Research Report
Effectiveness of Adding a Pelvic Compression
Belt to Lumbopelvic Stabilization Exercises for
Women With Sacroiliac Joint Pain: A Feasibility
Randomized Clinical Trial
Kelli J. Brizzolara, PT, PhD, OCS1
Sharon Wang-Price, PT, PhD, OCS, COMT, FAAOMPT1
Toni S. Roddey, PT, PhD, OCS, FAAOMPT2
Ann Medley, PT, PhD, CEEAA1
ABSTRACT
Objectives: To examine the effects of lumbopelvic stabi-
lization exercises (LSE) and pelvic compression belts on
muscle behavior in women with sacroiliac joint.
Study Design: Feasibility randomized clinical trial.
Background: Patients with unilateral lumbopelvic pain
have been shown to have altered muscle recruitment pat-
terns of the transverse abdominis (TrA) and internal oblique
muscles. The effects of LSE and pelvic compression belts
on muscle behavior are unknown in this population.
Methods and Measures: Twenty-five women with unilat-
eral sacroiliac joint pain were randomly assigned to the
LSE plus belt (LSE + belt) group or the LSE group. Both
groups received the same LSE for 12 weeks with the first
4 weeks under supervision. The LSE + belt group also
received a pelvic compression belt for the first 4 weeks.
Outcome measures, including the Modified Oswestry Low
Back Pain Disability Questionnaire, Numeric Pain Rating
Scale, and percent change of muscle thickness for the TrA
and internal oblique, were collected at baseline, 4 weeks,
and 12 weeks. In addition, Global Rating of Change Scale
scores were collected at 4 and 12 weeks.
Results: The analysis of variance results revealed no sig-
nificant interaction for Modified Oswestry Low Back Pain
Disability Questionnaire, Numeric Pain Rating Scale, or
1Texas Woman’s University, T. Boone Pickens Institute of
Health Sciences-Dallas, School of Physical Therapy.
2Texas Woman’s University, Institute of Health Sciences-
Houston, School of Physical Therapy.
This study was funded by a grant from the Texas Physical
Therapy Foundation.
The authors declare no conflicts of interest.
Supplemental digital content is available for this article.
Direct URL citations appear in the printed text and are
provided in the HTML and PDF versions of this article on
the journal’s Web site (http://journals.lww.com/jwhpt/pages/
default.aspx).
DOI: 10.1097/JWH.0000000000000102
Journal of Women’s Health Physical Therapy
Copyright © 2018 Section on Women’s Health, American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
percent change of TrA and internal oblique; however, all
had significant improvements in over time. There was no
significant difference in Global Rating of Change Scale
scores between groups.
Conclusion: The results of this feasibility study did not offer
clear evidence of the benefit of pelvic compression belt
over LSE for those with sacroiliac joint pain. All participants
demonstrated an increased muscle thickness of TrA in the
first 4 weeks.
Key Words: compression belt, lumbopelvic stabilization,
sacroiliac joint pain, ultrasound imaging
INTRODUCTION
The prevalence of low back pain (LBP) in the United
States remains at epidemic proportions, and it will
affect the majority of Americans at some point in
their lifetime.1–3 Low back pain is also the most
common cause of activity limitation and long-term
disability worldwide.3 Of those with nonspecific LBP,
the estimated prevalence of sacroiliac joint (SIJ) pain
is approximately 10% to 25%.4–7 Although patterns
of SIJ pain vary from patient to patient, one com-
mon presentation is unilateral pain and localized
tenderness to moderate to deep palpation over the SIJ
region.8–10 Patients with unilateral lumbopelvic pain
have been shown to have altered muscle recruitment
patterns of the transverse abdominis (TrA) and inter-
nal oblique (IO) muscles.11–14 Lumbopelvic stabiliza-
tion exercises (LSE) and pelvic compression belts are
2 therapeutic interventions prescribed by physical
therapists that are thought to directly impact muscle
recruitment.
The underlying principle of LSE is retraining the
proper activation and coordination of trunk mus-
culature to increase spinal stability and to reduce
pain.15–21 Specifically, research has found a delayed
© 2018 Section on Women’s Health, American Physical Therapy Association 1
Research Report
and decreased activation of the TrA in patients with
LBP.11,22,23 A study by Teyhen et al14 demonstrated
that those with unilateral lumbopelvic pain showed
a smaller increase in thickness of the TrA during the
abdominal drawing-in maneuver using ultrasound
imaging. These findings indicate that patients with
unilateral lumbopelvic pain may have a decreased
ability to preferentially contract the TrA muscle,
which is an important segmental stabilizer of the lum-
bopelvic spine and is one of the fundamental muscles
targeted in LSE.14,24
Lumbopelvic stabilization exercises are widely used
by physical therapists and have been shown to suc-
cessfully decrease pain and disability in patients with
LBP.25–30 However, it is unknown exactly how many, if
any, of these patients would have been diagnosed with
SIJ pathology as their primary source of pain. This
subgroup can be difficult to define, as it is not uncom-
mon for patients with SIJ pain to have impairments
related to their lumbar spine concomitantly. To date,
no randomized controlled trials have documented the
effectiveness of LSE specifically for patients with SIJ as
the primary pain provocative structure.
A pelvic compression belt is another interven-
tion commonly prescribed to patients with SIJ pain
and dysfunction to limit SIJ motion, decrease pain,
and provide proprioceptive awareness.31,32 Although
there is limited evidence of the effectiveness of pelvic
compression belts, it has been shown that wearing a
belt can decrease SIJ motion by approximately 30%
when worn appropriately.33 To date, randomized
controlled trials evaluating the effectiveness of pelvic
compression belts have been conducted primarily
with the peripartum population. These studies have
reported positive outcomes in pain and activity levels
when pregnant women were given pelvic compression
belts as a part of a treatment plan.34,35 Furthermore,
there have been no studies examining the effect of
pelvic compression belts on muscular activation of
the deep abdominals, specifically the TrA and the IO,
using ultrasound imaging.
Ultrasound imaging is a noninvasive tool that
has been used to examine muscle behavior of the
TrA and IO muscles during a variety of functional
tasks.11,14,36,37 It has been established as a reli-
able38–41 and valid tool for assessing muscle thick-
ness,42,43 which can be considered one construct of
muscle function. Ultrasound imaging has been used
in patients with LBP11,28,30,36 and patients with SIJ
pain12–14 to demonstrate changes in muscle function
in these 2 populations.
Therefore, the primary purpose of this feasibility
study was to evaluate the effectiveness of using a
compression belt in addition to LSE in patients with
SIJ pain on disability level, pain intensity, and per-
cent change of muscle thickness for the TrA and the
2 © 2018 Section on Women’s Health, American Physical Therapy Association
Copyright © 2018 Section on Women’s Health, American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
IO. The secondary purpose was to assess (a) overall
perceived improvement for patients with SIJ pain, (b)
adherence to the exercise program, and (c) compli-
ance with the use of the pelvic compression belt.
METHODS
This feasibility study was a single-blinded, mixed-
design randomized clinical trial that was conduct-
ed in a university-based research center in Dallas,
Texas. The study was approved by the authors’
affiliated institutional review board and registered
at ClinicalTrials.gov (NCT01559948). Twenty-five
women with SIJ pain who were not currently being
treated for musculoskeletal pain were recruited from
the local area via flyers and word-of-mouth market-
ing. The inclusion criteria were women aged 18 to
65 years of any ethnicity with unilateral LBP that did
not extend past the knee and had tenderness with
moderate to deep palpation at the SIJ.8–10 In addition,
eligible participants had at least 2 out of 6 positive
SIJ provocation tests,44–46 including the compression,
distraction, Gaenslen down-leg, Gaenslens up-leg,
thigh thrust, and sacral thrust tests. A combination of
these 6 tests has been shown to be sensitive and spe-
cific for a clinical diagnosis of symptomatic SIJ.44–46
Three or more positive pain provocation tests have
produced the highest likelihood ratio for confirming
the SIJ as the pain provocative structure44,46; how-
ever, a positive result on 1 or 2 of these tests has been
used in a previously published study.14 Exclusion
criteria included current pregnancy or pregnancy in
the last 6 months; history of surgery to the lumbar
spine, pelvis, chest, or abdomen; history of congenital
lumbar or pelvic anomalies; any neurological signs in
the lower extremity; systemic arthritis; and history of
pelvic fracture.
Potential participants who met the inclusion crite-
ria were scheduled for a screening session to assess the
individual for eligibility for the study. The screening
session was performed by the principal investigator,
a board-certified orthopedic physical therapist with
12 years of experience. At the beginning of the screen-
ing session, the participants were informed of the
procedures, risks, and benefits of the study, and then
a written consent was obtained from each participant.
Next, a physical therapy examination was conducted,
including subjective history (age, duration of symp-
toms, onset of symptoms, side of pain, type of pain,
and other medical conditions), a neurological screen
of the lower quadrant, and an objective examination.
The neurological screen included dermatome and
myotome testing, reflex testing, and an upper motor
neuron screen for the lower extremities. The examina-
tion included a postural assessment in standing, active
movement testing of the lumbopelvic spine, combined
Volume 42 • Number 2 • May/August 2018

movements/quadrant testing of the lumbopelvic spine,
tests to determine any positional faults of the pelvis,
kinetic tests of the SIJ, lumbar segmental mobility
testing, the SIJ provocation tests (see Supplemental
Digital Content 1 Table, available at: http://links.lww.
com/JWHPT/A13, which describes the SIJ provoca-
tion tests), and palpation of the lumbopelvic spine. All
examination tests have been described previously.47
Participants were determined to be eligible for the
study when they had positive results from at least
2 of the SIJ provocation tests. Next, the principal
investigator collected the baseline outcome measures
(described in a later section) from each participant.
To ensure that the principle investigator was blinded
to group assignment, 1 research assistant, a doctoral
physical therapy (DPT) student, randomly assigned
each participant to 1 of 2 groups by drawing a num-
ber out of an opaque envelope. Those participants
who drew a “group 1” were placed in the LSE group,
while those who drew a “group 2” were placed in the
LSE plus belt (LSE + belt) group.
Study Outcome Measures
The primary outcome measures used in this study
were disability, pain level, and percent change of
muscle thickness for the TrA and the IO. The sec-
ondary outcome measures were overall level of
perceived improvement and compliance with the
exercise program and pelvic compression belt. All
primary outcome measures were collected at baseline,
4 weeks, and 12 weeks. The overall level of perceived
improvement and the compliance logs were collected
at 4 weeks and 12 weeks.
The Modified Oswestry Low Back Pain Disability
Questionnaire (Modified OSW) was used to deter-
mine LBP-related disability. The modified version
of the original OSW consists of 10 items assessing
different aspects of pain and function related to LBP
and replaces the sex life question in the original OSW
with the employment/homemaking question.48 The
Modified OSW is more commonly used in research
because it is less likely to have missing data as some
participants may skip the sex life question that is in
the original version. Each item is scored 0 to 5 (50
points total), with higher scores representing greater
disability. The minimal detectable change (MDC)
for this outcome measure is 10.5 points,49 and the
minimum clinically important difference (MCID) is 6
points.48 The Modified OSW is widely used in clini-
cal practice and in research for patients with LBP and
has been shown to be reliable in patients with LBP
(intraclass correlation coefficient > 0.90).48,50
The Numeric Pain Rating Scale (NPRS) was used
to assess pain intensity. The NPRS is an 11-point
scale with “0” representing “no pain” and “10”
representing “worst imaginable pain.”51,52 The NPRS
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Research Report
has been shown to have concurrent and predictive
validity as a measure of pain intensity.51,53 Both the
MDC and the MCID for the NPRS have been report-
ed to be 2 points in patients with LBP.54
The percent change of muscle thickness of the
TrA and the IO was determined using a SonoSite
Edge Ultrasound System (Sonosite Inc, Bothell,
Washington). Ultrasound imaging was conducted by
the primary investigator who has extensive training
with ultrasound imaging of deep abdominal muscle
morphology and more than 8 years of experience
using it in research. To obtain the images, the
muscles were imaged in brightness mode (b-mode)
with a 2- to 5-MHz broad-spectrum curvilinear
transducer. Images of the muscles were captured and
saved for later measurements. The thickness of the
muscles was measured at rest at the end of expira-
tion and during the abdominal drawing-in maneuver.
Ultrasonographic measurements have been compared
with electromyographic (EMG) data and shown to
be valid at detecting submaximal (ie, less than 20%-
30% maximum voluntary contraction) contractions
of the deep abdominal muscles.37,55 They also have
good-to-excellent reliability in healthy participants
and in those with LBP.38–41
The Global Rating of Change (GROC) Scale was
used to assess overall perceived improvement from
the beginning of the intervention. The GROC Scale
scores were collected at 4 weeks and at 12 weeks.
This is a scale ranging from −7 (“a very great deal
worse”) to 0 (“about the same”) to +7 (“a very
great deal better”). The GROC Scale scores between
+3 and +1 or between −3 and −1 represent small
changes, scores of +4 and +5 or −4 and −5 repre-
sent moderate changes, and scores +6 and +7 or −6
and −7 represent large changes.56 Furthermore, the
GROC Scale has been shown to have construct valid-
ity and to be able to separate “stable” patients from
“improved” patients.56
Ultrasound Imaging
During ultrasound imaging, the participants were
instructed to lie on a treatment plinth in the supine
hook-lying position with the feet about shoulder
width apart. Before obtaining the images, each par-
ticipant was given an explanation of how to per-
form the abdominal drawing-in maneuver. They were
instructed to draw their belly button in toward their
spine and hold this contraction for 5 seconds. The
transducer was then placed on the participant’s pain-
ful side just above the iliac crest at the midaxillary
line in accordance with previous ultrasound imaging
studies.36,40 The transducer was adjusted so that the
TrA muscle was centered on the imaging screen with
the TrA-fascial border on the right-hand side of the
screen. Three images were obtained at rest at the end
© 2018 Section on Women’s Health, American Physical Therapy Association 3
 Research Report
of expiration and 3 images with contraction (ie, during
the hold phase of the abdominal drawing-in maneu-
ver) were obtained with the average of the 3 trials used
for calculations.40 The images were stored for off-line
analysis. The muscle thickness for each muscle was
determined by the linear distance between the upper
and lower fascial lines at the midpoint of the muscle as
measured by ImageJ Software57 (National Institute of
Mental Health, Bethesda, MD) (see Figure 1).
The percent change of muscle thickness for the
TrA and the IO was calculated using the following
equation:
Percent Change = (Contracted – Rest)/(Rest)
× 100%.14,36,40
Treatment Procedures
Exercise sessions were conducted by 1 of 2 research
assistants (DPT students) depending on their avail-
ability. These DPT students underwent 15 hours of
training to become proficient in the study protocol,
the lumbopelvic exercise program, and the use of the
SIJ belt. All participants were instructed in the LSE
based on the program designed by Hicks et al.58 (see
Supplemental Digital Content 2 Table, available at:
http://links.lww.com/JWHPT/A14, which describes
the LSE and criteria for progression). To increase con-
sistency of the exercise program throughout the study,
the abdominal drawing-in maneuver with walking
was replaced with an abdominal drawing-in maneu-
ver with wall slides. In addition, the repetitions were
decreased to 20 in order to improve compliance with
the exercise program over the 12-week study period.
The objective of this exercise program was retraining
the proper activation and coordination of trunk mus-
culature to increase spinal stability and to reduce pain.
Participants were scheduled to attend supervised
exercise sessions 2 times a week for 2 weeks and once
a week for another 2 weeks of personalized exercise
instruction and progression of the exercise program.
Each participant was permitted to miss 1 scheduled visit,
Figure 1. Ultrasound image of the deep abdominals. EO
indicates external oblique; IO, internal oblique; TrA, trans-
verse abdominis.
4 © 2018 Section on Women’s Health, American Physical Therapy Association
Copyright © 2018 Section on Women’s Health, American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
if necessary. Therefore, all participants received a total of
at least 5 sessions over the first 4 weeks. The frequency
and duration of physical therapy sessions were selected
to be consistent with current clinical practice as observed
by the authors. In addition, participants were instructed
to perform the LSE as a daily home exercise program
(HEP) and complete a log to monitor compliance with
the program during the first 4 weeks of on-site physical
therapy sessions and the following 8 weeks of HEP.
Those who were in the LSE + belt group were
taught how to don/doff the compression belt and
were instructed to wear the belt low around the
pelvis just above the greater trochanter as much as
possible during all waking hours for the first 4 weeks
of the study.33 The research assistant put the belt on
the participant initially to show the correct place-
ment and snugness of the belt. The fit of the belt was
described as feeling secure around the pelvis during
all normal activities of daily living. Given a scale of
minimally, moderately, or severely snug, the partici-
pants were instructed that the belt should be adjusted
to feel moderately tight. Each participant then put
the belt on herself to demonstrate competence in
donning the belt. All instructions relating to the belt
were given by the same research assistant. Belt usage
logs were given to each participant to assess compli-
ance with wearing the belt during the first 4 weeks
of the study. No harmful or unintended effects from
the belt were reported in the study.
Statistical Analysis
IBM SPSS Statistics 19 software (IBM Corp, Armonk,
New York) was used to perform statistical analysis
for all collected data. Descriptive statistics, including
means and standard deviations, were calculated for
the baseline characteristics of the participants includ-
ing age, duration of symptoms, onset of symptoms,
side of pain, type of pain, and other medical condi-
tions. Descriptive statistics were also calculated for
physical examination data including the numbers of
positive SIJ provocation tests, presence of lordosis/flat
back/scoliosis, limitations of lumbopelvic spine move-
ment testing, quadrant test outcomes, standing flex-
ion test outcomes, lumbar posterior-anterior mobility,
and tenderness to palpation in lumbopelvic region.
Finally, descriptive statistics were calculated for the
collected outcome measurements including Modified
OSW scores, NPRS scores, the percent change of
muscle thickness of the TrA and the IO, the GROC
Scale scores, and adherence to the exercise program
and usage of the pelvic compression belt. For baseline
assessment of between-group differences, χ2 analysis
was used for categorical data and independent t tests
were used with all ratio-level data.
Four separate univariate analyses of variance
with repeated measures were used to analyze the
Volume 42 • Number 2 • May/August 2018

dependent variables (Modified OSW, pain, percent
change of TrA, and percent change of IO) after 4
weeks of intervention and at the 12-week follow-up.
Alpha was set at .05. When there was a significant
interaction, post hoc pairwise comparisons were
examined. The Mann-Whitney U test was used to
compare the differences in the GROC Scale scores
between the groups after 4 weeks and again after 12
weeks of intervention. The Wilcoxon signed rank test
was used to compare within-group differences in the
GROC Scale scores from the first 4 weeks to the last
8 weeks of the study. The alpha level was set at .05
for all statistical analyses.
RESULTS
Sixty-seven women with unilateral LBP that did
not extend past the knee telephoned or e-mailed
the investigators with interest in participating in the
study. Following screening, 41 of those did not meet
Figure 2. CONSORT diagram of participant flow through the study.
Journal of Women’s Health Physical Therapy
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Research Report
the inclusion criteria and 1 individual refused to
participate because of transportation and time com-
mitment issues. Therefore, 25 women enrolled in and
completed the study. The CONSORT diagram in
Figure 2 summarizes the enrollment, screening, and
randomization of the participants.
The characteristics of the participants are summa-
rized in Table 1, including age, duration of pain, onset
of pain, side of pain, type of pain, and other medical
conditions. The findings of the physical examination
are summarized in Table 2, the distribution of the
SIJ provocation testing is summarized in Table 3,
and the baseline data for the outcome measures are
summarized in Table 4. The groups were found to be
similar for all baseline variables except for postural
deviations. The LSE + belt group had more women
with lordosis than the LSE group.
The analysis of variance results revealed that
both groups showed significant improvements over
time for disability level (P < .001) and pain
© 2018 Section on Women’s Health, American Physical Therapy Association 5
Research Report

Table 1. Participant Characteristicsa Table 2. Baseline Physical Examination Dataa

LSE LSE + Belt Between-Group LSE LSE + Belt Between-Group
(n = 12) (n = 13) P (n = 12) (n = 13) P
Age SIJ provocation tests
3.0 (0.7) 3.0 (1.1) 1.00
positive (SD)
Mean (SD) 30.6 (8.0) 29.2 (11.21) .73
Posture deviations 1 5 .04
Range 22-46 22-61
Flat back 0 0
Duration of symptoms
Lordosis 1 5
Mean (SD) 70.5 (55.6) 81.0 (75.7) .69
Scoliosis 0 0
6-12 mo 2 2
Lumbopelvic ROM: Reduced
1-5 y 7 4 .30
Flexion 1 2 .58
>5 y 3 7
Extension 0 2 .16
Onset of symptoms
Side bending 1 3 .32
Gradual 8 7 .51
Rotation 0 2 .16
Sudden 4 6
Positive SIJ kinetic
Side of pain 9 6 .14
testing
Right 6 6 .85
Lumbar PA mobility
Left 6 7
Hypomobility (pain) 8 (5) 9 (6) .89
Abbreviations: LSE, lumbopelvic stabilization exercises; LSE + belt, Hypermobility (pain) 1 (1) 3 (2) .32
lumbopelvic stabilization exercises plus belt.
aP value for age determined by t test and χ2 analysis used for all Tenderness at SIJ
others. Right 5 6 .82
Left 3 4 .75

(P < .001), but there were no differences between Abbreviations: LSE, lumbopelvic stabilization exercises; LSE + belt,
lumbopelvic stabilization exercises plus belt; PA, posterior-anterior;
groups (Modified OSW: P = .65 and NPRS: P = ROM, range of motion; SIJ, sacroiliac joint.
.386). Based on the sample of 25 participants, post aP values determined by independent t test for SIJ provocation tests,

hoc analysis revealed that the observed power was and χ2 analysis for all others.
0.116, and partial η2 was 0.019, indicating a low
power and a small effect size, which could have
contributed to our nonsignificant findings.59 A post Although both groups demonstrated an average
hoc power analysis using G*Power indicated that of + 3 or greater on the GROC Scale scores, indicat-
more than 300 participants, with approximately ing that both groups perceived small positive changes
150 participants in each group, would be needed to toward improvement, the Mann-Whitney U tests
detect significant between-group differences in treat- showed no differences between groups from baseline
ment effects. However, from a clinical perspective, to 4 weeks (P = .728) or from 4 weeks to 12 weeks
the LSE group demonstrated an improvement in the (P = .347) for the GROC Scale scores. Finally,
Modified OSW scores by 12.83 points and 11.54 adherence to the exercise program was divided into
for the LSE + belt group. For pain, the LSE group 2 sections, the first 4 weeks and the last 8 weeks.
reported an average of 1.5 points improvement in Adherence was similar for both groups for both time
the NPRS, whereas the LSE + belt group reported frames (first 4 weeks, 66.2% for LSE, 66.7% for LSE
2.07 points of improvement which exceeded the
MDC and MCID of the NPRS.
The analysis of variance results showed that there Table 3. Distribution of SIJ Pain Provocation Testing
was no significant difference between groups for the Pain Provocation Test Number of Positive Responses, N = 25
TrA (P = .07) and the IO (P = .58) muscle thickness, SIJ compression 4
but that there was a significant difference over time.
SIJ distraction 14
For the percent change of TrA muscle thickness, both
groups increased from baseline to 4 weeks (P < .001) Posterior Shear Test 18
and decreased from 4 weeks to 12 weeks (P < .001). Gaenslen’s Test (right) 8
For the percent change of IO muscle thickness, both Gaenslen’s Test (left) 7
groups decreased from baseline to 4 weeks (P < .001) Sacral Thrust Test 21
and increased from 4 weeks to 12 weeks (P < .001 )
Abbreviation: SIJ, sacroiliac joint.
(see Figure 3).
6 © 2018 Section on Women’s Health, American Physical Therapy Association Volume 42 • Number 2 • May/August 2018
Copyright © 2018 Section on Women’s Health, American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
 Research Report

Table 4. Outcome Measurements (Mean ± SD) at Baseline,

consideration when interpreting the results of this
4 Weeks, and 3 Monthsa study. A much larger sample size would more defini-
Between-Group
tively determine any statistical between-group differ-
LSE LSE + Belt P ence between the 2 treatment approaches, LSE and
Disability (OSW)
LSE + belt.
Clinically, both groups made improvements great-
Baseline 23.00 ± 10.18 26.31 ± 10.10 .42
er than the MDC and the MCID of the Modified
4 wk 16.00 ± 5.78 18.00 ± 10.90 OSW scores over 12 weeks, with the most significant
3 mo 10.17 ± 8.55 14.77 ± 10.79
improvement for both groups occurring in the first
4 weeks of the study (7.00 points for the LSE group
Pain (NPRS)
and 8.31 points for the LSE + belt group). Given that
Baseline 2.75 ± 1.42 3.15 ± 2.04 .57 the majority of participants in our study had chronic
4 wk 1.75 ± 2.05 1.38 ± 1.76 SIJ pain, these improvements seem to be meaningful.
Although we did not include a true control group,
3 mo 1.25 ± 1.71 1.08 ± 1.66
the improvement observed in our study may imply
Percent change of TrA clinical benefits of LSE for the patients with chronic
Baseline 86.42 ± 41.94 66.64 ± 22.03 .16 SIJ pain.
4 wk 174.91 ± 68.28 145.31 ± 41.41
Subgrouping patients with SIJ pain may identify
those who benefit from the additional application
3 mo 78.11 ± 45.11 98.09 ± 64.47 of a compression belt along with LSE. Clinically,
Percent change of IO the application of pelvic compression belts is usu-
Baseline 5.99 ± 15.19 7.25 ± 10.17 .81 ally based on hypermobility or instability of the SIJ.
Given that the literature has not identified a clinical
4 wk −17.84 ± 10.41 −21.79 ± 7.11
test that has good diagnostic accuracy for assessing
3 mo 8.11 ± 15.66 6.67 ± 13.29 SIJ mobility, no specific tests were performed in this
Perceived improvement (GROC)e study for assessing hypermobility or instability of
4 wk 2.83 ± 2.44 3.23 ± 2.24 .73 the SIJ. Although compression belts are designed for
those suspected of hypermobility or instability, this
3 mo 4.17 ± 2.17 4.77 ± 2.20 .35
effect cannot be validated using the available clinical
Abbreviations: GROC, Global Rating of Change Scale; IO, inter- tests. However, the active straight leg raise (ASLR)
nal oblique; NPRS, Numeric Pain Rating Scale; OSW, Modified test is a clinical test that assesses the functional ability
Oswestry Low Back Pain Disability Questionnaire; TrA, transverse
abdominis.
to transfer loads in the pelvis60,61 and is commonly
aIndependent t tests determined P values for baseline data; P values used when considering the use of a pelvic compres-
for 4-week and 3-month data taken from between-group compari- sion belt. Future research in this area should consider
sons in ANOVAs; and P values for GROC determined by Mann- using the active straight leg raise test in attempting
Whitney U test. to subgroup those who may benefit most from pelvic
compression belts.
To be included in the study, participants must have
+ belt, P = .60; last 8 weeks, 52.3% for LSE, 46.4% exhibited 2 out of 6 positive SIJ provocation tests.
for LSE + belt, P = .94). For both groups, there was These tests have been shown to be positive identifiers
a significant difference in adherence between the first of the SIJ as the source of pain.44–46 Although all par-
4 weeks and the last 8 weeks of the program (LSE ticipants had at least 2 positive SIJ provocative tests,
group, P = .003; LSE + belt group, P = .001), with other sources, specifically the lumbar spine, could not
less compliance noted in the last 8 weeks. For the LSE be excluded as potential generators for their pain. The
+ belt group, the average adherence to wearing the physical examination included assessment of lumbar
belt was 5.9 ± 3.4 h/d. spine segmental mobility as well as pain with lumbar
segmental mobility testing. Although there were no
DISCUSSION significant differences between groups in the num-
ber of participants who had abnormal lumbar spine
In this feasibility study, the benefits of the pelvic segmental mobility or pain with segmental mobility
compression belt in addition to LSE could not clearly testing, caution should be used in interpreting these
be determined. Although both groups demonstrated results. The potential for multiple sources of pain in
meaningful improvement in disability level (>10.5 this study, such as the lumbar spine, may have con-
points), there were no significant differences between tributed to the lack of finding a difference between
groups. The post hoc small effect size and lack of groups and discounted the effects of the pelvic com-
power found in this study need to be taken into pression belt on those with SIJ pain. In addition, the
Journal of Women’s Health Physical Therapy © 2018 Section on Women’s Health, American Physical Therapy Association 7
Copyright © 2018 Section on Women’s Health, American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
 Research Report

Figure 3. Outcome measurements for disability level, pain intensity, and percent change of muscle thickness at baseline,
4 weeks, and 12 weeks. Disability levels are determined by Modified Oswestry Low Back Pain Questionnaire (Modified
OSW). Pain intensity levels are determined by Numeric Pain Rating Scale (NPRS). Percent change of internal oblique and
transverse abdominis muscle thickness is measured using ultrasound imaging. LSE indicates lumbopelvic stabilization
exercises.

LSE + belt group had more women with lordosis than
the LSE group at baseline. With an increase in lumbar
lordosis and, therefore, an increase in the amount of
lumbar extension in upright posture, the facet joints
may begin to have a greater weight-bearing function,
which can lead to pain and other impairments related
to the lumbar spine.47 This postural dysfunction may
have been a confounding variable in the study which
could have impacted our results.
For pain intensity (NPRS), although the average
pain intensity at baseline was mild to moderate, both
groups demonstrated significant improvements over
time. Over the 12-week time period, the LSE group
demonstrated a decrease in the NPRS by an average
of 1.50 points, whereas the LSE + belt group demon-
strated a decrease in the NPRS by an average or 2.07
points. The MDC and the MCID for the NPRS have
been reported to be 2 points in patients with LBP.54
Therefore, only the LSE + belt group demonstrated
a clinically meaningful change in pain intensity. This
finding may have been due to the relatively mild to
moderate pain intensity at baseline for both groups
resulting in a floor effect.
Previous research has demonstrated that LSE pro-
grams can reduce pain and disability in those with
LBP.27–30 However, no studies have examined this
finding in the subgroup of patients who demonstrate
SIJ as the primary pain provocative structure. This
study demonstrated that LSE can reduce pain and
disability in the subgroup of individuals with the SIJ
as the primary source of pain. Sasso et al62 previ-
ously reported successful outcomes using a structured
physical therapy program in those with SIJ dysfunc-
tion. However, no standardized outcome measures
were utilized in their study. It is unclear whether their
physical therapy intervention, including stabilization
exercises, was effective in reducing pain or improving
function. In contrast to the study by Sasso et al,62 this
feasibility study used 2 reliable and valid outcome
measures, the Modified OSW and the NPRS, to assess
function and pain level. The use of reliable and valid
outcome measures provides valuable clinical evidence
for using LSE as an intervention for this population.
There were no differences between groups in par-
ticipants’ perceived improvements after 4 weeks of
treatment and at the 12-week follow-up. Clinically,
both groups reported improvements from baseline to
4 weeks (2.83 for the LSE group, 4.17 for the LSE +
belt group) and from 4 weeks to 12 weeks (3.23 for
the LSE group, 4.77 for the LSE + belt group) of
+3 or greater. This represented small to moderate
positive changes in perceived improvement. These

8 © 2018 Section on Women’s Health, American Physical Therapy Association Volume 42 • Number 2 • May/August 2018
Copyright © 2018 Section on Women’s Health, American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.

subjective improvements may have been affected by
the relatively mild to moderate pain level and moder-
ate level of disability reported at baseline. Individuals
with severe disability at baseline may demonstrate
greater perceived change, thereby showing larger
changes in GROC Scale scores.
The underlying principle of LSE is retraining the
proper activation and coordination of trunk muscu-
lature to increase spinal stability and reduce pain.15–21
The results of this feasibility study confirm that these
exercise programs can affect muscle activation of
the TrA, in terms of increasing the percent change
of this muscle, after completing 4 weeks of LSE.
During the first 4 weeks of the study, the LSE group
demonstrated an 88.49% increase, while the LSE +
belt group demonstrated a 78.67% increase in TrA
muscle thickness. On the contrary, during this same
time frame, all participants demonstrated a decrease
(23.83% for the LSE group, 29.04% for the LSE +
belt group) in the percent change of IO. Based on the
ultrasound imaging results, the participants appeared
to use their TrA to a greater extent and IO to a lesser
extent during the first 4 weeks of treatment, thus
learning to preferentially activate the TrA. This find-
ing is consistent with one of the fundamental prin-
ciples of LSE programs.
However, during the last 8 weeks of the study,
the opposite effect on the muscle activation was
observed. That is, the percent change of TrA muscle
thickness significantly decreased and percent change
of IO significantly increased. Concurrently, we
noticed a significant decrease in the HEP compliance
during the last 8 weeks of the study for both groups
(51.2% for the LSE group, 48.7% for the LSE +
belt group). These trunk muscles appeared to revert
to their baseline performance when the participants
demonstrated decreased compliance with their HEP.
Although the muscle performance appeared to revert
to baseline levels, both groups reported decreased
pain and disability from baseline to 12 weeks. Hides
et al63 reported a similar finding in regard to the mul-
tifidus in patients with acute LBP. They compared
medical treatment with combined medical treatment
and specific, localized exercise therapy for the lumbo-
pelvic spine. Although pain and disability decreased
in both groups in the first 4 weeks of treatment, only
those who were in the exercise group demonstrated
improvements in multifidus muscle contraction. In
addition, long-term results showed that those who
received the specific, localized lumbopelvic exercises
had fewer recurrences of LBP.30 These findings sug-
gest that impairments in muscle activation can persist
despite improvements in pain and disability in those
with LBP, which may be one factor that contributes
to high recurrence rates of LBP. Persistent impair-
ments in muscle activation after pain and disability
Journal of Women’s Health Physical Therapy
Copyright © 2018 Section on Women’s Health, American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
Research Report
have improved, suggest a benefit to long-term follow-
up with a physical therapist, and should be empha-
sized when educating patients about the importance
of staying committed to regular performance of LSE
programs.
Finally, the results with regard to improved per-
cent change of TrA and decreased percent change
of IO after 4 weeks of intervention are somewhat
contradictory to those described by Hu et al,64 con-
cerning the muscle function of the deep abdominals
with the pelvic compression belt. Using EMG, Hu et
al64 found that the activity of the TrA and the IO in
healthy participants who have never been pregnant
was significantly reduced during the ASLR test and
with treadmill walking. This feasibility study found
that participants with unilateral LBP demonstrated an
increase in the percent change of the TrA. However,
there were a few differences to note between the 2
studies. Hu et al64 assessed the immediate change
in muscle response after donning the belt, while our
study assessed a more long-term change in the TrA
and the IO after wearing the belt for 4 weeks and
12 weeks. In addition, the participants in the study
by Hu et al64 were healthy nulligravidae. The differ-
ence in results may suggest that the compression belt
may affect healthy participants differently than those
with SIJ pain. In addition, Hu et al64 used EMG as an
assessment method while this study used ultrasound
imaging, which arguably could be measuring differ-
ent parameters as it relates to muscle function.
To date, there is no other evidence that has been
reported for the long-term effects that LSE have on
the muscle function of the TrA and the IO. Teyhen
et al36 and Henry and Westervelt65 used ultrasound
imaging to assess the short-term performance of a
basic LSE; however, these studies evaluated only the
muscle behavior 4 days after beginning the exercise.
No other studies have shown that those with SIJ pain
could demonstrate changes in their percent change
of muscle thickness for the TrA and the IO after per-
forming LSE for 4 weeks.
Limitations of the Study
There were several limitations in the study that may
have affected our results. First, the participants in
this study were not currently seeking medical care
for their SIJ pain but could make weekly visits to the
study site. In addition, the study included only female
participants. The participants in this study may not
be representative of the population of patients with
SIJ pain, which may limit the generalizability of
the study. We used clinical SIJ provocation tests to
confirm the location of pain. These tests have false-
positive and false-negative results, which could also
have affected those included or excluded from the
study, and therefore affected the results of the study.
© 2018 Section on Women’s Health, American Physical Therapy Association 9
Research Report
Furthermore, the low levels of pain and disability
reported by the participants at baseline could have
affected the discriminatory power between groups
due to floor effects. In future studies, the inclusion
criteria should be limited to at least moderate pain
intensity and disability scores. Medication intake and
activity level were documented at the 4-week and
12-week follow-up visits. Although the use of medi-
cation was reportedly low, we did not control this
variable. Finally, the parity status of the participants
was not collected. Inability to control these factors
might also have affected the results of the study.
Ultrasound imaging was used to measure the per-
cent change of muscle thickness for the TrA and the
IO in our study. However, ultrasonographic measure-
ment of the muscle thickness is a 2-dimensional rep-
resentation of muscle and may not represent muscle
activation. Although a standard procedure was fol-
lowed, there could be a potential for variation of the
ultrasound measurements due to the investigator’s
inconsistency in placement of the transducer. Before
obtaining the ultrasound images, all participants
were instructed in the performance of the abdominal
drawing-in maneuver using a standardized method.
However, there is still potential for variation in the
participants’ understanding of this exercise. All of
these issues relating to the use of ultrasound imaging
could have affected the results in our study.
This study examined the effects of LSE and pelvic
compression belts on the lateral abdominal muscle
thickness, specifically the TrA and the IO. The mul-
tifidus, another important segmental stabilizer of
the spine with attachments on the sacrum, was not
examined. Future research may consider examining
the activation of this muscle in patients with SIJ
pain.
CONCLUSION
The effect of pelvic compression in addition to LSE
could not be determined for those with SIJ as the pri-
mary pain provocative structure. Weekly supervised
exercise sessions appeared to be a factor for changes
in the muscle activation of the TrA and the IO. Both
groups demonstrated increased percent change of TrA
and decreased percent change of IO while meeting
regularly with the investigators for the first 4 weeks
of the study. However, these changes reverted to base-
line behavior when the participants stopped meeting
regularly with the investigators. We recommend that
therapists emphasize the importance of commitment
to an exercise program in order to maintain optimal
activation of the TrA and the IO and potentially
reduce future recurrences of LBP. Finally, due to the
small effect size, the results of this feasibility study
indicated that a randomized clinical trial with a much
10 © 2018 Section on Women’s Health, American Physical Therapy Association
Copyright © 2018 Section on Women’s Health, American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
larger sample size may be needed to definitively show
a significant difference in pain reduction due to add-
ing pelvic compression belts to LSE.
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