Elsevier

Manual Therapy

Volume 12, Issue 2, May 2007, Pages 86-97
Manual Therapy

Masterclass
Diagnosis and classification of pelvic girdle pain disorders—Part 1: A mechanism based approach within a biopsychosocial framework

https://doi.org/10.1016/j.math.2007.02.001Get rights and content

Abstract

The diagnosis and classification of pelvic girdle pain (PGP) disorders remains controversial despite a proliferation of research into this field. The majority of PGP disorders have no identified pathoanatomical basis leaving a management vacuum. Diagnostic and treatment paradigms for PGP disorders exist although many of these approaches have limited validity and are uni-dimensional (i.e. biomechanical) in nature. Furthermore single approaches for the management of PGP fail to benefit all. This highlights the possibility that ‘non-specific’ PGP disorders are represented by a number of sub-groups with different underlying pain mechanisms rather than a single entity.

This paper examines the current knowledge and challenges some of the common beliefs regarding the sacroiliac joints and pelvic function. A hypothetical ‘mechanism based’ classification system for PGP, based within a biopsychosocial framework is proposed. This has developed from a synthesis of the current evidence combined with the clinical observations of the authors. It recognises the presence of both specific and non-specific musculoskeletal PGP disorders. It acknowledges the complex and multifactorial nature of chronic PGP disorders and the potential of both the peripheral and central nervous system to promote and modulate pain. It is proposed that there is a large group of predominantly peripherally mediated PGP disorders which are associated with either ‘reduced’ or ‘excessive’ force closure of the pelvis, resulting in abnormal stresses on pain sensitive pelvic structures. It acknowledges that the interaction of psychosocial factors (such as passive coping strategies, faulty beliefs, anxiety and depression) in these pain disorders has the potential to promote pain and disability. It also acknowledges the complex interaction that hormonal factors may play in these pain disorders. This classification model is flexible and helps guide appropriate management of these disorders within a biopsychosocial framework. While the validity of this approach is emerging, further research is required.

Section snippets

Pelvic girdle pain disorders

Pelvic girdle pain (PGP) disorders represent a small but significant group of musculoskeletal pain disorders. Pain associated with the sacroiliac joints (SIJs) and/or the surrounding musculoskeletal and ligamentous structures represent a sub-group of these disorders. Specific inflammatory pain disorders of the SIJs, such as sacroiliitis, are the most readily identified PGP disorders (Maksymowych et al., 2005). However, PGP disorders more commonly present as ‘non-specific’ (no identified

Challenging the beliefs regarding the sacroiliac joints and the pelvis

The SIJ perhaps more than any other joint complex in the body has been shrouded by an enormous amount of mystique within the field of Manual Therapy—with complex, poorly validated and often confusing theories and treatment approaches associated with it. Beliefs of the clinician (that the pelvis is ‘displaced’ or ‘unstable’) commonly become the beliefs of the patients. For many patients these clinical labels can be detrimental with the potential to render the patient passively dependent on

Classification of pelvic girdle pain disorders

Chronic pain disorders are complex, multifactorial and need to be considered within a biopsychosocial framework. A different cluster of potential physical, pathoanatomical, psychosocial, hormonal and neuro-physiological factors is associated with each disorder (Fig. 1). Needless to say the interactions between these factors are very complex. This highlights the need for a flexible classification and management approach for each disorder.

Although the SIJs and the surrounding ligamentous and

Specific pelvic girdle pain disorders

Pelvic girdle pain disorders associated with specific pathological processes include inflammatory arthritis, sacroiliitis, infections and fractures. These disorders are amenable to specific diagnosis with appropriate blood screening and radiological investigation. They can be associated with altered patterns of motor control behaviour that are ‘adaptive’ and/or protective of the underlying disorder. Treating the signs and symptoms of these disorders by manual therapy and/or specific exercise

Non-specific inflammatory pelvic girdle pain disorders

There appears to be a group of PGP disorders that present as being inflammatory in nature, rather than mechanical. They are characterised by constant, disabling and non-remitting pain, located in the SIJs, that is provoked with weight bearing, pelvic compression (such as a SIJ belt) and with SIJ pain provocation tests. These disorders may show areas of increased uptake on bone scan but are not linked to a specific inflammatory disorder diagnosis based on blood screening. They may be relieved

Summary

This paper provides a broad clinical classification model for the management of chronic PGP disorders. It is a flexible, mechanism-based approach within a multifactorial biopsychosocial framework. The classification model directs appropriate management based on the underlying mechanism/s that drives the pain. Although there is growing support for the validity of this approach, further research is required into this area.

Acknowledgements

Many thanks to Dr Britt Stuge and Dr Wim Dankaerts for their clinical insights and advice in the final stages of writing this manuscript.

Note


Part 2 of this Masterclass can be viewed online only at doi:10.1016/jmath.2007.03.003.

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