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Does it matter if you make a diagnosis of SIJ pain

July 2023

Authors:

SMARTERehab

This paper was an invited commentary, therefore is an opinion based paper. It introduces a model to view pain as a disease, discusses some issues related to making a diagnosis, provides supplementary clinical reasoning of for making a diagnosis of sacroiliac joint pain and discusses the benefits of making a diagnosis of sacroiliac joint pain. Considering pain as a disease, which may concurrently have multiple mechanisms with multiple causes provides an avenue to understand the complexity involved. Simple sub-classification models and rehabilitation strategies are likely to have small benefits. A strong understanding of the principles of movement pattern control are required to appreciate the use of this in clinical reasoning. Movement pattern control is only one of other mechanisms that may be considered in musculoskeletal pain.

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Schwerpunkt | Einführung

Low back pain (LBP) is a global health priority. LBP direct

and indirect costs are enormous and place a signiﬁ cant

burden on society [ 1 ] . Most LBP is not attributable to a

structural change, inﬂ ammation and speciﬁ c disease and

is therefore considered “non-speciﬁ c” (NS-LBP) [ 2 ] . Pelvic

Girdle Pain (PGP) is a recognized subgroup of non-speciﬁ c

LBP. These are musculoskeletal disorders aﬀ ecting the pel-

vis [ 3 ] . It is deﬁ ned by pain experienced between the pos-

terior iliac crest and the gluteal fold, near the sacroiliac

joint (SIJ) and may radiate to the posterior thigh. This can

also occur in conjunction with/or separately in the symph-

ysis [ 4 ] . PGP primarily involves the SIJ, symphysis pubis and

associated ligaments and muscles, as well as the appreci-

ation for how these structures are inﬂ uenced by the whole

body [ 5 ] . It is estimated that approximately 30 % of LBP

may be due to PGP [ 6 – 8 ] and may be higher in certain popu-

lations [ 9 ] . Despite the numerous research initiatives and

interventions, the outcomes for NS-LBP are modest and it

is unknown if one therapy is superior to another [ 10 , 11 ] .

D o e s I t M a t t e r i f Y o u M a k e a

Diagnosis of Sacroiliac Joint

Related Pain?

Sean GT Gibbons

How can the sacroiliac joint be reliably identiﬁ ed as the source of pain? And is this even necessary for

an adequate therapy? Sean GT Gibbons takes a stand on both questions and explains why it is neces-

sary to make a reliable diagnosis.

Quelle: © Susi Schaaf, Bellheim

131

Korrekturexemplar: Veröffentlichung (auch online), Vervielfältigung oder Weitergabe nicht erlaubt. --- Proof copy: publication (also online), reproduction and further transmission is not allowed. --- Korrekturexemplar: Veröffentlichung (auch

Schwerpunkt | Einführung

The utility of making a patho-anatomical diagnosis of SIJ

pain may be a contentious topic within some rehab pro-

fessions. The criticism is largely based on the fact that it

has not been shown to improve core outcomes such as

pain, disability, or function. Although there are systemat-

ic reviews to support the use of physiotherapy interven-

tions [ 12 – 15 ] , this has been a poorly investigated topic

[ 16 ] . Further, high-quality clinical trials have not speciﬁ -

cally tested if making an SIJ diagnosis provides superior

outcomes for any intervention. Given that this has largely

been an unexplored area, the purpose of this paper will be

to introduce professional models relating to diagnosis,

provide supplementary clinical reasoning of SIJ pain and

discuss the beneﬁ ts of making an SIJ diagnosis.

Biosocial-Etio-Pathogenesis Framework

Non-speciﬁ c chronic LBP is conceived as a disease by the

International Association for the Study of Pain [ 17 ] . Virtu-

ally all diseases follow a pathway of stages in their causa-

tion (i. e., etiology), development, and presentation (i. e.,

pathogenesis) [ 18 , 19 ] . These stages are noted in Figure 1

(

▶ Fig. 1 ). Resolution could refer to full recovery, death, or

chronicity, therefore two other stages (trajectory and dis-

ability) have been added to better reﬂ ect chronic pain. This

“etio-pathogenesis framework” of disease has been criti-

cized for emphasizing the biological aspect of diseases.

Horwitz et al. (2022) proposed “biosocial pathogenesis”

to highlight the integration of a person’s biology, biogra-

phy, and lived experience [ 20 ] . The principles of this “Bio-

social Etio-pathogenesis Framework (BEF) are listed in Box

“ The Principles of the Biosocial-Etio-Pathogenesis Framework

(BEF) ”.

Also the aspects of each stage are highlighted in Figure 1

(

▶ Fig. 1 ). It is not the purpose of this paper to discuss the

details of each section. These will be a matter of debate as

related to musculoskeletal pain, however, the stages them-

selves should not be as they are universal to almost all dis-

eases.

THE PRINCIPLES OF THE BIOSOCIAL-ETIO-

PATHOGENESIS FRAMEWORK (BEF)

▪ Pathogenesis stages are virtually the same for all

diseases.

▪ Most diseases have multiple mechanisms.

▪ Each mechanism can have multiple and diﬀ erent

causes.

▪ Causes and mechanisms can be biological &

functional.

▪ A mechanism can be considered a cause

depending on the endpoint of interest.

▪ A mechanism can develop after the onset of

symptoms and may have nothing to do with the

initial onset of symptoms.

▪ A mechanism can shift priority during the

course of diseases.

▪ Management of diseases is directed towards the

mechanisms and their causes.

▪ A patho-anatomical diagnosis is not necessarily

required for rehabilitation of mechanisms.

▶ Fig. 1 The stages of the Biosocial-Etio-Ptahogenesis Framework with suggested brief descriptions of each stage. Non-speciﬁc chronic LBP is

conceived as a disease by the International Association for the Study of Pain [17]. Virtually all diseases follow a pathway of stages in their causation

(i. e., etiology), development, and presentation (i. e., pathogenesis), which are detailed in the ﬁ gure. The term "resolution" here can refer to complete

recovery, death or chroniﬁcation. Therefore, to better represent chronic pain, two additional stages have been added: Trajectory and Disability.

Tissue

Adaptation

Biopsychosocial

Model

Multifactorial Mechanisms Damage

Response

Clinical

Diagnosis

Outcome &

Screening Trajectory

Causes Initiation Clinical

Symptoms ChronicityProgression Resolution Disability

Etiology Pathogenesis Multi-dimensional Management

Environmental

Genetic

Individual

Social

Determinants

Tissue Loading

Behavioral

Appraisal

Neurological

Dysregulation

Immune

Dysregulation

Failed healing

Pathological

Changes

Subclinical

Issues

Patho-

anatomical

Diagnosis

Dealing with

Uncertainty

Diagnostic

Levels of

Certainty

Partial

Recovery

Total

Recovery

Recurrence

Rate

Natural

Recovery Time

Mechanisms

Causes

Barriers

Individualization

132

Tissue Loading Mechanisms

The BEF notes various mechanisms in the progression to-

wards the development of clinical symptoms. Of interest

to this paper are the tissue loading mechanisms. These are

simply the processes by which tissues develop increased

strain. Traditionally, the emphasis has been on biomechan-

ical factors as a mechanism to stress tissues. These include

a single application of a high load or stress; multiple mild

to moderate loads or sustained low loads [ 21 ] .

However, other mechanisms can be occurring concurrent-

ly. For example, the forces on the spine vary based on the

pattern of trunk ﬂ exion. During trunk ﬂ exion with a re-

duced lordosis (i. e., lumbar ﬂ exion pat tern), there is more

shear and with a normal or increased lordosis (i. e., hip ﬂ ex-

ion pattern) there is more compression [ 22 – 24 ] . This is

part of the validity of subgrouping movement pattern con-

trol in LBP rehabilitation [ 25 ] .

Another tissue loading mechanism is translation control

or shear forces. Tissues of the spine are more susceptible

to strain during shear than compression [ 26 ] .The report-

ed prevalence of spinal instability in CLBP is quite variable

but is not rare (e. g., 13–57 %) [ 27 ] . This forms part of the

validity of subgrouping for lumbar instability in LBP reha-

bilitation [ 25 ] .

It should be noted that a critical aspect of the motor con-

trol approach is that the hypothesis of what the patho-an-

atomical diagnosis is should match the region where there

is a lack of movement pattern control. If this is not pres-

ent, there should be a suspicion of referred pain or anoth-

er tissue-loading mechanism.

Clinical Reasoning in Diagnosing SIJ Pain

Multiple sources of information may be used to form a hy-

pothesis about a patho-anatomical diagnosis of SIJ pain

(e. g., pain location, aggravating and easing factors, phys-

ical assessment, and questionnaires). It is not normally re-

commended to use just one test or test battery.

Levels of Certainty

The musculoskeletal pain ﬁ eld does not have a lexicon to

describe “levels of certainty” in making a diagnosis such

as neuropathic pain [ 28 ] . A sample level of certainty for a

patho-anatomical diagnosis in musculoskeletal pain is in

Box “ Levels of Certainty ”. The development of levels of cer-

tainty could help clinicians in their hypothesis formation.

Unlike other ﬁ elds, it is unlikely to achieve a level of cer-

tainty of “deﬁ nite” due to the nature of pain. Similarly, it

may be challenging for the ﬁ eld to describe what consti-

tutes a “very likely” level of certainty.

A previous cluster of tests was considered useful for diag-

nosing pain arising from the SIJ [ 29 ] . However, a recent

systematic review and meta-analysis suggested the test

battery was better used for ruling out the SIJ if negative

[ 30 ] . The clinician can be left with some uncertainty, how-

ever, there are some other factors that the clinician may

use in their hypothesis formation.

LEVELS OF CERTAINTY

Based on certain criteria, a proposal is made here

for determining a level of certainty for patho-ana-

tomical diagnoses in musculoskeletal pain.

Unlikely

▪ Pain patterns are not known to be related to the

region.

▪ Pain provocation tests are negative.

▪ Special tests are negative.

▪ Questionnaires are below a cut-oﬀ point.

▪ Patient is able to consciously control movement

patterns in the region.

Possible

▪ Pain pattern & descriptors are congruent.

▪ Questionnaires are above a cut-oﬀ point.

▪ Patient is unable to cognitively control move-

ment patterns in the region.

▪ Hypothesis of patho-anatomical diagnosis

matches tissue loading mechanism.

▪ Symptom modiﬁ cation strategies are successful.

▪ Tests not yet investigated in studies are positive.

Probable

▪ Pain provocation tests are positive.

▪ Special tests are positive.

▪ Questionnaires are validated against an

accepted standard and above a cut-oﬀ pint.

Very Likely

▪ Investigations are positive plus criteria from

“Possible” and “Probable”.

Pain Mechanisms and Sensory

Hypersensitivity

The pain mechanism the subject presents with is one of

the criteria the clinician needs to consider before making

a patho-anatomical diagnosis. Since many of the strate-

gies used are based on pain provocation, the validity of the

tests depends on the subject having normal mechanical

responses to stimuli. This requires them to have primarily

a nociceptive pain mechanism.

Limitations of Studies

One of the limitations of diagnostic accuracy studies has

been to not consider nociplastic or neuropathic pain in the

exclusion criteria. Similarly, how we decide “normal” (no

symptoms) is questionable. The BEF above highlights that

mechanisms may be occurring before the onset of symp-

toms. Numerous conditions report sensory hypersensitiv-

ity [ 31 – 33 ] . These subjects may be included in studies as

133

Schwerpunkt | Einführung

“normal” since they do not necessarily have pain and

hence could have unexpected responses to pain provoca-

tion and other loading tests.

Movement Pattern

A useful example of how movement can help in clinical rea-

soning is if there is trunk ﬂ exion-related pain. For example,

if the trunk ﬂ exion is dominated by hip ﬂ exion rather than

lumbar ﬂ e xion and there is not an increased lumbar lordo-

sis, the region of tissue loading may be the hip and SIJ. This

movement pattern is seen in

▶ Fig. 2a , while a lumbar ﬂ ex-

ion pattern of trunk ﬂ exion is seen in

▶ Fig. 2b .

If the trunk ﬂ exion is associated with pain, a second phase

of examination may be considered. Concurrently, with

trunk ﬂ exion, the patient can be asked to perform an iso-

metric contraction of M. gluteus maximus. If this relieves

the pain, it may be more likely that the source of pain is the

SIJ since the M. gluteus maximus creates force closure to

the SIJ while creating posterior pelvic tilt (e. g., lumbar ﬂ ex-

ion). If the source of pain was the lumbar spine, it is more

likely that further ﬂ exion loading would aggravate the pain

rather than relieve it. It should be noted that this motor

control strategy is predicated on the patient being able to

generate suﬃ cient stiﬀ ness during the isometric contrac-

tion of the M. gluteus maximus. Therefore, this test may

be considered more “sensitive” than “speciﬁ c”.

A problem can arise in with interpreting movement pat-

terns. If there is concurrently a hip ﬂ exion pattern during

trunk ﬂ exion with increased lumbar extension, there could

be a “false positive” in the above example. An example of

a hip ﬂ exion pattern with increased lumbar extension is

seen in

▶ Fig. 2c . Here, a change in symptoms could occur

due to posterior pelvic tilt since it unloads increased lum-

bar extension rather than providing force closure to the

SIJ. In this scenario, the client can be asked to ﬂ ex further

rather than produce an isometric contraction of gluteus

maximus. If consciously ﬂ exing the lumbar spine further

during trunk ﬂ exion reduces symptoms, it may be indica-

tive of the lumbar spine as a source of symptoms. To use

movement patterns as an adjunct to diagnostic clinical

reasoning, the clinician should have a strong understand-

ing of movement patterns. Another scenario that requires

an understanding of movement patterns is described

below.

Pain Provocation Tests

Lumbar pain provocation tests have moderate reliability

[ 34 ] and may be helpful in clinical reasoning. For example,

if there is trunk ﬂ exion-related pain and the SIJ test battery

is positive and the lumbar spine pain provocation tests are

negative, it may help the clinician in their hypothesis for-

mation to help rule out the lumbar spine.

The accessory movements of the SIJ have been described

by Lee (2004) for hyper- and hypomobility [ 35 ] . However,

the tests may also be used for pain provocation. Reliabili-

ty studies for either of these have not been conducted so

the clinician should use caution with the amount of weight

they would put on these tests in their hypothesis forma-

tion. There may be limited clinical utility in using palpation

for diagnosing SIJ pathology given the small amount of

▶ Fig. 2 Various examples of movement patterns during for ward bend. An example of a patient with a trunk kinetic chain sequence of primarily hip

ﬂ exion. a Hip ﬂ exion pattern : An example of a patient with a trunk kinetic chain sequence of primarily hip ﬂ exion. b Lumbar ﬂ exion pattern : An

example of a patient with a trunk kinetic chain sequence of primarily lumbar ﬂ exion. c Hip ﬂ exion pattern with increased lumbar extension : An

example of a patient with a trunk kinetic chain sequence of primarily hip ﬂ exion with increased lumbar extension. © S. G. T. Gibbons

abc

134

motion at the SIJ [ 36 ] . In general, pain provocation tests

have greater reliability than tests of joint motion [ 37 ] .

Multiple Tissues Involved

Another limitation of diagnostic accuracy studies is the

lack of consideration for more than one tissue being in-

volved in the pain presentation. Diagnostic accuracy stud-

ies assume that one tissue is the source of pain, however,

in the model of motor control multiple tissues may be in-

volved.

First, if the tissues in a region are being loaded (with a

movement pattern, translation, or biomechanical load-

ing), multiple tissues can undergo strain and produce no-

ciception. Second, how the central nervous system com-

pensates for this is highly variable and complex (e. g., too

much and too little stiﬀ ness) [ 38 ] . It may be possible that

this compensation can produce secondary tissue loading

(e. g., myofascial pain). Third, different tissues may be

loaded in diﬀ erent directions.

For example, the SIJ/hip region may be loaded during a

trunk ﬂ exion pattern, however, the lumbar spine could be

loaded during the extension phase (return from ﬂ exion) of

this movement. In the latter scenario, the clinician needs

to be aware that if there are concurrently extension-relat-

ed symptoms, the pain provocation tests of the lumbar

spine do not help rule out the SIJ as a source of pain. This

should be considered in the above “Pain Provocation Tests”

section.

Too Much and Too Little Stiﬀ ness

If SIJ pain is suspected, the clinician should aim to ﬁ nd out

if there is too little or too much stiﬀ ness in the region. Too

little stiﬀ ness may manifest as hypermobility or loss of the

self-locking mechanism. Several clinical tests hypothesize

testing the self-locking mechanism of the SIJ. The back-

ground logic of the tests has been covered elsewhere [ 39 ] .

The Active Straight Leg Raise Test (ASLR) [ 40 ] has adequate

reliability but challenges the hip, SIJ, and lumbar regions.

The One Leg Standing Test has demonstrated adequate re-

liability [ 41 ] , however, the quality of the study was consid-

ered low in a systematic review [ 36 ] . The Prone Over Bed

Hip Extension Test had substantial reliability in an unpub-

lished study [ 42 ] . The self-locking tests may also be consid-

ered in the clinical reasoning of the source of the pain.

However, given that there is considerable overlap in the

muscles that control the lumbar spine and SIJ, it is possi-

ble to have an asymptomatic loss of force closure when the

source of the pain is in the lumbar spine [ 43 , 44 ] . These

limitations should be considered in the therapist’s clinical

reasoning.

If the self-locking tests are negative, the therapist should

consider that the pelvis has too much stiﬀ ness. Too much

stiﬀ ness may be present for a variety of reasons including,

behavioral factors (e. g., fear of movement), neurological

factors (e. g., a battery of primitive reﬂ exes), previous trau-

ma, or current trauma and related protection of irritable

tissue. These can be screened for in the subjective history

and physical assessment. The therapist should also con-

sider that there were false negative results in the self-lock-

ing tests.

Beneﬁ ts of Making an SIJ Diagnosis

One of the foundations of the BEF and in medicine is to

make a diagnosis. It is also one of the expectations of pa-

tients [ 45 ] . This has the potential to improve patient sat-

isfaction and the therapeutic relationship, which is sug-

gested to favorably inﬂ uence core outcomes [ 46 , 47 ] .

Personalized Recommendations

Another expectation of patients is self-care. Lifting recom-

mendations are a controversial topic [ 48 – 50 ] . A common

public perception is to “keep the back straight” when

bending or lifting. An understanding of an SIJ diagnosis

and the mechanism of tissue loading (e. g., habitual hip

ﬂ exion during trunk ﬂ exion) helps the therapist provide

personalized education. For example, in this clinical sce-

nario, the patient would need to increase ﬂ exion of the

lumbar spine to reduce the tissue loading. This also relates

to sitting advice. This type of presentation of habitual hip

ﬂ exion would be more likely to beneﬁ t from having the

hips higher than the knees to reduce hip ﬂ exion and pos-

terior pelvic tilt, which could reduce the loading of the SIJ.

Reducing Fears

The terminology related to lumbar diagnosis could have

negative inﬂ uences [ 51 ] . The reference to the SIJ and a sim-

ple tissue loading mechanism noted above (i. e., habitual-

ly hip ﬂ exion during trunk ﬂ exion) has the potential to re-

duce any anxiety related to lumbar pathology. This should

also be done in simple non-threatening language.

Limitation of Potentially Unnecessary

Investigations

Overuse of investigations is a common problem [ 52 ] . The

education of an SIJ diagnosis has the potential to reduce a

patient’s desire to seek lumbar imaging since it is in a dif-

ferent region.

D i ﬀ erent Schools of Thought in Physiotherapy

There are many diﬀ erent schools of thought in physiother-

apy rehabilitation. McKenzie method (Mechanical Diagno-

sis and Therapy) originally did not have a speciﬁ c strategy

for the treatment of the SIJ [ 53 ] , however it is now com-

mon practice to use the MDT-principles in rehabilitation

of the SIJ [ 54 ] . It may be important to exclude the SIJ if

there is not a directional preference or if the benefit is

short lived. This is worthy of further research.

135

Schwerpunkt | Einführung

In functional, behavioral, progressive resisted exercise, and

tissue adaptation models, the diagnosis of SIJ pain would not

make a diﬀ erence to the rehabilitation strategy. Although

there are many schools of thought in manual therapy, a

diagnosis of SIJ pain would likely inﬂ uence clinical reason-

ing and the application of techniques. One of the known

causes of altered movement patterns is a restriction to

motion [ 55 ] . Manual therapy can be directed towards the

areas of reduced movement to improve the clinical re-

sponse.

Speciﬁ c Stabilization Exercises (SSE)

Speciﬁ c stabilization exercises (SSE) are highly speciﬁ c iso-

metric contractions that aim to bias one muscle within a

group of synergists or superﬁ cial muscles. They are per-

formed with low force with minimal inﬂ uence on breath-

ing. They are generally started in a non-functional unload-

ed position (e. g., supine crook lying) and then integrated

into function [ 56 ] . The normal progression of this motor

control intervention is to combine with movement pattern

control and muscle eﬃ ciency. This is done either concur-

rently or as a progression on an individual basis.

SSE would be applied in a very similar manner with lumbar

articular-related pain or instability and SIJ pain. There may

be some diﬀ erences in clinical reasoning and choices of ex-

ercises on an individual level. For example, psoas major

and gluteus maximus may be better suited for producing

posterior rotation of the innominate and limiting anterior

rotation [ 57 – 59 ] . Deep sacral gluteus maximus may oﬀ er

speciﬁ c protection for the sacrotuberus and sacrospinal

ligaments [ 58 ] . M. transversus abdominis provides com-

pression [ 60 , 61 ] and may be a reason why light compres-

sion inﬂ uences the ASLR test. Lumbar multiﬁ dus has a less-

er inﬂ uence on the rehabilitation of SIJ pain than on the

lumbar spine [ 5 ] so may not always be chosen as an exer-

cise early in rehab, although it appears to be involved in

the nutation of the sacrum. The pelvic ﬂ oor may have more

of an inﬂ uence on some SIJ pain than on the lumbar seg-

ment, but there is little clinical evidence [ 61 , 62 ] . The pel-

vic ﬂ oor should be considered in the overall progression of

SSE since it is involved in the synergy of the diaphragm and

abdominal muscles as well as maintenance of intra-ab-

dominal pressure [ 63 ] .

Movement Pattern Control Exercises

Speciﬁ c movement pattern control exercises are exercis-

es in which one joint or region is consciously and main-

tained in a neutral position and an adjacent joint or region

is independently moved while maintaining normal breath-

ing. The exercises are generally performed with slow, low

force, repetitive movements requiring coordination of the

muscle activation to avoid co-contraction rigidity [ 56 , 64 ] .

In speciﬁ c movement pattern control rehabilitation, the

diagnosis of SIJ pain is critical to its success. A key example

is in the above example of trunk ﬂ exion-related pain. If the

source of the pain was in the lumbar spine and a tissue

loading mechanism was habitual and or poorly controlled

lumbar ﬂ e xion, one of the interventions would be to main-

tain the lumbar spine in neutral and ﬂ ex from the hips [ 65 ] .

As seen in the BEF above, causation should also be consid-

ered. Fundamentally, the goal would be to address the

cause(s) of why someone is habitually ﬂ exing from the

lumbar spine and change their movement pattern to in-

crease hip ﬂ exion. If the source of the pain was in the lum-

bar spine, this would be expected to help. However, if the

source of the pain was the SIJ the above strategy has the

potential to not help or could even worsen the presenta-

tion since there would be increased hip ﬂ exion and hence,

possibly increased tissue loading. If the SIJ was the source

of pain and the tissue loading mechanism was excessive

or habitual hip ﬂ exion, the goal would be to increase lum-

bar ﬂ exion and to address the cause(s) of why the patient

is habitually or excessively ﬂ exing from their hips. Thus,

the patho-anatomical diagnosis needs to match the mech-

anism in the clinical reasoning of exercise prescription or

the patient may not respond or possibly get worse.

Pain Control and Prognosis

Some patients have a goal of getting pain control on the

ﬁ rst day or very soon after commencing rehabilitation.

When a diagnosis of SIJ pain is made, it is easier to make

predictions of how to achieve this. For example, a simple

exercise in which the knee is pulled to the chest has the

potential to passively posteriorly rotate the innominate

and provide passive force closure and unload tissues. This

is analogous to Mechanical Diagnosis and Therapy. If the

mechanism of tissue loading was lumbar ﬂ exion, this could

increase loading by creating posterior pelvic tilt. Patients

who have good motor skill learning, a nociceptive pain

mechanism, and SIJ pain, with low behavioral factors have

the potential to quickly achieve pain control with SSE. The

logic of a motor control-based intervention is easy for this

subgroup of patients to understand and this has the po-

tential to improve adherence.

Implications of the Biosocial-Etio-

Pathogenesis Framework (BEF)

Sub-classiﬁ cation is the identiﬁ cation of subgroups form

a heterogeneous population. The subgroup may be a

patho-anatomical diagnosis, identify prognostic risk fac-

tors, predict a response to treatment or identify underly-

ing mechanisms [ 66 ] . The purpose of sub-classiﬁ cation is

to provide the right treatment for a speciﬁ c individual at

the right time during the course of management. A recent

systematic review suggests that sub-classiﬁ cation strate-

gies have not been successful [ 67 ] . The BEF highlights nu-

merous shortcomings in this. Given that multiple mecha-

nisms, each with diﬀ erent causes is involved, unidimen-

sional models are likely to have poor success in clinical

136

trials unless they have enriched inclusion criteria. Further,

there is no standard therapy for the control groups in clin-

ical trials. Given that heterogenous groups are given het-

erogeneous interventions, it is not surprising to ﬁ nd small

treatment eﬀ ects.

Tissue adaptation is an important part of the BEF and re-

habilitation. This simplistic model of tissue adaptation or

basic strengthening may be beneﬁ cial for personal train-

ers, novice health care practitioners or low-cost popula-

tion-based therapies, however more targeted rehabilita-

tion needs to consider all aspects of the BEF if we are to

achieve meaningful and long-lasting treatment eﬀ ects and

reduce disability rates. Relying on function and tissue ad-

aptation ignores the fundamental aspects of disease

etio-pathogenesis.

The BEF highlights some ﬂ aws in the tissue

adaptation model of rehabilitation [ 68 ] :

1. Healthy tissue adaptation does not always occur with

stressing the tissues (e.g., progressive loading).

2. Mechanisms and their causes are not addressed (e.g.,

tissue loading mechanisms may be present concurrent-

ly).

3. All tissues do not adapt the same. Without a diagnosis

and understanding of the mechanism, it is unknown

how to target loading (e.g., referred pain, nerve and

neuropathic pain).

4. There is considerable individual variability in response

to loading. It is unknown why an individual will respond.

5. There is no clinical test to know if a tissue needs to

adapt, is responding with healthy (or unhealthy) adap-

tation or enough healthy tissue adaptation has oc-

curred.

Some other weaknesses in the tissue

adaptation model with progressive loading

include:

1. Symptoms can improve independent of healthy tissue

adaptation.

2. Some people already have too much stiﬀ ness or are al-

ready strong. Adding strength can increase tissue load-

ing.

3. Progressive loading has a considerable behavioral com-

ponent in musculoskeletal pain. Any beneﬁ t may have

nothing to do with the progressive loading, but rather

the non-speciﬁ c beneﬁ ts of increased exercise since it

can’t be blinded.

4. High load and low load training have similar outcomes,

so we should question the need for progressive load-

ing.

5. Progressive loading can favor fast motor unit recruit-

ment over slow. Many aggravating factors are related

to low load positions and activities so it may be “non

functional” to perform higher loads.

Summary

Diseases develop through stages of etiology (causes), ini-

tiation (mechanisms), progression (damage response),

clinical symptoms, and resolution (

▶ Fig. 1 ). The BEF pro-

vides a strategy to organize the complexity of primary

musculoskeletal pain and aid in clinical reasoning. Modern

sub-classiﬁ cation should embrace this complexity and ad-

dress mechanisms (and causes) concurrently. We need to

develop rules for when one mechanism takes priority over

another (e.g., immune dysregulation over tissue loading).

The research has continuously shown that simple inter-

ventions provide basic results. The acceptance of more de-

tailed models over simplistic ones is a professional issue

and a matter of debate. Although harnessing tissue adap-

tation is important in rehabilitation, it has considerable

limitations and unknowns. Logically, it would be combined

with other mechanisms to produce a better treatment ef-

fect. Forming a hypothesis about a patho-anatomical di-

agnosis is a fundamental aspect of how diseases are man-

aged. From there, we can use the BEF to start to under-

stand the individual, the mechanisms contributing to the

presentation, and their causes so that targeted treatment

can be planned.

There is always uncertainty in clinical practice.The pro-

posed levels of certainty for making a patho-anatomical

diagnosis can aid the clinician’s hypothesis formation and

in placing emphasis on the information they obtain. It can

be developed further to include other pieces of informa-

tion clinicians use to make a patho-anatomical diagnosis.

It requires clinical acceptance, however, provides a ﬁ rst

step in the process of development. Caution has to be

made regarding overdiagnosis, but equally, underdiagno-

sis should be considered.

Movement and motor control can be used as a clinical rea-

soning tool in the diagnosis of SIJ pain and rehabilitation.

The clinician should appreciate that these tests have not

been researched when forming their hypotheses (i. e. the

clinician should not put high weight on the motor control

strategies described in making a diagnosis of SIJ pain)

In many schools of thought it does not make a diﬀ erence if a

diagnosis of SIJ pain is made, however, in speciﬁ c movement

pattern control, it is a crucial aspect of clinical reasoning and

application. It is also helpful in many manual therapies.

Making a patho-anatomical diagnosis should not be a con-

troversial topic in the physiotherapy profession unless

there are limitations in the scope of practice in a country

or region. It is trivial to base criticism on the lack of re-

search on core outcomes. This opinion paper highlighted

numerous possible beneﬁ ts of making an SIJ pain diagno-

sis. Future research is vital to our understanding of SIJ pain

and our development as a profession. It should consider

the stages of the BEF along with the principles of multiple

mechanisms and causes.

137

Schwerpunkt | Einführung

A u t h o r s

Sean GT Gibbons

graduated from Manchester University in

1995 and is an Assistant Clinical

Professor (Adjunct) at McMaster's

Advanced Orthopaedic Musculoskeletal/

Manipulative Physiotherapy specializa-

tion (Hamilton/Canada). He is a clinician

who does part-time research. His

research has mostly been on issues related to sub-classiﬁ ca-

tion in chronic primary musculoskeletal pain including who

will respond to speciﬁ c motor control exercises; the

inﬂ uence of learning diﬃ culties; motor imagery, cranial

nerve injury, and low-grade systemic inﬂ ammation.

Correspondence

Sean GT Gibbons

stabilityphysio@gmail.com

Bibliography

MSK – Muskuloskelettale Physiotherapie 2023 ; 27 : 130–138

DOI 10.1055/a-2074-8660

ISSN 2701-6986

Georg Thieme Verlag , Rüdigerstraße 14,

70469 Stuttgart, Germany

References

Bibliography at the end of the HTML version at www.thieme-con-

nect.de/products/ejournals/msk

138

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ResearchGate has not been able to resolve any citations for this publication.

Musculoskeletal practitioners’ perceptions of contextual factors that may influence chronic low back pain outcomes: a modified Delphi study

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Background: Optimal shaping of contextual factors (CFs) during clinical encounters may be associated with analgesic responses in treatments for musculoskeletal pain. These CFs (i.e., the patient-practitioner relationship, patient’s and practitioner’s beliefs/characteristics, treatment characteristics, and environment) have not been widely evaluated by musculoskeletal practitioners. Understanding their views has the potential to improve treatment quality and effectiveness. Drawing on a panel of United Kingdom practitioners’ expertise, this study aimed to investigate their perceptions of CFs during the management of patients presenting with chronic low back pain (LBP). Methods: A modified two-round online Delphi-consensus survey was conducted to measure the extent of panel agreement regarding the perceived acceptability and influence of five main types of CFs during clinical management of patients with chronic LBP. Qualified musculoskeletal practitioners in the United Kingdom providing regular treatment for patients with chronic LBP were invited to take part. Results: The successive Delphi rounds included 39 and 23 panellists with an average of 19.9 and 21.3 years of clinical experience respectively. The panel demonstrated a high degree of consensus regarding approaches to enhance the patient-practitioner relationship (18/19 statements); leverage their own characteristics/beliefs (10/11 statements); modify the patient’s beliefs and consider patient’s characteristics (21/25 statements) to influence patient outcomes during chronic LBP rehabilitation. There was a lower degree of consensus regarding the influence and use of approaches related to the treatment characteristics (6/12 statements) and treatment environment (3/7 statements), and these CFs were viewed as the least important. The patient-practitioner relationship was rated as the most important CF, although the panel were not entirely confident in managing a range of patients’ cognitive and emotional needs. Conclusion: This Delphi study provides initial insights regarding a panel of musculoskeletal practitioners’ attitudes towards CFs during chronic LBP rehabilitation in the United Kingdom. All five CF domains were perceived as capable of influencing patient outcomes, with the patient-practitioner relationship being perceived as the most important CF during routine clinical practice. Musculoskeletal practitioners may require further training to enhance their proficiency and confidence in applying essential psychosocial skills to address the complex needs of patients with chronic LBP.

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Background: Most of the studies evaluating lifting behavior only focus on very localized parameters such as lumbar spine flexion, while evaluations of whole-body strategies are largely lacking. To enable relatively simple evaluations of whole-body strategies, this study aimed at developing a novel index for quantifying the stoop-squat behavior, and to establish normative values of the index for healthy pain-free adults. Methods: A novel index, the Stoop-Squat-Index, was developed, which describes the proportion between trunk forward lean and lower extremity joint flexion, with possible values ranging from 0 (full squat lifting) to 100 (full stoop lifting). To enable the interpretation of the index in a real-life setting, normative values for lifting a moderately-weighted object (15-kg-box) with a full squat and a full stoop technique were established using motion capture data from 30 healthy pain-free individuals that underwent motion analysis of squat and stoop lifting in the context of a previously conducted study. Results: The results showed mean index values of lower than 30 and higher than 90 for the most relevant phases of the squat and stoop movements, respectively, with mean index values differing significantly from each other for the full duration of the lifting phases. Conclusions: The main advantages of the index are that it is simple to calculate and can not only be derived from motion capture data but also from conventional video recordings, which enables large-scale in-field measurements with relatively low expenditure. When used in combination with lumbar spine flexion measurements, the index can contribute important information, which is necessary for comprehensively evaluating whole-body lifting strategies and to shed more light on the debate over the connection between lifting posture and back complaints.

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Background and objective Chronic low back pain is pervasive, societally impactful, and current treatments only provide moderate relief. Exploring whether therapeutic elements, either unrecognised or perceived as implicit within clinical encounters, are acknowledged and deliberately targeted may improve treatment efficacy. Contextual factors (specifically, patient’s and practitioner’s beliefs/characteristics; patient-practitioner relationships; the therapeutic setting/environment; and treatment characteristics) could be important, but there is limited evidence regarding their influence. This research aims to review the impact of interventions modifying contextual factors during conservative care on patient’s pain and physical functioning. Databases and data treatment Four electronic databases (Medline, CINAHL, PsycINFO and AMED) were searched from 2009 until 15th February 2022, using tailored search strategies, and resulted in 3476 unique citations. After initial screening, 170 full-text records were potentially eligible and assessed against the inclusion–exclusion criteria. Thereafter, studies were assessed for methodological quality using a modified Downs and Black scale, data extracted, and synthesised using a narrative approach. Results Twenty-one primary studies ( N = 3075 participants), were included in this review. Eight studies reported significant improvements in pain intensity, and seven in physical functioning, in favour of the contextual factor intervention(s). Notable contextual factors included: addressing maladaptive illness beliefs; verbal suggestions to influence symptom change expectations; visual or physical cues to suggest pain-relieving treatment properties; and positive communication such as empathy to enhance the therapeutic alliance. Conclusion This review identified influential contextual factors which may augment conservative chronic low back pain care. The heterogeneity of interventions suggests modifying more than one contextual factor may be more impactful on patients’ clinical outcomes, although these findings require judicious interpretation.

Effectiveness of motor control exercises versus other musculoskeletal therapies in patients with pelvic girdle pain of sacroiliac joint origin: A systematic review with meta-analysis of randomized controlled trials

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BMC MUSCULOSKEL DIS

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Full-text available

Nov 2021

Objective: To determine if classification systems improve patient-reported outcomes for people with low back pain (LBP). Design: Systematic review with meta-analysis. Literature search: MEDLINE, EMBASE, CINAHL, Web of Science Core Collection and CENTRAL were searched from inception to 21 June, 2021. Reference lists of prior systematic reviews and included trials were screened. Study selection criteria: We included randomized trials comparing a classification system (e.g. McKenzie and STarT Back Tool) to any comparator. Studies evaluating participants with specific spinal conditions (e.g. fractures and tumors) were excluded. Data synthesis: Outcomes were patient-reported LBP intensity, leg pain intensity and disability. We used the Cochrane RoB2 tool to assess risk of bias, and the GRADE approach to judge the certainty of evidence. We used random effects meta-analysis with Hartung-Knapp-Sidik-Jonkman adjustment to estimate standardized mean differences (Hedges g) and 95% confidence intervals (95%CI). Sub-group analyses explored classification systems, comparator type, pain type and duration. Results: Twenty-four trials assessing classification systems and 34 assessing sub classes were included. There was low certainty of a small effect at end of intervention for LBP intensity (-0.31[-0.54,-0.07], p=0.014, n=4416, trials=21) and disability (0.27[ 0.46,-0.07], p=0.011, n=4809, trials=24) favoring classified treatments compared to generalized interventions, but not for leg pain intensity. At the end of intervention, no specific type of classification system was superior to generalized interventions for improving pain intensity and disability. None of the estimates exceeded the effect size that one would consider clinically meaningful. Conclusions: For patient-reported pain intensity and disability, there is insufficient evidence supporting the use of classification systems above generalized interventions when managing LBP. J Orthop Sports Phys Ther, Epub 15 Nov 2021. doi:10.2519/jospt.2022.10761.

Diagnostic Accuracy of Clusters of Pain Provocation Tests for Detecting Sacroiliac Joint Pain: Systematic Review With Meta-analysis

Article

Full-text available

Jul 2021
J ORTHOP SPORT PHYS

Objective: To assess the diagnostic test accuracy of pain provocation tests for the sacroiliac joint. Design: Systematic review of diagnostic test accuracy. Literature search: Eight electronic databases and reference lists of included studies and previous reviews. Study selection criteria: Studies investigating the diagnostic accuracy of clusters of clinical tests for sacroiliac joint pain. Data synthesis: Bivariate random effects meta-analysis was employed. Risk of bias and applicability concerns were assessed using the QUADAS-2 tool and the GRADE tool to judge credibility of evidence. Results: From 2195 records identified in the search, five studies were included that assessed clusters of pain provocation tests for the sacroiliac joint. The estimated likelihood ratios (LLR) and diagnostic odds ratio (DOR) were positive LLR (2.13, 95%CI: 1.2, 3.9), negative LLR (0.33, 95% CI: 0.11, 0.72) and DOR (9.01, 95% CI: 1.72, 28.4). GRADE ratings for the outcomes were of very low certainty. Assuming a point prevalence of sacroiliac joint pain of 20%, we calculated positive posterior probability of 35% (95%CI: 32%, 46 37%) and negative posterior probability of 8% (95%CI: 6%, 10%). Conclusions: A positive result on a sacroiliac joint pain provocation test cluster gives the clinician 35% certainty of having correctly identified sacroiliac joint pain. Clusters of pain provocation tests for the sacroiliac joint do not provide sufficient diagnostic accuracy for ruling in the sacroiliac joint as the source of pain. Clinicians can rule out the sacroiliac joint as the source of pain with more confidence-the negative post-test probability indicates the clinician can conclude with 92% certainty that a negative test result is correct. J Orthop Sports Phys Ther, Epub 1 Jul 2021. doi:10.2519/jospt.2021.10469.

Load Distribution in the Lumbar Spine During Modeled Compression Depends on Lordosis

Article

Full-text available

Jun 2021

Excessive or incorrect loading of lumbar spinal structures is commonly assumed as one of the factors to accelerate degenerative processes, which may lead to lower back pain. Accordingly, the mechanics of the spine under medical conditions, such as scoliosis or spondylolisthesis, is well-investigated. Treatments via both conventional therapy and surgical methods alike aim at restoring a “healthy” (or at least pain-free) load distribution. Yet, surprisingly little is known about the inter-subject variability of load bearings within a “healthy” lumbar spine. Hence, we utilized computer tomography data from 28 trauma-room patients, whose lumbar spines showed no visible sign of degeneration, to construct simplified multi-body simulation models. The subject-specific geometries, measured by the corresponding lumbar lordosis (LL) between the endplates of vertebra L1 and the sacrum, served as ceteris paribus condition in a standardized forward dynamic compression procedure. Further, the influence of stimulating muscles from the M. multifidus group was assessed. For the range of available LL from 28 to 66°, changes in compressive and shear forces, bending moments, as well as facet joint forces between adjacent vertebrae were calculated. While compressive forces tended to decrease with increasing LL, facet forces were tendentiously increasing. Shear forces decreased between more cranial vertebrae and increased between more caudal ones, while bending moments remained constant. Our results suggest that there exist significant, LL-dependent variations in the loading of “healthy” spinal structures, which should be considered when striving for individually appropriate therapeutic measures.

Are general practitioners referring patients with low back pain for CTs appropriately according to the guidelines: a retrospective review of 3609 medical records in Newfoundland using routinely collected data

Article

Full-text available

Nov 2020
BMC FAM PRACT

Background CT Imaging is often requested for patients with low back pain (LBP) by their general practitioners. It is currently unknown what reasons are common for these referrals and if CT images are ordered according to guidelines in one province in Canada, which has high rates of CT imaging. The objective of this study is to categorise lumbar spine CT referrals into serious spinal pathology, radicular syndrome, and non-specific LBP and evaluate the appropriateness of CT imaging referrals from general practitioners for patients with LBP. Methods A retrospective medical record review of electronic health records was performed in one health region in Newfoundland and Labrador, Canada. Inclusion criteria were lumbar spine CT referrals ordered by general practitioners for adults ≥18 years, and performed between January 1st-December 31st, 2016. Each CT referral was identified from linked databases (Meditech and PACS). To the study authors’ knowledge, guidelines regarding when to refer patients with low back pain for CT imaging had not been actively disseminated to general practitioners or implemented at clinics/hospitals during this time period. Data were manually extracted and categorised into three groups: red flag conditions (judged to be an appropriate referral), radicular syndrome (judged be unclear appropriateness), or nonspecific LBP (determined to be inappropriate). Results Three thousand six hundred nine lumbar spine CTs were included from 2016. The mean age of participants was 54.7 (SD 14 years), with females comprising 54.6% of referrals. 1.9% of lumbar CT referrals were missing/unclear, 6.5% of CTs were ordered on a red-flag suspicion, 75.6% for radicular syndromes, and 16.0% for non-specific LBP; only 6.5% of referrals were clearly appropriate. Key information including patient history and clinical exams performed at appointment were often missing from referrals. Conclusion This audit found high proportions of inappropriate or questionable referrals for lumbar spine CT and many were missing information needed to categorise. Further research to understand the drivers of inappropriate imaging and cost to the healthcare system would be beneficial.

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Article

Feb 2022
PSYCHOTHER PSYCHOSOM

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