segunda-feira, 7 de março de 2011

Sacroiliac Joint Pain - Part II

Until recently, attention has been focused almost exclusively on the role of discs and facets in low back pain. The restricted involvement in painful degenerative diseases was inferred from the limited range of motion of the sacroiliac joint [1].
Although the origin of pain is not questioned, the prevalence of sacroiliac dysfunction (defined as hypomobility or degenerative changes) as a source of low back pain is poorly appreciated. According to osteopathic literature, one third of low back pain occurrences may be directly related to sacroiliac dysfunction. In another study of 1293 patients, the prevalence of low back pain resulting from sacroiliac dysfunction was 22,5 per cent. Physical therapy treatment for sacroiliac joint dysfunction depends on the cause of the pain and focuses on trying to restore normal motion in the joint [1].

Physical Examination
To test the existence of SIJ dysfunction, there are some SIJ pain provocation tests that can be done. The distraction test, where direct posteriorly and laterally pressure is applied to the anterior and superior iliac. 

In the compression test, the patient is lying down on his or her side, and pressure is applied to the lateral iliac crest and directed toward the opposite iliac crest. 

In the sacral pressure test, the examiner gives a rapid, short to the sacrum with the palm of the hand, with the patient in the prone position. 

In the Gaenslen test, the patient lies down in the supine position, with the hip and knee maximally flexed to one side with the opposite hip extended. Pressure is then applied, to force the sacroiliac joint through its full range. 

The Patrick test is done with the patient in a supine position with one leg flexed so that the heel in on the contralateral knee. Movement is passively reinforced by pressing on the flexed knee [1]. 

Thigh thrust test is a posterior shearing stress that is applied to the sacroiliac joint through the femur [2].

According to a study performed by Laslett et al, 2005, the thigh thrust test is the most sensitive test and the distraction test is the most specific. Two of four positive tests (distraction, compression, thigh thrust or sacral thrust) or three or more of the full set of six are the best predictors of a positive intra-articular sacroiliac joint block. When all six tests are negative, painful sacroiliac joint may be ruled out [2].
In addition to the tests mentioned above, many other signs can be elicited, such as abnormal sitting posture, groin pain, buttock pain, sacral sulcus tenderness, gluteal trigger points, pointing to the posterior superior iliac spine as the main site of the pain, iliopsoas tenderness, pubic symphysis tenderness, lower quadrant abdominal pain, and an increase or decrease in pain with the following movements: flexion or extension, rotation, ipsilateral or contralateral flexion, straight leg raise, sitting, standing , walking, sacroiliac joint compression [4].

There are many causes of SIJ pain syndrome, which should be correctly diagnosed, in order to provide the best physical therapy treatment.
If the joint appears to be “stiff” or “locked” and needs to be more mobile to function properly, the pain will be decreased in response to manipulation or mobilization, which includes manual therapy, deep tissue massage, myofascial release, stretching exercises to decrease the tightness of the muscles surrounding. If the problem is a leg length discrepancy, a shoe lift can compensate; if the problem is weight, diet and exercise could be prescribed; abnormal gait and poor postural habits can be corrected. Falls prevention should also be done to avoid traumatic sacroiliac joint injury [1].
In case of  legs of unequal length, which can cause asymmetric forces on the pelvis resulting in pain, usually in the shorter limb, a shoe lift can be worn to compensate the leg length discrepancy. In case of muscle imbalance in the legs or unilateral weakness of lower extremity muscles, which can lead to abnormal transfer of stress and load through the torso in an asymmetric posture, increasing stress on one or the other side of the pelvis, strengthening exercises of the lower limb muscles can be done.  If the problem is weight gain, especially around the area of the trunk, adding stress to the SIJ, exercise and diet may be the answer. If scoliosis (curvature of the spine) is the cause of the problem, causing asymmetrical movement, leading to an abnormal load transfer and sacroiliac joint dysfunction, strengthening and stretching exercises and mobilization of the vertebral joints can be done. An altered gait patter and poor postural awareness and habits in sitting, standing and daily activities can load the sacrum incorrectly, and can be corrected trough postural retraining. Falls onto the buttocks, can strain the ligaments around the sacroiliac joint, creating instability. Fall prevention is essential to reduce the risk of traumatic SIJ injury [3].

[1] Maigne, J., Aivaliklis, A., Pfefer, F. (1996). Results of Sacriliac Joint Double Block and Value of Sacroiliac Pain Provocation Tests in 54 Patients With Low Back Pain. SPINE; 21: 1889-1892.
[2] Laslett, M., Aprill, C.N., McDonald, B., Young, S.B. (2005). Diagnosis of Sacroiliac Joint Pain: Validity of individual provocation tests and composites of tests. Manual Therapy; 10: 207-218.
[3] Sherman, A.L. (2006). Sacroiliac Pain: A Physical Therapy Perspective.  Post-Polio Health. Summer 22(3): 1-3.

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