8/21/2014

1

Jil l Schif f

Boissonnault

PT, PhD, WCS

DIFFERENTIAL DIAGNOSIS

AND MANAGEMENT OF

PUBIC SYMPHYSIS

DYSFUNCTION IN THE

OBSTETRIC CLIENT

By the end of this session the attendee will :

1 . Understand and apply to patient care the pathophysiology of peripartum pubic symphysis dysfunction

2. Select treatment interventions for the above- mentioned musculoskeletal dysfunction in the pregnant and postpartum client .

3. Consider appropriate home programs for clients with such musculoskeletal dysfunction.

4. Appreciate current evidence for the interventions the participants discuss.

OBJECTIVES

Anatomy review and differential diagnosis of

PSD in the perinatal period

Case of “Pubic Instability” or Pelvic Girdle

Pain in pregnancy

Case of Peripartum pubic symphysis

separation

Considerations for labor and delivery for the

woman with PSD

CONTENT PUBIC SYMPHYSIS

Joined by a fibrocartilaginous disc; fibrocartilaginous amphiarthroiss jt. Lined with hyaline cartilege.

Supported superiorly and inferiorly by ligaments

Motion occurs in sagital and frontal planes

Pathology includes

Separation

Instability with potential

‘unleveling’

Osteitis pubis

PATHOLOGY DURING THE CHILDBEARING

YEAR

PERI-PARTUM SEPARATED SYMPHYSIS

PUBIS (OR SYMPHYSOLYSIS OR DIASTASIS

SYMPHYSIS PUBIS)

www.e-radiography.net

8/21/2014

2

Frank separation is considered 10 mm or >

Pain does not seem to coincide with the degree of separation

Some mild separation (not necessarily painful) is considered normal in pregnancy and during contractions ( Boland 1933, Bjorklund 1997)

Can occur during pregnancy or postpartum Separation related to delivery seems most common, though

stats are unknown

DEFINITION AND PHYSIOLOGY

Prevalence: about 1/600 (range1/30-1/30,000!)

(Bolland 1933, Cappiello 1995, Snow, 1997, Dunivan 2009)

Peri-partum vs. pre-natal incidence-Unknown, but

literature discusses MOI related to delivery

Theoretical MOI

Fetal size

Maternal Position

Stiffness of pubic connective tissue

Rapid fetal descent (Snow 1997)

EPIDEMIOLOGY/PATHOPHYSIOLOGY OF

PERI-PARTUM PUBIC SYMPHYSIS

SEPARATION

Pathology to the pubic symphysis may be the

norm or quite common ( B r a n d o n 2 0 1 2 , H e r m a n n 2 0 0 7 , W u r d i ng e r 2 0 0 2 )

Bone marrow edema (76-86% in Hermann

study)

Fx (27% in Brandon study)

Capsular dysruption (rare)

Separation (rare)

Levator ani tears at the symphysis (common)

EPIDEMIOLOGY/PATHOPHYSIOLOGY OF

PERI-PARTUM PUBIC SYMPHYSIS

SEPARATION, CONT.

Pain management strategies

Post-partum pain medication

Referral to PT

Imaging (Scr iven, 1995)

CT

MRI

US

Radiograph

Surgical stabilization-internal or external (Luger 1995, Dunivan

2009, Osterhof f 2012)

Injections (Schwar tz, 1985)

Spinal cord Stimulator -1 Case ( Idrees 2012)

MEDICAL MANAGEMENT OF PERI-PARTUM

PUBIC SYMPHYSIS SEPARATION

Patient Interview Findings

Aggravation:

Transitional movements

Bed mobility

Hip abduction

Alleviation

Rest, Ice, Pain Relievers, Support belt, avoidance of weight shift (rolling walker)

Pain: Intense

Location at pubis with radiation into thighs, groin, perineum

COMMON SYMPTOM PRESENTATION

Frontal Plane Movement

that goes beyond physiologic

expectations

Superior of Inferior Shears

PUBIC SHEARS

www.docstoc.com

quizlet.com

8/21/2014

3

Patient Interview Findings

Aggravation:

Transitional movements

Bed mobility

Alleviation

Rest, Ice, Pain Relievers, Support belt, avoidance of

weight shift

Pain: Not as intense as with a separation

Location at pubis with radiation into thighs, groin,

perineum

COMMON SYMPTOM PRESENTATION-

SHEARS

• Painful, non-

infectious

inflammatory

condition of the

pubic bone and

symphysis

• Etiology: most

l ikely periosteal

trauma is initiating

factor

• Seen in athletes

and postpartum

women and after

urogynecological

surgical procedures

OSTEITIS

PUBIS

www.radpod.org

Present with: • Pain

• “Waddling” gait

• May be accompanied with low grade fever, elevated sed rate,

and mild leukocytosis

Radiographic findings • Reactive Sclerosis

• Rarefaction

• Osteolytic changes

OSTEITIS PUBIS, SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS OF PERI-PARTUM

GROIN PAIN

Consider osseous, joint and

soft-tissues in the region

&

Obstetric Complications

Ouch!

SI joint

Illium/Ischium

Pubic Symphysis

Low lumbar spine

Hip

Ligaments and discs

Musculature of the

region

ANATOMICAL CONSIDERATIONS SACROILIAC JOINT DYSFUNCTION AS A

SOURCE OF PERI-PARTUM PUBIC/GROIN PAIN

The sacral-iliac joint

can refer pain into

the groin and hip

Positional

dysfunction there

can disrupt the

normal anatomical

structure of the

pubic symphysis

en.wikipedia.org

8/21/2014

4

ILIUM AS A SOURCE OF SYMPTOMS

Positional

pathology (Ilial

rotations, upslips,

downslips)

www.eorthopod.com

LUMBAR SPINE AND DISC AS A SOURCE OF

SYMPTOMS

Upper lumbar

spine pathology

as pain referral

or radicular

symptoms into

the groin

www.medscape.org

HIP AS A SOURCE OF SYMPTOMS

OA of the hip

Labral tears

Bone Density Issues

Stress Fx

Bursitis

Femoral Acetabular

impingement

Separated Symphysis Pubis

Pubic Shear or unleveling of the

pubis 2◦ hormonally mediated joint instability

Osteitis Pubis

PUBIC SYMPHYSIS PATHOLOGY

Abruption of the placenta

Round ligament pain

Transient Osteoporosis of the Hip

in Pregnancy/Post-Partum

OTHER POTENTIAL OBSTETRIC SOURCES OF

SX

• Definition: placenta peels

away from the inner wal l of

the uterus before del ivery —

either par tial ly or completely

— i t 's known as placental

abruption

• Symptoms:

• Vaginal bleeding

• Abdominal/groin pain

• Back pain

• Uterine tenderness

• Rapid uterine contractions,

often coming one right after

another

ABRUPTION OF THE PLACENTA

www.moondragon.org

http://www.mayoclinic.com/health/placental-

abruption

8/21/2014

5

• Round ligament pain is sharp or jabbing, often felt in the lower belly or groin area on one or both sides.

• Intermittent in nature

• considered a normal part of pregnancy

• Exercise may cause the pain, as will rapid movements

• Round ligament has contractile tissue running through it; allows for “rebound”

ROUND LIGAMENT PAIN

tummytime.onslow.org

• Self - l imiting nature and

spontaneous recovery

• Fractures are infrequent

• True incidence during

pregnancy is unknown

• Onset: General ly in 3rd

tr imester

• TOH Pain locale: inguinal or

greater trochanteric regions

with referral to anter ior thigh .

• ROM: l imited at the hip

• Functionally restr icted weight

bearing ( B o i s s o n n a u l t , 2 0 0 1 )

TRANSIENT OSTEOPOROSIS OF THE HIP

(TOH) IN PREGNANCY/POSTPARTUM

MUSCLE PATHOLOGY AS A

SOURCE OF SYMPTOMS

Adductors

Iliopsoas

Abdominal obliques

TRIGGER POINTS

ILIUM, ISCHIUM AND MUSCULAR

INFLUENCES AND, CANNOT FORGET THE PELVIC FLOOR AS

A PAIN GENERATOR!

8/21/2014

6

Perform assessment in positions that the pt. can

tolerate (commonly supine only, if pp)

Goal of R/O structures above and below the CC (i.e.,

pubis)

Clear L-S, SI jts, Hips, Ilia

Use pt. report to R/O abruption, round ligament

Assess for muscle pathology if Hx and Physical Exam

lead you that way

Perform an internal assessment of PF if needed

PERFORM A LOWER QUARTER SCREENING

EXAM WITH SOME SPECIAL TESTS

Physical Exam

ASLR (Mens 2012): Research shows it to be better to detect

SI-jt pain, but can be sensitive to this

Palpation of symphysis (Vleeming 2008, Albert2001, 2002)

Modified Trendelenburg (Vleeming 2008, Albert2001, 2002)

SPECIAL TESTS AT THE PUBIC SYMPHYSIS

As a provocation

test

Clearing the Sacrum

Includes

Springing the

Sacrum in Sitting,

P4 test supine

PATELLAR PUBIC PERCUSSION TEST

TO R/O STRESS FX, BONE DENSITY ISSUES

Pt. Hx and possible MOI lead you there

R/O all other potential sources of Sx

Springing the pubis or palpation there very

tender

Trendellenburg painful

Bed mobility painful

Hip Abduction painful at Pubis

ASLR may be painful

May be unable to weight bear

AFTER CONSIDERATION/ASSESSMENT OF

VARIOUS PAIN GENERATORS; SETTLING ON

PUBIC SYMPHYSIS

Palpatory assymmetry absent

Attempt to “level out” pubis makes no

change

Essentially a “Rule-Out” Dx

DETERMINATION OF SEPARATION VS. SHEAR

8/21/2014

7

CASE 1: PUBIC INSTABILITY IN PREGNANCY;

PART OF PELVIC GIRDLE PAIN IN

PREGNANCY

www.aylesburyosteopath.co.uk

EPIDEMIOLOGY OF PELVIC GIRDLE PAIN IN

PREGNANCY

1460 women who formed incidence cohort, assessed at 33 wks gestation

1. Women who reported daily pain that could be objectively confirmed was 20.1%

Sub-grouped as follows:

Pelvic girdle syndrome (pain in all 3 joints) (6.0%)

Symphysioloysis (2.3%)

One-sided a sacroiliac syndrome (5.5%)

Double-sided sacroiliac syndrome (6.3%)

Misc (sx not objectively confirmed)

(Albert, 2002)

Parity ↑ Odds Ratio of having PGP in pregnancy

(Bjelland, 2010)

PROGNOSIS FOR OBSTETRIC PELVIC GIRDLE

PAIN

(Albert et al, 2001)

Cohort of 1789 women initially assessed at 33 wks

These women were re -examined (questionnaire and physical

exam) at regular

intervals for 2 years after delivery or until sx disappeared

At 2 yr postpartum, 21% with pelvic girdle syndrome (pain in

all 3 joints) stil l had pain

Indicators of highest relative risk for long term pain

High number of positive tests

Low mobility index

Conclusion: women with pelvic girdle syndrome or pain in all 3

joints, had poorest prognosis

MEDICAL MANAGEMENT OF PELVIC GIRDLE

PAIN IN PREGNANCY ’

Pain Medications

Belts and Supports-off the

shelf type

Referral to PT

PATIENT HX/INTERVIEW - PGP IN

PREGNANCY

Typical order of difficult ADLs for severe PGP listing most to

least:

standing still,

cycling,

walking,

sitting,

and lying

(Ronchett i , 2008)

Pelvic Girdle Pain Questionnaire : Self-

reported questionnaire that is condition specific for PGP

util iz ing 2 scales (activit ies/participation and symptoms);

highly reliable and valid in women with PGP during and after

pregnancy

(Stuge, 2011)

:

Ronchetti, 2008

P4 (Posterior pelvic

pain provocation test)

ASLR

Long dorsal ligament

tests

Quebec Back Pain

Disability Scale)

European Guidelines for PGP

SIJ Pain :

P4/thigh thrust

Patrick’s Faber test,

Palpation of the long dorsal SIJ ligament,

Gaenslen´s test.

Symphysis Palpation of the symphysis

Modified Trendelenburg test of the pelvic girdle

Functional pelvic test Active straight leg raise test

(V leeming, 2008)

PHYSICAL EXAM ASSESSMENT- PGP

IN PREGNANCY

8/21/2014

8

EBP FOR PT INTERVENTIONS- PGP/PUBIC

SHEAR IN PREGNANCY

Contraction of TRa ↓ laxity of SI-jt;

drawing-in maneuver ↓ laxity of SI-jt

(Richardson, 2002)

Systematic Reviews support use of

exercise for treatment or prevention of

PGP either alone or in combination with

acupuncture, advice and/or belts

(Boissonnault 2012, Stuge 2003)

EXERCISE FOR THE PGP/PUBIC SHEAR

CASE

Isolated activation of deep, local muscle system with

integration into all transitional movements: abdominal

drawing-in

Spine stabilization exercises in various positions: sidelying,

quadruped, Upright kneel

Functional Lower extremity strengthening with equal -

bilateral weight bearing: E.G., sit to stand, Rising and

lowering to half-kneel

Trunk/Pelvic girdle strengthening: anterior-posterior t i lt ing

standing, gluteus maximus, gluteus medius, back extensors

Fitness advice: which activit ies or machines?

EDUCATION FOR PGP/PUBIC SHEAR CASE

To ↓ catastrophizing and fear beliefs

use of FABQ and other self-administered

questionnaires can provide evidence for

the intervention

To empower self-management of the

condition

ADVICE FOR PGP/PUBIC SHEAR CASE

Postural alignment

Body mechanics

sleeping positions

ADLs (e.g., laundry, grocery-shopping)

Symmetrical movement

Sit-to-stand

Bed mobility

Isometric use of Adductors or Abductors in transitional activities (rolling, shifting)

Use of heat/ice (ice, especially over symphysis pubis)

MANUAL THERAPY OPTIONS FOR

PGP/PUBIC SHEAR CASE

Muscle Energy Rx

Direct Jt-mob to Sacral bases, ILAs

STM about posterior pelvis

(Murphy 2009, Licciardone 2010, George

2012)

BELTS/SUPPORTS AND GAIT AIDS

Support garments for Pelvic Girdle Pain: some

evidence for use

(Carr 2003, Mens 2006 , Ho 2009)

Consider assistive gait aid if gait continues to

be aggravating

Forearm crutches

Rolling walker

scooter

8/21/2014

9

THE CASE

30 yr old Gravida 2, para 1, @ 14 weeks gestation.

Has a 3-yr old dtr., and is a University professor

CC: pubic pain with occasional Left and Right SI-jt

pain

Hx of CC: Began @ 8 weeks and has worsened. Has

similar pain (less intense) in first pregnancy that

abated between pregnancies.

Pt. Goals: To continue working and exercising as

she does now.

FINDINGS OF PT. INTERVIEW: PGP/PUBIC

SHEAR

Rates pain 2/10-7/10

Location: “my groin, my left upper thigh and buttock and

sometimes after a really long day with lots of t ime on my feet

my left rear-end dimple and sometimes the same place on the

right”

Nature: Can be sharp (intermittent) or achey (can be constant

once it comes on).

Agg: climbing hill from parking ramp to office, roll ing over in

bed, walking > 10 min, sit -to-stand after sitt ing > 45 min

Alev: NWB rest, ice, Tylenol

PHYSICAL EXAM FINDINGS IN

PGP/PUBIC SHEAR CASE

Gait: antalgic and waddling a bit

Standing posture: unremarkable

Position testing in sitting: a superior left pubic

shear & Left on Left Sacral torsion

Palpation: painful over pubis. Painful also at Left

and Right SI jts over sacral sulci; Left dorsal

ligament painful

ASLR and P4+ on the left; weight shift onto L LE

provokes sharp groin pain and a duller, L -sided

posterior pain

Pubis Palpation

(or Springing)

for Tenderness

Asymmetric

Straight Leg

Raise Test-In

this Case, for

Trunk

Instability

MET to correct pubic shear

and sacral torsion; Direct

mobilization in sitt ing @

Left ILA

Exercise

Stabilization: trunk ex in 4

point

Strengthening ex: standing

pelvic tilts, TRa in 4-point

& sitting, glut medius

strengthening with

theraband, glut max

strengthening in 4-point

Body mechanics instruction

Sleep: get soft mattress pad and squeeze pillow between legs to roll and shift

Lifting 3-yr old

Postural alignment

Sleep with pillow between knees and avoid assymmetric sleeping postures

Sitting @ desk: avoid crossing LE’s; got her a foot rest and a work chair back support

PT INTERVENTIONS FOR PGP/PUBIC

SHEAR CASE

8/21/2014

10

MET: SUPERIOR PUBIC SHEAR CORRECTION

Greenman, PE. Principles of Manual Medicine

ASSESSMENT OF SACRAL BASE POSITION

IN SITTING

ASSESSMENT OF SACRAL BASE POSITION IN

4-POINT

MET: FORWARD SACRAL TORSION

CORRECTION

DIRECT MOBILIZATION IN SITTING FOR A

‘R ON R’ FORWARD SACRAL TORSION

Symmetrical movement

instruction

Sit-to-stand: symmetry

and/or with isometric

adduction or abduction

Ice to SI-jts and/or pubis

at home, prn

SI-belt: Found it helpful if

doing chores requiring

WB > 15 min. Preferred

Serola Belt (Serola.net)

Discussed fitness

program:

encouraged her to move

to aqua class/exercise

vs. land-based running

and zumba classes.

Self-mobilization for

pubic shear (supine)

and SI-Jt pain (seated

and standing)

PT INTERVENTIONS FOR PGP/PUBIC SHEAR

CASE, CONT.

8/21/2014

11

Self-

Mobilization

Of Pubis in

Sitting

SELF-MOBILIZATION OF A RIGHT SUPERIOR

PUBIC SHEAR (ALSO OF A POSTERIORLY

ROTATED RIGHT ILIUM)

SELF MOBILIZATION OF THE SACRUM PELVIC STABILIZATION VIA ADDUCTOR

SQUEEZE TO ASSIST IN ↓ PAIN WITH ROLLING

ROLLING WITH ISOMETRIC HIP ABDUCTION

SUPPORT BELT FOR PGP

IEM Maternity Sacroilic (SI) Support

iemortho.com

8/21/2014

12

CASE 2: SEPARATED SYMPHYSIS PUBIS (OR

SYMPHYSOLYSIS OR DIASTASIS SYMPHYSIS

PUBIS) DURING DELIVERY

www.e-radiography.net

28 yr old Gr 1 para 1, 26 hours postpartum, S/P vaginal delivery. Pt is a hospital RN

CC: excruciating pubic and groin pain, 9-10/10

Hx of CC: Pain began pp when pt attempted to stand to use toilet. Unsuccessful. Was catheterized and put on bedrest. PT referral initialized by nursing staff

In 2nd stage, spouse reported hearing a gun-shot-like pop as pt. pulled forward on squat bar while she was in semi-reclining & instructed to put feet on squat bar

MD ordered radiograph: 3 cm separation seen

Past Hx: no previous c/o pubic pain in pregnancy or prior to pregnancy

Pt lives with spouse in a two-story home

THE CASE

PATIENT INTERVIEW FINDINGS- MEDICAL

MANAGEMENT OF PERI-PARTUM PUBIC

SYMPHYSIS SEPARATION

Pain Location: at Pubis and up into groin bilaterally

with some ache in Left SI -jt

Nature: Sharp

Agg: Any bed mobility or attempt at WB or to move

legs

Alev: lying still, pain meds

Pt. Goals: able to return home, use stairs, care for

newborn, perform IADLs, RTW in 6 weeks as RN.

Pain management.

PHYSICAL EXAM FINDINGS- SEPARATED

SYMPHYSIS PUBIS DURING DELIVERY

Movement Assessment: Pt. could not roll, scoot or shift

in bed without pain > 6/10

Posture: WB unsuccessful without trochanteric belt

Mobility: with rolling walker and belt Pt. able to

ambulate for short distances with <4/10 pain

Palpation: exquisite pain at pubis -could not assess

position

Did not attempt additional physical assessment

IN-HOSPITAL PT INTERVENTIONS- SEPARATED

SYMPHYSIS PUBIS DURING DELIVERY

Gait: Rolling walker (parameters given); stairs -none if

possible; if necessary, consider going up and down on bottom

or at least foot -to-foot.

Pelvic support belt (parameters given)

Bed mobility training (log roll , use of adductor squeeze -gentle-

with pil low)

Soft mattress pad

Discussion on activity level:

With spouse present

Minimize WB; baby brought to her; no IADLs

3 weeks need for assistance

Appt. made for 6 wk FU in PT

OP PT PHYSICAL EXAM FINDINGS- SEPARATED

SYMPHYSIS PUBIS DURING DELIVERY

Palpation:

Left inferior sacral shear

Left superior pube

Tenderness still at pubis and at left SI-Jt

Pain with weight shift in standing

ASLR +

Did not attempt P4

Some fear avoidance (not formally assessed)

(Waddell 1993)

8/21/2014

13

OP PT INTERVENTIONS- SEPARATED

SYMPHYSIS PUBIS DURING DELIVERY

MET to correct pubic shear

MET to correct sacral shear

Self-mobilization for pubis and sacrum

HEP for Pelvic stabilization exercises

Seated

Standing on step

Glut, abdominal and back extensor strengthening

Encouraged continued use of pelvic belt, especially

when out of the house

Pubis Palpation

(or Springing)

for Tenderness

Asymmetric

Straight Leg

Raise Test-In

this Case, for

Trunk

Instability

MET: SUPERIOR PUBIC SHEAR CORRECTION

Greenman, PE. Principles of Manual Medicine

SELF-MOBILIZATION OF A RIGHT SUPERIOR

PUBIC SHEAR (ALSO OF A POSTERIORLY

ROTATED RIGHT ILIUM)

SELF MOBILIZATION OF THE SACRUM

8/21/2014

14

POST PUBIC SYMPHYSIS SEPARATION

BEGINNING STABILIZATION EXERCISE PT RECOMMENDATIONS FOR L&D- PELVIC

GIRDLE PAIN IN PREGNANCY

First Stage

Minimize walking

Avoid asymetric postures

Second Stage

Support LE’s, if semi-reclining, with pillows

folded under knees

Avoid WB postures if these provoke Sx (e.g., 4-

point, upright kneel)

Avoid squatting, especially if pain is @ pubis

PERI-PARTUM SEPARATED SYMPHYSIS PUBIS

REFERENCES

A s s o c i a t i o n o f t h e C h a r t e r e d S o c i e t y o f P h y s i o t h e r a p i s t s i n W o m e n ’ s H e a l t h : P r e g n a n c y R e l a t e d P e l v i c g i r d l e P a i n , L o n d o n , 2 0 0 7 , A s s o c i a t i o n o f C h a r t e r e d P h y s i o t h e r a p i s t s i n W o m e n ’ s H e a l t h .

A l b e r t H , G o d s k e s e n M , W e s t e r g a a r d J . P r o g n o s i s i n f o u r s y n d r o m e s o f p r e g n a n c y - r e l a t e d p e l v i c p a i n . A c t a O b s t e t G y n e c o l S c a n d . 2 0 0 1 ; 8 0 ( 6 ) : 5 0 5 - 1 0 .

A l b e r t H B , G o d s k e s e n M , W e s t e r g a a r d J G . I n c i d e n c e o f f o u r s y n d r o m e s o f p r e g n a n c y r e l a t e d p e l v i c j o i n t p a i n . S p i n e . 2 0 0 2 ; 2 7 ( 2 4 ) : 2 8 3 1 -4

B o i s s o n n a u l t J S , K l e s t i n s k i J U , P e a r c y K . T h e r o l e o f e x e r c i s e i n t h e m a n a g e m e n t o f p e l v i c g i r d l e a n d l o w b a c k p a i n i n p r e g n a n c y : a s y s t e m a t i c r e v i e w o f t h e l i t e r a t u r e . J o f W o m H e a l t h P T . 2 0 1 2 ; 3 6 ( 2 ) : 6 9 - 7 7 .

B o l a n d B F : S e p a r a t i o n o f s y m p h y s i s p u b i s : r e p o r t o f t e n c a s e s o c c u r r i n g d u r i n g d e l i v e r y , N E n g l J M e d 2 0 8 : 4 3 1 - 4 3 8 , 1 9 3 3 .

B r a n d o n C , J a c o b s o n J A , L o w L K , P a r k L , D e L a n c e y J , M i l l e r J . P u b i c b o n e i n j u r i e s i n p r i m i p a r o u s w o m e n : m a g n e t i c r e s o n a n c e i m a g i n g i n d e t e c t i o n a n d d i f f e r e n t i a l d i a g n o s i s o f s t r u c t u r a l i n j u r y . U l t r a s o u n d O b s t e t G y n e c o l . 2 0 1 2 A p r ; 3 9 ( 4 ) : 4 4 4 - 5 1

C a p p i e l l o G A , O l i v e r B C : R u p t u r e o f s y m p h y s i s p u b i s c a u s e d b y f o r c e f u l a n d e x c e s s i v e a b d u c t i o n o f t h e t h i g h s w i t h l a b o r e p i d u r a l a n e s t h e s i a , J F l o r i d a M e d A s s o c 8 2 : 4 3 8 - 4 4 3 , 1 9 9 5 .

D e S t e f a n o L , G r e e n m a n P . G r e e n m a n ’ s p r i n c i p l e s o f m a n u a l m e d i c i n e . B a l t i m o r e , M D : L i p p i n c o t t W i l l i a m s & W i l k i n s / W o l l t e r s K l u w e r , 2 0 1 1 .

D u n i v a n G C , H i c k m a n A M , C o n n o l l y A . S e v e r e s e p a r a t i o n o f t h e p u b i c s y m p h y s i s a n d p r o m p t o r t h o p e d i c s u r g i c a l i n t e r v e n t i o n . O b s t e t G y n e c o l . 2 0 0 9 A u g ; 1 1 4 ( 2 P t 2 ) : 4 7 3 - 5 .

D e p l e d g e J , M c N a i r P J , K e a l - S m i t h C , W i l l i a m s M . M a n a g e m e n t o f s y m p h y s i s p u b i s d y s f u n c t i o n d u r i n g p r e g n a n c y u s i n g e x e r c i s e a n d p e l v i c s u p p o r t b e l t s . P h y s T h e r . 2 0 0 5 D e c ; 8 5 ( 1 2 ) : 1 2 9 0 - 3 0 0 .

G a r a g i o l a D , T a r v e r R , G i b s o n L , R o g e r s R , W a s s J . A n a t o m i c c h a n g e i n t h e p e l v i s a f t e r u n c o m p l i c a t e d v a g i n a l d e l i v e r y : a C T s t u d y o n 1 4 w o m e n . A J R A m J R o e n t g e n o l 1 9 8 9 ; 1 5 3 : 1 2 3 9 – 1 2 4 1 .

H e r m a n n K G , H a l l e H , R e i s s h a u e r A , S c h i n k T , V s i a n s k a L , M u ¨ h l e r M R , L e m b c k e A , H a m m B , B o l l o w M . P e r i p a r t u m c h a n g e s o f t h e p e l v i c r i n g : u s e f u l n e s s o f m a g n e t i c r e s o n a n c e i m a g i n g . R o f o 2 0 0 7 ; 1 7 9 : 1 2 4 3 – 1 2 5 0 .

I d r e e s A . M a n a g e m e n t o f c h r o n i c s y m p h y s i s p u b i s p a i n f o l l o w i n g c h i l d b i r t h w i t h s p i n a l c o r d s t i m u l a t o r . J o u r n a l o f t h e P a k i s t a n M e d i c a l A s s o c i a t i o n 2 0 1 2 ; 6 2 ( 1 ) : 7 1 - 7 3 .

L e a d b e t t e r R E , M a w e r D , L i n d o w S . S y m p h y s i s p u b i s d y s f u n c t i o n : a r e v i e w o f t h e l i t e r a t u r e . J M a t e r n F e t a l N e o n a t a l M e d 2 0 0 4 ; 1 6 : 3 4 9 –3 5 4 .

L u g e r E , E l c h a n a n J , A r b e l R , D e k e l S . T r a u m a t i c S e p a r a t i o n o f t h e S y m p h y s i s P u b i s d u r i n g P r e g n a n c y : A C a s e R e p o r t . T h e J o u r n a l o f T r a u m a : I n j u r y , I n f e c t i o n , a n d C r i t i c a l C a r e 3 8 ( 2 ) : 1 9 9 5 , 2 5 5 - 2 5 6 .

M e n s J M , H u i s I n ' t V e l d Y H , P o o l - G o u d z w a a r d A . T h e A c t i v e S t r a i g h t L e g R a i s e t e s t i n l u m b o p e l v i c p a i n d u r i n g p r e g n a n c y . M a n T h e r . 2 0 1 2 A u g ; 1 7 ( 4 ) : 3 6 4 - 8 .

O s t e r h o f f G , O s s e n d o r f C , O s s e n d o r f - K i m m i c h N , Z i m m e r m a n n R , W a n n e r G A , S i m m e n H P , W e r n e r C M . S u r g i c a l s t a b i l i z a t i o n o f p o s t p a r t u m s y m p h y s e a l i n s t a b i l i t y : t w o c a s e s a n d a r e v i e w o f t h e l i t e r a t u r e . G y n e c o l O b s t e t I n v e s t . 2 0 1 2 ; 7 3 ( 1 ) : 1 - 7 .

S c h w a r t z Z , K a t z Z , L a n c e t M : M a n a g e m e n t o f p u e r p e r a l s e p a r a t i o n o f t h e s y m p h y s i s p u b i s . I n t J G y n e c o l O b s t e t 2 3 : 1 2 5 , 1 9 8 5

S c r i v e n M W , J o n e s D A , M c K n i g h t L . T h e i m p o r t a n c e o f p u b i c p a i n f o l l o w i n g c h i l d b i r t h : a c l i n i c a l a n d u l t r a s o n o g r a p h i c s t u d y o f d i a s t a s i s o f t h e p u b i c s y m p h y s i s . J R S o c M e d 1 9 9 5 ; 8 8 : 2 8 - 3 0 .

S n o w R E , N e u b e r t A G . P e r i p a r t u m p u b i c s y m p h y s i s s e p a r a t i o n : b o x s e r i e s a n d r e v i e w o f l i t e r a t u r e . O b s t e t G y n e c o l S u r v 1 9 9 7 ; 5 2 : 4 3 8 - 4 3 .

S t u g e B , H i l d e G , V o l l e s t a d N . P h y s i c a l t h e r a p y f o r p r e g n a n c y - r e l a t e d l o w b a c k a n d p e l v i c p a i n : a s y s t e m a t i c r e v i e w . A c t a O b s t e t G y n e c o l S c a n d . 2 0 0 3 ; 8 2 : 9 8 3 - 9 9 0 .

V l e e m i n g A , A l b e r t H B , O s t g a a r d H C , S t u r e s s o n B , S t u g e B . E u r o p e a n g u i d e l i n e s f o r t h e d i a g n o s i s a n d t r e a t m e n t o f p e l v i c g i r d l e p a i n . E u r S p i n e J . 2 0 0 8 ; 1 7 : 7 9 4 - 8 1 9 .

W a d d e l l G , N e w t o n M , H e n d e r s o n I , e t a l . A F e a r - A v o i d a n c e B e l i e f s Q u e s t i o n n a i r e ( F A B Q ) a n d t h e r o l e o f f e a r - a v o i d a n c e b e l i e f s i n c h r o n i c l o w b a c k p a i n a n d d i s a b i l i t y . P a i n . 1 9 9 3 ; 5 2 : 1 5 7 – 1 6 8 .

W u r d i n g e r S , H u m b s c h K , R e i c h e n b a c h J R , P e l k e r G , S e e w a l d H J , K a i s e r W A . M R I o f t h e p e l v i c r i n g j o i n t s p o s t p a r t u m : n o r m a l a n d p a t h o l o g i c a l f i n d i n g s . J M a g n R e s o n I m a g i n g 2 0 0 2 ; 1 5 : 3 2 4 – 3 2 9 .

A s s o c i at i on o f t h e C h a r t e r e d S o c i e t y o f P h y s i o t he r ap i s t s i n W o m e n ’ s H e a l t h : P r e g n an cy R e l a t e d P e l v i c

g i r d l e P a i n , L o n d on , 2 0 0 7 , A s s o c i at i on o f C h a r t e r e d P h y s i o t he r ap i s t s i n W o m e n ’s H e a l t h .

A l b e r t H , G o d s k e se n M , W e s t e r g a ar d J . P r o g n os i s i n f o u r s y n d r om e s o f p r e g n a nc y - r e l at e d p e l v i c p a i n .

A c t a O b s t e t G y n e c o l S c a n d . 2 0 0 1 ; 8 0 ( 6) :5 0 5 - 1 0.

A l b e r t H B , G o d s k e se n M , W e s t e r g aa r d J G . I n c i d e nc e o f f o u r s y n d r om e s o f p r e g n an cy r e l a t e d p e l v i c

j o i n t p a i n . S p i n e . 2 0 0 2 ; 2 7 ( 2 4 ) : 2 8 31 - 4

B j o r k l a nd K , L i n d g r e n P G , B e r g s t r om S , U l m s t e n U . s o n o g r aph i c a s s e ss m e nt o f s y m p h y s e al j o i n t

d i s t e n s i on i n t r a p a r t u m . A c t a O b s t e t G y n e c o l s c a n d i n av i c a 1 9 9 7 . 7 6 ( 3 ) : 2 2 7 - 3 2 .

B o i s s on nau l t W G , B o i s s on na ul t J S . T r a n s i e n t O s t e op or os i s o f t h e H i p A s s o c i at e d w i t h P r e g n a nc y

J O S P T . 2 0 0 1 ; 3 1 ( 7) :3 5 9 - 3 67

B o i s s on nau l t J S , K l e s t i n s k i J U , P e a r c y K . T h e r o l e o f e x e r c i se i n t h e m a n a g e m e nt o f p e l v i c g i r d l e a n d

l o w b a c k p a i n i n p r e g n a nc y : a s y s t e m a t i c r e v i e w o f t h e l i t e r a t u r e . J o f W o m H e a l t h P T . 2 0 1 2 ; 3 6 ( 2 ) : 6 9 -

7 7 .

B o l a n d B F : S e p a r a t i on o f s y m p h y s i s p u b i s : r e p o r t o f t e n c a s e s o c c u r r i ng d u r i n g d e l i v e r y , N E n g l J M e d

2 0 8 : 4 3 1 - 4 3 8, 1 9 3 3 .

B r a n d on C , J a c o b son J A , L o w L K , P a r k L , D e L a n c e y J , M i l l e r J . P u b i c b o n e i n j u r i e s i n p r i m i p a r ous

w o m e n: m a g n e t i c r e s o nan ce i m a g i n g i n d e t e c t i o n a n d d i f f e r e n t i a l d i a g n o s i s o f s t r u c t ur a l i n j u r y .

U l t r a s o un d O b s t e t G y n e c o l . 2 0 1 2 A p r ; 3 9 ( 4 ) : 4 44 - 51

C a p p i e l l o G A , O l i v e r B C : R u p t u r e o f s y m p h y s i s p u b i s c a u s e d b y f o r c e fu l a n d e x c e s s i v e a b d u c t i on o f t h e

t h i g h s w i t h l a b o r e p i d u r a l a n e s t h e s i a , J F l o r i d a M e d A s s o c 8 2 : 4 3 8 - 4 4 3, 1 9 9 5 .

D e S t e f an o L , G r e e nm a n P . G r e e nm an ’ s p r i n c i p l e s o f m a n u a l m e d i c i ne . B a l t i m o r e , M D : L i p p i n c o tt

W i l l i a m s & W i l k i n s / W ol l t e r s K l u w e r , 2 0 1 1 .

D u n i v a n G C , H i c k m a n A M , C o n n o l l y A . S e v e r e s e p a r at i on o f t h e p u b i c s y m p h y s i s a n d p r o m pt

o r t h o p e di c s u r g i c a l i n t e r v e nt i on . O b s t e t G y n e c o l . 2 0 0 9 A u g ; 1 1 4 ( 2 P t 2 ) : 4 7 3 - 5 .

D e p l e d g e J , M c N a i r P J , K e a l - S m i t h C , W i l l i a m s M . M a n a g e m e n t o f s y m p h y s i s p u b i s d y s f u n c t i on d u r i n g

p r e g n a nc y u s i n g e x e r c i s e a n d p e l v i c s u p p o r t b e l t s . P h y s T h e r . 2 0 0 5 D e c ; 8 5 ( 1 2) : 12 90 - 3 00 .

G a r a g i o l a D , T a r v e r R , G i b s o n L , R o g e r s R , W a s s J . A n a t o m i c c h a n g e i n t h e p e l v i s a f t e r u n c o m pl i c a te d

v a g i n a l d e l i v e r y : a C T s t u d y o n 1 4 w o m e n. A J R A m J R o e n t ge no l 1 9 8 9 ; 1 5 3 : 1 2 3 9 – 1 2 4 1 .

PERI-PARTUM PUBIC SYMPHYSIS

REFERENCES

H e r m a n n K G , H a l l e H , R e i s s h a u e r A , S c h i n k T , V s i a n s k a L , M u ¨ h l er M R , L e m b c k e A , H a m m B , B o l l o w M . P e r i p a r tu m c h a n g es o f t h e p e l v i c r i n g : u s e f u ln es s o f m a g n e t i c r e s o n a n c e i m a g i n g . R o f o 2 0 0 7 ; 1 7 9 : 1 2 4 3 – 1 2 5 0.

I d r e e s A . M a n a g e m e nt o f c h r o n i c s y m p h ys i s p u b is p a i n f o l l o w i ng c h i l d b i r t h w i t h s p i n a l c o r d s t i m u la t o r . J o u r n a l o f t h e P a k i s t a n M e d i c a l A s s o c i a t io n 2 0 1 2 ; 6 2 ( 1 ) : 7 1 - 7 3 .

L e a d b e t te r R E , M a w e r D , L i n d o w S . S y m p h ys i s p u b i s d y s f u nc t i o n : a r e v i e w o f t h e l i t e r a tu r e. J M a t e r n F e t a l N e o n a t a l M e d 2 0 0 4 ; 1 6 : 3 4 9 – 3 5 4 .

L u g e r E , E l c h a n an J , A r b e l R , D e k e l S . T r a u m a t i c S e p a r a t io n o f t h e S y m p h y s i s P u b i s d u r i n g P r e g n a n c y : A C a s e R e p o r t . T h e J o u r n a l o f T r a u m a: I n j u r y , I n f e c t io n , a n d C r i t i c a l C a r e 3 8 ( 2 ) : 1 9 9 5 , 2 5 5 - 25 6 .

L e n t z S . O s t e i t i s P u b i s : a R e v i e w . O b s t e t a n d G y n e c o l S u r v e y 1 9 9 5 ; 5 0 ( 4 ) : 3 1 0 - 3 1 5 .

M e n s J M , H u i s I n ' t V e l d Y H , P o o l - G o u d z waa rd A . T h e A c t i v e S t r a i g h t L e g R a i s e t e s t i n l u m b o p el v i c p a i n d u r i n g p r e g n a nc y . M a n T h e r . 2 0 1 2 A u g ; 1 7 ( 4) : 36 4 - 8 .

O s t e r h o f f G , O s s e n d o r f C , O s s e n d o r f - K im m ic h N , Z i m m e r m an n R , W a n n e r G A , S i m m e n H P , W e r n e r C M . S u r g i c a l s t a b i l i z a t io n o f p o s t p ar tu m s y m p h ys e a l i n s t a b i l i t y : t w o c a s e s a n d a r e v i e w o f t h e l i t e r a t u re . G y n e c o l O b s t e t I n v e s t . 2 0 1 2 ; 7 3 (1 ) : 1 - 7 .

S c h w a r t z Z , K a t z Z , L a n c e t M : M a n a g e m e nt o f p u e r p e r a l s e p a r a t io n o f t h e s y m p h y s i s p u b is . I n t J G y n e c o l O b s t e t 2 3 : 1 2 5 , 1 9 8 5

S c r i v e n M W , J o n e s D A , M c K n ig h t L . T h e i m p o r tan c e o f p u b ic p a i n f o l l o w i ng c h i l d b i r th : a c l i n i c a l a n d u l t r a so n o g rap h ic s t u d y o f d i a s t a s i s o f t h e p u b ic s y m p h ys i s . J R S o c M e d 1 9 9 5 ; 8 8 : 2 8 - 3 0 .

S n o w R E , N e u b e r t A G . P e r i p a r tu m p u b ic s y m p h y s i s s e p a r a t i o n : b o x s e r i e s a n d r e v i e w o f l i t e r a tu r e. O b s t e t G y n e c o l S u r v 1 9 9 7 ; 5 2 : 4 3 8 - 4 3 .

V l e e m i ng A , A l b e r t H B , O s t g a a r d H C , S t u r e s s o n B , S t u g e B . E u r o p e a n g u i d e l i ne s f o r t h e d i a g n o si s a n d t r e a t m e nt o f p e l v i c g i r d l e p a i n . E u r S p i n e J . 2 0 0 8 ; 1 7: 7 9 4 - 8 19 .

W a d d e l l G , N e w t o n M , H e n d e r s o n I , e t a l . A F e a r - A vo i d anc e B e l i e f s Q u e s t i o n na i re ( F A B Q ) a n d t h e r o l e o f f e a r - avo i d an c e b e l i e f s i n c h r o n i c l o w b a c k p a i n a n d d i s a b i l i t y . P a i n . 1 9 9 3 ; 5 2: 1 57 – 1 68 .

W u r d in g er S , H u m b s c h K , R e i c h e n b ac h J R , P e l k e r G , S e e w a l d H J , K a i s e r W A . M R I o f t h e p e l v i c r i n g j o i n t s p o s t p ar tu m : n o r m a l a n d p a t h o lo g ic a l f i n d ing s . J M a g n R e s o n I m a g i n g 2 0 0 2 ; 1 5 : 3 2 4 – 3 2 9 .

PERI-PARTUM PUBIC SYMPHYSIS

REFERENCES, CONT.

PELVIC GIRDLE PAIN IN PREGNANCY

REFERENCES

A l b e r t H , G o d s k e s e n M , W e s t e r g a a r d J . P r o g n o s i s i n f o u r s y n d r o m e s o f p r e g n a n c y - r e l a t e d p e l v i c p a i n . A c t a O b s t e t G y n e c o l S c a n d . 2 0 0 1 ; 8 0 ( 6 ) : 5 0 5 -1 0 .

A l b e r t H B , G o d s k e s e n M , W e s t e r g a a r d J G . I n c i d e n c e o f f o u r s y n d r o m e s o f p r e g n a n c y r e l a t e d p e l v i c j o i n t p a i n . S p i n e . 2 0 0 2 ; 2 7 ( 2 4 ) : 2 8 3 1 - 4 .

B j e l l a n d E K , A s k i l d A , J o h a n s e n R , E b e r h a r d - G r a n M . P e l v i c g i r d l e p a i n i n p r e g n a n c y : t h e i m p a c t o f p a r i t y . A m J o f O b s t e t G y n e c o l . 2 0 1 0 ; 2 0 3 : 1 4 6 . e 1 - 6 .

B o i s s o n n a u l t J S , K l e s t i n s k i J U , P e a r c y K . T h e r o l e o f e x e r c i s e i n t h e m a n a g e m e n t o f p e l v i c g i r d l e a n d l o w b a c k p a i n i n p r e g n a n c y : a s y s t e m a t i c r e v i e w o f t h e l i t e r a t u r e . J o f W o m H e a l t h P T . 2 0 1 2 ; 3 6 ( 2 ) : 6 9 - 7 7 .

C a r r C A ( 2 0 0 3 ) U s e o f a m a t e r n i t y s u p p o r t b i n d e r f o r r e l i e f o f p r e g n a n c y - r e l a t e d b a c k p a i n . J o u r n a l o f O b s t e t r i c , G y n e c o l o g i c , a n d N e o n a t a l N u r s i n g 3 2 , 4 9 5 – 5 0 2 .

G e o r g e J W , S k a g g s C D , T h o m p s o n P A , N e l s o n D M , G a v a r d J A , G r o s s G A . A r a n d o m i z e d c o n t r o l l e d t r i a l c o m p a r i n g a m u l t i m o d a l i n t e r v e n t i o n a n d s t a n d a r d o b s t e t r i c s c a r e f o r l o w b a c k a n d p e l v i c p a i n i n p r e g n a n c y . A m J O b s t e t G y n e c o l . 2 0 1 2 O c t 2 3 . p i i : S 0 0 0 2 - 9 3 7 8 ( 1 2 ) 0 1 9 6 9 - 2 . d o i : 1 0 . 1 0 1 6 / j . a j o g . 2 0 1 2 . 1 0 . 8 6 9 . [ E p u b a h e a d o f p r i n t ]

H o S S , Y u W W , L a o T T , C h o w D H , C h u n g J W , L i Y . E f f e c t i v e n e s s o f m a t e r n i t y s u p p o r t b e l t s i n r e d u c i n g l o w b a c k p a i n d u r i n g p r e g n a n c y : a r e v i e w . J C l i n N u r s . 2 0 0 9 J u n ; 1 8 ( 1 1 ) : 1 5 2 3 - 3 2 .

L i c c i a r d o n e J C , B u c h a n a n S , H e n s e l K , K i n g H H , F u l d a K G , S t o l l S T . O s t e o p a t h i c m a n i p u l a t i v e t r e a t m e n t o f b a c k p a i n a n d r e l a t e d s y m p t o m s d u r i n g p r e g n a n c y : a r a n d o m i z e d c o n t r o l l e d t r i a l . A m J O b s t e t G y n e c o l 2 0 1 0 ; 2 0 2 : 4 3 . e 1 – 8 .

M e n s , J . M . A . , V l e e m i n g , A . , S n i j d e r s , C . J . , S t a m , H . J . , G i n a i , A . Z . , 1 9 9 9 . T h e a c t i v e s t r a i g h t l e g r a i s i n g t e s t a n d m o b i l i t y o f t h e p e l v i c

j o i n t s . E u r . S p i n e J . 8 , 4 6 8 – 4 7 3 .

M e n s J M , D a m e n L , S n i j d e r s C J , S t a m H J . T h e m e c h a n i c a l e f f e c t o f a p e l v i c b e l t i n p a t i e n t s w i t h p r e g n a n c y - r e l a t e d p e l v i c p a i n . C l i n B i o m e c h 2 0 0 6 ; 2 1 : 1 2 2 - 7 .

M u r p h y D R , H u r w i t z E L , M c G o v e r n E E . O u t c o m e o f p r e g n a n c y - r e l a t e d l u m b o p e l v i c p a i n t r e a t e d a c c o r d i n g t o a d i a g n o s i s - b a s e d d e c i s i o n r u l e : a p r o s p e c t i v e o b s e r v a t i o n a l c o h o r t s t u d y . J M a n i p u l a t i v e P h y s i o l T h e r 2 0 0 9 ; 3 2 :6 1 6 -2 4 .

R o n c h e t t i I , V l e e m i n g A , v a n W i n g e r d e n J P . P h y s i c a l c h a r a c t e r i s t i c s o f w o m e n w i t h s e v e r e p e l v i c g i r d l e p a i n a f t e r p r e g n a n c y : a d e s c r i p t i v e c o h o r t s t u d y . S p i n e , 2 0 0 8 M a r 1 ; 3 3 ( 5 ) : E 1 4 5 - 5 1 .

R i c h a r d s o n C A , S n i j d e r s C J , H i d e s J A , D a m e n L , P a s M S , S t o r m J . T h e r e l a t i o n b e t w e e n t h e t r a n s v e r s u s a b d o m i n i s m u s c l e s , s a c r o i l i a c j o i n t m e c h a n i c s , a n d l o w b a c k p a i n . S p i n e , 2 0 0 2 F e b 1 5 ; 2 7 ( 4 ) : 3 9 9 - 4 0 5 .

S t u g e B , H i l d e G , V o l l e s t a d N . P h y s i c a l t h e r a p y f o r p r e g n a n c y - r e l a t e d l o w b a c k a n d p e l v i c p a i n : a s y s t e m a t i c r e v i e w . A c t a O b s t e t G y n e c o l S c a n d . 2 0 0 3 ; 8 2 : 9 8 3 - 9 9 0 .

S t u g e B , B e r g l a n d A : E v i d e n c e a n d i n d i v i d u a l i z a t i o n : i m p o r t a n t e l e m e n t s i n t r e a t m e n t f o r w o m e n w i t h p o s t p a r t u m p e l v i c g i r d l e p a i n . P h y s i o t h e r T h e o r y a n d P r a c t i c e . 2 0 1 1 ; 2 7 ( 8 ) : 5 5 7 - 5 6 5 .

S t u g e B , G a r r a t t A , K r o g s t a d J e n s s e n H , G r o t l e M . T h e p e l v i c g i r d l e q u e s t i o n n a i r e : a c o n d i t i o n s p e c i f i c i n s t r u m e n t f o r a s s e s s i n g a c t i v i t y l i m i t a t i o n s a n d s y m p t o m s i n p e o p l e w i t h p e l v i c g i r d l e p a i n . P h y s T h e r . 2 0 1 1 ; 9 1 : 1 0 9 6 -1 1 0 8 .

V l e e m i n g A , A l b e r t H B , O s t g a a r d H C , S t u r e s s o n B , S t u g e B . E u r o p e a n g u i d e l i n e s f o r t h e d i a g n o s i s a n d t r e a t m e n t o f p e l v i c g i r d l e p a i n . E u r S p i n e J . 2 0 0 8 ; 1 7 : 7 9 4 -8 1 9 .