I thought this horse was already beaten to death.  However, after speaking with a group of future 2014 DPT graduates, it came to my attention that palpation and movement-based diagnostics for pain arising from the SIJ are still being taught.  No, not at a weekend course on treatment of the SIJ to get CEUs, but yes, to the sponge-like minds in the next breed of physical therapists.

After this information was forwarded to me, I gave a long, confused, and somewhat evil eye their way. But it took me a few seconds to catch on…since they were taught this—they believed it.  How can you blame them? Go back to your days in school. At that stage in learning, the job is to take everything in and agree with it.  You haven’t built a skeptical mindset or second-guessed information.

Furthermore, it wasn’t as if individual tests (Gillet, Standing Forward Flexion, etc) were taught just to be taught.  We all went through the individual tests.  It is part of our history.   I can understand teaching individual tests, as long as the bottom line is spread (aka poor diagnostic utility), but we have better research now.  It is not like we do not know there is something bigger and better out there.

The argument from students towards my skepticism is that they were taught the combination of tests, not individual, that yield higher level evidence that SIJ is the source.  The culprit: an article by Pamela Levangie in 1999 entitled, “Four Clinical Tests of Sacroiliac Joint Dysfunction: The Association of Test Results With Innominate Torsion Among Patients With and Without Low Back Pain“.

Physiopedia cites this article with the following conclusion:

They reported that the cluster of these tests exhibited a sensitivity of 0.82, specificity of 0.88, + LR of 6.83, and – LR of 0.20.

I tell you, I don’t know how those numbers got pulled out of there. But needless to say, if it were pertinent, you would think the conclusions would rightly say so:

photo2

photo1

This article was published in 1999.  We all know there has been better research since that date.  You would think the old would be glossed over with the new.  I thought it had, but we are just keep on hanging on to these tests for hope.

I first learned the best diagnostic criteria for SIJ through my training at the Spinal Manipulation Institute, and created my own blog posts several years ago: part1a, part1b, part2, part3a, and part3b.

I am not the only blogger screaming this. I recommend checking out the clinical utility of provocation tests elsewhere too.  Recommendations include, Joe Brence’s blog Forward Thinking PT, Adam’s Sports Physio Blog, and Mike Reinold’s Blog.  Even though spread by wildfire from level 5 (if blogger’s are even level 5) evidence, this information should be out there on every SIJ course, no matter if you agree or disagree with the findings.  It is the best available to date comparing SIJ to the criterion standard.

The bottom line:  Even though the students were fresh learners, it seemed to me that it was difficult for them to understand a different viewpoint.  Makes me really think about what information is provided to clinicians first and how that shapes you.

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5 comments

  1. Harrison, great write-up here. I know the standard of evidence-based practice right now is to go with pain provocation tests. There is a serious lack of research that supports the movement-based tests. That being said, I feel like we can’t rely on what studies do and don’t say to this degree. I realize the Spinal Manipulation Institute disregards some information on the SIJ. I have heard from some that are certified through the group that they believe “you can’t palpate landmarks on the sacrum.” I disagree with this, but I recognize the bony asymmetries that may make this pointless anyway. My main point is just because there isn’t sufficient evidence to support something, doesn’t mean we should stop doing it. This is not the same thing as saying evidence against what we are doing. I frequently questions the skill of the PTs in manual therapy studies. Part of the problem is that in PT school we are taught to look for these large significant differences in movement and palpation, not the small ones that are clinically relevant. This may all sound like bias, but I cannot rely on the SIJ pain provocation cluster. I still use it, but I can’t tell you how many times I have had patients negative on all the tests but found asymmetries. I then proceeded to correct the asymmetries and relieved pain in the LEs. I am not even going to discuss the potential for non-painful SIJ dysfunction and its importance (consider how an asymptomatic hypomobile shoulder can lead to cervical pain) as there is no research on the topic. My point is, unless something better is found, we should not throw those palpation/movement-based tests under the bus, especially if we are getting significant changes. Thank you for your post.

    1. Chris,
      Thanks for your response! I do agree that we can’t just not do things as research doesn’t support it…I think I heard somewhere in medicine that this number is 70% or so. Quite a large number for supposedly a field where we think physicians know it all!
      I tell my students that if we waited for research, then we wouldn’t be able to do anything. However, on the other side of the coin, it takes ~17 years (sorry, do not have source) to get evidence into daily practice. This needs to improve. Social media has definitely assisted in this number and hopefully will bring it down…to get the best evidence out there.

      I do agree that we have all had your experience in obtaining a functional change without a positive clinical test, such as your example above. This is the other pillar of EBP…clinician expertise/experience.

      I would argue against correct asymmetries is that we do not know if those asymmetries are valid or not. Not to speak of if it is reliable if you and I would be able to detect the same asymmetry. The lack of reliability and validity make it impossible to create any type of greater evidence, other than level 5 or clinician expertise, that performing those same therapeutic interventions will assist other patients.
      Hv

  2. Hey Harrison, great post today.

    We have discussed this issue in the past and I am in agreement with you. Teaching and using palpation for asymmetry and mobility tests for SIJ assessment should be a dead subject, but many clinicians and people in academia are not willing to accept the overwhelming evidence on this subject that seriously challenges the reliability and more importantly the validity of these tests. It would be easy to understand if these tests were taught as a general knowledge for DPT students and the significant weaknesses of the tests were discussed in the PT programs and contrasted with the stronger evidence for SIJ pain provocation tests.

    The SIJ pain provocation tests have limitations as well and should be discussed in these programs. The SIJ pain provocation tests are highly predictive for a positive response to SIJ injection. This is very diagnostic for SIJ, but does not mean that the patient will or will not respond to conservative care. These tests do not guide us towards the best intervention for the treatment of SIJ pathology. Further study needs to be done to determine which intervention (HVLAT, mobs, exercise or combination etc…) would be best for patients that are positive for Laslett or Van der Wurff’s cluster tests. Another limitation is that the double SIJ injection is a criterion standard and not a true gold standard which decreases the possible validity of the tests.

    A common clinical reasoning error that I hear many DPT students and other clinicians make is that a treatment response proves their clinical assessment was correct. I hear this quite a bit regarding SIJ. There are studies demonstrating that manual therapy is not as specific as we would like to think. We like to believe that we are able to skillfully impact or target the assumed dysfunctional region, but unfortunately this is not true for mobilization or manipulation. Our treatment aimed at one structure maybe actually treating the dysfunctional structure at another level. A positive response to treatment just confirmed our bias in the assessment and may not represent the actual issue with the patient.

    Thanks again for the post,

    Eric

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