Assessing the Pelvic Alignment

[neuromuscular]

The useful tool is a test of pelvic angles using the landmarks of ASIS to ASIS, PSIS to PSIS and ASIS to PSIS (R&L) with hip abduction directly lateral in the coronal plane.

This reveals obvious and major distortions of the innominate bones into anterior or posterior rotations.

The practitioner does not have to guess.

The results change the treatment protocol in the majority of cases.

The following results are fairly consistent group to group.

No Back pain: No pelvic difference from anatomical neutral or ASIS and PSIS level to the horizontal plane.

Low back pain:

Only 10% have bilaterally equal pelvic angles that remain the same or very similar to each other throughout the hip abduction but increase equally thriought the hip abduction.

The remaining 90% have the following per centages:

60% anterior rotation of right innominate bone left posterior rotation
20% anterior rotation of the right innominate bone left remains close to level with the horizontal plane
20% anterior rotation of the right innominate bone and a lesser rotation of the left in the anterior direction

Most have not considered that the pelvic angles are of significance.

However, present success rates for low back pain are dismall( Archieve of Internal Medicine Septembet 24, 2007, etc., etc.,)

This leads to a protocol of treatment that can bring about a 90% success rate in change of pain by 90% and greated ROM.

Best regards,

Neuromuscular.

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[SagarNaik]

CLINICAL PREDICTION RULE FOR MANIPULATION IN BACK PAIN

■ Duration of symptom < 16 Days
■ Fear-Avoidance Beliefs Questionnaire (FABQ) work subscale score < 19
■ At least one hip with > 35 degrees of internal rotation ROM
■ Hypomobility in the lumbar region
■ No Symptoms distal to the knee

The presence of more variables of five in the prediction rule increases the likelihood of success with manipulation.

Reference: Flynn, T., Fritz, J., Whitman, J., Wainner, R., Magel, J., Rendeiro, D., Butler, B., Garber, M., Allison, S. A Clinical prediction rule for classifying patients with low back pain who demostrate short-term improvement with spinal manipulation. Spine; 27 (24), 2835-2843.

YouTube Video:


If video doesn't work in the post follow the link below.
YouTube - SI Region Manipulation for Low Back Pain

[neuromuscular]

CLINICAL PREDICTION RULE FOR MANIPULATION IN BACK PAIN

■ Duration of symptom < 16 Days
■ Fear-Avoidance Beliefs Questionnaire (FABQ) work subscale score < 19
■ At least one hip with > 35 degrees of internal rotation ROM
■ Hypomobility in the lumbar region
■ No Symptoms distal to the knee

The presence of more variables of five in the prediction rule increases the likelihood of success with manipulation.

Reference: Flynn, T., Fritz, J., Whitman, J., Wainner, R., Magel, J., Rendeiro, D., Butler, B., Garber, M., Allison, S. A Clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine; 27 (24), 2835-2843.

Dear Sagarnaik;

The manipulative approach has been used for many years by several disciplines including - osteopathic, chiropractic besides physiotherapy- with disappointing success rates and lack of proof that the manipulation worked. As stated there are several trials of the standard approaches that are giving success rates in the 27.5% to 34% success rates. That is too low for my liking.


If there is not change as I have often seen when comparing therapy procedures at seminars, then it is questionable that the therapy worked.

Therefore, I would request that you take the pelvic angle readings before therapy and after therapy. If there is no difference in the pretherapy and postterapy readings then it is questionable that thetherapy had the desired effect.

Manipulative therapy can have the effect of turning off the nociceptors and mechanoreceptors. Therefore, allowing the body to recalibrate to an abnormal position as if it were the normal antomical neutral position. The patient has no or limited pain, but is not at the ideal antomical neutral position and will return for treatment with a reoccurring problem Proprioceptive sense has a powerful ability to compensate in the body for position as we are just starting to fully realize.

Try the test and compare your results.

Best regards,

Neuromuscular

[Physio Dace]

Neuromuscular,

I have never heard of this assessment tool - its certainly not in common use in Aus. By the sounds of it you have some demographic data behind it use. Can you please post the reference that cites this tool and the data you quoted (inter/intra reliability would also be useful to know). As far as knew the use of positional fault theories to re-assess effectiveness of treatment is shaky as best. To state that you use this tool to compare effectiveness of different Rx techniques suggests that there is tight correlation between the test results and the cause of back pain - as far as I knew this is something we still don't know in >85% of cases. I would (as would the whole medical community) be very interested in this test if this was the case.

From this then, what is the rationale behind this tool in the context of NSLBP/back pain. It sounds as if it may be sensitive in this population but not very specific as it would be very susceptible to false positives arising from hip/SIJ dysfunction and anatomical variants etc. On the surface it sounds like it may be more useful as a functional/WB test in hip/SIJ pathology.

Also how do the results guide treatment choice as you eluded to?

Your response will be appreciated.

[neuromuscular]

Neuromuscular,

I have never heard of this assessment tool - its certainly not in common use in Aus. By the sounds of it you have some demographic data behind it use. Can you please post the reference that cites this tool and the data you quoted (inter/intra reliability would also be useful to know). As far as knew the use of positional fault theories to re-assess effectiveness of treatment is shaky as best. To state that you use this tool to compare effectiveness of different Rx techniques suggests that there is tight correlation between the test results and the cause of back pain - as far as I knew this is something we still don't know in >85% of cases. I would (as would the whole medical community) be very interested in this test if this was the case.

From this then, what is the rationale behind this tool in the context of NSLBP/back pain. It sounds as if it may be sensitive in this population but not very specific as it would be very susceptible to false positives arising from hip/SIJ dysfunction and anatomical variants etc. On the surface it sounds like it may be more useful as a functional/WB test in hip/SIJ pathology.

Also how do the results guide treatment choice as you eluded to?

Your response will be appreciated.

Dear Physio Dace:

The measuring of pelvic angles is not totally new. There have been several uses of the test at anatomical neutral. The new feature of the test that I am putting forth is to to the four sided pelvic angle assessment with hip abduction directly lateral in the coronal plane. This is the ASIS to ASIS , PSIS to PSIS, and the ASIS to PSIS (R&L). The most efficient foot postions are closed, 1 foot or 30 cm, 18 inches or 45 cm, 2 feet or 60- cm, 30 inches or 75 cm etc by 6 inch or 15 cm increments.

This makes the pelvic angles differ as the foot width position increases due to hip abduction.

If you want to be very accurate, you may use a set of lasers mounted to the wall with measuring marks and levels to compare the relative position of the landmarks to each other. However, the difference of pelvic angles and landmark positions is very obvious and the need for special equipment is not a priority. Some have suggested that a transit such as used by a surveyor would be of benefit, but the entire patient position moves inferior as the hip abduction occurs and the need to consult a landmark such as the umbilicus to compare the positions of the landmarks would be too much of a problem to work with it.

The differences of the ASIS to ASIS is often 1 cm to 4 cm This is readily discernable by the eye without aid. The increase of pelvic angle can be from neutral to over 20 degrees which you can measure with a goniometer.

Yes this test is not "mainline", but the trial of the test is being done by the OGI of the USA. The research paper should be out in the near future. the research person is having similar success that I had although he is over 1,000 kms away and I have not had collusion with him other than the putting forth of the test.

Patients can be taught to look in the mirror and compare their ASIS to ASIS to see if they are moving off line. They will often come in before pain as the positional change is obvious to them. These are patients where ergonomic factors affects their back pain. Most patients need little or no follow up after 3 to 6 treatments.

I do use this to compare pre and post therapy at seminars. I find that thepatient may have "less pain" than prior to the therapy, but that the bone positions have not been corrected to antomical neutral. It has probably been a proprioceptive sense change or nociceptor change that has brought a temproary pain reduction. However, I have found that long term pain reduction is obtained best when the pelvic angles remain stable throughout hte hip abduction.

This is new and I do not know what the statistics would be in Australia, since driver position is differenct and the dirver tends to lean on the right arm rest in the automobile, while here, the driver rests on the left arm rest. Would this have a difference/ I do not know.

Statistics obtained in Canada:

Patients with no back pain have no or lttle difference in pelvic angles from neutral.

!0% of all patients have bilateral pelvic angles which move either into anterior or posterior rotations as hip abduction increases. The angle remain bilateral, but are greater. These are such as the flat back or lordosis kyphosis type of postures.


90% of patients with back pain have differeing pelvic angels. The break down of the percentages has been posted.

Simply try the test and give me feedback.

I no longer look for SIJ dysfunction as the test of the standing SIJ with leg raise or torso flexion has been disproved by landmarking the PSIS to sacrum aand have the patient do hip abduction, In every case, the PSIS has moved superior to the sacrum. How can a supposed fixed or stuck joint move apart on its own? This test and others has wrongly concentrated our focus on the SIJ when there is a larger more global problem.

Hope that you have found this helpful.

Best regards,

Neuromuscular.

[Physio Dace]

Neuroman,

Thanks for the thorough reply. Just to clarify, its a static weight bearing test right? Also have you found that changes in alignment during the test are linked with the reproduction production of LBP symptoms - I ask this given that a change in alignment post-Rx seems to relate to improvement in symptoms - from what I gather anyway? Or is something that you see over time?

I look forward to reading the paper/s when they come to hand and until then I will trial the Ax tool on my LBP patients - out of interest any subgroups/classifications of NSLBP that you have found this tool to be most useful. e.g. either from McKenzie/O'Sullivan/Lee classifications etc? Or perhaps this will serve as yet another classification system.

Also what is the title of the test as it will be keyworded in upcoming research?

On face value it sounds like it may be useful, though I'm still a little skeptical when it comes to using/relying on alignment/asymmetry in the human body to correlate with musculoskeletal pain - particularly when it relates to non-specific LBP. Skepticism, as you can appreciate comes hand in hand with physio.

Is there a place for the use of a saggital plane LL position/movement within the test to simulate a more functional WB position?

Cheers for your input.

[neuromuscular]

Neuroman,

Thanks for the thorough reply. Just to clarify, its a static weight bearing test right? Also have you found that changes in alignment during the test are linked with the reproduction production of LBP symptoms - I ask this given that a change in alignment post-Rx seems to relate to improvement in symptoms - from what I gather anyway? Or is something that you see over time?

I look forward to reading the paper/s when they come to hand and until then I will trial the Ax tool on my LBP patients - out of interest any subgroups/classifications of NSLBP that you have found this tool to be most useful. e.g. either from McKenzie/O'Sullivan/Lee classifications etc? Or perhaps this will serve as yet another classification system.

Also what is the title of the test as it will be keyworded in upcoming research?

On face value it sounds like it may be useful, though I'm still a little skeptical when it comes to using/relying on alignment/asymmetry in the human body to correlate with musculoskeletal pain - particularly when it relates to non-specific LBP. Skepticism, as you can appreciate comes hand in hand with physio.

Is there a place for the use of a saggital plane LL position/movement within the test to simulate a more functional WB position?

Cheers for your input.

Dear Physio Dace:

The test is with full weight bearing in every position.

A supine and prone assessment are also used.

Since I am semi retired, the research paper will be done by a physio doing his Phd. I do not know the exact title.

The new feature is to use hip abduction in assessing pelvic angles. I have found no information that this has been done, even though there has been some done on just pelvic angles.

I will have to add more later if you are interested, so please contact me again.

Best regards,

Neuromuscular.

[linbin]

hi
i think most of the physios are well aware of the limited evidence supporting inter rater reliability of ASIS,PSIS,Lumbar segments .so how well anyone can determine the faults with the test mentioned here.i feel its more subjective also keeping in mind the structural variations among individuals

[neuromuscular]

hi
i think most of the physios are well aware of the limited evidence supporting inter rater reliability of ASIS,PSIS,Lumbar segments .so how well anyone can determine the faults with the test mentioned here.i feel its more subjective also keeping in mind the structural variations among individuals

Dear linbin:

To my knowledge, no one has tried the pelvic assessment with hip abduction. The hip abduction stresses the pelvis in a predictable way. There will alwauys be apprehension to new ideas.

As I have stated, just try the test. The differences are obvious.

Hope that this is helpful. I will be unavailable for some time.

Best regards,

Neuromuscular

[neuromuscular]

Just an update.

In the research for the abstract, the person doing the search of present papers has found no one who has considered the pelvic angle assessment with hip abduction.

Neither have any of the well respected authorities that I personally contacted in Europe and USA.

It is of note that many top experts are presently looking forward to the research paper due at year end or shortly there after. It will be done by a person from Lincoln Nebraska, USA.

This is a heads up for those who want to be with the latest research.

Best regards,

Neuromuscular

[river]

Thanks to neuromuscular for sharing this new assessment. My concern is the functional angle of the hip. Walking or stair climbing, involved more hip flexion then hip abduction though we can have patients with hip dysfunction in the coronal plan. There is also slight hip rotation (transverse plane). Also, factors like leg length discrepancy would distort the results. But I will be interested to read more about it when the paper is out. Also, what treatment protocols have you used to treat SIJ dysfunction/malalignment? If manipulation is not as effective, any inputs on Muscle energy techniques?

Cheers,
river

[neuromuscular]

Thanks to neuromuscular for sharing this new assessment. My concern is the functional angle of the hip. Walking or stair climbing, involved more hip flexion then hip abduction though we can have patients with hip dysfunction in the coronal plan. There is also slight hip rotation (transverse plane). Also, factors like leg length discrepancy would distort the results. But I will be interested to read more about it when the paper is out. Also, what treatment protocols have you used to treat SIJ dysfunction/malalignment? If manipulation is not as effective, any inputs on Muscle energy techniques?

Cheers,
river

Dear river:

Thank you for your interest.

The use of hip abduction is to see the effect of the adductors to the hip and pelvis. The standing SIJ test does not give accurate information on the SIJ when compared to the same test with hip abduction. The supposed "stuck" or "fixation" of the SIJ disappears as the PSIS moves superior and lateral to the sacrum.

What we see in the standing SIJ test with leg raise or torso flexion is the effect of the adductor longus on the contralateral side and the psoas on the ipsilateral side. This is why the joint moves together.

The hip flexion on stair climbing is not the problem, but the muscular imbalance of the patient.

The concept that this research is showing is that the one test does not give enough accurate information, but was too readily accepted over 100 years ago as showing a "stuck" SIJ and that we have never challenged that idea or concept, but kept building on it. In fact, it gives questionable results at best.

The lateral movement provides a specific measurable distortion. In normal people with no back pain, the pelvis remains level - PSIS TO PSIS, ASIS TO ASIS, AND PSIS TO ASIS (L&R).

In those who have low back pain the measurements are very much off normal to the point of obvious.

Leg length is a concern, but is it functional or anatomical? Anatomical can only be addressed with height adjustments to the shorter leg. Functional are a result of the rotation of the innominate bone and are corrected by the therapy. As the innominate bone rotates, the acetabulum is not in the center of rotation, so it moves superior or inferior and anterior or posterior as the rotation progresses. Depending on the rotation, the leg will appear short or long. In radiographic examination, the head of the femur can be closer or farther from the film plate. Further, in radiographnic examination the shape of the ischial foramen is distorted by the angle of the innominate bone in anterior or posterior rotation.

Hope that this is helpful to you.

Best regards,

Neuromuscular.

[neuromuscular]

To all from Neuromuscular:

The paper has been derlayed, but the research so far by a physiotherapist who is writing his doctorate paper is that the theory and therapy "have not failed yet" and that it has reduced the "outcomes" in clinic experience.

The paper will now be out in late 2009.

I will be giving a lecture on the subject to a major institue in Washington State this summer. If any would like the outline, I would be happy to forward it to you.

Best regards,

Neuromuscular

[estherderu]

hi neuromuscular,

Yes I am interested in the outcome.

Hope to hear from you when all the data is available

kind regards

esther de ru

[neuromuscular]

Dear Esterderu:

The presentation in Seattle, Wahington, USA was a great success. There were many notable physiotherapists who had Masters or Docturates that attended as well as the world renowned Ola Grimsby.

The overall reaction was very positive and the majority indicated that they would incorporate the pelvic assessment with hip ABD into the assessment time.

The five parts to the assessment were presented:

1: Gross anatomical or postural assessment with hip ABD
This is an overall view of the person from about 4 meters away as the patient does hip ABD. The assessment is from all four sides.

2: Landmark assessment of the ASIS to ASIS; PSIS to PSIS; and ASIS to PSIS (R&L) with hip ABD.

3: Supine assessment
4: Prone assessment
5 Gait assessment

The thought of Anomalies, Illusions and Conditioning were discussed and its impact on physiotherapy. For example, The Book MOVEMENT, STABILITY AND LOW BACK PAIN as edited bY Andry Vleeming et al was used as an example to show how the medical, chiropractic and physiotherapy worlds and others have conditioned people of various disciplines to look for SIJ problems. If you look at the index of that book, there are over 3 pages of references to the SIJ and zero references to the adductors. Interesting.

There was one patient and several therapists who were treated with the assessment and therapy. The reaction was very positive.

Hope you will try the aseessment.

Best regards,

Neuromuscular

[neuromuscular]

To All:

The paper has been delayed as the practitioner doing his docturate has opened two clinics due to the increase in patient load.

Of note, another area of interst has come to me in that a Canadian University would like to do a trial of the test.

Best regards,

Neuromuscular

[alophysio]

Hope it goes well for you neuromuscular.

Please let us know how that research goes (with the Canadian University).

Also, please let us know if the test changes in any way.

Hope it goes well for you.

cheers