C A SE REVIEW

®2015 Human Kinetics - IJATT 20(3), pp. 31-37

http://dx.doi.org/10.1123/ijatt.2014-0066

Patient Outcomes Utilizing the Selective

Functional Movement Assessment
and Mulligan Mobilizations With Movement
on Recreational Dancers With Sacroiliac
Joint Pain: A Case Series
Ryan Krzyzanowicz, MSEd, AT • Massachusetts College of Liberal Arts; Russell Baker,
DAT, AT, and Alan Nasypany, EdD, AT • University of Idaho; Frank Gargano, PT, DPT,
OCS, MCTA • Rehabilitex; and Jeff Seegmiller, EdD, AT • University of Idaho

Tthe sacroiliac joint (SIJ) has been identi­

fied as the origin of low back pain affecting
K EY P O IN T S
Mulligan mobilizations with movement
(MWM) and selective functional movement
assessment (SPMA) interventions can
► quickly decrease pain and improve function
in patients suffering from sacroiliac joint
pain.
Mulligan MWM and SFMA interventions
can produce clinically-significant changes
► across patient-oriented outcome instru­
ments that can be maintained through a
return to activity.
Mulligan MWM and SFMA interventions can
► be incorporated into a traditional clinical
examination to improve patient outcomes.
under tremendous amounts of stress.4 This
combination can place a dancer at more
13-25% of patients.1-3 risk of injury to the lumbar spine and SIJ.6
In the dance population, A dancer suffering from SIJ injury may pres­
low back pain has been ent with a variety of symptoms that could
reported to account for include: pain with palpation to the SIJ, pain
12-23% of all injuries.4'5 with pelvic loading movements (e.g., hip
In the dance medicine external rotation combined with jumping,
setting, many patients leaping, or twisting), and extension of the
report to the clinic com­ lumbar spine.7 In addition to pain, SIJ injury
plaining of low back and could result in decreased mobility of the SIJ
SIJ pain of unknown and dysfunctional movement of the SIJ.7
etiology.4 The SIJ plays One potential treatment option for SIJ
a vital role in the func­ pain is the utilization of Mulligan Concept
tional movement and Mobilizations with Movement (MWM). A
biomechanics of dance. MWM is a manual therapy intervention devel­
Turnout, or extreme oped by Brian Mulligan and couples acces­
external rotation of the sory mobilizations with physiological motion
hip, combined with the to treat positional faults of joints.8 Mulligan
extreme range of hip
extension can place the
proposed that positional faults may result in
subtle joint mal-alignment, which produces
pelvis and lumbar spine altered joint function, pain, or decreased

INTERNATIONAL JOURNAL OF ATHLETIC THERAPY & TRAINING MAY 2015 I 31

 range of motion.8 To date, the physiological process
by which positional faults may cause musculoskeletal
pain or dysfunction has not been clearly identified.9
The MWMs used in this case series consisted of a pos­
terior innominate, where the ilium is posteriorly rotated
on the sacrum and an anterior innominate, where the
ilium is anteriorly rotated on the sacrum.8-9 To date, no
research has been published investigating the use of
MWMs for treatment of SIJ dysfunction.
Another option for treating SIJ pain is to use the
selective functional movement assessment (SFMA), an
assessment instrument used to capture dysfunction
from a regional interdependence model and identify
appropriate intervention strategies based on those
findings.10 The purpose of the SFMA is to provide a
systematic approach to rank the quality of movement
(e.g., full range of motion during movement) and the
provocation of symptoms during a movement.10 Once
a top-tier assessment is completed, patients proceed
through any breakouts that may be needed.
A breakout is performed any time a movement is
not classified as functional nonpainful and is completed
by the clinician using a movement pattern isolation
map to identify potential causes for the dysfunction or
faulty movement patterns. Breakouts are used to help
guide the clinician to the area of dysfunction. Clinicians
should break down painful movements after dysfunc­
tional movements to reduce unnecessary pain provoca­
tion.10 Each breakout ends with one, or a combination
of three, patient classifications: (1) tissue extensibility
dysfunction (TED), (2) joint mobility dysfunction (JMD),
or (3) stability or motor control dysfunction (SMCD). A
TED could produce a dysfunctional nonpainful pattern
by having dysfunctional movement, usually of tissues
that span more than one joint (e.g., shortened tendons
or scar tissue).10 A JMD could produce a dysfunctional
nonpainful pattern due to the articular surfaces and
contractile and noncontractile tissues that connect
them having reduced mobility (e.g., facet syndrome).10
A SMCD could result in a dysfunctional nonpainful pat­
tern in two ways, either due to a stability dysfunction or
due to a motor control dysfunction (e.g., neurological
Ta ble 1 4 x 4
1—Nonweight Bearing 1—No resistance (pattern assistance)
2— Quadruped 2—No resistance
3— Kneeling 3—Resistance (pattern assistance)
4— Standing_________ 4—Resistance
32 I MAY 2015
processing issue).10 Once a breakout has been classi­
fied, the clinician should perform treatment and cor­
rective strategies based on the functional diagnosis.10
Once a dysfunctional movement pattern is iden­
tified, the SFMA can also be used as an intervention
using the paradigm of reset, reinforce, and reload.10
Resetting includes using manual therapy techniques,
such as the Mulligan concept, to treat the dysfunction
(e.g., JMD). Reinforce includes stretching exercises,
soft tissue mobilization, and forms of biofeedback
(e.g., kinesiology taping), and reload includes thera­
peutic exercises to improve dynamic loading.10 The 4
x 4 matrix is a functional exercise progression that
begins in nonweight bearing and no resistance, and
then progresses to standing and resistance (Table 1).
The 4 x 4 matrix can be used as a progression model
for increasing load and difficulty of exercises for the
patient.
The purpose of this investigation was to use the
SFMA and Mulligan mobilizations with movement
(MWM) on recreational dance patients who complained
of SIJ pain. Questions being investigated were: (a)
Does SFMA intervention and Mulligan MWM decrease
the level of impairment in patients suffering from SIJ
pain as measured by the Disablement in the Physi­
cally Active (DPA) scale? (b) Does SFMA intervention
and Mulligan MWM decrease patients’ reported pain
on the Numeric Pain Rating Scale (NPRS)?11-12 (c) Do
dancers with SIJ pain present with similar movement
dysfunctions as determ ined by an SFMA exam?
We documented the outcomes of three consecutive
patients who were diagnosed with SIJ pain and treated
with SFMA interventions and Mulligan MWM.
M e th o d s
An a priori case series analysis was used for the design
for this study. Three consecutive recreational dance
patients who presented to the Dance Medicine Clinic
complaining of SIJ pain were included in the study. The
patient population was a sample of convenience. All
patients were evaluated by an athletic trainer currently
Ma t r ix '0
INTERNATIONAL JOURNAL OF ATHLETIC THERAPY & TRAINING
enrolled in a doctoral program, with seven years’ expe­
rience and one year of experience using the Mulligan
concept. Patients were evaluated using a traditional
orthopedic evaluation.13 Once the orthopedic evalua­
tion was completed, patients were then taken through
the SFMA. Patients were classified into one of four
groups: (1) functional nonpainful, in which movem ent
is nonpainful and of great quality as defined by having
m ovem ent that is of full ROM and no symptoms; (2)
functional painful, in which the patient can perform
the m ovem ent with great quality but has pain with it;
(3) dysfunctional painful, in which the patient has an
abnormal movem ent pattern and associated pain with
movement; or (4) dysfunctional nonpainful, in which
the patient has a dysfunctional movem ent pattern, but
does not have pain with the m ovem ent.10
Clinical outcom es utilizing patient-oriented evi­
dence to determ ine the effectiveness of MWM and the
SFMA as an intervention for SIJ pain are limited. There­
fore, once the evaluations were completed, patients
were then given patient-report outcome measures, the
DPA scale, and the NPRS. The DPA scale is a patient-re­
ported outcome instrum ent designed for the physically
active. The DPA scale includes four outcomes measures,
measures of impairments (IMPs), functional limitations
(FLs), and disability (DIS), and includes questions
regarding health-related quality-of-life (HRQOL).14
The DPA is scored from 0 (floor) to 64 (ceiling), with
16 points being subtracted from the final tally to pro­
duce the patient’s score at that tim e.15 A change of 6
points for acute injury and 9 points for chronic injury
is considered a minimal clinically-important difference
(MCID).l5The NPRS is commonly used to measure pain
intensity with patients being asked to rate their pain on
a 0 (no pain) to 10 (worst possible pain) rating scale."
A 2 point change on the NPRS is considered a MCID."
Case Descriptions
History. A sum m ary of each patient’s history is pro­
vided in Table 2. Each patient had a positive FABER
(flexion, abduction, external rotation) test for pain over
the SIJ and positive lumbar quadrant test for pain over
the SIJ while extending and rotating toward the side
that was bothersome. Each of the patients denied any
history of spinal trauma, hip, or thigh pathology. Active,
passive, and resistive range of motion assessm ent in
trunk flexion and trunk extension did elicit pain in
each patient. Leg-length testing and the neurological
exam were unremarkable. All components of the exam­
INTERNATIONAL JOURNAL OF ATHLETIC THERAPY & TRAINING
ination and treatm ent of each patient were provided
by the sam e clinician. The institutional review board
com m ittee approved this study and each patient gave
written consent before initial evaluation for inclusion
in the study.
Intervention. A Mulligan MWM utilizing the foun­
dational principles described by Mulligan in his text
were adm inistered by the sam e treating clinician in
each clinical case.8 The direction of the applied mobi­
lization was dependent on the innom inate rotation of
each patient. Each MWM was performed in three sets
of 10 repetitions.8 The MWM technique applied was
based upon the recom m endations found in Mulligan
teachings and the “PILL” concept (i.e., pain free, imme­
diate effects that are long-lasting) was followed with
each patient during examination and treatm ent.8-16"7
Patients were expected to be pain free and experience
immediate relief while the MWM was being performed.
Exercises were selected for each patient based upon
the SFMA breakout findings, were based off of the 4 x
4 matrix of the SFMA, and were performed before the
Mulligan MWM intervention.10The top-tier of the SFMA
was not reassessed at discharge; only those patterns
that were dysfunctional were reassessed. All patients
were monitored for the rest of the academ ic semester.
To assess patient-reported outcomes a NPRS and
the DPA scale were used pre- and postintervention.
Patients completed NPRS pre- and postintervention
at initial clinical examination and at each subsequent
treatm ent, including at discharge. The DPA scale was
completed as part of the initial clinical examination,
at the end of each week, and at discharge. If a patient
was discharged before the end of a week, the patient
would complete the DPA scale during the discharge
visit. All of the patients were instructed not to perform
any other exercises or treatm ents during this time, but
were allowed to continue to participate in dance activ­
ities as normal. Patients were discharged upon being
pain free during dance activities and at rest, displaying
negative special tests (i.e., FABER, lumbar quadrant,
and long-sit tests), displaying functional nonpainful
m ovem ent patterns in previously impaired patterns,
and reporting a clinically-relevant DPA scale score. A
clinically-relevant DPA scale score is a score that was
within the established range of healthy people who
have completed the DPA scale.15
Based upon the physical exam ination (e.g., palpa­
tion, long-sit test), patient 1 was classified as having an
anterior rotation of the left ilium. To address the ilial
MAY 2015 I 33
 Ta b l e 2 Summary of I n it ia l P h y s ic a l E x a m s
Age (Years) Years
P atient and Sex Dancing Exam
1 18/F 12 P a t i e n t 1, a r e c r e a t i o n a l d a n c e r , r e p o r t e d t o t h e D a n c e M e d i c i n e C l i n i c c o m p l a i n i n g
o f lo w b a c k p a in th a t h a d p e r s is te d fo r a m o n t h . T h e s p e c ific d a n c e m o v e m e n t th a t
c a u s e d t h e m o s t p a i n w a s w h e n s h e l a i d s u p i n e f o r a b o u t 1 0 s, t h e n j u m p e d u p i n t o a
P lie p o s itio n . S h e r e p o r t e d h e r p a i n a s a 3 /1 0 o n th e N R P S w h ile d a n c i n g a n d a 3 /1 0
a t r e s t. C lin ic a l e v a l u a t i o n r e v e a l e d p a i n ( 5 /1 0 ) u p o n p a l p a t i o n o f t h e le f t Slj f r o m t h e
P SIS to t h e in f e r io r s a c ra l a n g le . T h e FA BER a n d l u m b a r q u a d r a n t t e s t s w e r e p o s itiv e
f o r Slj p a i n . P a l p a t i o n o f p e l v i c l a n d m a r k s a n d a p o s i t i v e lo n g - s i t t e s t i n d i c a t e d a n t e ­
r i o r r o t a t i o n o f t h e l e f t i n n o m i n a t e . H e r S F M A r e s u l t e d in a D N c l a s s i f i c a t i o n f o r t h e
th ir d c e r v ic a l p a t t e r n to th e rig h t, m u l t i s e g m e n t a l f le x io n , m u l t i s e g m e n t a l r o t a ti o n to
t h e rig h t, s in g le -le g s t a n c e (b ila te ra l), a n d o v e r h e a d s q u a t. H e r SFM A b r e a k o u t s in d i­
c a te d a SM C D ; th e in c o r p o r a tio n o f a M W M in to th e e v a lu a tio n in d ic a te d a n a n te r io r
p o s i t i o n a l f a u l t o f t h e S lj, w h i c h s i g n i f i e d t h e M W M w a s a n a p p r o p r i a t e i n t e r v e n t i o n .
T h e re m a in d e r o f th e o rth o p e d ic ev a lu a tio n w a s u n re m a rk a b le a n d sh e re p o rte d an
in itial D P A s c a l e s c o r e o f 3 1 .

2 19/F 16 P a tie n t 2, a r e c r e a ti o n a l d a n c e r , r e p o r t e d to th e D a n c e M e d ic in e C lin ic c o m p l a i n i n g o f

lo w b a c k p a in th a t h a d p e r s is te d for 12 m o n t h s . S h e h a d s o u g h t o u t o t h e r t r e a t m e n t
(e.g ., e le c t r i c s t i m u l a t i o n , t h e r a p e u t i c e x e r c i s e s ) p r e v i o u s l y f r o m o t h e r c l i n i c i a n s w i t h ­
o u t a n i m p r o v e m e n t i n h e r r e p o r t e d p a i n l e v e l . T h e p a t i e n t r e p o r t e d t h a t all s i n g l e - l e g
f u n c tio n a l m o v e m e n t s , s u c h a s t u r n i n g o r s q u a t t i n g , p r o d u c e d p a i n (7 /1 0 ) o n t h e left
s id e d u r in g d a n c e a c tiv itie s. W h ile a t re st, h e r p a in w a s r e p o r te d a s a 6 /1 0 o n th e
N P R S . C l i n i c a l e v a l u a t i o n r e v e a l e d p a i n w i t h p a l p a t i o n ( 5 / 1 0 ) o f t h e l e f t SIJ f r o m t h e
P SIS to th e in f e r io r s a c r a l a n g le . T h e FABER a n d l u m b a r q u a d r a n t te s ts w e r e p o s itiv e
f o r SIJ p a i n . P a l p a t i o n o f p e l v i c l a n d m a r k s a n d a p o s i t i v e l o n g - s i t t e s t i n d i c a t e d p o s ­
t e r i o r r o t a t i o n o f t h e left i n n o m i n a t e . H e r S F M A r e s u l t s i n c l u d e d D P p a t t e r n s d u r i n g
m u ltis e g m e n ta l flex io n a n d e x te n s io n a n d o v e r h e a d sq u a t. S h e h a d DN p a tte r n s
d u r i n g m u l t i s e g m e n t a l r o t a t i o n to t h e r i g h t a n d s in g le - l e g s t a n c e (b ila te ra l). H e r S F M A
b r e a k o u t s in d ic a te d a n e x te n s io n JM D a n d a SM C D . T h is led u s to c h o o s e M W M a s a n
i n t e r v e n t i o n to a d d r e s s t h e p o s t e r i o r p o s i t i o n a l fau lt. T h e r e m a i n d e r o f t h e o r t h o p e d i c
e v a l u a t i o n w a s u n r e m a r k a b l e a n d s h e r e p o r t e d a n in itial D PA s c a l e s c o r e o f 4 9 .

3 18/F 2 P a ti e n t 3 , a r e c r e a ti o n a l d a n c e r , p r e s e n t e d to t h e D a n c e M e d ic in e C lin ic c o m p l a i n ­
i n g o f r i g h t SIJ p a i n w h i l e p a r t i c i p a t i n g in d a n c e a c t i v i t i e s . T h e d a n c e m a n e u v e r t h a t
p r o d u c e d th e m o s t p a in (8 /1 0 ) w a s g o in g f r o m a sin g le -le g s t a n c e to a s q u a t w h e r e
s h e m o v e d h e r h a n d a c r o s s t h e fl o o r a n d t h e n r e t u r n e d to a fu lly e r e c t p o s i t i o n . S h e
r e p o r t e d t h a t h e r c u r r e n t p a i n h a d p e r s i s t e d fo r t h r e e d a y s b e f o r e r e p o r t i n g to th e
c lin ic fo r e v a lu a tio n . C lin ical e v a lu a tio n r e v e a l e d p a in (7 /1 0 ) w ith p a l p a t i o n o v e r th e
r i g h t SIJ t h a t r e f e r r e d i n t o h e r g l u t e u s m a x i m u s . T h e F A B E R a n d l u m b a r q u a d r a n t
t e s t s w e r e p o s i t i v e f o r SIJ p a i n . P a l p a t i o n o f p e l v i c l a n d m a r k s a n d a p o s i t i v e l o n g - s i t
te s t in d ic a te d a n a n te r io r ro ta tio n o f th e rig h t in n o m in a te . H e r SFM A re s u lts in c lu d e d
a FP p a t t e r n d u r i n g th e first c e r v ic a l p a t t e r n a n d m u l t i s e g m e n t a l r o t a ti o n to t h e rig h t.
S h e h a d a DN p a tt e r n w ith m u l ti s e g m e n ta l fle x io n a n d a D P p a tt e r n w ith sin g le -le g
s t a n c e (rig h t s id e o n ly ) a n d o v e r h e a d s q u a t. H e r S F M A b r e a k o u t s in d i c a t e d a h ip JM D ;
th e in c o r p o r a tio n o f a M W M in to th e e v a lu a tio n in d ic a te d a n a n te r io r p o s itio n a l fault
o f t h e SIJ, w h i c h s i g n i f i e d t h e M W M w a s a n a p p r o p r i a t e i n t e r v e n t i o n . T h e r e m a i n d e r
o f t h e o r t h o p e d i c e v a l u a t i o n w a s u n r e m a r k a b l e a n d s h e r e p o r t e d a n in itial D PA s c a l e
s c o r e o f 15.
Note. NRPS = Numeric Pain Rating Scale; SIJ = sacroiliac joint; PSIS = posterior superior iliac spine; FABER = flexion, abduction, external rotation: SFMA =
selective functional movement assessment: DN = dysfunctional nonpainful; SMCD = stability motor control dysfunction; MWM = mobilizations with movement;
DPA = Disablement in the Physically Active; DP = dysfunctional painful; JMD = joint mobility dysfunction; FP = functional painful.

34 I MAY 2015 INTERNATIONAL JOURNAL OF ATHLETIC THERAPY & TRAINING

rotation, an anterior MWM was applied. The MWM was Changes in DPA Scale Scores
performed by grasping and rotating the effected ilium
posteriorly while stabilizing the sacrum and having
the patient perform a prone press-up. The MWM was
applied nonweight bearing for three sets of 10 repeti­
tions during each treatment session. Rolling techniques
were performed to address the core SMCD identified
during the SFMA. The technique involved the patient
rolling from prone to supine on both sides, while using
the lower extremities and lumbar spine to initiate the
movement. Rolling patterns were performed to assist
with resetting foundational core stability and motor
control patterns.10 Figure I Disablement in the Physically Active (DPA) scale scores. *Note
during initial evaluation all DPA scale scores were obtained. Patient 1
Based upon physical examination (e.g., palpation, completed the DPA scale at 7 days (discharge). Patient 2 completed the
long-sit test), patient 2 was classified as having a DPA scale at 7 days and 18 days (discharge). Patient 3 completed the DPA
scale at 5 days (discharge).
posterior rotation to the left ilium. To address the ilial
rotation, a posterior MWM was applied. The MWM
was performed with clinician mobilization of the SiJ Changes in NPRS Scores
anterolaterally through the thenar eminence on the
posterior superior iliac spine and counter pressure on
the other ilium to prevent the patient from rolling.8
The patient also performed prone press-ups during
the MWM. The MWM was applied for three sets of 10
repetitions during each treatment session. The SFMA
breakouts led to stability exercises starting with pelvic
tilts, progressing into a quadruped pattern, and finally
finishing with double knee to single knee stability
exercises to address the identified SMCD.
Based upon physical examination (e.g., palpation, Figure 2 Numeric Pain Rating Scale (NPRS) scores from initial evaluation
long-sit test), patient 3 was classified as having an to discharge.
anterior rotation to the left ilium. To address the ilial
rotation, an anterior MWM was applied in the same
manner as described for patient 1. The MWM was dysfunctional movement in the multisegmental flexion,
applied in nonweight bearing for three sets of 10 single-leg stance, and overhead squat patterns using
repetitions during each treatment session. The SFMA the SFMA. Two of the three patients (patients 1 and
breakouts led to the identification of a JMD of the hip. 2) also had a core stability or motor control dysfunc­
Pelvic tilts and opposite arm-leg motion in a quadru­ tion using the SFMA. All three patients’ dysfunctional
ped position were performed to address the JMD. The individual SFMA movement patterns improved from
exercises were also meant to assist with the stability dysfunctional to functional postintervention.
of the pelvic girdle.

R e s u lts
From initial treatment to patient discharge, patients 1
and 2 experienced a MC1D on the DPA scale (9 points)
for chronic pain, while patient 3 experienced a MCID
for acute pain (6 points) (Figure 1).I4J5 Patient 3 was
the only patient who was classified as being in acute
pain. All three patients also experienced a MCID on the
NPRS (2 points) (Figure 2).n-12 All three patients had
D is c u s s io n
Based on clinically-significant improvements on the
NPRS, DPA scale, and SFMA classification, the com­
bination of SFMA and MWM intervention was an
effective intervention for the three patients in this case
series. All improvements were maintained until the
end of the semester, an average of 52 days following
intervention. The lack of a MCID for patient 3 on the
DPA scale may have been the result of her presenting

INTERNATIONAL JOURNAL OF ATHLETIC THERAPY & TRAINING MAY 2015 I 35

with an initial score that would be considered low for
persistent injury and within the range of scores of an
uninjured population based on previous research.14
While the treatm ent intervention resulted in clini-
cally-significant results for each patient, variance was
present regarding the num ber of treatm en ts until
discharge (Table 3). In this case series, it was noted
that patients with a longer duration of sym ptom s
(i.e., patients 1 and 2) required more treatm ents until
discharge. All three patients were able to continue to
participate in dance activities without restriction, while
also completing the full dance season without a return
of their original complaint. Following her discharge,
patient 3 did later report pain (rated 1/10 on the NPRS),
but continued to participate in her dance activities
without further treatm ent or exacerbation of pain.
Another interesting result of the case series was
the identification of a consistent pattern during the
perform ance of the SFMA. In each case, the patient
presented with dysfunctional multisegmental flexion,
single-leg stance, and overhead squat m ovem ent pat­
terns. While the exact cause of this is unknown, pain
and joint centration issues are possible explanations.
Multisegmental flexion dysfunction may have resulted
from pain10or altered biomechanics at the pelvic girdle,
limiting flexion.18 The overhead squat and single-leg
stance movem ent patterns may have resulted from
pelvic girdle dysfunction limiting m otion18 or pain
inhibiting appropriate motor control during the move­
m ent pattern.10 Further research should be conducted
to determ ine if these m ovem ent pattern dysfunctions
are commonly present in dancers with SIJ pain.
Previous research investigations have examined
the effect of manual therapy on treating SIJ pain.19-21
Cibulka19 exam ined a manipulative technique in a
case study of a patient with SIJ pain. The technique
involved the patient lying supine with their hands inter­
connected behind their head; with the clinician stabi­
36 I MAY 2015
lizing the anterior superior iliac spine of the opposite
side, the clinician brings the torso up and performs a
m anipulation.19 He concluded that manipulation could
be an effective manual therapy for patients with SIJ
pain.19 Erhard et al.20 exam ined patients with low back
pain and classified them into an extension exercise
group and a mobilization group.20 The exercise group
was treated with the McKenzie philosophy, while the
mobilization group was treated using the sam e tech­
nique as described by Cibulka.19'20 Erhard et al.20 found
that mobilization followed by general lumbar range of
motion exercises improved patients’ Oswestry Disabil­
ity scores more rapidly than exercise alone. Visser et
al.21 dem onstrated a 72% success rate in decreasing
pain with two treatm ents over the course of two weeks
in patients with SIJ pain receiving high-velocity low
amplitude (HVLA) thrust manipulations.21
In comparison, our results suggest even though
different outcome m easures were assessed than other
studies, that a combined intervention aimed at treat­
ing m ovem ent dysfunction and positional faults in
an individualized fashion may be effective (i.e., fewer
treatments, improved patient- and clinician-outcomes)
in treating SIJ pain. Despite the fact that dancers are
perceived to be more hypermobile com pared with the
average patient,22 the use of the SFMA was still able
to identify m ovem ent dysfunction in this population.
Using a m ovement assessm ent tool, such as the SFMA,
may be valuable in helping clinicians detect movement
dysfunction that may be related to SIJ pain. In addition,
MWM may be able to be com bined with SFMA-based
interventions to immediately result in a decrease of
pain and improved movement.
L im ita tio n s
The lack of a comparison group of patients with similar
clinical presentation used to confirm therapeutic bene­
fit is a primary limitation in this study; however, as this
INTERNATIONAL JOURNAL OF ATHLETIC THERAPY & TRAINING
was an a priori designed case series, the results can be
valued with greater strength than a retrospective case
series. Only having three patients in the case series was
a limitation, as having access to more patients possibly
allows for better identification of trends present when
using the SFMA in this population. The use of a specific
functional outcome scale, such as the Patient-Specific
Functional Scale and the use of the Oswestry Back
Index could have been used so that the results could
be more easily compared with other studies of SIJ pain.
Additional research is needed to determine the effec­
tiveness of Mulligan MWM and SFMA interventions on
treating SIJ pain.
C onclusion
For this case series, the use of the SFMA and Mul­
ligan MWM interventions was associated with clin-
ically-significant improvements in pain using the
NPRS, disability using the DPA scale, and functional
movement using the SFMA for each patient. The
ability to use patient outcome measures to effectively
demonstrate whether a specific intervention choice
produces a meaningful change for the patient is vital
when examining the effectiveness of an intervention.
Given that three consecutive patients with SIJ pain of
varying duration (3 days to 12 months) improved in
an average of 4.3 treatments, it would suggest that this
intervention strategy was successful. Although our find­
ings demonstrate the effectiveness of this intervention
strategy, more research is needed to determine the
physiological changes occurring, the effectiveness of
each technique, and if the results are dependent upon
specific classification as a responder to this approach
at initial examination. I
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Ryan K rzyzan ow icz is with the D epartm ent of Biology, Massachusetts
College of Liberal Arts, North Adams, MA.
Russell Baker and Alan N asypany are with the D epartm ent of Move­
m ent Sciences, University of Idaho, Moscow, ID.
J eff Seegm iller is the director of Medical Education for WWAMI, Uni­
versity of Idaho, Moscow, ID.
Frank Gargano is with Rehabilitex, Solon, OH.
M atthew Hoch, PhD, ATC, Old Dominion University, is the report
editor for this article.
MAY 2015 I 37
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