Care for your patients with pelvis and low back complaints, which are common sites for pain and bear the majority of the body’s weight
Poor posture aggravates pelvic and back pain, because imbalance causes stress on muscles and joints. Proper posture involves getting the body in alignment so that the pull of gravity is evenly distributed throughout the body. On the anterior-to-posterior (A-P) view, we should expect the head centered over the body and the shoulders, hips, and knees all of equal height.
A simple way to test posture on the lateral view is to have the patient stand with her head, back, buttocks, and heels touching the wall. Stick your hand between her lower back and the wall, and then between her neck and the wall. Ideally, there should be 1 to 2 inches between the lower back and the wall, and approximately 2 inches between the neck and wall. Next, have the patient take a couple of steps while keeping the posture that was formed while doing the wall test. If it feels comfortable, she is probably close to having ideal posture.
The mirror test is a simple way for patients to see how their posture looks to others on the A-P view. Instruct the patient to stand in front of a full-length mirror, close her eyes, then walk in place and move her head back and forth. After this, have her assume good posture, then tell her to open her eyes without changing that posture. Check to see if her head is straight, shoulders level, hips level, kneecaps face the front, and her ankles are straight.
A good way to improve a patient’s posture while standing is to examine the feet. Make note of excessive shoe wear. Take her shoes off and measure the foot arches in sitting and standing positions. If there is a significant difference, the patient probably has a pronation problem, and wearing flexible orthotics is advised when shoes are worn. The effects of heel-strike shock on the pelvis should also be considered.
A 1996 study1 showed the effects of sitting posture to find ways to improve conditions for paraplegics and others confined to wheelchairs. The amount of pressure on the ischial tuberosity (IT) and orientation of the pelvis when sitting on different types of cushions was measured. Poor sitting posture and increased pressure on the IT can lead to pressure sores and other health conditions. Use of a foam cushion composed of individual foam cells significantly reduced pressure and improved pelvic posture.
Esprit de Core
The buzzword in the health and fitness industry today is core strength, which stabilizes the spine, pelvis, shoulders, neck, and torso for effective movement. People with pelvic and low back pain usually have deconditioned core musculature, which causes stabilization trouble.
A popular method to condition the core is the Pilates method, developed by Joseph Pilates in the 1920s. Today, more than 5 million Americans perform this type of exercise routine.2 Pilates is a resistance-control exercise of stretching and strengthening movements, which teaches conditioning from the inside out. These exercises, typically performed on a floor mat, are effective, and when combined with programs incorporating active spinal surgical tubing exercises, are easy to demonstrate and can be performed at home.
Most chiropractors believe that adjustments to the sacroiliac will directly influence the pelvis. Results in a 1998 study3 compared the effectiveness of manipulations on the upper cervical and sacroiliac joint on hip range of motion (ROM). A single manipulation of the first cervical vertebra improved hip flexion ROM, while manipulation of the sacroiliac joint did not significantly increase ROM.
Another study4 examined the biomechanics of the sacroiliac joints. It found that the use of heel lifts and orthotics to level the sacral base, along with adjustments, was superior to adjustments alone. Also recommended are rehabilitative exercises, stretching, and stabilizing belts.
A 1994 study5 reported that 47% of pregnant women experience significant back or posterior pelvic (PP) pain during pregnancy. To differentiate lower back pain from PP pain, perform a PP pain provocation test. If patients are treated with low back strengthening exercises when they have PP pain, the pelvic pain increases. The use of a sacroiliac belt helped a majority of the women with PP pain, and those women who exercised at least 45 minutes per week prior to becoming pregnant had decreased sick leave.
The organs of the pelvic cavity should also be examined. Many are affected by urinary incontinence (UC) brought on by a variety of causes, such as bladder infection, obesity, childbirth, and neuromuscular disorders. UC is a significant problem in the older population, and pelvic floor rehab has been effective for those who develop UC following prostatectomy.6 Another study7 evaluated pelvic floor rehabilitation as a possible treatment for premature ejaculation. It was found that after 15 to 20 sessions of pelvic floor rehab, 61% of the patients were able to control the ejaculatory reflex.
Mooney8 reported that even with the restoration of normal joint mobility with manipulation, but without restoration of normal muscle dynamics, reintroduction of the improper lumbopelvic mechanics is likely. Sacroiliac joint pain subjects exhibit increased activation of the gluteal muscles on the side of pain, but without an offsetting increase in contralateral latissimus dorsi activity. This results in asymmetry of rotational strength and pelvic-torso motion during gait that can be corrected with rotational torso exercise.
To determine the functional cause of lumbopelvic pain, the evaluation should include gait, sagittal plane motion, one leg standing, active straight leg raise, motion palpation, reverse cross crawl, and quantitative Alaranta tests.
Kim D. Christensen, DC, CCSP, DACRB, CSCS, founded the SportsMedicine & Rehab Clinics of Washington. He is a team physician to high school and university athletic programs, a postgraduate faculty member at numerous chiropractic colleges, the president of the ACA Rehab Council, and a lecturer and the author of many musculoskeletal rehabilitation and nutrition texts. He can be reached via email: kimdchristensen@hotmail.com.
References
1. Koo TKK, Mak AFT, Lee YL. Posture effect on seating interface biomechanics: comparison between two seating cushions. Arch Phys Med Rehab. 1996;77(1):40–47.
2. Blum CL. Grace under pressure. Newsweek. 2000; 135(9):72–73.
3. Pollard H, Ward G. The effect of upper cervical or sacroiliac manipulation on hip flexion range of motion. J Manip Physiol Ther. 1998;21(9):611–617.
4. Harrison D, Harrison D, Troyanovich S. The sacroiliac joint: a review of anatomy and biomechanics with clinical implications. J Manip Physiol Ther. 1997;20(9):607–617.
5. Ostagaard HC, Zetherstrom G, Roos-Hanson E, Svanberg B. Reduction of back and posterior pelvic pain in pregnancy. Spine. 1994;19(8):894–900.
6. Galeri S, Sottini C. Physiotherapy of pelvic floor for incontinence. Arch Ital Urol Androl. 2001;73(3):143–146.
7. LaPera G, Nicastro A. A new treatment for premature ejaculation: the rehabilitation of the pelvic floor. J Sex Marital Ther. 1996;22(1):22–26.
8. Mooney V. Exercise Treatment For Sacroiliac Pain. Orthopedics. 2001;24:29–32.
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