TREATMENT EFFECTS WITH GONSTEAD’S TECHNIQUE ON COLLEGE LONG DISTANCE RUNNERS WITH PELVIC TILT OR DEFICIENCY.

The pelvic deficiency is defined as asymmetry Inequality on the length of the legs (inferior pelvic members). Pelvic deficiency or tilt was first documented in the 1970’s with radiograph studies, magnification, and distortion of control images, in 1980 established the standing measurements for radiograph line drawing analysis as Anisomelia or anatomic short leg.^{1, 2} Anatomic pelvic deficiency could be originated during the development or by many different factors as: fractures, diseases, surgical complications among many others. Such alterations developed a constant over stress in the lumbopelvic area; this will provoke adaptation processes called “Heuter Volkmanns” law, which produces soft tissue changes and “normal” structural changes.^{3, 6} This adaptive response could be observed on the measurement of the lumbosacral facets angle.^{7, 10} The 90 % of adult population shows a mean inequality of 5.2 mm¹ , for some authors this does not have any clinical significance if do not reach the 20 mm in accordance.^{11, 12} However, recently it has been observed that minimums of millimeters are related with alteration biomechanic.¹³

Gonsted is a technique used quickly by 58% of chiropractors. Gonstead’s chiropractic technique focuses mainly on the irregular base, movement disorders, intervertebral imbalances, and nerve dysfunction. Gonstead settings are high speed, short lever, and low amplitude. High speed consists of the rapid application of force. The exact contact in the vertebra near or in the vertebral midline is the short lever. The low amplitude is the depth of the force that is controlled at a superficial level, enough to affect the disc and joint.14 Gonstead Technique system has observed that a pelvic rotation or tilt could increase or diminish legs length up to 40%. ^{15, 18} A posterior ilium inclination accompanied of an external rotation will trigger leg shortening, whereas an anterior rotation will induce lengthen. To decrease a possible error factor, to determine the true short leg, the ilium and the rotation in millimeters were combined and multiplied by 0.4.^19,

On the other hand, sports activities such as long-distance racing have increased their popularity around the world due to the benefits that have a direct impact on health, improving the quality of life of people who practice this sport. However, runners have a high incidence of injuries, which can be caused by various factors. It has been reported that 3.3% to 11.5% of people who practice this activity have a hip injury. ^{20 22}

The main propose of this study was evaluate the effect of Gonstead Technique over the biomechanics (Inferior Posterior Ilium, Superior Anterior Ilium, Internal Ilium Rotation, External Ilium Rotation, Measured Deficiency, Posterior Sacrum, Anterior Sacrum, Inferior Sacrum, Lumbar angle, Ferguson angle, Lumbosacral angle) of long distance runners from the UNEVE Student Clinic, who has a pelvic deficiency or tilt.

The study was a longitudinal, prospective, self-controlled, and deliberated intervention (experimental). Twenty-one long distance runners from UNEVE to participate in this study, participants were included if they satisfied the following criteria: athletes diagnosed with pelvic tilt or deficiency using radiograph line drawing analysis by a biomechanic alteration. Long distance runners from 18 to 24 years old, both genders were included, and all has to sign a informed consent before acceptance. Exclusion criteria were athletes diagnosed with an anatomical pelvic deficiency or tilt, tumoration, fracture, ligament or muscle rupture and any sort of implants or adaptations to correct the pelvic deficiency or tilt. Athletes suffering bone fracture, muscle or ligament rupture during the intervention time or athletes who abandoned the treatment were remove of study. This research was performed under the policies of the Helsinki´s Declaration for human clinical research. As well as the policies stablished by the General Law of Health and its Regulation on clinical research. The 100% of the athletes signed an informed consent for the treatment and techniques used, as well as, explained to them.

Biomechanics measures included: Inferior Posterior Ilium, Superior Anterior Ilium, Internal Ilium Rotation, External Ilium Rotation, Measured Deficiency, Posterior Sacrum, Anterior Sacrum, Inferior Sacrum, Lumbar angle, Ferguson angle and Lumbosacral angle. All of these variables are quantitative and continual. The Gonstead’s technique was performed as described previously by Cooperstein.¹⁵

The Statistical Analysis was processed using Excel and SPSS (version 15) for the descriptive statistical analysis (mean, standard deviation, frequency, and average). Normality was determined by the Kolmogorov-Smirnov Test and a T-student, paired T test, Pearson correlation and ANCOVA were applied also. A p value of <0.05 with a 95% confidence interval were used as statistical significance values.

The 71.4% of the sample were females and 28.6% males. At first all the initial measurements of the ilium, lumbar, lumbosacral and Fergusson angle had a normal distribution according to Kolmorogov-Smirnov (KS) statistical analysis. There were no significant differences on the initial measurements by gender according to the T student test for independent samples. In conjunction (n=21), posterior sacrum, anterior sacrum and lumbar angle, there were not observed changes after the chiropractic treatment, in all the other measurements the changes were significant. As it is observed in Table 1, inferior posterior ilium was increased from 213.5 to 234.4 (p= 0.001), superior anterior ilium from 210.9 rise to 233.1 (p= 0.001), internal rotation ilium increases from 111.5 to 119.6 (p= 0.01), external rotation ilium diminishes from 121.6 to 113.7 (p = 0.006), and the measured deficiency decreased from initial 5.6 to a 2.8 at the end (p= 0.0001).

Table 1. Means averages before and after the chiropractic treatment.

Data are expressed as mean ± S.D

Otherwise, an inferior sacrum drops from 3.6 to 1.3 (p= 0.003), Ferguson angle diminish from 34.1 to 17.3 (p= 0.0001), and the lumbosacral angle increased from a initial15.4 to 34.2 (p= 0.0001), at the end. Before treatment with Gonstead´s technique we can observe a positive correlation between Measured Deficiency and Internal Ilium Rotation (r= 0.5; p=0.02), in the same way in Lumbar angle and Anterior Sacrum (r=0.4; p= 0.01). On the other hand, there is a negative correlation between Measured Deficiency and Lumbar angle (r=-0.5; p=0.01), and Measured Deficiency and Ferguson angle (r=-0.4; p=0.04). Finally, after treatment with Gonstead´s technique a positive correlation was registered between Internal Ilium Rotation and Inferior Posterior Ilium (r= 0.4; p=0.03), Internal Ilium Rotation and Superior Anterior Ilium (r= 0.4; p=0.03), Posterior Sacrum and Inferior Posterior Ilium (r= 0.6; p=0.01), Posterior Sacrum and Superior Anterior Ilium (r= 0.6; p=0.003), Anterior Sacrum and Inferior Posterior Ilium (r= 0.5; p=0.008), Anterior Sacrum and Superior Anterior Ilium (r= 0.5; p=0.01), only External Ilium Rotation and Lumbosacral angle (r= -0.4; p=0.04) was a negative correlation after treatment.

When the gender effects were separated from the sample (Table 2), on males the only significant differences were on: the Inferior Posterior Ilium increasing from 207.1 to 252.3 (p=0.0001), the Superior Anterior Ilium increasing from 204.3 to 250.5 (p= 0.0001), the Measured Deficiency decreasing from 6.5 to 3.6 (p= 0.04) and the Lumbosacral angle from 13.1 to 30.3 (p= 0.05). Instead, on the female gender there were observed differences on Superior Anterior from 213.5 to 226.1 (p= 0.05), the Internal Ilium Rotation increasing from 110. 0 to 118.2 (p=0.007), the External Ilium Rotation decreasing from 120.4 to 112.8 (p=0.004), the Measured Deficiency decreasing from 5.27 to 2.53 (p= 0.001), the Inferior Sacrum decreasing from 3.67 to 1.07 (p = 0.002), the Ferguson angle decreasing 36.3 to 16.1 (p=0.0001) and finally the Lumbosacral angle increasing from 16.3 to 35.8 (p= 0.0001).

Due to the distinct results that we evaluated, we analyze the effect of gender on the measurements before and after the treatment, assuming a covariance of 213.5 (both genders started with same value) on the Inferior Posterior Ilium, remarking that males raised to 252.6 increasing a 18.2% toward the final state, instead, females only raised to 227.2 or a 6.4% (p=0.0001). A similar effect was observed on the Superior Anterior Ilium, the covariates on males rise from 210.9 to 250.6 a 18.8%, by contrast females only rise to 226.0 equivalent to 7.1% (p=0.0001).

Table 2. Mean averages before and after the chiropractic treatment

Data are expressed as mean ± S.D

The results show significant anatomical changes when the statistical data were compared before and after treatment with the Gonstead technique on: inferior posterior ilium, superior anterior ilium, internal rotation ilium, external rotation ilium, measured deficiency, inferior sacrum, Ferguson angle and lumbosacral angle. Which is similar with the findings of Young et al.¹⁹ where is mentioned that chiropractors mostly find an inferior posterior ilium on patients with a pelvic tilt and a contrary rotated ilium. The research by Specht and DeBoer²⁰ corroborates the findings that those chiropractors that apply the Gonstead system as patient’s treatment technique, come upon that a pelvic rotation and tilt (radiograph line drawing analysis) are associated with a modification trough a 40% on legs length. A posterior pelvic tilting with an external rotation is related with a pelvic deficiency, whereas an anterior pelvic tilting and internal rotation are allied with an increase on the legs length. To compensate the pelvic deficiency measured with the 5:2 rule and determined the pelvic deficiency type (anatomical or physiological), the ilium bone and ilium rotation in millimeters were combined and multiplied by a constant 0.4 which it is part of the Gonstead’s technique rule.²⁰ Both processes, radiograph line drawing analysis and rule, were used to compare the pre and post treatment in this study.

We find a correlation +/- between an internal rotated ilium with an inferior posterior ilium and anterior superior ilium on the post treatment analysis, which is similar to the findings in other studies, related to a biomechanical alteration of the ilium, rotated and tilt associated with a pelvic deficiency.^{19, 20}

Likewise, we stratified by gender a comparative analysis (pre and post treatment) with all radiograph line drawings. We found significant statistical changes on the following: inferior posterior ilium, anterior superior ilium, deficiency measured and lumbosacral angle on males. On females the changes were on anterior superior ilium, external rotated ilium, measured deficiency, Ferguson and lumbosacral angles. These results are like the reports of Specht and DeBoer²⁰ regarding pelvic biomechanical changes which affect the measured deficiency in comparison with a pelvic deficiency observed and an anatomical or physiological shortening. It is important to mention, that there is no other research that compares gender with this type of adjustment.

Within this study, were found significant changes on radiograph line drawing analysis between genders, nonetheless, the objective of the 5:2 rule is to diminish the measured deficiency, and on the sample, we observed a 50% reduction on males and females, the initial and final difference were statistically significant.

A 100% of the sample showed biomechanical alterations on radiograph line drawing analysis. Significant biomechanical changes were observed using the 5:2 rule for Gonstead technique radiograph line drawing analysis, pre and post treatment, so this technique is effective to improve pelvic deficiency or tilt on the sample. Significant changes were observed between genders, having showed males a better response on the treatment. On the present study we concluded that the athletes showed biomechanical alterations which caused pelvic deficiency or tilt and treated with the Gonstead technique improved them significantly.

1. Eriksen K, Rochester RP. Orthospinology procedures: an evidence-based approach to spinal care. Lippincott Williams & Wilkins. Eds; 2007.

2. Alviso DJ, Dong GT, Lentell GL. Intertester reliability for measuring pelvic tilt in standing. Physical therapy 1988;68(9):1347-1351.

3. White A, Panjabi M. Clinical Biomechanics of the Spine. Philadelphia: J.B. Lippincott 1987:96-352.

4. Gossman MR, Sahrmann SA, Rose SJ. Review of length-associated changes in muscle. Physical Therapy 1982; 62:1799–1807.

5. Maratt JD, Esposito CI, McLawhorn AS, Jerabek SA, Padgett DE, Mayman DJ. Pelvic tilt in patients undergoing total hip arthroplasty: when does it matter?. The Journal of arthroplasty 2015; 30(3), 387-391.

6. Saltychev M, Pernaa K, Seppänen M, Mäkelä K, Laimi K. Pelvic incidence and hip disorders: A systematic review and quantitative analysis. Acta orthopaedica 2018; 89(1),66-70.

7. Yun HH, Murphy WS, Ward DM, Zheng G, Hayden B, Murphy SB. Effect of pelvic tilt and rotation on cup orientation in standing anteroposterior radiographs. HIP International 2019;1120700019831665.

Woodfield HC, Gerstman BB, Olaisen RH, Johnson DF. Interexaminer reliability of supine leg checks for discriminating leg-length inequality. Journal of manipulative and physiological therapeutics 2011; 34(4), 239-246.

9. Knutson GA. Incidence of foot rotation, pelvic crest unleveling, and supine leg length alignment asymmetry and their relationship to self-reported back pain. Journal of manipulative and physiological therapeutics 2002; 25(2), 1-7.

10. Giles LGF, Taylor JR. Lumbar spine structural changes associated with leg length inequality. Spine 1982; 7:159–162.

11. Mannello DM. Leg Length Inequality. J Manipulative Physiol Ther 1992; 15:576–590.

12. Gurney B. Leg length discrepancy. Gait Posture 2002;15:195-206.

13. Knutson Gary A. Anatomic and functional leg-length inequality: A review and recommendation for clinical decision-making. Part I, anatomic leg-length inequality: prevalence, magnitude, effects and clinical significance. Chiropractic & Osteopathy. 2005;13:11.

14. Cooperstein R, Lisi A. Pelvic torsion: anatomic considerations, construct validity, and chiropractic examination procedures. Top Clin Chiro 2000;7(3):38-49.

15. Cooperstein R, Morschhauser E, Lisi A, Nick TG. Validity of compressive leg checking in measuring artificial leg-length inequality. J Manipulative Physiol Ther 2003; 26:557–66.

16. Cooperstein R, Lew M. The relationship between pelvic torsion and anatomical leg length inequality: A review of the literature. J Chiropr Med 2009; 8(3):107-118.

17. Cooperstein R, Holzworth M, O’Brien A. INTRA-AND INTEREXAMINER RELIABILITY OF COMPRESSIVE LEG CHECKING AND CORRELATION WITH THE SIT-STAND TEST FOR ANATOMIC LEG LENGTH INEQUALITY. Chiropractic Journal of Australia 2017; 45(2).

Cooperstein R, Lucente M. Comparison of Supine and Prone Methods of Leg Length Inequality Assessment.Journal of chiropractic medicine 2017; 16(2), 103-110.

19. Young RS, Andrew PD, Cummings GS. Effect of simulating leg length inequality on pelvic torsion and trunk mobility. Gait Posture 2000; 11:217–23.

Specht DL, DeBoer KF. Anatomical Leg Length Inequality, Scoliosis and Lordotic Curve in Unselected Clinical Patients. J Manipulative Phisiol Ther 1991;14:368-375.

21. Miller C, Major N, Toth A. Pelvic stress injuries in the athlete. Sports medicine. 2003;33(13):1003-1012.

22. Van Gent RN, Siem D, van Middelkoop M, Van Os AG, Bierma-Zeinstra SMA, Koes BW. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. Br. J. Sports Med 2007;41(8):469-480.