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RE: With all of the talk about SIJ and inominate rotation--

 
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RE: With all of the talk about SIJ and inominate rotati... - August 9, 2010 11:12:39 AM   
proud

 

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quote:

ORIGINAL: Tom Reeves DPT ATC

So,

Mobilization is not to increase movement in a joint.

Seems counterintuitive.

How so...because of the term mobilization?


quote:

Our explanations may be slightly different but don't you think that explaining anything with confidence enhances the placebo response?


Yes....I worry more about long term nocebo myself.  


quote:

My overarching point here is, we cannot dismiss a theory because our testing procedures for that theory is incomplete or unreliable.


Read the article I suggested above.

quote:

FYI, I am confident that I see and correctly identify upslips almost every day. Often, people will come to me and have a plethora of symptoms that I can explain by a leg length discrepancy that causes a pile of neuromuscular responses which in turn cause biomechanical changes and responses that occur thousands of times. The pain response, wherever it is, is because of the thousands of overloads, not just one. I may treat them only with inferior glide self mobilization of the pelvis on the elevated side and insertion of a lift in the short shoe.


I'm not confident that ANY of the biomechanical explanations you just provided are in actuality the source of your patients improvements.


quote:

I realize that we have gone over this before ad nauseum and although I personally believe that I am open to changing my paradigm if I get adequate evidence to refute it, I have not yet been persuaded to abandon it.


I'd be curious as to what would persuade you? There is more than enough evidence that suggests biomechanical rationale's are unsupportable with known pain science.

quote:

What I am hearing is that you all do not ever see joints that are hypomobile because of structural changes or loss of accessory motion, yet I am confident that I see it almost every day. I treat it with mobilization and have success.


You think you are moving it (READ: altering things arthrokinematically). Read Threlkeld.

quote:

I say that the flaw is in the reliability of the testing, and not in the paradigm itself.


Nope.

< Message edited by proud -- August 9, 2010 12:33:23 PM >

(in reply to Tom Reeves DPT ATC)
Post #: 21
RE: With all of the talk about SIJ and inominate rotati... - August 9, 2010 10:09:37 PM   
TexasOrtho


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quote:

ORIGINAL: Tom Reeves DPT ATC

Our explanations may be slightly different but don't you think that explaining anything with confidence enhances the placebo response?


The nature of the placebo response is more patient than provider dependent, so I might quibble that it is entirely dependent upon our confidence per se. Nonspecific treatment effects such as placebo / nocebo relate more to the congruency of interactions between the two participants. Optimal placebo response can be skillfuly teased out by adept providers. Confidence is certainly one aspect of this interaction capable of eliciting a stronger response.

quote:

FYI, I am confident that I see and correctly identify upslips almost every day.


Based on the best and most recent available on this specific topic, I believe this confidence is sorely misplaced. The prevalence of SIJ pathology among patients suffering from low back pain is at best around 10%. Couple this pretest probability with the cluster of provicative tests per Laslett and you will find the chance of you falsely diagnosing SIJ pathology is incredibly high unless you see an astounding number of LBP cases each day.

quote:

Often, people will come to me and have a plethora of symptoms that I can explain by a leg length discrepancy that causes a pile of neuromuscular responses which in turn cause biomechanical changes and responses that occur thousands of times. The pain response, wherever it is, is because of the thousands of overloads, not just one. I may treat them only with inferior glide self mobilization of the pelvis on the elevated side and insertion of a lift in the short shoe.


You can explain them that way, but with all due respect you have nothing other than your intuition backing you up on this. There is incredibly poor support for LLD - LBP connection. Couple this with the fact LLD can only be accurately diagnosed with a rather specific radiographic study, you are on very thin ice with your confidence.

quote:

There is plenty of evidence that LLD can contribute to dozens of diagnoses that I will not cite here but it is there for the googling. I don't chase the symptoms, I use a biomechanical model in addition to discussion of pain perception, explanation of pain to the patient, and graded return to normal activity.


I keep looking for this "plenty of evidence" but continue to find none. I'll keep looking.

quote:

I realize that we have gone over this before ad nauseum and although I personally believe that I am open to changing my paradigm if I get adequate evidence to refute it, I have not yet been persuaded to abandon it.


I doubt I will convince you Tom, but you are testing the limits of how many 300lb gorrillas sitting in one room can be ignored.

quote:

What I am hearing is that you all do not ever see joints that are hypomobile because of structural changes or loss of accessory motion, yet I am confident that I see it almost every day.


Wrong. I simply question their relevance given the mounting evidence doing the same. Again, I think your confidence in light of both emerging theory and scientific evidence is misplaced.

quote:

I say that the flaw is in the reliability of the testing, and not in the paradigm itself.


I think its both.

< Message edited by TexasOrtho -- August 9, 2010 10:17:01 PM >


_____________________________

Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
Movement Science Podcast and Blog

(in reply to Tom Reeves DPT ATC)
Post #: 22
RE: With all of the talk about SIJ and inominate rotati... - August 10, 2010 10:30:53 AM   
Tom Reeves DPT ATC

 

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quote:

ORIGINAL: Sebastian Asselbergs

But Tom, don't you see you have a paradigm without any support? Other than: "it is a joint"?
How do you know how much that joint is supposed to move for that particular patient for that particular side for that particular day? How can you know that the "upslip" is not just an EFFECT of pain and its neuromuscular reaction?
How long are you prepared to wait for reliable tests?
Your confidence and positive outcomes really do not bring any "evidence" to the paradigm. They actually confirm that patients will get better when they are treated with confidence and with a special technique.  That may tell us more about the patient's nervous system than the technique or paradigm.

Yes, we have been around this block, but it is worth looking at biomechanics as a possible contributor or effect for painful conditions.  Not as a cause for pain.


Bas, If I am not mistaken, I have always said that biomechanics is a contributor and not a cause for pain.  I remember relaying an analogy using lung cancer as an example.  smoking, working in a dusty environment, having asbestos in your home or workplace, and genetics each make you more likely to get lung ca but there are people that are exposed to all of the risk factors and don't get lung CA and there are those that are exposed to none of them that do get lung CA.  Does that mean that it is not important to educate people to not smoke?

There are many people with screwed up biomechanics that have no symptoms whatsoever.  That doesn't make it irrelevant IMO.

As far as how much a joint is supposed to move for a particular patient, obviously that is a straw man arguement.  There is no answer to the question in this case.  Some is my best answer.  If I feel none, I try to get "some."

(in reply to Sebastian Asselbergs)
Post #: 23
RE: With all of the talk about SIJ and inominate rotati... - August 10, 2010 11:26:41 AM   
Sebastian Asselbergs

 

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OK, Tom. Why is my point about motion or loss of motion a "straw man argument"? Isn't it a reasonable question? Since YOU bring up the issue of "upslip" or "stuck", you must have a standard to which these are compared. And since humans are often asymmetrical, you need to explain in detail how this can be justified to patients.

"I feel no motion"  The problem here is with your "feel"; your perception of sacroiliac motion or lack thereof have been shown to be constructs of ones perception and are not to be relied on. At least, according to the research. Somehow that research is not enough to change your paradigm....

(in reply to Tom Reeves DPT ATC)
Post #: 24
RE: With all of the talk about SIJ and inominate rotati... - August 10, 2010 12:23:10 PM   
Tom Reeves DPT ATC

 

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I am not trying to pick a fight, sorry if it came off that way.  Maybe the term straw man was not used correctly.  I don't care about precisely how much motion there is, just that it is sort of in a normal range.  I know that sounds ridiculously vague and unscientific and it probably is. 

Yes, upslip is a term to describe a position that I palpate.  Yes I recognize that palpation has poor inter-rater reliability.  Yes, I recognize that humans are asymmetrical.  I went to a PT school affiliated with a DO medical school so, some of this stuff is fundamental to my education.  I realize that it is not precise.  I realize also, that the assessments I use are not infallible. 

When I do a leg length screening I do 10 separate screens.  If I find that 70% of those screens all point to one side being longer then I go with it.  If less than that I don't.  Its not like I am basing my entire treatment on one unreliable test.  Why is there an anterior drawer test, a Lachman's test, and a pivot shift test?  To reinforce the conclusion and to test hypotheses. 

If I suspect a LLD, and palpate an upslip I teach the patient to inferiorly glide their own pelvis.  When teaching this, I do it to them first and ask if it feels "good, bad, or neither"  Very maitland if you ask me

With all of that contrition, I still firmly believe that biomechanics is a contributor to the development of destructive movement patterns.  Destructive movement patterns destroy tissue.  Destroyed tissue often causes pain.  Let's step away from the SIJ for a moment. 

Posit:  Does poor throwing mechanics contribute to pathology in pitchers?
Understood that there is a wide variation in pitching mechanics between successful pitchers.  When I say "poor" I mean beyond that particular individual's tissue tolerance.

If we agree that it can happen in the throwing shoulder or elbow, then why can it not also happen in the SIJ?  I just don't think that we have the right tests. 

What does the research say about intra-rater reliability with palpation?  Most of the stuff that I have read suggest poor inter-rater but moderate to good intra-rater reliability. 

Again because it is not reliable, does not make it in-valid.




(in reply to Sebastian Asselbergs)
Post #: 25
RE: With all of the talk about SIJ and inominate rotati... - August 10, 2010 2:22:49 PM   
bonez

 

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Tom I for one understand where you are coming from. I think all here lose sight of the fact that a lot of the stuff done in our world can be found to have conflicting evidence surrounding it. Additionally they forget that like most of us if what you are doing is not working you "go back to the drawing board".

All of this is done because like most here you are not fostering dependance nor busting fuses on the hydro grid. 

(in reply to Tom Reeves DPT ATC)
Post #: 26
RE: With all of the talk about SIJ and inominate rotati... - August 10, 2010 3:25:11 PM   
Sebastian Asselbergs

 

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bonez, despite the fact that I appreciate most of your posts here, that last post is not in that category.
Why is it that asking questions, putting the onus on those who make certain claims (not you specific Tom), or challenging paradigms is considered "poor form" or "blasting"?
Would it be better if I just said: "Ok Tom, Dick or Harry: I do not agree with you, but you are nice anyway". ?
What is wrong with a fierce discussion (and this one wasn't so far!)?  It is through discussions like this in the past, that I have "gone back to the drawing board" and have come away knowing much more than before.

Geoff and Andrew and Tom and others I have fervently argued with, would undoubtedly do the same in person, with a glass of beer in our hands!
If in our more-and-more scrutized professions of rehabilitation therapists (to be inclusive....) we can not even tolerate strong and pointed debate amongst oursleves, we are in more trouble than I thought.
So far there have been no personal attacks, slamming, blasting or cheap shots - no-one is mad, angry, pissed off. Tom will do what he does - so will I - and both of us will think about what the other said (at least I know Tom and I both do that).

The remark of busting fuses is cute, as is the comment about "they forget" but I can`t tell who these refer to....

(in reply to bonez)
Post #: 27
RE: With all of the talk about SIJ and inominate rotati... - August 10, 2010 4:04:59 PM   
Tom Reeves DPT ATC

 

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Thanks Bonez.  Bas is right though.  I am not feeling particularly abused really, just a little defensive.  As I should.  I am the first to say that I am not a slave to the "big study" and perhaps place my clinical judgement, experience, and basic science common sense too high on the evidence scale.  

I read, but don't have access to a lot of journals, only abstracts.  I have kids and am busy otherwise, so I may be lazy when it comes to diving in to other, related areas.  I lurk at Somasimple and am most often frustrated there by the "voodoo" touchy feely vibe I get. 

The way I approach patient care (and life for that matter) is I develop, through research, experience, education, and practice a universal model of how things work.  When something doesn't fit that model, I have to look to modify my model.  It is a very gray model with lots of "could be"s and "might"s and "in many cases"s  because the model has a LOT of variables.  Lots of contributors to things.  I always try to get the the nub of it, give my patients things that they can do (fewer the better) to affect the most symptoms.

unsolicited story: You come home from vacation and your house smells strongly of mold/mildew.  You step onto the carpet and it is soaking wet, you reach to turn on the light and the light won't work, no power.  You then notice that the wallpaper is falling off and the ceiling is sagging down and is dripping.  What is the most important thing to fix?

Most classes I go to imply that their way fixes everything (Mulligan por ejemplo)  The older I get and more I have seen, the more obvious the exaggerations are.  I am not disputing the models that have been put forward here because I don't disagree with them.  I just don't think that the biomechanical model is as flawed as some say.  It is not the answer to everything either, but it contributes. 

Yes, someone will sprain their ankle because their proprioceptive system did not react in time but their ankle did actually roll over and tissues other than nerves were injured.  I mobilize tissues to make them move more.  Whatever Proud says, that's why I do it.  I am not saying that I am making collagen fibers longer, I am moving the joint.  Accessory motions get lost when people self protect.  In my ankle example, sometimes people lose (temporarily) the ability of the talus to glide posteriorly and therefore lose functional dorsiflexion.  Mulligan would mobilize the fibula or tape the fibula, I put their foot on the ground and glide their talus anteriorly, someone else might do some other type of therapeutic touch, some might manipulate, some might talk nicely, all are working on the neural system and the biomechanical system.

It is more integrated than some are implying.

BTW the answer is "fix the leaky roof"

(in reply to Sebastian Asselbergs)
Post #: 28
RE: With all of the talk about SIJ and inominate rotati... - August 10, 2010 7:45:26 PM   
proud

 

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quote:

You can explain them that way, but with all due respect you have nothing other than your intuition backing you up on this. There is incredibly poor support for LLD - LBP connection. Couple this with the fact LLD can only be accurately diagnosed with a rather specific radiographic study, you are on very thin ice with your confidence.


Just an interesting tid bit for everyone.

Where I work, our clients are "captive" so to speak in that they recieve all their rehab needs from our clinic( consisting of 7 PT's). Years ago when LLD was "in vogue" we had numerous patients walking out of the clinic with 1/8" or 1/4" heel lifts with the notion that our measured LLD somehow correlated with their back pain. And why wouldn't we think that...I mean we measured it...prescribed the lift....and VOILA! the patient returned painfree....

two years ago as the evidence mounted against LLD as some precurser to pain....we ventured on a bit of an expiriment.

All those patient whom were prescribed lifts inevitably return a year or two latter for an "update" of the lift( it's either worn out or something). Their back pain was "great" with the lift in...

Instead of just providing the lift, we entered into collaboration with the clinic physicians that we would obtain radiographic correlation to see if in fact these patients indeed did have true LLD's.

The answer: of 26 patients measured....ONE( that's 1) had a LLD greater than 2 mm......the rest averaged > .4mm. In other words....irrelevant.

Yet the patients suddenly "improved" with the lift.

What does that tell you? I know what it tells me....

< Message edited by proud -- August 10, 2010 7:58:33 PM >

(in reply to Tom Reeves DPT ATC)
Post #: 29
RE: With all of the talk about SIJ and inominate rotati... - August 10, 2010 9:06:08 PM   
Tom Reeves DPT ATC

 

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Proud,

How did they measure the LLD at the clinic?

Standing AP pelvis Xrays I'll bet. Did they ensure that both knees were in full extenson and that both feet were in the same degree of pronation and that both feet were pointing forward? probably not.

The test is invalid unless everything outside the picture is exactly the same.

Like in algebra, you have to subtract the same thing from both sides of the equation.

I suggest that a true LLD is actually only measured precisely with an MRI or CT so that it can be done in 3 dimensions. The standing AP pelvis Xray is considered the "gold standard" but if the criteria I mentioned above are not adhered to, its no better than measuring from the umbilicus to the medial malleolus.

(in reply to proud)
Post #: 30
RE: With all of the talk about SIJ and inominate rotati... - August 10, 2010 9:07:37 PM   
bonez

 

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quote:

ORIGINAL: Sebastian Asselbergs

bonez, despite the fact that I appreciate most of your posts here, that last post is not in that category.
Why is it that asking questions, putting the onus on those who make certain claims (not you specific Tom), or challenging paradigms is considered "poor form" or "blasting"?
Would it be better if I just said: "Ok Tom, Dick or Harry: I do not agree with you, but you are nice anyway". ?
What is wrong with a fierce discussion (and this one wasn't so far!)?  It is through discussions like this in the past, that I have "gone back to the drawing board" and have come away knowing much more than before.

Geoff and Andrew and Tom and others I have fervently argued with, would undoubtedly do the same in person, with a glass of beer in our hands!
If in our more-and-more scrutized professions of rehabilitation therapists (to be inclusive....) we can not even tolerate strong and pointed debate amongst oursleves, we are in more trouble than I thought.
So far there have been no personal attacks, slamming, blasting or cheap shots - no-one is mad, angry, pissed off. Tom will do what he does - so will I - and both of us will think about what the other said (at least I know Tom and I both do that).

The remark of busting fuses is cute, as is the comment about "they forget" but I can`t tell who these refer to....


Seb as I reread my post I stand by it. I did not single anyone out or attack anyone. It is entirely possible to offer a bone of support without pointing a finger. I am sorry if I offended you but you must have read more into my post than was there. This happens whem you respond to one thread inside another I believe.

The fuse busters refer to the "successful" practitioners who wave the magic electric gadgets over patients and collect fees.

(in reply to Sebastian Asselbergs)
Post #: 31
RE: With all of the talk about SIJ and inominate rotati... - August 10, 2010 9:10:47 PM   
bonez

 

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quote:

ORIGINAL: proud


Just an interesting tid bit for everyone.

Where I work, our clients are "captive" so to speak in that they recieve all their rehab needs from our clinic( consisting of 7 PT's). Years ago when LLD was "in vogue" we had numerous patients walking out of the clinic with 1/8" or 1/4" heel lifts with the notion that our measured LLD somehow correlated with their back pain. And why wouldn't we think that...I mean we measured it...prescribed the lift....and VOILA! the patient returned painfree....

two years ago as the evidence mounted against LLD as some precurser to pain....we ventured on a bit of an expiriment.

All those patient whom were prescribed lifts inevitably return a year or two latter for an "update" of the lift( it's either worn out or something). Their back pain was "great" with the lift in...

Instead of just providing the lift, we entered into collaboration with the clinic physicians that we would obtain radiographic correlation to see if in fact these patients indeed did have true LLD's.

The answer: of 26 patients measured....ONE( that's 1) had a LLD greater than 2 mm......the rest averaged > .4mm. In other words....irrelevant.

Yet the patients suddenly "improved" with the lift.

What does that tell you? I know what it tells me....


While I do not use heel lifts alot I do have the luxury of confirming there need on xray. There is very little support to radiation exposure if the only reason is to query LLD. It needs to be performed as a result of additional reasons.

(in reply to proud)
Post #: 32
RE: With all of the talk about SIJ and inominate rotati... - August 10, 2010 9:19:28 PM   
TexasOrtho


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I want to stop picking here so I'll let Laslett chime in on this issue. His series of articles in JMMT regarding the SIJ are my reference standard for this area right now.

quote:

The manual therapy literature is awash with books, chapters, and papers on the treatment of the sacroiliac joint. Most of these treatment methods are based explicitly or implicitly on the presumption that some biomechanical malfunction or dysfunction causes either the SIJ or other tissues to provoke the pain of which the patient complains. This hypothesis is fragile indeed, since the means by which such dysfunctions are identified rest upon a flimsy evidential base, disputed by published data showing tests for SIJ dysfunction to be unreliable and invalid.


quote:

The evidence favoring the perspective that mechanical SIJ dysfunctions are related to the experience of back and referred pain is less than convincing, despite the volume of papers published on the subject12,13. The range of motion in the SIJ is small, less than 4° of rotation and up to 1.6 mm of translation14,15. Additionally, in patients presumed to have an SIJ source of pain, Sturesson16 found no difference in range of motion between the symptomatic and asymptomatic sides.


quote:

A number of studies have addressed the problem of poor reliability of individual palpation SIJ tests by assessing groups or clusters of tests with somesuccess29-32. While this may provide some encouragement to those accustomed to using these tests, it is hard to see how this can be of real value. Clustering individually unreliable tests may improve reliability but still lacks face validity.


My emphases of course. I would encourage anyone interested in a thorough treatment of this topic to read more of this article and others in the series. This guy is pretty sharp and I think represents some of the best available evidence on this area.

Laslett M. Evidence Based Diagnosis and Treatment of the Painful Sacroiliac Joint. JMMT;16(3).

_____________________________

Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
Movement Science Podcast and Blog

(in reply to bonez)
Post #: 33
RE: With all of the talk about SIJ and inominate rotati... - August 10, 2010 9:20:16 PM   
proud

 

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TOM,

The radiologist reported the length of the femur and tibia seperately. Although I think you are discussing the "true" vs "apparent" LLD correct?

I know what you are saying but it is peculiar how little clinical corelation there was with our previous measurments don't you think?

(in reply to bonez)
Post #: 34
RE: With all of the talk about SIJ and inominate rotati... - August 10, 2010 10:09:35 PM   
Tom Reeves DPT ATC

 

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Proud,

I was talking about true LLD. If you think of an Xray like a shadow and the femur on one side is tilted in the sagittal plane more than the other it makes the comparison invalid just because of imaging error.

It is interesting that the xrays were so far off. Maybe i will try to get our docs to buy into the idea and I will compare my data with the xray after I train the xray techs(again) to do it precisely right.


How did you determine LLD clinically?

We do 10 things:
1. iliac crest height in stance (high one suggests long leg)
2. foot pronation (flatter foot suggests longer leg)
3. shoe wear pattern (see above, more pronation equals longer leg)
4. towel test (patient stands with a towel under one foot, shifts weight and determines if one feels more level)
5. hip hike test (patient stands with both knees straight and hikes one hip. The height of the hip hike is measured from the floor and the one that hikes he highest is deemed short)
6. Asis position (higher one suggests longer leg unless they are hyperlordotic in stance and the change in angle may rotate the long hip anteriorly)
Asis position must be normalized before proceeding to the remaining tests.
7. measured ASIS to medial malleolus (IMO this is the least reliable of the measurements)
8. apparent LLD ( observe the medial malleoli, which one looks longer)
the last two only measure one half of the leg each
9. Tibia length (patient in hooklying medial malleoli even and tibias vertical, which is longer. I use a level.)
10. femur length (patient remains in hooklying, same as tibia length assessment, PT thumbs on tibial tubercles and look down from above to see which one is more forward)

all of the above can score one of three ways Suggest a: long R, long L, or R=L

I split the ties and the percentage is roughly my index of confidence. i.e 7 R, 2 L, and 1 = is 75% confident in a long R leg.

this goes toward Rod's Laslett article that suggests that multiple unreliable tests in a greement combine into a more reliable conclusion.

(in reply to proud)
Post #: 35
RE: With all of the talk about SIJ and inominate rotati... - August 10, 2010 10:42:41 PM   
TexasOrtho


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...yeah but Tom. What about the part of that same sentence dealing with face validity? Seriously though, you do need to check out that series of articles. He gives a very honest account of how his thoughts on the matter have changed and evolved over the years. Pretty cool to read actually.

_____________________________

Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
Movement Science Podcast and Blog

(in reply to Tom Reeves DPT ATC)
Post #: 36
RE: With all of the talk about SIJ and inominate rotati... - August 10, 2010 11:28:37 PM   
TexasOrtho


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The following is from a recent article in Manual Therapy. Also a good overview on the SIJ.

O’Sullivan PB, Beales DJ. Diagnosis and classification of pelvic girdle pain disorders—Part 1:
A mechanism based approach within a biopsychosocial framework. Manual Therapy 2007;12:86-97.

quote:


2.1. The facts regarding the SIJs

_ The SIJs are inherently stable (Vleeming et al., 1990a, b; Snijders et al., 1993a).

_ The joints are designed for load transfer (Kapandji,1982; Gray and Williams, 1989) and can safely transfer enormous compressive loading forces under normal conditions (Snijders et al., 1993a).

_ The SIJ has little movement in non-weight bearing (average 2.5 degrees rotation) (Sturesson et al., 1989; Brunner et al., 1991; Jacob and Kissling, 1995; Vleeming et al., 1992a, b), and even less in weight bearing (average 0.2 degrees rotation) (Sturesson et al., 2000).

_ Movement of the SIJ cannot be reliably assessed by manual palpation, particularly in weight bearing (Sturesson et al., 2000; van der Wurff et al., 2000a, b).

_ Due to its anatomical makeup, intra-articular displacements within the SIJs are unlikely to occur. No study utilising a valid measurement instrument has identified positional faults of the SIJ—in fact theconverse is true (Tullberg et al., 1998).

_ Distortions of the pelvis observed clinically are likely to occur secondary to changes in pelvic and trunk muscle activity, resulting in directional strain and not positional changes within the SIJs themselves (Tullberg et al., 1998).

_ No study utilising a valid measurement tool has demonstrated that pelvic manipulation alters the position of the pelvic joints (Tullberg et al., 1998)

—pain relief from these procedures is likely to result from nociceptive inhibition based on neuro-inhibitory factors and/or altered patterns of motor activity (Wright, 1995; Pickar, 2002).

_ Asymmetrical laxity of the SIJs, as measured with Doppler imaging, has been shown to correlate with moderate to severe levels of symptoms in subjects with peripartum PGP (Damen et al., 2001). Generalised SIJ laxity is not associated with peripartum pelvic pain (Damen et al., 2001).

_ When clinical signs of reduced force closure have been identified (positive ASLR), the increased movement is identified at the symphysis pubis—not the SIJs (Mens et al., 1999). It is likely that the torsional forces occurring at the SIJs can cause strain across pain sensitised tissue.

_ Pain from the SIJ is located primarily over the joint (inferior sulcus) and may refer distally, but not to the low back (Fortin et al., 1994a, b; Schwarzer et al., 1995; Dreyfuss et al., 1996; Maigne et al., 1996; Slipman et al., 2000; Young et al., 2003; van der Wurff et al., 2006).

_ SIJ pain disorders can be diagnosed using clinical examination (Laslett et al., 2003; Young et al., 2003; Petersen et al., 2004; Laslett et al., 2005a, b). This includes the finding of pain primarily located to theinferior sulcus of the SIJs, positive pain provocation tests for the SIJs and an absence of painful lumbar spine impairment.

_ The SIJ has many muscles that act to compress and control it (force closure), thereby enhancing pelvic stability (creating stiffness) allowing for effective load transfer via the pelvis during a variety of functional tasks (Vleeming et al., 1990a, b, 1995; Snijders et al., 1993a, b; ; Snijders et al., 1998; Damen et al., 2002; Richardson et al., 2002; O’Sullivan et al., 2002a; Pool-Goudzwaard et al., 2004; van Wingerden et al., 2004; Mens et al., 2006; Snijders et al., 2006).

_ PGP disorders may be associated with ‘excessive’ as well as ‘insufficient’ motor activation of the lumbopelvic and surrounding musculature (O’Sullivan et al., 2002a; Hungerford et al., 2003; Pool-Goudzwaard et al., 2005; O’Sullivan and Beales, 2007).


_____________________________

Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
Movement Science Podcast and Blog

(in reply to TexasOrtho)
Post #: 37
RE: With all of the talk about SIJ and inominate rotati... - August 11, 2010 7:31:48 AM   
Sebastian Asselbergs

 

Posts: 2293
Joined: September 30, 1999
From: Barrie, Canada
Status: offline
bonez, I did not feel offended at all - no worries.
I just did not see this thread needing a "we all try to help our patients, and we do not know everything" type of post - simply because Tom and I disagree about the actual importance of biomechanics.

And Tom: you know I do not ignore biomechanics either. I just spend less time focusing on it, because I find focusing on the "system" that moves, supports, and braces us much more consistent with what we know of the perceptual (purely neurophysiological) aspects of human suffering, body, well-being and "sensations". 
With regards to the SI: after having gone through and used most of the "systems" of evaluation and treatment from Greenman, Mitchell, Lee, Canadian Ortho Division, even Kutchera, and after reading much of what Rod is referencing - I gave up on the nutations, upslips, outflares and such. I was feeding a perceptual fantasy - both mine and the patient's.

(in reply to TexasOrtho)
Post #: 38
RE: With all of the talk about SIJ and inominate rotati... - August 11, 2010 8:21:34 AM   
ysumpt2006

 

Posts: 266
Joined: April 1, 2005
From: Northeast Ohio
Status: offline
Wow, look what I started. I'm sorry for the lack of input, but I'm just taking the information in and digesting it.



_____________________________

Ken Shearer, PT
http://lonewolfstrength.wordpress.com

(in reply to Sebastian Asselbergs)
Post #: 39
RE: With all of the talk about SIJ and inominate rotati... - August 11, 2010 8:32:51 PM   
bonez

 

Posts: 701
Joined: August 29, 2007
Status: offline
Tom, Thanks for your 10 criteria. I do have some questions, if landmarks are reliable, crest hieght would be subject to being in the same spot on each side no?
Since the crest slopes downward anteriorly how do you gauge position?

If you have a pronated foot and the crest is low on that side how do you account for the effect of arch position on precieved length?

You mention the shadow effect on xray proper positioning to create a paralleogram(sp) really removes the distortion. If the feet are placed at the same distance as the femoral heads it does not matter how far the shift in sagital plane is the lengths will be equal it is simple geometry. The issue becomes elimination of rotational change as it doesnt correct through geometry.

Finally would hip hike not also be a function of soft tissue constraints in both the hike muscles and the passive holding elements?

Just queries

(in reply to ysumpt2006)
Post #: 40
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