This was just submitted to CSM 2014 Women's Health for a paper presentation.

Pelvic joint mobilization for false positive late pregnancy
instability             
 
A 29 year old female in the 32nd week of pregnancy had progressive
pelvic pain and perceived instability feeling that her pelvis was coming apart
in the front. She maintained hip adduction with all positional changes. Gait was
antalgic, with a narrow base of support and shortened stride length. Pelvic
instability in pregnancy is a well-established concept due to the enhancing size
of the fetus, with a background of hormonal priming; particularly relaxin and
  estrogen. Evaluation was performed in a very cautious and limited manner with
  the expectation that significant pelvic instability would be encountered.
  Instead, micromotion testing revealed a surprising, significant hypomobility in
  multiple directions. Within a single intervention her posture and mobility were
  much improved, along with significant pain reduction. She reported significant
  improvement in bladder control and went on to have an easy natural delivery. In
  this case the subjective sense of instability was most likely a reflection of
  the visceral and neural tension and compression in response to the
  3-dimensional non-physiological positioning of the pelvic articulations with
  induced spasm. This case of true hypomobility presenting as subjective
“instability” underscores the utility of joint micromotion testing, AKA
springing with awareness. Hypomobility and hypermobility are relevant peripartum
  constructs.

I  posted a proposal to teach a 2-day and 2 papers for CSM 2014 Women's Health Here
is one abstract.

Pelvic  joint mobilization for false positive late pregnancy instability

 A 29 year old female in the 32nd week of pregnancy had progressive pelvic pain and
perceived instability feeling that her pelvis was coming apart in the front. She
maintained hip adduction with all positional changes. Gait was antalgic, with a
narrow base of support and shortened stride length. Pelvic instability in
pregnancy is a well-established concept due to the enhancing size of the fetus,
with a background of hormonal priming; particularly relaxin and estrogen.
Evaluation was performed in a very cautious and limited manner with the
expectation that significant pelvic instability would be encountered. Instead,
micromotion testing revealed a surprising, significant hypomobility in multiple
directions. Within a single intervention her posture and mobility were much
improved, along with significant pain reduction. She reported significant
improvement in bladder control and went on to have an easy natural delivery. In
this case the subjective sense of instability was most likely a reflection of
the visceral and neural tension and compression in response to the 3-dimensional
non-physiological positioning of the pelvic articulations with induced spasm.
This case of true hypomobility presenting as subjective “instability”
underscores the utility of joint micromotion testing, AKA springing with
awareness. Hypomobility and hypermobility are relevant peripartum
constructs.

It has been busy. Last week submitted 3 abstracts for AAOMPT and this week 2 abstracts and a proposal to do a 2-day session plus 2 papers for combined section next year. Those programs are so finicky and not intuitive as they say so I cycle around a few times trying to do the simple! Will go teach in Cleveland this weekend and Las Vegas the following. Lori Layton will help with lab in Cleveland and Rob Shapiro in Las Vegas. Look forward to the challenge and grateful for the support.

THIS IS AN INTERESTING PAPER, WORTHY OF CONVERSATION.

Am J Sports Med. 2012
May;40(5):1113-8. Epub 2012 Mar 5.
 The effect of dynamic
femoroacetabular impingement on pubic symphysis motion: a cadaveric
study.
 Birmingham PM, Kelly BT,
Jacobs R, McGrady L, Wang M.
 Source
 Department of Orthopaedic
Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
[email protected]
 Abstract
 BACKGROUND:
 A link between
femoroacetabular impingement and athletic pubalgia has been reported clinically.
One proposed origin of athletic pubalgia is secondary to repetitive loading of
the pubic symphysis, leading to instability and parasymphyseal tendon and
ligament injury. Hypothesis/
 PURPOSE:
 The purpose of this study
was to investigate the effect of simulated femoral-based femoroacetabular
impingement on rotational motion at the pubic symphysis. The authors hypothesize
that the presence of a cam lesion leads to increased relative symphyseal
motion.
 STUDY  DESIGN:
 Controlled laboratory
study.
 METHODS:
 Twelve hips from 6
fresh-frozen human cadaveric pelvises were used to simulate cam-type
femoroacetabular impingement. The hips were held in a custom jig and maximally
internally rotated at 90° of flexion and neutral adduction. Three-dimensional
motion of the pubic symphysis was measured by a motion-tracking system for 2
states: native and simulated cam. Load-displacement plots were generated between
the internal rotational torque applied to the hip and the responding motion in 3
anatomic planes of the pubic symphysis.
 RESULTS:
 As the hip was internally
rotated, the motion at the pubic symphysis increased proportionally with the
degrees of the rotation as well as the applied torque measured at the distal
femur for both states. The primary rotation of the symphysis was in the
transverse plane and on average accounted for more than 60% of the total
rotation. This primary motion caused the anterior aspect of the symphyseal joint
to open or widen, whereas the posterior aspect narrowed. At the torque level of
18.0 N·m, the mean transverse rotation in degrees was 0.89° ± 0.35° for the
native state and 1.20° ± 0.41° for cam state. The difference between cam and the
native groups was statistically significant (P <
.03).
 CONCLUSION:
 Dynamic femoroacetabular
impingement as caused by the presence of a cam lesion causes increased
rotational motion at the pubic
symphysis.
 CLINICAL  RELEVANCE:
 Repetitive loading of the
symphysis by cam impingement is thought to lead to increased symphyseal motion,
which is one possible precursor to athletic
pubalgia.
 PMID: 22392561 [PubMed -
indexed for MEDLIN


 

There is one other study that I am aware of re pelvic bone deformation. An interesting consideration re the felt experience of springing with awareness.

Mean range of 3D deformation of the innominate bone (3.39 ±2.92
mm) is comparable to the range of symphysis motion (3.20 ± 2.58 mm; p >
  0.05). Largest deformation within the innominate was present in the transverse
  plane (1.41 ± 3.1 mm). Significant differences (p < 0.01) occured in the
  mobility of the pubic symphysis between male and female specimens. No
  significant gender differences were present in the deformation of the
  innominate bone.
 
Pool-Goudzwaard A, Gnat R, Spoor K. Deformation of the innominate
bone and mobility of the pubic symphysis during asymmetric moment application to
the pelvis. Man Ther. 2012 Feb;17(1):66-70. Epub 2011 Oct
20.

 Source
 Department of Neuroscience, Faculty of Medicine and Health
  Sciences, Erasmus MC University, Rotterdam, The Netherlands.
  [email protected]

 Abstract
 BACKGROUND:
 Angular motions of human joints are frequently accompanied by
bony deformations. In the case of the pelvis it is unknown how much deformation
within the innominate and movement within pelvic joints will occur during an
asymmetrical loading. Deeper insight into this topic could help to increase the
understanding of the biomechanics of the pelvis during e.g. locomotion and
improve interpretation of clinical tests in which manual force is asymmetrically
applied to the pelvic bones.
 OBJECTIVE:
 To test the occurrence of deformation within the innominate and
movement within the pubic symphysis during asymmetric moment application to the
pelvis.
 METHODS:
 In 15 embalmed specimens an incremental moment was applied to one
innominate bone in the sagittal plane with respect to the fixated contralateral
innominate. The three-dimensional (3D) deformation within the fixated
innominate, as well as displacement of the pubic symphysis, were described
during each increment of the moment. Maximal amount of deformation within the
fixated innominate was compared with displacement in the pubic symphysis and
tested for significant difference for all subjects and separately by
gender.
 RESULTS:
 Mean range of 3D deformation of the innominate bone (3.39 ±2.92
mm) is comparable to the range of symphysis motion (3.20 ± 2.58 mm; p >
  0.05). Largest deformation within the innominate was present in the transverse
  plane (1.41 ± 3.1 mm). Significant differences (p < 0.01) occured in the
  mobility of the pubic symphysis between male and female specimens. No
  significant gender differences were present in the deformation of the
  innominate bone.
 CONCLUSIONS:
 During asymmetrical loading both movement within the pubic
  symphysis as well as deformation within the innominate occur simultaneously.
  Deformation of the innominate is the largest in the transverse
plane.

One of my mentors Phillip Greenman, DO passed away on February 7, 2013. Below
is a quote from the sacral torsion chapter I wrote acknowledging his influence
on my work. He has influenced many. 


"I wish to express a debt of gratitude to the osteopathic profession, and in
particular to Philip Greenman, DO, who greatly influenced my development as a
hands-on clinician.  I hope my reinterpretation honors your vision and your
body of work." 



Philip E. Greenman, D.O. Philip E. Greenman, D.O., passed away on
February 5, 2013 in Tucson, AZ due to complications of pneumonia. Dr. Greenman
was born on February 25, 1928 in Deposit, NY, the only son of Joseph and Thelma
Greenman, and was a 1952 graduate of the Philadelphia College of Osteopathic
Medicine. He was in private practice in Buffalo, New York for almost twenty
years before accepting a position at Michigan State University in East Lansing,
MI in 1972, where he served as Professor and Associate Dean of the College of
Osteopathic Medicine before retiring to Tucson in 2004. Dr. Greenman authored a
noted medical textbook and was internationally known for his work and research
in the field of manual medicine. He is survived and fondly remembered by his
wife of 63 years, Patricia Bingham Greenman, his sons John and Jeffrey,
daughters-in-law Laura and Janet, and grandchildren Elizabeth, Alexander, Emily,
Matthew and Andrew. A memorial service will take place at Grace/St. Paul's
Episcopal Church in Tucson at a later date. Memorial gifts would be welcomed for
the Philip E. Greenman Endowed Residency (AS040) by sending a check payable to
"Michigan State University" to MSU College of Osteopathic Medicine, 965 Fee
Road, Room A310, East Lansing, MI 48824.

THEORY REPORT

REAPPRAISAL OF SOME FUNDAMENTAL MANUAL THERAPY CONCEPTS

Hesch J,  Hesch Institute,  Henderson, NV
Corresponding author: [email protected]
 
Every profession benefits from periodic appraisal of their foundational concepts. It is encouraging to note fundamental reappraisals of basic tenets such as recent works on evaluating concave-convex rule, and potential belief such as grade V manipulation being superior to grades I-IV mobilization. Other foundational beliefs and scales may be timely for reappraisal. Qualifiers may enhance the traditional joint movement scale. For example Grade I, II hypomobility can include a fixed, immutable hypo and hypermobility such as in the former; from genetics, age, disease, scar tissue, and for the latter etc. Treatable hypomobility may also be due to proximal or distal reflex or biomechanical faults, muscle guarding, etc. Similar rationale may apply to grades IV and V hypermobility. The mobilization scale could include a separate grade for constant force maintained at end of available range for an extended period of time, AKA viscoelastic creep. Non-synovial joints with dense connective tissue such as the SIJ, symphysis pubis, or joints such as the subtalar with an interosseous ligament, or joints with long-lasting restriction may benefit from creep mobilization. Another concept is that of end feel. A recent case presented  with a bone on bone end feel of both hips with ten degrees of internal rotation.  Initially reluctant, the author ultimately treated it with a gain to 45 degrees within two sessions. A separate topic for exploration would be the limits imposed by language and by categorization, and the value of clarifying  terminologies within manual therapy, medicine and the overall clinician-client  interaction.

Several members of a facebook sacroiliac joint group have informed me that SI-Bone has made their SIJ fusion device unavailalbe to a highly marketed SIJ fusion group. Sometime last year they removed that group from their website where they had a prominent presence.  I submit that a very small part of failed back pain population may benefit from SIJ stabilization but that for many it is not adequately determined and worse: we/they especially physical therapists who promote SIJ fusions DO NOT KNOW WHEN NOT TO RECOMMEND FUSION. I am in touch with some of the horrific failures, and hope for a much improved, and much more thorough algotithm...pray hard and pray fast and take action.

Dr. Paul Rockar, President of the APTA,  issued a press release today regarding
the recent segment in which a Physical Therapist discussed cutting edge
solutions for LBP on the Dr. Oz show. 
The statement is direct and I for one, applaud this effort.  
See it for yourself:
 
February 5, 2013
 
Dear Producer: 
APTA takes exception to the portrayal of ultrasound, Tiger Balm
patches, and bumpy balls as “cutting-edge physical therapy treatments” for back
pain in your recent segment “Cutting-Edge Solutions for Back  Pain.”  While modalities may be used by physical therapists as part of an  overall treatment plan, the focus of physical therapy treatment for back pain is  on evidence-based exercises to improve strength and flexibility, manual therapy  to improve the mobility of joints and soft tissues, and patient education on  ways to enhance recovery, prevent and relieve pain, and avoid recurrence.  These avenues of care offer long-term  solutions rather than temporary, intermittent  relief.

Pleased  to announce this was accepted for the American Academy of Orthopedic Manual  Therapy 2013 conference. As a platform paper or poster; TBD
Case  Study Report

THREE  CASES: PREDICTIVE VALUE OF PASSIVE PELVIC MOTION TESTING IN EARLY INFLAMMATORY  SPONDYLARTHROPATHY AND IN SACROILIAC FUSIONS FROM H1N1 VIRUS INFECTION AND FROM  HARDWARE INVASION VALIDATED WITH CT SCAN

Hesch J 
Hesch Institute, Henderson, NV,
USA
Corresponding author: [email protected] 

Background
and Purpose: Three cases with loss of passive pelvic macromotion (PM) and
sacroiliac joint (SIJ) micromotion (SIJM) are presented. Case one (C1) had an
H1N1 virus infection with pathological left SIJ fusion. Case 2 (C2) presented
with an extensive thoracic and lumbosacral fusion who requested consultation,
anticipated a SIJ fusion. Case three (C3) was an athlete treated because of
significant and lasting drop in performance. Description: The purpose of this
case series is to compare passive SIJM and PM loss with objective imaging (CT
scan) and explore diagnostic utility of SIJM and PM in a case of early,
not-yet-diagnosed inflammatory spondylarthropathy (IS). Outcomes: Unilateral
loss of PM and SIJM in C1 and C2 correlated positively with unilateral SIJ
fusion per CT scan. Normal joint space at S1 and S2 and absence of joint space
at S3 from hardware invasion was observed in C2. Inability to gain PM, SIJM in
C3 aroused suspicion of SIJ pathology and provoked rheumatologic referral.
Discussion and Conclusion: The PM and SIJM tests correlate with fused SIJ’s,
have utility for a subset of subjects who contemplate SIJ fusions, and for early
detection of IS in which early SIJ fibrotic changes may escape early detection,
delaying definitive diagnosis up to 10 years from initial onset.