Re: Diagnosis and Palpation in Manual Tx

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Yogi -> Re: Diagnosis and Palpation in Manual Tx (March 4, 2005 3:35:00 AM)
Barrett, my thought is that asymmetry may be pathological, or not. If there is pain in that area, then it may be a possible source for a neural deformation and resultant chemical irritation. At that point, treatment to correct the traumatic displacement (of whatever) to resume the individuals normal alignment is likely to relieve the tension, and resolve the pain. Many times I believe the abnormal neural tension is a result of a reflexive muscle contraction holding the malalignment chronically, after the original tissue injury has healed. That, of course, goes back to the old pain-spasm-pain theory. Since I have seen a neural entrapment last seven years, with immediate pain relief and normal active range after the nerve was released, I believe that my theory has some validity. Which is why I sort of think that MET and Srain/Counterstrain, Positional Release, as indirect techniques should affect the muscle tension, and that may allow the bony realignment (I've visually seen a spinous process realign post S/CS treatment, with immeiate pain relief), without a direct treatment to force realignment. I wonder what effect the rapid force has on the contractile tissue. Feedback is appreciated if you feel like it. Thanks.

JLS_PT_OCS -> Re: Diagnosis and Palpation in Manual Tx (March 4, 2005 5:53:00 AM)
I do think that a biomechanical/symmetry model may be a fair place to start if EBM/other methods aren't working. That is, if acute patient fails to improve with general manipulation/pain control, then perhaps a more specific technique aimed at that "problem" may have some value. But as a stand-alone paradigm to direct diagnosis/treatment, there seems to be little to recommend it at all. Having read several sources about asymmetry not being at all related to pain syndromes and/or predictive of recovery from such, I would be interested in some more of Roger's feedback as to why he teaches/ practices the way he does, and if he sees that as in line with the current best evidence. Roger, thanks for your kind reply, and again I appreciate your willingness to discuss this with all of us... J

Yogi -> Re: Diagnosis and Palpation in Manual Tx (March 4, 2005 6:42:00 AM)
Jason, I really appreciate the sudy you posted, but I don't get the same conclusion from it you did. I thought it showed clinical indicators for SMT treatment of pelvic assymetry, just as Flynn's did for LBP, so i thought you would argue for it as EBM. . . Conclusions: Frontal Plane PA and WBA were associated with a successful response to SMT. Clinical Relevance: Findings of this study may help identify a priori pts. who are likely to respond to SMT. Next you stated the clinical indicators yourself "Looking at predictive variables you had to have a sigificant pelvic (6mm) or weight bearing assymetry to benefit. "Perhaps like a lateral shift"? H. Duane Saunders illustrated two positional responses to disc bulges in the spine, scoliosis and lateral shift. Are you thinking of what I call an oblique takeoff, which does occur from a pelvic obliquity? Regardless, then your conclusion is that the study is "some more evidence that treating the assymetry may not be the way to go". Maybe not always, but again, my interpretation here is the study indicates when it may be the way to go, with a clinical indicator that corresponds to many PT's clinical experience. Here's a question for all. History of fall backwards on the right ischium. You measure in supine 2 cm.s less distance right ASIS to umbilicus than on the left. They complain of back pain since the fall, increased with weightbearing and walking. Tenderness to pressure along the right SI joint. Fall was six months ago, they had PT treatment of hot pack,e-stim, and US, and back exercises at a hosp OP clinic. Now you have a referral, OK, what's everyone going to do for treatment?

Pelfixer1 -> Re: Diagnosis and Palpation in Manual Tx (March 5, 2005 4:54:00 AM)
Dear Shill/Steve: Sorry I took so long to get back to you. I have read Pam's article regarding assemetry of the pelvis and the relationship (or lack of) to pain. First I have some thoughts about assessing the assymetry's. Measuring leg/extremity length from the asis's to the medial malleoli is not an accurate method of measuring extremity length. By using these two landmarks you are including the sacroiliac joint into the equation. The most accurate way of measuring extremity length is a standing radiograph, that measures from the femoral head (say the center) to a calcaneous. By using the asis you are measuring across the sacroiliac joint, which may be out of alignment. For example, if the the left ilium is malaligned (posteriorly rotated), the asis on that side is in an elevated position in comparison to the rignt and would affect your measurements. Extremity length differences are the result of malalignments at the pubic symphysis. For example, a elevated right pubis will cause a shortening affect on the right lower extremity. A depressed pubis (although rare) causes a lengthening affect on an extremity. An elevated crest and a shortened extremity on the same side is not due an upslip of the ilium. The illium does not upslip and this is inaccurate information. How assemetry's of the pelvis were measured is not my major concern. We know there were assymetry's regardless of how they were assessed. I do have concern about he conclusions reached. I assessed over 3,000 patients referred to me in my practice for pelvic, lowback, upper back, cervical spine, headache, Facial/TMJ, shoulder, knee and and foot pain. I took very detailed records on each patient that included the alignments of the asis's, extremity lengths, body posture faults, muscle imbalances, pain patterns, patient comments/reactions to treatment. After a period of time studying the information gathered, I was not only able to associate assymetry with specific pelvic malalignments, body postue fault, pain patterns and musculoskeletal expressions (muscle strength and length imbalances/restricted joint motion). For example, the ilial outflares are associated with lower extremity problems of the hip, knee and foot, posterior rotations are associated with spine-associated problems in the frontal and horizonal planes such as low back pain, scoliosis, shoulder problems such as impingement problems opposite the side of the posterior rotation, whereas malalignments of the pubis (elevations (90+% of the time affect the spine in the saggital plane such as low/upper back/cervical spine pain, headaches, facial pain/TMJ dysfuction/malocclsion. I would conclude from my clinical experiences that not only are pelvic assymetry/body posture faults associated with pain, but with specific treatment diagnoses that physical therapists see/treat on a daily basis. Thanks for asking my opinion!

Diane -> Re: Diagnosis and Palpation in Manual Tx (March 5, 2005 5:36:00 AM)
Hurray Roger, for starting to catagorize all this stuff to help us all be more systematic detectives. I agree that pubes are overlooked as being associated with asymmetry further 'upstream'. (It's not the pubes fault, don't blame them.. they are "behaving"that way according to some sort of abnormal muscular pull on them, as per Chris...) Yogi, [QUOTE]Here's a question for all. History of fall backwards on the right ischium. You measure in supine 2 cm.s less distance right ASIS to umbilicus than on the left. They complain of back pain since the fall, increased with weightbearing and walking. Tenderness to pressure along the right SI joint. Fall was six months ago, they had PT treatment of hot pack,e-stim, and US, and back exercises at a hosp OP clinic. Now you have a referral, OK, what's everyone going to do for treatment?[/QUOTE]Scuse me if I speak a language learned long ago that has since been surpassed. I would check leg length.. if legs were even I would treat for an inflare. If ASISs didn't even up after that I would definitely check pubes and treat those. If there was full range of the spine I wouldn't bother going there. I'd go mop up "tenderness" in the SI area with treatment directed toward superficial layer neuromodulation. If there was still some sort of pain on movement I'd apply kinesio tape in some creative way that would allow full painfree movement, then have the patient wear it for 4 or 5 days to 'relearn' normal painfree movement.

Pelfixer1 -> Re: Diagnosis and Palpation in Manual Tx (March 5, 2005 7:03:00 AM)
Diane: Once again,a fall on the buttocks will elevate the pubes (one or both) and this can be in varying degrees. Do not measure extremity length from asis to medial malleolus,for reasons stated in my previous post, because it is not the best way to measure extremity length. Instead, compare right to left height of the malleoli with the patient in supine. If the right one is shorter, then use a muscle energy technique that will descend it. Then assess the extremity length again and if the left is the short extremity, correct it; you know the patient had a bilaterally elevated pubis. Thanks!

Diane -> Re: Diagnosis and Palpation in Manual Tx (March 5, 2005 7:20:00 AM)
No no, thank you Roger!

chiroortho -> Re: Diagnosis and Palpation in Manual Tx (March 5, 2005 8:52:00 AM)
Very, very impressed with this thread. DCs have traditionally looked at leg lengths differently, and I appreciate the different approaches here. The prone leg check that I was trained to do hasn't made sense to me for YEARS, and I jettisoned it long ago.

dosrinc4 -> Re: Diagnosis and Palpation in Manual Tx (March 6, 2005 2:30:00 AM)
Roger, I was just about to ask: If both pubes are elevated, how would you know? Then read your next post. It is impressive that you are so confident that what you percieve as fact is actually factual. Many of your statements of fact can certainly be argued to the contrary, for example you state that measuring leg length is unreliable yet you rely on ASIS and/or malleolar height as an indicator of symmetry, haven't these bony landmark observations also been deemed unreliable? Don't get me wrong, I appreciate your obvious work and your contributions to the knowledge base, I just think we need to be careful about making statements of fact out of things that we can't prove to be true. Continued learning to us all. Rick

Pelfixer1 -> Re: Diagnosis and Palpation in Manual Tx (March 6, 2005 3:39:00 AM)
Dear Rick: Thank you for your question. Compare extremity lengths at the medial malleoli. The only way you know if both pubs are elevated is to manually correct/descend the pub that is elevated, then check the alignment again. If you then find that the extremity is short on the opposite side, your patient has/had a bilaterally elevated pubis. If you check the extremity lengths,and they have physical symptoms such as upper back, neck, head pain, TMJ, and they are both of equal length, perform the muscle energy technique on one side, check the extremity length again and see then if they are now short on the opposite side you just corrected. Hope that is a clear explanation.

Pelfixer1 -> Re: Diagnosis and Palpation in Manual Tx (March 6, 2005 4:08:00 AM)
Dear Rick: Sorry, I didn't address the other questions in your post. What I said was using the asis as a landmark to measure extremity length is an incorrect method because the measurement then involves the si joint--if the si joint is out of alignment (most likely posteriorly rotated)it makes your measurement inaccurate. Now, if both si joints were aligned, I would have less of a problem using the asis'. Movement of the pubic symphysis and sacroiliac joints are independent of each other, one movement does not effect the other's movement, in other words,(for example) elevated pubs do not affect movement at the sacroiliac joint and outflares of the ilium have no effect on the pubic symphysis. Evaluate and treat them as two seperate joints. Thanks again for you question.

steve -> Re: Diagnosis and Palpation in Manual Tx (March 6, 2005 5:50:00 AM)
Roger, Respectfully, I dont think you have answered Rick's question. Steve

Pelfixer1 -> Re: Diagnosis and Palpation in Manual Tx (March 6, 2005 6:15:00 AM)
Dear Steve: Rick has not said that (yet). Thanks!

apolipo -> Re: Diagnosis and Palpation in Manual Tx (March 6, 2005 7:19:00 AM)
Roger, I'm not clear on how both sides of the pubic symphysis can be elevated. Elevated in relation to what? I can see how the left pubic bone could be elevated in relation to the right and vice versa, but both at the same time? Also, I don't understand how alignemnt of the SI jts. and the pubic symphysis have no effect on each other. The pelvis only has 3 bones and 3 jts. and it would seem logical that movement at one would effect the others. Since all three jts. have strong connective tissue support, a force strong enough or long enough to change the alignment of one must have some effect on the others. I will concede that my manual skills are not as well practiced or as skilled as yours, but I'm having trouble making sense of a few things. mike t

Alex Brenner PT MPT OCS -> Re: Diagnosis and Palpation in Manual Tx (March 6, 2005 7:23:00 AM)
Roger, You are obviously very experienced but I think you make a lot of "leaps of faith" in your pelvic alignment assessments. Could you provide some published research to back up some of your claims? I personally am just not satisfied with anecdotal evidence. Thanks, Army

Pelfixer1 -> Re: Diagnosis and Palpation in Manual Tx (March 6, 2005 8:45:00 AM)
Dear Mike: Elevations of the pubs occur in the frontal plane and also move slightly posterior in the sagittal plane and yes, they are evaluated in relation to each other,"Movement occured 2.6mm in the vertical direction and 1.3mm in the posterior direction (sagittal plane) using a force plate during one-leg standing". (Meissner, A,Fell, M., Wilk, R., et al, Unfallchirung, Jun;99 (6):415-21 (1996) A shortened lower extremity on the side of the elevated pubic is correlated/matched with the patient's imaging studies(A-P of pelvis) that shows the pubis elevated on the side of the short extremity. The elevation has a postural unilateral effect of flexing/flattening the L-S joint/ on that side,bilateral elevations---the same affect as doing a pelvic tilt. Palpating (there's that word) the L-S joint with the patient in prone shows a decrease in the depth of the L-S joint on the side of the elevation. Please keep in mind that you are also relying on your patient's history, the most significant clues are the types of activities and exercises they have been involved with ---those ground reaction forces that push the pubs upward such as running, lifting heavy objects, working on the knees, ladder climbing, falls on the buttocks, obesity, sitting for long periods of time, especially without thigh support, leg presses/using the stepper in the gym, as well as their physical symptoms, especially upper thoracic, cervical, head and facial/TMJ from the spine/head being projected forward. Elevations of the pubs rotate the ilium posteriorly (pelvic tilt-type motion), but not at the sacroiliac joint, because it's movement is in a different plane. Thanks for the question.

jma -> Re: Diagnosis and Palpation in Manual Tx (March 6, 2005 9:00:00 AM)
Now there is a study worth looking into. JMA

Pelfixer1 -> Re: Diagnosis and Palpation in Manual Tx (March 6, 2005 9:19:00 AM)
Dear Army: Your "leaps of faith" comment was not warranted (or deserved). I have taken "baby steps" for twenty years studying the pelvis and how it moves and how to correct the pelvic joint malalignments. If you had read my earlier post(s) when I said I took meticulous clinical records on over 3,000 of my private patients who came to me (not sent)and analyzed the data that lead me to my conclusions. I also stated early on that I currently plan to study the pelvic joints using 3D reconstruction software, starting with the pubic symphysis to determine if what I am seeing/doing clinically is true/correct. By the way, how do you evaluate the pubic joints' alignment? Do you have any published work that supports your methods?

nari -> Re: Diagnosis and Palpation in Manual Tx (March 6, 2005 4:10:00 PM)
Unless I have missed something in the posts above, I cannot for the life of me see how the pubes can 'elevate in the frontal plane' and move posteriorly in the sagittal plane without something peculiar happening to the SIJs. When I last looked the pelvis was pretty solid between the SIJs and the symphysis... Am I missing something obvious? Nari

Alex Brenner PT MPT OCS -> Re: Diagnosis and Palpation in Manual Tx (March 6, 2005 9:15:00 PM)
Roger, Sorry, I am not trying to attack you, those were just the best words I could find to write what I was thinking. The work you have done is noble and the 3000 patients is great, however it is still just anecdotal evidence. I personally try to use the best current evidence in my PT interventions and I find that palpating and treating pelvic obliquities is not evidenced based (My definition of best current evidence are published randomized clinical trials in peer reviewed literature. I just have not found any studies to support your interventions). In fact there are some studies that show this type of intervention to be invalid. Your anecdotal evidence is nice but not strong enough evidence to convince me to come to your course. I still palpate boney landmarks during my examination but I do not put a lot of clinical "weight" on these findings because of the studies that have shown this to be invalid. I currently treat low back pain by the clinical prediction rule relying a lot on manipulation, exercises, and other interventions. To me this intervention is based on good sound evidence (see below). 1.) Flynn T, Fritz J, Whitman J, Wainner R, Magel J, Rendiero D. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine 2002; 27(24): 2835-2843. 2.) John D. Childs, PhD, PTMaj; Julie M. Fritz, PhD, PT; Timothy W. Flynn, PhD, PT; James J. Irrgang, PhD, PT; Kevin K. Johnson, Maj; Guy R. Majkowski, Maj; and Anthony Delitto, PhD, PT. A Clinical Prediction Rule To Identify Patients with Low Back Pain Most Likely To Benefit from Spinal Manipulation: A Validation Study Annals of Internal Medicine 21 December 2004 \| Volume 141 Issue 12 \| Pages 920-928. 3.) Erhard RE, Delitto A, Cibulka MT. Relative effectiveness of an extension program and a combined program of manipulation and flexion and extension exercises in patients with acute low back syndrome. Physical therapy 1994; 74(12):1093-1100. Lastly, [QUOTE] Measuring leg/extremity length from the asis's to the medial malleoli is not an accurate method of measuring extremity length. [/QUOTE]I thought this was a valid way to measure leg length inequality as shown by three separate studies. 1) Beattie P, Isaacson K, Riddle DL, Rothstein JM. Validity of derived measurements of leg-length differences obtained by use of a tape measure. Phys Ther. 1990;70:150-157. 2)Woerman AL, Binder-Macleod SA. Leg length discrepancy assessment: accuracy and precision in five clinical methods of evaluation. J Orthop Sports Phys Ther. 1984;5:230-239. 3) Goss, Moore. Compliance wearing a heel lift during 8 weeks of Military Training in Cadets with limb length equality. JOSPT March 2004, Vol 34 Number 3.

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