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1988; 68:1359-1363.PHYS THER. KoldehoffMichael T Cibulka,
Anthony Delitto and Rhonda MExperimental StudySacroiliac Joint in
Patients with Low Back Pain: An Changes in Innominate Tilt After
Manipulation of the
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Changes in Innominate Tilt After Manipulation of the Sacroiliac
Joint in Patients with Low Back Pain An Experimental Study MICHAEL
T. CIBULKA, ANTHONY DELITTO, and RHONDA M. KOLDEHOFF
The purposes of this study were to 1) propose a method to detect
sacroiliac joint dysfunction (SIJD), 2) test the interrater
reliability of the method on a group of patients with low back pain
(LBP), and 3) document changes in innominate tilt after
manipulation of the sacroiliac joint. Criteria for SIJD were
established by the authors. Twenty-six patients with unilateral LBP
were examined independently for presence of SIJD by two examiners.
Interrater agreement for presence or absence of SIJD was found to
be excellent (Cohen's Kappa = .88). Twenty of the patients who met
the criteria for SIJD were randomly assigned to an Experimental
Group (n = 10) or a Control Group (n = 10). The left and right
innominate bones of these 20 patients were measured for tilt before
and after the intervention period. The sacroiliac joint of the
patients in the Experimental Group was manip-ulated during the
intervention period, whereas the patients in the Control Group
received no treatment. Data were analyzed using a mixed
three-factor analysis of variance. The data analysis revealed that
the manipulation procedure resulted not only in an altered
innominate tilt of the same side but also in an equal and opposite
tilt of the opposite side (F = 67.07; df = 1,18; p < .05). The
results indicate that SIJD can be identified reliably in patients
with LBP and that a manipulative procedure purported to be specific
to the sacroiliac joint changes innominate tilt bilaterally and in
opposite directions.
Key Words: Backache; Manipulation, orthopedic; Manual therapy;
Sacroiliac joint.
Sacroiliac joint dysfunction (SIJD) has been hypothesized to be
a common cause of low back pain (LBP).1-3 The presence or absence
of SIJD is typically identified by two different palpatory tests,
one that reportedly detects reduced movement and the other that
identifies malalignment between the left and right innominate
bones.4 Accurate detection and subse-quent treatment depend
ultimately on the reliability and validity of the tests used to
identify SIJD.
Individual tests that are commonly used to identify SIJD have
been shown to have questionable reliability.5 Reliability is
necessary for dependability in a measure. Therefore, the
reliability of tests used to detect SIJD must either be improved or
abandoned. Two methods that have helped us improve the reliability
of SIJD tests in our clinic include 1) discussing sources of
disagreements that occur between therapists (eg, training) and 2)
combining the results of four different tests used to confirm or
deny the presence of SIJD. If these methods can improve the
reliability of tests used to detect SIJD, physical therapists may
be able to use these methods to identify patients with SIJD.
Movement tests are used to detect reduced movement of one
sacroiliac joint when compared with the opposite side.4 Palpatory
tests are also used to detect malalignment by iden-tifying
asymmetry between the left and right innominate bones.3(p56) Four
different patterns of malalignment between the innominate bones
have been described: 1) unilateral an-terior tilt of one innominate
bone,6,7 2) unilateral posterior tilt of one innominate bone,6'7 3)
bilateral antagonistic move-ment of the innominate bones (left and
right innominate tilt in opposite directions),3(pl9),8 and 4)
bilateral anterior tilt of the innominate bones.2
Despite the frequent use of movement tests, no study has been
conducted on patients with SIJD to determine whether or how
sacroiliac joint movement is altered by treatment. In addition, no
study has been published using patients to deter-mine the
relationship between the left and right innominate bones in SIJD.
The purposes of this study were to 1) propose a method to evaluate
the presence of SIJD in patients with LBP using a combination of
clinical tests described previ-ously,1,3,4 2) test the interrater
reliability of selected tests for SIJD on patients with LBP, and 3)
document changes in the tilt of the innominate bones in patients
with SIJD after a manipulation procedure commonly used to move the
sacro-iliac joint.
METHOD
The study was conducted in two phases (Fig. 1). Phase 1 involved
the establishment of SIJD in the patient population and the
assessment of the reliability of the method used to
M. Cibulka, MHS, is Physical Therapist, St. Louis Rehabilitation
and Sports Clinic, 400 C Truman Blvd, Crystal City, MO 63019
(USA).
A. Delitto, MHS, is Instructor, Program in Physical Therapy,
Washington University Medical School, and Consulting Physical
Therapist, Irene Walter Johnson Rehabilitation Institute, PO Box
8083, 660 S Euclid Ave, St. Louis, MO 63110.
R. Koldehoff, BS, is Physical Therapist, St. Louis
Rehabilitation and Sports Clinic.
This article was submitted September 22, 1987; was with the
authors for revision eight weeks; and was accepted March 15, 1988.
Potential Conflict of Interest: 4.
Volume 68 / Number 9, September 1988 1359
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establish the presence or absence of SIJD. Only patients with
SIJD were included in Phase 2.
Subjects
Twenty-six patients referred to our clinic for treatment of LBP
of nonspecific origin initially participated in this study.
Criteria for exclusion included pregnancy; diagnosis of anky-losing
spondylitis; and presence of neurological signs such as anesthesia,
absence of deep tendon reflexes, profound muscle weakness, and
straight leg raise of less than 45 degrees. In addition, patients
were excluded if they exhibited signs and symptoms consistent with
symptom magnification as de-scribed by Waddell et al.9 All patients
complained of LBP of sufficient degree to seek medical
intervention. The pain in all patients was localized to the lumbar
area and occasionally to the buttock area. No patient had pain
below the knee.
Phase 1
Establishing sacroiliac joint dysfunction. After receiving
informed consent from all patients, each patient was assessed
independently by two examiners (M.T.C. and R.M.K.) for the presence
or absence of SIJD. We defined SIJD as being present in a patient
if at least three of four tests commonly used to evaluate SIJD were
positive. These tests were the standing flexion test, the prone
knee flexion test, the supine long sitting test, and palpation of
posterior superior iliac spine (PSIS) heights for asymmetry on
sitting.
Measurement of sacroiliac joint dysfunction. The first clin-ical
test used to evaluate the presence or absence of SIJD was the
standing flexion test.1,4 The standing flexion test is de-signed to
detect abnormal movement in the sacroiliac joints. This test was
only used to determine whether a patient had SIJD. In this test,
the patient stood with feet 30.5 cm apart. The examiner's (M.T.C.
or R.M.K.) thumbs were placed on the inferior slope of the PSISs.
The patient was then asked to forward bend slowly and completely. A
positive test existed when one of the PSISs moved cranially more
than the opposite PSIS. The side that moves more cranially is
purported to be the hypomobile side.1,4
The prone knee flexion test was used to assess both abnor-mal
movement and malalignment in SIJD.1,4 The prone knee flexion test
was performed with the patient positioned prone on a treatment
table with the head in the midline position and his shoes on. The
therapist stood at the foot of the table and grasped the patient's
shoes with the thumbs passing over the heels of the shoes. The
shoes were approximated, and the relative lengths of the lower
extremities were compared by inspecting the heels of the shoes. The
patient's knees were then flexed to 90 degrees, and any change in
the length of the lower extremities was noted. A positive test
resulted when an observable change occurred between prone leg
length and prone knee flexion leg length in either leg. A negative
test resulted when no change in lower extremity leg length
oc-curred from the prone to the knee-flexed position. If a positive
test was found, the patient was also evaluated to determine
direction of innominate tilt. A posterior tilt of the innominate
bone is characterized by a relative shortening of the lower
extremity in the prone-lying position as compared with rela-tive
lengthening on knee flexion coupled with a positive standing
flexion test on that side. Conversely, an anterior tilt of the
innominate bone is characterized by a relative length-ening of the
lower extremity in the prone-lying position as
REFERRED WITH LOW BACK PAIN
PHASE 1 ASSESSED FOR
PRESENCE OF SIJD
IF NO SLID,
EXCLUDED FROM
PHASE 2
IF SIJD,
ENTER IN
PHASE 2
Fig. 1. Diagram of the general flow of the study. Interrater
agree-ment of presence or absence of sacroiliac joint dysfunction
(SIJD) was assessed in Phase 1. When the examiners were in
agreement concerning the presence of SIJD, the patient was assigned
to Phase 2 of the study.
compared with relative shortening on knee flexion. A positive
prone knee flexion test will presumably reflect SIJD.1,4
The supine long sitting test was also used to assess abnormal
movement and malalignment in SIJD.1,4 The supine long sitting test
was performed with the patient positioned supine. The examiner
placed his thumbs under the inferior border of each medial
malleolus. The two medial malleoli were then brought together for
comparison. The patient sat up with extended knees, and the
relative length of the malleoli were reassessed. A positive test
was considered to be an observable change in leg length between the
two positions. As in the prone knee flexion test, the lengthening
or shortening of the left and right side is relative, and a
positive test is reflective of SIJD.1,4
Palpation of the patient's PSISs in the sitting position was
also performed to help confirm SIJD and to help determine the
direction of innominate tilt.3(p56) An inequality of PSISs on
sitting is indicative of SIJD.3(p56) The patient sat on a flat
surface, and the PSISs were evaluated by placing each thumb under
the PSISs and then observing for symmetry. An uneven height of one
PSIS as compared with the other PSIS confirmed the presence of
SIJD. The side where the PSIS was low, when compared with the
opposite side, suggests that the innominate bone was tilted
posteriorly.3(p56)
Reliability. Intertester reliability was defined by the level of
agreement (beyond chance agreement) between the two ex-aminers'
independent classifications of patient status. Cohen's Kappa
statistic10 was used to assess level of agreement.
Phase 2
Of the 26 patients who agreed to participate in Phase 1, 20 (13
male, 7 female) were found to have SIJD after examina-tion by both
investigators (M.T.C. and R.M.K.), and were subsequently admitted
to Phase 2 of the study. These 20 patients were then randomly and
independently assigned to either a Control Group (n = 10) or an
Experimental (manip-ulation) Group (n = 10). The mean age of
patients who participated in Phase 2 was 26 1 1 years (range =
15-47 years).
Measurement of innominate tilt. An inclinometer was as-sembled
to measure left and right innominate tilt in degrees (Fig. 2). The
instrument was fashioned after the one described by Pitkin and
Pheasant.8 Intratester reliability of this device has been shown to
be "excellent" when assessed on one day (r =.84).11
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RESEARCH
Fig. 2. Inclinometer used to measure unilateral innominate
tilt.
The method for measuring innominate tilt was determined as
follows. Two therapists (M.T.C. and R.M.K.) performed the
measurements. One measurer (R.M.K.) located and spot-ted the
landmarks, and the other physical therapist (M.T.C.) obtained the
actual measurement of innominate tilt. The anterior superior iliac
spine (ASIS) and the PSIS were located, and a 1.5-cm round marker
was placed over the centers of both the ASIS and PSIS. The patient
was then asked to stand with knees straight, feet pointing forward
and 30.5 cm apart. The investigator then placed one tip of the
calipers on the ASIS and the other tip of the calipers on the
ipsilateral PSIS and then read the amount of innominate tilt (angle
of incli-nation) off the protractor. A zero-degree measurement (a
neutral measurement) on the inclinometer denoted that if an
imaginary line connected the ASIS and PSIS, the line would be
horizontal. Positive degrees were used to describe an an-terior
innominate tilt, and negative degrees were used to describe a
posterior innominate tilt.
Four measurements from each innominate bone were taken both
before and after a treatment period. The four measure-ments were
averaged to obtain a value used to evaluate the
effect of manipulation on innominate tilt. The examiner who
obtained the actual measurements was unaware of which patients
received the manipulation.
Treatment. The patients in the Control Group received no
treatment during the treatment period, whereas the sacroiliac joint
of patients in the Experimental Group was manipulated on the
opposite side of the positive standing flexion test, using a
technique described by Stoddard.12 The patient is positioned supine
in a side-bent position with the convexity toward the therapist.
The patient's upper trunk is rotated toward the therapist, and a
posterior force is applied to the contralateral (with reference to
the therapist) ASIS. We used this technique because it usually
eliminates SIJD in one treatment session. The side to be
manipulated was always the side corresponding to the lowest value
(most negative) obtained with the calipers.
Data Analysis
The average measurements of the innominate tilt obtained from
each patient were summarized using descriptive statistics and were
analyzed with a three-way analysis of variance (ANOVA) using a
mixed factorial design (2 x 2 x 2).13 Factor A consisted of the
between-groups factor (Control Group vs Experimental Group). Factor
B was a repeated-measures fac-tor and consisted of manipulated
versus nonmanipulated side of the pelvis. Factor C was a
repeated-measures factor and consisted of pretest versus posttest
measurements. For signif-icant two- or three-way interactions,
further analysis of simple main effects (F-ratio tests) was
performed using the same computer program. Results were considered
significant at the .05 level.
RESULTS
Results of the reliability assessment revealed a Cohen's Kappa
of .88. Obtaining a Cohen's Kappa this high in a clinical test is
considered excellent clinical agreement accord-ing to Feinstein.14
Table 1 summarizes measurements of innominate tilt before and after
the treatment period in the Experimental and Control Groups. The
ANOVA (Tab. 2) revealed a significant main effect with factor B and
a signifi-cant two-way interaction between manipulated and
nonma-nipulated sides (factor B) and before and after treatment
(factor C). These results, however, are precluded by the
sig-nificant three-way (A B C) interaction (F = 67.07; df = 1,18; p
< .05). The results of the simple main effects analyses show
that the manipulative technique, which was always performed on the
innominate bone side with the most nega-tive angle with respect to
the horizontal plane, changed the
TABLE 1 Means and Standard Deviations (in Degrees) of Innominate
Bone Measurements in Experimental and Control Groups Before and
After Treatment Period
Group
Control Experimental
Side with Most Negative Anglea
Pretest Posttest
s s
-4.0 3.5 -3.2 4.5 -4.9 7.2 1.0 6.6
Side with Least Negative Angle
Pretest Posttest
s s
7.1 3.4 6.9 3.8 6.3 6.4 1.0 6.6
a Manipulation was always performed on the side with the most
negative angle with respect to the horizontal plane.
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TABLE 2 Results of Three-way Analysis of Variance Using a Mixed
Factorial Design (2 x 2 x 2)
Source
Factor Aa
Error (A) Factor Bb
A x B Error (B) Factor Cd
A x C Error (C) B x C A x B x C Error (B x C)
df 1
18 1 1
18 1 1
18 1 1
18
SS
14.45 1885.50 1312.20
125.00 230.80
1.80 0.00 9.20
186.05 130.05 34.90
MS
14.45 104.75
1312.20 125.00
12.82 1.80 0.00 0.51
186.05 130.05
1.94
F 0.14
102.34c
9.75c
3.52 0.00
95.96c
67.07c
angle of the pelvis on the side to a more positive value (F =
24.46; df = 1,18; p < .05). Concomitant with this change on the
manipulated side was an opposite and almost equal change in the
innominate tilt of the nonmanipulated side, from a more positive to
less positive value (F = 161.74; df = 1,18; p < .05). The
differences in pretest and posttest measurements of innominate tilt
in the Control Group were not significant. These results are
summarized in Figure 3.
DISCUSSION
Analyzing only one test at a time, Potter and Rothstein have
shown a lack of reliability of tests used to measure SIJD.5
Although unreliable measures can lead to high observer
vari-ability, it is unlikely that a clinician will base an entire
assessment of a patient on one test alone.15 Instead, the clinician
depends on a battery of tests to rule out or confirm a clinical
diagnosis such as SIJD. We have shown that using predetermined
combinations of four of the same tests used individually by Potter
and Rothstein5 was reliable between two investigators in diagnosing
SIJD as defined in this study. A diagnoses-based combination of
many tests increases the specificity of any test.16 In addition,
the investigators in this study trained using a prescribed
methodology. Perhaps this additional training added to the
reliability of these measures.
A manipulative technique specific to a unilateral sacroiliac
joint created a significant change in innominate tilt bilaterally
in all of the patients in the Experimental Group. The results of
this study have shown that if the more posteriorly rotated of the
innominate bones is manipulated, the inclination of this innominate
bone will change in a more positive (anterior) direction
concomitant with an opposite change (posterior tilting) of the
opposite innominate bone. No change in innom-inate tilt, however,
was recorded in 9 of the 10 patients in the Control Group. This
result disconfirms the belief that the manipulative technique used
in this study is specific only to the side manipulated. This result
also confirms the suspicion of an expert in the area of SIJD
(Richard E. Erhard, unpub-lished data, May 1987) that the
manipulative technique results in a bilateral effect.
The movement test (standing flexion test) was only used to
confirm or deny the presence of SIJD. We could not find a reliable
and valid method of monitoring sacral position and motion. Knowing
the position of the sacrum in relation to
Fig. 3. Pelvic tilt (in degrees relative to horizontal plane) of
side with least negative angle of Control Group (LC), side with
least negative angle of Experimental Group (LE), side with most
negative angle of Control Group (MC), and side with most negative
angle of Experi-mental Group (ME), both before and after treatment.
Manipulative technique was always applied to the sacroiliac joint
of the side with the most negative angle.
both innominate bones would allow the clinician to determine
whether the manipulative technique had a bilateral effect on the
sacroiliac joints. Future studies are needed of sacroiliac joint
movement and its relation to sacral position in patients with
SIJD.
The relationship between innominate tilt and muscle im-balance
leading to LBP has been hypothesized elsewhere.17 The results of
this study suggest that treatments designed to primarily affect
unilateral innominate tilt in SIJD may create changes in the tilt
of both innominate bones. If the innomi-nate bones do move in equal
and opposite directions in SIJD, their malalignment may affect the
length of muscles that originate on the pelvis. Therefore, many
cases of altered muscle length may be caused by SIJD. These
alterations in muscle length may have important clinical relevance.
Clinical cases that we have observed indicate that an anterior tilt
of the innominate bones could stretch the hamstring muscles and
shorten the rectus femoris muscle. The hamstring muscles that are
stretched could then be predisposed to injury.18 On the opposite
side, a posterior tilt of the innominate bones could lengthen the
rectus femoris muscle and shorten the hamstring muscles.
Limitations
We recognize that a major limitation in this study is the lack
of information concerning the patients' symptomatic behavior
attributable to the treatment intervention. The ma-jor focus of
this study, however, was to document changes in innominate tilt as
a result of a manipulation technique pur-ported to be specific to
the sacroiliac joint. In addition, we avoided the ethical concern
of not treating subjects in the Control Group by treating them
immediately after the data for the study were collected. A
meaningful symptomatic com-parison between the Experimental and
Control Groups, there-fore, was not possible. A study of the
symptomatic change in patients after an intervention of
manipulation would be in-teresting and is a topic of future
research.
a Between groups (Control Group vs Experimental Group). b
Repeated measures (manipulated side vs nonmanipulated side). c p
< .05. d Repeated measures (pretest vs posttest).
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RESEARCH
CONCLUSIONS
The inclinometer has been shown to be a useful device in
detecting SIJD and measuring innominate tilt. Combining the
standing flexion test, the prone knee flexion test, the supine long
sitting test, and palpation of PSIS heights on sitting allows an
examiner to detect the presence of SIJD. The intertester
reliability of these tests has been shown to be acceptable when
used together. The data from this study also suggest that in SIJD
both innominate bones tilt in equal and opposite directions, one in
an anterior direction and the other in a posterior direction after
a manipulative technique specific to the sacroiliac joint.
Acknowledgments. We acknowledge Steven J. Rose, Richard E.
Erhard, and Richard W. Bowling for their con-structive input
throughout all phases of this study.
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1988; 68:1359-1363.PHYS THER. KoldehoffMichael T Cibulka,
Anthony Delitto and Rhonda MExperimental StudySacroiliac Joint in
Patients with Low Back Pain: An Changes in Innominate Tilt After
Manipulation of the
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