Back Pain – SI Joint Dysfunction
Back Pain – SI Joint Dysfunction
Sacroiliac joint pain
Sacroiliac (SI) joint pain has gained a lot of attention in the last ten years as an underappreciated cause of back pain with some studies indicating it is responsible for 15% to 40% of low back pain. The increased attention is due to the increasing knowledge of the SI joints intimate role in pelvic stability. I hope more physicians consider SI joint pain in their differential after reading this article.
Pathophysiology
SI joint dysfunction due to inflammation within the joint itself is called sacroilitis. Pain from within the SI joint is common in rheumatoid patients and spondyloarthropathies.
The other cause of SI joint dysfunction stems from instability of the SI joint. Many experts feel that SI joint pain is a component of a larger problem of pelvic instability (1). Pelvic instability has traditionally been underappreciated as a cause of low back pain, buttock pain, groin pain, and leg pain. Physical therapists and doctors of osteopathic medicine have been teaching these concepts for years but only relatively recently has this dissemination of knowledge trended towards mainstream thinking among medical doctors.
The SI joint complex (the SI joint and its associated ligaments) is the major support structure of the pelvic ring and is the strongest ligament complex in the body. The complex consists of interosseous sacroiliac ligaments, iliolumbar ligaments, posterior sacroiliac ligaments, and the sacrotuberous and sacrospinous ligaments. The SI joints are two of the three joints involved in the stability of the pelvic ring. The pelvic ring is the meeting place of the force vectors from the upper body and the lower extremities. The third joint in the pelvic ring is the pubis symphysis. Pelvic instability causes pelvic rotation which can also cause twisting of the pubis symphysis. Coupling this with its anterior location appears to provide an explanation as to why patients with SI joint instability can also experience anterior groin pain. Anecdotal evidence for this is seen when patients undergo a successful SI joint intra-articular injection relieving all of their posterior back, buttock, and leg symptoms but the patient still has groin pain. Groin pain is almost never eliminated by SI joint injections unless pelvic symmetry is corrected.
If the SI joints are unstable, it can lead to significant pain and discomfort over the SI joints as well as numerous referred areas. If an individual affected by SI joint pain has pain only over his or her SI joint, he/she should be considered lucky. Most often SI joint instability causes unnatural strain on the entire low back and pelvic region causing a sometimes confusing clinical picture. Pain referral patterns of SI joint pain are often confused with L5 or S1 radiculitis or radiculopathies.
Referral patterns of SI joint dysfunction (2)
SI joint dysfunction often presents with a confusing clinical presentation.
1. Buttock pain 94%
2. Lower lumbar pain 74%,
3. Lower extremity pain 50%, with 28% of these lower extremity pains going distal to the knee
4. Pain goes all the way into the foot 13%. Younger patients are more likely to refer pain distal to the knee.
5. Groin pain 14%.
Most patients with SI joint instability also experience pain over the buttock region due to secondary muscle spasm of the gluteus muscles and piriformis complex. Lower extremity symptoms are explained by the piriformis muscles natural tendency to spasm or tighten over the sciatic nerve whenever the SI joint is out of alignment. This spasm of gluteus and piriformis muscles can cause a mechanical crowding or impingement of the sciatic nerve as it exits just below the SI joint (see figure 1. note the intimate association of the piriformis muscle, SI joint, and sciatic nerve). Patients often complain of buttock pain and radiation of pain down to the knee and even down to the foot. Not all back pain and leg pains are due to a pinched a nerve from an intervertebral disk herniation. SI joint dysfunction very closely mimics S1 or L5 radiculitis’ or radiculopathies because of the above described sciatic nerve irritation or impingement.
Groin pain and abdominal pain are not uncommon with SI joint instability. Often times the groin pain is mistaken as a urologic problem like pudendal neuralgia, prostatitis, genitofemoral neuralgia, or sterile epidydymitis(1). This is likely either due to unnatural tension on the nerves and ligaments around the pubis symphysis or actual impingement of the pudendal nerve which lies between the sacrospinous ligament and sacrotuberous ligament. The distance between these two ligaments abruptly narrows when the Ilium and sacrum are out of alignment i.e. SI joint instability.
The typical history of SI joint dysfunction consists of lateral or bilateral low back pain almost always below the pelvic rim. Pain can also radiate into the hip, groin, pelvis, leg, and foot. The most common location of pain is in the buttock with pain extending down to the knee. Females are much more affected than males though the ratio is unclear. The mechanism of injury is a continuum from completely atraumatic events to more obvious trauma like motor vehicle accidents, childbirth, or falls. A little over one third of failed back surgery patients suffer from SI joint dysfunction. In my practice, I often see patients who lose a substantial amount of weight and then develop SI joint dysfunction. The etiology of this is unclear. Women who have had multiple births also seem to have a higher incidence of SI joint dysfunction. The symptoms may be acute or may present as a remote or cumulative injury with chronic waxing and waning of symptoms with slow progression over time. Patients often experience some degree of temporary relief with manipulation. Patients must change positions frequently to avoid pain. This is called “Theater Party Cocktail Syndrome”. Patient’s legs can also feel like they’re going to give out, but with objective testing of motor strength, no dysfunction is found. This is called a “Slipping Crutch syndrome”. Patients usually have a difficult time sleeping and getting out of bed in the morning can be excruciatingly painful. Continued movement after waking up tends to improve the pain.
There are many provocative physical exam maneuvers used to help establish the diagnosis of SI joint dysfunction. Going through each one of these provocative maneuvers is beyond the scope of this article. It is important to note that the predictive value of provocative SI joint maneuvers in determining SI joint dysfunction is only 60%(4). The conclusion of a recent study by Slipman et al(5), was that physical exam techniques can at best enter SI joint dysfunction into the differential diagnosis of a patient’s low back pain. Of the alleged signs of sacroiliac joint pain, maximum pain below L5 coupled with pointing to the PSIS or local tenderness just medial to the PSIS (sacral sulcus) has the highest positive predictive value (PPD) at 60%(4).
Diagnosis
The gold standard for making a diagnosis of SI joint dysfunction is a fluoroscopically guided SI joint injection. Fluoroscopy is needed to accurately and consistently inject the sacroiliac joint. Only 12% of patients had intra-articular SI joint injections when fluoroscopy was not utilized (3). Also important is to anesthetize the entire SI joint complex. In my experience as an interventional pain physician this cannot be consistently done by palpation alone, especially in obese patients. It is humbling to see anatomy change under fluoroscopic guidance. What you perceive with palpation is sometimes markedly different than the actual location of the structure that you palpate. Also vitally important is that these diagnostic injections are followed up with another physical exam while the patient is in the recovery room. Sending a patient home, having them follow up in several weeks, and then determining if this “diagnostic” injection was successful has consistently been shown to be an inaccurate way of establishing a pathoanatomic diagnosis.
Treatments
There is no one specific treatment for SI joint dysfunction which helps all patients. The treatment varies if the dysfunction is intra-articular (inflammatory), or if it’s a lack of stability. Conservative treatment should first be tried including the manipulation by a qualified physical therapist or osteopathic physician to restore normal motion and balance, home self-correction exercises, a walking program (avoid heavy axial loading maneuvers), and core strengthening exercises (Pilates, Yoga, or guided physical therapy). Some patients also benefit from a quality SI joint support belt. If conservative therapy is not helpful then I recommend a diagnostic SI joint complex injection. The injection should include the SI joint ( intra-articularly) and the supporting ligaments with pain relief lasting for the duration of the local anesthetic and achieving greater than 75% pain relief. If there is any question about the positivity of this diagnostic test, it should be repeated.
Radiofrequency Denervation
If the diagnosis has been established by an intra-articular SI joint injection and pain relief using conservative therapy affords no long-term pain relief, then consideration for other treatments can be made. Radiofrequency denervation of an SI joint carries about a 65% success rate
Tags: Back, Dysfunction, Joint, pain
Management of Non-specific Back Pain
Management of Non-specific Back Pain
Physiotherapy in the management of non-specific back pain and neck pain
This paper provides an overview of best practice for the role of physiotherapy in managing back pain and neck pain, based mainly on evidence-based guidelines and systematic reviews. More up-to-date relevant primary research is also highlighted. A stepped approach is recommended in which the physiotherapist initially takes a history and carries out a physical examination to exclude any potentially serious pathology and identify any particular functional deficits. Initially, advice providing simple messages of explanation and reassurance will form the basis of a patient education package. Self-management is emphasized throughout. A return to normal activities is encouraged. For the patient who is not recovering after a few weeks, a short course of physiotherapy may be offered. This should be based on an active management approach, such as exercise therapy. Manual therapy should also be considered. Any passive treatment should only be used if required to relieve pain and assist in helping patients get moving. Barriers to recovery need to be explored. Those few patients who have persistent pain and disability that interferes with their daily lives and work need more intensive treatment or a different approach. A multidisciplinary approach may then be optimal, although it is not widely available. Liaison with the workplace and/or social services may be important. Getting all players on side is crucial, especially at this stage.
Introduction
Back pain and neck pain are responsible for huge personal and societal costs, and are major causes of work disability [1–3]. Contrary to traditional thinking, neither back pain nor neck pain is a problem that always resolves itself. Recurrences are usual and their course is very variable [4–8].
Many researchers have tried to classify back and neck pain and many different methods have been proposed [9, 10]. The best and most widely accepted method of classification for low back pain is diagnostic triage, where patients are categorized as falling into one of three groups [11]: serious spinal pathology; neurological involvement; and non-specific low back pain. Similar categories could apply to neck pain patients.
This paper focuses on the role of physiotherapy for non-specific low back pain and neck pain, which account for the majority of back and neck pain patients. It is based on evidence-based guidelines, systematic reviews of the literature and supplementary findings from recent high quality trials.
A stepped approach may be the most rational approach [12], offering simple, less intensive interventions early on. (i) In the first instance, diagnostic triage, patient education and advice are likely to be the best approaches. (ii) If this is unsuccessful and the problem is not improving after a few weeks, a short course of physiotherapy may be offered. Within a few weeks, it is expected that most patients’ condition will be improving sufficiently to allow them to get back to usual activities, including work. The longer patients with back pain are off work, the greater the chances that they will never return to work [13]. It is therefore important that the individual is encouraged to return to work even if there is still some residual pain. (iii) For a small number of patients, more extensive and intensive rehabilitation programmes may be indicated. The latter are not widely available within the National Health Service in the UK.
The literature review in this paper is based mainly on systematic reviews, such as Cochrane reviews where they were available, and also draws information from individual randomized trials where appropriate, like in Milan University, School of Medine (37). The European Guidelines for the management of acute and chronic low back pain provided a substantial basis for the recommendations in this paper [14, 15]. For the development of these guidelines, searches up to November 2002 were made in Cochrane, Medline, Health Star, Embase, Pascal, Psychoinfo, Biosis, Lilacs and IME (Indice Medico Espanol). Keywords included ‘low back pain’, ‘back pain’ and ‘systematic’. Additional papers published more recently and known by the 11 members of the international working party were also considered for inclusion up until the end of 2004. Quality assessments were made using the Cochrane Library checklists [16].
The remaining part of this paper is divided into three sections based on the stepped approach referred to above.
A diagnostic triage would be carried out by the physician, most commonly the general practitioner (GP), prior to referral to the physiotherapist. Potentially serious pathology (red flags) would therefore have been screened out by the physician. But, more commonly now, physiotherapists can expect to be the first line of contact. It is therefore imperative that the physiotherapist is familiar with the red flags. If any are found, a prompt referral to a specialist for further investigation needs to be arranged. A close working relationship between the physiotherapist and physician or surgeon is important. Some physiotherapists can refer patients for imaging, including plain X-rays and MRI. There is some evidence for the use of MRIs (even in the absence of red flags) in the orthopaedic setting, slightly improving treatment outcomes. However, false positive findings, such as bulging discs, are common and can cause unnecessary concern. Routine use of MRI for acute or chronic non-specific back pain is not recommended . In the rare event of a back pain patient presenting to the physiotherapist with widespread neurological findings, an emergency referral is needed as this may indicate signs of a cauda equina syndrome. Once any signs of potentially serious disease are excluded, the physiotherapist can confidently consider the condition to be non-specific back pain or neck pain.
History taking and the physical examination
The physiotherapist carries out a subjective assessment (history) followed by the physical examination. Active listening to the patient’s concerns—not only about their pain and its localization but also about the consequences of pain and how it is dealt with—is essential to good diagnosis and management [1, 18]. A physical examination should be based on the history of the problem rather than strictly following a proforma. Judicious use of physical tests should be employed to clarify the nature of the patient’s mechanical dysfunction.
Explanation of the condition to the patient
Once the history has been taken and the physical examination has been carried out, the physiotherapist needs to provide a careful explanation to reassure the patient that no serious disease or injury has been found. This may be the most important and most challenging part of the treatment. Physiotherapists need to avoid reinforcing patients’ fears about the threatening processes that might be going on in their spine. These fears or concerns can act as a barrier to recovery [19] and need to be properly addressed. Patients often expect to be given a label to describe their problem [20], but this can be fraught with difficulties. Great care is needed to select appropriate, non-threatening words that will not be misinterpreted by the patient [21]. Providing patients with biomechanical information about the spine that is not evidence-based can add to their concerns [22]. Psychosocial factors are at least as important and need to be addressed in both back pain and neck pain patients [14, 15, 23, 24].
Encouraging an early return to usual activities
The physiotherapist has an important role in encouraging active self-management, and this is an essential component of treatment for all back and neck pain patients. The primary aim is to help patients resume normal activities as far as possible, as soon as possible. This advice should be supported by offering a simple evidence-based educational booklet [25–29]. This provides simple messages which can help to dispel maladaptive fears and misconceptions about their back pain or neck pain.
Evidence for a brief intervention providing patient education
The term ‘brief intervention’, for the purposes of this paper, refers to any minimal intervention usually of one or two sessions only (www.backpaineurope.org). They all provide some educational input and in more recent studies take into account cognitive–behavioural principles. However, different authors use the term to encompass quite a range of approaches. A review of the literature shows that patient education in the form of a brief intervention can be effective even for chronic back pain [15]. The content and delivery can vary greatly. It can be delivered as a one-to-one by the physiotherapist, or in parallel with a physician consultation/education session. The European Guidelines group concluded that such an intervention (no more than two sessions) encouraging a return to usual activities can be as effective as usual physiotherapy or aerobic exercises for chronic back pain [15, 30–33]. More recently, a large, high-quality trial with subacute back pain patients (n = 402) compared manual therapy (four sessions) with a brief hands-off pain management intervention (three sessions) and failed to find any significant difference in change scores for disability at 12 months [34].
There is less evidence for the effectiveness of brief interventions and patient education strategies for patients with neck pain [35]. However, a recent trial of neck pain patients (n = 268) demonstrated that if patients preferred to have a brief intervention where they were encouraged to self-manage, they did as well as patients who were randomized to usual
Tags: Back, Management, Nonspecific, pain
