Pelvic Girdle Dysfunction Literature Review

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Diagnostic Tools for the Sacroiliac Area and Pelvic Girdle Dysfunction

Diagnostic Injections to Evaluate Sacroiliac Joint Pain

An image-guided intra-articular blockade with a local anaesthetic is often used to confirm or exclude suspected sacroiliac joint (SIJ) involvement as this method is target-specific. There is however no true “gold standard” for SI joint mediated pain. Borowsky and Fagen (2008) reported an improved clinical outcome in patients with chronic sacroiliac region pain, through directing the corticosteroid dose not just intra-articular to the SIJ but also to the posterior interosseus ligament and S1-3 lateral branches. This suggests that there are other extra-articular sources of sacroiliac region pain.

A criterion of at least 75% relief from local anaesthetic is used by most studies and pain management societies as diagnostic.

Injections can be performed using:

• Fluoroscopy
• CT
• MRI
• Ultrasound

Blind injections (joint injections without image guidance) are not recommended.

Imaging

Limited evidence is available for the diagnostic accuracy of imaging modalities in diagnosing SIJ pain as a component of pelvic girdle pain. Plain radiographs of the pelvis may be used to rule out any other obvious reasons for pain. The shape of the and orientation of the SIJ creates difficulty in visualisation with conventional radiography. Other methods such as CT and MRI have an advantage as they are able to create multiplanar visualisation of the joint. CT scan was only 57% sensitive and 69% specific in the diagnosis of SIJ pain. MRI is useful to detect early inflammation and soft tissue pathology of the SIJ in patients with spondyloarthropathy.

Kim et al (2018) conducted a systematic review on the accuracy of diagnostic imaging and reported moderate diagnostic accuracy of CT, myelography and MRI. Read the complete article here: Diagnostic accuracy of diagnostic imaging for lumbar disc herniation in adults with low back pain or sciatica is unknown; a systematic review

Special tests

Static and Dynamic Special Tests of the SIJ

In the field of manual therapy, it is common to conduct palpation and motion testing of a joint as part of the examination and this is also commonly done in the assessment of the SIJ and the pelvic girdle. However, these types of static and dynamic palpation tests in the assessment of SIJ disorders have been determined to be unreliable and invalid in the literature. Furthermore, these tests lack diagnostic value as approximately 20% of asymptomatic participants were found to have positive findings. Some of these tests include:

• Standing flexion test
  • With patient standing, SIJ movement is assessed while the patient bends forward

• Seated flexion test
  • With the patient sitting, SIJ movement is assessed while the patient bends forward

• Prone knee flexion test

• Gillet test
  • With the patient standing, SIJ movement is assessed while the patient pulls the opposite knee to the chest

• Heel-bank test
  • With the patient in sitting SIJ movement is assessed while the patient places one foot on the treatment table

• Abduction test
  • With the patient in side-lying, a discrepancy in load transfer is assessed

• Thumb PSIS test
  • With the patient in sitting, the position of the PSIS is measured on a horizontal line in relation to each other

• Click-clack test
  • With the patient in sitting, movement of the left and right PSIS is assessed when the patient moves the trunk from lordosis to kyphosis

The plausibility of these tests used to diagnose movement dysfunction of the SIJ is clearly challenged in the available literature. Criticisms on these tests include various issues such as:

• Relying on clinicians to manually detect SIJ movement through multiple layers of tissue ref 34 Pallson
• The movements of the SIJ are so minute that external detection by manual methods are not possible (ref 35 Pallson)

Recent literature also reiterates the fact that although clinicians commonly use these tests to identify movement dysfunctions in the SIJ, the weight of evidence has not changed in the last couple of years and the use of these tests and models of movement dysfunction remains unsupported. (Pallson, Riczo, Goode, Klerx)

Testing clusters evidence

It is evident that individual SIJ tests have issues such as poor inter-rater reliability and that a single test is not reliable enough to be used in the diagnosis of SIJ pain or dysfunction. A more acceptable method is to make use of a cluster of tests (combining the results of a number of tests) Cibulka 1988; Laslett 2005, Robinson 2007, Dreyfuss, Riddle, Levangie) Arab et al 2009 reported a fair to substantial inter-tester reliability for the cluster of tests with the reliability the highest for the cluster with two positive tests out of four SIJ mobility tests. Other studies have also addressed the issue of poor reliability by assessing clusters or groups of tests with some success (Cibulka 1999, Riddle). Although clustering individual unreliable tests, may improve reliability, it still lacks face validity (Laslett 2008)

In a review by Goode in 2008 the conclusion was that movement testing should not be used to diagnose SIJ pain or dysfunction and it is suggested that clusters of pain provocation tests are the best way to diagnose SIJ pain to date.

Self administered testing

SIJCPR

Pain Provocation Tests

Laslett (2005) proposed that an effective way of identifying the SIJ as the source of pain is using a battery of five pain provocation tests. The diagnostic accuracy of these tests was assessed against an intra-articular anaesthetic block in 48 participants between the ages of 20 – 79. These tests include:

Distraction Test

Patient lies supine. Examiner applies a vertically orientated, posteriorly directed force to both the anterior superior iliac spines (ASIS). The anterior sacroiliac ligaments are stressed with this test and this test has the highest positive predictive value (0.6; 95% CI = 0.36 – 0.8) Fryer and Pearce 2012. Test sensitivity is 0.6 (036 -0.8) and specificity is 0.81 (0.65 -0.91). Laslett 2005

Thigh Thrust Test

Patient lies supine with affected side hip flexed to 90. Examiner stabilises the pelvis at the opposite ASIS with his/her hand, while providing steady increasing pressure through the axis of the femur. The posterior tissues of the SIJ are stressed with this test. This test has high inter-rater reliability (Kappa = 0.94, 0.64 -0.082 p <0.001). Test sensitivity is (0.36 -.88) and specificity is (0.50 -0.69) in moderate to high quality studies. Laslett 2005; Stuber 2007

Compression Test

Patient is in a side-lying position, with affected side up, facing away from the examiner, pillow between the knees. Examiner places a steady downward pressure through the anterior aspect of the lateral ilium, between the greater trochanter and the iliac crest. Test stresses the posterior SIJ ligament. This test has been found to be not reliable (Kappa = 0.63) Van der Wurff 2000

Gaenslen’s Manoeuvre

Patient lies supine with affected side leg neat the edge of table while patient’s shoulders are positioned towards the middle of the table. Patient draws non-affected side leg into full flexion and holds flexed knee, while the examiner holds the leg with hand placed over patient’s hand. This action keeps ilium on the non-tested side in slightly posterior and stable position. Test can indicate presence or absence of SIJ pain, pubic symphysis instability, hip pathology or a L4 nerve root lesion. (Albert 2000)

Sacral Thrust Test

Patient lies prone. Examiner applies a vertically directed force to the midline of the sacrum at the apex of the curve of the sacrum, directed anteriorly. This produces a posterior shearing force at the SIJ. (Laslett 2019)

[null Sacral Thrust Test]

Patient lies prone. Examiner applies a vertically directed force to the midline of the sacrum at the apex of the curve of the sacrum, directed anteriorly. This produces a posterior shearing force at the SIJ. (Laslett 2019)

FABER (Patrick’s) Test

Patient lies supine, examiner crosses patient’s affected side foot over the opposite-side thigh. Pelvis is stabilised at opposite ASIS. A gentle downward force is applied to the affected side knee and is steadily increased, exaggerating the motion of hip flexion, abduction and external rotation. This test is usually used to identify hip pathology, but it is useful in identifying SIJ pain when clustered with other tests. This test has high intra-rater reliability. Sensitivity is 0.69-0.77 and specificity 0.16-1.0 (Kappa = 0.83) Stuber 2007

The key SIJ pain provocation tests are distraction, compression, thigh thrust, Gaenslen and sacral thrust. Lalett 2019 The Faber test has also been validated but is as much a test of hip pain and function as it is a test of the SIJ. Laslett 2019 The algorhythm proposed by Laslett also indicates that centralisation via the McKenzie approach should be ruled out first and by doing this the sensitivity of the cluster of tests will improve from 78 % to 87 %. Three of the pain provocation tests need to be positive to be an indication of an SIJ problem.

Read this recent article published by Laslett: provide link

Self-administered tests

Olsen et al evaluated the use of self-administered tests for pelvic girdle pain  in pregnancy and concluded that these self-administered tests and questionnaires are possible to use for the testing and classification of women with suspected pelvic girdle pain. This may help to provide the basis for an early intervention.

The self-administered tests are:

Pain provocation

Self-administerd posterior pelvic pin provocation test (P4)

Self-administerd Faber test

Bridging test

Self-administered Trendelenburg test

MAT test

Functional test

Self-administered active straight leg raise

Self-administerd modified SLR test

Provide link to article https://link.springer.com/article/10.1186/1471-2474-15-138

Interventions for pelvic girdle dysfunction and sacroiliac pain

Manual Therapy

Manual therapy techniques reported in the literature are often aimed treating the immobility of the SIJ. cibulka 2002 Clinical opinion on the effectiveness of manual therapy also varies greatly. Few trials investigating this excist and those that are available are either uncontrolled or poorly controlled Booth 2019 Kamali 2012, 2018

Manual therapy has been shown to alter muscle tone and EMG activity in muscles related to SIJ stabilisation (hamstrings, quadriceps and abdominal muscles)Sole 2008, 2012

Clinton et al concluded that the evidence on manual therapy techniques for the treatment of PBLP and PGP is still emerging and could be considered as there is little to no reported evidence of adverse effects in the healthy antepartum population, but these recommendations are based on weak evidence.

Exercise

Exercise is recommended in the antepartum population with pelvic girdle pain. Both the ACOG and Canadian CPG’s recommends exercise for health benefits and there is a low risk and minimal adverse effects for the antepartum population. Clinton et al

Vleeming et al showed that many muscles contribute to optimal force closure of the SIJ. It is postulated that asymmetry or altered neuromuscular function of any of the muscles contributing to force closure may influence force closure and load transfer.

Many exercise interventions are designed to improve the stability around the pelvic girdle by strengthening the muscles to produce stronger force closure. The evidence for this is conflicting. Stuge et al 2004, compared the efficacy of specific lumbopelvic stabilisation exercises with individualised physiotherapy treatment without the use of stabilisation exercises. The specific stabilisation exercises provided reduction in pain, pain related disability and improved quality of life, whereas the compared group showed little change. Gutke et al showed little effect in the implementation of specifically designed pelvic stabilisation programs. Gutke 2010. Mens et al also reported little benefit  of specific exercises designed to strengthen diagonal trunk muscle systems thought to be active in force closure. Mens 2000

However, Pennick and Young conducted a Cochrane review and concluded that strengthening exercises and sitting pelvic tilt exercises lead to a reduction in pain and back-pain related sick leave. A recent systematic review on the effectiveness of exercise programs on lumbopelvic pain among postnatal women suggests the possible reasons for poor outcome results may be poor compliance and potential discomfort experienced in some exercise programs (Tseng 2015)

External Pelvic Compression

Pelvic compression belts have been used the rehabilitation of pelvic pain in various populations such as athletes and peripartum women Vleeming 1992. The mechanism of how these belts influence pelvic stability remains unclear. Booth et al SIJ lacxity have been reduced through wearing a pelvic compression belt Damen. It also improved neuromuscular performance in the stabilising muscles of the pelvis Sole 2008. Arumugam et al (2012) reported moderate evidence for external pelvic compression influencing lumbopelvic kinematic motion, pain, SIJ laxtity and neuromuscular control. Arumugam 2012.

Clinton et al recommends that clinicians should consider the use of a pelvic support belt in the antepartum population with pgp. However the recommendation is based on conflicting evidence as the studies reviewed reported on different patient populations, had different intervention and control groups as well as differences in duration of intervention application and timing of follow-up. Clinton 2017

Outcome measures

Clinton et al published clinical practice guidelines for pelvic girdle pain in the antepartum population. In these guidelines the relevance of patient-reported outcomes are discussed. The use of patient-reported outcome measures are practical to determine baseline disability, function and pain relief as well as change throughout the clinical course of treatment. Clinton et al recommends that these outcome measures should be used in combination with clinical examination to help with clinical decision making.

Some of the outcome measures recommended are:

Disability Rating Index

Oswestry Disability Index

Pelvic Girdle Questionnaire

Fear-Avoidance Beliefs Questionnaire, Physical Activity Subscale

Pain Catastrophising Scale

The complete clinical guidelines can be found here:  https://journals.lww.com/jwhpt/FullText/2017/05000/Pelvic_Girdle_Pain_in_the_Antepartum_Population__.7.aspx?casa_token=EWFXGxsE1_EAAAAA:p43d1NtiqIJJBKUb17my1PD9pLitgtTr2bjeM9fMI7y_ScmSLvtPPlPIXYgJb2C9Jp4ETKhlaHCS6rktgHtOo-N0eg

Wuytack and O’Donovan more recently conducted a systematic review into outcomes and outcome measures used in intervention studies of pelvic girdle pain and lumbopelvic pain. A total of 107 studies were included in the review and 46 outcomes were reported across all studies. Pain was the most reported outcome. Studies used different instruments to measure the same outcomes, particularly for outcomes of pain, function, disability and quality of life (Wuytak et al, 2019)

Read the complete systematic review here: https://link.springer.com/article/10.1186/s12998-019-0279-2

Food for Thought

Hodges et al 2019 published the following study: Building a collaborative model of sacroiliac joint dtsfunction and pelvic girdle pain to understand the diverse perspectives of experts. Out of the 21 invited potential contributors invited, 14 took part in the study. The findings of this study showed that there is a bias towards biomechanical factors. Furthermore the most efficacious treatments predicted by the model have modest to no evidence from clinical trials. These findings suggest that there is a mismatch between opinion and evidence and it provides insight into the complexity of pelvic girdle pain. Read the complete article here: https://www.researchgate.net/publication/333654198_Building_a_Collaborative_Model_of_Sacroiliac_Joint_Dysfunction_and_Pelvic_Girdle_Pain_to_Understand_the_Diverse_Perspectives_of_Experts

Another recent article by Pallson et al (2019) discussed the relevance of changing the narrative in the diagnosis and management of pain in the sacroiliac joint area. The article reviewed the evidence regarding the clinical detection and diagnosis of SIJ movement dysfunction and questions the continued use of assessing movement dysfunction despite a growing body of evidence undermining the biological plausibility based on such diagnoses. The authors suggests the need for a paradigm shift in clinical reasoning as assigning causality of pain to movement dysfunction of the SIJ is disputed by the available evidence. Patient education is vital and clinicians need to play a key role in this.  The complete article can be viewed here: https://www.semanticscholar.org/paper/Changing-the-Narrative-in-Diagnosis-and-Management-Palsson-Gibson/e9d974ccb20f00f773bc2f80a87efd9fb7d8e439

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