Medication

Medications can be very helpful in modifying pain. Choosing a medication involves selecting a medication specific for the problem. For example, the patient with recent trauma that appears to involve the intra-articular and/or periarticular sacroiliac joint related will likely respond well to consistent antiinflammatory medication usage for a set period of time. Conversely, the patient with insidious onset of posterior pelvic pain present for several months may not respond to the same medication. Therefore, the medication should be tailored to the presumed type of pain. Myofascial pain often responds well to tricyclic antidepressants or similar agents such as trazodone and cyclobenzaprine. Antiinflammatories may be helpful and should be tried, but should likewise be discontinued if no added benefit is achieved. Pain that appears to have a neurogenic component can be treated with antiinflammatories in the acute and subacute phases of treatment. Other medications specific for neurogenic pain again include the tricyclic antidepressants, and similar agents including trazodone and cyclobenzaprine. A variety of adjuvant analgesics such as an antiepileptic medication be helpful. These agents have various side effects such as dizziness and sedation that can impair function. Also, some of these medications require monitoring. The complexity of risk–benefit issues need to be taken into consideration when choosing the agent to prescribe. Narcotics and related medications such as tramadol can be helpful in reducing moderate to severe pain, but again, only for a defined duration. The physician should keep in mind that pain not responding well to a narcotic may not need more narcotic, but another agent to address the type of pain. Neurogenic pain commonly does not respond entirely to narcotic medication and an agent that addresses neurogenic pain used with the narcotic may produce more satisfactory pain reduction.

Manual therapy

Manual therapies can be used separately or in combination with other pain-reducing modalities. In fact, evidence suggests that decreasing musculoskeletal pain may be one of the most important roles for manual therapy.^1,2 In several studies, manual therapy has been shown to be superior to traditional modalities in reducing pain, sometimes even in the absence of change to objective variables, such as range of motion.^3,4 Accordingly, the authors believe it is important to consider manual therapy as a tool to reduce pain, and to pair it with rehabilitative strategies, such as stabilization exercise, to restore function. Unfortunately, there is a paucity of studies substantiating this position; however, the authors’ collective experiences suggest that this form of treatment can be beneficial.

Due to the range of treatments that may be necessary for complete resolution of symptoms, the authors recommend a collaborative approach to care. It is currently recognized that a chiropractor or osteopath will have a better background in manual therapy and a physical therapist or athletic trainer will be more qualified in exercise. However, it is important to recruit and work with practitioners based on their knowledge and skill, and not merely their degrees. Obviously, a practitioner who has abilities and knowledge across a broad range of modalities and therapeutic interventions can be very beneficial.

Therapeutic rehabilitation

Once pain has been reduced, participation in a therapeutic rehabilitation program will be more successful. There are many different approaches to a therapeutic program. The authors recommend considering multiple treatment theories and combining types of care according to the individual patient’s needs. This type of comprehensive approach is becoming more popular and will compress the timeline to return to function.

There is a vast array of physical therapy approaches to treatment of posterior pelvic pain. One theory proposed by Sahrmann^5,6 seeks resolution in symptoms by correcting muscle and joint dysfunction based on specific muscle(s) activation. This theory relies on conscious correction of motor patterns and avoiding activities that promote pain and/or poor movement patterns. A person treated for acute posterior pelvic pain utilizing this treatment method might be instructed to use crutches so as to not develop or enhance a poor gait pattern. In contrast, other theories of treatment develop recommendations based on gross movement patterns. An example is McKenzie’s theory of systematic treatment for spine dysfunctions.⁷ Treatment applied is based on specific movement patterns related to spine pathology. A spine stabilization program attempts to combine therapeutic exercises based on deficiencies in spine, abdominal, and hip muscle length and strength. This method also relies on conscious overriding of poor movement patterns. At times, deciding what is acceptable and unacceptable pain while performing exercises in the latter two treatment groups can be difficult for the patient. Another theory proposed by Gray⁸ recommends using multiple joint movement patterns to improve function but relies on unconscious retraining of movement. The movement patterns are directed either into the restrictive range of movement or away from the restriction. Movement pattern direction is determined by the patient’s pain tolerance. If moving towards the restrictive movement is too painful, applying joint motion, loading, and unloading in the movement pattern and plane tolerated is suggested. As the motion and pain improves, the direction and combination of planes of motion advances. Gray’s approach also incorporates the pelvic floor musculature, an area often omitted from traditional programs. The pelvic floor and diaphragm are thought to play an important role in core or trunk stability. This theory is somewhat ahead of current research validation, but is a growing area of interest in some centers. In general, Gray’s approach to treatment focuses on developing a therapeutic exercise program to resemble the patient’s functional activity requirements.

Regardless of what method or combination of methods are used, rehabilitation for posterior pelvic pain must incorporate spine, hip, and pelvic structures and mechanics. Pool-Goudzwaard et al.⁹ and Vleeming et al.¹⁰ have described the importance of the muscle and connective tissue network that assists in the stability of the lumbopelvis and specifically the sacroiliac joint. They have demonstrated through dissection and biomechanical modeling that there is a direct relationship between the tensioning of the dorsal sacral ligament, sacrotuberous ligament, erector spinae muscles, hamstrings, and the movement of the SIJ.¹¹ Additionally, the iliopsoas commonly works in a shortened position. This shortened position can enhance the development of an anteriorly rotated ilium (Fig. 115.1). Hamstring strengthening cannot be accomplished until the iliopsoas is restored to activating in a biomechanically efficient length. An anterior pelvic tilt forces the hamstring to work in a lengthened position. The hamstring is a key muscle in providing stability to the sacroiliac joint because of its direct attachment and/or fascial connections to the sacrotuberous ligament. Other muscles commonly found to be working in a shortened position include the rectus femoris, tensor fascia lata, adductors, quadratus lumborum, latissimus dorsi,¹² and obturator internus. Achieving appropriate muscle flexibility may take weeks to achieve. The authors advocate utilizing a stretching program that encompasses all three planes of motion. As muscle length is restored and stiffness reduced, strengthening of muscles inhibited by the biomechanical deficit can be completed. Neuromuscular re-education and facilitation techniques are helpful with this process. Closed kinetic chain strengthening should be attempted first and can then be incorporated into the lumbopelvic stabilization exercises. As trunk strengthening improves, adding multiplanar strengthening exercises will facilitate return to functional activities. Muscles commonly found to be weak include the gluteus medius, gluteus maximus, lower abdominals, and hamstrings. These are merely suggestions that are based on the authors’ experience with respect to muscle patterns of movement proposed by Janda,^13,14 and Norris.^15,16 As Norris points out,¹⁶ these ‘muscle imbalance categorization can usefully assist the astute practitioner, they are not cast in stone.’ Each patient presents with a unique set of circumstances with regards to pain, muscle imbalance, and joint mechanics. The healthcare practitioner must take the patient’s individual set of problems, strengths, and goals into account when creating a treatment program.

Fig. 115.1 (A) An anterior view of an anteriorly and (B) posteriorly rotated ilium. This view illustrates the changes that occur at the pubic symphysis and the hip as a result of a change in position of the ilium.

Manipulation is commonly used to treat posterior pelvic pain related to the sacroiliac joint. Manipulation is a term that may have several definitions. For the sake of discussion in this chapter it will refer to manipulation as treatment that involves manual techniques that restore joint motion. An explanation of the barrier systems utilized to direct manual therapy is useful in understanding the different approaches of manual medicine. The absolute end range of motion within any single plane of motion is referred to as the anatomic barrier (Fig. 115.2). Motion that goes beyond this barrier results in fracture, dislocation, or ligamentous or tendon tear. Within the total range of motion of any joint there are different limits to active and passive range. Active range of motion is limited by a physiological barrier. This barrier is maintained by muscle, ligament, tendon, and capsule. With passive range of motion, increased motion is obtained to the elastic barrier. Again, this barrier is maintained by the previously mentioned soft tissue structures, but at their endpoint of elasticity or length. A restrictive barrier forms as a result of a biomechanical dysfunction. This barrier reduces the active range of motion and increases the space between available active range of motion and the elastic barrier. A restrictive barrier is created by skin, fascia, long and short muscles, ligament, tendon, and joint capsules. Regardless of the specific type of manipulation used, the goal is to move the restrictive barrier back toward the elastic barrier. There are many techniques that can be used to achieve this goal. The choice of technique is examiner dependent as well as dependent on what is thought to be causing the restriction(s).

Fig. 115.2 Illustration of barriers enhances understanding of the basis of the theory of manipulation.

There are many different techniques used to manipulate a joint to restore motion. Strain–counterstrain developed by Jones,¹⁷ an osteopathic physician, is a technique where the healthcare provider palpates for tender points within the restricted area. There are many theories regarding the location and significance of trigger points. Overlap in location is noted in the trigger points identified as Travell’s myofascial trigger points,¹⁸ Chapman’s reflex points,¹⁷ and acupuncture. Strain–counterstrain utilizes any or all of these identified trigger points to assess and treat the patient. The treatment consists of the examiner monitoring the trigger point while passively positioning the patient until the pain is relieved at the trigger point. Once this position of relief is determined, it is maintained for 90 seconds. The examiner then passively repositions the patient back to a neutral position. In general, the position of comfort is found in the direction away from the restrictive barrier. Pain relief is thought to occur by reducing the inappropriate proprioceptor activity. The inappropriate strain reflex in the painful muscle is inhibited by stretching (counterstrain) the antagonist muscle. This technique is especially helpful to reduce pain related to muscle tone when more active intervention is painful.

Muscle energy techniques were first described in osteopathic medicine in the 1960s by physicians T.J. Ruddy and Fred Mitchell, Snr.¹⁹ More recently, further expansion has been made by Karel Lewitt and Vladimir Janda. The basic principle involves the healthcare provider passively placing a joint in the position away form the restrictive barrier and the patient then performs an isometric contraction against the force of the healthcare provider. After completing the contraction, the healthcare provider stretches the soft tissues to allow the joint to move through the restrictive barrier. This method of treatment applies both passive positioning and muscle activation to move through a barrier. Lewitt²⁰ has modified this approach and termed it postisometric relaxation (PIR). Importantly, PIR emphasizes a light contraction of the muscle and does not engage the stretch reflex. The procedure is very gentle and usually very comfortable. The doctor identifies the muscle that is overactive and takes the muscle to pathological barrier of functional resistance. The doctor will then ask the patient to lightly contract the muscle being lengthened for approximately 3–5 seconds. After the light contraction, the patient is asked to relax. With relaxation the doctor lengthens the muscle to a comfortable, improved length. This is typically repeated 3–4 times.

This approach is particularly beneficial for the acute and subacute patient. The contract relax method of treatment is commonly used by physical therapists and is similar to muscle energy. Patient positioning and isometric contraction are the same, but the examiner’s goal is to improve range of motion to the restrictive barrier while muscle energy attempts to obtain range through the restrictive barrier.

Active release therapy (ART) is a (patented) technique used to treat soft tissue problems involving muscles, tendons, ligaments, and nerves. ART is a method of soft tissue mobilization which lengthens hypertrophied or shortened muscles, tendons, ligaments, and connective tissue.²¹ Preliminary studies with ART have produced encouraging results with a variety of musculoskeletal conditions.²² Once the practitioner has identified the area of tension or adhesion of tissue, a firm manual contact is applied with the thumb or finger to the area of soft tissue pathology. The practitioner will then shorten the muscle or tissues being treated. While maintaining specific opposition on the area of identified tension or fibrosis, the practitioner will ask the patient to lengthen the muscle and release and/or break up the restrictive tissue. This often promotes better inter- and intramuscular gliding and can improve muscle activation. In cases of posterior pelvic pain, ART can help restore movement for the pelvis by addressing dorsal sacral ligament, sacrotuberous ligament, and hamstrings. This may also be applied to conditions of nerve entrapment by muscles or fascia. Common entrapment sites for posterior pelvic pain include sciatic, gluteal, or lateral femoral cutaneous nerve locations.

High-velocity low-amplitude (HVLA) manipulation is the technique often associated with the term ‘manipulation.’ Evidence and international guidelines identifying the efficacy of this type of manipulation for low back pain have flourished since 1986.^23–27 This type of manipulation is the form most commonly used by chiropractors. With this technique the patient is moved passively to the restrictive barrier and the examiner then applies an extrinsic force (quick thrust) to move the joint through the restrictive barrier.²⁸ Optimally, one joint is mobilized at a time and restoration of motion at that joint is achieved. The thrust is thought to gap the joint and the gapping is thought to cause the audible pop. While the effects of thrust manipulation remain poorly understood, evidence suggests that the impact is largely a central neurological mechanism.²⁹ Zhu et al.³⁰ demonstrated that decreased pain response after lumbar manipulation was associated with abnormal somatosensory-evoked potentials from paraspinal patients with low back pain. Lehman and McGill,³¹ in their preliminary investigation, suggested that manipulation could attenuate the muscular response that directly inhibits pain. Suter et al.³² studied the effects of SIJ manipulation on the inhibitory effect of the quadriceps muscle in knee joint pathology. They showed an interaction between manipulation and inhibition of voluntary activity produced by pain.

Joint mobilization is a general term coined by physical therapy which is similar in theory to HVLA with one exception. While the goal of HVLA is to move through the restrictive barrier, joint mobilization involves applying grades of pressure to improve motion up to the restrictive barrier but not through it. Lewitt,²⁰ a Czech neurologist, describes several approaches to this type of mobilization for the SIJ. This can include engaging the barrier of resistance and holding or rhythmically springing the barrier.

The risk surrounding HVLA for the lower back is often perceived high although it is actually relatively low. Shelkelle³³ estimated the serious complication rate for lumbar manipulation at 1 in 100 million manipulations. Haldeman³⁴ revealed that 16 of the 26 cases reported to have complications between 1911 and 1989 had been performed with anesthesia. Therefore, manipulation under anesthesia should be applied with caution.

Absolute contraindications to use of manipulation include joint hypermobility and instability, and the presence of inflammatory joint disease, or cauda equina syndrome. Relative contraindications include bone tumors, metabolic bone disease, primary joint disease, congenital or acquired fixed deformities, and vertebral basilar artery insufficiency. Disc herniation and severe spondylosis would also fall in the category of relative contraindications. In these cases with stable neurological findings, manipulation can often facilitate a window of recovery and restoration.

Manipulation used for posterior pelvic pain may include any one or combination of the aforementioned techniques. Choosing which to use is usually determined by the practitioner’s skill, experience, and training. When addressing asymmetries in the pelvis, a technique using muscle activation (ART, muscle energy, contract–relax) is often helpful. Utilizing the muscle activation is helpful as the muscles around the hip and pelvis are large, powerful, and have different functions depending on positioning of the hip. Repositioning can continue until all planes of motion have been addressed. The natural follow-up to the muscle activation treatment is a muscle flexibility and strengthening home exercise program that mimics the manipulation. For example, after a muscle energy technique is applied to reverse a unilateral anterior iliac rotation, the patient should be educated how to perform an iliopsoas stretch encompassing three planes (frontal, sagittal, transverse) of motion (Fig. 115.3). The home exercise program can then facilitate maintaining the improvements made with manipulation. A HVLA treatment might be chosen when muscle activation techniques have failed to provide consistent improvement. There are several sacral thrust maneuvers (Fig. 115.4). In general, a thrust is applied to the sacrum, but is directed in the plane of restriction. The theory is that the applied force will allow a return of improved motion to the joint. Again, the home exercise program should be created to enhance the benefits of the manipulation. For example, the patient who benefits from a sacral thrust performed distally, thereby freeing a unilateral posterior iliac rotation, will likely benefit from a hamstring stretch as part of the home exercise program.

Fig. 115.3 Example of an iliopsoas stretch that includes three planes of motion: sagittal (hip lunge), frontal (sidebending lumbar spine), and transverse (rotation of the hip) planes.

Fig. 115.4 One example of a HVLA sacral thrust performed for a diagnosed posterior sacral base dysfunction. The patient extends in a prone position by rising up on elbows. The practitioner places the heel of one hand on lumbosacral junction. The other hand is placed on the lower extremity to stabilize. Pressure is applied on the sacral base until the restrictive barrier is felt. As the patient exhales, the practitioner applies a short thrust anterior.

Commonly, a practitioner will combine a variety of types of manipulative treatment. Strain–counterstrain or myofascial release might first be used to reduce pain and improve soft tissue elasticity prior to performing a technique involving muscle activation or a thrust. Some practitioner’s skills may lie predominantly with HVLA treatments while others might only use muscle activation treatments. The right combination is the one the practitioner is most skilled at using and allows for maximal patient safety.

Adjunct therapy

SIJ belts are often offered as part of the treatment plan for posterior pelvic pain. The belts are used to provide compression to the pelvis (Fig. 115.5). This is particularly helpful in patients with hypermobility at the joint and/or significant muscle weakness. In addition to compression, proprioceptive feedback to the gluteal muscles can assist with neuromuscular re-education. Vleeming³⁵ reported that SIJ belts applied to cadaver models reduced SIJ rotation by 30%. In the clinical setting, Vleeming demonstrated that by stabilizing the ilium, the belts assist with improving hip flexion active range of motion. The healthcare provider must insure that the patient is able to apply the belt appropriately. The SIJ belt should be secured posteriorly across the sacral base and anteriorly, inferior to the anterior superior iliac spines. SIJ belts can dramatically reduce symptoms during walking and standing activities. However, patients with significant pain and weakness may find the belt helpful in reducing symptoms when worn during sedentary activities as well. Recommendations regarding the use of SIJ belts should be individualized, based on the patient’s history and activity goals.

Fig. 115.5 Sacroiliac joint belt is worn just below the anterior superior iliac spine.

Other adjunct treatment considerations include orthotics and shoe modifications. If a leg length discrepancy is noted on physical examination, the examiner should determine if it is a functional or anatomical discrepancy. A shoe lift to correct a functional leg length discrepancy can be helpful in the acute setting to manage pain with weight bearing or ambulating. After the pain with weight bearing has improved, the healthcare provider should determine if the shoe lift should continue to be used. The goal should be to reduce or resolve the functional leg length discrepancy via the therapeutic rehabilitation program. There is some recent evidence that footwear modifications can have systemic effects.³⁶ An inappropriate shoe lift can promote adaptive muscle imbalances, which may initially be asymptomatic. Over time, these changes in force transmission and absorption across the pelvis may become symptomatic. Anatomical leg length discrepancies should be determined as early in treatment as possible so that the appropriate modifications can be completed.

SIJ injections can be used as an adjunct to a physical therapy program if the patient’s progress plateaus or the program cannot be advanced because of pain provocation. The injections can also be used diagnostically if done under fluoroscopic guidance. Maigne³⁷ reported 18.5% of 54 patients diagnosed with SIJ pain responded to double SIJ block under fluoroscopic guidance. This study did not control for other treatments given and therefore accurately reports only what an injection alone can improve. Slipman et al. analyzed a cohort of 31 patients who underwent therapeutic SIJ intra-articular injection.³⁸ A minimum follow-up interval of 12 months was used. They found statistically and clinically significant improvement in visual analog scale (VAS) ratings and Oswestry scores. The average VAS rating reduction was in excess of 30 (out of 100). Luukkainen and colleagues³⁹ reported improved visual analog scale and pain index scores at 1 month after a periarticular SIJ steroid injection. This study included 13 patients who received steroid compared to 11 who received saline and lidocaine. The injections were performed by palpation over the painful site at the SIJ region and no control was made for other treatments. In another study, 10 of 12 patients who underwent SIJ steroid injection via MRI guidance reported an improved VAS at 3-month follow-up.⁴⁰ Again, no control or standardization of other conservative treatment was completed. Though study numbers at this time are small, there is evidence to suggest that SIJ injections should be used as an adjunct treatment in pain management.

Recently, studies have reported improvement in chronic SIJ pain treated with radiofrequency ablation (RFA). Ferrante and associates⁴¹ reported a 50% reduction in VAS reports for at least 6 months in 33 patients. The authors noted that a positive response to treatment was associated with an atraumatic inciting event, reduction in the area of referred pain on the pain diagram, normalization of SIJ pain provocation tests, and reduction in opioid use with radiofrequency denervations. Although the Ferrante study suggests that RFA was achieved, this conclusion is suspect. The technique used simply entailed placing three probes into the joint. It is more likely that osseous and/or cartilaginous injury resulted from the local heating effect rather than a denervation procedure. Yin and colleagues⁴² reported a retrospective review of 14 patients who underwent sensory stimulation-guided sacral lateral branch radiofrequency neurotomy for treatment of chronic SIJ pain. Sixty-four percent experienced consistent relief in pain with a 50% reduction in visual integer pain score 6 months after the procedure. Included in these successful outcomes were 36% who had complete relief in their symptoms. In another study, Cohen⁴³ reported choosing radiofrequency ablation candidates for chronic SIJ pain by performing diagnostic blocks at the levels innervating the SIJ (L4–5 dorsal rami and S1–3 lateral branches). Thirteen of 18 patients reported significant relief with nine reporting greater than 50% relief at follow-up. These nine underwent radiofrequency ablation of all branches previously blocked. Eight out of nine (89%) obtained 50% or greater pain relief that continued at 9-month follow-up.

Using the same basic theories behind radiofrequency ablation, Calvillo et al.⁴⁴ reported two cases of chronic SIJ pain treated by implanting a neuroprosthesis at the third sacral root. The authors reported that the patients continued to use analgesics before and after the procedure, but the patients reported that their activities of daily living were ‘more tolerable.’ These procedures appear to have some promise in the treatment of chronic SIJ pain. More studies are needed to determine long-term outcomes and determine which patients might be good candidates.

SIJ hypermobility unresponsive to the above-outlined program is a difficult problem. SIJ arthrodesis⁴⁵ and percutaneous fixation⁴⁶ have been utilized for instability. Long-term outcome studies thus far have not been completed and it is unknown what happens to surrounding articulations with the lumbar spine, contralateral SIJ, and hip years after SIJ fusion. Other therapies such as prolotherapy have been proposed as an invasive but less permanent option. Prolotherapy is described as the provocation of the laying down of an increased volume of normal collagen material in ligament, tendon, or fascia in order to restore function of the tissue at a specific site.⁴⁷ Provocation is achieved by provoking an inflammatory response at the location. A wide variety of agents have been used to provoke local inflammation, including high-concentration glucose solutions to phenol alcohol. Often it is a combination of agents. Though the safety⁴⁸ and clinical outcomes have been reported,⁴⁹ no prospective, controlled studies exist to date on the specific use of prolotherapy and SIJ dysfunction.

Acute phase of treatment for a traumatic injury (1–3 days)

Acute injury is often associated with a direct trauma such as a fall or marked increase in intensity, frequency, or duration of a specific activity. Often, sacroiliac joint pain presents as a progressive problem with fluctuations in symptoms. The patient may only experience symptoms during certain activities, including sports or exercise. In the acute setting, antiinflammatory medications and icing are helpful. Relative rest after an acute injury assists with pain management. This includes restricting running or excessive walking as these activities often provoke sacroiliac joint pain. Identifying the activity that may aggravate symptoms is important, especially in those with a progressive onset of symptoms. In general, avoiding activities that require a single-leg stance (activities such as bowling, skating, running, elliptical trainer, and stair stepper) is helpful in alleviating symptoms. In the acute setting, a shoe lift might be used temporarily to help reduce pain associated with weight bearing when a functional leg length discrepancy is present. As pain improves and the leg length discrepancy resolves, the lift can be removed. An SIJ belt may be helpful, especially in patients who complain of clicking or the sense of instability. Many patients find that the belts help reduce pain, especially with walking and standing. Correcting asymmetries in muscle length or stiffness should start as soon as possible and progressed within pain-free limits. Muscle energy techniques are particularly helpful as they require patient activation of muscle groups, and therefore pain tolerance is easily monitored. Joint mobilization and HVLA can be very effective at this stage. Importantly, the ilium or sacroiliac joint opposite the site of pain and inflammation is most commonly the restricted complex. Therefore, joint mobilization and/or manipulation to the side opposite to the pain is indicated and a general guideline for manual therapy. A home stretching and/or self-mobilization program should reinforce the manual techniques used to correct the SIJ dysfunction.

Recovery phase (3 days to 8 weeks)

Once pain has been controlled and the injured area has been rested, correction of the functional biomechanical deficit and tissue overload complex⁵⁰ becomes the focus of rehabilitation. Balancing lower extremity muscle length and strength is important because of direct and indirect force transmission across the ilium and sacrum. Muscle length must be restored to facilitate appropriate joint mechanics at the hip, SIJ, and spine. Again, in this phase of treatment muscle energy and active release techniques are often successful in reducing pain as well as restoring functional motion. In cases where the above techniques have been partially successful or unsuccessful at relieving pain and improving motion, HVLA or mobilization techniques may be helpful. The home exercise program should include self-mobilization exercises to insure carry-over of the manually applied treatment. Once the mobilization has been successful the focus of treatment should turn to maintaining muscle length while improving muscle strength and endurance. Maintaining muscle flexibility with exercises that address all three planes of motion will also reinforce improvements made with the manual techniques. Medications during this time should include nonsteroidal antiinflammatory medications. These medications should be initiated with consistent daily dosage and then weaned as needed and eventually discontinued. If sleep is a problem due to pain, taking advantage of the sedating side effect of muscle relaxers may be helpful by prescribing them for nighttime use. Narcotics and medicines such as tramadol, may be useful but in a limited setting. The goal is to minimize their use. If improvements are plateauing or limited by pain, a therapeutic SIJ steroid injection may be useful with regard to treatment, and a positive response makes one feel more comfortable about the diagnosis. The authors recommend these injections be performed with fluoroscopic guidance to insure accuracy of placement and reduce complications caused by misplacement. The patient should be made aware that the injection is an adjunct treatment utilized to facilitate the progress of physical therapy. As pain improves, the exercise prescription should advance. Muscle flexibility and strengthening exercises should progress to weight bearing, utilizing all three planes of motion. As this improves, the home program should start to incorporate or mimic functional, exercise, or sport-specific activities. Return to unrestricted activities or exercise occurs once the patient is pain free, range of motion and strength have been restored, the patient has demonstrated good technique with activities, and has returned to or initiated an aerobic training program. Education with regards to the importance of a maintenance program should be completed prior to discharge.

Treatment for a nontraumatic injury (1–3 days)

The treatment course of a nontraumatic injury should progress similarly to that of a traumatic injury. Initially, the etiology of the problem may not be clear or identified and, as a result, a period of trial and error can often ensue. For example, if the patient began with a segmental restriction at L5–S1 and continues to have posterior pelvic pain that is responding only in part to therapy directed at the SIJ, the restriction at L5–S1 may need to be addressed before further progress can be made. Again, the L5–S1 restriction can be treated with a variety of therapeutic interventions including joint mobilization, manipulation, muscle energy, and contract–relax. Care must be taken to resolve neurogenic pain symptoms. This can be addressed via medications, neuromobilization, and injections. Recurrent or continuous neurogenic pain can inhibit progress being made with muscle flexibility and strength. Clearing hip dysfunction can also be a key factor in progressing a treatment program for posterior pelvic pain. Godges and colleagues⁵¹ described this scenario in a case report of a 74-year-old female with posterior pelvic pain thought to be related to the SIJ. They presented a detailed description of successive physical examinations and physical therapy sessions. The iliac and sacral restrictions resolved within a few sessions of combined manual techniques, neuromuscular re-education, and muscle flexibility and strengthening exercises. Despite these improvements, the patient continued to have pain and activity limitations. Further progress was made once the range of motion (ROM) of the hip on the symptomatic side improved to becoming more symmetrical with the ROM on the asymptomatic side. Adjunct treatments should be instituted in the nontraumatic patient in similar fashion as the traumatic patient. Again, care should be taken to look for areas of dysfunction away from the SIJ if the patient requires prolonged use of medications, or repeated injections. Repetitive manipulation to the SIJ can have long-term side effects of joint hypermobility. Freeing restrictions at the spine and pelvis can be vital in making SIJ manual therapy successful.

Special populations

Pregnancy

Studies have suggested that between 50–80% of women suffer from low back pain and/or posterior pelvic pain (LBP/PPP) during pregnancy.^52–61 Ostgaard and Roos-Hansson⁶² demonstrated that during pregnancy pain is more commonly attributed to posterior pelvic pain and postpartum is more commonly occurring from dysfunctions within the lumbar spine.⁶³ Of 119 women with pain for more than 2 months postpartum, 27% were thought to have posterior pelvic pain, 18% lumbar spine pain, 39% posterior pelvic and lumbar pain, and in 16% no pain could be provoked on physical examination. Understanding these different etiologies can better direct treatment plans.

Treatment for posterior pelvic pain during pregnancy should progress similar to that in the nonpregnant population. Exceptions include the care that should be taken in both examining and applying manual therapy treatments in the pregnant population. Ligamentous laxity promotes joint hypermobility. Overzealous ROM or manipulation can provoke both further pain and dysfunction in this population. On the other hand, SIJ belts can be exceptionally helpful in reducing pain by providing proprioceptive feedback and compression to the gluteal muscles that help provide joint stability. Stabilization exercises should be promoted with care and not all activities should be performed in the supine position. The home exercise program will need to be adjusted as the abdominal girth increases. Instead of lengthening the lever arm with strengthening exercises, it may need to be reduced to adjust for biomechanical inefficiencies. Education is key with regards to activities of daily living, ergonomics of lifting (Fig. 115.6), and position choices during labor when possible. For example, laboring in a side-lying position with the hip in full flexion, abduction and external rotation may further provoke posterior pelvic pain that began during pregnancy.

Fig. 115.6 Review of lifting techniques is important in treating women with low back pain during pregnancy and postpartum. (A) The mother is demonstrating an inappropriate technique of lifting that increases forces to the lumbar spine. (B) The mother demonstrates an appropriate technique to maximize utilization of hip musculature during lifting, allowing the abdominal and gluteal muscles to brace and thereby reduce the risk of sheer forces applied to the lumbar spine.

Noren et al.,⁶⁴ in their study using an education and physiotherapy intervention, calculated a cost savings of US$53 000 for reducing LBP/PPP in pregnancy in 30 women. Education for LBP/PPP in pregnancy has also been studied and proven helpful in reducing the common chronicity seen with these patients.^35,61,62,65 These studies all suggest early advice for best results.

The authors’ preliminary studies also suggest an important role for assessing and treating the muscles and ligaments of the spine and pelvis in pregnancy-related LBP/PPP.⁶⁸ While several exercise-directed interventions have been proposed for soft tissue dysfunction in pregnancy-related LBP/PPP,^67–72 very little has been studied regarding manual soft tissue intervention.^73,74

The procedures the authors utilize most are the muscle energy and ART. While both address muscles, ligaments, tendons, and connective tissue, they are clinically different from traditional massage. PIR is a method of soft tissue mobilization which lengthens shortened muscles that are hypertonic or contain trigger points.²⁰

A few studies on LBP in pregnancy have included manipulation and mobilization in their treatment protocols with encouraging preliminary results.^60,75–77 McIntyre and Broadhurst⁷⁵ and Daly and Rapoza⁷⁶ showed a 90% success rate in reducing pain in women with pregnancy-related LBP by using thrust manipulation for sacroiliac dysfunction. Berg et al.⁶⁰ found 70% improvement in women with severe LBP in pregnancy who received specific SIJ mobilization. In a retrospective review, Daikow provided evidence of an 84% success rate in reducing back pain during pregnancy and back labor through manipulation.⁷⁶ The goal with these procedures is to reduce tension or restricted movement in the pain-generating structures, thereby decreasing the patient’s pain and assisting self-care strategies of activity modification, stretching, and exercise.