OBSTETRIC PUBIC SYMPHYSEAL DIASTASIS: IMAGING SUPPORT OF A 
 NOVEL BIOMECHANICAL MODEL
 Hesch,  J
 Hesch  Institute, Henderson NV, USA
 
Introduction
In  pregnancy pelvic joint and pelvic outlet widening occurs in response to
ligamentous softening, fetal growth, and parturition. Obstetric pubic symphyseal
diastasis (OPSD) is widening of the symphysis at mid-joint of 10mm or more.
Progressive widening can provoke severe pain and functional impairment. Most
recover with conservative care; surgical stabilization is typical for 25mm or
greater. Chronic painful pubic dysfunction due to OPSD is a poorly understood
disabilitywth chronic widening of less than 10mm, pain and functional
limitations. MRI and CT images undergird novel biomechanical interpretation,
suggesting treatment modification.
Purpose
To  present a novel hypothesis that OPSD involves a distinctly different
biomechanical trajectory rather than simply a traumatic escalation of peripartum
pelvic mechanics.
Materials  and Methods
Articles  gathered from www.PubMed.org and general web searches using key words
 symphyseal diastasis, pubic joint instability, obstetric instability, and pubic
 instability, covering 1997-2012. MRI and CT images were evaluated in cases of
acute OPSD with gapping of anterior-superior SI joint  (SIJ).
Results
Several  images demonstrated SIJ gapping with a peculiar previously unreported,
inferior-posterior retroarticular approximation; provoking further inquiry.
Testing with ligamented pelvis and flexible anatomical models was performed to
simulate obstetric joint and outlet widening. This included sacral nutation,
medial infolding of the ilia, and spreading of the ischial bones, lower pubic
and SIJ, as described in the literature. A distinct compressive end-point was
encountered in the superior-anterior SIJ and superior pubic joint, where no
further expansi on  could occur. Diastasis was introduced by cutting and separating the
joint.
Relevance 
Replicating  the gapping of the superior SIJ, congruent with the OPSD x-ray, MRI and  CT  images, actually reduced pelvic outlet dimension. Only by moving the pubes and  ilia in a cam-like manner, coupled with posteromedial glide at the SIJ’s,
primarily in the transverse plane, was pelvic outlet maximized. No other
trajectory was able to enhance outlet dimension to this degree.
Conclusions
 Imaging  and mechanical testing support the hypothesis of novel biomechanics with OPSD.  Research using this hypothesis may identify optimal intervention for acute and
chronic cases.
Discussion
The  unique properties of the axial ligament; size, location and decreased elastin, suggest that in the presence of OPSD it may function as a mechanical stop during
 parturition, maintaining optimal pelvic outlet dimension. In chronic cases,
 muscular and ligamentous recoil may be absent or insufficient, preventing
 form-closure. The chronic pubic dysfunction and OPSD populations are especially
 in need of improved care. In vivo biomechanical research during parturition is
 improbable. Computer modeling and pre/post intervention imaging and functional
 metrics seem reasonable.
 Implications
 A   diagnostic tool may already exist in the form of CT or MRI images in the
  medical record. Passive external forces directed at reducing the unique
  cam-like transverse plane movement of the ilia prior to or during application
  of a pelvic binder at the trochanters, an orthopedic standard of care may have
  merit. 
Keywords: obstetric pubic  symphyseal diastasis, SIJ, axial ligament, pelvic
binder.

http://erikdalton.com/low-back-pain-foot-posture/

It is a nice article though the description of the cuboid mechanics is not congruent with what I find clinically. Also, the description of the definition for pronation and supination change from non-weight bearing as described to weight bearing due to the forces of the ground resisitng abduction and adduction; which for the most part are confusing terms indeed. A deeper exploration should explain the difference between forefoot and rearfoot pronation/supination because some feet have for example rearfoot supination and forefoot pronation, especially in weight bearing and the perspective of the clinician becomes very important in communicating terminology, using terms such as compensated and uncompensated. I am proud to be one of the clinicians who influenced some of Erik's work on the SIJ/pelvis through my home study course.  Its OK Jerry you have worked hard and so much of your work is gratis, OK to share your pride

“Let me first differentiate between belief systems and science. 
  A belief system is a body of concepts, ideals or narratives that
through written or oral tradition and historical precedent have become an
  integral part of a culture. Verification is dependent on faith in its tenets:
  Ergo—subjective. A belief system need not concern itself with objective
  reality. 
This contrasts with science in which theories are
subject to objective evaluation by repeated experiment and measurement. Science
assumes a priori the existence of a measurable objective reality. Indeed,
science is the delineation of this reality. The precision of the replication of
experimental results and the accuracy of theory in making predictions, even when
both observers and theorists may initially have a wide variety of theoretical
  considerations, is the affirmation of the scientific approach to the   comprehension of the cosmos.” *

 SIJD with sub-clinical (cannot be measured objectively such as
with x-rays, MRI’s CT scans, etc., qualifies as a belief-system diagnosis. 
 
Severe pelvic instability is science. It is measured with x-ray,
CT scan, MRI and objective measures such as degrees of separation, whether at
the symphysis pubis joint (primary instability with intact SIJ) or symphysis
pubis instability with subsequent SIj instability. See Tile classification
system.

 For any and all who travel to see SIJ “experts” to see if they
need a SIJ fusion with adjustment (a completely subjective thing), you are
  entering a world that is objectively named: A BELIEF
SYSTEM.

 Jerry Hesch, MHS PT
*

• Dr.
  Michael K. Gainer is     Emeritus Professor of Physics and former chair of the
  Department of     Physics at St. Vincent College in Latrobe, PA. At St. Vincent
  he taught     astronomy and advanced undergraduate physics courses for physics
  majors.     He is the author of Real Astronomy for Small Telescopes, published
  by     Springer in the Patrick Moore Practical Astronomy Series in 2006. Prior
  to     his academic career he was a member of the scientific staff at the U.S.  
     Army Ballistics Research Laboratory at Aberdeen, MD. There he conducted    
  research on hyper velocity metal deformation in high intensity shock waves.    
  Above quote from Eskeptic Wednesday, January 23rd, 2013 
  |      ISSN
  1556-5696

This is a very kind and thoughtful feedback from a recent client. The feedback demonstrates the value of a whole-body articular evaluation and treatment. I believe also that the work paved the way for clarifying that which was amenable to hands-on care, and that which was not, rather than being a vague interlinked unclear pain generator. I am referencing the inguinal pain. I will write back and share some other thoughts to consider re the inguinal pain as part of her medical work up. I am very grateful for this kind feedback.

Dear Jerry,
  I just want to  thank  you again for helping me out with my back.  I feel like I am getting  my  life  back.  Medical Doctors, Chiropractors, Acupuncture, Physical Therapy, Physiatrists and Pain Specialists were not able to accomplish in nearly a year and a half (and more than 50 office visits) what you accomplished in twenty to thirty minutes during my first visit.  I am still in awe of the fact that I am no longer in constant pain.  It has been nearly two months since you treated me and I am continuing to improve in many respects.  I am still dealing with some nerve irritation when I sit but I have no back pain at all from sitting.  I can walk as long as I like.  I am able to do most chores around the house without paying the price afterwards.  I am even back to work and teaching a class online  this quarter for the university since I can sit with no back pain.  I can also  still move and turn my mid back at the thoracic lumbar junction where
it was  frozen before.  I am spreading the word about the great work you do.  I have  shared with my local physical therapist, pelvic floor therapist and the pain  doctor I was seeing in Seattle.  I have not had to see any of them since I saw  you in November.  I also shared information with my cousin, (the OB/GYN  from Bend, Oregon who also suffers from terrible back pain in the lumbar and SI  region)  whom I mentioned when I saw you in November.  She is very impressed  that I am still feeling great nearly two months later.  I believe she too will  be contacting you if she already hasn't.  
      My daughter, is doing well.  She occasionally has some knee pain but not with the same frequency as she had before she saw you in November.  
     Thank you so very much Jerry.  I will keep you posted and I will continue to share with people who have treated me and people who could use your help, the great work that you are doing and giving people their lives back.
Sincerely,
Chantelle Hildreth

Spine:
POST ACCEPTANCE, 15 January 2013
doi: 10.1097/BRS.0b013e318286b7dd
Clinical Case Series: PDF Only
Do L5 and S1 nerve root compressions produce radicular pain in a dermatomal pattern?Taylor, CS BSc, MBBS; Coxon, A PhD, MBCS, MICR; Watson, P BSc; Greenough, CG MD, MChir, FRCSPublished Ahead-of-Print


Abstract
Structured Abstract: Study Design. Observational case series.

Objective. To compare the pattern of distribution of radicular pain with published dermatome charts.

Summary of Background Data. Dermatomal charts vary, and previous studies have demonstrated significant individual subject variation.

Methods. Patients with radiologically and surgically proven nerve root compression caused by prolapsed intervertebral disc completed computerised diagrams of the distribution of pain and pins and needles. 98 patients had L5 compressions and 83 had S1 compressions.

Results. The distribution of pain and pins and needles did not correspond well with dermatomal patterns. Of those patients with L5 NRC, only 22 (22.4%) recorded any hits on the L5 dermatome on the front, and only 60 (61.2%) on the back with only 13 (13.3%) on both. Only 1 (1.0%) patient placed >50% of their hits within the L5 dermatome. Of those patients with S1 NRC, only 3 (3.6%) recorded any hits on the S1 dermatome on the front, and only 64 (77.1%) on the back with only 15 (18.1%) on both. No patients placed >50% of their hits within the S1 dermatome. Regarding pins and needles, 27 (29.7%) of L5 patients recorded hits on the front alone, 27 (29.7%) on the back alone and 14 (15.4%) on both. 19 (20.9%) recorded >50% of hits within the L5 dermatome. 3 (3.6%) S1 patients recorded hits on the front alone, 44 (53.0%) on the back alone and 18 (21.7%) on both. 12 (14.5%) recorded >50% of hits within the S1 dermatome.

Conclusion. Patient report is an unreliable method of identifying the anatomical source of pain or paraesthesia caused by nerve root compression.

Journal of  Bodywork & Movement Therapy just informed me that they are publishing my  book review of Chronic Pelvic Pain and Dysfunction: Practical Physical Medicine
in 2013;17:77-78. I cannot post the version they sent me, but legally I can post
the one I submitted:
Book  Review
CHRONIC  PELVIC PAIN AND DYSFUNCTION: Practical Physical Medicine
Leon  Chaitow, Ruth Lovegrove Jones 
Churchill  Livingstone, Elsevier 2012
ISBN  9780702035326
I  give this book a very enthusiastic 4.5/5 star recommendation. A slight confusion
may exist in part of the title “physical medicine.” The reader is not given a
clear definition thereof and it should not be confused with the medical
specialty named Physical Medicine and Rehabilitation, of which there is
apparently one contributing author. Rather, I believe that the term “Physical
Medicine” applies to a broad category of hands-on, non-surgical,
non-pharmacological approaches, practiced by a variety of clinicians, perhaps
appreciated by perusing the table of contents, and the interdisciplinary,
international list of contributing authors. Would “manual and movement
therapies” be the same as “physical medicine?” It begs some definition. The
contributing authors cover very wide territory, from multiple specialties. It
truly is an inter-disciplinary work. Hence it is not a book to sell an
alternative or complimentary paradigm, not a “we versus them” approach, but
rather, a large palate that acknowledges the singular complex canvas of complex
chronic pelvic pain that mandates multidisciplinary perspective, and certainly
benefits from skilled hands-on expertise. 

This  book has the accompanying DVD placed inside the front jacket, and there are
instructions for downloading and access to telephonic tech assistance if needed.
Fortunately, it opened with no difficulty and was very much appreciated. It is
very nice to see this very useful DVD in the inside front cover so that readers
will perhaps immediately access it. It is especially helpful in learning some of
clinical applications that are best understood visually and dynamically, versus
only being read. 

An  early disappointment is the fact that not all authors are identified beyond
acronyms such as “MD”. What is their medical specialty, such as urology, or
gynecology, etc.? From the foreword of the book: “…The nature of pelvic pain is
complicated,…This is a coherent volume that helpfully gathers the variety of
regimens and techniques.” This goal is accomplished with an interdisciplinary
group of 22 authors who bring a wealth of experience. The introductory chapter
states: “This book has a single primary aim – to offer a one stop source of
relevant information for clinicians – specialists, practitioners and therapists
– on the subject of non-malignant chronic pelvic pain (CPP), with particular
emphasis on current trends in physical medicine approaches to assessment,
treatment, management, and care.” 

Every  chapter is well written and very well referenced. The graphics and pictures are
very useful as are the various tables. Some of the authors use minor
terminologies that may differ from “American English”, such as “whilst,”
“saddle” for “seat”, “football” for “soccer”, etc., which simply reminds the
reviewer that this is an international group of authors, and perhaps reminds the
reader of this reviewers attempt at being thorough. The book does give broad
coverage in 16 chapters and several sub chapters. Several chapters provide very
unique perspective, such that it is with regret I make mention of only a few
(see previous recommendation re TOC). For example, a chapter authored by a
Urologist brings clinical gems that are clearly beyond textbook knowledge, and
which can only be accomplished with many years of dedicated observation and
experience. A remarkable chapter by an Irish physiotherapist is worth the price
of the book alone, titled; Practical anatomy, examination, palpation and manual
therapy release techniques for the pelvic floor. An exceptional chapter on
external soft tissue manipulation approaches is very thorough in presentation,
very well researched with over 100 references and an abundance of images. It is
followed by another exceptional one on connective tissue and the pudendal nerve,
with an abundance of hands-on eval and treatment strategies. The chapter on
urological CPP has broad overview in 7 pages and does not disappoint the manual
soft tissue clinician with 12 pages on neuromuscular treatment, especially of
internal trigger points. The reviewer feels compelled to remind the reader of
the exceptional DVD covering much of the clinical content. Both genders are
covered throughout the book, and in fact, there is a specific chapter titled
“Gender and CPP”. A noteworthy chapter on sports and CPP which happens to be the
longest chapter in the book, covers broad territory, including detailed coverage
of pressure studies on bicycle saddles (seats) as it relates to pudendal
neuralgia and several other important topics such as osteitis pubis, sports
hernia, hip pathology and peri-inguinal neuropathies, etc.. Many of the sub
topics could be a chapter unto itself, yet the introductory resource here is
still very valuable. 

In  other chapters, topic such as a recent improvement in a wand for self-treatment
of pelvic floor trigger points, and neuromodulation of sacral nerves with
electrodes applied distally (lower leg) truly meet the definition of “cutting
edge” as much as that term can be over utilized and pedestrian. The pudendal
neuralgia chapter is remarkably lucid. Very slight redundancy in some soft
tissue treatment and graphics is non-detracting, especially as different authors
bring unique perspective, and there are enough novel graphics of this complex
region. Limited coverage of the role of physical therapy in utilizing
manipulation and mobilization of the spine and pelvic girdle is disappointing,
seeming to favor the Osteopathic approach. Otherwise, there is an excellent
chapter specifically on Osteopathic approaches, except for an attempt within it
to over generalize the physical therapy approach to lumbopelvic dysfunction,
citing only one rehab model. A 5-star bonus is the appendix with functional
outcome scales with very helpful introductory paragraphs and instructions for
scoring. There are 11 listed clinical outcome measurement tools, including the
very comprehensive IPPS pelvic pain assessment form. The final inclusion is a
description of eight standard pelvic pain provocation tests from the European
guidelines. 

One  disappointment is what I call “a missing chapter element”. Partially covered in
a general manner within the multi-specialty and multidisciplinary (UK) chapter
and the interdisciplinary (US) chapter; is the team approach to this complex
topic, and the listing of multiple specialties. However, the missing element is
a much needed guide which would go beyond the assumption that the client is
already under the care of an appropriate medical physician(s) as part of the
team for CPP. The title of a proposed chapter would be something similar to:
“The necessity of screening for medical referral, what every manual,
alternative/complimentary, body/mind and movement practitioner should know.”
Additional coverage on the topic of pelvic joint instability, obstetric pubic
symphyseal diastasis and orthopedic trauma instabilities seem worthy of
inclusion, perhaps as its own chapter. Unfortunately, some of this is actually
trivialized in the first chapter as being a false belief system that predicts
failure of intervention, which mentions avoidance behavior leading to a belief
in pelvic instability, to interventions to stabilize it, and that this will only
lead to failure of intervention. Although this perception is valid at times,
frightening so, based on heavy-handed web based and social media marketing for
so-called sacroiliac joint instability, there is another side of the coin. Many
other times, as evidenced with traditional imaging, it is a valid contemporary
source of debilitating CPP, as evidenced by web sites such as the www.PelvicInstabilityAssociation.com,
(one of several) orthopedic trauma research, obstetric literature, diagnostic
categories for traumatic (external) and obstetric symphyseal diastasis,
etc.. 
The
book is a carefully crafted work that belongs in the hands of all hands-on
clinicians who specialize in the subject matter or who want to specialize, and
for others who simply desire to be more aware of it. Also as a relevant resource
to practitioners who utilize the team approach. The book has solid, vast,
theoretical underpinning within the first eight chapters, and the following
eight chapters are specific to intervention with an abundance of hands-on
techniques such that “Physical Medicine” practitioners can learn and integrate
in their practice, or, at the very least, fine-tune current skills. This text is
placed prominently on the reviewer’s accessible bookshelf in the clinic, and it
is endorsed with a 4.5/5 star recommendation. 
Jerry
Hesch, MHS, PT
Henderson,
NV USA