PREVIEW ONLY 7/04/2013. Andrew Ellis. The Dysfunctional Pelvis: A review of anatomy, biomechanics and management. Nichole Hamilton

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Be sure to convert to your own time zone at Andrew Ellis BSc (Ex. Sci), M.

Health Webinars (Australia/NZ) Host Presented by: Nichole Hamilton Will commence LIVE from Sunshine Coast,

at the end of 1997 Has a passion for physiotherapy education.

Click to minimize panel and see whole screen Type questions to be answered live at the end B.App.Sc.

she completed a certificate with Manual Concepts in Spinal Manual Therapy.

1 Be sure to convert to your own time zone at Andrew Ellis BSc (Ex. Sci), M. Phty The Dysfunctional Pelvis: A review of anatomy, biomechanics and management World Health Webinars CEO World Health Webinars (Australia/NZ) Host Presented by: Nichole Hamilton Will commence LIVE from Sunshine Coast, Australia at 7pm AEDT Be sure to convert to your own time zone at Nichole Hamilton Graduated from Sydney University at the end of 1997 Has a passion for physiotherapy education. She is the Queensland representative for the APA s Educator group. Click to minimize panel and see whole screen Type questions to be answered live at the end B.App.Sc.(Phty) Worked in private practice in London for five years under Dianne Lee and Shirley Sahrmann, and it is here she completed a certificate with Manual Concepts in Spinal Manual Therapy. Nichole has since worked as an assistant teacher on AMTA courses teaching manual therapy and MET techniques for the lumbar spine and pelvis. Started work with orthopaedic hip specialist Dr Michael O Sullivan in 2005 at North Sydney Orthopaedic and Sports Medicine Centre to develop post-operative protocol for hip arthroscopy. Physiotherapist Michael and Nichole have lectured together on management of labral tear and hip impingement since Nichole has subsequently worked as an assistant teacher for LJ Lee on her Discover the Sports Pelvis course. 1

The Dysfunctional Pelvis: A review of anatomy, biomechanics and management

Girdle Non optimal surrounding joints or respiratory Dysfunction pattern

Anatomy and Biomechanics Function of the pelvic girdle Tests of function

and options Innominate and sacrum Three vertically aligned joints comprise

2 The Dysfunctional Pelvis: A review of anatomy, biomechanics and management Posture, motor control, strength Acute Trauma, Repetitive Injury Perception Emotions Beliefs Experience of Pelvic Pain Altered Motor Control Altered load Pelvic Girdle Non optimal surrounding joints or respiratory Dysfunction pattern tissue Non-optimal pelvic floor function Summary Anatomy and biomechanics Anatomy and Biomechanics Function of the pelvic girdle Tests of function Reasons for dysfunction Common consequences of dysfunction Management ideas and options Innominate and sacrum Three vertically aligned joints comprise the pelvic ring: pubic symphysis and SIJs The SIJ is an L shaped synovial joint with a shorter vertical arm and a longer horizontal arm 2

Anatomy and biomechanics Ventral SI ligament Interosseous and Posterior ligaments Sacrotuberous ligament Sacrospinous ligament Iliolumbar ligament Long dorsal ligament Muscular System Inner Unit

Lats Multifidis Anterior: Adductors, Abdo fascia, Full notes available EO/IO after purchase from Lateral: Glut medius, QL Motor Control: Optimal function requires coordination of local and global

3 Anatomy and biomechanics Ventral SI ligament Interosseous and Posterior ligaments Sacrotuberous ligament Sacrospinous ligament Iliolumbar ligament Long dorsal ligament Muscular System Inner Unit Global System Pelvic floor Posterior : Glut max, piriformis, TL These notes Transversus fascia, are ES, a preview. Lats Multifidis Anterior: Adductors, Abdo fascia, Full notes available EO/IO after purchase from Lateral: Glut medius, QL Motor Control: Optimal function requires coordination of local and global systems with respect to force and timing Physiological movements Innominate Anterior and Posterior rotation Sacral Nutation and Counternutation Functions of the pelvic ring Functions to transmit forces or load safely between the lower limb and lumbar spine without Full notes available after musculoskeletal purchase from injury whilst protecting organs (Lee & Vleeming 1998) Stability of the pelvic ring Factors optimising SIJ load transfer efficiency Vertical orientation makes the SIJ s & PS susceptible to shear forces in the vertical plane (Snijders et al 1993) Therefore requires adequate lateral compression to stabilise and transfer load efficiently (Lee 1999) Integrated Model for optimal pelvic function (Lee & Vleeming 1998, 2004) Form Closure and the passive system Force Closure and the active system Optimal neural function and the motor control system 3

Pelvic Stability The closed packed position for optimal pelvic stability is a combination of: Sacral Nutation Full notes available after Innominate purchase Posterior from Rotation (Sturesson et

4 Pelvic Stability The closed packed position for optimal pelvic stability is a combination of: Sacral Nutation Full notes available after Innominate purchase Posterior from Rotation (Sturesson et 1989, 2000, Hungerford et al 2004) Reasons for non-optimal load transfer at the pelvis Unlocking at the SIJ during transfer of load is nonoptimal. This can be caused by a few factors, which can include: Loss of integrity of the passive system (ligamentous damage through trauma, joint inflammatory conditions) Active or control system impairment (loss of coordinated motor control or strength) Unlocking should not occur during activities that increase load through the pelvic girdle Consequences of non-optimal pelvic function Altered respiratory function (O Sullivan et al 2002) Altered or non-optimal pelvic floor function (O Sullivan etal 2002, Pool-Goudzwaard 2003) Altered motor control strategies (Hungerford et al 2003, 2004) Patterns of rigidity or bracing (Lee 2011) Altered load through surrounding tissue or joints (lumbar spine, hip) Pelvic girdle pain Examination and testing for SIJ dysfunction Is the pelvis a contributing factor to your patients presenting symptoms? To test for SIJ and These pelvic notes dysfunction are a preview. we need to analyse its ability to Slides achieve are normal limited. function: Functional Full tests notes of SIJ available load transfer after ability purchase from Tests of force closure and active system Tests of form closure and passive system Tests of load transfer: Does the SIJ unlock when loading? Tests of optimal load transfer The pelvic should be able to maintain a closed packed position when transferring load: combined sacral nutation and innominate posterior rotation If the pelvic UNLOCKS when transferring load this is a sign of non-optimal load transfer. Unlocking of the pelvis occurs with sacral counternutation and relative innominate anterior rotation Test for SIJ unlocking by palpating the innominate with one hand, and the central sacrum or ILA with the other thumb. Can the pelvis maintain CPP in single leg standing? Forward bending? Squat? If not, what does this tell us? 4

Tests for optimal load transfer Active Straight Leg Raise Tests ability to maintain LP stability during load transfer Patient Supine Actively raise one leg off plinth, then repeat on opposite side

with compression around the Full notes available after purchase pelvis from Does this improve or change patients ability to ASLR?

on bolster so SIJ is in loose packed position Palpate medial PSIS gently, and ASIS/iliac crest with palm and heel of opposite hand Apply gently oscillatory AP glide, feeling innominate movement into

To detect R1 and R2 only small forces required Tests of the passive system Comparison made from left to right: should feel symmetrical joint play in normal healthy subjects (Buyruk et al 1995, Damen

5 Tests for optimal load transfer Active Straight Leg Raise Tests ability to maintain LP stability during load transfer Patient Supine Actively raise one leg off plinth, then repeat on opposite side Differences in subjective effort noted and compensation strategies observed (Mens et al 1999, 2001, 2004) Load transfer testing with augmented force closure ASLR Test with Compression Retest ASLR with compression around the Full notes available after purchase pelvis from Does this improve or change patients ability to ASLR? (Mens et al 1999, Lee 2011) Tests of the passive system Passive Joint Glide tests: First proposed by Lee 1992, and fully described in Lee 2011 Patient supine with legs rested evenly either neutral or on bolster so SIJ is in loose packed position Palpate medial PSIS gently, and ASIS/iliac crest with palm and heel of opposite hand Apply gently oscillatory AP glide, feeling innominate movement into your fingers relative to sacrum When performing joint mobility tests remember there is very little joint play in the SIJ. To detect R1 and R2 only small forces required Tests of the passive system Comparison made from left to right: should feel symmetrical joint play in normal healthy subjects (Buyruk et al 1995, Damen 2002) Does the joint feel compressed? If there is joint play available, does a cue to switch on your core reduce this joint motion? If you take the joint into a closed packed position, is there any slack in the system? What might this indicate? (Lee 2011) Assessment &management pathways Q: Is the pelvis contributing to my patients symptoms? Test: Is the pelvis unlocking (showing signs of non-optimal load transfer) during the problem activity? Assessment &management pathways Q: Why is the pelvis unlocking? Loss of force closure and non-optimal active system? Test: ASLR, if positive does compression help? Anterior? Posterior? Can this be repeated in problem activity? NO: Pelvis less likely a contributing factor YES: Pelvis may be a contributor, further tests to determine WHY No, compression not helpful. Do not start treatment with core exercises aimed at increasing pelvic compression. What needs decompressing or release work? Yes, compression helps. Start exercises aimed at improving joint compression. This could include core endurance with appropriate cues, postural cues to optimise inner unit function, progress to functional dynamic control tailored to patient goals 5

Assessment &management pathways Q: Why is the pelvis unlocking? Loss of symmetry in the passive system?

Insufficient Too compression vs compressed No: Asymmetric glide Yes, joint glide symmetric.

be contributing to increased motion on In conjunction with other excessive compression? side of unlocking.

based Rx until joint passive integrity? Motor control retraining? glide symmetric Belt, core work, prolo?

patients understanding whilst minimising fear Manual therapy/release: Areas of hyertonicity and excessive

Guided by patients capacity and goals. Tailored to the individual with awareness of unique motor control strategies.

Treatment: Excessive Compression Tests: +ve load transfer ASLR ISQ/ worse with compression Compressed/assymetric

available Based after on purchase observation, from ASLR and palpation. Techniques can include massage, TPR, DN, MET.

6 Assessment &management pathways Q: Why is the pelvis unlocking? Loss of symmetry in the passive system? Loss of passive integrity? Test: Passive Joint These glide notes tests- are are a they preview. symmetric? Insufficient Too compression vs compressed No: Asymmetric glide Yes, joint glide symmetric. Less with compressed feel likely to need SIJ release What muscles might No: Asymmetric with based manual therapy. be contributing to increased motion on In conjunction with other excessive compression? side of unlocking. tests, does this patient Start with release Is there a loss of need postural advice? based Rx until joint passive integrity? Motor control retraining? glide symmetric Belt, core work, prolo? Treatment Options Education: Includes posture, addressing beliefs, pain education and management ideas, improving a patients understanding whilst minimising fear Manual therapy/release: Areas of hyertonicity and excessive compression that are contributing to non-optimal load transfer in the pelvis Functional exercise prescription: Guided by patients capacity and goals. Tailored to the individual with awareness of unique motor control strategies. Progressed with ideas of return to function. Treatment: Excessive Compression Tests: +ve load transfer ASLR ISQ/ worse with compression Compressed/assymetric joint glide Release areas Full of notes hypertonicity. available Based after on purchase observation, from ASLR and palpation. Techniques can include massage, TPR, DN, MET. Typical culprits can include piriformis, superficial ES, ischiococcygeus Address postural strategies that might be contributing to excessive compression with patient education Understanding a patients specific compression patterns and using this information to downtrain or correct dysfunctional patterns in movement with exercise Retraining Movement Patterns 6

Treatment: Insufficient Compression Tests: +ve load transfer tests ASLR improved with compression Joint glide equal These and notes unrestricted are a preview.

(Hodges et al 1999) This might include cues and exercise to improve accurate activation and endurance of pelvic floor, transversus &/or multifidis.

Address postural strategies that can assist optimal inner unit function and progress to more dynamic control exercises with functional integration of global system, tailored to patient goals.

7 Treatment: Insufficient Compression Tests: +ve load transfer tests ASLR improved with compression Joint glide equal These and notes unrestricted are a preview. Start inner unit connection ideas with an education and awareness of the anticipatory nature of the inner unit. (Hodges et al 1999) This might include cues and exercise to improve accurate activation and endurance of pelvic floor, transversus &/or multifidis. This decision is based on palpation findings, RTUS Ax and ALSR with compression test. Address postural strategies that can assist optimal inner unit function and progress to more dynamic control exercises with functional integration of global system, tailored to patient goals. THANK YOU! I hope some of the Slides ideas shared limited. can help you determine if the pelvis might be a contributing factor in your patients presenting Full notes problems, available and that after you purchase have some from tools for assessment and management. Nichole Hamilton References Buyruk H M, Stam H J, Snijders C J, Vleeming A, Lameris J S, Holland W P J 1997 Measurement of sacroiliac joint stiffness with color doppler imaging and the importance of asymmetric stiffness in sacroiliac pathology. In: Vleeming A, Mooney V, Dorman T, Snijders C, Stoeckart R (eds) Movement, Stability and Low Back Pain. Churchill Livingston, Edinburgh, p 297 Damen L, Buyruk H, Guler-Uysal F, Stam H 2001 Pelvic pain during pregnancy is associated with assymetrical laxity if the sacro-iliac joints. Obs Gynae Scand 80: Damen L,Buyruk HM, Guler-Uysal F, Lotgering FK, Snijders CJ, Stam HJ 2002 Prognostic value of asymmetric laxity of the sacroiliac joints in pregnancy related pelvic pain. Spine 27(24):2820 Hodges P W, Cresswell A G, Thorstensson A 1999 Preparatory trunk motion accompanies rapid upper limb movement. Experimental Brain Research 124:69 Hungerford B, Gilleard W, Hodges P 2003 Evidence of altered lumbo-pelvic muscle recruitment in the presence of sacroiliac joint pain. Spine 28(14) Hungerford B, Gilleard W, Lee D Altered patterns of pelvic bone motion determined in subjects with posterior pelvic pain using skin markers. Clinical Biomechanics. Hungerford B, Gilleard W, Hodges P, Lee D 2004 Paper presented at the 5 th World Congress on Low Back and Pelvic Pain. Altered Lumbo-Pelvic muscle recruitment occurs in the presence of sacroiliac joint pain. Lee DG 2011 The Pelvic Girdle 4 th edition Elsevier Science Edinburgh pp, , , Lee D G, Vleeming A 1998 Impaired load transfer through the pelvic girdle a new model of altered neutral zone function. In: Proceedings from the 3rd interdisciplinary world congress on low back and pelvic pain. Austria Mens J, Vleeming A, Snijders C, Stam H, Ginai A 1999 The active straight leg raise test and mobility of the pelvic joints. European Spine 8:468 Mens J, Vleeming A, Snijders C, Koes B, Stam H 2001 Reliability and Validity of the active straight leg raise test in posterior pelvic pain since pregnancy. Spine 27(2):196 O Sullivan P, Beales D, Beetham J, Cripps J, Graf F, Lin I, Tucker B, Avery A 2002 Altered motor control strategies in subjects with sacroiliac joint pain during the active straight leg raise test. Spine 1:21(1): E1-8 Pool-Goudzwaard A Proceedings of the 8 th Scientific Conference of the IFOMT. The relation between low back and pelvic pain, pelvic floor activity and pelvic floors disorders. Snijders C, Vleeming A, Stoeckart R 1993 Transfer of lumbosacral load to the iliac bones and legs. 1: Biomechanics of self bracing of the sacroiliac joints and its significance for treatment and exercise. Clinical Biomechanics 8: Vleeming A, Mooney V, Dorman T, Snijders C (eds) 1995b Second Interdisciplinary world congress on low back pain: The intergrated function of the lumbar spine and sacroiliac joint, San Diego. Wingerden J, Vleeming A, Ronchetti I 2004 Paper presented at the 5 th World Congress on Low Back and Pelvic Pain. Physical compensation strategies in female patients with chronic low back pain and chronic pelvic girdle pain. Join US on Facebook Live Q & A With Nichole Hamilton 7

8 Coming up next week Part 4 / 6 in our Hip & Groin Series Anterior hip impingement and labral tears: A case of biomechanical overload?" To review anatomy and understand the biomechanics of the hip within the pelvis To understand the potential reasons for labral tear, both structural and biomechanical Live Q & A With Nichole Hamilton Review postural concepts and motor control around the hip To understand the potential effects of the thorax and lower limb on hip dysfunction Develop clinical reasoning pathway for physiotherapy management for anterior hip pain Nichole Hamilton Thank you From Nichole Hamilton & World Health Webinars Australia / NZ 8

The Pelvic Girdle: how does research assist best clinical practice for treatment of pelvic girdle pain and the Sacroiliac joint

The Pelvic Girdle: how does research assist best clinical practice for treatment of pelvic girdle pain and the Sacroiliac joint Written by Barbara Hungerford PhD, APAM Pelvic Girdle pain (PGP) is a broad