WHAT IS PREGNANCY RELATED PELVIC GIRDLE PAIN (PrPGP)?
“PrPGP is defined as any pain between the iliac crests and the gluteal fold, particularly in the vicinity of the sacro-iliac joints. The pain can radiate down the posterior thigh and can also occur in conjunction with/or separately in the pubic symphysis. The endurance capacity for standing, walking and sitting is diminished.” (Vleeming et al 2008)
Up to 50% of women will experience PrPGP. PrPGP is strongly associated with a negative impact on psychological and emotional wellbeing (Acharya et al 2019). Unfortunately, women with PrPGP are 3x more likely to experience post partum depressive symptoms (Gutke et al 2007).
WHAT DOES PELVIC GIRDLE PAIN FEEL LIKE?
It can start as early as the 1st trimester but typically presents towards the 2nd and 3rd trimester. Women will complain that the following tasks aggravate their symptoms:
- Turning over in bed
- The first few steps in the morning
- Getting in and out of the car
- Climbing stairs
- Getting dressed
Women with PrPGP may experience a sharp stabbing pain and the leg may feel like it could give way. Some may also explain that they feel a grinding or clicking sensation in the area too.
WHAT CAUSES PELVIC GIRDLE PAIN?
It’s more than an issue in the tissues…
1. Hormonal
The increased levels of relaxin, progesterone, and estrogen all combine to soften the strong ligaments surrounding the pelvis. Those ligaments start to hold more water and become more elastic so that when it comes time to birth your baby, the pelvis opens to create space. FYI relaxin starts to peak at 10-12 weeks gestation (the reason why you feel PPGP early on, maybe?) and remains elevated throughout pregnancy but is undetectable in the first few days post-partum. Also to note- this does not make your pelvis unstable.
2. Biomechanics and load
Pregnancy is a phase of big change on so many levels. There is increased stretching of the supportive muscles and fascia including the abdominal wall, linea alba (diastasis) and pelvic floor muscles. There are associated changes in posture to accomodate your growing fetus too. These changes all contribute to the pregnancy wobble that some of you may experience.
3. Poor movement patterns
When you load your pelvis asymmetrically such as when you hold a toddler in your ‘good arm’, or a heavy handbag on one side we will often see an asymmetry between the two sides of your pelvis. Don’t get me wrong here, no 2 sides are exactly the same (in strength or flexibility), however, pregnancy is just one of those phases where it’s a different ball game. One side becomes stiffer and one side is more mobile, which means with every step you take, there is an uneven force going through the two sides of the pelvis.
4. The pregnancy factor
Palsson et al (2015) study showed that pregnant women experienced lower pain sensitivity thresholds compared to pregnant women. This factor was possibly explained by the physical changes the body undergoes during pregnancy but also owing to changes in emotional health.
WHAT ARE THE RISK FACTORS FOR PPGP?
- Previous history of lower back pain
- Previous PGP
- Previous history of trauma such as fall, motor vehicle accident or sports injury
- BMI > 25
- Strenuous work during pregnancy
- Depression
- Hypermobile joints (no evidence for this one)
- Multiparity (no evidence for this one either)
WILL MY PELVIC GIRDLE PAIN BECOME CHRONIC?
The great news is that there is a greater than 90% chance that you will be better in the postnatal period. And the “strongest predictor of PrPGP not becoming chronic after pregnancy is the belief that it won’t”. (Vollestad and Stuge 2009).
CAN I PREVENT PELVIC GIRDLE PAIN?
Unfortunately, we don’t have a lot of research to answer this question however a study done by Owe et al (2015) found that in women who performed high impact exercise 3x week were 14% less likely to suffer with severe PrPGP. Click here to learn more about exercising in pregnancy.
If we address modifiable risk factors such as reduce BMI, improve mental health and educate women to empower them (err..read my blog!), we are likely to make an impact, right?
WHAT’S THE LINK BETWEEN PELVIC GIRDLE PAIN AND PELVIC FLOOR FUNCTION?
Research tells us that up to 50% of women with PGP will often report changes to their bladder, bowel or sexual function. Have you noticed this too? Has your treating clinician screened your bladder, bowel and sexual health?
Pregnancy related weight gain results in the stretching of the pelvic floor muscles and sphincter relaxation resulting in weakness of these structures. This may mean some women experience stress urinary incontinence (sneeze pee sound familiar?). The great news is that we have level one evidence to support pelvic floor muscle training to address stress urinary incontinence. However, what we know from research is that women who suffer PrPGP actually present with a reduced levator hiatus and elevated vaginal resting pressures i.e. increased pelvic floor muscle tone (overactivity) so strengthening your pelvic floor or doing kegels is likely to make things worse.
WHAT IS THE TREATMENT FOR PELVIC GIRDLE PAIN?
‘It is no longer acceptable to consider musculoskeletal pain solely as a peripheral phenomenon’ (Pool-Goudzwaard et al 2020). Addressing the following factors is crucial to achieve your goals:
- Biological- hormones, central and/or peripheral sensitisation, neuro-immune response, inflammation
- Psychological- sleep, stress, depression/anxiety, your beliefs, active vs. passive coping strategies
- Social- work support, family support, life transitions, relationships
There is so much you can do, but the first step is education and understanding what is going on with your individual pelvis.
Take Home-1
Make an appointment with a Women’s Health Physio for a one-on-one assessment and physiotherapy treatment. What we assess for is symmetry, biomechanics, and motor control. Some ladies may benefit from hands on therapy to help control the pain and release some tight muscles. Sometimes I may tape or offer a support belt- but not everyone as we want to avoid a dependence on this.
Take Home-2
Regardless of the pain, ALL women will benefit from exercise to help create support for the pelvis. The glutes, pelvic floor and deep core are muscle groups that work together to create closure and strength around your pelvis.
Can I stress here though…once the pain is settled, its not the end of your rehab journey. Ongoing exercise to activate the right muscles and inhibit unhelpful movement patterns to promote efficient and task specific load transfer strategies will mean you have one less thing to worry about in life.
I would like to thank Angela James from the Sydney Pelvic Clinic for the amazing resources and knowledge provided during the recent pelvic pain course, from which the material is this blog is reflective of.
If you feel like you could benefit from specialised guidance and treatment for your pelvic girdle pain recovery, reach out by calling/whatsapp or email.
Reference:
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(6):794-819. doi:10.1007/s00586-008-0602-4
Shijagurumayum Acharya, R., Tveter, A., Grotle, M. et al. Prevalence and severity of low back- and pelvic girdle pain in pregnant Nepalese women. BMC Pregnancy Childbirth 19, 247 (2019)
Gutke A, Josefsson A, Oberg B. Pelvic girdle pain and lumbar pain in relation to postpartum depressive symptoms. Spine (Phila Pa 1976). 2007 Jun 1;32(13):1430-6. doi: 10.1097/BRS.0b013e318060a673. PMID: 17545912.
Vøllestad NK, Stuge B. Prognostic factors for recovery from postpartum pelvic girdle pain. Eur Spine J. 2009 May;18(5):718-26. doi: 10.1007/s00586-009-0911-2. Epub 2009 Feb 24. PMID: 19238458; PMCID: PMC3234007.
Owe KM, Bjelland EK, Stuge B. Exercise level before pregnancy and engaging in high-impact sports reduce the risk of pelvic girdle pain: a population-based cohort study of 39 184 women British Journal of Sports Medicine 2016;50:817-822.
Palsson TS, Beales D, Slater H, O’Sullivan P, Graven-Nielsen T. Pregnancy is characterized by widespread deep-tissue hypersensitivity independent of lumbopelvic pain intensity, a facilitated response to manual orthopedic tests, and poorer self-reported health. J Pain. 2015 Mar;16(3):270-82.
Pool-Goudzwaard A, Beales D, Bussey M. Introduction to the special issue on pelvic pain. Musculoskelet Sci Pract. 2020;48:102168.
