INTRODUCTION

Important things to think about before starting the course, especially to make the most of the clinical component.

The examination and treatment sections, clinical examples, and case studies included in this course will support discussions on pelvis neuromuscular control and how nociceptive activity and pain impact pelvic function. A detailed explanation of neuromuscular activity is beyond the scope of this program. For in-depth information on pelvis self-bracing mechanisms, fascial systems, and involved muscles, refer elsewhere (Vleeming et al, 2012). The integration of pain neuroscience with manual therapy can also be researched in other sources (Louw et al, 2020).

The material in this course questions commonly recommended examination and treatment methods for pelvic girdle pain and dysfunction. The points discussed are relevant to the ongoing debate on pelvic girdle pain and dysfunction. These issues will be covered during the introduction; reviewing them in advance helps participants prepare questions and discussion points. However, you don't need a deep understanding of these topics to be effective in the course's practical section.

A comprehensive textbook on this innovative approach to the examination and treatment of pelvic girdle pain and dysfunction will be published within the next 18 months.🤞

Mobilisation With Movement for treatment of fearful responses, bracing patterns, and maladaptive compensatory movements

• MWM, when used for examination and treatment, integrates elements of manual therapy, functional exercise, and cognitive therapy 
• Mobilization component of pelvis MWM techniques specifically modify forces acting on the body so that neural afferent activity from innervated joint structures, ligaments, fascia, tendons, muscles, and skin is normalized, resulting in reassertion of a normal response from the CNS
• Application of forces to prevent abnormal nociceptor activity from eliciting abnormal motor responses (guarding, bracing, inhibition)
• Pelvis MWM techniques not only render a movement pain-free but also provide appropriate physical support and guidance to the patient as they perform a movement that may have been both long-standing and painful
• Pelvis MWMs can INSTANTANEOUSLY control fear responses and abnormal motor responses, including guarding, bracing, and inhibition
• Video case studies and real-time demonstrations of these phenomena will be presented during the course.

Pelvic Girdle Pain and Pain Provocation Tests

Pelvic girdle pain (PGP) is often classified with LBP (Kamper et al. 2015) or described as a specific form of LBP (Vleeming et al. 2008). The continued use of terms like "non-specific LBP," "non-specific PGP disorders" (O'Sullivan & Beales 2007a), and, more recently, "non-specific SIJ-related pain" (Palsson et al. 2019) arguably causes more confusion than clarity. "The very use of the term LBP as a 'quasi diagnosis'—when pain is a symptom, not a disease—reflects a general lack of knowledge" (Cusi 2010). 

Most validated pelvic girdle tests are pain-provocation tests (Vleeming et al., 2008). The literature might lead clinicians to believe that if pain provocation tests are negative, the sacroiliac joint is unlikely to cause pelvic girdle pain. However, this might not be true. Specific pain provocation tests (PPTs), used in combination, predict only intra-articular (intracapsular) SIJ pathology (Laslett, 2013, June 3; Laslett, 2008; Laslett et al., 2005a; Laslett et al., 2005b; Laslett and Williams, 1994; Laslett et al., 2003). Consequently, SIJ PPTs have unknown validity for the ligamentous components of the SIJ or any pelvic structure external to the SIJ (Vleeming et al, 2008; Laslett, 2013, June 3). Therefore, their ability to diagnose ligamentous components of the SIJ or any pelvic structures outside the SIJ remains unclear (Vleeming et al., 2008).

Even in a recent review article assessing evidence for the clinical detection and diagnosis of pain in the SIJ region (Palsson et al., 2019), this point is not explicitly clarified. As a result, clinicians using these SIJ pain-provocation tests may misinterpret the results.

A pain provocation test that uses direct palpation at the pain site is very useful for pinpointing areas under abnormal stress. An example is local pain caused by direct palpation of the long dorsal ligament (LDL) in many patients with failed pelvis force closure (Vleeming et al. 2008, Vleeming et al. 2012) and palpation of the pubic symphysis (Vleeming et al 2008).

Pelvic Dysfunction – the big picture

“Dysfunction” is defined as abnormal or impaired functioning (Berube et al. 2008). Sacroiliac PPTs are not intended to identify pelvic dysfunction (Laslett 2013, June 3). Identifying the anatomical source of pain does not automatically explain why a particular structure is painful (Cusi 2010). Consequently, PPTs likely provide limited information to determine effective treatment for PGP and pelvic dysfunction.

The SIJ has a unique role in mitigating ground reaction contact stress during ambulation (Lovejoy 1988, 2007). The morphology and motion of the SIJs may be optimized for upright bipedal walking (Toyohara 2024) Efficient form and force closure of the SIJ protects other body parts against injury (Vleeming et al. 2012, Vleeming 2016). Consequently, ineffective pelvic form and force closure (pelvic dysfunction) may cause abnormal distribution of stress and strain distribution throughout the body, potentially contributing to injury and pain in areas remote from the pelvis. The biotensegrity conceptual model helps visualize how this might happen (Dischiavi, 2018; Levin, 2007, 2017).

The consequences of pelvic dysfunction, altered load pathways and maladaptive movement patterns

• Expert anatomists and anthropologists describe how a major function of the pelvis is to protect other parts of the body from injury
• Vleeming (2016) points out that the shock-absorbing role of the pelvis is vital to protect the brain from excessive loading from ground reaction forces
• It should not be surprising, therefore, that failure of form and force closure mechanisms resulting in excessive loading and altered loading pathways can result in pain being experienced in other parts of the body
• Empirical clinical observations suggest that this is a common phenomenon that can be clearly demonstrated using the functional examination testing methods described in this workshop
• The video of the active pelvic hike and lengthen (APHAL) test illustrates how pelvic dysfunction may cause neck pain and headaches.

Pelvic Dysfunction - The reductionist approach is not useful

Laslett (2013, June 3) described research into SIJ dysfunction as problematic because manual tests of mobility or position of the sacrum or innominate lack reliability, and there is no way to determine the existence or significance of SIJ dysfunction. That pelvic dysfunction and PGP are linked to changes in the small amount of intra-pelvic motion at the SIJ, or ‘abnormal’ relative positions of bones, is an outdated view. Palsson et al. (2019) reviewed the evidence regarding the clinical detection and diagnosis of SIJ movement dysfunction. They questioned the continued use of movement dysfunction assessment and subsequent treatment paradigms based on such diagnoses. A systematic review of sacroiliac mobility tests conducted in adult patients with non-specific LBP, PGP, and/or SIJ pain found that they are poorly reliable and valid. It concluded that their use in clinical practice is problematic (Klerx et al. al 2020). Assessment of sacroiliac joint mobility by palpation is almost certainly useless for evaluating pelvic dysfunction. However, it still receives unwarranted attention from researchers and literature reviewers. Pelvic dysfunction is likely a failure of the pelvis, through many complex mechanisms, to effectively transmit loads and forces during normal physical activity. Assessment and treatment methods must reflect that complexity and incorporate biomechanical, neurophysiological, and psychosocial elements.

Functional Tests – The active straight leg raise (ASLR) 

The ASLR test is the only functional test recommended in the "European Guidelines for the Diagnosis and Treatment of Pelvic Girdle Pain" (Vleeming et al. 2008). According to Mens et al. (2001), the ASLR can test the integrity of load transfer function between the lumbosacral spine and lower limbs. If pelvic control is adequate, the leg should rise effortlessly, and the pelvis should not move relative to the thorax and lower extremities (Lee 2011). The test is considered positive if the subject exhibits difficulty lifting the leg or displays a maladaptive movement pattern (Mens et al., 2001, 2002a; Beales, 2009a, b; Beales et al., 2010; Lee, 2011). 

Functional Tests – The ASLR test and MWM 

Applying specific passive or active forces to the pelvis during the ASLR test can enhance or normalize compensatory neuromuscular strategies (Beales, 2009a & b, Beales et al., 2010, Mens, Vleeming, 1999, O'Sullivan et al., 2002a, Pool-Goudzwaard et al., 1998). This addition to the original ASLR is commonly used to identify pelvic dysfunction (Cook and Hegedus, 2012; Lee and Lee, 2011; Lee and Vleeming, 2007) and is termed the augmented ASLR (AASLR) by the course presenter.

The AASLR and pelvis MWM techniques share commonalities. The leg raise in the AASLR test is comparable to the active movement component of the pelvis MWM. Applying external forces to the innominates in the AASLR test is equivalent to the "mobilization" component of a pelvis MWM.

The original ASLR test described by Mens et al. (2001) and the AASLR test rely on a combination of visual observations by the examiner and subjective reporting of movement quality by the patient, but do not consider the influence of pain. This is problematic because pain alone significantly impacts the subjective and objective outcome of the ASLR test (Palsson et al. 2015).  They found that pain alone significantly affects both the subjective and objective outcomes of the ASLR test. They recommend considering pain when using the test in both research and clinical practice. There is a clear need to develop and validate more functional tests for the pelvis; ideally, these tests should account for the influence of pain.

The presenter has created new tests for pelvic dysfunction that are based on the clinical reasoning process used with MWM techniques. Regarding the ASLR, pelvis MWM testing involves visual and qualitative judgments made by both the clinician and the patient, but most importantly, it inherently considers the effect of pain. The clinician identifies the movement or activity during which the patient experiences pain or dysfunction and then, using MWM clinical reasoning, applies external forces to the pelvis to eliminate pain and maladaptive movement responses when the patient repeats the symptomatic movement. The points of force application, directions, magnitudes, and force combinations depend entirely on real-time feedback from the patient. Pelvis MWM tests are considered positive if they relieve (not provoke) pain and restore normal function. If the pelvis MWM test is positive, examination findings are used to develop a specific MWM manual therapy technique for that case.

Pelvis MWM for treatment of pelvic girdle pain and pelvic dysfunction

Over the past thirty years, published research has greatly enhanced our understanding of pelvic function, pelvic dysfunction, PGP, and PPGP (pregnancy-related pelvic girdle pain). Despite this progress, advances in clinical management have been slow to develop (Meijer et al. 2020). Notable research findings, particularly regarding the mechanisms of failed load transfer through the pelvis, seem to have been overlooked or misunderstood. For example, there is still reliance on a reductionist approach to active rehabilitation, which involves isolating individual muscles or muscle groups and their actions (Dischiavi et al. 2018).

Confirmation bias and “throwing the baby out with the bath water” are frequently perpetuated in physiotherapy practice (Taylor and Kerry, 2017; Nicholls, 2018; Filippo and Mourad, 2021). The physiotherapy approach to neuromusculoskeletal pain is increasingly shifting toward a hands-off management of patients through pain neuroscience education and exercise therapy (Geri et al. 2019), along with a demonization of manual therapy because it is seen as “passive.” While much of this criticism is justified, it is important to recognize that not all forms of manual therapy are passive. MWM, when used for examination and treatment, combines elements of manual therapy, functional exercise, and cognitive therapy.

Active exercise should be the preferred treatment for most neuromusculoskeletal conditions, but sometimes, exercise therapy fails. Having the patient perform an exercise while unrecognized yet clinically significant maladaptive movement patterns (dysfunction) are present may be ineffective or even harmful. The presenter notes that this is often where modern rehabilitation falls short. Pelvis MWMs can serve as breakthrough techniques to eliminate specific maladaptive behaviors and prepare patients for “conventional” exercise.

Pelvis MWMs – application and theoretical mechanisms

An effective pelvis MWM technique makes movement pain-free and provides proper physical support and guidance to the patient during movement. Forces are applied to the pelvis to normalize neural afferent activity from innervated joint structures, surrounding ligaments, fascia, tendons, and muscles, restoring a normal response from the CNS. Pelvis MWMs can be observed and subjectively reported by the patient to immediately control fearful and abnormal motor responses, including guarding, bracing, and inhibition.

MWMs can be performed by the clinician and patient working together or as a self-treatment by the patient. MWMs can be integrated into functional exercise training to help restore normal low-load and high-load movement strategies. Although their clinical effectiveness has not been definitively proven, MWMs have a substantial evidence base and are used in accordance with the principles of 'evidence-informed practice' (Vincenzino et al. 2011, Kumah et al. 2019, Hing et al. 2020).  

Based on extensive research, pelvis MWM examination procedures and MWM treatment techniques DO NOT: 

• Require palpation to determine the relative position of bones.
• Rely on passive manual tests of intra-pelvic motion, such as sacroiliac or pubic symphysis range of movement.
• Depend on findings from pain provocation tests.
• Necessitate belief in any theory of pelvic or sacroiliac joint dysfunction, including the "positional fault" hypothesis.
• Depend on establishing a diagnosis, classification, or identification of a specific pathology or a "pain generator."

Mobilisation With Movement made simple!

• Identify a symptomatic or dysfunctional movement or activity. 
• Apply and maintain pain-free accessory mobilization components. With the mobilization forces in place, repeat the symptomatic movement or activity. 
• If the movement is now pain-free, repeat it three times with end-range overpressure. 
• When the symptomatic movement is re-tested, it should show significant improvement. 
• Progress the patient to self-treatment techniques and functional rehabilitation as soon as possible.

The target population for pelvis MWMs

Much of the evidence-based treatment guidance for pelvic pain and dysfunction comes from studies involving subjects with severe pelvic girdle pain and central nervous system sensitization. However, these guidelines might not be suitable for individuals with less severe pelvic pain and no signs of significant peripheral or central neural sensitization. Patients with longstanding pelvic pain and dysfunction who are most likely to respond to MWMs are those described in a hypothetical ‘mechanism-based’ classification system by O’Sullivan & Beales (2007a) as having peripherally mediated (mechanically induced) pelvic girdle disorders characterized by reduced, excessive, or significantly abnormal form or force closure.

Pelvis MWM examination and treatment techniques should be regarded as a specific part of a comprehensive biopsychosocial approach to pelvic girdle pain and dysfunction. Many other factors need to be considered and addressed through different forms of treatment. These are outside the scope of this presentation but will be discussed during case study presentations and question sessions.

The material in this workshop has been developed and refined over the past 30 years. It was a deliberate choice to delay researching the clinical aspects of the pelvis MWM approach until it was fully developed. There are now high-quality scientific studies supporting the fundamental concept of the approach, and clinical research is finally beginning. The long-term perspective we have taken will ultimately benefit both clinicians and the individuals seeking their care. 

References

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Vleeming A 2016 Understanding Lumbar & Pelvic Girdle Pain:  An Evidence Based Course on Clinical Anatomy, Biomechanics & Effective Rehabilitation. Auckland University of Technology, Auckland, New Zealand