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). The subsequent tests include; the Distraction Test, Thigh Thrust Test, Compression Test and the Sacral Thrust Test.
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. 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.
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). 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.
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.
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.
The reliability in terms of inter-examiner Kappa is 0.54-0.76.
|Study||Reliability||Sensitivity||Specificity||Positive likelihood ratio (LR+)||Negative likelihood ratio (LR-)||QUADAS (0-14)|
|Laslett & Williams||0.72||NT||NT||NA||NA||NA|
|Dreyfuss et al.||0.61||71||26||1.02||1.11||10|
|Kokmeyer et al.||0.6||NT||NT||NA||NA||NA|
|Laslett et al. (right leg)||NT||53||71||1.8||0.66||12|
|Laslett et al. (left leg)||NT||50||77||2.2||0.65||12|
|Ozgocmen et al. (right leg)||NT||44||80||2.29||0.68||10|
|Ozgocmen et al. (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 and originally produced by Whiting et al. 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. 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. However, Cook and Hegedus 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.
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. 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.
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. states that a positive injection is when there is 90% pain relief is reported while Laslett et al. states 80% pain relief is appropriate to classify a positive injection.
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