a study to compare the effect of lumbar spine adjustments

THA 615. 534 BOS

A Study to Compare the Effect of Lumbar Spine Adjustments,

Rectus Femoris Muscle Stretches and a Combination of Both

Treatments on the Flexibility of the Rectus Femoris Muscles

A Dissertation Submitted in Partial Fulfilment of the Requirements for the Master's Degree in

Technology: Chiropractic, in the Faculty of Health Sciences at the

University of Johannesburg

By

Angie Boshoff (Student number: 802001415)

Johannesbuig 2005

UJ LI C LIBRARY TEM: 123808

DECLARATION

I, Anee Boshoff declare that the conception and execution of this dissertation represents my

own work. It is being submitted for the Masters Degree of Technology at the University of

Johannesburg. It has not been submitted for any degree or examination at any other

Technikon, College or University previous to this date.

Signature of Candidate:

Anee Boshoff

On this Tmksda

the 2!(}1 of Felorn(q

2006

Signature of Supervisor:

Dr. S. Wilcox M. Tech (Chiro) SA, B.Sc (Med)(Hons) Biokinetics (UCT), BA Phys Ed (UP)

On this 11(\,lAreA the Andk of

(Foiolcuo-j 2006

Signature of Co-supervisor:

Dr. M. Moodley (M. Tech Chiropractic, SA)

On this 774÷,,e_s D Al the `@-.13b of ee> g_u r)(aH

2006

ii

DEDICATION

Firstly I want to thank my Creator for health, intelligence and guidance throughout my studies

but more so in life.

I want to thank my parents who taught me the value of hard work and perseverance. Thank

you for your support both financially and emotionally. I am eternally grateful.

Thank you to my fiancé who gave me constant support and motivation, without you the road

would have been much harder.

To my family and friends, thanks for your input and interest in my studies it pushed me

through the tough times.

I am grateful for all of you in my life and I hope I made you proud.

iii

ACKNOWLEDGEMENTS

I would like to thank my supervisor, Dr. Wilcox, for her high standard of work ethics, prompt

and very competent input and guidance to make this dissertation worthwhile. Without your

help and support I would never have finished this study so efficiently.

Dr. Moodley, my co-supervisor, your wisdom and competence assisted me until the end of

this long road. Thanks for all the valuable input and advice.

Thanks go out to Adam for all your patience to help me make sense of the statistical

information in this study. The amount of time and frustration you saved me is priceless.

iv

ABSTRACT

This unblinded, randomised pilot study was performed to determine and compare the effect of

innervation specific lumbar spine adjustments and stretching on the flexibility of the rectus

femoris muscles in asymptomatic subjects.

Twelve asymptomatic subjects between the ages of 20 and 30 years were recruited by the use

of advertisements placed around the University of Johannesburg, Doornfontein Campus. The

inclusion criteria required that the patient had decreased rectus femoris muscle flexibility

(testing positive on the rectus femoris contracture test) and no history of, or any current

osteoarthritis or pathology of the hips or knees. The patients were randomly placed into one

of three groups by drawing a group number from a closed bag. Group 1 consisted of four

subjects receiving a single lumbar spine adjustment per treatment relating to the most

restricted segment in the L2-L4 area as well as bilateral proprioceptive neuromuscular

facilitation (PNF) of the rectus femoris muscles; Group 2 consisted of four subjects receiving

bilateral rectus femoris muscle stretches (PNF); and Group 3 consisted of four subjects who

received a single lumbar spine adjustment at the L2-L4 area to the most restricted segment

found. One adjustment per treatment was performed. With the subject in the rectus femoris

contracture test position, a goniometer was used to measure the knee range of motion

bilaterally before and after treatments. These measurements were used as objective data.

Each subject was treated twelve times over a four to six week period.

The objective results indicated that there was a statistically significant improvement in rectus

femoris muscle flexibility in both Group 1 and Group 3.

In conclusion, it was shown that specific adjustments at the spinal level of the nerve

innervation for the rectus femoris muscle resulted in an improvement of the flexibility of the

rectus femoris muscle and with a greater effect on the leg ipsilateral to the side of the spinal

adjustment. This gives support for the effectiveness of innervation specific spinal

adjustments.

TABLE OF CONTENTS

DECLARATION ii

DEDICATION iii

ACKNOWLEDGEMENTS iv

ABSTRACT v

TABLE OF CONTENTS vi

LIST OF FIGURES ix

LIST OF GRAPHS ix

LIST OF TABLES x

LIST OF APPENDICES xi

CHAPTER ONE - INTRODUCTION 1

1.1 WHY DO RESEARCH ON THE RECTUS FEMORIS MUSCLE FLEXIBILITY? 1

1.2 AIM 2

1.3 HYPOTHESES 2

1.4 EXPECTED OUTCOMES 3

CHAPTER TWO - LITERATURE REVIEW 4

2.1 NEUROLOGICAL CONNECTIONS BETWEEN MUSCLE AND THE SPINAL

CORD 4

2.2 SPINAL MANIPULATIVE THERAPY 10

2.2.1 The Effect of Spinal Manipulative Therapy on Muscle Tone 10

2.3 STRETCHING 12

2.3.1 Definition and Stretching Techniques 12

2.3.2 Proprioceptive Neuromuscular Facilitation (PNF) 13

2.4 MUSCLE FLEXIBILITY 13

2.4.1 Definition 13

2.4.2 The Importance of Flexibility 13

vi

2.5 THE RECTUS FEMORIS MUSCLE 14

2.5.1 Anatomical Attachments 14

2.5.2 Innervation 15

2.5.3 Functions 17

2.5.4 Actions that Shorten the Rectus Femoris Muscles 17

2.6 POSTURE 18

2.6.1 Ideal Posture 18

2.6.2 Posture Types 19

2.6.3 Posture and Shortened Rectus Femoris Muscles 20

CHAPTER THREE - METHODOLOGY 25

3.1 PATIENT RECRUITMENT 25

3.2 PATIENT SELECTION AND INCLUSION CRITERIA 25

3.3 PATIENT ETHICS 26

3.4 SAMPLE SIZE AND TREATMENT REGIME 26

3.5 PROCEDURE 27

3.5.1 First Visit 27

3.5.2 Follow-Up Visits 27

3.5.3 Treatment at Follow-Up Visits 27

3.6 OBJECTIVE MEASUREMENTS AND THE EXECUTION THEREOF 30

3.7 VALIDITY AND RELIABILITY OF THE GONIOMETER 30

3.8 STATISTICAL ANALYSIS 31

CHAPTER FOUR - RESULTS 32

4.1 INTRODUCTION 32

4.2 DEMOGRAPHIC DATA 33

4.3 BEFORE AND AFTER TREATMENT MEASUREMENTS IN GROUPS 34

4.4 WILCOXON TESTING 38

4.5 SCATTERPLOT OF PERCENTAGE CHANGES 40

4.6 ONE-SAMPLE T-TEST STATISTICS 43

vii

CHAPTER FIVE - DISCUSSION 47

5.1 TREATMENT EFFECT ON THE RECTUS FEMORIS MUSCLE FLEXIBILITY 47

5.2 BEFORE AND AFTER TREATMENT MEASUREMENTS IN GROUPS 47

5.3 WILCOXON TESTING 48

5.4 SCATTERPLOT OF PERCENTAGE CHANGES 49

5.5 ONE-SAMPLE T-TEST STATISTICS 49

5.6 SUMMARY 50

CHAPTER SIX - CONCLUSION AND RECOMMENDATIONS...... 51

6.1 CONCLUSION 51

6.2 RECOMMENDATIONS 51

REFERENCES 53

APPENDICES 58

viii

Figure 2.1:

Figure 2.2:

Figure 2.3:

Figure 2.4:

Figure 2.5:

Figure 2.6:

Figure 2.7:

Figure 2.8:

Figure 2.9:

Figure 2.10:

Figure 2.11:

Figure 2.12:

LIST OF FIGURES

Neurological Connections Between Muscle and the Spinal Cord 5

Diagrammatical Illustration of the Stretch Reflex 7

Diagrammatical Representation of Reciprocal Inhibition 8

The Neurological Effect of GTO's of Skeletal Muscle 9

The Dual Effect of an Isometric Contraction in Skeletal Muscle 9

Anatomical Attachments of the Rectus Femoris Muscle 15

Arteries and Nerves of Anterior Thigh 16

Ideal Posture 19

Four Types of Postural Alignment 20

Excessive Anterior Pelvic Tilt Resulting in an Increased Lumbar

Lordosis 21

Kyphosis-Lordosis Posture 22

Military-Type Posture 23

LIST OF GRAPHS

Graph 4.1: Loess Curve Fit per Group Average (Right Leg) 41

Graph 4.2: Loess Curve Fit per Group Average (Left Leg) 42

ix

LIST OF TABLES

Table 4.1: Demographic Data 33

Table 4.2: Group 1-Treatment Results 34



Table 4.5: Wilcoxon Test (Right Leg) 39

Table 4.6: Wilcoxon Test (Left Leg) 40

Table 4.7: Combination Group: Adjusted Side's Leg Measurements (One Sample

T-Test Statistics) 43

Table 4.8: Adjustment Group: Adjusted Side's Leg Measurements (One Sample

T-Test Statistics) 44

Table 4.9: Combination Group: Unadjusted Side's Leg Measurements (One

Sample T-Test Statistics) 45

Table 4.10: Adjustment Group: Unadjusted Side's Leg Measurements (One

Sample T-Test Statistics) 46

x

APPENDIX A:

APPENDIX B:

APPENDIX C:

APPENDIX D:

APPENDIX E:

APPENDIX F:

APPENDIX G:

APPENDIX H:

APPENDIX I:

APPENDIX J:

APPENDIX K:

APPENDIX L:

APPENDIX M:

APPENDIX N:

APPENDIX 0:

APPENDIX P:

APPENDIX Q:

APPENDIX R:

APPENDIX S:

LIST OF APPENDICES

ADVERTISEMENT 58

RECTUS FEMORIS CONTRACTURE TEST 59

CONTRA-INDICATIONS TO SPINAL MANIPULATIVE

PROCEDURE 60

SUBJECT INFORMATION AND CONSENT FORM 62

CASE HISTORY 64

PERTINENT PHYSICAL 69

LUMBAR SPINE AND PELVIS REGIONAL 71

HIP REGIONAL 77

KNEE REGIONAL 82

USING A GONIOMETER TO MEASURE THE PASSIVE

LENGTH OF THE RECTUS FEMORIS MUSCLE 88

SOAP NOTE 89

SEATED TRANSVERSO-DELTOID ADJUSTMENT 90

PNF STRETCH OF RECTUS FEMORIS MUSLES 91

HI-LOW GRAPH FOR COMBINATION GROUP

(RIGHT LEG) 92

HI-LOW GRAPH FOR STRETCH GROUP

(RIGHT LEG) 93

HI-LOW GRAPH FOR ADJUSTMENT GROUP

(RIGHT LEG) 94

HI-LOW GRAPH FOR COMBINATION GROUP

(LEFTLEG) 95

HI-LOW GRAPH FOR STRETCH GROUP

(LEFT LEG) 96

HI-LOW GRAPH FOR ADJUSTMENT GROUP

(LEFT LEG) 97

xi

CHAPTER ONE — INTRODUCTION

1.1 WHY DO RESEARCH ON THE FLEXIBILITY OF THE RECTUS FEMORIS

MUSCLE ?

The rectus femoris muscle was chosen because it is the only quadriceps muscle that crosses

two-joints, more specifically the hip joint. This was important because by crossing the hip

joint and attaching to the pelvis, the rectus femoris muscle can have a direct effect on the

orientation of the pelvis and therefore on posture. (Travell and Simons 1997)

The rectus femoris muscle is one of the major postural muscles on the anterior aspect of the

body. Under both normal and pathological circumstances postural muscles have the

predisposition to shorten and lead to pathological postures. (Chaitow 1996)

The second reason for choosing the rectus femoris muscle was because there were reliable

and valid testing procedures available to assess its flexibility.

Flexibility and strength are universally accepted as playing a huge role in the rehabilitation of

patients with pathological postures (Luttgens and Wells 1982). The degree of postural

balance can be restored by releasing the tense and tight muscle through stretching prior to

initiating a strengthening program. Joint manipulation is another way to normalise hypertonic

and shortened muscles. (Chaitow 1996)

The stretching method of proprioceptive neuromuscular facilitation focuses on the

significance of the closely related components in the function of joints and muscles. It makes

use of this by applying a resisted isometric exercise. When a muscle is isometrically

contracted, the antagonist will be inhibited, and will relax immediately following this.

Therefore the antagonist of the shortened muscle may be isometrically contracted, to attain a

degree of ease and additional movement in the shortened muscle tissues. (Chaitow 1996)

Good evidence exists proving that displacement of vertebrae; changes nerve activity in

afferent nerves innervating muscle spindles and other threshold receptors (Bolton 2000).

1

Spinal manipulative therapy influences the mechanoreceptors, proprioceptors and nociceptive

afferents of both joint capsules and musculotendinous structures; resulting in decreased

muscle tone (Evans 2001). Knutson and Owens (2003) proposed that a muscle stretch

produced through manipulation, can affect the hypertonic muscle to normalise passive tone by

re-establishing co-ordination between intrafusal and extrafusal fibres. It is hypothesized that

an inhibitory reflex response may be produced by spinal manipulative therapy that is

segmental in origin with the clinical efficacy of a decreased motoneuron activity, which in

turn may lead to a reduction of muscle hypertonicity (Dishman, Ball and Burke 2002).

1.2 AIM

The aim of this study was to determine if level specific chiropractic adjusting will have a

measurable effect on the flexibility of the distal muscle it innervates and how the effect of

chiropractic adjusting alone relates to the effect of stretching and a combination of adjusting

and stretching on the flexibility of the relevant muscle.

1.3 HYPOTHESES

Hypothesis 1:

Innervation specific (L2-L4) chiropractic spinal adjustment and PNF stretching of the rectus

femoris muscles will result in an increase in rectus femoris muscle flexibility. This increase

in rectus femoris muscle flexibility will be superior to the other two groups.

Null hypothesis 1:

Innervation specific chiropractic spinal adjustment and PNF stretching of the rectus femoris

muscles will not result in an increase in rectus femoris muscle flexibility and will not be

superior to the other two groups.

Hypothesis 2:

PNF stretching of the rectus femoris muscle alone will result in an increase in rectus femoris

muscle flexibility.

2

Null hypothesis 2:

PNF stretching of the rectus femoris muscle alone will not result in an increase in rectus

femoris muscle flexibility.

Hypothesis 3:

Innervation specific (L2-L4) chiropractic spinal adjustment on its own will cause an increase

in rectus femoris muscle flexibility. This increase in rectus femoris muscle flexibility will be

superior to the stretching group.

Null hypothesis 3:

Innervation specific (L2-L4) chiropractic spinal adjustment on its own will not cause an

increase in rectus femoris muscle flexibility and will not be superior to the stretching group.

1.4 EXPECTED OUTCOMES

The expected outcome of this study is an improvement in the flexibility of the rectus femoris

muscles. It is proposed that the group that undergoes adjustments and PNF stretching will

have the best improvement in the flexibility; followed by the adjustment group and then the

stretching group.

The study will benefit the chiropractic community by proving or disproving the importance of

level specific adjustments when treating muscle flexibility.

3

CHAPTER TWO — LITERATURE REVIEW

2.1 NEUROLOGICAL CONNECTIONS BETWEEN MUSCLE AND THE

SPINAL CORD

Two general types of specialised receptors exist in muscles namely: golgi tendon organs

(GTO's) and muscle spindles. A schematic illustration of the afferent and efferent

innervation of muscle is shown in figure 2.1. GTO's are tension receptors in tendons and are

stimulated during muscle contraction and muscle relaxation. These receptors give rise to fast

conducting lb afferent nerve fibres that enter the dorsal horn of the spinal cord. The lb fibre

then splits into two directions, sending fibres into the dorsal or posterior column which

signals higher centres regarding tendon tension, and sending fibres to the dorsal horn where

they synapse on an inhibitory interneuron which then synapses on the cell body of the alpha-

motoneuron serving the same muscle. Therefore "autogenic inhibition" is the general

function of the GTO excitation and involves the inhibition of the contraction of the muscle

within which it is found in order to help prevent damage due to overloading of the muscle

tissues. Muscle spindles are a complex subdivision of muscle anatomy. (Knutson and Owens

2003)

Muscle spindles are primarily length-measuring receptors that are rooted in the bulk of the

muscle tissue. The muscle fibres termed "extrafusal" are found outside the spindle and the

"intrafusal" fibres are situated inside the muscle spindle. Alpha-motoneurons supply the

extrafusal muscle fibres, while the intrafusal fibres are innervated by the gamma fibres. Both

infra and extrafusal muscles are supplied by beta-motoneurons and receive monosynaptic

inputs from both Ia and II afferent fibres, which are sensory fibres from the muscle spindle.

The central, non-contractile portion of the muscle spindle gives rise to the Ia and II afferent

nerve fibres. When stretching a muscle, both extra and intrafusal muscle fibres are stretched

simultaneously. Spindle sensory excitation and Ia and II output occurs when the intrafusal

muscle fibres are stretched. Spindles can be excited independently of extrafusal muscle

stretching via gamma-motoneurons that supply the contractile ends of the intrafusal fibres.

Stimulation of the gamma afferents causes the ends of the spindle to contract separately from

the extrafusal fibres, thus stretching the central region of the spindle and exciting the spindle

4

Long Descending Fibers

Gaigi Tendan Organ

ORG

Intratusal Fibers Chain Fiber BegFiber

r Stretch ending

1° Stretch Ending

Extrefu sal Fibers

telesonesece

eitsoceeuron

sensory Ia and II fibres. One study found that an increase in sympathetic outflow depresses

the feedback control of muscle length. Muscle spindle afferents are thought to form a

proprioceptive chain, from the eye to the foot, involved in controlling posture and position by

their cortical projections. (Knutson and Owens 2003)

Figure 2.1: Neurological Connections between Muscle and the Spinal Cord. (Knutson and

Owens 2003)

Bolton (2000) reviewed the segmental afferent input from spinal structures, stating that

muscles contain multiple sensory receptors and that each spinal structure has its own neural

receptors.

Evidence exists stating that the displacement of vertebrae alters nerve activity in afferent

nerves innervating muscle spindles and other low (mechanical) threshold receptors. These

receptors are responsive to mechanical changes which occur during a spinal manipulation.

(Bolton 2000)

5

Stimulation of these receptors has been shown to activate central reflex pathways and specific

somato-somatic reflexes in experimental animals. It has been demonstrated that these reflexes

can be brought about by a spinal adjustment. (Haldeman 2000)

Because muscle fibres only contract with an action potential that stimulates the muscle,

skeletal muscle tone results entirely from a low rate of nerve impulses sent from the spinal

cord. In the majority of hypothetical models regarding joint dysfunction, muscle hypertonicity

is an active part in the cause, maintenance and effects of the pathological complex. Studies

have shown that spinal manipulation normalised muscle function. (Knutson and Owens 2003)

Two neurophysiological phenomena help to explain facilitation and inhibition of the

neuromuscular systems. The first being autogenic inhibition, illustrated by figure 2.2; which

is mediated by afferent fibres from a stretched muscle, acting on the alpha motor neurons

supplying that muscle, ultimately causing it to relax. By stretching a muscle, the motor

neurons supplying that muscle receive both excitatory and inhibitory impulses from the

receptors. If the stretch is continued for an extended period of time, the inhibitory impulses

from the golgi tendon organs eventually overrule the excitatory impulses and therefore cause

relaxation. Because inhibitory motor neurons receive impulses from the golgi tendon organs,

while the muscle spindle creates an initial reflex excitation leading to contraction, the golgi

tendon organs send inhibitory impulses that last for the duration of increased tension. This

occurs due to either passive stretching or active contractions that eventually dominate weaker

impulses from the muscle spindle. This inhibition seems to protect the muscle from injury

through reflex contractions that occur as result of excessive muscle stretching. (Prentice and

Voight 2001)

6

Type II afferent nerve fibers from Golgi

tendon organs Dorsal

Type la afferent nerve fibers from muscle spindle

Ventral

00% Golgi tendon

organ

Muscle spindle

Gamma efferent fiber .....___causes reflex

relaxation Alpha motor neuron causes reflex contraction

Figure 2.2: Diagrammatical Illustration of the Stretch Reflex. (Prentice and Voight 2001)

Reciprocal inhibition is the second mechanism and involves the relationship between the

agonist and the antagonist muscles. The agonists are the muscles that contract to produce

joint motion and the agonistic pattern is the resulting movement. The muscles that stretch to

allow the agonist pattern to occur are called the antagonistic muscles. This is represented in

figure 2.3. When motor neurons of the agonist muscles receive excitatory impulses from

afferent nerves, the motor neurons that supply the antagonist muscles are inhibited by afferent

impulses. Thus contraction or prolonged stretch of the agonist muscle must elicit relaxation

or inhibit the antagonist. Similarly a quick stretch of the antagonist muscle facilitates a

contraction of the agonist. For both facilitation and inhibition, proprioceptive neuromuscular

facilitation (PNF) relies greatly on the actions of the agonist and the antagonist muscle

groups. (Prentice and Voight 2001)

7

Quadriceps .

Ventral

Hamstrings

Dorsal

Figure 2.3: Diagrammatical Representation of Reciprocal Inhibition. (Prentice and Voight

2001)

During an isometric muscle contraction, the antagonistic muscle will be inhibited and will

relax immediately after the agonist contraction. Therefore the agonist of a shortened muscle

may be isometrically contracted to achieve a degree of relaxation and additional movement in

the shortened tissues. Figure 2.4 is a schematic representation of the neurological effects of

the loading of the golgi tendon organs of skeletal muscle by means of an isometric

contraction, which produces a post-isometric relaxation effect in that muscle (Chaitow 1996).

8

Response from Golgi tendon organ

Strong contraction of skeletal muscle

Motor end plate

lb afferent

fibre )

Cessation of discharge

Dorsal root ganglion

Dorsal root

I ntemeu rone releasing inhibitory

J mediator

Motor neurone

Ventral root

Dorsal root ganglion

Interneurone releasing inhibitory mediator

Motor neurone — of agonist

muscle Motor neurone of antagonist muscle

Muscle spindle

Agonist muscle

Antagonist muscle

Figure 2.4: The Neurological Effect of GTO's of Skeletal Muscle. (Chaitow 1996)

Figure 2.5 represents the reciprocal effect of an isometric contraction of a skeletal muscle,

resulting in an inhibition of its antagonist (Chaitow 1996).

Figure 2.5: The Dual Effect of an Isometric Contraction in Skeletal Muscle. (Chaitow 1996)

9

2.2 SPINAL MANIPULATIVE THERAPY

2.2.1 THE EFFECT OF SPINAL MANIPULATIVE THERAPY ON MUSCLE TONE

The neurological effects, of a spinal manipulative adjustment (SMT) on the human motor

system, are a commonly researched topic (Haldeman 2000). Cailliet (1995) stated that one of

the benefits from a manipulation, is a reflex stimulation that relaxes the extrafusal muscle

fibres (Cailliet 1995). Joint manipulation that results in an articular cavitation has a particular

reflex effect on the periarticular and muscular structures, which is different from a

mobilisation that involves progressive stretching (Maigne 1995).

Knutson and Owens (2003) proposed that a muscle stretch produced via manipulation or other

methods, can affect the hypertonic muscle to normalise passive tone by re-establishing co-

ordination between intrafitsal and extrafusal fibres (Knutson and Owens 2003).

Spinal manipulative therapy (SMT) may result in a global inhibitory response through the

integration of afferent feedback along the entire neuraxis, producing a hypoalgesic effect.

SMT may also create an inhibitory reflex response that is segmental in origin. Although the

exact mechanisms are not known, SMT may involve a decline in motoneuron activity, which

may result in a reduction of hypertonicity in muscles. (Dishman, Ball and Burke 2002)

Muscle tone is defined as the stiffness or resistance of the muscle to passive movement.

Stiffness is the result of the inherent viscoelastic or the mechanical properties of muscle

tissues. (Knutson and Owens 2003)

Mechanoreceptors, proprioceptors and nociceptive afferents of both joint capsules and

musculotendinous structures are seen as the probable "gateway" through which the nervous

system (motor "tone") would be influenced by a manipulation. It is implied that a reduction

of alpha-motorneurone excitability or the activity to innervated muscles results in the

"relaxation of hypertonic muscles". An explanation for the behaviour of this "hypertonic

muscle" is that its innervation is mediated by sensitized spinal interneurones. These muscles

elicit properties of secondary hyperalgesia; often described in association with "myofascial

trigger points" and have spontaneous electromyographic activity. "Taut bands" within the

10

muscle will give rise to increased muscle "stiffness" resulting from these hyperalgesic

regions. (Evans 2001)

It has been demonstrated that after a high-velocity, low-amplitude manipulation of the

zygapophyseal joints, reductions in spontaneous electromyographic activity of paraspinal

muscles as well as reduced hyperalgesia of paraspinal myofascial trigger points occurred.

(Hsieh and Hong 1990)

A study conducted by Herzog, Scheele and Conway (1999) concluded that high-speed, low-

amplitude spinal manipulative therapy results in clear, measurable and repeatable

electromyographic responses in a distinct area that is specific to the treatment administered

and that there is a direct link between the electromyographic response associated with SMT

and a reduction in electromyographic activity in hypertonic muscles.

The articular mechanoreceptor afferent nerve fibres travel to the motoneuron pools within the

central nervous system exerting coordinated reflexogenic effects on muscle tone. Collateral

branches from these afferent nerve fibres allow manipulation of an individual joint to effect

motor unit activity both in the muscle over the joint being manipulated, as well as in more

remote muscles, including those on the opposite side of the body. This mechanism gives rise

to the reflex changes in muscle tone with joint manipulation. (Wyke, Glasgow, Twomey,

Scull, Kleynhans and Idczak 1985)

It is anticipated that a high-velocity low-amplitude thrust activates mechanoreceptors and

proprioceptors from structures within and surrounding the manipulated joint. The distorted

afferent input coming from the stimulation of these receptors is thought to result in changes in

motoneuron excitability, leading to the disturbance of a projected pain-spasm cycle. (Suter,

McMorland, Herzog and Bray 2000)

The nervous system has been viewed as the intermediary of health and strength to all

individual organs and tissues. The dorsal root ganglia lie within the intervertebral canal in

close proximity to the articular capsule, except for the first and second cervical segments.

They contain all the cell bodies of all sensory neurons, except for those found in the cranial

nerves. The dorsal root ganglions are far more sensitive to mechanical stimulation than are

nerve roots, spinal nerves or peripheral nerves. (Lantz 1995)

11

The anterior primary divisions of L2 to S3 innervate the anterior part of the sacroiliac joint,

these divisions also project onto the femoral and tibial nerves which supply the main lower

limb. When the sacroiliac joint is being adjusted a change in the sensory input may affect

efferent pathways at different segmental levels of the spine. Neurophysiological effects of

spinal manipulation have been detected in distant body segments from where the

manipulations were performed. (Suter, McMorland, Herzog and Bray 2000)

2.3 STRETCHING

2.3.1 DEFINTION AND STRETCHING TECHNIQUES

Gatterman (1990) defines stretching as the separation of the origin and insertion of a muscle

or the attachments of fascia or ligaments by applying constant pressure at a right angle to the

fibre of the muscle or fascia.

Stretching refers to the process of muscle lengthening. There are five stretching techniques.

Static stretching involves stretching a muscle to the point of discomfort and then holding it at

this point for a certain time. Although this form of stretching is the safe and efficient; it does

very little to improve coordination and lacks specificity. Ballistic or dynamic stretching

makes use of bobbing, bouncing, rebounding and rhythmic types of movement where

momentum moves the body or limb to forcibly increase the length of the muscle. This is a

controversial method of stretching as it does not provide enough time for the muscle tissues to

adapt to the stretch. It increases muscle tension by initiating the stretch reflex, but makes it

more difficult to stretch connective tissue. The passive stretching technique is done with the

muscle relaxed and not making any contribution to the range of motion. An external force is

used to increase range of motion. It allows for stretching beyond the active range but has a

greater risk of soreness and injury if the external force is not used correctly. One

accomplishes active stretching by using your own muscles to increase range of motion

without external help. The advantage of this type of stretching is that one develops active

flexibility which is known to have a higher correlation with sport achievements than does

passive flexibility. Major disadvantages are that it initiates the stretch reflex and cannot be

used during injury or dysfunction. The fifth stretching technique is known as proprioceptive

neuromuscular facilitation which is discussed below. (Alter 1998)

12

2.3.2 PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION (PNF)

Modified PNF-techniques have been shown to be superior to conventional stretching

techniques (Schuback, Hooper and Salisbury 2004). This stretching technique was initially

developed as a rehabilitative physical therapy procedure to improve range of joint motion

(Alter 1998). It applies neurophysiological principles which are grounded on the theory that

motor output is dependent on the sensory input and that antagonistic muscles are linked by

reflexes through reciprocal inhibition. Under the hypothesis that an inhibitory interneuron

decreases the activity in the alpha-motor neuron to the antagonist muscle, it is suggested that

PNF-methods, especially those concerning reciprocal activation, provide the best potential for

muscle lengthening. (Schuback, Hooper and Salisbury 2004)

2.4 MUSCLE FLEXIBILITY

2.4.1 DEFINITION

Flexibility is crucial to allow for the greatest effectiveness of the musculoskeletal system

(Buschbacher 2002). Gatterman (1990) defines flexibility as the ability of a structure to

deform under the submission of load. Kendall, McCreary and Provance (1993) expand on

this definition stating flexibility to be the ability to willingly adapt to changes in position or

alignment. Prentice and Voight (2001) defined flexibility as the ability to move a joint or

series of joints through a full, non-restricted, pain-free range of motion.

2.4.2 THE IMPORTANCE OF FLEXIBILITY

Flexibility is reliant on both joint range of motion and muscle flexibility. For most activities

of daily life "normal" flexibility is required. However sport related activities require

increased flexibility for peak performance. Therefore a lack of flexibility may result in poor

sport performance and uncoordinated or uncomfortable movement patterns. It is also true that

poor flexibility increases the chance of musculotendinous injuries. (Prentice and Voight

2001)

13

Schuback, Hooper and Salisbury (2004) confirm and elaborate on this by stating that the

flexibility of the quadriceps muscles, thus including the rectus femoris muscle, is vital in

injury prevention, postural and muscular imbalance, preservation of full joint range of motion,

finest musculoskeletal function and advanced performance in sports.

2.5 THE RECTUS FEMORIS MUSCLE

The rectus femoris muscle forms part of the quadriceps femoris muscle group. This muscle

group forms the anterior muscle bulk of the thigh and consists of four muscles; the rectus

femoris, vastus lateralis, vastus intermedius and the vastus medialis muscles. Distally all four

muscles in the quadriceps femoris group have a common attachment on the patella and a

sesamoid bone; which is attached to the tibial tuberosity by the patellar ligament. (Travell

and Simons 1997)

The quadriceps muscle group is the largest and most powerful muscle in the body and is

known as the great extensor of the leg (Moore and Dailey 1999).

2.5.1 ANATOMICAL ATTACHMENTS

The rectus femoris muscle crosses both the hip and the knee joints. As illustrated in figure 2.6

it is located between the vastus lateralis and vastus medialis muscles and on top of the vastus

intermedius muscle. Proximally the rectus femoris has two tendons that attach to the anterior

inferior iliac spine and to the furrow above the posterior brim of the acetabulum. Its distal

tendon joins the three vasti muscles to attach to the proximal border of the patella. It is

indirectly linked to the tibia via the patellar ligament that spans the distal border of the patella

and the tibial tuberosity. The rectus femoris muscle is crossed obliquely by the sartorius

muscle from the anterior inferior iliac spine to its medial border. Anatomical variations are

rare, where the rectus femoris muscle has only one proximal attachment to either the anterior

inferior iliac spine or to the rim of the acetabulum. (Travell and Simons 1997)

14

Rectus femoris

Vastus lateralis

Lateral patellar

retinaculum

Patellar ligament_

Vastus medialis

Patella

Medial patellar

retinaculum

Tibial tuberosity

Tibia

Anterior inferior

iliac spine

Level of Cross

section

Figure 2.6: Anatomical Attachments of the Rectus Femoris Muscle. (Travell and Simons

1997)

2.5.2 INNERVATION

The quadriceps femoris muscle group shares nerve innervation from branches of the femoral

nerve, which is composed of the second, third and fourth lumbar spinal nerves. The femoral

nerve runs deep to the sartorius muscle and then enters the adductor canal along the medial

border of the vastus medialis, which receives direct innervation from branches of the femoral

nerve. Branches of the femoral nerve then travel between the rectus femoris and the vastus

intermedius muscles to supply the remaining three quadriceps muscles. A strand from one of

the branches of the femoral nerve that supplies the vastus intermedius muscle pierces the

muscle and innervates the articularis genu muscle and the knee joint. (Travel! and Simons

1997) The innervation of the rectus femoris muscle is shown in figure 2.7.

15

Lateral circumflex femoral artery •

Deep femoral artery

Rectus femoris --muscle

Adductor - longus muscle

Lateral femoral cutaneous nerve (cut) Tensor fasciae latae muscle (retracted)

Sartorius muscle (cut)

Gluteus scle minim us

and medius muscles Femoral nerve,

artery and vein

Pectineus muscle

Vastus Adductor canal medialis (opened by muscle removal of

sartorius muscle)

Saphenous nerve

Nerve to vastus medialis muscle

Adductor magnus muscle

Membranous roof of distal adductor canal covers entrance of femoral vessels to popliteal space

Saphenous nerve and saphenous

• branch of descending genicular artery

Sartorius muscle (cut)

Articular branch of descending genicular artery (emerges from vastus medialis muscle)

Patellar plexus

Infrapatellar branch of Saphenous nerve

Medial superior genicular artery (from popliteal artery)

Medial inferior genicular artery (from popliteal artery)

Figure 2.7: Arteries and Nerves of Anterior Thigh. (Netter 1994)

16

2.5.3 FUNCTIONS

The four heads of the quadriceps femoris muscle work together as the main extensors of the

leg at the knee when the leg and foot are free to move. The rectus femoris muscle crosses

both the hip and the knee joint and therefore, depending on the segment that is fixed, either

flexes the thigh at the hip or flexes the pelvis on the thigh, it also aids in abduction of the

thigh in supine subjects. During standing and body positioning there is late activation of the

rectus femoris muscle with hip flexion, backward bending, squatting and sitting down.

During stair climbing the rectus femoris muscle activity starts at the beginning of the stance

phase until the second phase of double support, when the opposite foot is placed on the step

above. When descending stairs, the rectus femoris muscle is active during the stance period,

but is most active at the start and end of stance. The rectus femoris muscle is very active

when one lifts an object with the knees flexed and the activity in the rectus femoris doubles

when the load being lifted is held away from the body. (Travell and Simons 1997)

2.5.4 ACTIONS THAT SHORTEN THE RECTUS FEMORIS MUSCLES

Overload of any muscle will result in it becoming shortened over a prolonged period of time.

Therefore use a safe technique that spares your quadriceps as well as your paraspinal muscles

to lift heavy objects off the floor, when doing the squatting exercise never bend the thigh

lower than horizontal or parallel to the floor and when rising from a deep seated chair use

your arms to assist your quadriceps muscles. Prolonged immobilisation of the rectus femoris

will also result in it becoming shortened. Therefore avoid sitting in an acute angle of hip

flexion, do not sit with one foot under the other buttock for prolonged periods of time and do

not sleep with your hips flexed and your knees extended as it will place your rectus femoris

muscles in a shortened position resulting in it becoming shortened. (Travell and Simons

1997)

17

2.6 POSTURE

2.6.1 IDEAL POSTURE

The ideal posture viewed from the side, is described by making use of a plumb alignment with

both anatomical structures and surface landmarks on the body that coincide with the plumb

line (Kendall, McCreary and Provance 1993).

When examining ideal posture from a side view, surface landmarks can be used in relation to

the plumb line. The plumb line should run through the ear, through the bodies of the cervical

vertebrae and through the shoulder joint, provided that the arms hang in normal alignment in

relation to the thorax. The plumb line then roughly halves the trunk and runs approximately

through the greater trochanter of the femur. It continues slightly anterior to a midline through

the knee and ends a little anterior to the lateral malleolus of the ankle. (Kendall, McCreary

and Provance 1993)

When using anatomical structures that concur with the line of reference, the apex of the

coronal suture is somewhat anterior to the plumb line. The plumb line should run through the

external auditory meatus, through the axis of the odontoid process, through the bodies of the

lumbar vertebrae and through the sacral promontory. The centre of the hip should lie slightly

anterior to the plumb line and the axis of the knee joint should be posterior in relation to the

plumb line. Lastly the plumb line should intersect the calcaneocuboid joint. (Kendall,

McCreary and Provance 1993)

Figure 2.8 illustrates this posture analysis with both the surface landmarks and the anatomical

structures. The subject in the figure shows excellent postural alignment except for slight

anterior head carriage. In the lateral view, the anterior and posterior muscles attaching to the

pelvis should maintain it in ideal alignment. Anteriorly the abdominal muscles pull upwards

and the hip flexors pull downward. On the posterior aspect the back muscles pull upward and

the hip extensors pull downward. (Kendall, McCreary and Provance 1993)

18

Back Extensors Abdominals

Rectus abdominis External oblique

Hip Flexors Psoas major Iliacus

Tensor fasciae latae

Rectus femoris

Hip Extensors

Gluteus maximus

Hamstrings

Figure 2.8: Ideal Posture (Kendall, McCreary and Provance 1993)

2.6.2 POSTURE TYPES

The normal curves of the spine consist of a slight cervical and lumbar lordosis and a slight

thoracic kyphosis. A normal lumbar curve will result in a neutral pelvis alignment. In faulty

postural positions the pelvis may be anterior, posterior or laterally tilted. Any tilting of the

pelvis results in a faulty alignment of the spine and hip joints. In figure 2.9 view B the pelvis

is tilted anteriorly resulting in flexion of the hip joint; the lower back arches forward causing

19

B

Kyphosis-lordosis posture. Flat-back posture. Sway-back posture. Ideal alignment

an excessive lumbar lordosis. A posteriorly tilted pelvis is demonstrated in views C and D.

The pelvis tilts backwards and the hip joints then extend causing the lumbar spine to flatten.

In a lateral pelvic tilt, the one hip is higher than the other and this then creates a spinal

scoliosis with the convexity toward the low side of the pelvis. (Kendall, McCreary and

Provance 1993)

Figure 2.9: Four Types of Postural Alignment (Kendall, McCreary and Provance 1993)

2.6.3 POSTURE AND SHORTENED RECTUS FEMORIS MUSCLES

Shortening of different muscle groups, particularly in the hip and the two joint muscles, can

add to a range of postural and joint dysfunctions (Scully and Barnes 1989).

20

Increased cervical curve

Increased thoracic curve

Increased lumbar curve

Anterior pelvic tilt

Shortened rectus femoris muscles may result in an anterior pelvic tilt due to its attachment to

the pelvis. An anterior pelvic tilt, illustrated in figure 2.10, leads to biomechanical changes in

the entire body that result in unhealthy postures like; the "Kyphosis-Lordosis Posture" (Figure

2.11) and the "Military-Type Posture" (Figure 2.12). (Kendall, McCreary and Provance

1993)

Figure 2.10: Excessive Anterior Pelvic Tilt Resulting in an Increased Lumbar Lordosis.

(Levangie and Nortin 2001)

Figure 2.11 illustrates the resultant kyphosis lordosis posture type due to an anterior pelvic

tilt. Anterior head carriage and cervical hyperextension are present. The scapulae are

abducted on the hyperkyphotic thoracic spine. The lumbar lordosis is excessive, the pelvis is

tilted anteriorly and the hip joints are flexed. The knee joints are slightly hyperextended

while the ankle joints exhibit slight plantar flexion due to the backward inclination of the leg.

21

The neck extensor and hip flexor muscles; including the rectus femoris muscles, are short and

strong. The weak and elongated muscles include the neck flexors, the erector spinae and

external oblique upper back muscles. The hamstring muscles are slightly elongated but may

not be weak. The rectus abdominis is not necessarily elongated but due to the depressed

position of the chest it offsets the effect of the anterior pelvic tilt. (Kendall, McCreary and

Provance 1993)

Figure 2.11: Kyphosis-Lordosis Posture. (Kendall, McCreary and Provance 1993)

In the military type posture (figure 2.12) the head is in the neutral position with normal

cervical and thoracic curves. A hyperlordosis is noted in the lumbar spine as well as an

anterior pelvic tilt, slightly hyperextended knees and slightly plantar flexed ankle joints. The

anterior abdominals are weak and elongated while the hamstrings are elongated but may not

22

be weak. The lower back and hip flexor muscles are perceived as short and strong. (Kendall,

McCreary and Provance 1993)

Figure 2.12: Military-Type Posture. (Kendall, McCreary and Provance 1993)

In these postures where there is excessive anterior pelvic tilt as a result of shortened hip

flexors like the rectus femoris muscles, the lower lumbar vertebrae are forced anteriorly. The

upper lumbar vertebrae compensate for this by moving posteriorly to keep the head over the

sacrum. The result is an increase in the lumbar lordosis and in order to balance the lordotic

lumbar curve and keep the head over the sacrum, the posterior convexity of the thoracic spinal

curve increases and becomes kyphotic. The cervical concave curve will also increase to keep

the head over the sacrum. (Levangie and Nortin 2001)

23

Facet joints are innervated by the medial branch of the dorsal rami and are pain sensitive.

These unhealthy postures cause positional changes in facet joint orientation. This results in

biomechanical dysfunction of the facet joints and is a possible source of lower back pain.

(Souza 2001)

Mechanical dysfunctions that may develop as a result of the posture changes may be altered

by correcting the flexibility of the rectus femoris muscle (Kendall, McCreary and Provance

1993).

The body makes its own compensations to maintain the head over the sacrum, but these

postural changes are never as proficient as the posture being replaced. A person with

shortened hip or knee flexors, thus including rectus femoris muscles, is not able to maintain a

normally contoured and upright spinal posture. Instead, the body reacts by tilting the pelvis

anteriorly creating an increased lumbar lordosis. Resulting compensations include an

increased thoracic kyphosis and a cervical lordosis with an anterior head carriage. In this

resultant posture the head is still oriented over the sacrum but most points on the trunk have

been displaced farther from the centre of gravity, therefore the torque necessary to maintain

alignment of these segments is far greater. In turn this results in excessive joint degeneration.

Finally as a result of the hip and knee flexors being tight the sternocleidomastoid muscles

become tight due to the forward head posture and the lumbar erector spinae muscles tighten

up from the increased lumbar lordosis. In addition to these shortened muscles their

antagonistic muscles weaken. (Scully and Barnes 1989)

Previous studies have shown that adjusting the specific spinal level of innervation of a certain

organ or muscle had an effect on that structure due to reflex responses resulting from the

adjustment (Budgell 2000).

Therefore by adjusting a certain spinal level to affect a specific muscle's flexibility will in

turn have a positive effect on posture and a good posture is necessary for optimal spinal health

(Levangie and Nortin 2001).

24

CHAPTER THREE - METHODOLOGY

The purpose of this study was to determine and compare the effect of innervation specific

lumbar spine adjustments and stretching; on the flexibility of the rectus femoris muscles in

asymptomatic subjects with bilateral rectus femoris muscle contracture.

3.1 PATIENT RECRUITMENT

Recruitment of subjects was done by placing advertisement posters around the University of

Johannesburg, Doornfontein Campus (Appendix A).

3.2 PATIENT SELECTION AND INCLUSION CRITERIA

Subjects who responded to the advertisement were contacted to schedule an appointment to

determine whether or not the subject fulfilled all the inclusion criteria. Subjects who fulfilled

the following criteria were included in the study:

• Positive bilateral rectus femoris contracture tests:

Rectus femoris muscle shortening demonstrated with the Rectus Femoris

Contracture test (Appendix B). This test is also known as the Kendall Test and

was used to measure the knee flexion angle of the tested leg. This angle is

linked to the length of the rectus femoris muscle. The subject lay supine with

their pelvis close to the edge of the plinth. The subject then flexed one knee

and hip and held it close to their chest until their spine was passively pushed

flat on the plinth. The opposite leg was the test leg and remained relaxed and

hanging over the edge of the plinth. The test leg's angle of knee flexion should

remain at 90 degrees when the opposite leg is flexed to the chest to indicate a

negative or normal test. This knee flexion angle was then measured with a

goniometer by using the line of the femur as zero degrees. A straight test leg

would be measured as 0 degrees. If the test leg extends beyond 90 degrees of

25

knee flexion a positive rectus femoris contracture is present and indicates a

shortened rectus femoris muscle. (Magee 2002)

Between the ages of 20 and 30 years.

Subjects were excluded if they displayed:

A history or presence of osteoarthritis, pathology or any symptoms of pain, stiffness,

swelling and decreased range of motion in the hips, knees or lower back.

Any conditions that were contraindicated to chiropractic adjusting (Appendix C).

3.3 PATIENT ETHICS

During this study ethical measures were applied by; ensuring autonomy of the participating

subjects, informing them about their voluntary participation and freedom to withdraw at any

time during the study. Privacy, confidentiality and anonymity were strictly applied at all

times. All subjects were informed about the benefits of the study and feedback concerning

the study was given on request. After the subjects received and understood all the above

information they gave their informed consent through their signature on the subject

information and consent form (Appendix D).

3.4 SAMPLE SIZE AND TREATMENT REGIME

Subjects who fitted all the inclusion criteria for this study were randomly placed into one of

three groups. The subjects were asked to pull a designated group number out of a closed bag.

Each group consisted of two males and two females. Group 1 received a combination of

lumbar spine rotary adjustments (L2-L4) and PNF stretching of their rectus femoris muscles.

Group 2 was the stretching group and only received PNF stretching. Group 3 was the

adjustment group and only received a rotary lumbar spine adjustment on each treatment.

26

3.5 PROCEDURE

3.5.1 FIRST VISIT

All subjects that fitted the inclusion criteria received identical diagnostic assessments after

being placed in their designated groups. The first visit was scheduled and involved the

following:

Completing a case history (Appendix E)

Under going a pertinent physical examination (Appendix F)

Assessments of the lumbar spine and pelvis (Appendix G), hip (Appendix H) and

knee (Appendix I) regional examinations.

Signing an informed consent form (Appendix D)

All these regional examinations were done to confirm that no hip, knee and or spinal

osteoarthritis, or any other condition affecting normal knee and hip range of motion existed.

3.5.2 FOLLOW-UP VISITS

All subjects were treated twelve times over a four to six week period.

Follow-up visits were 10-15 minutes in duration.

A maximum of three days between follow-up treatments was allowed.

Objective measurements in the rectus femoris contracture test position were performed

with a goniometer before and after each treatment in the follow-up visit (Appendix J).

3.5.3 TREATMENT AT FOLLOW-UP VISITS

All follow-up treatments for group 1 consisted of the following:

Bilateral objective measurements in the rectus femoris contracture test (Appendix J)

position performed with a goniometer.

This pre-treatment reading was then documented in the SOAP notes (Appendix K). A

SOAP note is a summary of the objective and subjective findings, as well as the

diagnosis and the treatment plan.

Segmental lumbar spine rotary motion palpation was performed to determine which of

the L2/3, L3/4 or L4/5 segmental motion units were the most restricted. The subject

27

was seated and faced away from the examiner. The subject's arms were then crossed

over their chest. The examiner stood at the side of the subject and took a thumb

contact on the ipsilateral aspect of the lumbar spinous process. The subject was

rotated ipsilaterally to end range of motion. Segmental motion was felt while the joint

was challenged into further rotation. Loss of the segmental motion; where the spinous

process should approximate the palpating thumb, or loss of the springy end feel; which

is felt as the segment is challenged for joint play, indicates restricted motion. The

entire lumbar spine was palpated in this manner from cephalad to caudad. (States

1985)

Only one seated rotary lumbar spine adjustment known as the transverso-deltoid

adjustment (Appendix L) was then performed on the most restricted segment of L2/3,

L3/4 or L4/5 spinal motion unit. This adjustment can be applied to rotary restrictions

of the lower thoracic joints and all the lumbar vertebrae. The subject sat straddling the

table. Their arms were crossed over the chest; homolateral arm on top and their hands

placed onto the opposite shoulders. The doctor's position was 90 degrees posterior to

the patient. The doctor's contralateral arm reached around the subject and held onto

the subject's contralateral deltoid area. The doctor's homolateral hand made a

pisiform contact on the transverse or mamillary process of the restricted segment. The

doctor's contralateral arm rotated the subject's torso until the "joint slack" in the

restricted segment was removed. Simultaneously the doctor's homolateral contact

hand thrusted anteriorly with the elbow supported in the inguinal region. (Kirk,

Lawrence and Valvo 1991)

The level and side of the adjustment was recorded on the SOAP notes.

PNF stretching of both rectus femoris muscles was then performed (Appendix M).

The subject lay prone with the operator standing on the opposite side of the leg being

stretched. The operator used their cephalad hand to stabilise the subject's pelvis. The

subject's affected leg was flexed at the knee until maximum resistance in the rectus

femoris muscle was reached. This stretch was held for 10-15 seconds. This was

followed by a 7-10 second isometric contraction of the involved rectus femoris muscle

as the subject tried to straighten the leg against the operator's resistance. The subject

then activated the antagonistic muscles by actively flexing their knee. Finally the 10-

15 second stretch was repeated with the operator flexing the subject's knee (Chaitow

1996). A continued sustained stretch of anywhere between 6 to 60 seconds is

28

sufficient time for the golgi tendon organs to respond to the increase in tension. The

maximum time for the isometric contraction of the muscle being stretched is 10

seconds. This causes an increase in the tension that stimulates the golgi tendon organs

to result in a reflex relaxation of the antagonist before the muscle is stretched again.

This process is referred to as autogenic inhibition. (Prentice and Voight 2001)


position were performed with a goniometer.

This post-treatment reading was then documented in the SOAP notes (Appendix K).




This pre-treatment reading was then documented in the SOAP notes (Appendix K).

PNF stretching of both rectus femoris muscles was then performed as described for

group 1 (Appendix M).







This pre-treatment reading was then documented in the SOAP notes (Appendix K).

Segmental lumbar spine rotary motion palpation was performed, as for group 1 to

determine which of the L2/3, L3/4 or L4/5 segmental motion units were the most

restricted.

Only one seated rotary lumbar spine adjustment known as the transverse-deltoid

adjustment (Appendix L) was then performed, as described for group 1 on the most

restricted segment of L2/3, L3/4 or L4/5 spinal motion unit.

The level and side of the adjustment was recorded on the SOAP notes.




29

3.6 OBJECTIVE MEASUREMENTS AND THE EXECUTION THEREOF

The universal goniometer was used to achieve objective measurements. This measured the

knee flexion angle when the subject was positioned in the rectus femoris contracture test

position. Measurements were taken bilaterally on each knee before and after treatment. The

knee flexion angle in this test position relates to the length or flexibility of the rectus femoris

muscle. The goniometer is essential to assess improvement in joint flexibility and has an

important place in the clinical rehabilitation setting (Prentice 1997).

The axis of the goniometer was placed on the lateral aspect of the knee joint line above the

head of the fibula. This area was marked with a permanent marker on the first measurement

to ensure more accurate future measurements. The greater trochanter of the femur and the

lateral malleolus of the fibula were used as reference points for the protractor arms of the

goniometer. The stationary arm was placed on the femur while the other arm was movable

and aligned with the fibula.

3.7 VALIDITY AND RELIABILITY OF THE GONIOMETER

The goniometer is essential to assess improvement in joint flexibility and has an important

place in the clinical rehabilitation setting (Prentice 1997).

The protractor measures 180-degrees, with one axis that joins two arms. When measuring,

one arm is kept stationary on a definite landmark while the other arm is movable around the

axis or fulcrum of the protractor (MacDougall, Wenger and Green 1989).

Rothstein, Miller and Roettger (1983) did a study to assess the reliability of goniometeric

measurements of passive elbow and knee positions in symptomatic patients. The results

proved that intratester reliability and intertester reliability was highly reliable. (Rothstein,

Miller and Roettger 1983)

The reliability and validity of goniometric measurements at the knee joint was proved again in

1987 by Gogia, Braatz, Rose and Norton when they did a study on thirty healthy subjects

using a standard goniometer. (Gogia, Braatz, Rose and Norton 1987)

30

In 1997 the intertester and intratester criterion validity and reliability of the universal

goniometer were compared with the parallelogram goniometer for active knee flexion in

healthy subjects. The study proved to be of clinical importance and found that both types of

goniometers were equally reliable and valid when measuring active knee flexion. (Brouseau,

Tousignant, Budd, Chartier, Duciaume, Plamondon, O'Sullivan, O'Donoghue and Balmer

1997)

3.8 STATISTICAL ANALYSIS

One sample T-testing and curve fitting tests were done. Statistical data analysis was

performed by applying the results to mathematical graph patterns in order to obtain a visual

representation of the data and trends for each consecutive treatment.

The data was transformed into a percentage change to make the data more assessable. A five

percent significance level (p < 0.05) was used throughout the analysis.

Tests were then performed to see what percentage change for a given treatment was

significant from zero. The tests calculated the p-value, which is used to assess if the data was

statistically significant.

31

CHAPTER FOUR — RESULTS

4.1 INTRODUCTION

The objective data collected for this study was accumulated by using a universal goniometer

to measure the passive knee flexion angle, with the subject in the rectus femoris contracture

test position. The universal goniometer was shown to be a valid and reliable instrument

(Brouseau, Tousignant, Budd, Chartier, Duciaume, Plamondon, O'Sullivan, O'Donoghue and

Balmer 1997). Measurements were taken bilaterally before and after each treatment.

Graphs were constructed to determine if any of the groups followed recognisable

mathematical graph patterns to obtain a visual representation of the data and the trends for

each consecutive treatment.

To make the data more quantifiable, it was transformed into a percentage change. A five

percent significance level (p < 0.05) was maintained throughout the analysis. The after

treatment reading minus the before treatment reading divided by the before treatment reading

formula was used to calculate the percentage change. A positive value for the percentage

change indicates an improvement from the before treatment to the after treatment results for

the given treatment. Tests were then performed to see what percentage change for a given

treatment was significant from zero.

During the statistical testing both the parametric and non-parametric tests were adopted due to

the nature of the data and the p-value. A p-value is considered significant ifp<0.05.

This study proved to be of clinical importance and showed statistical significance.

32

4.2 DEMOGRAPHIC DATA

The subjects used for this study were aged between 20 and 30 years, the mean age was 25.3

years. Each group consisted of 50% male and 50% female subjects.

Subjects in group 1 were between 22 and 29 years of age, with a mean age of 25.5 years. In

group 2 the subjects were between 23 and 28 years of age and the mean age was 24.5 years.

Subjects in group 3 were between 23 and 29 years of age, with a mean age of 26 years.

Table 4.1 shows the above data in an all-inclusive format.

Table 4.1: Demographic Data

Data

Group 1

Combination

Group

Group 2

Stretch

Group

Group 3

Adjustment

Group

Combined

Total

Age Distribution 22-29 23-28 23-29 22-29

Mean Age 25.5 24.5 26 25.3

Gender

Distribution

2 Females

2 Males

2 Females

2 Males

2 Females

2 Males

6 Females

6 Males

33

4.3 BEFORE AND AFTER TREATMENT MEASUREMENTS IN ALL THREE

GROUPS

Before and after treatment results tables are a useful way to demonstrate the before and after

treatment changes in each group in comparison to consecutive treatments. In Table 4.2

(group 1), Table 4.3 (group 2) and Table 4.4 (group 3) the measurements are given as the

average value of the measurements of all the subjects in the specific group.

When analysing Table 4.2, it was noted that on the right leg that not all the before treatment

values on consecutive treatments were lower than the previous treatments' after treatment

values. On all treatments the after treatment values were higher than the before treatment

values.

Table 4.2: Group 1-Treatment Results

COMBINATION GROUP

Treatment

Number

Right Leg Left Leg

Before After Before After

1 52.3 56.0 50.0 56.3

2 57.3 62.3 52.5 55.8

3 56.5 62.8 56.3 63.3

4 58.3 62.8 56.8 60.3

5 63.5 64.8 58.8 63.5

6 67.0 68.5 60.0 63.8

7 60.5 64.3 56.5 60.5

8 63.8 64.8 57.5 61.3

9 59.0 63.3 58.3 65.3

10 61.0 65.5 59.8 62..8

11 65.3 67.8 59.3 61.5

12 62.8 66.0 57.3 60.0

The measurements of the left leg also showed that not all the before treatment values on

consecutive treatments were lower than the previous treatments' after treatment values. On

all treatments the after treatment values were higher than the before treatment values. The

biggest ranges between before and after treatment values were seen at treatment 1, 3, and 9.

34

A clinical significance of the treatment results in the combination group was noted. The

measurements on the right rectus femoris muscle showed that the average group reading

before treatment one was 52.3 degrees and the average group reading before treatment twelve

was 62.8. Therefore there was an improvement of 10.5 degrees in the flexibility of the right

rectus femoris muscle in the combination group. The difference for the combined group

readings before treatment one and before treatment twelve of the rectus femoris muscle on the

left leg indicated a clinically significant improvement in the rectus femoris flexibility of 7.3

degrees.

On the combined group readings for the right leg in the combination group the treatment

results after the first treatment was 56 degrees on average and 66 degrees on average for the

after treatment twelve readings. This showed a clinical significant improvement in the rectus

femoris muscle flexibility of 10 degrees for the group on average after the treatments. The

improvement in the flexibility of the rectus femoris muscle on the left leg after treatment one

was 56.3 and 60 after treatment 12. Therefore a 3.7 degree rectus femoris muscle flexibility

improvement was observed in the left leg.

In table 4.3 results of the right leg showed a gradual rise from treatment 1, with the peak of

the results at treatment 8 followed by a decrease in values with the fmal treatment value

higher than the starting value. On all treatments the after treatment values were higher than

the before treatment values. The results of the left leg indicates that in all treatments the after

treatment values were higher than the before treatment values. Treatment 1 showed the

biggest improvement between before and after treatment values and a slightly improved norm

value at treatment 12, although this final reading was higher than the reading at the start of the

treatment 1.

35


STRETCH GROUP

Treatment

Number

Right Leg Left Leg


1 49.0 55.0 47.8 56.8

2 49.3 52.5 54.0 52.8

3 53.0 56.5 54.5 55.3

4 55.8 57.3 54.8 56.0

5 60.0 62.3 57.8 61.8

6 59.8 67.0 55.8 59.3

7 61.5 62.3 58.8 59.8

8 63.5 65.5 58.0 58.5

9 63.3 64.3 58.0 60.0

10 62.3 63.0 57.8 58.8

11 60.3 57.5 58.8 57.3

12 57.3 58.8 56.3 56.5

A clinical significance of the treatment results in the stretch group was noted. The


before treatment one was 49 degrees and the average group reading before treatment twelve

was 57.3. Therefore there was an improvement of 8.3 degrees in the flexibility of the right



left leg indicated a clinical significant improvement in the rectus femoris flexibility of 8.5

degrees.

On the combined group readings for the right leg in the stretch group the treatment results

after the first treatment was 55 degrees on average and 58.8 degrees on average for the after

treatment twelve readings. This showed a clinically significant improvement in the rectus

femoris muscle flexibility of 3.8 degrees for the group on average after the treatments. The

flexibility of the rectus femoris muscle on the left leg after treatment one was 56.8 and 56.5

after treatment 12.

36

Table 4.4 showed that in the right leg measurements there were a constant gradual rise from

treatment 1 through to treatment 12. It was noted that there was a decrease in the range of

before and after treatment values towards the end of the treatment program. The consecutive

before treatment values are lower than the previous after treatment values. On all treatments

the after treatment values are higher than the before treatment values. The results of the left

leg measurements indicated that a gradual rise in the graph pattern was noted. Gradual

consistent improvements were seen from treatment 1 to treatment 12. On all treatments the

after treatment values are higher than the before treatment values.


ADJUSTMENT GROUP

Treatment

Number

Right Leg Left Leg


1 57.3 64.8 56.8 65.5

2 60.8 68.8 55.8 58.5

3 59.8 65.8 61.5 62.8

4 64.0 70.0 61.3 66.8

5 63.8 66.8 61.8 67.5

6 66.0 70.8 65.0 71.5

7 68.0 72.5 67.3 71.5

8 70.0 72.8 65.3 70.3

9 70.3 72.5 68.3 71.5

10 72.5 75.7 70.0 76.0

11 75.3 80.0 68.5 76.5

12 77.3 80.3 71.8 77.8

A clinical significance of the treatment results in the adjustment group was noted. The


before treatment one was 57.3 degrees and the average group reading before treatment twelve

was 77.3. Therefore there was an improvement of 20 degrees in the flexibility of the right



37

left leg indicated a clinical significant improvement in the rectus femoris flexibility of 15

degrees.

On the combined group readings for the right leg in the adjustment group the treatment result

after the first treatment was 64.8 degrees on average and 80.3 degrees on average for the after

treatment twelve readings. This showed a clinical significant improvement in the rectus

femoris muscle flexibility of 15.5 degrees for the group on average after the treatments. The

improvement in the flexibility of the rectus femoris muscle on the left leg after treatment one

was 65.5 and 77.8 after treatment 12. Therefore a 12.3 degree rectus femoris muscle

flexibility improvement was observed in the left leg.

4.4 WILCOXON TESTING

The Wilcoxon testing was done to determine if the improvement in rectus femoris flexibility

in each separate group was of any statistical significance. Note that in this test the level of

significance used was p < 0.10. The p-values, in bold, indicates a high level of statistical

significance. The Wilcoxon test is a non-parametric test used for the data of small groups.

Because of the size of the groups, p < 0.10 was used to indicate the significance at a 90%

level instead of a 95% level where p< 0.05.

38

Table 4.5: Wilcoxon Test (Right Leg)

GROUP MEAN STANDARD DEVIATION

TREATMENT 12 (AFTER) —

TREATMENT 1 (BEFORE) (p < 0.10)

COMBINATION

Treatment 1: Right: Before 52.25 % 7.46 %

0.066 Treatment 12: Right: After 66 % 8.29 %

STRETCH

Treatment 1: Right: Before 49 % 12.57 %

0.273 Treatment 12: Right: After 5 8.75 % 17 %

ADJUSTMENT

Treatment 1: Right: Before 57.25 % 14.98 %

0.069 Treatment 12: Right: After 0.25 % 80.25 7.93 %

The most extreme improvement in the rectus femoris flexibility on the right leg was evident in

the adjustment group, with an improvement of 23% percent; followed by the combination

group, with an improvement of 13.75% and lastly by the stretch group with an improvement

of 9.75 %. With p < 0.10 the combination group had the most statistical significance,

followed by the adjustment group and then by the stretch group.

39

Table 4.6: Wilcoxon Test (Left Leg)

GROUP MEAN STANDARD DEVIATION

TREATMENT 12 (AFTER) —

TREATMENT 1 (BEFORE)

(p < 0.10

COMBINATION

Treatment 1: Left: Before

50 % 14.99 % 0.144

Treatment 12: Left: After

60 % 4.76 %

STRETCH


47.75 % 16.15 % 0.068


56.5 % 14.48 %

ADJUSTMENT


56.75 % 11.53 % 0.068


77.75 % 4.65 %

The most extreme improvement in the rectus femoris flexibility on the left leg was evident in

the adjustment group, with an improvement of 21% percent; followed by the combination

group, with an improvement of 10% and lastly by the stretch group with an improvement of

8.75 %. With p < 0.10 the stretch and adjustment group had the same clinical significance,

followed by the combination group in the left leg.

4.5 SCATTERPLOT OF PERCENTAGE CHANGES

These scatterplot graphs were used to visualise the group treatment results in relation to each

other. Loess curves were fit to the treatment results per group to visually compare the

percentage change in the flexibility or muscle length per treatments. In the loess method,

weighted least squares are used to fit linear or quadratic functions of the predictors at the

centres of neighbourhoods. The radius of each neighbourhood was chosen so that the

neighbourhood contains a specified percentage of the data points. (Cohen 2001)

40

15.00—

10.00 — rV

C coo -c

n

▪

o ffs 5.00 —4-1 C IV

0_ ..ea

no 0.00—

-5.00 —

2

4 6 8

10

12

Treatment

a

Group Combo

Stretch 0 Adjust

Fit line for Combo

Fit line for Stretch

- Fit line for Adjust

Graph 4.1: Loess Curve Fit per Group Average (Right Leg)

In graph 4.1 the combination group is indicated in blue and showed an improvement until

treatment 4. From treatment 4 to 6 the treatment results of the rectus femoris muscle

flexibility slightly decreased and thereafter a gradual improvement is seen until treatment 10

where there was a slight decrease in the flexibility of the rectus femoris muscles to the end of

the treatment protocol. The green line indicates the stretch group that had a good initial

improvement in the flexibility of the rectus femoris muscles but had a great decrease in the

flexibility of the rectus femoris muscles until treatment 4 and then a more gradual decrease in

the flexibility of the rectus femoris muscles towards treatment 10. Between treatments 11 and

12 the graph rises and falls down to the same level again. The adjustment group is the red

line. This group had the best initial improvement in the flexibility of the rectus femoris

muscles and shows a gradual decrease in the flexibility of the rectus femoris muscles

throughout the treatment protocol.

41

fin C 15.00 — Id -C

01 Of 4111+ 10.00 C

11. ir 5.00 -• w

Group Combo Stretch

0 Adjust Fit line for Combo

Fit fine for Stretch

Fit fine for Adjust

1 4 8 8 10 12

Treatment

Graph 4.2: Loess Curve Fit per Group Average (Left Leg)

Graph 4.2 indicates that all the groups had the biggest improvement at treatment 1. The

combination group is indicated in blue and shows a gradual decline in the flexibility of the

rectus femoris muscles up to treatment 5. Between treatments 5 and 7 a plateau was reached.

Thereafter a rise was noted until just after treatment 8, from here to treatment 12 the graph

tapers down. The stretch group in green shows the greatest improvement in the flexibility of

the rectus femoris muscles at treatment 1, but falls dramatically from treatment 1 to treatment

3. From treatment 4 to treatment 5 a rise in the graph indicating a decrease in the flexibility

of the rectus femoris muscles are indicated but again the graph tapers down toward treatment

7. Then between treatment 8 and 9 a slight improvement in the flexibility of the rectus

femoris muscles occurs but from treatment 10 to 12 the graph drops again to a level above

zero. The red line illustrates the adjustment group. At treatment 1 there was a good initial

improvement in the flexibility of the rectus femoris muscles; from treatment 1 to 3 a fall in the

graph is indicated. Between treatment 3 and 6 the graph rises only to gradually drop in the

flexibility of the rectus femoris muscles until treatment 8. From treatment 8 to 12 an

improvement in the flexibility of the rectus femoris muscles was seen and this was noted to be

42

the greatest of all the groups. At the end of the treatment all the groups showed improvement

in the flexibility of the rectus femoris muscles.

4.6 ONE-SAMPLE T-TEST STATISTICS

One sample T-testing was done to the combination and adjustment groups. The

measurements of the leg ipsilateral to the side of the spine being adjusted as well as on the

measurements of the leg correlating to the side of the spine not being adjusted, to determine if

the side of the spine being adjusted had a greater effect on the correlating leg being measured.

The after treatment reading minus the before treatment reading divided by the before

treatment reading formula was used to calculate the percentage change. A positive value for

the percentage change indicates an improvement from the before treatment to the after

treatment results for the given treatment. Tests were then performed to see what percentage

change for a given treatment was significant from zero. Note that a 5 percent level of

significance was used where p < 0.05.

Table 4.7: Combination Group: Adjusted Side's Leg Measurements (One Sample

T-Test Statistics)

Test Value = 0

Treatment t

df Mean Standard Deviation

Significance (2-tailed) (p<0.05)

1 Percentage 2.663 3 16.6% 12.5% 0.076

2 Percentage 2.911 3 97.8% 6.7% 0.062

3 Percentage 3.462 3 14.2% 8.2% 0.041

4 Percentage 4.453 3 10.2% 4.6% 0.021

5 Percentage 14.185 3 6.5% 0.9% 0.001

6 Percentage 1.926 3 5.3% 5.6% 0.150

7 Percentage 4.090 3 8.1% 3.9% 0.026

8 Percentage 5.337 3 4.3% 1.7% 0.013

9 Percentage 0.998 3 7.1% 14.2% 0.392

10 Percentage 9.840 3 9.1% i 2% 0.002

11 Percentage 6.310 3 6.3% 2% 0.008

12 Percentage 3.332 3 8.3% 5% 0.045

43

In the combination group the mean and standard deviation of each treatment was calculated.

The mean gives an average score while the standard deviation reflects the amount by which

each score differs from, or is scattered about, the mean. From the above table we see that the

small standard deviation indicates that the scores do not vary greatly around the mean. Note

that at treatment 5, 10 and treatment 11 the biggest improvement occurred, as the significance

was 2-tailed. The sustainability of the treatment was proved by continued improvement at the

final treatments. The p-values, in bold, indicates a high level of significance (p < 0.05) in

more than 65 percent of the cases.

Table 4.8: Adjustment Group: Adjusted Side's Leg Measurements (One Sample

T-Test Statistics)

Test Value = 0

Treatment t df

Mean Standard Deviation


1 Percentage 2.597 3 15.% 11.6% 0.081

2 Percentage 3.910 3 13.% 6.7% 0.030

3 Percentage 4.733 3 10.6% 4.5% 0.018 4 Percentage 3.289 3 15.8% 9.9% 0.046

5 Percentage 3.747 3 12% 6.4% 0.033 6 Percentage 4.848 3 11.4% 4.7% 0.017 7 Percentage 3.477 3 10.3% 5.9% 0.040

8 Percentage 3.201 3 9.4% 5.9% 0.049 9 Percentage 4.673 3 6.8% 2.9% 0.019 10 Percentage 13.283 3 9.4% 1.4% 0.001

11 Percentage 2.328 3 14.3% 12.3% 0.102

12 Percentage 13.277 3 9.1% 1.4% 0.001

The mean and standard deviation of each treatment in the adjustment group had been

calculated. In the adjustment group the standard deviation was even smaller than in the

combination group, indicating that there is little variance around the mean. A sustained

improvement was noted throughout the treatment in the adjustment group. The p-value, in

bold, indicates a high level of significance (p < 0.05) in more than 80 percent of the cases.

44

Table 4.9: Combination Group: Unadjusted Side's Leg Measurements (One Sample

T-Test Statistics)

Test Value = 0

Treatment t df



1 Unadjusted:Percentage 4.837 3 4.9% 2% 0.017

2 Unadjusted:Percentage 1.234 3 4.2% 6.7% 0.305









11 Unadjusted:Percentage 0.946 3 1.4% 2.95 0.414


In table 4.9 the mean and standard deviation of each treatment in the adjustment group had

been calculated. The standard deviation indicates little variance around the mean. Less

improvement is noted in the combination group measuring the unadjusted leg. The best

improvements occurred at treatment 4 and 10. The least improvement was noted at treatment

8. The p-value, in bold, indicates a low level of significance (p < 0.05) in less than 20 percent

of the cases.

45

Table 4.10: Adjustment Group: Unadjusted Side's Leg Measurements (One Sample

T-Test Statistics)

Test Value = 0

Treatment t df


Significance (2- tailed)

(p<0.05)













In table 4.10 the mean and standard deviation of each treatment in the adjustment group had

been calculated. The standard deviation indicates little variance around the mean. Less

improvement is noted in the adjustment group measuring the unadjusted leg. The best

improvements were noted at treatment 2 and 12 and the lowest improvement occurred at

treatment 8. The p-value, in bold, indicates a low level of significance (p < 0.05) in less than

20 percent of the cases.

46

CHAPTER FIVE — DISCUSSION

5.1 TREATMENT EFFECT ON THE RECTUS FEMORIS MUSCLE

FLEXIBILITY

The results of the study will be discussed with reference to the statistical analysis performed

in Chapter 4, the hypothesis proposed in Chapter 1, and the theories to explain possible

outcomes discussed in Chapter 2.

All the subjects participating in this study had a positive rectus femoris contracture test.

Group 1 (combination group) and Group 3 (adjustment group) received a transverso-deltoid

adjustment. On each treatment a single adjustment was performed on the side of the detected

motion restriction that was perceived as being the worst. Group 1 (combination group) and

Group 2 (stretch group) received a PNF stretch of the rectus femoris muscles. The treatment

results of all groups were of clinical importance as the final measurements showed

improvement from the initial measurements (refer to tables 4.2 to 4.4).

5.2 BEFORE AND AFTER TREATMENT MEASUREMENTS IN ALL THREE

GROUPS

The results of table 4.2 indicated that there was no constant pattern of improvement or

worsening of the flexibility of the rectus femoris muscles. This might be because the

stretching and the adjustments are working against each other. Previous studies have shown

that adjusting the specific spinal level of innervation of a certain organ or muscle had an

effect on that structure due to reflex responses resulting from the adjustment (Budgell 2000;

Suter, McMorland, Herzog and Bray 1999 and Pollard and Ward 1997). It might be that the

reflex response created by the spinal adjustment works in competition with the stretch reflex

that occurs in muscles when being stretched, possibly because of the fact that "autogenic

inhibition" is the general function of the GTO excitation and involves the inhibition of the

contraction of the muscle within which it is found in order to help prevent damage due to

overloading of the muscle tissues (Knutson and Owens 2003).

47

Table 4.3 showed that the results on the flexibility of the rectus femoris muscles had an initial

improvement but then the rectus femoris muscle flexibility slightly tapered down towards the

end of the treatment. The outcome of the stretch reflex was a protective contraction, to

protect against further stretch so that the muscle maintains a constant length (Paul, Jaskoviak

and Schafer 1993). The effect of the stretch reflex can last up to a few minutes (Shankar

1999). This protective contraction, due to the stretch reflex, might be the reason why a

decrease in rectus femoris flexibility was noted towards the end of the treatment.

The results of group 3 were shown in table 4.4. A gradual and constant improvement in the

flexibility of the rectus femoris muscles was the trend and thought to be due to the stimulation

of the spinal nerve from the adjustments being delivered. Joint manipulation that results in an

articular cavitation has a particular reflex effect on the periarticular and muscular structures,

which is different from a mobilisation that involves progressive stretching (Maigne 1995).

With clinical significance the overall results indicated that the adjustment group had the

greatest improvement in the rectus femoris flexibility. The combination group had the second

best results of rectus femoris muscle flexibility improvement followed by the stretching

group.

53 WILCOXON TESTING

The results of both tables 4.5 and 4.6 showed statistical significance and prove the adjustment

group to be the most successful in improvement of the rectus femoris muscle flexibility. This

was possibly due to the stimulation of the nerves that innervate the rectus femoris muscle as

discussed previously. The combination group was second and the stretch group was third in

the level of improvement of rectus femoris muscle flexibility. The possible reasons for these

results were discussed above.

48

5.4 SCATTERPLOT OF PERCENTAGE CHANGES

Scatterplots being drawn showed the treatment results of all the groups in relation to each

other. All the groups had good initial improvement and ended with a final treatment

measurement greater than the starting measurement. The results on the right legs showed

Group 3 to have the greatest initial improvement followed by Group 2 and then Group 1.

Groups 1 and 3 showed a greater end result than Group 2 (refer to graph 4.1). On the left legs

the results of the initial treatment showed Group 2 to have the greatest improvement and

Groups 1 and 3 to start off on the same level of improvement. The final measurements

proved Group 3 to have the greatest improvement followed by Group 1 and lastly by Group 2

(refer to figure 4.8). This could be because the effect of the adjustment on the muscle

overrode the effect that the stretching had.

It is anticipated that a high-velocity low-amplitude thrust activates mechanoreceptors and

proprioceptors from structures within and surrounding the manipulated joint. The distorted

afferent input coming from the stimulation of these receptors is thought to result in changes in

motoneuron excitability, leading to the disturbance of a projected pain-spasm cycle. (Suter,

McMorland, Herzog and Bray 2000)

5.5 ONE-SAMPLE T-TEST STATISTICS

These tests in groups 1 and 3 indicated that the side of the spine being adjusted showed

greater improvement in the ipsilateral leg than in the contralateral leg. It also proved Group 3

to have had a more constant and greater improvement than the other groups. Both Groups 1

and 3 showed a statistically significant improvement in rectus femoris flexibility with Group 3

also having the greatest level of statistical significance (refer to tables 4.7 to 4.10). It may be

that when adjusting a lumbar vertebra on the right that the right nerve root is stimulated more

than on the left nerve root and therefore has a greater effect on the ipsilateral muscle that it

innervates.

The difference in the levels of rectus femoris muscle flexibility improvement between the

right and the left leg may be speculated as being related to a difference in the number of times

a certain side of the spine was adjusted in Group 1 and Group 3. In the groups that received

49

stretching dominancy of a specific leg might have affected the flexibility. It is common to

find one side of the body more resistant to stretching due to a number of factors (Shankar

1999). For example the different results in the two legs could be due to rotation in the pelvis.

If the sacroiliac joints are not being addressed pelvic rotation may lead to leg length

discrepancies which may affect the muscles in this area (Suter, McMorland, Herzog and Bray

1999).

5.6 SUMMARY

Muscle imbalances, like shortened rectus femoris muscles, are associated with habitual poor

posture, occupational or recreational activities in which there are repeated use of specific

muscles without sufficient exercise of antagonistic muscles. Imbalance that affects body

alignment is an essential factor in many painful postures. (Kendall, McCreary and Provance

1993)

Deviations from the optimal posture may be large enough to create unbalanced forces around

the joints and causes the body to compensate for these changes. Prolonged faulty postures

may over time result in structural adaptations. In the ideal posture the hip is in a neutral

position and the pelvis is level. Shortened rectus femoris muscles often result in an anterior

pelvic tilt which increases the lumbosacral angle. This causes an increase in the shearing

stress at the lumbosacral joint that in turn may produce an increased lumbar lordosis in a

standing posture. (Levangie and Nortin 2001)

Therefore the hypothesis proposed in Chapter 1 had been reached. In this study adjusting the

spinal level that is the level of innervation of the rectus femoris muscle showed statistically

significant improvement in the flexibility of the rectus femoris muscles in the group that

received only an adjustment as a treatment. The subjects in all three groups showed

improvement, with the results of the adjustment group being the best.

50

CHAPTER SIX — CONCLUSIONS AND RECOMMENDATIONS

6.1 CONCLUSIONS

Objective improvements in the flexibility of the rectus femoris muscles were shown in all the

groups but more so in the adjustment and combination groups. These improvements were

shown to be both clinically and statistically significant.

Thus, the study helps to support the hypothesis that adjusting the spine at the level that is the

level of innervation of the rectus femoris muscle showed statistically significant improvement

in the flexibility of the rectus femoris muscles in the group that received only an adjustment

as a treatment.

6.2 RECOMMENDATIONS

Improvements in the validity and accuracy of the results in the study may be achieved by

applying the following modifications to this study:

Use a larger sample group to give more statistically relevant information.

Use symptomatic subjects in the study. Patients with lower back pain or hip pain

could be used.

Have a two week post treatment follow-up measurements to determine if the treatment

had a lasting effect.

More accurate measurements could be taken by using a flexometer, as it consists of a

gravity needle and a strap that attaches to the limb. With this device there is no need to

identify the axis of rotation or to use anatomical land marks for measurements.

(MacDougall, Wenger and Green 1989)

A double-blinded study would make the study more objective and eliminate examiner

bias. A possible way to do this would be to have one doctor examine, the before

treatment measurement and treat the subject while another doctor does the

measurements after the treatment without knowing the pre-treatment readings.

51

Different lumbar spine adjustment techniques could be compared, for example, side

posture rotary lumbar adjustment.

A different stretching technique could also be applied.

Measure both passive and active knee joint flexion angle when measuring the rectus

femoris muscle flexibility.

Use subjects with the same dominant side to eliminate interference with results.

Wait a few minutes before remeasuring the resting muscle flexibility to allow the

effects of a possible stretch reflex to wear off.

52

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254, 256-262, 283-284.

Valmassy RL (1996). Clinical Biomechanics of the Lower Extremities. Missouri: Mosby

Inc., pp. 133-138.

56

Wyke B, Glasgow E, Twomey L, Scull E, Kleynhans A and Idczak R, Eds (1985). Articular

Neurology and Manipulative Therapy. Aspect of Manipulative Therapy, 2nd ed. Churchill-

Livingston, pp. 72-77.

57

APPENDIX A: ADVERTISEMENT

Come f®l flee CilT.L-ofplaztc toeffftmellavo

At TWR Day Clinic Gate 7, Sherwell Road, Doornfontein

Take part in a research study that is aimed to improve your hip and knee flexibility.

(Participants must be between the ages of 20 to 30)

Contact Anee Boshoff For further information

083 564 7573

58

APPENDIX B: RECTUS FEMORIS CONTRACTURE TEST

Negative Rectus Femoris Contracture Test

Positive Rectus Femoris Contracture Test

A

59

APPENDIX C: CONTRA — INDICATIONS TO SPINAL MANIPULATIVE PROCEDURES (Gatterman 1990 pp. 67, 68)

1. Vascular conditions Artherosclerosis of major blood vessels Abdominal aortic aneurysm

2. Tumours Lung Thyroid Prostate Breast Bone

3. Bone infections Tuberculosis Osteomyelitis

4. Traumatic Fractures Joint instability or hypermobility Severe sprains or strains Unstable spondylolisthesis

5. Arthritic conditions Rheumatic arthritis Ankylosing spondylitis Psoriatic arthritis Unstable or late stage osteoarthritis Uncoarthritis

6. Metabolic disorders Clotting disorders Osteopaenia

7. Psychological considerations Malingering Hysteria Hypochondriasis Pain intolerance

60

8. Neurological complications Disc lesions Space-occupying lesions

61

APPENDIX D: SUBJECT INFORMATION AND CONSENT FORM

Dear Participant

I am Anee Boshoff, an MTech Chiropractic student of the Faculty of Health Sciences,

University of Johannesburg. I want to invite you to participate in my research study.

The purpose of this study is to determine the effect of chiropractic adjustments on the

flexibility of the rectus femoris muscles. These are muscles in the area of your thighs. I will

fully explain all the procedures and will answer all your questions to the best of my abilities.

Your participation in this study is voluntary and you are free to withdraw participation at

anytime, without penalty.

You must be between 18 and 30 years of age, must not have osteoarthritis of the hip and/of

knee joint and must have a shortened quadriceps (thigh) muscle to be able to participate in

this study. A permanent marker will be used in the form of a small dot on the side of your

knee to ensure more accurate measurements but will wash off completely at the end of this

trial. After you have been selected to participate in this study, you will randomly be divided

into one of three groups. Each group will receive a different treatment. You will be required

to attend twelve treatments of approximately 40 minutes each, with a maximum of three days

between treatments, at the University of Johannesburg Chiropractic Day Clinic.

Your privacy will be protected by ensuring your anonymity and confidentiality. In other

words, you will not be identified by name of by any other personal characteristics. The

benefit of this study is that you will receive free treatment in the interest of your wellness.

You may experience some discomfort, such as tenderness, due to the nature of the treatment,

but this will be carefully monitored, and will not have long lasting effects.

After this study is completed, I will provide you with feedback regarding the outcomes, if you

so wish.

62

Should you have any concerns or queries, the following persons can be contacted:

Researcher: Angie Boshoff 083 564 7573

Supervisor: Dr. S Wilcox 083 273 6974

Co-supervisor: Dr. M Moodley 011 406 2065

I have been fully informed as to my rights as to the procedure to be followed in this study. I know that any question, which I may have, will be answered.

Date: Researcher:

Date: Patient:

63

APPENDIX E: CASE HISTORY

UNIVERSITY oa

JOHANNESBURG

UNIVERSITY OF JOHANNESBURG CHIROPRACTIC DAY CLINIC

CASE HISTORY

Date:

Patient: File No:

Age: Sex: Occupation:

Student: Signature:

FOR CLINICIAN'S USE ONLY

Initial visit clinician: Signature:

Case History:

Examination:

Previous: TWR Current: TWR

Other Other

X-ray Studies:


Other Other

Clinical Path. Lab:


Other Other

Case status: PTT: Conditional: Signed off: Final sign out:

Recommendations:

1

64

Students case history

Source of history:

Chief complaint: (patents own words)

Present illness:

Location

Onset

Duration

Frequency

Pain (character)

Progression

Aggravating factors

Relieving factors

Associated Sx's and SO

Previous occurrences

Past treatment and outcome

2

65

Other complaints:

Past history

General health status

Childhood illnesses

Adult illnesses

Psychiatric illnesses

Accidents/injuries

Surgery

Hospitalisation

Current health status and lifestyle

Allergies

Immunizations

Screening tests

Environmental hazards

Safety measures

Exercise and leisure

Sleep patterns

Diet

Current medication

Tobacco

Alcohol

Social drugs

Family history: immediate family:

Cause of death

3

66

DM

Heart disease

TB

HBP

Stroke

Kidney disease

CA

Arthritis

Anaemia

Headaches

Thyroid disease

Epilepsy

Mental Illness

Alcoholism

Drug addiction

Other

Psychosocial history:

Home situation Daily life Important experiences Religious beliefs

Review of systems:

General

Skin

Head

Eyes

Ears

Nose/sinuses 4

67

Mouth/throat

Neck

Breasts

Respiratory

Cardiac

Gastro-intestinal

Urinary

Genital

Vascular

Musculoskeletal

Neurologic

HaematologIc

Endocrine

Psychiatric

5

68

APPENDIX F: PERTINENT PHYSICAL

UNIVERSITY OF "

JOHANNESBURG


Pertinent Physical

Student Name Doctor name ----------

Patient Information

Signature Signatu

Name Age-

Occupation Sex

Vitals:

Weight

Respiratory rate

Pulse rate----------

Blood pressure

Inspection Palpation

Percuss

Auscultation

Thorax

Abdomen

69

klilteggli Palpation Percussion Auscuitaion

,

...

Cranial Nerves Motor System Sensory Cerebellar system stens

Newelleak system

1

70

APPENDIX G: LUMBAR SPINE AND PELVIS REGIONAL

UNIVERSITY OF

JOHANNESBURG


REGIONAL EXAMINATION LUMBAR SPINE AND PELVIS

Date:

Patient:

Clinician:

Student:

A. STANDING

BODY TYPE POSTURE OBSERVATION:

Muscle Tone Bony + Soft Tissue Contours Skin Scars Discolouration Step deformity

4. SPECIAL TESTS

Schober's Test Spinous Percussion Treadmill Minor's Sign Quick Test Trendelenburg Test

File No:

Signature:

Signature:

71

fight Rotation Left Rotation

Left Lateral Fl xion ght Lateral Flexion

Forward flexion

40 - 602 (15cm from floor) Extension

20 - 352 UR Rotation

3 - 182 UR Lat Flexion = 15- 202

Flexion

5. RANGE OF MOTION

Extension

/ = Pain free limitation

// = Painful limitation

6. GAIT

Rhythm, pendulousness On Toes (S1) On Heels (L4, 5) Halt Squat on one leg (L2, 3, 4) Tandem Walking

7. MOTION PALPATION — sacroiliac joints

B. SITTING

01. SPECIAL TESTS

Tripod Test Kemp's Test Valsaiva Manoeuvre

2

72

2. MOTION PALPATION

Jt. Pia Lett RI ht Jt. Rai P/A Let P/A Let Fle Ext LF AR PR Fie Ext LF AR PR

T10 . T11

T12 L1 • L2

14

..- 15 11 L R1 U L

C. SUPINE

01. OBSERVATION

Hair, Skin, Nails Fasciculation

2. PULSES

Femoral Popliteal Dorsalis Pedis Posterior Tibial

MUSCLE CIRCUMFERENCE

LEFT RIGHT THIGH cm cm CALF cm cm

LEG LENGTH

LEFT RIGHT ACTUAL cm cm APPARENT cm cm

a

73

5. ABDOMINAL EXAMINATION

Observation Abdominal Reflexes Auscultation Abdomen and Groin Palpation Abdomen and Groin

Comments:

NEUROLOGICAL EXAMINATION

DERMATOMES Lett Right MYOTOMES Len Right REFLEXES Left Right T12 Hip Flexion

(1.111.2) Patellar (1.3, 4)

Lt Knee Extension (12, 3, 41

Medial Hamstring (1.5)

L2 Knee Flexion (L5/S1)

Lateral Hamstring (Si)

L3 Hip IM. Rot (1.LS)

Tibialis Posterior (L4, 5)

L4 Hip Ext. Rot (L5/S1)

Archilles (sysz

1.5 Hip Adduction (L2, 3, 4)_

Plantar Reflex

Si Hip Abduction (W)

S2 Ankle Doraillexion (LWLS)

S3 Hallux Extension (1.5) Ankle Plantar Flexion (Si/S2) Eversion (SI) Inversion (1.4) Hip Extension (L5/S1)

4

74

7. SPECIAL TESTS

SLR

WLR

Braggard's

Bowstring

Sciatic Notch Pressure

Sign of the Buttock

Bilateral SLR

Patrick Faber

Gaenslen's Test

Gapping Test

"Squish" Test

Gluteus Maximus Stretch

Thomas' Test

Rectus Femoris Contracture Test

Hip Medial Rotation

Psoas Test

LATERAL RECUMBENT

Sacroiliac Compression

Ober's Test

Femoral Nerve Stretch Test

Myotomes: - Quadratus Lumborum Strength - Gluteus Medius Strength

75

PRONE

Facet joint challenge

Myofascial Trigger points:

Quadratus Lumborum Gluteus Medius Gluteus Maximus Piriformis Tensor Fascia Late Hamstrings

Skin Rolling

Erichsen's Test

Sacroiliac Tenderness

Pheasant's Test

Gluteal Skyline

Myotomes:

Gluteus Maximus strength

NON-ORGANIC SIGNS

Pin-point pain

Axial Compression

Trunk Rotation

Bum's Bench Test

Flip Test

Hoover's Test

Ankle Dorsiflexion Test

Pin-point pain

6

76

APPENDIX H: HIP REGIONAL

UNIVFaRSITY

JOHANNESBURG


REGIONAL EXAMINATION THE HIP

Date:

Patient: File No:

Clinician: Signature:

intern: Signature:

OBSERVATION

Gait

Posture

Weight bearing

Use of support

Balance

Proprioception (stork standing test)

Skin

ANTERIOR VIEW

Bony contours

Soft tissue contours

Swelling

77

LATERAL VIEW

Buttock contour

Hip flexion deformity

Lumbar spine lordosis

POSTERIOR VIEW

Lumbar spine scoliosis

Body contours

Soft tissue contours

ACTIVE MOVEMENTS

I I LEFT RIGHT Flexion (110 -120) I Extension (10 -15) r

1 . Abduction (30 - 50) 1

; Adduction (30) 'Lateral rotation (40 - 60) Medial rotation (30 - 40)

COMMENTS:

PASSIVE MOVEMENTS (note end feel and range of motion)

LEFT RIGHT Flexion Extension Abduction Adduction

[ Lateral rotation [ Medial rotation

2

78

RESISTED ISOMETRIC MOVEMENTS

LEFT RIGHT Hip flexion Hip extension Hip abduction Hip adduction Hip medial rotation Hip lateral rotation Knee flexion Knee extension

COMMENTS:

(Note specific muscle involvement if applicable).

JOINT PLAY

LEFT

RIGHT Caudal glide (Long leg traction) Compression Lateral distraction

COMMENTS:

SPECIAL TESTS

Patrick — FABER test

Tredelenberg's test (assess hip instability)

Craig's test (femoral anteversion)

Sign of the buttock (assess site of lesion)

Thomas test (rectus femoris hypertonicity)

3

79

Ober's test (ITB contracture)

Noble compression test (ITB friction syndrome)

Piriformis test

Hamstring contracture test

DERMATOMES

LEFT

RIGHT Lt L2 L3 S3 S4 1

PALPATION

ANTERIOR ASPECT

Iliac crest

Greater trochanter

AS1S

InguinaI ligament

Femoral triangle

Hip joint

Symphysis pubis

POSTERIOR ASPECT

Iliac crest

PSIS

Ischia! tuberosity

4

80

Greater trochanter

Sacroiliac joints

Sacrococcygeal joints

COMMENTS:

RADIOGRAPHIC EXAMINATION

DIAGNOSIS

TREATMENT PROTOCOL

CLINICIAN'S COMMENTS

81

APPENDIX I: KNEE REGIONAL

UNIVERSITY

JOHANNESBURG


'REGIONAL EXAMINATION

THE KNEE

File No: Date:

Patient: D.O.B.:

X-ray No.: Pat Lab No.: ,

Intern: Clinician:

Signature: Signature:

82

2

OBSERVATION

STANDING AND SEATED

ANTERIOR 'VIEW

Q-angle

Genu Varum

Genu Valgum

Swelling / Bony enlargements

•• Patella position

Tibial torsion

Skin

POSTERIOR VIEW

Swelling

Skin

LATERAL 'VIEW

Genu Recurvatum

Patella Alta

Patella Baja

General comments

ACIREIMMELISS1

LEFT RIGHT

Flexion (0° - 135°)

Extension (0° - 015°)

Medial rotation (20° - 30°)

Lateral rotation (30° - 40°)

83

PASSIVE MOVEMENTS

(Note end feel and range of motion)

LEFT RIGHT

Flexion

Extension

Medial rotation

Lateral rotation

Patellar movement

RESISTED ISOMETRICS — KNEE

LEFT

RIGHT

Flexion

Extension

RESISTED ISOMETRICS — ANKLE

LEFT

RIGHT

Plantar flexion

Dorsiflexion

LIGAMENT • US ASSESSMENT

One - Plane Medial Instability

Valgus stress (Abduction)

- Extended

- Resting Position

One - Plane Lateral Instability

Varus stress (Adduction)

- Extended

- Resting Position

One - Plane Anterior Instability

Lachman Test

Anterior Drawer Test

84

One - Plane Posterior Instability

Posterior "Sag" Sign

Posterior Drawer Test

Anterior Medial Rotary Instability

Slocum Test (Foot laterally rotated 15°)

Anterior Lateral Rotary Instability

Slocum Test (Foot medially rotated 30°)

Macintosh Test

Losee test

Postero-medial Rotary Instability

Hughston's Drawer Sign

Postero-lateral Rotary Instability

Jacob Test

Hughston's Drawer Sign

Tests for Meniscus Injury

McMurray Test

"Bounce Home" Test

O'Donoghue's Test

Apley's Test

Helfet Test

Plica Tests

Mediopatellar Plica Test

Plica "Stutter" Test

Hughston's Plica Test

Tests for Swelling

Brush / Stroke Test

Patellar Tap Test

85

5

Tests for Chondromalacia Patella

Clarke's Sign

McConnell's Test

Other Tests

Wilson's Test (Osteochondritis Dessicans)

Fairbank's Test (Patella Dislocation)

Noble Compression Test (ITB Friction)

'• Quadriceps Contusion Test

Leg Length Discrepancy

Joint Play Movements

Backward Movement of the Tibia on the Femur

Forward Movement of the Tibia on the Femur

Medial Translation of the Tibia on the Femur

Lateral Translation of the Tibia on the Femur

Depression (Distal Movement) of the Patella

Antero-posterior Movement of the Tibiofibular Joint

Palpation

Abnormal Tenderness

Swelling

Nodules

Abnormal Temperature

Reflexes and Cutaneous Distribution

LEFT

RIGHT

Patellar Reflex (L3, L4)

Medial Hamstring Reflex (L5, SI)

Dermatomes

L2

L3

L4

86

L5

S1

S2

S3

Radiographic Examination

Diagnosis

Treatment Protocol

Clinician's Comments

87

APPENDIX J: USING A GONIOMETER TO MEASURE THE PASSIVE LENGTH OF THE RECTUS FEMORIS MUSCLE

Described as done by Valmassy R.L. (1996):

The passive length of the rectus femoris muscle is determined by measuring the knee flexion

angle. The patient is in the position for the rectus femoris contracture test while the

goniometer is centred on the lateral epicondyle of the femur. The fixed arm is placed in line

with the length of the femur, pointing to the greater trochanter. The mobile arm points to the

lateral malleolus of the fibula. Note that no overpressure is applied allowing gravity to act on

the knee joint. The normal rectus femoris length will measure a 90 degree knee flexion angle.

88

APPENDIX K: SOAP NOTE

(MNIttS We'

CHIROPRACTIC DAY CLINIC SOAP NOTE:

Patient: Visit No:

File No: Student:

Date: Clinician: S: 0:

A: P:

Comments:

Patient: I Visit No:

File No: I Student:

Date: ~, Clinician: S: 0:

A:

'P:

Comments:

89

APPENDIX L: SEATED TRANSVERSO-DELTOID ADJUSTMENT

This adjustment can be applied to rotary restrictions of the lower thoracic joints and all the

lumbar vertebrae. The subject sat straddling the table. Their arms were crossed over the

chest; homolateral arm on top and their hands placed onto the opposite shoulders. The

doctor's position was 90 degrees posterior to the patient. The doctor's contralateral arm

reached around the subject and held onto the subject's contralateral deltoid area. The doctor's

homolateral hand made a pisiform contact on the transverse or mamillary process of the

restricted segment. The doctor's contralateral arm rotated the subject's torso until the "joint

slack" in the restricted segment was removed. Simultaneously the doctor's homolateral

contact hand thrusted anteriorly with the elbow supported in the inguinal region. (Kirk,

Lawrence and Valvo 1991)

90

APPENDIX M: PNF STRETCH OF RECTUS FEMORIS MUSCLES

The subject lay prone with the operator standing on the opposite side of the leg being

stretched. The operator used their cephalad hand to stabilise the subject's pelvis. The

subject's affected leg was flexed at the knee until maximum resistance in the rectus femoris

muscle was reached. This stretch was held for 10-15 seconds. This was followed by a 7-10

second isometric contraction of the involved rectus femoris muscle as the subject tried to

straighten the leg against the operator's resistance. The subject then activated the antagonistic

muscles by actively flexing their knee. Finally the 10-15 second stretch was repeated with the

operator flexing the subject's knee. (Chaitow 1996)

91

Mean T Mart After a Right Before D

F G R

F S

O F

111111111111 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th

APPENDIX N: HI-LOW GRAPH FOR COMBINATION GROUP

(RIGHT LEG - RECTUS FEMORIS FLEXIBILITY)

TREATMENT

92

(RIGHT LEG — RECTUS FEMORIS FLEXIBILITY)

Mean I Rmirt Before

It 1 1 iI(If 1st 2nd 3rd 4th 5th 6th 7th 6th 8th 10th 11th 12th

TREATMENT

APPENDIX 0: HI-LOW GRAPH FOR STRETCH GROUP

66 —

D

E 63—

R

E GEI-

S

57. F

X 51 —

0

N 48—

93

APPENDIX P: HI-LOW GRAPH FOR ADJUSTMENT GROUP (RIGHT LEG - RECTUS FEMORIS FLEXIBILITY)

D 8°- E G R

75—

S

E

0 F

65 •-•

X

0 6°— N

MO, I

II III I I I I ) ; I 1st 2nd 3rd 4th 5th 8th 7th 8th 9th 10th 11th 12th

TREATMENT

Mean T Right After J. Right Before

94

I I 4 I I I 1 1st 2nd 3rd 4th 5th 6th Ah eat Mb 10th 11th 12th

TREATMENT

APPENDIX Q: HI-LOW GRAPH FOR COMBINATION GROUP (LEFT LEG — RECTUS FEMORIS FLEXIBILITY)

65*

G R

so-

0 F

F L 55—

E

x I 0 N

so—

Mean T Left After J• Left Before

95

62.5

O ssz- F

F 52.5 — L

X 500 —

0 tV

D E

60.0-

R E E 575

IMO

I II

I I I h i

47.5 —

I I I I I I I I I I I 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th

TREATMENT

APPENDIX R: HI-LOW GRAPH FOR STRETCH GROUP (LEFT LEG — RECTUS FEMORIS FLEXIBILITY)

Mean

I teelfl Vora

96

Mean Left

I Left Lore

I ilt III I It 1st 2nd 3rd 4th Sth 8th 7th 6th 9th 10th 11th 12th

APPENDIX S: HI-LOW GRAPH FOR ADJUSTMENT GROUP (LEFT LEG)

D

75 — R E E S 70 —

0 F

F 65 L E X

60 — 0 N

TREATMENT

97

a study to compare the effect of lumbar spine adjustments

Documents