A COMPARATIVE STUDY TO INVESTIGATE THE DIFFERENCE

BETWEEN THE INTER-EXAMINER RELIABILITY OF GILLET’S TEST AND

THE STANDING FLEXION TEST IN MOTION PALPATION OF THE

SACROILIAC JOINT

A dissertation submitted to the

Faculty of Health Sciences, University of Johannesburg,

in partial fulfilment of the requirement for the degree of Masters of

Technology: Chiropractic by

Theodorus Hermanus Cloete

(Student number: 802046776)

Supervisor:___________________________________ ___________

Dr. C. Hay Date

Co-Supervisor:________________________________ ___________

Dr. T. Hollinshead Date

ii

DECLARATION

I, Theodorus Hermanus Cloete, declare that this dissertation is my own, unaided work. It is

beng submitted in partial fulfilment for the Master‟s degree in Technology, in the

programme of Chiropractic, at the University of Johannesburg. It has not been submitted

before for any degree of examination in any other Technikon or University.

__________________________

Theodorus Hermanus Cloete

Signed at _____________________.

On This day the ____________ of the month of ____________ 2009.

iii

AFFIDAVIT: MASTER’S AND DOCTORAL STUDENTS

TO WHOM IT MAY CONCERN

This serves to confirm that I, ________________________________________________

(Full Name(s) and Surname)

ID Number _________________________ Student number_______________________

enrolled for the Qualification ______________________________________________ in

theFaculty of ___________________________________________________________,

herewith declare that my academic work is in line with the Plagiarism Policy of the

University of Johannesburg which I am familiar with.

I further declare that the work presented in the __________________________________

(minor dissertation/dissertation/thesis) is authentic and original unless clearly indicated

otherwise and in such instances full reference to the source is acknowledged and I do not

pretend to receive any credit for such acknowledged quotations, and that there is no

copyright infringement in my work. I declare that no unethical research practices were

used or material gained through dishonesty. I understand that plagiarism is a serious

offence and that should I contravene the Plagiarism Policy notwithstanding signing this

affidavit, I may be found guilty of a serious criminal offence (perjury) that would amongst

other consequences compel the UJ to inform all other tertiary institutions of the offence

and to issue a corresponding certificate of reprehensible academic conduct to whomever

request such a certificate from the institution.

Signed at __________________on this ___________day of _______________ 20___. Signature_______________________________ Print name_____________________ STAMP COMMISSIONER OF OATHS Affidavit certified by a Commissioner of Oaths This affidavit conforms with the requirements of the JUSTICES OF THE PEACE AND COMMISSIONERS OF OATHS ACT 16 OF 1963 and the applicable Regulations published in the GG GNR 1258 of 21 July 1972; GN 903 of 10 July 1998; GN 109 of 2 February 2001 as amended.

iv

DEDICATION

I dedicate this work to my parents and family, who have always supported me through the

tough times. You were always the ones backing me when nobody else believed in me.

My mother, who is still the most perseverant woman I have ever met. Your nurturing and

compassionate qualities have a lot to do with my healing abilities and my dedication to help

others.

My father, whose unwavering dedication and advise have brought me where I am today.

Without you, I am nothing.

My brothers Teunis and Gert. Your friendship and companionship through the years have

been central in my success.

Thank You.

v

ACKNOWLEDGEMENTS

My darling Nadia, I love you for all that you are. You were, and still are, my angel and light

in the darkness. You brightened up my days and you often rescued me from evil. You find

it so easy to care for people. Your qualities reflected in me, and because of you I am a

better person. Thank you.

Dr. Tina Hollinshead, thank you for your endless efforts in this project.

Dr. Caroline Hay and Dr. Yelverton, your guidance has been instrumental. Your tasks are

often unappreciated in the profession of Chiropractic. You are assets to our profession.

Chiropractic in South Africa would be lost without you.

My lecturers in 5th year need special thanks, as they were the first group of people who

handled me with respect, renewing my passion for the profession of Chiropractic.

Thank you all.

vi

ABSTRACT

It has been well documented in literature that at least 80% of the general population will

suffer from lower back pain or dysfunction at one stage in their lives. Recent literature

suggests Sacroiliac joint dysfunction to be a common cause of lower back pain. Clinical

interest in the dysfunction and the consequences of this joint being a major cause of lower

back pain is growing, as more biomechanical clinicians are finding Sacroiliac joint disorders

to be a common occurrence in clinical practice (Pool-Goudzwaard, Vleeming, Stoekart,

Snijders and Mens, 1998).

Sacroiliac syndrome is characterised by loss of joint play or altered mobility in the

Sacroiliac joint‟s range of motion, and is usually associated with altered structural

relationships in the region of the Sacroiliac joint (Grieve, 2001). This loss of normal

movement is often adjusted by Chiropractors to regain normal mobility, however the

correct diagnosis of the loss of mobility is required to induce the correct treatment.

Motion palpation has been scrutinised by many researchers who widely questioned its

inter-tester reliability. As yet there has been no consensus as to a „gold standard‟ for

motion palpation of the Sacroiliac joint. This study aims to reconfirm the inter-examiner

reliability of two such motion palpation tests, i.e. Gillet‟s motion palpation and the Standing

Flexion test.

One hundred participants underwent a double blind experimental study where the results

from eight different examiners were recorded to obtain the reliability of the tests. Four

examiners tested the participants using Gillet‟s motion palpation and four examiners used

the Standing Flexion test. The results were recorded as either right, left or no restriction.

The results were then compared and correlated.

There was no statistically significant reliability found in either of the two tests. The mean

reliability for the Standing Flexion test was found to be 59.31% while the Gillet‟s Motion

Palpation produced a mean reliability of 56.38%. These two values are considerably lower

than the expected 80% indicating low reliability between the two tests. The only slight

vii

linear correlation was found between left and right sided restrictions and this was very low

when compared to no restriction findings. This indicates that the participants may not have

had restrictions to begin with, but the examiners were looking for restrictions, as

Chiropractors do.

In this study, neither of the two tests was found to be clinically useful for determining the

presence of Sacroiliac joint dysfunction or the side of dysfunction present. Further research

finding a „gold standard‟ for detection of Sacroiliac joint dysfunction is necessary.

viii

TABLE OF CONTENTS

DECLARATION .......................................................................................................................... ii

DEDICATION ............................................................................................................................ iv

ACKNOWLEDGEMENTS .......................................................................................................... v

ABSTRACT ............................................................................................................................... vi

TABLE OF CONTENTS ........................................................................................................... viii

LIST OF FIGURES .................................................................................................................... xi

LIST OF TABLES .................................................................................................................... xiii

CHAPTER 1: INTRODUCTION ................................................................................................. 1

1.1 Introduction ................................................................................................................ 2

1.2 The Problem Statement ............................................................................................. 3

1.3 Aims ........................................................................................................................... 4

CHAPTER 2: LITERATURE REVIEW ....................................................................................... 5

2.1 Introduction ................................................................................................................ 6

2.2 The Anatomy of the Sacroiliac Joint .......................................................................... 6

2.2.1 Osseous anatomy of the Sacroiliac joint ................................................................ 6

2.2.2 Ligaments of the Sacroiliac joint ............................................................................ 8

Anterior Sacroiliac Ligament .................................................................................. 9

Posterior Sacroiliac Ligament .............................................................................. 10

Interosseous Ligaments ....................................................................................... 11

The Sacrotuberous and Sacrospinous Ligaments ............................................... 11

Iliolumbar Ligaments ............................................................................................ 11

The Pubic Symphysis .......................................................................................... 12

2.2.3 Muscular anatomy of the Sacroiliac joint.............................................................. 13

2.2.4 Innervation of the Sacroiliac joints ....................................................................... 14

2.2.5 Joint development and degenerative changes ..................................................... 14

2.2.6 Gender differences and pregnancy changes ....................................................... 16

2.2.7 Stability ................................................................................................................ 17

Form Closure ....................................................................................................... 17

Force Closure ...................................................................................................... 19

Musculofascial Systems of the Lumbopelvic Complex ........................................ 22

2.3 Biomechanics of the Sacroiliac Joint ....................................................................... 24

ix

2.3.1 Symmetrical motion of the Sacroiliac joints during flexion and extension ............ 26

2.3.2 Asymmetrical motion of the Sacroiliac joints ........................................................ 29

2.3.3 Gait ...................................................................................................................... 29

2.4 Sacroiliac Joint Dysfunction ..................................................................................... 31

2.4.1 Causes of Sacroiliac joint dysfunction ................................................................. 32

2.4.2 Types of Sacroiliac joint dysfunctions .................................................................. 33

2.5 Sacroiliac Joint Syndrome ....................................................................................... 34

2.5.1 Patient history of Sacroiliac joint syndrome ......................................................... 34

2.5.2 Symptoms and signs of Sacroiliac syndrome ...................................................... 35

2.6 Detecting Sacroiliac Joint Dysfunction ..................................................................... 36

2.7 Reliability of the Different Tests Used in Manual Testing ......................................... 36

2.7.1 Pain provocation tests ......................................................................................... 37

2.7.2 Motion palpation tests .......................................................................................... 37

Gillet’s (Spine) Test ............................................................................................. 38

The Standing Flexion Test ................................................................................... 39

2.8 Management of Sacroiliac Syndrome ...................................................................... 39

2.9 Conclusion ............................................................................................................... 41

CHAPTER 3: METHODOLOGY .............................................................................................. 42

3.1 Participant Selection ................................................................................................ 43

3.2 Inclusion Criteria ...................................................................................................... 43

3.3 Exclusion Criteria ..................................................................................................... 43

3.4 Procedure ................................................................................................................ 44

3.4.1 The manual tests used in this study ..................................................................... 45

Gillet’s (Spine) Test ............................................................................................. 45

The Standing Flexion Test ................................................................................... 48

3.5 Statistical Analysis ................................................................................................... 49

CHAPTER 4: RESULTS .......................................................................................................... 51

4.1 Descriptive Statistics ................................................................................................ 52

4.2 Statistics for Restrictions Found .............................................................................. 52

4.3 Correlations Between the Findings .......................................................................... 58

4.4 One-sample t-test .................................................................................................... 59

CHAPTER 5: DISCUSSION .................................................................................................... 61

x

5.1 Descriptive Statistics ................................................................................................ 62

5.2 Statistics from Restrictions Found ........................................................................... 62

5.3 Correlations Between the Two Tests ....................................................................... 63

5.4 Alternative Explanations Offered by Previous Studies ............................................. 63

5.5 The Difficulty and Complexity Associated with Sacroiliac Joint Dysfunction

Diagnosis .................................................................................................................. 65

CHAPTER 6: CONCLUSION AND RECOMMENDATIONS .................................................... 67

6.1 Conclusion ............................................................................................................... 68

6.2 Recommendations ................................................................................................... 68

REFERENCES ........................................................................................................................ 70

APPENDICES ......................................................................................................................... 79

Appendix A: Advertisement

Appendix B: Case Hisory

Appendix C: Pertinent Physical Examination

Appendix D: Lumbar Spine and Pelvis Regional Examination

Appendix E: Patient Information and Consent Form

Appendix F: Examination Form

xi

LIST OF FIGURES

Figure 2.1: The articulating surfaces of the Sacroiliac joint are shown histologically...........7

Figure 2.2: The complementary auricular articulating surfaces of the Iliac bone and the

Sacrum..............................................................................................................8

Figure 2.3: The ligaments of the Sacroiliac joint..................................................................9

Figure 2.4: Transverse section through the Sacroiliac joint...............................................10

Figure 2.5: Transverse section through the pelvis.............................................................12

Figure 2.6: Stability in the Sacroiliac joint..........................................................................17

Figure 2.7: Form and Force closure in the pelvic area......................................................18

Figure 2.8: The Long Dorsal Sacroiliac ligament...............................................................20

Figure 2.9: Force closure of the Sacroiliac joint................................................................20

Figure 2.10: The Multifidus muscle......................................................................................22

Figure 2.11: Nutation and counter-nutation of the Sacrum..................................................26

Figure 2.12: Movement of the Sacroiliac joint according to Farabeuf, and Bonnaire and

Bue..................................................................................................................27

Figure 2.13: Movement of the Sacroiliac joint according to Wiesl.......................................28

Figure 2.14: The influence of various muscles reacting to gravity on the stability of the

pelvis................................................................................................................28

Figure 2.15: Combined activities of the left and right Ilia, the Sacrum and Lumbar spine

during walking..................................................................................................31

Figure 2.16: Sequence of onset of Sacroiliac joint dysfunction in the absence of

ligamentous and muscular support..................................................................33

Figure 2.17: Pain referral pattern caused by Sacroiliac joint dysfunction............................35

Figure 3.1: Gillet‟s (Spine) Test during motion Palpation..................................................46

Figure 3.2: Position of the thumbs before starting Gillet‟s Motion palpation of the

Sacroiliac joint..................................................................................................46

Figure 3.3: Gillet‟s Motion palpation is shown with the start position shown on the left

and the movement being seen while flexing the leg, shown on the right.........47

Figure 3.4: The Standing Flexion test................................................................................48

Figure 4.1: Frequency of examiners correlating to finding the left side restricted.............53

Figure 4.2: Frequency of examiners correlating to finding the right side restricted...........54

xii

Figure 4.3: Frequency of examiners correlating to finding no restrictions..........................55

Figure 4.4: Frequency of reliability of each test..................................................................56

Figure 4.5: The average percentage reliability found by Gillet‟s Motion Palpation and the

Standing Flexion test as compared to the expected value for the test to be

considered reliable............................................................................................60

xiii

LIST OF TABLES

Table 4.1: Difference of one or more for right (R), left (L) or no restriction (N) results using

Standing Flexion test and Gillet‟s Motion Palpation...........................................57

Table 4.2: Differences between the numbers of examiners deciding on the side of

restriction using the Standing Flexion test and Gillet‟s Motion Palpation...........57

Table 4.3: Correlations between left, right and no restriction findings between the two

tests...................................................................................................................58

Table 4.4: Correlation between the reliability percentages obtained between Gillet‟s

Motion palpation and the Standing Flexion test................................................59

1

CHAPTER 1: INTRODUCTION

2

1.1 Introduction

It has been well documented in literature that at least 80% of the general population will

suffer from lower back pain or dysfunction at one stage in their lives. The possible causes

of this pain could be endless, as the origin could be from any of the tissues in the

surrounding area including bone, muscular, ligamentous, visceral and/or nervous tissue

involvement (Pool-Goudzwaard et al., 1998).

Goldthwait and Osgood (1905) considered the Sacroiliac joint to be the main cause of

lower back pain as early as 1905. In 1934 Mixter and Barr (1941) changed the focus to the

herniated disc and surrounding structures as the main cause of back pain. Recent

literature (Fukui and Nosaka, 2002; Porterfield and De Rosa, 1998a) however suggests

Sacroiliac joint dysfunction to be a more common cause of lower back pain than previously

thought. Clinical interest in the dysfunction and the consequences of this joint being a

major cause of lower back pain is growing, as more biomechanical clinicians are finding

Sacroiliac joint disorders to be a common occurrence in clinical practice.

The Sacroiliac joints are known to cause buttock and leg pain, as well as compensational

biomechanical dysfunction throughout the entire lower back. These Sacroiliac joints can

cause pain in a variety of ways, including being affected by inflammation, infection,

malignancy and crystal deposition. A great deal of medical and complementary medicine

practitioners now consider Sacroiliac joint dysfunction to be the most likely cause of pain in

the Sacroiliac joint and subsequent lower back pain (Hodge and Bessette, 1999; Potter

and Rothstein, 1985; Weksler, Velan, Semionov, Gurevitch, Klein, Rozentsveig and

Rudich, 2007).

Sacroiliac Syndrome (such as during Sacroiliac joint dysfunction) comprises a loss of joint

play, and is characterised by movement restriction, impaired function and pain (DeFranca

and Levine, 1996). This loss of joint play, or altered mobility in the Sacroiliac joints‟ range

of motion, is usually associated with altered structural relationships in the region of the

Sacroiliac joint (Grieve, 2001). This type of joint dysfunction has been described as

malalignment, fixation, hyper- or hypomobility, restriction or subluxation. In this study the

3

term dysfunction will mainly imply a lack of mobility in the joint, which is a disturbance of

the normal mechanical functioning of the joint. It does, therefore, not include Sacroiliac joint

hypermobility (Cassidy and Mierau, 1992).

Sacroiliac joint dysfunction can also be divided into flexion and extension restrictions. Each

of these types of restrictions has a specific direction of hypomobility and associated clinical

features (Hesch, 1997).

Although the prevalence in the general population is not known, literature in the medical

field has noted a prevalence of Sacroiliac joint dysfunction of between 19.3% and 47.9%

depending on the group being studied (Toussaint, Gawlik, Rehder and Rüther, 1999). Two

studies performed in 1995 and 2008 respectively found that 30% of the chronic lower back

pain patients‟ pain originated from Sacroiliac joint dysfunction (Rezaeian, Alifard, Goodarzi,

Karimi and Asgharoi, 2008; Schwarzer, Aprill and Bogduk, 1995). A variety of hypothetical

diagnostic criteria for Sacroiliac joint dysfunction have been created due to the lack of

knowledge about the true pathophysiology of the mechanisms involved. This has also led

to vast differences in prevalence values between studies performed on the Sacroiliac joint

(Tullberg, Blomberg and Branth, 1998).

The fact remains that the Sacroiliac joint is a pain generating structure, especially in the

presence of lower back pain. This pain can be caused by the surrounding structures as a

result of lack of motion, or excessive motion in the joint, or mechanical irritations in the joint

itself (Cassidy and Mierau, 1992). Even if it is a pain generating structure, Sacroiliac joint

dysfunction can also be present in the absence of pain (Botha, Yelverton and Potgieter,

2008). The factors that cause a dysfunctional Sacroiliac joint remain unclear at this stage.

1.2 The Problem Statement

In order to adequately treat lower back pain it is crucial to make an accurate diagnosis as

to what the possible cause of the pain is and to treat it accordingly. In the Chiropractic

profession this entails mainly the administering of the appropriate adjustive therapy to

fixated or restricted joints. For this treatment to attain its optimal benefit the adjustments

4

must be delivered to the correct joints and along the correct planes of fixations, i.e. the

fixated or restricted joints. As there is currently no „perfect‟ diagnostic test for Sacroiliac

hypomobility, this can be difficult. There are however many recognised tests with relatively

good validity, including the two tests being utilised in this research.

1.3 Aims

This study aims to investigate the inter-examiner reliability of Gillet‟s motion palpation

(Spine test) and Standing Flexion motion palpation individually. These two tests are

relatively well known to Chiropractors and especially to Chiropractic students at the

University of Johannesburg, as these techniques are taught in the curriculum. There is

however little research substantiating their use in clinical practice (as will be explained in

more detail in the literature review).

This study‟s second aim is to compare the above-mentioned tests, thus proving which

would be more reliable in clinical investigations. This would yield very important results in

the diagnosis of Sacroiliac disturbances or dysfunctions, as Chiropractors in the clinical

setting would be better equipped to know which of these tests has a better chance of

detecting exactly which joint is restricted, thus facilitating the correct treatment to the

correct joint.

5

CHAPTER 2: LITERATURE REVIEW

6

2.1 Introduction

Humans are the only vertebrates with a movable Sacroiliac joint articulation, which

probably developed due to the functional effects of upright walking (Schafer and Faye,

1990). In previous years the Sacroiliac joint has been bombarded with much criticism

regarding its function, mobility and involvement in lower back, posterior thigh and buttock

pain production.

The following provides background information on the anatomy of the Sacroiliac joint. It will

include osseous, ligamentous and muscular anatomy, as well as sex differences,

development and biomechanics. The diagnosis and treatment of Sacroiliac joint

dysfunction will also be included.

2.2 The Anatomy of the Sacroiliac Joint

2.2.1 Osseous anatomy of the Sacroiliac joint

The Sacroiliac joint is a true diarthrodial joint with a synovial fluid-filled joint cavity, articular

cartilage and a fibrous joint capsule lined by a synovial membrane (Gatterman, 2004). The

Sacroiliac joints are unique in many ways, one being that they contain fibrocartilage in

addition to hyaline cartilage (refer to Figure 2.1) (Forst, Wheeler, Fortin and Vilensky,

2006). The articulating surface of the Ilium consists of fibrocartilage, while the articulating

side of the Sacrum consists of hyaline cartilage, which is also 3 times thicker than the

fibrocartilage found on the Iliac side (Harrison, Harrison and Troyanovich, 1997). This

would aid the joint in one of its functions as a shock absorber.

Below these cartilage surfaces lie articulating surfaces from the Sacrum and Ilium, which

are described as ear-shaped or auricular (refer to Figure 2.2). This C-shaped surface has

its convexity facing anteriorly and inferiorly (Gatterman, 2004). The longer arm of the joint

surface points posterolaterally and caudally, while the shorter arm points posteriorly and

cranially (Bernard and Cassidy, 1991). They possess irregular elevations and depressions

7

which produce interlocking of the bones, which provides stability by minimising movement

(Forst et al., 2006; Moore and Dalley, 1999).

Figure 2.1: The articulating surfaces of the Sacroiliac joint are shown histologically. The top

section shows the hyaline cartilage on the Sacrum articulating with the fibrocartilage from

the Ilium shown at the bottom. (Advanced Pain Management Surgery,

2006)

According to a study done where 534 patients were scanned using Computed Tomography

(CT), no two patients had exactly the same joint appearance. Great variance and

irregularity was shown in the joint surface structure, with almost 20% of the scanned

patients showing an accessory joint (Prassopoulos, Faflia, Voloudaki and Gourtsoyiannis,

1999).

8

Figure 2.2: The complementary auricular articulating surfaces of the Iliac bone (left) and

the Sacrum (right). (Orthopedic Manual Physical Therapy Institute of Dallas Inc., 2005)

These accessory Sacroiliac joints are thought to be acquired fibrocartilaginous joints that

result from stresses of weight bearing. They develop posterior to the articular surface of the

Sacroiliac joint between the rudimentary transverse process of the second sacral vertebra

and the Ilium. It has been estimated to be found in between 8% and 35.8% of the general

population. The incidence increases with age and weight, and is more common in

Caucasians than in Africans. They have very rarely been noted before the fourth decade of

life and their contribution to Sacroiliac pain is unknown (Bernard and Cassidy, 1991).

According to Moore and Dalley (1999) the Sacroiliac joints are strong, synovial joints that

form the articulation between the Sacrum and the two Iliac bones. The two Sacroiliac joints

lie within the pelvic ring at an oblique angle to the sagittal plane. The Sacrum is suspended

between the two Iliac bones, and is attached to them via Interosseous and Sacroiliac

ligaments (Gatterman, 2004).

2.2.2 Ligaments of the Sacroiliac joint

The Sacroiliac ligament complex resists movement of the Sacrum between the two Ilia and

prevents mainly x-axis rotation (nutation) secondary to the forces of gravity (Bernard and

9

Cassidy, 1991). Together, these ligaments counteract gravitational forces and prevent

distraction of the Sacroiliac joint, especially during upright posture and during the gait cycle

(Mior, Ro and Lawrence, 1999).

The ligaments of the Sacroiliac (SI) joint (refer to Figure 2.3) consist of the anterior SI

ligaments, the comparatively thicker and stronger posterior SI ligaments, the strong

interosseous ligaments, the Sacrotuberous and Sacrospinous ligaments dorsally, and the

Iliolumbar ligaments (Harrison et al., 1997).

Figure 2.3: The ligaments of the Sacroiliac joint. Viewed from the posterior aspect (left),

and from the anterior aspect (right). Pelvic Instability Network Support (2005)

Anterior Sacroiliac Ligament

The Anterior SI ligament (refer to Figure 2.4) forms part of the joint capsule and is an

anterior thickening of this. It is very well developed near the arcuate line and the Posterior

Inferior Iliac Spine (PIIS) of the Ilium. This ligament, together with the Interosseous

ligament, binds the Sacrum to the Ilium while opposing separation of joint surfaces and

translation of the Sacrum superiorly and inferiorly (Harrison et al., 1997).

10

Figure 2.4: Transverse section through the Sacroiliac joint. This shows the anterior articular

compartment and the posterior ligamentous compartment. (Barnard and Cassidy,

1991)

Posterior Sacroiliac Ligament

The Posterior SI ligament covers the Interosseous ligaments dorsally, and branches to

form a connection with the Sacrotuberous and Sacrospinous ligaments (Harrison et al.,

1997). This ligament fills the deep recess between the Ilium and Sacrum posteriorly, known

as the Sacroiliac fissure. It serves as an attachment site for the deep fibres of the Multifidus

and Gluteus Maximus muscles (Mior et al., 1999). Due to its posterior location, the main

function of this ligament is to resist flaring and gapping of the joint posteriorly (Bogduk,

1998).

The Posterior SI ligament has two components: a short and a long dorsal ligament. The

short component is a continuation of the Interosseous ligament owing to fibres that span

laterally and superiorly. The long component has more vertical fibres, which assist in

preventing counter-nutation (refer to Section 2.3.1) of the Sacrum with respects to the Ilium

(Bogduk, 1998). It also blends with the Sacrotuberous ligament inferiorly (Mior et al., 1999).

11

Interosseous Ligaments

The Interosseous ligaments are very strong, and form the main bond between the Ilia and

the Sacrum (refer to Figure 2.4). They fill the irregular space behind and above the joint,

and are reinforced by the Posterior Sacroiliac ligaments (Gatterman, 2004). It is the largest

syndesmosis (slightly movable articulation where the contiguous bony surfaces are united

by an interosseous ligament (Oxford Concise Medical Dictionary, 2003)) in the body.

These ligaments are the main restraint resisting joint separation (postero-superior gapping)

(Mior et al., 1999).

The Sacrotuberous and Sacrospinous Ligaments

Together, these two ligaments provide resilience to the sacroiliac region when the vertebral

column receives sudden weight increases (Moore and Dalley, 1999). They assist the

capsular ligaments in stabilisation of the joint (Mior et al., 1999).

The Sacrotuberous ligament attaches to the Posterior Superior Iliac Spine (PSIS)

superiorly and branches to attach to the Ischial tuberosity inferiorly (Mior et al., 1999). Its

main function is to oppose sacral nutation (refer to Section 2.3.1) (Harrison et al., 1997).

The Sacrospinous ligament is a thin, triangular ligament (Harrison et al., 1997) which

attaches to the PSIS superiorly and branches from the Posterior SI ligaments to attach to

the Ischial spine inferiorly. This ligament, together with the Sacrotuberous ligament, allows

limited upward movement of the inferior end of the Sacrum as it anchors it to the Ischium

(Bogduk, 1998), and prevents posterior displacement of the sacral apex during nutation

(Mior et al., 1999).

Iliolumbar Ligaments

The Iliolumbar ligaments run from the transverse processes of the fourth and fifth lumbar

vertebrae to attach to the Iliac crests, merging with the Interosseous ligament (refer to

12

Figure 2.5). The main function of these ligaments is to resist all motion between the lower

lumbar spine and the Sacrum. It prevents a translation or distraction of the Sacrum

superiorly out of the pelvic girdle and separation of the Ilia from the Sacrum (Harrison et

al., 1997).

Figure 2.5: Transverse section through the pelvis. The Interosseous ligaments of the

Sacroiliac joint are shown with its close approximation with the Iliolumbar ligament.

(Gudgel and Colloca, 2007)

The Pubic Symphysis

The Pubic symphysis, supported by the Superior pubic, Arcuate pubic and the Interpubic

ligaments must also be seen as part of the Sacroiliac joint due to its biomechanical function

(Harrison et al., 1997). It forms the anterior articulation between the two Ilia and functions

as both a shock absorber similar to an intervertebral disc, and as the centre of rotation for

the movement of the Iliac bones during the gait cycle (refer to Section 2.4). The oval-

shaped ends of the pubic bones are covered by a thin layer of hyaline cartilage and are

connected by a layer of fibrocartilage forming the Interpubic disc (Defranca and Levine,

1996).

The additional ligaments offering support to the Pubic symphysis include the Anterior and

Posterior Pubic Ligaments and the Superior and Inferior Pubic Ligaments (Defranca and

Levine, 1996). Aponeurotic expansions from the Transversus abdominis muscles, Internal

13

and External oblique abdominis muscles and Adductor muscles reinforce the anterior

surface of this joint (Norkin and Levangie, 1992).

2.2.3 Muscular anatomy of the Sacroiliac joint

There is no single muscle that primarily induces movement in the Sacroiliac joint

(Greenman, 1997). There are, however, various muscles surrounding the joint, as well as

those situated in the trunk and lower extremities, that indirectly induce movement in one of

the many planes of movement. These movements are discussed in more detail later (refer

to Section 2.4).

The muscles surrounding the joint function to brace the area causing compression and

creating stability for effective load transfer, rather than to generate actual movement in the

Sacroiliac joints (Harrison et al., 1997).

The Piriformis muscle is as close to a prime mover as exists for the Sacroiliac joint. It

attaches proximally to the ventral surface of the Sacrum from the second to the fourth

sacral levels (S2-S4), on the superior margin of the Greater sciatic notch and

Sacrotuberous ligament. The muscle then leaves the pelvis through the Greater sciatic

foramen, filling it almost completely and eventually attaches to the superior border of the

Greater trochanter on the Femur. Nerve supply is received via the ventral rami from the 1st

and 2nd sacral levels (S1 and S2) (Moore and Dalley, 1999). The primary function of the

Piriformis muscle is external rotation and abduction of the Femur, while some authors

describe it as being an internal rotator of the Femur when the hip is flexed past 90°

(Greenman, 1997).

Other muscles influencing the function of the Sacroiliac joint include the sacral Multifidii

muscles, the Lattisimus Dorsi muscles (Rosenberg, 2008), the abdominal muscles, the

adductor group of muscles of the medial thigh, the Psoas muscles passing directly anterior

to the joint surfaces, the Quadratus Lumborum muscles, Gluteal muscles, the Hamstring

and the Quadriceps muscles (Greenman, 1997). The function of these muscles will be

discussed in more detail later in this chapter.

14

2.2.4 Innervation of the Sacroiliac joints

Moore and Dalley (1999) state that the Sacroiliac joint receives its main innervation from

the Superior gluteal nerves and the dorsal rami of the S1 and S2 nerves, all stemming from

the sacral plexus. The superior anterior part of the capsule is innervated by the ventral

rami from the fourth and fifth lumbar levels (L4 and L5) (Forst et al., 2006). The capsule

and overlying ligaments have unmyelinated free nerve endings that transmit pain and

thermal sensation (Bernard and Cassidy, 1991).

Histological investigations of the Sacroiliac joint reveal the presence of nerve fibre within

the capsule. Microscopic evidence suggests paciniform-encapsulated mechanoreceptors

and a single non-paciniform mechanoreceptor. This suggests that position sense

(proprioception) and pressure information are transmitted by the Sacroiliac joint (Forst et

al., 2006).

Communication also exists between the Sacroiliac joint and nearby neural structures.

Nerves running directly over the joint provide articular branches that innervate the joint

capsule. These same nerves also supply the muscles surrounding the joint, and provide a

unique feedback mechanism, called an arthrokinetic reflex, which regulates muscle tone

(Bernard and Cassidy, 1991).

When the capsule is disrupted, as is the case during Sacroiliac joint dysfunction, the

inflammatory mediators leak to the nearby neural structures causing radicular pain in

certain subjects (Forst et al., 2006).

2.2.5 Joint development and degenerative changes

The joint space of the Sacroiliac joint develops in a group of mesenchymal cells between

the primitive Sacrum and Ilium around 10 to 12 weeks of gestation. During the first

trimester the Ilium has ossified and the Sacrum is made up of hyaline cartilage (Bernard

and Cassidy, 1991). On the sacral side, the hyaline cartilage is present almost

immediately, while on the iliac side, chondrocytes develop underneath the layer of

15

mesenchyme. After birth and during infancy this layer of mesenchymal tissue slowly

disappears leaving a surface that will eventually develop into fibrocartilage (Cassidy and

Mierau, 1992).

The Sacroiliac joint surfaces start off being parallel to the lumbar spine axis in the newborn,

but with the stresses of weight-bearing during walking, the joint changes it‟s orientation in

the coronal and sagittal plane with the Sacrum eventually becoming wedge-shaped from

anterior to posterior and from cranial to caudal (Bernard and Cassidy, 1991).

The articular surfaces at birth are smooth and flattened. These surfaces become

roughened during development into adulthood. It is presumed to be influenced by

mechanical forces of bipedal gait and growth (Bernard and Cassidy, 1991). The iliac

surface develops a ridge along its long axis, while the sacral side develops a concavity that

fits into the ridge found on the iliac surface (Norkin and Levangie, 1992). These changes

occur in the teenage years, and contribute to the stability of the joint. As the interdigitation

in the joint grows, it limits sacral nutation, a concept explained later in this chapter (Bernard

and Cassidy, 1991).

Degenerative changes occur on the iliac side as early as the third decade of life. This

manifests as increased joint irregularity, fibrillation, crevice formation and clumping of

chondrocytes. These types of changes only occur on the sacral side in the fourth and fifth

decade of life, i.e. the degeneration lags behind by between ten and twenty years on the

sacral side (Bowen and Cassidy, 1981). The degenerative changes include: osteophyte

interdigitations and fibrous connections across the joint surface, roughening and erosions

of joint surfaces with occasional exposed subchondral bone, plaque formation; and flaky,

yellow amorphous debris on the joint surfaces (Bowen and Cassidy, 1981). These changes

are most notable after the fifth decade of life, when the cartilage starts to degenerate and

ossification starts occurring between the two surfaces (Willard, 1997). Further changes

following this stage include plaque formation and erosion of cartilage. Degenerative

changes become more pronounced as age increases and include thickening of the

capsule, joint surfaces becoming more irregular and osteophyte formation. Mobility is still

present at this stage, but is restricted, and total ankylosis of the joint is only rarely found

16

(Defranca and Levine, 1996). In a study of forty paired Sacroiliac joint specimens, true

bony fusion was never found and bony ankylosis was only found in one specimen (Bowen

and Cassidy, 1981).

The degenerative changes in the Sacroiliac joint are thought to have a significant

correlation with the production of lower back pain symptoms (Harrison et al., 1997). It has

been noted however that 24.5% of asymptomatic people over the age of fifty years show

degenerative changes in the Sacroiliac joint. It is therefore very difficult to distinguish

between the normal aging process and those that are considered pathological (Porterfield

and De Rosa, 1998b).

2.2.6 Gender differences and pregnancy changes

Although pregnant women were excluded from this study, it is important to note the

differences in the biomechanics of the Sacroiliac joint between females and males.

Pregnancy also causes some interesting differences in movement, leading to a brief

discussion in the following text.

The anatomy of the female pelvis is broader and more opened out than that of the male

pelvis. The pelvic brim of the female pelvis is larger, but is shorter from top to bottom

(Kapandji, 1974). The Sacrum in the adult female is shorter and wider, and has a more

concave shape anteriorly. The pelvic suface of the Sacrum faces more inferiorly, resulting

in a larger lumbosacral angle. Due to the fact that the Iliac bones in females lie more

laterally and oblique in comparison to males, the angles of the lower extremity are

generally more valgus in nature (Alderink, 1991).

The movement of the Ilium in relation to the Sacrum also differs slightly in females, in that it

generally has more overall movement compared to that of males in the same age group

(Bussey, Milosavljevic and Bell, 2008). During pregnancy there is up to 250% more

mobility within the Sacroiliac joint due to the hormone Relaxin being released by the body.

The mobility of the Sacroiliac joint is also well documented to increase during menstruation

(Defranca and Levine, 1996). This increased mobility of the ligaments during pregnancy or

17

menstruation is important to note while taking a history of the condition, since the

increased joint laxity could contribute to pain generation.

2.2.7 Stability

The stability of the Sacroiliac joints is extremely important as they have to support the

weight of the head, arms and trunk. Several factors contribute to Sacroiliac joint stability

including structural and dynamic factors. A widely accepted theory exists, stating that

stability in the Sacroiliac joints is obtained through a combination of ligamentous support

and sufficient functioning of the associated muscles. These factors have also broadly been

grouped into „form closure‟ and „force closure‟ (refer to Figure 2.6) (Mooney, 1997).

Figure 2.6: Stability in the Sacroiliac joint. It arises from a combination of self-bracing and

force closure mechanisms responsive to gravitational stress. (Kuchera, 1997)

Form Closure

Form closure describes the osseous interlocking joint surfaces and the other anatomical

structures that cause passive stability in the Sacroiliac joint (Porterfield and De Rosa,

1998a). This is a stable configuration in which no extra forces are needed to maintain the

state of the system (Vleeming, Snijders, Stoeckart and Mens, 1997). No lateral forces

would be required for the stability of the pelvis in perfect form closure, but in this case no

18

movement would be possible. Therefore, additional forces are required for stability namely

force closure (refer to Figure 2.7) (Sturesson, Uden and Vleeming, 2000).

Form closure is dependent on two very important factors, namely the wedge shape of the

Sacrum and the interlocking surfaces of the joint. Since the Sacrum is primarily shaped like

a triangle fitting vertically between the two Iliac bones, the force from above pushes the

bones into each other, inducing a self-locking mechanism (Kapandji, 1974). Not only does

the force of the trunk from above seat the Sacrum deeper into the Ilium, certain ligaments

(Sacrotuberous, Sacrospinous and Interosseous) increase in tension, which decreases the

ability of the Sacrum to move within the pelvis (Porterfield and De Rosa, 1998a).

Figure 2.7: Form and Force closure in the pelvic area. The object is held in place by (A)

form closure, (B) force closure and (C) a combination of both, less friction and thus less

compression being needed than in (B). (D) shows the mechanism of an arch. Force F may

be raised by ligaments, muscles or a pelvic belt just cranial to the greater trochanter and

caudal to the sacroiliac joint. This force prevents lateral movement of the Ilia to secure to

form of an arch. (Snijders, Vleeming, Stoeckart, Mens and Kleinrensink, 1997)

As mentioned previously in the discussion on the osseous anatomy of the Sacroiliac joint,

the complexity and orientation of the joint surfaces within the Sacroiliac joint is very unique.

These irregular depressions and elevations within the joint are reciprocal to the opposite

articulating surface and resembles a very complex 3-dimensional jigsaw puzzle. These

roughened surfaces are described as asymmetrical in size, shape and direction, as well as

lying in numerous planes of movement. This interlocking mechanism contributes to the

stability of the joint (Forst et al., 2006; Moore and Dalley, 1999).

19

The articular cartilage of the Sacroiliac joints is also abnormal in relation to those found

elsewhere in the human body. Even before birth the joint surfaces are not smooth,

especially on the Iliac side. In comparison to cartilage studied in the knee it was noted to

have much higher friction, owing to increased stability in the joint (Vleeming et al., 1997).

These features cause increased friction at the Sacroiliac joints reflecting the adaptation of

bipedality of humans. Consequently, less muscle and ligamentous force is required to keep

the body upright and bear the weight of the torso, arms and head (Vleeming et al., 1997).

Force Closure

Force closure requires muscular involvement and ligamentous tension to create stability in

the Sacroiliac joints (Porterfield and De Rosa, 1998a). This stability can be created by

various muscles associated with movement of the Sacroiliac joint, as well as tension

created within the supporting ligaments caused by various movements in the pelvis.

The force of the body weight tends to push the Sacral promontory into flexion (nutation).

Tension is then developed in the supporting ligaments (especially the Sacrotuberous

ligaments) and counteracts this downward and forward movement of the Sacrum (Norkin

and Levangie, 1992). Increased tension created in the Sacrotuberous, Sacrospinous, Long

Dorsal Sacroiliac and Interosseous ligaments causes the posterior parts of the Iliac bones

to be pulled together, causing compression of the Sacroiliac joints (Vleeming et al., 1997).

This aids in the self-locking mechanism. Thus, when stress is applied to the joint, it

decreases the ability of the Sacrum to move within the pelvis (refer to Figure 2.8)

(Porterfield and De Rosa, 1998a).

As mentioned before, there exists no typical intrinsic muscle for the Sacroiliac joint. The

muscles surrounding the joint function to brace the area causing compression and creating

stability for effective load transfer, rather than to generate actual movement in the

Sacroiliac joints. This self-bracing mechanism helps with the transfer of forces during

activities such as walking, running or even sitting (Harrison et al., 1997). These muscles

are said to contribute to the self-locking mechanism of the Sacroiliac joints in a cross-like

20

configuration (refer to Figure 2.9). Posteriorly, these muscles are the Latissimus dorsi and

Gluteus maximus muscles, which work in conjunction with the Thoracolumbar fascia and

the Iliotibial tract. Anteriorly, the muscles involved are the External and Internal abdominal

obliques and the Transverse abdominals (Snijders et al., 1997).

Figure 2.8: The Long Dorsal Sacroiliac ligament. (A) shows the Long Dorsal Sacroiliac

ligament being stressed in situations where there is a loss of lumbar lordosis, such as

during pregnancy. (B) shows the restraint of forward gliding motion of the Sacrum being

created dynamically by the extension of the Biceps femoris attachment onto the

Sacrotuberous ligament. (Mooney, 1997)

Figure 2.9: Force closure of the Sacroiliac joint. It becomes stable on the basis of dynamic

force closure as well as structural orientation. The crossing musculature is noted. (A): 1 –

Latissimus dorsi, 2 – Thoracolumbar fascia, 3 – Gluteus maximus, 4 – Iliotibial tract. (B): 5

– Linea alba, 6 – External abdominal oblique, 7 – Transverse abdominus, 8 – Piriformis, 9

– Rectus abdominis, 10 – Internal abdominal oblique, 11 – Inguinal ligament. (Mooney,

1997)

21

Transverse abdominis muscle contraction has a direct effect on the stability of the

Sacroiliac joint. According to a study done by Richardson, Snijders, Hides, Damen, Pas

and Sorm (2002) measuring Sacroiliac joint laxity on 13 healthy individuals using Doppler

imaging and electromyographic recording, the laxity of the Sacroiliac joint significantly

decreased with contraction of the Transverse abdominis muscles. This provides evidence

that the line of force in which the Transverse abdominis works has a direct stabilising

function on the Sacroiliac joint.

Some muscles also generate stability within the Sacroiliac joint through their fibrous

expansions blending with the anterior and posterior Sacroiliac joint ligaments. The Gluteus

maximus, Biceps femoris and Piriformis muscles all have expansions that attach to the

Sacrotuberous ligaments. Contraction of these muscles directly increases tension inside

the ligament, forming a self-bracing mechanism, which aids in joint stability (Walker, 1992).

The Erector spinae muscle is pivotal in that it extends and loads the pelvis and spine.

Attaching to the Sacrum, it induces nutation in the Sacroiliac joint, tensing the

Sacrotuberous, Sacrospinous and Interosseous ligaments. It also pulls the posterior sides

of the Iliac bones together, resisting counter-nutation. This means that during nutation the

superior part of the Sacroiliac joint is compressed and the inferior side is widened due to

the action of the Erector spinae muscle (Vleeming et al., 1997).

Research shows that the muscles responsible for nutation of the Sacrum are an extension

of the Multifidus muscles lying deep to the Erector Spinae muscles (Willard, 1997). The

muscles arise proximally from the lumbar vertebrae and associated tissues, attaching

distally to the Sacral crest, Interosseous Sacroiliac ligaments, Thoracolumbar fascia and

the Iliac crest. The tendinous slips of the muscles pass underneath the Long Dorsal

Sacroiliac ligament to attach to the Sacrotuberous ligament. The fibres of the Multifidus

muscles are vertically aligned (refer to Figure 2.10) which makes it a significant extensor of

the Sacrum and lumbar spine. The muscle spans multiple segments of the lumbar spine,

giving it the role of prime stabiliser of the lumbar spine. Additionally, by attaching and

increasing the tension in the Thoracolumbar fascia and Sacroiliac ligaments, Multifidus

22

muscle activation also contributes to the self-bracing mechanism of the pelvis (Willard,

1997).

Figure 2.10: The Multifidus muscle. It is very important in the production of back pain as it

is the only muscle in the back that has fibres attaching to the Sacrum, providing a great

deal of stability to the Sacroiliac joints. (Real Body

Work, 2009)

Musculofascial Systems of the Lumbopelvic Complex

The stability of the lumbopelvic region is dependent on the thoracolumbar fascia, fascia

lata and abdominal fascial systems (refer to Figure 2.9). Two important similarities exist in

each of these fascial systems. Firstly, the muscles attached to the fascia pull on this fascia

while contracting, causing a tensile force. Secondly, the muscles are enveloped within

fascia, broadening this fascia and exerting a pushing force which also increases the

tension on the fascia (Porterfield and De Rosa, 1998b). Thus, any muscle contraction or

activity causes compression of the Sacroiliac joint surfaces increasing joint stability

(Harrison et al., 1997).

The thoracolumbar fascia is a non-contractile tissue attaching to several powerful muscles

that together play an important part in the function of the lumbar spine. Tension is created

by contraction of the contractile tissues attaching to it, namely the Latissimus dorsi,

23

Transverus abdominis, Internal abdominal oblique and Gluteus maximus muscles.

Mechanically linked through this fascia are the contralateral Gluteus maximus and

Latissimus dorsi muscles. Since they cross the joint, contraction of these muscles

increases the compressive forces across the joint, increasing the stability within the

Sacroiliac joints. The superficial and deep Erector spinae and Multifidus muscles lie within

the thoracolumbar fascia and contraction of these muscles causes broadening, and

therefore, a „pushing‟ force on the fascia (Porterfield and De Rosa, 1998b).

The stabilising action of the thoracolumbar fascia is proven in a study on elite rowers. In

this study it is suggested that the stabilising effect of the thoracolumbar fascia is diminished

by reversal of the body motion during rowing. This disrupts the action of the Posterior

oblique muscle stabilising system, allowing a decrease in joint surface contact promoting

Sacroiliac joint instability and joint dysfunction (Timm, 1999).

The fascia lata encloses the Gluteus maximus muscle, covers the Gluteus medius muscle

and blends with the aponeurotic expansion of the Vastus lateralis muscle of the

Quadriceps muscle. Contractions of these muscles increases the fascial tension, but

because they are also encased within the fascia, cause broadening of the fascia adding to

the tension. Other muscles adding to this broadening, „pushing‟, effect include the

Hamstrings, Adductors and Quadriceps muscles (Porterfield and De Rosa, 1998b).

Anteriorly lie the abdominal muscles with their related fascia. This fascial system receives

contributions from the External abdominal oblique, Internal abdominal oblique, Transversus

abdominis and Rectus abdominis muscles. These aponeuroses together form an

abdominal fascia latticework that functions very similarly to the posteriorly placed

thoracolumbar fascia in inducing stability within the lumbopelvic complex (Porterfield and

De Rosa, 1998b). As mentioned earlier, the Transverse abdominis muscle plays a major

part in this function.

All the above mentioned structures play a role in creating stability within the Sacroiliac joint.

Ligaments, muscles and musculofascial systems all have to work in unison to produce

force closure to allow proper biomechanics of the Sacroiliac joint. If the force closure is not

24

sufficient due to lack of muscle activity or insufficient ligamentous support, instability can

occur in the Sacroiliac joints, causing possible symptomatic changes leading to lower back

pain (Mooney, 1997).

2.3 Biomechanics of the Sacroiliac Joint

Since the start of research on Sacroiliac joints there have been disputes as to exactly how

much the Sacroiliac joint moves in the normal individual. Pitkin and Pheasant (1936) used

x-rays and an inclinometer to measure amounts of movement in the Sacroiliac joints and

found an average of between 3 and 19 degrees of movement. More recent studies using

superior technology in the form of roentgen stereophotogrammetric analysis (currently

considered the gold standard in movement studies) have proposed the movement in the

Sacroiliac joints to be much less than previously thought. Sturesson et al. (2000) found the

average rotation to be only 2.5 degrees with an average translation of only 0.7 mm. This is

considerably less than the 5.5 mm of translation and 11 degrees of rotation found in Pitkin

and Pheasant‟s studies performed in 1936.

It is often easier to recognise that there are moments created within and around the

Sacroiliac joint rather than actual movements being created. These are caused by ground

reaction and trunk forces, as well as by powerful muscles attaching to the pelvis. The

cartilage surfaces compress into each other during weight-bearing, increasing the stability

of the pelvis with force closure (Porterfield and De Rosa, 1998a).

Despite this small amount of movement available in the Sacroiliac joint, consensus exists

among clinicians that it is required that the joint move due to its integral role in the

biomechanics of the pelvis. It is also well known to be a major cause in the production of

lower back pain (Weksler et al., 2007).

At this point it should be emphasised that the Sacroiliac joints can never be observed as

working in isolation, but must always be considered within the pelvic ring and the

lumbosacral spinal column. Four other joints contribute to pelvic biomechanics: the

Lumbosacral joint, the Pubic symphysis and the two Hip joint articulations (Gatterman,

25

2004). This can also be described as movement in a closed kinematic chain, as movement

of any of these joints results in movement in at least some of the other linked joints (Norkin

and Levangie, 1992).

In a closed kinematic chain, movement in one joint in the chain induces a reactive

movement in the connecting joints of the chain. The pelvis articulates with the legs below,

which are firmly connected to the floor by the combining effects of gravity and friction.

Above, the pelvis is connected to the trunk. These connections from above and below

suggest the pelvis is in a closed kinematic chain (Huson, 1997).

The kinesiology of the pelvic ring can be seen as being similar to that of a single spinal

segment, i.e. one that functions similar to the 3-joint complex described by Sandoz (1981).

The Sacroiliac joints guide and restrict motion in the same way the posterior facet joints do

in the spinal column, while the elastic, compressible disc of the pubic symphysis allows for

the same 6 degrees of freedom as the intervertebral discs (Gatterman, 2004).

The opposing articulating surfaces of the Sacroiliac joint direct its movement in a track-

bound motion (Gatterman, 2004). Trends that have emerged from kinematic studies

include that the range of motion is small and decreases with age, it is greater in women

and increases even more during pregnancy, and that the predominant motion is rotation

around the x-axis with some translation on the z-axis (Cassidy and Mierau, 1992).

Due to their important role in transmission of weight, the Sacroiliac joints are unique in that

they possess little movement compared to other synovial joints in the body (Moore and

Dalley, 1999). Both in static positions and during mobility, the lumbosacral unit performs a

key role in the transfer of weight from the torso and the upper limbs to the lower

extremities. The same can also be said for the opposite direction of force transfer, i.e. any

force coming from the ground is transferred through the pelvic ring and lumbosacral

complex to the upper half of the body (Williard, 1997).

26

2.3.1 Symmetrical motion of the Sacroiliac joints during flexion and extension

Kapandji (1974) describes the classic theory of nutation of Farabeuf (1894), otherwise

known as sacral flexion, which occurs during forward flexion of the spine (refer to Figure

2.11). It describes the promontory of the Sacrum moving anteriorly and inferiorly about an

axis that lies just posterior to the Sacroiliac joint. During the same movement, the apex of

the Sacrum and Coccyx move posteriorly. When this occurs bilaterally the antero-posterior

diameter of the superior pelvic brim becomes smaller, while the pelvic outlet inferiorly

becomes larger in diameter (Kapandji, 1974). Associated with this movement is an

approximation of the Iliac crests and a separation of the Ischial tuberosities. This

movement is resisted by the Sacrotuberous and Sacrospinous ligaments (DeFranca and

Levine, 1996).

Figure 2.11: Nutation (shown on the left) and counter-nutation (shown on the right) of the

Sacrum. A – anterior, P – posterior. (Maigne, 2006)

Exactly the opposite occurs during counter-nutation, where the sacral promontory moves

posteriorly and superiorly while the Coccyx moves anteriorly and inferiorly, which occurs

during extension of the trunk. Counter-nutation causes the antero-posterior diameter of the

superior pelvic brim to enlarge, while the pelvic outlet decreases in size (Kapandji, 1974).

Conversely, this causes separation of the Iliac crests and approximation of the Ischial

tuberosites (DeFranca and Levine, 1996).

27

According to Farabeuf (1894) the centre of rotation of Sacroiliac joint movement is

postulated as being located posterior to the articular facet. Other studies found the centre

of rotation to be at different locations. Bonnaire and Bue (1899) found the axis of rotation to

be located between the cranial and caudal segments of the sacral facet of the joint (refer to

Figure 2.12). During another study using Computer Assisted Tomography (CAT scans)

(Wiesl, Tsourmas, Feffer, Citrin and Patronas, 1984) the axis was found to be either

anterior and inferior to the Sacrum, or that rotation does not occur at all and that pure

translation occurs along the axis of the caudal portion of the Sacroiliac joint articular facet

(refer to Figure 2.13). Wiesl et al. (1984) proposed the movement to be more posterior to

anterior movement, with the cephalad segment of the articulating surface being more

mobile than the caudal segment (Maigne, 2006). All these arguments once again

emphasise the difficulty of studying this joint, as there seems to be so many variations in

types of movement that occur.

Figure 2.12: Movement of the Sacroiliac joint according to Farabeuf, and Bonnaire and

Bue. The axis of movement according to Farabeuf is shown on the left, while the

movement axis according to Bonnaire and Bue is shown on the right. The axis of rotation is

indicated by a + sign. A – anterior, P – posterior.

(Maigne, 2006)

28

Figure 2.13: Movement of the Sacroiliac joint according to Wiesl. The centre of rotation is

indicated by a + sign. A – anterior, P – posterior. (Maigne, 2006)

Nutation is increased during standing, especially if an increased lumbar lordosis is present.

Counter-nutation occurs when the spine is flattened while lying supine or prone and can be

altered by flexion of the hips to its full range of motion (Vleeming et al., 1997).

While leaning forward, the line of force of gravity moves anterior to the hip joints (refer to

Figure 2.14). It may also move forward with a protruding abdomen or in the later stages of

pregnancy. When it does, the Ilia rotate anteriorly on the Sacrum. Holding a strong pelvic

tilt while leaning forward creates ligamentous tension and is therefore important for

posterior pelvic stability. This is best done by contraction of the Rectus abdominis,

Abdominal oblique and Hamstring muscles. The Transversus abdominis muscle apparently

has only a scant effect on posterior pelvic tilt (DonTigney, 2005).

Figure 2.14: The influence of various muscles reacting to gravity on the stability of the

pelvis. (DonTigney, 2005)

29

2.3.2 Asymmetrical motion of the Sacroiliac joints

Antagonist or asymmetrical movement occurs at the Sacroiliac joints since it is a paired

reciprocal motion that occurs during walking (Gatterman, 2004). This reciprocal movement,

as occurs during Gillet‟s motion palpation, is important for the purposes of this study.

Gillet‟s test tests for motion restriction of the Sacroiliac joints, and will be fully explained in

the text below.

During the standing position, when the subject lifts the right knee, the right Ilium rotates

posteriorly around the x-axis, known as Sacroiliac joint flexion. The Sacrum is considered

to undergo nutation on the flexing hip side and counter-nutation on the weight-bearing side.

As soon as the Sacroiliac joint reaches its end range of motion, further flexion of the hip will

cause the entire pelvis to rotate on the weight-bearing leg. The flexed Ilium will leverage

the Sacrum posteriorly and inferiorly, causing extension of the weight-bearing Ilium at that

Sacroiliac joint (DeFranca and Levine, 1996). Antero-superior motion of the Ilium occurs

relative to the Sacrum during extension and postero-inferior motion occurs during flexion at

the Sacroiliac joint (Gatterman, 2004).

Due to the angle at which the Sacroiliac joints lie, their motion of flexion and extension

occurs about an axis that causes coupled movement. This causes a degree of in- and

outflaring during flexion and extension. During flexion the Posterior Superior Iliac Spines

move posteriorly, inferiorly and medially while the Ischia move anteriorly, superiorly and

laterally. The reverse occurs during extension of the Sacroiliac joint (Walters, 1993). The

anterior-posterior rotation of the Ilia occurs around an axis at the Pubic Symphysis

anteriorly and a posterior axis on each side of each Sacroiliac joint (Greenman, 1997).

2.3.3 Gait

The gait cycle includes the activities that occur during walking from the point of initial

contact of one lower extremity to the point at which the same lower extremity contacts the

ground again. During one cycle each extremity passes through a stance phase and a

swing phase (Norkin and Levangie, 1992).

30

The stance phase starts when one heel contacts the ground (heel strike) and continues for

as long as one part of that foot contacts the ground (toe-off). This makes up 60% of the

gait cycle during normal walking. The swing phase begins as soon as the toe of the same

foot leaves contact with the ground and stops just before heel strike of the same foot

(Norkin and Levangie, 1992).

During gait there is a rhythmic movement of the pelvis in different plains (DeFranca and

Levine, 1996). Some authors describe the movement as a gyroscopic action of the Sacrum

in a figure-of-eight motion between the two Ilia (Gatterman, 2004).

During heel strike of the right leg and left toe-off (refer to Figure 2.15) the right Ilium is

rotated posteriorly and the left Ilium anteriorly (Greenman, 1997) in the horizontal plane,

causing the Sacrum to undergo nutation on that side. This also causes posterior rotation of

the ipsilateral 5th lumbar vertebra transverse process (DeFranca and Levine, 1996). The

Sacrum is level and the lumbar spine is straight, and both face to the left due to pelvic

rotation to the left. When the right stance phase is reached, the right Ilium is rotating

anteriorly and the left posteriorly. At right midstance, there exists maximal loading of the

right hip and Sacroiliac joint. At this point the Sacrum, lying between the Ilia, is rotating to

the right, side bending to the left and moving into nutation at the left Sacral base

(Greenman, 1997). The pelvis sways towards the weight-bearing limb during midstance

(DeFranca and Levine, 1996), while the lumbar spine flexes laterally to the right and

rotates to the left. At left heel strike the left Ilium starts its anterior rotation, and as the right

leg enters the swing phase, it begins to rotate posteriorly. At this point the Sacrum has

returned to level between the two Ilia, while the lumbar spine is straight and the pelvis is

rotated to the right (Greenman, 1997). The sacral base therefore moves from nutation

during heel-strike to counter-nutation at toe-off during the gait cycle (DeFranca and Levine,

1996).

31

Figure 2.15: Combined activities of the left and right Ilia, the Sacrum and lumbar spine

during walking. 1 and 2 at right heel strike, 3 and 4 at right midstance, 5 and 6 at left heel

strike, 7 and 8 at left leg stance.

(Greenman, 1997)

Movement at the Sacroiliac joint is produced by contraction of a number of muscles as the

joint is surrounded by some of the largest and most powerful muscles in the body.

Contraction of the Erector spinae, Psoas, Quadratus lumborum, abdominal and Glutei

muscles all place shear and moment forces on the Sacroiliac joint, inducing movement

(Cassidy and Mierau, 1992). There are also numerous small muscles crossing both the hip

and Sacroiliac joints, including the Gemelli, Obturator internus and externus, Piriformis and

Gluteus minimus and medius, that function to stabilise the hip and Sacroiliac joints (Boers,

1999).

2.4 Sacroiliac Joint Dysfunction

Kirkaldy-Willis and Hill (1979) describe Sacroiliac syndrome as a collection of signs and

symptoms that result from mechanical irritation of the Sacroiliac joint (Cassidy and Mierau,

1992). It must be emphasised that Sacroiliac syndrome is always caused by Sacroiliac joint

32

dysfunction, but Sacroiliac joint dysfunction can also be asymptomatic and not cause any

pain or symptoms associated with the syndrome.

Mechanical dysfunction involves altered structural relationships, which results in abnormal

movements and ultimately pain (Grieve, 2001). Altered mobility, or dysfunction, of the

Sacroiliac joint is considered to be the most widely accepted cause of Sacroiliac syndrome.

This implies a malfunction in the normal mechanics of the joint, which implies either

excessive or decreased movement occurring within the joint. The obvious problem with this

theory is that the normal biomechanics of the joint are not well understood and the

movements are generally slight and difficult to detect (Cassidy and Mierau, 1992).

Sacroiliac joint restriction or hypomobility are known to cause excessive rotary forces on

the lumbar spine which may induce subsequent disc degeneration. A lumbar scoliosis may

develop away from the side of pain, eventually leading to compensatory thoracic and

cervical biomechanical changes, leading to pain. Overstress of the hip, knee, ankle and

foot joints have also been noted in patients experiencing Sacroiliac joint dysfunction

(Schafer and Faye, 1990).

2.4.1 Causes of Sacroiliac joint dysfunction

Sacroiliac joint dysfunction is most commonly caused by mechanical factors, but may also

result from pre-existing inflammation or disease (DeFranca and Levine, 1996). These

occurrences are, however, minimal.

The mechanical causes of Sacroiliac joint dysfunction develop through the loss of stability,

as described earlier in the text, altering the self bracing mechanism (Mior et al., 1999).

Conditions that cause prolonged loading of the Sacroiliac ligaments, i.e. standing or sitting

for extended periods or a structural short leg, can cause these ligaments to show some

creep deformation. Creep is described as a change in strain under application of a

constant stress. Creep deformation of the ligaments of the Sacroiliac joints is caused when

repeated stresses load these ligaments, and is stress and strain dependant (Oza,

Vanderby and Lakes, 2006). Single or multiple injuries therefore decrease the stability of

33

the joint and cause hypermobility, giving rise to symptomatic lower back pain (Harrison et

al., 1997).

In the absence of anterior pelvic support from muscular contraction when the line of gravity

moves anteriorly during forward bending, the Ilia will tend to rotate cephalad and laterally

on the Sacrum at the level of the third sacral level (S3) and caudad and laterally on the

Sacrum at S1. The muscles surrounding the pelvis are required to stay contracted to

maintain stability. An absence of anterior pelvic support gives rise to a loss in ligamentous

balance with the Sacrotuberous ligament being loosened. Increased tension also occurs in

the Hamstring muscles to balance the moment of force. This disturbed ligamentous

balance will cause the Ilium bone to subluxate cephalad and laterally on the Sacrum on an

acetabular axis (refer to Figure 2.16) (DonTigney, 2005).

Figure 2.16: Sequence of onset of Sacroiliac joint dysfunction in the absence of

ligamentous and muscular support. (DonTigney, 2005)

34

2.4.2 Types of Sacroiliac joint dysfunctions

Literature mentions the Sacroiliac joint to be considered as two joints (even though they

are the same articulation), i.e. 1) the Ilium moving on the Sacrum and 2) the Sacrum

moving within the two Ilia (Saunders, 1995).

The Sacrum can commonly be neglected as a restriction in assessment of lower back and

pelvic pain, especially in paediatric care. Trauma or repetitive stresses placed on the

Sacrum in the case of improper lifting of babies, or when attempting to walk and constantly

falling on the Sacrum have been known factors in causing Sacral restrictions (Anrig, 1999).

For the purposes of this study determining the types of dysfunction in the Sacroiliac joint

will not be necessary. In other words, it does not matter whether it is a flexion or extension

restriction, or whether it is a Sacral or Ilial restriction. The sole purpose of this study is to

measure which side has dysfunctional movement in relation to the norm.

2.5 Sacroiliac Joint Syndrome

Sacroiliac joint syndrome always occurs when a patient exhibits a dysfunction in movement

of the Sacroiliac joint, but not all Sacroiliac joint dysfunctions cause the pain and symptoms

associated with the syndrome. A brief history and symptoms of Sacroiliac joint syndrome

will be explained in the following texts, as it is often easiest to detect a Sacroiliac joint

problem by performing a good history on the patient before performing various tests to

confirm the suspicion (Bernard, 1997).

2.5.1 Patient history of Sacroiliac joint syndrome

The history of Sacroiliac syndrome is that of mechanical backache with no pain referral into

the leg or foot. Common examples include a young woman with history of pregnancy,

dysmenorrhea or child delivery, persons with altered gait due to hip, knee, ankle or foot

disorders, or activity-related incidents relating to sports, dancers or military recruits.

35

Sacroiliac joint dysfunction may also arise after hip surgery, spondylolisthesis or spinal

fusion giving rise to the associated Sacroiliac joint syndrome (Cassidy and Mierau, 1992).

2.5.2 Symptoms and signs of Sacroiliac syndrome

The pain arising from Sacroiliac joint syndrome is usually localised over the Posterior

Superior Iliac Spine and buttock (Figure 2.17). It has been known to refer pain into the

groin and leg in a pattern that does not follow any dermatome. Since the Sacroiliac joint

receives its nerve supply from many different spinal levels, the diagnosis can become

difficult (Cassidy and Mierau, 1992).

Figure 2.17: Referral pattern caused by pain originating from the Sacroiliac joint. (Netter,

1989)

Physical findings include pain or tenderness over the sacral sulcus and the posterior

Sacroiliac joint line. The range of motion of the lumbar spine may elicit pain during forward

flexion and lateral bending to the opposite side of the affected side, and the Hamstring

muscles on the symptomatic side are also commonly found to be tight (Quon, Bernard,

Burton and Kirkaldy-Willis, 1999).

The pain may cause the patient to walk with a slight limp. Along with the tenderness of the

Sacroiliac joint, paraspinal lumbar muscle spasm and Gluteal trigger points may occur

36

unilaterally. Straight leg raising may be reduced on the side of involvement due to

Hamstring tightness, but there will be no neurological deficit in the form of reduced

reflexes, numbness or weakness of muscle contraction. If these do occur the examination

should be directed towards more serious causes for the low back pain (Cassidy and

Mierau, 1992).

Pain is often aggravated by walking, stair climbing, turning over in bed and standing on the

affected leg. It can further be aggravated by maintaining a set position or activity for

prolonged periods. Frequent alterations in activity or posture often bring relief (Timm,

1999). An adaptive lumbar scoliosis away from the side of pain may occur, leading to

compensatory changes throughout the spine (DeFranca and Levine, 1996).

2.6 Detecting Sacroiliac Joint Dysfunction

As mentioned before, the Sacroiliac joint is believed to be a common cause of lower back

pain and Sacroiliac joint dysfunction (or even syndrome) and may also co-exist with other

sources of low back pain. In a study done by Quon et al. (1999) on patients with

spondylolisthesis (forward or backward slippage of one vertebral segment relative to the

rest of the vertebrae in the spinal column), 25% experienced pain originating from the

Sacroiliac joint. Pain over the Sacroiliac joint combined with 3 positive Sacroiliac joint tests

allows the practitioner to make a diagnosis of the syndrome with confidence. If the

symptoms abated with Sacroiliac joint adjusting, mobilisation or injection, the diagnosis

could be confirmed (Quon et al., 1999).

2.7 Reliability of the Different Tests Used in Manual Testing

The tests primarily used by manual therapists in clinical practice for diagnosing Sacroiliac

joint dysfunction can grossly be divided into pain provocation tests and motion palpation

tests.

37

2.7.1 Pain provocation tests

Pain provocation tests commonly used in practice include Gaenlens‟, Patrick FABERS‟,

Erichsens‟, Gapping, “Squish” and Sacroiliac joint compression tests. According to

literature (Hestboek and Leboef-Yde, 2000) pain provocation tests are generally more

reliable than motion palpation tests, especially concerning inter-examiner reliability.

However, recent studies by Foley and Buschbacher (2006) have found that the validity of

these same pain provocation tests can sometimes be questioned. This is confirmed when

the Sacroiliac joint is injected with a pain block under guidance of fluoroscopy and the pain

is still produced by the provocation tests. This false positive finding can likely be attributed

to involvement of peri-articular muscles or ligaments. A recent study done at the University

of Johannesburg also confirmed that at least 50% of restrictions occur at the opposite side

of the painful Sacroiliac joint (Botha, Yelverton and Potgieter, 2008).

2.7.2 Motion palpation tests

Motion palpation testing forms the basis of what the profession of Chiropractic science is

all about, i.e. to detect aberrations in biomechanical movement and to correct these

dysfunctions in order for functional movement equilibrium to be restored (Strasser, 2008).

In a study (Toussaint et al., 1999) which compared three different motion palpation tests

(Gillet‟s, Standing Flexion and Iliac Springing) of the Sacroiliac joint, and an Iliac

compression test (pain provocation test) the results showed higher positive findings for the

Standing flexion test than for the other two palpation tests. The researchers suggest that

both Gillet‟s and Standing Flexion tests be positive on the same side for increased quality

of diagnostic assessment of SI dysfunction. In conclusion the authors state that the tests

do show moderate consistency, but should be viewed with caution, as the examiners were

not blinded during the study.

Potter and Rothstein (1985) also tested the inter-examiner reliability of 13 selected SI-joint

tests most commonly used in everyday Chiropractic practice. Seventeen symptomatic

patients were evaluated by 8 different examiners. Two examiners assessed a patient using

38

all 13 tests and their results were compared. Their results showed that 11 of the 13 tests

were unreliable (less than 70% agreement). Gillet‟s test and the Standing Flexion Test did,

however, prove to have the highest agreement amongst all these unreliable tests.

The motion palpation tests being used in this study will be discussed in more detail later in

Chapter 3. They are the Gillet‟s test (Spine test) and the Standing Flexion test.

Gillet’s (Spine) Test

Carmichael (1987) investigated the inter- and intra-examiner reliability of using the Gillet‟s

test for diagnosing SI-joint dysfunction. Fifty three college students were examined by 10

examiners after which their blinded findings were correlated using Cohen‟s un-weighted

kappa statistic for concordance. His findings showed an 85.2% intra- and an 89.2% inter-

examiner reliability. This suggests the Gillet‟s test is clinically useful and reliable for

assessing SI-joint mobility.

A study done by Grieve (2001) investigated the validity of 4 tests in diagnosing mechanical

Sacroiliac dysfunction. It analysed data from 57 patients being referred by General

Practitioners who were suffering from low-back, buttock and leg pain. The study found,

among others, that the Gillet‟s test for motion palpation was a sensitive and specific test.

A later study however found the Gillet‟s test to be less reliable than previously thought.

Meijne, van Neerbos, Aufdemkampe and van der Wurff (1999) also investigated the intra-

and inter-examiner reliability of the Gillet‟s test by testing and re-testing 37 subjects using 2

examiners (former physiotherapy students). The subjects were sub-divided into

symptomatic and asymptomatic groups. According to their data analysis, only the

symptomatic group exceeded the minimum 80% level of accordance, hence making the

test relatively unreliable for asymptomatic patients.

A study by Herzog, Read, Conway, Shaw and McEwen (1989) also assessed the inter-

and intra-examiner reliability of Gillet‟s motion palpation by using 10 qualified Chiropractors

and 10 patients with SI-joint dysfunction. They found the intra-examiner reliability to be

39

significantly reliable. The inter-examiner reliability was, however, only reliable for some of

the scores. Also, contrary to popular belief, higher expertise of the examining doctors was

found to be associated with lower intra-examiner agreement scores. The severity of the low

back problems did not influence any of the agreement scores. This study is however

limited as only 11 patients were screened.

The Standing Flexion Test

Vincent-Smith and Gibbons (1999) measured the inter- and intra-examiner reliability of the

Standing flexion test for determining Sacroiliac joint dysfunction. Nine examiners

performed the test on nine asymptomatic subjects. Inter-examiner testing proved

statistically insignificant reliability (42%) while intra-examiner reliability was only moderately

reliable (68%). Again, the validity of this test can be questioned, as the amount of subjects

screened was low.

According to Egan, Cole and Twomey (1996) the Standing Flexion test is an unreliable test

for measuring Sacroiliac joint dysfunction. They compared positive Standing Flexion tests

to symptoms associated with Sacroiliac joint dysfunction, i.e. low back pain, postural

unsteadiness and skeletal asymmetry. They found one-third of the subjects with a positive

Standing Flexion test to be asymptomatic, i.e. far too many false positives (Egan et al.,

1996). It is however a widely known fact to Chiropractors that symptoms need not exist for

a joint to be fixated or restricted in motion.

2.8 Management of Sacroiliac Joint Syndrome

The obvious eventual outcome for treatment of dysfunction of the Sacroiliac joint is to

correct the biomechanical imbalances and reduce pain.

Inflammation in the tissues surrounding the Sacroiliac joint can be classified into three

separate stages: acute, sub-acute and chronic (Onofrio, 1999).

40

During the acute stage (three to four days post-injury) there exists swelling in the joint

which usually occurs within a few days after the injury. Redness and swelling is present

due to vascular changes. There is exudation of cells and chemicals locally that cause the

swelling and pain (Onofrio, 1999). It is a benign and self-limiting disorder at this stage and

most patients will recover fully without medical (Chiropractic or allopathic) intervention.

However, 60% of these cases suffer a second episode of back pain within two years

(Cassidy and Mierau, 1992). Conservative treatment in the initial acute phase can include

icing (to bring down the local inflammatory response) and gradual mobilisation of the joint

(Gatterman, 2004).

The sub-acute stage is marked by healing and repair and occurs up to the second or third

week after the injury. New capillary beds grow into the damaged areas and are supported

by connective tissue growth (collagen fibre). This new tissue is fragile and must be handled

gently as it is easily injured (The Body Worker, 1999).

The chronic inflammatory stage is the remodelling stage, during which signs of

inflammation are absent and scar tissue is maturing. This stage is present from two weeks

up to one or two years after the injury. Maturation (growth of the fibroblasts into fibrocytes)

and remodelling (organisation of and shrinking of collagen fibre along lines of stress) occur

within the tissues during this stage (The Body Worker, 1999).

During the sub-acute and chronic stages of the condition treatment can include manual

therapy of the joint in the form of Chiropractic adjustments and treatment of the

surrounding musculature and ligaments involved in the condition. The goal should be to

maximise function in the joint despite initial pain (Foley and Buschbacher, 2006). Although

adjustments of the Sacroiliac joint have not been shown to produce lasting positional

changes in the Sacroiliac joint, it will probably still have an effect on the surrounding

tissues, therefore providing clinical importance (Tullberg et al., 1998).

41

2.9 Conclusion

Although movement of the Sacroiliac joint has come under much controversy, it is well

accepted that it is a major cause in the production of mechanical lower back pain.

Sacroiliac joint dysfunction needs to be properly diagnosed and a gold standard is required

for diagnosis of this condition. This would make the choice of treatment to be administered

easier for the clinician and eliminate false positives or false negatives.

This research was aimed at determining which test for the diagnosis of Sacroiliac joint

dysfunction would give the most clinical reliability towards assessment and accurate

treatment of this condition. As mentioned before both tests are readily used in clinical

practice, and whether either of them is clinically reliable remained to be proven in this

study.

42

CHAPTER 3: METHODOLOGY

43

3.1 Participant Selection

One hundred participants were randomly selected for the purposes of this study through

advertisements (Appendix A) placed in and around the University of Johannesburg

Doornfontein Campus. These participants were either a patient under the care of the

Chiropractic Day Clinic at the University of Johannesburg Doornfontein Campus,

Chiropractic students currently studying Chiropractic at the University of Johannesburg or

members of the general public.

Due to logistical purposes it was not possible to see all 100 participants in one session,

therefore as many participants were seen at any possible time when 8 examiners fulfilling

the requirements could be summoned to take part in the study. The examiners asked to

participate in the study were Chiropractic 6th or 7th year students at the University of

Johannesburg Doornfontein Chiropractic day clinic. They were of similar skill level, i.e. all

had to have completed a minimum of 35 new patients and were all given a refresher

course on the methodology of the techniques to be performed before the examination

started. This served to benefit the skill level of the examiners in diagnosing Sacroiliac joint

dysfunctions. A minimum of 8 examiners were always used.

3.2 Inclusion Criteria

Asymptomatic persons between the ages of 18 and 40 years.

3.3 Exclusion Criteria

Persons experiencing any neurological symptoms, i.e. paraesthesia, myotomal

weakness or decreased reflexes in the lower limbs

Persons experiencing paralysis in the lower half of their bodies

Persons who have been diagnosed with arthropathies (e.g. Ankylosing spondylitis)

Persons who have known developmental abnormalities of the spine or pelvis (e.g.

Spinae Bifida, Hemi-pelvis)

44

Any other conditions that may have caused a leg length inequality, such as a

congenital short leg, malposition of the hip/foot/ankle

Persons who have had previous lower back, pelvic or hip surgery

Pregnancy or childbirth, from the 1st trimester to 1 year after delivery.

3.4 Procedure

The potential participants were screened in order to determine whether they could be

included in the study. The screening process involved the researcher performing a Case

History (Appendix B) done prior to the participants being examined. A Pertinent Physical

Examination (Appendix C) and a Lumbar Spine and Pelvis Regional Examination

(Appendix D) were performed after the testing procedures were done by the researcher to

make sure the researcher and examining students were not biased in any way towards

their findings. If any of the exclusion criteria were met the participants were excluded from

the study. The participants were also required to read and sign a Participant Information

and Consent Form (Appendix E).

The eight examiners were placed in adjacent rooms. Each participant was given an

envelope containing eight A5 sized Examination Forms (Appendix F). The participant

entered the first room and was examined by Examiner Number One using Gillet‟s motion

palpation to detect Sacroiliac joint dysfunction. After examining the participant the

examiner completed the Examination Form (Appendix F), which included the side of

restriction and placed it in the envelope. The participant then moved to the next room

where Examiner Number Two examined the participant using the Standing Flexion test and

completed the Examination Form. After completion the participant then moved to rooms

Three to Eight where the examiners examined the participants using Gillet‟s and Standing

Flexion tests in alternating order. Four examiners therefore assessed the participants using

Gillet‟s motion palpation and 4 different examiners assessed the participants using the

Standing Flexion Test. Each participant was examined a total of 8 times reducing the

amount of mobilisation of the joint, thus giving more accurate readings. Eight examinations

45

(four for each technique) were performed on each participant in an attempt to make the

study as clinically viable as possible.

After each palpation the participant collected and kept the folded Examination Forms in an

envelope so that the examiners were not aware of the previous examiners‟ findings. The

examiners were not allowed to communicate to the participants or to each other in any way

during the examination as this could have influenced their findings. After the 8

examinations were completed the envelopes were handed to the researcher.

This entire procedure was repeated until a total of 100 participants were screened. The

sealed envelopes were opened at the end of the day and the Examination Forms were

taken out and kept in a safe, secret place until after the study was completed, at which time

the results were collected and sent to STATKON for analysis.

3.4.1 The manual tests used in this study

Gillet’s (Spine) Test

This test is otherwise known as the Stork Standing test, and is used to determine the side

of the restriction of the Ilium bone moving on the Sacrum. With the participant standing and

the examiner seated or kneeling behind the participant, the examiner‟s right thumb

palpated the inferior slope of the right Posterior Superior Iliac Spines (PSISs) and the left

thumb palpated the midline of the Sacrum at the same level, i.e. at the level of the second

Sacral segment (refer to Figures 3.1, 3.2 and 3.3). The participant then flexed the right hip

and knee to a minimum of 90 degrees. The Sacroiliac joint motion is considered normal if

the thumb on the right PSIS moves caudal one to two centimeters (Gatterman, 2004) and

abnormal if the thumb on the right PSIS does not move or if it rises relative to the left

thumb placed in the midline (Tong, Heyman, Lado and Isser, 2006).

In a restricted joint the thumb over the PSIS does not move caudally and the participant

consequently rotates the entire buttock downward and forwards (Gatterman, 2004). This

46

part of the test measures positively for superior joint restriction or flexion fixation. The test

is then repeated on the left side. The dysfunction is recorded as left, right, or no restriction.

Figure 3.1: Gillet‟s (Spine) Test during motion palpation. Normal movement is shown on

the left, while aberrant movement (restriction) is shown on the right. (Bernard, 1997)

Figure 3.2: Position of the thumbs before starting Gillet‟s Motion palpation of the Sacroiliac

joint. (Photo by Author)

47

Figure 3.3: Gillet‟s Motion palpation is shown with the start position shown on the left and

the movement being seen while flexing the leg, shown on the right. (Photo by Author)

During normal Sacroiliac joint function, when raising the right leg, the right Posterior

Superior Iliac Spine moves posteriorly, inferiorly and then anteriorly relative to the Sacrum.

With dysfunctional motion the Ilium is unable to move at the Sacroiliac joint and, in an effort

to lift the leg, the participant will tend to compensate by tilting the pelvis. This will cause the

right PSIS to move superiorly relative to the Sacrum indicating a positive result for

restriction in the Sacroiliac joint motion palpation (Bernard, 1997).

Gillet‟s (Spine) test can also test for extension restrictions of the Sacroiliac joint, i.e. fixation

in the lower part of the joint. This is performed by placing the contacts on the same

landmarks and asking the participant to extend the leg backwards toward the examiner.

This study, however, only compares this test to a test which also tests for flexion

restrictions (Standing Flexion test). Participants were therefore not examined further with

this part of the test.

48

The Standing Flexion Test

With the participant standing and the examiner seated or kneeling behind the participant,

the examiner palpated the inferior slopes of the bilateral Posterior Superior Iliac Spines

(PSIS) of the Ilia with his/her thumbs. As the participant bent forward to touch the floor, the

examiner‟s thumbs followed the PSIS cephalad as the Sacrum nutated between the Ilia

(refer to Figure 3.4). A full account of the symmetrical motion and biomechanics of the

Sacroiliac joints was explained in greater detail in Section 2.3.1.

During further flexion, more lumbar motion occurred and the Sacrum began to counter-

nutate between the Ilia simultaneously (Wourman, 1993). If one side moves more cephalad

than the other side by greater than 1 cm, that is considered abnormal (Tong et al., 2006).

This occurs due to the Ilium, being fixated to the Sacrum at the Sacroiliac joint, moving

upwards together with it as the spine moves into flexion. Therefore, there is sacral nutation

at the Sacroiliac joint during flexion. The dysfunction is recorded as symmetric (no

restriction), left, or right (Tong et al., 2006).

Figure 3.4: The Standing Flexion test: The position of the thumbs before starting the

motion palpation of the Sacroiliac joint is shown on the left, while the actual movement is

shown in the picture on the right. (Photo by Author)

49

False positives of this test include hypertonicity of the Erector spinae, Hamstring,

Piriformis, Quadratus lumborum, Gluteus maximus or posterior Iliotibial band muscles.

Unilateral restrictions within the hip joints, or fourth or fifth lumbar vertebrae may also

cause false positives (Potter and Rothstein, 1985).

The overtake phenomenon occurs when one PSIS is lower than the other while the

participant is standing, and it moves to end higher than the other PSIS during flexion. Since

the Sacrum follows as the spine flexes, if a dysfunction exists in the Sacroiliac joint on one

side, the Ilium will follow the Sacrum and move further cephalad than the other (DeFranca

and Levine, 1996).

3.5 Statistical Analysis

After all the examinations were completed, the researcher collected the envelopes and the

data was captured and analysed by STATKON at the University of Johannesburg. The

results were subjected to statistical methods, obtaining data which could be interpreted as

being either reliable or unreliable (in terms of inter-examiner reliability). These methods

provided comprehensive detail for the accurate analysis of the data captured in order to

make accurate deductions on the reliability of the tests being tested (Black, 2002).

If the assumption was made that both tests were reliable, one could assume that both

reliabilities are similar. Also, the results obtained from the tests would be similar. This could

be tested by means of descriptive statistics (including Chi-squared and T-tests) and

correlation studies (Corder and Foreman, 2009). The Chi-squared test is used to determine

whether there is a significant difference between the expected and the observed

frequencies. The T-test will be used to compare the obtained reliability percentages to a

known percentage accepted in Chiropractic literature (Corder and Foreman, 2009). Using

these methods one could comprehensively deduce whether the tests were similar in their

reliability.

For reliability purposes, when the same restriction was found, 100% reliability was

assigned to that particular participant. When three examiners found a left (or right) sided

50

restriction and one found a different restriction, 75% was assigned. Two left and two right

results (or no restriction) were assigned 50% reliability. When three different results were

obtained for a participant (e.g. two left, one none and one right) 33% reliability was

assigned. This was done with both the Standing Flexion test and Gillet‟s Motion Palpation.

This indicated a stronger measure of reliability for these tests.

51

CHAPTER 4: RESULTS

52

4.1 Descriptive Statistics

One of the main criteria for using the participants in the study was that they were

asymptomatic in terms of back pain. Thus, all one hundred participants examined were

pain free. The participants were not asked whether they had experienced lower back pain

previously and therefore this could not be correlated to reliability figures to ascertain if high

reliability figures were related to previous lower back pain, as was found in previous study

(Herzog et al., 1989).

In total, of the 100 participants used in this study, 56 were female and 44 were male. The

oldest person tested was 42 years and the youngest was 19 years old, with the mean age

being 24 years old. No correlation was found between the age or gender of the participants

and the results of the reliability of the tests.

In this chapter the data is subjected to statistical methods in order to obtain which test is

more statistically reliable. These methods provided comprehensive detail for the accurate

analysis of the data captured in order to make accurate deductions.

4.2 Statistics for Restrictions Found

Figures 4.1, 4.2 and 4.3 represent the similarity of frequency in which the examiners found

a left, right or no restriction respectively. This was calculated by means of the Chi-squared

method (Corder and Foreman, 2009). The research was started with the assumption that

there is no difference between the findings of the examiners performing Gillet‟s Motion

Palpation and the Standing Flexion tests. These figures depict the number of participants

producing a left, right or no restriction from the examiners in either none of the four times,

once, twice, three times or four times for each of the two motion palpation techniques.

53

Figure 4.1: Frequency of examiners correlating to finding the left side restricted

Figure 4.1 shows that 17 of the 100 participants tested showed no left sided restriction

while using Gillet‟s Motion palpation, compared to 15 of the 100 participants showing no

left sided restriction using the Standing Flexion method. Forty of the 100 participants tested

showed one left sided restriction while testing with Gillet‟s Motion palpation, compared to

39 of the 100 participants showing one left sided restriction using the Standing Flexion

method. Twenty-seven participants showed two left sided restriction while using Gillet‟s

Motion palpation, compared to 26 of the 100 participants showing two left sided restriction

using the Standing Flexion method. Fourteen participants showed three left sided

restriction while using Gillet‟s Motion palpation, compared to 17 of the 100 participants

showing three left sided restriction using the Standing Flexion method, and 2 participants

showed four left sided restriction while using Gillet‟s Motion palpation, compared to 3 of

the 100 participants showing four left sided restriction using the Standing Flexion method.

54

Figure 4.2: Frequency of examiners correlating to finding the right side restricted

Similarly Figure 4.2 shows that 11 of the 100 participants tested showed no right sided

restriction while using Gillet‟s Motion palpation, compared to 12 of the 100 participants

showing no right sided restriction using the Standing Flexion method. Thirty of the 100

participants tested showed one right sided restriction while using Gillet‟s Motion palpation,

compared to 32 of the 100 participants showing one right sided restriction using the

Standing Flexion method. Thirty-three participants showed two right sided restrictions

while using Gillet‟s Motion palpation, compared to 29 of the 100 participants showing two

right sided restrictions using the Standing Flexion method. Twenty-three participants

showed three right sided restriction while using Gillet‟s Motion palpation, compared to 21

of the 100 participants showing three right sided restriction using the Standing Flexion

method, and 3 participants showed four right sided restriction while using Gillet‟s Motion

palpation, compared to 6 of the 100 participants showing four right sided restriction using

the Standing Flexion method.

55

Figure 4.3: Frequency of examiners correlating to finding no restrictions.

Figure 4.3 shows that 41 of the 100 participants tested showed no results with no

restrictions while using Gillet‟s Motion palpation, compared to 50 of the 100 participants

showing no results with no restrictions using the Standing Flexion method. Forty-two of

the 100 participants tested showed one no restrictions while using Gillet‟s Motion

palpation, compared to 34 of the 100 participants showing one no restrictions sided

restriction using the Standing Flexion method. Fourteen participants showed two no

restrictions results while using Gillet‟s Motion palpation, compared to 13 of the 100

participants showing two no restrictions results using the Standing Flexion method. Only 3

participants showed three no restrictions results while using Gillet‟s Motion palpation,

compared to 3 of the 100 participants showing three no restrictions results using the

Standing Flexion method. There were no results with four findings with no restrictions for

either Gillet‟s Motion palpation or the Standing Flexion test.

When comparing the frequencies of findings in this way, the tests show relatively good

reliability between one another. The differences between the frequency of findings between

the Gillet‟s Motions palpation and the Standing Flexion Test are negligible, or at least very

low. If the p-value was less than 0.05 in the calculation, the theories used to determine the

56

results could be rejected. However, the values of 0.879, 0.654 and 0.311 respectively for

Left, Right and No Restriction indicate high concordance between the testing groups. The

No Restriction value was the only significant result found. According to this test there

seems to be high concordance between the results obtained, indicating high reliability of

the tests being tested.

Figure 4.4: Frequency of reliability of each test

However, when tabulating the frequencies of reliabilities of the two tests, a completely

different picture arises (refer to Figure 4.4). Figure 4.4 relates the reliability assigned to the

results of each participant tested (refer to Section 3.5 as to how this was obtained). The

figure shows that 36 of the participants produced only 33% reliability using Gillet‟s Motion

palpation, with a similarly low 32 participants producing 33% reliability using the Standing

Flexion test. Eighteen participants produced 50% reliability using the Standing Flexion test

compared to 19 out of 100 using the Gillet‟s Motion palpation. Forty participants produced

75% while using Gillet‟s Motion palpation compared to 41 participants producing 75%

reliability using the Standing Flexion test. Only 9 participants received 100% reliability

using the the Standing Flexion test versus 5 out of 100 achieving 100% using the Gillet‟s

Motion palpation. This figure also indicates that nearly 50% of the participants produced

57

50% or less reliability when tested by the examiners, which indicates that many examiners

differed in their findings, signifying relatively low inter-examiner reliability.

Table 4.1: Difference of one or more for right (R), left (L) or no restriction (N) results using

Standing Flexion test and Gillet‟s Motion Palpation

L N R 25

L N - 12

L - R 29

- N R 21

- - - 13

Total 100

Table 4.1 shows the number of tests performed when at least one or more differences

were noted in the examinations using the Standing Flexion test and Gillet‟s Motion

Palpation. As indicated by the table, in only 13 cases of the 100 participants measured,

there existed complete 100% reliability (no differences). It also shows that in 25 of the

participants there were at least one difference between left, right and no restriction. In 12

participants there existed only a difference between left and no restriction, in 21

participants there were a difference between right and no restriction, and 29 of the

participants showed differences between left and right restrictions. All these values point to

low reliability of the tests being used in the examination process.

The differences obtained between the results from the examiners deciding on left, right or

no restriction were tabulated (refer to Table 4.2).

Table 4.2: Differences between the numbers of examiners deciding on the side of

restriction using the Standing Flexion test and Gillet‟s Motion Palpation

Left Right No restriction

No Difference 34 25 42

Difference of 1 Examiner

47 47 36

Difference of 2 Examiners

14 25 20

Difference of 3 Examiners

5 3 2

58

The table shows that while testing 34 of the participants, there was no difference between

the numbers of examiners finding a left sided restriction. Also, 25 times no difference was

found while finding right sided restrictions and similarly 42 times no difference was found

while finding no restriction. In 47 of the participants there was a difference of 1 examiner

between the numbers of examiners finding a left sided restriction, 47 times 1 examiner

difference was found while finding right sided restrictions and similarly 36 times 1 examiner

difference was found while finding no restriction. Fourteen of the participants showed a

difference of 2 examiners between the numbers of examiners finding a left sided

restriction. Also, 25 times a 2 examiner difference was found while finding right sided

restrictions and similarly 20 times a 2 examiner difference was found while finding no

restriction. Five of the participants showed a difference of 3 examiners between the

numbers of examiners finding a left sided restriction, 3 times a 3 examiner difference was

found while finding right sided restrictions and similarly twice a 3 examiner difference was

found while finding no restriction.

This table does indicate that there were more instances during which no difference, or a

difference of only 1 examiner, was present during the testing process than differences of 2

or 3 examiners. This indicates a comparatively higher statistical significance between these

two tests and therefore high reliability.

4.3 Correlations Between the Findings

Table 4.3: Correlations between left, right and no restriction findings between the two tests

Findings Spearman’s rho

(correlation coefficient) p-value

Left 0.264 0.008

Right 0.211 0.035

None -0.017 0.867

According to the correlation calculations performed on the obtained data, motion palpation

findings of the left and of the right restriction showed a positive linear relationship (0.264

and 0.211 respectively) (refer to Table 4.3). This indicates that, although slight, the findings

59

between the two tests can be compared in a positive fashion. A positive correlation

indicates a linear relationship (indicating relatively high reliability) while a negative

correlation indicates low reliability. The findings suggesting no restrictions, however, do not

indicate a linear relationship as it produced a correlation of -0.017. This negative

correlation indicates that the two tests produced unreliable results for the findings of no

restrictions.

Additionally, the p-value from the left and right restrictions was found to be below 0.05

(0.008 and 0.035 respectively) making the values significant. For the findings of no

restriction however the p-values were higher than 0.05 (0.867) making them statistically

insignificant and therefore unreliable.

Table 4.4: Correlation between the reliability percentages obtained between Gillet‟s Motion

palpation and the Standing Flexion test.

Findings Spearman’s rho

(correlation coefficient) p-value

Reliability Percentage

between the two tests -0.016 0.871

Similarly, when comparing the data from the reliability percentage between the two motion

palpation results (refer to Table 4.4) no linear relationship can be found. The Correlation

Coefficient is quoted as having a negative -0.016 relationship (p-value 0.871) indicating a

statistically insignificant result and therefore low reliability between these variables.

4.4 One-sample t-test

The final test performed on the data was to compare the total reliability to 80% according to

previous studies performed on this topic (Meijne et al., 1999; Mitchell, Urli, Breitenbach and

Yelverton, 2004). These studies suggest that for these tests to be accurate at least 80%

reliability needs to be achieved.

60

Figure 4.5: The average percentage reliability found by Gillet‟s Motion Palpation and the

Standing Flexion test as compared to the expected value for the test to be considered

reliable

The mean reliability for the Standing Flexion test was found to be 59.31% while the Gillet‟s

Motion Palpation produced a mean reliability of 56.38% (refer to Figure 4.5). These two

values are considerably lower than the expected 80% indicating low reliability between the

two tests, giving a clear indication of low inter-examiner reliability of these two tests.

Both tests became significantly reliable when a t-test was done to compare them at

approximately 55% reliability. This equates to the fact that at least 45% of the time

Chiropractors in the clinic (when they only use one test to diagnose Sacroiliac joint

dysfunction) incorrectly predict the restricted side, which has obvious implications in terms

of treatment.

61

CHAPTER 5: DISCUSSION

62

5.1 Descriptive Statistics

The participants used in this study were in a very narrow age group (88 of the 100

participants were younger than 27 years old) as most of them were students recruited from

in and around the University of Johannesburg. According to a previous study which

examined 159 males and 128 females using a CT scan to assess fusion in the Sacroiliac

joint, fusion was found to be clearly gender specific. It was more common in males to have

fusion of the Sacroiliac joint as compared to females. It was also found to be age specific,

with more fusions being detected in older population groups (Dar, Khamis, Peleg,

Masharawi, Steinberg, Peled, Latimer and Hershkovitz, 2008).

In this study, however, no correlation was found between the age or gender of the

participants and the results of the reliability of the tests. This could be linked to the

generally young age of the participants, with almost all being less than 30 years of age.

5.2 Statistics from Restrictions Found

According to the data obtained from the tests conducted, Gillet‟s motion palpation achieved

a total inter-examiner reliability of 56.38%, which is significantly lower than the 80%

expected for this type of test to be considered reliable. The Standing Flexion test achieved

only 59.31% inter-examiner reliability which is confirmed when doing the one-sample t-test.

When comparing the results of the two tests against each other, neither test proved to be

reliable.

The percentage reliability obtained for each of the participants by the examiners was found

to be relatively low. Thirty-six of the participants produced only 33% reliability using Gillet‟s

Motion palpation with a similarly low 32 participants producing 33% reliability using the

Standing Flexion test. Similarly nearly 50% of the participants produced 50% or less

reliability when tested by the examiners. This indicates that many examiners differed in

their findings, signifying reasonably low inter-examiner reliability.

Additionally, according to Table 4.1 during only 13 of the 100 participants measured there

existed complete 100% reliability (no differences), pointing again to low reliability.

63

5.3 Correlations Between the Two Tests

Spearman‟s rho (ρ) showed that the examiners favoured choosing a side of restriction

rather than deciding to indicate that no restriction existed. A trend was noted for the

examiners to be inclined to find either a right or left sided restriction while no restriction was

less frequently found. The comparison of reliability between the two tests was shown to be

statistically insignificant. These results point towards examiners being inclined to choose a

side of restriction when they were unsure, and the sides of restriction did not correlate with

the findings found by other examiners.

This finding is supported by cross tabulating the correlations of left and right, left and no

restriction and right and no restriction. This shows that the only significant positive

correlation is achieved when you cross tabulate left and right restriction findings,

supporting the speculation that examiners were choosing sides rather than being accurate

with their examinations. The tests therefore indicated low inter-examiner reliability.

The Sacroiliac joint is a pain-generating structure, but Sacroiliac joint dysfunction can also

be present in the absence of pain (Botha, Yelverton and Potgieter, 2008). One could argue

that the participants had no restrictions to begin with, and that the examiners were

essentially looking for restrictions. Results may have varied if only symptomatic

participants with noted Sacroiliac joint dysfunction or even low back pain were assessed.

This is a noted deficiency in this study, but it highlights the fact that Chiropractors (or in the

case of this study Chiropractic students) tend to look for restrictions when examining a

patient even when the option of „no restriction‟ is given.

5.4 Alternative Explanations Offered by Previous Studies

One of the major obstacles of this research was to establish a diagnosis of Sacroiliac joint

dysfynction when no “gold standard” for its diagnosis existed (Dreyfuss, Dreyer, Griffin,

Hoffmann and Walsch, 1994). Breitenbach, Steckoll and Khoury (2003) points out that the

results must be considered explorative because currently no “gold standard” exists for

64

measuring the true side of Sacroiliac joint dysfunction. Therefore, none of the tests being

measured could be compared against a known, correct test value.

In addition, Breitenbach, Steckoll and Khoury (2003) also mentioned mechanisms that

could have given rise to false positives or false negatives. These could include congenital

bony abnormalities not previously detected and unknown to the participants. These

abnormalities or pathologies (such as unilateral or bilateral sacralisation) may cause

abnormalities or differences in the ground reactive forces transmitted through to the

Sacroiliac joints, influencing the joint movement and the subsequent diagnosis (Mior et al.,

1999). The participants in this study were asked whether they know of existing congenital

abnormalities to exclude this from the study, but these abnormalities could have been

present without the participants knowing, influencing the results.

Also, the effects of pathology or abnormality of the myofascial systems and ligaments of

the pelvis on the movements of the Sacroiliac joints during performing the Standing Flexion

test and Gillet‟s Motion Palpation are not fully understood. A tight Hamstring muscle, for

example, could draw the Ilium posteriorly on the Sacrum causing a false negative finding

during the Standing Flexion test. As the myofascial systems surrounding the Sacroiliac

joints play an important role in form and force closure required for stability of the joint,

when there are any abnormalities, pathology or even muscular imbalances, dysfunction will

result (Mitchell et al., 2004).

This study only defined Sacroiliac joint dysfunction as the joint being in a state of

hypomobility. It was further divided into flexion and extension restrictions, but because the

two tests only measured the movements of the Sacroiliac joint in flexion, only flexion

restrictions were measured. Had this study been more specific to include flexion or

extension restrictions, additional data may have provided more accurate results for the

tests being measured.

65

5.5 The Difficulty and Complexity Associated with Sacroiliac Joint Dysfunction

Diagnosis

There is considerable controversy surrounding the reliability of the manual examination

tests used in this study. All previous studies examining these tests follow a similar school

of thought, which is either comparing the test to itself (intra-examiner reliability) or

comparing it to another test (inter-examiner reliability) which is followed in this study.

Previous testing of Gillet‟s motion palpation and the Standing flexion test are no exceptions

and they have been proven to be reliable in previous studies (Carmichael, 1987; Cibulka

and Koldenhoff, 1999; Toussaint et al., 1999). However, other similar studies have found

these tests to be unreliable with regards to inter-examiner reliability (Fryer, McPherson and

O‟Keefe, 2005; Meijne et al., 1999; Sturesson et al., 2000; Vincent-Smith and Gibbons,

1999).

As there are no pathognomonic, radiographic or laboratory investigations available which

can be considered as the standard method of diagnosing Sacroiliac joint dysfunction,

manual testing is considered to be the “gold standard” (Toussaint et al., 1999). One

manual examination test alone, however, cannot be considered to be diagnostic, and

therefore multiple tests are required to be positive for the test to be considered positive and

to produce good inter-tester reliability (Cibulka and Koldenhoff, 1999).

One aspect not yet considered is that each participant was motion palpated by eight

different examiners. If each examiner asked the participant to move the joint at least twice

on each side, the joint was mobilised through the range of motion at least sixteen times.

This could have caused a restricted Sacroiliac joint to be mobilised during the continuous

testing and subsequently the last examiners would have detected minimal restrictions.

Another aspect to the diagnosis of Sacroiliac joint dysfunction is its complex nature.

Breitenbach, Steckoll and Khoury (2003) briefly explained how complex the motion

palpation of the Sacroiliac joint can be and how many different factors play a role in

influencing the results obtained and the subsequent diagnosis. Pain in the Sacroiliac joint

can have its origin in many structures. Pathology in the joint can be one of the origins of

66

pain but it can also arise from different structures (skeletal, muscular, ligamentous visceral

and/or nervous tissue) surrounding the joint (Mior et al., 1999). These can be affected by a

variety of pathological processes including inflammation or infection (Potter and Rothstein,

1985).

Chiropractors diagnose a functional lesion as a primary diagnosis, in this case a Sacroiliac

joint dysfunction. Other lesions, however, that are not functional lesions may present in

isolation or in combination with the found functional lesions. They may mimic the Sacroiliac

joint dysfunction (observed as a false positive) or when in combination, prevent the

Sacroiliac joint dysfunction from being accurately detected (observed as a false negative

diagnosis). Examples of myofascial or ligamentous pathology must again be considered

here (Mitchell et al., 2004).

67

CHAPTER 6: CONCLUSION AND RECOMMENDATIONS

68

6.1 Conclusion

There exists no “gold standard” test that determines whether a Sacroiliac joint is

dysfunctional or restricted in movement. Until such a test is found, we are unable to

compare these tests against a valid measurement. The presence of a dysfunction therefore

remains hypothetical (Hestboek and Leboef-Yde, 2000).

This study found both the Standing Flexion test and the Gillet‟s motion palpation to be

unreliable in motion palpation of the Sacroiliac joint as they both proved statistically

insignificant. This is in accordance with previous research performed on these tests.

Some of the previous studies‟ limitations supplemented this research in order to further the

knowledge of the diagnosis of the Sacroiliac joint (Meijne et al., 1999; Sturesson et al.,

2000; Vincent-Smith and Gibbons, 1999). The conclusion from the results found in this

study is that neither of these tests is clinically useful in determining Sacroiliac joint

dysfunction.

Future studies should draw from the results of this study and continue the search for the

“gold standard” of Sacroiliac joint motion palpation. Finding one test that fulfils the criteria

of a “gold standard” or a cluster of tests that become the “gold standard” should be the

main aim of further studies. More than one test found positive to make the diagnosis will

also improve the reliability of the diagnosis, improving the eventual treatment being

administered to the correct joint (Toussaint et al., 1999). This would essentially improve the

accuracy of administration of treatment required by Chiropractors to correct dysfunction

and essentially improve the process of healing.

6.2 Recommendations

The results obtained from future studies could be altered by applying some alterations

which may influence the outcomes. Some shortcomings in this research include:

Only asymptomatic participants were examined. A comparison study between

symptomatic and asymptomatic participants could improve the accuracy of the results

69

obtained between the two tests, as a link has been found between the reliability of the

tests and lower back pain (Herzog et al., 1989)

Bilateral restrictions of the Sacroiliac joint were not taken into account while performing

this study. The majority of bilateral restrictions occur as a flexion restriction on the one

side and an extension restriction on the opposite side. This variable could be added to

future studies

The diagnosis was limited to only two tests. If more tests were used in the study the

diagnosis may provide more accurate results

No imaging studies were performed to detect structural lesions that would influence the

diagnosis or results

The two tests used to diagnose the dysfunction in the joint only tested for right or left

sided flexion restrictions. Extension restrictions are also commonly found and can be

detected using the Gillet‟s test while extending the leg backwards. This could be added

to future motion palpation studies involving Gillet‟s test

The motion palpation testing could be performed on different age groups, or even

types of sports (e.g. golfers, tennis players, etc.) to assess whether age or the type of

activity has any bearing on the specificity of the tests. This would also relate to the

relationship found previously between back pain and restrictions found, as well as the

relationship between amount of movement of the Sacroiliac joint and age

Future researchers should bear in mind that, while performing the motion palpation

tests, excessive motion could cause the Sacroiliac joints to be mobilised and the

dysfunctional joint could produce a false negative result.

Sacroiliac joint hypermobility was not taken into account as a causative factor of

Sacroiliac joint dysfunction in this study and could be looked at in future studies.

70

REFERENCES

71

Advanced Pain Management Surgery. (2006). Available from:

http://www.apmsurgery.com/images/sacroiliac_joint_microscopic_view.bmp.

(Accessed 25 May 2009).

Alderink, G.J. (1991). The Sacroiliac Joint: Review of Anatomy, Mechanics and

Function. Journal of Orthopedic and Sports Physical Therapy, 13(2):71-84.

Anrig, C. (1999). Sacrum Subluxation. Dynamic Chiropractic, 17(11):May 17. Available

from: http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=36064.

(Accessed on 10 August 2009).

Bernard, T.N. (1997). The Role of the Sacroiliac Joints in Low Back Pain: Basic

aspects of pathology and management. In: Movement, Stability and Low Back Pain.

The essential Role of the Pelvis. Edited by: Vleeming, A., Mooney, V., Dorman, T.,

Snijders, C., Stoeckart, R. New York, Churchill Livingstone. 1997. pp. 73-88.

Bernard, T.N. and Cassidy, J.D. (1991). The Sacroiliac Joint Syndrome:

Pathophysiology, Diagnosis and Management. In: The Adult spine: Principles and

Practice. Edited by Frymoyer, J.W. New York, Raven Press, Ltd. pp. 2107-2130.

Black, T.R. (2002). Data Quality. In: Understanding Social Science Research. 2nd

Edition. London, Sage Publications, pp. 86-87.

Boers, T.A. (1999). Manual Therapy. In: Managing Low Back Pain. 4th Edition. Edited

by Krikaldy-Willis, W.H. and Bernard, T.N. University of Michigan, Churchill

Livingstone. pp. 314-315.

Bogduk, N. (1998). The sacroiliac joint. In: Clinical Anatomy of the Lumbar Spine and

Sacrum, 3rd Edition. Edited by Campbell, A. London, Churchill Livingstone. pp. 177-

185.

Bonnaire, E. and Bue, V. (1899). Dela Mobilitè des articulations pelviennes. Annual of

Gynecology and Obstetrics. Issue number 52, p. 256.

Botha, E.C., Yelverton, C. and Potgieter, R. (2008). The Prevalence of Restriction at

one Sacroiliac joint in relation to Pain of the Contra-lateral Joint. Unpublished Masters

Dissertation. Johannesburg, University of Johannesburg.

Bowen, V. and Cassidy, J.D. (1981). Macroscopic and Microscopic Anatomy of the

Sacroiliac Joint from Embryonic life until the Eighth decade. Spine, 6(6): 620-627.

72

Breitenbach, J.G., Steckoll, G.M., Khoury, M. (2003). The Validity of the Sacral Base

Pressure Test in detecting Sacroiliac joint Dysfunction. Unpublished Masters

Dissertation. Johannesburg, Technikon Witwatersrand.

Bussey, M.D., Milosavljevic, S. and Bell, M.L. (2008). Sex Differences in the Pattern of

Innominate Motion during Passive Hip Abduction and External Rotation. Manual

Therapy, 14(5): 514-519.

Carmichael, J.P. (1987). Inter- and Intra-examiner Reliability of Palpation for Sacroiliac

Joint Dysfunction. Journal of Manipulative and Physiological Therapeutics, 10(4):164-

171.

Cassidy, D.J. and Mierau, D.R. (1992). Pathophysiology of the sacroiliac joint. In:

Principles and Practice of Chiropractic, 2nd Edition. Edited by Haldeman, S. New York.

Appleton and Lange, pp. 211-223.

Cibulka, M.T. and Koldenhoff, R. (1999). Clinical Usefulness of a Cluster of Sacroiliac

Joint Tests in Patients With and Without Low Back Pain. Journal of Orthopaedic and

Sports Physical Therapy, 29(2):83-88.

Corder, G.W. and Foreman, D.I. (2009). Nonparametric Statistics for Non-Statisticians:

A Step-by-Step Approach. New Jersey: Wiley, pp. 12, 13, 123-131, 156-174.

Dar, G., Khamis, S., Peleg, S., Masharawi, Y., Steinberg, N., Peled, N., Latimer, B.

and Hershkovitz, I. (2008). Sacroiliac Joint Fusion and the Implications for Manual

Therapy Diagnosis and Treatment. Manual Therapy, 13(2):155-158.

DeFranca, G.G. and Levine, L.J. (1996). Clinical Assessments: General

Considerations. In: Pelvic Locomotor Dysfunction: A clinical approach. Edited by

Collila, J. Gaithersburg, Aspen Publishers, pp. 140, 141, 145, 146.

DonTigney, R. L. (2005). Pathology of the Sacroiliac Joint, its Effect on Normal Gait

and its Correction. Journal of Orthopaedic Medicine, 27:61-69.

Dreyfuss, P., Dreyer, S., Griffin, J., Hoffmann, J. and Walsch, N. (1994). Positive

Sacroiliac Screening Tests in Asymptomatic Adults. Spine, 19(10):1138-1143.

Egan, D., Cole, J. and Twomey, L. (1996). The Standing Forward Flexion Test: An

Inaccurate Determinant of Sacroiliac Joint Dysfunction. Physiotherapy, 82(4):236-242.

Farabeuf, L. H. (1894). Annual of Gynecology and Obstetrics, 41:407. Cited in:

Kapandji, I.A. (1974). The Physiology of the Joints. Volume 3, 2nd Edition. New York,

Churchill Livingstone, pp. 54-71.

73

Foley, B.S. and Buschbacher, R.M. (2006). Sacroiliac Joint Pain: Anatomy,

Biomechanics, Diagnosis and Treatment. American Journal of Physical Medicine and

Rehabilitation, 85:997-1006.

Forst, S.L., Wheeler, M.T., Fortin, J.D. and Vilensky, J.A. (2006). The Sacroiliac Joint:

Anatomy, Physiology and Clinical Significance. Pain Physician, 9(1):61-68.

Fryer, G., McPherson, H.C. and O‟Keefe, P. (2005). The Effect of Training on the Inter-

examiner and Intra-examiner Reliability of the Seated Flexion Test and Assessment of

Pelvic Anatomical Landmarks with Palpation. International Journal of Osteopathic

Medicine, 8(4):131-138.

Fukui, S. and Nosaka, S. (2002). Pain Patterns Originating from the Sacroiliac Joints.

Journal of Anesthesia, 16(3): 245-247.

Gatterman, M.I. (2004). Chiropractic Management of Spine Related Disorders, 2nd

Edition. Philadelphia. Lippincott Williams and Wilkins, pp. 129-149.

Greenman, P.E. (1997). Clinical Aspects of the Sacroiliac Joint in Walking. In:

Movement, Stability and Low Back Pain. The essential Role of the Pelvis. Edited by:

Vleeming, A., Mooney, V., Dorman, T., Snijders, C. and Stoeckart, R. New York,

Churchill Livingstone, pp. 235-242.

Grieve, E. (2001). Diagnostic Tests for Mechanical Dysfunction of the Sacroiliac Joints.

The Journal of Manual and Manipulative Therapy, 9(4):198-206.

Goldthwait, J.H. and Osgood, R.B. (1905). A Consideration of the Pelvic Articulations

from an Anatomical, Pathological and Clinical Standpoint. Boston Medical Surgeons

Journal, 152(21):593-601.

Gudgel, J.W. and Colloca, C.J. (2007). Neuromechanical Considerations of the

Sacroiliac Joint. The American Chiropractor, 29(12). Available from:

http://www.theamericanchiropractor.com/articledetail.asp?articleid=864&category=3.

(Accessed 9 September 2009).

Harrison, D.E., Harrison, D.D. and Troyanovich, S.J. (1997). The Sacroiliac Joint: a

Review of Anatomy and Biomechanics with Clinical Implications. Journal of

Manipulative and Physiological Therapeutics, 20(9):607-617.

Herzog, W., Read, L.J., Conway, P.J.W., Shaw, L.D. and McEwen, M.C. (1989).

Reliability of Motion Palpation Procedures to Detect Sacroiliac Joint Fixations. Journal

of Manipulative and Physiological Therapeutics, 12(2):86-92.

74

Hesch, J. (1997). Evaluation and Treatment of the most Common Patterns of

Sacroiliac Joint Dysfunction. In: Movement, Stability and Low Back Pain. The essential

Role of the Pelvis. Edited by: Vleeming, A., Mooney, V., Dorman, T., Snijders, C. and

Stoeckart, R. New York, Churchill Livingstone, pp. 535-537, 540.

Hestboek, L. and Leboef-Yde, C. (2000). Are Chiropractic tests for the Lumbo-pelvic

spine reliable and valid? A systematic critical literature review. Journal of Manipulative

and Physiological Therapeutics, 23(4):258-273.

Hodge, J.C. and Bessette, B. (1999). The incidence of sacroiliac joint disease in

patients with low-back pain. Canadian Association of Radiology Journal, 50(5):321-

323.

Huson, A. (1997). Kinematic models and the human pelvis. In: Movement, Stability and

Low Back Pain. The essential Role of the Pelvis. Edited by: Vleeming, A., Mooney, V.,

Dorman, T., Snijders, C. and Stoeckart, R. New York, Churchill Livingstone, pp. 123-

131.

Kapandji, I.A. (1974). The Physiology of the Joints. Volume 3, 2nd Edition. New York,

Churchill Livingstone, pp. 54-71.

Kirkaldy-Willis, W.H. and Hill, R.J. (1979). A More Precise Diagnosis for Low Back

Pain. Spine, 4(2):102-109.

Kuchera, M.L. (1997). Treatment of Gravitational Strain Pathology. In: Movement,

Stability and Low Back Pain. The essential Role of the Pelvis. Edited by: Vleeming, A.,

Mooney, V., Dorman, T., Snijders, C. and Stoeckart, R. New York, Churchill

Livingstone, p. 488.

Maigne, R. (2006). Biomechanics of the Sacroiliac Joint. In: Diagnosis and treatment of

pain of vertebral origin. 2nd Edition. Edited by Nieves, W.L. Boca Raton, Taylor and

Francis, pp. 59-63.

Meijne, W., van Neerbos, K., Aufdemkampe, G. and van der Wurff, P. (1999).

Intraexaminer and Interexaminer Reliability of the Gillet‟s Test. Journal of Manipulative

and Physiological Therapeutics, 22(1):4-9.

Mior, S.A., Ro, C.S. and Lawrence, D. (1999). The Sacroiliac Joint. In: Low Back Pain:

Mechanism, Diagnosis and Treatment. Edited by: Cox, J.M. 6th Edition, Maryland,

Williams and Wilkins, pp. 209-229.

75

Mitchell, T.D., Urli, E.K., Breitenbach, J., Yelverton, C. (2004). The Predictive Value of

the Sacral Base Pressure Test in Detecting Specific Types of Sacroiliac Joint

Dysfunction. Unpublished Masters Dissertation. Johannesburg, Technikon

Witwatersrand.

Mixter, W.J. and Barr, J.S. (1941). Posterior protrusion of the lumbar intervertebral

discs. Journal of Bone and Joint Surgery, 23(2):444-456.

Moore, K.L. and Dalley, A.F. (1999). Clinically Orientated Anatomy. 4th Edition.

Baltimore, Maryland, Lippincott Williams and Wilkins, p. 340.

Mooney, V. (1997). Sacroiliac joint Dysfunction. In: Movement, Stability and Low Back

Pain. The essential Role of the Pelvis. Edited by: Vleeming, A., Mooney, V., Dorman,

T., Snijders, C. and Stoeckart, R. New York, Churchill Livingstone, p. 40.

Netter, F.H. (1989). Atlas of Human Anatomy. New Jersey, CIBA-GEIGY Corporation,

p. 147.

Norkin, C.C. and Levangie, P.K. (1992). Joint Structure and Function: A

Comprehensive Analysis. 2nd Edition. Philadelphia, F.A. Davis Company. pp. 157, 450.

Onofrio, J. (1999). Stages of Inflammation. In: Massage School Notes. Available from:

The Body Worker. http://www.thebodyworker.com/physio_inflammation_overview.htm.

(Accessed 9 July 2009).

Orthopedic Manual Physical Therapy Institute of Dallas Inc. (2005). Available from:

www.orthopedicmanualphysicaltherapy.com/spine_rehab.html (Accessed 25 March

2009).

Oxford Concise Medical Dictionary (2003). Edited by Martin, E.A. 6th Edition. Oxford

University Press, New York, p. 671.

Oza, A.L., Vanderby, R. and Lakes, R.S. (2006). Creep and Relaxation in Ligament:

Theory, Methods and Experiment. In: Mechanics of Biological Tissue. Edited by

Holzapfel, G.A. and Ogden, R.W. Berlin Heidelberg, Springer, pp. 379-397.

Pelvic Instability Network Support (2005). Available from:

http://www.pelvicgirdlepain.com/anatomy.htm. (Accessed 23 March 2009).

Pitkin, H.C. and Pheasant, H.C. (1936). Sacroarthrogenetic Arthralgia: A Study of

Sacral Mobility. Journal of Bone and Joint Surgery, 18(2):365-374.

76

Pool-Goudzwaard, A.L., Vleeming, A., Stoekart, R., Snijders, C.J. and Mens, J.M.A.

(1998). Insufficient lumbopelvic stability: a clinical, anatomical and biomechanical

approach to „a-specific‟ low back pain. Manual Therapy, 3(1):12-20.

Porterfield, J.A. and De Rosa, C. (1998a). Articulations of the lumbopelvic region. In:

Mechanical Low Back Pain, Perspectives in Functional Anatomy. 2nd Edition. Edited by

Biblis, M. Philadelphia, WB Saunders, pp. 121-161.

Porterfield, J.A. and De Rosa, C. (1998b). Lumbopelvic musculature: structural and

functional considerations. In: Mechanical Low Back Pain, Perspectives in Functional

Anatomy. 2nd Edition. Edited by Biblis, M. Philadelphia, WB Saunders, pp. 61-119.

Potter, N.A. and Rothstein, J.M. (1985). Intertester reliability for selected clinical tests

of the sacroiliac joint. Physical Therapy, 65(11):1671-1675.

Prassopoulos, P.K., Faflia, C.P., Voloudaki, A.E. and Gourtsoyiannis, N.C. (1999).

Sacroiliac Joints: Anatomical Variants on CT. Journal of Computer Assisted

Tomography, 23(2):323-327.

Quon, J.A., Bernard, T.N., Burton, C.V. and Krikaldy-Willis, W.H. (1999). The Site and

Nature of the Lesion. In: Managing Low Back Pain. Edited by: Krikaldy-Willis, W.H. and

Bernard, T.N. 4th Edition. New York, Churchill Livingstone, pp. 125-128.

Real Body Work (2009). Available from:

http://realbodywork.com/learn/torso/multifidus.htm. (Accessed 1 July 2009).

Rezaeian, Z.S., Alifard, F., Goodarzi, Z., Karimi, A. and Asgharoi, M. (2008).

Prevalence of Sacroiliac dysfunction in patients with Low back pain referring to

hospitals in Isfahan (a Pilot study). Journal of Research in Rehabilitation

Sciences, 4(1):87.

Rosenberg, S. (2008). Lumbo-pelvic Matrix: A Biomechanical approach for

Assessment and Treatment of the Lumbar Spine and Pelvis. Course conducted at

Rosebank Sports Clinic. Johannesburg.

Richardson, C.A., Snijders, C.J., Hides, J.A., Damen, L., Pas, M.S. and Sorm, J.

(2002). The relationship between the Transverse Abdominis muscles, Sacroiliac joint

mechanics, and low back pain. Spine, 27(4):399-405.

Sandoz, R. (1981). Some Reflex Phenomena Associated with Spinal Derangements

and Adjustments. Annual of the Swiss Chiropractic Association, 7:45–65.

77

Saunders, H.D. (1995). Evaluation, Treatment and Prevention of Musculoskeletal

Disorders. 3rd Edition. Philadelphia, The Saunders Group, pp. 15-22.

Schafer, R.C. and Faye, L.J. (1990). Motion Palpation and Chiropractic Technic. 2nd

Edition. Huntington Beach, California. The Motion Palpation Institute, pp. 241-304.

Schwarzer, A.C., Aprill, C.N. and Bogduk, N. (1995). The sacroiliac joint in chronic low

back pain. Spine, 20(1):31-37.

Snijders, C.J., Vleeming, A., Stoeckart, R., Mens, J.M.A. and Kleinrensink, G.J. (1997).

Biomechanics of the interface between spine and pelvis in different postures. In:

Movement, Stability and Low Back Pain. The essential Role of the Pelvis. Edited by:

Vleeming, A., Mooney, V., Dorman, T., Snijders, C. and Stoeckart, R. New York,

Churchill Livingstone, pp. 103-112.

Strasser, A. (2008). Palpation: The Art and Science of Chiropractic Diagnosis. Spine

Universe. Available from:

http://www.spineuniverse.com/displayarticle.php/article154.html. (Accessed 10 August

2009).

Sturesson, B., Uden, A. and Vleeming, A. (2000). A Radiostereometric Analysis of

Movements of the Sacroiliac Joints during the Standing Hip Flexion Test. Spine,

25(3):364-368.

Timm, K.E. (1999). Sacroiliac Joint Dysfunction in Elite Rowers. Journal of Orthopedic

and Sports Physical Therapy, 29(5):288-293.

Tong, H.C., Heyman, O.G., Lado, D.A. and Isser, M.M. (2006). Interexaminer

Reliability of Three Methods of Combining Test Results to Determine Side of Sacral

Restriction, Sacral Base Position, and Innominate Bone Position. Journal of American

Osteopath Association, 106(8):464-468.

Toussaint, R., Gawlik, C.S., Rehder, U. and Rüther, W. (1999). Sacroiliac Joint

Diagnostics in the Hamburg Construction Workers Study. Journal of Manipulative and

Physiological Therapeutics, 22(3):139-143.

Tullberg, T., Blomberg, S. and Branth, B. (1998). Manipulation Does Not Alter the

Position of the Sacroiliac Joint. A Roentgen Stereophotogrammetric Analysis. Spine,

23:1124-1129.

78

Vleeming, A., Snijders, C.J., Stoeckart, R. and Mens, J.M.A. (1997). The Role of the

Sacroiliac Joints in Coupling Between Spine, Pelvis, Legs and Arms. In: Movement,

Stability and Low Back Pain. The essential Role of the Pelvis. Edited by: Vleeming, A.,

Mooney, V., Dorman, T., Snijders, C. and Stoeckart, R. New York, Churchill

Livingstone, pp. 54-65.

Vincent-Smith, B. and Gibbons, P. (1999). Inter- and Intra-examiner Reliability of the

Standing Flexion Test. Manual Therapy, 4(2):87-93.

Walker, J.M. (1992). The Sacroiliac Joint: A Critical Review. Physical Therapy,

72(12):903-916.

Walters, P.J. (1993). Pelvis. In: Textbook of Clinical Chiropractic: A Specific

Biomechanical Approach. Edited by: Plaugher, G. Baltimore, Williams and Wilkins, pp.

150-187.

Weksler, N., Velan, G.J., Semionov, M., Gurevitch, B., Klein, M., Rozentsveig, V. and

Rudich, T. (2007). The Role of Sacroiliac Joint Dysfunction in the Genesis of Low Back

Pain: The Obvious is not Always Right. Archive of Orthopaedic Trauma Surgery,

127(10):885-888.

Wiesl, W., Tsourmas, N., Feffer, H.L., Citrin, C.M. and Patronas, N. (1984). Study of

Computer Assisted Tomography. The incidence of positive CAT scan in an

asymptomatic group of patients. Spine, 9(6):549-551.

Willard, F.H. (1997). The Muscular, Ligamentous and Neural Structure of the Lower

Back and its Relation to Back Pain. In: Movement, Stability and Low Back Pain. The

essential Role of the Pelvis. Edited by: Vleeming, A., Mooney, V., Dorman, T.,

Snijders, C. and Stoeckart, R. New York, Churchill Livingstone, pp. 3-35.

Wourman, A.L. (1993). Basic Spinal Mechanics. In: Evaluation, Treatment and

Prevention of Musculoskeletal Disorders. Edited by: Saunders, H.D. and Saunders, R.

3rd Edition. Michigan, Saunders Group, pp. 15-22.

79

APPENDICES

80

Appendix A: Advertisement

Are You Between the ages of 18 and 40?

FREE CHIROPRACTIC LOWER BACK

ASSESSMENT !!!

Call Ronnie : 084 441 9570

81

Appendix B: Case Hisory

UNIVERSITY OF JOHANNESBURG

CHIROPRACTIC DAY CLINIC

CASE HISTORY

Date:_______________ Patient: ____________________________ File No: __________ Age: ______ Sex: ___________ Occupation: ________________ Student:________________________ Signature: ________________

FOR CLINICIAN’S USE ONLY Initial visit clinician: __________________Signature: ________________ Case History: ________________________________________________

Examination: Previous: UJ Current: UJ Other Other X-ray Studies: Previous: UJ Current: UJ Other Other Clinical Path. Lab: Previous: UJ Current: UJ Other Other Case status: PTT: Conditional: Signed off: Final sign out: Recommendations:

Students case history 1. Source of history:

82

2. Chief complaint: (patient’s own words)

3. Present illness:

Location

Onset

Duration

Frequency

Pain (character)

Progression

Aggravating factors

Relieving factors

Associated Sx’s and Sg’s

Previous occurrences

Past treatment and outcome 4. Other complaints: 5. Past history

General health status

83

Childhood illnesses

Adult illnesses

Psychiatric illnesses

Accidents/injuries

Surgery

Hospitalisation 6. Current health status and lifestyle

Allergies

Immunizations

Screening tests

Environmental hazards

Safety measures

Exercise and leisure Sleep patterns

Diet

Current medication

Tobacco

Alcohol

Social drugs

7. Family history:

Immediate family:

Cause of death DM Heart disease TB HBP Stroke Kidney disease

84

CA Arthritis Anaemia Headaches Thyroid disease Epilepsy Mental illness Alcoholism Drug addiction Other

8. Psychosocial history:

Home situation Daily life Important experiences Religious beliefs

9. Review of systems:

General

Skin

Head

Eyes

Ears

Nose/sinuses

Mouth/throat

Neck

Breasts

Respiratory

Cardiac

Gastro-intestinal

85

Urinary

Genital

Vascular

Musculoskeletal

Neurologic

Haernatologic

Endocrine

Psychiatric

Appendix C: Pertinent Physical Examination

PERTINENT PHYSICAL

(Note: This form may only be used when you have completed 35 new patients) Student Name: Signature:

Doctor Name: Signature:

Patient Information: Name: Occupation:

Age: Sex:

Vitals:

86

Height: Weights:

Pulse Rate: Respiratory Rate:

Blood Pressure:

Inspection Palpation Percussion Auscultation

Thorax

Inspection Palpation Percussion Auscultation

Abdomen

87

Cranial Nerves Motor System Sensory System Cerebellar

System

Neurologic

System

Appendix D: Lumbar Spine and Pelvis Regional Examination

REGIONAL EXAMINATION LUMBAR SPINE AND PELVIS

Date: _____________________ Patient: ___________________________ File No: _________________ Clinician: ___________________________ Signature: _______________

Student: ___________________________ Signature: ______________ STANDING

BODY TYPE POSTURE OBSERVATION: -

88

Muscle Tone Bony + Soft Tissue Contours Skin Scars Discolouration Step deformity

SPECIAL TESTS

Schober’s Test Spinous Percussion Treadmill Minor’s Sign Quick Test Trendelenburg Test

89

RANGE OF MOTION

Forward flexion = 40 - 60º (15cm from floor) Extension = 20 - 35º L/R Rotation = 3 - 18º L/R Lat Flexion = 15 - 20º

Flexion Left Rotation Right Rotation

Left Lateral Flexion Right Lateral Flexion

Extension / = Pain free limitation // = Painful limitation 6. GAIT

Rhythm, pendulousness On Toes (S1) On Heels (L4, 5) Halt Squat on one leg (L2, 3, 4) Tandem Walking

7. MOTION PALPATION – sacroiliac joints

B. SITTING 01. SPECIAL TESTS

Tripod Test Kemp’s Test Valsalva Manoeuvre

90

2. MOTION PALPATION

Jt. Play Left Right Jt. Play

P/A Lat Fle Ext LF AR PR Fle Ext LF AR PR P/A Lat

T10

T11

T12

L1

L2

L3

L4

L5

U L S1 U L

C. SUPINE

01. OBSERVATION

Hair, Skin, Nails Fasciculations

2. PULSES

Femoral Popliteal Dorsalis Pedis Posterior Tibial

3. MUSCLE CIRCUMFERENCE

LEFT RIGHT

THIGH cm cm

CALF cm cm

4. LEG LENGTH

LEFT RIGHT

ACTUAL cm cm

APPARENT cm cm

91

5. ABDOMINAL EXAMINATION

Observation Abdominal Reflexes Auscultation Abdomen and Groin Palpation Abdomen and Groin

Comments: _____________________________________________________

NEUROLOGICAL EXAMINATION

DERMATOMES Left Right MYOTOMES Left Right REFLEXES Left Right

T12 Hip Flexion (L1/L2)

Patellar (L3, 4)

L1 Knee Extension (L2, 3, 4)

Medial Hamstring (L5)

L2 Knee Flexion (L5/S1)

Lateral Hamstring (S1)

L3 Hip Int. Rot (L4/L5)

Tibialis Posterior (L4, 5)

L4 Hip Ext. Rot (L5/S1)

Archilles (S1/S2)

L5 Hip Adduction (L2, 3, 4)

Plantar Reflex

S1 Hip Abduction (L4/5)

S2 Ankle Dorsiflexion (L4/L5)

S3 Hallux Extension (L5)

Ankle Plantar Flexion (S1/S2)

Eversion (S1)

Inversion (L4)

Hip Extension (L5/S1)

92

7. SPECIAL TESTS

SLR

WLR

Braggard’s

Bowstring

Sciatic Notch Pressure

Sign of the Buttock

Bilateral SLR

Patrick Faber

Gaenslen’s Test

Gapping Test

“Squish” Test

Gluteus Maximus Stretch

Thomas’ Test

Rectus Femoris Contracture Test

Hip Medial Rotation

Psoas Test LATERAL RECUMBENT Sacroiliac Compression Ober’s Test Femoral Nerve Stretch Test Myotomes: - Quadratus Lumborum Strength

- Gluteus Medius Strength PRONE Facet joint challenge

93

Myofascial Trigger points:

Quadratus Lumborum

Gluteus Medius

Gluteus Maximus

Piriformis

Tensor Fascia Lata

Hamstrings Skin Rolling Erichsen’s Test Sacroiliac Tenderness Pheasant’s Test Gluteal Skyline Myotomes:

Gluteus Maximus strength NON-ORGANIC SIGNS Pin-point pain Axial Compression Trunk Rotation Burn’s Bench Test Flip Test Hoover’s Test Ankle Dorsiflexion Test Pin-point pain

Appendix E: Patient Information and Consent Form

Participant Information and Consent form

94

The aim of this research project is to test the inter-examiner-reliability of the Standing-

Flexion test and Gillet‟s motion palpation, and to compare the two.

If you are accepted into the study and you have read, understood and signed the consent

form, you will undergo an examination of the lower back and pelvis. Thereafter 2 different

tests will be performed on you 4 times. Hence, you will be examined for a total of 8 times.

You are only required to come once, and no charges will be levied.

After analysis of the data, if successful, this research could improve the way we as

Chiropractors diagnose lower back, and especially, pelvic dysfunction. This could in turn

aid in more accurate treatment of low back pain.

If interested, you can be informed about the outcomes of the study.

Participation in the study is voluntary and you are free to refuse to participate or

discontinue participation at any point if you choose to do so.

I, the researcher, have fully explained the procedure to the participant to the best of my

ability.

Date:_______________ Researcher:___________________________________

I have been fully informed as to the procedures to be followed. In signing this consent form,

I agree to the method, and understand that I am free to withdraw my participation from the

study at any time. I understand that if there are any questions, they will be answered.

Date:________________ Participant:___________________________________

Appendix F: Examination Form

Participant nr:_________________________________________ Examiner nr:_______________________________________

95

Gillet’s Motion palpation Please indicate your findings with means of an „X‟ in the relevant box.

LEFT NO RESTRICTION RIGHT

------------------------------------------------------------cut line-------------------------------------------------------- Participant nr:_______________________________________ Examiner nr:_____________________________________

Standing Flexion Motion palpation Please indicate your findings with means of an „X‟ in the relevant box.

LEFT NO RESTRICTION RIGHT