The Open Pain Journal




ISSN: 1876-3863 ― Volume 12, 2019
RESEARCH ARTICLE

Sacroiliac Joint Pain: A Study of Predisposing Factors in an Indonesian Hospital



Yusak M.T. Siahaan*, Vinson Hartoyo
Department of Neurology, Siloam Hospital Lippo Villagen, Jalan Boulevard Jendral Sudirman, Tangerang 15811, Indonesia

Abstract

Background:

Sacroiliac joint pain has been one of the most common causes of lower back pain, regardless of gender. Diminished pain after an anaesthetic block has been the only gold standard diagnostic procedure, making the diagnosis become challenging due to the needs of fluoroscopic procedure. Thus, a study to find predisposing factors of sacroiliac joint pain is pivotal for primary prevention and prognosis predictor.

Objective:

Our study aims to find predisposing factors of sacroiliac joint pain in Indonesian patients.

Methods:

We conducted a prospective study on patients with a chief complaint of lower back pain whose pain diminished after anaesthetic block.

Results:

We found 99 subjects, with a male to female ratio of 1:2.19, aged from 21 to 75 years old (mean: 42.88). In addition to multiparous pregnancy and obesity, office-based occupation and prolonged sitting duration are also becoming major predisposing factors of sacroiliac joint pain (50.5% and 51.51% respectively). We also found majority of the patients with a history of vertical trauma with the onset of pain 1 year post trauma.

Conclusion:

We found some factors that can be considered to trigger sacroiliac joint pain that are: female gender, advancing age, pregnancy history, long sitting duration and office worker occupation.

Keywords: Indonesia, Low back pain, Predisposing factors, Sacroiliac joint pain, Multiparous pregnancy, Vertical trauma.


Article Information


Identifiers and Pagination:

Year: 2019
Volume: 12
First Page: 1
Last Page: 5
Publisher Id: TOPAINJ-12-1
DOI: 10.2174/1876386301912010001

Article History:

Received Date: 12/05/2018
Revision Received Date: 27/11/2018
Acceptance Date: 11/01/2019
Electronic publication date: 19/02/2019
Collection year: 2019

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© 2019 Siahaan and Hartoyo.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at Department of Neurology, Siloam Hospital Lippo Villagen, Jalan Boulevard Jendral Sudirman, Tangerang 15811, Indonesia; Tel: +6221 0815 8627 0028; E-mail: yusak.mangara@siloamhospitals.com





1. INTRODUCTION

Sacroiliac joint pain is defined as pain originating from unusual movement in the sacroiliac joint structure. The pain provoked by sacroiliac joint dysfunction can cause a range of disabilities, including a continuously intense pain level accompanied by a limited range of motion. Sacroiliac joint pain has become one of the biggest contributors to lower back pain of mechanical origin, regardless of gender. It has been estimated that 13% of prolonged lower back pain cases are caused by sacroiliac joint pain, which has a prevalence of 15–38%. Women have a 3–4 times higher risk of suffering from sacroiliac joint pain than men [1Cohen SP, Chen Y, Neufeld NJ. Sacroiliac joint pain: a comprehensive review of epidemiology, diagnosis and treatment. Expert Rev Neurother 2013; 13(1): 99-116.
[http://dx.doi.org/10.1586/ern.12.148] [PMID: 23253394]
-3Manchikanti L, Singh V, Falco FJE, Benyamin RM, Hirsch JA. Epidemiology of low back pain in adults. Neuromodulation 2014; 17(Suppl. 2): 3-10.
[http://dx.doi.org/10.1111/ner.12018] [PMID: 25395111]
].

Diagnosing the pain caused by inflammation of the sacroiliac joint can be challenging due to its ambiguous clinical manifestations, which are difficult to distinguish from herniated intervertebral discs, facet joint pain, and gluteal muscle spasms. Radiological examinations, which usually help exclude other musculoskeletal disorders, have been proven to have low specificity and sensitivity in diagnosing sacroiliac joint pain, and they will, most likely, show no abnormalities [1Cohen SP, Chen Y, Neufeld NJ. Sacroiliac joint pain: a comprehensive review of epidemiology, diagnosis and treatment. Expert Rev Neurother 2013; 13(1): 99-116.
[http://dx.doi.org/10.1586/ern.12.148] [PMID: 23253394]
, 4Laslett M. Evidence-based diagnosis and treatment of the painful sacroiliac joint. J Manual Manip Ther 2008; 16(3): 142-52.
[http://dx.doi.org/10.1179/jmt.2008.16.3.142] [PMID: 19119403]
-6Visser LH, Nijssen PGN, Tijssen CC, van Middendorp JJ, Schieving J. Sciatica-like symptoms and the sacroiliac joint: clinical features and differential diagnosis. Eur Spine J 2013; 22(7): 1657-64.
[http://dx.doi.org/10.1007/s00586-013-2660-5] [PMID: 23455949]
]. Anesthetic blocks have long been considered the gold standard procedure for diagnosing sacroiliac joint pain, with the pain being alleviated after the injection. One disadvantage of this procedure is the requirement for supporting facilities, which can only be met in tertiary healthcare centers [7Simopoulos TT, Manchikanti L, Singh V, et al. A systematic evaluation of prevalence and diagnostic accuracy of sacroiliac joint interventions. Pain Physician 2012; 15(3): E305-44.
[PMID: 22622915]
].

Numerous studies have been conducted to gain more information about sacroiliac joint pain, including researching the factors that trigger this pain, which will contribute to improved diagnostic procedures. However, most of these studies have been conducted in the Western region, while the data about the predisposing factors for sacroiliac joint pain in the Eastern region is still lacking [4Laslett M. Evidence-based diagnosis and treatment of the painful sacroiliac joint. J Manual Manip Ther 2008; 16(3): 142-52.
[http://dx.doi.org/10.1179/jmt.2008.16.3.142] [PMID: 19119403]
, 8Irwin RW, Watson T, Minick RP, Ambrosius WT. Age, body mass index, and gender differences in sacroiliac joint pathology. Am J Phys Med Rehabil 2007; 86(1): 37-44.
[http://dx.doi.org/10.1097/PHM.0b013e31802b8554] [PMID: 17304687]
, 9Sabino J, Grauer JN. Pregnancy and low back pain. Curr Rev Musculoskelet Med 2008; 1(2): 137-41.
[http://dx.doi.org/10.1007/s12178-008-9021-8] [PMID: 19468887]
]. Therefore, we conducted a study to determine the clinical profile of patients with sacroiliac joint pain and its predisposing factors in Indonesia.

2. MATERIALS AND METHODS

This research study included 99 patients with age ranging from 17–75 years old who presented to the outpatient Neurology Clinic of Siloam Hospital Lippo Village in Tangerang, Indonesia, with chief complaints of pain in the buttock region, with or without radiation. Their physical examination findings included positive Fortin finger test results and positive results in 1 or 2 of the provocative tests. All patients included in this study were evaluated with regard to their predisposing factors, pain scores, and neurological examinations. Then, the diagnosis of sacroiliac joint pain was made by using an anesthetic block and observing a decrease in the pain score of more than 75%. The patients with autoimmune disease histories and disorders seen in their pelvic radiological scans were excluded from this study.

The injection procedure used in this study was based on the procedure from a study by Liliang et al. First, the patient was placed in a prone position on a fluoroscopy table in order to visualize the median line of the sacroiliac joint. Then, the fluoroscopy machine was placed in an ipsilateral oblique position and slowly moved 10– 20o towards the contralateral oblique position until optimal visualization of the hyperlucent region of the sacroiliac joint was obtained. The injection target was then located in the inferior medial part of the sacroiliac joint corresponding to the posterior side. Finally, a 2% lidocaine solution was injected medially, 1–2 cm above the inferior side of the sacroiliac joint [10Liliang PC, Liang CL, Lu K, Weng HC, Syu FK. Modified fluoroscopy-guided sacroiliac joint injection: a technical report. Pain Med 2014; 15(9): 1477-80.
[http://dx.doi.org/10.1111/pme.12492] [PMID: 25158990]
]. The pain score evaluation was conducted 15 minutes after the injection, and the results were deemed positive if there was a decrease of a minimum of 75% in the pain score.

3. RESULTS

A total of 99 subjects (31 males and 68 females, with a male to female ratio of 1:2.19) aged 21 to 75 years old (mean=42.88 years old) were included in this study (Table 1). The majority of the subjects were 40–49 years old (35.35%, n=35). Interestingly, the majority of the female subjects had pregnancy histories (79.41%, n=54), with sacroiliac joint pain being found more often in those subjects with histories of more than 3 pregnancies (30.9%, n=32) when compared to those with histories of 3 or less pregnancies (22.3%, n=22). When comparing the body mass indexes, we found that the majority of the subjects fell into the 25–29.9 kg/m2 range, which is categorized as overweight (28.3%). With regard to the occupational history, we found that the majority of the subjects (50.5%) worked in offices in which they spent most of their time sitting (8 hours or more). We also found that 54.5% of the subjects reported histories of lower back trauma (vertical fall) with post-trauma intervals of greater than 1 year (35.3%). Sacroiliac joint pain was also detected in those subjects who reported that they participated in routine exercise more than 4 times a week for a duration of more than 1 hour (10.1%, n=10). More than half of the subjects (51.51%, n=51) also reported prolonged sitting durations of more than 6 hours as one of the predisposing factors.

4. DISCUSSION

Sacroiliac joint pain is one of the most common causes of lower back pain encountered in daily practice. Numerous treatment modalities have been developed for lower back pain, including sacroiliac joint pain. Initially, a patient is usually prescribed conservative treatment, such as bed rest, anti-inflammatory medications, and physical therapy [2Cohen SP. Sacroiliac joint pain: a comprehensive review of anatomy, diagnosis, and treatment. Anesth Analg 2005; 101(5): 1440-53.
[http://dx.doi.org/10.1213/01.ANE.0000180831.60169.EA] [PMID: 16244008]
]. Interventional procedures (e.g., intra-articular injections) are reserved for those who fail to respond to conservative treatment. This type of treatment is usually administered using a freehand tech nique, such as unguided, palpation-guided, blind, or clinical examination-guided injections. However, some studies have indicated that these approaches are unreliable. One of the earliest studies conducted by Jones et al. reported a heterogeneous needle placement success rate [11Jones A, Regan M, Ledingham J, Pattrick M, Manhire A, Doherty M. Importance of placement of intra-articular steroid injections. BMJ 1993; 307(6915): 1329-30.
[http://dx.doi.org/10.1136/bmj.307.6915.1329] [PMID: 8257889]
]. A more recent study by Rosenberg et al. revealed that in 33 patients under going freehand sacroiliac joint injections, there were intra-articular needle placements in only 22% of the injections [12Rosenberg JM, Quint TJ, de Rosayro AM. Computerized tomographic localization of clinically-guided sacroiliac joint injections. Clin J Pain 2000; 16(1): 18-21.
[http://dx.doi.org/10.1097/00002508-200003000-00004] [PMID: 10741814]
]. Fortunately, ultrasound-guided sacroiliac joint injections have demonstrated high success rates of up to 90%, resulting in better clinical responses, which is one of the reasons why we chose the technique that we used in our study [13Pekkafahli MZ, Kiralp MZ, Başekim CC, et al. Sacroiliac joint injections performed with sonographic guidance. J Ultrasound Med 2003; 22(6): 553-9.
[http://dx.doi.org/10.7863/jum.2003.22.6.553] [PMID: 12795552]
, 14Koski JM, Hammer HB. Ultrasound-guided procedures: techniques and usefulness in controlling inflammation and disease progression. Rheumatology (Oxford) 2012; 51(Suppl. 7): vii31-5.
[http://dx.doi.org/10.1093/rheumatology/kes331] [PMID: 23230092]
].

Many studies have been conducted to determine the predisposing factors for sacroiliac joint pain. Some of the most important predisposing factors reported were the gender, age, body mass index, trauma history, and activity rate.

4.1. Gender and Age

Women have long been considered to have a greater risk of developing lower back pain than men. The lower back pain rate increases significantly during pregnancy, and it continues to increase after delivery. The differing anatomy of the female pelvic region, when compared to males, has been speculated to play a part in the distinctive functions of both pelvic regions. Overall, the sacrum to sacroiliac joint ratio is different between the genders, with significant changes observed in males with an advancing age [2Cohen SP. Sacroiliac joint pain: a comprehensive review of anatomy, diagnosis, and treatment. Anesth Analg 2005; 101(5): 1440-53.
[http://dx.doi.org/10.1213/01.ANE.0000180831.60169.EA] [PMID: 16244008]
, 8Irwin RW, Watson T, Minick RP, Ambrosius WT. Age, body mass index, and gender differences in sacroiliac joint pathology. Am J Phys Med Rehabil 2007; 86(1): 37-44.
[http://dx.doi.org/10.1097/PHM.0b013e31802b8554] [PMID: 17304687]
, 15Vleeming A, Schuenke MD, Masi AT, Carreiro JE, Danneels L, Willard FH. The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. J Anat 2012; 221(6): 537-67.
[http://dx.doi.org/10.1111/j.1469-7580.2012.01564.x] [PMID: 22994881]
].

Irwin et al. determined that the gender and age were not correlated with the pathological causes of sacroiliac joint pain, but they did find that sacroiliac joint pain occurred more commonly in females than males (61% and 39%, respectively) [8Irwin RW, Watson T, Minick RP, Ambrosius WT. Age, body mass index, and gender differences in sacroiliac joint pathology. Am J Phys Med Rehabil 2007; 86(1): 37-44.
[http://dx.doi.org/10.1097/PHM.0b013e31802b8554] [PMID: 17304687]
]. The results of that study were similar to those of a study by Taheri et al., which reported that sacroiliac joint pain was found more commonly in female patients (57.9%). That study also found an increased frequency in the 40–55 years old age group in both genders [16Taheri A, Moallemy A, Dehghanian A, Vatankhah P. Evaluation of the relationship between age, gender, and body mass index, and lumbar facet joint pain. Indian J Pain 2016; 30(1): 19-22.
[http://dx.doi.org/10.4103/0970-5333.173454]
]. These results support those from a study by DePalma et al., which reported that sacroiliac joint pain was associated with older age [17DePalma MJ, Ketchum JM, Saullo TR. Multivariable analyses of the relationships between age, gender, and body mass index and the source of chronic low back pain. Pain Med 2012; 13(4): 498-506.
[http://dx.doi.org/10.1111/j.1526-4637.2012.01339.x] [PMID: 22390231]
]. This increased frequency may be attributed to the diminishing flexibility of the ligaments with age [15Vleeming A, Schuenke MD, Masi AT, Carreiro JE, Danneels L, Willard FH. The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. J Anat 2012; 221(6): 537-67.
[http://dx.doi.org/10.1111/j.1469-7580.2012.01564.x] [PMID: 22994881]
].

Table 1
Demographic information and risk factors of the subjects.


4.2. Pregnancy

In our study, we found sacroiliac joint pain more often in female subjects with histories of 2 or 3 pregnancies when compared to those with fewer or none. A review by Pennick and Young in 2013 reported that 2 out of 3 pregnant women experienced pain in the sacroiliac joint region [18Pennick V, Young G. Interventions for preventing and treating pelvic and back pain in pregnancy. Cochrane Database Syst Rev 2017; 18: CD001139.]. Ghodke stated that out of 50 study subjects, 26% were women suffering from postpartum sacroiliac joint pain. This study also revealed that sacroiliac joint pain was more common in multiparous women [19Ghodke PS, Shete D, Anap D. Prevalence of Sacroiliac Joint Dysfunction in Postpartum Women-A Cross Sectional Study. J Physiother Phys Rehabil 2017; 02(03): 3-5.]. However, these results were not reported in the studies by Pennick and Young or Ghodke et al., but some of the factors that cause sacroiliac joint pain include the changes in the patency and strength of the pelvis due to hormonal fluctuation. An increase in the body weight, a lordotic posture, and widening of the pelvic outlet during labor also play roles in these changes to the pelvic anatomy [9Sabino J, Grauer JN. Pregnancy and low back pain. Curr Rev Musculoskelet Med 2008; 1(2): 137-41.
[http://dx.doi.org/10.1007/s12178-008-9021-8] [PMID: 19468887]
, 18Pennick V, Young G. Interventions for preventing and treating pelvic and back pain in pregnancy. Cochrane Database Syst Rev 2017; 18: CD001139.-21Munro A, George RB, Chorney J, Snelgrove-Clarke E, Rosen NO. Prevalence and predictors of chronic pain in pregnancy and postpartum. J Obstet Gynaecol Can 2017; 39(9): 734-41.
[http://dx.doi.org/10.1016/j.jogc.2017.01.026] [PMID: 28624445]
].

4.3. Body Mass Index

Obesity is becoming one of the major risk factors for sacroiliac joint dysfunction, which can trigger pain. This is mainly attributed to changes in the supporting cartilage, resulting in pain, stiffness, and restricted activity of the axial muscles [8Irwin RW, Watson T, Minick RP, Ambrosius WT. Age, body mass index, and gender differences in sacroiliac joint pathology. Am J Phys Med Rehabil 2007; 86(1): 37-44.
[http://dx.doi.org/10.1097/PHM.0b013e31802b8554] [PMID: 17304687]
]. Contrarily, this study showed that more than half of the subjects had normal body mass indexes when compared to previous studies.

4.4. Trauma

Holmes et al. conducted retrospective analyses showing that 44–58% of the patients with sacroiliac joint pain had trauma histories (e.g., falls, traffic accidents, exercise injuries, and fractures); however, the studies did not specify the exact percentages for each predisposing factor [22Holmes SL, Cohen SP, Cullen MFL, Kenny CD, Wain HJ, David S. Sacroiliac joint pain.Pain Medicine: An Interdiciplinary Case-Based Approach 2015; 160-82.
[http://dx.doi.org/10.1093/med/9780199931484.003.0010]
]. In our study, we found that 54.5% of the subjects reported fall trauma histories from 1 to 5 years before the first onset of sacroiliac joint pain. These results are consistent with those of the studies by Holmes et al. Fall trauma can eventually lead to damage in the ligaments that weave through the structure of the sacroiliac joint, causing anomalous joint movement and triggering pain from degenerative arthritis [1Cohen SP, Chen Y, Neufeld NJ. Sacroiliac joint pain: a comprehensive review of epidemiology, diagnosis and treatment. Expert Rev Neurother 2013; 13(1): 99-116.
[http://dx.doi.org/10.1586/ern.12.148] [PMID: 23253394]
, 22Holmes SL, Cohen SP, Cullen MFL, Kenny CD, Wain HJ, David S. Sacroiliac joint pain.Pain Medicine: An Interdiciplinary Case-Based Approach 2015; 160-82.
[http://dx.doi.org/10.1093/med/9780199931484.003.0010]
].

4.5. Activity Rate

We determined that the activity rate was one of the important predisposing factors for sacroiliac joint pain. The results of our study showed that the majority of our subjects (89.8%) did not exercise regularly, while only 10.2% reported that they participated in routine exercise regimens (4 or more times per week). It has been well established that heavy physical activity and a high exercise rate are among the risk factors of developing sacroiliac joint pain. Contrary to other research studies, we found that the majority of the patients were physically inactive. One possible theory proposed for these results was the reduced flexibility of the sacroiliac joint caused by the atrophy of the muscles and ligaments [23Teichtahl AJ, Urquhart DM, Wang Y, et al. Physical inactivity is associated with narrower lumbar intervertebral discs, high fat content of paraspinal muscles and low back pain and disability. Arthritis Res Ther 2015; 17(1): 114.
[http://dx.doi.org/10.1186/s13075-015-0629-y] [PMID: 25947906]
]. However, we believe that it is too soon to propose such a theory because further research is still needed.

4.6. Sitting Duration

In this study, 51% of the subjects reported long sitting durations during the day (more than 8 hours), while 44% reported that they sat for 1–3 hours. These findings correspond to the occupational histories of the subjects, 50.5% of which were office workers. Sitting can cause inflammation due to repetitive microtrauma, which causes stretching and damage in the main ligaments of the sacroiliac joint, leading to anomalous joint movements [24Kurosawa D, Murakami E, Ozawa H, et al. A diagnostic scoring system for sacroiliac joint pain originating from the posterior ligament. Pain Med 2017; 18(2): 228-38.
[PMID: 28204687]
, 25Kurosawa D, Murakami E, Aizawa T. Groin pain associated with sacroiliac joint dysfunction and lumbar disorders. Clin Neurol Neurosurg 2017; 161: 104-9.
[http://dx.doi.org/10.1016/j.clineuro.2017.08.018] [PMID: 28866262]
].

4.7. Occupational History

Our study revealed that office workers were more likely to develop sacroiliac joint pain due to their very long sitting position durations (more than 6 hours). As mentioned above, maintaining a sitting position for a long period of time is associated with repetitive microtrauma to the main ligaments that support the sacroiliac joint, leading to pain due to the degenerative arthritis process [26Lis AM, Black KM, Korn H, Nordin M. Association between sitting and occupational LBP. Eur Spine J 2007; 16(2): 283-98.
[http://dx.doi.org/10.1007/s00586-006-0143-7] [PMID: 16736200]
, 27Gupta N, Christiansen CS, Hallman DM, Korshøj M, Carneiro IG, Holtermann A. Is objectively measured sitting time associated with low back pain? A cross-sectional investigation in the NOMAD study. PLoS One 2015; 10(3): e0121159.
[http://dx.doi.org/10.1371/journal.pone.0121159] [PMID: 25806808]
].

CONCLUSION

The results of this study showed that some of the factors that trigger sacroiliac joint pain are the female gender, being in the 40–59 years old age group, a multiple pregnancy history, sitting for more than 6 hours during the day, and working in an office. However, further research is needed to determine whether there are other sacroiliac joint pain triggers, and to confirm our results.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

This study was approved by the ethical committee of Pelita Harapan University (ethical approval number 001/K-LKJ/ETIK/VIII/2017).

HUMAN AND ANIMAL RIGHTS

No Animals were used in this research. All human research procedures followed were in accordance with the ethical standards of the committee responsible for human experimentation (institutional and national), and with the Helsinki Declaration of 1975, as revised in 2013.

CONSENT FOR PUBLICATION

All participants provided written informed consent to participate.

CONFLICT OF INTEREST

Both authors of this study, Yusak Mangara Tua Siahaan and Vinson Hartoyo, declare that they have no biomedical financial interests or potential conflicts of interest.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

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[http://dx.doi.org/10.1097/PHM.0b013e31802b8554] [PMID: 17304687]
[9] Sabino J, Grauer JN. Pregnancy and low back pain. Curr Rev Musculoskelet Med 2008; 1(2): 137-41.
[http://dx.doi.org/10.1007/s12178-008-9021-8] [PMID: 19468887]
[10] Liliang PC, Liang CL, Lu K, Weng HC, Syu FK. Modified fluoroscopy-guided sacroiliac joint injection: a technical report. Pain Med 2014; 15(9): 1477-80.
[http://dx.doi.org/10.1111/pme.12492] [PMID: 25158990]
[11] Jones A, Regan M, Ledingham J, Pattrick M, Manhire A, Doherty M. Importance of placement of intra-articular steroid injections. BMJ 1993; 307(6915): 1329-30.
[http://dx.doi.org/10.1136/bmj.307.6915.1329] [PMID: 8257889]
[12] Rosenberg JM, Quint TJ, de Rosayro AM. Computerized tomographic localization of clinically-guided sacroiliac joint injections. Clin J Pain 2000; 16(1): 18-21.
[http://dx.doi.org/10.1097/00002508-200003000-00004] [PMID: 10741814]
[13] Pekkafahli MZ, Kiralp MZ, Başekim CC, et al. Sacroiliac joint injections performed with sonographic guidance. J Ultrasound Med 2003; 22(6): 553-9.
[http://dx.doi.org/10.7863/jum.2003.22.6.553] [PMID: 12795552]
[14] Koski JM, Hammer HB. Ultrasound-guided procedures: techniques and usefulness in controlling inflammation and disease progression. Rheumatology (Oxford) 2012; 51(Suppl. 7): vii31-5.
[http://dx.doi.org/10.1093/rheumatology/kes331] [PMID: 23230092]
[15] Vleeming A, Schuenke MD, Masi AT, Carreiro JE, Danneels L, Willard FH. The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. J Anat 2012; 221(6): 537-67.
[http://dx.doi.org/10.1111/j.1469-7580.2012.01564.x] [PMID: 22994881]
[16] Taheri A, Moallemy A, Dehghanian A, Vatankhah P. Evaluation of the relationship between age, gender, and body mass index, and lumbar facet joint pain. Indian J Pain 2016; 30(1): 19-22.
[http://dx.doi.org/10.4103/0970-5333.173454]
[17] DePalma MJ, Ketchum JM, Saullo TR. Multivariable analyses of the relationships between age, gender, and body mass index and the source of chronic low back pain. Pain Med 2012; 13(4): 498-506.
[http://dx.doi.org/10.1111/j.1526-4637.2012.01339.x] [PMID: 22390231]
[18] Pennick V, Young G. Interventions for preventing and treating pelvic and back pain in pregnancy. Cochrane Database Syst Rev 2017; 18: CD001139.
[19] Ghodke PS, Shete D, Anap D. Prevalence of Sacroiliac Joint Dysfunction in Postpartum Women-A Cross Sectional Study. J Physiother Phys Rehabil 2017; 02(03): 3-5.
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Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


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