University of Wollongong Research Online University of Wollongong Thesis Collection University of Wollongong Thesis Collections 2000 The effect of chiropractic manual therapy on the spine, hip and knee Henry P. Pollard University of Wollongong Recommended Citation Pollard, Henry P., The effect of chiropractic manual therapy on the spine, hip and knee, Doctor of Philosophy thesis, Department of Biomedical Science, University of Wollongong, 2000. http://ro.uow.edu.au/theses/1097 Research Online is the open access institutional repository for the University of Wollongong. For further information contact Manager Repository Services: [email protected]. THE EFFECT OF CHIROPRACTIC MANUAL THERAPY ON THE SPINE, HIP AND KNEE. A thesis submitted in partial fulfillment of the requirements of the award of the degree Ph.D. from THE UNIVERSITY OF WOLLONGONG by HENRY P. POLLARD BSc, Grad Dip Chiropractic, Grad Dip App Sc, M Sport Sc DEPARTMENT OF BIOMEDICAL SCIENCE FACULTY OF HEALTH & BEHAVIOURAL SCIENCES 2000 1 Declaration The work presented in this thesis is the original work of the author except as acknowledged in the text. I, Henry Pollard hereby declare that I have not submitted any material as presented in this thesis either in whole or in part for a degree at this or any other institution. Signed: Date: ui OO 2 Dedication This thesis is dedicated to three very special people in my life. To my mother Rosetta who worked so very hard for so long to enable me the opportunity to seek an education. To my father Don for fostering an environment of encouragement and support. To my wife Grace for providing unconditional support so that I could satisfy my educational needs. You are all dear to my heart and I love you very much. 3 Acknowledgements To my supervisor and mentor Dr Graham Ward I extend my greatest thanks. Your expert direction and knowledge has been critical to the successful completion of this thesis, and your engaging style of academia should be viewed as a template for others to emulate. To the following chiropractors I extend my thanks for their support in various parts of the five studies: Su Lin Chen, Maree Chilton, Amanda Spence, Ian Taylor, Stuart Browne, Brad Hunter, Colin Jones, Nick Wilcox, Brian Wilder, Howard Vernon, David Stransky, Evan Rogers, Ian Roberts, Paul Hillard, Robert Koklich, Antonio Fresca, and Peter Geroulas. I wish to thank the Australian Spinal Research Foundation for financially supporting two of the five studies. I also wish to thank the University of Wollongong for providing seeding money to begin this study. 4 Abstract This thesis examined the effect of commonly used manual therapy protocols on the range of motion (ROM) of the hip joint. The first study compared two hip manual therapy treatments for increasing ROM at the hip and lumbar spine. 57 chronic back pain sufferers between 18 and 40 years voluntarily entered a randomised clinical trial with three groups of hip treatment (manipulation, stretching and control). Only the manipulation group increased the hip ROM significantly when compared to control. Also, manipulation of the hip was associated with significantly less back pain than the other group when compared to the control. Neither experimental group was significantly different to the control for changing lumbar ROM. The second study investigated the effect of manual therapy treatment on chronic knee pain and hip ROM in 57 subjects (between 47 and 70 years) with knee osteoarthritis. The results showed that manual therapy significantly decreased the short term pain reported by subjects, but the treatment did not change the hip ROM. The third study compared the effectiveness of an upper cervical manipulation or a manipulation of the sacroiliac joint for increasing hip ROM in 52 healthy university students. The results demonstrated that the two manipulation treatments resulted in increased ROM at the hip, but only the cervical procedure significantly increased hip ROM. The fourth study used similar methodology to the third to compare the effect of a sub occipital stretching technique to a hamstring stretching technique in 60 healthy university students. I have demonstrated that the two stretching treatments both increased hip ROM but only the spinal group was significant. The fifth study found that a group of healthy students receiving manipulation to the L3/4 motion segment statistically increased short term quadriceps femoris muscle strength. Taken together, these results help to document for the first time the effect of several clinical protocols used by manual therapists to increase the ROM at the hip joint. I conclude that: manipulation of the hip should be considered in protocols trying to achieve increased hip ROM, and that treatment of the spine demonstrated an improvement in peripheral joint function of the hip. Key words Chiropractic, Physiotherapy, Osteopathy, Manipulation, Stretching, Hip, Lumbar, Knee, Neck, Pain, Osteoarthritis, RCT 5 Table of contents Title Page 1 Declaration 2 Dedication 3 Acknowledgement 4 Abstract 5 Table of contents 6 List of figures 9 List of tables 10 Glossary of abbreviations 15 Chapter One 16 Introduction 17 Purpose of the study 21 Significance of the study 25 Chapter Two Review of the literature 27 Introduction 27 History of manual therapy 31 The Goals of Manual therapy 34 Stretching 39 Introduction 39 Who uses stretching 40 Types of stretches 42 The Static Stretch 42 The Ballistic Stretch 43 The Slow Stretch 43 Proprioceptive Neuromuscular Facilitation (PNF) Stretches 44 Time in stretch 45 The mechanism of increased ROM with stretches 46 EMG evidence for Mechanism of PNF (CRAC) stretching 55 Importance of warmup 58 Flexibility Sex differences 59 Stretching to prevent injury 61 Effect of a number of treatments 66 Summary stretching 72 Mobilisation 74 Manipulation 79 Indications And Contradictions For Manual Therapy..... 83 Indications for Stretching 83 Indications for Mobilisation 84 Indications for Manipulation..... 86 Contraindications for manual therapy 87 Contraindications for Mobilisation & Stretching 87 Contraindications for Manipulation 87 6 Function anatomy of the lumbopelvic region 91 Functional significance of the hamstring muscle group to the low back 91 The role of the hamstrings in LBP 93 EMG 95 Lumbopelvic rhythm 97 Stabilisation mechanisms of the lumbopelvic region 104 Cantilever model of the spine 104 Intra-abdominal pressure mechanism 105 Posterior ligament system 106 Thoracolumbar fascia mechanism 106 The hydraulic amplifier 107 Arch model of the spine 108 Trunk muscle action 109 Spinal extensor muscles 109 Lumbar ROM in the Sagittal Plane Ill Lumbar spine 112 Diurnal variation in lumbar ROM 114 Electrical activity in the lumbar spinal extensors during lumbar flexion 115 The sacroiliac joint contribution to sagittal plane flexibility of the lumbopelvic rhythm 116 The structure and function of the SIJ 116 A brief description of hip anatomy 118 Hip ROM 118 Joint Congruency of the hip 119 The thoracolumbar fascia (TLF) 119 Movement and hip flexion range of motion 121 Mechanics of the Straight Leg Raise 123 The Toe Touch Test (TTT) 126 Myoelectric Activity during the straight leg raise 127 Myoelectric Activity in the Toe Touch Test (TTT) 127 Assessment procedures 129 Measurement of Lower Back Pain 135 Chapter Three Abstract 141 Hypotheses 142 Aims 143 Materials And Methods 145 Results 158 Discussion 170 Recommendations 192 Conclusion 194 Chapter Four Abstract 196 Introduction 197 7 Materials And Methods 200 Results 203 Discussion 209 Conclusion 214 Chapter Five Abstract 216 Introduction 217 Materials And Methods 219 Results 223 Discussion 225 Conclusion 232 Chapter Six Abstract 234 Introduction 235 Materials And Methods 238 Results 241 Discussion 243 Conclusion 248 Chapter Seven Abstract 250 Introduction 251 Methods And Materials 258 Results 261 Discussion 263 Conclusion 270 Chapter Eight Discussion 271 Chapter Nine Conclusion 291 Chapter Ten Recommendations 295 Chapter Eleven References 297 Chapter Twelve Appendix One 372 Appendix Two 375 Appendix Three 375 8 List of figures Figure 2.1 Classification of grades of movement. p76 Figure 2.2 Emotive analogy of manipulation and gunshot. p77 Figure 2.3 Schematic of paraphysiological range achieved with manipulation. p82 Figure 2.4 Maitland's grading system. p89 Figure 2.5 Anatomy of the posterior thigh. p92 Figure 2.6 Normal lumbopelvic rhythm (LPR). p98 Figure 2.7 Flexion and extension phases of the LPR. pi00 Figure 2.8 Cantilever model of the spine pi04 Figure 2.9 Intra-abdominal pressure pl05 Figure 2.10 The thoracolumbar fascia (TLF) pi07 Figure 2.11 The hydraulic amplifier pi07 Figure 2.12 The arch model of the spine (Part 1) pi08 Figure 2.13 The arch model of the spine (Part 2) pi09 Figure 3.1 Surface markings for experimental protocol. pl49 Figure 3.2 Schematic of hip and lumbar angles for experimental protocol. pi50 Figure 3.3 Diagram of SLR position of practitioner. pi52 Figure 3.4 Hip manipulative procedure part one. pi54 Figure 3.5 Hip manipulative procedure part two. pl55 Figure 3.6 Hip stretching procedure. pi56 Figure 4.1 T)iagramatic representation myofascial release of patellofemoral joint. p201 9 List of tables Table 1.1 Summary Of Comparison Of Stretching Methods p64 Table 2.1 A comparison of results from studies of lumbar ROM from full extension to full flexion using roentgenographic analysis, pi 12 Table 2.2 A comparison of reliable assessments of hip and lumbar range of motion. pl31 Table 3.1 Pre treatment SLR ROM differences between males and females in degrees (Paired