MS 2 - Pelvic Girdle Assessment/Dx, Stabilization

Palpatory obliquities are consistent from supine to standing (static)? - standing ASIS lower and PSIS higher, iliac crest same and pain L, L innominate ant rotated relative R, side pain side dysfunction

- if in standing feels ASIS lower/PSIS higher and iliac crest same and pain on L — L innominate is anterior rotated relative to R - side of pain is the side of dysfunction

Dynamic palpatory tests obliquities are inconsistent? - moving from one position to other they are moving too much, either hypermob or instability, pain switching sides

- if they are inconsistent - as they are moving from one position to the other they are moving too much - either hypermobility or instability; may see pain switching sides

Dynamic palpatory tests obliquities remain consistent? - same dynamic, L stuck ant rot as palpate do you feel just R side move bc L side already there and stuck, make more hypomob

- same thing with dynamic tests - L stuck anterior rotation, as palpate do you feel just the R side move bc the L side is already there and is stuck - make more hypomobility

Palpatory obliquities are inconsistent from static supine to stand? - put supine do exact same thing, same thing then consistent, jt dysfunction and hypomobility

- then put supine and do the exact same thing - if find the same thing then consistency (more likely joint dysfunction, hypomobility)

Upslip - ASIS, PSIS, ischial tub, iliac crest, leg shorter, QL tight - IL QL c-r and pull down, SL and manip or mob down

ASIS higher PSIS higher ischial tub higher, iliac crest higher leg appear shorter, QL tight IL QL contract relax and pull back down, SL and manip or mob down

R Post Innominate Rotation - ASIS, PSIS, ischial tub - iliac crest, leg appear short, HS tight - manually move ant rotate, ms energy hip flexor

ASIS higher PSIS lower Ischial tub lower iliac crest - equal, need to come in and palpate from side leg appear shorter, HS tight manually move to ant rotate, ms energy to hip flexors

R Anterior Innominate Rot - ASIS, PSIS, ischial tub - iliac crest, leg length apparent/appears - hip flexor tight, motion correct manually move post rotate, ms energy HS

ASIS lower PSIS higher ischial tub higher iliac crest - equal, need to come in and palpate from side leg length apparent closer to floor, leg appear longer hip flexor tight corrective motion: manually move to post rotate, ms energy HS contract

Key Objective Findings - aberrant mvmt, +/- list, gowers, catch pain thru motion, RLL, extend back to get stability when move into flex/come back up, d/t poor stability, transition motion hard - + shear, PA, protective spasm, prone instability, poor ms pattern, dec multifidus tone

Aberrant movement patterns to include: +/- list, gowers sign, catch pain through motion, reverse lumbar lordosis · RLL - extend back to get stability when moving into flexion and then coming back up · due to poor stability, transition motion hard + sheer, + PA, protective spasm, + prone instability test Poor muscle patterning, decreased mutifidus tone

Hypomobile ID Obliquity - restore tx - ant/post rotated, upslip, general stay with basic biomech, how much ms and joint - mob manip ms energy

Anterior rotated innominate Posterior rotated innominate Upslip Very general - stay with basic biomechanics how much from ms or the joint restricted Tx: mob manip ms energy

· Functional Biomechanics - Forward Bend - ant rotate innominate, PSIS sup direction, nut inc relative for first 45-60 deg, extensibility reach so get counternut with continued FB - first watch and see how move, ms tight/afraid/facet locking, try to neutralize, take hands roll down thru each vertebra, get full lumbar flex with sacral nut relative innominates - full, then has to come hips so ant rotate, palp and see if moving on PSIS if innominates rotating together, sacral sulci on each side, first part motion see sacrum move forward, lumbar down then sacrum does not move and motion hips, feel wiggle

Anterior rotation of the innominate PSIS travel equally in a superior direction Sacral nutation increases relative to the innominates for the first 45-60 degrees of FB Extensibility of the tissues is reached so get sacral Counternutation with continued FB o first watch them and see how they move - are there ms tight, afraid to move, cannot move bc of facet locking, etc. - then try to neutralize - take hands and roll down through each vertebra - as this is happening, getting full lumbar flexion with sacral nutation relative to innominates - this is full - has to come from hips which is where they get the anterior rotate - palpate and see if moving on PSIS - see if innominates are rotating together - then see if sacral sulci on each side - first part motion see sacrum move forward, then once lumbar done then sacrum does not move and the motion comes from the hips - want to feel a wiggle, do not move as a lump

Anterior and Posterior Rotation of the Innominate - ant rot = ant pelvic tilt, bilat with FB, unilat LE extension, associated counternut - post rot = post pelvic tilt, bilat with LB extension, unilat LE flex , associated nutation - normal mvmt patterns

Anterior rotation of the innominate - anterior pelvic tilt - Bilateral occurs with forward bend - Unilateral occurs with LE extension - Associated with sacral Counternutation Posterior rotation of the innominate - posterior pelvic tilt - Bilateral occurs with LB extension - Unilateral occurs with LE flexion - Associated with sacral nutation o these are normal movement patterns - may need to teach them how to bend and move appropriately

Hypermobile Exam Findings +/- positional fault if out alignment, correct if see, +/- gowers if motor control lock out back as come up, hypermob in LB - poor control WS, walk or unilat, dec control hip or ankle strategies, ankle no problem, hip think motor control - poor isolate and endurance stab ms, pos trendelenberg, multifidi/TrA, pelvic floor and diaphragm - antalgic gait, look out alignment stand but lay down fine, change dynamic and static palpatory tests could be MC but change from one position to the other meaning not control as well as should, inc jt play/glides, active SLR good when pos

Exam Findings +/- positional faults · positional faults if out of alignment - may or may not see (if you do then correct) +/- gower sign · gowers if motor control, lock out back as come up · see a lot of hypermob in LB Poor control, with weight shift · walk or unilateral stuff - WS and then decreased control, ankle or hip strategies (ankle no problem, hip think motor control issue) Poor isolation and endurance of stabilizing muscles · pos trendelenberg, look at multifidi and TrA of stab ms, pelvic floor/diaphragm Antalgic gait · look at gait, might see look out of alignment when standing but lay down perfectly fine Change in dynamic and static palpatory tests · could be motor control but change from one position to the other, meaning not control as well as should Increased arthrokinimatic glides + Active SLR spec .97 sen .87 :Mens 2002 · active SLR good when positive

· Functional Biomechanics - Backwards Bend - innominate PSIS sacrum, stab pelvis and bend from back - PSIS move to post pelvic tilt, bilat feel this at PSIS and sacrum, stab pelvis and not allow pelvic motion first, sacrum should move post relative innominate, once take up all motion lumbar spine - rest motion from hip, move post pelvic rot, sacrum will not move as innominate moves post so into nut

Innominate, PSIS, Sacrum can do the same thing with the backwards bend - stabilize the pelvis, want bending from the back PSIS should move down into posterior pelvic tilt bilaterally feel this at PSIS and sacrum - stabilize pelvis and not allow pelvic motion first (sacrum should move posterior relative to the innominate, once take up all motion from lumbar spine, rest of motion comes from the hip and move into posterior pelvic rotation the sacrum will not move as the innominate moves posterior relative to sacrum)

Hyper Intervention - medical sclerosing prolotx pharm, inject med irritate and scar down, painful and uncomfortable, do not see first 2-3 days, do not want to dec inflam - fusion after failed conservative tx, not great outcomes, do medical after failed conservative - pt acute subacute chronic stages apply, control pain correct obliquity, stabilization

Medical · Sclerosing/ prolotherapy/ pharmacology o inject into SIJ a medication or anything to really irritate the jt in hopes to get it to scar down — really painful and uncomfortable o do not see them for first 2-3 days, do not want to dec inflammation · Fusion ( after failed conservative Rx only) · not great outcomes - only do medical after failed conservative PT · Acute, sub acute, chronic stages apply · Control pain, correct obliquity · Stabilization

Hypo Treatment - mob/manip/restore alignment - acute dec pain inflam and ms spasm, sx heavy, cannot mob or manip until dec pain, modality/STM/rom/gentle traction/grade 1-2 mob - subacute inc rom strength posture and body mech, tolerate more into mobility - chronic ergonomics, dynamic stab, self manage - biggest focus restore alignment, first time resolve quickly and HEP

Mob/manip/restore alignment Acute - Decrease pain, inflammation and MS spasm · sx are heavy - cannot mob or manip until dec pain · modalities, STM, rom, gentle traction, grade 1-2 mobs Sub Acute - Increase ROM, strength, promote good posture and body mechanics · tolerate more, into mobility Chronic - Ergonomics, dynamic stability, self management biggest focus restore alignment if first time then resolve quickly and make sure give HEP

Objective Measurements, Cont - MS length, imbalance piriformis spasticity pull things over, leg length imbalance, hip flexor force SIJ - leg length measurement, true vs apparent - provocation test confirm SIJ source sx, test clusters most reliable, joint mob

Ms Length · imbalance - piriformis spasticity can pull things over · leg length imbalance · hip flexor forces on SIJ Leg Length Measurements · True, apparent Provocation tests- · Confirm SIJ is the source of symptoms · Test clusters are most reliable Joint Mobilization

Prognosis Hyper

Prognosis - longer than isolated hypermobility, 2-3 mo d/t retraining of motor control system

Therex Intervention - restore normal MC, ms isolate and activate, co contract, trunk stability with inc load, functional strengthening - activate trA and multifidi, progress co contract and keep pelvis neutral, then control/change BOS add in arm leg mvmt, then progress fxn strength, control stability while work mobility

Restore normal motor control - ms isolation and activation Co-contraction Trunk stability with increasing load Functional strengthening activate TrA and multifidi, progress co contraction and keep pelvic neutral then control and then change BOS/add in arm or leg movements progress functional strengthening, control stability while working mobility

Hyper Stabilization - stage 1 isolate/facilitate ms, multifidus, trA pelvic floor - stage 2 add bilat limb movements avoid UL WB, dec BOS and inc load, avoid shearing SI do bilat and then move unilat WB once good control, bridge w ball/roll out and in, unilat in LB - stage 3 stab during controlled mvmt, advance - stage 4 stab with speed, protective mech comes in when move faster

Stage 1- isolate and facilitate key muscles (multifidus, trA, pelvic floor) Stage 2- add bilat limb movements (avoid UL WB); decrease BOS, increase load · avoid shearing SI so do bilateral and then move unilat WB once really good control · bridge up with ball, roll legs out and in · can do unilat in LB Stage 3 - Stabilize during controlled movements (advance this) Stage 4 - Stabilize with speed · protective mechanism comes in when move faster

Activation Multifidus - ex with VMO, palp tone multifidi none when inhibited, feel bounce rxn

ex: treat knee - contract quad, want VMO contract but cannot get nice so push through can palpate tone multifidi - no tone when inhibited, feel bounce reaction

Positional Faults Innominate

named for the side the SX are on (examples are on R)

Torsion is produced at the pelvis

now unilateral - what happens one side versus the other

Activation Pelvic Floor, Diaphragm - elevate pelvic floor inc stability, do not lift push down, contract bearing down when poor control, diaphragm never relaxed, always some inc pressure and stab if up/moving

o Activation Pelvic Floor - elevation of pelvic floor increases stability - do not lift push down (contract by bearing down) when poor control o Activation Diaphragm - never relaxed - always some increased pressure and stabilization if up and moving

· CPR: Stabilization - age <40, SLR >91, pos prone instability, aberrant motion

o Age <40 o SLR>91 degrees o Positive Prone instability test o Aberrant motion present

· Anatomy - articular sacrum 5 fused vertebra base at top apex at bottom, SIJ where it meets the innominates - innominates ilium ischium pubis, lig, R/L side pelvis

o Articular - Sacrum - 5 fused vertebra · Base · Apex - Innominates · ilium, ischium, pubis - Ligaments o base is the top, apex is the bottom - SIJ is where it meets the innominates (R and L side pelvis)

· Common Compensatory Patterns - breath holding, only hold when hold breath, oblique activation, increased RA activity, trunk forward flex, inc WB thru feet, post pelvic tilt, mvmt pelvis trunk LE

o Breath holding - only hold when hold breath o Oblique activation o Increased RA activity o Trunk forward flexion o Increase WBing through feet o Posterior pelvic tilt o Movement of pelvis, trunk or LEs

· Diagnosis - dx achieved, what need to tx SIJ, hx/rule out LBP, reproduction sx with 3/5 provocation test - dysfunction guide tx direction, need to tell you HOW to tx SIJ - positional test, dynamic tests, confounding variable addressed with posture ms balance and leg length

o Diagnosis Is achieved - what you need to tx SIJ - History and - R/O LBP - Reproduction of symptoms with 3 of 5 provocation tests. o Dysfunction and guide treatment directions - this is what you need to tell you HOW to tx SIJ - Positional tests and - Dynamic tests - Confounding variable are addressed with posture muscle balance and leg length

· Literature - Intrabdominal Pressure - diaphragm onset contract prior to movement, indep respiration - pelvic floor role incont, may see in pt LBP, cauda equina, inhibit pelvic floor, other types, anticipatory, comes on prior, inc abd pressure when cough sneeze or else incontinent

o Diaphragm - Onset of contraction prior to onset of movement - Independent of respiration o Pelvic floor - Role in incontinence · may see incontinence with patients with LBP · is it cauda equina, inhibition pelvic floor, other types incontinence? - Anticipatory · comes on prior - increase intrabd pressure when cough sneeze etc or else incontinence

· Screening - Teaching the Action - ed pt, explain skill not strength, relax abd, pre contract never get good contraction, diaphragm to compensate, relax/make sure still breathing, draw up and in - avoid mvmt trunk/pelvis, dissociate breathing, palp medial to ASIS, breathe in out and activate, hold breath and make sure hold so not involve breathing, then once have can dissociate, slow and controlled hold 10 sec, use gravity by hands/knees hard to activate

o Educate patient - first explain - skill not strength o Relax abdominals - relax - if pre contracted will never get good contraction - can use diaphragm to compensate - relax and make sure still breathing o Draw up and in o Avoid movement or trunk and pelvis o Dissociate breathing - palpate medial to ASIS, breathe in and out and activate (hold breath and make sure hold so not involving breathing, then once have can dissociate breathing) o Slow and controlled motion hold 10sec - use gravity by hands and knees if hard to activate

· Pain with Normal Mobility - exam findings - leg length/trendelenberg, ms imbalance, look down kinetic chain

o Exam Findings - Leg length/ Trendelenburg - Ms imbalance - Look down kinetic chain

· Sacrum Dysfunction Exam Findings, Tx - positional fault specific sacrum in relation to innominate - palp base sacrum/apex and feel other side is one more prominent than the other, palp lig sacrotub more nutated do not like to press on this, long sacroiliac more tender counternut, prominence/recreate sx - dynamic motions as well, prone press up, sacrum counternut and come back, stuck nut can bring more flexed, think obliquity, does it get more prominent and which position - tx restore alignment

o Exam Findings - Positional fault - specific positional fault sacrum in relation to innominate as well - palpate base sacrum - and apex and feel either side is one side more prominent than the other - palpate lig - sacrotuberous more nutated do not like to press on this, long sacroiliac more tender if counternutated - prominence and recreate sx · dynamic motions as well, bring to prone press up - sacrum counternut and come back, if stuck nutated can bring more flexed · if think obliquity - does it get more prominent and which position o Treatment - Restore alignment

Hypomobile - Exam Findings - hip ROM WNL esp ext, do not have ext move from LB, neg LB scan, bending forward back side to side and pelvis, how to diff, keep pelvis stable bend only from LB, reproduce pelvis or LB, get only back from stab/repeat - palp obliquity stays the same, dec or fixed mobility with kinetic testing, kinetic dynamic test not moving as well on one side consistent no matter what motion - dec jt mon to hip hypo, if can but one piece puzzle, joint mob LB does not reproduce sx, if do then from LB, tx this not SI, consider L5-S1 bc close and then tx L5 first and then SI - provocation tests positive, dx bc r/o back and pos provocation, assoc ms or leg length whether apparent or fixed, very connected think through

o Exam Findings - hip ROM WNL - especially ext, if do not have ext then will be moving from LB to get it - Negative LB scan · neg LB scan - bending forward back side to side and pelvis how to differentiate (keep pelvis stable and bend only from LB) - could reproduce pain from pelvis or LB, try and get only back by stabilizing and repeating - Palpatory obliquity fixed · palp obliquity - stays the same - Decreased/ fixed mobility with kinetic testing · kinetic dynamic test - not moving as well on one side is consistent no matter what motion - Decreased arthrokinematic glides (jnt mob) · joint mob to hip hypo - if can but just one piece puzzle · joint mob to LB does not reproduce sx (if do reproduce pain then coming from back and tx this before looking at SI), consider L5-S1 because close and then tx L5 first and then SI - Provocation tests + · dx bc rule out back and pos provocation - MS length, Leg length · assoc ms or leg length whether fixed or apparent - very connected so have to think through

· Anatomy - TA Contribution to Spinal Stiffness - fascia attach TP lumbar vertebra, inc tension TL fascia, inc intrabd pressure, inc spinal stiffness thru inc tension in TL fascia, connect multifidi, contract inc tension on TF psoas also attach prevent motion if ms spasm/strain

o Fascia attaches to the transverse process of each lumbar vertebra o Increases tension in the thoracolumbar fascia o Increases intra-abdominal pressure o Increase spinal stiffness through increased tension in thoracolumbar fascia - connect to multifidi - contract causes increased tension on TF - psoas also attach and can prevent motion if muscle spasm/strain

Fatty Infiltrate Multifidi, Ms Inhibition - fatty infiltrate if ms not work/activate, look images and report, fat white - ms inhibition can also see US, see changes contract/relax, palpate multifidi very close SP

o Fatty Infiltrate Multifidi - if ms not working and activating, get fatty infiltrate of the muscle - look at images not just the report - fat is white o Muscle Inhibition - can also see on US - see changes when contract and relax - palpate multifidi are very close to the SP

· Control of Spinal Orientation - hypermob associated loose lig and jt capsule, inc neutral zone, local ms poor control, load deformation, no change total rom - normal rom, neutral zone inc and changes, ms not compensating to hold it better and keep zone, will see sx

o Hypermobility is associated with looseness of ligaments and the joint capsule o Increased Neutral zone o Local Muscles poor control o Load-deformation o No change in total ROM o normal ROM - but the neutral zone is what increases and changes - this is because the ms are not compensating to hold it better and keep zone - and increased neutral zone - will see sx

· Hypermobility, Instability - loss stiffness, stretch passive structure lig disc - neutral zone how much does spine move, lumbar instability can see change alignment in XR/see translation at levels, shallow vs nice tight

o Loss of stiffness o stretching of passive structures, lig disc o neutral zone - how much does the spine move o just think hypermobility - lumbar instability can see change alignment in XR (diagnostic - see translation at those levels) o shallow cup vs nice tight cup

· Research - Controversy - MD pelvis fused, osteopath rotation axis, tx by sx and not abnormalities - controversial SIJ anatomic structure in lumbar can cause LBP if injured, mech dysfunction inflam infection trauma degeneration all been attributed - controversy biomech, specific articular not validated, lit/studies/theories suggest both function and dysfunction SIJ - pelvic motion 3 planes coronal sagittal and transverse, combo in normal gait 1-3 deg, agree SIJ multidirectional force transducer transition forces jump and land up thru spine safely

o MD - pelvis is fused o osteopathic approach - rotation on axis o another group says treat by symptoms and not talk about abnormalities o Although still somewhat controversial, the sacroiliac joint (SIJ) is generally accepted as an anatomic structure within the lumbar complex that if injured can be a cause of lower back pain. Mechanical dysfunction, inflammation, infection, trauma, and degeneration all have been attributed to the SIJ in up to 15% of patients with nonspecific LBP. o Controversy on Biomechanics: The specific articular biomechanics are still not validated. - Literature, post mortem in vivo studies, and clinical theories suggest both the function and dysfunction of the SI joint. - Pelvic motions occur in 3 planes (coronal, sagittal and transverse). A combination of these motions occur during the normal gait cycle (Greenman) - this is between 1 and 3 degrees - Vlemming et al suggest the average values of rotation and translation Function o Agreement that the SI joint acts as a multidirectional force transducer - we want a stable spine and want mobile legs - SIJ has to transition the forces from jumping and landing up through the spine safely

· Force Closure - ms active co contract, inner unit tonic/local/stab, LA and multifidus control sacral position, TA and pelvic floor inc intra-abd pressire, direct fibers control, corset action translates pressure over SIJ, intraabd pressure indirect - outer phasic/gross/mvmt, glut max and CL lats, glut min/med and CL add co contract cause compression force across SI

o Muscle system /Active stability/ Co-contraction o Inner unit (tonic/ local/ stabilizing muscles) - Levator anni and multifidus control sacral position - TrA and PF increase intra-abdominal pressure - direct fibers control - PF - pelvic floor - the corset action translates to pressure over the SIJ - intraabdominal pressure is indirect o Outer unit (phasic/ gross/ movement muscles) - Gluteus maximus and the contralateral latissimus dorsi - Gluteus medius and minimus and the contralateral adductors - co-contract and cause compression force across the SI

· Objective findings - observe rom palp wb/non wb, kinetics test/dynamic mvmt and static as well - ms length, leg length associated as well, provocation tests, reproduce to be sure SI, jt mob

o Observation o ROM o Palpation - WB and Non WB - Kinetics tests/dynamic palpation - kinetics tests - dynamic movement - static as well o Muscle length o Leg length measurements - associated as well - ms length and control leg length o Provocation tests - provocation - you need to reproduce this to be sure SI o Joint mobilization

· Coccyxadynia Fx/Sublux - fall buttocks, missed chair or toilet, post pregnancy, fall ski, radiate pain - subjective localized over coccyx - exam sitting posture painful, pain on palp and mobs

o Onset - Fall on buttocks/ missed chair/toilet seat - fallen on buttocks, post pregnancy - fallen skiing, radiate pain to buttocks o Subjective - Localized over coccyx o Exam Findings - Sitting posture very painful - Pain palpation/ mobs

· Pain with Normal Mobility - onset - overuse articular and myofascial structure, dysfunction somewhere else, biomech - pain not SI, often piriformis, same location pain everything neg, palp and provocation neg

o Onset - Overuse articular and myofascial structures - Dysfunction somewhere else- biomechanical - pain not coming from SI - often piriformis - same location pain but everything negative - palpation and provocative negative

· Hypermobile Onset, Subjective - repetitive micro/major trauma, hormones, hx SI dys, shearing unilat, prolonged position, twisting - pain location buttocks, tight, pubic symphysis groin - look similar hypo terms area pain, pain location can switch sides, inconsistent, +/- click pop, inc unilat WB and weight shift, dec rest position does not stress joint, sitting leg crossed stress jt need be in neutral

o Onset - Repetitive micro trauma/ major trauma - Hormonal changes - hx SI dysfunction - shearing unilateral, prolonged position, twisting o Subjective - Pain location buttocks/ tight/ pubic symphysis/ groin · look similar hypo in terms of area pain but pain location can switch sides, inconsistency - +/- clicking popping - Incr. unilateral WB and weight shift - Dec. rest in position does not stress joint if someone sitting and legs crossed stresses joint, need to be in neutral

· Pelvic Girdle Fx - trauma and radiographs, one pelvic fx will have another one, ring so break one side will break another - subjective pain/unable WB, exam point tender over bony prominence, always screen full rom and knee/hip strength, look at roll over palp and if significant pain see pelvic fx, post surgical or multiple trauma

o Onset - Trauma/ + radiographs - one pelvic fracture then will have another one - ring so break one side will break another o Subjective - Pain/ unable WB o Exam Findings - Point tenderness over bony prominence - always screen full rom and knees/hips and strength - look at roll over, palpate and if significant pain see pelvic fx - may see post surgical or after multiple trauma

· Sacrum Dysfunction Onset, Subjective - trauma lift twist, sacrum easiest to tx, then innominate, reassess tx after to see if good - subjective same +/- pop

o Onset - Trauma/lift/twist - sacrum easiest to tx, then innominate - reassess tx after to see if good o Subjective - Same +/- pop

· Hypomobile - Onset, Subjective - transfer weight, land or awk mvmt, step down knee straight, shearing thru SIJ, insidious look positional stressor, associated sitting or standing all the time, trauma lift fall twist - subjective going past knee - look LB, possibly irritate nerve SIJ inflamed but <1% unless sig trauma, weight shift happening, inc pain, pain reveal over SI/into buttocks or post thigh, inc walk stairs roll STS

o Onset - think about transfer of weight - landed or awkward movement, stepping down knee straight - shearing thru SIJ; insidious look for positional stressor, associated with sitting or standing all the time - trauma/fall/lift/twist/ insidious - look positional stressors o Subjective - if going past the knee - have to look at LB - possibly could irritate the nerve if SIJ inflamed but <1% of the time unless significant trauma to it - is a weight shift happening and inc pain - Pain reveal over SI/ into buttocks or post thigh - Incr. walking/ stairs/ rolling/ sit to stand

· Solving the Clinical Puzzle - palp kinetics ID type dysfunction, palp static and dynamic help figure out way to tx - ms length ID confounding, leg length, causing anything - provocation confirm SIJ dx, jt mob, provocation and jt mob recreate sx, do not have pain then it is not a problem ie posture

o Palpation - Kinetics tests- Identifies the type of dysfunction - palpation - static and dynamic help figure out way to treat o Muscle length- Identifies confounding factors - Leg length measurements - ms and leg length confounding factors ie are they causing any factors o Provocation tests- confirms SIJ diagnosis - Joint Mobilization - provocation and joint mob to recreate sx o if do not have pain then it is not a problem - ie posture

· Definition -2008 European guidelines to PGP - PGP arise relation pregnancy, trauma, arthritis, OA, pain btwn post iliac crest and gluteal fold, dx reached after exclude lumbar and reproduce by specific clinical tests - small region pain, think back pain first and tx first if not working reproduce ST and start thinking SI

o Pelvic girdle pain generally arises in relation to pregnancy, trauma, arthritis, and osteoarthritis. Pain is experienced between posterior iliac crest and gluteal fold. The diagnosis of PGP can be reached after the exclusion of lumbar causes and reproducible by specific clinical tests. o these are the most updated ones we have o this may seem overwhelming - get understanding of anatomy and biomechanics o small region pain - over SI joint o think back pain first and treat back pain first - if not working need to reproduce pain with special tests and start thinking SI

· Palpatory Test - WB and Non WB Kinetic Tests - positional and movement - ID obliquity, standing look align ASIS/PSIS/height iliac crests and supine alignment - dynamic/kinetic FB, gillets, prone pressup knee bend, long sit, active SLR, prone press up on stomach/cobra look innominate, long sit leg length, active SLR ms control - reliability alone poor, clustered 3/4 palp test improve clinical value

o Positional and movement tests o Identify obliquity - in standing, look at alignment of ASIS, PSIS and height of iliac crests in standing and supine o Standing alignment/ supine alignment o Dynamic/Kinetic (movement tests) - Forward bend, Gillets, Prone press-up/knee bend, Long sitting, Active SLR - prone press up on stomach and cobra position, look at innominate - long sitting - leg length - active SLR - ms control o Meta-analysis revealed reliability alone is poor, clustered with 3 of 4 palpatory test improves clinical value - 2008 European guidelines to PGP

· Diagnosis of Exclusion - process elimination, most common SI lumbar and hip dysfunction, look at these first, once ruled out look SI - make sure back/hip not reproducing, tx back, reproduce sx and see if better, if not then look at hip and do the same thing over, if better then continue to tx - R/O l spine, common pain refer over SIJ, L3-4 facet, L4-5 n root/exit and travel right over SIJ, piriformis/sciatic n right over there too

o Process of elimination o Most common sources of SI pain are lumbar and hip dysfunction o first thing - look at low back and hip (once this is ruled out then look at SI) - make sure back and hip are not reproducing the sx - treat the back, reproduce sx and see if better, if not then look at hip and do the same thing over - if better then continue to treat o R/O lumbar spine - common pain referral over SIJ · can refer down - L3-L4 facet - L4- L5 nerve root · L4-5 nerve root exit and travels right over SIJ - piriformis/ sciatic nerve · piriformis and sciatic n are right over there too

· Key Subjective Findings - recurrent pain, switches sides, unstable, onset after period inactivity, hx many episodes LBP, each time less to hurt back, underlying dec motor control, more prone hurting - agg with walk STS prolonged esp bad position, dec supported position/neutral

o Recurrent pain, switches sides, feels unstable, onset can be after period inactivity - hx after many episodes LBP, each time less and less force to hurt the back - underlying decreased motor control, more prone to hurting themselves o Aggravating relieving factors - Inc. walking, sit to stand, prolonged positions (especially if bad position) - Dec. Supported positions (maintain neutral)

· Arthrokinematics: Nutation; Counternutation - nutation/flexion, stable position, motion resisted sacrotub and interosseous lig, bilat in initial stages forward bending relative, unilat flexion LE - counternut/extension, motion resisted long sacroiliac

o Sacral Nutation /Sacral Flexion - Stable position - Motion resisted by the sacrotuberous and interosseous ligament - Occurs bilaterally in the initial stages of forward bending (relative) - Occurs unilaterally during flexion of the LE o Sacral Counter Nutation /Sacral Extension - Motion resisted by the long sacroiliac ligament

· Assessment Supine with use surface EMG/US - screen clinical diagnostic, palp med ASIS, look sym side to side, inhibited esp side pain

o Screening o Clinical o Diagnostic o Palpate medial ASIS o Look for symmetry - side to side - may be inhibited one side or not (esp side of pain)

· Model of Assessment - screening test abd draw in action supine, palp PBU with leg load/how well control - clinical assessment abd draw in action prone, PBU obj measure - diagnostic assessment measure deep ms function, fine wire EMG real time US

o Screening test: abdominal drawing-in action supine - Palpation, PBU with leg loading (how well control) o Clinical assessment: abdominal drawing-in action prone - Prone abdominal drawing-in test/ PBU (objective measurement) o Diagnostic measurement: measure of deep muscle function - Fine wire EMG, real-time ultrasound

· Treatment Prescription - select correct pt pop, restore ms control both isolated control and co contract, norm motion, progress BOS load speed, fxn activity/based on desired

o Selecting the correct patient population o Restoring muscle control both isolated control and co-contraction o Normalizing motion o Progressions, BOS, Load, Speed o Functional Activities - based on their desired activity

· Clinical Evaluation of Spinal Control - side support, lower/come back, to feet, lift up leg/arm - ext endurance, co contract back ext endurance - active bilat SLR, PBU under pressure dec legs move - dead bug PBU, can add in alt arm/leg or just one at a time - unilat bridge, pelvis moves keep neutral or leg drops - get to form fatigue, pain lose control ms shaking

o Side Support test - lower and come back up - side support - to feet, lift up one leg and arm o Extensor endurance test - co contract back extensor endurance test o Active Bilateral SLR - bilateral SLR - PBU under (pressure drops, legs move) o Dead Bug/ PBU - dead bug - can add in alternate arms or legs or just one at a time depending on what they can do o Unilateral bridging - bridge - when pelvis moves (thumbs ribs fingers pelvis, keep neutral) or leg drops o can time to FORM FATIGUE (pain, lose control, ms shaking)

· Take Home Message - Stabilization - stage 1 isolate/facilitate key ms, stage 2 add limb mvmt dec BOS inc load, CC to OC - stage 3 stab during control mvmt, fxn based and incorporate body mech, stage 4 stab speed activity sport

o Stage 1- isolate and facilitate key muscles o Stage 2- add limb movements, decrease BOS, increase load, Closed to open chain o Stage 3 - Stabilize during controlled movements, function based/ incorporate body mechanics o Stage 4 - Stabilize with speed, activity, sport

· Pain with Normal Mobility - subjective - same hypo and hyper, subj WB stance same, could be overpron foot, true leg length cause pain

o Subjective - Same as hypo/hyper - subjective wb stance same - could even be overpron of foot - true leg length could be causing pain

· Emphasis of Intervention - therex, body mech, education - brace stomach, contract abd when moving/stab ms, can change pain by contract ms and working on functional motions to help pt, teach body mech, move appropriately, how to stab mvmt

o Therex o Body mechanics, Education o brace stomach and contract abd while moving - stabilizing ms - can change pain by contracting ms and working on functional motions help the patient! - teach body mechanics, move appropriately, how to stab mvmt

· Is there a role for the Transversus Abdominis in lumbo-pelvic stability? - controlled indep CNS, fire feed forward protective mech, anticipatory before ms come on, if not train independently - contract tonically, low load all the time no matter which direction moving, interact with diaphragm and pelvic floor and multifidi same feed forward mechanism, cylinder to inc intra abd pressure to stab - anticipatory regardless load speed visual feedback, trunk emg/LE activation fine wire, ms of diaphragm, MF, trA increase intraabd pressure and cause indirect stability of spine

o Tra is controlled independently CNS - fires independently, feed forward protective mechanism - comes on anticipatory before ms come on - if not, we need to train it independently o Contracts tonically - low load - tonically on all the time no matter what direction moving o Interaction with the Tra, diaphragm and pelvic floor - interact diaphragm, pelvic floor, multifidi and tra in same feed forward mechanism (cylinder to increase intra abd pressure to stabilize) o Anticipatory regardless of load, speed, visual feedback o TRUNK EMG ACTIVITY - LE Activation - fine wire emg - ask pt to move leg - onset activation with RF (preplanning of tra, RA, MF) - did this for all ms, found that ms of diaphragm, MF, trA increase intraabd pressure and cause indirect stability of spine

Pelvic Fx treatment - acute IP external fixator compensate mob function, fixate external, get them up, lots upper body strength to move, need WC cannot log roll, twist in bed, back up into reclined chair, can move bc fixated and get as functional as possible - OP assess hypo or hyper

o Treatment - Acute inpatient- external fixator- compensate/ mobility/ function · fixate pelvis externally · see acute - get them up · lots upper body strength to move, need WC, cannot log roll · twist in bed, back up into reclined chair · can move bc fixated -get them as functional as possible - Outpatient - assess for hypo/hyper mobility

· Coccyxadynia Fx/Sublux - treatment - mob or protect, look to see if flex or ext, ext pregnancy external mob, flex if fall or hit, internal mob or refer womens health - function and strength, could be fx, get US on it and tend to not tx, protect first and see how they feel, cutout or towel roll, function and strength, how did they fall

o Treatment - Mob or protect · look to see if flex or extended · ext in pregnancy, external mob · flex if fall or hit, internal mob or refer womens health - Function/ strength · could be fx - good to get US on it and tend to not tx (protect first and see how they feel) · cutout or towel roll · function and strength - how did they fall

· Pain with Normal Mobility - treatment - tx dysfunction, sx around SIJ not hypo not obliquity - look leg length, ms imbalance, piriformis, poor positions - glute med fatigued/overpron, think about everything and see control pain - tx exclusion, r/o back and pelvis, what do you do and where do you go

o Treatment - tx the dysfunction! even though sx around SIJ not hypo not obliquity - look leg length, ms imbalance, piriformis, poor positions - glute med fatigued and overpronated — think about everything and see if can control pain - tx exclusion - rule out back, pelvis - what do you do and where do you go

· Treatment Techniques - trunk stab local ms, timing and recruitment pattern, restore movmt - CC stability, OC harder stability, progression - abd therex some best stability, side plank moving, pike on ball, roll out on ball

o Trunk stabilization - Local muscles - timing & recruitment patterns o Restoring movement o Closed chained - helps with stability o Open chained - harder with stability o progression - see lecture notes Abdominal Therex o some of the best for stability o side plank moving o pike on ball o roll out on ball

· Stability of the Pelvis - achieve active passive nm control work together (ALL) to transfer loads, dynamic stab intrinsic/extrinsic, form - passive, force - active - bone congruity look like and lig structure, bone congruency and lig loose diff less passive stability, ms need to work dynamic stab - form looking passive, force closure ms ability to improve stab by external forces causing compression across joints/what we can change

o achieve when active passive and neuromuscular controls work together to transfer loads - they ALL need to work o dynamic stability - intrinsic/extrinsic o form closure - passive stability o force closure - active stability o what does the bone congruity look like and lig structure o if lig loose or bone congruency is different then there will be less passive stability o this will require ms to work - dynamic stability (extrinsic ms; intrinsic ??) o form looking at passive stability; force closure is the muscles ability to improve stability by the external forces causing compression across the joints (this is what we can change!)

· LBP and Dysfunction - normal no hx LBP, acute, hx and not having any, TrA and multifidus principal ms affected LBP - tonic change to phasic, no isolation, same activation come on later, turn on/off with motion, not on all the time change phasic with BP, type 1 to type 2, activation delayed, varies with direction speed visual feedback - loss spinal stiffness, inc neutral zone, ms inhibition, loss stability/inhibition deep local ms with pt LBP, never getting prior ms function back unless intervene

o did normal (no hx LBP), acute LBP, then hx LBP and not having any at the time o Tra and Multifidus are the principal muscles affected in LBP o Tonic change to phasic (no isolation) - same activation but came on later, turn on and off with motion (not on all the time — change to phasic) with BP o Type I change type II fiber changes o Activation delayed and varies with direction, speed, visual feedback o Loss of spinal stiffness (increased neutral zone) o Muscle inhibition - loss of stability, loss and inhibition of deep local muscles with patients with LBP - never getting prior ms function back unless we intervene

· Palpate Multifidus Consistency - feel rebound, inc/dec tone, sensitivity palp, side to side/below and above, segmental inhibit, activate swell out into fingers, feel inc tension, formal test see TrA - contract TrA indep feel this instantly, pelvic floor able contract as well, do not try and stop mid flow bc UTI, feeling of pull up and in, once isolate 10s x 10, think about rest stab, indep then co contract

o feel for rebound, increased and decreased tone o Sensitivity of palpation - Side to side and below and above comparison o Segmental inhibition o Activate "swell out into my fingers" fell for increased tension o Formal test: see Tra o contract TrA independently - will feel this instantly o pelvic floor able to contract as well (do not try and stop mid flow bc UTI — but that is the feeling of pull up and in) o once isolate - 10s x 10 — then think about rest stability o independent then co contraction

· Perusing a Dysfunction - palpation

o guide treatment and treatment only

· Provocation Tests - stress jt, anything reproduce pain - patrick/faber, compress distract, post shear/thigh thrust - gaenslen L and R, sacral thrust/spring test, cranial shear - 3/5 inc specificity

o just try to stress joint, anything reproduce pain o Patrick's/Fabre o Compression* o Distraction* o Posterior Shear/Thigh Thrust* o Gaenslen left* and right* o Sacral thrust/Spring test o Cranial Shear (Laslett: 3 of 5 * increase specificity)

· Abdominal draw in test prone - the formal test - use if need #, PBU to 70, breath old and hold, draw in slowly, resume breathing, hold 10s x10, norm reduction 6-10 mmhg, rectus abd contract pressure inc vs down

o only use if really need number o PBU inflated to 70mmHg o Breath out and hold o Draw-in slowly o Resume respiration o Hold 10 sec x 10 o Norm is reduction 6-10 mmHg - if rectus abd contract - pressure goes up vs down

· Examination: History - postpartum/preg do not need to r/o LB and hip - trauma fall bungie jump, anythign shear force, land one leg, fall land on hip, dashboard injury - lig laxity issues, hypermob, preg/PMS release relaxin inc lig laxity thruout, look inc mobility specific part of month - habitual posture, trauma/lig laxity child holding on one side cause shearing force, stand one leg all the time causing continued issues - PMH RA or anky spon, arthritic changes start SIJ, ask AM stiff and how long, length time sx, can start young - pain pattern, somatic pain rarely below knee, pain going past the knee then from back/radicular or look piriformis or assoc SI stuff

o postpartum or pregnancy - do not need to rule out LB/hip as much o Any trauma/ fall/ bungie jump? - anything that caused a shear force? like landing on one leg and not the other, falling and landing on hip, dashboard injuries? o Any ligamentous laxity issues? - Hypermobility , pregnancy, PMS (hormone relaxin incr.) - pregnancy or menstrual cycle releases relaxin - causes lig laxity throughout (this is not specific to the pelvis), looking for increased mobility at a specific part of the month o Habitual Postures - trauma and lig laxity, child holding on one side causes shearing forces, standing on one leg all the time causing continued issues o PMH: RA, Ankylosing Spondylitis? - arthritic changes start in the SIJ - make sure asking questions (AM stiffness and how long, length of time sx); this can start young o Pain Patterns - Somatic pain referral rarely below the knee - if pain going past the knee - coming from the back - radicular sx down leg then look at back; may have associated SI stuff ie piriformis tight

· The use of real - time US imaging for feedback in rehabilitation - use stab ex, imaging ms mvmt pattern and timing, assess facilitation strategies/effectiveness tx, measure ms size - enhance motor learning, KP, visualize contraction, teach relaxation, ex can help isolate to initiate contract

o use for stabilization exercises o Imaging of muscle movement/patterns/ timing o Assess facilitation strategies and effectiveness of treatment o Measure of muscle size (objective) o Enhance motor learning - Knowledge of performance - Visualize the contraction - Teach relaxation o ex: can help to isolate to initiate contract

Prognosis - hypermob there will not change until spine changes, control good ex program, will take time

prognosis - hypermobility is there and will not change until spine changes - controllable with good exercise program (can take some time)

CPR mob/manip SIJ - same LB, FABQ <19, sx <16, no sx below knee, hypo segment LB, hip IR >35

regional manip - manips either SIJ or lower part of the LB same CPR as LB manips FABQ <19, sx < 16 days, no sx below knee, hypo segment LB, hip IR >35 deg

Sacral Counternutation - sacral ext, base/apex, dec lumbar lordosis, ext LB - long SI lig restricted, correct by push into flex, spring on base rel nutation, rotated base more prominent side do jt mob on same side

sacral extension sacral base superficial, sacral apex deep posture decreased lumbar lordosis, extension LB long SI lig - soft tissue restricted correct counternutation by pushing into flexion, spring on base to bring relative nutation if rotated - sacral base more prominent on that side, do joint mob on the SAME side

Sacral Nutation - sacral flex, sacral base/apex, posture flex LB, inc lordosis - sacrotub/interosseous lig restricted, correct push into ext, spring apex to bring rel counternut - rotate side deeper push on opp side, deeper L push on R

sacral flexion sacral base deep, apex superficial posture in flexion LB - inc lumbar lordosis sacrotub/interosseous lig soft tissue restricted correct with nutation by pushing into extension, spring on apex to bring to relative counternut if rotated - side deeper push on the opp side (ie deeper on L then push on R)

Activation TrA - contract trA pull and contract around area, thicken and move without excessive IO/EO, palpate what feels like, isolated vs co contracted

when contract - trA pull and contract around the area want to see it thicken and move without excessive of the IO/EO palpate what it feels like - isolated vs co contracted

this position is RELATIVE to the position of the innominates - go into flex sacrum tilt forward relative to innominate - flex just from LB innominate stays sacrum moves forward, bring knee to flex get post pelvic tilt and moving back, sacrum not moving so considered in flex, stable position lig taut - go into ext sacrum tilt back pelvis moves forward, extension LE innominate forward but sacrum still get counternut

when we go into flexion, sacrum will tilt forward relative to the inominate flexion - just flex from LB = innominate stays, sacrum moves forward bring knee up into flexion, get posterior pelvic tilt and moving back, sacrum is not moving so considered in flexion this is the stable position where the lig are taut go into extension, sacrum tilts back as the pelvis moves forward extension of LE - innominate forward but sacrum still, get counternutation

Ligaments: Interosseous - ant, major stabilizer SI

· Interosseous ( anterior) - Major stabilizer SI (very stable)

Lig: long sacroiliac - post multifidus some fibers insert, hold sacrum tilting backwards and going into sacral ext, looking to inc stability, lig huge can get inc pull on lig from ms fibers

· Long sacroiliac (posterior) - Multifidus has some fibers insert on the lig o holds the sacrum from tilting backwards and going into sacral extension o looking to increase stability - lig huge stability; can get increased pull on lig from the ms fibers

Climbing or Walking - R innominate post rot, L ant rot, R sacrum nut/L counternut relative innominate - R leg forward relative post rot on R leg same as if bring flex, L leg relative ant, have torsion sacrum not moved but relative - R relative nut, L relative counternut, vice versa with L leg in front

· R innominate posteriorly rotates · L innominate anteriorly rotates · The R sacrum is nutated · L side is counter nutated -- relative to the innominates · if the R leg is forward will get relative posterior rotation on R leg (same as if bringing to flexion), L leg is relative anterior · in that position we have a torsion - sacrum has not moved but this is relative · R sacrum relatively nutated, L side relatively counternutated · this is vice versa when the L leg is in front

Lig: Sacrotuberous - post, stab sacral flex and taut WB, sacrum to ischial tub - stab position in sacral flexion taut WB - palpate piriformis close to this and sciatic can get irritated and all affect one another, sx referred if irritate or trauma in area

· Sacrotuberous (posterior) - Stabilizes in sacral flexion and taught in WB o goes sacrum to ischial tuberosity o stabilizes into a position in sacral flexion - taut in WB o can palpate piriformis and it is very very close to this and sciatic nerve - these can get irritated and all affect one another - sx can be referred if irritation or trauma in area

Standing on one leg produces form and force closure (Gillet Test) - WB leg req form closure, NWB and transfer weight req force, in order to stand on one leg you have form/force closure to help stabilize - gillet looks stab and biomech, as standing, lift up one leg and feel rot relative to innominate, look other side stab needs to happen when on one leg/transfer force, what are ms doing

· WB leg requires form closure · NWB and the transfer of weight requires force · in order to stand on one leg you have form and force closure to help stabilize · gillet - looks at stabilize and biomechanics · as standing, lift up one leg and feel rotation relative to innominate · look at other side - stability that needs to happen when on one leg/transfer of force - what are the ms doing?

Active SLR - motor control, lift leg up, get shearing if hyper or unstable cause pain - get belt pelvic stab and passive stab as well as ms stab - press in and inc form closure SLR, or curl up get abd ms active, hold lift leg force closure, then decide which one dec pain and guides tx, belt or ms strength

· motor control, lift leg up · get shearing with this if hypermobile or unstable - this will cause pain · get belt for pelvic stability and passive stability as well as ms stab · press in and increase form closure with SLR · or curl up get the abd ms active, hold then lift leg - force closure · then decide which one dec pain and guides tx - belt or ms strength

Long Sitting - sup to sit test, pt lay down look med mal - one further than other think leg length, true or apparent - true med mal ischial tub will cause shearing SI fix if greater than 2 cm, not SIJ leg length problem - apparent if pelvis stuck ant rotated position which makes leg shorter - sit to sup, ant rot, will see leg length change regardless if ant or post stuck position

· supine to sit test - having pt lay down, look at med mal · if see one further than other, think leg length - test true or apparent · true - med mal to ischial tub then will cause shearing SI (fix if greater than 2 cm) · not SIJ this is a leg length problem · apparent - if pelvis is stuck in anterior rotated position - makes leg shorter · when do sit to supine - put them in anterior rotated, will see leg length change regardless if in anterior or posterior stuck position