Evidence-based Medicine and the Sacroiliac...

EvidenceEvidence--based Medicine based Medicine and the Pelvic Girdleand the Pelvic Girdle

Sayers John Miller, PhD, PT, ATCSayers John Miller, PhD, PT, ATCPenn State UniversityPenn State University

EvidenceEvidence--based Medicinebased Medicine

““EvidenceEvidence--based medicine (EBM) is the based medicine (EBM) is the integration of best research evidence integration of best research evidence with clinical experience and patient with clinical experience and patient valuesvalues””SackettSackett et al. (2000)et al. (2000)

How to Practice EBMHow to Practice EBM

11-- Convert the need for information into an Convert the need for information into an answerable questionanswerable question22-- Track down the best evidence with which to Track down the best evidence with which to answer the questionanswer the question33-- Critically appraise evidence for validity, impact Critically appraise evidence for validity, impact and applicabilityand applicability44-- Integrate the critical appraisal with our clinical Integrate the critical appraisal with our clinical expertise and with our patientexpertise and with our patient’’s unique biology, s unique biology, values and circumstancesvalues and circumstances55-- Evaluate our effectiveness and efficiency in Evaluate our effectiveness and efficiency in executing steps 1executing steps 1--4 and seek ways to improve 4 and seek ways to improve them both for next timethem both for next time((SackettSackett et al. 2000)et al. 2000)

Types of QuestionsTypes of Questions

DiagnosisDiagnosis–– ReliabilityReliability

Kappa, ICCKappa, ICC

–– ValidityValiditySensitivity, specificity, LRSensitivity, specificity, LRMethodologyMethodology

Treatment Treatment –– OutcomesOutcomes

Systematic reviews, RCT, cohort studies, caseSystematic reviews, RCT, cohort studies, case--control, control, casecase--series, expert opinionseries, expert opinionLR, effect size, risk reduction, numbers needed to treatLR, effect size, risk reduction, numbers needed to treat

KappaKappa

K = (PoK = (Po--Pe)/(1Pe)/(1--Pe)Pe)–– K = generalized KappaK = generalized Kappa–– Po = proportion of observed agreementPo = proportion of observed agreement–– PePe = proportion of agreement expected = proportion of agreement expected

by chanceby chanceInterpretationInterpretation–– K = 1, perfect agreementK = 1, perfect agreement–– K = 0, chance agreementK = 0, chance agreement–– K = K = --N, less than chance agreementN, less than chance agreement

ReliabilityReliability

KappaKappa–– 0.000.00--0.200.20 SlightSlight–– 0.210.21--0.400.40 FairFair–– 0.410.41--0.600.60 ModerateModerate–– 0.610.61--0.800.80 SubstantialSubstantial–– 0.810.81--1.001.00 Almost perfectAlmost perfect

IntraclassIntraclass Correlation Correlation Coefficients (ICC)Coefficients (ICC)

Rates reliability by comparing Rates reliability by comparing variability of different raters of same variability of different raters of same subject to total variation across all subject to total variation across all ratings and all subjectsratings and all subjectsICC = ICC = σσ2 2 (b) / (b) / σσ2 2 (b) + (b) + σσ2 2 (w) (w)

Where: Where: σσ2 2 (b) is variance of trait between (b) is variance of trait between subjects and, subjects and, σσ2 2 (w) is pooled variance within subjects(w) is pooled variance within subjects

Sensitivity/SpecificitySensitivity/Specificity

SensitivitySensitivity–– Proportion of people with the disorder who have Proportion of people with the disorder who have

a positive testa positive testSpecificitySpecificity–– Proportion of people without the disorder who Proportion of people without the disorder who

have a negative testhave a negative testSpPinSpPin–– When a test has high Specificity, a positive result When a test has high Specificity, a positive result

rules in the diagnosis.rules in the diagnosis.SnNoutSnNout–– When a test has high Sensitivity, a negative When a test has high Sensitivity, a negative

result rules out the diagnosis.result rules out the diagnosis.

Calculation of Calculation of Sensitivity/Specificity/LRSensitivity/Specificity/LR

Sensitivity = a/(Sensitivity = a/(a+ca+c))Specificity = Specificity = d/(b+dd/(b+d))LR+ = sensitivity/(1LR+ = sensitivity/(1--specificity) = (a/specificity) = (a/a+c)a+c)÷÷(b/b+d(b/b+d))LRLR-- = (1= (1--sensitivity)/specificity = (sensitivity)/specificity = (c/a+c)c/a+c)÷÷(d/b+d(d/b+d))PPV = a/(PPV = a/(a+ba+b))NPV = NPV = d/(c+dd/(c+d))PrePre--test probability = (test probability = (a+c)/a+b+c+da+c)/a+b+c+d))

ddccTest negativeTest negativebbaaTest positiveTest positive

Disease Disease negativenegative

Disease Disease positivepositive

How Do You Know How Do You Know Condition is Present?Condition is Present?

Gold standardsGold standards–– SI jointSI joint

Pain mapping: Provocative injection Pain mapping: Provocative injection Pain: Fluoroscopically guided anesthetic injection Pain: Fluoroscopically guided anesthetic injection (double block) with specified level of pain reduction (double block) with specified level of pain reduction (75(75--90%)90%)Movement: Movement: RadiostereophotogrammetricRadiostereophotogrammetric analysisanalysis

–– DiscDiscDiscogramDiscogram

–– Facet jointFacet jointPain: Fluoroscopically guided anesthetic injection Pain: Fluoroscopically guided anesthetic injection (double block)(double block)

Likelihood Ratio (LR)Likelihood Ratio (LR)

Likelihood ratioLikelihood ratio–– The likelihood that a given test result The likelihood that a given test result

would be expected in a patient with the would be expected in a patient with the disorder compared with the likelihood disorder compared with the likelihood that that same result would be expected that that same result would be expected in a patient without the disorderin a patient without the disorder

PrePre--test probabilitytest probability–– The proportion of people with the The proportion of people with the

disorder in the population at risk at a disorder in the population at risk at a specific time or time intervalspecific time or time interval

Positive LR (LR +)Positive LR (LR +)

Probability of patient with the condition Probability of patient with the condition having a positive test/probability of patient having a positive test/probability of patient without the condition having the resultwithout the condition having the resultLR+ = Sensitivity/1LR+ = Sensitivity/1--SpecificitySpecificityScore interpretation (Score interpretation (JaeschkeJaeschke et al. 1994)et al. 1994)–– 2.02.0--5.0 generates small shift in probability5.0 generates small shift in probability–– 5.05.0--10.0 generates moderate shift in probability10.0 generates moderate shift in probability–– >10.0 generates large and often conclusive shift >10.0 generates large and often conclusive shift

in probabilityin probability

Negative LR (LRNegative LR (LR--))

Probability of an individual with the Probability of an individual with the condition having a negative condition having a negative test/probability of an individual test/probability of an individual without the condition having a without the condition having a negative testnegative testLRLR-- = 1= 1--Sensitivity/SpecificitySensitivity/Specificity

Likelihood Ratio Likelihood Ratio InterpretationInterpretation

>10>10 Large increase in likelihood Large increase in likelihood 55--1010 Moderate increase in likelihood Moderate increase in likelihood 22--55 Small increase in likelihoodSmall increase in likelihood11--22 Minimal increase in likelihoodMinimal increase in likelihood11 No change in likelihoodNo change in likelihood0.50.5--1.01.0 Minimal decrease in likelihoodMinimal decrease in likelihood0.20.2--0.50.5 Small decrease in likelihoodSmall decrease in likelihood0.10.1--0.20.2 Moderate decrease in Moderate decrease in IikelihoodIikelihood<0.1<0.1 Large decrease in likelihoodLarge decrease in likelihood

Predictive ValuePredictive Value

Positive predictive value (PPV)Positive predictive value (PPV)–– Proportion of people with a positive test Proportion of people with a positive test

who have the disorderwho have the disorder

Negative predictive value (NPV)Negative predictive value (NPV)–– Proportion of people with a negative test Proportion of people with a negative test

who are free of the disorderwho are free of the disorder

Levels of EvidenceLevels of Evidence

1a: SR with homogeneity of 1a: SR with homogeneity of RCTRCT’’ss1b: Individual RCT with narrow CI1b: Individual RCT with narrow CI1c: All or none 1c: All or none 2a: SR with homogeneity of cohort studies2a: SR with homogeneity of cohort studies2b: Individual cohort study (low quality 2b: Individual cohort study (low quality RCTRCT’’ss))2c: Outcomes research2c: Outcomes research3a: SR with homogeneity of case3a: SR with homogeneity of case--control studiescontrol studies3b: Individual case3b: Individual case--control studycontrol study4: Case4: Case--series (poor quality cohort or case studies)series (poor quality cohort or case studies)5: Expert opinion without explicit critical appraisal , 5: Expert opinion without explicit critical appraisal , or based on physiology, bench research or first or based on physiology, bench research or first principlesprinciples

Oxford Centre of Evidence-based Medicine Levels of Evidence (May 2001)

Grades of Grades of RecommendationRecommendation

A: Consistent Level 1 studiesA: Consistent Level 1 studiesB: Consistent Level 2 or 3 studies or B: Consistent Level 2 or 3 studies or extrapolations from Level 1 studiesextrapolations from Level 1 studiesC: Level 4 studies or extrapolations C: Level 4 studies or extrapolations from Level 2 or 3 studiesfrom Level 2 or 3 studiesD: Level 5 evidence or troubling D: Level 5 evidence or troubling inconsistent or inconclusive studies of inconsistent or inconclusive studies of any levelany level

PEDroPEDro ScaleScale

1.1. Eligibility criteria specifiedEligibility criteria specified2.2. Subjects randomly allocated to groupsSubjects randomly allocated to groups3. 3. Allocation concealedAllocation concealed4.4. Groups similar at baseline regarding most important prognostic Groups similar at baseline regarding most important prognostic indicatorsindicators5.5. Blinding of all subjectsBlinding of all subjects6.6. Blinding of all therapists performing treatmentBlinding of all therapists performing treatment7.7. Blinding of all assessors who measured at least one key Blinding of all assessors who measured at least one key outcomeoutcome8.8. Measures of at least one key outcome were obtained from Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groupsmore than 85% of the subjects initially allocated to groups9.9. All subjects for whom outcome measures were available All subjects for whom outcome measures were available received the treatment or control condition as allocated or, whereceived the treatment or control condition as allocated or, where re this was not the case, data for at least one key outcome was this was not the case, data for at least one key outcome was analyzed by analyzed by ““intention to treatintention to treat””10.10. The results of betweenThe results of between--group statistical comparisons are group statistical comparisons are reported for at least one key outcome reported for at least one key outcome 11.11. The study provides both point measure and measures of The study provides both point measure and measures of variability for at least one key outcomevariability for at least one key outcome

www.pedro.fhs.usyd.edu.au

PrevalencePrevalence

15% in chronic low back pain patients 15% in chronic low back pain patients –– MaigneMaigne et al. 1996 (18.5%)et al. 1996 (18.5%)–– SchwarzerSchwarzer et al. 1995et al. 1995

Chronic low back pain (Chronic low back pain (BogdukBogduk 2005)2005)–– Internal disc disruption (39%)Internal disc disruption (39%)–– Sacroiliac joint (15%)Sacroiliac joint (15%)–– ZygapophysialZygapophysial joint (<10%, young, 32% elderly)joint (<10%, young, 32% elderly)–– Iliac crest syndrome (30Iliac crest syndrome (30--50%)50%)–– IliolumbarIliolumbar ligament (<10%)ligament (<10%)–– SpondylolysisSpondylolysis (<6%)(<6%)

Sacroiliac Joint Sacroiliac Joint ExaminationExamination

HistoryHistoryPain locationPain locationLandmark palpationLandmark palpationMotion palpation Motion palpation Pain provocation testsPain provocation testsMultiple testsMultiple tests

Diagnosis with Orthodox Diagnosis with Orthodox Clinical ExaminationClinical Examination

Poor ability to diagnose SI joint painPoor ability to diagnose SI joint pain–– SchwarzerSchwarzer et al. 1995et al. 1995

No component of history, physical No component of history, physical exam test or ensemble of them is able exam test or ensemble of them is able to identify SI joint painto identify SI joint pain–– DreyfussDreyfuss et al. 1996et al. 1996

Pain LocationPain Location

Fortin et al. (1994)Fortin et al. (1994)–– Asymptomatic subjectsAsymptomatic subjects–– Provocative fluoroscopically guided injectionsProvocative fluoroscopically guided injections–– Common referral Common referral

Area 10 cm caudal and 3 cm lateral to PSISArea 10 cm caudal and 3 cm lateral to PSIS–– Confirmed with injections in patients with LBPConfirmed with injections in patients with LBP

10 of 16 had at least 50% reduction in pain 10 of 16 had at least 50% reduction in pain

DreyfussDreyfuss et al.(1996)et al.(1996)–– Documented pain referral patterns in LBP patients Documented pain referral patterns in LBP patients

with positive response to SIJ block and withoutwith positive response to SIJ block and without–– Broad referral patterns: buttocks, groin, entire LE Broad referral patterns: buttocks, groin, entire LE –– No referral above L5 in SI joint patientsNo referral above L5 in SI joint patients

Fortin Finger TestFortin Finger Test

Fortin and Fortin and FalcoFalco (1997)(1997)–– 56 consecutive LBP patients56 consecutive LBP patients–– 2 examiners selected the same 12 patients 2 examiners selected the same 12 patients

based upon (4 additional after Patrickbased upon (4 additional after Patrick’’s test)s test)Pain localized with one fingerPain localized with one fingerPain Pain inferomedialinferomedial to PSIS within 1 cmto PSIS within 1 cmPatient pointed to same area on two trialsPatient pointed to same area on two trials

–– All 16 had provocationAll 16 had provocation--positive SI joint injectionspositive SI joint injections4 injected bilaterally negative on non4 injected bilaterally negative on non--painful sidepainful side

–– 10 patients had further evaluation with negative 10 patients had further evaluation with negative lumbar imaginglumbar imaging

Pain LocationPain Location

DreyfussDreyfuss et al. (1996)et al. (1996)–– Sacral Sacral sulcussulcus tendernesstenderness

Sensitivity: 0.84Sensitivity: 0.84--0.93, Specificity: 0.100.93, Specificity: 0.10--0.170.17LR = 1.00LR = 1.00

–– PSIS pointingPSIS pointingSensitivity: 0.71, Specificity: 0.47Sensitivity: 0.71, Specificity: 0.47LR = 1.33LR = 1.33

KristianssonKristiansson & & SvSväärdsuddrdsudd (1996)(1996)–– SacrospinousSacrospinous ligamentligament

Sensitivity: 0.64, Specificity: 0.89Sensitivity: 0.64, Specificity: 0.89+ LR = 0.72+ LR = 0.72

–– PSISPSISSensitivity: 0.35, Specificity: 0.98Sensitivity: 0.35, Specificity: 0.98+ LR = 0.36+ LR = 0.36

Landmark PalpationLandmark Palpation

Potter & Rothstein (1985)Potter & Rothstein (1985)–– 17 low back pain patients, 8 therapists17 low back pain patients, 8 therapists–– InterInter--examiner agreementsexaminer agreements

In standingIn standing–– ASIS (38%), PSIS (35%), iliac crests (35%)ASIS (38%), PSIS (35%), iliac crests (35%)

In sittingIn sitting–– ASIS (44%), PSIS (35%), iliac crests (41%)ASIS (44%), PSIS (35%), iliac crests (41%)


OO’’HaireHaire & Gibbons (2000)& Gibbons (2000)–– 10 subjects, Ten 510 subjects, Ten 5thth year osteopathic studentsyear osteopathic students–– PSIS, SS, ILA positional relationships (prone)PSIS, SS, ILA positional relationships (prone)–– IntraIntra--examiner examiner

PSIS, K = 0.33 (0.07 to 0.58), ILA, K = 0.21 (PSIS, K = 0.33 (0.07 to 0.58), ILA, K = 0.21 (--0.05 to 0.69), 0.05 to 0.69), SS, K = 0.24 (0.02 to 0.60)SS, K = 0.24 (0.02 to 0.60)

–– InterInter--examinerexaminerPSIS, K = 0.04, ILA, K = 0.08, SS, K = 0.07 PSIS, K = 0.04, ILA, K = 0.08, SS, K = 0.07

Flynn et al. (2002)Flynn et al. (2002)–– 55 patients, 2 physical therapist examiners55 patients, 2 physical therapist examiners–– InterInter--examiner (kappa)examiner (kappa)

ASIS in standing (0.31), Iliac crests in standing (0.23), PSIS iASIS in standing (0.31), Iliac crests in standing (0.23), PSIS in n sitting (0.23), PSIS in standing (0.13), sitting (0.23), PSIS in standing (0.13), ischialischial tuberositytuberosity in in prone (0.03), pubic tubercle in supine (prone (0.03), pubic tubercle in supine (--0.04)0.04)


Albert et al. (2000)Albert et al. (2000)–– 2269 subjects, pelvic topography 2269 subjects, pelvic topography –– 4 pairs 4 pairs

of landmarks of landmarks –– ASIS, PSIS, IC, Greater ASIS, PSIS, IC, Greater trochanterstrochanters

(standing)(standing)–– InterInter--examiner reliabilityexaminer reliability

Kappa = 0.55Kappa = 0.55

–– Diagnosis of SIJDDiagnosis of SIJDSensitivity (0.77), Specificity (0.32), LR+ (1.13)Sensitivity (0.77), Specificity (0.32), LR+ (1.13)


Waters (2003)Waters (2003)–– Systematic reviewSystematic review–– ““Insufficient evidence to advocate the use Insufficient evidence to advocate the use

of static palpation tests to indicate SIJ of static palpation tests to indicate SIJ dysfunctiondysfunction””

Diagnosis Diagnosis -- MobilityMobility

Gold standardGold standard–– RadiostereometricRadiostereometric ((SturessonSturesson 1998)1998)–– CT scan (CT scan (SmidtSmidt et al. 1997)et al. 1997)–– 33--D video D video kinematickinematic (Hungerford & (Hungerford &

GilleardGilleard 1998)1998)

Motion PalpationMotion Palpation

SmidtSmidt et al. (1997)et al. (1997)–– 5 fresh cadavers (525 fresh cadavers (52--68 years old)68 years old)–– CT scan, lead markers on sacrum and CT scan, lead markers on sacrum and iliumsiliums–– Angular (Angular (sagittalsagittal))

Bilateral flexion to extension (7Bilateral flexion to extension (7°° left, 8left, 8°° right)right)Reciprocal hip flex/ext (5Reciprocal hip flex/ext (5°° left, 8left, 8°° right)right)Range (3Range (3°° to 17to 17°°))

–– LinearLinearPSIS to sacrum (4 to 8 mm)PSIS to sacrum (4 to 8 mm)

SturessonSturesson et al. (1989)et al. (1989)–– In Vivo (18In Vivo (18--45 years old, with/without back pain)45 years old, with/without back pain)–– RadiostereophotogrammetricRadiostereophotogrammetric analysisanalysis–– Angular (Angular (sagittalsagittal): Flex to Ext (2.5): Flex to Ext (2.5°° ±± 0.50.5°°), range (1.6), range (1.6°° to 3.9to 3.9°°))–– Translation: 0.7 mm (0.1Translation: 0.7 mm (0.1--1.6mm)1.6mm)

SturessonSturesson et al. (2000)et al. (2000)–– In Vivo (28In Vivo (28--35 35 yrs.oldyrs.old, 6 women with pelvic pain after pregnancy), 6 women with pelvic pain after pregnancy)–– RadiostereophotogrammetricRadiostereophotogrammetric analysis, standing in straddle positionanalysis, standing in straddle position–– Angular movement of Angular movement of innominatesinnominates: 1.9: 1.9°°, range (1.3, range (1.3°° to 2.4to 2.4°°))

GilletGillet’’ss TestTest

ValidityValidity–– DreyfussDreyfuss et al. (1994)et al. (1994)

16% false positives (4.2% males, 26.4% females)16% false positives (4.2% males, 26.4% females)Test positive in asymptomatic subjects (20%)Test positive in asymptomatic subjects (20%)

–– DreyfussDreyfuss et al. (1996)et al. (1996)Sensitivity (0.43), Specificity (0.68), LR (1.3)Sensitivity (0.43), Specificity (0.68), LR (1.3)

–– SturessonSturesson (1998)(1998)Invalid, equal movement both sidesInvalid, equal movement both sidesInvasive Invasive radiostereometricradiostereometric testingtesting

–– Hungerford & Hungerford & GilleardGilleard (1998)(1998)Valid, 7.01 degrees of posterior rotationValid, 7.01 degrees of posterior rotationVideo kinematicsVideo kinematics

–– Hungerford et al. (2003)Hungerford et al. (2003)Delayed onset of OI, Delayed onset of OI, MultifidusMultifidus & Glut Max in stance leg in & Glut Max in stance leg in SIJP patients versus controlsSIJP patients versus controlsEarly onset of biceps Early onset of biceps femorisfemoris


ReliabilityReliability–– IntraIntra--examinerexaminer

MeijneMeijne et al. (1999)et al. (1999)–– Kappa = Kappa = --0.005 to 0.0730.005 to 0.073

Carmichael (1987)Carmichael (1987)–– Kappa = 0.02 (85.3% agreement)Kappa = 0.02 (85.3% agreement)

Herzog et al. (1989)Herzog et al. (1989)–– 68% positive finding, 79% negative finding, 68% positive finding, 79% negative finding,

72% positive on correct side (p<0.01)72% positive on correct side (p<0.01)


ReliabilityReliability–– InterInter--examinerexaminer

Flynn et al. (2002)Flynn et al. (2002)–– Kappa = 0.59Kappa = 0.59

MeijneMeijne et al. (1999)et al. (1999)–– Kappa = Kappa = --0.032 to 0.0810.032 to 0.081

DreyfussDreyfuss et al. (1996)et al. (1996)–– Kappa = 0.22 (54% agreement)Kappa = 0.22 (54% agreement)

Carmichael (1987)Carmichael (1987)–– Kappa = 0.18 (89.2% agreement)Kappa = 0.18 (89.2% agreement)

Herzog et al. (1989) Herzog et al. (1989) –– 65% positive finding, 61% correct side (P<0.01)65% positive finding, 61% correct side (P<0.01)

Potter & Rothstein (1985)Potter & Rothstein (1985)–– 47% agreement47% agreement

Standing Flexion TestStanding Flexion Test

ValidityValidity-- ColachisColachis et al. (1963)et al. (1963)

-- Symptomatic malesSymptomatic males-- Radiographs with Radiographs with KirschnerKirschner wires in wires in PSISsPSISs-- Superior movement of Superior movement of PSISsPSISs with forward flexionwith forward flexion

–– DreyfussDreyfuss et al. (1994)et al. (1994)101 asymptomatic subjects101 asymptomatic subjects13% false positives (10.4% in males, 17% in females)13% false positives (10.4% in males, 17% in females)

–– Egan et al. (1996)Egan et al. (1996)128 asymptomatic subjects with or without history of 128 asymptomatic subjects with or without history of LBPLBP24% false positive 24% false positive Positive test correlated with taller, heavier, male and Positive test correlated with taller, heavier, male and asymmetric subjects. Also those with history of PBPasymmetric subjects. Also those with history of PBP


ReliabilityReliability–– IntraIntra--examinerexaminer

VincentVincent--Smith & Gibbons (1999)Smith & Gibbons (1999)–– Kappa = 0.46 (68% agreement)Kappa = 0.46 (68% agreement)

–– InterInter--examinerexaminerFlynn et al. (2002)Flynn et al. (2002)

–– Kappa = Kappa = --0.080.08Riddle et al. (2002)Riddle et al. (2002)

–– Kappa = 0.32Kappa = 0.32VincentVincent--Smith & Gibbons (1999)Smith & Gibbons (1999)

–– Kappa = 0.052 (42% agreement)Kappa = 0.052 (42% agreement)Van Van derder WurffWurff et al.(1996)et al.(1996)

–– Kappa = 0.29 (74% agreement) Kappa = 0.29 (74% agreement) Potter & Rothstein (1985)Potter & Rothstein (1985)

–– 44% agreement44% agreement


LimitationsLimitations–– Positive test may only indicate nonPositive test may only indicate non--

specific change in specific change in lumbolumbo--pelvicpelvic--hip hip mechanicsmechanics

–– False positives False positives Unilateral restriction of motion at hipUnilateral restriction of motion at hipUnilateral restriction of low lumbar jointsUnilateral restriction of low lumbar jointsUnilateral tightness of Unilateral tightness of myofasciamyofasciaLeg length inequalityLeg length inequality

Seated Flexion TestSeated Flexion Test

ValidityValidity–– DreyfussDreyfuss et al. (1994)et al. (1994)

8% false positives (8.3% males, 7.5% females)8% false positives (8.3% males, 7.5% females)

Reliability (InterReliability (Inter--examiner)examiner)–– Albert et al. (2000)Albert et al. (2000)

Kappa = >0 (88% agreement)Kappa = >0 (88% agreement)

–– Flynn et al. (2002)Flynn et al. (2002)Kappa = 0.25Kappa = 0.25

–– Potter & Rothstein (1985)Potter & Rothstein (1985)50% agreement50% agreement

Diagnosis Diagnosis –– Pain Pain ProvocationProvocation

Gold Standard Gold Standard –– Injection with local anesthetic (single)Injection with local anesthetic (single)

FalseFalse--positive rate in facet joints of 38%positive rate in facet joints of 38%

–– Double blocks advocated in pain literature Double blocks advocated in pain literature

Problems with gold standardProblems with gold standard–– Only investigates intraOnly investigates intra--articulararticular pain sourcespain sources–– May not affect all parts of joint capsuleMay not affect all parts of joint capsule–– Needle passage through structures may increase Needle passage through structures may increase

painpain–– VAS cutVAS cut--off selectionoff selection

Should be as close to 100 as possibleShould be as close to 100 as possible

Thigh ThrustThigh Thrust

ValidityValidity–– LaslettLaslett et al. (2005)et al. (2005)

Sensitivity (0.88), Specificity (0.69), PPV (0.58), NPV Sensitivity (0.88), Specificity (0.69), PPV (0.58), NPV (0.92), LR+ (2.80), LR(0.92), LR+ (2.80), LR-- (0.18)(0.18)

–– OstgaardOstgaard et al. (1994) et al. (1994) Sensitivity (0.80), Specificity (0.81), PPV (0.71), NPV Sensitivity (0.80), Specificity (0.81), PPV (0.71), NPV (0.88), LR+ (4.07), LR(0.88), LR+ (4.07), LR-- (0.23)(0.23)

–– DreyfussDreyfuss et al. (1996)et al. (1996)Sensitivity (0.36), Specificity (0.50), LR+ (0.8)Sensitivity (0.36), Specificity (0.50), LR+ (0.8)

–– BroadhurstBroadhurst & Bond (1998)& Bond (1998)Sensitivity (0.80), Specificity (1.00)Sensitivity (0.80), Specificity (1.00)

Thigh ThrustThigh Thrust




LaslettLaslett & Williams (1994)& Williams (1994)–– Kappa = 0.88 (94% agreement)Kappa = 0.88 (94% agreement)

KokmeyerKokmeyer et al. (2002)et al. (2002)–– Kappa = 0.69Kappa = 0.69

Albert et al. (2000)Albert et al. (2000)–– Kappa = 0.70Kappa = 0.70

GaenslenGaenslen’’ss TestTest



LaslettLaslett & Williams (1994)& Williams (1994)–– Kappa = 0.72Kappa = 0.72--0.75 (88% agreement)0.75 (88% agreement)

KokmeyerKokmeyer et al. (2002)et al. (2002)–– Kappa = 0.58Kappa = 0.58


Motion/Pain ProvocationMotion/Pain Provocation

Potter & Rothstein (1985)Potter & Rothstein (1985)–– Percentage agreementPercentage agreement

GilletGillet (47%), seated flexion (50%), standing (47%), seated flexion (50%), standing flexion (44%), prone knee flexion (24%), flexion (44%), prone knee flexion (24%), supine gapping (94%), supine gapping (94%), sidelyingsidelying compression compression (76%), supine long sit (40%)(76%), supine long sit (40%)

Motion/Provocation/Motion/Provocation/PalpationPalpation

DreyfussDreyfuss et al. (1996)et al. (1996)Reference standard Reference standard –– Single injection with fluoroscopy, 90% reduction in painSingle injection with fluoroscopy, 90% reduction in pain

MethodMethod–– Tests picked by a panel of experts from various professionsTests picked by a panel of experts from various professions–– 85 patients, 2 examiners (MD, Chiropractor)85 patients, 2 examiners (MD, Chiropractor)

ResultsResults–– InterInter--examiner reliabilityexaminer reliability

GilletGillet (0.22), sacral spring (0.15), sacral (0.22), sacral spring (0.15), sacral sulcussulcus tenderness (0.41), and tenderness (0.41), and sacral thrust (0.30) sacral thrust (0.30) Groin pain (0.70), buttock pain (0.71), SI joint pain (0.67), Groin pain (0.70), buttock pain (0.71), SI joint pain (0.67), GaenslenGaenslen’’sstest (0.61), thigh thrust (0.64), Patricktest (0.61), thigh thrust (0.64), Patrick’’s (0.62), PSIS pointing (0.60)s (0.62), PSIS pointing (0.60)

–– ValidityValidityGilletGillet, thigh thrust, Patrick, thigh thrust, Patrick’’s test, s test, GaenslenGaenslen’’ss, sacral thrust (LR 0.1, sacral thrust (LR 0.1--1.3)1.3)

–– No component of history, physical exam test or ensemble of them No component of history, physical exam test or ensemble of them identified SI joint pain (responders to block)identified SI joint pain (responders to block)

–– No pain above L5 in patients who responded to SI injection and PNo pain above L5 in patients who responded to SI injection and PSIS SIS pointing or sacral pointing or sacral sulcussulcus pointing (PPV 0.60) pointing (PPV 0.60)

Pain ProvocationPain Provocation

LaslettLaslett & Williams 1994& Williams 1994–– Five physical therapist pairsFive physical therapist pairs

Thigh thrust (0.88), 94% agreementThigh thrust (0.88), 94% agreementGaenslenGaenslen (0.72(0.72--0.75), 88% agreement 0.75), 88% agreement Compression (0.73), 88% agreement Compression (0.73), 88% agreement Distraction (0.69), 88% agreement Distraction (0.69), 88% agreement Cranial shear (0.61), 84% agreement Cranial shear (0.61), 84% agreement Sacral thrust (0.52), 78% agreement Sacral thrust (0.52), 78% agreement

Pain ProvocationPain Provocation

MaigneMaigne et al. 1996et al. 1996–– 54 patients (unilateral pain, x54 patients (unilateral pain, x--ray/CT to rule out ray/CT to rule out

low backlow back–– Double block gold standard (75% reduction)Double block gold standard (75% reduction)–– 18.5% prevalence18.5% prevalence–– No significant correlation between double block No significant correlation between double block

response and SI joint pain provocation testsresponse and SI joint pain provocation testsDistraction, compression, Distraction, compression, GaenslenGaenslen, Patrick, resisted , Patrick, resisted hip external rotation, sacral thrusthip external rotation, sacral thrust19/54 decreased 75% with initial block19/54 decreased 75% with initial block10/19 decreased 75% with confirmatory block10/19 decreased 75% with confirmatory block


Albert et al. (2000)Albert et al. (2000)–– Two physical therapists, 34 pregnant Two physical therapists, 34 pregnant

women, 8 symptomaticwomen, 8 symptomatic–– InterInter--examiner reliability (kappa)examiner reliability (kappa)

MenellMenell’’ss (0.87), separation (0.84), (0.87), separation (0.84), compression (0.84), thigh thrust (0.70), compression (0.84), thigh thrust (0.70), PatrickPatrick’’s (0.54), pelvic topography (0.55), s (0.54), pelvic topography (0.55), palpation of long dorsal ligament (0.34), palpation of long dorsal ligament (0.34), PiedalluPiedallu’’ss test (>0)test (>0)


Flynn et al. 2002 Flynn et al. 2002 –– (55 patients, 2 physical therapist examiners)(55 patients, 2 physical therapist examiners)

Provocation tests (kappa)Provocation tests (kappa)–– Posterior shear (0.70), sacral Posterior shear (0.70), sacral sulcussulcus test (0.64), Patrick test (0.64), Patrick

test (0.60), test (0.60), GaenslenGaenslen (0.54), resisted hip abduction (0.41), (0.54), resisted hip abduction (0.41), sacral thrust (0.41), compressionsacral thrust (0.41), compression--distraction (0.26)distraction (0.26)

Motion tests (kappa)Motion tests (kappa)–– GilletGillet (0.59), seated flexion (0.25), long(0.59), seated flexion (0.25), long--sitting (0.21), sitting (0.21),

prone knee bend (0.21), standing flexion (prone knee bend (0.21), standing flexion (--0.08)0.08)

Symmetry tests (kappa)Symmetry tests (kappa)–– ASIS in standing (0.31), Iliac crests in standing (0.23), ASIS in standing (0.31), Iliac crests in standing (0.23),

PSIS in sitting (0.23), PSIS in standing (0.13), PSIS in sitting (0.23), PSIS in standing (0.13), ischialischialtuberositytuberosity in prone (0.03), pubic tubercle in supine (in prone (0.03), pubic tubercle in supine (--0.04)0.04)

YesYes.83.83.41.41Bemis (23)Bemis (23)Long sitting Long sitting

NoNo.68.68.43.43DreyfussDreyfuss (58)(58)GilletGillet’’ss

YesYes1.001.00.77.77BroadhurstBroadhurst (50)(50)Resisted Resisted abductionabduction

No No YesYes

.16.161.001.00

.69.69

.77.77DreyfussDreyfuss (58)(58)BroadhurstBroadhurst (50)(50)

PatrickPatrick’’s signs sign

YesYesNoNoYesYes

.81.81

.50.501.001.00

.80.80

.36.36

.80.80

ÖÖstgaardstgaard (64)(64)DreyfussDreyfuss (58)(58)BroadhurstBroadhurst (50)(50)

Thigh thrustThigh thrust

NoNoYesYesNoNo

.29.291.001.00.90.90

.53.53

.27.27

.03.03

DreyfussDreyfuss (58)(58)Blower (45)Blower (45)Russell (39)Russell (39)

Sacral thrustSacral thrust

NoNoNoNo

.26.26

.72.72.71.71.21.21

DreyfussDreyfuss (58)(58)Russell (39)Russell (39)

GaenslenGaenslen

YesYesNoNo

1.001.00.90.90

.00.00

.07.07Blower (45)Blower (45)Russell (39)Russell (39)

CompressionCompression

YesYesNoNo

1.001.00.90.90

.21.21

.11.11Blower (45)Blower (45)Russell (39)Russell (39)

DistractionDistraction

ValidValidSpecificitySpecificitySensitivitySensitivityAuthor (Method Author (Method score)score)

TestTest

van der Wurff et al. 2000

Composite TestsComposite Tests

CibulkaCibulka et al. (1998)et al. (1998)–– Standing flexion test, PSIS levels in sitting, Standing flexion test, PSIS levels in sitting,

supine/long sit test, prone knee flexion testsupine/long sit test, prone knee flexion testIntraIntra--examiner reliability: Kappa = 0.86examiner reliability: Kappa = 0.86InterInter--examiner reliability: Kappa = 0.88 (examiner reliability: Kappa = 0.88 (CibulkaCibulka, , 1988)1988)

–– Hip internal and external rotationHip internal and external rotationICC (1,3) = 0.97 (IR) and 0.98 (ER) ICC (1,3) = 0.97 (IR) and 0.98 (ER)

–– Hip external rotation ROM greater than internal Hip external rotation ROM greater than internal rotation on side of posterior rotation on side of posterior innominateinnominate rotation rotation in patients with SI joint regional painin patients with SI joint regional pain


CibulkaCibulka et al. (1999)et al. (1999)TestsTests–– Standing flexion test, PSIS levels in sitting, Standing flexion test, PSIS levels in sitting,

supine/long sit test, prone knee flexion testsupine/long sit test, prone knee flexion test–– Reliability (previous studies)Reliability (previous studies)

IntraIntra--examiner reliability: Kappa = 0.86 (1998)examiner reliability: Kappa = 0.86 (1998)InterInter--examiner reliability: Kappa = 0.88 (1988)examiner reliability: Kappa = 0.88 (1988)

Composite scoreComposite score–– 3 of 4 tests positive3 of 4 tests positive

Sensitivity 0.82, Specificity 0.88Sensitivity 0.82, Specificity 0.88LR 6.83LR 6.83PPV 0.86, NPV 0.84PPV 0.86, NPV 0.84


Riddle et al. (2002)Riddle et al. (2002)65 patients, 34 therapists65 patients, 34 therapistsInterInter--examiner reliability (kappa)examiner reliability (kappa)–– Standing flexion test (0.32)Standing flexion test (0.32)–– Prone knee flexion (0.26)Prone knee flexion (0.26)–– Supine long sit test (0.19)Supine long sit test (0.19)–– Sitting PSIS levels (0.37)Sitting PSIS levels (0.37)Composite testing reliabilityComposite testing reliability–– Kappa = 0.11Kappa = 0.11--0.230.23


KokmeyerKokmeyer et al. 2002et al. 2002–– 2 final year PT students, 78 subjects, 59 2 final year PT students, 78 subjects, 59

symptomaticsymptomatic–– 5 SIJ tests (Distraction, compression, 5 SIJ tests (Distraction, compression,

GaenslenGaenslen, Patrick, thigh thrust), Patrick, thigh thrust)Individual tests (kappa): Distraction (0.46), Individual tests (kappa): Distraction (0.46), compression (0.58), compression (0.58), GaenslenGaenslen (0.58), Patrick (0.58), Patrick (0.62), thigh thrust (0.69)(0.62), thigh thrust (0.69)Composite tests (kappa): 3/5 (0.70), 1/5 Composite tests (kappa): 3/5 (0.70), 1/5 (0.63), 2/5 (0.74), 4/5 (0.71), 5/5 (0.66)(0.63), 2/5 (0.74), 4/5 (0.71), 5/5 (0.66)

Pain Provocation: Pain Provocation: Composite TestsComposite Tests

LaslettLaslett et al. 2003et al. 2003–– Double block gold standard (80% Double block gold standard (80%

reduction)reduction)–– 3 or more SI tests positive 3 or more SI tests positive

Distraction, compression, thigh thrust, Distraction, compression, thigh thrust, GaenslenGaenslen’’ss, sacral thrust, sacral thrustWith centralizers inWith centralizers in

–– Sensitivity 0.91, Specificity 0.78Sensitivity 0.91, Specificity 0.78–– LR+ = 4.16 (95% CI, 2.16 to 8.39), LRLR+ = 4.16 (95% CI, 2.16 to 8.39), LR-- = 0.12= 0.12

With centralizers removedWith centralizers removed–– Sensitivity 0.91, Specificity 0.87Sensitivity 0.91, Specificity 0.87–– LR+ = 6.97 (95% CI, 2.70 to 20.27), LRLR+ = 6.97 (95% CI, 2.70 to 20.27), LR-- = 0.11= 0.11

Pain Provocation: Pain Provocation: Composite Tests Composite Tests

LaslettLaslett et al. 2005et al. 2005–– 3 or more positive tests3 or more positive tests

Distraction, compression thigh thrust, sacral thrust, Distraction, compression thigh thrust, sacral thrust, GaenslenGaenslen

–– Sensitivity = 0.94, Specificity = 0.78Sensitivity = 0.94, Specificity = 0.78–– LR+ = 4.29, LRLR+ = 4.29, LR-- = 0.80= 0.80–– AUC = 0.842AUC = 0.842

–– 2 of 4 tests positive2 of 4 tests positiveDistraction, thigh thrust, compression, sacral thrustDistraction, thigh thrust, compression, sacral thrust

–– Sensitivity 0.88, Specificity 0.78Sensitivity 0.88, Specificity 0.78–– LR+ = 4.00 (95% CI, 2.13 to 8.08), LRLR+ = 4.00 (95% CI, 2.13 to 8.08), LR-- = 0.10= 0.10–– AUC = 0.819AUC = 0.819

Pain Provocation: Pain Provocation: Composite TestsComposite Tests

LaslettLaslett et al. (2005)et al. (2005)–– Individual testsIndividual tests

Distraction: Sensitivity (0.60), Specificity (0.81)Distraction: Sensitivity (0.60), Specificity (0.81)Compression: Sensitivity (0.69), Specificity (0.69)Compression: Sensitivity (0.69), Specificity (0.69)Thigh thrust: Sensitivity (0.88), Specificity (0.69)Thigh thrust: Sensitivity (0.88), Specificity (0.69)GaenslenGaenslen: Sensitivity (0.50: Sensitivity (0.50--0.53), Specificity (0.710.53), Specificity (0.71--0.77)0.77)Sacral thrust: Sensitivity (0.63), Specificity (0.75)Sacral thrust: Sensitivity (0.63), Specificity (0.75)

–– Optimal rule for use in diagnosisOptimal rule for use in diagnosisDistraction and thigh thrust most sensitive and specificDistraction and thigh thrust most sensitive and specificOrder of performanceOrder of performance

–– Distraction, thigh thrust, compression, sacral thrustDistraction, thigh thrust, compression, sacral thrust–– Stop when two positiveStop when two positive

Systematic ReviewsSystematic Reviews

HestboekHestboek &&LeboeufLeboeuf--YdeYde (2000)(2000)–– SI joint motion palpation tests slightly reliable SI joint motion palpation tests slightly reliable

but not shown to be validbut not shown to be valid–– Only palpation for pain has acceptable resultsOnly palpation for pain has acceptable results

French et al. (2000)French et al. (2000)–– Common clinical methods of detecting Common clinical methods of detecting

manipulablemanipulable lesion not reliablelesion not reliablevan van derder WurffWurff et al. (2000)et al. (2000)–– Mobility and pain provocation tests unreliable Mobility and pain provocation tests unreliable

except for except for GaenslenGaenslen test and thigh thrusttest and thigh thrust–– Need further research emphasizing multiple tests Need further research emphasizing multiple tests

and pain provocation testsand pain provocation tests


van van derder WurffWurff et al. (2000)et al. (2000)–– Poor methodological quality in studies of Poor methodological quality in studies of

validity of mobility and pain provocation validity of mobility and pain provocation studiesstudies

–– Only Only OstgaardOstgaard study (thigh thrust) study (thigh thrust) showed potentially acceptable showed potentially acceptable methodologymethodology

–– Questionable if any SI joint test are of Questionable if any SI joint test are of value in clinical practicevalue in clinical practice


Waters (2003)Waters (2003)–– ““Insufficient evidence to advocate the use of Insufficient evidence to advocate the use of

static palpation tests to indicate SIJ dysfunctionstatic palpation tests to indicate SIJ dysfunction””

FreburgerFreburger & Riddle (2001)& Riddle (2001)–– ““Some evidence to support use of pain Some evidence to support use of pain

provocation tests and patientprovocation tests and patient’’s pain description s pain description in the identification of dysfunction in the SI joint in the identification of dysfunction in the SI joint regionregion””

PatrickPatrick’’s, thigh thrust, compression/distraction, s, thigh thrust, compression/distraction, resisted hip abduction, sacral resisted hip abduction, sacral sulcussulcus tendernesstendernessNo lumbar pain, pain below L5, pain in region of PSIS, No lumbar pain, pain below L5, pain in region of PSIS, pain in groinpain in groin

Problems with ResearchProblems with Research

Low methodological qualityLow methodological qualityExecution of tests in nonExecution of tests in non--standard or inexperienced standard or inexperienced mannermannerMultiple tests may change musculoskeletal system Multiple tests may change musculoskeletal system and previous test may influence subsequent testsand previous test may influence subsequent testsQuestionable gold standardQuestionable gold standardUse of asymptomatic subjects can influence statistical Use of asymptomatic subjects can influence statistical measuresmeasures–– Kappa takes into account frequency of (+) and (Kappa takes into account frequency of (+) and (--), producing ), producing

higher kappa values for agreement on positive findingshigher kappa values for agreement on positive findingsUse of asymptomatic subjects make it difficult to demonstrate Use of asymptomatic subjects make it difficult to demonstrate agreement above chanceagreement above chance

–– Sensitivity difficult to demonstrate when there is Sensitivity difficult to demonstrate when there is disproportionate number of negative findingsdisproportionate number of negative findings

–– Good specificity can be showGood specificity can be show

Active Straight Leg Raise Active Straight Leg Raise TestTest

MensMens et al. (2001)et al. (2001)–– Subjects (200 PPPP, 50 healthy controls)Subjects (200 PPPP, 50 healthy controls)–– ReliabilityReliability

Patient (ICC = 0.83)Patient (ICC = 0.83)Assessor (ICC = 0.82)Assessor (ICC = 0.82)Patient to assessor (ICC = 0.77)Patient to assessor (ICC = 0.77)

–– ValidityValidityOverall (Sensitivity = 0.87, Specificity = 0.94, LR 13.3)Overall (Sensitivity = 0.87, Specificity = 0.94, LR 13.3)QBPDS score > 45 (Sensitivity = 1.00)QBPDS score > 45 (Sensitivity = 1.00)QBPDS score < 45 (Sensitivity = 0.73)QBPDS score < 45 (Sensitivity = 0.73)Thigh thrust (Sensitivity = 0.69)Thigh thrust (Sensitivity = 0.69)Correlation with thigh thrust ( 0.27)Correlation with thigh thrust ( 0.27)

Differential DiagnosisDifferential Diagnosis

Young et al. (2003)Young et al. (2003)–– 81 chronic low back pain patients81 chronic low back pain patients–– DiscogramsDiscograms, injections (single), injections (single)–– Pain generatorsPain generators

DiscogenicDiscogenic painpain–– Midline lumbar pain, pain with rising from sitting, Midline lumbar pain, pain with rising from sitting, –– Centralization (sensitivity = 0.47, specificity = 1.00)Centralization (sensitivity = 0.47, specificity = 1.00)

Sacroiliac painSacroiliac pain–– Unilateral pain below L5, pain with rising from sitting, Unilateral pain below L5, pain with rising from sitting,

3 or more pain provocation test positive3 or more pain provocation test positive–– Centralization (sensitivity = 0.09, specificity = 0.79)Centralization (sensitivity = 0.09, specificity = 0.79)

Facet joint painFacet joint pain–– Midline lumbar pain?, no pain with rising from sitting Midline lumbar pain?, no pain with rising from sitting –– Centralization (sensitivity = 0.00, specificity = 0.89)Centralization (sensitivity = 0.00, specificity = 0.89)

CentralizationCentralization

ValidityValidity–– Young et al. (2003)Young et al. (2003)

Sensitivity = 0.47, Specificity = 1.00Sensitivity = 0.47, Specificity = 1.0047% of patients with (+) 47% of patients with (+) discogramdiscogram centralizedcentralized100% of patients who centralized had (+) 100% of patients who centralized had (+) discogramdiscogram

–– DonelsonDonelson et al. (1997)et al. (1997)Sensitivity = 0.94, Specificity = 0.52Sensitivity = 0.94, Specificity = 0.5264% of patients with (+) 64% of patients with (+) discogramdiscogram centralizedcentralized74% of patients who centralized had (+) 74% of patients who centralized had (+) discogramdiscogram69% of patients who 69% of patients who peripheralizedperipheralized had (+) had (+) discogramdiscogram

CentralizationCentralization

KilpikoskiKilpikoski et al. (2002)et al. (2002)2 MDT trained therapists2 MDT trained therapistsReliabilityReliability–– CentralizationCentralization

Presence: kappa = 0.7 (95% agreement)Presence: kappa = 0.7 (95% agreement)Direction: kappa = 0.9 (90% agreement)Direction: kappa = 0.9 (90% agreement)

–– Patient classificationPatient classificationMain syndrome: kappa = 0.6 (95% agreement)Main syndrome: kappa = 0.6 (95% agreement)Specific subgroup: kappa = 0.7 (74% agreement)Specific subgroup: kappa = 0.7 (74% agreement)

Directional PreferenceDirectional Preference

Long et al. (2004)Long et al. (2004)Prospective, cohort study with 312 patients Prospective, cohort study with 312 patients Patient groupsPatient groups–– 230 (74%) had directional preference and used as subjects230 (74%) had directional preference and used as subjects–– Directional preference matched, DP opposite, evidenceDirectional preference matched, DP opposite, evidence--

based group (multibased group (multi--directional, middirectional, mid--range lumbar exercises)range lumbar exercises)

ResultsResults–– 74% of those meeting inclusion criteria had DP74% of those meeting inclusion criteria had DP–– 83% extension, 7% flexion, 10% lateral responders83% extension, 7% flexion, 10% lateral responders–– Matched group showed significantly greater improvement Matched group showed significantly greater improvement

than other two groups in all outcome measuresthan other two groups in all outcome measuresBack pain, leg pain, disability, medication, activity interferenBack pain, leg pain, disability, medication, activity interference, ce, depression inventorydepression inventory

Facet Joint PainFacet Joint Pain

Revel et al. (1992)Revel et al. (1992)Low back pain patientsLow back pain patients7 variables7 variables–– Age greater than 65Age greater than 65–– Pain not worsened with forward flexionPain not worsened with forward flexion–– Pain not worsened with rising from forward flexionPain not worsened with rising from forward flexion–– Pain well relieved by Pain well relieved by recumbencyrecumbency–– Pain not exacerbated by coughingPain not exacerbated by coughing–– Pain not worsened by extension rotation Pain not worsened by extension rotation –– Pain not worsened by hyperextensionPain not worsened by hyperextension

Responders to facet injectionResponders to facet injection–– When 5 variables presentWhen 5 variables present–– Sensitivity = 80%, Specificity = 78%Sensitivity = 80%, Specificity = 78%–– LR = 3.64LR = 3.64


Revel et al. (1998)Revel et al. (1998)80 chronic low back pain patients80 chronic low back pain patients–– 43 (+) for 5 or more variables, 37 (+) for less than 5 variables43 (+) for 5 or more variables, 37 (+) for less than 5 variables

Saline or single facet joint injection (Saline or single facet joint injection (LidocaineLidocaine))–– 75% reduction in VAS score75% reduction in VAS score

5 significant predictors of (+) response to 5 significant predictors of (+) response to LidocaineLidocaine–– 100% of responders, 66% of non100% of responders, 66% of non--respondersresponders–– Pain not worsened with rising from forward flexionPain not worsened with rising from forward flexion–– Pain well relieved by Pain well relieved by recumbencyrecumbency–– Pain not exacerbated by coughingPain not exacerbated by coughing–– Pain not worsened by extension rotation Pain not worsened by extension rotation –– Pain not worsened by hyperextensionPain not worsened by hyperextension–– (Age over 65, pain not worsened with forward flexion)(Age over 65, pain not worsened with forward flexion)

5 variables with pain relieved with 5 variables with pain relieved with recumbencyrecumbency includedincluded–– 92% of responders, 80% of non92% of responders, 80% of non--respondersresponders


LaslettLaslett et al. (2004)et al. (2004)116 patients116 patientsRevelRevel’’s criterias criteriaDouble injection with 75% pain reductionDouble injection with 75% pain reduction–– SenSen (0.11), Spec (0.91), LR+ (1.2) (0.11), Spec (0.91), LR+ (1.2) –– PPV (0.273), NPV (0.771)PPV (0.273), NPV (0.771)

Potentially helpful criteriaPotentially helpful criteria–– No increase in pain rising from flexionNo increase in pain rising from flexion–– No pain with cough & sneezeNo pain with cough & sneeze–– Age over 65Age over 65

Differential DiagnosisDifferential Diagnosis

LaslettLaslett et al. (2005)et al. (2005)216 Chronic LBP patients216 Chronic LBP patientsClinical diagnosis vs. reference standardClinical diagnosis vs. reference standard–– 67% received 67% received pathoanatomicpathoanatomic diagnosisdiagnosis–– 10% had more than one tissue involved10% had more than one tissue involved–– DiagnosisDiagnosis

Exact match 32%, partial match 51%, chance 13%Exact match 32%, partial match 51%, chance 13%

–– Patient categorizationPatient categorizationDisc, facet, SI, hip, nerve root, spinal Disc, facet, SI, hip, nerve root, spinal stenosisstenosisPT vs. radiologist: 56% agreement, chance 33%, PT vs. radiologist: 56% agreement, chance 33%, kappa = 0.31kappa = 0.31

Diagnostic CategoriesDiagnostic Categories

DiscDisc–– Centralization, Centralization, peripheralisationperipheralisation, directional preference with , directional preference with

repeated endrepeated end--range movementsrange movements–– Lumbar pain in exact midlineLumbar pain in exact midline

FacetFacet–– RevelRevel’’s criteria and no centralizations criteria and no centralization

SISI–– 3 or more (+) pain provocation tests with no centralization3 or more (+) pain provocation tests with no centralization

Nerve rootNerve root–– Referred pain with nerve tension testsReferred pain with nerve tension tests

Spinal Spinal stenosisstenosis–– IntermitentIntermitent claudicationclaudication relieved by sitting or flexed posturesrelieved by sitting or flexed postures

HipHip–– Movements of hip provoked pain more than lumbar or SI testsMovements of hip provoked pain more than lumbar or SI tests

Laslett et al. 2005

ManipulationManipulation

TullbergTullberg et al.(1998)et al.(1998)–– RadiostereophotogrammetricRadiostereophotogrammetric analysisanalysis–– No change in sacrum/No change in sacrum/iliumilium alignment after alignment after

manipulationmanipulation–– Positive clinical tests prior became negative afterPositive clinical tests prior became negative after–– ? soft tissue/neuromuscular reflex ? soft tissue/neuromuscular reflex

Herzog et al. (1999)Herzog et al. (1999)–– SI joint manipulation produced immediate increase SI joint manipulation produced immediate increase

in EMG activity in in EMG activity in glutealsgluteals, erector , erector spinaespinae, , latissimuslatissimus dorsidorsi, , trapeziustrapezius deltoid and deltoid and spleniusspleniusmusclesmuscles

–– NeurologicNeurologic effect rather than biomechanical effecteffect rather than biomechanical effect

ManipulationManipulation

PivaPiva et al. 2003et al. 2003–– Iliac crest level measurement deviceIliac crest level measurement device–– ICC (1,1) for standing 0.80 (95% CI = 0.7ICC (1,1) for standing 0.80 (95% CI = 0.7--0.9) 0.9)

and for seated 0.73 (95% CI = 0.6and for seated 0.73 (95% CI = 0.6--0.8) with 0.8) with SEM 0.91 and 0.86 degrees, respectivelySEM 0.91 and 0.86 degrees, respectively

Childs et al. 2003Childs et al. 2003–– SI manipulationSI manipulation–– Improved IC and WB symmetry after Improved IC and WB symmetry after

manipulationmanipulation–– Decreased pain and improved function 3Decreased pain and improved function 3--4 days 4 days

after studyafter study–– Results due to neuromuscular system effectsResults due to neuromuscular system effects

Muscle Energy TechniqueMuscle Energy Technique

LenehanLenehan et al. (2003)et al. (2003)–– Increased trunk rotation ROM in asymptomatic Increased trunk rotation ROM in asymptomatic

but restricted subjectsbut restricted subjects10.6610.66°° improvement on restricted side (1.09 effect improvement on restricted side (1.09 effect size)size)

Schenk et al. (1997)Schenk et al. (1997)–– Increased lumbar extension ROM in Increased lumbar extension ROM in

asymptomatic but restricted subjectsasymptomatic but restricted subjects77°° improvement in restricted subjectsimprovement in restricted subjects

Schenk et al. (1994)Schenk et al. (1994)–– Increase cervical rotation ROM but not flexion, Increase cervical rotation ROM but not flexion,

extension or extension or sidebendingsidebending in asymptomatic but in asymptomatic but restricted subjectsrestricted subjects

77--88°° ROT, 5ROT, 5--88°° SB, 2SB, 2°° F, 2F, 2°° EE

Muscle Energy in LBPMuscle Energy in LBP

Wilson et al. (2003)Wilson et al. (2003)Pilot study (8 men, 8 women)Pilot study (8 men, 8 women)–– All had lumbar ERS dysfunctionAll had lumbar ERS dysfunction

GroupsGroups–– Neuromuscular reNeuromuscular re--ed and strength training (Control)ed and strength training (Control)–– Neuromuscular reNeuromuscular re--ed and strength plus METed and strength plus MET

ResultsResults–– 83% reduction in 83% reduction in OwestryOwestry in MET group (mean score 7%)in MET group (mean score 7%)–– 65% reduction in 65% reduction in OwestryOwestry in control group (mean score in control group (mean score

15%)15%)–– 38 point drop in 38 point drop in OwestryOwestry, 6 considered clinically significant, 6 considered clinically significant–– Average of 3 MET treatments in MET groupAverage of 3 MET treatments in MET group–– Patients can return to prePatients can return to pre--injury occupation with injury occupation with OwestryOwestry

scores as high as 10scores as high as 10--12%12%

Clinical Prediction RuleClinical Prediction Rule

Flynn et al. (2002)Flynn et al. (2002)Prospective, cohort study of 71 LBP patientsProspective, cohort study of 71 LBP patientsReference standard Reference standard –– 50% improvement in 50% improvement in OwestryOwestry over a 2over a 2--4 day 4 day

periodperiod

Identified 5 variables Identified 5 variables –– Duration of symptoms < 16 daysDuration of symptoms < 16 days–– At least one hip with >35At least one hip with >35°° of internal rotationof internal rotation–– Lumbar Lumbar hypomobilityhypomobility–– FABQ work score <19FABQ work score <19–– No symptoms distal to the kneeNo symptoms distal to the knee


If 4 of 5 variables present, there is a 95% If 4 of 5 variables present, there is a 95% chance of decreasing chance of decreasing OwestryOwestry score by score by 50% over a 250% over a 2--4 day period by 4 day period by manipulating the manipulating the lumbopelviclumbopelvic region with region with a technique reported to effect the SI a technique reported to effect the SI joints joints CPRCPR–– Sensitivity 0.63, Specificity 0.97, PLR 24.38Sensitivity 0.63, Specificity 0.97, PLR 24.38–– Probability of success with manipulation 95%Probability of success with manipulation 95%–– PrePre--test probability of success 45%test probability of success 45%


Individual variablesIndividual variables–– Duration of symptoms <16 daysDuration of symptoms <16 days

Sensitivity 0.56, Specificity 0.87, PLR 4.39Sensitivity 0.56, Specificity 0.87, PLR 4.39

–– FABQ Work score <19FABQ Work score <19Sensitivity 0.84, Specificity 0.49, PLR 1.65Sensitivity 0.84, Specificity 0.49, PLR 1.65

–– Symptoms not distal to kneeSymptoms not distal to kneeSensitivity 0.88, Specificity 0.36, PLR 1.36Sensitivity 0.88, Specificity 0.36, PLR 1.36

–– At least one hip IR > 35At least one hip IR > 35°°Sensitivity 0.50, Specificity 0.85, PLR 3.25Sensitivity 0.50, Specificity 0.85, PLR 3.25

–– HypomobilityHypomobility at one or more lumbar levelsat one or more lumbar levelsSensitivity 0.97, Specificity 0.23, PLR 1.26Sensitivity 0.97, Specificity 0.23, PLR 1.26


Childs et al. (2004)Childs et al. (2004)PEDroPEDro score = 8/10score = 8/10Groups (131 consecutive patients)Groups (131 consecutive patients)–– Manipulation vs. stabilization exerciseManipulation vs. stabilization exercise–– Positive on CPR, negative on CPRPositive on CPR, negative on CPR

ResultsResults–– Manipulation + CPR (+) showed greater improvement in Manipulation + CPR (+) showed greater improvement in

1wk, 4 wk and 6 mo disability than:1wk, 4 wk and 6 mo disability than:Manipulation + CPR (Manipulation + CPR (--))Exercise + CPR (+)Exercise + CPR (+)

–– No difference between exercise groupsNo difference between exercise groups–– LR+ 13.2 for success at one weekLR+ 13.2 for success at one week–– NNT for success at 1 wk = 1.3, 4 wk = 1.9NNT for success at 1 wk = 1.3, 4 wk = 1.9–– 92% chance of success (+CPR), 7% (92% chance of success (+CPR), 7% (--CPR) at 1 wkCPR) at 1 wk

Where Do We Go From Where Do We Go From Here?Here?

Patient subgroup classification Patient subgroup classification Diagnostic testsDiagnostic testsValidity and reliabilityValidity and reliabilityImproved methodologyImproved methodologyBetter reference standardsBetter reference standards–– Clinical outcomes Clinical outcomes

Outcome studiesOutcome studies–– Larger clinical trialsLarger clinical trials–– MetaMeta--analysisanalysis

Think outside the boxThink outside the box

Thank YouThank You

Evidence-based Medicine and the Sacroiliac...

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