6.1 Need for the study
Sacroiliac joint is the joint in the bony pelvis between the sacrum and the ilium of the pelvis, which are joined together by strong ligaments.1
Sacroiliac joint dysfunction is a condition in which pain is caused by the sacroiliac joint that connects the sacrum and the pelvis. SI joint pain is believed to be caused by either too much movement (hypermobility) or too little movement (hypomobility) at the joint. SIJD refers to any type of misalignment between the sacrum and the ilium. SIJD is a movement abnormality of one pelvic bone in relation to another.2,4
Classification of hypomobile dysfunction3
Unilateral restrictions of the innominate bone and/or sacrum can be classified according to the position in which the restriction bone is held. The following restrictions are commonly seen in clinical practice.
- Flexed/ laterally rotated innominate bone (posterior rotated/outflared)
- Extended/medially rotated innominate bone (anterior rotated/inflared)
- Superiorly subluxed/extended(flexed) innominate bone
- Unilateral sacral flexion/extension
- Sacral torsion
Degenerative arthritis, pregnancy, leg length discrepancy, metabolic disorders like gout, inflammatory conditions like rheumatoid arthritis, ankylosing spondylitis, psoriasis, joint infection like tuberculosis etc all contribute to SI joint dysfunction3.
SI joint pain mimics low back and leg pain caused by lumbar disc herniation.2
It typically results in pain on one side very low in the back or in the buttocks.2
Mulligan’s concept of MWM is the concurrent application of both therapist applied accessory and patient generated active physiological movements. The passive accessory joint mobilization is applied following the principles of Kaltenborn ( parallel or perpendicular to the joint plane). The accessory glide must be painfree.5
Previously there were studies done for spinal conditions using following therapies such as
- Effect of Mulligan SNAG in the lumbar flexion range7
- Effect of Mulligan traction straight leg raising on ROM in low back pain9
- Modified SNAG in acute locked thoracic spine11
- Exercise therapy for low back pain13
- MET in pelvic joint dysfunction14
Till now, there is very few literature available on the efficacy of Mulligan techniques. To my knowledge there is not even a single study been done to evaluate the effectiveness of MWM on sacroiliac joint dysfunction.
Hence the aim of this study is to evaluate the short term effects of Mulligan’s mobilization with movement in SI joint dysfunction.
Hypothesis :
Experimental hypothesis :
- There will be improvement in pain levels and hypomobility after application of MWM and conventional therapy in SI joint.
- There will be improvement in pain levels and hypomobility after application of conventional therapy alone in SI joint.
- There will not be any improvement in pain levels and hypomobility after application of MWM and conventional therapy in SI joint.
- There will not be any improvement in pain levels and hypomobility after application of conventional therapy alone in SI joint.
Kinser, AM, Sands, WA, Stone, MH (2009)conducted a study to test the reliability and the incremental trials (r = 0.999). In conclusion, with previous familiarization and practice, an investigator may have high reliability in the rate of force application. The device itself was also highly correlated with readings from a force plate and, therefore, may be considered valid. Construct validity of a pressure algometer (1000-Hz sampling rate) by manually applying pressure on a force plate (500-Hz sampling rate): 10 sets of 5 applications to 80N and 1 set of 5 applications to each force level: 20, 30, 40, 50, 60, 70, 80, 90, 100, and 110N. Average Pearson (r) correlations between the maximum force reading of the algometer and force plate were excellent in both trials to 80N (r = 0.990).6
Maria Moutzouri, Evdokia Billis, Nikolaos Strimpakos, Polixeni Kottika and Jacqueline A Oldham (2008)conducted a study to know the effects of the Mulligan SNAG mobilization in the lumbar flexion range of asymptomatic subjects as measured by the Zebris CMS20 3-D motion analysis system. It was a randomized double blinded controlled study on 49 healthy subjects. 25 subjects received SNAGS and 24 received Sham mobilization. SNAG mobilization applied at two lumbar levels in asymptomatic subjects did not demonstrate significant differences in the lumbar flexion ROM when compared to placebo group.7
Andrea Reid, Trevor B Birmingham and Greg Alcock (2007)conducted a study to know the efficacy of MWM for patients with limited dorsiflexion after ankle sprains found to have increase in dorsiflexion range which served as immediate treatment after ankle sprains. It was a crossover type of study on 23 subjects who had sustained unilateral ankle sprain within the past 2 years and restriction in weight bearing dorsiflexion. Results suggest that a talocrural MWM improves ankle dorsiflexion immediately following treatment.8
Toby Hall, Claus Beyerlein, Ulla Hansson, Hun Teck, Lim, Merela Odermark and David Sainsbury (2006)conducted a study to know the effect of Mulligan traction straight leg raise on ROM in low back pain. It was a pilot study on 19 subjects with low back pain with a unilateral limitation of SLR. Results provide preliminary evidence for the use of the Mulligan TSLR technique in the management of low back pain when a limitation of SLR is present, however further studies are required to substantiate these findings.9
Matalie Collins, Pamela Teys and Bill Vicenzino (2004)conducted a study to know the initial effects of Mulligan’s mobilization with movement technique on dorsiflexion and pain in subacute ankle sprains. It was a double blinded randomized controlled trial on 14 subjects with subacute grade 2 lateral ankle sprains. This study investigated whether a Mulligan’s MWM technique improves talocrural dorsiflexion, a major impairment following ankle sprains and relieves pain in subacute population. The result indicated that the MWM treatment for ankle dorsiflexion had a mechanical rather than hypoalgesic effect in subacute ankle sprains.10
S J Horton (2002)did a case study in treatment of acute locked thoracic spine with modified SNAG. A 20 year old male university student presented with acute left side back pain adjacent to level of T8/9 intervertebral joint. The case responded rapidly to modified SNAG technique.11
Kucukdeveci, Ayse A, Tennant, Alan, Elhan, Atilla H, Niyazoglu, Hava (2001)conducted a study to validate the Turkish version of the roland morris disability questionnaire for use in low back pain.A total of 81 outpatients with low back pain, 64 of which were followed up on a second occasion, were assessed by the RMDQ. Reliability was assessed using internal consistency and the intraclass correlation coefficient. Internal construct validity was assessed by Rasch analysis; external construct validity was assessed by association with pain and spinal movement. Responsiveness was tested by both the nonparametric and parametric effect sizes. Internal consistency of the RMDQ is found to be adequate (>0.85) at both times, with high intraclass correlation coefficient also at both time points. Internal construct validity of the scale is good, indicating a single underlying construct. Expected associations with pain confirm external construct validity. There is little evidence of differential item functioning. The scale is at the ordinal level. Responsiveness of the RMDQ is good and greater than observed change in spinal movement.12
Maurits Van Tulder, Antti Malmivaara, Rosmin Esmail and Bart Koes (2000)conducted a review on exercise therapy for low back pain. It was a randomized controlled type of study. In this review 39 trials were identified. The result does not indicate that specific exercises are effective for treatment of acute low back pain and exercise therapy was just effective as conventional physiotherapy for chronic low back pain.13
Ullacarin Wreje, Bengt Nordgren and Hans Aberg (1992)conducted a study on manual treatment of dysfunction of the pelvic joint. It was a controlled study on 46 subjects with pelvic dysfunction. After dropouts and exclusions 18 subjects received manual treatment in the form of MET while 21 patients served as control and received placebo treatment in the form of massage. Subjective pain assessment and mobility test showed no significant difference.14
6.3 Objectives of the Study :
- To evaluate the short term effects of Mulligan’s mobilization with movement in SI joint dysfunction.
- To evaluate the short term effects of conventional therapy in SI joint dysfunction.
- To compare the short term effects of Mulligan’s mobilization with movement and conventional therapy in SI joint dysfunction.
7 / Materials and Methods :
7.1 Source of Data
- Padmashree clinic, Bangalore
- E.S.I Hospital, Rajajinagar, Bangalore
- K.C.G Hospital, Malleshwaram, Bangalore
- Population – Subjects with low back pain ( SI joint dysfunction)
- Sample design – Purposive or judgemental sampling
- Study design – The Switching Replications Quasi experimental design
- Sample size – 40
- Duration of the study – 2 week
- TENS
- ULTRASOUND
- PRESSURE ALGOMETER
- Both male and female subjects
- Patients with history of low back pain
- Subjects eliciting positive pain provocation tests for SI joint dysfunction (e.g. pelvic gapping test, pelvic compression test, sacral thrust)
- Patients with inflare dysfunction
- Patients with outflare dysfunction
- SI pain walking
- Patients with history of low back pain due to reasons other than SI joint involvement
- SI joint pain during pregnancy
- Positional dysfunctions due to lower limb involvement or anomalies
Subjects who fulfil the inclusion and exclusion criteria will be included in the study and a written/informed consent will be taken from them.
Before conducting the actual experiment, the patients with inflare and outflare dysfunction are investigated by following tests –
Positional tests15 :
- Assessment of iliac bony landmark. In anterior ilium, the ASIS is anterior, medial and inferior in supine while PSIS is described as being superior, anterior and lateral.
- Determination of iliac crest with patient standing
- Palpating iliac shelf in standing. The anterior iliac shelf is 2” portion of ilium immediately above ASIS, palpated in supine. Posterior shelf is the portion of ilium midway between midline of spine and most lateral part of ilium, palpated in prone.
Passive extension and medial rotation of ilium on sacrum – Patient in side lying position on non test side, examiner places one hand over the ASIS and other hand over PSIS with fingers palpating the posterior ilium and sacrum. Pull ilium forward with hand over ASIS and push the posterior ilium forward with the other hand while feeling the relative movement of the ilium on the sacrum and compare on both sides. If affected side moves less, it indicates hypomobility and outflare.16
Passive flexion and lateral rotation of ilium on sacrum – Patient is positioned as for the previously mentioned test. In this the anterior ilium is pushed backward with the anterior hand and the posterior hand pull the ilium posteriorly while palpating the relative movement and compare on both sides. If affected side moves less, it indicates hypomobility and inflare.16
Experimental protocol to be conducted :
Initially on the day 1, the pre test is conducted to know the extent of disability using ROLAND MORRIS DISABILITY QUESTIONNAIRE and PAIN PRESSURE THRESHOLD with the use of PRESSURE ALGOMETER. Patients are then divided into 2 groups in a non randomised manner.
Group A is given Mulligan’s mobilisation with movements.
Group B acts as control and receives conventional therapy like ultrasound and TENS.
The duration of the study will be 1 session per day for 1 week where each session will consist of 3 sets of 10 repetitions of MWM technique.
After a week the post test is conducted for both the groups using ROLAND MORRIS DISABILITYQUESTIONNAIRE (RDQ) and PAIN PRESSURE THRESHOLD with the use of PRESSURE ALGOMETER to know the prognosis of the subjects.
Now, Group B is given Mulligan’s mobilisation with movements.
Group A acts as control and receives conventional therapy like ultrasound and TENS.
The duration of the study will be 1 session per day for 1 week where each session will consist of 3 sets of 10 repetitions of MWM technique.
After a week again the post test is conducted using ROLAND MORRIS DISABILITY QUESTIONNAIRE (RDQ) and PAIN PRESSURE THRESHOLD with the use of PRESSURE
ALGOMETER to know the prognosis of the subjects.
Procedure for using RDQ :
It is in the form of a questionnaire which is filled by the patients.
Scoring–The patient is instructed to put mark next to each appropriate statement. Clinical improvements over time can be graded based on analysis of serial questionnaire scores, for e.g, if at beginning the patient score was 12 and at the conclusion of treatment the score was 2 (10 points of improvement) we would calculate an 83% (10/12x100) improvement.
Procedure for using PRESSURE ALGOMETER :
A simple hand held pressure algometer is devised for measuring pain threshold. It is kept over tender points to know the pain threshold.17
A pressure algometer apparatus consists of pressure sensitive probe meant for sensing variations in pressure applied to a localised site on patient’s body and pressure gauge meant for providing pressure readout.17
The probe is kept over the tender area (SI joint) or painful localised area, the pressure is applied and the patient is asked to indicate when they first start feeling pain as opposed to pressure. The patient has to be typically observed for any outward signs of pain, e.g, flinch, expression etc.17
The readings (numbers) obtained through algometer are expressed in Pounds per Square Inch (PSI).
Procedure for Mobilisation With Movement :
Outflare – The patient lies prone, the therapist should stand on the contralateral side and place the thenar eminence of right hand on the slightly protruding posterior border of the opposite ilium and push it away from you (laterally). This should produce no pain. Now have the patient to do a passive extension in lying (half press up) provided there is no pain. 3 sets of 10 can be given.18
Inflare – Patient lies prone and therapist should stand at his side, opposite to the lesion. Fixate the sacrum with the border of one hand and place the fingers of other hand under the right ASIS if right SI is involved. Pull up the ilium on sacrum and hold this position while patient does 10 half press ups, provided these are pain free. 2 further sets of 10 may now be done.18
SI pain walking – If you suspect an inflare, stand behind the patient and use the hand placement for prone lying. Now with the ilium held back have them walk. When indicated they will walk with no pain.18
Procedure for Transcutaneous Electrical Nerve Stimulation :
The electrodes are placed very close to where the pain is perceived to be, one electrode is sited over the place where the most intense pain is felt or the greatest tenderness elicited.19
TENS is most often applied as short pulses of around 50µs at 40-150Hz, this is called conventional TENS and is high-frequency, low intensity stimulation. The intensity is turned up gradually until a pricking or tingling sensation is felt. It should be neither painful nor should it cause a muscle contraction. The duration and timing of treatment will be 15mins.Electrodes are fixed to the skin with adhesive tape. A conditioning gel is applied between electrode and skin.19
Procedure for Ultrasound Therapy :
This is given over the painful area.The couplant should be applied to the skin surface. The treatment head is moved continuously over the surface while even pressure is maintained in order to iron out the irregularities in the sonic field. The emitting surface must be kept parallel to the skin surface to reduce reflection and pressed sufficiently firmly to exclude any air. The pattern of movement can be a series of overlapping parallel strokes, circles or figures of 8.The intensity must be returned to 0 before the transducer is removed from the tissue contact.19
Continuous mode is used. Intensity for acute, 0.1 to 0.25 W/cm2 and for chronic, 0.25 to 1 W/cm2. Frequency of 0.75 MHz will be used as it penetrates deep through the tissue. Duration of treatment would be 8 min.19
Outcome Measures :
- Roland Morris Disability Questionnaire.
- Pain Pressure Threshold (PPT) using Pressure Algometer.
1. ONE-WAY ANOVA for group differences.