Saturday, March 29, 2008

SIJ Motion: I still can't feel anything
Early in my PT career, I thought I had the hands of a guerrilla. No condition made me feel more like a primate than during my evaluation and assessment of sacroiliac dysfunction. We must have spent 4-6 weeks in school studying motion and palpation tests for the SI joint and I really felt I had it down.

After a few weeks of practicing and seeing a ton of spine cases at the clinic I was working, I had an epiphany: What would happen if these tests were found to have little evidence supporting their utility? Would I change my approach? What are the alternative explanations for the patient's presentation?

Suddenly I felt a pretty anxious feeling that maybe this fear shouldn't be confined to the SI joint. What if other things I was taught in PT school were out of phase with best evidence? Did that mean I should be bitter and demand my money back because everything my instructors told me wasn't pure unbiased fact? I'll get back to these questions in a moment...

Today's investigation is recently published in the Journal of Manual and Manipulative Therapy on the clinical utility of studying SIJ motion. The systematic review explores the clinical utility of static and dynamic motion palpation testing for the SIJ. After reviewing seven articles that met the inclusion criteria for the review, the authors found the following ranges of movement at the SIJ.

Rotational motion:

  • Motion along the X axis ranged from -1.1 to 2.0 degrees
  • Motion along the Y axis ranged from -0.8 to 4.0 degrees
  • Motion along the Z axis ranged from -0.5 to 8.0 degrees

Translational motion:

  • Translational movement along the X axis ranged from -0.3 to 8.0 mm
  • Translational movement along the Y axis ranged from -0.2 to 7.0 mm
  • Translational movement along the Z axis ranged from -0.3 to 6.0 mm

The authors conclude motion and palpation testing for SIJ motion indeed may have very limited clinical utility. While not the first investigation into the utility of this type of assessment, it builds greater strength to the notion we should continually reevaluate our understanding of what it is we are assessing and treating in our patients.

Back to my earlier questions. The answers to these questions are simple. We should always be willing to at least consider changing our approaches to a clinical problem when faced with strong evidence to do so. To some, this statement may seem a plea toward a robotic 2-D approach to clinical problem solving. Believe me it isn't. True evidence based practitioners attempt to reconcile their clinical intuition with the best available evidence. Often we find this process of reconciliation difficult, but we chose this profession and all the benefits it provides us.

We must be willing to subject to the hopper of the scientific method and see what comes out of it. If we do this regularly, the process becomes less laborious and more invigorating. The end results are victories on at least a few fronts. Our patients get better outcomes and our profession grows stronger.

As far as being bitter about being taught SIJ motion testing in school in spite of overwhelming and opposing evidence? Keep in mind our instructors are there to open the door for us to learn. The responsibility is ours, not theirs, to guide our own decision making in the clinic. Keep this in mind and you will never stop learning! Have a great weekend.

Goode, A., Hegedus, E.J., Sizer, P., Brismee, J., Linberg, A., Cook, C.E. (2008). Three-dimensional Movements of the Sacroiliac Joint: A Systematic Review of the Literature and Assessment of Clinical Utility. Journal of Manual & Manipulative Therapy, 16(1), 25-38.

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