Introduction

Although it is generally accepted that movement changes with pain, there is little agreement regarding the processes that underlie movement changes and their relevance to rehabilitation of musculoskeletal pain (Hodges & Moseley 2003, Tsao et al. 2010). Additionally, one of the main difficulties in the diagnosis of pain in the pelvis is the overlap of signs and symptoms in various conditions, including medical conditions not directly related to musculoskeletal injuries (Nam & Brody 2008). As discussed in Chapters 1, 2, 3, 8 and 12, these can include urinary tract infection, prostatitis and other urinary, bowel and sexual dysfunctions. The urological, neurological, muscular, skeletal and fascial systems may all have a role to play to varying degrees, and consideration of each is necessary to provide a more accurate diagnosis, and a more valid paradigm on which to base treatment. Furthermore, as discussed in Chapter 2, pain perceived to be within the pelvis can be referred from the thoracolumbar spine, sacroiliac joint and the hip (Lee 2004), and since the body operates as a complete movement system, each component of the system is capable of influencing distal and proximal regions.

In this chapter, the authors consider the concept of movement as a physiological system, and describe a method of assessment based on analysis of a patient’s movement (dys)function, combined with an assessment of their injury history and pain presentation (Sahrmann 2002). Rehabilitation is then focused upon restoring efficient movement patterns, improving function, and less on treating the pain per se. Manual therapists have traditionally used the client’s pain patterns and physical findings, such as pain provocation tests, to identify structures contributing to mechanical pain. However, in the presence of central sensitization and neurogenic pain mechanisms, the reliability of such a pathoanatomical assessment to identify the sources of pain can be limited, particularly as the relationship between pain and the state of the tissues becomes weaker as pain persists (Moseley 2007). Classification of movement patterns, used to identify the mechanical causes of pain, may be similarly limited in the presence of central sensitization, where any mechanical stimulus may be sufficient to generate a painful response. At all times then, current pain physiology, and other contributing factors to chronic pelvic pain (CPP), as discussed in Chapters 1, 2 and 3, need to be considered when assessing the movement system. The role of clinical reasoning is further described in Chapter 7.

Assessment of the movement system

As discussed in Chapters 1 and 2, the movement system is modulated by many factors from across somatic, psychological and social domains (Moseley 2007). It is recognized that the nervous system is likely to coordinate muscle activity to meet the demands for stable movement, so it will not only be affected by the task, posture or movement direction, but potentially the real or perceived risk of injury (Hodges & Cholewicki 2007). Motor changes have been documented to occur throughout the movement system, at the motoneuron level and coordination of muscle behaviour, to changes in organization of the motor cortex (for a review see Tsao et al. 2010). Strategies adopted during pain and injury can increase protection of injured or painful parts, but can have mechanical consequences that may prolong pain states, or result in a higher incidence of recurrence (Hodges & Moseley 2003, van Dieen et al. 2003). In controlled clinical trials, rehabilitation of these motor changes has been linked to clinical improvement, resulting in improvements in pain and dysfunction (Cowan et al. 2003, Ferreira et al. 2006). More recently such improvements have also been shown to be associated with recovery of plastic changes at the motor cortex (Tsao et al. 2010).

Various classifications for the analysis of movement and the sub-classification of movement dysfunction have been proposed (McGill 2002, Sahrmann 2002, McKenzie & May 2003, O’Sullivan 2005) and in some instances are gaining good evidence of validity and reliability (Van Dillen et al. 1998, 2003, Dankaerts et al. 2006, Harris Hayes et al. 2009, 2010). It is beyond the scope of this chapter to describe the benefits and limitations of each classification system; however it is reasonable to suggest that the multidimensional problem of chronic low back and pelvic pain should also encompass biopsychosocial principles (Linton 2000, Waddell 2004, Woby et al. 2004, 2007) which are discussed in Chapter 7. The following section describes the evaluation, classification, and subsequent rehabilitation of lumbopelvic movement disorders based upon the work of Sahrmann (2002).

Sahrmann (2002) suggested a classification system for the analysis of lumbopelvic movement and the subsequent prescription of treatment based on clinically assessed movement system dysfunction. A central tenant of the system is that ‘faulty movement can induce pathology, not just be a result of it, and musculoskeletal pain syndromes are seldom caused by isolated events but are the consequence of habitual imbalances in the movement system’ (Sahrmann 1993). Therefore, specific postures and movements that produce pain need to be identified and corrected, as misalignment and aberrant movement patterns might result in further pain and future recurrences (Van Dillen et al. 2003).

The objective examination has two major components:

Table 6.1 Items from original examination (Van Dillen et al. 1998) proposed as important for classification of mechanical low back pain organized by test position, symptom behaviour with variations of the test position or movements within the test position, and clinical judgements of quality of alignment or movement

Test position	Symptom behaviour with	Judgement of alignment or movement
Standing	• Standing • Posterior pelvic tilt against wall • Forward bending • Corrected† forward bending • Return from forward bending • Corrected return from forward bending • Side bending

Sitting Supine   Hook (crook) lying Prone Quadruped

* A judgement of relative flexibility refers to a judgement made by the examiner about the relative timing of movement of the lumbar region and the proximal joints when the patient performs a trunk or a limb movement. In general, a patient exhibits a relative flexibility impairment if the lumbar region moves in the first 50% of the range of the overall movement or excessively during the overall movement.

† Corrected test items are follow-up items in which the lumbar region is repositioned to achieve a neutral alignment, or movement of the lumbar region is restricted relative to what was observed with the previous symptomatic test item. The effect of the changes in alignment and movement on symptoms is assessed.

‡ Because rotation and side-bending are coupled motions in the lumbar region, items that refer to judgements of alignment and movement of lumbar region rotation or pelvic rotation include side-bending alignment or movement.

There are several unique components to this examination system:

The information obtained from this assessment allows the patient to be categorized into one of five different categories, named after the type of mechanical factors hypothesized to be factors in the contribution of mechanical low back pain (MLBP) (Van Dillen et al. 2003):

Although the classifications are termed lumbar movement impairments, the analysis is technically of the lumbopelvic region. Additionally as discussed in Chapters 1, 2 and 3, not only do proximal regions of dysfunction affect distal segments of the movement system, the lumbar spine refers pain to the pelvis and hip and CPP definitions involve the pelvis, anterior abdominal wall, lower back and/or buttocks (ACOG 2004, Fall et al. 2010).

The musculoskeletal factors that need to be considered include the passive and active stiffness of the lumbopelvic spine and hips which will be influenced by muscle and fascial systems, all under neuronal control. Assessment of the neural system is therefore also critical, as irritability of, and the ability of the nerve trunk to glide along its neural canal, will affect the perceived length of the muscle (Hall et al. 1998; Walsh et al. 2009). Structural differences such as bony variation of the pelvis and femur, imbalances of strength, length, timing and magnitude of recruitment of the trunk and hip muscles will also need to be assessed during test movements, as well as specific functional activities.

Common postural types (see Kendall et al. 2005, Sahrmann 2002)

Table 6.2 shows the proposed MLBP categories with the associated signs, symptoms and general treatment guidelines. Although it should be stressed that this movement assessment system has not yet been fully validated, the construct validity of the movement impairment-based classification system provided support for three out of the five categories (Van Dillen et al. 2003) and recently the inter-tester reliability based on this classification system has been shown to be substantial (Harris-Hayes & Van Dillen 2009).

Table 6.2 Proposed mechanical low back pain categories with associated signs and symptoms and general treatment guidelines (taken from Van Dillen et al. 2003)

Category	Associated signs and symptoms	General treatment guidelines
Flexion	Tendency for the patient to move the lumbar spine in the direction of flexion with movements of the spine or extremities. Lumbar spine alignment tends to be flexed relative to neutral with the assumption of postures. Symptoms occur or increase with positions and movements associated with flexion of the lumbar spine. Symptoms are decreased with restriction of lumbar flexion	Functional instruction: 1. Bed positioning/mobility: Don’t curl your spine as you sit up in bed. Roll to your side and push yourself up with your arms to come to sitting 2. Sitting: Sit with your back supported, your shoulders over your hips, your hips and knees level, or your knees positioned lower than your hips. You may need a small towel roll in your lower back region for support. Don’t sit slumped 3. Sit to stand: Scoot yourself to the edge of the chair keeping your back upright. Get up against the edge of the chair before sitting down. Don’t bend in your back getting up and down. Bend the hips and knees 4. Standing: Don’t stand with your pelvis swayed forward Exercise: 1. Train trunk muscles (paraspinals and abdominals) to work isometrically with performance of limb movements (e.g. standing against a wall, flex shoulders while keeping lumbar region neutral) 2. Training to isolate hip flexion without lumbar spine flexion (e.g. rock backward in quadruped keeping lumbar region neutral) 3. Exercise to increase flexibility of any muscles contributing to lumbar flexion (e.g. stretch gluteus maximus while supine keeping lumbar region supported in neutral) 4. Exercise to shorten muscles that may assist in reducing lumbar spine flexion alignment (e.g. iliopsoas strengthening in sitting while keeping lumbar region neutral) Support: 1. Taping of lumbar region to discourage lumbar flexion 2. Use of abdominal support, particularly during activities that encourage lumbar flexion

Extension Signs and symptoms are similar to those described for flexion except that they are associated with extension of the lumbar spine. Symptoms are decreased with restriction of lumbar extension Functional instruction:

Exercise:

Rotation Signs and symptoms are similar to those described for flexion except that they are associated with rotation of the lumbar spine.
Symptoms are decreased with restriction of lumbar rotation Functional instruction:

Exercise:

Support:

Rotation with flexion Tendency for the patient to move the lumbar spine in the direction of rotation and flexion with movements of the spine or extremities.
Lumbar spine alignment tends to be flexed and rotated relative to neutral with the assumption of postures. Symptoms (often unilateral) occur or increase with positions and movements associated with rotation and flexion of the lumbar spine. Symptoms are decreased with restriction of lumbar rotation and flexion The same as for the rotation and flexion categories with an emphasis on (1) symmetry of performance of functional activities, (2) attaining symmetry of muscle activity and flexibility with exercises, and (3) support to discourage flexion and asymmetry of alignment and movement of the lumbar region Rotation with extension Signs and symptoms are similar to those described for rotation with flexion except that they are associated with rotation and extension of the lumbar spine.
Symptoms (often unilateral) are decreased with restriction of lumbar rotation and extension The same as for the extension and the rotation categories with an emphasis on (1) symmetry of performance of functional activities, (2) attaining symmetry of muscle activity and flexibility with exercises, and (3) support to discourage extension and asymmetry of alignment and movement of the lumbar region

The aim of the assessment is to identify the postural alignment strategies and the habitual movement patterns which may contribute to the individual’s presenting condition. Each syndrome has specific key tests, which help identify the alignment strategies assumed by the individual and confirm the direction of the movement patterns. The patient is then observed during performance of symptom-provoking functional activities, to determine if the same strategies are repeated. Functional instruction is then directed toward modifying the patient’s preferred strategies. Exercise prescription is directed toward correcting the patient-preferred movement and alignment strategies identified on examination. Emphasis is on modifying the strategies that (1) are symptom-provoking and (2) can be modified to decrease the patient’s symptoms during the examination (Van Dillen et al. 2003). This systematic approach is repeated in order to classify movement impairment syndromes of the hip and is described later in this chapter (Table 6.3). It should also be emphasized that, in the authors’ opinion, if the client holds negative beliefs and attitudes associated with pain, such as exhibiting fear-avoidance behaviours without an understanding of current pain biology, the way in which these corrective exercises are explained could contribute to their fear of movement and potentially make their pain problem worse. In this instance, addressing the patients’ attitudes, beliefs and understanding needs to be the therapists’ main priority (O’Sullivan 2005).

Lumbopelvic cylinder and chronic pelvic pain

In the presence of postural changes, respiratory demands, lumbopelvic pain (LPP) and stress incontinence, muscles of the lumbopelvic cylinder (LPC) are altered (Hemborg et al. 1985, Hodges & Richardson 1996, 1998, Hides et al. 1996, Moseley et al. 2002, Hodges & Gandevia 2000, O’Sullivan et al. 2002, Jones et al. 2006, Hodges et al. 2007, Dickx et al. 2008). However, it appears that skilled voluntary activation of muscles with altered motor recruitment can reduce pain, disability and recurrence rate for musculoskeletal conditions (Hides et al. 2001, Cowan et al. 2003, Ferreira et al. 2006), restore motor co-ordination including automatic postural adjustments (Cowan et al. 2003, Tsao & Hodges 2007, 2008), reversing cortical reorganization in people with recurrent pain (Tsao et al. 2010). These findings suggest then, that in addition to the five categories of movement dysfunction described above, muscles of the LPC should be evaluated and rehabilitated, when appropriate, in patients with CPP, although to date there is no scientific trial that has evaluated this clinical approach in this sub-group of chronic pain patients.

The pelvic floor muscles (PFM) form the bottom of the LPC, with the respiratory diaphragm its top, and transversus abdominis (TrA) the sides. The spinal column is part of this cylinder and runs through the middle, supported posteriorly by segmental attachments of lumbar multifidus and anteriorly by segmental attachments of psoas (posterior fasciculii) to the abdominal muscles (Jones 2001). Intra-abdominal pressure (IAP) is generated by co-activation of the PFM, the diaphragm and the abdominal muscles (Hemborg et al. 1985, Hodges & Gandevia 2000), implying that co-ordinated co-activation of the muscles of the LPC is necessary in order to balance the functional demands of continence, respiration and lumbopelvic stability (Hemborg et al. 1985, Hodges & Gandevia 2000, Pool-Goudzwaard et al. 2004, Hodges et al. 2007). Muscles of the LPC work at low levels at all times and increase their activity when the central nervous system can predict timing of increased load, such as occurs in coughing, lifting or limb movements (Constantinou & Govan 1982, Moseley et al. 2002, Barbic et al. 2003). Further details regarding the diaphragm (Chapter 9) and the PFM (Chapter 13) will be found in the appropriate chapters, while the next section describes the assessment and rehabilitation of muscles of the LPC.

Assessment and rehabilitation of muscles of the lumbopelvic cylinder

Assessment and rehabilitation of muscles of the lumbopelvic cylinder