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Jerry Hesch, MHS, PT Letters to the Editor: Some Clarification on Sacroiliac Dysfunction Article
Published online rapid response PT J
1.Hungerford B, Gillerard W, Lee D. Altered patterns of pelvic bone motion determined in subjects with posterior pelvic pain, using skin markers. Clin Biomech. 2004;19:456-464.
Dear Editor,
This study is based on the premise that asymmetrical excursion of pelvic landmarks during the Stork Test is indicative of sacroiliac joint (SIJ) motion, based on a previous study utilizing skin markers(1). Another researcher Smidt performed a study with skin markers and reported 9 degrees of SIJ motion with reciprocal straddle (RS) position(2) and in a seperate study; the range was 22 to 36 degrees of rotation (3). However, the RS study was repeated with the use of tantalum balls implanted and measured with sterophotogrametric analysis in which the excursion in several subjects did not exceed 2.1 degrees (4). Another similar study reported that SIJ manipulation did not alter intra-articular position, but did in fact reduce pelvic landmark excursion (5). This begs alternate explanations, other than intrartiular SIJ motion as causative of pelvic landmark asymmetry.
We created a home-made model by xeroxing onto plastic overlays, a medial view of the sacrum and seperate view of the ilium from an anatomical text. Lines were placed along the x and y axes so that they could be alligned and movement of ilium on sacrum could be measured. With an axis at the mid S2 joint, and a goniometer overlying the axis: I marked off 2 degrees of rotation within the joint, consistent with research reports (4). The vertical excursion of the PSIS was equal to 1mm (1 degree). This should be doubled to 2mm (2 degrees), as the anatomical drawing was 50% the size of an adult pelvic model. Can clinicans actually perceive a 2mm excursion of the PSIS; or is the excursion of the PSIS much greater than the actual intraarticular SIJ motion? I sumbmit that there is more going on than the singlular model of SIJ motion.
In the current study, the foot, ankle, knee, hip and trunk (and pelvis) were not significantly constrained and thus the pelvis could be influenced by any or all of them; and compensatory motions could induce asymmetrical motions of the pelvis-as-a-unit, moving on the ovoid shaped femoral heads. In fact, asymmetrical pelvic excursion is a normative function of gait(5). Depending on the location of the axis of motion of the entire pelvis, the PSIS can move more so than the sacrum in the complete absence of intrarticular SIJ motion. A study using middle aged persons with fused SIJ's (ankylosing spondylitis) can be used to demonstrate this principle. Additionally, altered soft tissue tone in the lumbopelvic region during the stork test can give some artifact to actual bony landmark excursion. Alternately, the possibility exists that movment of pelvic landmarks in one plane may give false palpatory cues of motion in another plane.
As the pelvis is foundational to both the spine and the lower extremities, its relevance to normal biomechanical function encourages continued study. The authors are to be commended for demonstrating a high degree of intertherapist agreement of pelvic landmark excursion with the Stork Test. This work is foundational to future studies on the clinical utility of the Stork Test. We do not question their results, but rather their focus on intrapelvic motion versus motion of pelvis-as-a-unit, moving in 3-dimensional space.
Sincerely Yours, Jerry Hesch, MHS, PT
Chris Gregor-Maxwell, MS, PT, AT
The Hesch Method SIJ Seminars
1.Hungerford B, Gillerard W, Lee D. Altered patterns of pelvic bone motion determined in subjects with posterior pelvic pain, using skin markers. Clin Biomech. 2004;19:456-464. 2. Smidt GL, McQuade K, Wei SH, Barakatt E. Sacroiliac kinematics for reciproacl straddle positions. Spine 1995;20:1047-54. 3. Smidt GL. Interinominate range of motion. in Movement, Stability and Low Back Pain. Churchill Livingstone 1997;187-191. 4. Sturesson B, Uden A, Vleeming A. A radiostereometric analysis of movement of the sacroiliac joints in the reciprocal straddle position. Spine 2000;25:214-217. 5. Tullberg T, Blomberg S, Branth B, Johnsson R. Manipulation does not alter the position of the sacroiliac joint. Spine 1998;23:1124-1129. 5. Levangie P. Hip Joint. in Levangie P, Norkin C. Joint Structure & Function. F.A. Davis 2005:366-371. Author's Response: None SACROILIAC JOINT DYSFUNCTION IN PREGNANCY Letter published in Winter edition J Women 's Health PT RE: Cullaty M. Suspected sacroiliac joint dysfunction; modifying examination and intervention during pregnancy. J Women 's Health PT. 2006;30:18-24.
Dear Editor,
We congratulate Martha Cullaty, MPT, MEd on her cases study which tackled a challenging client who was 7-months pregnant, with severe pain and considerable functional limitations. The author described some limitations of palpation and positioning, and then described some valuable alternative positions. However, some useful alternatives were Nat utilized, such as sitting and side lying. Specifically, sitting on a backless bench or stool, with the patient's upper torso supported on a plinth with or without extra pillows for support, gives the clinician excellent ability to palpate structures that would normally be palpated in prone. [Some pregnant patients can indeed tolerate short periods of prone lying, if pillows are utilized above and below the abdomen.] The "Muslim prayer position" for maximized flexion often gives useful information which is absent in other flexion postures such as sitting. All of these alternate positions could have enabled the author to directly palpate the sacrotuberous ligament. Changes in the tone of the sacrotuberous ligament tone can be used to evaluate response to treatment of the anterior ilium (AI) sacroiliac joint (SI) dysfunction (SIJD)..1 Tone should change from hypertonic to near normal (at least when non weight-bearing) if treatment repetition and duration are adequate.
Because the pelvic asymmetry was present at the beginning of all 15 visits, without maintained correction, we cannot help but wonder if enhancing the evaluation and treatment, would have been worthy of consideration. The Muscle Energy Treatment (MET) paradigm2 recognizes lumbar, sacral and symphysis pubis motion dysfunction. I believe that these structures should be evaluated, such as in sitting or side-lying. As the SIJ is a triplanar structure, perhaps the corrections failed to be maintained because the author's choice of treatment in this case emphasized only one plane of dysfunction. One reference in the case study used MET in all 3 planes to treat lumbosacral movement dysfunction.3 Cullaty's case study treated the left SIJ in one plane (extension) and the direction of force was an average of 30-45 degrees away from the average para-sagittal plane of the joint. DonTigny4 has described a treatment for Al that addresses all 3 planes, taking the knee to the outside of the axilla, with hip in flexion, abduction and external rotation.
The author was very appropriate in addressing hip extension restriction. We could not discern from the article whether or not the bilateral hip restriction was treated or whether treatment focused on the left side DonTigny suggests that AI can be unilateral or bilateral and can couple with an upslip movement dysfunction of the ilium. Bilateral AI remains a possibility in this case presentation. Symmetrical ASIS's do not rule out bilateral SIJD. In agreement with Cullaty's statement that treatment effects support or discourage the working diagnosis of SIJD, DonTigny uses continued leg shortening on each side as evidence for bilateral Al, and treatment is continued on both sides; until no further shortening occurs. Cullaty was generous with her use of references, I believe that bilateral SIJD is not reported much in the research literature, particularly the MET literature. However, bilateral SIJD is in fact, a part of the larger Osteopathic SIJ paradigm; of which MET is only one treatment approach.5 I envision that our profession will someday have our own comprehensive model of SIJ evaluation and treatment, which at present is in the process of evolving.
Another model suggests that whether unilateral or bilateral, Al is part of a sequence of SIJ/pelvic movement dysfunctions that should all be sequentially treated.' Joints other than the SIJ proper are intimately related to SIJD. Specifically, the pubic symphasis is a key structure in pelvic stability. (OK, we need a reference here.) Also, we have found that direct palpatioi of the pubic crests, tubercles, length of the anterior pubic bone, and the PS cartilage provides a wealth of information, note only on symmetry, bit also concerning tone an pain. Although the client in this case study was in considerable pain and dysfunction, I could still envision some assessment of this structure, and in fact treatment through indirect techniques.. An outcomes study has recently been submitted for presentation and publication which utilizes this newer approach. The average number of visits to resolve SIJD in the pregnant population was less than 6.8 Another diagnostic consideration for the case study would be thoraco-lumbar movement dysfunction. This could be primary, perhaps more likely secondary, consistent with the postural and pain pattern. This has been addressed by Maigne.
9 Another consideration would be space-enhancing pressure on the para-inguinal nerves (neuropathy). Empirically I can state that neuropathy can occur without a loss of light touch sensation, perhaps due to considerable overlap and the fact that a great portion of them are deep to the skin, within the inguinal canal. Peripheral neuropathy could be a concomitant diagnosis with SIJD, and I suspect it would frustrate treatment attempts, until parturition.
We compliment the author on mentioning creep, although not a MET concept, it is nonetheless; very relevant regarding SIJD. She addressed the problem of creep through strengthening and by prescribing a non-elastic SIJ support. We look forward to future contributions on this topic from Ms. Cullaty and again congratulate her on a publication so early in her career. We thank her and the editor for the opportunity to dialogue on this challenging topic. Worthy of mention, what is perhaps is an underutilized free resource on this and other clinical topics; is the APTA Mentors group.
Sincerely Yours,
Jerry Hesch, MHS, PT
Christina Gregor-Maxwell, MS PT AT
1 Hesch J. Evaluating sacroiliac joint play with spring tests. J ObGyn PT. 1996;20(3):4-7.
2 Greenman PE. Principles of Manual Medicine. Baltimore: Williams & Wilkins; 1989:88-93, 204-270.
3 Wilson E, Payton 0, Donegan-Shoaf L, Dec K. Muscle energy technique in patients with acute low back pain: a pilot clinical trial. J Orthop sports Phy Ther. 2003;33:502-512.
4 DonTigny R. Anterior dysfunction of the sacroiliac joint as a major factor in the etiology of idiopathic low back pain syndrome. Phys Ther. 1990;70(4):250-265.
5 Greenman PE. Principles of Manual Medicine. Baltimore, Williams & Wilkins. 1989:224.
6 Hesch J. The Hesch method of treating sacroiliac joint dysfunction: integrating the si, symphysis pubis, pelvis, hip, and lumbar spine. Henderson, NV self published, 2006.
7 Chase D. Personal communication. 2005.
9 Maigne R. Low back pain of thoracolumbar origin. Arch Phys A/Ied Rehabil.1980;61(9)389-95.
SACROILIAC JOINT HYPERMOBILITY/HYPOMOBILITY POST PARTUM
Published in J OB/GYN PT 15:2, June 1991
Dear Editor:
I just renewed my membership and was happy to receive the March 1991 issue of) OB/GYN PT. I am in agreement with the letter to the editor written by Trenna Wicks. I share her excitement for the pertinent information in your journal. I also agree with her that hypomobility is a significant problem and especially so in the postpartum population. In my evaluation I use 11 basic joint spring tests. For complex sacroiliac dysfunction there are 22 different joint spring tests available. It has also been my experience that in treating hypomobility one does achieve more balance in the pelvic joints. What appears to be a hypomobility in one direction often represents a hypermobility or the preferred term, relative or apparent hypermobility, in the opposite direction. In treating the hypomobility, one is also treating the antagonistic hypermobility. I believe that treating the pelvis as a triplaner joint with a potential of up to 6 degrees of freedom is a very important concept in, seeking balance in these important articulations. The influence-of the very powerful mechanorcceptors, which are abundant in this region, and their obligatory influence on pelvic girdle and pelvic floor muscle tone cannot be ignored.
The importance of pelvic floor strengthening in effecting internal stability cannot be ignored. I am grateful for the influence of several prominent OB/GYN section members inthis regard.
I have no doubt that a joint spring test applied to the pelvic region evaluates not only articular mobility, but also the important influence of muscle. I do think that one of the purest joint spring tests is an anterior to posterior spring test on each pubic bone with the client in supine. I think that this might also be an external evaluation of the influence of the pelvic floor. I have noted a fairly consistent hypermobility in this joint in the pastpartum population and especially in the multiparous population, even several years after delivery. I do not think we can assume that stability is automatically established after delivery without evaluating for such. I did have a client who presented with significant hypermobility with A-P spring testing applied to the symphysis pubis. After achieving tri-planer symmetry of her lumbopelvic region and having her perform 100 repetitions of Kegel's exercises daily, she achieved stability within 2 weeks. I was very pleased with the degree of stability and indeed was quite surprised. The next day, however, she presented again, as she did on the first day, with significant hypermobility. In this example, I suspect hormonal influence to be significant.
I do think that we will see an emerging trend of evaluating the sacroiliac and pubic symphysis joints on the basis of joint spring tests and perhaps less so on the basis of gross motion tests, which may not reveal actual mobility or actual dysfunction.
Thank you for the opportunity to express my opinions.
Jerry Hesch
Albuquerque, New Mexico
SACROILIAC
PublishedThe Journal of Manual & Manipulative Therapy vol. 8 No. I (2000), 29 .31
An article by DonTigny entitled "Critical Analysis of the Sequence and Extent of the Result of the Pathological Failure of Self-Bracing of the Sacroiliac Joint"' clearly, contributes to our understanding of the sacroiliac joint (SIJ). Articles in other journals and books demonstrate the interdisciplinary interest in the problem of pelvic joint pain and movement dysfunction.
Problems have been demonstrated with all older models of SIJ dysfunction as new research re-examines the nature of the sacroiliac joint in depth. It is time that we as a profession re-define what SIJ dysfunction is, specifically; what are the biomechanics of the structure, what are the postural and movement dysfunctions, what are the pain patterns, and how do we effectively evaluate and treat the SIJ. I will share some conclusions I have reached in evaluating this structure over the past 20 years.
I believe that Mr. DonTigny is correct in his finding that anterior ilial dysfunction is the most common movement dysfunction of the ilium. In contrast with the traditional method of evaluation, I have been using additional landmarks for palpation and accessory motion testing' and I am convinced that anterior ilium is a tri-plane phenomenon. It rarely accompanies torsion of the sacrum about an oblique axis, but often accompanies puresacral rotation about a vertical axis and it sometimes accompanies a contralateral posterior ilium as has been noted by Cibulka et al'. After resolving the anterior/posterior ilium patterns a transverse plane pat-tern often emerges and should be addressed. This I refer to as a Type 1 Right Inflare/Left Outflare' in contrast to the infrequent traditional Intlare/Outflare3, The Outflare is noted by a posterior PSIS with restricted anterolateral accessory motion as tested in prone.
The expanded evaluation format has convinced me that sacral torsions (oblique axis) are actually quite rare, sacral rotation about a vertical axis is quite common and “unilateral flexion and extension of the sacrum'' probably do not exist.
This approach has been shown to achieve significant pain relief in one visit, increase passive SLR, and have greater than 70h intertester agreement' for the majority of palpation and passive motion tests'. Intertester agreement has been poor with most traditional tests. Fluroscooy has demonstrated several of the passive accessory motion tests to evoke movement in the SIJ9.
It is an exciting time as much new \vork is being done in this area. I believe that our profession will continue to evolve in its understanding of this complex problem. I thank DonTigny for his many contributions and this journal and for allowing me to express these ideas.
Jerry Hesch, PT
REFERENCES
1. DonTigny RL. Critical analysis of the sequence and extent of the result of the pathological failure of self-bracing of the sacroiliac joint. The Journal of Manual & Manipulative Therapy 1999: 7(41:1;3-181.
2. Hesch J. Aisenbrey J. Guarino J. Manual Therapy Evaluation of the Pelvic Joints Using Palpatory and Articular Spring Tests. Presented at the First interdisciplinary World Congress .on Low Back Pain and Its Relation to the
Sacroiliac Joint: November 6, 1992, San Diego, CA
3. Hesch J. Evaluation and Treatment of the Most Common Pattern of Sacroiliac Joint Dysfunction. In: Movement, Stability & Low Back Pain; The essential Role of the Pelvis. Vleeming A, Mooney V, Dorman T, Smijders C, Stoeckart R, eds. London: Churchill Livingstone, 199; 535-545.
4. Cibulka MT, Delitto A, Koldehoff RM. Changes in innominate tilt after manipulation of the sacroiliac joint in patients with low back pain: an experimental study. Physical Therapy 1988; 68:1359-1363.
5. Greenman PE: Principles of Manual Medicine. Baltimore: Williams & Wilkins, 1989: 246-257.
6. Mitchell F. Structural Pelvic Function. Academy of Applied Osteopathy. 1958: 72-90.
7. Olson L. Effects from the Hesch Method of Pelvic Mobilization on Lumbar Flexion, SLR. and Standing Pelvic Inclination Angles in Patients with Low Back Pain. Masters Thesis Finch University/The Chicago Medical School, 1998.
8. Potter N, Rothstein J. Intertester Reliability for Selected Tests of the Sacroiliac Joint. Physical Therapy 1985; 65:1671-1677.
9. Bernard T. Video presentation on sacroiliac joint injection. Presented at the First Interdisciplinary World Congress on Low Back Pain and Its Relation to the Sacroiliac Joint: November 6. 1992, San Diego, CA.
The Journal of Manual & Manipulative Therapy vol. 8 No. I (2000), 29 .31
1.Hungerford B, Gillerard W, Lee D. Altered patterns of pelvic bone motion determined in subjects with posterior pelvic pain, using skin markers. Clin Biomech. 2004;19:456-464.
Dear Editor,
This study is based on the premise that asymmetrical excursion of pelvic landmarks during the Stork Test is indicative of sacroiliac joint (SIJ) motion, based on a previous study utilizing skin markers(1). Another researcher Smidt performed a study with skin markers and reported 9 degrees of SIJ motion with reciprocal straddle (RS) position(2) and in a seperate study; the range was 22 to 36 degrees of rotation (3). However, the RS study was repeated with the use of tantalum balls implanted and measured with sterophotogrametric analysis in which the excursion in several subjects did not exceed 2.1 degrees (4). Another similar study reported that SIJ manipulation did not alter intra-articular position, but did in fact reduce pelvic landmark excursion (5). This begs alternate explanations, other than intrartiular SIJ motion as causative of pelvic landmark asymmetry.
We created a home-made model by xeroxing onto plastic overlays, a medial view of the sacrum and seperate view of the ilium from an anatomical text. Lines were placed along the x and y axes so that they could be alligned and movement of ilium on sacrum could be measured. With an axis at the mid S2 joint, and a goniometer overlying the axis: I marked off 2 degrees of rotation within the joint, consistent with research reports (4). The vertical excursion of the PSIS was equal to 1mm (1 degree). This should be doubled to 2mm (2 degrees), as the anatomical drawing was 50% the size of an adult pelvic model. Can clinicans actually perceive a 2mm excursion of the PSIS; or is the excursion of the PSIS much greater than the actual intraarticular SIJ motion? I sumbmit that there is more going on than the singlular model of SIJ motion.
In the current study, the foot, ankle, knee, hip and trunk (and pelvis) were not significantly constrained and thus the pelvis could be influenced by any or all of them; and compensatory motions could induce asymmetrical motions of the pelvis-as-a-unit, moving on the ovoid shaped femoral heads. In fact, asymmetrical pelvic excursion is a normative function of gait(5). Depending on the location of the axis of motion of the entire pelvis, the PSIS can move more so than the sacrum in the complete absence of intrarticular SIJ motion. A study using middle aged persons with fused SIJ's (ankylosing spondylitis) can be used to demonstrate this principle. Additionally, altered soft tissue tone in the lumbopelvic region during the stork test can give some artifact to actual bony landmark excursion. Alternately, the possibility exists that movment of pelvic landmarks in one plane may give false palpatory cues of motion in another plane.
As the pelvis is foundational to both the spine and the lower extremities, its relevance to normal biomechanical function encourages continued study. The authors are to be commended for demonstrating a high degree of intertherapist agreement of pelvic landmark excursion with the Stork Test. This work is foundational to future studies on the clinical utility of the Stork Test. We do not question their results, but rather their focus on intrapelvic motion versus motion of pelvis-as-a-unit, moving in 3-dimensional space.
Sincerely Yours, Jerry Hesch, MHS, PT
Chris Gregor-Maxwell, MS, PT, AT
The Hesch Method SIJ Seminars
1.Hungerford B, Gillerard W, Lee D. Altered patterns of pelvic bone motion determined in subjects with posterior pelvic pain, using skin markers. Clin Biomech. 2004;19:456-464. 2. Smidt GL, McQuade K, Wei SH, Barakatt E. Sacroiliac kinematics for reciproacl straddle positions. Spine 1995;20:1047-54. 3. Smidt GL. Interinominate range of motion. in Movement, Stability and Low Back Pain. Churchill Livingstone 1997;187-191. 4. Sturesson B, Uden A, Vleeming A. A radiostereometric analysis of movement of the sacroiliac joints in the reciprocal straddle position. Spine 2000;25:214-217. 5. Tullberg T, Blomberg S, Branth B, Johnsson R. Manipulation does not alter the position of the sacroiliac joint. Spine 1998;23:1124-1129. 5. Levangie P. Hip Joint. in Levangie P, Norkin C. Joint Structure & Function. F.A. Davis 2005:366-371. Author's Response: None SACROILIAC JOINT DYSFUNCTION IN PREGNANCY Letter published in Winter edition J Women 's Health PT RE: Cullaty M. Suspected sacroiliac joint dysfunction; modifying examination and intervention during pregnancy. J Women 's Health PT. 2006;30:18-24.
Dear Editor,
We congratulate Martha Cullaty, MPT, MEd on her cases study which tackled a challenging client who was 7-months pregnant, with severe pain and considerable functional limitations. The author described some limitations of palpation and positioning, and then described some valuable alternative positions. However, some useful alternatives were Nat utilized, such as sitting and side lying. Specifically, sitting on a backless bench or stool, with the patient's upper torso supported on a plinth with or without extra pillows for support, gives the clinician excellent ability to palpate structures that would normally be palpated in prone. [Some pregnant patients can indeed tolerate short periods of prone lying, if pillows are utilized above and below the abdomen.] The "Muslim prayer position" for maximized flexion often gives useful information which is absent in other flexion postures such as sitting. All of these alternate positions could have enabled the author to directly palpate the sacrotuberous ligament. Changes in the tone of the sacrotuberous ligament tone can be used to evaluate response to treatment of the anterior ilium (AI) sacroiliac joint (SI) dysfunction (SIJD)..1 Tone should change from hypertonic to near normal (at least when non weight-bearing) if treatment repetition and duration are adequate.
Because the pelvic asymmetry was present at the beginning of all 15 visits, without maintained correction, we cannot help but wonder if enhancing the evaluation and treatment, would have been worthy of consideration. The Muscle Energy Treatment (MET) paradigm2 recognizes lumbar, sacral and symphysis pubis motion dysfunction. I believe that these structures should be evaluated, such as in sitting or side-lying. As the SIJ is a triplanar structure, perhaps the corrections failed to be maintained because the author's choice of treatment in this case emphasized only one plane of dysfunction. One reference in the case study used MET in all 3 planes to treat lumbosacral movement dysfunction.3 Cullaty's case study treated the left SIJ in one plane (extension) and the direction of force was an average of 30-45 degrees away from the average para-sagittal plane of the joint. DonTigny4 has described a treatment for Al that addresses all 3 planes, taking the knee to the outside of the axilla, with hip in flexion, abduction and external rotation.
The author was very appropriate in addressing hip extension restriction. We could not discern from the article whether or not the bilateral hip restriction was treated or whether treatment focused on the left side DonTigny suggests that AI can be unilateral or bilateral and can couple with an upslip movement dysfunction of the ilium. Bilateral AI remains a possibility in this case presentation. Symmetrical ASIS's do not rule out bilateral SIJD. In agreement with Cullaty's statement that treatment effects support or discourage the working diagnosis of SIJD, DonTigny uses continued leg shortening on each side as evidence for bilateral Al, and treatment is continued on both sides; until no further shortening occurs. Cullaty was generous with her use of references, I believe that bilateral SIJD is not reported much in the research literature, particularly the MET literature. However, bilateral SIJD is in fact, a part of the larger Osteopathic SIJ paradigm; of which MET is only one treatment approach.5 I envision that our profession will someday have our own comprehensive model of SIJ evaluation and treatment, which at present is in the process of evolving.
Another model suggests that whether unilateral or bilateral, Al is part of a sequence of SIJ/pelvic movement dysfunctions that should all be sequentially treated.' Joints other than the SIJ proper are intimately related to SIJD. Specifically, the pubic symphasis is a key structure in pelvic stability. (OK, we need a reference here.) Also, we have found that direct palpatioi of the pubic crests, tubercles, length of the anterior pubic bone, and the PS cartilage provides a wealth of information, note only on symmetry, bit also concerning tone an pain. Although the client in this case study was in considerable pain and dysfunction, I could still envision some assessment of this structure, and in fact treatment through indirect techniques.. An outcomes study has recently been submitted for presentation and publication which utilizes this newer approach. The average number of visits to resolve SIJD in the pregnant population was less than 6.8 Another diagnostic consideration for the case study would be thoraco-lumbar movement dysfunction. This could be primary, perhaps more likely secondary, consistent with the postural and pain pattern. This has been addressed by Maigne.
9 Another consideration would be space-enhancing pressure on the para-inguinal nerves (neuropathy). Empirically I can state that neuropathy can occur without a loss of light touch sensation, perhaps due to considerable overlap and the fact that a great portion of them are deep to the skin, within the inguinal canal. Peripheral neuropathy could be a concomitant diagnosis with SIJD, and I suspect it would frustrate treatment attempts, until parturition.
We compliment the author on mentioning creep, although not a MET concept, it is nonetheless; very relevant regarding SIJD. She addressed the problem of creep through strengthening and by prescribing a non-elastic SIJ support. We look forward to future contributions on this topic from Ms. Cullaty and again congratulate her on a publication so early in her career. We thank her and the editor for the opportunity to dialogue on this challenging topic. Worthy of mention, what is perhaps is an underutilized free resource on this and other clinical topics; is the APTA Mentors group.
Sincerely Yours,
Jerry Hesch, MHS, PT
Christina Gregor-Maxwell, MS PT AT
1 Hesch J. Evaluating sacroiliac joint play with spring tests. J ObGyn PT. 1996;20(3):4-7.
2 Greenman PE. Principles of Manual Medicine. Baltimore: Williams & Wilkins; 1989:88-93, 204-270.
3 Wilson E, Payton 0, Donegan-Shoaf L, Dec K. Muscle energy technique in patients with acute low back pain: a pilot clinical trial. J Orthop sports Phy Ther. 2003;33:502-512.
4 DonTigny R. Anterior dysfunction of the sacroiliac joint as a major factor in the etiology of idiopathic low back pain syndrome. Phys Ther. 1990;70(4):250-265.
5 Greenman PE. Principles of Manual Medicine. Baltimore, Williams & Wilkins. 1989:224.
6 Hesch J. The Hesch method of treating sacroiliac joint dysfunction: integrating the si, symphysis pubis, pelvis, hip, and lumbar spine. Henderson, NV self published, 2006.
7 Chase D. Personal communication. 2005.
9 Maigne R. Low back pain of thoracolumbar origin. Arch Phys A/Ied Rehabil.1980;61(9)389-95.
SACROILIAC JOINT HYPERMOBILITY/HYPOMOBILITY POST PARTUM
Published in J OB/GYN PT 15:2, June 1991
Dear Editor:
I just renewed my membership and was happy to receive the March 1991 issue of) OB/GYN PT. I am in agreement with the letter to the editor written by Trenna Wicks. I share her excitement for the pertinent information in your journal. I also agree with her that hypomobility is a significant problem and especially so in the postpartum population. In my evaluation I use 11 basic joint spring tests. For complex sacroiliac dysfunction there are 22 different joint spring tests available. It has also been my experience that in treating hypomobility one does achieve more balance in the pelvic joints. What appears to be a hypomobility in one direction often represents a hypermobility or the preferred term, relative or apparent hypermobility, in the opposite direction. In treating the hypomobility, one is also treating the antagonistic hypermobility. I believe that treating the pelvis as a triplaner joint with a potential of up to 6 degrees of freedom is a very important concept in, seeking balance in these important articulations. The influence-of the very powerful mechanorcceptors, which are abundant in this region, and their obligatory influence on pelvic girdle and pelvic floor muscle tone cannot be ignored.
The importance of pelvic floor strengthening in effecting internal stability cannot be ignored. I am grateful for the influence of several prominent OB/GYN section members inthis regard.
I have no doubt that a joint spring test applied to the pelvic region evaluates not only articular mobility, but also the important influence of muscle. I do think that one of the purest joint spring tests is an anterior to posterior spring test on each pubic bone with the client in supine. I think that this might also be an external evaluation of the influence of the pelvic floor. I have noted a fairly consistent hypermobility in this joint in the pastpartum population and especially in the multiparous population, even several years after delivery. I do not think we can assume that stability is automatically established after delivery without evaluating for such. I did have a client who presented with significant hypermobility with A-P spring testing applied to the symphysis pubis. After achieving tri-planer symmetry of her lumbopelvic region and having her perform 100 repetitions of Kegel's exercises daily, she achieved stability within 2 weeks. I was very pleased with the degree of stability and indeed was quite surprised. The next day, however, she presented again, as she did on the first day, with significant hypermobility. In this example, I suspect hormonal influence to be significant.
I do think that we will see an emerging trend of evaluating the sacroiliac and pubic symphysis joints on the basis of joint spring tests and perhaps less so on the basis of gross motion tests, which may not reveal actual mobility or actual dysfunction.
Thank you for the opportunity to express my opinions.
Jerry Hesch
Albuquerque, New Mexico
SACROILIAC
PublishedThe Journal of Manual & Manipulative Therapy vol. 8 No. I (2000), 29 .31
An article by DonTigny entitled "Critical Analysis of the Sequence and Extent of the Result of the Pathological Failure of Self-Bracing of the Sacroiliac Joint"' clearly, contributes to our understanding of the sacroiliac joint (SIJ). Articles in other journals and books demonstrate the interdisciplinary interest in the problem of pelvic joint pain and movement dysfunction.
Problems have been demonstrated with all older models of SIJ dysfunction as new research re-examines the nature of the sacroiliac joint in depth. It is time that we as a profession re-define what SIJ dysfunction is, specifically; what are the biomechanics of the structure, what are the postural and movement dysfunctions, what are the pain patterns, and how do we effectively evaluate and treat the SIJ. I will share some conclusions I have reached in evaluating this structure over the past 20 years.
I believe that Mr. DonTigny is correct in his finding that anterior ilial dysfunction is the most common movement dysfunction of the ilium. In contrast with the traditional method of evaluation, I have been using additional landmarks for palpation and accessory motion testing' and I am convinced that anterior ilium is a tri-plane phenomenon. It rarely accompanies torsion of the sacrum about an oblique axis, but often accompanies puresacral rotation about a vertical axis and it sometimes accompanies a contralateral posterior ilium as has been noted by Cibulka et al'. After resolving the anterior/posterior ilium patterns a transverse plane pat-tern often emerges and should be addressed. This I refer to as a Type 1 Right Inflare/Left Outflare' in contrast to the infrequent traditional Intlare/Outflare3, The Outflare is noted by a posterior PSIS with restricted anterolateral accessory motion as tested in prone.
The expanded evaluation format has convinced me that sacral torsions (oblique axis) are actually quite rare, sacral rotation about a vertical axis is quite common and “unilateral flexion and extension of the sacrum'' probably do not exist.
This approach has been shown to achieve significant pain relief in one visit, increase passive SLR, and have greater than 70h intertester agreement' for the majority of palpation and passive motion tests'. Intertester agreement has been poor with most traditional tests. Fluroscooy has demonstrated several of the passive accessory motion tests to evoke movement in the SIJ9.
It is an exciting time as much new \vork is being done in this area. I believe that our profession will continue to evolve in its understanding of this complex problem. I thank DonTigny for his many contributions and this journal and for allowing me to express these ideas.
Jerry Hesch, PT
REFERENCES
1. DonTigny RL. Critical analysis of the sequence and extent of the result of the pathological failure of self-bracing of the sacroiliac joint. The Journal of Manual & Manipulative Therapy 1999: 7(41:1;3-181.
2. Hesch J. Aisenbrey J. Guarino J. Manual Therapy Evaluation of the Pelvic Joints Using Palpatory and Articular Spring Tests. Presented at the First interdisciplinary World Congress .on Low Back Pain and Its Relation to the
Sacroiliac Joint: November 6, 1992, San Diego, CA
3. Hesch J. Evaluation and Treatment of the Most Common Pattern of Sacroiliac Joint Dysfunction. In: Movement, Stability & Low Back Pain; The essential Role of the Pelvis. Vleeming A, Mooney V, Dorman T, Smijders C, Stoeckart R, eds. London: Churchill Livingstone, 199; 535-545.
4. Cibulka MT, Delitto A, Koldehoff RM. Changes in innominate tilt after manipulation of the sacroiliac joint in patients with low back pain: an experimental study. Physical Therapy 1988; 68:1359-1363.
5. Greenman PE: Principles of Manual Medicine. Baltimore: Williams & Wilkins, 1989: 246-257.
6. Mitchell F. Structural Pelvic Function. Academy of Applied Osteopathy. 1958: 72-90.
7. Olson L. Effects from the Hesch Method of Pelvic Mobilization on Lumbar Flexion, SLR. and Standing Pelvic Inclination Angles in Patients with Low Back Pain. Masters Thesis Finch University/The Chicago Medical School, 1998.
8. Potter N, Rothstein J. Intertester Reliability for Selected Tests of the Sacroiliac Joint. Physical Therapy 1985; 65:1671-1677.
9. Bernard T. Video presentation on sacroiliac joint injection. Presented at the First Interdisciplinary World Congress on Low Back Pain and Its Relation to the Sacroiliac Joint: November 6. 1992, San Diego, CA.
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