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LITHUANIAN UNIVERSITY OF HEALTH SCIENCES
DEPARTMENT OF REHABILITATION
FACULTY OF MEDICINE
Sacroiliac Joint Pain and Rehabilitation
Author: LAKSHYAJEET VIRDI
Supervisor: Doc. Gra
ž
ina krutulytė
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TABLE OF CONTENTS
1. SUMMARY………...3 2. SANTRUKA………..4 3. ACKNOWLEDGMENTS………..6 4. CONFLICT OF INTEREST.………...6 5. ABBREVIATION LIST ……….…...7 6. INTRODUCTION ………..87. AIMS AND OBJECTIVES ………9
8. LITERATURE REVIEW ……….10
8.1 Low back pain ……….10
8.1.1 Prevalence of low back pain ………10
8.1.2 Risk factors……….………..12
8.1.3 Classification ……….………..12
8.1.4 Diagnosis of LBP……….……….14
8.1.5 Multi-disciplinary considerations……..………15
8.2 Sacroiliac joint anatomy ………..……….15
8.2.1 Sacroiliac joint pain and dysfunction ……….………..16
8.2.2 Sacroiliac joint pain prevalence ……….………..17
8.2.3 Demographic ………..………..17
8.2.4 Etiology and risk factors ……….………...18
8.2.5 Diagnosis ………..………20
8.2.6 Management ………..………...24
8.2.7 Rehabilitation ………..……….26
9. RESEARCH METHODS AND METHODOLOGY ………….………29
9.1.1 Systematic literature review………..………29
9.1.2 Inclusion and exclusion criteria………..………...29
9.1.3 Prisma flow chart……….….……….30
10. RESULTS……….……….……..31
10.1 Summary of the studies……….32
11. DISCUSSION OF THE RESULTS ……….………..35
12. CONCLUSION ………..………39
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1. SUMMARY
Author: Lakshyajeet Virdi
Title: Sacroiliac joint pain and rehabilitation
Aim: The study aims to evaluate rehabilitation methods for Sacroiliac joint pain. Objectives:
1. To describe low back pain and Sacroiliac joint pain is the population. 2. To describe management methods for Sacroiliac joint pain and dysfunction. 3. To evaluate rehabilitation methods for Sacroiliac joint pain.
Methods: Search was conducted on the electronic database PubMed and PEDro, articles in the English language between the years 2011-2021 were selected from PubMed, articles with participants under the age of 18 were not selected. The search from PubMed with the keywords “sacroiliac joint pain”, “sacroiliac joint dysfunction”, and “rehabilitation” resulted in 182 articles, and on adding the filter including articles in the last 10 years resulted in 76 articles from which 7 were selected. Another article from PEDro was added in the review on the search parameters similar to the previously mentioned. A total of 8 articles were included in the review.
Results: There were 4 randomized control trials, a case report, a comparative study, case series, and a quasi-experimental study. In the case report the patient a multi-disciplinary approach with a total of 20 physiotherapy interventions for 1-year the longest in the review. 7 of the studies used some level of manipulation technique to either treat or correct the pelvic alignment before the treatment or as an adjunct to the main therapy. The study that did not perform any manipulation followed a gluteus strengthening program, which proved effective in reducing the pain of the participants. 6 of the studies had an intervention with exercise therapy. 1 study had an inter-articular corticosteroid injection as a control group. All the studies showed improvement in the patients. All the studies had used pain provocation test to diagnose the pain source to be the sacroiliac joint, some studies also used a combination of a clinical history of the symptoms with clinical examination to select the participants.
Conclusion: Rehabilitation methods such as manual therapy and exercise therapy can be considered as effective treatment methods for treating Sacroiliac joint pain. Manual therapy proved to provide a reduction in pain sooner when compared to exercise therapy. Exercise therapy such as strengthening the muscles surrounding the pelvis and stabilizing was effective in reducing the pain and dysfunction. Both or either of these methods can be performed depending on the individual cases.
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2. SANTRAUKA
Autorius: Lakshyajeet Virdi
Tema: Kryžkaulinio klubakaulio sąnario skausmas ir reabilitacija
Tikslas: Tyrimo tikslas - įvertinti reabilitacijos metodus, skirtus sakroiliakinio sąnario skausmui malšinti.
Tyrimo uždaviniai:
1. Apibūdinti nugaros skausmą ir kryžkaulio sąnario skausmą - tai populiacija. 2. Aprašyti sakroiliakinio sąnario skausmo ir disfunkcijos gydymo metodus. 3. Įvertinti reabilitacijos metodus, skirtus sakroiliakinio sąnario skausmui malšinti.
Metodas: Paieška buvo atlikta elektroninėse duomenų bazėse „PubMed“ ir „PEDro“, pasirinktose iš „PubMed“ 2011–2021 m. straipsniai anglų kalba, straipsniai, kurių dalyviai buvo jaunesni nei 18 metų, nebuvo atrinkti. „PubMed“ atlikus paiešką pagal raktinius žodžius „ kryžkaulinio klubakaulio sąnario skausmas“, „ Kryžkaulinio klubakaulio sąnarių funkcijos sutrikimas“ ir „reabilitacija“ rasta 182 straipsniai ir pridėjus filtrą, apimančią paskutinių 10 metų straipsnius, rasti 76 straipsniai, iš kurių dar 7 buvo vienas PEDro straipsnis įtraukti į apžvalgą pagal paieškos parametrus, panašius į tuos, kurie minėti aukščiau. Iš viso į apžvalgą buvo įtraukti 8 straipsniai.
Rezultatai: Buvo atlikti 4 atsitiktinių imčių kontroliuojami tyrimai, viena atvejo ataskaita, lyginamasis tyrimas, atvejų serija ir beveik eksperimentinis tyrimas. Atvejo ataskaitoje pacientui buvo taikomas daugiadisciplininis požiūris, iš viso per 20 metų atliekant 20 fizioterapijos intervencijų - ilgiausiai iš visų peržiūrėtų tyrimų. Septyni tyrimai naudojo manipuliavimo technikos lygį gydant ar koreguojant dubens sąnario būklę prieš gydymą arba kaip papildomą gydymą pradiniu lygiu. Tyrime, kuriame nebuvo atlikta manipuliacija, buvo naudojama sėdmenų raumenų stiprinimo programa, kuri pasirodė esanti veiksminga mažinant dalyvių skausmą. Intervencinė mankštos terapija buvo naudojama šešiuose tyrimuose. 1 tyrime intraperitoninė kortikosteroidų injekcija buvo naudojama kaip kontrolinė grupė . Visų tyrimų metu pacientų būklė pagerėjo. Visuose tyrimuose skausmą provokuojantis testas buvo naudojamas siekiant nustatyti, ar skausmo šaltinis yra kryžkaulio sąnarys, o kai kuriuose tyrimuose dalyvių atrankai taip pat buvo naudojama klinikinė istorija ir klinikiniai tyrimai.
Išvatliktaada: Reabilitacijos metodai, tokie kaip manualinė terapija ir mankšta, gali būti laikomi veiksmingu gydymo metodu gydant sakroiliakinio sąnario skausmą. Įrodyta, kad manualinė terapija, palyginti su fizine terapija, greičiau sumažina skausmą. Pratimų terapija, pavyzdžiui, dubenį supančių
5 raumenų stiprinimas ir stabilizavimas, buvo veiksminga mažinant skausmą ir disfunkciją. Abu arba bet kuris iš šių metodų gali būti taikomi priklausomai nuo individualių atvejų.
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3. ACKNOWLEDGMENTS
Firstly, I would like to thank my family and friends for supporting me throughout and providing me the moral support needed to finish my work.
I would like to give my sincerest gratitude to my supervisor for assisting me in finishing my thesis.
4. CONFLICT OF INTEREST
The author reports no conflict of interest.7
5. ABBREVIATIONS LIST
LBP- Low back pain
SIJ- Sacroiliac joint
SIJD-Sacroiliac joint dysfunction
SIJP- Sacroiliac joint pain
ALBP- Acute low back pain
CLBP- Chronic low back pain
NSLBP- Non-specific low back pain
RULA- Rapid upper limb assessment
CS- Central sensitization
MS- Musculoskeletal
COVID-19- Coronavirus disease 2019
RF- Radiofrequency
ODI- Oswestry disability index
HVLA- High-velocity low-amplitude
LVLA-Low-velocity low-amplitude
VAS- Visual analog scale
NPRS- Numeric pain rating scale
MET-Muscle energy technique
PSIS-Posterior superior iliac spine
ASIS-Anterior superior iliac spine
IA-Intra-articular
CT-Computer tomography
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6. INTRODUCTION
Lower back pain (LBP) is an extremely common occurrence and pain generator regarding the musculoskeletal system, about 60% to 80% of people will experience pain in the lower back at least once in their life. LBP affects people of all ages. In many cases, the etiology of lower back pain is unknown so it is labeled/designated nonspecific (1). The incidence of LBP has increased by over 50% in the last couple of decades which imposes a huge burden on nations globally. Low and middle-income countries seem to take a greater impact as the social support system and healthcare systems are not able to deal as effectively as high-income countries. However, high-income are affected by the financial burden. Given the fact that LBP affects an individual on many facets of life such as social, psychological that negatively impact the personal and work life of an individual (2).
Sacroiliac joint pain (SIJ) is a pain in the lower back or the sacral region which is commonly caused by sacroiliac joint dysfunction (SIJD). SIJD is caused by changes in the normal range of motion of the joint, hypermobility, or hypomobility of the joint which can cause instability of the joint. SIJD can be the cause of LBP in about 15 to 40% of cases. The pain from the sacroiliac joint can cause radiation of the pain to the thigh and groin and can also cause sciatica (3).
A diagnosis proposed by The International Association for the Study of Pain (IASP) for sacroiliac joint dysfunction is suggested as pain in the sacroiliac joint region that can be replicated with pain provocation tests that are relieved by local anesthetic intra-articular injection. Intra-articular injection guided by fluoroscopy with local anesthetic and/or corticosteroids (4).
Conservative management of SIJ pain includes pelvic stabilization exercises to allow for postural control, cold application, medications such as anti-inflammatory, manual medicine techniques, muscle balancing of the trunk and lower extremities, manipulation, sacroiliac belts, massage, patient education, aerobic conditioning, electrotherapeutic modalities (3),(5). If conservative treatment fails then more invasive tools can be considered such as pain block injections, prolotherapy, radiofrequency denervation, cryotherapy, and surgical treatment. They are shown to achieve different levels of success (5).
The review will aim to investigate the current literature on the Rehabilitation of sacroiliac joint pain and dysfunction.
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7. AIMS AND OBJECTIVES
Aim: The study aims to evaluate rehabilitation methods for Sacroiliac joint pain.
Objectives
1. To describe low back pain and Sacroiliac joint pain in the population. 2. To describe management methods for Sacroiliac joint pain and dysfunction. 3. To evaluate rehabilitation methods for Sacroiliac joint pain.
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8. Literature review
8.1.1 Low back pain
Low back pain (LBP) frequently causes disability in individuals throughout the world, largely due to the nature of the pain and its debilitation effects on the individual, it plays a big role in reducing the quality of life in people suffering from LBP (6).
It causes disturbances in both the private and work-life of the person affected by LBP. These disturbances include sleep disorders, absence from work, decrease in productivity, and inability to carry out the personal and work commitments undertaken by the individual (7). Chronic LBP is expensive as it causes decreased work output which could be from the inability to sit and work or absence from work completely and also for the health care system in treating the disability caused (8). It is estimated that for some countries in the Western world, the cost of back pain ranges from 1%-2% of the gross national product (GDP). It has been calculated by certain experts that in the US the cost of back pain exceeds $100 billion per year (7).
LBP can begin with acquiring subpar posture at work, heavy lifting with incorrect form while heavy lifting, pushing, pulling, flexion of the trunk, rotation, and hypertension, in essence, several causes can be caused by movement of the trunk in different planes of motion. Being obese or overweight, insufficient physical activity (PA) can also be an additional factor in increasing the pain intensity (7). Frequently the cause of LBP is without any structural abnormalities and could be from impaired biomechanics. The different types of LBP can be divided by the character of the pain and the specific structural pathology causing it. Axial LBP could arise from sacroiliac joint, intervertebral joint, facet joint, paraspinal musculature, whereas radicular pain could arise from a herniated intervertebral disc and spinal stenosis. In some cases, both types of pain could coexist. It should be noted that different origins and mechanisms of the pain could present with different quality and character of the pain including the location and radiation of the pain as well. LBP can be a precipitation factor in depression, fear of pain, and ongoing compensation claims (6).
8.1.2 Prevalence of low back pain
Low back pain prevalence in Lithuania – in a study done in 2016 about Musculoskeletal (MS) pain in Lithuania, which included the people working in offices or had a desk job, where the majority of the participants were women, with a mean age of 45.9 ± 11.1 years and mean time duration of computer use for work of 10.7 ±5.5 years. Most of the participants worked on the computer for at least 6 hours a
11 day. About 50% of the participants complained of low back pain. A basal metabolic index (BMI) of more than 25 kg/m^2 had a high correlation with LBP. Participants who reported poor social support had a higher chance of suffering from LBP. Not taking breaks every 2 hours also is associated with an increased risk of low back pain (9). With the increase of a point in the rapid upper limb assessment (RULA) score, we can expect the chances of LBP incidence to increase by 30 % (9).
An epidemic status can be given to the widespread prevalence of LBP (10). It is reported that the lifetime incidence of LBP to be in the range of 51% 84% at least some point in a person's life (6). The incidence of the first-time LBP in a year was reported between the range of 6.3% and 15.3% by a systematic review whereas the one-year incidence of any episode of LBP was reported between the range of 1.5% to 36%. Some studies have reported an increase in the incidence of chronic LBP in the last few decades in some parts of the world (10). In pregnant women, the prevalence of LBP has been described to be present in 75% mostly in the last trimester (11).
LBP is prevalent in its spread in different levels of society however, there are some factors like age, sex, education, and occupation history that play a role in its incident. LBP is more common in women, and so is older age, the incidence of LBP increases up to the age of 60-65 years. The occupation history and lower education level play an important role in the severity and the prognosis, as it is linked with higher incidence and worse prognosis in lower education levels. Manual workers report an incidence of about 40% and office workers or people with a more sedentary work report an incidence of about 18.3%. The difference also exists in people who have different lifestyles in their private life report a similar incidence of LBP (10).In a study, it was reported that there was not any difference between the prevalence of LBP in urban and rural areas. When the difference in the prevalence between high-income countries was higher when compared to middle-income or low-income countries was done however, the difference between middle-income and low-income countries was done no statistical difference was found. However, a strong correlation was found between the Human Development Index (HDI) of a country and the prevalence of LBP (12). Findings from a systematic review reported conflicting results when comparing the incidence of low back pain and physical exercise in either leisure time or work time. This study was done including school children and both in the general population (13).
Effects of Coronavirus disease 2019 (COVID-19) pandemic lockdown in the prevalence of LBP. A study was done in Riyadh (Saudi Arabia) noted an increase in the prevalence of LBP from 38.8% to 43.8 % after the COVID-19 pandemic quarantine lockdown. The participants of the study were aged between 35 to 49 years old with a BMI of at least 30, self-reporting of sitting for prolonged periods (especially not sticking to ergonomic recommendations), undergoing distance learning or teleworking, and did not take part insufficient physical activity reported increased intensity of LBP (7).
12 8.1.3 Risk factors for low back pain
Understanding risk factors LBP is important as it can be beneficial in treating it. There are various suspected factors in causing LBP, the main categories are activity-related and individual factors which could be demographic-related, it should be noted that these are not all-inclusive (10).
LBP is often associated with poor posture while sitting, obesity, lifting heavy with poor technique, repetitive movements especially when the muscles of the trunk are fatigued, trunk flexion, rotation, and hyperextension, age, educational status, job satisfaction, occupational factors, psychosocial factors (7) (14). Women have been reported to be three times more vulnerable to LBP when compared to men. Co-morbidities do not seem to affect the outcome for the recovery from LBP. The duration of sick leave due to LBP is not affected by working for long shifts (more than 8 hours), a previous history of LBP, nor does the marital status. It was found that the higher pain intensity had a co-relation with worse outcomes and active coping was related to better outcomes in the work environment (10).
The risk of LBP in adolescence is like that of adults. The prevalence is found to be up to 70%-80%. The incidence evidence is inconclusive when lifestyle and sports activities are considered with mixed evidence in the literature (10). There is only a weak association found in the causes of LBP in the current literature. Risk factors include many factors but are slightly population-specific (10).
8.1.4 Classification of LBP
Understanding the origin of the source of the pain is fundamentally important as the treatment is based on it. The system for the classification of LBP seems to be underdeveloped and no one accepted system exists. A way in which we could classify is on the location of the pain, which is commonly divided into Axial which is limited to the lower back, radicular which the pain radiates along the nerve and the pain is referred along the lower limb (6). LBP can be influenced by factors such as psychological, anxiety, depression, stress a detailed history of these factors should be taken. Psychosocial factor history (15). The classification of the pain is essential for clinicians for the treatment as the approach changes depending on the category of the pain and cause (6). The classification of LBP can be made on the duration of the symptoms and also based on the characteristic of the pain.
Acute low back pain (ALBP) seems to be the most common reason for visits to the emergency rooms. If without any presence of red flags ALBP seems to be a self-limiting disease. So, in clinical practice, it is important during the examination of the patient to rule out any of the red flags caused for low back pain. Red flags include neurological defects of great magnitude, tumors, infection, paralytic syndrome,
13 signs of progressively worsening of neurological symptoms recent trauma, milder trauma for patients over the age of 50, fractures that need urgent treatment., unintentional weight loss, fever without any cause, history of cancer, I/V drug use, corticosteroids, patients age of more than 70 years, and osteoporosis (15)(16)(17).
Chronic low back pain (CLBP) develops in patients when the initial presentation of acute pain lasts persists for more than 3 months or the pain lasting longer than the expected healing time. The presence of structural changes has been found in CLBP of the paraspinal muscles, they are found to be weak and susceptible to fatigue. Poor muscle coordination in the paraspinal muscles has been evident in developing CLBP (18). CLBP is one of the leading causes of disability throughout the world. CLBP can be regarded as a disease and not a symptom due to the well-defined underlying causes when present (15).
Classification of LBP between nociceptive, neuropathic, and central sensitization (CS) is based on the study by Nijs et al. 2015 (19). To treat pain effectively and efficiently in patients with LBP the distinction should be made between nociceptive, neuropathic, CS pain. There have been some arguments regarding the inclusion of CS pain as neuropathic pain. A study was done which classified patients with any kind of pain into neuropathic, nociceptive, and CS pain which took evidence from opinions from numerous experts, in the study the authors used this classification and applied it to LBP (19). Article conducted by Nijs et al. 2015 describes criteria from which clinicians can differentiate between neuropathic, nociceptive, and CS pain in patients with LBP (19).
Nociceptive pain occurs from a real threat to non-neural tissue and arises from activation of nociceptors (19). When there is actual damage or potential for actual damage if the harmful stimuli persist on the body due to internal or external causes this sensation is transmitted from the source by the peripheral nervous system and to the central and autonomic nervous system. This sensation is referred to as nociception (20). It is a reaction to chemical, thermal, or mechanical stimuli (19).
Neuropathic pain is the sensation of pain caused by lesions or disease of the somatosensory system (21). Usually, the most common cause is lumbar radicular pain. Nociceptive and neuropathic both are classified as specific low back pain as there is a clear cause for the pain. As opposed to non-specific Low Back Pain (NSLBP) where a specific cause cannot be regarded as the source of pain generation. In about 85% of the cases, it is said the LBP to be non-specific (19).
Central sensitization (CS) is described as a hypersensitivity for the pain to the somatosensory system amplification in the sensation of pain when a source of nociceptive pain is absent with an increased sensation of pain perceived in the central nervous system (CNS) (19) (22). CS occurs when there is a chronic pain state in an individual or when transitioning between acute and chronic pain. Not all patients
14 who suffer from chronic pain will develop CS. Some evidence for certain treatment modalities has been shown to alter the abnormal pain perception in the CNS that causes the altered perception of pain (22).
Axial Low back pain It was found that about 28% of individuals who presented with acute axial LBP did not recover fully after 12 months ended up developing chronic LBP. Certain factors which predispose an individual to develop chronic pain include advanced age, higher pain and dysfunction score on baseline testing, worse outlook on pain and perception of pain, fear of persistent pain, and ongoing compensation claims (6). A systematic review conducted by Itz et al. 2015 concluded that patients with axial LBP for less than 3 months who visited a primary health care setting had worse outcomes. About 30% of patients recovered in 3 months but 65% still suffered from persistent pain up to 1-year post initial treatment. This shows us that individuals who do not recover in 3 months have a higher risk of developing chronic axial LBP (6). The differential diagnosis for axial LBP included pathology with intervertebral disc, facet joints, and paraspinal musculature (6).
Radicular pain is precipitated due to inflammation or lesions on the dorsal root or the ganglion. Usually, the pain radiated from the buttocks down to the leg. Lumbar disc herniation is the culprit in most cases. Radicular pain travels along the affected nerve or nerves without neurological impairment (15).
8.1.5 Diagnosis LBP Imaging
Imaging techniques such as magnetic resonance imaging (MRI) are not recommended for routine evaluations of CLBP, NSLBP (23). MRI is a resource-intensive modality with high sensitivity and low specificity for screening of structural abnormalities making it inadvisable to be used for suspected spinal pathology especially in a primary health care setting. (23). Early plain radiographic imaging detects asymptomatic minor abnormalities which are associated with poorer prognosis. Plain radiographic imaging is beneficial to assess the bony structures of the spine and possibly evaluate any abnormalities, while MRI is useful for locating the source of the neurological or soft tissue abnormality (16). Imaging should be reserved for individuals with a history of a dangerous cause of LBP, the presence of neurological deficits on physical examination, or the presence of an unclear clinical picture (15),(23).
According to the recommendation by the American College of Radiology imaging for LBP should be not be done within 6 weeks of the initial presentation if red flags are absent (15) (16). If pain persists after the initial treatment, then other somatic causes of the pain should be considered which could have been missed in the initial evaluation of the patient, imaging is not a recommendation in the case of an ineffective treatment. Imaging that will change the treatment approach should be performed (23).
15 A study that included patients without any history of a dangerous cause of acute or subacute LBP compared the difference in intensity of pain between patients who went immediate imaging with patients that did not; and reported no difference between the groups when measurements were done at 3, 6, and 12 months (24). Another study compared the outcome between patients receiving immediate imaging and 6 weeks after diagnosis, reported to have the same outcome between the groups, and concluded unnecessary imaging can lead to progression of the pain to chronic from acute (23).
Imaging should be considered for patients who have not improved after 6 weeks after initial treatment(23). Early assessment during 2-4 weeks after initial diagnosis should be considered if disability due to LBP is impeding with professional performance or is causing absence from work for a prolonged period and in cases where the treatment requires a multidisciplinary approach imaging should be performed before commencing the treatment (23).
8.1.6 Multidisciplinary considerations
Patients who are unable to resume daily activities, pain relief for longer than 12 weeks after initial treatment following the guidelines should be evaluated holistically with a multidisciplinary team evaluation. The same goes for patients with chronic nonspecific low back pain (CNSLBP) exacerbation, patients which have an increased risk for chronic pain should be evaluated earlier at 6 weeks if pain persists. During the patient evaluation, peculiarities of the patients' case should be completely considered and a collective team decision is to be made on the further actions (23).
There is some evidence of cognitive behavior therapy and meditation-associated stress-reducing therapies can potentially provide relief in individuals suffering from CLBP. High-level evidence for short-term effectiveness and medium level evidence for long-term effectiveness for yoga as a treatment method for CLBP, improvements were observed by 26 weeks of treatment. A multidisciplinary rehabilitation approach can lead to improvement in pain and disability caused by LBP (16).
8.2 Sacroiliac joint anatomy
The sacroiliac joint (SIJ) is a di-arthrodial joint between the sacrum two ilia (25),(26). The joint by adulthood takes a “C” shape. The joint is still classified as a synovial joint regardless of 75% of its superior joint surface is not synovial. It is surrounded by a fibrous capsule. The anterior capsule is
16 covered by comparatively thin ligaments which by combining with the anterior ligaments form the iliolumbar ligament. The posterior capsule is often not present or rudimentary. The posterior border of the SIJ is formed by strong interosseous ligaments (26).
The muscles surrounding the sacroiliac joint are muscled glutaeus maximus and glutaeus medius, biceps femoris, erector spinae, latissimus dorsi, piriformis, psoas, transversus abdominis and obliques, and thoracodorsal fascia. The compressive forces which act on the pelvis work on closing the pelvis bones together. The muscles adjoining the SIJ like the gluteus maximus have fibers extending and forming the anterior and posterior joint ligaments (26). The innervation of the SIJ and surrounding structures such as subchondral bone, capsule, and ligaments is by spinal nerves T12-S4. The SIJ is mainly innervated by the lateral branches of the S1, S2, and S3 dorsal rami and the branches of the L5 dorsal ramus (27). The motion of the sacroiliac joint is only a small amount, the joint permits rotational motion and translation motion of the sacrum and ilium (25). The SIJ can be palpated in the posterior superior iliac spine (PSIS) and the area inferior to it (1).
8.2.1 Sacroiliac joint pain and dysfunction
Sacroiliac joint pain (SIJP) or dysfunction can be attributed to the changes in the movement of the joint due to alteration in the stiffness and laxity of the supporting structures of the joint (25). Sacroiliac joint dysfunction (SIJD) can be a reason for the pain of the SIJ. It is a common cause of LBP occurring in 16% to 30% of people. Diagnosing SIJD is rather tricky due to there not being a gold standard accepted worldwide and that is regardless of the source for LBP (28). Currently, there seems to be no widely accepted single clinical examination technique that is sensitive and specific enough for SIJD. Imaging studies modalities cannot differentiate from an asymptomatic and symptomatic patient with joint pain. Alteration in motion can cause, Hypermobility which leads to micro instability of the SIJ which further causes pain and is a complex entity to treat. Hypermobility is often caused due to a decrease in function of the surrounding structures in the pelvic and the lumbosacral region which leads to a functional and structural deficit in the joint (29). Hypomobility of the SIJ is over time the joint becomes less mobile as a result of compensatory mechanisms, which are believed to be caused by a hypermobility joint earlier in life to which the body responds to and as a protective mechanism stiffens the surrounding structures leading to hypomobility later in life (29). Joint subluxation Is usually a result of a trauma involving high energy (29).
17 A systematic review conducted by Simopoulos et al. 2012 recorded an estimated prevalence of SIJP to be in the range of 10-62% although the study mentioned most of the studies analyzed to suggest the prevalence to be around 25%. Local anesthetic blocks were used as the method in determining the SIJP prevalence, single and double blocks were used and considered different percentages of pain relief with at least 50% pain relief to be considered as positive (28). It should be noted that the studies had different criteria for the patient sample selection which shows the big difference in the prevalence of SIJ pain. Different studies report different percentages of the occurrence but regardless of that, it is a significant amount to be regarded as an impactful entity. Generally, the accepted prevalence in patients with LBP is around 16-30% (30).
For individuals suffering from CLBP, the source of the pain has been reported to be the SIJ in 20% of the cases (31). Although different percentages have been reported in other studies, it’s an important factor for acute and chronic LBP (25). The sacroiliac joint seems to be one of the most common causes of chronic LBP with regards to axial low back pain. Complications from failed back surgeries resulting in LBP are about 29% making the SIJ the most likely source of LBP in patients with post-surgical lumbar or lumbosacral fusion (32). Pregnancy-related LBP in 20% of the cases the cause has been attributed to posterior pelvic pain (11).
8.2.3 Demographics of sacroiliac joint pain
A study performed by Telli et al. 2020 including patients aged from 20 to 60 years with a diagnosis of lumbar disc herniation (LDH) evaluated the prevalence of SIJD. The correlation between education level and incident of low back pain with SIJD was reported to be 14.1% for illiterate participants, 44.9% in participants with up to primary school and middle school level education, 14.1% of participants with high school level education, and 5.1% of participants with university-level education (33). This shows the prevalence to be the highest in individuals with primary and secondary school level education and the least to be in individuals with a university level of education and the trends were similar to be in participants without SIJD. The occupation of the participants was found to be 46.2% were housewives, 7.7% to have a sedentary occupation, 26.9% had a physically tiring job, 19.2% were retired (33). Reported the only significant difference to be in the gender of the participants where 75.6% of the women were positive with SJD and 24.4% of the men. It should be noted that the study consisted of 63.2% females and 36.8% males (33). Another study reported the occurrence of SJD to be 55.9% in women from the chosen sample size. They suggested the causative factors to be due to changes in the SI caused by fertility, lower levels of exercise, or lifestyle factors (33).
18 8.2.4 Etiology and risk factors for sacroiliac joint pain
Changes occur with age as early as the third decade of life in the iliac part of the joint, more commonly in men. There are also higher elevations and lower depressions in the surface of the joint with the increase in age, which owe their presence to the longer exposure to gravitational stress over an individual’s lifetime. The joint capsule becomes thicker and fibrous in the fifth and sixth decade of life, and as age advances, during the sixth and seventh decade of life the changes become more pronounced and degeneration of the joint takes place due to the progressive thickening of the joint capsule leading to erosion of the joint surface which exposes the deeper subchondral bone. The composition of the joint capsule is altered in more advanced age, from cellular to comparatively more collagenous (29).
Biomechanical explanation of the sacroiliac joint pain. The literature does not agree sometimes on the degree of movement in the SIJ. Previously it was believed that the SIJ had motion in early life but due to degeneration, which caused fusing of the joint this diminished the movement of the joint. In more recent times, it was demonstrated that the SIJ retains its movement throughout a person's life (29). A study proved that the cause of the high ridges formed in the later years of life was caused by the forces that the joint went through throughout a person's life and it made the joint more stable and reporting that the joint retained its movement (29).
The risk factors for the development of SIJ can be attributed to various causes such as a high energy motor vehicle accident usually caused due to the position of the foot on the break at the time of the impact transferring energy through the lower limbs to the spine, lateral vehicle collision which results in the impact to the lateral side of the pelvic ring, a misstep or jumping or landing on an uneven surface unexpectedly which causes a sudden jerk and transfers the impact to the SIJ, or a fall on the buttocks. A history of conditions such as previous lumbar fusion surgery, polyarthritis, and the history of pregnancies and pregnancies is a major factor in developing SIJD in women (32).
Table 1: Etiology of sacroiliac joint pain
Etiology of Sacroiliac joint pain (34) (27)
Traumatic Sudden/repetitive heavy lifting and/or strain
Soft tissue injury by a fall (on the sacroiliac joint)
19 Injury caused indirectly by a high energy
motor vehicle collision Fracture of the pelvic ring
Atraumatic From an infection
Previous lumbar fusion or lumbosacral fusion Pregnancy (dysfunction due to increased laxity of the ligaments caused by the hormones) Spondyloarthropathy
Osteoarthritis and other degenerative changes of the joint
Scoliosis Enthesopathy
A discrepancy in leg length Rheumatoid arthritis
Inflammatory bowel disease Autoimmune disorders
A study showed that the United States Senior National Rowing Team had a prevalence of SJD to be present in 54.1% of the team. Concluding that rowers are at risk of developing SIJD due to the loads applied and the biomechanical movement patterns on the transverse plane transferred through the lumbosacral region. The normal equilibrium of the muscles may be disrupted due to the imbalance in movement patterns and the forces that are transferred through the SI region and pelvis. A study conducted on cross country skiers found evidence of lumbosacral dysfunction in athletes performing at a high level who used the asymmetrical V-skating technique. In conclusion, any physical activity or sports which have a high frequency of high loads of energy transfer through the torso and lower extremities puts an increased biomechanical strain on the SIJ could lead to an injury or dysfunction of the SIJ putting the athletes at risk. (29).
Another risk factor can be attributed to lumbar fusion in a study that included participants with 1- and 2-level lumbar fusions, biomechanical investigation of the forces experienced which show an increase in stress transfer through to lumbar spine to the SIJ. It is widely accepted that after lumbar fusion there is degeneration of the adjacent lumbar segments. It has been reported by various authors the after a multilevel lumbar fusion there is a correlation with SIJ pain in the joint caudally adjacent to lumbosacral fusion (25).
20 A directly proportional correlation has been described between the number of spinal levels fused and the incidence of postoperative SIJP. The postoperative SIJP has been attributed to the reduced lumbar lordosis and failure to restore the natural lumbar spine curvature resulting in an abnormal alignment of the lumbar spine (25).
8.2.5 Diagnosis of sacroiliac joint pain
A correct diagnosis is important as an incorrect diagnosis will lead to an increased burden on the already strained healthcare system as well as the wrong treatment plan. There is no widely accepted gold standard for diagnosing LBP of any cause (28). SIJD contributes to a considerable proportion of LBP and yet it has been underestimated possibly due to the multifactorial etiology and the difficulties faced while diagnosing SIJ pathology (32).
There have been conflicting arguments for the accuracy and use of anesthetic pain block for the diagnosis of SIJ pain. However, a controlled local anesthetic block is usually accepted as the most reliable modality for the diagnosis of SIJP. Even though it is an expensive, comparatively invasive, and operator-dependent procedure that requires experience in interpreting the findings, applying the block consequently so making it not feasible to be used in daily clinical practice as the primary diagnostic tool (28).
Firstly, it is recommended to eliminate conditions such as tumors, fractures of the sacrum, hip pain, facet joint pain, muscular pain, intervertebral disc disease, infections, inflammatory diseases, ankylosing spondylitis, or rheumatological conditions by clinical, laboratory testing and imaging. Following the guidelines given by the International Association for the Study of Pain, for the diagnosis for SIJ dysfunction, a set of positive pain provocation tests and a positive invasive pain block during the clinical evaluation is considered the minimum requirements (35) (36).
To confirm the diagnosis local anesthetic pain blocks are applied. Fluoroscopy-guided or computer tomography (CT) -guided intra-articular (IA) pain block injection can be considered as reliable interventions in diagnosing SIJP. The injection is administered in the inferior aspect of the SIJ. For therapeutic intervention, a combination of corticosteroids and local anesthetics are used for pain relief.
21 The pain from dysfunction from the sacroiliac joint starts as lumbar pain often below the waistline and downwards to the legs and groin and other parts sometimes below the knee in the L5-S1 dermatome on taking the history of the pain however it can also be mimicked by other causes of LBP (35) (4). The characteristic of the pain is found to be achy without any burning or tingling/numbness (4).
Figure 1: Pain referred zone density adopted from the work of Dreyfuss et al. (26)
Imaging
Imaging studies could also be performed to identify the structure of the SIJ for any discrepancies in the joint. But often these studies are inconclusive and do not yield a positive confirmation of the SIJ dysfunction and require further testing. But can be done to exclude red flags such as infection, fracture, and malignancy that could affect the SIJ (32). Imaging results should be interpreted carefully as patients can still present with a normal-looking X-ray and still suffer from SIJ pain. (35).
Imaging can be especially useful when the suspected diagnosis is sacroiliitis (37). CT scan has been observed to have a sensitivity of 57% and specificity of 69% in identifying a positive response when compared with pain block of SIJ by intraarticular injection. Bone scans have been observed to have a sensitivity of 46 % even though a high specificity of 90% when the pain was confirmed by an intraarticular block (36). A radiological imaging conformation for accuracy is recommended when administering a pain block injection of the SIJ (24).
22 Pain provocation tests
A single pain provocation cannot be relied on for confirmation of SIJP however a cluster of tests have been reported to provide good results. Generally, 3 positive tests out of a cluster of 5 or 6 tests with the presence of clinical signs can suggest the pain source to be from the SIJ. These tests can be regarded as screening tests. The tests are considered if the pain felt by the patient can be replicated through the tests. Usually, further testing should be performed to confirm the diagnosis for SIJP (35).
Table 2: Pain provocation tests description (this list is not all-inclusive)
FABER test The iliac crest of the opposite side is depressed down to maintain the position of the pelvis, the contralateral hip is in a flexed position and is depressed down gradually (35).
Gaenslen’s test The examination is done while the patient is lying on their side. The hip is flexed with the lower leg in the extended position while the examiner extends the hip while the other hand is supporting the iliac wing (35).
Lasègue test An active functional test. The patient is in a supine position and is instructed to lift the lower leg while keeping the knee straight and tensed (35).
Compression test
Both the iliac wings are compressed towards each other as the patient is lying on their side. The examiner's elbows are extended and placed on the upper part of the iliac crest of the patient and force is applied towards the floor (38).
Long ligament test/finger sign
The test is considered positive if the pain is replicated by applying pressure on the superior portion of the SIJ (35).
Fortin finger test
The patient is asked to locate the pain with one finger and if the pain is inferomedial to the PSIS within a 1cm area and the patient can point at the same location at least twice then the test is considered positive (38).
Distraction test (gapping test)
The patient is lying on their back, the examiner places their palms on the anterior superior iliac spine (ASIS) and applies pressure downwards and laterally (38).
Shear test The subject is lying in a prone position, the examiner applies force on the sacrum in the coccygeal region towards the cranium. The ilium is immobilized and there is a
23 force applied on the legs and traction forces are applied on the sacrum. The test is considered positive if this maneuver elicits pain (38).
Gillet test The test is conducted with the patient standing and facing away from the examiner with their feet 12 inches apart. Both of the PSIS are located, the patient is asked to stand on one leg with the contralateral hip flexed and the knee flexed towards the chest (38).
Intra-articular diagnostic block
The IA diagnostic block has a dual purpose of diagnosis and can be used as a therapeutic modality when combined with corticosteroids. In a study done by Simopoulos et al. 2015 measuring the diagnostic accuracy and therapeutic effeteness of SIJ interventions. The study recorded the effectiveness of IA diagnostic block for the diagnosis and effectiveness as a treatment. The study reported accuracy of level II with at least 70% relief in pain for dual diagnostic blocks and a level III evidence with at least 75% relief in pain with a single diagnostic block. (8) The pain blocks can be performed with lidocaine and bupivacaine can be used for the second block. A dual block is required to rule out a false positive (32).
The accuracy of an IA diagnostic block depends on the experience of the therapist administering the block. The rates of false positives have been noted from 12.5% to 26 %. In some cases, it is challenging to differentiate the pain from intra-articular with extra-articular pain. Studies have shown that there is some effect of extra-articular pain-blocking with IA pain block which involves the surrounding structures. Generally, in clinical practice, a local anesthetic block is used for the diagnosis and a local anesthetic block with corticosteroids has been used as therapy. Usually, an injectate volume of 1 to 2 mL is used (8)(32).
Fluoroscopy-guided block
The gold standard for diagnosis is considered to be a fluoroscopy-guided block (28). This method also has two purposes of diagnosis and treatment. A fluoroscopy-guided block is more accurate than an ultrasound-guided block. It is widely followed practice to advance posterior towards the SI joint. Generally, a needle of 22-gauge is used. A contrast medium of 0.25 mL in quantity is generally sufficient to verify the correct position of the needle. The arthrograms images for the intervention required are
24 anterior-posterior, ipsilateral oblique, contra-lateral oblique, and lateral images. The contrast media can flow out of the joint especially in cases where a joint capsular tear is present. Injecting 1-2 mL of local anesthetic is used for pain blocking. The procedure is considered positive for SIJP when there is a 75% improvement in the pain after a single diagnostic block. In case of reduction of pain is from 50%-75% pain can be considerably attributed to the SIJ (32).
Extraarticular sources of pain
Locating the pain source when SIJ is a suspect can be complicated. In many cases, the pain emerges possibly from extraarticular sources such as the ligaments and capsule. Pain from the extraarticular sources can be frequently missed. However, it’s been shown to be a common cause of pain generator (32),(39). Intraarticular SIJ pain block can underrepresent the incidence of pain from the surrounding structures of the joint for example from the posterior interosseous ligaments. The reason being the effect of the IA pain block on extra-articular regions (39). Combination with S1-S3 lateral branch block has been shown to have greater improvement in pain on the visual analog scale (VAS) when compared to SIJ injection alone (32) (33).
A study conducted by Dreyfuss et al. describing multiple sites and depts locating the source of pain concluded a positive pain block of the lateral sacral branch to be a better indicator for selecting patients for RF ablation when compared to intraarticular pain block (32).
In a study conducted by Borowsky et al. 2008 comparing the improvement in pain between a combined IA and extra-articular (EA) and only IA pain block found the group with combined IA and EA injection observed a greater improvement in pain when assed by the VAS and a greater improvement in the ability to perform daily activities (39).
8.2.6 Management of Sacroiliac joint pain Psychological considerations
The evidence indicates higher incidence and poorer treatment outcomes in patients with concomitant psychological issues when treating LBP. A strong correlation has been found with the incidence of psychiatric diagnoses such as depression, anxiety, and substance abuse, and LBP, and these diagnoses were made before the presence of LBP (40).
25 Conservative options
Conservative interventions should be focused on managing the underlying condition. In cases of true leg length discrepancy, shoe inserts can be used for more even distribution of the weight on the SIJ. SIJP due to changes in the spinal alignment, gait mechanics manual manipulative therapy, and physical therapy can improve mobility and reduce pain (40).
Exercises to stabilize the pelvis have been shown to improve pain, a study showed improvement in pain with balancing the activity and coordination of the ipsilateral gluteus and contralateral latissimus dorsi muscles and restoring the normal myoelectric activity. Pelvic stabilization belts have been shown to reduce exaggerated rotation of the SIJ in the sagittal plane in pregnant women (40). Pharmacological intervention with nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants have been shown to provide pain relief (32).
Prolotherapy
Prolotherapy is the injection of platelet-rich plasma (PRP) or hyperosmolar dextrose in the area where the treatment is desired. The injection is made in the periarticular space and/or intra-articular joint space. Studies comparing the effectiveness of prolotherapy with IA corticosteroids have shown prolotherapy to be possible more effective in reducing pain (32).
Radiofrequency denervation
Radiofrequency denervation (RFD) has been described to show modest improvement in pain (25). The mode of action for RFD is to decrease pain by administering radiofrequency waves that heat the nerve fibers resulting in decreasing sensory pain signaling (32). A study conducting a meta-analysis of radiofrequency (RF) neurotomy in CLBP and SIJP describing the differences in effectiveness between RF neurotomy and other non-surgical conservative treatments, concluded there to be a significant improvement in ODI compared with sham treatment or medical treatment (30). A study on radiofrequency denervation of the L4 and L5 primary dorsal rami and S1-S3 lateral branches concluded significant relief in pain from the procedure comparing it to the control group (41).
A study describing a new bipolar radiofrequency ablation (b-RFA) technique concluded a reduction in operating time by 50%, decreasing the X-ray exposure by 80%, and reducing the cost of treatment by $ 1000 per case when compared to cooled radiofrequency ablation (c-RFA). It should be noted the study
26 recommended investigating by RCT to confirm superiority over the previously used methods for RFA (27). A study comparing the improvement in CLBP due to facet joints, SIJ, or a combination of facet joints, SIJ, or intervertebral disc reported no significant improvement with RFD combined with standard exercise, the findings did not support the use of RF denervation for treating CLBP when the above mentioned are the sources of pain generation (42). A study confirming the source of the pain to be SIJ by diagnostic block, comparing the effectiveness of intraarticular methylprednisolone with pulsed RF of the lateral sacral branches, L4 medial branch, and the L5 dorsal rami described an improvement in pain and functional disability in patients with SIJD (43). Another study showed improvement in pain with RF to be by 50% or more. Improvement in pain at 1, 3, and 6 months to be 73%, 60%, and 55% of the patients respectively (44). The anatomical variation in the course of the sacral nerves and the branches of the L5 poses a challenge for a consistently accurate RFD (27).
SIJ corticosteroids injection
An MRI- guided corticosteroid injection of the SIJ has been observed to be an effective treatment. The high cost of the treatment makes the treatment difficult to be performed in routine practice (28). The evidence supporting the short-term or long-term effectiveness is weak. (25). The literature reviewed in a study showed minimal improvement in pain when compared to placebo. A study showing the effectiveness of SIJ injections reported improvement by 50% or more in 20% of the patients receiving corticosteroids IA injection after 1 month but no improvement at 3 and 6 months post-intervention (44).
The gold standard diagnosis method to be fluoroscopically guided intraarticular block which is also used as a treatment, and various methods that are used for the treatment of SIJP (32).
8.2.7 Rehabilitation of sacroiliac joint pain
The treatment approach is highly argued. No fixed protocol is used in exercises, manipulation therapy. The more invasive diagnostics tests double as the treatment. Treatment could be separated into two categories: to treat the root cause of the pathology and symptomatic relief (34).
Treatment of SIJP through physical therapy methods is possible (45). Treatment depends on the clinical presentation of the SIJP and the etiology. Various treatments can be used depending on the specific case, treatment tolerance, compliance. For example, surgical repair after trauma or potentially self-limiting post-pregnancy (34).
27 According to a review, non-operative methods of treatment are usually not used (46). A review confirms the validation of strong abdominals, quadriceps, and hamstring are important in the secure functioning of the SIJ (46). Exercise therapy strengthening the transversus abdominis may provide useful in treating SIJP (32). A review indicated exercise, manipulation, and Kinesio taping to be effective physiotherapy methods in reducing pain and disability for patients with SIJP (45).
Physiotherapy
Physiotherapy (PT) methods include strengthening exercises, teaching core bracing techniques, SIJ manipulation, patient education, aerobic conditioning, heat, and transcutaneous electrical nerve stimulation (TENS) (45). Various methods of PT can be used together depending on the case. Due to the biomechanical differences in the functional levels of the various patients typically, the ideology behind PT is to match the corresponding muscle length of the muscle to restore balance and ideally restore normal biomechanics, motor control, and functioning leading to a more efficient and safer distribution of the forces through the sacrum and ilium, to restore the strength balance between the major flexors and extensors and from side to side regarding the muscles supporting the SI joints and surrounding tissues. PT methods such as exercise and manipulation are safe to be considered in most patients owing to the very few drawbacks for most patients. A typical PT regiment can be given for 4-6 weeks. PT should only be given to the patients who can tolerate the given program of PT without pain, there is little implication in continuing the PT for longer than 6 weeks without any improvements but this could differ depending on the therapy program applied. The main principles of the PT exercise revolve around the strengthening of the core muscles stabilizing the pelvis and the spine and strengthening of the more superficial global stabilizers. There are no exercises that can be applied for all hence they should be specifically chosen for each patent depending on the clinical picture, physical ability, and the compliance of the patient. (25).
Exercises
Strengthening of the core muscles is useful in improving pain (25). The obliques, transversus abdominis, can be strengthened by exercises (34).
There seems to be controversy in administering non-operative treatment methods for SIJ pain caused by microtrauma as it is claimed there isn't clear evidence regarding the effectiveness of physical therapy, stabilization exercises, and manual manipulation that is caused by the different forms of techniques used hence making a comparative analysis difficult (35).
28 Manual medicine
Manual therapy is often used in the treatment of SIJP includes chiropractic adjustments, osteopathic manual treatment. The studies done on the effectiveness of manual therapy conclude them to improve the outcome of the patients involved in the procedures however, the studies seem to be poorly controlled and suffer from a small sample size, no control group, using unreliable tests for the diagnosis of SJP. Dreyfuss et. al. study concluded there is an absence of correlation between the motion of the joint and pain relief after SIJ intra-articular block. Hence the effectiveness of manipulation therapy can be argued. Frequent joint mobilization could imply a persistent muscular imbalance. However, manual therapy is a low-risk intervention and its use in clinical practice could yield helpful results (25).
Figure 2: SIJ manipulation image adopted from the work of Kamali et.al 2012(48)
Figure 3: Lumbar manipulation image adopted from the work of Kamali et.al 2012 (48)
Kinesio taping
A single participant case study measures the effectiveness of Kinesio taping (KT) in a 20-year-old female amateur swimming athlete with increased lumbosacral angle and anterior pelvic tilt, LBP and SIJP diagnosed with provocation tests. The main aim was to decrease the degree of anterior pelvic tilt. The KT application method was on the posterior pelvic tilt taping (PPTT) (47).
29
9. Research method and methodology
9.1.1 Systematic literature search
This systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) recommendations. The research for the articles was conducted on the electronic database PubMed. The search was made to investigate the rehabilitation of Sacroiliac joint pain. The following keywords were used for the search parameters “sacroiliac joint pain”, “sacroiliac joint dysfunction”, and “rehabilitation”. The PRISMA flow diagram for the study selection is represented in Fig 3.
9.1.2 Inclusion and exclusion criteria
The studies were selected to be included in the study according to the criteria mentioned in
Table 3.
Table 3: Inclusion and exclusion criteria
Inclusion criteria Exclusion criteria
Cases studies Literature reviews
Free full text or access to database through Lithuanian University of Health Sciences (LUHS) subscribed databases
Systematic reviews
Published in the last 10 years (2011-2021) Meta-analysis studies Studies with rehabilitation intervention
performed
Studies with surgical intervention performed as therapy
Studies in the English language Presence of other inflammatory condition and spinal pathology
30 9.1.3 Prisma flow diagram
Records identified through PubMed from 2011 to 2021 (n = 76 ) S cree n in g In clud e d E lig ibili ty Id e n tifica tio n
Additional records identified through PEDro
(n = 1 ) Records after duplicates removed
(n = 76 )
Records screened (n = 76 )
Records excluded (n = 67 ) Full-text articles assessed
for eligibility (n = 74)
Studies included in the systematic review
(n = 7)
Total number of studies included (n=8)
31
10. Results
The initial search on PubMed resulted in 182 articles after applying the filter which only included articles in the last 10 years this resulted in 76 articles. These articles were screened by a single reviewer and 7 articles were selected according to the criteria mentioned in Table 3. The methods of research of the selected articles included randomized control trials (RCT), case series, quasi-experimental study. The studies selected included manual therapy, stabilization, and other exercises as interventions. Another article was added later on research from PEDro. A summary of the selected articles is mentioned in Table 4 and the interventions in Table 5.
The articles included in the study measure the pain by VAS, numeric pain scale NPRS and for the measurement of the disability ODI, OSW, RAND-36 questionnaire was used and a study used clinical examination to measure the outcomes and some other tests such as the “timed up and go”, “self-paced walk”, PALM was also done in some studies. The outcomes were measure at baseline and post-intervention and up to a year in a case report.
The total number of participants in all the articles combined is recorded to be a total of 281 in this study with the largest participants included being 60 (48) and the smallest to be a case with a single participant (49). The treatment length ranged from a single intervention for the manipulation group, 4 weeks for the exercise group, and up to 12 months in a case study that used multi-disciplinary and multimodality treatment methods. All the groups except one (50) had some level of manipulative intervention as either the main treatment or an adjunct to the main therapy. Six studies had exercise-related interventions. A single study had IA injection as a control. The longest follow-up time to be 24 weeks post initial intervention.
32 10.1 Summary of the articles
Table 4: Summary of the study design
Study Design Number of
patients
Diagnostic method to select participants
Kamali et al. 2012 (51)
Comparative study
N=32 A cluster of pain provocation test
Visser et al.2013 (52)
RCT N=51 Clinical, radiological grounds and a cluster of pain provocation tests
Jonley et Al. 2015 (49)
Case report N=1 Clinical examination and cluster of pain provocation tests
Kamali et al. 2018 (53)
RCT N=30 A cluster of pain provocation tests
Aurélio et al. 2018 (50)
Case series N=8 A cluster of pain provocation tests
Nejati et al. 2019 (3)
RCT N=51 A cluster of pain provocation tests
Garcí-Peñalver et al. 2020 (48)
A Quasi-experimental design
N=60 A cluster of pain provocation test
Sanika et al. 2021 (54)
RCT N=48 History of pain, with anteriorly rotated SIJD positive pain provocation tests
33
Table 5: Summary of the intervention outcomes
Study
Age Method Outcome
measured Time/ follow up Result Kamali et al. 2012(51) SIJ -24.75 ± 3.53 SIJ+ Lumbar- 24.25 ± 3.13 HVLA SIJ manipulation, both HVLA SIJ and Lumbar rotational manipulation VAS and ODI Baseline, 48 hours, and one-month post-Intervention A single session of combined SIJ and lumbar manipulation was more effective than SIJ manipulation alone Visser et al.2013 (52) Mean age-46.2 years ( ± 13.9, range 20– 73). Physiotherapy(PT), manual therapy(MT), intraarticular(IA) injection VAS and RAND-36 questionna ire Baseline, 6 weeks and 12 weeks Patients improved in PT- 20% In MT- 72% IA injection- 50% Jonley et al. 2015 (49) 35-year-old A multimodal and multidisciplinary approach with a total of 20 physical therapy sessions OSW, NPRS Treated for up to 12 months Follow up at 1 year the OSW score was 0% Kamali et al. 2018 (53) S- 40.2 ± 14.26 M-42.07 ± 14.03 Manual therapy (M) And stabilization exercise (S) VAS, ODI (Iranian version) (M) 2 week, (S) 4 week
Both the groups improved without statistical differences between them. Aurélio et al. 2018(50) Mean age 33 years Range (18-43) Exercises to
strengthen the gluteus maximus
VAS, ODI 5 weeks All the participants saw an increased strength in the affected gluteal muscle and a decrease in pain Nejati et al. 2019(3) Mean age 46.8 Range (23-60) Exercise therapy (ET), manipulation therapy (MT), exercise and VAS, ODI, Roland-Morris back pain 6, 12 and intervention and follow up to 24 weeks
All the groups were effective, combined therapy did not result in significant
34 PALM- palpation meter
HVLA-High-velocity low amplitude
OSW-Oswestry Low Back Pain Disability Questionnaire
ODI- Oswestry disability index
NPRS-Numeric Pain Rating Scale
VAS-Visual analogue sacle
MET- Muscle energy technique
manipulation therapy combined (EMT) questionna ire, timed up and go, Self-paced walk
the MT group had better result only at 6 weeks Garcí-Peñalver et al. 2020(48) Mean age 33.86 years, ± 9.98 Range (18-63) Thrust technique, muscle-energy technique, and stimulated technique Outcome measure based on positive or negative dysfunctio n post-interventio n Baseline, immediately post-intervention, one month after the initial treatment Thrust manipulation was better at
improving short- and long-term outcome whereas the MET group only at short term Sanika et al. 2021(54) Mean age (EX)38.83 ± 11.4 years, (C): 34.96 ± 9.5 years Experimental group (EX): MET, gluteus maximus activation Control group(C): MET, flexion-based exercises ODI, PALM, VAS
Base line and 4 weeks post-intervention
Both the groups showed improvements
35
11. Discussion of the results
This systematic review included eight studies (3,48,50-55) describing the rehabilitation methods for Sacroiliac Joint Pain, showing the effectiveness of different methods in decreasing pain and disability caused by dysfunction of the SIJ leading to pain. The studies applied various methods for rehabilitating, such as manual therapy, muscle strengthening. This review did not include any studies with treatment with Kinesio tape.
A study by Kamali et al. 2012 (51) comparing two manipulative therapy techniques and their outcomes. Compared efficacy of high-velocity low-amplitude (HVLA) SIJ manipulation and combined HVLA SIJ and lumbar manipulation for SIJ pain in women aged between 20-30 years, reported there to be a significant improvement in both the groups immediately, 48 hours and one month after the treatment on VAS and ODI. Neither of the treatment was considered superior to the other as no statistical difference was found between them (51). Reporting a single manipulation treatment of combined lumbar and SIJ was better when compared to SIJ alone in terms of improving disability. However, they noted spinal HVLA to be a useful method for the treatment of SIJ syndrome.
A study conducted by Visser et al. 2013 (52) comparing the effectiveness of physiotherapy, manual therapy, and local SIJ corticosteroid intra-articular injection on individuals with SIJ-related leg pain. Reported an improvement of pain by VAS in all three methods of treatment. However, physiotherapy which included exercise therapy aimed at improving the SIJ flexibility and improving the strength of the muscles of the back and pelvic floor muscles saw the least improvement from all the groups with an improvement of 20% of the patients. The exercise therapy intervention was 6 weeks long with once a week guided physiotherapy session. The regime was to perform exercises five to six times a day in the first week and reducing it to 3 times a day till the pain disappeared. It should be noted the group included 15 individuals and the other two groups 18 individuals due to the participants unable to finish the treatment plan for various reasons. (52). The manual medicine group received HVLA manipulation of the SIJ, the success rate was recorded to be 72% the highest of the three groups (52). In the control group receiving radiologically fluoroscopic-guided intra-articular SIJ injection, they were observed to have a success rate of 50%. However, the treatment proved helpful in reducing pain initially but there was a need for a second injection 2 weeks after the first intervention. It should be noted the injected substance was a mixture of 20 mg of Kenacort and 30 mg of lidocaine (52).
The study by Jonely et al. 2015 (49) included a 35-year-old nulliparous woman with a history of a fall from 4 feet onto the lower back and the sacrum 14 years ago and subsequent pain. The initial intervention with lumbopelvic strengthening and stabilization training, muscle energy technique for pubic symphysis, right sacroiliac joint nutation manipulation, and pelvic ring belting below the level of the ASIS resulted
