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High-velocity, low-amplitude manipulation (HVLA) does not alter three-dimensional position of sacroiliac joint in healthy men: A quasi-experimental study

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... Moreover, it has been reported that the mobility of the SIJ depends on a position of the joint and the load it is applied to. Increasing the load on the SIJ leads to a ventral inclination of the sacrum with stretching of dorsal ligaments, which shifts the bone position and interferes with its mobility (Tullberg et al., 1998) (de Toledo et al., 2020. ...
... As demonstrated in related studies, through the Roentgen stereophotogrammetric analysis, high-velocity, and lowamplitude thrust manipulation in the SIJ does not alter the position relationship between the sacrum and the ilium bone in healthy individuals (de Toledo et al., 2020). Although the analyzing method is different, the aforementioned results are consistent with our findings. ...
... Therefore, the mechanism of the oblique-pulling manipulation in treating SIJ dysfunction needs to be reconsidered. Because of its importance in maintaining the joint mobility, ligament around SIJ has aroused far more concern, such as IL, sacrotuberous ligament (STL), and long dorsal sacroiliac ligament (LDL) (Vleeming et al., 1996) (van Wingerden et al., 1993) (de Toledo et al., 2020. STL showed extensive connections with the gluteus maximus muscle, long head of the biceps femoris muscle, and ...
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Background: Oblique-pulling manipulation has been widely applied in treating sacroiliac joint (SIJ) dysfunction. However, little is known about the biomechanical mechanism of the manipulation. This study aims to analyze the SIJ motion under oblique-pulling manipulation, in comparison with compression and traction loads. Methods/Study Design: A total of six specimens of embalmed human pelvis cadavers were dissected to expose the SIJ and surrounding ligaments. Through a servo-hydraulic testing system, biomechanical tests were performed on the stable pelvis and the unstable pelvis with pubic symphysis injury (PSI). A three-dimensional (3D) photogrammetry system was employed to determine the separation and nutation in three tests: axial compression (test A), axial traction (test B), and oblique-pulling manipulation (test C). Results: After applying the testing loads, the range of nutation was no more than 0.3° (without PSI) and 0.5°(with PSI), separately. Except for test B, a greater nutation was found with PSI ( p < 0.05). Under both conditions, nutation following test A was significantly greater than that of other tests ( p < 0.05). SIJ narrowed in test A and separated in tests B and C, where the range of motion did not exceed 0.1 mm (without PSI) or 0.3 mm (with PSI) separately. Under both conditions, the separation of SIJ in test C was not as apparent as the narrowness of SIJ in test A ( p < 0.05). Compared to SIJ, a more significant increasing displacement was found at the site of the iliolumbar ligament ( p < 0.05). Nevertheless, when the force was withdrawn in all tests, the range of nutation and separation of SIJ nearly decreased to the origin. Conclusion: Pubic symphysis is essential to restrict SIJ motion, and the oblique-pulling manipulation could cause a weak nutation and separation of SIJ. However, the resulting SIJ motion might be neutralized by regular standing and weight-bearing load. Also, the effect on SIJ seems to disappear at the end of manipulation. Therefore, the stretching and loosening of surrounding ligaments need to be paid more attention to.
... Die resultierenden intervertebralen Bewegungen beschränkten sich jedoch nicht ausschließlich auf das bei der Manipulation adressierte Bewegungssegment (Dunning, et al., 2013;Flynn, et al., 2012;Gál, et al., 1997a;1997b;Herzog, Kats und Symons, 2001;Ianuzzi und Khalsa, 2005;Kulig, Landel und Powers, 2004;Ross, Bereznick und McGill, 2004). Zahlreiche Forschungsgruppen untersuchten postmanipulativ biomechanische Parameter wie den intradiskalen Druck (Maigne und Guillon, 2000), die spinale Hypomobilität (Fritz, et al., 2011), die segmentale intervertebrale Beweglichkeit (Fernández-de-las-Peñas, Downey und Miangolarra-Page, 2005;Gál, et al., 1995;1997a;1997b), die Gelenkstellung (de Toledo, Kochem und Silva, 2020;Tullberg, et al., 1998), die Separation der Zygapophysealgelenke (Cramer, et al., 2002) und den aktiven Bewegungsumfang der Wirbelsäule (Bialosky, et al., 2009a;Cardinale, et al., 2015;Flynn, et al., 2012;Martínez-Segura, et al., 2006;Whittingham und Nilsson, 2001). Da die postmanipulativ erzielten Veränderungen dieser biomechanischen Parameter überwiegend temporärer Natur waren, wandte sich die Wissenschaft mehr und mehr von den rein biomechanischen Erklärungsmodellen ab (Bialosky, et al., 2009a;Flynn, et al., 2012). ...
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Hintergrund: Physiotherapeut*Innen verwenden die spinale Gelenkmanipulation u.a. zur Behandlung bestimmter arthrogener Dysfunktionen. Postmanipulativ verändert sich neben dem Schmerz- und Beweglichkeitsstatus häufig das Aktivierungsmuster bestimmter Muskeln. Ziele: Detektion kurzfristiger Auswirkungen spinaler Gelenkmanipulation auf die EMG-Aktivität, Schmerz und die aktive Beweglichkeit bei erwachsenen Menschen und der Unterschied zu anderen therapeutischen Maßnahmen. Design: Systematisches Review Informationsquellen: Primäre Informationsquellen (MEDLINE, EMBASE, CINAHL, PEDro), sekundäre Informationsquellen (Open Grey, Dart-Europe, Expertenbefragungen, clinicaltrials.gov, ICTRP, Referenzlisten) Auswahlkriterien: Design (RCTs, randomisierte Cross-Over-Studien), Spezies (Humanstudien), Sprachen (Deutsch, Englisch), Publikationszeitraum (01/2000 – 03/2020) Studienbewertung: Evidenzklassen nach CEBM (relative Beweiskraft), PEDro-Skala (methodologische Qualität), modifizierte CIRCLe SMT (interventionsspezifische Berichterstattung) Ergebnisse: Von insgesamt 901 Treffern wurden 13 Primärarbeiten mit akkumuliert 443 Proband*Innen zur Bearbeitung dieser systematischen Übersichtsarbeit inkludiert. Die vorliegende Arbeit konnte keine generalisierbare Aussage über die kurzfristigen Auswirkungen spinaler Gelenkmanipulation auf die EMG-Aktivität, Schmerzen und die aktive Beweglichkeit bei erwachsenen Menschen liefern, indizierte aber schwache Evidenz für jeden Ergebnisparameter. Das detektierte postmanipulative Aktivierungsverhalten der Muskulatur konnte sowohl exzitatorisch als auch inhibitorisch sein. Mittels Subgruppenanalysen wurde ein potentieller Einfluss der Krankheitsbilder auf die postmanipulative EMG-Aktivität eruiert. Es gibt moderate Evidenz dafür, dass eine lumbale Rotationsmanipulation bei Patient*Innen mit nichtspezifischen Rückenschmerzen zu einer signifikanten Reduktion der EMG-Aktivität der paravertebralen Muskulatur während des Haltens in voller Rumpfflexion und der Extensionsbewegung aus der vollen Flexion führt. Ebenso besteht moderate Evidenz dafür, dass eine lumbopelvine Rotationsmanipulation der betroffenen Seite bei Patient*Innen mit einem Patellofemoralen Schmerzsyndrom zu einem signifikanten An-stieg der EMG-Aktivität des M. gluteus medius führt. Schwache Evidenz besteht da-für, dass segmentspezifische Manipulationen im Bezug auf die EMG-Aktivität und Schmerzen keinen Benefit im Vergleich zu global ausgeführten Techniken bringen. Unklar bleibt, ob eine spinale Gelenkmanipulation kurzfristig signifikante Benefits im Vergleich zu Placebo-, Pseudoplacebo- oder anderen therapeutischen Kontrollinterventionen im Bezug auf die EMG-Aktivität, Schmerzen und die aktive Beweglichkeit bei erwachsenen Menschen bietet. Limitationen: Die methodologische Qualität über die Studien hinweg lag bei 5,77/10 Punkten und war mäßig. Das Risiko für Performance Bias über die Studien hinweg war sehr hoch. Das Risiko für Spectrum bzw. Detection Bias war moderat. Das Risiko der Verzerrungen aufgrund der interventionsspezifischen Berichterstattung über die Studien hinweg wurde als gering angesehen. Die individuellen Primär-arbeiten waren hinsichtlich der wichtigsten Studienmerkmale heterogen. Schlussfolgerungen: Die spinale Gelenkmanipulation soll allenfalls supportiv zur überwiegend aktiven Behandlung von veränderten muskulären Aktivierungsmustern, Schmerzen und Bewegungseinschränkungen eingesetzt werden. Die spinale Gelenkmanipulation eignet sich, um Patient*Innen bereits innerhalb einer Therapieeinheit die Adaptabilität des neuromuskuloskelettalen Systems bzw. die Modifikationsmöglichkeit für Symptome und Bewegung zu visualisieren. Somit kann weitere passive, assistive oder idealerweise aktive Bewegung fazilitiert werden. Registrationsnummer: PROSPERO - CRD42020160690 Stichworte: Spinale Gelenkmanipulation, EMG, Schmerz, aktive Beweglichkeit
... 11 More recently, it has also been confirmed that local manipulation does not alter mobility of the SIJ in healthy men. 12 We wish to reinforce that existing evidence confirms that manual assessment of SIJ mobility is not feasible (due to the minute nature of movement), is not reliable, and cannot usefully inform clinical decisions. Furthermore, manipulation does not result in any positional change of the SIJ. ...
... En ostéopathie et en thérapies manuelles de manière générale, il y a un réel besoin de mieux comprendre comment objectiver les paramètres observables analysés via les tests globaux utilisés dans la routine de test du diagnostic ostéopathique. Plusieurs études ont été menées dans ce sens en utilisant l'analyse 3D pour analyser les changements de position de la sacro-iliaque avant et après traitement ostéopathique (34,35) . Cependant, les résultats qui utilisent ce type de méthodologie ne permettent pas d'individualiser le mouvement propre de la sacro-iliaque, principalement dû au fait que les mouvements sont très faibles (< 2° en rotation et 1 mm en translation) (34) . ...
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The evaluation of the risk of low back pain remains complex as it lacks evidence-based recommendations and a reliable functional test. The one-sided tilt test can provide additional information on the dynamics of the lum-bo-pelvic complex. However, little is known about the expected movement. This study aims to identify different patterns of movement during the test in a healthy population of triathletes and provide preliminary normative values.
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Background: High-velocity low-amplitude (HVLA) spinal manipulation is commonly used in the treatment of spinal pain syndromes. The mechanisms by which HVLA-manipulation might reduce spinal pain are not well understood, but often assumed to relate to the reduction of biomechanical dysfunction. It is also possible however, that HVLA-manipulation involves a segmental or generalized inhibitory effect on nociception, irrespective of biomechanical function. In the current study it was investigated whether a local analgesic effect of HVLA-manipulation on deep muscle pain could be detected, in healthy individuals. Methods and materials: Local, para-spinal muscle pain was induced by injection of 0.5 ml sterile, hyper-tonic saline on two separate occasions 1 week apart. Immediately following the injection, treatment was administered as either a) HVLA-manipulation or b) placebo treatment, in a randomized cross-over design. Both interventions were conducted by an experienced chiropractor with minimum 6 years of clinical experience. Participants and the researcher collecting data were blinded to the treatment allocation. Pain scores following saline injection were measured by computerized visual analogue pain scale (VAS) (0-100 VAS, 1 Hz) and summarized as a) Pain duration, b) Maximum VAS, c) Time to maximum VAS and d) Summarized VAS (area under the curve). Data analysis was performed as two-way analysis of variance with treatment allocation and session number as explanatory variables. Results: Twenty-nine healthy adults (mean age 24.5 years) participated, 13 women and 16 men. Complete data was available for 28 participants. Analysis of variance revealed no statistically significant difference between active and placebo manipulation on any of the four pain measures. Conclusion: The current findings do not support the theory that HVLA-manipulation has a non-specific, reflex-mediated local or generalized analgesic effect on experimentally induced deep muscle pain. This in turn suggests, that any clinical analgesic effect of HVLA-manipulation is likely related to the amelioration of a pre-existing painful problem, such as reduction of biomechanical dysfunction.
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Objective Report the long-term efficacy of radiofrequency denervation for sacroiliac joint pain at six, twelve and eighteen months. Method Third-two adults’ patients with sacroiliac join pain diagnosis were included for a prospective study. Primary outcome measure was pain intensity on the Numeric Rating Scale (NRS). Secondary outcome measure was Patient Global Impression of Change Scale (PGIC). Results Short-term pain relief was observed, with the mean NRS pain score decreasing from 7.7 ± 1.8 at baseline to 2.8 ± 1.2 at one month and to 3.1 ± 1.9 at six months post-procedure (p < 0.001). Long-term pain relief was sustained at twelve and eighteen months post-procedure, with NRS pain remaining at 3.4 ± 2.1 and 4.0 ± 2.7, respectively. Conclusion Radiofrequency denervation of the SIJ can significantly reduce pain in selected patients with sacroiliac syndrome.
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[Purpose] Physical therapists, osteopathic practitioners, and chiropractors often perform manual tests to evaluate sacroiliac joint (SIJ) mobility. However, the available evidence demonstrates an absence of reliability in these tests and in investigations with kinematic analysis. The aim of this study was to verify the three-dimensional kinematic reliability in SIJ movement measurements. [Subjects] This cross-sectional study analyzed 24 healthy males, aged between 18 and 35 years. [Methods] Three-dimensional kinematic analysis was performed for measurements of posterior superior iliac displacement and greater trochanter (femur) displacement during hip flexion movement in an orthostatic position. The distance variations were measured from a reference point in 3 blocks. The intra-observer reliability was compared with the mean of three 3 blocks using the interclass correlation coefficient (ICC) and a 99% significance level. [Results] The measurements indicated a strong correlation among blocks: ICC = 0.94 for right side SIJ and ICC = 0.91 for left side SIJ. The mean displacement between the reference points was 7.7 mm on the right side and 8.5 mm on the left side. [Conclusion] Our results indicate that three-dimensional kinematic analysis can be used for SIJ mobility analyses. New studies should be performed for subjects with SIJ dysfunction to verify the effectiveness of this method.
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Objetivo identificar a prevalência de dor lombar inespecífica e os fatores associados em adolescentes de Uruguaiana/RS. Métodos estudo transversal de base escolar, feito com adolescentes de 10 a 17 anos matriculados no turno diurno das redes municipal e estadual de ensino de Uruguaiana/RS. Foram avaliados 1.455 adolescentes. O procedimento de coleta dos dados ocorreu em duas etapas. Inicialmente foi aplicado um questionário sobre indicadores sociodemográficos, comportamentos e hábitos da rotina diária e histórico de dor lombar inespecífica. Posteriormente foram avaliadas as medidas de estatura, massa corporal, flexibilidade e força/resistência abdominal. Para a análise dos dados foram usados os métodos univariado, bivariado e multivariável e foi considerado nível de significância de 5% para todos os testes. Resultados a prevalência de dor lombar nos adolescentes avaliados foi de 16,1%. Por sexo, o masculino apresentou uma prevalência de 10,5% e o feminino, de 21,6%. As variáveis sexo, índice de massa corporal, força/resistência abdominal e nível de atividade física apresentaram associação estatisticamente significativa com a dor lombar inespecífica. Na análise ajustada o sexo (OR = 2,36; p < 0,001), a idade (OR = 1,14; p < 0,001) e o índice de massa corporal (OR = 1,44; p = 0,029) mantiveram significância no modelo final. Conclusões adolescentes do sexo feminino que apresentaram idades mais elevadas e estavam com sobrepeso ou obesidade têm mais chances de desenvolver dor lombar inespecífica.
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[Purpose] The present study aimed to determine the effect of an 8-week program of joint mobilization on changes in pelvic obliquity and pain level in seventeen female university students aged in their 20's with sacroiliac joint dysfunction by dividing them into two groups: a joint mobilization group (MWM) and a control group. [Subjects] Seventeen subjects were selected from female university students aged in their 20's attending N University in Cheon-An City, Korea, The subjects had sacroiliac joint syndrome, but experienced no problems with daily living and had no previous experience of joint mobilization exercise. The subjects were randomly assigned to a joint mobilization group of eight and a control group of nine who performed joint mobilization exercise. [Methods] Body fat and lean body mass were measured using InBody 7.0 (Biospace, Korea). The Direct Segmental Multi-frequency Bioelectrical Impedance Analysis Method (DSM-BIA) was used for body composition measurement. A pressure footstool (Pedoscan, DIERS, Germany) and a trunk measurement system (Formetric 4D, DIERS, Germany), a 3D image processing apparatus with high resolution for vertebrae, were used to measure 3D trunk images of the vertebrae and pelvis obliquity, as well as static balance ability. [Result] The MWM group showed a significantly better Balance than the control group. In addition, the results of the left/right and the front/rear balance abilities were significantly better than those of the control group. [Conclusion] This study proved that a combination of mobilization with movement and functional training was effective in reducing pelvis malposition and pain, and improving static stability control.
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Objective: To investigate the immediate effect of osteopathic manipulation of talocrural joint for anterior talocrural, on static balance, in young women. Methods: Twenty women were divided into two groups: manipulation of talocrural (MTG) and control (CG). It was analyzed the anterior-posterior (Y) and mediolateral (X) displacement with open and closed eyes in a baropodometry. Results: In the intergroup analysis, the oscillation showed higher in MTG (X and Y axes), at all times, compared to CG (p<0,05). In intragroup comparisons, the MTG increased significantly in the Y axis of oscillation, after intervention, with open eyes (p<0,05). Conclusion: The manipulation of talocrural joint decreased immediately the static anteroposterior balance in GMT with his eyes open.
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Objective: To investigate the immediate effects of manipulation of bilateral sacroiliac joints (SIJs) on the plantar pressure distribution in asymptomatic participants in the standing position. Design: Randomized, controlled, double-blind clinical trial. Participants: Sixty-two asymptomatic men and women (mean age, 20.66±2.56 years) randomly assigned to 2 groups. Interventions: The experimental group underwent mobilization without tension of the hips in the supine position and high-velocity, low-amplitude manipulation in the SIJs bilaterally. The control group underwent only mobilization, without tension of the hips in supine position. Outcome measures: Pre- and postintervention outcomes measured by an assessor blinded to the treatment allocation of the participants included a baropodometric analysis performed by using a force platform. Baseline between-group differences were examined with a Kolmogorov-Smirnov test. A chi-square test was used for categorical data. Analysis of covariance (ANCOVA) was used to assess differences between groups, with the preintervention value as covariant (95% confidence level). Results: At baseline, no variables significantly differed between groups. Baropodometric analysis showed statistically significant differences in the location of the maximum pressure point in the experimental group (p=0.028). Pre- and postintervention analysis with ANCOVA showed statistically significant differences between both groups in the left hindfoot load percentage (interaction p=0.0259; ANCOVA p=0.0277), right foot load percentage (ANCOVA p=0.0380), and surface of the right forefoot (interaction p=0.0038). There was also a significant effect in the variables that analyze the entire foot (left foot: surface [interaction p=0.0452], percentage of load [ANCOVA p=0.0295]) and between both groups (right foot: weight [interaction p=0.0070; ANCOVA p=0.0296]). Conclusions: Sacroiliac joint manipulation applied bilaterally in asymptomatic persons resulted in immediate changes in load distribution on plantar support in the standing position. Study limitations and suggestions for future studies are discussed.
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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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To compare the effect of sacroiliac joint (SIJ) manipulation with SIJ and lumbar manipulation for the treatment of SIJ syndrome. Thirty-two women with SIJ syndrome were randomly divided into two groups of 16 subjects. One group received the high-velocity low-amplitude (HVLA) manipulation to the SIJ and the other group received both SIJ and lumbar HVLA manipulation to both the SIJ and lumbar spine in a single session. The outcomes were assessed using visual analogue scale (VAS) at baseline, immediately, 48 h and one month after the treatment for pain and also Oswestry Disability Index (ODI) questionnaire at baseline, 48 h and one month after the treatment. Analysis revealed a statistically significant improvement immediately, at 48 h and one month after treatment for pain and significant improvement at 48 h and one month after treatment for functional disability in the SIJ manipulated group. A significant improvement immediately, at 48 h and one month after treatment for pain and significant improvement at 48 h and one month after treatment for functional disability in the SIJ and lumbar manipulated group was also found. Furthermore, there were significant differences within groups in ODI and VAS when using Friedman test in both groups. By using Wilcoxon rank sum test no differences were observed in change scores between the two groups immediately, 48 h and one month after the treatment for VAS, or after 48 h and one month after the treatment for the ODI. A single session of SIJ and lumbar manipulation was more effective for improving functional disability than SIJ manipulation alone in patients with SIJ syndrome. Spinal HVLA manipulation may be a beneficial addition to treatment for patients with SIJ syndrome.
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The sacroiliac joint (SIJ) is an integral part of both the lumbar spine and the pelvic girdle. It is frequently the source of low back pain and pelvic girdle pain. Recent research has permitted a deeper understanding of its function and assessment. The mechanical assessment of the SIJ as a transmitter of load between trunk and lower limbs, and as a means to absorb torsion stresses of the pelvis absorber of torsion is examined; history, clinical examination and imaging modalities are explored and the role of exercise and some interventional therapies are described in general terms.
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Developing an evidence base for making public health decisions will require using data from evaluation studies with randomized and nonrandomized designs. Assessing individual studies and using studies in quantitative research syntheses require transparent reporting of the study, with sufficient detail and clarity to readily see differences and similarities among studies in the same area. The Consolidated Standards of Reporting Trials (CONSORT) statement provides guidelines for transparent reporting of randomized clinical trials. We present the initial version of the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) statement. These guidelines emphasize the reporting of theories used and descriptions of intervention and comparison conditions, research design, and methods of adjusting for possible biases in evaluation studies that use nonrandomized designs.
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The purpose of this study was to examine the intertester reliability of 13 tests for sacroiliac joint (SIJ) dysfunction. Eight therapists examined 17 patients in two clinical settings. In each case, two therapists independently examined the patients and obtained results on all 13 of the SIJ tests. Patients with lumbosacral pain and unilateral lower extremity symptoms of a duration less than one year were examined. All the therapists had specialized in orthopedic physical therapy and had been trained in SIJ examination. Reliability was poor; 11 of the 13 tests resulted in less than 70% agreement. The two tests that relied solely on subjective patient response and imparted no information on SIJ position or mobility were within a range of 70% to 90% agreement. Our findings suggest the necessity of reviewing examination methods for the SIJ and improving reliability of clinical testing of this joint.
Article
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.
Article
Sacroiliac joint pain and dysfunction affect 15-25% of patients reporting low back pain, including reports of spontaneous, idiopathic, traumatic, and non-traumatic onsets. The poor reliability and validity associated with diagnostic clinical and imaging techniques leads to challenges in diagnosing and managing sacroiliac joint dysfunction. A 35-year-old nulliparous female with a 14-year history of right sacroiliac joint dysfunction was managed using a multimodal and multidisciplinary approach when symptoms failed to resolve after 2 months of physical therapy. The plan of care included four prolotherapy injections, sacroiliac joint manipulation into nutation, pelvic girdle belting, and specific stabilization exercises. The patient completed 20 physical therapy sessions over a 12-month period. At 6 months, the patient's Oswestry Disability Questionnaire score was reduced from 34% to 14%. At 1-year follow-up, her score was 0%. The patient's rating of pain on a numeric rating scale decreased to an average of 4/10 at 6 months and 0/10 at 1-year follow-up. A multidisciplinary and multimodal approach for the management of chronic sacroiliac joint dysfunction appeared successful in a single-case design at 1-year follow-up.
In the last 40 years, significant advances have been made in the understanding of the neurophysiologic processes involved in the experience of trauma and pain. This knowledge, together with the rapid growth and understanding in the behavioral health sciences, has expanded to include a much better appreciation of how these fields are converging and contribute to a process called neuroplasticity. These basic mechanisms common to all patients have important implications for clinical outcome and for improving clinical practice. This article is written for clinicians who manage patients with sacroiliac joint dysfunction, a specific type of nonspecific low back pain.
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True sacroiliac (SI) joint pain arises for well-established pathological reasons. For example, SI joint infection is characterised by non-specific, diffuse and poorly localised pain that makes an initial clinical diagnosis difficult, even though the condition is a prima facie SI joint lesion. On the other hand, the putative sacroiliac joint pain of the ‘sacroiliac joint syndrome’ that is by definition not associated with morphological and radiological abnormality, is a symptom commonly observed in clinical practice. Such a presentation possesses a typically well-localisable pain in the region overlying the posterior sacroiliac joint. contention is that composite SI joint pain provocation tests, whilst of arguably statistical ‘significance’, may lack clinical significance particularly in the light of anatomical research that presents an alternative patho-anatomic basis for localisable sacroiliac pain and may offer a rational basis for diagnosis and treatment.
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This article focuses on the (functional) anatomy and biomechanics of the pelvic girdle and specifically the sacroiliac joints (SIJs). The SIJs are essential for effective load transfer between the spine and legs. The sacrum, pelvis and spine, and the connections to the arms, legs and head, are functionally interrelated through muscular, fascial and ligamentous interconnections. A historical overview is presented on pelvic and especially SIJ research, followed by a general functional anatomical overview of the pelvis. In specific sections, the development and maturation of the SIJ is discussed, and a description of the bony anatomy and sexual morphism of the pelvis and SIJ is debated. The literature on the SIJ ligaments and innervation is discussed, followed by a section on the pathology of the SIJ. Pelvic movement studies are investigated and biomechanical models for SIJ stability analyzed, including examples of insufficient versus excessive sacroiliac force closure.
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The biomechanics of the sacroiliac joint makes the pelvic segment responsible for proper weight distribution between lower extremities; however, it is known to be susceptible to altered mobility. The objective of this study was to analyze baropodometric responses following thrust manipulation on subjects with sacroiliac joint restrictions. Twenty asymptomatic subjects were submitted to computerized baropodometric analysis before, after, and seven days following sacroiliac manipulation. The variables peak pressure and contact area were obtained at each of these periods as the average of absolute values of the difference between the right and left foot based on three trials. Data revealed significant reduction only in peak pressure immediately after manipulation and at follow-up when compared to pre-manipulative values (p < 0.05). Strong correlation was found between the dominant foot and the foot with greater contact area (r = 0.978), as well as between the side of joint restriction and the foot with greater contact area (r = 0.884). Weak correlation was observed between the dominant foot and the foot with greater peak pressure (r = 0.501), as well as between the side of joint restriction and the foot with greater peak pressure (r = 0.694). The results suggest that sacroiliac joint manipulation can influence peak pressure distribution between feet, but contact area does not seem to be related to the biomechanical aspects addressed in this study.
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Unlabelled: A systematic literature review was conducted to determine the diagnostic validity of the criteria for sacroiliac (SI) joint pain as proposed by the International Association for the Study of Pain (IASP). Databases were searched up to September 2007. Quality of the studies was assessed using a Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool. Sensitivity, specificity, and diagnostic odds ratios (DOR) were calculated together with 95% confidence intervals (CI). Statistical pooling was conducted for results of provocative tests. Eighteen studies were included. Five studies examined the pattern of SI joint pain, whereas another 5 examined stressing test specific for SI joint pain. None of the studies evaluated the diagnostic validity of the SI joint infiltration or the diagnostic validity of the IASP criteria set as a whole. In all studies, the SI joint selective infiltration was used as a gold standard; however, the technique, medications, and required pain relief after the infiltration varied considerably between the studies. Taking the double infiltration technique as reference test, the pooled data of the thigh thrust test (DOR, 18.461; CI, 5.82 to 58.53), compression test (DOR, 3.88; CI, 1.7 to 8.9), and 3 or more positive stressing tests (DOR, 17.16; CI, 7.6 to 39) showed discriminative power for diagnosing SI joint pain. Perspective: This review of clinical studies focused on the diagnostic validity of the IASP criteria for diagnosing SI joint pain. A meta-analysis showed that the thigh thrust test, the compression test, and 3 or more positive stressing tests have discriminative power for diagnosing SI joint pain. Because a gold standard for SI joint pain diagnosis is lacking, the diagnostic validity of tests related to the IASP criteria for SI joint pain should be regarded with care.
Article
The purpose of this study was to examine the intertester reliability of 13 tests for sacroiliac joint (SIJ) dysfunction. Eight therapists examined 17 patients in two clinical settings. In each case, two therapists independently examined the patients and obtained results on all 13 of the SIJ tests. Patients with lumbosacral pain and unilateral lower extremity symptoms of a duration less than one year were examined. All the therapists had specialized in orthopedic physical therapy and had been trained in SIJ examination. Reliability was poor; 11 of the 13 tests resulted in less than 70% agreement. The two tests that relied solely on subjective patient response and imparted no information on SIJ position or mobility were within a range of 70% to 90% agreement. Our findings suggest the necessity of reviewing examination methods for the SIJ and improving reliability of clinical testing of this joint.
Article
The standing hip flexion test was evaluated by using a radiostereometric analysis. To evaluate whether the commonly used standing hip flexion test reflects movement in the sacroiliac joints, or whether the increased load of one sacroiliac joint also reduces the mobility of the other sacroiliac joint according to the theory of form and form closure in the sacroiliac joints. The standing hip flexion test, used frequently to analyze sacroiliac joint mobility, is advocated as a test for study of normal or impaired motion in the sacroiliac joint. In this study, 22 patients considered to have sacroiliac pain were analyzed with radiostereometric analysis when standing and when performing the standing hip flexion test on the right and left sides. Very small movements were registered in the sacroiliac joints. When provoking one side, the rotations were small on both sides. The small movements registered support the theory of form and force closure in the sacroiliac joints. The self-locking mechanism that goes into effect when the pelvis is loaded in a one-leg standing position probably obstructs the movements in the sacroiliac joints. Therefore, the standing hip flexion test cannot be recommended as a diagnostic tool for evaluating joint motion in the sacroiliac joints.
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