|Year : 2018 | Volume
| Issue : 2 | Page : 42-50
Effectiveness of acupuncture and manipulation in the management of individuals with sacroiliac joint disorders based on clinical prediction rules
Ganiyu Sokunbi1, Fatima Gujba2, Bashir Bello1, Maryam Abdullahi3, Olajide Olowe3
1 Department of Physiotherapy, Bayero University Kano, Kano, Nigeria
2 Department of Medical Rehabilitation, University of Maiduguri, Borno, Nigeria
3 Department of Physiotherapy, Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Web Publication||25-Feb-2019|
Prof. Ganiyu Sokunbi
Department Physiotherapy, Bayero University Kano, Kano
Source of Support: None, Conflict of Interest: None
Background: Despite being identified as a serious health concern, effective means of managing chronic LBP with SIJ disorders based on sound evidence still remains controversial. Aims: The purpose of this study is to compare the effects of combined treatment (acupuncture, manipulative therapy, AMG) with manipulative therapy (MTG) and standard physiotherapy (STG) alone based on Flyn et al.'s clinical prediction rule (CPR). Methods: Eighty-one participants with disorders of lower back pain and Sacroiliac joint (SIJ) were randomised into the 3 treatment groups. Outcome measures of pain intensity, functional disability and quality of life were carried out at baseline, after 6 weeks of treatment and at 3-month follow up. Participants were treated according to the treatment in the group to which they are randomised. Results: Participants in the AMG showed grater improvement than the others after six weeks of treatment. Paired t – test showed significant difference (t = 3.142, P = 0.004) in the mean percentage improvement between those who met the CPR (64.39 (13.0)) and those who did not (49.44 (7.89)). In the AMG, 21 (77.8%) participants recorded treatment success while 6 (22.2%) recorded treatment failure. One of the hip having more than 350 of internal rotation showed significant predictive value in association with treatment success (Wald test score = 37.887, P = 0.035 with an odd ratio value of 0.857). Conclusion: A combined treatment consisting of acupuncture, manipulative therapy and exercises will offer greater benefits to patients with lower back pain and SIJ disorders. The presence of at least 35 degrees of internal rotation in one of the hip joint is predictive factor of treatment success with manipulative therapy and acupuncture in patient with lower back and SIJ disorders.
Keywords: Acupuncture, clinical prediction rules, physiotherapy, sacroiliac joint
|How to cite this article:|
Sokunbi G, Gujba F, Bello B, Abdullahi M, Olowe O. Effectiveness of acupuncture and manipulation in the management of individuals with sacroiliac joint disorders based on clinical prediction rules. Niger J Exp Clin Biosci 2018;6:42-50
|How to cite this URL:|
Sokunbi G, Gujba F, Bello B, Abdullahi M, Olowe O. Effectiveness of acupuncture and manipulation in the management of individuals with sacroiliac joint disorders based on clinical prediction rules. Niger J Exp Clin Biosci [serial online] 2018 [cited 2021 Feb 28];6:42-50. Available from: https://www.njecbonline.org/text.asp?2018/6/2/42/252842
| Introduction|| |
The sacroiliac joint (SIJ) is estimated to cause between 15% and 30% of cases of low back pain (LBP). The majority of prevalence studies have used intra-articular anesthetic blocks to establish the diagnosis of SIJ pain. Thus, the true prevalence may well be higher than the above estimates since extra-articular causes of SIJ pain would not be expected to result in a positive intra-articular anesthetic block. The impact of SIJ disorders in isolation in terms of its direct and indirect costs appeared not to have been well reported, but its impact on the economic front and work disability impact could be assumed to be on the same scale as LBP. In response to the huge cost and other consequences associated with SIJ disorders, there are many noninvasive treatment options, including physiotherapy for SIJ-mediated pain.
Acupuncture, manipulation, and exercises have been suggested as the treatment of choice for patients with one-sided SIJ pain, one-sided SIJ pain combined with symphysis pubis pain, and double-sided SIJ pain.,, A combination of acupuncture and physiotherapy have also been shown to be more effective than education in resolving SIJ pain. Currently, it appears that vast evidence in the form of empirical research and/or systematic reviews to support the best form of noninvasive treatment for SIJ disorders is still lacking, it is also not certain whether a combination of treatment modalities will or will not be better than a single-modality treatment. It seemed that the current approaches to treatment are based on the opinions of individual experts. Information is lacking on what homogeneous subgroup of patients among those with SIJ disorders will benefit optimally from a specific noninvasive intervention or combination of interventions.
The main purpose of this study was to evaluate the effectiveness of combined treatment protocol, comprising of acupuncture, SIJ manipulation, and standard treatment over SIJ manipulation and standard treatment, each as stand-alone treatment interventions. We also aimed to investigate whether patients with SIJ disorders who met the clinical prediction rules (CPRs) developed in identifying individual patients with lower back pain who are likely to benefits from manipulation by Flynn et al. will have a better treatment outcome than those who did not follow treatment with acupuncture manipulative therapy and standard physiotherapy. Thus, for this study, we hypothesize that patients with SIJ disorders who will undergo combined treatment protocol (acupuncture, manipulation, and standard treatment) will not differ significantly from those who will undergo spinal manipulation and standard treatment, and those who will undergo standard treatment alone in term of reduction in pain intensity and functional disability and improvement with quality of life. The second hypothesis is that patients who met the CPRs developed by Flynn et al. will not record significantly more improvement than those who did not meet the CPR after 6 weeks of treatment with combined treatment protocol (acupuncture, manipulation, and standard treatment). The third hypothesis is that none of the variables in Flynn et al.'s CPR will be able to significantly predict treatment success among participants who underwent a combination of acupuncture, manipulation, and standard treatment.
CPRs are a clinical diagnostic and classification tool that quantifies the individual contributions that various components of the history, physical examination, and basic laboratory results make toward the diagnosis, prognosis, or likely response to treatment in an individual patient. In this study, we used the CPRs developed by Flynn et al. The developed CPR contains five variables: symptom duration of <16 days (pain chronicity), at least one hip with more than 35° of internal rotation (hip internal rotation asymmetry), lumbar hypomobility, no symptoms distal to the knee (no radiculopathy), and a Fear-Avoidance Beliefs Questionnaire work subscale score of <19 points. CPR is met if at least four of the five components are met.
| Methods|| |
This study was conducted as a two-stage randomized clinical trial in which the first stage of the study determines if acupuncture and manipulative therapy group (AMG) was more efficient in reducing pain and functional disability and improving quality of life individuals with SIJ disorders than either Sacroiliac joint manipulation group (SMG) or standard physiotherapy treatment group (STG). During this stage, participants were assigned to any of the three treatments and were evaluated based on their improvement before treatment, after 6 weeks of treatment, and at 3 months' follow-up. The second stage of the study consisted of evaluation of patients in the AMG. These patients were categorized depending on whether they meet or did not meet at least four of the five CPRs described by Flynn et al. This was followed by further analysis determined if patients who satisfied at least four of the five CPRs had a better outcome than those who did not satisfy the criteria.
Recruitment and sample size estimation
Convenient samples of patients with chronic LBP and SIJ disorders attending the Orthopedic and Medical Outpatient clinics of the University of Maiduguri Teaching Hospital and the State Specialist Hospital in Maiduguri, Borno State, Nigeria. The study took place between January 2014 and September 2015. The Verbal Pain Rating Scale (VPRS) scores were used as the primary outcome of the study. Based on a previous study, on the use of acupuncture and manipulation in individuals with SIJ with a mean change in pain intensity of 7.0 and standard deviation of approximately 0.6 points after 6 weeks of treatment, considering a significance level of 5% and a statistical power of 80%, a minimum of 72 patients were considered for recruitment, with 24 participants in each of the three groups. A 10% dropout rate was considered; thus, the sample size was increased to 81 participants, 27 per group.
The main inclusion criteria were patients with nonspecific LBP with SIJ disorders of mechanical origin of at least 3-month duration and aged 18–65 years with three or more positive SIJ provocation tests. Three or more positive provocation SIJ tests have been reported to have a modest predictive power in relation to controlled comparative SIJ blocks in confirming the presence of SIJ dysfunction. To ensure the presence of SIJ dysfunction, an independent physiotherapist with over 15 years of experience of physiotherapy assessment and management of lower back and SIJ disorders assessed patients. The assessments included a detailed standardized physical examination and collection of baseline data. SIJ provocation tests were carried out as described by Ostgaard, Zetherstrom, and Roos-Hansson; these tests consist of SIJ anteromedial and posterolateral provocative tests, standing forward flexion test, Patrick's FABER test, a modified Trendelenburg's test, Lasegue test, and lumbosacral compression test. Patients on medication (drug treatment) were included if the medication has not made any significant impact on the pain and there had been no change in medicine and its dosage for 1 month or longer. The participants were asked not to undergo additional treatments for SIJ dysfunction during the intervention period.
We excluded patients with other pain conditions and systemic disorders such as cancer, tuberculosis, tumor, and other serious spinal pathological conditions. Patients with contraindications to either manipulation and/or acupuncture treatment were also excluded from the study.
Approval to carry out this study was obtained from the Research and Ethics Committee of the University of Maiduguri Teaching Hospital, Maiduguri, Nigeria. Detailed information on what the study was about, its potential benefits and possible side effects, and what would be expected of the participants during the study was provided on a participant information sheet, which was made available to the participants before the intervention. Participants were required to sign a written informed consent, and they were given enough time to consult with their doctors to decide if they would be suitable for this trial.
A computer-generated table was used to determine the allocation sequence before the study. Groups were coded, and the allocation was transferred to a series of presealed opaque envelopes as previously described. The randomization of the patients into groups, i.e., spinal manipulative group (SMG), acupuncture and manipulative therapy group (AMG), and standard physiotherapy treatment group (STG) was carried out after doing the baseline assessment of weight, height, and determination of body mass index (BMI).
The primary outcome measure for this study was VPRS while Rolland Morris Disability Questionnaire (RMDQ) and SF-36 were used as the secondary outcome measure. VPRS was used to measure pain intensity. VPRS is an acceptable tool with high test–retest reliability observed in both literate and illiterate patients with rheumatoid arthritis (r = 0.96 and 0.95, respectively) before and after medication. It has high construct validity, as it demonstrates high correlation with the Visual Analog Scale in patients with rheumatoid and other chronic conditions. Correlation ranges from 0.86 to 0.95. RMDQ was used to measure disability due to pain. A correlation coefficient of 0.72 with interclass correlation coefficient ranging from 0.42 to 0.53 has been reported for the use of RMDQ. The VPRS and RMDQ scores were measured immediately before the first treatment, at the end of the 6 weeks of treatment, and at 3 months' follow-up. The SF-36 was used to assess the patients' health-related quality of life (HRQOL). It consists of eight measurement scales, including physical functioning (10 items), role limitation due to physical functioning (4 items), bodily pain (2 items), general health (5 items), vitality (4 items), social functioning (2 items), role limitation due to emotional functioning (3 items), and mental health (5 items). The SF-12 is a psychometrically sound instrument for measuring HRQOL. The SF-12 has good internal consistency and test–retest reliability. Numerous studies have demonstrated that the SF-12 is reliable, exceeding the recommended Cronbach's alpha level of 0.70.
For the present study, improvement was defined as the reduction in pain intensity and functional disability scores as well as increase in the quality of life scores based on the analysis of VPRS, RMDQ, and SF36 Questionnaire scores. Percentage improvement was calculated based on the analysis of primary outcome measure for this study, i.e., VPRS scores, as (VPRS6 weeks− VPRSbaseline)/VPRSbaseline× 100%. Treatment success was defined as a percentage of improvement ≥50%, and treatment failure was defined as a percentage of improvement <50%.
Standard treatment group
Participants assigned to standard treatment group received treatments, including advice on lifting and back care as described, stabilization exercises, back strengthening, and flexibility exercises. The sequence of treatment was randomly decided using piece of papers concealed in an opaque envelope.
Sacroiliac joint manipulation group (SMG)
Participants in this group underwent both SIJ and manipulation in addition to receiving the same intervention as those in the STG.
Sacroiliac joint manipulation
SIJ manipulative technique specifically meant to target the SIJ rather than lumbopelvic area was used in this study. The patient assumed supine lying position. The therapist stands in the opposite side to be manipulated. The side to be manipulated was selected using the following criteria: first, the side of tenderness during sacroiliac and/or lumbar palpation, the side reported by the patient to be more painful during SIJ provocative test which also showed hypomobility during standing forward flexion test. The legs of the patient were moved away from the therapist side. The hands of the patient were behind his head in a crisscross fashion. The trunk of the patient was moved away from the therapist. The trunk of the patient was slowly and passively rotated toward the therapist's side and a quick posterior-inferior thrust was delivered to the anterior superior iliac spine [Figure 1]. The therapist noted if a cavitation (audible pop) was felt during the maneuver. If a cavitation was not felt, but patient's symptoms were not aggravated by the thrust, the patient was repositioned and the manipulation repeated a second time in the same side, and the third time in the same manner, if cavitation was heard after a thrust is delivered, the therapist will wait for a refractory period of 20 min before carrying out the next thrust.
Acupuncture and sacroiliac joint manipulation group
Participants in this group underwent both acupuncture SIJ and manipulation as described above in addition to receiving the same intervention as those in the STG as described above. The order of treatment was randomly determined by asking the participants to pick from an opaque paper envelope which contains strip of papers, on which the order of treatment to be carried out was indicated.
The patients were properly instructed on what to expect in terms of the acupuncture treatment and the possible side effects of acupuncture treatment. Each patient was positioned in a prone position, lying with proper pillow support under the abdomen, ankle joints, head and neck, and behind the knee joints for comfort. Acupuncture was given at selected acupuncture points for 20 min on the SIJ area using the widely accepted for treating SIJ dysfunction (6), namely, bladder (BL) 40, BL 60, BL 67, and liver 4. The procedure for acupuncture treatment, including needle stimulation was as described by Sokunbi and Kachalla.
Blinding of physiotherapist providing the intervention and patients to the different intervention received was unfeasible by the nature of this study. However, physiotherapist performing evaluation with the outcome measures was blinded to the patients' assigned treatment and the therapist providing the intervention was blinded to pretreatment assessment scores.
Frequencies and percentages were used to summarize categorical variables while means and standard deviation were calculated to summarize the data continuous variables. An intention-to-treat analysis was utilized, wherein all participants were analyzed in the group to which they were originally assigned regardless of whether or not they drop out or were lost to follow-up. A two-way repeated between-within analysis of variance was used to determine if the combined treatment was more efficient than the standard treatment in terms of reduction of pain and disability and improvement in the quality of life. Paired t- test was used to compare the level of improvement between those patients who met the CPR and those who did not among those who underwent the combined treatment. Logistic regression analysis was used to analyze the association between the variables in the CPR with treatment success among participants who underwent the combined treatment. Statistical analysis was done with SPSS for window, version 12 (Ligare, Sydney), and the level of statistical significance was set at 0.05.
| Results|| |
A total of 95 participants enrolled to participate in the study and screened, 81 participants who met the inclusion criteria were randomized into STG, SMG, and acupuncture and manual therapy (AMT). Four (14.81%) of the participants in the STG group due to relocation, 5 (18.5%) in the SMG due to relocation, and 3 (11.1%) in the AMG were lost without any stated reason at 3-month follow-up stage of data collection [Figure 2]. [Table 1] shows the demographic characteristics of the participants. The proportion of female participants ranged from 21 (77.78%) to 23 (85.19%) per group. Age, gender, BMI, and duration of pain did not differ significantly among the groups (P > 0.05) [Table 1]. The means and standard deviations for pain, functional disability, and quality of life at baseline, 6-week, and 3-month posttreatment follow-up are summarized in [Table 2]. Participants who underwent combined treatment, AMT group showed greater improvement than the spinal manipulative (SMG) and standard treatment (STG) in terms of reduction in the pain intensity and functional disability along with improvement in the quality of life [Table 2]. [Table 3] shows the results repeated measures between-within ANsOVA. [Figure 3] shows the mean percentage improvement of participants in the AMG group based on CPR status. Nineteen (70.3%) of the participants met all the variables of Flynn et al.'s CPR and recorded 64.39 (13.0) mean (SD) percentage improvements with pain reduction while 8 (22.7%) participants who did not meet the CPR status recorded a mean average improvement scores of 49.44 (7.89) with pain reduction. Paired t-test showed significant difference in the mean percentage improvement between those who met the CPR and those who did not met CPR rules (t = 3.142. P = 0.004). The second hypothesis was rejected. [Figure 4] shows the logistic regression model profiles. A significant effect for time in the reduction on pain intensity and functional disability as well as improvement in the quality of life (P < 0.0005) was observed. The partial η·2 values for group were high for pain intensity and functional disability and moderate for the quality of life [Table 3]. The interaction effects (time × group) for reduction in pain intensity and functional disability as well as improvement in the quality of life were not statistically significant (P > 0.05) [Table 3]. Thus, our first hypothesis was rejected.
|Table 2: Pain intensity, functional disability, and quality of life of participants at baseline, 6 weeks, and 3 months' posttreatment|
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|Table 3: Interaction effect, main effect, and effect size of intervention on pain intensity, functional disability, and quality of life|
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|Figure 3: Percentage improvement of participants in the AMG treatment group based on CPR status. *Significant. CPR: Clinical prediction rules, AMG: Acupuncture and manual therapy group|
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[Figure 3] shows the mean percentage improvement of participants in the AMG group based on CPR status. Nineteen (70.3%) of the participants met all the variables of Flynn et al.'s CPR and recorded 64.39 (13.0) mean (SD) percentage improvements with pain reduction while 8 (22.7%) participants who did not meet the CPR status recorded a mean average improvement scores of 49.44 (7.89) with pain reduction. Paired t-test showed significant difference in the mean percentage improvement between those who met the CPR and those who did not met CPR rules (t = 3.142. P = 0.004). The second hypothesis was rejected.
[Table 4] shows the outcome in terms of treatment success and treatment failure of participants in the combined treatment (AMG) group. Out of the 27 participants in the AMG, 21 (77.8%) recorded treatment success while 6 (22.2%) recorded treatment failure. All the participants who recorded treatment success, 21 (100%) had SIJ hypomobility and no pain distal to the knee joint components of the Flynn et al.'s CPR [Table 4].
|Table 4: Treatment outcome based on clinical prediction rules of the participants in the AMT treatment group|
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[Table 5] and [Figure 3] present the results of the logistic regression analysis. [Figure 3] shows that between 51.2% and 81.4% of the improvement with treatment success is explained by the variables in Flynn et al.'s CPR (Cox and Snell R2 = 0.512, Nagelkerke R2 = 0.814). The sensitivity and specificity of the regression model used in this analysis was 90.9 and 80.0, respectively. The positive predictive value was 91.5 while the negative predictive value was 66.6 [Figure 3]. The only variable of all the CPR variables tested that contributed significantly to the predictive ability of success with combined treatment (SMG) was “at least one of the hip having more than 35° of internal rotation” (Wald test score = 37.887, P = 0.035 with an odds ratio value of 0.857). The third hypothesis was rejected.
|Table 5: Association between clinical prediction rules variables and treatment success of the participants in AMT group|
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| Discussion|| |
The purpose of this study was to compare the efficacy of combined treatment (acupuncture, manual therapy, and physiotherapy standard treatment) with manual therapy (including standard physiotherapy treatment) and standard physiotherapy treatment alone on pain intensity, functional disability, and quality of life of participants with SIJ disorders. Despite the fact that LBP with SIJ disorders could be a multifactor biopsychosocial problem, the baseline characteristics of the participants in all the groups were similar. This indicates that none of the group was placed in a position of comparative advantage or otherwise over the others before the intervention.
There are many reported studies on manual therapy and exercises with or without acupuncture have been largely focused on patients with lower back pain. However, the clinical presentation and the approach to the management of LBP could differ if a patient is presented with coexisting disorders of back pain and SIJ. Thus, there is a need to find out what will be the best treatment applicable either in single or in combination if a lower back pain patient is presented with accompanying SIJ disorders.
The findings from this study have shown that combined treatment of spinal manipulation, acupuncture, and exercise could potentially offer greater improvement than a single-modal treatment for a patient with lower back pain and SIJ disorders. It is also important to note that reduction in pain intensity and functional disability as well as improvement in the quality of life was recorded by patients in the other groups; however, the statistically significant greater improvement in the combined treatment group was of clinical importance. First, the combined treatment protocol in the present study encompasses acupuncture, spinal manipulative, and physiotherapy standard treatment in the form of mobilization and exercises. Similar studies, in which, exercises and acupuncture have been shown to be effective in reducing pain, and functions in patients with SIJ disorders have been reported;,, however, only one of these three studies where manipulative therapy was carried out as one of the interventions demonstrated improvement at 3-month follow-up. Thus, it could be that the addition of spinal manipulative therapy along with acupuncture and standard treatment in the present study has impacted positively on the long-term effect of treatment in this group. Spinal manipulation has been said to be associated with the release of endorphins altered reflexogenic responses and improved soft-tissue mobility, which in turn could have contributed to greater improvement in the combined treatment group from 6 weeks of treatment until the end of follow-up. Restoration of normal SIJ alignment with consequent reduction in pain and function could also be said to be one of the potential benefits of manipulation, this assertion still remains contentious going by the findings of a study carried out by Tullberg, et al., in which no alteration in the position of the SIJ following manipulation of the SIJ joint was reported.
The findings from this study further corroborate a previous study where it was opined that positive reinforcement occurs when acupuncture, core stability exercises, and manual therapy are combined, leading to better pain reduction and improvement in function. Studies have shown that, in the short term, acupuncture has a positive effect on relief from pain, but when compared to conventional or alternative therapies, it was found not to be any more effective in reducing pain., However, when acupuncture is applied in conjunction with conventional therapies, greater improvement might be seen. Based on our findings, it could be said that if management strategies are going to be effective it is important too, where possible used a combined treatment approach that will not only address the problem of SIJ pain but also mobility and stability of the SIJ and lower spinal segment.
Physiotherapists have been largely involved in the management of disorders of the lower back and SIJ for many years. Yet, there is a lack of evidence of the most type of interventions and many of the therapists rely on the opinions of experts that are devoid of concrete empirical evidence. It is also not very clear at the moment whether homogeneous group of patients with SIJ disorders and/or lower back pain with SIJ disorders will benefit from a particular physiotherapy modality or a combination of modalities. Furthermore, there is a shortage of cost-effectiveness data for treatment of LBP with SIJ disorder. Therefore, despite being identified as a serious health concern, effective means of managing chronic LBP with SIJ disorders based on sound evidence still remains controversial. One of the tools in current use to quantify the individual contributions that various components patient's clinical features relevant investigations could make toward the diagnosis, prognosis, or likely response to treatment in an individual patient is CPR.
The present study showed that patients with LBP and SIJ disorders, who were treated with the combined treatment protocol, that met the CPR developed by Flynn et al. had better improvement than those who did not meet the CPR. Thus, it could be said that CPR designed by Flynn et al. for the use of manipulation for patients with lower back pain could also be applied to delineate patients with SIJ disorders that will respond positively not only to manipulative therapy but also to a combination of treatments, including manual therapy, exercises, and acupuncture, which is more of a reflection of the scenario of treatment in a typical physiotherapy clinic. Interestingly, none of the participants who recorded treatment success, in the combined treatment in the present study reported pain radiating below their knee joint and they all showed positive signs of lumbosacral hypomobility on the same side of SIJ disorders. Our findings also showed that having at least one of the hip joints recording at least 35° of internal rotation is predictive of treatment success with the combined treatment protocol. However, clinical diagnosis of SIJ from subjective and objective assessments as well as physical tests has not been without challenges. The physical testing procedures such as those who attempt to quantify hyper- or hypomobility are lacking reliability and validity., Tests involving palpation and visual observation are equally unreliable. Few studies have shown some evidence for validity of some of the SIJ diagnostic physical testing procedures., However, as they are compared to the results of a SIJ intra-articular injection, that are potentially only recording the incidence of intra-articular pain. The extra-articular SIJ ligaments are also a potential source of pain and may also be stressed by these mechanical tests.
Personal perception bias and recall bias from the use of self-report outcome measures in this study are some of the limitations of the study. However, considering the biopsychosocial nature of pain, it is very important to rate the amount and impact of treatment on pain and associated discomfort from the point of view of the patients. Future study might employ a mixed method approach encompassing qualitative interview and quantitative and other researcher developed outcome measures. Adhering strictly to the exclusion criteria has reduced the number of potential participants who indicated willingness to participate in this study while some participants were also lost during the 6-week treatment and to follow-up after the treatment. The future study with more participants than in the present study will potentially limit the possibility of type-2 error during statistical analysis.
| Conclusion|| |
A combined treatment modality approach of physiotherapy management consisting of acupuncture, manipulative therapy, and exercises will offer greater benefits to the patients with lower back pain and SIJ disorders than using each of the modalities in isolation. CPR developed by Flynn et al. for the use of manipulation on patient with lower back pain could also be useful to delineate patients with SIJ disorders and or/with lower back pain who are likely to record treatment success with manipulation acupuncture and standard physiotherapy treatment. Furthermore, the presence of at least 35° of internal rotation in one of the hip joints (at the same side of the SIJ disorders) is a predictive factor of treatment success in patients with lower back and SIJ disorders.
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Conflicts of interest
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]