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 The Journal of Manual & ManipulaTive Therapy
n
voluMe 16
n
nuMber 3
[151]
University o St. Augustine or Health Sciences, St. Augustine, FL.
InvIted Commentary
EdeeBsed Dss d Tetet  teP S Jt
P
eter
A. H
uijbregts
,
P, DP, OCS, FAAOMP, FCAM
A
s also noted by Dr. Laslett there isan overabundance o book and journal article reerences out therethat provide models or diagnosisand management o sacroiliac joint dys-unction (SIJD) based solely on author-ity-based knowledge and—in my opin-ion—unwarranted extrapolations romanecdotal clinical observations and rombasic science studies on lumbosacral re-gion anatomy and (patho) biomechanics.When I was rst introduced to Dr. Las-lett’s work on reliability o individual sac-roiliac joint pain provocation tests
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, Ihave to admit that I was elated and at thesame time conused.Identiying mysel strongly as aphysical therapist specializing in ortho-paedic manual physical therapy (OMP),SIJD or me was a very real construct. Ihad spent many years perecting meansboth to diagnose this dysunction withmanual diagnostic tests and to treat itwith specic manipulative interventionsand exercise instruction. However, timeand again the positional and motion pal-pation tests required or establishing aspecic OMP diagnosis o a positionalault and/or direction o hypomobility that then could guide those avored ma-nipulative interventions were shown tohave insucient reliability or clinicaluse. I was also well aware that these stud-ies showing insucient reliability ques-tioned the very validity o the SIJD con-struct
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. So nally, Laslett and Williams
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 had established that our provocationtests had sucient interrater reliability,whereas two other tests were noted to bepotentially reliable.Conusion set in or me aer this ini-tial elation when I realized that my clini-cal construct o SIJD, dened by Paris
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asa state o altered mechanics, character-ized by an increase or decrease rom theexpected normal or by the presence o anaberrant motion, was in act quite dier-ent rom a diagnosis o sacroiliac jointpain. At that time—and still to some ex-tent—my clinical reasoning was guidedby a mechanism-based classication sys-tem that was ounded on the premise thatimpairments identied during examina-tion were the cause o musculoskeletalpain and dysunction
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. So now I was ableto diagnose pain emanating rom the sac-roiliac joint but I was no closer to an evi-dence base or a diagnosis o SIJD thatcould then guide my specic OMP in-terventions.Over time my clinical reasoning—and that o many within physical ther-apy—has become increasingly infuencedby treatment-based classication. In thetreatment-based system, a cluster o signsand symptoms rom the patient history and physical examination is used to clas-siy patients into subgroups with specicimplications or management
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. In morerecent research also discussed in detail inDr. Laslett’s current review paper, Laslettet al
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incorporated the treatment-basedMcKenzie classication system with acluster o sacroiliac joint provocationtests and showed excellent sensitivity andspecicity values or the diagnosis o sac-roiliac joint pain. Sensitivity urther in-creased when diskogenic patients wereexcluded based on the repeated move-ment examination
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.Tere were some very strong pointsto this research indeed. One was the issueo adequate ace validity o the test clusterused based on established interrater reli-ability o the individual tests as also notedby Dr. Laslett here. O course, interraterreliability is increased even when cluster-ing individually unreliable tests i doingso increases the amount o options thatare considered agreement. By using atleast our proven reliable tests in the clus-ter o sacroiliac joint provocation testsstudied, Laslett et al
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greatly increasedthis aspect o research validity. Also, thisresearch allowed classication o at leastsome o the patients, i.e., the diskogenicpatients, to be included in a treatment-based system that then could determinetreatment. But still, even with this re-search we are again le with the questionas to what to do with patients we diagnosewith sacroiliac joint pain?Although we could argue about theappropriateness o using prevalence datarom studies in a specialized secondary care setting
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as pre-test values to establishpost-test probability o a diagnosis o sac-roiliac joint pain in patients with lowback pain presenting to physical therapy and other primary care settings, I agreewith Dr. Laslett’s suggestion o adoptingthe combination o a McKenzie evalua-tion and his cluster o sacroiliac jointprovocation tests as a sacroiliac joint clin-
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