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Treatment Tools

By Debbie Roberts, LMT

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Learning a Hands-Free Solution to Fix SI Dysfunction

We are a society of therapists geared to touch, feel and fix through fascia and muscles. We help facilitate better joint function by working our fingers to the bones. Have you ever worked and worked and the client still walked away in lumbar pain. If so, this article really is for you. I am going to share with you how to relieve SI dysfunction, provide better stabilization and not have to massage, knead or stretch tissue. Interested? But, don't hang up your hands just yet. You are still going to need them, just not in the usual sense with this principle of healing.

You know when you see a demonstration and it makes you scratch your head and wonder exactly how did that work? Well, that is how this article came into being. I was attending a fitness convention with a friend and in the list of workshops to choose from was a class titled, "Fixing SI Dysfunction." Of course, I was thinking what kind of fitness is going to fix an SI dysfunction? The gentleman teaching the class was a chiropractic physician. He asked for someone in the audience that had chronic lumbar pain to come forward and he would show how easy it is to help an SI dysfunction. My friend's son Robert, a trainer and ex-baseball player, fit the bill for the demonstration. The chiropractor assessed the SI and showed how Robert's SI joint was not stabilizing or closing in a one legged stance. The joint was functional in open chain but dysfunctional in closed chain.

His demonstration included showing us a bilateral comparison. It was obvious the side of dysfunction and it correlated with Robert's chronic pain side. Here is where the no hands approach comes in. He used breath work, visualization and isometrics to fix the dysfunction, not any form of hands on manipulation. When Robert stood up, a reassessment of the opening and closing of the SI joint was done and the SI joint was now functioning properly. Later that night and the next day, we asked Robert how he felt and he said there was no return of pain. I was sold and I needed to know how what appeared to be such a simple thing fixed a long standing chronic problem. So, I asked some questions, bought his book and found the importance of using principles and not methods.

yoga couple - Copyright – Stock Photo / Register Mark Method vs Principle

Do you know the difference between a method and a principle? A principle is a fundamental truth or proposition that serves as the foundation for a system of belief or behavior. There are hundreds of healing methods. In fact, when I researched it on many websites, there are sometimes 10 or more methods for every letter in the alphabet. Each healing practice is trying to create the same effect of better postural control, joint alignment, balance of the mind-body-spirit connection and relief of pain symptoms. What does acupuncture, ashiatsu oriental bar therapy, vitaflex, alexander technique, and bowen technique have in common? Well, they are all healing methods based on similar principles. Cross over into the exercise field and you see the very same thing with Cross Fit, kettle bells, the barre method, yoga and pilates again all based on similar principles. In both fields, we are going to see more and more different methods spring up so be aware. The new ones tend to replace the old ones with each trying to get the individual to their goals of better health and healing.  Everyone is looking for the one method that has all the answers instead of relying on the principle foundation these methods are born from. In fact, you're awareness of the basic principles will make any method you already have in your tool box better. Having a deeper understanding of the principles of human movement and rehabilitation will keep you alive and well in this ever changing healthcare stream.

The first principle to consider is the use of deep diaphragmatic breathing with the activation of the pelvic floor muscles to help reset the core musculature. In the absence of ideal respiratory patterns, the motor system will be forced to choose between respiration and stabilization, with preferential selection of the former (Hodges et al 2004). The diaphragm has an important role in stabilizing the core. It forms the top of the core canister with the internal and external obliques, quadratus lumborum, pelvic floor and transverse abdominus.

Proper breathing is a way of interrupting the "Fight or Flight" response or the overuse of the sympathic nervous system. When clients are over stimulated they recruit muscles in dysfunctional patterns. This can happen from sitting too long, an accident or injury, or a disease process. The loss of breathing from the belly and starting to breathe from the chest creates a core dysfunction and the wrong order of recruitment.

Exercise Example

Do the following exercise: Sit in a chair. Draw in your navel, now draw your shoulder blades back, now squeeze your glutes, hold your arms out at a 90 degree angle and start to type. How long would you last? A principle of recruiting the wrong muscles for the job is what you are learning here. This activity of sitting and typing should have been done by a low level activation of inner core muscles. By the habitual use of the body in this way day after day, sitting and not breathing properly, the deep core musculature gets replaced by muscles that are designed to move the spine not stabilize the spine.

The connection of how breath work effects SI function lies in understanding the Deep Facial Line. The DFL is the connection of psoas and the diaphragm just behind the kidneys, adrenal glands and the solar plexus, and just in front of the major spinal joint of the thoracolumbar junction. Also, connecting with the intervertebral discs of levels L1-L5, to attach to the lesser trochanter of the femur as well as blend into the pelvic floor. The junction of T12-L1 is a critical point of both stability and function in the human body. "The myofascial of the DFL is infused with more slow-twitch, endurance muscle fibers, reflecting the role the DFL plays in providing stability and subtle positioning changes to the core structure to enable the more superficial structures and lines to work easily and efficiently with the skeleton." (Tomas W. Myers, Anatomy Trains second edition.) The thoracopelvic canister joins the trunk with the bottom of the body and it functions to join breathing to walking.

Treatment Plan

The second principle to understand is the use of visualization. In the early 1900's, Mabel Todd developed an approach that is called "ideokinesis." Ideokinesis uses imagery and conscious thought patterns as ways to improve posture and habitual movement patterns. This concept was adopted and is still used within Feldenkrais, Alexander Technique, and many forms of athletics. And as a side bar, I use it with my stroke and Parkinson's patients.

Treatment plan for a SI dysfunction:

  1. Assess the function of the SI joint. You can do a standing or seated flexion test. Place your thumbs at the inferior aspect of the PSIS bilaterally. Have the client bend forward from the waist about 30 to 40 degrees. Observe the movement of the PSIS as the ilium moves on the sacrum. Restriction on one side will cause the iliosacral joint to lock prematurely on that side causing the PSIS to elevate sooner and probably farther than the PSIS on the other side.
  2. Assess in single leg stance. Place your thumb at the SI joint and the other hand on top of the ilium as the client goes into a single leg stance the fingers should move closer together indicating the joint is closing properly. If they move further apart this is showing a joint that is not closing properly.
  3. Assess how the client breathes. Are they using accessory muscles to raise and lower the rib cage and breathing in their chest and not their belly.
  4. Place the client in a supine position with their legs up approximately 19 inches or chair height. This will allow the pelvis to become even as you introduce the breath work.
  5. Begin the breath work with the client's hands over their ASIS and direct the breath there for at least three cycles of breath. Watch that they don't recruit other muscles to do the job of breathing.
  6. Next, move the client's hands over their ribs. Direct their breath in an outward direction expanding the rib cage. Do at least three cycles of breath.
  7. Next, move one of the client's hands over the belly button and then the other one in the small of the back. Direct the breath anterior to posterior opening the abdominal cavity. Do at least three cycles of breath.
  8. Have the client combine all three motions of breath down, out, anterior to posterior while visualizing the spine becoming long, the back muscles softening, the hips floating, and the shoulders sinking gently backwards. Be sure not to let them move body parts when you do the visualization. This is not about big recruitment of muscles this is about letting go.
  9. Have the client now do all three motions of breath and incorporate contracting the pelvic floor muscles. In women, this would be stopping the flow of urine, in men this would be pulling up the genitalia and holding for at least six seconds.
  10. You will now want to reactive psoas to do the right job, so using the thought process of non-movement to do the job. Lift a leg off the chair or whatever was used to prop the legs up with as if it was a feather place the leg back down repeat to the other side.
  11. Reassess the SI function and place the job of breathing properly as a home exercise to help keep the pelvic rhythm.

I have used these principles for more than just SI dysfunction. It will help with many forms of chronic pain. One of my students related they had used these principles for a very acute back spasm and the patient called the next day with amazement and relief of pain.

I want to leave you with a quote from Ralph Waldo Emerson that really made me think about the importance of the use of principles going forward as a massage and movement specialist: "As to methods there may be a million and then some, but principles are few. The man who grasps principles can successfully select his own methods. The man who tries methods, ignoring principles, is sure to have trouble."

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