Pelvic Postural Asymmetry Revisited
http://www.100md.com
《美国整骨期刊》
Phoenix, Arizona
I enjoyed reading the original contribution "Prevalence of Frontal Plane Pelvic Postural Asymmetry—Part 1," by Juhl et al in the October 2004 issue of JAOA—The Journal of the American Osteopathic Association (J Am Osteopath Assoc. 2004;104[10]:411–421). I found the article to be both insightful and informative, and I wish to present additional diagnostic and treatment information regarding pelvic postural asymmetry that I have found helpful in my practice.
I have observed that the os coxae sometimes contains intraosseous strains, making the innominate assume the distorted shape of a "bent wheel." These distortions usually originate along the developmental junctures of the ilium, ischium, and os pubis. All three of these bones unite at the acetabulum and at the iliopubic and ischiopubic junctions.
I have also observed that intraosseous strains affect not only the width and depth of the pelvic structure on the side of the strain. They can also affect the flaring of the lower extremity (a crucial factor in tracking while walking) and the depth of the acetabulum (an important factor in leg length and in developmental dysplasia of the hip in infants).
I have discovered an easy and effective diagnostic method for assessing the degree of pelvic asymmetry. It involves the use of two landmarks: (1) the pubic tubercle, and (2) the inferior aspect of the anterior superior iliac spine. One performs this assessment after normalizing pubic and sacroiliac mechanical malalignments. I usually place my thumb on the pubic tubercle and my index or middle finger under the anterior superior iliac spine to compare the relationships between these landmarks.
I offer the figures on page 425 for your consideration. Figure 1 shows a normal pelvic structure, with width and height symmetrical on both sides of the structure. Figure 2 shows a pelvic structure with less height on the left side. Figure 3 shows a structure with greater width on the right side. These figures exaggerate the magnitude of the typical pelvic asymmetry condition and are offered only to illustrate the osseous aspect of the somatic dysfunction involved in pelvic asymmetry.
Effective treatment of such asymmetric conditions consists of removing the intraosseous strain and normalizing the shape and symmetry of the right and left innominate bone. Many methods exist to achieve this normalization, but I usually find that myofascial release, peripheral application of the cranial concept, or neurofascial release are the most effective.
Although I have found this normalization to be efficacious for leg length discrepancies, many of my patients have also reported improvements in pelvic organ function in various conditions, including irritable bladder syndrome, irritable bowel syndrome, painful menses and other menstrual conditions, recurrent cystitis, and dyspareunia.
Response
John H. Juhl, DO
Ostrow Institute for Pain Management New York, NY
Dr Davidson's letter describes an approach to physical examination and treatment that begins with an evaluation of intraosseous strains after having normalized pubic and sacroiliac mechanical malalignments. Physical examination is the sine qua non of osteopathic medical theory and practice. Our article1 concerns itself with the statistical evaluation of a series of standing lumbosacral radiographs. The degree to which such radiographic images can be used to support the concept of the osteopathic lesion has long intrigued researchers in osteopathic medicine.2,3
Apparent differences in the dimensions of the hemipelvis as seen in radiographic images can be due to rotation about oblique, transverse, or vertical axes, variations in the size or shape of a bone, or different relationships between bones that move on each other.4 Studies, including those documented by Travell and Simons,5 based on physical examination of patients and skeletons, have shown that physical asymmetries in hemipelves exist. Travell and Simons5 reviewed literature on the small hemipelvis in both volumes of their work, but they did not differentiate bony intraosseous asymmetries from bony intraosseous strains.
I am not ready to make correlations between pelvic patterns of asymmetry on standing radiographic films and patterns of somatic dysfunction. We plan to address this topic in part 2 of our study. The more correlations between radiographic and physical examinations can be elucidated, however, the more firmly our understanding of somatic dysfunction and compensatory patterns can be linked into an evidence-based format.
The radiographic information on pubic displacement from the midline and the relative measurements from the pubic tubercle to the inferior aspect of the anterior superior iliac spine may be useful, but this information was not collected in our database. We collected measurements we described as "standing hemipelvis" and "seated hemipelvis," which we also plan to discuss in part 2 of our study.
I look forward to additional light being shed on these issues by Dr Davidson and other authors.
Footnotes
As the premier scholarly publication of the osteopathic medical profession, JAOA—The Journal of the American Osteopathic Association encourages osteopathic physicians, faculty members and students at osteopathic medical colleges, and others within the healthcare professions to submit comments related to articles published in JAOA and the mission of the osteopathic medical profession. The JAOA's editors are particularly interested in letters that discuss recently published original research.
Letters to the editor are considered for publication in JAOA with the understanding that they have not been published elsewhere and that they are not simultaneously under consideration by any other publication.
All accepted letters to the editor are subject to copyediting. Letter writers may be asked to provide JAOA staff with photocopies of referenced material so that the references themselves and statements cited may be verified.
Readers are encouraged to prepare letters electronically in Microsoft Word (.doc) or in plain (.txt) or rich text (.rtf) format. The JAOA prefers that letters be e-mailed to jaoa@osteopathic.org. Mailed letters should also be sent electronically, in one of the aforementioned electronic formats on an IBM-compatible CD or a 3 -inch disk, and addressed to Gilbert E. D'Alonzo, Jr, DO, Editor in Chief, American Osteopathic Association, 142 E Ontario St, Chicago, IL 60611-2864.
Letter writers must include their full professional titles and affiliations, complete preferred mailing addresses, day and evening telephone numbers, fax numbers, and preferred e-mail addresses. Authors are responsible for disclosing financial associations and other conflicts of interest.
Although JAOA cannot acknowledge the receipt of letters, a JAOA staff member will notify writers whose letters have been accepted for publication. Mailed submissions and supporting materials will not be returned unless authors provide self-addressed, stamped envelopes with their submissions.
All osteopathic physicians who have letters published in JAOA receive continuing medical education (CME) credit for their contributions. Writers of original letters receive 5 hours of AOA Category 1-B CME credit. Authors of published articles who respond to letters about their research receive 3 hours of Category 1-B CME credit for their responses.
Although JAOA welcomes letters to the editor, readers should be aware that these contributions have a lower publication priority than other submissions. As a consequence, letters are published only when space allows.
References
2. Beilke MC. Roentgenological spinal analysis and the technic for taking standing x-ray plates. J Am Osteopath Assoc.1936; 35:414 -418.
3. Pearson WM. Survey of 200 weight bearing X-ray studies. J Osteopathy.1938; 45:18 -21.
4. Denslow JS, Chace JA. Mechanical stresses in the human lumbar spine and pelvis. J Am Osteopath Assoc.1962; 61:705 -712.
5. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Two Volume Set. 2nd ed (vol 1), 1st ed (vol 2). Baltimore, Md: Lippincott Williams and Wilkins;1992 .(Stephen M. Davidson, DO)
I enjoyed reading the original contribution "Prevalence of Frontal Plane Pelvic Postural Asymmetry—Part 1," by Juhl et al in the October 2004 issue of JAOA—The Journal of the American Osteopathic Association (J Am Osteopath Assoc. 2004;104[10]:411–421). I found the article to be both insightful and informative, and I wish to present additional diagnostic and treatment information regarding pelvic postural asymmetry that I have found helpful in my practice.
I have observed that the os coxae sometimes contains intraosseous strains, making the innominate assume the distorted shape of a "bent wheel." These distortions usually originate along the developmental junctures of the ilium, ischium, and os pubis. All three of these bones unite at the acetabulum and at the iliopubic and ischiopubic junctions.
I have also observed that intraosseous strains affect not only the width and depth of the pelvic structure on the side of the strain. They can also affect the flaring of the lower extremity (a crucial factor in tracking while walking) and the depth of the acetabulum (an important factor in leg length and in developmental dysplasia of the hip in infants).
I have discovered an easy and effective diagnostic method for assessing the degree of pelvic asymmetry. It involves the use of two landmarks: (1) the pubic tubercle, and (2) the inferior aspect of the anterior superior iliac spine. One performs this assessment after normalizing pubic and sacroiliac mechanical malalignments. I usually place my thumb on the pubic tubercle and my index or middle finger under the anterior superior iliac spine to compare the relationships between these landmarks.
I offer the figures on page 425 for your consideration. Figure 1 shows a normal pelvic structure, with width and height symmetrical on both sides of the structure. Figure 2 shows a pelvic structure with less height on the left side. Figure 3 shows a structure with greater width on the right side. These figures exaggerate the magnitude of the typical pelvic asymmetry condition and are offered only to illustrate the osseous aspect of the somatic dysfunction involved in pelvic asymmetry.
Effective treatment of such asymmetric conditions consists of removing the intraosseous strain and normalizing the shape and symmetry of the right and left innominate bone. Many methods exist to achieve this normalization, but I usually find that myofascial release, peripheral application of the cranial concept, or neurofascial release are the most effective.
Although I have found this normalization to be efficacious for leg length discrepancies, many of my patients have also reported improvements in pelvic organ function in various conditions, including irritable bladder syndrome, irritable bowel syndrome, painful menses and other menstrual conditions, recurrent cystitis, and dyspareunia.
Response
John H. Juhl, DO
Ostrow Institute for Pain Management New York, NY
Dr Davidson's letter describes an approach to physical examination and treatment that begins with an evaluation of intraosseous strains after having normalized pubic and sacroiliac mechanical malalignments. Physical examination is the sine qua non of osteopathic medical theory and practice. Our article1 concerns itself with the statistical evaluation of a series of standing lumbosacral radiographs. The degree to which such radiographic images can be used to support the concept of the osteopathic lesion has long intrigued researchers in osteopathic medicine.2,3
Apparent differences in the dimensions of the hemipelvis as seen in radiographic images can be due to rotation about oblique, transverse, or vertical axes, variations in the size or shape of a bone, or different relationships between bones that move on each other.4 Studies, including those documented by Travell and Simons,5 based on physical examination of patients and skeletons, have shown that physical asymmetries in hemipelves exist. Travell and Simons5 reviewed literature on the small hemipelvis in both volumes of their work, but they did not differentiate bony intraosseous asymmetries from bony intraosseous strains.
I am not ready to make correlations between pelvic patterns of asymmetry on standing radiographic films and patterns of somatic dysfunction. We plan to address this topic in part 2 of our study. The more correlations between radiographic and physical examinations can be elucidated, however, the more firmly our understanding of somatic dysfunction and compensatory patterns can be linked into an evidence-based format.
The radiographic information on pubic displacement from the midline and the relative measurements from the pubic tubercle to the inferior aspect of the anterior superior iliac spine may be useful, but this information was not collected in our database. We collected measurements we described as "standing hemipelvis" and "seated hemipelvis," which we also plan to discuss in part 2 of our study.
I look forward to additional light being shed on these issues by Dr Davidson and other authors.
Footnotes
As the premier scholarly publication of the osteopathic medical profession, JAOA—The Journal of the American Osteopathic Association encourages osteopathic physicians, faculty members and students at osteopathic medical colleges, and others within the healthcare professions to submit comments related to articles published in JAOA and the mission of the osteopathic medical profession. The JAOA's editors are particularly interested in letters that discuss recently published original research.
Letters to the editor are considered for publication in JAOA with the understanding that they have not been published elsewhere and that they are not simultaneously under consideration by any other publication.
All accepted letters to the editor are subject to copyediting. Letter writers may be asked to provide JAOA staff with photocopies of referenced material so that the references themselves and statements cited may be verified.
Readers are encouraged to prepare letters electronically in Microsoft Word (.doc) or in plain (.txt) or rich text (.rtf) format. The JAOA prefers that letters be e-mailed to jaoa@osteopathic.org. Mailed letters should also be sent electronically, in one of the aforementioned electronic formats on an IBM-compatible CD or a 3 -inch disk, and addressed to Gilbert E. D'Alonzo, Jr, DO, Editor in Chief, American Osteopathic Association, 142 E Ontario St, Chicago, IL 60611-2864.
Letter writers must include their full professional titles and affiliations, complete preferred mailing addresses, day and evening telephone numbers, fax numbers, and preferred e-mail addresses. Authors are responsible for disclosing financial associations and other conflicts of interest.
Although JAOA cannot acknowledge the receipt of letters, a JAOA staff member will notify writers whose letters have been accepted for publication. Mailed submissions and supporting materials will not be returned unless authors provide self-addressed, stamped envelopes with their submissions.
All osteopathic physicians who have letters published in JAOA receive continuing medical education (CME) credit for their contributions. Writers of original letters receive 5 hours of AOA Category 1-B CME credit. Authors of published articles who respond to letters about their research receive 3 hours of Category 1-B CME credit for their responses.
Although JAOA welcomes letters to the editor, readers should be aware that these contributions have a lower publication priority than other submissions. As a consequence, letters are published only when space allows.
References
2. Beilke MC. Roentgenological spinal analysis and the technic for taking standing x-ray plates. J Am Osteopath Assoc.1936; 35:414 -418.
3. Pearson WM. Survey of 200 weight bearing X-ray studies. J Osteopathy.1938; 45:18 -21.
4. Denslow JS, Chace JA. Mechanical stresses in the human lumbar spine and pelvis. J Am Osteopath Assoc.1962; 61:705 -712.
5. Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Two Volume Set. 2nd ed (vol 1), 1st ed (vol 2). Baltimore, Md: Lippincott Williams and Wilkins;1992 .(Stephen M. Davidson, DO)