It looks like you're talking about the problem I mentioned in the final paragraph.
I believe that Gray's anatomy only acknowledged that the SI joint was a mobile structure, as opposed to a fused structure in the late 80's / early 90's (any anatomists out there care to correct me?) so any Dr's educated up to that time would be of that opinion.
Out of interest, how would you know that a chronic, complex biomechanical problem came from the SI joint then spread, rather than somewhere else, then spread to the SI joint?
I agree that it's overlooked in orthodox medicine, but I'd be shocked if it's overlooked by chiropractors/osteopaths; in fact, in my experience, it's over-diagnosed by lazy practitioners, who simple give that as the diagnosis for everything (I've worked for one, and locumed for others). That is bad diagnostics.
As for your final comment, yes, you would expect long distance runners to have a higher than average incidence of SI joint problems, purely by the nature of what they do (requiring high mobility in the joint, and then adding a lot of repeated, heavy impact loading)
SIJD - controversial reply
I can see you guys are professionals or patients - I agree that there still exist professionals who are either lazy or arrogant and that I also came across a respected orthopedic specialist in a pro sports injury clinic that was adamant it was not possible to injure an SI ligament - well that experience has provoked me to write this long but perhaps entertaining post !!!
I am aski instructor by the way !!
Do not give too much credibility to people who do not recognise that their own knowledge is limited.....especially when they are giving you advice about your health !!!
I am staggered by the attitude and arrogance of some doctors and physiotherapists (and even professional national sports team medical advisors - for example look at the reaction by the US Ski Team medics when Bode Miller, Eric Schlopy, Bryon Friedman all had prolotherapy and rave about it's success !) who dismiss certain treatments and ideas simply because they do not know anything about them. The one's I am thinking about use their own lack of knowledge as an argument as to why something cannot possibly exist or work. They know who they are, don' they ??
I find their arrogance mind boggling - their arrogance is only exceeded by their ignorance - beware !
I am particularly referring to conversations I have had about the treatment called Prolotherapy or Sclerosant therapy.
I have spent 3 years researching the treatment and during that time have been treated with astounding and rapid success - and I speak from experience of talking with many medically qualified people and patients ......but I know I can only be sure of what I have experienced..not what I have been told, read...or not read for that matter !
In my experience the most arrogant and dismissive "qualified" people with whom I have had conversations have been General Practitioners and Physiotherapists - these are people who hold a position of respect in society and to whom people look to for advice about their health. Ironically, they are the "medical" staff who require and go through a much shorter training than the doctors that I know who administer prolotherapy. They have considerably less (if any at all) experience in diagnosing and treating musculo-skeletal issues. Many GP's spend most of their time dealing with headaches, earaches, flu, period pains, depression, pregnant 15 year olds etc etc etc...they probably get to see an MRI scan once a year...if at all...and may not have a clue what they are even looking at - some admit this of course but many do not !
So when a physio (with their 2-4 yrs training under their belt) or a GP (with their 5-6 year training) , tells you that something is impossible just because they have not been taught about it (or because no drug company has sponsored it !!!)..question why some orthopaedic surgeons - who have taken possibly 14 years to get to the point where they can start to practice independently - who have had the same training as the GPs and physios at the beginning of their career, then studied much further for much longer, then specialised and focused in particular injuries and conditions FULL TIME...who then also often go on to study and qualify as Osteopaths....a further 4-5 years ( so now we have approximately 20 years of study and hands on experience in specific medicine and LIFE)...just ask yourself who is likely to have the greater knowledge...and strangely, the people to which I am now referring are open minded and curious.
Maybe the above-mentioned arrogant sceptics do not know that (and I quote..) "the American Association of Orthopedic Medicine
AAOM) promotes Orthopaedic Medicine by teaching doctors integrative diagnosis techniques and comprehensive/ integrative nonsurgical treatment methods including proliferant injections (prolotherapy), steroid injections, fluoroscopic spinal interventions, osteopathic manual medicine, therapeutic exercise and interventions with various pharmaceuticals/nutriceuticals/ herbal/ homeopathic based treatments."......well maybe these sceptical GPs and physios should be questioning why they have not read about it..why they have not informed themselves of what treatments are successful at treating their potential patients...why they have NOT
kept up with their own profession...mmm ??? Think about it !
The problem in finding a prolotherapist is that there are very very few of them. This is because the skill set and legal qualification required is much greater than just becoming a "doctor" or just an "osteopath" and certainly much greater than just a "physiotherapist"....after all...on paper...a physiotherapist when compared to the doctors that I know who perform prolotherapy..is like comparing the mechanic at your local
Ford garage with Ernst Fuhrmann, the man who designed the incredible, world beating Porsche type 547, 4 cam roller bearing engine for the Porsche 550 Spyder in 1954 - you get my point ??? One knows what goes on..the other needs to be told what to change and how !!
Okay - I know you are not all like that...and apologise to those who are not but choose to be offended......but I bet you know many who are !!
To be a good prolotherapist you need to specialise in musculo skeletal issues (so you are probably an osteopath - incidentally prolotherapy was part of the osteopaths training until the 1960's when the law changed so you then had to be a qualified medical doctor to treat people with the long needles used in prolo - so it was dropped from osteo training because they would never be allowed to do it unless they went on to become a doctor..another 5-6 years training...""oh oh..long time before earning any money..I will stick with just being an osteopath thanks")...so in the UK at least, you really have to be a medical doctor legally and in order to have sufficient knowledge in musculo skeletal issues...an osteopath too....this is before you really get any real life hands on experience...at the minimum.
Then to be any good.....you still have to have a great deal of experience even to accurately diagnose the problems...most ligament and tendon issues are not visible even on MRI (in fact especially on an MRI !!!)
You also need to be very sensitive with your hands and have natural skill and a steady hand....very steady hand...and be very confident...have you seen the needles and where they go ?????? Wow ! I have, I felt them, in my case they didn't hurt because I was treated by someone who had been doing this non stop for 35 years, a qualified doctor who then qualified as an osteopath having been treated by one and amazed by the result, then was treated by prolotherapist and further amazed by the result (and remains totally cured of the problem 35 years after the treatment !) - and so studied that technique too.This man has been the president of the British Osteopathic association and an examiner at London College of Osteopathic medicine.
Now..there are at least 2 orthopaedic surgeons that I have spoken with...remember they require much longer training than even my doctor !!...who treat with prolotherapy in place of surgery in many cases, they still research prolotherapy and they TEACH IT !! These surgeons practice at the ROYAL ORTHOPAEDIC HOSPITAL in the UK.....and still I hear some GP s or physio therapists say..."Prolotherapy cannot work because I haven't read about it, I haven't been taught about it so it must be rubbish...." Ie...they know NOTHING about it...but they insist that their own lack of knowledge proves that something doesn't exist !!
Well....what would you think of me if you asked me what I thought about your favourite book and I said - I haven't read it, I don't know anything about it - it's rubbish - would you consider me very credible ?
If anyone is interested I will be happy to tell them my case - and all the very expensive "specialists" I went to see - none of whom could fix me..or in many cases couldn't even see anything wrong despite MRI etc and them being orthopaedic trauma specialists in their own right..but had no knowledge whatsoever of prolotherapy - the treatment that has fully repaired my problem ( these qualified traumatologists and orthopaedic surgeons were very interested to read the information I had discovered and asked me to return to their clinic in Spain after my treatment in the UK to tell them about it - of course I did and they are now looking into it in detail).
I would love to share that story with any of you !
Do your own research - do not believe the first thing you read - do not believe the 100th thing you read - do your own research - talk to as many people as you can - find people with experience not uninformed opinions - find people who have had it and done it - then decide what to do.
Remember when you read an article and it says "experts say this , experts say that "...look up the definition of an expert - my friends from Argentina define an expert as somebody from the next town !!!!!
There is no doubt whatsoever that....
if you have an accurate diagnosis
if the injury is appropriate for prolotherapy - many are !!
if administered by a skilled and experienced therapist who uses the correct solution and gives enoguh treatments spread over the optimum timescale
if the patient follows the therapists advice regarding eg:
non use of antiinflammatories, diet...reduce sugar for example increase vitamin C, correct exercise
if the above situation applies...there is no doubt that prolotherapy is a natural, harmless complete and permament cure that in many cases leave the patient even stronger and mechanically more stable than before their injury.
It is such a shame that there are so few practitioners because 90% of people suffering today with arthritis and arthrosis pain, damaged discs and cartilage, damaged or just old, worn and loose ligaments could have their pain eliminated permanently - and save the NHS enormous amounts of money - the treatment requires skill and training but the material to do it costs nothing...a syringe, needle and simple solution of sugar, water and antisceptic..it takes half an hour and you just wlak straight out...no hospital time !!
Think about it - ask for it - make them make it available !!!
Good luck.
alls i know that SI joint instability was quite common in distance runners in one of the top high performance athletics institutes in the UK (hundreds of athletes living on campus training v hard)
patterns of groin, hamstring and calf injuries were solved by stabiliasing the 1 si and pevlis in general
everyone used to drive down to a v experience physio in northampton to get these issues revolved (took a long time to stabalise the joint in many cases). all the top bods at the institute of sport and british olympic med centre were pretty usch oblivious to these problems.
this was just a small sample of a few hundred athletes so not sure how wide spread these type of problems were
not medical fact i know but it happened
"Out of interest, how would you know that a chronic, complex biomechanical problem came from the SI joint then spread, rather than somewhere else, then spread to the SI joint?"
resolving the Si instability resolved the lower limb injuries. can only put 2 and 2 together in this case and have no medical proof that it was the SI causing the problems
Sorry posted twice
Hi Ian
is the physio in Northampton a maverick or unorthodox ?
I dont understand if his methods are so successfull why they would not be addopted by other top sports physios?
Regards steve
Hi Ian
is the physio in Northampton a maverick or unorthodox ?
I dont understand if his methods are so successfull why they would not be addopted by other top sports physios?Regards steve
Nope the total opposite.
He very experience in dealing with endurance athletes, dancers and gymnasts where pelvic stability is very important. In fact i only just learnt that he spent his first 5 yrs of private practice working with elite gymnasts and dancers so that pretty much exmplaines why hes v experienced in pelvic and trunk stability - these performers are generally very hypermobile BUT at the same time have very good core strength which can cope with such hypermobility. He trained in physio and then did a post grad course in advance physio at london medical college and then went onto study biomechanics and manual therapy.
Its widely accepted in the world of athletics that many overuse injuries come from pelvic instability - biomechanist, physio's, sports physiologies/scientics have all studied, testing - all been extensively testing from scientifin point of view. just because someone with a first class honours degree has not research this.....
Most physio work from this point of view but he is just better at tackling long term injuries. He will work through every possibility of whats causing/preventing an injury to heal. He will not draw people in by saying i know what the cuase of this problem is and can fix it in a few sessions. The fact is many long term injuries have multiple causes and all need to be addressed for the problem to be fixed. He's very experienced at working like this and just that much better than anyone else i've seen and i've seen some excellent physio's
Rememing that my problem was from running 80 miles a week. If i was the average person i would be fine and calf would not bother me (it only used to come on really bad after 30 mins of faster running but as a distance running i needed to do upto 2 hrs of training a day + i could not do any speed work). All the scans and test by the so called best sports dr's in the county came back clean and one even offered me an expolatory op to try and remove any scar tissue!!!!!! (it makes me sick thinking about it).
Finally the one of the coaches at the endurance centre of excellence in the midlands told me about the guy in northampton and at the time he actually worked for the institute of sport - i was mad that for the past few yrs they and been sending me down to london and up to leeds when the main man was at northampton and used to come up to treat athletes at the high perfroamcne centre where i lived nr (again it makes me really angry).
He did a very detailed examnination .looked at all my scans, test results, previuos treatment etc. He had me going over force plates and doing specific strength endurance tests that had been developed for athletes. He thought there has to be some reason why a calf injury is not fully recvering when there is nothing clinically wrong with it (as proved by scientific tests!)
The major findings he found from the test that my pelvic stability and control was quite poor even for a non sporty person. He talked about the tranfering of forces through the body going the running action and the role that the pelvic played in absorbing this force and transfering force through out the body. for someone who was constatling stressing their body ranges and values form the general population do not apply. Just like an average Haemoglobin blood count could be low for a distance runner (boy how many of us have had that problem being told our test are coming back in within the normal ranges by the local DR's) the having to present clinically proven scientific evidnece that in fact the normal range for an endurance athlkete is much higher!!!!!
He came up with a number of possibilites of what could be stressing my calves and worked through them.
He's very highly regarded within the sports world (and infact by many well known orthopeadic dr's, professors etc)but you get idiots on here who've fallen into the education trap (think that becuase they have a first class degree they know everything) claiming this is pure quackery!!!
whats the world coming to
a couple of case studies from his website. I oike the bit how its important to include the patient in the treatment process
"Back, rib and shoulder pain case study
This case study involves a 28 year old lady (Ms P) who had a 7 year history of right sided pain half way up her back and under the right shoulder blade. The pain was not becoming worse or improving but she recently realised that she was fed up with it and wanted to see if anything could be done.
She described 2 pains:
Pain 1 was a diffuse ache, present most of the time under the shoulder blade. It was aggravated by sustained postures, i.e. sitting or standing for any length of time. Keeping moving or lying down would ease it.
Pain 2 was an intermittent sharp pain approximately 1 inch to the right of her spine. It was a brief pain brought on by twisting, reaching up or lifting.
These pains started 7 years previously after seeing a therapist (not a Physiotherapist) for a lower back problem. That Practitioner had manipulated her spine all the way up quite forcefully and the pain occurred at this point. She had not gone back for a follow up visit.
Ms P was naturally concerned that no such manipulations be performed this time. She was reassured that this would not happen and that I would seek her consent to any treatment after fully explaining the nature and purpose of the treatment.
Past Medical History: nothing relevant.
Medication: only anti-inflammatory tablets as required.
Social History: Teacher. No children. Swims 3 times a week and uses a gym once a week.
Initial Thoughts
Due to the cause (being a forceful manipulation) the location, and the nature (description) the sharp pain was likely to be from a joint dysfunction. This is where , for any reason, a joint is not operating as it should. In this instance it was likely to be a spinal facet joint or a costovertebral joint (where the ribs join the spine).
The ache was likely to be muscular or referred pain from the spinal joint.
Initial Examination
This showed no observable scoliosis or other spinal deformity. The muscles to the right of the spine were more tense than they should be and there were a few tender places in them.
Movement testing showed no restrictions in the cervical (neck) and lumbar (lower back) spine movements. Thoracic spine (mid back) movements were painful, especially backward bending, twisting right and side-bending either left or right. The most restricted movement was twisting to the left.
Arm movements caused both pains when nearing full elevation. A deep breath in caused pain 1.
Treatment
Treatment initially was to relax the muscles on the right side of her back. This eased the ache and allowed a more thorough spinal assessment. The further findings were that accessory movements of the 4th, 5th and 6th thoracic vertebrae (T4-6) and the right 5th rib gave pain. Also, T5 was stuck in a right rotated position.
Ms P. was informed of the findings but the vertebra was not directly treated in this first visit due to her previously mentioned concerns. Instead she was taught 2 exercises to try to address the problem. 1 of these was to begin to twist that area to the left.
2nd Visit, 4 Days later.
Ms P. reported an improvement in the ache for a few days after treatment but it had started to come back. The sharp pain hadnt changed.
On examination: the muscles were again tight on the right side. Once these were relaxed off it was clear that the T5 problem hadnt changed.
Commonly this is an area that responds well to more forceful manipulative treatments but due to Ms Ps past experience it was decided to use a Muscle Energy Technique (MET) to realign her spine. This is a more gentle technique that uses the patients own muscle contractions as the force and usually feels more like a good stretch. The technique was used 3 times, each time allowing a greater degree of left rotation.
A new home exercise was given to increase the amount of stretch incorporating left rotation, side flexion and forward flexion. We discussed the impact of her daily activities and it was discovered that 2 things were probably not helping: sitting on the settee with feet up and looking to the right every evening; and that she also turned to the right at the end of each length when swimming. We agreed that she should avoid these for a short while.
3rd Visit, 1 Week Later.
Ms P was delighted with her progress and both pains were 60-70% better. There was no pain on breathing or reaching up anymore and she described her back as much freer. She actually came in requesting the same manipulation that we did last time! After examining the area it was clear that this was still the appropriate treatment but the muscle treatment did not need doing it had stayed relaxed for the week. The left rotation range was ¾ of what it should be (a good increase from where it had been).
The MET was repeated and left rotation then was equal to that right. Her home exercise was checked to ensure she was doing it correctly.
4th Visit, 1 Week Later.
Ms P reported being 95% or more better with no ache and had only felt a few hints of pain near the spine. The treatment was repeated a further time and she was checked to make sure no other problems were present. We did not book a further appointment because I expected the remaining discomfort to disappear over the following 2 weeks. She was to rebook if any symptoms remained but has not needed to.
Thoughts.
I feel that there is often too much acceptance of being in pain. This can be due to fear of treatment as in this case. Sometimes people believe they will not get better but they have not explored all the options.
There are usually a few treatment options for any given condition.
As Physiotherapists we feel it is important:
-to look at muscles as well as joints
-to think about the patients everyday activities and postures
-to try and include them in the treatment process"
[url]Lower back pain case study[/url]
"This is the case study of a 38- year old fit and healthy gentleman, who presented with an acute onset of severe lower back pain, an extremely common injury that will affect approximately 60% of us at one stage or another in our lives.
What follows is a basic account of my management, which demonstrates the importance of a thorough assessment and a close working relationship with local Specialist Surgeons to enable the best outcome possible in the shortest space of time.
Subjective Questioning
Problem: Constant, unremitting lower back pain, with shooting pain into the left leg from buttock to heel. He also reported the presence of pins and needles in his heel.
Aggravating factors: Any static position aggravated his back and leg pain if sustained for over 10-15 minutes.
Easing factors: There was nothing that he could do to ease his symptoms.
24hrs: He reported difficulty sleeping, but no significant difference pattern to his symptoms.
Special Questions to Exclude Serious Pathology: No alterations to bladder and bowel function, no sudden unexplained weight loss, no night-time fever/ malaise, no pins and needles/ numbness in groin region, no significant loss of leg strength.
History of Problem: A sudden unexplained episode of lower back pain and leg pain, that started 8 weeks ago. He reported a history of 1-2 episodes of localised lower back pain and occasional low-grade leg pain, but nothing ever of this magnitude.
Social History: Business man, who was normally very active and enjoyed playing rugby socially and running regularly.
Past Medical History: No medical problems of note.
General health: Good. No cardiovascular nor respiratory problems, no family history of lower back pain, arthritis, diabetes, epilepsy
Drug history: Due to the severity of his symptoms, his GP had prescribed strong pain-killers and muscle relaxants.
Objective Examination
Observation: Unable to maintain any position for longer than 1-2 minutes
Active movements: (Patient performed) Restricted and painful in all planes, especially flexion, which reproduced both back and leg symptoms.
Passive movements: (Physiotherapist performed) severe muscle spasm prevented an accurate assessment of segmental spine movement
Palpation: Local tenderness at the distal two joints of the Lumbar spine (L4/5), with widespread muscular spasm. Palpation of L4/5 elicited left leg symptoms.
Neurological Tests: Reflex testing, sensory and motor testing was normal and symmetrical side to side. There was evidence of significant sciatic nerve irritation when stretched
Analysis of Pathology
His symptoms led me to believe that he had intervertebral disc prolapse at L4/5, causing compression to the sciatic nerve root and leg symptoms. It was likely that his condition would become more serious if it was not managed quickly.
Initial Management
Immediate referral to an Orthopaedic Consultant in Northampton.
Orthopaedic Consultant Assessment
This gentleman was referred to a local Orthopaedic Consultant, who specialises in Spinal injury. Following an MRI our suspicion was confirmed. The scan also identified that a small part of the discs contents had leaked out, known as a sequestration. On discussion with the Consultant a surgical procedure was performed to remove part of the disc and stop the compression of the nerve.
Post-Operative Physiotherapy
Following a brief stay in hospital (4 days), the patient was re-referred to the clinic for post-operative care.
We have since been working on the following agreed goals:
1. Restoring full range of movement of spinal joints through local mobilisation, manipulation and active stretching.
2. Developing the strength and co-ordination of the local spinal muscles, which serve to protect the spine from injury. Evidence has proven a link between the education and strengthening of these muscles and a reduction in back pain. It has also been shown that these muscles will deteriorate quickly with pain and following surgery. They are best educated with a gradual specific strengthening program.
3. Restoring normal nerve movement along the length of the sciatic nerve, with nerve mobilisations and local soft tissue techniques.
Following six weeks of Physiotherapy, this gentleman is now resuming a running program and is left with only an occasional mild buttock pain, which I am confident we can eradicate with ongoing treatment.
It is now our plan to introduce sports specific rehab to enable him to resume rugby playing in the near future."
does a lot of injury prevention of screening of athletes.
Biomechanical Assessments
The Assessment can be described as a Full Service for the musculoskeletal system. It is a snapshot of your body far beyond a basic gym fitness test or running shop treadmill assessment. It is specifically aimed at the athlete but can be adapted to any sport or occupation. We are looking for areas of potential injury - short or long term, as well as areas in which performance can be enhanced with some specific remedial work. This will be discussed in detail and a plan formulated. The work will mostly be in the form of exercise or possibly combined with a treatment programme. To get the most from this procedure it is strongly advised that follow-up visits are organised to check on progress and to adapt the program. The assessment itself will not benefit you--it is the work that is done as a result of it.
The history of this process dates back to the mid '90s. Mark Buckingham was involved in the evolution of the Screening Program for UK Athletics and Phil Pask and Mark also developed the same program for England RFU in the build up to the 1999 World Cup.
The two hour assessment will start with a Musculoskeletal Screening which systematically works through the spinal and limb systems looking for areas of tightness, weakness, hyper and hypo-mobility. Muscle Imbalance, neural tightness and basic control of the joints will be examined. We then move to a progressive Motion Control Assessment from basic standing and walking through to a full Video Gait Analysis and sport specific movement profiling. An Isokinetic Test will be performed on one area of concern to give exceptionally detailed information on that problem.
Following the Assessment your physiotherapist will take you through the findings and discuss a plan of action. The plan of action could take the form of further physiotherapy sessions to work on problems and exercise work to be done by you or under supervision. It may also be decided that further investigations and opinions need to be sought.
The physiotherapy plan of action will be set out in stages with clear entry and exit criteria set for those stages. The first stage will be set in motion on the assessment day and arrangements made to follow-up when appropriate.
Hi Ian
this guy really sounds the bisiness, a 2hr assessment should make for little chance of a mis-diagnosis.
Does he have any printable veiws on overuse of HVTs on the SIJ ?
Regards steve
well he comes from the view point that in many cases its very difficult to be 100% sure what the underlying cause is - there are often multiple causes. he tries to approach with an open mind and does not rule out any possiblities until hes sure.
no nothing in printing on HVT. his view was that spinal manipulation can be (and often is overused). His view was that if a joint needs constantly manipulating then you there is an underlying cause of this that needs to be addressed. ie in your si keeps coming "out of alignment" then stability needs to be addressed. he also htought that too much manipulation can lead to hypermobility but this is very difficult to prove and does not like to rule out any possibility (many would say its impossible and not even entertain the thought!)
Finally he felt that if manipulation is used as a sole long term treatment approach (when little no no improvement is made) then the you have to question the validity of that approach for THAT PARTICULAR INDIVIDUAL!
i know he has done quite a few seminars down london way and used to work from St Marys Uni in west london one day a week.
just as a note i received an email that dontigny is coming over to the uk to run a seminar. I'll get the details for you
cheers
ian
Finally he felt that if manipulation is used as a sole long term treatment approach (when little no no improvement is made) then the you have to question the validity of that approach for THAT PARTICULAR INDIVIDUAL!
On that point especially, I'd say that he's far from unique.
It often takes a few treatments before you start seeing an improvement, but generally speaking if you haven't in 6 or so, then you're unlikley to, and by 10 you give up on that (I'd only get that far in very chronic cases). I'd also be surprised if there are that many therapists out there that would manipulation as the sole long term treatment (especially not if you're limiting this to the SI joint, which I think you're implying). Again, if you're being treated like this, I'd suggest you have either a lazy therapist, or someone who's more interest in your money than in your health.
I often use manipulation as the first choice therapy, and if it works well, then I propably won't bother looking into other things in the short term. For the long term I will always look into other things, most especially the soft tissues (combination of massage and rehab) and not infrequently, some amateur psychobabble.
I prefer to keep these other treatments in house if I can, because I can keep tabs on what the patient is doing, and it's so much easier to integrate their care properly - I don't do more than basic rehab currently as I simply don't have the space and equipment, and my knowledge is out of date. I'm very interested in taking on a sports therapist/physio/pilates teacher as soon as realistically possible though (almost did over the summer, but we couldn't offer enough security on income).
Look at my signature for why I think all this.
For the instance I've quoted from you, only 1 treatmetn regime has been tried, long-term and with no benefit; it's not working, try something else, or at least refer to someone who will/can
im sound with all of what BUT there are many out there who put people on long term programs of the same treatmement. I know someone who went for manipulation only for three yrs! over one hundred manipulations. after each session the pain would greatly reduce but return after two or 3 days!
my thoughts of pilates is that you need a teacher who has experience with back problems. many exercises are too advanced/incorrect technique used. too many exercises aimed at the general population
think your right when you say talk about trying to keep things in house to monitor. I went to a massage therapist who claimed they were experienced enough to do HVT. I had a look at his qualifications and did not bother going back (especially when he said back specialists were a bunch of money grabbing w's! - at the same time as saying i needed to come in 3 times a week!)
its good to read that not eveyone takes such an approach
thanks
ian
Expatient, I don't quite know what your motivation is for these posts. Are you a practitioner as well as an expatient? Where did you get the xrays you include on the link? This x-ray, for example, [DLMURL] 
[/DLMURL] you give as SIJD causing scoliosis but what is the line projected over the abdomen? If you look closer you will see that the patient has spina bifida and the line is a ventricular shunt for hydocephalus- plenty enough reason to have scoliosis and pelvic tilt. Pelvic tilt alone is meaningless- some will be due to scoliosis and some due to leg length discrepancy. A small number will be due to pelvic deformity-usually after major trauma. Pelvic tilt for whatever cause will cause degenerative change in the lower back but the SI joints show no more degenerative change than they do in the normal population (where it is almost universal in old age). It does worry me when single issue fanatics get together and, as in this case, use the xrays of someone who, for all I can tell, is wheelchair bound from a birth defect (spinal bifida) as an example of some fictitious disease.