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Re: Diagnosis and Palpation in Manual Tx
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Re: Diagnosis and Palpation in Manual Tx - March 7, 2005 1:16:00 AM
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dosrinc
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Joined: December 9, 2004
From: Bonita Springs
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Hello all great discussion,
In my eyes, elevation at the pubic symphisis without an effect at the SIJ is a mechanical impossibility. Simple physics would say this can simply not happen, you cannot lift one end of a bone while having no effect on the opposite end of that bone, where do the forces go?
Rick
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Re: Diagnosis and Palpation in Manual Tx - March 7, 2005 1:29:00 AM
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JLS_PT_OCS
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From: USA
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Roger,
I look forward to your publishing this research. If these pelvic assymetries really are risk factors for all the things you claim they are, that truly would be a leap forward for all of us in our evaluation/treatment methods.
However, like Army, I do not use these assymetries to drive diagnosis or treatment unless manipulation or strength/stability exercise fail.
Given the current state of research in this area, including the studies Army cited, do you feel that your course recommends a treatment approach consistent with current evidence?
Thank you for your time and attention in answering these questions, I realize it would be far easier to ignore them, and appreciate you going out on a limb in the way of education, sir.
Yogi-
I can see your point. I was getting to the fact that 6mm in the frontal plane is a lot, and my colleague here (one of the authors) helped me understand it better. Asssymetry like that really looked like a serious list in sitting, and those folks were hurtin' from acute lumbar pain. Unsuprisingly, they did well with manipulation.
In response to your case study, I would attempt lumbosacral manipulation depending on how close to the decision rule they were, and also consider a supine SIJ traction type manipulation that I have seen helpful on a few cases of that type. Again only if the EBM approach failed. :)
J
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Diagnosis and Palpation in Manual Tx - March 7, 2005 3:16:00 AM
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Yogi
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From: San Antonio, Tx., USA
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OK, as near as I can tell, with the clear-cut and obvious posterior rotation I postulated (by history, pain location, and severe bony landmark asymmetry), so far, Jason would consider treating, Diane said she would, and I gather Roger would. I'll assume Chris would. Should I do a poll? Myself makes 4 that would treat this SI, I think we can argue all we want about EBM and evaluation methods for SI, my point was, forget all that, are you going to help this person, or not.
Still would like someone to check me on my conclusion from the study Jason posted, is there a flaw in my logic and conclusion?
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Re: Diagnosis and Palpation in Manual Tx - March 7, 2005 3:31:00 AM
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JLS_PT_OCS
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Yogi-
Helping this person does not necessarily mean to treat a pelvic assymmetry.
But I like your approach of a patient mini case study, it is useful to illustrate where people fall on the issue.
This issue truly suffers from spectrum bias.
Here's my thoughts...
At one end of the spectrum, you have those with no asymmetry and general pain c/o and on the other you have folks with tons of assymmetry and a very nice "it hurts right here" type of complaint.
There's really no argument about those on either ends of the spectrum. It's those folks in the middle you have to think hard about.
I don't think anyone would argue that if you have tons of findings that in our biomechanical model indicate a certain dysfunction, that we would not treat that dysfunction. That is not, however, an endorsement of using that model to treat all patients or as a first line evaluation scheme.
This is an important distinction.
Just like the manipulation CPR is not an endorsement of manipulation as a general approach to all patients, but an example of a specific patient responding to a specific intervention. Just because I use the CPR and manipulate and someone gets better, that doesn't mean I should be manipulating everyone.
So if we all choose to treat a presumptive SIJ dysfunction in your patient case, that neither ends the discussion nor says anything definitive about the use of assymetry classifications to treat patients. It shows the possible utility of using assymetry to guide treatment in one specific patient case if a general EBM approach failed. No one (i think) is arguing that any model or scheme can't sometimes be helpful in the care of an individual patient, just that it should not be driving the train when the evidence doesn't support it. There is at least one person here arguing that the asymmetry is the problem that needs to be treated, and the treatment is driven by asymmetry findings. That is what I am disagreeing with.
Also, for falls on buttock with lateral LBP, I'm not sure I would even check assymetry before attempting the distraction manipulation.
:)
I think it's on the Basic Skill Set CD from Wainner/Flynn....
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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Re: Diagnosis and Palpation in Manual Tx - March 7, 2005 3:32:00 AM
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Pelfixer1
Posts: 25
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From: Spring Hill/Brooksville, Fl.
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Nari:
Thank you for your very insightful post. Your question is exactly what I struggled with initially in my study of the pelvic movements. This very movement was discussed among me, an associate, the computer artist/3D animator, a university professor helping me with my research design and nearly all the students I have had in my classes.
Once you begin to treat the pubs correctly, follow a number of patients and see your results, you will understand what I am telling you. You will also diagnosis elevated pub elevations before you examine them. For example, a patient will walk in with a condition mentioned below and in their history they say had a fall on their buttocks and they are in a forward head posture. Right away you make the educated guess that the pubs are educated. You examine them---sure enough. Once you take their history, see what posture they are in, know where their pain is, you will be able to predict what pelvic joint malalignments they have.
Elevations of the pubs will posteriorly rotate the ilium (because they are attached) as if you are performing a pelvic tilt,flexing the L-S joint first,then flattening the lumbar spine, increasing the thoracic kyphosis and projecting the head forward. Stand with you back against the wall, then flatten your lumbar spine spine against the wall. Your change in lumbar posture ends up projecting your head forward (FHP).This is why elevated pubs are associated with cervical/suboccipital/head/ TMJ/maloclussion problems.
Elevated pubs move the ilium yes, but they do not move the sacroiliac joint, because their movement planes are completely different. The pubes are in the sagittal plane, the si's approximately midway between the frontal and sagittal plane.
Thanks again!
_____________________________
Roger C. Skovly, P.T.,M.A.
4142 Mariner Boulevard
P.O. Box 413
Spring Hill, Fl. 34609
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Re: Diagnosis and Palpation in Manual Tx - March 7, 2005 3:38:00 AM
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dosrinc
Posts: 335
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From: Bonita Springs
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Wow, Roger you state that elevation of the pubes results in posterior rotation of the ilium and then flexion of the L/Sjunction, ie movement of the sacrum, so we have movement of the ilium and movement of the sacrum but no movement at the SIJ, what am I missing?
Rick
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Re: Diagnosis and Palpation in Manual Tx - March 7, 2005 3:39:00 AM
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Pelfixer1
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From: Spring Hill/Brooksville, Fl.
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To All Of You:
I have to run to Tampa (USF)to work on my research project, but will be back later today to carry on with the discussion.
Thanks very much!
_____________________________
Roger C. Skovly, P.T.,M.A.
4142 Mariner Boulevard
P.O. Box 413
Spring Hill, Fl. 34609
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Re: Diagnosis and Palpation in Manual Tx - March 7, 2005 8:29:00 AM
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Synergy
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From: Texas
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In my honest opinion, no movement at the SI joint with movement at the pubic symphasis does not make osteokinematic sense to me! Maybe I'm missing the something...who knows! If I may opine, movement in the sagittal plane at the pubis would create movement in the sagittal-frontal plane of the SI joint...if not pure rotation then at least translatory motion.
Correct me if I'm wrong, but I do believe Greenman states 'upslips' and 'downslips' create elavated/lowered ASIS, PSIS, iliac crests,pubes, etc.
_____________________________
Chris Adams, PT, MPT
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Re: Diagnosis and Palpation in Manual Tx - March 7, 2005 9:42:00 AM
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Diane
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Has anyone ever considered the possibility that the pelvis may have enough pliablity, not so much mobility at the joints, rather distortability by various sorts of ab pulls and forces and inner pulls by illiacus etc... that that could account for all the weird flares and slips and so on that we've been taught to spot and treat? I don't blame joints much anymore for anything. That double elevated pubes thing... could that be from pyramidalis or lower rectus misbehaving?
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Re: Diagnosis and Palpation in Manual Tx - March 7, 2005 10:37:00 AM
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Pelfixer1
Posts: 25
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From: Spring Hill/Brooksville, Fl.
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Dear Chris/Rick:
The sacroiliac joint does not move in the frontal/sagittal plane (arthokinetically). The ilium (bone) and sacrum do however move together as one unit. Take a pelvis and elevate the pubes and you will see that the axis of motion is at the hip joint and there is flexion of L5 on S1/extension of S1 on L5 and the LS joint becomes shallow.
Thanks!
_____________________________
Roger C. Skovly, P.T.,M.A.
4142 Mariner Boulevard
P.O. Box 413
Spring Hill, Fl. 34609
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Re: Diagnosis and Palpation in Manual Tx - March 7, 2005 12:03:00 PM
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dosrinc
Posts: 335
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From: Bonita Springs
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Roger, musn't the affected ilium at least move back into a closed packed position on the sacrum before the sacrum and ilium can move together, I know we are talking about mm of motion here even in a "normal" situation but when we are looking for symmetry in supine, we are in NWB and have lost any force closure of the SI. I have a plastic pelvis in front of me now and when I elevate the pube on one side, the first and obvious thing that happens is a post rotation of the ilium, taking up any ligamentous slack and close packing the SIJ, then the combined motion of the ilium and sacrum you described, now consider an SI with poor ligamentous integrity and/or poor articular congruity and I just don't see how you can state with such confidence that elevation of the pube creates no change at the SIJ
Diane: I do tend to agree with you that these assymetries may not be so much joint issues as they are muscular imbalance issue which may be why they respond so well to MET,, don't have the exact referrence but Stefan Bloomberg once looked at the effects of SI manipulation on joint position using radioopaque (SP?) markers and found that although symptoms were relieved and assymetries corrected there was no change in SIJ position. Sorry for the long post, going home now
Rick
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Re: Diagnosis and Palpation in Manual Tx - March 7, 2005 1:05:00 PM
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Pelfixer1
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Rick:
I do think there is a compression there however slight. I am saying there is no change in that there is no arthrokinetic motion (joint surface over joint surface)like the posterior rotations and the outflares. Sounds like we are saying the same thing. The ligaments of the pelvis are very strong. Cosson, M. "A Study pf Pelvic Ligament Strength",Eur J Obstet Gyncol Reprod Biol, 2003 Jul1;109(1):80-7.
_____________________________
Roger C. Skovly, P.T.,M.A.
4142 Mariner Boulevard
P.O. Box 413
Spring Hill, Fl. 34609
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Re: Diagnosis and Palpation in Manual Tx - March 7, 2005 1:20:00 PM
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Bill Egan
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From: Newton, MA
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Pelvic obliquity/assemtry
I always keep this in mind when I'm doing a biomechanical exam: If you are looking for something, you are probably going to find it. In other words if your favored hypothesis is that most people with LBP have a right anterior inominate, this is what you'll see.
I try to use tests that are mostly reliable and valid, and also ones that lead to a treatment decision.
Similar to Jason and Army I was brought up in the EBP model and utilize the CPR for manipulation with my patients.
That being said, I have not completely thrown out the osteopathic, biomechanical model. I find this useful to help guide my treatment selection. I have streamlined this model significantly since it was first taught to me in PT school.
After utilizing a technique I am much less concerned about its effects on assemtry or passive accessory mobility than immediate improvement in pain and overall function. Something that I have played with lately is retesting motor control, balance, or strength after manual treatment. For example, testing DNF control before and after techniques to improve OA flexion/sub occiptal flexibility.
Just my two cents
Bill
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Re: Diagnosis and Palpation in Manual Tx - March 7, 2005 2:55:00 PM
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Pelfixer1
Posts: 25
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Army:
Do you subscribe to using heel lifts for those with leg length discrepancies? Apparently this is a standard practice in the Army? If not, what is it you do for these people?
The other two studies relating to extremity length measurements I will withhold comment until I am able to read them.
How do you personally use the clinical predictability rule in treating spinal pain patients?
_____________________________
Roger C. Skovly, P.T.,M.A.
4142 Mariner Boulevard
P.O. Box 413
Spring Hill, Fl. 34609
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Re: Diagnosis and Palpation in Manual Tx - March 7, 2005 3:03:00 PM
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Shill
Posts: 1107
Joined: February 13, 2003
From: Madison WI USA
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Diane,
Distortability of the pelvis? Are you postulating some sort of flexing, giving, rubberlike ilia? The supposed biomechanics of the joints there are hard enough to believe, with the strong ligamentous structures that Roger mentions, which to me seems somewhat in contradiction to the ability of these joints to move enough to result in a leg length issue.
With all due respect, lets not theorize another enigmatic treatment or assessment technique with even less potential for reliable study.
_____________________________
Steve Hill PT
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Re: Diagnosis and Palpation in Manual Tx - March 7, 2005 7:51:00 PM
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Alex Brenner PT MPT OCS
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From: Kentucky
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[QUOTE]Do you subscribe to using heel lifts for those with leg length discrepancies? Apparently this is a standard practice in the Army? If not, what is it you do for these people?[/QUOTE]I quoted the article because in this particular article the authors measured leg length inequality utilizing the ASIS to lateral malleoli and had both interrater and intrarater reliability ICCs of .99. You stated above with that this type of measurement was not reliable or accurate and I am showing you three published articles in peer reviewed literature that say it is.
Clinical Prediction Rule: I personally will perform the lumbosacral region manipulation to those back pain patients that have at least 3 out of the 5 clinical predictors. This manipulation is applied along with some type of impairment based exercise and strengthening program.
Roger, thanks for coming on this forum and taking the time to answer these questions.
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: Diagnosis and Palpation in Manual Tx - March 7, 2005 10:07:00 PM
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Pelfixer1
Posts: 25
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From: Spring Hill/Brooksville, Fl.
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Dear Army:
Interrater reliability, but they used the incorrect landmarks/ method of measuring leg length. Measuring across a moveable joint (the sacroiliac joint), which could be aligned or malaligned absolutely destroys the reliability of the study.
Also, do you actually believe the percentage of subjects with short leg lengths would be that high as reported in the study? Wouldn't it be more likely that their pelvic joints could have been malaligned rather than having an actual short leg?
You didn't answer my question concerning the use of heel lifts for patient's with "short leg lengths"
Thank you very much for your answer and any additional thoughts on this subject.
_____________________________
Roger C. Skovly, P.T.,M.A.
4142 Mariner Boulevard
P.O. Box 413
Spring Hill, Fl. 34609
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Re: Diagnosis and Palpation in Manual Tx - March 7, 2005 11:37:00 PM
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Alex Brenner PT MPT OCS
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From: Kentucky
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[QUOTE]Measuring across a moveable joint (the sacroiliac joint), which could be aligned or malaligned absolutely destroys the reliability of the study.[/QUOTE]Do you have any evidence to support this claim? Are there any studies out there to support this claim?
I think there is probably a very high percentage of people with leg length inequality and 98% of them walk around every day with no pain.
I very,very seldom treat leg length inequality because I believe that there is a normal variant in the population that has this. Now if something is grossly off, like say 2 inch difference, then I would probably try an orthotic with the patient in addition to spine/pelvic care.
Bottom line: I think most LLI are normal variants, are asymptomatic, and do not require treatment to "realign" the pelvis.
I answered your question, now please answer mine. Where is your evidence?
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: Diagnosis and Palpation in Manual Tx - March 7, 2005 11:49:00 PM
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Alex Brenner PT MPT OCS
Posts: 1057
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From: Kentucky
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[QUOTE]I always keep this in mind when I'm doing a biomechanical exam: If you are looking for something, you are probably going to find it. In other words if your favored hypothesis is that most people with LBP have a right anterior inominate, this is what you'll see.[/QUOTE]Bill, I totally agree with this. If you are looking for a malalignment you can easily talk yourself into something by palpating. Just take a look at the model of the sacrum. There are so many bumps, sulcuses, ridges that are very different from sacrum to sacrum. We are all different. Add in the fat deposits, fascial layers, skin layers,muscles etc. How can there be any reliability or accuracy in this type of palpation? I think this is why we have some studies that show this to be unreliable.
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: Diagnosis and Palpation in Manual Tx - March 7, 2005 11:49:00 PM
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JLS_PT_OCS
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From: USA
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Roger,
Do you mean the "validity" of measuring leg lengths that way? The citation Army gives shows it's reliable, but if I understand you correctly you're saying that it is not valid.
I think in the last 2 or 3 years I have given out maybe 2 or 3 heel lifts for any LE or spinal problem. I just don't think there's much of anything out there to support their use. I couple that with my personal experience of it being of no help or worsening patients in my anecdotal experience. I think most of the assymmetry I find is unrelated to the patient's complaints, ie they do fine with me never assessing or treating it.
_____________________________
Jason Silvernail DPT, OCS, CSCS
"It isn't what you're able to do that requires your courage but rather what you have come to understand and are willing to express." - Barrett Dorko,PT
**I no longer post on RehabEdge**
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