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Don't Trust What Your Patients Say
When a patient presents to the office for care, they typically have a specific complaint – lower back pain, whiplash, sinus congestion, sciatica, etc. They are often not interested or engaged in what they consider "unrelated" personal health history.
News in Brief
D'Youville Vet Program Gets High Praise; A Moment of Silence for Dr. Paul Reginald ("Reg") Hug.
The Search for the Origin of the Wiggle Technique
When Bob had adjusted me previously, most of the time I knew what he was doing. But this time, he had me lie on the treatment table in the usual side-posture position, and he "wiggled" my sacroiliac with the fingers of both hands, while stabilizing my pelvis with his forearm.
Deciphering the New CMS-1500 Claim Form
Q: I am confused about how and when to use the new 1500 form, particularly block 14 and block 15. What is required and how do I properly fill out these fields? And do I actually have to use this new form or may I continue using the old version?
We Get Letters & E-Mail
Imagine What More Could Be Achieved With Your Support; A Lesson in Hygiene: What Do You Do in Your Office? Open Letter to the Profession.
Wellness: A New Buzzword at the Aging in America Conference
Aging in America is "the nation's largest gathering of a diverse, multidisciplinary community of professionals in healthcare, social service, government, business and philanthropy with expertise in providing services and products for older adults."
Shared Mechanisms Between Computer-Assisted Mechanical Adjusting and Contemporary Acupuncture?
Can contemporary acupuncture provide clues to the mechanisms responsible for pain relief provided by computer-assisted mechanical adjusting instruments, and clarify whether certain mechanical frequency combinations are superior to others for modulation of acute peripheral pain?
CRREW Rallies for Ongoing Acupuncture Relief Effort in the Philippines
On November 8, 2013, Typhoon Yolanda (Haiyan) made her way through the Philippine Islands, leaving in her wake at least 7,000 people dead, millions homeless and complete communities destroyed.
Employers Need Chiropractic First and Sooner
From the Journal of Occupational and Environmental Medicine comes a study that gives excellent direction to employers (and insurers) regarding the management of low back problems (LBP).
The Boston Benevolent Chiropractic Clinic: Standing Up for the Needy
Our chiropractic assistant, Bridget, greeted an arriving patient at the Emmanuel Church in downtown Boston. She said, "Hi, Michael, good to see you. It's been awhile. Have a seat and Dr. Ken will see you soon."
Working With The Yuan-Source Level: Resonance and the Extraordinary Vessels
How do we stay fresh with our medicine? As healers, how do we balance our medical selves with creative artistry? Chinese Medicine is not a fixed dogmatic entity, but a living system, reliant on a mysterious force called "resonance."
"Doctor ... Always Do the Right Thing"
So says "Da Mayor" in the iconic Spike Lee movie. As a fresh grad questioning in-network versus out-of-network, it struck me that some doctors have explicitly skirted the issue, while others have argued adamantly for the latter and "sticking it to the man."
Low Melatonin Linked to Risk of Advanced Prostate Cancer
Epidemiological and experimental studies suggest the hormone melatonin, which plays a role in regulating the sleep-wake cycle, may play a role in the development of prostate cancer, as lower melatonin levels have been associated with an increased risk of prostate (and breast) cancer.
Vibrational Medicine: Frequency Micro-Current and Color Acupuncture
Vibrational medicine involves the application of various forms of energy frequencies to the body for pain relief, healing and rejuvenation. Vibrational medicine will become a major growing trend in our medical systems for the following reasons:
Halt Allergies With Moxibustion Therapy
An allergy is an immune system disorder in which the body is hypersensitive to normally harmless substances in the environment.
News In Brief
Pacific College of Oriental Medicine obtains grant funding from NIH; Yo San University of Traditional Chinese Medicine Announces New President; Kentucky Gets Licensed; PCOM Receives Approval from WASC to Offer FPD.
The Importance of Knowing Mainstream Lingo
There is a secret lingo within mainstream medicine of which the vast majority of acupuncturists and Chinese medical professionals are unaware.
Home Sweet Medical Home
While the Affordable Care Act (ACA) has received its fair share of praise and criticism since its adoption, few question the value of its emphasis on collaborative, patient-centered health care.
Don't Trust What a Patient Says
When a patient presents to the office for care, they typically have a specific complaint in mind – lower back pain, whiplash, sinus congestion, sciatica, etc.
Medical Qigong for the Heart: Part I
According to the Center for Disease Control and Prevention, heart disease is the leading cause of death in the United States, affecting people of all ages and backgrounds. Coronary heart disease, in just the United States alone, costs close to 109 billion dollars a year.
Changes in Herbal Medicines from Ancient Times to the Present
The classical literature of Chinese medicine remains highly relevant in the modern era, as many of the basic theories and herbal combinations emphasized in clinical practice were first established in texts that are nearly 2000 years old.
Medial Knee Pain: 11 Potential Causes (and Corrections)
We have all seen patients with medial knee pain that either has no traumatic origin or lasts well beyond when it should be resolved. How can we help these patients? Here is an overview of clinical scenarios and how we can provide conservative care.
Replenishing and Restoring Jing
I learned an important principle from my great Taoist Master Sun Hak. He taught me that all people "leak" Jing, and that we can mitigate or stop this leaking, and as a result strengthen our life force, develop enhanced adaptability and lengthen our life.
New Leadership Era at the WFC
The World Federation of Chiropractic recently announced not only a new president, as is customary every two years, but also an incoming secretary-general, marking the first time since the WFC's inception in 1988 that someone other than David Chapman-Smith, Esq., will serve in that capacity.
July, 2014, Vol. 14, Issue 07
Exploring the Anterior Pelvic Tilt
By Whitney Lowe, LMT
Lumbopelvic pain is a common complaint that is not always remedied with many standard low back pain treatments. For many people, some treatments have been helpful, but the condition still persists.Frequently, the pain problem exists because an underlying postural or structural deviation has not been properly addressed. One such postural problem that might be considered is an anterior pelvic tilt, which can contribute to lumbopelvic pain in a number of ways.
The upright posture and locomotion of humans poses biomechanical balance challenges for the pelvis. The weight and force loads of the upper body are transmitted and distributed to the two lower extremities through the pelvis. When the pelvis is not aligned properly numerous biomechanical problems result, which can be painful and debilitating. Let's take a look at what constitutes an anterior pelvic tilt, some of its detrimental effects, and what role massage can play in helping to resolve it.
For the sake of this discussion, the pelvis will be addressed as a whole, even though it is composed of two separate halves, called innominates. The left and right innominate can move independent of each other, but most postural distortions occur when the left and right halves are both out of alignment in the same direction.
An anterior pelvic tilt occurs when the pelvis rotates anteriorly in the sagittal plane. The sacrum is tightly wedged between the two innominates so when the pelvis tilts anteriorly, the sacrum moves with it. The sacrum is tightly bound to the L5 vertebra, which is bound to adjoining vertebra. When the sacrum tips forward, the lower lumbar vertebrae are subsequently tilted forward, creating an increase in the lumbar lordosis at the same time.
There is a natural degree of anterior tilt in the pelvis that is necessary for proper movement and shock absorption. When the degree of tilt is too much, it is considered a dysfunctional anterior tilt. However, it is difficult to get an accurate determination of the exact degree of anterior tilt without a goniometer. Consequently, many clinicians use approximate alignment references to determine if the tilt is excessive.
However, just because it is challenging to define the anterior tilt, doesn't mean we should ignore it. Although massage therapists may not have the training to make accurate goniometer measurements, there are some simple tips for determining if a pelvic tilt could be a contributing factor to a clients pain. One way to evaluate the tilt with visual examination is to look at your client from the side. Place one finger on the posterior superior iliac spine (PSIS) and the other finger on the anterior superior iliac spine (ASIS). If the ASIS is more than a half inch lower (and slightly more in females), this would be considered a dysfunctional anterior tilt (Figure 1).
A degree of lordotic curvature in the lumbar region is necessary for proper shock absorption in the spine. However, too much lordosis causes multiple problems. As the lordosis is increased, there is increased pressure on the facet joints of the spine (Figure 2). The increased facet joint compression can lead to pain, irritation and even early arthritic changes in the spine.
An increased lordosis is frequently caused by excessive hypertonicity in the lumbar extensor muscles. Tightness in this muscle group is both a cause and an effect of the exaggerated anterior tilt. The lumbar extensor muscles are often tight in conjunction with the iliopsoas in a postural pattern known as the Lower Crossed Syndrome (Chaitow, Delany vol 1, 2000). A vicious cycle of muscle tightness and postural distortion ensues because muscle tightness contributes to the anterior tilt and is perpetually reinforced as a postural pattern. Myofascial trigger points in the lumbar extensors are also likely to develop as a result of the chronic tightness.
The increased lordosis may also decrease the opening of the intervertebral foramen which could lead to nerve root compression in the area. The risk of nerve root compression is increased if there are bone spurs or other obstructions along the edge of the foramen which encroach on the nerve with the exaggerated lordosis.
Another detrimental effect of the anterior tilt occurs at the Sacroiliac (SI) joint. There is only a slight degree of movement at the SI joint. For the most part, this joint is tightly bound so that the sacrum and ilia on both sides are almost locked into position with each other. The anterior pelvic tilt alters the force loads at the SI joint and is a frequent cause of SI joint pain and dysfunction.
Most of these potential effects are somewhat obvious, but another one that is not quite as clear is the increased risk of hamstring strains. When the pelvis tilts anteriorly, the ischial tuberosity rises in a superior direction, putting greater tensile stress on the hamstring muscle group. The elevated tensile load can lead to an increased incidence of hamstring strains, especially in active individuals.
So, is there a role for massage therapy in addressing this problem? There is a role for soft-tissue treatment, but there is also controversy and misunderstanding in constructing the most helpful treatment plan.
One of the biggest mistakes that clinicians make in attempting to treat the anterior pelvic tilt is to over-simplify the treatment strategy. For example, if you look at a person with an exaggerated anterior tilt from the side, it would appear that the lumbar extensors are tight and the abdominal muscles are weak and elongated, which is true. The mistake comes in attempting to address this distortion by strengthening the abdominal muscles with standard abdominal muscle exercises like sit-ups or crunches performed with the feet rigidly held in position.
When the feet are held rigidly in place for a sit-up exercise, it is called a closed-kinetic chain exercise. Unfortunately, performing a sit-up in a closed kinetic chain position strongly recruits the iliopsoas muscle. Since tightness in the iliopsoas is a contributing factor with this condition, further strengthening is counter to the intended treatment goal.
The key goal in a treatment strategy for the anterior pelvic tilt is to reduce tightness in the lumbar extensor muscles and iliopsoas. In many cases, the abdominal muscles, which appear weak and overstretched, are not weak because they lack sufficient exercise, but are instead weak because they are being neurologically inhibited by the tight lumbar extensors (their antagonists). Reducing tightness in the lumbar extensors will often allow the abdominal muscles to resume a normal level of tonus. A variety of massage techniques can be directly aimed at the lumbar extensors to reduce their hypertonicity.
One of the biggest mistakes that massage therapists make when attempting to address an anterior pelvic tilt is to focus just on the soft-tissue treatment with the idea being that reducing the muscle tightness will restore the proper pelvic position. Unfortunately, that rarely occurs. Postural distortions like the anterior pelvic tilt have developed from chronic habitual reinforcement. Even if you perform excellent massage work on these muscles, the person is likely to quickly slip back into the postural distortion if certain habitual patterns are not addressed.
Dysfunctional postural patterns need to be changed by constant reinforcement of new and more correct postural adaptations. Certain treatment systems like Alexander Technique, yoga or Feldenkrais are aimed at improving awareness of posture and position in order to make changes and reduce dysfunctional positions. However, it isn't always imperative that the client adopt one of these practices.
Sometimes, it can be as simple as teaching new postural positions and encouraging the client to be aware of his or her own postural positions and to reinforce that change as much as possible. Having the client explore the ergonomics of his or her home and work activities is also important. Does their work set up inspire a slumped position at a desk? Do they stand a lot, could they put one foot up on a small block? Can they take more breaks for stretching and be shown good stretching solutions?
As clinicians, our goal is to understand each individual's biomechanical stresses as best we can so we can craft a reliable treatment strategy most likely to achieve beneficial results. At the same time, keep in mind that the presence of an anterior pelvic tilt is not a guarantee of any of the above adverse outcomes. There are people who have an anterior tilt that do not develop any issues. That is why it takes a thinking practitioner to determine when the pelvic tilt might be a contributing factor to a client's pain.
Click here for more information about Whitney Lowe, LMT.
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