Evidence-based medicine is not restricted to randomized controlled trials, systematic reviews and meta-analyses. In the seminal article “Evidence-based medicine: what it is and what it isn’t”, Sackett et al 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. 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.” Certainly, cause and effect inferences cannot be made from observational studies; 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, 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), 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. 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? 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; 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 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?
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. 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. This implies that pain patterns formally believed to be intracapsular, may be related to extracapsular structures, most notably, the sacroiliac ligaments. 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.
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 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. 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 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 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). Per the three pillars of evidence-based practice, 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. 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 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.”
Sarah Hanna, PT, MPT, Cert. DN
President, Physical Therapy Rehabilitation Specialists
Fellow-in-Training, AAMT Fellowship in Orthopaedic Manual Physical Therapy
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
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