The influence of mobilisation of the sacroiliacal joint and an stabilizing or relaxation exercise program on pain, the function of the pelvic floor, the m. Transversus Abdominus and functional state in patients with pelvic girdle pain.

Low back pain (LBP) and pelvic girdle pain (PGP) during and after pregnancy is
common in the Netherlands. The point prevalence in women with a history of
LBP/PGP is 88,5% during pregnancy, which decreases to 53,8% two weeks after
delivery.
In woman without such a history is the point prevalence 67,4 during pregnancy
decreasing to 28,1 % two weeks after delivery (1).
The incidence of PGP during pregnancy is 20,1%. In 62,5 % of this group the
pain disappeared within a month after delivery. Two years after delivery 8,6 %
of the women still had PGP (2,3)

PGP during pregnancy gives often problems in daily life and absenteeism of work
(4).
Risk factors are: a history of LBP and/or a trauma of the pelvis in the past.
There is conflicting evidence (one study) for multiparous and high pressure at
work (5)

Despite the quantity of research, diagnosis and classification of PGP is
controversial. There has been no clear pathological anatomical explanation for
most of the pelvic diseases so far(6).
The concept version of the European Guidelines on the diagnosis and treatment
of Pelvic Girdle Pain (5) mentions a consensus definition of PGP: * Pelvic
girdle pain (PGP) generally arises in relation to pregnancy, trauma,
osteo-arthrosis and arthritis. Pain is experienced between the posterior iliac
crest and the gluteal fold, particularly in the vicinity of the sacroiliac
joints (SIJ). The pain may radiate in the posterior thigh and can also occur in
conjunction with/or separately in the symphysis. The endurance capacity for
standing, walking, and sitting is diminished.*
The diagnosis of PGP can be reached after exclusion of lumbar causes. The pain
or functional disturbances in relation to PGP must be reproducible by specific
clinical tests, such as the Active Straight Leg Raise (ASLR) and the Posterior
Pelvic Pain Provocation (PPPP)-test *

O*Sullivan and Beales describe a hypothetic *mechanism based* classification
system within a bio psychosocial framework. According to them the
classification system helps choosing the right treatment. Within the group a
specific PGP disorders they distinguish following subgroups: centrally induced
PGP and peripherally induced PGP.
Centrally induced PGP is commonly associated with extended, severe and constant
pain that is non-mechanical in nature. These disorders are often associated
with dominant psychosocial factors.
Peripherally mediated (mechanically induced) pelvic girdle pain disorders may
be classified into two clinical subgroups: the excessive force closure
(excessive activation of the motor system local to the pelvis) and the reduced
force closure (a loss of functional patterns of co-contraction of the local
force closure muscles of the pelvis)


The excessive force closure group is commonly associated with a negative ASLR.
Compression (manual or using a Sacro Iliacal Joint belt), is often provocative,
as is local muscle activation (pelvic floor, transverse abdominal wall, back
muscles, iliopsoas, gluteal muscles). They commonly hold habitual erect
lordotic lumbopelvic postures associated with high levels of co-contraction
across various of the muscles mentioned above.
The reduced force closure group are commonly associated with a positive ASLR
test (normalised with pelvic compression). Loss of functional patterns of the
pelvic floor, the transverse abdominal wall, the lumbar multifidus, iliopsoas
and the gluteal muscles. Their primary functional impairments are associated
with pain in weight bearing postures such as sitting, standing, walking and
cycling. Postures such as *sway* standing, *hanging off one leg*, *slump*
sitting are often seen.

The *selflocking-mechanism* is a combination of force closure and form closure.
Nutation of the sacrum enhances the form closure and contributes to stability
(7).
There is little research done treatment of PGP.
The concept guidelines advise an individual training program, emphasizing and
starting with activation and control of local deep lumbopelvic muscles.
Gradually include the training of more superficial muscles in dynamic exercises
to improve control mobility, strength, and endurance capacity. This program is
for the reduced forceclosure. Little research has been conducted to the effect
of manipulation with mobilisation with PGP.

Reducing of the force closure is advised for the subgroup excessive force
closure trough relaxation and cardiovascular exercise (6) From clinical
experience this approach appears very effective although clinical studies are
required to validate this.

In our clinic we see patients with PGP on a regular basis. From clinical
experience the combination of a mobilisation and an stabilizing or relaxing
exercise program of local and global muscles looks promising. Therefore , it*s
very important to substantiate this scientifically.

The goal of this study is to investigate the effect of a pelvic
physiotherapeutic / manual therapeutic treatment (usual care) in patients with
PGP (subgroups reduced force closure and excessive force closure)and the
influence on EMG signals of the pelvic floor

The influence of mobilisation of the sacroiliacal joint and an stabilizing or
relaxation exercise program on pain, the function of the pelvic floor, the m.
Transversus Abdominus and functional state in patients with pelvic girdle
pain.

This is a longitudinal study in which patients with pelvic pain, subgroups
reduced and excessive force closure, receiving a usual care pelvic
physiotherapeutic / manual therapeutic treatment (mobilization of the sacral
iliac joint and a stabilizing or relaxing exercise program) are followed.


Design:
Randomized Controlled Trail with two groups, an intervention group and a
control group.
The intervention group gets alongside a stabilizing or relaxing exercise
program and mobilization of the sacral iliac joint. The control group will
receive a stabilizing or relaxing exercise program during the first 6 weeks.
After 6 weeks, they also receive the mobilization of the sacral iliac joint.
The patients are randomly divided over the two groups.


This study will consist of 5 parts:

1. Questionnaires. With the validated questionnaires Pelvic Floor Inventories
Leiden (8.9), Quebeck Back Pain Disability Scale (QBPDS) (10), Numeric Pain
Rating Scale (NPRS) (11) Patient Specific Questionnaire (PSK) (12) is included
in this patient group The complaints in the pelvic region and the functional
status mapped
2. Provocation tests: With the validated challenge test ASLR and PPPP test, the
subgroup is mapped in this patient group (5, 16, 17).
3. Physical examination: With the Fingerfloor Distance Forward(VBA) (Forward
bending with stretched and closed legs. Measuring distance finger floor) and
sideways (Sideways bending with Stretched and Closed Legs. Measuring distance
Floor Finger) and Jointplay (joint mobility) research, the function of the
sacro iliac joints (SIG) is mapped in this patient group
4. Multiple Array Probe Leiden (MAPLe) (14): With the validated MAPLe, the
function of the pelvic floor in this patient group is mapped through EMG
5. Ultrasound: With Ultrasound, the function of the MTrA is mapped in this
patient group

Mobilization of the functional disorder of the sacral iliac joint and a
stabilizing or relaxing exercise program.

Intake: interview, 4 questionnaires, physical examination
Intake (continued): intra vaginal EMG examination with vaginal probe,
ultrasound (external)
3x Evaluation: 4 questionnaires, physical examination,intra vaginal EMG
examination with vaginal probe, ultrasound (external)

The intra vaginall EMG examination obtains the function of the pelvic floor in
an objective manner (Usual Care), and the ultrasound obtains an objective view
of the function of the transverse abdominal muscle. This contributes to the
determination of the subgroup in wich the patient belongs in order that the
appropriate intervention can be applied. By interpretation of the results of
the intravaginall EMG and ultrasound in time, one can analyze and interpret
the effect of the intervention on the pelvic floor and the transverse abdominal
muscle.