R E S E A R C H Open Access
Spinal manipulation in the treatment of
patients with MRI-confirmed lumbar disc
herniation and sacroiliac joint hypomobility:
a quasi-experimental study
, Fahimeh Kamali
, Ehsan Sinaei
and Farahnaz Ghafarinejad
Background: To investigate the effect of lumbar and sacroiliac joint (SIJ) manipulation on pain and functional
disability in patients with lumbar disc herniation (LDH) concomitant with SIJ hypomobility.
Methods: Twenty patients aged between 20 and 50 years with MRI-confirmed LDH who also had SIJ hypomobility
participated in the trial in 2010. Patients who had sequestrated disc herniation were excluded. All patients received
five sessions of spinal manipulative therapy (SMT) for the SIJ and lumbar spine during a 2-week period. Back and
leg pain intensity and functional disability level were measured with a numerical rating scale (NRS) and the
Oswestry Disability Index (ODI) at baseline, immediately after the 5th session, and 1 month after baseline.
Results: A significantly greater mean improvement in back and leg pain was observed in the 5th sessions and
1 month after SMT. Mean changes in ODI in the 5th session and 1 month after treatment also showed significant
improvement. The MCIC for NRS and ODI scores in the present study were considered 20 and 6 points, respectively.
Therefore, the mentioned improvements were not clinically significant in the 5th session or at 1-month follow-up.
Conclusion: Five sessions of lumbar and SIJ manipulation can potentially improve pain and functional disability in
patients with MRI-confirmed LDH and concomitant SIJ hypomobility.
Trial registration: Irct.ir (Identifier: IRCT2017011924149N33), registered 19 February 2017 (retrospectively registered).
Keywords: Spinal manipulation, Lumbar disc herniation, Sacroiliac joint, Back pain
Common low back problems include disc prolapse,
spinal stenosis and low back pain . Disc herniation
can be categorized as protrusion (disc contained by the
annulus fibrosus), extrusion (disc materials migrated out
through the annulus fibrosus, but contained by the pos-
terior longitudinal ligament) and sequestration (disc ma-
terials released into the spinal canal) . Disc prolapse
commonly presents with pain and numbness radiating
to the buttocks and legs due to spinal nerve or nerve
root compromise; however, it may be asymptomatic in
approximately 24% of all cases . Symptomatic lumbar
disc disease (SLDD) is a term used to differentiate be-
tween structural abnormalities without clinical symp-
toms and abnormalities that induce clinical
presentations . Approximately 95% of all instances of
lumbar disc herniation (LDH) occur at L4-L5 and L5-S1
Lumbar disc herniation commonly presents with low
back pain, and this problem is usually associated with
sacroiliac joint (SIJ) disorders. In fact, up to 30.7% of pa-
tients with LBP and sciatica also have SIJ dysfunction
. A recent study reported the prevalence of SIJ dys-
function as 72.3% among patients with LDH . Re-
searchers have claimed that depending on the type of SIJ
disorder, the lumbar spine (mostly L5) can also be
* Correspondence: email@example.com
Physical Therapy Department, School of Rehabilitation Sciences, Shiraz
University of Medical Sciences, Shiraz, Iran
Rehabilitation Sciences Research Center, Shiraz University of Medical
Sciences, Shiraz, Iran
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Shokri et al. Chiropractic & Manual Therapies (2018) 26:16
involved . The SIJ is part of the lumbar–pelvic–hip
complex; since this complex works as a mechanical unit,
the involvement of any structure can affect the position
and movement of other sections .
Generally speaking, most patients with SLDD prefer
conservative treatments to surgical intervention. To
date, evidence has supported several conservative treat-
ments for SLDD including traction , McKenzie exten-
sion exercises  and rehabilitation .
The use of spinal manipulative therapy (SMT) for pa-
tients with SLDD has also been suggested; however, its
safety and indications have remained debatable, particu-
larly in individuals with disc disruption or instability .
In this regard, the risk of SMT causing clinically wors-
ened disc herniation or cauda equine syndrome in pa-
tients with LDH is estimated to be less than one in 3.7
million . A systematic review in 2004 also confirmed
the safety and effectiveness of SMT for patients with
Some studies reported significant clinical improvements
in patients with SLDD after manipulation in comparison
to traction , heat  and sham manipulation ,
but no significant differences when compared to exercise
therapy and medical corsets . A recent study found
long-term improvement in pain and functional activity
after 1 year of follow-up , and another study in 2016
reported significant improvement in leg pain after 1 month
in patients with extrusion and sequestration of lumbar
discs, following manipulation .
Sacroiliac joint hypomobility has usually been over-
looked in the management of patients with LDH and low
back problems. However, there is no conclusive evidence
for the effectiveness of SMT in the treatment of patients
with LDH, and the evidence to date is contradictory.
Therefore, the present study aimed to investigate the ef-
fect of SMT applied to the lumbar spine and SIJ to treat
patients with SLDD who also had SIJ hypomobility.
Twenty patients (11 males, 9 females) aged 20–50 years
old with MRI-proven unilateral LDH were included IN
2010 if they had SLDD in the L4-L5 or L5-S1 segment
concomitant with ipsilateral SIJ hypomobility (Table 1).
Leg pain during 1 to 10 months before the study was
their major complaint, and the mean level of leg pain
during the previous 24 h was 30–70 out of 100 on a 0–
100 numerical rating scale (NRS). The time interval
allowed between the MRI diagnosis and inclusion in the
study was 3 months. Exclusion criteria were sequestrated
LDH with neurological signs, spinal canal stenosis, spon-
dylolisthesis, previous lumbar surgery and gross instabil-
ity. Patients a with positive well straight leg raise (SLR)
test, indicating rather large disc herniation and poor
prognosis for conservative treatments [15,16], were also
This was a pre–post test quasi-experimental study. The
participants were selected among patients referred to
physical therapy clinics of Shiraz, Iran. Sample size was
calculated based on the NRS pain score reported in a
previous related study (mean [95% CI] = 22 [15–30], α=
0.05, β= 0.02) . Written informed consent was ob-
tained and ethical approval was granted by the Shiraz
University of Medical Sciences Ethics Committee (ap-
proval number CT-88-4614).
Demographic data, pain intensity, functional disability
and clinical diagnostic tests were recorded at baseline.
After that, the patients received five sessions of manipu-
lative therapy on alternate days, and the outcomes were
reassessed after the 1st and 5th sessions and at a 1-
month follow-up. All patients received both lumbar and
SIJ manipulations in each treatment session.
Lumbar rotation manipulation
The neutral position of the spine was used for side-
posture lumbar manipulation. The patient lay on the
asymptomatic side (e.g. left) in the lateral recumbent
position, with his or her upper foot in the popliteal fossa
of the lower leg. Standing opposite to the patient, the
therapist grasped the patient’s lower shoulder and arm
and applied right rotation until motion was felt in the
desired segment of the lumbar spine. The patient was
rolled toward the therapist, with his or her arms posi-
tioned around the therapist’s right arm. The therapist’s
right forearm was in contact with the patient’s right ax-
illa and pectoral region to maintain appropriate rotation
from above. In this position, the therapist applied a
high-velocity low-amplitude thrust to the pelvis in an
anterior direction with his or her left forearm placed
Table 1 Participants’demographic characteristics (N= 20)
Age 37.86 ± 9.62
BMI 25.10 ± 3.12
Side of LDH Right 11 (55)
Left 9 (45)
Side of SIJ hypomobility Right 8 (40)
Left 12 (60)
Segment of LDH L4 - L5 5 (25)
L5 - S1 15 (75)
Abbreviations:BMI body mass index, LDH lumbar disc herniation, SIJ
Values are mean ± SD for continuous variables and number (percentage) for
Shokri et al. Chiropractic & Manual Therapies (2018) 26:16 Page 2 of 7
behind the patient’s right hip. The therapist pressed the
spinous process of the upper vertebra downward with
his or her right thumb, while pulling the spinous process
of the lower vertebra upward with his or her left thumb.
The procedure was done in a way that avoided exacer-
bating the patient’s pain at the barrier point  (Fig. 1).
Sacroiliac joint manipulation
The patients lay supine on a treatment table, with their
fingers interlocked behind their head. The therapist
stood contralateral to the side to be manipulated and
moved the patient onto his or her side, then leaned to-
ward the dysfunction side, rotated the patient, and
exerted a quick thrust to the anterior superior iliac spine
in the posterior and inferior directions [18,19] (Fig. 2).
The scores for back and leg pain were recorded separ-
ately on an NRS of 0 to 100, in which 0 indicated no
pain and 100 indicated the worst perceived pain .
The minimal clinically important change (MCIC) in
NRS score was 20 points [21,22].
The patients’functional disability level was determined
with the Oswestry Disability Index (ODI), a 10-item
questionnaire in which each item is scored from 0 to 5
. The maximum score on the ODI is 50, and higher
scores indicate greater functional disability. However, in
the present study the maximum score was 45, since the
sex life item was omitted due to cultural issues. There-
fore relative values are reported here as the total score/
total possible score × 10. The MCIC for the ODI was re-
ported as 6 points in a sample of patients with LBP who
received physical therapy .
Participants were also assessed with the SLR and
slump tests to diagnose LDH, and standing flexion, sit-
ting flexion and Gillet tests were used to diagnose SIJ
hypomobility. Although the evidence is contradictory,
some studies have reported acceptable reliability for the
SIJ test. [25–27] The results of five clinical tests were
recorded as positive or negative values at baseline, in the
5th session and 1 month after baseline.
The data were analyzed with the Statistical Package for
Social Sciences (SPSS), version 21.0 (IBM Corp.,
Armonk, NY, USA). The Kolmogorov–Smirnov test of
normality was conducted for all quantitative variables.
Repeated measure ANOVA was used to assess the
trends in changes in the NRS and ODI scores. Individual
time point differences were determined by the Bonfer-
roni post hoc test, and the results of the five clinical
tests were analyzed with the McNemar test.
The NRS score for back pain showed statistically signifi-
cant improvement in the 5th session (P= 0.034) and at
1-month follow-up (P= 0.047) compared to the baseline
value. In addition, statistically significant improvement
in the leg NRS score was seen in the 5th session (P=0.
010) and at 1-month follow-up (P= 0.006). Because the
MCIC for NRS scores in the present study was 20
points, NRS score improvements in back and leg pain
were not clinically significant in the 5th session or at 1-
month follow-up (Figs. 3and 4) (Table 2).
The ODI scores indicated statistically significant im-
provement in the 5th session (P= 0.001) and at 1-month
follow-up (P = 0.001). Because the MCIC for ODI score
in the present study was 6 points, the improvements
were not considered clinically significant at the 5th ses-
sion or at 1-month follow-up (Fig. 5) (Table 2).
In 78.3% of our patients, the sides of SIJ hypomobility
and LDH were the same. After treatment, the patients
showed statistically significant improvements in Gillet,
standing flexion and sitting flexion tests in the 5th ses-
sion and at 1-month follow-up (P≤0.001). The findings
also indicated 95% improvement in the results of the SIJ
Fig. 1 Lumbar rotation manipulation
Fig. 2 Sacroiliac joint manipulation
Shokri et al. Chiropractic & Manual Therapies (2018) 26:16 Page 3 of 7
hypomobility tests after SMT. We also observed a 20%
improvement in the SLR test results and a 15% improve-
ment in the slump test in the 5th session and at 1-
month follow-up after SMT, although these changes
were not statistically significant (Table 3).
The aim of the present study was to investigate the ef-
fect of SMT on pain, functional disability and the results
of clinical tests of SIJ function and LDH in patients with
unilateral SLDD plus SIJ hypomobility. Our findings sug-
gest that five sessions of lumbar and SIJ manipulation
can lead to statistically significant improvement in pain
and functional disability, which in turn may restore nor-
mal SIJ mobility in these patients.
Compared to common treatments for LDH, SMT is
reported to be 37,000 to 148,000 times safer than non-
steroid antiinflammatory drugs and 55,500 to 444,000
times safer than surgery . Neither worsening of
symptoms nor cauda equine syndrome were observed in
our participants after SMT. Epidemiologic data on the
rate of injuries caused by manipulation are limited. The
most common incidents are related to innocuous
physiologic reactions or short-term discomfort generated
at the treatment site. However, these are self-limiting
events that usually resolve within 24 h after SMT .
In rotational side-posture lumbar manipulation, the
impact of the facet joints limits axial rotation of the
lower lumbar vertebrae and consequently prevents an-
nulus fibrosus tearing . In the present study, patients
with sequestrated LDH who had neurological signs were
excluded because these patients may have bowel and
bladder disorders, and many (but not all) of them are
thus candidates for surgery . In the present study
manipulation was applied in the neutral flexion–exten-
sion position to reduce the risk of injury.
The diagnosis and treatment of SIJ hypomobility in pa-
tients with SLDD are important issues that have not been
adequately addressed in the literature. In 78.3% of our
cases, the side of SIJ hypomobility was the same as the
side of LDH. After treatment, 95% improvement was ob-
tained in the results of SIJ hypomobility tests (Table 2).
The SIJ has been reported to be one of the main sources
of low back disorders . A recent study also found that SIJ
dysfunction was a prevalent concomitant pathology in pa-
tients with LDH. Therefore, SIJ dysfunction should be con-
sidered in the treatment of these patients . Pelvic
asymmetry as well as hypermobility or hypomobility of the
spinal or sacroiliac joints can cause low back pain [3,30].
Any involvement of the SIJ can induce muscle spasm in the
piriformis, which in turn can lead to sciatic irritation and a
wide range of symptoms mimicking radiculopathy . In-
creased tension in the quadratus lumborum, iliopsoas or
hamstring muscles may also affect the SIJ mechanism of ac-
tion. Presumably, SIJ manipulation can decrease tension in
these muscles and consequently correct lumbar spine dys-
Several mechanisms have been theorized for the mech-
anical and neurophysiological basis of SMT, including
stimulation or modulation of the somatosensory system to
evoke neuromuscular reflexes . Forceful stretching of
the spinal muscles induces relaxation after SMT. Other
mechanisms are induced hypoalgesia , kinematic cor-
rection [34,35] and increased lumbar range of motion
. A brief reduction in intradiscal pressure during SMT
in cadavers and return to baseline within less than 1 min
was reported in one earlier study . Another study
showed reduced H-reflex amplitude in patients with uni-
lateral disc herniation, which improved after SMT .
The improved outcomes in our patients can be attributed
to two main factors. Firstly, SIJ manipulation may improve
normal functioning of the lumbar spine and related mus-
cles . Secondly, lumbar side-posture rotational ma-
nipulation can induce spinal muscle relaxation ,
Fig. 3 Trend in back pain intensity during the trial
Fig. 4 Trend in leg pain intensity during the trial
Shokri et al. Chiropractic & Manual Therapies (2018) 26:16 Page 4 of 7
improve lumbar range of motion , and briefly decrease
intradiscal pressure .
The results of the SIJ hypomobility tests (including the
Gillet test, standing flexion and sitting flexion tests) im-
proved significantly in the 5th session and after 1-month
follow-up compared to baseline values, whereas no sta-
tistically significant improvement was observed in the
SLR and slump tests. Spinal manipulative therapy may
enhance mobility of the SIJ and lumbar vertebrae, and
affect the muscles in these regions, thus accounting for
the improvement in pain and functional ability. How-
ever, significant changes in the slump and SLR tests may
require additional interventions such as soft tissue ma-
nipulation and nerve mobilization, which were not
tested in this study.
In one controlled trial, SMT and sham manipulation
were compared in 102 participants with MRI-confirmed
LDH; the SMT group showed significantly greater im-
provement in back and leg pain after 6 months .
Nevertheless, the intervention in that study was a com-
bination of soft tissue manipulation and thrust manipu-
lation, and the diagnosis and treatment of SIJ
hypomobility were not considered.
In a prospective cohort study, Leemann et al., investi-
gated the effect of high-velocity, low-amplitude SMT in
patients with acute or chronic MRI-confirmed LDH, and
reported clinically significant improvement in back and
leg NRS and ODI scores in both short-term and long-
term assessments . In a follow-up study, Ehrler et al.,
investigated the association of magnetic resonance im-
aging features, including axial location and type of her-
niation, with the outcomes of SMT in patients with
LDH . This study reported greater improvements in
symptoms among patients with sequestrated SLDD who
received SMT to the level of herniation. These studies,
however, did not consider the treatment of the SIJ in pa-
tients with LDH.
Burton et al., also compared SMT with chemonucleo-
lysis in the treatment of patients with SLDD, and
reported greater improvements in back pain and disabil-
ity in the first few weeks in the SMT group . Their
SMT, however, included a combination of thrust ma-
nipulation, mobilization and soft tissue stretching.
The results of previous studies have shown that SMT
is effective in the treatment of LDH . The study
most similar to ours is the one by Galm et al., which in-
cluded 150 patients with LDH, 46 of whom had SIJ dys-
function. All participants received routine physiotherapy,
mobilization and SMT in the prone position. Significant
improvements were reported in lumbar and ischiatic
pain in the SIJ dysfunction group. These authors con-
cluded that in the presence of lumbar and ischiatic
symptoms, appropriate treatment for SIJ dysfunction
should be considered regardless of intervertebral disc
Table 2 Mean values of back pain, leg pain and functional disability during the trial
1st session 5th session 1 month Times with statistically significant differences (P-value)
Back NRS 44.95 ± 26.18 42.00 ± 25.30 30.50 ± 19.32 29.75 ± 16.42 Baseline - 5th session (0.034)
Baseline - 1 month (0.047)
Leg NRS 49.50 ± 23.94 47.25 ± 24.35 36.00 ± 16.90 33.75 ± 13.75 Baseline - 5th session (0.010)
Baseline - 1 month (0.006)
ODI 14.45 ± 4.40 n.d. 11.35 ± 4.54 10.95 ± 4.27 Baseline - 5th session (0.001)
Baseline - 1 month (0.001)
Abbreviations:NRS numerical rating scale, ODI Oswestry Disability Index, n.d. not determined
Values are mean ± SD
Fig. 5 Trend in functional disability level during the trial
Table 3 Distribution of improvements in diagnostic test results
in the 5th session and after 1-month follow-up
Test 5th session 1 month
Gillet 1/19 < 0.001
1/19 < 0.001
Standing flexion 1/19 < 0.001
1/19 < 0.001
Sitting flexion 1/19 < 0.001
1/19 < 0.001
SLR 16/4 0.12 17/3 0.25
Slump 17/3 0.25 17/3 0.25
Abbreviations:SLR straight leg raising
Significant recovery compared to baseline
Shokri et al. Chiropractic & Manual Therapies (2018) 26:16 Page 5 of 7
pathomorphology . In this study, however, the num-
ber of treatment sessions and the results of SIJ and LDH
physical tests were not reported.
Our study had some limitations which should be
noted. The pre–post test design did not include a con-
trol group; consequently, the results cannot be consid-
ered evidence in support of the clinical efficacy of SMT
for patients with LDH and SIJ hypomobility. A
controlled trial is advisable in which combined manipu-
lations are compared to lumbar or SIJ manipulation sep-
arately, to elucidate whether using both lumbar and SIJ
manipulation together yields better outcomes than using
a single type of manipulation. The small sample size and
lack of long-term follow-up are other limitations. In
addition, we are aware that measuring physiologic re-
sponses to SMT by recording electromyographic activity
of the spinal muscles, the myotomes and dermatomes of
the involved nerve roots, would strengthen the results of
future studies. Also, more reliable tests for SIJ dysfunc-
tion are available and should be used in future studies.
Despite these limitations, we addressed some shortcom-
ings of previous studies. The strengths of the present
study were matching of the physical examination find-
ings with imaging findings, considering SIJ hypomobility
in the treatment of patients with LDH, and the applica-
tion of spinal thrust manipulation alone rather than a
combination of therapeutic methods.
Spinal manipulative therapy can potentially improve
pain, functional disability and SIJ mobility in patients
with LDH concomitant with SIJ hypomobility; therefore,
it can be implemented in physical therapy programs for
these patients. However, further studies with larger sam-
ple sizes, longer follow-up periods and real control
groups should be done to provide more accurate results.
LDH: Lumbar disc herniation; MCIC: Minimally clinically important change;
NRS: Numerical rating scale; ODI: Oswestry disability index; SIJ: Sacroiliac joint;
SLDD: Symptomatic lumbar disc disease; SMT: Spinal manipulative therapy
The authors would like to thank the Research Consultation Center (RCC) of
Shiraz University of Medical Sciences for their assistance with English-language
editing of this article, and K. Shashok (AuthorAID in the Eastern Mediterranean)
for improving the use of English in the revised manuscript.
Availability of data and materials
Please contact the corresponding author for raw data requests.
Concept development and design: ESh, FK, FG. Supervision: FK, FG. Data
collection/processing: ESh, FK, ES. Analysis/Interpretation: ESh, FK, ES. Writing
and critical review: ESh, ES. All authors read and approved the final manuscript.
Ethics approval and consent to participate
Approval was granted by the Shiraz University of Medical Sciences Ethics
Committee (approval code: CT-88-4614).
Consent for publication
Written informed consent was obtained from the patients for publication of their
individual details and accompanying images in this manuscript. The consent form
is held by the authors and is available for review by the Editor-in-Chief.
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Physical Therapy Department, School of Rehabilitation Sciences, Shiraz
University of Medical Sciences, Shiraz, Iran.
Rehabilitation Sciences Research
Center, Shiraz University of Medical Sciences, Shiraz, Iran.
Rehabilitation Sciences, Shiraz University of Medical Sciences, Abiverdi 1
St,Chamran Blvd., P.O. Box 71345-1733, Shiraz, Iran.
Received: 14 July 2017 Accepted: 4 April 2018
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