ARTICLE IN PRESS

1 56
2 Accuracy of the Diagnostic Tests of Sacroiliac 57
3 58
4 Joint Dysfunction 59
5 60
6 D1X XParisa Nejati, D2X XMD, MPH, a D3X XElham Sartaj, MDD4X aX D5X XFranad Imani, MDD6X bX D7X XReza Moeineddin, MDD8X Xc 61
7 D9X XLida Nejati, D10X XMSc, d and D1X XMarta Safavi, MDD12X aX 62
8 63
9 ABSTRACT 64
10 65
11 66
12
Objective: The purpose of this study was to assess the reliability and validity of motion palpation and pain 67
13
provocation compared with sacroiliac joint (SIJ) block as the gold-standard assessment method of patients with 68
sacroiliac joint dysfunction (SIJD).
14 69
Methods: A cross-sectional study was conducted in the Department of Sports and Exercise Medicine at Rasool
15 70
Akram Hospital. Forty-eight patients suspected of having SIJD were selected from a total of 150 patients on the basis
16 71
of a combination of symptoms, physical tests, and magnetic resonance imaging findings. The patients suspected of
17 having SIJD received the SIJ block, to which the accuracy of all the physical tests was compared. Sensitivity, 72
18 specificity, and positive and negative predictive values were calculated for each test. The receiver operating 73
19 characteristic curve and the area under the receiver operating characteristic curve were measured. 74
20 Results: The Flexion, Abduction and External Rotation (FABER) test had the highest specificity and positive 75
21 predictive values of the physical tests. Furthermore, the combination of the FABER test and the thigh thrust test 76
22 improved overall diagnostic ability more so than any of the other test combinations. 77
23
Conclusion: A combination of the motion and provocation tests increased specificity and positive predictive values, 78
24
and the FABER test had the highest of these single values. The palpation tests did not change after the SIJ block, 79
suggesting that their accuracy cannot be determined using this method. (J Chiropr Med 2020;xx;1-10)
25 80
Key Indexing Terms: Diagnostic Tests; Sensitivity and Specificity; Predictive Value of Tests
26 81
27 82
28 83
29 TAGEDH1INTRODUCTIONTAGEDEN dysfunction (SIJD). The latter is used in the case of a nonin- 84
30 flammatory condition of the SIJ that is characterized by a 85
Lower back pain (LBP) is one of the most common
31 reversible decreased mobility of the joint, resulting from 86
musculoskeletal complaints; almost 80% of people experi-
32 articular causes.5 87
ence pain in this area at least once in their lives.1 Despite
33 Sacroiliac joint dysfunction accounts for 10% to 27% of 88
its high prevalence, the etiology of LBP is not well known
34 the causes of mechanical lower back or buttock pain,6-10 and 89
and is nonspecific in approximately 85% of cases.2
35 one of its hallmarks is local tenderness in the SIJ.5 Sacroiliac 90
The disorders affecting the sacroiliac joint (SIJ), which
36 joint dysfunction can be the sole disorder, or it can be 91
is an area extending inferiorly in the medial part of the pos-
37 accompanied by disc herniation or spinal stenosis.11,12 92
terior superior iliac spine (PSIS),3,4 are defined using differ-
38 It is difficult to make an exact diagnosis of SIJD, not 93
ent terms that include sacroiliac strain, sacroiliac
39 only because historical, physical, or radiological evidence 94
instability, sacroiliac arthritis, and sacroiliac joint
40 is not absolute, but also because the symptoms can be the 95
41
a
result of other common conditions, such as facet syndrome 96
42
Department of Sports and Exercise Medicine, Rasool Akram and disc herniation.13-16 Because there is no widely 97
Hospital, Iran University of Medical Sciences, Tehran, Iran.
43 b
Department of Anesthesiology and Pain Medicine, Rasool
accepted reference standard for diagnosing SIJD, the SIJ 98
44 Akram Hospital, Iran University of Medical Sciences, Tehran, block is the preferred method for this purpose.17 With this 99
45 Iran. method, an anesthetic agent is injected into the SIJ under 100
c
46
d
Dr. Moeineddin Radiology Clinic, Qazvin, Iran. fluoroscopic guidance. The rationale for using the SIJ block 101
47
Islamic Azad University, Science and Research Branch, Teh- is that the SIJ has many nerves, which, when stimulated, 102
ran, Iran.
48
Corresponding author: Elham Sartaj, MD, Department of
can generate pain. Moreover, the level of evidence for the 103
49 Sports and Exercise Medicine, 8th Floor, Rasool Akram Hospital, specificity and validity of this diagnostic test is considered 104
50 Niyayesh Street, Sattarkhan Street, Tehran, Iran. moderate (level III).6,18-28 A number of authors recommend 105
51 (e-mail: Elham.sartaj@gmail.com). single-injection diagnostic block for clinical studies,29,30 106
52
Paper submitted May 30, 2019; in revised form December 10, although others suggest double (confirmatory) diagnostic 107
2019; accepted December 10, 2019.
53
1556-3707
block more accurately determines the source of pain by 108
54 © 2020 by National University of Health Sciences. using 2 different local anesthetics with different durations 109
55 https://doi.org/10.1016/j.jcm.2019.12.002 of action.5,13,18,31-42 110
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111 However, despite such recommendations, SIJ block is  Presence of pain exacerbated as a result of bending lat- 166
112 not cost-effective, nor is it practical for practitioners who erally or backward 167
113 lack training in intra-articular injections. These considera-  Positive results on at least 2 of the pain-provocation 168
114 tions have led clinicians to employ physical tests, with the tests (ie, Flexion, Abduction, and External Rotation 169
115 belief that even negative findings can be used in diagnosing [FABER], thigh thrust, Gaenslen, Yeoman, compres- 170
116 SIJD. The fact that there is a wide range of physical tests, sion, distraction, and Newton tests) and one of the 171
117 many of which are not as accurate as the SIJ block,6,40,43-49 motion palpation tests (ie, Gillet and forward flexion 172
118 calls into question several factors, including which tests are tests) 173
119 most helpful, whether the lack of agreement on clinical cri- 174
120 teria for an SIJD diagnosis makes utility of these tests con- 175
121 troversial,14-16 and whether using a combination of such Exclusion Criteria 176
122 tests can lead to better diagnosis. Patients were excluded if they met any of the following 177
123 The present study aimed to determine which physical criteria: 178
124 tests have the highest sensitivity, specificity, and predictive 179
125 values in determining the presence of SIJD compared with 180
 Pregnancy
126 the SIJ block, in addition to which combination of physical 181
 Receiving physical therapy modality and nonsteroidal
127 tests has the closest diagnostic value to the SIJ block. 182
anti-inflammatory drugs over a 72-hour period before
128 183
the study period
129 184
 A history of back surgery during the 6 months before
130 TAGEDH1METHODSTAGEDEN the study period
185
131 186
This cross-sectional study was carried out between 2016  Malignant tumors in the spine or pelvis
132 187
and 2018 and used convenience-based sampling to recruit  Sacroiliitis and infections of the SIJ
133 188
patients with lower back or buttock pain. A written consent  Presence of any fracture in the spine or pelvis
134 189
compatible with the International Council for Harmonisa-  Presence of other causes of LBP such as lumbar disc-
135 190
tion of Technical Requirements for Pharmaceuticals for opathy and spinal stenosis discovered via clinical
136 191
Human Use was obtained from all participants. Ethical examination and MRI scanning
137 192
approval for this study was obtained from an independent
138 193
ethics committee at Iran University of Medical Sciences.
139 Generally, SIJD-suspected participants were defined as 194
Patients with lower back or buttock pain were evaluated
140 patients with lower back or buttock pain whose symptoms 195
by a sports medicine specialist through a 2-step screening
141 indicated SIJD and who had positive results on at least 2 of 196
process. First, physical musculoskeletal examinations were
142 the pain provocation tests (ie, FABER, thigh thrust, Gaen- 197
used to identify patients who were subject to an SIJD diag-
143 slen, Yeoman, compression, distraction, and Newton tests) 198
nosis. Patients were then evaluated for pathologies of the
144 and 1 of the motion palpation tests (ie, Gillet and forward 199
lumbar spine and pelvis; those with pain in these areas that
145 flexion tests) in the absence of other causes of pain accord- 200
emanated from other causes, such as lumbar discopathy,
146 ing to MRI test results. 201
spinal stenosis, and spondylolisthesis, were excluded. Eli-
147 202
gible patients were subsequently evaluated using lumbosa-
148 203
cral and sacroiliac magnetic resonance imaging (MRI)
149 Background Data 204
scans to rule out other sources of pain and to further verify
150 Collected patient characteristics included sex, age, and 205
the results of the physical examinations.
151 body mass index (BMI). To determine the intensity of the 206
152 SIJ pain felt during each subjective test, a 100-mm visual 207
153
Inclusion Criteria analog scale (VAS) was used, where 0 represented no pain 208
154 and 100 denoted the most severe pain. The VAS scores 209
The following inclusion criteria were adopted during the
155 were recorded mainly to measure the decline in pain level 210
physical examinations and screening:
156 as a result of administering the SIJ block. 211
157 212
158  Aged 20 to 70 years 213
159  Presence of lower back or buttock pain with or without Motion Palpation Tests 214
160 radiation to lower extremities for at least 6 weeks Gillet Test. To perform the Gillet test, the examiner 215
161 before study enrollment stood behind the patient with one thumb on the PSIS and 216
162  Presence of pain or local tenderness in the SIJ region the other thumb on the sacrum. Then, the patient was 217
163 (ie, the joint between the sacrum and the ilium bones instructed to bend and pull up the leg corresponding to the 218
164 of the pelvis, covering an area extending inferiorly in PSIS being palpated. The test was repeated on the other 219
165 the medial part of the PSIS) side and compared bilaterally. 220
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221 The test was considered negative if the thumb on the right ASIS, spreading them away. The test was considered 276
222 PSIS moved inferiorly to the thumb placed on the sacrum. positive if the patient’s pain in the SIJ increased.3,48,55 277
223 In contrast, no movement on the PSIS or superior move- Newton’s Test. The patient lay in a supine position. The 278
224 ment to the other thumb on the sacrum was taken as a posi- examiner fully flexed and pressed the tested-side hip and 279
225 tive result.45,50-53 knee joints toward the abdomen. The test was considered 280
226 Forward Flexion Test. During the flexion test, the patient positive if the patient experienced increased pain in the SIJ. 3 281
227 was asked to slowly bend forward as much as possible with 282
228 the examiner’s thumbs on their left and right PSIS. Then, 283
229 the symmetry of the movement in the thumbs was assessed. SIJ Block (SIJ Injection) 284
230 A positive test result was defined as any superiority in the Patients who met the criterion for positivity were sus- 285
231 movement of the 2 thumbs, indicating hypomobility of the pected to have SIJD47 and were transferred to the pain pro- 286
232 ipsilateral SIJ.44,53 cedure room within an hour for the double SIJ block. This 287
233 test was performed by a pain specialist with more than 288
234 10 years of experience in spinal injections and who was 289
235 blind to the results of the physical tests. For the SIJ block, 290
236 Pain Provocation Tests (Subjective) the patient lay in a prone position with a pillow placed 291
237 FABER Test (Patrick’s Test). During the FABER test, the under the abdomen at the iliac crests. After prepping and 292
238 patient was asked to lie supine on the examination table. draping, a spinal 22G needle was inserted and positioned in 293
239 The examiner brought the hip joint into the FABER posi- the SIJ. Next, 1 mL of iodixanol (Visipaque) was injected 294
240 tions. One knee was flexed 90°, and the affected-side foot as the radiocontrast agent. The placement of the needle and 295
241 was rested on the opposite-side knee. Subsequently, the the spread of iodixanol was documented via fluoroscopy (a 296
242 examiner pressed the contralateral anterior superior iliac lateral view and a 3-quarter view). Additionally, 1.5 mL of 297
243 spine (ASIS) against the table and pushed the bent knee lidocaine 2% was used in the initial injection, and 1.5 mL 298
244 down toward the table.3,6 The test was considered positive of bupivacaine 0.5% was employed in the confirmatory 299
245 if the patient felt pain in the SIJ on the side where the knee block,5,6,18,26,31-42 producing a double SIJ block within an 300
246 was flexed. At this point, pain in the buttocks was sugges- hour of the SIJ block. The physical tests were repeated, and 301
247 tive of SIJD, whereas pain in the inguinal region could VAS pain scores were obtained again to measure possible 302
248 have indicated hip pathology. pain relief compared with the pre-SIJ block state.27 A pain 303
249 Thigh Thrust Test (Posterior Shear Test). With the thigh reduction of at least 60% indicated the presence of SIJD, 304
250 thrust test, the patient lay in a supine position while the and a reduction of smaller than 60% denoted the absence 305
251 tested-side hip joint was flexed to approximately 90° by the of SIJD.28,39,56 306
252 examiner. An anteroposterior shear force was applied to To measure the diagnostic validity of the physical tests, 307
253 the SIJ through the axis of the femur.3,43 Resulting pain they were compared with the SIJ block in the SIJD-sus- 308
254 indicated the test was positive. pected patients. The comparison was performed for each 309
255 Gaenslen Test. The patient lay supine, with the tested- individual test and different combinations. 310
256 side leg hanging over the edge of the table and the other The flowchart of the study is presented in Figure 1. 311
257 leg flexed to the chest. The examiner applied firm pressure 312
258 to the flexed knee, and a counterpressure was applied to the 313
259 knee of the hanging leg. The procedure was then repeated Statistical Methods 314
260 on the opposite side.29,54 The test was considered positive The findings of the evaluations were analyzed using 315
261 if the patient felt pain in the hanging-leg side. SPSS 23 (IBM Corporation, New York). The prevalence of 316
262 Yeoman Test. With this test, the patient was asked to lie SIJD in the patients with lower back or buttock pain was 317
263 prone. The examiner lifted the tested-side knee by extend- determined while considering their sex, age, and BMI. 318
264 ing it to 90° and then extended the hip joint with one elbow Also, 2 £ 2 contingency tables were created. Moreover, 319
265 on the patient’s buttock.3,47 Pain in the hanging-leg side sensitivity, specificity, and positive and negative predictive 320
266 was considered a positive result. values were calculated for each individual test and different 321
267 Compression Test. The patient lay in the lateral decubi- combinations of these tests based on the formulas presented 322
268 tus position, with the affected side up, and faced away in Table 1.57,58 323
269 from the examiner, who applied a downward pressure to The receiver operating characteristic curve is an overall 324
270 the ipsilateral iliac crest and ASIS. The test was considered measure of diagnostic efficacy. It is a plot of the true-posi- 325
271 positive if the patient felt pain in the SIJ on the contralateral tive rate against the false-positive rate of a diagnostic test. 326
272 side.3,48 This curve, which is defined as a plot of test sensitivity as 327
273 Distraction Test. The patient was placed supine on the the y coordinate vs test specificity or false-positive rate as 328
274 table. With the patient’s forearms crossed, the examiner the x coordinate, is an effective method for evaluating the 329
275 applied slow and steady outward pressure to the left and validity of diagnostic tests. 330
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331 Table 1. Calculation of the Sensitivity, Specificity, and Positive 386

332 and Negative Predictive Values of the Diagnostic Tests 387
333 Positive SIJ Block Negative SIJ Block 388
334 389
Positive physical test A (true positive) B (false positive)
335 390
336 Negative physical test C (false negative) D (true negative) 391
337 392
Sensitivity = (A/(A + C)) £ 100
338 Specificity = (D/(B + D)) £ 100 393
339 Positive Predictive Value = (A/(A + B)) £ 100 394
340 Negative Predictive Value = (D/(C + D)) £ 100 395
341 396
342 TAGEDH1RESULTSTAGEDEN 397
343 398
A total of 150 patients with lower back or buttock pain
344 399
were examined at the beginning of the study. Sixty-four of
345 400
these patients were selected to undergo an MRI. Of them, 9
346 401
patients were excluded as their LBP was the result of other
347 402
causes. Further, 7 patients refused to undergo the SIJ block.
348 403
Of the 48 remaining patients, 6 were male and 42 were
349 404
female, ranging in age from 23 to 69 years old (average of
350 405
47.7 years) and a mean BMI of 28.4.
351 406
Of the 48 patients undergoing the SIJ block, 39 experi-
352 407
enced a reduction of at least 60% in pain and were placed
353 408
in the SIJD-positive group, for a prevalence of 81.25%.
354 409
Although the pre-SIJ block VAS scores ranged from 60 to
355 410
100, with an average of 77, the post-SIJ block scores varied
356 411
between 10 and 30, with an average of 18 (Fig 2). No
357 Fig 1. The flowchart of the study. LBP, lower back pain; MRI, 412
magnetic resonance imaging; SIJ, sacroiliac joint. adverse effects of the SIJ block were observed.
358 413
Nine patients had a reduction in pain that was less than
359 414
The area under the curve (AUC) is the area under the 60% after the SIJ block and were assigned to the SIJD-neg-
360 415
receiver operating characteristic curve and a measure of how ative group. Of these patients, the pre-SIJ block VAS
361 416
well a parameter can distinguish between 2 diagnostic groups scores ranged from 50 to 90, with an average of 74,
362 417
(affected vs non-affected). The AUC can range from 0.5 (use- whereas the post-SIJ block scores ranged from 40 to 70,
363 418
less model) to 1.0 (perfect discrimination). A value higher with the average being 46 (Fig 3).
364 419
than 0.7 can be interpreted as reasonable or fair; a value Tables 2 and 3 show the sensitivity, specificity, and pos-
365 420
higher than 0.8 is considered acceptable.57 The surface of the itive and negative predictive values for each individual
366 421
curve was calculated and measured using SPSS. physical test and different combinations of these tests,
367 422
368 423
369 424
370 425
371 426
372 427
373 428
374 429
375 430
376 431
377 432
378 433
379 434
380 435
381 436
382 437
383 438
384 439
385 Fig 2. VAS scores before and after the SIJ block in SIJD-positive patients. SIJD, sacroiliac joint dysfunction; VAS, visual analog scale. 440
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441 496
442 497
443 498
444 499
445 500
446 501
447 502
448 503
449 504
450 505
451 506
452 507
453 508
454 509
Fig 3. VAS scores before and after the SIJ block in SIJD-negative patients. SIJD, sacroiliac joint dysfunction; VAS, visual analog scale.
455 510
456 511
Table 2. Sensitivity, Specificity, and Positive and Negative Predictive Values for Each Physical Test
457 512
FABER Test Thigh Thrust Test Gaenslen Test Yeoman Test Gillet Test Forward Flexion Test
458 513
459 Sensitivity (%) 71.8 74.4 61.5 64.1 100 100 514
460 515
Specificity (%) 66.7 44.4 33.3 33.3 0 0
461 516
462 PPV (%) 90.3 85.3 80 80.6 81 81 517
463 518
464 NPV (%) 35.3 28.6 16.7 17.6 - - 519
465 FABER, Flexion, Abduction and External Rotation; NPV, negative predictive value; PPV, positive predictive value. 520
466 521
467 522
468 523
469 524
470
respectively. The FABER test had the highest specificity 525
471
and positive predictive values. 526
Tables 4 and 5 present the distribution of the positivity Table 4. The Positivity of Each Physical Test in SIJD-Positive
472 and SIJD-Negative Patients 527
473
of each individual physical test and different combinations 528
of these tests, respectively, in SIJD-positive and SIJD-neg- Test SIJD-Positive SIJD-Negative
474 529
ative patients. FABER test Positive 28 3
475 530
476
The results for dual combinations of pain provocation 531
Negative 11 6
477
tests are shown in Table 6. A combination of FABER and 532
478
thigh thrust tests showed the highest improvement in the Thigh thrust test Positive 29 5 533
479
overall diagnostic power (as measured by improvement in 534
the AUC). More specifically, this combination resulted in Negative 10 4
480 535
481
an AUC of 69.2%, a sensitivity value of 71.7%, and a spec- 536
Gaenslen test Positive 15 6
482
ificity value of 66%. 537
483 Negative 24 3 538
484 539
Table 3. Sensitivity, Specificity, and Positive and Negative Pre- Yeoman test Positive 25 6
485 540
dictive Values for Different Combinations of Physical Tests
486 Negative 14 3 541
Three or More Four or More Five or More
487 542
Positive Tests Positive Tests Positive Tests
488 Gillet test Positive 39 9 543
Sensitivity (%) 94.9 92.3 59
489 544
Negative 0 0
490 Specificity (%) 11.1 22.2 55.5 545
491 Forward flexion test Positive 39 9 546
492 PPV (%) 82.2 83.7 85.1 547
493 Negative 0 0 548
NPV (%) 33.3 40 23.8
494 FABER, Flexion, Abduction, and External Rotation; SIJD, sacroiliac joint 549
495 NPV, negative predictive value; PPV, positive predictive value. dysfunction. 550
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551 Table 5. The Positivity of Different Combinations of Physical Although we observed a sensitivity value of 71.8% for 606
552 Tests in SIJD-Positive and SIJD-Negative Patients the FABER test, Broadhust et al59 reported this value to be 607
553 Combinations of Physical Tests SIJD-Positive SIJD-Negative 77% when the diagnostic criterion had been set at a reduc- 608
554
Fewer than 3 positive tests 0 0 tion of 70% in pain, but found a sensitivity of 50% when 609
555 the criterion was 90% pain relief. In contrast, this test had a 610
556 Three or more positive tests 37 8 lower sensitivity (57%) than in the studies by van der 611
557 Wurff et al,60,61 because the SIJ was injected blindly; 612
558
Fewer than 4 positive tests 3 2 blocking under fluoroscopic guidance can increase sensitiv- 613
559
Four or more positive tests 36 7 ity by raising the probability of infiltration into the SIJ. 614
560 In this study, the positive and negative predictive val- 615
561 Fewer than 5 positive tests 16 5 ues of the FABER test were 90.3 and 35.3%, respectively. 616
562 In the review article by Cattley et al,52 the FABER test 617
Five or more positive tests 23 4
563 was referred to as an unreliable and invalid test in SIJD 618
564
Fewer than 6 positive tests 29 8 diagnosis. The authors cited methodological quality, tech- 619
565 nique application, and VAS pain parameters as reasons 620
566 Six positive tests 10 1 for this. 621
567
SIJD, sacroiliac joint dysfunction. The thigh thrust test had a sensitivity of 74.4% and a 622
568 specificity of 44.4% in our study. The sensitivity and 623
569 specificity of this test were 36% and 50%, respectively, in 624
TAGEDH1DISCUSSIONTAGEDEN
570 Dreyfuss et al.45 Broadhurst et al59 reported a sensitivity 625
571 The findings of this study revealed that the positive pre- value of 80% with the pain relief criterion having been set 626
572 dictive values of the provocation tests were high (larger at 70%, and a sensitivity of 69% using a pain relief crite- 627
573 than 80%) and the sensitivity values of these tests exceeded rion of 90%. In both cases, study authors observed a spec- 628
574 60%. Moreover, the thigh thrust test was the most sensitive ificity value of 100%. The sensitivity, specificity, and 629
575 (74.4%), and the FABER test was the most specific positive and negative predictive values obtained in the 630
576 (66.7%). study by Laslett et al13 for the thigh thrust test were 50%, 631
577 Studies on the accuracy of the FABER test have been 69%, 58%, and 92%, respectively, using a pain reduction 632
578 inconsistent in their findings. For example, our study found threshold of 80%. The larger cutoff value was associated 633
579 its specificity to be 66.7%, but Dreyfuss et al45 reported a with a lower reported sensitivity; however, to reduce the 634
580 16% specificity for this test. This significant difference can probability of false positivity, it is better to use a cutoff 635
581 be attributed to that not only did the authors consider a value that is as close to 100% as possible in all of the 636
582 reduction of larger than 90% in VAS scores as SIJD-posi- physical tests. 637
583 tive but also administered a single injection of a local anes- The Gaenslen’s test had a sensitivity value of 61.5% and 638
584 thetic and a corticosteroid with long-term effectiveness. a specificity value of 33.3% in our study. The sensitivity, 639
585 Similarly, Broadhurst et al59 report a 100% specificity of specificity, and positive and negative predictive values 640
586 the FABER test. This is the result of the pain relief criterion found in Laslett et al13 for this test were 37%, 71%, 47%, 641
587 used, which was lower and thus more lenient in the current and 76%, respectively. The specificity of this test in the 642
588 study, and also that they injected the patients who had a study by Broadhurst59 was reported as 100%, which may 643
589 positive FABER test and not those with a negative FABER be attributed to the use of a different protocol (eg, setting a 644
590 result.59 higher cutoff and the injection of 4 cc of lidocaine being 645
591 646
592 647
593 Table 6. Sensitivity, Specificity, and Positive and Negative Predictive Values and AUC Levels in Dual Combinations of Provocative 648
594 Tests 649
595 FABER and FABER and FABER and Thigh Thrust Thigh Thrust Gaenslen 650
596 Thigh Thrust Gaenslen Yeoman and Gaenslen and Yeoman and Yeoman 651
597 Sensitivity (%) 71.7 48.71 43.58 48.71 43.58 35.89 652
598 653
599
Specificity (%) 66 77.77 66.66 66.66 55.55 55.55 654
600 655
PPV (%) 90.32 90.47 85 86.36 80.95 15.66
601 656
602 NPV (%) 35.29 25.92 21.42 23.07 18.51 77.7 657
603 658
604
AUC 69.2% 63.2 55.1 57.7 49.6 45.7 659
605 AUC, area under the curve; FABER, Flexion, Abduction, and External Rotation; NPV, negative predictive value; PPV, positive predictive value. 660
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661 restricted to patients with a positive result on the Gaen- positive predictive values but decreased sensitivity and 716
662 slen’s test). negative predictive values. This is particularly considerable 717
663 Regarding the other tests, the observed discrepancies if there are several tests being combined. Furthermore, a 718
664 between the studies may be due to the adoption of different combination of 3 or more positive provocation tests plus at 719
665 executive approaches. A review of the existing literature least 1 positive motion palpation test produced the best 720
666 indicates that studies have used various thresholds of pain results. 721
667 reduction after the SIJ block, ranging from 50% to 90%. Laslett et al40 showed that patients with a positive diag- 722
668 For instance, Polly56 and van der Wurff60 used a 50% pain nostic SIJ block are at least 3 £ and as much as 20 £ as 723
669 reduction as a diagnostic criterion for SIJD, but Irwin et likely to have had a combination of 3 or more positive pro- 724
670 al26 set a pain reduction of 70% after administering the con- vocative tests than patients with a negative SIJ block. Simi- 725
671 firmatory SIJ block. Schwarzer et al62 employed a single- larly, Laslett et al13 found that the positivity of 2 of 4 tests 726
672 injection SIJ block and set a threshold of 75% reduction in (ie, distraction, compression, thigh thrust, or sacral thrust) 727
673 pain; Maigne et al6 used a reduction of 75% but with a dou- or 3 or more provocation-motion tests were the best predic- 728
674 ble block. Slipman et al18 and Young et al63 used a reduc- tors of a positive SIJ block. 729
675 tion of 80% in pain after a single block. Lastly, Dreyfuss et In the present study, a combination of FABER and thigh 730
676 al45 used a single injection of a local anesthetic and cortico- thrust tests was more accurate than any other combination. 731
677 steroids, in addition to pain provocation tests, and adopted The next most accurate results were obtained from a combi- 732
678 a threshold of 90% reduction in pain severity. In the present nation of FABER and Gaenslen tests. Because FABER and 733
679 study, the threshold was set at 60% because all of the SIJD- thigh thrust tests had the highest sensitivity and specificity 734
680 suspected patients received the double block and this study values (see Table 2), it seems reasonable to use a combina- 735
681 used established, stringent inclusion criteria for identifying tion of these 2 tests for SIJD diagnosis. 736
682 SIJD-suspected patients, believing that these measures can Here, Gillet and forward flexion tests had a sensitivity 737
683 justify a threshold lower than those set in more lenient stud- value of 100% and 0 specificity. This is owing to the inclu- 738
684 ies.28 Indeed, studies that only used pain reduction without sion of patients with at least 1 positive palpation test in 739
685 any other diagnostic criteria had to set a higher threshold accordance with our eligibility criteria. It turned out that 740
686 for diagnosing positive SIJD.19,41,46,59 Gillet and forward flexion tests were both positive in all of 741
687 Some studies used the single block,18,19,59 whereas the included patients. The positive predictive value of both 742
688 others5,6,13,26,39,42,64 (including the current study) adopted these tests was 81%. 743
689 the double block approach. This study used the double It was also found that the results of neither the Gillet test 744
690 block because it has been demonstrated that the prevalence nor the forward flexion test changed after the SIJ block. 745
691 of SIJ pain is estimated to range between 10% and 38% This was because these tests indicate mobility of the ilium 746
692 using a double block paradigm, whereas the false-positive and the sacrum and are not influenced by the SIJ block. It 747
693 rate of the single block is 20% to 54%.28 seems that in SIJD cases without a biomechanical distur- 748
694 Additionally, in some studies,4 corticosteroids were bance, these motion tests are not necessarily positive and 749
695 injected instead of or in combination with lidocaine,19 also may be positive in patients without SIJD.3,50 Thus, it 750
696 which can influence the results of the SIJ block. More spe- is reasonable to use a combination of provocation tests and 751
697 cifically, corticosteroids have a delayed onset of action but motion palpation tests for SIJD diagnosis. 752
698 can reduce pain more effectively than lidocaine, which In contrast, Dreyfuss et al69 showed the false positivity 753
699 results in almost instant pain relief.65 of motion tests by observing that they were positive in 754
700 Although the SIJ block is considered the gold standard 20% of asymptomatic patients. They also found that the 755
701 in the diagnosis of SIJD, in 20% or sometimes up to 50% sensitivity and specificity of the standing flexion and Gil- 756
702 of cases, the SIJ block yields false-positive results, which let tests were poor19 because they were compared with the 757
703 can overestimate the sensitivity of the alternative diagnostic SIJ block as the gold standard. In this regard, other stud- 758
704 tools.16,28,66,67,68 These false results are caused by the ies70,71 compared motion tests with provocation tests and 759
705 extravasation of the locally injected anesthetic to the sur- showed that agreement ranged from 67% to 97% for pain 760
706 rounding structures, such as ligaments, muscles, and lum- provocation tests but was 48% for palpation tests. Further- 761
707 bosacral nerve roots, potential sources of pain. The vertical more, kappa values varied between 0.43 and 0.84 for 762
708 position of the SIJ makes this joint prone to the leakage of provocation tests but were 0.06 for palpation tests. 763
709 the anesthetic, and leakage may occur regardless of the Vanelderen et al also expressed that in the presence of a 764
710 type of SIJ block (eg, fluoroscopy, computed tomography weak predictive value of provocation tests, combined bat- 765
711 scan, sonography, and MRI) employed.28 Thus, gathering teries of physical tests can help ascertain SIJD diagnosis.72 766
712 supplemental forms of evidence through multiple tests can Hence, it can be concluded that joint hypomobility leading 767
713 help to diagnose SIJD more reliably. to positive motion tests does not mean a patient has SIJD, 768
714 According to the findings of this study, a combination of but the positivity of at least 3 provocation tests and at 769
715 the motion and provocation tests increased specificity and least 1 motion test increases the predictivity of SIJD. 770
 ARTICLE IN PRESS
8 Nejati et al Journal of Chiropractic Medicine
Sacroiliac Joint Diagnosis Month 2020

771 Among the provocation tests, a combination of FABER Analysis/interpretation (responsible for statistical analysis, 826
772 and thigh thrust tests was more successful in diagnosing evaluation, and presentation of the results): E.S., L.N. 827
773 SIJD. The authors believe that a combination of physical Literature search (performed the literature search): E.S., 828
774 tests in addition to patient history findings and clinical R.M. 829
775 data can compensate for the low diagnostic power of these Writing (responsible for writing a substantive part of the 830
776 tests. manuscript): P.N., E.S., L.N. 831
777 Critical review (revised manuscript for intellectual content, 832
778 this does not relate to spelling and grammar checking): 833
779 Limitations P.N., F.I., M.S. 834
780 A major limitation of the present study is that the adop- Other (list other specific novel contributions): R.M. (report- 835
781 tion of at least 1 positive palpation test as a diagnostic crite- ing the MRI of the patients) 836
782 ria resulted in the 0 specificity of the palpation tests 837
783 in SIJD-negative patients. Another limitation is the low 838
784 cutoff point (60%) in pain reduction. If this point was 839
785 more than 60%, this may have resulted in lower sensitiv- 840
786 ity in each test. If the number of participants and thus Practical Applications 841
787 the number of SIJ blocks was higher, there could have  In this study, using 2 palpation tests of Gillet 842
788 been various results regarding the accuracy of the physical and forward flexion was not suitable for diag- 843
789 tests. nosing sacroiliac joint dysfunction. 844
790  The prevocational tests were more reliable 845
791 than the Gillet and forward flexion that are a 846
792 TAGEDH1CONCLUSIONTAGEDEN marker of anterior rotation of ilium on the 847
793 sacrum. 848
794
This study found that the FABER test had the highest 849
 The combination of the provocative tests had
795
single specificity and positive predictive values of all of 850
more sensitivity than each test solitarily.
796
the provocation tests under discussion. Further, a combi- 851
797
nation of the FABER and thigh thrust tests improved the 852
798
overall diagnostic power. In addition, greater numbers of 853
799
positive physical tests contribute more to an SIJD diag- 854
nosis. It is also recommended that at least 3 provocation TAGEDH1REFERENCESTAGEDEN
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