**Pelvic Movement in Aging Individuals and Stroke Patients** Provisional chapter Pelvic Movement in Aging Individuals and Stroke

Hitoshi Asai

Patients

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40 Clinical Physical Therapy

Additional information is available at the end of the chapter Hitoshi Asai

http://dx.doi.org/10.5772/67510 Additional information is available at the end of the chapter

#### Abstract

The mobility of the lumbar spine (anteversion and retroversion) may be reflected in seated pelvic mobility. When sitting with the soles of the feet in contact with the floor, friction may restrict the flexion of the knees and, consequently, the pelvic anteversion. In general, joint mobility declines with advancing age. Lumbar spine mobility in anteversion and retroversion also decreases with advancing age. The first half of this chapter is based on a study that investigated the relationship between age and the maximum pelvic anteversion and the retroversion angles in healthy volunteers. The measurements were performed with the subject in a sitting position with free knee movement. On the other hand, the sitto-stand movement is one of the most mechanically demanding tasks undertaken during daily activity. The sacral sitting posture, which is a characteristic posture of stroke patients, is not ideal for smoothly executing the sit-to-stand movement. Stroke patients may adopt this posture due to the need to increase sitting stability. The second half of this chapter discusses a study that investigated the relationship between the pelvic anteversion and retroversion angles and the ability of stroke patients to perform the sit-to-stand movement.

Keywords: pelvic movement, anteversion, retroversion, aging, stroke, sit-to-stand

#### 1. Introduction

Maintaining sagittal balance is important to both sitting and standing. Sagittal balance, or "neutral upright sagittal spinal alignment," is a postural goal of surgical, ergonomic, and physiotherapeutic intervention [1]. Kyphotic curvature of the spine negatively impacts the quality of life (QOL) in elderly people [2]. Kasukawa et al. reported that the sagittal balance was well maintained in subjects who had both a good thoracic range of motion (ROM) and

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited.

good lumbar ROM and back muscle strength, which indicates that these factors are also related in maintaining sagittal balance [2]. The clarification of the relationship between the QOL and abnormal posture in elderly individuals may help to improve the QOL through preventive methods and exercises [3]. Although the degree of lumbar lordosis when sitting has been shown to be weakly associated with age, lumbar lordosis was not found to be affected by lifestyle, the level of physical activity, or an individual's type of work [4]. Little is known about the sitting posture of elderly individuals in comparison with young individuals [5]; thus, investigating the effects of aging on the sagittal spinal and pelvic alignment in the sitting position is important for clarifying the relationship between pelvic movement and the QOL. Sitting positions are generally categorized into two types: the quiet sitting position and the functional sitting position. A person sits in the functional sitting position during (or when anticipating) physical activity. The functional sitting position therefore requires control in various sitting postures.

Multiple movements of the spine and pelvis are needed to maintain the various sitting positions. The relationship between the movements of the lumbar spine and pelvis has been investigated [5, 6]. The relationship between the pelvic inclination angle and lumbar spine lordosis was more distinct in the sitting position than in the standing position [5, 7]. Thus, lumbar spine mobility (kyphosis and lordosis) may be reflected in seated pelvic mobility. However, it has been reported that joint mobility is generally reduced by aging. The trunk mobility of elderly individuals is inferior to that of young people [8–10]. In particular, lumbar spine mobility in both lordosis and kyphosis decreases with aging [1, 11, 12]. In addition, Keorochana et al. suggested that the degeneration of the interspinous ligaments with aging is one of the factors that contributes to the low mobility of the lumbar spine [13]. Hence, the movement patterns of elderly individuals may be restricted when they are seated because there is less variety in their sitting positions in comparison with young subjects.

The pelvic tilt in the sagittal plane may be affected by flexion and the extension mobility of the hip joints, because the pelvis moves forward and backward around the hip joint as a pivotal axis in the seated position. Since the hamstring muscles originate at the ischial tuberosity of the pelvis, the tension in the hamstring muscles has an effect on the pelvic inclination angle in the sitting position [14, 15]. Thus, a forward pelvic tilt may increase the tension in the hamstring muscles when sitting with a fixed knee angle and the sole of the foot in contact with the floor. Connective tissue compliance is considered a major factor in musculoskeletal flexibility [16]. Muyor et al. [17] reported that the forward pelvic tilt angle increased after hamstring muscle stretching, and Feland et al. [16] confirmed that pelvic mobility in the sagittal plane increased in elderly people after hamstring muscle stretching. The increase in the tension in the hamstring muscles when sitting with the soles of the feet in contact with the floor may restrict the pelvic forward tilt. Thus, the free movement of the knees should be possible during pelvic movement when sagittal plane pelvic mobility is investigated with a subject in a sitting position. However, some sitting pelvic mobility studies have not clearly described foot contact with the floor or the knee joint positioning [6, 18].

On the other hand, the recovery of sitting balance is commonly assumed to be essential for obtaining independence in other vital functions such as reaching, sit-to-stand, and sitting down [19–21]. The early assessment and management of trunk control should be emphasized after stroke [22]. Many researchers have suggested that the trunk control or sitting balance of early stage stroke patients can predict a late stage activities of daily living (ADL) outcome [19, 22, 23]. The sit-to-stand task is frequently performed and this ability is considered a prerequisite for upright mobility and therefore, for performing other important daily activities such as locomotion [24, 25]. Riley et al. suggested that the sit-to-stand movement is the most mechanically demanding task undertaken during daily activity [26]. The sit-to-stand movement represents a common functional movement that is practiced in the early stage of rehabilitation [27].

good lumbar ROM and back muscle strength, which indicates that these factors are also related in maintaining sagittal balance [2]. The clarification of the relationship between the QOL and abnormal posture in elderly individuals may help to improve the QOL through preventive methods and exercises [3]. Although the degree of lumbar lordosis when sitting has been shown to be weakly associated with age, lumbar lordosis was not found to be affected by lifestyle, the level of physical activity, or an individual's type of work [4]. Little is known about the sitting posture of elderly individuals in comparison with young individuals [5]; thus, investigating the effects of aging on the sagittal spinal and pelvic alignment in the sitting position is important for clarifying the relationship between pelvic movement and the QOL. Sitting positions are generally categorized into two types: the quiet sitting position and the functional sitting position. A person sits in the functional sitting position during (or when anticipating) physical activity. The functional sitting position therefore requires control in

Multiple movements of the spine and pelvis are needed to maintain the various sitting positions. The relationship between the movements of the lumbar spine and pelvis has been investigated [5, 6]. The relationship between the pelvic inclination angle and lumbar spine lordosis was more distinct in the sitting position than in the standing position [5, 7]. Thus, lumbar spine mobility (kyphosis and lordosis) may be reflected in seated pelvic mobility. However, it has been reported that joint mobility is generally reduced by aging. The trunk mobility of elderly individuals is inferior to that of young people [8–10]. In particular, lumbar spine mobility in both lordosis and kyphosis decreases with aging [1, 11, 12]. In addition, Keorochana et al. suggested that the degeneration of the interspinous ligaments with aging is one of the factors that contributes to the low mobility of the lumbar spine [13]. Hence, the movement patterns of elderly individuals may be restricted when they are seated because

The pelvic tilt in the sagittal plane may be affected by flexion and the extension mobility of the hip joints, because the pelvis moves forward and backward around the hip joint as a pivotal axis in the seated position. Since the hamstring muscles originate at the ischial tuberosity of the pelvis, the tension in the hamstring muscles has an effect on the pelvic inclination angle in the sitting position [14, 15]. Thus, a forward pelvic tilt may increase the tension in the hamstring muscles when sitting with a fixed knee angle and the sole of the foot in contact with the floor. Connective tissue compliance is considered a major factor in musculoskeletal flexibility [16]. Muyor et al. [17] reported that the forward pelvic tilt angle increased after hamstring muscle stretching, and Feland et al. [16] confirmed that pelvic mobility in the sagittal plane increased in elderly people after hamstring muscle stretching. The increase in the tension in the hamstring muscles when sitting with the soles of the feet in contact with the floor may restrict the pelvic forward tilt. Thus, the free movement of the knees should be possible during pelvic movement when sagittal plane pelvic mobility is investigated with a subject in a sitting position. However, some sitting pelvic mobility studies have not clearly described foot contact

On the other hand, the recovery of sitting balance is commonly assumed to be essential for obtaining independence in other vital functions such as reaching, sit-to-stand, and sitting

there is less variety in their sitting positions in comparison with young subjects.

with the floor or the knee joint positioning [6, 18].

various sitting postures.

42 Clinical Physical Therapy

Stroke patients have less stability in the sitting position in comparison with age-matched healthy subjects [28–30]. The reason for this is explained in a number of reports. In stroke patients, the activity of the rectus abdominis and latissimus dorsi muscles on the affected side of the body is reduced and delayed in comparison to both the unaffected side and control subjects [31]. Moreover, the temporal synchronization between the pertinent muscular pairs in stroke patients is lower in comparison to healthy subjects [32]. The following factors can also be considered to be related to the sitting position: firstly, stroke patients cannot adequately flex the hip when the trunk extensor muscles are contracted; secondly, it is difficult to maintain the trunk in a vertical position when the subject is seated due to the insufficiency of the abdominal muscles [33]. Thus, when stroke patients attempt to perform the sit-to-stand movement with a retroverted pelvis and kyphotic trunk, the standing up action is affected due to the insufficiency of pelvic anteversion and trunk extension. In addition, Campbell et al. suggested that deficits in the muscle strength and trunk amplitude of stroke patients result in reduced pelvic mobility, apparently as a strategy to protect against a potential risk of loss of balance when reaching in the sitting position [34].

Numerous studies investigating trunk movement have considered the supine position as one segment, ignoring the complexity of intervertebral movement [35]. Campbell et al. indicated that little attention has been paid to how elderly persons coordinate the head, pelvis, and trunk during movement [34]. Studies on the sitting posture of stroke patients have a similar tendency. Few studies have investigated the movement of the spine and pelvis separately. Verheyden et al. reported on pelvic movement during lateral reach movements in the sitting position [36], and Messier et al. described the movements of the upper trunk and pelvis when subjects touched a target placed in front of them with the forehead [37]. To execute the sit-to-stand movement smoothly, the pelvis must be leaned forward to flex the hip joint, and the trunk must be flexed in order to: (1) use the hip extension moment; (2) reduce the knee extension moment; and (3) project the center of gravity within the base of support [38–43].

Pelvic mobility plays an important role in the sit-to-stand movement in elderly people and stroke patients.

This chapter first discusses the age-related changes in the maximum anteversion and retroversion of the pelvic angles in the sitting position [44] and then explores the relationship between the ability to perform the sit-to-stand movement and the maximum pelvic anteversion and retroversion angles in stroke patients [45].
