SI Joint Dysfunction Rehabilitation Protocol (Lumbar Spine)

This protocol provides a guideline for physical therapy rehabilitation following diagnosis of SI Joint Dysfunction impacting the lumbar spine. It is crucial to tailor treatment to the individual patient, considering pain levels, functional limitations, and specific impairments. This protocol assumes proper diagnosis by a qualified healthcare professional.

Pathophysiology

Sacroiliac (SI) joint dysfunction refers to pain and altered biomechanics in the SI joint, which connects the sacrum (the triangular bone at the base of the spine) to the ilium (the largest bone in the pelvis). The SI joint is designed for load transfer between the spine and lower extremities and provides stability. Dysfunction can arise from several factors, including:

• Hypermobility: Excessive joint movement due to ligamentous laxity (e.g., pregnancy, trauma).
• Hypomobility: Restricted joint movement often due to muscle imbalances, arthritic changes, or trauma.
• Muscle Imbalances: Weakness or tightness in muscles surrounding the pelvis and lumbar spine (e.g., gluteals, core muscles, hamstrings, hip flexors) affecting joint stability and alignment.
• Trauma: Falls, car accidents, or repetitive microtrauma can directly injure the SI joint ligaments or surrounding structures.
• Leg Length Discrepancy: Can alter biomechanics and stress the SI joint.
• Arthritis: Degenerative changes in the joint cartilage.

Common Special Tests for SI Joint Dysfunction

These tests are used to assess for potential SI joint involvement. A cluster of positive tests increases diagnostic confidence.

• Gaenslen's Test: Stresses the SI joint by placing the patient supine with one leg hanging off the edge of the table and the other flexed to the chest.
• Patrick's (FABER) Test: Flexion, Abduction, and External Rotation of the hip. Pain in the SI joint region is a positive finding.
• Sacral Thrust Test: Applies a downward force to the sacrum while the patient is prone.
• Thigh Thrust Test: Hip is flexed and adducted, applying an anterior force to the SI joint.
• Compression Test: Sidelying with compression applied to the iliac crests.
• Distraction Test: Supine with compression applied to the ASIS bilaterally, distracting the SI joints.

Phase I: Protection Phase (Acute/Inflammatory)

Goals: Reduce pain and inflammation, protect the joint, and promote early healing.

• Pain Management:
• Rest and activity modification (avoid aggravating activities).
• Modalities: Ice, heat (depending on patient presentation and preference), electrical stimulation (TENS).
• Medications: As prescribed by a physician (NSAIDs, muscle relaxants).
• Gentle ROM Exercises:
• Pelvic tilts (anterior and posterior) in supine.
• Knee-to-chest stretches (single and double).
• Gentle lumbar spine rotations (hooklying).
• Muscle Activation:
• Transversus abdominis (TA) activation exercises (drawing the navel towards the spine while maintaining neutral spine).
• Multifidus activation (gentle contraction of the deep spinal muscles).
• Gluteal sets (isometric contractions of the gluteal muscles).
• Postural Education:
• Proper sitting and standing posture.
• Ergonomic assessment of workstation if applicable.
• Safe lifting techniques (avoid twisting, use legs).
• Bracing (Optional):
• SI belt may be considered to provide external support and stability.
• Duration: 1-2 weeks or until pain subsides significantly.

Phase II: Loading Phase (Subacute)

Goals: Restore normal muscle balance, improve joint mobility (if hypomobile), enhance stability, and gradually increase functional capacity.

• Progressive Strengthening:
• Begin with bodyweight exercises and progress to resistance bands or light weights.
• Focus on core stabilization: Planks (modified to full), side planks, bird dog exercise.
• Gluteal strengthening: Bridges, hip abduction with band, clam shells, single leg balance exercises.
• Hamstring strengthening: Hamstring curls, good mornings (light weight, proper form), Romanian deadlifts (light weight, proper form).
• Joint Mobilization (if hypomobile):
• Manual therapy techniques to address joint restrictions, performed by a qualified physical therapist. This could include SI joint mobilizations or muscle energy techniques.
• Stretching:
• Hamstring stretches.
• Hip flexor stretches.
• Piriformis stretches.
• Iliotibial (IT) band stretches.
• Proprioceptive Training:
• Single-leg stance with perturbations.
• Balance board or wobble board exercises.
• Cardiovascular Conditioning:
• Low-impact activities such as walking, swimming, or cycling.
• Functional Exercises:
• Squats (partial to full range of motion).
• Lunges (forward, lateral).
• Step-ups.
• Duration: 2-4 weeks, progressing exercises as tolerated.

Phase III: Return to Function Phase

Goals: Restore full functional capacity, optimize strength and endurance, prevent recurrence.

• Advanced Strengthening:
• Progress to higher-level exercises with increased resistance.
• Plyometric exercises (jump squats, box jumps) if appropriate.
• Sport-specific or activity-specific training.
• Endurance Training:
• Increase duration and intensity of cardiovascular activities.
• Incorporate interval training.
• Functional Progression:
• Simulate activities performed at work, home, or during recreational activities.
• Gradually increase the complexity and intensity of these activities.
• Maintenance Program:
• Continue with core strengthening and flexibility exercises to maintain stability and prevent recurrence.
• Regular self-assessment and modification of activities as needed.
• Education:
• Review proper body mechanics and posture.
• Discuss strategies for managing pain and preventing flare-ups.
• Duration: Ongoing, focusing on long-term maintenance and prevention.

Progression Criteria: Progression through each phase should be based on pain levels, functional improvements, and successful completion of specific criteria. Do not progress to the next phase if the patient experiences increased pain or is unable to maintain proper form during exercises.

Disclaimer: This protocol is intended as a general guideline and should not be considered a substitute for professional medical advice. Always consult with a qualified healthcare professional before starting any new treatment program.