153. SI Joint Pain Part 2: Manual Therapy, Exercise, and What the Research Says

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In this episode of PT Snacks podcast, we continue our discussion on the sacroiliac (SI) joint, discussing optimal manual techniques and exercises to help patients experiencing SI joint pain. We'll break down the function of the SI joint, explore the latest research on manual therapy, and explain why a combination of manual therapy and exercise is most effective. Join us as we cover high-level reviews and specific techniques to help your patients move better and feel better. Don't forget to hit the subscribe button, leave a review, and check out the special MedBridge discount in the show notes!

00:00 Introduction and Podcast Overview
00:26 Listener Feedback and Today's Topic Introduction
01:29 Understanding the Sacroiliac (SI) Joint
02:03 Manual Therapy Techniques for SI Joint
05:52 Mechanisms and Theories Behind Manual Therapy
13:46 Exercises for SI Joint Stabilization
15:44 Combining Manual Therapy and Exercise
16:57 Conclusion and Additional Resources

Trager RJ, Baumann A, Rogers H, et al. Efficacy of manual therapy for sacroiliac joint pain syndrome: a systematic review and meta-analysis of randomized controlled trials. J Man Manip Ther. 2024;32(2):71-85.

Nejati P, Safarcherati A, Karimi F. Effectiveness of exercise therapy and manipulation on sacroiliac joint dysfunction: a randomized controlled trial. Pain Physician. 2019;22(1):53-61.

Kamali F, Zamanlou M, Ghanbari A, Alipour A, Bervis S. Comparison of manipulation and stabilization exercises in patients with sacroiliac joint dysfunction: a randomized clinical trial. J Bodyw Mov Ther. 2019;23(1):177-182.

Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. J Orthop Sports Phys Ther. 2009;39(3):123-130.

Testa M, Rossettini G. Enhance placebo, avoid nocebo: h

Transcript

0:30

Hey everyone. Welcome to PT Snacks podcast. This is Kasey, your host, and if you're tuning in for the very first time, first of all, welcome. But what you need to know is that this podcast is meant for physical therapists and physical therapist students who are looking to grow your fundamentals in vice segments of time. Note that this is not meant to be medical advice, so use this information to your discretion. Now, today we're gonna talk a little bit more about the sacroiliac joint, but before we do that, if you've listened to at least three episodes of this show and you found it to be helpful, if you wouldn't mind leaving a review, that would mean the world to me, because that makes a huge difference in helping the show to grow. And if you've already done so, I really appreciate that you are willing to take some time out of your day. And be able to help this show. Thank you. Now diving in today's topic, we're going to do a follow-up episode because I did get in a question from someone in Quincy, Massachusetts that said, just listen to your episode on SI joint pain. Found it to be helpful, but could you do another at some point to include optimal manual techniques and exercises? Thank you. Yeah. Did you guys know that there is an option in the show notes where you can leave a message to me? You don't even have to shoot me an email. So if you have questions about this or requests for future topics, use it. I read those all the time. Today we are going to talk about just that manual techniques and exercise specifically to the sacred iliac joint, which I'm gonna call SI joint from here on out, how do we use it to help these patients to get better? If you're listening to this show, you're probably wanting to use it for your patients, right? So here's what I like to do with this episode. We're gonna cover more so a review of the function of the SI joint. And how we would treat that from a high level. And then, because what I'm talking about here is manual and exercise, we're gonna go a little more high level into what manual therapy is actually doing, according to our most recent research and how we utilize that. So I'll give examples of specific SA joint techniques as well as exercise. So, with that aside, remember that the SI joints role is to help with shock and forced dispersion. So when we are talking about the SI joint, remember that it doesn't really move a lot. It moves like maybe two to four millimeters. Previously, in a lot of our research we described SI joint as something that tends to get out of alignment, maybe counter mutated, rotated ups, slipped, that kind of stuff. We just haven't had a lot of research lately that has been supportive of that. We've moved away from it. That doesn't mean that doing some of the manual therapy techniques that are fostered around this are irrelevant because they can be helpful. We're just gonna talk about how we think manual works so that we can best utilize it to our discretion. So when we are thinking about, okay, I've got this patient in front of me, how can I help get them moving? A lot of our research was centered around using a combination of manual and therapy, manual therapy and exercise. We're gonna talk about why the combination of both of them has been found to be effective rather than maybe one or the other. Manual therapy was found to be more effective with short-term relief, meaning helping to calm things down, whereas exercise was helpful for more long-term benefit. So like any joint in the body, something that is irritated, it can be irritated from trauma, repetitive strain, or maybe compensation from surrounding structures. Like last episode, how I described this is common with people who have had lower lumbar fusions. That changes how force is distributed. So the body is having to adapt to a new load. Right? Relatively. Now if we are trying to calm things down, we want to help with pain modulation and easing the job of the joints so that it can have a chance to. Lower down its irritability and then hopefully in the future be able to absorb more stress. Understanding the root of the problem, its function, and how we meet where it is at now to where we want it to go. With these patients, a lot of times they may have pain with a lot of single leg related activities. If they are pregnant or breastfeeding, there are some hormonal changes that have happened, to cause maybe a little bit more propensity towards this happening or trauma. So understanding where this is coming from will help you to use your best judgment. If we need to offload them, maybe we are decreasing the strain that goes through that joint. Meaning if single leg requires a lot more transfer of load between the spine and lower extremities, which is this joint's job, maybe we start doing more double leg exercises or help them with transfers, like getting in and out of the car using both legs rather than off to one side until they're ready to go back to that stream. So ideally we are trying to help them build resilience in their structure. We just might have to use tools like manual therapy or even SI joint belts to help bridge the gap between what they need to do now and what we want them to do eventually in the future. So again, one of those big tools would be manual therapy. There are a lot of mechanisms and theories on how manual therapy works. Number one would be neurophysiological effects. This is the most strongly supported mechanism in the literature right now, and the theories on manual therapy. This could be high velocity, low amplitude, or for mobilizations, things like that. But there are central mechanisms, spinal mechanisms, and peripheral mechanisms that help with modulating pain. Centrally, we see activation of descending inhibitory pathways in the brainstem and spinal cord modulation of cort excitability, meaning in changes in somatosensory and motor cortex response. Decreased central sensitization, especially in those with chronic pain changes in pain pressure thresholds that are measured with alary, even in distant uninvolved regions. After local manual input in spinal mechanisms, we see segmental inhibition of nociceptive input via the dorsal horn modulation, and there's possibly even some gait theory. Escape control theory effects from a beta fiber activation inhibiting. C fiber nociception Peripheral mechanisms can be from local modulation of nociceptor activity and possible stimulation of interstitial or fascial mechano receptors such as rafini endings or pisidian cord pestles. Basically, this is helping the body to under, basically, this is helping to calm everything down. Whether it's from a dampen signal this is helping to calm things down. Other proposed theories, bio mechanical effects, probably more minor, but manual therapy may help to alter tissue stiffness, joint mobility, or muscle tone. However, these are not the primary drivers of pain relief, and the effects are very temporary. So joint specifically. Si. Some studies have shown transient changes in joint stiffness or position. They've used imaging or motion tracking to do but the effects tend to be very small and temporary. And remember that the SI joint movement is very limited. So even with thrust manipulation, actual realignment is pretty rare. Fascial and tissue findings been soft tissue techniques may help affect muscle tone, astic properties of fascia temporarily. And it may even help, manipulation may help to reduce muscle guarding or co contraction. But again, probably not the main mechanism of why this can be helpful. And then thirdly, psychosocial and contextual factors. We, manual therapy can naturally increase therapists patient interaction. So that patient we know therapeutic touch is very beneficial. There. We see an increase in confidence and perceived expertise when patients experience these treatments. There's also a placebo effect, potentially a belief that something is being realigned or fixed. If that therapist told them that in the first place conditioned responses, if they have had prior experiences with manual that were beneficial, they're probably gonna see that as beneficial. Again, they might even request it from you. That also works the other way, where if they've had negative experiences that might affect how they recover. As well as also almost giving them permission to move. A lot of patients, it's scary when you go through pain, especially when it's really intense and you're not really sure what is okay to do and what's not okay to do, and then all of a sudden you go to a healthcare professional and they do all this treatment on you and you feel better, and now you feel like it's okay to move. That's huge too. Even aside from maybe anything that we particularly do, they now feel more confident that they can do something. So with manual therapy, yes, it's absolutely a great tool to use. Even if the research doesn't really support changes in realignment, it still can help with calming pain down. There's some examples of manual therapy techniques that you might see in these studies are high velocity, low amplitudes thrust, or HVLA that are done in a sideline or a supine position. Muscle energy techniques where that therapist is using gentle resisted contractions to help alter muscle tone and. Alignment mobilization with movement. So therapist is basically adding a passive glide while the patient moves. And then soft tissue, mini techniques. A lot of, some several studies use a combination of these, so it's hard to really identify what technique is superior. But again, if your goal is pain modulation. Hopefully in your assessment you've picked up on what your patient is able to tolerate so you don't force them into positions that are pretty excruciating. And use the technique that has the greatest game with the least cost. You may not be able to figure that out right away, but it is better to choose something that you both benefit the most from rather than just doing a cookie cutter approach so you can. As you're assessing, see if they can even get into the position for the manual technique that you wanna do. And if they can't, it's probably not the right time. Maybe you can do it down the road, but calm their pain down a little bit first. And also if they've had a previous experience with other techniques that were positive, maybe you utilize that one. But it also is important for you to feel confident in the technique that you're gonna do too, as the treating therapist. So just to name those techniques a little bit more. I do think probably the best thing you could do is to look these up on YouTube. Pay attention to the positioning and what their expected outcome is with this technique. I was gonna try and describe it of our podcast. It's pretty hard to do So you can look up, there's a sideline SI joint manipulation, a supine manipulation. You can do some, there's some SI joint mobilizations that you can do in prone, where you're adding PA glides on the sacrum or the ileum. There's a muscle energy technique for a posterior dominant rotation as what they describe. So you're basically trying to put someone's ileum into a posterior rotation and then you're having them push against you. Contract for three to five seconds and then relax, and you bring the leg further into flexion. So you'll do this repetitively, like three to five times. There's also an energy technique for the anterior nominate. So is this one's kind of like a modified Thomas position. You're treating the leg that's hanging off the table and you're basically trying to continue to lower their leg while they're contracting using hip flexion, three to five seconds, relaxing, you bring them back into more hip extension. Repeat three to five reps. So you're trying to put that ileum into anterior rotation. And then there's several mobilization with movements where maybe you're adding a lateral posterior glide while the patient is doing some sort of hip flexion or squatting motion. Sacral rocking mobilizations. There's a ton, but some of these are more involved than others. So if your patient's pretty irritable, they may not. Tolerate some of the other ones versus if they're pretty high level, they may need something that's a little bit more helpful. A little, maybe they can tolerate something that's a little bit more involved. Now, a lot of the exercises that are utilized in these studies are core stabilization exercises, gluteal strengthening, posterior nominate, self mobilizations, functional motor control. And from what I've seen in a lot of research that I looked up, it's it's not really filtered out into someone's patient's skill level. Like for instance, some people might think bird dogs are the hardest, and for others they're like what am I doing? I'm just wiggling my legs and arms around. But just to dive in further, this is what they utilize core stabilization, like bird dogs, side planks, abdominal hollowing, gluteal strengthening like clamshells, bridges, sideline, hip abduction even just helping someone but improve their walking, squatting, transitioning movements. Yes, I'm being vague because this is a lot of the research. It's hard to find. People using the same exercise program. So what I would do is, again, see where your patient's at and where they wanna go. Think about what exercises, if they can tall, if they need pain modulation, you're trying to use exercises that may be offload, they're lower level versus exercises that are higher level. Like for instance, they need to do a lot of single leg exercises. Let's bridge the gap between what they're doing. Don't just give them a cookie cutter approach. Make sure that you're getting what you want outta the exercise and you're helping build your patient's expectations on what to expect so that y'all can work better together. And then for some patients they may just need something to help get them through. Like for instance, someone who's pregnant, they're not gonna be pregnant forever hopefully, but they may need something to help make their pregnancy a little bit more doable. So things like an SI joint belt can be helpful'cause you're basically decreasing the job that the SI joint needs to do. So we wanna utilize manual therapy to help keep things calm, but we also wanna use exercise to help with the long-term fix of making sure we've got more staff members to help manage the workload, like our active stabilizers, our muscles. Depending on the re what happened, if it's trauma, maybe that's just temporary until the tissues have healed. Maybe it's chronic. Let's look into other lifestyle factors. Are they recovering well? Do they have adequate nutrition? Do they have the building blocks they need to build the muscle mass. They need to help offload the rest of them. So there's art and science. It's important to get at both on understanding the needs of the joint itself. How we can best mold our approach to the individual that's in front of us. Exercise is a tool. Manual therapy is a tool. Use all the toolbox that you can to help put it all together. Build work back backwards from where the patient is in front of you to where they are now, so that you can look and see based on knowing the role of the SI joint, how you can offload it so it is less irritable and more receptive to exercise that may help build resiliency in the future. I hope this makes sense, but if it doesn't, feel free to reach out either through the link in the show notes or you can email me at pt Snacks podcast@gmail.com. And then I will do the best I can, or I'll find somebody who knows the answers. Right now, if you, if you are not following this show, make sure you do hit follow on the subscribe button wherever you are listening to this, right? But also, if you are trying to maybe get more CEUs, take deeper dives on these different topics. Maybe you're studying for a specialty exam like the OCS or SCS. Med Bridge is actually offering listeners over a hundred dollars off their year subscription, which is substantial. So if you just follow the link in the show notes, right? If you use the promo code in the show notes, that'll. So just use the promo code in the show notes at checkout and you'll get access to all of those For the OCS tests. There's practice tests, there's lessons. I thought it was super helpful for helping also get my eyes used to looking at a computer for a long period of time. But also they have. Tons of courses, webinars, all that, all the time. So highly recommend, and if you're a student, you get an even better discount, which you'll also find in the show notes. But other than that, I hope you guys have a great rest of your day and into next time.