David,
Mel: "Some therapists claim that "sacroiliac dysfunction" can be accurately
diagnosed by manual examination and treated successfully by manipulation.
You: "I'd say I can do that fairly well."
Me: So probably all other clinicians used in the reproducibility studies
said. Still, two systematic reviews found that diagnosing SIJ abnormalities
by means of palpation is unreliable. One could just as well toss a coin.
You: "I agree that from a purely mechanical viewpoint facts are adding up
against the possibility of diagnosing a SIJD by manual examination"
Me: "Facts [...] adding up"? That looks to be the understatement of the year
when it comes position- and mobility-diagnosis, looking at the reviews
done (1-4), which are based on large numbers of reproducibility studies.
You: "and treating it successfully with manipulation"
Me: Like you later already implied, here you are -- from a theoretical
research-rules point of view -- being too harsh (on yourself). In itself, a
method can still be (cost-)effective even though the diagnostic (sub)method
has been proven to be unreliable. Nevertheless, manipulation applied to LBP
patients without prior McKenzie assessment
has indeed been shown to be doubtful regarding effect, in not ineffective,
in chronic LBP patients (5). And there's another question: how do you know
for sure that the 'cracks' produced with an SIJ manipulation are produced by
the SIJ (chambers), and not by the L5-S1 facet(s)? They're darn close
together, so judging that by sound or feel seems extremely unreliable.
References:
1. Freburger JK, Riddle DL, Using published evidence to guide the
examination of the sacroiliac joint region. Phys Ther 2001; 81:1135-43.
2. Van der Wurff P et al, Clinical tests of the sacroiliac joint. Manual
Therapy 2000: 5(1):30-36.
3. Van der Wurff P et al, Clinical tests of the sacroiliac joint. Manual
Therapy 2000: 5(2):89-96.
4. Conijn FJJ, Diagnosing abnormalities of the sacroiliac joint - a review
of (systematic) literature reviews, and an update. Physical Therapist's
Literature Update 2001: 1(5): editorial (www.ptlitup.com | Archive & Search
| Editorial May 2001).
5. Ferreira M et al, Does spinal manipulative therapy help people with
chronic low back pain? Aust J Physiother 2002;48(4):277-84.
R.,
Frank
----- Oorspronkelijk bericht -----
Van: David Felhendler
Aan: [log in to unmask]
Verzonden: dinsdag 28 januari 2003 19:45
Onderwerp: Re: Sacroiliac Dysfunction and Treatment?
Hi Mel,
> Some therapists claim that "sacroiliac dysfunction" can be accurately
> diagnosed by manual examination and treated successfully by manipulation.
I'd say I can do that fairly well.
> However, there is considerable research which suggests otherwise. For
> example, although manipulation of the sacroiliac joint has been shown to
> normalise different types of clinical test results, it is not accompanied
by
> altered position of the sacroiliac joint, according to complex X-ray
> analysis. Thus, because the supposed positive effects are not a result of
a
> reduction of subluxation, further studies of the effects of manipulation
> should focus on the soft tissue response and neural factors.
I agree that from a purely mechanical viewpoint facts are adding up
against the possibility of diagnosing a SIJD by manual examination and
treating it successfully with manipulation.
However I think you're spot on when you're looking in other directions
such as neural factors. I think that one may learn to recognize
different patterns of pain, hypomobility, etc, which can guide you to
succesful diagnosis and treatment. But that doesn't mean that it was a
mechanical problem we solved. As someone once said,"That a technique
works does not validate the rationale behind it".
> Bengt Sturesson from Sweden shocked many practitioners at a congress in
> Vienna some years ago with his precise measurements of SI motion. Using
> radiostereometric x-ray imaging, he had shown that SI joint mobility in
> healthy people is much less than had been assumed before (i.e., it is only
> 0.5 -1.6 mm translation or 2-4 degrees rotation in a standing or sitting
> position), and that manual tests in which the practitioner assumes to
palpate
> SI motion in these positions, are therefore very questionable.
I'm well aware of this and I think this too clearly urges us to look in
other directions than the mechanical one.
David Felhendler, PT
Norrkoping, Sweden
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