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Gaenslen Test

From Physiopedia

Original Editor - Jason Therrien and Katie Finley

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Contents

Purpose

Gaenslen's Test is one of five provocation tests that can be used to detect musculoskeletal abnormalities and primary-chronic inflammation of the lumbar vertebrae and Sacroiliac joint. [1]

The other tests are the Distraction Test, Thigh Thrust Test, Compression Test and the Sacral Thrust Test (Laslett et al. 2005)

The clinical prediction rule of three or more provocation tests that provoke familiar back pain and non-centralisation of pain is a useful tool to identify the patients more likely to have SIJ pain than some other painful condition (Laslett, 2006). Diagnostic accuracy of composites of SIJ tests improves when interpretation is confined to back pain patients whose symptoms cannot be made to ‘centralise’ with repeated movement testing. Centralisation is highly specific to discogenic pain and positive SIJ tests in these patients should be ignored (Laslett, 2006).

Specifically, Gaenslen's test can indicate the presence or absence of a sacroiliac joint lesion, pubic symphysis instability, hip pathology, or an L4 nerve root lesion. It also stresses the femoral nerve. [2]

Technique

The patient is positioned in supine with the painful leg resting on the edge of the treatment table. The examiner sagitally flexes the non symptomatic side at the hip, with the knee also flexed, up to 90 degrees (Dreyfuss et al. 1996). The patient should hold the non-tested leg with both arms while the therapist stabilizes the pelvis and applies passive pressure to the tested leg to hold it in the hyperextended position. The therapist then applies more pressure so that the hip is put into further extension and adduction. A downward force is applied to the lower leg (symptomatic side) putting it into hyperextension at the hip, while a flexion based counterforce is applied to the flexed leg pushing it in the cephalad direction causing torque to the pelvis. (Cook & Hegedus (2013) Kokmeyer et al. 2002). 

If the patient’s normal pain is reproduced, the test is considered positive for SI joint lesion, hip pathology, pubic synthesis instability, or an L4 nerve root lesion. The femoral nerve may also be stressed by this test.[2]

Test both sides if the patient complains of pain bilaterally. It is important to gain positive signs in at least 3 of the SIJ provocation tests before diagnosing SIJ pathology (Laslett et al. 2005) 



 [3]

Evidence

Diagnostic Accuracy:

The reliability in terms of inter-examiner Kappa is 0.54-0.76. [4]


Cook and Hegedus, 2013
Study Reliability Sensitivity Specificity Positive likelihood ratio (LR+) Negative likelihood ratio (LR-) QUADAS (0-14)
Laslett & Williams (1994) 0.72 NT NT NA NA NA
Dreyfuss et al. (1996) 0.61 71 26 1.02 1.11 10
Kokmeyer et al. (2002) 0.6 NT NT NA NA NA
Laslett et al. (2005) (right leg) NT 53 71 1.8 0.66 12
Laslett et al. (2005) (left leg) NT 50 77 2.2 0.65 12
Ozgocmen et al. (2008) (right leg) NT 44 80 2.29 0.68 10
Ozgocmen et al. (2008) (left leg) NT 36 75 1.5 0.83 10


Sensitivity – The possibility of a positive test resulting in someone with the pathology
Specificity – The probability of a negative test resulting in someone without the pathology
Positive Likelihood Ratio (LR+) –The ratio of a positive test result in people with the pathology to a positive test result in people without the pathology.
Negative Likelihood Ratio (LR-) – The ratio of a negative test result in people with the pathology to a negative test result in people without the pathology.
Reliability – Likelihood of results from test to be reproduced again (Expressed as percentage or as decimal)

QUADAS score: replicated from Cook and Hegedus (2013) originally produced by Whiting et al (2003). Cook and Hegedus (2013) cited Whiting et al (2005). It is a quality tool to assess Diagnostic Accuracy Studies, reducing the risk that sampling bias, operator bias or poor study design could significantly influence findings (Whiting et al 2003). Score of 7-14 “yesses” has typically been seen to indicate a high quality diagnostic accuracy study while a score below 7 indicates a poor quality diagnostic accuracy study (de Graaf et al 2006, Sehgal et al 2005, Shah et al 2005). However, Cook and Hegedus (2013) suggest a score of 10 or more “yesses” should be associated with a high quality study and a score below 10 should be associated with poorly designed studies (Cook and Hegedus 2010, Hardaker et al 1990, Hegedus et al 2007).


Local anaesthetic sacroiliac intra articular joint block has come to be regarded as the definitive gold standard of diagnostic differential capable of demonstrating SIJ pain of SIJ origin. Fluoroscopic guidance when approaching SIJ anaesthetic infiltration is necessary as unguided placement of the needle reaches the joint in only 12% of patients. This enables the joint cavity to be located
accurately and then subsequently confirmed by contrast medium. Local anaesthetic may then be infiltrated (McGrath, 2004). However, the reference standard of diagnostic injection has limitations. Since only the internal structures of the SIJ are anaesthetised by the procedure, extra-articular SIJ ligamentous pain is not identified (Laslett, 2006).

Dreyfuss et al. (1996) state that a positive injection is when 90% pain relief is reported while Laslett et al. (2005) state 80% pain relief in their study was appropriate to classify a positive injection. A positive injection is the patient’s normal pain is relieved with an SIJ block, meaning that the SIJ is the definitive source for LBP or SIJ pain.

Resources

The value of sacroiliac pain provocation tests in early active sacroiliitis.

Factors related to the inability of individuals with low back pain to improve with a spinal manipulation.

Clinical tests of the sacroiliac joint. A systematic methodological review. Part 1: Reliability.

Computed tomography in diagnosis of septic sacroiliitis: report of three cases.

Pyogenic infections of the sacro-iliac joint.

Recent Related Research (from Pubmed)

References

References will automatically be added here, see adding references tutorial.

  1. F. J. Gaenslen (1927). "Sacro-iliac arthrodesis: indications, author’s technic and end-results". Journal of the American Medical Association 86: 2031–2035.
  2. 2.0 2.1 Dutton M. Orthopaedic Examination, Evaluation, and Intervention. 2nd ed. New York: McGraw Hill, 2008.
  3. Clinically Relevant Technologies, http://www.youtube.com/watch?v=Y2DrX6qy2yI; accessed May 2011
  4. Flynn T, Cleland J, Whitman J. Users’ Guide to the Musculoskeletal Examination: Fundamentals for the Evidence-Based Clinician. Buckner, KY: Evidence in Motion, 2008.

References
1. Cook C and Hegedus E., 2013. Orthopedic Physical Examination Tests: An Evidence Based Approach. 2nd ed.  New Jersey: Pearson Education
2. de Graaf I, Prak A, Bierma-Zeinstra S, Thomas S, Peul W, Koes B., Diagnosis of lumbar spinal stenosis: a systematic review of the accuracy of diagnostic tests. Spine. 2006;31:1168-1176
3. Dreyfuss P, Dreyer S, Griffin J, Hoffman J, Walsh N. Positive sacroiliac screening tests in asymptomatic adults. Spine. 1994; 19(10):1138-1143.
4. Dreyfuss P, Michaelsen M, Pauza K, McLarty J, Bogduk N., The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine 1996; 21(22): 2594-2602
5. Hardaker WT, Jr., Garrett WE, Jr., Bassett FH, 3rd., Evaluation of acute traumatic hemarthrosis of the knee joint. South Med J. 1990;83:640-644
6. Hegedus EJ, Cook C, Hasselblad V, Goode A, McCrory DC.,Physical examination tests for assessing a torn meniscus in the knee: a systematic review with meta-analysis. J Orthop Sports Phys Ther. 2007;37:541-550
7. Kokmeyer DJ, Van Der Wurff P, Aufdemkampe G and Fickenscher TC., The reliability of multitest regimens with sacroiliac pain provocation tests. Journal of Manipulative and Physiological Therapeutics 2002; 25(1):42-48
8. Laslett M., Pain provocation tests for diagnosis of sacroiliac joint pain. Australian Journal of Physiotherapy 2006; 52(3)
9. Laslett M, Aprill C, McDonald B and Young S., Diagnosis of Sacroiliac Joint Pain: Validity of individual provocation tests and composites of tests. Manual Therapy 2005; 10:207–218
10. Laslett M and Williams M., The reliability of selected pain provocation tests for sacro-iliac joint pathology. Spine 1994; 19:1243–1249
11. McGrath M., Clinical considerations of sacroiliac joint anatomy: a review of function, motion and pain. Journal of Osteopathic Medicine 2004; 7(1): 16-24
12. Ozgocmen S, Bozgeyik Z, Kalick M, Yildirim A., The value of sacroiliac pain provocation tests in early active sacroilitus. Clinical Rheumatology 2008; 27:1275-1282
13. Sehgal N, Shah RV, McKenzie-Brown AM, Everett CR., Diagostic utility of facet (Zygapophysial) joint injections in chronic spinal pain: a systematic review of evidence. Pain Physician. 2005;8:211-224
14. Shah RV, Everett CR, McKenzie-Brown AM, Sehgal A., Discography as a diagnostic test for spinal pain: a systematic and narrative review. Pain Physician. 2005;8:187-209
15. Van der Wurff P, Meyne W and Hagmeijer RHM., Clinical tests of the sacroiliac joint: A systematic methodological review. Part 2: Validity. Manual Therapy 2000; 5(2): 89-96
16. Whiting P, Harbord R, Kleijnen J., No role for quality scores in systematic reviews of diagnostic accuracy studies. BMC Medical Research Methodology 2005; 5:19
17. Whiting P, Rutjes A, Reitsma J, Bossuyt P and Kleijnen J., The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Medical Research Methodology 2003; 3:25

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