Introduction

All health practitioners spend considerable time gaining the knowledge necessary for their chosen career. What types of knowledge are there and what do practitioners need on a daily basis? Knowledge can be categorized as:

Propositional, or declarative, knowledge refers to the content knowledge that one’s profession is based on and includes factual information derived from formal research trials. In addition, this category includes theoretical knowledge developed from existing empirical protocols and principles, derived from dialogue with professionals in the same discipline, and logic (Higgs 2004).

Non-propositional, or procedural, knowledge pertains to knowing how to do things pertaining to one’s profession (craft and personal knowledge), such as how to mobilize a joint, release a hypertonic muscle, rewire a neural network, train a movement pattern and/or motivate an individual to change. This knowledge is gained through reflection on both professional and personal experiences (what worked, what did not work and how could it have been ‘done’ or handled differently to achieve a different outcome). Historically, non-propositional knowledge formed the basis for both medicine and allied health professionals including physiotherapy. All treatment is influenced by a practitioner’s perspective, their personal knowledge, values and beliefs. This factor contributes to the outcome of an intervention and is often not considered in clinical trials studying the efficacy of a particular treatment (i.e. a trial that aims to identify whether manipulation or exercise is more effective for the treatment of low back pain).

Most practitioners continue to take post-graduate courses or attend professional conferences to improve their knowledge pertaining to clinical theory and research (propositional) as well as their technical skills (non-propositional or craft); however, Rivett & Jones (2004) note that there is a tendency in both courses and conferences to neglect an essential component of daily clinical practice – clinical reasoning. How should the practitioner integrate into clinical practice the newly learned scientific and theoretical knowledge? Who is it appropriate for and when is the new skill appropriate to use? Clinical practice is, and always will be, a blend of science and ‘art’ with a healthy dose of logic and reasoning. Clinical expertise comes from reasoning, reflection, skill acquisition and the continual life-long pursuit of knowledge (propositional (declarative) and non-propositional (procedural and personal)) (Figure 7.1) (Jensen et al. 2007). This takes time, discipline and often mentorship and professional affiliation with both individuals and groups.

Figure 7.1 • Five components for the development of clinical expertise.

Adapted from Jensen et al. (2007) Expertise in Physical Therapy Practice, second ed. Saunders.

Recently, for best practice, there is increasing pressure for practitioners to become evidence-based when making all clinical decisions. However, it appears that this term, evidence-based practice, means different things to different people. What is evidence-based practice and what is its history?

Evidence-based practice: Where did it come from? Where is it going?

The term ‘evidence-based’ was first used in 1990 by David Eddy and ‘evidence-based medicine’ by Guyatt et al. in 1992. The methodologies used to determine ‘best evidence’ were largely established by the Canadian McMaster University research group led by David Sackett and Gordon Guyatt. Professor Archie Cochrane, a Scottish epidemiologist, has been credited with increasing the acceptance of the principles behind evidence-based practice (Cochrane 1972). Cochrane’s work was honoured through the naming of centres of evidence-based medical research, Cochrane Centers, and an international organization, the Cochrane Collaboration. Since the early 1990s there has been an explosion of research evidence, and accessibility to this evidence has been facilitated for those involved in research or formal study through easy internet access to full-text articles in indexed journals. Unfortunately, access to full-text articles is still limited, or expensive, for clinicians not affiliated with research centres or universities.

Evidence-based medicine categorizes and ranks the different types of clinical evidence. The terms ‘levels of evidence’ or ‘strength of evidence’ refer to the protocols for ranking the evidence based on the strength of the study to be free from various biases. The highest level of evidence for therapeutic interventions is a systematic review, or meta-analysis, including only randomized, double-blind, placebo-controlled trials that involve a homogeneous patient population and condition. Expert opinion has little value as evidence and is ranked the lowest due to the placebo effect, the biases inherent in both the observation, and reporting of the cases and difficulties in discerning who is really an expert.

Evidence-based practice (EBP) embraces all disciplines of health care (not just medicine) and has become synonymous with best practice, but what does the term really mean? To some, it appears that EBP means that a clinician can only use assessment tests and treatment techniques/protocols that have been validated through the scientific process with high-ranking studies as valued by the ‘levels of evidence’. This is difficult to adhere to for many reasons, one being that there is not enough evidence at this time. Indeed, could there ever be enough scientific evidence for every situation met in clinical practice? Sackett and colleagues define EBP as ‘the integration of best research evidence, with clinical expertise and patient values’ (Sackett et al. 2000) (Figure 7.2). They note that:

Figure 7.2 • The three components of evidence-based practice as defined by Sackett et al. (2000)

Clinical expertise, as noted above, comprises both propositional (declarative) and non-propositional (procedural, craft and personal) knowledge; in other words, knowing what, and how, to do the right thing at the right time (clinical reasoning and skill). The type of knowledge gained from scientific studies contributes to building only one kind of knowledge. In EBP according to Sackett et al.’s definition, clinical expertise plays an equal role alongside the research evidence. A third component of EBP is the patient’s values and goals, which come from the person for whom all of the research and expertise is intended to help.

Recently, the term ‘evidence-informed’ has surfaced, the intent being to suggest that since there is not enough research evidence for every situation met in clinical practice, the clinician should be informed of what is known and make their clinical decisions accordingly. However, if we adopt Sackett et al.’s definition of EBP, there is no need to modify the term since clinical expertise (reasoning and skill) is considered part of the definition of best practice.

Understanding pain: What do we need to know?

Understanding the neurophysiology of pain mechanisms is essential knowledge for treating patients with pelvic pain. Since the proposal of the gate control theory of pain by Melzack and Wall in 1965, significant advances in pain research and therapy have occurred. It is not our intent to provide an in-depth coverage of this topic here, but instead to highlight key features and establish a common language to be used throughout this chapter. See Chapter 3 for a full discussion of pain mechanisms in general, and as these relate to chronic pelvic pain.

Classifying pain

Classification by pain mechanisms

So what are the different biological mechanisms that drive the pain experience? Pain mechanisms can be further categorized (Gifford 1998, Butler 2000) as they relate to:

1. Input into the nervous system;

2. Processing in the nervous system;

3. Output from the nervous and other systems.

The brain receives continuous information from the body and the environment (input mechanisms or all sensory pathways) that is assessed and interpreted (processing at both conscious and unconscious levels) prior to producing a response (output mechanisms). Some of this incoming information is nociceptive. There are many factors that determine an individual’s behaviour and pain experience (physical, cognitive, emotional) in response to nociceptive input, including:

• Contextual factors of the immediate circumstance (i.e. how dangerous is this sensation in the light of environmental and internal factors?); as well as

• Past experiences and personal knowledge that collectively contribute to the individual’s beliefs, attitudes, emotions and physical responses.

Input mechanisms as they pertain to pain include all the sensory information reaching the CNS from the body internally and externally. This includes nociceptive pain from tissues including bones, ligaments, tendons, muscles, connective tissue, viscera, etc. (Gifford 1998, Butler 2000, Wright 2002) and peripheral neurogenic pain from neural tissue outside of the CNS. Processing occurs in the dorsal root ganglion and in the CNS. In the brain, an individual’s thoughts and feelings (cognitions + emotions = perception) are integrated and can influence the output mechanisms, which include:

1. Somatic or motor (altered posture, altered motor control);

2. Autonomic (increased sympathetic response for ‘fight or flight’);

3. Neuroendocrine (increased stress, heightened emotions, hormonal changes);

4. Neuroimmune.

Thinking within the context of stress biology creates a broader framework for understanding pain. Gifford (1998), in proposing the Mature Organism Model (Figure 7.3), notes that

… the sensation of pain is seen as a perceptual component of the stress response whose prime adaptive purpose is to alter our behaviour in order to enhance the processes of recovery and chances of survival. Stress biology and the stress response broadly considers the systems and responses concerned with maintaining homeostasis.

(Gifford 1998)

Figure 7.3 • The Mature Organism Model of Gifford (1998).

Adapted from Rivett & Jones (2004). Improving clinical reasoning in manual therapy. In: Jones, M.A., Rivett, D. (Eds.), Clinical reasoning for manual therapists, Churchill Livingstone; and Gifford (1998) Physiotherapy 84:27.

It has been proposed that continued activation of the stress-regulation systems and excessive or prolonged cortisol output has a destructive effect on peripheral tissues such as muscle, bone and nerve tissue, thereby perpetuating a vicious cycle of stress, pain and tissue injury (Melzack 2005).

In his Neuromatrix Theory of Pain, Ronald Melzack (2001, 2005) highlights the need to assess and treat the whole person, not just the painful parts.

The body is felt as a unity, with different qualities at different times. … [Together all outputs] produce a continuous message that represents the whole body [which he also describes] as a flow of awareness.

(Melzack 2001, 2005)

Melzack’s model has four components (2001, 2005):

1. The body-self neuromatrix – an anatomical substrate in the brain of the body-self;

2. Cyclical processing and synthesis of nerve impulses which produces a neurosignature;

3. The flow of neurosignatures is projected back to areas of the brain, the sentient neural hub, which converts them into the flow of awareness;

4. Activation of an action neuromatrix occurs to provide the pattern of movements to bring about the desired goal.

The neuromatrix, distributed throughout many areas of the brain, comprises a widespread network of neurons which generates patterns, processes information that flows through it, and ultimately produces the pattern that is felt as a whole body. The stream of neurosignature output with constantly varying patterns riding on the main signature pattern produces the feelings of the whole body with constantly changing qualities…. The final, integrated neurosignature pattern for the body-self ultimately produces awareness and action.

(Melzack 2005)

Figure 7.4 is a modification of Melzack’s representation of the body-self neuromatrix to illustrate the sensorial, cognitive and emotional dimensions of pain. Perhaps the best summary for this section highlighting the broad view we need to take when considering pain comes from this leader in the study of pain himself, Ronald Melzack (2001):

We have traveled a long way from the psychosocial concept that seeks a simple one-to-one relationship between injury and pain. We now have a theoretical framework in which a genetically determined template for the body-self is modulated by the powerful stress system and the cognitive functions of the brain, in addition to the traditional sensory inputs. The neuromatrix theory of pain – which places genetic contributions and the neural-hormonal mechanisms of stress on a level of equal importance with the neural mechanisms of sensory transmission – has important implications for research and therapy. The expansion of the field of pain to include endocrinology and immunology may lead to insights and new research strategies that will reveal the underlying mechanisms of chronic pain and give rise to new therapies to relieve the tragedy of unrelenting suffering.

Figure 7.4 • An adaptation of Melzack’s Body-Self Neuromatrix (Melzack 2001, 2005). HPA, hypothalamic–pituitary–adrenal

It is very clear that as clinicians we need to be aware of all the possible mechanisms that can create pain and to challenge ourselves to have an open mind as we seek to understand each individual’s unique pain experience in order to determine which mechanisms are primary and specifically related to their problem in all stages of their rehabilitation process.

O’sullivan (2005) noted that a limitation of many classification systems is that often only a single dimension (pathoanatomical, psychosocial, neurophysiological, motor control, signs and symptoms, etc.) is used to create subgroups. Classification systems will be most useful in clinical practice if variables across multiple domains are used to create subgroups.

Features that have been incorporated into different systems include (note this is not intended to be an exhaustive list):

In recent years, the development of clinical prediction rules (CPRs) has emerged as another way to classify patients. CPRs are derived statistically with the aim of identifying the combinations of clinical examination findings that can predict a condition or outcome. Thus, they are proposed to be a useful tool to assist in clinical decision-making by improving the accuracy of diagnosis, prognosis or prediction of response to specific treatment protocols (Beattie & Nelson 2006, Cook 2008, Fritz 2009). Development of CPRs in physiotherapy has mainly focused on the response to treatment protocols (Fritz 2009) in order to identify subgroups of patients most likely to respond to a specific treatment approach. It is important to note that, at this time, CPRs are still in their infancy of development and validation, and are not yet at the appropriate stage to be widely applied in clinical practice (Cook 2008).

It has been suggested that CPRs will best impact physiotherapy practice where there is complexity in the clinical decision-making process, and that ‘an appeal of CPRs is their potential to make [the] subgrouping process more evidence based and less reliant on unfounded theories and tradition’ (Fritz 2009). However, the use of CPRs should be balanced with the knowledge that:

Research on specific subgroups and development of classification systems will definitely provide a much better understanding of the specific impairments, mechanisms and psychosocial features that characterize subgroups and their response to treatment. As Melzack wrote about the evolution of the gate control theory of pain:

However, it is important to recognize that there are limitations on how information gained from classification systems, CPRs, clinical trials, and indeed the findings of any scientific study, can be translated and applied to the reality of clinical practice. Firstly, statistical averages tell us about the average response of the group defined by the characteristics used in design of the study. Individual responses may be to a greater or lesser degree than the average, or even in the opposite direction of the reported response. Indeed, practising clinicians are well aware of the many patients they have seen who do not fit the data from clinical trials or other studies. These clinical cases provide valuable insight and can generate questions for further research. Secondly, while the data provide relatively unbiased information, the interpretation and conclusions made from the data, and published alongside the data, are subject to bias just as much as clinical opinion is subject to bias. It is also important to recognize that a lack of data or science does not invalidate a technique or approach, nor does it mean that approaches that have been studied are necessarily superior. In clinical practice, application of any classification system/CPR requires care to ensure that it does not create a rigid, narrow mindset. Placing the patient ‘in a box’ could prevent the clinician from considering other options for treatment that may be greatly beneficial. Neglecting to provide these other options could then result in sub-optimal outcomes.

Consider the one domain of underlying pain mechanism as a way to create subgroups.

Butler (2000) notes that:

In their classification of pelvic pain disorders, O’sullivan & Beales (2007) categorize non-specific pelvic pain disorders into two groups: one that has centrally mediated pain, and one that has peripherally mediated pain. Although the group of centrally mediated pain is further classified into those with non-dominant psychosocial factors and those with dominant psychosocial factors, the treatment protocol for the subgroup of centrally mediated pelvic girdle pain is medical management (central nervous system modulation), psychological (cognitive-behavioural therapy), and functional capacity rehabilitation. Specific interventions directed at identified physical impairments in the periphery are not recommended, and yet it is highly unlikely that many patients will have 100% centrally mediated pain. In the authors’ experience, even in patients with a strong contributor of central sensitization to their pain experience, careful assessment often reveals specific meaningful tasks that relate to a consistent reproduction of symptoms. It is reasonable to suggest that even if peripheral mechanisms only contribute 20% to the complete picture, addressing that 20% in addition to the other approaches will provide the greatest chance for the best outcome. Furthermore, it is likely that by addressing the physical impairments, psychosocial variables will also be impacted, further advancing the goals of treating drivers of central sensitization. It is also crucial to recognize that our patients change as a result of their changing life circumstances and our interactions with them (both physical and personal). Thus, during the course of treatment continual re-evaluation is necessary to adapt the treatment programme accordingly. Sticking to a rigid plan based on an initial placement into a subgroup may result in the provision of sub-optimal care.

Finally, in our quest for better classification schemes and science to support and test our clinical approaches, it is important to remember that at the end of the day no matter how detailed and well defined our classification schemes, the person presenting to the clinician is a unique individual with unique life experiences. There will never be one recipe for treatment that is the best fit for all patients. Furthermore, patient values and beliefs are central to the treatment process, and if they do not want to receive what is considered ‘best practice’ from the current evidence, we cannot force it on them. Given the same impairment in the tissues, no two individuals will have exactly the same perception and presentation (experience and behaviour) because ‘how they manifest their pain or illness is shaped in part by who they are’ (Jones & Rivett 2004). A reminder, the highest level of evidence for therapeutic interventions is a systematic review, or meta-analysis, of only randomized, double-blind, placebo-controlled trials which involve a homogeneous patient population and condition. Is this possible in the light of what is known about pain? Do homogeneous populations really exist in clinical practice?

Science can provide us with an abundance of knowledge to challenge, refine, reshape and validate our clinical practice, but it cannot provide all of the information needed in any individual patient encounter; it does not paint the whole picture of the patient. In order to effectively treat patients, therapists need to have well-organized knowledge including propositional (knowledge ratified by research trials), non-propositional (professional craft or ‘knowing how’ knowledge) and personal (knowledge gained from personal experiences (Jones & Rivett 2004).

Personal and craft knowledge cannot be learned from RCTs, mechanistic studies, basic physiology studies, or clinical prediction rules. Ultimately, it is the development of clinical expertise that creates optimal patient care. According to Ericsson & Smith (1991) expertise has been defined as ‘having the ability to do the right thing at the right time’.

Clinical expertise has two components: skill acquisition (do the right thing) and clinical reasoning (at the right time) (Figure 7.5). Clinical reasoning skills facilitate the organization and integration of knowledge gained both in and out of the clinic, and the wise application of that knowledge for each individual patient.

Figure 7.5 • Clinical expertise comprises two components: skill acquisition (the ability to do the right thing) and clinical reasoning (at the right time)

Different classification systems provide us with a variety of perspectives to grow our knowledge base. However, hoping to find ‘the best classification system’ to apply in every situation in clinical practice is like searching for the Holy Grail – it cannot be found. We are unique people trying to help other unique people. We need to re-evaluate how we value the ‘levels of evidence’ and the role of science in directing clinical practice, and develop a more balanced view that values the insight that is uniquely derived from clinical practice. The clinical ‘lab’ plays a key role in new knowledge generation through the development of innovative techniques for assessment and treatment, which can then be tested by science. Knowledge gained from clinical experience is not more important than science, but it certainly is no less important. Overall, maintaining an open mind and broad perspective will assist both scientists and clinicians to discover how best to work together and learn from each other in the common goal of providing best care for our patients.

It’s about more than pain – Integrated systems for optimal health

While pain is important, it is also recognized that simply relieving a patient’s pain does not necessarily result in a full return to all functional activities. Furthermore, there are subgroups of patients, such as high-level athletes, whose functional goals and measures (race time, power delivery in a stroke for example) are just as, if not more, meaningful to them than the relief of pain. Indeed, there is an increasing market in helping people without pain to optimize performance as well as prevent injury by facilitating strategies for better posture and movement. Pain is not a problem for these people, but an inability to meet their functional goals is. Non-painful impairments are also recognized as a potential contributor to the development of pain, both in sites distal to the impaired area and in the area itself. Furthermore, if we take the broader view that ‘pain is an opinion on the organism’s state of health rather than a mere reflexive response to injury’ (Ramachandran in Doidge 2007), we need to alter our focus and consider what it means to be ‘in health’ and not only what it means to be ‘in pain’. The World Health Assembly has defined health as ‘a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity’ (WHO Constitution). Speaking at the 1985 annual conference of the American Medical Association (Seattle, USA), Dr. Paul Brenner defined health even more broadly as ‘the full acceptance and appreciation of life’. Restoring health is about more than removing disease; creating optimal strategies for function and performance is about more than removing pain.

What it means to be ‘in health’ is individually defined. Therefore, changing our focus from removing pain to restoring optimal health and optimal strategies for function and performance is intrinsically linked to the patient’s values and goals. Our role as clinicians is to best facilitate and empower patients on their journey to achieve their personal optimal health and function. To do this effectively, we need not only to understand their pain, but also to understand to them as a person. Jones & Rivett (2004) refer to this as ‘understanding both the problem and the person’:

This paradigm requires that clinicians broaden their perspectives and skill sets, and also opens up a wider range of potential and possibility for effecting change.

The Integrated Model of Function was developed from anatomical and biomechanical studies of the pelvis, as well as from the clinical experience of treating patients with lumbopelvic pain (Lee DG & Vleeming 1998, 2004, 2007, Lee DG 2004, Lee DG & Lee LJ 2008). From its inception, the Integrated Model of Function focused on the evaluation of the function of the pelvis, and how the pelvis effectively transfers loads across tasks with varying characteristics. The model addresses why the pelvis is painful by identifying the underlying impairments in four specific components: form closure, force closure, motor control and emotions. This is in opposition to pathoanatomical models that seek only to identify pain-generating structures. This model has continued to evolve with the publication of anatomical, biomechanical and neurophysiological research as well as the clinical expertise gained through collaborative efforts worldwide, and remains a useful framework to understand the pelvis in function and in dysfunction.

The Integrated Systems Model for disability and pain (Lee LJ & Lee DG 2011a) evolved from working with the Integrated Model of Function and was first introduced in 2007 as the System-Based Classification for Failed Load Transfer (Lee DG & Lee LJ 2007, Lee DG et al. 2008). We have since recognized that using the word ‘classification’ is limiting for this model because its primary purpose is not to place patients into homogeneous subgroups. In contrast, it is a framework to understand and interpret the unique picture of each individual patient in the clinical context to facilitate decision-making and treatment planning. The model provides a context to organize all the different types of knowledge needed (scientific, theoretical, professional craft, procedural, and personal) and provides for the development and testing of multiple hypotheses as the multidimensional picture of the patient emerges. A multimodal treatment plan can then be designed based on the complete picture of the person and their presenting problem(s).

The Integrated Systems Model for disability and pain allows clinicians to characterize all the components that contribute to what Melzack terms the ‘message that represents the whole body’ as a ‘flow of awareness’ (Melzack 2005). It is an integrated, evidence-based model that considers disability and pain as defined and directed by the patient’s values and goals. The model relates impairments found in systems, underlying pain mechanisms, and the impact of these impairments on their current whole-body strategies for function and performance. Thus the model analyses the patient’s current whole-body strategies, determines the underlying reasons for those strategies, and relates these to current knowledge about the necessary state required in all systems to provide optimal strategies for function and performance and, ultimately, for health. As a systems-based model, it has inherent flexibility to evaluate and integrate new evidence from research and innovative clinical approaches as they emerge. As a patient-centred model, it can continually adapt to changing goals and values of the patient. As the model applies to the whole person, rather than to a specific type of pain presentation or body region, it can be used across pain and disease populations and is not only applied to patients with pelvic pain. In the context of the lumbopelvic–hip (LPH) complex, the Integrated Model of Function fits within, and is encompassed by, The Integrated Systems Model for disability and pain. The Integrated Model of Function provides a way to subgroup patients with failed load transfer (FLT) in the LPH complex, i.e. those with a primary form closure, force closure, motor control or emotional deficits. The broader Integrated Systems Model for disability and pain also allows for subgrouping according to the primary system impairment but includes the role of the rest of the body, multiple system types, and all brain/mind states to the observed FLT in the LPH complex (considers more systems and causes both intrinsic and extrinsic to the pelvis). For example, is the primary impairment causing the FLT intrinsic to the pelvis itself (SIJ laxity → pelvic-driven pelvic pain) or extrinsic to the pelvis (thorax-driven or foot-driven pelvic pain) or due to a negative cognitive or emotional state. The Integrated Systems Model also considers the interaction and contribution of multiple systems (articular, myofascial, neural, visceral, hormonal, neuroendocrine, etc.). Several cases that highlight this approach can be found in the fourth edition of the Pelvic Girdle (Lee DG & Lee LJ 2011a).

Therefore, while The Integrated Systems Model is based on the identification of the multisystem impairments that are the key drivers behind the problems facing the whole person, which could then be used to subgroup patients, the primary purpose of the model is to provide a framework for building a unique tapestry that tells the patient’s story. It also facilitates clinical reasoning ‘on the fly’ as the patient’s story unfolds and the clinician begins to understand the significant pieces of their tapestry. When used reflectively, it is our goal that The Integrated Systems Model will facilitate, foster and promote the development of clinical expertise.

The Integrated Systems Model for disability and pain: A framework for understanding the whole person and their problem

Underlying constructs of the model

Before we can describe the components of The Integrated Systems Model, it is important to define its underlying constructs. These include the definitions of key terms and are as follows:

1. The terms body, function/functioning, disability, impairment and health condition are taken from the International Classification of Functioning, Disability and Health (ICF) definitions (2001, pp. 189–190):

a. Body functions are the physiological functions of body systems, including psychological functions. ‘Body’ refers to the human organism as a whole, and thus includes the brain. Hence, mental (or psychological) functions are subsumed under body functions.

b. Body structures are the structural or anatomical parts of the body such as organs, limbs and their components classified according to body systems.

c. Functioning is an umbrella term for body functions, body structures, activities and participation. It denotes the positive aspects of the interaction between an individual (with a health condition/(perceived problem(s))) and that individual’s contextual factors (environmental and personal factors).

d. Disability is an umbrella term for impairments, activity limitations and participation restrictions. It denotes the negative aspects of the interaction between an individual (with a health condition) and that individual’s contextual factors (environmental and personal factors).

e. Impairment is a loss or abnormality in body structure or physiological function (including mental functions).

f. Health condition is an umbrella term for disease, disorder, injury or trauma. A health condition may also include other circumstances such as pregnancy, ageing, stress, congenital abnormality or genetic predisposition.

2. A body system is a group of organs/structures with co-ordinated activities, achieving the same general function in the body. A system shares common characteristics, including:

a. Structure, defined by parts and their composition;

b. Behaviour, which involves inputs, processing and outputs of material, energy or information;

c. Interconnectivity, the various parts of a system have functional as well as structural relationships between each other (Wikipedia).

3. In a state of optimal health, an individual will have the option to choose from a wide variety of strategies that provide for optimal function and performance during any meaningful task (movement, activity, or role in a desired context and environment). Determining whether a task is meaningful requires understanding the person and their values and goals.

4. By definition, optimal function and performance occurs in a state of health, and will be a state free from undesired pain experiences. Given the definitions of health above, optimal function and performance is individually defined, and attainable in the presence of any health condition, although it may be influenced by specific features of the health condition.

5. Pain is not the only reason that people become disabled. Disability, or the inability to do what the person wants to do, can exist without pain.

6. Optimal function and performance for any task requires the synergistic, integrated operation of multiple systems in the body. ‘Synergy’ is defined as a ‘combined or cooperative action or force’ (Webster’s New World College Dictionary) and, ‘simply defined, it means that the whole is greater than the sum of its parts’ (Wikipedia). To ‘integrate’ is to ‘form, coordinate, or blend into functioning or unified whole’ (Merriam-Webster’s Online Dictionary). Synergy and integration require that each system, and thus the components of each system down to the cellular level, is functioning, and that the many complex feedback and feedforward mechanisms that control each system are working optimally. Then, the systems must work together to produce desired outputs in the body. Congruence of information received from feedback and sensory systems is also important. Not all the underlying mechanisms that produce the integrated, synergistic operation of body systems are fully understood, although science is continuing to reveal the connectedness and interdependence of body systems. Melzack’s concept of the body-self neuromatrix (see Figure 7.10) highlights this need for synergy and integration.

7. Impairment(s) in any one or combination of systems can give rise to undesired outputs in one or more systems. These outputs include painful states, non-optimal posture and movement (inefficient, loss of desired performance or output), loss of function, overactive and/or sustained stress response, and negative emotional states.

8. Designing and implementing the most effective treatment plan for restoring health depends on identifying the relevant impairments in the key systems that are barriers to healing and that need to be addressed in order to restore function and health. The relevance of each impairment is determined through a clinical reasoning process that uses a combination of different types of reasoning. Each impairment is evaluated in the context of meaningful tasks to determine how much the impairment contributes to the non-optimal strategies for function and performance, and the pain experience. The impairments/systems/regions with high contribution values are called the key ‘driver(s)’ in this model. The term ‘pain driver’ is used to refer to the underlying cause(s) of the pain experience, which could be the pain mechanism itself or a multitude of combined impairments that collectively increase physical and psychological stress and perpetuate the pain experience by exceeding the adaptive/coping mechanisms of specific tissues and the person as a whole. Note that, since the human body is dynamic, i.e. a changing entity, the key drivers for disability and/or pain at different points in time can change. Furthermore, the driver(s) of disability may be different than the driver(s) of pain.

9. The Integrated Systems Model is applicable to disability and/or pain of any duration; i.e., from acute onset to chronic, persistent or recurrent problems.

10. Every person is unique genetically, emotionally, cognitively, culturally and socially; the activities and roles that have meaning for them and their pain experience will be uniquely their own. In this way, the specific combination of impairments and systems that contribute to output experiences will be different for each patient. However, taken together, science and clinical expertise provide us with the necessary information to allow us to identify common patterns and parameters for normal and abnormal functioning of systems, as well as how subgroups of patients with certain common features (determined in research by inclusion and exclusion criteria of the study) respond to different treatment approaches. This information is invaluable and indispensable, and the continued pursuit of furthering our knowledge base (both propositional and non-propositional knowledge) in research and in the clinic creates a continually refined understanding of what allows us to enjoy health. However, knowledge gained from either the clinic or the research lab has limitations. Clinicians must constantly examine their emerging hypotheses for multiple types of bias. While clinical practice guidelines derived from research can be helpful and provide new insight, they may also be inappropriate and incorrect for certain patients. Therefore, caution is always necessary when developing general treatment protocols based on ‘homogeneous populations’ since homogeneous populations are an illusion and do not truly exist outside of research constructs.

11. Each person is a dynamic entity and can change from moment to moment and day to day. Science continues to find more evidence of this. Clinically, this implies that continual reassessment is essential for revising hypotheses about the drivers of the patient’s problem.

Figure 7.10 • Standing posture – 2 days postpartum. Note the anterior pelvic sway (horizontal arrow) and posterior pelvic tilt (curved arrow). The low lumbar spine is flexed (flattened) and the lumbar lordosis has shifted to the upper lumbar spine and lower thorax. This is a non-optimal standing posture for load transfer through the bones and joints of her lumbopelvis and associated organs. The lateral divots of the upper abdomen suggest that Kristi is still using the EOs excessively

Components of the model: The Clinical Puzzle – A tool for clinical reasoning and developing clinical expertise

The Clinical Puzzle (Figure 7.6) is a graphic that conceptualizes The Integrated Systems Model for disability and pain. It represents the person and their problem(s), and the systems that support optimal strategies for function and performance. The puzzle is used clinically and in teaching as a tool for clinical reasoning and decision-making.

Figure 7.6 • The Clinical Puzzle conceptualizes The Integrated Systems Model for disability and pain. The outer circle of the puzzle represents the strategies for function and performance that the patient currently uses for meaningful tasks (e.g. forward bending, one leg standing, step forward, sit, squat, etc.). The meaningful tasks chosen for analysis are determined from listening to the patient’s story. Failed load transfer (FLT; non-optimal alignment, biomechanics, and/or control required for the given task) may be due to one or more impairment(s) in any piece(s) and can ‘drive’ non-optimal strategies for function and performance. Conversely, non-optimal strategies can ‘drive’ impairments in any system(s). The centrepiece of the puzzle represents several systems that relate to the person and the sensorial (sensations, perceptions), cognitive (beliefs, attitudes, motivations) and emotional (fears, anger, anxiety) dimensions of their current experience. It also includes systemic systems (such as endocrine balance, immune function) and genetic factors. It is the place where primary symptoms, goals and barriers to recovery are noted. The four other pieces of the puzzle represent the various systems in which impairments are assessed and noted during the clinical examination. During this process, the therapist also considers and reflects upon the relationship of these impairments to the person in the middle of the puzzle (e.g. the meaning these impairments may or may not have, how they relate to health conditions or genetic factors, how they relate to the pain experience, etc.) and the relevance these impairments may have to the non-optimal strategies for function and performance during meaningful tasks. All clinical puzzles are unique since no two individuals have the same life experiences and this graphic is a useful tool for organizing the key information gained through the examination process and for reflection and interpretive reasoning of the findings

The person in the middle of the puzzle

At the centre of the model is the patient, the person in the middle of the Clinical Puzzle. Seeking to understand the unique makeup of the person (the colour, shape and content of their tapestry), without judgement, is the goal of listening to the patient’s story. It is essential that during the subjective examination the therapist create a supportive, compassionate environment that allows the patient to tell their story freely. Open-ended questions, such as ‘What can I do for you today?’ or ‘Please tell me your story’ create an invitation for the patient to share the things about their current experience that are most meaningful and relevant to them, along with their goals and values. This is in contrast to the therapist who has a checklist of questions to obtain answers to, and who strongly directs the subjective examination along a path that the therapist deems (in their wisdom) to be the best. This checklist format of subjective examination is more likely to miss out on essential information from the patient.

Understanding the person in the middle of the Clinical Puzzle also incorporates information about the sensorial, cognitive and emotional dimensions to their experience of their problem(s). Problems may be disability and/or pain. The sensorial dimension includes the location and behaviour of the problem(s), the cognitive dimension includes their beliefs and attitudes about their current experience, and the emotional dimension encompasses both positive and negative feelings about the experience. Problems such as incontinence (stress and/or urge), symptoms of pelvic organ prolapse (vaginal bulge or pressure), difficulty with breathing, and effortful movement, are all examples of problems that the patient may not talk about if they are only asked about their pain/symptoms, but that are important to identify when present. From these multiple dimensions, the therapist can glean potential barriers to, and potential facilitators of, recovery.

How the patient perceives their body, and their current experience of their body, constitutes the current state of their virtual body. The virtual body is made up of both conscious and unconscious components. As the objective examination proceeds, discrepancies between the actual body and the virtual body will become evident. An example of this would be when a patient perceives that they are standing with equal weight bearing on both feet, but postural examination reveals that the centre of mass is shifted to load one extremity to a greater degree than the other.

Meaningful tasks are postures and/or activities that are determined by aggravating activities, relieving activities, activities associated with negative beliefs and emotions (e.g. movements the patient is fearful of), activities in specific environments or contexts, and the patient’s goals (e.g. ‘What would you really like to do that you are not currently able to do due to this problem?’). All characteristics of meaningful tasks, including biomechanical requirements, environmental, social and emotional context must be considered during the objective examination in order to most accurately analyse the strategies used by the patient during the meaningful task analysis.

The centre of the puzzle (the person in the middle of the Clinical Puzzle) also represents the patient’s genetic makeup and systemic health status, including the nutritional, neuroendocrine, autonomic and homeostatic/stress/immune systems. Past experiences, social background and other psychosocial features are also a part of the centre of the puzzle. The experienced clinician will start to link information in the patient’s story and form initial hypotheses that direct the priorities of the objective examination to follow.

Strategies for function and performance

The meaningful tasks identified from the patient’s story direct the tasks chosen for analysis of strategies for function and performance, and are noted in the outside ring of the puzzle. These tasks, or the relevant component movements of the task, must be assessed to determine if the patient is using an optimal or non-optimal strategy for the meaningful task. Since the strategies that people use for whole-body function are a result of, and depend on, the integrated function of all systems in the body, including all the systems represented by the person in the middle of the puzzle, the ‘strategies ring’ encircles the entire puzzle. If a non-optimal strategy is observed, the objective findings characterizing how the strategy is non-optimal are written beside the task listed in the outer circle of the puzzle.

Articular, myofascial, neural, visceral systems

The four other pieces of the puzzle represent the systems that are assessed during the clinical examination. Specific impairments, as well as information gained from diagnostic tests (e.g. X-rays, MRI, etc.) and other sources, are charted within the relevant system in the puzzle. The therapist also considers and reflects upon the relationship of these impairments to the person in the middle of the puzzle (e.g. sensorial, cognitive and emotional dimensions of the problem(s)) and the relationship these impairments have to the non-optimal strategies for function and performance during meaningful tasks.

As the examination proceeds, the therapist evaluates whether or not the observed non-optimal strategies for function and performance for each meaningful task are appropriate or inappropriate given all the information available (beliefs about the task, state of tissue healing/integrity of tissue, characteristics of the task and the task context including load requirements, mobility requirements, level of predictability, threat value, availability of accurate proprioceptive input). Note that, for some tasks, the patient may have appropriate strategies (side bent lumbar spine posture due to acute radicular pain), while for other tasks the patient may have inappropriate strategies (fear of moving in any direction in the lumbar spine due to pain that only occurs in one direction of movement). If the therapist has reason to believe that a strategy is inappropriate, determining the reasons a patient chooses a particular strategy is essential for identifying the driver(s) of the problem and planning the most effective treatment programme.

Specific impairments in the articular, myofascial, neural and visceral systems are listed in Box 7.1. The articular system includes the bones and joints (passive structures) in the musculoskeletal system. The myofascial system includes muscle, tendinous and fascial connections, as well as the multiple layers of fascia throughout the body. The neural system includes all components of the central and peripheral nervous system. It also includes the neural drive to muscles, which is reflected in the resting tone and activity or control of the muscle system. The visceral system includes all the viscera of the body.

Box 7.1 The conditions associated with the four systems of the Clinical Puzzle

Articular

• Capsular sprain or tear

• Ligament sprain or tear (grades I–III)

• Labral or intra-articular meniscal tear

• Intervertebral disc strain/tear/herniation/prolapse

• Fracture

• Joint subluxation or dislocation

• Periosteal contusion

• Stress fracture, osteitis, periostitis, apophysitis

• Osteochondral/chondral fractures, minor osteochondral injury

• Chondropathy (softening, fibrillation, fissuring, chondromalacia)

• Synovitis

• Apophysitis

• Fibrosis/osteophytosis of the zygapophyseal and intervertebral joints, sacroiliac joint, hip joint

Myofascial

• Intramuscular strain/tear (grades I–III)

• Muscle contusion

• Musculotendinous strain/tear

• Complete or partial tendon rupture or tear

• Fascial strain/tear

• Tendon pathology – tendon rupture, partial tendon tears, tendinopathy (acute or chronic), paratendinopathy, pantendinopathy

• Skin lacerations/abrasions/puncture wounds

• Bursa – bursitis

• Muscular or fascial scarring or adhesions

• Loss of fascial integrity of the anterior abdominal wall including:

• Diastasis rectus abdominis

• Sports hernia (tear of transversalis fascia)

• Hockey hernia (tear of the external oblique)

• Inguinal hernia

• Loss of fascial integrity of the endopelvic fascia leading to cystocele, enterocele and/or rectocele

Neural

• Peripheral nerve trunk or nerve injury (neuropraxia, neurotemesis, axonotemesis)

• Central nervous system injury

• Altered motor control

• Absence of recruitment, inappropriate timing (early or late) of muscle recruitment

• Inappropriate amount (increased or decreased) of muscle activity (all relative to demands of task)

• Hypertonicity or hypotonicity of muscles at rest

• Altered neurodynamics

• Sensitization of the peripheral or central nervous system, altered central nervous system processing

Visceral

• Inflammatory organ disease or pathology (e.g. appendicitis, cystitis, acute ulcerative gastritis, pleuritis, endometriosis)

• Infective disorders of the pelvic organs

• Organ disease

An impairment in any piece(s) of the puzzle within the outer circle (the ‘systems’), or loss of congruence and synergy between the pieces of the puzzle, can ‘drive’ non-optimal strategies for function and performance. Conversely, non-optimal strategies for function and performance can drive or create impairments within any of the systems inside the puzzle (the person in the middle of the puzzle, the neural, myofascial, articular and visceral systems). Thus, the entire puzzle is connected, linked and interdependent and visually represents the integrated systems required for optimal health. All clinical puzzles are unique since no two individuals have the same life experiences.

If one considers all of the possible combinations of impairments and the associated findings that can lead to disability and/or pain, the pelvis can seem complicated. In reality, when reflective critical thinking and a thorough examination are used, the primary cause and initial treatment plan emerges. The Clinical Puzzle for The Integrated Systems Model is a useful tool for understanding the whole person and their problem(s). It allows for organization of key information gained through the examination process, comparing and contrasting this information to current propositional knowledge and personal knowledge of the clinician, and for reflection and interpretive reasoning of the findings. This facilitates the formation of hypotheses to explain the relationships between physical impairments, pain mechanisms, psychosocial features, disability, health conditions, and the patient’s values and goals. The goal of the clinical reasoning process, facilitated by the puzzle, is to determine which hypothesis provides the ‘most likely and most lovely’ (Kerry et al. 2008) explanation of the patient’s whole experience, from which an integrated multimodal treatment plan is formulated and implemented. As treatment evolves over several sessions, the focus often changes as the patient’s journey towards function and better health occurs.

What follows is a case study of a woman with peripartum pelvic pain. This case will illustrate how clinical reasoning and The Integrated Systems Model is used to establish a prescriptive treatment plan for the management of one clinical puzzle. All of the assessment tests described in the case below are fully described in Chapter 8 of the fourth edition of The Pelvic Girdle (Lee DG & Lee LJ 2011b).

Case study 7.1

Kristi’s story

Kristi was a 31-year-old mother who presented with pelvic pain (central sacral and pubic symphysis) at 31.5 weeks of her second pregnancy. Her first child was delivered vaginally 3 years prior and she felt that she had fully recovered from this pregnancy and delivery prior to conceiving her second child; she reported having no symptoms nor any difficulty performing any tasks prior to this time. Walking aggravated her symptoms, especially if she carried her son. She had no complaints of incontinence or difficulties breathing.

Strategies for function and performance

Standing posture

Kristi’s stood with a left lateral shift of her thorax relative to her pelvis (Figure 7.7) and the strategy she used to support her abdomen was non-optimal in that there was excessive use of the external obliques (EOs) bilaterally and insufficient use of transversus abdominis (TrA) (confirmed via ultrasound imaging). (Note: while we recognize that it is possible that there was a very small activation of TrA that is below the threshold for detection with ultrasound (Hodges et al. 2003a), clinical experience suggests that if no architectural change in TrA is seen on ultrasound imaging, then there is insufficient activation for functional tasks.)

Figure 7.7 • Standing posture at 31.5 weeks pregnant. (A) Note the left lateral shift of her thorax relative to her pelvis in the coronal plane (large arrow). Also note the indentations of the upper abdomen bilaterally (small arrows). This indentation is often seen when there is excessive activation of the external oblique in the strategy used for standing. (B) In this view, the orientation of her thorax over her pelvis looks acceptable; however, the strategy that she is using to maintain this alignment is non-optimal in that there is excessive use of the external oblique bilaterally (see Video 1)

One leg standing

Kristi found it more difficult to stand on the right leg and flex the left hip (right one leg standing, ROLS). With respect to intrapelvic mobility during this task, asymmetry of motion was noted between the left and right sides of the pelvis; the right side posteriorly rotated less during LOLS than the left side did in ROLS. In addition, there was failure to control motion at the right sacroiliac joint (SIJ) during ROLS (the right innominate rotated anteriorly relative to the sacrum).

Active straight leg raise

During the active straight leg raise (ASLR) test (Mens et al. 1999), Kristi did not note any difference in the effort required to lift her right or left leg; however, she did note that the effort to perform this task was reduced when her pelvis was compressed at the anterior aspect at the level of the anterior superior iliac spines (ASIS).

Curl-up task

Two things of concern occurred during a short head and neck curl-up task:

1. The infrasternal angle narrowed, which is reflective of excessive activation of the EOs;

2. The midline of the abdomen ‘domed’, which is suggestive of insufficient activation of the TrAs and this was confirmed via ultrasound imaging.

Clinical reasoning at this point

Kristi was using non-optimal strategies to support her growing abdomen for all tasks evaluated. Her inability to control motion of the right side of her pelvis during right single leg loading could explain both her low back and pelvic pain since repetitive anterior rotation of the right innominate during single leg loading during walking could be provocative to the articular and myofascial tissues of the lumbosacral junction, right SIJ and the pubic symphysis (peripherally mediated pain). Further tests are required to determine why Kristi was using non-optimal strategies, which at this point were characterized by excessive activation of the EOs and insufficient activation of the TrAs across all tasks. The fact that anterior compression of her pelvis made the ASLR task easier is consistent with the finding that there is insufficient activation of the TrAs. Taken together, the findings from strategy analysis support a hypothesis that a non-optimal pattern of abdominal wall recruitment (imbalance between the EO and the TrA) is contributing to FLT of the right side of the pelvis during multiple functional tasks, as well as contributing to overload of structures driving peripherally mediated pain. Further tests are needed to confirm or negate this hypothesis.

Articular system analysis

This system requires analysis whenever there is failure to control articular motion during any functional task. Given the location of Kristi’s pain, both the SIJs and pubic symphysis required analysis for mobility and integrity of the passive system restraints. The pubic symphysis was dynamically controlled and pain-free on stress testing, and there was no loss of integrity of the passive system. The mobility of the SIJs was symmetric when tested passively (compared to asymmetric when tested actively; see OLS above) and the passive restraints to articular motion were intact (i.e. no motion of the joint was palpable when the joint was tested in the close-packed position). These findings indicate that the articular system is not the cause of her lack of motion control during right single leg loading.

Neural system analysis

When Kristi was given a verbal cue intended to isolate a co-contraction of the deep system (TrA, pelvic floor) from the superficial muscle system, an asymmetrical response to the bilateral cue occurred between the left and right TrA; the left TrA responded (and was isolated from the superficial muscles) whereas the right did not respond at all. This finding was confirmed via ultrasound imaging. In addition, an asymmetrical response occurred between the left and the right IO; the right IO responded whereas the left did not. These findings support the hypothesis that Kristi’s current pattern of deep and superficial abdominal muscle recruitment was providing insufficient support to the anterior pelvis during the ASLR and other tasks. This indicates that the neural system needs to be trained in order to restore optimal load transfer through the right side of the pelvis. However, given that 66% of women present with a diastasis of the rectus abdominis in the third trimester (Boissonault & Blaschak 1988), the myofascial system warrants examination (and follow-up) in every pregnant woman attending for treatment (Lee DG 2011). One of the mechanisms by which TrA provides support to the lumbopelvis is via increasing fascial tension (Hodges et al. 2003b); if there are impairments in the myofascial system of the abdominal wall (midline abdominal fascia and linea alba), TrA may not be able to provide support to the pelvis regardless of whether optimal control by the neural system is restored. Thus, further tests are required to determine if Kristi’s inability to transfer load through the right side of her pelvis is primarily driven by a neural impairment, or a combination of both a neural and a myofascial impairment.

Myofascial system analysis

In individuals less than 45 years of age, the distance between the left and right rectus abdominis (i.e. the inter-recti distance) is considered to be ‘normal’ if it is no greater than 1 cm at a midway point between the pubic symphysis and the umbilicus (PU point), 2.7 cm just above the umbilicus (U point) and 0.9 cm at a midway point between the umbilicus and the xyphoid (UX point) (Rath et al. 1996). At 31.5 weeks gestation, Kristi was within these normal limits at the PU point (0.82 cm) and greater than this at both the U point (>width of probe at rest and 3.46 cm during a curl-up) and UX point (3.52 cm at rest and 3.03 cm during a curl-up) (Table 7.2, Figure 7.8 ). It was again noted that Kristi was using a non-optimal strategy for the curl-up task (insufficient and asymmetric activation of TrA and excessive activation of the EO). Palpation of the linea alba between the left and right rectus abdominis suggested it was intact; however, the ability of linea alba to transfer forces could not be assessed at this time since Kristi was unable to contract TrA optimally (neural impairment, see above). That is, since Kristi was unable to recruit an optimal isolated contraction of the deep system, the impact of a precontraction of the deep system on the inter-recti distance and the shape of the linea alba could not be assessed at this time.

Table 7.2 Inter-recti distance measured via ultrasound imaging both at rest and during a short head/neck curl-up task at 31.5 weeks gestation and 6 weeks postpartum. The rest measures are also provided at 14 weeks postpartum

Figure 7.8 • Inter-recti distance measured via ultrasound imaging. (A) PU point = 0.82 cm. (B) The medial borders of the rectus abdominis cannot be imaged and the distance between them is wider than the ultrasound probe (i.e. >4.66 cm) (C) U point during a curl-up. As the midline of the abdomen ‘domes’ and tension increases in the linea alba, the inter-recti distance narrowed to 3.46 cm. (D) UX point = 3.52 cm

Clinical impression derived from hypothesis development, reflection and interpretive reasoning

From this initial assessment, the primary hypothesis was that Kristi’s pain experience was primarily peripherally mediated and, according to The Integrated Systems Model the impairment that needed to be addressed first was in the neural system (see Kristi’s clinical puzzle, Figure 7.9). The passive restraints of the pubic symphysis and the right and left sacroiliac joints were intact (no articular impairment). The neural system assessment revealed deficits in the activation of both the deep and superficial systems; asymmetric responses were noted in both the TrAs and the internal obliques (IOs) in response to a verbal cue intended to isolate a symmetric response of the deep system. While the inter-recti distances at both the U and UX points of the linea alba (myofascial tests) were wider than normal values according to Rath et al. (1996), there appeared to be sufficient tension in this midline structure to effectively force close and control motion of the joints of the pelvis if the deep system (i.e. TrA and PF) was functioning optimally. This hypothesis would have to be tested after the neural system deficits were addressed.

Figure 7.9 • Kristi’s clinical puzzle at 31.5 weeks gestation. 1° c/o, primary complaints; L, left; R, right; PS, pubic symphysis; SIJ, sacroiliac joint; OLS, one leg standing; mob, mobility; ASLR, active straight leg raise; R = L, right and left leg equally hard to lift; ASIS, anterior superior iliac spine; ✓, OK; EO, external oblique; TrA, transversus abdominis; DRA, diastasis rectus abdominis; LA, linea alba

The findings from this examination were explained to Kristi and a treatment session followed to teach her a better strategy for supporting her abdomen and for transferring loads through her trunk and pelvis. This involved releasing (relaxing) the left and right EOs and then ‘waking up’ the right TrA and facilitating its co-contraction with the other muscles of the deep system. She was able to feel a ‘lightening of load’ on her pubic symphysis with this better strategy and was also able to stand on her right leg without losing control of the right side of her pelvis. Kristi was encouraged to practice this co-activation of the deep system (pelvic floor and TrA) frequently (three sets of ten contractions held for 10 seconds) over the remaining weeks of her pregnancy and a post-delivery home visit was advised (Lee LJ & Lee DG 2011b).

Two days postpartum

Kristi had an uneventful home delivery and incurred a small tear in her perineum requiring two stitches in the ‘muscular layer’ and one stitch in her skin. She reported that, during the final weeks of her pregnancy, she was able to control her pelvic pain when she engaged her deep system. Currently, her pelvic pain had recurred and additionally she was now experiencing pain in her perineum and occasional urinary incontinence.

Strategies for function and performance, myofascial and neural system analysis

Standing posture

Kristi’s standing posture was quite different from that noted at 31.5 weeks gestation (Figure 7.10). She stood with an anterior pelvic sway and a posterior pelvic tilt, a flattened lumbar lordosis, and increased extension of the upper lumbar spine and lower thorax.

One leg standing, active straight leg raise and curl-up tasks

Kristi was unable to control motion of either the left or right side of her pelvis during single leg loading; both legs were difficult to lift and the effort to do so was reduced when her pelvis was compressed anteriorly during the ASLR task. Significant doming of the midline of her abdomen was noted during a curl-up task (Figure 7.11). There was minimal palpable tension in the linea alba during the curl-up task when no attempt was made to precontract the transversus abdominis (myofascial system analysis). There was a significant diastasis of the rectus abdominis (DRA) from the U to UX points (>3 finger widths).

Figure 7.11 • Curl-up task 2 days postpartum. Note the doming in the midline of the abdomen. This is reflective of either imbalance of the deep and superficial abdominal muscles with insufficient activation of the deep system during this task or an inability of the midline fascia to transfer load. Further tests are necessary to differentiate the cause of the doming

Since Kristi had continued to practice an isolated contraction of her deep system in the final weeks of her pregnancy, it was not a surprise that she was still able to perform this task well even at 2 days postpartum. A symmetric activation of the left and right TrA, isolated from the EOs and IOs, occurred when she was given a cue to gently connect her ASISs together (neural system analysis). When she contracted the TrAs and then sustained the contraction as she performed the curl-up task, more tension was palpable in the linea alba and the doming was reduced. When cues were given to contract her pelvic floor, Kristi reported an increase in her perineal pain.

See Figure 7.12 for Kristi’s current clinical puzzle, reflect on the findings, and make a hypothesis as to what her management should be prior to reading the next section.

Figure 7.12 • Kristi’s clinical puzzle at 2 days postpartum. 1° c/o, primary complaints; L, left; R, right; PS, pubic symphysis; SIJ, sacroiliac joint; OLS, one leg standing; ASLR, active straight leg raise; R = L, right and left leg equally hard to lift; ✓, OK; TrA, transversus abdominis; DRA, diastasis rectus abdominis; U point, just above the umbilicus; UX, point halfway between the umbilicus and the xyphoid; LA, linea alba

Clinical reasoning and early postpartum management

At this very early postpartum stage, Kristi was doing quite well. She had sustained some trauma to her pelvic floor as a consequence of her vaginal delivery and this would need to be further assessed once her wounds had healed. In the meantime, she was given postural advice regarding her standing, sitting and nursing positions and advised to wear an abdominal binder to help support her pelvis as healing occurred (Figure 7.13). The binder would also help to ‘remind her brain’ as to the way her lower abdomen should be supported by the deep muscle system. She was also advised to apply ice to her perineum and to slowly increase the activation of her pelvic floor as her pain subsided. A subsequent in-office visit was recommended at 6 weeks postpartum.

Figure 7.13 • Postpartum abdominal binder. (A) This is the wrong way to wear a postpartum abdominal binder (i.e. tighter at the top). (B) This is the correct way to wear the binder, with more support at the inferior part thereby supporting the abdomen from ‘bottom up’

Six weeks postpartum

Kristi reported that she was now pain-free and no longer incontinent and was keen to return to her kickboxing class. She was managing all her homecare responsibilities with ease and was eager to ‘get fit’ once again. However, even though she was asymptomatic, several things of potential concern were noted on her follow-up examination.

Strategies for function and performance

Standing posture

Kristi was able to find a much better standing posture (Figure. 7.14A) although she still had a tendency to sway her pelvis anteriorly especially when she carried her newborn (Figure 7.14B). A better strategy for standing was reviewed (Figure 7.14C).

Figure 7.14 • Standing posture 6 weeks postpartum. (A) Slight anterior pelvic sway, which (B) increased when she held her baby. (C) Here, Kristi is standing with a better strategy while holding her baby

One leg standing and active straight leg raise tasks

Kristi found it more difficult to stand on the right leg and flex the left hip (ROLS). With respect to intrapelvic mobility during this task, asymmetry of motion was noted between the left and right sides of the pelvis; the left side posteriorly rotated less during ROLS than the right did during LOLS. This is an opposite mobility finding to her initial assessment. In addition, there was failure to control motion of both SIJs (initially it was just the right) with the left side unlocking (i.e. innominate anteriorly rotating) earlier in the task than the right. During the ASLR task, Kristi noted that the left leg was harder to lift and that the effort required to perform this task was reduced when compression was applied to the inferior part of her pelvis (level of the ischii and pubic symphysis).

Articular and neural system analysis

The passive mobility of the SIJs was symmetric and the integrity of the passive system restraints was intact, therefore the articular system was not hypothesized to be the cause of the unlocking noted during single leg loading. With respect to the deep muscle system, an isolated, symmetric response of the TrAs occurred with a cue to contract the pelvic floor; however, no response of the pelvic floor was seen via ultrasound imaging (both perineal and transabdominal approach) in response to any verbal cue (Lee DG & Lee LJ 2011b). Video 12A shows an optimal response of the pelvic floor to a cue to contract; note the cranioventral lift of the anorectal angle towards the neck of the bladder. This contrasts significantly with the lift seen in Video 12B, which contains perineal ultrasound imaging of her attempt to recruit her pelvic floor.

Curl-up task and myofascial system analysis

During a curl-up task, doming of the midline of the abdomen occurred and minimal tension was palpable in the linea alba, particularly just above the umbilicus; however, the infrasternal angle did not narrow (i.e. there didn’t appear to be excessive activation of the EOs during this task). At rest, the inter-recti distance was within normal limits at the PU point (0.96 cm), and still wider than normal at both the U (3.60 cm) and UX (1.42 cm) points (Table 7.2, Figure 7.15A). Just above the umbilicus, this distance narrowed to 2.14 cm during a curl up, which is within normal limits; however, the strategy that produced this narrowing was non-optimal in that insufficient tension was generated in the linea alba (note the sagging of the linea alba in Figure 7.15B). When Kristi activated the TrAs prior to doing the curl-up, the inter-recti distance at the U point was 2.12 cm (essentially no change); however, the strategy was better in that there was no doming of the midline abdomen and more tension could be seen, and felt, in the linea alba (Figure 7.15C, Video 13). Kristi also noted that it took less effort to curl when she activated the TrAs first. Coldron et al. (2008) have measured the inter-recti distance from 1 day to 1 year postpartum and note that the distance decreases markedly from day 1 to 8 weeks, and that without any intervention (e.g. exercise training or other physiotherapy) there was no further closure at the end of the first year. Whether training has any effect on the inter-recti distance has not been studied nor do we definitively know if closure is necessary for restoration of function in all women.

Figure 7.15 • Ultrasound images of the linea alba and response during a curl-up task. (A) This is the inter-recti distance at the U point at rest – 3.60 cm which is wider than normal values according to Rath et al. (1996) (2.70 cm). (B) During a curl-up with no precontraction of the deep system, Kristi’s strategy resulted in narrowing of the inter-recti distance (2.14 cm); however, note the ‘sagging’, which is reflective of minimal, if any, tension in the linea alba (C) When the deep system was activated prior to the curl-up task, the inter-recti distance at the U point also narrowed; however, the strategy chosen to curl-up was better in that the linea alba was tensed and sagged less

See Figure 7.16 for Kristi’s current clinical puzzle and reflect on the findings to determine what her management should be prior to reading the next section. Would you allow her to return to kickboxing at this time?

Figure 7.16 • Kristi’s clinical puzzle at six weeks postpartum. Imp, improves. See Figure 7.12 for further abbreviations

Clinical reasoning and management

Kristi was surprised to discover that her ‘Kegel’ exercises were not effectively producing a contraction of her pelvic floor. Bump et al. (1991) reported that 50% of women cannot effectively activate the pelvic floor in response to a verbal cue and either an internal or ultrasound imaging examination is needed to ensure that a response is occurring. Although she was not experiencing incontinence of urine, stool or gas, the OLS and ASLR tests as well as the results of her neural system evaluation support a specific training programme to ‘wake up’ and integrate her pelvic floor with the other muscles of the deep system. It is possible that this deficit was responsible for the ‘unlocking’ of both sides of her pelvis in single leg loading tasks and while she was disappointed at not being able to attend her kickboxing class immediately, she did understand the reasons why it was necessary to address the neural deficit and train her deep muscle system before increasing the loads through her pelvis.

Kristi was given the Pelvic Floor Educator™ (www.neenhealth.com) (Figure 7.17), which is a useful biofeedback tool for training the pelvic floor. She was instructed on how to use this tool to ensure proper activation of her pelvic floor and once she was able to do this, she was advised to integrate the contraction with her TrA cue such that the deep muscle system was trained together.

Figure 7.17 • The Pelvic Floor Educator™ (www.neenhealth.com) is a useful biofeedback tool for ‘waking’ up and training the pelvic floor

Fourteen weeks postpartum

Kristi reported that her pelvic floor contractions ‘felt much different’ after her session with Johanne and that she was now able to move the stick of the Pelvic Floor Educator™ properly. She had returned to a fairly high level of physical activity and was not experiencing any pain, symptoms of loss of pelvic organ support or incontinence of urine.

Strategies for function and performance

One leg standing and active straight leg raise

Kristi’s intrapelvic mobility was now symmetric (noted via the OLS task) and she was able to control motion of the left SIJ when she precontracted her deep system. Her automatic strategy (without a conscious precontraction of the deep system) did not provide control of this joint. During the ASLR task, Kristi did not report any effort difference to lift either leg and there was no change in the effort required to perform this task when compression was applied anywhere to her pelvis .

Curl-up task and myofascial system analysis

During a curl-up task, there was no doming of the midline of the abdomen and lovely tension was now palpable in the linea alba. The infrasternal angle, however, was now widening suggesting an imbalance of activation between the IOs and EOs during this task (with net vector from internal oblique). This was a change in strategy for this task from that used in the final trimester of her pregnancy. At rest, the inter-recti distance at the PU point was now 0.52 cm (reduced from 0.96 cm at 6/52 postpartum), at the U point was 2.62 cm (reduced from 3.60 cm at 6/52 postpartum) and at the UX point was 2.34 cm (an increase from 1.42 cm at 6/52 postpartum) (see Table 7.2). The widening of the upper portion of the linea alba is reflective of the non-optimal strategy she was using to do her curl-up exercises.

Neural system analysis

An isolated, symmetric response of the TrAs continued to occur with a cue to contract the pelvic floor and a small cranioventral lift could now be seen via ultrasound imaging of the pelvic floor (perineal approach). Her pelvic organs appeared to be well supported when she performed a valsalva manoeuvre.

Clinical reasoning and management

The widening of the upper portion of the linea alba can be explained by the over-activation of the IOs (or underactivation of the EOs) during the multiple curl-ups Kristi was doing to ‘get back in shape’. She was advised on how to correct this strategy (Video 15) to prevent further widening of the linea alba and perhaps to facilitate its closure. The treatment provided by Johanne Sabourin for Kristi’s pelvic floor had certainly ‘released and woken up’ the levator ani, yet more improvement was needed if effective load transfer and pelvic organ support were to be ensured throughout her lifetime. Kristi was advised to continue with the training programme provided and to work on integrating these new strategies into her activities of daily living and other physical activities (i.e. kickboxing) (Lee LJ 2011). She was also advised to return for a follow-up examination in 6 months time.

Summary

According to the definition of Sackett et al. (2000), we believe that The Integrated Systems Model is an evidence-based approach in that it considers the patient’s values (thoughts, feelings, expectations) and integrates the practitioner’s expertise (clinical reasoning and skills) and the available research evidence into decision-making for appropriate therapeutic interventions. In our experience, there are no recipes, prediction rules or guidelines for patients presenting with chronic pelvic disability with or without pain and it is likely that a multimodel approach will always be more effective for long-term success. While temporary improvement in function and/or pain may be gained by using one component of the therapeutic intervention (release or align or connect or move), it is the long-term solution that is sought by the patient. We strive to empower our patients to understand what is driving their disability or pain experience, to be aware of the contexts or situations that facilitate their poor strategies and to learn how they can change those strategies and move towards ones that are more optimal for their bodies and health (Empower through Knowledge, Movement and Awareness). In this way, we hope that they can Move better, Feel better, and Be better! More information on The Integrated Systems Model approach can be found in the fourth edition of The Pelvic Girdle and online at www.discoverphysio.ca.

This chapter has illustrated the myriad of factors the clinician may need to take into account when assessing and developing a treatment plan for the patient with CPP. The next chapter describes the multidisciplinary and multispeciality approach to the management of CPP, from a pain specialist (Chapter 8.1) and from a physiotherapeutic perspective (Chapter 8.2).