Self-Treatment of Chronic Low Back Pain Based on a Rapid and Objective Sacroiliac Asymmetry Test: A Pilot Study

Abstract

Background: Low back pain (LBP) is common, costly, and disabling. This study assesses a novel and simple LBP evaluation method and its merit in guiding the direction of a self-treatment exercise.

Methods: Randomized open-label intention is used to treat the study. Consecutive patients with LBP ≥ three months and pain ≥ 5/10 were evaluated in a Vancouver clinic with the sacroiliac forward flexion test (SIFFT) by comparing the height of posterior superior iliac spines using a level. Those with asymmetry ≥ 5 mm were offered participation. The assistant, who generated and encrypted the randomization, assigned participants: group 1 learned a two-minute, SIFFT-derived, sacroiliac-leveling exercise (SIFFT-E) as needed for LBP relief; group 2 used a pelvic stabilization belt as needed to prevent LBP, and group 3 continued the usual care. After one month, all participants used SIFFT-E and belt as needed for one month. The identifier number of this article in Clinicaltrials.gov is #NCT03888235. The trial is closed. Our primary outcome measure was the Oswestry disability index (ODI) (decrease) from baseline to one and two months. We also followed SIFFT improvement (decrease).

Findings: Of 72 LBP patients, 62 (86%) had ≥ 5 mm asymmetry. From zero to one month, the 21 (one dropout) SIFFT-E participants outperformed the 20 usual care participants for ODI improvement (12.5 ± 14.8 vs. -3.4 ± 14.9 points; mean difference 15.9 [CI 6.7-25.0]; P = 0.002 with number needed to treat (NNT) of 3.0 for ODI improvement ≥ 11). Belt use results were intermediate. At two months, after all the 62 participants used the exercise and belt as needed, combined ODI improvements were clinically significant (12.0 ± 18.4 points), and SIFFT asymmetry was reduced by 8.6 ± 8.6 mm. Five (8%) exercise and 12 (19%) belt wearers experienced mild side effects.

Interpretation: Sacroiliac asymmetry appears to be frequent. SIFFT may be clinically useful as an evaluation tool for prescribing a simple self-directed corrective exercise as seen by clinically significant improvements in function and asymmetry.

Keywords: acute low back pain; chronic low back pain (clbp); chronic non-specific low-back pain; low back pain physical exam; lower back pain (lbp); sacroiliac; sacroiliac displacement; sacroiliac joint dysfunctional pain; sacroiliac joint manipulation; treating low back pain.

Conflict of interest statement

I, Helene Bertrand, am half owner and director of Mary Helene Enterprises Inc., which owns the Canada and US patents for the topical use of mannitol for pain relief. Topical mannitol was not mentioned or used in the current study as the sacroiliac joints are too deep for the topical mannitol to reach them.. I, Helene Bertrand, am half owner and director of a company, Mary Helene Enterprises Inc., which makes QR cream, a mannitol-based pain relief cream. The cream was not used for this study nor was it mentioned to participants. The topical application of mannitol would not allow it to penetrate deep enough to reach the sacroiliac joints.

Copyright © 2021, Bertrand et al.

Figures

Figure 1. Sacroiliac forward flexion test (SIFFT)

The patient is leaning against the desk to relax the buttock muscles, making them softer and easier to press down on. The legs push the PSISs up, while the weight of the body brings the spine down, which rotates the sacrum anteriorly making the PSISs easier to feel. PSISs are located by pressing down firmly with the ulnar side of the thumbs while gradually advancing the cephalad toward the PSISs starting on either side of the intergluteal cleft. When the PSISs are reached, bony resistance is felt. For a video demonstration of the SIFFT technique, please refer to Video 1. The space between the thumb and the underside of each PSIS is marked with a surgical marker. The examiner then asks the participants whether and on which side they feel pain. The examiner then writes the letter B (for before) on the painful side or both sides if they have pain on both sides. In those with obesity or very muscular participants, ultrasound can be used to determine the PSIS levels.

Figure 2. SIFFT: Using a level on the lowest PSIS and marking the corresponding area under the higher PSIS

SIFFT, Sacroiliac forward flexion test; PSIS, posterior superior iliac spine.

Figure 3. SIFFT: Measuring the distance between PSIS levels in cm

SIFFT, Sacroiliac forward flexion test; PSIS, posterior superior iliac spine.

Figure 4. SIFFT-E stretch exercise to level a right anterior, left posterior sacroiliac malrotation

Place the right foot and the left knee on the floor hands on either side of the right foot. Lean forward so that the right thigh is pushing up hard on the right ASIS to level an anterior SI torsion. Slide the left knee as far back as possible to hyperextend the left thigh. A strong pull should be felt in the left groin to level a posterior SI torsion. Hold this position for a full two minutes. If only one side is affected, less pull or pressure is exerted on the nonpainful side. Of the 62 participants, 51 did this exercise. SIFFT, Sacroiliac forward flexion test; SIFFT-E, SIFFT-guided leveling exercise; SI, sacroiliac; ASIS, anterior superior iliac spine.

Figure 5. SIFFT-E treating a right anterior, left posterior sacroiliac torsion in dorsal decubitus

The patient lies in dorsal decubitus with their buttock on the edge of the examination table, right thigh flexed, and left thigh extended. The patient's right foot is placed against a cushion on the examiner's sternum, and the examiner leans forward hard to force the right thigh against the right ASIS for a right anterior SI torsion. The examiner presses down hard on the left thigh to hyperextend it for a left posterior SI torsion. If only one side is affected, the nonpainful side is simply held in place. The position is held for a full two minutes. Three of the 62 participants needed this treatment due to limited range of motion or their enlarged abdomen interfering with hip flexion in the stretch exercise. SIFFT, Sacroiliac forward flexion test; SIFFT-E, SIFFT-guided leveling exercise; SI, sacroiliac; ASIS, anterior superior iliac spine.

Figure 6. SIFFT-E treating a right anterior sacroiliac torsion: The right thigh pushes the right ASIS backward

Place the right foot on the seat of the chair with the hands holding the seat on either side of the foot. The left knee touches the front of the seat. Lean back. Pull up hard with both hands on the seat of the chair and hold for a full two minutes. Six of the 62 participants did the chair exercise. It indicated when the only tender PSIS is anteriorly displaced (higher than the other PSIS) and the arms are sufficiently strong to hold a two-minute pull. SIFFT, Sacroiliac forward flexion test; SIFFT-E, SIFFT-guided leveling exercise; ASIS, anterior superior iliac spine; PSIS, posterior superior iliac spine.

Figure 7. Repeat SIFFT test done after the SIFFT-E

After the two-minute SIFFT-E is done, the SIFFT is repeated, and the location of the PSISs is marked with the letter A for after. The level is used to measure their alignment. As a rule, when the PSISs are level, the back pain and limitation of function are relieved. In this participant who had pain on both sides, the higher PSIS on the right indicates a right anterior torsion of the innominate bone on the sacrum, while the lower PSIS on the left points to a left posterior torsion of the innominate bone on the sacrum. SIFFT, Sacroiliac forward flexion test; SIFFT-E, SIFFT-guided leveling exercise; PSIS, posterior superior iliac spine.

Figure 8. Trial profile for low back pain study

ODI, Oswestry disability index; SI, sacroiliac.

Figure 9. NRS (0-10) pain severity response to exercise or belt

Changes with SIFFT-E at time 0 (group 1, n = 21) (5.2 ± 2.5 to 2.0 ± 2.4 (62%); change score 3.2 ± 2.6; CI = 2.0-4.4; P

Figure 10. A new way to diagnose and treat low back pain in 70% chance of relieving the pain

Poster presentation #119, Canadian pain Society meeting May 24, 2018. A total of 180 charts (2015–2017) were reviewed. If the sacrotuberous ligament under a PSIS was tender, the corresponding SI joint was deemed affected. If the affected PSIS was higher than its mate, the SI joint was anteriorly subluxed. If it was lower, it was posteriorly subluxed. Anterior subluxation was corrected by jamming the thigh on the affected side against the anterior superior iliac spine (ASIS) using a chair. Posterior subluxation correction involved hyperextending the thigh on the affected side. Each exercise was held for two minutes. The chair exercise was strenuous, and the examining table treatment required an assistant. This prompted the development of the stretch exercise to allow low back pain sufferers a way to self-relieve their pain at all times. Exact measurement of the distance between the right and left PSIS levels was not taken. To measure the patients’ exercise effectiveness and their progress in leveling the PSISs, the SIFFT was developed. SIFFT, Sacroiliac-leveling exercise; PSIS, posterior superior iliac spine.