I think this was really well done to challenge practice patterns of this region with good support from the literature. I feel like a few quotes really summarize common poor clinical reasoning, which is contrary to current evidence, of diagnosing pain in this region-
– “Frequently, movement dysfunction of the SIJ is credited with being a driver of increased local tissue sensitivity and subsequent symptoms. The biological plausibility of reaching such conclusions based on movement detection and palpation of the SIJ has been questioned for more than 10 years.”
– “…although clinicians commonly seek to identify movement dysfunctions on the basis of such tests, weight of evidence has not changed in the last decade and the use of these tests and models of movement dysfunction testing of the SIJ remains unsupported.”

A personal challenge for me in clinical practice is delivering a message of the inherent stability of the spine and educating on benefits and intention behind exercises that I am prescribing. This becomes even more challenging with patients who are hanging on for dear life to a pathoanatomical diagnosis from Dr. Google, imaging, another healthcare provider, etc. I found some of the specific examples they gave for educating on pain in this area and treatment rational very helpful (ex: your spine/SIJ is a strong structure and the pain you are experiencing is due to increased sensitivity of this area; sensitive tissues respond well to load; manual therapy to decrease sensitivity for exercise participation), and also provide a good “template” that you can change to make specific to other body regions and patient presentations.

Such a good article that really calls out why we are still doing things that for one aren’t supposed by evidence and two that almost contradict each other (mobilize the SIJ but give stability exercises for home).

Thoughts:
– the movement that happens at the SIJ is SO minute, how can we think so highly of ourselves that we are able to detect it?
– if the movement is minimal, why treat it like it has a major impact (i.e. mobilizing to get back 1 degree of motion is likely not relevant to the patient)
– I think Anna picked two of the best quotes from the article – why are we even teaching PT students the Gillet test if we aren’t even good at finding the PSIS?!
– I love the idea of talking about tissue sensitivity and neurophysiologic mechanisms as a rationale for why exercise is the best bet in most of these patients.
– We as a profession are movement experts – not ANTI-movement experts. We’ve got to stop (intentionally or unintentionally) making people fearful of movement.

Great article with lots of good take aways to apply to our daily practice. Sending this to my coworkers!

This article does an excellent job of pointing out some flaws in our reasoning when it comes to SIJ dysfunction. I agree with Helen that it seems completely counterintuitive for us to mobilize a joint that has minimal motion to begin with and it seems pointless to mobilize here at all since we are so inaccurate with our detection of the movement.

I really liked how the authors discussed the pathoanatomical explanations and labels, and how that can influence the patient’s outlook and avoidance of activities. I know I still struggle some days with my explanations to patients about the cause of the problem, but I think that explaining how the SIJ/spine is more sensitive to that input will be helpful without using the more harmful words. I think that educating on this sensitivity, rather than “upslip/torsion/whatever” after Google or other healthcare professionals, will help us get these patients back into normal activities sooner rather than later and get them less focused on their pain as well. I think this framework will definitely help me be less clumsy with my words and help the patient get a better, less fear inducing idea of what’s going on.

This article highlights the importance of clinicians carrying with them a healthy sense of skepticism and to continually challenge their own beliefs. Additionally, it is articles like this that hopefully helps clinicians to take a step back, reflect, and make the necessary changes to their practice.

In reflection, I have found myself guilty of practicing many of the tests and measures, and nocebo infested remarks within this article. Although this isn’t necessarily wrong or bad, it is important to remain open-minded and to keep one’s practice plastic and ready for change, rather than being married to an ideology.

When working with future patients with SIJ dysfunction I feel my practice will benefit from moving away from pathoanatomic and biomechanical diagnoses. Instead, a focus on dispelling harmful beliefs, reinforcing resilience, and decreasing tissue sensitivity via load management will be most helpful.

This was an exquisite article that breaks down the problems with being absolutely dogmatic to one way of thinking (SIJ is the source of all back pain) when there isn’t much validity, reliability, or pathophysiological backing to it.

However, it made me think: what other dogmatic things am I carrying around with me? There are tons of things I do in clinic that are along the same lines. Joint mobility reliability and validity can also be questioned, but I still do it and tell the patient a “story” based on my own biases. When I talk about scap dyskinesia or some other biomechanical principle, how do I know I’m not doing the same thing as the SIJ advocates?

I would like to think I can lean on two different principles that make it okay to do so: Using the assess-treat-reassess model; avoiding Nocebo education. If a patient wants to lift their arm overhead for an ADL and I do a joint mobilization after seeing shoulder elevation and it improves upon reassessment, I feel like that’s enough clinical evidence to feel good about my biases. Then, if I educate the patient on how to do it themselves (avoid dependency) while avoiding scary language (out of place, dysfunctional, etc) and get them moving again (addressing fear avoidance) then I’ve done what I can to live with my own biases.

I think it’s only a matter of time before something we believe goes through the same thing that SIJ focused people are experiencing right now. As long was we do are due diligence to be patient specific, use clinical findings to drive treatment, and don’t instill negative beliefs, I feel better about navigating the ambiguous 14 lane highway of PT.

Great points Barrett. I think this article highlights a ton of principles we should be applying to our practice in general as opposed to just the SIJ. We need to consistently toe the line of “I think I know how to help your pain and here’s why,” and not sounding like the patient has a serious medical issue. Messages of fragility are unfortunately a consistent theme of orthopedic practice and we now know they have a harmful lasting effect. That being said, part of our jobs is to help people cope with MSK pain and potentially provide relief in some way. Typically we can link some tissue to the complaints, and want to educate our patients about what we think is going on.

How do you all relay your messages about movement diagnoses or tissues at fault without noceboing your patients?

Taylor-
How I relay these messages is very patient dependent. I am still learning day by day how to be a better educator and identifying specific characteristics of patients that can “handle” more specific explanations vs those that would do better without.

I tend to be very general with more emphasis on what sort of things the patient can do to help when there is a long history, multiple psychosocial factors, lower education level, etc.

Then, in contrast, some situations there are patients who want to know every little detail, and I have to spend a little more time going into things. I feel like in these situations, though, it is still important to watch what I am saying and give thorough education without unintentionally delivering a “nocebo” message.

What patient characteristics do y’all tend to associate with needing more care to not instill fear associated with education on your “diagnosis”? And on the flip side when do y’all feel more comfortable giving a more thorough explanation?

Taylor/Anna: I feel like it really depends on the patient in front of me. I feel like lately I’ve had a few patients that have a lower educational level, and they’re fixated on their “shattered” or “crushed” discs, so I’m having to educate on more specific structures than I think I typically would. I try to do my best to educate to their level of understanding, but it’s definitely much harder when all they hear from the doctor is crushed or shattered without any other information to decrease the fear associated with the injury. On the other hand, I have a couple of patients who are so hypervigilant and focused on their injury, that I try to stay less specific with my language to reduce their focus on that particular region. Definitely still a work in progress for me though. Do you guys have any strategies that y’all use for those hypervigilant patients to reduce focus on that body part?

I think hypervigiliance is a tough one. I feel like implying that we ignore their pain leads to the idea that they just have to learn how to “live with it” which isn’t the message we are actually sending. For me it’s particularly tough because I always screw up and ask them how they are feeling after interventions out of habit.

Not that this is a success story, but I am currently working with someone in their 70s with chronic pain, body chart 80% colored in kind of deal. They fell on their knee 6 months ago and fractured their patella. Their entire R LE now has allodynia and lots of pain which was her primary complaint, but if you got her talking, she would talk about her entire body and how it’s been that way for 40 or 50 years.

I’ve been performing desensitization techniques, pain science education, and just general movement to some success. However, during any intervention she was more than willing to tell me every little thing she felt, particularly during glute bridges. Thankfully, her pain kept moving around during this intervention (it was in her buttock, then her hamstring, then her core, then on the front, then her ankle).

I was able to use this as a springboard to tie in what we had talked about with pain science and check her understanding. I would ask her what she felt the reasonable explanation was for why her symptoms moved around so much and often times she would say she didn’t know. That meant I did a poor job of educating her and relating the pain science to her situation. After this happened several times where I was able to fill in the gaps, I’ve noticed that she’s reporting every little thing she feels less the greater her understanding of central sensitization becomes. We were also able to begin talking about how not every sensation = pain, tissue damage, or problem, and that there is a difference between the feeling of a stretch and tissue damage.

I was helped in this particular situation because her hypervigilance was paired with widespread symptoms that can’t make any sense. Therefore, I could politely challenge her to explain it and then reframe it with the missing gaps from pain science education. I think it would be much harder if it was a localized spot like the low back. I’m not sure how I would go about that situation.