Cinturon pelvico

ARTICLE IN PRESS

Manual Therapy 12 (2007) 86–97 www.elsevier.com/locate/math

Masterclass

Diagnosis and classification of pelvic girdle pain disorders—Part 1: A mechanism based approach within a biopsychosocial framework
Peter B. O’SullivanÃ, Darren J. Beales
School of Physiotherapy, Curtin University of Technology, GPO Box U1987, Perth, WA 6845, Australia Received 20 February 2007;received in revised form 21 February 2007; accepted 21 February 2007

Abstract The diagnosis and classification of pelvic girdle pain (PGP) disorders remains controversial despite a proliferation of research into this field. The majority of PGP disorders have no identified pathoanatomical basis leaving a management vacuum. Diagnostic and treatment paradigms for PGP disorders exist although many ofthese approaches have limited validity and are uni-dimensional (i.e. biomechanical) in nature. Furthermore single approaches for the management of PGP fail to benefit all. This highlights the possibility that ‘non-specific’ PGP disorders are represented by a number of sub-groups with different underlying pain mechanisms rather than a single entity. This paper examines the current knowledge andchallenges some of the common beliefs regarding the sacroiliac joints and pelvic function. A hypothetical ‘mechanism based’ classification system for PGP, based within a biopsychosocial framework is proposed. This has developed from a synthesis of the current evidence combined with the clinical observations of the authors. It recognises the presence of both specific and non-specific musculoskeletal PGPdisorders. It acknowledges the complex and multifactorial nature of chronic PGP disorders and the potential of both the peripheral and central nervous system to promote and modulate pain. It is proposed that there is a large group of predominantly peripherally mediated PGP disorders which are associated with either ‘reduced’ or ‘excessive’ force closure of the pelvis, resulting in abnormal stresses onpain sensitive pelvic structures. It acknowledges that the interaction of psychosocial factors (such as passive coping strategies, faulty beliefs, anxiety and depression) in these pain disorders has the potential to promote pain and disability. It also acknowledges the complex interaction that hormonal factors may play in these pain disorders. This classification model is flexible and helps guideappropriate management of these disorders within a biopsychosocial framework. While the validity of this approach is emerging, further research is required. r 2007 Elsevier Ltd. All rights reserved.
Keywords: Pelvic girdle pain; Sacroiliac joint; Classification; Pain mechanisms; Motor control

1. Pelvic girdle pain disorders Pelvic girdle pain (PGP) disorders represent a small but significant groupof musculoskeletal pain disorders. Pain associated with the sacroiliac joints (SIJs) and/or the surrounding musculoskeletal and ligamentous structures represent a sub-group of these disorders. Specific inflammatory pain disorders of the SIJs, such as sacroiliitis, are the most readily identified PGP disorders
ÃCorresponding author. Tel.: 61 8 9266 3629; fax: 61 8 9266 3699.

E-mail address:P.Osullivan@curtin.edu.au (P.B. O’Sullivan). 1356-689X/$ - see front matter r 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2007.02.001

(Maksymowych et al., 2005). However, PGP disorders more commonly present as ‘non-specific’ (no identified pathoanatomical basis), often arising during or shortly after pregnancy (Berg et al., 1988; Ostgaard et al., 1991; Bastiaanssen et al., 2005) orfollowing traumatic injury to the pelvis (O’Sullivan et al., 2002a; Chou et al., 2004). Frequently these pain disorders are misdiagnosed and managed as lumbar spine disorders, as pain originating from the lumbar spine commonly refers to the SIJ region. However, there is growing evidence that PGP disorders manifest as a separate sub-group with a unique clinical presentation and the need for specific...