Sacroiliac Joint Dysfunction, evaluation and physical therapy

Transcription

Sacroiliac Joint Dysfunction,
evaluation and physical therapy
management.
Combined Section Meeting 2006
San Diego, CA
February 1-5,2006
Michael T. Cibulka, PT, DPT, MHS, OCS
n
Assistant Professor,
Maryville University
Program in Physical
Therapy
q
n
St. Louis, MO.
President, Jefferson
County Rehabilitation &
Sports Clinic
q
Festus, MO.
1
Course Description
n
The purpose of this course is to explore
the evidence surrounding the evaluation
and treatment of the pelvis in
performing artists.
Course Objectives
n
n
n
n
Understand the anatomy of the sacroiliac
joint and its relationship to movement.
Examine the published evidence of sacroiliac
joint motion studies.
Examine the published evidence on the
evaluation of the sacroiliac joint.
Examine the evidence on the intervention of
the sacroiliac joint.
Sacroiliac Joints
n
Most have described the
sacroiliac joint articular
surfaces as a “kidney
bean” or “L” shaped with
its convexity located
anteriorly.
n
The sacroiliac joints is
usually located along the
S1, S2, and S3 sacral
vertebrae.
2
The Sacroiliac Joint: The Problem.
Different schools of thought.
q
q
The SIJ has little to no motion and barely moves.
The sacroiliac joint move in more than 3 different
degrees of freedom, allowing for independent
innominate movement of anterior/posterior tilts,
up-slips, down-slips, in and out flares, as well as
sacral torsions, side-bending, flexion and
extension lesions/problems.
Is the sacroiliac joint a “real” joint?
n
Evidence shows that the sacroiliac joint:
q
q
q
q
q
n
has synovial fluid.
has articular cartilage, hyaline on the sacral side,
more fibrous on the ilial side.
has a fibrous/synovial joint capsule.
degenerative changes develop with age.
and it moves.
The sacroiliac joint is a diarthrodial joint.
The Myth of Independent Innominate
Motion
n
Can the left innominate bone move anteriorly
or posteriorly independently of the right
innominate bone?
q
n
Osteopathic Muscle Energy Theories.
For independent motion to develop sufficient
movement must occur in the symphysis
pubis.
3
Symphysis Pubis: an amphiarthrodial joint
n
The joint is not considered a synovial joint
and moves very little.
q
q
LaBan in 1978 showed with standard radiography
that during alternate weight bearing the symphysis
pubis moves about 2 mm.
Recent studies by Walheim and Meissner show
that under normal conditions (not pregnancy) the
symphysis pubis moves between 1.0 and 2.0 mm
maximally.
Symphysis Pubis
n
Thus, although these studies show that the
symphysis pubis moves its motion is
extremely small and certainly not enough to
allow any sort of definable or even
observable independent left or right
innominate bone motion.
So how does the sacroiliac joint move?
n
To understand how the sacroiliac joint moves
one method is to examine its articular
surfaces.
q
n
The sacroiliac joints can only move along the path
of their articular surfaces.
As with all synovial joints the types of
movements that can occur are determined by
the contour or shape and the orientation of
the articular surfaces.
4
Articular Surfaces of the Sacroiliac joints
n
Solonen examined 30
pelvises and showed
that a wide variation
in the articular
surfaces exist
between individuals.
n
Solonen, K., The sacro-iliac joint in the light
of anatomical, roentgenological and clinical
studies. Acta Orthop Scand ( Suppl), 1957.
27: p. 1 -127.
Median sagittal angle describes the SIJ’s
articular surface from a frontal view
n
n
n
At S1 the average angle
was 11o with the apex of the
inclination angle formed
caudally.
S2 0o or a flat sagittal
surface with the apex angle
forming caudally.
S3 10o with the apex of the
inclination angle formed
cranially.
The angle made between the articular
surfaces in the horizontal plane
n
n
n
n
The inclination angle
thus could have its
apex dorsal or ventral.
At S1 the average
inclination angle was
21 o (range 0-75 o) with a
dorsal apex.
S2 12 o degrees with a
dorsal apex.
S3 10 o (range 0 -45 o)
with a ventral apex
5
The SIJ articular surfaces from a
horizontal perspective
n
n
n
n
The inclination angle
thus could have its
apex dorsal or ventral.
At S1 the average
inclination angle was
21 o (range 0-75 o) with a
dorsal apex.
S2 12 o degrees with a
dorsal apex.
S3 10 o (range 0 -45 o)
with a ventral apex
Conclusion from Articular Surfaces
Topography
n
n
n
n
The orientation of the articular surfaces are usually
not in any one plane.
Motion likely occurs in all three planes, sagittal,
frontal, and horizontal (tri -plane motion).
The articular orientation shows why with posterior
pelvic tilt the innominate bones “flare out” and with
anterior tilt they “flare in”.
Examining the orientation of the articular surfaces
allows understanding of why “in and out flares” have
been described.
Sacroiliac Joint Movement
n
A key concept in
understanding SIJ
motion is that the left
and right sacroiliac
joints are:
two structurally
separate joints that
functionally act as
one single joint.
6
Motion of bicondylar joints
n
Another important feature of
bicondylar joints is that:
movement of one bicondylar joint
must be accompanied by a correlative
movement at the other bicondylar
joint!
An example of another bicondylar joint:
The temperomandibular joint (TMJ)
n
n
The left TMJ can not move without also a
correlative movement developing in the right
TMJ.
Movement of one joint requires or demands
movement of the other mated joint.
q
This is because the singular mandible bone forms
both the left and right temperomandibular joints
condyles.
Sacroiliac Joint Motion
n
n
The innominate bones
move either anteriorly
or posteriorly
Together or
symmetrical motion.
q
n
As in anterior or posterior
tilt of the pelvis.
Separate or
asymmetrical motion.
q
During gait where one
moves anterior the other
posteriorly.
7
Evidence on sacroiliac joint motion
n
The first study was performed by Zaglas in
1851.
n
Zaglas observations showed enlarging and
contracting of the pelvic inlet and outlet
diameters on backward bending of the spine.
n
In 1930 Chamberlain demonstrated mobility
of the sacroiliac joints by determining the
difference in heights between the two pubic
rami on A/P radiographs with patients
standing on one leg
n
n
In 1936 Pitkin and
Pheasant described
movement of the
sacroiliac joints.
Describe motion as
primarily paired motion
of the innominate
bones where the
innominate bones move
in a symmetrical or
asymmetrical fashion.
n
Pitkin and Pheasant
call this asymmetrical
motion antagonistic
motion because the
innominate bones tilt in
opposite directions, one
in a primarily anterior
direction the other in a
posterior direction.
8
n
Weisl in 1954,
studied the
movements of the
sacroiliac joint
using a
radiographic
method.
n
n
Movement of the sacral
promontory was used
to define motion of the
sacroiliac joint.
These early studies
lacked understanding
of how the sacroiliac
joint moves.
n
Colachis in 1963
examined sacroiliac
joint motion by
inserting Kirshner
wires or pins into the
left and right
posterior innominate
bone of 12 adult
male medical
students
n
n
n
Nine different positions
were used to examine
for movement.
Colachis found 10 mm.
of movement between
the innominate bones
Weakness is that no
wires or pins were
placed in the sacrum.
n
Frigerio, in 1974,
performed the first
study of RSA on a male
cadaver pelvis. The
cadaver’s left hip was
extended 15 degrees
and abducted 30
degrees.
n
n
Frigerio found up to
26mm. of movement
when comparing the
iliac crests to the
sacrum.
Regrettably, no angular
motion was measured.
9
n
Egund in 1978 examined 4
subjects using the RSA
method. RSA is a method
where two orthogonally
directed radiograph tubes
take radiographs of the
pelvis.
n
Tantalum marker balls were
placed on the posterior
aspect of the sacrum and two
ilia bones to define the bones
and thus describe movement.
n
Subjects were measured
during many different
postures and
movements.
n
Egund found the
maximum sacroiliac joint
movement was 2
degrees of rotation.
n
Lavignolle, in 1983,
studied 5 subjects.
n
Subject’s trunks were
stabilized supine in a
special apparatus while
an investigator passively
flexed the right hip to 60
degrees and extended
the left hip by 15 degrees
to simulate walking or
running.
n
n
RSA was used to
determine motion;
however, no markers
were used only points on
the innominate and
sacrum bone.
Motion was determined
from these points; the
average sacroiliac joint
movement measured 1012 degrees in the five
subjects
n
1988 Cibulka, Delitto, and
Koldehoff performed a
study on 20 patients with
signs of sacroiliac joint
dysfunction to try and
determine the nature and
relative disposition between
the left and right innominate
bones assume in patients
with sacroiliac joint
dysfunction
n
This study was important in
showing that the pelvic
obliquity that develops in
patients with sacroiliac joint
dysfunction is the result of
an equal and opposite (one
anterior the other posterior)
tilt of the left and right
innominate bones.
10
Sturesson in 1989 used
an RSA method to
describe motion of the
sacroiliac joints.
Sturesson examined 6
patients (2 females, 4
males) using an RSA
technique to determine
the quantity of motion
available in the sacroiliac
joints.
n
n
n
n
Patients were studied with
many different movements.
Motion of the sacroiliac joint
was noted to occur in all three
body planes with most (90%)
of the motion developing in the
sagittal plane.
The amount of sacroiliac joint
motion measured was very
small (only 2.5 degrees of
movement at the most).
Roentgenstereophotogrammetric analysis
RSA
n
A radiographic technique use to
determine motion between 2 bodies or
objects.
n
RSA is considered a very precise and
reliable method of measuring motion
between two objects.
RSA (continued)
n
The biggest problem with RSA is its validity.
q
That it really measure what it purports to measure.
n
When using RSA to measure motion a
number of specific criteria must be met.
n
When describing a free body object the
markers must be placed in such a way
that they represent validly or fully the free
body objects.
11
RSA
For example if we were
to describe a box the
markers that define the
box markers would be
placed evenly or
isotropically in all of the
corners of the box and
not just one side.
n
RSA
n
Errors arise when
markers are placed in
just one plane (located
collinear), this sort of
placement does not
allow representation of
the free body object
and invalidates the
mathematical
procedure.
n
The method currently
used to study sacroiliac
joint motion is to use
tantalum balls to define
the ilium and sacrum
bones.
RSA
n
In Sturesson’s
study the patient
moved supine to
standing, and then
another
radiograph was
taken.
n
The two radiographic
tubes can only
measure two
dimensions while the
third dimension is
determined by using
a mathematical
procedure called the
least squares
method.
12
RSA
n
Thus the markers should
be placed in such a way
that the markers fully
represent the free body
object.
n
Failure to do so
invalidates the
mathematical least
square procedure used
to calculate the third
dimension.
Making inferences using RSA
n
Care must be taken when making inferences from
studies that use RSA when studying sacroiliac joint
motion.
q
q
q
n
New studies are needed that fully represent the ilia and
sacrum.
Difficulty in placing tantalum balls in the ischium or pubis,
must find new method of defining the objects.
This is especially true if considering the bicondylar
sacroiliac joint motions.
Or new technology that can do the job of measuring
complex motion is needed.
Studies on Sacroiliac Joint Motion
Coupled with Hip Joint Motion
n
Smidt, in 1995,
examined 32 normal
subjects (15 men, 17
females) with a
Metrecom an
electrogoniometer while
standing in a position
where one hip was fully
flexed and the other fully
extended (reciprocal
stance position).
Markers were placed on
the left and right ASIS
and PSIS’s, which
limited analysis to just
two dimensions.
The mean sagittal-oblique
composite motion for the
group was 9o, while
mean oblique-transverse
motion was 3o .
13
Studies on Sacroiliac Joint Motion
Coupled with Hip Joint Motion
n
Smidt, in 1997,
examined sacroiliac
joint motion on five
aged cadavers. The
pelvises were CTscanned while side
lying and the hips were
moved where one was
fully flexed and the
other fully extended
(reciprocal stance
position).
n
Smidt showed in the
non-weight bearing
position when the hip
joint is extended the
innominate bone
anteriorly tilts and when
the hip joint is flexed
the innominate bone
posteriorly tilts.
Summary of the Evidence of Sacroiliac
Joint Motion
n
n
n
n
n
Sacroiliac joint motion does occur.
Movement is small 2 -12 degrees.
Most studies show that antagonistic innominate
motion does occur.
Sturesson suggests that the symphysis pubis makes
the 2 innominate bones rotate as a unit around the
sacrum.
Care must be taken with inferences made from RSA
studies that examine sacroiliac joint motion.
Evaluation of the Sacroiliac Joints
n
n
n
n
n
n
Potter and Rothstein
Cibulka, Delitto, and Koldehoff
Freburger and Riddle
Laslett
Doppler Studies
Future studies
14
Potter, N.A. and J.M. Rothstein, Intertester reliability for
selected clinical tests of the sacroiliac joint. Phys Ther, 1985.
65(11): p. 1671-1675.
n
n
n
n
n
Examined 31 different sacroiliac joint tests.
Found poor intertester reliability between 8
different experienced orthopaedic PT’s.
Reliability was poor; 11 of the 13 tests
resulted in less than 70% agreement.
Each test was interpreted independent of the
other.
Not at all like a “real” clinical environment.
Cibulka, M.T., A. Delitto, and R.M. Koldehoff, Changes in
innominate tilt after manipulation of the sacroiliac joint in patients with
low back pain. An experimental study. Phys Ther, 1988. 68(9)
n
n
n
n
Used a cluster of 3 out of 4 sacroiliac joint
tests.
Used 2 experienced PT’s.
Found high reliability (Kappa=.88).
Used a clinical and iterative approach when
making the diagnosis of sacroiliac joint
dysfunction.
Riddle, D.L. and J.K. Freburger, Evaluation of the presence of sacroiliac joint
region dysfunction using a combination of tests: a multicenter intertester reliability study.
Phys Ther, 2002. 82(8): p. 772-781.
n
n
Examined SIJ test
using Cibulka format.
Thirty-four therapists
from 11 outpatient
centers examined 65
patients were used in
this study.
n
n
n
They found poor
reliability.
A problem was their
classification of SIJD
was not clear as to how
patients were classified
into diagnostic groups.
Also, most of the PT’s
were recently trained,
by reading a manual, in
using this method.
15
Laslett, M., The value of the physical examination in diagnosis of
painful sacroiliac joint pathologies. Spine, 1998. 23(8): p. 962-964
n
Laslett examined the
reliability of some of the
provocation tests and found
5 of 7 show good interexaminer reliability, these
include the distraction test
(.69 Kappa), compression
(.77 Kappa), thigh thrust
(.82 Kappa), and left and
right pelvic torsion test (.79
and .64 Kappa).
n
n
n
The cranial shear and
sacral thrust test both had
Kappa values below .35
which is only Fair
agreement
Problem with these tests
they really don’t guide
intervention.
Thus, the tests may be
“good” at detecting if SIJ
dysfunction is present or
not, but that is all they do!
Damen, L., T. Stijnen, M.E. Roebroeck, C.J. Snijders, and H.J. Stam,
Reliability of sacroiliac joint laxity measurement with Doppler imaging of vibrations.
Ultrasound Med Biol, 2002. 28(4): p. 407-414.
n
n
The Doppler method uses
ultrasound to measure laxity
of the sacroiliac joint
through vibration.
Subjects usually lie prone
while vibrations are applied
unilaterally to the anterior
superior iliac spine.
n
n
Vibrations are generated by
a vibrator and are
propagated through the
ilium through the sacroiliac
joint to the sacrum.
The intensity of vibrations
are measured successively
on both sides of the
sacroiliac joint.
Using ultrasound to detect SIJD
n
Differences in threshold
levels (measured in
threshold units, TU’s).
n
Usually in a stiff joint,
little difference in the
amplitude of vibration is
found between the left
and right sides.
n
n
A minimal difference
between threshold levels of
the sacrum and ilium is
usually an indication of a
stiff joint (less than 2 TU),
while a large difference is
indicative of a loose joint
(greater than 5 TU).
A left to right difference in
sacroiliac joint laxity >or=3
threshold units is
considered to indicate
asymmetric laxity of the
sacroiliac joints.
16
Using ultrasound to detect SIJD, the Pro
and Con’s.
n
n
US has been found to be reliable.
Validity has not yet been shown.
q
n
n
Thus one must show validity before accepting this
method as evidence for sacroiliac joint
dysfunction.
Like provocation tests, US may help detect,
but has not yet helped in guiding treatment.
More studies, especially validity, are needed!
Diagnosis of Sacroiliac Joint Dysfunction
An Iterative or Recursive Process!
n
Repeating routines or steps in a loop to
insure a parallel or agreed upon response.
q
For example: Repeating SIJ tests to confirm a left
posterior innominate finding.
n
q
q
All or most tests should agree if not go back to the
“drawing board”.
Most clinicians use this method!
Developing consensus when making a diagnosis.
Sacroiliac Joint Intervention
n
Are we mobilizing?
q
q
n
Manipulation
Mobilization
Or Stabilizing the Sacroiliac joint?
q
q
q
q
Stabilization
Belts or restraining devices
Prolotherapy
Exercise
17
Studies on Manipulation
n
n
n
Cibulka et al: 1986 Showed that a
manipulative technique directed at the
sacroiliac joint can eliminate pelvic obliquity.
Delitto et al: 1993 Showed that manipulation
combined with exercise resulted in significant
improvement in both signs and symptoms in
patients with sacroiliac joint dysfunction
Childs et al: 2004 Developed a clinical
prediction rule to help guide the intervention
of patients with low back pain.
Conclusion: The Sacroiliac Joint:
n
n
n
n
n
is a synovial joint.
is a bicondylar joint where motion of one joint
requires obligatory motion of the “other” joint.
can be detected and diagnosed.
combining information from the history and
physical examination improves diagnosis.
the sacroiliac joint can be effectively treated.
18
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7
EVALUATION AND MANAGEMENT OF LUMBAR-PELVIC
DYSFUNCTIONS
IN THE PERFORMING ARTIST
CASE STUDY: MUSCULAR IMBALANCES AND SIJ TREATMENT IN 3DANCERS
COMBINED SECTIONS MEETING
San Diego, CA
February 1-5, 2006
Presenter: Shaw Bronner PT, PhD, MHS, EdM, OCS; Director of ADAM Center
at Long Island University, Brooklyn, NY and Director of Therapy Services at Alvin
Ailey, New York, NY.
Description:
According to McGill et al. (2003)1, the spine is inherently unstable. The lumbar
spinal column, devoid of its muscular support, buckles under compressive
loading of only 90 N (20 lbs).1 Clinical instability was defined by White and
Punjabi (1990)2 as the loss of the spine’s ability to maintain its patterns of
displacement under physiologic loads, resulting in pain, deformity, or neurological
deficit. Segmental instability can be further defined as an increase in the size of
the neutral zone with a decrease in the capacity of the stabilizing system of the
spine (passive, active, and neural control) to maintain the spinal neutral zones
within physiologic limits so there is no pain, deformity, or neurological deficit.3
Fritz et al (2005)4 found inter-vertebral motion testing (lack of segmental
hypomobility) and lumbar flexion ROM to be predictive of radiographic lumbar
instability. In addition, higher Beighton scores (> 2/9) were found in subjects with
instability. 4
The annual incidence of lumbar-pelvic injuries in professional dance companies
has been reported to be 12 to 23%.5-8 Dance requires frequent work at extremes
of motion.9 They also frequently display benign joint hypermobility syndrome. An
increased odds ratio of 11.0 for benign joint hypermobility syndrome (with a
Beighton score of > 4/9) was found in ballet dancers at the Royal Ballet company
and school compared to age matched controls.10
The extreme motion requirements of dance combined with the ROM flexibility
found in dancers may help to explain the high rates of lumbar-pelvic injury found
in this population. Dancers frequently believe more motion is ‘better’ which may
be directly in opposition to the motion control parameters necessary to control
unstable segments. This can make them a particularly challenging patient
population.
Three cases are presented of dancers with motion control impairments of the
lumbar-pelvic region. Each dancer presented with generalized hypermobility on
vertebral and SIJ motion testing. Each dancer also presented with functional
movement dysfunctions in extension.
Case #1: ML was a 16 y.o. male dance student taking 15 technique
classes/week with additional rehearsals.
• Symptoms: chronic right lower lumbar, buttock, and posterior thigh pain.
• Vertebral testing: no hypomobility.
• Motion control impairment: extension.
• Functional movement dysfunction: Right arabesque and cambré back.
• Beighton score: not completed.
Diagnosis: Right L4-5-S1 segment multidirectional instability, SIJ instability, and
piriformis syndrome.
Case #2: AP was a 21 y.o. female dance student taking 15 technique
classes/week.
• Symptoms: intermittent right buttock pain.
• Motion control impairment: extension.
• Functional movement dysfunction: Right arabesque, end range grand
battement all directions.
• Beighton score: 7/9.
Diagnosis: Right piriformis syndrome with lumbar and SIJ instability.
Case # 3: MK was an 18 y.o. female dance student taking 11 technique
classes/week with additional rehearsals.
• Symptoms: chronic right LBP.
• Motion control impairment: extension and side bending.
• Functional movement dysfunction: Cambré back and Horton laterals.
• Beighton score: 2/9.
Diagnosis: L3-L4-L5 segment multidirectional instability.
Form closure is a considered position of stability due to the passive system of
joint surfaces and ligaments.11, 12 For example, the close-packed position for the
SIJ is nutation of the sacrum or posterior rotation of the innominates generally
demonstrates form closure.13 Force closure is a dynamic process performed by
local musculature (transverses abdominis, internal oblique, lumbar multifidus,
diaphragm, pelvic floor, etc) to enhance stiffness and control of the segment.
With instability of lumbar segments or SIJ, frequently there are dysfunctions in
dynamic force closure by the local stabilizers. Additionally, excessive motion
(extension) may be visualized at the unstable level. In the case of an unstable
SIJ, overuse of the piriformis may reflect an attempt to self stabilize this joint.
Increased piriformis elongation/tension has been suggested by Snijders et al
(2006) to contribute to SIJ stability. 14
Movies will be used to demonstrate the dance-specific activities that were
dysfunctional for these cases, with treatment strategies that were employed.
While traditional stabilization programs focus on control of a relatively small
‘neutral’ posture, the challenge in treating these patients is achieving force
closure at dynamic extremes while meeting aesthetic standards. Technique
problems specific to these dance movements will be discussed. Corrections were
selected that are acceptable to dance aesthetics but permitted a decrease in
stressors to the unstable segment.
Limitations: Due to the time constraints of our student injury clinics, no outcomes
measures were used. Treatment closure is frequently not possible, as the
students simply do not return if their pain is resolved or the semester is over.
Objectives: At the conclusion of this presentation, participants will be able to:
1. Understand risk factors for lumbar-pelvic motion control impairments in
dancers.
2. Describe the objectives for developing force closure in dancer-specific
activities.
Level: Multilevel.
Content: The major points in this presentation are:
1. Analysis of the dance-specific activity is key to assisting the dancer with
dynamic control of instability.
2. An understanding of the aesthetics of dance technique is helpful in gaining
the patient’s trust.
3. The extremes of motion at which many of the dance-specific activities
occur make treatment particularly challenging.
4. Dancers frequently believe more motion is ‘better’ which may be directly in
opposition to the motion control parameters necessary to control unstable
segments.
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Effect of comprehensive management on injury incidence and time loss.
American Journal of Sports Medicine. 2003; 31(3):365-373.
Garrick JG, Requa RK. Ballet injuries: An analysis of epidemiology and
financial outcome. American Journal of Sports Medicine. 1993;21(4):586590.
Nilsson C, Leanderson J, Wykman A, Strender LE. The injury panorama in
a Swedish professional ballet company. Knee Surgery, Sports
Traumatology, Arthroscopy. 2001; 9(4):242-246.
Solomon R, Solomon J, Micheli LJ, McGray E. The “cost” of injuries in a
professional ballet company: A five year study. Medical Problems of
Performing Artists. 1999; 14:164-169.
Bronner S. Reliability and validity of electrogoniometry measurement of
lower extremity dance movement [Dissertation]. Newark. NJ: Department
of Interdisciplinary Studies, School of Health Related Professions,
University of Medicine and Dentistry of New Jersey; 2005.
McCormack M, Briggs J, Hakim A, Grahame R. Joint laxity and the benign
joint hypermobility syndrome in student and professional ballet dancers. J
Rheumatol. 2004; 31(1):173-178.
Snijders CJ, Vleeming A, Stoeckart R. Transfer of the lumbosacral load to
iliac bones and legs: Part 1. Biomechanics of self-bracing of the sacroiliac
joints and its significance for treatment and exercise. Clin Biomech. 1993;
8:285-294.
Snijders CJ, Vleeming A, Stoeckart R. Transfer of the lumbosacral load to
iliac bones and legs: Part 2. Loading of the sacroiliac joints when lifting in
a stooped posture. Clin Biomech. 1993; 8:295-301.
Hungerford B, Gilleard W, Lee D. Altered patterns of pelvic bone motion
determined in subjects with posterior pelvic pain using skin markers. Clin
Biomech. Jun 2004; 19(5):456-464.
Snijders CJ, Hermans PF, Kleinrensink GJ. Functional aspects of crosslegged sitting with special attention to piriformis muscles and sacroiliac
joints. Clin Biomech. 2006; 21(2):116-121.
Non-operative Management of Lumbar st ress fract ures in dancers a nd figure
skaters
Airelle O. Hunter, PT, MPT, SCS, CSCS
Associate Director of Sports PT
Universit y of Delaware Physical Therapy Department
[email protected] (302)831-8893
References:
1. Axler C, McGill SM Low back loads over a variety of abdominal exercises:
searching for t he safest abdominal challenge M edicine and Science in Sports
and Exercise Vol 29 No 6 pp 804-810, 1997.
2. Epps C, Bowen JR: Complications in Pediatric Orthopaedic Surgery, 1 st ed, p
301-308. Philadelphia, Penns ylvania, J . B. Lippincott Co.,1995
3. Fairbank JCT, Couper J. Davies J B, O’Brien JP. The Oswestr y low back
pain disability questionnaire. Physiotherapy 1980;66(8):271-273.
4. Fritz, JM, Hicks GE, Mishock The Role of M uscle Strengt h in Low Back Pain
Orthopaedic Physical Therapy Clinic of North Am erica 9:4, Dec 2000 529-547.
5. Fritz JM, Erhard RE, Hagen BF Segmental Ins tability of the L umbar Spine.
Physical Therapy. 1998 78(8):889-896.
6. Hides J, Richardson C, J ull G M ultifidus Muscle Recovery is Not Automatic
After Resolution of Acute , First-Episode Low Back Pain Spine Vol 21 no 23 pp
2763-2769 1996
7. Kankaanpaa M, Taimela S, Airaksinen O, Hannine n O The Efficacy of Active
Rehab in Chro nic Low Back Pain Spine Vol 24, No 10pp 1034-1042 1999
8. Kahano vitz N, Nordin M, Verderame R, Yabut S, Parnianpour M, Viola K,
Mulvihill M Normal tr unk musc le streng th and end ura nce in women and the
effect of e xercise and electrical stimulation Spine Mar;12(2):112-8 1987
9. Manal T Use of Electrical Stimulation to Supplement Lumbar Stabilization for
a Figure Skater Following Lumbar Fusion Or thopedic Physical Therapy Practice
Vol 14:2:02 pg 30-32 2002
10. McGill SM Low Back Stability: From Formal Description to Issues for
Performance and Rehabilitation. Exercise and Sport Sciences Reviews. 2001
29(1): 26-31.
11. Richardson CA, Jull GA Muscle contro l-pain cont rol. What exercises would
you prescribe? M anual Therapy. 1995 1: 2-10.
12. Snyder-Mackler L, Ladin Z, Schepsis AA, Young JC. Electrical stimulation of
the t high m uscles af ter reconstr uction of t he anterior cruciate ligament. The
Journal of Bone and Joint Surgery. 73-A (7) 1025-1036, 1991.
13. Starring, D The Use of Electrical Stimulation and Exercise for Streng the ning
Lumbar Musc ulat ure: A Case Study JOSPT Vol14, 2 August 1991 61-64
1/19/2006
LUMBAR SPINE
STABILIZATION TRAINING
IN DANCERS
Leigh A. Roberts, PT, DPT, OCS; LAR
Physical Therapy, Ellicott City, MD
COMBINED SECTIONS MEETING
San Diego, CA
February 1-5, 2006
Objectives
1. Review anatomy of lumbar
stabilization
2. Review literature on lumbar
stabilization
3. Present a case study with dance
specific lumbar stabilization exercise
progression
2
Anatomy
• Bergmark 1989:
– Local Stabilizers (psoas major,
transversus abdominis, multifidus,
quadratus lumborum )
– Global Stabilizers (internal oblique,
external oblique, erector spinae, rectus
abdominis, lats )
• Panjabi 1992: Spinal Stability
• Snijders , Vleeming, Stoeckart 1993 & Lee
2001
– Form Closure / Force Closure
3
This information is the property of Leigh
Roberts and should not be copied or otherwise
used without expres written permission of the
author.
1
1/19/2006
Harmony of the Stabilizers
• TA, P, QL, M must work
together to provide
segmental stabilization
and based on their
anatomical position are
ideally located to create
intersegmental stiffness
across multiple planes of
motion (Jemmett, 2003)
4
Core Strengthening and
Neuromuscular Training
in the Literature
• For stabilization:
–Healthy: Stanforth 1998, Karst
2004, Hagins 1999
–With laxity in the SI Joint:
Richardson 2002
5
in the Literature
• For prevention:
–LBP: Nadler et al, 2002
–Knee Injury: Hewett et al,
1999
6
author.
2
1/19/2006
in the Literature
• For treatment
–LBP: O’Sullivan, 1997
–Motor control: Jull, 2000
7
Basic Concepts of Lumbar
Stabilization Exercises*
• SPINE: Neutral spine => Out of neutral
• MUSCLE: Awareness of correct muscle
activation
• PROGRESSION
• PLANES
• FUNCTIONAL
Lack of consensus on what
constitutes a core-strengthening
program
8
* Akuthota, 2004
Case Study #1
• 23 year old female professional dancer
• Chief complaint: low back pain / tailbone
pain and muscle “seizing”
• Insidious onset during Nutcracker
season
• 11-25-04 – woke up with pain, unable to
WB on R
• Stopped dancing 12-5-04
9
author.
3
1/19/2006
Medical History
•
•
•
•
X-ray: Spondylolisthesis
MRI: Minor disk bulge at L5-S1
PMH: Asthma, LBP Fall 2004, {R}
Ankle Pain
Patient Goals:
1. “Get better”
2. “Resume dancing”
3. “Be more efficient”
10
Physical therapy findings:
January 10, 2005
• Posture: Thoracic sway back, forward head
and rounded shoulders, muscular banding in
lower lumbar
• Palpation: Maximum pain on sacrum;
moderate on sacral multifidus, {R} QL, {R}
piriformis
• Joint Mobility: Hypomobility of sacrum,
thoracic spine; normal lumbar, sacroiliac joint
• ROM: Forward flexion limited 75%
• Special Tests: {-} SLR, slump test, sensory
testing, and spondylolisthesis perturbation 11
Treatment #1: January 11,
2005
• Clinical Hypothesis:
Sacral rigidity and
piriformis / iliacus
muscle spasm
• Functional Goal:
1st
– painfree
position,
– painfree weight transfer
onto R
– painfree parallel to turout
coupe on R
• Manual therapy:
joint mobilizations
• Exercise:
– Increase Lumbar
Flexion
– Re-educate Hip
External Rotation
• Function:
– Taking barre only
– No score for DFOS
or SF-36
author.
12
4
1/19/2006
Core Strength:
Multifidus Beginner
(SMPPF)
13
Core Strength:
Sidebridging Beginner
(SMPPF)
14
Standing Leg Turnout
Re-education: Beginner
(SMPPF)
author.
15
5
1/19/2006
Gesture Leg
Re-education: Beginner
(SMPPF)
16
Treatment # 10: February 10,
2005
Incomplete motor
learning of new turnout
pattern contributing to
muscle spasm and
compensations
• Functional Goal: Competent
turnout supine and standing
parallel to first using pelvic
floor
• Manual Techniques:
– Less frequency and
duration
• Exercise:
– Re-education
continued
• Function:
– Return to full class;
not able to perform
fast combinations
17
Core Strength:
Multifidus Intermediate
(SMPPF)
author.
18
6
1/19/2006
Core Strength:
Sidebridging Intermediate
(SMPPF)
19
Re-education - Intermediate
(SMPPF)
20
Gesture Leg
(SMPPF)
author.
21
7
1/19/2006
Standing / Gesture Leg
(SMPPF)
22
Treatment # 19: March 31,
2005
positional fault of
coccyx likely to be
increasing muscle tone
t/o {R} sacral/hip area
• Functional Goal:
painfree,
unobstructed full
external rotation of
{R} hip
• Manual techniques:
– As needed for lumbar,
sacrum, coccyx, hip
• Exercise:
– Footprints, single leg
work
• Function:
–
–
–
–
DFOS Objective: 82%
DFOS Subjective: 75%
SF36 Physical: %
SF36 Mental: %
23
Core Strength:
Multifidus Advanced
(SMPPF)
author.
24
8
1/19/2006
Core Strength:
Sidebridging Advanced
(SMPPF)
25
Re-education: Advanced
(SMPPF)
26
Gesture Leg
Re-education: Advanced
(SMPPF)
author.
27
9
1/19/2006
Standing / Gesture Leg
Re-education - Advanced
(SMPPF)
28
Treatment # 21: May 5, 2005
• Patient is discharged;
she has met all of her
goals and has returned
to full dance
• Manual techniques:
– As needed for
lumbar, sacrum,
coccyx, hip
• Exercise:
– Dance integration
• Function:
– Full dance
activities
29
3-Month follow-up:
September 6, 2005
•
•
•
•
DFOS Objective: 92%
DFOS Subjective: 98%
SF36 Physical: 42%
SF36 Mental: 60%
30
author.
10
1/19/2006
Acknowledgements
• Body Dynamics, Inc.
• Jennifer Gamboa, DPT, OCS, MTC
• Morgann Rose, Sonia DeVille
Cronmiller, MFA and Christina Vink ,
ATC
• Tara Jo Manal, MPT, OCS, SCS
• Shaw Bronner, PT, PhD, MHS, EdM,
OCS
31
References
1. Akuthota V, Nadler SF. Core Strengthening. Archives of
Physical Medince & Rehabilitation 2004; 85(3 Suppl 1): S8692.
2. Bergmark A. Stability of the lumbar spine: A study in
mechanical engineering. Acta orthopaedica scandinavia 1989;
60(Suppl 230):1-54.
3. Gamboa JM, Lavine PE, James C. Sacroiliac Joint Dysfunction
in Dancers. Proceedings of the 14 th Annual Meeting of the
International Association for Dance Medicine and Science
2004. San Francisco, CA.
4. Hagins M, Adler Keri, Cash M, Daugherty J, Mitrani G. Effects
of practice on the ability to perform lumbar stabilization
exercises. Journal of orthopaedic & sports physical therapy
1999; 29(9): 546-555
32
References (Con’t)
5. Hewett TE, Lindenfeld TN, RicoobeneJV, Noyes FR. The
effect of neuromuscular training on the incidence of knee
injury in female athletes. American Journal of Sports
Medicine 1999; 27(6): 699-706.
6. Jemmett RS, MacDonald DA, Agur AMR. Anatomical
relationships beteweensegmental muscles of the lumbar
spine in the context of multi-planar segmental motion: a
preliminary investigation. Manual Therapy 2003; 9:203-210.
7. Jull GA, Richardson CA. Motor Control problems in patients
with spinal pain: a new direction for therapeutic exercise.
Journal of Manipulative and physiological therapeutics 2000;
23(2): 115-117
33
author.
11
1/19/2006
8.
Karst GM, Willett GM. Effects of specific exercise
instructions on abdominal muscle activity during trunk
curl exercises. Journal of Orthopedic and Sports
Physical Therapy 2004; 34(1): 4-12.
9. Lee D. An integrated model of “joint” function and its
clinical application. In 4th Interdisciplinary World
Congress on Low Back and Pelvic Pain. 2001.
Montreal, Canada
10. Nadler SF, Malanga GA, Bartoli LA, Feinberg JH,
Prybicien M, Deprince M. Hip muscle imbalance and low
back pain in athletes: Influence of core strengthening.
Medicine & Science in Sports & Exercise2002; 34(1): 916.
34
11. O’Sullivan PB, Twomey LT, Allison GT. Evaluation of
specific stabilizing exercises in the treatment of chronic
low back pain with radiologic diagnosis of spondylolysis
or spondylolisthesis. Spine 1997; 22(24): 2959-2967.
12. Panjabi MM. The stabilizing system of the spine. Part II:
Neutral zone and instability hypothesis. Journal of Spinal
Disorders 1992a; 5(4): 390-397 Panjabi MM. The
stabilizing system of the spine. Part 1: Function,
dysfunction, adaptation and enhancement. Journal of
Spinal Disorders 1992b; 5(4): 383-389.
13. Phillips C. Stability in dance training. Journal of Dance
Medicine & Science2005; 9(1): 24-28.
14. Richardson CA, Snijders CJ, Hides JA, Damen L, Pas
MS, Storm J. The relation between the transversus
abdominis muscles, sacroiliac joint mechanics, and low
back pain. Spine 2002; 27(4): 399-405.
35
14. Snijders CJ, Vleeming A, Stoeckart R. Transfer of the
lumbosacral load to iliac bones and legs: Part 1.
Biomechanics of self-bracing of the sacroiliac joints and
its significance for treatment and exercise. Clinical
Biomechanics 1993; 8:285-294.
15. Stanford ME. Effectiveness of specific lumbar
stabilization exercises: A single case study. Journal of
Manual & Manipulative Therapy 2002; 10(1): 40-46.
16. StanforthD, Stanforth PR, Hahn SR, Phillips A. A 10week training study comparing Resistaball® and
traditional trunk training. Journal of Dance Medicine &
Science 1998; 2(4): 134-140.
36
author.
12

Sacroiliac Joint Dysfunction, evaluation and physical therapy

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