Whitney Lowe:

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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 Warner 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 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:

Right.

Whitney Lowe:

Being the key diagnostic criteria that physicians would use in identifying sacroiliac joint problems.

Til Luchau:

Yes. I mean, there's been so much work done in recent years on the accuracy question of making sure that these orthopedic tests can be replicated, can be useful information to other practitioners. Say a surgeon who's going to take over after a physical therapist. Things like that.

Whitney Lowe:

Yeah.

Til Luchau:

That's when it gets really crucial. Either you're doing a research project, you need to be precise about what you're measuring, or you're interfacing with other practitioners who are going to take your information and design treatments, or interventions, or surgeries based on what they're hearing from you. In those cases, anatomical accuracy is key.

Whitney Lowe:

Yeah.

Til Luchau:

I'm still going back to on my table, if it hurts, that's all I need to know. In the sense of, now I have a therapeutic target.

Whitney Lowe:

Yeah.

Til Luchau:

And I'm not going to insist it's the joint capsule, or it's the misalignment. Like I said, I'm agnostic that it could be any of those, but I'm going to work with the pain phenomena on its own through gently resetting that response.

Whitney Lowe:

Yeah. My understanding too is that that might not necessarily mean localized treatment. There was a paper, I think that came out in 2021 about the stecco fascial manipulation of treatment for SI joints disorders. It was talking about treatment applied.

Whitney Lowe:

A pretty significant distance away from the localized pain. I can't remember the measurement, maybe 20 centimeters, or something like that away from the side of primary problems. This is again emphasizing that a lot of times, working on not necessarily immediately localized tissues can certainly be beneficial in addressing those kinds of complaints.

Til Luchau:

Well, yeah. I mean, neurologically speaking, the target zone on the spinal cord for low back pain is really big. It's like a cloud more than a spot. It's not one wire going into a junction box. It's a whole field.

Whitney Lowe:

Yeah.

Til Luchau:

Then in the brain, once it gets to the brain, it's also a big zone of the sensory homunculus, say, or the insular cortex, or whatever those signals are targeting. It's like a big zone, there's a lots of crossovers. So, it's really hard to do the exact spot kind of thing.

Whitney Lowe:

Yeah.

Til Luchau:

Except when there is a spot. When there is a spot, you press and the client says, "Ouch." Then we can work with that spot. I'm not going to presume I need anything other than that sensitive spot. Or, in the case of the ilio and SI workshop that I'm teaching, when you push or pull on the leg, or pelvis in certain directions, and it evokes a little bit of that sensation, we don't know if it's specific, or general, and we don't quite know yet, what's going to help, but we can trust that finding as a therapeutic confirmation.

Whitney Lowe:

Yeah. Just to bang the drum on specificity and assessment once again, one of the things that I wanted to say here is that, one of the reasons that I like to try to zero in on trying to find as much specificity and accuracy to some of these symptoms is because a particular maneuver that provokes pain, may provoke pain for quite a number of different reasons.

Whitney Lowe:

As an example, in the sacroiliac joint region. Let's say your client is supine, and you're doing some type of movement, where you're bringing their thigh up towards their chest. And that's provoking pain in that region. That could be provoking pain, because the hamstrings, which are connected to the sacrotuberous ligament are pulling on the sacrum and irritating the SI joint.

Whitney Lowe:

That may produce pain in the gluteal region, and down the posterior lower extremity. That could also be producing pain, because you are stretching the sciatic nerve against the sacrospinous ligament when you do that, and that can cause gluteal pain and pain down the posterior side of the leg.

Til Luchau:

You could be causing pain from nociceptors right around the sacroiliac joint, from that posterior torsion of the ilia anterior nutation of the sacrum that happens when you bring the knee to the chest. Could be right there in that joint capsule. We don't know the target. We don't know the tissue at that point.

Whitney Lowe:

Yeah.

Til Luchau:

I don't know where you're going with this, Whitney, but I know that I can use that maneuver, the knee to the chest to gently dethreaten that kind of movement, and gently change someone's protective responses around that sensitivity of the pain.

Whitney Lowe:

Yeah.

Til Luchau:

Then I could also start to look in my book of orthopedic options, and try other things maybe they've learned from you, or from me, or from other people to look at some of those other possibilities. Like the sciatic nerve, or the hamstrings, or the SI joint itself.

Whitney Lowe:

Exactly. For me, it's always a process of looking for patterns. What kind of pattern is illustrated here? Is this something that looks like a pattern of neurological engagement where that gets significantly irritating when the client lifts their head up. A lot less likelihood that we're looking at a sacroiliac joint problem from tension through the sacrotuberous ligament, if lifting the hand forward is significantly aggravating that pain. That's a lot more likely to be a neurological involvement. Just little pieces that you can add on there that can help you zero in on what you're doing is I think quite helpful in many instances.

Til Luchau:

Super helpful. Whether you're treating empirically or analytically. Whether you're thinking like, "Here is something that I feel, and the client feels, and we're going to work with that." The empirical approach that I'm describing, or analytically, where we're thinking, "Oh. What could be producing this, and how can I start to list those out, and think those through in a more linear fashion, or an analytical approach? Either way, it's going to be helpful to be able to start to tease those them, and understand them.

Whitney Lowe:

Yeah. Excellent. What else have we got here? We were talking about anatomy. You've got some anatomy images, and things like that to distribute?

Til Luchau:

Yeah, thanks for that cue, and thanks for the discussion there too, because it's the questions of accuracy, the questions of what we do with the information. It's all contextual for me. It's like, why does it matter? And I love your answers. And how am I going to use those questions there? I want to show in terms of anatomy. I could talk about how many different systems have their own models of the sacroiliac pain, and how complex some of them are.

Whitney Lowe:

Yeah.

Til Luchau:

I'll just give a little preview of this one. Let me see if I can get it up on the screen properly.

Whitney Lowe:

Okay. We're there.

Til Luchau:

Okay. I have on the screen, for audio listeners only, a handout, made by an osteopathic student to try to remember all the different possible torsions, or rotations, or shears, at the SI joint. Those are all terms that refer to positional variations there that are thought to be functional or dysfunctional. But he's got a fairly extensive table that I had to try to memorize, and when I finally found this handout, I was like, "Oh my God, the key, the whole Rosetta Stone to understand all these different, left on left, right on right, right margin posterior, et cetera." Variations that the sacrum is thought to do.

Til Luchau:

This is the way I was used to be working through these complex variations of positional changes. And then at some point, when I had to go, because I mentioned in that earlier episode, when I had to go teach it in a useful way, I realized that I'm actually working at a much simpler way on the table, rather than at an analytical approach. I'm actually, again, looking to find out what is interesting in terms of sensation, since that's the motivator for most clients. It's something that doesn't feel right, doesn't move right, or doesn't feel right.

Til Luchau:

I want to find out exactly what I can do that reproduces that, and then start to use techniques to help either desensitize that, or help it be more mobile. Now, in the case of the SI joint, since there is not much movement there anyway, it's usually not about mobilizing, most of the mobility, like you said, comes from the hip joints.

Whitney Lowe:

Yeah.

Til Luchau:

I almost think about the SI joints as a sensing shock absorber. They take up a little bit of movement. They mechanically have a small function, a little springiness there perhaps, especially when you're young, but more than anything else they're probably giving our nervous system information about loading. They're probably telling us how the load is being distributed to the two legs, or how left and right legs are moving against each other in the joint.

Til Luchau:

So, I've shifted my own thinking from position. Can we get unrotated, or upslipped, or outflared, or whatever? Can we undo those things? To instead, how can we make sure that every direction of movement feels okay, and that there is some tolerance for the movement in every direction.

Whitney Lowe:

Let me ask you this question on the treatment processes that you go through and the way you think about this.

Til Luchau:

Yes.

Whitney Lowe:

Do you tend to ... Maybe this is a bit individual, but would you say that you tend to move people towards a barrier of discomfort and see if you can push that barrier of discomfort farther away? Or do you try to keep those movement things within comfort zone and just reinforce the comfort sensations and see if you can make those bigger?

Til Luchau:

Do I find a barrier and push against it, or do I stay way back from it and try to build capacity within that less challenging range?

Whitney Lowe:

Yeah.

Til Luchau:

It totally depends on the client's resilience, the rapport I have with them. If someone comes to me with an SI joint that flares up and gets painful on them, I'm not going to push it. More movement isn't going to helpful in my thinking, probably. Or at least in the past they've had things that flare that up through more challenge.

Whitney Lowe:

Yeah.

Til Luchau:

So, theirs is not about challenge, theirs is about calming down. That might work well within that mid-range of small movements that's just began to feel a little funny, and stop right there, and have someone breathe, and relax and essentially go through an autonomic or sensory new reset around that threshold. In some way, Whitney, I want to do more work with you around the hypermobility question, because it's such a puzzle.

Til Luchau:

I mean, in the simplest terms, a lot of manual therapies work to loosen things up. There's a paradox when we have a situation that might the case that things are "too loose." How do we help? It isn't just to go loosen things up more.

Whitney Lowe:

Yeah.

Til Luchau:

It may not be as simple as just going to strength it more either, but I still think there is a lot we can do, and that's a puzzle I'm unpacking for myself. I want to talk to you more about that.

Whitney Lowe:

It is. That's a question that ironically got posed to me very, very early on in my massage training, when I was early on in school, because my mother has Ehlers-Danlos syndrome.

Til Luchau:

Okay. Is that the condition where there is a lot of movement at the joints basically?

Whitney Lowe:

Yeah. Excessive amount of movement at the joints, very weak connective tissues. A lot of the things that we were learning about, you make everything loose. Everything was so loose already. It's like, what are you trying to do? She would have soft tissue pain. So, I'm thinking, why? Why is this painful? Because it's so loose to begin with.

Til Luchau:

Not because it's too tight.

Whitney Lowe:

Yeah. I think probably a lot of your work on the inflammatory stuff is relevant there, because there is probably a significant amount of that thing going on, but this gets back into, a lot of these things have a whole lot more to do with nervous system responses in many instances of what we're seeing.

Til Luchau:

Well, it's the nervous system that's transmitting, generating, interpreting those nociceptive signals. The nervous system is responsible for the pain phenomenon. So, let's work right there, is one of my points around that too. Unless it is mobility. It just feels stuck. And no, it doesn't flare up, it doesn't hurt. I'm totally strong, and healthy. Then it might be more of a mobility intervention I would do. How can we challenge it? The edges of where it moves, and have someone find ways to allow more movement to there.

Whitney Lowe:

Yeah. You brought up something earlier too, just to call attention to remembering that we are treating individuals when we do this kind of stuff.

Til Luchau:

Yeah.

Whitney Lowe:

And the significant amount of mobility that you might find in a 19 year old gymnast, and what you're going to do with them to try to work with excessive hypermobility, which you may not try to change that a whole lot, compared to the 48 year old office worker, or somebody like that who's having some, maybe more significant problems because of hyper-mobility and the wearing away of joints, and producing arthritic changes. Those strategies may be completely different.

Til Luchau:

They may be really different. I don't even know that my explanations are going to be the right ones, but I know that I'm going to start with them as ... I'm not going to push someone that moves a lot to move more, and even when I'm playing within their mid-range, to help dethreaten movement there, I'm going to be tracking how they're able to relax into it. Are they able to breathe? Are they able to stay present with the sensation. Those kinds of things.

Til Luchau:

The same with a person that doesn't move at all. It's more they're complaining about stiffness. Or I suspect, you got a really big difference left and right. There is some evidence, once study, at least, Damon, 2002, that says, "When people have a big difference between their left and right SI stiffness, they have more pain." At least in pregnancy, which maybe applies, and maybe doesn't.

Til Luchau:

Let's assume it does. One of my therapeutic approaches is, let's get the side that doesn't move as much to move just a little easier, and then we'll see what happens. It's not my therapeutic approach, it's a really traditional one in manual therapy.

Whitney Lowe:

Yeah. You bring up a really interesting point there too when you talk about the difference in movement capabilities from side to side, because a lot of people don't think about this very much, but in essence, one of the reasons that the pelvis needs that degree of mobility that it does, is that in a normal gait, stride ... For example, as you swing your right leg forward, and place it in front of you, and your left leg is behind you, your pelvis, your innominates on each side are rotating in opposite directions.

Til Luchau:

I got a visual for that right here.

Whitney Lowe:

All right. Excellent. I was doing this with my hands.

Til Luchau:

Here's this pelvis ... You're going to do it with your hands, but I'll try to describe for the listeners too.

Whitney Lowe:

Yeah.

Til Luchau:

You're saying that if you step forward with your, which leg did you say?

Whitney Lowe:

I said right leg forward, I think.

Til Luchau:

Okay. So, your innominates are doing that a little bit?

Whitney Lowe:

Yeah.

Til Luchau:

I'm exaggerating, with this flexible pelvis, I may end up showing how the right innominate might tip along with the femur, and the left reverse the other way.

Whitney Lowe:

Yeah. Those people watching the video, looking, you can see that motion at the sacroiliac joints, as well as the pubis symphysis. There is a little bit of motion occurring at each of the joints with every stride of our walking, or running. We so often think about these, both pathologically and in normal function, as, it's either both tipping forward, or both tipping back, or right side tilting, left side tilting, or whatever, but they need to operate in opposite movement in relation to each other, during every walking stride.

Til Luchau:

That's right, and not so much for range of motion, but so that you have shock absorber capacity, and so that your brain knows you're walking. That's part of the monopoly of sensory tapestry of the walking phenomenon. Right now in your chair, Whitney, and everybody else, if you just slide your right knee forward, so that you're essentially walking with your right seat bone in front of the chair, that's mimicking what happens at the SI joints left and right, during a stride. That thing Whitney just described.

Whitney Lowe:

Yeah.

Til Luchau:

And then just to even it out, slide the left knee forward, slide your left seat bone first, you're walking on your chair with your seat bones. That sensation you're feeling is similar to what you get while you're walking, how your brain modulates walking, it knows you're walking, senses or coordinates walking, all those things.

Whitney Lowe:

Yeah. Absolutely.

Til Luchau:

What do you call that motion, by the way? You're calling it anterior, what? Let's say you walk your seat bone forward on the right. You call it posterior tilt, did you say?

Whitney Lowe:

Well, it would posterior tilt, yeah, if you swing the lower extremity forward, that innominate is going to tilt backwards. So, yeah.

Til Luchau:

Tilt is a common one. That's what Joel Masculino calls it too. He had a cool article in that same issue, and I called him up just to talk about terminology. It's also called torsion in some models. It used to be called posterior torsion in the model I first trained in. It's the same thing though, it's the innominate just doing that tilting, sideways.

Whitney Lowe:

Yeah.

Til Luchau:

By the way, if I look at now the top of the pelvis, and say this pubis symphysis is spreading, like in giving birth, or something-

Whitney Lowe:

Yeah.

Til Luchau:

Where the innominates are moving at a horizontal plane, do you have a name for that? What do you call that?

Whitney Lowe:

Usually, and again for the nonvisual people, he's pulling the pelvis, and we're looking straight down into the pelvis from the superior angle, and the two halves of the ilium are moving out of way from each other, or flaring out. And that's usually the term I have heard is, inflare, or outflare.

Til Luchau:

Inflare, outflare.

Whitney Lowe:

Outflare when they tilt out, and inflare when they are tipping in.

Til Luchau:

Yeah. By the way, generally, it's usually taught, I learned it, as like they're both "outflaring" or "inflaring." Inflaring, you're compressing the pubis symphysis.

Whitney Lowe:

Yeah.

Til Luchau:

But it was a revelation to me to realize that that motion happens all the time, but at the same time. So, it's a contralateral, inflare or one outflare of the other. That again is walking, or if you want to feel it in your own body, slide your right knee forward. So, you walk your right seat bone in front of your chair, and then twist to the left with your spine and shoulders.

Til Luchau:

That puts essentially an outflare on your right, and in inflare on your left innominate at the SI joints. And you switch it out. So, you slide your left knee forward, left seat bone forward and twist to your right with your shoulders, that's going to do the opposite at the SI joints.

Whitney Lowe:

Yeah.

Til Luchau:

That happens in walking as well, all the things that I'm explaining.

Whitney Lowe:

So, while we're doing that I want to put one other image up on the screen here for just a second, because this is another one that is somewhat confusing for folks in relation to lateral tilting.

Til Luchau:

That's the next train of movement.

Whitney Lowe:

Yeah. We've been talking all about tilting forward, tilting backwards, but there's also the lateral tilt, which is the tilt to one side or the other. This happens frequently.

Til Luchau:

Well, you're showing. I don't need to show, I need to explain it verbally. You're showing a back view of the pelvis with a longer leg on the right side, and you're saying that side of the pelvis is taller, and you're going to tell her something about the movement that happens there at the innominate, I think.

Whitney Lowe:

Yeah. We're going to assume that a person has a structurally longer right leg. So, the bones of the right lower extremity, either femur, or tibia, or both, are measurably longer than those on the left side. And when that happens, the pelvis on the right side, in a standing position will sit higher, and you can sometimes do this with a visual examination, or a palpatory examination, and see the level of the thumbs. One's going to be higher on the side.

Til Luchau:

One of the bony landmarks will be farther from the floor, taller. That's how I understand it.

Whitney Lowe:

Exactly. Yeah. When the right side is higher, we call this a left lateral tilt. This is another place where people get a little bit confused.

Til Luchau:

Off the pelvis we have the innominate.

Whitney Lowe:

Well, innominate, it means no name, which I always thought that's interesting.

Til Luchau:

Well, that's another subject. Yes.

Whitney Lowe:

One innominate, you can have a right innominate, and a left innominate, or we can talk about both of them. In most instances, they're going to tilt together. The right one is going to be higher, and it's going to cause a whole structural thing to tilt more to the left side. So, that's why it's called a left lateral pelvic tilt.

Til Luchau:

I guess what I'm saying is, are you describing this as movement of the SI joint, or somewhere else at the hip joints?

Whitney Lowe:

Well, it's not so much movement as it is the way forces have to be distributed, because when this leg is longer, the femoral head pushes up against the top margin of the ASIS. The turbulent pushes the whole thing higher. That's just a structural positioning, a static positional movement that's going to make that higher. So, high on the right side is a left lateral tilt.

Whitney Lowe:

I always like to think about this as, if the pelvis is a bowl of water, it's going to spill out to which side? When the right side is high it spills to the left. And so we call that a left lateral pelvic tilt.

Til Luchau:

Yep.

Whitney Lowe:

You're smiling. You have something you're going to add?

Til Luchau:

I'm like the cat that ate the canary, I'm just waiting. Keep going. This is good. You're saying that's the movement of that. One side of the pelvis, the innominates on the right side would be a ... What did you call that again?

Whitney Lowe:

That would be a left lateral tilt if the left side is higher.

Til Luchau:

Left lateral tilt?

Whitney Lowe:

Yeah.

Til Luchau:

Okay. I have the opposite terminology, but go ahead, that's okay. All ears.

Whitney Lowe:

Well, no. Explain it to me there.

Til Luchau:

I follow Diane Lee, who says on the right side, if the right seat bone gets wider, and the ASIS gets narrower, that's a middle side flection, she calls it.

Whitney Lowe:

Okay. That would be something different, because what we're talking about-

Til Luchau:

It's not what you're talking about?

Whitney Lowe:

No.

Til Luchau:

I thought that's what you're talking about.

Whitney Lowe:

We're talking about, the entire innominate is getting lifted in a superior direction.

Til Luchau:

You're talking about upslip, or a translation at the SI joint?

Whitney Lowe:

Yeah.

Til Luchau:

Okay. Got you now.

Whitney Lowe:

There is shear forces, so a sliding force at the SI joints, probably on both sides, because one side is getting lifted higher than the other side. So, that's what produces unequal forces on the SI joint. This is the kind of thing that produces significant SI joint pain. When you have somebody says like, "Oh yeah. I just started this running regimen, and I'm running on the side of the road, and the road is domed." They may have one leg longer than the other on one side of the road, when they're running they're just in excruciating pain in their SI joint, because their long leg is on the short side of the road, when they're running they're just in excruciating pain in their SI joint, because their long leg is on the short side of the road, and it's really exacerbating that lateral tilt force.

Whitney Lowe:

Then they could turn around and run in the opposite direction on that side of the road like, "Oh, now that feels really good." Because now their long leg is on the longer side of the road. That's just an interesting thing with the laterals too.

Til Luchau:

It is. You're not talking about tilt, you're talking about upslip, I thought.

Whitney Lowe:

Well, some people-

Til Luchau:

Never mind. Let's not get caught up in the words, because I want to talk about longer legs.

Whitney Lowe:

Yeah. Okay.

Til Luchau:

Longer legs are ... Again, you just beautifully articulated the conventional view of a longer leg, how it could manifest the symptoms. I would posit that there is a lot of other things that could explain those symptoms too, even if one leg was structurally longer than the other.

Whitney Lowe:

Yeah. Absolutely.

Til Luchau:

So, someone could feel more comfortable running on a crown road in one direction the other way, just because their SI joints, they can't adapt in one way, or is more sensitized in one, you could say.

Whitney Lowe:

Yeah. Absolutely.

Til Luchau:

And with a longer bone, on one side of structurally longer leg, the sacrum is being asked to adapt asymmetrically, the SI joints, left to right. So, the most help I can give is to help them be more adaptable, help them be sensitized to the adaptation they're doing.

Whitney Lowe:

Yeah. The other point that I wanted to make about this. Let me come back over here to this image here for just a second, is, where we run into some problems with this, is in trying to determine causative factors on that, because sometimes people will put a person on the table, and pull their ankles towards them and look and say, "Oh, you've got one leg, longer or shorter than the other."

Whitney Lowe:

Let's say in this instance it's a person, and you put them supine on the treatment table. And then you pull their ankles towards you as a practitioner, and you look and the right side looks longer than the left side does. So, we are on the treatment table, right side looks longer than the left side does.

Whitney Lowe:

And you say to that person, "Oh, you've got a short left leg, and a longer right leg." Then, what you do is say, "Well, you need to put a heel lift in your shoe, so that can make those lengths equal." But what might be occurring with that individual is not that the right leg is structurally longer, but back over here ... Let's do this really quick from our little drawing.

Whitney Lowe:

Our quadratus lumborum over on this side, on the left side, is hypertonic, and pulling that ilium in a superior direction, causing a lateral tilt. And when you put that person supine on the treatment table, and look at their legs, this left side is going to look shorter than the right side. And if you put a heel lift under that short side, when this is a functional leg length discrepancy, as opposed to a structural one, you actually exacerbate or make that problem worse. And that can aggravate somebody's SI joint pain significantly.

Til Luchau:

I didn't let you make your point, before I was giving mine previously. Your point is there that it could be a functionally shorter leg, rather than a structurally shorter one. The explanation you gave, of quadratus tight on the shoulder side would be right along with a biomechanical model that has tissue tightness as the causative factor for those differences. Of course, we got to assume that people using orthotics, or prescribing them for sure are taking these things into account, and their models are much more complex than the ones we're describing here.

Whitney Lowe:

Yeah.

Til Luchau:

From another point of view, there are many things other than the QL, say. Someone might go, "Let me go work now on the QL on that side, to see if I can get that hip to drop." I've heard those kind of treatment approaches posited as well. And we actually do some of that kind of thing in our scoliosis work as well. There are so many things that could be responsible for one hip showing higher, or a functional leg length discrepancy.

Til Luchau:

I just got to say, again, I do go for movement more than position, even in that case. Can the left leg lengthen as much as their right leg? And then if it can't lengthen, what can I do to help it be willing to lengthen more comfortably? A QL might include different things. Who knows what? Transversus, latissimus, gluteus, things that they do at the knee. What I have to ask before I can pull a new reg, there is lots of factors there that could be a part of that left leg's willingness to lengthen.

Whitney Lowe:

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.