Pelvic Girdle Pain [also known as PGP and formerly referred to as Symphysis Pubis Dysfunction or SPD], is a common musculoskeletal condition in pregnancy. Research has shown it can affect up to 84% of pregnant women and 20% of these women will experience significant, debilitating pain, which has the capacity to affect their movement and function, heavily impacting upon their quality of life.
Common symptoms associated with PGP include;
- Pain presentations vary and pain may be present in the lower back, in the front or the back of the pelvis, in the bottom or gluteal region, hip region or may even refer into the legs.
- Pain may be increased by standing, bending, getting out of a chair, climbing stairs or walking.
- Pain may increase on movements which separate the legs, for example when turning in bed or getting out of a car.
- Pain may increase at night, causing difficulty in lying on sides, or in any position for too long, without support of pillows.
- Pain often increases with activity and the ability to do housework, care for children and perform everyday functions are reduced.
- Women may need to have time off work due to the pain.
- Women may suffer with anxiety and depressive symptoms which may drive their pain further.
Causes of PGP
There is not one factor known to cause PGP during pregnancy and research suggests that the condition is multidimensional. The following factors may play a role in its development and progression;
– A history of Low back pain or pelvic trauma in the past.
– Anxiety, emotional issues and psychological distress have been linked to exacerbating and driving the pain in PGP.
– Postural and hormonal changes during pregnancy may result in weakness and reduced co-ordination of the ‘inner core unit’ or the deep core muscles which provide support and stability to the pelvis. This places more strain on the joints and ligaments of the pelvis, and pain results.
– Family history and heredity have been suggested as contributing factors and a woman is more likely to experience PGP if her mother or sister has had it in the past.
– A woman is more likely to develop PGP the more pregnancies she has.
– Changes in movement behaviours [doing less or more, or alterations in how a woman moves and performs function], may result in changes in muscle function and soft tissue length which may also drive pain processes. The nervous system responds to pain which can reinforce these maladaptive behaviours and movement patterns.
– Contrary to popular belief, the level of evidence regarding PGP and the link with low Relaxin levels is low.
Diagnosing PGP
The diagnosis of PGP in pregnancy must be timely, in order for management to be effective, but many women are unsure or unaware of the treatment options which may be available to them. Furthermore, many health providers believe that PGP is normal during pregnancy and so this results in a lack of onward treatment referral for many women.
It is therefore important that care providers recognise symptoms so an appropriate and timely referral to the right health professionals can be made.
Radiological assessment of the symphysis pubis can determine if separation of the joint has occurred. Some research has suggested that widening of the symphysis pubis is normal during pregnancy, to enable the body to respond to the growing baby, however this becomes pathological if it becomes greater than 9.5mm wide and is then considered to be a result of inadequate muscle function, providing support to the joint.
A Physiotherapist will undertake functional tests and pain provocation tests during their assessment, however there is not one specific test which is diagnostic for this condition. Instead, a diagnosis is made on a positive or negative result of a combination of different movement and pain-provocation tests during your examination.
Treatment and Management tips for PGP
Treatment options and recommendations for PGP vary from one woman to another and must be tailored to suit each individual’s symptoms. Physiotherapy, Osteopathy and acupuncture all may be useful in treating pain and soft tissue issues which may be contributing to symptoms.
As well as seeing a health professional who is qualified and skilled in treating PGP, our top tips for managing the symptoms of this condition include;
- Get the right advice and see the right people!
Early recognition of PGP is important for effective management. If you feel you may be developing symptoms, inform your midwife or health provider. If they don’t refer you for Physiotherapy or for treatment, ask for another opinion or if you can, seek advice from a private practitioner. You may not need to have lots of costly treatment, and sometimes just receiving some simple advice and exercises in one session can be highly beneficial.
- Understand the problem
Understanding why you are in pain is crucial in managing PGP. Fear and anxiety are huge factors which may contribute or drive pain processes in any condition. If the brain perceives the body to be under threat, this will result in enhanced protective neurological reactions, which may lead to an increase in inflammatory and soft tissue responses, all which have the ability to drive pain further. Appropriate advice and education about the problem is therefore essential to reduce fear and anxiety, to enable you to manage the condition more effectively.
- Modify your activity
Sometimes it is important for activities to be modified, particularly when you are experiencing a painful condition such as PGP. It is important that activities which make your pain worse are limited, in order to reduce the level of threat perceived by your brain and nervous system. The more the pain is aggravated, the greater the perceived level of threat and the brain will continue to send out messages to protect the painful area. This may result in increased levels of inflammation and muscle spasm or tightness, which may make your pain worse. Undertaking a paced approach is often preferred, with small bouts of activity as pain allows, making sure you rest frequently and don’t do too much in one go. Activities such as bathing the children, shopping or hoovering are common aggravators of PGP and so if you can find someone to help you out as much as possible this will be useful.
- Be aware of your posture
Postural changes are very common in PGP. Muscles often tighten up as a protective response to the pain in your pelvis and this may affect how you carry yourself, sit, walk or stand. It is important to try to maintain a healthy, neutral posture as best you can, keeping your pelvis symmetrical as far as possible. Carrying children on one hip, or heavy bags slung across one shoulder may not be helpful and sitting with your legs crossed may also be an issue. When sitting, try to sit with your legs evenly hip width apart, try not to lean to one side and use a small pillow in the small of your back to support a neutral spine. You may find that using lots of pillows to support your spine and to rest in between your legs at night is also helpful.
- Strengthen your core and stretch tight muscles
We know that changes in how the muscles work together around the lumbopelvic and hip complexes during pregnancy may be a contributing factor to the development of PGP. The changes in posture and pelvic positioning as your baby grows may result in muscles weakening and this can lead to reduced stability and co-ordination of these muscles, leading to a loss of support around the pelvic joints. The body tries to adapt and compensate when these muscles weaken, and other muscles may become tight and overactive as a result. It is therefore not only important to consider strengthening work but also making sure that tight muscles are being released and stretched appropriately. A Physiotherapy assessment and tailored exercise program, which addresses your specific needs can be extremely effective and ensures that you are exercising appropriately, whilst improving your ability to function.
- Consider using a Pelvic stability belt
Depending on the factors that are contributing to your PGP, a pelvic stability belt may be useful. These may improve your ability to function and mobilise, and so can improve quality of life in PGP. These provide increased stability and support to the pelvic joints, when the muscles are not strong enough to adequately offer a good level of support. The belt therefore essentially does the job that the muscles are supposed to be doing during pregnancy. However belts do not work for everyone and they should only be worn for short bouts at a time. It is also important that you try to perform a strengthening exercise program, in combination with wearing the belt, to ensure that you are building up your core, whilst managing pain at the same time.
- Try to practice stress and anxiety relieving techniques
As mentioned above, the brain plays an important role in any painful condition, particularly those which continue for a long time. Addressing your beliefs and thoughts about your pain can be an important part of treatment. Anxiety, stress and negative thoughts or beliefs may increase sympathetic nervous system activity, which drives the ‘flight or fight’ response within the body, which increases the level of stress hormones circulating in the system. These hormones may sensitise your pain further and may also increase inflammatory processes which enhance the pain. Practising regular mindfulness and meditation practices can be very therapeutic in reducing this overall response in the nervous system. Try to practice these techniques daily for 10-15 minutes at a time. Just before you go to bed is a good time if you struggle to squeeze this in during the day. There are some really useful apps available such as Headspace and Calm, which have short meditations and breathing techniques that are useful for this purpose.
- Tips for birth preparation
Thinking about the birth ahead is important if you have PGP. Obviously we can’t always plan for everything or all eventualities, but ensuring you have some idea about pain relief options, including the use of TENs machines, can be empowering and will give you back a degree of control, as well as reducing the level of fear and threat around birth. Hypnobirthing may also be useful to assist in this process, as well as discussing any concerns you may have with your Physio, midwife or consultant. Being informed about positioning for birth can also be useful, with many women preferring to deliver on all fours or on their sides, to reduce the strain on their pelvis. Many women will make a 100% recovery from PGP by 3 months after delivery, however in a small percentage of women, symptoms will continue after this time. It is therefore important to seek help and advice as soon as you feel you are developing symptoms, which may be quite early on in your pregnancy.
If you are experiencing PGP please don’t suffer in silence – much can be done to help manage this condition and make life more comfortable for you.
If you have concerns about Pelvic Girdle Pain during your pregnancy, Physiotherapy input may help. Please contact us if you have any questions or if would like to know more about how we can help.
Verstraete EH, Vanderstraeten G, Parewijck W [2013] Pelvic Girdle Pain during or after Pregnancy: a review of recent evidence and a clinical care path proposal. Facts Views Vis Obgyn 5(1):33‐43.
