Treatment of the sacroiliac joint in patients with leg pain: a randomized-controlled trial

Efficacy of manual therapy for sacroiliac joint pain syndrome: a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

This study examined the efficacy of manual therapy for pain and disability measures in adults with sacroiliac joint pain syndrome (SIJPS).

METHODS

We searched six databases, including gray literature, on 24 October 2023, for randomized controlled trials (RCTs) examining sacroiliac joint (SIJ) manual therapy outcomes via pain or disability in adults with SIJPS. We evaluated quality via the Physiotherapy Evidence Database scale and certainty via Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Standardized mean differences (SMDs) in post-treatment pain and disability scores were pooled using random-effects models in meta-regressions.

RESULTS

We included 16 RCTs (421 adults; mean age = 37.7 years), with 11 RCTs being meta-analyzed. Compared to non-manual physiotherapy (i.e. exercise ± passive modalities; 10 RCTs) or sham (1 RCT) interventions, SIJ manual therapy did not significantly reduce pain (SMD: -0.88; 95%-CI: -1.84; 0.08, p = 0.0686) yet had a statistically significant moderate effect in reducing disability (SMD: -0.67; 95% CI: -1.32; -0.03, p = 0.0418). The superiority of individual manual therapies was unclear due to low sample size, wide confidence intervals for effect estimates, and inability to meta-analyze five RCTs with a unique head-to-head design. RCTs were of 'good' (56%) or 'fair' (44%) quality, and heterogeneity was high. Certainty was very low for pain and low for disability outcomes.

CONCLUSION

SIJ manual therapy appears efficacious for improving disability in adults with SIJPS, while its efficacy for pain is uncertain. It is unclear which specific manual therapy techniques may be more efficacious. These findings should be interpreted cautiously until further high-quality RCTs are available examining manual therapy against control groups such as exercise.

REGISTRATION

PROSPERO (CRD42023394326).

Effect of Sacropelvic Hardware on Axis and Center of Rotation of the Sacroiliac Joint: A Finite Element Study

BACKGROUND

The sacroiliac joint (SIJ) transfers the load of the upper body to the lower extremities while allowing a variable physiological movement among individuals. The axis of rotation (AoR) and center of rotation (CoR) of the SIJ can be evaluated to analyze the stability of the SIJ, including when the sacrum is fixed. The purpose of this study was to determine how load intensity affects the SIJ for the intact model and to characterize how sacropelvic fixation performed with different techniques affects this joint.

METHODS

Five T10-pelvis models were used: (1) intact model; (2) pedicle screws and rods in T10-S1; (3)pedicle screws and rods in T10-S1, and bilateral S2 alar-iliac screws (S2AI); (4) pedicle screws and rods in T10-S1, bilateral S2AI screws, and triangular implants inserted bilaterally in a sacral alar-iliac trajectory ; and (5) pedicle screws and rods in T10-S1, bilateral S2AI screws, and 2 bilateral triangular implants inserted in a lateral trajectory. Outputs of these models under flexion-extension were compared: AoR and CoR of the SIJ at incremental steps from 0 to 7.5 Nm for the intact model and AoR and CoR of the SIJ for the instrumented models at 7.5 Nm.

RESULTS

The intact model was validated against an in vivo study by comparing range of motion and displacement of the sacrum. Increasing the load intensity for the intact model led to an increase of the rotation of the sacrum but did not change the CoR. Comparison among the instrumented models showed that sacropelvic fixation techniques reduced the rotation of the sacrum and stabilized the SIJ, in particular with triangular implants.

CONCLUSION

The study outcomes suggest that increasing load intensity increases the rotation of the sacrum but does not influence the CoR, and use of sacropelvic fixation increases the stability of the SIJ, especially when triangular implants are employed.

CLINICAL RELEVANCE

The choice of the instrumentation strategy for sacropelvic fixation affects the stability of the construct in terms of both range of motion and axes of rotation, with direct consequences on the risk of failure and mobilization. Clinical studies should be performed to confirm these biomechanical findings.

The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain

Introduction

Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety.

Objective

The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders.

Methods

The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented.

Results

After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain.

Conclusion

The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.

Radiculopathy with concomitant sacroiliac dysfunction and lumbosacral degenerative disease: illustrative case

BACKGROUND

The sacroiliac joint (SIJ) is an important cause of low back pain and referred leg pain (RLP). Pain from SIJ dysfunction may occur in isolation or may result from a combination with lumbosacral area–mediated pain. SIJ fusion is one treatment modality for medically refractory symptoms and may also have a role in the treatment of RLP.

OBSERVATIONS

The authors present a challenging case of concomitant lumbosacral degenerative disease and SIJ dysfunction in a patient with radiculopathy. They provide clinical characteristics and imaging findings and discuss difficulties in dealing with the intersection of these two distinct diagnoses. In addition, the authors offer a review of the relevant literature, elucidating the role of SIJ dysfunction in causing radicular lower extremity pain, the relationship to concomitant lumbosacral degenerative disease, and outcome data for SIJ fusion as it relates to RLP.

LESSONS

With increasing numbers of patients undergoing spinal instrumentation in the setting of degenerative lumbosacral arthritis, as well as randomized controlled trial data demonstrating the efficacy of SIJ fusion for medically refractory SIJ dysfunction, it is important to recognize the challenges in understanding how both of these patient groups may present with radiculopathy. Failure to do so may result in incorrect patient selection, poor outcomes, and increased morbidity for at-risk patients.

International Society for the Advancement of Spine Surgery Policy 2020 Update-Minimally Invasive Surgical Sacroiliac Joint Fusion (for Chronic Sacroiliac Joint Pain): Coverage Indications, Limitations, and Medical Necessity

The index 2014 International Society for the Advancement of Spine Surgery Policy Statement-Minimally Invasive Surgical Sacroiliac Joint Fusion-was generated out of necessity to provide an International Classification of Diseases, Ninth Revision (ICD-9)-based background and emphasize tools to ensure correct diagnosis. A timely ICD-10-based 2016 update provided a granular threshold selection with improved level of evidence and a more robust and relevant database (Appendix Table A1). As procedures and treatment options have evolved, this 2020 update reviews and analyzes the expanding evidence base and provides guidance relating to differences between the lateral and dorsal surgical procedures for minimally invasive surgical sacroiliac joint fusion.

Evaluation and Management of Sacroiliac Dysfunction Utilizing an Evidence-Based Algorithmic Approach: A Case Study

The sacroiliac joint (SIJ) is an important contributor to persistent and functionally limiting lower back pain. Despite extensive debate and research, there is no definitive treatment recommendation or high-level evidence to support a conservative care treatment approach, nor interventional or surgical management procedures for the alleviation of pain originating from the SIJ. Traditional physical therapy and conservative approaches to generalized lower back pain often fail in this patient subset prompting sub-specialty consultation to a pain management center. Diagnosis of the SIJ as the pain generator can be accomplished through physical exam maneuvers and comparative diagnostic blocks; however, upon diagnosis, management remains a challenge. After the diagnosis of SIJ dysfunction is made in our young and active patient population, we have seen significant success in the application of an interdisciplinary and evidence-based treatment algorithm similar to the presented case. To our knowledge, this treatment approach has not been previously described.

Nonoperative Treatment Options for Patients With Sacroiliac Joint Pain

Sacroiliac joint (SIJ) pain is thought to be a component of low back pain in 20% of people who suffer with it chronically. There is no consistent objective diagnostic testing that includes SIJ pain as the diagnosis and thereby it can become a diagnosis of exclusion. Treatment of SIJ pain is variable, and no set method or protocol of treatment has been found to be efficacious or reliable. Thus, the healthcare provider is often left to create an individual treatment plan based on their own experiences and expertise. The purpose of this narrative review is to describe and discuss nonoperative treatment options for patients with SIJ pain. Further, coordination of treatment options and progression of treatment will be offered.

Comparing the Effectiveness of the Muscle Energy Technique and Kinesiotaping in Mechanical Sacroiliac Joint Dysfunction: A Non-blinded, Two-Group, Pretest-Posttest Randomized Clinical Trial Protocol

STUDY DESIGN

Two-group, pretest-posttest randomized clinical trial.

PURPOSE

To evaluate the efficacy of the muscle energy technique (MET) and Kinesiotaping (KT) in addition to conventional physiotherapy among patients with mechanical sacroiliac joint dysfunction (SIJD).

OVERVIEW OF LITERATURE

Patients with SIJD suffer from lower back and gluteal pain, as well as stiffness, due to restricted pelvic joint movement. To restore function and reduce pain among individuals with mechanical SIJD, the MET and KT may be helpful. However, a limited number of studies have compared MET and KT in mechanical SIJD.

METHODS

A total of 40 male and female participants aging between 30 and 50 years experiencing unilateral pain around the gluteal area, groin area, and lower limbs for more than 4 weeks but less than 1 year will be selected. Patients will then be randomized into two groups: METCp (n=20) and KTCp groups (n=20). The METCp group will receive MET along with conventional physiotherapy, while the KTCp group will receive conventional physiotherapy with KT. Both groups will receive three alternating days of treatment per week that will continue for 4 weeks. The modified Oswestry Disability Index, a digital pressure algometer, and sacroiliac joint motion testing will be used for evaluation. Between- and within-group pre- and post-intervention results for mechanical SIJD were compared using the Wilcoxon signed-rank test/paired t-test and Mann-Whitney U -test/independent t -test.

RESULTS

Modified Oswestry Disability Index, digital pressure algometer, and sacroiliac joint motion will be measured at baseline, 2nd week during intervention, and 4th week at the end of intervention.

CONCLUSIONS

The present study will provide data regarding the effects of MET and KT among patients with mechanical SIJD.

Individuals with sacroiliac joint dysfunction display asymmetrical gait and a depressed synergy between muscles providing sacroiliac joint force closure when walking

Walking is often compromised in individuals with low back and hip disorders, such as sacroiliac joint dysfunction (SIJD). The disorder involves reduced coactivation of the gluteus maximus and contralateral latissimus dorsi, which together provide joint stability during walking. The purpose of our study was to compare the kinematics and contributions of selected muscles to identified synergies during walking between healthy individuals and those with SIJD. Six women with unilateral SIJD and six age-matched healthy controls walked on a force-measuring treadmill at 1 m/s while we recorded kinematics and the activity of 16 muscles with surface EMG. Non-negative matrix factorization was used to identify patterns of EMG activity (muscle synergies). Individuals with SIJD exhibited less hip extension and lower peak vertical ground reaction forces on the affected side than the unaffected side. In contrast to controls, the SIJD group also displayed a depressed muscle synergy between gluteus maximus on the affected side and the contralateral latissimus dorsi. The results indicate that individuals with SIJD exhibited both reduced activation of gluteus maximus during a loading synergy present in walking and greater asymmetry between legs when walking compared with age-matched controls.

Patients with sacroiliac joint dysfunction exhibit altered movement strategies when performing a sit-to-stand task

OF BACKGROUND DATA

The ability to rise from a chair is a basic functional task that is frequently compromised in individuals diagnosed with orthopedic disorders in the low back and hip. There is no published literature that describes how this task is altered by sacroiliac joint dysfunction (SIJD).

PURPOSE

The objective of this study was to compare lower extremity biomechanics and the onset of muscle activity when rising from a chair in subjects with SIJD and in healthy persons.

STUDY DESIGN

Six women with unilateral SIJD and six age-matched healthy controls performed a sit-to-stand task while we measured kinematics, kinetics, and muscle activity.

MATERIALS AND METHODS

Subjects stood up at a preferred speed from a seated position on an armless and backless adjustable stool. We measured kinematics with a 10-camera motion capture system, ground reaction forces for each leg with force plates, and muscle activity with surface electromyography. Joint angles and torques were calculated using inverse dynamics. Leg-loading rate was quantified as the average slope of vertical ground reaction (VGRF) force during the 500-millisecond interval preceding maximal knee extension.

RESULTS

Between-leg differences in loading rates and peak VGRFs were significantly greater for the SIJD group than for the control group. Maximal hip angles were significantly less for the SIJD group (p=.001). Peak hip moment in the SIJD group was significantly greater in the unaffected leg (0.75±0.22 N⋅m/kg) than in the affected leg (0.47±0.29 N⋅m/kg, p=.005). There were no between-leg or between-group differences for peak knee or ankle moments. The onset of activity in the latissimus dorsi muscle on the affected side was delayed and the erector spinae muscles were activated earlier in the SIJD group than in the control group.

CONCLUSIONS

Subjects with SIJD have a greater VGRF on the unaffected leg, generate a greater peak hip moment in the unaffected leg, use a smaller range of motion at the hip joint of the affected leg, and delay the onset of a key muscle on the affected side when rising from a seated position.

The impact of progressive pelvic floor muscle exercise and manual therapy in a patient postpartum who met the criteria for sacroiliac joint pain based on Laslett's cluster of provocation signs

Sacroiliac joint (SIJ) pain has been identified as a primary or contributing source of pain in patients with low back pain. The Laslett cluster of SIJ pain provocation tests has the strongest evidence for noninvasive clinical testing. The purpose of this report was to describe the impact of physical therapy treatments for a patient postpartum with SIJ pain who satisfied the Laslett cluster. Specifically, the goal was to assess the impact of progressive pelvic floor muscle exercise and manual therapy. The Modified Oswestry Low Back Pain Disability Questionnaire (MODI) was the primary outcome measure used in this case. In addition, the Numeric Pain Rating Scale (NRPS) and Global Rating of Change (GROC) were used as secondary outcome measures. In this case report, the patient responded to the combined interventions with decreases in MODI, NRPS and GROC. Further research is warranted to develop stronger evidence to identify specific interventions for the treatment of SIJ pain.

Effect of Sacroiliac Joint Mobilization on the Level of Soft Tissue Pain Threshold in Asymptomatic Women

OBJECTIVE

This study aimed to evaluate the effect of sacroiliac joint (SIJ) mobilization and/or self-mobilization on the level of soft tissue pain threshold in 21- to 23-year-old asymptomatic women (n = 20).

METHODS

The FPIX Wagner Algometer was applied to compute the pressure pain threshold (PPT) over the right and left side of the iliolumbar ligament and lumbar erector spinae (L3). Measurements were taken of the right SIJ before and after a randomized protocol of oscillating mobilization, self-mobilization, and placebo treatment.

RESULTS

A main effect of intervention (mobilization, self-mobilization, placebo) was confirmed by analysis of variance, with increases in PPT over the iliolumbar ligament (F = 13.04, P < .05) and erector spinae (F = 12.28, P < .05) on the mobilized side. The Wilcoxon test indicated that SIJ mobilization increased PPT over the iliolumbar ligament (P < .05) and erector spinae (P < .05) on both sides. Self-mobilization increased erector spinae PPT on the exercised side (P < .05), whereas the placebo did not cause any changes in PPT (P > .05).

CONCLUSION

The study provides evidence of local and global pain modulation resulting from oscillatory mobilization of the SIJ in women without pain symptoms. Self-mobilization of the SIJ has limited analgesic application.

Predictive factors for reporting adverse events following spinal manipulation in randomized clinical trials - secondary analysis of a systematic review

While spinal manipulative therapy (SMT) is recommended for the treatment of spinal disorders, concerns exist about adverse events associated with the intervention. Adequate reporting of adverse events in clinical trials would allow for more accurate estimations of incidence statistics through meta-analysis. However, it is not currently known if there are factors influencing adverse events reporting following SMT in randomized clinical trials (RCTs). Thus our objective was to investigate predictive factors for the reporting of adverse events in published RCTs involving SMT. The Physiotherapy Evidence Database (PEDro) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for RCTs involving SMT. Domains of interest included: sample size; publication date relative to the 2010 CONSORT statement; risk of bias; the region treated; and number of intervention sessions. 7398 records were identified, of which 368 articles were eligible for inclusion. A total of 140 (38.0%) articles reported on adverse events. Articles were more likely to report on adverse events if they possessed larger sample sizes, were published after the 2010 CONSORT statement, had a low risk of bias and involved multiple intervention sessions. The region treated was not a significant predictor for reporting on adverse events. Predictors for reporting on adverse events included larger sample size, publication after the 2010 CONSORT statement, low risk of bias and trials involving multiple intervention sessions. We recommend that researchers focus on developing robust methodologies and participant follow-up regimens for RCTs involving SMT.