Asymmetric pelvic bracing and altered kinematics in patients with posterior pelvic pain who present with postural muscle delay

Differences in balance control despite self-reported resolution of pregnancy-related pelvic girdle pain. A cross-sectional study

BACKGROUND

Motor control patterns are altered when women with pregnancy-related pelvic girdle pain (PGP) experience pain. In low back pain, these adaptations can persist after recovery.

OBJECTIVES

This study aimed to assess balance control in postpartum women with and without a history of PGP during pregnancy.

DESIGN

Cross-sectional study.

METHOD

Eighteen postpartum women who reported to be recovered from PGP, and twelve postpartum women without a history of PGP during pregnancy performed two clinical tests: the single leg stance and active straight leg raise test. Primary outcomes were ground reaction forces measured with a force platform.

RESULTS

Multiple linear regression analyses showed smaller lateral displacement (β = -11cm; 95%CI: 19 to -3; p = 0.008) and lower displacement velocity of the Centre of Pressure (COP) (Ratio of Geometric Means (RGM) 0.76; 95%CI: 0.59 to 0.99; p = 0.043) during single leg stance in the participants with a history of PGP compared to participants without a history of PGP. Push-off force (β = -4.8 N; 95%CI: 22.0 to 12.5; p = 0.57) and asymmetry of push-off force (RGM 1.77; 95%CI: 0.62 to 5.04; p = 0.27) did not differ between groups. During the active straight leg raise test, no differences in lateral displacement (β = 3 cm; 95%CI: 3 to 8; p = 0.30) and COP displacement velocity (RGM 1.03; 95%CI: 0.70 to 1.52; p = 0.87) were observed.

CONCLUSIONS

Although the women with a history of PGP considered themselves recovered, their balance control during single leg stance was poorer compared to those without a history of PGP. No differences were found during the active straight leg raise test.

Trunk, pelvic and hip kinematics during the Stork test in pregnant women with pelvic girdle pain, asymptomatic pregnant and non-pregnant women

BACKGROUND

Pelvic girdle pain is prevalent during pregnancy, and women affected report weight-bearing activities to be their main disability. The Stork test is a commonly used single-leg-stance test. As clinicians report specific movement patterns in those with pelvic girdle pain, we aimed to investigate the influence of both pregnancy and pelvic girdle pain on performance of the Stork test.

METHODS

In this cross-sectional study, 25 pregnant women with pelvic girdle pain, 23 asymptomatic pregnant and 24 asymptomatic non-pregnant women underwent three-dimensional kinematic analysis of the Stork test. Linear mixed models were used to investigate between-group differences in trunk, pelvic and hip kinematics during neutral stance, weight shift, leg lift and single leg stance.

FINDINGS

Few and small significant between-group differences were found. Pregnant women with pelvic girdle pain had significantly less hip adduction during single leg stance compared to asymptomatic pregnant women (estimated marginal means (95% confidence intervals) -1.1° (-2.4°, 0.3°) and 1.0° (-0.4°, 2.4°), respectively; P = 0.03). Asymptomatic pregnant women had significantly less hip internal rotation compared to non-pregnant women 4.1° (1.6°, 6.7°) and 7.9° (5.4°, 10.4°), respectively (P = 0.04) and greater peak hip flexion angle of the lifted leg in single leg stance 80.4° (77.0°, 83.9°) and 74.1° (70.8°, 77.5°), respectively (P = 0.01). Variation in key kinematic variables was large across participants in all three groups.

INTERPRETATION

Our findings indicate that trunk, pelvic and hip movements during the Stork test are not specific to pregnancy and/or pelvic girdle pain in the 2nd trimester. Instead, movement strategies appear unique to each individual.

A multivariate model for predicting PPGP considering postural adjustment parameters

BACKGROUND

Prospective studies have described evidence about the risk of developing pregnancy-related pelvic girdle pain (PPGP) such as, parity, previous history of low back and pelvic girdle pain. No previous studies have prospectively associated PPGP with postural control.

AIM

This study aimed to identify postural control predictors of PPGP during pregnancy.

METHODS

Forty-six pregnant women were surveyed throughout their pregnancy for the presence of PPGP. At baseline, participants were evaluated for muscle latencies, mediolateral centre-of-pressure (COP) displacement and velocity during single-leg lift performed with eyes open and closed. PPGP was considered if they presented with one positive clinical assessment as well as pain within the pelvic area.

RESULTS

Eighteen (45%) of the participants developed PPGP. This group presented with PPGP around a mean 29th week (SD = 5.7), with mean pelvic pain intensity of 4 mm VAS (SD = 2) on a (0-10 cm VAS) and mean PPGP questionnaire score of 21.5 points (SD = 10.6) out of a possible 100 points with 0 indicating no functional disability. The two factors that were significantly associated with PPGP were the right and left biceps femoris (BF) muscle. For every 50 ms of difference of BF muscles latency between eyes open and closed, the risk of PPGP increases by 20% (right BF) and 30% (left BF) to develop PPGP.

CONCLUSION(S)

This study shows that BF muscle delay during single-leg lift presented at baseline was a significant predictor for the development of PPGP in late pregnancy.

The pelvic girdle pain deadlock: 1. Would 'deconstruction' help?

INTRODUCTION

Pelvic Girdle Pain (PGP) is an important clinical problem that deserves more attention. Several treatment regimens have been presented that appear to be somewhat promising, but it was reported that about 10% of patients still suffer from the problems 11 years after their inception. This situation should be improved.

PURPOSE

We present a personalized history, with first the acceptance of the concept of 'PGP', around 2005, and then continued problems in really understanding PGP's nature and causes. We propose to engage in 'deconstruction' of PGP, that is, disentangling the large variety of processes involved.

IMPLICATIONS

Deconstructing PGP is a venture into the unknown. Still, science should proceed on the basis of what we know already. To understand PGP, experts emphasize the importance of biomechanics or of psychology, and we propose to insert 'inflammation' between these two levels of understanding, that is to say, the full development from low grade local inflammation to systemic inflammation and neuroinflammation. Inflammation is bidirectionally related to biomechanical as well as psychological processes. For clinicians, challenging our "beliefs and understanding of PGP, rather than being 'stuck' with a preferred modus operandi" has major practical implications. It requires continuous monitoring of the patient, and a willingness to change direction. More scientific disciplines are relevant to understanding, and treating, PGP than a single human being can master. Creative flexibility of clinicians would be a promising starting point to improve overall treatment effects in PGP.

Anticipatory postural control differs between low back pain and pelvic girdle pain patients in the absence of visual feedback

PURPOSE

The aim of this study was to examine the effect of vision on anticipatory postural control (APA) responses in two groups of clinically diagnosed chronic low back pain patients, those with Posterior Pelvic Girdle pain and those with Non-Specific Low Back Pain compared to a matched group of healthy controls during the modified Trendelenburg task.

METHODS

Seventy-eight volunteer participants (60 females and 18 males) gave informed consent to take part in this study. 39 with confirmed LBP or PGP lasting longer than 12 weeks and 39 healthy matched controls performed 40 single leg lift tasks (hip flexion to 90° as quickly as possible) with their non-dominant lower limb. A force plate was used to determine the medial-lateral displacement of the center of pressure, and the initiation of weight shift; kinematics was used to determine initiation of leg lift; and electromyography was used to determine onset times from the external oblique (EO), internal oblique (IO) and lumbar multifidus (MF), gluteus maximus (GM) and biceps femoris (BF).

RESULTS

The PGP group showed significantly longer muscle onset latencies in the BF, EO MF with visual occlusion (F_2,746 = 4.51, p < .0001).

CONCLUSION

The muscle onset delays identified between the two LBP sub-groups suggests that pain may not be the primary factor in alteration of APA response. The PGP group show a greater reliance on vision which may signal impairment in multiple feedback channels.

Altered musculoskeletal mechanics as risk factors for postpartum pelvic girdle pain: a literature review

[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.

Effect of repeated application of rigid tape on pain and mobility deficits associated with sacroiliac joint dysfunction

BACKGROUND

Sacroiliac joint dysfunction (SIJD) accounts for up to 30% of patients with low back pain. Rigid taping techniques are often used for conservative treatment of SIJD related symptoms; however, its effectiveness has not been systematically evaluated.

OBJECTIVES

The aim of our study was to investigate the effect of rigid tape on pain, malalignment and mobility deficits associated with anterior innominate SIJD.

METHODS

Two groups (n= 37; experimental and control) diagnosed with SIJD participated in a randomized, controlled trial. Tape was applied for 2 weeks in the experimental group, whereas the control group received no treatment. 2 × 2 (group × time) GLM-MANOVA assessed effects of tape on pain; innominate rotation; and hip rotation range of motion. Chi-square and McNemar tests assessed the effect of tape on Gillet and Sitting forward flexion mobility tests; the Patrick, Posterior shear and Gaenslen pain provocation tests were used to test pain. Variables were assessed before (PRE) and after (POST) two weeks.

RESULTS

No group differences were observed for any variable PRE. Pain intensity, innominate rotation (p< 0.05) and number of positive mobility and pain provocation tests (p< 0.05) decreased from PRE versus POST in the experimental group. No differences were observed in the control group.

CONCLUSION

Two weeks of rigid tape for anterior innominate correction successfully reduced symptoms related to SIJD.

Kinematic and spatiotemporal gait characteristics in pregnant women with pelvic girdle pain, asymptomatic pregnant and non-pregnant women

BACKGROUND

Walking difficulties are common among pregnant women with pelvic girdle pain. This cross-sectional study investigated the influence of pelvic girdle pain, pregnancy and speed on spatiotemporal and trunk, pelvic and hip kinematics during gait in the 2nd trimester of pregnancy.

METHODS

Three-dimensional gait analysis at self-selected speed was performed in 25 pregnant women with pelvic girdle pain, 24 asymptomatic pregnant and 24 non-pregnant women. Linear mixed models were used to investigate between-group differences in gait variables. Adjustment for gait speed was included in the analysis. Correlations between speed and fear of movement, disability and pain were examined using Spearman correlation coefficient (r_s).

FINDINGS

Pregnant women with pelvic girdle pain walked 18% slower (estimated marginal means (95% confidence intervals) 1.18 (1.22, 1.24) meter/s) compared to asymptomatic pregnant women (1.44 (1.38, 1.50) meter/s) (P < 0.001). Moreover, with longer double limb support (5%, P = 0.04), shorter contralateral step length (3%, P = 0.03) and more restricted pelvic and hip kinematics (0.001 ≤ P ≤ 0.01) adjusted for speed. Only stance, double limb support and thoracic rotation (0.001 ≤ P ≤ 0.04) differed between asymptomatic pregnant and non-pregnant women. Speed was negatively correlated with fear of movement (r_s = -0.63, P = 0.01) and disability (r_s = -0.46, P = 0.03) in the pelvic girdle pain group.

INTERPRETATION

Gait is primarily influenced by pelvic girdle pain and less by pregnancy. Pregnant women with pelvic girdle pain walked slower and with a more rigid gait pattern compared to asymptomatic pregnant women, presumably related to altered load transfer. Our results may assist clinical evaluation of pelvic girdle pain, as well as direct future research.

A Narrative Review of Musculoskeletal Impairments Associated With Nonspecific Chronic Pelvic Pain

The purpose of this narrative review is to present the evidence relating to musculoskeletal impairments found in people with nonspecific chronic pelvic pain (CPP). The musculoskeletal impairments assessed in this review include pelvic floor muscle: performance, resting state, strength, activation, posture and movement patterns. A search was performed systematically using PubMed, Cochrane, CINAHL, Embase, and Web of Science databases from 1998 to 2018 to identify studies reporting the relationship between nonspecific CPP and musculoskeletal impairments of the hip, pelvis, and trunk. The search resulted in 2106 articles that were screened by two authors. Remaining articles were screened by an additional two authors for inclusion in this review. Thirty-one articles remained after initial screening. Full-text publications were reviewed and an additional 25 articles were excluded. Six additional articles were located through review of the reference lists of included articles. The final review included 12 publications. Seven of these studies were cross-sectional cohorts or case-control comparing patients with CPP to asymptomatic controls. The level of evidence for the studies included in this review was low at Levels 4 and 5. We were unable to draw clear conclusions regarding the relationships of musculoskeletal impairments and CPP because validity and use of terms and assessments were inconsistent. Further research is needed with standardized definitions and measurements to better understand the musculoskeletal system as it relates to nonspecific CPP.

What's Old Is New Again: The Sacroiliac Joint as a Cause of Lateralizing Low Back Pain

It has not been easy to identify mechanical failure of the sacroiliac joint (SIJ) with traditional imaging. The integrated model of function (Lee and Vleeming, 1998) suggests that under normal circumstances, form and force closure combined contribute to sacral nutation and “locking” the SIJ for optimal load transfer. This model is supported by clinical evidence and scintigraphic findings that contribute to successful therapy in 80% of cases. Single-photon emission computed tomography and x-ray computed tomography (SPECT-CT), a hybrid device, was used in a study of 1200 patients (64% female and 36% male patients with an average age of 42 years; range, 15–78 years) with a clinical diagnosis of SIJ incompetence (pelvic girdle pain syndrome). Standard clinical testing and an alternate series of tests were used as a reference standard for imaging. Symptoms were present for a mean of 43 months. Imaging finding were of increased uptake in the upper SIJ (S1–S2), with extension into the dorsal interosseous ligament and measurable by count profile. Associated findings of tendon enthesopathy reflected altered biomechanics around the pelvis. Ipsilateral adductor enthesopathy was found in 70% and contralateral hamstring enthesopathy in 60% of patients. SPECT-CT criteria for the diagnosis of SIJ incompetence were developed and validated. SPECT-CT is a valid and reproducible technique for the diagnosis of SIJ incompetence with high concordance and specificity compared to the reference standards. Findings are supportive of the integrated model of SIJ function proposed by Lee and Vleeming.

Movement of the sacroiliac joint during the Active Straight Leg Raise test in patients with long-lasting severe sacroiliac joint pain

BACKGROUND

The Active Straight Leg Raise is a functional test used in the assessment of pelvic girdle pain, and has shown to have good validity, reliability and responsiveness. The Active Straight Leg Raise is considered to examine the patients' ability to transfer load through the pelvis. It has been hypothesized that patients with pelvic girdle pain lack the ability to stabilize the pelvic girdle, probably due to instability or increased movement of the sacroiliac joint. This study examines the movement of the sacroiliac joints during the Active Straight Leg Raise in patients with pelvic girdle pain.

METHODS

Tantalum markers were inserted in the dorsal sacrum and ilium of 12 patients with long-lasting pelvic girdle pain scheduled for sacroiliac joint fusion surgery. Two to three weeks later movement of the sacroiliac joints during the Active Straight Leg Raise was measured with radiostereometric analysis.

FINDINGS

Small movements were detected. There was larger movement of the sacroiliac joint of the rested leg's sacroiliac joint compared to the lifted leg's side. A mean backward rotation of 0.8° and inward tilt of 0.3° were seen in the rested leg's sacroiliac joint.

INTERPRETATION

The movements of the sacroiliac joints during the Active Straight Leg Raise are small. There was a small backward rotation of the innominate bone relative to sacrum on the rested leg's side. Our findings contradict an earlier understanding that a forward rotation of the lifted leg's innominate occur while performing the Active Straight Leg Raise.

Concurrent validity and reliability of using ground reaction force and center of pressure parameters in the determination of leg movement initiation during single leg lift

Postural adjustment evaluations during single leg lift requires the initiation of heel lift (T1) identification. T1 measured by means of motion analyses system is the most reliable approach. However, this method involves considerable workspace, expensive cameras, and time processing data and setting up laboratory. The use of ground reaction forces (GRF) and centre of pressure (COP) data is an alternative method as its data processing and setting up is less time consuming. Further, kinetic data is normally collected using frequency samples higher than 1000Hz whereas kinematic data are commonly captured using 50-200Hz. This study describes the concurrent-validity and reliability of GRF and COP measurements in determining T1, using a motion analysis system as reference standard. Kinematic and kinetic data during single leg lift were collected from ten participants. GRF and COP data were collected using one and two force plates. Displacement of a single heel marker was captured by means of ten Vicon(©) cameras. Kinetic and kinematic data were collected using a sample frequency of 1000Hz. Data were analysed in two stages: identification of key events in the kinetic data, and assessing concurrent validity of T1 based on the chosen key events with T1 provided by the kinematic data. The key event presenting the least systematic bias, along with a narrow 95% CI and limits of agreement against the reference standard T1, was the Baseline COPy event. Baseline COPy event was obtained using one force plate and presented excellent between-tester reliability.