Manual Therapy xxx (2011) 1e6

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Manual Therapy
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Original article

Immediate and lasting improvements in weight distribution seen in baropodometry following a high-velocity, low-amplitude thrust manipulation of the sacroiliac joint
Daniel de Oliveira Grassi a, Marcial Zanelli de Souza a, Silvia Belissa Ferrareto a, Maria Imaculada de Lima Montebelo a, Elaine Caldeira de Oliveira Guirro b, *
a b

Physical Therapy Program, College of Health Sciences, Methodist University of Piracicaba, Rodovia do Acar, Km 156 Campus Taquaral, Piracicaba, SP, Brazil Department of Biomechanics, Medicine and Rehabilitation of the Locomotor Apparatus, Medical School of Ribeiro Preto, University of So Paulo, Brazil

a r t i c l e i n f o
Article history: Received 14 September 2010 Received in revised form 11 April 2011 Accepted 14 April 2011 Keywords: Weight distribution Baropodometry Sacroiliac joint manipulation

a b s t r a c t
The biomechanics of the sacroiliac joint makes the pelvic segment responsible for proper weight distribution between lower extremities; however, it is known to be susceptible to altered mobility. The objective of this study was to analyze baropodometric responses following thrust manipulation on subjects with sacroiliac joint restrictions. Twenty asymptomatic subjects were submitted to computerized baropodometric analysis before, after, and seven days following sacroiliac manipulation. The variables peak pressure and contact area were obtained at each of these periods as the average of absolute values of the difference between the right and left foot based on three trials. Data revealed signicant reduction only in peak pressure immediately after manipulation and at follow-up when compared to pre-manipulative values (p < 0.05). Strong correlation was found between the dominant foot and the foot with greater contact area (r 0.978), as well as between the side of joint restriction and the foot with greater contact area (r 0.884). Weak correlation was observed between the dominant foot and the foot with greater peak pressure (r 0.501), as well as between the side of joint restriction and the foot with greater peak pressure (r 0.694). The results suggest that sacroiliac joint manipulation can inuence peak pressure distribution between feet, but contact area does not seem to be related to the biomechanical aspects addressed in this study. 2011 Elsevier Ltd. All rights reserved.

1. Introduction Weight distribution between feet during standing is the result of an intricate relationship between various mechanisms, such as proprioceptive postural afferents, motor control, kinesthetic memory, and adequate joint mobility (Winter, 1995; Peterka, 2002; Tjernstrm et al., 2005; Niessen et al., 2009). The sacroiliac joint (SIJ) can be cited as a highly important region regarding force distribution to the lower extremities, since it directs the descending body weight composed of the axial structure, head and upper extremities downward through the pelvis, across its neighboring soft tissues and consequently down the legs (Nourbakhsh et al., 2006; Vleeming et al., 2008). This joint is known

* Corresponding author. Faculdade de Medicina de Ribeiro Preto, USP, Curso de Fisioterapia, Av. Bandeirantes, 3900, Monte Alegre, Ribeiro Preto/SP, CEP 14.049900, Brazil. Tel.: 55 16 3602 4415; fax: 55 16 3602 4413. E-mail address: ecguirro@fmrp.usp.br (E. Caldeira de Oliveira Guirro). 1356-689X/$ e see front matter 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2011.04.003

to be vulnerable to arthrokinematic restrictions due to abundant interaction of descending forces and ascending counter-forces that occur in this region (Snijders et al., 1993), which potentially favors the development of altered joint mobility (Maigne et al., 1996; Hancock et al., 2007). Dreyfuss et al. (1994) found that asymptomatic individuals may present SIJ alterations when screened by four specic tests. Although such alterations might initially be painless, it is believed that later adaptations of segmental muscles, such as the paraspinal muscles, could lead to biomechanical compensations of the surrounding soft tissues and potential overload of other structures (Brumagne et al., 2000; Hungerford et al., 2003). In the long-term, such condition can contribute to the installation and maintenance of an actual dysfunction on the SIJ segment (Hungerford et al., 2003). According to Potter and Rothstein (1985), the innominate bone can suffer primarily an anterior or posterior restriction in either side of the pelvis. These restrictions are believed to be produced and maintained by altered functions of muscles, ligaments, fascia,

Please cite this article in press as: Grassi DO, et al., Immediate and lasting improvements in weight distribution seen in baropodometry following a high-velocity, low-amplitude thrust manipulation of the sacroiliac joint, Manual Therapy (2011), doi:10.1016/j.math.2011.04.003

D.O. Grassi et al. / Manual Therapy xxx (2011) 1e6

and other components of the spinal complex, which in turn can compromise adequate motion of the SIJ and increase the chances of further adaptive consequences (Mitchell, 1965; Bemis and Daniel, 1987; Levangie, 1999), where ultimately some form of therapeutic intervention might be needed (Gibbons and Tehan, 2001; Riddle and Freburger, 2002; Poley and Borchers, 2008). In this context, it is plausible that adequate function of the SIJ is fundamental for proper weight distribution, since the wedgeshaped sacrum permits force vectors to be homogeneously directed to the iliac partners, across the segmental soft tissues, and consequently down to the lower extremities (Mahato, 2010). Therefore, it can be inferred that positional asymmetries of the SIJ may interfere with ones ability to maintain orthostatism which could lead to consequent alteration in weight distribution between the feet, for a non-harmonious relationship between body parts can result in greater tension and overload at the support base (Teodori et al., 2005). Various studies have utilized computerized baropodometry in order to investigate the relationship which the body has with the ground during walking, jumping, or while maintaining a standing posture, in a way which is possible to obtain data pertinent to postural oscillation, ground contact area of the feet, peak contact pressure, and various other variables (Fabris et al., 2006; LpezRodrguez et al., 2007; Albuquerque-Sendn et al., 2009). It is known that such variables are useful in detecting functional alterations that may point out certain risk factors, such as instability of the center of pressure, discrepancy in feet contact area, and excessive increase in plantar pressure (Gravante et al., 2005; Teodori et al., 2005; Lpez-Rodrguez et al., 2007). High-velocity, low-amplitude thrust (HVLAT) techniques represent one of the intervention strategies for treatment of altered joint motion, since their underlying philosophy abides by the principle of regional interdependence, where biomechanical alterations in a particular body region, such as the vertebral, pelvic and limb joint complexes, can compromise functionality of neighboring structures (Wainner et al., 2007; Boyles et al., 2009). Theoretically, the correction of such alterations promotes local or distal benecial responses (Budgell and Hirano, 2001; Martin, 2004; Budgell and Pollus, 2006). However, the mechanisms behind such events have not yet been completely elucidated. In light of the scarcity of research relating joint manipulation with weight distribution responses, the present study aimed at exploring possible relationships between weight distribution alterations and the SIJ segment in normal individuals. Thus, the objective of this study was to assess the behavior of baropodometric valuables after an HVLAT manipulation of the SIJ in asymptomatic subjects.

characteristics listed in the exclusion criteria and ve others did not return for a follow-up evaluation. Subjects were excluded from the sample if they presented a negative response for positional variations of the SIJ, pain in the lumbopelvic region, rheumatic or orthopedic diseases, previous surgery in the lumbopelvic region, peripheral neuropathies, and pregnancy. Subjects were also excluded for presenting radicular pain consistent with nerve root compression or any other neurological signs. An absence during the scheduled follow-up evaluation also resulted in an exclusion from the sample, as well as the presence of actual leg-length discrepancy as seen by the distance between the anterior-superior iliac spine (ASIS) and the medial malleolus (Beattie et al., 1990). A body mass index (BMI) outside normal values also served as an exclusion criterion, for it has been observed that obesity may interfere with manual therapy assessments (Moriguchi et al., 2009). Fig. 1 illustrates the subject ow diagram. 2.2. Examination procedure All evaluation procedures were conducted by a single researcher with 15 years of experience in the utilization of manual therapy techniques. During assessment, each subject informed the researcher which lower extremity they considered to be the dominant one. In sequence, the assessment of SIJ motion was conducted according to the response obtained during the validated functional maneuver known as long sitting test according to the criteria established by Bemis and Daniel (1987), which determines the side of altered SIJ motion, and if there is innominate asymmetry characterized by anterior or posterior innominate restriction. With the subjects in supine, the alignment between medial malleoli was observed. The subjects then pulled themselves up to a long sitting position and the alignment was again noted. An apparent shortening of a limb in relationship to the other indicates the presence of an anteriorly rotated innominate bone on that side, while an apparent lengthening in relationship to the other denotes posterior

2. Methods 2.1. Subjects This study was approved by the Human Research Ethics Committee of the institution under protocol number 66/09. The subjects were invited to participate by means of public announcements, indications and personal contacts. All subjects were informed about the purpose and relevance of the study, and those who agreed to volunteer signed an informed consent form. During the screening process, a total of 31 asymptomatic individuals, both men and women, were seen in order to determine their compatibility with the studys criteria and objectives. Of this initial group, 20 subjects (6 men and 14 women, 23.18 1.85 years of age and 22.69 3.41 body mass index) participated in the studys entirety, since six subjects presented

Fig. 1. Subject ow diagram.

Please cite this article in press as: Grassi DO, et al., Immediate and lasting improvements in weight distribution seen in baropodometry following a high-velocity, low-amplitude thrust manipulation of the sacroiliac joint, Manual Therapy (2011), doi:10.1016/j.math.2011.04.003

D.O. Grassi et al. / Manual Therapy xxx (2011) 1e6

innominate rotation on that side (Potter and Rothstein, 1985). A negative response for joint mobility alteration can be dened as the absence of notable differences between malleoli alignment before and after assuming the long sitting position (Bemis and Daniel, 1987). In another study, Fryer (2006) suggests that clinicians can reliably detect medial malleoli asymmetries in asymptomatic subjects. Van der Wurff et al. (2000) and other authors (Vincent-Smith and Gibbons, 1999; Robinson et al., 2007; Rajendran and Gallagher, 2010) have found that, when performed in an isolated manner, almost all mobility tests of the SIJ do not present satisfactory results in terms of reliability and validity to justify their clinical application. However, the literature also states that the use of multiple tests and measurements increases the chance of a correct diagnosis (Bemis and Daniel, 1987; Cibulka and Kolderoff, 1999; Laslett et al., 2005; Arab et al., 2009). In this manner, the comparison of leg-length and palpation of the ASIS were conducted as complementary measures on all subjects in order to conrm the positional alteration of the innominate bones found during the long sitting test. The side with altered joint mobility was noted in each subject. At the end of the evaluation, all subjects were submitted to a baropodometric assessment before and immediately after joint manipulation, as well as seven days later during a follow-up evaluation. 2.3. Outcome measures For assessment of baropodometric variables, a MatScaneTecScan pressure platform, with 2288 sensors, 436 mm 369 mm in size, and resolution of 1.4 sensor/cm2, was utilized in this study. The equipment was calibrated with the individual weight of each subject while they remained standing on it. No instructions were given to the subjects regarding how to step onto the device in order to allow them to assume their habitual standing posture. Three readings of approximately 6 s each (200 frames per reading) were taken while the subjects remained standing still with their eyes xed directly straight at the horizon line. They were instructed to step off and then step back on the platform after each reading. In this manner, the variables peak pressure (PP) and contact area (CA) were recorded before and immediately after joint manipulation, as well as during the one week follow-up. The arithmetic average of all frames was utilized in order to obtain a nal value for the right and left foot for each subject regarding values from both baropodometric variables at each period of the study. The foot with greater PP and CA was noted in each volunteer as well. In this experiment, the subjects did not have

visual access to their graphical representation of plantar pressure distribution in order to prevent postural adjustments which would inevitably interfere with the results. 2.4. Intervention With the SIJ asymmetry conrmed in either anterior or posterior innominate rotation, an HVLAT was applied to the joint in the following manner: (a) for positional alterations in anterior innominate rotation, the subject was placed side-lying on a low treatment table with the affected SIJ facing upwards. After proper positioning of the caudal and cranial halves of the body, contact was made with the researchers forearm near the ischial region and, after reduction of tissue slack and joint play, a thrust technique was applied during the subjects deep exhalation; (b) for restrictions in posterior innominate rotation, the same criteria was followed, however, the manipulative contact was made on the posterior region of the iliac bone (Fig. 2). All subjects were informed about the possibility of audible pops or clicks, also known as cavitations (Ross et al., 2004), occurring as a result of the manipulative technique. Such cavitations are desired in manipulative practice (Flynn et al., 2003; Evans, 2002), but in their absence, the technique was repeated for up to two times where the segment was then considered manipulated (Flynn et al., 2003). After manipulation, leg-length measurement, ASIS palpation, and the long sitting test were repeated and the responses recorded. 2.5. Follow-up Aiming to observe possible lasting effects obtained from manipulation, the researchers reevaluated each subject seven days after initial assessment. The leg-length measurement, ASIS palpation, the long sitting test, and the baropodometric readings were repeated in the same manner as cited previously. 2.6. Data analysis Data analysis was conducted by blinded researchers. The sample size was calculated with 80% statistical power and an alpha error of 0.05 by means of StatMate 2 program based on a previously conducted pilot study (GraphPad. Software v. 2.0). With these parameters, a total number of 18 subjects were determined. The ShapiroeWilk normality test was utilized, followed by the paired t-test, with a signicance level established at 5%. In order to evaluate the relationship between variables, the Spearmans coefcient

Fig. 2. Positions adopted in order to theoretically manipulate the sacroiliac joint in the presence of an anteriorly rotated innominate bone (left image) or a posteriorly rotated innominate bone (right image).

Please cite this article in press as: Grassi DO, et al., Immediate and lasting improvements in weight distribution seen in baropodometry following a high-velocity, low-amplitude thrust manipulation of the sacroiliac joint, Manual Therapy (2011), doi:10.1016/j.math.2011.04.003

D.O. Grassi et al. / Manual Therapy xxx (2011) 1e6 Table 1 The mean, standard error, and condence interval of values pertaining to peak pressure. Mean Standard Error 0.01838 0.03597 0.02836 95% CI Lower 0.07376 0.03489 0.06141 Upper 0.15069 0.18548 0.05733 0.000007* 0.006403* 0.94342 p

Before/After Before/Follow-up After/Follow-up

0.11223 0.11019 0.00204

n 20; CI, condence interval; *p < 0.05.

Fig. 3. Data regarding mean and standard error of the differences between feet for peak pressure (Kg/cm2) before and immediately after joint manipulation, as well as seven days after initial evaluation. *Signicant difference (p < 0.05) when compared to pre-manipulative values.

and remained at 8.00% one week later, indicating that improvement occurred in weight distribution between feet, for they became more alike each other. In contrast with this nding, the mean difference between feet for total CA was 4.70%, 5.10%, and 5.09% for before, after, and at follow-up, respectively. All subjects displayed a negative response on the long sitting test after manipulation and at follow-up. 4. Discussion There are few studies that observed baropodometric responses after the utilization of manipulative techniques in any body region, which therefore makes it difcult to compare their results with those obtained in this study. This research represents an exploratory approach toward understanding the effects of joint manipulation on weight distribution in subjects with asymptomatic SIJ restriction, considering that a relatively high percentage of individuals do in fact present some form of positional alteration of the SIJ without experiencing pain or discomfort (Dreyfuss et al., 1994). Recent studies have not yet been able to prove the efcacy of palpation and mobility tests as reliable and valid diagnostic tools (Van der Wurff et al., 2000; Robinson et al., 2007; Vincent-Smith and Gibbons, 1999), despite the fact that manual therapy texts advocate their use in clinical practice. Nevertheless, various authors report that the concomitant use of multiple tests and measurements increases the chance of a correct diagnosis (Bemis and Daniel, 1987; Cibulka and Kolderoff, 1999; Laslett et al., 2005; Arab et al., 2009). Also, in a recent study conducted by Moriguchi et al. (2009), signicant discrepancy was observed for the assessment of the ASIS in overweight patients when compared to normal subjects. The same authors also observed greater intra-rater reliability for locating anatomical landmarks, which concurs with current literature (Fryer, 2006; Vincent-Smith and Gibbons, 1999; Moriguchi et al., 2009; Stovall and Kumar, 2010). Therefore the authors of the present study established as an exclusion criteria subjects with BMI outside normal values, as well as opted to have a single rater obtain all manual palpatory measurements in order to improve the accuracy of assessments. The numeric differences between feet for the PP and CA variables were compared prior to manipulation, immediately after the technique, and at follow-up, in this manner allowing the assessment of the behavior of these variables at each phase of the study. It was noted that discrepancies found in pre-manipulative PP

correlation was applied. Values for PP and CA before, immediately after manipulation, and at follow-up were utilized in order to calculate the standard error and the condence interval. 3. Results The analysis took into consideration the difference between both feet for values from PP and CA, since these are possible to be obtained separately for each foot. Therefore, the foot with a lesser value was subtracted from the one with greater value, and the difference was utilized to assess the relationship between feet for each phase of the study regarding PP and CA. With regards to PP, data analysis revealed signicant reduction (p < 0.05) in the difference between feet immediately after manipulation and at the one week follow-up when compared to pre-manipulative values. However, the same analysis did not demonstrate such behavior for CA. Figs. 3 and 4 illustrate these results. The mean, standard error, and the condence interval (CI 95%; p < 0.05) of PP and CA values before, immediately after and at follow-up are represented on Tables 1 and 2. After observing Spearmans coefcient correlation, the following results were found: strong correlation between the dominant lower extremity and the foot with greater CA (r 0.978); good correlation between the restricted side and the foot with greater CA (r 0.884); weak correlation between the dominant lower extremity and the foot with greater PP (r 0.501); fair correlation between the restricted side with the foot with greater PP (r 0.694). During the pre-manipulative period, the mean difference between feet was 13.30%, considering the total PP of both feet. This difference was reduced to 8.04% immediately after manipulation

Table 2 The mean, standard error, and condence interval of values pertaining to contact area. Mean Standard Error 1.06011 1.12371 0.88582 95% CI Lower 2.72923 2.88228 1.87399 Upper 1.70846 1.82161 1.83409 0.636 0.642 0.982 p

Fig. 4. Data regarding mean and standard error of the differences between feet for contact area (cm2) before and immediately after joint manipulation, as well as seven days after initial evaluation.

Before/After Before/Follow-up After/Follow-up

0.51039 0.53034 0.01995

n 20; CI, condence interval.

Please cite this article in press as: Grassi DO, et al., Immediate and lasting improvements in weight distribution seen in baropodometry following a high-velocity, low-amplitude thrust manipulation of the sacroiliac joint, Manual Therapy (2011), doi:10.1016/j.math.2011.04.003

D.O. Grassi et al. / Manual Therapy xxx (2011) 1e6

values became signicantly normalized immediately after manipulation and remained this way one week after initial readings. This could be explained by proprioceptive strategies adopted by the body which, according to Horak et al. (1990), involve ankle and pelvic joints in order to coordinate balance responses. LpezRodrguez et al. (2007) also observed improvement in stabilometric variables pertaining to weight distribution after talocrural manipulation in athletes with a previous history of ankle sprain. Considering the present results, the authors assessed the relationship between the side of altered SIJ mobility or the dominant lower extremity with the foot that displayed greatest PP. However, in the sample utilized, the correlation turned out not to be considered strong between the side of joint alteration and the foot with greater PP, as well as between the dominant lower extremity and the foot with greater PP, indicating that the PP variable apparently is not under the inuence of such factors. The behavior of the CA variable did not demonstrate signicant difference after manipulation or at the follow-up period. The difference between feet for CA remained unchanged while PP exhibited improvement. This nding corroborates with results from Lpez-Rodrguez et al. (2007), where apparently a normalization of PP was not inuenced by the behavior of CA, which remained unaltered after the manipulative technique. However, a strong correlation was seen between the dominant lower extremity and the foot with greater CA (r 0.978), as well as between the restricted side and the foot with greater CA (r 0.884). One can infer that by not affecting CA behavior, the side of the altered innominate position does not play a determinant role on this variable, since foot contact surface area remained unchanged even after normalization of SIJ mobility, as demonstrated by the negative long sitting response after manipulation. This indicates that, despite the strong correlation, CA is probably not inuenced by the biomechanical aspects addressed in this study, represented by the side of sacroiliac restriction, but perhaps by postural habits, represented by the dominant lower extremity. Possibly, the joint manipulation did not signicantly affect CA, since the technique favors primarily biomechanical components of the joint (Herzog, 2010). It is the authors belief that the manipulation inuenced asymmetric tensions throughout the pelvic complex and resulted in more equal force distribution to the lower extremities, even though the literature is scarce with regards to this theory. Tullberg et al. (1998) found that thrust manipulation on the SIJ does not alter the positional relationship between the sacrum and the ilium, therefore other mechanisms must be involved in directing forces transmission throughout body segments. Furthermore, it is known that joint manipulation provides proprioceptive inputs that may inuence motor control and the direction of biomechanical forces and weight distribution between feet (Heikkil et al., 2000; Pickar, 2002; Childs et al., 2004; Lpez-Rodrguez et al., 2007). It is therefore suggested that SIJ manipulation generated sufcient proprioceptive stimulation to inuence the distribution of axial forces to the lower extremities, resulting in improved pressure layout of PP, but was unable to affect postural reorganization and surface CA. At the follow-up evaluation, it was observed that both the baropodometric responses and the normalization of joint mobility lasted for seven days after initial sacroiliac manipulation. Even though the literature presents a wide variety of data regarding joint manipulation in different body regions, the results from the present study corroborate with the concept that joint manipulation promotes lasting biomechanical effects in the body. For Flynn et al. (2003), SIJ manipulation permitted signicant clinical improvement in patients with low back pain for at least two days after treatment. Corroborating with these ndings, various

other studies conrmed that joint manipulation can promote desirable clinical effects which are possible to be conrmed in short-, mid-, and long-term follow-up evaluations for joint dysfunctions in the extremities and in the lumbar, thoracic, cervical regions (Cleland et al., 2005; Licciardone et al., 2005; Boyles et al., 2009). The literature demonstrates that many musculoskeletal disorders are related to the regional interdependence principle (Pollard and Ward, 1998; Bang and Deyle, 2000; Boyles et al., 2009; Strunce et al., 2009), therefore it becomes important to understand the specic effects of SIJ manipulation on weight distribution, for then it might become possible to establish new correlations between abnormal weight distribution, overload prevention, and the use of joint manipulation. This concept was assessed in a study where patients with low back pain presented weight distribution discrepancies between feet of up to 9% of total body weight (Childs et al., 2003). The same authors observed an evident improvement on side-to-side weight bearing through the use of a manipulative technique, as well as marked reduction in lumbar pain (Childs et al., 2004). Corroborating with these ndings, the present study revealed improvement in weight distribution after the manipulative intervention. However, in the aforementioned studies, the equipments utilized in order to evaluate the weight-bearing relationship between feet were two digital scales, which, even though are very practical for routine clinical practice, do not permit an observation of other aspects related to weight distribution, such as peak contact pressure and foot contact area. In this manner, the ndings from this study hope to complement the mosaic of different results found in the literature regarding SIJ manipulation, as well as aid in the development of future research pertaining to this subject. It will be up to other studies to give continuity to these results with greater samples, the use of sham and control groups, and utilizing symptomatic subjects with complaints in regions related to the SIJ and other locations responsible for weight distribution, such as the lumbar spine and other articulations and structures of the lower extremities. 5. Conclusion The application of HVLAT manipulation in sacroiliac restrictions promoted a positive inuence on weight distribution between feet of asymptomatic subjects, as seen by the normalization of the variable PP in computerized baropodometry. Such changes were observed immediately after the manipulative intervention as well as at the one week follow-up evaluation. Additionally, CA is apparently under the inuence of postural habits due to the strong correlation between it and the dominant lower extremity. In order to further elucidate the complex relationships of regional interdependence, the authors recommend that additional studies be conducted in order to analyze the effects of SIJ manipulation on weight distribution in individuals with symptomatic dysfunction and alterations in any structures related to weight bearing during orthostatism. References
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Please cite this article in press as: Grassi DO, et al., Immediate and lasting improvements in weight distribution seen in baropodometry following a high-velocity, low-amplitude thrust manipulation of the sacroiliac joint, Manual Therapy (2011), doi:10.1016/j.math.2011.04.003

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Please cite this article in press as: Grassi DO, et al., Immediate and lasting improvements in weight distribution seen in baropodometry following a high-velocity, low-amplitude thrust manipulation of the sacroiliac joint, Manual Therapy (2011), doi:10.1016/j.math.2011.04.003