Eur Spine J
DOI 10.1007/s00586-015-4369-0
ORIGINAL ARTICLE
Psychometric properties including reliability, validity
and responsiveness of the Majeed pelvic score in patients
with chronic sacroiliac joint pain
Stefan Bajada1 Khitish Mohanty1
Received: 21 June 2015 / Revised: 26 December 2015 / Accepted: 28 December 2015
Springer-Verlag Berlin Heidelberg 2016
Abstract
Purpose The Majeed scoring system is a disease-specific
outcome measure that was originally designed to assess
pelvic injuries. The aim of this study was to determine the
psychometric properties of the Majeed scoring system for
chronic sacroiliac joint pain.
Methods Internal consistency, content validity, criterion
validity, construct validity and responsiveness to change
was assessed prospectively for the Majeed scoring system
in a cohort of 60 patients diagnosed with sacroiliac joint
pain. This diagnosis was confirmed with CT-guided
sacroiliac joint anaesthetic block.
Results The overall Majeed score showed acceptable in-
ternal consistency (Cronbach alpha = 0.63). Similarly, it
showed acceptable floor (0 %) and ceiling (0 %) effects.
On the other hand, the domains of pain, work, sitting and
sexual intercourse had high ([30 %) floor effects. Signif-
icant correlation with the physical component of the Short
Form-36 (p = 0.005) and Oswestry disability index
(p B 0.001) was found indicating acceptable criterion
validity. The overall Majeed score showed accept-
able construct validity with all five developed hypotheses
showing significance (p B 0.05). The overall Majeed score
showed acceptable responsiveness to change with a large
(C0.80) effect size and standardized response mean.
Conclusion Overall the Majeed scoring system demon-
strated acceptable psychometric properties for outcome
assessment in chronic sacroiliac joint pain. Thus, its use in
this condition is adequate. However, some domains
& Stefan Bajada
stefan_bajada@yahoo.com
1
Trauma and Orthopaedic Department, Cardiff and Vales
NHS Trust, Cardiff, UK
demonstrated suboptimal performance indicating that
improvement might be achieved with the development of
an outcome measure specific for sacroiliac joint dysfunc-
tion and degeneration.
Keywords Sacroiliac joint
Outcome measures
Chronic
pain
Reliability
Validity
Introduction
The sacroiliac joint has been reported to be the cause of
symptoms in up to 22 % of patients referred with non-
specific back, pelvic or buttock pain [1]. Thus, the surgical
management of sacroiliac joint pain has recently received
much attention with reports of techniques such as open or
percutaneous sacroiliac joint fusion and stabilisation [2, 3].
Outcome assessments for the treatment of sacroiliac joint
pain have involved the use of generic measures including
health-related quality-of-life scales EuroQol-5D (EQ-5D),
Short Form (SF)-12 or SF-36, as well as disease-specific
measures including the Oswestry disability index (ODI); a
widely used outcome measure to quantify disability in back
pain patients and the Majeed scoring system [4, 5]. The
latter is a pelvis-specific measure that was developed and is
routinely used in the assessment of outcome following the
pelvic injuries [6, 7]. This contains seven items divided in
five domains with the following weightings: pain (30),
work (20), sitting (10), sexual intercourse (4) and standing
(36). The latter is made up by three subcategories: walking
aids (12), gait unaided (12) and walking distance (12). An
overall score of 0100 is calculated (in patients previously
working before injury) with 054 indicated poor results;
5569 a fair result; 7084 a good result and 85100 an
excellent result [8].
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Outcomes in clinical studies are highly reliant on
patient-reported outcome measures. Therefore the use of
instruments whose psychometric properties have been
rigorously established for the condition it is meant to
measure is essential; without these clinical studies may
come under question [9]. Important and accepted psycho-
metric properties include reliability, validity and respon-
siveness. Reliability defines whether the measure is
dependable and reproducibility. Validity refers to an
instrument ability to measure what it is supposed to mea-
sure. Validity consists of several types including content
validity (floor and ceiling effects), criterion validity (how
an instrument compares to an accepted gold-standard
instrument), and construct validity (if the instrument fol-
lows expected non-controversial hypotheses). Responsive-
ness to change is the ability of the instrument to detect
clinically important changes following intervention [10].
To our knowledge there are no outcome instruments
specifically designed or psychometrically assessed for
sacroiliac joint pain due to dysfunction or degeneration.
Thus, the aim of this study is to establish the psychometric
properties of the Majeed scoring system specifically for
this condition.
Patients and methods
Study groups
The study group consisted of 60 patients who were diag-
nosed with sacroiliac joint pain between February 2013 and
February 2015. All causes of sacroiliac joint pathology
were included (including post-pregnancy dysfunction,
sacroiliac osteoarthritis and inflammatory arthropathy).
The diagnosis was made following a corroborative history,
physical assessment and radiological investigations indi-
cating that the sacroiliac joint was the main source of pain.
The patients generally complained of buttock pain with
referral of pain to ipsilateral anterior/posterior thigh or
groin. The patients usually complained of diminished
endurance capacity for standing, walking and sitting. This
had a detrimental effect on the patients working, family
and social life. Clinical examination included a combina-
tion of positive sacroiliac joint provocation tests [11].
Patients had a combination of plain radiographs, computed
tomography (CT), isotope bone scans and magnetic reso-
nance imaging (MRI). There is poor evidence on the ability
of these investigations to confirm sacroiliac joint pathol-
ogy; however, they were helpful to diagnose degeneration
or to exclude other conditions. In clinical practice and
supported by current literature, the gold standard in diag-
nostic accuracy of sacroiliac joint disease is a CT-guided
sacroiliac joint anaesthetic block [12]. Thus, in this study,
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Eur Spine J
only patients who had at least one positive result (signifi-
cant decrease in pain levels even if temporary) from a CT-
guided sacroiliac joint injection were included. A subset of
this cohort (28 patients) underwent percutaneous sacroiliac
joint fusion utilising SI-LOK (Globus Medical, Alton,
UK) hydroxyapatite coated screws in a technique similar to
previously described [4]. As part of the rehabilitation
protocol, these patients prospectively completed post-op-
erative scores including SF-36, ODI, Majeed and EQ-5D-
5L at a mean of 14 months. Post-operative review
including routine radiographs rather than CT scans there-
fore fusion was not assessed in this study. The data were
collected and maintained prospectively in a computerized
database by an independent researcher.
Internal consistency
Pre-operative Majeed scores were used to establish overall
internal consistency for the main domains and subcate-
gories. A Cronbach alpha of [0.60 was considered
acceptable [10].
Content validity
Pre-operative Majeed scores were used to establish content
validity as previously described [10]. Floor effects (the
proportion of patients who obtain the lowest possible score)
and ceiling effects (the proportion of patients who obtain
the highest possible score) were determined for the overall,
the five main domains and three subcategories of the
Majeed score. Floor and ceiling effects of \30 % were
considered acceptable.
Criterion validity
Criterion validity was determined utilising pre-operative
Majeed scores. Correlation of the overall Majeed score to
the physical component of the SF-36 health-related quality-
of-life scale was performed. The ODI, an outcome measure
in back pain patients, was also correlated.
Construct validity
Pre-operative Majeed scores were used to establish con-
struct validity. Five hypotheses (constructs) were devel-
oped with consensus and were tested in this cohort as
follows:
1. Patients with higher pain levels are expected to have
lower overall Majeed scores. Pain levels were mea-
sured on a 5-point ordinal scale, with 1 point indicating
no pain or discomfort and 5 points indicating extreme
pain or discomfort.
Eur Spine J

2. Patients who had more difficulty with usual activities Results

(e.g. work, study, housework, family or leisure activ-
ities) would have lower overall Majeed scores. Func-
tion was measured on a 5-point ordinal scale, with 1
point indicating no problems doing usual activities and
5 points indicating inability to do usual activities.
3. Since the Majeed score is a disease-specific score, we
expect that it would correlate better with the physical
component rather than the mental component of the
SF-36 health-related quality-of-life scale.
4. Patients with a lower self-rated health would have
lower Majeed scores when compared to patients with
higher self-rated health scores. The EuroQol-5D (EQ-
5D) vertical visual analogue scale (VAS) where the
endpoints are labelled Best imaginable health state
and Worst imaginable health state was utilised.
5. Patients who are currently employed are expected to
have better pre-operative Majeed score then those not
in employment.
Responsiveness
Responsiveness to change was assessed by measuring
effect size and standardized response mean as previously
described [10]. The pre-operative Majeed scores were
compared to post-operative scores in 30 patients following
percutaneous sacroiliac joint fusion. The effect size was
calculated with the formula: (mean post-operative scor-
es - mean pre-operative scores)/standard deviation of pre-
operative score. The standardized response mean was cal-
culated with the formula: (mean post-operative scor-
e - mean pre-operative score)/standard deviation of the
change in score. Small effects are considered C0.20,
moderate effects were considered C0.50, and large effects
were considered at C0.80 [10].
Statistical analysis
Internal consistency
The Majeed scoring system demonstrated acceptable inter-
nal consistency with a Cronbach alpha of 0.63.
Content validity
The overall score of the pre-operative Majeed score was
47.4 13.1 (range 2283). The overall score showed a
negligible floor (0 %) and ceiling effect (0 %). The
standing domain including its subcategories of walking
aids, gait unaided and walking distance had accept-
able (\30 %) floor effects. Similarly, the main domains of
pain, work, sitting, sexual intercourse, standing including
its subcategories of gait unaided and walking distance had
acceptable (\30 %) ceiling effects. On the other hand, the
domains of pain, work, sitting and sexual intercourse had
high ([30 %) floor effects. Similarly, the subcategory of
walking aids had a high ([30 %) ceiling effect (Table 1).
Criterion validity
The overall Majeed score showed significant correlation
with both the ODI (r = -0.712, p = \0.001) and the
physical component of the SF-36 score (r = 0.531,
p = 0.005).
Construct validity
On testing the five hypotheses these all showed significant
(p B 0.05) results, i.e., all the developed noncontroversial
hypotheses led to expected results.
1. Patients with higher pain levels had significantly lower
scores on the Majeed scoring system when compared

The Minitab software package (version 17.0) was used for Table 1 Floor and ceiling effects for the overall and separate
domains
all statistical analyses. Factor analysis utilising Cronbach
alpha was used as a measure of internal consistency. Domain (points) Floor effect Ceiling effect
Continuous data were tested for normality using the Overall Majeed Score (0100) 0 (0 %) 0 (0 %)
AndersonDarling test. For normally distributed data, sta- Pain (030) 28 (46.6 %) 1 (1.7 %)
tistical differences and relationships between groups were Work (020) 26 (43.3 %) 5 (8.3 %)
examined using the unpaired Students t test. Correlation Sitting (010) 32 (53.3 %) 0 (0 %)
between different outcome measures and health-related
Sexual intercourse (4) 25 (41.6 %) 9 (15 %)
VAS was tested using Pearson coefficient, r. Correlation
Standing (036) 0 (0 %) 2 (3.3 %)
between ordinal scales for pain or activity and the Majeed
A Walking aids (012) 1 (1.6 %) 22 (36.6 %)
score was tested using Spearmans rho, rs. For all statistical
B Gait unaided (012) 2 (3.3 %) 9 (15 %)
analyses, p values of \0.05 were considered significant.
C Walking distance (012) 1 (1.6 %) 2 (3.3 %)
Values have been expressed as mean standard deviation
of the mean (SD). Domains with high effects ([30 %) shown in bold

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with patients with lower pain levels (rs = -0.563, Discussion

p B 0.001).
2. Patients with more difficulty with usual activities had In this study we report that overall the Majeed scoring
significantly lower scores on the Majeed scoring system demonstrated acceptable psychometric properties
system than did patients with less or no difficulty with (including internal consistency, floor and ceiling effects,
usual daily activities (rs = -0.442, p = 0.001). criterion validity, construct validity and responsiveness) for
3. Patients showed better correlation with the physical its use in chronic sacroiliac joint pain. Thus, its use in this
component (r = 0.531, p = 0.005) of SF-36 health- condition is both adequate and acceptable. However, some
related quality-of-life scale rather than the mental domains demonstrated suboptimal performance indicating
component (r = 0.365, p = 0.019). that improvement might be required. In particular we
4. Patients with lower self-rated health scored signifi- report high floor effects for the domains of pain, work,
cantly lower on the Majeed system than did patients sitting and sexual intercourse. This could limit the dis-
with higher self-rated health (r = 0.55, p = 0.005). criminative ability of these domains to assess functional
5. Patients who are in employment had significantly limitations. This was particularly high (53.3 %) for the
(p B 0.001) higher Majeed scores (53.6 12.1) when sitting domain. Majeed [8] originally reported that sitting
compared to patient not in employment (37.7 10.7). is an important function in relation to the pelvis but less so
than gait or walking ability, thus the score was purpose-
fully designed to give lower weighting to the patients
Responsiveness
sitting ability. However, in our personal experience chronic
sacroiliac joint pain is particularly disabling for patients
The overall Majeed score showed a large (C0.80) overall
sitting endurance; with the most symptomatic patients
effect size ([68.04 - 47.4]/13.1 = 1.58) and similarly a
unable to load their ipsilateral ischium for any prolonged
large (C0.80) overall standardized response mean
length; would fidget and shift sitting loads. Thus, we feel
([68.04 - 47.4]/18.6 = 1.11). The main domains of pain,
that any further outcome measure development should
sitting and sexual intercourse, as well as the subcate-
increase the weighting and discrimination in the sitting
gories of walking distance showed large (C0.80) effect
domain for this particular condition. In addition, there was
sizes and standardized response means. Also, the
a small effect in responsiveness assessment for the standing
domains of work and standing showed moderate (C0.50)
subcategories of walking aids and gait unaided. So indi-
effect sizes and standardized response mean. There was a
cating that these categories might have a lower ability to
small (C0.20) effect size and standardized response mean
assess improvement in function post-operatively. This
for the walking aids and gait unaided subcategories
could be due to the fact that patients with this non-trau-
(Table 2).
matic sacroiliac joint pain rarely have a significant walking
disability compared to pelvic trauma patients. This is
indicated in this study by the high ceiling effect for the
subcategory walking aids where no sticks were needed in
36.6 % of patients. Thus, if further development is under-
Table 2 Responsiveness to change taking the weighting or questioning could be changed in
these subcategories to reflect the findings.
Domain Effect size Standardized
response mean Limitations of this study are mainly due to the assess-
ment of just one disease (pelvic)-specific outcome measure.
Overall Majeed Score 1.58 1.11 Other measures such as Iowa, Hannover and Orlando pel-
Pain 1.97 0.96 vic outcome score could have been included to allow
Work 0.55 0.51 comparison of psychometric measures. Ultimately, allow-
Sitting 1.35 0.84 ing a choice of the best performing score or a best com-
Sexual intercourse 0.83 0.80 bination of domains and questions. In this study, we
Standing 0.78 0.66 specifically chose the Majeed score since its use has been
A Walking aids 0.31 0.32 previously reported in percutaneous sacroiliac joint fusion
B Gait unaided 0.45 0.48 for chronic pain [2, 4]. Also, Lefaivre et al. [13] reported
C Walking distance 1.14 0.82 that this system was the most often used disease-specific
Effect size and standardized response mean for the overall and sep- score in surgical treatment of pelvic ring disruptions. In
arate domains. Large effect (C0.80), moderate effect (C0.50) and addition, it has been reported to have a shorter completion
small effect (C0.20). Domains with small effects shown in bold time (mean 2.6 min) compared to the other pelvic scoring

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systems with adequate good patient acceptance [7]. Even
though these multiple scoring systems are utilised in pelvic
ring injuries their psychometric assessment is fairly limited
in the literature. The Majeed score is one of the few tested
and same as our study it showed construct validity; with
good correlation with physical function domain of the SF-
36 [13, 14]. However, to our knowledge reliability and
responsiveness to change had not been previously reported
even for traumatic pelvic conditions. It could be argued
that since the sacroiliac joint is a constitution of both the
pelvis and spine a back pain-specific rather than a pelvis-
specific scoring system should be utilised in these patients.
In fact both the Majeed score and ODI; the most commonly
used back pain score have fairly similar domains and
crossover questions. This is evidenced by the high corre-
lation (r = -0.712) we found between the two scores.
Thus, we feel that with the Majeed score the ODI would be
an adequate score to include in studies pertaining to this
condition. However, to our knowledge the ODI has not
been validated for sacroiliac joint conditions. The inclusion
of only patients who had at least one positive result from a
CT-guided intraarticular sacroiliac joint anaesthetic block
constitutes a strength in this study. Also, most of our
patients had positive response to fluroscopic-guided injec-
tions before referral to our unit. This specifically allows for
a potential homogenous patient cohort suffering from
sacroiliac joint pain with other sources of pain either
excluded or confirmed as minor contributing sources.
However, the diagnostic accuracy in this study could be
improved on if a double-diagnostic CT block selection
criteria was utilised as established in facet joint therapies
[15]. In fact, a false-positive rate at around 20 % was
reported for single sacroiliac joint injections [16]. Thus,
double comparative blocks with different agents would
eliminate false-positive responders or placebo responses.
Albeit an unintended consequence of employing stricter
diagnostic criteria may result in more false-negatives, and
thus treatment from patients who might benefit [12]. The
fact that sacroiliac joint pain could be heterogeneous (intra-
or extraarticular sacroiliac joint pathology) with complex
and variable nerve supply, can make anaesthetic block
diagnostic testing even more challenging. A retrospective
study, evaluated the sources of sacroiliac pain utilising
anaesthetic blocks to determine the contributions of its
intraarticular and extraarticular components. It concluded
that extraarticular sources comprised a significant propor-
tion of sacroiliac joint pain, and that performing only
intraarticular diagnostic blocks may underestimate the true
prevalence [17].
The surgical management of non-traumatic sacroiliac
joint pain has received much attention. Mason et al. [4]
reported on successful treatment with regards to clinical
outcome scores for percutaneous stabilisation at an early
average follow-up of 36 months in 55 patients. These
encouraging early and mid-term results have been repro-
duced in other studies [3, 5]. However, questions still
remain if these early results on clinical outcome measures
would be sustained in the long term. In this respect Kibs-
gard et al. [18] reported on a 23-year follow-up for open
sacro-iliac fusion. The patients with successful 1-year
outcomes retained significantly improved function and
reduced pain levels compared with the subgroup of patients
with unsuccessful 1-year outcomes. Non-union rate was
10 % with worse long term results. However, even though
patients reported satisfaction with the procedure they still
had moderate disability and moderate to severe pain
23 years after surgery. This dichotomy between patient
satisfaction and clinical outcome is known in surgical
management. This might be due to design of the patient-
reported outcome measures utilised. Thus, possibly indi-
cating that disease-specific and in this case pelvic-specific
measures might be required.
In summary, the Majeed scoring system demonstrated
acceptable psychometric properties for outcome assess-
ment in non-traumatic sacroiliac joint pain. Thus, its use in
this condition is suitable. This would allow adequate
assessment in the evolving treatment for this condition
utilising a pelvic-specific patient reported outcome mea-
sure. However, some domains demonstrated suboptimal
performance indicating that improvement might be
achieved with the development of an outcome measure
specific for chronic sacroiliac joint pain.
Acknowledgments We would like to thank Mark Goodson at the
University Hospital Llandough for data collection. As well as, Dr. Jan
Hermann Kuiper at Keele University for advice on study design.
Compliance with ethical standards
Conflict of interest No benefits in any form have been received or
will be received from a commercial party related directly or indirectly
to the subject of this article.
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