sides
in the same
individual.
The skin is the most superficial structure that overlies
the SIJ and provides the immediate tactile input to the
examiner. A subcutaneous adipose layer (SAp), liquid
at body temperature and supported by skin ligamentslT
fills the space between the skin and the deeper
posterior
layer of the lumbosacral fascia
and erectores spinae apo-
neurosis (ESA). The multiple fascicles
of lumbosacral
multifidus (M) lie deep to the lumbosacral fascia and
erectores spinae aponeurosis.
Beneath the skin and the supervening
muscle layers at
the level of approximately the posterior foramen of 52,
the posterior superior
interosseous
SIJ lies
a little lateral
and close to the 52 posterior sacral foramen at a variable
depth of between 5-7 cm beneath the skin (Fig. l, scale
bar). The joint opening faces somewhat posterio-
medially.
To extend a putative 'sensory
reach' to the posterior
SIJ from the skin surface the examiner will be required
to palpate through a number of different structures be-
ginning with the skin, some 3-4 mm thick at this level.
Under the skin lies a subcutaneous
layer composed of
predominantly adipose tissue interspersed with a liga-
mentous network of 'skin ligaments'
possessing
charac-
teristic organisation.lT
These appear to add mechanical
stiffness to the layer and perhaps
indirectly to the region.
Deep to this subcutaneous layer lies the thin posterior
layer of the lumbosacral fascia, inseparable from the
substantially
thicker layer (2 mm) of the erectores
spinae
aponeurosis.
These
two layers form the roof of a com-
partment enclosed by the sacral median ridge medially,
Fig. I . Tmnsv€Ise section of the pelvic region at the l€vel of 52 showing the followidg structurcs: GMx: gluteus
maximus, CMd: gluteus
medius, SIJ:
sacroiliac
joint, I: ilium, S: sacrum. M: multifidus, SAp: subcutaneous adipose tissue, Smc: sacral median crest, ESA: erectoles spinae aponeurosis.
M.C. McGrath f International Journal of Osteopathic
Medicine 9 (2006) 103-l0Z 105
and the ilium laterally.
within this compartment lies
the
muscular
mass
of fascicles
comprising
lumbosacral
mul-
tifidus (M). Deep to the collective
mass
of multifidus lies
a further thin ligamentous layer (not indicated),'t b._
neath which is found a variable layer of white adipose
and loose
connective
tissue
in which may be found a neu-
rovascular
network (posterior
sacral plexus).
This plexus
(not visible
in Fig. l) is closely
associated
with the dorsal
sacral
foramen and the emergent
neurovascular
bundles
of the dorsal sacral rami.te The ligamentous
structures
deep to multifidus also merge
with the interosseous
sa-
croiliac ligaments
of the posterior SIJ.
There
are
seven
discrete
anatomical
layers
of different
composition overlying the superior and middle aspects
of the sIJ. Listing these layers in order of encounrer
from the surface:
skin, adipose
tissue,
lumbosacral
fascia
and erectores
spinae
aponeuroses,
multifidus, ligamen-
tous layer, white adipose layer, sacroiliac interosseous
ligaments.
3. Discussion
Reviewing
the anatomy of the posterior sacroiliac
re-
gion highlights the anatomical difficulties associated
with the reliable
and valid palpation of the
joint. Indeed,
it may be concluded
that the
joint per se is anatomically
inaccessible
to palpation for the following reasons.
First,
it is the overlying skin that is physically palpated. Sec-
ond, the significant
anatomical depth and medially fac-
ing position of the superior, posterior interosseous
SIJ
together
with the interposing
layers,
renders
it inaccessi-
ble to indirect cutaneous
palpation. Third, the superior
and mid portion of the posterior SIJ is an anatomically
ill-defined
structure
of variably blended
SIJ interosseous
ligamentous,
posterior SIJ ligamentous
tissue
and fibro-
cartilage.
This complex ligamentous
region contains
the
long posterior sacroiliac ligament (LPSL). The LpSL
spans the posterior superior iliac spine to the largest,
third or fourth, lateral sacral tuberclesls
and overlies
the SIJ. The LPSL is penetrated
by the neurovascular
branches
of the dorsal sacral
rami as
they exit the sacral
area
to the gluteal region.tn
othets have highlighted the
need to discriminate between
low back pain generated
from the LSPL or the sJJ.20-22
palpation of this region
therefore has the capacity to elicit pain from a number
of different sources
other than the SIJ, and presently
of-
fers no reliable or valid way for discernment of the
underlying
pain generating
structure
or detection
of mo-
tion." Fourth, as palpation may be employed to detect
joint motionr2'rr
it appears
unlikely
thai thlre is a basis
for manually detecting
the tiny amount of motion at the
sIJ through overlying multiple tissue
layers. The vari-
able and convoluted nature of the left and right SIJ
contours ensures
a 'non-standardised'
anatomical pre-
sentation in the same and different individuals. with
scant and unpredictable movement in x axis rotation
(flexion/extension)
of I " to 2" , y axis translation (supe-
rior/inferior movement)
and z axis
translation (anterior/
posterior
movement)
of I mm.2o
Furthermore,
it is sug-
gested
_on
the basis
of a more recent MRI histological
study25
that the SIJ may be classified
as a symphysis
with some
of the characteristics
of a synovial
joint.
with manual palpation and motion testing
said
to be
distinctive features
of osteopathic
diagnosis
that differ
from the standard orthopaedic examination,26
there is
a call for ever more research
requiring the provision of
a credible
scientific
basis
for its use." However, the use-
fulness
of the more traditional means
of study, such as
blinded studies, is also recognized
to be limited.l2 In
spite of the 'evidence
deficit', from a broader perspec-
tive, the use
of palpation (touch) appears
to have unde-
niable value to both patient and practitioner, and an
awareness
of this is stated.28-31
Understanding the simultaneous,
confounding sen-
sory effects
of diagnostic palpation in both the patient
and the practitioner poses
a unique research
challenge
that may be impossible
to surmount. During diagnostic
palpation of the skin, a complex interaction of periph-
eral sensory
and central modulating mechanisms
comes
simultaneously
into play, in both the patient and the ex-
aminer. Low threshold
afferent
mechanoreceptors
in the
underlying tissue
respond to touch, pressure
and vibra-
tion stimuli and have locations that are precisely
map-
ped in the somatosensory
cortex with respect
to body
structure.32
These peripheral afferent
mechanoreceptors
synapse
in lamina IV and V of the dorsal
horn. Wide dy_
namic range neurons that respond both to innocuous
stimuli and to noxious stimuli are also
rocated
in lamina
v of the dorsal horn. It is understandable
that a high
level of activity in nociceptors
has the capacity to alter
the properties
and behaviour of the surrounding mecha-
noreceptors,
such that innocuous stimuli may be per_
ceived
as pain.32
Furthermore, the mere expectation
of
pain enhances
the response
to an innocuous stimuli.33
Extant pain may also
be of cortical origin in the absence
of pathology or dysfunction.34
A persistent,
innocuous
stimulus to low threshold skin mechanoreceptors
leads
to a l0%-20% reduction
in responsiveness.35
Addition-
ally, the idea of the pain-inhibiting-pain effect
is estab-
lished to have a basis in the activation of a central,
specific,
inhibitory pain control system.36
To complicate
matters this neural modulation occurs in two individ-
uals,
the practitioner and the patient, because
of a single
act of diagnostic
palpation. considering these
neurolog-
ical effects
together with the anatomical challenge
that
besets
tactile diagnostic
palpation, achieving
high levels
of validity for joint motion detection,
positional obser-
vations, tissue texture changes or pain provocation
may be insurmountable.
The development
of a linguafrancain manual health-
care by harmonising manual examination techniques,
106 M.C. McGrath f International Journal of Osteopathic Medicine 9 (2006) 103-107
standardising terminology and developing an qcceptable
reference
standardlt -uy collectively contribute to an
improved validity but as long as the confounding 'con-
stants' of anatomy and neurology persist,
a validity ceil-
ing will continue
to be present.
One recent double-blind,
randomized,
placebo-controlled
study3T of neck
pain pa-
tients, demonstrated no efficacy for diagnostic palpation
used in cervical endplay assessment,
as an indicator for
spinal manipulation. No association
was found between
palpatory findings and manipulation outcomes. Tseng
and co-workers38
also suggest that the predictors for
(identifying) immediate responders to cervical manipu-
lation in patients with neck pain do not include exami-
nation by palpation. No aspect of the physical
examination used in this study, whether 'initial cervical
range of motion', 'compression tests' or 'side gliding
tests' were
statistically significant
(P < 0.05).
A marginal
case of significance was made for the solitary finding of
'extension'
conducted in the 'compression
test' that was
associated with a P value of 0.07.
Further observations regarding the range of cervical
motion were made in another recent
study3e that sought
to assess
clinical tests
of musculoskeletal
dysfunction in
the diagnosis of cervicogenic
headache. The cervicogenic
headache group demonstrated consistently less neck
movement than the migraine and control groups
(P :0.048), in cervical flexion and extension. They
were also found to have a higher incidence of painful
upper cervical
joint dysfunction assessed by manual ex-
amination (P < 0.05)
Linear discriminant
analysis found
that the manual identification of painful, stiff joints at
CI12 described as 'painful joint dysfunction' demon-
strated a sensitivity of 80%. Thus, when the findings
of diagnostic palpation are based on pain-provocation
as opposed to joint motion, they appear to have better
diagnostic value.
How best to move forward beyond this substantially
unchanged, century-old diagnostic tradition? Consider
that diagnostic
palpation may be accessible
to technolog-
ical enhancement. For example, validity of diagnostic
palpation might be more reliably achieved by developing
a technologically
based approach that utilizes a combina-
tion of measures like electrical skin resistance,
skin tem-
peraturea0'al
and pressure provoked tendernessa2 in
a hand-held device that could be conveniently used.
Such a device could also offer the possibility of being
pre-programmed
with a data-base
of information that es-
tablishes a'reference norm'of the variables
considered. A
diagnostic hand-held device
of this nature could conceiv-
ably remove the portion of confounding contributed by
the practitioner subjectivity.
On this basis then, manual
palpation has the potential to become a standardised in-
ter- and intra- disciplinary diagnostic method.
In the meantime, palpation continues to remain a
traditional diagnostic
tool of manual medicine
although
its use appears likely to modify the very somatic
dysfunction that it seeks to detect. Similarly, it has re-
mained a distinctive osteopathic clinical tool for more
than a century.a3'oo This appears unlikely to change in
the immediate
future. However, promoting an increased
awareness of the limitations of diagnostic palpation in
an era of evidence-based
practice may be a way of en-
gaging the search for a technologically based alternative.
In this way, a potential exists to bring further insight
through research
and development into a defining diag-
nostic practice that appears uncritically considered
'routine'.
4. Conclusion
The anatomy of the posterior sacroiliac region is
highlighted. Attention is drawn to the position and
depth of the posterior SIJ and to the different and nu-
merous tissue layers that separate the skin from the
SIJ. The challenge
that the regional anatomy poses
to
diagnostic palpation is explored. Some of the complex
mechanisms
underlying this tactile method of diagnosis
are highlighted.
Seeking an'evidential' basis
upon which
to define this manual healthcare diagnostic intervention
may prove continually elusive based
on the presence
of
anatomical and sensory confounders. The development
of a sophisticated technologically based solution that
measures
pain provocation pressure
together with other
autonomic variables such as temperature or moisture
may be a way forward. A standardised,
pan-disciplinary
indicator of somatic dysfunction could then be used to
compare therapeutic
outcomes.
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... Greenman (2011), Cusi (2010) and McGrath (2010) have discussed SIJ mobility; Most notably the rotations and gliding movements, since anatomical features of the SIJ allow combined movements in the three planes and axes. They occur with a restricted range of 1 to 4 of rotation (Mcgrath, 2006;Veiga et al., 2015) and 1e1.6 mm of translation in the transversal and frontal planes. Such SIJ movements, besides their restrictions, might change according to age, gender, weight or during pregnancy (Veiga et al., 2015). ...
... Consider the omnipresent central influence of cortical input (cognition, perception, expectation) possessed by both the patient and by the clinician, together with the peripheral influence of manual pressure on low threshold afferent mechanoreceptors of touch, pressure and vibration and their associated wide dynamic range inter neurons in lamina IV and V at the dorsal horn. Such central and peripheral influences occur simultaneously in both parties at the point of manual engagement [17]. The resultant sensory melange is a minefield for objectivity, a vital clinical quality that degrades rapidly in a proportional manner with both the time and the intensity of the manual clinical engagement. ...
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The Vulcan Nerve Pinch has a memorable and unique place in the cultural iconography of Star Trek. The proposed Bow-string technique uses this image to anchor the proposal of a novel technique preliminarily described here. The technique may possess both diagnostic and therapeutic implications for somatic dysfunction in the cervical region. It is based upon the established viscoelastic properties of collagen, in particular time-dependent stress-relaxation. The technique is reliant upon a high level of patient-centred engagement and intervenes at the contralateral side to a patient’s active muscle effort. It is gentle, co-operative and runs for 2-4 minutes. It theoretically engenders significant collaginous material change (lengthening) through the stress-relaxation characteristic of collagen associated with the imposition of a fixed mechanical strain. It is anticipated that the technique may possess a considerably greater persistence of effect when compared with shorter duration, repetitive passive stretch techniques, reliant on patient relaxation.
... The association of innominate movement and positional anomalies with non-specific low back pain of sacroiliac iliac joint origin has always been a topic of contention, owing to difficulty in its evaluation. The complex anatomical orientation (McGrath, 2006), small ranges of three-dimensional (3D) motion (Goode et al., 2008) and large ranges of within-and between-subject variability (Bussey et al., 2009a(Bussey et al., , 2009b) makes non-invasive accurate diagnoses of innominate movement and positional anomalies difficult. However, recent techniques of electromagnetic palpation-digitization of pelvic landmarks has demonstrated promising results for noninvasive assessment of innominate movements in symptomatic as well as healthy individuals (Bussey et al., 2004(Bussey et al., , 2009aAdhia et al., 2012Adhia et al., , 2016aAdhia et al., , 2016bAdhia et al., , 2016cBussey and Milosavljevic, 2013). ...
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Electromagnetic palpation-digitization technique for measurement of innominate motion involves calculation of innominate rotation using the innominate vector length in the neutral (NEUT) and combined hip abduction and external rotation (HABER) test positions. The innominate vector length [i.e., the segment between anterior superior iliac spine (ASIS) and posterior superior iliac spine (PSIS)] is not a rigid structure and its deformation could introduce an error influencing the final innominate rotation measurement. The aim of this study is to determine if there is significant deformation occurring in innominate vector length when the hip is loaded into the HABER test position. A cross sectional study using sixteen healthy individuals and a single tester was conducted. Four pelvic landmarks, left and right PSIS and ASIS, were palpated and digitized using 3D digitizing stylus of Polhemus electromagnetic tracking device, in two hip test positions, NEUT and 50o HABER. The innominate vector lengths were calculated from the 3D coordinates of pelvic landmarks, for each hip test positions. Paired t-tests demonstrated no significant differences (p>0.05) in the innominate vector lengths at the side of the load as well as the opposite innominate when either the right or left hip was loaded; thus indicating no significant bone deformation in innominate segment during the HABER test position.
... Goode et al (2008) suggest that there may be limited clinical utility in using palpation for diagnosing SIJ pathology given the small amount of motion at the SIJ. There is also a general history of poor reliability of joint based tests that require the therapist to make a judgment on joint feel (McGrath 2006). Liebenson and Lewit (2003) highlight the issues regarding reliability and validity of manual palpation and suggest a battery of tests could be used before abandoning manual palpation. ...
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Narrativer Review: Active Straight Leg Raise, Einbeinstand und die manuelle Gelenkuntersuchung sind drei gangige Tests zur Untersuchung der sakroiliakalen Stabilitat. Unser Autor uberpruft deren Zuverlassigkeit und warnt davor, den Begriff Instabilitat routinemasig zu verwenden. Mit einer geeigneten Subklassifizierung und dem Translationskonzept konnte man den Disput um die Begriffe beenden – ein Vorschlag.
... Yet, presently there is a lack of accurate and reliable tests for assessing innominate movement anomalies in clinical populations (van der Wurff et al., 2000a(van der Wurff et al., , 2000bCattley et al., 2002;Stuber, 2007). Assessment of innominate motion is difficult owing to the complex anatomical orientation (McGrath, 2006;Vleeming et al., 2012), small ranges of three-dimensional motion (Goode et al., 2008), and the range of within-and between-participant variability (Bussey et al., 2009a(Bussey et al., , 2009b. ...
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Innominate kinematic anomalies resulting in low back pain (LBP) of sacroiliac joint (SIJ) origin (SIJ-positive), has always been a topic of contention, owing to difficultly in its evaluation. Recent technique of electromagnetic palpation-digitization has been able to accurately quantify innominate kinematics in healthy individuals. The purpose of this study is to determine if participants with LBP of SIJ origin (SIJ-positive) demonstrate significantly different innominate kinematics than participants with LBP of non-SIJ origin (SIJ-negative). Single-blinded cross-sectional case-control study. Participants [n(122)] between the ages of 18 to 50 years, suffering from chronic non-specific LBP (≥3 months) volunteered in the study. An experienced musculoskeletal physiotherapist evaluated and classified participants into either SIJ-positive [n(45)] or SIJ-negative [n(77)] group, using the reference standard pain provocation tests [≥3 positive tests = SIJ-positive]. A research physiotherapist, blinded to clinical groups, conducted the innominate kinematic testing using a valid and reliable electromagnetic palpation-digitization technique, during prone lying incremental hip abduction-external rotation test positions. The results of the mixed model regression analyses demonstrated that SIJ-positive participants exhibited significantly different innominate movement patterns and trends of rotation, but not innominate ranges of motion, when compared with SIJ-negative LBP participants. These findings demonstrate association between SIJ pain and altered innominate kinematics, and have led the groundwork for further exploration of clinical measurement, relevance, and management of these potentially important movement observations. Copyright © 2015 Elsevier Ltd. All rights reserved.
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The sacroiliac joint (SIJ) is often considered to be involved when people present for care with low back pain where the sacroiliac joint (SIJ) is located. However, determining why the pain has arisen can be challenging, especially in the absence of a specific cause such as pregnancy, disease, or trauma, where the SIJ may be identified as a source of symptoms with the help of manual clinical tests. Nonspecific SIJ-related pain is commonly suggested to be causally associated with movement problems in the sacroiliac joint(s); a diagnosis traditionally derived from manual assessment of movements of the SIJ complex. Management choices often consist of patient education, manual treatment, and exercise. Although some elements of management are consistent with guidelines, this perspective argues that the assumptions on which these diagnoses and treatments are based are problematic, particularly if they reinforce unhelpful, pathoanatomical beliefs. This article reviews the evidence regarding the clinical detection and diagnosis of SIJ movement dysfunction. In particular, it questions the continued use of assessing movement dysfunction despite mounting evidence undermining the biological plausibility and subsequent treatment paradigms based on such diagnoses. Clinicians are encouraged to align their assessment methods and explanatory models to contemporary science to reduce the risk of their diagnoses and choice of intervention negatively affecting clinical outcomes.
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The Vulcan Nerve Pinch has a memorable and unique place in the cultural iconography of Star Trek. This image is used to anchor the proposal of a novel manual technique, the Bowstring technique preliminarily described here. The technique may possess both diagnostic and therapeutic implications for regional somatic dysfunction in the cervical thoracic outlet. It is based upon the established viscoelastic properties of collagen, in particular the time-dependent stress-relaxation properties. It is suggested to rely upon a high level of patient centered engagement and intervenes at the contralateral side to a patient’s active muscle effort. It is gentle, co-operative and runs for 2 – 4 minutes. It theoretically engenders significant collaginous material change (lengthening) through the stress-relaxation characteristic of collagen associated with the imposition of a fixed mechanical strain. It is thought that the technique may possess a considerably greater persistence of effect, when compared with shorter duration, repetitive passive stretch techniques, reliant on patient relaxation.
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The Vulcan Nerve Pinch – cultural iconography anchors the proposal of a novel manual approach, the Bow-string technique. Abstract The Vulcan Nerve Pinch has a memorable and unique place in the cultural iconography of Star Trek. This image is used to anchor the proposal of a novel manual technique, the Bow-string technique preliminarily described here. The technique may possess both diagnostic and therapeutic implications for regional somatic dysfunction in the cervical thoracic outlet. It is based upon the established viscoelastic properties of collagen, in particular the time-dependent stress-relaxation properties. It is suggested to rely upon a high level of patient centered engagement and intervenes at the contralateral side to a patient's active muscle effort. It is gentle, cooperative and runs for 2 – 4 minutes. It theoretically engenders significant collaginous material change (lengthening) through the stress-relaxation characteristic of collagen associated with the imposition of a fixed mechanical strain. It is thought that the technique may possess a considerably greater persistence of effect, when compared with shorter duration, repetitive passive stretch techniques, reliant on patient relaxation. 2 The Vulcan Nerve Pinch – cultural iconography anchors the proposal of a novel manual approach, the Bow-string technique.
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Background & objectivesA wide range of procedures for the assessment of spinal and pelvic disorders has been described in the osteopathic literature, but little is known concerning the methods used by osteopaths in the United Kingdom (UK). This study examined the perception of usefulness and reported use of physical assessment procedures by UK osteopaths. Part 2 of this study will examine the commonly reported treatment methods.
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Non-specific low back pain and peripartum pelvic pain have aetiologies that may feature the sacroiliac region. This region possesses many potential pain-generating structures sharing common sensory innervation which makes clinical differentiation of pathoanatomy difficult. This anatomical study explores the relationship between the long posterior sacroiliac ligament (LPSL) and the lateral branches of the dorsal sacral nerve plexus. Twenty-five sides of the pelvis from 16 cadavers were studied, three for histological analysis and 22 for gross anatomical dissection. We found that the LPSL is penetrated by the lateral branches of the dorsal sacral rami of predominantly S2 (96%, 21/22) and S3 (100%, 22/22), variably of S4 (59%, 13/22) and rarely of S1 (4%, 1/22). Some of the penetrating lateral branches give off nerve fibres that disappear within the ligament. These findings provide an anatomical basis for the notion that the LPSL is a potential pain generator in the posterior sacroiliac region.
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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.
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Spike discharge activity was recorded from low-threshold, rapidly adapting, skin mechanoreceptive afferents (RA afferents) dissected from the median (forelimb) or tibial (hindlimb) nerves in anesthetized monkeys and cats. The spike activity was evoked by delivery of controlled sinusoidal vertical skin displacement ("flutter") stimuli to the receptive field (RF). The stimuli (15-30 Hz; 30-400 mum peak-to-peak amplitude; duration 0.8-15 s) were superimposed on a static skin indentation (0.5-1.0 mm) which was either maintained continuously throughout the run or applied trial-by-trial. The neural activity and the analog signal of the position of the stimulator probe were digitized at 10 kHz resolution and stored for off-line analysis. The main goal was to determine whether changes in the RA afferent response to skin flutter stimulation may be responsible for the enhanced capacity to discriminate stimulus frequency that accompanies a relatively brief (approximately equal to 1 min) pre-exposure to such stimulat...