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MODEL
Journal of Bodywork & Movement Therapies (2013) xx, 1e5
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/jbmt
PELVIC POSTURAL ASSESSMENT
Reliability of sagittal pelvic position assessments in standing, sitting and during hip flexion using palpation meter* Daniel Camara Azevedo, PT, MSc*, Henrique Santos, PT 1, Ricardo Luiz Carneiro, PT, MSc 1, Guilherme Trivellato Andrade, PT 1 Pontificia Universidade Catolica de Minas Gerais, Avenida Dom Jose Gaspar 500, Belo Horizonte 30535901, MG, Brazil Received 22 January 2013; received in revised form 17 May 2013; accepted 22 May 2013
KEYWORDS Pelvis; PALM; Pelvic tilt
Summary The objective of this study was to investigate reliability of assessing sagittal pelvic position using the palpation meter (PALM) in healthy subjects while sitting, standing and while in different hip flexion angles in standing. Twenty healthy subjects were assessed two times by the same examiner, with a 48-h interval between test sessions. Reliability indices of PALM measures (intraclass correlation coefficient, ICC), standard error of measurement (SEM) and smallest detectable change (SDC) were calculated. ICC values showed excellent intra-rater reliability for measurements of sagittal pelvic position in standing and sitting position and for both standing hip flexion angles (ICC Z .89e.96). SEM values ranged from .5 (hip flexion 90 ) to 1.5 (sitting position). SDC values ranged from 1.5 (hip flexion 90 ) to 4.0 (sitting position). The results of this study showed excellent intra-rater reliability for assessing sagittal pelvic position in standing, sitting and hip flexion in healthy subjects using the PALM. ª 2013 Elsevier Ltd. All rights reserved.
* The authors declare that there is no conflict of interest regarding this study. * Corresponding author. Tel.: þ55 31 32220259. E-mail addresses: [email protected] (D.C. Azevedo), [email protected] (H. Santos), ricardo@ portalnef.com.br (R.L. Carneiro), [email protected] (G.T. Andrade). 1 Tel.: þ55 31 32220259.
Introduction Assessment of pelvic position is commonly performed when evaluating patients with lumbosacral and lower extremity dysfunction (Krawiec et al., 2003; Sahrmann, 2001). Pelvic alignment represents an important mechanism for
1360-8592/$ - see front matter ª 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jbmt.2013.05.017
Please cite this article in press as: Azevedo, D.C., et al., Reliability of sagittal pelvic position assessments in standing, sitting and during hip flexion using palpation meter, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.05.017
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2 maintaining a good posture (During et al., 1985). There is some evidence that pelvic asymmetry is related to altered trunk motion and increased lumbar spine stress (Al-Eisa et al., 2006). Pelvic position can directly influence lumbar spine alignment (Endo et al., 2012), which is considered a risk factor in low back pain (Chaleat-Valayer et al., 2011; Dankaerts et al., 2006). Pelvic malalignment seems also related to anterior cruciate ligament injuries (Hertel et al., 2004). The pelvic assessment is usually performed with the patient in a standing position. This can be done in several ways, including palpation of the anterior and posterior superior iliac spines, use of inclinometers and use of the palpation meter (PALM) (Freburger and Riddle, 1999; Gajdosik et al., 1985; Hagins et al., 1998; Herrington, 2011). Sitting position has become the most common posture in the workplace (Endo et al., 2012), and is referred to as an aggravating factor in low back and hip pain (Samora et al., 2011; Williams et al., 1991). Therefore, assessing pelvic posture in this position seems also important. Pelvic behavior during hip flexion movement can also be related to low back pain (Roussel et al., 2009; Sahrmann, 2001). It is expected that the pelvis rotates posteriorly during hip flexion, thus increasing lumbar flexion (lumbopelvic rhythm) (Bohannon et al., 1985; Murray et al., 2002; Tully et al., 2002). However, increased posterior pelvic rotation (PPR) during hip flexion can cause excessive lumbar spine movement and increase lumbar spine stress (Sahrmann, 2001). For that reason, it may be useful to measure pelvic position in standing and in different hip flexion angles to assess lumbopelvic rhythm. The reliability of different methods of assessing pelvic position in standing has been investigated in several studies (Gajdosik et al., 1985; Hagins et al., 1998; Herrington, 2011; Krawiec et al., 2003). The use of PALM is a reliable way to assess pelvic position in this posture (see Materials section for PALM description) (Hagins et al., 1998; Herrington, 2011; Krawiec et al., 2003). We are unaware of studies investigating the reliability of pelvic position assessment in sitting and standing hip flexion. The objective of this study was to investigate intra-rater reliability of assessing sagittal pelvic position in healthy subjects while sitting, standing and while in different hip flexion angles in standing (45 and 90 ).
D.C. Azevedo et al.
Materials The PALM device (Performance Attainment Associates, St. Paul Minnesota, USA e http://www.spineproducts.com) was used to assess sagittal pelvic position (Fig. 1). It consists of an inclinometer and two caliper arms. The bubble inclinometer is a semi-circular arc with one-degree gradations that range from 0 to 30 on either side of the midline. The device is held with both examiner’s hands and the caliper tips are used to palpate the pelvic bony landmarks. The degree of deviation from horizontal is read from the inclinometer. The device costs approximately USD$200. A digital inclinometer (Dualer IQ, J Tech Medical Industries e Heber city, UT, USA) was used to control for hip flexion. Accuracy of this instrument has been described as 1 (J Tech, 2005).
Procedure The examiner was a Physical Therapy graduate student with little clinical experience and no previous experience in using the Palm device. The student was trained by the first author, who had 16 years of experience in orthopedic physical therapy and had been using the Palm in practice for 5 years. During the training period, the examiner had the opportunity to practice the measurements with 10 healthy subjects. The subjects were in a standing position with their feet aligned with their shoulders and were asked to look at a fixed point ahead to control for posture sway. They kept their arms crossed over the chest while the examiner palpated the anterior superior iliac spines (ASIS) and posterior superior iliac spines (PSIS). The palpation procedure was done as described by Herrington (2011). After marking both anatomical landmarks, the examiner positioned the caliper tips of the PALM device against those marks and the angle of pelvic inclination was recorded (Fig. 2). This measurement was done in the dominant leg side of the subject. Positive degree values were related to anterior pelvic rotation (APR), while negative values were related to PPR. This procedure was done three times and the average value was used for statistical analyses.
Methods Subjects Twenty healthy subjects (10 male and 10 female, mean age Z 25.3 4.3) participated in this study. A poster informing about the study was placed in the main building of the University and subjects volunteered to participate in the experiment (no payment or extra credit for class was given). Subjects had no orthopedic, rheumatologic or neurological disorders affecting the lumbar spine or the lower limbs. This project was approved by the Ethics Committee of the leading author’s Institution, and all subjects signed the informed consent form.
Figure 1 Sagittal pelvic position assessment using palpation meter (PALM).
Please cite this article in press as: Azevedo, D.C., et al., Reliability of sagittal pelvic position assessments in standing, sitting and during hip flexion using palpation meter, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.05.017
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Reliability of pelvic position assessments using palpation meter
Figure 2
Sagittal pelvic position assessment in standing.
To assess pelvic position during hip flexion, subjects were told to flex their hips by placing their foot on the dominant leg side against a step with different heights. Step height was determined so as to allow each subject to perform a hip flexion of 45 and 90 . The hip flexion angle was controlled through an inclinometer fixed on the lateral distal part of the subject’s thigh. After palpating and marking the ASIS and PSIS landmarks on the dominant side, sagittal pelvic position was assessed using the PALM in both hip flexion angles (Fig. 3). This procedure was done three times and the average value was used for statistical analyses. The anatomical landmarks were always erased between each measurement. Subjects were then asked to sit in a standard chair in a comfortable position. No instructions regarding how to sit were given because we wished to assess pelvic position in subjects’ preferred sitting position. After palpating and marking the anatomical landmarks, sagittal pelvic position was assessed using the PALM (Fig. 4). Subjects were then asked to stand up, marks were erased and the same procedure was repeated two times. The average value was used for statistical analyses. The assessment of sagittal pelvic position in those four positions (standing, sitting and standing hip flexion of 45 and 90 ) was repeated after 48 h to assess intra-rater reliability.
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Figure 3
Sagittal pelvic position assessment in hip flexion.
90 ). According to the Fleiss’ classification (Fleiss, 1986), ICC values above .75 indicate excellent reliability, values between .40 and .75 are fair to good, and values below .40 indicate poor reliability. The standard error of the
Statistical analyses An intraclass correlation coefficient (ICC) was calculated to assess intra-rater (ICC3,3) reliability of sagittal pelvic position in standing, sitting and standing hip flexion (45 and
Figure 4
Sagittal pelvic position assessment while sitting.
Please cite this article in press as: Azevedo, D.C., et al., Reliability of sagittal pelvic position assessments in standing, sitting and during hip flexion using palpation meter, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.05.017
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D.C. Azevedo et al.
measurement (SEM) was calculated using the formula SEM Z SD O1-ICC (de Vet et al., 2006). The smallest detectable change (SDC) was calculated using the formula SDC Z O2 1.96 SEM (Terwee et al., 2007). Differences in sagittal pelvic position between 1st and 2nd test sessions were examined using a paired t-test with a Bonferroni correction (significance level of P < .013).
Table 2 Intraclass correlation coefficient values (95% Confidence Interval), standard error of measurement (SEM) and smallest detectable change (SDC) values for intra-rater reliability of sagittal pelvic position.
Results Mean values and standard deviations for pelvic sagittal positions are presented in Table 1. ICC values and 95% confidence intervals are shown in Table 2. ICC values showed excellent intra-rater reliability for measurements of sagittal pelvic position in standing and sitting position, as well as in both standing hip flexion angles (45 and 90 ). SEM values ranged from .5 (hip flexion 90 ) to 1.5 (sitting position). SDC values ranged from 1.5 (hip flexion 90 ) to 4.0 (sitting position). The paired t-tests showed nonsignificant differences between the means of the 2 sessions across all positions (P > .013).
Discussion Several authors report excellent reliability for the assessment of pelvic position in standing (Gajdosik et al., 1985; Hagins et al., 1998; Herrington, 2011; Krawiec et al., 2003). The ICC, SEM and SDC values in standing position found in this study were similar to the values showed by others. Herrington (2011) found excellent intra-rater reliability when assessing pelvic position in the sagittal plane (ICC Z .87, SEM Z 1.1 and SDC Z 2.5). Hagins et al. (1998) showed excellent intra-rater (ICC Z .98, SEM Z 3.66) and inter-rater (ICC Z .89) reliability for this assessment. Different studies have investigated the influence of sitting posture on low back pain. Williams et al. (1991) found that back and leg pain can be decreased when patients sit with a lordotic posture as opposed to a kiphotic posture. Dankaerts et al. (2006) showed that different sitting postures are associated with nonspecific chronic low back pain. Lumbar alignment is influenced by pelvic alignment (De Carvalho et al., 2010; Endo et al., 2012). Therefore, analysis of lumbar alignment in the sitting position should consider pelvic alignment. The present study showed that it is possible to reliably assess sagittal pelvic position in sitting using the PALM. The ICC value for this position was .90, with low SEM and SDC values (SEM Z 1.5 , SDC Z 4.0 ). Assessing pelvic position during hip flexion is also important when evaluating a patient with low back pain
Positions
Intra-rater 1
SEM (degrees)
SDC (degrees)
Standing Sitting Hip flexion 45 Hip flexion 90
.92 .90 .89 .96
.7 1.5 .7 .5
1.8 4.0 2.1 1.5
(.80e.97) (.74e.96) (.72e.96) (.89e.98)
* In all ICC tests, p < .001.
(Roussel et al., 2009; Sahrmann, 2001). Several authors have found that lumbar flexion and PPR contribute to hip total flexion angle (Bohannon et al., 1985; Dewberry et al., 2003; Murray et al., 2002; Tully et al., 2002). Bohannon et al. (1985) found that a quarter to a third of total hip flexion movement resulted from PPR and that such movement begins within the first 8 of hip flexion. Murray et al. (2002) showed that the contribution of pelvic rotation to total hip flexion in standing can vary from 8% to 53%, and that it increases when hip flexion is performed in the supine position. Hip movement predominates in the early flexion phase (0%e20%) with the lumbar spine increasing its movement in the middle range (20%e80%), and becoming approximately equal to that of the hip in the last 20% of hip flexion. On average, every 3 of hip flexion was followed by 1 of lumbar flexion (Tully et al., 2002). An increase in lumbopelvic movement is expected when hip movement is limited (Milch, 1959). The PALM can reliably and conveniently be used to assess sagittal pelvic position during standing hip flexion. Reliability of assessing both hip flexion angles (45 and 90 ) was excellent, with low values for SEM and SDC. This study has some limitations. All subjects included were healthy, with no disorders affecting the lumbar spine or the lower limbs. We cannot presume the same reliability would be achieved in a sample of patients. We also did not assess inter-rater reliability. Although another study has shown excellent inter-rater reliability for assessing sagittal pelvic position in standing (Hagins et al., 1998), inter-rater reliability for such assessment in sitting and during standing hip flexion was not determined. Future studies should determine inter-rater reliability of this measurement. Previous studies assessing pelvic position with the Palm did not provide information about the examiner’s previous training and/or experience using the device. The results of this study suggest that examiners with little clinical
Table 1 Mean standard deviation (minimum e maximum) for sagittal pelvic position measures in degrees during standing and sitting position and standing hip flexion (45 and 90 ) on test days 1 and 2 (n Z 20). Position Standing Sitting Hip flexion 45 Hip flexion 90
1st day
6.4 17.7 1.2 3.0
2nd day
2.3 5.1 2.5 2.8
(2.3 to 10.0 ) (26.0 to 7.0 ) (3.3 to 5.7 ) (8.0 to 2.3 )
6.5 19.2 1.2 3.4
2.3 4.2 2.0 2.6
(2.3 to 10.3 ) (25.3 to 9.0 ) (3.7 to 4.7 ) (8.7 to 2.0 )
* paired t-tests showed non-significant differences between the means of the 2 sessions across all positions (P > .013).
Please cite this article in press as: Azevedo, D.C., et al., Reliability of sagittal pelvic position assessments in standing, sitting and during hip flexion using palpation meter, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.05.017
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Reliability of pelvic position assessments using palpation meter experience may reliably perform pelvic position measurements after some practice. Several inclinometers with long base or ruler attachments, are available in the market (ie. Baseline Bubble Inclinometer from Baseline e www. baselineproducts.net $60.00; Acumar Single Digital Inclinometer: $285.00 from Lafayette e http://www. lafayetteevaluation.com). These may also be used to measure pelvic position, however the reliability of such instruments/measurements remains to be determined.
Conclusion The results of this study showed excellent intra-rater reliability for assessing sagittal pelvic position in standing, sitting and hip flexion (45 and 90 ) in healthy subjects using the PALM.
References Al-Eisa, E., Egan, D., Deluzio, K., Wassersug, R., 2006. Effects of pelvic asymmetry and low back pain on trunk kinematics during sitting: a comparison with standing. Spine (Phila Pa 1976) 31, E135eE143. Bohannon, R.W., Gajdosik, R.L., LeVeau, B.F., 1985. Relationship of pelvic and thigh motions during unilateral and bilateral hip flexion. Phys. Ther. 65, 1501e1504. Chaleat-Valayer, E., Mac-Thiong, J.M., Paquet, J., Berthonnaud, E., Siani, F., Roussouly, P., 2011. Sagittal spinopelvic alignment in chronic low back pain. Eur. Spine J. 20 (Suppl. 5), 634e640. Dankaerts, W., O’Sullivan, P., Burnett, A., Straker, L., 2006. Differences in sitting postures are associated with nonspecific chronic low back pain disorders when patients are subclassified. Spine (Phila Pa 1976) 31, 698e704. De Carvalho, D.E., Soave, D., Ross, K., Callaghan, J.P., 2010. Lumbar spine and pelvic posture between standing and sitting: a radiologic investigation including reliability and repeatability of the lumbar lordosis measure. J. Manipulative Physiol. Ther. 33, 48e55. de Vet, H.C., Terwee, C.B., Knol, D.L., Bouter, L.M., 2006. When to use agreement versus reliability measures. J. Clin. Epidemiol. 59, 1033e1039. Dewberry, M.J., Bohannon, R.W., Tiberio, D., Murray, R., Zannotti, C.M., 2003. Pelvic and femoral contributions to bilateral hip flexion by subjects suspended from a bar. Clin. Biomech. (Bristol, Avon) 18, 494e499. During, J., Goudfrooij, H., Keessen, W., Beeker, T.W., Crowe, A., 1985. Toward standards for posture. Postural characteristics of
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the lower back system in normal and pathologic conditions. Spine (Phila Pa 1976) 10, 83e87. Endo, K., Suzuki, H., Nishimura, H., Tanaka, H., Shishido, T., Yamamoto, K., 2012. Sagittal lumbar and pelvic alignment in the standing and sitting positions. J. Orthop. Sci. 17, 682e686. Fleiss, J.L., 1986. Reliability of measurement. In: Fleiss, J.L. (Ed.), The Design and Analysis of Clinical Experiments. Wiley, New York, pp. 1e32. Freburger, J.K., Riddle, D.L., 1999. Measurement of sacroiliac joint dysfunction: a multicenter intertester reliability study. Phys. Ther. 79, 1134e1141. Gajdosik, R., Simpson, R., Smith, R., DonTigny, R.L., 1985. Pelvic tilt. Intratester reliability of measuring the standing position and range of motion. Phys. Ther. 65, 169e174. Hagins, M., Brown, M., Cook, C., 1998. Intratester and intertester reliability of the palpation meter (PALM) in measuring pelvic position. J. Man Manip. Ther. 6, 130e136. Herrington, L., 2011. Assessment of the degree of pelvic tilt within a normal asymptomatic population. Man Ther. 16, 646e648. Hertel, J., Dorfman, J.H., Braham, R.A., 2004. Lower extremity malalignments and anterior cruciate ligament injury history. J. Sport Sci. Med., 220e225. J Tech M, 2005. Dualer IQ User Guide. J Tech Medical, Salt Lake City. Krawiec, C.J., Denegar, C.R., Hertel, J., Salvaterra, G.F., Buckley, W.E., 2003. Static innominate asymmetry and leg length discrepancy in asymptomatic collegiate athletes. Man Ther. 8, 207e213. Milch, H., 1959. The measurement of hip motion in the sagittal and coronal planes. J. Bone Jt. Surg. Am. 41-A, 731e736. Murray, R., Bohannon, R., Tiberio, D., Dewberry, M., Zannotti, C., 2002. Pelvifemoral rhythm during unilateral hip flexion in standing. Clin. Biomech. (Bristol, Avon) 17, 147e151. Roussel, N.A., Nijs, J., Mottram, S., Van Moorsel, A., Truijen, S., Stassijns, G., 2009. Altered lumbopelvic movement control but not generalized joint hypermobility is associated with increased injury in dancers. A prospective study. Man Ther. 14, 630e635. Sahrmann, S.A., 2001. Diagnosis and Treatment of Movement Impairment Syndromes, first ed. Mosby, St Louis. Samora, J.B., Ng, V.Y., Ellis, T.J., 2011. Femoroacetabular impingement: a common cause of hip pain in young adults. Clin. J. Sport Med. 21, 51e56. Terwee, C.B., Bot, S.D., de Boer, M.R., van der Windt, D.A., Knol, D.L., Dekker, J., Bouter, L.M., de Vet, H.C., 2007. Quality criteria were proposed for measurement properties of health status questionnaires. J. Clin. Epidemiol. 60, 34e42. Tully, E.A., Wagh, P., Galea, M.P., 2002. Lumbofemoral rhythm during hip flexion in young adults and children. Spine (Phila Pa 1976) 27, E432eE440. Williams, M.M., Hawley, J.A., McKenzie, R.A., van Wijmen, P.M., 1991. A comparison of the effects of two sitting postures on back and referred pain. Spine (Phila Pa 1976) 16, 1185e1191.
Please cite this article in press as: Azevedo, D.C., et al., Reliability of sagittal pelvic position assessments in standing, sitting and during hip flexion using palpation meter, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.05.017
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Journal of Bodywork & Movement Therapies (2013) xx, 1e5
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/jbmt
PELVIC POSTURAL ASSESSMENT
Reliability of sagittal pelvic position assessments in standing, sitting and during hip flexion using palpation meter* Daniel Camara Azevedo, PT, MSc*, Henrique Santos, PT 1, Ricardo Luiz Carneiro, PT, MSc 1, Guilherme Trivellato Andrade, PT 1 Pontificia Universidade Catolica de Minas Gerais, Avenida Dom Jose Gaspar 500, Belo Horizonte 30535901, MG, Brazil Received 22 January 2013; received in revised form 17 May 2013; accepted 22 May 2013
KEYWORDS Pelvis; PALM; Pelvic tilt
Summary The objective of this study was to investigate reliability of assessing sagittal pelvic position using the palpation meter (PALM) in healthy subjects while sitting, standing and while in different hip flexion angles in standing. Twenty healthy subjects were assessed two times by the same examiner, with a 48-h interval between test sessions. Reliability indices of PALM measures (intraclass correlation coefficient, ICC), standard error of measurement (SEM) and smallest detectable change (SDC) were calculated. ICC values showed excellent intra-rater reliability for measurements of sagittal pelvic position in standing and sitting position and for both standing hip flexion angles (ICC Z .89e.96). SEM values ranged from .5 (hip flexion 90 ) to 1.5 (sitting position). SDC values ranged from 1.5 (hip flexion 90 ) to 4.0 (sitting position). The results of this study showed excellent intra-rater reliability for assessing sagittal pelvic position in standing, sitting and hip flexion in healthy subjects using the PALM. ª 2013 Elsevier Ltd. All rights reserved.
* The authors declare that there is no conflict of interest regarding this study. * Corresponding author. Tel.: þ55 31 32220259. E-mail addresses: [email protected] (D.C. Azevedo), [email protected] (H. Santos), ricardo@ portalnef.com.br (R.L. Carneiro), [email protected] (G.T. Andrade). 1 Tel.: þ55 31 32220259.
Introduction Assessment of pelvic position is commonly performed when evaluating patients with lumbosacral and lower extremity dysfunction (Krawiec et al., 2003; Sahrmann, 2001). Pelvic alignment represents an important mechanism for
1360-8592/$ - see front matter ª 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jbmt.2013.05.017
Please cite this article in press as: Azevedo, D.C., et al., Reliability of sagittal pelvic position assessments in standing, sitting and during hip flexion using palpation meter, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.05.017
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2 maintaining a good posture (During et al., 1985). There is some evidence that pelvic asymmetry is related to altered trunk motion and increased lumbar spine stress (Al-Eisa et al., 2006). Pelvic position can directly influence lumbar spine alignment (Endo et al., 2012), which is considered a risk factor in low back pain (Chaleat-Valayer et al., 2011; Dankaerts et al., 2006). Pelvic malalignment seems also related to anterior cruciate ligament injuries (Hertel et al., 2004). The pelvic assessment is usually performed with the patient in a standing position. This can be done in several ways, including palpation of the anterior and posterior superior iliac spines, use of inclinometers and use of the palpation meter (PALM) (Freburger and Riddle, 1999; Gajdosik et al., 1985; Hagins et al., 1998; Herrington, 2011). Sitting position has become the most common posture in the workplace (Endo et al., 2012), and is referred to as an aggravating factor in low back and hip pain (Samora et al., 2011; Williams et al., 1991). Therefore, assessing pelvic posture in this position seems also important. Pelvic behavior during hip flexion movement can also be related to low back pain (Roussel et al., 2009; Sahrmann, 2001). It is expected that the pelvis rotates posteriorly during hip flexion, thus increasing lumbar flexion (lumbopelvic rhythm) (Bohannon et al., 1985; Murray et al., 2002; Tully et al., 2002). However, increased posterior pelvic rotation (PPR) during hip flexion can cause excessive lumbar spine movement and increase lumbar spine stress (Sahrmann, 2001). For that reason, it may be useful to measure pelvic position in standing and in different hip flexion angles to assess lumbopelvic rhythm. The reliability of different methods of assessing pelvic position in standing has been investigated in several studies (Gajdosik et al., 1985; Hagins et al., 1998; Herrington, 2011; Krawiec et al., 2003). The use of PALM is a reliable way to assess pelvic position in this posture (see Materials section for PALM description) (Hagins et al., 1998; Herrington, 2011; Krawiec et al., 2003). We are unaware of studies investigating the reliability of pelvic position assessment in sitting and standing hip flexion. The objective of this study was to investigate intra-rater reliability of assessing sagittal pelvic position in healthy subjects while sitting, standing and while in different hip flexion angles in standing (45 and 90 ).
D.C. Azevedo et al.
Materials The PALM device (Performance Attainment Associates, St. Paul Minnesota, USA e http://www.spineproducts.com) was used to assess sagittal pelvic position (Fig. 1). It consists of an inclinometer and two caliper arms. The bubble inclinometer is a semi-circular arc with one-degree gradations that range from 0 to 30 on either side of the midline. The device is held with both examiner’s hands and the caliper tips are used to palpate the pelvic bony landmarks. The degree of deviation from horizontal is read from the inclinometer. The device costs approximately USD$200. A digital inclinometer (Dualer IQ, J Tech Medical Industries e Heber city, UT, USA) was used to control for hip flexion. Accuracy of this instrument has been described as 1 (J Tech, 2005).
Procedure The examiner was a Physical Therapy graduate student with little clinical experience and no previous experience in using the Palm device. The student was trained by the first author, who had 16 years of experience in orthopedic physical therapy and had been using the Palm in practice for 5 years. During the training period, the examiner had the opportunity to practice the measurements with 10 healthy subjects. The subjects were in a standing position with their feet aligned with their shoulders and were asked to look at a fixed point ahead to control for posture sway. They kept their arms crossed over the chest while the examiner palpated the anterior superior iliac spines (ASIS) and posterior superior iliac spines (PSIS). The palpation procedure was done as described by Herrington (2011). After marking both anatomical landmarks, the examiner positioned the caliper tips of the PALM device against those marks and the angle of pelvic inclination was recorded (Fig. 2). This measurement was done in the dominant leg side of the subject. Positive degree values were related to anterior pelvic rotation (APR), while negative values were related to PPR. This procedure was done three times and the average value was used for statistical analyses.
Methods Subjects Twenty healthy subjects (10 male and 10 female, mean age Z 25.3 4.3) participated in this study. A poster informing about the study was placed in the main building of the University and subjects volunteered to participate in the experiment (no payment or extra credit for class was given). Subjects had no orthopedic, rheumatologic or neurological disorders affecting the lumbar spine or the lower limbs. This project was approved by the Ethics Committee of the leading author’s Institution, and all subjects signed the informed consent form.
Figure 1 Sagittal pelvic position assessment using palpation meter (PALM).
Please cite this article in press as: Azevedo, D.C., et al., Reliability of sagittal pelvic position assessments in standing, sitting and during hip flexion using palpation meter, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.05.017
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Reliability of pelvic position assessments using palpation meter
Figure 2
Sagittal pelvic position assessment in standing.
To assess pelvic position during hip flexion, subjects were told to flex their hips by placing their foot on the dominant leg side against a step with different heights. Step height was determined so as to allow each subject to perform a hip flexion of 45 and 90 . The hip flexion angle was controlled through an inclinometer fixed on the lateral distal part of the subject’s thigh. After palpating and marking the ASIS and PSIS landmarks on the dominant side, sagittal pelvic position was assessed using the PALM in both hip flexion angles (Fig. 3). This procedure was done three times and the average value was used for statistical analyses. The anatomical landmarks were always erased between each measurement. Subjects were then asked to sit in a standard chair in a comfortable position. No instructions regarding how to sit were given because we wished to assess pelvic position in subjects’ preferred sitting position. After palpating and marking the anatomical landmarks, sagittal pelvic position was assessed using the PALM (Fig. 4). Subjects were then asked to stand up, marks were erased and the same procedure was repeated two times. The average value was used for statistical analyses. The assessment of sagittal pelvic position in those four positions (standing, sitting and standing hip flexion of 45 and 90 ) was repeated after 48 h to assess intra-rater reliability.
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Figure 3
Sagittal pelvic position assessment in hip flexion.
90 ). According to the Fleiss’ classification (Fleiss, 1986), ICC values above .75 indicate excellent reliability, values between .40 and .75 are fair to good, and values below .40 indicate poor reliability. The standard error of the
Statistical analyses An intraclass correlation coefficient (ICC) was calculated to assess intra-rater (ICC3,3) reliability of sagittal pelvic position in standing, sitting and standing hip flexion (45 and
Figure 4
Sagittal pelvic position assessment while sitting.
Please cite this article in press as: Azevedo, D.C., et al., Reliability of sagittal pelvic position assessments in standing, sitting and during hip flexion using palpation meter, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.05.017
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measurement (SEM) was calculated using the formula SEM Z SD O1-ICC (de Vet et al., 2006). The smallest detectable change (SDC) was calculated using the formula SDC Z O2 1.96 SEM (Terwee et al., 2007). Differences in sagittal pelvic position between 1st and 2nd test sessions were examined using a paired t-test with a Bonferroni correction (significance level of P < .013).
Table 2 Intraclass correlation coefficient values (95% Confidence Interval), standard error of measurement (SEM) and smallest detectable change (SDC) values for intra-rater reliability of sagittal pelvic position.
Results Mean values and standard deviations for pelvic sagittal positions are presented in Table 1. ICC values and 95% confidence intervals are shown in Table 2. ICC values showed excellent intra-rater reliability for measurements of sagittal pelvic position in standing and sitting position, as well as in both standing hip flexion angles (45 and 90 ). SEM values ranged from .5 (hip flexion 90 ) to 1.5 (sitting position). SDC values ranged from 1.5 (hip flexion 90 ) to 4.0 (sitting position). The paired t-tests showed nonsignificant differences between the means of the 2 sessions across all positions (P > .013).
Discussion Several authors report excellent reliability for the assessment of pelvic position in standing (Gajdosik et al., 1985; Hagins et al., 1998; Herrington, 2011; Krawiec et al., 2003). The ICC, SEM and SDC values in standing position found in this study were similar to the values showed by others. Herrington (2011) found excellent intra-rater reliability when assessing pelvic position in the sagittal plane (ICC Z .87, SEM Z 1.1 and SDC Z 2.5). Hagins et al. (1998) showed excellent intra-rater (ICC Z .98, SEM Z 3.66) and inter-rater (ICC Z .89) reliability for this assessment. Different studies have investigated the influence of sitting posture on low back pain. Williams et al. (1991) found that back and leg pain can be decreased when patients sit with a lordotic posture as opposed to a kiphotic posture. Dankaerts et al. (2006) showed that different sitting postures are associated with nonspecific chronic low back pain. Lumbar alignment is influenced by pelvic alignment (De Carvalho et al., 2010; Endo et al., 2012). Therefore, analysis of lumbar alignment in the sitting position should consider pelvic alignment. The present study showed that it is possible to reliably assess sagittal pelvic position in sitting using the PALM. The ICC value for this position was .90, with low SEM and SDC values (SEM Z 1.5 , SDC Z 4.0 ). Assessing pelvic position during hip flexion is also important when evaluating a patient with low back pain
Positions
Intra-rater 1
SEM (degrees)
SDC (degrees)
Standing Sitting Hip flexion 45 Hip flexion 90
.92 .90 .89 .96
.7 1.5 .7 .5
1.8 4.0 2.1 1.5
(.80e.97) (.74e.96) (.72e.96) (.89e.98)
* In all ICC tests, p < .001.
(Roussel et al., 2009; Sahrmann, 2001). Several authors have found that lumbar flexion and PPR contribute to hip total flexion angle (Bohannon et al., 1985; Dewberry et al., 2003; Murray et al., 2002; Tully et al., 2002). Bohannon et al. (1985) found that a quarter to a third of total hip flexion movement resulted from PPR and that such movement begins within the first 8 of hip flexion. Murray et al. (2002) showed that the contribution of pelvic rotation to total hip flexion in standing can vary from 8% to 53%, and that it increases when hip flexion is performed in the supine position. Hip movement predominates in the early flexion phase (0%e20%) with the lumbar spine increasing its movement in the middle range (20%e80%), and becoming approximately equal to that of the hip in the last 20% of hip flexion. On average, every 3 of hip flexion was followed by 1 of lumbar flexion (Tully et al., 2002). An increase in lumbopelvic movement is expected when hip movement is limited (Milch, 1959). The PALM can reliably and conveniently be used to assess sagittal pelvic position during standing hip flexion. Reliability of assessing both hip flexion angles (45 and 90 ) was excellent, with low values for SEM and SDC. This study has some limitations. All subjects included were healthy, with no disorders affecting the lumbar spine or the lower limbs. We cannot presume the same reliability would be achieved in a sample of patients. We also did not assess inter-rater reliability. Although another study has shown excellent inter-rater reliability for assessing sagittal pelvic position in standing (Hagins et al., 1998), inter-rater reliability for such assessment in sitting and during standing hip flexion was not determined. Future studies should determine inter-rater reliability of this measurement. Previous studies assessing pelvic position with the Palm did not provide information about the examiner’s previous training and/or experience using the device. The results of this study suggest that examiners with little clinical
Table 1 Mean standard deviation (minimum e maximum) for sagittal pelvic position measures in degrees during standing and sitting position and standing hip flexion (45 and 90 ) on test days 1 and 2 (n Z 20). Position Standing Sitting Hip flexion 45 Hip flexion 90
1st day
6.4 17.7 1.2 3.0
2nd day
2.3 5.1 2.5 2.8
(2.3 to 10.0 ) (26.0 to 7.0 ) (3.3 to 5.7 ) (8.0 to 2.3 )
6.5 19.2 1.2 3.4
2.3 4.2 2.0 2.6
(2.3 to 10.3 ) (25.3 to 9.0 ) (3.7 to 4.7 ) (8.7 to 2.0 )
* paired t-tests showed non-significant differences between the means of the 2 sessions across all positions (P > .013).
Please cite this article in press as: Azevedo, D.C., et al., Reliability of sagittal pelvic position assessments in standing, sitting and during hip flexion using palpation meter, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.05.017
+
MODEL
Reliability of pelvic position assessments using palpation meter experience may reliably perform pelvic position measurements after some practice. Several inclinometers with long base or ruler attachments, are available in the market (ie. Baseline Bubble Inclinometer from Baseline e www. baselineproducts.net $60.00; Acumar Single Digital Inclinometer: $285.00 from Lafayette e http://www. lafayetteevaluation.com). These may also be used to measure pelvic position, however the reliability of such instruments/measurements remains to be determined.
Conclusion The results of this study showed excellent intra-rater reliability for assessing sagittal pelvic position in standing, sitting and hip flexion (45 and 90 ) in healthy subjects using the PALM.
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Please cite this article in press as: Azevedo, D.C., et al., Reliability of sagittal pelvic position assessments in standing, sitting and during hip flexion using palpation meter, Journal of Bodywork & Movement Therapies (2013), http://dx.doi.org/10.1016/j.jbmt.2013.05.017
