Pelvic girdle pain (PGP), formerly known as symphysis pubis dysfunction (SPD), was first described in the time of Hippocrates (Snelling, 1870). Until recently, quantitative research, much of which has been undertaken in Scandinavia and the Netherlands, has focused on trying to establish the causes of PGP (Bjorklund et al, 2000; Vleeming et al, 2008), and to identify the frequency of incidence and diagnostic criteria (Albert et al, 2000; 2001; Laslett et al, 2005). It is estimated that around one in five pregnant women is affected (Hansen et al, 1996; Larsen et al, 1999; Wu et al, 2004). These studies concur on frequency of incidence, and more recent research has moved to consider issues around treatment and management options (Wedenburg et al, 2000; Stuge et al, 2003; 2004; Asian and Fynes, 2007; Elden et al, 2008) and breastfeeding (Bjelland et al, 2014). Guidelines have been developed on management and treatment (Vleeming et al, 2008; Health Service Executive (HSE), 2012; Pelvic Obstetric and Gynaecological Physiotherapy, 2014a). Qualitative research has explored the physical and psychological consequences of the condition (Shepherd and Fry, 1996; Shepherd, 2005; Wellock and Crichton, 2007; Crichton and Wellock, 2008).
It was previously believed that hormones were responsible for the problem and, therefore, that it would resolve after birth, at the time of stopping breastfeeding or after a certain (unspecified and variable) time had elapsed post-birth (MacLennan et al, 1986). This has been investigated in detail and it has been found that there is no correlation between relaxin levels and PGP (Hansen et al, 1996; Albert et al, 1997; Björklund et al, 2000; Marnach et al, 2003; Bjelland et al, 2014).
Other work has looked at the symphyseal gap and its relationship to pain in PGP; it has been found that this does not correlate to pain or severity of symptoms (Björklund et al, 1999; 2000). Studies have explored a range of therapeutic treatment options (Stuge et al, 2003; 2004; Beith, 2007) and it can be demonstrated that with early diagnosis, manual therapy treatment and a well-managed birth, the problem can be minimised and deterioration prevented. Breastfeeding has been noted to improve the rate of recovery in a largescale study (Bjelland et al, 2014).
The Pelvic Partnership charity receives hundreds of phone calls and emails each year from women who have not recovered, sometimes decades after having their babies, despite—or as a result of—receiving conservative treatment or advice on exercise. Yet even with long-term symptoms, when the women access manual therapy, they usually report rapid recovery from their symptoms. This is often combined with frustration that manual therapy has not been offered sooner, as the consequent pain, psychological distress and financial and social consequences of being unable to walk, care for their children and/or return to work, could have been avoided. Many women access manual therapy through private practitioners because it is not always available through NHS providers. By changing the way that PGP is understood, managed and ultimately treated, women will no longer have to seek private care, and can all enjoy a fulfilling pregnancy. The morbidity, both physical and psychological, of PGP will be reduced, and further, from a health economics perspective, the NHS and society as a whole can save significant amounts of money by preventing the consequences of long-term disability.
The Pelvic Partnership was set up in response to women's need for information and support when they were affected by PGP, and also responds to the information needs of health professionals including midwives, obstetricians, GPs, health visitors and physiotherapists, all of whom encounter women with PGP and seek ways to support, manage and treat the condition. The evidence from research is reflected in the experiences women reveal when they contact the Pelvic Partnership. The charity hears about missed opportunities for women to receive treatment because their care-givers are not aware of the treatment options available. This article aims to raise awareness of treatment and how to access it.
Incidence and presentation
PGP affects around one fifth of pregnant women (Albert et al, 2001; Wu et al, 2004). It causes physical, psychological and practical problems for affected women. It can range in severity from mild discomfort in the front or back of the pelvic joints, around the symphysis pubis or sacroiliac joints (SIJs), to women becoming housebound, bed-bound and wheelchair-bound in both the short and long term. Diagnosis can be made based on symptoms including pain in and around the pelvic joints occurring during or after pregnancy, and having an impact on a woman's mobility and ability to walk, climb stairs and turn over in bed (Vleeming et al, 2008; HSE, 2012; Pelvic Obstetric and Gynaecological Physiotherapy, 2014a; 2014b) There are diagnostic tests for SIJ pain (Laslett et al, 2005) but these are used in a treatment context rather than to diagnose PGP per se.
Pregnant women with PGP are often reassured that they will get better when they have had their baby. However, many take months to improve, and may never return to full function. It is estimated that around 7% of affected women still have severe symptoms at 2 years postpartum (Albert et al, 2001; Wu et al, 2004). Even those women who have made a good recovery without treatment often report the onset of more severe symptoms earlier in a subsequent pregnancy. However, women who have received manual therapy during and after an affected pregnancy usually report that symptoms in a subsequent pregnancy are not as severe, and that they recover more quickly both intrapartum and postnatally than in a previous pregnancy. They may even not experience symptoms at all in subsequent pregnancies.
Complicating conditions
There are conditions that can add to the complexity of PGP. These include hypermobility syndromes such as Ehlers-Danlos syndrome (EDS), or trauma that occurs during pregnancy (or at birth) which has an impact on the biomechanics of the pelvic joints. Such trauma might include abduction of the legs into a range where the woman would normally experience pain, for example, in lithotomy position or when epidural anaesthesia is in situ. If this has occurred, it should be taken into account when planning care and rehabilitation, rather than being taken as a reason for not attempting treatment (HSE, 2012; Pelvic Obstetric and Gynaecological Physiotherapy, 2014a; 2014b). Women with EDS have often functioned at a high or normal level prior to their pregnancy and the aim of rehabilitation, as with any other musculoskeletal injury, would be to restore their function to its previous level wherever possible.
Working with women towards recovery
When contacting the Pelvic Partnership, some women have said that they find it both frightening and disempowering to be told that they are the worst case that a practitioner has ever seen, or that there is nothing that can be done to improve their symptoms. Women with severe PGP symptoms may require additional psychological support or debriefing after a traumatic birth, in the same way that any other woman with a complex obstetric history may require additional support. The consequences of being unable to walk independently while pregnant or caring for a small baby should not be overlooked or underestimated.
Women may experience a range of symptoms, varying from minor symptoms during pregnancy to severe symptoms requiring the use of crutches and a wheelchair for mobility, which they may continue to need for months or years after birth, particularly after an instrumental birth (Albert et al, 2001).
The consequences of immobility and pain can be far-reaching. Some women accept being told that what they are feeling is the ‘normal’ aches and pains of pregnancy, or even that it is normal to have to crawl to get to the toilet in the last few weeks of pregnancy. In some extreme cases, particularly if she has experienced pain in a previous pregnancy, a woman may find the pain unbearable and, as a last resort, seek to terminate the pregnancy. The Pelvic Partnership has been alerted to a small number of cases in which women have taken their own lives as a consequence of PGP that was not treated effectively.
Review of the literature: approaches to management and treatment
Traditionally, there was a view that PGP was a hormonal problem caused by relaxin and the loosening of the pelvic ligaments during pregnancy (MacLennan et al, 1986) and that, therefore, nothing could be done about it during pregnancy. The treatment advocated was a combination of support including support belts, crutches and advice to rest, keep the legs together, and often to have induction of labour in the expectation that the pain would disappear when the baby was born. This was followed by a theory that there was a weakness in the core muscles, so core stability and pelvic floor exercises were advocated, and demonstrated better outcomes than no exercises (Stuge et al, 2004; Vleeming, 2008). Acupuncture has also been shown to help with pain relief and is better than no acupuncture (Wedenberg et al, 2000; Elden et al, 2008).
These approaches, however, do not take into account the mechanical joint asymmetry element of PGP. Many women report that the pain starts after they have been physically active, after a day of walking or a following a slip, such as stepping out of the bath awkwardly. All pregnant women have changes in their relaxin levels, but only one in five women is affected by PGP. If women rest or avoid movements that cause pain, the pain settles, only to return when they become active again—this would not be the case if hormones were directly responsible for the pain. Women who receive manual therapy to restore symmetry of movement to the pelvic joints improve in function and experience a reduction in pain levels; again, this would not be the case if the problem was purely hormonal (Buyruk et al, 1999; Damen et al, 2001; HSE, 2012).
Ostgaard et al (1994) identified that sympyseal pain did not occur unless the SIJs were involved. Buyruk et al (1999) showed that women with PGP have asymmetry of sacroiliac movement when tested with Doppler imaging by vibration. This correlates with asymmetry of movement found when testing the pelvic joints in a manual therapy assessment (Damen et al, 2001). Such an assessment will look at the symmetry of movement using tests such as a stork test (single-leg standing), seated flexion tests, and gliding of the SIJ as well as looking at symmetry (not pain) at the symphysis pubis joint. These assessment tests enable the manual therapist to identify the hypo-mobile joint, restore function to the joints and, if necessary, treat surrounding compensating or tight muscles. This should result in the woman walking out of a treatment session with improved function and reduced pain.
From a biomechanical perspective, this asymmetry of joint movement results in the ring of pelvic joints no longer functioning normally. Normally, when moving from sitting to standing, the sacrum moves forwards and the SIJs, which are large and stable, brace to take the weight of the trunk and pass it through to the legs. If one of the SIJs is not moving normally, this movement does not happen, and as a result the symphysis pubis—a smaller, less stable joint—takes the load, and quickly becomes irritated and painful. The longer this asymmetry continues, the more painful the symptoms become, and gradually the muscles and the SIJs themselves become irritated and painful. By restoring the symmetry of movement through simple manual therapy techniques, this asymmetry can usually be resolved and function should improve with each treatment session.
The causes of PGP are unclear. The European guidelines (Vleeming et al, 2008) reviewed all the evidence and concluded that possible contributory factors such as age, weight, parity, use of the oral contraceptive pill and physical fitness were not indicators of an increased risk of developing PGP. This is also reflected in the population of women who contact the Pelvic Partnership, who include all ages, parities and cultural backgrounds. The European guidelines concluded that a previous history of low back pain may predispose women to developing PGP. However, this accounts for a large proportion of the population. Therefore, rather than looking for reasons for the occurrence of PGP which are unlikely to be changeable for most of the population, it may be more helpful to consider how to treat the condition when it occurs.
Based on the work of Buyruk et al (1999) and Damen et al (2001), manual therapists—including physiotherapists, osteopaths and chiropractors—have changed their approach from one of management and waiting for recovery, to a proactive approach, actively working to restore symmetry of the pelvic joints using hands-on techniques to achieve symmetry of movement. Women are assessed each time they attend for treatment, looking at symmetry of movement of the pelvic joints, and any asymmetry is treated using manual therapy techniques including muscle energy techniques, trigger point techniques for tight or painful muscles, pelvic floor muscle release technique for overactive pelvic floor muscles where appropriate, acupuncture for muscle release, and other manual therapy techniques as required. Most women will notice improvement of their symptoms afterwards.
The myths relating to hormonal causes of PGP, which have arisen over time, have been superseded by current evidence about the mechanical origins of PGP and its consequent positive response to manual therapy (Table 1).
| Facts | Myths |
|---|---|
| Mechanical | Hormonal |
| Treatable | Untreatable |
| Can occur at any stage in pregnancy | Only occurs in late pregnancy |
| Can affect any woman | Affects women who are not active enough |
| If managed well, does not need to be so serious in a subsequent pregnancy | Gets worse with each pregnancy |
| May continue for months or years postnatally | Will get better as soon as the baby is born |
| Breastfeeding makes no difference, and is best for both mother and baby | Will end when the woman stops breastfeeding |
The role of midwives
Midwives have contact with women throughout their pregnancy and childbirth experience, so knowing how to support and signpost women with PGP is key. Early referral for manual therapy and monitoring of the woman's progress will enhance the rapidity of her recovery. Likewise, birth planning that considers the mobility she has, ability to change position in labour, choice of place of birth and pain relief should be planned in advance (Wellock and Crichton, 2007; Pelvic Obstetric and Gynaecological Physiotherapy, 2014a; 2014b). This may enable the woman to feel confident that her choices are being supported, and also ensure that appropriate facilities are available for women with mobility problems, including birth pools, midwifery-led units and homebirth. This is likely to reduce the need for epidural, which can lead to intervention and cause delayed postnatal recovery owing to aggravation of the pelvic joint problems (Shepherd, 2005; Pelvic Obstetric and Gynaecological Physiotherapy, 2014a; 2014b).
Psychological support from midwives is also important for many women (Shepherd, 2005; Wellock and Crichton, 2007; Crichton and Wellock, 2008). Some women receive excellent support from their midwife or GP, while others may need additional help from supervisors of midwives, consultant midwives or professional counsellors to help to plan their birth and ensure that they receive the assistance they need. Debriefing after birth is often helpful in coming to terms with a difficult birth experience—whether it is perceived by the health-care team as traumatic or not—and can be helpful as part of planning a subsequent birth (Shepherd, 2005; Crichton and Wellock, 2008).
Conclusion
PGP is a treatable condition, which can be addressed and improved at any stage in pregnancy. PGP is a symptom of asymmetry of movement of the pelvic joints, including a stiffness of the sacroiliac joints at the back of the pelvis. Presenting symptoms include pain, mobility problems, and emotional and practical consequences of such immobility. The earlier treatment is started, in the form of hands-on manual therapy, the more likely the woman is to recover from her symptoms. There is also a notable difference in the experiences that women report in a pregnancy where they are supported to access effective treatment, and where their concerns relating to the birth of their baby and birth-planning are listened to and supported.
The Pelvic Partnership
The Pelvic Partnership provides information and support to women with pelvic girdle pain (PGP) as well as to health professionals, to promote early treatment of PGP during pregnancy wherever possible, and an expectation of good recovery. The charity has telephone and email helplines manned by volunteers, and can supply copies of its factsheet on request. It relies entirely on donations and grants for funding.