背景與目的: 妊娠相關骨盆帶疼痛是一種在妊娠期間和妊娠後常見的肌肉骨骼疾病，對許多產後婦女的身心健康造成重大影響。但至今特別針對產後妊娠相關骨盆帶疼的研究非常有限。以往的研究僅初步描述妊娠相關骨盆帶疼痛婦女，其自評日常活動受限程度，但並沒有針對其身體功能失能情形進行客觀量化評估。此外，在懷孕期間和產後的婦女中常見腰椎骨盆肌肉的肌肉損傷或功能障礙。患有妊娠相關骨盆帶疼痛的產後婦女，是否可能因腰椎骨盆肌肉功能較差而導致骨盆帶疼痛尚不清楚。目前尚無研究全面性地探討妊娠相關骨盆帶疼痛的產後婦女之主要腰椎骨盆肌肉功能。因此，本研究的主要目的是比較有無妊娠相關骨盆帶疼痛的產後婦女，其腰椎骨盆肌肉功能與身體功能表現。本研究也探討腰椎骨盆肌肉功能和身體功能與其骨盆帶疼痛程度和失能程度的相關性。方法：本研究採病例對照研究設計，共招募60名皆接受陰道分娩的產後婦女，包括30名患有妊娠相關骨盆帶疼痛，和30名年齡、胎次和產後時間相符的無妊娠相關骨盆帶疼痛的婦女。研究結果評估項目包含了疼痛失能程度、腰椎骨盆肌肉功能與身體功能評估三大類。疼痛程度、失能狀況及健康相關生活品質，分別以疼痛數字等級量表、骨盆帶疼痛功能問卷、與SF-36生活品質量表之自填問卷評估。身體功能表現評估則包含自主性直膝抬腿疲勞測試、三公尺計時起走測試與六公尺快速行走測試。腰椎骨盆肌肉功能是用超音波影像系統測量休息時和肢體動作時(自主直膝抬腿)腹肌與腰椎多裂肌肉的肌肉厚度、收縮活化情形和腹直肌分離的距離。本研究亦以非侵入式的經腹部超音波影像測量在休息時、最大自主收縮和主動直膝抬腿期間的膀胱底部位置與位移量，代表骨盆底肌肉功能。結果：患有妊娠相關骨盆帶疼痛的產後婦女其非疼痛側的腹內斜肌(p=0.003)與腹外斜肌(p=0.009)的休息時肌肉厚度比無妊娠相關骨盆帶疼痛的產後婦女明顯更厚；但兩組之間在疼痛側肌肉厚度沒有顯著差異。在主動直膝抬腿時，與無妊娠相關骨盆帶疼痛的產後婦女相比，患有妊娠相關骨盆帶疼痛的產後婦女其雙側腹內斜肌的肌肉厚度變化和佔總腹肌收縮比例顯著地增厚(p<0.05)，而雙側腹外斜肌則顯著地變薄(p<0.05)。患有妊娠相關骨盆帶疼痛的產後婦女，其骨盆底肌功能與無妊娠相關骨盆帶疼痛的產後婦女相比也較差。在休息時患有妊娠相關骨盆帶疼痛的產後婦女，其膀胱基部位置顯著降低(p=0.002)，在自主收縮時向上位移顯著較大(p=0.028)。然而，其他肌肉包含腹橫肌，腰椎多裂肌、上下腹直肌距離以及主動直膝抬腿時的膀胱基底位移在兩組間沒有差異。患有妊娠相關骨盆帶疼痛的產後婦女，其自主性直膝抬腿疲勞測試總持續時間比無妊娠相關骨盆帶疼痛的產後婦女明顯更短(p<0.05)，六公尺快速行走測試所需時間更長(p=0.017)，但三公尺計時起走測試沒有差異。相關性分析結果發現，患有妊娠相關骨盆帶疼痛的產後婦女之非疼痛側腹內斜肌和腹外斜肌休息肌肉厚度與其疼痛程度和失能程度具有低度正相關(r=0.306 to 0.341, p<0.05)。妊娠相關骨盆帶疼痛產後婦女在主動直膝抬腿時，非疼痛側的腹內斜肌佔總腹肌收縮比例，與疼痛和失能程度具有低度正相關(r=0.306, p=0.018)，但與腹外斜肌的肌肉厚度變化和佔總腹肌收縮比例則呈現低至中度負相關(r=-0.317 to -0.421, p<0.05)。患有妊娠相關骨盆帶疼痛的產後婦女之疼痛和失能程度，與在主動直膝抬腿時，其疼痛側的腹內斜肌厚度變化或活化程度與佔總腹肌收縮比例具有低度正相關(r=0.314 to 0.537, p<0.05)，但與腹外斜肌則呈現低至中度負相關(r=-0.394 to -0.492, p<0.05)。妊娠相關骨盆帶疼痛產後婦女休息時，膀胱位置較低與其疼痛程度亦呈現低度正相關(r=0.313, p=0.015)。再者，妊娠相關骨盆帶疼痛產後婦女之自主性直膝抬腿疲勞測試與六公尺快速行走測試表現與其疼痛和失能程度亦呈現低至中度正相關(r=-0.277 to -0.293，p<0.05與r=0.276 to 0.423, p<0.05)。結論：本研究的超音波影像測量結果顯示，尤其是腹外斜肌和腹內斜肌的形態特徵和活化策略，在有和無妊娠相關骨盆帶疼痛的產後婦女中存在差異。這個差異可能是種增加骨盆穩定的代償策略，以完成動作任務。患有妊娠相關骨盆帶疼痛的產後婦女中，也觀察到較差的骨盆底肌功能與較差之身體功能表現，包括骨盆傳遞負荷能力較差和快步行走速度較慢。腰椎骨盆肌肉功能和身體功能表現的下降，可能部分解釋了其疼痛和失能的嚴重程度。此研究提供初步證據和理由，但未來仍需更全面或隨機分配試驗研究，以了解腰椎骨盆肌肉運動介入對患有妊娠相關骨盆帶疼痛的產後婦女之效益。

Introduction: Pregnancy-related pelvic girdle pain (PPGP) is a common musculoskeletal disorder that develops during and after pregnancy. Persistent PPGP cause significant impacts on both physical and mental health in many postpartum women. Despite the fact that several studies on postpartum lumbopelvic pain have been conducted, there are distinct clinical presentations or pathogenic mechanisms that distinguish the pelvic girdle pain from the low back pain. To date, very limited evidence in this specific population of postpartum women with PPGP. Previous studies only reported the self-described activity limitations during daily activities, but no objective assessment of the physical function in postpartum women with PPGP. Furthermore, muscle damages, impairments or dysfunctions of the lumbopelvic muscles have been commonly observed in women during pregnancy and postpartum. Whether postpartum women with PPGP may have poorer lumbopelvic muscle function and consequently lead to producing pelvic girdle pain remains unclear. No study has comprehensively investigated all the major lumbopelvic muscles including abdominals, lumbar multifidus and pelvic floor muscles between the postpartum women with and without PPGP from different perspectives such as morphological characteristics during resting and activation levels during tasks. Therefore, the main purpose for this study was to compare the lumbopelvic muscle function and physical function in the postpartum women with and without PPGP. In addition, the correlations of lumbopelvic muscle function and physical function to the levels of pain and disability in postpartum women with PPGP were investigated. The findings of this study is important for fully understanding the pathomechanism, impairments, and disability of the PPGP, and thus to develop an effective intervention for postpartum women with PPGP.

Methods: This is a case-control study for postpartum women with PPGP. A total of 60 participants including 30 postpartum women with PPGP (PPGP group) and 30 age-, parity- and postpartum duration-matched postpartum women without PPGP (healthy group) were recruited. All women received vaginal delivery when they gave the birth. The PPGP clinical screening tests were performed in all participants to ensure the group classifications. Pain intensity, disability level, and health-related quality of life were assessed respectively using the numeric rating scale (NRS), Pelvic girdle questionnaire (PGQ), and 36-item short form survey (SF-36). The performance of physical function were objectively assessed using the active straight leg raises fatigue task (ASLRF), timed up and go test (TUG), and 6-meter fast walking test (6MW). The lumbopelvic muscle function was assessed using the ultrasonography (ACUSON NX3TM Ultrasound System, Siemens Solution USA, Inc.). The muscle thickness during resting (i.e., morphologic characteristics) and muscle thickness changes during performing active straight leg raise (ASLR) were measured including the internal oblique muscle (IO), external oblique muscle (EO), transverse abdominis (TA), and lumbar multifidus (MF). Additionally, the inter-rectus distance (IRD) for upper and lower abdominal regions were obtained. The pelvic floor muscles (PFMs) function was first assessed using the transabdominal ultrasonographic measures of the bladder base position and displacement during resting, maximal voluntary contraction and ASLR.

Results: For the abdominal muscles morphology, the PPGP group had significantly thicker IO (p=0.003) and EO (p=0.009) on the non-painful side compared to the healthy group, but no significant difference between the groups on the painful side. The muscle thickness changes and ratio of the total abdominal muscle for the bilateral IO were significantly thicker (p<0.05) during ASLR in the PPGP group compared to that in the healthy group, while bilateral EO were significantly thinner (p<0.05). The PPGP group also had poorer PFMs function compared to the healthy group as significantly lower bladder base position during resting (p=0.002) and greater upward displacement during voluntary contraction (p=0.028) were found. Although the TA, lumbar MF, upper and lower IRD, as well as the bladder base displacement during ASLR did not differ between groups. Furthermore, the total duration of the ASLRF task was significantly less (p<0.05) and 6MW test was longer (p=0.017) in the PPGP group than the healthy group, but no difference for the TUG test. The postpartum women with PPGP who had greater resting thickness of IO and EO on the non-painful side had higher level of pain and disability (r=0.306 to 0.341, p<0.05). The postpartum women with PPGP who had greater ratio of IO on non-painful side (r=0.306, p=0.018) during ASLR, and smaller thickness changes and ratio of EO during ASLR had higher level of pain and disability (r=-0.317 to -0.421, p<0.05). Postpartum women with PPGP also demonstrated larger thickness changes and ratio of IO on painful side (r=0.314 to 0.537, p<0.05) during ASLR, and smaller thickness changes and ratio of EO during ASLR had higher level of pain and disability (r=-0.394 to -0.492, p<0.05). Postpartum women with PPGP who had lower bladder position during resting had higher level of pain (r=0.313, p=0.015). The postpartum women with PPGP who had impaired physical function had higher level of pain and disability (r=-0.277 to -0.293，p<0.05 and r=0.276 to 0.423, p<0.05).

Conclusion: The current ultrasonographic results demonstrated that the morphologic characteristics and activation strategies of abdominal muscles especially the EO and IO were different between the postpartum women with and without PPGP that might be a compensatory strategy for improving pelvic stability in order to accomplish the functional tasks. Poorer PFMs function was also observed in the postpartum women with PPGP. Impaired physical function including poorer load-holding ability of the pelvis and slower brisk walking speed were further found in the postpartum women with PPGP. Those declines in lumbopelvic muscle function and physical function may partly explained the severity of pain and disability. The current study provides evidence and justification for the need for additional research and a different approach for postpartum women with PPGP.

1. Wu WH, Meijer OG, Uegaki K, Mens JM, van Dieen JH, Wuisman PI, et al. Pregnancy-related pelvic girdle pain (PPP), I: Terminology, clinical presentation, and prevalence. Eur Spine J. 2004;13(7):575-89.
2. Vleeming A, Albert HB, Ostgaard HC, Sturesson B, Stuge B. European guidelines for the diagnosis and treatment of pelvic girdle pain. Eur Spine J. 2008;17(6):794-819.
3. Laslett M, Aprill CN, McDonald B, Young SB. Diagnosis of Sacroiliac Joint Pain: Validity of individual provocation tests and composites of tests. Manual Therapy. 2005;10(3):207-18.
4. Casagrande D, Gugala Z, Clark SM, Lindsey RW. Low Back Pain and Pelvic Girdle Pain in Pregnancy. J Am Acad Orthop Surg. 2015;23(9):539-49.
5. Sabino J, Grauer JN. Pregnancy and low back pain. Curr Rev Musculoskelet Med. 2008;1(2):137-41.
6. Bergstrom C, Persson M, Nergard KA, Mogren I. Prevalence and predictors of persistent pelvic girdle pain 12 years postpartum. BMC Musculoskelet Disord. 2017;18(1):399.
7. Elden H, Gutke A, Kjellby-Wendt G, Fagevik-Olsen M, Ostgaard HC. Predictors and consequences of long-term pregnancy-related pelvic girdle pain: a longitudinal follow-up study. BMC Musculoskelet Disord. 2016;17:276.
8. Gutke A, Josefsson A, Oberg B. Pelvic girdle pain and lumbar pain in relation to postpartum depressive symptoms. Spine (Phila Pa 1976). 2007;32(13):1430-6.
9. Nielsen LL. Clinical findings, pain descriptions and physical complaints reported by women with post-natal pregnancy-related pelvic girdle pain. Acta Obstet Gynecol Scand. 2010;89(9):1187-91.
10. Mens JM, Vleeming A, Snijders CJ, Ronchetti I, Stam HJ. Reliability and validity of hip adduction strength to measure disease severity in posterior pelvic pain since pregnancy. Spine (Phila Pa 1976). 2002;27(15):1674-9.
11. Stuge B. Pelvic girdle pain: examination, treatment, and the development and implementation of the European guidelines. 2012.
12. Verstraete EH, Vanderstraeten G, Parewijck W. Pelvic Girdle Pain during or after Pregnancy: a review of recent evidence and a clinical care path proposal. Facts Views Vis Obgyn. 2013;5(1):33-43.
13. Schauberger CW, Rooney BL, Goldsmith L, Shenton D, Silva PD, Schaper A. Peripheral joint laxity increases in pregnancy but does not correlate with serum relaxin levels. Am J Obstet Gynecol. 1996;174(2):667-71.
14. Ireland ML, Ott SM. The effects of pregnancy on the musculoskeletal system. Clin Orthop Relat Res. 2000(372):169-79.
15. Katonis P, Kampouroglou A, Aggelopoulos A, Kakavelakis K, Lykoudis S, Makrigiannakis A, et al. Pregnancy-related low back pain. Hippokratia. 2011;15(3):205-10.
16. Stuge B, Mørkved S, Haug Dahl H, Vøllestad N. Abdominal and pelvic floor muscle function in women with and without long lasting pelvic girdle pain. Manual Therapy. 2006;11(4):287-96.
17. Mens JMA, Pool-Goudzwaard A. The transverse abdominal muscle is excessively active during active straight leg raising in pregnancy-related posterior pelvic girdle pain: an observational study. BMC Musculoskeletal Disorders. 2017;18(1):372.
18. Fernandes da Mota PG, Pascoal AG, Carita AI, Bo K. Prevalence and risk factors of diastasis recti abdominis from late pregnancy to 6 months postpartum, and relationship with lumbo-pelvic pain. Man Ther. 2015;20(1):200-5.
19. Gluppe S, Ellstrom Engh M, Kari B. Women with diastasis recti abdominis might have weaker abdominal muscles and more abdominal pain, but no higher prevalence of pelvic floor disorders, low back and pelvic girdle pain than women without diastasis recti abdominis. Physiotherapy. 2021;111:57-65.
20. Parker MA, Millar LA, Dugan SA. Diastasis Rectus Abdominis and Lumbo-Pelvic Pain and Dysfunction-Are They Related? Journal of Women’s Health Physical Therapy. 2009;33(2):15-22.
21. Sperstad JB, Tennfjord MK, Hilde G, Ellstrom-Engh M, Bo K. Diastasis recti abdominis during pregnancy and 12 months after childbirth: prevalence, risk factors and report of lumbopelvic pain. Br J Sports Med. 2016;50(17):1092-6.
22. Whittaker JL, Warner MB, Stokes M. Comparison of the sonographic features of the abdominal wall muscles and connective tissues in individuals with and without lumbopelvic pain. J Orthop Sports Phys Ther. 2013;43(1):11-9.
23. Long G, Fang ZY, Xiang-Sheng T, Feng Y, Hao-Ning M, Qing-Ying H, et al. Symmetry in Paraspinal Muscles as a Predictor of the Development of Pregnancy-Related Low Back and Pelvic Pain: A Prospective Study. Orthop Surg. 2021;13(8):2255-62.
24. Fonti Y, Giordano R, Cacciatore A, Romano M, La Rosa B. Post partum pelvic floor changes. J Prenat Med. 2009;3(4):57-9.
25. Lee DG, Lee LJ, McLaughlin L. Stability, continence and breathing: the role of fascia following pregnancy and delivery. J Bodyw Mov Ther. 2008;12(4):333-48.
26. Grob ATM, Hitschrich N, van de Waarsenburg MK, Withagen MIJ, Schweitzer KJ, van der Vaart CH. Changes in global strain of puborectalis muscle during pregnancy and postpartum. Ultrasound Obstet Gynecol. 2018;51(4):537-42.
27. Dufour S, Vandyken B, Forget MJ, Vandyken C. Association between lumbopelvic pain and pelvic floor dysfunction in women: A cross sectional study. Musculoskelet Sci Pract. 2018;34:47-53.
28. Loving S, Thomsen T, Jaszczak P, Nordling J. Pelvic floor muscle dysfunctions are prevalent in female chronic pelvic pain: a cross-sectional population-based study. Eur J Pain. 2014;18(9):1259-70.
29. Pool-Goudzwaard AL, Slieker ten Hove MC, Vierhout ME, Mulder PH, Pool JJ, Snijders CJ, et al. Relations between pregnancy-related low back pain, pelvic floor activity and pelvic floor dysfunction. Int Urogynecol J Pelvic Floor Dysfunct. 2005;16(6):468-74.
30. Eliasson K, Elfving B, Nordgren B, Mattsson E. Urinary incontinence in women with low back pain. Man Ther. 2008;13(3):206-12.
31. Starzec-Proserpio M, Rejano-Campo M, Szymanska A, Szymanski J, Baranowska B. The Association between Postpartum Pelvic Girdle Pain and Pelvic Floor Muscle Function, Diastasis Recti and Psychological Factors-A Matched Case-Control Study. Int J Environ Res Public Health. 2022;19(10).
32. Bastiaanssen JM, de Bie RA, Bastiaenen CH, Heuts A, Kroese ME, Essed GG, et al. Etiology and prognosis of pregnancy-related pelvic girdle pain; design of a longitudinal study. BMC Public Health. 2005;5:1.
33. Mogren IM. BMI, pain and hyper-mobility are determinants of long-term outcome for women with low back pain and pelvic pain during pregnancy. Eur Spine J. 2006;15(7):1093-102.
34. Olsson C, Buer N, Holm K, Nilsson-Wikmar L. Lumbopelvic pain associated with catastrophizing and fear-avoidance beliefs in early pregnancy. Acta Obstet Gynecol Scand. 2009;88(4):378-85.
35. To WW, Wong MW. Factors associated with back pain symptoms in pregnancy and the persistence of pain 2 years after pregnancy. Acta Obstet Gynecol Scand. 2003;82(12):1086-91.
36. Nilsson-Wikmar L, Holm K, Oijerstedt R, Harms-Ringdahl K. Effect of three different physical therapy treatments on pain and activity in pregnant women with pelvic girdle pain: a randomized clinical trial with 3, 6, and 12 months follow-up postpartum. Spine (Phila Pa 1976). 2005;30(8):850-6.
37. Gutke A, Ostgaard HC, Oberg B. Association between muscle function and low back pain in relation to pregnancy. J Rehabil Med. 2008;40(4):304-11.
38. Gutke A, Ostgaard HC, Oberg B. Predicting persistent pregnancy-related low back pain. Spine (Phila Pa 1976). 2008;33(12):E386-93.
39. Gutke A, Ostgaard HC, Oberg B. Pelvic girdle pain and lumbar pain in pregnancy: a cohort study of the consequences in terms of health and functioning. Spine (Phila Pa 1976). 2006;31(5):E149-55.
40. Ostgaard HC, Roos-Hansson E, Zetherstrom G. Regression of back and posterior pelvic pain after pregnancy. Spine (Phila Pa 1976). 1996;21(23):2777-80.
41. Robinson HS, Vollestad NK, Veierod MB. Clinical course of pelvic girdle pain postpartum - impact of clinical findings in late pregnancy. Man Ther. 2014;19(3):190-6.
42. Wuytack F, Daly D, Curtis E, Begley C. Prognostic factors for pregnancy-related pelvic girdle pain, a systematic review. Midwifery. 2018;66:70-8.
43. Panjabi MM. The stabilizing system of the spine. Part I. Function, dysfunction, adaptation, and enhancement. J Spinal Disord. 1992;5(4):383-9; discussion 97.
44. Lee DG, Vleeming A, editors. CHAPTER 40 – An integrated therapeutic approach to the treatment of pelvic girdle pain2007.
45. Vleeming A, Snijders C, Stoeckart R, Mens J. The role of the sacroiliac joints in coupling between spine, pelvis, legs and arms. In: Vleeming A, Mooney V, Dorman T, Snijders CJ, Stoeckart R, editors. Movement, Stability & Low Back Pain: Churchill Livingstone; 1997. p. 53 - 71.
46. Vleeming A, Stoeckart R, Volkers AC, Snijders CJ. Relation between form and function in the sacroiliac joint. Part I: Clinical anatomical aspects. Spine (Phila Pa 1976). 1990;15(2):130-2.
47. Vleeming A, Volkers AC, Snijders CJ, Stoeckart R. Relation between form and function in the sacroiliac joint. Part II: Biomechanical aspects. Spine (Phila Pa 1976). 1990;15(2):133-6.
48. Snijders CJ, Vleeming A, Stoeckart R. Transfer of lumbosacral load to iliac bones and legs Part 2: Loading of the sacroiliac joints when lifting in a stooped posture. Clin Biomech (Bristol, Avon). 1993;8(6):295-301.
49. Snijders CJ, Vleeming A, Stoeckart R. Transfer of lumbosacral load to iliac bones and legs Part 1: Biomechanics of self-bracing of the sacroiliac joints and its significance for treatment and exercise. Clin Biomech (Bristol, Avon). 1993;8(6):285-94.
50. Stuge B, editor Pelvic girdle pain: examination, treatment, and the development and implementation of the European guidelines2012.
51. Mitchell B, Verrills P, Vivian D. Sacroiliac joint pain: Diagnosis and treatment. Australasian Musculoskeletal Medicine. 2012;17(1):15-24.
52. Pool-Goudzwaard AL, Vleeming A, Stoeckart R, Snijders CJ, Mens JM. Insufficient lumbopelvic stability: a clinical, anatomical and biomechanical approach to 'a-specific' low back pain. Man Ther. 1998;3(1):12-20.
53. Vleeming A, Schuenke MD, Masi AT, Carreiro JE, Danneels L, Willard FH. The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. J Anat. 2012;221(6):537-67.
54. Arumugam A, Milosavljevic S, Woodley S, Sole G. Effects of external pelvic compression on form closure, force closure, and neuromotor control of the lumbopelvic spine--a systematic review. Man Ther. 2012;17(4):275-84.
55. Vleeming A, Pool-Goudzwaard AL, Hammudoghlu D, Stoeckart R, Snijders CJ, Mens JM. The function of the long dorsal sacroiliac ligament: its implication for understanding low back pain. Spine (Phila Pa 1976). 1996;21(5):556-62.
56. Bogduk N, Macintosh JE. The applied anatomy of the thoracolumbar fascia. Spine (Phila Pa 1976). 1984;9(2):164-70.
57. Willard FH, Vleeming A, Schuenke MD, Danneels L, Schleip R. The thoracolumbar fascia: anatomy, function and clinical considerations. J Anat. 2012;221(6):507-36.
58. Vleeming A, Pool-Goudzwaard AL, Stoeckart R, van Wingerden JP, Snijders CJ. The posterior layer of the thoracolumbar fascia. Its function in load transfer from spine to legs. Spine (Phila Pa 1976). 1995;20(7):753-8.
59. Bergmark A. Stability of the lumbar spine. A study in mechanical engineering. Acta Orthop Scand Suppl. 1989;230:1-54.
60. Hodges PW, Richardson CA. Contraction of the abdominal muscles associated with movement of the lower limb. Phys Ther. 1997;77(2):132-42; discussion 42-4.
61. Hodges PW, Richardson CA. Relationship between limb movement speed and associated contraction of the trunk muscles. Ergonomics. 1997;40(11):1220-30.
62. Hodges P, Cresswell A, Thorstensson A. Preparatory trunk motion accompanies rapid upper limb movement. Exp Brain Res. 1999;124(1):69-79.
63. Moseley GL, Hodges PW, Gandevia SC. External perturbation of the trunk in standing humans differentially activates components of the medial back muscles. J Physiol. 2003;547(Pt 2):581-7.
64. Hodges PW, Richardson CA. Inefficient muscular stabilization of the lumbar spine associated with low back pain. A motor control evaluation of transversus abdominis. Spine (Phila Pa 1976). 1996;21(22):2640-50.
65. Marshall P, Murphy B. The validity and reliability of surface EMG to assess the neuromuscular response of the abdominal muscles to rapid limb movement. J Electromyogr Kinesiol. 2003;13(5):477-89.
66. Radebold A, Cholewicki J, Panjabi MM, Patel TC. Muscle response pattern to sudden trunk loading in healthy individuals and in patients with chronic low back pain. Spine (Phila Pa 1976). 2000;25(8):947-54.
67. Borg-Stein J, Dugan SA. Musculoskeletal disorders of pregnancy, delivery and postpartum. Phys Med Rehabil Clin N Am. 2007;18(3):459-76, ix.
68. Calguneri M, Bird HA, Wright V. Changes in joint laxity occurring during pregnancy. Ann Rheum Dis. 1982;41(2):126-8.
69. Stolarczyk A, Stępiński P, Sasinowski Ł, Czarnocki T, Dębiński M, Maciąg B. Peripartum Pubic Symphysis Diastasis-Practical Guidelines. J Clin Med. 2021;10(11).
70. Sipko T, Grygier D, Barczyk K, Eliasz G. The occurrence of strain symptoms in the lumbosacral region and pelvis during pregnancy and after childbirth. J Manipulative Physiol Ther. 2010;33(5):370-7.
71. Carvalho M, Lima LC, de Lira Terceiro CA, Pinto DRL, Silva MN, Cozer GA, et al. [Low back pain during pregnancy]. Rev Bras Anestesiol. 2017;67(3):266-70.
72. Cherni Y, Desseauve D, Decatoire A, Veit-Rubinc N, Begon M, Pierre F, et al. Evaluation of ligament laxity during pregnancy. J Gynecol Obstet Hum Reprod. 2019;48(5):351-7.
73. Deering RE, Cruz M, Senefeld JW, Pashibin T, Eickmeyer S, Hunter SK. Impaired Trunk Flexor Strength, Fatigability, and Steadiness in Postpartum Women. Med Sci Sports Exerc. 2018;50(8):1558-69.
74. Gilleard WL, Brown JM. Structure and function of the abdominal muscles in primigravid subjects during pregnancy and the immediate postbirth period. Phys Ther. 1996;76(7):750-62.
75. Weis CA, Triano JJ, Barrett J, Campbell MD, Croy M, Roeder J. Ultrasound Assessment of Abdominal Muscle Thickness in Postpartum vs Nulliparous Women. J Manipulative Physiol Ther. 2015;38(5):352-7.
76. Chiarello CM, Falzone LA, McCaslin KE, Patel MN, Ulery KR. The effects of an exercise program on diastasis recti abdominis in pregnant women. Journal of women’s health physical therapy. 2005;29(1):11-6.
77. Mota P, Gil Pascoal A, Bo K. Diastasis recti abdominis in pregnancy and postpartum period. Risk factors, functional implications and resolution. Current women's health reviews. 2015;11(1):59-67.
78. de Groot M, Pool-Goudzwaard AL, Spoor CW, Snijders CJ. The active straight leg raising test (ASLR) in pregnant women: differences in muscle activity and force between patients and healthy subjects. Man Ther. 2008;13(1):68-74.
79. Mantle J, Haslam J, Barton S, Polden M, ScienceDirect. Physiotherapy in obstetrics and gynaecology: Butterworth-Heinemann Edinburgh, Scotland; 2004.
80. Suryawanshi DA, Kale A. Prevalence of Low Back Pain in the immediate postpartum period with DRAM. 2020.
81. Saleem Z, Khan AA, Farooqui SI, Yasmeen R, Rizvi J. Effect of Exercise on Inter-Recti Distance and Associated Low Back Pain Among Post-Partum Females: A Randomized Controlled Trial. J Family Reprod Health. 2021;15(3):202-9.
82. Chan SS, Cheung RY, Yiu KW, Lee LL, Leung TY, Chung TK. Pelvic floor biometry during a first singleton pregnancy and the relationship with symptoms of pelvic floor disorders: a prospective observational study. BJOG. 2014;121(1):121-9.
83. Dietz HP, Scoti F, Subramaniam N, Friedman T, Shek KL. Impact of subsequent pregnancies on pelvic floor functional anatomy. Int Urogynecol J. 2018;29(10):1517-22.
84. Rogers RG, Ninivaggio C, Gallagher K, Borders AN, Qualls C, Leeman LM. Pelvic floor symptoms and quality of life changes during first pregnancy: a prospective cohort study. Int Urogynecol J. 2017;28(11):1701-7.
85. Al-Asmakh M. Reproductive functions of progesterone. Middle East Fertility Society Journal. 2007;12(3):147.
86. Goldsmith LT, Weiss G. Relaxin in human pregnancy. Annals of the New York Academy of Sciences. 2009;1160(1):130-5.
87. Van Geelen H, Ostergard D, Sand P. A review of the impact of pregnancy and childbirth on pelvic floor function as assessed by objective measurement techniques. Int Urogynecol J. 2018;29(3):327-38.
88. Lee DG. The pelvic girdle: an integration of clinical expertise and research: Elsevier Health Sciences; 2011.
89. Afshari P, Dabagh F, Iravani M, Abedi P. Comparison of pelvic floor muscle strength in nulliparous women and those with normal vaginal delivery and cesarean section. Int Urogynecol J. 2017;28(8):1171-5.
90. Friedman S, Blomquist JL, Nugent JM, McDermott KC, Muñoz A, Handa VLJO, et al. Pelvic muscle strength after childbirth. 2012;120(5):1021.
91. Stær-Jensen J, Siafarikas F, Hilde G, Benth JŠ, Bø K, Engh ME. Postpartum Recovery of Levator Hiatus and Bladder Neck Mobility in Relation to Pregnancy. Obstetrics & Gynecology. 2015;125(3):531-9.
92. Lipschuetz M, Cohen SM, Liebergall-Wischnitzer M, Zbedat K, Hochner-Celnikier D, Lavy Y, et al. Degree of bother from pelvic floor dysfunction in women one year after first delivery. European journal of obstetrics, gynecology, and reproductive biology. 2015;191:90-4.
93. Sjödahl J, Gutke A, Ghaffari G, Strömberg T, Öberg B. Response of the muscles in the pelvic floor and the lower lateral abdominal wall during the Active Straight Leg Raise in women with and without pelvic girdle pain: An experimental study. Clin Biomech (Bristol, Avon). 2016;35:49-55.
94. Mens JM, Huis in 't Veld YH, Pool-Goudzwaard A. Severity of signs and symptoms in lumbopelvic pain during pregnancy. Man Ther. 2012;17(2):175-9.
95. Noren L, Ostgaard S, Johansson G, Ostgaard HC. Lumbar back and posterior pelvic pain during pregnancy: a 3-year follow-up. Eur Spine J. 2002;11(3):267-71.
96. MacLennan AH, MacLennan SC. Symptom-giving pelvic girdle relaxation of pregnancy, postnatal pelvic joint syndrome and developmental dysplasia of the hip. The Norwegian Association for Women with Pelvic Girdle Relaxation (Landforeningen for Kvinner Med Bekkenlosningsplager). Acta Obstet Gynecol Scand. 1997;76(8):760-4.
97. Hansen A, Jensen DV, Wormslev M, Minck H, Johansen S, Larsen EC, et al. Symptom-giving pelvic girdle relaxation in pregnancy. II: Symptoms and clinical signs. Acta Obstet Gynecol Scand. 1999;78(2):111-5.
98. Persson M, Winkvist A, Dahlgren L, Mogren I. "Struggling with daily life and enduring pain": a qualitative study of the experiences of pregnant women living with pelvic girdle pain. BMC Pregnancy Childbirth. 2013;13:111.
99. Mens JM, Vleeming A, Stoeckart R, Stam HJ, Snijders CJ. Understanding peripartum pelvic pain. Implications of a patient survey. Spine (Phila Pa 1976). 1996;21(11):1363-9; discussion 9-70.
100. Fagevik Olsen M, Gutke A, Elden H, Nordenman C, Fabricius L, Gravesen M, et al. Self-administered tests as a screening procedure for pregnancy-related pelvic girdle pain. Eur Spine J. 2009;18(8):1121-9.
101. Elden H, Lundgren I, Robertson E. Life's pregnant pause of pain: pregnant women's experiences of pelvic girdle pain related to daily life: a Swedish interview study. Sexual & reproductive healthcare : official journal of the Swedish Association of Midwives. 2013;4(1):29-34.
102. Mackenzie J, Murray E, Lusher J. Women's experiences of pregnancy related pelvic girdle pain: A systematic review. Midwifery. 2018;56:102-11.
103. Engeset J, Stuge B, Fegran L. Pelvic girdle pain affects the whole life--a qualitative interview study in Norway on women's experiences with pelvic girdle pain after delivery. BMC Res Notes. 2014;7:686.
104. Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken). 2011;63 Suppl 11:S240-52.
105. Stuge B, Garratt A, Krogstad Jenssen H, Grotle M. The pelvic girdle questionnaire: a condition-specific instrument for assessing activity limitations and symptoms in people with pelvic girdle pain. Phys Ther. 2011;91(7):1096-108.
106. Grotle M, Garratt AM, Krogstad Jenssen H, Stuge B. Reliability and construct validity of self-report questionnaires for patients with pelvic girdle pain. Phys Ther. 2012;92(1):111-23.
107. Stuge B, Jenssen HK, Grotle M. The Pelvic Girdle Questionnaire: Responsiveness and Minimal Important Change in Women With Pregnancy-Related Pelvic Girdle Pain, Low Back Pain, or Both. Phys Ther. 2017;97(11):1103-13.
108. Ware JE, Jr. SF-36 health survey update. Spine (Phila Pa 1976). 2000;25(24):3130-9.
109. Ware JE, Jr., Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30(6):473-83.
110. Bajada S, Mohanty K. Psychometric properties including reliability, validity and responsiveness of the Majeed pelvic score in patients with chronic sacroiliac joint pain. Eur Spine J. 2016;25(6):1939-44.
111. de Vries GE, Jorritsma W, Dijkstra PU, Geertzen JH, Reneman MF. The construct validity of the Short Form-36 Health Survey for patients with nonspecific chronic neck pain. Int J Rehabil Res. 2015;38(2):137-43.
112. Badhiwala JH, Witiw CD, Nassiri F, Akbar MA, Jaja B, Wilson JR, et al. Minimum Clinically Important Difference in SF-36 Scores for Use in Degenerative Cervical Myelopathy. Spine (Phila Pa 1976). 2018;43(21):E1260-E6.
113. Klovning A, Avery K, Sandvik H, Hunskaar S. Comparison of two questionnaires for assessing the severity of urinary incontinence: The ICIQ-UI SF versus the incontinence severity index. Neurourol Urodyn. 2009;28(5):411-5.
114. Lim R, Liong ML, Lau YK, Yuen KH. Validity, reliability, and responsiveness of the ICIQ-UI SF and ICIQ-LUTSqol in the Malaysian population. Neurourol Urodyn. 2017;36(2):438-42.
115. Karmakar D, Mostafa A, Abdel-Fattah M. A new validated score for detecting patient-reported success on postoperative ICIQ-SF: a novel two-stage analysis from two large RCT cohorts. Int Urogynecol J. 2017;28(1):95-100.
116. Nystrom E, Sjostrom M, Stenlund H, Samuelsson E. ICIQ symptom and quality of life instruments measure clinically relevant improvements in women with stress urinary incontinence. Neurourol Urodyn. 2015;34(8):747-51.
117. Gray J, Aginsky KD, Derman W, Vaughan CL, Hodges PW. Symmetry, not asymmetry, of abdominal muscle morphology is associated with low back pain in cricket fast bowlers. J Sci Med Sport. 2016;19(3):222-6.
118. Teyhen DS, Gill NW, Whittaker JL, Henry SM, Hides JA, Hodges P. Rehabilitative ultrasound imaging of the abdominal muscles. J Orthop Sports Phys Ther. 2007;37(8):450-66.
119. Liaw LJ, Hsu MJ, Liao CF, Liu MF, Hsu AT. The relationships between inter-recti distance measured by ultrasound imaging and abdominal muscle function in postpartum women: a 6-month follow-up study. J Orthop Sports Phys Ther. 2011;41(6):435-43.
120. Kiesel KB, Uhl TL, Underwood FB, Rodd DW, Nitz AJ. Measurement of lumbar multifidus muscle contraction with rehabilitative ultrasound imaging. Man Ther. 2007;12(2):161-6.
121. Okamoto M, Murayama R, Haruna M, Matsuzaki M, Kozuma S, Nakata M, et al. Evaluation of pelvic floor function by transabdominal ultrasound in postpartum women. J Med Ultrason (2001). 2010;37(4):187-93.
122. Ikeda M, Mori A. Vaginal palpation versus transabdominal ultrasound in the comprehension of pelvic floor muscle contraction after vaginal delivery: a randomised controlled trial. BMC Womens Health. 2021;21(1):53.
123. Sherburn M, Murphy CA, Carroll S, Allen TJ, Galea MP. Investigation of transabdominal real-time ultrasound to visualise the muscles of the pelvic floor. Australian Journal of Physiotherapy. 2005;51(3):167-70.
124. Kim J-S, Choi J-D, Shin W-S. Effect of different contraction methods on pelvic floor muscle contraction in middle-aged women. Physical Therapy Rehabilitation Science. 2015;4(2):103-7.
125. Whittaker JL, Thompson JA, Teyhen DS, Hodges P. Rehabilitative ultrasound imaging of pelvic floor muscle function. J Orthop Sports Phys Ther. 2007;37(8):487-98.
126. Deering RE, Senefeld J, Pashibin T, Neumann DA, Cruz M, Hunter SK. Fatigability of the Lumbopelvic Stabilizing Muscles in Women 8 and 26 Weeks Postpartum. J Womens Health Phys Therap. 2018;42(3):128-38.
127. Evensen NM, Kvale A, Braekken IH. Reliability of the Timed Up and Go test and Ten-Metre Timed Walk Test in Pregnant Women with Pelvic Girdle Pain. Physiother Res Int. 2015;20(3):158-65.
128. Evensen NM, Kvale A, Braekken IH. Convergent validity of the Timed Up and Go Test and Ten-metre Timed Walk Test in pregnant women with pelvic girdle pain. Man Ther. 2016;21:94-9.
129. Roush J, Heick J, Hawk T, Eurek D, Wallis A, Kiflu D. Agreement in Walking Speed Measured Using Four Different Outcome Measures: 6-Meter Walk Test, 10-Meter Walk Test, 2-Minute Walk Test, and 6-Minute Walk Test. Internet Journal of Allied Health Sciences and Practice. 2021;19(2).
130. Lam HS, Lau FW, Chan GK, Sykes K. The validity and reliability of a 6-Metre Timed Walk for the functional assessment of patients with stroke. Physiother Theory Pract. 2010;26(4):251-5.
131. Linek P, Saulicz E, Wolny T, Mysliwiec A. Intra-rater reliability of B-mode ultrasound imaging of the abdominal muscles in healthy adolescents during the active straight leg raise test. PM R. 2015;7(1):53-9.
132. Wilson A, Hides JA, Blizzard L, Callisaya M, Cooper A, Srikanth VK, et al. Measuring ultrasound images of abdominal and lumbar multifidus muscles in older adults: A reliability study. Man Ther. 2016;23:114-9.
133. Teyhen DS, Miltenberger CE, Deiters HM, Del Toro YM, Pulliam JN, Childs JD, et al. The use of ultrasound imaging of the abdominal drawing-in maneuver in subjects with low back pain. J Orthop Sports Phys Ther. 2005;35(6):346-55.
134. Cuellar WA, Blizzard L, Callisaya ML, Hides JA, Jones G, Ding C, et al. Test-retest reliability of measurements of abdominal and multifidus muscles using ultrasound imaging in adults aged 50-79 years. Musculoskelet Sci Pract. 2017;28:79-84.
135. Arab AM, Behbahani RB, Lorestani L, Azari A. Assessment of pelvic floor muscle function in women with and without low back pain using transabdominal ultrasound. Man Ther. 2010;15(3):235-9.
136. Cohen J. Statistical power analysis for the behavioral sciences–second edition. 12 Lawrence Erlbaum Associates Inc. Hillsdale, New Jersey. 1988;13.
137. Mukaka MM. A guide to appropriate use of correlation coefficient in medical research. Malawi medical journal. 2012;24(3):69-71.
138. Sung ES, Kim JH. The difference effect of estrogen on muscle tone of medial and lateral thigh muscle during ovulation. J Exerc Rehabil. 2018;14(3):419-23.
139. Beales DJ, O'Sullivan PB, Briffa NK. Motor control patterns during an active straight leg raise in chronic pelvic girdle pain subjects. Spine (Phila Pa 1976). 2009;34(9):861-70.
140. Shadmehr A, Jafarian Z, Talebian S. Changes in recruitment of pelvic stabilizer muscles in people with and without sacroiliac joint pain during the active straight-leg-raise test. J Back Musculoskelet Rehabil. 2012;25(1):27-32.
141. Hu H, Meijer OG, Hodges PW, Bruijn SM, Strijers RL, Nanayakkara PW, et al. Understanding the Active Straight Leg Raise (ASLR): an electromyographic study in healthy subjects. Man Ther. 2012;17(6):531-7.
142. Moore KL, Dalley AF, Agur AM. Clinically oriented anatomy: Lippincott Williams & Wilkins; 2013.
143. Mens JM, Vleeming A, Snijders CJ, Stam HJ, Ginai AZ. The active straight leg raising test and mobility of the pelvic joints. Eur Spine J. 1999;8(6):468-73.
144. Schuenke MD, Vleeming A, Van Hoof T, Willard FH. A description of the lumbar interfascial triangle and its relation with the lateral raphe: anatomical constituents of load transfer through the lateral margin of the thoracolumbar fascia. J Anat. 2012;221(6):568-76.
145. Barker PJ, Briggs CA, Bogeski G. Tensile transmission across the lumbar fasciae in unembalmed cadavers: effects of tension to various muscular attachments. Spine (Phila Pa 1976). 2004;29(2):129-38.
146. Mens JM, Vleeming A, Snijders CJ, Koes BW, Stam HJ. Reliability and validity of the active straight leg raise test in posterior pelvic pain since pregnancy. Spine (Phila Pa 1976). 2001;26(10):1167-71.
147. Yang H-S, Kwon O-Y, Lee Y-S. Changes in the Thickness of Trunk Stabilizer Muscles According to Increased Lifting Loads in Stoop Lifting. Journal of Physical Therapy Science. 2013;25(1):121-4.
148. Rath AM, Attali P, Dumas JL, Goldlust D, Zhang J, Chevrel JP. The abdominal linea alba: an anatomo-radiologic and biomechanical study. Surgical and radiologic anatomy : SRA. 1996;18(4):281-8.
149. Rett M, Braga MD, Bernardes N, Andrade S. Prevalence of diastasis of the rectus abdominis muscles immediately postpartum: Comparison between primiparae and multiparae. Revista Brasileira de Fisioterapia. 2009;13:275-80.
150. Sevensma KE, Leavitt L, Pihl KD. Anatomy, Abdomen and Pelvis, Rectus Sheath: StatPearls Publishing, Treasure Island (FL); 2022 2022.
151. Wan Q, Lin C, Li X, Zeng W, Ma C. MRI assessment of paraspinal muscles in patients with acute and chronic unilateral low back pain. The British journal of radiology. 2015;88(1053):20140546.
152. Battié MC, Niemelainen R, Gibbons LE, Dhillon S. Is level- and side-specific multifidus asymmetry a marker for lumbar disc pathology? The spine journal : official journal of the North American Spine Society. 2012;12(10):932-9.
153. Herschorn S. Female pelvic floor anatomy: the pelvic floor, supporting structures, and pelvic organs. Reviews in urology. 2004;6 Suppl 5(Suppl 5):S2-s10.
154. DeLancey JOL. Structural support of the urethra as it relates to stress urinary incontinence: The hammock hypothesis. American Journal of Obstetrics and Gynecology. 1994;170(6):1713-23.
155. Stuge B, Saetre K, Braekken IH. The association between pelvic floor muscle function and pelvic girdle pain--a matched case control 3D ultrasound study. Man Ther. 2012;17(2):150-6.
156. Barbosa PB, Franco MM, Souza Fde O, Antônio FI, Montezuma T, Ferreira CH. Comparison between measurements obtained with three different perineometers. Clinics (Sao Paulo, Brazil). 2009;64(6):527-33.
157. Giallo R, Rose N, Vittorino R. Fatigue, wellbeing and parenting in mothers of infants and toddlers with sleep problems. Journal of Reproductive and Infant Psychology. 2011;29(3):236-49.
158. Gao LL, Chan SW, You L, Li X. Experiences of postpartum depression among first-time mothers in mainland China. J Adv Nurs. 2010;66(2):303-12.
159. Friedman S, Blomquist JL, Nugent JM, McDermott KC, Muñoz A, Handa VL. Pelvic muscle strength after childbirth. Obstet Gynecol. 2012;120(5):1021-8.