Spine & Joint Centre’s approach of pelvic girdle pain (PGP)

Author:
Jan-Paul van Wingerden, PhD
Director Spine & Joint Centre

The Spine & Joint Centre is a Dutch outpatient rehabilitation center. It was founded in 1996 by dr. Andry Vleeming. The initial therapy is based on the principle of ‘form and force closure’. Since then the therapy has evolved with many additions and improvements. Our present form of therapy will be described in this paper.

Form and force closure

Form and force closure is a biomechanical model describing how joints in the human body are mechanically controlled. The model was developed especially for the dorsal joints of the pelvis, the sacro-iliac (SJ) joints, but is applicable to all joints in our body. The model describes how the shape of bone and cartilage contributes to the robustness of the joint. In case of the SI joints it is the roughness of the cartilage that increases the form component of joint robustness. For proper joint control the elements of the SI joint (ilium and sacrum) need to be pushed together with a certain amount of force. This compressive force finally determines the robustness and stiffness of the SI joint.

 Disturbed SI joint function

Due to mechanical impact control of compressive force of the SI joints may be compromised. On the one hand this leads to non-optimal muscle activation, especially of the m. transversus abdominis. Compensation by other muscles, like the pelvic floor muscles or piriformis muscle occurs. Lasting over-activation of these muscles leads to secondary problems like incontinence, or compression of the ischial nerve, leading to pain, tingling and even numbness in leg and foot, mimicking radicular signs.

Secondly the SI joint can be inflamed with pain and swelling. The swelling (fluid) in the joint, presses the joint components from each other, compromising the form-closure component. When this occurs patients may experience a sudden increase in complaints and giving way of the leg (not being able to stand on the leg). This sign is often mistaken for radicular problems. Finally when inflamed, due to the swelling, the SI joint is pressed in a counter nutated position. In this position the robustness of the joint is compromised, and continuous overload may take place leading for the patient in a vicious circle that is hard to break through.

Spine & Joint Centre’s rehabilitation program

Although the problem of SI joint dysfunction is mainly physical, behavioral aspects are important in prolonging of the complaints and in the solution. And of course SI joint problems may cause physical impairments that may have severe social impact.

When SI joint function is disturbed, physical capacity is compromised. Because of this overload of the SI joint already occurs under normal daily loading circumstances. Most patients try to fight the problem and stay active, or have social demands (work, family) that challenge them to remain their activities. All this contributes to rendering SI joint problems to become chronic.

Therefore behavior of the patient needs to be addressed too. Behavior needs to be adjusted so it contributes to recovery of the SI joints. To effectively change behavior, education of the patient is essential. Therefore our therapy consists of the following steps:

Explain the patient the underlying mechanisms of SI joint problems

1. Agree with the patient upon which steps need to be taken to address the problem
2. Start with relaxation exercises to diminish compensating muscle activity
3. Start with balancing daily load with physical capacity by introducing resting moments. (every 1-2 hours a 10-15 minute break).
4. Apply preliminary exercises aimed at providing proper situation for muscle exercises (DonTigny auto mobilization SI joints, normalizing lumbar lordosis)
5. Stimulate activation of stabilizing muscles like m. transversus abdominis
6. Apply proper physical control (minimizing compensatory muscle activations) under increased loading situations.

Rehabilitation program

The regular rehabilitation program consists of 16 sessions of three to four hours, over 8 weeks (2 sessions per week). Sessions are provided in groups of 6-10 patients with one therapist for every two patients. Furthermore psychology and ergotherapy are available when necessary. One training session consists of the following aspects:

• Warming up (transition from daily life to focus on recovery)
• Training program 1 (individual and groupwise)
• Lesson/education
• Training program 2 (individual and groupwise)
• Cooling down (closure of session)

Instructional program

The instructional aspect of the rehabilitation focusses on stimulation of commitment to perform the proper actions and behavior for recovery. For this the patient needs information on the underlying mechanisms of the SI joint problem, how pain works, the role of emotions, how choices can be made, how to communicate with your environment (spouse, family, friends, employer) to create optimal circumstances for recovery, etcetera.

Evaluation

The results of every individual patient are monitored. For experienced pain a visual analogue (VAS) score is used. For limitations in daily life the Quebec Backpain Disability Scale (QBDS) is used.

To determine the result the principle of Minimal Clinical Important Change (MCIC) is applied.

This scientifically approved principle prescribes that an improvement of 30% of 20 points relative to the initial score can be considered as a clinical relevant improvement.

Results Spine & Joint Program

In our organization we treat severe chronic pain patient. On average they suffer pain for 6 years. The have consulted medical specialists (often more than one) and have had several sessions of therapy.

95% of our patients improve after 8 weeks of rehabilitation. Of which 60-70% with a clinical relevant improvement (MCIC).

At the three months after therapy evaluation improvement remains, with only a few recurrences.

The 5 year evaluation we had some years ago showed prolonged effect in the majority of patients.

Conclusion

SI joint problems can be severe and disabling, with major mental and social impact. Effective recovery is possible in most cases, but required good analysis of the problem and committing of the patient to the rehabilitation program.

Failure occurs mostly when there is insufficient commitment or the inability of the patient to perform the required exercises properly. Sometimes other diseases are underlying like rheumatic arthritis, cancer or other systemic disease. Sometimes the cause of failure can not be determined. Very incidentally the disturbed SI joint control is of such severity and impact (SI joint instability) that surgical intervention should be considered. In these incidental cases patients are referred to an orthopedic or trauma surgeon.