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Non-surgical interventions for excessive anterior pelvic tilt in symptomatic and non-symptomatic adults: a systematic review

Last updated: 03-22-2020

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Non-surgical interventions for excessive anterior pelvic tilt in symptomatic and non-symptomatic adults: a systematic review

Non-surgical interventions for excessive anterior pelvic tilt in symptomatic and non-symptomatic adults: a systematic review
1Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
2Department of Clinical Research, University of Southern Denmark, Odense, Denmark
3University College Absalon, Center of Nutrition and Rehabilitation, Department of Physiotherapy, Region Zealand, Denmark
Find articles by Anders Falk Brekke
Søren Overgaard
1Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
2Department of Clinical Research, University of Southern Denmark, Odense, Denmark
Find articles by Søren Overgaard
Asbjørn Hróbjartsson
2Department of Clinical Research, University of Southern Denmark, Odense, Denmark
4Odense Patient data Explorative Network (OPEN), Odense, Denmark
5Centre for Evidence-Based Medicine Odense (CEBMO), Odense University Hospital, Odense, Denmark
Find articles by Asbjørn Hróbjartsson
Anders Holsgaard-Larsen
1Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
2Department of Clinical Research, University of Southern Denmark, Odense, Denmark
1Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
2Department of Clinical Research, University of Southern Denmark, Odense, Denmark
3University College Absalon, Center of Nutrition and Rehabilitation, Department of Physiotherapy, Region Zealand, Denmark
4Odense Patient data Explorative Network (OPEN), Odense, Denmark
5Centre for Evidence-Based Medicine Odense (CEBMO), Odense University Hospital, Odense, Denmark
Anders Falk Brekke, Ortopædkirurgisk afdeling, Afd. O. Odense Universitetshospital (OUH), Sdr. Boulevard 29, 5000 Odense C, Denmark. Email: kd.uds.htlaeh@ekkerbfa
Copyright © 2020 The author(s)
This article is distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International (CC BY-NC 4.0) licence ( https://creativecommons.org/licenses/by-nc/4.0/ ) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed.
Abstract
Excessive anterior pelvic tilt is suspected of causing femoroacetabular impingement, low back pain, and sacroiliac joint pain. Non-surgical treatment may decrease symptoms and is seen as an alternative to invasive and complicated surgery. However, the effect of non-surgical modalities in adults is unclear. The aim of this review was to investigate patient- and observer-reported outcomes of non-surgical intervention in reducing clinical symptoms and/or potential anterior pelvic tilt in symptomatic and non-symptomatic adults with excessive anterior pelvic tilt, and to evaluate the certainty of evidence.
MEDLINE, EMBASE, Web of Science and Cochrane (CENTRAL) databases were searched up to March 2019 for eligible studies. Two reviewers assessed risk of bias independently, using the Cochrane Risk of Bias tool for randomized trials and the ROBINS-I tool for non-randomized studies. Data were synthesized qualitatively. The GRADE approach was used to assess the overall certainty of evidence.
Of 2013 citations, two randomized controlled trials (RCTs) (n = 72) and two non-RCTs (n = 23) were included. One RCT reported a small reduction (< 2°) in anterior pelvic tilt in non-symptomatic men. The two non-RCTs reported a statistically significant reduction in anterior pelvic tilt, pain, and disability in symptomatic populations. The present review was based on heterogeneous study populations, interventions, and very low quality of evidence.
No overall evidence for the effect of non-surgical treatment in reducing excessive anterior pelvic tilt and potentially related symptoms was found. High-quality studies targeting non-surgical treatment as an evidence-based alternative to surgical interventions for conditions related to excessive anterior pelvic tilt are warranted.
Cite this article: EFORT Open Rev 2020;5:37-45. DOI: 10.1302/2058-5241.5.190017
Keywords: femoroacetabular impingement, non-surgical interventions, pelvic tilt
Introduction
Excessive anterior pelvic tilt is a position of the pelvis in a standing posture where the tilt is larger than what is considered normal. Pelvic tilt measurements obtained from radiographic imaging are used in surgical planning and research assessments. In the clinic, pelvic tilt is measured using inclinometry as the angle between a line connecting the anterior and posterior superior iliac spine (ASIS and PSIS) and in the normal healthy population, the reference value of anterior pelvic tilt is about 8 degrees. 1 – 3 However, as excessive anterior pelvic tilt is not defined by a fixed cutoff point in the literature, the present study uses a definition of an anterior angle greater than 8 degrees.
Excessive anterior pelvic tilt is not an isolated clinical disorder or pathology. Nonetheless it is commonly suspected of causing unspecific low back pain (LBP) and pelvic girdle pain. 4 – 8 The pelvis is closely related to the hip joint as it rotates/tilts anteriorly and posteriorly, around a bicoxofemoral axis, in the sagittal plane. 9 Anterior pelvic tilt decreases normal acetabular anteversion (opening towards anterior), 10 , 11 which potentially may affect patients with acetabular retroversion. Acetabular retroversion is a type of developmental hip dysplasia causing an excessive anterior coverage of the femoral head and therefore potentially causing primary femoroacetabular impingement (FAI). 12 Primary FAI, which occurs as a result of morphological abnormalities (e.g. acetabular retroversion), should be distinguished from secondary FAI (e.g. excessive pelvic tilt). 13 Acetabular retroversion is associated with pain, functional limitations and early development of osteoarthritis of the hip. 14 Present curative treatment of acetabular retroversion is anterior osteoplasty or re-orientation of the acetabulum by a periacetabular osteotomy (PAO). 15 , 16 In the normal pelvis, without anatomical signs of acetabular retroversion, excessive anterior tilt may cause a functional positive sign of acetabular retroversion resulting in secondary FAI earlier in the arc of motion. 12 , 17 Thus, a reduction of anterior pelvic tilt may lead to reduced symptoms of primary and/or secondary FAI, which may have implications regarding non-surgical treatment in patients with acetabular retroversion. 17 Treatment methods focusing on reducing excessive anterior pelvic tilt are therefore of importance, and textbooks in the field of physical therapy, training, and rehabilitation 18 – 23 suggest various procedures in the therapeutic treatment of symptoms associated with excessive anterior pelvic tilt. Most commonly, physical training focusing on musculoskeletal correction of the postural alignment through increased muscle strength, flexibility, and functional coordinative training is suggested. 18 – 23 However, there seems to be a lack of evidence for the different non-surgical treatment modalities used to correct excessive anterior pelvic tilt and their potential effect on symptoms and level of pelvic tilt.
Therefore, the objective of this systematic review was to investigate the effect of non-surgical treatments in improving patient- and observer-reported outcomes related to symptoms, function and pelvic tilt in symptomatic and non-symptomatic adults, and to assess the overall certainty of evidence.
Methods
Protocol and registration
The systematic review protocol was developed in accordance with the PRSMA-P statement 24 and registered online at PROSPERO id: CRD42017056927. Literature search criteria and methods were established and agreed on by all authors.
Eligibility criteria
Studies were eligible if they were non-surgical interventions aiming at reducing symptoms and/or anterior pelvic tilt in symptomatic or healthy participants over 18 years old with excessive anterior pelvic tilt.
Studies were excluded in cases with populations restricted to specific diseases or severe conditions such as neurological diseases (e.g. cerebral palsy, stroke), diseases affecting the posture (e.g. Duchenne muscular dystrophy, spondylolisthesis), degenerative conditions (e.g. spondylosis, hip osteoarthritis), intervertebral discus herniation and osteosynthesis of the lumbopelvic region. Finally, studies on pregnancy were excluded because of the naturally changed spinopelvic posture.
No language restrictions were imposed. In cases of articles reported in other languages than English or Nordic languages, Google translate would have been used.
Information sources
The electronic databases MEDLINE, EMBASE, Web of Science and Cochrane Central Register for Controlled Trials (CENTRAL) were searched for relevant studies up to February 2017. The electronic search was complemented by reference tracking of the included studies. An additional search for relevant new studies added to the databases was carried out in March 2019, and yielded no further studies to be included.
Search
The specific search strategy was created with input from the project team together with a Health Sciences Librarian Tove Faber Frandsen ( Appendix 1 ).
Study selection
The first reviewer (AFB) screened titles and abstracts for potentially eligible studies. Two independent review authors (AFB and AH-L) screened the full text articles for final inclusion. Disagreement was resolved through discussion. Reasons for excluding trials were recorded.
Data collection process
Data item extraction was carried out by one reviewer (AFB), using a standard extraction form developed for this review. Study (author, year of publication, study design), participants (eligible criteria, sample size, age, type of impairment and symptoms), intervention type, outcomes (patient reported and/or observer reported), results and adverse effects.
Assessment of patient-reported outcomes extracted from the included studies was primary for the present study. These outcomes were: pain (e.g. visual analogue scale (VAS), numeric ranking scale (NRS) and questionnaire subscales), health-related quality of life (questionnaire subscale) and level of function (questionnaire subscale). Assessment of observer-reported outcomes was secondary. These outcomes were: radiographs in standing, inclinometry in standing and potentially other validated measures of pelvic tilt in standing. In case of incomplete outcome reporting, the study authors would be contacted for additional information.
Risk of bias in individual studies
The risk of bias for each study was assessed independently and then discussed by two authors (AFB and AH-L) using Cochrane Collaboration’s tool for assessing risk of bias in randomized controlled trials 25 and the ROBINS-I tool (Risk Of Bias In Non-randomized Studies – of Interventions). 26 In case of disagreement, a third author (AH) was consulted. The overall risk of bias across the studies for both the randomized controlled trials (RCTs) and intervention studies without control was assessed finally.
Synthesis of results
Due to expected and encountered variation of study designs and heterogeneity in results, data were synthesized qualitatively. Assessment of the overall certainty of the evidence was inspired by The Grades of Research, Assessment, Development and Evaluation (GRADE) approach. 27
Results
Study selection
Of 2013 citations, 10 full-text articles were assessed for eligibility; of those 10, four were included in the final qualitative synthesis ( Fig. 1 ).


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