SI Dysfunction? Manipulate it, Exercise it, or BOTH

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Effectiveness of Exercise Therapy and Manipulation on Sacroiliac Joint Dysfunction: A Randomized Controlled Trial
Nejati P, Safarcherati A, & Karimi F.  Pain Physician. 2019; 22:53-61.
Take Home Message: Overall, exercise and manipulation may provide early improvements for patients with sacroiliac joint dysfunction. However, patients should be re-evaluated before 6 months to determine treatment plans moving forward since the combination of exercise and manipulation was not better than performing exercise or mobilizations alone after 6 months.

Sacroiliac joint dysfunction is a common cause of low back pain.  While exercise is considered to be effective for generalized low back pain, it remains unclear what is the best way to treat low back pain caused by sacroiliac joint dysfunction.  The authors of this study conducted a randomized controlled trial to evaluate the effectiveness of exercise therapy, manipulation therapy, and exercises + manipulation therapy among people with sacroiliac joint dysfunction. They confirmed sacroiliac joint dysfunction based on a lack of radiating symptoms and positive sacroiliac joint dysfunction special tests.  The authors randomized 56 participants into the 3 groups and assessed their pain through a visual analog scale and functionality with the Oswestry Disability Index (ODI), Roland Morris Back Pain Questionnaire, the timed up and go test, and self-paced walk tests at 6, 12, and 24 weeks. Participants receiving exercise therapy were taught how to perform daily exercises at home and told to attend one in-person session each week for 12 weeks.  The exercises included self-mobilization exercises, sacroiliac joint stretches, and spinal stabilization exercises. Initially, the participants receiving mobilizations received 2 manual mobilizations (posterior innominate mobilization and sacroiliac manipulation; see paper for more details). A total of 51 participants with an average age of 47 completed the study (17 per group). Participants in the manipulation therapy group tended to have slightly less self-reported functional disability (ODI) at baseline than the other groups.  A participant receiving mobilization therapy was more likely to do better overall than someone receiving exercise therapy at 6 weeks. However, by 12 weeks a participant receiving exercise therapy was likely to do similar if not better than the person receiving the mobilization therapy. The combination of exercise and manipulation was better than exercise alone at week 6 for pain and the timed up-and-go function test. However, again a participant performing exercises alone was likely to have similar outcomes at 12 or 24 weeks as someone receiving the combination treatment strategy. Finally, the combination of exercise and manipulation had better self-reported pain and function at week 12 than someone receiving mobilizations only. By week 24, the authors observed no differences among the three treatment strategies.

A key finding from this study was that manipulation therapy produced quick improvements while exercise therapy offered potentially better results over 12 weeks; but, by 24 weeks all 3 approaches were similar.  Low back pain treatment is a clinical challenge, but it appears that manipulation may be an effective initial approach.  It appears that the manipulation was only completed at one session during the research study.  It would have been interesting to see whether individuals were “out of alignment” at the time of follow up, and how that corresponded to their pain and function measures.  I also would have liked to know how muscle energy compared to the manipulation group as this is something that is often done clinically. Prior investigators have shown that muscle energy is efficacious for patients with low back pain.  Exercises may reinforce the manipulation and avoid a reoccurrence of sacroiliac joint dysfunction.  It was interesting to note that if the manipulations were not effective after 2 attempts, the patient was excluded from the study.  This may have caused an overestimation of manipulation effectiveness, or that those participants may have been better suited for the exercise group.  Surprisingly, the exercise and manipulation group did not have an overall better result at 24 weeks.  It would be interesting to see whether people were adhering to their home exercise program, or what activities they resumed.  Overall, exercise and manipulation may provide early improvements in sacroiliac dysfunction outcomes patients, but patients should be re-evaluated before 6 months to determine treatment plans moving forward.
**Under Study Protocol #2) SI Joint Stretches the authors state “the trainer”.  It is unclear who this is, but I do not endorse the use of the term trainer within this article or elsewhere**
Questions for Discussion:  Do you currently use patient-reported outcomes with patients with low back pain?  What do you find to be the most successful treatment strategy to deal with sacroiliac joint dysfunction?
Reviewed by: Jeffrey Driban
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