Meet The Experts - Vol. 3
Report of Daisuke Kurosawa
Jan-Paul van Wingerden, PhD
November 2, 2023
Jan-Paul van Wingerden, PhD gave us a great education.
He is a very important authority on the physiotherapy of the sacroiliac joints. He is the director of the Spine and Joint centre, founded by Dr. Andry Vleeming.
I actually visited him in 2009 to learn about the doppler imaging of vibrations for testing the laxity of the sacroiliac joint.
I had the pleasure of having him lecture for 30 minutes at the April SIMEG Webinar and was very happy to see him again in person at the Low back and Pelvic Girdle Pain conference in Melbourne for the first time in 14 years. The details of actual exercise therapy were not available at the last webinar. We, Japanese staff, asked him to give a lecture and workshop nonofficially after the one-day program with the following title.
# Physical therapy for SIJ dysfunction vol.2.
Clinical practice tips: physical assessment items, treatment strategies, and how to conduct group sessions
Jan-Paul van Wingerden, PhD, The Spine and Joint centre in Rotterdam
Dr. Jan-Paul van Wingerden and Dr. Timothy Doorson taught us their methods. I would like to share with everyone what we have learned:
- His facility has a group of patients with low back and pelvic girdle pain that has not improved after surgery, pain clinics, and everything else that has been done in other hospitals and facilities. So the patient base is considered quite severe.
- We physicians try to strictly determine whether the pathology is in the lumbar spine or in the pelvis (sacroiliac joint), because the goal of treatment (areas to inject local anesthetics, areas to operate on) changes depending on the pathology. For physical therapists, however, the relationship between the lumbar spine and the pelvis is usually more coupled, and it does not make much sense to separate them in training programs. However, there is a difference in that it takes longer to recover from a combined pelvic problem than from the lumbar spine alone.
- Actual sessions: The basic program consists of one or two sessions per week for eight weeks, each session lasting three hours.
- The first thing to do is to interview the patient: patients often say that they have had a lumbar disc herniation for two years, but in fact there was a history of low back problems before that, and it is the result of the herniation. Therefore, it is reasonable to assume that the process is much longer. In most cases, there is a pelvic girdle problem behind the lumbar disc herniation.
- Next, movement is evaluated. The patient walks, goes up and down stairs, lifts a ball on the floor, then lies on a bed and performs active SLR. The sequence of movements is evaluated. The same angle and sequence should be used each time and the images should be recorded.
- Note that fast movements may be compensatory movements. It indicates that the muscles are weak and unable to move slowly.
- Evaluate the movement of the lumbar spine using motion analysis software. If there is symptom weight in the lumbar spine, there will be little lumbar movement and forward flexion at the hip joint. If there is a pelvic problem, there is increased tension in the hips and the patient is unable to bend forward with sufficient hip flexion.
- Don't do exercise therapy right away. Teach them how to relax first. Use a pillow or something to help them find a position where they can really relax. Most people are tense from work, child care, and housework.
- In many facilities, therapists often start exercise right away when patients are in a high state of tension.
- Calm the emotional part of patients and make them feel positive. This requires staff who have studied psychology as well as physiotherapy, but patients' feelings may differ between Japan and Europe.
- Do not give them a lot of information in the beginning, but let them learn how to relax first. Then the body will feel a little better, so they will want to know and trust the therapist.
- The next step is to do exercises. I didn't understand this particular example, but the point is to start with a very minimal load. The focus is on the abdominal trunk muscles. Make them feel the tension in their abdomen when they cough, so that they can do this without coughing.
- Make sure the abdominal muscles are strong when doing active SLR. Extend both hands to form a triangle, do not break it, and then swing it from side to side by a therapist. Support it with the abdominal trunk, and then relax. This is one way to do it. Do not contract the transversus abdominis muscle suddenly. Increase the load gradually.
- Then a group session (4 PTs to 8 patients). 1 PT sees 2 patients. One patient has a break to observe the other patient and the PT's treatment, during which he/she can be objective and get feedback from other patients in the same situation. Four PTs are in the same room so they can see how each other's exercises are going and discuss what could be better. It's good for the patient and good for the other PTs because it's not closed off.
- There is no need to do anything to the sacroiliac joint itself. The pain will go away as the patient gains abdominal strength, trunk stability, and improved activities of daily living. When the lumbar spine is properly lordotic, walking becomes easier.
- Finally, the video of the patient's movement after 8 weeks was very much improved. From the pre-treatment condition, it is miraculous and impressive.
I had expected physiotherapy specific to the pathology of the sacroiliac joint, but now I realize that it is not really like that. We must learn from his facility's approach, because they see a significant number of patients per year who could not be treated anywhere else and achieve results with their treatment. It is challenging to choose surgical treatment for patients with chronic pain syndromes, in particular those involving the sacroiliac joint. Spine and Joint Center's approach is different in depth from other physical therapies. If there is still no alternative after such a treatment of them, then we should perform surgery. I would like to learn more from him and I would like my PT colleagues to learn at his facility for a period of time and bring back good things to Japan.
I learned of the existence of sacroiliac joint dysfunction from the effects of manual therapy techniques that specifically work on the sacroiliac joints. I asked Jan-Paul if there were any techniques that specifically work on the sacroiliac joints, and he said that in Europe, manual therapy, like our AKA Hakata method, usually tries to treat patients with its own techniques, and the patients become dependent on them. Also, as in paternalism, the patient is instructed not to do any unnecessary exercises after receiving manual therapies. Instead, patients need to be able to self-care. I believe that the time we can be associated with is a tiny part of the patient's lifetime, and a huge amount of time is under the patient's control. So his recommendation for self-care is very understandable.