Documente Academic
Documente Profesional
Documente Cultură
September 2013
Supervisor: Dr Annette Haywood
Word Count: 14,388
Module Credit Value: 60
Abstract
Background
Pelvic Girdle Pain (PGP) is a musculoskeletal condition that affects 20% of pregnant women.
PGP can have a marked impact on a womans quality of life, sleep, functional activities and
absenteeism from work. Physiotherapists routinely treat PGP using a variety of approaches
which include advice, stability exercises, pelvic belts, stretches and manual therapy.
However, at Sheffield Teaching Hospitals, manual therapy techniques were not routinely
used as part of usual care for antenatal women with PGP, despite a body of literature to
support their use.
Methods
Using a mixed-methods design, 46 participants completed the Pelvic Girdle Questionnaire at
baseline and 6weeks after assessment; 24 women received usual care and 22 women
received a manual therapy treatment approach as an adjunct to usual care. Data were
analysed using descriptive and inferential statistics. Semi-structured interviews were
undertaken with 7 women who had received a manual therapy treatment approach and
thematic framework analysis was applied to the data.
Results
Although no significant differences were observed between the usual care and manual
therapy groups, a significant difference between the PGQ scores at baseline and 6 weeks was
observed in the manual therapy group. Qualitative analysis revealed five distinct themes;
living with PGP, practicalities of entering the physiotherapy system, patient expectation
pre-treatment, response to manual therapy and relationship with physiotherapist.
Conclusions
Clinically, these results may indicate that treatment with manual therapy will improve
womens outcomes. Although there is not enough evidence of a change in PGQ scores
between the two groups, there is a trend showing manual therapy could improving PGQ
2
scores more than usual care alone. Overall women reported reduced pain and improved
function after receiving a manual therapy treatment approach alongside usual care.
Acknowledgements
My sincere thanks go to my clinical supervisor, Dr Annette Haywood, who has provided truly
amazing support from the start of this dissertation. Her guidance, knowledge, enthusiasm and
words of encouragement have kept me focused and on target throughout, and I am grateful
for her incredibly quick response to questions. Annettes unfailing mentorship has enhanced
my work and experience of completing this MSc.
I wish to thank Dr Dawn Teare, who provided me with statistical advice and reassurance
during the quantitative results phase.
And finally to my friends and family: my good friends and mum, thank you for all the
support and childcare you have provided in times of need to allow me to meet deadlines. To
my husband Daniel, whose constant love and support has enabled me to complete a
challenging two years of study. And to Thomas, Sophie and Oliver, my children, who fully
accepted the times when I could not be there at weekends to play. Your frequent question of
how many more words have you got left? certainly encouraged me to keep writing.
Table of Contents:
Abstract ................................................................................................................................................... 2
Background ..................................................................................................................................... 2
Aims & Objectives .......................................................................................................................... 2
Methods........................................................................................................................................... 2
Results ............................................................................................................................................. 2
Conclusions ..................................................................................................................................... 2
Acknowledgements ................................................................................................................................. 4
Table of Contents: ................................................................................................................................... 5
Abbreviations .......................................................................................................................................... 9
Glossary ................................................................................................................................................ 10
Chapter 1: Introduction ......................................................................................................................... 11
1.1 Background ..................................................................................................................................... 11
Diagram 1: Basic anatomy of the pelvic girdle. ............................................................................ 11
1.2 Rationale ......................................................................................................................................... 12
1.3 Definitions....................................................................................................................................... 13
1.3a Definition of a manual therapy treatment approach .................................................................. 13
1.3b Definition of usual care ............................................................................................................. 14
Chapter 2: Literature Review ................................................................................................................ 15
2.1 Search Strategy ............................................................................................................................... 15
2.2 The effectiveness of manual therapy in PGP .................................................................................. 15
2.3 How does manual therapy work? Biomechanical and neurophysiological considerations............. 17
2.4 Which treatment approach? ............................................................................................................ 18
2.5 The value of qualitative data ........................................................................................................... 18
2.6 What is unique about this study? .................................................................................................... 19
2.7 Overall Aims of the project ............................................................................................................. 20
2.8 Research Questions with specific Aims and Objectives ................................................................. 20
2.8a Question 1 ................................................................................................................................. 20
Objectives ..................................................................................................................................... 20
2.8b Question 2 ................................................................................................................................. 20
Objectives ..................................................................................................................................... 20
Chapter 3: Methodology ....................................................................................................................... 21
3.1 Introduction ..................................................................................................................................... 21
3.2 Choice of Methods .......................................................................................................................... 21
3.3 Staff Training .................................................................................................................................. 22
3.4 Quantitative Methods ...................................................................................................................... 22
3.4a Sampling and Recruitment ........................................................................................................ 22
Table 1: Inclusion and exclusion criteria for quantitative recruitment ......................................... 23
3.4b Sample size ............................................................................................................................... 23
3.4c Procedure and Data Collection.................................................................................................. 23
3.4d Data Analysis ............................................................................................................................ 24
3.5 Qualitative Methods ........................................................................................................................ 24
3.5a Sampling and Recruitment ........................................................................................................ 24
Table 2: Inclusion/exclusion criteria for qualitative recruitment .................................................. 24
3.5b Sample size ............................................................................................................................... 24
3.5c Procedure and Data Collection.................................................................................................. 25
3.5d Data Analysis ............................................................................................................................ 25
3.5e Development of Interview Guide .............................................................................................. 26
3.6 Mixed methods data analysis .......................................................................................................... 26
3.7 Researcher Details .......................................................................................................................... 27
3.8 Reliability and Validity ................................................................................................................... 27
3.9 Ethical Considerations .................................................................................................................... 27
Chapter 4: Quantitative and Qualitative Results ................................................................................... 29
4.1 Introduction ..................................................................................................................................... 29
4.2 Quantitative Results ........................................................................................................................ 29
4.2a Participants ................................................................................................................................ 29
4.2b Setting ....................................................................................................................................... 29
4.2c Data Analysis ............................................................................................................................ 29
4.3 Descriptive Statistics ....................................................................................................................... 30
Graph 1: Trimesters, (in weeks) at assessment for the usual and manual groups ......................... 30
Graph 2: Variety in parity between the usual and manual group at assessment ........................... 31
Graph 3: A box and whisker plot for the summary statistics for the PGQ at baseline and at 6
weeks for both groups ................................................................................................................... 31
Table 3: Different variables for the interview subgroup against the usual care and manual therapy
groups............................................................................................................................................ 32
4.4 Inferential Statistics ........................................................................................................................ 32
Graph 4 shows a Q-Q plot for the full data set for PGQ scores at baseline .................................. 33
4.5 Qualitative Results .......................................................................................................................... 35
4.5a Participants ................................................................................................................................ 35
Table 4: Demographics and PGQ data from women interviewed ................................................ 35
4.5b Setting ....................................................................................................................................... 35
4.5c Data Analysis ............................................................................................................................ 35
Table 5 Summary of the themes and subthemes that emerged from data analysis ....................... 36
4.5.1 Theme 1: Living with Pelvic Girdle Pain .................................................................................... 37
4.5.1a Pain expectations during pregnancy ....................................................................................... 37
4.5.1b Pain levels before seeking help .............................................................................................. 37
4.5.1c Impact on daily life ................................................................................................................ 38
4.5.1d Views about recovery postpartum.......................................................................................... 38
4.5.2 Theme 2: Practicalities of entering the physiotherapy system ..................................................... 39
4.5.2a Referral process ...................................................................................................................... 39
4.5.2b Location of physiotherapy appointments ............................................................................... 40
4.5.3 Theme 3: Patient expectation pre-treatment ................................................................................ 40
4.5.3a Negative mind-set .................................................................................................................. 41
4.5.3b Hopeful treatment will help ................................................................................................... 41
4.5.3c Unsure expectations ............................................................................................................... 41
4.5.4 Theme 4: Response to the manual therapy treatment approach (plus usual care) ....................... 41
4.5.4a Initial response ....................................................................................................................... 41
4.5.4b Functional change .................................................................................................................. 42
4.5.4c Perception of alignment ......................................................................................................... 42
4.5.4d Exceeded expectations ........................................................................................................... 43
4.5.5 Theme 5: Relationship with Physiotherapist ............................................................................... 43
4.5.5a Trust in Physiotherapist .......................................................................................................... 43
4.5.5b Empathy from the Physiotherapist ......................................................................................... 44
4.5.5c Womans dignity respected .................................................................................................... 44
4.5.5d Recommendation of Physiotherapy ....................................................................................... 44
4.6 The emergence of unexpected data ................................................................................................. 45
Chapter 5: Discussion ......................................................................................................................... 46
5.1 Introduction ..................................................................................................................................... 46
5.2 Quantitative data discussion............................................................................................................ 46
5.3 Qualitative data discussion.............................................................................................................. 47
5.3a Living with Pelvic Girdle Pain .................................................................................................. 47
5.3b Practicalities of entering the physiotherapy system .................................................................. 48
Abbreviations
CI
Confidence Interval
GP
General Practitioners
HCP
MT
Manual therapy
PGP
PGQ
PT
Physiotherapist
RHH
ScHARR
SIJ
Sacro-iliac joint
STHFT (STH)
WH
Womens health
Glossary
Biomechanics = biomechanics is the science of movement of a living body, including how
muscles, bones, tendons and ligaments work together to produce movement.
Biopsychosocial approach = systematically considers biological, psychological, and social
factors and their complex interactions in understanding health, illness, and health care
delivery.
Gravidity = defined as the number of times that a woman has been pregnant
Hydrotherapy = water based exercises
Hypoalgesia = occurs when painful stimuli are interrupted or decreased somewhere along the
path between the input and the places where they are processed and recognized as pain in the
conscious mind. Therefore pain can be reduced due to the hypoalgesic effect of manual
therapy
Manual therapy approach = techniques include mobilisations, manipulation, muscle energy
techniques and stretches
Mobilisation = is a manual therapy intervention, is classified by five 'grades' of motion, each
of which describes the range of motion of the target joint during the procedure. Mobilisations
are believed to produce selective activation of different mechanoreceptors in the joint. Joint
mobilisation is primarily indicated for reversible joint hypomobility.
Musculoskeletal = refers to muscles, tendons, ligaments, bones and joints and associated
tissues that move the body and maintain its form
Neurophysiological = of or concerned with neurophysiology which is defined as the branch
of physiology that deals with the functions of the nervous system.
Neuromuscular = pertaining to or affecting both nerves and muscles.
Parity = defined as the number of times that a woman has given birth to a foetus with a
gestational age of 24 weeks or more, regardless of whether the child was born alive or was
stillborn.
Sacro-iliac joint dysfunction = a failure of load transfer through the sacro-iliac joints
Trimester = pregnancy is split into 3 periods: 1st trimester = weeks 4-12, 2nd trimester =
weeks13-28, 3rd trimester = weeks 29-42
Usual care = At Sheffield Teaching Hospitals, the physiotherapist currently treat pelvic
girdle pain with advice, education, stability exercises, stretches, pelvic belts and elbow
crutches.
10
Chapter 1: Introduction
1.1 Background
Pelvic Girdle Pain (PGP) is a musculoskeletal condition which can affect two sub-groups of
the population; non-pregnant patients and those with pregnancy-related PGP.1 This research
will focus on the latter. PGP was redefined in 2008 in the European Guidelines1 as pain that
can occur between the level of the posterior iliac crests and the gluteal folds, commonly
within close proximity to the sacroiliac joints (SIJ). The pain may refer to the posterior aspect
of the thigh and may be felt in the symphysis pubis alongside or independently from the other
common sites of pain.1 Diagram 1 below illustrates the anatomy of the pelvic girdle, with the
common sites of pain highlighted in red.
The point prevalence of women affected by PGP during pregnancy is approximately 20%1
and research suggests that whilst most women spontaneously recover quickly post-delivery,
pain can persist in 7% of cases for more than two years postpartum.2 PGP can have a marked
impact on a womens quality of life,3 affecting sleep,4 functional activities such as climbing
stairs, walking, climbing stairs and turning over in bed57 and can cause absenteeism from
work due to pain.8 In Scandinavian countries, it has been shown that on average, seven weeks
of sick leave are taken during the perinatal period due to pregnancy related back pain.8 Using
the latest figures from the Chartered Institute of Personnel and Developments Absence
Management Report, the average annual cost of employee absence per employee is 600.9 In
Sheffield, PGP-related sick leave could cost the local economy 80,760 per year. This is a
11
crude estimate based on Sheffield Teaching Hospitals (STH) seeing 1000 women per year
with PGP.10
PGPs aetiology is still unclear and likely to be multi-factorial, with research indicating that
altered biomechanics and neuromuscular control, hormonal changes and the weight of the
foetus all contribute to its onset.1,11 The risk factors known to be associated with the
development of PGP include trauma to the pelvis and a previous history of low back pain.1
Risk factors associated with PGP continuing in the postpartum period are; prolonged labour,7
a high proportion of pain provocation tests being positive12 and high severity of PGP during
pregnancy.13 Women during their third trimester of pregnancy who experienced high pain
ratings (related to PGP) have an increased incidence; of assisted delivery, caesarean section
and a longer and more painful time during labour.14 Despite the negative impact PGP has on
the womans experience and quality of life during pregnancy and postpartum period,3,5,15 it is
still thought of as a self-limiting, transient problem by health-care professionals (HCPs).
Women are led to believe that their symptoms are normal aches and pains of pregnancy.6
Current evidence relating to the treatment of antenatal PGP support the use of hydrotherapy,16
individualised physical therapy with a focus on exercises,8,13 specific stabilising exercises,17
acupuncture,18 and providing adequate information.1The use of pelvic belts and joint
mobilisations or manipulations can be used to see if they provide symptomatic relief, only for
a few sessions and not as a single treatment for PGP.1,1921
1.2 Rationale
In Sheffield there are 7000 births a year. During 2012-13, approximately 1000 referrals were
made to Womens Health (WH) Physiotherapy Outpatients for PGP.10 Currently in STH,
physiotherapists treat antenatal women who present with PGP with advice, education,
exercises, stretches, pelvic belts and elbow crutches. However, the WH service does not
routinely assess and treat using a physiotherapy manual therapy treatment approach, with
specific joint mobilisation techniques. There are however, a few studies which support the
use of manual therapy for PGP.19,20 In addition, there is anecdotal and research evidence
within the physiotherapy profession that manual therapy can address the joint dysfunction,
alleviate pain, and therefore improve womens functional ability.2225
12
A combination of several factors prompted the researcher to explore the area in greater depth:
Firstly, there is paucity in the literature regarding the effectiveness of a manual therapy
treatment approach for PGP. Also there is a lack of qualitative evidence from patients with
PGP relating to their experience of manual therapy treatments. Finally, due to the
researchers professional background of using manual therapy techniques to treat
musculoskeletal conditions, this prompted questions as to how PGP was treated antenatally. It
is envisaged the results from this project may support the use of a manual therapy treatment
approach as an adjunct to usual care. This may lead to improvements in the outcome and
experience of physiotherapy for these women who have to cope with PGP during and after
their pregnancy.
1.3 Definitions
1.3a Definition of a manual therapy treatment approach
Sacroiliac joint (SIJ) dysfunction can be described as a failure of load transfer through the
SIJ.30 The SIJ can be assessed for its level of function/dysfunction by performing a thorough
clinical examination in which combinations of tests are applied to the SIJ. When a joint is
assessed as hypomobile (stiff), different mobilisation techniques can be used to restore
normal joint mobility and alignment. These hands-on techniques include mobilisations,
muscle energy techniques, manipulation and stretches.26 A manual therapy treatment
approach will only be used when a full individual assessment has been performed on every
woman by the physiotherapist, and judged to be an appropriate treatment. The participants
13
who received a manual therapy treatment approach plus usual care have been referred to as
the manual therapy group.
14
that looked at mobilisation or manipulation as a way to treat PGP, but the studies were
excluded in the final results and analysis. This was due to a lack of a control group and small
15
sample sizes. A decade has passed and there is still no randomised controlled trial (RCT) that
has emerged for PGP, evaluating the effectiveness of mobilisations as an adjunct to
physiotherapy treatment. However, in 2012 a RCT was published,23 comparing chiropractic
specialists providing manual therapy, stabilisation exercises and patient education versus
standard obstetric care. The results showed a significant reduction in pain and improvement
in the quality of daily activities in favour of the multi-modal treatment approach. Although
this study did not have a placebo control group and treatment effects could not be attributed
to each of the specific treatments, it does reflect a pragmatic, real life situation when treating
pregnant women with PGP. Rarely in clinical practice would women be treated with only one
approach,44 and so the results from this study are encouraging to physiotherapists who use
manual therapy as an adjunct to usual care. The outcome from this study provided further
justification for this research.
The lack of literature regarding effectiveness of manual therapy as an intervention for PGP in
pregnancy led the researcher to review the literature relating to back pain in the non-pregnant
population. Four reviews of the efficacy of manual therapy in the treatment of chronic
musculoskeletal pain4447 concluded that there is some strong evidence supporting
manipulations, mobilisations, muscle energy techniques and spinal stabilisation for treating
chronic low back pain. Three case reviews conducted in 200324 demonstrated that a combined
treatment approach integrating manual therapy with specific exercises and patient education
was effective in reducing pain and improving function in patients with pelvic girdle
dysfunction. Criticisms are applicable to the majority of the articles in this literature review;
the heterogeneity of the studies, small sample sizes, diversity of interventions and
methodological flaws in study design, prevent finding statistically significant results. The
conclusions of many research papers summarise with inconclusive evidence of the efficacy
or effectiveness of manual therapy in PGP.
16
with motherhood, relationships with partners and work.38 Other studies corroborate these
findings5 and Mogren3 found women had a less favourable perceived health status when PGP
persisted postpartum.3 Considering what is known about PGP in the literature, women are
still often led to believe that PGP should be accepted as normal aches and pain of
pregnancy.6
Establishing benefits of treatment only using quantitative data can be misleading. Results
from a RCT found only small to moderate benefits from adding manual therapy to general
practice care.57 However, subsequent qualitative analysis demonstrated clearer differences
between the groups than when compared with the quantitative analysis. This suggests that
patient satisfaction with treatment might not be reflected in the outcomes measured through
validated outcome questionnaires. For this reason, the researcher used a mixed methods
approach; examining the treatment of PGP from both a self-reported outcome measure and
patient experience, will lead to positive changes in the service for the patient.
Whilst waiting for higher standards of clinical research to emerge, physiotherapists rely on
thorough examination, sound clinical reasoning, theoretical knowledge and the patients
history to treat PGP in pregnancy. This gap in the research knowledge prompted the
researcher to look at her own practice as a physiotherapist and develop a pragmatic piece of
research which would look to develop the service locally and contribute to the wider
knowledge base regarding the use of a manual therapy approach as an adjunct to usual care
when treating PGP.
19
Objectives
To identify appropriate patient case notes, in order to evaluate the PGQ for both
usual care and manual therapy treatment approach plus usual care patients.
2.8b Question 2
What are womens experiences of a manual therapy treatment approach when treated for PGP
by the Womens Health Physiotherapy team?
Objectives
To identify and recruit women who have received a manual therapy treatment
approach for PGP by the WH Physiotherapy team.
Chapter 3: Methodology
3.1 Introduction
To answer the research question fully, a pragmatic approach was used to complement a
mixed methods design. This approach allowed the researcher to be led by current service
needs, with the research being driven from a practical perspective rather than a fixed
ontological or epistemological position.59,60 Feilzer61 suggested that pragmatism can combine
different paradigms and a question(s) can be examined using the most appropriate methods.61
Mixed methods research integrates elements of quantitative and qualitative research
approaches and data produced should be mutually illuminating.62,63
A non-experimental, concurrent triangulation approach within a mixed method design was
used.64 This approach is characterised by the collection of quantitative and qualitative data
concurrently, yet independently, and results are then merged. Triangulation refers to
combining and comparing the findings from different sources of data to ascertain if they
substantiate the other.62,63 The advantage of this approach is that it utilises the strengths of
each quantitative and qualitative method64,65 and data is blended in the discussion ascertain if
the results differ or converge.64 It also has a shorter data collection phase (compared with
sequential approaches), which suited the researchers timeframes.
Mixed methods designs have specific advantages over the single approach designs;62,63
stronger inferences can be made by the results and both confirmatory and exploratory
questions can be addressed together.60,63 Research by OCathain60 concluded that mixed
methods studies were more comprehensive, which was cited by researchers as the main
justification for using multiple methods.60 Criticisms exist for the mixed methods approach
for two main reasons; the discrepancy between the paradigms intrinsic to quantitative and
qualitative methods59,63 and the ontological and epistemological stance of each method.62
22
Exclusion Criteria
English speaking
Non-English speaking
23
Exclusion
English speaking
Non-English speaking
26
findings.71 Therefore, quantitative and qualitative data were synthesised to allow for potential
connections and further interpretation.59
27
participant chose for the interview to take place at their home, the researcher was guided by
STHs Lone Working Policy.
Research has highlighted that PGP can negatively affect the womens quality of life during
pregnancy and their ability to cope with motherhood.4 After the interview, if the researcher
felt the participant required additional support from other HCPs, with the participants
consent, an appropriate referral would be made.
Anonymity was ensured as participants names were not recorded against the data collected
from the PGQs. The data would be assigned a number which could not link to participants in
any way. The interviews were tape recorded and transcribed verbatim. Pseudonyms were
given to the participants in order to analyse and discuss the results effectively. The
participants responses remained anonymous to the physiotherapy team. Physiotherapists
were also be given pseudonyms if they were mentioned in the interview.
All data was locked in a filing cabinet and the laptop holding the data was password
protected. The tape recordings will be disposed of appropriately when the dissertation has
been awarded a pass by the University.
Finally, the study was granted approval by the Clinical Effectiveness Unit at STH (see
appendix 5) and ethical approval was gained from the University of Sheffields School of
Health and Related Research (ScHARR) (see appendix 6).
28
4.2a Participants
A non-random, purposive sample of data was collected in the form of PGQs from two groups
of women; 26 who received usual care and 22 who received a manual therapy treatment
approach plus usual care. The PGQ was measured at initial assessment which gave a baseline
score (%) and after 6 weeks, for each participant, which totalled 96 outcome measures. Four
PGQ results from 2 women were excluded in the usual group. This was due to one woman
having a urinary tract infection, which was treated with antibiotics and cleared the pain and
the second womans baby changed position which totally relieved her pain.
4.2b Setting
The baseline data was collected at the patients initial assessment with the physiotherapist
and the 6 week follow up PGQs were completed by the researcher.
29
Graph 1: Trimesters, (in weeks) at assessment for the usual and manual
groups
30
Measures of central tendency were computed to summarise the data for the PGQ at baseline
and PGQ at 6 weeks, in the usual and manual therapy groups. Measures of dispersion were
used to understand the variability of scores for the PGQ data. The summary statistics are
presented in the box and whisker plot that follows (see Graph 3).
Graph 3: A box and whisker plot for the summary statistics for the PGQ at
baseline and at 6 weeks for both groups
31
It appears the PGQ mean scores in both groups are similar at baseline. Based on the large
standard deviation, it appears that the PGQ scores are spread at baseline and 6 weeks in both
groups. The box and whisker plot shows that women in the manual therapy group started with
a higher minimum and maximum PGQ score compared with the usual care group, indicating
an increased level of pain and functional restrictions. However at 6 weeks, the PGQ score has
the lowest minimum and maximum values in the manual therapy group compared to the usual
care group.
A sub-group analysis looked at the seven women who were interviewed in the qualitative arm
of this study to see if there were any comparisons or differences between these women and
the overall sample. Table 3 presents the key variables of interest.
Table 3: Different variables for the interview subgroup against the usual
care and manual therapy groups
Variable
Age (years)
Gestation at
assessment (weeks)
Trimester (average)
Parity (average)
PGP Baseline (%)
PGP 6 weeks (%)
Number of physio
appointments
Interview Group
(n=7)
32.5
27
Manual therapy
Group (n=22)
31
25
2.43
1
67.4
51
2.14
2.54
0.83
53
52.6
0
2.18
1.3
57
47.3
1.82
These results indicate that the seven women interviewed were of similar ages, gestation,
parity and trimester to the other groups. Interestingly these women had a higher PGQ score at
baseline and had slightly more physiotherapy appointments compared to the manual therapy
group (2.14 vs. 1.82); however the protocol stated that the participant information sheet could
only be given out to women on their second physiotherapy appointment.
Graph 4 shows a Q-Q plot for the full data set for PGQ scores at baseline
A paired samples t test was conducted to compare the PGQ scores at baseline and 6 weeks
in the usual care group revealing no significant difference (t(23)= 0.097, p= 0.923, 95% CI 7.94, 8.72), between the PGQ scores at baseline (M=52.96, SD=18.22) and 6 weeks
(M=52.63, SD=23.47) in the usual care group. These results suggest that usual care does not
have an effect on the PGQ score when compared at baseline and 6 weeks. Clinically, it may
indicate that treatment with usual care will not improve the womens outcomes.
A paired samples t test was then conducted to compare the PGQ scores at baseline and 6
weeks in the manual therapy group. There was a significant difference (t(21) = 2.18, p=
0.041, 95% CI 0.43, 18.85), between the PGQ scores at baseline (M=56.91, SD=20.09) and 6
weeks (M=47.27, SD=22.44) in the usual care group. These results suggest that manual
therapy does have a positive effect on the PGQ score when compared at baseline and 6
weeks. The estimated effect size is 9.64 (mean difference), but this is an imprecise estimate
due to a wide confidence interval. Clinically, it may indicate that treatment with manual
therapy will improve the womens outcomes.
An independent-samples t-test was conducted to compare the PGQ baseline scores for the
usual and manual groups. There was not a significant difference (t(44)= -0.699, p= 0.49, 95%
CI -7.43, 15.34), in the PGQ baseline scores for usual care group (M=52.96, SD=18.22) and
manual therapy group (M=56.91, SD=20.09). These results suggest that the PGQ scores were
33
similar in both groups at baseline; therefore clinically the women started physiotherapy with
a similar level of pain and functional problems.
The research question sought to investigate if PGQ scores could be improved using a manual
therapy treatment approach in conjunction with usual care, compared with usual care alone.
An independent samples t-test was conducted to compare the change in PGQ scores (6weeksbaseline) for the usual and manual groups. There was no significant difference (t(44)= 1.49,
p=0.143, 95% CI -3.15, 20.91), in the mean change in PGQ score in the manual therapy
group (M=9.22, SD=20.56) and usual care group (M=0.33, SD=19.88). Using the 95%
confidence interval, we are 95% confident that the true population mean difference in PGQ
score between manual therapy and usual care lies somewhere between -3.15 to 20.91%, but
our best estimate of the mean difference is 8.89%. However, the CI of the difference is
unbalanced around zero, with only 3.15 below and 20.91 above. This could indicate that
although there is not enough evidence of a change in PGQ scores between the two groups,
there is a trend towards showing that manual therapy could improve the PGQ scores more
than usual care alone. The clinically minimum important difference is currently unknown as
it is a new outcome measure and once published, will assist in making a judgement towards
the clinical relevance of these results.
Finally a one-sampled t-test was conducted on data from the seven women who were
interviewed to compare their change in scores having all received a manual therapy treatment
approach as an adjunct to usual care. There was a significant difference (t(6)= 2.78, p=0.032,
95% CI 2.88, 45.11) in the change in PGQ score (M=24, SD=22.83). Referring back to the
baseline characteristics of these women (age, gestation, trimester, parity, and baseline PGQ
scores), there was very little variation between the groups. This would indicate that the
manual therapy had a significant effect on their PGQ outcomes even after 1-2 treatment
sessions, which is now explored using the qualitative data from the semi-structured
interviews.
34
4.5a Participants
Seven women were recruited to the study between June and August 2013. A further 3 women
were contacted, but did not respond. A decision was made not to pursue these women
because they were close to their delivery date, and it would have been inappropriate to
continue with potential recruitment. Nine women from the manual therapy group had only
had one session of physiotherapy, and although it included manual therapy, did not meet the
inclusion criteria of 2 sessions of physiotherapy before recruitment. Finally, due to the
limited time frame for the study, August was the cut off point for further recruitment to
ensure there was adequate time for the researcher to analyse the data. Demographics and
PGQ data from the seven women recruited are shown in table 4.
Age
(years)
Gestation at
assessment
(weeks/40)
Gravidity Parity
Number of
treatment
sessions
Anna1
Beth
Cara
Daisy
29
30
31
37
22/40
27/40
32/40
28/40
2
2
1
3
1
1
0
2
Emily
Frances
Grace
24
38
39
30/40
29/40
26/40
1
3
1
0
2
0
2
3
2
2 with
treatment
continuing
2
2
2
PGQ
score
(%) at
baseline
88
96
31
71
PGQ
score
(%) at 6
weeks
59
36
18
80
52
80
54
62
65
37
4.5b Setting
One woman chose to be interviewed in the physiotherapy department before her appointment
and the remaining six chose to be interviewed at their own home, around Sheffield.
35
arising from the last interview. A particular topic area was classed as a theme if more than
one woman raised the topic area, thus preventing idiosyncratic themes developing. Appendix
8a and 8b demonstrates an audit trail of how the data was initially coded, with themes
beginning to emerge. These themes were initially descriptive and then became refined until
five overarching themes were identified with a various number of subthemes in each category
(see table 5).
Table 5 Summary of the themes and subthemes that emerged from data
analysis
Theme
1) Living with Pelvic Girdle Pain
Subtheme
a) Pain expectations during pregnancy
b) Pain levels before seeking help
c) Impact on daily life
d) Views about recovery postpartum
a) Referral process
b) Location of physiotherapy appointments
3) Patient Expectation
Pre-treatment
a) Negative mind-set
b) Hopeful treatment will help
c) Unsure expectations
a) Initial response
b) Functional change
c) Perception of alignment
d) Exceeded expectation
5) Relationship with
Physiotherapist
a) Trust in physiotherapist
b) Empathy from the physiotherapist
c) Womans dignity respected
d) Recommendation of physiotherapy
The results will now be presented under these themes, utilising quotations from the women.
Appendix 9 shows how the data from individual women were charted to allow comparisons
across cases.
36
38
39
My midwife referred meI got straight inrang up next day and got an
appointment within a few days, cant say better than that! Frances
40
Sore for a couple of days then after that its been perfecttotally solved the problem
there and then, it was amazing Grace
Secondly, the time it took to respond post treatment varied between women. Grace described
the treatment as a miracle as she responded immediately to manual therapy, while others
noticed it was over the coming days that they noticed improvements.
The day after (treatment) I didnt need the crutches, I could walktheres a
difference, a big difference Beth
Thirdly, some women reported their pain disappeared post manual therapy treatment; while
others reported reduced pain, both which closely link to the functional improvements seen in
the next subtheme.
Suddenly it was as if I got this instant relief Anna (one day after treatment)
Obviously I werent cured but I could do a lot more than I could when I went
indefinitely not as severe as before Frances
Tender for that day then eased for about a week Emily
43
44
45
Chapter 5: Discussion
5.1 Introduction
This chapter discussed the results of this mixed methods study, in order to answer the
research questions, whilst drawing upon current literature to inform the discussion. A
concurrent triangulation strategy was used, whereby the qualitative results informed the
quantitative results.64 Interpreting data produced by analysing inductively and deductively
and then brought together, allowed a multidimensional perspective which enhanced the
ability to answer the research questions.61
46
CI suggests that change in the means between the two groups was heading in a favourable
direction and further research with a larger sample size might detect a change. Another factor
to consider was that all women were six weeks more advanced in their pregnancy and the
physical implication of the size of their pregnant bump could have an impact on outcomes.
Previous clinical trials have shown manual therapy (mobilisation/manipulation) to be
effective for chronic, sub-acute and acute low back pain in adults, excluding the pregnant
population.46 However, randomised controlled trials (RCTs) can be too protocol driven and
not reproducible in the clinical setting. Results from RCTs do not always support the results
seen in clinical practice.46 This may be explained by evidence that supports non-specific or
therapeutic treatment effects which can occur as a result of clinician/patient interactions,46
which are non-measurable, yet can contribute to effectiveness of a treatment. An advantage
of this study was that a pragmatic mixed methods design was used, aiming for outcomes to be
evaluated in normal clinical conditions. The quantitative results indicate that a manual
therapy treatment approach used in conjunction with usual care has a positive effect on
womens pain and function.
47
function and this can have a significant impact on womens daily lives. This finding is
commonly echoed in the literature.5,15,38,40
There was belief among some women in this study that pain during pregnancy was seen as
expected by HCP and women accepted that they should live with it. This finding was
supported by a study where women reported having to endure pain in everyday life,
questioning at which point was it acceptable to seek help.40 In another study39 women felt
midwives could be dismissive of their symptoms and GPs told women that pain was normal
and they should put up with it until after delivery. Women in this current study described
how it was at times, impossible to complete tasks at home, such as taking children to school
and the shopping. Reliance on partners or extended family had also increased. This reliance is
mirrored by women in other research findings.5,15,38 Two existing studies confirmed the
findings that women were often misdiagnosed/mislabelled.5,40 Women in this study were told
by HCPs that they had a urinary tract infection or baby was lying on a nerve and this
misdiagnosis led to a delayed referral to the physiotherapists.
Women interviewed were hopeful that recovery postpartum would be spontaneous and their
pain would disappear once the baby was born. These findings are supported by Perssons
study who reported women expected the pain to vanish instantly and life would go back to
normal.15 Although epidemiological studies have reported 93% of women recover within
three months postpartum,2 7% of women with serious PGP postpartum can have pain for up
to 2 years and beyond.12 Women who do not recover by six months postpartum are unlikely
to improve further.13 This highlights the importance of treating these women early to prevent
chronic PGP postpartum developing.
suggest they can spend a significant amount of time dealing with frustrated and emotionally
fragile women with PGP who are not coping with their pain. Physiotherapy appointments
have to be reorganised to fit urgent patients into the system, whist the physiotherapists have
to provide advice and support the woman over the telephone. The amount of time women
waited for appointment provoked strong reactions, often feeling frustrated that they ought to
have been seen sooner. This reflects the work of Wellock and Crichton who noted that
women did not get an appointment when they felt it was needed the most.39 However, some
women reported a very quick referral process and were satisfied, which show inconsistencies
in the referral process which need to be addressed.
The following sequence of events in the referral process, as reported by the women in this
study, could potentially have a negative effect on birth outcomes; firstly the womans delayed
presentation to her GP/midwife, followed by the wait for the health care professional to make
the referral, followed by the time it takes to see a physiotherapist could potentially increase
the womens pain. Recent research concluded that women who, during their third trimester of
pregnancy experienced high pain ratings, had an increased incidence of assisted delivery,
caesarean section and a longer and more painful time during labour.14 The possible
explanation for this relate to physiological, mechanical and psychological reasons, which are
outside the scope of this discussion and are explained fully in Brown et al paper.14 This
association between increased pain and complications during labour make it even more
pertinent to identify and actively treat women with PGP in a timely manner to reduce their
pain antenatally, thus optimising their birth experience. Therefore a more efficient system of
referring these women into physiotherapy has benefits for both the woman and the clinicians
who care for them throughout the perinatal phase. If the womens pain level is managed well
in the antenatal period, and medical complications/interventions are reduced, this could
potentially lead to financial savings within the clinical directorate of obstetrics and
gynaecology. Research has also linked high pain scores during pregnancy with pain
persisting postpartum12 and so effective antenatal treatment could reduce the risk of these
women developing a chronic condition.
49
were a less frequently reported dimension of satisfaction.74 The systematic review found that
patients had lower expectations but higher satisfaction when presenting with an acute
condition, compared to a chronic condition.74 This results is highlighted and discussed further
in 5.2d, regarding response to manual.
Another study reported that women with PGP had not had their expectations met regarding
experience of care.39 This current study had contrasting findings; women emphasised how
their response to manual therapy their initial expectations. This could possibly be explained
by the results of a study by Bishop et al,75 who found that patients with low back pain,
expected active treatment interventions (such as exercise and manual therapy), to be more
effective than passive treatment interventions. Although this was with participants in the nonpregnant population, there is no reason why this explanation could not be applied to pregnant
women with PGP. Also, as previously discussed, women are often on the edge of being able
to cope with their pain and so any improvement, no matter how small, may translate to a
large functional improvement and improved ability to cope.
50
Surprisingly, all seven women had strong perceptions regarding re-alignment of their pelvic
joints. It is unsure if this is the belief held by the woman or passed on by the physiotherapist.
Although it is important for physiotherapist to explain the likely mechanism of
physiotherapy, it is also detrimental to the patient to use clinical labels which potentially
elevate anxiety levels.56 Terms such as slipped or dropped may have increased the
womans passive dependence on the physiotherapist to fix them and unhelpfully reinforced
negative behaviours such as fear avoidance.56 Clinical distortions seen within the pelvis are
thought to be due to muscular activity, causing functional impairments rather than anatomical
changes.56 Perhaps physiotherapists should use descriptors such as uneven/asymmetrical
movement when comparing left to right sides of the pelvis for positional faults. The manual
therapy treatment approach was delivered alongside usual care, which highlights the
importance of using multiple approaches to treat PGP. Initially, women may need manual
therapy to ensure positional faults are rectified, alongside active rehabilitation to address
motor control deficits, within a bio-psychosocial framework.56
care were interviewed, and not women who received usual care only, who may have
recommended the usual care only. Overall, there is evidence to support that if patients are
satisfied they are likely to comply with treatment and their quality of life will be higher.74
fail to show difference over time despite patients being highly satisfaction with treatment.57
Alternatively, the PGQ outcome measure could have been used alongside a wellbeing
questionnaire in order to detect subtle, yet important changes in quality of life.
The parallel mixed data analysis and interpretation have allowed the quantitative and
qualitative results talk to each other page 26663 which has demonstrated that the results
converged. The qualitative data from this study has facilitated the interpretation of the
quantitative data to provide a greater understanding of womens experiences of a manual
therapy treatment approach, alongside usual care.
5.5 Limitations
Recruitment for the interviews did not reach the desired 8-10 participants, but seven semistructured interviews were completed. There is on-going debate in the literature regarding
how many interviews is enough.68 The data from this study indicated that after the seventh
interview, no new themes were emerging. However, this would have been confirmed if
another interview could have been completed. Due to time limitations of the study, no further
recruitment was possible. In a study by Persson,15 who interviewed women regarding their
experiences of living with PGP, they found that after 8 interviews no significant new
information was collected. This increased the researchers confidence that data saturation had
been achieved.
The recommended target of 50 women in each group for the PGQ was not achieved for
several reasons: at the time of data collection annual leave, junior rotations and staff changes
all affected the stability of the womens health team and the time available to collect data.
Therefore it was the researchers responsibility to collect the 46 PGQ, within which there was
a three month time frame due to the constraints of completing the Masters.
Potential bias exists within this study. Firstly, selection bias could have impacted on the
qualitative results. The women who agreed to be interviewed may have been the patients who
responded well to a manual therapy treatment approach. However, when the baseline
characteristics were compared, no major discrepancies existed. The researchers own views
as a physiotherapist could have affected the results, however this potential bias was
minimised through several discussions with the academic supervisor to validate the themes
53
emerging from the data. Finally, women who were interviewed knew the researcher was a
physiotherapist and the researcher is aware of how positionality can affect results. This could
have made the women feel they needed to over emphasise the success of the manual therapy
treatment. The researcher was aware of this and kept to the interview guide and every attempt
was made to remain neutral. The advantage of being a physiotherapist is that women
intrinsically felt open about discussing their story, which could have added to the quality of
the data.
54
Chapter 6: Conclusion
6.1 Summary of key points
This mixed methods study combined PGQ data and data from semi-structured interviews to
ascertain if; a manual therapy treatment approach used as an adjunct to usual care could
improve the PGQ score when compared to usual care alone and establish womens
experiences of being treated by this approach. There is evidence to support that a manual
therapy treatment approach, when used in conjunction with usual care has a positive effect on
womens pain and function between baseline and 6 week follow up. Although there is
insufficient evidence of a change in PGQ scores between the two groups, there is a trend
towards showing that manual therapy could improve the PGQ scores more than usual care
alone. A larger sample size may confirm this trend.
This study showed how PGP can impact on many aspects of a womens daily life which is
supported in the literature.14,38,39,39,40 The findings highlighted women had a mixed
experience of entering the physiotherapy system and mixed expectations pre-treatment.
Women reported a very positive experience of receiving a manual therapy treatment approach
and valued the relationship with the physiotherapist. There is increasing acknowledgement
from within the physiotherapy profession that research into the patients view of the service
should be undertaken( page 244 line 2)77 in order to ascertain patient satisfaction. Increased
knowledge regarding the experiences of a patient has two benefits. Firstly it could contribute
to improving the quality of care and provide a greater understanding of recovery.78
Improvements in the way women with PGP are treated from the start of the referral process
are needed to improve their experience and ultimately quality of life.15
The qualitative data indicated that the referral process needs to be reviewed in order to make
the process consistent and equitable for all women in Sheffield with PGP. Diagnosis from
GPs and midwives needs to be made early, with prompt referral into physiotherapy. This
55
may involve educating/updating health care professionals about PGP and updating the
physiotherapy referral criteria.
A review of the information that a woman receives at their first midwife appointment or 12
week antenatal appointment may support including an information booklet on PGP. This
would provide women with valuable information that would allow early self-management
and prevent them reaching a feeling of desperation to get seen by a physiotherapist. An
information sheet could be made available on STH/Jessop website regarding PGP to allow
open access for all women.
Self-referral into physiotherapy may allow women to feel in control of their pain and decide
when they need treatment by a physiotherapist. Erroneously self-referral has an unhelpful
perception that it will increase demand for physiotherapy services beyond current capacities.
Research by the Department of Health has shown self-referral does not lead to increased long
term demand.80
Development of a care pathway for women with PGP could be devised collaboratively
involving the health care professionals who treat these women during their journey through
pregnancy.
56
treatment approach plus usual care has on work attendance/sick leave, when compared to
usual care alone.
Further qualitative interviews, could be completed with women who have received usual care
only, and compare the finding to the experience women had with a manual therapy treatment
approach.
57
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63
Appendices
Appendix 1: Pelvic Girdle Questionnaire
Pelvic Girdle Questionnaire
First Assessment
To what extent do you find it problematic to carry out the activities listed below because of
pelvic girdle pain? For each activity tick the box that best describes how you are TODAY
How problematic is it for you
because of your pelvic girdle pain to:
Not at all
(0)
To a small
extent
(1)
To some
extent
(2)
To a large
extent
(3)
1. Dress yourself
2. Stand for less than 10 minutes
3. Stand for more than 60 minutes
4. Bend down
5. Sit for less than 10 minutes
6. Sit for more than 60 minutes
7. Walk for less than 10 minutes
8. Walk for more than 60 minutes
9. Climb stairs
10. Do housework
11. Carry light objects
12. Carry heavy objects
13. Get up/sit down
14. Push a shopping cart
15. Run
16. Carry out sporting activities*
17. Lie down
18. Roll over in bed
19. Have a normal sex life*
20. Push something with one foot
* If not applicable, mark box to the right.
[
T
y[
pT
ey
None (0)
Some (1)
Moderate (2)
Not at all
(0)
To a small
extent
(1)
To some
extent
(2)
Considerable (3)
p
ae
qa
u
To a large extent o
q
(3)
tu
eo
t
fe
r
of
m
r
64 o
tm
h
et
65
66
67
Dr Annette Haywood
CLAHRC SY Health Inequalities Theme Project Manager/Research Coordinator
University of Sheffield
School of Health and Related Research
Room 1.09b
The Innovation Centre
217 Portobello
Sheffield
S1 4DP
Email: a.haywood@sheffield.ac.uk
Tel: 0114 222 0802
68
CONSENT FORM
Participant Identification Number for this project:
.................
Name of Participant
................
Name of person taking consent
Date
..
Date
Signature
..
Signature
69
Interview Guide
The following topic guide and possible questions will be discussed in a semi-structured
interview. If a response from the participant leads into a different topic, the researcher will try
to remain fluid in the interview, with the aim of achieving a conversation with a purpose
based around the interview guide.
The research question is: What are womens experiences of a manual therapy treatment
approach when treated for Pelvic Girdle Pain (PGP) by the Womens Health Physiotherapy
team?
Introduction
I will introduce myself and thank the participant for agreeing to be interviewed as part of a
project . I will explain the purpose of the interview is to find out about their personal
experience of the treatment they received for pelvic girdle pain from the Womens Health
Physiotherapy service. I will confirm that the interview will be a maximum of 45 minutes and
they can stop the interview at any stage or choose not to answer a question. I will ask the
participant to sign the consent form at this stage. I will remind them that the interview will be
tape recorded.
Pre-Interview Conversation/Ice-breakers
How many weeks pregnant are you? Is this your first pregnancy? Are you keeping well
during this pregnancy (apart from the PGP).
Referral Pathway
Q How did you get to be seen by a Physiotherapist?
[Prompt: Patient pathway, did a midwife or GP refer or did the patient self-refer. How long
did they wait?]
Patient Expectations
Q Once referred to physiotherapy, what did you expect the Physiotherapists could do for
you?
70
Q Do you have any thoughts as to how quickly you will recover from PGP after the baby
arrives?
[Prompt: Did the participant know PGP could be treated or thought they would they have to
live with it, were they expecting any specific type of treatment? Expecting immediate
symptom relief?]
Contact with the Physiotherapist
Q Describe what happened the first time you saw the physiotherapist.
Prompt:
How did you feel after the first assessment?
Did you feel the physiotherapist answered your questions?
Were your expectations met?
What treatment(s)/exercises were you given?
Did the physiotherapist discuss the treatment options with you?
Did you get a choice of how you wanted to be treated?
Are you aware of any other treatments that you would have liked to have been offered?
Were you seen again? If not, was that your choice?
Treatment Explored
Q How did you feel about having hands on treatment?
Prompt: Was your dignity respected? Did you feel embarrassed at any stage? Was there an
immediate improvement in pain or function?
Environment
Q Do you have any thoughts to the location of your treatment? (i.e at RHH)
Prompt: Privacy? Any other suggestions as to where you would like to be treated?]
Summary
Q What was particularly good about the Physiotherapy treatment?
Q What could have been done better at any point in your treatment?
71
Q If someone you know experiences PGP in the future, would you recommend to them to get
referred to see a womens health physiotherapist at RHH?
End of Interview
I will thank the participant again for their time and honesty during the interview and state that
their responses will remain anonymous. I will ask them if they have any further questions or
comments to add before stopping the tape recorder.
72
73
74
Kirsty Woodhead
Ethics Committee Administrator
Cc: Annette Haywood
75
ID
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
Group
1=Usual
Care
2=Manual
therapy
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
DOB
Age
Gestat
-ion
Trimester
Gravidity
Parity
Baseline
PGQ
6 week
PGQ
27.03.84
13.12.82
27.02.87
06.11.80
21.02.79
30.05.81
15.01.85
23.07.80
18.08.87
29.10.82
04.09.93
01.01.90
28.01.82
17.08.85
29.04.77
09.10.85
14.09.77
20.06.90
05.06.79
13.11.84
12.01.82
02.04.75
29.04.85
08.03.85
23.04.77
15.02.81
22.04.77
13.03.81
28.02.82
30.04.85
10.08.84
01.06.79
08.11.80
11.08.82
19.12.81
02.02.76
09.05.84
06.08.89
12.06.74
23.08.74
20.07.78
09.03.88
28.08.89
12.08.81
07.08.77
07.03.83
24.08.74
11.09.84
29
30
26
32
34
32
28
33
26
30
19
23
31
27
36
27
35
23
34
28
31
38
28
28
36
32
36
32
31
28
28
34
32
30
31
37
29
24
39
28
35
25
24
32
36
30
39
28
31
32
24
24
18
31
33
33
31
22
31
32
31
34
31
24
28
31
28
27
26
21
30
31
32
20
20
16
23
33
18
18
25
27
32
28
22
30
26
29
18
19
28
23
26
30
26
27
3
3
2
2
2
3
3
3
3
2
3
3
3
3
3
2
2
3
2
2
2
2
3
3
3
2
2
1
2
3
2
2
2
2
3
2
2
3
2
3
2
2
2
2
2
3
2
2
1
1
1
5
2
2
1
7
1
1
1
1
1
2
2
2
1
1
2
2
2
3
4
1
1
2
1
2
3
2
4
2
3
2
1
3
2
1
1
3
2
3
2
3
2
2
2
4
0
0
0
4
1
1
0
4
0
0
0
0
0
1
1
1
0
0
1
1
1
1
2
0
0
1
0
1
2
1
3
1
2
1
0
2
1
0
0
2
1
2
1
2
1
1
1
3
68.0
33.0
62.6
53.3
88.0
82.6
66.6
45.3
44.4
44.0
50.0
44.0
36.0
57.3
18.0
33.3
54.0
76.0
49.0
32.0
65.0
52.0
41.0
30.0
77.0
81.0
35.0
80.0
57.0
28.0
55.0
39.0
69.0
96.0
31.0
71.0
88.0
52.0
54.0
80.0
52.0
36.0
75.0
48.0
55.0
46.0
28.0
77.0
50.0
41.3
48.6
70.8
88.0
62.3
44.9
95.8
47.8
27.5
44.9
57.9
.0
98.5
19.0
34.7
44.0
17.0
19.0
20.0
70.0
32.0
69.0
30.0
71.0
75.0
40.0
36.0
55.0
7.0
78.0
28.0
71.0
36.0
18.0
80.0
59.0
62.0
37.0
65.0
59.0
36.0
80.0
12.0
76.0
36.0
22.0
56.0
Number of
treatment
sessions
1
2
2
1
2
1
1
3
2
3
2
3
2
2
1
1
3
3
2
1
1
1
76
77
78
Subtheme
1)
Living with Pelvic
Girdle Pain
a) Pain expectations
during pregnancy
Anna
Beth
b) Views about
recovery
postpartum
c) Pain levels
before seeking help
d) Impact on daily
life
2) Practicalities of
entering the
physiotherapy
system
a) Referral process
b) Location of
physiotherapy
appointments
3)
Patient Expectation
Pre-treatment
a) Negative mindset
Emily Frances
Grace
c) Unsure
expectations
5) Relationship
with
Physiotherapist
Daisy
b) Hopeful
treatment will help
4)
Response to the
manual therapy
treatment approach
(plus usual care)
Cara
a) Initial response
b) Functional
change
c) Perception of
alignment
d) Exceeded
expectations
a) Trust in
Physiotherapist
b) Empathy from
the physiotherapist
c) Womans dignity
respected
d) Recommendation of
Physiotherapy
79
80