ORIGINAL ARTICLE

Frequency of Sacroiliitis in Low due to Prolonged Sitting

Nabiha Mujahid Faruq,1 Parkash Israni2 and Nosheen Zehra3

ABSTRACT Objectives: To assess the frequency of Sacroiliitis in patients with (LBP) due to Prolonged Sitting Methodology: A cross-sectional study was conducted in Physiotherapy Department of Ziauddin University Hospital among patients with history of low back pain and continuous sitting for minimum 3 hours. Data was collected from 216 patients who were selected through convenience sampling technique. A pre tested and structured questionnaire was used to collect data. Data was entered and analyzed by using SPSS version 17. Results: It was found that out of 216 patients, 127 (58.8%) had sedentary work. Mean of pain intensity in VAS scale was found as 4.81 ±1.63. It was observed that sitting has been the most aggravating factor for LBP and it was relieved by rest, physiotherapy and medication. Association of frequency of LBP with gender and daily continuous sitting was found significant with p-value=0.03 and 0.00 respectively. Among LBP patients Faber’s test was used for diagnosis of Sacroiliitis. Faber’s test association with type of work was found significantly positive in those with sedentary work with p-value=0.031. Conclusion: The study showed that there was significant association of prolonged sitting with Sacroiliitis in patients with LBP. Key words: Low back pain, prolonged sitting, sacroiliitis.

How to cite this article: Faruq NM, Israni P, Zehra N. Frequency of sacroiliitis in low back pain due to prolong sitting. J Dow Uni Health Sci 2014; 8(1): 26-30. INTRODUCTION accepted that about 13% (95% CI: 9-26%) of patients with persistent low back pain have the origin of pain Low back pain (LBP) refers to the pain felt in lower confirmed as the SIJ.5,15 Risk factors of Sacroiliitis back region. Such pain or discomfort affects the lower include poor posture, weak muscles, bending or twisting back as it supports most of our body's weight. Sitting the back, improper lifting, Ankylosing , has been associated with risk of developing LBP.1 history of bone, joint or skin infections, Injury or Other risk factors of LBP may include old age, family trauma, , , obesity and history, pregnancy, compression fractures, back surgery, Illicit drug use.2 Treatment options may include various congenital deformity, sedentary lifestyle, poor posture ways of relieving . Non-steroidal Anti- and physical stress.2 inflammatory drugs can be useful in some cases. Sacroiliitis is an inflammatory of the sacroiliac Physiotherapy can be helpful in relieving pain in the joints that causes pain and stiffness of the lower back lower back and buttock region that can be associated frequently radiating into the buttocks. The relationship with Sacroiliitis. There may be some severe cases that between the (SIJ) and low back pain may require cortisone injection to block nerve pain. has been a subject of debate among some researchers The reason behind this research is to assess the regarding SIJ pain as a major contributor to the low association between sitting and presence of LBP and back pain problem3 with others regarding italso as frequency of Sacroiliitis in LBM. Research by unimportant or irrelevant.4,15 It is now generallyBlack KM was restricted to those occupations that require sitting for more than half of working time.1 Department of Physical Therapy1,2, Department of Community Health Sciences3, Ziauddin University, Karachi, Here “sitting” was discussed in the context of Western Pakistan. standards. Sitting was described as an erect posture in which the head and trunk are vertical, the lower legs Correspondence: Nabiha Mujahid Faruq, Department of Physical Therapy, Ziauddin University, Karachi, Pakistan. are bent at about 90 degrees at the hips and knees, and the feet are firmly placed on the floor.7 LBP has been Email: [email protected] 26 Journal of the Dow University of Health Sciences Karachi 2014, Vol. 8 (1): 26-30 Frequency of sacroiliitis in low back pain due to prolong sitting identified as one of the most costly disorders among Sample size was calculated with WHO sample size the worldwide working population.1,8,11,20 It can be estimation calculator. For sample size calculation caused by lifting a heavy object, sudden movements, prevalence of SIJ in LBP was taken as 13%, at 95% prolonged sitting in same position (especially in cars, confidence level and keeping 0.05 margin of error. The trucks and poorly designed chairs),9 or have an injury minimum number of participants required for inclusion or accident. Compared to standing posture, sitting in the sample was calculated as 174 but total 216 causes decrease in lumbar and at the same patients were included in the study. time increases low back muscle activity, disc pressure, and also the pressure on the Ischium, which are Data were collected through non probability convenience associated with Occupational LBP.8 Lower back sampling technique. For sample selection, those patients commonly reduces tolerance for the prolonged sitting of LBP were included in the study that had routine sitting required by many occupations and routine daily of more than 3-4 hours continuously every day. Patients activities.9 who had previous history of degeneration, post-operative, carcinoma and other diseases that might cause back pain Sacroiliac joint (SIJ) pain is a challenging condition were not included in the study. accounting for approximately 20% of cases of low back pain.1 Pain is present in the region of the SIJ.A pre tested and structured questionnaire was used to Stressing the SIJ by clinical tests reproduces the patient’s collect data. Patients were interviewed and detailed pain and selective infiltration of that joint relieves the history related to pain was asked and noted in the pain completely.10 In another study there were 70 questionnaire. (52%) patients with LBP of whom 31 (45%) had A diagnostic test was performed known as Faber’s test Computed Tomography (CT) evidence of Sacroiliitis. for the diagnosis of Sacroiliitis on patients with LBP. These were categorized by frequent episodes of morning spinal stiffness and positive sacroiliac compression The patient was in supine lying position, where the tests even in patients in which Sacroiliitis was not knee was flexed and the ankle was placed on the suspected.11 Schwarzer et al.12 have demonstrated that opposite knee. The hip was placed in flexion, abduction, the SIJ is a likely cause of low back pain in up to 30% and external rotation (from where the name FABER of patients presenting to a clinic. Daum13 stated that the comes from). The examiner applied a posteriorly SIJ is an underappreciated cause of LBP and pelvic pain, directed force against the medial knee of the bent leg towards the table top. A positive test occured when as well as a source of pain referred to the proximal lower 31 extremities. The incidence of sacroiliac joint disease in groin pain or buttock pain was produced. patients with LBP has been earlier evaluated by using Purpose of the study was explained to participants and CT scans of lumbosacral spine of the 64 patients, 48 informed consent was taken before including these cases (75%) had CT evidence of at the patients in the study. Data were entered and analyzed sacroiliac joint. The authors concluded that there is a by using SPSS version 17. Frequencies and percentages high incidence of sacroiliac joint arthritis in patients 14 were calculated for qualitative variables while mean undergoing evaluation for LBP. and standard deviation for quantitative variables. Chi Purpose of this research is therefore to steer future square test was used to find association for qualitative research into areas with the greatest potential. Sacroiliac variables and p vale <0.05 was considered as significant. pain can be a cause of low back pain while prolonged sitting is a known risk factor of low back pain but the RESULTS association of prolonged sitting with Sacroiliitis has Total n= 216 patients were included in the study with not been discussed or researched in detail so far. Due mean age of 37 + 9 years. There were 120 (55.6%) to this, it is observed that quite frequently Sacroiliac males and 96 (44.4%) females. Out of the 216 patients, pain is missed out when assessing low back pain, 89 (41.2%) had active work stations while 127 (58.8%) focusing on other causes. There is an increasing demand had sedentary work. Of total, 144 (66.7%) patients had for evidence based health care. So the aim of this study a daily sitting of 3 hours while 72 (33.3) sat for 4 or was to assess the frequency of Sacroiliitis in patients more hours continuously every day. with Low Back Pain due to Prolonged Sitting. Among these patients 107 (49.5%) had frequent Low METHODOLOGY back pain, 45 (20.8%) had occasional, 39 (18.1%) had A cross sectional study was conducted in Physiotherapy constant and 25 (11.6%) had it once in a while. Intensity Department of Ziauddin Hospital, Karachi, Pakistan. of pain was measured by Visual Analogue Scale (VAS) Data were collected from patients who visited OPD which expresses pain numerically i.e. from 1-10, 1 being for management of LBP. Study was completed in 6 the mildest intensity of pain and 10 most severe. Mean months. of pain intensity in VAS scale was found as 4.81 ±1.63.

Journal of the Dow University of Health Sciences Karachi 2014, Vol. 8 (1): 26-30 27 Nabiha Mujahid Faruq, Parkash Israni and Nosheen Zehra Table 1: Aggravating and Relieving factors of LBP in 17 (7.9%) pain radiated to both legs, in 18 (8.3%) to Percentage (%) Frequency right leg and in 13 (6%) to the left. Aggravating Factors Patients included in our study were also asked about Standing 22.2 48 the aggravating and relieving factors of LBP. It was Sitting 73.1 158 found that pain was aggravated mostly during sitting Walking 18.1 39 position with frequency of 158 (73.1%) while other Bending 38.9 84 factors were standing, walking, bending and extension Extension 12.5 27 (Table 1). Similarly, relieving factors found were Relieving factors medication in 120 (55.6%), physiotherapy in 118 Rest 50.5 109 (54.6%) and rest in 109 (50.5%) patients (Table 1). Medication 55.6 120 Physiotherapy 54.6 118

Table 2: Association of Low Back Pain Frequency with Different Factors

Constant Frequently Occasionally Once in a while Total P- value n (%) n (%) n (%) n (%) n (%) Gender Male 23 (10.6) 61 (28.2) 17 (7.9) 19 (8.8) 120 (55.6) 0.03 Female 16(7.4) 46 (21.3) 28 (13.0) 6 (2.8) 96 (44.4) Type of Work Active 20 (9.3) 37 (17.1) 20 (9.3) 12 (5.6) 89 (41.2) 0.24 Sedentary 23 (9.2) 74 (29.6) 27 (10.8) 14 (5.6) 127 (58.8) Daily Continuous Sitting 3 Hours 19 (8.8) 81 (37.5) 34 (15.7) 10 (4.7) 144 (66.7) 0.00 4 and more Hours 20 (9.3) 26 (12) 11 (5.1) 15 (6.9) 72 (33.3) Association of LBP was studied with different factors Table 3: Association of Faber’s Test with Different Factors such as gender, type of work and daily continuous sitting Positive Negative Total P- value (Table 2). Regarding association of frequency of pain n (%) n (%) n (%) with gender, significant difference was found (p-value Gender < 0.00). Among 120 (55.6%) males who were included Male 94 (43.5) 26 (12) 120 (55.6) in the study 61 (28.2%) had pain frequently, on the other 0.82 Female 76 (35.2) 20 (9.3) 96 (44.4) hand total 96 (44.4%) females who were included in Type of Work the sample, 46 (21.3%) had frequent LBP. In the same Active 64 (29.6) 25 (11.6) 89 (41.2) way frequency of LBP was significantly associated with 0.031 Sedentary 106 (49.1) 21 (9.7) 127 (58.8) daily continuous sitting hours (p-value < 0.000). In 81 Daily Continuous (37.5%) patients who had daily sitting of 3 hours had Sitting frequent LBP and 26 (12%) patients who had daily 3 Hours 116 (53.7) 28 (13.0) 144 (66.7) 0.221 sitting for more than 4 hours had frequent LBP. 4 or More Hours 54 (25.0) 18 (8.3) 72 (33.3) Association of frequency of LBP with type of work although not found significant but still both in active Detailed history regarding the LBP of patients was and sedentary type of work, pain occurred frequently taken and for pain duration it was found that 79(36.6%) as 37 (17.1%) and 74 (29.6%) respectively. (Table 2) patients had LBP since 3-5 weeks and only 20(9.3%) had it for more than a year. Others had LBP for a When the association of Faber’s test (Diagnostic test couple of weeks 34(15.7%), 2-6 months 54(25%) and for Sacroilitis) with gender, type of work and daily 7-12 months 29(13.4%) respectively. Among all continuous sitting was studied it was found significant (p-value = 0.031) with type of work as 64 (29.6%) in patients, 86 (39.8%) felt LBP during heavy work load, active and 106 (49.1%) in sedentary work type. Among 73 (33.8%) felt it during the day, 22 (10.2%) felt the 120 (55.6%) males included in the study Faber’s test pain all the time, 18 (8.3%) in the morning and 17 was positive in 94 (43.5%) while it was positive in 76 (7.9%) at night. (35.2%) out of 96 (44.4%) females in the study. Out of all study patients, 130 (60.2%) felt dull pain, 33 Considering daily continuous sitting hours, Faber’s (15.3%) felt sharp, 29 (13.4%) diffused, 12 (5.6%) test was positive in 116 (53.7%) who had sitting for burning, 10 (4.6%) tender and only 2 (0.9%) felt pinching three hours and in 54 (25%) who had sitting for four type of pain. In 168 (77.8%) pain was localized while hours or more. (Table 3)

28 Journal of the Dow University of Health Sciences Karachi 2014, Vol. 8 (1): 26-30 Frequency of sacroiliitis in low back pain due to prolong sitting DISCUSSION Visual Analogue Scale (VAS) has been very useful in defining pain numerically. The scale indicates 1-10 On the basis of the results of this study, it is apparent numbers where 1 refers to minimum pain and 10 most that our objective is proven affirmative. There have severe. Yasuchike A. et al mentioned in his study that been numerous researches regarding Low Back Pain use of VAS scoring system for the evaluation of LBP over the years in relation to various other contributing has been extremely effective in both young and older factors and differential diagnosis of LBP but not many 16 have shown significant work in relation to the key patients. In our research, mean pain intensity on VAS words of our study i.e. Low Back Pain, Prolonged scoring system was 4.81 ±1.63 and the nature of pain sitting and Sacroiliitis. Sitting has always been a was dull and it was localized in the lower back and debatable subject for researchers of LBP.15 buttock region. Various studies have established that intervertebral There is no universally accepted gold standard for the discs, facet joints and sacroiliac joints are potential diagnosis of low back pain originating from the sources of low back and lower extremity pain.1-13 The sacroiliac joint.22 To evaluate the value of pain sacroiliac joint is accepted as a potential source of low provocation tests in Sacroiliitis, Salih O et al proved back and/or buttock pain with or without lower that pain provocation tests which include Faber’s Test extremity pain. The sacroiliac joint has been implicated had acceptable reliability in detection of sacroiliitis.19 as the primary source of pain in 10% to 27% of patients We also used Faber’s test in our research as a diagnostic with suspected sacroiliac joint pain.22-30 Astfalek RG tool in patients with low back pain due to continuous et al in their recent study reported that nearly all patients sitting to diagnose sacroiliitis and it was found to be with non specific low back pain described sitting as very effective. Faber’s test was positive in 53.7% 17 the most prevalent aggravating factor. patients whose daily sitting was for three hours and Because of very low activation of lumbar muscles in 25% patients whose daily sitting was for four hours or sitting position, the load is diffused on other structures more. like ligaments and intervertebral discs. Due to the viscoelasticity of these structures and low activation Norman AB et al in their study also support the view of lumbar muscles, the lumbar spine inclines towards that the pain in very low back area can come from de-conditioning and degeneration which may be a Sacroiliac joint. In this study a double blinded trial cause for low back pain.18 It was seen in our study that was carried out. Three pain Provocation tests were in 73.1% patients, the main aggravating factor of low applied and were found to have a high degree of back pain was sitting. sensitivity and specificity in confirming the diagnosis of SIJ dysfunction.21 Considering the fact that so many According to Black KM et al, the prevalence rate of studies have proven that Faber’s test was an effective reported LBP in those occupations that require the pain provocation test for the diagnosis of Sacroiliitis, worker to sit for the majority of a working day is it was chosen to be the diagnostic test in this study. significantly higher than the prevalence rate of the general population.1 Going through different studies It has been observed that low back pain is a common like these it was quite apparent that long duration of problem faced by those who have a sedentary lifestyle sitting has been causing pain in the lower back among that involves prolonged sitting. Sacroiliitis was found large group of population of almost all ages. But the as a major factor that causes low back pain in such study by Laslett M. explains the relationship between individuals. Now when we know how injurious the sacroiliac joint and LBP and according to him this prolonged sitting can be, by causing sacroiliitis and has been a subject of debate with some researchers but low back pain, as physiotherapist, it is our responsibility now it is generally accepted that 13% of patients with to bring awareness in people and guide them regarding LBP have the origin of pain confirmed as Sacroiliiac the harmful effects of prolonged sitting specially for joint dysfunction.15 those who have a sedentary life style. Individuals Daum13 stated that the SIJ is an underappreciated cause working in offices where their nature of work is of LBP and pelvic pain, as well as a source of pain restricted to a desk or computer unit, those are the ones referred to the proximal lower extremities. Schwarzer badly affected. These long sessions of sitting can be et al.12 states that sacroiliac joint (SI joint) is a frequent divided into shorter sessions by standing up and source of low back and referred pain in lower extremity, stretching yourself after every thirty minutes to an hour being an indicator of source of pain in approximately if you do not have access to move around. Otherwise 30% of patients with chronic low back pain1st. Laslett 15 12 13 a small walk around your work station may be more M et al. Schwarzer et al. and Daum have supported effective in breaking the cycle of prolonged sitting. In the fact that sitting, low back pain and sacroiliitis have this way there will be more active working environment a strong interconnection with each other so was our objective and result; both were in favour of this along with reduced chance of low back pain induced hypothesis. by sacroiliitis.

Journal of the Dow University of Health Sciences Karachi 2014, Vol. 8 (1): 26-30 29 Nabiha Mujahid Faruq, Parkash Israni and Nosheen Zehra CONCLUSION 16 Yasuchika A, Shiro S, Koichi N, Arata N, Hiroshi T, Seiji O, et al. Evaluation of Nonspecific Low Back Pain Our study concludes that there is high frequency of Using a New Detailed Visual Analogue Scale for Patients Sacroiliitis in patients who were suffering from low in Motion, Standing, and Sitting: Characterizing back pain due to prolonged sitting. The Diagnostic test Nonspecific Low Back Pain in Elderly Patients, Pain for Sacroiliitis (Faber’s test) was found positive in Res Treat 2012; 2012: 680496. majority of patients who had low back pain and a 17 Astfalck RG, O’Sullivan PB, Straker LM, Smith AJ. A sedentary work type. detailed characterisation of pain, disability, physical and psychological features of a small group of REFERENCES adolescents with non-specific chronic low back pain. Manual Therapy 2010; 15:240–7. 1 Black KM, Korn H, Nordin M. Association between 18 Mörl F, Bradl I. Lumbar posture and muscular activity sitting and occupational LBP. Eur Spine J 2007; 16:283-98. while sitting during office work, J Electromyography 2 Freburger JK, Holmes GM, Agans RP, Jackman AM, Kinesiol 2012;:362-8. Darter JD, Wallace AS, et al. The rising prevalence of chronic low back pain. Arch Intern Med 2009; 169:251-8. 19 Salih O. The value of sacroiliac pain provocation tests in early active sacroiliitis, 2008; 27:1275-82. 3 DonTigny RL. Anterior dysfunction of the sacroiliac joint as a major factor in the etiology of idiopathic low 20 Michael TC. The Treatment of the Sacroiliac Joint back pain syndrome. Phys Ther 1990; 70:250–65 Component to Low Back Pain: A Case Report. J Am discussion 262–5. Phy Ther Assoc 1992; 72: 917-22. 4 Waddell G. The Back Pain Revolution. Edinburgh, UK: 21 Norman AB, Malcolm JB, Pain provocation Tests for Churchill Livingstone; 1998. the Assessment of Sacroiliac joint. J Spinal Disorder 1998; 11:341-5. 5 Maigne JY, Aivaliklis A, Pfefer F. Results of sacroiliac joint double block and value of sacroiliac pain 22 Rupert MP, Lee M, Manchikanti L, Datta S, Cohen SP, provocation tests in 54 patients with low back pain. Pain Physician 2009; 12:399-418. Spine 1996; 21:1889–92. 23 Hansen HC, McKenzie-Brown AM, Cohen SP, 6 Waddell G, Burton AK. Occupational health guidelines Swicegood JR, Colson JD, Manchikanti L. Sacroiliac for the management of Low Back Pain at work: Evidence joint interventions: A systematic review. Pain Physician Review. Occup Med (Lond) 2001; 51:124-35. 2007; 10:165-84. 7 Dainoff MJ. Ergonomics of seating and chairs. In: 24 McKenzie-Brown A, Shah RV, Sehgal N, Everett CR. Salvendy C (ed) Handbook of human factors and A systematic review of sacroiliac joint interventions. ergonomics. Boca Raton: CRC Press 1999. Pain Physician 2005; 8:115-25. 8 Makhsous M, Lin F, Bankard J, Hendrix RW, Hepler 25 Boswell MV, Trescot AM, Datta S, Schultz DM, Hansen M, Press J. Biomechanical effects of sitting with HC, Abdi S, et al. Interventional techniques: Evidence adjustable ischial and lumber support on occupational based practice guidelines in the management of chronic low back pain: evaluation of sitting load and back spinal pain. Pain Physician 2007; 10:7-111. muscle activity, BMC Musculoskelet Disord 2009; 10:5-7. 26 Manchikanti L, Singh V, Pampati V, Damron K, Barnhill 9 Reinecke SM, Hazard RG, Coleman K. Continuous R, Beyer C, et al. Evaluation of the relative contributions passive motion in seating: A new strategy against low of various structures in chronic low back pain. Pain back pain. J Spinal Disorders 1994; 7:29-35. Physician 2001; 4:308-16. 10 Merskey H, Bogduk N. Classification of chronic pain: 27 Cohen SP. Sacroiliac joint pain: A comprehensive review descriptions of chronic pain syndromes and definitions of anatomy, diagnosis and treatment. Anesth Analg nd of pain terms. 2 ed. Seatle, WA: IASP Press 1994. 2005; 101:1440-53. 11 Steer S, Jones H, Hibbert J, Kondeatis E, Vaughan R, 28 Foley BS, Buschbacher RM. Sacroiliac joint pain: Gibson T. Low back pain, sacroiliitis, and the relationship Anatomy, biomechanics, diagnosis, and treatment. Am with HLA-B27 in Crohn’s disease. J Rheumatol 2003: J Phys Med Rehabil 2006; 85:997-1006. 30:518-22. 29 Forst SL, Wheeler MT, Fortin JD, Vilensky JA. The 12 Schwarzer AC, Aprill CN, Bogduk N. The Sacroilliac sacroiliac joint: Anatomy, physiology and clinical Joint in Low Back Pain. Spine 1995; 20:31-7. significance. Pain Physician 2006; 9:61-7. 13 Daum WJ. The sacroilliac joint: An underappreciated 30 Zelle BA, Gruen GS, Brown S, George S. Sacroiliac pain generator. Am J Orthop 1995; 24: 475-7. joint dysfunction: Evaluation and management. Clin J 14 Hodge JC, Bessette B. The incidence of sacroiliac joint Pain 2005; 21:446-55. disease in patients with low back pain. Can Assoc Radiol 31 Broadhurst N, Bond M. "Pain provocation tests for the J 1999; 50:321-3. assessment of sacroiliac joint dysfunction."J Spinal 15 Laslett M. J Man Manip Ther 2008; 16:142–52. Disorders 1998; 11:341-5.

30 Journal of the Dow University of Health Sciences Karachi 2014, Vol. 8 (1): 26-30