Sacroiliac Joint Special Test Cluster: Difference between revisions
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== Background == | == Background == | ||
Test Item Cluster (TIC) is a group of special tests which are developed to facilitate clinical decision making by improving the diagnostic utility. | Test Item Cluster (TIC) is a group of special tests which are developed to facilitate clinical decision making by improving the diagnostic utility. | ||
The ability to accurately differentiate a diagnosis of sacroiliac joint (SIJ) pain is clinically important. Although debated throughout literature, it is generally accepted that 10-25% of patients who present with mechanical low back or buttock pain will have this pain secondary to sacroiliac joint pain. | The ability to accurately differentiate a diagnosis of sacroiliac joint (SIJ) pain is clinically important. Although debated throughout literature, it is generally accepted that 10-25% of patients who present with mechanical low back or buttock pain will have this pain secondary to sacroiliac joint pain.</span><ref name="Simopoulos et al 2012">Simopoulos TT, Manchikanti L, Singh V, Gupta S, Hameed H, Diwan S, Cohen SP. A systematic evaluation of prevalence and diagnostic accuracy of sacroiliac joint interventions. Pain Physician 2012;15:E305-44.</ref><span style="line-height: 1.5em;"> To be able to correctly diagnose the sacroiliac joint as a source of pain will allow clinicians to be able to deliver appropriate treatment methods to the correct patients, thereby providing the patient with a more timely recovery. | ||
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<br> A study by Levangie et al<ref name="Levangie">Levangie P. Four clinical tests of sacroiliac joint dysfunction: the association of test results with innominate torsion among patients with and without low back pain. Phys Ther. 1999;79:1043-1057</ref> had developed a TIC for identifying SIJ dysfunction with the following tests: standing flexion test, sitting PSIS palpation, supine long sitting test, and prone knee flexion test. The investigators assessed the diagnostic utility of those tests by comparing findings of patients who complained of LBP with those of patients being treated for other physical impairments not related to the back. They reported that the cluster of these tests exhibited a sensitivity of 0.82, specificity of 0.88, + LR of 6.83, and - LR of 0.20. It needs to be noted, however, that the reliability of those special tests used for this TIC is poor. Inter-rater reliability kappa values of standing flexion test, sitting PSIS palpation, and prone knee flexion test are reported as follows: 0.08 - 0.32, 0.23 - 0.37, 0.21 - 0.26 respectively.<ref name="Cleland">Cleland J. Orthopaedic clinical examination: an evidence-based approach for physical therapists. Saunders: Elsevier, 2007</ref> Additionally, validity of the results should be evaluated carefully due to the reference standard used for this study. | |||
A study by Levangie et al<ref name="Levangie">Levangie P. Four clinical tests of sacroiliac joint dysfunction: the association of test results with innominate torsion among patients with and without low back pain. Phys Ther. 1999;79:1043-1057</ref> had developed a TIC for identifying SIJ dysfunction with the following tests: standing flexion test, sitting PSIS palpation, supine long sitting test, and prone knee flexion test. The investigators assessed the diagnostic utility of those tests by comparing findings of patients who complained of LBP with those of patients being treated for other physical impairments not related to the back. They reported that the cluster of these tests exhibited a sensitivity of 0.82, specificity of 0.88, + LR of 6.83, and - LR of 0.20. It needs to be noted, however, that the reliability of those special tests used for this TIC is poor. Inter-rater reliability kappa values of standing flexion test, sitting PSIS palpation, and prone knee flexion test are reported as follows: 0.08 - 0.32, 0.23 - 0.37, 0.21 - 0.26 respectively.<ref name="Cleland">Cleland J. Orthopaedic clinical examination: an evidence-based approach for physical therapists. Saunders: Elsevier, 2007</ref> Additionally, validity of the results should be evaluated carefully due to the reference standard used for this study. | |||
More recently, Laslett et al<ref name="Laslett et al 2003">Laslett M, Young S, Aprill C, McDonald B. Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac provocation tests. Aust J PHysiother 2003;49:89-97</ref> assessed the diagnostic utility of the McKenzie evaluation combined with the following SIJ tests: distraction, thigh thrust, Gaenslen, compression, and sacral thrust. The McKenzie assessment consisted of flexion in standing, extension in standing, and right/left side bending, flexion in lying and extension in lying. The repeated movements were performed in sets of 10, while centralization and peripheralization of symptoms were recorded. The centralization phenomena with repeated movement was used to identify the patients with discogenic pain. After the McKenzie evaluation, patients with discogenic pain was ruled out. Authors found that the cluster of SIJ tests used within the context of a specific clinical reasoning process can facilitate identifying the involvement of SIJ dysfunction. <br> | More recently, Laslett et al<ref name="Laslett et al 2003">Laslett M, Young S, Aprill C, McDonald B. Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac provocation tests. Aust J PHysiother 2003;49:89-97</ref> assessed the diagnostic utility of the McKenzie evaluation combined with the following SIJ tests: distraction, thigh thrust, Gaenslen, compression, and sacral thrust. The McKenzie assessment consisted of flexion in standing, extension in standing, and right/left side bending, flexion in lying and extension in lying. The repeated movements were performed in sets of 10, while centralization and peripheralization of symptoms were recorded. The centralization phenomena with repeated movement was used to identify the patients with discogenic pain. After the McKenzie evaluation, patients with discogenic pain was ruled out. Authors found that the cluster of SIJ tests used within the context of a specific clinical reasoning process can facilitate identifying the involvement of SIJ dysfunction. <br> | ||
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Laslett et al<ref name="Laslett et al">Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Man Ther 2005;10:207-218</ref> further investigated the diagnostic power of pain provocation sacroiliac joint (SIJ) tests individually and in various combinations, in relation to a diagnostic injection. The tests employed in this study were: distraction, right sided thigh thrust, right sided Gaenslen's test, compression and sacral thrust. Those tests were chosen due to its acceptable inter-rater reliability. They found that composites of provocation SIJ tests had significant diagnostic utility. Any 2 of 4 selected tests (distraction, thigh thrust, compression, and sacral thrust) have the best predictive power. When all 6 SIJ provocation tests does not reproduce symptoms, the SIJ pathology can be ruled out. | Laslett et al<ref name="Laslett et al">Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Man Ther 2005;10:207-218</ref> further investigated the diagnostic power of pain provocation sacroiliac joint (SIJ) tests individually and in various combinations, in relation to a diagnostic injection. The tests employed in this study were: distraction, right sided thigh thrust, right sided Gaenslen's test, compression and sacral thrust. Those tests were chosen due to its acceptable inter-rater reliability. They found that composites of provocation SIJ tests had significant diagnostic utility. Any 2 of 4 selected tests (distraction, thigh thrust, compression, and sacral thrust) have the best predictive power. When all 6 SIJ provocation tests does not reproduce symptoms, the SIJ pathology can be ruled out. | ||
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== SIJ Dysfunction Gold Standard Testing == | |||
The current ‘gold standard’ for diagnosing sacroiliac pathologies is a diagnostic nerve block, whereby anaesthetic is inserted into the SIJ, under fluoroscopy guidance. Some authors argue that if the patient achieves 50-75% pain relief, on 2 occasions with short and long acting nerve block, a diagnosis of SIJ dysfunction can be made, but with caution.<ref name="Van der Wurff et al 2006">Van der Wurff P, Buijs EJ, Groen GJ. A multitest regimen of pain provaction tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures. Arch Phys Med Rehabil 2006;87:10-4.</ref><ref name="Berthelot et al 2006">Berthelot JM, Labat JJ, Le Goff B, Gouin F, Maugars Y. Provocative sacroiliac joint maneuvers and sacroiliac joint block are unreliable for diagnosing sacroiliac joint pain. Joint Bone Spine 2006;73:17-23.</ref> | |||
<span style="line-height: 1.5em;">However, even with a gold standard there are issue reported in the literature with the injection process. Five instances of leakage of anaesthetic from the SIJ nerve blocks resulting in temporary sciatic nerve palsy have been reported,</span><ref name="Van der Wurff et al 2006">Van der Wurff P, Buijs EJ, Groen GJ. A multitest regimen of pain provaction tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures. Arch Phys Med Rehabil 2006;87:10-4.</ref><span style="line-height: 1.5em;"> with one study stating that leakage of the contrast medium used to guide nerve block injections was found in 61% of patients.</span><ref name="Berthelot et al 2006">Berthelot JM, Labat JJ, Le Goff B, Gouin F, Maugars Y. Provocative sacroiliac joint maneuvers and sacroiliac joint block are unreliable for diagnosing sacroiliac joint pain. Joint Bone Spine 2006;73:17-23.</ref><span style="line-height: 1.5em;"> There is now thought that the gold standard of SIJ nerve block may not be the most appropriate</span><ref name="Szadek et al 2009">Szadek K, van der Wurff P, van Tulder M, Zuurmond W, Perez R. Diagnostic validity of criteria for sacroiliac joint pain: A systematic review. J Pain 2009;10:354-68.</ref><span style="line-height: 1.5em;"> and so the IASP diagnostic criteria for SIJ pain no longer as valid as it once was. A review by Berthelot (2006) also concluded that joint injections are unreliable for diagnosing sacroiliac joint pain;</span><ref name="Berthelot et al 2006">Berthelot JM, Labat JJ, Le Goff B, Gouin F, Maugars Y. Provocative sacroiliac joint maneuvers and sacroiliac joint block are unreliable for diagnosing sacroiliac joint pain. Joint Bone Spine 2006;73:17-23.</ref><span style="line-height: 1.5em;"> however, this study did not show clarity in the description of the methods used to search and screen each paper, and so the possibility of bias within the literature chosen increases, thereby raising questions as to the validity of this conclusion. This is not in agreement with a review conducted by Simopoulos et al (2012), which concluded that sacroiliac joint blocks are valid as a gold standard, however based on the literature reviewed; there could be a false positive rate of 20%.</span><ref name="Simopoulos et al 2012">Simopoulos TT, Manchikanti L, Singh V, Gupta S, Hameed H, Diwan S, Cohen SP. A systematic evaluation of prevalence and diagnostic accuracy of sacroiliac joint interventions. Pain Physician 2012;15:E305-44.</ref> | |||
<span style="line-height: 1.5em;">With these factors in mind finding a method which is both cost effective and has strong enough predictive values to accurately diagnose pathologies, thereby avoiding unnecessary cost and invasive procedures, and aiding in correct treatment of patients.</span><br>These studies were evaluated against the CEBM criteria for a diagnostic reference study in order to assess the methodological quality of the studies and to review the validity of the results and conclusions made by each study.<br> | |||
== Description of Provocation Tests<ref name="Cleland" /> == | == Description of Provocation Tests<ref name="Cleland" /> == | ||
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== | == <span style="font-size: 13px;" class="Apple-style-span" />Diagnostic Value of Individual SIJ Provocation Tests<ref name="Laslett et al" /><br> == | ||
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Background[edit | edit source]
Test Item Cluster (TIC) is a group of special tests which are developed to facilitate clinical decision making by improving the diagnostic utility.
The ability to accurately differentiate a diagnosis of sacroiliac joint (SIJ) pain is clinically important. Although debated throughout literature, it is generally accepted that 10-25% of patients who present with mechanical low back or buttock pain will have this pain secondary to sacroiliac joint pain.</span>[1] To be able to correctly diagnose the sacroiliac joint as a source of pain will allow clinicians to be able to deliver appropriate treatment methods to the correct patients, thereby providing the patient with a more timely recovery.
A study by Levangie et al[2] had developed a TIC for identifying SIJ dysfunction with the following tests: standing flexion test, sitting PSIS palpation, supine long sitting test, and prone knee flexion test. The investigators assessed the diagnostic utility of those tests by comparing findings of patients who complained of LBP with those of patients being treated for other physical impairments not related to the back. They reported that the cluster of these tests exhibited a sensitivity of 0.82, specificity of 0.88, + LR of 6.83, and - LR of 0.20. It needs to be noted, however, that the reliability of those special tests used for this TIC is poor. Inter-rater reliability kappa values of standing flexion test, sitting PSIS palpation, and prone knee flexion test are reported as follows: 0.08 - 0.32, 0.23 - 0.37, 0.21 - 0.26 respectively.[3] Additionally, validity of the results should be evaluated carefully due to the reference standard used for this study.
More recently, Laslett et al[4] assessed the diagnostic utility of the McKenzie evaluation combined with the following SIJ tests: distraction, thigh thrust, Gaenslen, compression, and sacral thrust. The McKenzie assessment consisted of flexion in standing, extension in standing, and right/left side bending, flexion in lying and extension in lying. The repeated movements were performed in sets of 10, while centralization and peripheralization of symptoms were recorded. The centralization phenomena with repeated movement was used to identify the patients with discogenic pain. After the McKenzie evaluation, patients with discogenic pain was ruled out. Authors found that the cluster of SIJ tests used within the context of a specific clinical reasoning process can facilitate identifying the involvement of SIJ dysfunction.
Laslett et al[5] further investigated the diagnostic power of pain provocation sacroiliac joint (SIJ) tests individually and in various combinations, in relation to a diagnostic injection. The tests employed in this study were: distraction, right sided thigh thrust, right sided Gaenslen's test, compression and sacral thrust. Those tests were chosen due to its acceptable inter-rater reliability. They found that composites of provocation SIJ tests had significant diagnostic utility. Any 2 of 4 selected tests (distraction, thigh thrust, compression, and sacral thrust) have the best predictive power. When all 6 SIJ provocation tests does not reproduce symptoms, the SIJ pathology can be ruled out.
SIJ Dysfunction Gold Standard Testing[edit | edit source]
The current ‘gold standard’ for diagnosing sacroiliac pathologies is a diagnostic nerve block, whereby anaesthetic is inserted into the SIJ, under fluoroscopy guidance. Some authors argue that if the patient achieves 50-75% pain relief, on 2 occasions with short and long acting nerve block, a diagnosis of SIJ dysfunction can be made, but with caution.[6][7]
However, even with a gold standard there are issue reported in the literature with the injection process. Five instances of leakage of anaesthetic from the SIJ nerve blocks resulting in temporary sciatic nerve palsy have been reported,[6] with one study stating that leakage of the contrast medium used to guide nerve block injections was found in 61% of patients.[7] There is now thought that the gold standard of SIJ nerve block may not be the most appropriate[8] and so the IASP diagnostic criteria for SIJ pain no longer as valid as it once was. A review by Berthelot (2006) also concluded that joint injections are unreliable for diagnosing sacroiliac joint pain;[7] however, this study did not show clarity in the description of the methods used to search and screen each paper, and so the possibility of bias within the literature chosen increases, thereby raising questions as to the validity of this conclusion. This is not in agreement with a review conducted by Simopoulos et al (2012), which concluded that sacroiliac joint blocks are valid as a gold standard, however based on the literature reviewed; there could be a false positive rate of 20%.[1]
With these factors in mind finding a method which is both cost effective and has strong enough predictive values to accurately diagnose pathologies, thereby avoiding unnecessary cost and invasive procedures, and aiding in correct treatment of patients.
These studies were evaluated against the CEBM criteria for a diagnostic reference study in order to assess the methodological quality of the studies and to review the validity of the results and conclusions made by each study.
Description of Provocation Tests[3][edit | edit source]
| Tests | Description (Positive Findings) |
| Distraction | Pt supine. Examiner applies posterolateral directed pressure to bilateral ASIS. (Reproduction of pain) |
| Compression | Pt sidelying. Examiner compresses pelvis with pressure applied over the iliac crest directed at the opposite iliac crest. (Reproduction of symptoms) |
| Thigh Thrust | Pt supine. Examiner place hip in 90 deg flexion and adduction. Examiner then applies posteriorly directed force through the femur at varying angles of abduction/adduction. (Reproduction of buttock pain) |
| Gaenslen's | Pt supine with both legs extended. The test leg is passively brought into full knee flexion, while the opposite hip remains in extension. Overpressure is then applied to the flexed extremity. (Reproduction of pain) |
| Sacral Thrust | Pt prone. Examiner delivers an anteriorly directed thrust over the sacrum. (Reproduction of pain)
|
<span style="font-size: 13px;" class="Apple-style-span" />Diagnostic Value of Individual SIJ Provocation Tests[5]
[edit | edit source]
| Distraction | Compression | Thigh Thrust | Gaenslen's (R) | Gaenslen's (L) | Sacral Thrust | |
| Sensitivity | 0.60 | 0.69 | 0.88 | 0.53 | 0.50 | 0.63 |
| Specificity | 0.81 | 0.69 | 0.69 | 0.71 | 0.77 | 0.75 |
| + LR | 3.20 | 2.20 | 2.80 | 1.84 | 2.21 | 2.50 |
| - LR | 0.49 | 0.46 | 0.18 | 0.66 | 0.65 | 0.50 |
Diagnostic Utility of TIC for SIJ Provocation Tests
[edit | edit source]
Laslett et al[4] identified the TIC for SIJ dysfunction after the McKenzie evaluation to rule out discogenic pain. When 3 of 4 tests (distraction, thigh thrust, Gaenslen, sacral thrust, compression) are positive, it indicates SIJ dysfunction. The diagnostic utility was as follows:
| Values (95% CI) | |
| Sensitivity | 0.91 (0.62, 0.98) |
| Specificity | 0.78 (0.61, 0.89) |
| + LR | 4.16 (2.16, 8.39) |
| - LR | 0.12 (0.02, 0.49) |
A follow up study by Laslett et al[5] demonstrated that the Gaenslen's test did not contribute positively when tests were combined and may be omitted from the diagnostic process without compromising diagnostic confidence. The optimal rule was to perform the distraction, compression, thigh thrust and sacral thrust tests but stopping when there are 2 positives. The diagnostic value of 2 positive tests of the 4 selected test was as follows:
| Values (95% CI) | |
| Sensitivity | 0.88 (0.64, 0.97) |
| Specificity | 0.78 (0.61, 0.89) |
| + LR | 4.00 (2.13, 8.08) |
| - LR | 0.16 (0.04, 0.47) |
Recent Related Research (from Pubmed)[edit | edit source]
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References[edit | edit source]
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- ↑ 1.0 1.1 Simopoulos TT, Manchikanti L, Singh V, Gupta S, Hameed H, Diwan S, Cohen SP. A systematic evaluation of prevalence and diagnostic accuracy of sacroiliac joint interventions. Pain Physician 2012;15:E305-44.
- ↑ Levangie P. Four clinical tests of sacroiliac joint dysfunction: the association of test results with innominate torsion among patients with and without low back pain. Phys Ther. 1999;79:1043-1057
- ↑ 3.0 3.1 Cleland J. Orthopaedic clinical examination: an evidence-based approach for physical therapists. Saunders: Elsevier, 2007
- ↑ 4.0 4.1 Laslett M, Young S, Aprill C, McDonald B. Diagnosing painful sacroiliac joints: a validity study of a McKenzie evaluation and sacroiliac provocation tests. Aust J PHysiother 2003;49:89-97
- ↑ 5.0 5.1 5.2 Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests. Man Ther 2005;10:207-218
- ↑ 6.0 6.1 Van der Wurff P, Buijs EJ, Groen GJ. A multitest regimen of pain provaction tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures. Arch Phys Med Rehabil 2006;87:10-4.
- ↑ 7.0 7.1 7.2 Berthelot JM, Labat JJ, Le Goff B, Gouin F, Maugars Y. Provocative sacroiliac joint maneuvers and sacroiliac joint block are unreliable for diagnosing sacroiliac joint pain. Joint Bone Spine 2006;73:17-23.
- ↑ Szadek K, van der Wurff P, van Tulder M, Zuurmond W, Perez R. Diagnostic validity of criteria for sacroiliac joint pain: A systematic review. J Pain 2009;10:354-68.
