Lumbo-Pelvic Mobilizations

[mtm34]

Any insight from PTs/SPTs on this one...
I had a patient today that tested positive for a pelvic component (+standing flexion test, seated asymmetry, prone knee bend, supine leg length) and I concluded she had an Anterior Inominate on the right, so I performed a lumbopelvic roll directed at that AI, when I rechecked the landmarks I was unsuccessful so my CI instructed me to try the same technique on the other side- a lumbopevlic roll directed at the left PI... it worked.

I can't explain why it worked... it seems counter intuitive to direct a posterior mobilization at a posterior inominate. Any considerations why this does work or any other techniques that would be useful. Thanks.

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[Akiramay]

We're on the knee in my musculoskeletal class right now, working our way up, so I'm not quite there yet. lol But I'd be interested as well to know the answer!

 

[jesspt]

Any insight from PTs/SPTs on this one...
I had a patient today that tested positive for a pelvic component (+standing flexion test, seated asymmetry, prone knee bend, supine leg length) and I concluded she had an Anterior Inominate on the right, so I performed a lumbopelvic roll directed at that AI, when I rechecked the landmarks I was unsuccessful so my CI instructed me to try the same technique on the other side- a lumbopevlic roll directed at the left PI... it worked.

I can't explain why it worked... it seems counter intuitive to direct a posterior mobilization at a posterior inominate. Any considerations why this does work or any other techniques that would be useful. Thanks.

Well, it could hve been a posterior inominate. Or maybe it was an anterior inominate. Or the inominate was upslipped. Downslipped. In-flared. Out-flared. Or maybe, just maybe, it was in the picture perfect position.

Palptory, postitional diagnosis is notoriously unreliable, and, if you're curious, I can email you a great reference that is essentially a review of the numerous studies that have looked at the reliability of palpatory positional diagnosis. But, the gist is, that it essentially demonstrates poor reliability. With poor reliability it is impossible to establish the validity of these type of tests in regards to determining cause for low back pain.

This may sound like a broken record from your musculoskeletal or statistics class.

That does not mean that the manipulation you performed isn't beneficial. But it does mean that we, as a profession, should probably think about the criteria we use to determine whether a patient is a candidate for manipulation.

As for myself, I use none of the tests you describe, due to their poor reliability. Rather, I use pain provocation tests to determine SIJ involvement, which have been shown to have better reliability and validity. If possitive, I will often performe the same manipulation you performed.

One other thing to think about. You said:

when I rechecked the landmarks I was unsuccessful so my CI instructed me to try the same technique on the other side- a lumbopevlic roll directed at the left PI... it worked.

How do you define "worked?" In my opinion, "worked" should mean that the patients symptoms were reduced. Given our inability to accurately palpate pelvic landmarks, stating anything else, such as better pelvic alignment" is likely a flasehood.

 

[mtm34]

Jess,
Thanks for replying. I assume it was an AI because the PSIS on that side was higher and the illiac crest was lower. I am aware of the inconsistency of palpatory findings but at my institution and their facilities on every low back eval there is a section dedicated to illiac positions and asymmetries. I am very curious as to what the SIJ pain provocation test you use is, any info would be greatly appreciated.
To clarify 'worked' which was a poor word choice, I meant that along with an audible cavitation there was decreased pain and a marked improvement in pelvic landmarks.

 

[jesspt]

Jess,
Thanks for replying. I assume it was an AI because the PSIS on that side was higher and the illiac crest was lower. I am aware of the inconsistency of palpatory findings but at my institution and their facilities on every low back eval there is a section dedicated to illiac positions and asymmetries. I am very curious as to what the SIJ pain provocation test you use is, any info would be greatly appreciated.
To clarify 'worked' which was a poor word choice, I meant that along with an audible cavitation there was decreased pain and a marked improvement in pelvic landmarks.

This article discusses the relevant statistics regarding SIJ pain provcation tests, and also provides diagrams.

 

[soccer31]

I agree with jesspt that the reliability with palpation is just not good, which it makes it hard to understand what was going on with your patient. Which side was he/she symptomatic? Because usually that is how I define which side is rotated.

As far as the mobilization you used, I am assuming it was a supine instead of side lying lumbopelvic roll since you didn't specify and you were targeting the inonimate, not the lumbar spine. This mobilization is in fact a more general one, that "resets the system" giving you a window that the patient can now tolerate pain and exercise (which it is what happened since the pain went away and now you could work on ROM and strength). The rule of thumb is that you should actually do on both sides, followed by WB and hand-hell rocks. The only exception would be if the first side cavitates then you do not do the other side. I know this doesn't answer your question of why it worked on one side but not the other, but to be honest I am not sure if there is an answer for that.

How did that patient classify according to the CPR for spinal manipulation? That is a better criteria to fulfill when deciding to perform a mobilization. You might want consider a muscle energy technique instead if a patient has a positive pelvic component but a negative CPR.

 

[mtm34]

Yes, I used a supine lumbopelvic roll. As far as the CPR was concerned this patient was 5/5. Age was below 40, symptoms were within 16 days, hypomobility with spring testing, no peripheral symptom, low FABQ. As far as muscle energy is concerned I have had little permanent success with those techniques, they seem work in NWB and once the pt WB's the asymmetry comes back... do you know of any studies that show good reliability for muscle energy?

 

[jesspt]

Why are either of you concerned with asymmetry? It is so common in the asymptomatic population as to make it rarely relevant.

Also, reliability refers to tests and assessment techniques, and is not typically used for treatment, so you can't look at reliability of of muscle energy techniques. You could look at the reliability of the osteopathic examination that practitioners have historically used to determine which technique they would use. In fact, that has been looked at. And, the reliability is quite poor.

 

[MinnDasota]

Like Jesspt,

I also use provocation tests to guide my treatment of possible SIJ pain. I also use those special tests, but only as an adjunct to my provocation findings. Have had great results with this.

Jess, thanks for the article. I have a student and want to give her this to back up some of what I recently have taught her.

 

[jesspt]

Like Jesspt,

I also use provocation tests to guide my treatment of possible SIJ pain. I also use those special tests, but only as an adjunct to my provocation findings. Have had great results with this.

Jess, thanks for the article. I have a student and want to give her this to back up some of what I recently have taught her.

Let me know if you would need any more. I have quite a few articles that outline SIJ assessment as well as those that look at the reliability of palpatory tests.