Journal of Back and Musculoskeletal Rehabilitation 26 (2013) 33–36 33

DOI 10.3233/BMR-2012-0347
IOS Press

Manipulation and selective exercises decrease

pelvic anteversion and low-back pain: A pilot
study
Alexandre Carvalho Barbosaa,b,∗, Fábio Luiz Mendonça Martinsa,c ,
Michelle Cristina Sales Almeida Barbosab and Rúbia Tenile dos Santosd
a
Department of Physiotherapy, Federal University of Valleys of Jequitinhonha and Mucuri, Diamantina, Brazil
b
Department of Health Education, Federal University of Valleys of Jequitinhonha and Mucuri, Diamantina, Brazil
c
Department of Medicine, Italian University Institute of Rosario, Rosario, Argentina
d
Department of Physiotherapy, Seama College, Macapá, Brazil

Abstract.
OBJECTIVES: To study the effect of a protocol involving joint manipulation and specific exercises for pelvic stability to
influence proprioceptive input to the spinal tissues and to observe the effects on sensorimotor function.
METHODS: Seven patients with pelvic anteversion and low back pain participated in an eight-week protocol (three sessions per
week/nonconsecutive days). At each session, a high-velocity, low-amplitude manipulative thrust was applied to the sacroiliac
joint, followed by quadriceps eccentric and hamstring concentric contractions. The perceived pain symptoms, pelvic anteversion
as determined by photogrammetry analysis, and the electromyographic activity of the rectus femoris and lateral and medial
hamstrings during flexion and extension exercises were assessed before and after treatment. Non-parametric tests were used to
compare the groups before and after treatment with α = 0.05.
RESULTS: Perceived pain symptoms decreased after treatment (p = 0.0007). The differences in the pelvis angles (p = 0.0130)
suggested significant differences between the assessments, and the electromyographic activities of all the muscles during isometric
voluntary contraction increased.
CONCLUSION: The eight-week manipulation/exercise protocol was effective for these subjects’ needs. Further research should
include a greater sample size to confirm the results and to determine the lead factors of pelvic stability.

Keywords: Physiotherapy, manipulation, electromyography, low back pain

1. Introduction
The sacroiliac joints (SIJ) are richly innervated by
nociceptors and proprioceptors, and these joints are the
primary source of low-back pain (LBP) episodes (ap-
proximately 40% of cases). LBP is well recognized as
a public health problem, impacting up to 80% of adults
at some point in their lives, and also the major con-
tributor to disability and to increasing costs in health
∗ Address for correspondence: Alexandre Carvalho Barbosa, MSc,
Department of Physiotherapy – Federal University of Valleys of Je-
quitinhonha and Mucuri, MGT 367 Road-Km 583, n◦ 5000, Alto da
Jacuba, Diamantina, MG, Brasil. Tel.: +55 38 3532 1200; Fax: +55
38 3531 9008; E-mail: alexwbarbosa@yahoo.com.br.
care [1,2]. The SIJ are closely related to the persistent
causes of LBP [3], and lesions in this joint might cause
biomechanical changes with different pain patterns due
to the joint’s complex structure and innervation. Joint
stability is important during usual body activities or
to maintain standing position and, despite having low
mobility, the SIJ are related to pelvic torsional asym-
metry (TA), which is defined as a positional rotation
of one iliac to another, often associated with sacroiliac
dysfunction [4].
The dynamic factor, provided by the adjacent mus-
cles, and the static factor, provided by the joint compo-
nents (cartilage, capsule, ligaments and synovia), con-
tribute to joint stability. Therefore, to influence motor
control, the stimulus to modulate the muscle and joint

ISSN 1053-8127/13/$27.50  2013 – IOS Press and the authors. All rights reserved
34 A.C. Barbosa et al. / Manipulation and selective exercises decrease pelvic anteversion and low-back pain
receptors becomes significant to the patient’s function-
al recovery. An increasing body of evidence suggests
that spinal manipulation provides an important benefit
to patients with LBP [5]. Joint manipulation has been
studied to stimulate these sensory receptors and to af-
fect the central nervous system (CNS) at the spinal seg-
mental level and the cortical level. Therefore, the neu-
rophysiological effects and treatment results for mus-
culoskeletal disorders may be dependent on the magni-
tude of forces applied by manual intervention [6].
A study showed that different proprioceptive training
induces neural adaptations that specifically affect the
recruitment and the trigger rates of the motor units at
the beginning of voluntary contraction [7]; however,
the association of muscle and joint techniques, which
are specific to TA, remains unclear.
The approach in this current study is to use a protocol
involving joint manipulation and specific exercises for
pelvic stability as a tool to influence proprioceptive
input to the spinal tissues and to observe the effects on
sensorimotor function.
2. Method
The participants were 7 sedentary adult subjects (18–
35 years of age). The inclusion criteria were to present
pelvic anteversion and LBP without radiculopathy. The
subjects were selected by physiotherapeutic assessment
and photogrammetry analysis. The local ethics com-
mittee for human investigation approved the procedures
employed in the study, and all the subjects gave their
written informed consent prior to participation.
2.1. Outcome measurements
The photographs were acquired using a Sony dig-
ital camera, 7 mega pixels, set on a tripod 3 meters
away from the subject, properly centralized and leveled
at a height of 85 cm, in a well-lit and reserved room,
with anti-glare protection. The volunteers were pho-
tographed in side view with their arms crossed on their
chest. Circular red markers were placed at the anterior
superior and posterior superior iliac spines. Two lines
were drawn using the program ALCimagem [8]: the
first between the iliac spines and the other parallel to
the ground, with an angle of 180 degrees between the
lines [9].
2.2. Instrumentation
A biological signal acquisition module with four ana-
log channels was used. The conversion of analog to dig-
ital signals was performed by an A/D board with 14-bit
resolution input range, sampling frequency of 2000 Hz,
common rejection module greater than 100 dB, signal
noise ratio less than 03 μV RMS and impedance of
109 ohms. The electromyography (EMG) signals were
recorded by root mean square (RMS) in μV and the av-
erage frequency in Hz with surface electrodes (20 mm
diameter and a center-to-center distance of 20 mm). A
reference electrode was placed on the left lateral epi-
condyle. Prior to fixation of the electrodes, the skin
was cleaned with 70% alcohol to eliminate residual fat,
followed by exfoliation using a specific sand paper for
skin and a second cleaning with alcohol. The muscles
analyzed by surface EMG were as follows: (1) rec-
tus femoris (RF), (2) lateral hamstring (LH): biceps
femoris, (3) medial hamstrings (MH): semimembra-
nosus and semitendinosus [10,11]. Each volunteer per-
formed 3 maximum isometric voluntary contractions
(MVC) of extension and flexion of the leg, each lasting
6 seconds with a 3-minute interval between contrac-
tions, measured by a digital dynamometer. The data
were obtained from the average of the three MVC. The
extension strength was determined with the patient in
a sitting position, hip and knee angled at 90 degrees.
Flexion was determined with the patient in a standing
position and with an initial 90 degrees of knee flexion.
Using a 10-cm line, the patient was asked to mark the
point that represents the current intensity of pain. The
Visual Analogue Scale (VAS) value was then calculat-
ed by measuring the distance in centimeters from the
right edge of the line.
2.3. Therapeutic interventions
The experimental protocol was applied for 8 weeks
(3 sessions per week/nonconsecutive days). At each
session, a high-velocity, low-amplitude manipulative
thrust was applied to the SIJ with the contact hand on a
specific area of the pelvis (posterior superior iliac spine,
ischial tuberosity, sacral ala). Short, controlled move-
ment of the doctor’s upper body, shoulder and arm,
often combined with a slight falling or “body-drop”
movement creates the motion, momentum and position
for the thrust, which is delivered through the contact
hand. Next, isotonic muscle exercises were performed
at MVC 12% load. The specificity of the kinesthetic
stimuli was observed to affect the motor engram and
to decrease pelvis anteversion. Each volunteer was po-
sitioned on the treatment table with 90 degrees of hip
flexion and the knee extended. The subject proceeded
with sets of isotonic eccentric contractions for quadri-
 A.C. Barbosa et al. / Manipulation and selective exercises decrease pelvic anteversion and low-back pain
Table 1
Rehabilitation guidelines: quadriceps eccentric contractions and
hamstring concentric contractions
Activity Duration
Week 1 exercises 4 sets of 15 repetitions / 15 second hold
Week 2 exercises 3 sets of 15 repetitions / 15 second hold
Week 3 exercises 4 sets of 10 repetitions / 10 second hold
Week 4 exercises 3 sets of 10 repetitions / 10 second hold
Week 5 exercises 4 sets of 12 repetitions / 15 second hold
Week 6 exercises 3 sets of 12 repetitions / 15 second hold
Week 7 exercises 4 sets of 8 repetitions / 10 second hold
Week 8 exercises 4 sets of 8 repetitions / 10 second hold
ceps flexion. Next, while in a prone position with
knee and hip extension, the subject performed isotonic
concentric contractions until 90 degrees of knee flex-
ion were reached. The number of repetitions and series
varied in each session, providing asymmetric stimuli,
not allowing accommodation and providing constant
neurophysiological response by the mechanoreceptors
(Table 1).
2.4. Data analysis
We applied a pre- (A1) and post-assessment (A2),
and the values obtained in the EMG analysis, pho-
togrammetry and VAS were used for statistical com-
parisons. The Shapiro-Wilk test was used to test the
Gaussian distribution of the variables under study. As
normality was rejected, the Wilcoxon non-parametric
test was used to determine whether the differences be-
tween the samples were significant at the p < 0.05
level. All the statistical analyses were performed using
BioEstat software (Version 5.0; BioEstat; Belém, PA,
Brazil) [12].
3. Results
The subjects presented no complaints of adverse ef-
fects due to the exercise or the manipulation protocol.
The results of the pain assessment were obtained using
VAS. Significant results (p = 0.009) were obtained be-
tween the baseline and final assessments with average
results as follows: A1: 5.83 ± 1.59 cm and A2: 1.29 ±
0.58 cm.
The difference of the pelvis angles (p = 0.009),
observed in the photogrammetry, suggested a signifi-
cant difference between the assessments (A1: 20.38 ±
5.70 degrees and A2: 14.63 ± 2.17 degrees).
The statistical analysis showed a significant increase
in the RF, IL and IM electromyographic signal dur-
ing maximal isometric voluntary contraction after eight
weeks of treatment (Table 2).
35
4. Discussion
The SIJ are richly innervated by nociceptors and
proprioceptors [1]. Histological analysis confirms the
presence of nerve fibers (myelinated and demyelinat-
ed) in the capsule and ligaments and in the mechanore-
ceptors and nociceptors, suggesting that pain and pro-
prioceptive information is transmitted from the SIJ [2].
Therefore, we expected that by providing specific stim-
uli to the joint and muscle, positional changes and pain
response could be noted. A previous study, including
only the muscle protocol at 20% of maximum load,
demonstrated that the pelvic positioning and subject
pain perception can be altered by physical therapy inter-
vention [3]. However, including articular intervention,
neurophysiological stimuli to deform articular struc-
tures rich in sensory inputs, should lead to changes in
the axoplasmic afferent inflow. We inferred that these
changes brought awareness to the CNS, modifying mo-
tor patterns and suggesting that the CNS is able to
contribute to reduce clinical symptoms [13]. A study
showed that manipulations applied peripherally in the
cervical spine can cause changes in cortical plastici-
ty, altering somatosensory processing and sensorimotor
integration, leading to pain decrease and functional re-
structuring by manipulative treatment [14]. Joint stim-
ulus might also cause nociceptive inhibition by releas-
ing plasmatic β-endorphins [3]. Significant improve-
ments were observed after treatment with respect to the
subjects’ usual perceived pain and reduced pain dur-
ing functional dynamic activities. The trunk kinematics
were expected to improve during functional activities
because the movement patterns were executed more
correctly and thus reduced the stress on the SIJ and con-
sequently decreased pain symptoms. We speculate that
improved motor control motion played an important
role in the improvement of pain symptoms.
For dynamic stabilization of the SIJ, the ideal pattern
to improve positional control seems to be a protocol that
combines muscle control without exhausting the mus-
culoskeletal system and concomitantly activates the re-
ceptors in the muscles and joints. The sensory map is
continuously corrected by sensory feedback according
to proprioceptive priority, given by the influx of afferent
receptors [15]. Muscle or joint receptors are received
from the protocol proprioceptive priority stimuli to cor-
rect the anteversion disorder. In this type of TA, the hip
flexor muscles are predominant in the closed kinetic
chain, rotating and decreasing ilium mobility. Analyz-
ing the hip extensor muscles, the opposite pattern may
be noted: the hamstring’s failure to stabilize the hip
36 A.C. Barbosa et al. / Manipulation and selective exercises decrease pelvic anteversion and low-back pain
Muscle electrical activity. A1: baseline in millivolts (mV); A2: final evaluation in millivolts (mV); Δ%: delta
percentage (%); p: significant differences; RF: rectus femoris; IL: ischiotibial lateral; IM: ischiotibials medial
Extension
RF IL
A1 1.10 ± 0.30 1.01 ± 0.21
A2 1.57 ± 0.04 1.26 ± 0.13
Δ% 29.71 20.29
p 0.0005 0.004
flexor action. Instead, to only stretch the hip flexors,
we propose for these muscles to prioritize the eccentric
isotonic exercise to induce proprioceptive stimuli and
to develop the muscles that eccentrically stabilize the
system. Similarly, the use of concentric exercise was
recommended for the hamstrings, providing specificity
for the system [3]. The results indicate that EMG activ-
ity in all the muscles examined increased significant-
ly, and these changes may be due to the neurophysio-
logic mechanism, with more muscle fibers being acti-
vated for the same task. The protocol does not allow
us to infer significant changes in structural tissue, so
we suggest only improved coordination by better sen-
sory feedback and hence, greater control over muscle
contraction during the pelvis stabilization.
In conclusion, this study demonstrated that an eight-
week manipulation/exercise protocol was effective for
the subjects’ needs. Further research should include a
greater sample size to confirm the results and to deter-
mine the lead factors of pelvic stability.
Conflict of interest
There is no conflict of interest.
Acknowledgements
We gratefully acknowledge the technical support
from the Department of Physiotherapy of UFVJM and
Seama College.
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Flexion
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1.34 ± 0.01 1.57 ± 0.04 1.26 ± 0.13 1.34 ± 0.01
44.90 29.90 20.05 37.85
0.0005 0.0005 0.002 0.0005
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