Effect of the Abdominal Drawing in Maneuver and. Band on Lumbopelvic Kinematics in Subjects With. Lumbar Extension Rotation Syndrome

Transcription

1 Effect of the Abdominal Drawing in Maneuver and Self Stretching the Tensor Fasciae Latae Iliotibial Band on Lumbopelvic Kinematics in Subjects With Lumbar Extension Rotation Syndrome Onebin Lim The Graduate School Yonsei University Department of Physical Therapy

2 Effect of the Abdominal Drawing in Maneuver and Self Stretching the Tensor Fasciae Latae Iliotibial Band on Lumbopelvic Kinematics in Subjects With Lumbar Extension Rotation Syndrome Onebin Lim The Graduate School Yonsei University Department of Physical Therapy

3 Effect of the Abdominal Drawing in Maneuver and Self Stretching the Tensor Fasciae Latae Iliotibial Band on Lumbopelvic Kinematics in Subjects With Lumbar Extension Rotation Syndrome A Masters Thesis Submitted to the Department of Physical Therapy and the Graduate School of Yonsei University in partial fulfillment of the requirements for the degree of Master of Science Onebin Lim December 2012

4 This certifies that the masters thesis of Onebin Lim is approved. Thesis Supervisor: Chunghwi Yi Ohyun Kwon: Thesis Committee Member #1 Heonseock Cynn: Thesis Committee Member #2 The Graduate School Yonsei University December 2012

5 Acknowledgements Writing my thesis was a greater challenge than I initially expected, and had it not been for the help of many people around me, this thesis would have never been completed. My thesis committee provided me with outstanding mentoring, and the time, energy, and expertise they devoted to ensuring that my research was meaningful is gratefully appreciated. I would like to acknowledge each of them for their contribution to my thesis. First of all, I would like to express my deepest gratitude to Professor Chunghwi Yi for his great support during this thesis, and the heartfelt encouragement he provided throughout my graduate study. Whenever I had doubts and worries, he was there for me and sincerely wished for my success. I would also like to convey my respect and appreciation to Professor Ohyun Kwon for his enormous help. He taught me how to question my thoughts and express ideas, his insightful advice helped me overcome many crises and finish this thesis. I am also grateful to Professor Heonseock Cynn for his smile, kindness, and intelligent advice. His continual attention and detailed comments on my research helped me focus my ideas. I also sincerely thank Professors Sanghyun Cho, Hyeseon Jeon, and Seunghyun Yoo, who helped expand my knowledge and perspectives.

6 I am indebted to Professor Soyeon Park for her constant encouragement, guidance, and insight. I am truly grateful to Minhee Kim, Dohheon Jung, and Jia Hong for providing continual support, constructive feedback, and encouragement through the joys and sorrows of graduate student life. I thank Silah Choi, Jeongah Kim, Woosuk Lim, and Jaeik Sohn for helping me with laboratory work and providing valuable support. I would like to thank all of the members in the Graduate School Department of Physical Therapy. They have provided me with tremendous mental support and friendship during my school years. More than anybody, I wish to express my deepest love and gratitude to my parents who have provided tremendous mental and physical support. Without their strong belief in me and endless encouragement, I could never have finished my graduate study. Thus, I would like to dedicate this thesis to my parents.

7 Table of Contents List of Figures iii List of Tables iv Abstract v Introduction 1 Methods 4 1. Subjects 4 2. Clinical Measurements Visual Analogue Scale Tensor Fasciae Latae Iliotibial Band Length Test 7 3. Experimental Equipment Three Dimensional Motion Analysis System 9 4. Outcome Measurements Kinematic Data Procedures Interventions Statistical Analysis 15 Results General Characteristics of Subjects Lumbopelvic Rotation Angle Lumbopelvic Rotation Movement Onset 17 i

8 4. Tensor Fasciae Latae Iliotibial Band Length Pain Intensity 19 Discussion 22 Conclusion 26 References 27 Abstract in Korean 36 ii

9 List of Figures Figure 1. Hip lateral rotation position 12 Figure 2. Abdominal drawing in maneuver training using a pressure biofeedback unit 14 Figure 3. Self stretching the tensor fasciae latae iliotibial band 14 Figure 4. Lumbopelvic rotation angle between group differences 20 Figure 5. Lumbopelvic rotation movement onset between group differences 20 Figure 6. Tensor fasciae latae iliotibial band length between group differences 21 Figure 7. Pain intensity between group differences 21 iii

10 List of Tables Table 1. Movement system impairment based lumbar extension rotation classification criteria 6 Table 2. General characteristics of subjects 16 iv

11 ABSTRACT Effect of the Abdominal Drawing in Maneuver and Self Stretching the Tensor Fasciae Latae Iliotibial Band on Lumbopelvic Kinematics in Subjects With Lumbar Extension Rotation Syndrome Onebin Lim Dept. of Physical Therapy The Graduate School Yonsei University The purpose of this study was to compare the effect of a 2 week period of the abdominal drawing in maneuver (ADIM) and tensor fasciae latae iliotibial band (TFL ITB) self stretching on lumbopelvic rotation angle, lumbopelvic rotation movement onset, TFL ITB length, and pain intensity during active prone hip lateral rotation. Twenty two subjects with lumbar extension rotation syndrome accompanying shortened TFL ITB (16 males and 6 females) were recruited for this study. The subjects were instructed how to perform ADIM training or ADIM training v

12 plus TFL ITB self stretching program at home for a 2 week period. A three dimensional ultrasonic motion analysis system was used to measure the lumbopelvic rotation angle and lumbopelvic rotation movement onset. An independent t test was used to determine between group differences for each outcome measure (lumbopelvic rotation angle, lumbopelvic rotation movement onset, TFL ITB length, and pain intensity). The level of significance was set as α = The results showed that ADIM training plus TFL ITB self stretching decreased the lumbopelvic rotation angle, delayed the lumbopelvic rotation movement onset, and elongated the TFL ITB significantly more than did ADIM training alone. Pain intensity was lower in the ADIM training plus TFL ITB self stretching group than the ADIM training alone group; however, the difference was not significant. In conclusion, ADIM training plus TFL ITB self stretching performed for a 2 week period at home may be an effective treatment for modifying lumbopelvic motion and reducing low back pain. Key Words: Abdominal drawing in maneuver, Lumbar extension rotation syndrome, Lumbopelvic kinematics, Tensor fasciae latae iliotibial band. vi

13 Introduction Low back pain (LBP) is a common musculoskeletal problem that affects 70 85% of the population at some point in their lifetime (Hartvigsen et al. 2000; O Sullivan 2005; Walker, Muller, and Grant 2004). Several investigators have proposed that repeated lumbopelvic motion plays a role in the development and course of LBP symptoms (Adams et al. 2002; McGill 1997; Sahrmann 2002). LBP symptoms associated with increased lumbopelvic motion, particularly early in the range of trunk and lower extremity movements during daily activities (Gombatto et al. 2006; Hoffman et al. 2011; Luomajoki et al. 2008; Roussel et al. 2009; Shum GL, Crosbie J, and Lee RY 2005). Sahrmann (2002) reported that hip lateral rotation (HLR) was impaired in individuals who had LBP symptoms. Specifically, people with LBP symptoms showed a coupled movement pattern that moved the lumbopelvic region and hip joint simultaneously in the early part of the HLR test (Gombatto et al. 2006). Manually restricting lumbopelvic motion during the HLR test has been reported to decrease LBP symptoms (Van Dillen et al. 2009). Sahrmann (2002) found an increase in lumbopelvic rotation during the active HLR test in the prone position in people with lumbar extension rotation syndrome. The Movement System Impairment (MSI) classification system for low back pain categorizes patients with mechanical LBP into five subgroups according to alignment, movements, and symptoms associated with LBP (Sahrmann 2002). The relationship between LBP and limited HLR is of interest because decreased HLR causes - 1 -

14 compensatory lumbopelvic rotation which exerts force on the lumbar region (Ellison JB, Rose SJ, and Sahrmann SA 1990; Mellin 1990; Vad et al. 2004). This force results in low magnitude loading, cumulative microtrauma, increased tissue stress in the lumbopelvic region and, eventually, LBP (McGill 1997; Sahrmann 2002). The abdominal drawing in maneuver (ADIM), a method of lumbar stabilization training (Akuthota, and Nadler 2004; Hodges, and Richardson 1996), is an effective neuromuscular intervention for lumbar instability associated with LBP (Akuthota, and Nadler 2004; Macedo et al. 2009; von Garnier et al. 2009). ADIM can be achieved by the co contraction of the transversus abdominis (TrA), internal oblique (IO), and multifidus muscles, together with minimal contraction of other superficial abdominal (external oblique; EO) and paraspinal muscles (Cynn et al. 2006; Hides et al. 2006). Co contraction of the TrA and multifidus muscles restricts rotation or returns the lumbar spine to the neutral position from a rotated position by tensioning the lateral attachment of the thoracolumbar fascia (Hodges, and Richardson 1999). Previous studies have shown that ADIM training using a pressure biofeedback unit can prevent unwanted lumbopelvic motion and enhance training effect of lumbar stability (Cynn et al. 2006; Park et al. 2011; von Garnier et al. 2009). Limited HLR range is associated with shortened tensor fasciae latae iliotibial band (TFL ITB) (Sahrmann 2002). The TFL ITB acts as a flexor, abductor, and medial rotator of the hip joint and extensor and lateral rotator of the knee joint (Kendall et al. 2005). The altered TFL ITB length gives rise to compensatory hip joint motion and impaired movement in the lumbopelvic region. Shortness of the TFL ITB limits HLR - 2 -

15 and increases lumbopelvic motion in the transverse plane in patients with LBP (Sahrmann 2002). Fredericson et al. (2002) reported that the TFL ITB standing stretch with arms extended overhead effectively increased TFL ITB length. Previous studies have reported using verbal instruction, tactile feedback, and manual stabilization during HLR to modify excessive lumbopelvic motion and decrease LBP (Hoffman et al. 2011; Scholtes et al. 2010). However, a home exercise program is necessary to successfully modify lumbopelvic motion and reduce LBP. To our knowledge, no study of the effect of ADIM training and ADIM training plus self stretching the TFL ITB on lumbopelvic motion during active prone HLR has been published previously. The purpose of the present study was to compare the effect of a 2 week intervention consisting of ADIM training or ADIM training plus self stretching of the TFL ITB on lumbopelvic rotation angle, lumbopelvic rotation movement onset, TFL ITB length and pain intensity during active prone HLR in people with lumbar extension rotation syndrome accompanying shortened TFL ITB. We hypothesized that ADIM training plus self stretching of the TFL ITB would decrease the lumbopelvic rotation angle, delay the lumbopelvic rotation movement onset, increase TFL ITB length, and decrease pain intensity more than ADIM training alone

16 Methods 1. Subjects Prior to recruiting study subjects, we performed a power analysis to determine the number of subjects required to achieve the effect size of 2.28, the alpha level of 5%, and the power of 80% based on the pilot study performed on subjects with lumbar extension rotation syndrome accompanying shortened TFL ITB. The results of the power analysis showed that this study would require 10 subjects. Twenty-two subjects (16 male and 6 female) with lumbar extension rotation syndrome accompanying shortened TFL ITB participated in this study. Inclusion criteria included a limited hip adduction range (< 10 ) caused by a shortened TFL ITB (Kendall et al. 2005) and reported LBP for more than 6 months (Von Korff 1994). Twenty two subjects were randomly allocated into one of two intervention groups: ADIM training, or ADIM training plus TFL ITB self stretching. Subjects were screened by an examiner who has completed an academic course on the MSI classification system. The examiner selected 22 subjects from 100 subjects based on the MSI classification criteria for lumbar extension rotation syndrome (Sahrmann 2002; Trudelle Jackson, Sarvaiya Shah, and Wang 2008; Van Dillen et al. 1998). Of the 100 subjects examined, 78 subjects were excluded from the study because they did not meet the selection criteria for lumbar extension rotation syndrome. The - 4 -

17 classification criteria for lumbar extension rotation syndrome are shown in Table 1. These classification criteria consist of alignment and movement tests. Primary tests are provocation tests that are designed to assess movements or stresses in extension and rotation motion. Secondary tests are confirming tests that are designed to correct or inhibit the extension and rotation motion. If the primary test is positive, the secondary test is performed. When movement or symptom reduced in the secondary test, finally it is confirmed as positive. A previous study reported that the percentages of agreement were % with the kappa values ranging for the symptom behavior items, and the percentages of agreement were % with the kappa values ranging for the alignment and movement items (Van Dillen et al. 1998). The exclusion criteria were: having (1) rectus femoris muscle shortness determined using Ely s test, (2) iliopsoas muscle shortness determined using Thomas test, (3) femoral torsion (antetorsion or retrotorsion) determined using Craig s test, (4) significant weakness in the hip lateral rotator muscles lower than grade 3 (fair) determined using the manual muscle testing, and (5) a history of spinal fracture or surgery, disc herniation, spinal deformity, pain or parasthesia below the knee, systemic inflammatory problem, or other serious musculoskeletal problem that could interfere with HLR in the prone position. The present study was approved by the Yonsei University Wonju Campus Human Studies Committee, and the subjects were given details of the experiment and provided written informed consent prior to their participation

18 Table 1. Movement system impairment based lumbar extension rotation classification criteria Test position Standing Supine Side lying Prone Quadruped Sitting Primary test Standing Forward bending Return from bending Lateral flexion Trunk rotation Single leg standing Hip flexor length Unilateral hip and knee flexion Hip abduction/lateral rotation Straight leg raise Shoulder flexion to 180 degrees Hip lateral rotation Hip abduction with lateral pelvic tilt Hip adduction Knee flexion Hip rotation Hip extension Quadruped Rocking backward Rocking forward Shoulder flexion Sitting Knee extension Secondary test Corrected standing None Corrected return from bending Corrected lateral flexion None None None Corrected unilateral hip and knee flexion Corrected hip abduction/lateral rotation Corrected straight leg raise None None None None Corrected knee flexion Corrected hip rotation Corrected hip extension Corrected quadruped Corrected rocking backward None Corrected shoulder flexion None Corrected knee extension - 6 -

19 2. Clinical Measurements 2.1 Visual Analogue Scale Pain intensity was measured using a visual analogue scale (VAS). A 100 mm VAS was used to assess pain intensity in the low back (Huskisson 1974). The subjects were asked to rate their level of pain on a VAS consisting of a 100 mm line with 0 (no pain) at one end and 100 (the worst pain) at the other end. The VAS has been commonly used in studies evaluating the changes in pain intensity associated with rehabilitation for LBP (Niemisto et al. 2003) 2.2 Tensor Fasciae Latae Iliotibial Band Length Test TFL ITB length was evaluated by two examiners using the modified Ober s test (Kendall et al. 2005). An inclinometer (Johnson Magnetic Angle Locator, Johnson, Mequon, WI, USA) was used to measure TFL ITB length. The subject was instructed to lie on their side with the bottom leg flexed at the hip and knee to straighten the lower back. One examiner placed the inclinometer on the distal lateral thigh and held a subject s leg at the knee throughout the test with the horizontal position defined as 0 before passive adduction was performed (Herrington, Rivett, and Munro 2006). The other examiner stabilized the subject s pelvis to prevent downward lateral pelvic tilt on the tested side. The subject was instructed to raise the top leg keeping it aligned with the trunk and then allowed it to drop toward the bottom leg (adduction). The test was performed until the subject could feel resistance in the stretched TFL ITB. At - 7 -

20 that point, the examiner recorded the degree of adduction from the horizontal position. The modified Ober s test was positive if the subject s leg remained abducted and did not fall to the examination table. In other words, if the subject s leg dropped less than 10 below horizontal, it was recorded as a positive test (Kendall et al. 2005). Melchione and Sullivan (1993) reported good intra and inter rater reliability (ICC 0.94 and 0.73, respectively) using the modified Ober s test

21 3. Experimental Equipment 3.1 Three Dimensional Motion Analysis System A three dimensional ultrasonic motion analysis system (CMS HS, Zebris, Medizintechnik, Isny, Germany) was used to measure the kinematic parameters of lumbopelvic and hip joint. The motion analysis system operates with high measurement accuracy according to the travelling time measurement of ultrasound pulses. We used the intraclass correlation coefficient (ICC 3,1) to calculate the intra rater reliability of active HLR and lumbopelvic rotation in the pre intervention session and found excellent intra rater reliability (ICC = 0.98 and 0.93, respectively)

22 4. Outcome Measurements 4.1 Kinematic Data The kinematic data obtained from the three dimensional ultrasonic motion analysis system were used to measure the lumbopelvic rotation angle and lumbopelvic rotation movement onset during active HLR. Two sets of ultrasound triple markers were used: one was placed on the midline of the pelvis by fastening a strap around the pelvis at the level of the posterior superior iliac spines to measure lumbopelvic kinematics (lumbopelvic rotation angle and lumbopelvic rotation movement onset) (Cynn et al. 2006; Oh et al. 2007; Park et al. 2011). The second set of triple markers was placed under on the distal 1/3 of the fibula to measure HLR. The measuring sensor, which consisted of three microphones to record the ultrasound signals from the markers, was positioned lateral to the subject on the side being tested. Angles were calibrated to 0 relative to the prone position with the knee flexed at 90. The sampling rate was 20 Hz, and the kinematic data were analyzed using the Win data ver software (Zebris, Medizintechnik, Isny, Germany). The lumbopelvic rotation movement onset was defined as the time at which the angle of the lumbopelvic motion exceeded a threshold of 1 (Gombatto et al. 2006). The mean value of the lumbopelvic rotation angle was calculated from the last 5 s of isometric contraction during HLR. The mean value of three trials was calculated to determine the lumbopelvic rotation angle and the lumbopelvic rotation movement onset

23 5. Procedures The procedures included clinical measurements involved in subject recruitment and laboratory measurements during the active HLR test. Subjects first completed the following clinical tests: 1) the VAS, 2) the modified Ober s test. Following completion of the clinical tests, laboratory measurements were made. Each subject was instructed to lie prone position (Figure 1). The starting position was prone with knee flexed at 90 on the side with the shortened TFL ITB and the other knee extended (Gombatto et al. 2006). If the TFL ITB was tight in both legs, the tighter of the two was designated as the test side. Before the HLR test, a thermoplastic splint (KLARITY Elastic, Klarity Medical & Equipment (GZ) Co. Ltd., Lan Yu, China) was placed on the knee joint to minimize excessive tibial movement caused by the knee joint laxity (Figure 1). Different thermoplastic splints were made for the males and females to accommodate gender differences in the circumference and width of the knee joint. The laboratory procedures were as follows: 1) The degree of active HLR was determined by asking the subject to laterally rotate the hip as far as possible; 2) A target bar was positioned at 50% of the maximum active HLR to prevent excessive stretching of the soft tissue of the hip and to provide tactile feedback to stop active HLR when the medial aspect of the distal tibia touched the target bar. The subject performed HLR for 10 s, including a 5 s concentric contraction and a 5 s isometric contraction. A 1 min rest period was scheduled between trials. Movement speed and time were controlled using a metronome. The start signal was an auditory cue (beeper

24 sound) emitted by the Noraxon TeleMyo system (Park et al. 2011). All subjects were familiarized with the experimental procedure for approximately 30 min prior to the testing. The subjects were instructed to rest for 10 min after the familiarization period to minimize muscle fatigue. Figure 1. Hip lateral rotation position

25 6. Interventions The interventions were ADIM training and ADIM training plus self stretching the TFL ITB. Subjects in the ADIM training group performed ADIM in the prone position and were provided with visual feedback using a pressure biofeedback unit (Stabilizer, Chattanooga group Inc., Hixson, TN, USA; Figure 2). The 3 chamber pressure cell of the pressure biofeedback unit was inflated to 70 mmhg. The subject was asked to reduce the level of pressure by approximately 10 mmhg based on visual feedback from an analog pressure gauge during prone HLR. To perform the contraction correctly, the subjects were instructed to Pull your belly button up and in towards your spine without pelvic movement during exhalation. It is difficult for patients with LBP to maintain a 60 mmhg level using the pressure biofeedback unit. Thus, the subjects were instructed to perform ADIM training 20 min a day, 7 days per week for a 2 week period. The subjects in the ADIM training plus TFL ITB self stretching group were instructed to first stretch the TFL ITB and then ADIM. Subjects were told to perform TFL ITB self stretching 2 sets of 10 repetitions a day, 7 days per week, for a 2 week period (Figure 3). The TFL ITB stretch was performed in the upright standing position with arms extended and hands clasped overhead. The leg to be stretched was extended, adducted, and externally rotated and then placed behind the non tested leg. The subject was then instructed to exhale while slowly bending the trunk laterally in the direction opposite the test leg (Fredericson et al. 2002). The subjects were instructed to hold the stretched position for 10 s and rest for 2 min between sets. The

26 subjects were instructed to stop the exercise if it caused a sharp pain or discomfort in the lumbopelvic region. Furthermore, the subjects were told that muscle fatigue and a stretched out feeling could be expected after each stretching session. Figure 2. Abdominal drawing in maneuver training using a pressure biofeedback unit. Figure 3. Self stretching the tensor fasciae latae iliotibial band

27 7. Statistical Analysis Sample size and power calculations were performed using the statistical power analysis program, G*Power ver software (Franz Faul, University of Kiel, Germany). Kolmogorov-Smirnov tests were performed to assess whether continuous data approximated a normal distribution. Subjects were randomly allocated to the experimental groups using the Microsoft Excel 2007 software (Microsoft Corporation, Redmond, WA, USA); thus, we expected a homogenous distribution of variance and did not anticipate significant pre intervention between group differences on any outcome measure. However, we conducted an independent t test to analyze the pre intervention values between groups. A paired t tests was used to determine within group (before and after an intervention) changes and the independent t test was used to determine between group differences for each outcome measure (lumbopelvic rotation angle, lumbopelvic rotation movement onset, TFL ITB length, and pain intensity). Cohen s d statistic was used to calculate the effect size for each outcome comparison and was calculated as the difference in the group means divided by the pooled standard deviation (Cohen 1988). All statistical analyses were performed using PASW Statistics ver software (SPSS, Inc., Chicago, IL, USA). The level of significance was set as α =

28 Results 1. General Characteristics of Subjects The general characteristics of the 22 subjects including gender, age, height, weight, body mass index, and active HLR are shown in Table 2. Table 2. General characteristics of subjects ADIM a training group (n 1 =11) ADIM training plus TFL ITB b self stretching group (n 2 =11) t (N=22) Gender (male/female) 9/2 7/4 Age (yrs) 23.1 ± 1.8 c 23.8 ± Height ( cm ) ± ± Weight ( kg ) 67.9 ± ± BMI d ( kg / m2 ) 23.2 ± ± Active HLR e ( ) ± ± a ADIM: Abdominal drawing in maneuver. b TFL ITB: Tensor fasciae latae iliotibial band. c Mean ± standard deviation. d BMI: Body mass index. e HLR: Hip lateral rotation. p value is comparison of groups using an independent t test. p

29 2. Lumbopelvic Rotation Angle The lumbopelvic rotation angle decreased significantly under the post intervention compared with the pre intervention (ADIM training: pre = 4.94 ± 1.18, post = 1.82 ± 0.52, t (10) = 2.76, p = 0.01, d = 4.22; ADIM training plus TFL ITB self stretching: pre = 5.48 ± 0.92, post = 1.53 ± 0.26, t (10) = 19.71, p < 0.01, d = 5.95). The ADIM training plus TFL ITB self stretching decreased the lumbopelvic rotation angle significantly more than the ADIM training alone (pre intervention minus post intervention, ADIM training: mean difference = 3.12 ± 0.73 ; ADIM training plus TFL ITB self stretching: mean difference = 3.95 ± 0.66, t (20) = 2.76, p = 0.01, d = 1.19, Figure 4). 3. Lumbopelvic Rotation Movement Onset The lumbopelvic rotation movement onset delayed significantly under the post intervention compared with the pre intervention (ADIM training: pre = 1.53 ± 0.38 s, post = 2.85 ± 0.86 s, t (10) = 5.97, p < 0.01, d = 1.82; ADIM training plus TFL ITB self stretching: pre = 1.58 ± 0.22 s, post = 3.56 ± 0.50 s, t (10) = 9.94, p < 0.01, d = 3.04). The ADIM training plus TFL ITB self stretching delayed the lumbopelvic rotation angle significantly more than the ADIM training alone (ADIM training: mean difference = 1.31 ± 0.72 s; ADIM training plus TFL ITB self stretching: mean difference = 1.98 ± 0.65 s, t (20) = 2.23, p = 0.03, d = 0.96, Figure 5)

30 4. Tensor Fasciae Latae Iliotibial Band Length The TFL ITB length was measured using the modified Ober s test and was expressed as the hip horizontal adduction angle. In the ADIM training, the TFL ITB length did not increase significantly under the post intervention compared with the pre intervention (ADIM training: pre = 8.09 ± 0.94, post = 8.27 ± 1.00, t (10) = 1.00, p = 0.34, d = 0.29). In the ADIM training plus TFL ITB self stretching, the TFL ITB length increased significantly under the post intervention compared with the pre intervention (ADIM training plus TFL ITB self stretching: pre = 8.27 ± 0.90, post = ± 1.43, t (10) = 6.82, p < 0.01, d = 2.06). The hip horizontal adduction angle was significantly greater under the ADIM training plus TFL ITB self stretching compared with the ADIM training alone (ADIM training: mean difference = 0.18 ± 0.60 ; ADIM training plus TFL ITB self stretching: mean difference = 2.27 ± 1.10, t (20) = 5.51, p < 0.01, d = 2.35, Figure 6)

31 5. Pain Intensity The pain intensity decreased significantly under the post intervention compared with the pre intervention (ADIM training: pre = ± 8.31 mm, post = ± 6.03 mm, t (10) = 11.57, p < 0.01, d = 3.49; ADIM training plus TFL ITB self stretching: pre = ± mm, post = ± 9.51 mm, t (10) = 11.21, p < 0.01, d = 3.37). The pain intensity rating was lower in the ADIM training plus TFL ITB self stretching group than in the ADIM training group; however, the difference was not statistically significant (ADIM training: mean difference = ± mm; ADIM training plus TFL ITB self stretching: mean difference = ± 9.81 mm, t (20) = 1.03, p = 0.31, d = 0.44, Figure 7)

32 Figure 4. Lumbopelvic rotation angle between group differences (A: Abdominal drawing in maneuver training group, B: Abdominal drawing in maneuver training plus tensor fasciae latae iliotibial band self stretching group) *p = Figure 5. Lumbopelvic rotation movement onset between group differences (A: Abdominal drawing in maneuver training group, B: Abdominal drawing in maneuver training plus tensor fasciae latae iliotibial band self stretching group) *p =

33 Figure 6. Tensor fasciae latae iliotibial band length between group differences (A: Abdominal drawing in maneuver training group, B: Abdominal drawing in maneuver training plus tensor fasciae latae iliotibial band self stretching group) *p < Figure 7. Pain intensity between group differences (A: Abdominal drawing in maneuver training group, B: Abdominal drawing in maneuver training plus tensor fasciae latae iliotibial band self stretching group)

34 Discussion The purpose of the present study was to compare the effect of a 2 week intervention with ADIM training or ADIM training plus TFL ITB self stretching on lumbopelvic rotation angle, lumbopelvic rotation movement onset, TFL ITB length, and pain intensity during active prone HLR in people with lumbar extension rotation syndrome accompanying shortened TFL ITB. The pre intervention lumbopelvic rotation angle during HLR was 4.94 ± 1.18 in the ADIM training group and 5.48 ± 0.92 in the ADIM training plus TFL ITB self stretching group. These results agree with previous reports of excessive lumbopelvic motion in people with lumbar extension rotation syndrome (Gombatto et al. 2006; Harris Hayes, Van Dillen, and Sahrmann 2005; Hoffman et al. 2011; Scholtes et al. 2010; Van Dillen et al. 2007). Following the intervention in our study, lumbopelvic rotation was reduced to 1.82 ± 0.52 and 1.53 ± 0.26 in the ADIM training and ADIM training plus TFL ITB self stretching groups, respectively. Our results indicate that the lumbopelvic rotation angle decreased significantly following both interventions. Lumbopelvic rotation angle between group differences were 3.12 ± 0.73 in ADIM training and 3.95 ± 0.66 in ADIM training plus TFL ITB self stretching. Our results indicate that the ADIM training plus TFL ITB self stretching decreased the lumbopelvic rotation angle significantly more than the ADIM training alone, although the difference was minimal. Our results suggest that an improved abdominal control and an elongated TFL ITB could play a greater role in minimizing

35 the lumbopelvic rotation angle. Our findings are consistent with previous research showing that insufficient abdominal control and shortened TFL ITB could contribute to increased lumbopelvic rotation during active HLR (Sahrmann 2002). The pre intervention lumbopelvic rotation movement onset during HLR was 1.53 ± 0.38 s in the ADIM training group and 1.58 ± 0.22 s in the ADIM training plus TFL ITB self stretching group. This implies that the early lumbopelvic rotation movement onset could be attributed to the lack of control by the abdominal muscles and the shortened TFL ITB. This finding concurs with the results of previous studies reporting that LBP is associated with early lumbopelvic rotation during active limb movement (Sahrmann 2002; Van Dillen et al. 2007; Van Dillen, Maluf, and Sahrmann 2009; Van Dillen, and Sahrmann 2006). The results of the present study showed that the lumbopelvic rotation movement onset was significantly delayed following both interventions, suggesting that both abdominal control and stretching of the TFL ITB contribute to the delayed lumbopelvic rotation movement onset. Moreover, our results showed that ADIM training plus TFL ITB self stretching delayed the lumbopelvic rotation movement onset significantly more than the ADIM training alone, although the difference was minimal. The current study suggests that treatment may require not only training of the abdominal control, but also stretching of the TFL ITB to delay the lumbopelvic rotation movement onset during the HLR. The ADIM training plus TFL ITB self stretching group showed a significantly greater increase in the hip horizontal adduction angle than did the ADIM training alone group. The present study showed that ADIM training plus self stretching the

36 TFL ITB elongated the TFL ITB. Shortening of the TFL increases ITB tension resulting in excessive lumbopelvic movement to compensate. Our results are consistent with those of a previous study showing that stretching in an upright standing position with arms extended overhead is an effective method for increasing TFL ITB length (Fredericson et al. 2002). The level of pain intensity determined using a VAS was significantly reduced following both interventions. The level of pain intensity was lower in the ADIM training plus TFL ITB self stretching group than in the ADIM training group; however, the difference was not statistically significant. Our results suggest that the reduction in pain may be associated with a reduction compressive stress induced by restricted lumbopelvic rotation during HLR. Previous studies reported that people with lumbar extension rotation syndrome have a tendency to extend and rotate the lumbar spine during lower extremity movements. Furthemore, repetitive movement in a specific direction contributes to cumulative microtrauma of the lumbar tissue and eventually results in LBP (Maluf, Sahrmann, and Van Dillen 2000; Mueller, and Maluf, 2002). The present study has several limitations. First, we studied the effect of the ADIM training and self stretching the TFL ITB using a standardized movement test, and it is not clear whether our results can be generalized to other functional activities in subjects with lumbar extension rotation syndrome. Second, in our measurement of the lumbopelvic rotation motion, the angle was calculated based on movement of the level of posterior superior iliac spine marker and did not account for motion of the

37 upper trunk that may have contributed to lumbopelvic rotation. Third, the present study used surface markers to index bone movement; thus, artifacts resulting from skin movement were present. Because the lumbopelvic rotation movement was small, skin movement artifacts may have had an impact on our outcome measure. Finally, the 2 week test period was a short term intervention. Further research is needed to determine the long term effect of ADIM training and self stretching the TFL ITB on lumbopelvic kinematics during HLR in subjects with lumbar extension rotation syndrome

38 Conclusion The present study compared the effect of a 2 week intervention with ADIM training or ADIM training plus TFL ITB self stretching on lumbopelvic rotation angle, lumbopelvic rotation movement onset, TFL ITB length, and pain intensity during active prone HLR in people with lumbar extension rotation syndrome accompanying shortened TFL ITB. The results indicate that compared with ADIM training alone, ADIM training plus TFL ITB self stretching significantly decreased the lumbopelvic rotation angle, delayed the lumbopelvic rotation movement onset, and elongated the TFL ITB. The reported decrease in pain intensity was greater in the ADIM training plus TFL ITB self stretching group than in the ADIM training group; however, the difference was not significant. In conclusion, ADIM training plus TFL ITB self stretching performed for a period of 2 weeks may be an effective treatment for modifying lumbopelvic motion and reducing LBP

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48 국문요약 요추신전회전증후군을가진대상자에게복부 당기기방법과대퇴근막긴장근 - 장경인대자가신장 운동이요추골반운동형상학에미치는영향 연세대학교대학원 물리치료학과 임원빈 본연구의목적은대퇴근막긴장근-장경인대가짧은요추신전회전증후군대상자에게엎드린자세에서능동고관절외회전시복부당기기방법과대퇴근막긴장근-장경인대자가신장운동이요추골반회전각도, 요추골반회전움직임개시시간, 대퇴근막긴장근-장경인대길이, 통증강도에미치는영향을비교하는것이다. 본연구를위해대퇴근막긴장근-장경인대가짧은요추신전회전증후군이있는 22명의대상자 ( 남자 16명과여자 6명 ) 가참여하였다. 대상자들은 2주간집에서

49 수행될복부당기기방법과대퇴근막긴장근-장경인대자가신장운동수행방법을교육받았다. 3차원초음파동작분석기는요추골반회전각도, 요추골반회전움직임개시시간을측정하는데사용하였다. 독립 t-검정은결과분석 ( 요추골반회전각도, 요추골반회전움직임개시시간, 대퇴근막긴장근-장경인대길이, 통증강도 ) 에대한집단간차이를알아보기위해사용하였다. 통계학적유의수준 α = 0.05로하였다. 연구결과복부당기기방법만적용하였을때보다복부당기기방법과대퇴근막긴장근- 장경인대자가신장운동을함께적용하였을때, 요추골반회전각도는유의하게감소하였고, 요추골반회전움직임개시시간은유의하게지연되었으며, 대퇴근막긴장근-장경인대길이는유의하게신장되었고, 통증강도는감소하였지만유의미한차이는보이지않았다. 결론적으로, 2주간복부당기기방법과대퇴근막긴장근-장경인대자가신장운동을함께적용한중재방법이요추골반움직임을교정하고요통을감소시키는데효과적인중재방법으로사료된다. 핵심되는말 : 대퇴근막긴장근 - 장경인대, 복부당기기방법, 요추신전 회전증후군, 요추골반운동형상학