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The Effect of Passive Lumbar Mobilization on Hip Flexor Strength -A Pilot Study

Article in Indian Journal of Physiotherapy and Occupational Therapy - An International Journal · April 2016
DOI: 10.5958/0973-5674.2016.00054.X

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 DOI Number: 10.5958/0973-5674.2016.00054.X

The Effect of Passive Lumbar Mobilization on Hip Flexor

Strength - A Pilot Study

Lo Chi-ngai1, Chiu Tai-wing Thomas1, Cheung Chi-Kong2

1
Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong,
2
Wai Ji Christian Service, Hong Kong

ABSTRACT

The topic of muscle inhibition has been investigated for certain period of time, several causes have been
proposed, including pain, joints mechanics, sensory and spinal dysfunction. However, the number of
randomized controlled trials is not enough. The purpose of this study was to conduct a pilot study to
find out if lumber mobilization reduces hip flexor muscle inhibition.

24 participants were qualified for the study. Participants were randomly divided into experimental
group and control group. A handheld dynamometer was used to measure the hip flexor strength
before and after a L2-3 joint mobilization or a placebo treatment .

Results: The percentage change in torque was higher (p < 0.001) in the experimental group after the
intervention. The results suggested that passive mobilization on L2-3 may increase the strength of hip
flexor for people without active low back pain.

Keywords: Inhibition; passive mobilization; spine.

INTRODUCTION optimal contraction during a maximal-voluntary

contraction)(3).
The topic of muscle inhibition has been
investigated for a period of time, several causes were Previously, researches have performed manual
proposed, including pain and injury (1, 2), aberrant therapy on various spinal levels to reduce the muscle
joint mechanics (3, 4), sensory (5) and spinal dysfunction inhibition (2-4,6,7). However, most studies were not
(2,6,7)
. Previously, authors addressed the conditions randomized controlled trials. Under the umbrella of
of peripheral inhibition and use of manual therapy manual therapy, both manipulation (high velocity,
to restore muscle strength from inhibition (3, 6, 7). low amplitude thrust) and mobilization (rhythmic
However, the number of randomized controlled trials oscillation) were included. Actually the number of
under this topic is still inadequate. studies on either manipulation or mobilization was
small. Specifically, hip flexor inhibition has not been
Several authors proposed similar ideas that investigated yet.
muscle inhibition, including quadriceps, deep neck
flexors, lower trapezius and shoulder external The purpose of this study was to conduct a
rotators, are associated with spinal disorders (1-4,6, 7 ) randomized controlled trial to assess if manual
which involved pain. The use of manual mobilization mobilization on the lumbar spine can improve hip
might be able to restore the muscle strength. flexor muscle strength in asymptomatic subjects.

Hip control plays an important role in the METHODOLOGY

lower limb kinetic chain(8). One of the causes of
Subjects: Throughout the period from May
hip flexor weakness could be due to non-fatigable
2012 to January 2013, subjects were recruited in the
muscle inhibition (ie, inability to recruit all motor
community who fulfilled the inclusion criteria: adults
units in the same functional muscle group to their
in both genders, who were 18 years old or above
82 Indian Journal of Physiotherapy and Occupational Therapy. April-June 2016, Vol. 10, No. 2

and had no active back or hip pain. Active back or flexor strength decreased remarkably (ie. a non-
hip pain was defined as existing pain, a recent (<4 fatigable weakness) (7) compared with the opposite
weeks) diagnosis by doctors or conditions which side and / or the quadriceps strength.
was receiving active treatment. People with a history
After the first screening, twenty-four suitable
of back pain for more than 3 months ago (but no
participants were found to have hip flexor inhibition.
current pain) were also included. Wri!en consent
Participants were allocated into the experimental
was granted from the participants prior to inclusion.
group and the control group randomly; they received
Subjects could not fulfill the inclusion criteria were
another hip flexor strength testing with a handheld
excluded.
dynamometer. To measure the hip flexor strength,
Ethical approval was granted by the Human subjects were asked to perform hip flexor break test
Subjects Ethics Sub-commi!ee in the Hong Kong again by a blinded second investigator in a separated
Polytechnic University. room. The handheld dynamometer was put on the
anterior thigh just proximal to the patella (11). The
RANDOMIZATION peak force was taken from the reading of the digital
Twenty-four qualified subjects were recruited handheld dynamometer. Subjects were instructions
in this study. A blocked randomization was applied to have a 10-min warm up (hip flexor, quadriceps
according to genders (10 females and 14 males). stretching and gentle jogging) before the strength
Equal number of ‘I’ (Intervention / Experimental) test. The hip flexor strength was tested for four times,
and ‘C’ (Control) le!ers were put in sealed envelopes, twice before the intervention and twice after, with a
ie. 5 "I" 5 "C" in female group and 7 "I" 7 "C" in male minimum of 4 minutes rest in between the trials. Both
group. Subjects were required to draw to envelopes legs were tested; the second investigator was blinded
randomly but the le!ers were read by the first form the grouping and side(s) of inhibition.
investigator only.
The use of hand-held dynamometer and the hip
INSTRUMENTATION flexors isometric strength test in the supine position
was reported to have excellent test-retest reliability
A calibrated hand-held dynamometer, the (12, 13)
.
Nicholas manual muscle tester (MMT) model 01160
(Lafaye!e Instrument Company, Lafaye!e, IN 47903, INTERVENTION
USA), was adopted to measure the isometric hip
Subjects in the experimental group received a
flexion strength.
passive grade III spinal rotation mobilization at L2-
PROCEDURE 3 segment, at a rate of 80-90 times per minute for 1
minute according to Maitland’s approach (14), on the
Initially forty-one subjects were recruited, clinical involved side(s).
red flags, contraindications and medical conditions
were screened, and all participants fulfilled the The participant was asked to side-lie on the
inclusion criteria of the study. contralateral side. Both legs were bent up to the range
when the neutral position of L2-3 junction was found
Subjects were screened by the first investigator by the investigator’s palpating hand. The lower leg
for hip flexor strength. For the hip flexor ‘break’ test, was straightened so the knee of the uppermost leg
the participant was asked to lie on his/her back, lift rested over the side of the plinth. The participant’s
the thigh up to 90 degree and keep the position while trunk was rotated till the hip started to lift off the
the investigator pushed hard and tried to break the plinth. The uppermost arm of the participant rested
participant's resistance (9). The subject was instructed on the chest wall. The investigator put one hand
to build up maximal strength in 1-2 seconds, tester on participant’s shoulder to stabilize upper part of
gradually overcame the hip flexor force and stopped the trunk and the other hand on hip to generate the
at the moment the hip gave way within 4 seconds (10). force. A rotatory force in large amplitude (grade III)
oscillations was applied forwards through the hand
Participants were considered as qualified when
on hip (14).
a manual muscle test showed one or both sides hip
 Indian Journal of Physiotherapy and Occupational Therapy. April-June 2016, Vol. 10, No. 2 83

Subjects in the control group received a placebo were used for analysis.
treatment in which the subjects were asked to lie flat,
The PASW Statistics 18 for Windows (SPSS Inc,
face up. The affected thigh(s) was put in 90 degree
Chicago, IL) was used to analyze the data. Paired-t test
hip flexion and was held passively for 30 seconds by
was applied to find out the difference in the hip flexor
the hands of the investigator, then back to neutral
strength / torque, before and after the intervention,
position. The procedure was repeated twice, so
in both groups, with α set at .05. Comparison on hip
that the control group and the experimental group
flexor strength, torque and change in torque between
received same treatment time in the room.
two groups was conducted by independent-t test,
SAFETY AND COMPLIANCE with α set at .05.

Passive spinal rotation mobilization is a low RESULTS

risk procedure. Contraindications were screened
Two participants, one in the control group and
including spinal cord compression, instability of
one in the experimental group, could not complete
joints, severe pain, infection, local malignancy and
all the assessments since considerable muscles spasm
active inflammatory arthritis (14). The subjects were
occurred during the isometric hip flexor strength test;
healthy individuals, none of them complained of pain
therefore they withdrew from the study.
in the back or hips before and after the procedures.
The baseline demographic; including age, weight
PRIMARY OUTCOME
and leg length had no significant difference between
The reading on the dynamometer was taken as the two groups (Table 1). Existing or previous
the primary outcome, which showed the maximal musculoskeletal conditions were noted in both
hip flexor strength in kg. Leg length was measured, groups including history of back pain, presence of
in terms of meter, from the middle of the hip joint knees pain and ankle sprain.
to the anterior thigh just above the patella. A mark
There were 14 sets of data in the control group
was made on the skin to ensure same position for
(6 left legs and 8 right legs), and 15 sets in the
the dynamometer to be placed on throughout the
experimental group (7 left legs and 8 right legs).Hip
measurements.
flexors strength and torque were found to have
Torque (Nm) = Hip flexor strength(N) x leg significant increase in the experimental group after
length(m) % Change in torque = (Post torque –Pre the intervention, but not in the control group (Table
torque) / Pre torque x 100 2). The experimental group demonstrated a higher
positive percentage change in torque, (15.65% ±
STATISTICAL ANALYSIS 13.32%) than the control group (-1.89% ± 5.44%) (p <
The hip flexor strength was measure twice before 0.001). (Table 3)
and twice after the intervention, the average values

Table 1. Characteristics of participants

Control Experimental

No. of participants 11 11

Gender 5 females; 6 males 4 females; 7 males

20-58 18-35
Age in year p = 0.839
28.1 ± 13.0 27.2 ± 6.8

Body weight in kg 42.0-113.6 45.0-75.0

p = 0.446
65.77 ± 20.48 60.42 ± 10.05
84 Indian Journal of Physiotherapy and Occupational Therapy. April-June 2016, Vol. 10, No. 2

Cont... Table 1. Characteristics of participants

Leg length in meter 0.33-0.48 0.38-0.47

p = 0.179
0.39 ± 0.07 0.42 ± 0.35

Side(s) of inhibition 3 left, 5 right, 3 bilateral 3 left, 4 right, 4 bilateral

2 knee pain 1 history of back pain

Other information 2 history of back pain
1 sprained ankle 1 sprained ankle

Date showed range, Mean ± standard deviation (S.D.)

Table 2. Within group paired t-test

Control group (N=14)

Pre test Post test p-value
Strength (N) 162.9 ± 34.2 167.4 ± 52.9 0.639
Torque (Nm) 68.2 ± 25.9 67.0 ± 27.1 0.400
Experimental group (N = 15)
Pre test Post test
Strength (N) 152.8 ± 56.8 167.2 ±52.9 *0.041
Torque (Nm) 66.1 ± 27.8 75.2 ± 28.2 *0.001

*Significant difference p< 0.05

Table 3. Statistics comparison between the control group and the experimental group

Control Experimental
95% CI p value (2-tailed)
(N = 14) (N = 15)

Pre test strength (N) 162.9 ± 34.2 152.8 ± 56.8 -25.9 – 46.2 0.569

Post test strength (N) 167.4 ± 52.9 167.2 ± 52.9 -40.1– 40.5 0.991

Pre test torque (Nm) 68.2 ± 25.9 66.1 ± 27.8 22.6 – -18.5 0.838

Post test torque (Nm) 67.0 ± 27.1 75.2 ± 28.2 -29.3 – 12.9 0.431

*% change in torque -1.89 ± 5.44 15.65 ± 13.32 -24.9- -10.2 *< 0.001

95% CI : Confidence Interval of the difference measurement, for measuring neurological inhibition
of the quadriceps muscle was rather objective (17).
LIMITATIONS
Nevertheless, in previous twitch EMG research (18),
For the methodology, since it was a small applicability on hip flexor was not investigated,
sample size pilot study, the results of the study were further EMG study on measurement of hip flexor
preliminary. inhibition is warranted.

In this study, hip flexor inhibition was determined Without specific objective measurement on hip
by manual muscle break test only. However, flexor inhibition, a false negative could exist in the
evidence of manual muscle testing on the validity for screening stage if a subject who had muscle strength
neurological inhibition is not convincing (15,16). Suter much stronger than the investigator (15).
et al. (3,6) and Drover et al. (1) advocated objective EMG
 Indian Journal of Physiotherapy and Occupational Therapy. April-June 2016, Vol. 10, No. 2 85

To correlate the non-fatigable weakness to To establish a generalized result, sample size was
relevant spinal level, Wang and Meadows (7) had calculated with the assumption with significance level
conduct several neurological tests which included (2 tailed) = 0.025, standard deviation = 2.75, power =
Brisk reflex, muscles tenderness to palpation, 0.8. Hip flexors torque (Nm) was taken as outcome
hypertonicity, hypersensitive and trophic change. measure, in which the difference in means between
The authors did not apply those tests since the two groups = 0.82, location of mean in control group
subjects were asymptomatic in the spine, the jerk as a percentile of the experimental group = 0.9.
reflex is not available for hip flexor, also the reliability
A total of 356 subjects will enter this two-
of hypersensitivity sign shown in Wang and
treatment parallel-design study, while 392 subjects
Meadows’ (7) paper was just fair (agreement = 0.68).
will be required if the 10% drop out rate is included.
To test for the neurological signs in L2, the superficial
The probability is 80 percent that the study will detect
cremasteric reflex (9, 19) is a specific reflex test for
a treatment difference at a two-sided 0.05 significance
L1 and L2, however, it is not practical in clinical
level.
situation. Patellar tendon reflex combining with
anterior thigh sensation test could be considered for In previous studies on the effects of manual therapy
testing L2 neurological signs (9,20) in further study. on muscle strength, the results were controversial.
As mentioned, passive spinal mobilization was sub-
DISCUSSION
divided into rhythmic oscillation (mobilization) or
Through the spinal mobilization, it might be high velocity, low amplitude thrust (manipulation)
possible to alert the efferent pathways (3, 6, 7) because of (14)
. In those previous studies, spinal mobilization (2,4,7)
direct mechanical influence to the spinal, particularly seems to be able to alert peripheral muscle activities
L2-3 level (9). The hip flexor iliopsoas is anatomically while the effects of manipulation were not consistent
(3,6,26-30)
a!ached on the lumbar spine, and psoas major .
muscle acts as the stabilizers of lumbar lodorsis (21-
23) The result of this study was similar to previous
. Therefore, during lumbar rotation mobilization,
studies in which passive spinal mobilization could
driving force might have direct mechanical influence
instantly increase muscle strength (2,4,7).
to the hip flexor muscles. The arthrokinetic reflex
by alerting tonic or phasic receptors might also CONCLUSION
contribute to the increase in strength (5).
The results of this clinical trial demonstrated
To address the probability of learning effect or a proportional increase in the hip flexor torque
placebo effect, which might contribute to the increase in subjects without back pain after a passive
of the hip flexor strength, a control group was mobilization on the spine L2-3 level. Since it was a
included in this study for comparison. In the control small scale pilot study, the results were preliminary
group, the average torque in the follow up was and the methodology should be improved in future
decreased. Since isometric contraction is a maximum study.
muscle contraction test, muscles’ fatigue could exist
after repetitive measurements (24,25). Acknowledgment: The authors acknowledge
Rachel Yu Pui Wa for her assistance in data collection;
To determine the carry over effect, in future Hong Kong Chi Do Taekwondo Association,
study, extending the follow up period, by days or and HKSKH Lady MacLehose Centre for their
weeks, could be considered. In this way, muscles’ participation in subject recruitment and providing
fatigue factor due to repeated measurement could the venues.
be further minimized. Similar to cross over study,
the intervention can be added on the control group Funding Sources and Conflicts of Interest: The
after the second assessment, so that the pool of data authors reported no funding or conflicts of interest
can increase. was involved in this study.
86 Indian Journal of Physiotherapy and Occupational Therapy. April-June 2016, Vol. 10, No. 2

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