Your Sacroiliac Joint: An Owner’s Manual

This post was contributed by Ann Wendel, PT.  Ann is the owner of PranaPT, a member of WebPT and active on social media. Thanks to Ann for being a resource and thought leader!

Preface

Anyone who is active in social media in the field of physical therapy knows that these are exciting times. PT’s are interacting in the public forum about practice issues affecting the current and future state of the profession. As more PT’s begin blogging, Tweeting, and connecting on LinkedIn groups, increasing opportunities exist to explore the role of communication. Last month I became intrigued with the idea of taking one research study and having two therapists with different communication preferences write about it. I asked Jason Silvernail, DPT, DSc if he would be up for partnering with me on this experiment.

Here is a link to a study that looked at techniques for evaluating the SIJ. Then, here is a Letter to the Editor written by Jason and Kyle Ridgeway, DPT. Their letter was written to describe their thoughts regarding the research and its applicability to clinical practice. It was written in language that would be understood by other physical therapists and healthcare providers. Finally, we will post my review of the study, written as I would word it for my blog, which is read by other therapists, but also the general public who is looking for more information regarding back pain. The “spirit” of this endeavor was to show how two therapists reading the same study would write about their thoughts, in words appropriate for their audience. This is important, because patients search the internet for information about their pain and possible treatments and part of our mission as PT’s is to educate the public.

I feel like the spirit of the post really does go hand in hand with the #solvept idea. Last week, several of us got talking on Twitter about things that we have privately discussed in email or DM. As other people joined in, someone said that they couldn't keep track of the conversation, and that we needed a hashtag. A physical therapist named Selena suggested #solvept. The idea of #solvept involves dissecting research among a peer group of PT's, and then successfully sharing information with the public, to allow them to make informed decisions about the type of care they want to seek out. As the #solvept group grows, and more ideas are shared, we hope that we may influence the direction that our profession takes in the next decade by influencing legislation and public support.

It is important to note that WebPT is not taking sides on this study, or any evaluation or treatment technique. However, WebPT does have a vested interest in educating the PT community and helping to provide an outlet for information exchange. The comments/discussion should stay focused on the interesting idea of PT's sharing information to different target audiences, and NOT veer off on a tangent about the actual research presented (i.e. We don't want 200 comments regarding whether or not you believe the study was valid.) We are doing the post to stimulate conversation about two different ways of sharing information gleaned from the same article. Please respect these guidelines if you plan on commenting.

Your Sacroiliac Joint: An Owner’s Manual

by Ann Wendel

Greater than 80% of the population will have back pain at some point in their lives. Theories and treatment techniques abound, offering a glimmer of hope to the average person in pain. With so many options to choose from, how do you, as a patient, make an educated decision about what type of practitioner to see for treatment? And once you decide which type of practitioner to see, how can you be sure that they are utilizing Evidence Based treatment?

For our purposes, we are going to discuss what you should expect if you choose a physical therapist as your practitioner. Physical therapists are experts at the evaluation and treatment of musculoskeletal conditions. In 46 states and the District of Colombia (D.C.), patients have the ability to consult with a physical therapist without seeing their physician first, under Direct Access Laws.

This means that as a patient living in any of these states, you can choose to schedule an appointment with a physical therapist to have an evaluation of your back and to develop a plan of care to address your concerns. Many physical therapists can offer you an appointment within 48 hours, allowing you to begin treatment for your condition without waiting several weeks to see a physician who specializes in spine care. The physical therapist will do a thorough evaluation of your medical history and current condition. They will spend time with you, to watch you move, to look at the quality and quantity of your motion, and to perform hands on evaluation techniques.

Low back pain should not be looked at as a “one size fits all” condition. Each patient’s presentation is unique, as are the factors that contribute to pain and healing. Back pain is a multifactorial issue – meaning it is caused and perpetuated by many factors working together. Your therapist should look at your specific condition based on your past medical history, current symptoms, social factors, occupation, nutritional status, and risk factors such as smoking.

Your therapist should perform multiple tests during the physical exam which can help to assess your spine. Therapists gain useful information by placing their hands on you to look for tenderness, and to palpate structures to determine what provokes your symptoms. Therapists also perform mechanical testing in order to utilize an impairment-based clinical reasoning approach. Current research points to the effectiveness of utilizing a patient-response, impairment-based approach versus an overly biomechanical approach to the assessment, treatment, management, and understanding of pain.

You should look for a physical therapist who can explain the many factors that contribute to your pain versus one who is quick to tell you that your pain is being caused by a misalignment of your spine or pelvis. If the therapist is quick to announce that your pain is coming from an SI joint that is out of alignment based only on the results of their palpation, in the absence of multiple symptom provoking tests, you should ask more questions. Current research does not support treatment based solely on palpation of the symmetry of the bony structures of the spine and pelvis. Evidence from diagnostic and therapeutic studies of the SI joint doesn’t suggest a clinically useful role for diagnosis via palpatory movement. Symptom provocation testing, rather than positional palpation, appears to have greater support in the current literature.

As enticing as it is to believe that a simple, quick “adjustment” or “manipulation” of a joint could take away your pain, you should know that a therapist should not make the decision to manipulate your spine based solely on their palpation skills. The results from the entire evaluation should be taken as a whole, to utilize a clinical reasoning approach to decide which patients may benefit from manipulation. If your therapist has utilized a manipulation, they should also provide patient education to explain your condition, and to teach you about how the body perceives and modulates pain. Ideally, your therapist will provide you with a multidimensional treatment that includes hands on work as well as exercises to strengthen and re-educate motor control of the segments of the spine that need to be better stabilized.

Beware of practitioners that offer you a “quick fix” and feel free to ask questions until you are satisfied that you are placing yourself in the right hands. You should feel that your questions and concerns are addressed prior to beginning treatment for any spine injury. A physical therapist that is up to date on the most current research will assist you in reaching your functional goals. Keep in mind that the most recent research shows that even the use of manual provocation and double blind injection studies has not eliminated the serious doubts and clinical challenges associated with the "SI joint-related pain" clinical entity and that the publication of SI joint palpatory movement schemes in light of the considerable evidence against them may perpetuate a bio-mechanical model of pain and dysfunction that is culturally popular but poorly supported in the scientific literature.

As healthcare professionals, physical therapists should base their evaluation and treatment techniques on methods well supported in peer reviewed literature. As a patient, you should make a well-educated decision about who you partner with for the care of your spine.