Foot to jaw problems

These are two graphs showing pelvic torsion before and after heel raise/ foot platform therapy.

 

Once pelvic torsion is reduced the true, or closer to true leg length is revealed.

 

Measuring pelvic torsion to within 0.5 degrees is impressive. How was this achieved? What are the 95% confidence intervals of your between day variability?

 

I will look forward to your blog on LLI starting, please let me know when it starts.

 

Simon
These are simple graphs I but together to demonstrate the point I was making about pelvic torsion. I am two years into my PhD and half way through my data collection. I have made a simple analysis of some of the data recently but intend making detailed and thorough analysis over the next couple of years once all the data is in. Our CI should be fairly reliable for each body type. i.e. different body type (meso/endo/ectomorphic) will elicit a different pelvic result. As long as you indentify the correct pathway that individual fits into (I call a small group of MSK compensation mechanisms ‘Functional pathways’ in my research). In other words an ectomorphic body type with a LLI should compensate in a predictable manner, so that the PE (point estimation) could be made of any unknown patient with the same parameters. I know from my experience and research that I can look at a patient from a distance, and if you know they have a LLI you could say they probably would have a ‘Single femoral pathway, P.I ilium long side’ (one of my pathways) as a compensation mechanism. Obviously this requires further clarity as I progress through the PhD. My patient this morning was a tall runner; 2.5cm LLI; left long. He had a P.I ilium on the left, so his supine couch measurement was longer than his true difference, and in stance the acetabulum was lowered to achieve vestibular balance. His left ilium was 2 degrees +ve (P.I) and right 12 degrees +ve (normal range 8 to 12 degrees). This is typical of most upright individuals with a LLI.
I would ask anybody interested in what I am doing to please bare with me. I have been at the coalface in MSK biomechanics for the last twenty-two years in sport and I am dusting off the cobwebs when it comes to research. I feel that my twenty-two years experience looking at the whole kinetic chain has revealed some interesting finding, which I feel I need to validate, test and explain to my peers. I would be delighted to have any visitors to our research centre here at Sub-4. Simon, I had made at a precision engineers, a digital pelvic inclinometer made to suit my needs, which gives me my data. It has been so successful that I use it on every patient now.

 

Clifton, when measuring bony landmarks under skin it is notoriously difficult to obtain narrow confidence intervals from repeated measures. It certainly won't be accurate to 0.5 degrees. You will need to demonstrate the instruments between day reliability.

 

what is interesting Simon is that the inter-rater reliability using the traditional ASIS to medial malliolus measurement has a poor reliability score, however using the DPI was more reliable. What we consider important in the clinical setting is for the practitioner to establish the correct compensation mechanism (pathway) as his was helpful for treatment modality i.e. do you raise the short limb or not. The actual accuracy of the technique i.e. my theory is more for convincing people like yourself about the reliability of the procedure before you would start to use it on your own patients. Therefore the academic argument is more to get your confidence than usefulness in the clinic. What are your thoughts on this? Where are you based Simon?

 

Explained better: Actually the DPI is very accurate with inter-rater reliability than the traditional ASIS to medial malleolus technique, as you know. Knowing the accuracy and how repeatable a new measuring instrument is has importance to convince other practitioners that a new clinical technique is worthy of trying on one of their own patients. We have found that although we will rarely obtain exactly the same result, we have mainly established the same 'functional pathway' from a previously determined model that details each pathway. Therefore a practitioner being able to recognize the pathway is clinically important as it gives them confidence when to and when not to use a heel raise. When you think you recognize a particular set of functional variables to make your diagnosis the DPI will either confirm or ring alarm bells so that prescriptive errors are not made. E.g. a P.I ilium which is lower than the contralateral normal side would not be raised, however, a P.I ilium which is still higher than the normal contralateral side would have a heel raise put under the normal side. Does this make sense? I would be interested in your thoughts on this.

 

So what reliability co-efficients did you use? What did you find?

The actual accuracy of the technique is critical to all that follows. If you claim to make changes in a given variable via any therapy then you need to demonstrate that the changes are real and not just due to the between day variation and error in your measurements.

I'm in Plymouth

 

Clifton thank you for the response. I practice in Southern California, U.S.A.

LLI and FnLLI are very important and interesting topics and obviously relevant to patient care and worthy of exploration. Every profession appears to have differing approaches to assessing and treating these entities and often differing nomenclature. Over the years I have adapted to referring to them as Leg Length Difference (LLD - anatomic) and Functional Leg Length Difference (FnLLD), probably because of my time here on the Arena.

I was taught a certain methodology to assess FnLLD and began documenting a notation in every patients chart where there was an apparent FnLLD as you would expect. I developed protocols for treating specific findings that borrow from other professions as well, I found the 'straight' chiropractic approach wanting, which is what I believe you have alluded to. The 'leg-length check used by many chiropractors is simply a lazy approach and I often do glance at the prone attitude of the feet, more out of habit but I don't base my treatment decisions on it. It is more of a screening tool to alert me to the need to perform a more complete assessment.

Over the years I do not recall noticing specific body 'types' as inherently possessing more commonly a finding such as PI ilium on one side or the other. That is an interesting observation of yours. What I have noticed as I stated is that the greater majority of patients with a functional short leg present with FnLLD on the right. I cannot explain why this would occur but it does.

Over time I ceased using heel lifts as I was taught and found much better results by addressing the bony misalignment in tandem with any muscular involvement. It is a complex issue and although lifts seem appropriate my experience tells me otherwise. I have in fact encountered numerous patients presenting with lifts with increased low back and sacroiliac symptomatology (likewise I am cautious about utilizing lifts in scoliosis patients and never place one under the leg opposite the side of the lumbar convexity, this I hope we would all agree on?).

I certainly do not have all of the answers and am always open to any new ideas that will aid me to become a better practitioner but at the same time I a cautious about placing patients into categories based on body type. A number of clinicians have attempted this, foot typing is similar and we all know the pitfalls of that paradigm. At the same time I admire your zeal and taking on such a heady task. I look forward to reading your research and discussing it with you in the future.

I wonder if anyone might have access to this article for my own personal curiosity?

Heuristic exploration of how leg checking procedures may lead to inappropriate sacroiliac clinical interventions Robert Cooperstein MA, DC Journal of Chiropractic Medicine Volume 9, Issue 3, September 2010, Pages 146-153

 

Very good points that you make Simon, which I am in agreement with. I look forward to sharing more results with you as they arise over the next few months. I am obviously doing my PhD part-time because my working life is manic running Sub-4 etc, as enjoyable as it is. You have a PhD Simon don't you? In what capacity do you work? PP; university ? I asked where you are based as i you are ever up this way call in I would like to demonstrate what we are doing here.

 

Where are you doing your PhD, and who are your supervisors? Yes I have a PhD. I used to work in the University sector, I now work in private practice and consultancy. Where is your lab?

I take it from your answer to my post that you have not performed any reliability studies on your measurement techniques yet?

 

Hi David,

quote:
Over the years I do not recall noticing specific body 'types' as inherently possessing more commonly a finding such as PI ilium on one side or the other. That is an interesting observation of yours. What I have noticed as I stated is that the greater majority of patients with a functional short leg present with FnLLD on the right. I cannot explain why this would occur but it does.

What is interesting is that we have both seen similar patterns in our patients MSK, but go about treating them in very different ways, both with good results I assume. I can offer you my explanation of the shorter right leg, which is what I too have found. I find more A.S ilium's which will measure shorter whilst supine on a couch but what the limb is actually trying to do it raise itself during stance and gait. It is a compensation mechanism. It the longer limb can move P.I then the right often will remain in the normal orientation, but an AS and PI can co-exist together.

We differ in that I am a strong believer that most people start with a bony LLI and the posture changes around that over the years. I am not a fan of putting everything in neat little boxes, my observation are of what I think has been naturally organised, but is an on-going exploration.


I will try and get this for you:
Heuristic exploration of how leg checking procedures may lead to inappropriate sacroiliac clinical interventions Robert Cooperstein MA, DC Journal of Chiropractic Medicine Volume 9, Issue 3, September 2010, Pages 146-153[/QUOTE]

 

Some, this is why I am a little guarded on the arena, but I am about to start a more thorough analysis. I have been using these techniques for years and I know they work, but that is not good enough to make claims yet. My PhD is at Wolverhampton university and my tutor is Dr Fiona Berryman, a spinal researcher currently working at Royal Orthopaedic Hospital in Birmingham. Very clever lady!

I look forward to meeting you and discussing further.

 

We are based in Staffordshire, you are welcome any time.

 

I am originally from Great Wyrley, near Cannock, Staffs. So I'll maybe pop in sometime when I'm up there.

Please try to answer direct questions, directly though Clifton. To re-iterate:
have you performed any reliability studies on your measurement technique yet?

Good luck with your studies.

 

Hi Simon

Thank you for the advice. If you are up this way let me know. To answer your question I am about to do some Band-Altman analysis over this next few wees comparing inter-rater reliability of traditional tape measurements and DPI measurements. Just in the process of finishing the written body of my paper. When finished I'd like your opinion on it.

 

Hey Clifton,

I'm with Simon on this in that until we know the reliability of your measuring device all further discussions/assumptions/conclusions regarding your research are moot. Please keep us updated with the results - I too would be interested to know what your limits of agreement are.

Ian

 

Totally with you and fully respect your questions. I will keep you posted.

What are/ were your research areas?

 

The last thing Ian did was on reliability/ validity of clinical measurement. He'll be publishing soon. RIGHT, Ian? :morning:

 

Been working on it tonight instead of standing out in the cold watching the fireworks

 

Burnt my thumb entertaining a five year old, but it was worth it.

 

The price of parenthood.

Me, I'm living the friday night dream. Reading through JAPMA submission guidelines with a Bovril and waiting for Ghostbusters to start on fiver+1.

 

I came across this while perusing the net, might be pertinent to some of Clifton and Paul's comments? I scanned it but haven't read it through quite yet:

 

Sparkler?

Got to be done though mate.

 

Thank you very much David, I look forward to reading it.