Posture assessment and treatment is only a part of patient care and yes many explanations exist. Because I can only be responsible for my own clinical behaviour I choose to make a quick discernment of the relevance to the patients overall presentation (not always possible in the short-term). A recent cases was a woman who could not sleep because she knew the scheduled sacroiliac joint fusion was not the right thing. This based on a large degree on a physical therapist explaining that because her faulty pelvic posture did not "correct" that becvause she was still symptomatic; she had SIJD AKA SIJ instability. INsanity. Bizarre. Yes I found faulty posture but clarified that it was present in standing and not in prone or supine. Yes, i know of the studies that discourage my belief that I can palpate SUBTLE asymmetries, such as 5mm or less and the studies that show 11mm or more of leg length difference is relevant (search Lynton F Giles if interested). The cause of her faulty posture was a lack of hip extension which responded very readily-one treatment of two minutes and taught self-treatment. Another case a PT with perfect pelvic posterior yet a lack of passive accessory motion which we restored, one treatment and taught self care and she can now sleep two visits total, grateful. The research encourages cautious interpretation, the research encourages us to up our game, not to discontinue. When we discern that the posture does not appear to be maleable nor contributory to prevailing symptoms or patients goals (one of the pillars of EBP) we move on. In the realm of probability honoring the research that does exist and honoring the research that does not yet makes for humble, committed care. When the posture model applies, apply therapeutic effort, when it does not then go to then next relevant screen.
From message 09-03-2013: Erik Dalton Yes Jerry~ You're chapter in Dynamic Body continues to receive rave reviews. Love to do something with you in the future.
Hi Grant, I appreciate your open mind and enthusiasm. Chad Cook in book Orthopedic Manual Therapy an evidence based approach advocates test-retest approach. I am teaching a lumbopelvic-hip course this week and advocate that it can be articular (rare) and can be a postural-movement whole body pattern. I have to understand things in order to apply and have significantly reinterpreted the traditional biomechanical model. The model taught in muscle energy based on Mitchell's 1970 book was fully articulated in 1958 by his father who culminated, synthesized the knowledge base which at that time covered the early and mid century. I have a book chapter in Movement Stability and Low Back Pain: the essential roldeof the pelvis. Old, and my perspective of course has changed but it is a good introduction. I prefer to test motion that is passively induced THROUGH the structure and admit we cannot isolate motion only IN the joint. For the simple fact that I teach courses that include the term sacroiliac I get a lot of flack but the problem is more complex than what is addressed in the published knowledge base part of evidence-based practice. Even that is over-interpreted, but that is another conversation. It is tricky to use hip pain provocation tests and ascribe pain to the SIJ, it is tricky to use injection with dye and fluroscopy into the SIJ, achieve pain relief and then state that the SIJ is the pain generator. There are several injection studies that explain why and are relatively ignored by those who promote the use of injection to bolster a cause such as evidence-based SIJ eval and tx and worse: SIJ fusion where enormous marketing dollars are being spent. Just go to spine journal and the other one, J of Spine (NASS) and look at the ads, same for online search, meaning in print and web. The complexity of the problem cannot be denied and it is more relevant for specific populations, women who have had children, golfers, foottball/soccer, etc, meaning in a greater context; not just SIJD. I appreciate that you try, that you do test and retest, readily admit what you do not know because THAT is the basis of learning; receptivity and humility. Were I a patient, you would be my clinican.
To Monsieur Kanye West:
Congratulations on the birth of your daughter, Nord! This is a truly auspicious time for you -- and so it is with great sadness that we must lodge a formal complaint against the song "I am a God" from your new album Yeezus.
Our organization represents bakers across France, many of whom have taken great offense at this particular rhyming couplet:
“In a French-ass restaurant
Hurry up with my damn croissants”
Assuming you, as a man of means, dine exclusively at high-end restaurants and boulangeries during your voyages to Paris, it could not be possible that the delay of your "damn" croissants originated from slow service. And certainly, you are not a man to be satisfied with pre-made croissants from the baked goods case reheated and tossed out on a small platter. No -- you had demanded your croissants freshly baked, to be delivered to your table straight out of the oven piping hot.
And it was with great joy you ordered croissants -- not crêpes or brioches -- because only croissants can proudly claim that exquisite combination of flaky crust and a succulent center. The croissant is dignified -- not vulgar like a piece of toast, simply popped into a mechanical device to be browned. No -- the croissant is born of tender care and craftsmanship. Bakers must carefully layer the dough, paint on perfect proportions of butter, and then roll and fold this trembling croissant embryo with the precision of a Japanese origami master.
This process, as you can understand, takes much time. And we implore the patience of all those who order croissants. You may be familiar with the famous French expression, "A great croissant is worth waiting a lifetime for."
We could easily let this water pass under the bridge, as they say, but we take your lyrics very seriously. From the other lines in the song, we have come to understand that you may in fact be a "God." Yet if this were the case -- and we, of course, take you at your word -- we wonder why you do not more frequently employ your omnipotence to change time and space to better suit your own personal whims. For us mere mortals, we must wait the time required for the croissant to come to perfect fruition, but as a deity, you can surely alter the bread's molecular structure faster than the speed of light, no? And with your omniscience, perhaps you have something to teach us about the perfect croissant. We await your guidance and insights.
We appreciate your continued patronage of French culture. (Your frequent references to menage perhaps speak an interest in the structure of the French household?) We hope from the deepest recesses of our hearts, however, that in the future you give croissants the time they need to fully mature before you partake. With that, we say, adieu. And our member Louis Malpass from Le Havre wants you to know that he loves "Black Skinhead."
Association of French Bakers
Dear Jerry, I like your perseverance and 360° approach on treating SIJ dysfunctions,, but I feel we should really read the comment on Berthelot's 2006 article (one of the cornerstones of your work) by Laslett et al and then next read the systematic review by Szadek KM, van der Wurff P, van Tulder MW, Zuurmond WW, Perez RS. in
J Pain. 2009 Apr;10(4):354-68. "Diagnostic validity of criteria for sacroiliac joint pain: a systematic review". We can only establish that the SIJ is in part a potential source of nociception without any possibility of establishing what the actual cause is. I agree with Ina Diener; the actual possible movement in the SIJ is less than 6° which is not reliably palpable in any sort of way.
So any therapy based on these very low level evidence assumptions is based in reality only on clinical expertise and natural course combined with a possible placebo effect.
Let's say so to our patients: we do not know what the cause of your LBP is, but we have a potential treatment which might be effective....
Jerry Hesch • Erik,
I know that passive mobility tests do induce movement through the SIJ and that the springing with awareness (modification of traditional spring tests) can discern lack of movement going through the SIJ, and I know that there is a grey zone in which they are unable to replicate physiological forces. I have a few you tube videos showing the spring tests on the first H1N1 virus case in the nation who had a fused SIJ and in a client who was worked up for an SIJ fusion and I informed her with spring tests that she was already fused. A review of her CT scan revealed previously unreported encroachment of thoracolumbar fusion hardware into the lower SIJ on the right with no visible joint space. What absolutely astonished me about these two examples was the complete lack of left to right (1st one) and right to left (2nd) pelvic side-glide. No literature, kinesiology or joint structure and function textbook or published paper prepared me for that! I like the terminology lumbopelvic-hip which I use to convey that it is a system. In respecting the published studies I also respect the wide gap in topics where research is lacking. While movement is limited in the joints the spring tests are performed at a distance hence there is a multiplier effect between actual and perceived and I perform them using my whole body, hence an enormous number of receptors participate as opposed to just pushing with my arms. Sometimes specific treatment yields very dramatic results and quickly ends chronic severe pain and costly care as is shown in a video I posted that has Downslip and Upslip in the title. There is a link where the child's mother excoriates the medical profession and reiterates his journey. No research exists to support what I did for him, meaning no published. There are many topics still in need of research. I do spend a lot of time educating my clients and gently dismantling their cultural "SIJD" MYTHOLOGY. I think we all seek the same outcome for our clients. Thank you. best regards, Jerry Hesch
From a LinkedIn blog on pelvic asymmetry August 2013
Taso Lambridis • Hi Jerry,
Thanks for the very clear comments surrounding the pubic symphysis, I do take a very similar approach to this as you do & yes radiographic findings certainly are more helpful than when considering the SIJ. Apologies for any misunderstanding around the comment regarding Andre Vleeming, it was directed to an earlier comment by Roel Lameris. Not sure if you are attending the upcoming world congress in Dubai end of Oct/begining Nov but certainly lookinf forward to any new material that comes out of the conference and any new perspectives that Andre & others involved in the area may have for us. Regards, Taso
I find the A-P films of the pelvis to be challenging because they typically are taken either in standing or supine and not from a perpendicular angle to the sagittal orientation of the pubic bones. Nonetheless, they can give some information and at times one can measure the interpubic width at the middle of the joint which as you probably know, is an accepted protocol.
I have a modified machinists tooll that is best described as a plunger with a ruler which I use on very rare occasions when a client presents with a significant palpable depression of the symphyseal fibrocartilage. I also use a Carpenters contour gauge to measure pre-and-post shape of the pubic bones and fibrocartilage. In an ideal world of course, we would have access to imaging tools and a litany of good research to guide us. In the absence thereof, given that there are knowledge gaps, as I know you agree, we have to do the best with what we have to help our patients. There is a paucity of published research to guide treatment of the symphysis pubis. The orthopedic trauma literature as I posted earlier, does bring a novel perspective to the traditional physical therapy and women’s health physical therapy approach to both pubic joint dysfunction and pubic joint AKA symphysis pubis diastasis, AKA symphyseal diastasis.
Sadly, in parts of the world there are women who are still in wheelchairs from having had intentional, meaning surgical cutting of the symphysis pubis to facilitate easy birth. In some regions such as Zimbabwe this is a life saving procedure and the statement is made that they do not suffer any long-term sequelae. However, there is no objective measurement to demonstrate that they do heal. Separately, there is a very small amount of literature which hints at a difference in ability to recover and a difference in experienced pain related to childbirth and to trauma as related to childbirth such as intentional or non-intentional symphyseal diastasis. So, the topic of pelvic asymmetry as relates to the symphysis pubis is a very relevant topic and it has to do with an underserved population. I would hate to even imply that medicine and rehabilitation ignores such and has a paternalistic and chauvinistic undergirding. Who knows?
I did intend to attend the world Congress in Dubai and I had two abstracts accepted. One on the very topic of symphyseal diastasis, presenting MRI images for a novel biomechanical interpretation. However, I have decided to focus my resources of economy and time and need, and will schedule surgery around that time. I do have 2 presentations at AAOMPT in October, much more economically feasible. Will you attend the congress?
No need to apologize I just wanted to clarify that it was not I who made the comment regarding Andry Vleeming.
I look forward to hearing more of your work. Thank you for your thoughtful, engaging, and polite interactions.
With best regards,
From an email I received today.
I just wanted to give you an update on what I found out at my recent surgical consult
The surgeon, Dr. Kenneth………. , completely feels that my problem is my disc is basically very "worn out" were his words. He was very surprised that not a single surgeon mentioned it could be a pain generator for almost year of seeing doctors. When he injected, he completely reproduced my achy type of pain to a T. I had some IV meds as they were doing it but I was fully aware and having a conversation along with still feeling plenty of pain so I know what I felt. It gave me validation that you were right.
Anyway, we discussed surgical options. So overall it was a good appointment with a lot of good information. My question for you is, …….
Again, you were right!
Jerry's reflection: Her pain presentation was very straight-forward yet appropriate diagnosis has been very evasive. Her pain is disabling, she cannot work, she has young children, why? I wish i knew.
July FB post:
Jerry Hesch presented a course: "The Hesch Method: Integrating the Body" this past weekend in Berkeley CA
Wow--a really original and effective approach. He did some actual case demonstrations that really showed the importance of inter-linking these whole body patterns. Then his treatment approach was via the dense connective tissue (type 3 receptors).
Clear, simple instruction. Very available to learn
I really recommend you check out his work. He will be presenting at the AAOMPT Annual Conference
Peter Fabian, PT http://peterfabian.com/physical-therapy/
The immediate effect of posteroanterior mobilization on reducing back pain and stiffness - See more at: http://www.physiospot.com/research/the-immediate-effect-of-posteroanterior-mobilization-on-reducing-back-pain-and-stiffness/comment-page-1/#comment-11806
“…Posteroanterior mobilization was found to bring about immediate desirable effects in reducing spinal stiffness and the magnitude of back pain. The restoration of the mechanical properties of the spine may be a possible mechanism that explains the improvement in pain after manual therapy
Jerry Hesch responds:
Just anopther perspective. I am fascinated by reflexogenic influences on spinal stiffness. I observe two frequently occurring sources of significant T3-4 and upper body of sternum and upper cervical stiffness. One is a posterior glide fixation of the sacrum which takes a gentle 10 minutes to reduce. The aforementioned segments soften significantly. The other source is a bilateral or unilateral treatable subtalar varus and adduction fixation and the other is significant restriction of hip internal rotation tested in supine with hips and knees in neutral or in prone springing the posterior trochanters. A recent client I will never forget seemed to have a bone-on-bone end feel but I treated the hip anyway because I discerned that the significant upper cervical restriciton would not respond to direct work, and he gained 45 degrees of hip internal rotationa nd significant gain in upper cervidal mobility and reduction in symptoms. This does not detract from the utility of direct PA mobilization for spinal stiffness when the etiology is local. Thank you. Jerry Hesch -
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.