The PGM Method - Sacroiliac Belt and Patient Education

Original Editor - Deborah Riczo

Top Contributors - Tarina van der Stockt  

Introduction[edit | edit source]

Pelvic girdle dysfunction can be a debilitating condition with significant physical, psychological and socioeconomic problems. Patient education and the use of a sacroiliac belt are important treatment strategies in the Pelvic Girdle Musculoskeletal Methodsm, or PGM Methodsm. Assessing the pelvic girdle using the PGM special tests and then balancing the muscles of the pelvic girdle (Course 5 & 6) followed by activating the deep core and targeted stretching and strengthening exercises (Course 7) are all vital components previously covered.[1]


Use of a Sacroiliac Belt[edit | edit source]

The use of a sacroiliac belt is often prescribed for patients with pelvic girdle dysfunction.  Pelvic compression belts or sacroiliac belts are being used in the rehabilitation of people with pelvic girdle pain in a wide variety of populations and across the lifespan; including those who are antepartum, had experienced trauma, sports injury or unexplained onsets of pain.[2] In athletes, it is sometimes prescribed and applied when pain provocation tests for the sacroiliac joint (SIJ) are positive without the belt and negative when the belt is fitted with adequate tension.[3]

The application or use of an SIJ belt is often seen as a method to restore pelvic stability.[4] The mechanism by which external pelvic compression exerts any changes is still unclear.[2] Soisson et al[5] investigated the effects of a pelvic belt on pelvic morphometry, muscle activity and body balance in patients with sacroiliac joint dysfunction and found little evidence that compressive forces were exerted on the SIJ or pelvis. Although a majority of SIJ patients reported decreased pain intensity with a pelvic belt, the mean pain-altering affects averaged over all the patients in the study were minute in the short-term and non-significant. The authors suggest that further research is necessary to investigate and establish differences between SIJ patients and controls in a more long-term and dynamic setting to interpret the dynamic effects of pelvic belts.[5]

Other studies have shown that the use of a sacroiliac belt may provide SIJ and pelvic girdle stability by an increase in force closure[6][7], but this remains controversial.[5] Studies have also shown that pelvic compression belts can reduce SIJ laxity and improve neuromuscular performance in the stabilising muscles of the pelvis.[8][9] Kim et al[10] (2013) investigated effects of a pelvic belt on EMG activity of the abdominal muscles and found that the wearing of a pelvic belt decreased EMG activity of the rectus abdominis (RA), the external obliques (EO) and the internal obliques (IO), thus less effort was required to perform an active straight leg raise (ASLR) when wearing the belt. Furthermore, Kim et al[11] (2014) investigated patients with chronic low back pain and found that external pelvic compression resulted in a reduction of muscle exertion around the pelvis during hip extension in prone.[11] These results support the thought that persistent pain may be associated with greater activation of the muscles involved in force closure, rather than just SIJ instability.[2]

Arumugam et al[12] (2012) conducted a systematic review on the effects of external pelvic compression on form closure, force closure, and neuromotor control of the lumbopelvic spine and reported moderate evidence for the role of pelvic compression in influencing lumbopelvic kinematic motion, reducing pain, SIJ laxity in individuals with and without lumbopelvic dysfunction.[12]

Bertuit et al[4] (2018) analysed the effect of a pelvic belt on pain in pregnancy-related pelvic girdle pain and found that the use of pelvic belts over an average duration of 9 weeks did reduce pelvic girdle pain, especially in the area of the SIJ. Daily activities such as standing, walking and sitting were easier in this study population. The study also suggested that different types of belts may have different effects on global, SIJ and back pain during pregnancy, but this hypothesis needs further investigation and confirmation.[4]

The use of a pelvic compression belt has been shown to improve sitting to standing quality of movement[13] and improve motor control during bridging.[14]

In the clinical practice guidelines for pelvic pain in the antepartum population by Clinton et al[15] it is recommended that clinicians should consider the application or use of a support belt in the antepartum population with pelvic girdle pain, but the recommendation is based on conflicting evidence.[15]

Types of Sacroiliac Belts[edit | edit source]

There are many different sacroiliac belts available on the market to choose from and it is recommended that a clinic has a few different belts and sizes for patients to try on if possible. Deborah has found in her clinical practice that patients preferred the Serola Sacroiliac Belt when given choices. If patients are ordering on their own, the clinician should make sure the patient has the correct hip measurements and understand the return policy of their chosen product.

Sacroiliac Belt and the Active Straight Leg Raise Test[edit | edit source]

The active straight leg raise test (ASLR) assesses the ability of the pelvis to transfer load. It also assesses the functional integrity of the lumbopelvic force closure system in patients with pelvic girdle pain.[20]

With the patient lying in supine, the patient is asked to alternately actively lift each leg approximately 20 cm of the bed/plinth. Observe for substitution strategies such as: abdominal wall bulging, trunk rotation, breath holding, rib flaring, drawing in of the rib cage or overactivation of the contralateral hamstring to perform the lift. Determine whether the movement provokes any lumbopelvic pain. With no reproduction of pain, one of the legs may feel heavier to lift. The physiotherapist then applies a sustained passive compression and the patient repeats the ASLR. With the application of manual compression during the ASLR test the effort to lift the “painful” or "heavy" leg would be reduced, indicating a positive test and benefit to additional compression/force closure of the SIJ.[21]

[22]

Lee (2004) proposed that by varying the location of the compression during the ASLR, further information can be gained regarding which of the local stabilisers are compromised. For example:

  • Manual compression to approximate the anterior superior iliac spine (ASIS) replicates force closure anteriorly as if the Transversus Abdominis activity is increased.
  • Compression posteriorly to approximate the PSIS replicates force closure posteriorly as if multifidus activity is increased.
  • Compression in the direction of medial femoral rotation approximates the pubic symphysis and replicates pubococcygeus (anterior pelvic floor) activity

If the patient's pain is exacerbated with compression and the ASLR is more difficult to perform, it is suggested that the patient has too much force closure and in this case, the patient would not benefit from a sacroiliac belt.

Patient Education[edit | edit source]

Patient education is a very broad topic and includes the important area of healthy lifestyle behaviours (diet, nutrition, activity level, body weight, sleep, smoking, alcohol) and wellness. Dimensions of wellness can be visualized by various forms of the wellness wheel which can be used for patient education and are widely available. There are usually 7 or 8 vital areas: relational, emotional, financial, spiritual, environmental, intellectual, vocational, and physical.

Determining the area of needed patient education falls on the careful assessment of the physiotherapist, and, if indicated, requires a referral to a specialized health care professional for further assessment and interventions. Depending on the practice pattern of the physiotherapist’s geographic area, this could be a direct referral or can be conveyed back to the primary care physician with the recommendation for further specialized care (dietician, psychologist, social worker, etc). The patient’s needs before the physiotherapist are multifactorial and a holistic approach is highly recommended. In some cases, the physiotherapists may choose to hold on physiotherapy and request re-referral at the appropriate time.

In this section, observations regarding the subjects of posture, body mechanics and ergonomics, and pain will be discussed.

Posture[edit | edit source]

Postural assessment and advice are common methods used by physiotherapists with their patients with spinal issues.[23] The concepts of “postural health” and "optimal posture" have been extensively discussed over the years and there are broadly accepted beliefs regarding good and bad postures.[24][25] In a recent study on the perceptions of physiotherapists on optimal sitting and standing posture[23] it is evident that most physiotherapists that took part in the study believe that training a specific spinal posture is relevant in clinical practice. The study also reported that physiotherapists mostly believe that an upright lordotic spinal posture in both sitting and standing are optimal. However, there is a lack of strong evidence that any specific posture is the cause of spinal pain.[23]

Reasons for selecting certain postures are often related to beliefs associated with biomechanical domains and stereotypes for optimal posture. These include better load distribution, a lordotic lumbar curvature, the natural shape of the spine and what posture appears to be more relaxed. These beliefs are likely to influence clinical practice and the advice given to patients on postural re-education.[23]

Physiotherapists seldom select an optimal posture that involves lumbar flexion or forward head posture even though research has shown that healthy individuals often habitually adopt flexed sitting positions.[26][27] Clinicians should also consider that patients may also have strong beliefs on what the correct posture should be and this does influence their behaviour, whether it is based on evidence or not.[28]

Taking into consideration the evidence or lack thereof, the anatomic variation and the complex nature of pain and injury it might be relevant to clinicians to consider that there may not be one optimal posture, but rather that any position (lordotic or kyphotic) that is maintained for a period of time without interruption may actually lead to discomfort and pain[29] and that clinicians should advise their patients accordingly.[23]

For this reason, Deborah Riczo suggests that physiotherapists not use the labels “good” and “bad or poor” posture when describing postural positions as these are value-based terms not backed by research. Educating the patient on moving in and out of postures more frequently and the idea of the mind/body connection, and feelings of confidence in certain postures may be more beneficial.

See this infographic on posture: Should we re-evaluate how we look at posture?[30]

Deborah Riczo created the following YouTube playlist that you can share with your patients:Dr. Deborah Riczo, doctor of physical therapy:why POSTURE in standing, sitting, feeding baby, & lying can cause/contribute to YOUR PAIN & WHAT to do

Non-optimal strategies[edit | edit source]

As physiotherapists, however, we can critically look for non-optimal strategies that may be a play in our patients. According to Diane Lee, these non-optimal postural strategies can be used for managing load through the trunk. These are: "butt gripping", "back gripping" and "chest gripping". These non-optimal strategies may lead to a variety of symptoms, such as low back pain, pelvic pain and groin pain.[31]

  1. Butt gripping
    • Butt gripping postures are often seen in men with an athletic history (hockey players, soccer players), dancers who walk with feet pointing out and also in mothers.
    • Muscles that will be overworked in this postural strategy are the piriformis and the ischiococcygeus, and there will be a loss of lordosis in the lumbar spine.
    • The consequence of butt gripping strategy:
      • Head of the femur is forced anteriorly in the hip and stresses the anterior tissue at the anterior pelvis and this may lead to groin pain or symphysis pubis pain
      • Restricted hip movement, especially movements such as bending forward, squatting and sitting
  2. Back gripping
    • This strategy is commonly seen in dancers, gymnasts. It is also referred to as the military stance.
    • Muscles that are overworked in this postural strategy are the erector spinae. Often the rectus abdominus is overstretched in this position and patients may present with a long lordosis
    • Consequences of a back gripping strategy are:
      • Forcing the joints of the spine together, causing mid or lower back pain, especially with long periods of standing
      • Reduced/ limited ability of the spinal joint to flex forward and lengthening of rectus abdominus – leading to a loss of support
  3. Chest gripping
    • This strategy is often seen in postpartum women who are trying to regain a flat stomach, as well as in athletes who perform many sit-ups and oblique abdominal curl-ups.
    • Muscles that are overworked in this type of strategy are the external obliques in an attempt to flatten the stomach. A loss of lordosis is also evident.
    • Chest grippers need to learn how to breathe properly!
    • Consequences of the chest grip strategy are:
      • Compression of joints in the rib cage  - this will influence trunk rotation and extension
      • Restricted ability of rib cage to expand  - this may lead to disordered breathing patterns
      • Increased intra-abdominal pressure – this puts pelvic organs at risk for prolapses and for stress urinary incontinence

You can find some more info and videos on how to address these postural strategies here: Butt-grippers, Back-grippers and Chest Grippers by Diane Lee

For more on posture, you can also read this Physiopedia page: Posture

Body mechanics and Ergonomics[edit | edit source]

Body mechanics describe the ways we move. It includes how we hold our bodies when we sit, stand, lift, carry, bend and sleep. Awkward postures over time and repetitive movements may cause pain and dysfunction. When assessing a patient with pelvic girdle dysfunction things to consider may include[32]:

  • Person always standing on one leg
  • Person always carrying on one side (for example carrying a child on the hip or always carrying the laundry basket on one side)
  • Repetitive overhead reaching activities
  • It is also recommended to screen for ergonomics at home and work to determine if further on-site/virtual assessment is indicated. This would include computer workspace set-up.
    • Examples of common problems in computer set-up for patients with pelvic girdle dysfunction include
      • inadequate chair/monitor height
      • excessive leaning forward resulting in compression hip/groin
      • forward head and overall kyphosis
  • Ask the patient what activities he/she does during the day that is perhaps aggravating their condition[32]

For more information on Body Mechanics read this Physiopedia Page: Injury Prevention and Body Mechanics

Pain[edit | edit source]

Physiotherapists are experts in managing pain and very often pain is the reason for patients coming to physiotherapy. The reasons may be for an acute injury, or chronic pain or an acute episode of pain on a chronic pain condition. Patient education is paramount in the management of pain. Things to consider:

  • Tissue Healing Time
  • The use of pain medication by the patient and their beliefs around this
  • Factors such as anxiety and depression
  • Stress Management Skills of the patient
    • How do they cope with stress?
    • Factors that affect stress and also patient outcome include[32][33]:
      • sleep
      • relationships
      • nutrition
      • attitude
      • body weight
      • perceived health
      • finances
    • Read more about stress and pain here: Considering the Stress Pain Cycle
  • Patient Education on Pain
    • Patient education is an essential component of effective patient care in all healthcare settings.[34] It provides a way for clinicians to communicate relevant information, improve patient self-efficacy and self-management skills and improve clinical outcomes such as pain, disability and function.[34]
    • Read more about patient education and pain here: Patient Education in Pain Management
    • Some points to consider when educating your patients about pain:
      • Pain is biopsychosocial. Biological factors such as tissue damage, injury and inflammation influence pain. Psychological factors such as perceptions, emotions and stress also influence pain. Pain is also multi-factorial and complex. These various factors interact in ways that are individual, context-dependent and unpredictable.[35]
      • Melzack[36] (2010) describes pain as the output of a highly intricate protective system that functions like an alarm. Threats that are detected in the periphery are communicated to the brain. The brain interprets the information and pain is created if the need for protection is perceived. Different factors such as injury, inflammation, emotions, stress, memories and general health influence the sensitivity of this system.
      • Pain is dependent on perception and pain can be experienced in the absence of tissue damage. For example Brinjikji et al[37] (2015) reported that back pain cannot be linked to specific pathology.
      • Psychosocial factors such as anxiety, catastrophizing and fear of movement increase the risk of chronic pain. Optimism and self-efficacy predict recovery from injury. These variables can be altered through patient education in a positive way.[38]

Greg Lehman has an excellent free workbook on pain science for clinicians and patients and it provides a good overview of pain principles, key messages, pain contributors and recovery strategies. The workbook can be downloaded from here. Recovery Strategies. Your pain guidebook

Below are some videos on chronic pain from leading experts in the field.


References[edit | edit source]

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