BioMechanics Archives:: September 2005 Contact Point
Prolotherapy results inspire practitioner's curiosity
By Jerry Hesch
Reading the news article on prolotherapy ("Prolotherapy relieves groin pain in study of soccer, rugby players," June, page 11), I felt compelled to share some comments. Though limitations of the study cannot be adequately ascertained given the brevity of the article, the short-term results are very impressive. Prolotherapy, using lidocaine for analgesia and dextrose as a proliferant, over the course of 17 months resulted in significant reduction in pain and return to painfree sports participation at full capacity in 20 of 24 participants. Two subjects were not able to return full capacity and two had pain when participating. The use of lidocaine with a proliferant is supported by the results, but the lack of a control group means we cannot separate the different mechanisms of action. The athletes who did not achieve a successful outcome may experience some degree of disability, which is likely to spill into other facets of their lives. I have firsthand knowledge of abdominal neuropathies, having sustained a pelvic fracture and multiple ANs due to a severe motorcycle accident. I submit that the possibility of such neuropathies is worth considering for those who have lasting disability and unresolved groin pain. Successful ablation of the genitofemoral and accessory obturator nerves has not resulted in sensory loss in my personal experience, yet did provide substantial pain relief, along with improvement in function. (In researching my own neuropathies I have not had any success locating studies on the use of fibrinogen/fibrin glue for prolotherapy, yet the mechanism of action appears to be consistent with the goals of prolotherapy. I would be grateful to hear if anyone is performing research with this application.) Extreme pain, even if a screen for inguinal hernia is negative (no bulge), can imply an ilioinguinal neuropathy. Pressure above the inguinal ligament may refer to the medial calf and is easily confused with a coexisting S1 radiculopathy when in fact the dysesthesia may be mediated by the terminal saphenous portion of the femoral nerve. Response to the same pressure can skip the proximal thigh and cause a diffuse sense of warmth in the foot. Cautious digital pressure on the scrotal contents can be revealing in the presence of genitofemoral AN. Other-less common-hernias, such as at the obturator foramen, should be ruled out. Referral to a genitourinary or surgical specialist is warranted for recalcitrant groin pain. The proximity of the hip joint mandates traditional screening and a standard medical workup to rule out common and occult pathologies for patients with chronic groin pain. The concluding quote of the news article: "Treating immature athletes (for Osgood-Schlatter disease with prolotherapy), who in the past have been asked to stop playing for two months, for the first time will emphasize healing the cartilage attachment and patellar tendon prior to the formation of an ossicle," seems rather ambitious, given that the study is presently in search of funding. Although briefly mentioned in that final paragraph, I would like to request elaboration on how the goals of prolotherapy are different from other standards of care for Osgood-Schlatter disease, such as those of the American Academy of Orthopaedic Surgeons or the American College of Sports Medicine. I thank the authors for sharing their impressive study, which motivates me to express my gratitude to all authors and inquisitive clinicians, to dialogue, review the literature, and, lastly, to remain hopeful.
Jerry Hesch, MHS, PT Henderson, NV
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Regional Interdependence
Published in August 2008 PT Advance Magazine
Dear Editor,
I enjoyed the article Investigating a new model of assessing musculoskeletal disorder by Brent Swartzlander, DPT, OCS, in the August 11, 2008 edition. The concept of "Regional Interdependence" may be an old concept which of recent times is being expounded upon, yet unfortunately, it surely is not part of normative Physical Therapy practice, except in the minority. The term of course is fairly recent, and I suspect only used in the first of 20 references used for the article. I submit that as we are early in our use of the terminology, that it may undergo some enhancement over time. What is to be celebrated is the fact that are an increasing number of case studies and articles that demonstrate benefit from utilization of the concept, such as thoracic mobilization enhancing cervical function and decreasing pain, etc.. I believe that in time the term Regional Interdependence may evolve; perhaps a new term would be Interregional Interdependence. Why? Because distal regions of the body, rather than only proximal regions, do in fact interact. One example, a treatable anterior talus on the right (this mimics left rotation of lowest segments) will invoke a right rotation of C1, with a typical motion compensatory coupling at Occiput-C1. This is reflexively driven, as treatment of the primary problem in the foot and ankle can be manually resolved, and the upper cervical pattern will be significantly improved upon retesting. This reflex distal release occurs instantaneously, before the client stands, thus it is not gravity dependant. On occasion, a part of the cervical pattern will tend to recur, and may require specific treatment. An alternate name might be Interregional Interdependence Permutation Model. Why? Because the body does undergo permutation during the course of treatment, thus the body responds in a very counter-intuitive manner, in which what you see on initial examination is in fact, not what you get as you start to treat proximal to distal, inferior to superior, etc. For example, upon restoring normal costo-vertebral mobility at one segment, the compensatory restriction on the opposite side of the body at a superior segment may spontaneously resolve, yet the corresponding thoracic segment may then present anew, with restricted mobility, not encountered initially. Noteworthy is the fact that the body can have different restrictions of the
musculoskeletal system in different positions. Thus it is important to evaluate the structures in neutral weight bearing (WB) and in flexion and extension WB, in non weight bearing extension and flexion, etc. One of the most relevant postures is "Muslim Prayer Position", in which the entire spine, pelvis and lower extremities are fully flexed. This posture often reveals restrictions that are not noted in other positions or contexts. So perhaps a working model might be titled the Interregional Multiple Context Postural Model. How nice it would be if all case studies and research articles mentioned the proximal and distal compensations and adaptations to the primary musculoskeletal dysfunction, which is the primary focus of stated article. It is somewhat surprising that at present, this is extremely rare. Thank you for allowing me to share my thoughts.
Sincerely,
Jerry Hesch, MHS, PT
Talus (Talocrural Joint) Mobilization
not published, I never completed it, so did not submit in a timely manner
RE: Landrum E, Kelln Cdr B.M., Parente W. R., Ingersoll C. D., Hertel J. Immediate Effects of Anterior-Posterior Talocrural Joint Mobilization After Prolonged Ankle Immobilization: A Preliminary Study. J Man & Manip Ther 16(2):100-105.
Dear Editor,
RE: Landrum E, Kelln Cdr B.M., Parente W. R., Ingersoll C. D., Hertel J. Immediate Effects of Anterior-Posterior Talocrural Joint Mobilization After Prolonged Ankle Immobilization: A Preliminary Study. J Man & Manip Ther 16(2):100-105.
This study is very encouraging for a variety of reasons. I am delighted that it is a preliminary study, as there is so much potential for enhancements with future studies. While I am not a researcher, I do enthuse about the topic of the study.
Future study with the use of a control group that receives only the instrumented ankle arthrometer (IAA) would allow determination of whether or not the IAA had a treatment effect in enhancing ankle dorsiflexion.
The IAA could be applied to the posterior calcaneus only, in order to tease out some data on the role of anterior glide of the calcaneus. It is my belief that anterior glide of the calcaneus is a very important part of the procedure used to restore posterior glide of the talus with the end result of increased ankle dorsiflexion. It appears to add a sagittal rotational element to the calcaneus and therefore the talus.
The IAA seems to be a relevant tool that can be applied to many structures throughout the body to research appropriate forces for optimal joint mobilization. It might also be used to evaluate joint laxity and hypomobility throughout the body.
The treatment applied to the talus is described as Anterior to Posterior Glide of the Talus (APGT). It is referenced in 6 studies mentioned in the above article. I have recently struggled over this terminology. The term APGT seems appropriate if one is describing what they are performing directly to the talus alone. Yes, the specific force I apply to the talus is appropriately called APGT. It also seems appropriate when one looks at the anatomy of the distal tibia, which articulates with the dome of the talus. In the sagittal plane, the distal tibia is fairly flat, having only a mild anterior-posterior concavity. I am hard pressed to find an adequate picture demonstrating that, having looked in several clinical textbooks. I easily find pictures that demonstrate the significant convexity of the dome of the talus. My anatomical model came to the rescue and it demonstrates that the dome of the talus makes only a relatively small amount of contact with the distal tibia*, and that the contact points on each bone changes throughout the range of dorsiflexion and plantarflexion. At present, A-P or P-A glide of the talus is a theoretical construct lacking hard data. Perhaps glide and roll would be more appropriate. In time I hope to pursue this question via literature research. I submit that mobilizing the distal tibia on the talus can be described as a glide, when the force is A-P or P-A.
*Neumann made this point in a brief general statement comparing contact surface areas for the ankle, knee and hip.
Sincerely Yours,
Jerry Hesch
Not published, submitted, though I did not pursue revision recommendations Cervical Pain Thoracic Manipulation Dear Editor,
RE: Krauss J, Creighton D, Ely J. D., Podlewska-Ely J. The Immediate Effects of Upper thoracic Translatoric Spinal Manipulation on Cervical Pain and Range of Motion: A Randomized Clinical Trial. J Man & Manip Ther 16(2):93-99.
The recent article provoked some thoughts I would like to share. The authors are to be commended for adding to the knowledge base by showing cervical pain reduction and cervical motion gains, in clients treated with thoracic manipulation. This is an important relationship and this study, along with other similar ones, should guide contemporary practice. In the discussion section the authors mentioned several ideas for future studies on the same topic. I would like to add to that list. The relationship of the costal joints to thoracic and cervical spinal motion might be appropriate for inclusion in future studies. It seems plausible that the authors may be altering rib mobility with thoracic manipulation. Alternately, there may be cases in which rib mobilization is a necessary antecedent to successful thoracic mobilization. The ribs form a joint with the thoracic segments which has been detailed by several authors. (Neumann Levangie) and treatment directed to the rib joints has been described (Flynn, dvorac) . The costo-transverse and costo-corporal joints are very close to the thoracic facet joints, particularly at the 3rd thoracic segment, per direct observation Future studies could evaluate rib mobility before and after thoracic mobilization to determine whether or not direct rib mobilization is necessary, and then evaluate the influence on cervical pain and mobility.
Thank you very much.
Sincerely Yours,
Jerry Hesch, MHS, PT
jerryhesch@cox.net
POSTERIOR GLIDE OF HIP STUDY (ABSTRACT FOLLOWS LETTER BELOW)
Letter not accepted for publication Hesch Seminars - Jerry Hesch, PT
8228 Willow Cabin St www.HeschMethod.com Las Vegas, Nevada 89131-1438 email:Jerryhesch@Ivcm.com
(702) 655-9597 hm/office (702) 561-0143 cell phone
Letter not accepted for publication
April 3, 2003
Guy G. Simoneau, PT, PhD, ATC Editor-in-Chief
J of Orthopedic & Sports Physical Therapy
1111 N. Fairfax St. Suite 100Alexandria, VA 22314-1436
RE: Linn Harding, Mary F. Barbe, Amy Marks, Raymond Ajai, Jennifer Lardiere, Heather Sweringa, Katherine Shepard
Posterior-Anterior Glide of the Femoral Head in the Acetabulum: A Cadaver Study
J Orthop Sports Phys Ther. 2003;33:118-125.
Dear Editor-in-Chief,
I would like to express my appreciation to the authors of the above study. As a former manual therapy clinician and a manual therapy educator, I find the study to be very relevant. In November I was teaching a seminar n the sacroiliac joint pelvis, and lumbar spine. I demonstrated how a client can present with a significant reduction of hip extension with concommitant positive tests for sacroiliac dysfunction. This includes altered pelvic landmarks in standing, a positive March test, and a positive Standing Flexion Test; yet the crux of the problem is in the hip. I made the comment that this pattern presents as though the head of the femur were stuck in flexion and posterior glide, yet I could not envision the hip as having much posterior glide available, based on my understanding of the joint. However, anterior glide passive motion testing revealed hypomobility, in addition to-the loss of active and-passive hip extension. A generalization can be made stating that the shaft of the femur is a bowed structure in the sagittal plane, and is convex anteriorly. In supine' a client with a purported posterior glide fixation will present with the hip in some degree of flexion, such that the greatest portion of the femur appears to more anterior than the contralateral femur, except at the most superior portion. The correction involves anterior glide and gentle stretch into extension, typically with the client in prone, with the knee flexed. This treatment is often very effective in a short period of time, typically 2-3 minutes. The standing pelvic landmarks are then much improved and the standing sacroiliac motion screening tests are typically rendered negative; hence, they were previously false positive.
This study is relevant because manual therapists evaluate anterior and posterior glide of the femur, and alteration of those accessory motions, along with reduced hip extension, can be associated with false positive sacroiliac screening tests. Recent studies have suggested that these standing sacroiliac motion tests do not actually provoke any significant motion within the sacroiliac joints, and other structures are implicated.1, 2 Perhaps this is simply a pattern of
maintained shortening of the hip flexors, and treatment via anterior glide of the hip may be unnecessary. I look forward to evaluating this possibility.
The authors dedicated more than a full page to the section titled: Limitations of Study and Recommendations for Future Research. I believe that they did an excellent job of utilizing objective thinking in this section and it may be very useful for future studies. I was surprised at the degree of excursion of the femoral head with distraction in loose pack position. I believe that there are clinical ramifications worthy of further study.
I was also surprised at the amount of force utilized in the study (up to 356 Newtons). I have described up to 176 Newtons for spring testing the ilium, and lesser forces at the sacrum, ischium and symphysis pubis.' If further study on hip mobilization is performed on living subjects, I believe that pilot testing will reveal that much smaller forces are necessary, in order to avoid pain provocation.
Again, I believe that the research and the article were very well executed, and are very relevant to manual therapists. Thank you.
Sincerely Yours,
Jerry Hesch, PT
The Hesch Method Sacroiliac Seminars
1. Sturesson B, Uden A, Vleeming A. A radiostereometric analysis of movements of the sacroiliac joints during the standing hip flexion test. Spine. 2000;25(3):364-368.
2. Egan D, Cole J, Twomey L. The standing forward flexion test: an inaccurate determinant of sacroiliac joint dysfunction. Physio.1996;82(4):236-242.
3. Hesch J. The most common patterns of sacroiliac joint dysfunction. In: Movement, Stability & Low Back Pain: the Essential Role of the Pelvis. Vleeming A, Mooney V, Dorman T, Snijders C, Stoeckart R, eds. New York, NY: Churchill Livingstone; 1997.
Posterior-Anterior Glide of the Femoral Head in the Acetabulum: A Cadaver Study
Linn Harding, Mary F. Barbe, Amy Marks, Raymond Ajai, Jennifer Lardiere, Heather Sweringa, Katherine Shepard
Study Design: Descriptive study employing cadaver dissection and measurement of posterior-anterior (PA) glide of the femoral head in the acetabulum. Objective: To quantify PA glide of the femoral head in the acetabulum in a cadaveric sample. Background: Posterior-anterior glide of the femoral head within the acetabulum is a joint mobilization procedure described in orthopaedic physical therapy texts, yet there is no published evidence that the joint structures of the hip allow such movement. This study attempted to quantify PA glide of the femoral head in the hip joints of embalmed cadavers. Methods: Twelve hips, 3 male and 9 female, from 8 embalmed cadavers were employed in this study. Hips were dissected to the level of the joint capsule and a metal rod inserted through the femoral neck served as a mobilizing handle. A load cell was installed into this handle so that mobilizing forces could be monitored. A dial gauge, which recorded displacement of the femoral head, was mounted to the pelvis via bone pins and an external fixator. Results: Using mobilizing forces of 89, 178, 267, and 356 N, mean femoral head displacements of 0.57, 0.93, 1.20, and 1.52 mm were recorded. Within the 89-N trials, PA displacement ranged from a minimum of 0.04 mm to a maximum of 1.54 mm. Within the 356-N trials, PA displacement of the femoral head ranged from a minimum of 0.25 mm to a maximum of 2.90 mm. Conclusion: In an embalmed cadaveric model, measurable PA glide of the femoral head within the acetabulum does exist and it is highly variable between individuals.
J Orthop Sports Phys Ther. 2003;33:118-125.
Key Words: accessory movement, cadaver hip joint, joint mobilization, posterior-anterior glide
TROCHANTERIC BURSITIS PROTONICS
Published in J of the Section on Women’s Health 27:3, December 2003
Letter to the Editor
Dear Editor,
This letter is in response to the article titled "Management of a Woman Diagnosed with Trochanteric Bursitis With the Use of a Protonics® Neuromuscular System" from Volume 2, 1:12-16, April 2003 issue of JSOWH. The stated purpose was to describe a woman with trochanteric bursitis who had 3 physical therapy visits which focused on achieving neutral pelvic position via unilateral hamstring recruitment using a Protonic® Neuromuscular System. The authors are to be commended in significantly reducing the signs and symptoms in 2 visits which were 6 weeks apart. The next visit a year later revealed that the client was significantly improved from the symptoms that had plagued her for 2 years. In the conclusion they state: "Attention to pelvic positioning using the Protonics® resulted in successful outcomes for this woman with trochanteric bursitis." This is such an important case report because it raises many issues.
I appreciated the author's theoretical development of the problem of trochanteric bursitis in the introduction section of the article. In the section titled Purpose the authors' state that "The theory behind the case was that the trochanteric bursa was irritated and compressed by the ITB because of the asymmetrical pelvic position and restoring a position of symmetry would abolish the symptoms." A detailed evaluation was performed and I will focus on several positive findings. Hip rotation was measured in sitting and the difference noted was 5° (20 left versus 25° of external rotation). Assuming a possible standard 5% error rate the actual difference might actually be 2.5°. In addition to observing a possible functionally shortened left lower extremity, 6 special tests were pictured and described as "being used to assess pelvic femoral position." The tests are: the Ober Test (bilaterally positive, more so left), and Modified Ober, Thomas Test and Modified Thomas Test (positive left), and supine Left and Right Lower Trunk Rotation (restricted to the left). These findings were purported to suggest a left anteriorly rotated inominate (ilium). The focus of the case was stated, which was "to correct faulty mechanics through the kinetic chain by correcting the pelvic asymmetry to a neutral position." An alternate explanation could be that the limitation of left lower trunk rotation could be due to limited left hip abduction/flexion/external rotation or the opposite motion in the right hip, or both instead of the lower trunk, though it was not discerned. It is certainly surprising and perhaps controversial, that no attempt was made to directly evaluate the strength and endurance or facilitation/inhibition of the muscle group that was targeted for strengthening or recruitment. No attempt was made to compare it to the asymptomatic side prior to and after intervention.
I struggle with the author's conclusion of an anterior left ilium based on the hip and trunk tests mentioned. Several of the books referenced in the article contain chapters detailing evaluation of the sacroiliac (SIJ/SIJs), hips, and pelvis (as a unit). In this study, there was no observation of the pelvic posture, which is typically performed anteriorly and posteriorly in the following postures: standing, sitting, supine, and prone. I believe that
confusion has surrounded the pelvic structure and a brief survey of the writings in our own profession and in others will affirm this. The SIJ joint has 5/6 synovial characteristics and therefore should be evaluated in the same manner as other synovial joints. Many passive motion tests (spring tests) have been developed or adopted and modified for grading passive accessory motion of SIJ joints and symphysis pubis, and thettraditional palpatory evaluation has also been expanded upon.' The pelvic evaluation described in the article literally shies away from direct palpation, direct observation, and direct motion testing of the pelvis and SIJ, instead utilizing rather indirect hip and lower trunk motion, and hip muscle length tests. The author's did state that these tests were "thought to suggest an anteriorly tilted, forwardly rotated, left l inominate and a left femur that moved with it into passive internal rotation." Since this is a distinct departure from the norm of SIJ/pelvic evaluation, additional details explaining the rationale are certainly warranted. On that basis I reviewed the only study from the article that addressed this issue via research.' This was a student project with a sample of 10 measuring pelvic angle with an inclinometer before and after intervention with the Protonics® strengthening device. The mean anterior pelvic tilt was 19.9° (SD=6.9). Five subjects experienced a change of 3.2° (SD=5.3) of unilateral pelvic tilt and 2 subjects experienced worsening of anterior ilium and the 3 remaining were unchanged. While changes were determined to be significant, it is important to interpret these results in terms of clinical practice and ask if 3.6° of change is clinically relevant. The study might be judged as weak on this basis along with the small sample size. Unfortunately, pilot testing was not performed to determine the degree of intratester reliability, thus the measurements are in question. The authors brought this relevant topic to the forefront, by performing a relevant first study and these issues can be addressed in a future study.
Perhaps this nondirect approach may stem from the fact that. multiple studies since the mid 1980s have shown poor inter and intra-tester reliability with respect to palpation and with gross motion testing of the SIJ via the traditional paradigm. Further-more, recent studies have shown that the standing motion tests and manipulation do not actually induce any significant motion in the SIJ joint itself, though no doubt the pelvis itself may move as a unit in tri-dimensional space.''' These studies may be discouraging to clinicians who only use the traditional motion tests and do not utilize direct passive motion testing. Fortunately, there is an approach that appears to be an improvement over the traditional approach. This approach utilizes a few additional land-marks for palpation which is performed in stable postures and also utilizes passive motion testing to grade mobility on a 6-point scale.5.6 The findings with palpation and passive motion testing when Anterior Ilium is present; are not subtle. Furthermore, in the presence of Anterior Ilium, several directions of motion would present as distinctly hypo mobile and the opposite directions would present as hyper mobile. Anterior Ilium is a motion dysfunction that occurs in all 3 planes of the body and evaluation and treatment must address all 3 planes. Motion does occur in the SIJs with passive motion testing as demonstrated with fluoroscopy.' Additionally, recent research demonstrates greater than 70% intratester agreement with most of the palpatory and passive motion tests taught by the new paradigm.' This approach acknowledges the probability that SIJ motion restriction is often due to an external restrictor such as posture of the pelvis or deep muscle guarding; which restricts movement from going through the joint, as opposed to motion restriction occurring only within the joint.
The authors in the case study used a Protonics® device to strengthen the hamstrings in order to address the pelvic posture. While studies have shown that the hamstring muscle can restrict motion in the SIJ, it typically occurs at end range, such as with straight leg raising.' In performing the literature review of the Protonics® device the authors reviewed several impressive studies that used the device for patellofemoral pain. However, without detailing any statements from the studies regarding improved pelvic position, the following conclusion was made: "From these 2 studies, the Protonics® System appears to be beneficial in managing patients with patellofemoral syndrome via repositioning of the pelvis and femur Pelvic and femur repositioning may have application for individuals having trochanteric bursitis." If the studies which were referenced reached these conclusions, it was not evident from reading the article. It would be ideal to reference the studies with more detail in order to adequately under gird the conclusions. I reviewed Timm's impressive study (referenced in case study) on patellofemoral pain."' While there was statistically significant improvement in patellar alignment and a decrease in pain, there was no speculation whatsoever regarding ilium position. It is also possible that repositioning of the patella itself, or repositioning of only the femur, or both, excluding the ilium; could also be implicated.
It is intriguing indeed that at the end of the 1st visit 3 special tests were rendered negative. In future studies it would be interesting to deter-mine how long these benefits are maintained. It would appear that the results achieved in the first 6 weeks may be due to the intervention; of course this retrospective case study could not by its very nature, be rigidly controlled. It is very difficult, however, to ascribe all or even the majority of benefits between 6 weeks and 52 weeks to the treatment paradigm, as there are simply too many confounding variables. Additional details on the presence or absence of potential intervening variables and control thereof would strengthen the case study. Nonetheless, the case report is not to be discounted and certainly gives direction for future study.
As a disabled PT with former episodes of SIJ dysfunction, I would require any treating clinician (especially Physical Therapists) to directly evaluate position and mobility of the pelvic structure rather than rely only on tests that have a greater emphasis on hip mobility and hip muscle length. I would require that the structure be evaluated in neutral, and at end range flexion and extension of the lumbar spine and hips. I would also require that strength, endurance, facilitation, and inhibition be evaluated in the involved side and be compared to the non-symptomatic side before purchasing a strengthening device. I compliment the authors for addressing pain and function and passive motion tests of the hip and in publishing their case report so that debate can occur. I am motivated to learn more about the Protonics® brace and how it can be appropriately utilized in our profession, especially with regards to patellofemoral pain. Thank you for allowing me to share my thoughts and concerns.
Sincerely yours, Jerry Hesch, PT
Founder, the Hesch Method of Treating SIJ Dysfunction
http://www.heschmethod.com
REFERENCES
1. Hesch J. Evaluating sacroiliac joint play with spring tests. J Ob Gyn PT. 1996;20 (3) :4-7.
2. Antoun N, Kerns K, Kramer A, et al. The influence of the Protonics® knee brace on pelvic position. Research Reports 2000. Loma Linda, Calif: School of Allied Health Professionals; 2000:21-36.
3. Tullberg T, Blomberg S, Branth B, et al. Manipulation does not alter the position of the sacroiliac joint. Spine. 1998;23(10): 1124-1129.
4. Sturesson B, Uden A, Vleeming A, et al. A radiosterometric analysis of movements of the sacroiliac joints during the hip flexion test. Spine. 2000;23 (3) :364-368.
5. Hesch J. The Hesch Method of Treating Sacroiliac Joint Dysfunction. Course workbook. Las Vegas, NV: 2002.
6. Hesch J. Evaluation and treatment of the most common pattern of sacroiliac joint dysfunction. In: Movement, Stability and Low Back Pain: the Essential Role of the Pelvis. Vleeming A, Mooney V, Dorman T, et al. London: Churchill Livingston; 1997:535-545.
7. Bernard T. The sacroiliac joint as a source of low back pain: an orthopedic perspective. Video presentation.. Presented at The First Interdisciplinary World Congress on Low Back Pain and the Sacroiliac Joint.
November 6, 1992, San Diego, CA.
8. Olson L, Kramer T. Establishing the reliability of the hesch method's spring and positional tests in patients with low back pain. Presented at World Physical Therapy Congress. June 8, 2003, Barcelona, Spain.
9. Vleeming A, Stoeckart R, Snijders CJ. The sacrotuberous ligament: a conceptual approach toits dynamic role in stabilizing the sacroiliac joint. Clin Biomec. 1989; 4:201-203.
10. Timm KE. Randomized controlled trial of Protonics7 on patell,tr pain, position, and function. Med Sci Sports Exercise 1998; 30(5):665-670.