European guidelines on the diagnosis and treatment of pelvic girdle pain.

Andry Vleeming*

* On behalf of the COST B13 Working Group on Guidelines for on the diagnosis and treatment of pelvic girdle pain.

Andry Vleeming (chairman) Clinical anatomist (NL)

Hanne B Albert Physical therapist (DK)

Hans Christian Östgaard Orthopedic surgeon (SWE)

Britt Stuge Physical therapist (NOR)

Bengt Sturesson Orthopedic surgeon (SWE)

GUIDELINES ON THE DIAGNOSIS AND TREATMENT OF PELVIC GIRDLE PAIN.

Summary of basic studies, epidemiology and risk factors for pelvic girdle pain (PGP)

• Pelvic girdle pain (PGP) is a specific form of low back pain (LBP), that can occur separately or in conjunction with LBP; a new definition of PGP is recommended.

• Although it is possible to focus on and specify PGP, functionally the pelvis can not be studied in isolation.

• PGP is related to non-optimal stability of the pelvic girdle joints • The typical anatomy of the sacroiliac joint (SIJ) (which is characterized by a coarse cartilage texture, cartilage-covered grooves and ridges, a wedge-like shape of the sacrum, and a propeller-like shape of the joint surface) leads to the highest coefficient of friction of diarthrodial human joints. This friction can be altered according to the loading situation and serves to stabilize the pelvic girdle.

• Nutation of the sacrum (flexion of the sacrum relative to the ilia), is generally the result of load bearing and a functional adaptation to stabilize the pelvic girdle.

• More research is needed in patients with PGP to verify whether counternutation of the SIJ (anterior rotation of the ilia relative to the sacrum) in load bearing situations is a typical sign of non-optimal stability of the pelvic girdle.

• The incidence/point/ prevalence of pregnant women suffering from PGP is about 20%. The evidence for this result is strong.

• Risk factors for developing PGP during pregnancy are most probably: a history of previous LBP, and/or previous trauma to the pelvis. There is slight conflicting evidence (one study) against the following risk factors; pluripara and high work load. There is agreement that non risk factors are: contraceptive pills, time interval since last pregnancy, height, weight, smoking and most probably age (one study reports that young age is a risk factor).

• No studies have been published on the risk factors for the non-pregnant population to develop PGP, or which women or men are at risk of developing chronic PGP.

Summary of recommendations for diagnosis and imaging of PGP

• To make the diagnosis PGP the following tests are recommended for use during the clinical examination: (see appendix 1) • SIJ Pain: Posterior pelvic pain provocation test (P4), Patrick’s faber test, palpation of the long dorsal SIJ ligament, and Gaenslen´s test.

• Symphysis: Palpation of the symphysis and modified Trendelenburg’s test of the pelvic girdle.

• Functional pelvic test: Active straight leg raise test (ASLR).

• It is recommended that a pain history be taken with specific attention paid to pain arising during prolonged standing and/or sitting. To ensure that the pain is in the pelvic girdle area, it is important that the precise area of pain be indicated: the patient should either point out the exact location on his/her body, or preferably shade in the painful area on a pain location diagram.

Diagnostic imaging

• There are limited indications for the use of conventional radiography due to its poor sensitivity in detecting the early stages of degeneration and arthritis of the SIJ.

• In most cases of nonankylosing spondylitis (non-AS) PGP, there is limited value for imaging.

• Magnetic Resonance Imaging (MRI) discriminates changes most effectively in and around the SIJ. Early AS and tumors can be easily detected. To establish the diagnosis of PGP imaging techniques are generally only needed in AS, for patients showing “red flag” signs, and when surgical intervention procedures are considered.

• Do not use scintigraphy for PGP.

• Use pain referral maps for PGP.

• Do not use local SIJ injections as a diagnostic tool for PGP. A combination of simple manual diagnostic tests, with high sensitivity and specificity, will analyse a broader spectrum of PGP complaints.

Recommendations for treatment of PGP

• Consider using physical therapy during pregnancy.

• We recommend an individualized treatment program, including specific stabilizing exercises, as part of a multifactorial treatment.

• Consider using water gymnastics (exercises) during pregnancy.

• Consider using acupuncture during pregnancy.

• Consider using therapeutic intra-articular SIJ injections for ankylosing spondylitis (under imaging guidance).

• Do not surgically fuse sacroiliac joints.

Recommendations for future research Basic studies

• Verify whether counternutation of the SIJ (anterior rotation of the ilium relative to the sacrum) in load bearing situations is a typical sign of non-optimal stability of the pelvic girdle in PGP patients.

Diagnosis

• More studies are needed on diagnostic procedures for PGP. The diagnostic tests currently proposed need re-evaluation and trials for falsifications have to be set up.

• More research is needed to verify whether patients with PGP based on ankylosing spondylitis react to the same diagnostic procedures as do non-AS PGP patients.

• Studies are needed with fluoroscopic-guided intra-articular anesthetic SIJ blocks, together with local superficial injections of extra-articular SIJ ligaments and compared to manual diagnostic tests.

• Randomized trials are needed as well as an universal protocol for diagnostic/ follow up procedures after fusion surgery.

• Further evaluate disease-specific outcome measures for PGP.

• Treatment • Different treatment modalities and applications should be investigated to establish evidence for specific recommendations. Future studies should include PGP patients in different cohorts, such as patients with ankylosing spondylitis.The methodological quality of a study is as important as the quality of the intervention studied. High methodological quality does not necessarily guarantee that a study offers a high quality of intervention. Relevant treatment modalities to be studied include: - comparison of exercise programs with and without the use of a pelvic belt - comparison of individualized physical therapy with group treatment - comparison of cognitive interventions with exercise programs.

Study the effect of manipulation, mobilization, massage and relaxation in PGP patients.

• Randomized trials are needed to establish the effect of fusion surgery in PGP patients not responding to non-operative treatment.

The complete article will be available under: www.backpaineurope.org