ARTICLE IN PRESS

Journal of Biomechanics 39 (2006) 627–635

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Possible harmful effects of high intra-abdominal pressure on

the pelvic girdle
Jan Mens, Gilbert Hoek van Dijke, Annelies Pool-Goudzwaard,
Victor van der Hulst, Henk Stam
Department of Rehabilitation Medicine, Erasmus Medical Centre, Dr. Molewaterplein 40, 3015 Rotterdam, GD, The Netherlands
Accepted 13 January 2005

Abstract

The present study explores the hypothesis that a high intra-abdominal pressure (IAP) loads the ligaments of the pelvic girdle to
such an extent that frequent periods of high IAP might cause pain and/or interfere with recovery of patients with pelvic girdle pain
(PGP). In a theoretical model the size of the load of IAP on the pelvic girdle was computed. The diameters of abdomen and pelvis
needed for the calculations were measured on MRI scans; the IAP values during activities were gained from literature. In slim,
healthy subjects the calculated load on the pelvic ring during activities of daily living was 26.0–52.0 N with peaks to 135 N. During
straining, vigorous work or heavy exercises the load could increase to values ranging from 104 to 520 N. The load is higher in
subjects with pain or fatigue, or in case of a distended abdomen. When the load on the pelvic ring induced by IAP is larger than
100 N, the force exceeds the force at which a pelvic belt relieves complaints in PGP; at 90 N, the force is larger than the force at
which isometric hip adduction provokes pain in PGP. We conclude that the size of the load induced by IAP on the pelvic girdle
seems to be sufficient to cause pain in patients with PGP and might interfere with recovery. It seems worthwhile to give patients with
PGP instructions to reduce IAP as much as possible during activities.
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Keywords: Low back pain; Intra-abdominal pressure; Biomechanics; Pelvic bones

1. Introduction concluded that the increase in IAP should be marked as

Although the influence of intra-abdominal pressure
(IAP) on the lumbar spine has been extensively
discussed, to our knowledge the influence of IAP on
the pelvic girdle has not been studied. Bartelink (1957)
was the first to study IAP in relation to low back pain.
His measurements of IAP in healthy subjects during
lifting showed that athletic subjects lifting 90 kg had an
IAP of 1.85 N/cm2, whereas in slightly built people the
pressure was sometimes not more than 0.80 N/cm2. If
the body had been flexed without a weight being lifted,
IAP was only slightly increased. The greater the lifted
weight the greater the increase in pressure. Bartelink
Corresponding author. Tel.: +31 10 4633160; fax: +31 10 4633843.
E-mail address: jan.mens@zonnet.nl (J. Mens).
biomechanically beneficial for the lumbar spine, espe-
cially during heavy lifting. He estimated that the
‘abdominal balloon’ could provide a decrease of the
spinal load by ‘several hundred pounds’.
Since the study of Bartelink many investigators have
shown that the amount of load reduction by the
pressured ‘abdominal balloon’ is less than has been
suggested by Bartelink (Garg, 1992). Various calcula-
tions resulted in reductions ranging from 2.6% to 40%.
However, one of the limitations of the calculations
based on mathematical models, is the controversy that
contraction of most of the muscles needed to produce
the IAP results in compression of the spine. Direct
measurements of the intradiscal pressure in healthy
subjects during various tasks showed a positive correla-
tion between IAP and intradiscal pressure (Schultz et al.,

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doi:10.1016/j.jbiomech.2005.01.016
 ARTICLE IN PRESS
628 J. Mens et al. / Journal of Biomechanics 39 (2006) 627–635
1982); however, the correlation was poor (0.36).
Measurements of the intradiscal pressure in healthy
subjects showed that performing the Valsalva maneuver
(voluntary pressurization of the intra-abdominal cavity)
raised the intradiscal pressure in four of the five tasks
rather than decreasing lumbar spine compression
(Nachemson et al., 1986). The idea of Bartelink that
the pressured ‘abdominal balloon’ unloaded the spine by
‘several hundred pounds’ is now largely abandoned.
Nevertheless, many investigators still believe that the
pressured ‘abdominal balloon’ has an important func-
tion in stabilization of the spine (Garg, 1992; Marras
and Mirka, 1996; Cholewicki et al., 1999a, b). It has
been questioned whether IAP directly stabilizes the
spine or whether the contraction of several muscles
stabilizes the spine, and whether the increase in IAP is
just a by-product of the contraction of those muscles
(Marras and Mirka, 1996).
Reported harmful effects of IAP concern herniation
of the borders of the ‘abdominal balloon’ (abdominal
wall, diaphragm, vaginal and rectal prolapse) and
urinary incontinence (Davis, 1959). Moreover, an
increase of IAP brings about an increase of the pressure
in blood vessels outside the ‘abdominal balloon’,
producing headache and ruptures of blood vessels
causing innocent haematomas, but which may be the
cause of intra-ocular or cranial bleeding leading to
blindness and even death (McGill et al., 1990; Narloch
and Brandstater, 1995; Dickerman et al., 1999). A
harmful effect on the lumbar spine and/or pelvic girdle
pain (PGP) has, to our knowledge, never been
suggested. When we realize that patients with low back
pain feel more pain in situations when IAP is high, it
seems obvious to assume that an increase in IAP may
harm the lumbar spine; for example, when coughing,
sneezing or straining (Seferlis and Carlsson, 2000;
Vroomen et al., 2002). These symptoms are normally
considered as indicators of a lumbosacral radicular
syndrome. However, these symptoms are often also
positive in non-specific low back pain (Seferlis and
Carlsson, 2000; Vroomen et al., 2002). Seferlis and
Carlsson (2000) reported that pain on coughing
provoked pain in 36 (31%) of 116 patients with various
forms of acute low back pain. Vroomen et al. (2002)
made the same observation in a group of 122 patients
with low back pain with radiation in the leg, but without
a radicular syndrome: 40 of them (33%) felt more pain
on coughing, sneezing or straining.
A relation between IAP and activities that increase
the risk for low back pain has been well documented
(Fairbank et al., 1980; Nicholson et al., 1981; David,
1985; Baty and Stubbs, 1987). The relation was so clear
that Fairbank et al. (1980) proposed to use the rise in
IAP during weightlifting as an objective measure of low
back pain. Some authors advised to protect the lumbar
spine by reducing activities with a high IAP: activities
with an IAP level lower than 1.20 N/cm2 were regarded
as safe for men and 0.60 N/cm2 for women (Nicholson
et al., 1981; David, 1985). In those studies, the level of
the IAP was interpreted as a response to load but, as far
as we know, it has never been suggested that an increase
in IAP could be the cause of pain.
During the last 15 years, research on low back pain
indicates that patients with PGP, especially with
pregnancy-related PGP, represent a distinct subgroup
of low back pain (Vleeming et al., 1992; Östgaard et al.,
1994; Pool-Goudzwaard et al., 1998; Mens et al., 1999,
2001, 2002; Damen et al., 2002; Wu, 2004). Although the
influence of IAP on the spine has been largely
elucidated, the load on the pelvic girdle due to an
increase in IAP is still a matter of investigation. In a
pilot study in 53 patients with pregnancy-related PGP,
26%, 28% and 32% of the patients indicated pain on
coughing, sneezing and straining, respectively (unpub-
lished data). This latter study was performed in the
group described below (see Section 2.1.4).
We hypothesize that a high IAP loads the ligaments of
the pelvic girdle. Many patients with PGP feel relief
when wearing a pelvic belt and feel (increase of) pain
during isometric adduction of the hips. We assume that
IAP overloads the ligaments of the pelvic ring when the
load on the pelvic ring exceeds the force at which a
pelvic belt relieves pain in patients with PGP, and at
which the force of isometric adduction of the hips
provokes pain in PGP.
The present study investigates the hypothesis that a
high intra-abdominal pressure loads the ligaments of the
pelvic girdle to such an extent that frequent periods of
high IAP might cause pain and/or interfere with
recovery of patients with PGP. First we computed the
size of the load induced by the IAP on the pelvic
ligaments during activities of daily living (ADL). Then
we compared this force with the force at which a pelvic
belt relieves or at which isometric hip adduction
provokes pain in PGP. An additional aim was to gain
information about the kind of instructions patients with
PGP need to minimize the harmful effects of IAP.
2. Methods
2.1. Part I—Collecting data for calculations
2.1.1. Dimensions of the abdominal-pelvic cavity
The abdominal and pelvic cavities are two parts of the
same ‘balloon’. The abdominal-pelvic cavity is sur-
rounded by the diaphragm, the anterior part of the
lumbar spine, the muscles of the abdominal wall and the
pelvic floor. Arbitrarily, the horizontal plane through
the most cranial point of the iliac crest was chosen as the
border between the pelvic and abdominal part of the
cavity. The size of the area ðA ¼ areaÞ and circumfer-
 ARTICLE IN PRESS
J. Mens et al. / Journal of Biomechanics 39 (2006) 627–635
ence (C ¼ circumference) of the mid-sagittal plane of
the cavities were measured by means of MRI scans in
two female subjects (Fig. 1A–C). Subject A had a flat
abdomen (not pregnant, nulliparous) and subject B had
a distended abdomen (pregnancy 28 weeks). In addition,
the height (h) of the pelvic part of the abdominal wall
was measured (distance between the upper edge of the
pubic symphysis and the cranial border of the pelvic
cavity). In the transversal plane, at the level of the
superior anterior iliac spine, the angle alpha was
measured between the abdominal wall and the frontal
plane (Fig. 2A–C).
2.1.2. IAP during activities
There are many studies on the influence of activities
on IAP in patients with low back pain as well as in
healthy subjects. A search was made in PubMed with
the search terms IAP, intra abdominal pressure, back
and measurement. The reference lists of those publica-
tions were also screened. Pressures were expressed in
N/cm2 (1 kPa ¼ 0.1 N/cm2 and 1 mmHg ¼ 0.0133 N/cm2).
Fig. 1. Mid-sagittal plane: (A) MRI of subject A, with a flat abdomen, (B) MRI of subject B, with a distended abdomen and (C) drawing. For
legends see Table 1.
629
2.1.3. Size of the protective force of a pelvic belt
A literature search was performed in PubMed with
the search terms: pelvic, belt and sacroiliac. The
reference lists of those publications were also screened.
2.1.4. Size of the provoking force of isometric hip
adduction
During a 15-month period (1-9-1998 to 1-12-1999),
patients with PGP were selected from an outpatient
clinic specialized in rehabilitation of low back pain and
PGP. Included were patients with pain, which started
during pregnancy or within 3 weeks after delivery, with
duration of at least 6 months and localized between the
upper level of the iliac crests and the gluteal fold.
Posterior pelvic pain provocation test was positive
(Östgaard et al., 1994), the score on the Active Straight
Leg Raise (ASLR) test was positive (score 3–10 on a
scale ranging from 0 to 10) (Mens et al., 2001), a pelvic
belt lowered the score on the ASLR test and pain could
be provoked by isometric hip adduction. Patients were
excluded in case of systemic diseases of the locomotor
 ARTICLE IN PRESS
630 J. Mens et al. / Journal of Biomechanics 39 (2006) 627–635
Fig. 2. Transversal plane at the level of the superior anterior iliac spine.
(A) MRI of subject A, with a flat abdomen, (B) MRI of subject B, with
a distended abdomen and (C) drawing. For legends see Table 1.
system or with major psychological disorders. The
method to measure (maximal) adduction strength was
based on a former study (Meeteren et al., 1997). The
measurement took place with a handheld dynamometer
(Microfet, Hoggan Health Industries Inc., Draper,
Utah, USA) in the supine position, the knees at 901
and the feet placed on the couch. Reliability of the
strength measurement has been shown to be good
(Meeteren et al., 1997; Mens et al., 2002).
2.2. Part II—Calculations
Using the principles of physics and mathematics the
forces applied on the pelvic ring were calculated.
The force by which the left and the right half of the
abdominal and pelvic cavity are pushed apart
(to ‘lateral’) is given by
F lateral ¼ p
A, (1)
where p is IAP and A is the area of the mid-sagittal
plane of the abdominal-pelvic cavity (Fig. 1A–C). In
accordance with Laplace’s law (Rhoades and Tanner,
1995), the tension T in the wall of the cavity is found by
T ¼ F lateral =C, (2)
where C is the circumference of this plane. From (1) and
(2), we conclude:
T ¼ ðp
AÞ=C. (3)
The tensed abdominal wall pulls both pelvic halves
together (to ‘central’). The size of the force is
F central ¼ T
h
cosines alpha; (4)
where h is the height of the pelvis, and alpha the angle in
the transversal plane between the abdominal wall and
the frontal plane.
3. Results
3.1. Part I—Data for the calculations
3.1.1. Dimensions of the abdominal-pelvic cavity
The dimensions of both subjects are summarized in
Table 1. The angle (alpha) between the abdominal wall
and the frontal plane in subject A is about 01 indicating
a flat abdomen (Fig. 2A–C).
3.1.2. IAP during activities
IAP increase has been established during many
activities of daily living and during exercises (Table 2).
The highest values were measured during lifting. IAP
increased with the load and the amount of bending. IAP
increase of patients with back pain is largely the same as
in healthy controls as long as no pain has been provoked
during the activities (Hemborg and Moritz, 1985). For a
given task, IAP is higher as soon as subjects feel pain or
fatigue (Fairbank et al., 1980; Davis, 1981; Williams and
Lind, 1987).
Baty and Stubbs (1987) monitored the IAP level
of healthy subjects during the 8-h working day of
geriatric nurses. In total, 87% of the IAP peaks were
between 0.27 and 0.53 N/cm2 and 13% were higher than
 ARTICLE IN PRESS
J. Mens et al. / Journal of Biomechanics 39 (2006) 627–635 631

Table 1
Measured sizes in subject A and B

Subject A Subject B

Weight in kg 56 65
Height in cm 165 165
Area abdomino-pelvic cavity (A) in cm2 261 411
Circumference of abdomino-pelvic cavity (C) in cm 94 103
Angle (alpha) between abdominal wall and the frontal plane in degrees 0 21.5
Area pelvic cavity (a) in cm2 131 176
Height (h) of the pelvis in cm 9.8 12.7
Tension (T) in the abdominal wall in N/cm 2.8 IAPa 4.0 IAPa
Force pushing both pelvic halves apart (Flateral) in N 131 IAPa 176 IAPa
Force induced by the abdominal wall, protecting the pelvic ring (Fcentral) in N 27 IAPa 47 IAPa
Net load on pelvic ring in N 104 IAPa 129 IAPa
Critical IAP (exceeding force of pelvic belt) in N/cm2 0.96 0.78
Critical IAP (exceeding hip adductor force) in N/cm2 0.87 0.70
a
IAP ¼ Intra Abdominal Pressure expressed in N/cm2.

Table 2 were about the same. Mens et al. (1999) performed an in

IAP values during various activities (Bartelink, 1957; Keddie and Neill,
1967; Legg, 1981; Hemborg et al., 1983; Kumar and Davis, 1983;
Nordin et al., 1984; Palatini et al., 1989; McGill et al., 1990; Cresswell
et al., 1994; Goldish et al., 1994; Miyamoto et al., 1999; Cholewicki et
al., 2002; Neumann and Gill, 2002)
Coughing
Laughing
Straining
Forward bending
Back lifting
Leg lifting
Weight lifting (professionals)
0.53 N/cm2 with peaks to 1.33 N/cm2. Nicholson et al.
(1981) measured IAP peaks per professional activity in
telecommunication engineers and assessed that in most
of their tasks IAP was between 0.40 and 1.20 N/cm2, but
pressures between 1.20 and 2.00 N/cm2 were not
exceptional.
So, during ADL, most IAP peaks are between 0.25
and 0.50 N/cm2; a minor part of the peaks are between
0.50 and 1.30 N/cm2. During straining, vigorous work,
or heavy exercises IAP reaches peak values between 1
and 2 N/cm2. In extremely powerful weightlifters IAP
may reach values of 5 N/cm2. The more muscle power a
subject has, the higher the IAP levels can be reached
during the performance of tasks.
3.1.3. Size of the protective force of a pelvic belt
Three studies have investigated the force induced by a
pelvic belt (Vleeming et al., 1992; Mens et al., 1999;
Damen et al., 2002). Vleeming et al. (1992) investigated
the mobility of the sacroiliac joints in human cadavers
and found a significant decrease of sacroiliac mobility
when a pelvic belt had been applied with a tension of 50
and 100 N; the influence of a tension of 50 and 100 N
vivo study in patients with pregnancy-related PGP. The
influence of various tensions of a pelvic belt was studied
on the ability to perform an active straight leg raising
maneuver. The tensed belt resulted in a significant
improvement. A tension of about 50 N seemed to be
IAP in N/cm2
sufficient. Damen et al. (2002) investigated the influence
0.49–1.70 of a pelvic belt on the stability of the pelvic joint by
0.93 means of Doppler Imaging of Vibrations (DIV). The
0.96–2.95 signal of the DIV changed significantly when a pelvic
0.53
belt was tensed around the pelvis. They concluded that a
0.54–1.86
0.60–3.65 pelvic belt reduces the mobility of pelvic joints, and a
2.5–5.0 tension of 100 N does not reduce mobility more than
50 N. Thus a tension of 50 N in a pelvic belt seems to be
sufficient to protect the pelvic ring against (a part of the)
pain during ADL.
3.1.4. Size of the provoking force of isometric hip
adduction
A total of 53 patients with PGP with pain at isometric
hip adduction were included. Mean age was 32.5 years
(SD 3.8 years), height 170.5 cm (SD 6.6 cm) and weight
72.8 kg (SD 14.3 kg). Mean (maximal) strength at
isometric hip adduction was 90 N (SD 48 N).
3.2. Part II—Calculations
(1a) Forces within the wall of the abdominal-pelvic
cavity: Substitution in formula (3) of the data for area
and circumference found for subject A (area ¼ 261 cm2
and circumference 94 cm) and subject B (area ¼ 411 cm2
and circumference 103 cm) results in the relation
between the IAP and the tension T in the abdominal
wall:
T subject A ¼ 2:8 cm
IAP; (5)
T subject B ¼ 4:0 cm
IAP: (6)
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632 J. Mens et al. / Journal of Biomechanics 39 (2006) 627–635
So in case of a given IAP, the load on the abdominal
wall in the distended abdomen is 1.4 times as much as in
the flat abdomen.
(1b) Force loading the pelvic part of the abdominal-
pelvic cavity: Substitution in formula (1) of the data for
area and circumference found for subject A
(area ¼ 131 cm2) and subject B (area ¼ 176 cm2) results
in the relation between the IAP and the force loading the
pelvic part of the abdominal-pelvic cavity:
F lateral subject A ¼ 131 cm2
IAP;
F lateral subject B ¼ 176 cm2
IAP:
(1c) Protective forces induced by the abdominal wall:
Substitution in formula (4) of the data for the height (h)
of the pelvic part of the abdominal wall, cosines alpha
and tension in the abdominal wall (formula (5) and (6)):
F central ¼ T
h
cosines alpha:
For subject A:
F central subject A ¼ 2:8 cm
IAP
9:8 cm
1:0,
F central subject A ¼ 27 cm2
IAP:
For subject B:
F central subject B ¼ T subject B
h
cosines alpha;
F central subject B ¼ 4:0 cm
IAP
12:7 cm
0:93,
F central subject B ¼ 47 cm2
IAP:
So, in subject A, the force loaded by the IAP (Flateral) is
about 4.9 times (131/27) the size of the protective force
provided by the abdominal wall (Fcentral). In subject B
this ratio is 3.7 (176/47).
(1d) Net load induced by IAP: The negative influence
of the force induced by the IAP (Flateral) will partially be
compensated by the increase of the protective force by
the increased tension in the abdominal wall (Fcentral).
The net load on the pelvic ring induced by IAP is
Load ¼ F lateral  F central .
For subject A:
Loadsubject A ¼ ð131227Þ cm2
IAP;
Loadsubject A ¼ 104 cm2
IAP:
For subject B:
Loadsubject B ¼ ð176247Þ cm2
IAP;
Loadsubject B ¼ 129 cm2
IAP:
So the load on the pelvic ring induced by IAP is 24%
higher in subject B than in subject A.
3.2.1. Forces loaded by IAP during activities
During ADL the IAP rises 0.25–0.50 N/cm2 with
peaks to 1.30 N/cm2.
These values were substituted in formula (13) and
(14). So the load on the pelvic ring in subject A during
ADL is 26.0–52.0 N with peaks to 135 N. In subject B
these values are 32.3–65.0 N with peaks to 168 N.
During straining, vigorous work or heavy exercises
IAP reaches values between 1 and 5 N/cm2. The load in
those situations is 104–520 N in subject A, and
129–645 N in subject B.
3.2.2. Protective force induced by a pelvic belt
With the assumption that 50 N tension in a pelvic belt
seems to be sufficient to protect the pelvic girdle against
(7)
(a part of) the pain, the (compressive) force induced by a
(8) pelvic belt works as well at the anterior as at the
posterior side of the pelvis, so the force is
2  50 ¼ 100 N. It should be noted that it is theoretically
possible to increase the tension in the belt to protect the
pelvis against higher loads.
The IAP at which the protective force of the pelvic
(9) belt will be exceeded by the load of IAP will be
computed with the formula:
F beltoLoad: (15)
Substitution in formula (15) of the formula for load
ð10Þ ((13) and (14)):
For subject A:
F beltoLoadsubject A ,
100 No104 cm2
IAP;
ð11Þ IAP4100=104 N=cm2 ,
IAP40:96 N=cm2 . ð16Þ
For subject B:
F beltoLoadsubject B ,
100 No129 cm2
IAP;
IAP4100=129 N=cm2 ,
IAP40:78 N=cm2 . ð17Þ
So the protective force of the pelvic belt will be exceeded
(12) by the load of IAP at values of IAP higher than 0.96
N/cm2 in a flat abdomen and higher than 0.78 N/cm2 in
a distended abdomen.
ð13Þ 3.2.3. Size of the provoking force of isometric hip
adduction
During isometric measurement the force of the
adductors must be compensated by the connections
between both pelvic halves. In other words the
ð14Þ
adductors load the pelvic ring with the same force as
is measured between the knees. Adduction strength
was on average 90 N. Most of the PGP patients felt
pain at a lower tension of the adductors and increased
the tension irrespective of the pain. It is uncertain
how many of them increased the IAP during their
attempts.
The IAP at which the provoking influence of IAP will
exceed the provoking force of isometric hip adduction
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J. Mens et al. / Journal of Biomechanics 39 (2006) 627–635
will be computed with the formula:
Load4F adductors: (18)
Substitution in formula (18) of the formula for load
((13) and (14)):
For subject A:
Loadsubject A 490 N;
104 cm2
IAP490 N;
IAP40:87 N=cm2 . ð19Þ
For subject B:
Loadsubject B 490 N;
129 cm2
IAP490 N;
IAP40:70 N=cm2 . ð20Þ
So the provoking influence of IAP will exceed the
provoking force of isometric hip adduction with values
of IAP higher than 0.87 N/cm2 in a flat abdomen and
higher than 0.70 N/cm2 in a distended abdomen.
4. Discussion
The load induced by the IAP on the pelvic girdle is
calculated as 131–176 cm2 IAP. This force will be
partially compensated by increased tension in the
abdominal wall and the pelvic floor. The load on the
pelvic ring during ADL ranges from 26.0 to 52.0 N with
peaks to 135 N in a flat abdomen and from 32.3 to
65.0 N with peaks to 168 N in a distended abdomen.
During straining, vigorous work or heavy exercises the
load is 104–520 N in a flat abdomen and 129–645 N in a
distended abdomen. Thus, during many situations, the
load on the pelvic ring induced by IAP is of the same
size, or even higher than the force at which a pelvic belt
relieves pain (100 N) or isometric hip adduction
provokes pain (90 N). The harmful influence of IAP
increases with the size of the abdomen. So the load
induced by IAP on the pelvic girdle is sufficient to
cause pain in patients with PGP and might interfere
with recovery.
A pelvic belt is frequently advised in the treatment of
PGP (Wu, 2004). Theoretically the use of a belt seems to
be justified, because the parts of the pelvic girdle will be
compressed together by the belt. However, as a side
effect of this wanted effect, IAP may increase by
decreasing the volume of the abdominal–pelvic cavity.
Poppel et al. (2000) showed that lumbar supports do not
influence IAP. The influence of pelvic belts on IAP had
never been studied, but when large lumbar supports
do not increase IAP, it may be assumed that neither will
a pelvic belt of 6 cm wide placed over the lower part of
the abdomen.
633
Another popular treatment for PGP is instruction on
how to contract the transversus abdominis (TA) and the
pelvic floor muscles (Pool-Goudzwaard et al., 1998;
Richardson et al., 2002; Wu, 2004; Stuge et al., 2004).
The theoretical background is the same as for the use of
a pelvic belt: compression of the parts of the pelvic girdle
together. In many situations the TA will also contract
when subjects make an effort to contract the pelvic floor
muscles (Sapsford et al., 2001; Neumann and Gill,
2002). Increase of IAP during the co-contraction of TA
and pelvic floor is only 0.08–0.12 N/cm2 (Neumann and
Gill, 2002).
We may conclude that the popular methods to treat
PGP (a pelvic belt, tensing TA and the pelvic floor
muscles) do not increase IAP; this fact supports the
idea that effective measures for PGP should not
increase IAP.
In the present study the assumption had been made
that IAP overloads the ligaments of the pelvic ring when
the load on the pelvic ring exceeds the force at which a
pelvic belt relieves pain in patients with PGP. It is not
logical to think that the distribution of the load
generated by the IAP over the various parts of the wall
of the cavity is exactly the same as the distribution of the
load induced by isometric hip adduction or by a pelvic
belt. The load during isometric adduction will act as a
separating force on the pelvis, but will also induce a
torque moment. The consequence is that isometric
adduction loads especially the anterior parts of the
pelvic ring: the ligaments around the pubic symphysis
and the anterior parts of the sacroiliac joints. This is in
line with the experience that pain during isometric
adduction is mostly localized around the symphysis
pubis. Thus the influences of IAP, of a pelvic belt and of
isometric hip adduction are not exactly focused on the
same structure. The most important conclusion of the
present study is that the size of the three forces is of the
same class.
One of the limitations of the study is that we did not
ask the patients with PGP to perform a Valsalva
maneuver to verify if an increase in IAP would result
in provocation of pain and if this pain could have been
reduced by means of a pelvic belt. The results could have
given extra support to the presented theory.
It seems that almost everyone has the tendency to
strain when having to perform a difficult task. Bartelink
believed that, during weight lifting, subjects had a ‘reflex
contraction of the abdominal wall’ in combination with
‘a (subconscious) voluntary contraction’ (Bartelink,
1957). It seems possible to instruct a person to change
this habit (Hemborg et al., 1985; McGill et al., 1990).
The IAP during exhaling was about 0.20 N/cm2 less than
with breath held (McGill et al., 1990). If we assume that
IAP loads the pelvic ring it seems worthwhile to
investigate the possibility to reduce IAP by special
instructions during peak tasks. Another way to reduce
 ARTICLE IN PRESS
634 J. Mens et al. / Journal of Biomechanics 39 (2006) 627–635
IAP seems to avoid maximal performance of a subject,
to prevent serious provocation of pain and to pre-
vent fatigue during exercises (O’Sullivan et al., 2002;
Williams and Lind, 1987).
Acknowledgements
The study was funded by a grant of the Stichting
Algesiologie, project 98–0503.
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