IJCRR

Introduction
the pain of the pelvic affects one out of every five pregnant women, causes physical impairment, and is a leading cause of maternity leave. ^1,2 consequently, it should be considered a significant women's health problem. After delivery, the rate of recovery has been reported to be better. ³ Pelvic girdle pain (PGP), on the other hand, may develop into a condition of chronic pain and disability in some women, with serious personal and social consequences.⁴ The diagnosis is a subjective health complaint since it is founded on the woman's subjective perception rather than empirical results. However, (PGP)usually appears in the beginning half of pregnancy and disappears immediately after delivery,³ suggesting that reproductive factors are likely to play a role. ^5,6,7,8 Despite that the causes of pelvic girdle may differ from the causes of other pain conditions, however, the factors that affect the recovery process can be the same. The number of pain sites and the severity of the pain have been considered as important factors in the progression from acute to subacute pain to chronic pain and disability. ⁸ In cases of (PGP), these factors are also related to a poor prognosis. Little is known about prognostic factors (PGP), except for pain intensity during pregnancy, and most studies suffer from methodological flaws such as insufficient research samples and/or improper design. Low-level laser therapy (LLLT) is a bio stimulatory physical modality that aids in tissue regeneration and pain relief by inducing collagen formation and enhancing tissue tensile strength, proving LLLT's effectiveness in tissue repair and pain management. This study aims comparing the effects of pelvic exercises and low-level laser therapy (LLLT) in the treatment of PGP on pain and pelvic flower structure. ⁹ exercise programs for after delivery pelvic pain stabilization, enhanced functional capacity, and pain reduction.  Segmental muscles are strengthened, the neutral spine is stabilized, and the prime movers are reinforced in the stabilizing series. Stabilization exercises aim to concentrate training on specific muscles that are necessary for stability, to reflect the full spectrum of possible difficulty levels, and to increase moment to the muscles that stabilize the lumbar spine. Stabilization of timber. Lumbar stabilization exercises mainly act through transverses abdominis and multifidus, which mainly stabilize the spine. ^10,11,12

Subjects, Materials and methods

Study design: It is Experimental design and Comparative study type. It was carried out between March 2019 and May 2020.it followed the Guideline of the Declaration of Helsinki on the conduct of human research.

Participants: Sixty women with pelvic girdle pain were included in this study and randomly assigned into two equal groups. These works were piloted in the physical therapy sector of Imbaba general Hospital, Cairo University.

Inclusion Criteria:

Participants' age is at least ≥20 years old. Group, (A): composed of 30 patients, treated with low-level laser therapy only.  Group(B) include 30 women's, treated with pelvic exercises only, for twelve sessions over four week's period; three sessions per week.  The ethical committee clearance and informed consent of the subjects were taken. patients have all rights to withdraw from the study at any time without any responsibility.

Study methods Instrumentation

Laser machine stricture: Laser medium: Semiconductor - Gallium Aluminum- Arsenide (Ga Al As), Model & manufacture: Sundom Laser-(Taiwan) RG - 300IB, Wavelength: 810 nm, Output power: 500mw±20mw, Mode: Continuous Wave (CW), Spot diameter: ≤ 10mm^.

Assessment procedures: complete medical history will be checked including age, weight, and height and body mass index (BMI). All patients will be assessed before and after the treatment program.

Outcome Measure:

Pain: Visual analogue scale (VAS) is assessing pain that is a 10 mm calibrated line with zero representing no pain and10 representing worst pain. [Time Surround: Baseline to six weeks after treatment].¹³

Serum cortisol level: is a hormone excreted by the adrenal gland. It is the major corticosteroid. It accounts for around 95% of all glucocorticoid production in the body.¹⁴ It is released during stress. Cortisol levels are higher during pain relative to non-pain. A blood sample will be taken to determine plasma cortisol levels since there is a positive correlation between pain severity and cortisol level.⁵   1ml blood samples from cubital vein two times. One sample baseline and at 4 weeks after treatment.¹⁵

Posterior pelvic pain provocation test (PPPPT): This test is used to differentiate between pelvic girdle pain and LBP (especially in postpartum women). It assesses the presence of sacroiliac dysfunction. One measure will be done at baseline and 4 weeks after.¹⁶

FABER Test: Flexion, Abduction and External Rotation. These three movements combined result in a clinical pain provocation test to find pathologies at the hip, lumbar and sacroiliac region. Time Frame: Baseline to 4 weeks after treatment.¹⁷

Intervention

Treatment procedures: sixteen women's randomly classified into two groups.
A) Laser machine stricture: Laser medium: Semiconductor - Gallium Aluminum- Arsenide (Ga Al As), Model & manufacture: Sundom Laser-(Taiwan) RG - 300IB, Wavelength: 810 nm, Output power: 500mw±20mw, Mode: Continuous Wave (CW), Spot diameter: ≤ 10mm. Procedures: A) the laser therapy is applied to the sacral region by laser probe at the top, and the anterior pelvis. During all therapy sessions, the physiotherapist wears protective glasses, and the treatment area is locked, with limited access and no reflective surfaces. The standard probe moved 1cm/second from a starting point to an end-point repeatedly during the treatment period at sacral points, bilaterally. Energy density    288 J/cm² Fluency of irradiation of 36 J/cm² per point, exposure of 120 seconds per point, eight points of irradiation on the pelvic area 4 point sacral region and 4 points on the pubic area the typical probe held perpendicular to the body surface and pressed to the skin.^11,18

B) Pelvic exercises: The stress was on bridging the transverse abdominal muscles, posterior pelvic rocking exercise, bilateral hip abduction and adduction exercise, hip shrugging, and bilateral knee elevation. The participants were asked to lie on their sides, kneel, sit, and stand. The participants were encouraged to use their transversely focused abdominal muscles regularly during their everyday activities. They performed two sets of exercises about 10-15 times each (initially 10 times in the six sessions after that15 times, for the other twelve sessions).Respite for 30-second to one minute between each exercise. Home program session achieved for 10 minutes twice a day. Each session lasted 45 minutes.¹⁹

Statistical analysis

The scores of VAS, PPPPT, and Faber test and cortisol levels in each group before and after the treatment were compared with paired-sample t-test. The change between the two groups measured before and after physiotherapy was analyzed. A statistical significance was known as p-value <0.05

Ethical approval: The study has been approved by the Research Ethics Committee of the National Institute of laser enhanced science, University of Cairo.

Informed consent: Informed consent has been obtained from all study participants.

Results: None of the 60 female patients was excluded or dropped out of the study during or after the study period. Patient demographic data including age as well as weight, height and body mass index (BMI), were collected, which are summarized in Table(1).

Therefore, there is a significant difference between Group-A and Group-B, showing that low-level laser therapy (LLLT) is more effective than pelvic exercises on pelvic girdle pain (p<0.05).

In a group comparison, in the pretreatment test, no significant differences were observed between pain and cortisol levels. In the comparison of groups in post-treatment test. Significant differences were noted between the two groups. Therefore, the pain value (p = 0.001^*) and the serum cortisol level (p = 0.001^*) for both Groups but group (A) improved significantly compared to the other group (B). As shown in this table-(2), there are statistical differences in the two groups studied in this regard.

The percentage of Faber test readings of pelvic pain for Group (A) increased by 86.6%, the value for Group (B) increased by 80%. The Chi-square tests (Post hoc tests) revealed that there was no significant difference in the Faber Test between (groups A versus B) (X2= 0.131, p-value =0.99). The mean of posterior pelvic pain provocation test readings of pelvic pain for Group (A) increased by 73.4%, the value for Group (B) increased by 80%, The Chi-square tests (Post hoc tests) revealed that there was no significant difference in the posterior pelvic pain provocation test between (group A versus B) (X²= 1.176, p-value =0.472). within groupsMcNemar's tests" revealed that there was a significant difference of the Faber test and posterior pelvic pain provocation test in these two groups with (p=0.0001*). This significant improvement in favour to post-test in compared to pretest, as see in the table (3).

Discussion