CMCT Versus CSE in Treatment of SIJ Pain

The sacroiliac joint (SIJ) pain is a significant contributor to LBP at any age, but it affects the elderly and young active people more frequently. Based on estimates from several studies, the SIJ causes pain in 10-38% of LBP patients. Altered lumbopelvic stability causes faulty movement of the spine during limb movement, and the faulty movement may cause mechanical irritation to the adjacent joint which when repeated and accumulated may cause LBP or SIJP. Additionally, it was revealed that patients with LBP have altered movement strategies in the form of uncontrolled movements which cause symptoms. This uncontrolled movement can be defined as 'an inability to cognitively control movement at a specific site and direction, while moving elsewhere to benchmark standards'.

Despite the need to identify the most effective treatment options for SIJ pain, controversy still remains with unclear definite conclusion regarding the use of physiotherapy interventions in those patients. Clinically, the diagnosis pathway has become more definite, but the treatment algorithm is less well-defined with conflicting evidence of the standard treatment either invasively or conservatively. For the management of SIJP, the conventional approach which includes ultrasound (US) application combined with muscle energy technique (MET) for the lumbopelvic region can be successfully used. Moreover, core stabilization exercises are considered a fundamental component of physiotherapy with the goal to improve the strength and coordination of deep core stabilizers such as the transversus abdominis, multifidus, and pelvic floor muscles, which are critical for maintaining lumbopelvic stability, reducing pain and disability and also, lowing the risk of recurrent injury. Among the conservative interventions, cognitive movement control training has begun to emerge as a promising management approach and garnered attention in recent years because it involves active cognitive participation and focuses on improving stability and neuromuscular control of the lumbosacral region.

Despite that stabilization and motor control exercises, in the context of the physiotherapy literature, are a well-established management method for LBP and SIJ region pain, there is still limited evidence on which stabilization or motor control training approach is more effective and leads to better outcomes in patients with LBP of sacroiliac origin. Unfortunately, within the available literature, various treatment plans for SIJ pain have been described but there are few published studies regarding postural lumbopelvic stability and SIJ and as a result, the assessment and management of SIJP subjects with potential balance or postural control deficits are valuable and needed.

Although the effectiveness of motor control training in reducing pain in the lumbar spine was confirmed, the need for the selection of exercises due to the occurrence of various forms of movement pattern disorders is still critical. This underlies the need to recognize individual differences in clinical presentation and/or which activities and functions are painful and difficult to do. Therefore, here is the importance of cognitive movement control training in targeting the patient's own complaint and also tailoring interventions based on assessment.

So, CMCT can be an effective form of treatment for lumbopelvic pain because this type of exercises restores normal muscle activation, proprioceptive reeducation, and retraining of movement patterns with a positive effect of on disability and pain severity in the short-term and long-term.

Despite it has been shown to have great clinical utility at the hip and groin and also, on the non-specific low back pain with positive effects on disability and pain severity in the short and long terms, there are no clear results about the effect of cognitive movement control retraining on patients with SIJP. Therefore, here is the significance of this study.

Inclusion criteria

• Age of the subjects will range between 18 - 45 years for young middle-aged adults.
• Unilateral SIJ pain lasting for at least 3 months, in lower back, buttock, groin, posterior superior iliac spine (PSIS) and with or without referral pain to the lower extremities.
• SIJ pain below L5 region.
• Non-centralized LBP i.e. has no directional preference.
• Score positive on 3 out of 5 SIJP provocation tests: compression, distraction, sacral thrust, thigh thrust, Gaenslen's.

Exclusion criteria

• Limb-length discrepancy,
• Clear signs of nerve root compression (radiating pain, motor and/or sensory deficits,
• Previous major back surgery or injury, fracture or arthritis of spine, pelvis, hip, knee or ankle joint,
• Seronegative spondyloarthropathies,
• Visual or vestibular deficit,
• Unable to follow command/ cognitive deficits,
• Postpartum women less than six months,