Show Notes:

03: Til and Whitney discuss sacroiliac joint pain and hand-on therapies: causes, controversies, and considerations.

In this episode,

  • What causes SIJ pain? 
  • Does the SIJ move a little, or a lot? 
  • What about hypermobility? 
  • What are the controversies? 
  • What does the research say? 
  • Key considerations for manual therapists, 
  • and much more.

Join two of the leading educators in manual therapy, bodywork, and massage therapy, as they delve into the most intriguing issues, questions, research, and client conditions that hands-on practitioners face. Stimulate your thinking with imaginative conversations, tips, and interviews related to the somatic arts and sciences. With Whitney Lowe and Til Luchau.

Resources discussed in this episode:

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Your Hosts:

Til Luchau Advanced-Trainings        whitney lowe
Til Luchau                          Whitney Lowe

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Your Hosts:

Til Luchau Advanced-Trainings        
         Til Luchau                           

whitney lowe
      Whitney Lowe

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(The Thinking Practitioner Podcast is intended for professional practitioners of manual and movement therapies: bodywork, massage therapy, structural integration, chiropractic, myofascial and myotherapy, orthopedic, sports massage, physical therapy, osteopathy, yoga, strength and conditioning, and similar professions. It is not medical or treatment advice.)

Full Transcript:

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The Thinking Practitioner Podcast:
Episode 03: Sacroiliac Joint Pain: Causes, Controversies, and Considerations

Broadcast date: 12/18/2019
©Copyright The Thinking Practitioner Podcast, Til Luchau & Whitney Lowe

Whitney Lowe:                 Welcome to the Thinking Practitioner podcast.

Til Luchau:                         A podcast where we dig into the fascinating issues, conditions and quandaries in the massage and manual therapy world today.

Whitney Lowe:                 I'm Whitney Lowe.

Til Luchau:                         And I'm Til Luchau.

Both:                                   Welcome to The Thinking Practitioner.

Whitney Lowe:                 Okay, welcome, everyone. And how are you doing today, Til?

Til Luchau:                         It's a good day. It's great to be here. I'm looking forward to our topic here, looking forward to diving in.

Whitney Lowe:                 Great. We're going to be looking at some issues related to sacroiliac challenges today, and this is certainly one that can take us way off in the weeds because there's a lot of things going on here.

Til Luchau:                         Lot of things going on with the SI joints. Hey, I had an idea. Why don't we try doing the whole podcast without saying the letter A?

Whitney Lowe:                 Yeah. I got your little thing on Facebook the other day. I made a little contribution there. I think you're saying it without. Is that all right? Yeah.

Til Luchau:                         You were awesome. You did the whole thing without the letter A at all.

Whitney Lowe:                 Right. For our listeners, tell them what we're talking about-

Til Luchau:                         Oh, there was a Facebook post with somebody's question. Can you write a whole paragraph without the letter A, and Whitney aced it. You really got a good one.

Whitney Lowe:                 Yeah. Of course, I should have been doing all kinds of other stuff where I was like, "Oh, I got to do this." I was up late last night. I'm going to make something good here.

Til Luchau:                         Of course, I was busy prepping for the podcast.

Whitney Lowe:                 Right. You were doing your homework. I was procrastinating.

Til Luchau:                         On my Facebook post, right?

Whitney Lowe:                 Yeah. So tell me, what do you think about the SI joints. This is a complex issue here, and one of the questions that I know we get a lot as practitioners, especially for those who may not have delved into looking at the complex biomechanics in this region a lot. How might we know that the SI joints could be involved in pain conditions or various dysfunctions that our clients are presenting with?

Til Luchau:                         Well, that's a key question. How do we know that it's the SI joint when someone hurts? And I just got to say at the beginning here. This is one of the areas in the body where there is so much controversy about what's going on. And diametrically opposed models of what's happening and then how to help it too, and a lot of us were trained in one way and then we're reevaluating those points of view and looking at different options.

Til Luchau:                         But back to the clients, really, what counts is what we do with our clients or patients who come in, and your question how do we know if the SI joint might be involved when they have, there's pain provocation test that you can do and maybe I might pick your brain with what some of those. I got a few I use myself. But any time someone has low back pain, I'm noting in the back of my head, maybe the SI is involved.

Til Luchau:                         In fact, the study say up to 30% of the time, the SI joint pain will be experienced is low back pain.

Whitney Lowe:                 Yeah. I've run into that too. There was a couple of studies that we were both looking at for our discussion today and I was quite surprised at how high those statistics were of the relationship of SI joint pain with the common low back problems. I mean that certainly makes it more difficult and the non-specificity that people feel of trying to say like, "Well, it just kind of hurts," kind of this whole general area and they're starting to rub over their whole low back and lumbosacral region without really being able to pinpoint anything. I think that's one of the things that makes it particularly difficult to chase down.

Til Luchau:                         That's classic. Someone says, "My back hurts," and then when I finally get them to point to it, I don't know where they're going to point. I don't know if that means their shoulder or all the way down to their buttock. It could be anywhere. But yeah, any time there's low back pain, I think to myself, "Okay, is the SI involved?"

Til Luchau:                         And you mentioned reading that in one of our papers, I remember years ago some of the early experiments were around nerve blocks where they would actually numb out the SI joint and see how many cases of back pain went away with just that intervention and that was like about 10%. That was the statistic we all quoted for a while, about 10% of back pain since seemed to have an SI origin. Now, they're saying like up to 30%. Different authors are saying that much.

Til Luchau:                         Yeah, low back pain. A lot of times people will experience it as hip pain too, sensitive SI or sensitized SI. Pelvic pain, could be down the leg. It's a generalized zone, like you said, generalized symptom but the SI joint could be a contributor to any of those kind of complaints.

Whitney Lowe:                 One of the things that struck me from those papers in that particular statistic because that statistic did appear in a couple of different papers that I was looking at. And they would go on to say to those papers that they have such a difficult time accurately identifying when the sacroiliac joint is a component part of something or what actually is causing the pain in many SI joint problems.

Whitney Lowe:                 So it made me wonder, if that's really true and they have such difficulty pinpointing it, how do they know that really is present in that large number of back pain complaints if we have such a difficult time isolating these things. And I think it illustrates the real quagmire that we often find ourselves in trying to piece these things into separate pieces and say what part of this is SI joint, what part of it is low back pain and how are they independent or how are they related so many times?

Til Luchau:                         Great questions. I know the 10% thing that came from a nerve blocks. It was later debated. People said, "No, you can't actually be that specific with a nerve block to just get the SI of it." Yeah, all of the statistics end up being debated and usually, where it gets to is like there's a lot of uncertainty.

Whitney Lowe:                 Yeah.

Til Luchau:                         There's a lot of uncertainty.

Whitney Lowe:                 What have you come across in terms of identifying what are sort of the causes of SI joint pain predominantly?

Til Luchau:                         Well, classically as a Rolfer, I was trained that if the SI hurts to look at whole body involvement and look at integration and alignment. It could be a gait issue and it was assumed that if there was some sort of asymmetrical pattern going on that that was probably a contributor to the SI pain.

Til Luchau:                         Actually, in that point of view, we're less concern about pain than we were about alignment or rather integration for its own sake. But that model that if there is some pain, then we look to the alignment of the body comes partly out of the osteopathic tradition and chiropractors have similar kind of ideas where it's like there's an optimal position that we're comparing things to and looking to see if they match. And if they don't, then we use that as a working strategy to go after someone's pain.

Whitney Lowe:                 Yeah. There's a couple of things that I had seen too in some of these papers that we're trying to categorize that causes of these different pains, these sort of pain generators if we can say that, and really breaking them up into two main categories. One category essentially being a true, like you said, mechanical dysfunction or pathology of the sacroiliac joint whether that is the fact.

Whitney Lowe:                 And anatomically, this is an unusual joint and that we usually think of the moving joints of our body as ones where there's a nice smooth, gliding surface in between the two contacting bones. And really at the sacroiliac joint, we have a much different anatomical arrangement because there's this sort of interlocking ridge and depression process that kind of locks those two bones into position. And when they're slightly off, that's a mechanical thing that seems like it would be a generator of pain sensations for the sacroiliac joint.

Til Luchau:                         You're saying when they don't ... The theory is that when they don't fit quite right or when they fit too tight?

Whitney Lowe:                 Well, it could be both. Ideally, there should be some degree of mobility in there and we'll get into this in a little bit talking about how much mobility there really is there, but they've mentioned there could be hypermobility which is too much mobility and that could lead to pain problems as could not enough mobility.

Whitney Lowe:                 But because this is a joint that tends to sort of lock into position as it transmits the entire body weight of the upper body down to the lower extremity. And remember, the sacrum is really wedged in between the two halves of the pelvis there, so it is kind of a pretty tight fit in there. And all of our bones are covered by the periosteum which is one of the most pain sensitive tissues in the body.

Whitney Lowe:                 So even a little bit of irritation of those contact surfaces could be a pain generator in there. So that being a primary pain generator and the other category would be SI joint pain of some other origin that seems to be referred to that whole area.

Til Luchau:                         Okay. Let's break it down a little bit. You're saying there's local structures there within the joint that could be sensitive and generating nociceptive signals like the bone could actually do that. You're saying the ligaments around it or soft tissues or joint capsules could all do that.

Whitney Lowe:                 Yeah. Again-

Til Luchau:                         That's what generates the nociception but then now here's where I want to let you make your points. But I'm already tempted to jump in and start throwing out some of the debates, because the debates are whether the role of external influence is in that joint. Whether something like posture or use of position, is it primary generator pain or if it's irrelevant. Or whether hypermobility causes pain or doesn't, or whether it's too tight to cause or doesn't, all those things are debates interestingly enough.

Til Luchau:                         And I don't want to muddy the waters because I want to take it step by step and really get to what I've found here what you found to be most useful. I just want to note that as we go.

Whitney Lowe:                 Yeah. And I think you're touching on something that's really pertinent because a lot of times I think especially in the SI joint region here, we end up sort of chasing our tails sometimes and this becomes almost a chicken and egg thing like is the movement dysfunction the driver of the SI joint pain or is the movement dysfunction the reaction to the SI joint pain that's causing-

Til Luchau:                         That's right. Sounds right. And there's therapeutic narratives both. And it turns out there's evidence for both.

Whitney Lowe:                 Yeah.

Til Luchau:                         I mean, where do you want to go from there? I'm curious about how you work with that or do you want to keep unfolding some of these debates and dynamics around the pain?

Whitney Lowe:                 Well, one of the things that I want to touch base on is something that you reference a moment ago and talking about too some of the methods that are used to evaluate this because that's one of the biggest controversies that I think that we come across here is that in recent years, the debate about how accurate are many of the evaluation methods that are used to identify SI joint dysfunctions.

Whitney Lowe:                 There's quite a number of special orthopedic tests. There's a lot of posture and palpation movement to evaluation things, most of which have come under pretty significant scrutiny as not being so accurate. I think that we're kind of back to the question like, "Well, how do we know that there's a movement problem?"

Til Luchau:                         Yeah, you're talking about positional assessments where like is one ASI is higher than the other or that kind of thing, is that what you're referring to?

Whitney Lowe:                 Yeah. And the transitional positional problems, the upslips, the pelvic rotations and the things like that that may effect that particular region. Yeah, I think a lot of those things have common significant question for how relevant or then how much should we keep using them?

Til Luchau:                         That's right. And the objections there are one, they don't seem to correlate with pain. We can't find a bunch of people with crooked pelvises and say they hurt more. It turns out they don't except there's one exception, that's pregnant women and we'll get into that in a second.

Til Luchau:                         So position doesn't seem to correlate with pain. Movement doesn't seem to correlate with pain. So you mentioned hypermobility, well, it turns out that there's actually no evidence or convincing evidence. This is what the quote ... I'm reading in these papers where we looked that hypermobility is related to pain except in this subset of postpartum and pregnancy cases.

Til Luchau:                         And even there, so we better go there. Even there, the hypermobility question is linked to differences left and right.

Whitney Lowe:                 Yeah, and I think we're really facing this challenge of like when we talk about hypermobility in this area, how accurate are we really at identifying that because most of the more current research has said that the accuracy of palpating landmarks and being able to feel emotion accurately through manual investigation is pretty poor, like really poor actually.

Whitney Lowe:                 And I've seen lots of practitioners placed their hands on the pelvis as well and say, "Well, here you feel this particular upslip," or you can feel the sacrum tilting here this particular way if you do that. But I think we're really waiting deeply into that world of palpatory ... What is that term, palpatory.

Til Luchau:                         Well, the argument goes like this. Someone says you can't really palpate that. The palpaters says, "Well, you're just not good enough." But there's something to that and yet, a lot of these tests, I don't think anything has been studied as much in this realm either as the SI joint or the pelvis. It turns out that independent of rater experience or skill that the evidence kind of supports what you're saying that it's hard for two practitioners to get very accurate agreement on what's going on in a lot of these positional tests.

Til Luchau:                         Some are better than others and you can dial them down to like straight translation tests under certain conditions. You can get pretty good inter-rater reliability. But then guess what? It turns out that isn't even relate to pain either. But by and large, the palpation especially if positioned, it's hard to get agreement both with other people and with yourself the next time you go back and check it, get to it later.

Til Luchau:                         And so, besides the fact that the movement doesn't seem correlate with pain, the palpatory inaccuracy is the other main argument made against that traditional way of working with SI joint pain.

Whitney Lowe:                 Yeah. And I think too some ... I see periodically too some fundamental misunderstandings about biomechanics, about sacroiliac biomechanics creeping into some of these discussions where people will sort of exaggerate a little bit of what really is happening mechanically at the SI joint by talking about a sacrum that is tilted and rotated at a certain degree or this leg length discrepancy or sort of a pelvic tilt that's tilting the sacrum a certain way or something like that.

Whitney Lowe:                 But it's important that we, I think remember the SI joint only has about four degrees of tilting forward and back motion or somewhere in that ballpark range, it's really, really small.

Til Luchau:                         Well, let me put it this way. I'm interrupting, I'm sorry but at least, that's the most commonly cited number. There's actually a whole lot of different numbers that every author is convinced is accurate about that and they ranged ... I did a kind of survey when I wrote my book. They ranged everything from 2/10's of a millimeter up to 8 millimeters of translation.

Whitney Lowe:                 Wow. I wonder how that translates into degrees of movement for-

Til Luchau:                         degrees, it goes from a fraction of 1 degree up to 30 degrees.

Whitney Lowe:                 Really, 30?

Til Luchau:                         There's one study that shows ... Yeah. 30 degrees of movement. This was in warmed up gymnast who could nutate their sacrums, tilt their sacrums within the pelvis 30 degrees. 30 degrees is as much as one hour on a clock face.

Whitney Lowe:                 Yeah, that's interesting.

Til Luchau:                         But no, that 4 degree number you quoted, you'll read that a lot of places.

Whitney Lowe:                 Yeah, right.

Til Luchau:                         Which is really pretty small. 4 degrees is like that will be tough to tell especially through clothing or especially through tissue and all that kind of stuff.

Whitney Lowe:                 Yeah. Backing up just a little bit because you mentioned a term a moment ago and I just want to clarify that maybe for some of our listeners who may not be familiar with the term of nutation and counter-nutation. Can you touch base on that a little bit of what that is in reference to?

Til Luchau:                         Nutation is the term that refers to movement or tilting of the sacrum rather within the pelvis. It's Latin for nodding. It's the sacrum itself rotating within the ring of the pelvis. So it's an angular or rotating motion at the SI joints.

Whitney Lowe:                 Yeah, and an important thing, I think for us to also consider to remember is that both nutation and counter-nutation are in reference to movement of the sacrum in relation to the pelvis. So the sacrum can tilt forward-

Til Luchau:                         To the iliosacral, right.

Whitney Lowe:                 ... or the ilium could tilt backwards and both of those would produce a nutation of the sacrum relative to the ilium. So, it doesn't-

Til Luchau:                         You tell me. The way I've been using as nutation, the way I learned it. Nutation applies to the sacrum, and then other terms apply to the ilium. But at the joint surface, it might be the same motion.

Whitney Lowe:                 Right, exactly.

Til Luchau:                         Nutation at the sacrum will be a posterior rotation or posterior torsion of the ilium, same thing.

Whitney Lowe:                 While I was looking up this term sometime years ago, I ran into ... And this maybe ... This is totally off the topic here that I ran into something that was in referenced to the moon, the term nutation when I looked it up having something to do with the tilting or angular facing of the moon as well.

Til Luchau:                         Interesting.

Whitney Lowe:                 I can't remember exactly what's those but yeah, I looked up that, yeah.

Til Luchau:                         You know what we need? We need like a geek checker.

Whitney Lowe:                 Oh, that would be great.

Til Luchau:                         We need like someone who just rings this little bell and holds it says, "Wait, you guys are just going way down that rabbit, through that geek rabbit hole. Time to pull it out." I don't know if we're there yet, but no, let's geek on.

Whitney Lowe:                 Well, hey, I'll tell you what? Why don't we take a break for our halftime sponsor and we'll go look up this thing about the moon and then we'll have to come back and see what we found out about it.

Til Luchau:                         Sounds good.

Whitney Lowe:                 Yeah, okay. Well, we won't actually look that up but or maybe we should. Let me look that up really quick.

Til Luchau:                         Yeah, I'm curious. I never heard that. I just know it as nodding.

Whitney Lowe:                 Okay. All right, so we are back from our halftime break and we did take a moment to look. I didn't read this whole thing right now but for anybody who wants to geek out on this, I did find a Wikipedia page on astronomical nutation-

Til Luchau:                         I'm looking at that too. We're looking at the same place.

Whitney Lowe:                 ... phenomenon which causes the orientation of the axis, rotation of a spinning astronomical object to vary over time.

Til Luchau:                         Yeah, nodding. It nods. The moon nods a little bit in its orbit, so does the earth, and so does the sacrum. The debate is how much and if that really matters anyway.

Whitney Lowe:                 Yeah. So fascinating. Well, back to this whole process with our movement of the sacrum. So we have a slight degree of movement that happens there also the difficulty of evaluating this. So here's a question that I want to ask because it comes up obviously for me a great deal as well. Since we have found a lack of reliability and validity in many of these evaluation procedures for trying to and attempting to identify sacroiliac joint dysfunction, should we do any of them? Should we do them at all? Is there any benefit to them? What do you think about that?

Til Luchau:                         I struggled with this a lot because I was trained fairly conventionally. A lot of influence from Greenman, a lot of influence from various osteopathic editions. We learned very complicated models of right on right, left on right, upslip, downslip, sacral dynamics and used them a lot and taught them a lot.

Til Luchau:                         And then when it came time to actually teach a dedicated workshop on the SI joints, I realized what I'm really doing in practice and what really seems to help isn't that complicated. So there's some very complicated protocols and diagnostic models for assessing that motion, large or small whatever you think, but it turns out that in practice, what I was doing was pretty simple.

Til Luchau:                         So I ended up doing what turns out the research happens to support, lucky me, I look for sensitivity in the pelvis, at the SI joint through a series of tests. They are modeled after traditional orthopedic tests but I'm not looking to try to measure movement as much as gauge the client's sensitivity, their perception of movement. And I do follow footsteps who said, "If it's different left and right, they're more likely to have pain. It turns out that's true. It's only true if they're pregnant. It's only been studied to pregnant. This hasn't been ruled in or ruled out for non-pregnant people.

Whitney Lowe:                 Yeah. Something that you said there made me think of something else that I wanted to bring up that we haven't really touched on yet because we've been talking pretty much along the lines of skeletal mechanics of the SI joint but there's been quite a bit of emphasis especially in the work that Vleeming had done, and some of the work that Tom Myers had done and I'm sure you're very familiar with this stuff from your background in the structural integration world of the fascial connections across this region with a numerous different tissues that may transmit tensile loads across the area by the very fact that this tissue span across that particular region.

Whitney Lowe:                 Anything you would want to relay about that because you were talking about the treatment protocols or the treatment strategies that we're using and it seems like as manual therapy practitioners, many of us are focusing a lot more attention on soft tissues than we are on attempting to move bony positions or anything like that. So that might be more relevant for some of these things.

Til Luchau:                         Yeah. I hear you. I mean you're right. We're talking probably most as a soft tissue practitioner. However, in my approach, I'm doing it the other way. We're looking at bony movement. But, yeah, I'm familiar with those models of soft tissue crossing the joints and how they might influence it. And there's probably something to it but, boy, that's a big topic.

Til Luchau:                         I don't include them that much in my treatment model because I have a few problems with them conceptually. Well, I don't have a problem with long fascial connections crossing joints affecting them. I don't have a problem with that at all. I just don't ... Boy, I don't go for the line thing.

Whitney Lowe:                 Tell me about that.

Til Luchau:                         Well, on average, 30% of the muscles fascia connects to a fascia nearby. This is so interconnected. It's an interconnected network where 70% of the skeletal muscles' force goes to a bone. 30% of them goes out to neighboring fascia. If you start to trace that out and line, pretty quickly gets distributors, more like branches than lines.

Whitney Lowe:                 Can I pause for a second there because I want to ... I've been trying to track this down a little bit. I really love to delve into this a little bit more of where you've gotten this thing about the 30% of the force transmitted out that way. Is that true in most all muscles or is that only true in certain ones?

Til Luchau:                         That's a great question.

Whitney Lowe:                 Where do you see that?

Til Luchau:                         I remember there's an average I'm happy to dig up that reference for you. But remember it is an average and I'm sure it varies muscle by muscle. But let's say as an average through the body. So now I'm not trying to trace long lines past multiple joints. Let's say it's valid as an average. By the time you go over two joints, you've already distributed quite a bit of that force so that-

Whitney Lowe:                 Yeah, that makes a great deal of sense. And I would think that there are places maybe if you just say the first local connection has a pretty good bit of the capability of transmitting some tensile loads. For example, like the hamstrings being a very powerful muscle group and that the fibers blending in with the sacrotuberous ligament has a good chance of affecting SI joint mechanics by hamstring tightness.

Til Luchau:                         Makes sense to me.

Whitney Lowe:                 But something that's coming from the foot and has a lot of other stopping points where it's tethered along the way is going to have a lot less or lot more dissipation of that tensile force.

Til Luchau:                         Yeah, right, tethered, even connected in functional ways. The force does get distributed around the whole limb and out in different ways. There's been some very elegant mapping of lines and that they've been able to find them in dissection but it's not a model that I use in my thinking. I don't split that way.

Til Luchau:                         As much as the global picture of force transmission going out into a larger network of connected tissues. Call me out of the geek rabbit hole if I'm going there too much. But that hamstrings fibers going into a sacrotuberous ligament thing, again, that's another 30% factor where looking to see when you can find fibers, they tend to be more superficial. So probably the fibers aren't transmitting as much force and that's only in 30% of the people.

Til Luchau:                         So the other 70%, there's no direct fibers from hamstrings and the sacrotuberous ligaments. But they both attach to the same bone along the same angles. So through the connections of bone, they're clearly probably part of that force closure of the SI joint.

Whitney Lowe:                 Yeah. And that's another term that we run across a good bit in this discussion that maybe we can just sort of break that up a little bit too for our listeners who may come across this, the term of force closure and form closure as concepts there. Elaborate on that a little bit.

Til Luchau:                         This is Vleeming again. Force closure is a motor or myofascial or muscular forces acting on a joint to lock into a position to make it more stable. Form closure is just the shape of the bones and the structure of the ligaments and things like that allowing the position that gives the joint stability.

Whitney Lowe:                 So we might think, for example, that if something is a problem that is a result a form closure, meaning a bony structural either positional or anatomical factor, it may be a bit more challenging for us to make an intervention that's going to be making a significant change than if something is a force closure that is, let's say, maybe generated more by soft tissue. Would say that's accurate?

Til Luchau:                         Well, again, if you're thinking like a massage therapist, maybe. But let's think a little bigger for a second. You're saying that if my main tool is relaxing things, then maybe if it's a force closure problem, I don't have many options. Actually I don't know. I don't know is our main tool is relaxing things, first of all, even as massage therapist. I think there's a lot of effects we have on pain and sensitivity.

Til Luchau:                         And let's go back to biomechanical model. Vleeming's thing was that the soft tissues could inhibit form closure. I'm making sure I'm saying it right now. They could, att tight structures, could inhibit the joint's full motion and not allow it to essentially make itself stable. So his model was if you can look at things mobile, a lot of time in the right direction, and this one was posterior rotation of the ilium on the sacrum, that would make the joint feel more stable because you'd be relying more in the bones or ligaments at that point.

Til Luchau:                         So there are some biomechanical arguments for how we can actually help force and form closure. And then there's the whole debate about are those particularly relevant because there's other models that say it's not the biomechanics, it's the sensitivity, you could say, or the ways that we're protecting the joint that had more to do with pain anyway.

Whitney Lowe:                 And I was going to bring that up because we just touched on that and we have been sort of couching the majority of our discussion within the lens, the biomechanical lens of perspective here. And there obviously is a number of other things that it could very relevant and pertinent fact associated with this. There was something that I ran across here and I'd put them on and let's see if I can dig it up in a moment here of talking about movement system challenges and kinesiophobia, the fear of movement that people have when they have some kind of pain sensation in there and how that a lot of the SI joint pain simply maybe more result of some of those other types of factors and not necessarily a purely biomechanical thing in many of these cases.

Til Luchau:                         Maybe all of that, it's hard to tease it out. Maybe all of them has some of that in there. It's hard to say this is biomechanical pain, this is psychological pain, this is social pain. They're all in there for every pain.

Whitney Lowe:                 Another interesting thing that I ran across and this was in a kinesiology book, I believe it was, that made me ponder the question about how important and dominating is the whole idea of the biomechanical model of SI joint pain and the whole, you're looking at hypermobility or hypomobility issues. In this particular book, they were referencing a couple of studies that, let me try and get to say, we're saying 85% of asymptomatic people over the age of 60 have some degree of degenerative changes in the SI joint, meaning arthritic changes or some kind of degeneration in there.

Whitney Lowe:                 And by the eighth decade, about 10% of the population have fused SI joints. That was kind of mind-blowing because granted you can assume that most of people in their eighth decade are not really moving around that much but a lot of them are, moving around quite a good bit and it's like if that pretty significant number of people can have their SI joints fused, the really basic question of how relevant is a lot of all this, I'm not going to say obsession, but extensive focus on the mechanics of movement exactly.

Til Luchau:                         And it turns out that SI pain diminishes after a certain age too. Even though movement also diminishes, so does pain. So that's the argument that's made and linking movement with pain. It turns out that people that end up having less movement as they get older have less pain too. But then there's cases where the opposite is true, so it's impossible to say ... I want to keep circling back to what's practical because we can question any of these things and end up with a whole lot of questions.

Til Luchau:                         You can say listen the more hypermobility there is, there's also the more painful. That's the conventional view. Well, that doesn't hold up either, so what do I do? If it's not about it being tight, if it's not about being loose, what does that leave me with?

Whitney Lowe:                 Yes, so let's get back to that and sort of like that's the $10,000 question is like what everybody has been sitting here waiting 20 minutes for us to answer the question. What am I supposed to be doing? What do you think are kind of the most favorable current strategy? I'm not saying obviously there's one answer for everything but what are your current thoughts on sort of best approaches in the majority of these cases?

Til Luchau:                         Well, I'll tell you my bias. And again, I can't say for everybody listening but again in our trainings, the approach I take, it's about proprioceptive refinement. It's about helping people feel better in their joints and that involves feeling them better, having a more accurate perceptive ability was happening through joints. If you can actually help people have better body awareness essentially, a lot of times that normalizes pain. It's a counterintuitive. But the better people feel their bodies, the better they feel in their bodies.

Whitney Lowe:                 Well, Til, and again, this is a bit of conjecture because we don't have really any good evidence of that to see if there was some ... I can't remember where this was that I had originally come upon this. It may be in some of Moseley's writings when they were talking about cortical smudging which is the sort of lack of clarity in the brain maps of our body, of where everything is now. And they were saying that there is possibly some indication that chronic pain conditions enhanced cortical smudging, meaning they sort of make the body map less clear and less specific about what's going on.

Whitney Lowe:                 And that to me kind of like made this jump, I don't know, maybe a little early to make the jump. But just thinking, well, I do think that there is a great deal of benefit in soft tissue manual therapy for, like you said, enhancing proprioceptive awareness and might that in fact sharpen those cortical maps and that might be a big part of what our beneficial effects of treatment are in what we're doing, much more so than some of the drilling down into the specifics of feeling like we're elongated in this particular tissue. We're making that thing happen though or whatever we've been saying that we've been doing all this time.

Til Luchau:                         Precisely. We're refining people's brain maps. We're also increasing their ability to deal with signal. We're doing some descending modulation. We're doing some de-threatening. We're doing some good things with our touch that basically means that even if there is some irritation of the tissues that are generating a nociceptive signal, it's not as problematic as it was before the work we do.

Whitney Lowe:                 Yeah. A lot of it is just finding ways, I think too, in like you said enhance the proprioceptive awareness, enhance the felt sense in there and finding all kinds of things just to sort of wake everything maybe back up a little bit. And that could in and of itself be a really particularly helpful strategy, more so than kind of chasing down the rabbit hole of saying like, "Well, am I improving sacral nutation range of motion by X amount or am I getting this pelvic angle fixed here to be back to normal or something?"

Til Luchau:                         And I want to hear what you suggest or what you do in your approach. But there's one more thing around that line is that I do use mobility techniques. I do actually feel for things that move and things that don't, and while I'm monitoring the client's proprioception and for sure there's sensitivity, I'll encourage them to move more in the ways that they don't because a couple of things might be happening there. One is it's giving us sensation that someone can feel and reset around so it's normalizing sensation. It might be hydrating the joints or the structures and there's some evidence that that could be helpful for nociception.

Til Luchau:                         But mostly, it's a way that for people to feel differences left and right, it goes back to this idea that if we increase people's awareness of their body in a non-noxious way, then things were less.

Whitney Lowe:                 And what you said to do there was particularly interesting. And I agree with all of your sort of treatment strategy ideas here. And I would just add that I think a lot of what we tend to be doing if we're taking that kind of perspective is the motion palpation that we might engage in or even the treatment processes and things that we're doing in a variety of different ways have both diagnostic and treatment components to them because we are both feeling for how does this is feel like it's moving. Is this moving freely? Is this moving the way it should?

Whitney Lowe:                 And the very act of touching and calling proprioceptive awareness to that area even with the little thing that we might do could really enhance the shift in the neurological system to get that area beginning to move more freely and then reinforcing that a lot with the client. We touched on this a little bit in the very first episode when we were talking about both of our backgrounds and looking at things through a psychological lens of how does the person felt since?

Whitney Lowe:                 What do you do when the treatment room when you encourage somebody about, "Hey, this feels like it's moving more freely. Do you feel that moving more freely there?" And that positive encouragement about the movement is a really beneficial aspect of making those neurological changes as well.

Til Luchau:                         Dethreatening sensation, dethreatening movement.

Whitney Lowe:                 Yeah.

Til Luchau:                         That's what our work does quite a bit pretty effectively too.

Whitney Lowe:                 Yeah.

Til Luchau:                         We should have episode about language sometimes too because the studies we read had a couple of recommendations around language. They're recommending not to use the term instability with athletes because it could be deserving. It could be solving problem.

Whitney Lowe:                 Right. There is a massage therapist up in Minnesota, a gentleman named Jason Erickson who coined a great term that's been adopted by lots of folks, lots of us who ... Because I think, it's a great term. He talks about trying to enhance yesiception with his clients. So, meaning the opposite of nociception, all of those things that are producing the ... And there's all kinds of things that might enhance the yesiception, whether that's both language that's touch, that's palpation, it's movement. It's all those factors that do the very opposite of perpetuating nociceptive drivers within the system.

Til Luchau:                         Yeah. It sounds right.

Whitney Lowe:                 Well, did we solve the sacroiliac problem for the world in today?

Til Luchau:                         Well, I mean I don't know because it's an ongoing debate. But certainly, I want to cook it down to practical things people can do. Just helping your client feel better, helping them feel their bodies better, helping with movement, helping them be less afraid of what's happening there, even a little more open-mindedness like statements about there's no evidence that instability relates to pain in people that aren't pregnant. That's a factual statement that could be dethreatening.

Til Luchau:                         Now, we don't want to go arguing with people about their beliefs at all and that's why we need a whole episode to talk about this language thing. But anything we can do to help people entertain the possibility or having an open mind about their symptoms is helpful.

Whitney Lowe:                 Yeah. And I think that an important takeaway from this too is ... And I want to backtrack a little bit in that we have talked about some of the challenges with validity and reliability with some of the traditional evaluation methods and things like that. I also don't want to throw out the idea that I think it's valuable and important for us to understand sacroiliac biomechanics even with the fact that there are some uncertainties and inaccuracies in terms of the way we have looked at things in the past.

Whitney Lowe:                 I still think it really helps to understand a great deal about the groundwork of the functional mechanics of that region and then overlay that with the other approaches that we've taken here in order to really make them the most effective.

Til Luchau:                         That's what we're sorting through in our field I think is like which is the baby, which is the bathwater, are we throwing it all out or what are we keeping here? And I happen to be a biomechanics, not myself, and looking to always to translate it into things that really work in practice.

Whitney Lowe:                 Yeah. Well, great. Wonderful chatting with you today about sacroiliac dilemmas and things. I hope that our listeners picked up a few maybe pearls and tidbits that might be helpful in their practice from that as well. Since this is such a complex topic, I have a feeling we will probably revisit this in some future episodes as well and we'll chase down a few other rabbit holes with that.

Til Luchau:                         Yeah. Let us know, listeners, your questions, your thoughts if there's things you want us to dive into in this topic or others, just getting touch.

Whitney Lowe:                 Yeah. And in the meantime, look up seeing what happens with force closure and form closure of the moon. How about that?

Til Luchau:                         Sounds good.

Whitney Lowe:                 Since it's got nutational properties, we'll look at that as well. All right, thanks, everybody, for hanging out with us today on The Thinking Practitioner. We'll be back again and we'll see you next time.

Til Luchau:                         Thanks through our sponsors, you guys really make it possible for Whitney and I to have a good time talking to each other and share this with everybody else.

Whitney Lowe:                 And you can stop by our website for show notes, information on CE credits for the show and any extras that we have available. And that can be found on our podcast website at www.thethinkingpractitioner.com. And Til, where can people find you on the web?

Til Luchau:                         That would be advanced-trainings.com or my name, Til Luchau. How about you, Whitney, where could people going to find you?

Whitney Lowe:                 And they can find me at the academyofclinicalmassage.com and also following on Twitter, @whitlowe, and on Facebook as well under my name or the Academy of Clinical Massage on Facebook.

Til Luchau:                         Nice. If you have questions, just email us at info@thethinkingpractictioner.com or look for us on social media.

Whitney Lowe:                 And please don't forget to, if you can, take a moment to rate us on iTunes or wherever else you listen to your podcast because it does help other people find this show as well.

Til Luchau:                         Thanks, everybody.

Whitney Lowe:                 All right, sounds good. We'll see you next time.

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