The Thinking Practitioner Podcast:

Episode 154: Listener Favorite: Sacroiliac Joints: The Next Level 

Whitney Lowe:

The Thinking Practitioner Podcast is supported by ABMP, the Associated Bodywork & Massage Professionals. ABMP membership gives professional practitioners like you a package including individual liability insurance, free continuing education, and quick reference apps, online scheduling and payments with PocketSuite, and much more.

Til Luchau:

ABMP's CE courses, podcast and Massage & Bodywork Magazine always feature expert voices and new perspectives in the profession, including Whitney Lowe. Hi Whitney.

Whitney Lowe:

Howdy sir.

Til Luchau:

And myself Til Luchau, Thinking Practitioner listeners can save on joining ABMP at abmp.com/thinking.

Til Luchau:

Hey Whitney, you do write for Massage & Bodywork and we're going to talk about one of your articles today. How are things going?

Whitney Lowe:

Going very well. I've been off for a couple weeks. I enjoyed listening to you do some episodes with some other great folks around here and I took some time off this summer and was doing some roaming around in the Canadian Rockies and very good to be back here behind the microphone again with you. So good to see you again and yourself.

Til Luchau:

Likewise. Good. Just back from roaming also. I took my microphone with me so I was-

Whitney Lowe:

You did.

Til Luchau:

... broadcasting from the road a little bit there. I did that one with Ruth Werner last time and we missed having you there, but it was a lot of fun. It's also great to be back. And then you and I are going to Montreal. I'm going tomorrow for the Fascial Research Congress and we'll both be there next week. So that'll be great to have that time together.

Whitney Lowe:

Yeah. We may end up doing an in-person recording or something like that, which would be a first for us.

Til Luchau:

Yeah, we'll do something. We're going to do something around that because it's a... You know, you realize that I have only met you briefly twice in-person?

Whitney Lowe:

I do realize that, and I can't even remember when. I remember you said there was sometimes, and I can't even remember when it was, but it was-

Til Luchau:

Conventions.

Whitney Lowe:

... a decade or more ago.

Til Luchau:

Yeah. These were at AMTA conventions or something like that. Just combined said how to you use your booth. So no, we'll actually get the meet in-person. And I'm smaller than I look on camera.

Whitney Lowe:

So am I. So we'll have that in common.

Til Luchau:

Awesome.

Whitney Lowe:

Yeah. I was doing this podcast with Allison Denny a couple months ago and telling her this story when I first started teaching, I really had to work at knowing my stuff really inside and out because not only was I a small person, but I look a whole lot younger than I am. And when I was starting teaching I was in my late 20s and I look like I was 15. So I have always had to use that as a means of compensating for the physical appearance.

Whitney Lowe:

It was funny a lot too when I used to teach with Denny and he's just this big magnanimous presence in the room and big tall guy and everything. So it was two very different perspectives there.

Til Luchau:

That's great. Yeah, well like I said, it's going to be great to meet you and no, you know your stuff, so that's the pleasure as well.

Whitney Lowe:

So speaking of stuff, what are we doing today? What are we talking about today?

Til Luchau:

I wanted to talk with you about the sacroiliac joints and about the bones that connect the ilia, the big bones of the pelvis, mnemonic bones, et cetera. But not only do I love talking about that part of the body and those joints, even though we already discussed it in Episode 3, but it's like there's never enough to say, but you just published a cool article about that in Massage & Bodywork. I got it right here. Current Concepts and Sacroiliac Joint Dysfunction. I wanted to talk about that some.

Til Luchau:

And then I am teaching one of my principles courses, where we meet for four live online lectures about the ilia and SI joints and that starts free intro on September 28th. I'll give more information at the end of the show. September 28th, what year is this, 2022. And then the lecture start October 5th but if you're catching the episode later, they're going to be by recording.

Whitney Lowe:

Yeah. Okay. That sounds like good.

Til Luchau:

Yeah, that's it. I'm looking for this topic. I just here, right here at the beginning, I wanted to give a shout out to Jeff Bramhall and Bori Suranyi for doing... They did an in depth secret shopper review of my last principles class. I didn't even know that Jeff was in the class. He took the class and then he did a whole podcast episode about it that I found by accident. I was listening to this nervously, I was like, "What's this guy going to say about this whole course because look like he advertised a review of advanced trainings until Luca." I was like, "Okay, here we go."

Whitney Lowe:

Here we go yeah.

Til Luchau:

But their podcast is called Hands at the Table. We'll put a link in the show notes here as well and I won't do any kind of plot spoilers. You're going to have to hear how they reviewed our class.

Whitney Lowe:

Yeah, well, I'll look for it. I'll go listen to that podcast too.

Til Luchau:

Yeah, I was on the edge of my seat. Anyway, they did a good job of being really analytical and thorough about it. But let's do that for the pelvis. Let's be analytical and thorough as well as experiential, because I want to move a little bit. But what if we start with the anatomy of the sacroiliac joints. Whitney, what do you think? You want to start there?

Whitney Lowe:

That sounds like a good starting place. Yeah. I was going to talk a little bit about some key concepts of anatomy and mechanics related to this. We are doing something a little bit different today for those who've been listeners for a while. This show is going to appear in video as well. That's the plan.

Whitney Lowe:

So, I'm going to put some stuff on the screen. So those of you who are listening to the audio version, we will make reference to some things that we're showing on the screen. We'll try to describe those as much as possible, but there will also be links to the video version on our respective sites and we'll put that in the show notes and talk about that at the end as well. So, that is the plan. So, without further ado, let's take a look in there and see what we're talking about here at the sacroiliac joints.

Whitney Lowe:

So, first thing is we want to take a reminder of where we are. We are looking at the place where the sacrum meets the illum on each side, and there is a, of course, left and right sacroiliac joints.

Whitney Lowe:

Couple things from bony architecture that I wanted to call attention to. This particular image does not necessarily show this really thoroughly, and I think, Til, you've got some other images that will show this more clearly. But these joints are unlike many of the other joints in the body, which are smooth, gliding surfaces in that there's a very rough and irregular contact surface here on the side of the sacrum and a similar rough and irregular contact surface on the ilium, which meets each other and interlocks. So, it's this interlocking sort of mechanics of the bone itself, not to mention all the other soft tissue structures around there, but that's a big key part of making stability in the sacroiliac joint is the interlocking alignment.

Whitney Lowe:

Consequently, when that alignment is somewhat off and we'll talk about what might cause it to be off in other situations, this may cause some of the other significant pain problems when those bony contours are not aligning with each other. It's pretty easy to see how that might occur. I'm going to mention some other things a little bit later on too about the high percentage of nociceptors that are inside the sacroiliac joint and many of the other connective tissue structures around here that are highly and richly innovated that play a role in a lot of those pain complaints that we see.

Whitney Lowe:

So, a couple other key things here too that I wanted to highlight with anatomical structures, in particular the ligamentous structures around here. So, you have the binding anterior sacroiliac ligaments on the front side, and then they're also pretty significant binding on the backside here.

Whitney Lowe:

So, these ligaments hold this joint relatively firmly because it's a very important process of trying to transmit the body weight from the central core axis of the skeleton into the appendicular skeleton and that comes across, of course through the two sides of the sacroiliac joints here. So, transmitting that weight from each side. And let's just briefly illustrate that. Weight's coming down here, it's distributed across these joints on each side going directly across those sacroiliac joint. So, these ligaments are holding those that sacrum in position. Another image up here, just let me show this real quickly that highlights some of these major structures here-

Til Luchau:

Hey, before you get out of that one, is it too late to go back to that?

Whitney Lowe:

Nope. Right there.

Til Luchau:

So, on the screen there for the listeners, we have a view of the back side of the body with Whitney's really cool software and he's showing these massive ligaments around the SI joints, and he's shown lines

that show the spines weight transmission splitting there at the sacrum and being transmitted into each side of the pelvis, each left and right ilium. Did I get that right, Whitney?

Whitney Lowe:

Yes, sir. Absolutely.

Til Luchau:

And then there's strong ligaments all around those joints and you're talking about the role those ligaments have in that weight transmission. We can really see that wedge-shaped arrangement of the sacrum there. It's like a downward pointing wedge or the arrowhead in the bottom of the spine. So, you can imagine that weight pushing that sacrum down between those bones and wanting to pull them apart, but the ligaments resisting that and loading from that weight-bearing function and really snugging that joint up.

Whitney Lowe:

Yeah. One of my anatomy instructors in massage school spoke about this in this similarity to the architectural design of a keystone in a bridge, which the keystone is that very top stone that's wedged like this in there that holds the arc across a whole bridge across the whole pelvis like that. And then that wedge comes in there and it holds those two things and binding them together and distributes the weight across each side, hopefully equally. But that's something that we're going to also look into here is that sometimes that doesn't happen equally.

Til Luchau:

So, hopefully, left and right sides of the arch and there is some evidence. I'm going to go back and talk about alignment when you're done with your part, but there's also evidence that that equally thing is at least in terms of stiffness is an important factor.

Whitney Lowe:

Yeah. So, just to take another quick look here at listing several of these other stabilizing ligaments in addition to the ones that we looked at. Up here from the transverse process of L5 over across to the ilium is the iliolumbar ligament.

Til Luchau:

This is between the lumbar vertebrae and the top iliac crest almost in the backside of that, huh?

Whitney Lowe:

Exactly. While that doesn't necessarily span directly between the sacrum and the ilium because there's such a firm connection between L5 and the sacrum, the iliolumbar ligament, which is coming in and attaching to the side of the transverse process of L5 creates a lot of, or does certainly aid in stability with the sacroiliac joint spanning right across it there.

Whitney Lowe:

This is another key one down here, the sacrotuberous ligament which we see spanning from the sacrum down to the ischial tuberosity. So, again, most ligaments tell you where they're going and what they connect by their name. So this is from the sacrum to the ischial tuberosity, big sacrotuberous ligament.

Til Luchau:

Nice. So, it's like if that sacrum's an arrowhead that goes from the point of the arrowhead at a perpendicular angle diagonally out to the pelvis. So, it's like the lower end of that wedge shaped sacrum that's being held in by those big sacrotuberous ligaments.

Whitney Lowe:

Yeah. And again, in anatomy books, these structures are pictured and shown as they are here as isolated structures but we'll talk a little bit more later on too about the fact that they really aren't isolated structures and in fact there's a lot of fascial continuities from lower extremity muscles directly into that sacrotuberous ligament. So, tension, for example, in hamstring muscles can easily be transmitted through the sacrotuberous ligament to the sacrum itself.

Til Luchau:

So, there's lots of tissues around them in spite of what we see in the anatomy books that are part of that weight transmission or tension function as well.

Whitney Lowe:

Yeah, absolutely. Another one here we don't hear about quite as often, but also very important is the sacrospinous ligament and it is going from the tip end of the sacrum over to the ischial spine. This is a little bony projection here on the side of the ischium, the ischial spine. That is also one of the other major stabilizing ligaments. You can see it here in relation to the sacrotuberous ligament on the other side. So, it is deep to that sacrotuberous ligament.

Til Luchau:

So, for our listeners, that would be deep to, or in front of and it's running almost perpendicular to the floor and a horizontal plane, is straight out to the side of the pelvis while those big sacrotuberous ligaments are running at an angle.

Whitney Lowe:

Yeah. Exactly. And we also pay a good bit of attention to that particular ligament. It is one that doesn't get talked about a lot, but is pretty relevant for some of the major nerve entrapment problems with the sciatic nerve getting squeezed against that sacrospinous ligament.

Til Luchau:

Sciatic nerve, pudendal nerve. Yeah.

Whitney Lowe:

That's right, those are certainly important there. So, the other thing I mentioned a moment ago, just of very key importance here, because the sacroiliac joint has so many ligamentous structures associated with it and other soft tissues and connective tissues associated with attempting to maintain the stability in this area, there are a lot of nociceptors in here, which means a lot of sensory receptors that may be reporting pain in a number of different circumstances. But one of the big challenges, and we'll talk some more about this with sacroiliac joint problems, is those it's sometimes difficult to determine are these structures the victim, or are they the culprit?

Whitney Lowe:

They can be the cause of some pain sensations in many cases, or sometimes they may get strained, or irritated as the result of some of the kind of mechanical loading on them and when they're the victim. So, that's a tough one to figure out sometimes in terms of what's actually happening in there.

Til Luchau:

Yeah. We talked about that some in episode three as well. A kind of chicken and egg problem. In the end it's like, what can we do to help? So, I want to get to that as well.

Whitney Lowe:

Yeah, good. So, that's a basic rundown of some key structural factors with that SI joint.

Til Luchau:

Nice. That's it?

Whitney Lowe:

Well, I just wanted to stop there with some basic stuff. We can go into some of the mechanics and mechanical things.

Til Luchau:

All right.

Whitney Lowe:

Let me go ahead and mention that. So, before we leave this, while we're still on the screen here, for those who are watching visually...

Til Luchau:

I'll try to do the sportscasters' thing, try to describe what I'm seeing.

Whitney Lowe:

Yes. Like, "What he's showing there is so." The other thing that I wanted to mention is about motion in the sacroiliac joint, because this is a little bit challenging and confusing for some people to recognize. We mentioned this in our earlier episode too that there is a variety of different discussions of how much motion occurs at the sacroiliac joint, and what's happening with the sacroiliac region.

Whitney Lowe:

Let's come over here for just a moment. For those of us watching our visual indication here, I want to make a couple of notations about what we see were some of the postural challenges that people have when you have a pelvis that tips in this direction.

Til Luchau:

Anteriorly.

Whitney Lowe:

We refer to this as an anterior tilt of the pelvis. So, the anterior superior iliac spine is tilting downwards, and the backside is tilting back up. That's rotational movement there happening essentially, so the pelvis gets tilted. Now, biomechanically, a lot of people misunderstand this concept, and they say, "Well, this is happening because you're rotating this around the sacrum." But in reality, most of your anterior pelvic tilt is tilting around the axis here at the iliofemoral joint.

Til Luchau:

So, more of it's at the hips instead of at the SI joints?

Whitney Lowe:

Much more at the hips than at the SI joint. There is a slight degree of movement at the SI joint, but it's not very much movement. Less than about four degrees is the average of what you hear in a lot of literature.

Til Luchau:

I'm bookmarking that as a different ... I have some different numbers, but it's a small amount.

Whitney Lowe:

Yeah. Are you going to go through that topic of what your numbers are?

Til Luchau:

When I started teaching this course, the principles course in the ilia, I had to go do a bunch of catch-up on my homework. So, I went and looked at an informal survey of all the different ranges of SI joint movement that I could find. And they ranged everywhere from less than 1%, to 18 degrees in normal people. This is an interesting trend, and I think we also mentioned that at an earlier episode, over the years, as measurement technologies have gotten better, the amount of movement that's considered normal has gone down.

Whitney Lowe:

Yeah.

Til Luchau:

So, the four degrees you quoted is about the low average of what's said, but there is really decent evidence, that people can range anywhere from one degree, all up to 18. With some anomalies of like 30 degrees in gymnasts and things like that.

Whitney Lowe:

Yeah.

Til Luchau:

It doesn't even really matter the number, in my thinking, it's still a small amount of movement.

Whitney Lowe:

Yeah.

Til Luchau:

It's a small amount of movement. We can do a lot more with our tipping our pelvis, than the sacrum does within the pelvis.

Whitney Lowe:

One other thing that I was interested to come across when we were talking about this is that that amount of movement at the sacroiliac joint decreases with age, as we do see in many places. There was a lot of references that I saw to people in more advanced age, having it be close to a fused joint. That they really had lost so much motion. I don't know if we want to call it loss, but it seems to be one of those things that occurs naturally with aging is a much lesser degree of movement occurring at the sacroiliac joint as mobility is decreased.

Til Luchau:

I got a few things about that.

Whitney Lowe:

When you talk about the anterior tilt of the pelvis, that's the motion of the pelvis, that's the motion of the innominate bones, the pelvis, the ilium, ischium, and pubis together, rotating around the femoral head. But the tipping forward and backward of the sacrum is actually called either nutation, when the sacrum, the top, or the plateau, and the sacrum tips in an anterior, or forward direction, that's referred to as nutation.

Til Luchau:

Sorry. That's like if I arch my back and my tailbone sticks out posteriorly that's anterior nutation, you're saying, of the sacrum?

Whitney Lowe:

Yes. And then counter-nutation would be when it tips back in the opposite direction. Now, here is where this gets a little wonky. Again, we can get a little bit geeky with this.

Til Luchau:

I'm ready.

Whitney Lowe:

This is going to be more helpful for those that are watching the video, but I'll try to describe this as much as possible.

Til Luchau:

Okay. Me too.

Whitney Lowe:

Let's see the illustration here again. If your pelvis is tilting forward and rotating in an anterior direction, like this. Once again, we're talking about that anterior rotation of the pelvis, where the ASIS tips forward. If your sacrum is relatively stable and not moving, when the pelvis- 

Til Luchau:

Within that bony range here.

Whitney Lowe:

Within that bony range, within the range that it has, if your pelvis tips forward, and your sacrum does not necessarily go with it, you essentially get counter-nutation movement at the sacroiliac joint, because the pelvis rotates forward, and the sacrum doesn't rotate. So, it would be the same as the sacrum tilting backwards in relation to the pelvis.

Whitney Lowe:

The key with this is, is that most of the times when you're talking about the anterior pelvic tilt, it's tilting more than the four to eight degrees, or whatever it is. So, at a certain point, it starts rotating forwarding and the binding of those ligaments are going to start pulling it forward with the whole pelvis arrangement. So, it's going to start tipping forward anyway.

Til Luchau:

Can I ask you a question?

Whitney Lowe:

Yeah.

Til Luchau:

And if you don't want to answer it, you can ask it back to me and I'll try.

Whitney Lowe:

Okay.

Til Luchau:

The question is, why would we care what that's called?

Whitney Lowe:

What it's called?

Til Luchau:

Yeah. Why would we care that when you have anterior tilting of the ilium, you have counter-nutation of the sacrum? Why would we care?

Whitney Lowe:

I would say we care if we're trying to find some causative movements that are producing pain. For example, if we say like, when you tilt your pelvis forward this really hurts, it's the same hurt you get when the sacrum tilts back.

Til Luchau:

Yes.

Whitney Lowe:

Then you could say, "Oh well, that's because both of those are actually counter-nutating the sacrum." To me that's where it would be helpful is to precisely pick apart what's really the movement that's aggravating the discomfort.

Til Luchau:

You totally talked me into it. If you had asked me that question back, I'd hope I would have given that answer too. In other words, it helps us deconstruct what might be hurting. It helps understand the movements that might be pain evocative. If our client says, "It hurts in this case when I look up, or I back bend, that really hurts down there in the lower back." That would be a place that we'd start to suspect.

Whitney Lowe:

Exactly.

Til Luchau:

Actually, I said it backwards, didn't I? The counter-nutation would be, "It hurts when I bend over to tie my shoes." That would be painful counter-nutation of the sacrum.

Whitney Lowe:

Yeah. It would be. The trick is, and again, we just really can't measure this very well, is how much nutation is happening, or counter-nutation is happening.

Til Luchau:

Yes.

Whitney Lowe:

And then at a certain point, you lose that motion, because the whole operation tilts. So, even if there are some relative counter-nutation with the sacrum at first, once the pelvis keeps rotating, and the sacrum, even if it's tipped backwards, the whole business is going to tip forward after a certain point.

Til Luchau:

Once we're past that one to 18 degrees, whatever it is, the whole pelvis ring tilts on to hip joints, probably.

Whitney Lowe:

Yeah.

Til Luchau:

So, if there is pain, especially later in that cycle, I would start to wonder-

Whitney Lowe:

Yeah.

Til Luchau:

In any case, that's the way we use that information is to deconstruct the painful movements to know what our target might be.

Whitney Lowe:

And here is why I think that is so helpful is because there are so few methods of really effectively identifying what's causing a lot of pain problems and sacroiliac joint disorders. Many of the assessment methods are not highly precise, and so the more precision that we can get about certain types of movement things, the better we can get at identifying where primary problems might be.

Til Luchau:

That is such a great cue up for what I want to say later. That's so great. Thank you.

Whitney Lowe:

Shall we hear it right now, before you forget?

Til Luchau:

Yeah. And the evidence turns out to bear this out, is that tests that provoke sensation tend to be a whole lot more accurate, than tests where you're having to infer a problem based on position, or movement. In other words, if you feel like something is out of line, maybe that's a problem, may be, or not. The tests that are built on positional alignment, don't have a whole lot of inter-radar, or intra-radar reliability. However, the test in general that provoke a sensation on the client's part are pretty clear. We press it, it hurts. We know now. Something is going on there.

Whitney Lowe:

Yeah.

Til Luchau:

And those tend to have a really high degree of reliability, both when I go back and check it later, but also other people checking it. Then that also tells me what I need to work with. I'm favoring those quite a bit in my approach to this with clients. We really are looking for sensitivity, even more than magnitude or movement in most cases.

Whitney Lowe:

That is exactly what most of the literature has pointed to is that a lot of those positional identification tests are not so accurate. In fact, many of the pain provocation tests are not accurate by themselves. They're considered more accurate as a suite of tests that you do.

Til Luchau:

Yes. Can I dig into that?

Whitney Lowe:

Yes.

Til Luchau:

In any case, that's the way we use that information is to deconstruct the painful movements to know what our target might be.

Whitney Lowe:

And here is why I think that is so helpful is because there are so few methods of really effectively identifying what's causing a lot of pain problems and sacroiliac joint disorders. Many of the assessment methods are not highly precise, and so the more precision that we can get about certain types of movement things, the better we can get at identifying where primary problems might be.

Til Luchau:

That is such a great cue up for what I want to say later. That's so great. Thank you.

Whitney Lowe:

Shall we hear it right now, before you forget?

Til Luchau:

Yeah. And the evidence turns out to bear this out, is that tests that provoke sensation tend to be a whole lot more accurate, than tests where you're having to infer a problem based on position, or movement. In other words, if you feel like something is out of line, maybe that's a problem, may be, or not. The tests that are built on positional alignment, don't have a whole lot of inter-radar, or intra-radar reliability. However, the test in general that provoke a sensation on the client's part are pretty clear. We press it, it hurts. We know now. Something is going on there.

Whitney Lowe:

Yeah.

Til Luchau:

And those tend to have a really high degree of reliability, both when I go back and check it later, but also other people checking it. Then that also tells me what I need to work with. I'm favoring those quite a bit in my approach to this with clients. We really are looking for sensitivity, even more than magnitude or movement in most cases.

Whitney Lowe:

That is exactly what most of the literature has pointed to is that a lot of those positional identification tests are not so accurate. In fact, many of the pain provocation tests are not accurate by themselves. They're considered more accurate as a suite of tests that you do.

Til Luchau:

Yes. Can I dig into that?

Whitney Lowe:

Yes.

Til Luchau:

In any case, that's the way we use that information is to deconstruct the painful movements to know what our target might be.

Whitney Lowe:

And here is why I think that is so helpful is because there are so few methods of really effectively identifying what's causing a lot of pain problems and sacroiliac joint disorders. Many of the assessment methods are not highly precise, and so the more precision that we can get about certain types of movement things, the better we can get at identifying where primary problems might be.

Til Luchau:

That is such a great cue up for what I want to say later. That's so great. Thank you.

Whitney Lowe:

Shall we hear it right now, before you forget?

Til Luchau:

Yeah. And the evidence turns out to bear this out, is that tests that provoke sensation tend to be a whole lot more accurate, than tests where you're having to infer a problem based on position, or movement. In other words, if you feel like something is out of line, maybe that's a problem, may be, or not. The tests that are built on positional alignment, don't have a whole lot of inter-radar, or intra-radar reliability. However, the test in general that provoke a sensation on the client's part are pretty clear. We press it, it hurts. We know now. Something is going on there.

Whitney Lowe:

Yeah.

Til Luchau:

And those tend to have a really high degree of reliability, both when I go back and check it later, but also other people checking it. Then that also tells me what I need to work with. I'm favoring those quite a bit in my approach to this with clients. We really are looking for sensitivity, even more than magnitude or movement in most cases.

Whitney Lowe:

That is exactly what most of the literature has pointed to is that a lot of those positional identification tests are not so accurate. In fact, many of the pain provocation tests are not accurate by themselves. They're considered more accurate as a suite of tests that you do.

Til Luchau:

Yes. Can I dig into that?

Whitney Lowe:

Yes.

Til Luchau:

In any case, that's the way we use that information is to deconstruct the painful movements to know what our target might be.

Whitney Lowe:

And here is why I think that is so helpful is because there are so few methods of really effectively identifying what's causing a lot of pain problems and sacroiliac joint disorders. Many of the assessment methods are not highly precise, and so the more precision that we can get about certain types of movement things, the better we can get at identifying where primary problems might be.

Til Luchau:

That is such a great cue up for what I want to say later. That's so great. Thank you.

Whitney Lowe:

Shall we hear it right now, before you forget?

Til Luchau:

Yeah. And the evidence turns out to bear this out, is that tests that provoke sensation tend to be a whole lot more accurate, than tests where you're having to infer a problem based on position, or movement. In other words, if you feel like something is out of line, maybe that's a problem, may be, or not. The tests that are built on positional alignment, don't have a whole lot of inter-radar, or intra-radar reliability. However, the test in general that provoke a sensation on the client's part are pretty clear. We press it, it hurts. We know now. Something is going on there.

Whitney Lowe:

Yeah.

Til Luchau:

And those tend to have a really high degree of reliability, both when I go back and check it later, but also other people checking it. Then that also tells me what I need to work with. I'm favoring those quite a bit in my approach to this with clients. We really are looking for sensitivity, even more than magnitude or movement in most cases.

Whitney Lowe:

That is exactly what most of the literature has pointed to is that a lot of those positional identification tests are not so accurate. In fact, many of the pain provocation tests are not accurate by themselves. They're considered more accurate as a suite of tests that you do.

Til Luchau:

Yes. Can I dig into that?

Whitney Lowe:

Yes.

Til Luchau:

In any case, that's the way we use that information is to deconstruct the painful movements to know what our target might be.

Whitney Lowe:

And here is why I think that is so helpful is because there are so few methods of really effectively identifying what's causing a lot of pain problems and sacroiliac joint disorders. Many of the assessment methods are not highly precise, and so the more precision that we can get about certain types of movement things, the better we can get at identifying where primary problems might be.

Til Luchau:

That is such a great cue up for what I want to say later. That's so great. Thank you.

Whitney Lowe:

Shall we hear it right now, before you forget?

Til Luchau:

Yeah. And the evidence turns out to bear this out, is that tests that provoke sensation tend to be a whole lot more accurate, than tests where you're having to infer a problem based on position, or movement. In other words, if you feel like something is out of line, maybe that's a problem, may be, or not. The tests that are built on positional alignment, don't have a whole lot of inter-radar, or intra-radar reliability. However, the test in general that provoke a sensation on the client's part are pretty clear. We press it, it hurts. We know now. Something is going on there.

Whitney Lowe:

Yeah.

Til Luchau:

And those tend to have a really high degree of reliability, both when I go back and check it later, but also other people checking it. Then that also tells me what I need to work with. I'm favoring those quite a bit in my approach to this with clients. We really are looking for sensitivity, even more than magnitude or movement in most cases.

Whitney Lowe:

That is exactly what most of the literature has pointed to is that a lot of those positional identification tests are not so accurate. In fact, many of the pain provocation tests are not accurate by themselves. They're considered more accurate as a suite of tests that you do.

Til Luchau:

Yes. Can I dig into that?

Whitney Lowe:

Yes.

Til Luchau:

In those cases that I've dug into on myself, accuracy is usually defined as correlating with an image that we can take. Can I feel something with my hands that is accurate in the sense that it correlates with a radiograph, or an MRI, or some image that we can take to verify what was assumed to be true for palpation. I'm saying, my pain provocation tests are nearly a 100% accurate in terms of they do provoke pain.

Whitney Lowe:

Yeah.

Til Luchau:

So, I've redefined the accuracy too in saying, "All I'm interested in is what provokes pain, and if I can press on something and my client says, "Ouch." I tend to believe them." That provokes pain, a 100% accurate, right there.

Whitney Lowe:

Yeah.

Til Luchau:

Then, the question is, what does that mean in terms of the anatomy? I don't know. I'm going to stay agnostic on that, but I have techniques that can help work with that sensation. I'm targeting the sensation of the pain itself more than the misalignment, or the presumed positional fault, or different things like that.

Whitney Lowe:

Yeah. There was a wonderful old YouTube video, and maybe we'll put this in the show notes too, that's on the physio tutors website, which is a great educational website aimed at physical therapists, physiotherapists. They're referring to Laslett, who's one of the authors that have talked a lot about this process of clustering tests for the sacroiliac joint.

Whitney Lowe:

They said, Laslett has zeroed in on four of those commonly used tests as being the ones that are most accurate, and those being the ones to focus the most attention on for, do we get a consistent finding from all four of those, or is it two of the four are positive, and two are not, or whatever. Then also there's another article, and we'll link to this in the show notes too, from Szadek. I'm not sure how to pronounce that.

Whitney Lowe:

They were making reference to a piece that came out in the International Association for The Study of Pain, as a diagnostic criteria for sacroiliac joint problems. They said, three key things would be necessary; one, is there pain present in the sacroiliac region? The second one was, is there a group of tests that can be selectively identified as causing problems in this cluster of tests? If two of the four are positive, then that would be considered another factor. Then the third one was selectively infiltrating the joint with an anesthetic, and the pain goes away.

Til Luchau:

In those cases that I've dug into on myself, accuracy is usually defined as correlating with an image that we can take. Can I feel something with my hands that is accurate in the sense that it correlates with a radiograph, or an MRI, or some image that we can take to verify what was assumed to be true for palpation. I'm saying, my pain provocation tests are nearly a 100% accurate in terms of they do provoke pain.

Whitney Lowe:

Yeah.

Til Luchau:

So, I've redefined the accuracy too in saying, "All I'm interested in is what provokes pain, and if I can press on something and my client says, "Ouch." I tend to believe them." That provokes pain, a 100% accurate, right there.

Whitney Lowe:

Yeah.

Til Luchau:

Then, the question is, what does that mean in terms of the anatomy? I don't know. I'm going to stay agnostic on that, but I have techniques that can help work with that sensation. I'm targeting the sensation of the pain itself more than the misalignment, or the presumed positional fault, or different things like that.

Whitney Lowe:

Yeah. There was a wonderful old YouTube video, and maybe we'll put this in the show notes too, that's on the physio tutors website, which is a great educational website aimed at physical therapists, physiotherapists. They're referring to Laslett, who's one of the authors that have talked a lot about this process of clustering tests for the sacroiliac joint.

Whitney Lowe:

They said, Laslett has zeroed in on four of those commonly used tests as being the ones that are most accurate, and those being the ones to focus the most attention on for, do we get a consistent finding from all four of those, or is it two of the four are positive, and two are not, or whatever. Then also there's another article, and we'll link to this in the show notes too, from Szadek. I'm not sure how to pronounce that.

Whitney Lowe:

They were making reference to a piece that came out in the International Association for The Study of Pain, as a diagnostic criteria for sacroiliac joint problems. They said, three key things would be necessary; one, is there pain present in the sacroiliac region? The second one was, is there a group of tests that can be selectively identified as causing problems in this cluster of tests? If two of the four are positive, then that would be considered another factor. Then the third one was selectively infiltrating the joint with an anesthetic, and the pain goes away.

Til Luchau:

Yeah. Let's just highlight too, when you talk about the left leg lengthening, we're not actually lengthening this person's length, just so everybody understands what we're talking about here.

Til Luchau:

Lengthening is a movement more than a static situation.

Whitney Lowe:

Right.

Til Luchau:

Being willing to get longer.

Whitney Lowe:

Yeah. They're not the rubber stretchy Gumbies that we're going to link them there.

Til Luchau:

Exactly. This is an example. Not only are positions, and the whole terminology is complicated, but we start to talk about the pelvis in language that combines position and movements.

Whitney Lowe:

Yeah.

Til Luchau:

It isn't always clear. Like a tilted pelvis is a movement terminology that describes a position.

Whitney Lowe:

Yeah.

Til Luchau:

That's some of the confusion you and I are just running into as well. It's so important to tease those apart if you want to get really methodical about it. It does inform our treatment approaches too. If I assume that that high left hip has been pulled up by a tight QL, that's a different thing than thinking, "So, it can drop in walking or whatever?" Then, how could I help it drop? There might be a lot of things that could help it be willing to drop.

Whitney Lowe:

Yeah. Where do we go from here? You got other things that you want to touch base?

Til Luchau:

Where do we go from here?

Whitney Lowe:

Yeah.

Til Luchau:

There's that last plane. I just should do one more thing. We talked about what I call torsion, the anterior posterior tilt. We talked about nutation of the sacrum. We talked about inflare, outflare. I mentioned the name lateral side bending of the pelvis. We said the whole pelvis could go up and down the leg length, but if you scoot yourself over at listeners, and the cohost, to the edge of your chair, if your arms allow that, you can get one seat bone off the chair, or you can turn sideways in the chair. So, you hang one seat bone off your chair, and there is on that. That's putting that kind of force through your pelvis in the frontal plane.

Til Luchau:

I'm just trying to outflare, you could say. I'm just trying to inflare. That's such an important ... Do it in the other side too. So, let the other seat bone hang off. This is great by the way. These self care possibilities, I learned them from the work of Richard DonTigny, who's a physical therapist who specialized in SI joints stuff.

Til Luchau:

Then I recently used a couple of his illustrations and articles in massage and bodywork. When we found him, in an assisted living facility in Bozeman, Montana, where he was so delighted to hear from someone still reading his work. We had a fun time talking about his illustrations, and the ideas that he used, which you can see in those articles. He was a pioneer in using these self care ideas that I just showed you, hanging your things off the chair, or bringing the knee to your chest, like you described, to help people manage their own SI joint discomfort.

Whitney Lowe:

Yeah. All right.

Til Luchau:

But early on, he wasn't saying, "Let's mobilize it." He was saying, "Let's make sure that movement's comfortable to both directions," he would say, to both sides. It wasn't like correct the position, it was more like, "Let's mobilize it, and help it be more comfortable."

Whitney Lowe:

Yeah. I think I remember coming across some of his work and writings too that were in leanings, movement stability and low back pain. Is that the title of that book?

Til Luchau:

Yeah. We can look that up. When we dialed it down a lot more precisely, DonTigny was one of those pioneers who was saying, "Here is a bunch of stuff that just really seems to help." That's pretty much, I think our high points. We probably lost the right percentage of our audience by now.

Whitney Lowe:

I don't think so. Probably.

Til Luchau:

Congratulations to the survivors who made it this far.

Whitney Lowe:

Yeah. As you can see, lots and lots of thing to dig into. And Til, you're going to dig into that in your upcoming online class. Again, your principles series class. I'll let you plug that one more time-

Til Luchau:

It's that. All right. Well, I'm going to plug it, because I'm going to ... Like we mentioned before we went on air, I'm going to invite you to come give a little guest spot there. We might even bring out this podcast to serve as example. I might even maybe cook it down to an even shorter version, because that ilia and SI joints class is live online.

Til Luchau:

There's four lectures. They happen every two weeks. You can be there live, and have questions, you can go to the small groups where we discuss them, or not, those are optional. You could actually take a client and turn your camera and show us working on them, and we will coach you individually as a part of that class, or not. That's optional too, but the whole price is pretty affordable and it's based on those four live online lectures that happen every two weeks, starting October 5th, 2022, or later by recording.

Til Luchau:

The free intro is on September 28th, optional, but it'll give you a sense of what the class is like. It's one of our principles courses, where we're really trying to take people to the next step in their work and understanding the principles behind what they're doing, and how we use that in our approach as well.

Whitney Lowe:

Awesome. It sounds like a great thing.

Til Luchau:

Put a link for them in the show notes, advancedtrainings.com, if you want to go look it up now, but otherwise, check out the show notes. Should I go ahead with the closing sponsor?

Whitney Lowe:

Yes. Probably we'll do a wrap up here for today. I think that was a great deep dive into these things here. So, who's our sponsor wrapping up?

Til Luchau:

Our closing sponsor is Handspring Publishing, who's been with us from the beginning, and really from the beginning of my publishing career, because when I was looking for a publisher for a book, I was fortunate enough to have two offers; one from a large international media conglomerate, and the other from Handspring, which at that time was just a small publisher ran by four people out of Scotland, who loved great books, and loved our field. And to this day, I'm glad I chose to go with them.

Til Luchau:

Handspring, not only did they help me make the books I wanted to share with you the Advanced Mal Fascial Technique series, but their catalog has emerged and persisted as one of the leading collections of professional level books written, especially for body workers, movement teachers and all professionals who use movement or touch to help patients achieve wellness.

Whitney Lowe:

And note, that Handspring was recently joined with Jessica Kingsley Publishers, Integrative Health-Singing Dragon Imprint, where their amazing impact continues. So, you can head on over to their website at handspringpublishing.com, to check on the list of titles, and be sure to use the code TTP, at checkout, for a discount. Thank you, again, very much, Handspring.

Whitney Lowe:

We would like to say a thank you to all of our sponsors, and of course to you our listeners as well. You can stop by our sites for show notes, handout transcripts or any extras. You can find that stuff-

Til Luchau:

Video.

Whitney Lowe:

Yes, a video on this one. True. You can find this one over at academyofclinicalmassage.com, and Til, where can people find that for you?

Til Luchau:

Advanced-trainings.com, is my site, where we'll put this episode's video, audio and transcript. If there are questions or things you want to hear us talk about on the podcast, just email us at info@thethinkingpractitioner.com, or look for us on social media. I'm @Til Luchau on all forms of social media. Where are you, Whitney?

Whitney Lowe:

Most days I can be found on social media under my name as well, also at @Whitlow over on Twitter. So some form of that can help find me. You can rate us on Apple Podcasts as it does help other people find the show. That is quite important actually. And you can hear us on Spotify, Stitcher, Google Podcast, or wherever else you happen to listen.

Whitney Lowe:

Please do share the word, tell a friend. And thank you again so much for taking some time out to listen to us. We hope we maybe enriched your sacroiliac understanding a little bit, and you can help some other folks out there who are in need of your help as well.

Til Luchau:

Indeed. Thanks for hanging with me, Whitney.

Whitney Lowe:

Great to be with you once again, sir. And we'll be back again in just a couple weeks on another deep dive into some fascinating enriching topic there.