Elsevier

Manual Therapy

Volume 12, Issue 2, May 2007, Pages e1-e12
Manual Therapy

Masterclass
Diagnosis and classification of pelvic girdle pain disorders, Part 2: Illustration of the utility of a classification system via case studies

https://doi.org/10.1016/j.math.2007.03.003Get rights and content

Abstract

Pelvic girdle pain (PGP) disorders are complex and multi-factorial and are likely to be represented by a series of sub-groups with different underlying pain drivers. Both the central and peripheral nervous systems have the potential to mediate PGP disorders. Even in the case of a peripheral pain disorder, the central nervous system can modulate (to promote or diminish) the pain via the forebrain (cognitive factors).

It is hypothesised that the motor control system can become dysfunctional in different ways. A change in motor control may simply be a response to a pain disorder (adaptive), or it may in itself promote abnormal tissue strain and therefore be ‘mal-adaptive’ or provocative of a pain disorder. Where a deficit in motor control is ‘mal-adaptive’ it is proposed that it could result in reduced force closure (deficit in motor control) or excessive force closure (increased motor activation) resulting in a mechanism for ongoing peripheral pain sensitisation. Three cases are presented which highlight the multi-dimensional nature of PGP. These cases studies outline the practical clinical application of a classification model for PGP and the underlying clinical reasoning processes inherent to the application of this model. The case studies demonstrate the importance of appropriate classification of PGP disorders in determining targeted intervention directed at the underlying pain mechanism of the disorder.

Introduction

Pelvic girdle pain (PGP) of musculoskeletal origin has become recognised as a clinical entity distinct from that of low back pain. Not unlike low back pain though, clarity in the classification of PGP disorders is regularly lacking in both research and clinical settings. Failure to effectively classify these disorders in a meaningful manner has resulted in confusion about PGP disorders in the same way that a lack of classification of back pain has contributed to the problems surrounding the diagnostic label of ‘non-specific’ low back pain. The failure to meaningfully classify PGP disorders based on their underlying pain mechanism ultimately leads to difficulties in providing appropriate care for the patient, as the treatment may not be directed at the mechanism/s that drive the pain disorder.

In the accompanying article to this paper, a non-exclusive classification system based on a biopsychosocial approach has been presented (O’Sullivan and Beales, 2007a). The underlying basis of this model is one of understanding the mechanism/s involved in the development and maintenance of PGP disorders. It recognises the multi-faceted nature and complex interaction of these mechanisms. This mechanism-based approach directly leads to and facilitates the uptake of appropriate management strategies.

To demonstrate the utility of this classification system three case studies are presented. Note: Where not else stated, subjective data presented in the case studies (fear, beliefs, anxiety, depression scales, etc.) represent a 10-point numerical rating score from data collected from the Orebro Musculoskeletal Pain Questionnaire (Linton, 2005).

Section snippets

Subjective examination findings

39-year-old female; married; two children

Work: home duties

History: 5 year history of chronic PGP that began during her second pregnancy and did not resolve. She reported that after the birth of her second child she became disabled and sought various treatments to manage her disorder. These interventions included manipulation, stabilisation exercises and a pelvic belt. She reported little benefit from these treatments over a period of 2 years. Over this time she had become inactive and very

Summary

These three distinct cases act as clinical examples highlighting the importance of classification and specifically directed management of PGP disorders. Working within a biopsychosocial framework is critical for the management of these disorders. Management strategies that target both the physical and cognitive impairments associated with these disorders has the potential to positively impact on long-term PGP disorders.

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