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Physical Characteristics of Women With Severe Pelvic Girdle Pain After Pregnancy
Abstract
Descriptive cohort study.
This study aims to further elucidate the differences in physical characteristics of women with severe pregnancy-related pelvic girdle pain (PGP).
There is increasing interest in pelvic girdle pain (PGP). To our knowledge, this is the first study on a large population of patients with severe PGP, after pregnancy, based on high cutoff scores on diagnostic PGP tests.
Two hundred five patients were selected from the outpatient clinic of a rehabilitation center. Patients were divided in 3 inclusion groups based on the total number of positive scores on 5 diagnostic tests; i.e., active straight leg raise test, posterior pelvic pain provocation test, long dorsal sacroiliac ligament test, and hip abduction and adduction strength tests. These inclusion groups were related to the data on trunk strength test, general provocation tests, Quebec Back Pain Disability Scale (QBPDS) and activities of daily living.
A typical pattern of PGP emerges from this study. The mean group score on the active straight leg raise, posterior pelvic pain provocation, and long dorsal sacroiliac ligament tests became higher when more than 3 inclusion tests were positive. Hip abduction and adduction strength became lower with more positive tests. The QBPDS score was overall high and significantly higher for 5 positive tests compared with 3 and 4 positive tests. This shows that the number of positive tests, the individual score on the diagnostic tests, and the QBPDS could all be an indicator for severity of PGP. Among the general pain provocation tests, both the passive hip flexion test and the upper and middle sacral thrust test scored high. The maximal isometric strength of trunk muscles was below the 10th percentile compared with women without complaints and was even less for 5 positive inclusion tests. It is confirmed that there is a typical order for difficulties with daily activities for PGP patients as follows (most difficult first): standing still, cycling, walking, sitting, and lying.
The study shows that the level of severity in PGP can be adequately assessed by a combination of specific tests.
... Patients with PGP have reduced tolerance to standing, walking, sitting, and changing positions [1]. Pregnancy-related PGP may appear as early as the first trimester of pregnancy or can be delayed up to 3 weeks postpartum [2]. PGP is associated with significantly more pain and functional limitations than lower back pain [3]. ...
... Firstly, diverse diagnoses and terminology were used in the mentioned studies, which could lead to discrepancies in prevalence. In our research, postpartum PGP was defined as a pain that persisted postpartum or occurred within the first weeks after delivery [2]. However, in the study of Stomp van den Berg et al. [44] 25% of the 234 women who had PGP at 12 weeks postpartum had no PGP between 0 and 6 weeks after delivery. ...
... However, it has to be noted that the cited studies followed women experiencing PGP already during pregnancy. The occurrence of pregnancy-related PGP may be delayed up to the first weeks postpartum [2]. By following all women (with and without pain), our study could capture those individuals that developed pain after the initial examination, 24-72 h postpartum. ...
Background
Pelvic girdle pain (PGP) is a type of pregnancy-related lumbopelvic pain. This study aimed to examine the prevalence, severity, and factors associated with postpartum PGP in a selected group of postpartum women in Poland.
Methods
This was a prospective, observational study. In phase 1, 411 women were recruited 24–72 h postpartum. The prevalence of PGP was assessed by a physiotherapist using a series of dedicated tests. Pelvic floor muscle function and presence of diastasis recti were assessed via palpation examination. Age, education, parity, mode of delivery, infant body mass, body mass gain during pregnancy, the use of anesthesia during delivery and were recorded. In a phase 2, 6 weeks postpartum, the prevalence of PGP and its severity were assessed via a self-report.
Results
In phase 1 (shortly postpartum), PGP was diagnosed in 9% (n = 37) of women. In phase 2 (6 weeks postpartum), PGP was reported by 15.70% of women (n = 42). The univariable analyses showed a higher likelihood of PGP shortly postpartum in women who declared PGP during pregnancy (OR 14.67, 95% CI 4.43–48.61) and among women with abdominal midline doming (OR 2.05, 95% CI 1.04–4.06). The multivariable regression analysis showed significant associations in women with increased age (OR 1.12, 95% CI 1.01–1.21) and declaring PGP during pregnancy (OR 14.83, 95% CI 4.34–48.72).
Conclusion
Although the prevalence of postpartum PGP among women in Poland is lower than reported in other countries, it is experienced by almost every tenth women shortly postpartum and every sixth can report similar symptoms 6 weeks later. Age, PGP during pregnancy and abdominal midline doming were associated with experiencing PGP shortly postpartum.
... Disability and pain intensity in pregnancy are associated with sick leave due to pain in pregnancy and persistent pain [16,18,19]. Some studies have focused on prevalence, consequences, risk factors, prognostic factors [2,9,13,[16][17][18][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35] and protecting factors while others have evaluated treatment outcomes [36][37][38]. However, the prevalence predictors and consequences of long-term pregnancy-related PGP have been poorly investigated. ...
... previous caesarean section [21,26,30], and higher fetal weight [20], PGP-related variables e.g. previous low back pain (LBP) [2,31], hypermobility [16], severe pain [2,16], decreased function [31], ≥8 h sleep or rest/day [20], PGS [13,32], difficulty in performing the Active Straight Leg Raise test [33], number of positive pain provocation tests [31,34,39] and emotional distress [25]. ...
... Pregnancyrelated predictors for long-term PGP were: a history of LBP before index pregnancy, a high number of positive pain provocation tests, a positive symphysis pressure test, and a modified Trendelenburg or Patrick's test. Some of the predictors were already known from shorter follow-up studies such as a history of LBP before pregnancy [2,9,27,31] and a high number of positive pain provocation tests in pregnancy [31,34], but Faber (Patrick's) test, the modified Trendelenburg's and the symphysis pubic pressure tests as predictors are new findings. However, the Faber (Patrick's) test, as a predictor must be interpreted with caution since this is not a specific test for PGP. ...
Background
Pelvic girdle pain (PGP) is a multifactorial condition, which can be mentally and physically compromising both during and after pregnancy. However, long-term pregnancy-related PGP has been poorly investigated. This longitudinal follow-up study uniquely aimed to describe prevalence and predictors of PGP and its consequences on women’s health and function up to 11 years after pregnancy.
Methods/Design
A postal questionnaire was sent to 530 women who participated in 1 of 3 randomized controlled studies for PGP in pregnancy. Women who reported experiencing lumbopelvic pain were offered a clinical examination. Main outcome measure was the presence of long term PGP as assessed by an independent examiner. Secondary outcomes were: working hours/week, function (the Disability Rating Index, and Oswestry Disability Index), self-efficacy (the General Self-Efficacy Scale), HRQL (Euro-Qol 5D and EQ-Visual scale), anxiety and depression, (Hospital anxiety and depression scale,) and pain-catastrophizing (Pain Catastrophizing Scale), in women with PGP compared to women with no PGP.
Results
A total of 371/530 (70 %) women responded and 37/ 371 (10 %) were classified with long-term PGP. Pregnancy-related predictors for long-term PGP were number of positive pain provocation tests (OR = 1.79), history of low back pain (LBP) (OR = 2.28), positive symphysis pressure test (OR = 2.01), positive Faber (Patrick’s) test (OR = 2.22), and positive modified Trendelenburg test (OR = 2.20). Women with PGP had significantly decreased ability to perform daily activities (p < .001), lower self-efficacy (p = 0.046), decreased HRQL (p < .001), higher levels of anxiety and depression (p < .001), were more prone to pain catastrophizing, and worked significantly fewer hours/week (p = 0.032) compared to women with no PGP.
Conclusions
This unique long-term follow up of PGP highlights the importance of assessment of pain in the lumbopelvic area early in pregnancy and postpartum in order to identify women with risk of long term pain. One of 10 women with PGP in pregnancy has severe consequences up to 11 years later. They could be identified by number of positive pain provocation tests and experience of previous LBP. Access to evidence based treatments are important for individual and socioeconomic reasons.
... There are pain provocation and functional ability tests Vermani et al., 2009;Kanakaris et al., 2011). The combined use can minimize the false negative cases (Albert et al., 2000;Ronchetti et al., 2008;Kanakaris et al., 2011). Vleeming et al. (2002) found a low correlation between the P4 and LDL test. ...
... The PGQ has a good discriminant validity and can be recommended in the assessment of symptoms and disability (Grotle et al. 2012). The Quebec Back Pain Disability Scale (QBPDS) and Visual Analogue Scale (VAS) are commonly used in the evaluation of functional status and pain Ronchetti et al., 2008;Mens et al., 2012a). ...
... Diagnostic tests and pain and disability scales are also useful in classification for severity (Damen et al., 2002b;Gutke et al, 2008b;Ronchetti et al., 2008;van Kessel-Cobelens et al.,2008;Robinson et al., 2010b;Mens et al., 2012a). Characteristics for severity are described in Table II. ...
Pelvic girdle pain (PGP) is a common condition during or after pregnancy with pain and disability as most important symptoms. These symptoms have a wide range of clinical presentation. Most doctors perceive pregnancy related pelvic girdle pain (PPGP) as 'physiologic' or 'expected during pregnancy', where no treatment is needed. As such women with PPGP mostly experience little recognition. However, many scientific literature describes PPGP as being severe with considerable levels of pain and disability and socio-economic consequences in about 20% of the cases.
We aimed to (1) inform the gynecologist/obstetrician about the etiology, diagnosis, risk factors, and treatment options of PPGP and (2) to make a proposition for an adequate clinical care path.
A systematic search of electronic databases and a check of reference lists for recent researches about the diagnosis, etiology, risk factors and treatment of PPGP.
Adequate treatment is based on classification in subgroups according to the different etiologic factors. The various diagnostic tests can help to make a differentiation in the several pelvic girdle pain syndromes and possibly reveal the underlying biomechanical problem. This classification can guide appropriate multidimensional and multidisciplinary management. A proposal for a clinical care path starts with recognition of gynecologist and midwife for this disorder. Both care takers can make a preliminary diagnosis of PPGP and should refer to a physiatrist, who can make a definite diagnosis. Together with a physiotherapist, the latter can determine an individual tailored exercise program based on the influencing bio-psycho-social factors.
... 32 As pregnancy advances, hormonerelated laxity has been hypothesized to cause articular mechanoreceptors to become less sensitive to position changes, dampening muscle responses to perturbations 2,4 and possibly contributing to weakening of the abdominal muscles overstretched by the growing fetus. 4 Systemic laxity may then lead to sacroiliac joint instability, 2 which is commonly experienced during pregnancy [33][34][35] and can result in pelvic muscle reflexive inhibition and compensatory gait movements. 2 In this case series, continued systemic effects of elevated pregnancy hormone levels combined with the third-trimester weight gain may have played a role in the increased anterior pelvic tilt at P3 and the subsequent decrease observed 12 to 16 weeks PP when weight loss would have occurred and the effects of pregnancy hormones should have dissipated. ...
... 48 Although cramps do not cause lasting damage to the muscle, they can be very painful especially at night in bed 48 and are a common complaint for more than 50% of pregnant women. 40,48 Low back pain, 29,39 pregnancy-related pelvic girdle pain, 9,16,17 pelvic hypermobility, 31,[33][34][35]49 and other musculoskeletal dysfunctions such as calf cramping 40,48 are common in pregnancy and may affect the gait or function of women through pregnancy and beyond. 8,[33][34][35]39,49 In a study of 1600 pregnant women, more than 65% complained of difficulty walking distances greater than 200 m or on uneven terrain and 55% reported difficulty walking even 50 m. ...
... 40,48 Low back pain, 29,39 pregnancy-related pelvic girdle pain, 9,16,17 pelvic hypermobility, 31,[33][34][35]49 and other musculoskeletal dysfunctions such as calf cramping 40,48 are common in pregnancy and may affect the gait or function of women through pregnancy and beyond. 8,[33][34][35]39,49 In a study of 1600 pregnant women, more than 65% complained of difficulty walking distances greater than 200 m or on uneven terrain and 55% reported difficulty walking even 50 m. 33 Walking was found to increase pelvic pain in 80% of those already with pain. ...
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... 32 As pregnancy advances, hormonerelated laxity has been hypothesized to cause articular mechanoreceptors to become less sensitive to position changes, dampening muscle responses to perturbations 2,4 and possibly contributing to weakening of the abdominal muscles overstretched by the growing fetus. 4 Systemic laxity may then lead to sacroiliac joint instability, 2 which is commonly experienced during pregnancy [33][34][35] and can result in pelvic muscle reflexive inhibition and compensatory gait movements. 2 In this case series, continued systemic effects of elevated pregnancy hormone levels combined with the third-trimester weight gain may have played a role in the increased anterior pelvic tilt at P3 and the subsequent decrease observed 12 to 16 weeks PP when weight loss would have occurred and the effects of pregnancy hormones should have dissipated. ...
... 48 Although cramps do not cause lasting damage to the muscle, they can be very painful especially at night in bed 48 and are a common complaint for more than 50% of pregnant women. 40,48 Low back pain, 29,39 pregnancy-related pelvic girdle pain, 9,16,17 pelvic hypermobility, 31,[33][34][35]49 and other musculoskeletal dysfunctions such as calf cramping 40,48 are common in pregnancy and may affect the gait or function of women through pregnancy and beyond. 8,[33][34][35]39,49 In a study of 1600 pregnant women, more than 65% complained of difficulty walking distances greater than 200 m or on uneven terrain and 55% reported difficulty walking even 50 m. ...
... 40,48 Low back pain, 29,39 pregnancy-related pelvic girdle pain, 9,16,17 pelvic hypermobility, 31,[33][34][35]49 and other musculoskeletal dysfunctions such as calf cramping 40,48 are common in pregnancy and may affect the gait or function of women through pregnancy and beyond. 8,[33][34][35]39,49 In a study of 1600 pregnant women, more than 65% complained of difficulty walking distances greater than 200 m or on uneven terrain and 55% reported difficulty walking even 50 m. 33 Walking was found to increase pelvic pain in 80% of those already with pain. ...
Objective: To study pregnancy-related changes in women's gait.
Study Design: A prospective longitudinal descriptive case series with repeated measures.
Background: Past studies of pregnancy-related gait changes have not followed women from before pregnancy through the natural progression of pregnancy and into postpartum to assess gait parameters and kinematic changes of the lower extremities, pelvis, and spine.
Subjects: Two nulliparous women, aged 21 and 39 years.
Methods and Measures: Subjects were assessed before pregnancy (P0); near the end of the first (P1), second (P2), and third trimesters (P3); and 12 to 16 weeks postpartum (PP). Two-dimensional gait analysis of digital video was performed for each subject walking barefoot at a self-selected pace. Gait parameters and joint angles of the spine and lower extremity were visually analyzed for all stages of pregnancy to identify potential changes.
Results: Gait speed was at least 10 cm/s slower than P0-P1, and PP gait speed was at least 10 cm/s faster than P3. Compared to P0 and P1, ankle dorsiflexion decreased at P3 in all phases of gait by at least 5° at P3, and decreased ankle dorsiflexion continued at PP. Increased hip flexion and anterior pelvic tilt at P3 reversed in PP. No consistent changes were observed in knee, thoracic spine index, or cervical spine index during the course of study.
Conclusions: Gait speed, hip angle, and pelvic tilt in gait changed during pregnancy and then returned to values similar to those before pregnancy by 12 to 16 weeks postpartum. Ankle dorsiflexion decreased in all phases of gait during pregnancy and the reduction in ankle dorsiflexion persisted postpartum. Pregnancy-related spinal and lower extremity changes in women's gait should be monitored to prevent or reduce potential dysfunction.
... Psychological back pain can begin or carry over as a continuation of pregnancy back pain. The subconscious mind might take the opportunity to use the end of pregnancy as a chance to start a psychologically induced pain syndrome (include depression, fatigue, listlessness, pain, malaise and anger) [5] . ...
... Extracorporeal shock wave therapy has been used for the treatment of neumerous musculoskeletal disorders, including calcified tendonitis of shoulder, lateral epiconylities, achilles and patellar tendinopathies, chronic planter fasciitis, osteonecrosis of the femoral head, and delayed union and nonunion of fractures [5] . The rational for the use of ESWT for these conditions is based on stimulation of soft tissue healing by local hyperemia, revascularization. ...
... Profiling of women post-partum who are experiencing PLPP further highlights the biopsychosocial nature of these pain disorders. In terms of pain features, pain intensity has been correlated to higher levels of disability in PLPP (Gutke et al., 2011) as has positive pain provocation testing (Ronchetti et al., 2008;Mukkannavar et al., 2014). In the psychological domain depression (Gutke et al., 2007) can be a feature of pregnancy-related PLPP, and kinesiophobia has been documented as a potential contributor (Gutke et al., 2011). ...
... Women were included if they were greater than or equal to 3 months postpartum. Women were recruited into two groups; a pain free group, and those with PLLP that originated during pregnancy or within 3 weeks postpartum (Ronchetti et al., 2008). The pain area was defined posteriorly from the below the 12th ribs to the glutaeal folds and included the anterior pelvis (Chang et al., 2013). ...
For a small but significant group, pregnancy-related lumbopelvic pain may become persistent. While multiple factors may contribute to disability in this group, previous studies have not investigated sleep impairments, body perception or mindfulness as potential factors associated with disability post-partum.
To compare women experiencing no pain post-pregnancy with those experiencing pregnancy-related persistent lumbopelvic pain (either low- or high-level disability) across multiple biopsychosocial domains.
Cross-sectional.
Participants completed questionnaires for thorough profiling of factors thought to be important in pregnancy-related lumbopelvic pain. Specific measures were the Urinary Distress Inventory, Medical Outcomes Study Sleep Scale, Back Beliefs Questionnaire, Tampa Scale for Kinesiophobia, Depression Anxiety Stress Scale, Coping Strategies Questionnaire, Pain Catastrophising Scale, The Fremantle Back Awareness Questionnaire and the Mindful Attention Awareness Scale. Women where categorised into three groups; pain free (n = 26), mild disability (n = 12) and moderate disability (n = 12) (based on Oswestry Disability Index scores). Non-parametric group comparisons were used to compare groups across the profiling variables.
Differences were identified for kinesiophobia (p = 0.03), body perception (p = 0.02), sleep quantity (p < 0.01) and sleep adequacy (p = 0.02). Generally subjects in the moderate disability group had more negative findings for these variables.
Disturbances in body-perception, sleep and elevated kinesiophobia were found in pregnancy-related lumbopelvic pain subjects with moderate disability, factors previously linked to persistent low back pain. The cross-sectional nature of this study does not allow for identification of directional pathways between factors. The results support the consideration of these factors in the assessment and management of pregnancy-related lumbopelvic pain.
Copyright © 2015 Elsevier Ltd. All rights reserved.
... During pregnancy women may experience a variety of musculoskeletal complaints including low back pain [1][2][3][4][5][6] and/ or pelvic girdle pain [1,[7][8][9][10][11][12][13]. Pubic symphysis dysfunction is a distinct subgroup of pelvic girdle pain [1] and during pregnancy causes pain and limits everyday activities [14] in at least 3-8% of women [1,15]. ...
... Pubic symphysis dysfunction is a distinct subgroup of pelvic girdle pain [1] and during pregnancy causes pain and limits everyday activities [14] in at least 3-8% of women [1,15]. Symptoms can be very debilitating, do not necessarily resolve after childbirth [1,7,15] and often recur in subsequent pregnancies [15,16]. Despite an adverse impact on quality of life [14,15,17], the cause of pregnancy-related symphyseal pain is poorly understood [18], with hormonal, genetic and/or biomechanical factors implicated in the pathogenesis [19] of this relatively common but under-estimated problem [15]. ...
Pregnancy-related pubic symphysis pain is relatively common and can significantly interfere with daily activities. Physiotherapist-prescribed pelvic support belts are a treatment option, but little evidence exists to support their use. This pilot compared two pelvic belts to determine effectiveness (symptomatic relief), tolerance (comfort) and adherence (frequency, duration of use).
Unblinded, 2-arm, single-center, randomized (1:1) parallel-group trial. Twenty pregnant women recruited from the community (Dunedin, New Zealand), with physiotherapist-diagnosed symphyseal pain, were randomly allocated to wear either a flexible or rigid belt for three weeks. One author, not involved in data collection, randomized the allocation to trial group. The unblinded primary outcome was the Patient Specific Functional Scale (PSFS). Secondary outcomes were pain intensity during the preceding 24 hours and preceding week (visual analogue scale [VAS]), and disability (Modified Oswestry Disability Questionnaire [MODQ]). Duration of use (hours) was recorded daily by text messaging. Participants were assessed at baseline, by weekly phone interviews and at intervention completion (three weeks). To assess comfort, women wore the alternate belt in the fourth week.
Twenty pregnant women (mean ± SD age, 29.4 ± 6.5 years; mean gestation at baseline, 30.8 ± 5.2 weeks) were randomized to treatment groups (flexible = 10, rigid =10) and all were included in analysis. When adjusted for baseline, PSFS scores were not significantly different between groups at follow up (mean difference -0.1; 95% CI: -2.5 to 2.3; p =0.94). Pain in the preceding 24 hours reached statistical significance in favor of the flexible belt (VAS, p = 0.049). Combining both groups' data, function and pain were significantly improved at three weeks (mean difference -2.3; 95% CI: 1.2 to 3.5; p< 0.001). Belts were worn for an average of 4.9 ± 2.9 hours per day; women preferred the flexible belt. No adverse events were reported.
These preliminary results suggest the flexible pelvic support belt may be more effective in reducing pain and is potentially better tolerated than a rigid belt. Based on these data, a larger trial is both feasible and clinically useful.
Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12614000898651 , 25th August, 2014.
... The importance of investigating pregnancy-related pelvic girdle pain (PGP) as distinct from low back pain (LBP) within reported LPP is supported in the literature [10, 13, 14, 30]. The conditions of LBP and PGP may coexist; however different management strategies are required for each condition [13,383940. Sub-grouping of LPP also assists in identifying those women most at risk of long-term dysfunction [38, 41]. ...
... The conditions of LBP and PGP may coexist; however different management strategies are required for each condition [13,383940. Sub-grouping of LPP also assists in identifying those women most at risk of long-term dysfunction [38, 41]. The prevalence rate of reported LBP only for this study was 17%, which is similar to that described by Gutke [30], and lower than the prevalence of PGP (33%) or combined LBP and PGP (50%) [30, 42]. ...
Unlabelled:
Objective. To investigate the prevalence and nature of lumbo-pelvic pain (LPP), that is experienced by women in the lumbar and/or sacro-iliac area and/or symphysis pubis during pregnancy. Design. Cross-sectional, descriptive study. Setting. An Australian public hospital antenatal clinic.
Sample population:
Women in their third trimester of pregnancy. Method. Women were recruited to the study as they presented for their antenatal appointment. A survey collected demographic data and was used to self report LPP. A pain diagram differentiated low back, pelvic girdle or combined pain. Closed and open ended questions explored the experiences of the women. Main Outcome Measures. The Visual Analogue Scale and the Oswestry Disability Index (Version 2.1a). Results. There was a high prevalence of self reported LPP during the pregnancy (71%). An association was found between the reporting of LPP, multiparity, and a previous history of LPP. The mean intensity score for usual pain was 6/10 and four out of five women reported disability associated with the condition. Most women (71%) had reported their symptoms to their maternity carer however only a small proportion of these women received intervention. Conclusion. LPP is a potentially significant health issue during pregnancy.
... 3 Although the majority of symptoms subside 1 to 3 months after delivery, 1,33 up to 37% of women continue to have symptoms that last beyond the postpartum period (initial 3 months postdelivery). 35 Oftentimes, these symptoms become chronic in nature, 35 with approximately 7% of women exhibiting substantial disability. 42 Predictors for having persistent postpartum pain include low endurance of trunk flexors, older age, and pain in early pregnancy, 12 and the method of delivery does not appear to be a factor related to postpartum LBP. ...
... 3 Although the majority of symptoms subside 1 to 3 months after delivery, 1,33 up to 37% of women continue to have symptoms that last beyond the postpartum period (initial 3 months postdelivery). 35 Oftentimes, these symptoms become chronic in nature, 35 with approximately 7% of women exhibiting substantial disability. 42 Predictors for having persistent postpartum pain include low endurance of trunk flexors, older age, and pain in early pregnancy, 12 and the method of delivery does not appear to be a factor related to postpartum LBP. ...
Case report.
Postpartum low back and hip dysfunction may be caused by an incomplete recovery of abdominal musculature and impaired neuromuscular control. The purpose of this report is to describe the management of a postpartum runner with hip and low back pain through exercise training via ultrasound imaging (USI) biofeedback combined with running-form modification.
A postpartum runner with hip and low back pain underwent dynamic lumbar stabilization training with USI biofeedback and running-form modification to reduce mechanical loading. Muscle thickness of transversus abdominis and internal oblique was measured with USI preintervention and 7 weeks after completion of the intervention. Additionally, 3-dimensional lower extremity joint motions, moments, and powers were calculated during treadmill running.
The patient's pain with running decreased from a constant 9/10 (0, no pain; 10, worst pain) to an occasional 3/10 posttreatment. Transversus abdominis muscle thickness increased 6.3% during the abdominal drawing-in maneuver and 27.0% during the abdominal drawing-in maneuver with straight leg raise. Changes were also noted in the internal oblique. These findings corresponded to improved lumbopelvic control: pelvic list and axial rotation during running decreased 38% and 36%, respectively. The patient's running volume returned to preinjury levels (8.1-9.7 km, 3 days per week) with no hip pain and minimal low back pain, and she successfully completed her goal of running a half-marathon.
The successful outcomes of this case support the consideration of dynamic lumbar stabilization exercises, USI biofeedback, and running-form modification in postpartum runners with lumbopelvic dysfunction.
Therapy, level 4.
... Given the importance of muscle strength to physical functioning, this study provides novel insights into pathways between pregnancy during adolescence and worse physical function over the long term. Weakness in the muscles around the hips, including the hip adductor, has been found to be associated with the presence and severity of pelvic girdle pain related to pregnancy [22,32]. Thus, together with previous literature, our results support the importance of assessing adductor muscle strength during pregnancy for all women, especially among adolescents, to detect early those at higher risk of physical and painful disorders. ...
Adolescent childbirth is associated with worse physical function over the long-term. Differential loss of muscle strength during pregnancy and postpartum for adolescents compared to adults may be one explanation for this, but research examining these differences is lacking. The objective of this study as to assess hand grip strength and hip adduction muscle strength in adolescents and adults during pregnancy and postpartum. A prospective cohort study was carried out with adolescent (13 to 18 years) and adult (23 to 28 years) primigravid women. Assessments were performed at three timepoints: before the 16 th gestational week, during the third trimester, and between the fourth and sixth week postpartum. Hand grip strength (continuous and muscle weakness if ≤ 20.67 kgf) and hip adductor measures (continuous and muscle weakness if ≤ 13.8 kgf) were assessed using dynamometry. Generalized estimating equations modelled longitudinal relationships between muscle weakness and age group. More adolescents had hip adductor weakness than adults in the third trimester of pregnancy (62.5% vs. 31.8%, p < 0.005), which was corroborated by the longitudinal analyses. For all women, there were higher odds of hip adductor weakness in the third trimester (OR = 4.35; p< 0.001) and postpartum (OR = 9.45; p < 0.001) compared to the 16 th gestational week. No significant difference in HGS was observed between age groups or across the different timepoints. The higher proportion of hip adductor weakness among adolescents may indicate a need for resistance training during and after pregnancy and physical therapy if weakness or injury is noted.
... Предрасполагаю щими факторами к возникновению дисфункции КПС служат асимметрия длины ног, сколиоз, операции на позвоночнике (в большей степени, спондилодез, который приводит к изменению биомеханики позвоночника и повышенной нагрузке на КПС), молодой возраст (спортсмены) либо пожилой, длительное мышечное напряжение (например, бег трусцой), травмы, аномалии крестца [9]. Также часто встречается синдром КПС при беременности, т. к. из-за гиперлордоза, увеличения веса, растяжения связок повышается нагрузка на крестцово-подвздошный сустав [10][11][12][13]. ...
The article considers a clinical case of treatment of one of the variants of nonspecific back pain – sacroiliac joint syndrome. In this case, we tried to demonstrate the importance of timely and accurate determination of the cause of dorsalgia using currently available tools: medical scales, X-ray and MRI examination, diagnostic drug blockade of the pain zone. A scrupulous analysis of complaints, anamnesis and clinical manifestations of the patient, a differential diagnosis with a number of diseases with a similar clinical picture, as well as the choice of treatment tactics based on federal clinical recommendations for the treatment of patients with nonspecific back pain made it possible to quickly determine the diagnosis and cope with the pain syndrome. Therapy with the inclusion of medications, physiotherapy, manual therapy, post-isometric relaxation, physical therapy, posture correction allowed the patient to stop the pain syndrome and return to an active lifestyle. Dexketoprofen (Dexalgin®) was prescribed to relieve the pain syndrome. Optimization of the method of administration of the drug is a step-by-step scheme for prescribing dexketoprofen: parenteral administration of 2 injections (50 mg) intramuscularly daily for 2 days, then transfer to oral Dexalgin intake – 25 mg 2 times a day for 3 days under the guise of proton pump inhibitors – Esomeprazole 40 mg 1 time a day, the use of a patch with a local anesthetic, vitamins of group B – 12 days, therapeutic and diagnostic drug blockades – contributed to a significant reduction in the intensity of the pain syndrome and allowed to prevent its transformation into a chronic process. As a result of the use of complex, pathogenetically based therapy, a rapid positive therapeutic effect was achieved.
... A serious negative side effect of high relaxin production during pregnancy is pelvic girdle pain, which is associated with difficulty in walking. 87,88 It has been estimated to affect approximately 20% to 25% of pregnant women 89 and emerges as a consequence of the increased flexibility and the resulting lack of stability in the pelvis. If the human pubic symphysis would open to a degree as seen in several nonhuman mammals, upright walking would be almost impossible. ...
... In the ASLR test, the subjects who scored 2 and above were considered positive 13 and the P4 test was used to diagnose Pelvic girdlepain [13][14][15][16] . The test was said to be positive when the patient could feel the same pain in the gluteal area on the provoked side 17,18 . ...
Background: Pelvic Girdle Pain (PGP) is a musculoskeletal pain that arises between the posterior iliac crest and gluteal fold, at the sacroiliac joint and also radiates posteriorly in the thigh. PGP give rise to very intense pain and disability than Low Back Ache (LBA). It is a common condition during pregnancy and post-delivery. Joint laxity increases pelvic rotation and lumbar lordosis which results in adaptive hip extensor muscle weakness. Hence the studies focus on identifying the lumbar lordosis and hip extensor strength of PGP. Aim of the Study: To identify the association between lumbar lordosis and PGP and to identify the association between hip extensor strength and PGP among post-partum women. Material and Methodology: Based on inclusion and exclusion criteria a total of 80 postpartum women were assessed based on the diagnostic criteria the women were divided into two groups. Group A consists of women with PGP and group B consists of women without PGP. Both groups were assessed for lumbar lordosis using flexicurve and hip extensor strength using a manual muscle tester. Data collected was analyzed using. Outcome Measure: Flexicurve to assess lumbar lordosis. Manual muscle tester to assess hip extensor strength. Result: The study showed that the mean lumbar lordosis was significantly higher in women with PGP than in women without PGP, p = 0.001. There was a 15.46° ± 6.91° higher angle observed in persons who had pelvic girdle pain compared to those who did not have pelvic girdle pain. The mean hip extensor strength for group ‘A’ (average of right and left side) was 12.74 ± 0.73kg, whereas it was significantly higher in group ‘B’. Conclusion: The study concludes that there is a positive association between lumbar lordosis and hip extensor weakness in pelvic girdle pain.
... The QBPDS was originally developed to assess pain-related disability in people with low back pain (Kopec et al., 1995) and is valid and reliable (Schoppink et al., 1996;Smeets et al., 2011). As suggested in clinical guidelines Bastiaenen et al., 2017), the QBPDS can be used in an adapted form for patients with PGP, replacing the words 'back pain' with 'pelvic pain' (Damen et al., 2001;Mens et al., 2002;de Groot et al., 2008;Ronchetti et al., 2008). Measurement properties for this adapted form of the QBPDS are unavailable. ...
Background
Motor control patterns are altered when women with pregnancy-related pelvic girdle pain (PGP) experience pain. In low back pain, these adaptations can persist after recovery.
Objectives
This study aimed to assess balance control in postpartum women with and without a history of PGP during pregnancy.
Design
Cross-sectional study.
Method
Eighteen postpartum women who reported to be recovered from PGP, and twelve postpartum women without a history of PGP during pregnancy performed two clinical tests: the single leg stance and active straight leg raise test. Primary outcomes were ground reaction forces measured with a force platform.
Results
Multiple linear regression analyses showed smaller lateral displacement (β = −11cm; 95%CI: 19 to −3; p = 0.008) and lower displacement velocity of the Centre of Pressure (COP) (Ratio of Geometric Means (RGM) 0.76; 95%CI: 0.59 to 0.99; p = 0.043) during single leg stance in the participants with a history of PGP compared to participants without a history of PGP. Push-off force (β = −4.8 N; 95%CI: 22.0 to 12.5; p = 0.57) and asymmetry of push-off force (RGM 1.77; 95%CI: 0.62 to 5.04; p = 0.27) did not differ between groups. During the active straight leg raise test, no differences in lateral displacement (β = 3 cm; 95%CI: 3 to 8; p = 0.30) and COP displacement velocity (RGM 1.03; 95%CI: 0.70 to 1.52; p = 0.87) were observed.
Conclusions
Although the women with a history of PGP considered themselves recovered, their balance control during single leg stance was poorer compared to those without a history of PGP. No differences were found during the active straight leg raise test.
... Pregnancy-related pelvic girdle pain (PPGP) is a common condition both prenatally and postpartum and often recurs in subsequent pregnancies [1]. PPGP affects 23-36% of women during pregnancy [2,3] and 10-30% following delivery, up to ten years postpartum [4,5]. ...
Objectives
Pregnancy-related pelvic girdle pain (PPGP) contributes to significant prenatal and postpartum impairments; however, various clinical practices exist around the conservative treatment of this condition. This study sought to reach a consensus on the essential components of PPGP management through an international Delphi survey of experts in women's health.
Design and participants
Eighty-seven international experts in the field of PPGP were invited to participate and surveyed over three rounds. Round 1 of the survey utilised open-ended questions to gain feedback on 16 components of PPGP management previously identified by a focus group. Feedback from panel members guided modification and refinement of questions for Rounds 2 and 3. A 5-point Likert scale was used to rate level of agreement, with a minimum threshold for consensus of ≥75% agreement set across all survey rounds.
Results
Forty four of the 87 (50%) invited professionals agreed to participate in the panel, with 77% (34/44) of panellists contributing to all three rounds. Of the 16 initial components, 15 were included in Round 2. The final consensus was reached on 10 important components of assessment and management after Round 3: pain education; postural and ergonomic advice; social and lifestyle factors; psychological factors, cultural considerations, strengthening exercise, other exercise, exercise precautions, manual therapy and the use of crutches.
Conclusion
This study identified 10 key components that should be considered in the management of PPGP. In addition, these components provide a potential framework for future research around the conservative management of PPGP.
... 31 It has been used to assess pelvic girdle pain in postpartum women. 35 All questionnaires were administered at 12 weeks (during week 12 of the core strengthening program). Women who participated in the additional maintenance phase were also asked to complete the questionnaires at 24 weeks. ...
Diastasis rectus abdominis (DRA) is characterized by a widening between the rectus abdominis muscles and thinning of the linea alba. It is common during pregnancy and may contribute to postpartum low back pain (LBP) and stress urinary incontinence (SUI). Core strengthening is thought to improve DRA, but there is no widely accepted exercise program. To assess changes in interrectus distance (IRD) and participant-reported outcomes (PROs) after an online core strengthening program in postpartum women with DRA. Prospective observational study. Forty-three postpartum women (36.7 ± 3.5 years) with DRA, which was diagnosed as an IRD 2.0 cm or more using musculoskeletal ultrasound, participated in a 12-week online core strengthening program focused on daily transversus abdominis activation with coordinated breathing and pelvic floor muscle engagement. IRD and PROs were assessed at baseline and 12 weeks. A subset of 19 women participated in an additional 12-week maintenance phase, and outcomes assessments were performed at 24 weeks. The 12-week online core strengthening program significantly decreased IRD above and below the umbilicus at rest (slope [95% confidence interval]: −0.56 [−0.74, −0.38] and −0.26 [−0.45, −0.06]; P < .001 and P = .009, respectively) and below the umbilicus during contraction (−0.39 [−0.58, −0.20]; P < .001). Improvements in LBP-related disability (P = .002) and SUI (P = .001) were also observed. Participation in the maintenance phase significantly improved IRD at 24 weeks compared with 12 weeks (P < .0125). Satisfaction averaged 7.43 ± 2.23. The 12-week online core strengthening program reduced IRD and improved LBP-related disability and SUI. Program participation for 12 additional weeks further reduced IRD. These results suggest that the online core strengthening program can be used in postpartum women with DRA.
... Women commonly experience pelvic girdle pain during pregnancy, with reported prevalence of Pregnancy-related Pelvic Girdle Pain (PPGP) ranging from 23 to 65% depending on the study methods used [2][3][4]. Women with PPGP often have impaired mobility, with 7 to 12.5% having to use crutches or a wheelchair [5][6][7]. PPGP symptoms affect their ability to cope with everyday life for which they feel unprepared and which they feel is not acknowledged [8][9][10]. PPGP is also a leading cause of sick leave during pregnancy [11][12][13]. ...
Background
Pregnancy-related Pelvic Girdle Pain (PPGP) is a common complaint. The aetiology remains unclear and reports on risk factors for PPGP provide conflicting accounts. The aim of this scoping review was to map the body of literature on risk factors for experiencing PPGP.
Methods
We searched the databases PubMed, Embase, CINAHL, PsycINFO, MIDIRS, and ClinicalTrial.gov (3 August 2020). We selected studies with two reviewers independently. Observational studies assessing risk factors for PPGP were included. Studies examining specific diagnostic tests or interventions were excluded.
Results
We identified 5090 records from databases and 1077 from ClinicalTrial.gov. Twenty-four records met the inclusion criteria. A total of 148 factors were examined of which only 14 factors were examined in more than one study. Factors that were positively associated with PPGP included a history of low back or pelvic girdle pain, being overweight/obese, already having a child, younger age, lower educational level, no pre-pregnancy exercise, physically demanding work, previous back trauma/disease, progestin-intrauterine device use, stress, depression and anxiety.
Conclusions
A large number of factors have been examined as potential risk factors for PPGP, but there is a lack of repetition to be able to draw stronger conclusions and pool studies in systematic reviews. Factors that have been examined in more than five studies include age, body mass index, parity and smoking. We suggest a systematic review be conducted to assess the role of these factors further in the development of PPGP.
... Pain may be isolated to the pubic symphysis or experienced in conjunction with posterior PGP (located between the posterior iliac crest and gluteal fold, predominantly in the region of the sacroiliac joints) . Although symptoms usually resolve soon after delivery, they may persist post-partum (Albert et al., 2001;Owens et al., 2002;Ronchetti et al., 2008) and/or recur in subsequent pregnancies (Owens et al., 2002;Mens et al., 1996). ...
Background
Symphyseal pain (SP) experienced during pregnancy is a common condition that can negatively influence function and wellbeing. Despite its adverse impact on quality of life, standardised diagnostic criteria for SP as a distinct type of pelvic girdle pain (PGP) are lacking.
Objectives
To develop a reliable self-administered instrument that could differentiate SP from posterior PGP in pregnant women, and ultimately be used for epidemiological or clinical purposes.
Method
Qualitative data from 17 women (four focus groups) were used to develop a questionnaire. The questionnaire was tested against physical therapy diagnoses based on clinical assessment in 122 pregnant women with SP (n = 41), posterior PGP (n = 41) or no PGP (n = 40); 30 women repeated the questionnaire a day later to assess reliability. Multinomial logistic regression models were used to assess the performance of candidate items in distinguishing between the groups.
Results/findings
The single questionnaire item relating to location of worst pain (diagrammatic form) is useful for differentiating SP from posterior PGP and individuals with no PGP. The worst pain location question with the addition of the Pelvic Girdle Questionnaire provides a measure of “SP with impact”, and is the best combination for distinguishing SP and posterior PGP. Test-retest reliability scores were excellent.
Conclusion
These findings provide new opportunities for diagnosing pregnancy-related SP, and highlight questionnaire items which best differentiate SP from posterior PGP. These items could be used in future epidemiological research, and in clinical settings as a quick, effective screening tool.
... Kombinacija obeh mehanizmov preprečuje strižne sile in to imenujemo mehanizem samozaklepanja ali mehanizem steznika medeničnega obroča. Diagnostični testi za ugotavljanje bolečine v medeničnem obroču med nosečnostjo morajo biti objektivni ter občutljivi in specifični za preiskovano populacijo (11). Ti testi so ultrazvočna preiskava, rentgenska preiskava, računalniška tomografija in magnetnoresonančna tomografija. ...
ABSTRACT Introduction: if increased ligament laxity during pregnancy is not compensated for by altered neuro-motor control, this can lead to pelvic girdle pain, which we can assess using the Colour Visual Analogue Scale (CVAS) and the Active Straight Leg Raise (ASLR) test. Methods: Sixty expectant mothers who were twelve or more weeks pregnant were included. Pelvic girdle pain was assessed using the two tests mentioned above. Each assessment was repeated twice. Results: Pearson's correlation coefficient showed a good correlation between the CVAS and ASLR tests at both the first (r = 0.755)and second measurements (r = 0.808). The difference between the first and second measurement with the CVAS was significant (p = 0.03), while there were no significant differences between the first and second measurement with the ASLR test.The ASLR test also showed high repeatability (ICC=0.96). Conclusions: The ASLR test is valid, reliable and sensitive enough and is a strong competitor to all other clinical tests for the assessment of pelvic girdle pain in pregnant women.
Keywords: pelvic girdle pain during pregnancy, pain assessment, scales.
... In humans, a wide symphysis during pregnancy and birth is associated with severe pelvic girdle pain 55,56 , which is common among athletes and patients with traumatic pelvic injuries 53,57 . It is aggravated by weight-bearing and associated with difficulty in walking 58 . ...
Without cesarean delivery, obstructed labor due to a disproportion of the fetus and the maternal birth canal can result in maternal and fetal injuries or even death. The precise frequency of obstructed labor is difficult to estimate because of the widespread use of cesarean delivery for indications other than proven cephalopelvic disproportion, but it has been estimated that at least one million mothers per year are affected by this disorder worldwide. Why is the fit between the fetus and the maternal pelvis so tight? Why did evolution not lead to a greater safety margin, as in other primates? Here, we review current research and suggest new hypotheses on the evolution of human childbirth and pelvic morphology. In 1960, Washburn suggested that this "obstetrical dilemma" arose because the human pelvis is an evolutionary compromise between two functions, bipedal gait and childbirth. However, recent biomechanical and kinematic studies indicate that pelvic width does not considerably affect the efficiency of bipedal gait and thus is unlikely to have constrained the evolution of a wider birth canal. Instead, bipedalism may have primarily constrained the flexibility of the pubic symphysis during pregnancy, which opens much wider in most mammals with larger fetuses than in humans. We argue that the birth canal is mainly constrained by the trade-off between two pregnancy-related functions: while a narrow pelvis is disadvantageous for childbirth, it offers better support for the weight exerted by the viscera and the large human fetus during the long gestation period. We discuss the implications of this hypothesis for understanding pelvic floor dysfunction. Furthermore, we propose that selection for a narrow pelvis has also acted in males due to the role of pelvic floor musculature in erectile function. Finally, we review the cliff-edge model of obstetric selection to explain why evolution cannot completely eliminate cephalopelvic disproportion. This model also predicts that the regular application of life-saving cesarean has evolutionary increased rates of cephalopelvic disproportion already. We address how evolutionary models contribute to understanding and decision-making in obstetrics and gynecology as well as in devising health care policies.
... From this comparative perspective, the question arises why the human pubic symphysis is so inflexible despite the strong obstetric burden. The medical literature provides one (mechanistic) explanation for the lack of larger symphyseal flexibility: great symphyseal width in humans during pregnancy and birth is associated with severe pelvic girdle pain (Björklund, Bergström, Nordström, & Ulmsten, 2000;Björklund, Nordström, & Bergström, 1999), which is a poorly understood condition but common among athletes, patients with traumatic pelvic injuries, and pregnant women (Becker et al., 2010;Cheer & Pearce, 2009;Ronchetti, Vleeming, & van Wingerden, 2008). It is aggravated by weight-bearing and associated with difficulty in walking (Jain, Eedarapalli, Jamjute, & Sawdy, 2006). ...
Objectives
The narrow human birth canal evolved in response to multiple opposing selective forces on the pelvis. These factors cannot be sufficiently disentangled in humans because of the limited range of relevant variation. Here, we outline a comparative strategy to study the evolution of human childbirth and to test existing hypotheses in primates and other mammals.
Methods
We combined a literature review with comparative analyses of neonatal and female body and brain mass, using three existing datasets. We also present images of bony pelves of a diverse sample of taxa.
Results
Bats, certain non‐human primates, seals, and most ungulates, including whales, have much larger relative neonatal masses than humans, and they all differ in their anatomical adaptations for childbirth. Bats, as a group, are particularly interesting in this context as they give birth to the relatively largest neonates, and their pelvis is highly dimorphic: Whereas males have a fused symphysis, a ligament bridges a large pubic gap in females. The resulting strong demands on the widened and vulnerable pelvic floor likely are relaxed by roosting head‐down.
Conclusions
Parturition has constituted a strong selective force in many non‐human placentals. We illustrated how the demands on pelvic morphology resulting from locomotion, pelvic floor stability, childbirth, and perhaps also erectile function in males have been traded off differently in mammals, depending on their locomotion and environment. Exploiting the power of a comparative approach, we present new hypotheses and research directions for resolving the obstetric conundrum in humans.
... Women also said their pain slowed them down and they felt physically restricted, in line with past literature demonstrating that many women with PPGP report disability during pregnancy and postpartum. 10,41 Furthermore, women felt their PGP was draining and tiring. Early motherhood is a time inherently characterised by reduced sleep due to the needs of the infant, but most women in this study felt their PGP added to this exhaustion although they were all first-time mothers and thus could not make comparisons with previous experiences. ...
Pelvic Girdle Pain (PGP) is common during pregnancy and negatively affects women's lives. When PGP persists after a birth, the way it impacts on women's lives may change, particularly for first-time mothers as they adjust to motherhood, yet the experiences of women with persistent PGP remain largely unexplored.
The objective of this study was to explore primiparous women's experiences of persistent PGP and its impact on their lives postpartum, including caring for their infant and their parental role.
A descriptive qualitative study.
Following institution ethical approval, 23 consenting primiparous women with PGP that had started during pregnancy and persisted for at least 3 months postpartum participated in individual interviews. These were recorded, transcribed, and analysed using thematic analysis.
Four themes emerged: (1) 'Putting up with it: coping with everyday life'; women put up with the pain but had to balance activities and were grateful for support from family and friends to face everyday challenges, (2) 'I don't feel back to normal'; feelings of physical limitations, frustration and a negative impact on their mood were described, (3) 'Unexpected'; persistent symptoms were unexpected for women due to a lack of information given about PGP, (4) 'What next?'; the future of their symptoms was met with great uncertainty and women expressed worry about having another baby.
For first-time mothers, having persistent PGP postpartum impacts their daily lives in many ways. These findings provide important information for healthcare providers, which will improve their understanding of these women's experiences, enhance rapport, and can be used to provide information and address concerns, to optimise maternity care during pregnancy and beyond.
© 2015 American Physical Therapy Association.
... Prolonged pelvic girdle pain, lasting more than 6 months postpartum is estimated in 3%-30% of women. [43] As a component of pelvic ring pain, SIJ dysfunction is commonly seen in peripartum pain conditions. Pain management techniques for SIJ pathology include local steroid injections, radiofrequency thermocoagulation (RFTC), cooled radiofrequency, and cryoneurolysis of the nerves innervating the SIJ under fl uoroscopic guidance. ...
Chronic pelvic pain (CPP) is defined as nonmalignant pain perceived in the structures related to the pelvis that has been present for more than 6 months or a non acute pain mechanism of shorter duration. Pain in the pelvic region can arise from musculoskeletal, gynaecological, urologic, gastrointestinal and or neurologic conditions. Key gynaecological conditions that contribute to CPP include pelvic inflammatory disease (PID), endometriosis, adnexa pathologies (ovarian cysts, ovarian remnant syndrome), uterine pathologies (leiomyoma, adenomyosis) and pelvic girdle pain associated with pregnancy. Several major and minor sexually transmitted diseases (STD) can cause pelvic and vulvar pain. A common painful condition of the urinary system is Interstitial cystitis(IC. A second urologic condition that can lead to development of CPP is urethral syndrome. Irritable bowel syndrome (IBS) is associated with dysmenorrhoea in 60% of cases. Other bowel conditions contributing to pelvic pain include diverticular disease,Crohn′s disease ulcerative colitis and chronic appendicitis. Musculoskeletal pathologies that can cause pelvic pain include sacroiliac joint (SIJ) dysfunction, symphysis pubis and sacro-coccygeal joint dysfunction, coccyx injury or malposition and neuropathic structures in the lower thoracic, lumbar and sacral plexus. Prolonged pelvic girdle pain, lasting more than 6 months postpartum is estimated in 3% to 30% of women. Nerve irritation or entrapment as a cause of pelvic pain can be related to injury of the upper lumbar segments giving rise to irritation of the sensory nerves to the ventral trunk or from direct trauma from abdominal incisions or retractors used during abdominal surgical procedures. Afflictions of the iliohypogastric, ilioinguinal, genitofemoral, pudendal and obturator nerves are of greatest concern in patients with pelvic pain. Patient education about the disease and treatment involved is paramount. A knowledge of the differential diagnosis of the pain generators leads to a diagnosis specific management of the pain condition. Using a multidisciplinary approach can improve outcomes for patients suffering from the condition and minimize the associated disability.
... However, in a small percentage of patients complaints about pain persist and symptoms may last for years. The prevalence for PGP and/or LBP after delivery ranges from 5% to 37% (Ronchetti, Vleeming, and Wingerden, 2008). ...
The aim of this work was to investigate the effectiveness of physical therapy for the treatment of low back pain (LBP) and pelvic girdle pain (PGP) related to pregnancy after delivery. A systematic review of studies published since 1985 in the databases Medline, PEDro, SciELO, SCOPUS, LILACS, and the Cochrane Library was made. Studies that focused on postpartum LBP or PGP, without being related to pregnancy or in other non-pregnant patients, were excluded, as were papers addressing LBP or PGP indicating radiculopathy, rheumatism, or any other serious disease or pathologic condition. In accordance with the exclusion criteria and duplicate articles, of the 105 articles retrieved only six were considered for quality assessment with the PEDro Scale. Among these six papers, two were follow-ups, such that only four trials were included in this review. All trials used exercise for motor control and stability of the lumbopelvic region, but with different intervention approaches. The study affording the best evidence used individual guidance and adjustments given by the physiotherapists. Nevertheless, this systematic review was inconclusive and showed that more randomized clinical trials, with good quality, are needed.
... The LDL can be palpated in the area directly caudal to the PSIS, and upon palpation feels like a bone-hard structure (Fig. 7). The ligament is of special interest, as women who complain of lumbopelvic back pain during pregnancy frequently experience pain within the boundaries of this ligament (Fortin et al. 1994a;Vleeming et al. 1996Vleeming et al. , 2002Ronchetti et al. 2008). Pain localized to this area is also common in men. ...
This article focuses on the (functional) anatomy and biomechanics of the pelvic girdle and specifically the sacroiliac joints (SIJs). The SIJs are essential for effective load transfer between the spine and legs. The sacrum, pelvis and spine, and the connections to the arms, legs and head, are functionally interrelated through muscular, fascial and ligamentous interconnections. A historical overview is presented on pelvic and especially SIJ research, followed by a general functional anatomical overview of the pelvis. In specific sections, the development and maturation of the SIJ is discussed, and a description of the bony anatomy and sexual morphism of the pelvis and SIJ is debated. The literature on the SIJ ligaments and innervation is discussed, followed by a section on the pathology of the SIJ. Pelvic movement studies are investigated and biomechanical models for SIJ stability analyzed, including examples of insufficient versus excessive sacroiliac force closure.
... 21 Prolonged pelvic girdle pain, lasting beyond 6 months postpartum, is estimated in 3% to 30% of women. 98 Such dysfunction most often results in pain that localizes to the posterior superior iliac spine and pubic symphysis. 21 There are many theories to the cause of pelvic girdle pain, but the diagnosis remains elusive. ...
Pelvic pain is a common condition. Treatment interventions have traditionally targeted biomedical conditions with variable success. Utilizing a systematic approach to examination of the pelvic girdle and related organ systems contained within the pelvis will aid the clinician in identifying the painful structure(s) as well as the associated impairments limiting functional recovery. From this, a complete management program can be instituted. The following description of gynecologic, urologic, gastrointestinal, musculoskeletal, and neurologic conditions that can cause or are associated with chronic pelvic pain leads to conservative management proposals based on the available evidence. Finally, nonoperative interventional strategies are described, which target the pain system from a cognitive behavioral perspective, address movement dysfunctions, and address interventional pain technique possibilities.▪
... A thorough medical history, physical examination and appropriate laboratory tests should always be performed to successfully reach the diagnosis of PPGP. Obviously, a multidisciplinary approach and consultation may be needed, as this syndrome expands to a wide field of anatomically related medical specialties [4,6,24,40,60]. An algorithm of the necessary diagnostic workup is presented inFigure 1. ...
A large number of scientists from a wide range of medical and surgical disciplines have reported on the existence and characteristics of the clinical syndrome of pelvic girdle pain during or after pregnancy. This syndrome refers to a musculoskeletal type of persistent pain localised at the anterior and/or posterior aspect of the pelvic ring. The pain may radiate across the hip joint and the thigh bones. The symptoms may begin either during the first trimester of pregnancy, at labour or even during the postpartum period. The physiological processes characterising this clinical entity remain obscure. In this review, the definition and epidemiology, as well as a proposed diagnostic algorithm and treatment options, are presented. Ongoing research is desirable to establish clear management strategies that are based on the pathophysiologic mechanisms responsible for the escalation of the syndrome's symptoms to a fraction of the population of pregnant women.
Importance:
Pelvic girdle pain is often thought to be a recent phenomenon, but this condition was described as early as 400 BC by Hippocrates. Despite being identified for years, confusion continues about the definition and management of this ailment affecting many pregnancies.
Objective:
The purpose of the review is to assess the incidence, etiology, pathophysiology, risk factors, diagnosis, management, and pregnancy outcomes/recovery of current pregnancies, and outcomes of future pregnancies complicated by pelvic girdle pain.
Evidence acquisition:
Electronic databases (PubMed and Embase) were searched from 1980 to 2021 with the only limitation being that the articles were in English. Studies were selected that examined associations between pelvic pain/pelvic girdle pain and pregnancy.
Results:
There were 343 articles identified. After reviewing the abstracts, 88 were used in this review. Pelvic girdle pain is a common condition of pregnancy, affecting a reported 20% of pregnant women. The pathophysiology is poorly understood and likely multifactorial, involving both hormonal and biomechanical changes that occur during pregnancy. Several risk factors have been identified. This diagnosis is most commonly made based on symptoms related to pelvic pain during pregnancy. Treatment should be multimodal, including pelvic girdle support, stabilizing exercises, analgesia, and potentially complementary therapies. The effects on future pregnancies are uncertain, although some limited information suggests an increased risk of recurrent PGP in subsequent pregnancies.
Conclusions:
Pelvic girdle pain in pregnancy is a common condition that is often overlooked as a normal part of pregnancy but has a significant impact on quality of life during, after, and in subsequent pregnancies. Multimodal therapies are available and are largely low cost and noninvasive.
Relevance:
Our aim is to increase the awareness of pelvic girdle pain in pregnancy as a common but often underdiagnosed and undertreated condition.
Background
Patients with sacroiliac joint dysfunction are limited in daily life activities such as gait, climbing stairs and rising from a chair. It is well known that individuals with chronic low back pain have impaired balance compared to healthy individuals. This cross-sectional case-control study aims to investigate spatiotemporal parameters, center of pressure and mass, pelvic angles and other joint angles in patients with sacroiliac joint dysfunction in comparison with healthy controls.
Methods
Motion analysis existed of three tasks: (1) normal gait, (2) single-leg-stance, and (3) sit-to-stance. Spatiotemporal parameters, center of pressure, pelvic angles and other joint angles were measured using a twelve-camera, three-dimensional motion capture system and ground reaction force platforms.
Findings
Thirty subjects were recruited for this study; ten patients, ten matched controls and ten healthy student controls. For gait, patients had a lower cadence, longer double support phase, shorter step length and slower walking speed than controls. For single-leg-stance, patients had a smaller hip angle of the risen leg than controls. Also, variability in center of pressure was larger in patients. For sit-to-stance, the total time to perform the task was almost doubled for patients compared to controls.
Interpretation
This study demonstrates that patients with sacroiliac joint dysfunction have an impaired gait, more balance problems during standing and standing up compared to healthy controls. This novel information assists to further comprehend the pathology and disease burden of sacroiliac joint dysfunction, in addition, it may allow us to evaluate the effect of current therapies.
Dieser Artikel gibt einen Einblick in biomechanische Aspekte des weiblichen Beckens in der Schwangerschaft. Neben den biomechanischen Einflüssen am knöchernen Becken und am Bewegungsapparat wird auch auf biomechanische Aspekte des inneren (viszeralen) Beckens und des Beckenbodens eingegangen. Im Rahmen des biopsychosozialen Krankheitsmodells fokussiert sich dieser Artikel also auf die biologische Komponente. Dabei werden auch funktionelle Zusammenhänge des Beckens mit anderen Körperregionen dargestellt.
Pelvic girdle pain (PGP) is defined as pain experienced between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the sacroiliac joint. Pelvic girdle pain is common postpartum, may result from pregnancy-related factors, and is a leading cause of disability postpartum. The purpose of this clinical practice guideline is to provide evidence-based recommendations for physical therapist management of PGP in the postpartum population. Postpartum individuals may experience PGP beginning during pregnancy, immediately after childbirth, or up to 2 years after delivery. Although most cases of PGP in pregnancy resolve spontaneously, a subset of postpartum individuals may experience persistent pain. Based upon critical appraisal of literature and expert opinion, 23 action statements for risk factors, systems screening, examination, diagnosis, prognosis, theoretical models of care, and intervention for postpartum individuals with PGP are linked with explicit levels of evidence. A significant body of evidence exists to support physical therapist intervention with postpartum clients with PGP to reduce pain and disability. Emerging evidence suggests that further investigation of biopsychosocial factors is warranted, especially factors that influence the development of persistent pain in the postpartum population. Future research is needed in several areas to optimize examination and intervention strategies specific to postpartum individuals and guided by a classification system for PGP that includes elements of pain, movement, and biopsychosocial factors. The authors provide clinical practice guidelines for providing physical therapy to postpartum individuals with PGP.
Purpose of Review
This paper seeks to review the important musculoskeletal issues that arise for pregnant and postpartum women. It outlines the background, diagnosis, and management of these musculoskeletal issues; reviews the existing and recent literature; and offers clinical opinions from the perspective of women’s health PM&R physicians.
Recent Findings
Existing and recent literature on pelvic girdle pain, lumbosacral back pain, pubic symphysis separation, transient osteoporosis, rectus diastasis, and postpartum neuropathy offer some new insights on management, which is often context-dependent. Management requires individualized physical therapy and precautions for delivery and postpartum. Emerging alternatives like acupuncture for pelvic girdle pain (PGP) and surgical reconstruction for diastasis recti abdominis (DRA) may be considered.
Summary
The various musculoskeletal pathologies that occur in the peripartum period can produce significant disability for women. With timely diagnosis and treatment, however, these musculoskeletal issues are often transient in nature and do not result in long-term functional deficits.
Background:
It has been reported that in 13-32% of patients with chronic low back pain, the pain may originate in the sacroiliac (SI) joints. When treatment of these patients with analgesics and physiotherapy has failed, a surgical solution may be discussed. Results of such surgery are often based on small series, retrospective analyses or studies using a minimal invasive technique, frequently sponsored by manufacturers.
Purpose:
To report the clinical outcome concerning pain, function and quality of life following anterior arthrodesis in patients presumed to have SI joint pain using validated questionnaires pre- and post-operatively. An additional aim was to describe the symptoms of the patients included and the preoperative investigations performed.
Material and methods:
Over a 6 year period we treated 55 patients, all women, with a mean age of 45 years (range 28-65) and a mean pelvic pain duration of 9.1 years (range 2-30). The pain started in connection with minor trauma in seven patients, pregnancy in 20 and unspecified in 28. All patients had undergone long periods of treatment including physiotherapy, manipulation, needling, pelvic belt, massage and chiropractic without success, and 15 had been operated for various spinal diagnoses without improvement. The patients underwent thorough neurological investigation, plain X-ray and MRI of the spine and plain X-ray of the pelvis. They were investigated by seven clinical tests aimed at indicating pain from the SI joints. In addition, all patients underwent a percutaneous mechanical provocation test and extra-articular local anaesthetic blocks against the posterior part of the SI joints. Before surgery all patients answered the generic Short-Form-36 (SF-36) questionnaire, the disease specific Balanced Inventory for Spinal Disorders (BIS) questionnaire and rated their level of pelvic and leg pain (VAS, 0-100). At follow-up at a mean of 2 years 49 patients completed the same questionnaires (89%).
Results:
At follow-up 26 patients reported a lower level of pelvic pain than before surgery, 16 the same level and six a higher level. Applying Svensson's method RPpelvic pain=0.3976, with 95% CI (0.2211, 0.5740) revealed a statistically significant systematic improvement in pelvic pain. At follow-up 28 patients reported a higher quality of life and 26 reported sleeping better than pre-operatively. In most patients the character of the pelvic pain was dull and aching, often accompanied by a stabbing component in connection with sudden movements. Referred pain down the leg/s even to the feet and toes was noted by half of the patients and 29 experienced frequency of micturition.
Conclusions:
It is apparent that in some patients the SI joints may cause long-term pain that can be treated by arthrodesis. We speculate that continued pain despite a healed arthrodesis may be due to persistent pain from adjacent ligaments. The next step should be a prospective randomized study comparing posterior fusion and ligament resection with non-surgical treatment.
Implications:
Anterior arthrodesis can apparently relieve pain in some patients with presumed SI joint pain. The problem is how to identify these patients within the low back pain group.
Catastrophizing, a cognitive behavioral aspect of pain, is defined as an excessively negative orientation against a noxious stimulus. The primary goal of the present study is to assess the association between catastrophizing and lumbopelvic pain intensity during the pregnancy period, the secondary goal is to explore the variation of pain catastrophizing, anxiety and depression, and the tertiary goal is to investigate the relationship between catastrophizing and quality of life. After approval, pregnant women with lumbopelvic pain were invited to join in the study. During admission, participants were asked to complete questionnaires including Pain Catastrophizing Scale, Beck Anxiety Inventory, Beck Depression Inventory-II, and Short Form-36. Age, gravida, parity, number of abortus, number of live-births and the pain intensity score were recorded. A total of 429 women were enrolled in the study. Pain catastrophizing scores showed a fluctuation during pregnancy, and were significantly correlated with the scores of Beck Anxiety Inventory, Beck Depression Inventory, Visual Analog Scale, and Short Form-36 sub-scales including social functioning, vitality, physical functioning and mental health. The present study demonstrated that catastrophizing level shows an alteration throughout the pregnancy period, and variation in catastrophizing shows an approximately similar course with pain intensity, depression and anxiety.
Objective: To compare inter rectus distance (IRD) of pregnant women with pelvic girdle pain (PGP) with those with other types of pregnancy-related back pain (BP).
Study Design: Cross-sectional case-control design.
Background: Abdominal and pelvic muscular stability is reduced in PGP. Compromise to these muscles occurs in diastasis rectus abdominis (DRA), resulting in a larger IRD. There is minimal conflicting research relating to DRA and PGP.
Methods and Measures: The IRD of 66 pregnant women with self-reports of BP was first measured using nylon digital calipers with the abdominal muscles at rest and during a curl-up. All participants were evaluated using a pain location drawing, the numerical rating scale, the posterior pelvic pain provocation test, active straight leg raise, and the sacral compression test. Post hoc, a blinded research assistant classified subjects either into a PGP group if 3 of these tests were positive or into a nonspecific BP group.
Results: In both groups, the IRD was widest at the umbilicus, narrowest below the umbilicus, and decreased with a curl-up. Odds ratios (ORs) were adjusted for factors when a relationship with PGP was suggested as follows: pregnancies 2 or more (OR = 1.07; 95% confidence interval [CI] = 0.40-2.87), weeks of gestation more than 25 (OR = 1.28; 95% CI = 0.49-3.35), and abdominal circumference more than 103 cm (OR = 1.75; 95% CI = 0.65-4.72). The adjusted ORs were very close to 1 with CIs that contain 1, indicating that PGP does not seem to be related to the IRD.
Conclusions: There was no significant difference in the IRD of pregnant women with PGP compared with BP at any location or contraction condition.
The postpartum period in a woman's life is filled with numerous changes, including physical changes, changes in sleep habits, and learning how to best care for a newborn. A common goal among postpartum women is to either begin or resume an active lifestyle, which often includes physical activity such as running, biking and swimming. The postpartum athlete may discover barriers that prevent her from returning to or beginning an exercise routine. These obstacles include muscle weakness, fatigue, depression and physical changes that require exercise modification. The physical therapist is well-suited to properly assess, treat and manage the care of the postpartum athlete. Postpartum athletes wishing to begin or resume training for triathlons require special consideration, as the triathlete must balance training to compete in three different sports.
The purpose of the paper is to identify the unique physical and physiological changes that occur to the female during the postpartum period. In addition, injuries that are more commonly seen during the postpartum period will be discussed. Recommendations for beginning or resuming an exercise program will be reviewed. Lastly, sport-specific training for the postpartum triathlete, including challenges presented with each triathlon component, will be discussed.
During pregnancy, the mouse pubic symphysis (PS) remodels in a hormone-controlled process that involves the separation and modification of the fibrocartilage into an interpubic ligament for a safe delivery, followed by its relaxation prior to parturition and its postpartum recovery. New insights on the remodeling of extracellular matrix (ECM) as well as on the secretion of factors and cell behaviors involved in molecular connective tissue turnover arise from studies of animal models. The mouse PS, as a musculoskeletal element, presents a diversity of remodeling responses during the first pregnancy, parturition, and postpartum. However, impaired postpartum recovery occurs in multiparous senescent mice. Thus, the PS model could be used in future studies to investigate the complex molecular mechanisms of ECM remodeling. This articulation could also help to understand risk factors that affect the biomechanical properties of the mouse reproductive tract and its supportive structures, and thereby improve our understanding of pelvic disorders.
De bekendste vorm van lagerug- en bekkenpijn is die bij vrouwen tijdens de zwangerschap (prepartum) en na de bevalling (postpartum) op. In verband met internationale consensus ten aanzien van een eenduidige naamstelling, praten we tegenwoordig over ‘pelvic girdle pain’ (PGP) of ‘pregnancy-related pelvic girdle pain’ (PPGP). Voor dit laatste bestaat de Nederlandse term: zwangerschapsgerelateerde lagerug- en bekkenpijn (ZLBP). Hiermee worden pijnklachten van het bekken bedoeld en dus valt ook bekkenbodempijn onder deze benaming. Eerdere, onvolledige benamingen voor deze klachten waren: bekkeninstabiliteit, peripartum pelvic pain (PPPP), peripartum bekkenpijnsyndroom of symfysiolyse. Vroeger sprak men ook wel van zwangerschapshernia of zwangerschapsischias (Bastiaenen, 2004).
The purpose of the paper is to present the problems related to various biomechanical changes taking place in the musculoskeletal system in pregnant women concerning body posture and pain problems and especially low back pain. The changes of the functional motion range of the trunk as well as the limitations and difficulties in daily life activities and work performance are taken into consideration. The influence of pregnancy on postural stability and gait is also presented in the paper. The knowledge gathered in the article should be helpful to those who provide the child birth classes as well as to physicians and physical therapists in prevention and treatment of musculoskeletal complaints of women during pregnancy and post partum.
The work presented in this thesis examines whether a more prominent role of functional anatomy within multidisciplinary treatment of non-specific chronic low back pain (NCLBP) will increase its therapeutic effect. The multidisciplinary treatment of NCLBP is based on the biopsychosocial (BPS) model. This model is derived from systems theory and was introduced by Engel in 1977 to replace the traditional biomedical model.
Fundamental to the BPS model is that not only biological but also psychological and social aspects are included in the aetiology of diseases, such as chronic back pain. However, in the ongoing development of new diagnostic and therapeutic techniques based on this BPS model, the behavioural aspects prevailed whilst the physical aspects (especially physical exercises) lagged behind. Consequently, in contemporary multidisciplinary treatment protocols, physical training is subordinate and mainly in service of the desired modification of behaviour.
Recent studies of multidisciplinary programmes for NCLBP show that the results of these predominantly psychological, behaviourorientated treatments are far from optimal. Therefore, the question arose as to how multidisciplinary treatment can be improved. One option for improvement is to intensify the application of functional anatomical knowledge and incorporate corresponding specific training within existing multidisciplinary programmes.
Functional anatomical research has made significant progress in the last decade; this has led to new knowledge on spine function and, consequently, to the development of new physical exercises. In the context of multidisciplinary treatment of NCLBP patients, and based on the new functional anatomical knowledge, the aim of this thesis was to address the following questions:
1. Taking into account the available recent data on functional anatomy, is there a need to reconsider the role of the physical domain within the BPS model?
2. Will a more pronounced role of functional anatomy in the BPS model contribute to better diagnosis?
3. Will functional anatomy applied in the BPS model contribute to improved therapy?
: To educate the obstetrics community regarding postpartum labral tears, an avoidable and treatable potential complication of pregnancy in the postpartum period.
: From 2009 to 2011, 10 women presented to the second author's office with persistent hip pain that had begun during pregnancy or during delivery. These 10 postpartum women presented with signs and symptoms of labral tears, which were subsequently confirmed with arthroscopy and surgically repaired.
: Each patient experienced relief of symptoms within 4 months after the procedure. All patients were satisfied with surgery, and all patients had improvement in modified Harris hip score. The average preoperative modified Harris hip score was 53.1 and the average postoperative modified Harris hip score was 84.3 (P<.001).
: An acetabular labral tear should be considered part of the differential diagnosis for hip pain in postpartum women. Additionally, freeing the distal lower extremity to externally rotate during labor may prevent an acute labral tear. When nonoperative management fails, surgery may lead to positive outcomes.
: II.
Impairment of pelvic organ support has been described in mice with genetic modifications of the proteins involved in elastogenesis, such as lysyl oxidase-like 1 (LOXL1) and fibulin 5. During pregnancy, elastic fiber-enriched pelvic tissues are modified to allow safe delivery. In addition, the mouse pubic symphysis is remodeled in a hormone-controlled process that entails the modification of the fibrocartilage into an interpubic ligament (IpL) and the relaxation of this ligament. After first parturition, recovery occurs to ensure pelvic tissue homeostasis. Because ligaments are the main supports of the pelvic organs, this study aimed to evaluate elastogenesis in the IpL during mouse pregnancy and postpartum. Accordingly, virgin, pregnant, and postpartum C57BL/6 mice were studied using light, confocal, and transmission electron microscopy as well as Western blots and real-time PCR. Female mice exhibited the separation of the pubic bones and the formation, relaxation, and postpartum recovery of the IpL. By the time the IpL was formed, the elastic fibers had increased in profile length and diameter, and they consisted of small conglomerates of amorphous material distributed among the bundles of microfibrils. Our analyses also indicated that elastin/tropoelastin, fibrillin 1, LOXL1/Loxl1, and fibulin 5 were spatially and temporally regulated, suggesting that these molecules may contribute to the synthesis of new elastic fibers during IpL development. Overall, this work revealed that adult elastogenesis may be important to assure the elasticity of the pelvic girdle during preparation for parturition and postpartum recovery. This finding may contribute to our understanding of pathological processes involving elastogenesis in the reproductive tract.
Transversus abdominis (TA), obliquus internus (OI), and obliquus externus (OE) are involved in multiple functions: breathing, control of trunk orientation, and stabilization of the pelvis and spine. How these functions are coordinated has received limited attention. We studied electromyographic (EMG) activity of right-sided muscles and 3-dimensional moments during treadmill walking at six different speeds (1.4-5.4km/h) in sixteen healthy young women. PCA revealed time series of trunk moments to be consistent across speeds and subjects though somewhat less in the sagittal plane. All three muscles were active during ⩾75% of the stride cycle, indicative of a stabilizing function. Clear phasic modulations were observed, with TA more active during ipsilateral, and OE during contralateral swing, while OI activity was largely symmetrical. Fourier analysis revealed four main frequencies in muscle activity: respiration, stride frequency, step frequency, and a triphasic pattern. With increasing speed, the absolute power of all frequencies remained constant or increased; the relative power of respiration and stride-related activities decreased, while that of step-related activity and the triphasic pattern increased. Effects of speed were gradual, and EMG linear envelopes had considerable common variance (>70%) across speeds within subjects, suggesting that the same functions were performed at all speeds. Maximum cross-correlations between moments and muscle activity were 0.2-0.6, and further analyses in the time domain revealed both simultaneous and consecutive task execution. To deal with conflicting constraints, the activity of the three muscles was clearly coordinated, with co-contraction of antagonists to offset unwanted mechanical side-effects of each individual muscle.
There is a lack of knowledge about the possible role of catastrophizing in lumbopelvic pain during and after pregnancy and in postpartum physical ability.
The aims of this study were to explore how catastrophizing fluctuates over time during and after pregnancy and to investigate the associations between catastrophizing and lumbopelvic pain and between catastrophizing and postpartum physical ability.
A prospective questionnaire was used.
The Pain Catastrophizing Scale was used to assess exaggerated negative thoughts about pain experiences in weeks 19 to 21 and weeks 34 to 37 of pregnancy and at 6 months postpartum. The Disability Rating Index was used to assess physical ability at 6 months postpartum. The occurrence of lumbopelvic pain was reported by participants. Parametric and nonparametric tests were used for the analyses.
A total of 242 of 324 women were categorized according to reported levels of catastrophizing. A majority of women (57.9%) reported not catastrophizing at all test occasions, whereas 10.3% reported catastrophizing at all occasions. For the remaining 31.8%, the levels of catastrophizing varied over time. Women who catastrophized at 1 or more of the occasions reported higher proportions of postpartum lumbopelvic pain and had more restricted postpartum physical ability than women who did not catastrophize.
The fact that some women did not complete the questionnaire at all test occasions might have reduced the generalizability of the results.
The common idea that levels of catastrophizing are "stable" within personality should be reconsidered, because for 1 of 3 women, the levels of catastrophizing changed over time. A majority of women reported not catastrophizing. However, catastrophizing in relation to pregnancy seems to be associated with lumbopelvic pain and postpartum physical ability. The results indicated that the role of catastrophizing in this context should be studied further.
To develop criteria for the classification of fibromyalgia, we studied 558 consecutive patients: 293 patients with fibromyalgia and 265 control patients. Interviews and examinations were performed by trained, blinded assessors. Control patients for the group with primary fibromyalgia were matched for age and sex, and limited to patients with disorders that could be confused with primary fibromyalgia. Control patients for the group with secondary-concomitant fibromyalgia were matched for age, sex, and concomitant rheumatic disorders. Widespread pain (axial plus upper and lower segment plus left- and right-sided pain) was found in 97.6% of all patients with fibromyalgia and in 69.1% of all control patients. The combination of widespread pain and mild or greater tenderness in greater than or equal to 11 of 18 tender point sites yielded a sensitivity of 88.4% and a specificity of 81.1%. Primary fibromyalgia patients and secondary-concomitant fibromyalgia patients did not differ statistically in any major study variable, and the criteria performed equally well in patients with and those without concomitant rheumatic conditions. The newly proposed criteria for the classification of fibromyalgia are 1) widespread pain in combination with 2) tenderness at 11 or more of the 18 specific tender point sites. No exclusions are made for the presence of concomitant radiographic or laboratory abnormalities. At the diagnostic or classification level, the distinction between primary fibromyalgia and secondary-concomitant fibromyalgia (as defined in the text) is abandoned.
This study analyzed an education and training program concerning back and pelvic problems among pregnant women.
The program was aimed at reducing back and pelvic posterior pain during pregnancy.
Low back and posterior pelvic pain accounts for the majority of sick leave among pregnant women. No previous study has suggested any type of solution to this problem.
Four hundred and seven consecutive pregnant women were included in the study and randomly assigned into three groups. Group A served as controls while different degrees of interventions were made in groups B and C.
Serious back or posterior pelvic pain developed in 47% of all women. Pain-related problems were reduced in groups B and C (P < 0.05), and sick-leave frequency was reduced in group C (P < 0.01). For some of the women in this group, pain intensity was also reduced 8 weeks post partum (P < 0.05). Weekly physical exercise before pregnancy reduced the risk for back pain problems in pregnancy (P < 0.05). A non-elastic sacro-iliac belt offered some pain relief to 82% of the women with posterior pelvic pain.
An individually designed program reduced sick leave during pregnancy. Working with groups was less effective. Differentiation between low back and posterior pelvic pain was essential. Good physical fitness reduced the risk of back pain in a subsequent pregnancy. Reduction of posterior pelvic pain by a non-elastic pelvic support was experienced by 82% of the women with posterior pelvic pain.
The purpose of this study was to investigate which demographic parameters are most important in relation to lumbar dynamometry performance in patients with chronic low back pain (LBP). Forty-five chronic LBP patients participated in this study. Gender, age, weight and height were determined and a lumbar dynamometry measurement was carried out, using the Isostation B200. Student's t-test, ANOVA techniques and correlation coefficients were used to investigate the relationships between each demographic parameter and lumbar dynamometry performance. Stepwise multiple linear regression analyses were performed afterwards to determine which demographic parameters are most important in relation to lumbar dynamometry performance. Results indicate significant relationships (1) between gender, height, weight and all lumbar dynamometry parameters and (2) between age and three of the six isometric torque parameters. No significant relationship was found between age and maximum velocity parameters. Results of the stepwise multiple linear regression analyses show that the demographic parameters explain 27-47% of the variance in maximum isometric strength parameters and 19-25% of the variance in maximum velocity parameters. Gender is the most important demographic parameter, being related to nearly all maximum isometric torque parameters (percentage explained variance 6-37%) and height is the only important demographic parameter related to the velocity parameters (percentage explained variance 19-25%). Weight and age account for only a small amount of variance in lumbar dynamometry parameters (percentage explained variance 5-7%), meaning that these parameters are non-relevant predictors.
Pain in the pelvic joints and lower back, a major problem for pregnant women, has proved resistant to precise measurement and quantification. To develop a classification system, the clinical tests used must be able to separate pelvic from low back pain; they must also have a high inter-examiner reliability, sensitivity and specificity, and preferably be easy to perform. The aim of this study was to describe a standardised way of performing tests for examining the pelvis, and to evaluate inter-examiner reliability, and establish the sensitivity and specificity of 15 clinical tests. It was designed as a longitudinal, prospective, epidemiological cohort study. First, 34 pregnant women were examined by blinded examiners to establish inter-examiner reliability. Second, a cohort of 2269 consecutive pregnant women, each responded to a questionnaire and underwent a thorough and highly standardised physical examination (15 tests with 48 possible responses) of the pelvic joints and surrounding areas. The 535 women who reported daily pain from the pelvic joints and had objective findings from the joints were divided, according to symptoms, into four classification groups and one miscellaneous group. The results of the study showed inter-examiner agreement of the tests was high, calculated in percentage terms, at between 88 and 100%. Using the Kappa coefficient, most tests kept the high agreement: six tests had an inter-examiner agreement of between 0.81 and 1.00, three between 0.61 and 0.80, and two between 0.60 and 0.41. Five tests showed superior sensitivity. The specificity of the tests was between 0.98 and 1.00, except the value for pelvic topography, which was 0.79. These results show that it is possible to standardise examination and interpretation of clinical tests of the pelvic joints, resulting in a high degree of sensitivity, specificity and inter-examiner reliability.
To enhance the understanding of the pathophysiology of women with peripartum pelvic pain, it is necessary to couple anatomical insights with relevant clinical research. In this context, the long dorsal sacroiliac ligament is especially of interest because it was noticed that women diagnosed with peripartum pelvic pain frequently experience pain within the boundaries of this ligament. Njoo (1) found a high intertester reliability and a high specificity for long dorsal sacroiliac ligament pain. The present article focuses on the possible role of the long dorsal sacroiliac ligament in the pain pattern of women with peripartum pelvic pain. The diagnostic and therapeutic consequences are considered.
A cross-sectional analysis was performed in a homogenous group of women meeting strict criteria for posterior pelvic pain since pregnancy, diagnosed as having peripartum pelvic pain and excluded for any history of fracture, neoplasm or previous surgery of the lumbar spine, the pelvic girdle, the hip joint or the femur. The patients were also excluded for signs indicating radiculopathy: asymmetric Achilles tendon reflex and/or (passive) straight leg raising restricted by pain in the lower leg.
The study group comprised 178 women diagnosed with peripartum pelvic pain, selected from the outpatient clinic of a specialized rehabilitation center. Selection was based on criteria enabling a strict division between lumbar and pelvic complaints. Pain in the long dorsal sacroiliac ligament was detected by standardized palpation of the long dorsal sacroiliac ligament by specifically trained physicians and scored on a modified scale. Comparisons with the posterior pelvic pain provocation test and the active straight leg raise test was carried out.
The present study confirms that the long dorsal sacroiliac ligament frequently shows tenderness on palpation in patients with peripartum pelvic pain. Sensitivity was 76%. Sensitivity in a group of 133 women of the study group that scored positive on both active straight leg raise and posterior pelvic pain provocation tests was 86%. When only severe pelvic patients were included, sensitivity increased to 98%. In comparisons between the posterior pelvic pain provocation and the long dorsal sacroiliac ligament tests on the left and right side, Pearson's correlation coefficient was 0.33 and 0.41, respectively. In comparisons between the active straight leg raise and the long dorsal sacroiliac ligament tests on the left and right side, Pearson's correlation coefficient was 0.35 and 0.41, respectively.
The present study, carried out on a group of peripartum pelvic pain patients with strict in- and exclusion criteria, attempts to further elucidate the pathophysiology of patients with peripartum pelvic pain by adding a simple pain provocation test. It is concluded that the combination of the active straight leg raise, the posterior pelvic pain provocation and the long dorsal sacroiliac ligament pain tests combined with the proposed in- and exclusion criteria seems promising in differentiating between mainly lumbar and pelvic complaints. Although the sensitivity of the long dorsal sacroiliac ligament pain test seems promising, further clinical study is necessary in targeting specifically the long dorsal sacroiliac ligament. It is suggested that studies initiated to show the prevalence of sacroiliac joint pain in patients presenting nonspecific lumbopelvic pain, by using intra-articularly double block injection techniques, should include a peripheral injection of at least the long dorsal sacroiliac ligament.
This study is a prospective, consecutive, 3-year cohort study of women with back pain in an index pregnancy. The aim was to describe the physical status and disability among women with back pain 3 years after delivery. Pain was identified as lumbar back pain, posterior pelvic pain or combined lumbar as well as posterior pelvic pain. Previous studies have established that all three types of pain can be reduced by structured physiotherapy during pregnancy, and the beneficial effect may last for several years. Though it is known that some women have residual pain for a long time, the relative incidence of the three pain types and their degree of disability associated with each have never been reported. Neither has any study presented findings of a physical examination of women 3 years post partum with a focus on the type of pain. All women who were registered as having experienced back pain during an index pregnancy were interviewed by mail 3 years post partum. Women who had residual back pain filled in an additional questionnaire and were physically examined. Out of 799 pregnant women, 231 had some type of back pain during the index pregnancy, and 41 women had pain 3 years later. Women with combined lumbar and posterior pelvic pain were significantly more disabled ( P<0.05) and had significantly lower endurance in the lumbar back and hip abduction muscles ( P<0.01). Some 5% of all pregnant women, or 20% of all women with back pain during pregnancy, had pain 3 years later. The key problem may be poor muscle function in the back and pelvis.
Pregnancy-related lumbopelvic pain has puzzled medicine for a long time. The present systematic review focuses on terminology, clinical presentation, and prevalence. Numerous terms are used, as if they indicated one and the same entity. We propose "pregnancy-related pelvic girdle pain (PPP)", and "pregnancy-related low back pain (PLBP)", present evidence that the two add up to "lumbopelvic pain", and show that they are distinct entities (although underlying mechanisms may be similar). Average pain intensity during pregnancy is 50 mm on a visual analogue scale; postpartum, pain is less. During pregnancy, serious pain occurs in about 25%, and severe disability in about 8% of patients. After pregnancy, problems are serious in about 7%. The mechanisms behind disabilities remain unclear, and constitute an important research priority. Changes in muscle activity, unusual perceptions of the leg when moving it, and altered motor coordination were observed but remain poorly understood. Published prevalence for PPP and/or PLBP varies widely. Quantitative analysis was used to explain the differences. Overall, about 45% of all pregnant women and 25% of all women postpartum suffer from PPP and/or PLBP. These values decrease by about 20% if one excludes mild complaints. Strenuous work, previous low back pain, and previous PPP and/or PLBP are risk factors, and the inclusion/exclusion of high-risk subgroups influences prevalence. Of all patients, about one-half have PPP, one-third PLBP, and one-sixth both conditions combined. Overall, the literature reveals that PPP deserves serious attention from the clinical and research communities, at all times and in all countries.
Previous research indicates that physical examination cannot diagnose sacroiliac joint (SIJ) pathology. Earlier studies have not reported sensitivities and specificities of composites of provocation tests known to have acceptable inter-examiner reliability. This study examined the diagnostic power of pain provocation SIJ tests singly and in various combinations, in relation to an accepted criterion standard. In a blinded criterion-related validity design, 48 patients were examined by physiotherapists using pain provocation SIJ tests and received an injection of local anaesthetic into the SIJ. The tests were evaluated singly and in various combinations (composites) for diagnostic power. All patients with a positive response to diagnostic injection reported pain with at least one SIJ test. Sensitivity and specificity for three or more of six positive SIJ tests were 94% and 78%, respectively. Receiver operator characteristic curves and areas under the curve were constructed for various composites. The greatest area under the curve for any two of the best four tests was 0.842. In conclusion, composites of provocation SIJ tests are of value in clinical diagnosis of symptomatic SIJ. Three or more out of six tests or any two of four selected tests have the best predictive power in relation to results of intra-articular anaesthetic block injections. When all six provocation tests do not provoke familiar pain, the SIJ can be ruled out as a source of current LBP.
To determine the prevalence of back pain and its development over the first postpartum period, 817 women who had been followed through pregnancy were studied a minimum of 12 months after delivery. More than 67% of the women experienced back pain directly after delivery, whereas 37% said they had back pain at the follow-up examination. Most of the women who had recovered became pain-free within 6 months. Factors that correlated to persistent postpartum back pain were the presence of back pain before pregnancy, the presence of back pain during pregnancy, physically heavy work, and multipregnancy. Of these four factors, physically heavy work was found to have the strongest association with persistent back pain at 12 months.
Background:
Pelvic pain in pregnancy has been suggested to be more common in Scandinavia than in the rest of the world, to be culturally specific for the region and to reflect a change in attitude among pregnant women. Little is known of the prevalence of pelvic pain in pregnancy in low-income countries.
Objective:
To explore whether perceived pelvic pain among pregnant women differs between affluent and poor societies.
Subjects and methods:
Four observational studies, comprising a total of 752 women, were carried out in circumstances ranging from wealth to poverty, focusing on the reported prevalence, location and degree of pelvic pain in pregnancy. In Uppsala, Sweden, and in Rufiji, Tanzania, the women were interviewed in late pregnancy. In Jakobstad, Finland, and in Zanzibar Town, Zanzibar, the women were approached after delivery before discharge.
Results:
The reported prevalence of pelvic pain in pregnancy was 49% in Uppsala and 66% in Rufiji, 77% in Jakobstad and 81% in Zanzibar, with an overall similarity of location and degree of pain.
Conclusion:
No geographical differences were found in perceived pelvic pain among pregnant women, irrespective of the socio-economy of the countries.
Study Design. A prospective randomized controlled 6‐year follow‐up study of women with back pain during pregnancy. Objectives. To describe the long‐term development of back pain in relation to pregnancy and to identify the effects of a physiotherapy and patient education program attended during pregnancy. Summary of Background Data. Pain incidence and intensity during pregnancy can be reduced by physiotherapy. No study has described the development of pain experienced for a period of years after delivery or the long‐term effect of physiotherapy. Methods. Pregnant women, registered consecutively, were randomly assigned to one control group and to two intervention groups and were observed throughout pregnancy, with follow‐up after 3 months and 6 years. Results. The first phase of the study was completed by 362 women. After 3 months, 351 and after 6 years, 303 women had been observed. Back pain among 18% of all women before pregnancy and among 71% during pregnancy declined to 16% after 6 years. Pain intensity was highest in Week 36 (visual analog score, 5.4) and declined markedly 6 years later (visual analog score, 2.5). Slow regression of pain after partus correlated with having a back pain history before pregnancy, (r = 0.30; P < 0.05), with high pain intensity during pregnancy (r = 0.45; P < 0.01), and with much residual pain 3 months after pregnancy (r = 0.41; P < 0.01). These correlations were not found in the intervention groups. Furthermore, frequency of back pain attacks at 6 years correlated with frequency of attacks during pregnancy (r = 0.41; P < 0.01) and with a vocational factor (r = −0.25; P < 0.01). Physiotherapy and patient education had no effects on back pain development among women without pain during pregnancy. Conclusions. Back pain during pregnancy regressed spontaneously soon after delivery and improved in few women later than 6 months post partum. Expected correlations between back pain in relation to pregnancy and back pain 6 years later were not present in the intervention groups who had attended a physiotherapy and education program during pregnancy. The program had no prophylactic effects on women without back or pelvic pain during pregnancy.
Study Design.: An analysis was made of the self‐reported medical histories of patients with peripartum pelvic pain. Objectives.: To compile an inventory of the disabilities of patients with peripartum pelvic pain, analyze factors associated with the risk for development of the disease, and to formulate a hypothesis on pathogenesis and specific preventive and therapeutic measures. Summary of Background Data.: Pregnancy is an important risk factor for development of chronic low back pain. Understanding the pathogenesis of pelvic and low back pain during pregnancy and delivery could be useful in understanding and managing nonspecific low back pain. Methods.: By means of a questionnaire, background data were collected among patients of the Dutch Association for Patients With Pelvic Complaints in Relation to Symphysiolysis. Results were compared with the general population. Subgroups were compared with each other. Results.: Peripartum pelvic pain seriously interferes with many activities of daily living such us standing, walking, sitting, and all other activities in which the pelvis is involved. Most patients experience a relapse around menstruation and during a subsequent pregnancy. Occurrence of peripartum pelvic pain was associated with twin pregnancy, first pregnancy, higher age at first pregnancy, larger weight of the baby, forceps or vacuum extraction, fundus expression, and a flexed position of the woman during childbirth; a negative association was observed with cesarean section. Conclusions.: It is hypothesized that peripartum pelvic pain is caused by strain of ligaments in the pelvis and lower spine resulting from a combination of damage to ligaments (recently or in the past), hormonal effects, muscle weakness, and the weight of the fetus.
The review of the origin, the diagnosis and treatment of pregnancy-related pelvic
pain led to the conclusion that laxity of the S!Js may play a central role in the
understanding of this syndrome. The department of Biomedical Physics and
Technology and the department of Rehabilitation have studied the biomechanical
properties of the pelvic joints, in particular the SUs for many years. Because no
instrumented method was available, Snijders proposed a new vihration method for
the in vivo assessment of SIJ laxity. This resulted in the method of Doppler
imaginj\ of vibrations (DIV), which runs as a continuous thread throughout this
thesis. 3·14
Chapter 2 describes the intra- and inter-tester reliability indexes of D!V in SIJ
laxity measurements performed by several testers, including one experienced tester
as well as inexperienced testers. The contribution of various sources of
measurement enor associated with the measurement design is also addressed.
Chapter 3 presents the pregnancy part of a longitudinal study on 163 subjects with
and without PRPP. This study was designed to investigate the association between
PRPP and S!J laxity at 36 weeks of pregnancy. Chapter 4 describes the postpartum part of the study presented in chapter 3. The
aims of this study were to describe the association between PRPP and SIJ laxity 8
weeks after childbirth and to determine to what extent asymmetric laxity of the
SUs during pregnancy has predictive power with regard to postpartum PRPP.
Chapter 5 presents a study designed to establish the influence of a pelvic belt on
S!J laxity. The belt was tested at two positions (low: at the level of the pubic
symphysis, and high: just below the anterior superior iliac spines) and at two
tensions (50 and 100 N) in ten healthy subjects.
Finally, the study in chapter 6 investigates the influence of a pelvic belt at low and
high position on SIJ laxity and its effect on the active straight leg raise (ASLR) test
in 25 women with PRPP.
Background:
Previous studies concerning symptom-giving pelvic girdle relaxation in pregnancy have to our knowledge been retrospective. We wanted to 1) determine the incidence during pregnancy and the prevalence two, six, and twelve months post partum, 2) identify possible predisposing factors, and 3) determine the frequency and duration of sicklisting, prospectively.
Material and methods:
A cohort of 1600 consecutive pregnant women filled in a questionnaire. At the routine prenatal examinations they were asked about pelvic pain. Those who fulfilled the inclusion criteria were examined by a rheumatologist to confirm the diagnosis. The affected women were seen again two, six, and twelve months post partum. All participants were asked about sicklisting in pregnancy.
Results:
The incidence during pregnancy was 14%, the prevalence two, six, and twelve months post partum were 5%, 4%, and 2% respectively. Multivariate analysis indicates that the most important predisposing factor is pelvic pain in a previous pregnancy. Other factors were uncomfortable working conditions, lack of exercise, and previous low back pain and low abdominal pain. At least 37% of the women with symptom-giving pelvic girdle relaxation had been sicklisted in pregnancy due to pelvic pain, on average for twelve weeks.
Conclusion:
Symptom-giving pelvic girdle relaxation is a considerable problem both in pregnancy and post partum. The occupational risk can possibly be prevented. The syndrome has a great social impact because of the frequent sicklisting.
Background. Pelvic pain in pregnancy appears to be a problem that is increasing. This study was undertaken to describe and analyze the relationship between subjective symptoms, daily disability, and clinical findings in women with symptom-giving pelvic girdle relaxation in pregnancy. Materials and methods. Out of 1600 pregnant women 238 had pelvic pain. After a clinical examination 11 women were excluded due to low back pain. The rest, 227 women, was considered having symptom-giving pelvic girdle relaxation during pregnancy. Results. Symptom-giving pelvic girdle relaxation in pregnancy seriously interferes with many activities of daily living such as housekeeping, walking, working, and sexual life. The women's statements of pelvic pain are well correlated to the number of positive clinical tests. Conclusion. Symptom-giving pelvic girdle relaxation in pregnancy causes considerable disabilities concerning daily activities.
To develop criteria for the classification of fibromyalgia, we studied 558 consecutive patients: 293 patients with fibromyalgia and 265 control patients. Interviews and examinations were performed by trained, blinded assessors. Control patients for the group with primary fibromyalgia were matched for age and sex, and limited to patients with disorders that could be confused with primary fibromyalgia. Control patients for the group with secondary-concomitant fibromyalgia were matched for age, sex, and concomitant rheumatic disorders. Widespread pain (axial plus upper and lower segment plus left- and right-sided pain) was found in 97.6% of all patients with fibromyalgia and in 69.1% of all control patients. The combination of widespread pain and mild or greater tenderness in ⩾ 11 of 18 tender point sites yielded a sensitivity of 88.4% and a specificity of 81.1%. Primary fibromyalgia patients and secondary-concomitant fibromyalgia patients did not differ statistically in any major study variable, and the criteria performed equally well in patients with and those without concomitant rheumatic conditions. The newly proposed criteria for the classification of fibromyalgia are 1) widespread pain in combination with 2) tenderness at 11 or more of the 18 specific tender point sites. No exclusions are made for the presence of concomitant radiographic or laboratory abnormalities. At the diagnostic or classification level, the distinction between primary fibromyalgia and secondary-concomitant fibromyalgia (as defined in the text) is abandoned.
To determine the prevalence of back pain and its development over the first postpartum period, 817 women who had been followed through pregnancy were studied a minimum of 12 months after delivery. More than 67% of the women experienced back pain directly after delivery, whereas 37% said they had back pain at the follow-up examination. Most of the women who had recovered became pain-free within 6 months. Factors that correlated to persistent postpartum back pain were the presence of back pain before pregnancy, the presence of back pain during pregnancy, physically heavy work, and multipregnancy. Of these four factors, physically heavy work was found to have the strongest association with persistent back pain at 12 months.
The prevalence of back pain was studied in 855 pregnant women who were followed from the 12th week of pregnancy, every 2nd week, until childbirth. The 9-month period prevalence was 49%, with a point prevalence of 22-28% from the 12th week until delivery. Because 22% of the women had back pain at the 12th week of the pregnancy, the 6-month incidence was 27%. Based on pain drawings, back pain was classified into three groups: In one group, pain was localized to the sacroiliac areas and increased as pregnancy progressed; in the other two groups, pain either decreased or did not change, respectively. True sciatica with a dermatomal distribution occurred in only 10 women (1%). Back problems before pregnancy increased the risk of back pain, as did young age, multiparity, and several physical and psychological work factors.
All pregnant women from a well defined area (the central district of the County of Ostergötland, Sweden) attending antenatal clinics over a period of seven months were interviewed with regard to low back pain during pregnancy. Of 862 women who answered the questionnaires, about half developed some degree of low back pain. Seventy-nine women who were unable to continue their work because of severe low back pain were referred to an orthopedic surgeon for an orthoneurologic examination. The most common reason for severe low back pain was dysfunction of the sacroiliac joints. Physically strenuous work and previous low back pain were factors associated with an increased risk of developing low back pain and sacroiliac dysfunction during pregnancy.
The purpose of this study was to answer the following questions: Do clinical signs in pregnant women with pelvic pain differ from signs in those without pelvic pain? Is there variation between the test signs found by four observers? Are the clinical signs correlated to pain and physical disability? Twenty pregnant women with pelvic pain and 20 pregnant women without pelvic pain were participating. Each woman reported her own pain sensation and physical disability and each woman was examined by 4 physiotherapists independently. Sixty-one clinical tests were applied. Only 8 tests showed predominantly positive signs in the pain group. These tests showed agreement between different observers judged by a kappa coefficient > 0.40. The number of positive clinical signs was well correlated to the reported pain and physical disability. The value of an extensive examination of posture, muscles and joints on pregnant women with pelvic pain is dubious.
An analysis was made of the self-reported medical histories of patients with peripartum pelvic pain.
To compile an inventory of the disabilities of patients with peripartum pelvic pain, analyze factors associated with the risk for development of the disease, and to formulate a hypothesis on pathogenesis and specific preventive and therapeutic measures.
Pregnancy is an important risk factor for development of chronic low back pain. Understanding the pathogenesis of pelvic and low back pain during pregnancy and delivery could be useful in understanding and managing nonspecific low back pain.
By means of a questionnaire, background data were collected among patients of the Dutch Association for Patients With Pelvic Complaints in Relation to Symphysiolysis. Results were compared with the general population. Subgroups were compared with each other.
Peripartum pelvic pain seriously interferes with many activities of daily living such us standing, walking, sitting, and all other activities in which the pelvis is involved. Most patients experience a relapse around menstruation and during a subsequent pregnancy. Occurrence of peripartum pelvic pain was associated with twin pregnancy, first pregnancy, higher age at first pregnancy, larger weight of the baby, forceps or vacuum extraction, fundus expression, and a flexed position of the woman during childbirth; a negative association was observed with cesarean section.
It is hypothesized that peripartum pelvic pain is caused by strain of ligaments in the pelvis and lower spine resulting from a combination of damage to ligaments (recently or in the past), hormonal effects, muscle weakness, and the weight of the fetus.
A prospective, consecutive cohort analysis of the regression of the incidence and intensity of back and posterior pelvic pain after delivery in pregnant women was done.
To identify back and posterior pelvic pain from mid-pregnancy to 5 months after delivery and to illustrate differences between these two pain types.
Chronic back pain may start during a pregnancy, and regression of unspecified back pain after delivery may be slow and incomplete. Few studies have distinguished back pain from posterior pelvic pain in pregnancy, and no study has presented follow-up data after delivery with respect to pain types.
One hundred and sixty four of 368 pregnant women studied had back or posterior pelvic pain and were offered individual group physiotherapy and training. The women were observed until 5 months after delivery. Standardized clinical examination protocols and questionnaires were used.
Posterior pelvic pain was experienced by 124 women, and back pain was experienced by 40 women during pregnancy. After delivery, however, back pain was more common. Pain intensity was higher among women with posterior pelvic pain during pregnancy, whereas after delivery pain intensity was higher among women with back pain. A correlation was found between the presence of high pain intensity during pregnancy and little regression of pain after delivery.
One of every three pregnant women studied experienced posterior pelvic pain, and one of every nine women experienced back pain. Posterior pelvic pain was more intense during pregnancy, and back pain was more intense and more common after delivery. High pain intensity in pregnancy indicated a bad prognosis.
In this prospective, consecutive, controlled cohort study, the authors analyzed the impact of a differentiated, individual-based treatment program on sick leave during pregnancy for women experiencing lumbar back or posterior pelvic pain during pregnancy.
To identify patients with pain early in pregnancy and, by means of individual information and differentiated physiotherapy, reduce sick leave during pregnancy.
Sick leave for back pain during pregnancy is common, and treatment programs have been aimed at reducing pain, for that reason. In Sweden, the average sick leave due to back pain during pregnancy is 7 weeks.
All pregnant women who attended a specific antenatal clinic and experienced lumbar back or posterior pelvic pain were included in an intervention group, and results were compared with women in a control group from another antenatal clinic.
The intervention group comprised 54 women, compared with 81 women in the control group. Thirty-three women were on sick leave for an average of 30 days in the intervention group versus 45 women for an average of 54 days in the control group (P < 0.001). The reduction in sick leave reduced insurance costs by approximately $53,000 U.S.
Sick leave for lumbar back and posterior pelvic pain in the intervention group was significantly reduced with the program, and the program was cost effective.
A prospective randomized controlled 6-year follow-up study of women with back pain during pregnancy.
To describe the long-term development of back pain in relation to pregnancy and to identify the effects of a physiotherapy and patient education program attended during pregnancy.
Pain incidence and intensity during pregnancy can be reduced by physiotherapy. No study has described the development of pain experienced for a period of years after delivery or the long-term effect of physiotherapy.
Pregnant women, registered consecutively, were randomly assigned to one control group and to two intervention groups and were observed throughout pregnancy, with follow-up after 3 months and 6 years.
The first phase of the study was completed by 362 women. After 3 months, 351 and after 6 years, 303 women had been observed. Back pain among 18% of all women before pregnancy and among 71% during pregnancy declined to 16% after 6 years. Pain intensity was highest in Week 36 (visual analog score, 5.4) and declined markedly 6 years later (visual analog score, 2.5). Slow regression of pain after partus correlated with having a back pain history before pregnancy, (r = 0.30; P < 0.05), with high pain intensity during pregnancy (r = 0.45; P < 0.01), and with much residual pain 3 months after pregnancy (r = 0.41; P < 0.01). These correlations were not found in the intervention groups. Furthermore, frequency of back pain attacks at 6 years correlated with frequency of attacks during pregnancy (r = 0.41; P < 0.01) and with a vocational factor (r = -0.25; P < 0.01). Physiotherapy and patient education had no effects on back pain development among women without pain during pregnancy.
Back pain during pregnancy regressed spontaneously soon after delivery and improved in few women later than 6 months post partum. Expected correlations between back pain in relation to pregnancy and back pain 6 years later were not present in the intervention groups who had attended a physiotherapy and education program during pregnancy. The program had no prophylactic effects on women without back or pelvic pain during pregnancy.
Pelvic pain in pregnancy appears to be a problem that is increasing. This study was undertaken to describe and analyze the relationship between subjective symptoms, daily disability, and clinical findings in women with symptom-giving pelvic girdle relaxation in pregnancy
Out of 1600 pregnant women 238 had pelvic pain. After a clinical examination 11 women were excluded due to low back pain. The rest, 227 women, was considered having symptom-giving pelvic girdle relaxation during pregnancy.
Symptom-giving pelvic girdle relaxation in pregnancy seriously interferes with many activities of daily living such as housekeeping, walking, working, and sexual life. The women's statements of pelvic pain are well correlated to the number of positive clinical tests.
Symptom-giving pelvic girdle relaxation in pregnancy causes considerable disabilities concerning daily activities.
Previous studies concerning symptom-giving pelvic girdle relaxation in pregnancy have to our knowledge been retrospective. We wanted to 1) determine the incidence during pregnancy and the prevalence two, six, and twelve months post partum, 2) identify possible predisposing factors, and 3) determine the frequency and duration of sicklisting, prospectively.
A cohort of 1600 consecutive pregnant women filled in a questionnaire. At the routine prenatal examinations they were asked about pelvic pain. Those who fulfilled the inclusion criteria were examined by a rheumatologist to confirm the diagnosis. The affected women were seen again two, six, and twelve months post partum. All participants were asked about sicklisting in pregnancy.
The incidence during pregnancy was 14%, the prevalence two, six, and twelve months post partum were 5%, 4%, and 2% respectively. Multivariate analysis indicates that the most important predisposing factor is pelvic pain in a previous pregnancy. Other factors were uncomfortable working conditions, lack of exercise, and previous low back pain and low abdominal pain. At least 37% of the women with symptom-giving pelvic girdle relaxation had been sicklisted in pregnancy due to pelvic pain, on average for twelve weeks.
Symptom-giving pelvic girdle relaxation is a considerable problem both in pregnancy and post partum. The occupational risk can possibly be prevented. The syndrome has a great social impact because of the frequent sicklisting.
Pelvic pain in pregnancy has been suggested to be more common in Scandinavia than in the rest of the world, to be culturally specific for the region and to reflect a change in attitude among pregnant women. Little is known of the prevalence of pelvic pain in pregnancy in low-income countries.
To explore whether perceived pelvic pain among pregnant women differs between affluent and poor societies.
Four observational studies, comprising a total of 752 women, were carried out in circumstances ranging from wealth to poverty, focusing on the reported prevalence, location and degree of pelvic pain in pregnancy. In Uppsala, Sweden, and in Rufiji, Tanzania, the women were interviewed in late pregnancy. In Jakobstad, Finland, and in Zanzibar Town, Zanzibar, the women were approached after delivery before discharge.
The reported prevalence of pelvic pain in pregnancy was 49% in Uppsala and 66% in Rufiji, 77% in Jakobstad and 81% in Zanzibar, with an overall similarity of location and degree of pain.
No geographical differences were found in perceived pelvic pain among pregnant women, irrespective of the socio-economy of the countries.
To evaluate the results of a multidisciplinary and behavioral program for chronic back pain.
Prospective cohort study.
In 1996, a total of 143 patients with chronic back pain participated in a 4-week multidisciplinary and behavioral treatment program in an outpatient centre for work reintegration (Rug AdviesCentrum) in Zeist, Eindhoven and Noordwijk, the Netherlands. At the start and six months after termination, data were collected on trunk muscle performance, pain intensity, disability and stress related physical complaints, and after 6 months about return to work, analgesics use, and health care utilization. Score differences between the first and the second measurements were tested on statistical significance using paired t-tests and on clinical relevance using the reliable change-index.
The study group comprised 99 males and 44 females with a mean age of 41.6 years (range: 23-58). After 6 months the outcome variables were significantly improved statistically: depending on the outcome variable used, the improvement was clinically relevant in 44-91% of patients. The obtained percentage of full return to work at 6-months follow-up was 87%, while 80% had used no pain killers and 91% had made no use of health care facilities.
The program resulted in important improvements in patients with chronic back pain.
The aim of the present study was to describe, on the basis of specific classification criteria and for a period of two years after delivery, the prognosis for women suffering from pregnancy-related pelvic joint pain, and to describe the characteristics influencing the prognosis.
One thousand seven hundred and eighty-nine pregnant women who were booked for delivery at Odense University Hospital formed a cohort to investigate the prognosis. Women whose reported daily pain from pelvic joints could be objectively confirmed were divided, according to symptoms, into five subgroups (n=405) - four classification groups (pelvic girdle syndrome, symphysiolysis, one-sided sacroiliac syndrome and double-sided sacroiliac syndrome) and one miscellaneous. The women in the five subgroups were re-examined at regular intervals for two years after delivery or until disappearance of symptoms (whichever was less). Thre hundred and forty-one women from the 5 subgroups participated in the postpartum follow-up.
The majority (62.5%) of women in the four classification groups experienced disappearance of pain within a month after delivery. Two years after parturition 8.6% were still suffering from pelvic joint pain (determined subjectively and objectively). Persistence of pain was found to vary significantly from one classification group to another. None of those initially classified as suffering from symphysiolysis had pain 6 months after delivery in comparison to the 21 percent of those with pelvic girdle syndrome who continued to have pain at the two-year mark.
This study shows that pregnancy-related pelvic joint pain had an excellent postpartum prognosis (in general) in three out of four classification groups. The women with pelvic girdle syndrome (pain in all 3 pelvic joints) had a markedly worse prognosis than the women in the other three classification groups. High number of positive test and a low mobility index were identified as giving the highest relative risk for long term pain.
A cross-sectional analysis was performed in a group of women meeting strict criteria for posterior pelvic pain since pregnancy (PPPP). The scores on the Active Straight Leg Raise Test (ASLR test) were compared with the scores of healthy controls.
To develop a new diagnostic instrument for use in patients with PPPP. The objectives of the present study were to assess the validity and reliability of the ASLR test.
Various diagnostic tools are used to diagnose PPPP, but there is still a need for simple tests with high reliability, sensitivity, and specificity.
Reliability of the ASLR test was assessed in a group of 50 women with lumbopelvic pain of various etiologies and various degrees of severity. Sensitivity was assessed in 200 patients with PPPP and specificity in 50 healthy women. Sensitivity and specificity of the ASLR test were compared with the posterior pelvic pain provocation test (PPPP test).
The test-retest reliability measured with Pearson's correlation coefficient between the two ASLR scores 1 week apart was 0.87. The intraclass correlation coefficient (ICC) was 0.83. Pearson's correlation coefficient between the scores of the patient and the scores of a blinded assessor was 0.78; the ICC was 0.77. In the patient group, the ASLR score ranged from 0-10; in the control group it ranged from 0-2. The best balance between specificity and sensitivity was found when scores 1-10 are designated as positive and zero as negative. With this cut-off point sensitivity of the test was 0.87 and specificity was 0.94. The sensitivity of the ASLR test is higher than the sensitivity of the PPPP test; an advantage of the ASLR test is the simplicity of measuring the score.
The ASLR test is a suitable diagnostic instrument to discriminate between patients who are disabled by PPPP and healthy subjects. The test is easy to perform; reliability, sensitivity, and specificity are high. It seems that the integrity of the function to transfer loads between the lumbosacral spine and legs is tested by the ASLR test.
A cross-sectional analysis was performed with a group of women meeting strict criteria for posterior pelvic pain after pregnancy. The active straight leg raise test and common severity measurement scales of lumbopelvic pain were scored.
To assess the validity of the active straight leg raise test as a disease severity scale for patients with posterior pelvic pain after pregnancy.
Various diagnostic tools are used to measure disease severity in patients with posterior pelvic pain after pregnancy, but simple tests with high reliability and validity still are needed.
The investigation was performed with 200 women who had posterior pelvic pain after pregnancy. The validity of the active straight leg raise test as a severity scale was investigated by comparing the test score with the medical history, scores on self-reported disability scales, pain and tiredness, and pain provocation tests. The usefulness of the active straight leg raise test as a severity scale was compared with that of the Québec Back Pain Disability Scale. The influence of several demographic and anthropometric variables on the active straight leg raise score was investigated.
The active straight leg raise score ranged from 0 to 10 and correlated as expected with all severity scales. The correlation between the scores on the active straight leg raise test and the Québec Back Pain Disability Scale was 0.70. No association was found between the active straight leg raise score and age, parity, duration of the postpartum period, height, or weight.
The active straight leg raise test can be recommended as a disease severity scale for patients with posterior pelvic pain after pregnancy.
A cohort study was conducted.
To develop a test battery for evaluating the course of posterior pelvic pain since pregnancy.
Properly validated scales to evaluate the course of posterior pelvic pain since pregnancy are scarce. Moreover, the use of many tests would be too strenuous for the patient and has an unfavorable cost-benefit ratio.
The ability of 48 effect measures to detect clinically relevant changes over time (responsiveness) was tested in patients with posterior pelvic pain since pregnancy. In this test, 35 measures were evaluated in a group of 44 patients, and 16 measures in a group of 56 patients (three measures were evaluated in both groups). All the tests were performed at baseline and after 8 weeks treatment. A global impression of improvement (improved or not improved) scored by the patient was used as the standard for assessing the course of the disease. Responsiveness was examined by calculating the standardized response mean of the improved patients and by using a two-tailed Mann-Whitney nonparametric test to compare the patients who had improved and those who had not improved.
Of the 48 effect measures, 26 measures of five categories (activities of daily living, pain, hip muscle strength, spine mobility, and spine muscle strength) showed good correlation with the patient's global impression of improvement. The measures in the "mobility of the pelvic joints" category were insufficient for assessing clinical change in posterior pelvic pain since pregnancy. The measures in the "fatigue" and "pain provocation tests" categories correlated only moderately with clinical change.
It seems possible to gain appropriate information about the course of posterior pelvic pain since pregnancy with a small test battery. The usefulness of the Québec Back Pain Disability Scale, the hip adduction strength assessment, and the active straight-leg-raise test was proved by the current study. The value of 23 other instruments was substantiated, but further studies are needed to confirm their usefulness. The correlation of 22 evaluated measures with the patient's global improvement was too weak for them to be recommended as measures of clinical changes over time in posterior pelvic pain since pregnancy. It is recommended that clinicians and investigators compile a small test battery by selecting the best representatives of the five measurement categories that have good correlation with the patient's global impression of improvement.
A cross-sectional analysis was performed in patients with posterior pelvic pain since pregnancy (PPPP). The strength of adduction of the hips was measured and compared with the scores of commonly used disease severity measures of lumbopelvic pain.
To assess the reliability and validity of using hip adduction strength as measure of disease severity in patients with PPPP.
Various tools are used to measure disease severity in PPPP; there is still a need for simple tests with high reliability and validity.
Intra- and intertester reliability of hip adduction strength measurement was assessed in two small groups of women with PPPP. Validity of hip adduction strength to measure disease severity was investigated in a group of 200 patients with PPPP by comparing the test scores with the medical history, scores on self-reported scales on disability, pain, and tiredness, pain provocation tests, and the active straight leg raise test. Responsiveness of hip adduction strength was assessed in a group of 75 patients with PPPP. Global impression of improvement, scored by the patient, was used as criterion standard. The responsiveness of the hip adduction strength was expressed as the standardized response mean and was compared with the responsiveness of the Quebec Back Pain Disability Scale.
The intratester reliability for measuring hip adduction strength and the intraclass correlation coefficient were both 0.79. The intertester reliability for measurement of adduction strength and the intraclass correlation coefficient were also both 0.79. Hip adduction strength correlated as expected with all disease severity measures. Responsiveness of the hip adduction strength was large (standardized response mean = 0.93) and slightly less than that of the Quebec Back Pain Disability Scale (standardized response mean = 1.20).
Hip adduction strength can be recommended to measure disease severity in PPPP, especially to describe groups of patients and to evaluate the course of the disease in groups as well as in individual patients. Decreased hip adduction strength appears to be caused by the inability to use the hip muscles rather than by weakness of the muscles.
To compare the diagnostic accuracy of a multitest regimen of 5 sacroiliac joint (SIJ) pain provocation tests with fluoroscopically controlled double SIJ blocks using a short- and long-acting local anesthetic in order to reduce the exposure of patients to unnecessary invasive SIJ procedures.
Prospective, observational study.
Hospital setting.
Sixty patients with chronic low back pain.
Not applicable.
Visual analog scale score and receiver operating characteristic (ROC) curve.
Twenty-seven patients responded positively to the blocks, of whom 23 were found positive after the multitest regimen and 4 were negative. For the nonresponders (n=33), these figures were 7 positive and 26 negative. The calculated sensitivity and specificity were .85 (95% confidence interval [CI], .72-.99) and .79 (95% CI, .65-.93), respectively. Positive and negative predictive values were .77 (95% CI, .62-.92) and .87 (95% CI, .74-.99), respectively. The positive likelihood ratio was 4.02 (95% CI, 2.04-7.89); the negative likelihood ratio was .19 (95% CI, .07-.47). The area under the ROC curve was .799.
The test regimen with 3 or more positive tests is indicative of SIJ pain. It can be used in early clinical decision making to reduce the number of unnecessary minimally invasive diagnostic SIJ procedures.
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