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Effects of Neuromuscular Control Training and Proprioceptive
Exercise on Pain, Pelvic Stability, and Functional Outcomes in
Patients with Sacroiliac Joint Dysfunction
Sarfraz Ahmad¹*, Maryam Murtaza², Chaman Lal³, Mahnoor Zehra⁴, Jeeya Paul⁵, Ishma Illyas⁶, Hafiza
Mubeen sahar⁷, Hafiza Mubashra zahid⁸
¹ Physiosic Neuro Spine and Joints Pain Care Center, Pakistan
²House officer at Independent University Hospital, Faisalabad, Pakistan
³BSPT, PPDPT (M.Phil Physiotherapy), MPH, MA (Physical Education & Sports Injuries), R.EEGT
(ABRET-USA), PGC in Clinical Neurophysiology (AKUH), Diploma in Pain Management (UK),
Diploma in Pharmacy (PPCL), PhD Health Sciences Scholar, Pakistan.
⁴ Senior Physiotherapist, Pakistan
⁵ Assistant Professor Faculty of Allied Health SciencesRoyal University of Medical and Information
Sciences (RUMIS)(formerly Royal Institute of Medical Sciences - RIMS), Multan, Pakistan
⁶ Physiotherapist at InMotion Rehabilitation Clinic, Pakistan
⁷ Physiotherapist at Alkarim Hospital,Nankana sahib
⁸ Senior physiotherapist at Alkarim Hospital,Nankana sahib
*Corresponding Author
DOI: https://doi.org/10.51583/IJLTEMAS.2026.150600280
Received: 30 June 2026; Accepted: 13 July 2026; Published: 03 August 2026
ABSTRACT
Objective: Evaluate the efficacy of neuromuscular control training combined with proprioceptive exercises on
pain reduction, pelvic stability, and functional outcomes in patients with sacroiliac joint (SIJ) dysfunction
compared to standard care.
Methods: A prospective, randomized controlled trial with 124 participants (intervention n=62, control n=62)
conducted over 12 weeks at three academic medical centers. Intervention group received 2-3 supervised sessions
per week of structured neuromuscular training targeting core stabilizers and proprioceptive exercises. Control
group received standard care consisting of patient education and general exercise. Primary outcomes assessed at
baseline, weeks 4, 8, 12, and 24: Visual Analog Scale (VAS) pain (0-10), Posterior Superior Iliac Spine Distance
Ratio (PSIS-DR) for pelvic stability assessment, and Lower Extremity Functional Scale (LEFS, 0-80 points).
Secondary outcomes included Oswestry Disability Index (ODI), Short Form-36 (SF-36) quality of life measures,
proprioceptive function, and core muscular strength.
Results: Intention-to-treat analysis of 121 participants (97.6% retention). Intervention group demonstrated
statistically significant and clinically meaningful improvements across all primary outcomes. VAS pain
reduction: 5.2±1.8 points (77% improvement) in intervention versus 1.3±1.5 points (19% improvement) in
controls (p<0.001, 95% CI: 3.1-4.9). Pelvic stability improvement: 3.4±1.1 mm (41.5% reduction in asymmetry)
in intervention versus 0.6±0.8 mm (7.1% reduction) in controls (p<0.001, 95% CI: 2.4-4.4). LEFS functional
improvement: 28.5±6.7 points (88% recovery) in intervention versus 7.2±5.3 points (23% recovery) in controls
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(p<0.001, 95% CI: 18.3-23.8). Large effect sizes (Cohen's d) demonstrated for all primary outcomes (d=1.8-2.6).
Benefits sustained at 6-month follow-up with minimal regression. 68% of intervention participants achieved
clinically normal pelvic alignment versus 11% in controls (p<0.001). Session adherence: 95.2% (34.2±2.1 of 36
prescribed sessions). Home exercise compliance: 78.4%. Adverse events: no serious adverse events; mild self-
limiting muscle soreness in 30% of intervention participants during week 1-2.
Conclusion: Structured neuromuscular control training combined with systematic proprioceptive exercise is
highly effective for managing sacroiliac joint dysfunction, providing substantial and durable improvements in
pain, pelvic stability, and functional capacity. This conservative intervention demonstrated superior efficacy
compared to standard care with excellent safety profile and high patient adherence. Evidence supports position
as first-line management for SIJ dysfunction.
Keywords: Sacroiliac joint dysfunction, neuromuscular control, proprioceptive training, core stability, pelvic
stability, conservative management, rehabilitation, randomized controlled trial
INTRODUCTION
Epidemiology and Clinical Significance
Sacroiliac joint (SIJ) dysfunction represents a significant and often underdiagnosed contributor to chronic
musculoskeletal pain and disability worldwide. Epidemiological data suggest that 15-30% of individuals
presenting with chronic low back pain have primary or secondary SIJ-related pathology as a significant pain
generator. The prevalence escalates substantially in specific populations, including pregnant and postpartum
women (up to 76%), athletes engaged in explosive movements or rotational sports (up to 35%), and individuals
performing repetitive heavy lifting activities. The annual incidence of new SIJ dysfunction cases is estimated at
2-6% of the general adult population, generating substantial healthcare costs through direct medical expenses
and indirect productivity losses estimated at $100-200 billion annually in developed nations. Despite its
prevalence and clinical impact, SIJ dysfunction remains often overlooked or misattributed to other spinal
pathologies, resulting in delayed diagnosis and prolonged suffering.
Anatomical and Biomechanical Considerations
The sacroiliac joint is a complex, partially synovial articulation formed between the ala of the sacrum and the
ilium, representing one of the body's largest weight-bearing joints. The joint surfaces exhibit high variability in
morphology, including planar, C-shaped, and L-shaped configurations with irregular cartilage distributions,
creating inherent biomechanical diversity. The SIJ functions as the critical intermediary structure transferring
substantial axial loads (estimated at 50-80% of upper body weight during standing and walking) between the
vertebral column and lower extremities while simultaneously maintaining dynamic pelvic stability throughout
functional activities. This weight-bearing function, combined with force transmission requirements, necessitates
precise neuromuscular control and proprioceptive feedback mechanisms. The joint is stabilized by an
exceptionally complex and dense network of ligamentous structures, including the anterior SIJ ligament,
posterior SIJ ligaments, interosseous ligament, sacrotuberous ligament, sacrospinous ligament, and long
posterior SIJ ligament, collectively providing significant passive stability. However, passive ligamentous
stability alone is insufficient; the joint requires dynamic stabilization through coordinated activity of multiple
muscle groups to maintain optimal alignment and prevent aberrant motion patterns during functional tasks.
Neuromuscular Control Deficits in SIJ Dysfunction
Recent advances in biomechanical research and electromyographic analysis have revealed that SIJ dysfunction
frequently results from neuromuscular control deficits rather than primarily structural or degenerative
abnormalities. Longitudinal studies employing real-time ultrasound imaging demonstrate that individuals with
SIJ dysfunction exhibit significantly altered recruitment patterns of core stabilizing muscles, particularly the
transversus abdominis (TrA), multifidus (MF), and deep abdominal obliquus internus muscles. Specifically,
these muscles demonstrate delayed activation onset relative to limb movement (averaging 150-200 ms delays
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compared to 0-50 ms in asymptomatic controls), reduced magnitude of contraction during functional tasks, and
loss of anticipatory pre-activation occurring prior to perturbations. The deep gluteus maximus and gluteus
medius muscles, critical for hip stabilization and pelvic control during single-leg stance and ambulation,
demonstrate significant weakness and altered activation patterns in individuals with SIJ dysfunction.
Simultaneously, hyperactivation of superficial stabilizers (rectus abdominis, external obliquus) and hip flexor
muscles is commonly observed, representing a compensatory mechanism that paradoxically increases SIJ shear
forces. This altered recruitment pattern creates a vicious cycle: inadequate deep stabilizer activation -> increased
SIJ micromotion -> altered proprioceptive feedback -> further deterioration in motor control patterns.
Proprioceptive Dysfunction as a Mechanistic Factor
Proprioception, defined as the sensory perception of joint position, movement, and acceleration through
mechanoreceptor feedback, plays a critical but underappreciated role in SIJ dysfunction pathogenesis. The
sacroiliac joint region contains an exceptionally high density of mechanoreceptors—specifically Pacinian
corpuscles, Ruffini endings, Golgi tendon organs, and free nerve endings—distributed throughout the joint
capsule, ligaments, and adjacent musculature. These mechanoreceptors provide continuous afferent input to the
central nervous system regarding SIJ position, movement velocity, and applied forces, enabling the motor cortex
and cerebellum to generate precisely coordinated stabilizing muscle contractions. Dysfunction of proprioceptive
pathways occurs through multiple mechanisms: (1) joint capsule and ligament injury or inflammation disrupting
mechanoreceptor function; (2) hypermobility-induced excessive mechanoreceptor discharge leading to neural
adaptation and reduced sensitivity; (3) altered proprioceptive integration at spinal and supraspinal levels; (4)
chronic pain-induced inhibition of proprioceptive processing. Research employing dynamic posturography and
directional kinesiometry demonstrates that individuals with SIJ dysfunction exhibit significantly impaired
proprioceptive acuity, manifesting as reduced ability to replicate joint positions and increased postural sway
during balance tasks. The consequence of proprioceptive dysfunction is substantial delay in neuromuscular
response latency to perturbations and diminished precision of stabilizing muscle recruitment.
Limitations of Current Management Approaches
Current management of SIJ dysfunction encompasses a spectrum of interventions with variable efficacy.
Pharmacological approaches, including nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and
opioid analgesics, provide temporary symptom relief but do not address underlying neuromuscular deficits and
carry significant risks of adverse effects and dependency, particularly with prolonged opioid use. Manual therapy
techniques, including manipulation, mobilization, and soft tissue techniques, demonstrate moderate short-term
benefit (effect sizes 0.5-0.8) but effects typically plateau within 4-6 weeks without concurrent neuromuscular
training. Injection-based interventions, including SIJ intra-articular corticosteroid injections and radiofrequency
ablation, provide temporary pain relief averaging 3-6 months but do not restore neuromuscular control or
proprioceptive function, resulting in high recurrence rates upon effect duration expiration. Surgical fusion
procedures carry substantial risks including permanent movement restriction, adjacent-level degeneration, and
revision surgery rates of 15-25% at 5-year follow-up. Generic exercise programs without specific SIJ-targeted
neuromuscular and proprioceptive components demonstrate modest improvements, suggesting that exercise
intensity and specificity are critical determinants of clinical efficacy. Recent systematic reviews conclude that
multimodal interventions combining manual therapy with targeted exercise demonstrate superior outcomes
compared to single-modality approaches, yet evidence specifically addressing the combined effects of structured
neuromuscular control training with systematic proprioceptive rehabilitation remains limited.
Rationale and Study Objectives
The identified evidence gaps and theoretical mechanistic rationale support investigating a comprehensive
intervention combining neuromuscular control training targeting deep stabilizing muscles with systematic
proprioceptive exercise designed to restore accurate joint sensorimotor function. Hypothesis: Structured
neuromuscular control training combined with proprioceptive exercise would produce statistically significant
and clinically meaningful improvements in pain (primary hypothesis: >=2.0 point VAS reduction), pelvic
stability (primary hypothesis: >=3.0 mm PSIS-DR improvement), and functional capacity (primary hypothesis:
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>=15 point LEFS improvement) compared to standard care in patients with SIJ dysfunction. Secondary
hypotheses predicted improvements in disability, quality of life, proprioceptive function, and muscular strength,
with sustained benefits through 6-month follow-up. This randomized controlled trial aims to provide high-quality
evidence regarding intervention efficacy to inform clinical practice guidelines and rehabilitation protocols.
METHODS
Study Design
This was a prospective, parallel-group randomized controlled trial with 1:1 allocation ratio. The study was
conducted at virtual university Lahore. The study protocol was approved by instituional board. All participants
provided written informed consent prior to study participation. The study adhered to CONSORT (Consolidated
Standards of Reporting Trials) 2025 guidelines for reporting.
Participant Selection Criteria
Inclusion Criteria: (1) Age 18-65 years; (2) Clinically confirmed SIJ dysfunction based on positive findings on
>=3 of 5 standardized SIJ provocation tests (Fortin Finger Test, Patrick's FABER test, SIJ compression test, SIJ
distraction test, thigh thrust test); (3) Pain localized to SIJ region (below posterior superior iliac spine level) for
>=6 weeks duration; (4) Baseline pain intensity >3/10 on Visual Analog Scale; (5) Willingness to attend 2-3
supervised sessions weekly for 12 weeks; (6) Access to transportation to attended study sites.
Exclusion Criteria: (1) Pregnancy or postpartum status <12 weeks; (2) Previous SIJ injection within 3 months or
SIJ fusion surgery; (3) Diagnosis of inflammatory spondyloarthropathy (ankylosing spondylitis, reactive
arthritis, psoriatic arthritis); (4) Neurological disorders affecting lower extremity function (spinal cord injury,
peripheral neuropathy, stroke); (5) Contraindications to exercise participation (severe cardiovascular disease,
uncontrolled hypertension); (6) Current litigation or workers' compensation claims related to back pain; (7)
Inability to understand informed consent or follow study procedures; (8) Concurrent participation in other
clinical trials.
Randomization and Blinding
Participants were randomized using a computer-generated random number sequence with variable block sizes
(blocks of 4 and 6) to ensure balanced group allocation. Randomization was stratified by site (three locations)
and baseline pain severity (<=7 vs >7 on VAS 0-10 scale) to ensure balanced distribution of these potentially
confounding variables. Randomization was performed by an independent statistician not involved in participant
recruitment or data collection, with allocation sequences provided in sealed opaque envelopes. Due to the nature
of the intervention, blinding of participants and therapists delivering the intervention was not feasible. However,
outcome assessors, data analysts, and statistical analysts remained blinded to group allocation throughout the
study. Assessment sessions and data analysis were conducted in separate locations from intervention delivery to
minimize unblinding risk. Participants were instructed not to reveal their group allocation to assessors.
Study Interventions
Intervention Group Protocol
The intervention group received 12 weeks of supervised neuromuscular control training combined with
proprioceptive exercise, delivered at frequency of 2-3 sessions per week for a total of 36 supervised sessions.
Sessions were delivered by licensed physical therapists with minimum 5 years clinical experience in pelvic
dysfunction management and who completed 20 hours of specialized training in the intervention protocol prior
to study initiation. Each session lasted 45-50 minutes with standardized structure:
- Warm-up Phase (5 minutes): Low-intensity aerobic activity (recumbent bicycle or walking) to increase heart
rate to 60-70% maximum and prepare musculature.
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- Core Stabilization Training Phase (15 minutes): Progressive neuromuscular activation exercises targeting
transversus abdominis, multifidus, and deep obliquus internus muscles. Exercise progression occurred
systematically every 2 weeks following established principles: Week 1-2: Activation exercises in supine position
(transversus abdominis drawing-in maneuver, multifidus activation, co-contraction training); Week 3-4:
Activation with arm and leg movements in supine and quadruped positions; Week 5-6: Progression to kneeling
and standing positions with increased loading; Week 7-8: Dynamic stabilization exercises during functional
movement patterns; Week 9-12: Integration of core stabilization with sport/activity-specific movement patterns.
- Proprioceptive Training Phase (15 minutes): Systematic proprioceptive rehabilitation through balance and
postural control exercises progressing from stable to unstable surfaces. Exercise progression: Week 1-2: Double-
leg stance exercises on stable surface with visual feedback; Week 3-4: Single-leg stance on stable surface
progressing to unstable surfaces (foam pad, BOSU ball); Week 5-6: Dynamic balance exercises (Star Excursion
Balance Test, tandem stance); Week 7-8: Perturbation-based training with therapist-applied perturbations during
balance tasks; Week 9-12: Sport/activity-specific proprioceptive challenges.
- Functional Integration Phase (10 minutes): Integration of core stabilization and proprioceptive training into
functional movement patterns relevant to individual participant goals (occupational tasks, sports activities,
recreational activities). Exercises included: stair climbing, sit-to-stand transfers, walking with directional
changes, reaching tasks, sport-specific movement patterns.
- Cool-down Phase (5 minutes): Systematic stretching of hip musculature, hamstrings, piriformis muscle, and
lumbar paraspinal muscles held 30 seconds per stretch with 2-3 repetitions.
Home Exercise Program: All intervention participants received prescribed home exercise program consisting of
5-10 minutes daily practice of core stabilization and proprioceptive exercises learned during supervised sessions.
Participants received written and photographic instructions and were trained in proper exercise execution.
Compliance was monitored through exercise logs completed by participants at each supervised session, with
therapist review and reinforcement.
Control Group Protocol
The control group received standard care consisting of: (1) Educational sessions (2-3 sessions, 20-30 minutes
each) covering SIJ anatomy, biomechanics, pain physiology, activity modification strategies, and ergonomic
principles; (2) General stretching and flexibility exercises: instruction in hamstring stretches, hip flexor stretches,
piriformis stretches, and lumbar rotation stretches, performed 1-2 times weekly during brief 15-minute sessions;
(3) Over-the-counter analgesic use as needed (acetaminophen or NSAIDs per standard dosing). No structured
neuromuscular control training or proprioceptive exercise was provided to control participants. This control
condition represents standard care typical of primary care and general physical therapy settings.
Outcome Measures and Assessment Schedule
Primary Outcome Measures
1. Pain Intensity: Measured using 11-point Visual Analog Scale (VAS, 0=no pain, 10=worst pain
imaginable) for worst pain, best pain, and average pain over the previous week. Primary analysis utilized
average pain score.
2. Pelvic Stability: Measured using Posterior Superior Iliac Spine (PSIS) Distance Ratio (PSIS-DR),
assessed through digital palpation and surface marker placement. Participants positioned in standing;
examiner placed bilateral PSIS markers and measured vertical distance using digital calipers with 0.1
mm precision. Three repeated measurements were obtained and averaged. Asymmetry of >=5 mm was
considered clinically abnormal. Intra-rater reliability established in pilot study (ICC=0.92).
3. Functional Status: Measured using Lower Extremity Functional Scale (LEFS), a 20-item self-report
questionnaire assessing lower extremity function on scale 0-80 points (higher scores indicate better
function). Minimal clinically important difference established at 9-12 points. Cronbach's alpha=0.96.
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Secondary Outcome Measures
1. Disability: Oswestry Disability Index (ODI), 10-item questionnaire with scores 0-100% indicating
degree of disability (higher scores = greater disability). Minimal clinically important difference: 10-15
points.
2. Quality of Life: Short Form-36 Health Survey (SF-36) assessing physical and mental health domains (0-
100 scale per domain, higher = better quality).
3. Proprioceptive Function: Single-leg stance time (seconds until loss of balance, maximum 60 seconds);
Star Excursion Balance Test (SEBT) composite score measuring dynamic balance and lower extremity
stability.
4. Muscular Strength: Core muscular isometric strength assessed using dynamometry, measuring
transversus abdominis and multifidus contraction force (Newtons) with standardized positioning and
instruction.
5. Patient Satisfaction: Global Rating of Change scale (-5 to +5, where +5 = completely resolved, 0 = no
change, -5 = much worse).
Assessment Schedule
Baseline assessments: Conducted within 1 week prior to randomization. Follow-up assessments: Week 4 (early
intervention response), Week 8 (mid-intervention), Week 12 (end of intervention), and Week 24 (6-month
follow-up to assess durability). All assessments conducted by blinded, trained assessors following standardized
protocols. Assessment locations separated from intervention delivery locations. Participants instructed not to
discuss group allocation with assessors.
Statistical Analysis Plan
Sample Size Determination: Power analysis indicated 62 participants per group (124 total) were required to
detect a clinically meaningful difference of 2.0 points on VAS pain scale (estimated standard deviation 2.2
points, alpha=0.05 [two-tailed], power=0.90). Secondary power analyses confirmed adequate power for PSIS-
DR (expected difference 3.0 mm, SD=1.8) and LEFS (expected difference 15 points, SD=12).
Primary Analysis: Intention-to-treat (ITT) analysis including all randomized participants regardless of protocol
adherence or completion status. Between-group comparisons for continuous variables conducted using
independent samples t-tests with two-tailed significance testing (alpha=0.05). Within-group changes assessed
using paired t-tests. Two-way repeated measures ANOVA evaluated time-group interactions across all
assessment timepoints, with Bonferroni correction applied for multiple comparisons. Effect sizes (Cohen's d)
calculated for all primary outcomes; d>0.8 considered large effect.
Missing Data: Missing data imputed using multiple imputation by chained equations (MICE) with 50 iterations,
assuming data missing at random. Sensitivity analyses conducted comparing ITT results with complete case
analysis.
Secondary Analyses: Subgroup analyses examined treatment effects stratified by age (<40 vs >=40 years),
gender, baseline pain severity (<=7 vs >7 VAS), and baseline pain duration (<6 months vs >=6 months).
Multivariate linear regression evaluated predictors of treatment response. Per-protocol analysis included
participants with >=80% session adherence. Statistical Software: SPSS version 28.0 (IBM Corp., Armonk, NY)
used for all analyses. Significance threshold: p<0.05 (two-tailed). 95% confidence intervals reported for all
primary outcomes.
RESULTS
Participant Flow and Baseline Characteristics
Screening and Recruitment: Of 156 individuals screened for study eligibility at three participating centers, 124
met inclusion/exclusion criteria and provided written informed consent. Main reasons for exclusion: (n=18) did
not meet SIJ diagnostic criteria; (n=8) pregnancy status; (n=3) prior SIJ injection within 3 months; (n=2)
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inflammatory arthropathy diagnosis; (n=1) inability to commit to intervention schedule.
Randomization: 124 eligible participants were stratified by center and baseline pain severity and randomized to
intervention (n=62) or control (n=62) groups. Post-randomization withdrawals: (n=2) intervention group
withdrawal prior to treatment initiation due to schedule conflicts; (n=1) control group withdrawal due to work-
related relocation. Final analysis sample: 121 participants (97.6% retention rate). ITT analysis included all 124
randomized participants.
Table 1: Baseline Demographic and Clinical Characteristics
Variable
Intervention (n=60)
Control (n=61)
p-value
Age, years, mean ± SD
42.3 ± 11.2
41.8 ± 10.9
0.743
Female, n (%)
38 (63.3%)
36 (59.0%)
0.562
Body Mass Index, kg/m², mean ± SD
26.8 ± 4.1
27.2 ± 3.9
0.581
Pain Duration, months, median (IQR)
6 (4-12)
7 (4-13)
0.621
Baseline VAS Pain (0-10), mean ± SD
6.8 ± 1.5
6.9 ± 1.6
0.789
Baseline LEFS (0-80), mean ± SD
32.4 ± 11.3
31.8 ± 10.7
0.728
Baseline PSIS-DR (mm), mean ± SD
8.2 ± 1.3
8.4 ± 1.2
0.631
Baseline ODI (%), mean ± SD
38.2 ± 12.1
39.1 ± 11.8
0.681
Number of Positive SIJ Tests, mean ± SD
4.1 ± 0.8
4.2 ± 0.7
0.512
Primary Outcomes
Pain Outcomes (Visual Analog Scale)
Significant and progressive pain reduction occurred in the intervention group across all assessment timepoints
compared to controls (p<0.001 at all timepoints). At baseline, VAS pain scores were comparable between groups
(Intervention: 6.8+-1.5 points; Control: 6.9+-1.6 points; p=0.789), confirming successful randomization. By
week 4, the intervention group demonstrated mean pain reduction of 1.8+-0.9 points (26% reduction from
baseline) compared to 0.3+-0.4 points (4% reduction) in controls, representing a between-group difference of
1.5 points (p<0.001, 95% CI: 1.1-1.9). This early substantial improvement suggests rapid neuromuscular
adaptation and pain mechanism modification.By week 8, pain reduction accelerated in the intervention group,
achieving 4.0+-1.2 points reduction (59% from baseline; VAS score 2.8+-1.4) compared to 0.8+-0.5 points in
controls (12% reduction; VAS 6.1+-1.5), representing 3.2-point between-group difference (p<0.001, 95% CI:
2.7-3.7). This trajectory suggests cumulative neuromuscular training effects with progressive stabilization and
proprioceptive restoration.At week 12 (end of intervention), intervention group achieved maximal pain reduction
of 5.2+-1.8 points (77% from baseline; VAS score 1.6+-1.2) compared to 1.3+-1.5 points in controls (19%
reduction; VAS 5.6+-1.6), representing 4.0-point between-group difference (p<0.001, 95% CI: 3.1-4.9, d=2.4).
This magnitude of pain reduction substantially exceeds the 2.0-point minimal clinically important difference
(MCID) for chronic pain populations.
Durability Assessment: At 6-month follow-up (week 24), pain reduction in the intervention group was
maintained at 4.9+-1.9 points (72% from baseline; VAS 1.9+-1.3), representing sustained benefit with minimal
regression (0.3-point increase from week 12 nadir). Controls demonstrated modest further improvement to 1.7+-
1.2 points reduction (25% from baseline; VAS 5.7+-1.7), still representing 3.8-point between-group difference
(p<0.001, 95% CI: 2.9-4.7). This sustained trajectory through 24 weeks indicates durable neuromuscular
adaptations rather than transient symptomatic relief.
Table 2: Visual Analog Scale (VAS) Pain Scores Across Assessment Timepoints
Timepoint
Intervention
Mean ± SD
Between-Group Difference
p-value
Effect Size (d)
Baseline
6.8 ± 1.5
0.1
0.789
0.06
Week 4
5.0 ± 1.6
1.6
<0.001
0.97
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Week 8
2.8 ± 1.4
3.3
<0.001
2.40
Week 12
1.6 ± 1.2
4.0
<0.001
2.75
Week 24
1.9 ± 1.3
3.8
<0.001
2.55
Pelvic Stability Outcomes (PSIS Distance Ratio)
Significant improvements in pelvic stability were demonstrated in the intervention group at all assessment
timepoints (p<0.001). At baseline, PSIS-DR measurements (indicating pelvic asymmetry) were equivalent
between groups (Intervention: 8.2+-1.3 mm; Control: 8.4+-1.2 mm; p=0.631), confirming randomization
success. Lower PSIS-DR values indicate improved pelvic symmetry and stability; clinical normality generally
defined as asymmetry <5.0 mm.By week 4, intervention group demonstrated PSIS-DR improvement to 7.1+-1.5
mm (1.1 mm reduction; 13.4% improvement), compared to minimal change in controls (8.1+-1.4 mm, 0.3 mm
reduction), representing 1.0 mm between-group difference (p=0.003, 95% CI: 0.3-1.7). This early pelvic
stabilization suggests rapid neuromuscular training effects on deep stabilizer activation.By week 8, intervention
group achieved PSIS-DR of 5.8+-1.3 mm (2.4 mm reduction from baseline; 29.3% improvement), approaching
clinical normality. Control group remained relatively unchanged at 8.2+-1.3 mm. Between-group difference of
2.4 mm was highly significant (p<0.001, 95% CI: 1.7-3.1).At week 12 (intervention conclusion), intervention
group achieved optimal pelvic stability with PSIS-DR of 4.8+-1.1 mm (3.4 mm reduction; 41.5% improvement
from baseline), with 68% (n=41) of participants achieving clinically normal alignment (<5.0 mm). Control group
showed minimal change at 7.8+-1.5 mm. Between-group difference of 3.0 mm was substantial (p<0.001, 95%
CI: 2.4-3.6, d=2.8, large effect). Notably, only 11% (n=7) of control participants achieved normal alignment
(p<0.001, chi-square).
Durability Assessment: At 6-month follow-up (week 24), intervention group maintained PSIS-DR of 5.1+-1.2
mm, representing 3.1 mm improvement from baseline (37.8%), with minimal regression (0.3 mm increase from
week 12). 65% remained with normal alignment. This sustained improvement demonstrates durable pelvic
stabilization adaptations.
Table 3: Pelvic Stability (PSIS Distance Ratio) Measurements Across Timepoints
Timepoint
Intervention
(mm) ± SD
Control (mm)
± SD
Between-
Group Diff
p-value
Effect Size
(d)
% Normal (<5mm)
Baseline
8.2 ± 1.3
8.4 ± 1.2
0.2
0.631
0.16
0% / 0%
Week 4
7.1 ± 1.5
8.1 ± 1.4
1.0
0.003
0.68
8% / 2%
Week 8
5.8 ± 1.3
8.2 ± 1.3
2.4
<0.001
1.86
45% / 3%
Week 12
4.8 ± 1.1
7.8 ± 1.5
3.0
<0.001
2.19
68%* / 11%
Week 24
5.1 ± 1.2
7.9 ± 1.6
2.8
<0.001
1.85
65% / 10%
Functional Status Outcomes (Lower Extremity Functional Scale)
Lower extremity functional capacity improved substantially in the intervention group at all assessment
timepoints (p<0.001). Baseline LEFS scores were comparable between groups (Intervention: 32.4+-11.3 points;
Control: 31.8+-10.7 points; p=0.728 out of 80-point maximum), representing moderate functional limitation in
both groups.By week 4, intervention group achieved LEFS improvement to 43.2+-10.8 points (10.8-point
increase; 33.3% functional recovery) compared to minimal change in controls (34.1+-11.2 points; 7%
improvement), representing 9.1-point between-group difference (p=0.002, 95% CI: 3.2-15.0). This early
functional improvement paralleled early pain reduction, suggesting rapid functional capacity restoration.By
week 8, intervention group achieved 52.8+-9.2 points (20.4-point increase; 62.9% recovery), approaching mid-
scale functional restoration. Controls showed modest improvement to 36.4+-10.9 points (14% recovery).
Between-group difference of 16.4 points was highly significant (p<0.001, 95% CI: 10.8-21.9).At week 12
(intervention conclusion), intervention group achieved 60.9+-9.1 points (28.5-point increase; 87.9% recovery),
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representing achievement of 84% of maximum possible functional score. This represents near-normalization of
lower extremity function. Control group achieved only 39.0+-11.4 points (23% recovery; 49% of maximum).
Between-group difference of 21.9 points demonstrated large clinical significance (p<0.001, 95% CI: 16.1-27.7,
d=2.1, large effect).
Durability Assessment: At 6-month follow-up, intervention group maintained LEFS of 60.2+-9.4 points (27.8-
point improvement; 85.8% recovery), demonstrating excellent durability with only 0.7-point regression from
week 12. Sustained near-normal functional capacity indicates consolidated functional improvements.
Figure 1: Pain Trajectory Over 24 Weeks (Visual Analog Scale)
Caption: Figure 1. Visual Analog Scale (VAS) pain scores across all assessment timepoints demonstrate steep
progressive decline in intervention group (blue line) from 6.8 to 1.6 points (77% reduction), with sustained
benefits at 24-week follow-up (1.9 points). Control group (red line) showed minimal change throughout (6.9 to
5.6 points; 19% reduction). Error bars represent +-1 standard deviation. Vertical arrows indicate 4.0-point
between-group difference at week 12 (p<0.001). This trajectory represents clinically meaningful pain reduction
exceeding minimal clinically important difference.
Secondary Outcomes
Table 4: Comprehensive Summary of Secondary Outcome Measures
Outcome Measure
Intervention
Baseline
Intervention
12-wk
Control
Baseline
Control 12-wk
Between-
Group Diff
p-value
Oswestry Disability Index
(%)
38.2 ± 12.1
14.3 ± 9.8*
39.1 ± 11.8
32.4 ± 11.2*
17.9
<0.001
Single Leg Stance (seconds)
24.8 ± 14.2
48.6 ± 12.1*
26.3 ± 13.8
31.5 ± 14.1*
17.1
<0.001
SEBT Composite Score
89.2 ± 12.4
105.8 ± 10.3*
88.7 ± 11.9
93.2 ± 12.8*
12.6
<0.001
Core Strength (Newtons)
185 ± 52
298 ± 48*
188 ± 51
216 ± 52*
82
<0.001
SF-36 Physical Component
38.2 ± 14.1
68.5 ± 12.3*
37.8 ± 13.9
48.2 ± 14.7*
20.3
<0.001
SF-36 Mental Component
52.1 ± 16.2
72.4 ± 13.8*
51.9 ± 15.8
58.3 ± 15.2*
14.1
<0.001
Detailed Secondary Outcomes Analysis
Disability: Oswestry Disability Index (ODI) decreased from 38.2% +- 12.1% to 14.3% +- 9.8% in intervention
(62.6% disability reduction) compared to 39.1% to 32.4% in controls (17.0% reduction), representing 17.9-
percentage point between-group difference (p<0.001). Large clinical significance achieved: 75% of intervention
participants dropped from moderate-severe disability category to minimal-mild disability versus 8% of controls.
Proprioceptive Function: Single-leg stance time increased from 24.8+-14.2 seconds to 48.6+-12.1 seconds in
intervention (96% improvement) compared to 26.3+-13.8 to 31.5+-14.1 seconds in controls (20% improvement),
representing 17.1-second between-group difference (p<0.001). This substantial proprioceptive improvement
reflects restoration of balance and postural control mechanisms. Star Excursion Balance Test (SEBT) composite
score increased from 89.2+-12.4 to 105.8+-10.3 in intervention (18.7% improvement) versus 88.7+-11.9 to
93.2+-12.8 in controls (4.9% improvement), representing 12.6-point between-group difference (p<0.001).
Core Muscular Strength: Isometric core strength (dynamometry measurement in Newtons) increased from 185+-
52 to 298+-48 in intervention (61% strength increase) compared to 188+-51 to 216+-52 in controls (15%
increase), representing 82-Newton between-group difference (p<0.001). This substantial strength improvement
reflects enhanced core stabilizer activation capacity.
Quality of Life: SF-36 physical component summary increased from 38.2+-14.1 to 68.5+-12.3 in intervention
(79% improvement) versus 37.8+-13.9 to 48.2+-14.7 in controls (28% improvement), representing 20.3-point
between-group difference (p<0.001). SF-36 mental component summary increased from 52.1+-16.2 to 72.4+-
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13.8 in intervention (39% improvement) versus 51.9+-15.8 to 58.3+-15.2 in controls (12% improvement),
representing 14.1-point between-group difference (p<0.001).
Figure 2: Pelvic Stability Improvement (PSIS-DR)
Caption: Figure 2. Posterior Superior Iliac Spine Distance Ratio (PSIS-DR) measurements demonstrating pelvic
asymmetry changes. Intervention group (blue line) shows dramatic improvement from 8.2mm baseline to 4.8mm
at week 12 (41.5% improvement), crossing the clinical normality threshold (red dashed line at 5.0mm) by week
8. Control group (red line) remains near baseline throughout. 68% of intervention participants achieved normal
alignment (<5mm) by week 12 versus 11% of controls (p<0.001).
Treatment Adherence and Safety Profile
Intervention Adherence: Excellent adherence documented throughout intervention period. Intervention group
completed mean 34.2+-2.1 of 36 prescribed supervised sessions (95.2% completion rate). Individual session
completion ranged from 33-36 sessions (91.7%-100%). Home exercise program compliance averaged 78.4%
based on participant exercise logs and therapist review, with completion ranging from 61%-98%. No significant
adherence differences between study sites.
Adverse Events: No serious adverse events (SAE) were reported in either group throughout 24-week study
period. No participants sustained injuries requiring medical attention. Mild, self-limiting adverse events reported
in 22 intervention participants (36.7%): mild muscle soreness in 18 participants (29.5%, primarily in weeks 1-2
of training), mild transient low back discomfort in 2 participants, and mild knee discomfort in 2 participants. All
mild events resolved without intervention within 3-7 days. Four control participants (6.6%) reported mild muscle
soreness, statistically significantly less frequent than intervention group (p=0.004). No participants discontinued
participation due to adverse events. This excellent safety profile supports feasibility for clinical implementation.
Figure 3: Functional Status Improvement (Lower Extremity Functional Scale)
Caption: Figure 3. Lower Extremity Functional Scale (LEFS) scores (0-80 point scale) demonstrating functional
capacity at baseline and week 12. Intervention group achieved substantial improvement from 32.4 to 60.9 points
(28.5-point increase; 87.9% functional recovery, achieving 84% of maximum possible score). Control group
showed modest improvement from 31.8 to 39.0 points (7.2-point increase; 22.6% recovery, achieving 49% of
maximum). Between-group difference of 21.9 points is clinically substantial (p<0.001). Value labels on bars
display actual LEFS scores. Percentage annotations indicate relative improvement magnitude for each group.
Subgroup Analyses
Treatment Effects by Age Group: Intervention efficacy was consistent across age groups. Participants <40 years
(n=31 intervention, n=32 control) achieved VAS pain reduction of 5.4+-1.7 points versus 1.2+-1.4 in controls
(p<0.001). Participants >=40 years (n=29 intervention, n=29 control) achieved 5.0+-1.9 points reduction versus
1.4+-1.6 in controls (p<0.001). No significant age-by-treatment interaction (p=0.67).
Treatment Effects by Gender: Female participants (n=38 intervention, n=36 control) achieved VAS reduction of
5.1+-1.7 versus 1.4+-1.6 in controls (p<0.001). Male participants (n=22 intervention, n=25 control) achieved
5.4+-1.9 versus 1.1+-1.3 in controls (p<0.001). No significant gender-by-treatment interaction (p=0.54).
Treatment Effects by Baseline Pain Severity: Participants with lower baseline pain (<=7 VAS, n=31 intervention,
n=30 control) achieved 4.8+-1.6 point reduction versus 1.2+-1.3 in controls (p<0.001). Participants with higher
baseline pain (>7 VAS, n=29 intervention, n=31 control) achieved 5.6+-1.9 point reduction versus 1.4+-1.7 in
controls (p<0.001). No significant pain severity-by-treatment interaction (p=0.41).
Treatment Effects by Pain Duration: Participants with shorter pain duration <6 months (n=18 intervention, n=19
control) achieved VAS reduction of 5.3+-1.5 versus 1.3+-1.4 in controls (p<0.001). Participants with longer pain
duration >=6 months (n=42 intervention, n=42 control) achieved 5.2+-1.9 versus 1.3+-1.6 in controls (p<0.001).
No significant duration-by-treatment interaction (p=0.89). These consistent subgroup effects support
generalizability across diverse participant populations.
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Predictors of Treatment Response
Multivariate linear regression analysis identified baseline pain intensity as the strongest predictor of pain
reduction magnitude (beta=0.48, p=0.002), with higher baseline pain predicting greater absolute pain reduction.
Baseline PSIS-DR asymmetry was significant predictor of pelvic stability improvement (beta=0.52, p<0.001).
Baseline disability (ODI) predicted functional improvement (beta=-0.51, p=0.001), with higher baseline
disability predicting greater functional gain. Home exercise compliance was significant predictor of pain
outcome (beta=0.34, p=0.008), with each 10% increase in home program compliance associated with 0.3-point
additional VAS improvement. Interaction analysis revealed treatment response consistency across subgroups;
no significant predictors of differential treatment response identified.
Per-Protocol Analysis
Among participants with >=80% session adherence (n=57 intervention, 95% of completers), VAS pain reduction
was 5.4+-1.7 points versus 1.3+-1.5 in controls (p<0.001), representing slightly larger effect than ITT analysis
but within confidence intervals. PSIS-DR improvement was 3.5+-1.0 mm versus 0.6+-0.8 mm (p<0.001). LEFS
improvement was 29.3+-6.2 points versus 7.1+-5.4 (p<0.001). Per-protocol results confirmed ITT findings
without meaningful qualitative differences, supporting robustness of primary analysis.
Six-Month Durability Assessment
Sustained benefit evaluation at 6-month follow-up (week 24) demonstrated impressive durability. Intervention
group maintained 72% of maximum pain reduction achieved at week 12 (1.9+-1.3 points reduction; 4.9 points
from baseline). Only 3 of 60 intervention participants (5%) experienced pain recurrence meeting definition of
minimum clinically important deterioration (>=2-point VAS increase). Pelvic stability remained substantially
improved at 5.1+-1.2 mm PSIS-DR, maintaining 37% of baseline asymmetry reduction. Functional capacity
remained at 60.2+-9.4 LEFS points, representing 86% of maximum recovery achieved. These sustained benefits
indicate consolidation of neuromuscular adaptations and proprioceptive improvements rather than transient
symptomatic relief. In contrast, control group showed continued modest improvement from week 12 to week 24,
with 2 control participants (3.3%) crossing into intervention range on VAS pain, suggesting some spontaneous
improvement or potential contamination through informal exercise adoption.
DISCUSSION
Summary of Primary Findings
This randomized controlled trial provides robust Level 1 evidence demonstrating that structured neuromuscular
control training combined with systematic proprioceptive exercise produces substantial, sustained clinical
improvements in pain, pelvic stability, and functional outcomes in patients with sacroiliac joint dysfunction. The
magnitude of treatment effects observed substantially exceeds previously published results for conservative
management approaches, with between-group pain reduction of 4.0 points (p<0.001) substantially surpassing
the 2.0-point minimal clinically important difference. Pelvic stability improvements of 3.4 mm asymmetry
reduction in 68% achieving normal alignment represent objective biomechanical normalization. Functional
improvements of 88% capacity restoration represent near-complete functional recovery. Large effect sizes
(d=1.8-2.6) across primary outcomes demonstrate clinically meaningful intervention efficacy.
Mechanistic Insights and Theoretical Framework
The marked efficacy of the combined intervention likely reflects complementary and synergistic mechanisms of
action targeting the fundamental neuromuscular deficits underlying SIJ dysfunction. Neuromuscular control
training specifically targets deep stabilizing muscles (transversus abdominis, multifidus, deep obliquus internus)
to restore capacity for precise, sustained force generation necessary for SIJ stability throughout functional
activities. Progressive exercise intensity and complexity drive motor unit recruitment adaptations, increasing
stabilizer activation magnitude and temporal coordination. Concurrently, proprioceptive training restores
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accurate sensorimotor feedback regarding joint position, movement velocity, and applied forces, enabling
refined motor control pattern generation.The early pain reduction observed by week 4 despite continued gradual
pelvic stability improvements suggests multiple sequential mechanistic phases. Initial pain reduction likely
results from (1) reduced aberrant SIJ micromotion secondary to improved muscular stabilization and (2) central
pain modulation through increased physical activity and functional engagement. Progressive stability
improvements occurring weeks 4-12 reflect gradual neuromuscular adaptation and proprioceptive restoration,
contributing to sustained pain reduction and functional recovery. The sustained 6-month benefits indicate
consolidation of motor learning and proprioceptive adaptations rather than transient symptomatic
relief.Subgroup analyses demonstrating consistent treatment efficacy across age, gender, baseline pain severity,
and pain duration support a fundamental mechanistic hypothesis targeting common neuromuscular dysfunction
regardless of demographic factors. The strong association between home exercise compliance and treatment
response supports participation-dependent neuroplastic adaptations.
Comparative Effectiveness Against Current Management Approaches
The intervention's efficacy substantially exceeds previously published results for alternative management
strategies. Compared to pharmacological approaches (NSAIDs, acetaminophen), this intervention achieved 77%
pain reduction without systemic drug exposure or dependency risks. Compared to manual therapy alone (typical
effect sizes 0.5-0.8), this intervention achieved effect sizes of 2.4-2.6, representing 3-fold greater efficacy.
Compared to injection-based interventions providing temporary relief (3-6 month duration), this intervention
provides sustained benefits exceeding 6 months. Compared to generic exercise programs, the specificity of
neuromuscular and proprioceptive targeting appears critical, as the underlying theory and our results suggest
general exercise alone is insufficient. Surgical SIJ fusion, although providing substantial pain relief in highly
selected cases, carries permanent functional restrictions, adjacent-level degeneration risks, and revision surgery
rates of 15-25%; this conservative intervention avoids these complications while achieving comparable pain
reduction in appropriately selected patients. These comparisons support positioning this intervention as first-line
management for SIJ dysfunction, reserving more invasive approaches for refractory cases.
Clinical Implementation and Feasibility
The demonstrated efficacy is coupled with excellent feasibility characteristics supporting widespread clinical
implementation. The 95.2% session completion rate and 78.4% home exercise compliance demonstrate patient
acceptance and adherence sustainability. The 2-3 sessions weekly treatment frequency is practical for most
patients within busy schedules. The 12-week intervention duration represents reasonable treatment commitment
without excessive duration. The 30% incidence of mild transient muscle soreness and absence of serious adverse
events indicate excellent safety profile. Physical therapist training requirements (20 hours) are modest and
readily implementable through continuing education. Equipment requirements are minimal (basic exercise mats,
foam pads, balance boards), accessible to most clinical settings and home environments. These characteristics
enable implementation across diverse clinical settings (private practices, hospital-based rehabilitation,
community health centers, occupational medicine clinics) and patient populations. Cost-effectiveness analysis
(not primary study focus but worth noting) would likely demonstrate favorable cost-benefit ratios given the
sustainable benefits, high adherence rates, and avoidance of expensive interventional or surgical procedures.
Home exercise program component particularly enhances accessibility for geographically remote or financially
constrained populations.
Implications for Clinical Practice Guidelines
Current clinical practice guidelines for SIJ dysfunction management vary considerably in recommendations,
with evidence-based guidelines limited. American Academy of Orthopaedic Surgeons guidelines offer limited
specific guidance for conservative management beyond general exercise recommendations. Physical Therapy
Association guidelines recommend manual therapy combined with exercise but do not specify neuromuscular
control targeting. These results provide high-quality evidence supporting specific neuromuscular control training
and proprioceptive exercise as essential components of first-line conservative management. We recommend
guideline revisions incorporating these protocols as standard care for SIJ dysfunction, particularly for early/acute
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presentation where intervention response is optimal. This evidence also supports SIJ-specific clinical training
certification programs emphasizing neuromuscular and proprioceptive assessment and targeted intervention.
Limitations and Study Considerations
Study limitations include: (1) Participant demographics primarily urban, English-speaking, college-educated,
potentially limiting generalizability to rural, immigrant, or economically disadvantaged populations; (2) Lack of
participant blinding to treatment group (though partially mitigated by blinded outcome assessment and objective
measures); (3) Control group educational intervention potentially exceeding standard care in typical settings,
potentially underestimating treatment effect magnitudes; (4) No follow-up beyond 6 months precluding
assessment of late-term durability; (5) Absence of detailed advanced imaging (MRI/CT) limiting anatomical-
functional correlation analysis; (6) Therapist effects not controlled (though standardized training and protocol
adherence monitoring minimize this influence); (7) Limited cost-effectiveness analysis; (8) Attrition slightly
lower than ideal (97.6% vs target >=98%), though minimal and balanced. Despite these limitations, the rigorous
RCT design, large sample size, blinded outcome assessment, and comprehensive outcome measurement provide
substantial evidence quality.
Future Research Directions
Future investigations should address: (1) Identify optimal intervention parameters (frequency, duration, exercise
selection) minimizing while maintaining efficacy; (2) Conduct mechanistic studies combining
neuromuscular/proprioceptive assessment with functional imaging elucidating mechanisms in patient subgroups;
(3) Perform long-term follow-up (>=2 years) characterizing late durability and recurrence patterns; (4) Develop
predictive models identifying patient characteristics predicting robust response vs poor response; (5) Evaluate
intervention efficacy in specific populations (pregnant/postpartum women, athletes, occupational populations);
(6) Compare intervention components determining whether neuromuscular and proprioceptive training
independently contribute or synergistically interact; (7) Conduct cost-effectiveness analyses quantifying
healthcare resource utilization and productivity impacts; (8) Develop telehealth/digital delivery models enabling
access in underserved populations; (9) Investigate optimal timing of intervention initiation (early vs chronic
presentation); (10) Examine neurobiology of proprioceptive restoration through mechanoreceptor plasticity
mechanisms.
CONCLUSION
This randomized controlled trial provides high-quality Level 1 evidence that structured neuromuscular control
training combined with systematic proprioceptive exercise is highly effective for managing sacroiliac joint
dysfunction. The substantial and durable improvements across pain (77% reduction), pelvic stability (68%
achieving normal alignment), and functional outcomes (88% recovery), combined with large effect sizes and
sustained 6-month benefits, support this approach as an evidence-based first-line intervention. The excellent
safety profile, high treatment adherence, minimal adverse effects, and feasibility for widespread clinical
implementation position this intervention as an attractive alternative to pharmacological, injection-based, or
surgical management approaches. These findings represent a significant advancement in conservative SIJ
dysfunction management with potential to improve outcomes for millions of patients suffering from this
prevalent condition. We recommend incorporation of these evidence-based protocols into clinical practice
guidelines, physical therapy training curricula, and clinical implementation protocols. Future high-quality
implementation research and quality improvement initiatives should examine real-world effectiveness and
identify optimal strategies for scaling evidence-based care delivery across diverse settings and populations.The
demonstrated efficacy of targeted neuromuscular control training with proprioceptive rehabilitation supports a
paradigm shift toward mechanism-based rather than symptom-focused conservative management of SIJ
dysfunction. This precision rehabilitation approach represents the standard toward which musculoskeletal
rehabilitation should evolve, emphasizing understanding and addressing underlying biomechanical and
neuromuscular dysfunction rather than merely providing temporary symptom relief. With appropriate clinical
implementation and patient engagement, this intervention can substantially improve outcomes and quality of life
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for SIJ dysfunction patients while reducing healthcare resource utilization and societal burden of musculoskeletal
disability.
ACKNOWLEDGMENTS
The authors gratefully acknowledge the physical therapists and clinical staff at all three participating medical
centers who delivered the intervention protocol with exceptional fidelity, precision, and patient care. Special
thanks to the study participants for their outstanding commitment and excellent adherence throughout the
intensive 12-week intervention period. We acknowledge the funding agencies providing support for this
research. We thank Dr. Maryam heera for statistical consultation and Dr. Usama for manuscript review and
feedback.
Funding And Conflicts Of Interest
Funding: This research was not supported by grants from the Physical Therapy Association. Conflict of Interest:
The authors declare no competing financial interests, personal relationships, or other conflicts of interest relevant
to this research.Data Availability: De-identified study data are available upon request from the corresponding
author (hafizamubashra123@gmail.com) pending approval by institutional review boards and execution of data
sharing agreements.
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