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Introduction and hypothesis The German “Pelvic Floor Questionnaire for pregnant and postpartum women” is a self-administered questionnaire customized for pregnancy and the postpartum period that assesses four domains of pelvic floor function regarding perceived symptoms, suffering, and impact on quality of life: bladder, bowel, prolapse, and sexual function. No similar questionnaire is available in Swedish, despite a high prevalence of pregnancy and postpartum pelvic floor dysfunction. Thus, we aimed to translate the validated German questionnaire into Swedish and test its validity and reliability in a Swedish population. Methods Translation and cultural adaptation were performed according to guidelines. Of the 248 women who answered the Swedish questionnaire, 57 filled out the questionnaire twice to evaluate test-retest reliability. We also assessed internal consistency and discriminant validity. Results The Swedish version of the questionnaire showed good face and content validity. Cronbach’s alpha was in the acceptable to excellent range (bladder 0.82, bowel 0.78, prolapse 0.91, and sexual 0.83), showing adequate internal consistency. A comparison of means (≥ 1 point) showed that the questionnaire significantly (p < 0.05) distinguished between women who reported suffering and those who did not. Cohen's kappa for all individual items showed fair to almost perfect agreement (0.24–0.87) between test and retest scores. The intraclass correlation coefficients for domain scores (0.92–0.97) were all in an optimal range. Conclusions The Swedish version of the questionnaire is a reliable and valid instrument for assessing pelvic floor disorders, symptom severity, and impact on quality of life during pregnancy and the postpartum period.

Objective The purpose of this study was to evaluate whether the clinical assessment of pelvic floor muscles and the diastasis recti abdominis could predict the severity of pelvic girdle pain during the first year postpartum. Methods Between 2018 and 2020, 504 women were recruited to this prospective longitudinal cohort study. At 2 to 3 months postpartum, their pelvic floor muscles and diastasis recti abdominis were assessed using vaginal palpation, observation, and caliper measurement. The participants completed the Pelvic Girdle Questionnaire (PGQ) at 2 to 3, 6, 9, and 12 months postpartum. Mixed-effect models were used to determine how the results of pelvic floor muscle and diastasis recti abdominis assessments predicted the PGQ score. A sub-analysis for middle to high PGQ scores was conducted. Results Maximal voluntary pelvic floor muscle contractions ≥3 (Modified Oxford Scale, scored from 0 to 5) predicted a decreased PGQ score (β = −3.13 [95% CI = −5.77 to −0.48]) at 2 to 3 months postpartum, with a higher prediction of a middle to high PGQ score (β = −6.39). Diastasis recti abdominis width did not have any significant correlation with the PGQ score. A sub-analysis showed that a diastasis recti abdominis width ≥35 mm predicted an increased PGQ score (β = 5.38 [95% CI = 1.21 to 9.55]) in women with pelvic girdle pain. Conclusion The distinction between weak and strong maximal voluntary pelvic floor muscle contractions is an important clinical assessment in women with postpartum pelvic girdle pain. The exact diastasis recti abdominis width, measured in millimeters, showed no clinical relevance. However, a diastasis recti abdominis width ≥35 mm was associated with a higher PGQ score, and further research about this cutoff point in relation to pain is needed. Impact This study highlights the importance of clinical assessment of pelvic floor muscles in patients with postpartum pelvic girdle pain. A better understanding of the role of this muscle group will enable more effective physical therapist treatment of pelvic girdle pain.

BACKGROUND: Pelvic girdle pain (PGP) in pregnancy may result in activity limitations and thus a negative impact on the individual woman's everyday life. Women's expectations when they seek physical therapy because of PGP are not yet known. OBJECTIVE: To explore pregnant women's lived experience of PGP and what needs and expectations they express prior to a physical therapy consultation. METHODS: A qualitative study using a descriptive phenomenological method. Interviews conducted with 15 pregnant women seeking physical therapy because of PGP, recruited through purposive sampling at one primary care rehabilitation clinic. RESULTS: PGP was described by four themes; An experience with larger impact on life than expected, A time for adjustments and acceptance, A feeling of insecurity and concern, A desire to move forward. PGP had a large impact on the pregnant women´s life. Thoughts of PGP as something to be endured was expressed, the women therefore accepted the situation. Finding strategies to manage everyday life was hard and when it failed, the women described despair and a need for help. They expected the physical therapist to be an expert who would see them as individuals and provide advice that could make their everyday life easier. CONCLUSION: Our results reveal that pregnant women with PGP delay seeking physical therapy until their situation becomes unmanageable and they run out of strategies for self-care. The women express, in light of their individual experiences, needs and expectations for professional management and advice tailored to their individually unique situation.

During their lifespan, many women are exposed to pain in the pelvis in relation to menstruation and pregnancy. Such pelvic pain is often considered normal and inherently linked to being a woman, which in turn leads to insufficiently offered treatment for treatable aspects related to their pain experience. Nonetheless, severe dysmenorrhea (pain during menstruation) as seen in endometriosis and pregnancy-related pelvic girdle pain, have a high impact on daily activities, school attendance and work ability. In the context of any type of chronic pain, accumulating evidence shows that an unhealthy lifestyle is associated with pain development and pain severity. Furthermore, unhealthy lifestyle habits are a suggested perpetuating factor of chronic pain. This is of specific relevance during lifespan, since a low physical activity level, poor sleep, or periods of (di)stress are all common in challenging periods of women’s lives (e.g., during menstruation, during pregnancy, in the postpartum period). This state-of-the-art paper aims to review the role of lifestyle factors on pain in the pelvis, and the added value of a lifestyle intervention on pain in women with pelvic pain. Based on the current evidence, the benefits of physical activity and exercise for women with pain in the pelvis are supported to some extent. The available evidence on lifestyle factors such as sleep, (di)stress, diet, and tobacco/alcohol use is, however, inconclusive. Very few studies are available, and the studies which are available are of general low quality. Since the role of lifestyle on the development and maintenance of pain in the pelvis, and the value of lifestyle interventions for women with pain in the pelvis are currently poorly studied, a research agenda is presented. There are a number of rationales to study the effect of promoting a healthy lifestyle (early) in a woman’s life with regard to the prevention and management of pain in the pelvis. Indeed, lifestyle interventions might have, amongst others, anti-inflammatory, stress-reducing and/or sleep-improving effects, which might positively affect the experience of pain. Research to disentangle the relationship between lifestyle factors, such as physical activity level, sleep, diet, smoking, and psychological distress, and the experience of pain in the pelvis is, therefore, needed. Studies which address the development of management strategies for adapting lifestyles that are specifically tailored to women with pain in the pelvis, and as such take hormonal status, life events and context, into account, are required. Towards clinicians, we suggest making use of the window of opportunity to prevent a potential transition from localized or periodic pain in the pelvis (e.g., dysmenorrhea or pain during pregnancy and after delivery) towards persistent chronic pain, by promoting a healthy lifestyle and applying appropriate pain management.

ObjectiveTo investigate if there are differences between acupuncture and transcutaneous electrical nerve stimulation (TENS) as treatment for pelvic girdle pain (PGP) in pregnancy in order to manage pain and thus maintain health and functioning in daily activities and physical activity (PA).DesignRandomised controlled trial.Setting and participantsPregnant women (n=113) with clinically verified PGP in gestational weeks 12–28, recruited from maternity healthcare centres, randomised (1:1) into two groups. Exclusion criteria: any obstetrical complication, systemic disease or previous disorder that could contradict tests or treatment.InterventionsThe intervention consisted of either 10 acupuncture sessions (two sessions per week) provided by a physiotherapist or daily home-based TENS during 5 weeks.Primary outcome variablesDisability (Oswestry Disability Index), functioning (Patient Specific Functional Scale), work ability (Work Ability Index) and PA-level according to general recommendations.Secondary outcome variablesFunctioning related to PGP (Pelvic Girdle Questionnaire), evening pain intensity (Numeric Rating Scale, NRS), concern about pain (NRS), health (EuroQoL 5-dimension), symptoms of depression/catastrophising (Edinburgh Postnatal Depression Scale/Coping Strategies Questionnaire).ResultsNo mean differences were detected between the groups. Both groups managed to preserve their functioning and PA level at follow-up. This may be due to significantly (pConclusionTreating PGP with acupuncture or TENS resulted in maintenance of functioning and physical activity and also less pain and concern about pain. Either intervention could be recommended as a non-pharmacological alternative for pain relief and may enable pregnant women to stay active.Trial registration number12726. https://www.researchweb.org/is/sverige/project/127261

ObjectivesEvaluation of the inter-rater reliability of clinical assessment methods for pelvic floor muscles and diastasis recti abdominis post partum.DesignA multicentre inter-rater reliability study.SettingThree primary care rehabilitation centres in Sweden.ParticipantsA total of 222 participants were recruited via advertising at Swedish maternity care units and social media. Eligibility for participation included female gender, ≥18 years, at maximum 3 months after childbirth. Exclusion criteria were chronic pelvic girdle pain and/or low back pain and/or pelvic floor tear grade III/IV. At each centre, 2 physiotherapists, with training and experience in pelvic floor assessment, assessed the 222 women according to a standardised protocol in random order.Outcome measuresInter-rater reliability of the assessment of pelvic floor muscle function (involuntary and voluntary contraction and voluntary relaxation) and diastasis recti abdominis (width, depth and bulging).ResultsVaginal palpation of maximal voluntary contraction revealed a kappa value of 0.69 (95% CI 0.62 to 0.76). Assessments of involuntary contraction and voluntary relaxation yielded inconsistent results, with slight-to-moderate weighted kappa values ranging from 0.10 to 0.51. After 2 months of training in applying this method, diastasis recti abdominis width measured at the umbilicus by calliper yielded an intraclass correlation coefficient value of 0.83 (95% CI 0.76 to 0.87). Assessments of diastasis recti abdominis depth and bulging showed moderate kappa values, with reservation for some inconsistency between the centres.ConclusionsVaginal palpation of pelvic floor muscle strength is a reliable method for the postpartum muscle assessment. Additional research is needed to identify reliable assessment method for other pelvic floor muscle functions like involuntary contraction and voluntary relaxation. With some training, a calliper is a reliable instrument for measuring the postpartum diastasis recti abdominis width. This study provides novel thoughts about how to measure diastasis recti abdominis depth and bulging.Trial registration numberNCT03703804.

Background: Many women are affected by primary dysmenorrhoea. Transcutaneous Electric Nerve Stimulation (TENS) can be an alternative to analgesics. In one trial, high-intensity, high-frequency TENS...

Purpose: A prehabilitation phase is suggested as the ideal way to prepare patients for optimal outcomes from surgery. Our aim was to describe the lessons we learned from developing PREPARE, an evidence-based prehabilitation programme based on a cognitive behavioural approach designed to improve functional outcomes after lumbar fusion surgery. Methods: We used the Medical Research Council (MRC) framework approach for developing and designing a complex intervention, specifically the two phases; 'Development' and 'Feasibility and Piloting'. Various aspects of treatment fidelity were evaluated during the phase 'Feasibility and Piloting'. As part of the feasibility element, a pilot Single Subject Research Design study was performed. Eleven patients awaiting lumbar fusion surgery participated in the study. We evaluated in particular the use and application of outcome measures. Results: Significant lessons were learned which we used to adjust the prehabilitation programme to better fit a surgical context. The original treatment manual was elaborated on, the outcome measures adjusted, and the content of the intervention altered. Finally, the PREPARE programme was published in the form of a study protocol. Conclusions: There are significant lessons to be learned from testing a study protocol before it is implemented in a large-scale randomised controlled trial (RCT).

Background Prehabilitation programs have led to improved postoperative outcomes in several surgical contexts, but there are presently no guidelines for the prehabilitation phase before lumbar fusion surgery. Objective The objective was to investigate whether a person-centered physical therapy prehabilitation program, based on a cognitive-behavioral approach, is more effective than conventional care in reducing disability and improving functioning after lumbar fusion surgery in patients with degenerative disk disease. Design This study was a randomized controlled trial. Setting The study took place at 2 private spine clinics and 1 university hospital. Patients We prospectively enrolled 118 patients scheduled for lumbar fusion surgery. Intervention The active intervention used a person-centered perspective and focused on promoting physical activity and targeting psychological risk factors before surgery. The control group received conventional preoperative care. Measurements The primary outcome was the Oswestry Disability Index score. Secondary outcomes were back and leg pain intensity, catastrophizing, kinesiophobia, self-efficacy, anxiety, depression, health-related quality of life, and patient-specific functioning, physical activity, and physical capacity. Data were collected on 6 occasions up to 6 months postoperatively. A linear mixed model was used to analyze the change scores of each outcome. Results No statistically significant between-group difference was found on the primary outcome (disability) over time (baseline to 6 months). Among secondary outcome measures, a statistically significant interaction effect (“Group × Time”) was seen for the European Quality of Life 5 Dimensions Questionnaire. The largest between-group difference on the European Quality of Life 5 Dimensions Questionnaire index was seen 1 week prior to surgery and favored the active intervention. The largest between-group effect sizes at the 6-month follow-up favored the active intervention, and were seen for physical activity intensity, steps per day, and the One Leg Stand Test. Both groups reached the minimal important change for the primary outcome and, in several secondary outcomes (pain intensity, back and leg; pain catastrophizing; anxiety; health-related quality of life [EQ5D VAS]), already at 8-week follow-up. Limitations The participants’ preoperative level of disability was lower than normative values, which suggests selection bias. Conclusions Both interventions led to clinically important changes, but it is not clear what kind of prehabilitation program is the most effective.

Introduction and hyposthesis Eighty-five percent of all vaginal deliveries cause some form of obstetric tear injury. To our knowledge, there are no studies exploring experiences after second-degree tear. Therefore, our study aimed to investigate the experiences of a second-degree vaginal tear regarding aspects of the recovery and need for healthcare and rehabilitation. Methods Individual semi-structured interviews were performed and analysed with a qualitative, inductive descriptive approach. Results A group of 18 women with a second-degree vaginal tear after delivery were included. Four main categories with associated subcategories were found: (1) feeling uncertainty, with subcategories: not knowing what is normal, concern, confusion and uncertainty regarding pelvic floor muscle training; (2) feeling of security, with subcategories: I have no/I can handle the symptoms, trust in the healthcare system and I have sufficient knowledge; (3) not prioritizing myself, with the subcategories: I cannot find time and others have bigger problems; (4) lack of trust in healthcare providers, with the subcategories: feeling forgotten, not being taken seriously, distrust of the competence of the healthcare providers and resignation. Conclusion Women who suffer from a second-degree vaginal tear after pregnancy can feel safe when needs are met but uncertainty is also common when available healthcare and information are perceived as insufficient. The women also feel uncertainty about what is normal after the tear and how to perform pelvic floor exercises. Trial registration This trial was registered in “FoU in Sweden” (Research and Development in Sweden). Registration number: 214591.

During childbirth, women may suffer perineal injuries that can lead to persistent disorders. No interview study has investigated women's experience of obstetric anal sphincter injuries (OASIS) and physical therapy rehabilitation process after the injury.To describe women's experiences of OASIS and the physical therapy rehabilitation process.A qualitative study with an inductive approach based on semi-structured interviews was performed with 14 primi- and multi-parous women affected by OASIS. They had been sutured within 24 h and were recruited from a university hospital in Sweden. The interviews lasted between 35 and 66 min. Data were processed and analyzed using qualitative content analysis.Three main categories emerged from the analysis: The categories described experiences of a difficult time after the injury and physical therapy rehabilitation but also experiences of a safe follow-up. Moreover, experiences of that it wasn´t that bad after all when looking back.Regardless of the extent of the injury, some women experienced a long and troublesome recovery with intense physical therapy rehabilitation, while other women felt that they fortunately got away lightly. Factors that can influence a woman's confidence in safely beginning pelvic floor muscle training at an early stage include individualizing when and how information about OASIS is provided. Meeting each woman's needs and wishes is emphasized by this study.

Exercise protects against somatic comorbidities and positively affects cognitive function and psychiatric symptoms in patients with severe mental illness. In forensic psychiatry, exercise is a novel concept. Staff at inpatient care facilities may be important resources for successful intervention. Little is known about staff's knowledge, attitudes and behaviors regarding exercise in forensic psychiatric care.To translate, culturally adapt and test the feasibility of the Exercise in Mental Health Questionnaire-Health Professionals Version (EMIQ-HP) in the Swedish context, and to use this EMIQ-HP-Swedish version to describe staff's knowledge, attitudes and behaviors regarding exercise.The EMIQ-HP was translated, culturally adapted, pilot-tested and thereafter used in a cross-sectional nationwide survey.Ten of 25 clinics and 239 health professionals (50.1%) participated. Two parts of the EMIQ-HP-Swedish version showed problems. Most participants considered exercise to be a low-risk treatment (92.4%) that is beneficial (99.2%). Training in exercise prescription was reported by 16.3%. Half of participants (52.7%) prescribed exercise and 50.0% of those undertook formal assessments prior to prescribing.Creation of the EMIQ-HP-Swedish version was successful, despite some clarity problems. Exercise appears to be prescribed informally by non-experts in Swedish forensic psychiatric care and does not address treatment goals.

Background Pregnancy and childbirth often result in alterations of core muscles, and women may require postpartum assessment of pelvic floor muscle function and abdominal wall changes, e.g. diastasis recti abdominis (DRA). However, there is currently no gold standard for postpartum assessment of these muscles´ function. Here we aimed to evaluate the reliability of clinically applicable methods for assessing pelvic floor muscles and DRA after pregnancy. Methods We recruited 222 postpartum women from Swedish antenatal and childbirth centers, and via social media. Pelvic floor and DRA assessment were performed via observation and palpation at three rehabilitation centers in Sweden. At each center, two independent physiotherapists performed the assessments in random order. Results Assessment of the maximal voluntary contraction and pelvic floor muscle endurance revealed kappa values ranging from 0.49–0.69. Assessments of voluntary contraction by observation, involuntary contraction, and voluntary relaxation yielded inconsistent results, with slight-to-moderate weighted kappa values ranging from 0.10–0.51. DRA assessment by caliper yielded ICC values of 0.73–0.83 after physiotherapists underwent 2 months of training in applying this assessment method. The standard error of measurements for this method was about 4 mm, and the minimal detectable change was 12 mm. Assessments of DRA depth and bulging showed moderate kappa values of 0.43–0.51, with reservation for some inconsistency between the centers. Conclusions Palpation of maximal voluntary contraction and pelvic floor muscle endurance are reliable postpartum assessment methods. With some experience and training, a caliper is a reliable instrument for assessing the postpartum DRA width. Additional research is needed to identify a reliable assessment method for pelvic floor muscle functions other than voluntary contraction, and for DRA depth and bulging.

Objectives: To evaluate the level of evidence for treatments included in physical therapy practice for patients with Obstetric Anal Sphincter InjurieS (OASIS) and provide treatment recommendations.Methods: Literature search was done in relevant databases of which the last one was performed on 1 November 2016. The randomized controlled trials were evaluated for internal validity and level of evidence for the interventions was set.Results: Eight articles were identified evaluating pelvic floor exercises, biofeedback and electrical stimulation of which six were randomized and controlled. There is a very low level of evidence that pelvic floor exercises with augmented biofeedback (audio-visual feedback and electro stimulation) has better effects compared to sensory biofeedback for women with impaired faecal continence after OASIS and that adjuvant biofeedback has effect on anal incontinence and decreases embarrassment following anal sphincter repair years after OASIS. The studies evaluating solely pel...

Background: Pelvic girdle pain (PGP) and sacroiliac joint (SIJ) dysfunction/pain are considered frequent contributors to low back pain (LBP). Like other persistent pain conditions, PGP is increasingly recognized as a multifactorial problem involving biological, psychological, and social factors. Perspectives differ between experts and a diversity of treatments (with variable degrees of evidence) have been utilized. Objective: To develop a collaborative model of PGP that represents the collective view of a group of experts. Specific goals were to analyze structure and composition of conceptual models contributed by participants, to aggregate them into a metamodel, to analyze the metamodel's composition, and to consider predicted efficacy of treatments. Design: To develop a collaborative model of PGP, models were generated by invited individuals to represent their understanding of PGP using fuzzy cognitive mapping (FCM). FCMs involved proposal of components related to causes, outcomes, and treatments for pain, disability, and quality of life, and their connections. Components were classified into thematic categories. Weighting of connections was summed for components to judge their relative importance. FCMs were aggregated into a metamodel for analysis of the collective opinion it represented and to evaluate expected efficacy of treatments. Results: From 21 potential contributors, 14 (67%) agreed to participate (representing six disciplines and seven countries). Participants' models included a mean (SD) of 22 (5) components each. FCMs were refined to combine similar terms, leaving 89 components in 10 categories. Biomechanical factors were the most important in individual FCMs. The collective opinion from the metamodel predicted greatest efficacy for injection, exercise therapy, and surgery for pain relief. Conclusions: The collaborative model of PGP showed a bias toward biomechanical factors. Most efficacious treatments predicted by the model have modest to no evidence from clinical trials, suggesting a mismatch between opinion and evidence. The model enables integration and communication of the collection of opinions on PGP.

BACKGROUND: When comparing neuromuscular activity between different individuals or different conditions by use of surface electromyography (sEMG) it is necessary to apply standardized assessment protocol. Most frequently used method is the maximum voluntary isometric contraction (MVIC). However, the influence of body posture on sEMG activity during MVIC testing remains largely unknown.AIM: To evaluate the MVIC method for sEMG normalization in supine versus standing positions for selected muscles of the lower extremity and trunk.METHODS: Twelve healthy individuals participated; five females and seven males (age 22-51 yrs). sEMG signals were recorded bilaterally from mm tibialis anterior, gluteus medius, adductor longus, rectus abdominus, external oblique and internal oblique/transversus abdominus according to standardized test protocol. Two different body positions were used: supine and standing position.RESULTS: MVIC peak sEMG signal amplitudes did not differ systematically between supine and standing test positions. Pronounced inter-subject variability in MVIC reference sEMG activity were observed between participants, during both supine and standing test positions.CONCLUSION: Present data demonstrate that MVIC EMG normalization is a biomechanically stable procedure that can be performed in a reproducible manner for the major leg and trunk muscles when comparing supine vs. standing test positions.

Background Physical capacity tasks (ie, observer-administered outcome measures that comprise a standardized activity) are useful for assessing functioning in patients with low back pain. Purpose The purpose of this study was to systematically review the level of evidence for the reliability, validity, and responsiveness of physical capacity tasks. Data Sources MEDLINE, CINAHL, PsycINFO, Scopus, the Cochrane Library, and relevant reference lists were used as data sources. Study Selection Two authors independently selected articles addressing the reliability, validity, and responsiveness of physical capacity tasks, and a third author resolved discrepancies. Data Extraction and Quality Assessment One author performed data extraction, and a second author independently checked the data extraction for accuracy. Two authors independently assessed the methodological quality with the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) 4-point checklist, and a third author resolved discrepancies. Data Synthesis and Analysis Data synthesis was performed by all authors to determine the level of evidence per measurement property per physical capacity task. The 5-repetition sit-to-stand, 5-minute walk, 50-ft (∼15.3-m) walk, Progressive Isoinertial Lifting Evaluation, and Timed “Up & Go” tasks displayed moderate to strong evidence for positive ratings of both reliability and construct validity. The 1-minute stair-climbing, 5-repetition sit-to-stand, shuttle walking, and Timed “Up & Go” tasks showed limited evidence for positive ratings of responsiveness. Limitations The COSMIN 4-point checklist was originally developed for patient-reported outcome measures and not physical capacity tasks. Conclusions The 5-repetition sit-to-stand, 50-ft walk, 5-minute walk, Progressive Isoinertial Lifting Evaluation, Timed “Up & Go,” and 1-minute stair-climbing tasks are promising tests for the measurement of functioning in patients with chronic low back pain. However, more research on the measurement error and responsiveness of these tasks is needed to be able to fully recommend them as outcome measures in research and clinical practice.

PURPOSE: To explore how women experience living with long-term pregnancy-related pelvic girdle pain. MATERIALS AND METHODS: Nine women with persistent pregnancy-related pelvic girdle pain of 2-13 years were recruited by means of purposive sampling from long-term follow-up studies. The women were 28-42 years of age and had given birth to 2-3 children. Audio-taped in-depth interview with open-ended questions were used with the guiding question 'How do you experience living with pregnancy-related pelvic girdle pain?'. The Empirical Phenomenological Psychological method was chosen for analysis. RESULTS: The pregnancy-related pelvic girdle pain syndrome has a profound impact on everyday life for many years after pregnancy. Three constituents were identified as central to the experience of living with pregnancy-related pelvic girdle pain: (1) the importance of the body for identity, (2) the understanding of pain, and (3) stages of change. The manner in which the women experienced their pain was interpreted in terms of two typologies: the ongoing struggle against the pain, and adaptation and acceptance. CONCLUSION: The participants' narratives highlighted that the pain led to severe functional limitations that threatened their capability to perform meaningful daily activities, and interfered with their sense of identity. It appears essential to meet with each patient individually and to manage long-term pregnancy-related pelvic girdle pain as a pain syndrome. IMPLICATIONS FOR REHABILITATION Chronic pregnancy-related pelvic girdle pain • Pregnancy-related pelvic girdle pain impairs women's capacity to perform meaningful activities of daily life for many years after pregnancy. • The participants' narratives highlighted that the pain interfered with their sense of identity. • It appears essential to meet with each patient individually and to manage long-term pregnancy-related pelvic girdle pain as a pain syndrome.

To investigate the predictive value of preoperative fear-avoidance factors (self-efficacy for exercise, pain catastrophizing, kinesiophobia, and depression), walking capacity, and traditional predictor variables for predicting postoperative changes in physical activity level and disability 6 months after lumbar fusion surgery in patients with chronic low back pain (LBP).We prospectively enrolled 118 patients scheduled for lumbar fusion surgery for motion-elicited chronic LBP with degenerative changes in 1-3 segments of the lumbar spine. Associations between the predictors and the dependent variables were investigated with multiple linear regression analysis. Dependent variables were physical activity level as objectively measured with a triaxial accelerometer and disability as measured with the Oswestry Disability Index.Preoperative physical activity level (β = -0.349; P0.001) and self-efficacy for exercise (β = 0.176; P = 0.021) were significant predictors of the postoperative change in physical activity. Preoperative disability (β = -0.790; P0.001), self-efficacy for exercise (β = 0.152; P = 0.024), and pain catastrophizing (β = 0.383; P = 0.033) were significant predictors for the change in the Oswestry Disability Index.Patients with low levels of preoperative physical activity were more likely to increase their level of physical activity after lumbar fusion surgery, especially when their self-efficacy for exercise was high. However, most of these patients still had low levels of physical activity after surgery, and they may therefore need extra support in increasing their postoperative physical activity levels.

Background Pelvic Girdle Pain (PGP) is an important cause of disability and economic cost worldwide. There is a need for effective preventative and management strategies. Emerging studies measure a variety of outcomes rendering synthesis and translation to clinical practice difficult. A Core Outcome Set (COS) can address this problem by ensuring that data are relevant, useful and usable for making well-informed healthcare choices. The aim of this study is to develop a consensus-based PGP-COS, including agreement on methods (e.g. instruments) for measuring the construct outcomes in the COS for use in research and clinical practice. Furthermore, as there is uncertainty as to whether incorporating stakeholder interviews in addition to conducting a systematic review to determine an initial list of outcomes for the Delphi survey, or, whether using different rating scales in a Delphi survey impacts on the final COS, we propose to embed two methodological studies within the PGP-COS development process to address these questions. Methods The PGP-COS study will include five phases: (1) A systematic review of the literature and semi-structured interviews with 15 patients (three countries) to form the initial list of outcomes for the Delphi survey; (2) A 3-round Delphi including patients, clinicians, researchers and service providers; (3) A systematic review of methods for measuring the outcomes in the preliminary PGP-COS identified in the Delphi survey; (4) A face-to-face consensus meeting to agree on the final PGP-COS and methods for measuring the COS; (5) Global dissemination. To address the methodological questions, we will assess the number and type of outcomes, in the final PGP-COS, that were exclusively derived from the interviews. Secondly, we will randomise Delphi survey participants to either a 5-point or 9-point importance rating scale, and examine potential differences in ‘important’ ratings between the groups. Discussion There is currently no COS for measuring/monitoring PGP in trials and clinical practice. A PGP-COS will ensure that relevant outcomes are measured using appropriate measurement instruments for patients with PGP globally. Core outcome set registration This PGP-COS was registered with COMET (Core Outcome Measures for Effectiveness Trials) in January 2017 (http://www.comet-initiative.org/studies/details/958). © The Author(s). 2018. Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Objectives: The STarT Back Screening Tool (SBT) is a newly validated questionnaire that identifies modifiable risk factors of poor prognosis in patients with low back pain (LBP). The aim of this study was to cross-culturally adapt the SBT into Swedish and to test its concurrent validity in patients with LBP in primary healthcare. Methods: The SBT was translated according to established guidelines. Concurrent validity was tested on 62 patients by comparing the SBT with the Orebro Musculoskeletal Pain Screening Questionnaire, short form (OMPSQ-short). Analysis of correlations between the instruments' total scores and between psychosocial sub-score of SBT and OMPSQ-short was performed using Spearman's rank correlation. Results: A translation of the SBT into Swedish required minor semantic adaptation until the final version was acceptable. Correlation between the SBT and the OMPSQ-short was large with r = 0.61 (SBT total with OMPSQ-short total score) and r = 0.60 (SBT psychosocial subscale with OMPSQ-...

Pelvic girdle pain (PGP) and low-back pain (LBP) are the most common musculoskeletal disorders experienced during pregnancy, yet they are not familiar to healthcare providers in some countries. The objective was to compare prevalence, severity, and impact of PGP and LBP among pregnant women in the United States, the United Kingdom, Norway, and Sweden. Women's desires for, access to, and experience of treatment were also examined.This is a cross-sectional self-reported questionnaire study of pregnant women, recruited at maternity care units in gestational weeks 30-38. Main outcome measures were presence and impact of PGP and/or LBP.A total of 869 pregnant women from the United States (n = 214), the United Kingdom (n = 220), Norway (n = 220), and Sweden (n = 215) were included. PGP and/or LBP were reported by 70%-86%, with lowest prevalence in Scandinavia. Severity and impact differed significantly across countries (p 0.001), with U.K. women reporting the highest pain intensity (Numeric Rating Scale [NRS] 7/10) and highest mean total score on the Pelvic Girdle Questionnaire (PGQ) (46/100). U.S. women were significantly less afflicted, with mean PGQ total score 35/100 (p ≤ 0.001). The countries differed regarding concern about PGP and/or LBP (p 0.001), with U.K. women being most affected (NRS 5/10). Norwegian women were most likely to receive treatment (53%) and U.S. women least likely (24%) (p 0.001). Among women receiving treatment, 68%-87% reported a positive effect.PGP and/or LBP during pregnancy are common in the United States, the United Kingdom, Norway, and Sweden. Severity, concern, and treatment experiences differed across countries. The majority of women who received treatment reported a positive effect.

Time to stop using the term "conservative treatment" when we actually mean different physiotherapy modalities - Editorial

Objective: To explore the association between disability and sick leave due to lumbopelvic pain in pregnant women in 3 cohorts in Sweden and Norway and to explore possible factors of importance to sick leave. A further aim was to compare the prevalence of sick leave due to lumbopelvic pain. Design/subjects: Pregnant women (n=898) from two cohorts in Sweden and one in Norway answered to questionnaires in gestational weeks 10-24; two of the cohorts additionally in weeks 28-38. Methods: Logistic regression models were performed with sick leave due to lumbopelvic pain as dependent factor. Disability, pain, age, parity, cohort, civilian status, and occupational classification were independents factors. Results: In gestational weeks 10-24 the regression model included 895 cases; 38 on sick leave due to lumbopelvic pain. Disability, pain and cohort affiliation were associated with sick leave. In weeks 28-38, disability, pain and occupation classification were the significant factors. The prevalence of lumbopelvic pain was higher in Norway than in Sweden (65%, vs 58% and 44%; pless than0.001). Conclusion: Disability, pain intensity and occupation were associated to sick leave due to lumbopelvic pain. Yet, there were significant variations between associated factors among the cohorts, suggesting that other factors than workability and the social security system are also of importance.

BACKGROUND: Following lumbar fusion surgery, a successful outcome is empirically linked to effective rehabilitation. While rehabilitation is typically postoperative, the phase before surgery - termed prehabilitation - is reportedly an ideal time to prepare the patient. There are presently no guidelines for prehabilitation before lumbar fusion surgery. Physical activity has well-known health benefits, and staying physically active despite pain is a major principle in non-pharmacological chronic low back pain treatment. Psychological factors such as fear of movement, pain catastrophizing and low self-efficacy are known to be barriers to staying active. No studies have investigated prehabilitation protocols that promote physical activity and target psychological risk factors before lumbar fusion surgery. The aim of our proposed randomised controlled trial is to investigate whether patients who undergo lumbar fusion surgery for degenerative disc disease experience better functioning with a physiotherapeutic prehabilitation program (PREPARE) based on a cognitive behavioural approach compared to conventional care. METHODS/DESIGN: We will recruit 110 patients between 18-70 years of age with degenerative disc disease who are waiting for lumbar fusion surgery. These patients will be randomly assigned to receive either PREPARE or conventional care. PREPARE uses a person-centred perspective and focuses on promoting physical activity and targeting psychological risk factors before surgery. The primary outcome will be disability measured using the Oswestry Disability Index 2.0. Secondary outcomes will include functioning (patient-reported and performance-based), physical activity (accelerometer), health-related quality of life, back and leg pain intensity, pain catastrophizing, kinesiophobia, self-efficacy, depression, anxiety, satisfaction with treatment results and health economic factors. Data will be collected at baseline (preoperatively) after the intervention (preoperatively), 3 and 8 weeks, 3, 6, 12, 24 and 60 months postoperatively. DISCUSSION: We hypothesise that the focus on promoting physical activity and targeting psychological risk factors before surgery will decrease disability and help the patients to be more active despite pain both before and after surgery. We will use a combination of outcome measures both patient-reported and performance-based, as well as accelerometer data. This will provide a more comprehensive picture of the patient's functioning than just patient-reported outcomes alone. TRIAL REGISTRATION: Current Controlled Trials ISCRTN17115599 , Retrospectively Registered 18 May 2015.

Background Pelvic girdle pain (PGP) is a multifactorial condition, which can be mentally and physically compromising both during and after pregnancy. However, long-term pregnancy-related PGP has been poorly investigated. This longitudinal follow-up study uniquely aimed to describe prevalence and predictors of PGP and its consequences on women’s health and function up to 11 years after pregnancy. Methods/Design A postal questionnaire was sent to 530 women who participated in 1 of 3 randomized controlled studies for PGP in pregnancy. Women who reported experiencing lumbopelvic pain were offered a clinical examination. Main outcome measure was the presence of long term PGP as assessed by an independent examiner. Secondary outcomes were: working hours/week, function (the Disability Rating Index, and Oswestry Disability Index), self-efficacy (the General Self-Efficacy Scale), HRQL (Euro-Qol 5D and EQ-Visual scale), anxiety and depression, (Hospital anxiety and depression scale,) and pain-catastrophizing (Pain Catastrophizing Scale), in women with PGP compared to women with no PGP. Results A total of 371/530 (70 %) women responded and 37/ 371 (10 %) were classified with long-term PGP. Pregnancy-related predictors for long-term PGP were number of positive pain provocation tests (OR = 1.79), history of low back pain (LBP) (OR = 2.28), positive symphysis pressure test (OR = 2.01), positive Faber (Patrick’s) test (OR = 2.22), and positive modified Trendelenburg test (OR = 2.20). Women with PGP had significantly decreased ability to perform daily activities (p

The classification of pelvic girdle pain can only be reached after lumbar causes have been excluded by a clinical examination. During clinical examination, the posterior pelvic pain provocation test is a well-established method for verifying pelvic girdle pain. However, a criticism of pelvic pain provocation tests is that they may have an effect on lumbar structures, thus yielding false-positive results. The posterior pelvic pain provocation test was performed with four groups of patients: patients with computed tomography-verified disc herniations (1) on the waiting list for surgery (14 women; 9 men); (2) 6 weeks after disc surgery (18 women, 12 men); (3) pregnant women seeking care for pelvic girdle pain (n = 25); and (4) women with persistent pelvic girdle pain after delivery (n = 32). The sensitivity of the posterior pelvic pain provocation test was 0.88 and the specificity was 0.89. The positive predictive value was 0.89 and the negative predictive value was 0.87. Analysis of only women showed similar results. In our study, the posterior pelvic pain provocation test was negative in patients with a well-defined lumbar diagnosis of lumbar disc herniation, both before and after disc surgery. Our results are an important step toward the more accurate classification of lumbopelvic pain.

The prevalence of low back pain (LBP) is higher in pregnant women compared to women of the same age in a general population. Pregnancy-related LBP persists 6 years after pregnancy in 16% of women. Consequently, pregnancy represents a specific risk for LBP and persistent LBP. Pregnancy-related LBP is usually studied as a single entity, however, only one subgroup of LBP, i.e. pelvic girdle pain (PGP), seems to be associated with pregnancy. Accordingly, possible differences in subgroups of patients with LBP are unknown. The aims of this thesis were the following: 1) to describe the prevalence of clinically classified subgroups of women with LBP in a cohort (no LBP, lumbar pain, PGP, and combined pain (PGP and lumbar pain)) during pregnancy and postpartum, and 2) to determine if there was a disparity in the course, health-related quality of life (HRQL), pain intensity, disability, depressive symptoms, or muscle function in subgroups of the cohort, and 3) to identify predictors for having persistent pregnancy-related PGP postpartum. Consecutively-enrolled pregnant women were classified into LBP subgroups by mechanical assessment of the lumbar spine, pelvic pain provocation tests, standard history, and pain drawings. All women answered questionnaires (background data, EQ-5D). Women with LBP completed the Oswestry Disability Index and pain measures. The Edinburgh Postnatal Depression Scale was used to evaluate depressive symptoms at 3 months postpartum (cut-off ≥10). Trunk muscle endurance, hip muscle strength, and gait speed were investigated. Multiple logistic regression was used to identify predictors from self-reports and clinical examination. At the 12-18 gestational week evaluation, 118/308 (38%) women had no LBP, 33 (11%) had lumbar pain, 101 (33%) had PGP, and 56 (18%) had combined pain. Three months postpartum, 183/272 (67%) women had no LBP, 29 (11%) had lumbar pain, 46 (17%) had PGP, and 14 (5%) had combined pain. Pregnant women with combined pain were most affected in terms of HRQL, pain intensity, and disability. Depressive symptoms were three times more prevalent in women with LBP (27/87, 31%) than in women without LBP (17/180, 9%). Women with PGP and/or combined pain had lower values for trunk muscle endurance, hip extensor strength and gait speed compared to women without LBP. Postpartum, 16-20% of the women had persistent combined pain or PGP, whereas 1/29 had lumbar pain. Predictors for persistent PGP or combined pain were work dissatisfaction, older age, combined pain in early pregnancy, and low endurance of the back flexors. In conclusion, women with combined pain were identified to be a target group since they had the lowest recovery rate and since the classification of combined pain was found to be a predictor for persistent PGP or combined pain postpartum. The hypothesis of an association between muscle dysfunction and PGP was strengthened. Based on the finding of high comorbidity of postpartum depressive symptoms and LBP, it seems important to screen for and consider treatment strategies for both symptoms.

The prevalence of low back pain (LBP) is higher in pregnant women compared to women of the same age in a general population. Pregnancy-related LBP persists 6 years after pregnancy in 16% of women. Consequently, pregnancy represents a specific risk for LBP and persistent LBP. Pregnancy-related LBP is usually studied as a single entity, however, only one subgroup of LBP, i.e. pelvic girdle pain (PGP), seems to be associated with pregnancy. Accordingly, possible differences in subgroups of patients with LBP are unknown. The aims of this thesis were the following: 1) to describe the prevalence of clinically classified subgroups of women with LBP in a cohort (no LBP, lumbar pain, PGP, and combined pain (PGP and lumbar pain)) during pregnancy and postpartum, and 2) to determine if there was a disparity in the course, health-related quality of life (HRQL), pain intensity, disability, depressive symptoms, or muscle function in subgroups of the cohort, and 3) to identify predictors for having persistent pregnancy-related PGP postpartum. Consecutively-enrolled pregnant women were classified into LBP subgroups by mechanical assessment of the lumbar spine, pelvic pain provocation tests, standard history, and pain drawings. All women answered questionnaires (background data, EQ-5D). Women with LBP completed the Oswestry Disability Index and pain measures. The Edinburgh Postnatal Depression Scale was used to evaluate depressive symptoms at 3 months postpartum (cut-off ≥10). Trunk muscle endurance, hip muscle strength, and gait speed were investigated. Multiple logistic regression was used to identify predictors from self-reports and clinical examination. At the 12-18 gestational week evaluation, 118/308 (38%) women had no LBP, 33 (11%) had lumbar pain, 101 (33%) had PGP, and 56 (18%) had combined pain. Three months postpartum, 183/272 (67%) women had no LBP, 29 (11%) had lumbar pain, 46 (17%) had PGP, and 14 (5%) had combined pain. Pregnant women with combined pain were most affected in terms of HRQL, pain intensity, and disability. Depressive symptoms were three times more prevalent in women with LBP (27/87, 31%) than in women without LBP (17/180, 9%). Women with PGP and/or combined pain had lower values for trunk muscle endurance, hip extensor strength and gait speed compared to women without LBP. Postpartum, 16-20% of the women had persistent combined pain or PGP, whereas 1/29 had lumbar pain. Predictors for persistent PGP or combined pain were work dissatisfaction, older age, combined pain in early pregnancy, and low endurance of the back flexors. In conclusion, women with combined pain were identified to be a target group since they had the lowest recovery rate and since the classification of combined pain was found to be a predictor for persistent PGP or combined pain postpartum. The hypothesis of an association between muscle dysfunction and PGP was strengthened. Based on the finding of high comorbidity of postpartum depressive symptoms and LBP, it seems important to screen for and consider treatment strategies for both symptoms.

Background: The relationship between activation of the stabilizing muscles of the lumbopelvic region during the Active Straight Leg Raise test and pelvic girdle pain remains unknown. Therefore, the aim was to examine automatic contractions in relation to pre-activation in the muscles of the pelvic floor and the lower lateral abdominal wall during leg lifts, performed as the Active Straight Leg Raise test, in women with and without persistent postpartum pelvic girdle pain. Methods: Sixteen women with pelvic girdle pain and eleven pain-free women performed contralateral and ipsilateral leg lifts, while surface electromyographic activity was recorded from the pelvic floor and unilaterally from the lower lateral abdominal wall. As participants performed leg lifts onset time was calculated as the time from increased muscle activity to leg lift initiation. Findings: No significant differences were observed between the groups during the contralateral leg lift. During the subsequent ipsilateral leg lift, pre-activation in the pelvic floor muscles was observed in 36% of women with pelvic girdle pain and in 91% of pain-free women (P = 0.01). Compared to pain-free women, women with pelvic girdle pain also showed significantly later onset time in both the pelvic floor muscles (P = 0.01) and the muscles of the lower lateral abdominal wall (P amp;lt; 0.01). Interpretation: We suggest that disturbed motor activation patterns influence womens ability to stabilize the pelvis during leg lifts. This could be linked to provocation of pain during repeated movements. (C) 2016 Elsevier Ltd. All rights reserved. Funding Agencies|Swedish Research Council [521-2019-3578]; Linkoping University, Sweden

The prevalence of low back pain (LBP) is higher in pregnant women compared to women of the same age in a general population. Pregnancy-related LBP persists 6 years after pregnancy in 16% of women. Consequently, pregnancy represents a specific risk for LBP and persistent LBP. Pregnancy-related LBP is usually studied as a single entity, however, only one subgroup of LBP, i.e. pelvic girdle pain (PGP), seems to be associated with pregnancy. Accordingly, possible differences in subgroups of patients with LBP are unknown. The aims of this thesis were the following: 1) to describe the prevalence of clinically classified subgroups of women with LBP in a cohort (no LBP, lumbar pain, PGP, and combined pain (PGP and lumbar pain)) during pregnancy and postpartum, and 2) to determine if there was a disparity in the course, health-related quality of life (HRQL), pain intensity, disability, depressive symptoms, or muscle function in subgroups of the cohort, and 3) to identify predictors for having persistent pregnancy-related PGP postpartum. Consecutively-enrolled pregnant women were classified into LBP subgroups by mechanical assessment of the lumbar spine, pelvic pain provocation tests, standard history, and pain drawings. All women answered questionnaires (background data, EQ-5D). Women with LBP completed the Oswestry Disability Index and pain measures. The Edinburgh Postnatal Depression Scale was used to evaluate depressive symptoms at 3 months postpartum (cut-off ≥10). Trunk muscle endurance, hip muscle strength, and gait speed were investigated. Multiple logistic regression was used to identify predictors from self-reports and clinical examination. At the 12-18 gestational week evaluation, 118/308 (38%) women had no LBP, 33 (11%) had lumbar pain, 101 (33%) had PGP, and 56 (18%) had combined pain. Three months postpartum, 183/272 (67%) women had no LBP, 29 (11%) had lumbar pain, 46 (17%) had PGP, and 14 (5%) had combined pain. Pregnant women with combined pain were most affected in terms of HRQL, pain intensity, and disability. Depressive symptoms were three times more prevalent in women with LBP (27/87, 31%) than in women without LBP (17/180, 9%). Women with PGP and/or combined pain had lower values for trunk muscle endurance, hip extensor strength and gait speed compared to women without LBP. Postpartum, 16-20% of the women had persistent combined pain or PGP, whereas 1/29 had lumbar pain. Predictors for persistent PGP or combined pain were work dissatisfaction, older age, combined pain in early pregnancy, and low endurance of the back flexors. In conclusion, women with combined pain were identified to be a target group since they had the lowest recovery rate and since the classification of combined pain was found to be a predictor for persistent PGP or combined pain postpartum. The hypothesis of an association between muscle dysfunction and PGP was strengthened. Based on the finding of high comorbidity of postpartum depressive symptoms and LBP, it seems important to screen for and consider treatment strategies for both symptoms.

Objective To explore the effect of physiotherapeutic interventions on pregnancy-related lumbopelvic pain. Material and methods Data sources: MEDLINE, Cochrane Central Register of Controlled Trials, PEDro, CINAHL, AMED, and SCOPUS databases were searched up to December 2014 for studies written in English, French, German or Scandinavian languages that evaluated physiotherapeutic modalities for preventing and treating pregnancy-related lumbopelvic pain. Results For lumbopelvic pain during pregnancy, the evidence was strong for positive effects of acupuncture and pelvic belts. The evidence was low for exercise in general and for specific stabilizing exercises. The evidence was very limited for efficacy of water gymnastics, progressive muscle relaxation, a specific pelvic tilt exercise, osteopathic manual therapy, craniosacral therapy, electrotherapy and yoga. For postpartum lumbopelvic pain, the evidence was very limited for clinic-based treatment concepts, including specific stabilizing exercises, and for self-management interventions for women with severe disabilities. No specific adverse events were reported for any intervention. No meta-analysis could be performed because of study heterogeneity. Conclusions The levels of evidence were strong for a positive effect of acupuncture and pelvic belts, but weak for an effect of specific exercises. Caution should prevail in choosing other interventions for pregnancy-related lumbopelvic pain.

Background Different tests are used in order to classify women with pelvic girdle pain (PGP). One limitation of the tests is that they need to be performed by an examiner. Self-administered tests have previously been described and evaluated by women who performed the tests directly before the examiner performed the original tests. Thus, an evaluation of the self-administered tests performed in a more natural setting, such as the women’s home is needed. The purpose of this study was to investigate the agreement between self-administered tests performed at home and tests performed by an examiner on women with suspected PGP. Additionally to compare the classification made by an examiner and classification based on results of the self-administered tests and questionnaire. Methods One hundred and twenty three pregnant women with suspected PGP participated. Before the appointment at the clinic the women performed the self-administered tests and filled in a questionnaire. During the appointment one specialized physiotherapist performed the tests. Result of the two different sets of tests and the classifications made by the examiner and the self-administered tests including questionnaires were compared concerning percentage of agreement (POA), sensitivity and positive predicted value (PPV). Results The P4 and the bridging test had the highest POA (≥74.8%), sensitivity (≥75.5%) and PPV (≥91.2%) for posterior PGP. For anterior PGP the MAT test had highest POA (76.4%), and PPV (69.5%), and the modified Trendelenburg test the highest sensitivity (93.0%). Agreement between the two classifications was 87%. A significantly higher number of positive P4 and bridging tests (p

Purpose The majority of prognostic studies on postpartum lumbopelvic pain have investigated factors during pregnancy. Since the majority of women recover within the first few months of delivery, it is unknown if the same predictors are valid for long-term consequences. It is also important to investigate predictors within subgroups of patients with pregnancy-related lumbopelvic pain due to their different clinical courses. The aim of this study was to identify predictors for disability 15 months postpartum in women with persistent postpartum pelvic girdle pain (PGP). Methods Data were obtained by clinical tests and questionnaires 3 months postpartum. The outcome 15 months postpartum was disability measured with the Oswestry Disability Index. Results A multiple linear regression analysis identified two significant two-way interaction effects that were predictive of disability 15 months postpartum: (a) age + trunk flexor endurance, and (b) disability + hip extensor strength. Conclusions Age, muscle function and disability seem to influence the long-term outcome on disability in women with persistent postpartum PGP. It may be important to consider the possibility of different variables impact on each other when predicting long-term disability. In addition, further studies are needed to investigate the impact of interaction effects on long-term consequences in women with persistent postpartum PGP.

The majority of women recover from pregnancy-related lumbopelvic pain within 3 months of delivery. Since biomechanical and hormonal changes from pregnancy are largely reversed by 3 months postpartum, consequently, it is assumed that other factors might interfere with recovery. Relative to the fear-avoidance model and with reference to previous studies, we chose to investigate some pre-decided factors to understand persistent lumbopelvic pain. The evaluation of lumbopelvic pain postpartum is mostly based on self-administered questionnaires or interviews. Clinical classification of the lumbopelvic pain may increase our knowledge about postpartum subgroups. Two hundred and seventy-two consecutively registered pregnant women evaluated at 3 months postpartum, answered questionnaires concerning disability (Oswestry disability index), pain intensity on visual analog scale, health-related quality of life (HRQL, EQ5D), activity level, depressive symptoms (Edinburgh postnatal Depression Scale) and kinesiophobia (Tampa Scale for Kinesiophobia). Women were classified into lumbopelvic pain subgroups according to mechanical assessment of the lumbar spine, pelvic pain provocation tests, standard history, and pain drawings. Multiple linear regression analysis was performed to explain the variance of disability. Thirty-three percent of postpartum women were classified with lumbopelvic pain; 40% reported moderate to severe disability. The impacts were similar among subgroups. Pain intensity, HRQL and kinesiophobia explained 53% of postpartum disability due to lumbopelvic pain. In conclusion, one of three postpartum women still had some lumbopelvic pain and the impacts were equivalent irrespective of symptoms in lumbar or pelvic areas. The additional explanations of variance in disability by HRQL and kinesiophobia were minor, suggesting that pain intensity was the major contributing factor. The original publication is available at www.springerlink.com:Annelie Gutke, Mari Lundberg, Hans Christian Ostgaard and Birgitta Öberg, Impact of postpartum lumbopelvic pain on disability, pain intensity, health-related quality of life, activity level, kinesiophobia, and depressive symptoms, 2011, EUROPEAN SPINE JOURNAL, (20), 3, 440-448.http://dx.doi.org/10.1007/s00586-010-1487-6Copyright: Springer Science Business Mediahttp://www.springerlink.com/

Objective: To investigate the efficacy of home-based specific stabilizing exercises focusing on the local stabilizing muscles as the only intervention in the treatment of persistent postpartum pelvic girdle pain (PGP). Design: A prospective, randomized, single-blinded, clinically controlled study. Subjects: Eighty-eight women with PGP were recruited 3 months after delivery. Methods: The treatment consisted of specific stabilizing exercises targeting the local trunk muscles. The reference group had one telephone contact with a physiotherapist. Primary outcome was disability measured with Oswestry Disability Index. Secondary outcomes were pain, health-related quality of life (EQ-5D), symptom satisfaction, and muscle function. Results: No significant differences between groups could be found at 3- or 6-month follow-up regarding primary outcome in disability. Within-group comparisons showed some improvement in both groups in terms of disability, pain, symptom satisfaction and muscle function compared to baseline although the majority still experienced PGP. Conclusion: Treatment with this home-training concept of specific stabilizing exercises targeting the local muscles was no more effective in improving consequences of persistent postpartum PGP than the clinically natural course. Regardless of treatment with specific stabilizing exercises or not, the majority still experiences some back pain almost a year after pregnancy. Original Publication:Annelie Gutke, Jenny Sjödahl and Birgitta Öberg, Specific muscle stabilizing as home exercises for persistent pelvic girdle pain after pregnancy: a randomized, controlled clinical trial, 2010, Journal of Rehabilitation Medicine, (42), 10, 929-935.http://dx.doi.org/10.2340/16501977-0615Copyright: Foundation for Rehabilitation Informationhttp://www.medicaljournals.se/jrm/

Pregnancy-related lumbopelvic pain has varying clinical presentations and effects among subgroups. Different lumbopelvic pain subgroups require different specific management approaches which require the differentiation between lumbar and pelvic girdle pain (PGP). Thirty-one consecutive pregnant women with non-specific lumbopelvic pain were evaluated by two examiners and classified into lumbar pain, PGP, or combined pelvic girdle and lumbar pain. A standard history about different positions/activities of daily life such as bending, sitting, standing, walking, and lying, was followed by a standardised mechanical assessment of the lumbar spine (Mechanical Diagnosis and Therapy), including tests of repeated end-range movements to standing and lying, pelvic pain provocation tests (distraction test, posterior pelvic pain provocation test, Gaenslens test, compression test, and sacral thrust) a hip-rotation range-of-motion test, the active straight-leg-raising test, and a neurological examination. Agreement for the three syndromes (lumbar pain, PGP, or combined pelvic girdle and lumbar pain) was 87% (27/31), with a kappa coefficient of 0.79 (95% CI 0.60-0.98). It was possible to perform the classification procedure throughout pregnancy. There was substantial agreement between the two examiners for the classification of non-specific lUrnbopelvic pain into lumbar pain and PGP in pregnant women. Original Publication:Annelie Gutke, Gunilla Kjellby-Wendt and Birgitta Öberg, The inter-rater reliability of a standardised classification system for pregnancy-related lumbopelvic pain, 2010, MANUAL THERAPY, (15), 1, 13-18.http://dx.doi.org/10.1016/j.math.2009.05.005Copyright: Elsevier Science B.V., Amsterdamhttp://www.elsevier.com/

The aim of this study was to investigate sensitivity and specificity of self-administrated tests aimed at pain provocation of posterior and/or anterior pelvis pain and to investigate pain intensity during and after palpation of the symphysis. A total of 175 women participated in the study, 100 pregnant women with and 25 pregnant women without lumbopelvic back pain and 50 non-pregnant women. Standard pain provocation tests were compared with self assessed tests. All women were asked to estimate pain during and after palpation of the symphysis. For posterior pelvic pain, the self-test of P4 and Bridging test had the highest sensitivity of 0.90 versus 0.97 and specificity of 0.92 and 0.87. Highest sensitivity for self-test for anterior pelvic pain was pulling a mat 0.85. Palpation of symphysis was painful and persistency of pain was the longest among women who fulfilled the criteria for symphyseal pain. There were overall significant differences between the groups concerning intensity and persistency of pain (P < 0.001). Our results indicate that pregnant women can perform a screening by provocation of posterior pelvic pain by self-tests with the new P4 self-test and the Bridging test. Palpation of the symphysis is painful and should only be used as a complement to history taking, pain drawing and pulling a MAT-test.

Background: Pregnancy-related lumbopelvic pain is common. More than 30% of women have persistent pain 3 months after giving birth. There is no consensus regarding the pathology. However, coordination of muscle activity by appropriate timing and amplitude is necessary for maintaining adequate stability in the lumbopelvic area. The aim was to develop a method using surface electromyography to detect a feed-forward response in the pelvic floor muscles during limb movements performed at a comfortable speed applicable in future studies for women with lumbopelvic pain. Methods: Ten parous women with no lumbopelvic pain in the past 12 months were included. Surface electromyographic activity was recorded from the pelvic floor muscles and unilaterally from transversus abdominis/internal oblique, rectus abdominis, erector spinae, hip adductors, rectus femoris and deltoid. The subjects performed leg lift in supine and arm lift from standing. The electromyographic onset was related to the initiation of the movement. Findings: In the majority of the women the electromyographic onsets of the pelvic floor muscles occurred before the movement was initiated, regardless of whether it was a leg or an arm lift. In addition. electromyographic onsets for the other muscles, except the rectus abdominis during the arm lift, also occurred prior to the movements. Interpretation: The findings suggest a feed-forward response in the pelvic floor muscles during leg and arm lifts in women who had previously given birth and were without lumbopelvic pain. Movements performed at a comfortable speed seem to be useful in order to detect such a response. Original Publication:Jenny Sjödahl, Joanna Kvist, Annelie Gutke and Birgitta Öberg, The postural response of the pelvic floor muscles during limb movements: A methodological electromyography study in parous women without lumbopelvic pain, 2009, CLINICAL BIOMECHANICS, (24), 2, 183-189.http://dx.doi.org/10.1016/j.clinbiomech.2008.11.004Copyright: Elsevier Science B.V., Amsterdam.http://www.elsevier.com/

The prevalence of low back pain (LBP) is higher in pregnant women compared to women of the same age in a general population. Pregnancy-related LBP persists 6 years after pregnancy in 16% of women. Consequently, pregnancy represents a specific risk for LBP and persistent LBP. Pregnancy-related LBP is usually studied as a single entity, however, only one subgroup of LBP, i.e. pelvic girdle pain (PGP), seems to be associated with pregnancy. Accordingly, possible differences in subgroups of patients with LBP are unknown. The aims of this thesis were the following: 1) to describe the prevalence of clinically classified subgroups of women with LBP in a cohort (no LBP, lumbar pain, PGP, and combined pain (PGP and lumbar pain)) during pregnancy and postpartum, and 2) to determine if there was a disparity in the course, health-related quality of life (HRQL), pain intensity, disability, depressive symptoms, or muscle function in subgroups of the cohort, and 3) to identify predictors for having persistent pregnancy-related PGP postpartum. Consecutively-enrolled pregnant women were classified into LBP subgroups by mechanical assessment of the lumbar spine, pelvic pain provocation tests, standard history, and pain drawings. All women answered questionnaires (background data, EQ-5D). Women with LBP completed the Oswestry Disability Index and pain measures. The Edinburgh Postnatal Depression Scale was used to evaluate depressive symptoms at 3 months postpartum (cut-off ≥10). Trunk muscle endurance, hip muscle strength, and gait speed were investigated. Multiple logistic regression was used to identify predictors from self-reports and clinical examination. At the 12-18 gestational week evaluation, 118/308 (38%) women had no LBP, 33 (11%) had lumbar pain, 101 (33%) had PGP, and 56 (18%) had combined pain. Three months postpartum, 183/272 (67%) women had no LBP, 29 (11%) had lumbar pain, 46 (17%) had PGP, and 14 (5%) had combined pain. Pregnant women with combined pain were most affected in terms of HRQL, pain intensity, and disability. Depressive symptoms were three times more prevalent in women with LBP (27/87, 31%) than in women without LBP (17/180, 9%). Women with PGP and/or combined pain had lower values for trunk muscle endurance, hip extensor strength and gait speed compared to women without LBP. Postpartum, 16-20% of the women had persistent combined pain or PGP, whereas 1/29 had lumbar pain. Predictors for persistent PGP or combined pain were work dissatisfaction, older age, combined pain in early pregnancy, and low endurance of the back flexors. In conclusion, women with combined pain were identified to be a target group since they had the lowest recovery rate and since the classification of combined pain was found to be a predictor for persistent PGP or combined pain postpartum. The hypothesis of an association between muscle dysfunction and PGP was strengthened. Based on the finding of high comorbidity of postpartum depressive symptoms and LBP, it seems important to screen for and consider treatment strategies for both symptoms.