CPR+for+diagnosis+of+low+back+pain+and+SI+joint+dysfunction

= CPR For Diagnosis of Low Back Pain and SI Joint Dysfunction =



Clinical questions: What clinical prediction rules can be used to make diagnosis of LBP more accurate? Low Back Pain - Pain in the lower back relating to problems with the lumbar spine, discs between the vertebrae, ligaments around the spine and discs, spinal cord and nerves, muscles of the low back, internal organs of the pelvis and abdomen, or the skin covering the lumbar area [1] .

Common Sources -Majority of cases are linked to a general condition or mechanical nature [2]
 * Muscle strain/sprain
 * Stenosis
 * Degenerative disc disease
 * Sacroiliac joint dysfunction
 * Skeletal irregularities

Low Back Pain Prevelance
 * 80% of the population experiences low back pain in their lifetime
 * 20% of cases progress to chronic stage
 * 3rd most burdensome condition in the US in terms of mortality/poor health (2010)
 * 30%-40% of workforce reports some back pain at any given time
 * <span style="font-family: Arial,Helvetica,sans-serif;">Most common cause of work-related disability <span style="font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">[3,4]

<span style="font-family: Arial,Helvetica,sans-serif;">Low Back Pain Cost

<span style="font-family: Arial,Helvetica,sans-serif;">Overall a $200 billion/year problem <span style="font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">[5,6]
 * <span style="font-family: Arial,Helvetica,sans-serif;">Costs >$50 billion/year in lost work productivity.

<span style="font-family: Arial,Helvetica,sans-serif;">Typical Medical Diagnostic Costs


 * <span style="font-family: Arial,Helvetica,sans-serif;">MD office visit $200
 * <span style="font-family: Arial,Helvetica,sans-serif;">Low back X-Ray $200-$300
 * <span style="font-family: Arial,Helvetica,sans-serif;">MRI $800-$1,300
 * <span style="font-family: Arial,Helvetica,sans-serif;">Low back CT $1,000-$1500
 * <span style="font-family: Arial,Helvetica,sans-serif;">Over the counter pain medication $15/month
 * <span style="font-family: Arial,Helvetica,sans-serif;">Prescription pain medication $100/month

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 18px;">Diagnosing Generalized LBP <span style="font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;"> [7]

 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px;">Frenquently misdiagnosed
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px;">Traditionally diagnosed on expert opinion
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 12px;">Need for CPRs to help sub-type LBP diagnosis


 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 18px;">Lumbar Spinal Stenosis (LSS) <span style="font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;"> [8] **

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;"> Narrowing of the spinal canal and intervertebral foramen <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;"> The most common cause is Osteoarthritis
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">Most common in people over the age of 60
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">More than 200,000 people per year [9]
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">Interferes with function and ADLs


 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 18px;">Common Symptoms of LSS **<span style="font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;"> [7]
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">Low back pain
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">Numbness or tingling in the lower extremities
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">Weakness in the lower extremities


 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 18px;">CPR for LSS **
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">Systematic review in the JOSPT reported a CPR for LSS that has been validated
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">Consists of 10 variables
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">Derived from a study published in the European Spine Journal


 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 18px;">Derivation <span style="font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;"> [10] **
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">Study used multivariate linear regression to determine what factors were useful for predicting presence of LSS
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">Factors were compared to a panel of experts that was used as the gold standard <span style="font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;"> [10]
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">Primary symptoms of the 469 participants in the study were pain or leg numbness <span style="font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">[10]
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">Sensitivity of .92 and specificity of .72 <span style="font-family: Arial,Helvetica,sans-serif; font-size: 80%; vertical-align: super;">[10]
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">Results based on a point scale


 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 18px;">Overview of LSS diagnostic CPR **


 * **Variable** || **Score** ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Age (years) ||  ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;"><60 || <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;"> 0 ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">60-70 || <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;"> 1 ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">>70 || <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;"> 2 ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Diabetes ||  ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Present || <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;"> 0 ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Absent || <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;"> 1 ||
 * <span style="color: #000000; font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Intermittent claudication ||  ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Present || <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;"> 3 ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Absent || <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;"> 0 ||
 * <span style="color: #000000; font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Exacerbation of symptoms when standing ||  ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Present || <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;"> 2 ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Absent || <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;"> 0 ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Symptoms improve with trunk flexion ||  ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Present || <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;"> 3 ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Absent || <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;"> 0 ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Symptoms induced with trunk flexion ||  ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Present || <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;"> -1 ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Absent || <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;"> 0 ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Symptoms are induced with trunk extension ||  ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Present || <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;"> 1 ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Absent || <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;"> 0 ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Peripheral artery circulation ||  ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Dorsalis pedis artery has diminished pulse or ABI <0.9 || <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;"> 0 ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Dorsalis pedis artery easily be palpated or ABI >0.9 || <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;"> 3 ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Achilles tendon reflex ||  ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Normal || <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;"> 0 ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Absent or low || <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;"> 1 ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Straight leg raise test ||  ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Positive || <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;"> -2 ||
 * <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;">Negative || <span style="font-family: 'AdvPTimesB',serif; font-size: 10.6667px;"> 0 ||


 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 18px;">Variables **

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;"> <60 = 0 <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;"> 60-70 = 1 <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;"> >70 = 2
 * **<span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">Age **

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;"> -Present = 0 <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;"> -Absent = 1
 * **<span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">Comorbidity of Diabetes **

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;"> -Present = 3 <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;"> -Absent = 0
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">**Intermittent Claudication**

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;"> -Present = 2 <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;"> -Absent = 0
 * **<span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">Exacerbation of symptoms when standing **

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;"> -Present = 3 <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;"> -Absent = 0
 * **<span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">Symptoms improve with trunk flexion **

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;"> -Present = -1 <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;"> -Absent = 0
 * **<span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">Symptoms induced with trunk flexion **

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;"> -Present = 1 <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;"> -Absent = 0
 * **<span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">Symptoms induced with trunk extension **

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;"> -Dorsalis pedis pulse diminished or ABI <0.9 = 0 <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;"> -Dorsalis pedis pulse easily palpated or ABI >0.9 = 3
 * **<span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">Peripheral artery circulation **

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;"> -Normal = 0 <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;"> -Absent or low = 1
 * **<span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">Achilles tendon reflex **

<span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;"> -Positive = -2 <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;"> -Negative = 0
 * **<span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">Straight leg raise test (specificity of .74 for lumbar disc herniation) [11]**

https://youtu.be/LdAD9GNv8FI?t=50s [12]


 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 18px;">Score Cutoff **
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;">Score >7 indicates possible lumbar stenosis [10]
 * <span style="font-family: Arial,Helvetica,sans-serif; font-size: 14px;"> Not a definitive tool, but can be very helpful


 * Inflammatory Back Pain **

http://kids.britannica.com/comptons/art-166962/Ankylosing-spondylitis-is-an-arthritic-condition-that-can-fuse-bones

http://www.indeedcare.com/physiotherapy-for-ankylosing-spondylitis/
 * Inflammatory back pain isn't a condition, it's a group of symptoms [13]
 * Inflammation of the vertebrae, facet joints, or tendon and ligament attachment sites
 * Associated with conditions known as spondylo-arthritides
 * //Ankylosing spondylitis (Also known as Axial Spondyloarthritis)- Most common spondylo-arthritide in IBP. Inflammation of the vertebrae, that can cause severe pain and functional limitation. In some advanced cases, the inflammation of bones can lead to fusion of the spine and cause a forward stooped posture// [13]
 * SI Joint is most commonly involved (sacroiliitis)
 * Can affect other joints of the body, and rarely, the heart and lungs
 * Genetic link: marker known as HLA-B27, found in 95% of caucasians with ankylosing spondylitis [13]
 * Prevalence: 0.4%-1.4%, depending on the population. The cause of chronic low back pain in 4%-5% of patients [14]

Why need a Clinical Prediction Rule? [7]

 * Inflammatory back pain may take several years to show up radiographically.
 * Early identification is crucial to successful management of the disorder
 * CPR's can't definitely diagnose IBP, but can indicate whether further testing needs to be done, and how to manage the treatment.

__Objective:__
Differentiate between inflammatory back pain and mechanical low back pain by identifying individual features of each disorder.

__Methods:__

 * 213 patients recruited, with the patients required to be less than or equal to 50 years old.
 * Each patient had already been diagnosed prior to the study. This allowed the researchers to use a questionnaire to identify common symptoms in AS
 * Unblinded trained examiner provided face to face interviews to give the questionnaires.
 * Each patient answered various questions about their symptoms, as well as had a measurement taken of their low back flexion ROM.

__What They Found:__
From the questionnaire, these 4 variables were identified as the most independent combination of predictors of Inflammatory Back Pain from Mechanical Low Back Pain. [7] If two or more variables are present in the patient, the sensitivity is 0.73 and the specificity is 0.81 [7]

__Validation Studies:__ [7]
1. Sleper et al: 20 patients, sensitivity:0.84, Specificity: 0.63 2. Sleper et al: 648 patients, sensitivity: 0.70, specificity: 0.81 3. Chan et al: 25 patients, sensitivity: 0.92, specificity: 0.67

[7]

__Objective:__
Inflammatory Back Pain is an important symptom of Axial Spondyloarthritis, and a newer criteria is discussed

__Methods:__
 * 20 patients who had back pain and possibly had AS, were observed by 13 different rheumatologists who are considered experts in AS
 * Each expert interviewed the patients and judged whether they had IBP based on parameters typical for the disorder
 * The expert's judgment was used as a dependent variable in a logistical regression to determine the best individual parameters for IBP diagnosis

__What They Found:__ [7] From the experts judgment, the best predictors for IBP were 5 different items If 4 or more of the above variables are positive in the patient, then the sensitivity is 0.77, and the specificity is 0.92.

1. Sieper et al: 648 patients, sensitivity: 0.80, specificity: 0.72
** LBP resulting from Sacroiliac Joint **

Sacroiliac Joint (2)

http://www.spinehealth.com/images/sacroiliac-joint-pain.jpg

Where the sacrum and ilium articulate to support the weight of the upper body when upright and shift the load to the lower extremities with ambulation. Pain can be caused by overuse, trauma, ligament instability, secondary to other conditions/pregnancy, or uneven biomechanics with ambulation; and is a result of the SI joint becoming inflamed. It is described as dull or sharp pain that can radiate to the butt, thighs, groin, or upper back. The vague description and patterns of symptoms often lead to misdiagnosis. It is commonly misdiagnosed as a LBP cause by Lumbar Discs/Zygapophyseal Joints/Nerve Roots/ and others. 17,18

With LBP being such a frequent phenomenon there is a need for a Clinical Prediction Test for differential diagnosis. Examination of the Lumbar Spine and Pelvis have not been proven successful and there has not been a definitive composite of symptoms or clinical signs adopted. Contrast enhanced intra-articular anesthetic injections have been the test to show diagnostic value with a sensitivity of 98% and a low false positive rate. (science ss) The International Association for the Study of pain has proposed criteria for Spinal Pain stemming from the Sacroiliac Joint as: Pain in the sacroiliac joint region with or without referred pain to lower limb girdle or lower limb and must fulfill all the following criteria: 1. Pain in S.I. Joint regio. 2. Selective clinical stress tests of the S.I. Joint reproduces patient's pain. 3. Injection of local anesthetic to symptomatic joint completely relieves the patient of pain. (IASP) 18,19

How can we accurately and confidently identify the S.I. Joint as the cause of a patient’s LBP?

The Problem

Stress Testing of S.I. Joint can reproduce symptoms of S.I. origin BUT stress testing cannot load that specific structure without involving others. When familiar pain is provoked there cannot be certainty it is the S.I. Joint.

The Solution

Composite of multiple different stress tests. Isolating structures with each test can rule out structures and narrow down the structure of origin.

Present Study

This was a validation and expansion study from one they conducted in 2003 which

“identified a composite of three provocation SIJ tests in the absence of centralization during repeated movement testing has clinically useful sensitivity, specificity and positive likelihood ratio (93%, 89% and 6.97%, respectively) 20

Key Search Words
 * Sacroiliac joint;
 * Low back pain;
 * Physical examination;
 * Diagnosis;
 * Validity;
 * Sensitivity;
 * Specificity

Inclusion Criteria
 * Patients with buttock pain, with or without lumbar or lower extremity symptoms.
 * Patients were scheduled for the clinical evaluation
 * Each patient had undergone imaging studies
 * Had variety of unsuccessful therapeutic interventions.
 * They were referred for diagnostic evaluation and procedures by a variety of medical and allied health practitioners and a few were self-referred.

Exclusion Criteria
 * o Patients were excluded from the study if they were unwilling to participate,
 * o had only midline or symmetrical pain above the level of L5,
 * o had clear signs of nerve root compression (complete motor or sensory deficit), or
 * o were referred for specific procedures excluding SIJ injection.
 * o Those deemed too frail to tolerate a full physical examination, were also excluded.

Operational Definitions 20,21
 * //<span style="color: #2e2e2e; font-family: Calibri,sans-serif;">The familiar symptom // <span style="color: #2e2e2e; font-family: Calibri,sans-serif; line-height: 1.5; vertical-align: baseline;">: Pain or other symptoms (such as aching, burning, paraesthesiae or numbness) identified on a pain drawing. Patient verified and distinguished form other symptoms during examination. It can be manipulated and abolished during testing.
 * //<span style="color: #2e2e2e; font-family: Calibri,sans-serif;">Positive provocation SIJ test // <span style="color: #2e2e2e; font-family: Calibri,sans-serif; line-height: 1.5; vertical-align: baseline;">: A provocation SIJ test that produces or increases familiar symptoms.
 * //<span style="color: #2e2e2e; font-family: Calibri,sans-serif;">Positive SIJ injection // <span style="color: #2e2e2e; font-family: Calibri,sans-serif; line-height: 1.5; vertical-align: baseline;">: Injection that provokes familiar pain and local anesthetic injected reduced it. Positive injections were given a confirmatory block injection.


 * Overview **

<span style="color: #2e2e2e; font-family: Calibri,sans-serif; vertical-align: baseline;">Sixty-two patients agreed to participate. Forty-eight patients satisfied all inclusion criteria. There were no significant differences between positive and negative responders to diagnostic injection with regards to age, gender, working status, Dallas and Roland questionnaire results or pain intensity prior to examination. <span class="apple-converted-space" style="color: #2e2e2e; font-family: Calibri,sans-serif; vertical-align: baseline;"> Injection and examination were done in the same day blinded from one another and results were recorded on separate data collection forms. Therapists were blinded to previous results of imaging and injections. 6 provocation test were selected and have shown acceptable inter-examiner reliability. <span style="color: #2e2e2e; font-family: Calibri,sans-serif; vertical-align: baseline;">Individually the test are not very strong but with 3+ positive tests there was a sensitivity of 93.8%, specificity of 78.1%, and AUC of 0.842 for S.I. Joint being the cause of LBP. Distraction test has the single highest predictive value and thigh thrust, compression, and sacral thrust improved diagnostic ability. These should be performed first and two positive results are satisfactory for diagnosis and not further testing is needed, AUC of (0.819, s.e. 0.054) sensitivity of 0.88 and specificity of 0.78. This is to avoid subjecting patients to extra tests and discomfort. All patients with S.I. Joint being identified by injection as the cause had at least one positive test therefore if all are negative S.I. Joint can be ruled out. Injection and tests had no adverse effects reported aside from short term local discomfort and soreness. 20

//** ü <span style="color: #2e2e2e; font-family: Calibri,sans-serif;">The sacroiliac pain provocation tests: ****//
 * Examination & Tests **
 * ü <span style="color: #2e2e2e; font-family: Calibri,sans-serif; vertical-align: baseline;">Patient History **
 * ü <span style="color: #2e2e2e; font-family: Calibri,sans-serif; vertical-align: baseline;">VAS Pain Scale **
 * ü <span style="color: #2e2e2e; font-family: Calibri,sans-serif; vertical-align: baseline;">Disability Questionnaires (Dallas & Roland) **
 * ü <span style="color: #2e2e2e; font-family: Calibri,sans-serif; vertical-align: baseline;">McKenzie Examination **
 * ü <span style="color: #2e2e2e; font-family: Calibri,sans-serif; vertical-align: baseline;">Hip Joint Assessment **


 * 1) <span style="color: #2e2e2e; font-family: Calibri,sans-serif;">I. Sacral Distraction (Most Specific) <span style="font-family: Calibri,sans-serif;">[[image:Sacral Distraction.jpg]]
 * 2) <span style="color: #2e2e2e; font-family: Calibri,sans-serif;">II. Thigh Thrust <span style="font-family: Calibri,sans-serif;"> (Most Sensitive)[[image:Thigh Thrust.jpg]]
 * 3) <span style="color: #2e2e2e; font-family: Calibri,sans-serif;">III. Gaenslen's test <span style="font-family: Calibri,sans-serif;">[[image:Gaenslen's test.jpg]]
 * 4) <span style="color: #2e2e2e; font-family: Calibri,sans-serif;">IV. SIJ Compression <span style="font-family: Calibri,sans-serif;">[[image:SI Compression.jpg]]
 * 5) <span style="color: #2e2e2e; font-family: Calibri,sans-serif;">V. sacral thrust <span style="font-family: Calibri,sans-serif;">[[image:Sacral Thrust.jpg]]
 * 6) <span style="color: #2e2e2e; font-family: Calibri,sans-serif;">VI. fluoroscopically guided contrast enhanced SIJ arthrography injection




 * Limitations and Future Research **

<span style="color: #2e2e2e; font-family: Calibri,sans-serif; vertical-align: baseline;">Patients in the study were more chronic and disabled than the average patient with this condition. Further trials should be conducted to confirm its generalization to the general population. <span style="color: #2e2e2e; font-family: Calibri,sans-serif; vertical-align: baseline;">Tests were performed in sequence without a specified rest period which could cause interactions and confounding effects of each test individually. <span style="color: #2e2e2e; font-family: Calibri,sans-serif; vertical-align: baseline;">Severe pain with all body movements and tests is more likely from a different source and S.I. Joint should not be diagnosed as the underlying cause. <span style="color: #2e2e2e; font-family: Calibri,sans-serif; vertical-align: baseline;">Diagnostic Injections are the only clinical test that can be compared against for validity but false positives/false negatives are possible. In this study a second injection was done to confirm the diagnosis and found a false positive rate of zero.(surgical science) 20,21

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 * __ References __**