Pregnancy and Pelvic girdle pain Physiotherapy
Pregnancy Related Pelvic Girdle Pain: Words Can Hurt
Imagine you are 32 weeks pregnant with your first child and you start to have pain in the low back and pubic area when you change position, sit or stand for longer periods or when you walk. The pain makes it very difficult for you to function and you worry about whether you can continue to work and manage your household. Now imagine you have seen your health care provider and have been told that your pelvis is separating because of the hormone Relaxin and that you need to put up with this until after you have your baby, as “it will probably get better afterwards”. “Be careful” “If it hurts, don’t do it”, “Your pubic bone is splitting”, “Your pelvis is unstable”. These are common words of advice or explanations pregnant women with pelvic girdle pain (PGP) receive from their healthcare providers, including physiotherapists. (From the Canadian Physiotherapy Association – Pain Science Division)
Pelvic girdle pain is characterized by pain around the pubic and sacroiliac joints, and can present as pain in the inner groin and adductor area, the buttocks and the sides of the hips and is aggravated most commonly by maintaining sustained postures or changing position. Pelvic girdle pain affects approximately 16-25% (Kanakaris 2011) of pregnant women, although it is very likely underreported and dismissed as a normal consequence of pregnancy. Prognosis is very good, with a majority of women improving within a few months after delivery and only approximately 5-8.5% (Kanakaris 2011) going on to have persistent symptoms.
Before and in addition to any manual therapy and or exercises we give to our patients, we should make clear accurate communication a priority. Urban myths regarding breastfeeding being associated with laxity-related musculoskeletal pain should be put to rest. Suggestions to “be careful” (suggesting fragility), restrict function (reinforcing disability), to rest more and avoid activity (usually makes symptoms worse) should be set aside. Too many women have weaned their babies early, in hopes this would alleviate their Pelvic girdle pain, a decision based upon “helpful” advice, often from their physiotherapist, despite the fact that there is no evidence to support this. Many women are sadly advised not to lift their babies for several weeks after delivery in order to not aggravate their Pelvic girdle pain.
The good news is that Pelvic girdle pain can be managed very successfully, and women can be shown effective self management programs which allow them to take control of their own care and become more confident, comfortable and active during their pregnancies. Women can be shown how to integrate good strategies into daily activities so that they can manage work, daily activities and child/baby care independently during pregnancy and postpartum. Studies have also shown that vaginal deliveries are not only safe for women with PGP, they are even preferable. Bjelland (2012) found a 2-3 fold increased risk of severe Pelvic girdle pain postpartum in women with PGP after a planned Cesarean Section.
Pelvic Girdle pain Leads to a Significant Decrease in QoL
Five main categories emerged: 1. Pelvic girdle pain affects the ability to cope with every day life a) Postpartum depression- 3x more prevalent in this group of women (Gutke 2007) 2. Coping with motherhood and changing roles a) 20% avoid future pregnancies because of fear of LBP/PGP (Brynhildsen 1998) 3. Relationship between partners often reached the breaking point 4. Questioning one’s identity as defined by profession and work 5. Lack of acknowledgement of pain and disability Elden H. et al: Life’s pregnant pause of pain: Pregnant women’s experiences of pelvic girdle pain related to daily life: A Swedish Interview Study. Sexual & Reproductive Healthcare. (2013) Engeset J. et al. Pelvic girdle pain affects the whole life—a qualitative interview study in Norway on women’s experiences with pelvic girdle pain after delivery. BMC Res Notes. (2014) 7: 686.
I believe physiotherapists have a privileged role in helping to shape the experience of pregnant women with Pelvic girdle pain. Physiotherapists are in the ideal position to calm anxiety, correct misconceptions and educate our patients about their condition in a way that decreases the threat of their pain and gives them permission to move. Physical activity is now seen as a critical part of a healthy pregnancy. Pregnant women should accumulate at least 150 minutes of moderate-intensity physical activity each week over a minimum of three days per week; however, being active every day is encouraged. Following the 2019 Guideline for Physical Activity throughout Pregnancy can reduce their risk of pregnancy-related illnesses such as gestational diabetes, high blood pressure and preeclampsia by 25 percent. (https://csepguidelines.ca/guidelines-for-pregnancy/)
Pain Management in Pregnancy: Joint SOGC/CSEP Clinical Practice Guidelines Nov 2018
1.Pelvic floor muscle training (e.g., Kegel exercises) may be performed on a daily basis to reduce the risk of urinary incontinence. Instruction in proper technique is recommended to obtain optimal benefits.
2.Pelvic floor muscle training with a physiotherapist is recommended to prevent urinary incontinence during pregnancy and after delivery
3. Core stability training with a physiotherapist is recommended to prevent and treat back and pelvic pain during and following pregnancy.
4. Pregnant women who experience lightheadedness, experience nausea, or feel unwell when they exercise flat on their back should modify their exercise position to avoid the supine position
Supervised antenatal and postnatal pelvic floor muscle training has been shown to be protective against UI, particularly in high risk groups Boyle et al 2012, Stafne et al 2012, Reilly et al 2002. PFMT may be recommended to women as first-line measure to prevent UI.