Research Review: Alterations of Diaphragm Behavior in Individuals with Sacroiliac Joint Pain
By Jinny McGivern, PT, DPT, Certified Yoga Instructor
Edited by Brent Brookbush DPT, PT, MS, PES, CES, CSCS, ACSM H/FS
Original Citation: O’Sullivan, P. B., Beales, D. J., Beetham, J. A., Cripps, J., Graf, F., Lin, I. B., … & Avery, A. (2002). Altered motor control strategies in subjects with sacroiliac joint pain during the active straight-leg-raise test. Spine, 27(1), E1-E8. ABSTRACT
The above picture depicts the members of our core stabilizers who make up our "cylinder" of support. Image courtesy of https://osteopathysouthwest.wordpress.com/2013/09/21/sacroiliac-joint-dysfunction/
Why is this relevant?: The sacroiliac joint (SIJ) is the "bridge" or "keystone" between the spine and the lower extremity. It is subject to high levels of stress and load as we perform daily activities such as walking, climbing stairs, squatting and lifting. As O'Sullivan et al. reports in this research, 13-30% of non-specific low back pain may be related to SIJ dysfunction. Our deep core stabilizers, including the diaphragm and pelvic floor, play a role in stabilization of the SIJ (see Intrinsic Stabilization Subsystem (ISS) ). This research demonstrates how these muscles behave differently in individuals with and without SIJ pain during a task that requires a load transfer through the pelvis. These differences in behavior are essential to our understanding of optimal SIJ motion and intervention for neuromuscular and stability impairments that may be present in patients/clients with SIJ pain.
Study Summary
| Study Design | Cohort study |
| Level of Evidence | 2b - Individual cohort study |
| Subject Demographics | Thus study considered 2 groups of subjects: 13 individuals with SIJ pain (SIJP group) & 13 age, gender & BMI matched pain free controls (PFC group).
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| Outcome Measures | Outcome measures were collected during 3 conditions: rest, ASLR, ASLR with manual compression. The following parameters were assessed:
Test-retest repeatability study was performed for 5 subjects to establish reliability of the outcome measures. |
| Results | No significant difference in age, gender or anthropometric measurements between SIJP & PFC groups. Respiratory Function
Respiration patterns
Diaphragm Excursion
Pelvic Floor Descent
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| Conclusions | This research demonstrates that the behavior of the diaphragm is altered in individuals with SIJ pain during activities that require load transfer through the pelvis. This research supports the inclusion of the diaphragm & pelvic floor as members of the core musculature that aid in providing stability to the lumbopelvic-hip complex. |
| Conclusions of the Researchers | This research indicates that the movement of the diaphragm & pelvic floor, as well as minute ventilation, differs between individuals with SIJ pain & pain free controls during performance of an ASLR. This research demonstrates that these changes may be related to a lack of form and/or force closure of the SIJ because the application of manual compression to the SIJ eliminated the differences in the behavior of these muscles between groups. |
Form closure of the SIJ is achieved via structural congruity of the bones. Force closure is achieved via dynamic muscular stabilization (concepts from the work of Vleeming). Image courtesy of http://www.methodistorthopedics.com/online-courses/online-courses/sacroiliac-joint-dysfunction.
Review & Commentary:
There are many features of this research that contribute to its strong methodology. The results on the makeup of each subject group indicate that good control matching procedures were implemented to minimize confounding variables between groups. Well defined inclusion criteria for the SIJP group provided a clear clinical picture of how the researchers delineated primary SIJ pain. It was appropriate that individuals with a history of lower extremity injury/pain be excluded from the PFC group because it is known that mechanics of the lower extremity have an impact at the SIJ. The test-retest repeatability study within the larger study allowed the reader to appreciate that the methods used to collect the data were reliable.
One limitation of this study was that the SIJP group consisted of a mix of individuals who were post pregnancy and those who were not. Pregnancy results in a series of unique changes to a women's body which may result in dysfunction that is different from mechanisms of trauma or repetitive stress. Future researchers should repeat this study with groups of individuals who are exclusively post-partum and those who have not had children. It would also be interesting to observe if differences in motor control existed between those with chronic SIJP versus those with a more acute injury/trauma. It would have been beneficial if EMG of the diaphragm and pelvic floor could also have been assessed. This would have allowed the findings of the movements of muscle to be correlated with muscle activity. The addition of EMG of the Transverse Abdominis (TVA) and/or Internal Oblique (IO) would have provided insight into how these muscles interacted with respect to timing of activity onset and intensity of firing during the ASLR & ASLR with compression conditions. Finally, future researchers should investigate the changes in behavior of these muscles during functional tasks in weight bearing positions such as standing, walking and squatting.
Our deep core stabilizers are often described as being arranged as a closed cylinder with the diaphragm and pelvic floor as the the top and bottom of the cylinder (see Intrinsic Stabilization Subsystem (ISS) ). TVA , IO and multifidi form the side walls of the cylinder. With respect to core stabilization function, it is thought that the diaphragm and pelvic floor maintain pressure at the top and bottom of the cylinder so that as TVA contracts and increases pressure on the sides of the tube, intra abdominal pressure thereby trunk rigidity is successfully increased. This research reports that in those with SIJ pain, the diaphragm moves less inferiorly (and in some not at all). The pelvic floor dropped down during the ASLR. It is reasonable to hypothesize that this absence of a solid top & bottom of our "support cylinder" results in a relatively unsuccessful increase in trunk rigidity and lack of stability which may play a role in continuing the cycle of pain in individuals with SIJ dysfunction.
Why is this study important?
This study is important because it provides a comparison of core muscle function between individuals with and without SIJ pain. This allows better understanding of the components of dysfunction in individuals with pain to allow us to design interventions and assessments to aid in improving movement impairment.
How does it affect practice?
In a previously posted research review (Kolar et al. ), it was demonstrated that in pain free individuals the diaphragm typically descends to a more inferior level when there is muscle activity in the lower extremity over rest conditions. This may aid in achieving an optimal increase in intra-abdominal pressure and stability. This research reports that in individuals with SIJ pain, the diaphragm does not descend as it should during an activity involving movement of the lower extremity. A very simple practical application of this information is to encourage your clients to BREATHE smoothly and evenly during exercise and functional activities. This research indicates that both respiratory rate and tidal volume varied from breath to breath as individuals with SIJP performed an ASLR. While encouraging breathing is not likely to "fix" significant dysfunction causing SIJ pain, it is a key element to restore as your patient or client progresses through exercise and manual therapy interventions to ensure optimal functioning of all sides of the "canister" (ISS ) of the core. If you suspect significant pelvic floor dysfunction (possible in the presence of ongoing bladder dysfunction, pelvic pain, ongoing SIJ pain that hasn't responded to stabilization or manual therapy interventions) in a patient or client with SIJ pain, you may want to refer them to a physical therapist that specializes in rehabilitation of the pelvic floor. (Possibly connecting to other red flags???)
How does it relate to Brookbush Institute Content?
This research supports the Lumbo Pelvic Hip and Sacroiliac Joint Motion predictive models of postural dysfunction as described by the Brookbush Institute. In both of these dysfunctions the Intrinsic Stabilization Subsystem (ISS) , which includes the diaphragm and pelvic floor, is viewed as under-active, which is consistent with the behavior of these muscles observed by the researchers above. Within the model of Sacroiliac Joint Motion Dysfunction , the Brookbush institute goes on to detail how other muscles of the lower extremity and trunk factor into SIJ dysfunction and potentially pain in this region. Other muscles that are typically observed to be under-active in this dysfunction include the Gluteus Maximus and Gluteus Medius . Below is a series of videos for isolated activation techniques for TVA (how the Brookbush Institute activates the ISS ), Gluteus Maximus, Gluteus Medius, and a gluteus maximus/TVA combo activation exercise. These are followed by reactive integration techniques for each. These activities require the given muscle group to respond in a time dependent fashion this adding an additional challenge. These activities should be performed after release, stretch and mobilization techniques as recommended in the Sacroiliac Joint Dysfunction Corrective Exercise and Sample Routine article .
Transverse Abdominis TVA Isolated Activation
Hardest Quadruped Progression Ever
Gluteus Maximus Isolated Activation
Gluteus Medius Isolated Activation
Gluteus Maximus with TVA Activation
Sidestepping Gluteus Medius Reactive Integration
Gluteus Maximus Reactive Integration
Core Reactive Integration Crunch & Catch
© 2014 Brent Brookbush
Questions, comments, and criticisms are welcomed and encouraged -