Brenda Casanova

Article Review of “Efficacy of Mulligan Mobilization Versus Muscle Energy Technique in

Chronic Sacroiliac Joint Dysfunction”

The purpose of this article was to compare the effectiveness of Mulligan’s mobilization

with movement and muscle energy technique on sacroiliac mobility, anterior pelvic tilt angle,

and pain intensity of patients with chronic sacroiliac joint dysfunction. Not only does the

sacroiliac joint transmit weight from the upper body and trunk to the pelvis and lower

extremities, it also transfers forces produced by the lower extremities to the trunk and upper

body. A hypomobile SIJ that does not effectively absorb forces can affect other areas of the

body, causing problems such as low back pain. Manual therapies including muscle energy

techniques (MET) and Mulligan’s mobilization with movement (MWM) are used to treat

sacroiliac joint dysfunction.

To assess sacroiliac joint dysfunction, the researchers of this article utilized doppler

imaging of vibrations (DIV), palpation meter (PALM), and the Visual Analog Scale (VAS). DIV was

used to measure sacroiliac joint mobility through applying 60 Hz of vibration to the anterior

inferior iliac spine (ASIS). PALM was used to assess skeletal alignment by measuring the pelvic

tilting angle by placing a mark on the ASIS and posterior inferior iliac spine (PSIS). From there,

an inclinometer was used to determine the degrees of inclination between the two points.

Finally, pain intensity was measured by the Visual Analog Scale (VAS). These measures were

taken prior to treatment and immediately after treatment had ended (4 weeks from the initial

assessment).

The sample size consisted of 45 patients with chronic sacroiliac dysfunction (pain over

the SIJ and hypomobility) between the ages of 30-50 years of age. There were three groups (A,
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B, and C) of 15 patients. Group A received Mulligan’s mobilization with movement using

anterior and posterior innominate methods and was given 3 sets with 10 repetitions for 12

sessions. For a posterior innominate, the patient was prone, and therapist applied an anterior

and superior force on the posterior border of the opposite ilium while the patient actively

extended their trunk. The patient was also in the prone position for anterior innominate while

the therapist fixated one of his hands on the sacrum and pulled anteriorly on ipsilateral ASIS.

The patient performed pain-free active trunk extension while the therapist’s force was

maintained. MWM was performed in conjunction with conventional treatment consisting of

ultrasound, infrared and therapeutic exercise programs (sit-up exercises, bridging exercise, back

extension from prone, hamstring and erector spinae stretches). Group B received MET 3 times

for 12 sessions of the anterior and posterior pelvic girdle muscles including iliopsoas, erector

spinae, hamstrings, and quadratus lumborum. A restriction barrier was determined by the

therapist and the patients were instructed to perform a 20-30% of their maximum voluntary

contraction. This technique consisted of 7-10 second hold times. MET was performed along with

the conventional treatment program mentioned above. Group C was the control group that

received only the conventional treatment program.

The study concluded that both MWM and MET had significantly decreased anterior

pelvic tilt angle and pain levels in patients with chronic sacroiliac joint dysfunction when

compared to the control group. There was no significant difference between MWM and MET

groups for pelvic tilt angle and pain levels. However, MWM showed significant improvement in

SIJ mobility when compared to MET. There was also a significant decrease in pain with all three

groups compared to pre- and post-interventions. The article concluded that MWM is more
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effective than MET when treating patients with chronic sacroiliac joint mobility; however there

were various limitations within this study.

Limitations presented in this study included small sample size, outcome measures were

not taken at same time, and only short-term effects were observed. Reduced conformity when

taking outcome measures and a small sample size decreases the validity and reliability of the

research. Further testing should be done to confirm the results of this article. Although the

patient’s pain, VIS, and PALM were improved initially, the study did not follow-up on the lasting

effects of MWM and MET on chronic sacroiliac dysfunction. Additionally, exclusion criteria of

this study included pregnant females, patients with inflammatory conditions, and hypermobility

of the sacroiliac joint which are major contributors to SIJ joint dysfunction. Including a larger

percent of the population would have increased the external validity of this study. When

applying this research to clinical practice, be conscious of the term “chronic sacroiliac joint

dysfunction” as it excludes SIJ hypermobility. Furthermore, the research does not mention the

ratio of males to females in this study and only considers patients between the age of 30 and

50. Although there are limitations presented in this study, the researchers took the following

measures to increase the reliability and validity of this study.

The outcome measures used in this article to examine sacroiliac joint dysfunction were

presumed to be valid, reliable, and accurate. There was no significant difference among the

groups in age, height, weight, and BMI using descriptive statistics and ANOVA. Previous

literature has utilized VIS, PALM, and VAS to assess SIJ dysfunction. Two-way mixed MANOVA

was used determine the effectiveness of the treatment of sacroiliac mobility, anterior pelvic

tilting angle, and pain. Although VIS detects joint mobility in a research setting, it is highly
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unlikely I will be able to use this as an assessment tool in the clinic. Instead, I will be using tests

such as the stork test and the forward bend test in sitting and standing to assess sacroiliac joint

mobility. With that being said, I would assume those tests to be less sensitive to change and I

would be curious to know if the conclusion of this research (that MET was significantly better

when addressing SIJ hypomobility) would be true utilizing clinical outcome measures instead of

research outcome measures.

This article caught my attention as I am interested in orthopedic and woman’s health

physical therapy. According to this article about 15% of low back pain is caused by dysfunction

of the sacroiliac joint. Therefore, it is important to assess not only the spine but the pelvic and

sacroiliac region as well for patients with low back pain. In clinical practice it will be significant

to note which treatment technique, in this case MWM or MET, will be the most successful

treatment. This research concluded that MWM was significantly better when treating SIJ

hypomobility. However, MET and MWM both improved pain and SIJ joint alignment. Clinically, I

will be able to apply this research keeping in mind the sample population and the limitations

presented in this study. In future practice, I will be able to try both techniques, especially if the

first one is unsuccessful. Although this research did not touch on Maitland mobilizations, I

would be curious to see how it stacks up against MWM and MET when treating sacroiliac

dysfunction. I would also like to investigate the effects of stabilization exercises on sacroiliac

joint hypomobility to address patients with ligamentous laxity in the low back and pelvic

regions. Reviewing this article has led me to continue researching the most effective treatment

options when considering sacroiliac dysfunction.

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Resource

1. Alkady, Sabah Mohammed Easa, Kamel, Ragia Mohammed, AbuTaleb, Enas, Lasheen, Yasser,

Alshaarawy, Fatma Anas. Efficacy of Mulligan Mobilization Versus Muscle Energy Technique in

Chronic Sacroiliac Joint Dysfunction. International journal of physiotherapy. 2017;4(5).

doi:10.15621/ijphy/2017/v4i5/159427