Hip and Pelvic Rotation Differences in Chronic LBP Cases (Aug 2018)

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View this email in your browser Peak Performance Physical Therapy & Sports Training EVIDENCE-BASED PRACTICE UPDATE August 2018 New insights into hip rotation and chronic back pain: When back pain isn't coming from the back   CURRENT EVIDENCE Hoffman, S. Johnson, M. Zou, D. Van Dillen, L. Sex Differences in Lumbopelvic Movement Patterns During Hip Medial Rotation in People with Chronic Low Back Pain. Arch Phys Med Rehabil.  2011; 92: 1053-1059.  by Allison Pulvino, PT, MSPT, CMP, CAFS Background: There have been numerous links between back pain and hip motion, but not many comparing the differences between the sexes with medial hip rotation and the possibility of low back pain. This study attempts to assess how medial hip rotation in males and females may differ with mobility as well as pain levels. Method: 62 subjects were selected from a larger randomized controlled clinical trial, and an equal numbers of males and females (n=31) were utilized. Subjects were required to have low back pain for a minimum of 12 months. Active hip medial rotation in prone was measured using a 6-camera, 3-dimensional motion capture system to collect and process kinematic data. The measurements were assessing hip and pelvic motions, with angular displacements calculated between the initial and final position of the pelvic and lower leg segments. Results: Men demonstrated significantly more total lumbopelvic rotation motion than women, as well as having decreased hip medial rotation before the start of the lumbopelvic rotation. Also, men were found to have less total hip medial rotation than women. A much greater proportion of men reported increased symptoms (60%) than women (34.5%) on one or both sides during active medial hip rotation. Hoffman et al do conclude that men and women average varying levels of medial hip rotation, and affects can be seen proximal to the assessed hip. Although this study does have limitations, it can lead to special considerations of appropriate lumbar and hip treatment interventions for males versus females due to the level of lumbopelvic mobility as it relates to lack of hip mobility.  THE PEAK PERFORMANCE PERSPECTIVE So many people report being frustrated with back pain that just never seems to go away with stretching the sore structures, and/or performing the classic “core strength” exercises that they may have been taught. But what many still don’t know is that their back pain may not be coming from their actual spine limitations, but other adjacent or even distant regions of the body. Our hips, being able to move in three planes separately along with all the combined motions possible, provide the mobility necessary for ADL or sports/recreation tasks, but it is well known that current cultural habits include prolonged sitting or standing for the better part of the day, which mutually contributes to certain directions begin to develop other ROM deficits over time. Hoffman et al are wise to explore the relationship of hip internal rotation with chronic LBP and also any gender-based differences that might exist. It’s increasingly accepted that kinetic chain deficits are a contributing factor to the onset of low back pain. The activities we enjoy that involve bringing our hips past ranges that we have not been accustomed to with normal ADL (for example, kicking a soccer ball or swinging a golf club) can produce compensatory movements and eventually strain at the low back.  Too often low back pain is treated locally and appreciation for underlying kinetic chain deficits is ignored.   Men and women are now more than ever performing many of the same recreational activities such as weightlifting, rock climbing, golf, lacrosse, etc. This study sheds some light on the subject of why males may report more limitations with certain activities than females. Males had less hip IR than females and lumbopelvic compensatory motion. While Hoffman et al did not measure hip IR in a WB functional position, this motion limitation would be expected to potentially impact functional tasks. For example, from the proximal to distal (or “top-down” directed motion) aspect we can stress our hips with spinal/pelvic movements over the femur.  If you are standing still and a sudden loid noise causes you to turn to the left to look and you lack adequate left hip IR, then the lumbar segments would likely experience excessive left rotational stress, potentially leading to back strain. Similar examples would be a right-handed thrower during release and follow-through phases or a mother reaching into the passenger side back seat to lift a child from her car seat. More classic distal on proximal (or “bottom up” directed motion) examples of similar kinetic chain examples would be when changing position and by stepping over something or cutting during athletics like soccer or football. Limited hip IR, as found by Hoffman, et al, causing earlier and larger lumbopelvic motion could then bring stresses more proximal to the spine.  Some important limitations exist in this Hoffman, et al study. They studied only NWB internal rotation AROM done distal on proximal style. It must be remembered that we move differently actively versus passively, NWB vs WB, and directionally when proximal over distal. These are functional biomechanics differences that relate to normal human movements and demands that this study did not specifically examine. Motor control and tissue tensions will differ in WB and NWB environments.  Concentric muscle actions (studied by Hoffman et al) may result in different forces and influences than when required to perform eccentrically, as is often the case with functional movements against gravity.  Finally, this study did not examine cause-effect relationships, so care must be taken to avoid assuming the hip IR loss was contributing to the LBP since it also could have developed afterwards and be the result of and not a cause of the LBP. This is where a very thorough three-dimensional movement assessment is necessary to actually pinpoint one, two or even more structures that may be limiting this person’s eventual goal of swinging that golf club, or playing in a full tennis match without low back pain limiting this favorite activity.     THE PEAK PERFORMANCE EXPERIENCE Richard stated recently: “I was able to golf three out of the last four days without any back pain, and only feeling stiffness in my back with prolonged sitting now for work. Golfing has been going much better! HX: Patient is 52 y/o male and reported having back pain after golf one day and when he woke up the next morning he felt “locked up.” He had right-sided lower back pain and right great toe numbness. His main goal was to be able to golf without pain as that’s what he loves in the summer. Patient Initial Subjective: Patient’s lower R side back pain can get up to 8/10 and was 5/10 at initial exam. The pain was much worse in the morning and felt somewhat better as the day would progress. Pain with golfing, any distance driving, sitting more than ten minutes, and standing more than ten minutes. His right side of his back feels constantly sore. ODI score was 38%. Objective Data: Patient demonstrates R thoracic convexity with forward flexion, R ischial tuberosity higher than L, decreased medial arches B feet, positive Thomas and Ely’s test B with negative Slump and SLR B. Tenderness reported R psoas, R iliacus and proximal ITB and QL. See table below.                   Treatment: Manual therapy: Muscle energy technique for SI jt correction prn, B anterior hip capsular mobilizations, R iliacus/TFL/ITB myofascial release, thoracic P-A mobilizations. Hip mobility: Functional dynamic multiplanar stretches/mobility drills for psoas, IR, ER done in WB.  Thoracic and lumbar mobility: Elevated hip isolated thoracic R/L rotation with shoulder pullback, seated thoracic extensions over chair back  prn daily with feet elevated, prone on elbows, prone press-ups, side-lying rotation with hip flexion, isolated R rotation for backswing loading R hip, isolated L rotation for follow-through loading L hip. Neural: Supine and seated sciatic nerve glides TID as able. Strength: Calf strength-Seated to standing progression single leg calf raises to allow for proper push-off at terminal stance. Trunk stability: Birddogs, incline planks with lateral taps, incline planks with alternating hip extension for sagittal control. Hip stability dynamic control: Hip IR and also extension stimulus via reaching and tubing resistance and balancing Golf swing progression: Half to full swing progression practicing loading each hip separately for each backswing and then follow through. Full swing performed only after single leg load with acceptable triplanar hip motion + trunk rotation noted   You can trust the Physical Therapists at PEAK PERFORMANCE to do a thorough evaluation, to search for related but underlying contributing factors to kinetic chain dysfunction, and to design exercise progressions that both respect tissue healing and creatively use biomechanics principles to prevent symptoms and optimize carryover to your patients' functional goals. Call us at 218-0240 to discuss your patient's specific needs.   Allison Pulvino, PT, MSPT, CMP, CAFS Peak Performance is just minutes away from your patients in Penfield, Fairport, Pittsford, Brighton, Rochester and, of course, East Rochester.   We promise Individualized, hands-on and biomechanically appropriate Physical Therapy for your patients.  No "one-size-fits-all" approaches. We WILL go the extra mile and "dig deeper" to discover underlying causes for injury risk and delayed recovery using the most advanced Evidence Based methods available and, we’re able to make unique adjustments to exercise prescriptions to speed the return to function and to minimize or prevent symptoms from interfering.    No surprises. No hassles. Confident your patient is in the right place.   COME VISIT US AT 161 E Commercial St Just 1 mile off 490 exit (585) 218-0240 www.PeakPTRochester.com

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