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"SIJD" with sciatica, PN and muscle weakness

2/29/2012

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Actual Email reply to an inquiry re "SIJD" with sciatica, PN and muscle weakness.
February 26,2012 
 
Dear  XXXXXX

    You have been on my concern list having read some of your posts, though I do not do any form of aggressive marketing to the group, as most already have health care providers, though if I  had a magic wand, would screen a few, XXXXXXX is also on my worry list, and I worry about some who slowly sip the kool aide and end up getting an sijd fusion for a problem that comes from somewhere else. The marketing can be unintentional and very subtle. The name of the group should be changed to something that encompasses the entire spectrum of co-factors; especially the lumbar spine and hip, and gynecological...My philosophy, "Conservative care, put patient first," and above all “DO NO HARM.” Like I told my recent client, “people need information.” That is what I do as much as I do highly skilled manual therapy to the whole body, because injuries affect the WHOLE BODY. When one has complex sijd with a lumbar or thoracic spine as primary, or when the signs of sijd are simple false negatives, not the real cause, you can present as such. SIJD is a diagnosis of exclusion after the thoracic spine (rare disc herniation there) and thoroughly ruled out lumbar pathology, disc herniation, stenosis with impingement, radiculopathy, etc, then thoroughly clear the hips, and gynecology, you can go on and screen for sijd.

     I  perform very thorough whole-body evaluations including all of the above and my sij eval is much more thorough that the current standard, has been for 25+ years. The current tests are really not the “gold standard” that is being marketed. If ever in Las Vegas and you want an evaluation plus or minus treatment my work is complete within 1, 2, or 3 visits, going much further than standard PT and working very hard to make patients independent of me able to  manage the sijd but of course need continued strengthening via formal PT or some program at home. You can read about it in the patient section at  www.HeschInstitute.com
then: FOR PATIENTS

     If I knew more about your condition, I could be more helpful, but the only way to do that is to invest a reasonable amount of time, I read the records you send and call you afterwards. This typically is accomplished in 30 minutes sometimes 45, rarely more. So a phone consult is done before we ever schedule a visit, and sometimes it does not need to go any further. I have helped a few in this manner and sometimes help means encouraging a specific workup that has not been done, and last week I discouraged someone from coming to see me because I know that his problem is neurosurgical/pathology that is beyond my advanced skill set. Sometimes the eval can be useful when a change of perspective is needed, as people do tend to “marry the diagnosis” and sometimes that will not and cannot satisfy in the long run. I do know the limits of my knowledge, a very important perspective all clinicians should embrace (when to refer, when this paradigm is not the correct one, etc.).

     I hope this is helpful. Best advice; think outside the sijd box.

     I do know that some do benefit from surgical stabilization, but dislike the failures of the marketing process, attracting some with WRONG DIAGNOSIS.

Best  Regards,
Jerry Hesch
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COCCYX ARTICLE JUST PUBLISHED

2/23/2012

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Noteworthy that about 1/3 seemed to have mechanical cause the other 2/3 noteworthy.
Eur Spine  J. 2012 Feb 22. [Epub ahead of print]
Magnetic resonance imaging findings in the painful adult coccyx.
Maigne JY, Pigeau I, Roger B.

Source
Medicine Physique, Hotel-Dieu Hospital, Hotel-Dieu de Paris, 75181, Paris
cedex 04, France, jy.maigne@htd.aphp.fr.
 
Abstract
OBJECTIVE:
Imaging of the painful coccyx currently relies on standard and dynamic radiography. There are no literature data on MRI of the coccyx. This examination could provide information on the cause of pain.


METHODS:
172 patients with severe chronic coccydynia underwent MRI and dynamic radiography of the coccyx.


RESULTS:
Disc abnormalities (seen in 70 patients) were related to either the presence of intradiscal liquid effusion (17/70), or abnormality of the endplates similar to Modic 1 changes (38/70), or uncertain abnormalities (15/70). Abnormalities of the tip of the coccyx (seen in 41 patients) were located in the surrounding soft tissues: venous dilatations (18/41), soft tissue inflammation (13/41) and ambiguous images (9/41). Vertebral bone oedema was observed in five cases and a benign tumour was observed once. The type of imaging feature depend broadly on the mobility of the coccyx: the 105 cases with a mobile coccyx mainly presented
abnormal features mainly in a disc (63 cases vs. 4 cases for the tip), whereas the 67 patients with a rigid coccyx mainly showed abnormal features at the tip (37 cases vs. 7 for the joints, p < 0.001).

 CONCLUSIONS:
We recommend MRI of the painful coccyx when dynamic radiography fails to reveal clearly a pathological lesion (i.e., normal or slightly increased mobility of the coccyx or a rigid coccyx lacking a spicule).
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Nice follow up: severe sciatica 2 years duration

2/22/2012

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This is a spontaneous Email from a PT from out of state.  I saw her once and gave a strong letter suggesting a work up for discitis (infection in the disc) and this or a lower thoracic herniateion after testing with provocation, first in neutral, then extension, then child pose, tapping T1-S5.  She had 2 fairly normal MRI’s yet severe sciatica for 2 years, obviously in significant duress, runs a large practice, has a 3 year old and a one year old and this really affects her ability to be a mom. 

“…I have felt improvment no doubt due to seeing you. I have more range of motion without
such a stiff end range in every position I tried. I would have unrelievable pressure that seems you have really helped. I do think the underlying cause you are probably right on track with the discitis. After researching it, it makes more since.  This is the best I have felt in over a year, and the cheapiest thing yet.


 …Shirley Sarhmann has a great outlook on the effects on mal alignment and recoil etc.…If
someone would put her methods and yours together, it would be amazing. In fact that was the approach I took. I had two 270 pound men who were thinking of surgery become pain free by using your and her techniques. And they lost no weight….THank you, Thank you, Thank you. And I will now return any help i can to  you
. “
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Pelvi Pain Book is Remarkable

2/17/2012

1 Comment

 
Book Review

 CHRONIC PELVIC PAIN AND DYSFUNCTION: Practical Physical Medicine
 Leon Chaitow, Ruth Longrove 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 ofscreening 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 as being a belief system that predicts failure of intervention (see Figure 1.1).  Although this perception is valid at times, 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.PelvicInstability.org.au, (one of several) orthopedic trauma research, obstetric literature, 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
1 Comment

Checking Spinous Processes for Alignment

2/16/2012

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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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MASSAGE THERAPIST GRATEFUL FOR "THE METHOD"

2/15/2012

1 Comment

 
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!

1 Comment

Brief Commentary on T4 Syndrome

2/8/2012

2 Comments

 
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 ·
2 Comments

SACROILIAC INSTABILITY NEEDS A WHOLE BODY EVAL: one example knee and ankle

2/7/2012

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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!!!.
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HIP HIKING VERSUS UPSLIP ILIUM

2/6/2012

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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?
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Fascia, Contractile Elements Neural Influences

2/5/2012

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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.
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    Jerry Hesch, MHS, PT, DPT(s) – Las Vegas Physical Therapy

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    Dr. Jerry Hesch, DPT, MHS, PT

    Married 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.

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