INTRODUCTION:

One of the most common and public health problem affecting people globally is the low back pain. Low back pain is the common conditions that affect an individual at least once in their life time. It is said to be the major cause leading to activity limitation, hospitalization, surgical procedure and other major and minor health problems. It has become a real problem causing personal, public and financial burden. It affects everyone but people between 40-80 years are the most commonly affected. But there is no clear evidence on which the rate of low back pain is high. Some studies suggest that females are more prone than men¹.

The joint between sacrum and ilium bones of the pelvis is the sacroiliac joint (SI Joint). They are connected by ligaments namely, Anterior sacroiliac ligament, posterior sacroiliac ligament, Interosseous sacroiliac ligament, Sacrotuberous ligament and Sacrospinous ligament. Sacroiliac joint is a strong, weight transferal synovial plane joint. There are two sacroiliac joint in human body on each side (right and left). The joint is capable of minimal movements. They are paired c-shaped or L-shaped joints which are covered by hyaline cartilage in sacral surface and fibrocartilage in iliac surface².

Thoracolumbar fascia, Gluteus Maximus, Gluteus medius, Piriformis, Latissmusdorsi, psoas, pelvic floor and diaphragm, abdominal obliques, biceps femoris and transverse abdominus are the muscles involved in the sacroiliac joint. Ilium supports the sacrum which in turn supports the spine. Sacroiliac dysfunction is the major problem causing pain in the sacroiliac joint. Some of the pre-disposing factors are limb-length discrepancy ,age, arthritis, surgery(spine), muscle weakness, pregnancy, degeneration and trauma .sacroiliac joint pain is present unilaterally below the L5 region³. Some important functions of sacroiliac joint are the shock absorption for spine and interlocking mechanism provides stability during walking.

The signs and symptoms which include lower back pain, hip pain, buttocks pain, sciatic leg pain, groin pain, urinary frequency and transient numbness, pricking and tingling pain. It may range from dull aching to sharp and stabbing pain. Symptoms may worsen during prolonged sitting, standing, lying, bending forward, stair climbing, weight lifting, squatting and rising from a chair⁴.

The sacroiliac joint is a frequent origin for pain in pelvic girdle and lower back with referred pain to the lower extremity⁵. It affects 10%-25% of population. It is a condition of changed mechanics, either an increment or diminishing from the typical normal or the presence of an abnormal movement. The pain arising from the sacroiliac joint and is caused by increased or abnormal motion of the ilia around the sacrum and irritation of sacroiliac joint structures⁶.

About 15% of low back pain is caused due to sacroiliac joint dysfunction. Upper body weight is transmitted into pelvis and lower extremities through sacroiliac joint. Any reduction in movement of sacroiliac joint can lead to dysfunction. There is evidence that manual therapy techniques can help in improving the pain and ROM of sacroiliac joint. Mobilization with Movement is a safer ‘hands on’ technique that can be performed in patients with any joint dysfunction. Since there is a lack of evidence in effectiveness of MWM on sacroiliac joint dysfunction, this study is done to analyse the effects of MWM on pain, ROM, and change in functional activities associated with sacroiliac joint dysfunction.

MATERIALS AND METHODS:

A Quasi Experimental Study was conducted at Saveetha college of Physiotherapy OPD, Thandalam, chennai. Following the approval of Scientific Review Board and ethical committee, data collection procedure was initiated. Total of 40 subjects were selected according to inclusion and exclusion criteria and informed consent was obtained from the subjects. It is a double blinded study. Subjects were not blinded as they were informed regarding the study and the intervention to be given while obtaining the informed consent. Non- equivalent convenient sampling method was used. They were explained about the safety and simplicity of the procedure.

Inclusion criteria:

· Both Genders.

· Age 30-60 years.

· Unilateral sacroiliac joint pain or movement dysfunction.

· Restricted Range of Lumbosacral flexion.

Exclusion criteria:

1. Acute injury/ fracture in lower limb.

2. Pregnant females.

3. Previous hip operations.

4. Pain and discomfort in the lumbar spine.

5. Stenosis/ Spondylolisthesis/ disc disease.

6. Congenital spinal deformity.

7. Destructive lesions of the spine.

8. Inflammatory pathology.

9. Post-partum.

10. Hypermobility of sacroiliac joint.

PROCEDURE:

Participants were randomized into two groups (group A and B) of twenty each. Subjects in Group A were given conventional exercises and Interferential therapy (IFT). Subjects in Group B were given Mobilization with Movement (MWM), conventional exercises and Interferential therapy (IFT). For this two group Translation of Oswestry Low back pain disability questionnaire into Tamil will be given before and after the treatment.²²

Table 1 - Treatment protocol

Intervention	Program	Reps/sets	Duration
Conventional Exercise	Back extension, posterior pelvic tilt, partial sit ups, bridging exercise	3-5 repetitions/day	7 sessions
Mulligan’s Mobilization with Movement	Postero-medial glide, Antero-lateral glide	10 repetitions/set upto 3sets/day Day 1- only 3 repetitions	7 sessions
Interferential therapy	Quadripolar method	80-100 Hz, 10 minutes	7 sessions

RESULTS:

The collected data was tabulated and analysed using descriptive and interferential statistics. To all parameters mean and standard deviation (SD) was used. All the values were tabulated and statistically analysed using paired and un-paired t tests. Paired t test was used to compare data within groups and unpaired t test was used to compare the data between the groups. p value <0.05 is considered statistically significant.

Table 2: Comparison of pre-test and post-test mean values of NPRS of group A and group B

Parameter	Pre-test	Post-test	P value
Group A	6.05+/-1.23	4.85+/-1.23	<0.0001*
Group B	6.90+/-0.72	2.60+/-1.54	<0.0001*
P value	0.0113	<0.0001*

*-p value significant

Table 3: Comparison of pre-test and post- test values of ROM of group A and group B

Parameter	Pre-test	Post-test	P value
Group A	33.45+/-9.05	36.05+/-9.09	<0.0001*
Group B	33.95+/-7.61	44.35+/-8.34	<0.0001*
P value	0.8509	0.0046

*-p value significant

Table 4: Comparison of pre-test and post- test values of ODI scores of group A and group B

Parameter	Pre-test	Post-test	P value
Group A	33.000+/-4.499	31.050+/-4.475	<0.0001*
Group B	35.475+/-4.890	27.025+/-4.145	<0.0001*
P value	0.1040	0.0054

*-p value significant

DISCUSSION:

The aim of the study is to investigate the effectiveness of Mulligan’s Mobilization with Movement in subjects with sacroiliac joint dysfunction. This study demonstrates that Mobilization with Movement applied to subjects with sacroiliac joint dysfunction in experimental group has shown statistical significance and clinical improvement over conventional exercises and Interferential therapy (IFT) given to subjects in control group. It is a double blinded study. The patient was not blinded as they were informed regarding the study and the intervention to be given while obtaining the informed consent.

In this study, 40 subjects were selected and 20 subjects were studied in Group A and 20 subjects were studied in Group B. subjects in control group, Group A received conventional treatment including conventional exercises and Interferential therapy (IFT) and subjects in experimental group, Group B were given Mobilization with Movement, conventional exercises and Interferential therapy (IFT).

The outcome measures were evaluated using Numeric pain Rating scale (NPRS) for pain, Range of Motion (ROM) for evaluating lumbosacral flexion, Oswestry Disability Index (ODI) for evaluating the functional abilities of patients with sacroiliac joint dysfunction. Both the groups were homogeneous at baseline measurement of NPRS, ROM and ODI. Group A and Group B followed a course of treatment for a period of 7 sessions. Comparison of the NPRS scores of Group A and Group B shows that Group B has a significant reduction in pain. Post-test values of ROM in lumbosacral flexion shows that the ROM has improved significantly in Group B than in Group A. Even though the functional outcome scores were homogeneous at baseline in both the groups, the disability scores have reduced significantly in Group B, than in Group A.

In this study, Mobilization with Movement in subjects with sacroiliac joint dysfunction has proved that improved outcomes on pain, range of movement of lumbosacral spine and functional abilities of daily living.

Reda Kotb Abd Elrazik et al (2016)., states that Mulligan’s Mobilization with Movement is a technique to restore spinal mobility and found immediate reduction in pain within a week following the treatment. Sabah Mohammed Easa Alkady et al (2017)., concluded that Mulligan’s Mobilization with Movement is more effective in managing patients with sacroiliac joint dysfunction and found significant effect on decreasing pain level and improving sacroiliac mobility. In this study, we combined Mobilization with Movement with therapeutic exercises and Interferential therapy (IFT) for 7 sessions and found immediate relief of pain and improvement in ROM and functional abilities.

Conventional exercises including strengthening exercises for back and abdominal muscles was choosen for comparison as it was found by O.A. Olawale et al (2014)., that most patients with sacroiliac joint dysfunction was successfully treated with these strengthening exercise program. O.A. Olawale et al (2014)., also showed that Interferential therapy combined with therapeutic exercise could help to reduce pain intensity and increase spinal range of motion in patients with low back pain. Fairbank JCT and Pynsent, PB (2000) showed that immediate reduction in NPRS and significant improvement in ODI scores of daily living activities.

The range of motion of the sacroiliac joint in both the groups showed steady improvement. The subjects in group B showed quicker improvement in the range of motion than in group A. This has not been documented as the range was not recorded in frequent intervals other than the response from the patient who got the treatment and the physiotherapist who gave the intervention. The final range documented showed a plateau and was taken as the final range of improvement available.

Rehabilitation goals are based on the needs of an individual. Though all the subjects had difficulty to carry out their different needs, the one thing that appeared to be in common was pain. Our goal focussed on reducing pain, which eventually improved pain-free ROM and improvement in Oswestry score (ODI). These parameters where observed to have provided significant improvement with Mulligan’s Mobilization with Movement group than the group treated with conventional exercises and modalities.

CONCLUSION:

The current study shows that application of Mobilization with Movement was more benefited than the group that received conventional exercises and modalities. The patients were randomly allocated to these groups and results were tabulated and the statistics were derived.

In this study, Mobilization with Movement of the sacroiliac joint in subjects with sacroiliac joint dysfunction shows clinical and statistical improvement in the outcome of pain, range of motion and quality of life.

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Received on 06.01.2019 Modified on 28.02.2019

Research J. Pharm. and Tech. 2019; 12(6): 2977-2980.

DOI: 10.5958/0974-360X.2019.00503.1