It’s preventable through postural re-education, sleep positioning, and strengthening postural stabilizers
Vol. 26 • Issue 12 • Page 15
Women’s Health
Women who experience sacroiliac joint dysfunction during pregnancy suffer from pain and discomfort that may prevent them from being physically active. “Women suffering from sacroiliac joint dysfunction often have difficulty with activities of daily living,” said Vanda Szekely, PT, women’s health physical therapist at Texas Children’s Pavilion for Women in Houston.
With a focus on improving pelvic alignment and mechanics at the sacroiliac (SI) joint, located in the pelvis between the sacrum and the ileum, this condition is highly treatable.
“If the condition is misdiagnosed or goes untreated, an individual can experience chronic low back pain that interferes with activities such as bending, lifting and transitioning from different positions,” observed Monica Metri, DPT, senior physical therapist at Franklin Hospital in Valley Stream, N.Y. Franklin Hospital is part of North Shore-LIJ Health System.
According to Krystle Kempen, PT, DPT, continuing functional complaints of SI pain include difficulty standing, cycling, walking, sitting, sleeping and lying. “A staggering number of women have musculoskeletal complications during pregnancy,” said Kempen, a physical therapist at Athletico Physical Therapy in Milwaukee, Wis. “Pregnancy and postpartum periods should be among the most exciting times in a woman’s life. Don’t let this experience be dampened by common musculoskeletal complaints that are preventable and treatable.”
What is SI Joint Dysfunction?
Sacroiliac joint dysfunction is caused by motion or changes in the normal positioning of the joint, Metri explained. Poor SI joint mechanics can strain the surrounding tissues, ligaments and muscles, and cause inflammation at the joints.
There are at least five axes of motion in the sacrum, according to Szekely. “Sacral nutation happens along the three transverse axes, torsion is movement along the two oblique axes, and sacral shears are off-axis,” she said. “Either limited mobility or too much mobility at these joints may produce symptoms.”
SI dysfunction causes pain in the patient’s posterior pelvis, and is often described as deep stabbing pain in the L5/S1 region, Metri told ADVANCE. Symptoms will increase with prolonged sitting, standing, walking, stair climbing, unilateral standing, or torsion activities.
According to Kempen, SI pain commonly presents with posterior pelvic tilt in the erect position, limited range of motion with maximal forward bend, and significantly limited hip mobility. “Pain from the SI joint may radiate down into the groin or posterior thigh,” she said. “It is four times more likely for a patient to have SIJ pain unilaterally.”
Causes and Risk Factors
During pregnancy, fluctuating hormones and increased weight can cause biomechanical stresses, including pelvic and spinal alignment changes and joint laxity. Pregnant women at risk may have experienced prior lumbar pain, display back or sacroiliac joint pain, incurred trauma to the pelvis, or experienced pain in a previous pregnancy.
More research is needed to clearly understand the etiology, symptoms, risk factors and treatment of sacroiliac conditions, Kempen explained. “There are several theories about the specific cause of sacroiliac dysfunction, including biomechanical stresses, risk factors prior to pregnancy, and protective mechanisms of the body,” she said.
Neuroendocrine changes associated with pregnancy, such as increases in progesterone, estrogen and relaxin, can cause SI dysfunction, according to Metri. “Changes in hormones tend to cause an increase in ligamentous laxity and pain,” she said. “During pregnancy, the hormone relaxin causes an increase in the extensibility and pliability of ligaments and joints to aid in the birthing process.”
Relaxin, according to Kempen, is a hormone that assists with preparation for laxity in the ligaments to make room for increased excursion of the pelvic ligaments during child bearing. “As their bodies prepare for child labor, patients may experience aching hips or pelvic pain and heartburn,” she shared. “This hormone that makes joints more pliable leaves prenatal women more susceptible to sacroiliac dysfunction.”
Szekely believes that relaxin does not work alone in SI joint dysfunction. Other hormones, she explained, have been identified as possible factors, including estrogen, progesterone, cortisol and estradiol. “Together with relaxin, they have a combined effect on joints,” she said.
Numerous physiologic, musculoskeletal, and hormonal changes take place during pregnancy, observed Szekely. Postural changes, overstretched abdominals and pelvic floor muscles, gait changes, and increased joint laxity during pregnancy can contribute to the prevalence of SI joint dysfunction.
Developing the Diagnosis
Physical therapy assessment of SI joint dysfunction must begin with a thorough patient history. “SI joint dysfunction affects the entire pelvic girdle, which has to be taken into consideration with evaluation and treatment,” Szekely said. “We need to keep in mind that the sacrum is wedged between the pelvic bones, and the pubic symphysis completes the ring.”
Patients typically report pain occurring with transitional movements such as performing sit-to-stand, rolling in bed, or walking up an incline or stairs, Szekely explained. The pain that accompanies transitional movements is usually a sharp pain at the SI joint involved, stated Szekely. Sometimes patients mention the sense of instability, grinding, or clicking with movement.
Because there is not one gold-standard test for SI dysfunction, diagnostic tests are best administered in combination, and the patient should test positive on at least three tests for an accurate diagnosis, explained Kempen and Szekely.
SI dysfunction can be diagnosed by positive pain provocation tests, including posterior pelvic pain provocation (P4), Patrick’s Faber test, Gaenslen’s test, the active straight leg test (ASLR), long dorsal ligament palpation, SI joint distraction or compression test, the Stork test, and the modified Trendelenburg.
Manual muscle testing with SI dysfunction, Kempen explained, typically reveals decreased hip abduction, adduction, and extension.
Therapists also assess for tenderness over the symphysis pubis and the long dorsal ligament. “The objective component of the evaluation consists of a postural, gait and mobility assessment,” Szekely said. “The iliac crest, ASIS, PSIS, sacral base and ILAs are palpated while standing and seated.”
Hip internal and external ROM measurements, along with palpation of ligamentous structures around the sacrum, are also on Szekely’s checklist during an evaluation. “Depending on how far along the patient is, I like to assess the sacral base and ILAs in seated with movement, forward-bending and extension,” she said.
Three-stage Treatment Plan
Kempen believes treatment should be approached in three stages, consisting of an acute, recovery, and maintenance phase. During the acute phase, she said, the focus is on rest and progressive mobilization.
Treatment in the recovery phase includes muscle energy techniques for pain relief, manual therapy to address muscular spasm, and therapeutic exercises. Lastly, the maintenance phase corrects motor control patterns, implements neuromuscular re-education, and includes therapeutic exercises to improve muscular balance and symmetry.
According to Metri, the treatment plan focuses on modifying the positions of treatment, such as supine, side-lying, and quadruped, or elimination of certain activities. It may be beneficial to use external stabilizers such as belts or corsets specifically designed for use during pregnancy. Stabilization exercises and flexibility interventions with muscle energy techniques are part of treatment during and after pregnancy, she explained.
Kempen believes it’s important to educate patients about biomechanical strategies to reduce strain to the sacroiliac joint, such as avoiding extreme asymmetries including stair climbing and riding a bike. She instructs patients to be conscious of their positioning and take precautions such as navigating stairs sideways with a railing and avoiding asymmetrical positions of the hips, such as crossing legs, lunges, bicycles, or the figure-four position during sleep.
Patients must learn proper body mechanics while bending and lifting, and maintain a neutral spine throughout daily activity, said Metri. “These approaches assist in reducing tension placed on the SI joint through extremes of motion,” she said. “Sleeping postures such as sleeping face-up with a pillow under the knees can decrease tension placed at the SI joint.”
The treatment plan at Texas Children’s Pavilion for Women focuses on improving pelvic alignment and mechanics at the SI joints and consists of 6-8 visits, 1-2 times a week. “Manual therapy such as muscle energy techniques, direct mobilization with respiratory assist in seated, and myofascial release techniques are a part of the treatment session,” Szekely said.
According to Szekely, postural re-education, sleep positioning, and strengthening postural stabilizers are key components in the treatment of this patient population.
Getting the Right Care
Sacroiliac joint dysfunction is a difficult diagnosis to treat due to pain and functional mobility limitations, said Metri. “To decrease pain, patients benefit from constant mind-body awareness for preventive measures and a PT-driven strength and flexibility program,” she said.
Kempen stresses the importance of consulting an appropriate women’s health provider. “A physical therapist should be specifically trained in women’s health and/or sacroiliac dysfunction to properly treat this condition,” she said. “Women’s health providers have received extensive training on anatomy and physiology of pelvic floor muscles and impairments specific to prenatal and postnatal musculoskeletal injuries.”
Szekely cautions women to be aware of how their bodies are changing during pregnancy and know how these changes can cause strain. “We can successfully help the body to compensate for these changes by improving posture, [altering] body mechanics, and modifying how the patient moves,” she said. “The changes, like altered posture and increased laxity at the joints, are normal changes that happen with pregnancy, but pain is not normal.”
Resources
Bjorkluund K, et al. Symphyseal distension in relation to serum relaxin levels and pelvic pain in pregnancy. Acta Obstetricia et Gynecologia Scandinavica. April 2000;79:269.
Greenman P. Principles of Manual Medicine. 2003 Lippincott Williams & Wilkins.
Hungerford B, et al. Evidence of altered lumbopelvicmuscle recruitment in the presence of sacroiliac joint pain. Spine. 2003 Jul 15;28(14):1593-600.
Irion J, Irion G. Women’s Health in Physical Therapy. 2010 Lippincott Williams & Wilkins, a Wolters Kluwer business.
Lyons M. Care of the Pregnant Patient. Course Manual, Herman & Wallace Pelvic Rehabilitation Institute. April 6-7, 2013. Houston, Texas.
Mooney V, Pozos R, Vleeming A, Gulick J, Swenski D. Exercise treatment for sacroiliac pain; Abstract. Orthopedics. 2001 Jan;24(1):29-32.
Neville C, Giglio S, Divis Head S, Cathcart D, Stephenson R, Aceron Badillo S. Physical Therapy in Pregnancy. Course Manual, Section on Women’s Health of the American Physical Therapy Association 2010. Houston, Texas.
Pel JJM, Spoor CW, Pool-Goudzwaard AL, Hoek van Dijke GA, Snijders CJ. Biomechanical Analysis of Reducing Sacroiliac Joint Sheer Load by optimization of Pelvic Muscle and Ligament Forces. Ann Giomed Enf. 2008 March;36(3):415-424.
Petersen LK, et al. Normal serum relaxin in women with disabeling pelvic pain during pregnancy. Gynecol Obstet Invest. 1994;38(1):21-3.
Vleeming A, Albert HB, Ostgard HC, Sturesson B, Stuge B. European guidelines for the diagnosis and treatment of pelvic girdle pain. Eur Spine J. 2008 Jun;17(6):794-819
