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Association between composites of selected motion palpation and pain provocation tests for sacroiliac joint disorders
Accepted Manuscript Association between composites of selected motion palpation and pain provocation tests for sacroiliac joint disorders Manijeh Soleimanifar, PT, Ph D, Assistant Professor, Noureddin Karimi, PT, PhD, Assistant Professor, Amir Massoud Arab, PT, Ph.D, Associate Professor PII:
S1360-8592(16)30095-X
DOI:
10.1016/j.jbmt.2016.06.003
Reference:
YJBMT 1368
To appear in:
Journal of Bodywork & Movement Therapies
Received Date: 10 January 2016 Revised Date:
26 April 2016
Accepted Date: 1 June 2016
Please cite this article as: Soleimanifar, M., Karimi, N., Arab, A.M., Association between composites of selected motion palpation and pain provocation tests for sacroiliac joint disorders, Journal of Bodywork & Movement Therapies (2016), doi: 10.1016/j.jbmt.2016.06.003. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Association between composites of selected motion palpation and pain provocation tests for
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sacroiliac joint disorders Authors:
1. Manijeh Soleimanifar, PT, Ph D Assistant Professor, Biomechanic Research Center, Department of Physical Medicine and Rehabilitation, AJA University of Medical Science
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[email protected]
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2. Noureddin Karimi PT., PhD Assistant Professor, Department of Physical Therapy, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. [email protected]
Corresponding author:
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3. Amir Massoud Arab, PT., Ph.D Associate Professor, Department of Physical Therapy, University of Social Welfare and Rehabilitation Sciences [email protected]
Amir Massoud Arab, PT., Ph.D
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Associate Professor
Department of Physical Therapy
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University of Social Welfare and Rehabilitation Sciences Evin, Koodakyar Ave. Tehran, Iran. Zip Code: 1985713831 Tel:
(98) 21 22180039 (Office)
(98) 21 22358149 (Home)
Fax:
(98) 21 22180039
[email protected]
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Motion Palpation and Pain Provocation Tests of Sacroiliac Joint
Key Words:
Sacroiliac joint; Provocative test; Motion palpation test
References:
32
Tables:
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Ethic approval:
Human subjects committee at the University of Social Welfare and
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Abbreviated title:
Rehabilitation Sciences approved this study. All subjects signed an informed consent form
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before participating in the study
Conflict of interest: Financial support of student research committee at University of Social
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Welfare and Rehabilitation Sciences
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Abstract Background: The sacroiliac joint (SIJ) has been implicated as a potential source of low back
evaluate SIJ dysfunction
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and buttock pain. Several types of motion palpation and pain provocation tests are used to
Objective: The purpose of this study was to investigate the relationship between motion
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palpation and pain provocation tests in assessment of SIJ problems.
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Design: This study is Descriptive Correlation.
Methods: 50 patients between the ages of 20 and 65 participated. Four motion palpation tests (Sitting flexion, Standing flexion, Prone knee flexion, Gillet test) and three pain provocation tests (FABER, Posterior shear, Resisted abduction test) were examined. Chi-square analysis was used
of tests.
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to assess the relationship between results of the individuals and composites of these two groups
Results: No significant relationship was found between these two groups of tests.
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Conclusions: It seems that motion palpation tests assess SIJ dysfunction and provocative tests
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assessed SIJ pain which is not related to each other Key Words: Sacroiliac joint; Provocative test; Motion palpation test
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INTRODUCTION Lumbo-pelvic pain is one of the most common health-related problems that has a major impact on quality of life and on health care costs (Shearar, Colloca et al. 2005). Epidemiologic studies
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have indicated a lifetime prevalence of 70-80% in the western population (Ehrlich, Chaltaev et al. 1999). Based on clinical findings, assumptions and scientific experiments, several factors have been associated with the development of lumbo-pelvic disorder (Van der Wurff, Hagmeijer
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et al. 2000). The sacroiliac joint (SIJ) is commonly implicated as a potential source of the pain in low back, buttock and pelvic girdle pain syndromes with or without lower extremity symptoms
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(Fortin, Dwyer et al. 1994, Schwarzer, Aprill et al. 1995, Slipman, Whyte et al. 2001). Schmid (1985) reported SIJ dysfunctions in 467( 35%) subjects among 1344 cases with lumbopelvic pain (Schmid 1985). Schwarzer et al. (1995: 36) found 13% to 30% prevalence of sacroiliac joint pain detected by a combination of SIJ diagnostic blocks and pain provocation
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tests in 199 patients with lumbo-pelvic pain (Schwarzer, Aprill et al. 1995). In another study of 1293 patients, the prevalence of pain resulting from SIJ dysfunction was 22.5% (Bernard TN 1987 ).
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Considering the prevalence of SIJ disorders, it is important to assess SIJ pain and dysfunction in order to treat the problem in an appropriate way in patients with lumbo-pelvic pain attending
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physical therapy clinics (Freburger and Riddle 2001). A fundamental element of initial patient assessment is to identify a diagnosis in order to resolve the problem with the diagnosis-specific treatment. This basic principle of clinical practice is sometimes difficult for pain disorders in the lumbo-pelvic region because a definitive diagnosis often cannot be made (Hall, McIntosh et al. 2009).
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It should be considered that sacroiliac tests could be influenced by other structures in the low back, hip joint and other tissues around the SIJ (Maigne, Aivaliklis et al. 1996).Correct diagnosis is not only critical for selecting the appropriate treatment, but also in attempting to establish an
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appropriate prognosis.
A wide variety of clinical diagnostic tests are used by physical therapists to evaluate patients suspected of having problems in the SIJ region. In general SIJ tests are classified into three
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categories: (1) motion palpation tests to assess movement; (2) pain provocation tests to stress SIJ
of the SIJ (Freburger and Riddle 2001).
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structures and (3) tests designed to assess the location and relative symmetry of bony land mark
Pain and dysfunction are dissimilar concepts and should be differentiated from each other in clinical practice. It is a common and incorrect practice to confuse or treat these concepts as equivalent or synonymous. Dysfunction of the SIJ is defined as a state of relative hypo mobility
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within a portion of the joint's range of motion with subsequent altered structural (positional) relationships between the sacrum and the ilium (Meijne, van Neerbos et al. 1999, Van der Wurff, Hagmeijer et al. 2000). In clinical practice SIJ pain is not necessarily accompanied with
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sacroiliac dysfunction and dysfunctions do not essentially result in pain in the SIJ, as it is claimed that SIJ dysfunction is not necessarily symptomatic and tests for dysfunction might be
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positive in subjects with no lumbo-pelvic pain (Laslett 2008). The entity of SIJ dysfunction can be either symptomatic or asymptomatic. The reason that an SIJ dysfunction becomes painful is still not fully understood (Meijne, van Neerbos et al. 1999).Thus, in clinical assessment and scientific presentation of the clinical findings these concepts (pain, dysfunction) should be discriminated.
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Among SIJ tests, pain provocation tests attempt to assess whether or not the structure being stressed is a source of pain. However, tests for mobility or anatomical position (motion palpation tests) are commonly used to assess possible SIJ motion dysfunction. Tests for motion
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dysfunction cannot be assumed to identify a source of pain, and tests for sources of pain cannot be assumed to test for motion dysfunction. Although it is possible that these two types of SIJ tests have a correlation, there is no substantial evidence to support the relationship between
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motion palpation and pain provocation tests and this association is still unclear.
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Current evidence suggests that a single test cannot be sufficient for diagnosing SIJ pain or somatic dysfunction. It has been suggested that the use of a cluster of tests (combining the results of a number of tests) is a more acceptable clinical method to diagnose SIJ problems (Cibulka, Delitto et al. 1988, Haas 1991, Cibulka and Koldehoff 1999, Van der Wurff, Hagmeijer et al. 2000, Kokmeyer, van der Wurff et al. 2002, Riddle and Freburger 2002, Laslett, Aprill et al.
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2005, Robinson, Brox et al. 2007).
Many clinicians use a multi-test regimen (composites of SIJ tests) to assess patients attending
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physiotherapy clinics with a lumbo-pelvic problem. Different types of motion palpation and pain provocation have been reported in the literature. Magee (1997), for example, described 31 tests
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that have appeared in the literature for use on patients suspected of having SIJ dysfunction (Magee 1997). Van der Wurff et al. (2000a, b) published a systematic review article on reliability and validity studies of SIJ tests. Three pain provocation tests had acceptable sensitivities and specificities; the Patrick-FABER test, Thigh thrust or Posterior Shear test and Resistive Abduction test. These three tests were selected for use in this study especially since the articles that published these findings had fairly high methodology quality scores that validated the authors’ conclusions (Van der Wurff, Hagmeijer et al. 2000, van der Wurff, Meyne et al. 2000). 6
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Additionally, four motion tests were selected for this study because of their common utilization in physical therapy clinics: the Standing flexion test; Gillet test; Sitting flexion test; and Prone
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knee flexion test. To our knowledge, no study has been conducted to investigate the relationship between the two types of SIJ tests; motion palpation tests to assess SIJ motion dysfunction, and pain provocation
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tests to assess SIJ pain. Considering the importance of evidence based practice, the current study collectively examined the selected SIJ pain provocation and motion palpation tests and identified
MATERIALS AND METHOS Design
Subjects
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Descriptive Correlational Design
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the correlation between single and composites of the tests.
A total of 50 subjects with lumbo-pelvic pain who had been referred by physicians for outpatient
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physical therapy evaluation and intervention, participated in the study. The patient population in this study was a sample of convenience made up of subjects who were between the ages of 20-65
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(mean age = 43±10 years). All subjects signed an informed consent form approved by the human subjects committee at the University of Social Welfare and Rehabilitation Sciences before participating in the study. Patients were included in the study if their reported pain was below L5, over the posterior aspect of SIJ around posterior superior iliac spine (PSIS) and buttock with or without leg pain. The patients were excluded if they had only midline or symmetrical pain above the level of L5 or radicular pain with neurological deficits (sensory or
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motor deficit) (Laslett, Young et al. 2003, Young, Aprill et al. 2003, Laslett, Aprill et al. 2005). Subjects with a history of spinal surgery, fracture of the spine, pelvis or lower extremities, hospitalization for severe trauma or car accident, leg length difference, hip/knee dysfunctions,
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pregnancy, any systemic disease and liver and/or kidney failure were also excluded. Intervention
A physical therapist that was blinded to patient information tested the subjects. The examiner
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undertook seven clinical SIJ tests in random order. The procedure for each test was as follows: MOTION TESTS
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Gillet test:
The Gillet test assesses SIJ mobility with sensitivity 8% and specificity 93% (Levangie 1999). To perform this test, the subjects stands while the examiner sits behind the patient and palpates each of the patient's PSIS, one at a time, with one thumb on the inferior aspect of the PSIS while
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simultaneously palpating the sacrum with the other thumb staying parallel to the first thumb. The subject is then instructed to stand on one leg while pulling the opposite leg up toward the chest with hip and knee flexion. The test is then repeated on the other side and compared bilaterally.
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The test is negative when either PSIS moves posterior-inferiorly in relation to the sacrum. If the
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PSIS on the ipsilateral side of the knee flexion does not move or moves posterior-inferiorly only minimally or even paradoxically moves superiorly, it indicates a positive test (Potter and Rothstein 1985, Dreyfuss, Michaelsen et al. 1996, Meijne, van Neerbos et al. 1999, Magee 2002). A positive Gillet test indicates limited movement of the SIJ. Standing flexion test:
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The standing flexion test assesses SIJ mobility with sensitivity 17% and specificity 79% (Levangie 1999). To perform this test, the subject stands while the examiner sits behind the patient and palpates both of the patient's posterior superior iliac spines on their inferior margins.
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The examiner maintains his/her eyes level with the palpating thumbs while the subject bends forward slowly as if to touch his/her toes as far as comfortable while keeping both legs straight (knees extended).(Vincent-Smith and Gibbons 1999). The examiner assesses the symmetry of
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movement of both PSIS landmarks.
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The test is negative if both PSIS landmarks appear to move equally and symmetrically; the test is positive on the side in which the PSIS moves superiorly more than the other side. A positive result in a standing flexion test indicates limited movement of the ilium on the sacrum, and therefore limited SIJ motion on the side of the superior PSIS(Vincent-Smith and Gibbons 1999, Magee 2002).
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Sitting flexion test:
The sitting flexion test assesses SIJ mobility with sensitivity 9% and specificity 93% (Levangie
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1999).The procedure is similar to standing flexion test except that it is performed with the patient sitting on a level surface. A positive result in this test indicates limited movement of the sacrum
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on the ilium, and limited SIJ motion on the side of the superior PSIS (Potter and Rothstein 1985, Magee 2002).
Prone knee flexion test:
The prone knee flexion test assesses for SIJ mobility with sensitivity 100% and specificity 83% (Trainor and Pinnington 2011). The subject’s position is prone while the examiner holds both heels and passively flexes the knees to 90 degrees. The leg lengths are compared by examining 9
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the left and right soles of the heel in the prone and prone knees flexed position. The test is negative if no relative change in leg lengths between two positions occurred. If one leg appears shorter than the other in the prone knee extended position, apparent lengthening of the short leg
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in prone knees flexed position implies a hypothesized posterior innominate rotation (Potter and Rothstein 1985, Cibulka and Koldehoff 1999, Riddle and Freburger 2002).
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PAIN PROVOCATION TESTS Thigh thrust or posterior shear test:
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The thigh trust test assesses for SIJ as the source of pain. This test has excellent reported sensitivity( 80%), specificity( 81%) for SIJ pain (van der Wurff, Meyne et al. 2000). The subject’s position is supine. The examiner flexes the hip joint of the leg at the side of tested SIJ to approximately 90 degree of flexion and slight adduction. At this position the thigh is about
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perpendicular to the table while the knee remains relaxed. The examiner with one hand cups the sacrum and wraps the other arm and hand around the flexed knee. An axial pressure is applied in the direction of the long axis of the femur, which causes anterior to posterior shear to the tested
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SIJ. The test is considered positive when familiar pain is provoked over the posterior aspect of the symptomatic SIJ (Kokmeyer, van der Wurff et al. 2002, Laslett, Young et al. 2003, Laslett,
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Aprill et al. 2005). This procedure is repeated for the other side. Patrick-FABER test:
The Patrick-FABER test assesses for SIJ pain with sensitivity 77% and specificity 100% (van der Wurff, Meyne et al. 2000, Stuber 2007). The patient lies supine on the table. The examiner brings the ipsilateral hip into flexion, abduction and external rotation. The knee is flexed to ninety degrees on the affected side and the foot is rested on the unaffected knee. Then the 10
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examiner holds the contra lateral anterior superior iliac spine (ASIS) against the examination table, the affected-side knee is pushed towards the examination table, a maneuver which provides external rotation of the leg at the hip joint. The test is positive when familiar buttock or
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groin pain below L5 is reproduced (Maigne, Aivaliklis et al. 1996, Magee 2002, Robinson, Brox et al. 2007).
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Resisted abduction test:
The resisted abduction test assesses for SIJ pain with sensitivity 87% and specificity 100% (van
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der Wurff, Meyne et al. 2000, Stuber 2007).The subject’s position is supine with the leg fully extended as well as being abducted to 30 degree. The examiner holds the ankle and pushes medially while the subject pushes laterally. The test is positive when familiar pain is produced over the SIJ below L5 (Broadhurst and Bond 1998).
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STATISTICS
The association between single and composites of motion palpation and pain provocation tests
Results:
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was assessed by chi- square analysis. The P-value was chosen at α = 0.05.
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Fifty subjects (30 male and 20 female) between the ages of 20 and 65 with a mean age of 43±10 years participated in the study. The subjects’ mean height was 168 ± 7 cm and mean weight was 68 ± 10 kg.
Table-1 presents the descriptive statistics (frequency distribution) of the positive and negative results for each single motion palpation and provocation test taken in the study. Frequency distributions for cluster of provocation and motion palpation tests are displayed in Table 2. 11
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Table- 3 represents the results of chi-square analysis to identify the associations among the single motion landmark tests and pain provocation tests.
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The chi-square for the relationship between single tests varied from 0.02 to 2.57. No significant association was found between each single motion palpation and pain provocation test (P> 0.05). The results of the correlation between cluster of pain provocation and motion palpation tests
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discretely are accessible in Table 4. The range of chi- square for this relationship was 0.067 to 2.162. No significant association was found between each cluster of motion palpation and pain
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provocation tests (P> 0.05).
DISCUSSION
The purpose of this study was to investigate the correlation between motion palpation and pain
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provocation tests for SIJ considering the single and composites of the tests. The results derived from this study demonstrate no significant correlation between single pain provocation and motion palpation tests. Similar findings were found when the correlation was
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assessed for the composites of the two sets of SIJ tests. In general, these two groups of SIJ tests (provocation and motion palpation) have no significant
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relationship with each other. In other words, positive or negative results of single or cluster tests of each group did not correlate with the positive or negative result of other groups. Pain provocation tests attempt to identify whether or not the structure being stressed is a source of pain. Whereas tests for mobility or anatomical position may be used to assess possible changes or functional disorders i.e. joint motion dysfunction. The SI joint is not a single joint but rather a complex of fibrous (superior) and true synovial (inferior) articulations. For that reason, The SI joint is generally relatively immobile and designed for stability rather than mobility 12
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helping in transferring weight-bearing forces between lower extremities, hips and the lumbar spine through its complex biomechanics. Based on its anatomy, one may anticipate that some degree of joint play, glide or shear may indeed be felt by the trained operator probably as a subtle
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change in the quality of movement rather than gross changes in the ranges of mobility.
Tests for dysfunction cannot be assumed to identify a source of pain, and tests for sources of pain cannot be assumed to test for motion dysfunction. It is entirely possible that the two have a
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correlation, but there is good evidence that the relationship, if any, may not be causal. Examples are: a herniated disk may cause nerve root (radicular) pain. The disk is the cause not the source
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and the nerve root is the source, but not the cause of radicular pain. There are instances in which a positive MRI identifying a herniated disc is commonly but incorrectly assumed to identify the causative lesion but surgical removal may have no effect on the radicular pain. Another example is a patient with a stiff but painless knee who presents with knee and thigh pain which is referred
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from a hip problem. The knee 'dysfunction' is obvious, but the pain referred to the knee region is the reason for the patient presenting for diagnosis and treatment. Another and probably the greatest conflict and controversy regarding “sacroiliac articulations” may arise from the fact that
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many potential cases of so-called “SI pain” pointed to the region of the PSIS may be the result of lumbosacral (L5-S1) disc degeneration and/or facet osteoarthritis potentially referring into
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sacroiliac region via sclerotomal or capsular/annular mechanoreceptors and nociceptors' pain distribution pattern.
During the past decades, several studies have assessed the psychometric properties (reliability, validity) of the tests for SIJ pain and dysfunction. Motion palpation evaluation is a very subjective diagnostic step that depends primarily on the operator’s ability to palpate associated tissue changes and may notoriously be prone to major inter and/or intra-observer bias and 13
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variability. Thus it may potentially be confusing to relate some very subjective changes that perceived mainly during motion palpation of sacroiliac joint to a phenomenon of joint dysfunction that implies some degree of functional loss or abnormality in the articulation.
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Current evidence suggests that a single test might not be sufficient for diagnosing SIJ pain. It has been suggested that the use of a cluster of tests (combining the results of a number of tests) is a more acceptable clinical method to diagnose SIJ pain or dysfunction (Cibulka, Delitto et al.
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1988, Haas 1991, Freburger and Riddle 2001, Kokmeyer, van der Wurff et al. 2002, Riddle and Freburger 2002, Laslett, Aprill et al. 2005, Van Der Wurff, Buijs et al. 2006, Robinson, Brox et
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al. 2007). In this study, we attempted to select the tests with acceptable levels of validity, i.e., high sensitivity and/or specificity, as reported in the systematic methodological reviews of related articles (Broadhurst and Bond 1998, van der Wurff, Meyne et al. 2000). The result of a clinical test or clinical procedures can be influenced by several factors such as the
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participants, the therapists and the clinical tests. In former studies, some researchers have used asymptomatic subjects while others used a population of back patients when evaluating SIJ tests. In this study, LBP participants with clinical signs related to SIJ were included and patients with
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symptoms indicating another source of LBP were excluded. The data were collected considering
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how to interpret the participants’ responses to the tests. Did the participant recognize the pain (concordant), or was it another pain (discordant)? The results of the tests were recorded positive only in reproducing concordant pain on the same side as the joint being tested. The tests in this study were classified as either positive or negative. Given these findings and the fact that no similar study has been published in this field suggests that more extensive studies should be conducted with the aim of examining the relationship between pain provocation tests and motion tests, considering the concepts of pain and 14
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dysfunction separately. This line of inquiry may improve accuracy of diagnosis of patients with low back pain. This study found that neither single nor cluster tests of pain provocation and motion palpation
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tests of SIJ have significant correlation with each other. A finding obtained during this study confirms the idea that pain and dysfunction have two different etiologies. It is a common and
differentiated from each other in clinical practice.
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incorrect practice to confuse or treat these concepts as equivalent or synonymous and should be
Acknowledgement: The authors would like to thank student research committee at University of
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Social Welfare and Rehabilitation Sciences.
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Bernard TN, K.-W. W. (1987 ). "Recognizing specific characteristics of nonspecific low back pain." Clinical Orthopaedics 217(266-80). Broadhurst, N. A. and M. J. Bond (1998). "Pain provocation tests for the assessment of sacroiliac joint dysfunction." Journal of spinal disorders 11(4): 341-345. Cibulka, M. T., A. Delitto and R. M. Koldehoff (1988). "Changes in innominate tilt after manipulation of the sacroiliac joint in patients with low back pain." Physical therapy 68(9): 1359-1363. Cibulka, M. T. and R. Koldehoff (1999). "Clinical usefulness of a cluster of sacroiliac joint tests in patients with and without low back pain." Journal of Orthopaedic and Sports Physical Therapy 29: 83-89. Dreyfuss, P., M. Michaelsen, K. Pauza, J. McLarty and N. Bogduk (1996). "The value of medical history and physical examination in diagnosing sacroiliac joint pain." Spine 21(22): 2594. Ehrlich, G. E., N. G. Chaltaev and M. World Health Organization. Department of Noncommunicable Disease (1999). Low back pain initiative, World Health Organization, Department of Noncommunicable Disease Management. Fortin, J. D., A. P. Dwyer, S. West and J. Pier (1994). "Sacroiliac joint: Pain referral maps upon applying a new injection/arthrography technique: Part I: Asymptomatic volunteers." Spine 19(13): 1475. Freburger, J. K. and D. L. Riddle (2001). "Using published evidence to guide the examination of the sacroiliac joint region." Physical therapy 81(5): 1135. Haas, M. (1991). "Interexaminer reliability for multiple diagnostic test regimens." Journal of manipulative and physiological therapeutics 14(2): 95. Hall, H., G. McIntosh and C. Boyle (2009). "Effectiveness of a low back pain classification system." The Spine Journal 9(8): 648-657. Kokmeyer, D. J., P. van der Wurff, G. Aufdemkampe and T. Fickenscher (2002). "The reliability of multitest regimens with sacroiliac pain provocation tests." Journal of manipulative and physiological therapeutics 25(1): 42-48. Laslett, M. (2008). "Evidence-based diagnosis and treatment of the painful sacroiliac joint." The Journal of Manual & Manipulative Therapy 16(3): 142. Laslett, M., C. N. Aprill, B. McDonald and S. B. Young (2005). "Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests." Manual therapy 10(3): 207-218. Laslett, M., S. B. Young, C. N. Aprill and B. McDonald (2003). "Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests." Australian Journal of Physiotherapy 49(2): 89-98. Levangie, P. K. (1999). "Four clinical tests of sacroiliac joint dysfunction: the association of test results with innominate torsion among patients with and without low back pain." Physical therapy 79(11): 1043-1057. Magee, D. (1997). Orthopaedic Physical Assessment. Philadelphia, Pa: WB Saunders Co. Magee, D. (2002). Orthopedic Physical Assesment. Phildelphia. Maigne, J. Y., A. Aivaliklis and F. Pfefer (1996). "Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain." Spine 21(16): 1889. Meijne, W., K. van Neerbos, G. Aufdemkampe and P. van der Wurff (1999). "Intraexaminer and interexaminer reliability of the Gillet test." Journal of manipulative and physiological therapeutics 22(1): 4-9. Potter, N. A. and J. M. Rothstein (1985). "Intertester reliability for selected clinical tests of the sacroiliac joint." Physical therapy 65(11): 1671. Riddle, D. L. and J. K. Freburger (2002). "Evaluation of the presence of sacroiliac joint region dysfunction using a combination of tests: a multicenter intertester reliability study." Physical therapy 82(8): 772.
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Table 1. Descriptive statistics (frequency distribution) of the positive and negative results for each single motion palpation and provocation test
Frequency 12 Sitting flexion test(%) (24)
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Gillet test(%)
Frequency
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12
Standing flexion test(%)
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Tests
Negative
38
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Positive
(76) 38
(24)
(76)
8
42
(16)
(84)
18
32
(36)
(64)
22
28
(44)
(56)
16
34
(32)
(68)
13
37
(26)
(74)
Prone knee flexion test(%)
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FABER test(%)
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Posterior shear test(%)
Resisted abduction test(%)
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Table 2. Descriptive statistics (frequency distribution) of the positive and negative results for each cluster motion palpation and provocation test
Positive
Negative
Frequency
Frequency
20
30
Composites of two motion palpation tests (%)
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Tests
(60)
14
36
(28)
(72)
4
46
(8)
(92)
16
34
(32)
(68)
9
41
(18)
(82)
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Composites of three motion palpation tests (%)
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(40)
Composites of four motion palpation tests (%)
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Composites of two pain provocation tests (%)
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Composites of three pain provocation tests (%)
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Table 3. Chi-square analysis of single motion landmark tests and pain provocation tests
Tests
FABER test
Posterior shear test
Resisted abduction test Statistic
p-Value
Statistic
p-Value
Sitting flexion test
3.226
0.072
2.351
0.125
Standing flexion test
3.226
0.072
3.304
0.129
Gillet test
3.640
0.056
1.390
0.238
Prone knee flexion test
1.273
0.259
1.211
1.754
0.185
1.719
0.190
2.794
0.095
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p-Value
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Statistic
0.045
0.831
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Table 4:Chi-square analysis of cluster motion landmark tests and pain provocation tests
Composites of three pain provocation tests
Statistic
P-Value
Statistic
P-Value
Composites of two motion palpation tests
0.961
0.327
1.084
0.298
Composites of three motion palpation tests
0.121
0.728
1.443
0.230
Composites of four motion palpation tests
3.621
0.057
2.956
0.086
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Tests
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Composites of two pain provocation tests
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S1360-8592(16)30095-X
DOI:
10.1016/j.jbmt.2016.06.003
Reference:
YJBMT 1368
To appear in:
Journal of Bodywork & Movement Therapies
Received Date: 10 January 2016 Revised Date:
26 April 2016
Accepted Date: 1 June 2016
Please cite this article as: Soleimanifar, M., Karimi, N., Arab, A.M., Association between composites of selected motion palpation and pain provocation tests for sacroiliac joint disorders, Journal of Bodywork & Movement Therapies (2016), doi: 10.1016/j.jbmt.2016.06.003. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Association between composites of selected motion palpation and pain provocation tests for
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sacroiliac joint disorders Authors:
1. Manijeh Soleimanifar, PT, Ph D Assistant Professor, Biomechanic Research Center, Department of Physical Medicine and Rehabilitation, AJA University of Medical Science
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[email protected]
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2. Noureddin Karimi PT., PhD Assistant Professor, Department of Physical Therapy, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran. [email protected]
Corresponding author:
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3. Amir Massoud Arab, PT., Ph.D Associate Professor, Department of Physical Therapy, University of Social Welfare and Rehabilitation Sciences [email protected]
Amir Massoud Arab, PT., Ph.D
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Associate Professor
Department of Physical Therapy
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University of Social Welfare and Rehabilitation Sciences Evin, Koodakyar Ave. Tehran, Iran. Zip Code: 1985713831 Tel:
(98) 21 22180039 (Office)
(98) 21 22358149 (Home)
Fax:
(98) 21 22180039
[email protected]
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Motion Palpation and Pain Provocation Tests of Sacroiliac Joint
Key Words:
Sacroiliac joint; Provocative test; Motion palpation test
References:
32
Tables:
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Ethic approval:
Human subjects committee at the University of Social Welfare and
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Abbreviated title:
Rehabilitation Sciences approved this study. All subjects signed an informed consent form
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before participating in the study
Conflict of interest: Financial support of student research committee at University of Social
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Welfare and Rehabilitation Sciences
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Abstract Background: The sacroiliac joint (SIJ) has been implicated as a potential source of low back
evaluate SIJ dysfunction
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and buttock pain. Several types of motion palpation and pain provocation tests are used to
Objective: The purpose of this study was to investigate the relationship between motion
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palpation and pain provocation tests in assessment of SIJ problems.
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Design: This study is Descriptive Correlation.
Methods: 50 patients between the ages of 20 and 65 participated. Four motion palpation tests (Sitting flexion, Standing flexion, Prone knee flexion, Gillet test) and three pain provocation tests (FABER, Posterior shear, Resisted abduction test) were examined. Chi-square analysis was used
of tests.
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to assess the relationship between results of the individuals and composites of these two groups
Results: No significant relationship was found between these two groups of tests.
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Conclusions: It seems that motion palpation tests assess SIJ dysfunction and provocative tests
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assessed SIJ pain which is not related to each other Key Words: Sacroiliac joint; Provocative test; Motion palpation test
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INTRODUCTION Lumbo-pelvic pain is one of the most common health-related problems that has a major impact on quality of life and on health care costs (Shearar, Colloca et al. 2005). Epidemiologic studies
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have indicated a lifetime prevalence of 70-80% in the western population (Ehrlich, Chaltaev et al. 1999). Based on clinical findings, assumptions and scientific experiments, several factors have been associated with the development of lumbo-pelvic disorder (Van der Wurff, Hagmeijer
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et al. 2000). The sacroiliac joint (SIJ) is commonly implicated as a potential source of the pain in low back, buttock and pelvic girdle pain syndromes with or without lower extremity symptoms
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(Fortin, Dwyer et al. 1994, Schwarzer, Aprill et al. 1995, Slipman, Whyte et al. 2001). Schmid (1985) reported SIJ dysfunctions in 467( 35%) subjects among 1344 cases with lumbopelvic pain (Schmid 1985). Schwarzer et al. (1995: 36) found 13% to 30% prevalence of sacroiliac joint pain detected by a combination of SIJ diagnostic blocks and pain provocation
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tests in 199 patients with lumbo-pelvic pain (Schwarzer, Aprill et al. 1995). In another study of 1293 patients, the prevalence of pain resulting from SIJ dysfunction was 22.5% (Bernard TN 1987 ).
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Considering the prevalence of SIJ disorders, it is important to assess SIJ pain and dysfunction in order to treat the problem in an appropriate way in patients with lumbo-pelvic pain attending
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physical therapy clinics (Freburger and Riddle 2001). A fundamental element of initial patient assessment is to identify a diagnosis in order to resolve the problem with the diagnosis-specific treatment. This basic principle of clinical practice is sometimes difficult for pain disorders in the lumbo-pelvic region because a definitive diagnosis often cannot be made (Hall, McIntosh et al. 2009).
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It should be considered that sacroiliac tests could be influenced by other structures in the low back, hip joint and other tissues around the SIJ (Maigne, Aivaliklis et al. 1996).Correct diagnosis is not only critical for selecting the appropriate treatment, but also in attempting to establish an
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appropriate prognosis.
A wide variety of clinical diagnostic tests are used by physical therapists to evaluate patients suspected of having problems in the SIJ region. In general SIJ tests are classified into three
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categories: (1) motion palpation tests to assess movement; (2) pain provocation tests to stress SIJ
of the SIJ (Freburger and Riddle 2001).
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structures and (3) tests designed to assess the location and relative symmetry of bony land mark
Pain and dysfunction are dissimilar concepts and should be differentiated from each other in clinical practice. It is a common and incorrect practice to confuse or treat these concepts as equivalent or synonymous. Dysfunction of the SIJ is defined as a state of relative hypo mobility
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within a portion of the joint's range of motion with subsequent altered structural (positional) relationships between the sacrum and the ilium (Meijne, van Neerbos et al. 1999, Van der Wurff, Hagmeijer et al. 2000). In clinical practice SIJ pain is not necessarily accompanied with
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sacroiliac dysfunction and dysfunctions do not essentially result in pain in the SIJ, as it is claimed that SIJ dysfunction is not necessarily symptomatic and tests for dysfunction might be
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positive in subjects with no lumbo-pelvic pain (Laslett 2008). The entity of SIJ dysfunction can be either symptomatic or asymptomatic. The reason that an SIJ dysfunction becomes painful is still not fully understood (Meijne, van Neerbos et al. 1999).Thus, in clinical assessment and scientific presentation of the clinical findings these concepts (pain, dysfunction) should be discriminated.
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Among SIJ tests, pain provocation tests attempt to assess whether or not the structure being stressed is a source of pain. However, tests for mobility or anatomical position (motion palpation tests) are commonly used to assess possible SIJ motion dysfunction. Tests for motion
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dysfunction cannot be assumed to identify a source of pain, and tests for sources of pain cannot be assumed to test for motion dysfunction. Although it is possible that these two types of SIJ tests have a correlation, there is no substantial evidence to support the relationship between
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motion palpation and pain provocation tests and this association is still unclear.
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Current evidence suggests that a single test cannot be sufficient for diagnosing SIJ pain or somatic dysfunction. It has been suggested that the use of a cluster of tests (combining the results of a number of tests) is a more acceptable clinical method to diagnose SIJ problems (Cibulka, Delitto et al. 1988, Haas 1991, Cibulka and Koldehoff 1999, Van der Wurff, Hagmeijer et al. 2000, Kokmeyer, van der Wurff et al. 2002, Riddle and Freburger 2002, Laslett, Aprill et al.
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2005, Robinson, Brox et al. 2007).
Many clinicians use a multi-test regimen (composites of SIJ tests) to assess patients attending
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physiotherapy clinics with a lumbo-pelvic problem. Different types of motion palpation and pain provocation have been reported in the literature. Magee (1997), for example, described 31 tests
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that have appeared in the literature for use on patients suspected of having SIJ dysfunction (Magee 1997). Van der Wurff et al. (2000a, b) published a systematic review article on reliability and validity studies of SIJ tests. Three pain provocation tests had acceptable sensitivities and specificities; the Patrick-FABER test, Thigh thrust or Posterior Shear test and Resistive Abduction test. These three tests were selected for use in this study especially since the articles that published these findings had fairly high methodology quality scores that validated the authors’ conclusions (Van der Wurff, Hagmeijer et al. 2000, van der Wurff, Meyne et al. 2000). 6
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Additionally, four motion tests were selected for this study because of their common utilization in physical therapy clinics: the Standing flexion test; Gillet test; Sitting flexion test; and Prone
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knee flexion test. To our knowledge, no study has been conducted to investigate the relationship between the two types of SIJ tests; motion palpation tests to assess SIJ motion dysfunction, and pain provocation
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tests to assess SIJ pain. Considering the importance of evidence based practice, the current study collectively examined the selected SIJ pain provocation and motion palpation tests and identified
MATERIALS AND METHOS Design
Subjects
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Descriptive Correlational Design
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the correlation between single and composites of the tests.
A total of 50 subjects with lumbo-pelvic pain who had been referred by physicians for outpatient
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physical therapy evaluation and intervention, participated in the study. The patient population in this study was a sample of convenience made up of subjects who were between the ages of 20-65
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(mean age = 43±10 years). All subjects signed an informed consent form approved by the human subjects committee at the University of Social Welfare and Rehabilitation Sciences before participating in the study. Patients were included in the study if their reported pain was below L5, over the posterior aspect of SIJ around posterior superior iliac spine (PSIS) and buttock with or without leg pain. The patients were excluded if they had only midline or symmetrical pain above the level of L5 or radicular pain with neurological deficits (sensory or
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motor deficit) (Laslett, Young et al. 2003, Young, Aprill et al. 2003, Laslett, Aprill et al. 2005). Subjects with a history of spinal surgery, fracture of the spine, pelvis or lower extremities, hospitalization for severe trauma or car accident, leg length difference, hip/knee dysfunctions,
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pregnancy, any systemic disease and liver and/or kidney failure were also excluded. Intervention
A physical therapist that was blinded to patient information tested the subjects. The examiner
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undertook seven clinical SIJ tests in random order. The procedure for each test was as follows: MOTION TESTS
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Gillet test:
The Gillet test assesses SIJ mobility with sensitivity 8% and specificity 93% (Levangie 1999). To perform this test, the subjects stands while the examiner sits behind the patient and palpates each of the patient's PSIS, one at a time, with one thumb on the inferior aspect of the PSIS while
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simultaneously palpating the sacrum with the other thumb staying parallel to the first thumb. The subject is then instructed to stand on one leg while pulling the opposite leg up toward the chest with hip and knee flexion. The test is then repeated on the other side and compared bilaterally.
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The test is negative when either PSIS moves posterior-inferiorly in relation to the sacrum. If the
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PSIS on the ipsilateral side of the knee flexion does not move or moves posterior-inferiorly only minimally or even paradoxically moves superiorly, it indicates a positive test (Potter and Rothstein 1985, Dreyfuss, Michaelsen et al. 1996, Meijne, van Neerbos et al. 1999, Magee 2002). A positive Gillet test indicates limited movement of the SIJ. Standing flexion test:
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The standing flexion test assesses SIJ mobility with sensitivity 17% and specificity 79% (Levangie 1999). To perform this test, the subject stands while the examiner sits behind the patient and palpates both of the patient's posterior superior iliac spines on their inferior margins.
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The examiner maintains his/her eyes level with the palpating thumbs while the subject bends forward slowly as if to touch his/her toes as far as comfortable while keeping both legs straight (knees extended).(Vincent-Smith and Gibbons 1999). The examiner assesses the symmetry of
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movement of both PSIS landmarks.
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The test is negative if both PSIS landmarks appear to move equally and symmetrically; the test is positive on the side in which the PSIS moves superiorly more than the other side. A positive result in a standing flexion test indicates limited movement of the ilium on the sacrum, and therefore limited SIJ motion on the side of the superior PSIS(Vincent-Smith and Gibbons 1999, Magee 2002).
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Sitting flexion test:
The sitting flexion test assesses SIJ mobility with sensitivity 9% and specificity 93% (Levangie
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1999).The procedure is similar to standing flexion test except that it is performed with the patient sitting on a level surface. A positive result in this test indicates limited movement of the sacrum
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on the ilium, and limited SIJ motion on the side of the superior PSIS (Potter and Rothstein 1985, Magee 2002).
Prone knee flexion test:
The prone knee flexion test assesses for SIJ mobility with sensitivity 100% and specificity 83% (Trainor and Pinnington 2011). The subject’s position is prone while the examiner holds both heels and passively flexes the knees to 90 degrees. The leg lengths are compared by examining 9
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the left and right soles of the heel in the prone and prone knees flexed position. The test is negative if no relative change in leg lengths between two positions occurred. If one leg appears shorter than the other in the prone knee extended position, apparent lengthening of the short leg
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in prone knees flexed position implies a hypothesized posterior innominate rotation (Potter and Rothstein 1985, Cibulka and Koldehoff 1999, Riddle and Freburger 2002).
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PAIN PROVOCATION TESTS Thigh thrust or posterior shear test:
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The thigh trust test assesses for SIJ as the source of pain. This test has excellent reported sensitivity( 80%), specificity( 81%) for SIJ pain (van der Wurff, Meyne et al. 2000). The subject’s position is supine. The examiner flexes the hip joint of the leg at the side of tested SIJ to approximately 90 degree of flexion and slight adduction. At this position the thigh is about
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perpendicular to the table while the knee remains relaxed. The examiner with one hand cups the sacrum and wraps the other arm and hand around the flexed knee. An axial pressure is applied in the direction of the long axis of the femur, which causes anterior to posterior shear to the tested
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SIJ. The test is considered positive when familiar pain is provoked over the posterior aspect of the symptomatic SIJ (Kokmeyer, van der Wurff et al. 2002, Laslett, Young et al. 2003, Laslett,
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Aprill et al. 2005). This procedure is repeated for the other side. Patrick-FABER test:
The Patrick-FABER test assesses for SIJ pain with sensitivity 77% and specificity 100% (van der Wurff, Meyne et al. 2000, Stuber 2007). The patient lies supine on the table. The examiner brings the ipsilateral hip into flexion, abduction and external rotation. The knee is flexed to ninety degrees on the affected side and the foot is rested on the unaffected knee. Then the 10
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examiner holds the contra lateral anterior superior iliac spine (ASIS) against the examination table, the affected-side knee is pushed towards the examination table, a maneuver which provides external rotation of the leg at the hip joint. The test is positive when familiar buttock or
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groin pain below L5 is reproduced (Maigne, Aivaliklis et al. 1996, Magee 2002, Robinson, Brox et al. 2007).
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Resisted abduction test:
The resisted abduction test assesses for SIJ pain with sensitivity 87% and specificity 100% (van
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der Wurff, Meyne et al. 2000, Stuber 2007).The subject’s position is supine with the leg fully extended as well as being abducted to 30 degree. The examiner holds the ankle and pushes medially while the subject pushes laterally. The test is positive when familiar pain is produced over the SIJ below L5 (Broadhurst and Bond 1998).
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STATISTICS
The association between single and composites of motion palpation and pain provocation tests
Results:
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was assessed by chi- square analysis. The P-value was chosen at α = 0.05.
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Fifty subjects (30 male and 20 female) between the ages of 20 and 65 with a mean age of 43±10 years participated in the study. The subjects’ mean height was 168 ± 7 cm and mean weight was 68 ± 10 kg.
Table-1 presents the descriptive statistics (frequency distribution) of the positive and negative results for each single motion palpation and provocation test taken in the study. Frequency distributions for cluster of provocation and motion palpation tests are displayed in Table 2. 11
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Table- 3 represents the results of chi-square analysis to identify the associations among the single motion landmark tests and pain provocation tests.
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The chi-square for the relationship between single tests varied from 0.02 to 2.57. No significant association was found between each single motion palpation and pain provocation test (P> 0.05). The results of the correlation between cluster of pain provocation and motion palpation tests
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discretely are accessible in Table 4. The range of chi- square for this relationship was 0.067 to 2.162. No significant association was found between each cluster of motion palpation and pain
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provocation tests (P> 0.05).
DISCUSSION
The purpose of this study was to investigate the correlation between motion palpation and pain
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provocation tests for SIJ considering the single and composites of the tests. The results derived from this study demonstrate no significant correlation between single pain provocation and motion palpation tests. Similar findings were found when the correlation was
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assessed for the composites of the two sets of SIJ tests. In general, these two groups of SIJ tests (provocation and motion palpation) have no significant
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relationship with each other. In other words, positive or negative results of single or cluster tests of each group did not correlate with the positive or negative result of other groups. Pain provocation tests attempt to identify whether or not the structure being stressed is a source of pain. Whereas tests for mobility or anatomical position may be used to assess possible changes or functional disorders i.e. joint motion dysfunction. The SI joint is not a single joint but rather a complex of fibrous (superior) and true synovial (inferior) articulations. For that reason, The SI joint is generally relatively immobile and designed for stability rather than mobility 12
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helping in transferring weight-bearing forces between lower extremities, hips and the lumbar spine through its complex biomechanics. Based on its anatomy, one may anticipate that some degree of joint play, glide or shear may indeed be felt by the trained operator probably as a subtle
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change in the quality of movement rather than gross changes in the ranges of mobility.
Tests for dysfunction cannot be assumed to identify a source of pain, and tests for sources of pain cannot be assumed to test for motion dysfunction. It is entirely possible that the two have a
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correlation, but there is good evidence that the relationship, if any, may not be causal. Examples are: a herniated disk may cause nerve root (radicular) pain. The disk is the cause not the source
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and the nerve root is the source, but not the cause of radicular pain. There are instances in which a positive MRI identifying a herniated disc is commonly but incorrectly assumed to identify the causative lesion but surgical removal may have no effect on the radicular pain. Another example is a patient with a stiff but painless knee who presents with knee and thigh pain which is referred
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from a hip problem. The knee 'dysfunction' is obvious, but the pain referred to the knee region is the reason for the patient presenting for diagnosis and treatment. Another and probably the greatest conflict and controversy regarding “sacroiliac articulations” may arise from the fact that
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many potential cases of so-called “SI pain” pointed to the region of the PSIS may be the result of lumbosacral (L5-S1) disc degeneration and/or facet osteoarthritis potentially referring into
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sacroiliac region via sclerotomal or capsular/annular mechanoreceptors and nociceptors' pain distribution pattern.
During the past decades, several studies have assessed the psychometric properties (reliability, validity) of the tests for SIJ pain and dysfunction. Motion palpation evaluation is a very subjective diagnostic step that depends primarily on the operator’s ability to palpate associated tissue changes and may notoriously be prone to major inter and/or intra-observer bias and 13
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variability. Thus it may potentially be confusing to relate some very subjective changes that perceived mainly during motion palpation of sacroiliac joint to a phenomenon of joint dysfunction that implies some degree of functional loss or abnormality in the articulation.
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Current evidence suggests that a single test might not be sufficient for diagnosing SIJ pain. It has been suggested that the use of a cluster of tests (combining the results of a number of tests) is a more acceptable clinical method to diagnose SIJ pain or dysfunction (Cibulka, Delitto et al.
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1988, Haas 1991, Freburger and Riddle 2001, Kokmeyer, van der Wurff et al. 2002, Riddle and Freburger 2002, Laslett, Aprill et al. 2005, Van Der Wurff, Buijs et al. 2006, Robinson, Brox et
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al. 2007). In this study, we attempted to select the tests with acceptable levels of validity, i.e., high sensitivity and/or specificity, as reported in the systematic methodological reviews of related articles (Broadhurst and Bond 1998, van der Wurff, Meyne et al. 2000). The result of a clinical test or clinical procedures can be influenced by several factors such as the
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participants, the therapists and the clinical tests. In former studies, some researchers have used asymptomatic subjects while others used a population of back patients when evaluating SIJ tests. In this study, LBP participants with clinical signs related to SIJ were included and patients with
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symptoms indicating another source of LBP were excluded. The data were collected considering
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how to interpret the participants’ responses to the tests. Did the participant recognize the pain (concordant), or was it another pain (discordant)? The results of the tests were recorded positive only in reproducing concordant pain on the same side as the joint being tested. The tests in this study were classified as either positive or negative. Given these findings and the fact that no similar study has been published in this field suggests that more extensive studies should be conducted with the aim of examining the relationship between pain provocation tests and motion tests, considering the concepts of pain and 14
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dysfunction separately. This line of inquiry may improve accuracy of diagnosis of patients with low back pain. This study found that neither single nor cluster tests of pain provocation and motion palpation
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tests of SIJ have significant correlation with each other. A finding obtained during this study confirms the idea that pain and dysfunction have two different etiologies. It is a common and
differentiated from each other in clinical practice.
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incorrect practice to confuse or treat these concepts as equivalent or synonymous and should be
Acknowledgement: The authors would like to thank student research committee at University of
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Social Welfare and Rehabilitation Sciences.
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Bernard TN, K.-W. W. (1987 ). "Recognizing specific characteristics of nonspecific low back pain." Clinical Orthopaedics 217(266-80). Broadhurst, N. A. and M. J. Bond (1998). "Pain provocation tests for the assessment of sacroiliac joint dysfunction." Journal of spinal disorders 11(4): 341-345. Cibulka, M. T., A. Delitto and R. M. Koldehoff (1988). "Changes in innominate tilt after manipulation of the sacroiliac joint in patients with low back pain." Physical therapy 68(9): 1359-1363. Cibulka, M. T. and R. Koldehoff (1999). "Clinical usefulness of a cluster of sacroiliac joint tests in patients with and without low back pain." Journal of Orthopaedic and Sports Physical Therapy 29: 83-89. Dreyfuss, P., M. Michaelsen, K. Pauza, J. McLarty and N. Bogduk (1996). "The value of medical history and physical examination in diagnosing sacroiliac joint pain." Spine 21(22): 2594. Ehrlich, G. E., N. G. Chaltaev and M. World Health Organization. Department of Noncommunicable Disease (1999). Low back pain initiative, World Health Organization, Department of Noncommunicable Disease Management. Fortin, J. D., A. P. Dwyer, S. West and J. Pier (1994). "Sacroiliac joint: Pain referral maps upon applying a new injection/arthrography technique: Part I: Asymptomatic volunteers." Spine 19(13): 1475. Freburger, J. K. and D. L. Riddle (2001). "Using published evidence to guide the examination of the sacroiliac joint region." Physical therapy 81(5): 1135. Haas, M. (1991). "Interexaminer reliability for multiple diagnostic test regimens." Journal of manipulative and physiological therapeutics 14(2): 95. Hall, H., G. McIntosh and C. Boyle (2009). "Effectiveness of a low back pain classification system." The Spine Journal 9(8): 648-657. Kokmeyer, D. J., P. van der Wurff, G. Aufdemkampe and T. Fickenscher (2002). "The reliability of multitest regimens with sacroiliac pain provocation tests." Journal of manipulative and physiological therapeutics 25(1): 42-48. Laslett, M. (2008). "Evidence-based diagnosis and treatment of the painful sacroiliac joint." The Journal of Manual & Manipulative Therapy 16(3): 142. Laslett, M., C. N. Aprill, B. McDonald and S. B. Young (2005). "Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of tests." Manual therapy 10(3): 207-218. Laslett, M., S. B. Young, C. N. Aprill and B. McDonald (2003). "Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests." Australian Journal of Physiotherapy 49(2): 89-98. Levangie, P. K. (1999). "Four clinical tests of sacroiliac joint dysfunction: the association of test results with innominate torsion among patients with and without low back pain." Physical therapy 79(11): 1043-1057. Magee, D. (1997). Orthopaedic Physical Assessment. Philadelphia, Pa: WB Saunders Co. Magee, D. (2002). Orthopedic Physical Assesment. Phildelphia. Maigne, J. Y., A. Aivaliklis and F. Pfefer (1996). "Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain." Spine 21(16): 1889. Meijne, W., K. van Neerbos, G. Aufdemkampe and P. van der Wurff (1999). "Intraexaminer and interexaminer reliability of the Gillet test." Journal of manipulative and physiological therapeutics 22(1): 4-9. Potter, N. A. and J. M. Rothstein (1985). "Intertester reliability for selected clinical tests of the sacroiliac joint." Physical therapy 65(11): 1671. Riddle, D. L. and J. K. Freburger (2002). "Evaluation of the presence of sacroiliac joint region dysfunction using a combination of tests: a multicenter intertester reliability study." Physical therapy 82(8): 772.
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Robinson, H. S., J. I. Brox, R. Robinson, E. Bjelland, S. Solem and T. Telje (2007). "The reliability of selected motion-and pain provocation tests for the sacroiliac joint." Manual therapy 12(1): 72-79. Schmid, H. J. A. (1985). "Iliosacrale Diagnose und Behandlung 1978–1982." Manuelle Medizin 23: 101108. Schwarzer, A. C., C. N. Aprill and N. Bogduk (1995). "The sacroiliac joint in chronic low back pain." Spine 20(1): 31. Shearar, K. A., C. J. Colloca and H. L. White (2005). "A randomized clinical trial of manual versus mechanical force manipulation in the treatment of sacroiliac joint syndrome." Journal of manipulative and physiological therapeutics 28(7): 493-501. Slipman, C. W., W. S. Whyte, D. W. Chow, L. Chou, D. Lenrow and M. Ellen (2001). "Sacroiliac joint syndrome." Pain Physician 4(2): 143-152. Stuber, K. J. (2007). "Specificity, sensitivity, and predictive values of clinical tests of the sacroiliac joint: a systematic review of the literature." The Journal of the Canadian Chiropractic Association 51(1): 30. Trainor, K. and M. A. Pinnington (2011). "Reliability and diagnostic validity of the slump knee bend neurodynamic test for upper/mid lumbar nerve root compression: a pilot study." Physiotherapy 97(1): 59-64. Van Der Wurff, P., E. J. Buijs and G. J. Groen (2006). "A multitest regimen of pain provocation tests as an aid to reduce unnecessary minimally invasive sacroiliac joint procedures." Archives of physical medicine and rehabilitation 87(1): 10-14. Van der Wurff, P., R. H. M. Hagmeijer and W. Meyne (2000). "Clinical tests of the sacroiliac joint* 1:: A systematic methodological review. Part 1: Reliability." Manual therapy 5(1): 30-36. van der Wurff, P., W. Meyne and R. H. M. Hagmeijer (2000). "Clinical tests of the sacroiliac joint:: A systematic methodological review. Part 2: Validity." Manual therapy 5(2): 89-96. Vincent-Smith, B. and P. Gibbons (1999). "Inter-examiner and intra-examiner reliability of the standing flexion test." Manual therapy 4(2): 87-93. Young, S., C. Aprill and M. Laslett (2003). "Correlation of clinical examination characteristics with three sources of chronic low back pain* 1." The Spine Journal 3(6): 460-465.
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ACCEPTED MANUSCRIPT
Table 1. Descriptive statistics (frequency distribution) of the positive and negative results for each single motion palpation and provocation test
Frequency 12 Sitting flexion test(%) (24)
TE D
Gillet test(%)
Frequency
M AN U
12
Standing flexion test(%)
RI PT
Tests
Negative
38
SC
Positive
(76) 38
(24)
(76)
8
42
(16)
(84)
18
32
(36)
(64)
22
28
(44)
(56)
16
34
(32)
(68)
13
37
(26)
(74)
Prone knee flexion test(%)
EP
FABER test(%)
AC C
Posterior shear test(%)
Resisted abduction test(%)
18
ACCEPTED MANUSCRIPT
Table 2. Descriptive statistics (frequency distribution) of the positive and negative results for each cluster motion palpation and provocation test
Positive
Negative
Frequency
Frequency
20
30
Composites of two motion palpation tests (%)
RI PT
Tests
(60)
14
36
(28)
(72)
4
46
(8)
(92)
16
34
(32)
(68)
9
41
(18)
(82)
M AN U
Composites of three motion palpation tests (%)
SC
(40)
Composites of four motion palpation tests (%)
TE D
Composites of two pain provocation tests (%)
AC C
EP
Composites of three pain provocation tests (%)
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ACCEPTED MANUSCRIPT
Table 3. Chi-square analysis of single motion landmark tests and pain provocation tests
Tests
FABER test
Posterior shear test
Resisted abduction test Statistic
p-Value
Statistic
p-Value
Sitting flexion test
3.226
0.072
2.351
0.125
Standing flexion test
3.226
0.072
3.304
0.129
Gillet test
3.640
0.056
1.390
0.238
Prone knee flexion test
1.273
0.259
1.211
1.754
0.185
1.719
0.190
2.794
0.095
SC 0.271
M AN U TE D EP AC C 20
p-Value
RI PT
Statistic
0.045
0.831
ACCEPTED MANUSCRIPT
Table 4:Chi-square analysis of cluster motion landmark tests and pain provocation tests
Composites of three pain provocation tests
Statistic
P-Value
Statistic
P-Value
Composites of two motion palpation tests
0.961
0.327
1.084
0.298
Composites of three motion palpation tests
0.121
0.728
1.443
0.230
Composites of four motion palpation tests
3.621
0.057
2.956
0.086
SC
M AN U
AC C
EP
TE D
Tests
RI PT
Composites of two pain provocation tests
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