Pelvic Girdle Pain: A mixed methods evaluation

of a manual therapy treatment approach plus

usual care versus usual care alone.

A dissertation submitted in partial fulfilment of the

requirements for the degree of Master of Clinical Research
at
The School of Health and Related Research,
The University of Sheffield
Registration Number
110133588

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.

Aims & Objectives

The research aimed to establish whether or not a newly introduced manual therapy treatment
approach added to usual care improved patient reported outcome measures in women with
PGP, compared to usual care alone. A further aim was to gain insight into womens
experience of a manual therapy treatment approach when treated for PGP.

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

5.3c Patient Expectations pre-treatment............................................................................................ 49

5.3d Response to a manual therapy treatment approach (plus usual care) ........................................ 50
5.3e Relationship with physiotherapist ............................................................................................. 51
5.4 Quantitative and Qualitative data synthesis .................................................................................... 52
5.5 Limitations ...................................................................................................................................... 53
5.6 Learning Points ............................................................................................................................... 54
Chapter 6: Conclusion........................................................................................................................... 55
6.1 Summary of key points ................................................................................................................... 55
6.2 Recommendations for future practice ............................................................................................. 55
6.3 Recommendations for future research ............................................................................................ 56
References ............................................................................................................................................. 58
Appendices............................................................................................................................................ 64
Appendix 1: Pelvic Girdle Questionnaire ......................................................................................... 64
Appendix 2: Participant Information Sheet ...................................................................................... 65
Appendix 3: Consent Form ............................................................................................................... 69
Appendix 4: Interview Guide ............................................................................................................ 70
Appendix 5: Clinical Effectiveness Unit Approval .......................................................................... 73
Appendix 6: ScHARR Ethics Letter of Approval ............................................................................. 75
Appendix 7: Raw data from the 46 PGQs......................................................................................... 76
Appendix 8a Photo showing a section of the transcript from interview 1 with early coding and
theme development ........................................................................................................................... 77
Appendix 8b: Photo showing section of transcripts from interview 1, 2 and 3 with further coding
and theme development across cases ................................................................................................ 78
Appendix 9: Charting the womens responses to allow cross case comparisons .............................. 79

Abbreviations
CI

Confidence Interval

GP

General Practitioners

HCP

Health Care Professionals; include GPs, midwives and physiotherapists

in this study

MT

Manual therapy

PGP

Pelvic Girdle Pain

PGQ

Pelvic Girdle Questionnaire

PT

Physiotherapist

RHH

Royal Hallamshire Hospital

ScHARR

School of health and related research

SIJ

Sacro-iliac joint

STHFT (STH)

Sheffield Teaching Hospitals Foundation Trust

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.

Diagram 1: Basic anatomy of the pelvic girdle.

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 manual therapy approach is recommended by The Association of Chartered

Physiotherapists in Womens Health (ACPWH)26 and the Royal College of Physicians of
Ireland.27 The clinical practice guidelines recommend that appropriate manual therapy should
be used in conjunction with exercises, advice, pain control and pelvic belts/crutches. The
researcher is aware of local and national NHS trusts successfully using a manual therapy
treatment approach which forms routine care for PGP patients. There are several post
graduate courses specifically teaching different manual therapy techniques for the
management of PGP28,29 and The Pelvic Partnership state on their About Us page on their
website PGP is a common and, in most cases, treatable condition using manual therapy
techniques, paragraph 3.29

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.

1.3b Definition of usual care

Currently, usual care for the treatment of PGP in STH can include advice, education, stability
exercises, stretches, pelvic belts and elbow crutches. The participants who received usual
care only have been referred to as the usual group.

14

Chapter 2: Literature Review

2.1 Search Strategy
A comprehensive literature search was undertaken to ensure the relevant literature was
reviewed. The University of Sheffields Star Plus system was used to access the following
electronic articles and databases: Medline via OvidSP, ASSIA (Applied Social Sciences
Index and Abstracts) via ProQuest, Cochrane Library, CINAHL via EBSCO, Scopus,
PsycINFO via OvidSP and PubMed. Due to the paucity in the literature the electronic
databases were searched from their inception until August 2013, with language restricted to
English. Boolean logic was applied to the search strategy, combining free text words such as
pelvic girdle pain (PGP) AND treatment, pelvic girdle pain AND manual therapy AND
pregnan*, which uses a search strategy called truncation (*). Additional sources searched
included Google Scholar, Physiotherapy Evidence Database (PEDro), AMED, the Chartered
Society of Physiotherapists website, including professional discussion boards and The
Association of Chartered Physiotherapists in Womens Health website. Also the National
Institute for Health and Clinical Excellence, Antenatal Care Guidelines were reviewed. All
reference lists from the articles retrieved were pursued, which utilised a technique called
snowballing.31 The grey literature was searched to explore non published papers using
System for Information on Grey Literature in Europe (SIGLE).32

2.2 The effectiveness of manual therapy in PGP

The retrieved literature highlighted that many published papers are reviews of PGP in terms
of classification, diagnosis, prognosis and management of the condition.1,2,6,18,26,3336 There
are studies investigating sick leave associated with PGP8,37 and studies focused on the
experience of PGP from the womans perspective.3,5,14,15,3840 Only two review papers were
found that specifically evaluated the effects of spinal manipulation or mobilisations on PGP
during pregnancy.41,42 Four clinical studies looked at the effect of mobilisations on the
outcome of pain in clinical settings, specific to PGP.1921,23
A systematic review 41 suggested that mobilisation as a treatment intervention may be
appropriate to treat joint dysfunction occurring at the SIJs. This was based on four studies19
21,43

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

2.3 How does manual therapy work?

Biomechanical and neurophysiological
considerations
The use of manual therapy in clinical practice is based around case study research,
biomechanical and pain theories and clinical experience, supported by professional
guidelines. Current literature suggests that the actual mechanisms through which manual
therapy is thought to work are not established.22 A full review of the literature on the biology
of manual therapy is not within the scope of this study. For more information please see
Khalsa et al.48 Bialosky suggested that the likely mechanism of why manual therapy works
was due to biomechanical and neurophysiological mechanisms.22 Biomechanical theories as
to how manual therapy reduces pain are complex. In the 1990s, Vleeming et al25 introduced
the terms force closure, which relates to how the SIJ is compressed by the action of
muscles and ligaments, and form closure relating to how the anatomical features create
stability around the SIJ. If the SIJ is stiff or lax, stability of the joint is compromised and it is
postulated that manual therapy can restore optimal joint alignment, mobility,24 reduce
pain22,49 and addresses form closure. Stabilisation exercises attempt to balance forces
through the pelvis and enhance force closure. Lederman in 201150 questioned whether an
individuals biomechanics can actually be the cause of low back pain (in non-pregnant
population) and argues that tremendous forces would be required to correct structural
misalignments.50 However, Lee51 disputed these suggestions as the literature was not
critically reviewed and only articles to support Ledermans views were used. Lee suggested
that clinically, patient receive an intervention as part of a multi-modal approach, with
treatment tailored to their specific needs.51
There is a significant body of evidence to support the hypoalgesic effect of manual therapy.
This is achieved by activating descending pain inhibitory systems52 and pain-gate
mechanisms as described by Melzack and Wall.53 Wrights review summarised that a
hypoalgesic effect of spinal manipulative therapy may occur through stimulation of the
descending inhibitory pain systems. A systematic review demonstrated the central nervous
system was stimulated in response to passive joint mobilisations.54 Manual therapy was
capable of inducing changes that were 20% greater than control conditions with regards to
pain related outcome measures. This research related to cervical spine mobilisation and not
SIJ mobilisation, but the mechanism of effect should be clinically transferrable to other
17

joints. To summarise, a combination of peripheral, spinal cord and supraspinal mechanisms

may be activated in response to manual therapy to modulate a persons experience of pain.22
Historically, biomechanical and neurophysiological mechanisms have been viewed as
separate entities; Bialoskys paper suggested combined interactions exist to explain the
effects of manual therapy.22 There have been a plethora of studies looking at biomechanical
effects of manual therapy, ranging from positional changes to the joint post manual therapy
and reliability of palpation for joint position.22 Individually these studies have not
demonstrated good reliability of palpation or techniques and have only demonstrated
transient joint position changes. Bialosky therefore suggests that manual therapy applies a
mechanical force, causing a chain of neurophysiological responses in the central and
peripheral nervous system, which can explain the clinical outcomes seen post manual
therapy.22

2.4 Which treatment approach?

Currently within the Physiotherapy profession there is much debate about what a hands-on
approach achieves when treating musculoskeletal conditions .55 Some researchers feel the
biomechanical model for treating musculoskeletal conditions is outdated50 and does not
reflect the advances within the pain sciences. It is felt that mechanistic treatments based on
correcting movement dysfunction are too simplistic. OSullivan suggested that both a
mechanism based classification system for PGP can be embedded within a bio-spychosocial
framework.56 This would satisfy both the manual therapy and bio-psycho-social treatment
approaches.56 OSullivan devised a classification framework based upon the potential
mechanisms that can drive PGP, aimed at guiding the clinician through appropriate
management options. Peripherally mediated (mechanically induced) PGP disorders, can arise
from reduced force closure, may benefit, in the short term from mobilisation, manipulation
and muscle energy techniques.56

2.5 The value of qualitative data

Persson15 concluded that PGP affected women negatively with regards struggling with daily
life and enduring pain and improvements in treatment are essential to increase quality of
life.15 A recent study showed that PGP affected womens everyday lives, the ability to cope
18

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.

2.6 What is unique about this study?

The researcher is not aware of existing studies that have studied the effects of combining
manual therapy to usual care alongside patient interviews to gain an insight into their
experience of a manual therapy treatment approach. Past qualitative research has focused on
living with PGP5,15,38 and postpartum treatment,17 rather than experience of antenatal
treatment. In the latest systematic review aimed at establishing if antenatal physical therapy
interventions improve functional outcomes, a variety of outcome measures were used.18
However, to date no studies have used the most recently established and validated outcome
measure for PGP; the Pelvic Girdle Questionnaire (PGQ), which was released in 2011.58

19

2.7 Overall Aims of the project

To establish whether or not a newly introduced manual therapy treatment approach

added to usual care, improves patient reported outcome measures in women with
PGP, compared to usual care alone.

To gain an insight into womens experience of a manual therapy treatment approach

when treated for PGP by the Womens Health Physiotherapy team.

To make recommendations for the future development of the WH Physiotherapy

service, specific to PGP.

2.8 Research Questions with specific Aims and

Objectives
2.8a Question 1
Can a manual therapy treatment approach when used as an adjunct to usual care improve the
Pelvic Girdle Questionnaire (PGQ) outcome score, when compared with usual care alone in
the treatment of Pelvic Girdle Pain (PGP)?

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.

To assess the effectiveness of using a manual therapy approach as an adjunct to usual

care by applying appropriate descriptive and statistical analysis to the quantitative
data.

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.

Use semi-structured interviews to explore patients experience of a manual therapy

treatment approach provided by the WH Physiotherapy team.

Use a qualitative approach to analyse the findings.

20

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

3.2 Choice of Methods

To address different facets of the research question, two methods were selected. Participants
completed the condition-specific Pelvic Girdle Questionnaire (PGQ) outcome measure, (see
appendix 1) to generate quantitative data. It comprised of twenty-five questions relating to
womens self-reported perceptions on how problematic it is for functional activities to be
21

completed. Semi-structured interviews were deemed an appropriate method of generating

qualitative data to answer the second research question. This method was chosen for
pragmatic reasons, primarily because it best suited the researchers skills. It also allowed
rigour to be maintained62 and participants perspectives to be more fully represented.66 Also,
opinions and beliefs could be explored in depth64,67 in relation to womens experiences of a
manual therapy treatment approach. Unstructured interviews were not chosen partly due to
the researchers lack of interviewing experience, with Robson noting they are not an easy
option for the novice page 288. 59 The researcher felt it appropriate to use an interview guide
to allow the interview to feel like a conversation with a purpose page 67,66 whilst giving
the researcher confidence in knowing the research question was being explored.

3.3 Staff Training

The researcher delivered two, two and a half hour in-service training sessions as part of her
role as a clinical specialist physiotherapist. The content of these sessions aimed at
teaching/updating physiotherapists from the WH team about the assessment and treatment of
PGP using a manual therapy approach. It was a new approach for some physiotherapists and
a refresher for others. There was a mixture of Band 5, 6 and 7 physiotherapists who attended
the training.

3.4 Quantitative Methods

3.4a Sampling and Recruitment
The study population was antenatal women with PGP who were referred to WH
physiotherapy outpatients at the Royal Hallamshire Hospital (RHH). To identify the most
appropriate participants a purposive sampling strategy was used, which pragmatically
reflected the availability of the participants.62 The inclusion and exclusion criteria are shown
in table 1 below.

22

Table 1: Inclusion and exclusion criteria for quantitative recruitment

Inclusion Criteria

Exclusion Criteria

Over 16 years old

Under 16 years old

English speaking

Non-English speaking

Referred for Pelvic Girdle Pain

Referred with a musculoskeletal condition

which is not Pelvic Girdle Pain

Completed the Pelvic Girdle Questionnaire at

Not completed both PGQs (at assessment

assessment and repeated again at six weeks

and at six weeks)

3.4b Sample size

It was estimated that data from 50 participants from the usual care existing service and 50
participants from manual therapy approach plus usual care new service should be collected.
This was based on recommendations from the Clinical Effectiveness Unit at STH as a basis
to provide sufficient information to change practice.

3.4c Procedure and Data Collection

Data were collected over a 3 month period, with usual care data collected retrospectively by
the researcher. The data was extrapolated from the PGQs which were already completed by
the participants between the months of November 2012 and February 2013. This PGQ was
completed upon new participant assessment and again, six weeks later. This data reflected
current practice or usual care. The researcher collected the usual care data at the six week
follow-up point by telephoning participants, to ease time and caseload pressures of the WH
team.
The manual therapy treatment approach plus usual care data was collected by the researcher
and members of the WH team. This occurred between May 2013 and July 2013. The
researcher was involved in telephoning patients to collect their 6 week follow-up PGQ data,
if they were not seeing their physiotherapist, six weeks after assessment. Baseline data was
collected at the participants first assessment. This data reflected the new service of a manual
therapy approach being offered, as an adjunct to usual care.
Participants data remained anonymous. Data were also recorded for gestation (in weeks) at
assessment, participants date of birth, gravidity, parity and number of treatment sessions.

23

3.4d Data Analysis

To ensure the quantitative results were communicated effectively, descriptive statistics were
applied to the data, which included means, percentages and frequencies. Inferential statistical
analysis using t-tests was undertaken to establish possible relationships between the manual
therapy and usual care groups.

3.5 Qualitative Methods

3.5a Sampling and Recruitment
The study population was antenatal women with PGP who were referred to WH
Physiotherapy Outpatients at RHH, having been treated with a manual therapy approach plus
usual care. To identify the most appropriate participants, a purposive sampling strategy was
used as it allowed the researcher to think critically about the characteristics of the population
under investigation.62 The inclusion and exclusion criteria used are shown in table 2 below.

Table 2: Inclusion/exclusion criteria for qualitative recruitment

Inclusion

Exclusion

Over 16 years old

Under 16 years old

English speaking

Non-English speaking

Received a manual therapy treatment

Received usual care treatment only

approach to treat PGP

3.5b Sample size

For non-probabilistic data, where there is a group of homogenous individuals and the aim is
to understand experiences and common perceptions, Guest et al (2006) postulated 6-12
interviews should suffice to achieve data saturation.68 For this project, the researcher would
aim to interview between 8 and 10 women, which was based upon the assumption that the
sample would reach theoretical saturation and provide adequate data to make meaningful
comparisons to answer the research question.66 The decision for the sample size was also
influenced by pragmatic factors such as the researchers time constraints within her Masters
degree, and anticipated recruitment rates.
24

3.5c Procedure and Data Collection

Over the period of May-July 2013, women who were potentially suitable to participate in
interviews were known to the WH team as they were being treated with a manual therapy
approach for their PGP. A patient information sheet (PIS) (see Appendix 2) was given to
these women individually at their second appointment with the Physiotherapist, inviting them
to participate in a semi-structured interview. When the potential participant was given a PIS,
they were asked by their physiotherapist if the researcher could contact them directly after a
few days, allowing sufficient time for the information to be read. The physiotherapist
recorded this on a separate sheet in the researchers file and then called the researcher to alert
her to a potential recruit. Potential participants were also able to directly contact a lead
physiotherapist, who acted as a gatekeeper, but none chose this method.
The researcher contacted the potential participant by telephone and talked through the PIS
and answered any questions regarding the semi-structured interview. At this stage potential
participants were given adequate time (minimum of 24 hours) to consider participation in a
semi structured interview. A follow-up phone call was then made to establish if they wished
to participate or not. Because the women were at varying stages of pregnancy, had (potential)
work and childcare commitments and were in pain, the researcher felt it was not acceptable to
ask the potential participant to come into the physiotherapy department for unnecessary
visits. Therefore, the researcher judged a telephone call the best method of talking through
the PIS, rather than face to face contact. When verbal consent was obtained, a time and date
was arranged for the semi-structured interview, which took place at the RHH or the
participants home.
On the day of the interview, written informed consent was obtained using the consent form
(see appendix 3). Each interview lasted a maximum of 45 minutes and the researcher used an
interview schedule to guide the interview (see appendix 4). The interviews were audio
recorded, then anonymised and transcribed verbatim.

3.5d Data Analysis

Thematic framework analysis proposed by Ritchie and Spencer (1994)69 was used to analyse
the data generated from the interviews. This approach was selected due to its systematic
stages that, when applied to data, created a transparent audit trail of how themes were
derived.69 It also allowed the researcher to explore the research topic while being open to new
themes emerging from the data. The following five stages were applied to the data:
25

1) Familiarisation: overview of key points gained by immersion in the data.

2) Identifying a thematic framework: recurrent themes were noted from the interview
transcripts, which were based on a priori themes in the interview guide and from emergent
themes arising from the data.
3) Indexing: The thematic framework was then systematically applied to each data set.
4) Charting: Allowed data to become organised within the themes and compared across cases.
5) Mapping and interpretation: allowed associations, explanations and concepts to be
developed from the data.
Other qualitative approaches such as Grounded Theory70were not selected because it was not
possible for the researcher to view the interview data without preconceptions.62 This was due
to the researchers background as a physiotherapist, prior contact with women who had
experienced PGP and spending 18 months researching PGP.

3.5e Development of Interview Guide

The timing, flow and structure of the interview were tested by piloting it with a colleague
who had experienced severe PGP during her pregnancy. The data generated from this
interview allowed the researcher to refine the topic guide and prompts. The researcher also
discussed with her line manager pertinent topic areas relevant to the service, which shaped
the topic guide. The available literature regarding PGP also shaped the content of the
interview, with the researcher being mindful to ensure the research question was being
answered.

3.6 Mixed methods data analysis

Parallel mixed data analysis63 was undertaken which involved completing the separate stages
of analysis as described in 3.4d and 3.5d. Although the analyses were completed
independently, the inferences made from the separate results were synthesised to establish if
the results converged or diverged.63 Integration of results is an important factor in mixed
methods design.62 However a recent study has shown evidence of a lack of integration of
findings from the different components.71 With full integration of the findings, the amount of
knowledge generated can be richer than the knowledge produced from independent

26

findings.71 Therefore, quantitative and qualitative data were synthesised to allow for potential
connections and further interpretation.59

3.7 Researcher Details

The researcher is a 35 year old female with 12 years experience as a musculoskeletal
physiotherapist. The researcher has a new role as a Clinical Specialist Physiotherapist in
Womens Health which has been a contributory factor behind applying a manual therapy
treatment approach to women with PGP. She had also had three children and feels
empathetic towards women experiencing PGP. The researcher is mindful of the potential
biases that can occur because of these factors and will be explored further in the discussion.

3.8 Reliability and Validity

The PGQ had acceptably high validity and reliability in people with PGP both antenatally and
postpartum which was demonstrated in a recent research paper.58 A further research paper
concluded that the PGQ had good test-retest reliability, internal consistency and construct
validity for women with PGP.72 Therefore it is a recommended outcome measure for
evaluating symptoms and disability in patients with PGP.
Four criteria were proposed by Guba and Lincoln (1994),that together demonstrate
trustworthiness of qualitative data; confirmability, dependability, transferability and
credibility.73 The researcher ensured the interview data remained trustworthy by; combining
quantitative and qualitative methods to triangulate the findings, potential researcher bias was
declared, negative information was presented and peer debriefing was used.63,64 An audit trail
was used which helped minimise threats to validity and reinforced the researches reliability.59
Data and emerging themes form the interviews were cross-checked by the academic
supervisor, which enhanced validity.59,62

3.9 Ethical Considerations

It was the researchers aim to interview women before or after antenatal hospital
appointments to prevent the participant making an additional journey. Or, the researcher
would offer to interview the participant in their own home to minimise their discomfort. If the

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

Chapter 4: Quantitative and Qualitative

Results
4.1 Introduction
First the quantitative and then the qualitative results will be presented separately and
appropriate analysis undertaken. The results were synthesised to answer the mixed methods
research questions.

4.2 Quantitative Results

It is important to keep the research question in mind when trying to ascertain what statistical
analysis/test to perform on the data. The research question is: Can a manual therapy treatment
approach when used as an adjunct to usual care improve the Pelvic Girdle Questionnaire
(PGQ) outcome score, when compared with usual care alone in the treatment of Pelvic Girdle
Pain?

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.

4.2c Data Analysis

Both descriptive and inferential statistical analysis was applied to the data. There was no
missing data to report. SPSS Version 20 was used to facilitate data management and analysis.
The raw data from the PGQ is given in appendix 7.

29

4.3 Descriptive Statistics

There were 24 women in the usual group and 22 in the manual group. Mean ages of the usual
and manual groups were 30 and 31 years respectively and mean gestation at initial
assessment was 28 weeks for the usual group and 25 weeks for the manual group. Data was
collected relating to trimesters which are illustrated by Graph 1. Sixteen women (72.5%)
form the manual and 11 women (45.8%) from the usual groups were in their second
trimester. The usual care group had more than double the women in their third trimester
(13/24 or 54.2%) than compared to the manual group (5/22 or 22.7%). The differences and
similarities in parity in the usual and manual groups are shown in Graph 2.

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

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

Usual Care Group

(n=24)
30
28

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.

4.4 Inferential Statistics

Inferential statistical analysis assumes data is Normally distributed. To test this assumption, a
Q-Q plot analysis in SPSS was performed. Graph 4 demonstrates the data was Normally
distributed at baseline and parametric tests were therefore selected to compare the data. The
Q-Q plot for PGQ scores at 6 weeks is not shown, as the results are almost identical to those
in Graph 4.
32

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

4.5 Qualitative Results

The qualitative research question is: What are womens experiences of a manual therapy
treatment approach when treated for PGP by the Womens Health Physiotherapy team?

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.

Table 4: Demographics and PGQ data from women interviewed

Name

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.

4.5c Data Analysis

The five stages of Framework Analysis69 were applied to the qualitative data which allowed
for themes and subthemes to emerge from the interview transcripts. Although only seven
women were interviewed, the data appeared to be reaching saturation with no new themes
1

Pseudonyms have been assigned to the seven women interviewed

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

2) Practicalities of entering the

physiotherapy system

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

4) Response to the manual therapy

treatment approach (plus usual
care)

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

4.5.1 Theme 1: Living with Pelvic Girdle Pain

The interview data clearly showed that PGP affected women in different ways, but four
subthemes emerged which unified the womens perspective of living with PGP. They were as
follows:

4.5.1a Pain expectations during pregnancy

Some women expressed a level of being resigned to the fact that during pregnancy you
should expect pain, including when they have a pre-existing condition prior to becoming
pregnant.
I was also having sacral painI heard that a lot of people get that in
pregnancy...I was kind of living with that Cara
I have endometriosisI have an awful lot of scar tissue and when I started with
pains I kind of thought this is just my womb growingI expected to have a painful
pregnancy Grace
Anna had a telephone encounter with a physiotherapist who told her to;
Pull yourself togetheryoure a pregnant woman...your body is going through all
sorts of different changes and things...and yes you are going to feel some
(pain).Anna
Anna questioned whether or not she should seek professional advice for her PGP. When
women do seek advice from a HCP, it can actually reinforce the womens feeling of having
to live with the pain as their pain was often misdiagnosed, with blame being placed on the
weight of the baby, or water infections.
I went to see my midwife and she just told me that my baby was laid on a nerveand
when it moved this pain would go, but it didnt. So I went to see my doctor and he told
me the sameI went to see my midwife again and she told me the same again.after
a week I woke up one morning and couldnt move Beth

4.5.1b Pain levels before seeking help

Six out of the seven women experienced severe pain before actually seeing a HCP, which led
to feelings of desperation in some. Some women implied there is a level of pain you have to
tolerate until seeking advice from HCPs.
My lifes changed now (third pregnancy and having PGP three times) so I was
proper like devastated Its severe painits pain you cant bear. Daisy
Before seeing physio with this pain got to the point when I thought I cant cope
with this pain Frances
37

4.5.1c Impact on daily life

From a womens perspective PGP had a significant effect on functional abilities,
relationships and quality of life. Words that women used to describe their experience of
living with PGP are negative such as struggling, nightmare, impossible which suggested
women are feeling helpless when faced with PGP. All aspects of womens lives were affected
form daytime activities, sleep, relationships with their partners and reliance they had on other
family members.
My husband works 6 days a week and he was at home just on a Sunday and we were
finding that we were trying to do everything on a Sundaygo shoppingchange the
beds Anna
Im going to have to stop my children going to schoolthen my mother-in law and
father-in-law said you cant stop school for the girls, we pick them up for youbut
they are elderly people as well Daisy
I was struggling to put on my trousers and underwear, I just couldnt bend, the pain
in my legs were so severe Frances
One woman had already experienced severe PGP during her first two pregnancies and she
had started with PGP at 18 weeks during her third pregnancy. She expressed a level of
desperation which had a profound effect on her perceived ability to cope with the pregnancy.
It (the pain) was a nightmare, I remember going to my husband...you know
what...end this pregnancy for meI dont want itI could not cope with it Daisy
She even delayed having her third child due to her past experiences of PGP.
My daughters have got massive age differencethe reason is I couldnt cope with
the painand after 6 years (gap) I can say I have the exact same problemits (the
pain) thereit never leaves me Daisy

4.5.1d Views about recovery postpartum

The womens insight about recovering from PGP postpartum were mixed, not based on any
known facts but just hopeful that a full recovery will be made.
To be honest I could not see an endIm going to be like this forever and because I
was only 19 weeks (pregnant) at the timeI knew I got another 21 weeks like this so
no, I could not see an end Anna
Not expecting it to go overnight but it will in time Emily
Hope it will just disappearthe weight of the baby will go Frances

38

4.5.2 Theme 2: Practicalities of entering the

physiotherapy system
This theme developed after provoking strong and varied responses from the women
interviewed regarding their referral experience into physiotherapy. Two subthemes arose
from the data and are as follows:

4.5.2a Referral process

It would appear that some women had a very positive referral experience with a short wait for
their first physiotherapy appointment. Whereas, other women had to endure long waiting
times whilst becoming increasingly desperate to be seen. The womans individual perception
on what was an appropriate length of time to wait may be associated with the amount of pain
they were in whilst waiting for an appointment. This can be illustrated using the PGQ scores
at baseline and using qualitative data to express the womens referral experience, which is a
clear advantage of using mixed methods research. For example, Anna and Grace had PGQ
baseline scores of 88% and 54% respectively and they had a negative experience of the
referral process, expressing that it should be easier to get seen by a physiotherapist:
Four weeks is a long timeto wait for an appointmentI was in so much pain, I
wasnt sleeping at night...I was pleading with her (GP)I need to see somebody
Anna,
Really frustratingyoure obviously in a really bad way and she (midwife) said she
would send an urgent faxit took me 3 weeks to get a letterto make an appointment
thenanother 3 weeks to actually get to see a physiotherapistthe fact that when I
saw her she fixed me in 2 seconds flat was like why on earth could this not have
happened 6 weeks ago? Grace
Whereas Cara had a PGQ baseline score of 31% and she thought 3-4 weeks was a
reasonable amount of time to wait.
Three main pathways into physiotherapy were described by the women; referral via GP,
midwife and triage. It appears to be pot luck as to how quickly the initial HCP recognised
womens symptoms as PGP and then referred the woman for physiotherapy.
The referral process was really easy I rang the triage numberand they (midwife)
filled out the referral over the phone Cara, (who self-referred via triage.)
I had seen about 5 doctors (laugh), been to see the midwife Beth
Saw my midwife who referred me and a week later I was seen Emily

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

4.5.2b Location of physiotherapy appointments

Three distinctive issues arose from this subtheme. Firstly, women had varying opinions
regarding the location of treatment i.e. RHH, Jessops or at a local GP surgery. Some women
were satisfied with having to get 1-2 buses to the hospital; others always came with a relative.
All the women said they would prefer to be treated locally at a GP clinic, although recognised
that they would travel anywhere for the best treatment.
I dont mind travelling, its just the times of the appointments you have to set off an
hour before for parking as well and then rush back for the childrenbut if youve got
to go, youve got to go (referring to Jessops) Frances
Women then discussed the aspect of getting around the hospital site itself relating to mobility
and pain. For physiotherapy, women were seen at two possible locations; either at Jessop
Hospital or in physiotherapy outpatients at RHH. There are slopes to negotiate between these
sites and the bus stop/car park.
That was a nightmare...it was in different places every time I went and kept getting
confused and going to the wrong placethe car parks were full so I ended up parking
miles awayand had to hobble up to the hospital Grace
Somebody with that much PGP getting from the shuttle bus starting from the
Hallamshire right up to Jessops was a nightmareby the time I got up there I was
totally exhausted and I was using crutches as well Anna
Lastly, women commented on the treatment environment at a room level. Some found the
physiotherapy room at RHH unpleasant and others were not bothered by the room.
The room at the Hallamshire was really grotty...felt sorry for the physio having to
work in it all day...the antenatal room was brilliant Cara
Im happy (with the treatment rooms) I dont mind really it doesnt bother me at
all Daisy

4.5.3 Theme 3: Patient expectation pretreatment

Interestingly womens pre-treatment expectations regarding what physiotherapy could
achieve were contrasting, but fell into 3 subthemes.

40

4.5.3a Negative mind-set

This mind-set mainly represented the views from women who had experienced negative
encounters with other HCP in the past and so physiotherapy was almost tarred with the same
brush.
I wasnt expecting much...this (physiotherapy) is not going to do anything for meI
really didnt think Id have any joy from it at all Anna
They (physiotherapists) are not going to help me much because I know, Ive been
through it in the past twice Daisy

4.5.3b Hopeful treatment will help

Some women described being in so much pain they were just hopeful that physiotherapy
would help in some way.
Ive had a couple of experiences of physio in the past and it has been very helpful so I
was kind of more hopeful than just seeing a consultant Grace

4.5.3c Unsure expectations

Other women were completely neutral and open to what the treatment would involve. None
of the women interviewed had heard about any specific types of physiotherapy treatment for
PGP through family/friends, prior to being assessed:
I didnt know what to expectI just wanted it to stop Beth
I didnt really know (what to expect) to be honest, Id never had physio Frances

4.5.4 Theme 4: Response to the manual therapy

treatment approach (plus usual care)
Within this theme, data from all seven women interviewed populated the following four
subthemes. This data specifically helped to answer the research question regarding their
experience of manual therapy treatment.

4.5.4a Initial response

The data from the women provided information regarding three different reactions to manual
therapy. Firstly it appeared that the majority of the women initially felt sore after manual
therapy.
The day after I couldnt walk, I couldnt bend and I thought what has this woman
(physiotherapist) done to me Anna
41

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

4.5.4b Functional change

All of the women described how their functional abilities improved significantly post
treatment, even if their pain did not go completely. There was a sense of increased
independence and freedom to undertake their daily activities.
I go out nowI can manage to pick my daughters upwalk around the house go
see my friendsI can now manage my lifego out shopping with my husbandyou
guys (physiotherapist) have made my life much easier Daisy
Can do more or less everything normally without any pain.eases for just over a
week Emily
The women appeared to appreciate the small changes in their abilities which contributed to
improved activities of daily living.
I can turn over in bed more easily, take the neighbours dog for a walkmore
confident about getting out and about if I hadnt have had it (manual therapy) I
dont know where Id be now Grace

4.5.4c Perception of alignment

Across all seven women, there was a belief that manual therapy affected the position of their
pelvis. Without observing the treatment session directly, it is unclear if these were
perceptions that were generated by the patient or, if it is how the physiotherapist described
what the manual therapy treatment is doing.
42

My pelvis wasnt rotatingI wasnt in line basically Cara

This joint has come out (pubis) and plus its stuck somewhere Daisy
Pelvis round the back had dropped Emily
My pelvis had slipped Frances

4.5.4d Exceeded expectations

There was a strong consensus of opinion that the results of the manual therapy approach
exceeded the womans expectation. This was even more obvious when the initial pretreatment expectations had been negative, giving an outcome that was polarised from initial
expectation to actual results. Anna and Grace reported the effect of manual therapy lasting for
ten weeks after just one session of manual therapy, which surprised them.
Didnt think I would come out feeling any better but I did feel better so you cant say
better than that Frances
I dont know what I expected to be fair but she sorted me out straight awayIm
glad I cameI dont think I would have lasted much longer if I had not had it
(manual therapy) done Beth
The groin pain was better but I was still getting it, but the sacral pain had totally
goneI cant think of anything else, any reason why it would go all of a sudden
Cara

4.5.5 Theme 5: Relationship with

Physiotherapist
All seven women interviewed, reported a positive attitude towards the physiotherapist and a
sense of relief that a HCP understood their problem.

4.5.5a Trust in Physiotherapist

When women spoke about being in severe pain, they appeared to become passive in their
treatment with the physiotherapist and totally put their trust in them.
When you are in that much pain..I would have done anything to get the results
Anna
I just let her (physiotherapist) do whatever she needed to do Beth
I went there and she was checking me and she said does it (pubis) give you a bit of
painshe picked it up, I never mentioned it so I completely trust her Daisy

43

4.5.5b Empathy from the Physiotherapist

Women positively recalled the feelings of empathy and understanding shown by the
physiotherapists and felt their PGP was validated during the appointment.
They (physio) dont look at you as if you are silly Emily
So many medical professionalsbecause Ive had endometriosis..see me as a womb
and a pair of ovaries.I didnt feel like that about the physio at all. She sympathised
and understood and was really nice, it makes a huge difference as to how you come
away from an appointment Grace
She (the physiotherapist) saw me walk towards her and she knew instantly I was in
quite a lot of pain which was nice because somebody recognised then that I was in
agony Anna

4.5.5c Womans dignity respected

With regards to how the women felt during the treatment session, all women agreed they
were comfortable having manual therapy techniques applied to their pelvis by the
physiotherapist.
I was more than comfortable with it (hands on treatment) Anna
It (the treatment) wasnt intrusive, I felt totally comfortable Cara
Privacy was always maintained Emily

4.5.5d Recommendation of Physiotherapy

All seven women interviewed were quick to recommend physiotherapy after receiving
treatment for their PGP. This was despite some women having a negative referral experience,
or a perceived long wait for their appointment or low expectations of physiotherapy prior to
treatment.
If somebody says to me you want to swap hands (on) treatment or just like what they
had given me previous 2 pregnancies (exercises) I will never swap it...I will 100%
support the physios Daisy
Theyll (physio) sort you out straight away Emily
Yes definitely, thats the first place you should go Grace

44

4.6 The emergence of unexpected data

When the researcher telephoned the women to obtain the PGQ score at 6 weeks for both
groups, women often provided qualitative comments without being prompted. These
spontaneous comments were not planned for in the methods, but using unexpected data61
has added to a deeper level of understanding and explanation. For example, 18/46 women
scored worse on the PGQ at 6 weeks, however the worsening scores were accompanied by
the following subjective comments:
Less pain now than at the first appointment PGQ score increasing from 55 to 75%.
(manual group)
Great within a few days and then pain returns with PGQ staying unchanged at
36% (manual group)
The pain feels much better but increased PGP score from 35 to 40% (manual
group)
Further insight as to why some women showed an improvement on the PGQ can be
highlighted with the following comments;
Stopped work at 30 weeks, with PGQ reducing from 62.6 to 48.6% (usual group)
Not driving now as finished work with PGQ reducing from 66.6 to 44.9% (usual
group)

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

5.2 Quantitative data discussion

The descriptive and inferential analysis revealed a number of unexpected findings.
Descriptive analysis of the results confirms that at baseline there was very little variation
between age, gestation, trimester and PGQ baseline scores for the women between the two
groups. This suggests that the sample of women in this study may be representative of the
population of pregnant women with PGP in Sheffield. This study was not designed with a
sample size calculation and the researcher did not expect to obtain statistical significance for
any of the comparative tests. The main significant finding was with the manual therapy
group, comparing PGQ scores at baseline and at 6 weeks follow up. This suggests there is
evidence that using manual therapy as an adjunct to usual care reduced the PGQ score after 6
weeks. The treatment effect was supported by the qualitative data, discussed in section 5.2d.
This study showed the estimated size of effect was 9.64% however; the clinically minimum
important difference has yet to be published for the PGQ. This study suggests that a change
of 9.64% or more in the PGQ could be clinically significant. Further studies would need to be
repeated with a sample size calculation and control of potential confounders.
The independent t-test was used to compare the difference in the means (change in PGQ
score) at baseline and 6 weeks between the usual and manual groups, which revealed a nonsignificant result. Therefore, to answer the research question; there is insufficient evidence
that a manual therapy treatment approach when used as an adjunct to usual care improved the
PGQ scores when compared to usual care. One reason for achieving non-significance was
possibly the small sample size as a power calculation was not performed. However, the 95%

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.

5.3 Qualitative data discussion

Gaining patient views is important in health service research because it adds to the
understanding of a specific condition or disease, an intervention or an outcome, grounded in
the real world.60 Through the analysis of seven semi-structured interviews, five themes
containing subthemes were identified and will now be discussed.

5.3a Living with Pelvic Girdle Pain

The three subthemes of pain expectation during pregnancy, pain levels before seeking help
and impact on daily life, blended together in the literature,15,38,40 which demonstrated these
subthemes are highly interlinked. One of the core categories that emerged from Perssons
study was struggling with daily life and enduring pain.15 This corresponded to the living
with PGP theme in this study. The repeated themes between different studies can
emphasises the effect PGP has on restricting womens activities of daily living and the need
for the condition to be recognised and managed early by HCP. This study generated similar
themes to the body of literature, and therefore could act to validate existing findings as
credible and perhaps generalizable. A recurrent finding in this study was that PGP limited

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.

5.3b Practicalities of entering the physiotherapy system

Women in this study showed how frustrating it can be visiting the GP or midwife on more
than one occasion before a referral was made. This can possibly be explained and supported
by the current research as highlighted above of being expected to live with the pain or
misdiagnosis. By the time the women are then referred to see a physiotherapist, and have to
wait for their first appointment, women are often in severe pain which potentially has a
negative effect on the womens expectations of what physiotherapy can offer. This level of
desperation to be seen can have a negative impact on the womens health physiotherapy
team working within the outpatient department. Anecdotal evidence from the WH team
48

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.

5.3c Patient Expectations pre-treatment

The researcher found limited research regarding pre-treatment expectations, as research is
commonly focused on patient satisfaction during physiotherapy care.74 In a systematic review
of patient satisfaction with musculoskeletal physical therapy, expectations of physical therapy

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.

5.3d Response to a manual therapy treatment approach

(plus usual care)
A recurrent theme for this study showed that six out of seven women reported an increase in
pain for one to two days post treatment and then their pain diminished or completely cleared.
This expected treatment soreness was explored in a qualitative study by Carlesso et al,76
where patients perspectives of potential adverse responses to manual physiotherapy were
sought.76 The study concluded that 96% of respondents felt that mild adverse responses that
were mild were tolerable, if there was a trend that their condition was improving overall.
Mild adverse responses included increase pain, soreness and existing symptoms to name but a
few. The same study found that 98% of respondents agreed that if the physiotherapist warned
of a potential adverse response after treatment, then the adverse response became more
acceptable. Relating this research to clinical practice, it emphasises the importance of
clinicians communicating well with their patients and has the potential to improve the
therapeutic relationship. Treatment expectations and effective communication have also been
associated with patient satisfaction.77

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

5.3e Relationship with physiotherapist

The theme of relationship with the physiotherapist resonated with the findings from a study
by Stuge.78 Women reported that physiotherapists had taken them seriously and were treated
as individuals, which reflected this studys finding. Women in this study felt the
physiotherapist validated their pain, which can be lacking form doctors, as highlighted in
another study, with GPs who suggested pain was a normal part of pregnancy.5 A systematic
review which looked at patient satisfaction with musculoskeletal physiotherapy, concluded
that one of the key determinants of patient satisfaction was the interpersonal attributes of the
physiotherapist.74 These attributes included caring, friendliness and efficient communication,
which support the findings of this study.
In a recent study,76 90% of respondents agreed that trust in their physiotherapist was
important and it reduced the concerns if a mild adverse event occurred. This can be seen in
the results presented above, where women who are desperate for their pain to go will do
anything to get pain relief.
A positive finding from this study suggests women were satisfied with the treatment they
received as all participants would recommend physiotherapy to friends or family members
with PGP. Conversely, the results from Wellock et al, show women were disappointed with
the care they received.39 However, only women who received manual therapy alongside usual
51

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

5.4 Quantitative and Qualitative data synthesis

The following section will discuss the integration of some the qualitative and quantitative
results which when combine together can give a more detailed understanding of the results.
Initially the physiotherapy WH team had concerns regarding the effect that a manual therapy
treatment approach would have on caseloads, assuming that more appointments would be
needed. Conversely, the data shows that, on average, women in the manual therapy group had
only 1.82 appointments compared to one appointment in the usual care group. This is
supported by the qualitative data, in which women report that after the first session of
treatment they noted an improvement in their pain and function. The current appointment
system allows for antenatal women with PGP to be seen for a second time, if required, so the
results from this study should not have a negative impact on the physiotherapists caseload.
The quantitative data suggests that at the womens first appointment, 2.2% are in their first
trimester, 58.7% are in the second and 39.1% are in their third trimester. This appears to be
supported by the qualitative findings where women delay going to see their midwife or GP
until they can no longer cope with the pain. The literature suggests there is a possible increase
in pain around the sixth to seventh month (2nd trimester) due to a new stage of stretching of
the dermal tissue.79 This is accompanied by a shift in the centre of gravity in the body as a
result of the growing uterus which in turn increases the lordosis and strain across the painsensitive ligaments.79 It may be prudent to review the literature that is distributed to women
early in their pregnancy, to inform them about PGP and the need to seek early advice and
treatment from qualified healthcare professionals.
The unexpected qualitative data collected from women whilst completing their 6 week PGQ,
highlights the potential limitations of outcome measure tools used in clinical practice. The
data demonstrated a discrepancy between (on occasions) a worsening PGQ score, but
subjective reports of improvements in terms of pain and function. This is supported in the
literature which recognises that outcomes, measured through validated questionnaires may
52

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.

5.6 Learning Points

This study has provided the researcher with invaluable knowledge and a deeper insight into
womens experience of receiving manual therapy for the treatment of PGP. This will enable
the researcher to reflect on the findings and change clinical practice and the service
accordingly. The research journey has given the researcher new skills which will be
transferable into future projects. Experience of writing a research proposal, gaining approval
from ethics, conducting, transcribing and analysing interview data, and using SPSS have
resulted in a comprehensive understanding of the mixed methods approach.

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

6.2 Recommendations for future practice

The third aim of this study was to make recommendations for the future development of the
WH Physiotherapy service, specific to PGP, which are as follows:

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.

6.3 Recommendations for future research

This study indicated that women with PGP benefited from a multifactorial treatment
approach. A larger, funded, pragmatic mixed methods trial could look to evaluate the
effectiveness of a manual therapy treatment approach in conjunction with usual care, with the
following factors taken into consideration: use of a sample size calculation, control for
potential confounders and a longer follow-up of patients including postpartum. Appropriate
outcome measures to assess quality of life could be added to the PGQ outcome measure.
Treatment protocols could be developed as a guide to treatment rather than a strict recipe, in
order for treatments to be reproducible. Other NHS Trusts in the UK could be included in a
multi-centre trial.
It would be beneficial to complete an economic evaluation in order to establish the cost PGP
has on the local/national economy. Further research could look at the effect a manual therapy

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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Appendices
Appendix 1: Pelvic Girdle Questionnaire
Pelvic Girdle Questionnaire
First Assessment

Percentage = Score/total x 100

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.

How much pain do you experience?

[
T
y[
pT
ey
None (0)

Some (1)

Moderate (2)

21. In the morning

22. In the evening

To what extent because of pelvic

girdle pain:

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

23. Has your leg/have your legs given way?

24. Do you do things more slowly?
25. Is your sleep interrupted?
Scoring procedure: the scores are summarized and recalculated to percentage scores from 0 (no problem
at all) to 100 (to a large extent).

t
fe
r
of
m
r

64 o
tm
h
et

Appendix 2: Participant Information Sheet

PARTICIPANT INFORMATION SHEET

Pelvic Girdle Pain: A mixed methods evaluation of a manual therapy treatment

approach plus usual care versus usual care alone.
You are being invited to take part in an interview for a research project being undertaken as
part of a Masters dissertation at the University of Sheffield. Before you decide if you would
like to participate, it is important for you to understand why the project is being done and
what it will involve. Please take time to read the following information carefully and discuss
it with others if you wish. If there is anything that is not clear or if you would like more
information my contact details can be found at the end of this sheet. Take time to decide
whether or not you wish to take part.
Thank you for reading this.
What is the purpose of the project?
At Sheffield Teaching Hospitals we are looking to treat women who have pelvic girdle pain
with some hands on Physiotherapy treatments. This will happen as part of the usual care
that the service provides, which may also include advice, education, exercises, stretches,
pelvic belts and crutches. By speaking to women like you who have been treated with hands
on Physiotherapy for your pelvic girdle pain, I will be able to find out about your experience
of the treatment you received by Womens Health Physiotherapy team. This will help the
team to develop the service and understand the needs of women who have pelvic girdle pain.
The entire project will last 4-5 months but your involvement will only take approximately 45
minutes of your time.
Why have I been invited?
When you were seen by your Physiotherapist for your pelvic girdle pain, she treated you with
a hands on approach which is called manual therapy. I would like to find out about your
experience of the treatment. I will be asking a small number of women to talk to me so I am
able to gather a range of opinions/information.

65

Do I have to take part?

It is up to you to decide whether or not to take part. If you do decide to take part you will be
given this information sheet to keep. If you wish to take part I will ask you to sign a consent
form. You can still change your mind at any time without giving a reason. If you no longer
wish to take part you can withdraw at any point without it affecting any current or future
health care that you receive.
What will happen to me if I take part?
If you would like to take part I will arrange a time for you to come into the Physiotherapy
Outpatient department at the RHH or Jessops Hospital at a time/day that suits you. Or we
could meet after an appointment with your physiotherapist or midwife/consultant to save
another journey to the hospital. Alternatively, if you prefer to be interviewed in your own
home, then this can be arranged.
I will ask you some questions about the service and the treatment you have received which
will last around 45 minutes. This is known as an interview. The interview will take place in a
private room and if you agree I would like to tape-record the interview so I can remember
what you have said. This will allow me to further understand what women are telling me and
may ultimately lead to changes in the service.
After the interview I will not need to see you or contact you again. I will be happy to share a
summary of the findings after all the interviews are analysed and the project is completed.
What are the possible disadvantages of taking part?
If you agree to be interviewed, then you may have to attend the hospital for an additional
visit, which may cause you discomfort due to the nature of your pelvic girdle pain. To
minimise this potential discomfort, the interview could take place in your home. Your
antenatal or postnatal care will not be affected in any way by agreeing to take part in this
project.
What are the possible benefits of taking part?
You will not benefit directly if you agree to take part in the interview. It is hoped the
information you provide will improve the care for future women who attend the Womens
Health Physiotherapy service for the treatment of pelvic girdle pain.
What if there is a problem?
If you are not satisfied with how you have been approached or treated during the interview
then please contact my supervisor Dr Annette Haywood. Her details are at the end of this
sheet. Or you can complain through the NHS complaints procedure, by contacting Helen
Morewood, Clinical Services Manager, Outpatients, RHH.

66

Will my taking part in this project be kept confidential?

As a clinical researcher I will behave in a way that is fully guided by ethical principles and
legal/regulatory requirements. All the information that I collect about you during the course
of the project will be kept strictly confidential. With your permission, I will inform my
manager of any issues you may have regarding the care you received. Once the interview is
recorded, the questions and answers will be typed out and only seen by me and my academic
supervisor at the University of Sheffield. Your name will never be linked with the answers
you give as I want to hear your true thoughts and opinions. The Physiotherapist who treated
you will not be aware of your responses. If another person is named in the interview, they
will not be identified.
You will not be able to be identified in any reports or publications that may be written as a
result of this service evaluation. Any quotes used from the interview will be anonymised. The
audio tape of the interview will be kept in a locked filing cabinet during the project and it will
be destroyed after the service evaluation has ended.
What will happen to the results of the project?
This work is forming a part of my Clinical Research Masters degree and the process and
results will be used to complete my dissertation. I will also be reporting the results to the
Clinical Effectiveness Unit at Sheffield Teaching Hospitals NHS Foundation Trust and to my
managers within Therapy Services. This process will hopefully inform the Trust as to how we
can improve patient experiences and care with women who have pelvic girdle pain. The
findings may be written up as a paper that could be published in a journal. If you would like a
copy of the summary of findings then please contact me as per the details at the end of this
sheet.
Who is organising and funding the project?
I am a Clinical Specialist Physiotherapist in Womens Health and I am completing a Masters
degree funded by the National Institute for Health Research (NIHR). I am studying at the
School of Health and Related Research (ScHARR) at the University of Sheffield. The project
is supported by my employer, Sheffield Teaching Hospitals NHS Foundation Trust (STHFT)
and by the University of Sheffield.
Who has ethically reviewed the project?
This project has been reviewed and approved by the Clinical Effectiveness Unit at STHFT. It
has also passed through the ScHARR Ethics Review Procedure from within the University of
Sheffield.

67

What do I do if I want to take part in the interview?

If you have given your permission, the researcher will contact you in a few days once you
have had a chance to read through this information sheet. Or before then, you can contact Jon
Fawcett on 0114 2713090. Jon is a Lead Physiotherapist in Outpatients at the RHH who will
then pass on your details to me, Clare Monaghan, the clinical researcher. I will contact you to
talk about the details in this information sheet and answer any questions you may have.
Thank you for taking the time to read the information sheet.

Contact for further information

If you have any questions about the project you can contact:
Clare Monaghan
Clinical Specialist Physiotherapist
B Floor Royal Hallamshire Hospital
Glossip Road
S10 2JF
Tel: 0114 2713090
Email: ctmonaghan1@sheffield.ac.uk
Helen Morewood
Clinical Service Manager - Outpatients
Therapy Services
Sheffield Teaching Hosptials Foundation Trust
0114 2712766
Pager 07623891600
Email: Helen.morewood@sth.nhs.uk

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

Appendix 3: Consent Form

CONSENT FORM
Participant Identification Number for this project:

Title: Pelvic Girdle Pain: A mixed methods evaluation of a manual therapy

treatment approach plus usual care versus usual care alone.
Name of Researcher: Clare Monaghan
Please initial box
1. I confirm that I have read and understood the information sheet dated
.. (version 1.3) explaining the above study. I have given thought
to the information, asked questions where necessary and I am satisfied with
these answers.
2. I understand that my participation is voluntary and that I am free to withdraw
at any time without giving any reason. There will not be any impact on my
health care should I wish to withdraw. I am also able to decline to answer
any question(s) during the interview. The lead researcher should be contacted
on 07939 206477 should I wish to withdraw.
3. I understand that my responses will be kept strictly confidential. My name will
not be associated with the interview responses and the information I provide
will not be identifiable in any written material associated with the study. I give
permission for members of the research team to have access to my anonymised
responses.
4. I understand and agree to the interview being audio recorded and the data will
be stored securely and disposed of appropriately. Any quotations used will be
anonymised
5. I agree to take part in the above project.

.................
Name of Participant
................
Name of person taking consent

Date
..
Date

Signature
..
Signature

69

Appendix 4: Interview Guide

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?

Q Tell me about any home exercises you were given (Compliance)

Prompts: If you were given exercise to do at home, were you able to complete them? If not,
why not?
Q What are your thoughts about how Physiotherapy treatment has affected you and your
PGP? (Outcomes)
Prompt: Did the physiotherapy change your pain or improve/worsen your ability to carry out
daily activities? What can cant you do now? Or is it any different to before

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

Appendix 5: Clinical Effectiveness Unit Approval

73

74

Appendix 6: ScHARR Ethics Letter of Approval

Kirsty Woodhead
Ethics Committee Administrator
Regent Court
30 Regent Street
STheeleffpiehldonSe1: 4+D4A4 (0) 114 2225453
Fax: +44 (0) 114 272 4095 (non confidential)
Email: k.woodhead@sheffield.ac.uk
Our ref: 0618/KW
30 January 2013
Clare Monaghan
ScHARR
Dear Clare
Pelvic Girdle Pain: A mixed methods evaluation of a manual therapy treatment approach
plus usual care versus usual care alone.
I am pleased to inform you that your supervisor has reviewed your project and classed it as low risk
so you can proceed with your research. The research must be conducted within the requirements of
the hosting/employing organisation or the organisation where the research is being undertaken. You
are also required to ensure that you meet any research ethics and governance requirements in the
country in which you are researching. It is your responsibility to find out what these are.
I have received the necessary electronic copy of your application together with your Supervisors
decision in line with the new streamlined University Ethics procedure, which I will keep on file.
Yours sincerely

Kirsty Woodhead
Ethics Committee Administrator
Cc: Annette Haywood

75

Appendix 7: Raw data from the 46 PGQs

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

Appendix 8a Photo showing a section of the transcript

from interview 1 with early coding and theme
development

77

Appendix 8b: Photo showing section of transcripts from

interview 1, 2 and 3 with further coding and theme
development across cases

78

Appendix 9: Charting the womens responses to allow

cross case comparisons
Theme

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