By Ben Csiernik
Understanding and managing pelvic girdle pain from a person-centred biopsychosocial perspective (Beales, Slater, Palsson & O’Sullivan, 2020)
The following is a summary of the main points established by the authors, including quotes from the paper. For a complete understanding and appreciate of context, we encourage everyone to read the paper in its entirety.
The goal of this framework is to help guide clinicians to effectively implement contemporary person-centred care to musculoskeletal disorders, with an emphasis on pelvic girdle pain. The framework itself is found at the bottom of the page!
We utilize the common-sense model of illness to assess how a person’s perceptions of their pain/illness influence their emotional and their behavioral response to their condition. Currently, a structural and biomechanical view towards the assessment and treatment of pelvic girdle pain, including opinions and views seen towards SI joint pain. Below are phrases commonly seen, and how we should avoid them and use other recommended phrases instead.
Inappropriate phases include: “your pelvis is unstable” or “your pelvis alignment is out, or your pelvis can go out of alignment”. “A weak core is causing your pelvic pain”.
Instead, recommendations for patient centred positive phrases include “Pelvic pain means that your pelvic structures are sensitized. Movement avoidance, muscle tension, lack of sleep, inactivity, stress and worry can sensitize them” and “The brain acts as an amplifier; the more you worry about your pain and focus on it, the worse it gets”
Neurobiological Aspects of Pelvic Girdle Pain
There is a distinction between nociception and pain, as nociceptors can be active and stimulated in the absence of pain. Clinicians MUST understand that pain is complex, and is not always indicative of tissue damage. Most importantly, be aware of how we describe and shape a patient’s pain, as at the end of the day it is their pain experience, and not ours.
An example: The authors outline that just because someone has a decreased range of motion and pelvic girdle pain, does not mean that the range of motion issues is causing the pain. Instead, it is likely that the decreased range of motion is occurring because moving beyond that range affects the sensitized structures in the area. This is an important distinction, and we need to be careful of assigning causality in our findings.
Communication and the Therapeutic Alliance, Interviewing, Physical Exam
When working with a patient with pelvic girdle pain, we should consider motivational interviewing, which includes open ended questions, and listening with the intent of understanding the patient, not listening for the intent to respond.
If a patient presents with misconceptions around their pain (“my pelvis is out”), it is important to not flat out disagree with the patient. Instead, understand their perspective, and help develop a personal and meaningful understanding and conceptualization that the patient can appreciate. Reframe their ideas of their pain, while including them in the process!
In pelvic girdle pain, ensure you are asking about comorbidities, including asking about disorders of incontinence, as well as pain and discomfort with sexual activity. These are commonly seen in people with sensori-motor changes of the pelvic floor and other abdominal musculature. Bringing on specialists to your rehabilitation team will likely be required in these cases!
Physical exam testing, including Laslett’s SI joint testing, can help test for localized sensitization, but does not indicate which structure is affected specifically. During movement assessment, observation of patients for pain behavior reactions (bracing, guarding, breath holding) can demonstrate either aggravating positions, or demonstrate that a patient may be scared of experiencing pain when moving into this position. It is important to try and distinguish if these can be modified by explaining to patients that hurt does not necessarily equal harm.
During the physical exam, it is important to explore if some of the pain behavior reactions are due to fear (cognitive), the process of moving a certain way (behavioral), noted tissue stress, and of course, a combination of all factors that contribute to pain between the person and their environment.
Consider the teach back test. Once your history and physical is complete, and you have educated the patient, ask them to repeat back what they have learned today. They should be able to adequately explain what they have learned, and how to frame/explain their experience.
Cognitive Functional Therapy (CFT)
CFT has a focus on coaching and empowering the person living with pelvic girdle pain on ways to self-manage, increase their self-efficacy, and build resilience. The three key processes include 1) making sense of pain, 2) exposure with control, and 3) lifestyle change. This is outlined in the framework that can be found in the paper.
For more literature on cognitive functional therapy, links can be found at the end.
As outlined in the studies linked below, CFT has been shown to help decrease pain, and improve cognitive understanding and perceptions towards pain. CFT has not been studied in persons with pelvic girdle pain to date, though research is being conducted.
This framework helps further promote positive narratives, and discourage the use of incorrect, and harmful narratives surrounding pelvic girdle pain. Understanding that a person living with pelvic girdle pain has an emotional, psychological, and physical connection with their pain is necessary. This assessment and care pathway should be considered when assessing and treating a patient with pelvic girdle pain.
Further CFT resources:
1) Cognitive Functional Therapy for People with Nonspecific Persistent Low Back Pain in a Secondary Care Setting—A Propensity Matched, Case–Control Feasibility Study (2020) https://academic.oup.com/painmedicine/article-abstract/doi/10.1093/pm/pnaa034/58129
2) Improvements in clinical pain and experimental pain sensitivity after cognitive functional therapy in patients with severe persistent low back pain (2020): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7004508/
3) Cognitive functional therapy compared with a group-based exercise and education intervention for chronic low back pain: a multicentre randomised controlled trial (RCT) (2019) https://bjsm.bmj.com/content/early/2019/11/08/bjsports-2019-100780.abstract
4) Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain (2018) https://academic.oup.com/ptj/article/98/5/408/4925487