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Pelvic Girdle Pain

Pelvic Girdle Pain (PGP/SPD)

Pelvic girdle pain (PGP) refers to a collection of musculoskeletal disorders caused by the uneven movement or stiffness of the pelvic joints, resulting in pain and discomfort in the pelvis and lumbopelvic (lower back) area and musculoskeletal pain radiating to the perineum and upper thighs. People struggling with PGP may experience pain from the lower back down to the thighs. PGP is primarily common during pregnancy and postpartum and usually resolves after birth [1]

Pelvic girdle pain is a collective term that refers to all pelvic pains, including symphysis pelvic dysfunction (SPD). PGP ranges from moderate to severe pain, limiting daily life activities. The joints that get affected due to PGP include:

      • The sacroiliac joint
      • The symphysis pelvic joint
      • Ligaments and muscles associated with the joints

This article will highlight the causes, symptoms of PGP/SPD, as well as effective ways for pain relief.

A lady with pelvic girdle pain

Why Is Pelvic Girdle Pain and Symphysis Pelvic Dysfunction (SPD) More Common During Pregnancy?

It is estimated that PGP affects one in every five pregnant women, but why pregnant women experience PGP is not known. This is sometimes called pregnancy-related pelvic girdle pain (PGP) or symphysis pubis dysfunction (SPD). PGP can develop as early as the first trimester but it is usually more frequent in the later stages of pregnancy.

There are three joints present in the pelvis that work together and move very minimally. They include pubic symphysis in the front and two sacroiliac joints in the back. During pregnancy, these joints become more mobile due to certain factors [2].

Firstly, pregnancy causes a change in weight that puts extra pressure on the pelvis, resulting in a change in the shape of the pelvis. Pelvis typically widens, and pelvic joints loosen, leading to pelvic girdle pain.

Secondly, the release of the relaxin hormone softens the ligaments and tough tissues connecting the joints, increasing the flexibility of pelvic muscles. The increased flexibility of pelvic muscles widens the pelvic, which is actually good during birth. The release of relaxin hormone is at peak during 8-10 weeks of pregnancy, and that’s the period when most pregnant women report PGP [3].

If you are breastfeeding, placing a cushion behind your back may help. Ensure you are in the most comfortable position and avoid any strain on your lower back. Moreover, for childbirth, a caesarean section is typically not recommended with PGP by healthcare providers as for it can slow down your recovery.

What Are the Causes Of Pelvic Girdle Pain (PGP)?

The following are some common causes of mild to severe PGP:

  • Osteoarthritis or arthritis
  • Sports injuries
  • A family history of lower back pain
  • A fall
  • Trauma
  • Muscle weakness or tightness, tissue laxity, weight gain, and hormonal changes related to pregnancy and postpartum.
  • Falling downstairs
  • A motor vehicle accident
  • Several types of movements, such as leaning on one leg or widening the legs.
  • Poor muscle function in the pelvis during pregnancy [4]

What Are the Symptoms Indicative Of Pelvic Girdle Pain (PGP)?

The symptoms of PGP may vary from moderate to severe. Some patients experience pain at both sides, while in others, PGP is only one-sided. However, the symptoms of PGP should not be confused with those of sciatica. Common signs and symptoms include:

  • Pain radiating in the posterior thigh
  • Feeling or hearing a clicking or grinding in the pelvic area
  • Pain felt across both sides of the lower back
  • Pain experienced over the pubic bone at the front
  • Pain in the perineum (the area between genitals and the anus) [5]

Functional Complaints:

Patients, as well as pregnant women with PGP, may also experience issues with transitional movements, such as:

  • Decreased ability to do homework
  • Discomfort and pain during weight-bearing activities
  • Difficulty walking
  • Difficulty standing for 30 minutes or longer
  • Difficulty or pain during straddle movements, such as getting in or out of the bath
  • A waddling gait
  • Difficulty with climbing stairs
  • Load transfer failure [6]

Risk Factors For Pelvic Girdle Pain (PGP):

The following are some risk factors for PGP based on strong evidence:

  • Smoking
  • Increased body mass index (BMI)
  • Orthopaedic dysfunction
  • Work dissatisfaction
  • Prior history of pregnancy
  • History of PGP during previous pregnancies
  • History of trauma to the pelvis
  • Pelvic floor muscle dysfunction
  • Joint hypermobility
  • Emotional distress during pregnancy

How Is PGP Diagnosed?

If you have pelvic girdle pain, your general practitioner will refer you to a physiotherapist. You can also seek help from an osteopath or a chiropractor. The physiotherapist will examine your hips and back if you have pain coming from pelvic joints.

There are various tests that can be performed to diagnose PGP. The tests include pain palpation tests (palpation of the symphysis and long dorsal ligament) and pain provocation tests. The active straight leg raise (ASLR) test can also be used as a functional test [7].

Treatment For PGP:

Making lifestyle changes and working with a physiotherapist are the main ways to treat PGP:

1. Medication: Your doctor might recommend you take painkillers, such as paracetamol. But it is important to know that paracetamol is not sure to be an effective pain reliever for pelvic girdle pain. Therefore, it is important to take advice from the doctor on how much paracetamol to take.

2. Physiotherapy: Physiotherapy treatment of pelvic girdle pain (PGP) depends on the physiotherapist. Physiotherapy includes:

  • Walking or standing up to protect your pelvis and back during regular movements.
  • Restoration of normal movement of joints and muscles in the pelvis by hands-on therapy.
  • Use a pelvic support belt or crutches to get relief from pain, especially during any physical activity.
  • Exercise to strengthen the pelvic floor, hip and joint muscles and improve the pelvis and lower back stability.
  • Gym-type exercises in water.

3. Alternative Therapies: Alternative therapies can also be used to manage PGP. They include:

  • Prolozone Therapy
  • Complementary therapies, including reflexology, massage, or manual therapy
  • Meditation like yoga or mindfulness
  • Hypnosis
  • Acupuncture
  • A TENS machine

During pregnancy, some of the promising interventions for PGP include a semi-elastic belt, acupuncture, and certain specialized stabilizing exercises.

Coping With Pelvic Girdle Pain: Some Preventive Tips:

Besides medications and physiotherapy, making small changes to everyday activities can help ease the pain:

  • Stick to the pelvic floor exercises that your physiotherapist has recommended to you.
  • Wear flat supportive shoes
  • Avoid activities that worsen your pain, such as carrying a baby on your hip or sitting cross-legged.
  • Get dressed sitting down.
  • Place a pillow between your legs before sleeping. Sleep on your side with your legs bent.
  • Avoid breaststroke if you are into swimming.
  • Avoid standing on one leg for long periods of time.
  • Try different ways to climb stairs.
  • Reduce non-essential weight-bearing activities
  • Avoid lifting heavy weights.
  • Keep your knees together while getting in or out of the car.
  • You can ask the physiotherapist and your midwife for help in factoring PGP into your birth plan.
  • Be as active as you can and within limits.

The Bottom Line:

Pelvic girdle pain is characterized by a dull and stabbing pain usually experienced between the gluteal folds and posterior iliac crest, specifically in the vicinity of sacroiliac joints. PGP mainly affects pregnant women, limiting their ability to perform daily activities. Physiotherapy and medication can help ease the pain, but making minor changes to your lifestyle habits can go a long way in managing the pain.

It is very important to check with healthcare professionals before taking any medications during pregnancy

References

  1. Vermani E, Mittal R, Weeks A. Pelvic Girdle Pain and Low Back Pain in Pregnancy: A Review. Pain Pract 2010;10:60–71. https://doi.org/https://doi.org/10.1111/j.1533-2500.2009.00327.x.
  2. Bergström C, Persson M, Mogren I. Pregnancy-related low back pain and pelvic girdle pain approximately 14 months after pregnancy – pain status, self-rated health and family situation. BMC Pregnancy Childbirth 2014;14:48. https://doi.org/10.1186/1471-2393-14-48.
  3. NHS UK (2016). Pelvic pain in pregnancy: https://www.nhs.uk/pregnancy/related-conditions/common-symptoms/pelvic-pain/
  4. Symphysis pubis dysfunction: a practical approach to management’ published in The Obstetrician & Gynaecologist (2006;8:153–8), which is available at: onlinelibrary.wiley.com/doi/10.1576/toag.8.3.153.27250/pdf, and on information from Pelvic, Obstetric and Gynaecological Physiotherapy (POGP) and Pelvic Partnership.
  5. ACPWH. 2012. ACPWH guidance on the safe use of transcutaneous electrical nerve stimulation (TENS) for musculoskeletal pain during pregnancy. Association of Chartered Physiotherapists in Women’s Health [now POGP]. pogp.csp.org.uk [Accessed August 2019]
  6. Bergström C, Persson M, Nergård K-A, Mogren I. Prevalence and predictors of persistent pelvic girdle pain 12 years postpartum. BMC Musculoskelet Disord 2017;18:399. https://doi.org/10.1186/s12891-017-1760-5.
  7. NICE. 2018. Sciatica (lumbar radiculopathy). National Institute for Health and Care Excellence, Clinical Knowledge Summaries. cks.nice.org.uk [Accessed August 2019]
  8. Casagrande D, Gugala Z, Clark SM, Lindsey RW. Low Back Pain and Pelvic Girdle Pain in Pregnancy. JAAOS – J Am Acad Orthop Surg 2015;23.
  9. Clinton S, LaCross J. Clinical Practice Guidelines. J Womenʼs Heal Phys Ther 2017;41:100–1. https://doi.org/10.1097/JWH.0000000000000080.
  10. Nielsen L-L. Clinical findings, pain descriptions and physical complaints reported by women with post-natal pregnancy-related pelvic girdle pain. Acta Obstet Gynecol Scand 2010;89:1187–91. https://doi.org/https://doi.org/10.3109/00016349.2010.501853.
  11. Vleeming A, Albert HB, Ostgaard HC, Sturesson B, Stuge B. European guidelines for the diagnosis and treatment of pelvic girdle pain. Eur Spine J 2008;17:794–819. https://doi.org/10.1007/s00586-008-0602-4

PGP can begin as early as the first trimester but it’s more common later in pregnancy

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