Muscle Energy Techniques and Sacral Manipulation on Pain, Functional Disability and Quality of Life
Condition: Sacroiliac Joint Dysfunction
MeSH terms: Joint Diseases
Study type: Interventional

Summary: 
      -  The study will be randomized clinical trial. This study will be conducted in University
           of Lahore Teaching Hospital, Lahore, Pakistan. A sample size of 84 will be randomly
           allocated into two experimental groups, (42 participants in each group), by lottery
           method. The participants, randomly allocated to the experimental group A, will receive
           Muscle Energy Technique (METs), Post isometric relaxation technique specifically, in
           addition with routine physical therapy as TENS, Hot pack, and strengthening exercises.
           METs will be performed on piriformis, iliopsoas, erector spine muscles, 1 set of 5
           repetitions and 10 seconds hold.

        -  Participants in experimental group B, will get Sacroiliac joint manipulations with
           routine physical therapy by principal investigator.

        -  Both experimental groups will receive twelve treatment sessions and those will be given
           over a period of six weeks (2 sessions per week, each session of 30-40 minutes).

        -  Assessor will take outcome measures at baseline and at the end of 6th treatment week
           through Short Form McGill Pain Questionnaire, Roland-Morris Low Back Pain & Disability
           Questionnaire and Short Form Survey; SF-20.
    

Detailed description: 
      -  Recruitment: Participants will be recruited and referred by orthopedic surgeon,
           University of Lahore Teaching Hospital to Physical Therapy Department.

        -  Screening: Diagnostic & pain provocative tests (Faber, Thigh thrust and Gillet tests)
           will be applied on recruited participants for screening. With all three positive tests,
           participants will be confirmed for positive SI joint dysfunction and will be considered
           eligible for entering the study.

        -  The FABER (Patrick's) Test stands for Flexion, Abduction and External Rotation. The
           participants will be positioned in supine. The leg will be placed in a figure-4 position
           (hip flexed and abducted with the lateral ankle resting on the contra-lateral thigh
           proximal to the knee. While stabilizing the opposite side of the pelvis at the anterior
           superior iliac spine, an external rotation, abduction and posterior force will be then
           lightly applied to the ipsilateral knee until the end range of motion would achieve. A
           further few small-amplitude oscillations would be applied to check for pain provocation
           at the end range of motion. A positive test will be the one that reproduces the
           participants' pain or limits their range of movement.

        -  Thigh thrust test is a posterior pelvic pain provocative test. It will be performed with
           the participant in supine lying, with the hip flexed to 90° (with bent knee) to stretch
           the posterior structures. By applying axial pressure along the length of the femur, the
           femur will be used as a lever to push the ilium posteriorly. One hand will be placed
           beneath the sacrum to fixate its position while the other hand will be used to apply a
           downward force to the femur. Broadhurst and Bond suggest adding hip adduction towards
           the mid line while Laslett & Williams advise to avoid excessive adduction due to
           discomfort for the participant. Test will be positive if it aggravates the pain in
           sacroiliac joint.

        -  The Stork test, also known as the Gillet Test, assesses the movement of the sacroiliac
           joint between the innominate and sacrum through the clinician's palpation, which may be
           a useful test for clinical evaluation of a subject's ability to stabilize intra-pelvic
           motion. The assessment of the Gillet's test involves palpation of the posterior superior
           iliac spine (PSIS). There are 2 phases to the Gillet's test: the stance phase and the
           hip flexion or swing phase. To perform this test, the patient will be asked to stand
           while the examiner will palpate the posterior superior iliac spine (PSIS) with one thumb
           and will palpate the base of the sacrum with the other thumb medial to the PSIS. The
           participants will be then instructed to stand on one leg while pulling the hip of the
           side being palpated into 90° or more of hip flexion. The test will then be repeated on
           the other side and compared bilaterally. The principal investigator will compare each
           side for quality and amplitude of movement. The test will be positive when the PSIS on
           the ipsilateral side (same side of the body) of the knee flexion move minimally in the
           inferior direction, doesn't move or is associated with pain. A positive test will be an
           indication of sacroiliac joint hypo-mobility.

        -  Randomization and Allocation: Afterwards, participants confirming the eligibility
           criteria will be randomly allocated, through lottery method, into two experimental
           groups (Group A, Group B).

        -  Blindness: Study will be single, assessor blinded and an independent investigator will
           perform randomization and will inform the patients and therapist about the allocation.

        -  Intervention: The participants, randomly allocated to the experimental group A, will
           receive METs (Post isometric relaxation technique specifically) in addition with routine
           physical therapy (TENS, Hot pack, and strengthening exercises). METs will be performed
           on piriformis, iliopsoas, erector spine muscles, 1 set of 5 repetitions and 10 seconds
           hold. Participants in experimental group B, will get Sacroiliac joint manipulations with
           routine physical therapy by principal investigator.

        -  Duration: Twelve treatment sessions will be given over a period of six weeks (2 sessions
           per week, each session of 30-40 minutes).

        -  Outcome Variables and Measures

             1. Pain (Short Form McGill Pain Questionnaire)

             2. Functional Disability (Roland-Morris Low Back Pain & Disability Questionnaire)

             3. Quality of Life (Short Form Survey; SF-20)

        -  Outcome measures will be taken at baseline and at the end of last treatment session i.e.
           6th week. Collected data will be than analyzed.
    

Intervention name(s): Muscle Energy Technique; Sacral Manipulation
Intervention type(s): Other; Other
Intervention description(s): Post isometric relaxation: Patient will be asked to perform isometrics on piriformis, iliopsoas and erector spinae muscles one by one. Each isometric contraction will be held for 10 seconds. After 10 seconds, contraction will be released with an exhalation. These contractions will be repeated for 5 times in one session.
Routine physical therapy including TENS, Hot pack and strengthening exercises will also be delivered along with Muscle Energy Technique.; To manipulate an iliac anterior rotation displacement sacroiliac joint dysfunction and to restore posterior rotation of the ilium, participant will be positioned in side lying. Therapist will place one hand at Anterior superior iliac supine (ASIS) and the other at Ischial tuberosity. A quick thrust will be applied and ASIS will be pushed posteriorly while Ischial tberosity anteriorly. This will be maintained for 10 to 30 seconds.
To manipulate an iliac posterior rotation displacement sacroiliac joint dysfunction and to restore anterior rotation of the ilium, participant will be in prone position. One hand of therapist will be at Posterior superior iliac supine (PSIS) and the other one at pubic rami. A quick thrust will be delivered and PSIS will be moved anteriorly while pubic rami posteriorly. This will be maintained for 10 to 30 seconds.
Routine physical therapy including TENS, Hot pack and strengthening exercises will also be delivered along with Sacral Manipulation.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Sacroilitis