Gaenslen Test

Contents

 Purpose

Gaenslen's Test is one of the five provocation tests that can be used to detect musculoskeletal abnormalities and primary-chronic inflammation of the lumbar vertebrae and Sacroiliac joint (SIJ).[1] The subsequent tests include; the Distraction Test, Thigh Thrust Test, Compression Test and the Sacral Thrust Test.[2]

The clinical prediction rule of three or more positive provocation tests that provoke familiar back pain and non-centralisation of pain is a useful tool to identify patients that are more likely to have SIJ pain than some other painful condition.[3] 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.[3]

Specifically, Gaenslen's test can indicate the presence or absence of a SIJ lesion, pubic symphysis instability, hip pathology, or an L4 nerve root lesion. It can also stress the femoral nerve.[4]

Technique

The patient begins positioned in supine with the painful leg resting on the edge of the treatment table. The examiner sagitally flexes the non symptomatic hip, while the knee also flexed (up to 90 degrees).[5] The patient should hold the non-tested (asymptomatic) leg with both arms while the therapist stabilizes the pelvis and applies passive pressure to the leg being tested (symptomatic) to hold it in a hyperextended position. 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.[6][7]  

If the patient’s normal pain is reproduced, the test is considered positive for a SIJ lesion, hip pathology, pubic synthesis instability, or an L4 nerve root lesion. Meanwhile the femoral nerve may also be stressed by this test.[4]

It is recommended to test both sides if the patient complains of pain bilaterally. Importantly, at least three positive signs of the SIJ provocation tests are required before possible diagnosis of SIJ pathology.[2]


 [8]

Evidence

Diagnostic Accuracy:

The reliability in terms of inter-examiner Kappa is 0.54-0.76.[9]

 

Cook and Hegedus Review[6]
Study Reliability Sensitivity Specificity Positive likelihood ratio (LR+) Negative likelihood ratio (LR-) QUADAS (0-14)
Laslett & Williams[10] 0.72 NT NT NA NA NA
Dreyfuss et al.[5] 0.61 71 26 1.02 1.11 10
Kokmeyer et al.[7] 0.6 NT NT NA NA NA
Laslett et al. (right leg)[2] NT 53 71 1.8 0.66 12
Laslett et al. (left leg)[2] NT 50 77 2.2 0.65 12
Ozgocmen et al. (right leg)[11] NT 44 80 2.29 0.68 10
Ozgocmen et al. (left leg)[11] 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[6] and originally produced by Whiting et al.[12][13] It is a quality tool to assess Diagnostic Accuracy Studies that reduces the risk that sampling bias, operator bias and/or poor study design may influence findings.[12] Scores 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.[14][15][16] However, Cook and Hegedus[6] 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.[6][17][18]


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.[19] 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.[3]

A positive injection occurs when the patient’s normal pain is relieved with an SIJ block, meaning that the SIJ is the definitive source of pain. Dreyfuss et al.[5] states that a positive injection is when there is 90% pain relief is reported while Laslett et al.[2] states 80% pain relief is appropriate to classify a positive injection.

See Also

http://www.physio-pedia.com/Posterior_pelvic_pain_provocation_test_(aka_Thigh_Thrust_aka_Posterior_Shear)
http://www.physio-pedia.com/Sacral_Thrust_Test
http://www.physio-pedia.com/Posterior_pelvic_pain_provocation_test_(aka_Thigh_Thrust_aka_Posterior_Shear)

 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

  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 2.2 2.3 2.4 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
  3. 3.0 3.1 3.2 Laslett M., Pain provocation tests for diagnosis of sacroiliac joint pain. Australian Journal of Physiotherapy 2006; 52(3)
  4. 4.0 4.1 Dutton M. Orthopaedic Examination, Evaluation, and Intervention. 2nd ed. New York: McGraw Hill, 2008.
  5. 5.0 5.1 5.2 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
  6. 6.0 6.1 6.2 6.3 6.4 Cook C and Hegedus E., 2013. Orthopedic Physical Examination Tests: An Evidence Based Approach. 2nd ed. New Jersey: Pearson Education
  7. 7.0 7.1 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. Clinically Relevant Technologies, http://www.youtube.com/watch?v=Y2DrX6qy2yI; accessed May 2011
  9. Flynn T, Cleland J, Whitman J. Users’ Guide to the Musculoskeletal Examination: Fundamentals for the Evidence-Based Clinician. Buckner, KY: Evidence in Motion, 2008.
  10. Laslett M and Williams M., The reliability of selected pain provocation tests for sacro-iliac joint pathology. Spine 1994; 19:1243–1249
  11. 11.0 11.1 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
  12. 12.0 12.1 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
  13. 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
  14. 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
  15. 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
  16. 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
  17. 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
  18. 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
  19. McGrath M., Clinical considerations of sacroiliac joint anatomy: a review of function, motion and pain. Journal of Osteopathic Medicine 2004; 7(1): 16-24




Dreyfuss P, Dreyer S, Griffin J, Hoffman J, Walsh N. Positive sacroiliac screening tests in asymptomatic adults. Spine. 1994; 19(10):1138-1143.
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

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