THE CONSERVATIVE TREATMENT OF PAIN IN THE SACROILIAC REGION DURING PREGNANCY: A CASE STUDY Paulsen TE, BSc (Physiotherapy) P art-tim e Lecturer, D epartm ent of P hysiotherapy, U niversity of the Witwatersrand. SUMMARY A case study of a pregnant woman complaining of pain in the left sacroiliac area is presented. In a field where differences of opinion between authorities are common, the importance of clinical presentation and assess­ ment is stressed. The selection of techniques is discussed highlighting some of the implications of treating the sacroiliac joint (SIJ) during pregnancy. OPSOMMING ’n Gevalle studie van 'n swanger vrou wat kla van pyn in haar linker sakroiliale area, word aangebied. In 'n veld waar outoriteite dikwels van mekaar verskil, word die belangrikheid van die kliniese voorkoms en die evaluering van die pasiSnt, benadruk. Die keuring van verskillende teg- nieke word bespreek, met verwysing na sommige van die behandelingsimplikasies van die sakroilialegewrig ge- durende swangerskap. INTRODUCTION The reported incidence of low back pain during pregnancy is substantial1*8. Research suggests that approximately 50% of preg­ nant women experience back pain which is of sufficient intensity and duration to affect their lifestyle in some way2,5'7'9. CASE REPORT Examination Subjective Assessment An active 32 year old woman (24 weeks pregnant), presented with pain in the lower left side of her back in a small area around the left sacroiliac joint (SU). She described the pain as constant, dull and deep which, on certain movements, became very severe. The move­ ments which could set off the very severe pain included going from sitting to standing or taking full weight through her left leg. However, they were unpredictable iii their effect and did not always bring on the severe reaction. During the day when at rest, the patient reported the pain as being 2 on a 5-point scale of severity. The occasional severe “spasms” could be as severe as 5 out of 5, returning to 2 if she kept still. She was able to sleep comfortably on either side with a pillow between her legs. She reported no severe pain on first waking in the morning, although she needed to be careful how she got up out of bed. There had been a gradual awareness of increasing discomfort over the previous week which she thought may have been aggravated during an antenatal exercise class three days previously. The more severe intermittent pains had started the day following this class. H er occupation as a freelance journalist involved varying periods sitting at a desk at a computer, as well as regular travel. She had been working normally, and apart from attending regular antenatal exer­ cise classes, played social tennis about once a week. In November 1991 when she was 11 weeks pregnant she reported being sore and stiff in the same area. She had received physiotherapy treatment on four occasions from another physiotherapist, which consisted o f massage and what sounded like a rotation manipulation. The pain had eased off but she was uncertain as to whether the treatment had helped very much. This was her first pregnancy which had progressed normally. Objective Assessment On observation the patient had a slight increase in the normal curvature of her lumbar spine. No other abnormalities were ob­ served, but she moved slowly and cautiously and did not bear full weight on her left leg. Lumbar flexion was restricted to the level of the mid-shin due to pain in the left sacroiliac area. The patient “climbed up her legs” in order to return to the upright position. Spinal extension and lateral flexion to the left and right were full range and pain free with overpressure. Spinal rotation to the left and right were full range but elicited a slight twinge o f pain with manual overpressure. The following SU tests were found to be positive. In supine, oscillating movements aimed at opening the posterior surfaces of the SU’s produced a slight increase in pain in the left SU area. In right side lying, forward and backward rotation o f the iliac crests repro­ duced a similar increase in pain. Tension tests, peripheral joint tests and a neurological examin­ ation were unremarkable. Tests such as the prone knee bend and all the palpation tests were performed in a modified position in side lying, with a pillow between the legs. On palpation slight protective muscle spasm was noted alongside the lumbar spine. Central, and left and right unilateral pastero-ante- rior movements on the twelfth thoracic to the first sacral vertebrae produced no increase in pain. Left and right transverse pressures on the spinous processes on the same vertebrae and oscillatory press­ ures on the sacrum from it’s proximal to distal end gave similar results. According to Grieve10, the only area where the SU can be pal­ pated is on the ilium in the region o f the posterior inferior iliac spine. Palpation at this locality was very tender, particularly when the pressure applied was directed antero-laterally. Treatment One (24-2-92) Due to the severity o f the patient’s pain and because the joints had been subjected to a fair amount of movement during the exam­ ination, the following treatment was given. As described by Mait­ land6, a small rotatory movement (grade II-) of the pelvis towards the right was performed for 30 seconds. No discomfort was felt during the mobilisation. H er level o f pain was unchanged and flexion was the same, but returning to the upright position was easier. On trunk rotation to the left she reported only a slight increase in discomfort in the left SU area, while rotation to the right was full range and pain free with overpressure. The SU tests remained unchanged. This mobilisation technique was performed twice more for 30 seconds. Neurological examination was unchanged and remained so throughout the rest of the treatment o f the patient. Treatment Two (25-2-92) The following day, she reported that she felt sore for a few hours following the treatment and had a few severe spasms during that time. However, she was now feeling “generally much better” but still assessed her pain as 2/5. She could weight bear normally through the left leg. Trunk flexion and rotation was full range and painfree while the SU tests remained positive. It was decided to use a slightly larger amplitude movement (grade Bladsy 14 Fisioteraple, Februarle 1993 P eel 49 no 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) ff^ r ■* fC ^ .*; < ^ v«#rd^wo ff tJoO '̂ - î T v ^ * & * * ' ' V5K $ u & > y e ) ' io o ^ ( & If you’d like to work in th e US, co n ta c t HPI. We’ve helped m ore physical th e ra p ists find g re a t jo b s in A m erica th an any oth er recruiter. Top pay, expert licensing an d visa p rocessing. F ees paid by your em ployer. sIIIIIIHPi The Leader in International Healthcare Recruiting 812 Oak Street, Winnetka, IL 60093 USA (Reverse Charges) 708-441 -8384 Fax:708-441-8401 The McKenzie Institute International has pleasure in announcing its intention to commence its Education Programme in South Africa. The Programme consists of four Educational Courses: Part A - The Lumbar Spine Part B - The Cervical and Thoracic Spine Part C - Problem Solving Part D - Manipulative Technique The McKenzie Institute offers a ten week Diploma Programme in New Zealand. Passes in Parts A - D are a pre-requisite for entry to the Diploma Programme. All Courses in South Africa will be p re s e n te d by C re d e n tia le d McKenzie Institute Lecturers. For further details on the Institute's Education Programme, contact: Lawrence Dott (Executive Director) McKenzie Institute International P O Box 93 Waikanae NEWZEALAND Fax: 64 4 293 2897 W O R K IN T H E USA PHYSIOTHERAPISTS EXCELLENT JOBS We handle all licensure and visa paperwork. Minimum commitment of one year required. TRN fees paid by employer. Therapy Resource Network, Inc. P.O. Box 5430 199 North Main Street Plymouth, Michigan, 48170 Call: 0 9 1 -3 1 3 45 5-666 0 PPS - Because you just don't know when misfortune could strike PPS — Professional Cover For Professionals The best sickness and disability benefits, a tax-free lump sum on retirement, group term life cover, retirement annuity schemes and Profmed — the medical aid scheme tailored for the professional. Available to Graduate Professionals only. S o ... start out right, call PPS today. The Professional Provident Society of South Africa P.O. Box 1089 HOUGHTON 2041 Tel No: (011) 486-1088 Fax No: (011) 486-2946, <23 4581E R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) INSTRUCTIONS FOR AUTHORS The Type of Article Contributions to the South African Journal o f Physiotherapy are invited on any topic related to physiotherapy or rehabilitation. A full-length article may be • a report on research • a description of an approach • a literature review • a presentation o f a theory. A short report may be • a case report • a clinical report • a treatment technique or suggestion. Legal Considerations • contributions will be considered for publication in the South African Journal o f Physiotherapy on condition that * they have not been published previously * they have not been submitted for publication elsewhere. • the Publications Division of the SASP reserves the copyright of all material published. Acceptance Articles are accepted on the understanding that they are subject to editorial revision. Presentation Articles • articles should be restricted to between 2,000 and 2,500 words. • copy submitted should be typewritten with double spacing and wide margins • word processors may be used provided the typeface is clear and legible. • a title page should be supplied as a separate sheet and include the name(s)', qualifications and affiliation(s) o f the author(s), together with addresses and telephone numbers (at home and at work). • each article must be accompanied by a summary of not more than 200 words. This should be on a separate sheet. It should be intelligible without reference to the main text. It must be in both official languages. • key words which sum up the content of the article which are not a duplication of the title must be included. Three words are sufficient for referencing and indexing. • all abbreviations should be spelt out when first used. • the metric system is to be used throughout. Letters to the editor • if a letter is intended for the correspondence column it should be marked “for publication”. • it should not be longer than 400 words. References • all references should be typed on a separate sheet. • references should be cited in sequential order. Do not list them alphabetically. • they are identified in the text by superscript arabic numbers. • references should be set out in the Vancouver style and only approved abbreviations o f journal titles should be used. • it is the author’s responsibility to verify references from the original sources. • “Unpublished observations” and “personal communications” may be cited in the text, but not in the reference list • manuscripts accepted but not yet published may be cited, fol­ lowed by “(in press)”. The format for reference is as follows: Journals: Not more than three authors 1. Ellison P, Browning C, Larson B etal. A scoring system for the Milani-Comparetti and Gidoni method o f neurologic assessment in infancy. Phys Ther 1983;63:1414-142. 2. Pryor JA and Webber BA. An evaluation of the forced expira­ tion technique as an adjunct to postural drainage. Physiotherapy 1979;65( 10):304-307. Books: 1. Maitland G D. Vertebral Manipulation. 4th ed. London: But- terworths, 1977:24. 2. Lipow HW and McQuitty JC. Cystic Fibrosis. In: Rudolf AM, ed. Pediatrics. Norwalk, Connecticut: Appleton-Century-Crofts, 1982:1433-1440. Illustrations • tables and figures should be kept to a minimum and be on separate sheets. • each table should be numbered and have a clear title. Tables should not repeat material stated in the text. All tables and figures must be referenced in the text in sequential order. • figures should be in black ink on stiff white paper. The lettering should be done professionally or by means of a stencil to allow for reduction in size. • photocopies are not acceptable. • graphics printed on dot-matrix printers are not acceptable. • photographs should be of good quality on glossy paper. Human subject must not be identifiable or their pictures must be accom­ panied by written permission to use the photograph. • all illustrations should be clearly marked on the reverse side with arabic numerals, author’s name and article, and an indication o f the top side. • all legends must be typed on a separate sheet. • if a figure has been published before, the author must submit written permission from the copyright holder to reproduce the material. Manuscript submission • a covering letter, which must include the signature o f each co­ author, should accompany each manuscript. • the original copy of the paper as well as two copies, must be submitted. A further copy o f the manuscript should be retained by the author. • permission to reprint figures or extracts from other publications should be included with the manuscript on submission. ___________ CASE STUDIES___________ Authors are invited to submit articles in a new category - “Case Studies” - to the SA Journal of Physiotherapy. Guidelines: Articles should be not longer than 1,000 words or 3 pages typed in double spacing. The article should comprise • Short abstract: 40 - 50 words • Short background to the problem • Description of case history - assessment, treatment, results of treatment • Conclusion - summary and recommenda­ tions. Bladsy 16 Fisioterapie, Februarie 1993 P e e l 49 no 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) II) which was repeated 3 times for 30 seconds. Coming up from the fully flexed position was easier and the SU tests produced slightly less pain than before. This was followed by a light massage in side tying. Treatment Three (28-2-92) Three days later the patient reported that she was only aware o f a dull pain (1/5), and had felt an occasional twinge in the left SU. She had also noticed some “general stiffness” in her lower back after sitting at her desk for some time, but this eased once she got up and moved around. Medially directed pressure on the anterior superior iliac spines (ASIS) caused a twinge of pain in the left SU. This movement was then used as a treatment technique for 30 seconds and following the SU posterior gapping technique, a retest o f this movement produced diminished pain in the affected area. A back massage was followed by posture correction, and advice on back care and back exercises. Treatment Four (13-3-92) The patient had been on assignment, travelling around the country for the previous couple of weeks. On examination, the only finding o f any note was slight spasm o f the lower erector spinae for which a back massage was given. The patient agreed that she would make further appointments if they were needed. Treatment Five (27-3-92) Two weeks later the patient presented with some pain and stiff­ ness in the sacroiliac area following a game o f tennis two days previously. At this stage the pain had eased considerably (1/5), and the stiffness was negligible. However, she was going away on holiday for a few weeks and wanted it checked. Full range active rotation to the left in sitting and medially directed pressure on the ASIS in supine increased her pain. Treatment con­ sisted o f a rotation mobilisation o f the pelvis to the right in side lying using a fairly large amplitude o f movement, done three times for 30 seconds. This was followed by the SU posterior gapping technique, done for 30 seconds with sufficient force such that it initially pro­ duced a slight increase in her resting pain. On retesting her move­ ments she reported the pain as being “definitely easier”. Telephonic follow-up a month later found the patient “very happy” with her back. Two months later her back was still clear o f all symptoms. DISCUSSION The SlJ-lmplications for Treatment Although the debates concerning the mechanics of the sacroiliac joint are beyond the scope of this paper, it is interesting to note that most authors agree that the function and mechanics of the joint are far from clear4, •10’1112' 13-14 There is even greater difference regarding the test procedures for sacroiliac dysfunction and the number of different syndromes that may be found on such examination. Therefore, when the SU was suspected of involvement in this patient’s pain, the number of tests was limited, particularly when the first ones performed were found to be positive. Selection of techniques Because o f the severity o f the patient’s pain, rotation mobilisation was chosen as the first technique, even though the SU was thought to be involved. It is also considered an appropriate first technique to use in lumbar pain with unilaterally distributed symptoms6. Once the rotation mobilisation was shown to be of benefit and the test for posterior gapping o f the SU’s continued to reproduce the patient’s pain, this test procedure became the logical treatment technique to use next6,13. Pregnancy and the use of manual mobilisation techniques Authorities disagree on the precautions and contraindications which need to be considered regarding the use of mobilisation and manipulation techniques during pregnancy6,9,16. It was therefore considered wiser to err on the side o f caution and not to perform anything more vigorous than gentle mobilisation techniques. This is however, an important area for further investiga­ tion. CONCLUSION In spite o f the lack o f understanding o f the mechanics o f tbe SU and its diagnosis and treatment during pregnancy, the notion o f tbe “two compartment method of thinking”, as described by Maitland,8 provides a sound framework for clinical application. By separating that which is theoretical and speculative, from that which presents clinically, the therapist is able to base the treatment and it’s progres­ sion primarily on the patient’s symptoms, without losing sight o f any underlying pathology. This study has highlighted the fact that gentle mobilisation tech­ niques may be used to good effect, even in circumstances where our theoretical knowledge may be far from complete. REFERENCES 1. Abramson D, Roberts SM, Wilson PD. Relaxation of the pelvic joints during pregnancy. Surg Gynec Obst 1934;5S:595-613. 2. Berg G, Hammar M, Moller-Nielsen J et al. Low back pain (luring pregnancy. Obst Gynec 1988;71(l):71-75. 3. Bullock JE, Jull GA, Bullock MI. The relationship of low back pain to postural changes during pngpancy.AustJPhysiother 1987;33(1): 10-17. 4. DonTigny RL. Function and pathomechanics of the sacroiliac joint. Phys Ther 1985;65(l):35-43. 5. Fast A Shapiro D, Ducommun E l et al. Low back pain during pregnancy. Spine 1987;12(4):368-371. 6. Maitland GD. Vertebral Manipulation. Sth ed. London: Butterworths, 1986. 7. Mantle MJ, Greenwood RM, Currey HLF. Backache in pregnancy. Rheum Rehab 1977;16(2):95-101. 8. Wells PE. H ie examination of the pelvic joints. In: Grieve GP, ed. Modem Manual therapy o f the Vertebral Column. Edinburgh: Churchill Living­ stone 1986;590-602. 9. Polden M, Mantle J. Physiotherapy in Obstetrics and Gynaecology. Oxford: Butterworth-Heinemann, 1990. 10. Grieve GP. The sacro-iliac joint. Physiother 1976;62(12):384-400. 11. Wells PE. Movement of the pelvic joints. In: Grieve GP, ed. Modem Manual Therapy o f the Vertebral Column. Edinburgh: Churchill Living­ stone 1986;176-181. 12. White AA, Panjabi MM. Clinical Biomechanics o f the Spine. 2nd Ed. Philadelphia: JB Lippincott Co, 1990. 13. Corrigan B, Maitland GD. Practical Orthopaedic Medicine. London: Butterworths, 1983. 14. Nyberg R. Pelvic Girdle. In: Payton OD, ed. Manual o f Physical Therapy. New York: Churchill Livingstone 1989;363-382. 15. Aitken GS. Syndromes of Lumbo-pelvic Dysfunction. In: Grieve GP, ed. Modem Manual Therapy o f the Vertebral Column. Edinburgh: Churchill Livingstone 1986;473-477. 16. Grieve GP. Mobilisation o f the Spine: Notes on examination, assessment and clinical method. 4th ed. Edinburgh: Churchill Livingstone 1984. T his case study was p a rt o f a p ro je c t su b m itted to th e M a n ­ ipulative T h e ra p ists G ro u p o f th e So u th A fric a n S ociety o f P hysiotherapy, in p a rtia l fulfillm ent o f th e p o st-g ra d u a te c o u rse in O rth o p a e d ic M an ip u lativ e T h e ra p y 1. Physiotherapy, February 1993 Vol 49 no 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )