time for prolonged creep mobilization, etc. Later will do a post on research re manipulation versus lesser grades of mobilization, equally effective. See J Manual & Manipulative Therapy editorial, this issue.
Jerry Hesch This is my beef with MET (muscle energy technique). If you make a claim that something is stuck based on how it looks, and your goal is to correct motion, why not then retest the specific motion properties which are PASSIVE ACCESSORY MOTIONS, which I test using Springing With Awareness. The MET apprach does not test this fine micromotion joint property. I sometimes help women (much more frequently than men with this syndrome) who are alligned!!!!!!!!!!!!!! Problem is the sacrum is alligned, yet is completely stuck in posterior glide tractioning the sacral nerves. So the ilia are stuck as is the symphysis pubis as is the L5-S1. So models of asymmetry fail in this regard whereas springing with awareness done at all segments regardless of how they look will discern these. Yes, some highly skilled users of MET may debate this point but as a general statment it is valid that these things are often missed with that paradigm. Let's compare techniques sometime, I submit there is a time for MET, a
time for prolonged creep mobilization, etc. Later will do a post on research re manipulation versus lesser grades of mobilization, equally effective. See J Manual & Manipulative Therapy editorial, this issue.
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HAVING BEEN ACCUSED OF BEING ARROGANT AND EGOCENTRIC FOR NAMING THE WORK I DEVELOPED, THE APPROACH USE, IT IS NICE TO GET A COMPLIMENT FROM A BRIGHT ONE LIKE CHRIS, WHO HAS STUDIED A LOT OVER A FEW DECADES AND IS DISCERNING.
Chris Harry B Crawford http://www.capstonemethod.com/tag/chris-crawford/ Jerry, I want to thank for the work you have developed. After taking your seminar in Norfolk I began to use your approach in my practice. I have a client that had seen a very good PT, a great local Chiropractor and an old school Osteopath. They all at some point had told him that was all they could do for him. I had been through my whole bag of Manual Therapy tricks. I work a lot with sacral torsions, upslips, etc. I have tried everything I know several times. This guy had a crazy pattern. I couldn't wait to access him with your spring tests and Hesch Method approach. He came in yesterday. After one treatment, and the first words out of his mouth were "you fixed me". I wanted to do a back flip! Amazing work, thank you! Jerry Hesch I find severe restrictions require treatment of the ribs bilaterally if a symmetrical motion restriction , otherwise, if unilateral; a rib on none side of restricted thoracic segment and on the other side typically a few segments below (or above). Me thinks the sympathetic chain a big player, has attachment ton rib head. Rib treatemtn very direct, obeys a fe rules, most complex at #1. Unfortunately some works really over complicate the mechanics, make it very essoteric, more than it needs to be per this opinion. Big secret: low force long time, minutes in one or two direction, then reeval, then eval the other motions as may permutate.
2 minutes ago · Jerry Hesch Allow me to go oblique. If you find a competent manual therapist ask them to do a complete evaluation of the foot and ankle joints, knee, hip, T-spine, rib cage, cervical and shoulder girdle in addition to whatever lumbar and "SIJ" eval they do. Here is a very interesting example.
Jerry Hesch I recently consulted on a SIJ case that chose not to go the surgical route and was nearing the end of her rehab, utilizing a team approach. She was unstable in the knee and ankle! Jerry Hesch I told her: "This is a one in 500. Your talus (big bone in ankle) is stuck posteriorly, very rare, not even on the radar of most manual therapists. Your distal femur (top knee bone) is stuck in posterior glide also. I demonstrated her lack of balance with a surprise push and unilateral standing on that leg versus right. A one-time fix at knee and 2x at ankle. Stable now. Bingo that is a part of the problem. Jerry Hesch In summary, i suggest that the body works as an integrated whole and, a real hands-on whole body evaluation is important especially when full progress is not happening over time. Yes, stability of the left ankle and left knee contributed to left sided "instability". this one would have been another SI fusion failure if she had gone that route. Stability in the left SIj is a sum total of the stability in the left foot and ankle, the left knee, the left hip, the left SIJ, the left symphysis pubis, the left lumbar spine and trunk and shoulder girdle (see the latissimus dorsi muscle that connects pelvis and shoulder) and ROSITA THE MUSICIAN gimme a drum roll...THE SIJ ON THE OTHER SIDE!!!. Jerry Hesch:
I define hip hiking as active and muscular driven. Upslip I define as subtle because there is remarkably little vertical mobility in the sacroiliac by design, thus, even true instability seldom manifests as Upslip. Upslip will have an absence of superior and of inferior passive joint motion testing of 10 to 40# varying client to client. The sacrotuberous ligament is lax in an Upslip, not so in hip-hiking. Posted in manual therapy blog, https://www.facebook.com/groups/288423771210717/293725407347220/ lots of interesting topics. Jonathan George started it recently. Great thinker, great clinician somewhere in New Hamshire? Where are you Jon? A little bit meandering, but a few key concepts worth the read, perhaps!
Jon, yes and no regarding nerve impulse. The ratios of the collagen and ground substance summate as the physical, deformable properties along with length, circumference of body AND of origin and insertion, etc.; Newtonian physics. These have been known at least in general terms for a very long time which does not detract at all from DR Gracovetsky's very unique perspective, which continues to evolve. His body of work of course greatly exceeds his recent chapter. Yes, but not directly. There are 4 mechanoreceptors (at least) to ligament and these have a profound real time regulating influence on muscle tone. Muscle tone has a significant and perhaps clinically underappreciated effect on ligament tone. I discovered on myself (applying treat the other side strengthening approach) that I could resolve a chronic laxity of 2nd MP joint that was lax and painful. It was decades old and resolved in 2 minutes treating it reflexively via the opposite side, same anatomical location. That is eye-popping crazy to observe. It of course will not work if the TRUE CAUSE is actual ligament damage that arbitrarily is moderate plus to severe. I have followed the work on mechanoreceptors for 3 decades, Barry Wyke work and Crutchfield and Barnes, and many others. Any text on Orthopedic Physical Therapy and on Orthopedic Manual Physical Therapy should give broad coverage to the physical properties and the innervation. One that really influenced me was Currier and Nelson Dynamics of Human Biological Tissues. Robert Schleip has a brilliant chapter in Dalton's Dynamic Body book (other than a peculiar stab against sacral torsion contrasting it with "Inclusion of facilitated active client MICROMOVEMENTS during hands-on work." I teach my clients on day one to do self-directed micro-movements to correct and self-treat the sacral movement and self-correct the torsion; rather than develop a dependent patient-practitioner relationship; noble Indeed! Perhaps he has read my chapter by now and is pleased with the manner in which I practice and teach. If not, he should. The ligaments only "contract" based on extrinsic forces, there are no active contractile elements in ligaments. The ratios as you propose do vary person to person to some degree and within the person the ligamentum lfavum in the spine has more yellow elastin than the other spinal ligaments, the pubic ligament and fibrocartilage contain larger amounts of elastin than typical ligaments. This is an interesting study. there are many causes of inguinal pain. this is a surprising result, because the innervation level of the inguinal area is higher in the spine, such as T12-L1-L2 and this report speaks of fusions at L4-L5. These results are surprising and are sure to provoke conversation.
Spine: 15 January 2012 - Volume 37 - Issue 2 - p 114–118 doi: 10.1097/BRS.0b013e318210e6b5 Clinical Case Series Lumbar Disc Degeneration Induces Persistent Groin Pain Oikawa, Yasuhiro MD; Ohtori, Seiji MD, PhD; Koshi, Takana MD, PhD; Takaso, Masashi MD, PhD; Inoue, Gen MD, PhD; Orita, Sumihisa MD, PhD; Eguchi, Yawara MD, PhD; Ochiai, Nobuyasu MD, PhD; Kishida, Shunji MD, PhD; Kuniyoshi, Kazuki MD, PhD; Nakamura, Junichi MD, PhD; Aoki, Yasuchika MD, PhD; Ishikawa, Tetsuhiro MD; Miyagi, Masayuki MD; Arai, Gen MD; Kamoda, Hiroto MD; Suzuki, Miyako MD; Sainoh, Takeshi MD; Toyone, Tomoaki MD, PhD; Takahashi, Kazuhisa MD, PhD Abstract Study Design. Prospective study of 212 patients with groin pain but without low back pain. Objective. To evaluate discogenic groin pain without low back pain or radicular pain. Summary of Background Data. Patients feel low back pain originating from discogenic disease. It has been reported that the rat lower lumbar discs are innervated mainly by L2 dorsal root ganglion neurons. Thus, it is possible that patients feel referred groin pain corresponding to the L2 dermatome originating from intervertebral discs; however, the referred pain has not been fully clarified in humans. Methods. We selected 5 patients with groin pain alone for investigation. The patients suffered from groin pain and showed disc degeneration only at 1 level (L4-L5 or L5-S1) on magnetic resonance imaging. Patients did not show any hip joint abnormality on radiography or magnetic resonance imaging. To prove that their groin pain originated in degenerated intervertebral discs, we evaluated changes in groin pain after infiltration of lidocaine into hip joints and examined pain provocation on discography, pain relief by anesthetic discoblock, and finally anterior lumbar interbody fusion surgery. Results. All patients were negative for hip joint block, positive for pain provocation on discography, and positive for pain relief by anesthetic discoblock. Furthermore, bony union was achieved 1 year after anterior interbody fusion surgery in all patients, and visual analogue scale score of groin pain was significantly improved at 1 year after surgery in all patients (P < 0.05). Conclusion. In the current study, we diagnosed discogenic groin pain, using magnetic resonance imaging, infiltration of lidocaine into the hip joint, pain provocation on discography, pain relief by anesthetic discoblock, and lumbar surgery. It is important to consider the existence of discogenic groin pain if patients do not show low back pain. Inquiry from a sacroiliac FB group:
For those of you who had surgery from Shamie, Rudolf or Kube-how are you doing? How did they handle the alignment situation prior to surgery? Did they monitor for nerve issues during surgery? Thanks much. Any other surgeons one would recommend outside the GA team. Thanks Jerry Hesch One who turns away clients because she/he discerns that there are other issues present. Any surgeon who does not believe that magically everyone who walks in the door needs their kool aide surgery. One who educates, refers out, orders more tests when appropriate, one who stays in touch with medical literature, one who has the patient's best interest at heart, one whose Physician:Patient (I call them clients) is one of committment such that if you have any problem, any concern after the intervention; you can get a return call in 48 hours, sooner for emergency, one who communicates with your at-home physician team, one who does not pay anyone to Facebook market him, one who does not do surreptitious private messaging marketing, one who does not say "You want to get you life back don't you?" who has the balls to stand up to any physical therapist who tries to dictate what kind of hardware to install, one who does not have a financial relationship with the Physical Therapist, nurse, PA, or kool aide stand. Who understands that joint alignment and alignment of the external landmarks: ASIS, PSIS, pubic tubercles, pubic crest, sacrum and PSIS, ischial tuberosity et al; ARE NOT ONE AND THE SAME. One who values constant continuing education as opposed to dogma, on who belongs to several professional organizations, and who refers to Physical Therapists who are members of APTA, Orthopedic Section APTA, AAOMPT, active in clincal AND research, writing and presenting, (or at least 2 of these) PT who reads Spine journals, JOSPT, PTJ, J MAnual & maniupulative Therapy, etc., etc. One whose success rates are objectively measured. Whether this surgeon and PT are in GA as you ask or in Norfolk, or Tuscon; well worth the research. and more... SACROILIAC FUSION ALIGNMENT????
I see fusion x-rays in which the vertical measurements are fairly "aligned" but the medial to lateral are NOT, and I see symphysis pubis that are NOT aligned. Please explain. Is there some hidden research or even sound theory that states "you only have to align the vertical aspect of the ilia" prior to some form of SI fusion, but not the medial to lateral? Not the symphysis pubis??? Separately, I have good research that indicates that you cannot use these x-rays to determine "alignment" because of something called boundary conditions, AKA frame of reference. If the person is x-rayed lying on the table a slight muscle spasm of any major lumbopelvic muscle can cause asymmetry, such that an x-ray will look like the pelvis is "mis-aligned". The SI joint might very well be perfectly aligned. I could go on and on, but the alignment mythology does not hold up to scrutiny. There is a deeper problem and yes we should optimize structure and function, but there is a vast grey zone between alignement of the pelvic bones and what happens inside the SI joints and inside the symphysis pubis. This I know, you cannot have an aligned SI fused joint and have a misaligned symphysis pubis joint (with very few exceptions). Cherry picking literature to pass out purple kool aide = $. There are more than a dozen dysfunctions that are missed with the traditional SI alignment theory. For example, lower pubic alignment; not even evaluated. Medial to lateral ischial alignment: not even evaluated in this vintage paradigm. Anterior – to - posterior ischial alignment; not even evaluated. Oblique PSIS (mobility and) alignment, Anterior/posterior glide PSIS movement and "alignment" yadayadaya! Apparent superior/inferior pubic alignment is not being addressed in these case series. I can help as can many others. Perhaps this new not for profit (or non-profit; 2 distinct legal entities) should work on better prevention, better screening, not proving that the grape kool aide is best. Sign me up if science is what we want. It is what we need; not mythology. However if marketing is what is needed...Sacroiliac belief systems are quite a bit like faith based beliefs. They are not factual in whole, much is by definition; faith based. I suggest that anyone considering SI fusion follow the protocol to the nth degree. COMPLETELY rule out lumbar as primary, COMPLETELY RULE OUT hip as primary, etc. The carnage is immoral. SI-Bone gets mentioned frequently, but they are the manufacturer. The responsibility of how it is applied falls in the hands of those clinicians that are allowing and encouraging these surgeries, and it is their responsibility to follow the protocol COMPLETELY. The manufacturer cannot legislate how the individual practitioner practices. There is and has been very good care for SIJD happening all over the country as has been for decades. This new kool aide in which SIJD is POORLY DEFINED becomes a trash-can diagnosis for any, and all kinds of failed back syndrome, is dumber than goats smoking weed. Sign me JERRY HESCH, MHS, PT HESCH INSTITUTE accountable to the Ethiics and standards of the American Physical Therapy Association, the Nevada Association APTA, the State of Nevada Physical Therapy licensing board, AAOMPT, etc. Call me on the carpet if I violate any of the above. Jonathan and group
Part of THE METHOD I use treats joint restrictions at Occiput-C1 in a very close to neutral position, using less than 10 degrees of side bending and rotation. There is very limited motion available at this joint and retesting cautiously with coupling of other upper segments will be an added measure of success. I treat everything below first, meaning below C4 to the toes, because biomechanically and reflexively C1-C2 will compensate with contralateral rotation and slight side glide. Then I treat top down, Occiput-C1, then C1-C2 if restricted, and C3 if indicated. I am referencing unilateral patterns a bilateral is another beast. Great questions you pose! Afterwards I do soft tissue work but proceeding with soft tissue work sometimes can be very helpful, less so if reflexogenic response at play. Always helpful after, and oftentimes much softer in response to the joint work. |
Dr. Jerry Hesch, DPT, MHS, PTMarried with 4 grown kids. Earned my Doctorate at A.T. Still University in Tempe, AZ, MHS at the University of Indianapolis and my BS PT at University of New Mexico. I enjoy working with my hands and particularly making glass objet d'art. Powered by Calendar Labs Archives
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