Prolotherapy 2 - Medical Assessment Protocol

PROLOTHERAPY & PRP INJECTIONS FOR SIJ & PUBIC SYMPHYSIS INSUFFICIENCY.

Written by Barbara Hungerford & based on the research and clinical practice of

DrJ Saunders, DrM Cusi, DrB Hungerford, T Wisbey-Roth, Dr P Lucas

MEDICAL /PHYSIOTERHAPY TREATMENT PROTOCOL

In order to ensure that prolotherapy or PRP into the pelvic ligaments is only provided to patients who have a true ligament insufficiency, a protocol has been created that determines each patients’ appropriateness for treatment. This protocol is based on the work and research of DrAndryVleeming, Diane Lee, Dr Jan Mens, Dr Hans Ostgaard, Dr Thomas Dorman and Dr Barbara Hungerford, plus numerous other clinicians who continue to strive for the answers on best medical treatment for lumbo-pelvic injuries.

The protocol outlined here assesses the sacroiliac joint and pubic symphysis only.
All steps in this protocol must be undertaken to determine what the appropriate treatment should be.

Step 1
The therapist must clear any pubic symphysis or sacroiliac joint articular dysfunctions, such as fixated joint or compressed joint dysfunctions. This assumes that the therapist has therefore received training from either Barbara Hungerford (Physiotherapist, Sydney, Australia), Diane Lee (Physical Therapist, Vancouver /White Rock, BC, Canada), or Linda Joy Lee (Physical Therapist, Vancouver, BC, Canada)

Step 2
Assess pubic symphysis function and stability
The pubic symphysis should be assessedto determine if pelvic instability is occurring due to insufficiency of the pubic symphysis ligaments, SIJ ligaments, or both. In order to make a diagnosis of pubic symphysis ligament laxity the following tests will all be positive:

1. The Pubic Shear Test
1. PT palpates the superior pubic tubercles with both index fingers
2. Ask the patient to lengthen the right leg along the bed, and feel whether pubic alignment remains stable, or whether an inferior translation of the right pubic ramus occurs during this maneuver. Repeat on the left.
3. Retest while patient activates their core muscles. Improved?

1. Pubic Passive Joint Glide test
1. PT positions the right heel of the hand onto the superior border of the right pubic ramus and heel of left hand onto the inferior border of the left pubic ramus.
2. PT creates a translational force of the right pubic ramus inferiorly relative to the left (left supports left ramus), and then of the left ramus superiorly relative to the right.
3. Ask patient to gently activate their core muscles (pelvic floor and transversus abdominis). Retest pubic rams translation during activation. All joint translation should be controlled.
4. Swap hands so that right heel is on left superior border of the left pubic ramus and heel of left hand onto the inferior border of the right pubic ramus. Retest stability of joint to resist translation.
2.             Flamingo View x-rays, comparing pubic translation while standing on each leg should be performed if pubic instability is diagnosed by the clinical tests. All three tests would need to be positive to consider a provisional diagnosis of pubic instability.

Step 3
Assess sacroiliac joint function and stability
In order to make a diagnosis of SIJ ligament laxity the following tests will all be positive:

1. The Stork test on the side of single leg support (Hungerford et al, 2004). The innominate will rotate anteriorly relative to the sacrum as the patient stands onto that leg
2. PPPP Test (Posterior pelvic pain provocation test) (Ostgaard et al, 1995). Posterior translation of the innominate in supine lying with the hip in 90 degrees hi flexion may provoke the patients symptoms.
3. ASLR Test (Active Straight Leg Raise Test) (Mens et al, 1999, 2000). During an ALSR the patient will describe either difficulty lifting the leg on the affected side, pain, or an inability to maintain the lumbo-pelvic region in neutral during the maneuver.
4. ASLR Test with passive compression. Passive compression across either the pubic symphysis or sacroiliac region tends to significantly improve the ability to perform the ASLR (refer to Lee D. 2004).
5. Passive SIJ articular glide Test (Lee D. 2004). The therapist will palpate a significant increase in articular translation of the iliac surface relative to the sacral surface in either the A-P or the vertical plane of the joint, on the side of the injury in comparison to the uninjured side. This increase in articular translation will also be present when the therapist moves the joint surfaces in to the closed pack position of the sacroiliac joint (normally there should be no translation palpable in the closed pack position). The increased articular translation on the side of the injury will not be reduced significantly (>50%) with activation of the local lumbo-pelvic stabilization muscles i.e transversus abdominis, lumbar multifidus, and the pelvic floor. (Normally local muscle activation will induce the closed pack position of the sacroiliac joint and minimize any movement at the SIJ). This step assumes that the patient has been taught how to specifically activate the local stabilizing muscles of the lumbo-pelvic region.
6. All SIJ tests must be positive to make a provisional diagnosis of an inability to stabilize the SIJ (failed load transfer through the pelvis).

Step 4
Research ash shown that activation of transversus abdominis (TA), lumbar multifidus, and gluteus maximus can increase tension in the posterior layers of Thoraco-lumbar fascia, and thereby increase SIJ stiffness (Barker et al, 2004; Richardson et al, 2002; van Wingerden et al, 2004). The majority of patients who report posterior pelvic pain of musculo-skeletal origin, will improve their ability to stabilize the pelvis during functional tasks by learning how to turn these muscles on and strengthen them. This occurs because improved function of the lumbo-pelvic muscles creates the necessary tension onto the sacroiliac and pubic ligaments, with the consequence of increased articular compression during weight bearing. That means the pelvis is more stable during movement.

The protocol developed by the LBIG group suggests that all clients who have been diagnosed with Failed load transfer through the pelvis undergo a 3 month program of specific retraining for lumbo-pelvic stability. The client must be able to activate the local lumbo-pelvic muscles prior to re-assessment of pelvic stability.

The areas to focus on are:

• isolation of TA, lumbosacral multifidus, &pubococcygeus (the core) in neutral lumbo-pelvic alignment, without substitution of rectus abdominis, the obliques, erector spinae, or coccygeus.
• ability to maintain an isolated activation of ‘the core’ during functional tasks such as sitting, walking, lifting.
• ability to maintain isolated contraction of the core for extended periods (endurance)
• ability to maintain core activation as they progress to exercises that enhance
• gluteus medius activity without substituting TFL or adductors
• gluteus maximus activity without substituting hamstrings

Step 4 Final Diagnosis
After 3 months, reassess the pelvic function and stability as previously described in step 3.

If all tests remain positive, and the ability to activate and maintain core activation does not significantly improve the SIJ passive articular glides, then the test results suggest that force closure from the muscle activation is not being transmitted via the fascia and posterior SIJ ligaments to adequately compress the SIJ and create joint stability. In other words, the positive results suggest that damage to the posterior SIJ ligaments is affecting the force closure mechanism that increases functional stability of the SIJ (Vleeming et al, 1995). In this circumstance, prolotherapy may be indicated to enhance the collagen structure of the affected ligaments, thereby augmenting force closure. CT guided injections of glucose are suggested in order to ensure that the proliferant is specifically released into the affected ligaments.

DISCLAIMER

As of December 2005, the only radiological technique that can show specific damage to the posterior SIJ ligaments via signs of micro movement at the SIJ is SPECT CT scan. This test has a high radiation level and must be considered according to the specific needs of the patient and therapists in regards to diagnosis.

 The protocol outlined above is based on conservative palpation techniques and therefore can not be considered as precise for the determination of which ligament has been damaged.

It is up to the treating therapist to determine if the client has actually performed the exercise program sufficiently to be eligible for reassessment and consideration for referral for prolotherapy or PRP.