If you experiencing pain outlined on this diagram (alaskaspineinstitute/sites/default/files/Sacroiliac-Pain-Areas1.jpg), you might have condition which is described in my article, please read or contact me if you have any further questions… Acute Sacroiliac Joint Dysfunction Management Svetlana Kotlin, P.T., D.P.T. It is generally accepted that the protruded disc is a primary cause of pain in the spine in spite of the fact that neurogenic symptomatology is not always verified by physical examination. Presently, nearly 16% to 30% of cases of low back pain (LBP) correlate with sacroiliac joint (SIJ) dysfunction (Vanelderen, Szadek, Cohen, De Witte, Lataster, Patijn and…Van Zundert, 2010). The confusion exists due to the similarity in symptom and pain distribution between both pathologies discogenic or radicular LBP and SIJ dysfunction and it is not uncommon among clinicians to frequently overlook SIJ pathology (Weksler, Velan, Semionov, Gurevitch, Klein, Rozentsveig and Rudich, 2007). The SIJ pain is subdivided into extra articular and intra articular origins, fractures, myofascial dysfunctions, enthesopathies and ligamentous injuries as well as spondyloarthropathies, infections, malignancies, and arthritis respectively (Vanelderen et al., 2010). For the purpose of making a differential diagnosis, SIJ pain can be further subdivided into non-rheumatic and rheumatic pathology (Gupta, 2009). There is a hypothesis of the fixation and subluxation of the SIJ dysfunction due to biomechanical abnormalities as a source of LBP, but this remains controversial (Liebenson, 2007). Shear stresses, inflammation, and repetitive torsional forces can be a source of pain as well. Some clinicians and physical therapists rely on clinical examination alone when validity of such practice is not established. Multiple tests have been studied to assist in diagnosis of SIJ pain, they are called provocative tests. When used individually, these provocative tests have poor predictive value and need to be combined into a specific group to significantly contribute to the diagnosis of SIJ impediments (Vanelderen et al., 2010; Van der, Buijs, and Groen, 2006). Radiologic tests, on the other hand, may help to rule out “red flags” of possible underlying pathology, but may not prove to be helpful in diagnosis of SIJ dysfunction. Consistent revisions the International Association for the Study of Pain (IASP), consistent revisions will provide practitioners with valuable standards for the diagnosis of SIJ pathology (Chou, Qaseem, Snow, Casey, Cross, Shekelle, and Owens, 2007). According to IASP, SIJ pain is a pain of SIJ origin which can be replicated by tension and cluster of the provocative tests and then released after administration of joint injection with anesthetic media (Vanelderen et al., 2010). Physical therapists are well familiar with the anatomical structure of SIJ that interdepends mainly on sacroiliac ligaments, piriformis muscles, and gluteus and medius muscles (Vanelderen et al., 2010). The SIJ is innervated by dorsal sacral rami. The pain pattern is usually noted in the low lumbar area which refers as far as gluteal region, groin, abdomen, lower limb, and foot but can expand into upper lumbar region as well. Physical therapists usually address risk factors in assessment and rehabilitation of the patient with suspected SIJ dysfunction; it might be one or all, trauma, leg length discrepancies, scoliosis, abnormal gait patterns, lumbar fusion surgery with the sacral fixation, pregnancy, specific recreational activities, or heavy lifting or physical exertion (Vanelderen et al., 2010). The discriminative diagnosis for SIJ dysfunction should be made only if 3 or more positive tests elicited from the 7 most important clinical tests prove positive. Meta-analysis confirmed that “3 or more positive provocative tests resulted in a specificity and sensitivity of 79% and 85%, and 78%, and 94%, respectively” (Vanelderen et al., 2010, p.472). The tests which typically reproduce SIJ pain as follows: compression, distraction, Patrick’s, Gaenslen, thigh thrust, Fortin’s finger, and Gillet test (Vanelderen et al., 2010). Occasionally, patients are referred for physical therapy after they received diagnostic/therapeutic injections that consist of local anesthetic and corticosteroids. Physical therapists recognize that SIJ therapeutic injections are just a short-lived relief from pain. Regardless if follow up injections will be prescribed by the physicians or not, patients are provided with exercise programs specific to their pathology. Even if the injections are frequently transitory, they do offer a window of opportunity to intensify the rehabilitation process to achieve maximal benefit. There is no clear evidence of when to repeat an injection or if it should be repeated at all. Physical therapy usually begins with correcting any mechanical or leg-length asymmetries, utilizing muscle energy therapy, manual and neuromuscular techniques, modalities (heat, ultrasound, LASER, functional electrical neuro-muscular re-education of the lumbar dorsal spine musculature), stretching excessively tight lumbar and pelvic muscles, and strengthening weak and inhibited muscles. Core stabilization exercises should begin in the neutral spine position or a pelvic position to minimize acute SIJ pain. Patients are progressed through core stabilization exercises at increased intensity and challenging dynamic spinal stabilization, functional positioning as well as balance and proprioceptive activities. Individualized exercise programs should address strengthening of the core muscles surrounding the spine and restoring postural position of the femoral-pelvic-lumbar complex in a specific ways with the emphasis on the position of the femoral head in the acetabulum (Boyle, 2011, Figure 1-5, pp. 155, 157-159). In the past several years, Pilates training has become very popular among physical therapists in rehabilitation of SIJ pain and LBP in general. Eventually, the patient progresses to recreational -or sport- or work-related training designated to return patients to their previous level of functioning. With development of chronic pain, a SIJ belt should provide stability by limitation in SIJ rotation and hypermobile ligaments. The SIJ belt also will prevent recurrence of the leg-length inequalities. Medical imaging for SIJ pain is indicated primarily in cases when “red flags” are suspected. Radiography, magnetic resonance imaging (MRI), scintigraphy, computed tomography (CT), positron emission tomography and computed tomography (PET/CT) as well as other imaging techniques did not demonstrate consistent findings with gold standard injection confirmed SIJ pain (Vanelderen, et al. 2010). Some researchers suggest that MRI can identify acute inflammation after the patient is diagnosed with spondylarthropathy (Braum and Hermann, 2010). According to IASP criteria, the SIJ pain should subside after intra articular SIJ injection with anesthetic media (Chou et al., 2007). Due to its prevalence to produce false-positive and false-negative outcomes, clinicians should exercise caution in interpreting gold standard diagnostic corticosteroids and local anesthetic blocks even though they hold the highest evidence rate of 1 B+ (Vanelderen et al., 2010). The use of fluoroscopy is beneficial and reliable only when the physician infiltrates SIJ under fluoroscopic guidance (see Fig. 1). In the event of difficulty with accessing the SIJ utilizing fluoroscopy, the utilization of CT or MRI is advised instead to guide injections into the painful area. Controlled randomized studies of 24 patients demonstrate the efficacy of both intra and extra articular infiltrations with a mixture of anesthetic and steroid as evidenced by a significant decrease in pain score on the visual analog scale (VAS) reported by the control group (Vanelderen et al., 2010). Another study cited by the same authors confirmed the benefit of injections by demonstrating a pain decrease of >79% in the control group while no benefit was noted in the placebo group. Presently, a majority of evidence leans toward intra articular SIJ injection, but only for short term pain relief (Cui, Xiao, Shuxia, Zhenjun, Hengguo, Liangyi, and... Guangfu, 2010). Typically, conventional x-rays are utilized to evaluate skeletal changes of SIJ as they relate to the specific pathology. The spine examination consists of a detailed image of the L5-S1 disk space, an anterior-to-posterior (AP) axial projection of bilateral SIJ, two oblique projections of unilateral SIJ, and lateral projection of lumbosacral junction and yields 61% sensitivity for diagnosis of SIJ impediments (Tilson, Strickland, and Gibson, 2006; Boissonnault, 2005; Inanc, Atagündüz, Şen, Biren, Turoǧlu, and Direskeneli, 2005, p.591). The downside of the radiographs is their limited ability to identify earlier structural damage such as sclerosis (peri-articular lesion), erosions (distraction of the joint) and ankylosis (severe bone damage) of SIJ (Braum and Hermann, 2010). Radiographic grading outlines the amount of damage SIJ is going through with 0 being normal and 4 being significant for severe abnormality (Braum and Hermann, 2010, p.128). Radiography has a low diagnostic accuracy and should not be not be relied upon for diagnosis of acute sacroiliitis (Geijer, Gadeholt, Göthlin, and Göthlin, 2009). In contrast to conventional x-rays which detect only structural damage of SIJ, MRI, which sensitivity is 89% in detecting acute and chronic inflammation of SIJ, is a good tool when the acute changes have to be identified in these joints in order to detect the beginning stage of progressive disease (Braum and Hermann, 2010; Inanc et al., 2005). It is estimated that if it remains undetected, sacroiliitis will progress considerably within 3- 7 years causing severe damage to SIJ. Short tau inversion recovery (STIR) and fat saturated T2 weighted fast spin echo MRI sequences identify even minor accumulation of fluid and inflammation areas which are seen as high intensity areas. In the event of examining fatty degeneration, erosions, osseous sclerosis, joint space narrowing the T1-weighted fast spin echo sequence should be the examination of choice. This type of sequence will display bone marrow, muscles, ligaments, bones, and joints. Finally, the cartilage bone area will produce high contrast due to low intensity of the fatty bone marrow on T2-weighted gradient echo (GRE) (Braum and Hermann, 2010). Researchers also estimated that 10 to 12 slices are required in examining the entire sacral bone from anterior to posterior border as well as semi coronal images to assess the entire SIJ including the fact that some times gandolinium enhanced fat saturated sequences are required to confirm acute sacroiliitis. The early detection of ankylosing spondylitis by MRI may allow the start of aggressive therapies to prevent degeneration of SIJ (Bennett, McGonagle, Connor, Hensor, Sivera, Coates …and Marzo-Ortega, 2008). Computed tomography (CT), due to its higher sensitivity for detecting early structural changes, is more accurate than conventional radiographs. However, both conventional radiographs and CT can detect only structural changes of SIJ as compared to higher sensitivity and specificity in detecting early SIJ inflammation or fatty infiltrations of bone marrow by MRI (Braum and Hermann, 2010; Gupta, 2009). CT has greater a sensitivity for detecting chronic changes vs. MRI (Geijer et al., 2009). Therefore, CT plays a minor role in the initial evaluation of SIJ and additionally considered unsafe due to its high radiation emissions. It can be used, however, in the detection of stress fracture of sacrum, small tumors, and identification of Forrestier’s disease (Braum and Hermann, 2010; Boissonnault, 2005). When acute sacroiliitis is suspected, the patient will benefit from MRI imaging to detect abnormalities in cartilage and subchondral bone or early changes e. g. edema of bone marrow (Geijer, et al., 2009). At times, MRI may not be available and it is more expensive, so CT examination becomes the method of choice (Geijer, et al., 2009). While scintigraphy found to be less feasible with 55% sensitivity in diagnosis of acute sacroiliitis, a single study of 15 patients evaluated by quantitative PET/CT demonstrated 80 % of sensitivity. However follow up systemic literature review revealed 50% sensitivity and 80% specificity for imaging utilizing PET/CT which calls for need for additional studies for this potentially valuable modality (Strobel, Fischer, Tamborrini, Kyburz, Stumpe, Hesselmann, Johayem, von Schulthess, Michel, and Ciurea, 2010). Majority of the clinical tests for SIJ pathologies and theoretical explanations of possible types of subluxations are anecdotal in nature as they are generally based on poorly designed studies, personal opinion and clinical experience alone. The applicability of imaging to the physical therapy practice is growing along with the profession and its ambition in moving towards primary care medicine. It is important that the physical therapist incorporates an assessment of available imaging based on evidence-based clinical studies to assist in their clinical decision-making. The available research revealed insufficient clinical evidence in regards to the imaging tools for diagnostics of the SIJ dysfunctions with the exception of MRI, which can visualize sacroiliitis in patients with yet normal radiographs of SIJ and gold standard blocks with fluoroscopy. It is also evident, that the physical therapist should play a primary care role in identification of the SIJ pathologies. Utilizing provocative clinical testing allows the physical therapist to differentiate between SIJ and discogenic pathologies and can be easily performed during the initial evaluation of patients presenting with the LBP complaints. Early diagnosis and conservative intervention may prevent progressive deterioration of these joints. It would seem practical to evaluate SIJ pathology by applying a cluster of provocative clinical tests that demonstrated sensitivity and specificity above 60%. (Stuberr, 2007). Such early intervention should result in timely referral to an orthopeadic specialist for more aggressive diagnostic tests and procedures (SIJ infiltrations or MRI) to be rendered to patients who did not respond to conservative therapy. Knowledge of the specific site of injection and imaging techniques could give the physical therapist information necessary for making a better clinical decision. Specified in this research is the fact that it would be necessary for the physical therapist to contact the physician and suggest plane radiographs and MRI studies when “red flags” are identified or the patient failed to demonstrate progress in a timely fashion. Furthermore, physical therapists should not have any obstacles in acquiring radiographs or impressions as soon as the Health Insurance Portability and Accountability Act (HIPAA) form is signed by the patient. Conventional physical therapy might be the best choice for people presenting with acute SIJ dysfunctions and early interventions might slow down structural SIJ damages. Furthermore, physical therapists may educate their patients on the rehabilitation process, which should not be focused on the involvement of the referring physician in obtaining imaging as a first choice. References Boissonnault, W.G. (2005). Primary Care for the Physical Therapist: Examination and Triage (2nd ed.). St. Louis, MO: Elsevier Saunders. ISBN 0-7216-9659-7 Bennett, A., McGonagle, D., OConnor, P., Hensor, E., Sivera, F., Coates, L., & ... Marzo- Ortega, H. (2008). Severity of baseline magnetic resonance imaging-evident sacroiliitis and HLA-B27 status in early inflammatory back pain predict radiographically evident ankylosing spondylitis at eight years. Arthritis & Rheumatism, 58(11), 3413-3418. Boyle, K. L. (2011). Managing a Female Patient with Left Low Back Pain and Sacroiliac Joint Pain with Therapeutic Exercise: A Case Report. Physiotherapy Canada, 63(2), 154-163. doi:10.3138/ptc.2009-37 Braum, L., & Hermann, K. A. (2010). Utility of Imaging in the Diagnosis and Assessment of Axial Spondyloarthritis. International Journal Of Advances In Rheumatology, 8(4), 127-135. Chou, R., Qaseem, A., Snow, V., Casey, D., Cross, T., Shekelle, P., and Owens, D. (2007 Diagnosis and treatment of low back pain: A joint clinical practice guideline from American College of Physicians and the American Pain Society. Annual Internal Medicine, 147, -491. Retreived October 12, 2012 from annals.org. Cui, Y., Xiao, Z., Shuxia, W., Zhenjun, Z., Hengguo, Z., Liangyi, F., & ... Guangfu, D. (2010). Computed tomography guided intra-articular injection of etanercept in the sacroiliac joint is an effective mode of treatment of ankylosing spondylitis. Scandinavian Journal Of Rheumatology. 39(3), 229-232. doi:10.3109/03009740903313613 Inanc, N. N., Atagündüz, P. P., Şen, F. F., Biren, T. T., Turoǧlu, H. T., & Direskeneli, H. H. (2005). The investigation of sacroiliitis with different imaging techniques in spondyloarthropathies. Rheumatology International, 25(8), 591-594. doi:10.1007/s00296-004-0490-9 Geijer, M. M., Gadeholt Göthlin, G. G., & Göthlin, J. H. (2009). The Validity of the New York Radiological Grading Criteria in Diagnosing Sacroiliitis by Computed Tomography. Acta Radiologica, 50(6), 664-673. doi:10.1080/02841850902914099 Gupta, A.D. (2009). Sacroiliac joint pathologies in low back pain. Journal of Back and Musculoskeletal Rehabilitation. 22, 91–97 91. DOI 10.3233/BMR-2009-0221 Leiebenson, C. (2007). Rehabilitation of the Spine. A practitioner’s Manual. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins. Morimoto, D., Isu, T., Kim, K., Matsumoto, R., & Isobe, M. (2011). Unexplained lower abdominal pain associated with sacroiliac joint dysfunction: report of 2 cases. Journal Of Nippon Medical School = Nippon Ika Daigaku Zasshi, 78(4), 257-260. (18) Stuberr, K.J. (2007).Specificity, sensitivity, and predictive values of clinical tests of the sacroiliac joint: a systematic review of the literature The Journal of the Canadian Chiropractic Association. 51(1), 30-41 Strobel, K., Fischer, D.R., Tamborrini, G., Kyburz, D., Stumpe, K.D.M., Hesselmann, R.G.X., Johayem, A., von Schulthess, G.K., Michel, B.A., & Ciurea, A. (2010). F-Fluoride PET/CT for detection of sacroiliitis in ankylosing spondylitis. European Journal of Nuclear Medicine and Molecular Imaging. 37, 1760-1765. DOI 10.1007/s00259-010-1464-7 Tilson, E.R., Strickland, G.D., & Gibson, S.D.(2006 ). An overview of radiography, computed tomography, and magnetic resonance imaging in the diagnosis of lumbar spine pathology. Orthopaedic Nursing. 25(6), 415-420 Van der, W.P., Buijs, E.J., & Groen, G.J. (2006), A multi test regimen of pain provocation tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures, Archives of Physical and Medical Rehabilitation. 87 10–14. Vanelderen, P., Szadek, K., Cohen, S., De Witte, J., Lataster, A., Patijn, J., & ... Van Zundert, J. (2010). 13. Sacroiliac Joint Pain. Pain Practice, 10(5), 470-478. doi:10.1111/j.1533-2500.2010.00394.x Weksler, N., Velan, G. J., Semionov, M., Gurevitch, B., Klein, M., Rozentsveig, V., & Rudich, T. (2007). The role of sacroiliac joint dysfunction in the genesis of low back pain: the obvious is not always right. Archives Of Orthopaedic & Trauma Surgery, 127(10), 885-888. doi:10.1007/s00402-007-0420-x Figure Captions Figure 1. Infiltration of Anesthetic with Fluoroscopy. (Available up on request) Adapted from “Unexplained lower abdominal pain associated with sacroiliac joint dysfunction: report of 2 cases”, by Morimoto, D., Isu, T., Kim, K., Matsumoto, R., & Isobe, M. (2011). Journal Of Nippon Medical School = Nippon Ika Daigaku Zasshi, 78(4), 257-260
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