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Research Review By Dr. Michael Haneline©

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Date Posted:

March 2021

Study Title:

Clinimetric properties of sacroiliac joint mobility tests: A systematic review

Authors:

Klerx S, Pool J, Coppieters M, Mollema E & Pool-Goudzwaard A

Author's Affiliations:

HU University of Applied Sciences Utrecht, Institute of Movement Sciences, Utrecht, the Netherlands; The Hopkins Centre, Menzies Health Institute Queensland, Griffith University, Australia; Faculty of Behavioral and Movement Sciences, Vrije Universiteit, Amsterdam, the Netherlands; SOMPT University of Physiotherapy, the Netherlands.

Publication Information:

Musculoskeletal Science and Practice 2020; 48: 102090. https://doi.org/10.1016/j.msksp.2019.102090.

Background Information:

Sacroiliac joint (SIJ) pain is a common type of mechanical low back pain that is thought to affect 15-30% of persons with chronic, non-radicular low back pain. SIJ dysfunction refers to abnormal anatomy and/or biomechanical function in the form of either hypermobility or hypomobility of the SIJ.

Assessment of the SIJ generally includes two categories of clinical tests:
  1. Pain provocation tests: which have shown poor reliability and validity in systematic reviews; and
  2. Dysfunction (or mobility) tests: which are designed to assess altered SIJ mobility, although these tests also have not demonstrated satisfactory reliability and validity.
Previous reviews have questioned whether SIJ mobility tests are of any value in clinical practice; however, the most recent review was published nearly 20 years ago, and any recent studies were therefore not included.

Therefore, the objective of this study was to conduct an up-to-date systematic review to verify whether recommendations regarding the use of SIJ mobility tests should be revised regarding clinimetric properties, including reliability, validity and responsiveness, in people with non-specific low back pain, pelvic girdle pain and/or SIJ pain.

Pertinent Results:

After the screening of 1381 articles that were found during the literature search, removing duplicates, and following full-text assessment, 12 studies met the inclusion criteria. Eleven studies considered the reliability and two studies the validity of SIJ mobility tests. As a refresher – reliability refers to the reproducibility of the clinical test and validity refers to whether a given test measures what it claims to measure.

Only three reliability studies (1-3) were found to be of fair methodological quality. The other reliability and validity studies were considered to be of poor methodological quality and therefore were excluded.

The level of evidence found in the three studies with fair methodology was considered to be low. In addition, the reported level of evidence for the Gillet test was conflicting. No study assessed validity.

The following SIJ mobility tests were assessed for inter-tester reliability (i.e. can two testers reach the same conclusion):
  1. Click-clack test (patient sitting, movement of the left and right posterior superior iliac spine [PSIS] is assessed when the patient moves the trunk from lordosis to kyphosis) was reported to have substantial agreement (κ: 0.61 to 0.80).
  2. Standing flexion test (patient standing, SIJ movement is assessed while the patient bends forward) moderate agreement (κ: 0.41 to 0.60).
  3. Seated flexion test (patient sitting, SIJ movement is assessed while the patient bends forward) had substantial agreement (κ: 0.61 to 0.80).
  4. Gillet test (patient standing, SIJ movement is assessed while the patient lifts the opposite knee toward the chest) had slight agreement in one study and fair agreement in another study.
  5. Prone knee flexion test (patient prone, leg length discrepancy is compared between test positions) had fair agreement (κ: 0.21 to 0.40).
  6. Heel-bank test (patient sitting, SIJ movement is assessed while the patient places one foot on the treatment table) had fair agreement (κ: 0.21 to 0.40).
  7. Abduction test (patient side-lying, a discrepancy in load transfer is assessed) had fair agreement (κ: 0.21 to 0.40).
  8. Thumb-posterior superior iliac spine (PSIS) test (patient sitting, the position of the PSIS was measured on a horizontal line in relation to each other) had fair agreement (κ: 0.21 to 0.40).
A cluster of SIJ mobility tests (Gillet test, standing flexion test, seated flexion test and the prone knee flexion test) was examined for inter-tester reliability. The test cluster showed higher reliability as compared to the individual tests.

Clinical Application & Conclusions:

Based on reviews published almost 20 years ago, the latest clinical recommendation does not support the use of SIJ mobility tests due to poor clinimetric properties (4-5). Similarly, the authors of this current review concluded that the previous recommendation remains the same – that SIJ mobility tests should not be utilized in clinical practice.

Even though Arab et al. (3) reported reliability for individual SIJ mobility tests as fair and moderate, the authors of this review were critical because the corresponding confidence intervals were very wide. Wide confidence intervals indicate general imprecision of the estimate, which questions the reproducibility of the reported reliability values.

The inter-tester reliability for the cluster of tests was found to be fair to substantial, and highest for the cluster with two out of four positive SIJ mobility tests. The reliability values were of a clinically useful magnitude; however, the authors were concerned about reliability because:
  1. the test cluster consisted of individual SIJ mobility tests with uncertain reliability due to large confidence intervals;
  2. the reliability of the test clusters was reported for the left and right SIJ rather than for the affected and unaffected side which may have inflated the reported reliability;
  3. there was no rationale as to why the cluster with two positive tests would have the highest reliability.
Reviewer’s Comment:
Notwithstanding the authors’ conclusion that SIJ mobility tests should not be utilized in clinical practice, I consider them to be of value, together with other clinical SIJ tests, when determining when to apply SIJ manipulation/mobilization. Furthermore, SIJ mobility tests are taught in manual therapy academic programs worldwide.

The authors may have been too stringent in their study exclusion criteria and discounting of the included studies’ reported acceptable agreement because of wide confidence intervals. Given the SIJ study limitations that were pointed out by the authors, further research is needed in this area that corrects previous methodological faults and includes sufficient numbers of participants.

Study Methods:

This was a systematic review that utilized the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

A literature search of the following databases was conducted: PubMed, CINAHL, Embase, SPORTDiscus and Cochrane Library. In addition, the reference lists of eligible articles were scanned for additional relevant studies. Articles were screened for inclusion by 2 reviewers who worked independently. A third reviewer was consulted if there were any disagreements.

Inclusion Criteria:
  • the article had to report on clinimetric properties of SIJ mobility tests performed in adult patients with non-specific low back pain, pelvic girdle pain and/or SIJ pain; and
  • the mobility tests had to be performed in a clinical setting.
Exclusion Criteria:
  • technical tests that could not be performed in clinical practice;
  • studies that evaluated SIJ mobility tests in patients with a specific disorder (e.g., ankylosing spondylitis); and
  • systematic reviews.
The ‘Consensus-Based Standards for the Selection of Health Measurement Instruments’ (COSMIN) Protocol for Systematic Reviews of Measurement Properties were used to assess the studies’ quality and for data extraction. Two researchers independently rated the included studies’ quality using the COSMIN scorecard. Any disagreements were resolved using a third investigator.

The COSMIN appraisal tool was also used to assess the various measurement properties (e.g., reliability, content validity, structural validity, criterion validity and responsiveness) which rated them on a 4-point ordinal scale (excellent, good, fair, poor). The studies’ overall quality score had to be rated as fair or higher to be selected for data extraction and data pooling.

No consensus guidelines are available for systematic reviews on measurement properties, so the authors used the Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE) criteria to determine levels of evidence and adjusted them by taking methodological quality of the studies and adequacy of the measurement properties into account.

Study Strengths / Weaknesses

This was a well-conducted systematic review that followed accepted systematic review guidelines.

Limitations of this review included the following:
  • Very few studies were included. When determining which studies to include in the review, 9 out of 12 were excluded due to insufficient methodological quality.
  • The included reliability studies were only of fair methodological quality, mainly because the sample sizes were too small for the amount of tests and combinations that were investigated.
  • Another limitation is that a meta-analysis could not be performed because so few studies were included and the fact that they assessed different SIJ mobility tests in different populations.

Additional References:

  1. Meijne W, Neerbos K, Aufdemkampe G, Wurff P. Intraexaminer and interexaminer reliability of the Gillet test. J Manip Physiol Ther 1999; 22(1): 4–9.
  2. van Kessel-Cobelens AM, Verhagen AP, Mens JM, Snijders CJ, Koes BW. Pregnancy-related pelvic girdle pain: intertester reliability of 3 tests to determine asymmetric mobility of the sacroiliac joints. J Manip Physiol Ther 2008; 31(2): 130–136.
  3. Arab AM, Abdollahi I, Joghataei MT, Golafshani Z, Kazemnejad A. Inter- and intra-examiner reliability of single and composites of selected motion palpation and pain provocation tests for sacroiliac joint. Man Ther 2009; 14(2): 213–221.
  4. van der Wurff P, Hagmeijer R, Meyne W, Clinical tests of the sacroiliac joint: a systematic methodological review. part 1: reliability. Man Ther 2000a; 5(1): 30–36.
  5. van der Wurff P, Meyne W, Hagmeijer R. Clinical tests of the sacroiliac joint: a systematic methodological review. part 2: validity. Man Ther 2000b; 5(2): 89–96.

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