Challenges facing doctor and patient in treating Sacroiliac Joint Dysfunction planning big surgeries that may not be the correct surgery
POSITIVE TEST: Positive likelihood ratio: , 95 confidence interval: [,] Posterior probability (odds): 59 (1.4) 95 confidence interval: [42,74]
Challenges facing doctor and patient in treating Sacroiliac Joint
Dysfunction
planning big surgeries that may not be the correct surgery
Figure Figure77 presents Fagan's nomogram using data from Laslett et al52 in which three or more positive SIJ tests are considered positive for SIJ pain without consideration of the centralization phenomenon. The likelihood ratio for a positive test (three or more SIJ tests provoke the patient's familiar pain) is so the probability of SIJ pain more than doubles from 26 to 59. The likelihood ratio of a negative test is yielding a post-test probability of 4. Sacroiliac joint dysfunction tests include discussing your history and pain experience, a physical examination, tests to rule out other sources of pain, like lumbar spine pain and hip pain, and these commonly accepted methods: Symptoms that suggest that the sacroiliac joint (SIJ), as opposed to the problems of the lumbar spine or hip, include: Based on recent research, the IASP criteria have been superseded for a variety of reasons. Diagnostic injections must be performed under image intensifier control because blind injections rarely succeed in placing injectate within the SIJ cavity46,47.
Sacroiliac Joint Injection: Another Test for SI Joint Pain
The tested leg remains above the opposite leg, indicating the dysfunction around the affected side hip joint or SI joint or muscles around the hip joint (iliopsoas spasm). A test with high sensitivity and low specificity cannot be used to make a diagnosis because of the high proportion of cases with positive tests but negative to the reference standard; i. e. , there is a high false positive rate. A test with high specificity and low sensitivity is useful in making the diagnosis, but a large proportion of cases positive to the reference standard will have negative tests; i. e. , there is a high false negative rate33,34. Consequently, if making the diagnosis of SIJ dysfunction is the objective, tests for dysfunction need to have high specificity with respect to an acceptable reference standard. Here is a paper from March 2020 in the Journal of Brachial Plexus and Peripheral Nerve Injury (3). Lets see if you find something familiar in what these doctors from University Hospital in Basel, Switzerland, and Johns Hopkins University are saying about the misdiagnosis of your problems. Dear Dr. Whelton, .
. . Just wanted to let you know that I got two results with your SI joint protocol so far. One patient recovered in 4 weeks (to be discharged this week)! As for the second patient, he is pain-free in a little over 2 weeks. Both men were doing the exercises like a religion and never skipped a day. I have another one now at the stage of having good and bad days, an indication that the protocol is working. Prior to this, she used to have to eat breakfast standing for the greater part of the past 6 word got out to my other patients and I have been crazy busy! Thanks for sharing this knowledge on behalf of my patients as well!. . . E John (June 2020) If one of these tests determines you have SI joint dysfunction, then you should know that there are multiple ways to treat this conditionfrom physical therapy to exercise. An August 2019 paper in the PM & R: the journal of injury, function, and rehabilitation, (6) noted how complex a diagnosis of sacroiliac joint dysfunction is. The senior author, Whelton, has appeared to have identified the root cause of SI joint dysfunction as an upslip and/or out-flare of the innominate on the side of pain in 12 patients using the aforementioned tests.
For example, a test with a positive likelihood ratio of 10 indicates that a positive test result is 10 times more likely in patients with the disease in question than in those known to be free of that disease. The likelihood ratio of a negative test describes the test's ability to rule out the disorder for which the test is applied. As the value of a negative likelihood ratio approaches zero, the test's power to rule out the disease in question approaches perfection. Conversely, as the value of the negative likelihood ratio increases towards 1. 0, the test's ability to rule out the disorder approaches random chance79. When both the prevalence of the disorder and the results of a test are known, likelihood ratios permit calculation of the change in odds and probability of a disorder being present or absent80. Prior to any examination, the probability of a given disorder being present is its prevalence. For example, if the prevalence of SIJ pain is 1381, its pre-examination probability is . The diagnostic value of a test is reflected by how much the probability of the disorder increases when the test is positive and by how much it falls when it is negative. The diagnostic value of a given test can be depicted using Fagan's nomogram () in which the pretest probability, prevalence, positive and negative likelihood ratios, and post-test probabilities are presented graphically.
The investigation expanded. In a paper from October 2017, the sameJapanese research team publishing in the medical journal Clinical Neurology and Neurosurgery (15)looked to identify the prevalence of groin painin patients withsacroiliac joint dysfunction,lumbar spinal canal stenosis, andlumbar disc herniationwho did not have hip disorders. Before I continue with the research on Prolotherapy for sacroiliac joint dysfunction, I would like to reinforce the argument that we need to shift focus away from the problems of the discs to problems of the ligaments in treatingSacroiliac joint dysfunction. Then, the clinician can perform the Quadrant Test. 2 The Quadrant Test is another common test to confirm SI joint dysfunction. For the Quadrant Test, the patient is in the standing position and asked to perform lumbar extension with side bending to each side.
The research team concluded: Dysfunctional upper sections of the sacroiliac joint are associated with pain in the upper buttock and lower sections with pain in the lower buttock. Groin pain might be referred from the upper SIJ sections. The first thing the doctor may offer you is anti-inflammatory medications, a sacral belt (low spine support brace),and a recommendation to change your activities and/or lifestyle to avoid more stress on the sacroiliac joint. Some doctors may suggest cortisone into the sacroiliac joint and warn the patients of possible cortisone injection side effects. Likelihood ratios are summary statistics derived from sensitivity and specificity values. The likelihood ratio for a positive test is an estimate of the probability of the condition/disease. Random guessing will produce a positive likelihood ratio of 1. 0. Values higher than 1. 0 represent probability better than random chance. The higher the value, the better the test.
Most of the patients had failed several forms of conservative and invasive treatments and some were recommended to have SI joint fusion surgery by their surgeons. Both women and men may report problems of urinary problems, including frequency or urgency. Men will often report erectile dysfunction that is not responsive to traditional erectile dysfunction treatments. Women may report painful sex and other sexual dysfunctions. Interestingly, although the technique used in this study is described as affecting the SI region, it was lumbar hypomobility that entered the prediction model. This finding reinforces the idea that the manipulation technique is not specific to the SI region but impacts the lumbar spine as well90. The authors analyzed the records of 100 consecutive patients from three institutions, who underwent decompressive surgery without instrumentation. The diagnosis of SIJ-related pain was confirmed by periarticular infiltration. The radiological changes of the sacroiliac joint were assessed in plain radiographs in both groups: patients with SIJ pain (group 1) and patients without SIJ pain (group 2) So that we can able to determine our patients diagnosis and hopefully, we can able to diagnose pathology or dysfunction around the SI joint or hip joint or muscles around the hip joint.
For some people, despite being told that their surgery was very successful, they still have pain. For some people, the surgery did not go as planned at all. We usually see the post-surgical patients in the last two groups. The research clinicians say to diagnose sacroiliac joint dysfunction as the cause of pain, you need to be able to find, treat, and alleviate that pain. Typically this is done with a nerve block that offers some degree of sacroiliac pain relief. But . . . There are fundamentally two methods for achieving stability of the sacroiliac joint. Surgical fusion is the extreme solution that is rarely required. Other less invasive techniques include Prolotherapy or the current method of PRP injection. There are other interventions not available to physical therapists that may have value in the treatment of persistent SIJ pain. Corticosteroid injections88,97,98, phenol injections99, and radiofrequency neurotomy100104 are minimally invasive and appear to be effective in a proportion of cases of SIJ pain, especially if there is imaging evidence of sacroiliitis.
The optimal technique of injection was established in 199248 and is described in the current edition of the practice guidelines issued by the International Spine Intervention Society42. Because false positive responses to single diagnostic blocks into synovial joints are common49, comparative or placebo-controlled blocks are now considered essential before a diagnosis of SIJ mediated pain is confirmed42. Women are at risk for developing SI joint problems due to childbirth. Female hormones are released during pregnancy that allow the connective tissues in the body to relax. The relaxation is necessary so that during delivery, the female pelvis can stretch enough to allow birth. This stretching results in changes to the SI joints, making them hypermobile (extra or overly mobile). Over a period of years these changes can eventually lead to wear-and-tear arthritis. During pregnancy, the SI joints can cause discomfort both from the effects of the hormones that loosen them and from the stress of carrying a growing baby in the pelvis. The more pregnancies a woman has, the higher her chances of developing SI joint problems.
Like any other joint in the body, the sacroiliac (SI) joint can degenerate or its support ligaments can become loose or injured. When this happens, people can feel pain in their buttock and sometimes even well above their buttock and higher on the skeleton. This is especially true with lifting, running, walking or even sleeping on the involved side. Ligaments are bands of fibrous tissue that connect bones to each other, like the vertebrae to each other and the sacrum to the pelvis. The sacrum is the part of the spine below the fifth and last lumbar vertebrae and above the coccyx. The uppermost portion of our pelvis is called the ilium. The area that connects these structures is the sacroiliac joint (SI): Sacro from the sacrum, iliac from the ilium. A positive Faber test means that the test reproduces the patients pain and limits range of motion (ROM). Limited ROM means there will be less movement around the area.
- Fifty-nine (46.5) patients with sacroiliac joint dysfunction had groin pain, In these patients, pain provoked by the sacroiliac joint dysfunction shear test and the tenderness of the posterior superior iliac spine and long posterior sacroiliac ligament were significant physical signs that differentiated sacroiliac joint dysfunction from lumbar stenosis and lumbar disc herniation.
Prolotherapy has been recommended by some reports, but the quality of evidence is poor, and methods and subjects are heterogeneous105. The evidence in favor of these interventions is limited106. Surgical debridement107 and fusion108 are more invasive but appear to offer a moderate chance of pain reduction and functional improvement in patients with confirmed SIJ pain unresponsive to more conservative interventions. If these tests do not show signs of sacroiliac joint dysfunction, then your doctor may use an SI joint injection to diagnose your condition. Injections are one the most accurate methods of diagnosing SI joint dysfunction. Research like that above shows that there is no consensus in the medical community, based on recent research, that can quantify the amount of pain symptoms sacroiliac joint dysfunction causes or even determine if that pain is, in fact, coming from the sacroiliac joint. This understanding of the non-understanding of where sacroiliac joint comes from has concerned some researchers about recommending patients for sacroiliac joint fusion surgery and, further, why it should not be recommended.
- The prevalence of groin pain in patients with sacroiliac joint dysfunction was higher than in those with lumbar stenosis and lumbar disc herniation.
- When patients who do not have hip disorders complain of groin and lumbogluteal pain, not only lumbar disorders but also sacroiliac joint dysfunction should be considered.
Reproduction in symptoms is considered a positive test to the painful side. A December 2020 study in the Journal of Pain Research (11) tries to help doctors understand the difficult concept of failed sacroiliac joint dysfunction treatments. Here are the learning points: Sacroiliac joint inflammation is a difficultdiagnosis to determine as it may come from an infectious disease or be caused by a rheumatology disorder. For manypatients, inflammation of the sacroiliac joint is NOT caused by infectious disease but by chronic degenerative inflammation including ankylosing spondylitis (chronic joint inflammation between the vertebrae between the spine and pelvis). In some cases, a rheumatologist willbe consulted. In this article, we are going to talk about sacroiliac joint dysfunction treatments that may help you avoid fusion surgery. Some people who have fusion surgery for problems of sacroiliac joint dysfunction have a very successful surgery and their pain has been eliminated or greatly reduced.
Because a nerve block does not work, for some, this should not rule out the pudendal nerve. In a May 2020 study in the journal Pain Medicine (3), researchers noted that two common methods of nerve blocks using ultrasound guidance, one injection is given at the ischial spine or the other option the injection is given at the Alcocks or Pudendal canal were on average 80 accurate for hitting their mark. Many problems can lead to Degenerative Arthritis of the SI Joints. It is often hard to determine exactly what caused the wear and tear to the joints. One of the most common causes of problems at the SI joint is an injury. The injury can come from a direct fall on the buttocks, a motor vehicle accident, or even a blow to the side of your pelvis. The force from these injuries can strain the ligaments around the joint. Tearing of these ligaments can lead to too much motion in the joint. The excessive motion can eventually lead to wear and tear of the joint and pain from degenerative arthritis. Injuries can also cause direct injury of the articular cartilage lining the joint. This too, over time will lead to degenerative arthritis in the joint.
A common condition that we see is pelvic floor dysfunction which causes pudendal neuralgia or compression of the pudendal nerve. The most common treatment for pelvic floor dysfunction are the different types of physical therapy and they are often helpful but very seldom do I find that it cures people.Source: https://www.massagetherapyreference.com