Bekken. Load Transfer Tests

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The O ne-Leg Standing Test and the Active Straight Leg Raise Test: AClinical Interpretation of T wo T ests of Load T ransfer through the Pelvic Girdle

Diane G. Lee Physiotherapist Corporation Linda-Joy Lee: LJPT Consulting www.dianelee.ca www.ljptconsulting.ca

DianeLeeBSR,FCAMT,CGIMSPublishedintheOrthopaedicDivisionReview 2005

I readwith interest and some concern the discussion in the last issue of theOrthopaedicDivision

Reviewonevidencebasedpractiseandhow itis impactingourclinicalpractise. Ofconcernwasthe

statementmadebyPeterHuibregts inhisarticleLumbarspinecoupledmotion:A literaturereview

withclinical implications thatAt this time,noevidencebaseddiagnostic tools ineitherhistoryor

physical examination seem to be available to the primary care manual medicine practitioner to

determine thenatureof these interindividualdifferences (how the lumbarspinecouples inmotion

andhowtousethisinformationfortreatmenttechniqueselection). Fairenough,howevernowwhat

doIdoifIwanttotreatmypatient? OnwhatdoIguidemytechniqueselectionfortherestorationof

functioni.e.mobilityandstability?Inthesameissue,DianeJacobeloquentlyremindsusofMelzacks

post Cartesion neuromatrix theory that proposes that most of what is called chronic pain is

neurological malfunction more than it is physical, tissuebased dysfunction therefore using pain

provocation tests (which they do have reliability and sensitivity for the pelvic girdle Laslett &

Williams1994) isnot theway togoeither.BothRichardRosedaleandScottWhitmorequoteSackett

who feels that Evidencebasedmedicine is the integration ofbest research evidencewith clinical

expertise and patient values. I like this sentence a lot tobe an evidencebased clinician, Sackett

suggeststhatwemustuseacombinationofevidencefromtheresearch,clinicalexpertiseandpatient

input;notjustresearch. Totheworkingclinicianthismustringtruesinceweneedmanymoreclinical

tests/techniques than are currently scientifically reliable, valid, sensitive and specific to assess and

treatourpatients.

Recently,two

tests

of

load

transfer

through

the

pelvic

girdle

have

been

scrutinized

scientifically;

the

onelegstandingtest(alsoknowninCanadaastheipsilateralandcontralateralkinetictestorGillettest

(Hungerfordetal2004))andtheactivestraightlegraisetest(Mensetal2001,2002). Idliketoexplain

howthesetestscanhelptheclinicianwhenprescribingaspecificexerciseprogramforstabilizationof

thepelvicgirdle.Partsofwhatfollowsisproveninthescientificiteratureandpartstillremainsbased

onclinicalexperience;evidencebasedpractisealaSackett.Thefollowingdescriptionsofthesetestsis

takeninpartfromthe3rdeditionofthePelvicGirdle(Lee2004).


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O ne Leg Standing TestThis

test

is

also

known

as

the

Gillet

test,

stork

test

or

kinetic

test

and

examines theabilityof the lowback,pelvisandhip to transfer load

unilaterally (support phase) as well as for the pelvis to allow

intrapelvic rotation (Hungerford et al 2004). Initially, the patient is

instructed to stand on one leg and to flex the contralateral hip and

knee towards thewaist.Theability toperform this task isobserved.

Thepelvisshouldnotanteriorly/posteriorly/laterally tiltnorrotate in

the transverseplane as theweight is shifted to the supporting limb.

Thetestisrepeatedontheoppositeside. Subsequently,theintrapelvic

motionwhichoccursduringthistaskcanbeexaminedasfollows:

1.

Hip

flexion

phase

(ipsilateral

kinetic

test):

With

one

hand,

palpatetheinnominateattheinferioraspectoftheposteriorsuperior

iliacspine(PSIS)andattheiliaccrestonthenonweightbearingside.

Withtheotherhand,palpateeitherthemediansacralcrestatS2orthe

ILAofthesacrumonthesamesideastheinnominatebeingpalpated.

Instruct the patient to flex the ipsilateral hip (same side you are palpating) and note the posterior

rotationoftheinnominaterelativetothesacrum. Comparetheamplitudeandquality(resistance)of

thismovementtothecontralateralside. Thisisnotatestformobilityofthesacroiliacjointbutratheratest of osteokinematicmotion of the low lumbar vertebrae, the innominate and the sacrum. Many

factorscanimpedeosteokinematicmotion,thesacroiliacjointisone.Themotionshouldbesymmetric

betweentheleftandrightsidesofthepelvicgirdle.

2. Support phase: On theweightbearing side,with one hand,palpatetheinnominateat the inferioraspectoftheposteriorsuperior

iliac spine (PSIS)andat the iliaccrest. With theotherhand,palpate

either themediansacralcrestatS2,or the ILAof thesacrum,on the

samesideastheinnominatebeingpalpated.Instructthepatienttoflex

thecontralateralhip(sideyouarenotpalpating)andnotethemotion

of the innominate relative to the sacrum (contralateral kinetic test).

Especiallynotethemovementthatoccursastheweightistransferred

onto the supporting leg (initial loading) and the contralateral leg is

comingoff

the

ground.

The

innominate

should

either

posteriorly

rotate or remain still relative to the sacrum (in a posteriorly rotatedposition;what isobservedwilldependonthestartingpositionofthe

innominate(Hungerfordetal2004)).


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Apositivetestoccurswhentheinnominateanteriorlyrotatesorinternallyrotatesrelativetothesacrum

(failed load transfer throughthepelvicgirdle) (Hungerfordetal2004)or flexesrelative to the femur

(failedloadtransferthroughthehipjoint). Thisisalessstablepositionforloadtransferboththrough

thepelvis

and

the

hip.

Clinically,ifthepatientcantransferweightthroughthelegwithoutlosingthestablepositionforthe

sacroiliacjoint (sacralnutation/posterior rotation of the innominate) then thepelvic girdle is stable.

Thiswillrequireoptimalformclosure,forceclosureandmotorcontrol. Ifduringtheweighttransfer

the innominate is felt tomove out of its stable position (internally and/or anteriorly rotate) then a

diagnosisoffailedloadtransferwithinthepelvicgirdlecanbemadeandfurthertestsarerequiredto

identifywhythepelvicgirdleisnolongerabletotransferload. Someintrapelviccausescouldbe:

1. lossofarticularstabilityofeitherthesacroiliacjoint/sorpubicsymphysislossofformclosure2. lossofneuromyofascialstabilitylossofforceclosure/motorcontrol. Thisisahugecomponentand

may

relate

to

timing

of

specific

muscle

activation,

strength

or

endurace

of

both

the

local

lumbopelvicstabilizersortheglobalthoracopelvicand/orhipstabilizers.

Obviously,manymoreclinicaltestsareneededtodifferentiatetheabove. Theonelegstandingtestcan

alsobeusedclinicallytodetermineapatientsprogress,forexampletodeterminewhenthepatientis

readytobeginverticalloadingexercises.

Active Straight Leg R aise TestThesupineactivestraightlegraisetest(ASLR)(Mensetal2001,2002)hasbeenvalidatedasaclinicaltest

for measuring effective load transferbetween the trunk

andlower

limbs.

When

the

lumbopelvic

hip

region

is

functioningoptimally,thelegshouldriseeffortlesslyfrom

the table (effortcanbegraded from05)and thepelvis

should not move (flex, extend, laterallybend or rotate)

relative to the thorax and/or lower extremity. This

requiresproperactivationofthemuscles(bothinthelocal

andglobal systems)which stabilize the thorax, lowback

and pelvis. Several compensation strategies havebeen

noted (Richardson et al 1999,Lee 2004,Lee&Lee 2004)

when stabilizationof the lumbopelvic region is lacking. TheASLR test canbeused to identify these

strategies.The

application

of

compression

to

the

pelvis

has

been

shown

(Mens

et

al

1999)

to

reduce

the

effortnecessarytoliftthelegforpatientswithpelvicpainandinstability. Itisproposed(Lee2004)that

byvaryingthelocationofthiscompressionduringtheASLR,further informationcanbegainedwhich

willassisttheclinicianwhenprescribingexercisestoimprovemotorcontrolandstability(Lee2004,Lee

&Lee2004).


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The supinepatient isasked to lift theirextended legoffof the tableand tonoteany effortdifference

betweentheleftandrightleg(doesonelegseemheavierorhardertolift). Thestrategyusedtostabilize

thethorax,

the

low

back

and

the

pelvis

during

this

task

is

observed.

The

leg

should

flex

at

the

hip

joint

andthepelvisshouldnotrotate,sidebend,anteriorlyorposteriorlytiltrelativetothelumbarspine. The

ribcageshouldnotdrawinexcessively(overactivationoftheexternalobliquemuscles),norshouldthe

lowerribs flareoutexcessively (overactivationof the internalobliquemuscles).Overactivationof the

externalandinternalobliquewillresultinabraced,rigidribcagethatlimitslateralcostalexpansionon

inspiration. Thethoracicspineshouldnotextend(overactivationoftheerectorspinae),norshouldthe

abdomenbulge(breathholdingvalsalva). Inaddition,thethoraxshouldnotshiftlaterallyrelativeto

thepelvicgirdle. Theprovocationofanypelvicpainisalsonotedatthistime.

Thepelvis isthencompressedpassivelyandtheASLR isrepeated;anychange ineffortand/orpain is

noted.The

location

of

the

compression

can

be

varied

to

simulate

the

force

which

would

be

produced

by

optimalfunctionofthelocalsystem. Althoughstillahypothesis,clinicallyitappearsthatcompressionof

theanteriorpelvisattheleveloftheASISssimulatestheforceproducedbycontractionoflowerfibresof

transversusabdominis(andtheanteriorabdominalfascia)andcompressionoftheposteriorpelvisatthe

levelofthePSISssimulatesthatofthesacralmultifidus(andthethoracodorsalfascia). Compressionof

theanteriorpelvisat the levelof thepubicsymphysis simulates theactionof theanteriorpelvic floor

whereascompressionoftheposteriorpelvisattheleveloftheischialtuberositiessimulatestheactionof

the posterior pelvic wall and floor. Compression can also be applied to one side anteriorly and

simultaneously to theopposite sideposteriorly.Youare looking for the locationwheremore (or less)

compression reduces the effortnecessary to lift the leg; the placewhere the patient notes That feels

marvellous!

Further

examination

of

the

lumbopelvic

core

musculature

(i.e.

response

to

a

verbal

cue

to

contract) confirms or negates the findings of the ASLR test and confirms which muscles require

retraining. TheASLRtestcanbeusedthroughoutthetreatmentprogramtoguidetheclinicianastohow

toaddormodifytheexercisesgiven,i.e.whentostartwithtransversusabdominisvs.whentostartwith

multifidus.

T he Active Straight Leg Raise Test and S acroiliac BeltsExternalsupportofthepelvicgirdle(tapingorabelt)isusedonlyasanadjuncttotherestorationof

forceclosure. Damenetal(2002ca,b)wereabletoshowusingDopplerimagingthatthestiffnessofthe

SIJ increaseswhenabelt isapplied to thepelvis. Therearemanysacroiliacbeltsonthemarketand

mostwill

be

effective

in

providing

some

degree

of

compression

(Vleeming

et

al

1992).

However,

patients sometimes requiremore or less compression than ageneralbelt can supply andoften it is

difficult to specify the location of the compression (bilateral anterior,bilateral posterior, unilateral

anteriorand/orunilateralposterior). ThisledtothedevelopmentofanewsacroiliacbeltTheCom

pressor(Lee2002)(Fordistributorsources see Compressorthiswebsite).


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Essentially this belt consists of a light

fabricmaterialwhich iswrappedaround

thepelvic

girdle

and

secured

with

Velcro. The compression straps are

then attached to the belt specifying the

location of compression. The straps can

be overlapped (doubled up) to increase

the amount of compression at that

location. Four straps of two different

lengths are included with the belt. The

active straight leg raise test is used to

determineexactlywhereandhowmuchcompression isneeded. Ifbilateralanteriorcompressionof

thepelvis

(approximate

the

ASISs)

allows

the

patient

to

lift

the

leg

with

less

effort,

then

two

straps

are

appliedbyanchoringeachbandlaterallyandpullingthemtotheanteriormidline(pubicsymphysis).

Onebandisappliedatatime.Ifbilateralposteriorcompressionofthepelvis(approximatethePSISs)

allows thepatient to lift the legwith lesseffort, then twostrapsareappliedbyanchoringeachband

laterallyandpullingthemtotheposteriormidline. Onebandisappliedatatime. Ifunilateralanterior

compression and unilateral posterior compression is the most effective, then oneband is applied

anteriorlyandonebandposteriorly. Oncethebandsareapplied,theASLR isrepeated. Thepatient

shouldnoticeamarkeddifference in theability to transfer load through thepelvicgirdle througha

reductionintheeffortrequiredtoliftthelegwheneithersupineorinstanding. Thesameprinciples

andtestsareappliediftapeisusedinsteadoftheCompressor.

Initially, the pelvis shouldbe taped or supported by abelt whenever the patient is vertical (i.e.

standing, sittingorduringanyactivityofdaily living). As forceclosure returns, thepatient should

weanoffthebeltbyreducingtheamountofcompression(loosenthetensioninthecompressionstraps)

andfinallyremovingthebeltaltogetherforshortperiodsoftime(beginwithhour). Ultimately,they

shouldbeabletoeliminatetheneedforanyexternalsupport.

The one leg standing test and the active straight leg raise test are nowbeing usedworldwide in

ongoingresearchoffunctionanddysfunctionofthepelvicgirdle. Theyareoftenusedforestablishing

inclusioncriteriaandalso formonitoringclinicaloutcomes. For thepracticingclinician, theycanbe

used,inpart,toestablishadiagnosisoffailedloadtransferthroughthepelvicgirdle(instability)and

subsequentlyas

monitoring

tools

of

progress.

However,

many

more,

as

yet,

non

validated

tests

are

required for treating the pelvic girdle in clinical practice. By integrating the best evidence with

clinicalexpertise,perhapswewilleventuallyanswer thequestionWhat is thebestway to restore

optimal function of the lumbopelvichip region?Intheend,wemaydiscoverthatthere

ismorethanonewayandthankfullyso.


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Biomechanics17(7):495DamenL,MensJMA,SnijdersCJ,StamJH2002bThemechanicaleffectsofapelvicbelt inpatientswith

pregnancyrelatedpelvicpain.PhDthesis,ErasmusUniversity,Rotterdam,theNetherlands

HungerfordB,GilleardW,LeeD2004Alterationofpelvicbonemotiondeterminedinsubjectswithposterior

pelvicpainusingskinmarkers.ClinicalBiomechanics(19):456

LaslettM,WilliamsW1994Thereliabilityofselectedpainprovocationtestsforsacroiliacjointpathology.Spine

19(11):1243

LeeD2002TheCompressoravailableonlinefromwww.optp.com

LeeD2004ThePelvicGirdle,3rdeditionElsevierScience

LeeD,LeeLJ2004AnIntegratedApproachtotheAssessmentandTreatmentoftheLumbopelvichipRegion

DVD.www.dianelee.ca

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A,

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Ginai

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Z

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straight

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and

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raisetestinposteriorpelvicpainsincepregnancy.Spine26(10):1167

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measuringdiseaseseverityinpatientswithposteriorpelvicpainafterpregnancy.Spine27(2):196

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instability: a study of the biomechanical effects of pelvic belts. American Journal of Obstetrics and

Gynecology166(4):1243

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