Changes in pelvic floor and diaphragm kinematics and respiratory patterns in subjects with sacroiliac joint pain following a motor learning intervention: A case series

doi:10.1016/j.math.2006.06.006

Manual Therapy

Volume 12, Issue 3, August 2007, Pages 209-218

https://doi.org/10.1016/j.math.2006.06.006 Get rights and content

Abstract

This study was a case series design. The objectives of the study were to investigate the ability of a motor learning intervention to change aberrant pelvic floor and diaphragm kinematics and respiratory patterns observed in subjects with sacroiliac joint pain (SIJP) during the active straight leg raise (ASLR) test.

The ASLR test is a valid and reliable tool to assist in the assessment of load transference through the pelvis. Irregular respiratory patterns, decreased diaphragmatic excursion and descent of the pelvic floor have been reported in subjects with SIJP during this test. To date the ability to alter these patterns has not been determined.

Respiratory patterns, kinematics of the diaphragm and pelvic floor during the ASLR test and the ability to consciously elevate the pelvic floor in conjunction with changes in pain and disability levels were assessed in nine subjects with a clinical diagnosis of SIJP. Each subject then undertook an individualized motor learning intervention. The initial variables were then reassessed.

Results showed that abnormal kinematics of the diaphragm and pelvic floor during the ASLR improved following intervention. Respiratory patterns were also influenced in a positive manner. An inability to consciously elevate the pelvic floor pre-treatment was reversed. These changes were associated with improvement in pain and disability scores.

This study provides preliminary evidence that aberrant motor control strategies in subjects with SIJP during the ASLR can be enhanced with a motor learning intervention. Positive changes in motor control were associated with improvements in pain and disability. Randomized controlled research is required to validate these results.

Introduction

The sacroiliac joint (SIJ) and surrounding ligamentous structures are reported to be a source of symptoms in subjects with a diagnosis of non-specific chronic low back pain (Young et al., 2003). Recent research has focused on a test that investigates the ability of a subject to transfer load between the lower limb and the trunk, called the active straight leg raise (ASLR) test. The validity and reliability of this test procedure has been established in subjects with clinically diagnosed SIJ pain (SIJP) (Mens et al., 1999, Mens et al., 2001; O’Sullivan et al., 2002a). This test involves lying supine and raising the leg 5 cm off the supporting surface. The test is positive when accompanied by a primary sensation of profound heaviness of the leg (±pain), which is relieved with the application of compression across the ilium. This test is reported to be positive in a sub-group of subjects with SIJP (Mens et al., 1999; Pool-Goudzwaard et al., 2005). It has been proposed that the reduction in the sensation of heaviness with the application of compression across the ilia reflects enhanced force closure through the SIJ (Pool-Goudzwaard et al., 1998; O’Sullivan et al., 2002a).

Recent research has documented motor control deficits in the presence of SIJP (O’Sullivan et al., 2002a). O’Sullivan et al. (2002a) reported in a group of SIJP subjects with a positive ASLR the presence of aberrant motor control strategies observed during the ASLR test when compared to pain-free controls. Using real time ultrasound and spirometry, the authors’ demonstrated decreased diaphragmatic motion, increased descent of the pelvic floor, increased minute ventilation and respiratory rate, and altered breathing patterns in the pain subjects during the ASLR. These aberrant motor control strategies were eliminated with the addition of manual compression through the ilia applied during the ASLR.

It was hypothesized that these disruptions might represent a deficit in local motor control (pelvic floor, transverse abdominal wall) within the lumbopelvic region in these subjects. This manifested as the adoption of splinting or bracing strategies of the abdominal wall with associated disrupted patterns of respiration during the ASLR, not observed in the normal subjects (O’Sullivan et al., 2002a). Furthermore the normalization of these patterns with the application of compression supported this notion. The adoption of these splinting strategies appears to represent an underlying deficit in the motor control systems ability to provide adequate local compression, or force closure, to the SIJs during the ASLR (O’Sullivan et al., 2002a). This concept is also supported by the report that abdominal bracing is less effective than preferential activation of the transverse abdominal wall muscles for increasing the compression across the SIJs (Richardson et al., 2002).

To test the validity of this hypothesis we proposed that the application of a motor learning intervention directed to the local stabilizing muscles of the pelvis would result in the normalization of the aberrant motor control strategies displayed by these subjects, with associated reductions in pain and disability.

Previous studies have reported motor learning interventions to be effective in altering specific motor control deficits in the presence of chronic low back (O’Sullivan et al., 1997, O’Sullivan et al., 1998) and knee pain (Cowan et al., 2002), but to date no study has investigated these specific changes with SIJP during the ASLR test.

Section snippets

Methods

Nine subjects (8 female and 1 male) with a clinical diagnosis of SIJP and a positive ASLR test were recruited for this study. These subjects were recruited directly from a previous study by O’Sullivan et al. (2002a) providing a series of clinical case studies. Four of the 13 subjects from the original study declined to be involved in the intervention aspect of the study as they were already under different forms of management. The inclusion criteria included pain over the SIJ without proximal

Intervention model

The motor learning intervention model utilized in this study was adapted from work described elsewhere (O’Sullivan et al., 1997; Richardson et al., 1999; O’Sullivan, 2005b). This model is directed by the specific classification of a group of disorders where deficits in motor control appear to be a mechanism for increased strain and resultant ongoing pain (Elvey and O’Sullivan, 2005; O’Sullivan, 2005a). Within this management model the impairments of motor control that are considered to be

Results

The individual pre-treatment data for respiratory rate, tidal volume, diaphragmatic motion and pelvic floor kinematics for these subjects was extracted from our previous study (O’Sullivan et al., 2002a) and reprocessed as a new group to provide the pre-intervention baseline for this case intervention series.

Discussion

This study provides preliminary evidence that a specific motor learning intervention for subjects with SIJP can positively change pelvic floor and diaphragm kinematics and patterns of respiration observed during the ASLR. These changes were associated with concurrent reductions in pain and disability in a group of chronically disabled pelvic pain subjects. However as this study is a case series and did not have a control group or blinded independent investigators, the findings should be viewed

Acknowledgments

We would like to acknowledge the statistical support of Marie Blackmore and the assistance of Julie Beetham, Anita Avery, Ivan Lin, Beatrice Tucker, Jillian Crisp, Felicitas Graf and Chris Perkin.

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Original articleChanges in pelvic floor and diaphragm kinematics and respiratory patterns in subjects with sacroiliac joint pain following a motor learning intervention: A case series

Abstract

Introduction

Section snippets

Methods

Intervention model

Results

Discussion

Acknowledgments

Manual Therapy

Journal of Electromyography and Kinesiology

Manual Therapy

Journal of Electromyography and Kinesiology

Pain

Manual Therapy

Manual Therapy

Clinical Biomechanics

Australian Journal of Physiotherapy

Clinical Biomechanics

Clinical Biomechanics

The Spine Journal

Knowledge about and ability to correct pelvic floor muscle exercises in women with urinary stress incontinence

Neurourology and Urodynamics

Excursion–volume relation of the right hemidiaphragm measured by ultrasonography and respiratory airflow measurements

Thorax

Physical therapy alters recruitment of the vasti in patellofemoral pain syndrome

Medicine and Science in Sports and Exercise

Functional anatomy of the pelvic floor and urinary continence mechanism

A contemporary approach to manual therapy

The Oswestry low back pain disability questionnaire

Physiotherapy

Psychologic factors in low-back-pain disability

Clinical Orthopaedics and Related Research

Long-term effects of specific stabilizing exercises for first-episode low back pain

Spine

Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain

Spine

Results of sacroiliac joint double block and value of sacroiliac pain provocation tests in 54 patients with low back pain

Spine

Original article
Changes in pelvic floor and diaphragm kinematics and respiratory patterns in subjects with sacroiliac joint pain following a motor learning intervention: A case series