Sacroiliac joint pain can be a challenging condition to treat. One of the clinical pearls that I feel changed my practice for the better is the palpation and direct treatment of the dorsal sacral ligament. At a course many years ago, I listened to Diane Lee describing some ofAndry Vleeming's work addressing the potential role of the long dorsal sacral ligament (LDL) in pelvic pain. His valuable research was conducted in women who had complaints of peripartum pain, and it has been my experience that the information is easily extrapolated to other patient populations.
Vleeming and colleagues describe the long dorsal sacroiliac ligament anatomy as attaching to the lateral crest of the 3rd and 4th sacral segments (and sometimes to the 5th segment), and as having connections to the aponeurosis of the erector spine group, the thoracolumbar fascia, and the sacrotuberous ligament. Functionally, nutation in the sacroiliac joint will slacken the ligamentous tension in the LDL and counternutation will tension the ligament. This structure can be palpated directly caudal to the posterior superior iliac spine (PSIS).
The referenced study examined how many women had tenderness in the LDL who were also diagnosed with peripartum pelvic pain. Patients included in the study had pain in the lumbopelvic region, pain beginning with pregnancy or within 3 weeks of childbirth, were not pregnant at the time of the study, and were between the ages of 20-40. In patients with peripartum pelvic pain, 76% of the women reported tenderness in the LDL- this number increased to 86% when only patients scoring positively on the active straight leg raise test and posterior pelvic pain provocation (PPPP) test were included.
The study proposes that strain in the LDL may occur from a counternutated sacrum and/or an anterior pelvic tilt position. In my clinical experience and as instructed to many pelvic health therapists by expert clinicians such as Diane Lee, balancing the pelvic structures, activating stabilizing muscles of the inner core (pelvic floor, multifidi, transverses abdominis), and addressing soft tissue dysfunction in the ligament frequently resolve long standing localized pain in the sacroiliac joint area. The authors of the study conclude that "…knowledge of the anatomy and function of the LDL and the simple use of a pain provocation test…could be helpful in gaining a better understanding of peripartum pelvic pain." They also reported that combining tests such as the ASLR, the PPPP test, and the long dorsal sacral ligament palpation test "seems promising" in the differentiation of patients categorized as having pelvic pain versus lumbar pain.
To learn more about sacroiliac joint anatomy and function, diagnosis and treatment, come to Peter Philip's very popular continuing education course, Sacroiliac Joint Treatment, offered for the last time this year in Baltimore in July!
Postpartum depression is a very real, frequently occurring phenomenon that has potentially serious adverse effects on the mother, the child, and on the family as a whole. Serious consequences can include, according to McCoy et al, marital disruption, child neglect or abuse, and suicide. While there are many factors including hormonal shifts that can influence a woman in the postpartum period, strong predictive risk factors can include age less than 25, readmission to the hospital, inability to breastfeed, and lower self-reported health of the mother. A rehabilitation professional is uniquely poised to monitor a postpartum woman over an episode of care and can screen for changes in mood, behavior, or identify risk factors.
Screening for postpartum depression is often completed clinically utilizing the Edinburgh Postnatal Depression Scale. There is a shortened version, the EPDS-3, that asks about self-blame, states of anxiety, and feeling scared, and the shortened version has been documented to have excellent sensitivity. Postpartum psychosis and postpartum post-traumatic stress disorder can also negatively impact a woman's health and a provider needs to be alert for concerning symptoms.
Satisfaction with birth experience has been found to be a risk factor for developing postpartum depression. While we cannot affect a mother's birth experience after the fact, we can offer witness to her feelings, thoughts, and concerns, and we can offer support as rehabilitation professionals. What better way to learn about a patient's challenges and current sense of health than to allow a woman to share her experiences about pregnancy, labor and delivery. Inquiring in an open, non-judgmental manner about a patient's history can provide space for a patient to describe her experiences, perceptions, joys, and concerns. Having a working knowledge of the risk factors allows for therapeutic conversations and referrals in the clinical setting.
In the postpartum course, we discuss the above issues as well as how to observe, listen to, and assess a woman who may need referral for postpartum mental health screening. We also discuss the recent research shedding light on issues of depression in new fathers. The next opportunity to take Care of the Postpartum Patient is in Oakland, CA at the end of March. A great resource page on the womenshealth.gov website is the "Depression During and After Pregnancy Fact Sheet" that can be printed out and shared with patients. Other links and information is also located on the website that can be accessed by clicking here.
Abnormal hip joint development causes 25-50% of all hip disease, according to an article by Goldstein and colleagues on hip dysplasia in the skeletally mature patient. An acetabulum that is dysplastic tends to be shallow and anteverted while the dysplastic femur tends to have a small femoral head and an increased neck shaft angle. These abnormalities cause increased joint contact pressures and lead to joint breakdown in the hip, and are associated with issues such as altered hip and knee biomechanics, hip instability, hip impingement, and labral or chondral dysfunction.
Developmentally, the altered joint surface contact also affects acetabular development: the well-formed contact pressure in healthy hip development helps to deepen the acetabulum. The shape and position of the acetabulum and femoral head will also influence the relative angle of the femoral neck, represented as retroversion or anteversion. Soft tissue changes occur in response to the altered bony mechanics that affect length-tension curves in the muscles and therefore affect muscle performance. Because of the primary and secondary dysfunctions that can occur with hip dysplasia, early recognition of hip dysfunction is important.
Measurements for hip position are easy to implement in the clinic and can include Craig's Test for femoral anteversion/retroversion. Treatment approaches focusing on hip abduction strengthening have been demonstrated to improve hip stability in patients with dysplastic hip. With shared structures including muscles between the hip and pelvis, pelvic rehabilitation providers must be able to assess the hip's influence on conditions of pelvic pain or other dysfunctions. To learn about detailed examination and treatment of the hip, there is still time to register for the Institute's upcoming continuing education course instructed by Ginger Garner.
A recent MedScape articlewarns that "no amount" of alcohol is safe in terms of avoiding cancer risk. Although the mechanisms between alcohol and cancer are not well understood, according to the article, alcoholic beverages can contain at least 15 ingredients that are carcinogenic, such as acetaldehyde, acrylamide, aflatoxins, arsenic, benzene, cadmium, ethanol, ethyl carbamate, formaldehyde, and lead. Potential causative mechanisms for alcohol-related cancer include that alcohol interferes with folate metabolism, and that in relation to breast cancer, alcohol can increase estrogen levels and stimulate mammary cell growth. Hard liquor can affect the oral cavity, the esophagus (especially hard liquor and the colon, rectum, and liver.
According to the author, patients who have health issues related to cancer should be warned to stop using alcohol and should be referred to cessation programs. Pregnant women and youth should be counseled not to drink at all. Alcohol consumption is recommended to be limited to 1 drink per day in women and 1.5 drinks per day for men. Alcohol screening is recommended as a "routine" part of an office visit. Whether the screening is completed on a written or electronic intake, or as part of the verbal history, patients should be asked to report the number of drinks per day, week, or month. Validated screening tools and referral resources that are helpful for patients are listed in this article written by Dr. Friedan.
Smoking in combination with alcohol can worsen the risk for detrimental health effects, especially in the oral cavity, the pharynx, larynx, and esophagus. Physical therapist intervention as a part of smoking cessation education can be an important and effective part of health management. Bladder health is also negatively impacted by smoking, as described in an earlier blog post. As physical therapists and other pelvic rehab providers become more involved in wellness education and integrate smoking and alcohol consumption into their clinical practice, increased knowledge about cancer-related lifestyle issues can be helpful. The Institute offers our Oncology series including a Female and Male focused course on cancer and the pelvic floor. The next opportunity to take Oncology and the Pelvic Floor: Female Reproductive and Gynecologic Cancers is June in Orlando. If you are interested in hosting one of our oncology courses, contact the Institute!
George Thiele, MD, published several articles relating to coccyx pain as early as 1930 and into the late 1960's. His work on coccyx pain and treatment remains relevant today, and all pelvic rehabilitation providers can benefit from knowledge of his publications. Thiele's massage is a particular method of massage to the posterior pelvic floor muscles including the coccygeus. Dr. Thiele, in his article on the cause and treatment of coccygodynia in 1963, states that the levator ani and coccygeus muscles are tender and spastic, while the tip of the coccyx is not usually tender in patients who complain of tailbone pain. The same article takes the reader through an amazing literature review describing interventions for coccyx pain in the early 20th century.
Examination and physical findings, according to Dr. Thiele, include slow and careful sitting with weight often shifted to one buttock, and frequent change of position. He also describes poor sitting posture, with pressure placed upon the middle buttocks, sacrum, and tailbone. Postural dysfunction as a proposed etiology is not a new theory, and in Thiele's article he states that poor sitting posture is "…the most important traumatic factor in coccygodynia…" and even referred to postural cases as having "television disease."
In reference to treatment, Thiele suggests putting a patient in Sims' position (left lateral side lying or recumbent position), and placing the gloved index finger into the rectum with the thumb over the coccyx externally, palpating the coccyx between the thumb and index finger. The finger is then moved laterally, in contact with the soft tissues of the coccygeus, levator ani, and gluteus maximus muscles. The finger is moved with moderate pressure "…laterally, anteriorly, and then medially, describing an arc of 180 degrees until the finger tip lies just posterior to the symphysis pubis." The massaging strokes, applied to a patient's tolerance, are applied 10-15 repetitions on each side with the patient being asked to bear down during the massage strokes. Dr. Thiele recommended daily massage 5-6 days, then every other day for 7-10 days, and gradually less often until symptoms are resolved.
Thiele's massage for coccygodynia is one excellent tool in the treatment of coccyx pain. For a comprehensive view of coccyx pain, check out faculty member Lila Abatte's Coccyx Pain Evaluation and Treatment continuing education course, coming up in New Hampshire in September!
An interesting study assessed the ability of fluorescence imaging to measure the benefits of manual lymphatic drainage (MLD a key component of complete decongestive therapy (CDT). Lymphatic dysfunction, often developing into lymphedema, affects a significant population of our patients who undergo treatment for breast cancer or pelvic cancer. Complete decongestive therapy includes manual lymphatic drainage, compression bandaging, therapeutic exercise, and specific skin care techniques. A theory describing the beneficial effects of MLD, as explained in this article, is that MLD stimulates a contractile or "pumping" mechanism within the superficial lymphatic system.
Although effects of MLD can be measured by limb volume assessment, this study aimed to investigate if in fact contractile function is improved. The investigators used near-infrared fluorescence, or NIR fluorescence, to measure "…the apparent propulsive lymph velocities..and…the period or time of arrival between successive propulsive events." Twelve subjects diagnosed with Grade I or II unilateral lymphedema and 10 controls were included in this research and were treated by a certified lymphedema therapist. The manual lymphatic drainage preparatory protocol for an involved upper extremity included lymphatic massage to the cervical lymph nodes x 5 minutes, then the neck, axillary region of the contralateral arm, and the ipsilateral inguinal region. Lower extremity MLD also started at the neck, then treatment was directed to the contralateral inguinal nodes and ipsilateral axillary nodes. The control subjects received massage to the neck for 3 minutes, bilateral axillary region massage x 5 minutes or bilateral inguinal regions, depending on if the upper or lower limb was imaged in the study. The appropriate limb was then treated with MLD massage techniques.
Prior to and after the treatment, images were collected that allowed the researchers to visualize the imaging contrast agent that was injected through intradermal route into the patient's upper or lower extremities. The results of the study, although limited by statistical power by the low number of subjects, demonstrated that after the manual lymph drainage, in subjects and in controls, treatment had the potential to improve lymph transport. Despite the overall evidence of potential for improvement, there were two subjects in the upper extremity lymphedema group who did not show an improved lymph transport after treatment. One of these subjects also did not respond to MLD and bandaging treatment that followed for six weeks after the fluorescence study. In the lower extremity treatment group, overall apparent lymph velocity and a decrease in the period between propulsive events was noted. The authors state that NIR fluorescence could be utilized to help predict patients who may benefit from manual lymph drainage. The imaging may also help identify functioning lymphatic vessels towards which the therapist can direct manual techniques for draining the limb effectively.
While this study was directed towards the lymphatic dysfunctions of the limbs, what does a pelvic rehabilitation therapist need to know when treating dysfunctions of lymph in the pelvis? Lymphatic function can easily be interrupted following surgeries, or radiation for pelvic cancers, or even following orthopedic injuries. Join Debora Hickman at her continuing education course Manual Lymphatic Drainage for Pelvic Pain in San Diego next month to learn technique in applying MLD for the pelvis!
Do women who have pelvic girdle pain in pregnancy have altered gait patterns? The answer to this question was the aim of a study published in the European Spine Journal in 2008 by Wu and colleagues. Pelvic girdle pain, defined by Vleeming and colleagues as "…a specific form of low back pain (LBP) that can occur separately or in conjunction with LBP…" has been estimated to occur as often as 50% in pregnancy. (Gutke et al., 2006) Unfortunately, of the women who develop pelvic girdle pain in pregnancy, research has demonstrated that 1 in 4 women will develop chronic postpartum pain. (Ostgaard et al., 1991) Pelvic girdle pain can appear as mild, moderate, or severely debilitating, and can be confirmed using provocation tests such as the posterior pelvic provocation test and the active straight leg raise (ASLR). Our role as pelvic rehabilitation providers is critical in minimizing the functional impact of pelvic girdle pain during and following pregnancy.
In regards to gait changes in women who present with PGP in pregnancy, in general, walking velocity is reduced, is negatively correlated with fear of movement, and there are changes in thorax and pelvic rotations. In the study by Wu and colleagues, kinematics were examined in 11 women with PGP and 12 pelvic-healthy controls. Findings within the patients with PGP include that transverse segmental rotation amplitudes were larger, and peak thorax rotation occurred earlier in the stride cycle at higher velocities. The authors suggest that this change in thorax rotation may aid in avoiding excessive spinal rotations caused by larger segmental rotations, or in limiting the motion in the lumbopelvic region.. They further describe that in healthy subjects, pelvic rotations are relatively out-of-phase with the lower extremities at lower velocities, and more in-phase during higher velocities, and that this pattern may be altered in the presence of PGP.
What is the clinical relevance of this information? The primary author in the study also reported on postpartum pelvic girdle pain and gait, and found that changes in trunk and pelvic coordination persist in the postpartum period, and that an individual may employ a variety of adaptive strategies to deal with pain and possibly weakness during gait. What changes in movement strategies does a patient present with in early postpartum versus late postpartum? Does a woman, if she has never been offered rehabilitation, spontaneously recover from these gait adaptations? How does fear of movement and pain-avoiding strategies affect her movement even decades later? In the absence of having gait laboratories, clinical observation of walking at varied speeds can identify patterns of movement that may be aggravating a spinal or pelvic condition. Does she rotate her trunk with a reciprocal limb pattern? Does she limit rotation at the pelvis and overcompensate in the thoracic spine? Observation of patterns that fit clinical symptoms may assist in avoiding persisting gait alterations. Early recognition of pelvic girdle dysfunction in pregnancy and throughout the postpartum period may allow her to avoid compensations in gait that contribute to musculoskeletal dysfunction. To learn about more exciting concepts in postpartum recovery, come to the Care of the Postpartum Patient in Houston in June or in Chicago area in September!
Gutke, A., Östgaard, H. C., & Öberg, B. (2006). Pelvic girdle pain and lumbar pain in pregnancy: a cohort study of the consequences in terms of health and functioning. Spine, 31(5 E149-E155.
Ostgaard, H. C., Anderson, G. B. J., & Karlson, K. (1991). Prevalence of back pain in pregnancy: A review. Spine, 16(5 549-552.
Vleeming, A., Albert, H. B., Östgaard, H. C., Sturesson, B., & Stuge, B. (2008). European guidelines for the diagnosis and treatment of pelvic girdle pain. European Spine Journal, 17(6 794-819.
During a pelvic muscle assessment, patients who have pelvic pain or other dysfunction that includes pelvic floor muscle tenderness will often ask the pelvic rehabilitation practitioner the following question: "Doesn't everyone have tenderness if you push on the muscles like that?" The answer should be "no," and we have research to support this claim. While it may seem incredibly simple to a pelvic rehabilitation provider that a "healthy muscle does not hurt" and that in order to optimize muscle function, the length-tension curve should be optimized, this knowledge is not universally understood by most patients. Tenderness, especially if severe or if the intensity of the discomfort inhibits a healthy muscle contraction, can be eased so that a patient can learn to appropriately contract and relax the pelvic floor muscles.
While logical to rehabilitation providers, the concept that healthy muscles are typically devoid of significant tenderness must be well-established if we wish patients, providers, and payor sources to join in our belief that diminishing such tenderness can be a marker of progress. (Of course we keep in mind that function trumps tenderness, especially when a person has no functional limitations despite presenting with muscle tension or tenderness.) Researchers have aided our profession in establishing that significant muscle tenderness is not present in young, healthy, asymptomatic patients.
In research published last year, Kavvadias and colleagues assessed pelvic floor muscle tenderness in 17 asymptomatic, nulliparous female volunteers (mean age 21.5 years with results indicating low overall pain scores. The authors also aimed to examine inter-rater and test-retest reliability of specific muscle tenderness testing using a visual analog scale (VAS) and a muscle examination method recommended by the International Continence Society (ICS) over 2 testing sessions. This study used a cut-off score of 3 or less on the 0-10 VAS to determine clinically non-significant pain. Inter-rater and test-retest reliability was reported as good to excellent for palpation to the posterior levator ani, obturator internus, piriformis muscle, and for pelvic muscle contraction, yet found to be poor to fair for pelvic floor muscle tone and anterior levator ani palpation. Resulting scores on the VAS were less than 3 for all muscles tested, leading the investigators to conclude that in nulliparous women aged 18-30 who have no lower urinary tract (LUT) symptoms or history of back or pelvic pain, tenderness "…should be considered an uncommon finding."
While this research is in moderate contrast to some research cited in the report, the authors point out that the exclusion criteria and the ages of the women were more narrow in their studied population. Other authors such as Montenegro et al. (2010) have also reported a low prevalence of pelvic muscle tenderness in healthy volunteers (4.2%) whereas Tu et al. reported a high prevalence of tenderness (75%) in women who present with chronic pelvic pain. For male patients, Hetrick et al. concluded that patients with chronic pelvic pain syndrome, or CPPS, have more pain and tension in pelvic and abdominal muscles than men without pain.
The value of research that establishes markers of health in tissues relating to function cannot be underestimated within the realm of pelvic rehabilitation. If we propose or document that reducing tender points, tension and muscle dysfunction is valuable for our patients, research that creates a baseline of non tenderness in patient populations is needed. The research from Kavvadias and colleagues assists our cause, as we can put this information together with other valuable modes of intervention to address pelvic muscle dysfunction within a holistic model of care. If you are interested in discussing further research about pelvic muscle tension, tenderness, and muscle releases, check out faculty member Ramona Horton's Myofascial Release for Pelvic Dysfunction, taking place next in Dayton, Ohio, this June.
Treating patients who have chronic pelvic pain is challenging for many reasons. The nature of chronic pain in any body site often means that the patient has a multifactorial presentation that requires a team approach to interventions. And because the pelvis also contains the termination of several body systems such as the urologic, reproductive, and gastrointestinal, there exists potential for addressing a musculoskeletal issue that is masking a medical issue which requires intervention by a medical provider. The phrase "When you have a hammer, everything looks like a nail" can be applied to patient care for any discipline. When a patient presents with chronic pelvic pain, pelvic rehabilitation therapists can usually find tender pelvic muscles to treat. Is the pelvic muscle tenderness from guarding due to visceral pain or infection?
In a 2013 article in the journal General Practitioner, Dr Croton describes red flag symptoms in acute pelvic pain. These include pregnancy, pelvic or testicular masses, and vaginal bleeding and/or pain in postmenopausal women. During the history taking, patients can be asked about menstrual patterns, possibility of pregnancy, and sexual history. Further medical evaluation may include a pregnancy test, ultrasound, laparoscopy, and urine tests to rule out infection. While the above is not an exhaustive list, it reminds the pelvic rehabilitation provider to always keep in mind the potential for medical evaluation and intervention. Once a patient has been deemed to have "only chronic pelvic pain," a new, equally challenging list emerges: is the pain generated by an articular issue, myofascial dysfunction, neuropathy, psychological stress, or postural pattern? Is the pain local, such as in the pubis symphysis or in the sacroiliac joint ligaments, or are the symptoms referred from a nearby structure, such as the abdominal wall or the thoracolumbar junction? And what are the best methods to examine in a systematic way the various theories about the origins of a patient's pain?
Peter Philip has created a course to provide answers to the above questions. He combines skills in both orthopedics and manual therapy, and pulls from an extensive knowledge about pelvic pain and differential diagnosis which was the research topic of his Doctor of Science degree. Peter's course provides clearly instructed techniques in anatomical palpation, spinal and joint assessment, and he also instructs in how the nervous system and cognition can impact a patient's perception of pain. The course will be offered at the end of this month in Seattle- don't miss this chance to refine skills in differential diagnosis for chronic pelvic pain!
Concepts in "core" strengthening have been discussed ubiquitously, and clearly there is value in being accurate with a clinical treatment strategy, both for reasons of avoiding worsening of a dysfunctional movement or condition, and for engaging the patient in an appropriate rehabilitation activity. Because each patient presents with a unique clinical challenge, we do not (and may never) have reliable clinical protocols for trunk and pelvic rehabilitation. Rather, reliance upon excellent clinical reasoning skills combined with examination and evaluation, then intervention skills will remain paramount in providing valuable therapeutic approaches.
Even (and especially) for the therapist who is not interested in learning how to assess the pelvic floor muscles internally for purposes of diagnosis and treatment, how can an "external" approach to patient care be optimized to understand how the pelvic floor plays a role in core rehabilitation, and when does the patient need to be examined by a therapist who can provide internal examination and treatment if deemed necessary? There are many valuable continuing education pathways to address these questions, including courses offered by the Herman & Wallace Institute that instruct in concepts focusing on neuromotor coordination and learning based in clinical research.
One article that helps us understand how the trunk can be affected by the pelvic floor was completed in 2002 by Critchley and describes how, in the quadruped position, activation of the pelvic floor muscles increased thickness in the transversus abdominis muscles. Subjects were instructed in a low abdominal hallowing maneuver while the transversus abdominis, obliquus internus, and obliquus externus muscle thickness was measured by ultrasound. While no significant changes were noted in obliques muscle thickness, transversus abdominis average measures increases from 49.71% to 65.81% when pelvic floor muscle contraction was added to the abdominal hollowing. Clinical research such as this helps us to understand how verbal cues and concurrent muscle activation may affect exercise prescription.
A collection of clinical research concepts such as the article by Critchley is valuable in connecting points of function and dysfunction for patients with trunk and pelvic conditions- a large part of many clinicians' caseloads. The Pelvic Floor Pelvic Girdle continuing education course instructs in foundational research concepts that tie together the orthopedic connections to the pelvic floor including lumbopelvic stability and mobility therapeutic exercises. Common conditions such as coccyx pain and other pelvic floor dysfunctions are instructed along with pelvic floor screening, use of surface EMG biofeedback, and risk factors for pelvic dysfunction. If you would like to pull together concepts in lumbopelvic stability with your current internal pelvic muscle skills, OR if you would like to attend this course to learn external approaches, you can sign up for the class that takes place in late September in Atlanta.