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Pregnancy-related pelvic girdle pain and its relation to muscle function
Linköping University, Department of Medicine and Health Sciences, Physiotherapy. Linköping University, Faculty of Health Sciences.
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Pregnancy-related lumbopelvic pain affects approximately 50% of all pregnant women. For the majority the pain disappears during the first  months after delivery; however, for a significant number of women, the pain is persistent, with little improvement for more than three months after delivery. Moreover, women who experience persistent lumbopelvic pain three months postpartum are at substantial risk for new episodes or for chronic lumbopelvic pain later in life. Hence, pregnancy-related lumbopelvic pain should be considered a major public health issue. In order to develop and offer specific treatment strategies, it is important to identify different subgroups of lumbopelvic pain based on different clinical presentations. Pelvic girdle pain (PGP) is one of the major subgroups of pain related to pregnancy. There is no consensus regarding the underlying mechanisms although instability in the pelvis has been proposed as one of the possible mechanism; thus, further studies are necessary to determine how to treat these women. The local lumbopelvic muscle system, including the pelvic floor muscles (PFM) is thought to contribute to the stabilization of the pelvis and they are also the target for many treatment strategies for lumbopelvic pain.

The overall aim of this thesis was to improve rehabilitation for women with persistent postpartum PGP by investigating three areas, including: 1) the postural response of the PFM, 2) the effect of home-based specific stabilizing exercises (SSE) that target the local lumbopelvic muscle system and, 3) predictors for disability at 15 months postpartum.

The thesis comprises three studies: A) a methodological study, B) an experimental study, and C) a clinical randomized controlled trial (RCT). The data is mainly based on muscle function, including recordings of electromyographic (EMG) activation, muscle endurance, and muscle strength. We also collected subjective ratings of disability, healthrelated quality of life, and pain.

The methodological study showed that the designed protocol, which included limb movements performed at a comfortable speed in both standing and supine positions, was useful for detecting a postural response in the PFM. The experimental study demonstrated that women with persistent postpartum PGP and those free of pain exhibited a feed-forward mechanism in the PFM that responded in anticipation to leg lifts performed in a supine position. However, we cannot rule out the possibility that women with difficulties in transferring load between the trunk and legs (i.e., those with functional pelvic instability) might have a different postural response in the PFM. In the present study, one woman with persistent postpartum PGP failed to present a feed-forward mechanism in the PFM, in agreement with previous studies on other parameters of the PFM from other similar groups.

The clinical RCT demonstrated that the concept of home-based SSE with visits every second week with the treating physiotherapist was not more effective than the clinical natural course for improving subjective ratings or muscle function in women with persistent postpartum PGP.

A linear regression analysis revealed a complex picture that suggests that disability 15 months postpartum in women with persistent PGP could be partially predicted by two interaction effects comprising factors from different dimensions: biological, physical functioning, and self-rated function. The proposed association between muscle function and PGP was strengthen. New approaches are most likely needed to further identify subgroups of patients with persistent postpartum PGP that can be considered homogeneous for treatment.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2010. , 79 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1188
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-60194ISBN: 978-91-7393-351-3OAI: oai:DiVA.org:liu-60194DiVA: diva2:355620
Public defence
2010-10-29, Berzeliussalen, Campus US, Linköpings universitet, Linköping, 09:00
Opponent
Supervisors
Available from: 2010-10-07 Created: 2010-10-07 Last updated: 2015-03-24Bibliographically approved
List of papers
1. The postural response of the pelvic floor muscles during limb movements: A methodological electromyography study in parous women without lumbopelvic pain
Open this publication in new window or tab >>The postural response of the pelvic floor muscles during limb movements: A methodological electromyography study in parous women without lumbopelvic pain
2009 (English)In: CLINICAL BIOMECHANICS, ISSN 0268-0033, Vol. 24, no 2, 183-189 p.Article in journal (Refereed) Published
Abstract [en]

Background: Pregnancy-related lumbopelvic pain is common. More than 30% of women have persistent pain 3 months after giving birth. There is no consensus regarding the pathology. However, coordination of muscle activity by appropriate timing and amplitude is necessary for maintaining adequate stability in the lumbopelvic area. The aim was to develop a method using surface electromyography to detect a feed-forward response in the pelvic floor muscles during limb movements performed at a comfortable speed applicable in future studies for women with lumbopelvic pain.

Methods: Ten parous women with no lumbopelvic pain in the past 12 months were included. Surface electromyographic activity was recorded from the pelvic floor muscles and unilaterally from transversus abdominis/internal oblique, rectus abdominis, erector spinae, hip adductors, rectus femoris and deltoid. The subjects performed leg lift in supine and arm lift from standing. The electromyographic onset was related to the initiation of the movement.

Findings: In the majority of the women the electromyographic onsets of the pelvic floor muscles occurred before the movement was initiated, regardless of whether it was a leg or an arm lift. In addition. electromyographic onsets for the other muscles, except the rectus abdominis during the arm lift, also occurred prior to the movements.

Interpretation: The findings suggest a feed-forward response in the pelvic floor muscles during leg and arm lifts in women who had previously given birth and were without lumbopelvic pain. Movements performed at a comfortable speed seem to be useful in order to detect such a response.

Keyword
Low back stability, Feed-forward, Abdominal muscles, Temporal parameters
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-17289 (URN)10.1016/j.clinbiomech.2008.11.004 (DOI)
Note
Original Publication: Jenny Sjödahl, Joanna Kvist, Annelie Gutke and Birgitta Öberg, The postural response of the pelvic floor muscles during limb movements: A methodological electromyography study in parous women without lumbopelvic pain, 2009, CLINICAL BIOMECHANICS, (24), 2, 183-189. http://dx.doi.org/10.1016/j.clinbiomech.2008.11.004 Copyright: Elsevier Science B.V., Amsterdam. http://www.elsevier.com/ Available from: 2009-07-02 Created: 2009-03-16 Last updated: 2015-03-24Bibliographically approved
2. The Postural response of the pelvic floor muscles during the active straight leg raise test in women with and without persistent postpartum pelvic girdle pain: an experimental study
Open this publication in new window or tab >>The Postural response of the pelvic floor muscles during the active straight leg raise test in women with and without persistent postpartum pelvic girdle pain: an experimental study
(English)Manuscript (preprint) (Other academic)
Abstract [en]

The hypothesis was that women with pelvic girdle pain (PGP) would lack a feedforward mechanism in the pelvic floor muscles (PFM) in relation to a functional instability problem. Eight women with PGP and 10 pain-free women were included. A clinical examination was performed to verify that participants with PGP fulfilled the diagnostic criteria used in this study. Surface electromyographic activity was recorded from the PFM and unilaterally from abdominal muscles and the rectus femoris muscle. Participants performed leg lifts (performed as Active Straight Leg Raise (ASLR) tests), first with one leg and then with the other. The lift was also performed with an extra weight strapped on one leg. Median onset of PFM activity occurred before the initiation of the lifts in both groups. One woman experienced more severe PGP/dysfunction demonstrated by a higher score on the ASLR test during the clinical examination. This woman presented onset of PFM activity after the initiation of the lifts. The findings suggest that a feed-forward response of the PFM is present during leg lifts in women with and without postpartum PGP. However, one can speculate that a lack of feed-forward in the PFM may be associated with a load transfer problem.

Keyword
Low back pain; joint instability; electromyography
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-60188 (URN)
Available from: 2010-10-07 Created: 2010-10-07 Last updated: 2015-03-24
3. Specific muscle stabilizing as home exercises for persistent pelvic girdle pain after pregnancy: a randomized, controlled clinical trial
Open this publication in new window or tab >>Specific muscle stabilizing as home exercises for persistent pelvic girdle pain after pregnancy: a randomized, controlled clinical trial
2010 (English)In: Journal of Rehabilitation Medicine, ISSN 1650-1977, Vol. 42, no 10, 929-935 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To investigate the efficacy of home-based specific stabilizing exercises focusing on the local stabilizing muscles as the only intervention in the treatment of persistent postpartum pelvic girdle pain (PGP).

Design: A prospective, randomized, single-blinded, clinically controlled study.

Subjects: Eighty-eight women with PGP were recruited 3 months after delivery.

Methods: The treatment consisted of specific stabilizing exercises targeting the local trunk muscles. The reference group had one telephone contact with a physiotherapist. Primary outcome was disability measured with Oswestry Disability Index. Secondary outcomes were pain, health-related quality of life (EQ-5D), symptom satisfaction, and muscle function.

Results: No significant differences between groups could be found at 3- or 6-month follow-up regarding primary outcome in disability. Within-group comparisons showed some improvement in both groups in terms of disability, pain, symptom satisfaction and muscle function compared to baseline although the majority still experienced PGP.

Conclusion: Treatment with this home-training concept of specific stabilizing exercises targeting the local muscles was no more effective in improving consequences of persistent postpartum PGP than the clinically natural course. Regardless of treatment with specific stabilizing exercises or not, the majority still experiences some back pain almost a year after pregnancy.

Place, publisher, year, edition, pages
Foundation for Rehabilitation Information, 2010
Keyword
Low back pain; postpartum; physical therapy; exercise therapy, pelvic floor; specific stabilizing exercises; trunk muscles
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-60189 (URN)10.2340/16501977-0615 (DOI)000284748600006 ()
Note
Original Publication: Annelie Gutke, Jenny Sjödahl and Birgitta Öberg, Specific muscle stabilizing as home exercises for persistent pelvic girdle pain after pregnancy: a randomized, controlled clinical trial, 2010, Journal of Rehabilitation Medicine, (42), 10, 929-935. http://dx.doi.org/10.2340/16501977-0615 Copyright: Foundation for Rehabilitation Information http://www.medicaljournals.se/jrm/ Available from: 2010-10-07 Created: 2010-10-07 Last updated: 2011-01-13
4. Predictors for disability in women with persistent postpartum pelvic girdle pain
Open this publication in new window or tab >>Predictors for disability in women with persistent postpartum pelvic girdle pain
(English)Manuscript (preprint) (Other academic)
Abstract [en]

The majority of studies on postpartum lumbopelvic pain have investigated predictors for women experiencing lumbopelvic pain during pregnancy. Since the majority of women recover within the first months of delivery it is unknown if the same predictors are valid for disability in women with persistent postpartum pelvic girdle pain (PGP). The aim of this study was to identify predictors for disability in women with persistent PGP 15 months postpartum. Factors were obtained by clinical tests and questionnaires 3 months postpartum. Outcome 15 months postpartum was disability measured with Oswestry Disability Index. A multiple linear regression analysis identified two significant two-way interaction effects that predicted for disability in women with persistent PGP at 15 months postpartum: a) age + trunk flexor endurance, b) disability + hip extensor strength.

Keyword
Muscle function; pregnancy-related low back pain; prognostic factor
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-60190 (URN)
Available from: 2010-10-07 Created: 2010-10-07 Last updated: 2010-10-07Bibliographically approved

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