8° Interdisciplinory Werkd Congress on Low Back & Pelvic Pain PELVIC GIRDLE PAIN: THE SENSITIVITY AND SPECIFICITY OF THE LONG DORSAL SACROILIAC LIGAMENT TEST De Vries HJ, MSc, Vieeming A, PhD, Ronchetti I, MSc, van Wingerden JP, BSe Spine & Joint Centre, the Netherlands , wow.spineandioiitnl, vries(@spineandiointnl Introduction The last decade saw increasing efforts among clinicians and researchers to study pain and the etiology of pelvic girdle pain (PGP). PGP generally arises in relation with pregnancy, trauma or reactive arthritis. Pain is experienced between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the sacroiliac joints (SU). The pain may radiate in the posterior thigh and can also occur in conjunction with, or separately in the symphysis, The ‘endurance capacity for standing, walking and sitting is diminished.! ‘The prevalence of pregnant women suffering from PGP is close to 20%. The pain or functional disturbances in relation to PGP must be reproducible by specific clinical tests.’ Possibly, one of these tests is the long dorsal sacroiliac ligament (LDL) test. Pain in the lumbar spine and pelvic region frequently complicates pregnancy. The anatomical origin of the pain is unknown, Many hypotheses on the pathogenesis of PGP after pregnancy focus on decreased stability of the pelvic girdle." One of the structures near the SI-joint that could easy be overloaded is the LDL, which hes been described anatomically and functionally by Viecming et al. as a mechanical counter-nutational strain of the LDLS The study of Hungerford et al. supports this finding. They conclude that anterior rotation of the innominate (as measured using skin markers) during weight bearing, occurred in symptomatic subjects with PGP, suggesting failure to stabilize intra-pelvic motion for load transfer, In controls, the innominate roteted posterior; this may reflect activation of optimal lumbo-pelvic stabilization strategies for load transfer," The LDL can be palpated directly caudal to the posterior superior iliac spine, as a taut superficial structure, frequently mimicking the feeling of a bony structure, Fibres of the LDL connect the posterior superior iliac spine and a small part of the iliac crest, with the lateral crest of the third and fourth segments of the sacrum. * This observation is consistent with other descriptions of the insertion of the LDL,"!“"? In women with PGP after pregnancy, the LDL is of special interest because many of these women indicate their pain specific within the boundaries of this ligament, If the LDL is a structure that plays an important role in the pain, pattern of patients with PGP, it will likely give tenderness or pain on palpation. Different studies confirm this. m8 According to Willard ct al., anatomically the neurovascular bundles of the lateral branches of the dorsal rami lie between ‘numerous, discontinuous interwoven bands of dense connective tissue" over the posterior sacral surface. ‘On this basis it has been suggested that a potential for pain generation exists."* McGrath et al, investigated the anatomy/morphology of the LDL; in that study the name ‘long posterior sacroiliac ligament’ was used. Their morphological findings offer “a potential patho-anatomical mechanism that may explain the identification of localized pain in the sacroiliac region, usually interpreted as referred pain from the sacroiliac Joint. The lateral branches of the dorsal sacral rami appear vulnerable to trauma or ischaemic challenge. This may account for sacroiliac joint related ‘non-specific’ low back pain or for pregnancy related PGP.” {t has been indicated in the recent European Guidelines on the diagnosis and treatment of pelvic girdle pain, that “although the sensitivity of the LDL test seems promising, further clinical study is necessary”.' For a test to have good reliability, it needs to be sufficiently sensitive and specific. The present article focuses on the sensitivity and specificity of the LDL test in @ group of severe PGP patients and healthy controls. One of the goals is to establish normative values for the cut-off score of the LDL test. 488 Barcelona, November 20076" Interdisciplnary Werld Congress on Low Back & Pelvic Poin Material and Methods Patients and controls Patients were selected from the outpatient clinic of a rehabilitation centre, specialized in the treatment of lumbopelvic pain. A total of 254 patients with PGP after pregnancy were included. Mean age of the patients was 32.9 £ 4.7 years, Parity ranged from I to 6 with a median of 2. Mean duration of complaints was 3.5 + 3.5 years, Mean Visual Analogue Seale (VAS) pain was 55.5 + 22.0 and mean Quebec Back Pain Disability Scale (QBPDS) was 57.9 + 12.5, ‘Control subjects were 44 healthy persons (25 men, 19 women) that were recruited from a sports club, university and physiotherapy practice. Mean age of the controls was 38 13.2 years. Mean VAS pain was 0.1 + 0.6 and mean QBPDS was 4.1 + 4.2, Inclusion criteria of the patients 1. Pain in the pelvic region, defined as pain experienced between the upper level of the iliac crests and the gluteal fold. Pain beginning during pregnancy or within 3 weeks after delivery. ‘The patient was not pregnant and the last delivery was 6 months to 5 years previously. ASLR+test 2 2 and modified PPPP-test > 2. Aged 20-50 years. Inclusion criteria of the controls No low back pain or petvie girdle pain for at least 5 years; 2. A.score < 5 mm on VAS for pain (maximum score is 100); 3. A score < 15 on the QBPDS at the moment of examination (maximum score is 100); 4 5. 1 ‘Not pregnant, or gave birth at least 6 months before examination; Aged 18-65 years. Exclusion criteria of the patients and controls 1. A history of fracture, neoplasm or previous surgery of the lumbar spine, the pelvic girdle, the hip joint or the femur. 2. Signs indicating radiculopathy as asymmetric tendon reflex and/or (passive) straight leg raising restricted by pain in the lower leg. 3. A systemic disease of the locomotor system 4. Insufficient knowledge of the Dutch language to fill in forms. Examination procedure The LDL test, The long dorsal sacroiliac ligament can be palpated directly caudal to the posterior superior iliae spine, as a taut superficial structure, frequently with the feeling of a bony structure, It is important that palpation is sirictly between the boundaries of the ligament, and not confused at the medial side with the m. multifidus and at the lateral side with the attachment of the m. gluteus maximus. Although the LDL is a superficially located structure, experience shows that adequate training in anatomy in vivo of this area is a necessity to properly locate the ligament. The patients and controls were tested for tenderness by bilateral palpation of the LDL, lying in prone position. The tests were executed by a skilled examiner, trained for specific anatomical palpation of the LDL. The LDL test score relied on the patients statements of pain or tenderness at the examination, ‘The LDL test was scored on a modification of the scale proposed by the American College of Rheumatology to grade tender points in fibromyalgia: no pain = 0; mild pain = 1; moderate pain = 2; unbearable pain = 3.” The LDL test is thus scored on a 4-point scale, differentiated between left and right side. The scores of the unilateral sides ranged from 0-3. Njoo found a high intertester agreement for LDL testing; therefore, in the present study LDL. tenderness was scored by one examiner (0.76 kappa; 0.64-0.88)."! The ASLR test is used as described by Mens et al.” Single leg score ranges from 0-5; the score of both legs is summed. The ASLR test was positive in the present study when the bilateral score was at least > 2 ‘The PPPP test is used as described by Ostgaard ct al.”* Additionally to the original description, the PPPP test was scored in the same way as the LDL test; on a 4-point scale, differentiated between left and right side. The modified PPPP test was positive in the present study when the bilateral score was at least > 2. Statistical analysis SPSS statistical software (version 14.0) was used for data analysis. Barcelona November 2007 ‘4206" interaiscipiinary World Congress on Low Bock & Pelvic Pain Results Score on LDL test In the patients, 202 (80%) had a unilateral score > 2. In the control group, 2 subjects (4.5%) had a unilateral score > 2. Among the patients, 22 (8.6%) scored completely negative on the test (left and right side 0). In the group of controls, 27 (61.4%) scored completely negative on the test Sensitivity of the LDL test Table | shows the data on the sensitivity of the LDL test in 254 patients with PGP and the specificity of the LDL test in 44 healthy controls In the patients, 232 indicated pain on palpation of the LDL (sensitivity = 91%). The LDL test was scored positive with a unilateral score > I. When the LDL test was assessed positive with a unilateral score 2 2, 202 patients indicated pain on palpation of the LDL (sensitivity = 80%). Specificity of the LDL test In the group of 44 controls the specificity of the LDL test is 61% when the test was assessed positive with 2 unilateral score > 1. When the LDL test was assessed positive with a unilateral score 2 2, the specificity is 96% (Table 1). ‘Table 1: Sensitivity of the long dorsal sacroiliac ligament (LDL) test in 254 patients with pelvic girdle pain (PGP) after pregnancy and specificity in 44 healthy contvols. Cut-off unilateral LDL test score Sensitivity Specificity 1 232/254 = 91% 2744 = 61% 22 202/254 = 80% 42/44 = 96% 23 104/254 = 41% Discussion ‘An earlier study on the LDL showed a high incidence of local tenderness after palpation of the LDL in women with PGP afier pregnancy.® Those results indicated that the LDL frequently shows tendemess on palpation in PGP patients, and scored positive in 76% of that study population. However, if the cut-off score for inclusion of PGP patients is raised to include both « positive ASLR and PPPP test on at least one side, 86% of the PGP patients score positive on the LDL test. If the cut-off score for inclusion of PGP patients is further raised to include an ASLR test >3 and PPPP test > 2 on at least one side, sensitivity of the LDL test was 98%.° In the present study, the sensitivity of the LDL test in a group woman with PGP after pregnancy is 91% when using almost the same cut-off scores for inclusion as were used in the study of 2002, which found a sensitivity of 98%. ‘The only difference is that in the study of 2002 a cut-off > 3 was used for the ASLR test; the present study uses a cut-off 2 for the ASLR test. That explains the difference in sensitivity between the two groups with PGP. The LDL test was scored positive in all cases in which the patient indicated unilateral pain after palpation of the LDL, irrespective of whether the pain was mild, moderate or severe. Albert et al evaluated 15 tests used in the classification procedure in pregnancy related PGP. In that investigation also the palpation of the LDL was evaluated. The sensitivity of the test in four classified subgroups with pelvic Joint pain ranged from 0% in the symphysiolysis group to 49% in the group with pelvic girdle syndrome, the specificity was 100%, This conclusion about the sensitivity is quite different compared with the present article, which shows a sensitivity of 80%. The specificity of 100% is comparable with that in the present article of 96%. ‘An explanation of this difference could be the different execution of the test and the severity of the patients, In the article of Albert etal, the test was executed lying on the side with flexion in both hip and knee, the areas above the Si-joints are palpated, which is clearly different than the test used as described in the present article. The located palpation, as well as the judgement to be positive, is different. These differences possibly explain also the difference in inter-tester reliability in the evaluation of Albert et al. (kappa 0.34) compared to the conclusion of Njoo (kappa 0.76)."" In the present study 44 healthy controls were examined on the LDL test. One of the goals is to establish a normative cut-off score on a 4-point modified pain scale for this test. 490 Barcelona, November 20078" Inrerdisciplinary World Congress an Low Bock & Pelvic Pain Table | shows that the specificity of the LDL test is 61% when the test is assessed positive in all cases in which pain is indicated. In this case there will be many false-positive scores. When the unilateral LDL test scores positive with a score > 2 (moderate or severe pain), the specificity increases to 96%. For a reliable use of the LDL test it is thus better to assess the test positive with a unilateral score of 2 or higher. In that case, the sensitivity of the LDL test is 80% (Table 1). It is concluded that the LDL test is a high specific test when it is assessed ta be positive with ascore>2, When scoring the LDL test in @ group of patients with non-specific low back pain, with no strict distinction between lumbar and pelvic pain, Njoo reported a sensitivity of 21%."' In a group of PGP patients, Vieeming et al.* found a sensitivity of 76% and in the present article the sensitivity is 80%. Compared with non-specific low back pain patients, the sensitivity of the LDL test seems much higher in patients with PGP. These results indicate that the LDL test can possibly be used as a diagnostic test that is able to differentiate between PGP and low back pain. ‘This conclusion needs further investigation. In conelusion, based on the present study, the data indicate that the sensitivity (80%) and specificity (96%) of the LDL test are high. For using the LDL test in practice, the unilateral cut-off score of the LDL test has to be raised to 22 (moderate or severe pain). Experience shows that adequate training in anatomy in vivo of this area is a necessity to properly locate the ligament and to carry out the LDL test. References 1. European Guidelines on the diagnosis and treament of pelvie girdle pain. COST Action B13 Available at: www backpaineurope.org. Submitted 2. Albert H, Godskesen M, Westergaard J. Evaluation of clinical tests used in classification procedures in pregnancy-related pelvic joint pain. Eur Spine J 2000; 9:161-166. 3. Ostgaard HC, Zetherstrim G, Roos-Hansen E, et al. Prevalence of back pain in pregnancy. Spine 1994; 16:549-55 4. Larsen EC, Wilken-Jensen C, Hansen 4, etal. Syrptom-giving pelvic girdle relaxation in pregnancy. 1: Prevalence and rise factors. Acta Obstet Gynecol Scand 1999; 78: 105-110. 5. Vleeming 4, Pool-Goucewaard AL, Hammudoglu D, et al. The function of the long dorsal sacroiliac ligament. Spine 1996; 21:562-565, 6. Vleeming A, Vries de HJ, Mens JMA, et al. 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