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ORIGINAL CONTRIBUTION |
From the Department of Physical Medicine and Rehabilitation (Tong, Heyman, Lado, Isser); and the Spine Program (Tong, Heyman), University of Michigan in Ann Arbor. No funding was received from any pharmaceutical or equipment companies.
Address correspondence to: Henry C. Tong, MD, Michigan Head & Spine Institute, Southfield Michigan, 29275 Northwestern Hwy, Ste 100, Southfield, MI 48034-5700. E-mail: hctong2{at}medscape.com
Context: Sacroiliac joint dysfunction is diagnosed based on the combined results of several palpatory examinations. Previous studies have compared the interexaminer reliability of only one of these methods of diagnosis.
Objective: To compare the interexaminer reliability of three methods of combining palpatory examinations to determine the side of sacroiliac joint dysfunction, sacral base position, and innominate bone position.
Design: Blinded single-cohort reliability study.
Methods: Patients with low back pain underwent two identical sets of
palpatory examinations given by two physicians, separately, at a university
spine center. The results of each set were compiled and interpreted by three
methods: using the test result with the highest interexaminer reliability
(method 1), requiring at least one test result to be abnormal for the variable
to be abnormal (method 2), and requiring all test results to be abnormal for
the variable to be abnormal (method 3). The 
was calculated for each
method.
Results: There were 24 subjects (mean age, 68.3 years), of which 15
(62%) were women. The was consistently higher with method 1, at 0.47,
0.08, and 0.32 for the sacral position, innominate bone position, and side of
sacroiliac joint dysfunction, respectively. Corresponding values for method 2
were 0.09, 0.4, and 0.16, and for method 3 were 0.16, 0.1, and
–0.33.
Conclusion: Using the results of the most reliable examination consistently has the best interexaminer reliability.
It has been suggested that interexaminer reliability may be improved by
combining results from several tests into a composite multitest score
(MTS).4
Haas4 noted, based
on probability calculations, that the expected rate of agreement is lowest
when a middle threshold value is used (eg, three of five tests are required to
yield positive results before the MTS is considered positive). Thus, the
(kappa) statistic is theoretically more likely to be greater when
middle threshold values are used. However, this concept has only been
evaluated in a few
studies.5–7
Two of these
studies5,7
evaluated one method of combining the results of four tests to determine the
presence of SIJ dysfunction, and had conflicting findings. The method used by
Cibulka et al5
required positive results from at least three of four tests before results of
the MTS were considered conclusive. The authors showed that a cluster of four
tests had substantial interexaminer reliability
(=0.88).5
When the same four tests were reevaluated in a multicenter study by Freburger
and Riddle,6 the
interexaminer reliability was found to be fair (=0.23). A study
evaluating the MTSs of four SIJ provocation tests noted substantial
reliability (=0.7) when using a method that required five tests, with
the results of at least three being positive prior to
diagnosis.7 However,
these studies did not adequately evaluate the benefit of the MTS because they
only presented the reliability of the resulting composite scores and not the
interexaminer reliability of the individual tests for
comparison.6–9
Two studies did present the reliability of individual tests and the MTS.9,10 Keating et al9 evaluated 46 subjects and showed only slightly stronger reliability with the MTS. Boline et al10 did not show improvement with the MTS. These two studies suggest that MTSs do not improve interexaminer reliability when compared with the individual test results.9,10 However, these studies only looked at one method of combining the individual test results.
The effect of MTSs on the interexaminer reliability of diagnoses for the sacral and innominate bone positions was not examined by any of the studies mentioned previously.1–10 When treating patients using a directed manual treatment program, it is not enough to simply determine the presence of an SIJ dysfunction. The results of at least two of the individual palpatory examinations need to be combined to obtain diagnoses for the sacral and innominate bone positions.11
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Methods |
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 Top Methods ResultsCommentReferences |
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Palpatory examinations were conducted to evaluate three variables: the presence and side of SIJ dysfunction, the sacral position, and the innominate bone position (Figure). For all of the tests, examiners used their dominant eyes as recommended by Greenman.11 The institutional review board of the University of Michigan Medical School in Ann Arbor approved the study, and informed consent was obtained from all subjects.
Diagnostic Methods
The resulting data from the three different models were then combined to determine the side of SIJ dysfunction, sacral position, and innominate bone position.
Statistical Analysis
Data were analyzed using SPSS software (version 10.1; SPSS Inc, Chicago,
Ill). Because all of the tests and the diagnoses for the sacral and innominate
bone positions are categorical variables, the value of was calculated
to determine interexaminer
reliability.12 The
statistic reports the amount of agreement seen after adjusting for the
amount of agreement that is expected to occur by chance
alone.13 Landis and
Koch14 recommended
using a coefficient of 0.2 as the lower limit for fair, 0.4 for
moderate, 0.6 for substantial, and 0.8 for almost perfect reliability.
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Results |
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TopMethodsResultsCommentReferences |
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The interexaminer reliability of each palpatory examination is summarized
in Table 2. Of the
examinations for SIJ dysfunction, the standing stork test had the best
interexaminer reliability, with a of 0.27 (P=.07), and the
seated flexion test had the worst interexaminer reliability, with a of
–0.06 (P=.68). The standing flexion test had a of 0.14
(P=.37). Sacral base position with trunk flexion (=0.37;
P=.002) had better interexaminer reliability than sacral base
position with trunk extension (=0.05; P=.26). For the
innominate bone position tests, the medial malleolus symmetry test
(=0.21; P=.3) had better interexaminer reliability than the
supine anterior superior iliac spine symmetry test (=0.15;
P=.48).
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The interexaminer reliability of the resulting sacral position diagnosis
and innominate bone position diagnosis for the three diagnostic methods are
summarized in Table 3.
The interexaminer reliability of sacral position when divided into all nine
possible categories was incalculable due to the large number of categories and
small number of subjects. Consequently, we calculated the interexaminer
reliability of sacral positioning as characterized by the two components that
determine sacral position: sacral base position (normal, anterior, or
posterior) and side of dysfunction (bilateral, left, or right). The
interexaminer reliability of sacral base position for all three methods was
poor to fair, with scores ranging from 0.08 to 0.16. The interexaminer
reliability for determining the side of SIJ dysfunction was fair with the
first (=0.32) and second method (=0.4), and poor with the third
method (=0.1). The innominate bone position had moderate interexaminer
reliability (=0.47) when calculated by method 1 and poor reliability
when methods 2 and 3 were used. Method 1 yielded the best results, finding
moderate reliability for one variable, fair reliability for one variable, and
poor reliability for one variable. Method 2 was second, finding fair
reliability for one variable and poor reliability for one variable. Method 3
was the worst, finding poor reliability for all three variables.
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Post hoc analysis was performed because it was noted that one of the
secondary examiners consistently had poor correlation with the initial
examiner. Because of this finding, the data were reanalyzed, excluding the
subjects seen by the examiner in the second group. As shown in
Table 2, the
interexaminer reliability of all of the tests improved with the remaining 18
subjects. Specifically, the increased to 0.11 (P=.56) for the
seated flexion test, 0.5 (P=.009) for the standing stork test, 0.3
(P=.11) for the standing flexion test, 0.47 (P=.001) for the
sacral base position with trunk flexion, 0.26 (P=.12) for the sacral
base position with trunk extension, 0.29 (P=.26) for the supine
anterior superior iliac spine, and 0.49 (P=.046) for medial malleolus
symmetry. The resulting reliability of the sacral base position diagnosis with
all three methods remained poor ( range, 0.16–0.21). The
reliability of the side of dysfunction remained poor with method 3, but
improved to 0.49 (P=.009) with method 1 and 0.6 (P=.001)
with method 2. The reliability of the innominate bone position diagnosis
remained poor with methods 2 and 3, but improved to 0.84 (P<.001)
with method 1.
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Comment |
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TopMethodsResultsCommentReferences |
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Maximizing interexaminer reliability is essential, as most of the studies evaluating palpatory examinations of the sacrum and pelvis have shown poor to fair interexaminer reliability.1 When they noted poor interexaminer reliability, Flynn et al15 correctly decided not to include palpatory examinations in their analyses. Dreyfuss et al16 noted poor interexaminer reliability with the palpatory examinations yet still used their results in the analyses. However, they did not explain whether they used the physician's findings or the chiropractor's findings, calling into question the validity of their conclusion that the palpatory examination had poor sensitivity and specificity in determining SIJ pain.16
The current study found that using the test with the best interexaminer reliability (method 1) consistently yielded the score with the highest interexaminer reliability. For example, the standing stork test had the best interexaminer reliability in testing for SIJ dysfunction. Using looser criteria (method 2) had slighter better interexaminer reliability to determine the side of SIJ dysfunction. However, this method also had significantly worse reliability when determining the innominate bone position. Using stricter criteria (method 3) consistently had the worst interexaminer reliability for both sides of SIJ dysfunction and innominate bone position.
Previously mentioned studies either did not give the interexaminer reliability of the individual tests5,7,17 or they evaluated the interexaminer reliability of only one method of combining multiple palpatory examination results.9,18 Our study does not support the recommendation by Haas4 that an intermediate range threshold should be used. However, because of the small number of subjects in our study, the present analysis cannot definitively refute Haas' recommendation.
Our findings suggest that maximizing the interexaminer reliability is a prerequisite to conducting studies that truly evaluate the sensitivity and specificity of the palpatory examination, and thus validate this aspect of osteopathic medicine. In addition, maximizing interexaminer reliability is important for clinical care because prescribed manual treatments are based on the results of the palpatory examination. By using the most reliable method to diagnose the cause of low back pain, the physician can be more confident in his or her treatment decisions.
Our study has several strengths. Interexaminer reliability was evaluated for a variety of palpatory examinations and diagnostic methods. In addition, we examined the interexaminer reliability of examinations that detect sacral position and innominate bone position in addition to SIJ.
When interpreting the results of this study, several limitations should be considered. First, the results need to be replicated by other studies. A larger study with more tests to further evaluate this issue is planned by the authors. Also, even though the medial malleolus symmetry test has better reliability than the supine anterior superior iliac spine symmetry test, the former test may not be a valid measure of innominate bone position if the subject has a significant leg length discrepancy. Finally, interexaminer reliability is not the only factor to determine what integration method should be used to diagnose structural dysfunction. Sensitivity and specificity may take precedence over reliability in certain instances.
Our study shows that the maximum interexaminer reliability occurs when only the result of the most reliable test is used to determine the side of SIJ dysfunction, sacral base position, and innominate bone position. Therefore, this method should be used when making clinical management decisions to ensure that the most appropriate treatment is implemented for each patient.
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References |
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TopMethodsResultsCommentReferences |
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3. Freburger JK, Riddle DL. Using published evidence to guide the
examination of the sacroiliac joint region. Phys Ther.2001; 81:1135
–1143.
4. Haas M. Interexaminer reliability for multiple diagnostic test regimens. J Manipulative Physiol Ther.1991; 14:95 –103.[Medline]
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