Sacroiliac Distraction Test
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Description and Purpose[edit | edit source]
The SIJ (Sacroiliac joint) Distraction (Colloquially know as Gapping) test is used to add evidence, positive or negative, to the hypotheses of an SIJ sprain or dysfunction when used in the Laslett SIJ Cluster testing. This test stresses the anterior sacroiliac ligaments (Cook and Hegedus 2013, Cook et al 2007, Laslett 2008, Laslett et al 2005, Laslett et al 2003). This test has also been described as the Transverse Anterior Stress Test or the Sacroiliac Joint Stress Test.
Technique[edit | edit source]
1. The patient lies supine and the examiner applies a vertically orientated, posteriorly directed force to both the anterior superior iliac spines (ASIS) (Cook and Hegedus 2013, Laslett 2008, Laslett et al 2005, Laslett et al 2003).
Note: Cook and Hegedus (2013) suggest applying a sustained force for 30 seconds before applying a repeated vigorous force in an attempt to reproduced the patient’s symptoms. However, Laslett (2008) does not suggest any timings or changes in force.
Because of the lack of standardization in the technique it is quite feasible different therapists will practise this test different ways, giving rise to variability in response and lowering the inter-tester reliability (Laslett et al 2005, Levin et al 2005). No evidence to suggest either method is preferable (Levin et al 2005), therefore, more evidence needed.
2. The presumed effect is a DISTRACTION of the anterior aspect of the sacroiliac joint. (Laslett et al 2005, Laslett et al 2003)
3. A test is positive if it reproduces the patient's symptoms. This indicates SIJ dysfunction or a sprain of the anterior sacroiliac ligaments (Cook and Hegedus 2013, Cook et al 2007, Laslett 2008, Laslett et al 2005, Laslett et al 2003)
However, this test should be used in concordance within a SIJ testing cluster to ensure maximum reliability and validity when confirming hypotheses (Albert et al 2000, Kokmeyer et al 2002, Laslett 2008, Laslett et al 2005,Laslett et al 2003, Ozgocmen et al 2008, Robinson et al 2007). See Laslett SIJ testing cluster for further information
Evidence[edit | edit source]
The Diagnostic Accuracy of the Distraction test for SIJ dysfunction is described below (Original data from Cook and Hegedus (2013).
| Author | Reliability | Sensitivity | Specificity | LR+ | LR- | QUADAS Score (0-14) Cook and Hegedus 2013 | QUADAS Score (0-14) Gunning 2013 | CEBM (0-5) With qualitative J | Study Conclusion |
| Albert et al 2000 | 84% | 4-14 (Average = 9) | 100 | NA | NA | 7 | 7 | Score = 4 Patient Spectrum 535 women fulfilling broad inclusion criteria with daily pain at gestation week 33. Reference Standard Reference standard performed on all participants Independent blind comparisons with Gold standard No gold standard used but 2 examinations performed by individual and blinded assessors Test characteristics Presented as expected but without likelihood ratios Reproducibility Method and all analyses detailed clearly. All reproducible |
Test has reasonable specificity and inter-rater reliability and should be used as an assessment tool in pregnant women |
| Blower and Griffin 1984 | 63% | Not tested | 89 | NA | NA | 5 |
6 - Reference standard used but minimal description. 2 studies reported in 1. Very messy study.
|
Score = 2 Patient Spectrum Consecutive admissions of AS patients with varying stages of progression. Reference Standard Performed on all participants Independent Blind comparisons with Gold Standard No gold standard used/ Blind testing of index test but not reference standard Test Characteristics Specificity produced but not sensitivty Reproducibility
|
Test has reasonable reliability and sensitivity and can be used to aid assessment of AS with LBP |
| Kokmeyer et al 2002 | 46% | Not tested | Not tested | NA | NA | NA | Abstract only |
Score = 2 (Abstract only) |
Test is best when used within a multitest cluster of 5 SIJ tests. |
| Laslett et al 2005 | Not tested | 60 | 81 | 3.2 | 0.5 | 12 | 12 - Full usage of normally available clinical data not allowed. Unclear if intermediate results reported. | Score = 5 Patient Spectrum 48 subjects with broad spectrum. Accepting range of buttock pain with/without Lumbar or lower limb symptoms. Excluded if midline pain above L5 Reference Standard Every subject received reference standard diagnosis via Fluroscopy contrast guidance of a diagnostic spinal injection. Independent blind comparisons with Gold standard Therapist and Radiologist blinded to opposite assessment. Gold standard diagnostic spinal injection used. Test characteristics Presented as expected Reproducibility Concisely and clearly detailed method and results analysis |
Test best used when used within a multitest cluster (Laslett et al 2005) |
|
Laslett and Williams 1994 (Cited Cook and Hegedus 2008) |
69% | Not tested | Not tested | NA | NA | NA | Unable to obtain paper | Unable to obtain paper | NA |
| McCombe et al 1989 | 36% | Not tested | Not tested | NA | NA | NA | Abstract only | Score = 0 (Abstract only) Patient Spectrum 83 subjects but unclear in abstract how met or inclusion criteria. Unclear as to extent and type of LBP Reference Standard Unclear from abstract. Study tests inter-rater reliability of multiple tests but still unclear Independent blind comparisons with Gold standard Unclear from abstract Test characteristics Unclear from abstract Reproducibility Some description of methods and analysis in abstract but not reproducible. |
NA |
| Ozgocmen et al 2008 | Not tested | 23 | 81 | 1.24 | 0.94 | 10 | 10 – unclear if MRI interpreted with physio findings. Withdrawls not explained. No intermediate results. | Score = 4 Patient Spectrum Unclear as to how subjects were recruited from clinic and unclear as to extent of dysfunction, except present for 3 months + Reference Standard MRI used on all tests subjects Independent blind comparisons with Gold standard Physiotherapists were blinded of MRI results while assessing subject. Test characteristics Presented as expected Reproducibility Very detailed method and analysis |
Test has acceptable reliability when used in early stage sacroilitis. However, reliability, sensitivity and specificity improved when in a multi-test cluster. |
| Potter and Rothstein 1985 | 94% | Not tested | Not tested | NA | NA | NA | 5 – No reference measure used. Study investigate inter-rate reliability. | Score = 3 Patient Spectrum 17 subjects with wide range of symptoms. Unilateral buttock pain, 1 year + with/without lumbar or lower limb pain or paraesthesia. Accepted pts who would normally be tested for SIJ dysfunction. Reference Standard Reference standard identical to index test but carried out on every subject by independent and blind assessor Independent blind comparisons with Gold standard No gold standard used but assessors independent and blind of each other. Test characteristics Only reliability and assessor agreement assessed Reproducibility Very detailed and specific description of method and analyses |
Reliability of test is poor |
| Robinson et al 2007 | 82% | Not tested | Not tested | NA | NA | NA | 10 – Reference standard not independent of index test + clinicians deprived of pain localisation on examination | Score = 3 Patient Spectrum 61 subjects with either AS, post partum pelvic pain or no pain. Reference Standard Tests performed on every subject twice but 2 random, separate, independent and blind assessors in a random order. Independent blind comparions with Gold standard Reference standard same as index test and not gold standard. Assessors were independent and blinded. Test characteristics Only reliability and assessor agreement reported. Reproducibility Well detailed methodology and analyses |
Reliability of the test is moderate to good. However, test is better when performed in a multi-test cluster. |
| Russell et al 1981 | Not tested | 11 | 90 | 1.1 | 0.98 | 5 | PUBmed indexed but no abstract available therefore, not obtained | Unable to obtain | Test not valid (van der Wruff cited Russell et al 1981) |
| Average (Mean) | 65.4% | 25.75 | 88.2 | 1.85 | 0.81 | 7.8 | 7.8 | 2.57 | Test is acceptable used on its own, but it is best used within a cluster |
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)
Notes:
- Ham et al 1996 used the Distraction test as a measure for pelvic fracture so it was not included from Cook and Hegedus (2013).
- Ozgocmen et al 2008 assessed patients with acute sacroilitis
- QUADAS score replicated from Cook and Hegedus (2013). Originally produced by Whitling et al (2003). Cook and Hegedus (2013) citied Whitling et al (2005). It is a quality tool to assess Diagnostic Accuracy Studies (Whitling 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 “yesses” should be associated with a high-quality study and a score below 10 should be associated with poor designed studies (Cook and Hegedus 2010, Hardaker et al 1990, Hegedus et al 2007).
- A systematic review by van der Wurff et al (2000b) found that ¾ of studies included which looked at distraction found that it was not a valid test and 2/3 in van der Wurff et al (2000a) found it unreliable.
- Stuber (2007) found only one study in a systematic review investigating Distraction Test (Laslett et al 2005). Stuber (2007) reported 60% sensitivity. The search excluded any papers which didn’t compare to a gold standard. This explains why only one study in Stuber (2007) was included as most of the studies from Cook and Hegedus (2013) did not utilize a gold standard comparative.
- New evidence has come out since then suggesting the test is sufficiently and reasonably reliable and valid when used independently but is best when used in a cluster (Laslett et al 2008, Laslett et al 2005, Laslett et al 2003, Ozgocmen et al 2008, Robinson et al 2007, Stuber 2007)
- Gold standard/Reference standard for SIJ dysfunction is a sacroiliac joint injection confirmed under fluoroscopy or CT-guidance using a local anesthetic solution.
- The injection is performed twice on 2 separate visits with the diagnosis being confirmed when the patient reports a significant change in relief from pain.
- Maigne et al (1998), Maigne et al (1996) and Schwarzer et al (1995) have used at least a 75 percent change in relief of pain before a response to injection is considered positive and the SIJ deemed the source of pain.
- However, there is some debate that injection into ligament posterior to joint rather than an intra-articular injection is actually more effective (Borowski et al 2007, Murakami et al 2008)
- A brief search on PubMed and Medline with the search term (sacroiliac joint AND (distraction test OR gapping test OR Transverse Anterior Stress Test OR Sacroiliac Joint Stress Test OR pain provocation)) returned 27 results on PubMed showing no other studies other than the ones published in Cook and Hegedus (2013)
Conclusion[edit | edit source]
'Although this test does have moderate to good reliability(Robinson et al 2007) and is reasonably accurate in diagnosing SIJ dysfunction/sprain(Laslett et al 2005)The evidence shows that it is best used when used within a cluster (SIJ cluster testing / Test Item Clusters for Sacroiliac Dysfunction) (Albert et al 2000, Kokmeyer et al 2002, Laslett 2008, Laslett et al 2005,Laslett et al 2003, Ozgocmen et al 2008, Robinson et al 2007).
See Laslett Cluster Testing for further information
Link to Laslett Testing (SIJ cluster testing)
Resources[edit | edit source]
See Also[edit | edit source]
References[edit | edit source]
Albert H, Godskesen M, Westergaard J (2000). Evaluation of clinical test used in classification procedures in pregnancy-related pelvic joint pain. Eur Spine J. 2000; 9(2):161-166
Blower P, Griffin A (1984). Clinical Sacroiliac tests in ankylosing spondylitis and other causes of lower back pain – 2 studies. Annales Rheumatic Disorders. 1984;43:192-195
Borowsky CD, Fagen G.(2008) Sources of sacroiliac region pain: insights gained from a study comparing standard intra-articular injection with a technique combining intra- and peri-articular injection. Arch Phys Med Rehabil. Nov;89(11):2048-56
Cook, C, Hegedus, E. (2013). Orthopedic Physical Examination Test: An Evidence Based Approach. New Jersey: Prentice Hall.
Cook C, Hegedus E (2011). Diagnostic utility of clinical tests for spinal dysfunction. Man Ther. 2011;16:21-25
Cook, C., Cleland, J., Huijbregts, P. (2007). Creation and Critique of Studies of Diagnostic Accuracy: Use of theS methodological Quality Assessment Tool. J Manipulative Physiol Ther, 15(2), 93-102.
Dutton M (2008). Orthopaedic Examination, Evaluation, and Intervention. 2nd ed. New York: McGraw Hill, 2008.
de Graaf I, Prak A, Bierma-Zeinstra S, Thomas S, Peul W, Koes B (2006). Diagnosis of lumbar spinal stenosis: a systematic review of the accuracy of diagnostic tests. Spine. 2006;31:1168-1176
Ham SJ, van Walsum DP, Vierhout PAM (1996). Predictive value of the hip flexion test for fractures of the pelvis. Injury, 1996, 27:543-544
Hardaker WT, Jr., Garrett WE, Jr., Bassett FH 3rd (1990). Evaluation of acute traumatic hemarthrosis of the knee joint. South Med J. 1990;83:640-644
Hegedus EJ, Cook C, Hasselblad V, Goode A, McCrory DC (2007). 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
Kokmeyer DJ, Van der Wurdd P, Aufdemkampe G, Fikenscher TC (2002). The reliability of multitest regimens with sacroiliac pain provocation tests. J Manipulative Physiol Therapy. 2002;25(1):42-48
Konin, J., Wiksten, D., Isear, J., Brader, H. (2002). Special Test for Orthopedic Examination. New Jersey: Slack.
Laslett M, (2008). Evidence-Based Diagnosis and Treatment of the Painful Sacroiliac Joint. J Man Manip Ther. 2008; 16(3): 142–152.
Laslett M, Aprill C, McDonald B, Young S (2005). Diagnosis of sacroiliac joint pain: validity of individual provocation tests and composites of test. Man Ther. 2005;10:207-218.
Laslett M, Young SB, Aprill CN, McDonald B, (2003). Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac joint provocation tests. Aust J Physiother 2003;49:89–97.
Laslett M, Williams M (1994). The reliability of selected pain provocation test for sacroiliac joint pathology. Spine. 1994;19(11):1243-1249
Levin U, Nilsson-Wikmar L, Stenström CH (2005). Variability within and between evaluations of sacroiliac pain with the use of distraction testing. J Manipulative Physiol Ther. 2005 Nov-Dec;28(9):688-95.
Maigne JY, Boulahdour H, Chatellier G (1998). Value of quantitative radionucleotide bone scanning in the diagnosis of sacroiliac joint syndrome in 32 patients with low back pain. Eur Spine J, 1998; 7:328-331
McCombe P, Fairbank J, Cockersole B, Pynesent P (1989). Reproducibility of physical signs in the low back pain. Spine, 1989;14:908-917
Maigne JY, Aivaliklis A, Pfefer F (1996). Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain. Spine 1996;21:1889-1892
Murakami E, Tanaka Y, Aizwa T (2007). Effect of peri-articular and intra-articular lidocaine injections for sacroiliac joint pain: prospective comparative study. J Ortoped Science. 2007;12:274-280.
Ozgocmen S, Bozgeyik Z, Kalcik M, Yildrim A (2008). The value of sacroiliac pain provocation tests in early active sacroilitis. Clin Rheumatol. 2008;27:1275-1282
Potter NA, Rothstein JM (1985). Intertester reliability for selected clinical tests of the sacroiliac joint. Phys Ther. 1985;65(11):1671-1675
Robinson HS. Brox JI. Robinson R. Bjelland E. Solem S. Telje T (2007). The reliability of selected motion- and pain provocation tests for the sacroiliacjoint. Manual Therapy. 12(1):72-9, 2007 Feb.
Russell A, Maksymovich W, LeClerq S (1981). Clinical examination of the sacroiliac joints: a prospective study. Arthritis Pheumatism. 1981;24:1575-1577.
Schwarzer AC, April CN, Bogduk N (1995). The sacroiliac joint in chronic low back pain. Spine 1995;20:31-37
Sehgal N, Shah RV, McKenzie-Brown AM, Everett CR (2005). Diagostic utility of facet (Zygapophysial) joint injections in chronic spinal pain: a systematic review of evidence. Pain Physician. 2005;8:211-224
Shah RV, Everett CR, McKenzie-Brown AM, Sehgal A (2005). Discography as a diagnostic test for spinal pain: a systematic and narrative review. Pain Physician. 2005;8:187-209
Stuber KJ (2007). Specificity, sensitivity, and predictive values of clinical tests of the sacroiliac joint: a systematic review of the literature. J Can Chiropr Assoc. 2007 March; 51(1): 30–41.
Whitling P, Harbord R, Kleijnen J (2005). No role for quality scores in systematic reviews of diagnostic accuracy studies. BMC Med Res Methodol. 2005;5:19
Whiting P, Rutjes AWS, Reitsma JB, Bossuyt, Kleijnen J (2003). 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
van der Wurff P, Meyne W, Hagmeijer RHM (2000a). Clinical tests of the sacroiliac joint: A systematic methodological review. Part 1: Reliability. Manual Therapy Volume 5, Issue 2, May 2000, Pages 89–96
van der Wurff P, Meyne W, Hagmeijer RHM (2000b). Clinical tests of the sacroiliac joint: A systematic methodological review. Part 2: Validity. Manual Therapy Volume 5, Issue 2, May 2000, Pages 89–96
- ↑ Physiotutors. Distraction Test | Sacroiliac Joint Provocation. Available from: https://www.youtube.com/watch?v=OUwzaMVgGMk
