Spinal Manipulation and Dry Needling for Sacroiliac Dysfunction: a Case Study

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Evidence-based medicine is not restricted to randomized controlled trials, systematic reviews and meta-analyses.[1] In the seminal article “Evidence-based medicine: what it is and what it isn’t”, Sackett et al[1] stated, “Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannized by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient.” Although randomized controlled trials are considered the “gold standard” for experimental designs, the descriptive case study does have a place in clinical research and it is appropriately ranked as level III evidence on the hierarchy.[2,3] By definition, descriptive studies are observational and do not have a comparison group.[2] The benefits of using a descriptive study are for trend analysis and hypotheses generation;[4,5] moreover, “descriptive studies are often a springboard into more rigorous studies with comparison groups.”[6] Certainly, cause and effect inferences cannot be made from observational studies;[6] therefore, I have been very careful not to make such inferences from my personal experience of living with, and finding a “cure” for, chronic posterior pelvic pain or sacroiliac dysfunction.

For my own pain, spinal manipulation and dry needling were “game changers”. Dr. James Dunning helped me to understand the power of these techniques, clinically, as I was his “subject” for the SI joint presentation during the SMT-1 Spinal Manipulation and DN-2 Dry Needling courses. It has now been more than 18-months, and I continue to be virtually pain and disability free. First, I wish to provide a little history and context to my experience. Before taking SMT-1 and DN-2, I experienced posterior pelvic pain (or what many would classify as sacroiliac joint dysfunction) for approximately 2 years secondary to an automobile accident. My symptoms included Fortin region[7,8] pain on the right side with lower extremity referred pain into the lateral thigh and lower leg just proximal to the lateral malleolus. Using a multi-test regimen of pain provocation tests,[9-11] pain in the Fortin area,[7,8] and negative centralization of my lower extremity symptoms with repeated movements or sustained postures,[10] the SI joint was diagnosed as the primary pain generator. In addition, I also had tenderness over the medial aspect of the piriformis muscle (acupoint BL54),[12] which provided further evidence of SI involvement. Dr. Dunning then delivered a high-velocity low-amplitude (HVLA) thrust manipulation targeting the right (symptomatic side) SI joint, which resulted in multiple audible cavitations.[13,14] Yes, it did make multiple audible popping sounds! All of my symptoms were immediately eliminated, the leg symptoms disappeared, and my Fortin region pain was gone. I walked back and forth in the clinic in front of 36 other PTs taking SMT-1, amazed that my pain was gone.[15] I immediately returned to my active lifestyle of running and lifting without any apparent need for specific stabilization exercises[16-18] or bracing devices. However, a little over 6 months later, I began to experience Fortin’s region pain in certain sitting and recumbent postures. However, this time, the pain was intermittent and much less intense—a 2/10 instead of 5-6/10. It also seemed to be position-dependent. Thankfully, I had registered to attend Dr. Dunning’s DN-2 Dry Needling course, during which I again communicated my symptoms. I expected that he would want to perform another HVLA thrust, but he recommended that we dry needle the dorsal sacroiliac ligaments (acupoints BL27-29). After one session of dry needling to the dorsal SI ligaments[19,20] (not targeting muscular trigger points), I have been pain and disability free for over 14 months. In fact, I continue to be pain free to this day and maintain an active lifestyle. So what exactly took place here? Was my SI joint stiff, stuck, fixated, or out of place? Was it “form” or “force” closure problem?[16] Did Dr. Dunning put my bones back in place or were they never out of place? Using x-ray analysis, one study found HVLA thrust manipulation does not alter the position of the SI joint;[21] however, two other studies reported changes in iliac crest symmetry, side-to-side weight bearing, and/or innominate tilt immediately following HVLA thrust manipulation in patients with low back pain.[22,23]

Szadek et al[24] noted that the peri-articular structures of the sacroiliac joint might be a source of pain in patients with posterior pelvic dysfunction. Perhaps my SI joint was fixated or stuck, and that may explain why the HVLA thrust manipulation provided immediate and lasting pain relief for 6 months—i.e. could the manipulation have addressed a “form” closure problem? Additionally, is it possible that the extra-articular ligaments of the SI joint had been traumatized and had made adaptive changes since the automobile accident? Could dry needling using multiple needles with unidirectional and simultaneous sustained low-load tensioning have made changes to the collagen and/or nociceptive input from the damaged dorsal SI ligaments or connective tissue?[25-28] After hearing the didactic components of the SMT-1 Spinal Manipulation and DN-2 Dry Needling courses, experiencing a single session of HVLAT manipulation and dry needling, and conducting a detailed literature review of the topic, I now believe that there may be both an intra and peri-articular component to SI dysfunction. Importantly, my experience is only a “case study”, and my comments are therefore only suggestive of a hypothesis regarding the etiology of my chronic SI condition.

Some of my colleagues have remarked, “I’ve always treated the SI with the premise that there is a mechanical block or positional fault” (i.e. ‘joint out of place’) perhaps causing altered tension in the peri-articular ligaments, with altered muscle motor control, timing and/or inhibition. With the restoration of movement following manipulation, perhaps there is decreased pain and muscle activation of the gluteals and improved sensory input from normalizing tension in the ligaments. Maybe the dorsal ligaments of the sacroiliac joint are still adaptively shortened and act as a pain generator post-manipulation because they are not reflexively altered as has been found to be the case with improved feed-forward activation timing of the transverse abdominus immediately following HVLA thrust manipulation to the sacroiliac joint?[29]

From my own personal experience as both a patient with SI dysfunction and as a clinician, I am beginning to consider whether I should stop thinking of the intra-articular structures of the SIJ as a sole source of pain/dysfunction and also consider the extra-articular connective tissue. If we consider the possibility that the SIJ is stiff, stuck, fixated, or out of place, is it not be reasonable to suggest that this misalignment (sounds evil saying this!) could also contribute to abnormal strains to the connective tissue (dorsal ligaments of the SIJ), predisposing it to adaptive shortening and disorganization of the collagen fibers. Perhaps the HVLA thrust manipulation addressed the arthrogenic dysfunction of the SIJ and had some affect on the surrounding connective tissue as well since I had complete pain relief for 6 months following a single manipulation to my SI joint by Dr. Dunning.

However, I postulate that not all the dysfunctional tissue was addressed during the manipulation and, for this reason, the recurrence of Fortin region pain, approximately 6 months later, occurred in certain positions that stressed the SIJ and posterior extra-articular connective tissues. Interestingly, side lying or sitting with excessive anterior pelvic tilt reproduced Fortin region pain. When my pain returned, it was specific to the Fortin region and did not descend into the thigh or lower leg as was the case before the HVLA thrust manipulation. There are 7 soft tissue layers that overlie Fortin’s area before encountering the posterior SI joint.[30] Certainly there are tissues in this region besides intra-articular structures that can be a source of pain.[24,31] Critics of using a double diagnostic injections as the gold standard for identifying the SI joint as the primary pain generator are quick to point out that 61% of the time, the injected anesthetic leaks out of the joint, but patients still report pain relief.[31] This implies that pain patterns formally believed to be intracapsular, may be related to extracapsular structures, most notably, the sacroiliac ligaments.[24] In my personal experience, needling only the soft tissue in Fortin’s region with the intention of targeting the dorsal SIJ ligaments and imposing unidirectional, sustained low-load tension for approximately 15-30 second intervals (quite painful I must say), completely eliminated my pain for over a year.[28]

My guess is that critiques of HVLA thrust manipulation techniques and/or dry needling (i.e. those PTs that tend to leave out the “bio” component of the “biopsychosocial approach”—perhaps due to a lack of skill in manipulative therapy—and think they can “talk away” chronic musculoskeletal pain without using any form of manual therapy) will question my history of low back issues or weakness. It should be noted that I do not have a history of low back pain; rather I have a history of Fortin’s area pain[7,8] and referral into the lower extremity—i.e. no pain above the level of the PSIS. Importantly, I was positive on greater than 3 of 6 and 3 of 5 pain provocation tests on the validated Laslett et al[9,10] and van der Wurff et al[11] multi-test regimens, respectively. Yes, I did experience symptoms into the thigh and lower leg (i.e. below the knee), and contrary to the inclination of many practitioners that seem to believe the SI joint can’t refer below the knee, the literature clearly supports that the SI joint can indeed refer into the lower leg and even the foot.[8] Instead of focusing on stabilization and motor control to achieve “force closure”, perhaps targeting the tissue structure responsible for harboring the pain can more efficiently restore function by simply breaking the cycle of pain inhibition[32,33]—even when it has become chronic (i.e. longer than 12-weeks) and is viewed by many as a “brain problem” as the tissues have had a chance to heal already.

In short, here is my opinion on what occurred with my injury, chronic pain state, and full recovery. My initial treatment was simply HVLA thrust manipulation targeting the right SI joint with complete abatement of all Fortin region and lower extremity pain for 6 months. When the Fortin region pain recurred 6 months later, needling the dorsal SIJ ligaments alleviated the pain completely for over a year. From a subjective standpoint, I would also have to admit that my pelvis felt “out-of-place” for the 6 months until it was manipulated[22,23]—yes it sounds like I have turned to the dark side, I know. Although there appears to be no reliable symmetry or motion tests to determine if I had a positional fault and/or movement dysfunction of the SI joint,[30,34-37] I did perceive a positional asymmetry in my pelvis and leg length discrepancy which seemed to immediately improve post-HVLA thrust manipulation.[15,22,23] Importantly, due to the poor inter- and intra-rater reliability of SI joint symmetry and motion testing and poor target and direction specificity of SI manipulation techniques,[30,34,35,38] symmetry tests for “malposition” and motion tests for movement restrictions were not performed prior to Dr. Dunning delivering the initial SI joint HVLA thrust manipulation. So how did he know what direction to manipulate “in to” or “out of”? Interestingly, Clements et al[39] found direction specificity wasn’t required for “successful” HVLA thrust manipulation. In fact, the only assessment findings were: a positive multi-test regimen of three or more of the Laslett et al[9,10] and van der Wurff et al[11] pain provocation tests, pain specific to Fortin’s region,[7,8] non-centralizing pain with repeated movements and/or sustained postures,[9,10] and tenderness over the medial side of the piriformis (acupoint BL54).[12] Per the three pillars of evidence-based practice,[1] to include the literature, my time as a clinician, and my experience as a patient, I am no longer convinced that the traditional recipe that most physical therapists employ for SI dysfunction, which in the main calls for “force closure”, specific stabilization, core strengthening, motor control, co-contraction of the lumbar multifidus and transverse abdominus etc. treatments, is optimal—or perhaps what I had is extremely unusual and not the norm for posterior pelvic and leg pain. In addition, while I do believe considering the “psychosocial” and central mediated aspects of chronic pain are useful, I wonder if the physical therapy profession is beginning to forget about the “bio” in biopsychosocial.

I now appreciate that when a pain provocation test is positive during the multi-test regimen,[9-11] I cannot assume it is positive solely due to intra-articular dysfunction. Understanding that it is possible to obtain positive pain provocation tests from stressing the peri-articular structures is important.[24] As clinicians, this opens our treatment strategies to include both articular (HVLA thrust manipulation or non-thrust mobilization) and peri-articular (dry needling or other forms of instrument-assisted manual therapy) targeted treatments for those diagnosed as having an SI joint dysfunction.

In recent years, it seems that single trials have led many to worship clinical prediction rules,[40-43] believe “the pop isn’t necessary”,[44,45] think only “one pop is specific”,[13,14,38] or that the transverse abdominus is the only muscle authorized by God to “stabilize” the spine;[16,46-48] however, I think it would serve the clinician well to remember what Sacket et al[1] so eloquently stated, “External clinical evidence can inform, but can never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and, if so, how should it be integrated into a clinical decision.”

Authors:

Sarah Hanna, PT, MPT, Cert. DN
President, Physical Therapy Rehabilitation Specialists
Fellow-in-Training, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Phoenix, AZ

Raymond Butts, PhD, DPT, MSc (NeuroSci) Cert. DN, Cert. SMT
Coordinator, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Senior Instructor, Spinal Manipulation Institute & Dry Needling Institute
Atlanta, GA

References

1. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. Bmj. Jan 13 1996;312(7023):71-72.
2. Grimes DA, Schulz KF. An overview of clinical research: the lay of the land. Lancet. Jan 5 2002;359(9300):57-61.
3. Vandenbroucke JP, von Elm E, Altman DG, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration. Ann Intern Med. Oct 16 2007;147(8):W163-194.
4. Lu CY. Observational studies: a review of study designs, challenges and strategies to reduce confounding. Int J Clin Pract. May 2009;63(5):691-697.
5. Benson K, Hartz AJ. A comparison of observational studies and randomized, controlled trials. N Engl J Med. Jun 22 2000;342(25):1878-1886.
6. Grimes DA, Schulz KF. Descriptive studies: what they can and cannot do. Lancet. Jan 12 2002;359(9301):145-149.
7. Fortin JD, Falco FJE. The Fortin finger test: an indicator of sacroiliac pain. The American Journal of Orthopedics. 1997;26:477-480.
8. van der Wurff P, Buijs EJ, Groen GJ. Intensity mapping of pain referral areas in sacroiliac joint pain patients. J Manipulative Physiol Ther. Mar-Apr 2006;29(3):190-195.
9. Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Man Ther. Aug 2005;10(3):207-218.
10. Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests. Aust J Physiother. 2003;49(2):89-97.
11. van der Wurff P, Buijs EJ, Groen GJ. A multitest regimen of pain provocation tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures. Arch Phys Med Rehabil. Jan 2006;87(1):10-14.
12. Fishman LM, Dombi GW, Michaelsen C, et al. Piriformis syndrome: diagnosis, treatment, and outcome–a 10-year study. Arch Phys Med Rehabil. Mar 2002;83(3):295-301.
13. Dunning J, Mourad F, Barbero M, Leoni D, Cescon C, Butts R. Bilateral and multiple cavitation sounds during upper cervical thrust manipulation. BMC Musculoskelet Disord. 2013;14:24.
14. Ross JK, Bereznick DE, McGill SM. Determining cavitation location during lumbar and thoracic spinal manipulation: is spinal manipulation accurate and specific? Spine (Phila Pa 1976). Jul 1 2004;29(13):1452-1457.
15. Shearar KA, Colloca CJ, White HL. A randomized clinical trial of manual versus mechanical force manipulation in the treatment of sacroiliac joint syndrome. J Manipulative Physiol Ther. Sep 2005;28(7):493-501.
16. Mens JM, Snijders CJ, Stam HJ. Diagonal trunk muscle exercises in peripartum pelvic pain: a randomized clinical trial. Phys Ther. Dec 2000;80(12):1164-1173.
17. Stuge B, Veierod MB, Laerum E, Vollestad N. The efficacy of a treatment program focusing on specific stabilizing exercises for pelvic girdle pain after pregnancy: a two-year follow-up of a randomized clinical trial. Spine (Phila Pa 1976). May 15 2004;29(10):E197-203.
18. Stuge B, Laerum E, Kirkesola G, Vollestad N. The efficacy of a treatment program focusing on specific stabilizing exercises for pelvic girdle pain after pregnancy: a randomized controlled trial. Spine (Phila Pa 1976). Feb 15 2004;29(4):351-359.
19. Dunning J, Butts R, Mourad F, Young I, Flannagan S, Perreault T. Dry needling: a literature review with implications for clinical practice guidelines. Phys Ther Rev. Aug 2014;19(4):252-265.
20. Lewit K. The needle effect in the relief of myofascial pain. Pain. Feb 1979;6(1):83-90.
21. Tullberg T, Blomberg S, Branth B, Johnsson R. Manipulation does not alter the position of the sacroiliac joint. A roentgen stereophotogrammetric analysis. Spine (Phila Pa 1976). May 15 1998;23(10):1124-1128; discussion 1129.
22. Cibulka MT, Delitto A, Koldehoff RM. Changes in innominate tilt after manipulation of the sacroiliac joint in patients with low back pain. An experimental study. Phys Ther. Sep 1988;68(9):1359-1363.
23. Childs JD, Piva SR, Erhard RE. Immediate improvements in side-to-side weight bearing and iliac crest symmetry after manipulation in patients with low back pain. J Manipulative Physiol Ther. Jun 2004;27(5):306-313.
24. Szadek KM, van der Wurff P, van Tulder MW, Zuurmond WW, Perez RS. Diagnostic validity of criteria for sacroiliac joint pain: a systematic review. J Pain. Apr 2009;10(4):354-368.
25. Langevin HM, Bouffard NA, Badger GJ, Churchill DL, Howe AK. Subcutaneous tissue fibroblast cytoskeletal remodeling induced by acupuncture: evidence for a mechanotransduction-based mechanism. J Cell Physiol. Jun 2006;207(3):767-774.
26. Langevin HM, Bouffard NA, Badger GJ, Iatridis JC, Howe AK. Dynamic fibroblast cytoskeletal response to subcutaneous tissue stretch ex vivo and in vivo. Am J Physiol Cell Physiol. Mar 2005;288(3):C747-756.
27. Langevin HM, Bouffard NA, Churchill DL, Badger GJ. Connective tissue fibroblast response to acupuncture: dose-dependent effect of bidirectional needle rotation. J Altern Complement Med. Apr 2007;13(3):355-360.
28. Langevin HM, Churchill DL, Cipolla MJ. Mechanical signaling through connective tissue: a mechanism for the therapeutic effect of acupuncture. Faseb J. Oct 2001;15(12):2275-2282.
29. Marshall P, Murphy B. The effect of sacroiliac joint manipulation on feed-forward activation times of the deep abdominal musculature. J Manipulative Physiol Ther. Mar-Apr 2006;29(3):196-202.
30. McGrath MC. Palpation of the sacroiliac joint: an anatomical and sensory challenge. International Journal of Osteopathic Medicine. 2006;9(3):103-107.
31. Berthelot JM, Labat JJ, Le Goff B, Gouin F, Maugars Y. Provocative sacroiliac joint maneuvers and sacroiliac joint block are unreliable for diagnosing sacroiliac joint pain. Joint Bone Spine. Jan 2006;73(1):17-23.
32. Arendt-Nielsen L, Graven-Nielsen T, Svarrer H, Svensson P. The influence of low back pain on muscle activity and coordination during gait: a clinical and experimental study. Pain. Feb 1996;64(2):231-240.
33. Hodges PW, Moseley GL. Pain and motor control of the lumbopelvic region: effect and possible mechanisms. J Electromyogr Kinesiol. Aug 2003;13(4):361-370.
34. Freburger JK, Riddle DL. Using published evidence to guide the examination of the sacroiliac joint region. Phys Ther. May 2001;81(5):1135-1143.
35. Riddle DL, Freburger JK. Evaluation of the presence of sacroiliac joint region dysfunction using a combination of tests: a multicenter intertester reliability study. Phys Ther. Aug 2002;82(8):772-781.
36. Robinson HS, Brox JI, Robinson R, Bjelland E, Solem S, Telje T. The reliability of selected motion- and pain provocation tests for the sacroiliac joint. Man Ther. Feb 2007;12(1):72-79.
37. Holmgren U, Waling K. Inter-examiner reliability of four static palpation tests used for assessing pelvic dysfunction. Man Ther. Feb 2008;13(1):50-56.
38. Beffa R, Mathews R. Does the adjustment cavitate the targeted joint? An investigation into the location of cavitation sounds. J Manipulative Physiol Ther. Feb 2004;27(2):e2.
39. Clements B, Gibbons P, McLaughlin P. The amelioration of atlanto-axial rotation asymmetry using high velocity low amplitude manipulation: Is the direction of thrust important? Journal of Osteopathic Medicine. 2001;4(1):8-14.
40. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine (Phila Pa 1976). Dec 15 2002;27(24):2835-2843.
41. Fernandez-de-las-Penas C, Cleland JA, Palomeque-del-Cerro L, Caminero AB, Guillem-Mesado A, Jimenez-Garcia R. Development of a clinical prediction rule for identifying women with tension-type headache who are likely to achieve short-term success with joint mobilization and muscle trigger point therapy. Headache. Feb 2011;51(2):246-261.
42. Cleland JA, Mintken PE, Carpenter K, et al. Examination of a clinical prediction rule to identify patients with neck pain likely to benefit from thoracic spine thrust manipulation and a general cervical range of motion exercise: multi-center randomized clinical trial. Phys Ther. Sep 2010;90(9):1239-1250.
43. Vicenzino B, Collins N, Cleland J, McPoil T. A clinical prediction rule for identifying patients with patellofemoral pain who are likely to benefit from foot orthoses: a preliminary determination. Br J Sports Med. Sep 2010;44(12):862-866.
44. Flynn TW, Fritz JM, Wainner RS, Whitman JM. The audible pop is not necessary for successful spinal high-velocity thrust manipulation in individuals with low back pain. Arch Phys Med Rehabil. Jul 2003;84(7):1057-1060.
45. Evans DW, Lucas N. What is ‘manipulation’? A reappraisal. Man Ther. Jun 2010;15(3):286-291.
46. Lederman E. The myth of core stability. Journal of Bodywork and Movement Therapies. 2010;14:84-98.
47. MacDonald DA, Moseley GL, Hodges PW. The lumbar multifidus: does the evidence support clinical beliefs? Man Ther. 2006;11(4):254-263.
48. Holm S, Indahl A, Solomonow M. Sensorimotor control of the spine. J Electromyogr Kinesiol. Jun 2002;12(3):219-234.

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