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June 6, 2023

Lumbar-Hip Flexion Motion: A Comparative Study Between Asymptomatic Individuals and Chronic Low Back Pain

Sufferers Discover the difference between the lumbar-hip flexion motion of asymptomatic individuals and those with chronic low back pain in this comparative study.

Brent Brookbush

Brent Brookbush

DPT, PT, MS, CPT, HMS, IMT

Research Review: Lumbar-Hip Flexion Motion: A Comparative Study Between Asymptomatic and Chronic Low Back Pain in 18- to 36-Year-Old Men

By Amy Martinez DPT, PT

Edited by Brent Brookbush DPT, PT, COMT, MS, PES, CES, CSCS, ACSM H/FS

Original Citation: Porter, J. L., and Wilkinson, A. (1997). Lumbar-hip flexion motion: a comparative study between asymptomatic and chronic low back pain in 18-to 36-year-old men. Spine, 22(13), 1508-1513. - ABSTRACT

Why this study is Relevant: A growing body of research has established relationships between chronic low back pain (CLBP) and movement impairments (1-3). The findings of this 1997 study demonstrate a correlation between chronic low back pain (CLBP) and a loss of lumbar spine flexion, as well as a sub-group who also demonstrated a loss of hip flexion during a toe-touch task. Human movement professionals addressing CLBP may be able to assume a loss of lumbar flexion range of motion during forward bending, but should assess hip flexion range of motion and address noted restrictions.

Study Summary

Study DesignCase-control Study
Level of EvidenceLevel III: Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies and case-control studies
Participant CharacteristicsDemographics
  • Number of participants: 32 (15 in the study group and 17 in the control group)
  • Age: 18-36
    • Study group average age: 28 years, 8 months
    • Control group average age: 26 years, 0 months

  • Gender: Male

Inclusion Criteria

Study Group:

  • Adult males
  • Current or previous episode of central low back pain (L1 to L5), with or without radiation
  • Pain that lasted for more than 49 days within the last year and required time off work and/or medical treatment

Control Group:

  • Adult males
  • No low back pain within the previous 12 months that:
    • Interfered with daily activities
    • Required medical treatment

Exclusion Criteria

Study Group:

  • Radiating pain distal to the gluteal crease

Control Group:

  • NA
Methodology
  • Participants were selected via a convenience sample of white male volunteers, aged 18-36
  • A single examiner performed all data collection
  • Participants performed a toe-touch by bending forward from a relaxed standing position as far as comfortably possible with knees in extension, and then returning to an upright position
  • 3 toe-touch trials were completed:
    • 2 practice trials
    • 1 recorded trial

Data Collection and AnalysisData Collection
  • A 3-Space Tracker system was used, with the source placed over the sacrum and the superior margin adjacent to the lumbosacral junction and the sensors attached to the skin overlying T12 and the lateral femoral condyle
    • The sensor at T12 provided data on lumbar spine contributions
    • The sensor at the lateral femoral condyle provided data on hip contributions

  • Angular displacement was recorded with the following intervals of forward bending:
    • 15 degrees
    • 30 degrees
    • 60 degrees
    • 90 degrees
    • 120 degrees (if attainable by the participant)
    • End range of forward bending

  • Data from each sensor was taken at the intervals and converted to a percentage contribution

Statistical Analysis

  • Unpaired t tests assessed differences between the groups within the following parameters:
    • Mean relative contributions of the lumbar spine at each interval
    • Mean maximal forward bending motion
    • Mean maximal lumbar flexion range of motion
    • Mean maximal hip flexion range of motion

Outcome Measures
  • History of chronic low back pain
  • Standing forward bending or "toe-touch" test
  • Lumbar flexion range of motion
  • Hip range of motion
Results
  • Unpaired t tests identified the mean values of maximal forward bending (t = 2.56, P = 0.016) and maximum range of lumbar flexion (t = 3.38, P = 0.002) as significantly less for the CLBP group than the control group
  • The mean value of maximum range of hip flexion was not significantly different between the groups (t = 0.41, P = 0.683)
  • The lumbar spine accounted for 57.7% of the total movement until 90 degrees of forward bending in the CLBP group and 62.91% in the control group
  • The mean contribution of the lumbar spine for motion between 90-120 degrees of forward bending was 23.51 +/- 5.22% in the CLBP group and 24.87 +/- 3.69% in the control group
  • At forward bending ranges >90 degrees, 2 subgroups emerged among the CLBP participants:
    • Half of the participants demonstrated an increased lumbar spine contribution and decreased hip flexion
    • The other half demonstrated motion similar to the control group, with decreased lumbar spine contribution and increased hip flexion

Our ConclusionsCLBP group participants demonstrated reduced maximum forward bending and maximum lumbar flexion range of motion during a toe touch task. A sub-group emerged demonstrated a loss of hip flexion range of motion. These findings support the altered movement patterns described in the predictive model of lumbo pelvic hip complex dysfunction (LPHCD).
Researchers' Conclusions

Participants with CLBP demonstrated significant reductions in the total range of forward bending and maximum lumbar flexion range compared with those in the asymptomatic group. In examining the contribution of full hip flexion range of motion during the toe-touch task, two subgroups emerged among participants with CLBP.  One demonstrated reduced hip mobility, and the other demonstrated movement patterns similar to those of the asymptomatic group.  These findings indicate the importance of assessing lumbar and hip flexion motion in individuals with CLBP to identify movement abnormalities.

Hip mobilization anterior to posterior. (Image: Courtesy of www.BrentBrookbush.com)

Review & Commentary:

This study adds to the growing body of research investigating the relationship between lumbar spine and hip flexion range of motion in individuals with chronic low back pain (CLBP). During forward bending, participants with CLBP demonstrated decreased lumbar flexion when compared to the control group. Notably, two subgroups emerged among those with CLBP during forward bending greater than 90 degrees: one with increased lumbar spine flexion and limited hip flexion, and the other with movements similar to the control group. The findings reinforce the correlation between limited lumbar and hip flexion during functional activities and CLBP (2, 3).

The study had many methodological strengths, including:

  • It fills a gap in the body of research by demonstrating the relationship between lumbar spine and hip flexion range of motion and CLBP, specifically during uninterrupted forward bending.
  • Because the study design included age and gender matched controls, researchers accounted for these variables which may have confounded results.
  • One researcher obtained all measures for all participants, enhancing the reliability of data collection.
  • Lumbar flexion and hip flexion were measured during uninterrupted toe touching, increasing the transferability of findings to functional tasks, for example, tying shoes, picking something up off the floor, of performing a self-selected stretch.

Weaknesses that should be noted prior to clinical integration of the findings include:

  • The control group had no reported LBP within the last 12 months, which may imply some controls had LBP in years prior. Note: CLBP is so common a control group with no history of LBP may result in a sampling bias.
  • Data was recorded from only the third of three toe-touch movements. Obtaining averaged data from multiple attempts may have increased the reliability of the data.
  • Participants in each group were not matched for factors such as height and weight which may have confound results. More rigor in matching experimental and control groups may be recommended in future research.

Why This Study is Important:

Forward bending is a functional activity that requires coordinated motion of the lumbar spine, pelvis and hips, and this motion is often painful in those with chronic low back pain (CLBP). This study compared the contribution of lumbar spine and hip motion to continuous forward bending in asymptomatic individuals and those with CLBP using video motion capture technology. Research suggests that lumbar and hip flexion restriction are correlated with CLBP (4, 5); however, previous studies measured range of motion (ROM) separately, or measured by pausing the participant during forward bending task. The use of video to measure ROM during continuous motion may approximate functional activities better. This study demonstrated lumbar spine flexion is correlated with CLBP; however, sub-groups of with- and without hip flexion restriction were also noted.

How the Findings Apply to Practice:

During forward bending, participants with CLBP demonstrated decreased lumbar flexion when compared to the control group. Notably, two subgroups emerged among those with CLBP during forward bending greater than 90 degrees: one with increased lumbar spine flexion and limited hip flexion, and the other with movements similar to the control group. Human movement professionals addressing CLBP may be able to assume a loss of lumbar flexion range of motion during forward bending; however, hip flexion range of motion and potentially lumbar spine instability should likely be assessed separately.

How does it relate to Brookbush Institute Content?

The Brookbush Institute's (BI) regarded the body as an adaptive, holistic system in the development of comprehensive predictive models of postural dysfunction . The findings of this study are consistent with the changes in osteokinematic motion and muscle activity proposed in the Lumbo Pelvic Hip Complex Dysfunction (LPHCD) model. Human movement professionals should consider incorporating a dynamic postural assessment such as the Overhead Squat Assessment (OHSA) or forward bending as used in this study, and further, specific assessments for lumbar spine and hip flexion range of motion.

The following videos illustrate common assessment techniques; and interventions to facilitate hip flexor release and lengthening.

Overhead Squat Assessment: Sign Clusters - Lumbo Pelvic Hip Complex Dysfunction

Hip Flexion Goniometry

Tensor Fasciae Latae Release Self-Adminestered Static Releease

Tensor Fasciae Latae Manual Static Release

Kneeling Hip Flexor Stretch

Manual Hip Flexor Stretch

Active Hip Flexor Stretch

Dynamic Hip Flexor Stretch (Upright Lunge Series)

Bibliography:

  1. Barbee Ellison, J., Rose, S. J., & Sahrmann, S. A. (1990). Patterns of hip rotation range of motion: a comparison between healthy subjects and patients with low back pain. Physical Therapy, 70(9), 537-541.
  2. Shum, G. L., Crosbie, J., & Lee, R. Y. (2005). Effect of low back pain on the kinematics and joint coordination of the lumbar spine and hip during sit-to-stand and stand-to-sit. Spine, 30(17), 1998-2004.
  3. Wong, T. K., & Lee, R. Y. (2004). Effects of low back pain on the relationship between the movements of the lumbar spine and hip. Human movement science, 23(1), 21-34.
  4. Cailliet, R. (1988). Low Back Pain Syndromes (4th ed.). Philadelphia: F.A. Davis Company.
  5. Mayer, T. G., Tencer, A. F., Kristoferson, S., & Mooney, V. (1984). Use of noninvasive techniques for quantification of spinal range-of-motion in normal subjects and chronic low-back dysfunction patients. Spine, 9(6), 588-595.

© 2018 Brent Brookbush

Questions, comments, and criticisms are welcomed and encouraged.

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