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Pregnancyrelated LowBackandPelvicGirdlePain: howcanwehelp?
HeatherPierceMidwife/Physiotherapist:WestmeadHospital
August2009
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Aimsoftodaystalk
Overviewofanatomy&functionofthepelvic girdle
Definitionofpregnancyrelatedpelvicgirdle pain
Aetiology/Riskfactors/Treatment
Whatcanwedotohelp?
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Factorsinfluencing pregnancy&birthoutcomes
Pierce, 2008
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ThePelvicGirdle
Attachesthevertebralcolumntothelowerlimbs
withthestrongestligamentsofthebody
Transmitsweight/forcesbetweentheupperbody andthelowerlimbs
Pivotalpoint:strengthandstabilityisessential
foroptimalfunction
Supportsandprotectsthebladder,uterus, bowel/rectum
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ThePelvicGirdle
Marieb
& Hoehn
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Ilium:MedialView
Figure 7.27c
Marieb
& Hoehn
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Ligamentsofthepelvis
Mayes
Midwifery p.276, fig. 16.3
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Ligamentsofthepelvis
Basmajian
fig 104
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Deepmusclesofhip
Figure 10.20bc
Marieb
& Hoehn
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Musclesof anteriorthigh
Figure 10.19a
Marieb
& Hoehn
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MusclesoftheAbdominalWall
Figure 10.11aMarieb
& Hoehn
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MusclesoftheAbdominalWall
Figure 10.11b
Marieb
& Hoehn
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Superiorviewofpelvicfloor
Figure 10.12a
Marieb
& Hoehn
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Thesacralplexus
Marieb&Hoehn,fig13:11,p.516
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PelvicStabilisingsystem:
Spinalstabilisingsystem(Panjabi1992):
Passivemusculoskeletalsystem
Activemusculoskeletalsystem
Neural&feedbacksystem
Formclosure:osteoarticular/ligamentous
Forceclosure:myofacial
(Lee&Vleeming,2000)
Corestability:thepelvicfloorandthedeep abdominalmuscles
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Lumbo pelvic stability: Posterior oblique system
Lee,1996
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Thepelvicgirdleinpregnancy, childbirth&postpartum
Landmarksenableassessmentofgrowth,
position&descentoffetusduringpregnancy
&birth
Bonycanalthroughwhichthefetusmuch
passforvaginalbirth
Pelvicgirdlepain:pregnancyrelated
Intrapartum
trauma:instrumentaldelivery, coccydinia,symphysis
pubisdysfunction,
diastasis
symphysis
pubis
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Movementofpelvicjointsduring childbirth
Palastanga,Field&Soames
fig.4.56,p.397
20mminferior& 7mmanterior
movementofthe ilium
onthe
sacrum;Forcepsmaycause
agrade5posterior movementofthe
sacrum,Possibleruptureof
pubicligamentsBleedinginto
sacroiliacjoint sacroiliitis
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Fascia,pregnancyandbirth
Lineaalba:complexCTthatconnectsleft&
rightabdominalmuscles
Averageinterrecti
distance=0.9
1cm, diastasis
occurswhendistanceis>12cm
Traumatothelinea
alba&/orendopelvic fascia
Nonoptimalstrategiesforposture&
movement&/orbreathingcreatefailedload
transferthatcanleadtopain,incontinence&
breathingdisorders
(Leeetal,2008)
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PregnancyrelatedLowBack &/orPelvicGirdlePain
Historicalperspective:literaturedifficultto
evaluate&drawconclusionsduetovariationin
terminologies&classificationmethods:
Pelvicinstability
Posteriorpelvicpain
Pelvicjoint/girdlesyndrome
Symptomaticpelvicgirdlerelaxation
Symphysiolysis
Symphysis
pubisdysfunction/diastasis
OftennotdifferentiatedfromLBP
Reportedprevalenceratesoftheconditionvary
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PregnancyrelatedLowback andPelvicGirdlePain
Painofmusculoskeletaloriginthatis
experiencedinthelumbarand/orsacro
iliacareaduringpregnancyorinthe
immediatepostpartumperiod.Painmay
occurinconjunctionwithorseparatelyin thesymphysis
pubis
(Vleeming,Albert,Ostgaard,Sturesson,&Stuge,2008)
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Symphysis
pubisdysfunction
?Increasedmobilityofthepubicjoint
Normalgapinpregnancyupto9mm,canbe>
10mm,norelationshipbetweendegreeof
separation&clinicalsymptoms
Symptomsrangefrommildintermittentgroin/
pubicpaintoseveredisablingpain
Oftenaudibleclickorcrunchofthejoint
Onsetcanbeinsidiousortraumatic
?Surgicalfixationifdiastasis
>4cm
Diastasis
ofsymphysis
pubis:different
condition?
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Lowbackandpelvicgirdlepain
~50%womenexperience backand/orpelvicgirdle
pain(PGP)during pregnancy(?Severity)
Importanttodifferentiate LBPandPGP
Incidence(point prevalence)ofPGPis~
20
42%
?Functionalimpairment
withcombinedLBP/PGP
% pregnant women with back &/or pelvic pain
long term pain
activities effected
after birth
pregnancy
0
10
20
30
40
50
60
%
(Bastiaanssen, de Bie, Bastiaenen, Essed, & van den Brandt,
2005; Vleeming
et al., 2008; Wu et al., 2004)
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Morbidityofpregnancyrelated LBP&/orPGP
Reducedabilitytomaintainanactivelifestyle
duringpregnancy(Olsson&NilssonWikmar,2004)
Severecasesrequiremobilityaidseg
walking stick/crutches/wheelchair
Venousthrombosisispossiblecomplications
ofbedrestorreducedmobility(Babarinsa,
Adewole,Fatade,&Ajayi,1999)
Riskofchronicpaincondition(Robinson,Eskild,
Heiberg,&EberhardGran,2006)
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Morbidityofpregnancyrelated LBP&/orPGP
Risktopsychologicalhealth,depression(Brown&Lumley,2000;Gutke,Josefsson,&Oberg,
2007;Mogren,2006).
Increasedsickleave(Olsson&NilssonWikmar,2004)
?Associatedwithurinaryincontinence
(Lee,Lee,&McLaughlin,2008;PoolGoudzwaard
etal.,2005;
Smithetal.,2008).
?Increaseduseofanalgesicsduring
pregnancy
?Influenceonmobilityinlabourandmodeof
birth
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Aetiology
Hormonalfactors?Canhaveincreasemobilityof
pelvicjointsbutnotcorrelatedpain
Relaxin/alterationinrelaxin
receptors:evidence inconclusive
Oralcontraceptivesmayinfluencecollagen metabolism
Asymmetricalmovementorpositioningofpelvic
joints/alteredpelvicgirdlebiomechanics
secondarytoalteredneuromuscularcontrol
Diet/diabetes/other?
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Risksfordevelopingback/pelvicpain duringpregnancy
Previoushistoryofbackpain
Previoustraumatothepelvis
Conflictingevidence:
physicallydemandingwork
multiparity
hypermobilejoints(connectivetissueinsufficiency)
Obesity/BMI(EuropeanGuidelinesondiagnosisandtreatmentofpelvicgirdle
pain,2008)
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Management
Thereisevidenceofareducedunderstanding
ofthesignificanceofpregnancyrelatedLBP
andPGPamongstcaregivers(Fredriksen,Moland,&Sundby,2008;Owens,Pearson,&
Mason,2002;Wellock
&Crichton,2007)
Theconditionisoftendescribedasaminor disorder
orcommondiscomfort
thatmust
beendureduntilafterthebabyisborn
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Whatcanwedotohelp?
Acknowledge
Antenatal/postnatalreferral
Advice
forback/pelvicgirdlepain:
Avoidactivitiesthatcauseunevenweightonlegs
ortwistingthebodyeg:standingononeleg,
sittingcrosslegged,vacuuming/sweeping,stairs
Avoidbending,lifting&carryingheavythings
Reducestridelength
Usestabilitystrategiesforposturalchange
Anticipate:Mobilityandpositioninginlabour
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TreatmentofLBP&/orPGP CochraneReview(Pennick
andYoung,2007)
Individualisedprogrammefocusingon
specificstabilising/strengthening
exercisesandpelvictilts
Pelvicbeltforsymptomaticrelief
Watergymnastics:2xRCTs
Specialpillows:lowlevelevidence
Information(education):noevidence
Acupuncture/stretches/physiotherapy
appeartorelievepainmorethan usual
carealone(ie
analgesics,
physicalmodalities,belt)
Allstudieshavemoderatetohighbias
EuropeanGuidelines(2008)
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References
Babarinsa,I.A.,Adewole,I.F.,Fatade,A.O.,&Ajayi,A.B.(1999).
Obstetricpubicsymphysis
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Bastiaanssen,J.M.,deBie,R.A.,Bastiaenen,C.H.G.,Essed,G.G.M.,&
vandenBrandt,P.A.(2005).Ahistoricalperspectiveonpregnancy
relatedlowbackand/orpelvicgirdlepain.EuropeanJournalofObstetrics
andGynecologyandReproductiveBiology,120(1),314.
Bastiaenen,C.H.G.,deBie,R.A.,Wolters,P.M.J.C.,Vlaeyen,J.W.S.,
Leffers,P.,Stelma,F.,etal.(2006).Effectivenessofatailormade
interventionforpregnancyrelatedpelvicgirdleand/orlowbackpainafter
delivery:shorttermresultsofarandomizedclinicaltrial
[ISRCTN08477490].BMCMusculoskeletalDisorders,7,19.
Brown,S.,&Lumley,J.(2000).Physicalhealthproblemsafterchildbirth
andmaternaldepressionatsixtosevenmonthspostpartum.British
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EberhardGran,M.,&Eskild,A.(2008).Diabetesmellitusandpelvicgirdle
syndromeinpregnancyisthereanassociation?Acta
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Pregnancy-related Low Back and Pelvic Girdle Pain: how can we
help?Aims of todays talkFactors influencing pregnancy & birth
outcomesThe Pelvic GirdleSlide Number 5The Pelvic GirdleSlide
Number 7Ilium: Medial ViewSlide Number 9Ligaments of the
pelvisLigaments of the pelvisDeep muscles of hipMuscles of anterior
thighMuscles of the Abdominal WallMuscles of the Abdominal
WallSuperior view of pelvic floorThe sacral plexusPelvic
Stabilising system:Lumbo- pelvic stability: Posterior oblique
systemThe pelvic girdle in pregnancy, childbirth & postpartum
Movement of pelvic joints during childbirthFascia, pregnancy and
birthPregnancy-related Low Back &/or Pelvic Girdle
PainPregnancy-related Low back and Pelvic Girdle PainSymphysis
pubis dysfunctionLow back and pelvic girdle painMorbidity of
pregnancy-related LBP &/or PGPMorbidity of pregnancy-related
LBP &/or PGPAetiologyRisks for developing back/pelvic pain
during pregnancyManagementWhat can we do to help?Treatment of LBP
&/or PGP Cochrane Review (Pennick and Young, 2007)Slide Number
34ReferencesSlide Number 36Slide Number 37Slide Number 38Slide
Number 39
