Clinical Pain Provocation Sacroiliac Joint Tests
A large number of clinical tests have been proposed to assess movement or asymmetry of the SIJ. These tests have been examined for intra- and inter-examiner reliability in studies of varying quality. In general, inter-examiner reliability of individual tests is poor13,1725, but some tests have shown adequate reliability26,27. There is also evidence that greater experience in using these tests results in poorer inter-examiner reliability compared to the reliability of novices24,28.Reliability of Palpation SIJ Tests Aimed at Identifying Dysfunction
If the important factor was sacral torsion, however, the test should be detecting it regardless of duration of symptoms. The stronger association among those subjects with more acute LBP (<3 months' duration) may suggest another as yet unknown mechanism for the association between the sitting flexion test and LBP. The sitting flexion test was most strongly associated with the supine-to-sit test. Although the supine-to-sit test is apparently used to test sacroiliac joint mobility, I did not find any authors who proposed that the supine-to-sit test is sensitive to sacral motion rather than innominate motion. There are other interventions not available to physical therapists that may have value in the treatment of persistent SIJ pain. Corticosteroid injections88,97,98, phenol injections99, and radiofrequency neurotomy100104 are minimally invasive and appear to be effective in a proportion of cases of SIJ pain, especially if there is imaging evidence of sacroiliitis. Prolotherapy has been recommended by some reports, but the quality of evidence is poor, and methods and subjects are heterogeneous105. The evidence in favor of these interventions is limited106. Surgical debridement107 and fusion108 are more invasive but appear to offer a moderate chance of pain reduction and functional improvement in patients with confirmed SIJ pain unresponsive to more conservative interventions.
I performed the right and left Gillet tests using a commonly advocated technique and decision ,45 If the measurement was positive on either the right or the left side, the Gillet test was considered positive. The standing flexion test and the sitting flexion test were conducted using a common set of techniques and decision criteria,5,15 as was the supine-to-sit test. 4,5,8 Another procedure that has been somewhat successful is called radiofrequency ablation. After a diagnostic injection has confirmed that the pain is coming from the SI joint, the small nerves that provide sensation to the joint can be burned with a special needle called a radiofrequency probe. In theory, this destroys any sensation coming from the joint, making the joint essentially numb. This procedure is not always successful. It is temporary but can last for up to two years. It can be repeated if needed. Based on recent research, the IASP criteria have been superseded for a variety of reasons.
Although the association might be stronger among males and among people 35 to 50 years of age, the data must be considered inconclusive given the imprecision of the estimated associations. The Gillet test demonstrated virtually no association with static innominate torsion (OR= [95 CI=, ]) and only a very weak association with PSIS asymmetry in a standing position (OR= [95 CI=, ]). The stronger association between the Gillet test results and LBP as opposed to measurements of innominate torsion might support the contention that the Gillet test assesses sacroiliac joint hypomobility and that it is the hypomobility rather than innominate torsion that leads to LBP. This hypothesis, however, may be contradicted by the possible increase in strength of the relationship among males and among people between 35 and 50 years of age. Males and older individuals may have less mobile sacroiliac ,54 Decreases in mobility would be expected to increase the number of positive tests among males and older individuals (regardless of the association with LBP). However, the number (and proportion) of positive tests was similar for both age groups; male subjects actually had fewer positive test findings (about one half as many) than did female subjects.
Diagnostic injections must be performed under image intensifier control because blind injections rarely succeed in placing injectate within the SIJ cavity46,47. The optimal technique of injection was established in 199248 and is described in the current edition of the practice guidelines issued by the International Spine Intervention Society42. Because false positive responses to single diagnostic blocks into synovial joints are common49, comparative or placebo-controlled blocks are now considered essential before a diagnosis of SIJ mediated pain is confirmed42. In the final set of analyses, I determined the frequencies of positive and negative test results for each test among the subjects with and without LBP, as well as the estimated crude odds ratios and 95 CIs for the associations (Tab. 5). The data indicate a strong positive association between Gillet test results and LBP (OR= [95 CI=, ]). Confidence intervals, however, were wide due, in part, to the small number of positive test results.
Diagnostic Accuracy of Palpation SIJ Tests Aimed at Identifying Dysfunction
In my study, I used a cross-sectional approach with a sample of adult patients seeking physical therapy services: (1) to assess the magnitude of the association between innominate torsion and the results of 4 clinical tests of sacroiliac joint dysfunction, (2) to estimate the performance characteristics (sensitivity, specificity, positive predictive value, and negative predictive value) of these tests in identifying patients with innominate torsion, and (3) to assess the magnitude of association between the results of the clinical tests and nonspecific LBP of less than 1 year's duration.
43,44 The crest level tester was placed around the subject's waist from behind and firmly seated on top of the iliac crests by feel alone (Fig. 3). Once the crest level tester was firmly seated on the iliac crests, I visually assessed the position of the bubble in the level. If more than half of the bubble was within the central marks, I considered the crests to be symmetric (negative); if more than halfway outside the markings to the left or right, the crests were considered asymmetric (positive). I repeated the procedure once or twice again from the beginning before recording the determination reached twice. I used the same procedure for assessing posterior iliac crest level while the subjects were sitting. Repeated assessments were not used for reliability estimates because I could not be blinded to the initial measurement. A test with high sensitivity and low specificity cannot be used to make a diagnosis because of the high proportion of cases with positive tests but negative to the reference standard; i. e.
As the value of a negative likelihood ratio approaches zero, the test's power to rule out the disease in question approaches perfection. Conversely, as the value of the negative likelihood ratio increases towards 1. 0, the test's ability to rule out the disorder approaches random chance79. When both the prevalence of the disorder and the results of a test are known, likelihood ratios permit calculation of the change in odds and probability of a disorder being present or absent80. Prior to any examination, the probability of a given disorder being present is its prevalence. For example, if the prevalence of SIJ pain is 1381, its pre-examination probability is . The diagnostic value of a test is reflected by how much the probability of the disorder increases when the test is positive and by how much it falls when it is negative. The diagnostic value of a given test can be depicted using Fagan's nomogram () in which the pretest probability, prevalence, positive and negative likelihood ratios, and post-test probabilities are presented graphically. Figure Figure77 presents Fagan's nomogram using data from Laslett et al52 in which three or more positive SIJ tests are considered positive for SIJ pain without consideration of the centralization phenomenon.
During the data collection session, I or a research assistant obtained informed consent and had each subject complete a self-administered questionnaire from which descriptive data were obtained. I conducted a physical examination in a fixed order for all subjects. The examination consisted of measurements of the height of the pelvic landmarks, iliac crest level, and leg lengths and the 4 clinical tests of sacroiliac joint dysfunction. I served as the only examiner to avoid interrater reliability issues. At the beginning of data collection, I was usually unaware of whether subjects had LBP. To reduce the possibility that patients' behavior would indicate whether they had LBP, I treated all subjects as if they had LBP. All subjects were unknown to me, and I performed only the measurements described in this article. Consequently, my judgments of positive or negative test results were not influenced by patient history or other evaluative findings. In spite of a relatively small number of positive results on the Gillet test, there was 4. 5 times more LBP among subjects with positive test results than among subjects with negative test results. The data yielded a specificity of 97, but a sensitivity of only 12. The association was stronger when only subjects with LBP who had not experienced pain relief were included.
The odds ratios and 95 CIs for these associations are presented in Table 6. Only the association between the results of the sitting flexion test and the results of the supine-to-sit test appeared to be potentially important (OR= [95 CI=, ]). It has been pointed out that diagnostic injection into the SIJ can provide data on an intra-articular source of pain but not on pain arising from the extra-articular ligaments3,51. In addition, injectate may spread from a successful intra-articular injection to adjacent structures including the dorsal sacral foramina, the L5 spinal nerve and lumbosacral plexus84. It is clear that the reference standard for diagnosing SIJ pain is not perfect. This has been used to discredit the procedure as well as the clinical tests predictive of the diagnostic injection outcome85. This view, however, is not universally accepted111. A recent review of SIJ interventions concluded that there is limited evidence in support of diagnostic and therapeutic procedures for the SIJ106.
A double-blind trial was carried out to determine the sensitivity and specificity of three commonly used pain provocation tests for sacroiliac joint dysfunction. The trial involved 40 patients, all of whom reported pain when they were subjected to each of the three tests. Half of the patients (20) had the symptomatic sacroiliac joint injected with 4 ml of 1 lignocaine, whereas the other 20 patients received 4 ml of normal saline to the painful joint. The level of pain produced by each of the three tests was assessed pre- and posttest injection using a visual analogue scale of 0-100. If the pain could be suppressed by 70 with injection of either normal saline or 1 lignocaine into the symptomatic sacroiliac joint under image intensification, the test was considered to be positive for pain arising from the sacroiliac joint. None of the patients receiving normal saline had their pain suppressed to any significant degree, whereas those patients receiving 1 lignocaine had their pain suppressed sufficiently for the three pain provocation tests to have a specificity of 100 for each test and a sensitivity range of 77-87. This study indicates that the three tests, when used in combination, have a high predictive value for pain arising from the sacroiliac joint.
- Pain provocation tests for the assessment of sacroiliac joint dysfunction. Bogduk N. Bogduk N. J Spinal Disord. 1999 Aug;12(4):357-8. doi: J Spinal Disord. 1999. PMID: 10451054 No abstract available.
This was done to explore whether other variables reflecting asymmetry might be more strongly associated with test results than innominate torsion as I estimated it. The alternative measures of innominate asymmetry included PSIS and iliac crest asymmetry in standing and sitting positions, ASIS asymmetry in a standing position, and supine leg-length difference. These alternative measures include most, if not all, of the landmarks commonly used in the clinic to assess innominate torsion. I measured these alternative asymmetry variables and used fixed cutoff points to determine positive or negative findings, as opposed to using personal judgment as is often done in the clinic. Findings for PSIS asymmetry, ASIS asymmetry, and leg-length difference were considered negative if asymmetry was 4 mm or less and positive if asymmetry exceeded 4 mm. Only the Gillet test showed a potentially important increase in association with one of these variables, but this finding was not statistically significant. There were no substantive changes in the relationship of the remaining test results with any of the explored alternative asymmetry variables.
Clinical Pain Provocation Sacroiliac Joint Tests
The sitting flexion test and supine-to-sit test also showed a positive association with LBP (OR= [95 CI=, ] and [95 CI=, ], respectively), but the odds ratios were substantively weaker than for the Gillet test and CIs revealed considerable imprecision. The standing flexion test was not positively associated with LBP (OR= [95 CI=, ]). The sitting flexion test was only weakly associated with LBP (OR= [95 CI=, ]), except among subjects with sitting iliac crest asymmetry where the association increased to (95 CI=, ). As for the Gillet test, however, the small number of positive test results among the comparison group make it difficult to draw conclusions from the data. The sitting flexion test is viewed by some authors4,14,15 as a reflection of asymmetrical positioning (torsion) of the sacrum rather than torsion of the innominates, but data to support this hypothesis are lacking. Because the sacrum was not evaluated in this study, asymmetry of the sacrum might still be a factor and might explain the increase in association between the sitting flexion test results and LBP over the test's association with innominate torsion.
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No one had positive results on all 5 tests. The odds ratio for the association between innominate torsion and 2 or more positive tests was (95 CI=, ). The cumulative test performance was no stronger than the performance of the supine-to-sit test alone. The sensitivity, specificity, positive predictive value, and negative predictive value for the ability of each test to identify subjects with positive innominate torsion and subjects with negative innominate torsion are also presented in Table 4. As might be expected from the estimated odds ratios, test sensitivity and negative predictive values were uniformly low (8-44). I also examined the criterion test results that Bemis and Daniel4 claimed could be used to diagnose iliosacral dysfunction (innominate torsion). These investigators used a combination of a positive standing PSIS asymmetry finding, a positive standing flexion test finding, and a negative sitting flexion test finding to diagnose individuals with innominate torsion; those subjects with negative findings on all 3 tests were assigned to a comparison group.
The data in my study did not support the use of the Gillet test, standing flexion test, sitting flexion test, or supine-to-sit test to differentiate between subjects with and without static innominate torsion in a patient sample. Using 2 or more tests in parallel or using alternative measures of innominate torsion did not substantially improve the usefulness of the measurements. Subgroup and covariate analyses did not suggest that explanatory variables may have masked or distorted a positive relationship. This study does not argue against use of the 4 tests for assessing sacroiliac joint hypomobility or positional problems with the sacrum. Data to support that use, however, have not been reported. The data from my study indicate that only the Gillet test showed a substantive association with LBP, although the basis for the association cannot be determined from these data. My findings do not, in my opinion, argue against continued use of the 4 studied tests of sacroiliac joint dysfunction. Having potentially ruled out one possible basis for these tests (innominate torsion) and having raised a question about the relationship of test results to LBP, clinicians should be cautious in their use until more data are available.
, there is a high false positive rate. A test with high specificity and low sensitivity is useful in making the diagnosis, but a large proportion of cases positive to the reference standard will have negative tests; i. e. , there is a high false negative rate33,34. Consequently, if making the diagnosis of SIJ dysfunction is the objective, tests for dysfunction need to have high specificity with respect to an acceptable reference standard. I explored the association of innominate torsion with positive findings on 2 or more tests. According to some authors,5153 the results of 2 or more dichotomous tests used in parallel will be more sensitive than the results of a single test, assuming that the measures reflect complementary phenomena rather than redundant data. Of those subjects with positive innominate torsion, 13. 4 (n=21) had positive results on 2 or more tests, whereas 11. 5 (n=10) of those subjects without torsion had positive results on 2 or more tests. Two subjects, one with positive innominate torsion and one with negative innominate torsion, had positive results on 3 of the 4 tests.
The 2 hypotheses as to what causes sacroiliac pain appear to be the bases for the classification of LBP as being due to iliosacral dysfunction,4 sacroiliac joint dysfunction,58 lumbosacral dysfunction,9 sacroiliac joint malalignment,10 sacroiliac hypermobility or hypomobility,11 or sacroiliac regional Each of these classification or diagnostic schemes is based on the assumption that sacroiliac joint dysfunction can be identified by use of tests to assess either innominate torsional asymmetry or sacroiliac joint hypomobility. The common tests include determination of posterior superior iliac spine (PSIS) level in a standing or sitting position, the Gillet test (also known as the march or stork test), the standing flexion test, the sitting flexion test (or Piedallu's sign), and the supine-to-sit test. These tests are also widely promoted as part of a LBP examination in orthopedic, osteopathic, physical therapy, and chiropractic educational 21 Yet, there is neither consensus on nor evidence to support the underlying hypotheses on which these tests are based.
These data suggest that there may be no reduction in mobility among males and older individuals, or the data may indicate the existence of some other mechanism for positive Gillet findings than joint hypomobility. I determined the frequencies of positive and negative test results for each test among those subjects with positive and negative innominate torsion, as well as the odds ratios and 95 CIs (Tab. 4). Missing values resulted from the subjects' refusal or inability to be tested or from inability to palpate landmarks due to obesity. Odds ratios and 95 CIs for the association between test results and innominate torsion for the Gillet, standing flexion, sitting flexion, and supine-to-sit tests were (95 CI=, ), (95 CI=, ), (95 CI=, ), and (95 CI=, ), respectively. Only the odds ratio of the supine-to-sit test was much above 1. 0, and the CI for this slightly higher odds ratio was wide (indicating imprecision of the estimate). As an additional set of alternative analyses, I assessed the association of test results with alternative measures of innominate asymmetry other than estimates of innominate torsion.
The Gillet test results showed a stronger positive association with standing iliac crest level (OR= [95 CI=, ]) than with innominate torsion (OR= [95 CI=, ]), although the stronger association is still relatively imprecise and not statistically significant at P . 05. Given this stronger estimate of association, I recalculated sensitivity, specificity, and predictive values for the Gillet test with standing iliac crest asymmetry. Gillet test performance characteristics did not change in any substantive way from those for calculated innominate torsion. My data suggest that the Gillet test, standing flexion test, sitting flexion test, and supine-to-sit test do not appear useful in identifying people with estimated innominate torsion. Although some of the associations with innominate torsion were weakly positive, the sensitivity and predictive values indicate that the tests are not useful for identifying patients with torsion. Controlling variables such as leg-length differences, standing iliac crest level, or sitting iliac crest level did not substantively alter the relation between test results and innominate torsion.
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The resulting odds ratio applying these same criteria to data from this study was (95 CI=, ). Although I measured PSIS asymmetry rather than using personal judgment alone as did Bemis and Daniel, the combination of test results recommended by Bemis and Daniel did not strengthen the association between test results and innominate torsion. Diagnosis begins with a complete history and physical exam. Your Osteopath will ask questions about your symptoms and how the pain is affecting your daily activities. Your Osteopath will also want to know what positions or activities make your symptoms worse or better. You will be asked questions about any injuries in the past and about any other medical problems you might have such as any arthritis that runs in the family. Interestingly, although the technique used in this study is described as affecting the SI region, it was lumbar hypomobility that entered the prediction model. This finding reinforces the idea that the manipulation technique is not specific to the SI region but impacts the lumbar spine as well90. As a final set of analyses, I explored the relationship among test results to determine whether 2 or more of the tests appeared to be assessing a similar phenomenon.
Despite the shortcomings, controlled blocks under fluoroscopic guidance remain the best available reference standard for identifying intra-articular SIJ pain. Restricting the interpretation of the SIJ tests to non-centralization cases improves the specificity of three or more positive pain provocation SIJ tests from 78 to 87 with the sensitivity remaining at 9152. Patients satisfying these criteria have a high probability that SIJ pain will be confirmed by diagnostic injection of local anesthetic. This clinical reasoning process may be considered a clinical prediction rule for the identification of a subset of patients most likely to have pain of SIJ origin. For convenience, we may refer to this as the SIJCPR. Non-invasive clinical testing for SIJ pain rests on pain provocation tests that stress the SIJ structures and provoke the usual or familiar pain of which the patient complains. The key tests (distraction, compression, thigh thrust, Gaenslen's, and sacral thrust) have been described in detail in previous publications19,5052 and are reproduced in Figures Figures115.
There also does not appear to be any argument that PSIS asymmetry estimates static (positional) changes in the innominates rather than joint mobility. I also did not include clinical tests designed to provoke symptoms, because provocation tests are used to determine whether the sacroiliac region is a source of pain rather than to identify innominate torsion (or hypomobility). I wanted to explore whether treatment for the subjects with LBP may have reduced the number of positive test findings, thereby reducing the association between test results and LBP. Although I was unable to determine whether treatment had changed test results, I removed from the analysis all data obtained from subjects with LBP who identified themselves as better than when they decided to seek treatment. Although removing these subjects' data did not necessarily eliminate all data obtained for subjects who might have had treatment, it did eliminate the data of those subjects for whom treatment (or time) provided pain relief.
The likelihood ratio for a positive test (three or more SIJ tests provoke the patient's familiar pain) is so the probability of SIJ pain more than doubles from 26 to 59. The likelihood ratio of a negative test is yielding a post-test probability of 4. In addition to measuring PSIS and ASIS heights and calculating innominate torsion, I also measured leg lengths and determined iliac crest levels while subjects were standing and iliac crest levels while subjects were sitting. These variables allowed me to explore whether asymmetry of leg lengths or iliac crests might affect the results of the tests. I measured leg lengths with the subjects positioned supine, using a cloth tape measure to measure the distance from the ASIS to the lateral Leg lengths were each measured twice to permit estimates of reliability. The markings on the tape measure were not observed for either the first of second measurement until my hand positions on the tape measure were set and the tape measure was removed from the subject. Iliac crest level was assessed using a crest level tester (Med-level Model M2000*).
In this subgroup, the association between the Gillet test and LBP became stronger (OR= [95 CI=, ], although the CI widened due to the smaller numbers. The association of 2 or more positive test findings increased to an odds ratio of (95 CI=, ). Sacroiliac joint dysfunction tests include discussing your history and pain experience, a physical examination, tests to rule out other sources of pain, like lumbar spine pain and hip pain, and these commonly accepted methods: I performed the 4 clinical tests and, based on the measurements, judged each test to be positive or negative. Repeated test assessments were not recorded because I could not be blinded to the first outcome result when obtaining a second measurement during the same (and only) data collection session. I repeated a test only when I believed that the first result was equivocal and, as I believe is done in the clinical setting, made a single judgment of the result.
Although the use of alternate asymmetry variables improved the association between test results and asymmetry for some of the tests, the test performance characteristics (and therefore their usefulness) were not substantively improved. Using composite test results (positive if 2 or more tests had positive findings) also did not substantively improve the association with innominate torsion. I identified 4 commonly used clinical tests of sacroiliac joint dysfunction as the focus of this study: (1) the Gillet test, (2) the standing flexion test, (3) the sitting flexion test, and (4) the supine-to-sit test. This study was part of a larger study I conducted to investigate the association between estimated innominate torsional asymmetry and In the larger study, as well as in this study, PSIS levels (or asymmetry) in standing and sitting positions, unlike the other 4 tests, were measured rather than assessed using clinical judgment.
If conservative treatment is unsuccessful, injections may be suggested by your doctor. As described above, injections are used primarily to confirm that the pain is coming from the SI joint. A series of cortisone injections may be recommended to try to reduce the inflammation in and around the SI joint. Cortisone is a powerful anti-inflammatory medication that is commonly used to control pain from arthritis and inflammation. Likelihood ratios are summary statistics derived from sensitivity and specificity values. The likelihood ratio for a positive test is an estimate of the probability of the condition/disease. Random guessing will produce a positive likelihood ratio of 1. 0. Values higher than 1. 0 represent probability better than random chance. The higher the value, the better the test. For example, a test with a positive likelihood ratio of 10 indicates that a positive test result is 10 times more likely in patients with the disease in question than in those known to be free of that disease. The likelihood ratio of a negative test describes the test's ability to rule out the disorder for which the test is applied.
Association of Test Results With Static Innominate Torsion: Frequencies, Odds Ratio (ORs) and 95 Confidence Intervals (CIs), Sensitivity, Specificity, Positive Predictive Values (PVs), and Negative Predictive Values
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