Comparative StudyThe effect of two manipulative therapy techniques and their outcome in patients with sacroiliac joint syndrome
Introduction
Low back pain is a significant health problem having a major impact on the quality of life and on health care costs (van Tulder et al., 2002). At the beginning of the twentieth century, the sacroiliac joint (SIJ) was considered the most important source of low back pain (Weksler et al., 2007). SIJ syndrome may be the result of direct trauma, unidirectional pelvic shear, repetitive and torsional forces, inflammation or idiopathic onset (Hansen et al., 2007). Kirkaldy-Willis and Burton described the symptoms of SIJ syndrome, including pain over the posterior aspect of SIJ varying in severity, referred pain to the groin, greater trochanter, posterior thigh, knee, lateral or posterior calf to the ankle, foot and toes (Kirkaldy-Willis and Burton, 1992). Clinical findings include tenderness over the SIJ and aggravation by pain provocation test (Cibulka et al., 1988).
An array of SIJ examination maneuvers have been described in the medical, osteopathic, physical therapy and chiropractic literature designed to either provoke SIJ pain or detect aberrant motion (Gibbons et al., 2000, Isaacs et al., 2001, Greenman, 2003, Hertling and Kessler, 2005, Maitland et al., 2005, Edmond, 2006). However, the examination maneuvers for aberrant motion have been demonstrated to have poor inter- and intra-tester reliability (Hancock et al., 2007). The value of pain provocation tests in the diagnosis of sacroiliac is controversial. While Maigne and colleagues challenged the accuracy of the common pain provocation test, Broadhust and Bond showed a high sensitivity and specificity for the FABER, posterior shear and resisted abduction pain provocation tests (Weksler et al., 2007). A diagnosis based on three or more positive provocation tests of a group of 6 tests, including Yeoman’s test, Gaenslen’s sign, the FABER test (Patrick’s sign), the compression test, resisted hip abduction or a positive posterior pelvic pain provocation test (thigh thrust test), has been reported to have the highest sensitivity and specificity for the diagnosis of SIJ syndrome (Weksler et al., 2007).
Several treatments have been advocated by clinicians for SIJ syndrome, although research into their efficacy remains sparse or even nonexistent (Ferrante et al., 2001). Spinal manipulation is an intervention commonly used in the treatment of individuals with LBP and has been reported to be more effective than placebo (Rasmussen, 1979, Postacchini et al., 1988, Wreje et al., 1992, Conway et al., 1993) or other interventions (Koes et al., 1992, Delitto et al., 1993, Erhard et al., 1994, Triano et al., 1995).High-velocity low-amplitude (HVLA) thrust manipulation has been claimed to be one of the most frequently used forms of spinal manipulation (Flynn et al., 2006).
Spinal manipulation was used in the treatment of patients with low back pain and significant improvement in ODQ and NRS scores were obtained from thrust and nonthrust manipulative therapy techniques, but significant differences in the ODQ score was obtained in favor of the thrust manipulation group (Cleland et al., 2009). Several studies have reported various physiological or functional outcomes from SIJ manipulation such as reduction in muscle inhibition (Suter et al., 1999, Suter et al., 2000), electromyographic neuromuscular reflex response (Herzog et al., 1999, Colloca and Keller, 2001), decreased Hoffman reflex (Murphy et al., 1995), improved gait symmetry (Herzog et al., 1991), improved innominate bone tilt (Cibulka et al., 1988), and decreased pain and functional disability (Shearar et al., 2005). However, few clinical studies have evaluated the effectiveness of SIJ manipulation (Osterbauer et al., 1993).
SIJ is a part of lumbar–pelvic–hip complex comprising the fourth and fifth lumbar joints, the two hip joints and pubic symphysis (Hertling and Kessler, 2005). The SIJ movements are claimed to synchronize with the hip and L5–S1 junction (Slipman et al., 2001). The sacrum is mechanically associated with the spine and this complex should be considered as a mechanical unit. Involvement of any one structure affects the positioning and movement of the others (Hertling and Kessler, 2005). Authors have claimed that according to the type of SIJ involvement, the lumbar spine (mostly L5) is involved in the bilateral extension, bilateral flexion, flexion-side bending-rotation dysfunction or extension-side bending-rotation dysfunction. If there is lumbar spine involvement concomitant with sacroiliac involvement, then the treatment of lumbar segments is recommended to be performed before the SIJ (Gibbons et al., 2000, Isaacs et al., 2001, Greenman, 2003).
To the best of the author’s knowledge, no study has evaluated the effectiveness of two manual manipulative therapy techniques in the treatment of patients with SIJ syndrome. The aim of the present study was to investigate the relative effectiveness of two manipulative therapy techniques in patients with SIJ syndrome.
Section snippets
Methods
A single blind randomized clinical study was conducted in the clinic of Rehabilitation College of Shiraz University of Medical Sciences. 50 female patients attending physical therapy and already being treated for LBP were screened for eligibility criteria. Thirty-two patients aged between 20 and 30 years met the inclusion criteria. The inclusion criteria were female patients who had an acute unilateral or bilateral SIJ syndrome during the past 6 weeks; those in whom the level of pain over the
Analysis
The p-value of the Kolomogrov–Smirnov test of normality was performed and our data were not normally distributed. The change scores in relation to the baseline scores were calculated for each subject in each trial (i.e. Baseline-immediately after) and the Wilcoxon rank sum test was used for the analysis of between group differences at each trial. For within group differences, Wilcoxon signed-rank test was used between each pair of trials separately. P < 0.05 was considered as significant for
Participant characteristics
Of the 32 participating subjects, 16 were randomized to each group. There were no statistically significant differences in age, BMI (kg/m2) and duration of symptoms between the two groups. The baseline values before intervention was checked by Wilcoxon rank sum test and there were not significant differences between the two groups (Table 1).
Visual analogue pain scale
Analysis by using Wilcoxon signed-rank test revealed a statistically significant improvement immediately (Z = −3.423, p = 0.001), at 48 h (Z = −3.433, p
Comparison of outcomes
In the present study, by using Wilcoxon rank sum test, there were no significant differences in ODI and pain change scores between the two groups. SIJ is a part of lumbar–pelvic–hip complex (Hertling and Kessler, 2005). The sacrum is mechanically associated with the spine and this complex should be considered as a mechanical unit. Involvement of any one structure affects the positioning and movement of the others (Hertling and Kessler, 2005). According to claims of authors in the field of
Conclusion
It is concluded that both treatment techniques, e.g. SIJ manipulation and lumbar & SIJ manipulation, significantly improve pain and functional disability in patients diagnosed with SIJ syndrome. Neither SIJ manipulation nor lumbar and SIJ manipulation was found to be more effective than the other in reducing pain and functional disability in the treatment of this patient population. Therefore manual spinal thrust manipulation may be considered as an effective treatment option for patients with
Funding sources
Support was obtained from the Vice-Chancellery for Research Office, Shiraz University of Medical Sciences.
Conflicts of interest
There were no identified conflicts of interest.
Acknowledgements
We would like to thank Dr.Shokrpour for her assistance with manuscript editing and the clinic of Rehabilitation College of Shiraz University of Medical Sciences for their assistancein data collection.
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