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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 demonstrated suboptimal performance indicating that


Purpose The Majeed scoring system is a disease-specific improvement might be achieved with the development of
outcome measure that was originally designed to assess an outcome measure specific for sacroiliac joint dysfunc-
pelvic injuries. The aim of this study was to determine the tion and degeneration.
psychometric properties of the Majeed scoring system for
chronic sacroiliac joint pain. Keywords Sacroiliac joint  Outcome measures  Chronic
Methods Internal consistency, content validity, criterion pain  Reliability  Validity
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 Introduction
pain. This diagnosis was confirmed with CT-guided
sacroiliac joint anaesthetic block. The sacroiliac joint has been reported to be the cause of
Results The overall Majeed score showed acceptable in- symptoms in up to 22 % of patients referred with non-
ternal consistency (Cronbach alpha = 0.63). Similarly, it specific back, pelvic or buttock pain [1]. Thus, the surgical
showed acceptable floor (0 %) and ceiling (0 %) effects. management of sacroiliac joint pain has recently received
On the other hand, the domains of pain, work, sitting and much attention with reports of techniques such as open or
sexual intercourse had high ([30 %) floor effects. Signif- percutaneous sacroiliac joint fusion and stabilisation [2, 3].
icant correlation with the physical component of the Short Outcome assessments for the treatment of sacroiliac joint
Form-36 (p = 0.005) and Oswestry disability index pain have involved the use of generic measures including
(p B 0.001) was found indicating acceptable criterion health-related quality-of-life scales EuroQol-5D (EQ-5D),
validity. The overall Majeed score showed accept- Short Form (SF)-12 or SF-36, as well as disease-specific
able construct validity with all five developed hypotheses measures including the Oswestry disability index (ODI); a
showing significance (p B 0.05). The overall Majeed score widely used outcome measure to quantify disability in back
showed acceptable responsiveness to change with a large pain patients and the Majeed scoring system [4, 5]. The
(C0.80) effect size and standardized response mean. latter is a pelvis-specific measure that was developed and is
Conclusion Overall the Majeed scoring system demon- routinely used in the assessment of outcome following the
strated acceptable psychometric properties for outcome pelvic injuries [6, 7]. This contains seven items divided in
assessment in chronic sacroiliac joint pain. Thus, its use in five domains with the following weightings: pain (30),
this condition is adequate. However, some domains 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
& Stefan Bajada overall score of 0100 is calculated (in patients previously
stefan_bajada@yahoo.com
working before injury) with 054 indicated poor results;
1
Trauma and Orthopaedic Department, Cardiff and Vales 5569 a fair result; 7084 a good result and 85100 an
NHS Trust, Cardiff, UK excellent result [8].

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Outcomes in clinical studies are highly reliant on only patients who had at least one positive result (signifi-
patient-reported outcome measures. Therefore the use of cant decrease in pain levels even if temporary) from a CT-
instruments whose psychometric properties have been guided sacroiliac joint injection were included. A subset of
rigorously established for the condition it is meant to this cohort (28 patients) underwent percutaneous sacroiliac
measure is essential; without these clinical studies may joint fusion utilising SI-LOK (Globus Medical, Alton,
come under question [9]. Important and accepted psycho- UK) hydroxyapatite coated screws in a technique similar to
metric properties include reliability, validity and respon- previously described [4]. As part of the rehabilitation
siveness. Reliability defines whether the measure is protocol, these patients prospectively completed post-op-
dependable and reproducibility. Validity refers to an erative scores including SF-36, ODI, Majeed and EQ-5D-
instrument ability to measure what it is supposed to mea- 5L at a mean of 14 months. Post-operative review
sure. Validity consists of several types including content including routine radiographs rather than CT scans there-
validity (floor and ceiling effects), criterion validity (how fore fusion was not assessed in this study. The data were
an instrument compares to an accepted gold-standard collected and maintained prospectively in a computerized
instrument), and construct validity (if the instrument fol- database by an independent researcher.
lows expected non-controversial hypotheses). Responsive-
ness to change is the ability of the instrument to detect Internal consistency
clinically important changes following intervention [10].
To our knowledge there are no outcome instruments Pre-operative Majeed scores were used to establish overall
specifically designed or psychometrically assessed for internal consistency for the main domains and subcate-
sacroiliac joint pain due to dysfunction or degeneration. gories. A Cronbach alpha of [0.60 was considered
Thus, the aim of this study is to establish the psychometric acceptable [10].
properties of the Majeed scoring system specifically for
this condition. Content validity

Pre-operative Majeed scores were used to establish content


Patients and methods validity as previously described [10]. Floor effects (the
proportion of patients who obtain the lowest possible score)
Study groups and ceiling effects (the proportion of patients who obtain
the highest possible score) were determined for the overall,
The study group consisted of 60 patients who were diag- the five main domains and three subcategories of the
nosed with sacroiliac joint pain between February 2013 and Majeed score. Floor and ceiling effects of \30 % were
February 2015. All causes of sacroiliac joint pathology considered acceptable.
were included (including post-pregnancy dysfunction,
sacroiliac osteoarthritis and inflammatory arthropathy).
Criterion validity
The diagnosis was made following a corroborative history,
physical assessment and radiological investigations indi-
Criterion validity was determined utilising pre-operative
cating that the sacroiliac joint was the main source of pain.
Majeed scores. Correlation of the overall Majeed score to
The patients generally complained of buttock pain with
the physical component of the SF-36 health-related quality-
referral of pain to ipsilateral anterior/posterior thigh or
of-life scale was performed. The ODI, an outcome measure
groin. The patients usually complained of diminished
in back pain patients, was also correlated.
endurance capacity for standing, walking and sitting. This
had a detrimental effect on the patients working, family
Construct validity
and social life. Clinical examination included a combina-
tion of positive sacroiliac joint provocation tests [11].
Pre-operative Majeed scores were used to establish con-
Patients had a combination of plain radiographs, computed
struct validity. Five hypotheses (constructs) were devel-
tomography (CT), isotope bone scans and magnetic reso-
oped with consensus and were tested in this cohort as
nance imaging (MRI). There is poor evidence on the ability
follows:
of these investigations to confirm sacroiliac joint pathol-
ogy; however, they were helpful to diagnose degeneration 1. Patients with higher pain levels are expected to have
or to exclude other conditions. In clinical practice and lower overall Majeed scores. Pain levels were mea-
supported by current literature, the gold standard in diag- sured on a 5-point ordinal scale, with 1 point indicating
nostic accuracy of sacroiliac joint disease is a CT-guided no pain or discomfort and 5 points indicating extreme
sacroiliac joint anaesthetic block [12]. Thus, in this study, pain or discomfort.

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

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