Strain Counter-Strain vs Maitland Mobilization for Sacroiliac Joint Pain

Comparative Effects of Strain Counter-Strain Versus Maitland Mobilization Technique (Grade II and III) for Reducing Pain and Functional Limitation in Patients With Sacroiliac Joint Dysfunction

This randomized clinical trial compares two manual therapy techniques for treating sacroiliac joint dysfunction, a condition that causes lower back and buttock pain. The two techniques are strain counter-strain, an indirect positional release method, and Maitland mobilization grades II and III, a direct joint oscillation technique. Thirty-four participants aged 20 to 40 years with confirmed sacroiliac joint dysfunction will be randomly assigned to receive either strain counter-strain or Maitland mobilization three times per week for four weeks. Both groups will also receive a 10-minute moist hot pack before each treatment. Pain will be measured using the Numeric Pain Rating Scale and functional limitation using the Modified Oswestry Disability Index at baseline and after four weeks. The study aims to determine which technique is more effective for reducing pain and improving function in this patient population.

This is a double-blind, parallel-group, randomized clinical trial to be conducted at three hospitals in Faisalabad, Pakistan: National Hospital Faisalabad, Health 360 Faisalabad, and Madinah Teaching Hospital Faisalabad. The study duration is six months following synopsis approval. A total of 34 participants will be enrolled using simple random sampling. Inclusion criteria include: age 20 to 40 years, both males and females, pain at the sacroiliac joint region below L5 radiating to buttocks or back of thigh for at least 8 weeks, baseline pain intensity of 3 or more on the Numeric Pain Rating Scale, Modified Oswestry Disability Index score of at least 30 percent, and at least three positive provocation tests out of five (Gaenslen test, distraction test, compression test, thigh thrust test, and sacral thrust test). Exclusion criteria include: recent lumbar or hip surgery, lumbar or pelvic fracture, infectious conditions such as bone tumors or tuberculosis, inflammatory joint diseases such as rheumatoid arthritis or ankylosing spondylitis, and refusal to provide informed consent. Participants will be randomly assigned to two groups of 17 each. Group A will receive strain counter-strain technique targeting the quadratus lumborum, piriformis, and erector spinae muscles. The therapist will position the patient comfortably for 90 seconds per muscle, repeated three times per muscle, for three sets per session. Group B will receive Maitland mobilization grades II and III applied to the sacrum. Grade II will be used in week one and early week two for pain reduction, using 3 to 4 sets of 30-second oscillations. Grade III will be introduced by the end of week two and used primarily in weeks three and four for 40-second sets to improve mobility. Both groups will receive a 10-minute moist hot pack to the gluteal area before each treatment. Treatments will be delivered three times per week for four weeks. Outcome measures will be assessed at baseline and after completion of the fourth week. The Numeric Pain Rating Scale is an 11-point scale from 0 (no pain) to 10 (worst possible pain). The Modified Oswestry Disability Index contains ten sections each scored 0 to 5, converted to a percentage where higher scores indicate greater disability. Data will be analyzed using SPSS version 20. Between-group comparisons will be conducted using independent t-tests for normally distributed data or Mann-Whitney U tests for non-normal data. Within-group comparisons will use paired t-tests or Wilcoxon signed-rank tests. Statistical significance will be set at p less than 0.05.

Inclusion Criteria:

• Age 20 to 40 years, including both males and females
• Pain at the level of the sacroiliac joint region below L5 and radiating to the buttocks or back of thigh
• Pain duration of 8 weeks or longer
• Baseline pain intensity of 3 or greater on the Numeric Pain Rating Scale
• Modified Oswestry Disability Index score of at least 30 percent
• At least 3 positive provocation tests out of 5: Gaenslen test, distraction test, compression test, thigh thrust test, and sacral thrust test
• Willing and able to provide written informed consent

Exclusion Criteria:

• Age below 19 years or above 40 years
• Recent lumbar or hip surgery within the past 6 months
• Lumbar or pelvic fracture
• Infectious conditions including bone tumors, nerve root irritation, and tuberculosis of the spine or hip
• Pre-diagnosed inflammatory joint diseases including rheumatoid arthritis and ankylosing spondylitis
• Any condition that contraindicates manual therapy
• Pregnancy (if applicable - you may want to add this, as SIJ pain is common in pregnancy but manual therapy protocols may differ)
• Unable or unwilling to provide informed consent