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RE: SI leg length discrepency
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RE: SI leg length discrepency - November 30, 2007 7:56:12 AM
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Sebastian Asselbergs
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My question is: "where is the actual evidence that LLD has clinical relevance or has been shown to be a cause of problems in human function? And at what difference?" I know the theoretical constructs of asymmetry and "stress going up the chain", but where is the actual solid evidence that this is significant in a clinical way?
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RE: SI leg length discrepency - November 30, 2007 8:51:20 AM
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Tom Reeves DPT ATC
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cred,
My patients take it well, because they feel better. I tell them that their legs are different lengths and that it has caused or contributed to whatever problem they have. I don't make a big deal about it but if someone sat on a wallet that was 2" thick and they had back pain, you would tell them to remove the wallet. If their legs are of different lengths, and they stood at a 3 degree lateral tilt all of the time you should shim the short leg. It just seems like common sense to me.
Sebastian,
the solid evidence is first, in my clinical experience, second, there are plenty of articles that suggest LLD as a factor, not necessarily the cause, in multiple problems. I have linked to several in the past and don't have the time to do it again now. And third, it makes sense given what we know about joints preferrring to live in mid range and venture out into end range periodically. if you sit a at a party and the only person you really want to talk to is sitting directly to your right on a couch, you probably wouldn't just maximally rotate your neck to the right.
If the leg is long, the optical righting reflex influences parts of our body to functionally shorten, i.e. flexed knee, pronated foot, upslipped or posteriorly rotated inominate on the long side, and functionally lengthen i.e. fully extended knee, supinated foot, anteriorly rotated inominate, the short side. those accomodations over time and sometimes acutely, cause various joints to live at or near end range. that contributes to dysfunction, discomfort, and degeneration. Why not elimininate a mechanical load that is assymetrical?
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RE: SI leg length discrepency - November 30, 2007 8:52:31 AM
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Tom Reeves DPT ATC
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follow-up question.
When you treat the back, do you actually find that the problem is in the back? or is it elsewhere, dumping on the back and causing dysfunction?
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RE: SI leg length discrepency - November 30, 2007 10:25:38 AM
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Shill
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Tom,
Sure hypomobile joints can be mobilized to become normal. The idea I am getting at is that neither you, me, or the best SI man/woman/robot in the world can reliably tell whether the motion at the SI joint is hypo, hyper, or normal. So, that said please dont tell me that you mobilize cranial sutures as well, because in my mind, the two (SI directed treatments for "maladies" at the SI joint, and craniosacral treatment) treat "pathologies" that are not able to be defined with methods that are objective, or with tests that are reliable. The SI joint as a source of pathology seems more logical and plausible than treating the cranial sutures, but it has not been validated enough for my satisfaction. I would propose that one who relies heavily on the treatment of the SI joint get all of his or her patients, and about 100 more normal people and take films of the pelvis. Then pick the ones who hurt based solely on the to radiographic supposed pelvic malalignment. These studies have shown that asymmetry is the norm, and I will look for the references for this after I am through with the rant.
There have been enough studies on this to make me, as a practitioner pushing towards expertise, reflect upon this area of my field and say "This is bunk". Thats right, bunk.
Im currently reading a book entitled "Why People Believe Weird Things - Pseudoscience, Superstition, and Other Confusions of our Time", by Michael Shermer, PhD. In this book, common misconceptions and misinterpretations of information are expanded upon. Chapter 3 outlines "How Thinking Goes Wrong". The first topic in this chapter is Problems in Scientific Thinking, and I am sure, based on your posts that you do think scientifically. However, "Theory Influences Observations" is the first sub section of this chapter, and describes what can go on with SI analysis, treatment, etc.
"What we observe is not nature itself, but nature exposed to our method of questioning" - Werner Heisenberg. This goes on to say that "The theory in part constructs the reality. Reality exists independent of the observer, of course, but our perceptions of reality are influenced by the theories framing our examination of it."
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RE: SI leg length discrepency - November 30, 2007 11:25:06 AM
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Tom Reeves DPT ATC
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Shill, I have also read that book and do not doubt that my theory influences what I think I see. that said, i am not really basing my treatment on hypo or hyper mobility, but rather the absence of motion. I might describe an SIJ that I think is hypomobile, but rarely base a treatment upon it. I am confident that I can feel whether or not an SIJ moves.
Lerner's book is enlightening. I agree with the vast majority of his points, it is like taking a logic class. that said, we learn new things every day about how the body works. We formulate a hypothesis based upon what we think we already know then try to fit what we see into that model. The model of SIJ function/motion and that of leg length discrepancies is not contradicted by what we know from anatomy and physiology.
We know that there is an articular surface at the SIJ, we know that bones do not grow at the same rate as the contralateral analog. Is it possible, that those that have attempted to research some of these things do not have at their disposal the proper tools to measure something that has not been measured properly in the past?
I know that I sound like a DC defending subluxations and I am not. I do not believe that CST is anything more than voodoo.
If you believe in the philosophy of Heisenberg and take it to the end, we cannot ever know anything.
theories cannot be proven, they can only be disproven. Disprove mine.
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RE: SI leg length discrepency - November 30, 2007 2:03:16 PM
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Shill
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Ahh yes, the burden of proof. But whose burden is it? Who has to prove what to whom? I dont need to disprove your theories, as I mentioned above others have already done the work, or at least enough to reach a level I am currently satisfied with. To quote Michael Shermer again, "The person making the extraordinary claim has the burden of proving to the experts that his or her belief has more validity than the one almost everyone else accepts".
In regards to the Heisenberg quote, I think the "knowing" potential is improved once the bias is eliminated through the abandonment of prior theories.
In regards to your inquiry regarding the sensitivity of the tools to used to measure, sure it is possible that the tools arent yet there. Sometimes the equipment constructs the results.
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RE: SI leg length discrepency - December 5, 2007 7:32:02 PM
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Sebastian Asselbergs
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quote:
`` that said, i am not really basing my treatment on hypo or hyper mobility, but rather the absence of motion.``
This I cannot reconcile with logic. `Hypo`means lack of, `mobility`relates to motion....and this is not along the same line as `lack of motion`....Mmmh.
That you are confident that you can feel a SI joint move is, well....something I can not argue at all. I can not judge or determine the validity of your confidence, but I can argue the reliability of the tests that supposedly determine SI joint abnormalities in motion or mobility. I have taken years of detailed manual techniques for assessment and treatment, both from PTs as from DOs. I have really learned to palpate and did become sensitive to all kinds of stuff I think I felt. Nasty studies have shown my wonderful sensitive tests quite poor. And guess what. Since I have stopped using the approach of detailed manual scrutiny, my outcomes are actually better - fewer visits towards patient independence.
(Tom, dont get me wrong: that last remark was a reflection on MY practice - not yours....Your outcomes may well trump mine with YOUR approach - that is the nature of personalities and the skills they apply)
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RE: SI leg length discrepency - December 6, 2007 3:43:04 PM
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kiwi PT
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I definately agree that there are problems with SI test and motion palpation, and understand that many pain free normals display such so-called dysfunctions. Do those of you who dismiss these methods of testing still address the SI joint via manual therapy? If so, how? I find determing a R on R or R on L to be rather tricky. I would say though I have definately had patients who reported immediate significant decrease in pain with ambulation following upslip correction or MET for an IS anterior.
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RE: SI leg length discrepency - December 6, 2007 4:18:08 PM
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Tom Reeves DPT ATC
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Sebastian,
Perhaps I was not clear. I am confident that I can palpate whether or not the ilium moves, but am not confident whether or not it is "normal" "more than normal" or "less than normal". In other words, the gradation of movement in the SIJ I believe is not a reliable test but the all or none type of assessment I am confident that I can ascertain. If there is articular cartilage, then movement should occur. If the SIJ does not move, there is a reason. Joint stasis causes degerative changes and subsequent pain. I went to PT school in Des Moines affiliated with a DO medical school so we had perhaps more ME and position/motion analysis than most entry level PTs.
Kiwi,
I do not use the R on R etc . . . anymore, I find that it matters little. I have been to two courses taught by Richard Jackson PT and learned to simplify my SI evaluation to anterior/posterior rotation of the inominates, Sacral rotation in the transverse plane, and to a lesser degree, pelvic inflares and outflares (I rarely look for these and when I do look, I rarely see them). I treat upslips and leg length discrepancies almost every day. My outcomes are great. I average between 3 and 4 visits for low back pain and that is with Oswestry scores improving to no less than 45 out of 50 points.
Maybe there is something to that pesky biomechanical classification system.
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RE: SI leg length discrepency - December 6, 2007 4:31:42 PM
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Shill
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From: Madison WI USA
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I rarely, if ever, address the SI joint via manual or any other therapy. To respond to the decreased pain after Upslip correction or MET for IS anterior, I would have to know how you did these. Describe in detail how these were done, and then ask "did my treatment cause an effect ONLY at those tissues?" How do I know that? The fact that there was relief does not necessarily mean it was because something was "corrected". Great result, but how it occurred is up for much debate.
I choose to get the relief through means that the patient can reproduce on his or her own when I am not around to pull on his or her leg.
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RE: SI leg length discrepency - December 6, 2007 5:31:10 PM
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kiwi PT
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I certainly agree that repeated attempts to mobilize the SI or IS without seeing lasting results over the course of several visits does not make sense and one should modify approach based on pt response. I think attempts to do so over the course of a few visits is worth a shot. One could explain to the patient that the findings are "normal" in some people and that it may or may not be related to their pain, but that you will attempt an SI or IS treatment procedure and see how they respond. How exactly does a technique work at the tissue level is intelectually interesting, worthy of study, but not my primary concern. How does AP mob at GH improve ER? Lots of things work for reasons other than why we think they work.
The previous posts about FAB are very interesting and I would bet that the language used by therapists does play a part (sacral tosion does sound nasty).
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RE: SI leg length discrepency - December 6, 2007 5:46:05 PM
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kiwi PT
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Is it rarely or ever that address the SI via manual?
If it is rarely what is it then that would cause you to do so?
I'm not criticizing just trying to understand
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RE: SI leg length discrepency - December 6, 2007 7:09:41 PM
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Tom Reeves DPT ATC
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Shill,
If you rarely if ever address the SIJ with manual or other therapy, does that mean that you don't think it is a source of pain? Or do you think that treating other body parts alleviate dysfunction at the SIJ? Please explain.
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RE: SI leg length discrepency - December 7, 2007 1:52:00 AM
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bonez
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This is an interesting thread. I'll barge in as an evidence based chiro with a couple of decades of experience. Back when the only thing we tried to research was SI motion testing all of the studies showed acceptable intra examiner relability but very poor interexaminer relability and not much has changed 20 years later. The discussion of upslip ,flare,torsion has been around forever to along with piles of plans for treatment. These all have their proponents.
Much of these guys have been recently left scratching their collective heads with the PHD thesis work by to chiros involved in teaching at CMCC. Their work was in biomechanics at Mcmaster and they looked at HVLA side posture manipulation the planned location of cavitation(expectation of positive trearment) and where actual cavitation occured.
It was a complex study with force transducers surface mounted microphones etc. Bottom line even the best manipulators with the best techniques generated affects not near the locations that they anticipated.
I don't believe that the actual SI was studied but it does make you go hmmmmm.
All this time however my evidence based collegues have seen for years the same questions arise wrt. leg length treatment response and we have beat these topics around the bush.
While we will always have a interprofessional wall it really is to bad that we could not find similar language as I believe that learning from each others dead ends might result in better outcomes for the patient
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RE: SI leg length discrepency - December 7, 2007 11:29:08 AM
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Shill
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Tom.
Both, in a way. Sure the SI, when directly stimulated with noxious testing, can cause a pain message to be sent to the brain. For the sake of clarity, in my above post, I should have used the phrase "directly treating". Directly treating the SI, when one has no active control over moving, or being able to actively stabilize the joint to me seems fruitless. How does anyone suggest that any manipulation or "correction" will stick? The SI will do what it wants (no, I do not believe it has a brain), as it is an accessory joint. It moves because of other things, other joints around it, not because of itself. I treat the other things. I am fully aware of the biomechanical rationale for mobilizing hypomobile joints and stabilizing hypermobile joints. The results I get by NOT directly treating it, and rather concentrating on the lumbar spine, and/or hip are fantastic, and really, this is a debate than can go around and around ad infinitum. What I do at the lumbar spine is generally through repeated movements. For all I know, the change with these movements occurs at the SI itself, rather than any change at the lumbar spine to bring about pain relief. But it really doesnt matter to the patient in front of me, as long as he or she is able to better control and reduce his or her pain, and reproduce this at home, through the treatment I have provided. Im sure you feel the same way, in that what you do gives the patient in front of you relief as well. Im not denying you get great results.
My rationale for my distaste with all things SI is that I can not buy into confusing nomenclature of ridicuous invented pseudopathologies of malposition/rotation/slippage, in the absence of serious trauma, that can not actually be found through means other than unreliable palpations. I need sound, objective rationale to get excited about attaching myself to an approach. The entire basis of these approaches is faulty, in my humble opinion, and that which has no base can not stand.
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RE: SI leg length discrepency - December 10, 2007 9:42:21 AM
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Tom Reeves DPT ATC
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"My rationale for my distaste with all things SI is that I can not buy into confusing nomenclature of ridicuous invented pseudopathologies of malposition/rotation/slippage, in the absence of serious trauma, that can not actually be found through means other than unreliable palpations. I need sound, objective rationale to get excited about attaching myself to an approach. The entire basis of these approaches is faulty, in my humble opinion, and that which has no base can not stand."
Shill,
I was with you until your last paragraph, quoted above. The positions described by the people I have studied with/under are not talking about positions outside what is normal range for the SIJ. Rather, they are talking about positions at or too near the end range for that joint. do you believe that the subtalar joint can develop arthritis because of thousands of steps taken where it does not pronate properly? I know that you believe that posture can cause muscular overload from you postings on the scapular pain thread. i agree with your assessment there.
It seems to me that perhaps you change your mind regarding the legitimacy of a biomechanical model when you change joints.
If it can be true of one joint, why cannot the same rationale be true of another. I submit to you that an SI course taught by an evidence based PT would be of use to you. I think that your outcomes might get even better and your evaluations simplified.
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RE: SI leg length discrepency - December 10, 2007 1:09:34 PM
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MS_PT
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not trying to hijack this thread, but....
Tom, did you find the richard jackson courses helpful? I have taken the standard fare of biomechanical assesment courses through IMTS, but I feel there is so much noise in my head from all the different "diagnoses" that my evaluation method suffers, thus I am looking for a simplified approach.
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RE: SI leg length discrepency - December 10, 2007 3:54:09 PM
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Tom Reeves DPT ATC
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MSPT,
I found it to be very helpful. I came from an osteopathic background and learned all of the R on L and L on R etc . . . The course made the evaluation much easier, was functional and immediately applicable to my patients when I returned to work on Monday.
Cred,
Most of the course was evidence based. He provided references from a variety of journals including: JBJS, Spine, JAMA, Radiology, Gynecology and Obstetrics, Southern Medical Journal, Am Journal of Roentgenology, Canadian Medical Association, Connective Tissue Research and others. Not to mention the references to anatomy texts, dissections and biomechanics which are also part of evidence based intervention. Remember, evidence based practice is not limited to those things proven by double blind studies.
The parts of my evaluation that I learned in the course that were evidence based largely have to do with the movement patterns of the pelvic girdle, and the presence or lack of that movement perceived with palpation and consistent with the patient's complaints. the tests themselves have not been studied to my knowledge and tested for validity. I have read on this forum that they have been found to be unreliable (intertester?) There is a good article in PTjournal online (http://www.physicaltherapyonline.org/cgi/content/full/81/5/1135) that concludes that much of our evaluation has poor intertester reliability but when multiple tests are used and coordinated with history, location of pain, and pain patterns, they become more reliable.
That said, it is my contention that we simply have not been able to accurately measure the tests' reliability and the proper questions have not been asked when the research has been done.
I must be a guru guy. What I learned in the RJ classes was meaningful to me, fit into my conceptions of how the SIJ moves, what the consequences are when a joint that is supposed to move does not, and by using the strategies learned in the courses have helped my outcomes immensely.
I work in a rural hospital with too few numbers to do a large enough study to have any power. I also lack the institutional support to order CT or MRI studies to correlate/confirm what I see clinically. Excuses? yes. am I going to change my practice? not until someone gives me a better model.
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RE: SI leg length discrepency - December 10, 2007 9:03:14 PM
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Shill
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From: Madison WI USA
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Tom,
There is really no sense in attempting to persuade me to think differently about the SI joint. IF there becomes a need to change because of some shift in the universe of evidence, I will do that. But not before.
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RE: SI leg length discrepency - December 10, 2007 10:22:44 PM
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Tom Reeves DPT ATC
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OK, I guess we are done here, Who is to say that we cannot feel movement? Did you not feel the hair between sheets of paper during palpation exercises in PT school? I am sure that the reader of the CT of the hair would say that it was not palpable. I feel what I feel, my patients get better, my treatment is based on anatomy, biomechanics, common sense, and experience.
Unless there is a shift in the universe of evidence (good one shill) I will continue to treat my SIJ patients the way I do. When they stop getting better will be a good sign of that shift.
< Message edited by Tom Reeves DPT ATC -- December 11, 2007 7:50:28 AM >
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