Shifts in Pelvic
Inclination Angle and Parasympathetic Tone Produced by Rolfing Soft Tissue Manipulation
JOHN T. COTTINGHAM, STEPHEN W. PORGES, and KENT
RICHMOND
First published in ‘Physical Therapy’, Vol. 68, No. 9, p.1364-70,
September 1988
The effects of soft tissue manipulation (Rolfing
method) were evaluated on young healthy men using two dependent variables: 1)
angle of pelvic inclination and 2) parasympathetic activity. Pelvic inclination
was assessed by determining the angle of standing pelvic tilt (SPT) with an
inclinometer. Autonomic tone was assessed by a measure of cardiac vagal tone
(amplitude of respiratory sinus arrhythmia) derived from monitoring heart rate.
Thirty‑two subjects, preselected for exhibiting an anteriorly tilted
pelvis, were randomly assigned to either an Experimental Group (n = 16) that
received a 45‑minute Rolfing pelvic mobilization session or a Control
Group (n = 16) that received a 45‑minute control session without
manipulation. Dependent variables were assessed before the 45‑minute
session, immediately after the session, and 24 hours later. Comparing pretest
to posttest assessments, the Experimental Group demonstrated a significant
decrease in SPT angle and a significant increase in vagal tone. The Control
Group did not show significant pretest or posttest differences. The results
provide theoretical support for the reported clinical uses of soft tissue
pelvic manipulation for 1) certain types of low back dysfunction and 2)
musculoskeletal disorders associated with autonomic stress.
Back to
professional article collection
Key Words: Autonomic nervous system, Manual therapy, Parasympathetic
nervous system, Soft tissue syndromes.
J. Cottingham, MS, is Certified Advanced Rolfing Practitioner, Staff
Manual Therapist and Research Associate, Frances Nelson Health Center, 1306
Carver Dr. Champaign, IL 61820 (USA).
S. Porges, PhD, is Director,
Developmental Assessment Laboratory, and Professor, Department of Human
Development, College of Education, University of Maryland at College Park,
College Park, MD 20742
K. Richmond, MHS, is Physical Therapist, Christie Clinic, 101 W
University Ave, Champaign, IL 61820
Advocates of manual therapy have
target,,. based their methods on the traditional osteopathic premise that an
integrated or balanced musculoskeletal structure will be reflected in optimal
physiological function. (1,2) According to A. T. Still there is no real
difference between
structure and function: they are two
sides of the same coin. If structure does not tell us anything about function,
it means we have not looked at it correctly. (1)
It has been reported in the manual
therapy literature, for example, that shifts in autonomic activity accompany
derotation of the anteriorly tilted pelvis lil the sagittal plane. (3‑5)
As the anteriorly tilted pelvis is released, a posterior pelvic shift occurs
that is accompanied by changes in body temperature, arterial pulse, and
breathing patterns. Presumably, these autonomic shifts involve an afferent‑efferent
feedback loop with mediation of peripheral autonomic outflow via higher neural
centers.
According to Rolf, the founder of
the Rolfing method of Soft tissue manipulation and movement education, the
angle of pelvic 'Inclination is a keystone to "Integrating" the
body's "weight masses" in the gravitational field. (4) Rolf
hypothesized that the "balanced" or "horizontal" pelvis in
the erect, standing position could he approximated clinically by the following
anatomical landmarks: 1) a horizontal line connecting the superior border of
the pubic symphysis and the tip of the coccyx and 2) a Vertical line connecting
the pubic symphysis and the anterior superior iliac spine (ASIS). (3) These
relationships are shown in Figure 1.
Physical therapists and physiatrists
have also reported the angle of pelvic inclination in the standing position as
a method of clinical assessment. (6‑10) A technique for measuring this
angle (7-10) that has shown strong intratester reliability (8,11) is the
standing pelvic tilt (SPT). Standing pelvic tilt is defined as the angle of
inclination made by the line between the ASIS and the posterior superior iliac
spine (PSIS) and its intersection with the horizontal plane (Fig. 2). Standing
pelvic tilt has been assessed by three different procedures, all with
intratester reliabilities of .88 or greater: 1) by determining the angle
directly from radiographs, (12) 2) by marking the ASIS and PSIS bony landmarks
on the subject and calculating the angle from trigonometric formulas, (8,9) and
3) by marking the bony landmarks on the subject and reading the angle directly
from an inclinometer. (10,13) Note that Rolf's proposed balanced pelvis would
have a SPT angle of about 6 degrees (Fig. 2), as compared with an actual mean
SPT angle of 8.4 degrees found in a group of 20 young healthy male subjects.
(8)
Considerable clinical evidence
exists that soft tissue manual therapy to the pelvic girdle reduces the angle
of inclination in the anteriorly tilted pelvis. (1‑4) Thus, pelvic
mobilization has been recommended as a treatment modality for certain low back
dysfunctions. (1‑5) Unfortunately, these accounts are usually
descriptive, involving palpation, photographs, and radiographs without proper
quantification, controls, and follow‑up testing. (14,15)
Cottingham et al previously reviewed
clinical accounts that describe pelvic mobilization as a treatment for certain
musculoskeletal disorders associated with autonomic stress (eg, myofascial pain
syndrome, restricted breathing patterns). (16) They also reviewed accounts of
human and animal experimental investigations concerning tactile and electrical
stimulation to the pelvic region and associated autonomic reflexes. (17‑23)
Overall, both the clinical accounts and the experimental work support the
contention that soft tissue pelvic manipulation increases parasympathetic
nervous system (PNS) tone while dampening sympathetic nervous system (SNS)
response.
Cottingham et al also demonstrated
that a single three‑minute manipulation ‑ Rolfing pelvic lift‑elicited
a somatovisceral‑PNS reflex in a group of healthy young male subjects.
(16) This reflex was characterized by a significant increase in PNS tone for
the duration of the manipulation. A control procedure administered to the same
subjects did not produce this reflex response.
Parasympathetic activity for
Cottingham et al's study was assessed from variations in the heart rate pattern
associated with breathing known as respiratory sinus arrhythmia (RSA). (16)
Respiratory sinus arrhythmia is the rhythmic acceleration of heart rate
associated with inspiration and deceleration in heart rate associated with
expiration. It has been shown to be predominantly mediated by cardioinhibitory
fibers of the vagi; hence, it has been proposed to be an index of cardiac PNS
activity or vagal tone. (24‑27) Experimental investigations involving
pharmacological and electrophysiological manipulations have demonstrated that
the amplitude of RSA is a reliable and valid estimate of cardiac PNS tone. (28‑31)
Porges developed an accurate technique of quantifying the RSA amplitude through
the application of time‑series statistical techniques and labeled this
procedure vagal tone. (31)
The purpose of this study was to
examine the immediate and sustained effects of Rolfing soft tissue pelvic
mobilization on two dependent variables: 1) an anatomical,
"structural" variable (angle of pelvic inclination) and 2) a
physiological, "functional" variable (cardiac PNS tone).
Based on the preceding review of the
literature, (16) we formulated two hypotheses regarding the immediate and
sustained effects of soft tissue pelvic manipulation. First, for an
experimental group of subjects who were preselected for exhibiting an
anteriorly tilted pelvis and who received Rolfing pelvic manipulation, a
decrease in the angle of anterior pelvic tilt would be evident immediately
after the session and after a 24‑hour follow‑up assessment. (A
control group would show no changes in anterior pelvic tilt.) Second, the same
experimental group would display a concurrent increase in PNS activity
immediately after and 24 hours after the Rolfing pelvic manipulation. (A
control group would exhibit no change in PNS tone.)
METHOD
Subjects
A sample of 32 healthy men between
the ages of 21 and 35 years (X = 27 years) was selected for this investigation.
All subjects reported no known health problems and were nonsmokers. Subjects
were also preselected for exhibiting an anteriorly tilted pelvis in the
sagittal plane. An investigation by Gajdosik et al found a mean SPT angle of
8.4 degrees for 20 young healthy men, with a range of 1.66 to 17.15 degrees and
a standard error of .46 (8) Because we wanted to observe possible reductions in
pelvic inclination angle, we therefore defined anterior pelvic tilt as having a
SPT angle of about one standard error above this mean value (ie, >9°). The
subjects were then randomly assigned to either an Experimental Group (n = 16)
or a Control Group (n = 16). At least one month before the study, both groups
had received a standardized 10‑session series of the Rolfing method (1)
and thus were equally familiarized with this soft tissue manipulative
procedure. Four of the 10 sessions involved substantial pelvic manipulation.
(1) All subjects were selected on a volunteer basis from the professional
practice of the primary investigator (J.T.C.) Each subject signed an informed
consent statement to participate. The consent form and procedure were approved
by the Frances Nelson Health Center Board of Directors.
Instrumentation and Materials
The angle of pelvic inclination for
SPT was measured by an inclinometer consisting of a universal protractor[1]
and a bar‑clamp caliper. The inclinometer was used to determine the angle
formed by the horizontal plane and a line drawn between the ASIS and PSIS (Fig.
2).
Parasympathetic activity was
assessed with a Vagal Tone Monitor,[2]
a microcomputer‑based device that calculates vagal tone and heart rate on‑line.
Electrodes were placed bilaterally on the ventral wrists of the subject, and
electrocardiographic activity was monitored by an ECG amplifier.[3]
The output of the ECG amplifier was the input to the Vagal Tone Monitor. A
quiet environment was maintained with an average temperature of 25°C (range =
24°‑26°).
Procedure
Before data collection, the subjects
were informed about the nature of the study. The SPT angle and PNS tone
measurements were taken during three test trials: I) before the 45‑minute
treatment period, 2) immediately after the treatment period, and 3) 24 hours
after the treatment period. One experimenter performed and recorded all
measurements for the study and was aware of subjects' group assignments. The
primary investigator administered the manipulative procedure.
Pretest measurement of standing pelvic tilt. With the subject dressed in gym shorts and standing with feet parallel
(internal malleoli 2 in[4]
apart), the experimenter palpated the ASIS and PSIS bilaterally and marked
these bony landmarks with adhesive tape. The subject was then instructed to
assume a normal standing posture with weight evenly distributed on both feet.
The experimenter placed the arms of the caliper on the marked ASIS and PSIS of
the fight ilium and recorded the inclination angle directly from the inclinometer.
This procedure was repeated for the left ilium.
Pretest measurement of parasympathetic activity. Following the, SPT assessments, the subject was
positioned supine on a treatment table with the electrodes on the ventral wrists..
The subject was allowed five minutes to adapt to the environment. The subject's
ECG activity was then monitored with the Vagal Tone Monitor for a 2.5minute
period.
Treatment period. Following the
pretest assessments, the subjects in the Experimental Group received Rolfing
soft tissue manipulation of the pelvic region. The three primary myofascia]
regions manipulated were the iliopsoas, deep hip rotator, and hamstring
muscles. (3) The adductor and paravertebral musculature was also manipulated
briefly. Each subject was positioned for the first, 15 minutes on his night
side, then for 15 minutes on his left side, and for the final 15 minutes in a
supine position. During the treatment period, Control Group subjects were
placed in the identical three positions, 15 minutes each, but did not receive
the manipulative procedure,
Posttest measurements. Assessments of
SPT angle and PNS activity were taken in the same manner described for the
pretests.
Data Quantification and Analysis
Angle of SPT was read from the
inclinometer to the nearest one‑half degree. The two readings from the
right and left ilia were averaged to compensate for any asymmetry between the
ilia in the sagittal plane.
For the pretest, posttest, and 24‑hour
follow‑up assessments, vagal tone and heart rate were assessed during
sequential 30‑second periods for 2.5 minutes, Mean values of vagal tone
and heart rate were calculated for each 2.5‑minute test period. The Vagal
Tone Monitor calculated cardiac vagal tone by extracting the variance associated
with the amplitude of RSA. The RSA amplitude variance was then transformed to
the natural logarithm to normalize its distribution. (32) Thus, vagal tone is
expressed in logarithmic units on a scale of I to
10. A detailed description of this,
procedure was presented previously. (16)
Mixed‑design analyses of
variance (ANOVAs) with group as the between-subject factor and test trial as
the repeated within‑subject factor were calculated for SPT angle, vagal
tone, and heart rate. Subsequent post hoc testing to identify paired
differences between test trial. means was determined by Tukey's Honestly
Significant Difference (HSD) test. Reciprocal shifts in, SPT angle and vagal
tone were analyzed by sign tests for matched pairs. An alpha. level of .05 was
used for. statistical significance.
RESULTS
Standing Pelvic Tilt
The ANOVA for SPT angle demonstrated
a significant main effect for trial (F = 20.6; df = 2,56 ; p <.01) (Tab. 1).
A significant group by trial interaction (F = 12.2; df = 2,56; p < .0 1),
however, was also found. Post hoc. simple‑effects tests with ANOVAs for
each group indicated that only the Experimental Group showed significant
differences in SPT angle over the three test trials (F = 21.3; df = 2,123; p < To identify paired
differences, Tukey's HSD test was calculated on all combinations of the three
trial. means of the Experimental Group. The pretest mean SPIT angle was found
to be significantly higher than the posttest and. 24‑hour‑ follow‑up
test means (p <.O1). The posttest mean was not found to be significantly
different than the 24‑hour follow‑up mean. These relationships are
illustrated in Figure 3.
Vagal Tone
The ANOVA for vagal tone
demonstrated a significant main effect for trial (F 7.3 5; df = 2,56; p < .0
1) (Tab. 2). A significant group by trial' interaction (F = 10.4; df = 2 , 56;
p.<.01), however, was also found. Simple‑effects tests indicated that
only the Experimental Group exhibited significant mean differences in vagal
tone over the three assessment trials (F = 12.3; df 7,28
.0 1). Tukey's HSD test demonstrated
that, the posttest and 24‑hour follow‑up. means were significantly
higher than the pretest (p < .0 1). The posttest and 24‑hour follow‑up
means for‑ vagal tone did not differ significantly (Fig. 4).
Heart Rate
The ANOVA for heart rate indicated a
significant main effect for trial (F = 3.26; df = 2,56: p < .05) (Tab. 3). A
significant group by trial interaction (F = 3.7; df = 2,56; p < .05),
however, was also found. Simple‑effects post hoc analyses demonstrated
that only the Experimental Group exhibited differences across the test
trials (F = 3.8; df = 2,28; p <
.05). To deter‑mine significant differences between the trials, Tukey's
HSD test was performed. The heart rate pretest mean was found to be
significantly higher than the heart rate posttest mean (p < .05). The heart
rate pretest mean did not differ significantly from the 24‑hour follow‑up
mean. The posttest and 24‑hour follow‑up means were not
significantly different (Fig. 5).
Reciprocal Shifts in Standing Pelvic Tilt Angle and Vagal Tone
In the Experimental Group. 13
subjects who demonstrated a decrease in SPT angle from the pretest to the
posttest showed a corresponding increase in vagal tone levels. Twelve Experimental
Group subjects exhibited this reciprocal relationship from the pretest to the
24‑hour follow‑up assessment. Sign tests for matched pairs
indicated the negative sign of the differences was significant in both cases (p
< .01).
Identical comparisons were made in
the Control Group. Sign tests for matched pairs indicated the negative sign of
the differences was not significant in either case.
DISCUSSION
Data and Hypotheses
The data strongly support both
hypotheses concerning the effects of soft tissue pelvic manipulation on the
angle of pelvic inclination and PNS function. To our knowledge, this is the
First experimental investigation that demonstrates the traditional manual
therapy premise concerning anatomical structure and physiological function.
Specifically, shifts in pelvic alignment, are accompanied by concurrent changes
in PNS activity.
The Experimental Group demonstrated
a significant reduction in the SPT angle (lie, reduction in interior pelvic
tilt) following tile manipulative procedure ‑Not only did an immediate
decrease in SPT angle result in relation to tile pretest, but tile 24‑hour
follow‑up assessment Indicated that this shift in pelvic angle continued
without a significant return toward the pretest level. The Control Group,
receiving no manipulation, did not exhibit a significant change in anterior
pelvic tilt.
Parasympathetic function, as
measured by vagal tone, was found to significantly increase in the Experimental
Group for both the posttest and the 24‑hour follow‑up test. The enhanced
vagal tone showed no significant reduction from the posttest to the 24‑hour
follow-up. No significant changes in vagal tone were found in the Control
Group. For the Experimental Group, heart rate displayed a significant increase
in PNS activity lie, a decrease in heart rate) in the posttest but not in the
follow‑up assessment. 'The difference in magnitude of statistical effect
between vagal tone and heart rate may be due to the specificity of vagal tone
as a PNS index; that is, the vagal tone measure is determined predominantly by
cardio‑vagal inhibitory efferents, whereas heart rate is determined by
several non‑PNS components in addition to vagal activity. (16,31)
Physiological Mechanisms
Standing pelvic tilt. Manipulation and
stretching of the fascial sheaths, ligaments, and tendons have long been
reported by physical therapists, occupational therapists. and other manual
therapists as methods of correcting pelvic rotations and related problems. (2‑4,16,33)
Certainly, the reduction in anterior pelvic tilt found in those subjects who
received Rolfing manipulation supports these clinical observations.
One possible mechanism underlying
the decrease in anterior pelvic tilt may involve connective tissue's essential
quality of plasticity, that is, its capacity to change shape when mechanical
pressure is administered. Rolf (4) and others (34,35) proposed that manual
pressure applied to the soft tissues produces a phase transition in the ground
substance of connective tissue (eg, fascia), from a colloid "gel"
(semisolid) phase to a "sot" (liquidlike) phase. On the molecular
level, several authors have proposed that the glycoprotein structure of
connective tissue's ground substance breaks down with the addition of heat (eg,
from mechanical pressure or electrical stimulation). (33, 35‑38) When pressure is removed, the ground substance
"reshapes" and returns to a "transformed and hydrated" gel
phase. (4,35) An investigation that would tend further plausibility to this
mechanism would involve measuring the connective tissue temperature during soft
tissue manipulation and comparing this finding to the temperature needed to
produce a phase transition in the ground substance.
The other possible mechanism
involves changes in tone of flexor‑internal rotator and extensor‑external
rotator muscle groups that attach to the pelvic girdle. Hunt and Massey
conducted an electromyographic analysis of six basic movements before and after
10 sessions of the Rolfing method. (39) For the group receiving the soft tissue
manipulation, the posttest measurements demonstrated decreased EMG activity in
the antagonist muscles of several agonist‑antagonist pairs, including the
iliopsoas‑hamstring and gluteus medius muscles and the gluteus minimus‑deep
lateral hip rotator muscles. Similar shifts in EMG patterns between agonist and
antagonist pelvic muscle groups may account in part for the reduction in SPT
angle found in our study.
Parasympathetic activity. Most
theories concerning pelvic mobilization's effects on autonomic function have
emphasized how the mechanical stimulation of local, peripheral nerves and
plexuses elicit spinal and segmental autonomic reflexes. (2‑4,19)
In this study, however, the enhanced
PNS activity was still apparent 24 hours after the experimental treatment.
Thus, the autonomic shifts demonstrated cannot be explained entirely in terms
of transient, regional somatovisceral reflexes. Instead, a sustained, systemic
shift in PNS outflow appears to be modulated from supraspinal levels. Gellhorn
demonstrated similar autonomic shifting, or "tuning," in animal
investigations involving mechanical stimulation of afferent receptors (eg,
carotid sinus) and direct electrical stimulation of higher neural centers (eg,
hypothalamus). (22) Prolonged stimulation produced autonomic changes in the
direction of dominance for one autonomic branch with concurrent suppression in
the other branch (law of reciprocity). (22,40,41) Other investigators have
similarly produced PNS and SNS dominance in animals through electrical
stimulation of the limbic system (eg, amygdala). (40,41)
The vagal tone data from this study
provide further support for Gellhorn`s construct of autonomic tuning. (40)
Because vagal tone is mediated by central nervous system mechanisms (24‑28) because in our study soft tissue pelvic
manipulation was shown to significantly increase vagal tone levels for at least
24 hours, these pelvic manipulations apparently also produced a shift in CNS
modulation of PNS activity. Thus, the mechanism possibly involves an afferent‑efferent
feedback loop that would include the following components: 1) stimulation of
somatic and visceral afferents in the pelvic region, 2) conduction of this
information up the spinal cord to supraspinal centers (eg, brain stem and
hypothalamus), and 3) supraspinal modulation of peripheral autonomic output
(eg, cardiac vagal outflow) that in turn modifies the subsequent sensory input.
(2, 41)
Clinical Implications
The results of this investigation
suggest two possible clinical applications of the Rolfing method of soft tissue
manipulation. First, the finding that Rolfing pelvic manipulation evoked a
significant reduction in anterior pelvic tilt supports its use in treating
certain low back problems (ie, low back dysfunction associated with anterior
tilt of the sacral base and ASISs and depression of the pubic symphysis).
(6,10,42)
A second clinical implication
concerns the use of the Rolfing method in the treatment of certain autonomic
stress disorders. The vagal tone assessments of this investigation clearly
demonstrated that soft tissue pelvic mobilization produced a strong and
sustained increase in vagal tone, presumably with a concurrent decrease in SNS
activity. This repatterning of autonomic outflow implies a reduction of chronic
SNS arousal responses and a shift toward a relaxed, attentive physiological
state associated with enhanced vagal activity. Vagal tone (RSA amplitude)
appears to be an index of overall CNS function as well as PNS tone and has been
used to assess newborns` neurological status, (31) attention disorders, (43)
clinical depth of general anesthesia,(44) and autonomic stress. (16,45) Thus,
the Rolfing technique may be an appropriate treatment for musculoskeletal
disorders that are related to autonomic dysfunction, including myofascial pain
syndromes (ie, primary fibromyalgia), restricted breathing patterns, and
certain hyperactive behaviors. (2,17,18)
This study demonstrated that soft
tissue pelvic mobilization produced a 24‑hour shift in SPT angle and PNS
tone in healthy young adults. The longevity of these results and the relative
contribution of component manipulations in producing them, however, remains
unknown. From a clinical viewpoint, these factors are extremely important in
further defining appropriate therapeutic use of this modality.
CONCLUSION
A group of young healthy men,
preselected for exhibiting an anteriorly tilted pelvis, were randomly assigned
to either an Experimental Group (n = 16) or a Control Group (n = 16). The
Experimental Group received a 45‑minute Rolfing soft tissue pelvic
mobilization session, and the Control Group received no manipulation. In
comparisons of a pretest assessment with immediate posttest and 24‑hour
follow‑up assessments, the Experimental Group showed a significant
decrease in SPT angle and a significant increase in PNS activity. The Control
Group did not demonstrate significant changes in pelvic angle or PNS tone.
Possible physiological mechanisms underlying these findings were discussed. The
reduction in anterior pelvic tilt produced by Rolfing pelvic manipulation
supports its clinical use as a treatment for certain types of low back
disorders. Likewise, the sustained increases in PNS (vagal) tone that followed
the manipulative procedure support the Rolfing technique's use in
musculoskeletal dysfunctions associated with autonomic stress and characterized
by excessive SNS tone and reduced PNS activity.
Acknowledgment. We thank the
late George W. Day, MA, Department of English, Tidewater College, Virginia
Beach, Va, for his direction and criticism in preparing this manuscript.
Evaluation of mobility of hip and
lumbar vertebrae of normal young women, Arch Phys Med Rehabil 43:1‑8,
1962
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