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Diagnosis and classification of pelvic girdle pain disorders, Part 2: Illustration of the utility of a classification system via case studies

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Diagnosis and classification of pelvic girdle pain disorders, Part 2: Illustration of the utility of a classification system via case studies

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Abstract

Pelvic girdle pain (PGP) disorders are complex and multi-factorial and are likely to be represented by a series of sub-groups with different underlying pain drivers. Both the central and peripheral nervous systems have the potential to mediate PGP disorders. Even in the case of a peripheral pain disorder, the central nervous system can modulate (to promote or diminish) the pain via the forebrain (cognitive factors). It is hypothesised that the motor control system can become dysfunctional in different ways. A change in motor control may simply be a response to a pain disorder (adaptive), or it may in itself promote abnormal tissue strain and therefore be 'mal-adaptive' or provocative of a pain disorder. Where a deficit in motor control is 'mal-adaptive' it is proposed that it could result in reduced force closure (deficit in motor control) or excessive force closure (increased motor activation) resulting in a mechanism for ongoing peripheral pain sensitisation. Three cases are presented which highlight the multi-dimensional nature of PGP. These cases studies outline the practical clinical application of a classification model for PGP and the underlying clinical reasoning processes inherent to the application of this model. The case studies demonstrate the importance of appropriate classification of PGP disorders in determining targeted intervention directed at the underlying pain mechanism of the disorder.

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... [1, 28, 34, 51, 52, 66, 79, 86, 90, 91, 101, 108, 135, 141, 147, 151-153, 160, 170, 175-178, 189, 193-195, 197, 200, 230, 231, 235, 253] Pain consistently provoked by specific postures. [28,51,91,108,[151][152][153]200] Predisposed by prior experiences including trauma, associated with illness/disease or poor general health, or associated with gene expression. [41,130,147,152,153,207,251] Pain is responsive to physical activity, exercise, or graded/repeated movement. ...
... [28,51,91,108,[151][152][153]200] Predisposed by prior experiences including trauma, associated with illness/disease or poor general health, or associated with gene expression. [41,130,147,152,153,207,251] Pain is responsive to physical activity, exercise, or graded/repeated movement. [51,52,65,99,152,153] ...
... [41,130,147,152,153,207,251] Pain is responsive to physical activity, exercise, or graded/repeated movement. [51,52,65,99,152,153] ...
Article
Mechanism-based classification of pain has been advocated widely to aid tailoring of interventions for individuals experiencing persistent musculoskeletal pain. Three pain mechanism categories are defined by the International Association for the Study of Pain: nociceptive, neuropathic, and nociplastic pain. Discrimination between them remains challenging. This study aimed to: build on a framework developed to converge the diverse literature of pain mechanism categories to systematically review methods purported to discriminate between them; synthesise and thematically analyse these methods to identify convergence and divergence of opinion; and report validation, psychometric properties and strengths/weaknesses of these methods. The search strategy identified papers discussing methods to discriminate between mechanism-based categories of pain experienced in the musculoskeletal system. Studies that assessed validity of methods to discriminate between categories were assessed for quality. Extraction and thematic analysis were undertaken on 184 papers. Data synthesis identified 200 methods in five themes: clinical examination, quantitative sensory testing, imaging, diagnostic and laboratory testing, and pain-type questionnaires. Few methods have been validated for discrimination between pain mechanism categories. There was general convergence but some disagreement regarding findings that discriminate between pain mechanism categories. A combination of features and methods, rather than a single method, was generally recommended to discriminate between pain mechanism categories. Two major limitations were identified: overlap of findings of methods between categories due to mixed presentations, and many methods considered discrimination between two pain mechanism categories but not others. The results of this review provide a foundation to refine methods to differentiate mechanisms for musculoskeletal pain.
... An international body of opinion has developed over the last 10 years, suggesting that the heterogeneity inherent in the diagnosis of NSLBP may itself be contributing to the small effect sizes repeatedly observed in interventional trials (McCarthy et al., 2004;McCarthy and Cairns, 2005;Brennan et al., 2006). A small body of work is beginning to provide evidence for the superior effect of targeted intervention to specific subgroups of NSLBP against guideline recommendation management of all NSLBP (Fritz et al., 2003;Long et al., 2004;Brennan et al., 2006;O'Sullivan and Beales, 2007a;O'Sullivan and Beales, 2007b). Thus, diagnostic approach to NSLBP may have a direct influence on effectiveness. ...
... Here, authors have reported systems developed through professional consensus and proposed them without empirical data for their validity. A number of these systems have been subsequently evaluated for reliability and prognostic validity, with varying degrees of success (McKenzie and May, 2003;O'Sullivan and Beales, 2007a;O'Sullivan and Beales, 2007b). The second approach has involved an 'unsupervised' or statistical approach. ...
... Although information on pain location, change in pain in response to movement and regional hypo/hypermobility were recorded, no distinct clusters of these signs and symptoms were evident. These clinical features have been advocated as important responses in the subclassification of NSLBP by previous authors (Fritz et al., 2000;Werneke and Hart, 2001;Van Dillen et al., 2003;O'Sullivan, 2006;O'Sullivan and Beales, 2007a;O'Sullivan and Beales, 2007b); however, this method did not replicate any subgroups described previously. This may have been due to a lack of sensitivity of the cluster analysis, particularly in a model with a large number of variables in relation to the number of subjects. ...
Article
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Non-specific low back pain (NSLBP) accounts for over 85% of all low back pain. Homogenous subgroups may exist within this diagnosis. This study derived a clinical examination and evaluated the examination's ability to identify homogenous subgroups in NSLBP. Patients with NSLBP were examined using a standardized clinical examination. Each patient was examined by two physiotherapists. Data were analysed for item reliability and the presence of distinct subgroups using cluster analysis. Cross-validation of the clusters identified was conducted. Three hundred and one patients were examined. The inter-tester reliability of the majority of items was moderate to substantial (52% of items with kappa > 0.40). A K-means cluster analysis of the two data sets revealed agreement on the presence of two subgroups. One group (n = 47, 16%) had higher fear avoidance beliefs, anxiety and disability. They were more likely to be provoked by pain provocative tests. They were also more likely to be judged as having central sensitization and a dominant psychosocial component to their presentation. The identification of a group of hypervigilant NSLBP patients should allow the interventions to be targeted towards this group. A valid, standardized clinical examination does contribute to the diagnostic management of NSLBP.
... O'Sullivan suggested a classification scheme to assist in better understanding the pathophysiologic mechanisms to this condition and in providing causal treatment. 22,23 This testing sequence is included under musculoskeletal assessment of the pelvic ring discussed in Part I of this series. ...
... Mechanical dysfunction of the sacroiliac or symphysis pubis joint and/or pelvic ring has been proposed as a mechanism of this prolonged pain. 22,23,99 However, motor control dysfunction has also been implicated and should be assessed in all patients presenting with prolonged pelvic girdle pain. 100 As a component of pelvic ring pain, SIJ dysfunction is commonly seen in peripartum pain conditions. ...
... The optimal pelvic position is one where the abdominal contents can be supported by the pubic symphysis, as well as the pelvic floor, and has been described as a neutral lordosis. 23,224 Providing the patient with bony landmarks from which to assess the correct performance of pelvic alignment will enhance self-directed learning and success. Using the heel of the hand on the ASIS and the fingertips on the pubic tubercle bilaterally serves as easily identified landmarks. ...
Article
  Pelvic pain is a common condition. Treatment interventions have traditionally targeted biomedical conditions with variable success. Utilizing a systematic approach to examination of the pelvic girdle and related organ systems contained within the pelvis will aid the clinician in identifying the painful structure(s) as well as the associated impairments limiting functional recovery. From this, a complete management program can be instituted. The following description of gynecologic, urologic, gastrointestinal, musculoskeletal, and neurologic conditions that can cause or are associated with chronic pelvic pain leads to conservative management proposals based on the available evidence. Finally, nonoperative interventional strategies are described, which target the pain system from a cognitive behavioral perspective, address movement dysfunctions, and address interventional pain technique possibilities.▪
... Evidence is growing that Pregnancy-related Pelvic girdle Pain (PPP) is a distinct clinical entity, the exact causes of which still remain unknown [26, 27]. Total prevalence of PPP during pregnancy has been estimated at 22.5% [41], with 10% of patients having mild symptoms only, 10% deserving at least some medical attention, and 2.5% having serious pain and/or disability [28]. ...
... Indeed, several structural abnormalities have been observed, e.g., vertical displacement of a pubic bone (“symphyseal step”) was reported while patients were standing on one leg [22], and laxity of the sacroiliac joints appeared to be asymmetric [5], probably related to painful tension in the long dorsal ligaments [38]. Still, in different patients, and in the same patient at different times, different structures appear to be involved [9, 20], and the aetiology of PPP is probably multifactorial [25–27]. ...
Article
Full-text available
Walking is impaired in Pregnancy-related Pelvic girdle Pain (PPP). Walking velocity is reduced, and in postpartum PPP relative phase between horizontal pelvis and thorax rotations was found to be lower at higher velocities, and rotational amplitudes tended to be larger. While attempting to confirm these findings for PPP during pregnancy, we wanted to identify underlying mechanisms. We compared gait kinematics of 12 healthy pregnant women and 12 pregnant women with PPP, focusing on the amplitudes of transverse segmental rotations, the timing and relative phase of these rotations, and the amplitude of spinal rotations. In PPP during pregnancy walking velocity was lower than in controls, and negatively correlated with fear of movement. While patients' rotational amplitudes were larger, with large inter-individual differences, spinal rotations did not differ between groups. In the patients, peak thorax rotation occurred earlier in the stride cycle at higher velocities, and relative phase was lower. The earlier results on postpartum PPP were confirmed for PPP during pregnancy. Spinal rotations remained unaffected, while at higher velocities the peak of thorax rotations occurred earlier in the stride cycle. The latter change may serve to avoid excessive spine rotations caused by the larger segmental rotations.
... A reduction in velocity of movement during hip and spine flexion in people with low back pain of sacroiliac origin has been presented before (Bussey and Milosavljevic, 2015). Increased muscle contraction, causing smaller and slower movement, has been observed in patients with PGP (O'Sullivan et al., 2002;O'Sullivan and Beales, 2007). This can be an indication for augmented constraint of movement, known as tight control patterns (Van Dieën et al., 2019). ...
Article
Background Motor control patterns are altered when women with pregnancy-related pelvic girdle pain (PGP) experience pain. In low back pain, these adaptations can persist after recovery. Objectives This study aimed to assess balance control in postpartum women with and without a history of PGP during pregnancy. Design Cross-sectional study. Method Eighteen postpartum women who reported to be recovered from PGP, and twelve postpartum women without a history of PGP during pregnancy performed two clinical tests: the single leg stance and active straight leg raise test. Primary outcomes were ground reaction forces measured with a force platform. Results Multiple linear regression analyses showed smaller lateral displacement (β = −11cm; 95%CI: 19 to −3; p = 0.008) and lower displacement velocity of the Centre of Pressure (COP) (Ratio of Geometric Means (RGM) 0.76; 95%CI: 0.59 to 0.99; p = 0.043) during single leg stance in the participants with a history of PGP compared to participants without a history of PGP. Push-off force (β = −4.8 N; 95%CI: 22.0 to 12.5; p = 0.57) and asymmetry of push-off force (RGM 1.77; 95%CI: 0.62 to 5.04; p = 0.27) did not differ between groups. During the active straight leg raise test, no differences in lateral displacement (β = 3 cm; 95%CI: 3 to 8; p = 0.30) and COP displacement velocity (RGM 1.03; 95%CI: 0.70 to 1.52; p = 0.87) were observed. Conclusions Although the women with a history of PGP considered themselves recovered, their balance control during single leg stance was poorer compared to those without a history of PGP. No differences were found during the active straight leg raise test.
... Therefore, they suggested that 'patients with unilateral lumbopelvic pain who have a positive ASLR test may benefit from motor control exercises that specifically target activation of the deep abdominal musculature' [12]. O'Sullivan and Beales suggested that motor control impairments in longlasting PGP show a large variation: 'non-specific' PGP disorders are represented by a number of sub-groups with different underlying pain mechanisms rather than a single entity.' [13,14] These authors recommend adapting the therapeutic intervention based on this subclassification. Nevertheless, in physiotherapy for PGP, contraction of the TrA is emphasised, implying that the role of the muscle to compress both innominate bones against the sacrum is diminished. ...
Article
Full-text available
Background: Many studies suggest that impairment of motor control is the mechanical component of the pathogenesis of painful disorders in the lumbo-sacral region; however, this theory is still unproven and the results and recommendations for intervention remain questionable. The need for a force to compress both innominate bones against the sacrum is the basis for treatment of pregnancy-related pelvic girdle pain (PGP). Therefore, it is advised to use a pelvic belt and do exercises to enhance contraction of the muscles which provide this compression. However, our clinical experience is that contraction of those muscles appears to be excessive in PGP. Therefore, in patients with long-lasting pregnancy-related posterior PGP, there is a need to investigate the contraction pattern of an important muscle that provides a compressive force, i.e. the transverse abdominal muscle (TrA), during a load transfer test, such as active straight leg raising (ASLR). Methods: TrA thickness was measured by means of ultrasound imaging at rest and during ASLR in 43 non-pregnant women with ongoing posterior PGP that started during a pregnancy or delivery, and in 39 women of the same age group who had delivered at least once and had no current PGP (healthy controls). Results: In participants with PGP, the median TrA thickness increase with respect to rest during ipsilateral and contralateral ASLR was 31% (SD 46%) and 31% (SD 57%), respectively. In healthy controls, these values were 11% (SD 25%) and 13% (SD 22%), respectively. Conclusions: Significant excessive contraction of the TrA is present during ASLR in patients with long-lasting pregnancy-related posterior PGP. The present findings do not support the idea that contraction of the TrA is decreased in long-lasting pregnancy-related PGP. This implies that there is no rationale for the prescription of exercises to enhance contraction of TrA in patients with long-lasting pregnancy-related PGP.
... For women who are prone to pain experiences early in life, as related to menstruation [85] and pregnancy [4], learning healthy pain management is a priority. This includes the assessment and management of the individual woman with pain in the pelvis, taking into account her history, her present context and framing her messages into biopsycho-social and bio-inflammatory-psychological perspectives [29,[86][87][88][89][90]. In this context, it is important for women who experience pain (cyclic pain from menstruation, local pregnancy-related pain, persistent pain at postpartum) to learn to approach activity despite pain. ...
Article
Full-text available
During their lifespan, many women are exposed to pain in the pelvis in relation to menstruation and pregnancy. Such pelvic pain is often considered normal and inherently linked to being a woman, which in turn leads to insufficiently offered treatment for treatable aspects related to their pain experience. Nonetheless, severe dysmenorrhea (pain during menstruation) as seen in endometriosis and pregnancy-related pelvic girdle pain, have a high impact on daily activities, school attendance and work ability. In the context of any type of chronic pain, accumulating evidence shows that an unhealthy lifestyle is associated with pain development and pain severity. Furthermore, unhealthy lifestyle habits are a suggested perpetuating factor of chronic pain. This is of specific relevance during lifespan, since a low physical activity level, poor sleep, or periods of (di)stress are all common in challenging periods of women’s lives (e.g., during menstruation, during pregnancy, in the postpartum period). This state-of-the-art paper aims to review the role of lifestyle factors on pain in the pelvis, and the added value of a lifestyle intervention on pain in women with pelvic pain. Based on the current evidence, the benefits of physical activity and exercise for women with pain in the pelvis are supported to some extent. The available evidence on lifestyle factors such as sleep, (di)stress, diet, and tobacco/alcohol use is, however, inconclusive. Very few studies are available, and the studies which are available are of general low quality. Since the role of lifestyle on the development and maintenance of pain in the pelvis, and the value of lifestyle interventions for women with pain in the pelvis are currently poorly studied, a research agenda is presented. There are a number of rationales to study the effect of promoting a healthy lifestyle (early) in a woman’s life with regard to the prevention and management of pain in the pelvis. Indeed, lifestyle interventions might have, amongst others, anti-inflammatory, stress-reducing and/or sleep-improving effects, which might positively affect the experience of pain. Research to disentangle the relationship between lifestyle factors, such as physical activity level, sleep, diet, smoking, and psychological distress, and the experience of pain in the pelvis is, therefore, needed. Studies which address the development of management strategies for adapting lifestyles that are specifically tailored to women with pain in the pelvis, and as such take hormonal status, life events and context, into account, are required. Towards clinicians, we suggest making use of the window of opportunity to prevent a potential transition from localized or periodic pain in the pelvis (e.g., dysmenorrhea or pain during pregnancy and after delivery) towards persistent chronic pain, by promoting a healthy lifestyle and applying appropriate pain management.
... Several etiological factors have been suggested for pregnancy-related PGP; biomechanical [22,[43][44][45], hormonal [8,10,[46][47][48][49], metabolic [50], genetic [27,40,51,52], and biopsychosocial factors [19,53]. ...
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Pelvic girdle pain (PGP) during pregnancy is common and, indeed, has always been considered normal. It is commonly associated with moderate to severe pain that impairs everyday activities such as getting up from a chair, bending, walking, working in the home and caring for children, as well as, of course, paid employment. Also, PGP is a frequent cause of sick leave during pregnancy. The aetiology of PGP is poorly understood and there is no official nomenclature, no effective evidence- based preventive measures or treatment, known risk factors or detailed knowledge of the clinical course of the various subgroups of this condition. Objectives The objectives for this project were to determine the prevalence of PGP during pregnancy in a random population of women, detect factors associated with the development of this condition, explore what influences taking sick leave due to PGP, and examine whether pregnant women with PGP, who have been sub-grouped on the basis of two clinical tests, differ with regards to demographic characteristics and/or the clinical course of PGP during the second half of their pregnancy. Methods The thesis consists of three papers, based on two separate data collections at Stavanger University Hospital. Paper I and II originate from a retrospective cohort study conducted in 2009, in which women giving birth at Stavanger University hospital in a 4-month period were asked to fill in a questionnaire on demographic features, pain, disability, PGP, pain-related activities of daily living, sick leave in general and for PGP, frequency of exercising before and during pregnancy, and Oswestry Disability Index. Inclusion criteria were singleton pregnancy of at least 36 weeks and competence in the Norwegian language. Drawings of the pelvic and low back area were used for the localization of pain. PGP intensity was then rated retrospectively on a numerical rating scale. Non-parametric tests, multinomial logistic regression and sequential linear regression analysis were used in the statistical analysis. Paper III originate from a prospective longitudinal cohort study carried out in 2010. Inclusion criteria were the as for the retrospective data collection and took place at the second-trimester routine ultrasound examination. All eligible women (n=503) filled in questionnaires and answered a weekly SMS question during pregnancy until delivery. Women with pain in the pelvic area underwent a clinical examination following a test procedure recommended in the European guidelines for the diagnosis and treatment of PGP. Results Paper I report that nearly 50% of the women experienced moderate and severe PGP during pregnancy. Approximately half of them had PGP syndrome, whereas the other half experienced lumbopelvic pain. Ten percent of the women experienced moderate and severe LBP alone. These pain syndromes increased sick leave and impaired general level of function during pregnancy. Approximately 50% of women with PGP had pain in the area of the symphysis pubis. The analysis of risk factors did not present a unidirectional and clear picture. In Paper II PGP is reported to be a frequent and major cause of sick leave during pregnancy among Norwegian women, which is also reflected in activities of daily living as measured with scores on all Oswestry disability index items. In the multivariate analysis of factors related to sick leave and PGP were work satisfaction, problems with lifting and sleeping, and pain intensity risk factors for sick leave. Also, women with longer education, higher work satisfaction and fewer problems with sitting, walking, and standing, were less likely to take sick leave in pregnancy, despite the same pain intensity as women being on sick leave. In Paper III, 42% (212/503) reported pain in the lumbopelvic region and 39% (196/503) fulfilled the criteria for a probable PGP diagnosis. 27% (137/503) reported both the posterior pelvic pain provocation (P4) and the active straight leg raise (ASLR) tests positive at baseline in week 18, revealing 7.55 (95% CI 5.54 to 10.29) times higher mean number of days with bothersome pelvic pain compared with women with both tests negative. They presented the highest scores for workload, depressed mood, pain level, body mass index, Oswestry Disability Index and the number of previous pregnancies. Exercising regularly before and during pregnancy was more common in women with negative tests. Conclusions Pelvic pain in pregnancy is a health care challenge in which moderate and severe pain develops rather early and has important implications for society. The observed associations between possible causative factors and moderate and severe LBP and PGP in the analysis of the retrospective data may, together with results from other studies, bring some valuable insights into their multifactorial influences and provide background information for future studies. Some pregnant women with PGP show a higher pain tolerance, most likely dependant on education, associated with work situation and/or work posture, which decreases sick leave. These issues are recommended to be further examined in a prospective longitudinal study since they may have important implications for sick leave frequency during pregnancy. If both P4 and ASLR tests were positive mid-pregnancy, a persistent bothersome pelvic pain of more than 5 days per week throughout the remainder of pregnancy could be predicted. Increased individual control over work situation and an active lifestyle, including regular exercise before and during pregnancy, may serve as a PGP prophylactic.
... A combination of hormonal and biomechanical aspects, inadequate motor control, and stress on ligament structures are the most common hypotheses behind the development of PGP. 1,6 In the physical therapy management of PGP, a couple of the important structures are the bony pelvis and the myofascial system of the anterior abdominal wall, mainly the separation of the pubic symphysis and diastasis recti abdominis (DRA). It is essential to distinguish PGP-related pubic symphysis pain from peripartum diastasis of the pubic symphysis, characterized by the separation of the pubic bones above the physiological range (>1 cm 7 ). ...
Article
Objective Pregnancy-related pelvic girdle pain (PGP) may persist or occur postpartum and negatively affects women’s lives. There is uncertainty regarding the association between the structures of the bony pelvis, diastasis recti abdominis (DRA), pain processing, and PGP and to what extent these factors should be considered during physical therapy. This study aimed to evaluate the differences between women with and without PGP shortly after delivery regarding the separation of a pubic symphysis, DRA, and pain catastrophizing. Methods Women diagnosed with PGP 24 to 72 hours after vaginal delivery were matched to pain-free controls according to age and parity. Ultrasound evaluations of diastasis recti (interrecti distance) during rest and curl-up task and pubic symphysis (interpubic width) were performed. The Pain Catastrophizing Scale was used to assess the level of catastrophizing. A special Cox regression model was used to fit a conditional logistic regression for a 2-to-1 matched case–control study. Results Thirty-five women with clinically diagnosed PGP and 70 matched controls were included in the study. The PGP group had a significantly higher pre-pregnancy body mass index than the control group. After adjusting for body mass index in multiple conditional logistic regression, the interpubic distance (odds ratio [OR] = 1.64; 95% CI = 1.22-2.20) and interrecti distance during curl-up (OR = 2.01; 95% CI = 1.08-3.74) were significantly associated with PGP. Pain catastrophizing and interrecti distance at rest were not associated with PGP in univariable or multivariable analysis. Conclusions Pain catastrophizing is similar for women with and without PGP early postpartum. However, the degree of the pubic symphysis and rectus abdominis separation during the curl-up task are positively associated with PGP shortly after delivery.
... La neuroplasticité du système nerveux central face à la douleur (pour revue, voir [41]) est donc un facteur qui doit être pris en compte dans la résolution des problématiques musculosquelettiques. Par exemple, pour « démystifier » l'interprétation que fait le patient de sa douleur (e.g. lombalgie [42]), il est recommandé d'utiliser des stratégies dites « cognitives » basées sur la compréhension de la physiopathologie de la douleur [43] ou l'imagerie motrice pour préparer le mouvement [44]. De plus, bien que les mécanismes spinaux et corticaux sous-jacents ne soient pas identifiés, il est aussi bien connu que le renforcement musculaire unilatéral a des effets bilatéraux ; c'est ce que l'on appelle la « cross education » [45]. ...
Article
Les effets de la douleur sur le mouvement ont été largement décrits dans la littérature. Ces travaux convergent vers la conclusion que le contrôle du mouvement est altéré par la douleur. Le mouvement s’adapterait pour réduire la contrainte dans le tissu douloureux, et ce, pour diminuer la douleur et/ou protéger ce tissu. Bien que logique, cette hypothèse n’avait jusqu’à présent jamais été testée. L’analyse de la littérature révèle que bien que la diminution de la contrainte dans le tissu douloureux soit certainement l’objectif des adaptations motrices, cet objectif n’est pas systématiquement atteint. Au-delà de cette finalité biomécanique, les adaptations dépendent du contexte psycho-social de l’individu, expliquant en partie la variabilité interindividuelle des adaptations observées. Finalement, nous rapportons des résultats récents suggérant qu’au-delà des effets bénéfiques à court terme, les adaptations motrices peuvent avoir des conséquences négatives à long terme.
... Once the diagnosis and characteristics of the dysfunction have been identified, management strategies specific to each patient's needs may be applied. 90,[94][95][96] Clinical examinations schema is based on the location of initial pain onset. Using this information, the clinician selects the primary area for examination: (1) sacroiliac joint and pelvic ring; (2) pelvic floor; (3) thoracolumbar and lumbar spine region; (4) coccyx; (5) hip region to include the groin, buttock, and greater trochanteric areas; or (6) suprapubic/abdominal region (Appendix S1). ...
Article
Chronic pelvic pain is defined as the presence of pain in the pelvic girdle region for over a 6-month period and can arise from the gynecologic, urologic, gastrointestinal, and musculoskeletal systems. As 15% of women experience pelvic pain at some time in their lives with yearly direct medical costs estimated at $2.8 billion, effective evaluation and management strategies of this condition are necessary. This merits a thorough discussion of a systematic approach to the evaluation of chronic pelvic pain conditions, including a careful history-taking and clinical examination. The challenge of accurately diagnosing chronic pelvic pain resides in the degree of peripheral and central sensitization of the nervous system associated with the chronicity of the symptoms, as well as the potential influence of the affective and biopsychosocial factors on symptom development as persistence. Once the musculoskeletal origin of the symptoms is identified, a clinical examination schema that is based on the location of primary onset of symptoms (lumbosacral, coccygeal, sacroiliac, pelvic floor, groin or abdominal region) can be followed to establish a basis for managing the specific pain generator(s) and manage tissue dysfunction.
... With the exception of five case studies, physical therapy treatment of patients diagnosed with SIJ pain via injection or Laslett's cluster of pain provocation tests has not been documented in the literature (Ensor, 2016;George, Clinton, and Borello-France, 2013;Horton and Franz, 2007;Jonely, Brismée, Desai, and Reoli, 2015;O'Sullivan and Beales, 2007). In 2013, a randomized control trial investigated the effects of exercise and manual therapy in patients with SIJ pain (Visser et al, 2013). ...
Article
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Sacroiliac joint (SIJ) pain has been identified as a primary or contributing source of pain in patients with low back pain. The Laslett cluster of SIJ pain provocation tests has the strongest evidence for noninvasive clinical testing. The purpose of this report was to describe the impact of physical therapy treatments for a patient postpartum with SIJ pain who satisfied the Laslett cluster. Specifically, the goal was to assess the impact of progressive pelvic floor muscle exercise and manual therapy. The Modified Oswestry Low Back Pain Disability Questionnaire (MODI) was the primary outcome measure used in this case. In addition, the Numeric Pain Rating Scale (NRPS) and Global Rating of Change (GROC) were used as secondary outcome measures. In this case report, the patient responded to the combined interventions with decreases in MODI, NRPS and GROC. Further research is warranted to develop stronger evidence to identify specific interventions for the treatment of SIJ pain.
... Different strategies are required to provide varying degrees of pressure across the joint surfaces. Excessive, or insufficient, pressure across the SIJ can be identified as causes of deficient function and provide diagnostic clues (Vleeming et al., 1990b;Pool-Goudzwaard et al., 1998;Mens et al., 1999;Hungerford et al., 2003;O'Sullivan and Beales, 2007;Willard, 2007). ...
Article
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The sacroiliac joint (SIJ) is an integral part of both the lumbar spine and the pelvic girdle. It is frequently the source of low back pain and pelvic girdle pain. Recent research has permitted a deeper understanding of its function and assessment. The mechanical assessment of the SIJ as a transmitter of load between trunk and lower limbs, and as a means to absorb torsion stresses of the pelvis absorber of torsion is examined; history, clinical examination and imaging modalities are explored and the role of exercise and some interventional therapies are described in general terms.
... After delivery, severe pain and disability remain in 3-7% of women [1,3,4]. Although the aetiology of PGP is unknown, possible underlying mechanisms are hormonal, biomechanical, inadequate motor control and stress on ligament structures [5]. PGP is regarded as pathological when a woman needs professional help to cope with her daily life activities and it is suggested that PGP deserves serious attention from both clinical and research perspectives [3]. ...
Article
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Background The aim of this study was to explore how pelvic girdle pain after delivery influences women’s daily life in Norway. Knowledge about living with post-partum pelvic girdle pain is lacking. Method A phenomenological–hermeneutical design with qualitative semi-structured interviews was used. A strategic selection procedure was chosen to recruit participants from physiotherapy clinics and a regional hospital in Norway. Five women with clinically verified pelvic girdle pain after delivery were included. Data were imported into NVivo9 and analysed in three steps: naïve reading, structural analysis and comprehensive understanding of the text. Results Three themes influencing the women’s daily life were identified: 1) activity and pain, 2) lack of acknowledgment of pain and disability, and 3) changed roles. A daily life with pain and limited physical activity was difficult to accept and made some of the women feel discouraged, isolated and lonely. Despite this, the women had a positive attitude to their problems, which may have positively increased their ability to cope. The findings also revealed the importance of a reciprocal influence between the woman and her environment, and that social support was crucial. Conclusions Pelvic girdle pain may influence women’s lives for months and years after delivery. Health care professionals should appreciate and focus on the patient’s knowledge and skills. Understanding the daily experiences of women with pelvic girdle pain might help improve rehabilitation strategies for these patients.
Article
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Pregnancy related pelvic pain (PRPP) refers to musculoskeletal type of persistent posterior pelvic pain during and after pregnancy with feature of reduced endurance capacity for standing, walking and sitting which leads to severe discomfort and considerable impairment of daily activities. To test the effect of pressure biofeedback stabilizer training, on the pain and dysfunction of a thirty year old subject who presented with PRPP. Single case design. Oswestry pain and disability index, TrA efficacy. An initial assessment was followed by treatment sessions which consist of 2 phases (Phase A & Phase B). The baseline phase (A) consists of conventional therapeutic exercises while the intervention phase (B) consists of pressure biofeedback training in conjunction with the conventional therapeutic exercises. The study data demonstrated that the subject showed minimal improvement in pain, disability and TrA efficacy during the baseline phase and shown a steady improvement in all these variables during the intervention phase. Core muscle performance (TrA) can be retrained with pressure biofeedback stabilization training program in subject with PRPP thereby reducing pain and disability.
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Background: Non-specific chronic low back pain disorders have been proven resistant to change, and there is still a lack of clear evidence for one specific treatment intervention being superior to another. Methods: This randomized controlled trial aimed to investigate the efficacy of a behavioural approach to management, classification-based cognitive functional therapy, compared with traditional manual therapy and exercise. Linear mixed models were used to estimate the group differences in treatment effects. Primary outcomes at 12-month follow-up were Oswestry Disability Index and pain intensity, measured with numeric rating scale. Inclusion criteria were as follows: age between 18 and 65 years, diagnosed with non-specific chronic low back pain for >3 months, localized pain from T12 to gluteal folds, provoked with postures, movement and activities. Oswestry Disability Index had to be >14% and pain intensity last 14 days >2/10. A total of 121 patients were randomized to either classification-based cognitive functional therapy group n = 62) or manual therapy and exercise group (n > = 59). Results: The classification-based cognitive functional therapy group displayed significantly superior outcomes to the manual therapy and exercise group, both statistically (p < 0.001) and clinically. For Oswestry Disability Index, the classification-based cognitive functional therapy group improved by 13.7 points, and the manual therapy and exercise group by 5.5 points. For pain intensity, the classification-based cognitive functional therapy improved by 3.2 points, and the manual therapy and exercise group by 1.5 points. Conclusions: The classification-based cognitive functional therapy produced superior outcomes for non-specific chronic low back pain compared with traditional manual therapy and exercise.
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Hintergrund Die Befundlage zu Risikofaktoren für einen günstigen/ungünstigen Verlauf operationalisiert über schmerzbezogene Parameter nach einem multimodalen Behandlungsprogramm, das in seiner Wirksamkeit als empirisch gut belegt gelten kann, ist uneinheitlich. Die klinische und praktische Relevanz hingegen ist hoch. In der vorliegenden Arbeit soll anhand einer Stichprobe aus dem Behandlungsalltag dieser nachgegangen werden. Material und Methode Insgesamt nahmen 681 Patienten an einem multimodalen Programm zur Behandlung von chronischen Rückenschmerzen teil. Davon nahmen 320 Patienten außerdem an einer Nachbefragung nach 12 Monaten teil. Vor dem Programm, direkt danach und 12 Monate später erhielten die Teilnehmer einen umfassenden Fragebogen zum Schmerzerleben, zu Symptomen von Angst und Depression sowie zur Arbeitssituation. Anhand einer regressionsanalytischen Auswertung sollen Prädiktoren für einen Therapieerfolg in den Parametern Schmerzintensität, Beeinträchtigung und Funktionskapazität bestimmt werden. Ergebnisse Insgesamt ist die Varianzaufklärung der gerechneten Modelle im unteren Bereich. Entscheidend für einen Therapieerfolg in einzelnen Parametern sind neben schmerzbezogenen Variablen das Ausmaß der Depressivität und der Body-Mass-Index (BMI).
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Musculoskeletal disorders are prevalent and a major burden on individuals and society. Information on relationships of patient involvement and responsibility to outcome is limited. This study aimed to explore relationships between self-reported outcome of physiotherapy treatment and attitudes toward responsibility for musculoskeletal disorders. A cross-sectional postal survey design was used. Patients (n=615) from an outpatient physiotherapy clinic, who had finished their physiotherapy treatment within the last 6 months were sent a questionnaire that included the Attitudes regarding Responsibility for Musculoskeletal disorders instrument (ARM), self-reported outcome of treatment and sociodemographic data. A total of 279 (45%) completed forms were returned. Multiple logistic regression analysis was used. The patients' scores on the four dimensions of ARM ("responsibility self active," "responsibility out of my hands," "responsibility employer," and "responsibility medical professionals"), controlled for age, sex, education, and physical activity as well as for number of treatments, main treatment, and physiotherapist, were associated with the patients' self-reported treatment outcome. Patients who attributed responsibility more to themselves were more likely (OR 2.37 and over) to report considerable improvement as the outcome of physiotherapy treatment. Because this study was conducted at only one physiotherapy outpatient clinic and had a cross-sectional design, the results should be replicated in other settings. Because patients' attitudes regarding responsibility for musculoskeletal disorders can possibly affect the outcome of physiotherapy treatment, it might be useful to decide whether to systematically try to influence the person's attitude toward responsibility for the management of the disorder or to match treatment to attitude.
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Many clinicians and researchers believe that there are subgroups of people with spinal pain who respond differently to treatment and have different prognoses. There has been considerable interest in this topic recently. However, problems occur when conclusions about subgroups are made that are inappropriate given the randomized controlled trial design used. The research design to choose, when developing a study protocol that investigates the effect of treatment subgroups, depends on the particular research question. Similarly, the inferences that can be drawn from an existing study will vary, depending on the design of the trial. This paper discusses the randomized controlled trial designs that are suitable to answer particular questions about treatment subgroups. It focuses on trial designs that are suitable to answer four questions: (1) 'Is the treatment effective in a pre-specified group of patients?'; (2) 'Are outcomes of treatment applied using a subgrouping clinical reasoning process, better than a control treatment?'; (3) 'Are the outcomes for a patient subgroup receiving a particular treatment (compared to a control treatment) better than for patients not in the subgroup who receive the same treatment?'; and (4) 'Are outcomes for a number of treatments better if those treatments are matched to patients in specific subgroups, than if the SAME treatments are randomly given to patients?'. Illustrative examples of these studies are provided. If the clinical usefulness of targeting treatments to subgroups of people is to be determined, an important step is a shared understanding of what different RCT designs can tell us about subgroups.
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A sub-group of pelvic girdle pain (PGP) patients with a positive active straight leg raise (ASLR) responds positively to the application of external pelvic compression during the test. This study investigated the effect of this phenomenon on electromyographic (EMG) activity of the trunk muscles and intra-abdominal and intra-thoracic pressures in subjects with a unilateral sacroiliac joint (SIJ) pain disorder (n=12). All subjects reported reduced difficulty ratings during an ASLR with pelvic compression (paired t-test: p<0.001), yet no statistically significant changes in the muscle activation or pressure variables were found. However, visual inspection of the data revealed two divergent motor control strategies with the addition of compression. Seven subjects displayed characteristics of a decreased EMG profile, while in the other five subjects the EMG profile appeared to increase. As such this study provides preliminary evidence of two disparate patterns of motor control in response to the addition of pelvic compression to an ASLR. The findings may reflect different mechanisms, not only in the response to pelvic compression, but also of the underlying PGP disorder.
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Repeated measures. To investigate motor control (MC) patterns in chronic pelvic girdle pain (PGP) subjects during an active straight leg raise (ASLR). The ASLR is a test used to assess load transference through the pelvis. Altered MC patterns have been reported in subjects with chronic PGP during this test. These patterns may impede efficient load transfer, while having the potential to impinge on respiratory function and/or to adversely affect the control of continence. Twelve female subjects with chronic PGP were examined. Electromyography of the anterior abdominal wall, right chest wall and the scalene, intraabdominal pressure, intrathoracic pressure, respiratory rate, pelvic floor kinematics, and downward leg pressure of the nonlifted leg were compared between an ASLR lifting the leg on the affected side of the body versus the nonaffected side. Performing an ASLR lifting the leg on the affected side of the body resulted in a predominant MC pattern of bracing through the abdominal wall and the chest wall. This was associated with increased baseline shift in intraabdominal pressure and depression of the pelvic floor when compared with an ASLR lifting the leg on the nonaffected side. This MC pattern, identified during an ASLR on the affected side of the body, has the potential to be a primary mechanism driving ongoing pain and disability in chronic PGP subjects.
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There is a lack of studies examining whether mechanism-based classification systems (CS) acknowledging biological, psychological and social dimensions of long-lasting low back pain (LBP) disorders can be performed in a reliable manner. The purpose of this paper was to examine the inter-tester reliability of clinicians' ability to independently classify patients with non-specific LBP (NSLBP), utilising a mechanism-based classification method. Twenty-six patients with NSLBP underwent an interview and full physical examination by four different physiotherapists. Percentage agreement and Kappa coefficients were calculated for six different levels of decision making. For levels 1-4, percentage agreement had a mean of 96% (range 75-100%). For the primary direction of provocation Kappa and percentage agreement had a mean between the four testers of 0.82 (range 0.66-0.90) and 86% (range 73-92%) respectively. At the final decision making level, the scores for detecting psychosocial influence gave a mean Kappa coefficient of 0.65 (range 0.57-0.74) and 87% (range 85-92%). The findings suggest that the inter-tester reliability of the system is moderate to substantial for a range of patients within the NSLBP population in line with previous research.
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Diverse views exist regarding the underlying nature of nonspecific low back pain (NSLBP). This study aimed to (i) develop a conceptual framework of NSLBP based on the expressed beliefs of those who treat and/or research NSLBP and (ii) determine whether these beliefs are discretely clustered and whether they are associated with participant characteristics. Surveys were completed by participants (n=162) of the 2006 Amsterdam International Low Back Pain Forum and a low back pain meeting (n=488) in Melbourne. Respondents reported beliefs regarding the nature of NSLBP. Probabilistic data-mining was used to detect 'clusters of belief' and between group differences were tested using Mann-Whitney U tests. Overall, there was an 84% response rate. Diverse beliefs were reported but multiple 'clusters of belief' to explain this diversity were not apparent. Whether predominantly engaged in clinical or research activity, people expressed similar beliefs, except that clinicians placed greater value on measures of physical impairment. There were conflicting views within the clinical and research community regarding the underlying nature of NSLBP. Within the constructs sampled, no unifying framework could explain the diversity of current beliefs. This is likely to reflect pervasive uncertainty about the etiology, and therefore best practice assessment, of NSLBP.
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An experimental study of respiratory function and kinematics of the diaphragm and pelvic floor in subjects with a clinical diagnosis of sacroiliac joint pain and in a comparable pain-free subject group was conducted. To gain insight into the motor control strategies of subjects with sacroiliac joint pain and the resultant effect on breathing pattern. The active straight-leg-raise test has been proposed as a clinical test for the assessment of load transfer through the pelvis. Clinical observations show that patients with sacroiliac joint pain have suboptimal motor control strategies and alterations in respiratory function when performing low-load tasks such as an active straight leg raise. In this study, 13 participants with a clinical diagnosis of sacroiliac joint pain and 13 matched control subjects in the supine resting position were tested with the active straight leg raise and the active straight leg raise with manual compression through the ilia. Respiratory patterns were recorded using spirometry, and minute ventilation was calculated. Diaphragmatic excursion and pelvic floor descent were measured using ultrasonography. The participants with sacroiliac joint pain exhibited increased minute ventilation, decreased diaphragmatic excursion, and increased pelvic floor descent, as compared with pain-free subjects. Considerable variation was observed in respiratory patterns. Enhancement of pelvis stability via manual compression through the ilia reversed these differences. The study findings formally identified altered motor control strategies and alterations of respiratory function in subjects with sacroiliac joint pain. The changes observed appear to represent a compensatory strategy of the neuromuscular system to enhance force closure of the pelvis where stability has been compromised by injury.
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The work presented in this thesis examines whether a more prominent role of functional anatomy within multidisciplinary treatment of non-specific chronic low back pain (NCLBP) will increase its therapeutic effect. The multidisciplinary treatment of NCLBP is based on the biopsychosocial (BPS) model. This model is derived from systems theory and was introduced by Engel in 1977 to replace the traditional biomedical model. Fundamental to the BPS model is that not only biological but also psychological and social aspects are included in the aetiology of diseases, such as chronic back pain. However, in the ongoing development of new diagnostic and therapeutic techniques based on this BPS model, the behavioural aspects prevailed whilst the physical aspects (especially physical exercises) lagged behind. Consequently, in contemporary multidisciplinary treatment protocols, physical training is subordinate and mainly in service of the desired modification of behaviour. Recent studies of multidisciplinary programmes for NCLBP show that the results of these predominantly psychological, behaviourorientated treatments are far from optimal. Therefore, the question arose as to how multidisciplinary treatment can be improved. One option for improvement is to intensify the application of functional anatomical knowledge and incorporate corresponding specific training within existing multidisciplinary programmes. Functional anatomical research has made significant progress in the last decade; this has led to new knowledge on spine function and, consequently, to the development of new physical exercises. In the context of multidisciplinary treatment of NCLBP patients, and based on the new functional anatomical knowledge, the aim of this thesis was to address the following questions: 1. Taking into account the available recent data on functional anatomy, is there a need to reconsider the role of the physical domain within the BPS model? 2. Will a more pronounced role of functional anatomy in the BPS model contribute to better diagnosis? 3. Will functional anatomy applied in the BPS model contribute to improved therapy?
Article
For a small but significant group, pregnancy-related lumbopelvic pain may become persistent. While multiple factors may contribute to disability in this group, previous studies have not investigated sleep impairments, body perception or mindfulness as potential factors associated with disability post-partum. To compare women experiencing no pain post-pregnancy with those experiencing pregnancy-related persistent lumbopelvic pain (either low- or high-level disability) across multiple biopsychosocial domains. Cross-sectional. Participants completed questionnaires for thorough profiling of factors thought to be important in pregnancy-related lumbopelvic pain. Specific measures were the Urinary Distress Inventory, Medical Outcomes Study Sleep Scale, Back Beliefs Questionnaire, Tampa Scale for Kinesiophobia, Depression Anxiety Stress Scale, Coping Strategies Questionnaire, Pain Catastrophising Scale, The Fremantle Back Awareness Questionnaire and the Mindful Attention Awareness Scale. Women where categorised into three groups; pain free (n = 26), mild disability (n = 12) and moderate disability (n = 12) (based on Oswestry Disability Index scores). Non-parametric group comparisons were used to compare groups across the profiling variables. Differences were identified for kinesiophobia (p = 0.03), body perception (p = 0.02), sleep quantity (p < 0.01) and sleep adequacy (p = 0.02). Generally subjects in the moderate disability group had more negative findings for these variables. Disturbances in body-perception, sleep and elevated kinesiophobia were found in pregnancy-related lumbopelvic pain subjects with moderate disability, factors previously linked to persistent low back pain. The cross-sectional nature of this study does not allow for identification of directional pathways between factors. The results support the consideration of these factors in the assessment and management of pregnancy-related lumbopelvic pain. Copyright © 2015 Elsevier Ltd. All rights reserved.
Article
Pelvic girdle pain (PGP) is frequently managed by physiotherapists. Little is known about current physiotherapy practice and beliefs in the management of PGP disorders. The primary aim of this study was to investigate current practice and beliefs in management of PGP among physiotherapists working in Norway and Australia. A secondary aim was to compare current practice with clinical guidelines. A questionnaire was developed and electronically distributed to physiotherapists in Norway (n=65) and Australia (n=77). Treatment and management were determined via responses to 2 case vignettes (during pregnancy, not related to pregnancy), with participants selecting their four primary preferences for treatment and management from a list of 33 possibilities. During pregnancy, ‘education around instability’ and ‘soft tissue treatment’ were selected amongst the most common interventions by physiotherapists in both countries. Norwegian physiotherapists selected ‘pelvic floor exercises’ more frequently, while Australian physiotherapists more commonly selected ‘correcting functional impairments’. In the other case, common responses from both countries were ‘hip strengthening in weight bearing’ and ‘correction of functional impairments’. Norwegian physiotherapists selected ‘general physical exercise’ and ‘general education’ more frequently, while Australian physiotherapists more commonly selected ‘hip strengthening in non-weight bearing’ and ‘muscular relaxation of the abdominal wall/pelvic floor’. Beliefs about PGP were generally positive in both groups while knowledge of and adherence to clinical guidelines were limited. The findings provide direction for future research related to the management and treatment of PGP, and targets for education of physiotherapists working in this area.
Article
Background: The Pelvic Girdle Questionnaire (PGQ) is a condition-specific measure for women with pelvic girdle pain (PGP). The PGQ includes items relating to activity/participation and bodily symptoms and has reliability, validity, and feasibility for use in research and clinical practice. Objective: The purpose of this study is to examine the responsiveness and to determine the minimal important change (MIC) of the PGQ and to compare the PGQ with other outcome measures. Design: This study used a prospective cohort design. Methods: There were 801 women who responded to a booklet of questionnaires in the last trimester of their pregnancy and within 3 months post partum. Responsiveness analyses followed recommendations from The COnsensus-based standards for the selection of health measurement instruments (COSMIN) checklist. The responsiveness of the PGQ was tested by examining correlation between the change scores of the PGQ total and the other patient-reported outcome measures. Results: A total of 606 women (76%) reported PGP, low back pain (LBP), or both. Of these women, 441 (73%) responded to the follow-up questionnaire post partum. The PGQ (both subscales and total score) discriminated most accurately between improved and non-improved participants with an area of 72% under the receiver operator characteristic (ROC) curve. The MIC values indicated that a change score smaller than 25 for total score and activity subscale and a change score of 20 for the symptom subscale should be regarded as insignificant. The baseline PGQ score had a large impact on the MIC estimates for the absolute change scores but not on the relative percentage change scores. Five out of 6 hypotheses were supported (83%). Limitations: The type of anchor and definition of important change used might be a weakness in women who are changing from pregnant to postpartum status. Conclusions: The PGQ showed acceptable responsiveness in women with PGP, LBP, or both.
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RÉSUMÉ - La douleur pelvienne chronique est un problème en pelvi-périnéologie, qui semble toucher la femme plus que l´homme. Elle est définie par «The American College of Obstetricians and Gynecologists» comme une douleur localisée au niveau de l'abdomen au-dessous de l'ombilic, ainsi que dans les régions pelvienne, lombo-sacrale et fessière, durant depuis au moins 6 mois, qui n'est ni cyclique, ni associée à une lésion organique. Les diagnostics souvent posés sont l'endométriose, le syndrome vésical douloureux (cystite interstitielle), la prostatite chronique, ainsi que les syndromes du muscle élévateur de l'anus et du colon, ou de l'intestin irritable. Le syndrome myofascial pelvien douloureux est caractérisé par une hypertonie musculaire associée à des cordons myalgiques et à des points trigger myofasciaux et se manifeste par une douleur des muscles du plancher pelvien, du périnée et des fascias pelviens voisins. Les points trigger myofasciaux peuvent se développer dans tous les muscles du corps humain, y compris au niveau de la région pelvienne. Ils semblent ici engendrer des sensations référées au niveau de la vessie, de la prostate, du vagin, du rectum, du coccyx, du sacrum, de toute la région pelvienne, du bas du dos, du bas de l'abdomen et de la région postérieure de la cuisse. ABSTRACT - Chronic pelvic pain is a problem in perineology, which seems to affect women more than men. It is defined by "The American College of Obstetricians and Gynecologists" as pain localized in the abdomen below the umbilicus, as well as in the pelvic, lumbosacral, and gluteal regions, lasting for at least 6 months, which is neither cyclic nor associated with an organic lesion. Common diagnoses include endometriosis, painful bladder syndrome (interstitial cystitis), chronic prostatitis, and anal and colonic elevator muscle or irritable bowel syndromes. Painful pelvic myofascial syndrome is characterized by muscle hypertonicity associated with myalgic cords and myofascial trigger points and manifests as pain in the pelvic floor muscles, perineum, and surrounding pelvic fascias. Myofascial trigger points can develop in all muscles of the human body, including the pelvic region. Here they appear to generate referred sensations in the bladder, prostate, vagina, rectum, coccyx, sacrum, entire pelvic region, lower back, lower abdomen, and posterior thigh region.
Article
Objectives: Improvements in pain management might be achieved by matching treatment to underlying mechanisms for pain persistence. Many authors argue for a mechanism-based classification of pain, but the field is challenged by wide variation in proposed terminology, definitions and typical characteristics. This study aimed to: (i) systematically review mechanism-based classifications of pain experienced in the musculoskeletal system; (ii) synthesise and thematically analyse classifications, using the International Association for the Study of Pain categories of nociceptive, neuropathic and nociplastic as an initial foundation; and (iii) identify convergence and divergence between categories, terminology, and descriptions of each mechanism-based pain classification. Methods: Databases were searched for papers that discussed a mechanism-based classification of pain experienced in the musculoskeletal system. Terminology, definitions, underlying neurobiology/pathophysiology, aggravating/easing factors/response to treatment, and pain characteristics were extracted and synthesised based on thematic analysis. Results: From 224 papers, 174 terms referred to pain mechanisms categories. Data synthesis agreed with broad classification based on ongoing nociceptive input, neuropathic mechanisms, and nociplastic mechanisms (e.g. central sensitisation). “Mixed”, “other”, and the disputed categories of “sympathetic” and “psychogenic” pain, were also identified. Thematic analysis revealed convergence and divergence of opinion regarding definitions, underlying neurobiology and characteristics. Discussion: Some pain categories were defined consistently, and despite the extensive efforts to develop global consensus on pain definitions, disagreement still exists regarding how each could be defined, subdivided and their characteristic features that could aid differentiation. These data form a foundation for reaching consensus on classification.
Article
Introduction Clinicians need support to effectively implement a biopsychosocial approach to people with pelvic girdle pain disorders. Purpose A practical clinical framework aligned with a contemporary biopsychosocial approach is provided to help guide clinician's management of pelvic girdle pain. This approach is consistent with current pain science which helps to explain potential mechanistic links with co/multi-morbid conditions related to pelvic girdle pain. Further, this approach also aligns with the Common-Sense Model of Illness and provides insight into how an individual's illness perceptions can influence their emotional and behavioural response to their pain disorder. Communication is critical to supporting recovery and facilitating behavior change within the biopsychosocial context and in this context, the patient interview is central to exploring the multidimensional nature of a persons' presentation. Focusing the biopsychosocial framework on targeted cognitive-functional therapy as a key component of care can help an individual with pelvic girdle pain make sense of their pain, build confidence and self-efficacy and facilitate positive behaviour and lifestyle change. There is growing evidence of the efficacy for this broader integrative approach, although large scale effectiveness trials are still needed. An in-depth case study provides guidance for clinicians, showing ‘how to’ implement these concepts into their own practice within a coherent practical framework. Implications This framework can give clinicians more confidence in understanding and managing pelvic girdle pain. The framework provides practical strategies to assist clinicians with implementation; assisting the transition from knowing to doing in an evidence-informed manner that resonates with real world practice.
Article
It is estimated that 10–30% of all low back pain is attributed to the sacroiliac joints. There are many challenges to diagnosing and treating the sacroiliac joints. Central to this challenge is determining whether the sacroiliac joint is the primary source of pain or dysfunction. This paper considers the complexities of diagnosis and management of sacroiliac joint dysfunction by providing a best evidence informed overview of the mechanics of the sacroiliac joint, the aetiology of sacroiliac joint dysfunction and the most current diagnostic strategies and management options for dysfunctions of these joints from a biopsychosocial perspective. This comprehensive chapter aims to shed light on the challenges of managing sport and exercise-related sacroiliac joint pain, and in so doing highlight the paucity of high quality research investigation of the joint, and the clinical uncertainty that is an unavoidable feature of addressing dysfunction of this joint.
Chapter
Pregnancy and childbirth bring along several changes to a woman’s body, especially to the musculoskeletal system. Pregnancy represents a window of opportunity for the adoption of an active and healthy lifestyle, but it is also a risk period for musculoskeletal disorders, impairments, and other discomforts. This chapter addresses the evidence-based knowledge on the most prevalent pelvic floor muscle dysfunction (urinary incontinence), diastasis recti abdominis, pregnancy-related low back pain, and/or pelvic girdle pain, since these factors are reported to have a negative effect on daily activities. The chapter also provides recommendations for treatment of such disorders and guidance on how to recover functional capacity.
Article
Endometriosis-associated pelvic pain is a common and often challenging problem. For certain patients, pain persists or recurs despite adequate medical or surgical therapy targeted to endometriosis. In this patient population, there is often the presence of coexisting pain conditions such as irritable bowel syndrome, painful bladder syndrome and myofascial pain as well central sensitisation. An interdisciplinary approach where both peripheral pain triggers and central sensitization are addressed is likely to lead to improved pain and quality of life. The approach to the evaluation and treatment of the patients with persistent/chronic pelvic pain and endometriosis is outlined in this article.
Article
Objective: To present a case study and discuss the role of an orthopaedic medicine approach (OMA) to clinical diagnosis and treatment of sacroiliac joint (SIJ) disorder in the light of recent research evidence. Case study: A 38-year-old female suffering from pain over the SIJ and right buttock was diagnosed to have an SIJ disorder using an orthopaedic medicine assessment. She was managed by a multi-disciplinary treatment approach in which improvement coincided with the addition of manipulation. The patient showed an improvement in the numerical pain rating scale from 6 to 0 and the revised Oswestry back disability score reduced from 25 to 3% at discharge. Discussion: Latest research evidence suggests that a composite of tests is more valid and reliable in the diagnosis of SIJ dysfunction than individual tests. Conclusion: The OMA may be improved by the use of a composite of tests for the diagnosis of SIJ disorder. © The Society of Orthopaedic Medicine and the British Institute of Musculoskeletal Medicine 2011.
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Background: To examine the association among pelvic girdle pain (PGP), urinary incontinence (UI) and pelvic floor muscle (PFM) function in pregnant women in second and third trimester. Methods: 300 pregnant women who admitted for standard pregnancy care were enrolled in the study. Urinary incontinency was measured via the international consultation on incontinence questionnaire short form. Pelvic girdle pain was diagnosed according to existing guidelines. Vaginal examination assessed pelvic muscles contract- relax patterns and muscle strength. The software stata version 13 (Stata Corp., TX, USA) was used for data analysis. Results: Overall 300 women (150 with PGP and 150 without PGP) were included in final analyses. There was not significant differences between the demographic data including, body mass index before pregnancy, maternal age, mode of delivery. Prevalence of urinary incontinence in women with pelvic girdle pain was 41.5 percent (CI 95%: 32.01- 51.48) while the prevalence of urinary incontinence in women without pain was 21.9 percent (CI 95%: 14.99-30.03). Using logistic regression, the relationship between urinary incontinence and pelvic girdle pain was significant. (CI 95%: 1.07-3.31, P=0.02). Multivariate logistic regression analysis was used to evaluate the relationship between PGP and pelvic floor muscle function and results showed that pelvic floor muscle strength in women with PGP was significantly lower than women without PGP. (CI 95%: 0.24-0.68, OR= 0.4, P
Article
Objective: Little is known about how static standing balance changes post total knee arthroplasty (TKA). The primary aim of this study was to examine the sensitivity to change and redundancy of center of pressure (COP) variables post-TKA. The secondary aim was to compare the sensitivity of these measures to standard clinical assessments of one repetition maximum knee extension strength and fast pace gait speed. Design: 466 participants performed instrumented double-limb standing balance tests with eyes open at four and 12 weeks post-TKA. Measures of COP standard deviation, amplitude, root mean square, path length, detrended fluctuation analysis (DFA) and signal frequency content for the medial-lateral (ML) and anterior-posterior (AP) axes were examined. Results: Significant decreases in total path length, ML variables related to sway velocity and AP signal complexity and frequency were observed. Inter-session Cohen's d effect size (ES) revealed the strongest effect was for high velocity ML path length, with a 12% decrease in this rapid sway. This variable, along with AP mean instantaneous frequency and AP DFA, were the only ones significantly different with effect sizes >0.20 and non-redundant (Spearman's rho <0.75). The ES of COP-derived variables (maximum = 0.45) were lower than gait speed (1.40) and knee extensor strength (1.54). Conclusion: Increased high velocity ML sway is present at four compared to 12 weeks post-TKA. This augmented rapid sway may provide increased challenges to the postural control system at a time coinciding with reduced strength levels, which could have implications for physical function during activities of daily living.
Chapter
Musculoskeletal pain is a common occurrence in pregnancy and postpartum. Pelvic girdle pain (PGP) is now a well-recognized entity that is prevalent in 20 % of women during pregnancy and after delivery and is known to occur by itself or in association with low back pain (LBP). This can seriously impact the quality of life of women and have socioeconomic impact from loss of days from work. Symptomatic treatment, relative rest, avoidance of maladaptive movements, and an individually tailored physical therapy program are the treatment strategies that have been shown to be marginally effective. Lack of timely diagnosis and interventions has been associated with increased risk of having prolonged labor, instrumental and operative delivery which may further increase the chances of having PGP in the postpartum period in addition to increasing the risks for the baby. The management options particularly nonsurgical interventions are underutilized due to lack of comprehensive knowledge on approach and fear of inducing risks to the unborn fetus by healthcare professionals. In this chapter, we discuss the treatment approach and the efficacy and safety of the nonsurgical interventional procedures in the management of lumbopelvic pain in pregnancy and postpartum period based on existing evidence in literature and our personal experience.
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De bekendste vorm van lagerug- en bekkenpijn is die bij vrouwen tijdens de zwangerschap (prepartum) en na de bevalling (postpartum) op. In verband met internationale consensus ten aanzien van een eenduidige naamstelling, praten we tegenwoordig over ‘pelvic girdle pain’ (PGP) of ‘pregnancy-related pelvic girdle pain’ (PPGP). Voor dit laatste bestaat de Nederlandse term: zwangerschapsgerelateerde lagerug- en bekkenpijn (ZLBP). Hiermee worden pijnklachten van het bekken bedoeld en dus valt ook bekkenbodempijn onder deze benaming. Eerdere, onvolledige benamingen voor deze klachten waren: bekkeninstabiliteit, peripartum pelvic pain (PPPP), peripartum bekkenpijnsyndroom of symfysiolyse. Vroeger sprak men ook wel van zwangerschapshernia of zwangerschapsischias (Bastiaenen, 2004).
Article
BACKGROUND: Walking is often impaired in pregnancy-related pelvic girdle pain (PPP), but the precise pathogenesis remains poorly understood. OBJECTIVE: To better understand the walking velocity, gait and changes in movement coordination in patients with PPP and to explore its underlying mechanism of movement pathology. METHODS: The gait kinematics of 12 healthy pregnant women and 12 pregnant women with PPP were compared, focusing on the amplitudes of transverse pelvic, lumbar, and thoracic segmental rotations, the timing and relative phase of these rotations, and the amplitude of spinal rotations. RESULTS AND CONCLUSION: The walking velocity of pregnant women with PPP was lower than that of the controls, and negatively correlated with fear of movement. While patients' amplitudes were larger in transverse pelvic, lumbar, and thoracic segmental rotations, and there were large inter-individual differences. The spinal rotations did not differ between groups. In the patients, peak thorax rotation occurred earlier in the stride cycle at higher velocities, and relative phase was lower, probably to avoid excessive rotational torque in the sacroiliac joints and the spine.
Book
Providing clinicians with a comprehensive, evidence-based summary of musculoskeletal health in pregnancy and postpartum, this is the first book of its kind to describe the physiologic changes, prevalence, etiology, diagnostic strategies, and effective treatments for the most common musculoskeletal clinical conditions encountered during this phase of life. Lumbopelvic pain, upper and lower extremity diagnoses, labor and delivery considerations, including the impact on the pelvic floor, and medical therapeutics will be discussed. Additionally, the importance and influence of exercise in pregnancy, the long-term implications of musculoskeletal health in pregnancy and current and future directions for research will be addressed. The childbearing period is a time of remarkable reproductive and musculoskeletal change, predisposing women to potential injury, pain, and resultant disability. Musculoskeletal Health in Pregnancy and Postpartum offers musculoskeletal medicine specialists, obstetricians and any clinicians involved in the care of pregnant or postpartum women the tools necessary to prepare for, treat and prevent these concurrent injuries during an already challenging time. http://www.springer.com/us/book/9783319143187
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Objective signs to assess impairment in patients who are disabled by peripartum pelvic girdle pain hardly exist. The purpose of this study was to develop a clinical test to quantify and qualify disability in these patients. The study examined the relationship between impaired active straight leg raising (ASLR) and mobility of pelvic joints in patients with peripartum pelvic girdle pain, focusing on (1) the reduction of impairment of ASLR when the patient was wearing a pelvic belt, and (2) motions between the pubic bones measured by X-ray examination when the patient was standing on one leg, alternating left and right. Twenty-one non-pregnant patients with peripartum pelvic girdle pain in whom pain and impairment of ASLR were mainly located on one side were selected. ASLR was performed in the supine position, first without a pelvic belt and then with a belt. The influence of the belt on the ability to actively raise the leg was assessed by the patient. Mobility of the pelvic joints was radiographically visualized by means of the Chamberlain method. Assessment was blinded. Ability to perform ASLR was improved by a pelvic belt in 20 of the 21 patients (binomial two-tailed P = 0.0000). When the patient was standing on one leg, alternating the symptomatic side and the reference side, a significant difference between the two sides was observed with respect to the size of the radiographically visualized steps between the pubic bones (binomial two-tailed P = 0.01). The step at the symptomatic side was on average larger when the leg at that side was hanging down than when the patient was standing on the leg at that side. Impairment of ASLR correlates strongly with mobility of the pelvic joints in patients with peripartum pelvic girdle pain. The ASLR test could be a suitable instrument to quantify and qualify disability in diseases related to mobility of the pelvic joints. Further studies are needed to assess the relationship with clinical parameters, sensitivity, specificity and responsiveness in various categories of patients. In contrast with the opinion of Chamberlain, that a radiographically visualized step between the pubic bones is caused by cranial shift of the pubic bone at the side of the standing leg, it is concluded that the step is caused by caudal shift of the pubic bone at the side of the leg hanging down. The caudal shift is caused by an anterior rotation of the hip bone about a horizontal axis near the sacroiliac joint.
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The questionnaire is divided into ten sections selected from a series of experimental questionnaires designed to assess limitations of various activities of daily living. The chosen sections were those found to be most relevant to the problems suffered by people with low back pain. Each section contains six statements. A study of 25 patients with primary low back pain has already been mentioned. Their symptoms tended to resolve quickly and changes in their mean disability score can be seen over the first three weeks after referral to the spinal disorders department. The disability score was also used to demonstrate that there was no difference in the severity of symptoms in two sub-groups of patients in the same study. All new patients referred to the department complete the questionnaire when they first attend. The disability score is used as a guide to a patient's treatment programme. It cannot be used in isolation since it makes no allowance for the demands of a patient's job, his age or psychological make-up. However, it does ensure that important aspects of disability which are often forgotten are recorded in the patient's notes. Later, changes in the score may be used in monitoring the subsequent progress of the patient through treatment.
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The management of peripheral neuropathic pain or nerve trunk pain relies upon accurate differential diagnosis. In part neurogenic pain has been attributed to increased activity in, as well as to abnormal processing of non-nociceptive input from, the nervi nervorum. For neurogenic pain to be identified as the dominant feature of a painful condition there should be evidence of increased nerve trunk mechanosensitivity from all aspects of the physical examination procedure. Consistent dysfunction should be identified on key active and passive movements, neural tissue provocation tests as well as nerve trunk palpation. A local cause for the neurogenic pain disorder should also be identified if the condition is to be treated by manual therapy. A treatment approach is presented which has been shown to have efficacy in the relief of pain and restoration of function in cervicobrachial pain disorders where there is evidence according to the outlined examination protocol of nerve trunk pain.
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A normative, single-group study was conducted. To determine whether there is a difference in electromyographic activation of specific lumbopelvic muscles with the adoption of common postures in a pain-free population. Clinical observations indicate that adopting passive postures such as sway standing and slump sitting can exacerbate pain in individuals with low back pain. These individuals often present with poor activation of the lumbopelvic stabilizing musculature. At this writing, little empirical evidence exists to document that function of the trunk and lumbopelvic musculature are related to the adoption of standardized standing and sitting postures. This study included 20 healthy adults, with equal representation of the genders. Surface electromyography was used to measure activity in the superficial lumbar multifidus, internal oblique, rectus abdominis, external oblique, and thoracic erector spinae muscles for four standardized standing and sitting postures. The internal oblique, superficial lumbar multifidus, and thoracic erector spinae muscles showed a significant decrease in activity during sway standing (P = 0.027, P = 0.002, and P = 0.003, respectively) and slump sitting (P = 0.007, P = 0.012, and P = 0.003, respectively), as compared with erect postures. Rectus abdominis activity increased significantly in sway standing, as compared with erect standing (P = 0.005). The findings show that the lumbopelvic stabilizing musculature is active in maintaining optimally aligned, erect postures, and that these muscles are less active during the adoption of passive postures. The results of this study lend credence to the practice of postural retraining when facilitation of the lumbopelvic stabilizing musculature is indicated in the management of specific spinal pain conditions.
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Research suggests that clinical examination of the lumbar spine and pelvis is unable to predict the results of diagnostic injections used as reference standards. The purpose of this study was to assess the diagnostic accuracy of a clinical examination in identifying symptomatic and asymptomatic sacroiliac joints using double diagnostic injections as the reference standard. In a blinded concurrent criterion-related validity design study, 48 patients with chronic lumbopelvic pain referred for diagnostic spinal injection procedures were examined using a specific clinical examination and received diagnostic intraarticular sacroiliac joint injections. The centralisation and peripheralisation phenomena were used to identify possible discogenic pain and the results from provocation sacroiliac joint tests were used as part of the clinical reasoning process. Eleven patients had sacroiliac joint pain confirmed by double diagnostic injection. Ten of the 11 sacroiliac joint patients met clinical examination criteria for having sacroiliac joint pain. In the primary subset analysis of 34 patients, sensitivity, specificity and positive likelihood ratio (95% confidence intervals) of the clinical evaluation were 91% (62 to 98), 83% (68 to 96) and 6.97(2.70 to 20.27) respectively. The diagnostic accuracy of the clinical examination and clinical reasoning process was superior to the sacroiliac joint pain provocation tests alone. A specific clinical examination and reasoning process can differentiate between symptomatic and asymptomatic sacroiliac joints
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This study was a case series design. The objectives of the study were to investigate the ability of a motor learning intervention to change aberrant pelvic floor and diaphragm kinematics and respiratory patterns observed in subjects with sacroiliac joint pain (SIJP) during the active straight leg raise (ASLR) test. The ASLR test is a valid and reliable tool to assist in the assessment of load transference through the pelvis. Irregular respiratory patterns, decreased diaphragmatic excursion and descent of the pelvic floor have been reported in subjects with SIJP during this test. To date the ability to alter these patterns has not been determined. Respiratory patterns, kinematics of the diaphragm and pelvic floor during the ASLR test and the ability to consciously elevate the pelvic floor in conjunction with changes in pain and disability levels were assessed in nine subjects with a clinical diagnosis of SIJP. Each subject then undertook an individualized motor learning intervention. The initial variables were then reassessed. Results showed that abnormal kinematics of the diaphragm and pelvic floor during the ASLR improved following intervention. Respiratory patterns were also influenced in a positive manner. An inability to consciously elevate the pelvic floor pre-treatment was reversed. These changes were associated with improvement in pain and disability scores. This study provides preliminary evidence that aberrant motor control strategies in subjects with SIJP during the ASLR can be enhanced with a motor learning intervention. Positive changes in motor control were associated with improvements in pain and disability. Randomized controlled research is required to validate these results.
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The Tampa scale for kinesiophobia (TSK) was developed to measure fear of movement/(re)injury in chronic pain patients. Although studies of the Dutch adaptation of the TSK have identified fear of movement/(re)injury as an important predictor of chronic pain, pain-related avoidance behaviour, and disability, surprisingly little data on the psychometric properties of the original English version of the TSK are available. The present study examined the reliability, construct validity and factor structure of the TSK in a sample of chronic pain patients (n=200) presenting for an interdisciplinary functional restoration program. Consistent with prior evaluations of the Dutch version of the TSK, the present findings indicate that the English TSK possesses a high degree of internal consistency and is positively associated with related measures of fear-avoidance beliefs, pain catastrophizing, pain-related disability and general negative affect. The TSK was not related to individual differences in physical performance testing as assessed using standardised treadmill and lifting tasks. Confirmatory factor analyses suggest that the TSK is best characterized by a three-factor trait method model that includes all 17 of the original scale items and takes into account the distinction between positively and negatively keyed items. The results of the present study provide important details regarding the psychometric properties of the original English version of the TSK and suggest that it may be unnecessary to remove the negatively keyed items in an attempt to improve scale validity.
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The diagnosis and classification of pelvic girdle pain (PGP) disorders remains controversial despite a proliferation of research into this field. The majority of PGP disorders have no identified pathoanatomical basis leaving a management vacuum. Diagnostic and treatment paradigms for PGP disorders exist although many of these approaches have limited validity and are uni-dimensional (i.e. biomechanical) in nature. Furthermore single approaches for the management of PGP fail to benefit all. This highlights the possibility that ‘non-specific’ PGP disorders are represented by a number of sub-groups with different underlying pain mechanisms rather than a single entity.
Understanding pain for better clinical perspective: a psychological perspective
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