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Diagnosis and classification of pelvic girdle pain disorders - Part 1: A mechanism based approach within a biopsychosocial framework
Abstract
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.
... It also has signs and symptoms indicating pain originating from the Sacro-Iliac Joint (SIJ) and surrounding soft structures such as connective tissue and myofascial. The pain or discomfort must be reproducible by clinical tests [1][2][3] . ...
... It affects the endurance capacity of walking, standing and sitting 1 . Many theories suggest that there could be an underlying reason for SIJ getting "displaced" or "fixated" and ending up in "positional faults" 3 . PGP can be classified into two type's Specific PGP and Non-Specific PGP. ...
... Non-specific pelvic girdle pain has no identified pathoanatomical basis. It may occur due to factors such as hormonal, and biomechanical aspects, inadequate motor control and ligament stress, and increased shear force on pelvic joints and it can also arise during pregnancy or postdelivery 1,3 . ...
Background: Pelvic Girdle Pain (PGP) is a musculoskeletal pain that arises between the posterior iliac crest and gluteal fold, at the sacroiliac joint and also radiates posteriorly in the thigh. PGP give rise to very intense pain and disability than Low Back Ache (LBA). It is a common condition during pregnancy and post-delivery. Joint laxity increases pelvic rotation and lumbar lordosis which results in adaptive hip extensor muscle weakness. Hence the studies focus on identifying the lumbar lordosis and hip extensor strength of PGP. Aim of the Study: To identify the association between lumbar lordosis and PGP and to identify the association between hip extensor strength and PGP among post-partum women. Material and Methodology: Based on inclusion and exclusion criteria a total of 80 postpartum women were assessed based on the diagnostic criteria the women were divided into two groups. Group A consists of women with PGP and group B consists of women without PGP. Both groups were assessed for lumbar lordosis using flexicurve and hip extensor strength using a manual muscle tester. Data collected was analyzed using. Outcome Measure: Flexicurve to assess lumbar lordosis. Manual muscle tester to assess hip extensor strength. Result: The study showed that the mean lumbar lordosis was significantly higher in women with PGP than in women without PGP, p = 0.001. There was a 15.46° ± 6.91° higher angle observed in persons who had pelvic girdle pain compared to those who did not have pelvic girdle pain. The mean hip extensor strength for group ‘A’ (average of right and left side) was 12.74 ± 0.73kg, whereas it was significantly higher in group ‘B’. Conclusion: The study concludes that there is a positive association between lumbar lordosis and hip extensor weakness in pelvic girdle pain.
... 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]. ...
... Biomechanical factors in combination with hormonal factors are proposed as the most plausible hypothesis [3,7,52]. ...
... Hormones may be involved in several different factors related to PGP, including modulation of pain and collagen synthesis, as well as inflammatory processes [19,52]. During pregnancy, the gonadal hormones enhance pain sensitivity directly, potentially by modulating the responses of primary afferents on neurons of the dorsal horn and at supraspinal locations [63] and indirectly through their influence on emotional status [68]. ...
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.
... [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] ...
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.
... The etiology for PPGP is unclear yet understood to be multifactorial. The most cited contributors to PPGP to date are biomechanical and hormonal [1,4,5]. Recent evidence has shown no correlation between PPGP and pelvic floor muscle weakness [6], yet there is an association between PPGP and pelvic floor tenderness [7]. ...
... Recent evidence has shown no correlation between PPGP and pelvic floor muscle weakness [6], yet there is an association between PPGP and pelvic floor tenderness [7]. Of note, central pain mechanisms are emerging as important drivers of PPGP [3,5,8]. The psychosocial impacts of PPGP are well documented [5]. ...
... Of note, central pain mechanisms are emerging as important drivers of PPGP [3,5,8]. The psychosocial impacts of PPGP are well documented [5]. These issues are closely tied to physical limitations as these women find it difficult to work, sleep, and undertake normal activities [9]. ...
Purpose is cross-sectional survey investigated how Ontario private practice physiotherapists (PTs) who participated in the study, make clinical decisions about pregnancy-related pelvic girdle pain (PPGP) and also evaluated di erences between pelvic health and orthopaedic PTs in their knowledge of PPGP clinical practice guidelines (CPGs).
Methods: An electronic survey was developed and distributed to private practice PTs recruited via physiotherapy associations and organizations. It included questions about management strategies, best practices, and perspectives on CPGs.
Results: Seventy-eight individuals responded, 44 were included in the study (31 pelvic health, 13 orthopaedic). Pelvic health PTs had increased awareness regarding CPGs compared to orthopaedic PTs (74% vs. 38.5%, p<0.05), selected correct pain terminology (77% vs. 38%, p<0.05), and correctly found age as non-risk for PPGP (68% vs. 31%, p<0.05). is did not translate to clinical practice, as both groups selected management strategies incongruent with PPGP CPGs.
Conclusion: e ndings demonstrate that awareness of PPGP CPGs does not transfer into clinical practice, as participants selected treatment strategies that were incongruent with the current PPGP CPGs.
... Higher scores represent a higher disability and '0' represents 'no disability' on 24 items RMQ 19 . For convenience, we categorized the RMQ scores as mild (1)(2)(3)(4)(5)(6)(7)(8), moderate (9)(10)(11)(12)(13)(14)(15), and severe (> 15) disability. ...
... This corroborates with the literature suggesting that a score of > 25 on PSS-10 depicts a higher stress level 32 . The interplay of psychological factors in CLPP can potentially elevate pain and functional disability 10,66 . Further, in certain societies like India, women face misogyny which compromises their psychological health [67][68][69] . ...
Chronic lumbopelvic pain (CLPP) and its associated disabilities significantly affect women's social, professional, and personal lives. However, the specific factors contributing to CLPP in women remain unclear. To address this gap, this prospective cross-sectional study aims to identify the risk factors predicting CLPP in women and develop a prediction model that can predict CLPP in women. The study was conducted across Delhi, India, where free health camps were held, and 2400 women were assessed. Among the assessed individuals, the study revealed a high prevalence rate of CLPP among Indian women, standing at 70.4%. Seven risk factors namely, hamstring muscle tightness (> 20° on passive knee extension test), increased lumbar lordosis (> 11.5 cm of the lumbar lordotic index), reduced hip flexibility (> 15 cm on bent knee fallout test), altered foot posture (≥ 20 on foot posture index score), increased perception of psychological stress (> 25 on cohen’s perceived stress scale-10 score), reduced physical activity level (< 475 metabolic/minute on international physical activity questionnaire) and reduced performance of transversus abdominis muscle (≤ 5 on deep muscle contraction scale score) strongly predict the risks of CLPP in women. Identifying these risk factors is crucial for effectively preventing and managing CLPP symptoms, especially considering its high prevalence among Indian women. Health professionals should prioritize raising awareness about CLPP and its causative factors, as well as implementing strategies for early detection and intervention.
... A total of 33 relevant publications were identified. Of these, 22 were publications proposing an original classification system [5,6,[9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28]] and 11 presented additional information such as refinements or adaptations of a system that had already been identified [2,[29][30][31][32][33][34][35][36][37][38]. ...
... In some literature 'persistent pain' is defined as a 'constant or frequent pain lasting at least 3 months' [48], which could be synonymous with either of the terms 'continuous/constant' or 'recurrent/intermittent/episodic/cyclic' that are used in other systems. Another issue concerning the temporal dimension of CPP arises in classification systems that encompass acute pelvic pain conditions (e.g., classification of benign diseases associated with prostatic pain [14] and prostatitis syndromes [34][35][36] and classification of pelvic girdle pain disorders [27]), where the criteria to distinguish between 'acute' and 'chronic' are not clearly defined. It would seem critical for systems to unambiguously define terms related to duration and frequency. ...
Objective
To systematically review the classification systems for male chronic pelvic pain (CPP).
Methods
The Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), and Web of Science were searched. Any publication, with no restriction to publication date, was eligible. Publications had to propose a classification system for CPP in males or provide additional information of a system that had been identified. Systems were assessed with an adapted Critical Appraisal of Classification Systems tool.
Results
A total of 33 relevant publications were identified, with 22 proposing an original classification system. Systems aimed to: (i) diagnose CPP and/or differentially diagnose CPP from other conditions, (ii) differentially diagnose subtypes within CPP, or (iii) identify features that could inform underlying mechanisms and/or treatment selection. Conditions referred to as chronic prostatitis/chronic pelvic pain syndrome and interstitial cystitis/bladder pain syndrome were most represented. Clinical signs/symptoms, pathoanatomical investigations, and presumed pain mechanisms were used for classification. Quality of systems was low to moderate, implying limitations to consider for their interpretation.
Conclusions
Many classification systems for CPP in males exist. Careful consideration of their intended purpose is required. Future work should examine whether outcomes for patients are improved when decisions are guided by their use.
... Inevitably, any deviation in pelvic position, regardless of the plane in which it occurs, can potentially compromise sports performance, and increase the likelihood of injury [15][16][17][18][19][20][21][22]. Anterior pelvic tilt decreases both the upper and lower parts of rectus abdominis EMG activity while over-activating the rectus femoris, as opposed to the neutrally positioned or posteriorly tilted pelvis [15]. ...
... Anterior pelvic tilt decreases both the upper and lower parts of rectus abdominis EMG activity while over-activating the rectus femoris, as opposed to the neutrally positioned or posteriorly tilted pelvis [15]. This muscular imbalance, combined with imbalances between other antagonistic muscle groups of the core (e.g., trunk and hip extensors), may compromise the natural lumbar lordotic curve, promoting an unbalanced distribution of forces both locally and globally and the development of musculoskeletal pain syndromes (e.g., low back and sacroiliac joint pain) [16][17][18][19]. Excessive anterior tilt has also been associated with an increased likelihood of hamstring [20], anterior cruciate ligament injuries [21], and patellofemoral pain [22]. ...
Female athletes subjected to various types of impact loading, especially over a long period of time, may experience changes in their pelvic orientation, which may affect their sport performance and increase the likelihood of injury. The aim of the present study was to determine whether female athletes involved in high-impact loading sports (HILS), odd-impact loading sports (OILS), and repetitive non-impact loading sports (NILS) demonstrate changes in pelvis orientation compared to non-athletes (NATH). Pelvic orientation was determined using Euler/Cardan angles, calculated from the coordinates of the right, and left anterior superior iliac spines and pubic symphysis via a novel method. Two-way ANOVA tests showed significant differences between groups for pelvis position in the frontal plane (p < 0.05), with HILS and OILS demonstrating greater pelvic obliquity compared to NILS athletes and NATH. Significant main effects were also obtained for directions within the sagittal plane (p < 0.001). Significant within-group differences were observed in sagittal pelvic position among female athletes engaged in NILS (p < 0.01) and non-athletes (NATH) (p < 0.05), with a greater anterior pelvic tilt compared to posterior. Our findings suggest that pelvis orientation in female athletes across sports is influenced by sport-specific impact loads, potentially affecting performance and injury occurrence.
... The increased weight of the uterus puts pressure on the pelvic area, initiating the excessive stretching of the muscles, ligaments, and joints around the pelvic area [5,6]. Increased relaxin generates joint weakness as well [7,8]. ...
... The weight gain due to pregnancy can trigger compression and strain towards the spine and fibrous tissue and cartilage around the pelvis [5,6]. The SIJ in humans act as a support for the shear forces on the pelvis, and in quadrupeds, the SIJ is subjected more to bending forces [27]. ...
As the pregnancy progresses, the pressure on the sacroiliac joint/SIJ increases and causes pain. Chondrocytes will release prostaglandin E2 (PGE2) on cartilage traumatized tissue. Hypothetically, swimming is beneficial for training buoyancy and mechanical loading training towards cartilage. This study aimed to investigate the effect of swimming on downturns plasma and PGE2 expression in SIJ tissue of pregnant rats. This study was an experimental study involving thirty-six female rats that were grouped into six groups. The swimming training was performed two days for the adaptation process and nine days for core swim training with 60 minutes. Afterward, PGE2 plasma was collected from the lateral vein of the rat eyes before and after treatment. The SIJ cartilage was collected from pregnant rats at 20 days of pregnancy. PGE2 plasma levels in pregnant rats before treatment had higher levels than non-pregnant rats. The swim training provided a significant difference in plasma levels and PGE2 expression on SIJ in all groups (p 0,000). Our study provides evidence that pregnancy can increase PGE2 expression in the fibrous and cartilage tissues of the sacroiliac joint, which can be treated by effective swim training that downturns plasma and expression of PGE2 in SIJ of the pregnant rats.
... Nous vous souhaitons une bonne lecture, qui nous l´espérons, vous aidera à potentialiser votre traitement des patients souffrant d´un Syndrome Myofascial Douloureux. Généralités 113 A r t T h e m a © t m n o A r t T h e m a © t m n o 167 A r t T h e m a © t m n o 167 170 A r t T h e m a © t m n o 170 171 A r t T h e m a © t m n o 171 172 A r t T h e m a © t m n o 172 176 A r t T h e m a © t m n o 176 182 A r t T h e m a © t m n o 182 186 A r t T h e m a © t m n o 186 191 A r t T h e m a © t m n o 191 210 A r t T h e m a © t m n o A r t T h e m a © t m n o 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 PTrM peuvent se développer dans tous les muscles du corps humain, y compris au niveau de la région pelvienne. ...
... [158] A r t T h e m a © t m n o [158] Mo A r t T h e m a © t m n o 14 (7):959-967. [165] A r t T h e m a © t m n o [165] Ne A r t T h e m a © t m n o [167] A r t T h e m a © t m n o ...
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.
... In recent years, a cognitive behavioral approach and self-management strategies have been proposed for women with PGP [29]. In the above-described context, it seems valuable to take a closer look into the lifestyle factors of women suffering from 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. ...
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.
... This shift can be seen when comparing the PPGP clinical practice recommendations published in 2008 [17], to those published in 2017 [13]. Emotional distress, depression, anxiety, and stress perception, are considered strong prognostic indicators of ongoing disability in PPGP [6,8,18]. These psychological health indicators mark a three-fold risk of developing postpartum depression [7], and also demonstrate high correlations with disability and fear of movement [19], including avoidance of future pregnancies [20]. ...
... The significance of patients' beliefs and perceptions about their pain and their pain experience has been well demonstrated across a wide spectrum of orthopedic conditions including in the antepartum population. 18 Perception of pain has also been linked to the development of persistence [19,21]. Our study did not evaluate assessment but did evaluate management perspectives. ...
Background: Pregnancy-related pelvic girdle pain (PPGP) represents a common condition with implications for persistence. Currently, a practice gap appears to exist related to the assessment and management of pregnancy-related PGP. This study explored Irish physiotherapists' perspectives of PPGP. Methods: A survey from previous Canadian research was adapted and used to determine Irish physiotherapist's perspectives regarding PPGP. Women's health physiotherapists, private and public sector, were invited to complete an electronic survey. Results: Sixty of the 122 invited physiotherapists completed the survey for a response rate of 49%. Of these, 98% agreed that relevant health care providers need to be able to recognize a PPGP presentation, and 80% believed PPGP to be a complex clinical presentation requiring early detection and associated care. The vast majority of perspectives related to etiology and treatment focused on musculoskeletal influences, however addressing fear (84%) and employing pain neuroscience education (82%) were also indicated to be very important. Conclusion: Pregnancy-related PGP is a distinct presentation of PGP impacting women in the perinatal period and beyond differs in etiology due to perinatal and associated bio psychosocial influences. Irish physiotherapists perceive a number of important evolving psychosocial characteristics of PPGP, however unsubstantiated strong perspectives related to biomechanics and pelvic stability were also found. Knowledge translation efforts to support the provision of evidence-informed care are needed.
... Bjelland et al. 3) suggested that the presence of emotional distress during pregnancy was independently associated with the persistence of PGP after delivery. Although emotional aspects are considered as a risk factor for persistent PGP, there is no doubt that the sacroiliac joint can be a source of LBP or pelvic pain and the theory that PGP can be caused by pelvic instability has been supported by several studies [4][5][6] . Pelvic instability refers to a failure of the pelvic load transfer mechanism due to excessive pelvic joint movement. ...
... Pelvic instability refers to a failure of the pelvic load transfer mechanism due to excessive pelvic joint movement. Indeed, pelvic load transfer is supported by well-coordinated neuromuscular and articular systems known as the form-and force-closure model of these joints 6) . Thus, bony and muscular mechanisms directly influence the prognosis of PGP more than emotional and other factors. ...
[Purpose] The aim of this literature review was to detect the factors associated with pelvic girdle pain persisting for over 3 months in the postpartum period. [Methods] We performed a broad literature search for eligible studies published before May 1, 2018 using electronic databases and processed the data using a review process. [Results] In the initial online search, we identified 12,174 potential studies. Finally, 22 studies met the specified criteria and were included for examination of risk factors for persistent pelvic girdle pain after delivery. Pain intensity and disability during pregnancy were risk factors for pelvic girdle pain persisting for over 6 months after delivery. The active straight leg raising test predicted the risk of persistent pelvic girdle pain after delivery. Dysfunction of the pelvic floor muscles was also a risk factor for persistent pelvic girdle pain. [Conclusion] Pain intensity and disability during pregnancy, positive provocation tests, active straight leg raising test, and musculoskeletal mechanics were positively associated with pelvic girdle pain persisting for over 3 months after delivery.
... Passive treatment options include acupuncture, manual therapy and pelvic belts [3]. More active treatment options include specific exercises [4], exercises with strategies to either increase or decrease muscle activation [5], as well as more general exercises such as hydrotherapy. Specific education related to PGP is also an important aspect of physiotherapy [5]. ...
... More active treatment options include specific exercises [4], exercises with strategies to either increase or decrease muscle activation [5], as well as more general exercises such as hydrotherapy. Specific education related to PGP is also an important aspect of physiotherapy [5]. Although multiple treatment options are available, evidence supporting specific forms of intervention for PGP remains limited [6]. ...
... The concept of testing the deep muscles and Gross muscles could be rationalized by the following evidence. [22][23][24] The distortions of the pelvis as observed in SJD might occur secondary to the changes in pelvis and trunk muscle activity which might lead to directional strain and not positional changes within the sacroiliac joint. 22 Such secondary changes mentioned in the pelvis and trunk muscle activity imply study of the LS and GS of the sacroiliac joint. ...
... [22][23][24] The distortions of the pelvis as observed in SJD might occur secondary to the changes in pelvis and trunk muscle activity which might lead to directional strain and not positional changes within the sacroiliac joint. 22 Such secondary changes mentioned in the pelvis and trunk muscle activity imply study of the LS and GS of the sacroiliac joint. Secondly, a study conducted using Doppler imaging of vibrations to examine laxity on the sacroiliac joint reported that the voluntary unilateral contractions of relevant muscles of the pelvis resulted in reduced mobility of the sacroiliac joint on the ipsilateral side 23 . ...
Background and objective:
Altered Pattern of the Global Muscle system is presented in literature among individuals with sacroiliac Joint Dysfunctions. However, the pattern of changes in the Latissimus dorsi (LD) and gluteal maximus (GM) among sacroiliac joint dysfunctions (SIJD) is not reported. This study aimed to investigate the changes in the resting muscle thickness of the Latissimusdorsi and gluteal maximus in SIJD.
Method:
A total of 88 subjects (44 individuals with SIJD and 44 healthy individuals as matched control) was included in this study. The resting thickness of the Latissimusdorsi and gluteal maximus was measured using real time musculoskeletal ultrasonography and data was compared between the ipsilateral side and contra lateral side among subjects with SIJD as well as healthy subjects. Independent sample t test was used to analyze the data by using SPSS version-25.
Results:
The results showed that contralateral LD were reduced significantly among subjects with SIJD when compared with the other side and with control. It also showed that ipsilateral IO, TrA and GM were reduced significantly among subjects with SIJD when compared with the controls and with contralateral side.
Conclusion:
The reduced resting muscle thickness showed an altered motor pattern of Deep Muscles of local system and Gross muscles of global system among patients with sacroiliac joint dysfunction.
... As indicated in this study and confirmed in previous studies, most pregnant women benefit from exercise since it increases pain tolerance, improves or maintains physical fitness, helps with weight management, reduces the risk of gestational diabetes in obese women, and enhances psychologic well-being. [24][25][26][27] Limitations A limitation in this study is the retrospectively collected information on pain in previous pregnancies and pain before pregnancy, which may produce biased results. Another limitation was found in the data collection via the SMS-track system. ...
... Since sufficient force closure of the sacroiliac-joints requires appropriate muscular, ligamentous and fascial interaction, may women with pelvic pain in previous pregnancies have experienced that exercising improves muscle activation, recovers function and decreases pain. [24][25][26] Additionally, experiences of pain prevention and rehabilitation in previous pregnancies may work as an incitement to engage in physical activity and regular exercising, both before and during pregnancy. Our analysis also revealed a significant difference between test groups in women described feeling depressed, and that a pre-pregnancy BMI slightly higher than average had a significant impact on the mean number of bothersome days. ...
... Evidence has shown an alteration in motor control in pregnant women [3] and more recently, central pain mechanisms have been considered and implicated [4][5][6][7]. As such, to appropriately address the complexity of pregnancy-related PGP, physiotherapists and others must both acknowledge and part with common yet unsubstantiated beliefs surrounding the concept of "pelvic instability" [8]. Instead, current advances in pain science support the notion that pregnancy-related PGP represents sensitization of the structures of the pelvis [4][5][6][7]. ...
... Instead, current advances in pain science support the notion that pregnancy-related PGP represents sensitization of the structures of the pelvis [4][5][6][7]. Thus, attention must move away from biomechanics and engage the multiple underlying mechanisms such as the stress system (HPA axis) and associated coping, inflammatory load, status of the gut microbiome and sleep quality to name a few [5][6][7][8][9]. Despite the evidence supporting the need for a biopsychosocial perspective, recent research demonstrates that when it comes to pregnancy-related PGP, physiotherapists continue to preferentially use a biomechanical approach [9,10]. ...
... Many mechanisms have been proposed to explain PPGP, such as (1) form and force closure, which implies that both the geometric fit of the sacro-iliac joint surfaces as well as the muscles and ligaments around it keep the pelvis robust, (Kiapour et al., 2020;Pool-Goudzwaard et al., 1998), (2) load transfer, meaning the way forces and pressures are distributed through the pelvis during various movements (Snijders et al., 1993;Vleeming et al., 2008), (3) asymmetric sacroiliac joint laxity (Damen et al., 2001), (4) hormonal laxity (Aldabe et al., 2012), (5) weight gain (de Sousa et al., 2019) and (6) motor control deficits, which refers to the coordination and regulation of muscular activity for movement (Beales et al., 2010(Beales et al., , 2009de Groot et al., 2008;van Benten et al., 2022). Calls to abandon these unidimensional biomechanical explanations as the foundation for treatment approaches for PPGP are increasing (Meijer et al., 2020b(Meijer et al., , 2020aO'Sullivan and Beales, 2007). Instead, there are appeals to embrace the multifactorial contributions to PPGP, such as contextual factors, neurobiological aspects and the health and illness perceptions that people have of PPGP (Beales et al., 2020). ...
... In addition, the higher prevalence of SIJD observed in women agrees with previous studies [30][31][32] that have described the influence of hormonal factors on the higher prevalence of SIJ pain in women. In this regard, the peak in the production of estrogen and relaxin during the luteal phase of the menstrual cycle is considered to decrease the intrinsic strength and rigidity of collagen, which makes ligaments become laxer [34], altering their stabilizing capacity in joints [30], predisposing to the appearance of joint symptoms such as SIJD. ...
BACKGROUND: Sacroiliac Joint Dysfunction (SIJD) may be observed in 13% to 30% people with idiopathic low back pain (LBP). Latissimus dorsi (LD) muscle works by stabilizing the SIJ, providing a pathway for force transmission through the thoraco lumbar fascia. Literature has shown that muscles can change their activation pattern in response to pain, altering motor control. However, to date, there have been no studies evaluating the EMG activity of LD in people with SIJD while lifting a load, this could guide for a better understanding about how muscle activation occurs in this group of patients. AIM: To evaluate and compare activation of LD in people with LBP, SIJD and without LBP in load lifting. METHODS: One hundred fourteen people were evaluated and divided into 3 groups: LBP, SIJD and Control group. EMG signals were recorded from LD while the subjects lifted a load in a symmetrical posture. Subjects started in an upright position, grasped the box from the floor and returned to the initial position with flexed elbows. Root Mean Square (RMS) amplitude and latency were calculated. The Kruskal-Wallis and the post hoc Dunn’s tests were used to compare groups. RESULTS: Results showed that left LD in SIJD group is activated 26.21% more than in the control group and 23.98% than the LBP group (p = 0.02). Besides, right LD has a delayed onset in SIJD by 0.68 ms compare with the control group and 0.29 ms with LBP group (p = 0.03). CONCLUSION: In a specific group of individuals with SIJD, alterations in LD muscle activation, could be evidenced by an increased RMS amplitude which is accompanied with a delay in activation in the opposite side during lifting a load in a symmetrical posture.
... Pain in the posterior sacrum or the buttocks, of varying degrees, is how pelvic girdle pain manifests [52]. In most cases, it is related to recent pregnancies or pain that began while pregnant [53]. Around 1-16% of women experience pain beyond a year after giving birth [54]. ...
Chronic pelvic pain (CPP) is explained as a complaint of cyclic or non-cyclic pelvic pain lasting for at least six months with or without dysmenorrhea, dyspareunia, dysuria, and dyschezia. The etiology of symptoms can be categorized according to organ system involvement. Gynecological causes typically involve endometriosis-related pain, pelvic congestion syndrome, pelvic inflammatory disease, adenomyosis, hydrosalpinx, etc. Endometriosis-related pain is seldom non-cyclic and may present due to recurrent bleeding in endometriotic implants. Engorgement of veins leads to inadequate venous washout and presents chronic pelvic pain in pelvic congestion syndrome. The pressure effect of benign lesions of the uterus and cervix may lead to cyclic pain, as in uterine fibroids. Often presentation of diseases like hydrosalpinx may not present until it has overdistended or may at times present as acute pelvic pain if it undergoes torsion. Long-standing untreated pelvic inflammatory diseases in sexually active females is another cause of pelvic pain. The complaint of CPP is also shared due to the involvement of the gastrointestinal system in conditions like irritable bowel syndrome, inflammatory bowel diseases, long-standing abdominal hernias, colorectal cancer, etc. Alteration of the gut biome and dysregulated brain-gut associations lead to typical manifestations of chronic lower back pain and pelvic pain in irritable bowel syndrome. Colorectal tumors, when in the advanced stage, may spread to nearby tissues creating fistulas and affecting nearby nerves, causing pelvic, perineal, and sacral pain. Abdominal hernias with small bowel prolapse are always related to pelvic pain symptoms. Infections in the urinary tract like urethral syndrome, chronic prostatitis, and chronic recurrent cystitis present with CPP and voiding problems. Musculoskeletal etiologies, though varying in degrees, are responsible for isolated complaints of CPP. Examples include pelvic girdle pain, levator syndrome, coccygodynia, and pelvic floor prolapse.
... This approach has good inter-tester reliability [39][40] with a number of studies supporting the validity of the different subgroups on the physical domains [41][42][43][44][45][46] as well as cognitive domains [23]. It has been more effective at reducing pain, disability, fear beliefs, mood and sick leave at long-term follow-up than Manual Therapy and exercise [23]. ...
The biomedical approaches managing low back pain have led to an exponential increase in health-care costs, with a concurrent increase in disability and chronicity, due to the lack of person-centred management and the failure to adopt a biopsychosocial framework based on contemporary evidence. The need of potential treatments to take the complexity of low back pain into account and encompass a representative range of medical disciplines and disciplines allied to medicine, combined so as to offer maximum benefit to patients has emerged. Cognitive Functional therapy is a multidimensional, patient-centred intervention that directly explores and manages cognitive, psychological and social factors deemed to be barriers to recovery in chronic low back pain. This review presents a new treatment method of chronic low back pain, cognitive functional therapy and describe the principals of this approach. This approach could potentially help physiotherapists who seek to treat chronic low back pain in a more multidisciplinary way.
... This painful condition is related to physical and psychosocial aspects, including kinesiophobia, psychological distress, beliefs regarding curability, financial stress, and social isolation [3][4][5][6]. The alteration of motor control in people with pelvic pain has been documented [7] and can affect a change in the load transfer ability at the pelvis [8]. Pregnancy-related PPGP is commonly localized in the vicinity of the sacroiliac joint (SIJ) [9]. ...
Background:
Pregnancy-related posterior pelvic girdle pain (PPGP) is one of the most important clinical manifestations of postpartum back pain. Those affected often complain of discomfort during daily activities. It is hypothesized that altered motor control is associated with perceived pain. Pelvic support can regulate possible underlying altered motor control mechanisms and decrease pain. However, the influence of a lumbosacral orthosis, which is broader support that allows for a wider contact area and more skin sensory stimulation to restore proper motor function, has not yet been investigated in women with postpartum PPGP.
Objective:
This study investigates the efficacy of broader lumbar support and narrower pelvic support on pain, proprioception, disability, and muscle strength in women with pregnancy-related PPGP.
Methods:
This study will be a single-center, 3-armed, participant-blinded, randomized controlled trial. In total, 84 women diagnosed with pregnancy-related PPGP will be recruited and randomly assigned into 3 groups. Intervention groups A and B will receive pelvic and lumbar supports, respectively. Group C (control) will receive only a patient education leaflet containing advice on strengthening exercises, comfortable positions, and other practical information. The study outcomes are pain, effort score during the active straight leg raising test, maximum isometric hip flexion force, maximum isometric hip external rotation force, maximum isometric trunk rotation force, and joint position reproduction of hip abduction. The study outcomes will be measured at 4 time points: baseline (T1), immediately after the intervention (T2), 4 weeks following interventions began (at this time, the intervention period is completed) (T3), and 1 week after discontinuing the interventions (T4) to evaluate the possible lasting effects of wearing supports. Multivariate analysis of variance will be used to test between- and within-group differences.
Results:
Recruitment for this study will be started in summer 2022 and is expected to be completed by the end of fall 2022.
Conclusions:
This study will examine the efficacy of broader lumbar support as an early rehabilitative treatment for women receiving postpartum posterior pelvic pain support compared to those receiving a narrower pelvic support. We expect the broader lumbar support to impact pain management and disability better than the current narrower pelvic belt. Long-term follow-up studies will help determine whether such lumbosacral orthosis reduces pain and improves daily activities in women with pregnancy-related PPGP.
Trial registration:
Iranian Registry of Clinical Trials IRCT20150210021034N11; https://www.irct.ir/trial/54808.
International registered report identifier (irrid):
PRR1-10.2196/40553.
... This painful condition is related to physical and psychosocial aspects, including kinesiophobia, psychological distress, beliefs regarding curability, financial stress, and social isolation [3][4][5][6]. The alteration of motor control in people with pelvic pain has been documented [7] and can affect a change in the load transfer ability at the pelvis [8]. Pregnancy-related PPGP is commonly localized in the vicinity of the sacroiliac joint (SIJ) [9]. ...
BACKGROUND
Pregnancy-related pelvic girdle pain is one of the most important clinical manifestations of postpartum back pain. Those affected often complain of discomfort during daily activities. It is hypothesized that altered motor control is associated with perceived pain. Pelvic support can regulate possible underlying altered motor control mechanisms and decrease pain. However, the influence of a lumbosacral orthosis which is broader support that allows for a wider contact area and more skin sensory stimulation to restore proper motor function has not yet been investigated in women with postpartum pregnancy-related posterior pelvic girdle pain.
OBJECTIVE
This study investigates the efficacy of broader lumbar support and narrower pelvic support on pain, proprioception, disability, and muscle strength in women with pregnancy-related posterior pelvic girdle pain.
METHODS
This study will be a single-center, three-armed, participant-blinded, randomized controlled trial. Eighty-four women diagnosed with pregnancy-related posterior pelvic pain will be recruited and randomly assigned into three groups. Intervention groups A and B will receive pelvic and lumbar supports, respectively. Group C (control) will receive only a patient-education leaflet containing advice on strengthening exercises, comfortable positions, and other practical information. The study outcomes are pain, effort score during active straight leg raising test, maximum isometric hip flexion force, maximum isometric hip external rotation force, maximum isometric trunk rotation force, and joint position reproduction of hip abduction. The study outcomes will be measured at four time-points: baseline (T1), immediately after the intervention (T2), four weeks following interventions began (at this time, the intervention period is completed) (T3), and one week after discontinuing the interventions (T4) to evaluate the possible lasting effects of wearing supports. Multivariate analysis of variance will be used to test between- and within-group differences.
RESULTS
Recruitment for the present study will be started in Summer 2022 and is expected to be completed by the end of fall 2022.
CONCLUSIONS
This study will examine the efficacy of broader lumbar support as an early rehabilitative treatment for women involved in postpartum posterior pelvic pain compared to a narrower pelvic support. We expect the broader lumbar support to impact pain management and disability better than the current narrower pelvic belt. Long-term follow-up studies will help determine whether such lumbosacral orthosis reduces pain and improves daily activities in women with pregnancy-related posterior pelvic girdle pain.
CLINICALTRIAL
The study protocol is recorded in the Iranian Registry of Clinical Trials on April 31, 2021 (Registration reference: IRCT20150210021034N11).
... Realizar ejercicios de estabilización de la columna lumbar es útil para las mujeres embarazadas que sufren dolor lumbar y pélvico, mientras que la actividad física durante el periodo gestacional puede evitar que se produzcan episodios futuros de dolor lumbar y pélvico en embarazos posteriores 27 . Además de que ejercicio físico de cualquier tipo, en tierra o en agua, puede disminuir el DLE, cualquier forma de ejercicio mejora la capacidad funcional y reduce las incapacidades por enfermedad 28 . ...
ARTÍCULO DE REVISIÓN Resumen Introducción: El dolor lumbar es una condición de alta prevalencia en la población general. La gestación genera cambios fisiológicos que favorecen la aparición de síntomas dolorosos que pueden comprometer la calidad de vida. Método: Revisión de la literatura con términos MeSH en inglés y español en las bases de datos Embase, PubMed, Lilacs, Sage, Google Academics y Scielo desde el año 1994 hasta el año 2021. Se encontraron 74 artículos y fueron seleccionados 50, basados en su impacto clínico. Resultados: El dolor lumbar afecta a más del 50% de las mujeres embarazadas. Existen antecedentes gineco-obstétricos que pueden intervenirse para disminuir el riego o la intensidad de los síntomas. El diagnóstico es clínico, pero puede asociarse a imágenes diagnósticas cuando se sospechan condiciones de riesgo. El tratamiento se basa en intervenciones no farmacológicas como ejercicio y terapia física, pero pueden utilizarse algunos medicamentos e interven-ciones en dolor según su riesgo-beneficio materno y fetal. Conclusiones: El dolor lumbar en el embarazo es muy frecuen-te y debe ser conocido, diagnosticado y tratado por los profesionales de la salud que atienden esta población, dentro de un equipo multidisciplinario de tratamiento. Palabras clave: Dolor. Embarazo. Columna lumbar. Biomecánica. Abstract Introduction: Low back pain is a condition of high prevalence in the general population. Gestation generates physiological changes that favor the appearance of painful symptoms that can compromise the quality of life. Method: Review of the literature with MeSH terms in English and Spanish in the databases Embase, PubMed, Lilacs, Sage, Google Academics and Scielo from the year 1994 to the year 2021. Seventy-four articles were found and 50 were selected based on their clinical impact. Results: Low back pain affects more than 50% of pregnant women. There are gyneco-obstetric antecedents that can be intervened to reduce the risk or intensity of symptoms. The diagnosis of this entity is clinical, but it can be associated with diagnostic imaging when risk conditions are suspected. Treatment is based on non-pharmacological interventions such as exercise and physical therapy, but some medications and pain interventions can be used according to their risk of maternal and fetal benefit. Conclusions: Low back pain in pregnancy is very frequent, it should be known, diagnosed, and treated by health professionals who care for this population, based on a multidisciplinary treatment team.
... Pelvic girdle pain is complex and multifactorial, with no obvious etiology. However, some common factors range from peripheral or central nervous system involvement, altered laxity/stiffness of the muscles or tendinous or ligamentous structures, and 'maladaptive' body mechanics [25]. Although it has been suggested that the development of PGP is associated with high levels of ovarian and placental hormones during pregnancy, the evidence is inconsistent [26,27]. ...
Background:
Pelvic girdle pain is a common problem during pregnancy. For most women, the symptoms cease within the first 3-6 months of giving birth, but in some women the pain persists. In this study we investigate the sexuality and frequency of depressive symptoms in women with persistent pelvic girdle pain after childbirth and in healthy women.
Methods:
We conducted a case-control study of women with persistent pelvic girdle pain after childbirth and a control group of healthy women. The frequency of depressive symptoms and sexuality were measured using the self-rating version of the Montgomery-Asberg Depression Rating Scale and the McCoy Female Sexuality Questionnaire.
Results:
Forty-six women with persistent pelvic girdle pain and thirty-nine healthy women were enrolled. The frequency of depressive symptoms and the total score on female sexuality did not differ between the groups. However, pain during intercourse was more frequent (P < 0.001) in women with persistent pelvic girdle pain and caused them to avoid sexual intercourse frequently (P < 0.001). In multiple linear regression a higher frequency of depressive symptoms was reversely correlated with a lower score on female sexuality (β = - 0,41, p < 0,001 95% CI -0,6 - -0,22) This association remained after adjusting for obstetric variables and individual characteristics.
Conclusion:
Depressive symptoms and female sexuality were similar between women with persistent pelvic girdle pain after childbirth and healthy controls. However, pain during intercourse and avoidance of sexual intercourse were more frequent among women with pelvic girdle pain.
... [2][3][4] Although PGP and LBP are similar with overlapping features, they should be differentiated. 5,6 Low back pain is defined as pain between the twelfth rib and the gluteal fold, whereas PGP refers to pain near the sacroiliac joints between the posterior iliac crest and gluteal fold or in the symphysis pubis. 5 Pelvic girdle pain reduces women's quality of life and ability to work or to carry out day-to-day activities, and negatively influences their sleep. ...
Objective
The purpose of this study was to translate, cross-culturally adapt, and assess the reliability and validity of the Pelvic Girdle Questionnaire (PGQ) in pregnant Nepalese women.
Methods
The cross-cultural adaptation process was conducted according to the Guillemin guidelines. Reliability and validity were assessed using cross-sectional design. The participants responded to questionnaires of sociodemographics, the Nepali version of the PGQ, the Oswestry Disability Index, the Patient-Specific Functional Scale, the 5-item version of the Edinburgh Depression Scale, and the Numerical Pain Rating Scale. The internal consistency was assessed with Cronbach's alpha. The test–retest reliability was calculated using the intraclass correlation coefficient and smallest detectable change. Construct validity was assessed by testing 9 a priori hypotheses that examine correlations between the PGQ activity and symptom subscales, and also among the PGQ subscales and Oswestry Disability Index, Numerical Pain Rating Scale, Patient-Specific Functional Scale, and 5-item version of the Edinburgh Depression Scale. Spearman and Pearson's correlation were used to assess the correlations.
Results
A sample of 111 pregnant women were included in the study. The Cronbach's alpha for the Nepali version of the total PGQ was good (α = 0.83), and the test–retest reliability was acceptable (ICC2.1, 0.72) with a measurement error of SDC95% 18.6 points. Seven of the 9 hypotheses found support, which confirms acceptable construct validity of the Nepali PGQ.
Conclusion
The Nepali version of the PGQ is a reliable and valid tool for assessing pelvic girdle pain in pregnant Nepalese women.
... Neuromuscular control is defined as the activation of muscular restraints to restore joint stability under a functional demand (O'Sullivan and Beales, 2007). There is some evidence to indicate that acuity of hip proprioception could influence the functional joint stability of the pelvic region in people with painful musculos eletal conditions ( ang et al., 2016;Onishi et al., 2017). ...
Background
Pelvic belt is being used to alleviate the symptoms of lumbopelvic pain.
Objective
To investigate the immediate effects of a pelvic belt with a textured sacral pad in pregnant women with lumbopelvic pain.
Methods
Twenty-eight pregnant women participated in a randomized crossover study. Hip joint position sense, maximum hip flexion force, and perceived effort during the active straight leg raising test were measured in twenty-eight pregnant women with lumbopelvic pain. Outcomes were measured in three randomized conditions including no pelvic belt (control), with a pelvic belt, and while a sacral pad was used with the pelvic belt. Data were analyzed using a one-way repeated measures analysis of variance for each variable.
Results
Improvements in all study outcomes have been shown with a pelvic belt compared with the control condition. The addition of a textured sacral pad to the pelvic belt improved all study outcomes compared with the pelvic belt: hip joint position sense (p < 0.001; 95% confidence interval:1.3to2.3), perceived effort (p = 0.003; 95% confidence interval: 0.35 to 1.86), and maximum flexion force (p < 0.001; 95% confidence interval:2.77to6.47) in the active straight leg raising.
Conclusion
Further improvements were noted with the addition of the textured pad for all outcome measures. This finding may inform new benefits in adding a textured sacral pad to pelvic compression belts.
... Potential explanations for an association between SIJ pain and female gender and lower BMI include pregnancy related changes to the SIJ Dietrichs, 1991;Albert et al. 2000;Damen et al. 2002;Papageorgiou and Duchatel, 2002;Cusi, 2010), different biomechanical behavior of the SIJ between genders (Dietrichs, 1991;Ross, 2000;O'Sullivan and Beales, 2007), and displacement of weight line anterior to the pelvis in lower BMI subjects. Specific examples of pregnancy-related factors such as poor pelvic floor musculature conditioning, intra-articular bleeding during birthing process, and hormonal induced joint laxity may explain why we observed a significant relationship between female gender and SIJ pain DePalma et al. 2012. ...
The aim of this study was to compare the effect of gluteus medius strengthening exercises versus sacroiliac joint mobilization in anterior sacroiliac joint dysfunction. Comparative study. Thirty adult patients with pain, tenderness on posterior superior iliac spine and chronic low back pain from both genders participated in this study, their age was ranging from 25 to 40 years old, their body mass index was ranging from 20 to 25 (kg/m 2). The thirty patients were randomly divided into 2 equal groups with 15 patients each. Both groups were given conventional physiotherapy which included ultrasound and corrective exercises as a baseline treatment. Along with conventional physiotherapy Group A received strengthening exercises for gluteus medius subdivisions while Group B received mobilization techniques. The treatment duration was for 3 weeks. Provocation tests, pelvic tilt angle and pain were measured for evaluation before starting the treatment and then after 3 weeks. There was no significant difference in pain and pelvic tilt between both groups post-treatment (p > 0.05). There was a significant decrease in pain and pelvic tilt angle post treatment in group A and B compared with that pre-treatment (p > 0.001). There was no significant difference in the results of provocation tests between group A and B at pre and post treatment (p > 0.05). There was a significant decrease in the number of patients who had positive provocation tests post-treatment compared with that pre-treatment (p < 0.05) in both groups. Both the gluteus medius strengthening exercises and the sacroiliac joint mobilization techniques were effective in treatment of anterior sacroiliac joint dysfunction.
... Over 80% percent of people experience low back pain (LBP), and despite the growing research on assessment and treatment of LBP, 85% of the cases go undiagnosed and remain characterized as non-specific LBP (O' Sullivan, 2005;Dankaerts et al., 2007;O'Sullivan and Beales, 2007;Monie, Fazey and Singer, 2016). Up to 40% percent of those cases will become chronic (O' Sullivan, 2005). ...
With high rates of active population experiencing undiagnosed, nonspecific
low back pain, a new approach is needed with consideration of
dysfunctional movement patters that may lead to chronic back pain. Active straight leg raise (ASLR) is widely used diagnostic tests for LBP, but there is a lack of evidence of association with other clinical parameters and functional analyses used in evaluation of LBP. Hence, the primary aim of this study is to investigate association of ASLR test with the movement deficiencies in muscles and joints responsible for lumbo-pelvic stability in populations with and without low back pain. 100 physically active participants with (n=50) and without LBP (n=50) volunteered for the study. One-way ANOVA was used to examine for
potential differences between two groups, and multiple correspondence analysis (MCA) to examine the pattern of relationships between the measured variables. Participants without pain had significantly higher ASLR score (p < 0.001), demonstrated better hamstring flexibility (p < 0.001) and better gluteal activation
pattern (p < 0.01). On the other hand, participants with LBP had greater incidence of pelvic rotation during knee flexion, and hip internal rotation, relative to participants without LBP (p < 0.001). Results also demonstrate that participants with pain scored largely 1 on the ASLR which was also associated with hamstring tightness, calf tightness, limited trunk flexion, hypo-mobility of the trunk, and
posterior pelvic tilt. These findings indicate a strong association of low back pain with functional movement impairment and weakness in movement motor control. ASLR test should be used conjunction with other functional evolution tests to isolate the cause of LBP in physically active individuals.
... Among these dysfunctions, pubic symphysis pain (PSP) with a reported prevalence from 8.3% to 45% in pregnant woman [1][2][3][4] has been widely studied [5]. The adverse effects on the quality of life and the mental health [6] were reported in previous studies. Although the etiology of PSP is primarily speculated as the instability of pelvis resulting from a biomechanical change during pregnancy [7], there are still many factors that remain to be investigated. ...
Introduction: The etiology of pregnancy-related pubic symphysis pain (PSP) is usually considered as the change in pelvic biomechanics during pregnancy. However, the biomechanical changes that occur during puerperium, and the difference of radiographic dimensions in women with different types of PSP remains unknown. Materials and Methods: Fifty women with self-reported PSP were included. Two conventional X-ray radiographic dimensions obtained on the delivery day and one-month postpartum were compared by using paired t-test. Based on the self-reported VAS at one-month postpartum, variables between pain-recovery and non-recovery groups were also compared. Results: The comparison between pre- and post-values indicates a reduced distance between FLAMs (239.1 vs. 237.0 mm), PS separation (7.9 vs. 6.5 mm), and PS translation (4.1 vs. 3.1 mm). No significant differences were observed in the distance between FLAMs, width of PS separation, or pubic symphysial surface (PSS) angle between the recovery and non-recovery groups. However, the non-recovery group exhibited a significantly large change in PS translation at one-month postpartum than the recovery group (-1.8 vs. -1.1 mm). Conclusions: The pelvic radiography demonstrated a 'closure' alteration in the pelvic cavity diameter one-month postpartum with a decrease in the distance between FLAMs and shortened PS separation. The difference in radiographic diameters between groups was not clearly evident.
... Studies, which are performed to determine potential risk factors of the SIJP, have been reported as female gender, lower BMI, pregnancy-induced changes such as weak pelvic blood circulation and muscle endurance, SI joint hemorrhage occurring during birth and hormonal induced joint laxity, and gender realted different biomechanical behaviors in the SIJ (12,13). ...
Background:
Although sacroiliac joint dysfunction (SIJD) is generally regarded as a source of lumbar pain, its anatomical position and the absence of a diagnostic 'gold standard' lead to difficulties at examination and differential diagnosis. However, since sacroiliac (SI) joint blocks only provide information about pathologies of joint origin and since SIJD developing secondary to pathologies in structures around the joint can be missed. Provocation and palpation tests also need to be used in diagnosis.
Objectives:
The purpose of this study was to examine the reliability of clinical examination and provocation tests used in the diagnosis of SIJD.
Study design:
Retrospective analysis of prospectively collected data.
Setting:
Outpatient physical medicine and rehabilitation clinic.
Methods:
One hundred and seventeen patients presenting with lumbar and/or leg pain and diagnosed with SIJD through clinical evaluation were included in the study. Range of lumbar joint movement, pain location and specific tests used in the diagnosis of SIJD were evaluated. Positivity in 3 out of 6 provocation tests was adopted as the criterion.
Results:
75.2% of patients were female and 24.8% were male. Mean age was 46.41 ± 10.45 years. A higher level of females was determined in ender distribution. SIJD was determined on the right in 52.6% of patients and on the left in 47.4%. When SI joint provocation tests were analyzed individually, the highest positivity, in 91.4% patients diagnosed with SIJD, was in the FABER test. The lowest positivity, in 56.4% of patients, was determined in the Ganslen test. The same patients were assessed by the same clinician at 2 different times. In these data, the simple consistence, kappa and PABAK coefficient values of all tests were close to 1 and indicating good agreement. The thigh thrust (POSH) and sacral thrust tests exhibited very good agreement with a kappa coefficient of 0.90 and a PABAK coefficient of 0.92, while the FABER test exhibited good agreement with a kappa coefficient of 0.78 and a PABAK coefficient of 0.92.
Limitation:
Agreement between different observers was not evaluated, and also no comparison was performed with SI joint injection, regarded as a widely used diagnostic technique.
Conclusion:
The anatomical position of the SI joint and the lack of a diagnostic 'gold standard' make the examination and diagnosis of SIJD difficult. Most SI joint clinical tests have limited reliability and validity on their own, while a multitest regimen consisting of SI joint pain provocation tests is a reliable method, and these tests can be used instead of unnecessary invasive diagnostic SI joint procedures.
Key words:
Dysfunction, lumbar, sacroiliac joint, provocation test, sacroiliac joint pain, pain pattern.
... Since sufficient force closure of the sacroiliac joints requires appropriate muscular, ligamentous and fascial interaction, may women with pelvic pain in previous pregnancies have experienced that exercising improves muscle activation, recovers function and decreases pain. [24][25][26] Additionally, experiences of pain prevention and rehabilitation in previous pregnancies may work as an incitement to engage in physical activity and regular exercise, both before and during pregnancy. ...
Objective
To explore if pregnant women with pelvic girdle pain (PGP), subgrouped following the results from two clinical tests with high validity and reliability, differ in demographic characteristics and weekly amount of days with bothersome symptoms through the second half of pregnancy.
Design
A prospective longitudinal cohort study.
Participants
Pregnant women with pelvic and lumbopelvic pain due for their second-trimester routine ultrasound examination.
Setting
Obstetric outpatient clinic at Stavanger University Hospital, Norway.
Methods
Women reporting pelvic and lumbopelvic pain completed a questionnaire on demographic and clinical features. They were clinically examined following a test procedure recommended in the European guidelines for the diagnosis and treatment of PGP. Women without pain symptoms completed a questionnaire on demographic data. All women were followed weekly through an SMS-Track survey until delivery.
Primary and secondary outcome measures
The outcome measures were the results from clinical diagnostic tests for PGP and the number of days per week with bothersome pelvic pain.
Results
503 women participated. 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.
Conclusion
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.
... [1][2][3] However, there is growing evidence that pelvic disorders constitute a distinct subgroup of low back pain with a unique clinical presentation and the need for specific treatment, meaning there is a clinical classification that distinguishes the 2 specific conditions. [4][5][6][7][8][9] Pelvic girdle pain (PGP) related to pregnancy is experienced between the posterior iliac crest and the gluteal fold, particularly near the sacroiliac joints from which it may radiate to the posterior thigh. 6,[9][10][11][12] Commonly, studies that assess the functional capacity of pregnant women with PGP use tools developed for a nonpregnant population with low back pain. ...
Objective:
The purpose of this study was to evaluate test-retest reliability, construct validity, and internal consistency of the Brazilian version of the Pelvic Girdle Questionnaire (PGQ-Brazil).
Methods:
Analysis of the measurement properties was carried out in 4 steps. Step 1 was the pilot study, on which basis 4 hypotheses were formulated. These hypotheses were tested during the next step (construct validity, step 2) by completion of the questionnaire by the 2 groups (in pain [n = 105] and not in pain [n = 52]). For implementation of the PGQ-Brazil in the group with pain, we calculated the internal consistency (step 3) and, 7 days later, test-retest reliability (step 4) by re-application of the instrument in this group.
Results:
First, the PGQ-Brazil was able to discriminate between these groups (construct validity). Second, test-retest reliability (intraclass correlation coefficients for Activities subscale [0.97 with 95% confidence interval of 0.95-0.98] and Symptoms subscale [0.98 with 95% confidence interval of 0.97-0.98] and κ coefficient between 0.50 and 0.89 for the items) was found to be good; the Bland-Altman test indicated satisfactory agreement. The Rasch analysis indicated good internal consistency, and the instrument's ability to divide the participants into at least 3 levels of skills was confirmed. In contrast, a ceiling effect was observed, as 24% of pregnant women exhibited skills superior to what the PGQ-Brazil could evaluate.
Conclusions:
The PGQ-Brazil had good internal consistency, test-retest reliability, and construct validity in assessment of limitations in activities and symptoms of pregnant women with pelvic girdle pain.
Background
Lumbopelvic pain (LPP) is a surging problem among women worldwide. The genesis of LPP among women is complex as it constitutes a wide array of gynecological, hormonal, gastrointestinal, and obstetrical factors.
Objective
The objective was to develop and evaluate the content validity of a questionnaire designed to assess general LPP risk factors relevant to women.
Methods
The questionnaire was drafted by comprehensively drawing items from the literature. The drafted questionnaire was conceptualized using the modified Delphi method and sent to nine experts for professional opinions. Based on the expert evaluation, the draft questionnaire was modified/revised and again sent for expert responses.
Results
Overall, three rounds of Delphi were administered to reach a consensus between experts finally. The content validity ratio (CVR) and content validity index (CVI) of the questionnaire was calculated. The newly developed questionnaire constituted 19 items identifying LPP risks in women. The CVI of the overall questionnaire (S-CVI) was 0.99. The questionnaire also reached a universal agreement (S-CVI/UA) of 0.89. In terms of reliability, the internal consistency of the questionnaire was good (Cronbach's alpha of 0.8), with excellent test-retest reliability (intra-class correlation coefficient=0.99). The developed questionnaire has 3 domains: ergonomics, general health & well-being, and gynecology & obstetrics.
Conclusion
Using the findings of this Delphi study, we contend that the 19 items enlisted in the ‘LPP risk factor questionnaire’ depicts a multiplicity of LPP risk factors in women. This questionnaire would be beneficial for clinicians during the prevention and assessment phase of lumbopelvic pain.
Wie kann das Iliosakralgelenk zuverlässig als Schmerzquelle identifiziert werden? Und ist dies für eine adäquate Therapie überhaupt notwendig? Sean GT Gibbons nimmt zu beiden Fragen Stellung und begründet, warum eine möglichst zuverlässige Diagnosestellung notwendig ist.
This paper was an invited commentary, therefore is an opinion based paper. It introduces a model to view pain as a disease, discusses some issues related to making a diagnosis, provides supplementary clinical reasoning of for making a diagnosis of sacroiliac joint pain and discusses the benefits of making a diagnosis of sacroiliac joint pain. Considering pain as a disease, which may concurrently have multiple mechanisms with multiple causes provides an avenue to understand the complexity involved. Simple sub-classification models and rehabilitation strategies are likely to have small benefits. A strong understanding of the principles of movement pattern control are required to appreciate the use of this in clinical reasoning. Movement pattern control is only one of other mechanisms that may be considered in musculoskeletal pain.
Background
Evidence suggests links between several health conditions and lumbopelvic pain (LPP) in women beyond the commonly associated musculoskeletal origins of LPP.
Objective
This study explored the association of LPP with general health conditions, stress, exercise, and socioeconomic status in Indian women.
Methods
In a cross-sectional study, 500 urban women from diverse socioeconomic backgrounds were asked to fill out a self-report questionnaire that sampled their health and reproductive status.
Results
Women sampled were in the age range of 18-62 years. Overall, the prevalence of LPP was found to be 76.8% and was predominantly observed in women from the lower socioeconomic strata (70.5%), compared to women from the higher strata (29.4%). Multivariate logistic regression identified gynecological issues, such as menstrual problems (O.R.= 472.86, p<0.0001); polycystic ovarian syndrome (O.R.= 125.04, p=0.010); and health issues, such as urinary incontinence (O.R.=3078.24, p=0.001); chronic cough (O.R.= 84.97, p<0.0001); stress (O.R.= 474.27, p<0.0001) as being significantly related to LPP. Additionally, ‘ no exercise’ (O.R.= 360.15, p <0.0001) was also strongly associated with LPP.
Conclusion
Our data suggest that LPP is a significant problem in Indian women, with a greater prevalence in women from the lower strata of society. Importantly, given that several general, gynecological health issues, psychological stress, and a lack of exercise are associated with it, there is a need for LPP sensitization at a community and public health level. Regarding its prevention and long-term management, it is important to rule out and consider the impact of these factors on LPP, beyond its musculoskeletal origins.
Background
Pelvic girdle pain (PGP) is defined as pain experienced between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the sacroiliac joint. Pelvic girdle pain is common postpartum, may result from pregnancy-related factors, and is a leading cause of disability postpartum. The purpose of this clinical practice guideline is to provide evidence-based recommendations for physical therapist management of PGP in the postpartum population.
Key Points
Postpartum individuals may experience PGP beginning during pregnancy, immediately after childbirth, or up to 2 years after delivery. Although most cases of PGP in pregnancy resolve spontaneously, a subset of postpartum individuals may experience persistent pain. Based upon critical appraisal of literature and expert opinion, 23 action statements for risk factors, systems screening, examination, diagnosis, prognosis, theoretical models of care, and intervention for postpartum individuals with PGP are linked with explicit levels of evidence.
A significant body of evidence exists to support physical therapist intervention with postpartum clients with PGP to reduce pain and disability. Emerging evidence suggests that further investigation of biopsychosocial factors is warranted, especially factors that influence the development of persistent pain in the postpartum population. Future research is needed in several areas to optimize examination and intervention strategies specific to postpartum individuals and guided by a classification system for PGP that includes elements of pain, movement, and biopsychosocial factors.
The authors provide clinical practice guidelines for providing physical therapy to postpartum individuals with PGP.
Objective
To assess primiparous and multiparous women, and singleton and multiple pregnancies in a recently published randomized trial.
Study design: Secondary analysis of a randomized clinical trial was performed. In total, 500 women with sacroiliac dysfunction diagnosed in pregnancy were randomized into a study group (who received expert advice about therapeutic exercise) and a control group (who continued with their normal lifestyle habits). The outcome measures assessed were: pain intensity [visual analogue scale (VAS)]; and degree of functional disability (Quebec scale) at enrolment and after 3 and 6 weeks. Primiparous and multiparous women, and singleton and multiple pregnancies in the study and control groups were analysed separately.
Results
Sacroiliac dysfunction was more common in primiparous women compared with multiparous women (84.70% vs 77.16%), and in multiple pregnancies compared with singleton pregnancies (86.53% vs 80.07%). For all four subgroups analysed in this secondary analysis, the reduction in pain intensity (p=0.001) and the degree of functional disability (p=0.001) were better in the study group compared with the control group. Better results for the two outcome measures were found when comparing primiparous and multiparous women in the study group at follow-up, but the difference in functional disability disappeared 6 weeks after enrolment (p=0.383). There was no difference in the two outcome measures between singleton and multiple pregnances 3 and 6 weeks after enrolment (p=0.061, p=0.489 and p=0.741, p=0.353, respectively).
Conclusion
Expert advice about therapeutic exercise is effective for the reduction of symptoms of sacroiliac dysfunction in all four subgroups (primiparous and multiparous women, singleton and multiple pregnancies). Earlier reduction of pain intensity and degree of functional disability were obtained in primiparous women compared with multiparous women in the study group.
Pelvik kuşak ağrısı (PKA) yaygın olarak görülen bir kas-iskelet sistemi hastalığıdır. Gebelik, travma, artrit ve osteoartrit ile ilişkili olarak artan PKA, hormonal, biyomekanik, travmatik, metabolik, genetik, psikolojik, nörofizyolojik ve dejeneratif faktörlere bağlı olarak ortaya çıkmaktadır. PKA ağrı ve aktivite limitasyonu gibi durumlara yol açarak yaşam kalitesinde azalmaya yol açmaktadır. PKA’lı bireylerde açığa çıkan bu durumların hasta bildirimli ve performansa yönelik sonuç ölçümleriyle değerlendirilmesi, tedavi programının planlaması ve etkinliğinin gösterilmesi açısından önemli rol oynamaktadır. Bu çalışmanın amacı PKA’lı bireylerin tanı ve değerlendirilmesinde kullanılan klinik testleri ile hasta bildirimli ve performansa dayalı sonuç ölçümlerini derlemektir. Bu amaçla PubMed, Google Scholar ve ScienceDirect veri tabanlarında ilgili anahtar sözcükler kullanılarak 1 Aralık 2020 tarihine kadar yayımlanmış olan çalışmalarda tarama yapılmıştır. PKA’lı bireylerin tanısında kullanılan klinik testler ve değerlendirilmesinde kullanılan hasta bildirimli ve performansa dayalı sonuç ölçümleri psikometrik analizlerle sunulmuş, gerek performansa dayalı sonuç ölçümleri ve gerekse bunların karşılaştırıldığı çalışmaların oldukça az sayıda olduğu görülmüştür. Bu derlemenin bulgularının PKA’lı bireylerle çalışan tüm sağlık profesyonelleri ve araştırmacılar için yol gösterici olacağı düşünülmektedir.
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.
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.
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.
Background:
Core stability exercises have been widely advocated for management of patients with different musculoskeletal conditions, even though its effect on postpartum lumbopelvic pain (LPP) has not been fully investigated.
Objective:
This study was conducted to investigate the effect of core stability exercises on postpartum LPP.
Methods:
Thirty four women suffering from postpartum LPP were randomly assigned to the study or control group. The control group (n= 17) received infrared radiation and continuous ultrasound on lumbosacral region (L1-S5), whereas the study group (n= 17) received core stability exercises in addition to infrared radiation and continuous ultrasound three sessions a week for six weeks. Pain Pressure Threshold (PPT), Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) were assessed for all participants in both groups before and after the treatment program.
Results:
There was a significant improvement in PPT, VAS and ODI post-treatment compared with the pre-treatment in both groups (p= 0.001). There was a significant improvement in participants who received core stability exercises as compared to participants treated with the traditional treatment in PPT (P= 0.001), VAS (P= 0.001) and ODI (P= 0.009).
Conclusions:
Core stability exercises in addition to conventional treatment significantly decreased pain and improved function for women with postpartum LPP.
Objectives: To preliminarily investigate in patients with a primary complaint of non-acute knee pain for ≥ 1 month: 1) the proportion of patients with non-acute knee pain classified by Mechanical Diagnosis and Therapy (MDT) as Spinal Derangements, 2) the number of sessions taken to identify the concluding classification, and 3) the ability of MDT classifications, demographics, and symptomatic baselines to predict pain reduction at 1-month follow-up.Methods: This study reviewed data from outpatients managed with MDT. For modeling knee pain reduction at the 1-month follow-up, 3 MDT provisional or concluding classifications (Spinal Derangement, Knee Derangement, and Non-Derangement) and the following variables were included: 1) gender, 2) symptom duration, 3) presence of low back pain (LBP), 4) the Japanese Knee Osteoarthritis Measure, 5) average pain intensity at the initial session using a 0–10 numerical rating scale, and 6) the Kellgren–Lawrence grade.Results: Data from 101 patients were extracted. The percentage of patients with the concluding classification of Spinal Derangement was 44.6%. This was greater in those patient’s reporting concomitant LBP (p = .002) and without radiographic findings of knee osteoarthritis (p < .001). A concluding classification was determined by the fourth session in 80% of patients. Multiple regression modeling demonstrated that only the concluding classification significantly predicted the knee pain reduction at the 1-month follow-up.Discussion: These findings suggest the importance of careful screening assessments of the lumbar spine and the importance of detecting Derangements throughout the follow-up sessions for patients with a primary complaint of knee pain.
Introduction: Sacroiliac Joint (SIJ) is a familiar nociceptive source of Low Back Pain (LBP). Patients with SIJ pain commonly present with tenderness around the Posterior Superior Iliac Spine (PSIS) which can be recorded by using pressure pain algometer. Mechanical Diagnosis and Therapy (MDT) is a manual therapy technique which uses repetitive movements to assess and treat the dysfunction. MDT is found to be effective in treating SIJ pain; however, its effect on Pain Pressure Threshold (PPT) is not yet determined. Aim: To determine the effect of Mechanical Diagnosis and Therapy on Pain Pressure Threshold in Sacroiliac Joint pain. Materials and Methods: A total of 25 subjects with unilateral LBP of age group 20-65 years participated in the study. Subjects with the direction of preference, pain around the PSIS, positive on two out of four pain provocation tests were included in the study. These patients were given 30 repetitions of either anterior or posterior rotation of the innominate, for four sessions. PPT and Visual Analogue Scale (VAS) were used to measure the effect of treatment. Data were analysed by using paired t-test. Results: There was a significant improvement seen (p<0.01) in PPT and VAS after four consecutive sessions of treatment. Conclusion: A significant statistical difference was seen in PPT and VAS with p-value <0.01 at the end of four sessions of MDT treatment. The study suggests that MDT can be used effectively in managing SIJ tenderness around the PSIS and pain. However, future studies should focus on comparing MDT with a control group or with other manual therapy techniques. © 2018, Journal of Clinical and Diagnostic Research. All rights reserved.
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.
Study Design: A pain referral map generated from Part I of this study was tested in 54 consecutive patients. Pain diagrams, completed by each patient, were compared to the map generated from sacroiliac injections in 10 volunteers (Part I). Two clinicians, blinded to the examination of each individual, selected the diagrams most consistant with the pain map.
Objectives: To determine the applicability of a pain refereal map as a screening tool for sacroiliac joint dysfunction.
Summary of Background Data: Two independent examiners, blind to the patients' examinations, selected 16 individuals whose pain diagrams most represented the map generated in Part I. There was a 100% concordance of patients selected. All 16 patient selected had a provocation positive SI joint injection. Ten of these individuals also received lumbar discography and lumbar facet injections. Only the SI injection on the symptomatic side was provocation positive.
Methods: Patients selected for evaluation based on pain mapping received sacroiliac joint injection. Provocation-positive injections were used to confirm the diagnosis of sacroiliac joint dysfunction. Ten subjects subsequently underwent lumbar discography and lumbar facet joint injections to further confirm the diagnosis.
Results: Few studies involving low back pain have used pain referral maps. In the present study, patients were successfully screened for sacroiliac joint dysfunction using a pain referral map generated from provocation of asymptomatic volunteers.
Conclusion: Patients can be susccessfully screened for sacroiliac joint dysfunction based on comparison with a pain referral map. Further study on false negative rates of sacroiliac pain maps is needed.
Study Design: Pain pattern mapping of the sacroiliac joint in asymptomatic volunteers was investigated. Prospective evaluation of 10 volunteers who received sacroiliac joint injections was performed. The injections consisted of contrast material followed by Xylocaine.
Objectives: To determine the pain referral pattern of the sacroiliac joint in asymptomatic individuals.
Summary of Background Data: All 10 individuals experienced discomfort upon initial injection, with the most significant sensation felt directly around the injection site. Subsequent sensory examination revealed an area of hypesthsia running caudally from the posterior superior iliac spine.
Methods: Volunteers were asked to describe the nature and location of the sensation upon sacroiliac injection. Sensory examination immediately followed the injection to determine referral patterns.
Results: Sensory examination immediately after sacroiliac injection revealed an area of buttock hypesthesia extending approximately 10 cm caudally and 3 cm laterally from the posterior superior iliac spine. This area of hypesthesia corresponded to the area of maximal pain noted upon injection.
Conclusion: A pain referral map was successfully generated using provocative injections into the right sacroiliac joint in asymptomatic volunteers.
The purpose of this article is to describe the author's theories as to how anterior dysfunction of the sacroiliac joints (SIJs) is a major factor in the etiology of idiopathic low back pain syndrome (ILBPS). Most research and treatment have been directed toward the intervertebral disk; however, it is unlikely that disk dysfunction is always the primary etiology. A review of the literature is used to outline and describe the characteristics of ILBPS and to make a case that these characteristics are consistent with those of a specific dysfunction of the SIJs. Functions of the intervertebral disks and the SIJs are described and related to SIJ dysfunction and to some of its common consequences. Treatment is discussed as it relates to the pathomechanics and their correction.
This study analyzed an education and training program concerning back and pelvic problems among pregnant women.
The program was aimed at reducing back and pelvic posterior pain during pregnancy.
Low back and posterior pelvic pain accounts for the majority of sick leave among pregnant women. No previous study has suggested any type of solution to this problem.
Four hundred and seven consecutive pregnant women were included in the study and randomly assigned into three groups. Group A served as controls while different degrees of interventions were made in groups B and C.
Serious back or posterior pelvic pain developed in 47% of all women. Pain-related problems were reduced in groups B and C (P < 0.05), and sick-leave frequency was reduced in group C (P < 0.01). For some of the women in this group, pain intensity was also reduced 8 weeks post partum (P < 0.05). Weekly physical exercise before pregnancy reduced the risk for back pain problems in pregnancy (P < 0.05). A non-elastic sacro-iliac belt offered some pain relief to 82% of the women with posterior pelvic pain.
An individually designed program reduced sick leave during pregnancy. Working with groups was less effective. Differentiation between low back and posterior pelvic pain was essential. Good physical fitness reduced the risk of back pain in a subsequent pregnancy. Reduction of posterior pelvic pain by a non-elastic pelvic support was experienced by 82% of the women with posterior pelvic pain.
In the literature concerning the sacroiliac joint (SIJ) there are numerous specific tests used to detect joint mobility or pain provocation. In this article the authors have reviewed 11 studies which investigated the reliability of these tests. The methodological quality of the studies was tested by a list of criteria developed by the authors. This list consisted of three categories: (1) study population, (2) test procedures and (3) test results. To each criterion a weighting was attached. The methodological score for nine out of the 11 studies was found to be acceptable. The results of this review, however, could not demonstrate reliable outcomes and therefore no evidence on which to base acceptance of mobility tests of the SIJ into daily clinical practice. There are no indications that 'upgrading' of methodological quality would have improved the final conclusions. With respect to pain provocation tests, the findings did not show the same trend. Two studies demonstrated reliable results using the Gaenslen test and the Thigh thrust test. One study showed acceptable reliability for five other pain provocation tests; however, since other authors have described contradictory results, there is a necessity for further research in this area with an emphasis on multiple test scores and pain provocation tests of the SIJ.
Pain in the pelvic joints and lower back, a major problem for pregnant women, has proved resistant to precise measurement and quantification. To develop a classification system, the clinical tests used must be able to separate pelvic from low back pain; they must also have a high inter-examiner reliability, sensitivity and specificity, and preferably be easy to perform. The aim of this study was to describe a standardised way of performing tests for examining the pelvis, and to evaluate inter-examiner reliability, and establish the sensitivity and specificity of 15 clinical tests. It was designed as a longitudinal, prospective, epidemiological cohort study. First, 34 pregnant women were examined by blinded examiners to establish inter-examiner reliability. Second, a cohort of 2269 consecutive pregnant women, each responded to a questionnaire and underwent a thorough and highly standardised physical examination (15 tests with 48 possible responses) of the pelvic joints and surrounding areas. The 535 women who reported daily pain from the pelvic joints and had objective findings from the joints were divided, according to symptoms, into four classification groups and one miscellaneous group. The results of the study showed inter-examiner agreement of the tests was high, calculated in percentage terms, at between 88 and 100%. Using the Kappa coefficient, most tests kept the high agreement: six tests had an inter-examiner agreement of between 0.81 and 1.00, three between 0.61 and 0.80, and two between 0.60 and 0.41. Five tests showed superior sensitivity. The specificity of the tests was between 0.98 and 1.00, except the value for pelvic topography, which was 0.79. These results show that it is possible to standardise examination and interpretation of clinical tests of the pelvic joints, resulting in a high degree of sensitivity, specificity and inter-examiner reliability.
Exercises for low back and pelvic pain are supposed to increase muscle force to reduce symptoms, but they could exacerbate symptoms by loading of the spinal and pelvic structures. The purpose of this study was to investigate the value of graded exercises of the diagonal trunk muscle systems.
The subjects were 44 women with persistent pelvic pain after pregnancy (mean age=31.7 years, SD=3.2, range=23.6-37.5; mean period postpartum=4.1 months, SD=2.2, range=1.7-5.6).
Subjects were randomly assigned to 1 of 3 groups: (1) a group that performed exercises to increase the force of the diagonal trunk muscle systems, (2) a group that received training of the longitudinal trunk muscle systems, and (3) a group that was instructed to refrain from exercises. Pain, fatigue, perceived general health, and mobility of the pelvic joints as measured with radiographs were the outcome measures.
After 8 weeks, no differences were found among the 3 groups.
In treating patients with persistent pelvic pain, training of the diagonal trunk muscle systems, without individual coaching, has no additional value above instructions and use of a pelvic belt without exercises. Whether the treatment is ineffective or whether exacerbation of symptoms due to loading of the spinal and pelvic structures obscures any potential benefit of increased muscle force cannot be determined from the study design.
Study design:
A roentgen stereophotogrammetric analysis study of patients with sacroiliac joint dysfunction.
Objectives:
To investigate whether manipulation can influence the position between the ilium and the sacrum, and whether positional tests for the sacroiliac joint are valid.
Summary of background data:
Sacroiliac joint dysfunction is a subject of controversy. The validity of different sacroiliac joint tests is unknown. Long-standing therapeutic tradition is to manipulate supposed dysfunctions of the sacroiliac joint. Many manual therapists claim that their good clinical results are a consequence of a reduction of subluxation.
Methods:
Ten patients with symptoms and sacroiliac joint tests results indicating unilateral sacroiliac joint dysfunction were recruited. Twelve sacroiliac joint tests were chosen. The results of most of these tests were required to be positive before manipulation and normalized after manipulation. Roentgen stereophotogrammetric analysis was performed with the patient in the standing position, before and after treatment.
Results:
In none of the 10 patients did manipulation alter the position of the sacrum in relation to the ilium, defined by roentgen stereophotogrammetric analysis. Positional test results changed from positive before manipulation to normal after.
Conclusions:
Manipulation of the sacroiliac joint normalized different types of clinical test results but was not accompanied by altered position of the sacroiliac joint, according to roentgen stereophotogrammetric analysis. Therefore, the positional test results were not valid. However, the current results neither disprove nor prove possible beneficial clinical effects achieved by manipulation of the sacroiliac joint. Because the supposed positive effects are not a result of a reduction of subluxation, further studies of the effects of manipulation should focus on the soft tissue response.
Study Design. A roentgen stereophotogrammetric analysis study of patients with sacroiliac joint dysfunction. Objectives. To investigate whether manipulation can influence the position between the ilium and the sacrum, and whether positional tests for the sacroiliac joint are valid. Summary of Background Data. Sacroiliac joint dysfunction is a subject of controversy. The validity of different sacroiliac joint tests is unknown. Long‐standing therapeutic tradition is to manipulate supposed dysfunctions of the sacroiliac joint. Many manual therapists claim that their good clinical results are a consequence of a reduction of subluxation. Methods. Ten patients with symptoms and sacroiliac joint tests results indicating unilateral sacroiliac joint dysfunction were recruited. Twelve sacroiliac joint tests were chosen. The results of most of these tests were required to be positive before manipulation and normalized after manipulation. Roentgen stereophotogrammetric analysis was performed with the patient in the standing position, before and after treatment. Results. In none of the 10 patients did manipulation alter the position of the sacrum in relation to the ilium, defined by roentgen stereophotogrammetric analysis. Positional test results changed from positive before manipulation to normal after. Conclusions. Manipulation of the sacroiliac joint normalized different types of clinical test results but was not accompanied by altered position of the sacroiliac joint, according to roentgen stereophotogrammetric analysis. Therefore, the positional test results were not valid. However, the current results neither disprove nor prove possible beneficial clinical effects achieved by manipulation of the sacroiliac joint. Because the supposed positive effects are not a result of a reduction of subluxation, further studies of the effects of manipulation should focus on the soft tissue response.
Observations on sectioned and opened preparations of human sacroiliac joints (SI joints) show the presence of cartilage-covered ridges and depressions, which are complementary on the auricular surfaces. These macroscopically visible features of the joints, which become visible relatively early in life, are more pronounced in men than in women. This type of roughening, as well as that by increased coarseness of the auricular surface, is viewed as a nonpathologic adaptation to the forces exerted at the SI joints, leading to increased stability. Differences between men and women may be attributed to childbearing and to a difference in the center of gravity. It is emphasized that intra-articular ridges and depressions can be misinterpreted roentgenologically as osteophytes.
In the literature many tests are described which are designed to provoke pain or detect joint mobility in the sacroiliac joint (SIJ). However, in part 1 of this review, the authors stated that there is little evidence of reliability of these tests. In this article, the authors describe the methodological review of 11 studies, which have dealt with the validity of SIJ tests. The methodological quality of the studies was tested by using a list of criteria that consisted of three categories: 1) study population, 2) test procedure and 3) test results. A weighting for each criterion was developed. The methodological score for the studies was, in general, disappointing and looked promising for only two out of 11 studies (58 and 64 points). Four authors drew conclusions of positive validity from the tests they studied but other authors did not confirm these results. The conclusion of this methodological review is that there is no evidence to support the inclusion of mobility and pain provocation tests for the SIJ in clinical practice. Three major problems have been identified in validating SIJ dysfunction tests. Firstly, poor reliability of SIJ dysfunction tests exists, which may be improved by multiple test scores as postulated in part 1 of this review. Secondly, the methodological quality of validity studies needs to be developed to a much higher level with special consideration paid to sensitivity, specificity, confidence intervals and likelihood ratio values. And finally, there is a need for the proper use of a gold standard in assessing the validity of SIJ tests.
Study Design.: An analysis was made of the self‐reported medical histories of patients with peripartum pelvic pain. Objectives.: To compile an inventory of the disabilities of patients with peripartum pelvic pain, analyze factors associated with the risk for development of the disease, and to formulate a hypothesis on pathogenesis and specific preventive and therapeutic measures. Summary of Background Data.: Pregnancy is an important risk factor for development of chronic low back pain. Understanding the pathogenesis of pelvic and low back pain during pregnancy and delivery could be useful in understanding and managing nonspecific low back pain. Methods.: By means of a questionnaire, background data were collected among patients of the Dutch Association for Patients With Pelvic Complaints in Relation to Symphysiolysis. Results were compared with the general population. Subgroups were compared with each other. Results.: Peripartum pelvic pain seriously interferes with many activities of daily living such us standing, walking, sitting, and all other activities in which the pelvis is involved. Most patients experience a relapse around menstruation and during a subsequent pregnancy. Occurrence of peripartum pelvic pain was associated with twin pregnancy, first pregnancy, higher age at first pregnancy, larger weight of the baby, forceps or vacuum extraction, fundus expression, and a flexed position of the woman during childbirth; a negative association was observed with cesarean section. Conclusions.: It is hypothesized that peripartum pelvic pain is caused by strain of ligaments in the pelvis and lower spine resulting from a combination of damage to ligaments (recently or in the past), hormonal effects, muscle weakness, and the weight of the fetus.
We solve the problem of approximating in ℒ² a given random variable H by stochastic integrals GT(ϑ) of a given discrete-time process X. We interpret H as a contingent claim to be paid out at time T, X as the price evolution of some risky asset in a financial market, and G(ϑ) as the cumulative gains from trade using the hedging strategy ϑ. As an application, we determine the variance-optimal strategy which minimizes the variance of the net loss H − GT(ϑ) over all strategies ϑ.
Movement in eight sacroiliac joints was measured in preparations of embalmed elderly humans and compared with radiological findings. For the biomechanical part of the study the connections between sacrum and fifth lumbar vertebra were spared, as were the surrounding ligaments. The pelvis-spine preparation was fixed at the fifth lumbar vertebra. To induce movement, forces were directed at the acetabula. With digital displacement meters rotation was measured between the sacral and iliac part of the sacroiliac joint. In the sagittal plane both ventral rotation (as part of nutation) and dorsal rotation (as part of contranutation) could be demonstrated. Most sacroiliac joints were mobile, allowing a total rotation of up to 4°. Significant intraindividual differences in mobility occurred. One sacroiliac joint without mobility showed radiographically pronounced arthrosis. The impact of the findings on kinematic chain and clinical diagnosis is discussed. In the literature no data are available on the radiographic appearance of biomechanically studied sacroiliac joints. In the present study a biomechanical and radiological approach has been combined. The study emphasizes the clinical importance of intraindividual sacroiliac differences as well as the need for a thorough integration of pelvic and lumbar kinematics.
We developed a biomechanical model of load transfer by the sacroiliac joints in relation to posture. A description is given of two ways in which the transfer of lumbar load to the pelvis in a stooped posture can take place. One way concerns ligament and muscle forces that act on the sacrum, raising the tendency of the sacrum to flex in relation to the hip bones. The other refers to ligament and muscle forces acting on the iliac crests, raising the tendency of the sacrum to shift in caudal direction in relation to the hip bones. Both loading modes deal with the self-bracing mechanism that comes into action to prevent shear in the sacroiliac joints. When a person is lifting a load while in a stooped posture, the force raised by gravity acting in a plane perpendicular to the spine and the sacrum becomes of interest. In this situation a belt such as used by weight lifters may contribute to the stability of the sacroiliac joints. Verification of the biomechanical model is based on anatomical studies and on load application to human specimens. Magnetic resonance imaging pictures have been taken to verify geometry in vivo.
This study deals primarily with the stability of the base of the spine. The sacroiliac joints are vulnerable to shear loading on account of their predominantly flat surfaces. This raises the question of what mechanisms are brought into action to prevent dislocation of the sacroiliac joints when they are loaded by the weight of the upper part of the body and by trunk muscle forces. First a model is introduced to compare load transfer in joints with spherical and with flat joint surfaces. Next we consider a biomechanical model for the equilibrium of the sacrum under load, describing a self-bracing effect that protects the sacroiliac joints against shear according to 'the sacroiliac joint compression theory', which has been demonstrated in vitro. The model shows joint stability by the application of bending moments and the configuration of the pelvic arch. The model includes a large number of muscles (e.g. the gluteus maximus and piriformis muscles), ligaments (e.g. the sacrotuberous, sacrospinal, and dorsal and interosseous sacroiliac ligaments) as well as the coarse texture and the ridges and grooves of the joint surfaces.
As part of a research project, a classification of the syndromes of the sacroiliac joint (SIJ) was attempted. A critical review of the literature on these syndromes was conducted. As will become apparent, this review revealed: controversy concerning the overall frequency of these syndromes, a number of incomplete descriptions of particular syndromes, cases where different authors gave different descriptions of conditions with the same name, and cases where different authors appeared to give similar descriptions of syndromes with different names. The identification and classification of specific SIJ syndromes requires further study
Background:
Previous studies concerning symptom-giving pelvic girdle relaxation in pregnancy have to our knowledge been retrospective. We wanted to 1) determine the incidence during pregnancy and the prevalence two, six, and twelve months post partum, 2) identify possible predisposing factors, and 3) determine the frequency and duration of sicklisting, prospectively.
Material and methods:
A cohort of 1600 consecutive pregnant women filled in a questionnaire. At the routine prenatal examinations they were asked about pelvic pain. Those who fulfilled the inclusion criteria were examined by a rheumatologist to confirm the diagnosis. The affected women were seen again two, six, and twelve months post partum. All participants were asked about sicklisting in pregnancy.
Results:
The incidence during pregnancy was 14%, the prevalence two, six, and twelve months post partum were 5%, 4%, and 2% respectively. Multivariate analysis indicates that the most important predisposing factor is pelvic pain in a previous pregnancy. Other factors were uncomfortable working conditions, lack of exercise, and previous low back pain and low abdominal pain. At least 37% of the women with symptom-giving pelvic girdle relaxation had been sicklisted in pregnancy due to pelvic pain, on average for twelve weeks.
Conclusion:
Symptom-giving pelvic girdle relaxation is a considerable problem both in pregnancy and post partum. The occupational risk can possibly be prevented. The syndrome has a great social impact because of the frequent sicklisting.
The objectives of this study were to investigate the influence of pelvic belts on the stability of the pelvis and to discuss the treatment of peripartum pelvic instability.
In six human pelvis-spine preparations, sagittal rotation in the sacroiliac joints was induced by bidirectional forces directed at the acetabula. Weight-bearing was mimicked by the application of a compressive force to the spine. The biomechanical effect of a pelvic belt was measured in 12 sacroiliac joints.
The pelvic belt caused a significant decrease in the sagittal rotation in the sacroiliac joints. The effect of a 100 N belt did not differ significantly from that of a 50 N belt.
The combination of a pelvic belt and muscle training enhances pelvic stability. The load of the belt can be relatively small; location is more important. The risk of symphysiodesis, especially as a result of the insertion of bone grafts, is emphasized.
The prevalence of back pain was studied in 855 pregnant women who were followed from the 12th week of pregnancy, every 2nd week, until childbirth. The 9-month period prevalence was 49%, with a point prevalence of 22-28% from the 12th week until delivery. Because 22% of the women had back pain at the 12th week of the pregnancy, the 6-month incidence was 27%. Based on pain drawings, back pain was classified into three groups: In one group, pain was localized to the sacroiliac areas and increased as pregnancy progressed; in the other two groups, pain either decreased or did not change, respectively. True sciatica with a dermatomal distribution occurred in only 10 women (1%). Back problems before pregnancy increased the risk of back pain, as did young age, multiparity, and several physical and psychological work factors.
The sacroiliac joints of seven pelvic specimens were examined to determine functional, morphologic, and histopathologic aspects. The movements were measured in four intact pelvises (from two men and two women). The joint surfaces of all pelvises (from three men and four women) then were examined topographically by means of a photogrammetric method. After this, they were examined histologically to characterize any effects on function. The morphologic investigation revealed sex-specific differences. All joint surfaces from the female pelvises showed circular contours, the centers of which coincided with the iliac tuberosities. These morphologic characteristics were not discernible in the joint surfaces from the male pelvises; these had interlocking irregularities without a topographic pattern. As expected, this configuration involved distinct differences in mobility. Rotation of the sacrum was markedly less in the sacroiliac joints of men than in those of women.
The amount of friction between the articular surfaces of sacroiliac (SI) joints was determined and related to the degree of macroscopic roughening. Results show that articular surfaces with both coarse texture and ridges and depressions have high friction coefficients. The influence of ridges and depressions appears to be greater than that of coarse texture. The data are compatible with the view that roughening of the SI joint concerns a physiologic process.
Observations on sectioned and opened preparations of human sacroiliac joints (SI joints) show the presence of cartilage-covered ridges and depressions, which are complementary on the auricular surfaces. These macroscopically visible features of the joints, which become visible relatively early in life, are more pronounced in men than in women. This type of roughening, as well as that by increased coarseness of the auricular surface, is viewed as a nonpathologic adaptation to the forces exerted at the SI joints, leading to increased stability. Differences between men and women may be attributed to childbearing and to a difference in the center of gravity. It is emphasized that intra-articular ridges and depressions can be misinterpreted roentgenologically as osteophytes.
Twenty-five patients (21 females and 4 males) with sacroiliac joint disorders were studied with roentgen stereophotogrammetry in physiologic positions as well as in the extreme of physiologic positions. There was a constant pattern of motion with different load, especially around the transverse axis. The rotations were small and in mean between position 2.5 degrees (0.8 degree-3.9 degrees). The translation was, mean, 0.7 mm (0.1-1.6 mm). There was no difference between symptomatic and asymptomatic joints.
All pregnant women from a well defined area (the central district of the County of Ostergötland, Sweden) attending antenatal clinics over a period of seven months were interviewed with regard to low back pain during pregnancy. Of 862 women who answered the questionnaires, about half developed some degree of low back pain. Seventy-nine women who were unable to continue their work because of severe low back pain were referred to an orthopedic surgeon for an orthoneurologic examination. The most common reason for severe low back pain was dysfunction of the sacroiliac joints. Physically strenuous work and previous low back pain were factors associated with an increased risk of developing low back pain and sacroiliac dysfunction during pregnancy.
The superficial and deep lamina of the posterior layer of the thoracolumbar fascia have been studied anatomically and biomechanically. In embalmed human specimens, the posterior layer has been loaded by simulating the action of various muscles. The effect has been studied using raster photography.
To study the role of the posterior layer of the thoracolumbar fascia in load transfer between spine, pelvis, legs, and arms.
It has been determined whether muscles such as the gluteus maximus, latissimus dorsi, erector muscle, and biceps femoris are functionally coupled via the thoracolumbar fascia. The caudal relations of the posterior layer of the thoracolumbar fascia have not been previously studied.
Dissection was directed to the bilaminar posterior layer of the thoracolumbar fascia of 10 human specimens. The superficial and deep lamina were studied using visual inspection and raster photography. Tension to the posterior layer of the fascia was simulated by traction to various muscles and measured by studying the displacement in the posterior layer.
Traction to a variety of muscles caused displacement of the posterior layer. This implies that in vivo, the superficial lamina will be tensed by contraction of various muscles, such as the latissimus dorsi, gluteus maximus and erector muscle, and the deep lamina by contraction of the biceps femoris. Caudal to the level of L4 (in some specimens, L2-L3), tension in the posterior layer was transmitted to the contralateral side.
Anatomic structures normally described as hip, pelvic, and leg muscles interact with so-called arm and spinal muscles via the thoracolumbar fascia. This allows for effective load transfer between spine, pelvis, legs, and arms--an integrated system. Specific electromyographic studies should reveal whether the gluteus maximus muscle and contralateral latissimus dorsi muscle are functionally coupled, especially during rotation of the trunk. In that case, the combined action of these muscles assists in rotating the trunk, while simultaneously stabilizing the lower lumbar spine and sacroiliac joints.
This was a cross-sectional analytic study.
In relation to pain from the sacroiliac joint, this study sought to establish 1) its prevalence, 2) the validity of pain provocation, 3) whether any arthrographic abnormalities predict a response to joint block, and 4) whether certain pain patterns discriminate patients with this diagnosis.
The true prevalence of sacroiliac joint pain is unknown and despite a plethora of clinical tests, none of these tests has been validated against an established criterion standard. To our knowledge, arthrography of the sacroiliac joint had never been studied.
Forty-three consecutive patients with chronic low back pain maximal below L5-S1 were investigated with sacroiliac joint blocks under image intensifier using radiographic contrast followed by 2% lignocaine. Information was obtained on pain provocation, analgesia, and image pattern.
Thirteen patients (30%) obtained gratifying relief of their pain. Nine of these also exhibited tears of their ventral capsule. Groin pain was the only pain referral pattern found to be associated with response to sacroiliac joint block.
The sacroiliac joint is a significant source of pain in patients with chronic low back pain and warrants further study.
An analysis was made of the self-reported medical histories of patients with peripartum pelvic pain.
To compile an inventory of the disabilities of patients with peripartum pelvic pain, analyze factors associated with the risk for development of the disease, and to formulate a hypothesis on pathogenesis and specific preventive and therapeutic measures.
Pregnancy is an important risk factor for development of chronic low back pain. Understanding the pathogenesis of pelvic and low back pain during pregnancy and delivery could be useful in understanding and managing nonspecific low back pain.
By means of a questionnaire, background data were collected among patients of the Dutch Association for Patients With Pelvic Complaints in Relation to Symphysiolysis. Results were compared with the general population. Subgroups were compared with each other.
Peripartum pelvic pain seriously interferes with many activities of daily living such us standing, walking, sitting, and all other activities in which the pelvis is involved. Most patients experience a relapse around menstruation and during a subsequent pregnancy. Occurrence of peripartum pelvic pain was associated with twin pregnancy, first pregnancy, higher age at first pregnancy, larger weight of the baby, forceps or vacuum extraction, fundus expression, and a flexed position of the woman during childbirth; a negative association was observed with cesarean section.
It is hypothesized that peripartum pelvic pain is caused by strain of ligaments in the pelvis and lower spine resulting from a combination of damage to ligaments (recently or in the past), hormonal effects, muscle weakness, and the weight of the fetus.
In embalmed human bodies the tension of the long dorsal sacroiliac ligament was measured during incremental loading of anatomical structures that are biomechanically relevant.
To assess the function of the long dorsal sacroiliac ligament.
In many patients with aspecific low back pain or peripartum pelvic pain, pain is experienced in the region in which the long dorsal sacroiliac ligament is located. It is not well known that the ligament can be easily palpated in the area directly caudal to the posterior superior iliac spine. Data on the functional and clinical importance of this ligament are lacking.
A dissection study was performed on the sacral and lumbar regions. The tension of the long dorsal sacroiliac ligament (n = 12) was tested under loading. Tension was measured with a buckle transducer. Several structures, including the erector spinae muscle, the posterior layer of the thoracolumbar fascia, the sarcotuberous ligament, and the sacrum, were incrementally loaded (with forces of 0-50 newtons). The sacrum was loaded in two directions, causing nutation (ventral rotation of the sacrum relative to the iliac bones) and counternutation (the reverse).
Forced nutation in the sacroiliac joints diminished the tension and forced counternutation increased the tension. Tension in the long dorsal sacroiliac ligament increased during loading of the ipsilateral sacrotuberous ligament and erector spinae muscle. The tension decreased during traction to the gluteus maximus muscle. Tension also decreased during traction to the ipsilateral and contralateral posterior layer of the thoracolumbar fascia in a direction simulating contraction of the latissimus dorsi muscle.
The long dorsal sacroiliac ligament has close anatomical relations with the erector spinae muscle, the posterior layer of the thoracolumbar fascia, and a specific part of the sacrotuberous ligament (tuberoiliac ligament). Functionally, it is an important link between legs, spine, and arms. The ligament is tensed when the sacroiliac joints are counternutated and slackened when nutated. The reverse holds for the sacrotuberous ligament. Slackening of the long dorsal sacroiliac ligament can be counterbalanced by both the sacrotuberous ligament and the erector muscle. Pain localized within the boundaries of the long ligament could indicate among other things a spinal condition with sustained counternutation of the sacroiliac joints. In diagnosing patients with aspecific low back pain or peripartum pelvic pain, the long dorsal sacroiliac ligament should not be neglected. Even in cases of arthrodesis of the sacroiliac joints, tension in the long ligament can still be altered by different structures.
This prospective study consisted of the evaluation of a double sacroiliac block in patients with low back pain.
To determine the prevalence of sacroiliac pain in a selected population of patients suffering from low back pain, and to assess certain pain provocation tests.
Previous studies have implicated the sacroliac joint as a potential etiology of back and leg pain, but none has tested double anesthetic blocks in a prospective fashion.
Fifty-four patients with unilateral low back pain, pain mapping compatible with a sacroiliac origin, tenderness over the sacroiliac joint, and no obvious source of pain in the lumbar spine were selected for a double anesthetic block. The procedure consisted of a through clinical examination with a visual analog scale, testing of sacroiliac pain provocation tests followed by a first screening block with a short-acting anesthetic. A second examination consisting of the same tests assessed the efficacy of the first block. If results were positive, a confirmatory block was performed. All blocks were performed under fluoroscopic guidance.
Nineteen patients had a positive response to the first block. Among them, 10 (18.5%) were temporarily relieved by the confirmatory block. No pain provocation test reached statistical significance.
The present study suggests the sacroiliac joint is an uncommon but real source of low back pain. The accuracy of some of the presumed "sacroiliac pain provocations tests" is questioned.
A longitudinal, prospective, observational cohort study.
To assess the relationship between clinical back status and reported pain locations during and after pregnancy.
Back pain during pregnancy is a frequent clinical occurrence, even during the early stages of pregnancy. The cause is unclear. There are few data describing the results of a general physical examination of the back during pregnancy and there are no data on serial examinations. Such data could provide information about what structures cause the pain, which might have implications for the choice of treatment.
A cohort of 200 consecutive women attending an antenatal clinic was observed throughout the pregnancy terms, and repeated measurements of back pain and its possible determinants were taken using questionnaires and physical examinations in a standardized way, including a series of tests of configuration, mobility, and pain provocation.
Pain provocation tests were better at discriminating among women who reported back pain from women who reported no back pain from tests of configuration or mobility. The discriminatory power of the tests was better in the lower part of the spine than in the upper part. The best discrimination was achieved by combining some of the tests.
The results indicate that not one but several pain-releasing structures may be involved. These are probably the various pelvic ligaments, which may form a functional unit. These findings may have therapeutic implications.
This prospective study evaluated the diagnostic utility of historically accepted sacroiliac joint tests. A multidisciplinary expert panel recommended 12 of the "best" sacroiliac joint tests to be evaluated against a criterion standard of unequivocal gain relief after an intra-articular injection of local anesthetic into the sacroiliac joint.
To identify a single sacroiliac joint test or ensemble of test that are sufficiently useful in diagnosing sacroiliac joint disorders to be clinically valuable.
No previous research has been done to evaluate any physical test of sacroiliac joint pain against an accepted criterion standard.
Historical data was obtained, and the 12 tests were performed by two examiners on 85 patients who subsequently underwent sacroiliac joint blocks. Ninety percent or more relief was considered a positive response, and less then 90% relief was considered a negative response.
There were 45 positive and 40 negative responses. No historical feature, none of the 12 sacroiliac joint tests, and no ensemble of these 12 tests demonstrated worthwhile diagnostic value.
Sacroiliac joint pain is resistant to identification by the historical and physical examination data from tests evaluated in this study.
A prospective, consecutive cohort analysis of the regression of the incidence and intensity of back and posterior pelvic pain after delivery in pregnant women was done.
To identify back and posterior pelvic pain from mid-pregnancy to 5 months after delivery and to illustrate differences between these two pain types.
Chronic back pain may start during a pregnancy, and regression of unspecified back pain after delivery may be slow and incomplete. Few studies have distinguished back pain from posterior pelvic pain in pregnancy, and no study has presented follow-up data after delivery with respect to pain types.
One hundred and sixty four of 368 pregnant women studied had back or posterior pelvic pain and were offered individual group physiotherapy and training. The women were observed until 5 months after delivery. Standardized clinical examination protocols and questionnaires were used.
Posterior pelvic pain was experienced by 124 women, and back pain was experienced by 40 women during pregnancy. After delivery, however, back pain was more common. Pain intensity was higher among women with posterior pelvic pain during pregnancy, whereas after delivery pain intensity was higher among women with back pain. A correlation was found between the presence of high pain intensity during pregnancy and little regression of pain after delivery.
One of every three pregnant women studied experienced posterior pelvic pain, and one of every nine women experienced back pain. Posterior pelvic pain was more intense during pregnancy, and back pain was more intense and more common after delivery. High pain intensity in pregnancy indicated a bad prognosis.