Pregnancy Related Pelvic Pain: Difference between revisions

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== Introduction ==
[See also [[Chronic Pelvic Pain|Chronic Pelvic Pain]]]
[[Image:Pregnant cross-section.jpg|right|505x505px]]
 
According to the European guidelines created by Vleeming and colleagues,<ref name="VLEE">Vleeming A, Albert HB, Östgaard HC, Sturesson B, Stuge B. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2518998/ European guidelines for the diagnosis and treatment of pelvic girdle pain]. European Spine Journal Jun 2008; 17(6) : 794-819.</ref> “''Pelvic girdle pain (PGP) generally arises in relation to pregnancy, trauma, arthritis and osteoarthritis. Pain is experienced between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the sacroiliac joints (SIJ). The pain may radiate in the posterior thigh and can also occur in conjunction with/or separately in the symphysis''. ''The endurance capacity for standing, walking, and sitting is diminished. The diagnosis of PGP can be reached after exclusion of lumbar causes. The pain or functional disturbances in relation to PGP must be reproducible by specific clinical tests''”<ref name="VLEE" />
== Description ==
 
[[Image:Pregnant cross-section.jpg|right|300px]]  
 
According to the European guidelines of Vleeming and colleagues,<ref name="VLEE">Vleeming A, Albert HB, Östgaard HC, Sturesson B, Stuge B. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2518998/ European guidelines for the diagnosis and treatment of pelvic girdle pain]. European Spine Journal Jun 2008; 17(6) : 794-819.</ref> “''Pelvic girdle pain (PGP) generally arises in relation to pregnancy, trauma, arthritis and osteoarthritis. Pain is experienced between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the sacroiliac joints (SIJ). The pain may radiate in the posterior thigh and can also occur in conjunction with/or separately in the symphysis''.”<ref name="VLEE" />
== Clinically Relevant Anatomy  ==
== Clinically Relevant Anatomy  ==


The [[pelvis]] is composed of the sacrum, ilium, ischium and pubis. The pelvic bone consists the pubic symphysis and the sacroiliac joint.  
The [[pelvis]] is composed of the sacrum, ilium, ischium and pubis. The pelvic bone consists the pubic symphysis and the sacroiliac joint.  


[[Sacroiliac joint|Sacroiliac Joints]]<br>The sacroiliac joints allow for the transfer of forces between the spine and the lower extremity.<ref>Vleeming A, Schuenke MD, Masi AT, Carreiro JE, Danneels L, Willard FH. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3512279/ The sacroiliac joint: an overview of its anatomy, function and potential clinical implications.] Journal of anatomy. 2012 Dec 1;221(6):537-67.</ref> To read more about the function of the sacroiliac joints review: [[Sacroiliac Joint Force and Form Closure|Force and Form Closure]]  
[[Sacroiliac Joint|Sacroiliac Joints]]<br>The sacroiliac joints allow for the transfer of forces between the spine and the lower extremity.<ref>Vleeming A, Schuenke MD, Masi AT, Carreiro JE, Danneels L, Willard FH. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3512279/ The sacroiliac joint: an overview of its anatomy, function and potential clinical implications.] Journal of anatomy. 2012 Dec 1;221(6):537-67.</ref> To read more about the function of the sacroiliac joints review: [[Sacroiliac Joint Force and Form Closure|Force and Form Closure]]  
 
[[Pelvic Floor Anatomy|Pelvic Floor]]<br>The [[Pelvic Floor Anatomy|pelvic floor muscles]] have two primary functions in females:<ref name=":17">Raizada V, Mittal RK. [[Pelvic floor anatomy and applied physiology.]] Gastroenterology Clinics of North America. 2008 Sep 1;37(3):493-509.</ref>
# supports the abdominal viscera (bladder, intestines, uterus) and the rectum
# the mechanism for continence for the urethral, anal and vaginal orifices<ref name=":17" />
 
== Epidemiology /Etiology  ==


Pelvic girdle pain may begin around the 18th week of pregnancy and appears to peak between the 24th and 36th week.<ref name=":8">Bergstrom et al., P[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3937130/ regnancy-related low back pain and pelvic girdle pain approximately 14 months after pregnancy – pain status, self-rated health and family situation], BMC Pregnancy and Childbirth 201414:48, DOI: 10.1186/1471-2393-14-48</ref> Pelvic pain is common during with approximately 50% of women experiencing this pain during pregnancy.<ref name="WU">Wu WH, Meijer OG, Uegaki K, Mens JMA, Van Dieën JH, Wuisman PIJM, Östgaard HC. Pregnancy-related pelvic girdle pain (PPP), I : Terminology, clinical presentation, and prevalence. European Spine Journal Nov 2004; 13(7) : 575-589.</ref> 25% of the women who experience pelvic girdle pain report having severe pain and 8% report pain that causes severe disability. and disability.<ref>Albert H, Godskesen M, Westergaard J. Prognosis in four syndromes of pregnancy‐related pelvic pain. Acta obstetricia et gynecologica Scandinavica. 2001 Jun 1;80(6):505-10.</ref>  
[[Pelvic Floor Anatomy|Pelvic Floor]]<br>The [[Pelvic Floor Anatomy|pelvic floor muscles]] have two primary functions in females. The muscles:<ref name=":17">Raizada V, Mittal RK. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2617789/?_escaped_fragment_=po=7.50000 Pelvic floor anatomy and applied physiology.] Gastroenterology Clinics of North America. 2008 Sep 1;37(3):493-509.</ref>
# support the abdominal viscera (bladder, intestines, uterus) and the rectum
# control the mechanism for continence for the urethral, anal and vaginal orifices<ref name=":17" />


The etiology of pregnancy-related pelvic girdle pain has not been established in the literature<ref>Aldabe D, Milosavljevic S, Bussey MD. Is pregnancy related pelvic girdle pain associated with altered kinematic, kinetic and motor control of the pelvis? A systematic review. European Spine Journal. 2012 Sep 1;21(9):1777-87.</ref> however, the cause of this pain is believed to be multi-factorial and may be related to hormonal, biomechanical, traumatic, metabolic, genetic and degenerative factors.<ref>Homer C, Oats J. Clinical practice guidelines: Pregnancy care. Canberra: Australian Government Department of Health, 2018; p. 355–57</ref> <ref name=":18">Bhardwaj A, Nagandla K. Musculoskeletal symptoms and orthopaedic complications in pregnancy: Pathophysiology, diagnostic approaches and modern management. Postgrad Med J </ref> <ref name=":19">Kanakaris NK, Roberts CS, Giannoudis PV. Pregnancy-related pelvic girdle pain: An update. BMC Med 2011;9:15. doi: 10.1186/1741-7015-9-15.</ref>   
== Etiology ==
The etiology of pregnancy-related pelvic girdle pain has not been clearly established in the literature.<ref>Aldabe D, Milosavljevic S, Bussey MD. Is pregnancy related pelvic girdle pain associated with altered kinematic, kinetic and motor control of the pelvis? A systematic review. European Spine Journal. 2012 Sep 1;21(9):1777-87.</ref> However, the cause of this pain is believed to be multi-factorial and may be related to hormonal, biomechanical, traumatic, metabolic, genetic and degenerative factors.<ref>Homer C, Oats J. Clinical practice guidelines: Pregnancy care. Canberra: Australian Government Department of Health, 2018; p. 355–57</ref> <ref name=":18">Bhardwaj A, Nagandla K. Musculoskeletal symptoms and orthopaedic complications in pregnancy: Pathophysiology, diagnostic approaches and modern management. Postgrad Med J </ref> <ref name=":19">Kanakaris NK, Roberts CS, Giannoudis PV. Pregnancy-related pelvic girdle pain: An update. BMC Med 2011;9:15. doi: 10.1186/1741-7015-9-15.</ref>   


=== Hormonal ===
=== Hormonal ===
Women produce increased quantities of the hormone relaxin during their pregnancy. Relaxin increases ligament laxity in the pelvic girdle (and in other parts of the body) in preparation for the labour process. Increased ligament laxity may cause a small increase in the range of motion at the pelvis. If this increase in motion is not complimented by a change in neuromotor control (e.g., muscles around the pelvis act to improve stability), it is possible that pain may occur.<ref name="VLEE" /> However, the link between relaxin and pelvic girdle pain during pregnancy has not been well established in the literature.<ref name=":18" /><ref name=":19" /> Research to date also does not support the idea that an increase in the range of motion at the pelvis causes pain.<ref name="VLEE" /><ref>Damen L, Buyruk HM, Güler-Uysal F, Lotgering FK, Snijders CJ, Stam HJ. Pelvic pain during pregnancy is associated with asymmetric laxity of the sacroiliac joints. Acta obstetricia et gynecologica Scandinavica. 2001 Jan 1;80(11):1019-24.</ref> <ref>Sturesson B, Selvik G, UdÉn A. Movements of the sacroiliac joints. A roentgen stereophotogrammetric analysis. Spine. 1989 Feb;14(2):162-5.</ref>  
Women produce increased quantities of the hormone relaxin during their pregnancy. Relaxin increases ligament laxity in the pelvic girdle (and in other parts of the body) in preparation for the labour process. Increased ligament laxity may cause a small increase in the range of motion at the pelvis. If this increase in motion is not complimented by a change in neuromotor control (e.g., muscles around the pelvis act to improve stability), it is possible that pain may occur.<ref name="VLEE" /> However, the link between relaxin and pelvic girdle pain during pregnancy has not been established in the literature.<ref name=":18" /><ref name=":19" /> Research to date also does not support the idea that an increase in the range of motion at the pelvis causes pain.<ref name="VLEE" /><ref>Damen L, Buyruk HM, Güler-Uysal F, Lotgering FK, Snijders CJ, Stam HJ. Pelvic pain during pregnancy is associated with asymmetric laxity of the sacroiliac joints. Acta obstetricia et gynecologica Scandinavica. 2001 Jan 1;80(11):1019-24.</ref> <ref>Sturesson B, Selvik G, UdÉn A. Movements of the sacroiliac joints. A roentgen stereophotogrammetric analysis. Spine. 1989 Feb;14(2):162-5.</ref>  


=== Biomechanical ===
=== Biomechanical ===
As pregnancy progresses the gravid uterus increases load on the spine and pelvis. To accommodate for the growth of the uterus the pubic symphysis must soften and the laxity of the ligaments of the pelvis increases. The uterus shifts forward which changes the maternal centre of gravity and the orientation of pelvis.<ref>Ritchie JR. Orthopedic considerations during pregnancy. Clinical obstetrics and gynecology. 2003 Jun 1;46(2):456-66.</ref> This change in centre of gravity may cause stress or a change in load on the lower back and pelvic girdle.<ref name=":18" /><ref name=":9" /><ref name=":19" /> This change in load can result in compensatory postural changes (e.g., an increase in lumbar lordosis).<ref name=":18" /><ref name=":9" /><ref name=":19" />
As pregnancy progresses, the gravid uterus increases load on the spine and pelvis. To accommodate for the growth of the uterus the pubic symphysis must soften and laxity in the pelvic ligaments increases. The uterus shifts forward which changes the maternal centre of gravity and the orientation of pelvis.<ref>Ritchie JR. Orthopedic considerations during pregnancy. Clinical obstetrics and gynecology. 2003 Jun 1;46(2):456-66.</ref> This change in centre of gravity may cause stress or a change in load on the lower back and pelvic girdle.<ref name=":18" /><ref name=":9">Robinson H.S., Clinical course of pelvic girdle pain postpartum - impact of clinic findings in late pregnancy, Manual therapy 19 (2014) 190-196 </ref><ref name=":19" /> This change in load can result in compensatory postural changes (e.g., an increase in lumbar lordosis).<ref name=":18" /><ref name=":9" /><ref name=":19" />
 
There is also a significant reductions in the strength of the transversus abdominis, internal oblique, pelvic floor, lumbar multifidus and an inadequate coordination of the lumbopelvic muscles is often observed by pregnant women with PGP. When PGP arises in the 2nd and 3rd trimester of pregnancy, abdominal stretching and a shift of body gravity center can possibly cause this muscle impairment. The reduced force closure can lead to neuromuscular compensatory strategies. There are two common compensating strategies, namely the butt-gripping and the chest-gripping strategy. In the butt-gripping strategy,there is an overuse of the posterior gluteal muscles. In the chest-gripping strategy, the external oblique is in overdrive, which means that the external oblique is going to work/contract harder and faster to compensate for the underuse of the transversus abdominis. This leads to an incorrect load transfer between the thorax and the pelvis, which can cause hypertrophy of the external oblique. These strategies, the butt-gripping and chest-gripping strategies, may increase sheared forces in the SIJ, which might cause pain. In response to the pain there are two maladaptive forms of behavior: pain avoidance and pain provocation behavior, this can increase pain and disability.<ref name=":4">Danielle Casagrande et al., Low Back Pain and Pelvic Girdle Pain in Pregnancy, J Am Acad Orthop Surg 2015;00:1-11</ref><ref name=":2">E.H. Verstraete, G. Vanderstraeten, W. Parewijck. Pelvic Girdle Pain during or after Pregnancy: a review of recent evidence and a clinical care path proposal: a systematic review. Pubmed 2013; 5(1); 33-43</ref>


=== Risk Factors ===
=== Risk Factors ===
The risk factors for the development of pregnancy-related pelvic girdle pain are:
The risk factors for developing pregnancy-related pelvic girdle pain are:


*a previous history of low back pain or pelvic girdle pain.<ref name=":0">Pierce H, Homer CS, Dahlen HG, King J. Pregnancy-related lumbopelvic pain: listening to Australian women. Nursing research and practice. 2012;2012.</ref><ref name=":19" />   
*a previous history of low back pain or pelvic girdle pain.<ref name=":0">Pierce H, Homer CS, Dahlen HG, King J. Pregnancy-related lumbopelvic pain: listening to Australian women. Nursing research and practice. 2012;2012.</ref><ref name=":19" />   
*a previous trauma to the pelvis or back.<ref name=":0" /><ref name=":19" />  
*a previous trauma to the pelvis or back.<ref name=":0" /><ref name=":19" />  
*physical demanding work (e.g., twisting and bending the back several times per hour per day).<ref name="VLEE" /><ref name="WU" /><ref name=":3">Elden H., [https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-016-1154-0 Predictors and consequences of long-term pregnancy-related pelvic girdle pain: a longitudinal follow-up study],BMC Musculoskelet Disord. 2016; 17: 276.doi: 10.1186/s12891-016-1154-0
*physical demanding work (e.g., twisting and bending the back several times per hour per day).<ref name="VLEE" /><ref name="WU">Wu WH, Meijer OG, Uegaki K, Mens JMA, Van Dieën JH, Wuisman PIJM, Östgaard HC. Pregnancy-related pelvic girdle pain (PPP), I : Terminology, clinical presentation, and prevalence. European Spine Journal Nov 2004; 13(7) : 575-589.</ref><ref name=":3">Elden H., [https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-016-1154-0 Predictors and consequences of long-term pregnancy-related pelvic girdle pain: a longitudinal follow-up study],BMC Musculoskelet Disord. 2016; 17: 276.doi: 10.1186/s12891-016-1154-0
</ref><ref name=":4" /><ref>Ostgaard HC, Andersson GB. Postpartum low-back pain. Spine. 1992 Jan;17(1):53-5.</ref>
</ref><ref name=":4">Danielle Casagrande et al., Low Back Pain and Pelvic Girdle Pain in Pregnancy, J Am Acad Orthop Surg 2015;00:1-11</ref><ref>Ostgaard HC, Andersson GB. Postpartum low-back pain. Spine. 1992 Jan;17(1):53-5.</ref>
*multiparity<ref name=":15">Bjelland EK. et al., Hormonal contraception and pelvic girdle pain during pregnancy: a population study of 91.721 pregnancies in the norwegian mother and child cohort, Human reproduction. vol 0, No.0 pp1-7, 2013 </ref>
*multiparity - may play a causal role in the development of pregnancy-related pelvic girdle pain<ref name=":15">Bjelland EK. et al., Hormonal contraception and pelvic girdle pain during pregnancy: a population study of 91.721 pregnancies in the norwegian mother and child cohort, Human reproduction. vol 0, No.0 pp1-7, 2013 </ref>


== Characteristics/Clinical Presentation  ==
== Epidemiology  ==
Pelvic girdle pain may begin around the 18th week of pregnancy and appears to peak between the 24th and 36th week.<ref name=":8">Bergstrom et al., P[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3937130/ regnancy-related low back pain and pelvic girdle pain approximately 14 months after pregnancy – pain status, self-rated health and family situation], BMC Pregnancy and Childbirth 201414:48, DOI: 10.1186/1471-2393-14-48</ref> Pelvic pain affects approximately 50% of women during pregnancy.<ref name="WU" /> 25% of the women who experience pelvic girdle pain report having severe pain and 8% report pain that causes severe disability.<ref>Albert H, Godskesen M, Westergaard J. Prognosis in four syndromes of pregnancy‐related pelvic pain. Acta obstetricia et gynecologica Scandinavica. 2001 Jun 1;80(6):505-10.</ref>
== Clinical Presentation  ==
The clinical presentation of pregnancy-related pelvic girdle pain can vary from patient to patient and can change over the course of the patient's pregnancy.<ref name="WU" /> Since the causes of pregnancy-related pelvic girdle pain are multi-factorial and, it is important to incorporate a biopsychosocial approach to the diagnosis and treatment of this pain.


The clinical presentation of pregnancy-related pelvic girdle pain is characterized by a wide variation of symptoms.
=== Subjective History ===
Common symptoms related to pregnancy-related pelvic pain include:
*a difficulty walking quickly and covering long distances<ref name="VLEE" /><ref name="KANA">Kanakaris NK, Roberts CS, Giannoudis PV. Pregnancy-related pelvic girdle pain: un update. BMC Medicine Feb 2011; 9: 1-15.</ref><ref name="WU" />
*pain/discomfort/difficulty during sexual intercourse<ref name="KANA" /><ref name="WU" />
*pain/discomfort during sleep and/or a difficulty turning over in bed<ref name="WU" /><ref name="NIEL">Nielsen LL. Clinical findings, pain descriptions and physical complaints reported by women with post-natal pregnancy-related pelvic girdle pain. Acta Obstetricia et Gynecologica 2010: 89; 1187-1191.</ref>
*decreased ability to perform housework<ref name="WU" /><ref name="NIEL" />
*decreased ability to engage in activities with children<ref name="WU" /> 
*difficulty sitting<ref name="NIEL" />
*difficulty standing for 30 minutes or longer<ref name="NIEL" />
*pain in single leg stance i.e., climbing stairs<ref name="NIEL" />
*inability or difficulty running (postnatal) due to pain<ref name="NIEL" />
*decreased ability for mother-child interactions<ref name=":3" />
*pain/discomfort with weight bearing activities<ref name=":9" />
=== Pain ===
The onset of pain may occur around the 18th week of pregnancy and reaches peak intensity between the 24th and 36th week of pregnancy. The pain typically resolves by the third month in the postpartum period.<ref>Oätgaard HC, Andersson GB, Wennergren M. The impact of low back and pelvic pain in pregnancy on the pregnancy outcome. Acta obstetricia et gynecologica Scandinavica. 1991 Jan;70(1):21-4.</ref><ref name=":19" />


'''Pain'''<br>Often, the onset of pain occurs around the 18th week and reaches peak intensity between the 24th and 36th week of pregnancy. The pain can spontaneously disappear within 3 months, but 7-8% of the patients have a persisting, chronic pain.<ref name="WU" /><ref name=":2" /> Improvement of persistent PGP levels off around 6 months postpartum.<ref name=":3" /> More women experience PGP 18 months after delivery as breastfeeding decreased.<ref>BJELLAND EK et al., Breastfeeding and pelvic girdle pain: a follow up study of 10.603 women 18 months after delivery, BJOG an international journal of obstretics & gyneacology, October 2014, DOI:10.1111/1471-0528.13118 (: 2B)</ref>
==== Location ====
Pelvic girdle pain typically presents near the sacroiliac joints and/or gluteal area or anteriorly near the symphysis pubis<ref name="WU" />. The reported pain may radiate into the patient's groin, perineum or posterior thigh but does not mimic a typically sciatic nerve root distribution.<ref>Fast A, Shapiro D, Ducommun EJ, Friedmann LW, Bouklas T, Floman Y. Low-back pain in pregnancy. Spine. 1987 May;12(4):368-71.</ref><ref name=":6">Ostgaard HC, Zetherström G, Roos-Hansson E, Svanberg B. Reduction of back and posterior pelvic pain in pregnancy. Spine. 1994 Apr;19(8):894-900.</ref> The location of the pain may vary throughout the course of the pregnancy.<ref name=":7">Kristiansson P, Svärdsudd K, von Schoultz B. Back pain during pregnancy: a prospective study. Spine. 1996 Mar 15;21(6):702-8.</ref> A pain distribution diagram can be a useful tool in identifying the patient's pain and to help distinguish pregnancy-related pelvic girdle pain from [https://www.physio-pedia.com/Low_Back_Pain_and_Pregnancy pregnancy related low back pain].<ref name=":10" />


'''Localisation'''
==== Nature and intensity of pain ====
Pelvic girdle pain may be described as a stabbing,<ref>Östgaard HC, Roos-Hansson E, Zetherström G. Regression of back and posterior pelvic pain after pregnancy. Spine. 1996 Dec 1;21(23):2777-80.</ref><ref name=":1">Sturesson et al; Pain pattern in pregnancy and" catching" of the leg in pregnant women with posterior pelvic pain; Spine; 1997; PP 1880-1883 </ref> dull, shooting, or burning sensation.<ref name=":1" /> The intensity of pain on a 100 mm [[Visual Analogue Scale|visual analogue scale]] averages around 50-60 mm.<ref name=":7" /><ref name=":6" />


Pain is often localized deep in the sacral/gluteal region.<ref name="VLEE" /><ref name="WU" /> Following the guidelines the pain is experienced between the posterior iliac crest and the gluteal fold, mostly surrounding the sacroiliac joints.<ref name=":3" /> The localization of pain is deep and can be divided in five groups as mentioned above under ‘etiology and epidemiology’. It is even possible that localization of the pain changes over time.
=== Muscle Function and Perception  ===
* postpartum women may present with reduced hip abduction and adduction force<ref name=":13">Mens JM, Vleeming A, Snijders CJ, Ronchetti I, Stam HJ. Reliability and validity of hip adduction strength to measure disease severity in posterior pelvic pain since pregnancy. Spine. 2002 Aug 1;27(15):1674-9.</ref> which may be related to fear of pain/movement.<ref name=":13" />
* women may reported a feeling of "catching" in their upper leg during ambulation<ref name=":1" /> and/or report feeling the lack the ability to move their legs during the active straight leg test<ref>Mens JM, Vleeming A, Snijders CJ, Koes BW, Stam HJ. Reliability and validity of the active straight leg raise test in posterior pelvic pain since pregnancy. Spine. 2001 May 15;26(10):1167-71.</ref> which may suggest nervous system involvement.<ref name="WU" />
* altered gait coordination - women with postpartum pelvic girdle pain can present with a coupling between pelvic and thoracic rotations during gait (pelvic and thoracic rotations in the same direction occur at the same time) which has been proposed as a nervous system strategy used to cope with motor problems.<ref>Wu W, Meijer OG, Jutte PC, Uegaki K, Lamoth CJ, de Wolf GS, van Dieën JH, Wuisman PI, Kwakkel G, de Vries JI, Beek PJ. Gait in patients with pregnancy-related pain in the pelvis: an emphasis on the coordination of transverse pelvic and thoracic rotations. Clinical biomechanics. 2002 Nov 1;17(9-10):678-86.</ref>
== Pelvic Girdle Pain Examination  ==


'''Nature of pain'''
Before a diagnosis of pelvic girdle pain is reached potential lumbar spine pain and/or dysfunction should be ruled out.<ref name="VLEE" /> Once the lumbar spine is ruled out the sacroiliac joint, the symphysis pubis, and the pelvis should be assessed. 


Pelvic girdle pain has been described as “stabbing’’ , pain in the lower back as a “dull ache’’ and the pain in the thoracic spine is rather “burning’’. Other pain-descriptions are: shooting pain, feeling of oppression and a sharp twinge.<ref name=":2" /><br>Intensity of pain: The intensity of pain on a visual analogue scale (VAS) is usually around 50-60 mm.<ref name="KANA">Kanakaris NK, Roberts CS, Giannoudis PV. Pregnancy-related pelvic girdle pain: un update. BMC Medicine Feb 2011; 9: 1-15.</ref><ref name="WU" /> The pain may be mild or quite bearable in about half of the cases and very serious in about 25%.<ref name="VLEE" /><ref name="WU" /><ref name=":2" />
==== Sacroiliac joint ====
 
*[[Posterior pelvic pain provocation test|Posterior pelvic pain provocation test]] (P4)<ref name="VLEE" /><ref name="KANA" /><ref name="STU">Stuge B, Laerum E, Kirkesola G, Vollestad N. The efficacy of a treatment program focusing on specific stabilizing exercises for pelvic girdle pain after pregnancy: A randomized controlled trial. Spine Feb 2004 : 29(4) ; 351-359.</ref> <ref name="VOLLE">Vollestad NK, Stuge B. Prognostic factors for recovery from postpartum pelvic girdle pain. European Spine Journal Feb 2009: 18; 718-726.</ref>
'''Changes in the perception and execution of movements'''
 
Several women reported a “catching” sensation in their upper leg when they were walking. Patients with PGP also experienced a feeling of paralysis in their legs while they were lifting their leg in extension.<ref name="WU" /> <br>Changes in movement coordination: Women with postpartum PGP have a stronger coupling between pelvic and thoracic rotations during gait. This may be a strategy chosen by the nervous system to cope with motor problems.<ref name="WU" />
 
Patients, who suffer from pelvic girdle pain, have difficulty during:
 
#Walking (quickly): Alternated gait pattern (slower walking velocity, waddling type of gait)<ref name="VLEE" /><ref name="KANA" /><ref name="WU" />
#Sexual intercourse<ref name="KANA" /><ref name="WU" />
#During sleep: Turning in bed<ref name="WU" /><ref name="NIEL">Nielsen LL. Clinical findings, pain descriptions and physical complaints reported by women with post-natal pregnancy-related pelvic girdle pain. Acta Obstetricia et Gynecologica 2010: 89; 1187-1191.</ref>
#Housework<ref name="WU" /><ref name="NIEL" />
#Activities with children<ref name="WU" /> 
#Sitting<ref name="NIEL" />
#Standing for 30 minutes or longer<ref name="NIEL" />
#Climbing stairs<ref name="NIEL" />
#Running (postnatal)<ref name="NIEL" />
#Individual and socio-economic consequences<ref name=":3" />
#Impaired mother-child interactions<ref name=":3" />
#Weight bearing activities<ref name=":9">Robinson H.S., Clinical course of pelvic girdle pain postpartum - impact of clinic findings in late pregnancy, Manual therapy 19 (2014) 190-196 </ref>
 
== '''Prognosis''' ==
Women with anterior and posterior pain location have the worst pro.gnosis meanwhile an isolated anterior pain predicts a good prognosis.<ref name=":3" /> Breastfeeding is associated with small beneficial effect on the recovery process of the pelvic girdle pain in women with BMI &gt;25 kg/m² (low level of evidence)<ref name=":5">Bjelland EK et al., The effect of emotional distress on persistent pelvic girdle pain after delivery: a longitudinal population study, BJOG 2012, DOI: 10.1111/1471-0528.12029
</ref> The recovery rates decreased with increasing levels of pain severity at pregnancy week 30. Women who experienced emotional distress during pregnancy are more likely to report PGP after delivery.<ref name=":3" /> <ref name=":9" /> Poorer prognosis if women have PGP and low back pain.<ref name=":3" /><br>Women who exercise regularly (high impact exercise) have low risk to develop<ref>Owe K.M. et al. How does pre-pregnancy exercise influence the risk of pelvic girdle pain during pregnancy? 2015 Oslo university Hospital.</ref> PGP.
 
== Differential Diagnosis  ==
 
Diagnosis of pelvic pain in women can be challenging because many symptoms and signs are insensitive and nonspecific. As the first priority, urgent life-threatening conditions (e.g., ectopic pregnancy, appendicitis, ruptured ovarian cyst, ovarian vein thrombosis, placental abruption) , fertility-threatening conditions (e.g. pelvic inflammatory disease, ovarian torsion, endometritis), painful visceral pathologies of the pelvis (urogenital and gastrointestinal), lower-back pain syndromes (e.g. lumbar disc-lesion, rheumatism or sciatica) , bone or soft tissue infections, urinary tract infections, femoral vein thrombosis, rupture of symphysis pubis and bone or soft tissue tumors must be considered.<ref name="KANA" /><ref name=":12">Morgen, IM. et al; Low Back Pain and Pelvic Pain During Pregnancy: Prevalence and Risk Factors; Spine; 2005 April; pp 983-991 </ref>
 
The most common urgent causes of pelvic pain are pelvic inflammatory disease, ruptured ovarian cyst, and appendicitis; however, many other diagnoses in the differential may mimic these conditions, and imaging is often needed. Transvaginal ultrasonography should be the initial imaging test because of its sensitivities across most etiologies and its lack of radiation exposure. A high index of suspicion should be maintained for pelvic inflammatory disease when other etiologies are ruled out, because the presentation is variable and the prevalence is high. Multiple studies have shown that 20 to 50 percent of women presenting with pelvic pain have pelvic inflammatory disease. Adolescents, pregnant and postpartum women require unique considerations.<ref>Morino M, Pellegrino L, Castagna E, Farinella E, Mao P. Acute nonspecific abdominal pain: A randomized, controlled trial comparing early laparoscopy versus clinical observation. Ann Surg. 2006;244(6):881–888. (: 2A)</ref>
 
The differential diagnoses of low back pain and pelvic girdle pain is very similar. PGP is mostly located between the posterior iliac crest and the gluteal fold near the sacroiliac joints, it has possible symphysis dysfunction. Pain is intermittent and may be provoked by daily activities such as walking, sitting or standing. A careful medical history focusing on pain characteristics is necessary to make a definitive diagnosis. The patient should be asked about the location, intensity, radiation, timing, duration, and exacerbating and mitigating factors of the pain. Review of systems, gynecologic, sexual, and social history, in addition to physical examination and an appropriate laboratory test, helps to narrow the differential diagnosis.<ref name=":4" />
 
== Diagnostic Procedures  ==
 
To diagnose a pregnant woman with pelvic pain, symptoms must be distinguished from lumbar pain first. Tests for the sacroiliac joint show good reliability to distinguish low back pain from sacroiliac joint pain. A precise pain location of the provoked pain must be obtained for the test to have enough specificity.<ref name=":11">Pelvic Obstretic & Gyneacological Physiotherapy. Guidance for health professionals, pregnancy- related pelvic girdle pain. </ref> Further diagnosis can be reached from signs and symptoms experienced and described by the pregnant women. Common symptoms related to pregnancy-related pelvic pain include:<ref name=":10">O’Sullivan PB et al., Diagnosis and classification of pelvic girdle pain disorders—Part 1: A mechanism based approach within a biopsychosocial framework, Man Ther. 2007 May;12(2):86-97. (Level of evidence: 1B)</ref><ref name=":11" />
 
*Difficulty walking (waddling gait)
*Pain on weight bearing on one leg e.g. climbing stairs, dressing
*Pain and/or difficulty in straddle movements e.g. getting in and out of bath; turning in bed
*Clicking or grinding in pelvic area – may be audible or palpable
*Limited and painful hip abduction (though some women have normal or only partly limited abduction)
*Difficulty lying in some positions e.g. supine, side-lying
*Pain during normal activities of daily life
*Pain and difficulty during sexual intercourse
*Difficulty walking (waddling gait), with a diminished endurance capacity for standing, walking and sitting
*Pain: Distribution varies between individuals and includes:
**Lower back
**SPJ
**SIJ(s)
**Groin
**Anterior and posterior thigh
**Posterior lower leg
**Hip/trochanteric region
**Pelvic floor/perineum
 
If pain is evident in the sacroiliac joint, a combination of tests can be done to further exclude lumbar pain and other syndromes from the SIJ. A combination of the sacral sulcus tenderness test (or palpation of the long dorsal ligaments) and the pointing to the spina iliaca posterior superior (SIPS) test (or pointing to the joint test) have the best predictive value for pelvic pain. Two more sensitive tests are palpation of the symphysis and painful femoral compression, these two tests are also called posterior pelvic pain provocation test. The posterior pelvic pain (PRPP) provocation test and Patrick’s/Faber Test (flexion, abduction and external rotation) show high sensitivity if pain is evident in the SIJ.<ref name=":11" /><ref>Stuber KJ. Specificity, sensitivity, and predictive values of clinical tests of the sacroiliac joint: a systematic review of the literature. The Journal of the Canadian Chiropractic Association. 2007;51:30-41. </ref><ref>Hanne Albert et al., Evaluation of clinical tests used in classification procedures in pregnancy-related pelvic joint pain, Eur Spine J (2000) 9 : 161–166. </ref>
 
'''Other diagnostic tests and imaging for PRPP:'''
 
*Urinalysis, midstream specimen of urine (MSU).
*High vaginal swab (HVS) for bacteria and endocervical swab.<ref name="VLEE" />
*Pregnancy test.
*MRI (most suggested imaging modality to evaluate PGP)<ref name=":4" />
*Ultrasonography<ref name=":4" />
*FBC/A full blood count: this is a very common blood test and is used to check a person's general health as well as screening for specific conditions. The number of red cells, white cells and platelets in the blood are checked.
*Urgent ultrasound (if miscarriage or ectopic pregnancy is suspected).
*Laparoscopy<ref name=":5" />
 
== Outcome Measures  ==
 
[[Pelvic Girdle Questionnaire (PGQ)]]<ref>Stuge. B., The pelvic girdle questionnaire: a condition-specific instrument for assessing activity limitations and symptoms in people with pelvic girdle pain. phys ther 2011; 91:1096-1108 </ref><br>Timed up and go test (Fast pace)<ref name=":13">Evensen M.N. et al. Art1: Reliability of the timed up and go test and ten-metre timed walk test in pregnant women with pelvic girdle pain, , Physiotherapy Research International 20(3), December 2014, DOI: 10.1002./pri.1609 </ref> <br>10 m timed walk test (Fast pace)<ref name=":13" /> <br>[[Oswestry Disability Index]]<ref name=":3" />
 
== Examination  ==
The description with what the patient feels is important to know. Like a “catching feeling when walking” is often a sign of posterior pelvic pain, but further test need to be performed to see if it is really a posterior pelvic pain.<ref>Sturesson et al; Pain pattern in pregnancy and" catching" of the leg in pregnant women with posterior pelvic pain; Spine; 1997; PP 1880-1883 </ref> It is also very important to ask the patient about his pain history. The use of a pain location diagram is strongly recommended, so that we can be sure that the pain is localized in the pelvic area. The patient may also point out the pain location on his or her body.<ref name="VLEE" /><ref name=":12" />
 
The following tests are recommended for the clinical examination, to make the diagnosis of pelvic girdle pain:
 
''For SIJ pain:''
 
*[[Posterior pelvic pain provocation test|Posterior pelvic pain provocation test]] (P4)<ref name="VLEE" /><ref name="KANA" /><ref name="STU">Stuge B, Laerum E, Kirkesola G, Vollestad N. The efficacy of a treatment program focusing on specific stabilizing exercises for pelvic girdle pain after pregnancy: A randomized controlled trial. Spine Feb 2004 : 29(4) ; 351-359.</ref> <ref name="VOLLE">Vollestad NK, Stuge B. Prognostic factors for recovery from postpartum pelvic girdle pain. European Spine Journal Feb 2009: 18; 718-726.</ref> This is a pain provocation test used to determine the presence of sacroiliac dysfunction. It is used to distinguish between pregnancy-related pelvic pain (PRPP) and low back pain
*[[FABER Test|Patrick ‘s Faber test]] <ref name="VLEE" /><ref name="KANA" />&nbsp;  
*[[FABER Test|Patrick ‘s Faber test]] <ref name="VLEE" /><ref name="KANA" />&nbsp;  
*[[Long dorsal sacroiliac ligament (LDL) test|Palpation of the long dorsal SIJ ligament]] <ref name="VLEE" /><ref name="KANA" /><ref name="STU" /><ref name="VOLLE" />  
*[[Long dorsal sacroiliac ligament (LDL) test|Palpation of the long dorsal SIJ ligament]] <ref name="VLEE" /><ref name="KANA" /><ref name="STU" /><ref name="VOLLE" />  
*[[Gaenslen Test|Gaenslen’s test]] <ref name="VLEE" /><ref name="KANA" />  
*[[Gaenslen Test|Gaenslen’s test]] <ref name="VLEE" /><ref name="KANA" />  
*See also [http://www.physio-pedia.com/Sacroiliac_Joint_Special_Test_Cluster SIJ Special Test Cluster]
*For more information on the tests listed above see [http://www.physio-pedia.com/Sacroiliac_Joint_Special_Test_Cluster SIJ Special Test Cluster]


''Symphysis '':
==== Symphysis Pubis ====
*Palpation of symphysis<ref name="VLEE" /><ref name="KANA" /><ref name="STU" />
*Modified [[Trendelenburg Sign|trendelenburg’s sign]] of the pelvic girdle <ref name="VLEE" /><ref name="KANA" /><ref name="STU" />


*[[Symphysis pain palpation test|Palpation of symphysis]]<ref name="VLEE" /><ref name="KANA" /><ref name="STU" />
==== Functional Pelvic Test ====
*Modified [[Trendelenburg Test|trendelenburg’s test]] of the pelvic girdle <ref name="VLEE" /><ref name="KANA" /><ref name="STU" />
*[[Straight Leg Raise Test|Active straight leg raise test]] (ASLR test) <ref name="VLEE" /><ref name="KANA" /><ref name="STU" /><ref name="VOLLE" />


''Functional pelvic test'':  
=== Diagnostic Procedures ===
During pregnancy diagnostic imaging using radiation is contraindicated.<ref name=":10">Clinton SC, Newell A, Downey PA, Ferreira K. Pelvic Girdle Pain in the Antepartum Population: Physical Therapy Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Section on Women's Health and the Orthopaedic Section of the American Physical Therapy Association. Journal of Women's Health Physical Therapy. 2017 May 1;41(2):102-25.</ref> Ultrasound imaging and/or MRIs may be used for certain interventions and/or surgical planning or to rule out the presence of serious medical conditions.<ref>American College of Obstetricians and Gynecologists, Committee on Obstetric Practice. [https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Guidelines-for-Diagnostic-Imaging-During-Pregnancy-and-Lactation Guidelines for diagnostic imaging during pregnancy]. Obstet Gynecol. 2004;104:647-51.</ref>


*[[Straight Leg Raise Test|Active straight leg raise test]] (ASLR test) <ref name="VLEE" /><ref name="KANA" /><ref name="STU" /><ref name="VOLLE" />
=== Outcome Measures ===
The [[Pelvic Girdle Questionnaire (PGQ)]]<ref name=":5">Stuge. B., The pelvic girdle questionnaire: a condition-specific instrument for assessing activity limitations and symptoms in people with pelvic girdle pain. phys ther 2011; 91:1096-1108 </ref> was developed to evaluate impairments and/or the functional limitations caused my pelvic girdle pain during pregnancy and in the postpartum period.<ref name=":5" /> The PGQ has been found to significantly discriminated participants who were pregnant from participants who were not pregnant.<ref name=":12">Grotle M, Garratt AM, Krogstad Jenssen H, Stuge B. [https://academic.oup.com/ptj/article/92/1/111/2735206 Reliability and construct validity of self-report questionnaires for patients with pelvic girdle pain]. Physical therapy. 2012 Jan 1;92(1):111-23.</ref>


''Joint examination:''<ref name=":11" />  
Clinton and colleagues<ref name=":10" /> recommend using the [[Pain Catastrophizing Scale]] (PCS) and the [[Fear Avoidance Belief Questionnaire|Fear-Avoidance Beliefs Questionnaire]] (FABQ) when assessing and treating patients with pelvic girdle pain. Using these scales in your clinical practice can help provide you with a broader understanding of your patient's ability to mental process their pain and how their pain is affecting their daily activities. Currently only the Fear-Avoidance Beliefs Questionnaire-Physical Activity sub-scale has been validated for use during pregnancy.<ref name=":12" />


*Spine
== Differential Diagnosis ==
*Pelvic girdle
Patient-reported pelvic girdle pain can be associated with signs and symptoms of inflammatory, infectious, traumatic, neoplastic, degenerative, or metabolic disorders.<ref name=":10" /> Therefore, it is important to take a detailed subjective history and refer to the appropriate medical professional as indicated. Pelvic girdle pain can be a symptom of uterine abruption or referred pain due to urinary tract infection to the lower abdomen/pelvic or sacral region.<ref>Boissonnault JS, Klestinski JU, Pearcy K. The role of exercise in the management of pelvic girdle and low back pain in pregnancy: A systematic review of the literature. Journal of Women’s Health Physical Therapy. 2012 May 1;36(2):69-77.</ref> A referral to a medical professional is warranted if the patient reports any of the following:<ref name=":10" />
*Hip
* a history of trauma
*Assessment of the nerves supplying the muscles<ref name=":11" />
* unexplained weight loss
*Assessment of functional abilities<ref name=":11" />
* a history of cancer
Radiological investigations also have an essential role in the evaluation of PGP. Standard anteroposterior, inlet and outlet pelvic films are used to measure the degree of symphyseal separation. PGP syndrome leads to the separation of the symphysis pubis in pregnant women, which result in a higher degree. The use of flamingo can be useful in quantifying the degree of pelvic girdle instability.<ref name="KANA" />
* steroid use or drug abuse
== Medical Management ==
* human immunodeficiency virus or immunosuppressed state
* neurological symptoms/signs,
* a fever, and/or feeling systemically unwell
* severe pain that does not improve with rest <ref name=":10" />


=== Medical therapy for pelvic girdle pain during pregnancy ===
==== Differential Diagnosis for pregnancy-related pelvic girdle pain ====
*Intra-articular SIJ injections (under imaging guidance) for ankylosing spondylitis can be recommended. But high quality studies are required for SIJ therapeutic injection therapy.<ref name="VLEE" />
When assessing a patient who presents with pregnancy-related pelvic girdle pain the presence of pelvic floor muscle, hip, and lumbar spine dysfunction should be ruled out.<ref name=":10" /> Differential diagnoses can include;
*Taking simple analgesia (paracetamol)<ref name=":11" />
*Low potency opiates like codeïne and dihydrocodeine<ref name=":11" />
*Avoiding non-steroidal anti-inflammatory drugs (NSAID) during pregnancy<ref name=":11" />
*The use of a pelvic belt has shown to relieve the pain in many patients. Coxal and femur compression deactivated some dorsal hip muscles, reduced vertical SIJ shear forces and increased SIJ compression. This enhanced SIJ stability.<ref name=":14">Pel J.J et al., Biomechanical model study of pelvic belt influence on muscle and ligament forces, J Biomech. 2008;41(9):1878-84. </ref>
*Acetaminophen in oral or rectal form in cases of mild pelvic pain<ref name=":4" />
*Low-dose aspirin is considered safe during pregnancy<ref name=":4" />
*Cyclobenzaprine, a muscle relaxant<ref name=":4" />
*Opioids may be used on short-term and small dose for severe pain<ref name=":4" />
*Surgery can be performed during pregnancy if the pain is having a disabling, paralysing effect or if neurologic compromise is highly probable, although surgery is considered to have a limited role in PGP.<ref name=":4" />


=== Medical therapy for pelvic girdle pain after pregnancy ===
'''Hip dysfunction'''
*Different guiding techniques for intra-articular injections in the SIJ were used either under fluoroscopy or with CT or MRI guidance, this showed immediate pain relief with decreasing effects over time.<ref name="VLEE" />  
* possible femoral neck stress fracture due to transient osteoporosis<ref>Boissonnault WG, Boissonnault JS. Transient osteoporosis of the hip associated with pregnancy. Journal of Women’s Health Physical Therapy. 2005 Dec 1;29(3):33-9.</ref> <ref>Møller UK, við Streym S, Mosekilde L, Rejnmark L. Changes in bone mineral density and body composition during pregnancy and postpartum. A controlled cohort study. Osteoporosis International. 2012 Apr 1;23(4):1213-23.</ref><ref>Oliveri B , Parisi MS , Zeni S , Mautalen C . Mineral and bone mass changes during pregnancy and lactation . Nutrition . 2004 ; 20 ( 2 ): 235 – 240.</ref>
*The use of a pelvic belt may reduce mobility/laxity of the SIJ. Effective load transfer through the pelvis, has been improved by the application of a pelvic belt. It has a positive effect on pain and daily activities. A pelvic belt may also be fitted to test for symptomatic relief, but should only be applied for short periods.<ref name="VLEE" /><ref name=":14" />  
* bursitis/tendonitis, chondral damage/loose bodies, capsular laxity, femoral acetabular impingement, labral irritations/tears, muscle strains
* referred pain from L2,3 radiculopathy<ref name=":14">Tibor LM, Sekiya JK. Differential diagnosis of pain around the hip joint. Arthroscopy. 2008;24(12): 1407–1421.</ref>
* osteonecrosis of the femoral head<ref name=":14" />
* [[Paget's Disease|Paget’s disease]]<ref name=":14" />
* rheumatoid, and psoriatic and septic arthritis<ref name=":14" />
'''Lumbar spine dysfunctions and [https://www.physio-pedia.com/Low_Back_Pain_and_Pregnancy pregnancy-related low back pain]'''<ref name=":10" /> 
* [[spondylolisthesis]]
* [[Ankylosing Spondylitis (Axial Spondyloarthritis)|ankylosing spondylitis]]
* discal patterns of symptoms that fail to centralize
'''Bowel/bladder dysfunction'''<ref name=":10" /> 
* [[Cauda Equina Syndrome|cauda equina syndrome]]
* large lumbar disc, or
* other space-occupying lesions around the spinal cord or nerve roots


== Physical Therapy Management    ==
== Physical Therapy Management    ==
There appears to be theoretical evidence in the research literature to support activity modification and participation in the treatment of pregnancy-related pelvic girdle pain.<ref name=":10" /> There is conflicting evidence for the use of support belts, and exercise and the current evidence to support manual therapy is weak.<ref name=":10" /> However, clinical experience, knowledge and reasoning should be applied when implementing a treatment plan to address pain, discomfort and dysfunction related to pelvic girdle pain.


=== Physical therapy for pelvic girdle pain during pregnancy ===
=== Individualized exercise programs ===
According to the European guidelines by Vleeming and colleagues<ref name="VLEE" /> exercises are recommended during pregnancy. These exercises should focus on adequate advice concerning activities of daily living and avoid maladaptive movement patterns.<ref name="VLEE" /> It is important to follow an individualized program, focusing specifically on stabilizing exercises for a greater control.
The [https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Physical-Activity-and-Exercise-During-Pregnancy-and-the-Postpartum-Period American College of Obstetrics and Gynecologists (ACOG)] and the [https://sogc.org/wp-content/uploads/2013/01/129E-JCPG-June2003.pdf Canadian Clinical Practice Guidelines (CPGs)] recommend exercise during and after pregnancy as long as the patient does not present with any contraindications to exercise during their pregnancy. In women who present with pelvic girdle pain during or after their pregnancy, an individualized approach should be taken. Exercise may focus on motor control, strength of the abdominal, spinal, pelvis, and pelvic floor muscles.<ref>Elden H, Ladfors L, Olsen MF, Ostgaard HC, Hagberg H. [https://www.bmj.com/content/330/7494/761.full Effects of acupuncture and stabilising exercises as adjunct to standard treatment in pregnant women with pelvic girdle pain: randomised single blind controlled trial]. Bmj. 2005 Mar 31;330(7494):761.</ref><ref name="STU" /> If pelvic floor dysfunction is suspected, referral to a pelvic health physiotherapist is warranted. Aquatic exercises may provide a pain-free environment for women to exercise in during pregnancy.<ref>Pennick V, Liddle SD. [http://uir.ulster.ac.uk/26553/1/LBPP_in_pregnancy_Cochrane_review_2013.pdf Interventions for preventing and treating pelvic and back pain in pregnancy]. Cochrane Database of Systematic Reviews. 2013 Aug 1(CD0011):1-00.</ref>


=== Physical therapy for pelvic girdle pain after pregnancy ===
=== Manual therapy ===
After pregnancy, it is also important to focus on specific stabilizing exercises. It has been proven that this type of exercises have a positive effect on pain, functional status and health-related quality of life.<ref name="VLEE" /><ref name=":4" /><br>The treatment program actually includes several important factors like <ref name="STU" />&nbsp;:
Manual therapy (i.e., soft tissue mobilization/manipulation, myofascial release, muscle energy, and muscle-assisted range of motion) and massage therapy may provide symptomatic relief<ref>Khorsan R, Hawk C, Lisi AJ, Kizhakkeveettil A. Manipulative therapy for pregnancy and related conditions: a systematic review. Obstetrical & gynecological survey. 2009 Jun 1;64(6):416-27.</ref> and may be incorporated into treatments as required.<ref name=":10" />


*''Advice and education:'' Informing the patient about body awareness. The purpose of information is mainly to reduce fear and to encourage patients to take an active part in their treatment and/or rehabilitation. General information on PGP needs to be presented (anatomy, biomechanics, motor control) and the patients need to be reassured that their problems are not dangerous to them or their child and that they will probably improve/recover. Ergonomic advice in real life situations can also be helpful, these situations can be really specific like carrying or lifting a child. The patient needs to be encouraged to enjoy physical activity and manage and combine this with periods of rest in order to recuperate.<ref name="VLEE" />  
=== Support belts ===
*''Joint mobilization, massage, relaxation and stretching'' can be executed when indicated. Manipulation or joint mobilization may be used to test for symptomatic relief, but should only be applied for a few treatments. Adjusting asymmetrical motion of the SIJs prior to exercising with joint mobilization may influence optimal form closure and enhance the possibility to exercise without pain. Massage might be helpful, but it must be given as part of a multifactorial individualized treatment program.<ref name=":15" /> Manual therapy could be applied even though the evidence is conflicting.<ref name=":11" /><ref>Hall H. et al., The effectiveness of complementary manual therapies for pregnancy-related back and pelvic pain. Medicine (Baltimore). 2016 Sep; 95(38): e4723. </ref>  
Some patients may find support and/or pain reduction when using support belts.<ref>Vleeming A, Buyruk HM, Stoeckart R, Karamursel S, Snijders CJ. An integrated therapy for peripartum pelvic instability: a study of the biomechanical effects of pelvic belts. American Journal of Obstetrics & Gynecology. 1992 Apr 1;166(4):1243-7.</ref> <ref>Mens JM, Damen L, Snijders CJ, Stam HJ. The mechanical effect of a pelvic belt in patients with pregnancy-related pelvic pain. Clin Biomech (Bristol , Avon) 2006; 21(2):122-127.</ref> Belts can be worn to improve symptoms and encourage physical activity.  
*''Exercises to retrain motor control and strength of abdominal, spinal, pelvic girdle, hip and pelvic floor muscles''.<ref name=":11" /> Giving the patients specific stabilizing exercises can reduce pain intensity, lower disability and higher quality of life.<ref name=":16">Mens JM, Pool- Goudzwaard A, Stam HJ. Mobility of the pelvic joints in pregnancy-related lumbopelvic pain : a systematic review. Obstetrical Gynecological Survey Mar 2009; 64(3) : 200-208. (Level of evidence 1B)</ref>
*''Pain control'': Exercise in water can help.<ref name=":11" /> Conflicting evidence shows that acupuncture could relieve pain.<ref>Kaj Wedenberg et al; A prospective randomized study comparing acupuncture with physiotherapy for low‐back and pelvic pain in pregnancy; AOGS; 2000 May; 331-335 </ref>  Massage and osteo manipulative therapy can also help to reduce pain during pregnancy but further research is required.<ref>Helen Hall et al., The effectiveness of complementary manual therapies for pregnancy-related back and pelvic pain, Medicine (Baltimore). 2016 Sep; 95(38): e4723.</ref><ref>Pennick V. et al., Interventions for preventing and treating low-back and pelvic pain during pregnancy (Review), Cochrane Database Syst Rev. 2013 Aug 1;(8):CD001139. </ref> Craniosacral therapy has small pain-relieving effects. If it’s used in combination with standard treatment it diminishes morning pain and gives less deteriorated function. But it’s not recommended for pregnant women since the effect are clinically very small.<ref>Elden H. et al., Effects of craniosacral therapy as adjunct to standard treatment for pelvic girdle pain in pregnant women: a multicenter, single blind, randomized controlled trial, ELDEN H. et al., Januari 2013 AOGS, DOI: 10.1111/aogs.12096 </ref> TENS is a safe way to help patients with pain relief.<ref>Qiuttan M. et al.,Transcutaneous Electrical Nerve stimulation (TENS) in patients with pregnancy- induced low back pain and/ or pelvic girdle pain, phys. med rehab kuror 2016:26: 91-95. ISSN 0940-6689 </ref>
The program, for exercise and training, consists of:<ref name=":4" />


*Specific training of the abdominal muscles, which are transversely oriented. This must be performed with co-activation of the lumbar multifidus at the lumbosacral region.
=== Education and activity modification ===
*The following muscles will be trained: Gluteus maximus, latissimus dorsi, blique abdominal muscles, erector spinae, quadratus lumborum and the hip adductors and abductors.
Physiotherapists should educate their patients on the [https://www.sciencedirect.com/science/article/pii/S0004951414603408?via%3Dihub central pain mechanisms] that may be influencing their pain.<ref name=":20" /> Encouraging pain-free physical activity and exercise while also educating the patient on the importance of rest and relaxation are essential components of the physiotherapy treatment. Patients should be educated on ergonomics, lifting positions/postures during daily activities and during tasks with the baby and potentially toddlers as well as positions for sexual intercourse.  


In the initial stage, the treatment program focuses on the training of specific contractions of the deep muscle system, independently from the superficial muscle. The deep muscle system consists of transversus abdominis, obliquus internus, multifidus, pelvic floor and the diaphragm. During all exercises and daily activities they emphasize the importance of activating these muscles before adding the superficial muscles. Depending on clinical findings this focus was combined with information, ergonomic advice, body awareness training, relaxation of global muscles and mobilization.<ref name=":4" /><ref name=":16" /> Exercises for the superficial muscles were gradually added to the program, when low force contractions of the transversely oriented abdominal muscles were achieved.<ref name=":16" />
==Prognosis==
Pregnancy-related pelvic girdle pain appears to be a self-limiting condition that typically resolves by 3 months postpartum in a majority of women.<ref name=":19" /> However, due to the complexity of the condition, it has been recommended that a biopsychosocial approach aimed at improving the individual's self-knowledge and self-efficacy be used in the management of pelvic girdle pain to help minimize disability.<ref name=":2">E.H. Verstraete, G. Vanderstraeten, W. Parewijck. Pelvic Girdle Pain during or after Pregnancy: a review of recent evidence and a clinical care path proposal: a systematic review. Pubmed 2013; 5(1); 33-43</ref>
== Clinical Bottom Line  ==


The Therapy Master, which is an exercise device, can be utilized to facilitate the exercise progression for most of the exercises.<ref name=":4" /><ref name=":16" /> In literature, the patients performed these exercises 30 to 60 minutes, 3 days a week, and this for 18 to 20 weeks. They also started with three series of ten repetitions of each exercise.<ref name=":4" /> The quality of the execution of the exercise determined the number of exercises and number of repetitions. Each patient received specific stabilizing exercises out of a fixed menu (see photo). The patients may have muscle soreness, but the exercises may not provoke pain at any time. It’s also very important that the patient maintains lumbopelvic control during the performance of these exercises.<ref name=":4" /><ref name=":16" /> The exercises for enhancing the lumbopelvic control and stability should involve the entire spinal musculature. Focusing on only global muscles seems insufficient.<ref name=":15" />
Pregnancy-related pelvic girdle pain is a multifactoral condition that requires a biopsychosocial approach to treat. It is important to rule out any differential diagnoses when assessing patients who present with pelvic girdle pain. Current research and clinical guidelines should be used to inform and assist the physiotherapist's treatment plan for this condition.  
== Resources  ==
A recent study conducted by Dufour and colleagues<ref name=":20">Dufour S, Daniel S. Understanding Clinical Decision Making: Pregnancy-Related Pelvic Girdle Pain. Journal of Women’s Health Physical Therapy. 2018 Sep 1;42(3):120-7.</ref> found that a sample of surveyed physiotherapists were unaware of the current best practices and guidelines that have been published on pregnancy-related pelvic girdle pain.<ref name=":20" /> You can access the clinical practice guidelines from Section on Women’s Health and the Orthopaedic Section of the American Physical Therapy Association and the European guidelines in the links below.  


Patients often have a flare-up of pain when exercising, but this is likely from progressing the exercise load too quickly. This study used an exercise diary so the patient could describe her progression, and seemed to be effective in avoiding flare-ups.<ref name=":4" /> It is well documented that exercise supervision is critical for improving quality of exercise performance.<ref name=":4" /><ref name=":16" />
Clinton et al. (2017). [https://www.womenshealthapta.org/wp-content/uploads/2015/01/cpg-antepartum-pgp-clinton-newell-sowh-10-1-14.pdf Pelvic Girdle Pain in the Antepartum Population Physical Therapy Clinical Practice Guidelines  Linked to the International Classification of Functioning, Disability, and Health from the Section on Women’s Health and the Orthopaedic Section of the American Physical Therapy Association]
 
== Resources    ==


Vleeming A, Albert HB, Östgaard HC, Sturesson B, Stuge B. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2518998/ European guidelines for the diagnosis and treatment of pelvic girdle pain]. European Spine Journal. 2008 Jun 1;17(6):794-819.
Vleeming A, Albert HB, Östgaard HC, Sturesson B, Stuge B. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2518998/ European guidelines for the diagnosis and treatment of pelvic girdle pain]. European Spine Journal. 2008 Jun 1;17(6):794-819.
== Clinical Bottom Line  ==
We can conclude that pregnancy related pelvic girdle pain often is caused by instability of the pelvis or sacroiliac joint. Biomechanical (the wedge shape of the sacrum, the additional compression forces which are generated by the muscles, fascia and ligaments) and hormonal (relaxin, progesterone) factors have an impact on the dynamic stability. These factors can cause an increased motion of the pelvic joints which leads to a stabbing pain deep in the sacral/gluteal region. Patients who suffer from pelvic girdle pain, have difficulty during walking, running, climbing stairs, sexual intercourse and also during sitting and sleeping.
To make the diagnosis of pelvic girdle pain the following tests are recommended for the clinical examination: posterior pelvic pain provocation test , Patrick ‘s Faber test, palpation of the long dorsal SIJ ligament , Gaenslen’s test, palpation of symphysis, modified Trendelenburg’s of the pelvic girdle and the active straight leg raise test (ASLR test). It’s also very important to ask the patient about his pain history.
During and after pregnancy it is important to follow an individualized program, in which stabilization exercises are very important. During this program it is important to focus on adequate advice concerning activities of daily living and to avoid maladaptive movement patterns. The following muscles need to be trained during the exercise program: the abdominal muscles, M. gluteus maximus, M. latissimus dorsi, M. oblique abdominal muscles, M. erector spinae, M. quadrates lumborum end the hip adductors and abductors.
== Presentations  ==
<div class="coursebox">
{| class="FCK__ShowTableBorders" width="100%" cellspacing="4" cellpadding="4" border="0"
|-
| align="center" | <imagemap>
Image:Kegel or not.png |200px|border|left|
rect 0 0 830 452 [http://www.youtube.com/watch?v=w08iCzxnQBU]
desc none
</imagemap>
| [http://www.youtube.com/watch?v=w08iCzxnQBU '''Pelvic Physiotherapy - to Kegel or Not?''']
This presentation was created by Carolyn Vandyken, a physiotherapist who specializes in the treatment of male and female pelvic dysfunction. She also provides education and mentorship to physiotherapists who are similarly interested in treating these dysfunctions. In the presentation, Carolyn reviews pelvic anatomy, the history of Kegel exercises and what the evidence tells us about when Kegels are and aren't appropriate for our patients.
[http://www.youtube.com/watch?v=w08iCzxnQBU View the presentation]
|}
</div>
== References  ==
== References  ==
<references />
<references />


[[Category:Pelvic_Health]]  
[[Category:Pelvic Health]]
[[Category:Pelvis]]  
[[Category:Womens_Health]]
[[Category:Womens_Health]]
  [[Category:Pregnancy]]
  [[Category:Pregnancy]]
[[Category:Pelvis - Conditions]]
[[Category:Conditions]]

Latest revision as of 18:21, 25 April 2024

Original Editors - Marlies Verbruggen
Top Contributors - Marlies Verbruggen, Nicole Hills, Rotimi Alao, Andeela Hafeez, Lara Lagrange, Vanwymeersch Celine, Admin, Kim Jackson, Laura Ritchie, Rachael Lowe, Simisola Ajeyalemi, WikiSysop, Evan Thomas, Fasuba Ayobami and Wanda van Niekerk

Introduction[edit | edit source]

Pregnant cross-section.jpg

According to the European guidelines created by Vleeming and colleagues,[1] “Pelvic girdle pain (PGP) generally arises in relation to pregnancy, trauma, arthritis and osteoarthritis. Pain is experienced between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the sacroiliac joints (SIJ). The pain may radiate in the posterior thigh and can also occur in conjunction with/or separately in the symphysis. The endurance capacity for standing, walking, and sitting is diminished. The diagnosis of PGP can be reached after exclusion of lumbar causes. The pain or functional disturbances in relation to PGP must be reproducible by specific clinical tests”[1]

Clinically Relevant Anatomy[edit | edit source]

The pelvis is composed of the sacrum, ilium, ischium and pubis. The pelvic bone consists the pubic symphysis and the sacroiliac joint.

Sacroiliac Joints
The sacroiliac joints allow for the transfer of forces between the spine and the lower extremity.[2] To read more about the function of the sacroiliac joints review: Force and Form Closure

Pelvic Floor
The pelvic floor muscles have two primary functions in females. The muscles:[3]

  1. support the abdominal viscera (bladder, intestines, uterus) and the rectum
  2. control the mechanism for continence for the urethral, anal and vaginal orifices[3]

Etiology[edit | edit source]

The etiology of pregnancy-related pelvic girdle pain has not been clearly established in the literature.[4] However, the cause of this pain is believed to be multi-factorial and may be related to hormonal, biomechanical, traumatic, metabolic, genetic and degenerative factors.[5] [6] [7]

Hormonal[edit | edit source]

Women produce increased quantities of the hormone relaxin during their pregnancy. Relaxin increases ligament laxity in the pelvic girdle (and in other parts of the body) in preparation for the labour process. Increased ligament laxity may cause a small increase in the range of motion at the pelvis. If this increase in motion is not complimented by a change in neuromotor control (e.g., muscles around the pelvis act to improve stability), it is possible that pain may occur.[1] However, the link between relaxin and pelvic girdle pain during pregnancy has not been established in the literature.[6][7] Research to date also does not support the idea that an increase in the range of motion at the pelvis causes pain.[1][8] [9]

Biomechanical[edit | edit source]

As pregnancy progresses, the gravid uterus increases load on the spine and pelvis. To accommodate for the growth of the uterus the pubic symphysis must soften and laxity in the pelvic ligaments increases. The uterus shifts forward which changes the maternal centre of gravity and the orientation of pelvis.[10] This change in centre of gravity may cause stress or a change in load on the lower back and pelvic girdle.[6][11][7] This change in load can result in compensatory postural changes (e.g., an increase in lumbar lordosis).[6][11][7]

Risk Factors[edit | edit source]

The risk factors for developing pregnancy-related pelvic girdle pain are:

  • a previous history of low back pain or pelvic girdle pain.[12][7]
  • a previous trauma to the pelvis or back.[12][7]
  • physical demanding work (e.g., twisting and bending the back several times per hour per day).[1][13][14][15][16]
  • multiparity - may play a causal role in the development of pregnancy-related pelvic girdle pain[17]

Epidemiology[edit | edit source]

Pelvic girdle pain may begin around the 18th week of pregnancy and appears to peak between the 24th and 36th week.[18] Pelvic pain affects approximately 50% of women during pregnancy.[13] 25% of the women who experience pelvic girdle pain report having severe pain and 8% report pain that causes severe disability.[19]

Clinical Presentation[edit | edit source]

The clinical presentation of pregnancy-related pelvic girdle pain can vary from patient to patient and can change over the course of the patient's pregnancy.[13] Since the causes of pregnancy-related pelvic girdle pain are multi-factorial and, it is important to incorporate a biopsychosocial approach to the diagnosis and treatment of this pain.

Subjective History[edit | edit source]

Common symptoms related to pregnancy-related pelvic pain include:

  • a difficulty walking quickly and covering long distances[1][20][13]
  • pain/discomfort/difficulty during sexual intercourse[20][13]
  • pain/discomfort during sleep and/or a difficulty turning over in bed[13][21]
  • decreased ability to perform housework[13][21]
  • decreased ability to engage in activities with children[13]
  • difficulty sitting[21]
  • difficulty standing for 30 minutes or longer[21]
  • pain in single leg stance i.e., climbing stairs[21]
  • inability or difficulty running (postnatal) due to pain[21]
  • decreased ability for mother-child interactions[14]
  • pain/discomfort with weight bearing activities[11]

Pain[edit | edit source]

The onset of pain may occur around the 18th week of pregnancy and reaches peak intensity between the 24th and 36th week of pregnancy. The pain typically resolves by the third month in the postpartum period.[22][7]

Location[edit | edit source]

Pelvic girdle pain typically presents near the sacroiliac joints and/or gluteal area or anteriorly near the symphysis pubis[13]. The reported pain may radiate into the patient's groin, perineum or posterior thigh but does not mimic a typically sciatic nerve root distribution.[23][24] The location of the pain may vary throughout the course of the pregnancy.[25] A pain distribution diagram can be a useful tool in identifying the patient's pain and to help distinguish pregnancy-related pelvic girdle pain from pregnancy related low back pain.[26]

Nature and intensity of pain[edit | edit source]

Pelvic girdle pain may be described as a stabbing,[27][28] dull, shooting, or burning sensation.[28] The intensity of pain on a 100 mm visual analogue scale averages around 50-60 mm.[25][24]

Muscle Function and Perception[edit | edit source]

  • postpartum women may present with reduced hip abduction and adduction force[29] which may be related to fear of pain/movement.[29]
  • women may reported a feeling of "catching" in their upper leg during ambulation[28] and/or report feeling the lack the ability to move their legs during the active straight leg test[30] which may suggest nervous system involvement.[13]
  • altered gait coordination - women with postpartum pelvic girdle pain can present with a coupling between pelvic and thoracic rotations during gait (pelvic and thoracic rotations in the same direction occur at the same time) which has been proposed as a nervous system strategy used to cope with motor problems.[31]

Pelvic Girdle Pain Examination[edit | edit source]

Before a diagnosis of pelvic girdle pain is reached potential lumbar spine pain and/or dysfunction should be ruled out.[1] Once the lumbar spine is ruled out the sacroiliac joint, the symphysis pubis, and the pelvis should be assessed.

Sacroiliac joint[edit | edit source]

Symphysis Pubis[edit | edit source]

Functional Pelvic Test[edit | edit source]

Diagnostic Procedures[edit | edit source]

During pregnancy diagnostic imaging using radiation is contraindicated.[26] Ultrasound imaging and/or MRIs may be used for certain interventions and/or surgical planning or to rule out the presence of serious medical conditions.[34]

Outcome Measures[edit | edit source]

The Pelvic Girdle Questionnaire (PGQ)[35] was developed to evaluate impairments and/or the functional limitations caused my pelvic girdle pain during pregnancy and in the postpartum period.[35] The PGQ has been found to significantly discriminated participants who were pregnant from participants who were not pregnant.[36]

Clinton and colleagues[26] recommend using the Pain Catastrophizing Scale (PCS) and the Fear-Avoidance Beliefs Questionnaire (FABQ) when assessing and treating patients with pelvic girdle pain. Using these scales in your clinical practice can help provide you with a broader understanding of your patient's ability to mental process their pain and how their pain is affecting their daily activities. Currently only the Fear-Avoidance Beliefs Questionnaire-Physical Activity sub-scale has been validated for use during pregnancy.[36]

Differential Diagnosis[edit | edit source]

Patient-reported pelvic girdle pain can be associated with signs and symptoms of inflammatory, infectious, traumatic, neoplastic, degenerative, or metabolic disorders.[26] Therefore, it is important to take a detailed subjective history and refer to the appropriate medical professional as indicated. Pelvic girdle pain can be a symptom of uterine abruption or referred pain due to urinary tract infection to the lower abdomen/pelvic or sacral region.[37] A referral to a medical professional is warranted if the patient reports any of the following:[26]

  • a history of trauma
  • unexplained weight loss
  • a history of cancer
  • steroid use or drug abuse
  • human immunodeficiency virus or immunosuppressed state
  • neurological symptoms/signs,
  • a fever, and/or feeling systemically unwell
  • severe pain that does not improve with rest [26]

Differential Diagnosis for pregnancy-related pelvic girdle pain[edit | edit source]

When assessing a patient who presents with pregnancy-related pelvic girdle pain the presence of pelvic floor muscle, hip, and lumbar spine dysfunction should be ruled out.[26] Differential diagnoses can include;

Hip dysfunction

  • possible femoral neck stress fracture due to transient osteoporosis[38] [39][40]
  • bursitis/tendonitis, chondral damage/loose bodies, capsular laxity, femoral acetabular impingement, labral irritations/tears, muscle strains
  • referred pain from L2,3 radiculopathy[41]
  • osteonecrosis of the femoral head[41]
  • Paget’s disease[41]
  • rheumatoid, and psoriatic and septic arthritis[41]

Lumbar spine dysfunctions and pregnancy-related low back pain[26] 

Bowel/bladder dysfunction[26] 

  • cauda equina syndrome
  • large lumbar disc, or
  • other space-occupying lesions around the spinal cord or nerve roots

Physical Therapy Management[edit | edit source]

There appears to be theoretical evidence in the research literature to support activity modification and participation in the treatment of pregnancy-related pelvic girdle pain.[26] There is conflicting evidence for the use of support belts, and exercise and the current evidence to support manual therapy is weak.[26] However, clinical experience, knowledge and reasoning should be applied when implementing a treatment plan to address pain, discomfort and dysfunction related to pelvic girdle pain.

Individualized exercise programs[edit | edit source]

The American College of Obstetrics and Gynecologists (ACOG) and the Canadian Clinical Practice Guidelines (CPGs) recommend exercise during and after pregnancy as long as the patient does not present with any contraindications to exercise during their pregnancy. In women who present with pelvic girdle pain during or after their pregnancy, an individualized approach should be taken. Exercise may focus on motor control, strength of the abdominal, spinal, pelvis, and pelvic floor muscles.[42][32] If pelvic floor dysfunction is suspected, referral to a pelvic health physiotherapist is warranted. Aquatic exercises may provide a pain-free environment for women to exercise in during pregnancy.[43]

Manual therapy[edit | edit source]

Manual therapy (i.e., soft tissue mobilization/manipulation, myofascial release, muscle energy, and muscle-assisted range of motion) and massage therapy may provide symptomatic relief[44] and may be incorporated into treatments as required.[26]

Support belts[edit | edit source]

Some patients may find support and/or pain reduction when using support belts.[45] [46] Belts can be worn to improve symptoms and encourage physical activity.

Education and activity modification[edit | edit source]

Physiotherapists should educate their patients on the central pain mechanisms that may be influencing their pain.[47] Encouraging pain-free physical activity and exercise while also educating the patient on the importance of rest and relaxation are essential components of the physiotherapy treatment. Patients should be educated on ergonomics, lifting positions/postures during daily activities and during tasks with the baby and potentially toddlers as well as positions for sexual intercourse.

Prognosis[edit | edit source]

Pregnancy-related pelvic girdle pain appears to be a self-limiting condition that typically resolves by 3 months postpartum in a majority of women.[7] However, due to the complexity of the condition, it has been recommended that a biopsychosocial approach aimed at improving the individual's self-knowledge and self-efficacy be used in the management of pelvic girdle pain to help minimize disability.[48]

Clinical Bottom Line[edit | edit source]

Pregnancy-related pelvic girdle pain is a multifactoral condition that requires a biopsychosocial approach to treat. It is important to rule out any differential diagnoses when assessing patients who present with pelvic girdle pain. Current research and clinical guidelines should be used to inform and assist the physiotherapist's treatment plan for this condition.

Resources[edit | edit source]

A recent study conducted by Dufour and colleagues[47] found that a sample of surveyed physiotherapists were unaware of the current best practices and guidelines that have been published on pregnancy-related pelvic girdle pain.[47] You can access the clinical practice guidelines from Section on Women’s Health and the Orthopaedic Section of the American Physical Therapy Association and the European guidelines in the links below.

Clinton et al. (2017). Pelvic Girdle Pain in the Antepartum Population Physical Therapy Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health from the Section on Women’s Health and the Orthopaedic Section of the American Physical Therapy Association

Vleeming A, Albert HB, Östgaard HC, Sturesson B, Stuge B. European guidelines for the diagnosis and treatment of pelvic girdle pain. European Spine Journal. 2008 Jun 1;17(6):794-819.

References[edit | edit source]

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 Vleeming A, Albert HB, Östgaard HC, Sturesson B, Stuge B. European guidelines for the diagnosis and treatment of pelvic girdle pain. European Spine Journal Jun 2008; 17(6) : 794-819.
  2. ↑ Vleeming A, Schuenke MD, Masi AT, Carreiro JE, Danneels L, Willard FH. The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. Journal of anatomy. 2012 Dec 1;221(6):537-67.
  3. ↑ 3.0 3.1 Raizada V, Mittal RK. Pelvic floor anatomy and applied physiology. Gastroenterology Clinics of North America. 2008 Sep 1;37(3):493-509.
  4. ↑ Aldabe D, Milosavljevic S, Bussey MD. Is pregnancy related pelvic girdle pain associated with altered kinematic, kinetic and motor control of the pelvis? A systematic review. European Spine Journal. 2012 Sep 1;21(9):1777-87.
  5. ↑ Homer C, Oats J. Clinical practice guidelines: Pregnancy care. Canberra: Australian Government Department of Health, 2018; p. 355–57
  6. ↑ 6.0 6.1 6.2 6.3 Bhardwaj A, Nagandla K. Musculoskeletal symptoms and orthopaedic complications in pregnancy: Pathophysiology, diagnostic approaches and modern management. Postgrad Med J 
  7. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 Kanakaris NK, Roberts CS, Giannoudis PV. Pregnancy-related pelvic girdle pain: An update. BMC Med 2011;9:15. doi: 10.1186/1741-7015-9-15.
  8. ↑ Damen L, Buyruk HM, Güler-Uysal F, Lotgering FK, Snijders CJ, Stam HJ. Pelvic pain during pregnancy is associated with asymmetric laxity of the sacroiliac joints. Acta obstetricia et gynecologica Scandinavica. 2001 Jan 1;80(11):1019-24.
  9. ↑ Sturesson B, Selvik G, UdÉn A. Movements of the sacroiliac joints. A roentgen stereophotogrammetric analysis. Spine. 1989 Feb;14(2):162-5.
  10. ↑ Ritchie JR. Orthopedic considerations during pregnancy. Clinical obstetrics and gynecology. 2003 Jun 1;46(2):456-66.
  11. ↑ 11.0 11.1 11.2 Robinson H.S., Clinical course of pelvic girdle pain postpartum - impact of clinic findings in late pregnancy, Manual therapy 19 (2014) 190-196 
  12. ↑ 12.0 12.1 Pierce H, Homer CS, Dahlen HG, King J. Pregnancy-related lumbopelvic pain: listening to Australian women. Nursing research and practice. 2012;2012.
  13. ↑ 13.0 13.1 13.2 13.3 13.4 13.5 13.6 13.7 13.8 13.9 Wu WH, Meijer OG, Uegaki K, Mens JMA, Van Dieën JH, Wuisman PIJM, Östgaard HC. Pregnancy-related pelvic girdle pain (PPP), I : Terminology, clinical presentation, and prevalence. European Spine Journal Nov 2004; 13(7) : 575-589.
  14. ↑ 14.0 14.1 Elden H., Predictors and consequences of long-term pregnancy-related pelvic girdle pain: a longitudinal follow-up study,BMC Musculoskelet Disord. 2016; 17: 276.doi: 10.1186/s12891-016-1154-0
  15. ↑ Danielle Casagrande et al., Low Back Pain and Pelvic Girdle Pain in Pregnancy, J Am Acad Orthop Surg 2015;00:1-11
  16. ↑ Ostgaard HC, Andersson GB. Postpartum low-back pain. Spine. 1992 Jan;17(1):53-5.
  17. ↑ Bjelland EK. et al., Hormonal contraception and pelvic girdle pain during pregnancy: a population study of 91.721 pregnancies in the norwegian mother and child cohort, Human reproduction. vol 0, No.0 pp1-7, 2013 
  18. ↑ Bergstrom et al., Pregnancy-related low back pain and pelvic girdle pain approximately 14 months after pregnancy – pain status, self-rated health and family situation, BMC Pregnancy and Childbirth 201414:48, DOI: 10.1186/1471-2393-14-48
  19. ↑ Albert H, Godskesen M, Westergaard J. Prognosis in four syndromes of pregnancy‐related pelvic pain. Acta obstetricia et gynecologica Scandinavica. 2001 Jun 1;80(6):505-10.
  20. ↑ 20.0 20.1 20.2 20.3 20.4 20.5 20.6 20.7 20.8 Kanakaris NK, Roberts CS, Giannoudis PV. Pregnancy-related pelvic girdle pain: un update. BMC Medicine Feb 2011; 9: 1-15.
  21. ↑ 21.0 21.1 21.2 21.3 21.4 21.5 Nielsen LL. Clinical findings, pain descriptions and physical complaints reported by women with post-natal pregnancy-related pelvic girdle pain. Acta Obstetricia et Gynecologica 2010: 89; 1187-1191.
  22. ↑ Oätgaard HC, Andersson GB, Wennergren M. The impact of low back and pelvic pain in pregnancy on the pregnancy outcome. Acta obstetricia et gynecologica Scandinavica. 1991 Jan;70(1):21-4.
  23. ↑ Fast A, Shapiro D, Ducommun EJ, Friedmann LW, Bouklas T, Floman Y. Low-back pain in pregnancy. Spine. 1987 May;12(4):368-71.
  24. ↑ 24.0 24.1 Ostgaard HC, Zetherström G, Roos-Hansson E, Svanberg B. Reduction of back and posterior pelvic pain in pregnancy. Spine. 1994 Apr;19(8):894-900.
  25. ↑ 25.0 25.1 Kristiansson P, Svärdsudd K, von Schoultz B. Back pain during pregnancy: a prospective study. Spine. 1996 Mar 15;21(6):702-8.
  26. ↑ 26.00 26.01 26.02 26.03 26.04 26.05 26.06 26.07 26.08 26.09 26.10 26.11 Clinton SC, Newell A, Downey PA, Ferreira K. Pelvic Girdle Pain in the Antepartum Population: Physical Therapy Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Section on Women's Health and the Orthopaedic Section of the American Physical Therapy Association. Journal of Women's Health Physical Therapy. 2017 May 1;41(2):102-25.
  27. ↑ Östgaard HC, Roos-Hansson E, Zetherström G. Regression of back and posterior pelvic pain after pregnancy. Spine. 1996 Dec 1;21(23):2777-80.
  28. ↑ 28.0 28.1 28.2 Sturesson et al; Pain pattern in pregnancy and" catching" of the leg in pregnant women with posterior pelvic pain; Spine; 1997; PP 1880-1883 
  29. ↑ 29.0 29.1 Mens JM, Vleeming A, Snijders CJ, Ronchetti I, Stam HJ. Reliability and validity of hip adduction strength to measure disease severity in posterior pelvic pain since pregnancy. Spine. 2002 Aug 1;27(15):1674-9.
  30. ↑ Mens JM, Vleeming A, Snijders CJ, Koes BW, Stam HJ. Reliability and validity of the active straight leg raise test in posterior pelvic pain since pregnancy. Spine. 2001 May 15;26(10):1167-71.
  31. ↑ Wu W, Meijer OG, Jutte PC, Uegaki K, Lamoth CJ, de Wolf GS, van Dieën JH, Wuisman PI, Kwakkel G, de Vries JI, Beek PJ. Gait in patients with pregnancy-related pain in the pelvis: an emphasis on the coordination of transverse pelvic and thoracic rotations. Clinical biomechanics. 2002 Nov 1;17(9-10):678-86.
  32. ↑ 32.0 32.1 32.2 32.3 32.4 32.5 Stuge B, Laerum E, Kirkesola G, Vollestad N. The efficacy of a treatment program focusing on specific stabilizing exercises for pelvic girdle pain after pregnancy: A randomized controlled trial. Spine Feb 2004 : 29(4) ; 351-359.
  33. ↑ 33.0 33.1 33.2 Vollestad NK, Stuge B. Prognostic factors for recovery from postpartum pelvic girdle pain. European Spine Journal Feb 2009: 18; 718-726.
  34. ↑ American College of Obstetricians and Gynecologists, Committee on Obstetric Practice. Guidelines for diagnostic imaging during pregnancy. Obstet Gynecol. 2004;104:647-51.
  35. ↑ 35.0 35.1 Stuge. B., The pelvic girdle questionnaire: a condition-specific instrument for assessing activity limitations and symptoms in people with pelvic girdle pain. phys ther 2011; 91:1096-1108 
  36. ↑ 36.0 36.1 Grotle M, Garratt AM, Krogstad Jenssen H, Stuge B. Reliability and construct validity of self-report questionnaires for patients with pelvic girdle pain. Physical therapy. 2012 Jan 1;92(1):111-23.
  37. ↑ Boissonnault JS, Klestinski JU, Pearcy K. The role of exercise in the management of pelvic girdle and low back pain in pregnancy: A systematic review of the literature. Journal of Women’s Health Physical Therapy. 2012 May 1;36(2):69-77.
  38. ↑ Boissonnault WG, Boissonnault JS. Transient osteoporosis of the hip associated with pregnancy. Journal of Women’s Health Physical Therapy. 2005 Dec 1;29(3):33-9.
  39. ↑ Møller UK, við Streym S, Mosekilde L, Rejnmark L. Changes in bone mineral density and body composition during pregnancy and postpartum. A controlled cohort study. Osteoporosis International. 2012 Apr 1;23(4):1213-23.
  40. ↑ Oliveri B , Parisi MS , Zeni S , Mautalen C . Mineral and bone mass changes during pregnancy and lactation . Nutrition . 2004 ; 20 ( 2 ): 235 – 240.
  41. ↑ 41.0 41.1 41.2 41.3 Tibor LM, Sekiya JK. Differential diagnosis of pain around the hip joint. Arthroscopy. 2008;24(12): 1407–1421.
  42. ↑ Elden H, Ladfors L, Olsen MF, Ostgaard HC, Hagberg H. Effects of acupuncture and stabilising exercises as adjunct to standard treatment in pregnant women with pelvic girdle pain: randomised single blind controlled trial. Bmj. 2005 Mar 31;330(7494):761.
  43. ↑ Pennick V, Liddle SD. Interventions for preventing and treating pelvic and back pain in pregnancy. Cochrane Database of Systematic Reviews. 2013 Aug 1(CD0011):1-00.
  44. ↑ Khorsan R, Hawk C, Lisi AJ, Kizhakkeveettil A. Manipulative therapy for pregnancy and related conditions: a systematic review. Obstetrical & gynecological survey. 2009 Jun 1;64(6):416-27.
  45. ↑ Vleeming A, Buyruk HM, Stoeckart R, Karamursel S, Snijders CJ. An integrated therapy for peripartum pelvic instability: a study of the biomechanical effects of pelvic belts. American Journal of Obstetrics & Gynecology. 1992 Apr 1;166(4):1243-7.
  46. ↑ Mens JM, Damen L, Snijders CJ, Stam HJ. The mechanical effect of a pelvic belt in patients with pregnancy-related pelvic pain. Clin Biomech (Bristol , Avon) 2006; 21(2):122-127.
  47. ↑ 47.0 47.1 47.2 Dufour S, Daniel S. Understanding Clinical Decision Making: Pregnancy-Related Pelvic Girdle Pain. Journal of Women’s Health Physical Therapy. 2018 Sep 1;42(3):120-7.
  48. ↑ E.H. Verstraete, G. Vanderstraeten, W. Parewijck. Pelvic Girdle Pain during or after Pregnancy: a review of recent evidence and a clinical care path proposal: a systematic review. Pubmed 2013; 5(1); 33-43
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