Originalien 1 2 3 Manuelle Medizin 2018 · 56:239–248 Wolfgang von Heymann ·Horst Moll ·Geraldine Rauch https://doi.org/10.1007/s00337-018-0405-6 Orthopädische Praxis, Bremen, Germany Published online: 29 May 2018 Orthopädische Praxis, Leutkirch, Germany © The Author(s) 2018 Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Berlin Institute of Health, Institute of Biometry and Clinical Epidemiology, Humboldt-Universität zu Berlin, Berlin, Germany Study on sacroiliac joint diagnostics Reliability of functional and pain provocation tests grooves occur. The most frequent loca- indicate that these changes are the result Introduction tion of the ridges appears to be on the of mechanical factors, such as the supine Over the past 200 years, descriptions and ilium. These ridges are not identical with position, body weight, load on the femur, concepts of the many integrated com- osteoarthritis. However, the interdigitat- and strain on the pubic symphysis . ponents of human sacroiliac joints (SIJ) ing symmetrical grooves and ridges of Typically, the SIJ includes the sacral and pelvic girdle systems have emerged. the SIJ articular surfaces contribute to the segments S1, S2, and S3, although in- In particular, the concept of motion in highest coeﬃcient of friction of any di- clusion of the complete S3 segment in the SIJ has undergone a slow, convoluted arthrodial joint. This property enhances the SIJ is not common for females . evolution. Although initial writings sug- the stability of the joint against shearing In general, fusion of the sacral verte- gested that motion is normally present . The keystone-like bony anatomy of bra begins early in the second decade. between the ilia and sacrum, this idea the sacrum further contributes to stabil- The bony anatomy of the joint surface is fell out of favor in the mid-20th century ity within the pelvic ring. At its base, highly variable in size, shape, and con- . Now, current research supports the the sacrum is wider superiorly than in- tour among individuals, and the shape of existence of a limited motion in the av- feriorly; it is also wider anteriorly than the joint changes markedly from infancy erage range of 2–4° in all three planes posteriorly, permitting the sacrum to act to adulthood . The sacral auricular of this joint, but only in a lying position like a “wedge” towards caudally and dor- part is generally concave; however, of- . sally between the ilia within the pelvic ten an intra-articular bony tubercle is The SIJs are highly specialized joints ring. This anatomical structure of the present ventrally, in the middle aspect of that permit stable (yet ﬂexible) support sacrum in humans is adapted to resist the auricular surface of the sacrum. The of the upper body. In bipeds, the pelvis shearing from vertical compression (e. g., iliac part is predominantly convex. Large serves as a basic platform with three large gravity) and anteriorly directed forces on variations of the auricular surfaces exist, leversactingonit(thespineandtwolegs). the spine. Therefore, in an upright posi- resulting in intra-individual variations of u Th s, for bipeds submitted to gravity in tion, the mobility is even more restricted motion axes. an upright position, both the necessary and the total degree of mobility is less The SIJisunique inhavingelements tightness of the well-developed ﬁbrous than 1° . of a combined synarthrosis and a di- apparatus and the speciﬁc architecture of Immediately after birth, the general arthrosis—hence resulting in the term the SIJ result in limited mobility. Sacral orientation of the human SIJ is very sim- amphiarthrosis. The main portion of movement involves the SIJ, and most ilar to that of quadrupeds. The articular the joint is surrounded by a complex likely directly inﬂuences the discs and surfaces have thesameangular orienta- capsule and lined with cartilage (di- the higher lumbar joints as well . tion as the zygapophyseal joints of the arthrosis). Its shape is auricular, and The SIJ appears as a typical joint from lumbar vertebrae. Change begins as soon “opens” posteriorly. The sacrum and ilia the second month in utero onwards and as the child starts to walk upright. The have an extracapsular, dorsally located development of the joint cavity is com- sacrum enlarges laterally, and the artic- articulation (synarthrosis), which is aug- pleted by months 7–8. Examination of ular surfaces modify to a more complex mented by the vast iliosacral ligament 200 anatomical specimens revealed that adult curvature, resulting in the surface (ISL) that provides considerable internal the bony surfaces of the joint are smooth proﬁles of the joint bearing resemblance stability. Essentially, the SIJ is encased until puberty . At a later age, dif- to a propeller-like shape. Comparative in a capsule that has a smooth anterior ferent combinations of bony ridges and anatomical and paleontological research wall and irregular bands comprising the Manuelle Medizin 3 · 2018 239 Originalien posterior wall. The capsule is innervated, The reversible SIJ dysfunction follows painpattern; there are substantial contra- at least from the dorsal lumbosacral rami the pattern of a complex arthro-neuro- dictions in the analysis of the innervation (L5–S3) and is surrounded by several muscular reaction as an answer to no- [10–12, 14, 24, 27]. Today, there is still strong ligaments, such as the sacrotu- ciception . This complex nocireac- no gold standard in SIJ diagnostics. Even beral ligaments, sacrospinal ligaments, tioncomprisesthesegmentallyorganized Rx(ﬂuoroscopically)-guided intraarticu- long dorsal sacroiliac, and iliolumbar muscles that show a painful protective lar injections do not have reliable results ligaments, which therefore inﬂuence its contraction, as well as the vast ligamen- . Many irritation zones/points have range of motion. In turn, these ligaments tous apparatus of the pelvis that will de- been described . The clinical exam- are related to a complex thoracolum- velop painful insertions (here from seg- ination of function is not reliable and bar fascia composite derived from the ments L5–S3). reproducible [21, 25, 26]. In addition, aponeuroses of several large muscles Last but not least, the multilayered we have to take into consideration that (like the paraspinal and the abdomi- collagenous ﬁbers have to reorient them- theperceptionofpainatacertainpointof nal muscles) that surround the joint at selves according to the altered direction the anatomy does not mean that the noci- adistance . of mechanical load within the system of generatorofthispainisexactlywhere the the deep fascia of the abdominal, back, brain locates that pain. This means that and leg muscles. In addition, a densiﬁ- a chronic pain in the area of the SIJ may Diagnostics of SIJ dysfunction cation of the fascial layers through phys- also be a referred pain of any nocigener- What is meant by the “dysfunction” of ical forces or biomechanical processes ator in any structure segmentally inner- a joint that has so little mobility? Cur- will occur that reduces the gliding, with vated from L5 to S3 . Is there reliable rently, there are no data to prove one the result that a spontaneous return to information from the clinical ﬁndings at or the other hypothesis—is it really the normal function is impeded [28, 29]. all? In this respect, the publications are very small mobility, is it the aﬀection of Which changes occur in the joint it- conﬂicting and not unanimous [2, 8, 13, the capsule, or is it just a soft tissue re- self? Even today, we can only answer this 19, 20, 32–34, 40]. Nevertheless, these action in segmental connection with the question hypothetically. Based on the studies present some general ideas: SIJ? Therefore, we rely on observations of abovementioned data, it is quite plausi- 4 Not reliable are: pain and restriction in the region of the ble that the grooves and ridges that form j One single test pelvic girdle and the related connective themselves individually in every person j An inexperienced examiner tissues. during upright walking on the corre- j SIJ pain combined with low back On the one hand, structural changes sponding surfaces will always move in pain (LBP) exist in the bony parts of the joint, thesameway, they will follow a uniform 4 Reliable are: the synovia, and the capsule, which are pattern. j At least three pain tests with the caused either by long-lasting mechanical In case external inﬂuences disturb this same result overcharge in the sense of degenerative pattern, the grooves and ridges will no j An experienced examiner osteoarthritic changes altering the me- longer ﬁt, leading to a disturbance of the j Gluteal pain, also pseudo-radicular chanics by osteophytes. Alternatively, movement—perhaps similar to a train leg pain pathological autoimmune-reactive pro- that has been derailed. We can usually j Good positive or negative pre-test cesses (by inﬂammation) also lead to inﬂuence this biomechanical part of the probability a structural change of the joint, in complex nocireaction by mobilizing the j Pain provocation is more reliable the most severe situation represented joint partners (sacrum and ilium) in a di- than palpation of mobility by a synostotic fusion (i. e., ankylos- rection previously established to be pain- ing spondylitis). These changes are free or just by separating them from each The real functional mobility of the SIJ not reversible. However, they only oc- other. in a supine position is a complex three- cur in a small proportion of patients The very successful manual therapeu- dimensional nutation and counternuta- with respective complaints. On the tic techniques to treat SIJ-related pain tion movement of the sacrum towards other hand, the vast majority of patients based on a reversible dysfunction that the ilium in the range of 2–4°. This can present a reversible dysfunction during we teach today follow this hypothesis. only be tested in a lying position, using the examination, which sometimes dis- Therefore, it is an indispensable precon- a helicoidal axisthatvarieslargely even appears spontaneously, but more oeft n dition for treatment to diﬀerentiate be- between the SIJs of the same person . will dissolve only aer ft external inﬂuence tween structural damage and reversible The axis even depends on the ac- (mechanical, medication, etc.). dysfunction by diagnostic steps, and fur- tual function (standing on both or one Similar to the intervertebral joints thermore to identify the pain-free direc- leg, lying in supine or prone position; and using the forces of compression or tion of any movement in the latter. Al- ). During the nutation, the base of distraction, these reversible dysfunctions though this sounds plausible, in daily the sacrum moves cranially and ante- have the property to react to a respective practice it is not so easy. riorly, and during counternutation, the mechanical provocation with a diminu- Therefore, SIJ diagnostics remain dif- tip of the sacrum moves caudally and tion of pain in at least one direction. ﬁcult and uncertain. There is no typical anteriorly. During aging, the mobility 240 Manuelle Medizin 3 · 2018 Abstract · Zusammenfassung Manuelle Medizin 2018 · 56:239–248 https://doi.org/10.1007/s00337-018-0405-6 © The Author(s) 2018 W. vonHeymann·H.Moll·G. Rauch Study on sacroiliac joint diagnostics. Reliability of functional and pain provocation tests Abstract evaluated as being not reliable and only Background. As there is currently no gold Methods. Two raters investigated 161 subjects suitable as screening tests. standard for the diagnosis of SIJ dysfunction, (81 symptomatic with low back pain, Conclusions. The pain provocation tests, a broad variety of tests exist to clinically 80 asymptomatic controls) in a blinded which use palpable irritation deep in the identify pelvic girdle pain caused by reversible setting, each with a set of three functional and gluteal muscles with provocation in two SIJ dysfunction. Some of the pain provocation six pain provocation tests. Three of the pain planes, are at least as reliable as the already tests have already been evaluated. However, provocation tests had already been evaluated evaluated tests. We recommend adding SIJ the tests used by the majority of German and these were used for comparison with the irritation point diagnostics to the set of “3 out physicians competent in manual medicine non-evaluated tests. of 5 positive pain provocation tests” for safe (MM) have not yet been evaluated. Therefore, Results. The Cohen’s kappa coeﬃcients diagnosis of SIJ dysfunction. such an evaluation is necessary. of the newly evaluated tests were better Objective. The aims of the study were to (κ= 0.76–1.00) than those of the previously Keywords evaluate the reliability of functional and pain evaluated tests (κ= 0.65–0.89). The functional Low back pain · Pelvic girdle pain · Manual provocation tests used in SIJ diagnostics, and tests had a lower κ-coeﬃcient and an overly therapy · Reproducibility of results · Palpation to propose a useful set of reliable tests. wide conﬁdence interval (CI), and were thus Diagnostik von Dysfunktionen des Sakroiliakalgelenks. Studie zur Reliabilität von Funktions- und Schmerzprovokationstests Zusammenfassung Hintergrund. Da es bisher keinen Goldstan- Methodik. Zwei Untersucher prüften Schlussfolgerungen. Die Provokations- dard zur Diagnostik einer Funktionsstörung verblindet 161 Probanden (81 symptomatisch schmerztests, die die Irritation der tiefen des Sakroiliakalgelenks (SIG) gibt, existiert ein mit Kreuzschmerzen, 80 asymptomatisch) Glutealmuskulatur mit einer Provokation in großes Angebot an Tests, um klinisch eine mit jeweils 3 Funktions- und 6 Schmerzpro- 2 Dimensionen verwenden, sind mindestens reversible SIG-Dysfunktion als Ursache von vokationstests. Bereits evaluiert sind 3 der so zuverlässig wie die bereits evaluierten Beckengürtelschmerzenzu identiﬁzieren. Eini- Schmerzprovokationstest; sie wurden mit den Vergleichstests. Wir empfehlen daher, die ge Schmerzprovokationstest wurden bereits noch nicht evaluierten verglichen. Irritationspunktdiagnostik in das Testset evaluiert. Eine Prüfung der Tests, die von der Ergebnisse. Die Ergebnisse der Cohens- „3 aus 5 Provokationstests positiv“ aufzu- Mehrheit der deutschen Manualmediziner Kappa-Koeﬃzienten der neu evaluierten nehmen, um eine SIG-Dysfunktion sicher zu genutzt werden, ist jedoch noch nicht erfolgt. Test waren besser (κ= 0,76–1,00) als die der diagnostizieren. Ziel der Studie. Ziel waren die Evaluation bereits früher evaluierten (κ= 0,65–0,89). der Reliabilität von Funktions- und Schmerz- Die Ergebnisse für Funktionstests zeigten Schlüsselwörter provokationstests, die für die SIG-Diagnostik niedrigere κ-Koeﬃzienten und zu breite Unterer Rückenschmerz · Beckengür- verwendet werden, und der Vorschlag eines Konﬁdenzintervalle; daher sollten diese telschmerzen · Manuelle Therapie · allenfalls als Screeningtests verwendet Reproduzierbarkeit von Ergebnissen · zuverlässigen Testsets. werden. Palpation decreases in men. In young subjects and reliability  and low reproducibility from the SIJ is in fact a movement of in the horizontal position of the body we . Sturesson et al. checked these tests the external pelvis relative to the hips. ﬁnd 4°, in older men only 2°. in 22 patients with severe SIJ pain using This gives the manually perceived but With only 2–4° of three-dimensional radio-stereometric analysis (RSA). The misleading illusion that the SIJs are mov- mobility in a supine position and less results show minimal change of move- ing . Perhaps these functional tests than 1° in an upright position, it is ments during the test, and no diﬀerences react positively in the presence of SIJ very diﬃcult to produce clinically reli- between symptomatic and asymptomatic dysfunction by changing the behavior able signs of articular movements. In sides. When the pelvis is loaded in a one- of theconnectivetissues of thewhole fact, clinical manual movement tests are leg standing position while ﬂexing the pelvic girdle. completely unreliable for the SIJ . contralateral leg, patients are physically Commonly used diagnostic tests are challenged, which leads to bilateral in- Study aim and design 1. the standing-ﬂexion test (also called creased force closure of the SIJ [1, 3, 30]. bending-forward-test or Gillet-test or During this test, no SIJ motion occurs. Several studies have checked the reliabil- Piedallu-test) and 2. the spine-test (also The visibly changing position of bony ity of SIJ tests. In general, pain provoca- called hip ﬂexion test or stork-/ﬂamingo- landmarks like the upper posterior iliac tion tests seem to be more reliable than test). Unfortunately, these tests have low spine (SIPS) that is apparently derived functional tests in the diagnosis of SIJ Manuelle Medizin 3 · 2018 241 Originalien Fig. 1 8 Standing-ﬂexion test: both examiner’s thumbs pressed to the up- Fig. 2 8 Spine-test: oneexaminer’sthumbpressedtotheupperposterioril- perposterioriliacspinethesubjectsbendsforward–checkforasymmetrical iacspine,theothertothesacralcrest,thesubjectﬂexeshislegonthatsideup movement of the thumbs. With kind permission of J.-M. Werner to 90°; for free function of the SIJ, the iliac thumb should move downwards. With kind permission of J.-M. Werner dysfunctionwithoutstructurallesion[35, This is a diagnostic study with the pri- really completely without signs and 39]. The most frequently used tests are mary aim of evaluating the interrater reli- symptoms of dysfunction. the compression test, the femur-thrust ability between two independent exam- test, the pelvic torsion test, the FAbER iners with respect to the principles of The sample size was chosen to provide test (for ﬂexion, abduction, and external the three-step diagnosis. The secondary reasonable accuracy for estimation of the rotation; ), and the hip extension test aim was to evaluate the validity of the kappa coeﬃcient. In the planning stage, . Based on this speciﬁc diﬀerential three-step diagnosis compared to the al- itwasexpected thatthe level ofagreement diagnosis, the results of manual therapy ready evaluated SIJ testing procedures would be higher than 0.65, i. e., almost for SIJ-related gluteal and leg pain in (here: FAbER test, pelvic torsion test, perfect. The kappa value is calculated a prospective single-blinded trial were femur-thrust test). In the case of the as κ = (p0 – pc)/(1 – pc), where p0 is the better (72% success) than those of in- two pain provocation tests of the Physi- total agreement rate and pc the random jections (50%) or physiotherapy (20%; cians’ Seminar for Manual Therapy of agreement rate for a given cross-table. As ). SpinalandPeriperalJoints(MWE;check- we assume equal numbers of pathologi- In Germany, physicians have been ing a gluteal irritation point for pain-free cal and neutral cases, pc is expected to competent in the use of manual medicine direction cranial–caudal and ventral–- be 0.5. As a consequence, for κ = 0.65, it (MM) and have been teaching the dorsal) reaching suﬃcient reliability in follows that p0 would be 0.825. The esti- method for 65 years. They have de- Cohen’s kappa , these two tests were mated standard deviation (SD) is given veloped these tests through empirical to be added to the set of tests, reaching by SD(k)= √(p0(1 – p0)/(1 – pc)^2). For observations and good practical re- a set of ﬁve tests that are reliable for SIJ a kappa value of 0.65, the expected SD sults. Nobody has ever evaluated these diagnostics. is thus 0.76. The two-sided 95% con- tests incomparisontoother diagnostic ﬁdence interval (CI) for Cohen’s kappa techniques. Therefore, in the world of coeﬃcientisgivenas[k– 1.96*SD(k)/√n; Methods evidence-based medicine and reliabil- k+ 1.96 * SD(k)/√n]. For a total number ity studies, evaluation of these tests in of 150 subjects (75 cases, 75 controls) Patient recruitment and rationale comparison to each other has become the expected 95% CI will thus be given for sample size inevitable. The described approach uses by [0.53; 0.77]. Therefore, we planned to three steps to identify SIJ dysfunction, Recruitment of a total of 75 cases and recruit at least 150 subjects, which seems including an exact medical history and 75 additional controls was planned. suﬃcient and reasonable for evaluation aneurological examination: 4 The symptomatic subjects were of interrater reliability. 1. Check for articular mobility (M; recruited from patients who came to During the recruitment phase, we supposedly unreliable), a back pain rehabilitation clinic for were ﬁnally able to recruit 161 partici- 2. Check for articular painful irritation a 3-week inpatient treatment because pants (80 healthy subjects, 81 with low points (I; supposedly quite reliable) of chronic low back pain, not all had back pain or pelvic girdle problems). 3. Functional pain provocation of an SIJ dysfunction. irritation points (P; supposedly 4 The healthy subjects (controls) were highly reliable) recruited from physicians attending MM courses; not all of them were 242 Manuelle Medizin 3 · 2018 Fig. 3 8 Variability of leg length.a view from the side:start position with the subject lying supine, the legs of the subject are slightly lifted to have no contact with the table, b view from above:after the subject achieved the sitting position, the thumbs of the examiner should remain on the same level as in the lying position; if not, the test is registered as “positive ”.With kind permission of J.-M. Werner Fig. 4 8 Access“A”toSIJ-irritation. aThreeﬁngerwithslaterallyofthemedialiliacrim, bfourﬁngerwithsbelowtheiliaccrest, c the meeting-poiunt of the indexes is the point of the irritation.With kind permission of J.-M. Werner included subjects. Blinded to each other, leg of that side in hip and knee over Diagnostic procedures they checked the subjects in a short time 90°, the thumb on the SIPS should The two raters have both been teaching using a set of 10 diagnostic tests (one move caudally in normal function MM for more than 3 years with the same test was used in two versions), i. e., they (. Fig. 2). approach, so there was a short forma- ﬁnalized both examinations with a dif- 3. Variability of leg length (also Der- tion of only one weekend. The almost ference of less than 5 min. No treatment bolowsky test, sit-up test): the perfect overall agreement in the forma- was applied. There was no follow-up. subject lying in supine position, the tion period was established during an The 10 tests: examiner takes both ankles with educational course for teachers acting as 1. Standing forward ﬂexion test (also his hands, the thumbs in the same instructors in MM. There were 46 par- called Piedallu test, “Vorlauf- height at the ankle (. Fig. 3a); the ticipants (all physicians), who were in- phänomen”): the subject standing subject then sits up with eyes closed vestigated by the two raters. upright, the examiner ﬁxates both and no contact between the teeth; The inclusion criteria were an age be- posterior upper iliac spines (SIPS), anydeveloping asymmetryofthe tween 18 und 60 years, a body mass index the subjects bends forward; any “length” of the legs is registered (BMI)between18and30kg/m ,noradic- development of asymmetry of as a positive (pathological) sign ularcompressionsignsfromL5orS1. The the SIPS’ positions is registered (. Fig. 3b). subjects were assigned at random as ei- as a positive (pathological) sign 4. Irritation point A: the subjects ther patients or controls, waiting outside (. Fig. 1). lying relaxed in prone position, of the two separated examination rooms 2. Spine test (also called Gillet test, the examiner presses on both sides for the next free rater. They were exam- stork/ﬂamingo test): the subject the indexes in projection to the ined at random ﬁrst by either rater 1 or by standing upright, one hand sup- gluteal muscles, with the exact point rater 2. In addition, the raters changed ported, the examiner ﬁxates on the to be found three ﬁnger-widths the sequence of tests at random to avoid side to be tested the PSIS with one laterally of the SIJ (. Fig. 4a), four the bias ofthe subjects expecting the same thumb and with the other thumb ﬁnger-widths below the iliac crest sequence. The two raters investigated all the sacral crest. During bending the (. Fig. 4b). At the meeting point Manuelle Medizin 3 · 2018 243 Originalien Fig. 5 8 Access “B” to SIJ-irritation.a position the middle ﬁngers on the upper lateral iliac crest, b position the thumbs to the cranial end of the anal cleft, c bisecting the lines between middle ﬁnger and thumb you may ﬁnd the SIJ-irritation bilaterally. With kind permission of J.-M. Werner and pain is considered as a positive (pathological) irritation (. Fig. 5c). 6. Functional pain provocation in hor- izontal (frontal) plane of the lying subject: traction of the leg caudally (patient’s ankle between physician’s thighs) will induce a nutation move- ment of the sacrum; the reaction is checked at the positive irritation point (4 and/or 5). The examiner registers an increase or decrease of tension and pain at the irritation point. Pushing the leg to cranial Fig. 6 8 Check for pain-free direction cranial-caudal.aThemiddleﬁngerontheirritation,thesub- direction will indicate the reaction ject’s leg is tract down (nutation) or pushed upwards (counternutation) at the ankle between the ex- aminers thighs, b position of the middle ﬁnger in relation to the pelvic bones.With kind permission of to a counternutation movement of J.-M. Werner the sacrum (. Fig. 6a, b). 7. Functional pain provocation in vertical (sagittal) plane of the lying subject: compression to the sacral base (S1) will activate a nutation movement; compression to the tip of the sacrum (S5) will activate a counternutation movement. These directions of intraarticular forces will give information to the palpating ﬁnger at the irritation point, indicating a painful or pain- free direction of articular function provocation (. Fig. 7a, b). Fig. 7 8 Check for pain-free direction ventral-dorsal. a With the middle ﬁnger to the irritation, com- pression to the ilium will provoke a counternutation direction, b compression to the sacral base (S1) 8. Flexion abduction external rotation will provoke a nutation direction.With kind permission of J.-M. Werner test (FAbER test; also called sign of the 4 or Patrick test): with the of the index ﬁngers, the irritation indexes in projection to the gluteal subject lying in supine position, point is expected (. Fig. 4c). Any muscles. He ﬁnds the exact point the examiner lays the lateral ankle asymmetry in tissue consistency by dividing in two the distance of the sidetobetested at the level and pain is registered as a positive between the upper end of the of thepatella of theoppositeleg; (pathological) irritation. anal cleft and the lateral edge of he ﬁxates the pelvis with one hand 5. Irritation point B: the subjects the iliac crest (. Fig. 5a, b). Any to the opposite anterior superior lying relaxed in prone position, the asymmetry in tissue consistency iliac spine (ASIS) and presses the examiner presses on both sides the ipsilateral knee towards the table. 244 Manuelle Medizin 3 · 2018 Fig. 8 8 FAbER-test: the ankle of the side to be tested on level of the oppo- Fig. 9 8 Pelvic torsion test:one leg is positioned laterally of the table in hip site patella, the hip is in ﬂexion, abduction, external rotation; the pelvis is extension, the other leg is ﬂexed as much as possible in the hip; check for ﬁexed on the opposite side, the end-feel is tested.With kind permission of pain. With kind permission of J.-M. Werner J.-M. Werner Fig. 10 9 Femur-thigh- thrust. a The examiners contracted thenar is posi- tioned exactly under the sacrum, b with the weight of his body the examiners thrusts the subject’s knee/ femurinthedirectionofhis hand. With kind permission of J.-M. Werner As the test also reacts to hip pain 10. Femur-thigh thrust (also called Statistical analysis strategy and its osteoarthritic stiﬀness, the Ostgaard test or 4P test= posterior degree of ﬂexion, abduction, and pelvis pain provocation test): with All analyses were performed for each di- external rotation is not important. the subject lying in supine position, agnosed and evaluated side (right, left) Only thepaininthe region of the examiner bends the leg opposite separately. The interrater agreement for the sacroiliac joint counts for SIJ to him 90° in the hip and rolls the the three-step diagnostic approach was pathology (. Fig. 8). pelvis to his side, so he can position evaluated by means of Cohen’s kappa 9. Pelvic torsion test (also called one hand’s contracted thenar under coeﬃcient along with a corresponding Gaenslen test): with the subject the sacrum, leaving the ilium free 95% CI. Cohen’s kappa coeﬃcients were lying in supine position just on one (. Fig. 10a). Then he rolls the pelvis also calculated for each of the established edge of the table, the examiners back to a vertical position of the testsseparately. Sensitivityandspeciﬁcity positions thisside’sleg besides the femur and gives with the weight for the three-step diagnostic approach in table in an extension position of the of his body a thrust to the knee in comparison to several well-established hip; then he bends the other leg in direction of the own hand under tests were not evaluated separately, as hip and knee as much as possible. the sacrum (. Fig. 10b). Aeft r the number of positive diagnoses was too After checking for pain in the sacral registering “pain” or “no pain” in small, especially for the left side. Never- region, the test is repeated in the the region of the SIJ, he will repeat theless, the result of the diagnostic pro- other direction of pelvic torsion the test with the other femur. cedure wasdeﬁnedaspositive ifat least from the other side of the table three of the ﬁve established tests (irrita- (. Fig. 9). tion point craniocaudal, irritation point ventrodorsal, FAbER test, Gaenslen test, Manuelle Medizin 3 · 2018 245 Originalien cular irritation. All results are compiled Table 1 Cohen’s kappa coeﬃcients of the speciﬁc sacroiliac joint (SIJ) diagnostics; κ-values and 95% conﬁdence interval (CI) ranges in . Table 1. Right SIJ Right SIJ Left SIJ Left SIJ These results show that SIJ diagno- sis using the gluteal irritation in com- Cohen’s κ 95% CI Cohen’s κ 95% CI bination with the pain provocation in Forward ﬂexion 0.68 ± 0,089 0.51; 0.85 0.41 ± 0.13 0.16; 0.66 the cranial–caudal plane as well as in the (Piedallu) ventral–dorsal plane have an almost per- Spine test 0.53 ± 0.090 0.35; 0.71 0.59 ± 0.12 0.35; 0.83 (Gillet test) fect kappa coeﬃcient and are even more reliable than the already examined tests. Variable leg length 0.64 ± 0.08 0.48; 0.80 0.71 ± 0.07 0.57; 0.85 (sit-up test) We accepted the precondition  Irritation point (A) 0.96 ± 0.02 0.96; 1.00 1.00 ± 0.00 – that there is a need for at least three posi- tive tests out of ﬁve for the diagnosis of SIJ Irritation point (B) 0.86 ± 0.04 0.80; 0.94 0.75 ± 0.08 0.59; 0.91 dysfunction. Using the pain provocation Pain provocation 0.76 ± 0.06 0.64; 0.88 0.89 ± 0.06 0.87; 0.99 test cranial–caudal, pain provocation test Cranial–caudal ventral–dorsal, FAbERtest, pelvictorsion Pain provocation 0.93 ± 0.03 0.87; 0.99 0.86 ± 0.07 0.72; 1.00 Ventral–dorsal test, and femur thrust test, the interrater reliability for one of the possible three FAbER test 0.73 ± 0.11 0.51; 0.95 0.34 ± 0.19 0.00; 0.71 (Patrick/sign of 4) diagnoses (no SIJ dysfunction, dysfunc- Pelvic torsion test 0.65 ± 0.16 0.34; 0.96 0.39 ± 0.28 0.00; 0.94 tion right SIJ, and dysfunction left SIJ) (Gaenslen test) was evaluated: Femur-thigh thrust 0.89 ± 0.04 0.81; 0.97 0.89 ± 0.06 0.77; 1.00 4 No SIJ dysfunction (80 subjects): (4P test) Cohen’s κ = 0.93 ± 0.03; 95% CI [0.87; 0.99] 4 Right-side SIJ dysfunction (61 sub- and the 4P or femur-thrust test according cers, and 11 (6.8%) had thyroid disorders. jects): Cohen’s κ = 0.95 ± 0.03; 95% CI to Ostgaard) showed a positive result. They were included nevertheless, as all [0.89; 1.00] of them used the respective medication 4 Le-ft side SIJ dysfunction (20 sub- to control their speciﬁc problems. jects): Cohen’s κ = 0.94 ± 0.04; 95% CI Results In 8 (5.0%) subjects there were signs of [0.86; 1.00] Generally, the magnitude of Cohen’s some nerve root compression, but none kappa coeﬃcients for the agreement of from the lumbosacral region, so they Discussion and conclusion the two raters is interpreted as follows: were not excluded. Another 31 (19.3%) kappa values between 0 and 0.20 indicate showed signs and symptoms of interver- Limitations poor agreement, values between 0.21 and tebral dysfunction in the segments T12 0.40 indicate suﬃcient agreement, val- to L5, which was also not a criterion for The study is limited to a group of in- ues between 0.41 and 0.6 are interpreted exclusion. patients supposed to be impaired and as a substantial agreement, and kappa Forthethreefunctionaltests(standing to a group of physicians supposed to be coeﬃcients above 0.61 are interpreted as forward ﬂexion, spine test, and checking healthy subjects. However, there is no almost perfect agreement . the variability of leg lengths), we did not evidence that these groups react diﬀer- Although 168 subjects signed the in- expect good results for interrater agree- ently than other patients or other healthy formed consent to participate, 7 had to ment. They are not based on real mo- controls. There was no treatment at all be excluded from evaluation as they did bility within the SIJ, but rather on con- and no follow-up to check the reliabil- not fulﬁll the inclusion criteria, mainly nective tissue reactions. Therefore, they ity of the diagnoses by post-therapeutic becausethey weretoo oldortoo heavy. mayprobablybutnotreliablyberelatedto outcome. Of the included subjects, 82 (50.9%) were SIJ dysfunction. Although the observed Although the study was designed as male, 79 (49.1%) were female. The mean kappa values were not poor for each of a blinded study regarding the allocation age was 44.4 ± 8.9 years, the mean weight these functional tests, the 95% CI was too of the subjects to the raters, some symp- was 76.3 ± 13.4 kg, the mean height was wide to allow an appropriate interpreta- tomatic subjects tried to start a discus- 174.6 ± 10.0 cm, and the mean BMI was tion. Nevertheless, the observed kappa sion with the raters to get more infor- 24.8 ± 3.1 kg/m . The general physical values for the FAbER test and the pelvic mation about themselves. Therefore, it examination found in 3 (1.9%) subjects torsion test were almost equal to the data waseasyfor the raterstouncover the a pathologic condition in the central ner- from the references . In our study, respective allocation. As there were also vous system, 9 (5.6%) with cardiac prob- we only found similarly good and precise many symptomatic subjects among the lems (high blood pressure), 2 (1.2%) with results for the femur-thigh thrust as for “controls” and almost the same number asthma, 1 (0.6%) with nephrologic prob- the pain provocations to the gluteal mus- of asymptomatic subjects among the “pa- lems, 11 (6.8%) had previous gastric ul- tients,” we estimate this bias to be neg- 246 Manuelle Medizin 3 · 2018 sacroiliac joint block are unreliable for diagnosing ligible. As both groups presented both Interpretation and sacroiliacjointpain. JointBoneSpine73:17–23 results regarding the SIJ, the raters had recommendation 3. Böhni U (2015b) Lumbosakraler Übergang und to examine each subject without predis- Beckenring. In: Böhni U, Lauper M, Locher H (eds) Manuelle Medizin 1. Thieme, Stuttgart, position. Thisstudyshowsthatincludingthetradi- pp544–586 The number of subjects included was tionally used irritation points (or zones) 4. Böhni U, Locher H (2015a) Neurophysiologische not as high as necessary for suﬃcient in the gluteal muscles with pain provoca- Grundlagen der segmentalen Dysfunktion. In: Böhni U, Lauper M, Locher H (eds) Manuelle evaluation of a left SIJ pathology. The tion according to the possible directions Medizin1. Thieme,Stuttgart,pp186–191 relation between symptomatic right-side within the SIJ (nutation or counternuta- 5. Böhni U, Lauper M, Locher H (2012) Manuelle and the symptomatic le-side ft SIJ dys- tion) within a set of ﬁve tests is highly Medizin 2. Diagnostische und therapeutische Technikenpraktischanwenden. Thieme,Stuttgart, function conﬁrmed the empiric observa- reliable and will lead to good results for pp384–395 tion that the dysfunction of the right SIJ the diagnostic determination of a neu- 6. Bowen V, Cassidy JD (1981) Macroscopic and occurs much more often in our popula- tral function or a unilateral dysfunction microscopic anatomy of the sacroiliac joint from embryonic life to the eighth decade. Spine (Phila tion (4:1) than the left SIJ. Unfortunately, of the SIJ. Pa1976)6:620–628 the sensibility and speciﬁcity could not 7. Cohen J (1960) A coeﬃcient of agreement for be evaluated reliably, because of the small nominalscales. EducPsycholMeas20:37–46 Corresponding address 8. Dreyfuss P, Michaelsen M et al (1996) The value number of positive diagnoses for the left W. von Heymann of medical history and physical examination in side. Nevertheless, the model “3 out of diagnosing sacroiliac joint pain. Spine (Phila Pa Orthopädische Praxis 5 positive pain provocation tests” has al- 1976)21:2594–2602 Mendestr. 7, 28203 Bremen, Germany 9. Fortin J, Aprill C, Ponthieux B et al (1994) Sacroiliac ready been evaluated with an estimated email@example.com joint: pain referral maps upon applying a new sensitivity of 93.8% and a speciﬁcity of injection/arthrography technique. Part II: clinical 78.1% . evaluation. Spine19:1483–1489 Funding. The study was funded by the Physicians’ 10. Fortin JD, Tolchin RB (2003)Sacroiliacarthrograms Association for Manual Therapy on Spine and Ex- Regarding the evaluated manual tests, and post-arthrography computerized tomogra- tremities (DGMM-MWE); the raters and the tested only the most commonly used tests of phy. PainPhysician6:287–290 subjects received no refunding for participation one physicians’ association for MM were 11. Fortin JD, Kissling RO, O’Connor BL, Vilensky JA (1999) Sacroiliac joint innervation and pain. Am J investigated. However, the implementa- Orthop(BelleMead,NJ)28:687–690 tion of all other manual diagnostic tech- Compliance with ethical 12. Grob KR, Neuhuber WL, Kissling RO (1995) niques would havemadeit impossible Innervation of the sacroiliac joint of the human. guidelines ZRheumatol54:117–122 to achieve reliable results. Already the 13. Hancock MJ, Maher CG et al (2007) Systematic 10 tests are supposed to be the maximum review of tests to identify the disc, SIJ or facet Conﬂict of interest. W. von Heymann, H. Moll, possible in one setting. joint as the source of low back pain. Eur Spine J and G. Rauch declare that they have no competing 16:1539–1550 interests. 14. Ikeda R (1991) Innervationof the sacroiliac joint. Generalizability Macroscopicalandhistologicalstudies. NipponIka All procedures performed in studies involving human DaigakuZasshi58:587–596 participants were in accordance with the ethical stan- 15. Klein P, Sommerfeld P (2004) Biomechanik der dards of the institutional and/or national research The methods of examination evaluated menschlichen Gelenke – Grundlagen, Becken, committee and with the 1964 Helsinki declaration and to show suﬃcient agreement were very untere Extremität. Urban & Fischer, München, its later amendments or comparable ethical standards eﬃcient and can be generalized. Based pp142–168 (approved by the ethics commission of the Cham- 16. Landis JR, Koch GG (1977) The measurement ber of Physicians of Baden-Wuerttemberg under the on the results, the clinical examination of observer agreement for categorical data. number F-2016-037). Informed consent was obtained of a supposed SIJ dysfunction can be Biometrics33:159–174 from all individual participants included in the study. performed reliably using the gluteal ir- 17. Laslett M (2008) Evidence-based diagnosis and Additional informed consent was obtained from all treatment of the painful sacroiliac joint. 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Manuelle Medizin – Springer Journals
Published: May 29, 2018
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