Self-Treatment of Chronic Low Back Pain Based on a Rapid and Objective Sacroiliac Asymmetry Test: A Pilot Study
Helene Bertrand, K Dean Reeves, Rajneet Mattu, Remerlita Garcia, Mahir Mohammed, Ellen Wiebe, An-Lin Cheng, Helene Bertrand, K Dean Reeves, Rajneet Mattu, Remerlita Garcia, Mahir Mohammed, Ellen Wiebe, An-Lin Cheng
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
References
- Expenditures and health care utilization among adults with newly diagnosed low back and lower extremity pain. Kim LH, Vail D, Azad TD, et al. JAMA Netw Open. 2019;2:0.
- Real-world incidence and prevalence of low back pain using routinely collected data. Fatoye F, Gebrye T, Odeyemi I. Rheumatol Int. 2019;39:619–626.
- Cost-effectiveness of guideline-endorsed treatments for low back pain: a systematic review. Lin CW, Haas M, Maher CG, Machado LA, van Tulder MW. Eur Spine J. 2011;20:1024–1038.
- Prevalence of low back pain, seeking medical care, and lost time due to low back pain among manual material handling workers in the United States. Ferguson SA, Merryweather A, Thiese MS, Hegmann KT, Lu ML, Kapellusch JM, Marras WS. . BMC Musculoskelet Disord. 2019;20:243.
- Low back pain. Deyo RA, Weinstein JN. . N Engl J Med. 2001;344:363–370.
- Inclusion and exclusion criteria used in non-specific low back pain trials: a review of randomised controlled trials published between 2006 and 2012. Amundsen PA, Evans DW, Rajendran D, et al. BMC Musculoskelet Disord. 2018;19:113.
- Significance of the association between disc degeneration changes on imaging and low back pain: a review article. Rahyussalim AJ, Zufar ML, Kurniawati T. . Asian Spine J. 2020;14:245–257.
- Diagnostic evaluation of low back pain with emphasis on imaging. Jarvik JG, Deyo RA. Ann Intern Med. 2002;137:586–597.
- No association between MRI changes in the lumbar spine and intensity of pain, quality of life, depressive and anxiety symptoms in patients with low back pain. Babińska A, Wawrzynek W, Czech E, Skupiński J, Szczygieł J, Łabuz-Roszak B. . Neurol Neurochir Pol. 2019;53:74–82.
- Intertester reliability for selected clinical tests of the sacroiliac joint. Potter NA, Rothstein JM. . Phys Ther. 1985;65:1671–1675.
- Diagnostic validity of criteria for sacroiliac joint pain: a systematic review. Szadek KM, van der Wurff P, van Tulder MW, Zuurmond WW, Perez RS. J Pain. 2009;10:354–368.
- PEER systematic review of randomized controlled trials: management of chronic low back pain in primary care. Kolber MR, Ton J, Thomas B, et al. Can Fam Physician. 2021;67:0–30.
- Anticonvulsants in the treatment of low back pain and lumbar radicular pain: a systematic review and meta-analysis. Enke O, New HA, New CH, et al. CMAJ. 2018;190:0–93.
- Efficacy and safety of antidepressants for the treatment of back pain and osteoarthritis: systematic review and meta-analysis. Ferreira GE, McLachlan AJ, Lin CC, Zadro JR, Abdel-Shaheed C, O'Keeffe M, Maher CG. BMJ. 2021;372:0.
- Effect of pelvic compression on the stability of pelvis and relief of sacroiliac joint pain in women: A case series. Shadmehr A, Jafarian Z, Tavakol K, Talebian S. J Musculoskelet Pain. 2013;21:31–36.
- The mechanical effect of a pelvic belt in patients with pregnancy-related pelvic pain. Mens JM, Damen L, Snijders CJ, Stam HJ. Clin Biomech (Bristol, Avon) 2006;21:122–127.
- Pelvic belt effects on health outcomes and functional parameters of patients with sacroiliac joint pain. Hammer N, Möbius R, Schleifenbaum S, et al. PLoS One. 2015;10:0.
- Four clinical tests of sacroiliac joint dysfunction: the association of test results with innominate torsion among patients with and without low back pain. Levangie PK. Phys Ther. 1999;79:1043–1057.
- Mechanical diagnosis and therapy approach to assessment and treatment of derangement of the sacro-iliac joint. Horton SJ, Franz A. Man Ther. 2007;12:126–132.
- Insufficient lumbopelvic stability: a clinical, anatomical and biomechanical approach to 'a-specific' low back pain. Pool-Goudzwaard AL, Vleeming A, Stoeckart R, Snijders CJ, Mens JM. Man Ther. 1998;3:12–20.
- Sacroiliac joint hypermobility biomechanics and what it means for health care providers and patients. Enix DE, Mayer JM. PM R. 2019;11 Suppl 1:0–9.
- Different minimally important clinical difference (MCID) scores lead to different clinical prediction rules for the Oswestry disability index for the same sample of patients. Schwind J, Learman K, O'Halloran B, Showalter C, Cook C. J Man Manip Ther. 2013;21:71–78.
- Minimum clinically important differences in Oswestry disability index domains and their impact on adult spinal deformity surgery. Yoshida G, Hasegawa T, Yamato Y, et al. Asian Spine J. 2019;13:35–44.
- The clinical importance of changes in outcome scores after treatment for chronic low back pain. Hägg O, Fritzell P, Nordwall A. Eur Spine J. 2003;12:12–20.
- Cognitive and mind-body therapies for chronic low back pain and neck pain: effectiveness and value. Cherkin DC, Herman PM. JAMA Intern Med. 2018;178:556–557.
- Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK. Ann Intern Med. 2007;147:478–491.
- Low back pain: a call for action. Buchbinder R, van Tulder M, Öberg B, Costa LM, Woolf A, Schoene M, Croft P. Lancet. 2018;391:2384–2388.
- Skelly AC, Chou R, Dettori JR, et al. AHRQ Comparative Effectiveness Reviews. Vol. 556229. Rockville: Agency for Healthcare Research and Quality; 2020. Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Update. Rockville (MD): Agency for Healthcare Research and Quality (US)
Source: PubMed