The automatic pelvic floor muscle response to the active straight leg raise in cases with pelvic girdle pain and matched controls

Ultrasound assessment of the abdominal, diaphragm, and pelvic floor muscles during the respiratory and postural tasks in women with and without postpartum lumbopelvic pain: a case-control study

INTRODUCTION AND HYPOTHESIS

Postpartum lumbopelvic pain (PLPP) is common among women. Abdominal, diaphragm, and pelvic floor muscles (PFMs) modulate intraabdominal pressure as a part of the force closure mechanism. These muscles are exposed to changes during pregnancy that compromise the force closure mechanism. It was hypothesized that abdominal and PFMs activity, the direction of bladder base displacement, diaphragm thickness, and excursion might differ between women with and without PLPP during respiratory and postural tasks.

METHODS

Thirty women with and 30 women without PLPP participated in this case-control study. Ultrasound imaging was used to assess the abdominal, diaphragm, and PFMs during rest, active straight leg raising (ASLR) with and without a pelvic belt, and deep respiration.

RESULTS

The bladder base descent was significantly greater in the PLPP group than in the controls during deep respiration and ASLR without a belt (p = 0.026; Chi-squared = 6.40). No significant differences were observed between the groups in the abdominal muscles activity and diaphragm muscle thickness. There was a significant interaction effect of the group and the task for diaphragm excursion (F (2, 116) = 6.08; p = 0.00) and PFM activity (F (2, 116) = 5.22; p = 0.00). In the PLPP group, wearing a belt compromised altered PFM activation and direction of bladder base displacement.

CONCLUSION

The PFM activity, direction of bladder base displacement, and diaphragm excursion differed between groups during postural and respiratory tasks. Therefore, it is recommended to involve retraining of the PFMs and diaphragm muscle in the rehabilitation of women with PLPP.

What more comprehensive physiotherapy techniques than pelvic floor muscles training should be investigated in the context of post-prostatectomy? A narrative review

BACKGROUND

In a previous article, we have underlined the emerging level of evidence for the effectiveness of a more comprehensive functional physical therapy than solely pelvic floor muscles training (PFMT) for men after radical prostatectomy (RP). More and more authors suggest that physiotherapy programs should not focus only on the side effect of continence, but more generally on the interaction of continence disorders with all other side effects related to patient's physical and emotional functioning.

RESEARCH QUESTION

The aims of this narrative review are to highlight rehabilitation approaches unrelated to analytical PFMT that would seem relevant to consider in the future for post-RP men.

METHOD

Our narrative review sought to map the body of literature relevant to the primary objective (non-PFMT), supplementing the data from our previous review with additional recent articles that were not eligible due to not meeting the inclusion criteria for a systematic review.

RESULTS

After full text screening, 13 interventional studies have been selected. Intervention strategies were based on five major type of exercises: flexibility, synergism & co-activation, coordination & movement control, strength & endurance, aerobic & games therapy. Most of the studies of this narrative review focused on synergies, co-activations and movement control techniques that emphasized the deep abdominal muscles and PFMs reflexive activation. The wide variety of countries represented in the 13 studies with consistent results point to the potential effectiveness and replicability across various socio-cultural, ethnical, or religious contexts.

CONCLUSION

We found 13 studies from 9 different countries that provide a more complete rehabilitation approach than PFMT alone in men post-RP. Intervention strategies were built around five main types of exercises, with the majority of them emphasizing synergies, co-activations, and movement control techniques. In light of these data, we hope that future research will enable us to offer the most relevant and patient-centered physiotherapy treatment.

Effects of Conventional Exercises on Lower Back Pain and/or Pelvic Girdle Pain in Pregnancy: A Systematic Review and Meta-Analysis

Pregnant women frequently complain of low back discomfort associated with their pregnancies. On their quality of life, it could have a detrimental effect. Pregnancy-related low back pain (LBP) and pelvic girdle pain (PGP) are associated with substantial direct and indirect expenditures. Evidence addressing strategies to treat and prevent these illnesses needs to be clarified. This review aimed to examine the connection between exercise, LBP, and PGP. To find relevant studies (in the English language) that matched the inclusion and exclusion criteria, a systematic search of peer-reviewed literature was carried out using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, Scopus, the Web of Science, Pub Med, and ClinicalTrials.Gov. The publishing window was limited to the previous 10 years (2012-2022). Utilizing Review Manager version 5.4 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen), the results were examined. JADAD ratings were used to evaluate the quality of the included studies. To analyze the endpoints, the mean, standard mean difference (SMD), and 95% confidence intervals (CI) were determined. We chose 16 randomized controlled trials (RCTs) that included 1885 pregnant individuals with pelvic girdle and/or lower back discomfort. The combined data showed that the exercise group had lower VAS scores than the control group. The final result, however, did not significantly differ. Most of the studies had high JADAD scores, ranging from 3 to 5 points. Lower back pain and/or pelvic girdle discomfort during pregnancy are not influenced by exercise; however, women who are provided with a regular exercise program appear to manage the condition effectively with improved functional status.

Motor control of the spine in pregnancy-related lumbopelvic pain: A systematic review

BACKGROUND

Some studies observed differences in motor control of the spine between women with pregnancy-related lumbopelvic pain and matched controls. Understanding alterations in spine motor control may help optimizing treatment in this population. The objective is to determine if there are differences in motor control of the spine in pregnant and post-partum women with and without pregnancy-related lumbopelvic pain.

METHODS

Five databases were searched: MEDLINE, Embase, CINAHL, Web of Science and Evidence-Based Medicine Reviews (last search: February 4th 2021). Observational studies that compared motor control of the lumbopelvic spine (in terms of muscle activation [e.g. using EMG or ultrasound imaging] or kinematics) between women with pregnancy-related lumbopelvic pain and matched controls were included. Risk of bias was assessed with a modified version of STROBE statement for cross-sectional studies. No meta-analysis was performed.

FINDING

Fifteen studies were included. Compared to matched controls, pregnant women with pregnancy-related lumbopelvic pain showed differences in lumbar spine kinematic during walking and lifting, although not consistent between studies. The only consistent results were higher transversus abdominis muscle activation during leg movements in post-partum pregnancy-related lumbopelvic pain. Differences in pelvic floor muscle function was inconsistent.

INTERPRETATION

This systematic review identified multiple differences in motor control in pregnancy-related lumbopelvic pain population, predominantly in dynamic tasks. However, consistent differences in lumbopelvic spine motor control were rare. More studies are necessary to determine if motor control is different in pregnancy-related lumbopelvic pain to better understand alteration in motor control and to optimize the efficacy of rehabilitation treatments.

The Association between Postpartum Pelvic Girdle Pain and Pelvic Floor Muscle Function, Diastasis Recti and Psychological Factors-A Matched Case-Control Study

There is uncertainty regarding the association between abdominal morphology, pelvic floor function, and psychological factors in women with postpartum pelvic girdle pain (PGP). The aim of this case-control study was to evaluate the differences between women with and without persistent PGP regarding pelvic floor function, diastasis recti, and psychological factors 6−24 weeks postpartum. Pelvic floor manometry, palpation examination of abdominal muscles, the International Consultation on Incontinence Questionnaire Short Form, The Depression, Anxiety and Stress Scale—21, and the Pain Catastrophizing Scale were used. The PGP group presented with lower vaginal resting pressure (p < 0.001), more tenderness (p = 0.018) and impaired voluntary activation of pelvic floor muscles (p ≤ 0.001). Women with pain also had more distortion on the level of the anterior abdominal wall (p = 0.001) and more severe diastasis recti (p = 0.046) when compared to pain-free controls. Lower vaginal resting pressure was the strongest factor explaining PGP (OR 0.702, 95%CI 0.502−0.981). There were no differences in terms of the pelvic floor strength, endurance, severity of urinary incontinence and reported distress between the groups. Women with PGP 6−24 weeks postpartum differ in pelvic floor and abdominal muscle function from the pain-free controls. Vaginal resting pressure may be an important factor in pelvic girdle pain shortly postpartum. Further studies are needed to see a trend in changes over time.

Mechanisms Underlying Lumbopelvic Pain During Pregnancy: A Proposed Model

Up to 86% of pregnant women will have lumbopelvic pain during the 3rd trimester of pregnancy and women with lumbopelvic pain experience lower health-related quality of life during pregnancy than women without lumbopelvic pain. Several risk factors for pregnancy-related lumbopelvic pain have been identified and include history of low back pain, previous trauma to the back or pelvis and previous pregnancy-related pelvic girdle pain. During pregnancy, women go through several hormonal and biomechanical changes as well as neuromuscular adaptations which could explain the development of lumbopelvic pain, but this remains unclear. The aim of this article is to review the potential pregnancy-related changes and adaptations (hormonal, biomechanical and neuromuscular) that may play a role in the development of lumbopelvic pain during pregnancy. This narrative review presents different mechanisms that may explain the development of lumbopelvic pain in pregnant women. A hypotheses-driven model on how these various physiological changes potentially interact in the development of lumbopelvic pain in pregnant women is also presented. Pregnancy-related hormonal changes, characterized by an increase in relaxin, estrogen and progesterone levels, are potentially linked to ligament hyperlaxity and joint instability, thus contributing to lumbopelvic pain. In addition, biomechanical changes induced by the growing fetus, can modify posture, load sharing and mechanical stress in the lumbar and pelvic structures. Finally, neuromuscular adaptations during pregnancy include an increase in the activation of lumbopelvic muscles and a decrease in endurance of the pelvic floor muscles. Whether or not a causal link between these changes and lumbopelvic pain exists remains to be determined. This model provides a better understanding of the mechanisms behind the development of lumbopelvic pain during pregnancy to guide future research. It should allow clinicians and researchers to consider the multifactorial nature of lumbopelvic pain while taking into account the various changes and adaptations during pregnancy.

Pelvic floor and abdominal muscle responses during hypopressive exercises in women with pelvic floor dysfunction

AIM

To measure the neuromuscular activation of the pelvic floor and abdominal muscles concurrently with vaginal closure forces induced during a hypopressive exercise (HE) and to identify the contribution of the HEs sequences (posture and maneuver) in the muscle's activation.

METHODS

A cross-sectional study design was employed. Sixty-six women who had participated in a physical therapy program focused on HEs were recruited. Pelvic floor muscle (PFM) activation was measured using surface electromyography (sEMG) in supine and in the orthostatic position, and vaginal closure force was measured through vaginal dynamometry in supine. Activation of the abdominal, gluteal, and hip adductor muscles was measured using sEMG. Maximum effort voluntary contractions (MVCs) of the PFMs and reference contractions of the abdominal and hip muscles were acquired for normalization purposes. A HE was then performed in a supine position with one leg raised, then in an orthostatic position.

RESULTS

During the supine HE, the peak PFM sEMG amplitude was 74.4% to 86.5% (49.6%-109.6%) of MVC, the peak vaginal closure force was between 51.2% and 55.7% (95.5%-382.9%) of MVC, and the muscles of the lateral abdominal wall were activated between 25.4% and 35.3% of the reference contraction. During the orthostatic HE, PFM activation was 61.4% (40.1%-105.6%) of MVC, and the lateral abdominal wall muscles contracted at 22.8% of the reference activation level.

CONCLUSIONS

The PFMs, abdominal, gluteal, and adductor muscles are activated during the performance of a HE. The activation level of the PFMs and abdominal muscles is likely insufficient to result in strength gains; however, they could have an endurance effect.

Evidence of stabilizing exercises for low back- and pelvic girdle pain - a critical review

BACKGROUND

Pregnancy-related low back pain (LBP) and pelvic girdle pain (PGP) have been associated with an alteration in the strategy for lumbopelvic stabilization. Different core stabilization approaches exist, the evidence is however controversial.

METHODS

This paper discusses how to improve the evidence of exercises for women suffering from LBP and PGP during and after pregnancy. Exercises should be understood in a context, where the bio-psycho-social perspective directs the prescription of exercises, targeting both psychological and physical factors. The type of exercise probably should be individually tailored to the needs and capability of the individual and it is not only about the most appropriate exercise, it is about dosage and delivery of the exercises, and it is about performance. To promote adherence the use of patient preferences, with self-defined movement goals, may be a motivational basis for behavior change. Communication skills may facilitate positive beliefs and provide a motivational foundation for empowerment, self-efficacy and for self-management. To learn by discovery where the patient learns through their own experiences, might motivate the patients to active engagement and to behavioral change. Adherence probably will increase when the patients understand the aim and the rationale behind the exercises they are prescribed. However, with high adherence to exercises that maintains an inappropriate motor pattern, LBP and PGP possibly could proceed into chronicity.

CONCLUSION

Exercises need to be meaningful to the patient, relevant for daily activities, individualized according to patient preferences, guided and supervised to secure performance and quality.

[Relationship between perineal characteristics and symptoms and pelvic girdle pain: A literature review]

INTRODUCTION

Pelvic girdle pain (PGP) is characterized by the presence of pain in the posterior pelvic area, distally and laterally to the fifth lumbar vertebra, and/or at the pubic symphysis. PGP is a very common pain condition in women, especially during pregnancy and postpartum. After delivery, pain prevalence decreases to 7 % in the first three months. The current literature describes an association between pelvic girdle pain and different perineal characteristics and symptoms.

OBJECTIVES

A better understanding of perineal structures influence on PGP could assist towards the management of this condition. The aim of this review is to describe the peer-reviewed literature about perineal function in patients with PGP.

METHODS

A bibliographic search on PubMed was conducted. The key words used were: pelvic girdle pain, pregnacy-related low back pain, lumbopelvic pain, posterior pelvic pain, peripartum pelvic pain, pelvic girdle relaxation, pelvic joint instability, peripartum pelvic pain, sacroiliac joint pain, sacroiliac joint dysfunction, sacroiliac-joint related pelvic pain and pelvic floor. Two hundred and twenty-one (221) articles were identified. Out of them, a total of nine articles were selected. The level of evidence was determined using Oxford's scale.

RESULTS

Patients with PGP showed increased activity of the pelvic floor muscles (P=0.05) (LE3), decreased urogenital hiatus area (PGP 12.4 cm²±2.7, control 13.7 cm²±2.8, P=0.015) (LE3), shorter endurance time (PGP 17.8 s; control 54.0 s, P=0.00) (LE3), significantly later onset time during affected side leg elevation (PGP 25ms, control -129ms, P=0.01) (LE3), levator ani and obturator internus tenderness (PGP 25/26; control 5/25, P<0.001) (LE3) and a higher prevalence of vesico-sphincteric disorders compared to asymptomatic subjects (LE3).

CONCLUSION

This review confirms that subjects suffering PGP present particular perineal characteristics regarding morphology and biomechanics. It would be interesting to develop clinical research concerning pelvic floor release effect in PGP.

Prevalence of pregnancy-related pelvic girdle pain and associated factors in Australia: a cross-sectional study protocol

INTRODUCTION

Pregnancy-related pelvic girdle pain (PPGP) is a common musculoskeletal disorder. Women with PPGP report difficulty performing everyday functional activities, such as standing and walking. However, the magnitude of the problem remains unknown in Australia. It is important to determine how many women are affected by this condition and the factors associated with PPGP as this will direct healthcare services to being able to better manage women during pregnancy. Thus, this study aims to determine the prevalence of PPGP and associated factors in a Western Sydney population.

METHODS AND ANALYSIS

This study is a cross-sectional study to be conducted at a single hospital in Australia. Participants will be over 18 years of age, between 14 and 38 weeks gestation and recruited randomly from all pregnant women attending antenatal care. Participants will have anthropomorphic measures recorded, such as height and body weight, and be asked to complete questionnaires about their current pregnancy, sociodemographic information, ethnoculture, occupational factors and participation in functional activities. The classification of PPGP will be made as per the published guidelines and will include a physical examination.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the Human Research Ethics Committees of Westmead Hospital, Sydney, and Western Sydney University, Sydney. Dissemination of results will be via journal articles and conference presentations.

TRIAL REGISTRATION NUMBER

ACTRN12617000904370.

The transverse abdominal muscle is excessively active during active straight leg raising in pregnancy-related posterior pelvic girdle pain: an observational study

BACKGROUND

Many studies suggest that impairment of motor control is the mechanical component of the pathogenesis of painful disorders in the lumbo-sacral region; however, this theory is still unproven and the results and recommendations for intervention remain questionable. The need for a force to compress both innominate bones against the sacrum is the basis for treatment of pregnancy-related pelvic girdle pain (PGP). Therefore, it is advised to use a pelvic belt and do exercises to enhance contraction of the muscles which provide this compression. However, our clinical experience is that contraction of those muscles appears to be excessive in PGP. Therefore, in patients with long-lasting pregnancy-related posterior PGP, there is a need to investigate the contraction pattern of an important muscle that provides a compressive force, i.e. the transverse abdominal muscle (TrA), during a load transfer test, such as active straight leg raising (ASLR).

METHODS

TrA thickness was measured by means of ultrasound imaging at rest and during ASLR in 43 non-pregnant women with ongoing posterior PGP that started during a pregnancy or delivery, and in 39 women of the same age group who had delivered at least once and had no current PGP (healthy controls).

RESULTS

In participants with PGP, the median TrA thickness increase with respect to rest during ipsilateral and contralateral ASLR was 31% (SD 46%) and 31% (SD 57%), respectively. In healthy controls, these values were 11% (SD 25%) and 13% (SD 22%), respectively.

CONCLUSIONS

Significant excessive contraction of the TrA is present during ASLR in patients with long-lasting pregnancy-related posterior PGP. The present findings do not support the idea that contraction of the TrA is decreased in long-lasting pregnancy-related PGP. This implies that there is no rationale for the prescription of exercises to enhance contraction of TrA in patients with long-lasting pregnancy-related PGP.

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.

Response of the muscles in the pelvic floor and the lower lateral abdominal wall during the Active Straight Leg Raise in women with and without pelvic girdle pain: An experimental study

BACKGROUND

The relationship between activation of the stabilizing muscles of the lumbopelvic region during the Active Straight Leg Raise test and pelvic girdle pain remains unknown. Therefore, the aim was to examine automatic contractions in relation to pre-activation in the muscles of the pelvic floor and the lower lateral abdominal wall during leg lifts, performed as the Active Straight Leg Raise test, in women with and without persistent postpartum pelvic girdle pain.

METHODS

Sixteen women with pelvic girdle pain and eleven pain-free women performed contralateral and ipsilateral leg lifts, while surface electromyographic activity was recorded from the pelvic floor and unilaterally from the lower lateral abdominal wall. As participants performed leg lifts onset time was calculated as the time from increased muscle activity to leg lift initiation.

FINDINGS

No significant differences were observed between the groups during the contralateral leg lift. During the subsequent ipsilateral leg lift, pre-activation in the pelvic floor muscles was observed in 36% of women with pelvic girdle pain and in 91% of pain-free women (P=0.01). Compared to pain-free women, women with pelvic girdle pain also showed significantly later onset time in both the pelvic floor muscles (P=0.01) and the muscles of the lower lateral abdominal wall (P<0.01).

INTERPRETATION

We suggest that disturbed motor activation patterns influence women's ability to stabilize the pelvis during leg lifts. This could be linked to provocation of pain during repeated movements.