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.

 

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.