Pelvic girdle pain

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Pelvic Girdle Pain During Pregnancy

Historical articles show that pregnancy-related pelvic girdle pain has been recognizes for centuries. Mentioned by Hippocrates [1] and later described in medical literature by Snelling. [2] Pelvic Girdle Pain causes pain and instability in any of the three pelvic joints during and/or after pregnancy.

" The affection appears to consist of relaxation of the pelvic articulations, becoming apparent suddenly after parturition or gradually during pregnancy and permitting a degree of mobility of the pelvic bones which effectively hinders locomotion and gives rise to the most peculiar and alarming sensations". Snelling (1870).[2]


Contents

[edit] Introduction

The pelvis is the largest bony part of the skeleton. There are three joints, the symphysis pubis (SP), and two sacroiliac joints. A highly durable network of ligaments surrounds these joints giving them tremendous strength.

The pubic symphysis has a fibrocartilage joint which may contain a fluid filled cavity and is avascular; it is supported by the superior and arcuate ligaments. The sacroiliac joints are synovial, but their movement is restricted throughout life and they are progressively obliterated by adhesions. The nature of the bony pelvic ring with its three joints determines that no one joint can move independently of the other two. [3]

[edit] Images

Pubic symphysis

Posterior Sacroiliac joint

Anterior Sacroiliac joint

White fibrocartilage from an intervertebral fibrocartilage.

[edit] Pelvic Girdle Pain [PGP]

PGP disorder is complex and multi-factorial and likely to be represented by a series of sub-groups with different underlying pain drivers from peripheral or central nervous system [4] , altered laxity/stiffness of muscles [5], laxity to injury of tendinous/ligamentous structures [6] to ‘mal-adaptive’ body mechanics. [7]

Pregnancy begins the physiological changes through a pattern of hormonal secretion and signal transduction thus initiating the remodelling of soft tissues, cartilage and ligaments. Over time, the ligaments could be stretched either by injury or excess strain and in turn may cause pelvic girdle instability.

"The classification between hormonal and mechanical pelvic girdle instability is no longer used. For treatment and/or prognosis it makes no difference whether the complaints started during pregnancy or after childbirth." Mens (2005) [8]

For most women PGP resolves in weeks after delivery but for some it can last for years resulting in a reduced tolerance for weight bearing activities. Overall, about 45% of all pregnant women and 25% of all women postpartum suffers from PGP. [9] During pregnancy, serious pain occurs in about 25%, and severe disability in about 8% of patients. After pregnancy, problems are serious in about 7%. [10] There is no correlation between age, culture, nationality and numbers of pregnancies that determine a higher incidence of PGP. [11] [12]

Other Commonly used Terms are:

If you experience PGP during one pregnancy you are more likely to experience it in subsequent pregnancies; but the severity cannot be determined.[13]

[edit] Hormone Relaxin

It is a fact that some hormone levels increase during pregnancy, especially relaxin, estrogen and progesterone.

Relaxin is produced mainly by the corpus luteum of the ovary and breast, in both pregnant and non-pregnant females. During pregnancy it is also produced by the placenta, chorion, and decidua. The body produces relaxin during menstruation that rises to a peak within approximately 14 days of ovulation and then declines. In pregnant cycles, rather than subsiding, relaxin secretion continues to rise during the first trimester and then again in the final weeks. In males, relaxin is synthesized in the prostate and released in the seminal fluid.

During pregnancy relaxin has a diverse range of effects, including the production and remodelling of collagen thus increasing the elasticity of muscles, tendons, ligaments and tissues of the birth canal in view of delivery. This hormone also inhibits uterine contractile activity, allows nipple growth to occur, contributes to the rupture of the fetal membranes at term and is needed to support the establishment and maintenance of early pregnancy.

Relaxin works directly and indirectly on both the male and female body and has a chemical influence on the following tissues and systems:

  1. The striated and smooth muscles.
  2. The central nervous system and autonomic nervous systems.
  3. Connective tissues in the form of skin, ligament, tendon and cartilage.
  4. The cardiac muscles.

This hormone produces changes in collagen metabolism (chemical processes occurring within a living cell that is necessary for the maintenance of life), by inhibiting collagen synthesis (prevent or decrease a period in the cell cycle) and increasing matrix metalloproteinase’s, that increases collagenase production. Although relaxins main cellular action in pregnancy is to remodel collagen by biosynthesis, thus facilitating the changes of connective tissue, it does not seem to generate musculoskeletal problems. European Research has determined that relaxin levels are not a predictor of PGP during pregnancy. [14] [15] [16] [17][18][19]

Concentrations of relaxin during the two days immediately preceding parturition are significantly greater than all other days. After this time period relaxin is no longer manufactured in large amounts in the postnatal period but the effects of the hormones on the ligaments are still evident until about five months postpartum.

[edit] Causing Factors

Sometimes there is no obvious explanation for the cause of PGP but usually there is a combination of factors such as.

  1. The pelvic joints moving unevenly.
  2. A change in the activity of the muscles in the pelvis, hip, abdomen, back and pelvic floor.
  3. A history of pelvic trauma.
  4. The position of the baby altering the loading stresses on the pelvic ligaments and joints.
  5. Strenuous work. [20]
  6. Previous lower back pain.
  7. Previous pelvic girdle pain during pregnancy.
  8. Hypermobility, genetical ability to stretch joints beyond normal range.
  9. An event during the pregnancy or birth that caused injury or strain to the pelvic joints or rupture of the fibrocartilage.
  10. The occurrence of PGP is associated with twin pregnancy, first pregnancy and a higher age at first pregnancy. [21]

[edit] Symptoms

  • PGP can begin in the early weeks (wk 14-22).
  • Pain is usually felt low down over the Symphysis Pubis joint, which may be extremely tender to the touch.
  • Present swelling and/or inflammation over joint.
  • Difficulty lifting leg.
  • Pain pulling legs apart.
  • Unable to stand on one leg.
  • Unable to transfer weight through pelvis and legs.
  • Pain in hips and/or restriction of hip movement.
  • Transferred nerve pain down leg.
  • Can be associated with bladder and/or bowel dysfunction.
  • A feeling of symphysis pubis giving way.
  • Stand with a stooped over back.
  • Malalignment of pelvic and/or back joints.
  • Struggle to sit or stand.
  • Pain may also radiate down the inner thighs.
  • You may waddle or shuffle.
  • Aware of an audible ‘clicking’ sound coming form the pelvis.

The symptoms of PGP limit the ability for the woman to carry out most daily activities. She will experience pain involving movements such as dressing, getting in and out of the bath, rolling in bed, climbing the stairs and sexual activity. Pain will also be present when lifting, carrying, pushing or pulling.

[edit] Ligaments

Ligaments are composed strands of collagen fibers. Injured ligaments and other connective tissue may not heal properly after minor or repetitive motion injuries. Partial tears are usually much more painful than full tears, which can sometimes be painless. If ligaments are stretched, either by injury, excess strain on a joint, or by improper stretching techniques, the joint will become weaker, as the elongated ligaments are unable to properly support it. Because connective tissue such as ligaments must withstand a great deal stress in day to day activities and have a relatively low blood supply, injuries can take a very long time to heal injured ligaments tend to be less flexible, and more prone to repeat injury. Ligaments are strong structures which join two bones together, giving the skeleton strength and structural integrity. Because ligaments are so important in the stabilization of joints, they are also highly susceptible to injury.

Types of Ligament Instability

Stable Ligament. The ligaments are structurally sound, coping well with day to day activities.

Partial Ligament Instability. The ligament become weak/ injured and the muscles try to compensate to function properly. Due to the ligamentous instability the muscles fail to work effectively resulting in pain and weakness during daily activities.

Severe Ligament Instability. The ligaments are unable to support the joint and this gross instability cannot be compensated by muscle function resulting in severe pain and disability and an inability to perform daily activities.

[edit] Degrees of Pelvic Instability

Stable Pelvis. The woman does not have any signs or symptoms of pelvic instability. The ligaments and muscles work well during daily activities. These women usually do not have a history of lower back pain, pelvic trauma of hypermobile joints and have never been pregnant.

Partial Pelvic Instability. The ligaments alone do not support the joint sufficiently. The ligaments become weak or injured and the muscles try to compensate to function properly. If the stabilizing muscles of the pelvis fail to work effectively with the weak and injured ligaments, pain and weakness will be experienced during daily activities. This kind of pelvic instability often occurs after giving birth to a child weighing 3000 grams or more [8], hypermobility of joints during pregnancy or an incident during the birth causing some minor degree of damage to ligaments or joints of the pelvis. Treatment is required to re-establish the muscles around the pelvis to work more efficiently.

Complete Pelvic Instability. The pelvic joints cannot function properly without the support of the ligaments and muscles. Both are needed to maintain normal function. When the woman has complete instability the ligaments are unable to support the joint and this gross instability cannot be compensated by muscle function. There will be severe pain and disability. This type of pelvic instability usually only occurs after an incident during the pregnancy that has caused pelvic joint injury limiting the pelvis to remain stable; this can also occur during the delivery.

[edit] Walking with Pelvic Instability

The pregnant woman has a different pattern of "gait". The step lengthens as the pregnancy progresses due to weight gain and changes in posture. Both the length and height of the footstep shortens with PGP. Sometimes the foot can turn inwards due to the rotation of the hips when the pelvic joints are unstable. On average, a woman's foot can grow by a half size or more during pregnancy. Pregnancy hormones that are released to adapt the bodily changes also remodel the ligaments in the foot. In addition, the increased body weight of pregnancy, fluid retention and weight gain lowers the arches, further adding to the foot's length and width. There is an increase of load on the lateral side of the foot and the hind foot. These changes may also be responsible for the musculoskeletal complaints of lower limb pain in pregnant women.

During the motion of walking, an upward movement of the pelvis, one side then the other, is required to let the leg follow through. The faster or longer each step the pelvis adjusts accordingly. The flexibility within the knees, ankles and hips are stabilized by the pelvis. Normal gait tends to minimize displacement of centre of gravity whereas abnormal gait through pelvic instability tends to amplify displacement. During pregnancy there may be an increased demand placed on hip abductor, hip extensor, and ankle plantar flexor muscles during walking. To avoid pain on weight bearing structures a very short stance phase and limp occurs on the injured side(s), this is called Antalgic Gait.

[edit] Psychosocial Concerns

PGP in pregnancy seriously interferes with participation in society and activities of daily living such as housekeeping, walking, sexual life and working; the average sick leave due to posterior pelvic pain during pregnancy is 7 to 12 weeks. [22]

In some cases women with PGP may also experience emotional problems such as anxiety over the cause of pain, resentment, anger, lack of self-esteem, frustration and depression; she is three times more likely to suffer postpartum depressive symptoms.[23] Other psychosocial risk factors associated with woman experiencing PGP include higher level of stress, low job satisfaction and poorer relationship with spouse.[24]

[edit] Recovery and Treatment

Self Help Management

  • When getting into bed sit on the edge keeping knees close together, lie down on your side, lifting both legs at the same time. Reverse this to get up.
  • Try not to attempt to pull yourself up from lying on your back.
  • Keep knees together when rolling over in bed.
  • Sleep with a pillow between the legs; add more in other areas for support.
  • When getting into a car: Sit down first and then swing legs keeping them together.
  • Avoid sofas and chairs that are too low or too soft.
  • Try to reduce the stress on the joint.
  • Avoid any movement with your knees apart.
  • Take smaller steps when walking.
  • Avoid stairs if possible.
  • Take breaks.
  • Move within the limits of pain.
  • Avoid twisting, bending or squatting.

The majority of women will make a full recovery after they give birth. For others PGP can take from 11 weeks, 6 months or even up to 2 years postpartum to subside.[25] One of the main factors in helping women cope with is with education, information and support. Many treatment options are available such as, Physiotherapist, Osteopath, Chiropractor, Acupuncturist[26] [12] [10], Social Worker, Massage Therapy and Medical Specialist such as Orthopedic Surgeon. Some pelvic joint trauma will not respond to conservative type treatments, Orthopedic surgery might become the only option to stabilize the joints.

[edit] References

Pelvic Instability Network Support

  1. ^ Pubic Symphysis Separation. Fetal and Maternal Medicine Review (2002), 13: 141-155 Kelly Owens, Anne Pearson, Gerald Mason
  2. ^ a b Pain In Childbearing, Key Issues In Management, Margaret Yerby, Lesly Page.
  3. ^ SPD: The Clinical Presentation, Prevalence, Aetiology, Risk Factors and Morbidity. Malcolm Griffiths.
  4. ^ Diagnosis and classification of pelvic girdle pain disorders—Part 1: A mechanism based approach within a biopsychosocial framework Manual Therapy, Volume 12, Issue 2, May 2007, Peter B. O’Sullivan and Darren J. Beales.
  5. ^ European guidelines for the diagnosis and treatment of pelvic girdle pain.Eur Spine J. 2008 Feb 8 Vleeming A, Albert HB, Ostgaard HC, Sturesson B, Stuge B.
  6. ^ Possible role of the long dorsal sacroiliac ligament in women with peripartum pelvic pain. Acta Obstetricia et Gynecologica Scandinavica Volume 81 Issue 5 Page 430-436, May 2002, Andry Vleeming, Haitze J. de Vries, Jan M. A Mens, Jan-Paul van Wingerden
  7. ^ Diagnosis and classification of pelvic girdle pain disorders—Part 1: A mechanism based approach within a biopsychosocial framework. Manual Therapy, Volume 12, Issue 2, May 2007, Pages 86-97 Peter B. O’Sullivan, and Darren J. Bealesa.
  8. ^ a b About Pelvic Girdle Instability. Definition and Concept. Jan M.A. Mens.
  9. ^ Pregnancy-related pelvic girdle pain (PPP), I: Terminology, clinical presentation, and prevalence European Spine Journal Vol 13, No. 7 / Nov. 2004 W. H. Wu, O. G. Meijer , K. Uegaki, J. M. A. Mens, J. H. van Dieën, P. I. J. M. Wuisman, H. C. Östgaard.
  10. ^ a b Effects of acupuncture and stabilising exercises as adjunct to standard treatment in pregnant women with pelvic girlde pain: randomised single blind controlled trail. BMY 2005;330;761 H Elden, L Ladfors, M Fagevik Olsen, H-C Östgaard, H Hagber.
  11. ^ Is Pelvic Pain a Welfare Complaint? Acta Obstet Gynecol Scand. 2000 Jan, 79(1):24-30 Department of Women’s and Children Health KENNETH BJÖRKLUND, STAFFAN BERGSTRÖM .
  12. ^ a b Pelvic Girdle Pain in Pregnancy. BMJ 2005;331:249-250 (30 July), doi:10.1136/bmj.331.7511.249 Editorial, R William Stones,Kathleen Vits
  13. ^ Use of Hormonal Contraceptives and Occurrence of Pregnancy-Related Pelvic Pain: A Prospective Cohort Study in Norway. BMC Pregnancy Childbirth. 2004; 4: 11. Published online 2004 June 22. doi: 10.1186/1471-2393-4-11. Merethe Kumle, Elisabete Weiderpass, Elin Alsaker, Eiliv Lund
  14. ^ Circulating Levels of Relaxin are Normal in Pregnant Women with Pelvic Pain. Gynecol Obstet Invest. 1994;38(1):21-3. Albert H, Godskesen M, Westergaard JG, Chard T, Gunn L.
  15. ^ Normal Serum Relaxin in Women with Disabling Pelvic Pain During Pregnancy. Gynecol Obstet Invest. 1994;38(1):21-3, Petersen LK, Hvidman L, Uldbjerg N
  16. ^ Symphyseal Distention in Relation to Serum Relaxin Levels and Pelvic Pain in Pregnancy. Acta Obstet Gynecol Scand. 2000 Apr;79(4):269-75. Björklund K, Bergström S, Nordström ML, Ulmsten U
  17. ^ Relaxin is not related to symptom-giving pelvic girdle relaxation in pregnant women. Acta Obstet Gynecol Scand. 1996 Mar;75(3):245-9. Hansen A, Jensen DV, Larsen E, Wilken-Jensen C, Petersen LK.
  18. ^ Symphyseal distention in relation to serum relaxin levels and pelvic pain in pregnancy. Acta Obstet Gynecol Scand. 2000 Apr;79(4):269-75. Björklund K, Bergström S, Nordström ML, Ulmsten U.
  19. ^ Circulating levels of relaxin are normal in pregnant women with pelvic pain. Eur J Obstet Gynecol Reprod Biol. 1997 Jul;74(1):19-22. Albert H, Godskesen M, Westergaard JG, Chard T, Gunn L.
  20. ^ Psychosocial and Physical Work Environment and Risk of Pelvic Pain in Pregnancy. A Study within the Danish National Birth Cohort. Journal of Epidemiology and Community Health 2005;59:580-585, Mette Juhl, Per Kragh Andersen, Jørn Olsen, Anne-Marie Nybo Andersen
  21. ^ Understanding peripartum pelvic pain. Implications of a patient survey. Spine. 1996 Jun 1;21(11):1363-9; discussion 1369-70.Mens JM, Vleeming A, Stoeckart R, Stam HJ, Snijders CJ.
  22. ^ Reduction of Sick Leave for Lumbar Back and Posterior Pelvic Pain in Pregnancy. Spine. 22(18):2157-2160, September 15, 1997. Noren, Lotta RPT, Ostgaard, Solveig, Nielsen, Thorkild F, Ostgaard, Hans C
  23. ^ Pelvic girdle pain and lumbar pain in relation to postpartum depressive symptoms. Spine. 2007 Jun 1;32(13):1430-6. Gutke A, Josefsson A, Oberg B.
  24. ^ Risk factors in developing pregnancy-related pelvic girdle pain. Acta Obstet Gynecol Scand. 2006;85(5):539-44. Albert HB, Godskesen M, Korsholm L, Westergaard JG
  25. ^ Symptom-Giving Pelvic Girdle Relaxation in Pregnancy. I: Prevalence and Risk Factors. Acta Obstet Gynecol Scand. 1999 Feb;78(2):105-10. Larsen EC, Wilken-Jensen C, Hansen A, Jensen DV, Johansen S, Minck H, Wormslev M, Davidsen M, Hansen TM.
  26. ^ Acupuncture works for pelvic girdle pain in pregnant women. Editorial, BMJ.;2005; 330 (2 April), doi:10.1136/bmj.330.7494.0-c

[edit] Further reading

  • Recommendations for the Nomenclature of Receptors for Relaxin Family Peptides Pharmacol Rev 58:7-31,2006 Ross A. Bathgate, Richard Ivell, Barbara M. Sanborn, O. David Sherwood and Roger J. Summers [1]
  • European Guidelines on the Diagnosis and Treatment of Pelvic Girdle Pain[2]
  • Guidance for Healthcare Professional Pregnancy Related Pelvic Girdle.[3]
  • Guidance for Mothers and Mothers to be with Pregnancy Related Pelvic Girdle Pain.[4]
  • A historical perspective on pregnancy related lower back pelvic girdle pain.[5]
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