You are on page 1of 4

Journal of Back and Musculoskeletal Rehabilitation 26 (2013) 33–36 33

DOI 10.3233/BMR-2012-0347
IOS Press

Manipulation and selective exercises decrease

pelvic anteversion and low-back pain: A pilot
Alexandre Carvalho Barbosaa,b,∗, Fábio Luiz Mendonça Martinsa,c ,
Michelle Cristina Sales Almeida Barbosab and Rúbia Tenile dos Santosd
Department of Physiotherapy, Federal University of Valleys of Jequitinhonha and Mucuri, Diamantina, Brazil
Department of Health Education, Federal University of Valleys of Jequitinhonha and Mucuri, Diamantina, Brazil
Department of Medicine, Italian University Institute of Rosario, Rosario, Argentina
Department of Physiotherapy, Seama College, Macapá, Brazil

OBJECTIVES: To study the effect of a protocol involving joint manipulation and specific exercises for pelvic stability to
influence proprioceptive input to the spinal tissues and to observe the effects on sensorimotor function.
METHODS: Seven patients with pelvic anteversion and low back pain participated in an eight-week protocol (three sessions per
week/nonconsecutive days). At each session, a high-velocity, low-amplitude manipulative thrust was applied to the sacroiliac
joint, followed by quadriceps eccentric and hamstring concentric contractions. The perceived pain symptoms, pelvic anteversion
as determined by photogrammetry analysis, and the electromyographic activity of the rectus femoris and lateral and medial
hamstrings during flexion and extension exercises were assessed before and after treatment. Non-parametric tests were used to
compare the groups before and after treatment with α = 0.05.
RESULTS: Perceived pain symptoms decreased after treatment (p = 0.0007). The differences in the pelvis angles (p = 0.0130)
suggested significant differences between the assessments, and the electromyographic activities of all the muscles during isometric
voluntary contraction increased.
CONCLUSION: The eight-week manipulation/exercise protocol was effective for these subjects’ needs. Further research should
include a greater sample size to confirm the results and to determine the lead factors of pelvic stability.

Keywords: Physiotherapy, manipulation, electromyography, low back pain

1. Introduction care [1,2]. The SIJ are closely related to the persistent
causes of LBP [3], and lesions in this joint might cause
The sacroiliac joints (SIJ) are richly innervated by biomechanical changes with different pain patterns due
nociceptors and proprioceptors, and these joints are the to the joint’s complex structure and innervation. Joint
primary source of low-back pain (LBP) episodes (ap- stability is important during usual body activities or
proximately 40% of cases). LBP is well recognized as to maintain standing position and, despite having low
a public health problem, impacting up to 80% of adults mobility, the SIJ are related to pelvic torsional asym-
at some point in their lives, and also the major con- metry (TA), which is defined as a positional rotation
tributor to disability and to increasing costs in health of one iliac to another, often associated with sacroiliac
dysfunction [4].
The dynamic factor, provided by the adjacent mus-
∗ Address for correspondence: Alexandre Carvalho Barbosa, MSc,
cles, and the static factor, provided by the joint compo-
Department of Physiotherapy – Federal University of Valleys of Je- nents (cartilage, capsule, ligaments and synovia), con-
quitinhonha and Mucuri, MGT 367 Road-Km 583, n◦ 5000, Alto da
Jacuba, Diamantina, MG, Brasil. Tel.: +55 38 3532 1200; Fax: +55 tribute to joint stability. Therefore, to influence motor
38 3531 9008; E-mail: control, the stimulus to modulate the muscle and joint

ISSN 1053-8127/13/$27.50  2013 – IOS Press and the authors. All rights reserved
34 A.C. Barbosa et al. / Manipulation and selective exercises decrease pelvic anteversion and low-back pain

receptors becomes significant to the patient’s function- ital signals was performed by an A/D board with 14-bit
al recovery. An increasing body of evidence suggests resolution input range, sampling frequency of 2000 Hz,
that spinal manipulation provides an important benefit common rejection module greater than 100 dB, signal
to patients with LBP [5]. Joint manipulation has been noise ratio less than 03 μV RMS and impedance of
studied to stimulate these sensory receptors and to af- 109 ohms. The electromyography (EMG) signals were
fect the central nervous system (CNS) at the spinal seg- recorded by root mean square (RMS) in μV and the av-
mental level and the cortical level. Therefore, the neu- erage frequency in Hz with surface electrodes (20 mm
rophysiological effects and treatment results for mus- diameter and a center-to-center distance of 20 mm). A
culoskeletal disorders may be dependent on the magni- reference electrode was placed on the left lateral epi-
tude of forces applied by manual intervention [6]. condyle. Prior to fixation of the electrodes, the skin
A study showed that different proprioceptive training was cleaned with 70% alcohol to eliminate residual fat,
induces neural adaptations that specifically affect the followed by exfoliation using a specific sand paper for
recruitment and the trigger rates of the motor units at skin and a second cleaning with alcohol. The muscles
the beginning of voluntary contraction [7]; however, analyzed by surface EMG were as follows: (1) rec-
the association of muscle and joint techniques, which tus femoris (RF), (2) lateral hamstring (LH): biceps
are specific to TA, remains unclear. femoris, (3) medial hamstrings (MH): semimembra-
The approach in this current study is to use a protocol nosus and semitendinosus [10,11]. Each volunteer per-
involving joint manipulation and specific exercises for formed 3 maximum isometric voluntary contractions
pelvic stability as a tool to influence proprioceptive
(MVC) of extension and flexion of the leg, each lasting
input to the spinal tissues and to observe the effects on
6 seconds with a 3-minute interval between contrac-
sensorimotor function.
tions, measured by a digital dynamometer. The data
were obtained from the average of the three MVC. The
2. Method extension strength was determined with the patient in
a sitting position, hip and knee angled at 90 degrees.
The participants were 7 sedentary adult subjects (18– Flexion was determined with the patient in a standing
35 years of age). The inclusion criteria were to present position and with an initial 90 degrees of knee flexion.
pelvic anteversion and LBP without radiculopathy. The Using a 10-cm line, the patient was asked to mark the
subjects were selected by physiotherapeutic assessment point that represents the current intensity of pain. The
and photogrammetry analysis. The local ethics com- Visual Analogue Scale (VAS) value was then calculat-
mittee for human investigation approved the procedures ed by measuring the distance in centimeters from the
employed in the study, and all the subjects gave their right edge of the line.
written informed consent prior to participation.
2.3. Therapeutic interventions
2.1. Outcome measurements
The experimental protocol was applied for 8 weeks
The photographs were acquired using a Sony dig- (3 sessions per week/nonconsecutive days). At each
ital camera, 7 mega pixels, set on a tripod 3 meters
session, a high-velocity, low-amplitude manipulative
away from the subject, properly centralized and leveled
thrust was applied to the SIJ with the contact hand on a
at a height of 85 cm, in a well-lit and reserved room,
specific area of the pelvis (posterior superior iliac spine,
with anti-glare protection. The volunteers were pho-
ischial tuberosity, sacral ala). Short, controlled move-
tographed in side view with their arms crossed on their
ment of the doctor’s upper body, shoulder and arm,
chest. Circular red markers were placed at the anterior
often combined with a slight falling or “body-drop”
superior and posterior superior iliac spines. Two lines
were drawn using the program ALCimagem [8]: the movement creates the motion, momentum and position
first between the iliac spines and the other parallel to for the thrust, which is delivered through the contact
the ground, with an angle of 180 degrees between the hand. Next, isotonic muscle exercises were performed
lines [9]. at MVC 12% load. The specificity of the kinesthetic
stimuli was observed to affect the motor engram and
2.2. Instrumentation to decrease pelvis anteversion. Each volunteer was po-
sitioned on the treatment table with 90 degrees of hip
A biological signal acquisition module with four ana- flexion and the knee extended. The subject proceeded
log channels was used. The conversion of analog to dig- with sets of isotonic eccentric contractions for quadri-
A.C. Barbosa et al. / Manipulation and selective exercises decrease pelvic anteversion and low-back pain 35

Table 1
Rehabilitation guidelines: quadriceps eccentric contractions and
4. Discussion
hamstring concentric contractions
Activity Duration
The SIJ are richly innervated by nociceptors and
Week 1 exercises 4 sets of 15 repetitions / 15 second hold
proprioceptors [1]. Histological analysis confirms the
Week 2 exercises 3 sets of 15 repetitions / 15 second hold presence of nerve fibers (myelinated and demyelinat-
Week 3 exercises 4 sets of 10 repetitions / 10 second hold ed) in the capsule and ligaments and in the mechanore-
Week 4 exercises 3 sets of 10 repetitions / 10 second hold ceptors and nociceptors, suggesting that pain and pro-
Week 5 exercises 4 sets of 12 repetitions / 15 second hold
Week 6 exercises 3 sets of 12 repetitions / 15 second hold prioceptive information is transmitted from the SIJ [2].
Week 7 exercises 4 sets of 8 repetitions / 10 second hold Therefore, we expected that by providing specific stim-
Week 8 exercises 4 sets of 8 repetitions / 10 second hold uli to the joint and muscle, positional changes and pain
response could be noted. A previous study, including
ceps flexion. Next, while in a prone position with only the muscle protocol at 20% of maximum load,
knee and hip extension, the subject performed isotonic demonstrated that the pelvic positioning and subject
concentric contractions until 90 degrees of knee flex- pain perception can be altered by physical therapy inter-
ion were reached. The number of repetitions and series vention [3]. However, including articular intervention,
varied in each session, providing asymmetric stimuli, neurophysiological stimuli to deform articular struc-
not allowing accommodation and providing constant tures rich in sensory inputs, should lead to changes in
neurophysiological response by the mechanoreceptors the axoplasmic afferent inflow. We inferred that these
(Table 1). changes brought awareness to the CNS, modifying mo-
tor patterns and suggesting that the CNS is able to
2.4. Data analysis contribute to reduce clinical symptoms [13]. A study
showed that manipulations applied peripherally in the
We applied a pre- (A1) and post-assessment (A2), cervical spine can cause changes in cortical plastici-
and the values obtained in the EMG analysis, pho-
ty, altering somatosensory processing and sensorimotor
togrammetry and VAS were used for statistical com-
integration, leading to pain decrease and functional re-
parisons. The Shapiro-Wilk test was used to test the
structuring by manipulative treatment [14]. Joint stim-
Gaussian distribution of the variables under study. As
ulus might also cause nociceptive inhibition by releas-
normality was rejected, the Wilcoxon non-parametric
ing plasmatic β-endorphins [3]. Significant improve-
test was used to determine whether the differences be-
ments were observed after treatment with respect to the
tween the samples were significant at the p < 0.05
subjects’ usual perceived pain and reduced pain dur-
level. All the statistical analyses were performed using
ing functional dynamic activities. The trunk kinematics
BioEstat software (Version 5.0; BioEstat; Belém, PA,
were expected to improve during functional activities
Brazil) [12].
because the movement patterns were executed more
correctly and thus reduced the stress on the SIJ and con-
3. Results sequently decreased pain symptoms. We speculate that
improved motor control motion played an important
The subjects presented no complaints of adverse ef- role in the improvement of pain symptoms.
fects due to the exercise or the manipulation protocol. For dynamic stabilization of the SIJ, the ideal pattern
The results of the pain assessment were obtained using to improve positional control seems to be a protocol that
VAS. Significant results (p = 0.009) were obtained be- combines muscle control without exhausting the mus-
tween the baseline and final assessments with average culoskeletal system and concomitantly activates the re-
results as follows: A1: 5.83 ± 1.59 cm and A2: 1.29 ± ceptors in the muscles and joints. The sensory map is
0.58 cm. continuously corrected by sensory feedback according
The difference of the pelvis angles (p = 0.009), to proprioceptive priority, given by the influx of afferent
observed in the photogrammetry, suggested a signifi- receptors [15]. Muscle or joint receptors are received
cant difference between the assessments (A1: 20.38 ± from the protocol proprioceptive priority stimuli to cor-
5.70 degrees and A2: 14.63 ± 2.17 degrees). rect the anteversion disorder. In this type of TA, the hip
The statistical analysis showed a significant increase flexor muscles are predominant in the closed kinetic
in the RF, IL and IM electromyographic signal dur- chain, rotating and decreasing ilium mobility. Analyz-
ing maximal isometric voluntary contraction after eight ing the hip extensor muscles, the opposite pattern may
weeks of treatment (Table 2). be noted: the hamstring’s failure to stabilize the hip
36 A.C. Barbosa et al. / Manipulation and selective exercises decrease pelvic anteversion and low-back pain

Table 2
Muscle electrical activity. A1: baseline in millivolts (mV); A2: final evaluation in millivolts (mV); Δ%: delta
percentage (%); p: significant differences; RF: rectus femoris; IL: ischiotibial lateral; IM: ischiotibials medial
Extension Flexion
A1 1.10 ± 0.30 1.01 ± 0.21 0.74 ± 0.61 1.10 ± 0.30 1.00 ± 0.20 0.83 ± 0.50
A2 1.57 ± 0.04 1.26 ± 0.13 1.34 ± 0.01 1.57 ± 0.04 1.26 ± 0.13 1.34 ± 0.01
Δ% 29.71 20.29 44.90 29.90 20.05 37.85
p 0.0005 0.004 0.0005 0.0005 0.002 0.0005

flexor action. Instead, to only stretch the hip flexors, [2] Nachemson AL, Jonsson E. Neck and Back Pain: The scien-
we propose for these muscles to prioritize the eccentric tific evidence of causes, diagnosis and treatment Philadelphia:
Lippincott Williams & Wilkins; 2000.
isotonic exercise to induce proprioceptive stimuli and [3] Slipman CW, Whyte WS, Chow DW. Sacroiliac joint syn-
to develop the muscles that eccentrically stabilize the drome. Pain Physician 2001; 4: 143-52.
system. Similarly, the use of concentric exercise was [4] Barbosa AC, Costa DC, Santos RT, Callegari B, Pin
recommended for the hamstrings, providing specificity AS, Baraúna KMP. Effectiveness of kinesiotherapeutic-
proprioceptive protocol in patients with anteversion torsional
for the system [3]. The results indicate that EMG activ- pelvic asymmetries. Ter Man 2009; 8: 74-78.
ity in all the muscles examined increased significant- [5] Wilder DG, Vining RD, Pohlman KA, Meeker WC, Xia T,
ly, and these changes may be due to the neurophysio- Devocht JW, Gudavalli RM, Long CR, Owens EF, Goertz CM.
logic mechanism, with more muscle fibers being acti- Effect of spinal manipulation on sensorimotor functions in
back pain patients: study protocol for a randomised controlled
vated for the same task. The protocol does not allow trial. Trials 2011; 28: 12-161.
us to infer significant changes in structural tissue, so [6] Grindstaff TL, Hertel J, Beazell JR, Magrum EM, Ingersoll
we suggest only improved coordination by better sen- CD. Effects of lumbopelvic joint manipulation on quadriceps
sory feedback and hence, greater control over muscle activation and strength in healthy individuals. Manual Therapy
2009; 14: 415-20.
contraction during the pelvis stabilization. [7] Gruber M, Gruber SB, Taube W, Schubert M, Beck SC, Goll-
In conclusion, this study demonstrated that an eight- hofer A. Differential effects of ballistic versus sensorimotor
week manipulation/exercise protocol was effective for training on rate of force development and neural activation in
humans. J Strength Cond Res 2007; 21: 274-82.
the subjects’ needs. Further research should include a
[8] Motta LJ, Martins MD, Fernandes KP, Mesquita-Ferrari RA,
greater sample size to confirm the results and to deter- Biasotto-Gonzalez DA, Bussadori SK. Craniocervical posture
mine the lead factors of pelvic stability. and bruxism in children. Physiother Res Int 2011; 16: 57-61.
[9] Souza JA, Pasinato F, Basso D, Corrêa ECR, Silva AMT. Bio-
photogrammetry: reliability of measurements obtained with a
posture assessment software (SAPO). Rev Bras Cineantropom
Conflict of interest Desempenho Hum 2011; 13: 299-305.
[10] Beres-Jones JA, Johnson TD, Harkema SJ. Clonus after hu-
There is no conflict of interest. man spinal cord injury cannot be attributed solely to recurrent
muscle-tendon stretch. Exp Brain Res 2003; 149: 222-36.
[11] Harkema SJ, Hurley SL, Patel UK, Requejo OS, Dobkin
BH, Edgerton VR. Human lumbossacral spinal cord interprets
Acknowledgements loading during stepping. J Neurophysiol 1997; 77: 797-811.
[12] Parise ÉV, Araújo GC, Castro JG, Berdarrain FP. Epidemio-
logical profile of malaria in the state of Tocantins, Brazil, from
We gratefully acknowledge the technical support 2003 to 2008. Rev Inst Med Trop Sao Paulo 2011; 53: 141-7.
from the Department of Physiotherapy of UFVJM and [13] Zusman M. Forebrain-mediated sensitization of central pain
Seama College. pathways: ‘non-specific’ pain and a new image for manual
therapy. Manual Therapy 2002; 7: 80-88.
[14] Haavik-Taylor H, Murphy B. Cervical spine manipulation al-
ters sensorimotor integration: a somatosensory evoked poten-
References tial study. Clin Neurophysiol 2007; 118: 391-402.
[15] Lederman E. Fundamentals of Manual Therapy: Physiology,
[1] Forst SL, Wheeler MT, Fortin JD, Vilensky JA. The sacroili- Neurology and Psychology. Churchill Livingstone; 1st edition,
ac joint: anatomy, physiology and clinical significance. Pain 1997.
Physician 2006; 9: 61-68.