Research Review By Dr. Jeff Muir©


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Date Posted:

September 2022

Study Title:

Diagnostic Accuracy of Clusters of Pain Provocation Tests for Detecting Sacroiliac Joint Pain: Systematic Review with Meta-analysis


Saueressig T, Owen PJ, Diemer F, Zebisch J & Belavy DL

Author's Affiliations:

Physio Meets Science GmbH, Leimen, Germany; Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, Burwood, Australia; Department of Applied Health Sciences, Division of Physiotherapy, Hochschule for Gesundheit, Bochum, Germany

Publication Information:

Journal of Orthopaedic & Sports Physical Therapy 2021; 51(9): 422-431.

Background Information:

The sacroiliac joint (SIJ) is a potential source of pain which, although relatively common, varies in prevalence from 10-64% (1). Part of this variance is attributed to the difficulty in definitively identifying the SIJ as the source of a patient’s pain. Diagnosis of SIJ problems is often challenging, resulting in inconsistent recommendations regarding treatment. There is evidence from prior literature reviews that combining provocation tests into clusters (i.e. a set of provocation tests is performed and a diagnosis is made based on a specified number of positive or negative tests) results in improved inter-tester reliability and diagnostic performance relating to the SIJ (2-4). These reviews, however, are largely outdated and, in some cases, included multiple publications of the same cohort of patients.

As such, an updated, methodologically sound review is required. The aim of this study was to determine the diagnostic accuracy of SIJ provocation tests performed in clusters.

Pertinent Results:

Eligible Studies:
Initial searches identified 2195 studies, of which 15 underwent full-text review. 5 studies were subsequently identified as eligible for this review/meta-analysis. Of the eligible studies, 2 used consecutive sampling, 1 method was unclear, 1 was non-consecutive and 1 did not report their sampling methodology. Recruitment periods spanned 12-24 months; pain reduction thresholds varied from 50% reduction to 100%. The reported provocation tests included: distraction test; thigh thrust test; Gaenslen’s test; flexion, abduction, external rotation test (FABER); sacral distraction test; lateral compression test; Patrick test (aka FABER); Yeoman’s test; Newton test (full supine hip and knee flexion – pushed into abdomen); and the ipsilateral Gaenslen’s test.

Data Handling:
2-by-2 tables from each study were used. Where 2-by-2 tables were not available, the authors created tables from the reported diagnostic parameters. The pooled diagnostic odds ratio (DOR) was 6.02 (95% CI: 1.38, 26.32). The heterogeneity of the DOR was quite small (Cochran's Q=5.312, df=5, p=0.379, I2=0%).

Meta-Analytic Estimates:
Pooled sensitivity (0.83; 95% CI: 0.62,0.93), specificity (0.59; 95% CI: 0.36,0.79), and the false-positive rate (0.41; 95% CI: 0.21, 0.64) values were estimated from the study results and generally did not reflect strong evidence in support of the use of test clusters in SIJ pain. The calculated +LR was 2.13 (95% CI: 1.2, 3.9), the -LR was 0.33 (95% CI: 0.11, 0.72) and the DOR was 9.01 (85% CI: 1.72, 28.4).

Subgroup Analysis and Meta-Regression:
Due to the low number of studies, no subgroup analysis was possible.

Clinical Application & Conclusions:

The data from this review suggest that clusters of pain provocation tests for SIJ pain do not provide sufficient diagnostic test accuracy. Based on these results, a positive test result gives only a 35% certainty of correctly identifying the SIJ as the source of pain. Ruling out the SIJ as the source of pain has higher certainty (92% certainty that a negative test is correct), though, when using clusters of provocation tests. Clinicians should keep these differences in mind when evaluating results from clusters of tests, as the ability to rule in and rule out a diagnosis differed considerably.

Editor’s comment: This is yet another study indicating that ‘orthopedic’ physical examination tests aren’t perfect, even when performed and interpreted in combination, in this case for the SIJ. This is not surprising, and once again highlights the importance of putting physical examination findings in the proper context with the entirety of information you obtain during an initial examination, or subsequent assessment.

Study Methods:

Searched databases included: MEDLINE, CINAHL, Embase, ProQuest Dissertations & Theses Global, Open Access Theses and Dissertations, DART-Europe E-theses Portal and Web of Science from their inception to Sept/Oct 2020. No filters were used in the search and additional searches of reference lists of previously published systematic reviews were also searched for relevant articles. One reviewer completed the searches while 2 other reviewers independently screened the articles.

Selection Criteria:
Studies of adult patients with SIJ pain due to SIJ dysfunction, with or without leg pain published in German or English language were included. The index test was a cluster of pain provocation tests (distraction, compression, thigh thrust, Gaenslen’s and sacral thrust tests). Control interventions were intra-articular anesthetic blocks.

Data Extraction:
Data was extracted by 1 reviewer and checked by a second reviewer. Outcome data was extracted in duplicate. 2-by-2 tables were created for any studies where data was unreported, or tables were not included using sensitivity, specificity, prevalence and predictive values. Data not able to be reconstructed was requested from the original authors.

Risk of Bias Assessment and GRADE:
Risk of bias was evaluated using the QUADAS-2 tool (5). Studies were rated low risk, high risk or unclear risk. The GRADE approach was used to assess the certainty of evidence (6).

Statistical Analysis:
Diagnostic odds ratios (DORs) with 95% confidence intervals were calculated from 2-by-2 tables. Meta-analysis was performed on studies reporting clusters of a minimum of 3 positive tests, using a random-effects model. Sensitivity, specificity, false-positive rate, DOR, +LR and -LR were all calculated with 95% confidence intervals.

Study Strengths / Weaknesses:

  • The authors conformed to Cochrane and PRISMA guidelines.
  • The meta-analysis included sensitivity and specificity calculations.
  • Double counting of study populations (as observed in previously published reviews) was avoided.
  • Different clusters of tests were used across the different studies, resulting in high heterogeneity and a low number of eligible studies.
  • Most studies focused on patients whose pain was localized to the SIJ region, which may not accurately represent all patients who may hove pain from that joint, or related musculoskeletal issues.
  • Small-study effects and publication bias were not assessed due to the small number of studies included.

Additional References:

  1. Kennedy DJ, Engel A, Kreiner DS, Nampiaparampil D, Duszynski B, MacVicar J. Fluoroscopically guided diagnostic and therapeutic intra-articular sacroiliac joint injections: a systematic review. Pain Med 2015; 16: 1500-1518.
  2. Hancock MJ, Maher CG, Latimer J, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J 2007; 16: 1539-1550.
  3. Petersen T, Laslett M, Juhl C. Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews. BMC Musculoskelet Disord 2017; 18: 188.
  4. Szadek KM, van der Wurff P, van Tulder MW, Zuurmond WW, Perez RS. Diagnostic validity of criteria for sacroiliac joint pain: a systematic review. J Pain 2000; 10: 354-368.
  5. Whiting PF, Rutjes AW, Westwood ME, et al. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 2011; 155: 529-536.
  6. Schunemann JH, Mustafa RA, Brozek J, et al. GRADE guidelines: 21 part 1. Study design, risk of bias, and indirectness in rating the certainty across a body of evidence for test accuracy. J Clin Epidemiol 2020; 122: 129-141.

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