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The Somatic Connection  |   April 2012
Sacroiliac Pain May Be Reduced by Manipulation Identical to OMT Techniques
Article Information
The Somatic Connection   |   April 2012
Sacroiliac Pain May Be Reduced by Manipulation Identical to OMT Techniques
The Journal of the American Osteopathic Association, April 2012, Vol. 112, 158-159. doi:10.7556/jaoa.2012.112.4.158
The Journal of the American Osteopathic Association, April 2012, Vol. 112, 158-159. doi:10.7556/jaoa.2012.112.4.158
Kamali F, Shokri E. The effect of two manipulative therapy techniques and their outcome in patients with sacroiliac joint syndrome. J Bodyw Mov Ther. 2012;16(1):29-35.  
Physical therapy researchers at the Center for Human Movement Science Research at Shiraz University of Medical Sciences in Iran compared 2 types of manipulation in the treatment of patients with sacroiliac joint (SIJ) syndrome. This article was selected for review in “The Somatic Connection” not only because of the interesting site of the research—illustrating the worldwide interest in manual medicine and manual therapy—but also because of issues relevant to osteopathic principles and practice. 
I have rarely come across the term sacroiliac joint syndrome in osteopathic medical literature, but the syndrome's somatic dysfunction complex (based on the anatomic relationship between spinal levels L5 and S1) is well known and frequently described in osteopathic medical literature.1 The authors cite literature suggesting that the SIJ is the most important source of low back pain. They further describe the symptoms of SIJ syndrome as pain over the posterior aspect of the SIJ, together with referred pain to the groin, greater trochanter, posterior thigh, and knee, and from the lateral or posterior calf to the ankle, foot, and toes. Clinical findings of SIJ syndrome include tenderness over the SIJ and aggravation by pain provocation tests, which the authors describe as Yeoman test, Gaenslen sign, the FABER (Flexion Abduction External Rotation) test (ie, Patrick sign), the sacroiliac compression test, resisted hip abduction, and the posterior pelvic pain provocation test. 
All study participants were women who were aged between 20 and 30 years and who met the inclusion criteria of having acute unilateral or bilateral SIJ syndrome during the previous 6 weeks, a visual analog scale (VAS) pain rating of at least 30 (on a scale of 0 [no pain] to 100 [worst pain ever]), and no manipulative therapy within the previous month. Further inclusion criteria, determined during history taking and physical examination, were 3 or more positive results in the 6 previously mentioned pain provocation tests. The exclusion criteria were as follows: pain and discomfort in the lumbar spine; destructive lesions of the spine, ribs, and pelvis; cauda equina syndrome; gross instability; infection; pregnancy; spondylolysthesis; osteoporosis; or previous back surgery. 
Thirty-two patients were randomly assigned to 1 of 2 intervention groups. One group (n=16) received a session of manipulation of the SIJ, and the other group (n=16) received a session of SIJ manipulation and lumbar manipulation. The same physical therapist who performed the patient assessment also performed the manipulation. The SIJ manipulation described and pictured in the article appears to be identical to the osteopathic manipulative treatment (OMT) technique of high-velocity, low-amplitude that is used to manage somatic dysfunction of the posterior sacral margin—as pictured in Outline of Osteopathic Manipulative Procedures: The Kimberly Manual 2006.2 The lumbar manipulation described and pictured in the article appears to be identical to the lumbar roll OMT technique used to manage lumbar somatic dysfunction, also shown in the The Kimberly Manual.3 
Outcome measures in the study were pain intensity, as recorded on a 100-mm VAS, and functional disability, as measured by the Oswestry Disability Index (ODI) questionnaire. The VAS data were collected at baseline, immediately after manipulation, 48 hours after manipulation, and 1 month after manipulation. The ODI data were collected at baseline, 48 hours after manipulation, and 1 month after manipulation. 
Study results revealed that both intervention groups showed statistically significant improvement from baseline to immediately after, 48 hours after, and 1 month after manipulation (P<.05). No statistically significant difference in improvement was found between the groups. The authors concluded that a single session of manipulation produced clinically significant improvement in pain and disability in patients with SIJ syndrome. 
An obvious limitation to the study, noted by the authors, is that no control group was included—meaning that the study results cannot be taken as proof that spinal manipulation is clinically effective for patients with SIJ syndrome. Another limitation reported by the authors is that the investigators did not use SIJ block injections to verify the diagnosis of SIJ syndrome. 
These limitations notwithstanding, the study results seem to confirm my clinical experience—and likely the experience of others who teach OMT—that in almost all cases of low back pain, both the lumbar spine and SIJ need to be properly evaluated for somatic dysfunction and then managed with the appropriate application of OMT. However, an intriguing finding suggested by the design of this study is that management of the SIJ alone is sufficient for managing sacroiliac pain—and lumbar treatment may not be necessary. 
The authors' anatomic finding that L5 is rotated opposite of torsional rotation of the sacrum and, therefore, requires manipulation may not be accurate. Rather, it may be the case that SIJ thrust can impact L5 rotation. With due respect for long-held biomechanical principles, some reconsideration of these principles may be in order. 
The finding by Kamali and Shokri that a single session of manipulation was sufficient to produce apparent benefits to patients has cost-benefit implications. However, this finding needs to be verified by studies that incorporate results from control groups.—H.H.K. 
References
Greenman PE. Principles of Manual Medicine. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:364-366.
Halma K, Lockwood MD, Snider E, Vick D. Outline of Osteopathic Manipulative Procedures: The Kimberly Manual 2006 (Updated 2008). Kirksville, MO: A.T. Still University of Health Sciences-Kirksville College of Osteopathic Medicine; 2008:201.
Halma K, Lockwood MD, Snider E, Vick D. Outline of Osteopathic Manipulative Procedures: The Kimberly Manual 2006 (Updated 2008). Kirksville, MO: A.T. Still University of Health Sciences-Kirksville College of Osteopathic Medicine; 2008:173-174.