Pregnancy Related Pelvic Pain

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Search Strategy

In my research I utilized the following databases : pubmed, pedro, medscape and the catalogus of the library of the Vrije Universiteit Brussels . I used different search terms like pelvic girdle pain, pregnancy related pelvic girdle pain, pelvic pain, lumbopelvic pain, pelvic girdle pain stabilization and pelvic pain pregnancy physiotherapy.

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 thesacroiliac 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 %. 

Clinically Relevant Anatomy

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Epidemiology /Etiology

The exact underlying mechanisms, leading to the development of pelvic girdle pain in pregnancy, are uncertain or speculative. Literature actually proposed different, etiologic hypotheses like mechanical, traumatic, hormonal, metabolic and degenerative factors.
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. 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. 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. The stabilization, which is acquired by three specific anatomic characteristics, is mainly needed at the sacro-iliac joints. In the articular surfaces of the sacro-iliac joints there are ridges and grooves who 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 sacro-iliac joints to give the joints their stability. Women produce increased quantities of a polypeptide hormone, namely Relaxin, during their pregnancy. Consequently there is greater ligamental laxity, especially in the joints of the pelvis by relaxing the connective tissue. In pregnant women this leads to the widening and separation of the symphysis pubis. Mens et al. has recently established in his systematic review that patients, who suffer from pelvic girdle pain, have increased motion in their pelvic joints compared with healthy pregnant controls.
The increased motion of the pelvic joints results in negative consequences namely : 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.
We can divide the patients who suffer from pelvic girdle pain into five subgroups depending on symptoms.

1. Pelvic girdle syndrome : including symptoms of anterior and posterior pelvic girdle, symphysis pubis and bilateral joints
2. Symphysiolysis : including symptoms of the anterior pelvic girdle and pubic symphysis
3. One sided Sacroiliac syndrome : including symptoms of the posterior pelvic girdle and unilateral sacroiliac joint.
4. Double-sided Sacroiliac syndrome : including symptoms of the posterior pelvic girdle and bilateral sacroiliac joints
5. 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  
• Previous trauma to the pelvis or back  
• Previous history of pelvic girdle pain
• High-work load or strenuous work (twisting and bending the back several times per hour)

There are also a few factors who do not influence the risk for development of pregnancy–related pelvic girdle pain like :

• The use of contraceptive pills  
• Time interval since last pregnancy  
• Height
• Weight
• Smoking
• Age  
• Epidural / spinal anesthetic
• Analgesic techniques 
• Bone density
• Foetal weight 
• Number of previous pregnancies 
• Maternal ethnicity
  
  

Characteristics/Clinical Presentation

The clinical presentation of pregnancy related pelvic girdle pain is characterized by a wide variation of symptoms. These symptoms can be mild but can also be very serious sometimes.
The pain, which can be stabbing, burning or shooting, often starts around the 18th week but can also start after the delivery. It will often reach a peak intensity between the 24th and 36th week of pregnancy. The pain often disappears postpartum within 3 months. But 7-8% has persisting, chronic pain. ,,11] 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 the localization of the pain changes over time. The intensity of pain on a visual analogue scale (VAS) is usually around 50-60 mm.
Patients, who suffer from pelvic girdle pain, have difficulty during :

• Walking ( quickly): alternated gait pattern ( slower walking velocity)  
• Sexual intercourse  
• During sleep : Turning in bed
• Housework
• Increased intra-abdominal pressure
• Activities with children
• Sitting 
• Standing [
• Climbing stairs
• Running (postnatal)
  
  

Differential Diagnosis

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Diagnostic Procedures

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Outcome Measures

Pelvic Girdle Questionnaire (PGQ)

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) ,3,8,10,11,12]
• Patrick ‘s Faber test ,3,11]
• Palpation of the long dorsal SIJ ligament ,3,8,11,12]
• Gaenslen’s test ,3,10,11]

Symphysis :

• Palpation of symphysis ,3,8,11]
• Modified trendelburg’s test of the pelvic girdle ,3,8,11]

Functional pelvic test :

• Active straight leg raise test (ASLR test) ,3,8,12]

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.

Medical Management

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Physical Therapy Management

a) Physical therapy for pelvic girdle pain during pregnancy ( Evidence level C)

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. ( Evidence: C) 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. ,15]

b) Physical therapy for pelvic girdle pain after pregnancy ( Evidence level C)

A very important aspect of the therapy for pelvic girdle pain after pregnancy is the 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. ,,8,9]
The treatment program actually includes several important factors like [8] :

• Informing the patient about body awareness as well as ergonomic advice in real life situations. These situations can be really specific like carrying or lifting a child.
• Joint mobilization, massage, relaxation and stretching can be executed when indicated.
• However the accent has to remain on exercise and training.

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

• 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. [8,9]
Exercises for the superficial muscles were gradually added to the program, when low force contractions of the transversely oriented abdominal muscles were achieved. [9]

Summary of the exercises [8]
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Remark : CG stands for Control Group while SSEG refers to Specific Stabilizing Exercise Group.
The therapy master, which is an exercise equipment, can be utilized to facilitate the exercise progression for most of the exercises. [8,9]
In literature [8] 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. [8]
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. [8,9]
Patients often have a flare-up of pain when exercising. This might be caused by a too fast increase of the exercise load. This study [8] used an exercise diary so the patient could describe her progression. It seems to be an effective manner to avoid the flare-ups. [8]
It’s an accomplished fact that supervision of exercises is critically important in improving quality of exercise performance. [8,9]

Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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