Bekken- løsning? plager? smerter? Behandling av bekkenleddsmerter -’core’ & hva mer? • En tilstand med mange navn og uklare kriterier Heiberg 1995 • Fysiologisk bekkenløsning • Symptomgivende bekkenløsning • Bekkenleddsyndrom Dnlf 1990 • Pelvic girdle pain / PGP Vleeming 2008 Britt Stuge PT, PhD Oslo University Hospital fysio-terapi as • Bekkenleddsplager Stuge Dnlf 2010 1 • Bekkenleddsmerter Stuge Veilederen 2014 FYSIOTERAPIKONGRESSEN 2015 Diagnostics Pelvic girdle pain (PGP) • Provocation tests – – – – • ”Is a specific form of low back pain that can occur separately or in conjunction with low back pain ” • «A definition is proposed for pelvic musculoskeletal pain under the title ‘pelvic girdle pain (PGP)’ in order to exclude gynaecological and/or urological disorders, and to promote a consistent use of terminology» P4 (posterior pelvic pain provocation test) Patrick Faber Gaenslen’s test Modified Trendelenburg • Pain palpation tests – LDL – Symphysis • Functional test – ASLR test Stuge, Dnlf 2010 Vleeming, European guidelines 2008 3 ASSOCIATION BETWEEN PELVIC GIRDLE PAIN AND PELVIC FLOOR MUSCLE FUNCTION Etiology • Hormonal • Biomechanical • Psycho-social • Motor control De Rosa 2001 6 5 100 CG SSEG 80 60 40 20 Pain intensity (VAS 0-100) Oswestry score (0-100) 100 CG SSEG 80 • The study affording the best evidence used individual guidance and adjustments given by the physiotherapist 60 40 20 0 0 20 weeks 2 year postpar Baseline p=0.15 p<0.001 p<0.001 p<0.001 p=0.19 Baseline 1 year postpar 20 weeks 1 year postpar 2 year postpar – more studies are needed….. p<0.001 p<0.001 p<0.001 Systematic reviews • High quality evidence is lacking to make specific clinical recommondations for or against the use of lumbopelvic neuromuscular training in the rehabilitation of individuals after musculoskeletal injury Briggs 2013 • Targeted core stability training provides marginal benefits to athletic performance Reed 2012 • Strong evidence that stabilisation exercises are not more effective than any other form of active exercise in the long term – A trend of worse FABQ scores with stabilizing exercises • Weak associations between baseline TrA/LM characteristics and future clinical outcomes Wong 2013 • Focus on implementing multijoint free weight exercises, rather than core-specific exercises, to adequately train the core muscles in their athlete clients Marstuscello 2013 A treatment program Stuge 2014 Vleeming & Lee 2001 • The dialog and the individualized guidance seems to be experienced as positive for the women’s coping of their daily life • By being active agents in managing their PGP and therapy they learned to set themselves proximal goals • Perceived hope and self-efficacy seems to be essential for developing a capacity for self-management and an enhanced ability to benefit from appropriate learning experiences Maladaptive behaviour Patient care • Interventions should focus less on specific stabilizing muscles and more on behaviour and optimal dynamic control of movements • It might be that inherent underlying maladaptive movement may act as potential ongoing peripheral nociception rather than a strategy to avoid pain – A pattern of increased co-contraction of trunk stabilizing muscles during tasks that provoke pain and an inability to relax muscles are reported • The examination should – together with an assessment of the psycho-social factors and cognitive aspects – involve analysis of the functional impairments reported by the patient to determine whether the movement and pain behaviours are adaptive (protective) or maladaptive (provocative) • Choice of exercise to individual person • Quality of exercise performance Daenkerts 2011 Most effective exercise therapy • Individually designed treatment programs – Supervised • home exercise with regular therapist follow-up • encouraging adherence – to achieve optimal dosage Hayden 2005 Cognitive behavioral principles • Encorage the patient to: – reconceptualize pain – optimism/goal settings • change is possible! – play an active role in the treatment – self-efficacy – acknowledge their success • Individualizing treatment to the patient Kolt 2004