Increased Low Back Pain in Performance of a Pelvic Tilt Maneuver: A Report of Two Cases

Original Article

Increased Low Back Pain in Performance of a Pelvic Tilt Maneuver:

A Report of Two Cases

Salvatore J. Minicozzi, DC, CCEP1, Brent S. Russell, MS, DC2

1 Private practice of chiropractic, Sandy Springs, Georgia, USA

2 Professor, Dr. Sid E. Williams Center for Chiropractic Research, Life University, Marietta, Georgia, USA

[email protected]

Published: March 2019
Journal of the Academy of Chiropractic Orthopedists
March 2019, Volume 16, Issue 1

The original article copyright belongs to the original publisher. This review is available from: https://ianmmedicine.org ©2019 Minicozzi/Russell and the Academy of Chiropractic Orthopedists. This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

This report discusses the pelvic tilt therapeutic exercise as an examination procedure for low back pain (LBP). In the authors’ experience, most patients with mechanical LBP attain some relief from posterior tilting of the pelvis. This report describes 2 patients who experienced increased pain from the maneuver.

Case presentation

Two patients presented to the principal author with pain in the low back and right lower extremity. They had similar orthopedic, neurologic, and MRI examination findings, and received similar conservative chiropractic care, including drop-assisted manipulation, Active Isolated Stretching and Strengthening, and instruction in a home exercise program. One substantially improved, while the other went on to surgery. The pelvic tilt maneuver was a convenient method for monitoring patient response in both cases.

Discussion

In some ways this report simply evokes the mystery of why some patients improve and others, seemingly similar, do not. The authors do not claim to definitively answer the question; rather, we offer a useful examination tool. One objective is to inspire other practitioners to use the pelvic tilt maneuver and investigate further.

Conclusions

With patients who demonstrate an increase in symptoms during a pelvic tilt maneuver, clinical decisions may be aided by repeated use of the maneuver to monitor patient progress. Additional investigation could clarify whether it can be a reliable indicator and with which patients.

Indexing terms: Lordosis; lumbar region; low back pain; chiropractic

Background

The following report involves the longtime use by the principal author of a common therapeutic exercise, known as the “pelvic tilt”, as an examination procedure for patients with low back pain (LBP) and radicular thigh and leg pain. The pelvic tilt exercise is performed with the patient supine. The hips are flexed to 45 degrees, knees flexed to 90 degrees, and the patient is instructed to tilt the pelvis posteriorly and flatten the lumbar spine without raising their buttocks off the examining table or floor. [1] Performance of the posterior pelvic tilt maneuver involves some degree of flexion of the lumbar spine with a “flattening”, or reduction, of the lumbar lordosis. The pelvic tilt has long been recommended as exercise for relief of low back pain [1,2,3] and can still occasionally be found in patient education literature. Clinically, the authors have observed that most patients with mechanical LBP attain some relief from the maneuver. However, there are some for whom posterior tilting of the pelvis causes increased pain.

In a study [4] of 46 patients with LBP, lumbar radicular symptoms or both, those patients who experienced increased pain with a posterior pelvic tilt were found to have higher levels of pain and disability in activities of daily living than patients who experienced pain relief. [4] Both groups had mean decreased pain levels following chiropractic care, but only those who found the posterior pelvic tilt palliative appreciated a statistically significant change in disability. There were no statistically significant differences between those who found the posterior pelvic tilt palliative or provocative regarding whether they had pain only, paresthesia only, or both pain and paresthesia; whether their symptoms were more proximal or distal; or whether symptoms were more acute, subacute, or chronic. [4] For the convenience of the reader, those major findings have been reproduced in Tables 1 and 2.

Table 1: pain and disability findings from previous investigation. [4] Patients grouped according to increased or decreased pain upon performing a pelvic tilt maneuver.

Pre-care values

(n = 46)

Increased pain

(n=12)

Decreased pain

(n=34)

differences

QVAS a

6.0 ± 2.0

4.9 ± 1.5

1.1 (P = .04)

RODI b

55.5 ± 17.7

36.1 ± 13.8

19.4 (P < .001)

a QVAS: Quadruple Visual Analog Scale, b RODI: Revised Oswestry Disability Index

Table 2: pre-post results from previous investigation [4]

Participants with post-care data c

(n = 30)

Increased pain

(n=8)

Decreased pain

(n=22)

QVAS, Pre-care

6.3 ± 1.9

4.8 ± 1.7

QVAS, Post-care

3.6 ± 2.7

2.7 ± 1.3

Pre-post change

2.8 (P = .02)

2.1 (P < .001)

   

RODI, Pre-care

55.0 ± 17.3

36.1 ± 13.8

RODI, Post-care

33.0 ± 27.7

20.3 ± 12.8

Pre-post change

22.0 (P = .07)

18.4 (P < .001)

Such a maneuver might be expected to provoke pain in patients with conditions that are flexion intolerant, as flexion increases intradiscal pressure [5] and induces strain in the facet joints. [6,7,8]

The authors have observed that patients who find the posterior pelvic tilt especially provocative also tend to exhibit signs and symptoms of neural tension. Some of these patients have been observed to have poor responses to chiropractic and other conservative care.

One objective of this current report to describe 2 cases of LBP in which the pelvic tilt maneuver elicited an increase in symptoms, and to describe how each case differed in response to a therapy plan that included the pelvic tilt. Another is to provide a description of how use of the pelvic tilt response informed treatment planning and prognosis. Additionally, we hope that such case studies will inspire more research in this area.

Case presentation

Case 1: A 52-year-old data entry office worker, referred by her primary care physician, complained of severe bilateral low back pain radiating to the posterior right thigh, calf, and lateral aspect of the right foot, as well as burning and stabbing in both buttocks, ache in the lateral pelvic girdle bilaterally, and a general sense of weakness in both lower extremities. These symptoms had begun the previous day, after “turning the wrong way.” The pain was constant and severe, at 9 of a possible 10 on a Numeric Rating Scale (NRS), with aggravation by coughing and sneezing. She had to be assisted into the office. Her clinical features are summarized in Table 3.

On examination she was unable to achieve any active lumbar range of motion, and attempts in any direction aggravated her pain. A positive Minor’s sign was recorded. Straight Leg Raise on the right increased the patient’s low back pain at approximately 45 degrees, and Bragard’s and Sicard’s tests were positive, while a Well Leg Raise on the left was negative. Bechterew’s and Kemp’s tests bilaterally aggravated her pain. She was unable to lie on her right side. While lying on her left side, an Iliac Compression test increased her pain on the right. There was also an increase in her low back pain when she performed a posterior pelvic tilt, a phenomenon referred to as “Minicozzi’s sign”. [4] There was mildly diminished strength of the right tibialis anterior muscle. The patellar reflexes were increased bilaterally, and the Achilles reflexes were diminished bilaterally. The area along the S1 dermatome was hyperalgesic on the right. Her lumbar and lumbosacral erector spinae were hypertonic on the right side, with tenderness to palpation, particularly overlying the right L4-5 and L5-S1 facet joints. Passive joint end play was decreased bilaterally at L4-5 and L5-S1.

Magnetic resonance imaging of the low back, done approximately 1 year prior, showed evidence of a right hemi-laminotomy at L4-5. There was a disc bulge with a focal protrusion in the right paracentral region exerting mild mass effect on the right L5 nerve root. Adjacent epidural scar tissue was present as well. At T12–L1 and L1-2 there were disc bulges causing mild mass effect on the thecal sac. The original working diagnosis was severe low back muscle strain; but after reviewing the MRI, nerve root adhesion secondary to epidural scar tissue was added to the differential.

She was treated over the course of 8 visits with a Category III protocol Sacro-Occipital Technique blocking technique, [9] for approximately 10-15 minutes each time. Cryotherapy was applied for approximately 10-15 minutes each. She received high-velocity, low-amplitude, drop assisted adjustments following a Thompson Technique protocol in the pelvic, lumbar, thoracic, and cervical regions, and Active Isolated Stretching and Strengthening, [10] primarily targeting the pelvic, lumbar, and thigh muscles. Core strengthening was added at the 3rd visit with a focus on posterior pelvic tilt and abdominal hollowing exercises. These exercises, along with cryotherapy, were prescribed to the patient as a home exercise plan for the remainder of her treatment. The pelvic tilt exercises were prescribed to be done at 25 repetitions per session, along with 25 repetitions of abdominal hollowing. Her home therapy instructions were the same, but twice daily, with 20 minutes of cryotherapy to follow. The patient was treated a total of 8 times over a period of 4 weeks during which her symptoms decreased by 89% (from 9 to 1 on an 11-point NRS) and she was able to return to work without restrictions. She was seen once during the next month and reported no significant exacerbations.

Table 3: comparison of two cases

Case 1, 52 years old

Case 2, 32 years old

Severe bilateral low back pain radiating to the posterior right thigh, calf, and lateral right foot: burning, stabbing, ache, and general weakness

Severe bilateral low back pain radiating to both buttocks, postero-lateral left leg, right posterior thigh and calf, and plantar surface of right foot; w/ right foot drop: at times, sharp, sore, stiff, throbbing, or tingling

Onset: began the previous day. She had to be assisted into the office.

Onset: motor vehicle accident 10 months earlier; had already received injections and 10-12 visits of chiropractic care

Pain: constant and severe (9 on NRS), with aggravation by coughing and sneezing

Pain: constant and severe (10 on NRS), with aggravation by coughing and sneezing

ROM: unable to achieve active lumbar motion; attempts in any direction aggravated pain.

ROM: active motion unrestricted in all planes, but flexion and extension aggravated pain.

Orthopedic tests: SLR on right increased low back pain at 45°, w/Bragard’s and Sicard’s tests positive, but Well Leg Raise negative on left.

Bechterew’s and Kemp’s tests bilaterally aggravated her pain.

Unable to lie on her right side at all; while lying on her left side, an Iliac Compression test increased her pain.

Posterior pelvic tilt increased low back pain.

Orthopedic tests: SLR on right increased low back pain at 45°, w/Bragard’s and Sicard’s tests positive, but Well Leg Raise negative on left.

Bechterew’s test, bilaterally, aggravated her pain; Kemp’s test only on the right side.

Able to lie on either side

Posterior pelvic tilt increased low back pain.

Neurological tests: mildly diminished strength of the right tibialis anterior muscle; patellar reflexes were hyper-reflexive and Achilles hypo- reflexive, both bilaterally; right S1 dermatome hypersensitive.

Neurological tests: normal motor strength; normal patellar and Achilles reflexes; right L4 dermatome hypersensitive.

Palpation of joints and muscles: right side lumbar and lumbosacral erector spinal muscles hypertonic; tenderness over right L4-5 and L5-S1 facet joints; decreased passive joint end play at L4-5 and L5-S1, bilaterally.

Palpation of joints and muscles: decreased passive joint end play at L4-5 and L5-S1, bilaterally.

Previous magnetic resonance imaging: right hemi-laminotomy at L4-5; disc bulge with a focal protrusion w/ mass effect on right L5 nerve root; adjacent epidural scar tissue; T12-L1 and L1-2 disc bulges w/ mild mass effect on thecal sac.

Previous magnetic resonance imaging: degenerative disc changes at L5-S1 w/ right-central herniation and likely compression right S1 nerve root and free fragment against L5 pedicle; slight retrolisthesis of L5 relative to S1.

Case 2: A 32-year-old sales representative was referred by her neurosurgeon and complained of severe bilateral low back pain radiating to both buttocks, as well as to the postero-lateral left leg and the right posterior thigh and calf, and plantar surface of the right foot. She also had noticed some right foot drop. Her condition was the result of a motor vehicle accident 10 months earlier. The pain was constant and severe, rated 10 out of a possible 10 on the NRS, with aggravation by coughing and sneezing. She described the pain as some combination of sharp, sore, stiff, throbbing, and tingling. By the time of her consultation she had already received several epidural steroid injections and had a date scheduled for a micro-discectomy. She had tried chiropractic care with another physician who provided her with side-posture adjustments and flexion distraction therapy, but she had only temporary relief after an estimated 10-12 visits. The neurosurgeon recommended a final trial of chiropractic care before consideration for surgery. Her clinical features are summarized in Table 3.

Her lumbar active range of motion was unrestricted in all planes, but both flexion and extension aggravated her pain. Straight Leg Raise performed on the right side increased the low back pain at approximately 45 degrees, and Bragard’s and Sicard’s tests were positive, while a Well Leg Raise on the left was negative. Bechterew’s test was provocative bilaterally. Kemp’s test aggravated her pain only when performed on the right side and her low back pain was aggravated by performance of a posterior pelvic tilt (Minicozzi’s sign). [4] Myotomes and myotatic reflexes were intact. The area along the L4 dermatome was hyperalgesic on the right. Passive joint end play at L4-5 and L5-S1 was decreased bilaterally.

Magnetic resonance imaging, done approximately 20 months earlier, showed evidence of degenerative disc changes at L5-S1 with a right-central disc herniation, with the central portion likely compressing the right S1 nerve root and an extruded disc fragment abutting the bottom of the L5 pedicle. There were reactive changes in both L5 and S1 and a trace retrolisthesis of L5 relative to S1. There was no appreciable facet arthropathy and the rest of her lumbar MRI was normal. Her treatment was built upon a diagnosis of a sequestered disc.

She was treated during 2 visits with a Category III protocol Sacro-Occipital Technique [9] blocking technique, for approximately 10-15 minutes each time, as described above; cryotherapy for approximately 10-15 minutes each time; and Active Isolated Stretching and Strengthening, [10] primarily targeting the pelvic, lumbar, and thigh muscles. Core strengthening exercises were included during both visits, focusing on posterior pelvic tilt movements, along with abdominal hollowing exercises. These exercises and cryotherapy were also prescribed to the patient as a home exercise plan; however, despite being compliant with instructions, she reported no decrease in pain and ultimately opted for surgery.

Discussion

The patients described above had similar complaints and examination findings (Table 3). Their care was similar; though Category III blocking may differ from one patient to another in the exact angles that the blocks are placed at, and AIS treatments may differ in how much effort is directed at specific muscles. Both patients initially reported an increase in symptoms upon active pelvic tilt maneuver, but while one patient recovered the other went on to surgery.

The principal author’s working hypothesis, based upon the anatomy of the lower lumbar spine, has been that patients whose symptoms resolve or lessen could have adhesions or scar tissue from previous injury, or other limitations of connective tissue. This line of thought was derived from discussions of the Shoulder Depressor test in chiropractic orthopedic textbooks by Evans and Cipriano. [11,12] Evans [11] states that inflammation from trauma can contribute to scar tissue formation around the dura mater and nerve roots, and within joint capsules; Cipriano [12] specifically mentions the dural sleeves around the nerve roots. Under normal circumstances, nerve roots are free to move up to half an inch within the intervertebral canals; but scar tissue may “tether” or constrict such movement. [11] If such movement is impeded, the nerve root becomes stretched, which may cause pain. [11,12] Additionally, epidural fibrosis could be a factor for those patients who have previously had back surgery. [13] For patients in this category, repeated performance of the pelvic tilt as an exercise could help rehabilitate the affected tissues. The principal author’s working hypothesis for patients whose symptoms increase or do not improve has been that they could be experiencing neurologic impingement or encroachment to a degree that would require surgical intervention. There is little evidence to confirm or dispute the working hypothesis, and more research is needed in this area.

In any case, the pelvic tilt maneuver may be used as a convenient monitoring tool. Painful provocation may resolve as the patient improves. Persistent painful responses suggest another course of action is needed including but not limited to referral.

The patient cases above are part of a minority; most patients with low back pain experience decreased pain when titling the pelvis posteriorly. [4] Exactly why that is remains unclear, though there is evidence that low back pain patients for whom the posterior pelvic tilt is palliative tend to have lower levels of pain and disability. [4] There has been limited research of the pelvic tilt maneuver. Levine [14] demonstrated that patients can voluntarily flatten the lumbar lordosis in a standing position by performing a pelvic tilt. Gracovetsky [3] advocated the posterior pelvic tilt position as a way to relieve compressive forces in the spine in various activities, including lifting. Suputtitada [15] recommended a sitting version as exercise for relief of low back pain in pregnancy and Gürşen [16] recommended it after caesarean section childbirth, along with other exercises and Kinesio Taping. Shin [17] included anterior-posterior pelvic tilting as one exercise of several in a rehabilitation program. When used as an exercise, posterior tilting of the pelvis is of fairly low intensity; it may not use the abdominal muscles at a level that would strengthen them [18,19] but it does activate them to a greater degree than abdominal hollowing. [18,20] Schoenfeld [21] demonstrated that, during performance of a “plank” exercise, upper abdominal muscle activity could be increased by adding in posterior pelvic tilting. It may be relevant that patients with LBP tend to stand with a sight anterior pelvic tilt, [22,23] and one study found that a larger lumbar lordosis angle in those for whom flexion provoked pain. [23]

Limitations

In general, single cases cannot be assumed to represent the general population. There is a limit to what can be known about each of the individuals involved in these cases and the factors related to their responses (or lack of response) to the care provided. However, the 2 individuals included in this report are generally representative of a number of others seen by the principal author in many years of monitoring pelvic tilt responses.

In some ways this report simply evokes the mystery of why some patients improve from chiropractic care and others, seemingly similar, do not. The authors do not claim to definitively answer the question, but they do offer another tool that may help. One of our objectives is that other practitioners may use the pelvic tilt maneuver and investigate further.

Conclusions

Two patients with low back and right lower extremity pain of similar presentation experienced markedly different outcomes following a similar treatment protocol. The authors found the posterior pelvic tilt test to be helpful in monitoring patient response. Higher level study would be required to make any comment regarding the utility of posterior pelvic tilt as a diagnostic or prognostic test.

Consent

Written informed consent was obtained from the patients for publication of this report. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

SJM developed the examination method, conceived of the project, collected data, and contributed to manuscript preparation. BSR organized the information and drafted the bulk of the manuscript.

Acknowledgments

Thank you to Dr. Ronald Evans for extensive suggestions for reorganization of the original version of the manuscript, and to Dr. Kathryn Hoiriis for additional literature search and for publication advice. There were no sources of funding.

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