3 - PELVIC GIRDLE PAIN & PELVIC FLOOR REHAB Flashcards
(18 cards)
Anatomy of pelvic girdle
= Ring of bones at base of spine
+ table
Definition of PGP
= pain, instability & dysfunction of symphysis pubis joint and / or sacro-iliac joints
- May or may not be related to pregnancy
- Affects 1/5 pregnant women
- Trauma
- Reactive arthritis
- Endurance capacity for standing, walking & sitting decreased
- Significant impact on daily functioning, mental health & QoL
PGP differential diagnosis
Table
PGP: epidemiology & risk factors
Table
Biomechanics: SIJs
Nutation / counternutation
Passive & active stability
Lumbosacral junction mechanics
Table
Lumbosacral junction mechanics
Reciprocal movement
- Flexion of L5/S1: sacral base moves in counternutation (posterior movement)
- Extension of L5/S1: sacral bas moves in nutation (anterior movement)
- Right rotation & left side bending of L5: sacral base rotates left & side bends right
- Left rotation & right side bending of L5: sacral base rotates right & side bends left
Sacrum counterbalances movement of Lx spine at L5/S1
Assessment of PGP: subjective info & objective info
Subjective information
- Pain description, location, intensity, nature, onset
- Functional limitations, walking, stairs, turning in bed sit-to-stand
- Screening tools: Pelvic Girdle Questionnaire
Table
Assessment PGP: identify dysfunctional side
Mechanism of history
- Antenatal (AN) & postnatal (PN) patient’s problem = hypermobility (young, ligaments influenced by hormones, SIJ joint surfaces smooth & susceptible to shear)
- Sudden / traumatic onset may indicate hypomobility problem (joint has been forced beyond normal range & become stuck)
Pain distribution
- 1st episode of pain, unilateral pain only related to pregnancy / acute episode, painful side = dysfunctional side
- Chronic pain: dysfunction side / locked SIJ caused increased stress on opposite side & pain not on side
of dysfunction
- Some patients report bilateral distribution of pain
Assessment PGP: ligaments palpation & assessment question
Ligaments palpation
Palpation of sacral ligaments help identify dysfunctions
- If iliolumbar ligament painful = possible L5/S1 dysfunction
- If long dorsal ligament painful = SIJ dysfunction
Assessment questions
Challenge: painful side = dysfunctional side?
- Is it myofascial (force closure problem): which muscles long / weak or short / tight?
- Is it articular dysfunction (form closure problem)
- Is it the ilium or sacrum?
o Upslip/Downslip
o Anterior/posteriorly rotated
Special tests: list & describe each
ASLR
SIJ stability test
Posterior pelvic pain provocation
Compression
Distraction
Gillet test
Piedallu’s test
GAENSLEN’S
Table
Muscle length / strength test
- Quadratus lumborum
- Iliacus / psoas / rectus femoris
- Hip adductors
- Piriformis
- Hamstrings
- Posterior sling, latissimus dorsi & gluts
- Anterior sling, obliques & adductors
Treatments:
- hypermobile joints
- hypomobile
- MET technique
Hypermobile joint
+ ALSR
+ compression to ASLR & makes it easier
+ stability test
Reduced movements in Gillet test
Teach stability exercises & posterior sling exercises
Hypomobile joint
Questions: asymmetry real or apparent? articular dysfunction? overactive muscle?
+ stability test
Increased movements on Gillets & Piedallu tests
- If articular dysfunction, treat with manual therapy techniques
- If muscular tightness, treat with QL stretches
Table
Pelvic floor muscles:
- functions
- sphincteric muscles
- innervation
Functions
- Supports abdominopelvic viscera
- Resistance to increase intra-pelvic/abdominal pressure
- Sphincteric muscles relax to allow urination & defecation
- Prevents urine incontinence & fecal incontinence
- Prevent LBP, important in posture
- Sexual function
Sphincteric muscles
- Circular muscles acting as valves, regulating flow of substances like food, urine or feces through body
by opening or closing passages
- Contract to close passage
- Relax to open it => controlled movement
Innervation
- Pelvic floor muscles innervated by pudendal nerve (S2-S4) & sacral nerve roots (S3-S4)
- Pudendal nerve innervates perineum, external urethral & anal sphincters => voluntary control
- Sacral nerve roots innervate pubococcygeus & iliococcygeus muscles
Pelvic floor muscles:
- micturition relfex
- fascias
Table
Fascias
- Dynamic adaptable pelvic diaphragm capable of force transmission balanced amongst tensegrity of whole
body
- Literature review shows 3 different layers of continuity between pelvic floor, abdominal fascia & lumbar region
(superficial, superficial layer of deep fascia & deep layer of deep fascia
Anatomy of pelvic floor muscles
Anatomy of PFM
Anterior: Levator Ani:
o Pubococcygeus; anteriorly attaches to body of pubis ⚫️
o Iliococcygeus 🔵
Posterior: Coccygeus (Ischiococcygeus) 🟢
Inferior :
- Puborectalis 🔴
- External anal sphincter
- Central tendon (perineal body)
- Urogenital hiatus
- Rectal hiatus
- Perineal body
Types of muscle fiber of pelvic floor muscle
To guarantee continence pelvic floor muscles must be able to:
- Contract slowly to generate adequate squeeze pressure
- Rapidly & reflexively to counteract ground reaction forces or sudden changes to internal pressure
Levator ani muscle consists of:
- 54.9% - 70.3% slow type I muscle fibres
- 5.1% - 29.7% fast type II muscle fibres
Suggesting levator ani muscle’s main role = maintain optimal position of the PFM’s
Stress Urinary Incontinence (SUI) structurally related to proportion of type I & type II fibres
- 1:3 women affected by SUI
- Continent women produce faster voluntary contraction than incontinent women
Pelvic floor muscle dysfunction:
- causes
- symptoms
Causes
- Pregnancy & childbirth
- Chronic constipation
- Heavy or repeated lifting
- High impact exercise
- Being very overweight
- Chronic respiratory conditions
- Smoking
- Menopause
Table
Pelvic floor muscle rehabilitation:
- description
- exercise position
-exercise prescription
Importance of posterior cueing & breath synergy
Exercise positions
Supine, Crook Kying, Sitting, 4-point kneeling, Half-kneeling, Standing
Exercise prescription
Long squeezes: 10 sec holds, x10 reps, x3/day
Short squeezes: x10 reps x3/day
Take 3-5 months to strengthen
Can be started at any time in life & have benefits
Reminders are helpful
