Efficacy of manual therapy for sacroiliac joint pain syndrome: a systematic review and meta-analysis of randomized controlled trials

Abstract

Introduction: This study examined the efficacy of manual therapy for pain and disability measures in adults with sacroiliac joint pain syndrome (SIJPS).

Methods: We searched six databases, including gray literature, on 24 October 2023, for randomized controlled trials (RCTs) examining sacroiliac joint (SIJ) manual therapy outcomes via pain or disability in adults with SIJPS. We evaluated quality via the Physiotherapy Evidence Database scale and certainty via Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Standardized mean differences (SMDs) in post-treatment pain and disability scores were pooled using random-effects models in meta-regressions.

Results: We included 16 RCTs (421 adults; mean age = 37.7 years), with 11 RCTs being meta-analyzed. Compared to non-manual physiotherapy (i.e. exercise ± passive modalities; 10 RCTs) or sham (1 RCT) interventions, SIJ manual therapy did not significantly reduce pain (SMD: -0.88; 95%-CI: -1.84; 0.08, p = 0.0686) yet had a statistically significant moderate effect in reducing disability (SMD: -0.67; 95% CI: -1.32; -0.03, p = 0.0418). The superiority of individual manual therapies was unclear due to low sample size, wide confidence intervals for effect estimates, and inability to meta-analyze five RCTs with a unique head-to-head design. RCTs were of 'good' (56%) or 'fair' (44%) quality, and heterogeneity was high. Certainty was very low for pain and low for disability outcomes.

Conclusion: SIJ manual therapy appears efficacious for improving disability in adults with SIJPS, while its efficacy for pain is uncertain. It is unclear which specific manual therapy techniques may be more efficacious. These findings should be interpreted cautiously until further high-quality RCTs are available examining manual therapy against control groups such as exercise.

Registration: PROSPERO (CRD42023394326).

Keywords: Manual Therapy; Physical therapy; chiropractic; chiropractic manipulation; low back pain; meta-analysis; musculoskeletal manipulations; osteopathic manipulation; sacroiliac joint.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram outlining the initial search to final article inclusion. Abbreviations: sacroiliac joint pain syndrome (SIJPS).

Figure 2.

Meta-regression forest plot examining efficacy of sacroiliac joint manual therapy techniques on pain. Subgroups represent specific manual therapy types, each having its own effect estimate (black diamond). The bottom row (total) shows the overall meta-regression standardized mean difference for manual therapy across all studies (dotted line). An SMD of 0 indicates a null effect. A negative SMD point estimate suggests a potential reduction in pain (favors sacroiliac joint manual therapy). Mean pain scores and standard deviations are indicated in the experimental and control groups. Abbreviations: confidence interval (CI), inverse variance (IV), muscle energy technique (MET), spinal manipulative therapy (SMT), standard (std.).

Figure 3.

Contour-enhanced funnel plot. The dashed lines represent the fixed effect estimate (vertical dashed line) and corresponding 95% confidence interval limits (diagonal dashed lines), while the fainter vertical dotted line represents the random effects estimate used for our analysis. Shaded areas indicate significant p-values while the white central area indicates non-significant p-values.

Figure 4.

Meta-regression forest plot examining efficacy of sacroiliac joint manual therapy techniques on disability. Subgroups represent specific manual therapy types, each having its own effect estimate (black diamond). The bottom row (total) shows the overall meta-regression standardized mean difference for manual therapy across all studies (dotted line). An SMD of 0 indicates a null effect. A negative SMD point estimate suggests a potential reduction in disability (favors sacroiliac joint manual therapy). Mean pain scores and standard deviations are indicated in the experimental and control groups. Abbreviations: confidence interval (CI), inverse variance (IV), muscle energy technique (MET), spinal manipulative therapy (SMT).