Clinical Consult

Hi there.

I have a 27 y/o female pt who has been in 3 MVA's and had >3 months of previous chiro care prior to coming to see me.  She has a positive prone instability test, negative shear test, and painful recovery from forward flexion but no step or click.  All lumbar motion is full and painless except for the painful recovery from flexion.  Compression through the SIJ's relieve the pain, and she has tight R>L iliopsoas with positive Thomas test. All reflexes are normal and no myotome or dermatome deficits.

Things that are painful:

-Rolling in bed
-Supine to/from sit
-Walking for more than 8 blocks (she has to sit down and feels LE weakness and pain in hip flexors and LB)
-Prolonged sitting or prolonged standing (>30 minutes)

I have seen her for 10 visits including today and have put her on a stabilization program.  She is frustrated (as am I) that we have not made more progress with pain relief, specifically when walking. Treatment thus far has included transverse abdominus stabilization with LE hip flexion, knee flexion, bridging, etc. Quadruped stabilization, prone closing stabilization of the SIJ (ie swimming type motion) stabilization on the swiss ball in sitting, prone, and supine, and we tried a stabilization belt today.  I have also done iliopsoas release, contract relax, and manual stretching with post pelvic tilt.

Questions for the group:

1. How long do you find on average for treatment for instability?
2. When do you decide to stabilize using a SIJ belt?
3. When do you refer back for the LE weakness with walking?
4. Have you found any other stabilization techniques that work for you?

Any suggestions would be greatly appreciated.  Thank you.

Carina Lowry, PT

Comments

[Tim Flynn, PT, PhD]

Carina,
In response to
2. When do you decide to stabilize using a SIJ belt?
It appears that compression improves symptoms. Have you tried a gait belt as a cheap way to test if an SI belt might work?
1. Pre-test walking tolerance on treadmill. Measure time to 1st onset of pain.
2. Sit until symptoms subside.
3. Place a small gait belt around the pelvic, tighten it below the ASIS.
4. Retest on treadmill.
5. If symptoms improve it would be a could way to increase her tolerance.
Tim

[Carina Lowry]

Tim,

I did finally decide to use the SIJ belt yesterday with treadmill walking. She was able to walk 4 1/2 minutes before onset of pain but did not have to sit, which is an improvement over the previous pt reports. So I agree with you it may be a way to increase her tolerance. Has anyone seen any good articles about use of SIJ belts? I would have tried this earlier if I would have thought of it...

Carina

[Erik Schenck]

Carina,
First of all I am not an SI guru and I do not consider my self an expert in SI instability. Typically I attempt to address the deficits with similar techniques in a limited weight-bearing position and mat or ball based activities. I know that the classic approach is for general spinal and pelvic stabilization, increased flexibility of apparent shortened structures and use of external stabilization (belt) if helpful. One thing that I have found extremely helpful is introducing a progressive weight-bearing program. Many times I see a clinical presentation of decreased gluteal and pelvic strength rather than spinal and abdominal weakness. The pelvic weakness and instability could be the reason for the decreased ability to walk distances. I would induce that due to the instability and weakness, your patient is incorrectly recruiting the primary stabilizers of the pelvis and lower extremities. This may lead to increased work load and ultimately quicker fatigue of these structures. Try working on hip IR, ER, and ABD in functional motions such step up lunges, walking lunges and body weight squats, and progression to resisted walking activities. If you would like to e-mail me, I can provide some pictures of the activities that have worked for me. Again this is probably not the definitive answer to your patient’s problems, although it may give you some additional tools to try.

Hope it helps,
Erik
eschenck@acngroup.com

[Charles Sheets]

Here are two articles, one from a biomechanics and one from a more clinical mindset:

Damen L, Spoor CW, Snijders CJ, Stam HJ. Does a pelvic belt influence sacroiliac joint laxity? Clin Biomech (Bristol, Avon). 2002 Aug;17(7):495-8.

Pool-Goudzwaard AL, Vleeming A, Stoeckart R, Snijders CJ, Mens JM. Insufficient lumbopelvic stability: a clinical, anatomical and biomechanical approach to 'a-specific' low back pain.
Man Ther. 1998 Feb;3(1):12-20.

Diane Lee has also written quite a bit on sacroiliac dysfunctions and the use of bracing.

[Carina Lowry]

Thank you for the references; I will look those up.

Erik, I think you also may be on to something with the progressive WB sequence. We have begun this but still limited to partial WB due to pain in the knees from previous injuries. She has just recently been able to avoid "dipping" the pelvis with quadruped UE and LE lifting. So yes, we are working in closed chain but using the Total Gym and low steps to unweight as we don't have access to a pool.

I did check out your website at ACN and it's too bad you don't have those exercises on there...I'll have to email you.

Thanks for everyone's help so far.

Carina

[Deydre]

Carina:

Have you read any of the work by Mens et al?

From your description - it appears you patient probably has a positive active straight leg raise test. I would suggest attempting this test with and without manual compression of the SI joint. If compression of the SI joint allows the patient to actively lift the leg without the discomfort felt when they lifted the leg without compression - one may start to seriously consider the use of an SI belt...the proposed benefit follows the same logic of the test. Having said that - I like Tim's more functional task...

Also, if you look at Hodges work on the ASLR test and breathing with patient with posterior pelvic pain, you can see that they use a more global bracing technique via a vasalva type of maneuver in an attempt to stabilize the pelvis as they raise their leg...While those without dysfunction, tend to just locally contract the TrA musculature.

From an exercise standpoint - the question I would pursue is to determine if your patient is performing these exercises with that more global contraction technique or if the TrA/MF co-contraction is properly occurring...

I look forward to hearing how your patient progresses!

Deydre

[Carina Lowry]

Hi all.

I just thought I'd give an update on the patient that you have helped me with this month. Deydre, she did not have an active SLR test, and this test remained negative. I do think that she had and continues to have instability though, so I am not discounting the ASLR test. She did respond to the SIJ belt for stabilization with treatmill walking, and is now up to 10 minutes from 4 1/2. She also was able to walk in NYC this past week without increased pain; so it seems she is definitely making progress.

As for the TrA vs global bracing....I spend so much time on this in the early stages of the treatment. It is quite difficult sometimes to get the pt to really activate the TrA. I've tried manual cuing, placing the inflated BP cuff under the low back, etc. So any helpful hints for next time? How do you get the lightbulb moment to occur?

I also wanted to say THANKS Erik for sending me those exercises...they are really excellent and clear for the pt to understand, so I would recommend getting them for pt use. I have them on the computer at work so I can just download them and print them off.

Thank you for the articles also. It looks as if we are making progress...her goal is to be able to walk through Disneyworld during her honeymoon this summer....and that sounds like a great pt goal to me!

Carina