









































EVIDENCE-TO-PRACTICE REVIEW 
 

 

Best Practices for Clinical Evaluation of Sacroiliac Joint Pain: An 
Evidence-to-Practice Review 
Nicolette A. Harris, DAT, LAT, ATC, CSCS*; Adriana Peña, MS, LAT, ATC†; and Sofia Núñez Rivera, MS, 
LAT, ATC 
*Florida International University, Miami; †Sports Leadership and Management Academy, Miami, FL 

 
 
 

ABSTRACT 

Sacroiliac joint (SIJ) pain serves as an under-recognized 
source of chronic low back pain. Improvement in the accuracy 
of a clinical SIJ pain diagnosis lends a higher likelihood of 
appropriate treatment measures, better patient outcomes 
and decreased out-of-pocket costs. Therefore, the overall 
purpose of this evidence to practice review was to highlight 
the main points of a systematic review on the clinical 
diagnosis of SIJ pain. Searches of five electronic databases 
revealed 758 studies, nonetheless only six studies met final 
inclusion criteria. Studies included were assessed by the 
authors for methodological quality using the Quality 
Assessment of Diagnostic Accuracy Studies (QUADAS) tool. 
Evidence suggests pain provocation tests including distraction, 
thigh thrust, compression, sacral thrust, and Gaenslen’s are 
minimally useful individually at diagnosing sacroiliac joint 
pain. The thigh thrust test was the most sensitive and the 
distraction test was most specific. Furthermore, the 
compression test carried the strongest positive likelihood 
ratio. The highest likelihood ratio was reported when three or 
more of the following pain provocation tests were positive: 
distraction, compression, thigh thrust, sacral thrust, and 
Gaenslen’s test for both the right and left sides. A 
comparable likelihood ratio was found when any two of the 
remaining four tests were positive after excluding the left and 
right-side applications of the Gaenslen’s test. Prior to the 
performance of pain provocation tests, research suggests 
using McKenzie Mechanical Diagnosis and Therapy to 
exclude pain of disc origin. The use of safe, efficient, and 
clinically effective diagnostic evaluation techniques is 
essential to the provision of high-quality patient care. 
Key Phrases 
Diagnostic testing and physical examination: spine, thorax, 
and abdomen; low back pain; sacroiliac joint 

 
Correspondence 
Dr. Nicolette A Harris, Florida International University, 
11200 SW 8th St, WRC 145, Miami, FL 33199. 
E-mail: nstallwo@fiu.edu 
Twitter: @YoungProf_AT 

 
Full Citation 
Harris NA, Peña A, Núñez Rivera S. Best practices for clinical 
evaluation of sacroiliac joint pain: An evidence to practice 
review. Clin Pract Athl Train. 2021;4(1): 17-23. 
https://doi.org/10.31622/2021/0004.1.3.  
Submitted: August 17, 2020 Accepted: October 1, 2020. 

 
17 

ORIGINAL REFERENCE 
 

Sivayogam A, Banerjee A. Diagnostic 
performance of clinical tests for sacroiliac joint 
pain. Phys Ther Rev. 2011;16(6):462-467. 

SUMMARY 
 

CLINICAL PROBLEM AND QUESTION 
 

Approximately 10-30% of all low back pain is 

originated from the sacroiliac joint (SIJ).1 The SIJ is 
a large, auricular-shaped, and arthrodial synovial 
joint formed by the connection of the sacrum to the 
right and left iliac bones.2 The primary function of 
the SIJ is to absorb shock and transfer forces 
between the upper and lower extremities.3 More 
extensive dorsally, the ligaments of the SIJ 
function to limit motion in all planes.3 While the SIJ 
lacks significant range of motion, patients may 
possess hypomobility or hypermobility of the SIJ 
articulation.2 The most common mechanism for 
acute SIJ pain results from a combination of axial 
compression and rapid rotation, such as with 
twisting while carrying a heavy object or falling.1 

However, most athletes will experience a slow and 
progressive onset of symptoms resulting from 
repetitive activity performed over time.1 Common 
pathologies arising from the SIJ include: sprains, 
strains and dysfunction of the joint secondary to 
insufficient or excessive mobility.1 Factors that 
increase the risk of these conditions include leg 
length discrepancy, antalgic gait, scoliosis, and 
prolonged vigorous exercise.1 This multitude of 
triggers, makes low back pain of SIJ origin 
extremely challenging for the health care 
provider to clinically diagnose. 

Copyright © by Indiana State University Clinical Practice in Athletic Training 
All rights reserved. ISSN Online 2577-8188 Volume 4 – Issue 1 – February 2021 

mailto:nstallwo@fiu.edu
https://doi.org/10.31622/2021/0004.1.3


Best Practices for Clinical Evaluation of Sacroiliac Joint Pain: An Evidence-to-Practice Review 

18 
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All rights reserved. ISSN Online 2577-8188 

Clinical Practice in Athletic Training 
Volume 4 – Issue 1 – February 2021 

 

 

 

Regrettably, no single history presentation, clinical 
examination finding, or diagnostic imaging 
technique can definitely establish a diagnosis of 
sacroiliac joint pain.4 However, previous research 
has studied these measures in an effort to improve 
accuracy in the diagnosis of SIJ pain.5 While many 
publications have referenced controlled local 
anesthetic blocks as the best available tool to 
determine the source of SIJ pain, these measures 
are invasive and expensive, making them clinically 
unpractical for routine use in the ambulatory care 
setting.5 There are a variety of “special” tests 
used by clinicians in the evaluation and diagnosis 
of SIJ pain. These include motion palpation and 
pain provocation tests.6 Numerous studies have 
proposed palpation as a method to assess 
movement or asymmetry at the SIJ.7 However, 
generally their inter-examiner reliability has 
shown poor.7 This leaves clinicians to rely on pain 
provocation tests, which stress the structures of the 
SIJ and provoke reproduction of symptoms, as 
measures of non-invasive clinical evaluation of SIJ 
pain.7 Common pain provocation tests used for 
clinical evaluation include distraction, compression, 
sacral thrust, thigh thrust, and Gaenslen’s tests in 
addition to a host of others.7 The diagnostic 
accuracy of pain provocation tests has been 
called into question for its inability to discriminate 
pain of sacroiliac origin as compared to the 
reference standard.7 Consequently, clinicians must 
be aware of both the sensitivity, or ability to 
distinguish subjects with the disease, as well as the 
specificity, or the ability to identify patients 
without the disease associated with the tests used 
for effective diagnosis of SIJ pain.8 

Therefore, the overall purpose of the guiding 
paper was to systematically review and 
synthesize evidence associated with the clinical 
diagnosis of SIJ pain. More precisely, this 
Evidence to Practice Review aims to remedy the 
following research question: In patients with low 
back pain, which clinical evaluation tests are most 
accurate for diagnosing pain of sacroiliac origin? 

SUMMARY OF LITERATURE 
 

Authors of the systematic review performed a 
methodical search of MEDLINE, Scopus, AMED, 
CINAHL, and EMBASE databases to determine the 
diagnostic performance of clinical tests for SIJ 
pain. Searches were filtered to include only 
articles published in English between 1990 and 
2011. Studies specifically addressing SIJ 
dysfunction rather than SIJ pain were excluded. 
Single articles were included in the systematic 
review according to the following criteria: (1) 
patients were at least 18 years old, (2) had non- 
specific and non-pregnancy related low back 
pain and/or buttock pain with or without radiation 
into the lower extremity, (3) used clinical tests with 
clear definitions of positive and negative test 
results, and (4) provided sensitivity and specificity 
data. Initially 758 studies were identified, 
however 752 were excluded for failing to meet 
selection criteria. Of the six studies included, two 
studies evaluated the validity of each individual 
test; three studies evaluated the validity of 
several composites of tests; and one study 
evaluated the validity of both individual and 
composites of tests. All six of the studies included 
used a contrast-enhanced intra-articular 
anesthetic block as the reference standard. The 
number of patients enclosed in the studies ranged 
from 34 to 140 with a mean age between 42 and 
51 years old. 

SUMMARY OF OUTCOMES 
 

Studies included in the guiding systematic review 
were assessed for methodological quality 
autonomously by both authors using the Quality 
Assessment of Diagnostic Accuracy Studies 
(QUADAS) tool. The QUADAS tool consists of 14 
items which can be answered with a yes, no, or 
unclear. Nine of the 12 items relate to bias, while 
three of the 12 items related to the quality of the 
reporting and two of the 12 items conveyed 
variability. Intra-articular administration of an 
anesthetic block into the SIJ bilaterally was 



Best Practices for Clinical Evaluation of Sacroiliac Joint Pain: An Evidence-to-Practice Review 

19 
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Clinical Practice in Athletic Training 
Volume 4 – Issue 1 – February 2021 

 

 

 

agreed upon by the authors as the best available 
reference standard for fulfilling QUADAS item 
number 3 and correctly classifying SIJ pain. 
Furthermore, to achieve item number 4 of the 
QUADAS and to rule out spontaneous recovery or 
progression to more severe pain, the acceptable 
gap was agreed on by both authors as no more 
than seven days between performance of clinical 
and reference tests. Items 1,5, 10, 11, and 12 
were scored using a 3 for yes; items 3 and 6 were 
marked 2 for yes; and all other items were 
counted 1 for yes.6 A quality score of 17 was 
assigned to five of 6 items, while a quality score 
of 18 was allocated to the sixth study.6 

FINDINGS AND CLINCIAL IMPLICATIONS 
 

The systematic review guiding this paper aimed to 
assess the diagnostic performance of clinical tests 
commonly used to evaluate SIJ pain. For each 
clinical test, sensitivity and specificity were 
documented. In addition, positive predictive 
values (PPV) were included to describe how often 
a positive finding was correct, while negative 
predictive values (NPV) were provided to 
consider the accuracy of a negative test result. 
Furthermore, positive and negative likelihood 
ratios were extracted when available. Positive 
likelihood ratios (LR+) were used to provide 
confidence in the fact that the pathology was 
present when a test was positive. Likewise, 
negative likelihood ratios (LR-) express the 
probability that the condition was present despite 
a negative result on the diagnostic test. Evidence 
revealed that when used in isolation, most clinical 
tests had poor diagnostic performance.9 Clinical 
tests including the Gillet, pain over SIJ or groin or 
buttock, sitting position, posterior superior iliac 
spine pointing, sacral spring, and sacral sulcus 
revealed poor clinical utility as result of low 
specificity, low sensitivity, and positive likelihood 
ratio.9 However, the high sensitivity and specificity 
values of FABER, thigh thrust, and resisted 
abduction may make these tests better indicators 
of SIJ pathology.10 Furthermore, evidence 

suggests pain provocation tests including 
distraction, compression, thigh thrust, sacral thrust, 
and Gaenslen’s are not effective predictors of a 
positive intra-articular SIJ anesthetic block when 
used alone without any other tests.11 However the 
thigh thrust test was most sensitive, while 
distraction test was most specific and compression 
test carried the strongest positive likelihood ratio 
(Table 1).6,11 

Clinicians should choose a composite of tests which 
may strengthen the likelihood of an accurate 
clinical diagnosis. Evidence suggests an optimal 
ratio of pain provocation tests composites which 
can provide high specificity paired with low 
sensitivity while still maintaining a high likelihood 
ratio.11, 12 The highest likelihood ratio was 
reported when three or more of the following pain 
provocation tests were positive: distraction, 
compression, thigh thrust, sacral thrust, and 
Gaenslen’s test for both the right and left sides.11 

A comparable likelihood ratio was found when 
any two of the remaining four tests were positive 
after eliminating the left and right-side 
applications of the Gaenslen’s test (Figure 1).11 

The inclusion of positive and negative likelihood 
ratios in the individual studies helped to formulate 
the conclusion that when in the presence of pain 
below the lumbosacral region or groin, the three 
prime tests for diagnosis for SIJ pain are 
distraction, thigh thrust and compression.6 Only 
after all six SIJ pain provocation tests are 
negative, can SIJ pain be ruled out.11 Using clinical 
examination techniques with high diagnostic 
accuracy can eliminate or significantly reduce the 
need to refer patients for diagnostic imaging. 
Safe, effective, and efficient diagnostic 
techniques can help improve the quality of care. 
Furthermore, the use of clinical evaluation 
techniques can decrease health care costs, making 
care more equitable for everyone. 

To further reduce false positives, research 
suggests using the McKenzie evaluation to exclude 
pain of disc origin prior to the performance of 



Best Practices for Clinical Evaluation of Sacroiliac Joint Pain: An Evidence-to-Practice Review 

20 
Copyright © by Indiana State University 
All rights reserved. ISSN Online 2577-8188 

Clinical Practice in Athletic Training 
Volume 4 – Issue 1 – February 2021 

 

 

 
 
 

Table 1. Summary of Diagnostic Accuracy for Individual Clinical Tests of Sacroiliac Joint Pain 
 

Intervention Study Sensitivity (95% CI) Specificity (95% CI) + LR† 

Thigh thrust Dreyfuss et al.8 0.36 0.50  
 Broadhurst and 

Bond9 

0.80 1.00  

 Laslett et al.10 0.88 (0.64–0.97) 0.69 (0.82) 2.20 

Gaenslen’s Dreyfuss et al.8 0.71 0.26  
 Laslett et al.10 0.53 (0.30–0.75) R 0.71 (0.53–0.84) R 1.84 
  0.50 (0.27–0.73) L 0.77 (0.60–0.89) L 2.21 
Sacral thrust Dreyfuss et al.8 0.53 0.29  

 Laslett et al.10 0.63 (0.39–0.82) 0.75 (0.58–0.87) 2.50 
Distraction test Laslett et al.10 0.60 (0.36–0.80) 0.81 (0.65–0.91) 3.20 

Compression Laslett et al.10 0.69 (0.44–0.86) 0.69 (0.51) 2.20 
Note: *CI: confidence interval. 
†+LR: positive likelihood ratio. 

 

pain provocation tests.13 McKenzie Mechanical 
Diagnosis and Therapy (MDT) is a well-studied 
technique which utilizes repeated movements to 
assess musculoskeletal disorders of the spine and 
extremities.14 By performing repeated movements 
during the examination, patients may develop a 
direction of preference (e.g., truck flexion, 
extension, or lateral bending) that is correlated to 
a movement which centralizes the pain from the 
extremities to the spinal midline.14,7 Centralization 
has been reported as highly specific to discogenic 
pain, yet is not observed in patients with 
confirmed pain of sacroiliac origin.7 Therefore, we 
strongly recommend the prerequisite use of MDT 
by clinicians to rule out discogenic pain prior to 
evaluation of the SIJ using pain provocation tests. 
Moreover, current research suggests MDT can also 
be used in adjunct to pain provocation tests to as 
a method of alleviating pain and further 
strengthening SIJ pain diagnoses.14 Patients may 
be further classified with SIJ pain when repeated 
anterior and posterior innominate rotation 
movements alleviate pain and symptoms from the 
region of the posterior superior iliac spine (PSIS).14 

 

CLINICAL BOTTOM LINE 
 

Diagnostic tests are a critical component of health 
care. Information on the accuracy of diagnostic 
tests can help in clinical decision-making and assist 
in the provision of safe, timely, effective, efficient, 
and equitable care. Based on the findings of this 
review, we suggest a framework for improved 
diagnosis in the evaluation of SIJ pain. Evaluation 
of pain below the lumbosacral or groin region 
should begin with a thorough patient history. 
Moving forward, a McKenzie MDT evaluation 
assessing for centralization should be performed 
to rule out pain of discogenic origin. This should be 
proceeded by the performance of 6 pain 
provocation tests: beginning with distraction, thigh 
thrust, and compression tests and continuing with 
the sacral thrust and Gaenslen’s test for both the 
right and left sides as needed. The receipt of 3 or 
more positive tests provide the optimal balance 
between high specificity, low sensitivity, and a 
high likelihood ratio. We believe use of this 
criterion is best practice for establishing a highly 
accurate SIJ pain diagnosis. Alleviation of the 
patient’s symptoms through repeated anterior and 
posterior innominate rotation may further validate 
diagnosis, but more research is needed to support



Best Practices for Clinical Evaluation of Sacroiliac Joint Pain: An Evidence-to-Practice Review 

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Copyright © by Indiana State University 
All rights reserved. ISSN Online 2577-8188 

Clinical Practice in Athletic Training 
Volume 4 – Issue 1 – February 2021 

 

 

this recommendation. It is our view that improved 
diagnostic accuracy will lead to a higher 
likelihood of appropriate treatment measures, 
resulting in decreased out-of-pocket costs, 
improved patient care, and enhanced patient 
outcomes. 

REFERENCES 
 

1. Peebles R, Jonas CE. Sacroiliac joint 
dysfunction in the athlete: Diagnosis and 
Management.  Curr  Sports Med Rep. 
2017;16(5):336-342. 
https://doi.org/10.1249/JSR.0000000000 
000410. 

2. Cohen SP. Sacroiliac joint pain: a 
comprehensive review of anatomy, diagnosis, 
and treatment. Anesth Analg. 
2005;101(5):1440-53. 

3. Vleeming A, Schuenke MD, Masi AT, Carreiro 
JE, Danneels L, Willard FH. The sacroiliac joint: 
an overview of its anatomy, function and 
potential clinical implications. J Anat. 
2012;221(6):537-67. 
https://doi.org/10.1213/01.ANE.0000180 
831.60169.EA. 

4. Chauhan G, Hehar P, Loomba V, Upadhyay 
A. A Randomized Controlled Trial of 
Fluoroscopically Guided Sacroiliac Joint 
Injections: A Comparison of the 
Posteroanterior and Classical Oblique 
Techniques. Neurospine. 2019;16(2):317- 
324. 

5. Simopoulos TT, Manchikanti L, Gupta S, et al. 
Systematic Review of the Diagnostic accuracy 
and therapeutic effectiveness of sacroiliac 
joint interventions. Pain Physician. 2015;18(5): 
E713-56. 
https://pubmed.ncbi.nlm.nih.gov/26431129 
/. 

6. Sivayogam A, Banerjee A. Diagnostic 
performance of clinical tests for sacroiliac 

joint pain. Phys Ther Rev. 2011;16(6):462- 
467. 
https://doi.org/10.1179/1743288X11Y.00 
00000036. 

7. Laslett M. Evidence-based diagnosis and 
treatment of the painful sacroiliac joint. J Man 
Manip Ther. 2008;16(3):142-52. 
https://doi.org/10.1179/jmt.2008.16.3.14 
2. 

8. Šimundić AM. Measures of diagnostic 
accuracy:  basic definitions.  EJIFCC. 
2009;19(4):203-11. 
https://www.ncbi.nlm.nih.gov/pmc/articles/P 
MC4975285/. 

9. Dreyfuss P, Michaelsen M, Pauza K, McLarty 
J, Bogduk N. The value of medical history and 
physical examination in diagnosing sacroiliac 
joint pain. Spine 1996; 21:2594–602. 
https://doi.org/10.1097/00007632- 
199611150-00009. 

10. Broadhurst NA, Bond MJ. Pain provocation 
tests for the assessment of sacroiliac joint 
dysfunction. J Spinal Disord 1998; 11:341–5. 
https://pubmed.ncbi.nlm.nih.gov/9726305/. 

11. Laslett M, Aprill C, McDonald B, Young S. 
Diagnosis of sacroiliac joint pain: validity of 
individual provocation tests and composites of 
tests. Man Ther. 2005; 10:207–18. 
https://doi.org/10.1016/j.math.2005.01.00 
3. 

12. van der Wurff P, Buijs EJ, Groen GJ. A 
multitest regimen of pain provocation tests as 
an aid to reduce unnecessary minimally 
invasive sacroiliac joint procedures. Arch Phys 
Med Rehabil 2006; 87:10–4. 
https://doi.org/10.1016/j.apmr.2005.09.0 
23. 

13. Laslett M, Young SB, Aprill CN, Mcdonald B. 
Diagnosing painful sacroiliac joints: A validity 
study of a McKenzie evaluation and sacroiliac 

https://doi.org/10.1249/JSR.0000000000000410
https://doi.org/10.1249/JSR.0000000000000410
https://doi.org/10.1213/01.ANE.0000180831.60169.EA
https://doi.org/10.1213/01.ANE.0000180831.60169.EA
https://pubmed.ncbi.nlm.nih.gov/26431129/
https://pubmed.ncbi.nlm.nih.gov/26431129/
https://doi.org/10.1179/1743288X11Y.0000000036
https://doi.org/10.1179/1743288X11Y.0000000036
https://doi.org/10.1179/jmt.2008.16.3.142
https://doi.org/10.1179/jmt.2008.16.3.142
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4975285/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4975285/
https://doi.org/10.1097/00007632-199611150-00009
https://doi.org/10.1097/00007632-199611150-00009
https://pubmed.ncbi.nlm.nih.gov/9726305/
https://doi.org/10.1016/j.math.2005.01.003
https://doi.org/10.1016/j.math.2005.01.003
https://doi.org/10.1016/j.apmr.2005.09.023
https://doi.org/10.1016/j.apmr.2005.09.023


Best Practices for Clinical Evaluation of Sacroiliac Joint Pain: An Evidence-to-Practice Review 

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All rights reserved. ISSN Online 2577-8188 

Clinical Practice in Athletic Training 
Volume 4 – Issue 1 – February 2021 

 

 

 

provocation tests. Aust J Physiother. 
2003;49(2):89-97. 
https://doi.org/10.1016/s0004- 
9514(14)60125-2. 

14. Srivastava S, Kumar DK, Mittal H, Dixit S. 
Short-term effect of “Mechanical Diagnosis 
and Therapy” in the management of 
sacroiliac joint pain. J Clin Diagn Res. 
2018;12(8): 1-4. 

15. Petersen T, Laslett M, Juhl C. Clinical 
classification in low back pain: best-evidence 
diagnostic rules based on systematic reviews. 
BMC Musculoskelet Disord. 2017;18(1):188. 

16. Stanford G, Burnham RS. Is it useful to repeat 
sacroiliac joint provocative tests post-block? 
Pain Med 2010; 11:1774–6. 
https://doi.org/10.1111/j.1526- 
4637.2010.00968.x. 

https://doi.org/10.1016/s0004-9514(14)60125-2
https://doi.org/10.1016/s0004-9514(14)60125-2
https://doi.org/10.1111/j.1526-4637.2010.00968.x
https://doi.org/10.1111/j.1526-4637.2010.00968.x


Best Practices for Clinical Evaluation of Sacroiliac Joint Pain: An Evidence-to-Practice Review 
 

 

23 
Copyright © by Indiana State University                                                                                          Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                             Volume 4 – Issue 1 – February 2021 
 

   Figure 1. Diagnostic Algorithm for Sacroiliac Joint Pain  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

Pain below 
lumbosacral and/or 

groin region6 

Pain at PSIS15 

Centralization 
via MDI14 Distraction Thigh Thrust Compression Sacral Thrust Gaenslen’s 

Evaluate 
for Disc 

Pathology 

Evaluate 
for Disc 

Pathology 

Thigh Thrust Compression 

Compression 

Sacral Thrust 

Sacral Thrust 

Gaenslen’s 

Gaenslen’s 

SIJ Pain Diagnosis 
One or more 

positive tests11,6 
 

Sensitivity (95% CI) 
1.00 

Specificity (95% CI) 
0.44 

LR+ 1.78 
 

SIJ Pain Diagnosis 
Two or more 

positive tests11,6 
 

Sensitivity (95% CI)   
0.93 

Specificity (95% CI) 
0.66 

LR+ 2.73 
 
 

SIJ Pain Diagnosis 
Two or more positive tests11,6 

 
Sensitivity (95% CI)   0.93 
Specificity (95% CI) 0.66 

LR+ 2.73 
 
 

 NO 

(-) 

 NO 

(-) 

NO 

(-) 

NO 

(-) 

NO 

(-) 

YES 

(+) 

NO    (-) 

YES    (+) YES    (+) YES    (+) YES    (+) YES    (+) YES    (+) 

YES    (+) YES    (+) YES    (+) 

NO 

(-) 

NO 

(-) 

NO 

(-) 

YES    (+) YES    (+) YES    (+) 

NO 

(-) 

NO 

(-) 

YES    (+) 

MDT: McKenzie Mechanical 
Diagnosis and Therapy 
CI: Confidence Interval 
LR+: Positive Likelihood 
Ratio 


	Harris_Production
	ABSTRACT
	ORIGINAL REFERENCE
	SUMMARY
	SUMMARY OF LITERATURE
	SUMMARY OF OUTCOMES
	FINDINGS AND CLINCIAL IMPLICATIONS
	CLINICAL BOTTOM LINE
	REFERENCES

	Harris_102_Figure 1 - Final

