New research: No such thing as "stuck" SI joint

For over one hundred years, after the standing SI joint test showed that the PSIS moved with the sacrum, it has been believed that the SI joint is "stuck" in the majority with low back pain. A simple test is disproving this. Try this: Landmark the PSIS to sacrum and have the patient do hip abduction directly lateral in the coronal plane from closed to the maximum that the patient can achieve At 15 cm increments. In virtually all of the patients with a positive for a stuck SI joint the PSIS will move superior and lateral to the sacrum. When the PSIS to ASIS is measured on the side of the supposed stuck SI joint, the innominate bone will move into anterior rotation.

The true condition of the patient is better described as APAS, asymmetric pelvic angle syndrome. The research paper on this is being prepared.

hi,

interesting point...however, some bold assertions are made in your post...like the majority of patients have a 'stuck' SIJ...

...in fact, in my experience, the majority of patients have poor motor control. There are very few "stuck SIJs" out there i am afraid - but i do come across them from time to time.

The sympoms of a stuck SIJ in my opinion are:

1. inability to bear weight on the affected side IF the joint is stuck (fixated) in a "subluxed" position (for want of better terms!) - if is it stuck as in fused or fibrosed etc, it might actually be in a closed pack position in which case it will bear weight just fine thank you very much.

2. SIJ joint glide testing will reveal the affected SIJ WILL NOT move in the primary direction it is fixated in and may or may not move in the other direction - the SIJ has 2 arms to the joint - it is "j-shaped". And on a sidebar, most people do their SIJ joint testing with WAY TOO MUCH FORCE - the joint moves only a few degrees and a few mm in gliding - try to remember that.

3. on ASLR, a fixated joint may respond WORSE to compressions - either manually or with a belt because the joint is usually painful

4. on stork testing, the PSIS and S2 will not move relative to one another no matter what you do - true fixated joint is just that - doesn't move.

_____

i am presuming you might be an author of this 'new research' - i think what you will need to do is highlight the fact that most problems are motor control driven and that physios have been using misnomers to describe what they are seeing.

Why treatment for a "fixated joint" or "stuck SIJ" or any joint for that matter works (when the real problem is motor control) is because the manipulation/manual therapy often gives a neurophysiological effect and causes some relaxation of the gripping global muscles. Then once that is done, you can do the local muscle stabilisation - which will address the real motor control problem anyway. Therefore, the therapist has now reinforced their belief that they got the diagnosis right...when it was technically wrong - BUT the patient got better so what is the concern?? I personally prefer to be technically and practically correct!!

As for your APAS, i have found your entry here...Asymmetric pelvic angle syndroms, APAS - Injury Update Forum. What you describe is certainly not new my friend but kudos to you for working it out on your own...BTW, a syndrome is what you call something when you don't know why it is happening - in other words, in the absence of a definition/diagnosis. I have the diagnosis for you...Motor Control Dysfunction. Read Diane Lee's textbook on the The Pelvic Girdle 3rd edition and don't forget to include that reference in your research paper...otherwise you are ignoring a major player in pelvis treatment!!

As for your research, you assert that you had 100% false positive on stork test using your ABD test. A problem might be your sample size. Another problem might be palpation error - there is enough research to suggest that the stance phase of stork is reliable but not sure about the swing/hip flexion phase which is where your test would fall. You may want to do your research overseas where they use RSA and XRay to determine true bony movements.

If you are interested in letting me read your findings, please feel to email or PM me.

I hope what i have written helps...

Cheers

hmm... raises questions as to muscular slings and muscle patterning

Quote:

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Originally Posted by Canuck Physio

hmm... raises questions as to muscular slings and muscle patterning

---

Thank you.

You are right.

The test to prove this is as follows:

Landmarkws: ASIS to ASIS, PSIS to PSIS, ASIS to PSIS (R&L).

From standing closed leg position have the patient do hip abduction for each landmarking at 15 cm foot positions to the maximum for the patient.

The following statistics have been obtained:

Patients with no back pain: Pelvic angles near anatomical neutral throughout test range.

Back Pain:

Only 10% have bilaterally equal pelvic angles either in anterior or posterior rotation.

90% have differing pelvic angles or angles which increase in difference as the hip abduction proceeds.

60% have right anterior left posterior
20% have right anterior left neutral
20% have right in greater rotation than left.

See what your statistics are.

This was in over 1,000 patients.

A true stuck SI joint was not seen.

Best regards,

Neuromuscular.

Quote:

---

Originally Posted by alophysio

hi,

interesting point...however, some bold assertions are made in your post...like the majority of patients have a 'stuck' SIJ...

...in fact, in my experience, the majority of patients have poor motor control. There are very few "stuck SIJs" out there i am afraid - but i do come across them from time to time.

The sympoms of a stuck SIJ in my opinion are:

1. inability to bear weight on the affected side IF the joint is stuck (fixated) in a "subluxed" position (for want of better terms!) - if is it stuck as in fused or fibrosed etc, it might actually be in a closed pack position in which case it will bear weight just fine thank you very much.

2. SIJ joint glide testing will reveal the affected SIJ WILL NOT move in the primary direction it is fixated in and may or may not move in the other direction - the SIJ has 2 arms to the joint - it is "j-shaped". And on a sidebar, most people do their SIJ joint testing with WAY TOO MUCH FORCE - the joint moves only a few degrees and a few mm in gliding - try to remember that.

3. on ASLR, a fixated joint may respond WORSE to compressions - either manually or with a belt because the joint is usually painful

4. on stork testing, the PSIS and S2 will not move relative to one another no matter what you do - true fixated joint is just that - doesn't move.

_____

i am presuming you might be an author of this 'new research' - i think what you will need to do is highlight the fact that most problems are motor control driven and that physios have been using misnomers to describe what they are seeing.

Why treatment for a "fixated joint" or "stuck SIJ" or any joint for that matter works (when the real problem is motor control) is because the manipulation/manual therapy often gives a neurophysiological effect and causes some relaxation of the gripping global muscles. Then once that is done, you can do the local muscle stabilisation - which will address the real motor control problem anyway. Therefore, the therapist has now reinforced their belief that they got the diagnosis right...when it was technically wrong - BUT the patient got better so what is the concern?? I personally prefer to be technically and practically correct!!

As for your APAS, i have found your entry here...Asymmetric pelvic angle syndroms, APAS - Injury Update Forum. What you describe is certainly not new my friend but kudos to you for working it out on your own...BTW, a syndrome is what you call something when you don't know why it is happening - in other words, in the absence of a definition/diagnosis. I have the diagnosis for you...Motor Control Dysfunction. Read Diane Lee's textbook on the The Pelvic Girdle 3rd edition and don't forget to include that reference in your research paper...otherwise you are ignoring a major player in pelvis treatment!!

As for your research, you assert that you had 100% false positive on stork test using your ABD test. A problem might be your sample size. Another problem might be palpation error - there is enough research to suggest that the stance phase of stork is reliable but not sure about the swing/hip flexion phase which is where your test would fall. You may want to do your research overseas where they use RSA and XRay to determine true bony movements.

If you are interested in letting me read your findings, please feel to email or PM me.

I hope what i have written helps...

Cheers

---

The problem is not a motor problem per sae.

The problem is a guarding response or a neuromuscular holding pattern.

I have talked to Diane Lee and Andry Vleeming and I do not find any test of the SI joint as giving anything but 100% false positives.

The person doing the research is associated with a USA institute. His research is confirnming my assessment as accurate and giving a much higher success rate than previous theories. The resistant type and active type of testing do not address the main problems. The singular most accurate test and the most objective is the postural type of tests. Any other test has a subjective element.

The person doing the research will be publishing a research paper as his docturate. An international magazine has shown much interest in it. Further, as the editor states, many will find it a theory hard to accept as it runs counter to many theories.

However, success rates are low for treatment of low back pain, regardless of the methods used including that of Diane Lee, et al. See BMJ series by Helen Froost in 2004 and later in 2006, Archive of Internal Medicine September 24, 2007, Dr. Hamilton Hall of Canada in a lecture in U of Alberta November 12, 2004, ETC., ETC., ETC., ETC.,..... The success rate using this treatment protocol is over 90% unlike the 27.5% obtained in the Archive of Internal medicine. The proof will be in the pudding.

I have no problem with people challenging the theory and therapy, but first try the tests. Other wise it is just being closed minded.

Best regards,

Neuromuscular.

This concept will be hard for many as no research has been into pelvic angles.

Even the eminent work MOVEMENT STABILITY AND LOW BACK PAIN THE ESSENTIAL ROLE OF THE PELVIS did not have one contributor that mentioned pelvic angles. Neither were the adductors even mentioned in this work.

However, when the four sided test using the pelvic landmarks is done with hip abduction, the difference of pelvic angles becomes very pronounced such that even a novice can see the change. Angles move from 5 degrees to over 30 degrees in many. The problem has been that any postural assessment has been done at only anatomical neutral. The hip abduction is necessary to cause a specific stress to the pelvic area. Most resistance and movement testing has a very substantial subjective component. This test is pure objective facts about the patient's true condition.


I invite all to try the test of landmarks ASIS to ASIS, PSIS to PSIS, and ASIS to PSIS (R&L) with hip abduction directly lateal in the coronal plane at 15 cm increments. For most it will present new and perplexing information.

Therapy is affected. Present success rates for low back pain are dismal as several sources show. This assessment leads to therapy with a success rate in the order of over 90% in reducing pain by 90%. That may seem like a grand claim, but the research facility doing the follow up in Nebraska, USA is having equally successful results.

Further, the therapy does not trick the body to accept an abnormal position as normal, but returns the innominate bones and subsequently the other postural components to anatomical neutral.

I urge all to try the test with hip abduction. You will be impressed by the new data obtained.

Please send your feedback in once you have tried the test.

Best regareds,

Neuromuscular

Hi,

1. Speaking for myself, I am certainly open minded...in doing so though, i must be thorough and critically evaluating what you propose...

2. Can you see that by making such a definite statement such as "there is no such thing as a stuck SIJ" can be seen as closed-minded?? ;)

3. Motor control includes overactivity and neural patterning my friend - we might be disagreeing on terms here...

4. you mention the landmarks as ASIS to ASIS, PSIS to PSIS and ASIS to PSIS...If you are determining if the SIJ is stuck or not, then shouldn't you have a landmark on the sacrum itself??? One side of the joint will not be able to detect movement.

5. I am sorry for not understanding but can you explain what are the angles you are measuring - how are they formed? What planes are you measuring in?

6. You say measure hip ABD at 15cm foot positions - the leg moves in an arc. Also, different leg lengths will mean 15cm will be a different ABD angles for different people...do you mean 15degree increments? That would make more sense - angular kinematics vs linear kinematics.

7. If only ilial measurements were used, then i am unclear as to how you can ascertain what the problem/dysfunction is...

...back pain patients might have asymmetrical angles but htat could be from L5/S1, SIJ, Pubic Symph, and hip dysfunctions. From what i can deduce from the limited amount of information you have provided is that there is a dysfunction somewhere.

8. i will look up the references when i can.

9. i would like to compare my results of doing the test but i would like clearer methods and how to calculate the results...e.g. what do you mean by saying the majority have right ant rot, left post rotation - what is "anatomical neutral", etc etc.

10. From what i can concluded, the hip ABD test is testing whether or not you have pelvic-hip dissociation with contralateral hip stability. In other words, testing the client's motor control ability to maintain a stable pelvis whilst using an open chain movement.

11. From the post above this one, if there is no research done on pelvic angles, how would one use it and write it in an "eminent work".

12. if you use only the ASIS and PSIS in whatever combinations, the result is called "intra-pelvic torsion" (IPT) (as outlined by Diane and LJ Lee)...e.g. left ASIS and PSIS showing post rot and the right ASIS and PSIS showing ant rot = left IPT. It just tells you that the pelvis in not in neutral.

13. What is the therapy that is used to produce such wonderful results? Can you give a case study from over 1000 patients that you have seen?

14. Can you PM me the author of the research/PhD or his/her email or some other way of finding out what the method is please?

Thanks...your responses to the above would be very helpful.

Thank you for your continued interest.

I have found that most people with the exlusion of Ola Grimsby and possible Dr. Robert ELlis have difficulty with this concept. I have talked to or had communication with Andry Vleeming & Diane Lee. Both of which had some trouble with the concept. One was very closed to any orthopeadic testing or landmark testing.

I agree that we must be critical and not accept something just because someone sayes it is so.

I did mention a test of the PSIS to sacrum with hip abduction. This shows that the PSIS moves away from the sacrum with hip abduction, but moves with the sacrum with torso flexion and hip flexion. This disproves the first as inaccurate. It was used to disprove other so called SIJ tests. The original standing SIJ test and others is an illusion that has caused many to pursue the illusive problematic SIJ.

I agree that the statement of no stuck SIJ does sound close minded, but it was said to get attention and it is said with the evidence in over 1,000 patients. Further, it does not preclude tramatic injury where the joint is crushed or damaged, but does say that there is no such thing as a stuck SIJ in most patients as we commonly hear in books like ORTHHOPEADIC PHYSICAL ASSESSMENT by David Magee U of A to name just one of many. This is more commonly believed that one would like to see.


Motor contrl to me is the signal controlling the muascle as differentiated from the other control factors which affect the signal. For example, we study about muscle spindle, but who has studied the "calibration" of the muscle spindle or golgi tendoon organ. Can these ge recalibrated to a different setting or set point from normal? I have not seen any information or research onthis. Neither has any one that i mentioned this to.

The angles are from the horizontal plane. If you do the test you will note that either the PSIS moves inferior to the ASIS or the ASIS moves inferior to the PSIS. It is obvious. You may measure the angles or the distance that the PSIS or ASIS moves inferior to the other. You will not have to guess as the movement with hip abduction in most is very pronounced as hip abdcuction proceeds. The movement is from the horizontal plane. I used the PSIS as the level of the horizontal plane, but you may choose to do as you see fit.

The test must be full weight bearing as the postural control muscles cause the distortion. Therefore, a floor measure was used. Since I am still familiar with the foot and inches I used the equivalent of 6 inches or 15 cm for the initial test. I now use the one foot increment as I have become familiar with the test and know what I am looking for. Distortion increases most after 75 cm. It does not matter which kinetics you use as the distortion is with distance and the measure is only for a coomon reference.

The problem or dyfunction is evident from the distortion of the innominate bones. Once you use the test you will see the data that has been missed. The anterior pelvic angle on the right is from a contralateral cause. This causes a correction by the proprioceptive sense to keep the eyes in line with the feet and the distortion progresses.

Anatomical neutral as published and as I have seen, is when the ASIS and PSIS are level in the horizontal plane. The PSIS should not be inferior to the ASIS or to the other PSIS. The same is true of the ASIS.

I find that any test of motor ability has a very substantial subjective factor. I use the postural assessment first. It is most objective and provides the most objective data. It is much like the resisted tests of the Muscle Testing manual by Kendall. They are of some use, but there are too many subjective factors - even when an instrument replaces the human factor.

The reason that pelvic angles were not in the eminant work, which was research papers, is that none of the participating papers or the editor considered pelvic angles of any concern. There were extensive research papers on the SIJ but not one o the authors considered the pelvic angles or innominate bone position.

The therapy is direct pressure into the muscle at 90 degrees to the muscle body. the distortion is the indicator of the muscular problem.

Thank you again. Best regards.

dear everybody,

the discussion about the SI joint being able to move/not move get stuck/ or not, has been around as long as I have been a physio. I did train as a OMT with Cyriax and Kalternborn.... at the time, so you could say I have some extra education in this field.
I am, however, not going to react in detail to this Y/N discussion but with a little practical idea of mine.

Because I have always found spinal + SI mobilisation/manipulation physically strenuous and an extremely passive way of treating patients I optrd for a more active approach.
Whatever the real reason, stuck or not stuck, we will find asymmetric movement patterns and strenght differences in these patients.
One of the most efficient ways of dealing with this is, in my opinion, using the PNF trunk patterns. I can really recommend them to everybody.
If you never learnt them, ( most college´s + UNI´s only teach you the arm and leg patterns) you can go to the PNF website for the names of people who have followed the "official course(s). IPNFA

Why tell you?, because even without always knowing (Y/N stuck SI), using these techniques has helped me help many people get rid of their symptoms and pain.


Esther
Good luck with your discussion. I do find it very interesting but will leave that up to you.

[QUOTE=estherderu;23438]dear everybody,

the discussion about the SI joint being able to move/not move get stuck/ or not, has been around as long as I have been a physio. I did train as a OMT with Cyriax and Kalternborn.... at the time, so you could say I have some extra education in this field.
I am, however, not going to react in detail to this Y/N discussion but with a little practical idea of mine.

Because I have always found spinal + SI mobilisation/manipulation physically strenuous and an extremely passive way of treating patients I optrd for a more active approach.
Whatever the real reason, stuck or not stuck, we will find asymmetric movement patterns and strenght differences in these patients.
One of the most efficient ways of dealing with this is, in my opinion, using the PNF trunk patterns. I can really recommend them to everybody.




Thank you.

I agree that one hundred years of believing the the SIJ is the problem is too long. Try the test for APAS. You will find the data obtained of interest.

The problem with doing what we feel will make the patient better or makes the nociceptors " recalibrate " to allow for an abnormal condition is that we may not have made the patient's condtiion actually better.

We need an objective, reliable, accurate guage of how the patient is progressing.

I feel that in the low back or pelvic treatment the four sided assessment using the ASIS and PSIS landmarks gives us a benchmark for deciding if what we did actually improved the patient's condition by returning them to a more anatomical neutral.
I have been to several seminars where after the "therapy" the patient felt "better" and the ego of the therapist was pacified, but there was no difference in the pelvic position. So did they like the manipulative therapy that opens and closes joints but does more to reset the nociceptors to an atrificial normal than normalize the postural position of the patient to anatomical neutral.

The PSIS to sacrum with hip abduction will disprove the SIJ dysfunction "posivite" and is a guage of the joint better than the present "standards".

The SIJ is not stuck, but present direction is stuck in testing it. Try the APAS test on your patients to see if there is a change after your theraputic intervention. Please give me feedback.

Best regards,

Neuromuscular.

Please focus on the major thrust of the discussion:

SIJ testing is misleading us from the bigger picture of the differing of pelvic angles.
There is little on how differing of pelvic angles affects therapy.

Best regards,

Neuromuscular

Ahh the old "super pelvic alignment wit hhip abduction" test for LBP patients rears its head in yet another discussion thread. Sorry Neuroman but from the above discussion Alophysio has the better of the argument - your statements regarding this test are extremely rigid and possibly inflammatory - but good on you for pushing our buttons. Science wouldn't be science without critical anlaysis and arguments. I look forward to reading another plethora of threads on this topic......and perhaps some quality populational correlation studies to support your extremely high incidence rates. Oh and some biomechanical/motor control/neurophysiological etc theories to support why such malignments exist in LBP (you know cause/effect/chanceetc) would also be welcomed.

Onward soldiers....

Quote:

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Originally Posted by Physio Dace

Ahh the old "super pelvic alignment wit hhip abduction" test for LBP patients rears its head in yet another discussion thread. Sorry Neuroman but from the above discussion Alophysio has the better of the argument - your statements regarding this test are extremely rigid and possibly inflammatory - but good on you for pushing our buttons. Science wouldn't be science without critical anlaysis and arguments. I look forward to reading another plethora of threads on this topic......and perhaps some quality populational correlation studies to support your extremely high incidence rates. Oh and some biomechanical/motor control/neurophysiological etc theories to support why such malignments exist in LBP (you know cause/effect/chanceetc) would also be welcomed.

Onward soldiers....

---

This reply is like many who do not consider a difference of view point from the "normal". It is unfortunate that some will not try a test on its own merit, but just put it down because it is different.

The reserach abstract is scheduled for year end. The research is by another person in Lincoln Nebraska USA. It has confirmed that there are numberous flaws in the present SIJ dysfunction model.

I hope that it will be considered with less disdain at that time.

Best regards,

Neuromuscular

To all:

A presentation of this material was made in Seattle, Washington, USA on August 29, 2009.

Many of those in attendance had Masters and Docturate degrees in physiotherapy.

The overall reaction was a very strong positive.

The presentaiton included several demonstrations on one patient and several of the therapists.

The hip ABD was a novel idea, but well received.

I hope that all will try the test.

Best regards,

Neuromuscular

Neuro... having a different view of SIJ things that seem to run against the trend is one thing, but the one line at the end of all that guff about posture etc has me all trembling with excitement.

"The therapy is direct pressure into the muscle at 90 degrees to the muscle body. the distortion is the indicator of the muscular problem."

is that it?
whatever the presumed value of all that "new" understanding about sij dynamics may be, there seems to be a missing element. You are proposing , if I have this right , that a trigger point when pressed, may unleash the potential of all the SIJ has to offer, having been viewed as having been altered by your tests.
I do like the apparent simplicity of it though, once one has deciphered the detailed explanations and seen it done perhaps.
There is one thing I can't help thinking though, why bother?. My own experience leads me to the conclusion that pain, when felt in the area of the sacrum , is almost never due to the sij at all. I have not seen a dysfunctional sij that was painfull since the late eighties. Maybe there are some out there, but the ones that come my way have thier lumbar spinal dysfunctions and protective behaviours to blame for sij pain. The poor old sij, stuck or not stuck seems to me to be a very unlikely source of pain.
Can you outline why you would spend so much time on these proposals about sij dynamics please neuromuscular, is it to provide a solution to a specific pain issue, or is it an encouragement to see things through your goggles.
sorry about the line where I am trembling, I'm ok now.

Dear Ginger:

I feel that we agree more than disagree.

I have not found that the painful or pain originating from the SIJ is the problem. Yet, in text after text the SIJ dysfunction - or whatever you want to call it - tests are put forth. The title of this thread is "No such thing as "stuck" SI joint". Innominate bone positions through hip ABD give a very different picture.

The text of research papers called Movement, Stability and Low Back Pain is a prime example with 3 plus pages of references on the SIJ in the index and not one on the adductors!!!!

I have shown that if you do a PSIS to sacrum with hip ABD the supposed "stuck" joint moves apart - PSIS moves superior and lateral to the sacrum.

My test is not of the SIJ, but of the innominate bone positions through hip ABD. This will remain true from all indications. Mapping the bones from all four sides gives much "new" information on what is happening with the patient. No one that I know nor any of the masters or docturate physiotherapists this was presented to has ever heard of mapping the innominate bone positions through hip ABD.

The therapy that I use is pressure into the muscle at 90 degrees to the muscle fiber. It is not "trigger point" therapy per sae. Trigger points occur as active trigger points in lengthened muscles straining to maintian some sort of semblance of normality to the joint position.. Latent trigger points are in shortened muscles. These are more often the cause as they move the joint to an artificial neutral position that is not the ideal neutral position.

The therapy may stand or fall, but the assessment gives much in the way of accurate, objective information. The group in Seattle are having fun "playing with the assessment" . I hope much will come out of that.

Please try the mapping of the innominate bone positions using the ASIS to ASIS, PSIS to PSIS< and ASIS to PSIS(R&L). Then give me feedback.

My best to you,

Neuromuscular.:)

No thanks neuro, the old stork test does fine for me, but hey best of luck with it all.

Dear Ginger:

Sorry that you follow without question an antiquated test like the majority:(.

Many chose to follow Ptolemy over Galelio also. DO you believe that the earth is flat or round?

Try the test.

Best regards,

Neuromusxcular

Joints when mobile act as buffers to reduce forces that travel up and down the skeleton. Where joints are immobile , these forces may contribute to pain causing mechanisms removed from the site of the joint, by allowing torques and adventitious movements to become severe. The SIJ pair are a case in point. Without the force reduction effects of this pair of massive slow moving limited joints, forces travelling up the legs and pelvis , may not dissipate normally and continue on into the spine.
I personally am of the view that allowing a pair of apparently immobile joints that may impact on spinal behaviour to go unchallenged would be improper in a well designed treatment.
I do spend time to restore SIJ movements , which occurs almost all the time in those with overpronation problems of the feet, and find long term benefits from doing so , in concert with a range of manual therapies. The test I use is known as the STORK, which I have always found to be satisfactory. It is a movement test of one lower limb at a time and , in my view , is sufficient to demonstrate the mobility , or lack thereof of SIJ's. My results are usually very good, in those where this loss of movement is the consequence of altered biomechanics, ie, pronated feet. As stated earlier those with immobile SIJ's do not present with SIJ pain , but may have referred pain, to the sacral area , from lumbar structures associated with the disadvantage of this loss of movement.
While your interest in the posture and position of the pelvis is fascinating neuro, and it would seem consumes your energy and time, I would prefer , given there seems no advantage for me or my patients to alter my aproach, to just offer my congratulations on a stirling effort and my best wishes for further results . I hope your time is well spent.
Cheers

Dear ginger:

Not all things are as they appear.

On a hot day, the pavement appears to be wet due to the way light is refracted above the hot pavement.

Tests can be the same. It is too bad that you are closed to trying a test that could provide new and needed information on the pelvic bones and low back pain.

The low success rates for low back pain treatment in the BMJ, British Medical Journal, of 2004 and 2006 and the Archive of Internal Medicine of September 245, 2007 provide much food for thought.

Just try the innominate bone position test and compare your results with the STORK test. You may be surprised. Unless you are too closed to try it.

Best regards,

Neuromuscular.

I'm not surprised the british get poor results for manual therapy with LBP, I've worked there. Enough said. I get very good results from the methods I have been using and teaching for many years. LBP in most cases responds very well to a method known as CM, with good short and long term effect. Same goes for attention to SIJ's when needed, If the stork test reveals los of movement and I see a need to restore this movement , I can easily do so with mobilisation, the effects of which are usually revealed imediately with the same test.or treatment repeated till the test shows positive for mvt.

Dear Ginger:

Sorry, but the Archive of Internal Medicine was NOT British. It was of over 1200 people. The success rates were terrible.

Many people fear being in error. However, as the saying goes, the only thing to fear is fear itself.

You state that you are having success. On what basis? Prior to using this method, I thought that I was getting great success. However, when I started mapping innominate bone position throughout the range of hip ABD, I began to question my viewpoint. When I started to use the hip ABD or APAS test, I did survey after survey as well as the normal ROM tests and functional testing. I found that success rates increased. I did not fear that I was not the guru that I thought I was. The patient replys increased in satisfaction. I did comparison surveys, satisfaction surveys, etc.

To say something does not make it so.

Try the test! Unless it is a trait of those in AUstralia to avoid the unknown..? Why the big problem in trying a test???????

Best regards,

Neuropmuscular

Dear all:

I might add here that the original idea of the mapping of innominate bone position in the APAS test or innominate bone position test during hip ABD was to see if there were other causes than the standard infallible standing SIJ test or "STORK" test that is everywhere - and I might add that has a strong list of "believers".

By mapping the innominate bone position during hip ABD a different set of parameters is shown.

I cannot get over the strong reaction that has occurred to this. Are we afraid of the unknown??? Where is the scientific approach of try and see what your results are??? Very few have had the fortitude to try the test BEFORE challenging it. You might be surprised at your results and the new way of thinking that it engenders. Try the test. Please do not be closedminded.

Best regards,

Neuromuscular.

Hi Neuromuscular,

My friend, please try a different approach with Ginger - to me, it would seem you are trying to get him to agree by taunting, badgering and basically insulting him - all of which tends to cause anyone to close up to your ideas.

In defence of the stork test, a relatively recent study by Hungerford et al demonstrated that the stork test had inter-tester reliability on a Yes/No system.

I have no doubt that you both get get good results.

In defence of your APAS, to my mind, it is like a stork test in a different plane of motion (except both feet are on the ground!).

My difficulty with your test (APAS) is that you do not reference the sacrum therefore you cannot truly test each SIJ joint. For example, if i were to discover that the ASIS and PSIS of the left innominate is anterior and the ASIS and PSIS of the right innominate are posterior during increased ABD stance positions, then it is not proof of the SIJ moving but quite possible that the rotation of the whole pelvis is rotating on the hips...

If i may be so bold as to suggest the following...please remember the wise words fo Abraham Lincoln - "A drop of honey catches more flies than a gallon of gall."

One of the ways many people improve their ideas, systems and tests is to try to tear them down - what are the limitations of your test? What alternative explanations are there to explain the apparent test results?

I am thinking of the Disney system where they have (apparently) 3 rooms...
1. Ideas room - here everything is set up to foster idea generation and it is not allowed to point out flaws but to try promote the idea as far as possible.
2. Flaws room (i have no idea what they really call these rooms) - here they set out to destroy all ideas that come through - it is this refining by fire and sending back to the drawing board which produces their best ideas
3. Make it happen room - once an idea stands up, they make it happen.

If you cannot see any limitations to your test, i would suggest you are too close to it and not objective enough. Every test, every system, every idea has its limitations.

Please post your thoughts on what alternative explanations people have provided once they have tried your test...

My very best to you Neuromuscular...

Dear Alophysio:

Thank you for your reply.

Well said.

However, I cannot get over how few are willing to try the test BEFORE jumping in with contradictions.:( This is NOT good science, which we are all supposed to "believe" is the best approach. However, it does suggest a closed to other possibilities approach.:( I have done the Stork test or standing SIJ test with hip flexion or torso flexion, but others do not even try the hip innominate bone position test or APAS test and discredit it without knowing what would be shown by it.

I do not believe that the SIJ is the big first "cause" in most cases. It's movement is affected by outside forces other than the joint. In mapping the innominate bone position, a new set of parameters are given that are often at odds with the old train of thought.

I would love feedback from those who HAVE TRIED the innominate bone position test or APAS test to see if it does affect their viewpoint on what is needed to be done for the patient.

I find that the standing SIJ test or STORK test gives results that differ from the same landmarks with hip ABD. (This is not the APAS test or innominate bone position test, but just a comparison of the standing SIJ test to the same test with hip ABD instead of flexion to compare how the joint moves or does not move.). So if one does the standing SIJ test with hip flexion or torso flexion and does a comparison to the same landmarks of the PSIS to sacrum with hip ABD, the PSIS moves superior and lateral in the vast majority of people examined. What does this indicate? A false positive in the standing SIJ test with hip flexion or torso flexion vs the same test with hip ABD???? If it is a false positve, should we not be concerned???

I would love for as many as wish to try the two tests back to back and give me their results. We do not have to fear the unknown, just known the unknown and what we are seeing. :)

My best to you Alophysio,:)

Neuromuscular

Thanks neuromuscular.

As you know, i have given you feedback about your test.

However, perhaps addressing some of the concerns i raised in the previous post might help others see that you are "balanced" in your approach...at the moment, it seems that you are "pushing a barrow"

Perhaps trying to see things from other peoples point of view can help.

For example, can you see how not referencing the sacrum in your test means it is difficult to determine SIJ movement and that the rotation can be coming from the hip? Therefore it is difficult to say with certainty that the SIJ is NOT stuck because there are other explanations...

Your ideas are good - i just think there needs to be balance...

Additional Comment I forgot:
Dear ALOphysio:

I have given you reply some thought.

I would disagree with the idea that the inter-person results being similar is proof that the test is reliable. How so?

Hungerford may have found that all people conditioned to believe that the test is accurate got similar results. Pavlov did that with dogs when a bell rung at feeding times.

Science is not about being sweetie pie to everyone when they dish out gall.

Science is about what is accurate and what is not.

If we took a bus load of people into the outback in Australia who had never been out of the city, what would they "see" as they drove down the highway on a hot summer ( December to March) day? Would it not appear to all of them and would not all be in agreement that the road appears to have a layer of water on the road when in fact is is the refraction of light???????

So having every one agree that they saw the same thing does not make it so!!!

In the standing SIJ or stork test every one "sees" that the PSIS moves with the sacrum in hip flexion or torso flexion as a positive for joint problems. What does that prove??? Is it really a joint problem or not???

In the same landmarking with hip ABD the PSIS moves superior and lateral to the sacrum. What does that prove???

What is really the fact in this case? Is the joint stuck in one test and clear in the other or is there a false positive going on and we are ignoring the facts???

I humbly suggest that you try the two test back to back and decide for yourself and others do the same..

Try the standard test of the SIJ with hip flexion and torso flexion and then landmark the PSIS to sacrum with hip ABD. For every stuck joint, the PSIS moves superior and lateral in the second test. Period.

WHat does this suggest???

My best to you,

Neuromuscular.

Dear Alophysio:

I have given your reply more thought and it is obvious that you have not tried the comparison test of the SIJ that I have stated several times.

The APAS test or innominate bone position test is not the equivilant of the standing SIJ test, but I did state one that is.

To test the SIJ positives of the standing SIJ test or stork test you can do the following back to back:

Step one: Patient standing Practitioner landmarks the PSIS to sacrum. Patient does hip flexion and torso flexion while the practitioner maps the PSIS to sacrum. The standard standing SIJ test or stork test.

Any positives can be directly compared to the following:

Step two:

Patient standing. Practitioner landmarks the PSIS to sacrum. Patient does hip ABD to the ability of the patient to comply at increments of 25 cm, 50 cm, 75 cm, 100 cm, etc.

My results: ALL patients with a supposed stuck SIJ or "fixation" of the SIJ had the PSIS move superior and lateral to the sacrum in step two. What is your take on this phenomenon??? I see the supposed positive in step one as a false positive and has an easy explanation.

Science is out getting the facts.

Science is about accuracy.

Science is about verifiability.

Science is about knowing the full picture.

PLEASE READ THIS CAREFULLY AS THE TEST GIVEN IS NOT THE APAS TEST.

My best to you,

Neuromuscular

To All:

Let us be sure that we are all on the "same page".

The comparison test done to challenge the popular ubiquitous standing SIJ test or "stork" test is as foolows:

Step one:

Do standard SIJ test with hip flexion or torso flexion or both.
Patient standing. Practitioner landmarks the PSIS to sacrum from the posterior. Practitioner maps the SIJ of the PSIS to sacrum as hip flexion and subsequently the torso flexion is performed by the patient.

Step two:

Patient standing. Practitioner posterior to the patient landmarks the PSIS to sacrum. Practitioner maps the PSIS to sacrum as the patient does hip ABD to the following positions: 25 cm, 50 cm, 75 cm, 100 cm, to the ability of the patient to perform hip ABD. Practitioner maps the PSIS to sacrum through the entire hip ABD.

Note the positions of the PSIS to sacrum in each phase of the tests. Note any differences. What is your conclusion???

This IS comparing "apples to apples".

Do the APAS test to find out if you are missing other pertentant information on your patient/client.

Best regards,

Neuromuscular.

To All:

I would like to add that repeatability and inter-tester results ARE important ONLY IF THE TEST IS UNQUESTIONABLY RELIABLE. The stork test or standing SIJ test with hip flexion or torso flexion fails in that the same landmarks do a different movement in the same test with hip ABD.

My question is: How can this supposed "stuck" SIJ or "fixation of" the SIJ move apart in the second test if the first is accurate???

Inter-tester repeatability is important when the test is verifiable, accurate and has no loop holes. It is a scientific tool.

Please note that some have missed this part of the assessment.

My best to all,

Neduromuscular.

Dear Ed,

My friend, i HAVE done your test.

Again, it is not new to me because i work on principles, not following what someone says to do.

I test the PSIS and sacrum to all sorts of tests (in addition to other landmarks as well) as a test of LOAD TRANSFER.

My interest is in the joint and whether it is well controlled.

I am sure i have written here and to you privately that the cases of a "stuck" SIJ are rare and that motor control problems give the appearance of unlocking.

I too am frustrated by what people believe however have no fear - i am not dismissive of your claims, just critical - as all good scientists are my friend.

In your assertion that you have never seen a stuck SIJ, some logical conclusions result;

1. You are correct and there have not been any stuck SIJs come thru your clinic in all your years
2. You are incorrect and there HAVE been stuck SIJs but you have incorrectly assessed them

In addressing #1, there is nothing left to do - it would assume that your assessment of the SIJ is valid and reliable and correct. I believe you live here and truly believe this.

In addressing #2, i am not so sure you have fully considered all the possibilities...like
a. When you see the PSIS move superior to the sacrum - is it relative movement of the innominate compared to the sacrum or the whole pelvis rotating or twisting or simply a myofascial pull?
b. Your passion and emotions would beg the question...are you too close to your test to be objective? Honestly, you have addressed some scientific questions i have about the test but have you addressed the communication aspect? Insulting me and others certainly doesn't make me feel good about doing things for you or to even validate your test. However, i feel i understand you better than that which is why i have kept communication lines open...how many people have you found that have been as generous towards you as i have? It is not just because i have taken the time to be nice but perhaps your communication style puts people off...

Please consider...

thanks

Dear Alophysio:

The proper protocol on a thread is to use the code or user name on the thread, even if you do know the person by their given name.

My concern is that we are conditioned no matter how hard we refute the idea. It is like Lady Macbeth where it was said of her: "Me think the lady doeth protest too much." We can jump up and down and stand on our head, but peer groups condition us to accept the ideals of the peer group, so we find it hard to think "outside of the box".

On integrity, I am sure that Ptolemy was a man of integrity that believed that he was seeing the corect perspective. His theories and subtheories for the divergencies that he was seeing were very involved and seemed very correct. However, when Capernicus and later Galelio said that the very first assumption was not correct, the whole gagle of theories fell like a house made out of a deck of cards.

You appear to have read every author in the realm of physical therapy. I may not have read as many. Myk Hungerford's study that showed that there was conformity to the rules and that every tester came back with close or similar findings does not impute lack of integrity, but possible tunnel vision. If you frame a test to give certain results under certain conditions, it is like the bus load of people who all saw the reflected light off the pavement and thought it was "a layer of water" on the pavement. They all had the same findings. What would Myk Hungerford have found if they did the same test with hip ABD instead of hip flexion or trunk flexion. We do not know, because Myk Hungerford did not try that part of the comparison test!!! Why? because it was 1) unknown to her - she was ignorant of the implications of doing the comparison of hip ABD to the other way of doing the standing SIJ test, because her peer group had never considered it!: 2) she thougt it irrelevant for whatever reason. We may never know.

The movement of the PSIS away from the sacrum is relevant unless you wish to dismiss it. It is movement of a supposed "stuck" joint. How???

Load transfer tests to my experience are very inconsistent and subjective and carefully framed.

Science is being accurate and open to new ways of looking at things: not recyling old ideas to make something fit. Ptolemy made that mistake.

What are the reasons for reconsidering if a new perspective is needed? Numberus sources are showing low sucess rates in trial after trial of therapy for low back pain by several disciplines - load transfer testing et al (27.5 to mid 45% rates). ( I have quoted these, but others have dismissed this. Is it an ego problem? ) That should be reason enough to contemplate a new direction on its own. Further, Andry vleeming chairs an international convention on low back pain. If the treatment of low back pain were a "sure thing", why have a conference looking for new ideas???????

I feel that there is enough evidence, and the the comparison test is just one more test to question the status quo.

Best regards,

Neuromuscular.

Dear Neuromuscular,

Apologies about the tag - going between email and this got me into trouble...

1. The SIJ moves - we know this and there are tests that are there in the research and some research to prove reliability and some research that does not support reliability - you said yourself you haven't read the research - go and read at the least the abstracts - pubmed.com

2. The pelvis moves relative to the L5 and relative to each hip joint.

If you can acknowledge these points and that your test deals with both of these types of movement (internal and external) then fine.

If you cannot agree on these two points and your test, then i believe it is you that protests too much.

Good luck neuromuscular...my patience is wearing thinner... :(

Dear Alophysio:

I did not say that I have never read the research. I said that I have not read as much as you.

The point of interst is that the standing SIJ test with hip flexion or torso flexion is at odds with the same landmarks of PSIS to sacrum with hip ABD. That is the point of interest. In the standing SIJ test with hip flexion or torso flexion a positive beomes a negative in the standing SIJ test using PSIS to sacrum with hip ABD. How would you prove which one is the true "positive" of "negative"???

I find load transfer tests or weight transfer tests as too orchestrated to be unbiased. Which one would you prefer to be used? Why that test? What would it prove?

Further, I find that the anterior rotation indicated in the standing APAS test is from a contralateral side and unlike the common viewpoint that the anterior rotation of the innominate bone is from an ipsilateral cause.

That is of major impact on therapy.

Best regards,

Neuromuscular.

Hi Ed,

Refer to my last post and the 3 points above...you haven't addressed them yet...

Here they are again...

1. The SIJ moves
2. The pelvis moves relative to the L5 and to each hip.
3 Your test assesses movement of both point 1 (SIJ) and point 2 (L/S and hips).

Do you agree or not?

Dear Alophysio:

I believe that Ola Grimsby, as numerous others, has advocated and I believe has proved that the SIJ does move.

I have no problem with the concept. After all, why would a joint be where it is unless there was some sort of movement???

The innominate bones move relative to the sacrum and to each other. That is well attested to.

The test assesses movement not a "stuck" joint. It shows that the concept of "stuck' is not so. It shows a different cause than proposed by the "stork" test.

I am not sure why this is asked.

Best regards,

Neuromuscular

Neuromuscular,

What research has Ola Grimsby published? A search of Pubmed.com under "Grimsby O" produced nothing in the way of research on SIJ motion.

If you want to quote people who have proved that the SIJ moves, then do it properly - Sturesson for example who implanted metallic balls into people's pelvises...

With all due respect to Ola Grimsby, he is not the authority on SIJ motion...

You haven't addressed point 2 and 3...

2. The pelvis moves relative to the L5 and to each hip.
3 Your test assesses movement of both point 1 (SIJ) and point 2 (L/S and hips).

Again, the "stork test" in recent research is about FAILED LOAD TRANSFER - of which the causes are neuromyofascial and articular (fixation is a subset of articular causes).

See "Hungerford B" at PubMed Home - the articles are #2, #3 and #4 on the list as of today...

I have my evidence that my statements are accurate - that is, the stork test is for failed load transfer...AND they are published in the literature in the public domain...

...you state the stork test is for a fixated SIJ - where is your evidence?

You are attacking a test without basis by claiming the test claims a fixated pelvis when the published literature contradicts you.

I ask these questions of you because if you want to be taken seriously, then do serious work and at least read other people's research before you attack them...

Your test has flaws. I am DONATING my time to help you. If you are going to soak me for information, at least answer my questions!

You haven't addressed point 2 and 3...

2. The pelvis moves relative to the L5 and to each hip.
3 Your test assesses movement of both point 1 (SIJ) and point 2 (L/S and hips).

Dear Alophysio:

First, Ola Grimsby may not have published the work, but was involved in it. Yes Struessen was the person to do most of the offical publication. Ola has produced several books.

Second, with all due respect, you have not addressed by proof why the standing SIJ test with hip ABD gives differring results to the beloved standing SIJ test with hip flexion or torso flexion.(stork test) You have quoted only those who are "pro" "stork test or advocates of the "stork" test.

My whole point is: why the difference? One says there is a problem ( stork test), the other says No problem (hip ABD test). Why?

Several texts state that the test is of SIJ "fixation" or a "stuck" SIJ including the text ORTHOPEADIC PHYSICAL ASSESSMENT by David Magee. Every medical practitioner that I have talked to has been taught that the test is for a "fixation" of the SIJ. Chiropractors are taught that the test is for a "stuck" SIJ.

If you want to sublimate this by saying LOAD TRANSFER By all means do so, but show why other tests differ from it. That is the point.

Yes the pelvic bones move relative to other structures.

I would like people to try the tests and then formulate why the difference and then address why the test results differ. Just stating research that has not addressed the test using hip ABD does not discredit the test or its results. The hip ABD test casts a great doubt on the "stork" test.

All research to the present has ignored hip ABD. Regardless if you do the comparison test of PSIS to sacrum with hip ABD or the APAS test, the results differ from the standard "stork" test. Why? Yes the planes are different, but it should corroberate the "stork" test and not differ.

That is the whole point of the discussion. No one has done the hip ABD test in research to the present. It has not been published, because no one has done a trial on it or has viewed the hip ABD as relevant. Why???

The status quo is accept the "stork" test, because we say so. We have "figured out" just what it is - a LOAD TRANSFER TEST, so it has to be so.

Best regards,

Neuromuscular.

Thanks Neuromuscular,

Now we can move on to the next stage.

By your admission, the Stork test as described in recent literature is a LOAD TRANSFER TEST - which by definition has many causes, one of which is fixation.

The next step is that you claim you can see one result on the stork test (positive failed load transfer test) but "movement" on your APAS test.

By your own words, you have merely confirmed my position!

Quote:

---

I find that the standing SIJ test or STORK test gives results that differ from the same landmarks with hip ABD. (This is not the APAS test or innominate bone position test, but just a comparison of the standing SIJ test to the same test with hip ABD instead of flexion to compare how the joint moves or does not move.). So if one does the standing SIJ test with hip flexion or torso flexion and does a comparison to the same landmarks of the PSIS to sacrum with hip ABD, the PSIS moves superior and lateral in the vast majority of people examined. What does this indicate? A false positive in the standing SIJ test with hip flexion or torso flexion vs the same test with hip ABD???? If it is a false positve, should we not be concerned???

---

- from post #25

In other words, if you read the research on the Stork test by Hungerford, she too observes that failed load transfer results in anterior rotation of the innominate (superior and lateral movement)...

In other words, a positive stork test is the same as your APAS test.

QED...

Dear ALophysio:

Thank you.

However, unless we are talking about two different things, the postitve from the standing SIJ test with hip flexion and/or torso flexion is that the innominate landmark of the PSIS and the sacrum move as one unit together. How can that be the same as the PSIS of the innominate bone moving away from the sacrum in the comparison test ( which is not the APAS test) where the PSIS to sacrum landmarks are observed during hip ABD? I do not follow how a joint moving together as one unit is the same as the same joint moving apart (the bones moving seperately)???

Best regards,

Neuromuscular.