Like many aspects of diagnostic testing and most in musculoskeletal physiotherapy very few tests are definitive taken in isolation and the current trend is to use clinical prediction rules which group a number of tests in order to confirm or refute positivity. This allows the examiner to conclude with greater confidence when a group of tests are positive even in the presence of some non-positive tests.

Assessment of sacroiliac dysfunction – Foundations.

1. Active straight leg raise test.

2. Pain provocation test.

3. Kinetic tests.

4. Positional assessment.

5. Leg-length tests.

6. Passive movement assessment.

In previous posts I have discussed the role of positional assessment and Leg length testing in relation to mechanical assessment of the pelvic girdle. Today we will focus our discussion on the kinetic tests as they have been formally described. Several renowned authors have written on this topic over the years the most notable being Philip Greenman (an osteopath), Diane Lee (Canadian physiotherapist), Richard DonTingy (US physiotherapist) and Howard Turner (Australian Physiotherapist)  referred to above who has been conducting courses in the British Isles and internationally for the last 15 years on this topic.

Kinetic Tests

Forward Flexion in standing / sitting.

Hip Extension in standing.

Hip Flexion in standing (Stork / Fowler / Guillet Test).

Lateral Flexion in standin.

Rotation in standing / sitting.

When interpreting Kinetic tests it is important to recognize that the evidence of dysfunction does not infer a mechanism of pathology.

The pathology may lie in the articular system, the myofascial system.

The pathology may be local to the pelvic girdle and sacroiliac joint.

The pathology may be secondary to lumbar spine or general postural alignment characteristics

The interpretation of “positivity” is based on the extent of variance from expected norms and the number of positive tests.

The selection of legitimate targets for intervention is based on the degree of deviation on the kinetic tests rather than the side of dominant pain.

Those of you who treat the sacroiliac joint dysfunction frequently are well aware of the propensity of this joint to demonstrate alternating sides of symptoms which can sometimes leave a therapist “chasing pain” rather than identifying primary underlying mechanisms.

1. Forward Flexion in standing

Therapist : palpates inferior aspect of PSIS inferiorly

Patient : flexes forward to end of range.

Normal : PS IS move symmetrically bilaterally

Dysfunction: asymmetrical movement of PS I S. which may be early or late in the movement pattern or the PS I S. moves more Cephalad on flexion

2. Hip extension in standing

Therapist: palpates the idiom and sacrum on one sacroiliac joint.

Patient : extends the hip.

Normal: the PS I S raises cephalad relative to the sacrum

Dysfunction: PS I S. and sacrum move together

3. Hip Flexion in standing (Stork / Gillet / Fowler tests)

Therapist: palpates Ilium and sacrum of one SI joint

Patient: flexes they hit to 90° flexion.

Normal: PS I S. drops caudad relative to sacrum

Dysfunction: increased or decreased movement of Ilium relative to sacrum

4. Rotation in standing

Therapist: palpates Ilium and adjacent sacral segment.

Patient: rotates their torso.

Normal: sacrum lifts relative to PS I S.

Dysfunction: increased or decreased movement of sacrum relative to ilium

PS : the trunk  should rotate to the side of the tested S.i. joint.

5. Lateral flexion in standing

Therapist: palpates Ilium and sacrum of one SI joint.

Patient: performs lateral flexion.

Normal: PSIS drops and sacrum lifts on the side to which lateral flexion occurs

Dysfunction: increased or decreased movement of Ilium relative to sacrum

Clinical Thoughts?

1. Why does the Ilium move cephalad in standing flexion?
2. Why does the ilium move inferiorly relative to the sacrum in Gillet test?
3. How does the coupling of motion occur between Lumbar spine, Sacrum and Ilium in trunk rotation?
4. How do the pelvic biomechanics in lateral flexion occur ie how is the coupled motion achieved?

Enjoy the clinical challenge.

David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2010. | Permalink | One comment | Add to del.icio.us
Post tags: Anatomical terms of location, Conditions and Diseases, Diane Lee, Health, Howard Turner, Kinetic tests, Lumbar vertebrae, pelvic girdle dysfunction, pelvis, Philip Greenman, Physical therapy, Richard DonTingy, sacroiliac, Sacroiliac joint, Sacrum, SI Dysfunction

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These most commonly described are:

1)      Hip flexion test in standing (Stork, Fowler or Gillet test),

2)      Forward flexion in standing or sitting,

3)      Hip extension in standing,

4)      Lateral flexion in standing

5)      Rotation in sitting or standing.

The purpose of these tests is to provide a battery of procedures to quantify which sacroiliac joint shows the greatest degree of motion impairment indicative of a “so called” positive kinetic test.  The advantage of performing these tests in non weight-bearing means that other reference points involving the legs can be used to assist in the positional diagnosis.  The principle of the lying/sitting test is that it can be easier clinically to monitor changes in leg length than to monitor specific pelvic bony landmarks during the standing flexion test and therefore provide an additional layer of evaluation to quantify the pelvic position.

The first principle to establish is whether there is a true leg length difference present.  This is best established in a supine position where the iliac crests and ASIS are monitored on the pelvis together with the position of the medial malleoli of both legs.  If the pelvic alignment is symmetrical and there is a difference in the position of the medial malleoli then there is a suspicion of a true leg length difference. This can be further explored by the patient flexing their knees and evaluating the level of the superior patellas from a side view.  If this isn’t clearly visible placing a book or flat object across the top of the knees will demonstrate any inclination and thus alteration in leg length using this test.  Of course the critical issue in determining true versus apparent leg length difference is whether the clinical strategy is to use some form of orthotic device to compensate for the leg length difference and optimise stress distribution.

Patients with a true leg length difference may well need this type of corrective action but patients with an apparent leg length difference do not and the treatment strategy needs to be directed towards optimising lumbosacral and pelvic alignment.  This is a common pitfall in clinical practice and one reason why establishing true versus apparent leg length difference is such an important consideration.

The apparent change in leg length which occurs as a consequence of sacroiliac or lumbo pelvic dysfunction appears to arise from a number of biomechanical factors.  In supine an anterior innominate rotation carries the acetabulum forwards and down (relative to the axis of the SI joint) and therefore makes the leg on that side appear longer.  Conversely a posterior innominate rotation draws the acetabulum backwards and posteriorly (relative to the axis of the SI joint) apparently shortening the leg on the side of the posterior innominate rotation.

The mechanical effects of moving from supine lying to upright are based upon our current understanding of the kinematics of this movement.  In supine lying the acetabular lie anteriorly and craniad relative to the ischial tuberosities.  On moving to the long sitting position from supine flexion occurs initially in the thorax and then the lumbar spine at which point the pelvis starts to rotate forwards and eventually pivots over the tuberosities as one unit.  The acetabular are therefore moved further anteriorly and also downwards so that the legs appear to lengthen equally.  On returning to supine the reverse pattern occurs when the pelvis rotates backwards as a unit with the acetabular moved upwards and posteriorly drawing the legs equally with this movement pattern.

When sacroiliac joint motion is compromised (for whatever reason) these normal mechanics do not apply.  It is thought that the interference with Sagittal plane motion in this test is compensated for by transverse plane rotation whereby the side with the positive kinetic test (dysfunctional movement side) forces a swivelling action to occur about the opposite ischial tuberosity with the blocked side of the pelvis now moving / rotating backwards (transverse plane twisting – probably because the other side continues to rotate forward to end range) effectively shortening the leg on that side.  The reverse is true for a posterior rotated Ilium in which the leg will appear to lengthen in the long sitting position.

We must remember of course that these alterations in joint mechanics may not be primarily indicative of an articular dysfunction but may be a consequence of  myofascial restriction distorting movement patterns.  The clinical prioritisation of targets therefore comes down to a question of judgement on the primary mechanism, treating an apparent articular dysfunction and reassessing within a treatment session or expanding the repertoire of techniques to incorporate myofascial components if clinically indicated.  Myofascial components in the form of mechanical restrictions are easily evidenced by alterations in length / tension with appropriate length tests and in the absence of these findings the implication is of a motor control /strength deficit. Of course the real challenge is quantifying a mixed pattern of dysfunction related to both true and apparent components of a leg length difference but that’s for another day. So the lying sitting test is a useful assessment tool to add to the battery of kinetic tests when evaluating pelvic dysfunction

Enjoy the clinical challenge.

David

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2010. | Permalink | 3 comments | Add to del.icio.us
Post tags: Acetabulum, Anatomical terms of location, flexion, Kinetic tests, Lumbar vertebrae, pelvis, Rotation, Sacroiliac joint, si joint

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I’ve recently been reflecting on the clinical relevance of evaluating end-fee in clinical practice. The issue arose from  a conversation about interpreting patient response to manual therapy and whether “useful clinical change” was being achieved. Changing end-feel is certainly part of the manual therapists armory and needs to be considered in conjunction with range of motion as a measure of effectiveness. However in situations of established degenerative change the clinical objective may be to improve tolerance of static positions (typically lying in spinal conditions) and in these cases improving end-feel is often the key criteria in reducing symptoms without tangible range changes.

Conversely, failure to alter end- feel is a poor prognostic indicator and one where the clinician must be vigilant.

Knowing when not to treat is also a skill we must embrace.

I’ve included a refresher summary below of the issues associated with end-feel in spinal examination.

Different sensations of movement barriers can be perceived according to the tissues limiting motion, the anatomical region, and pathological change.  Cyriax describe a number of characteristic End-feels

1. Bone to bone
2. Spasm
3. Capsular feel
4. Springy block
5. Tissue approximation
6. Empty feel

Kaltenborn summary of end-feel

1. Normal soft end-feel due to soft tissue approximation
2. Normal firm end-feel due to capsular ligamentous stretching
3. Normal hard end-feel (bone to bone)

In pathological states the variations may be:

1. A firm less elastic feel (indicative of scar tissue or shortened connective tissue)
2. An elastic less soft end-feel (indicative of increased muscle tone)
3. An empty end-feel (patient limits movement prior to resistance)

(This is indicative of inflammation, serious pathology or fear avoidance behaviour)

ACCESSORY MOVEMENT

In order to allow physiological movement joint surfaces undergo combinations of rotation and translation.  These characteristics are determined by the shape of the joint surfaces, the ligament us and capsular tension and the inherent bony structures.

When a concave surface moves on a convex the direction of translation (slide) is in the same direction as that of the motion (rotation).  When a convex surface moves on a concave the translation is in the opposite direction to the motion.

Manual Examination

Objective: to determine the presence presence of vertebral motion (somatic) dysfunction.

Passive Physiological Intervertebral Motion (PPIVM’s)

Passive Accessory Intervertebral Motion (PAIVM’s)

Functional Technique

Flexion / Extension

- segmental range

- total range

Side flexion / Rotation

- segmental range

- total range

- coupled motion

- position dependent

Correlation of active movement , PPIVM’s & PAIVM’s to define diagnosis and prescribe optimal treatment strategies.

Saggittal plane motion: nutation / counternutation

Range:

Intra-pelvic motion a function of:

Inominate position (functional test in Siting)

Sacral position

Spinal position

Manual Examination Techniques

Physiological Motion

Lumbar flexion

Lumbar extension

Lumbar side flexion

Lumbar rotation

Lumbar shear

Accessory Motion

PA’s

Unilateral’s

Transvers’s

In combined positions

Positional assessment:

ASIS

PSIS

Iliac Crest

Standing hip flexion test

Standing hip extension test

Positional assessment:

Sacral base

Inferior lateral angles

Accessory glide

Shear (stress) test

Enjoy the clinical challenge

David

Gertzbein, S. D., R. Holtby, et al. (1984). “Determination of a locus of instantaneous centres of rotation of the lumbar disc by moire fringes.” Spine 9(4): 409-413.

Gertzbein, S. D., J. Seligman, et al. (1985). “Centrode patterns and segmental instability in degenerative disc disease.”  Spine 10(3): 257-261.

Loeble, W. Y. (1967). “Measurement of spinal posture and range of spinal movement.”  Annals of physical medicine 9: 103-110.

McFadden, K. D. and J. R. Taylor (1990). “Axial rotation in the lumbar spine and gaping of the zygapophyseal joints.”   Spine15(4): 295-299.

Panjabi, M., I. Yamamato, et al. (1989). “How does posture affect coupling in the lumbar spine.”  Spine 14(9): 1002-1011.

Pearcy, M. (1984). “Is there instability in spondylolisthesis.”  Spine 10(2): 175-177.

Pearcy, M., I. Portek, et al. (1984). “Three-dimensional x-ray analysis of normal movement in the lumbar spine.”  Spine 9(3): 294-297.

Seligman, J. V., S. D. Gertzbein, et al. (1984). “Computer analysis of spinal segmemt motion in degenerative disc disease with and without axial loading.”  Spine 9(6): 566-573.

Stokes, I. A. F. (1986). Three dimensional biplanar radiography of the lumbar spine. Modern Manual Therapy, London, Churchill Livingstone.

Stokes, I. A. F., D. G. Wilder, et al. (1981). “Assessment of patients with low back pain by biplanar radiographic measurement of intervertebral motion.”  Spine 6(3): 233-239

© David for PhysioDigest - an educational resource for the musculoskeletal rehabilitation community, 2009. | Permalink | No comment | Add to del.icio.us
Post tags: ACCESSORY MOVEMENT, Characteristics of End-feel, Clinical Assessment, Convex - Concave rule, End-feel, Kaltenborn, lunbar spine, manual therapy, pelvis, poor prognostic indicator, si joint, useful clinical change

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