Treatment of Pelvic and Sacroiliac Pain Flashcards
(37 cards)
Which type of interventions to treat the pain of SIJ dysfunction?
– Nonsteroidal anti-inflammatory drugs (NSAIDs) – Physical therapy – Corti costeroid injections – Manipulation – Radiofrequency denervation – SIJ belts – Surgery.
Quais são as três grandes teorias associadas aos tratamentos por terapia manual?
- Biomechanical: structural change including distance or movement.
- Neurophysiological: stimulus response that allows corresponding muscle relaxation.
- Muscle reflexogenic: modulation or gating of pain secondary to response.
Relativamente à teoria biomecânica, qual a evidência existente ao nível da manipulação?
- Thrust does not accurately target a specific joint;
- No change in joint position before and after manipulation (even after confirmation of change by the attending physiotherapist);
- No change in Hip ROM after SIJ manipulation.
Em termos de efeitos neurofisiológicos, o que a evidência nos diz acerca da terapia manual pélvica?
- Pain (and disability) is reduced in symptomatic subjects.
- Pain is decreased in patients with related hip and SIJ symptoms.
- Decrease in Lower extremity symptoms.
Em termos de efeitos musculo-reflexogénicos, o que a evidência nos diz acerca da terapia manual pélvica?
- SIJ functions to improve feed-forward mechanism of TrA.
- Soft tissue tension is decreased.
- Significant decrease in reflex excitability even after cutaneous stimulation.
Quais são os parâmetros notáveis da manipulação?
- Effects do not alter joint position but likely affect soft tissue.
- Fast thrust have greater neurophysiological affects.
- Thrust only works if muscle or joint capsule is affected.
- Must be performed on symptomatic subjects.
- Must be performed on same side as dysfunction and are enhanced when directed at the area of pain.
- Variable results may likely be a reflection of complex innervation pattern (rami from L5-S3) and large joint.
(Atenção: estudos efetuados entre 1995 e 1999)
Are the Manual Therapy Techniques Specific to the SIJ?
- No
- Lumbar spine also creates changes
- Even manipulation on cervical spine can create changes on SIJ.
- Audible may or may not be SIJ and is rarely at the targeted level (lembra-te que a fast thrust technique já é considerada manipulação, mesmo que não emita um estalo).
O que poderá otimizar os benefícios da manipulação sacroilíaca?
- Cerca de 80% da população que tem dor pélvica ou sacroilíaca responde positivamente à manipulação.
- A single session of SIJ and lumbar manipulation was more effective for improving functional disability than SIJ manipulation alone in patients with SIJ syndrome.
- Spinal HVLA manipulation may be a beneficial addition to treatment for patients with SIJ syndrome.
Which could be the best treatment of SIJ in patients with leg pain?
A RCT demonstrated that:
• Physiotherapy 20% of success;
• Manual therapy 72% of success;
• Intra-articular injection 50% of success.
Quais são os fortes ligamentos da sacroilíaca? E como resulta a estabilização em form closure?
- Ventral sacroiliac ligament
- Interosseous sacroiliac ligament
- Sacrotuberous ligament
- Sacrospinous ligament
- Iliolumbar ligament
- Long Dorsal ligament.
Os interósseo, sacrotuberoso, sacro espinhoso e iliolombar apresentam uma direção horizontal, enquanto o longo dorsal se dispõe na vertical, originando a form closure no sacro.
Quais são os músculos estabilizadores ativos primários da sacro-ilíaca? E secundários?
Primary:
• Multifidi
• Inferior Internal Oblique
• Transverse Abdominus
Secondary • Gluteus Maximus • Hamstrings • Erector Spinae • Latissimus Dorsi
Em que medida o transverso do abdómen e o oblíquo interno inferior interferem com a estabilidade?
• The TA and IIO pull medially on the ASIS thus increasing the stiffness of the SIJ ligaments.
Que achado clínico costumam apresentar indivíduos com dor SIJ?
- Generally individuals with SIJ pain demonstrate a delay in contraction of IO, multifidus and glut max in the support leg during standing hip flexion.
- Compensate with earlier activation of biceps femoris.
Quais são os princípios de gestão clínica?
- Focus on local muscles, TrA and multifidus.
- Low load, tonic isometric contractions.
- Include contraction of pelvic floor.
- Breath normally during abdominal drawing in action.
- Maintain specificity of deep muscle action independent of global muscles.
Como podemos gerir o exercício clínico específico?
- Focus on one particular muscle (of local system) at a time.
- Try different instruction, visual cues, or imagery.
- Try different postures and positions.
- Use various forms of facilitation and feedback.
- Use methods to decrease overactivity of global musculature.
After control of pain and local stabs what should we do?
Devemos focar-nos em exercícios de estabilidade dirigidos a outros músculos regionais que podem estar envolvidos. Ex: eretor da espinha, glúteo máximo, hamstrings, etc.
Os exercícios de estabilização resultam realmente?
There is moderate evidence to support the role of stabilization exercise in decreasing laxity of the sacroiliac joint, changing lumbopelvic kinematics, altering selective recruitment of stabilizing musculature, and reducing pain.
E os pacientes que não respondem a terapia manual, respondem a exercícios de estabilidade, mas ainda têm dor?
- We can consider the use of an SIJ Belt.
- Application of a belt significantly decreases mobility of the SIJ.
- The decrease of mobility is larger with the belt positioned just caudal to the anterior superior iliac spines than at the level of the pubic symphysis.
- The findings are in line with the biomechanical predictions and might be the basis for clinical studies about the use of pelvic belts in pregnancy-related pelvic girdle pain.
A utilização de cintas pélvicas ajuda mesmo?
- Application of SIJ belt decreased laxity by approximately 36% in women with pregnancy related pelvic girdle pain.
- Wearing a belt improved lifting strength by approximately 40%, while pain scores improved by 13%.
- A minimum tension of 50N is needed.
How to perform nutation mobilization?
The patient assumes a sidelying position with the painful side up. The painful leg is flexed beyond 90 degrees to engage the pelvis and promote passive physiological flexion/nutation of the sacrum. The clinician places his/her hands on the ischial tuberosity and ASIS to promote physiological rotation. The patient’s pelvis is passively moved to the first sign of concordant pain.
Describe the counternutation mobilization.
The patient assumes a sidelying position with the painful side up. The painful leg is extended and the table side leg flexed to 90 degrees to promote passive physiological extension/counternutation of the sacrum. The clinician cradles the leg with the caudal side hand further encouraging hip extension. The cranial sided hand is placed on the PSIS and promotes anterior rotation of the innominate. The patient’s pelvis is passively moved to the first sign of concordant pain.
Como aplicar a posterior rotation of the innominate muscle energy technique?
The leg on the painful side is flexed at the knee and hip and raised into as much hip flexion as the patient can tolerate. The opposite extremity is placed in neutral. The patient is instructed to push downward with the knee and hip against the resistance of the clinician with the involved side and simultaneously flex the opposite hip against hand resistance.
How it is performed the anterior rotation of the innominate muscle energy technique?
The leg on the painful side is placed in a position of flexion, abduction, and external rotation. The opposite extremity is placed in neutral. The patient is instructed to flex and adduct the affected lower extremity against resistance while in supine.
Como manipular a sacroilíaca?
The patient assumes a supine position and interlocks his/her fingers behind the head with elbow pulled together. The clinician side-flexes the patient’s body away and rotates the patient’s body toward them. The patient is rolled until end range and the clinician then applies a quick thrust at end range to the patient’s ASIS.
