Using published evidence to guide.pdf

Using Published Evidence to Guide

the Examination of the Sacroiliac

Joint Region

premise that the sacroiliac joint (SIJ) can be a source of pain

secondary to pathology (eg, spondyloarthropathy, infection,

malignancy, fracture), 1 whether SIJ dysfunction exists remains

controversial. “Sacroiliac joint dysfunction” is a term often used to describe

pain in or around the region of the joint that is presumed to be due to

biomechanical disorders of the joint (eg, hypomobility, malalignment, fixa-

tion, subluxation). 2,3 Some people consider the term “SIJ dysfunction” to be

a misnomer because it is difficult to determine whether the joint itself is the

source of the pain. 4,5 Due to the anatomy and location of the SIJ, examination

procedures presumed to test the joint may test other structures in the region.

Others dismiss the SIJ as a source of pain because well-recognized pain-

sensitive structures, such as the posterior facet joints and nerve roots, may

refer pain to the SIJ region. 5,6 Still other investigators have reported that 22% 7

to 30% 8 of subjects with pain around the SIJ region experienced some relief

following anesthetic injection of the joint. Pain relief following anesthetic

injection, however, does not necessarily indicate dysfunction of the joint.

Structures unrelated to the joint, but in the same region, may be affected due

to infiltration of anesthetic to soft tissues beyond the SIJ. 9 Despite the

controversy and differing views on the sources of pain in the SIJ region, we

believe many therapists commonly examine some of their patients for the

presence of what they call “SIJ dysfunction.” Batti and colleagues, 10 for

example, surveyed 186 Washington State therapists about the care of patients

with low back pain (LBP) and found that 75% of the therapists would use

screening procedures they believed tested SIJ function.

APTA is a sponsor of the

Decade, an international,

multidisciplinary initiative

to improve health-related

quality of life for people with

musculoskeletal disorders.

A variety of tests have been used by therapists to identify what we will refer to

as “dysfunction of the SIJ region.” These tests generally fall into 1 or 3

categories: (1) tests designed to assess the location and relative symmetry,

from left to right, of bony landmarks associated with the SIJ, (2) tests designed

[Freburger JK, Riddle DL. Using published evidence to guide the examination of the sacroiliac joint

region. Phys Ther. 2001;81:1135–1143.]

Key Words: Examination, Reliability, Sacroiliac joint dysfunction, Validity.

Janet K Freburger

Daniel L Riddle

Physical Therapy . Volume 81 . Number 5 . May 2001

1135

A lthough some people in the medical community accept the

There is some

to assess the movement of bony landmarks associated

with the SIJ, and (3) tests that require the application of

forces to the SIJ or related structures in an attempt to

reproduce the patient’s pain. Tests that fall into these 3

categories are typically performed without the assistance

of instrumentation (ie, the therapist uses visual estima-

tion or tactile input to make the diagnosis). Physical

therapists also use the patient’s medical history and

description of pain (eg, mechanism of injury, pain

location, factors that increase or decrease the pain) to

assist in the identification of dysfunction in the SIJ

region.

update, we conducted a

MEDLINE search from

1966 to June 2000 using

the key word “sacroiliac”

in combination with

each of the following key

words: “examination,”

“reliability,” and “validi-

ty.” In addition, the ref-

erence lists of all rele-

vant articles found in the

search were reviewed.

Articles were included in

our review if they met

the following criteria:

(1) examined the reli-

ability or diagnostic valid-

ity of data obtained with tests that were used to assess the

symmetry of bony landmarks, movement of bony land-

marks, or provocation of pain and (2) were conducted

on subjects suspected of having dysfunction in the SIJ

region. In addition, we included studies where research-

ers examined the diagnostic validity of the patient’s

medical history and pain description to identify dysfunc-

tion in the SIJ region. Finally, we eliminated studies that

examined the reliability of data obtained with tests of the

SIJ region that we believed are not commonly used in

the physical therapy clinic (eg, tests that use instrumen-

tation for the identification of dysfunction in the SIJ

region).

the use of pain

provocation tests

and the patient’s

description of pain

in the identification

of dysfunction in

In the past 2 decades, many studies have been conducted

to assess the psychometric properties (eg, reliability,

validity) of tests of the SIJ region. Initially, reliability

studies tended to dominate the literature because a

standard for assessing the diagnostic validity of data

obtained with these tests was not available. More

recently, a diagnostic test has been developed that is

considered by some to provide a suitable standard for

the confirmation of pain arising from the SIJ region.

The test is a fluoroscopically guided anesthetic block of

the SIJ. 8 A needle is inserted into the SIJ, and a contrast

medium is introduced into the joint space to confirm

that the needle is in the SIJ. An anesthetic is then

injected, and the patient’s pain response is assessed.

According to proponents of the test, a pain decrease of

50% or greater, depending on the criterion set by the

examiner, confirms the pain is coming from the SIJ

region. In the past 5 years, several studies have been

published in which anesthetic blocks were used to exam-

ine the diagnostic accuracy (ie, diagnostic validity) of

tests designed to detect dysfunction in the SIJ

region. 2,11–13 We contend that these studies have been

an important addition to the literature. Diagnostic

accuracy studies are especially important because

diagnostic tests can demonstrate high levels of reliabil-

ity, yet lack validity. 14

the sacroiliac joint

region.

We begin the update by discussing the evidence support-

ing or refuting the use of tests designed to assess the

symmetry or movement of bony landmarks associated

with the SIJ. We then review the literature on pain

provocation tests and use of the patient’s medical history

in the identification of dysfunction in the SIJ region. We

conclude by summarizing the evidence and, based on

this evidence, make recommendations on how therapists

can use these tests to determine the presence of dysfunc-

tion in the SIJ region. We do not review how these tests

might be used to guide treatment. Although we provide

brief descriptions of the various tests that were examined

The purpose of this update is to review studies that have

examined the reliability or diagnostic validity of data

obtained with clinical tests designed to detect dysfunc-

tion in the SIJ region. To identify articles reviewed in this

JK Freburger, PT, PhD, is NRSA Postdoctoral Research Fellow, Cecil G Sheps Center for Health Services Research, and Assistant Professor, Division

of Physical Therapy, University of North Carolina at Chapel Hill, CB 7590, 725 Airport Rd, Chapel Hill, NC 27599-7590 (USA)

(janet_freburger@med.unc.edu). Address all correspondence to Dr Freburger.

DL Riddle, PT, PhD, is Associate Professor, Department of Physical Therapy, Medical College of Virginia Campus, Virginia Commonwealth

University, Richmond, Va.

Both authors provided concept/idea, writing, data collection and analysis, clerical support, and consultation (including review of manuscript

before submission).

This work was partially supported by a National Research Service Award Post-Doctoral Traineeship from the Agency for Healthcare Research and

Quality sponsored by the Cecil G Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Grant No. T32 HS00032.

1136 . Freburger and Riddle

Physical Therapy . Volume 81 . Number 5 . May 2001

evidence to support

in the studies, readers are encouraged to review the

original articles to gain further insight.

tion in the SIJ region. The spring test was performed by

delivering a posteroanterior thrust to the superficial

aspect of the sacrum (in the area of the SIJ) and

assessing the amount of joint play at end-range. Dreyfuss

et al were unclear as to when the spring test is positive.

They did state that the symptomatic SIJ is compared with

the asymptomatic SIJ.

Symmetry and Movement Tests

Potter and Rothstein 15 examined the intertester reliabil-

ity of data obtained with various tests used by physical

therapists to evaluate the symmetry of bony landmarks

associated with the SIJ (ie, SIJ alignment). The tests

required the examiners to palpate a bony landmark

bilaterally (ie, anterior superior iliac spines [ASISs],

posterior superior iliac spines [PSISs], or iliac crests)

and make judgments about the relative heights of the

bony landmarks. These tests were the following: palpa-

tion of iliac crest levels, palpation of PSIS levels, and

palpation of ASIS levels, all with the patient positioned

sitting and then standing. The sample consisted of 17

patients suspected of having dysfunction in the SIJ

region. Randomly paired therapists examined the

patients. The percentage of agreement for the 6 tests

ranged from 35% to 43%, suggesting that the intertester

reliability for assessments of SIJ alignment is poor. We

found no other studies that examined the reliability or

validity of visual estimates of SIJ alignment on patients

suspected of having dysfunction in the SIJ region.

Dreyfuss et al 2 used SIJ diagnostic blocks and found that

the Gillet test and the spring test had little diagnostic

usefulness for identifying patients with dysfunction in

the SIJ region. They found little difference between the

results of the chiropractor’s and physician’s examina-

tions, and they reported sensitivity values ranging from

.46 to .69 for the Gillet and spring tests. Sensitivity is

defined as the proportion or ratio of true positive cases

detected by a test. 16 Dreyfuss et al also reported specific-

ity values ranging from .38 to .64 for the 2 tests. Specificity

is defined as the proportion or ratio of true negative

cases detected by a test. 16

One explanation for the findings of Potter and Roth-

stein 15 and Dreyfuss et al 2 is that asymmetries or move-

ments of bony landmarks associated with the SIJs are too

small to detect with palpation or visual assessment.

Measurements obtained with symmetry or movement

tests, therefore, may not be valid. Sturesson et al have

provided data to support this contention. In 2 recent

studies, 17,18 they used intraosseous markers and roent-

gen stereophotogrammetric analysis to assess SIJ motion

in subjects suspected of having dysfunction in the SIJ

region. In one study, 17 22 subjects were examined in a

variety of positions, including standing with hip flexion

(ie, Gillet test). In the other study, 18 6 female subjects

were examined in a variety of positions, including the

reciprocal straddle position (ie, standing with both feet

on the floor and one hip maximally extended and the

other hip maximally flexed). In both studies, Sturesson

et al found translatory motions of 2 mm or less and

rotary motions of less than 2 degrees. Earlier work by

Sturesson et al 19 and Egund et al 20 also conducted on

patients suspected of having dysfunction in the SIJ

region demonstrated similar findings.

Potter and Rothstein 15 also reported poor intertester

reliability for all of the tests they examined that required

the examiners to make judgments about the movement

of bony landmarks. The tests examined were as follows:

the flexion test with the patient positioned sitting and

standing (the patient flexed the trunk in a sitting or

standing position while the examiner palpated for move-

ment of the PSISs), the standing Gillet test (the patient

stood on one lower extremity and flexes the other hip

and knee toward the chest while the examiner palpated

for movement of the PSIS and sacral sulcus on the side

being flexed), the supine long sitting test (the patient

moved from a supine position to a long sitting position

while the examiner palpated the patient’s medial malle-

oli and determined any relative change in the lengths of

the lower extremities), and the prone knee flexion test

(the examiner grasped the patient’s feet while the

patient was positioned prone with knees extended and

then passively flexed the knees while noting any change

in the relative lengths of the legs). The percentages of

agreement between therapists for these tests ranged

from 24% to 50%. One limitation of Potter and Roth-

stein’s study was that they did not calculate kappa

coefficients. The percent agreement values they

reported may have been artificially high because they

were not corrected for chance agreement.

A recent study by Tullberg et al 21 provides further

evidence to question the accuracy of assessments of

asymmetry or movements of the SIJ with palpation and

visual estimation. Tullberg et al used intraosseous mark-

ers and roentgen stereophotogrammetric analysis to

determine whether the position of the SIJ changed

following manipulation and mobilization procedures.

They identified 10 patients who met the following crite-

ria: the patient had unilateral pain in the area of the SIJ;

and 3 examiners, with an unspecified amount of special-

ized training, agreed that the patient had at least 10 out

of 12 positive tests among those tests of the SIJ region.

Dreyfuss et al 2 also reported poor agreement between

the findings of a physician and those of a chiropractor

when performing the Gillet test (

.22) and the spring

test (

.15) on 85 subjects suspected of having dysfunc-

Physical Therapy . Volume 81 . Number 5 . May 2001

Freburger and Riddle . 1137

Nine of the 12 tests involved the assessment of move-

ment or symmetry of bony landmarks associated with the

SIJ.

Intertester agreement between the therapists for deter-

mining the presence of 3 positive tests was high (

.88).

Immediately prior to the manipulation and mobilization

procedures, each patient underwent the roentgen ste-

reophotogrammetric analysis in a standing position to

identify the position of the sacrum relative to the ilium.

Following the intervention, the roentgen stereophoto-

grammetric analysis and the 12 tests of the SIJ region

were repeated. The roentgen stereophotogrammetric

analysis indicated essentially no change in the position

of the sacrum relative to the ilium following the inter-

ventions. Translatory changes were on the order of 0.1

mm, and rotary changes were on the order of 0.3 degree.

Tullberg et al 21 did not report the reliability of data

obtained with these measures. These small changes may

have been due to measurement error. Despite the lack of

change in the position of the SIJ (ie, sacrum relative to

ilium), most of the tests of the SIJ region that Tullberg

et al judged to be positive prior to the intervention were

judged to be negative following the intervention.

We believe one limitation of the study by Cibulka et al 22

was that a “positive” test was apparently not referenced to

a particular side. For example, the standing flexion test

was considered positive when movements of the PSISs

were believed to be asymmetrical (ie, one PSIS moved

more cranially than the other). The 2 therapists, there-

fore, could have determined that the standing flexion

test was positive without agreeing on the type of asym-

metry present. One therapist may have found that the

right PSIS moved more cranially than the left PSIS,

which according to the authors would have indicated

that the right SIJ was hypomobile, whereas the other

therapist may have found that the left PSIS moved more

cranially than the right PSIS. In addition, each therapist

may have had contradictory findings on the 4 tests they

conducted. For example, one of the therapists may have

found a standing flexion test result that indicated what

the therapist believed was a hypomobile SIJ on the left,

a prone knee flexion test result that indicated a posterior

innominate rotation on the right, and a supine long

sitting test result that indicated a posterior innominate

rotation on the left.

The results of the study by Tullberg et al 21 raise ques-

tions about the validity of data obtained with movement

and symmetry tests for making judgments about the

alignment of the SIJs. Although the position of the SIJ

did not change following the intervention, the examin-

ers in the study reported that the tests were negative

following the intervention. One weakness of the study is

that Tullberg et al did not control for the potential

biases of the examiners. The examiners knew who

received the intervention and, therefore, may have been

biased when repeating the tests of the SIJ region. Fur-

thermore, Tullberg et al judged the mobilization and

manipulation to be successful based on the results of the

tests. They did not indicate whether the patients in the

study reported relief of symptoms or improvement in

function following the treatment.

The examination and treatment of dysfunction in the

region of the SIJ sometimes requires identification of the

type of asymmetry present and the correction of the

asymmetry. 4,6,22–24 For example, mobilization techniques

designed to treat a right posterior innominate rotation

require a different hand placement, point of force

application, and line of force application than mobiliza-

tion techniques designed to treat a left posterior innom-

inate rotation. 22,25 Knowledge of the degree of agree-

ment on the type of asymmetry that is present, therefore,

would be useful. We believe that the results of the study

by Cibulka et al 22 would be more powerful if we knew

that each therapist found 3 positive tests that were

consistent (ie, all indicated a problem on the left) and

that both therapists agreed on the type of dysfunction

present (ie, left posterior rotation of the innominate).

Combining the Results of Tests

Cibulka et al 22 suggested using a combination of symme-

try and movement tests to determine whether a patient

has dysfunction in the SIJ region and reported high

intertester agreement for the method they developed.

They determined that dysfunction in the SIJ region was

present in a patient if at least 3 of the following 4 tests

were positive: the standing flexion test, the prone knee

flexion test, the supine long sitting test, and palpation of

PSIS heights in a sitting position. Cibulka et al did not

quantify the size of the difference for the tests to be

positive. Their method also did not allow them to

actually show that the patient’s symptoms were originat-

ing from the SIJ. Two therapists with an unspecified

amount of training in the test procedures examined 26

patients with low back pain of a nonspecific origin.

The external validity of the results of the study of

Cibulka et al 22 also is limited because only 2 therapists

who were trained in the method participated in the

study. Furthermore, only 26 patients were examined.

Lastly, although the authors provided some evidence for

the reliability of data obtained from a combination of SIJ

region tests, they provided no evidence that the mea-

surements reflected dysfunction of the SIJ. This study

has yet to be replicated.

More recently, Cibulka and Koldehoff 26 reported on the

sensitivity, specificity, and predictive value of their tech-

nique for determining whether a patient has dysfunction

1138 . Freburger and Riddle

Physical Therapy . Volume 81 . Number 5 . May 2001

219), the

investigators did not have a standard for determining

whether patients truly had dysfunction in the SIJ region.

The sensitivity, specificity, and predictive value of their

approach cannot be determined without an acceptable

standard.

Despite the limitations of Potter and Rothstein’s study, 15

subsequent investigations demonstrated similar findings.

In a study of 51 patients receiving physical therapy for

unilateral low back or buttock pain, Laslett and Wil-

liams, 27

.64 –.82)

for measurements obtained with 5 of 7 tests used to

provoke pain in the SIJ region. The 5 tests were iliac

compression, iliac gapping, thigh thrust (with the

patient positioned supine and the hip and knee flexed to

90°, the examiner applied a downward force through the

longitudinal axis of the femur), pelvic torsion left (with

the patient positioned supine and the right leg off the

table, the examiner extended the right hip and maxi-

mally flexed the left knee and hip), and pelvic torsion

right. McCombe et al 28

Summary of Studies Examining the Reliability and

Validity of Data Obtained From Symmetry and

Movement Tests

Studies of individual clinical tests used to assess the

symmetry or movement of bony landmarks associated

with the SIJ indicate that the reliability and validity of

data obtained with these tests are poor. In addition, the

results of some of the more methodologically sound

radiographic studies indicate that the amount of motion

occurring at the SIJ in individuals with SIJ pathology is

extremely small (ie, less than 2 mm and less than

2°). 17–20 We do not believe that movements of this

magnitude can be assessed visually or with palpation. We

therefore believe the results of these radiographic stud-

ies suggest that tests designed to assess the symmetry and

movement of bony landmarks associated with the SIJ are

invalid for the identification of SIJ dysfunction.

also reported moderate inter-

.40 –.63) for measurements obtained

with the following tests used to provoke pain in the SIJ

region: active hip flexion, resisted hip lateral (external)

rotation, and palpation over the SIJ.

.09 and .11,

respectively). A possible explanation for the contradic-

tory findings of McCombe et al may be due to the fact

that 2 orthopedic surgeons and a physical therapist were

the examiners in their study. The examiners in the

studies by Potter and Rothstein and Laslett and Williams

were physical therapists. Furthermore, McCombe et al

did not standardize their test procedures. Potter and

Rothstein had therapists review the SIJ region tests and

come to a consensus regarding the operational defini-

tions. Laslett and Williams conducted 2 training sessions

to standardize the techniques of the therapists partici-

pating in their study.

Although the use of a combination of movement and

symmetry tests to identify dysfunction in the region of

the SIJ appears to yield more reliable data than the use

of a single test, further studies are needed to explore the

usefulness of this combination approach. More specifi-

cally, these studies need to address the issue of the type

of asymmetry present. In addition, studies using a suit-

able standard are needed to assess the validity of data

obtained with movement and symmetry tests for detect-

ing dysfunction in the region of the SIJ.

Pain Provocation Tests and Medical History/

Pain Description

Potter and Rothstein 15 reported what they considered to

be acceptable intertester agreement for 2 pain provoca-

tion tests. The percentages of agreement between ther-

apists were 76% for iliac compression (with the patient

positioned side lying, the examiner exerted a downward

force on the uppermost iliac crest) and 94% for iliac

gapping (with the patient positioned supine, the exam-

iner crossed his or her arms, placed the heels of his or

her hands on the ASISs, and pressed downward and

laterally). Potter and Rothstein did not justify their

criteria for acceptability nor did they calculate kappa

statistics for the examination procedures. The percent-

ages of agreement reported, therefore, are likely inflated

because they did not correct for chance agreement.

Furthermore, the sample size for the study was small (ie, 17

patients), limiting the generalizability of the results.

More recently, several researchers 2,11–13 have examined

the validity of measurements obtained with tests

designed to provoke pain in the SIJ region. Maigne et al 11

studied 54 patients with unilateral pain perceived to be

over the area of the PSIS region who had tenderness

over the SIJ and who were reported to have no sources of

pain in the lumbar spine. The subjects were first given a

short-acting anesthetic SIJ block (ie, a screening block).

Prior to and after the screening block, 7 pain provoca-

tion tests were performed on the subjects. Subjects who

responded positively to the screening block (ie, 75% or

more improvement in their pain) were given a confir-

matory anesthetic block 1 week later. Subjects were

considered to have dysfunction in the region of the SIJ if

their pain improved by at least 75% after the confirma-

tory block. Only 10 patients (18.5%) were diagnosed

with dysfunction of the SIJ region. The authors used

chi-square tests and found no relationships between the

pain provocation tests and dysfunction of the SIJ region.

Physical Therapy . Volume 81 . Number 5 . May 2001

Freburger and Riddle . 1139

in the region of the SIJ. Although this study was con-

ducted on a large sample of patients (N

found high intertester reliability (

tester reliability (

In contrast to the findings of Potter and Rothstein 15 and

Laslett and Williams, 27 McCombe et al 28 reported poor

intertester reliability for measurements obtained with

the iliac compression and gapping tests (

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