Dear Mr. Hesch,

 

I recently attended your course and you were kind enough to use me as a demonstration according to my symptoms. In Sept of 2013 I injured my wrist as a glass cup shattered cutting my wrist and sending me to the emergency room. I received five stitches and was in a wrist brace for three weeks. Ever since then I have had deep ache pain and compression over incision on R palmar ulnar process. I also found I developed hypermobility in the R wrist causing increased pain with wrist extension. Mr. Hesch manipulated my L wrist which he explained would turn on protective receptors in the R wrist increasing stability. After the treatment I did feel more stability in the R wrist with less discomfort during wrist extension and deep ache pain was no longer present. I also found activities such as holding a glass and typing were no longer bothersome at incision point later that day.

 

I was a dancer for 16 yrs performing ballet, pointe, hip hop, tap, jazz and modern. I have had R hip pain located over PSIS that radiates to R groin region. I have pain in those areas when sitting or standing for more than 30min and always felt as if I was dragging R LE when walking. I also notice R sternal pain when performing UE activities and would feel a prominent press against my bra on the R. I have also suffered from late day headaches starting at the R mastoid process and shooting into occiput coupled with a long history of jaw tightness. I experienced limited jaw movements from a young age waking up with soreness in jaw and needing to cut food into small pieces due to limited ROM of jaw.

 

Mr. Hesch diagnosed me using his spring methods and visual observations. Mr. Hesch treated all my symptoms with his techniques using foam rolls, manual over pressure and independent standing positions. I felt immediate relief with decreased jaw pain and neck pain with greater ease with cervical ROM as well. I noticed less pressure in R PSIS location and no longer felt as if I was dragging R LE upon walking. I also no longer had tenderness or protrusion in R sternum.

 

I was very pleased with the treatment and relief I received. I also appreciated the independence his style of treatment gave me to maintain relief on my own. I felt the Hesch Method was very informative, made sense with previous knowledge I had and demonstrated effectiveness in myself and others that were used as demonstrations during the course. I will be using the Hesch Method to treat my patients as a Physical Therapist Assistant and feel extremely equipped to handle lumbopelvic and sacroiliac dysfunctions due to the experience at his course and with his course workbook.

 

Thank you again for all your help, time and knowledge. I will be looking forward to another course with you.

 

Feel free to quote. 

Danielle Vieira, PTA

APM Spine and Sports Physicians  

Norfolk, VA  

https://www.youtube.com/edit?video_id=YOlBXCKZ5z0&video_referrer=watch

Spontaneous Email March 19, 2014

I enjoy helping our own, PT's lead such active lives so come with sports injuries and the work such as in nursing homes and hospitals is brutal on the body. I was pleased to be able to treat Emily at the last workshop, use gentle common sense Hesch Method. I am grateful for her feedback and hope to return to the region to present on the upper body and lower body. Also just today treated a very successful retired PT who treated olympic men's gymnastics and LPGA tours. Made some definitive gains and encountered some real limitations, and I take comfort in knowing the difference, calling my limitations early on.

As I reflect on the recent seminar I reflect on one of the most mobile scapulas I have seen and two very surprising stuck lateral clavicles and yes she did have some symptoms of thoracic outlet, early /mild symptoms. Mobilizing them forward make a significant difference in her posture, in the tone of her abdominals, in the scapular stability. I love it when the body surprises me and presents the unexpected, I always learn, become a little more attentive, a

This is Emily's email:

• [email protected]

Hi Jerry,
This is Emily Thomas. I was at the Hesch Method course in Sigourney and you worked on my knee and ribs/hip. I just thought I would let you know that I have been doing awesome since having you treat me. Since you treated my femur I have been able to do squats, lunges, and stairs without pain. When treating patients I have also been able to do resisted running with patients, push people in wheelchairs up/down the ramp, and demonstrate jumping exercises without any pain.
You also mobilized my lower right ribs to decrease pain and hip flexor tone. Every day I have been amazed at how much this has improved. I used to have a large amount of tightness and pain with running and spent a significant amount of time stretching my right hip flexors before and after working outs. As of today I have only had 2 out of 10 days where I felt my hip flexors were tight. In both instances I laid supine for 5 minutes with a 2" foam roll placed under those ribs. Both times I had immediate relief of symptoms upon standing.  This also fixed the sensation of hip pain when I needed to go to the bathroom.
In addition to having you treat me, we have had great success thus far with the information we learned in your class. My coworkers (Wendy and Sarah) and I have felt very confident with our skills and have made huge gains with some patients!
After talking with my boss and co-workers, we are all very interested in the possibility of hosting the Whole Body course. I work for RehabVisions which is a large company that has clinics in 11 states, but many of the clinics are based in small towns in Iowa and Nebraska.  I am assuming if they allowed us to host the class it would be only for RehabVision employees, but I am not certain of this. I looked at the course description and it appears you teach upper spine and UE one day, and lower spine and LE the next day.  One thing that is a little different with our company is that our Occupational Therapists see many of our shoulders and elbows. Due to that, we are wondering if it would be possible for the OTs to attend 1 day of the class and PTs to attend both days? If possible could you please send me information regarding the requirements and financial commitment for hosting a class? Once I receive that information I will contact our headquarters about hosting a class.
Thank you again for all your help and for any information you can get me about hosting a class!
Emily Thomas, DPT

Debra Murray Denison 9:32pm Mar 11
Silva Silvia Albertini, have you checked out Jerry Hesch? I saw Vicki in Oct, 2013 and I was not satisfied with her diagnosis, for several reasons, so I decided to get a second opinion before I jumped into an aggressive round of prolotherapy and or fixation. I highly recommend taking a peek at his website, if you haven't done so already:) He is very open to phone consults as well. He is a skilled PT that has a unique way of evaluating mobility of the pelvis. He looks at the pelvis as a whole not in pieces, meaning, not just the SIJ. I became hyper focused on my SIJ without considering the rest of my pelvis. Now I am thinking outside of the SIJD box. My pubic joint, based on "spring testing", is a major pain generator. So, now my focus is on stabilizing this joint, and it seems, so far, my SI's are thanking me. He will review your history with detail that I had never experienced....I have suffered for 17 years. I've been around the block, so to speak. Anyway, all of this to say it might be worth at least a phone call. All the best to you, this road is not for the weak. Here is his definition of SIJD:) http://www.heschinstitute.com/1/post/2014/01/sacroiliac-joint-dysfunction-aka-sijd-definition.html

https://www.youtube.com/watch?v=fffuQsutpJ4&feature=youtu.be

Good Morning Jerry!

I wanted to write and thank you once again for being able to fit me into your schedule at the last minute this past weekend.  And, to let you know how I’m doing.  I feel major changes in my body, particularly in my legs.  I still have “sensation” in my lower right back - but I’m thinking that it has changed in nature from “bad pain” to the sensation of healing muscles/soft tissue and “tightness” as opposed to things not moving together properly.  And, interestingly, some of the soft tissue around the old injuries in my right knee has “awakened” with a sensation that is not quite pain either.  Time will tell. But, I’m hopeful.

The fabulous new is that I felt good enough to go to the rink and test things out today.  Gently.  And, happily I was able to do a spin (sit spin) that I haven’t been able to attempt in over a year because of the strain it put on my lower back.  I tried to get one on video for you, but then accidentally deleted it.  Anyway, it was quite a happy feeling.  :-)  (I’ll try to get a video for you in the next few weeks if I continue to improve and am able to stay on the ice…felt bad that we didn’t have time to tape on saturday)

Anyway, I’m very much looking forward to getting the DVD with the rehab exercises/therapy on it.  I will work on it diligently and will let you know how things progress.  I don’t think I told you where to ship the DVD to.  We’ll be in Wyoming for the next month, so would you please ship it to the following address:

Thank you again for focusing your attentive and skillful healing on me this past weekend!  I am grateful.

Lori

http://www.youtube.com/edit?o=U&video_id=haZrk2_UEUM

Jerry Hesch This is an important case in which an SI support applied up high was not tolerated and the sacroiliac experts she consulted did NOT evaluate the stability of her pubic joint (symphysis pubis). She was given a standard diagnosis at a sacroiliac clinic of "Right Posterior Ilium with Upslip....." based on three gross movement tests that do not isolate the sacroiliac joint. Severe disc disease is present and MUST be given consideration. To suggest that fusing her sacroiliac joints alone in the presence of pubic joint instability and severe lumosacral disc disease requires a significant level of evidence. In February I presented the research evidence for surgical stabilization of the pubic joint (objective proof of separation) which in turn will stabilize the sacroiliac joint, unless the sacrospinous and sacrotuberous ligaments are torn. This at APTA CSM 2014. The evidence is in the published research. Conservative cases with pubic joint hypermobility, mild to moderate instability can heal with conservative measures for example a pubic joint support, NOT a sacroiliac support. This is a complex topic and I cannot do justice here.

Lila Abatte, PT, DPT, OCS just presented a workshop on the coccyx, the first ever that I am aware of, a whole two-days. She presented on the Hesch approach to the coccyx as part of the workshop.

Hi Jerry!

How are you?  I just wanted to let you know that the Hesch section of the Coccyx course was so well received!  I think you would have been proud and the participants were so clueless and amazed that addressing the sacrum/ilium aids in addressing the coccyx.  It was really good.  So you should get more participants taking your series.  The course will run again in September in New Hampshire I believe. 

I was able to go skiing today in Denver!  Woo-hoo!  I wasn’t easy, but I was very happy to be out there!

Thank you again (and so do the participants!)

Lila Abatte, PT, DPT, OCS
Instructor for Herman Wallace

DEFINITION OF SACROILIAC JOINT DYSFUNCTION

SIJ dysfunction is defined as altered mobility of the SIJ/pelvic structure per passive accessory motion tests, also named Springing with Awareness, which is a specific manner of performing spring tests. There is altered ligament and soft tissue tone such that hypermobility and hypomobility oftentimes co-exist, though they are typically very responsive to appropriate intervention. Oftentimes the posterior musculoskeletal complex is injured which also involves the ligamentous complex including the iliolumbar, dorsal SI ligaments (short and long) and sacrospinous and sacrotuberous. This model does not require that “the ilium is rotated on the sacrum, or the opposite”, in fact; oftentimes this simply is not the case per thorough research detailed elsewhere. Many times the restriction is extrinsic, and sometimes, yes; there is a true shift within the SIJ and symphysis pubis, these are simply much less common than the typical pelvic asymmetries that involve the pelvis moving on and with the hips in an asymmetrical manner.

Sometimes pain is not present as this joint is designed to tolerate large forces. When pain is present, it is typically below the belt line and overlying the SIJ into the buttock, posterior thigh and towards the trochanter and inguinal area. The spring tests are performed with the client’s body in stable positions. The tests are used to evaluate passive accessory motion. They are used to determine if hypermobility or hypomobility is present. The pelvis may or may not be symmetrical. In other words, a symmetrical pelvis can present with hypomobility or hypermobility that is treatable. SIJ dysfunction may also have altered proximal soft tissues, especially if asymmetry is present. The literature describes a fairly unique pain pattern with SIJD, however this model is a biomechanical model, and many more clients have treatable pelvic asymmetry that is relevant to the concept of prevention and optimizing biomechanical function. Pain does not have to be present in order to have SIJ movement dysfunction.  The presence of SIJD implies that the hips, the pelvis as a solitary structure, (such as when loaded in stance, in which SIJ motion is not occurring), and the lumbar spine all participate.  In truth, at least over time, the whole body participates with adaptations and compensations.

The term lumbo-pelvic-hip dysfunction is so much better than sacroiliac joint dysfunction (SIJD). This term brings awareness to the lumbar component and the pelvic component, and the hip rather than bringing focus to the solitary sacroiliac. I appreciate that there exists some literature in which the pain pattern for so-called SIJD is distinctly different from that of lumbar dysfunction. However, this is based on injections into the SIJ which are very problematic for a variety of reasons (please see my chapter on sacral torsion which details the problems with the pain model).  There is literature that supports the use of pain provocation tests as diagnostic of SIJD. Again, this is problematic on several levels. These tests do correlate well when used as a group and correlate with a positive response to SIJ injection, sometimes referred to as a “gold standard.” It is not a gold standard.

Murakami’s remarkable injection study too oftentimes is ignored. He notes that repeat injection reduces positive response (pain relief) in the SIJ by 50% and it continues downward with additional injections. Oftentimes there is an identified rent in the anterior capsule such that injection media leaks onto the lumbar plexus. Further to that, the nerve supply to the anterior SIJ, capsule and ligaments is L2-L3-L4, and the posterior capsule and ligaments is L5-S1-S2 and S3 (partial). Thus, any pain syndrome that causes referred pain may be reduced by injection into the SIJ by reducing the overall afferent input into the spinal cord. Murakami found that a small percentage responded well to injection into the SIJ as compared to posterior intra-articular injections, significantly so. Thus, it appears that SIJD is a posterior soft tissue phenomenon with respect to pain generators.

The cluster of SIJ pain provocation tests can easily be over-interpreted. The Hesch Method suggest that oftentimes these may be negative especially as a group, and yet there may be biomechanical dysfunction in the lumbopelvic-hip complex that is worthy of treatment. This model is primarily a biomechanical model, but does respect pain. The manner in which these tests are performed is at times such as in research and in protocols; performed the very same way in all patients. This can give false negatives and false positives. The Hesch Institute endorses a thorough lumbar and hip screen prior to any direct treatment to the SIJ. The Institute propounds that these tests need to be individualized for each patient in order to achieve the ideal angle and the ideal amount of force to isolate the SIJ, including the posterior soft tissues, especially ligaments. The clinician can palpate just medial to the PSIS on one side when performing each pain provocation test.

The problem of SIJ instability is another, a completely other problem. It is most unfortunate that it seems to be the default acceleration of failed response to a diagnosis of “SIJD.” Meaning that if they do not respond to usual interventions for SIJD, then the assumption becomes that their case is one of instability, which ups the ante in terms of invasive procedures and this can include surgery. I see some of these failures, failed response to surgical intervention, and I am unimpressed with the limited diagnostic process. I have encouraged additional workup for some who were in the process of getting worked up for surgery, I have had some that I discouraged surgery go forth and have surgical stabilization of the SIJ and have failed response. I had one case with an already fused SIJ per CT scan (multiple images) in which there was a hardware breach into the lower right SIJ. My input was not adequate, she went on to have this fused SIJ “surgically stabilized’ and went on to develop other symptoms. I have made recommendation for work up for consideration of SIJ stabilization surgery, but much less frequently than is being done in some parts of the country.

My first case was in 1984, very successful response after failed response to a poster lumbar fusion, then to an anterior lumbar fusion; still using a walker with wheels with the same SIJ pain syndrome, a year later. She threw the walker away after SIJ fusion and participated in race walks for charity. The surgical recommendation should not be made lightly, and SIJ surgery should NOT be the new answer for any and all types of failed back syndrome or even failed SIJD rehab syndrome. Sadly, the marketing machine marches on like a juggernaut. Only after very thorough testing, and very thorough treatment failure, should this be given consideration. When I see these cases (before or after) I thoroughly question them regarding the diagnostic process and I sadly report that I am appalled. Severe lumbar pathology, hip dysplasia and impingement syndromes have been part of these misdiagnosed surgical SIJD cases.

There is very good objective testing being done for cases of traumatic instability of the pelvic joints which may or may not include bony fracture.  I have written on this elsewhere and I hope that this level of objectivity will makes its way into that wide gray zone of chronic SIJD and so-called SIJ instability.

SIJ instability is not the same as SIJD, not the same as lumbopelvic-hip dysfunction. There is no such thing as isolated SIJD, it always co-exists with lumbopelvic-hip dysfunction. The psychosocial phenomenon of being under-acknowledged, underdiagnosed for a long time and then being given acknowledgement as having a valid and severe diagnosis of SIJD makes this population very vulnerable. It should be a degree of dysfunction. Perhaps a better diagnostic approach would be stated similar to “primary SIJD with co-existing lumbopelvic-hip dysfunction”.  Would this, could this improve diagnosis and treatment, and help prevent unnecessary permanent function-altering surgeries? Could it improve surgical outcomes for those who truly do have true instability and are in need of surgical stabilization. I think so I hope so. These patients deserve such.  Whenever the term “SIJD” is encouraged, we should think “lumbo-pelvic-hip dysfunction.”  I hope that this book reflects that.