Pregnancy-related Pelvic Girdle Pain How Can We Help 0809

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<ul><li><p>Pregnancyrelated LowBackandPelvicGirdlePain: howcanwehelp?</p><p>HeatherPierceMidwife/Physiotherapist:WestmeadHospital</p><p>August2009</p></li><li><p>Aimsoftodaystalk</p><p>Overviewofanatomy&amp;functionofthepelvic girdle</p><p>Definitionofpregnancyrelatedpelvicgirdle pain</p><p>Aetiology/Riskfactors/Treatment</p><p>Whatcanwedotohelp?</p></li><li><p>Factorsinfluencing pregnancy&amp;birthoutcomes</p><p>Pierce, 2008</p></li><li><p>ThePelvicGirdle</p><p>Attachesthevertebralcolumntothelowerlimbs withthestrongestligamentsofthebody</p><p>Transmitsweight/forcesbetweentheupperbody andthelowerlimbs</p><p>Pivotalpoint:strengthandstabilityisessential foroptimalfunction</p><p>Supportsandprotectsthebladder,uterus, bowel/rectum</p></li><li><p>ThePelvicGirdle</p><p>Marieb</p><p>&amp; Hoehn</p></li><li><p>Ilium:MedialView</p><p>Figure 7.27c</p><p>Marieb</p><p>&amp; Hoehn</p></li><li><p>Ligamentsofthepelvis</p><p>Mayes</p><p> Midwifery p.276, fig. 16.3</p></li><li><p>Ligamentsofthepelvis</p><p>Basmajian</p><p>fig 104</p></li><li><p>Deepmusclesofhip</p><p>Figure 10.20bc</p><p>Marieb</p><p>&amp; Hoehn</p></li><li><p>Musclesof anteriorthigh</p><p>Figure 10.19a</p><p>Marieb</p><p>&amp; Hoehn</p></li><li><p>MusclesoftheAbdominalWall</p><p>Figure 10.11aMarieb</p><p>&amp; Hoehn</p></li><li><p>MusclesoftheAbdominalWall</p><p>Figure 10.11b</p><p>Marieb</p><p>&amp; Hoehn</p></li><li><p>Superiorviewofpelvicfloor</p><p>Figure 10.12a</p><p>Marieb</p><p>&amp; Hoehn</p></li><li><p>Thesacralplexus</p><p>Marieb&amp;Hoehn,fig13:11,p.516</p></li><li><p>PelvicStabilisingsystem:</p><p>Spinalstabilisingsystem(Panjabi1992):</p><p> Passivemusculoskeletalsystem</p><p>Activemusculoskeletalsystem</p><p>Neural&amp;feedbacksystem</p><p>Formclosure:osteoarticular/ligamentous</p><p>Forceclosure:myofacial </p><p>(Lee&amp;Vleeming,2000)</p><p>Corestability:thepelvicfloorandthedeep abdominalmuscles</p></li><li><p>Lumbo pelvic stability: Posterior oblique system</p><p>Lee,1996</p></li><li><p>Thepelvicgirdleinpregnancy, childbirth&amp;postpartum</p><p>Landmarksenableassessmentofgrowth, position&amp;descentoffetusduringpregnancy</p><p> &amp;birth</p><p> Bonycanalthroughwhichthefetusmuch</p><p> passforvaginalbirth</p><p> Pelvicgirdlepain:pregnancyrelated</p><p>Intrapartum </p><p>trauma:instrumentaldelivery, coccydinia,symphysis</p><p> pubisdysfunction,</p><p> diastasis </p><p>symphysis </p><p>pubis</p></li><li><p>Movementofpelvicjointsduring childbirth</p><p>Palastanga,Field&amp;Soames</p><p> fig.4.56,p.397</p><p>20mminferior&amp; 7mmanterior</p><p> movementofthe ilium</p><p> onthe</p><p> sacrum;Forcepsmaycause</p><p> agrade5posterior movementofthe</p><p> sacrum,Possibleruptureof</p><p> pubicligamentsBleedinginto</p><p> sacroiliacjoint sacroiliitis</p></li><li><p>Fascia,pregnancyandbirth</p><p>Lineaalba:complexCTthatconnectsleft&amp; rightabdominalmuscles</p><p>Averageinterrecti </p><p>distance=0.9 </p><p>1cm, diastasis</p><p> occurswhendistanceis&gt;12cm</p><p>Traumatothelinea </p><p>alba&amp;/orendopelvic fascia</p><p>Nonoptimalstrategiesforposture&amp; movement&amp;/orbreathingcreatefailedload</p><p> transferthatcanleadtopain,incontinence&amp; breathingdisorders</p><p> (Leeetal,2008)</p></li><li><p>PregnancyrelatedLowBack &amp;/orPelvicGirdlePain</p><p>Historicalperspective:literaturedifficultto evaluate&amp;drawconclusionsduetovariationin</p><p> terminologies&amp;classificationmethods:</p><p> Pelvicinstability</p><p>Posteriorpelvicpain</p><p> Pelvicjoint/girdlesyndrome</p><p>Symptomaticpelvicgirdlerelaxation</p><p> Symphysiolysis</p><p>Symphysis </p><p>pubisdysfunction/diastasis</p><p> OftennotdifferentiatedfromLBP</p><p>Reportedprevalenceratesoftheconditionvary</p></li><li><p>PregnancyrelatedLowback andPelvicGirdlePain</p><p>Painofmusculoskeletaloriginthatis experiencedinthelumbarand/orsacro</p><p> iliacareaduringpregnancyorinthe immediatepostpartumperiod.Painmay</p><p> occurinconjunctionwithorseparatelyin thesymphysis</p><p> pubis</p><p>(Vleeming,Albert,Ostgaard,Sturesson,&amp;Stuge,2008)</p></li><li><p>Symphysis </p><p>pubisdysfunction</p><p>?Increasedmobilityofthepubicjoint</p><p> Normalgapinpregnancyupto9mm,canbe&gt;</p><p> 10mm,norelationshipbetweendegreeof separation&amp;clinicalsymptoms</p><p>Symptomsrangefrommildintermittentgroin/ pubicpaintoseveredisablingpain</p><p>Oftenaudibleclickorcrunchofthejoint</p><p> Onsetcanbeinsidiousortraumatic</p><p>?Surgicalfixationifdiastasis </p><p>&gt;4cm</p><p> Diastasis</p><p> ofsymphysis</p><p> pubis:different</p><p> condition?</p></li><li><p>Lowbackandpelvicgirdlepain</p><p>~50%womenexperience backand/orpelvicgirdle</p><p> pain(PGP)during pregnancy(?Severity)</p><p>Importanttodifferentiate LBPandPGP</p><p>Incidence(point prevalence)ofPGPis~</p><p> 20 </p><p>42%</p><p> ?Functionalimpairment</p><p>withcombinedLBP/PGP</p><p>% pregnant women with back &amp;/or pelvic pain</p><p>long term pain</p><p>activities effected</p><p>after birth</p><p>pregnancy</p><p>0</p><p>10</p><p>20</p><p>30</p><p>40</p><p>50</p><p>60</p><p>%</p><p>(Bastiaanssen, de Bie, Bastiaenen, Essed, &amp; van den Brandt, 2005; Vleeming</p><p>et al., 2008; Wu et al., 2004)</p></li><li><p>Morbidityofpregnancyrelated LBP&amp;/orPGP</p><p>Reducedabilitytomaintainanactivelifestyle duringpregnancy(Olsson&amp;NilssonWikmar,2004)</p><p>Severecasesrequiremobilityaidseg </p><p>walking stick/crutches/wheelchair</p><p>Venousthrombosisispossiblecomplications ofbedrestorreducedmobility(Babarinsa,</p><p> Adewole,Fatade,&amp;Ajayi,1999)</p><p> Riskofchronicpaincondition(Robinson,Eskild,</p><p> Heiberg,&amp;EberhardGran,2006)</p></li><li><p>Morbidityofpregnancyrelated LBP&amp;/orPGP</p><p>Risktopsychologicalhealth,depression(Brown&amp;Lumley,2000;Gutke,Josefsson,&amp;Oberg,</p><p> 2007;Mogren,2006).</p><p> Increasedsickleave(Olsson&amp;NilssonWikmar,2004)</p><p>?Associatedwithurinaryincontinence (Lee,Lee,&amp;McLaughlin,2008;PoolGoudzwaard</p><p> etal.,2005;</p><p> Smithetal.,2008).</p><p> ?Increaseduseofanalgesicsduring</p><p> pregnancy</p><p> ?Influenceonmobilityinlabourandmodeof</p><p> birth</p></li><li><p>Aetiology</p><p>Hormonalfactors?Canhaveincreasemobilityof pelvicjointsbutnotcorrelatedpain</p><p>Relaxin/alterationinrelaxin </p><p>receptors:evidence inconclusive</p><p>Oralcontraceptivesmayinfluencecollagen metabolism</p><p>Asymmetricalmovementorpositioningofpelvic joints/alteredpelvicgirdlebiomechanics</p><p> secondarytoalteredneuromuscularcontrol</p><p> Diet/diabetes/other?</p></li><li><p>Risksfordevelopingback/pelvicpain duringpregnancy</p><p>Previoushistoryofbackpain</p><p> Previoustraumatothepelvis</p><p>Conflictingevidence:</p><p> physicallydemandingwork</p><p>multiparity</p><p> hypermobilejoints(connectivetissueinsufficiency)</p><p>Obesity/BMI(EuropeanGuidelinesondiagnosisandtreatmentofpelvicgirdle</p><p> pain,2008)</p></li><li><p>Management</p><p>Thereisevidenceofareducedunderstanding ofthesignificanceofpregnancyrelatedLBP</p><p> andPGPamongstcaregivers(Fredriksen,Moland,&amp;Sundby,2008;Owens,Pearson,&amp;</p><p> Mason,2002;Wellock </p><p>&amp;Crichton,2007)</p><p>Theconditionisoftendescribedasaminor disorder</p><p> orcommondiscomfort</p><p> thatmust</p><p> beendureduntilafterthebabyisborn</p></li><li><p>Whatcanwedotohelp?</p><p>Acknowledge</p><p> Antenatal/postnatalreferral</p><p>Advice </p><p>forback/pelvicgirdlepain:</p><p> Avoidactivitiesthatcauseunevenweightonlegs</p><p> ortwistingthebodyeg:standingononeleg, sittingcrosslegged,vacuuming/sweeping,stairs</p><p>Avoidbending,lifting&amp;carryingheavythings</p><p> Reducestridelength</p><p>Usestabilitystrategiesforposturalchange</p><p>Anticipate:Mobilityandpositioninginlabour</p></li><li><p>TreatmentofLBP&amp;/orPGP CochraneReview(Pennick</p><p> andYoung,2007)</p><p>Individualisedprogrammefocusingon specificstabilising/strengthening</p><p> exercisesandpelvictilts</p><p> Pelvicbeltforsymptomaticrelief</p><p>Watergymnastics:2xRCTs</p><p> Specialpillows:lowlevelevidence</p><p>Information(education):noevidence</p><p> Acupuncture/stretches/physiotherapy</p><p> appeartorelievepainmorethan usual</p><p> carealone(ie</p><p> analgesics,</p><p> physicalmodalities,belt)</p><p> Allstudieshavemoderatetohighbias</p><p>EuropeanGuidelines(2008)</p></li><li><p>References</p><p> Babarinsa,I.A.,Adewole,I.F.,Fatade,A.O.,&amp;Ajayi,A.B.(1999).</p><p> Obstetricpubicsymphysis </p><p>arthropathy:astudyofninecases.Journalof ObstetricsandGynaecology.,19(6),620622.</p><p>Bastiaanssen,J.M.,deBie,R.A.,Bastiaenen,C.H.G.,Essed,G.G.M.,&amp; vandenBrandt,P.A.(2005).Ahistoricalperspectiveonpregnancy</p><p> relatedlowbackand/orpelvicgirdlepain.EuropeanJournalofObstetrics andGynecologyandReproductiveBiology,120(1),314.</p><p>Bastiaenen,C.H.G.,deBie,R.A.,Wolters,P.M.J.C.,Vlaeyen,J.W.S., Leffers,P.,Stelma,F.,etal.(2006).Effectivenessofatailormade</p><p> interventionforpregnancyrelatedpelvicgirdleand/orlowbackpainafter delivery:shorttermresultsofarandomizedclinicaltrial</p><p> [ISRCTN08477490].BMCMusculoskeletalDisorders,7,19.</p><p> Brown,S.,&amp;Lumley,J.(2000).Physicalhealthproblemsafterchildbirth</p><p> andmaternaldepressionatsixtosevenmonthspostpartum.British JournalofObstetricsandGynaecology</p><p> 107,11941201.</p></li><li><p>EberhardGran,M.,&amp;Eskild,A.(2008).Diabetesmellitusandpelvicgirdle syndromeinpregnancyisthereanassociation?Acta</p><p> Obstetricia</p><p> et</p><p> Gynecologica </p><p>Scandinavica,87(10),10151019.</p><p>Granath,A.B.,Hellgren,M.S.E.,&amp;Gunnarsson,R.K.(2006).Water aerobicsreducessickleaveduetolowbackpainduringpregnancy. JOGNN:JournalofObstetric,Gynecologic,&amp;NeonatalNursing,35(4),465</p><p> 471.</p><p> Gutke,A.,stgaard,H.C.,&amp;berg,B.(2006).Pelvicgirdlepainand</p><p> lumbarpaininpregnancy:acohortstudyoftheconsequencesintermsof healthandfunctioning.Spine,31(5),E149155.</p><p>Gutke,A.,Josefsson,A.,&amp;Oberg,B.(2007).Pelvicgirdlepainandlumbar paininrelationtopostpartumdepressivesymptoms.Spine,32(13),1430 1436.</p><p>Henderson,C.,&amp;MacDonald,S.(Eds.).(2004).Mayes </p><p>Midwifery:A textbookformidwives.</p><p> (13thed.).Edinburgh:Bailliere</p><p> Tindall.</p><p>Heuther,S.&amp;McCance,K.(Eds),(2004).Understandingpathophysiology (3rd</p><p>ed).Missouri:Mosby.</p><p>Lee,D.G.(1996).Instabilityofthesacroliliac </p><p>joint&amp;consequencestogait. JournalofManualandManipulativeTherapy,4(1),2229.</p></li><li><p>Lee,D.&amp;Vleeming,A.(2000).Currentconceptsonpelvicimpairment. Proceedingsofthe7th</p><p>ScientificConferenceoftheIFOMT,Perth,Australia, p188123.</p><p>Lee,D.G.,Lee,L.J.,&amp;McLaughlin,L.(2008).Stability,continenceand breathing:theroleoffasciafollowingpregnancyanddelivery.Journalof</p><p> Bodywork&amp;MovementTherapies,12(4),333348.</p><p> Magee,D.J.(1997)Orthopedic</p><p> PhysicalAssessment(3rd</p><p>ed) </p><p>Philadelphia: W.B.SaundersCompany.</p><p>Marieb,E.&amp;Hoehn,K.(2007)HumanAnatomy&amp;Physiology(7th </p><p>ed.) </p><p>San Fransisco:PearsonBenjaminCummings</p><p>Mogren,I.M.(2006).BMI,painandhypermobilityaredeterminantsof longtermoutcomeforwomenwithlowbackpainandpelvicpainduring pregnancy.Eur</p><p> SpineJ,15,10931102.</p><p>Mogren,I.M.(2006).Percieved </p><p>health,sickleave,psychosocialsituation, andsexuallifeinwomenwithlowbackpainandpelvicpainduring</p><p> pregnancy.Acta </p><p>Obstetricia </p><p>etGynecologica </p><p>Scandinavica,85,647656.</p><p>Olsson,C.,&amp;NilssonWikmar,L.(2004).Healthrelatedqualityoflifeand physicalabilityamongpregnantwomenwithandwithoutbackpain</p><p> inlate</p><p> pregnancy.Acta </p><p>Obstetricia </p><p>etGynecologica </p><p>Scandinavica,83,351357.</p></li><li><p>Palastanga,N.,Field,D.,Soames,R.(2000)Anatomy&amp;HumanMovement: Structure&amp;Function.</p><p> Oxford:ButterworthHeinemann</p><p>Panjabi,M.M.(1992).Thestabilising </p><p>systemofthespine.Part1: Function,dysfunction,adaptation&amp;enhancement.JournalofSpine</p><p> Disorders,5(4),383389.</p><p> Owens,K.,Pearson,A.,&amp;Mason,G.(2002).Symphysis</p><p> pubisdysfunction</p><p> acauseofsignificantobstetricmorbidity.EuropeanJournalofObstetrics andGynecologyandReproductiveBiology.,105(2),143146.</p><p>Pennick,V.E.,&amp;Young,G.(2008).Interventionsforpreventingand treatingpelvicandbackpaininpregnancy.CochraneDatabaseof</p><p> SystematicReviews(2).</p><p> Robinson,H.S.,Eskild,A.,Heiberg,E.,&amp;EberhardGran,M.(2006).Pelvic</p><p> girdlepaininpregnancy:theimpactonfunction.Acta </p><p>Obstetricia </p><p>et Gynecologica</p><p> Scandinavica,85(2),160164.</p><p>Smith,M.,Russell,A.,&amp;Hodges,P.(2008).Istherearelationshipbetween parity,pregnancy,backpainandincontinence?Int</p><p> Urogynecol</p><p> J,19(205</p><p> 211).</p><p> Stables,D.&amp;Rankin,J.(Eds)(2005).PhysiologyinChildbearing:with</p><p> anatomy&amp;relatedbiosciences(2nd </p><p>ed).Edinburgh:Elsevier.</p></li><li><p>Vleeming,A.,Albert,H.,Ostgaard,H.C.,Sturesson,B.,&amp;Stuge,B.(2008). Europeanguidelinesforthediagnosisandtreatmentofpelvicgirdlepain. Eur</p><p> SpineJ,17,794819.</p><p>Wellock,V.K.,&amp;Crichton,M.A.(2007).Understandingpregnantwomen's experiencesofsymphysis</p><p> pubisdysfunction:theeffectofpain.Evidence</p><p> BasedMidwifery,5(2),4046.</p><p> Wu,W.H.,Meijer,O.G.,Uegaki,K.,Mens,J.M.A.,vanDiee</p><p> n,J.H.,</p><p> Wuisman,P.I.J.M.,etal.(2004).Pregnancyrelatedpelvicgirdlepain (PPP)I:Terminology,clinicalpresentationandprevalence.Eur</p><p> SpineJ13,</p><p> 575589.</p><p>Pregnancy-related Low Back and Pelvic Girdle Pain: how can we help?Aims of todays talkFactors influencing pregnancy &amp; 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 &amp; postpartum Movement of pelvic joints during childbirthFascia, pregnancy and birthPregnancy-related Low Back &amp;/or Pelvic Girdle PainPregnancy-related Low back and Pelvic Girdle PainSymphysis pubis dysfunctionLow back and pelvic girdle painMorbidity of pregnancy-related LBP &amp;/or PGPMorbidity of pregnancy-related LBP &amp;/or PGPAetiologyRisks for developing back/pelvic pain during pregnancyManagementWhat can we do to help?Treatment of LBP &amp;/or PGP Cochrane Review (Pennick and Young, 2007)Slide Number 34ReferencesSlide Number 36Slide Number 37Slide Number 38Slide Number 39</p></li></ul>