Pregnancy Related Pelvic Pain

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[See also Chronic Pelvic Pain]

Definition/Description

According to the European guidelines of Vleeming et al , pelvic girdle pain can be defined as the following:
“Pelvic girdle pain 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.”
According to literature, the prevalence of women who suffer from pelvic girdle pain during their pregnancy is about 20 %. 

It’s a multifactorial condition with partly unknown aetiology. It used to be diagnosed as Symphysis Pubis Dysfunction but now it is a possible symptom. PGP has a possible biomechanical origin and could be related to non-optimal stability of the pelvic joints, characterized by a dull pain, most pronounced in forward flexion with restricted spine movement. PGP can be mentally and physically compromising both during and after pregnancy . PGP affect 1 in 5 pregnant women. Previous research reports a prevalence of PGP from the postpartum stage to 3 years after childbirth from 1 to 43 % , and 7 % at 6 years. [1 LOE:5, 2 LOE:3B, 28 LOE: 2C, 29 LOE: 2B, ,30 LOE: 2C, 31 LOE 5]

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.

Pelvic Floor
The Pelvic Floor is an area of muscles and connective tissue and has several functions:

1. Separating the pelvic cavity above from the perineal region below.
2. It provides support to the pelvic viscera (the bladder, intestines and uterus).
3. It assists with continence through control of the urinary and anal sphincters.
4. It facilitates birth by resisting the descent of the presenting part.
5. It helps to maintain optimal intra-abdominal pressure. [20, LOE:5]

Sacroiliac Joint
The sacroiliac joint is the connection between the spine and the pelvis . The main functions of the SI joint are: provide stability and compensate the load of the trunk to the lower limbs. The ligaments stabilizing the SI joint are the strongest ligaments in the body: [21, physiopedia] [22, PHYSIOPEDIA, reference]

1. Lig. Anterior Sacroiliac
2. Lig. Interosseus Sacroiliac
3. Lig. Posterior (Dorsal) Sacroiliac
4. Lig. Sacrotuberous
5. Lig. Sacrospinous

Pelvic Floor Anatomy
There are a lot of muscles who are attached to the sacrum to provide stability in the sacroiliac joint. These muscles are classified according to their primary function in the hip joint:

• Adduction: Adductor brevis/ longus /Magnus, Gracilis, Pectineus, Latissimus dorsi
• Abduction: Gluteus maxiumus/ medius/minimus, Tensor fascia lata,
• External rotation: Obturator internus /externus, Quadratus femoris/lumborum, Piriformis, Superior gemellus, Inferior gemellus, Pectineus, Adductor brevis/magnus, Gluteus maxiumus/ medius, Sartorius, Psoas minor
• Internal rotation: Tensor fascia lata, Gluteus medius/minimus, Semitendonosus,
• Retroflexion: Biceps femoris, Latissimus dorsi, Gluteus maxiumus/ medius, Semimembranosus, Semitendonosus, Adductor magnus
• Anteflexion: Iliacus, Sartorius, Tensor fascia lata, Rectus femoris, Psoas minor
• Anteflexion trunk: External oblique, Internal oblique
• Lateral flexion trunk: External oblique, Internal oblique, Multifidus
• Contralateral rotation trunk: External oblique
• Supporting the pelvic floor: Levator ani
• Abduction and flexion coccyx : Coccygeus
• Control of urination: Sphincter urethrae
• Bending flexion of the anus and tension of the vagina during an orgasm: Superficial transverse perineal ischiocavernous
• Compression abdomen: Transversus abdominus, Rectus abdominis, Pyramidalis, Internal oblique

Force and Form Closure

• Form closure: The sacrum and the ilium fit into each other and ensure stability.
• Force closure: This term is used to describe the other forces acting across the joint to create stability. Muscles, ligaments and the thoracolumbar fascia all contribute to force closure. It creates greater friction and therefore an increased stability. [22 PHYSIOPEDIA, reference]
  

Epidemiology /Etiology

Pregnancy related pelvic pain typically begins around the 18th week of pregnancy and peaks between week 24 and 36. Pelvic pain is common during pregnancy with a prevalence described variously as ranging from 50% to 70%. Between 14 to 22% of all pregnant women have serious pregnancy- related pelvic pain (PGP) and 5 to 8% of these women have severe pain and disability. Serious PGP is also present in 7% of women postpartum and lasts about 2 years after childbirth. [2 LOE:3 ][27 LOE:2A][31 LOE: 5]
The exact underlying mechanisms, leading to the development of pelvic girdle pain in pregnancy, are uncertain or speculative. [1] [2][3][5] Literature actually proposed different, etiologic hypotheses like biomechanical, genetic, traumatic, hormonal, metabolic and degenerative factors. [1][2][18]
On the basis of all of these hypotheses, the accumulated evidence supports the theory of a multifactorial condition. Meaning causes are multifactorial and often, no obvious explanation can be found.[2 LOE:3][33 LOE: 2A]

The combination of hormonal and biomechanical factors seems to be the most trustworthy hypothesis that can explain the development of pregnancy–related pelvic girdle pain. However no consensus of its association with the symptoms of PGP can be reached. This hypothesis is purely speculative and further research into their effect is needed. This can be explained by the presence of unspecified cofactors altering the clinical presentation of PGP. [2 LOE:3][34 LOE:1B][35 LOE:4]
During pregnancy the female body is exposed to certain factors that have an impact on the dynamic stability of the pelvis. The optimal stabilization of the pelvis is absolutely essential because the pelvis serves as a platform that must transfer the load from the trunk to the legs. Vleeming et al. published in 2008 a definition of optimal stability: “The effective accommodation of the joints to each specific load demand through an adequately tailored joint compression, as a function of gravity, coordinated muscle and ligament forces, to produce effective joint reaction forces under changing conditions”. Optimal stability depends on an efficient force closure, form closure, motor control and is influenced by our emotions. The central nerve system (CNS) chooses a dynamic (for example, inertia of limb segments and force-velocity relationships of muscles) or static (the force-length relationship of muscles and their moment arm-angle relationships or torque-angle relationships) movement strategy, depending on emotions (i.e. fear, anxiety) and perceptions, which results in specific muscle forces and in coordinated muscle activity. For example: when someone is feeling depressed, there will be a smaller concentration of the neurotransmitter serotonin available in the body of this person. Serotonin has an important role in our body posture, if there is a deficit of this neurotransmitter muscles will not work properly, which causes instability. [18 LOE:3A] [19 LOE:5] [23 LOE:2B]
So first of all the stabilization is from major concern because it determines if the load will be effectively transmitted. Secondly an optimal stabilization of the pelvis guarantees that the shear forces will be minimized across the joints.[35 LOE:4]
The stabilization, which is acquired by three specific anatomic characteristics, is mainly needed at the sacroiliac joints.[35 LOE:4] In the articular surfaces of the sacroiliac joints there are ridges and grooves that form the first part of stabilization. Secondly the sacrum has a wedge shape, which allows it to fit tightly between the ilia. Finally there are additional compression forces which are generated by the muscles, fascia and ligaments, that attach to the pelvis and act across the sacroiliac joints to give the joints their stability. Women produce increased quantities of a polypeptide hormone, namely relaxin, during their pregnancy. The effect of the levels of progesterone to the pelvic girdle ligaments is also established. Consequently there is greater ligamental laxity, especially in the joints of the pelvis by relaxing the connective tissue. In a systematic review, Mens et al.[6 LOE: 1B] recently established that patients who suffer from pelvic girdle pain have increased motion in their pelvic joints compared with healthy pregnant controls. If this is not compensated by altered neuromotor control, pain may result. The exact role of each specific hormone and the reasons for its variations in serum levels is not known, but the primary aim is to maintain pregnancy and to initiate delivery. [18 LOE:3][27 LOE:2A]

The increased motion of the pelvic joints results in negative consequences, namely that the efficiency of load transmission will be diminished. Furthermore the increase of motion will increase the shear forces across the joints. It’s possible that these increased shear forces are responsible for the pain in pregnant women with pelvic girdle pain. [1LOE:5] [5 LOE:1B][27 LOE:2A]

There is also a significant reduced 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 3th 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 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. [18 LOE:3B] [24 LOE:5][27 LOE:2A]
The increased motion of the pelvic joints results in negative consequences, namely that the efficiency of load transmission will be diminished. Furthermore the increase of motion will increase the shear forces across the joints. It’s possible that these increased shear forces are responsible for the pain in pregnant women with pelvic girdle pain. [1 LOE:5] [5 LOE:1B] The biomechanical theory shows that separation of the pubic symphysis for more than 10mm is an important threshold for PGP. However this is only the case for some of patients and is not applicable to patients with symptoms localised at the posterior pelvic girdle. [2 LOE:3A]
We can divide the patients who suffer from pelvic girdle pain into five subgroups depending on symptoms and the localization of pain. [1 LOE:5] [2 LOE:3A] [5 LOE:1B] [7 LOE:2B] [8 LOE:2B] [18 LOE: 3B]

Pelvic girdle syndrome : including symptoms of anterior and posterior pelvic girdle, symphysis pubis and bilateral joints
Symphysiolysis : including symptoms of the anterior pelvic girdle and pubic symphysis
One sided Sacroiliac syndrome : including symptoms of the posterior pelvic girdle and unilateral sacroiliac joint.
Double-sided Sacroiliac syndrome : including symptoms of the posterior pelvic girdle and bilateral sacroiliac joints
Miscellaneous : including inconsistent findings of the pelvic girdle.

The risk factors for the development of pregnancy–related pelvic girdle pain are :

• A previous history of low back pain [1 LOE:5] [2 LOE: 3A] [5 LOE: 1B] [3 LOE:3B] [6 LOE:1B] [27 LOE:2A]
• Previous trauma to the pelvis or back [1 LOE: 5] [2 LOE: 3A] [6 LOE: 1B] [27 LOE: 2A]
• Previous history of pelvic girdle pain[2 LOE: 3A] [5 LOE: 1B] [3 LOE: 3B][27 LOE: 2A][33 LOE:2A]
• High-workload or strenuous work (twisting and bending the back several times per hour)[1 LOE: 5] [2 LOE:3A] [5 LOE: 1B] [3 LOE:3B] [27 LOE: 2A]
• Parity-related factors [1 LOE:5][18 LOE:3B]

There are a few factors that had a weak evidence who influence the risk for development of pregnancy–related pelvic girdle pain: [9 LOE: 3B] [18 LOE:3B]

• Early menarche [30 LOE: 2C]
• IUDs (Intrauterine devices)[37 LOE: 2A]
• Increased weight during pregnancy[27 LOE: 2A]
• Softening of the pubic symphysis [37]
• High comorbidity index [30 LOE: 2C]
• BMI >30 [27 LOE:2A][30 LOE:2C]
• Previous low back pain [30 LOE: 2C]

There are also a few factors that had a conflicting evidence who influence the risk for development of pregnancy–related pelvic girdle pain like :

• The use of contraceptive pills [1 LOE:5] [2 LOE:3A][3 LOE:3B] [5 LOE:1B] [6 LOE:1B]
• Time interval since last pregnancy [1 LOE:5] [2 LOE:3A] [5 LOE:1B] [6 LOE: 1B]
• Height [1 LOE: 5][3 LOE: 3B] [5 LOE:1B]
• Weight High BMI [3 LOE:3B][1 LOE:5] [5 LOE1B] [32 LOE:2C]
• Smoking [1 LOE:5] [2 LOE:3A] [5 LOE:1B]
• Age[1 LOE:5] [2 LOE:3A] [3 LOE:3B] [5 LOE:1B] [6 LOE:1B] [32]
• Epidural / spinal anesthetic[2 LOE:3A][3 LOE:3B] [5 LOE:1B]
• Analgesic techniques[3 LOE:3B] [5 LOE:1B]
• Bone density[2 LOE: 3A] [3 LOE:3B]
• Higher Foetal weight [2 LOE:3A] [3 LOE:3B] [32 LOE:2C]
• Number of previous pregnancies [2 LOE:3A]
• Genetics between first degree relatives [2 LOE: 3A]
• Foetal size [2 LOE: 3A]
• The position of the the baby [2 LOE:3A]
• Hypermobility of the joints [32 LOE:2C] [33 LOE:2A]
• Previous abortion[3 LOE:3B]
• Maternal ethnicity [2 LOE:3A]
• Long term pgp: Strenuous work, sick leave, delivery rate, higher fetal weight, severe pain, decreased function, > 8h sleep/ rest, [32 LOE: 2C]
• Progestin- only contraceptive pills (progressieve PGP) [53 LOE: 2C]

Characteristics/Clinical Presentation

The clinical presentation of pregnancy related pelvic girdle pain is characterized by a wide variation of symptoms.

Pain
Timeline: 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. [3 LOE:3B] [18 LOE:3B]
Improvement of persistent PGP levels off around 6 months postpartum. [32 LOE: 2C] More women experience PGP 18 months after delivery as de breastfeeding decreased. [36 LOE:2B]

Localisation: Pain is often localized deep in the sacral/gluteal region. [1 LOE:5] [3 LOE:3B]Following the guidelines the pain is experienced between the posterior iliac crest and the gluteal fold, mostly surrounding the sacroiliac joints. [32 LOE:2C]
The localization of pain is deep and can be divided in five groups as mentioned above under ‘etiology and epidemiology’. It’s even possible that localization of the pain changes over time.
Nature of pain: 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. [18 LOE:3B]
Intensity of pain: The intensity of pain on a visual analogue scale (VAS) is usually around 50-60 mm. [2 LOE:3A] [3 LOE:3B] %The pain may be mild or quite bearable in about half of the cases and very serious in about 25%. [1 LOE:5][3 LOE:3B][18 LOE:3B]

Changes in the perception and execution of movements
Changes in the perception of movement: 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. [3 LOE:3B]
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. [3 LOE:3B]

- Patients, who suffer from pelvic girdle pain, have difficulty during:

• Walking (quickly): alternated gait pattern (slower walking velocity, waddling type of gait) [1 LOE:5] [2 LOE:3A] [3 LOE:3B]
• Sexual intercourse [2 LOE:3A] [3 LOE:3B]
• During sleep : Turning in bed [3 LOE:3B] [4 LOE:1B]
• Housework [3 LOE:3B] [4 LOE:1B]
• Activities with children [3 LOE:3B] [8 LOE:2B]
• Sitting [4 LOE:1B]
• Standing for 30 minutes or longer [4 LOE:1B]
• Climbing stairs [4 LOE:1B]
• Running (postnatal) [4 LOE:1B]
• Individual and socio-economic consequences [32 LOE:2C]
• Impaired mother-child interactions [32 LOE:2C]
• Weight bearing activities [46 LOE:2C]

Prognosis
Women with anterior and posterior pain location have the worst prognosis meanwhile an isolated anterior pain predicts a good prognosis. [32 LOE:2C] Breastfeeding is associated with small beneficial effect on the recovery process of the pelvic girdle pain in women with BMI >25 kg/m² (low level of evidence) [30 LOe:2C] 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. [32 LOE:2C, 46 LOE:2C]. Poorer prognosis if women have PGP and low back pain. [32 LOE:2C]
Women who exercise regularly (high impact exercise) have low risk to develop PGP. [54 LOE:3B]

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. [2 LOE:3A] (42 LOE:3A)

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.[12 LOE:2A]

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.[27 LOE: 2A]

Diagnostic Procedures

To diagnose a pregnant women 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.[31 LOE:5]
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:
[31 LOE:5][34 LOE:1B]

• 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:

1. Lower back
2. SPJ
3. SIJ(s)
4. Groin
5. Anterior and posterior thigh
6. Posterior lower leg
7. Hip/trochanteric region
8. 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 provocation test and Patrick’s/Faber Test (flexion, abduction and external rotation) show high sensitivity if pain is evident in the SIJ. [31 LOE:5][38 LOE:2B][56 LOE:2A]

Other diagnostic tests and imaging for PRPP:

• Urinalysis, midstream specimen of urine (MSU).
• High vaginal swab (HVS) for bacteria and endocervical swab.[1 LOE:5]
• Pregnancy test.
• MRI (most suggested imaging modality to evaluate PGP)[27 LOE:2A]
• Ultrasonography [27 LOE:2A]
• 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. [25 LOE:5]
• Urgent ultrasound (if miscarriage or ectopic pregnancy is suspected).
• Laparoscopy[7 LOE:2B]
  
  

Outcome Measures

Pelvic Girdle Questionnaire (PGQ) [49 LOE:2C]
Timed up and go (Fast pace) [47 LOE:2C]
10 m timed walk test (Fast pace) [47 LOE:2C]
Oswestry disability index [48 LOE:2C]

Examination

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 (P4) (PPPP): 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 [1][2][14] [10][11][15] [24]
• Patrick ‘s Faber test  
• Palpation of the long dorsal SIJ ligament
• Gaenslen’s test [38 LOE:2B]
• See also SIJ Special Test Cluster

Symphysis :

• Palpation of symphysis
• Modified trendelenburg’s test of the pelvic girdle

Functional pelvic test :

• Active straight leg raise test (ASLR test) [38 LOE: 2B [44 LOE: 3B]

Joint examination: [31 LOE:5]

• Spine
• Pelvic girdle
• Hip
• Assessment of the nerves supplying the muscles[31 LOE:5]
• Assessment of functional abilities [31 LOE:5]

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. [2 LOE: 3A]

Also 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. [45 LOE :2C]

It’s 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.  [42: LOE 3A]

Medical Management

a) Medical therapy for pelvic girdle pain during pregnancy

• Intra-articular SIJ injections (under imaging guidance) for ankylosing spondylitis can be recommended. But high quality studies are required for SIJ therapeutic injection therapy.[1 LOE:5]
• Taking simple analgesia (paracetamol) [31 LOE:5]
• Low potency opiates like codeïne and dihydrocodeine [31 LOE:5]
• Avoiding non-steroidal anti-inflammatory drugs (NSAID) during pregnancy [31 LOE:5]
• 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. [1 LOE:5][39 LOE: 2B]
• Acetaminophen in oral or rectal form in cases of mild pelvic pain[27 LOE:2A]
• Low-dose aspirin is considered safe during pregnancy[27 LOE:2A]
• Cyclobenzaprine, a muscle relaxant [27 LOE:2A]
• Opioids may be used on short-term and small dose for severe pain[27 LOE:2A]
• 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.[27 LOE:2A]

b) Medical therapy for pelvic girdle pain after pregnancy

• 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. [1: LOE 5]
  
• 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. [1 LOE:5] [39: LOE 1B]
  

Physical Therapy Management

a) Physical therapy for pelvic girdle pain during pregnancy

According to the European guidelines of Vleeming et al., exercises are recommended during pregnancy. These exercises should focus on adequate advice concerning activities of daily living and to avoid maladaptive movement patterns.  [1 LOE:5] It is important to follow an individualized program, focusing specifically on stabilizing exercises for a greater control.

There are not a lot of studies who examined the effects of exercises on pelvic girdle pain during pregnancy. These interventions are different with regard to duration and type of the exercises as well as performing individually or in groups. There should be more research for new therapies in the future.  [1 LOE: 5] [12 LOE: 2A]

b) Physical therapy for pelvic girdle pain after pregnancy

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. [1 LOE:5][13 LOE:5][8 LOE:2B][14 LOE:2B]
The treatment program actually includes several important factors like  :

• 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. [1 LOE:5]
• Ergonomics
• 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. [1 LOE:5] [17 LOE:5] Manual therapy could be applied even though the evidence is conflicting. [31 LOE:5] [55 LOE: 1A]
• Exercises to retrain motor control and strength of abdominal, spinal, pelvic girdle, hip and pelvic floor muscles. [31 LOE:5] Giving the patients specific stabilizing exercises can reduce pain intensity, lower disability and higher quality of life. [14 LOE:2B]
• Pain control: exercise in water can help. [31 LOE:5] Conflicting evidence shows that acupuncture could relieve pain. [43 LOE: 2B] Massage and osteo manipulative therapy can also help to reduce pain during pregnancy but further research is required. [27 LOE: 2A] [40 LOE :1A][41 LOE: 1A] . 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. [51 LOE: 2B]. TENS is a safe way to help patients with pain relief. [52 LOE: 1B]
  
  

=However the accent has to remain on exercise and training.

The program, for exercise and training, consists of [8 LOE:2B]:

• 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.
• The following muscles will be trained : M. gluteus maximus, M. latissimus dorsi, M. oblique abdominal muscles, M. erector spinae, M. quadrates lumborum end the hip adductors and abductors.

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 m. transversus abdominis (TrA), 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. [8 LOE:2B][14: LOE:2B]
Exercises for the superficial muscles were gradually added to the program, when low force contractions of the transversely oriented abdominal muscles were achieved.[14 LOE:2B]

The Therapy Master, which is an exercise device, can be utilized to facilitate the exercise progression for most of the exercises. [8 LOE:2B][14 LOE:2B]

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. [8LOE:2B]
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. [8 LOE:2B][14 LOE:2B] The exercises for enhancing the lumbopelvic control and stability should involve the entire spinal musculature. Focusing on only global muscles seems insufficient. [17 LOE:5]

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. [8 LOE:2B]
It’s well documented that exercise supervision is critical for improving quality of exercise performance. [8 LOE:2B][14 LOE:2B]

Key Research

Diana Lee, Linda-Joy Lee. The Pelvic Girdle. An integration of Clinical Expertise and Research. 2011(4)

Resources

[Pelvic Girdle Questionnaire (PGQ)]

http://www.womenshealthapta.org/wp-content/uploads/2013/12/Pelvic-Girdle-Questionnaire.pdf

Pelvic Girdle Questionnaire (PGQ)]
http://www.womenshealthapta.org/wp-content/uploads/2013/12/Pelvic-Girdle-Questionnaire.pdf
https://www.physio-pedia.com/Sacroiliac_Joint_Special_Test_Cluster
http://www.physio-pedia.com/Long_dorsal_sacroiliac_ligament_(LDL)_test
http://www.physio-pedia.com/Symphysis_pain_palpation_test
htttp://www.physio-pedia.com/FABER_Test

Clinical Bottom Line

We can conclude that pregnancy related pelvic girdle pain often is caused by instability of the pelvis or SI. 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 but 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.

Recent Related Research (from Pubmed)

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Presentations

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. View the presentation

References

see adding references tutorial.
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 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 1.27 [1.28] [1.29] [1.30] [1.31] [1.32] [1.33] [1.34] [1.35] [1.36] [1.37] 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. (Level of evidence 5)
2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 2.19 2.20 2.21 2.22 2.23 2.24 2.25 2.26 2.27 2.28 [2.29] [2.30] [2.31] Kanakaris NK, Roberts CS, Giannoudis PV. Pregnancy-related pelvic girdle pain: an update. BMC Medicine Feb 2011; 9: 1-15. (Level of evidence 3A)
3. ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 [3.13] [3.14] [3.15] [3.16] [3.17] 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. (Level of evidence 3B)
4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 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.(Level of evidence : 1B)
5. ↑ 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 5.13 5.14 Vermani E, Mittal R, Weeks A. Pelvic girdle pain and low back pain in pregnancy : A review. Pain practice : The official journal of World institute of pain Jan-Feb 2010 ;10(1): 60-71. (Level of evidence 1B)
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