Correction of Low Back Pain From Sacroiliac Malrotation With a Simple in Home Exercise
Condition: Sacroiliac Strain; Low Back Pain
MeSH terms: Back Pain; Low Back Pain
Study type: Interventional

Summary: 
      60 participants with low back pain will be examined to determine the direction and extent of
      sacroiliac malrotation. If malrotation exists, they will be randomized to 3 treatment groups:
      1 will be taught how to use their thigh to push the anterior superior iliac spine (ASIS)
      backwards for an anterior malrotation and their sartorius and rectus femoris to pull their
      ASIS and anterior inferior iliac spine (AIIS) forward for a posterior malrotation. 2: will be
      given a pelvic stabilization belt. 3: will return in one month. At the second visit at one
      month all participants will be treated with both exercise and belt. They will be reassessed
      at the third visit one month later: the scores for immediate and delayed treatment groups
      will be compared. Their response to these exercises and/or the pelvic belt will be tested at
      the first second and third visits, using the brief pain inventory pain, the Oswestry
      disability scores and the distance between the (posterior superior iliac spine) (PSIS)
      levels, filled out at every contact. Their satisfaction with previous treatments used will be
      compared to their satisfaction when using the exercise and belt.
    

Detailed description: 
      Potential participants with low back pain will answer a questionnaire to eliminate lumbar or
      hip pathology, ankylosing spondylitis or major leg length discrepancy as cause. If they state
      they do not have these, they will be given an appointment to be assessed to eliminate the
      presence of these conditions and to determine if they suffer from sacroiliac malrotation. To
      this effect, the sacroiliac forward flexion test (SIFFT) will be done: leaning on a counter
      with their body horizontal to tilt the pelvis forward and lower the sacrum and their legs
      vertical to push the innominate bones upwards via the hip joints, to expose the posterior
      superior iliac spines (PSISs). Pressure below the PSISs will be used to assess their inferior
      limits which will be marked and their levels assessed using a carpenter's level. The distance
      between the PSIS levels will be recorded. If there is tenderness under the higher PSIS, the
      ilium is malrotated anteriorly on the sacrum. If the area under the lower PSIS is tender, the
      ilium is malrotated posteriorly on the sacrum.

      Participants are then randomized into three groups: group 1 is taught how to assess the
      direction of the malrotation, then how to perform the appropriate corrective exercise:

        -  With the foot of the anteriorly rotated side and the knee on the posteriorly rotated
           side on the floor, hands on the floor on either side of the foot, the participant leans
           forward hard to push his anteriorly rotated ilium posteriorly with his thigh and
           stretches the opposite thigh posteriorly to pull the posteriorly rotated ilium forward.

        -  Anterior malrotation can also be corrected by placing the foot on the malrotated side on
           a chair seat, flexing the other knee to touch the seat edge and pulling with both hands
           up on the seat while leaning back, to drive the thigh against the anterior superior
           iliac spine (ASIS), thus pushing it backwards.

        -  If unable to do these, participants can lie supine on the table, thigh on the posterior
           side extended. On the anterior side the knee is flexed and the foot is on the
           assistant's sternum as he/she leans forward, pushing the thigh against the ASIS.
           Downward pressure on the sartorius and rectus femoris just above the knee causes the
           ASIS and the anterior inferior iliac spine (AIIS) to be pulled on, rotating the ilium
           anteriorly.

      Each position is held for 2 minutes, with up to 2 repetitions as needed. At home, the
      procedure is repeated as needed for pain relief.

      Group 2 are given a pelvic stabilization belt and taught how to apply it: tightly around the
      pelvis below the anterior superior iliac spines (ASISs), to stabilize the sacroiliac joints
      as malrotation occurs as a result of pelvic instability. The belt is used for activities
      known to cause back pain.

      Group 3 are instructed to continue their usual treatments and given an appointment to return
      one month later to receive instruction for the exercise and given the belt At 1 month all are
      reassessed. Group 1: use and effectiveness of the exercises is recorded and they are given
      the belt. Group 2: use and effectiveness of the belt is recorded and they are taught how to
      examine and correct their sacroiliac joints. Group 3: use and satisfaction with their current
      treatment is recorded. They are then taught the examination and corresponding exercise and
      given the belt.

      At 2 months, when all participants have used both treatments for one month, all are
      reassessed.

      Data collected includes:

      at the first visit: Diagnoses associated with low back pain: lumbar spondylosis, hip
      arthritis, hypermobility, leg length discrepancy.

      Conditions associated with sacroiliac malrotation, tendinitis of sacroiliac joint stabilizer
      muscles and lateral femoral cutaneous neuropathy. Muscle insertions tested include quadratus
      lumborum, gluteus medius and minimus, piriformis, iliopsoas, biceps femoris, semimembranosus
      and semitendinosus.

      At all visits:

      Brief pain inventory pain severity (BPI PS), the Oswestry low-back disability scores (ODI)
      and the distance in centimetres between the posterior superior iliac spine levels from the
      SIFFT test (PSISL), at intake, one month and two months visits. Together with the following:

      Use of pain medications alcohol and marijuana Use and satisfaction with other treatments for
      back pain relief (physiotherapy, acupuncture, yoga, core exercises, chiropractor, massage).

      Position of the malrotated sacroiliac joint or joints. Distance in centimetres between the
      levels of the PSISs before and after the corrective exercise. (Visits 2 and 3 for all, visits
      1, 2, 3 for group 1) Numeric rating scale pain score after the corrective exercise. Use of
      and satisfaction with the SI corrective exercise at first visit for group 1 and at the second
      and third visit for all.

      Use of and satisfaction with the pelvic belt at the first visit for group 2 and at the second
      and third visits for all.
    

Intervention name(s): Immediate corrective exercises; Immediate use of pelvic support belt; Delayed treatment
Intervention type(s): Procedure; Device; Other
Intervention description(s): The sacroiliac forward flexion test (SIFFT) finds the position of each innominate bone. Subjects learn 1 of 3 exercises. To correct anterior rotation, flex the thigh hard against the ilium, pushing it backwards. To correct posterior rotation, hyperextend the thigh to pull the ilium forward. 1.Genuflect, anterior foot and posterior knee on the floor hands on the floor on either side of the foot, sliding the knee backwards to hyperextend the thigh. 2. Supine, anterior foot on an assistant's sternum, posterior thigh hyperextended. Assistant leans forward, forcing the anterior thigh against the ilium and pushing down on the posterior thigh. 3. For anterior rotation alone: anterior foot on a chair seat, pulling up hard with both hands, leaning back, forcing the thigh against the ilium. Hold position for 2 minutes. Use as needed for pain control. They are reassessed one month later when they receive the pelvic support belt. Both treatments used together will be assessed one month after.; Participants will be given a pelvic support belt to stabilize their sacroiliac joints. The belt is fitted tightly around the pelvis, over the sacrum and below the anterior superior iliac spines (ASISs) to prevent opening the joint. (The upper part of the innominate bones flares out so pushing them inwards will move the lower part outwards, away from the sacrum, opening the sacroiliac joints, increasing their instability). They will use this belt for activities which have in the past precipitated back pain. They will be reassessed one month later.
At that time they will be given the exercises to correct their sacroiliac malrotation and the concurrent use of both treatments will be assessed at their last visit one month later.; Participants will continue the treatments they are currently using to relieve their low back pain for one month. At their one-month visit, they will be taught how to assess the direction of sacroiliac malrotation and how to do the corrective exercise. They will also be fitted for a pelvic stabilization belt.
Other intervention name(s): Immediate use of sacroiliac corrective exercises; Serola pelvic support belt; One month delay prior to receiving sacroiliac corrective exercises and pelvic support belt
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Of all the patients with low back pain, those with sacroiliac malrotation will be randomized to: group 1 an exercise to correct the malrotation, group 2 given a pelvic belt to stabilize the sacroiliac joints, group 3: use of usual treatment and treatment with the belt and exercise one month later. The degree of pain relief and improved function between the first visit and the second visit one month later will be assessed.
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Sacroiliac Instability; Sacroiliac Strain; Hypermobility; sacroiliac sprain; tendinopathy