Manual Therapy 2005 (Aug); 10 (3): 207–218 ~ FULL TEXT
Mark Laslett, Charles N. Aprill, Barry McDonald, Sharon B. Young
Department of Health and Society,
Previous research indicates that physical examination cannot diagnose sacroiliac joint (SIJ) pathology. Earlier studies have not reported sensitivities and specificities of composites of provocation tests known to have acceptable inter-examiner reliability. This study examined the diagnostic power of pain provocation SIJ tests singly and in various combinations, in relation to an accepted criterion standard.
In a blinded criterion-related validity design, 48 patients were examined by physiotherapists using pain provocation SIJ tests and received an injection of local anaesthetic into the SIJ. The tests were evaluated singly and in various combinations (composites) for diagnostic power. All patients with a positive response to diagnostic injection reported pain with at least one SIJ test. Sensitivity and specificity for three or more of six positive SIJ tests were 94% and 78%, respectively. Receiver operator characteristic curves and areas under the curve were constructed for various composites. The greatest area under the curve for any two of the best four tests was 0.842.
In conclusion, composites of provocation SIJ tests are of value in clinical diagnosis of symptomatic SIJ. Three or more out of six tests or any two of four selected tests have the best predictive power in relation to results of intra-articular anaesthetic block injections. When all six provocation tests do not provoke familiar pain, the SIJ can be ruled out as a source of current LBP.
Keywords: Sacroiliac joint; Low back pain; Physical examination; Diagnosis; Validity; Sensitivity; Specificity
From the FULL TEXT Article:
The sacroiliac joint (SIJ) can be a nociceptive source
of low back pain (Fortin et al., 1994a, b; Bogduk, 1995). SIJ pain has no special distribution or features and is similar to symptoms arising from other lumbosacral structures. There are no provoking or relieving movements or positions that are unique or especially common to SIJ pain (Dreyfuss et al., 1996; Fortin et al., 1994a, b; Schwarzer et al., 1995; Maigne et al., 1996; Fortin and Falco, 1997). The clinical diagnosis of symptomatic SIJ remains problematical, but the ability to make the diagnosis is an important objective. It may be presumed that treatment strategies for SIJ lesions should differ from strategies intended to relieve and treat pathologies
of other structures such as disk, nerve root or facet joint
pain. Without a readily accessible means of differentiating
between these possible sources of pain, treatment
strategies are perforce non-specific, and likely to have at
best, modest efficacy.
At present, a current acceptable method of confirming
or excluding the diagnosis of a symptomatic SIJ is
fluoroscopically guided, contrast enhanced intra-articular
anaesthetic block (Fortin et al., 1994b; Grieve, 1988; Merskey and Bogduk, 1994; Schwarzer et al., 1995; Sakamoto et al., 2001; Adams et al., 2002). While certain SIJ tests have been shown to have acceptable
inter-rater reliability (Laslett and Williams, 1994; Kokmeyer et al., 2002), current evidence suggests that these tests alone cannot predict the results of a criterion standard such as diagnostic injection (Dreyfuss et al., 1996; Maigne et al., 1996; Slipman et al., 1998). These reports have not reported the sensitivity, specificity or
likelihood ratios or provided data on the diagnostic
power of individual or composites of provocation SIJ
tests (Slipman et al., 1998). However, in a previous publication, the current authors have identified a composite of three provocation SIJ tests in the absence of centralization during repeated movement testing has clinically useful sensitivity, specificity and positive likelihood ratio (93%, 89% and 6.97%, respectively)
(Laslett et al., 2003).+
Conceptually, it seems reasonable to propose that
stress testing of the SIJ should provoke pain of SIJ
origin. However, clinical stress tests are unlikely to load
the targeted structure alone. Herein lies the problem.
When a test provokes familiar pain, the question arises
if this is evidence of pathology within the targeted
structure, or evidence of pathology in a different but
nearby structure that is also stressed at the same time.
However, if different stress tests of a structure provoke
pain, greater diagnostic confidence may result. The use
of composites of tests is common in musculoskeletal
medicine. When a straight leg raise test provokes
familiar leg pain, nerve root irritation from a herniated
lumbar disc may be suspected. However, pain, paraesthesiae
or skin anaesthesiae in a known segmental distribution, weakness of key muscles or reflexes must also be present before the diagnosis of a herniated lumbar disc can be made with any degree of confidence. Confirmation with computed tomography or magnetic
resonance imaging completes the composite of tests for
this diagnosis. The need for diagnostic research to
investigate the added value of composites of tests within
the diagnostic process has been emphasized (Deville et al., 2000; Grieve, 1988). This current study explored the utility of utilizing composites of SIJ provocation tests to predict the results of fluoroscopically guided, contrast enhanced SIJ blocks (diagnostic injection
Material and methods
The diagnosis of symptomatic SIJ pathology may
mean that either SIJ structures contain the pain
generating tissues, or that the SIJ functions or malfunctions
in such a way as to cause pain. Throughout this
report, references to symptomatic SIJ, SIJ pain or
pathology are confined to meaning that the pain
originates from the SIJ structures.
The study design is presented graphically in Fig. 1.
Physiotherapists (ML and SBY) visited a private
radiology practice in New Orleans specializing in the
diagnosis of spinal pain at regular intervals between
January 1997 and August 1998 to carry out the clinical
evaluations. Patients were not consecutive. Patients
deemed likely by clinic staff to have SIJ pain were
scheduled to receive the SIJ provocation tests on a day
when an examining physiotherapist visited the clinic.
The clinical examination and injection procedures were
completed the same day. No other treatment was
provided by the physiotherapist. The physiotherapists
were blinded to the results of previous diagnostic
injections and the results of previous imaging studies.
Diagnostic injection was conducted blind from the
results of SIJ provocation tests and the results of the
physiotherapy examination. Results from the clinical
and SIJ injection procedures were recorded on separate
standardized data collection forms. Informed consent
was sought prior to the clinical evaluations.
Patients with buttock pain, with or without lumbar or
lower extremity symptoms were invited to participate in
the study. Patients were scheduled for the clinical
evaluation in an opportunistic fashion with some
patients being examined by the physical therapist at
their initial visit to the clinic and others scheduled to
return on a day when the physical therapist was present.
Each patient had undergone imaging studies and had a
variety of unsuccessful therapeutic interventions. They
were referred for diagnostic evaluation and procedures
by a variety of medical and allied health practitioners
and a few were self-referred. Patients were drawn from
the New Orleans metropolitan area, with some intrastate
and interstate referrals.
Patients were excluded from the study if they were
unwilling to participate, had only midline or symmetrical
pain above the level of L5, had clear signs of nerve
root compression (complete motor or sensory deficit), or
were referred for specific procedures excluding SIJ
injection. Those deemed too frail to tolerate a full
physical examination, were also excluded.
Background data collection
Patient data recorded included age, gender, occupation,
employment status, pending litigation, duration of symptoms, aggravating/relieving factors and cause of current episode. The patient completed detailed pain drawings (Ohnmeiss et al., 1999; Beattie et al., 2000) and pain intensity was measured on a verbal analogue scale (VAS) (0 = "no pain" and 10 = "worst imaginable pain"). Disability was estimated with the Roland–Morris questionnaire (Roland and Morris, 1983; Jensen et al., 1992) and the Dallas Pain and Disability questionnaire (Lawlis et al., 1989).
The familiar symptom: The familiar symptom is the pain or other symptoms (such as aching, burning, paraesthesiae or numbness) identified on a pain drawing, verified by the patient as being the complaint that
has led the patient to seek diagnosis and treatment.
During a diagnostic test the familiar symptoms must be
distinguished from other symptoms produced by the
test, and may be produced, increased, decreased or
Choice of SIJ tests to evaluate: Tests based on palpation for positional faults or movement dysfunctions were not considered for inclusion in the current study, since adequate inter-examiner reliability has not been demonstrated in earlier studies (Potter and Rothstein, 1985; McCombe et al., 1989; Meijne et al., 1999). However, one study found that a selection of pain provocation tests were found to have acceptable reliability (Cohen’s Kappa 40.04) (Laslett and Williams, 1994) and these were considered as suitable procedures for evaluation of diagnostic validity.
Positive provocation SIJ test: A provocation SIJ test that produces or increases familiar symptoms. Negative provocation SIJ test: A provocation SIJ test that does not produce or increase familiar symptoms.
Positive SIJ injection: Slow injection of solutions provokes familiar pain, and instillation of a small volume of local anaesthetic (less than 1.5 cc) resulted in 80% or more relief of the pain for duration of effect of the anaesthetic agent. Anaesthetic effect was assessed by change in pre- and post-injection numeric pain rating scales. Patients reporting a concordant pain response
and at least 80% relief of their familiar pain were
scheduled for a confirmatory block. Lidocaine was used
in the initial injection and Bupivicaine was used in the
confirmatory block to eliminate the need for a sham
injection (Barnsley et al., 1993).
Negative SIJ injection: Diagnostic injections were considered indeterminate when there was a concordant pain response but insufficient pain relief, or when substantial pain relief was reported in the absence of provocation of familiar pain. Indeterminate responses
were considered negative for statistical analysis. Injections
not causing concordant pain provocation or analgesic response were deemed negative.
The clinical evaluation was carried out by physiotherapists
with 25 years (ML) and 17 years (SBY) experience in orthopaedic examinations of spinal pain patients and included a standard history and structured physical examination lasting between 30 min and 1 h. The structured physical examination included aMcKenzie examination of the lumbar spine (McKenzie, 1981), SIJ provocation tests (Laslett and Williams, 1994), and a hip joint assessment (Cyriax, 1975).
The sacroiliac pain provocation tests: The tests
employed in this study were: distraction (Figure 2), right sided thigh thrust (Figure 3), right sided Gaenslen’s test (Figure 4), compression (Figure 5) and sacral thrust (Figure 6) and have acceptable inter-rater reliability (Kokmeyer et al., 2002) and have been described previously (Cyriax, 1975; Laslett and Williams, 1994; Maigne et al., 1996; Laslett et al., 2003).
The technique used for fluoroscopically guided contrast
enhanced SIJ arthrography has been previously
described (Fortin et al., 1994b; Schwarzer et al., 1995). The radiologist examiner (CA) has over 20 years experience in diagnostic spinal injection procedures, including SIJ injection. The SIJ injection was given
within 30 min of completion of the physiotherapy
clinical examination. Pain drawings and numeric pain
rating scales for pain intensity were acquired prior to
and 30–60 min following diagnostic injection.
During this study, corticosteroid was introduced into
the joint as a therapeutic procedure when the initial
injection of contrast and Lidocaine provoked familiar
symptoms, as was normal practice at the clinic. The
radiologist documented the procedure(s) performed,
radiographic findings and conclusions. Pain provocation
and analgesic responses to SIJ injection were recorded.
Data reduction and analysis
Statistical calculations were performed using statistical
software Minitab (version 13.31 Minitab Inc. r2000), and CIA (version 2.0.4 r Trevor N Bryant, 2000 University of Southhampton) (Bryant, 2000). Two by two contingency tables were constructed and
sensitivity, specificity, positive and negative predictive
values, and likelihood ratios with 95% confidence intervals were calculated for each test independently and for composites of SIJ tests. Sensitivity, specificity, positive and negative predictive values have been calculated using the Wilson method (Altman et al., 2000; Bryant, 2000). Likelihood ratios have been calculated using the score method (Altman et al., 2000). Receiver operator characteristic (ROC) curves
are an overall measure of diagnostic efficacy (Altman et al., 2000, pp. 111–116). These curves combine sensitivity and specificity, and the area under the curve (AUC) is a summary measure of achieved discrimination, with perfect discrimination represented by an AUC of 1.0,
and scores equal to or less than 0.5 are equivalent to or
worse than can expected by random chance. The closer
the AUC approaches 1.0, the better discriminatory power the diagnostic test has in relation to the criterion or reference standard.
Sixty-two patients agreed to participate and were
examined by both radiologist and physical therapist. Of
these patients, three were unable to tolerate the physical
examination, two were pain free on the day of the
clinical assessment, seven had no SIJ injection, and two
had a bony obstruction causing a technical failure to
inject the SIJ. These patients were excluded from the
study. Forty-eight patients satisfied all inclusion criteria.
Twenty-seven patients received the clinical assessment at
their first clinic visit, 21 patients at the second.
There were no significant differences between positive
and negative responders to diagnostic injection with
regards to age, gender, working status, Dallas and
Roland questionnaire results or pain intensity prior to
examination. Table 1 presents basic demographic, and
disability data for all included patients.
Of the 48 patients satisfying inclusion criteria 16
patients had positive SIJ injections. There were no
adverse effects reported by patients from either the
physical examination or SIJ injection, other than
temporary local soreness at the injection site or increase
in discomfort from the clinical examination.
The provocation SIJ tests provoked familiar pain in
those patients confirmed by diagnostic injection as
having painful SIJ pathology more commonly than
those with negative injections. However, false positive
tests were common. Prevalence of positive tests in the
sample ranged from 29.2% to 50.0%. Sensitivity,
specificity, positive and negative predictive values and
likelihood ratios for each individual test are presented in
One approach to combining tests is simply to count
the number of positives. Two by two contingency tables
for the results of composites of all six SIJ tests (0, 1 or
more, 2 or more and so on) versus the results of
diagnostic injection and are presented in Table 3.
Sensitivity, specificity, positive and negative predictive
values and likelihood ratios were calculated and are
presented in Table 4. The optimum composite rule was
to identify the SIJ as the pain generator if there were
three or more positive tests, with estimated sensitivity of
93.8%, specificity of 78.1%, and AUC of 0.842 (s.e.
On the other hand, looking at specific combinations
of tests, it was found that the distraction test had the
highest single positive predictive value (PPV) and AUC,
the thigh thrust, compression and sacral thrust tests
improved the overall diagnostic ability (as measured by
improvement in AUC). The Gaenslen’s tests did not
improve the AUC value. This implies that Gaenslen’s
tests did not contribute positively and may be omitted
from the diagnostic process without compromising
diagnostic confidence. The optimal rule was to perform
the distraction, thigh thrust, compression and sacral
thrust tests but stopping when there are two positives.
This resulted in an AUC of (0.819, s.e. 0.054) with
sensitivity of 0.88 and specificity of 0.78. Table 5
presents two by two contingency tables for the four
tests that positively contribute to making the diagnosis
(distraction, thigh thrust, compression and sacral
thrust). Table 6 presents sensitivity, specificity, positive
and negative predictive values and likelihood ratios for
two positives of these four tests.
All patients with SIJ pathology identified by injection
had at least one positive test. Only one patient out of 16
with SIJ pain had a single positive test with 15 having
two or more positive SIJ tests. Consequently, one
reasonable clinical rule is that when all provocation
SIJ tests are negative, symptomatic SIJ pathology can be
ruled out. The thigh thrust test is the most sensitive test
and the distraction test is most specific.
Three or more of the six tests produce the highest
likelihood ratio (4.29), but removal of Gaenslen’s
test from the examination and application of the rule
"any two positive tests" of the remaining four tests
produces almost as good a result (likelihood ratio = 4.0). Because the thigh thrust and distraction tests have the highest individual sensitivity and specificity, respectively (see Table 3), performance of these tests first seems reasonable. If both tests provoke familiar pain, no further testing is indicated. If one test is positive, the compression test is applied and if
positive, a painful SIJ is likely and no further testing is
required. If compression is not painful the sacral thrust
test is applied. If this is painful, SIJ pathology is likely,
whereas if it is not painful, SIJ pain is unlikely. Not only
does this rule avoid subjecting patients to unnecessary
tests, but also would in most cases permit a diagnosis
even if one or more tests were not completed. Figure 7
presents a diagnostic algorithm for this reasoning
When severe pain occurs with all body movements
(e.g. acute disc prolapse, fractures, etc.), pain is
provoked by any test including the provocation SIJ
tests. In these circumstances interpretation of the SIJ
tests is inappropriate. In our opinion, where another
source of pain is known to be a major source of pain, the
interpretation of the SIJ tests as evidence of a
symptomatic SIJ should be avoided or entertained only
No single study can satisfy all criteria recommended
by advisory groups (Deyo et al., 1994) and this study is no exception. One threat to external validity within this study is that the patients in this study were more chronic and disabled than those usually seen in primary care or most secondary referral environments. While generalizability of the study results must be questioned, it is our anecdotal experience that most primary care and
secondary referral patient populations are less difficult
to examine and analyse, and these results understate
rather than overstate the diagnostic power of the
provocation SIJ tests. Additionally, the effects of
preceding provocation tests may confound interpretation
of single test results. Progressive increases or
decreases in pain responses to the second, third or
fourth tests cannot be ruled out as a confounding factor.
A different study design would be required to eliminate
this confounder, such as allowing a specified rest period
between tests, or applying only a single test to each
individual patient before the diagnostic injection. However,
the latter design would not permit evaluation of
groups or sequences of tests.
The criterion standard for the diagnosis of painful
lumbar facet joint is comparative anaesthetic or placebo
controlled blocks and this is widely accepted and utilized
in studies (Dreyfuss et al., 2003). However, standards used in recent studies of SIJ pain diagnosis are diverse. The International Association for the Study of Pain (IASP) has proposed criteria for making the diagnosis of symptomatic SIJ and are:
(1) pain is present in the region of the SIJ,
(2) stressing the SIJ by clinical tests that are selective for the joint reproduces the patient’s pain,
(3) selectively infiltrating the putatively symptomatic joint with local anaesthetic
completely relieves the patient of pain (Merskey and Bogduk, 1994).
In recent diagnostic studies of SIJ pain there are variations on a general theme. Fortin et al. (1994a) used patterns of pain distribution, provocation of pain during SIJ injection and a single anaesthetic block. Schwarzer et al. (1995) used a single injection in patients with pain ‘centred’ below L5/S1 and a 75% reduction in pain following injection of local anaesthetic. Dreyfuss et al. (1996) used a single injection of local anesthetic and cortico-steroid, noted pain provocation and required more than 90% reduction in the ‘main pain’ as distinct from a change in VAS assessment of pain generally. Maigne et al. (1996) used comparative double blocks in patients selected by pain drawing as likely to have SIJ pain and at least 75% reduction on a general pain VAS. Slipman et al. (1998) used an 80% reduction on a general pain VAS following single anaesthetic injection in consecutive LBPpa tients. In an earlier presentation of a subset of patients from the current study, we utilized double comparative blocks and 80% or more reduction in a verbal analogue scale of pain intensity and provocation of pain during SIJ injection as the criterion standard (Laslett et al., 2003).
In the current analysis, a single diagnostic injection
under fluoroscopic control and contrast enhancement
that provoked familiar pain was used and resulted in
80% or more relief of pain as measured by a verbal
analogue scale of pain intensity. Where familiar pain
was provoked during injection, corticosteroid was
injected in addition to local anaesthetic and the patient
scheduled for a confirmatory, comparative block. It is
noted that in a recent publication (Bogduk and McGuirk, 2002, p. 174), double comparative blocks are recommended for confirmation of the diagnosis. The
data collection for the current paper was between 1996
and 1998, at the time when mixtures of standards were
common. Future criterion standard validity studies
should use the standard recommended by Bogduk and
McGuirk without inclusion of corticosteroid in the
initial screening injection.
Although false positive rates for SIJ injections have
not been previously reported, a rate of 7.7% may be
calculated from data presented from one study (Schwarzer et al., 1995) and 20.5% from another (Maigne et al., 1996). In this current analysis, the 16 patients reporting a positive response to a single anaesthetic injection and 12 proceeded on to receive a second injection. All of
these patients reported a positive anaesthetic response,
confirming the diagnosis of SIJ pathology with a false
positive rate of zero. Of the four initial responders who
did not receive a confirmatory block, three derived such
pain relief from the initial block that a confirmatory
block was inappropriate. It is assumed that ablation of
pain following the initial block was a consequence of the
introduction of corticosteroid during the initial procedure.
One patient did not return for the scheduled
confirmatory block for unknown reasons.
In a worst-case scenario using the comparative
confirmatory blocks as a criterion standard, we can
propose that all four cases not returning for a
confirmatory block would have returned a negative
response to that procedure and the initial block deemed
false positive. Estimations (with 95% confidence intervals)
for sensitivity, specificity, positive/negative predictive
values would be 83.3 (55.2, 95.3), 69.4 (53.1,
82.0), 47.6 (28.3, 67.7), 92.6 (76.6, 97.9) percent,
respectively, and positive/negative likelihood ratios
would be 2.72 (1.57, 4.74) and 0.24 (0.66, 0.87),
respectively. The estimations from this scenario still
exceed what can be expected by random chance at the
lower 95% confidence limit. However, in this scenario
the false positive rate (95% confidence intervals) would
have been 30.6% (15.1, 45.6).
Although diagnostic injection is the only available
criterion standard against which clinical tests can
reasonably be evaluated for validity, it is acknowledged
that false negative and false positive responses to
injection are possible. Where there is a defect in the
articular capsule, leakage of anaesthetic into adjacent
areas may occur (Fortin et al., 1994a; Schwarzer et al., 1995), and pain relief may be a reflection of an anaesthetic affect of these structures rather than the SIJ structures. This possibility and the unknown effect
of psychosocial influences on pain responses to invasive
diagnostic procedures may contribute to the false
positive and negative rates. No attempt to estimate these influences was attempted during this study. In addition, intra-articular injection of anaesthetic has the potential to ablate SIJ pain when originating within the joint cavity, but is unlikely to have an anaesthetic effect on SIJ structures external to the joint (Grieve, 1988). (Maigne et al., 1996; Laslett et al., 2003) Where SIJ structures external to the joint cavity are actual pain generators, an intra-articular injection of local anaesthetic into and confined to the joint space will produce a false negative diagnostic result, whereas the clinical examination may possibly correctly identify the periarticular and unanaesthetized SIJ structures as pain generators.
The patients entered into this study were not
consecutive. The physiotherapists performing the clinical
examination were not residents in New Orleans
where the diagnostic injections were being carried out
and could visit only intermittently over a 19-month
period. Consequently, no estimate of prevalence should
be inferred from the data presented in this report.
Additionally, calculation of predictive values or false
positive rates in a sample, at least partially selected for
possible SIJ involvement, are not be generalizable to
other patient populations.
The results of this study are in contrast to the results
of earlier similar studies (Schwarzer et al., 1995; Dreyfuss et al., 1996; Maigne et al., 1996; Slipman et al., 1998), and the conclusion from a meta-analysis of studies of clinical tests for painful SIJs (van der Wurff et al., 2000). However, there is support for the use of pain provocation tests in SIJ diagnosis (Laslett et al., 2003) and these tests are preferred over palpation tests for mobility or position (Freburger and Riddle, 2001). It is difficult to account for the differences between our results and the results from other studies. However, some of the explanation may lie in differences in application of the examination technique. There is evidence that physiotherapists apply different degrees of force when utilizing SIJ provocation tests (Levin et al., 1998, 2001) and this may be one of several factors influencing results.
Provocation SIJ tests have significant diagnostic
utility. Six provocation tests were selected on the basis
of previously demonstrated acceptable inter-examiner
reliability. Two of four positive tests (distraction,
compression, thigh thrust or sacral thrust) or three or
more of the full set of six tests are the best predictors of
a positive intra-articular SIJ block. When all six SIJ
provocation tests are negative, painful SIJ pathology
may be ruled out.
Thanks to Duncan Reid, Wayne Hing, and the
Auckland University of Technology Multimedia Unit
for assistance with photographs.
Travel and Louisiana licensing costs for Mrs. Young
were funded by The McKenzie Institute International.
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