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Inter- and intra-examiner reliability of palpation for sacroiliac joint dysfunction

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164 Journal of Manipulative and Physiological Therapeutics
Volume 10. Number 4 • August, 1987
0161-4754/87/0164-0171 $02.00/0© 1987 JMPT
Inter- and Intra-Examiner Reliability of Palpation for
Sacroiliac Joint Dysfunction
JOEL P. CARMICHAEL, D.C:
ABSTRACT
The purpose of this study was to operationally define
and evaluate inter- and intra-examiner reliability of the
standing sacroiliac mobility (Gillet) test on 53 college
students. Both inter- and intra-examiner reliability data
showed high mean percentages of agreement (85.3%
and 89.2%, respectively.) Cohen's unweighted kappa
statistic for concordance was applied yielding "fair"
concordance for aggregate intra-examiner data and
"slight" concordance for aggregate inter-examiner data.
The intra-examiner reliability data suggests that the
Gillet test is clinically useful for a single examiner in
------------1
INTRODUCTION
Several mechanisms by which low back and leg pain
may originate from the sacroiliac joint have been pro-
posed (I, 2). Impaired sacroiliac joint mobility (i.e.,
dysfunction) is one such mechanism (3). Several meth-
ods of evaluating the mobility of this joint have been
described (2, 4). One such method is known as the
"Gillet test" (5), after one of its originators (6). This test
has been presented as a diagnostic procedure by Kir-
kaldy-Willis and Hill (4), Haldeman (7), Gitelman (8)
and others. These procedures have been offered to the
professions with little reported reliability data (9).
Two previous studies have been performed that ad-
dress the standing sacroiliac mobility test of Gillet.
Wiles (10) used the modified technique of Gitelman
and Grice coupled with two other unspecified tests to
arrive at a rating of mobility on a three-point ordinal
scale. This study concluded that the sacroiliac tests
(evaluated collectively) were specific (i.e., able to deter-
mine the presence of normality) but not sensitive (i.e.,
unable to determine the presence of abnormality).
These conclusions were, however, based on a calcula-
* Faculty Instructor, Montgomery Outpatient Health Center, Lo-
gan College of Chiropractic.
Submit reprint requests to: Joel P. Carmichael, D.C., 3612 Galley
Rd., Suite A, Colorado Springs, CO 80909.
Paper submitted May 12, 1986; in revised form September 15,
1986.
assessing the sacroiliac joint for mobility dysfunction,
especially at upper sacroiliac contact points. Linear
regression analyses suggest that the test is sensitive, in
that reliability improves with increasing perceived ab-
normality. Further revisions to the operational defini-
tion may improve both inter- and intra-examiner reli-
ability of the Gillet test. (J Manipulative Physiol Ther
1987; 10:164-171)
Key Indexing Terms: Sacroiliac Joint, Reliability,
Chiropractic, Diagnosis.
tion of the Pearson Product-moment correlation coef-
ficient. There is some controversy over the use and
meaning of this coefficient as an expression of the
degree of reliability of a test (II).
More recently Potter and Rothstein (5) examined the
reliability of the standing Gillet test. The palpatory
findings were rated nominally into three categories. The
results were reported as percent agreements, and a x'
goodness-of-fit test was applied to determine agreement
at the 70% and 90% levels. Agreement on the Gillet
test, as defined and performed by physical therapists,
was reported to be poor.
The operational definition of a test is important in
order to evaluate its reliability (11, 12). Few definitions
appear in the literature for the Gillet test (2, 4, 10).
None of these definitions reflect the detail necessary for
others to reproduce the test reliably. This study opera-
tionally defines the Gillet test in detail, and examines
inter- and intraexaminer reliability by ten examiners
on 53 subjects.
METHODS
Definition of Hand Contacts
The examiner, seated behind the standing subject,
takes a series of four paired manual contacts for each
sacroiliac joint. While each set of paired contacts is
maintained across one sacroiliac joint, the subject is I

asked to raise first the leg on the same side (i.e., when
palpating the right sacroiliac joint, the right leg would
be raised first), followed by the other leg.
Each pair of contacts consists of one midsagittal
thumb contact on the sacrum (or L5 spinous process,
in the case of the most superior contact) and one thumb
contact on the ilium (Figures I and 2). The placement
of these contacts will now be described, using the right
sacroiliac joint for illustrative purposes:
I. Contact 1. This is the most superior contact. The
left thumb is placed on the L5 spinous process and the
right thumb is placed superolateral to the PSIS just
beneath the crest of the ilium. The tip of the right
thumb is abutted superomedially against the outer in-
ferior margin of the rim of the iliac crest (upper dorsum
ilii):The thumbs should be level to one another, in the
same horizontal plane.
2. Contact 2. The left thumb contacts the Sl tuber-
cle. The right thumb is placed directly lateral to the
PSISat the same level as the left thumb. The tip of the
right thumb is abutted medially against the lateral
margin of the right posterosuperior iliac spine (PSIS).
3. Contact 3. The left thumb contacts the S3 tuber-
cle. The right thumb is abutted superiorly against the
inferior margin of the right PSIS.
4. Contact 4. The left thumb contacts the sacral apex.
The right thumb is placed inferolateral to the sacral
apex, just inferior to the right ischial.spine. The right
thumb is abutted laterally against the posteromedial
margin of the ischium. This ischial contact becomes
quite apparent as the subject flexes the right thigh,
thereby stretching gluteal tissue over the ischium and
Figure1. Bony landmarks used as contact points in the Gillet test.
, The large dots show where the thumbs are placed. The midline
COntactsare shared by both right and left thumbs, depending on
, which sacroiliac joint is being palpated. The arrows represent the
direction of thumb pressure used by the examiner on the innominate
COntacts.
Journal of Manipulative and Physiological Therapeutics 165
Volume 10. Number 4_ August, 1987
SACROILIAC JOINT DYSFUNCTION. CARMICHAEL
ITJ · D=:J
CO· ·•..· ·D:J
CIJ···;..• ..····o=J
••
co.··· ··
..co
Figure 2. Bony landmarks are replaced by eight two-celled boxes.
Each two-celled box represents one of the eight contacts described
(four on each sacroiliac joint). Each box is divided into two cells to
record an examiner's scores. When the right leg is raised the palpatory
finding is recorded in the right cell. The left cell is used for left leg
raises.
reducing the thickness of soft tissue through which this
bony landmark is palpated.
For all midline contacts, the examiner exerts thumb
pressure directly forward in a sagittal plane. In addition,
it is important to note that in all contacts except num-
ber 4, the fingers are wrapped around the pelvis ante-
riorly to gain a more complete tactile' sense of the
mobility of the ilium.
Definition of Examination Procedure
The subject stands with his back towards the seated
examiner, with handholds on either side to maintain
balance. Using the right sacroiliac joint as an example,
the right thumb is placed on the right ilium and the left
thumb takes the midsagittal contact.
The examiner applies the first set of manual contacts
(contact 1) to the right sacroiliac joint and the subject
is asked to raise the right leg as high as he can without
bending the knees. The subject is told to refrain from
holding the leg in the raised position, returning it freely
to the floor. As the subject's leg is moving, the examiner
observes (visual cue) and feels (palpatory cue) the rela-
tive motion occurring between the two thumb contacts.
It should be emphasized that the examiner is looking
and feeling for relative motion between the thumbs,
and not gross motion of the thumbs as a unit. The
latter could be produced by the subject who bends the
knee of the supporting leg during the leg raise,
'The process is repeated with the same contacts as the
subject is asked to raise the left leg.
Steps 1 and 2 are repeated for each of the subsequent
manual contacts (2 through 4) on the right sacroiliac
joint, and then the entire procedure is repeated for the
left sacroiliac joint. A total of 16 leg raises (8 right and
8 left) are thus performed by the subject.
166 Journal of Manipulative and Physiological Therapeutics
Volume 10- Number 4 - August, 1987
SACROILIAC JOINT DYSFUNCTION. CARMICHAEL
Selection of Subjects
Fifty-four college students volunteered for the proj-
ect. Only directly relevant diagnostic criteria were used.
Prior to the administration of the test, each subject was
shown a graphic pain rating scale (Figure 3) describing
levels of pain as: faint, weak, mild, moderate, strong
and intense (13). The volunteers were read a script
stating that if they experienced low back, buttock or leg
pain that was perceived as moderate or greater, they
would be excluded from further testing. One subject
was excluded on this basis.
Experimental Protocol
Ten student examiners trained together for nine ses-
sions over a 3-month period to standardize palpation
technique and to ensure that each examiner understood
the rating scale for the test (described below). Three
examiners had 3 yr of palpating experience, five had 2
yr of experience and two examiners had I yr or less.
While the level of examiner competence was variable,
the 3-month training period provided time for the less
experienced examiners to develop skill, and for the
more experienced examiners to eliminate idiosyncra-
cies,
A set of three examiners (grouped irrespective of
perceived skill level) palpated subjects in three adjacent
rooms. Upon completion of the first examination, each
examiner recorded his palpation findings on a score
sheet (Figure 4) and placed it in an opaque envelope to
conceal it from the other examiners. He would then
move to the next subject's room. In this manner, all
three palpators examined the same subject one time.
Finally, afourth palpation was performed in which each
examiner returned to the first room to re-palpate the
first subject in order to obtain intra-examiner data.
Hence, the intra-examiner palpations were spaced tem-
porally as far apart as possible to eliminate the possi-
bility of recall from memory. At no time were exam-
iners allowed to discuss their findings with one another
or with the subjects.
Three consecutive days were utilized to complete the
experiment. An advance schedule was made assigning
the examiners to a specific block of time to palpate
three-patient sets. In this manner, all examiners were
incorporated into the study, each palpating at least six
patients. Several examiners participated in more than
one "triad" of palpators.
FAINT WEAK MILD MODERATE STRONG INTEN~E
Figure 3. Graphic rating scale of pain {after Heft and Parker (13)).
N=-NORMAL
r- FIXATION
Figure 4. The score sheet used has a cell for each contact point and
each leg raised. Each cell represents one of the 16 parameters corre-
lated for reliability. Refer to text for definition of "normal" vs.
"fixation."
Nominal Rating of Palpatory Findings
The manual contact coupled with one leg raise (either
ipsi- or contralateral) was labeled a "parameter." Each
leg raise was numbered for data-collection purposes in
diagrammatic form (Figure 4). The examiner assigned
a score for the mobility perceived with each leg raise,
and then proceeded to the next set of contacts. In this
manner, a total of 16 scores for each subject was ob-
tained by each examiner.
Sacroiliac joint mobility was graded nominally as
follows. Normal: normal mobility is present when the
examiner's thumb moves downward (on the side of the
leg raise) relative to the other thumb. (Note: at contact
4, the normal movement is somewhat different. The
ischial contact will move downward and laterally when
the leg on that side is raised.) Fixation: sacroiliac dys-
function (fixation) exists when the relative mobility
between manual contacts is reduced or absent.
Statistical Analysis of Raw Data
Intra-examiner data was obtained on each of 16
parameters through analysis of scores from the first and
fourth palpations of each subject (these palpations being
performed by the same examine~). A "fixation" rating
was arbitrarily assigned a nommal score of I, and
"normal" was assigned a score ofO. Cohen's unweighted
kappa statistic for concordance (14) was then used to
obtain an overall kappa for all 53 subjects at each of
the 16 parameters. This equation calculates kappa, I
chance expected agreements (Pel and actual percent I
agreements (Po) (Figure 5).
Inter-examiner data included the first, second and
third palpations obtained on each subject. Nominal I
 Journal of Manipulative and Physiological Therapeutics 167
Volume to. Number 4 • August. 1987
SACROILIAC JOINT DYSFUNCTION. CARMICHAEL

scores were assigned as described above for intra-ex-

(1) Derivation of Cohen's kappa used in intraexaminer correlation:
aminer data. The equation of Fleiss (15) was used to
obtain the kappa statistic in this case, since correlation PARAMETER

of more than two ratings was performed. This equation Examiner A

was applied collectively to the scores of all 53 subjects Examiner B Normal Fixation Total
at each parameter (Figure 5). Normal 42~a 4~b 46=rl
Fixation 3~c 4~d 7 = {2
Total 45 =c, 8 =C2 53~N
RESULTS
Using an agreement matrix for each parameter like the one shown
A total of 1696 intra-examiner ratings were per- above, values for Po and P, were obtained:
formed. A fixation score was given in 9.6% of these
ratings. Actual agreements, chance agreements and
kappa values obtained for aggregate intra-examiner re-
liability data are shown in Table I. This data shows The formula for kappa is as follows:

positive values for kappa at 9 of 16 parameters (mean Po - Pc

= 0.180). Mean percent agreement was 89.2%. Figure K = 1 - Pc .
6 shows that the incidence of fixation is highest at Kappa has a value of 0 if observed agreement equals chance
parameters I, 2 and 9-12. Linear regression analysis agreement (Po = Pc); +1 if observed agreement is perlect (Po =
plotting incidence of fixation against kappa value for 1); and <0 if observed agreement is tess than chance-expected
each parameter demonstrated a statistically significant agreement (Po < Pc).
correlation (r = 0.83) between increasing perceived (2) Derivation of kappa, using the method of Fleiss (for many raters)
abnormality and higher levels of intra-examiner con- is as follows:
cordance. This data shown in Figure 7. N = total number of subjects,
The palpatory findings of all ten examiners were i = subject i fori = 1 toN,
analyzed individually for intra-examiner reliability. The j = category j for j = 1 to k (rating categories),
results are shown in Table 2. The mean actual agree- Ni,! = number of raters who assigned the ith SUbject to the jth
ment was 89.9% and the mean kappa value was 0.314. category.
Linear regression was performed to explore the rela- 1 "
Pj=N- L nlf
tionship between the presence of fixation and kappa n 1=1

value for the single examiner. The data, shown in Table = proportion of all assignments that were in the jth category.
3, fails to demonstrate a correlation between increasing 1 •
values of kappa and percent fixation (r = 0.11). p,~-( _ 1).L n'j(n" -1)
nn f=1

Two thousand five hundred forty-four inter-examiner = extent of agreement among n raters for the Hh subject.
ratings were performed, with fixations noted in 9.4%. _ 1 ~
Figure 8 shows the highest incidence of fixation at P~-N
n
z».
/~1
parameters I, 2, 3 and 9-12. Kappa values ranging = overall observed agreement.
from -0.0650 to 0.1931 (mean = 0.0232) for aggregate
inter-examiner data are seen in Table 4. Mean actual Pe= L P/
•
/=1
percent agreement was 85.3%. = overall chance-expected agreement.
Table 5 lists percent fixation and kappa values ob-
tained by parameter for global inter-examiner data.
This data was subjected to linear regression analysis
.~----
P -P ..
1 - Pe
= kappa, the degree of agreement beyond chance,
(Figure 9) and demonstrates a mildly significant corre-
lation (r = 0.66) between the presence of fixation and Figure S. Statistical formulae used in calculations: (1), derivation of
Cohen's kappa used in intra-examiner correlation. (2), derivation of
inter-examiner concordance.
kappa, using the method of Fleiss (15).
Finally, the data for triads ofpalpators were grouped
) and subjected to independent analysis for inter-exam-
I iner reliability. The results, displayed in Table 6, show tween the presence of sacroiliac fixation and a positive
that four of the seven triads of examiners achieved value of kappa for the grouped examiners.
positive values of kappa for at least one parameter, but
only one triad achieved an average kappa greater than DISCUSSION
. 0 (overall mean kappa value = -0.09). Linear regres- The kappa statistic is needed to determine whether
r sion analysis showed no relationship (r = -8.49) be- actual inter- and intra-examiner agreements reflect con-
I
168 Journal of Manipulative and Physiological Therapeutics
Volume 10. Number 4 e August, 1987
SACROILIAC JOINT DYSFUNCTION. CARMICHAEL

TABLE 1. Intra-examiner reliability

0.72
Actual Chance Standard
Parameter agreement agreement Kappa error
% %
0.2423 0.60
1 86.79 75.69 0.4568
2 81.13 74.30 0.2659 0.2335
3 84.91 82.84 0.1203 0.3018
4 86.79 84.44 0.1510 0.3200
0.48
5 96.23 96.30 -0.0192 0.7005
6 94.34 94.34 0.0000 0.5608
7 100.00 100.00 0.0000 4501.0310
8 96.23 96.23 0.0000 0.6936
0.36
9 86.79 56.96 0.6931 0.1580
10 77.36 69.38 0.2605 0.2068 <t.
a,
11 79.25 68.07 0.3501 0.2005
<{
12 75.47 73.05 0.0898 0.2262 0<: 0.24
13 90.57 81.38 0.4933 0.2872
14 92.45 92.45 0.0000 0.4808
15 100.00 100.00 0.0000 4501.0310
16 98.11 98.11 0.0000 0.9905 0.12
Mean 89.15 83.97 0.1800

10 20 ac

30
-0.12
% FIXATION
Figure 7. Relationship of examiner agreement and presence of ab-
25 normality for aggregate intra-examiner data. (Linear regression: y ::
0.02 Ix - 0.028; r ~ 0.83.)

20
TABLE 2. Intra-examiner reliability by individual examiner
Percent Percent
actual chance Standard
Z 15
a Examiner agreement agreement Kappa error
~ 1 97.5 92.7 0.66 0.40
>< 10 2 85.4 72.1 0.48 0.16
u:: 3 93.8 88.2 0.47 0.34
"'-
0 4 93.8 90.1 0.37 0.31
5 90.6 85.5 0.35 0.43
5 0.14
6 76.0 65.2 0.31
7 95.0 92.8 0.31 0.40
8 75.0 67.3 0.23 0.14
9 96.9 96.9 -0.01 0.57
1 2 3 4 5 6 7 B 9 10 11 12 13 14 15 16
10 94.8 94.9 -0.03 0.44
PARAMETER Mean kappa value = 0.314; mean actual agreement = 89.9%.
Figure 6. Relationship between percent fixation scored and sacroil-
iac position (parameter) for aggregate intra-examiner data.
TABLE 3.: Individual examiners: kappa V5. Percent fixation
Fixations
cordance beyond chance. Landis and Koch (16) have Examiner Kappa Notes
suggested the following guidelines for determining a %
quantitative level of significance for the value of kappa: 1 0.66 5.0
2 0.48 24.0
3 0.47 9.4
Value of kappa Strength of agreement 4 0.37 8.3
<0 Poor 5 0.35 12.5
6 0.31 34.4
0.00-0.20 Slight 7 0.31 6.3
0.21-0.40 Fair 8 0.23 33.0
Moderate 9 -0.01 3.1
0.41-0.60 5.2
10 -0.03
0.61-0.80 Substantial
Almost Perfect y ~ 0.0020< + 0.29; r ~ 0.11.
0.81-1.00
 Journal of Manipulative and Physiological Therapeutics 169
Volume Hl e Number e e August. 1987
SACROILIAC JOINT DYSFUNCTION. CARMICHAEL

parameter was made to determine where sacroiliac

25
mobility testing is most reliable. Table I lists kappa
values equal or. ill excess of moderate reliability at
Z 20 parameters I, 9 and 13, while fair reliability was
0

~ achieved at parameters 2, 10 and 11 for aggregate intra-

X examiner data. All of the above parameters are located
u::: ts
in the upper portion of the sacroiliac joints bilaterally.
;oR.
0
This would support the usefulness of the upper sacro-
10 iliac contact points, but not the lower points. However,
a symptomatic population should be evaluated before
the lower contact points are abandoned.
5
A similar observation is noted for aggregate inter-
examiner data. Table 4 illustrates tbat points I, 2, 9
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

TABLE 5. Inter-examiner aggregate data

PARAMETER
Figure 8. Relationship between percent fixation scored and sacroil- Percent
iac position (parameter) for aggregate inter-examiner data. Parameter Fixation (x) Kappa (y)
%
1 16.4 0.08
TABLE 4. Interexaminer reliability' 2 15.7 0.05
3 13.8 -0.02
Actual, Chance Standard 4 11.3 -0.07
Parameter agreement agreement Kappa error
5 4.4 -0.05
% % 6 3.1 -0.03
, 1 74.84 72.64 .. 0.0804 0.1647 7
. 2 74.84 73.50 0.0507 0.1691 8 1.3 -0.01'
3 78.62 78.96 -0.0162 0.2023 9 26.4 0.14
78.62 79.92 -0.0650 0.2092 10 11.0 -0.03
4-
91.58 -0.0461 0.3613 11 15.1 0.19
5 91·19
93.71 93.91 -0.0325 0.4332 12 12.6 0.04
6
7 100.00 100.00 13 8.8 0.06
97.52 -0.0127 0.6982 14 3.1 -0.03
8 97.48
9 66.04 60.54 0.1393 0.1141 15
16 0.6 -0.Q1
10 71.07 71.80 -0.0261 0.1605
11 78.62 73.50 0.1931 0.1691
12 82.39 78.01 0.0383 1.0179
13 84.91 83.94 0.0601 0.2438
14 93.71 93.91 -0.0325 0.4331 •
15 100.00 100.00
16 98.74 98.75 -6.3291 0.9937 0.16
Mean 85.30 84.28 0.0232
Note: "_H indicates a null correlation due to a calculated denomi- 0.12
nator of zero.

0.08

The results show that the Gillet test is fairly reliable

0.04
, '. ,.'
when used by a single examiner in repeated palpations
of the same patient (Table 2). This finding moderately
itIl.
supports intra-examiner reliability of the Gillet test. -c .. to , .201 . 30

Globally, for both inter- and intra-examiner data sets, ""-0.04

the Gillet test showed "slight" reliability (Tables 2 and
4). These findings mildly support intra-examiner relia-
-0.08
•
bility, and suggest that further refinements of the Gillet
test may produce even better results. Reproducible % FIXATION
palpatory findings could not be achieved when consid-
ering the independent three-examiner sets used in the Figure 9: Relationship of examiner agreement and presence of ab-
studyt'Iable 6). normality for aggregate inter-examiner data",(Linear regression: y =
An analysis of the kappa values at each individual 0.0069x - 0.048; r ~ 0.66.) .
170 Journal of Manipulative and Physiological Therapeutics
Volume IO-Number4-August.1987
SACROILIAC JOINT DYSFUNCTION. CARMICHAEL

TABLE 6. Kappa values for each triad of examiners

(Figure 9) for aggregate inter-examiner data, demon.
Parameter A B C D E F G strated moderate correlation. These findings show that
1 -0.20 -0.29 -0.13 0.10 0.17 0.11 0.13 the Gillet test is at least moderately sensitive for hath
2 -0.20 -0.29 -0.13 -0.21 -0.04 -0.07 0.17
-0.20 -0.13
inter-examiner and intra-examiner reliability. This isin
3 -0.13 -0.09 -0.29 0.29 0.07
4 -0.20 0.10 -0.17 -0.07 -0.20 contrast to the study by Wiles (10), who found the
5 -0.20 -0.07 -0.09 Gillet test (combined with other similar tests) to he
6 -0.04 -0.21 -0.09 specific, but not sensitive.
7
8 -0.06 Linear regressions using data grouped by individual
9 -0.20 -0.13 -0.13 -0.34 -0.20 -0.02 0.21 examiner and by examining triad failed to show a
10 -0.33 0.21 -0.17 -0.12 -0.02
11
relationship between the presence of perceived abnor-
-0.D1 -0.13 -0.02 0.07
12 -0.20 -0.04 -0.17 -0.04 0.41 mality and examiner agreement (Table 3).
13 0.24 -0.07 -0.13 Since this study represents a more detailed opera-
14 -0.13 -0.13 -0.04 -0.09 tional definition of the Gillet test yielding higher mean
15
16 actual percent agreements, it is possible that a direct
Mean -0.22 -0.19 -0.13 -0.01 -0.11 -0.D1 0.03 relationship exists between these two factors. Improved
kappa
levels of inter- and intra-examiner reliability might be
Note: U -" represents calculated denominator Of zero. achieved through further enhancement of the test's
operational definition. In addition, the use of more
experienced palpators and/or the use of a symptomatic
and 11-13-all upper sacroiliac points-showed slight population of subjects might also improve reliability.
agreement. This finding is, again, mildly supportive of Potential sources of error for both inter- and intraex- ,
inter-examiner reliability. In spite of this, the mean aminer reliability data include the following:
actual percent agreement for inter-examiner reliability
data (85.3%) markedly surpasses all previous published 1. The subject may not execute the leg raising pro-I
reports on the Gillet test, which ranged from 46.7% to cedure consistently from one examiner to the
77.9% (5, 10). This may represent an improvement in next,
methodology over the previous studies. 2. The soft tissues of the subject may be such that
Figures 6 and 8 show that the greatest incidence of the manual contacts are inconsistently placed,
perceived fixation is at the upper portion of the sacro- 3. Idiosyncracies among examiners in the perform- .
iliacjoints. This may be interpreted in at least two ways. ance of the testing procedure may produce dissim-
First, all volunteers were selected from a population of ilar palpation findings, and
chiropractic students who generally sit for extended 4. The testing procedure when performed repeti-
periods of time in the classroom each day. According tively may alter sacroiliac mobility.
to Dr. Gillet (6), sitting produces a spreading of the
ischial tuberosities and an approximation of the iliac The results of this study, especially with regard to
crests. This posture places a large demand for length intra-examiner correlation, are promising. Though pre-
upon the lower sacroiliac ligaments while placing no liminary, the findings firmly support the usefulness of
this test when applied by one examiner repeatedly on
demand for length upon the upper sacroiliac ligaments.
the same patient. In a normal clinical situation where
This sustained posture is conducive to upper sacroiliac
and iliolumbar ligamentous fixation and to normal the manipulative practitioner palpates the patient be-
lower sacroiliac mobility. The data supports this hy- fore and after a sacroiliac manipulation, a meaningful
pothesis. postadjustment assessment of the sacroiliac mobility
can be made.
A second possibility is that the Gillet test is unable
to determine the presence of abnormality at the lower
sacroiliac joint. Some would argue that flexing the knee CONCLUSION
during the leg raise would improve the results obtained This study attempts to more clearly define the per-
at the lower joint, but this remains to be objectively formance of the Gillet test, and examines this test for·
shown. both inter- and intra-examiner reliability using the
The results of linear regression analysis of perceived kappa statistic for concordance.
joint dysfunction vs. increasing examiner concordance On analysis of data by individual examiner, it was
suggest significant correlation on two groups of data. found that the Gillet test is fairly reliable, providing
The first group (Figure 7) for aggregate intra-examiner encouraging evidence for the conscientious use of this
data showed high correlation, while the second group test in the modern chiropractic clinic. Inter-examiner i

reliability was only mildly supported. For both inter-
and intra-examiner data, the upper sacroiliac contact
points described herein are more reliable than the lower
sacroiliac points.
Analysis of the data collectively seems to indicate
that the Gillet test possesses a degree of sensitivity (i.e.,
increasing examiner agreement with increasing per-
ceived abnormality).
This study suggests that reliability is an obtainable
goal for this widely used chiropractic procedure. The
Gillet test can generate reproducible palpatory findings
in the examination room when performed conscien-
tiously. Further attempts must be made to enhance the
operational definition if possible, and to determine
whether such enhancements have a direct effect on the
reliability of the test.
The manipulative sciences must continue to subject
their diagnostic techniques to reliability and validity
studies in order to clarify the indications for, and the
effects of, manipulation. Future studies of the Gillet
test must be directed toward a representative population
of patients with low back, buttock and/or leg pain.
ACKNOWLEDGEMENTS
The author gratefully acknowledges Dr. N. Kettner
for his guidance, and B. Aldrich, R. Byrd, R. Danbert,
C. Fulton, M. Jaffe, A. Jeans, M. Martinez, D. Meints
and G. Symko for their involvement in the project. Mr.
1. Conway is also acknowledged for sharing his com-
puter programming expertise.
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Journal of Manipulative and Physiological Therapeutics 171
Volume 10. Number 4 • August, 1987
SACROILIAC JOINT DYSFUNCTION. CARMICHAEL
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