Adaptations in pelvis,hip and knee kinematics during gait and muscle extensibility in low back pain patients: A cross-sectional study

Abstract

OBJECTIVES:

To compare pelvis, hip and knee kinematics during gait and extensibility of hip muscles between low back pain (LBP) and asymptomatic subjects.

METHODS:

Forty adult volunteers (11 men and 29 women) between 18 to 30 years from university population were included in this study. Twenty patients with LBP formed the LBP group, and 20 asymptomatic subjects formed the control group. Pelvic tilt and knee valgus, peak hip and knee joint excursion, and temporo-spatial variables were assessed during gait with Kinovea software. Extensibility of hip muscles was measured by Active Knee Extension test (AKE), modified Ober test, and Thomas test.

RESULTS:

There was a significant increase in pelvic tilt ( $p<$ 0.01), valgus angle ( $p<$ 0.01), and a significant decrease in hip extension ( $p<$ 0.01) in the LBP group compared to the control group. There was a significant decrease in extensibility of the hip flexors ( $p<$ 0.05) of the dominant leg and in the hip abductors ( $p<$ 0.01) in the LBP group compared to the control group.

CONCLUSIONS:

The findings of this study suggest that non-specific mechanic LBP patients present differences in the pelvis, hip and knee kinematics in sagittal and frontal plane during gait and less hip flexors and abductors muscles extensibility compared to asymptomatic subjects.

Keywords

Low back pain lower limb biomechanics gait

1. Introduction

Non-specific mechanic low back pain (LBP) represents 90% of LBP patients [42]. LBP is increasing in the young population and is more frequent in females [28, 36].

The etiology of LBP remains unclear. Biomechanical aspects from lumbo-pelvic-femoral complex seem to contribute to the development and progression of LBP [3]. Several authors have suggested that the lumbar spine should not be assessed in isolation from the lower limbs [30]. Currently, there is increasing evidence that LBP is associated with lower limb dysfunctions. Mobility alterations of lower limb musculoskeletal structures and the lack of coordination with the trunk during functional activity such as walking can be observed in LBP patients [16, 45].

Therefore, clinicians should consider the movement of the pelvis, hip and knee during functional tasks such as walking or sitting in LBP patients [24, 32]. Also, the muscle function of biarticular muscles from the pelvis to the knee should be assessed, in particular the extensibility [5, 20, 29, 35]. These muscles are implicated in static and dynamic stability of the lumbar spine. Losing extensibility of these muscles may favor changes in the lumbar spine movement and posture.

Many authors pay attention to the lumbar lordosis angle in different postures and movement [7]. In the last few years, authors have investigated the lower limbs kinematics in LBP patients, but these assessments have been performed by advanced three-dimensional (3D) motion analysis systems. These laboratory-based methodologies are usually performed in controlled environments, different from the clinical practice. Also, these methods need specific training and not all clinicians can afford the 3D systems. Two-dimensional (2D) analysis has shown to be a valid, reliable, accessible and free alternative to assess lower limb kinematics during gait [4, 10, 11, 18].

To our knowledge, there is a lack of evidence about pelvis, hip and knee kinematics during gait and the extensibility of the hip muscles in a clinical environment and with clinical tools [6, 30].

Consequently, the study of the pelvis, hip and knee kinematics and muscle extensibility may help to establish treatments based on the soft tissues of the lower limbs to the management of the LBP patients.

Thus, the purpose of this paper is to compare the pelvis, hip and knee kinematics, temporo-spatial variables and extensibility of hip muscles between LBP patients and the asymptomatic group.

2. Methods

2.1 Study design

A cross-sectional case-control study was carried out between February to April 2018. The procedures followed the STROBE Statement Guide [48].

The study followed the Helsinki criteria (2013) and Tai Pei criteria (2016) and was approved by the Institutional Ethics Committee. The purpose of the study was explained, and all volunteers signed an informed consent form.

2.2 Participants

Forty participants (29 females, 11 males) from a university population between the ages of 18 and 30 years participated in the study. Participants were screened for LBP and were divided either in the LBP group or the control group.

LBP patients were included if they presented mechanical non-specific LBP, defined as pain below the costal margin and above the inferior gluteal folds, not attributed to any specific cause, which persisted for at least three months, and with capacities to understand questionnaires. Patients with LBP were excluded if they had taken oral drugs or physiotherapy treatment in the last 3 months, and if they had a specific cause of LBP (e.g., traumatism, herniation disks, fractures, lumbar stenosis and anquilosant spondylitis), neurological disease, history of surgery in the lumbar spine or lower limbs, infections, tumor, cauda equina syndrome or other musculoskeletal disorders in the lumbar spine or lower limbs [7, 8].

Healthy participants were included if they had not presented LBP, and had comprehensive capacities to understand the questionnaire. Participants that presented the history of surgery, pain or musculoskeletal disorders in the lumbar spine or lower limbs were excluded.

2.3 Assessment

The socio-demographic parameters (age and sex) as well as height, weight, and body mass index (BMI) were assessed. Patients were instructed to evaluate the severity of LBP on a 10-cm Visual Analog Scale (VAS). Oswestry Questionnaire (OQ) was used to evaluate physical disability due to LBP. The OQ is a 10-item scale that quantifies disability related to LBP. The scores range from 0 to 100 with higher numbers indicating greater disability. Thomas test, modified Ober test and Active Knee Extension (AKE) test were applied to assess muscle extensibility in both lower limbs. The lower extremity dominant limb was defined as the preferred leg used to kick a ball, consistent to previous literature [13, 31]. The protocol of these tests have proven to be reliable [15, 23, 39, 41]. Pelvis, hip and knee joints kinematics in sagittal and frontal plane during gait and temporo-spatial parameters were analyzed using 2D Kinovea Software v. 8.15 in both lower limbs. This tool is valid and have shown to be reliable and was used in previous researches [4, 10, 18].

Muscle extensibility tests were measured by digital inclinometer (Lafayette Instrument Acumar ACU001 & ACU002) following the established protocol. Thomas test was used to assess hip flexors muscles, the inclinometer was positioned in an imaginary line between trochanter and lateral femur condyle (ICC: 0.97) [23]. Modified Ober test was applied to measure abductors muscles (ICC: 0.91) [39]. The angle was measured positioning on the digital inclinometer on lateral femur condyle. If the limb was horizontal, it was considered 0 ${}^{\circ}$ ; if below (adducted), it was recorded as a positive number; if above horizontal (abducted) it was recorded as a negative number. AKE test was used to evaluate hamstrings muscles and it was measured by digital inclinometer positioned on the anterior tuberosity of tibia (ICC: 0.89) [41]. Each measurement was repeated twice. An average of two measurements was used for later analysis.

To assess gait parameters, white markers were placed in anatomical references [12]: posterior spinous iliac superior (PSIS), anterior spinous iliac superior (ASIS), trochanter, external femur condyle, the center of patella, anterior tibial tuberosity and external malleolus. The subjects were instructed to walk 6 minutes to normalize gait pattern in a twenty meters corridor. After, two video cameras of 16 megapixels, Nikon Coolpix, model, one in the sagittal plane and frontal plane registered 4 meters of walking to capture a complete cycle of gait.

The videos were analyzed by an independent evaluator expert in 2D analysis to maintain the blinding. In the sagittal plane, peak hip and knee flexion and extension were registered. In the frontal plane, pelvic tilt and knee valgus angle in the stance phase of the gait was registered. The methodology to measure these angles was performed according to previous studies [25, 26, 33, 47].

2.3.1 Sagittal plane

Hip flexion and extension angles were measured with the intersection of two lines, one imaginary line from ASIS to PSIS and another imaginary line from trochanter and external femur condyle. Peak hip flexion was measured in talus contact and peak hip extension was measured in heel takeoff. Knee flexion and extension was measured with the intersection of two lines, one imaginary line from trochanter and external femur condyle and another imaginary line from external femur condyle and external malleolus. Peak flexion angle was measured in the initial swing and peak extension was measured in midstance.

2.3.2 Frontal plane

Pelvic tilt angle was quantified with the intersection of two lines, the imaginary line between both ASIS and the horizontal line. Valgus knee angle was quantified with the intersection of two lines, one imaginary line from ASIS to the center of the patella and another line from the center of the patella to the anterior tibial tuberosity. These angles were measured in the stance phase of the gait.

2.3.3 Temporo-spatial variables

Step length, stance and swing phase were measured. To calculate step length an imaginary line was defined between both heels. To measure these phases a chronometer available in Kinovea program was used. The chronometer started at the first heel contact and finished when the fingers took off. To measure swing phase the chronometer was started when the fingers took off and stopped when the heel made contact with the floor.

The dependent variables and the gait analysis were performed by two different evaluators blinded to the allocation of the patients to avoid the risk of bias and to maintain the blinding.

2.4 Statistical analysis

A revised sample size of 40 including a 95% confidence interval was calculated on the basis of the estimate what this would provide 80% power. The statistical power was calculated using G*Power 3.1. The statistical power was calculated for peak hip extension angle, pelvic tilt, and knee valgus variables with a sample of 40 participants. The statistical analyses were completed using statistical package for social studies (SPSS) version 20.0 for Windows (IBM SPSS, Chicago, IL, USA). Descriptive analyses, including mean (M) and standard deviation (SD) was used to summarize characteristics of the participants of all continuous variables. All continuous variables were evaluated for normality using Shapiro-Wilk test prior to comparative analysis. An independent $t$ -test was conducted to examine differences between both groups for parametric variables. Mann-Whitney U test was used to analyse the significant differences between groups for non-parametric variables. Differences between sex were evaluated using Chi-squared test.

The statistical significance value was set at 0.05 with a 95% confidence interval and a $p$ -value less than 0.05 considered to be significant.

3. Results

Forty volunteers were included in the study, 20 patients in the LBP group (33.3% men and 76.7% women, mean age: 24.6 $\pm$ 5.21 years; BMI: 23.06 $\pm$ 3.08) and 20 in control group (42.9% men and 57.1% women, mean age: 23.2 $\pm$ 5.01 years; BMI: 22.9 $\pm$ 2.82 Kg). The clinical and demographic features of the participants are presented in Table 1.

Table 1
Demographical and clinical characteristics of the participants

	LBP group	Control group	MD	$t$ -value	$p$ -value
	M $\pm$ SD	M $\pm$ SD
Age (years)	24.60 $\pm$ 5.21	23.20 $\pm$ 5.01	1.40	0.862	0.323 ${}^{*}$
BMI (Kg/m ${}^{2}$ )	23.06 $\pm$ 3.08	22.90 $\pm$ 2.82	0.16	0.175	0.864 ${}^{*}$
Sex (M/W)	5/15	6/14		$X^{2}=$ 0.124	0.728 ${}^{*}$
OQ (%)	25.15 (8.03)	–	–	–	–
VAS	5.68 (2.23)	–	–	–	–

M, Mean; SD, Standard deviation; MD, Mean difference; $p$ -value, Level of significance; ${}^{*}$ , Non-significant; M, Men; W, Women; OQ, Oswestry Questionnaire; VAS, Visual Analog Scale; $X^{2}$ , Chi-squared test.

Table 2

Mean and standard deviations of the muscle length test

	LBP group M $\pm$ SD	$p$ -value within group	Control group M $\pm$ SD	$p$ -value within group	$p$ -value between groups
Thomas test ( ${}^{\circ}$ )
D	2.39 $\pm$ 6.96	$<$ 0.001 ${}^{**}$	9.01 $\pm$ 8.22	0.002 ${}^{**}$	0.009 ${}^{**}$
ND	11.52 $\pm$ 10.52		15.17 $\pm$ 8.31		0.490 ${}^{*}$
Modified ober test ( ${}^{\circ}$ )
D	$-$ 1.35 $\pm$ 5.89	0.006 ${}^{**}$	3.72 $\pm$ 5.54	0.255	0.020 ${}^{**}$
ND	$-$ 7.11 $\pm$ 8.20		2.79 $\pm$ 7.15		0.001 ${}^{**}$
AKE test ( ${}^{\circ}$ )
D	113.66 $\pm$ 20.53	0.005 ${}^{**}$	119.94 $\pm$ 18.58	0.334	0.250 ${}^{*}$
ND	120.76 $\pm$ 21.76		122.16 $\pm$ 15.13		0.800 ${}^{*}$

M, Mean; SD, Standard deviation; $p$ -value, Level of significance; ${}^{*}$ , Non-significant; ${}^{**}$ , Significant; ( ${}^{\circ}$ ), Degree; AKE, Active Knee Extension; D, Dominant; ND, Non-dominant.

Table 3

Mean and standard deviations of gait parameters

	LBP group M $\pm$ SD	$p$ -value within group	Control group M $\pm$ SD	$p$ -value within group	$p$ -value between groups
Pelvic tilt ( ${}^{\circ}$ )
D	4.47 $\pm$ 2.51	0.003 ${}^{**}$	2.45 $\pm$ 1.95	0.101 ${}^{*}$		0.004 ${}^{**}$
ND	7.95 $\pm$ 2.66		3.95 $\pm$ 2.30		$<$	0.001 ${}^{**}$
Hip flexion ( ${}^{\circ}$ )
D	27.55 $\pm$ 4.63	0.117 ${}^{*}$	27.60 $\pm$ 4.28	0.584 ${}^{*}$		0.950 ${}^{*}$
ND	28.82 $\pm$ 5.13		27.22 $\pm$ 4.39			0.331 ${}^{*}$
Hip extension ( ${}^{\circ}$ )
D	4.60 $\pm$ 2.33	0.441 ${}^{*}$	6.85 $\pm$ 2.14	0.500 ${}^{*}$		0.003 ${}^{**}$
ND	4.22 $\pm$ 1.86		6.80 $\pm$ 1.98		$<$	0.001 ${}^{**}$
Knee flexion ( ${}^{\circ}$ )
D	58.65 $\pm$ 6.01	0.018 ${}^{**}$	59.20 $\pm$ 4.76	0.444 ${}^{*}$		0.623 ${}^{*}$
ND	61.00 $\pm$ 4.66		59.75 $\pm$ 5.74			0.765 ${}^{*}$
Knee extension ( ${}^{\circ}$ )
D	5.72 $\pm$ 3.23	0.428 ${}^{*}$	5.60 $\pm$ 2.45	0.583 ${}^{*}$		0.700 ${}^{*}$
ND	5.97 $\pm$ 3.46		5.60 $\pm$ 2.45			0.900 ${}^{*}$
Knee valgus ( ${}^{\circ}$ )
D	16.60 $\pm$ 4.56	0.003 ${}^{**}$	10.45 $\pm$ 2.50	0.064 ${}^{*}$	$<$	0.001 ${}^{**}$
ND	14.80 $\pm$ 4.12		9.85 $\pm$ 2.54		$<$	0.001 ${}^{**}$
Step length (cm)
D	44.38 $\pm$ 5.49	0.608 ${}^{*}$	43.75 $\pm$ 7.25	0.573 ${}^{*}$		0.620 ${}^{*}$
ND	43.96 $\pm$ 5.01		43.73 $\pm$ 7.04			0.830 ${}^{*}$
Swing time (s)
D	0.46 $\pm$ 0.87	0.406 ${}^{*}$	0.44 $\pm$ 0.66	0.680 ${}^{*}$		0.372 ${}^{*}$
ND	0.45 $\pm$ 0.86		0.43 $\pm$ 0.53			0.723 ${}^{*}$
Stance phase (s)
D	0.67 $\pm$ 0.10	0.720 ${}^{*}$	0.69 $\pm$ 0.12	0.496 ${}^{*}$		0.734 ${}^{*}$
ND	0.68 $\pm$ 0.86		0.69 $\pm$ 0.12			0.480 ${}^{*}$

M, Mean; SD, Standard deviation; $p$ -value, Level of significance; ${}^{*}$ , Non-significant; ${}^{**}$ , Significant; ( ${}^{\circ}$ ), Degree; (cm), Centimeters; (S), Seconds; D, Dominant; ND, Non-dominant.

A significant difference was found between groups. The LBP group showed decreasing muscle extensibility in the modified Ober test and dominant leg in the Thomas test. Significant differences between dominant and non-dominant side were found in the LBP group in all muscle extensibility tests. Differences between dominant and non-dominant side were found only in the Thomas test in the control group (Table 2).

The analysis showed an increase in pelvic tilt and knee valgus angle in the LBP group with respect to the control group in the frontal plane. LBP group showed less peak joint hip extension during stance phase with respect to the control group in the sagittal plane. No differences were found in the rest of the kinematic variables or temporo-spatial variables between groups. Significant differences between dominant and non-dominant side were found in pelvic tilt, valgus knee and knee flexion in LBP. The descriptive data and differences between groups, and between dominant and non-dominant side are shown in Table 3.

4. Discussion

The results of the present study have shown that mechanical non-specific LBP patients presented an increase in pelvic tilt and knee valgus angle in the frontal plane, and a decrease in peak hip extension in sagittal plane during stance phase, with respect to the control group. Also, LBP patients have presented decrease extensibility in hip flexors and abductors muscles, compared to the control group.

The outcomes obtained in functional capacity and pain intensity in the LBP group were similar to previous studies with LBP sample [22, 46].

The results achieved for peak hip extension were similar to previous studies with LBP patients [1]. Thomas and modified Ober tests were used to assess hip flexors extensibility and showed a significant decrease in the LBP group. The limited hip extension angle, obtained in this study and supported by previous studies, could be related to the extensibility of the main hip flexors. Several authors have demonstrated increasing the activity of the hip flexors, and erector spinae muscles [1, 6, 30, 37, 44] and decreasing the activity of the hip extensor muscles [9, 37] and rectus abdominal muscles [30, 44]. The results achieved in this study about the muscle function support previous evidence about the imbalances in lumbar-pelvic-femoral complex in LBP patients. To our knowledge, this is the first study that assesses the muscle function through the extensibility of the muscles comparing LBP patients with respect to control subjects.

The relationship showed between the peak hip extension angle, and the extensibility of hip flexors may influence an increment in the anterior pelvic tilt. This finding could provoke lumbar hyperextension, and generate uncontrolled movements in the lumbar spine, and mechanical stress [24]. These findings highlight the importance of assessing the extensibility of the lower limb muscles in LBP patients.

This study has demonstrated that pelvic tilt and the knee valgus angle is augmented in the LBP group during the stance phase of the gait compared to the control group. Also, our results showed decreasing the extensibility of the abductors muscles measured by modified Ober test in the LBP group. In physiological situations, gluteus medius and minimus control pelvic tilt during the stance phase of the gait [17]. The muscular imbalance between gluteus medius, minimus and tensor fasciae latae (TFL) is widely documented in the literature in LBP patients [2, 9, 38]. The gluteus medius and minimus weakness seem to increase the activity of TFL to maintain the pelvic position [2, 17, 43]. This fact may explain the increment of pelvic tilt during gait. Extensibility changes may develop Trendelenburg sign [19]. This finding has been related to uncontrolled side bending movements of the lumbar spine [19].

The physiological valgus angle is controlled by iliotibial band of the TFL and lateral ligaments of the knee. Valgus angle could be increased by the muscle imbalances showed between the gluteus medius, minimus, and TFL [14]. The results obtained in pelvic tilt and valgus angle may be explained by muscular imbalance. These findings highlight the importance of lower limb muscle function in LBP patients.

The data analysis showed statistical differences between the dominant and non-dominant side in kinematics and extensibility variables. The dominant side has shown a decrease in the knee flexion and the biarticular hip flexors extensibility. The biarticular hip flexors extensibility were implicated in knee extension movement which could explain the decrease in knee flexion. The non-dominant side has shown an increase in pelvic tilt and a decrease in the hip abductors muscles. A higher imbalance in the abductors muscles may develop a higher pelvic tilt during gait. These results highlight the need to assess both lower limbs for LBP patients. Lower extremity imbalance may contribute to development of LBP. Other authors have suggested lower extremity asymmetries as an important factor to lower limb differences [34]. However, this is the first study to analyze extensibility differences between dominant and non-dominant side in LBP patients.

With respect to space-temporal variables during gait, there were no differences between groups. This fact was shown in previous studies, not causing an impact on the gait conditions [27]. The differences observed in the sagittal and frontal plane could have developed compensatory movements patterns that not modified the temporo-spatial conditions.

Hip and knee muscular imbalance are strong predictors of lumbar dysfunction supporting the structural influences. The lumbar-pelvis-femoral complex works such that the body transmits stress from the lumbar spine to the hip and vice-versa [40]. Consequently, perturbations of the frontal and sagittal alignment result in an excessive load absorption at the respective joints.

There are some limitations that require attention. With respect to sample selection, only students and office workers between 18 to 30 years with and without the history of mechanical back pain were recruited. The cross-sectional design does not allow associating cause-effect of the showed differences. Future studies should investigate the effects in lumbar spine mobility and compared the angles of hip and rest of joints in other postures and movements, and future research should analyze and consider the sex of the sample. Clinical trials are needed to determinate the effects of hip flexors stretching in these patients.

5. Conclusion

The outcomes of this study demonstrate that non-specific mechanic LBP patients have an increase in pelvic tilt, valgus knee angle, and decrease in peak hip extension angle during gait compared to asymptomatic subjects. Also, LBP patients present a decrease in hip flexors and abductors muscles extensibility compared to asymptomatic subjects.

Footnotes

Conflict of interest

None to report.

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Adaptations in pelvis,hip and knee kinematics during gait and muscle extensibility in low back pain patients: A cross-sectional study

Abstract

OBJECTIVES:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1. Introduction

2. Methods

2.1 Study design

2.2 Participants

2.3 Assessment

2.3.1 Sagittal plane

2.3.2 Frontal plane

2.3.3 Temporo-spatial variables

2.4 Statistical analysis

3. Results

Table 1 Demographical and clinical characteristics of the participants

5. Conclusion

Footnotes

Conflict of interest

References

Table 1
Demographical and clinical characteristics of the participants