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Abstract
The sacroiliac joint (SIJ) is an important connection between the spine and pelvis. The shape and contour of the joint changes with life, i.e. it changes from flat shape to angular with the passage of time. SIJ is commonly involved in the painful conditions of pelvis and lower back. It can also result in transient numbness or tingling sensations and/or elevated level of urinary frequency. The complex anatomy and biomechanics of SIJ have an important role in the development of the low back pain and other symptoms, and they are also involved in making it difficult to diagnose and treat the problem. Therapeutic strategies for the problem include conservation management including activity modification, physical therapy, manipulation, and medication, and interventional management including injections, radiofrequency procedures, and surgery. Exercise treatment is considered as the most widely prescribed therapeutic strategy for the treatment of pain. Interferential current therapy is also effective as compared to many other therapeutic strategies. This paper deals with SIJ dysfunction, its signs and symptoms, and various therapeutic strategies, and points for future studies.
The sacroiliac joint (SIJ) refers to the joining place for the sacrum, which is located at the base of the spine, and the iliac bones, which are the large bones making up the pelvis to support the lower limbs in humans. Therefore, the joint can be considered as an important connection between the spine and pelvis. At the SIJ, there is very little movement as compared to many other parts and joints of the body. SIJ is commonly involved in the painful conditions of pelvis and lower back. Actually, the complex anatomy and biomechanics of SIJ have an important role in the development of the low back pain (Soisson et al., 2015), and they are also involved in making it difficult to diagnose and treat the problem (Hamidi-Ravari, Tafazoli, Chen, & Perret, 2014).
Anatomy and biomechanics of SIJ
SIJ is made up of articular surfaces joining the sacral bones and iliac bones, and several muscles and ligaments are also involved in the joint. The sacral surface in the joint has hyaline cartilage, whereas the ilial surface has fibrocartilage. It is also important to know that the true synovial joint is only the anterior third of the sacroilial interface, whereas the rest of joint has ligamentous connections. The shape and contour of the joint changes with life, i.e. it changes from flat shape to angular with the passage of time. In the body, the joint is the largest axial joint, i.e. on average it is about 17.5cm2 (Hamidi-Ravari et al., 2014).
This joint is primarily involved in the stability of the body parts related to the joint. Several mechanisms are found to be involved in the maintenance of stability. For example, ridge on the ilial surface along with depression on the sacral surface helps in decreasing the movement, thereby enhancing stability. Involvement of muscles and ligaments in the joint are of key importance in maintaining the stability. For example, the dorsal interosseous ligaments need more force to tear as compared to a pelvic fracture, and posterior SI ligaments prevent SIJ from opening by restricting the level of SI flexion. The structure of the SIJ is such that it is almost six times more resistant to medially directed forces. However, it shows only 1/20 the resistance in axial compression, whereas half the resistance in rotation. The muscles in the surrounding of the SIJ help in providing muscular forces, guiding movement, and enhancing the stability to the pelvic bones. However, the muscles are helpful in very small movements (Hamidi-Ravari et al., 2014). SIJ dysfunction is thought to be caused by the disturbance in these parts of the joints.
Signs and symptoms of SIJ dysfunction
SIJ dysfunction has an inconsistent presentation, and the pain can be localized or referred. Usually, the pain is present in the lower back, leg, buttocks, hip, and groin areas. The severity of pain may also change from achy and dull to stabbing and sharp. Pain can be aggravated by physical activity, bending, unspecified sustained positions, climbing, and sexual intercourse. Due to the involvement of muscles in the joint, spasms can also be found in patients. Tightness of the hamstrings, hip flexors, and quadriceps are among the common presentations of the muscle problems. Some patients may also report the symptoms of transient numbness or tingling and/or elevated level of urinary frequency (Hamidi-Ravari et al., 2014).
Diagnosis of SIJ dysfunction
The SIJ pain has a prevalence of about 75%. However, it is difficult to identify the involvement of SIJ in the low back pain. Physical examinations, history of the patients, and imaging studies have low sensitivity and specificity to diagnose SIJ dysfunction (Hamidi-Ravari et al., 2014). Some pain provocation tests have been designed to recognize the SIJ as the main source of pain, but most of them have poor reliability. In this case, injection of local anesthetics into the SIJ cavity is considered as the gold standard to confirm the diagnosis. These injections can also help in giving a temporary relief from pain (Soisson et al., 2015).
Therapeutic strategies
Primary purpose of the treatment of SIJ dysfunction is to reduce the pain and disability. The international association for the study of pain (IASP) recommended the conservative management of SIJ pain (Soisson et al., 2015). Conservation management may include activity modification, physical therapy, manipulation, and medication. On the other hand, interventional management may include injections, radiofrequency procedures, and surgery (Hamidi-Ravari et al., 2014).
Exercise treatment is considered as the most widely prescribed therapeutic strategy for the treatment of pain. This treatment is consisted of activity modification and physical therapy. Activity modification may include increase in mobility, strengthening and stretching the body parts, and rectifying any hyperactivity of muscle groups. However, patients have to identify the activities that would not aggravate the problem of pain as, for example, running or skating may aggravate the pain. With activity modification, a recovery phase can be reached after which the patient may start maximizing the functioning of the body parts by the use of therapeutic exercises as well as physical therapy (Hamidi-Ravari et al., 2014).
Physical therapy usually works on the abdomino–lumbo–sacro–pelvic–hip complex. With the help of physical therapy, pelvic floor muscles are strengthened, stretched, and stabilized. It is also helpful in correcting gait problems and considering dynamic and postural muscle imbalances. Strengthening of muscle imbalance can facilitate in increasing the shearing forces in one SIJ. In a study, researchers worked on five patients of SIJ dysfunction with hyperactivity of the muscles including latissimus dorsi and gluteus muscle. Researchers found that therapeutic exercise program helped in improving the strength and normal electrical activity of muscles in those patients (Hamidi-Ravari et al., 2014).
Interferential current therapy, a type of conservation management, is a treatment modality utilizing two alternating current signals having different frequencies that can develop “interference” at the intersection of the two sinusoidal waveforms. This therapeutic modality is used in treating the neurologic as well as musculoskeletal problems, and sometimes in the management of urinary incontinence. However, this therapeutic modality must not be used near implanted stimulators, or open incisions or any kind of abrasions (Wyss & Patel, 2012).
Studies on the effect of Interferential current therapy on SIJ dysfunction are scarce, but many studies are showing the efficacy of Interferential current therapy in chronic low back pain. In a study, researchers performed a randomized clinical trial on patients of chronic low back pain. Participants of the study were divided into two groups; one group was treated with interferential current while the other group (control group) was treated with transcutaneous electrical nerve stimulation. They were treated for five consecutive weeks, with two times per week intervention, i.e. overall 10 interventions. After completion of the time for intervention, researchers evaluated the pain of the participants of the groups. They found that the pain was significantly reduced in both groups, thereby showing that interferential current is helpful in treating the chronic low back pain, and that treatment was of equal significance to that of transcutaneous currents (Dohnert, Bauer, & Pavão, 2015).
In another randomized controlled trial, researchers compared the efficacy of transregional interferential current therapy with “usual care” treatment including mobilization, massage, and soft-tissue techniques. Participants of the two groups received 10 treatment sessions over a two-week time. The treatment sessions were 25 minutes long. After completion of the intervention, researchers evaluated the pain perception of the participants, and found significant short-term efficacy as compared to the “usual care” treatment. Participants of the interferential current therapy also reported improved functionality as compared to the other group (Albornoz-Cabello, Maya-Martín, Domínguez-Maldonado, Espejo-Antúnez, & Heredia-Rizo, 2016). However, further studies are required to know the effect of interferential current on SIJ dysfunction and other symptoms of the problem such as urinary frequency, transient numbness, and tightness of muscles.
Reports show that there is a 300% increase in the SIJ related intervention rates, and surgical interventions found the highest rate of increase. However, surgical interventions have reduced beneficial effects, and they are also expensive and have higher rates of complication as compared to non-surgical interventions. On the other hand, pelvic belts are considered as cost-effective, non-surgical therapeutic strategy for SIJ pain. Pelvic belts are also thought to be of help in improving neuromotor performance as well as form and force closure. However, further studies are required in knowing the efficacy of pelvic belts in SIJ mobility and their effects on pelvis (Soisson et al., 2015). Studies can also be performed on the combination of different therapeutic strategies in the treatment of SIJ dysfunction.
References
Albornoz-Cabello, M., Maya-Martín, J., Domínguez-Maldonado, G., Espejo-Antúnez, L., & Heredia-Rizo, A. M. (2016). Effect of interferential current therapy on pain perception and disability level in subjects with chronic low back pain: A randomized controlled trial. Clinical rehabilitation, 0269215516639653.
Dohnert, M. B., Bauer, J. P., & Pavão, T. S. (2015). Study of the effectiveness of interferential current as compared to transcutaneous electrical nerve stimulation in reducing chronic low back pain. Revista Dor, 16(1), 27-31.
Hamidi-Ravari, B., Tafazoli, S., Chen, H., & Perret, D. (2014). Diagnosis and Current Treatments for Sacroiliac Joint Dysfunction: A Review. Current Physical Medicine and Rehabilitation Reports, 2(1), 48-54.
Soisson, O., Lube, J., Germano, A., Hammer, K.-H., Josten, C., Sichting, F., . . . Hammer, N. (2015). Pelvic belt effects on pelvic morphometry, muscle activity and body balance in patients with sacroiliac joint dysfunction. PLoS One, 10(3), e0116739.
Wyss, J., & Patel, A. (2012). Therapeutic Programs for Musculoskeletal Disorders: Demos Medical Publishing.
