Mark Finch Learning

What is an Intra-Pelvic Torsion?

This is a long post about clinical reasoning of the pelvic girdle. In part to clear up misunderstandings and misinformation about this clinical reasoning tool.
TLDR: An IPT is a positional finding that is helpful for clinical reasoning in patients with nociceptive pain. No assumptions from the finding alone, changing it has to provide a meaningful change to the patient's experience. If it helps, work on structures and strategies that help facilitate alignment change.

Read on if you are interested!

What is an intra-pelvic torsion?
This is a term to describe the biomechanical movement of the pelvis. It describes the relative rotation of the two innominates and sacrum. This is the normal physiological movement of the pelvis. It's easy to feel on yourself. If you are sitting, rest your hands on your illiac crests then twist your body to the left, you'll feel the right side of your pelvis rotate anteriorly and the left side rotate posteriorly. Also notice that your right knee translates forward as a result of this torsion. This is the normal physiological motion of the pelvis and happens for most people without any pain or awareness. This terminology was coined by Diane Lee in her the various editions of her book, the latest: The Pelvic Girdle, an integration of clinical expertise and research. Fourth edition.

Who is this helpful for?
The first step in any clinical reasoning process should be to classify the likely mechanism of pain for that patient (nociceptive, neuropathic or nociplastic are the three agreed upon categories). Assessment of alignment is not usually helpful for people with nociplastic pain since it is mediated centrally and neuropathic pain involves more complex tests so lets exclude both of those. This assessment tool should be used for people with nociceptive pain, the kind that is provoked or relieved with mechanical movements and when people are usually showing you their pain with one finger.

What does it mean?
Alone this finding means nothing, it is no different to the resting position of any other joint, we can't make any assumptions about how it might be contributing to pain or dysfunction. In order to determine if this finding should be included in a treatment plan we first need to have a meaningful task. This is a task that represents a meaningful goal for the patient. The question "what can't you do that you'd like to be able to do?" usually leads us there. For example, 'Putting on my socks without pain' or 'Standing up after sitting without pain'

Once you have a meaningful task you can then determine if a change in the pelvis position (IPT) changes the meaningful task. It's important to understand that the patient decides wether this is meaningful, not the practitioner. If a change in alignment has no effect on the patient's task then that finding is meaningless. If it improves the meaningful task then your next step is to figure out what could facilitate a change in alignment.

Another note on meaning. Be sure to normalize these findings to your patient. Be careful not to give them the impression that their alignment is wrong or dysfunctional. It's just that it could be better with a different strategy.

What should I do about it?
If you have determined that the changing the alignment of the pelvis improves the meaningful task then the question is how can I help facilitate this alignment. We know that the mechanisms of manual therapy are multifactorial so you should consider as many options as possible. For example: Release techniques applied to any tissues that could be maintaining non-optimal alignment. Exploring unhelpful beliefs that could be contributing to bracing eg "I have to keep my pelvis stable". Motor control or movement strategies that could be unhelpful. Habits of sitting or moving that could be contributing to non-optimal alignment.

Is there any evidence for this?
No, but it is still Evidence Based Practice. This clinical reasoning process is unique to each patient so we'll never get population level data (evidence) for this sort of reasoning. Remember that Evidence Based Practice is a synergy of evidence, patient values and clinical expertise. This reasoning process relies on your clinical expertise (reasoning) and patient values (is this better for you?) and it falls inside the best evidence guidelines of reassurance and exercise. So, this clinical reasoning process definitely meets the threshold of Evidence Based Practice.

Summary:
Start with pain mechanism classification. This process is for people with nociceptive dominant pain.
Identify a meaningful task (what can't you do that you want to be able to do?)
Screen for alignment of the pelvis (and other regions).
Determine if a change in alignment changes the patient experience (Is that the same, better or worse?)
Normalise, don't pathologize.
Explore clinical strategies that can improve alignment and control.
Encourage meaningful function (all roads lead to movement).

If you made it this far you might be interested in an in-person course with me. Link in the comments.

This is a reminder that not all persistent pain is centrally driven. The amount of time a person has had pain does NOT tell you what the pain mechanism is.
who
Today I had a patient who was very concerned because they had been told their (clearly nociceptive) pain was central sensitization because it had been going on for more than 3 months. This is simply not true.
The description of pain and the behaviour of pain can tell us about the mechanism. If people are pointing with one finger, it is not nociplastic pain (central sensitization). If it is mechanically provoked or relieved, it is not nociplastic pain. Nociplastic pain doesn't make sense mechanically; it is broad, spreading, and not neuro-anatomically logical.
The nocebic effect of telling someone they have central sensitization is significant. This poor patient was concerned that their nervous system was broken and that their pain was now permanent.

Stop thinking of all pain as the same!
Did you know there are 3 broadly agreed upon mechanisms of pain? Different mechanisms deserve different treatment approaches.
Join me for a webinar this Wednesday to refine your clinical reasoning skills. Pain mechanism classification is a simple but effective tool for making excellent clinical decisions. It helps us make sense of conflicting treatment narratives and is something you can start doing immediately. You'll leave with clinical reasoning tools and simple strategies to implement into your practice.
Yes, this meets your PDP requirements.
60 minutes, with 30 minutes for questions.
$48
Wednesday 6pm PST.
Yes, you'll get a recording if you can't attend live.

Pain mechanism classification for Massage Therapists (April 16 2025) - Mark Finch Classifying the dominant pain mechanism helps clinicians to focus on a treatment approach that is most likely to help the patient.

There is no evidence for that!

In the context of clinical reasoning this statement just shows a fixed mindset and lack of reasoning. Clinical decision making is more than just knowing the evidence.

Three problematic phrases:
There is no evidence for that.
In my expereince.
I fixed a (insert diagnosis here).

These 3 problematic phrases represent common pitfalls of clinical reasoning. Each describes a lack of understanding and integration.

If you have made it this far, my webinar is for you!
April 9th 6pm PST
60 mins + 30 mins of questions.
Recording included.
$48
If you live in BC this webinar will meet PDP requirements and the webinar will be structured in a way that makes recording your learning easy.

Learn to integrate the ingredients of Evidence Based Practice.
Your clinical expertise (not just your clinical experience.Patient-centered care. Best available evidence. In this webinar we'll explore the components of EBP and how you can improve your practice through reflection.

https://learning.markfinch.ca/product/evidence-based-practice-for-massage-therapists-april-2025/

If you want to understand the role of postural screening in Evidence-Based Practice then this webinar is for you. Postural screening is very important clinical reasoning tool for some people with some kinds of pain.

Wednesday Feb 26th 6pm PST.

https://learning.markfinch.ca/product/postural-assessment-for-massage-therapists-feb-2025/

Webinar *tomorrow*
Did you know there are 3 generally accepted mechanisms of pain? These are broad, clinical descriptions that give us hints about the likely biological factors driving pain.
Pain mechanism classification is a simple tool to advance your clinical reasoning skills. This tool has really helped me clinically and also helped to understand the conflicting advice about treating people in pain. I'm excited to share it!
After this webinar, you'll be able to broadly classify the likely mechanism (nociceptive, neuropathic or nociplastic dominant) of your patient's pain and be able to choose an appropriate treatment approach.
You'll get a recording of the webinar (in case you can't make the time) and a pdf of the slides
May 15th 6pm PST
$38

Pain mechanism classification for Massage Therapists - Mark Finch Classifying the dominant pain mechanism helps clinicians to focus on a treatment approach that is most likely to help the patient.

Pain Mechanism Classification.
90 min webinar May 15th
$38

Did you know there are 3 generally agreed-upon pain mechanisms?

Nociceptive, Nociplastic, and Neuropathic pain all have quite different mechanisms so it makes sense to treat the people experiencing those pains differently.

Pain mechanism classification is a simple but powerful clinical tool to help you tailor your treatment and work more effectively. In this webinar, you'll learn how to classify the dominant pain mechanism (no special tools required), the evidence for this approach, and how it can change your treatment.

Pain mechanism classification for Massage Therapists - Mark Finch Classifying the dominant pain mechanism helps clinicians to focus on a treatment approach that is most likely to help the patient.

* Early bird rate finishes tomorrow*
Did you know there are 3 generally agreed upon pain mechanisms?
Nociceptive, Nociplastic and Neuropathic pain all have quite different mechanisms so it makes sense to treat the people experiencing those pains differently.
Pain mechanism classification is a simple but powerful clinical tool to help you taylor your treatment and work more effectively. In this webinar you'll learn how to classify the dominant pain mechanism (no special tools required), what the evidence is for this approach and how it can change your treatment.

Pain mechanism classification for Massage Therapists - Mark Finch Classifying the dominant pain mechanism helps clinicians to focus on a treatment approach that is most likely to help the patient.

My next webinar topic is pain mechanism classification. This simple tool has really make a difference for me in clinical reasoning and understanding how various conflicting opinions on the treatment of pain can all make sense.

Did you know there are 3 generally accepted mechanisms of pain? These are broad, clinical descriptions which give us hints about the likely biological factors driving pain. This is extremely helpful for clinicians to understand so that we can tailor treatments toward these mechanisms.

After this webinar you'll be able to broadly classify the likely pain mechanism (nociceptive, neuropathic or nociplastic dominant). I'll cover the evidence and provide case studies.

This webinar is well referenced, comes with a lifetime access recording and pdf of the slides.
90 minutes. $38 Early bird pricing ($28) ends in 4 days.

Pain mechanism classification for Massage Therapists - Mark Finch Classifying the dominant pain mechanism helps clinicians to focus on a treatment approach that is most likely to help the patient.

I'm so heartened by the number of folks who think Evidence Based Practice is important enough to attend a webinar on. Thanks to everyone who came along last week.

If you are interested in it but didn't make it I'll be doing another one in the fall and in the meantime check out the CMTBCs page on EBP resources (in the comments), I think its pretty good. There are plenty of resources for finding evidence and a nice definition.

If you are interested in building clinical expertise my upcoming webinars might interest you. The next one is on pain mechanism classification. This is a simple (and validated) tool that will help you make sense of all the conflicting information around the treatment of pain. Early bird price expires in 7 days.