sign in sign up
<<
Home , Pelvic girdle pain

‐related

Low Back and Pelvic Girdle :

how can we help?

Heather Pierce Midwife/Physiotherapist: Westmead Hospital August 2009 Aims of today’s talk

• Overview of anatomy & function of the pelvic girdle • Definition of “pregnancy‐related pelvic girdle pain” • Aetiology/ Risk factors/ Treatment

• What can we do to help?

Factors influencing pregnancy & birth outcomes

Pierce, 2008 The Pelvic Girdle

•Attaches the vertebral column to the lower limbs with the strongest of the body •Transmits weight/forces between the upper body and the lower limbs • Pivotal point: strength and stability is essential for optimal function •Supports and protects the bladder, uterus, bowel/rectum

The Pelvic Girdle

Marieb & Hoehn

Ilium: Medial View

Marieb & Hoehn

Figure 7.27c

Ligaments of the

Mayes’ Midwifery p.276, fig. 16.3 Ligaments of the pelvis

Basmajian fig 104

Deep muscles of

Marieb & Hoehn

Figure 10.20b–c Muscles of anterior thigh

Marieb & Hoehn

Figure 10.19a Muscles of the Abdominal Wall

Marieb & Hoehn Figure 10.11a

Muscles of the Abdominal Wall

Marieb & Hoehn

Figure 10.11b Superior view of

Marieb & Hoehn

Figure 10.12a The sacral plexus

Marieb& Hoehn, fig 13:11, p. 516 Pelvic Stabilising system:

• Spinal stabilising system (Panjabi 1992): • Passive musculoskeletal system • Active musculoskeletal system • Neural & feedback system • Form closure: osteoarticular/ligamentous

• Force closure: myofacial (Lee & Vleeming, 2000)

• ‘Core stability’: the pelvic floor and the deep abdominal muscles Lumbo‐

pelvic

stability:

Posterior

oblique

system

Lee, 1996 The pelvic girdle in pregnancy, childbirth & postpartum

• Landmarks enable assessment of growth, position & descent of fetus during pregnancy & birth • Bony canal through which the fetus much pass for vaginal birth • Pelvic girdle pain: pregnancy‐related • Intrapartum trauma: instrumental delivery, coccydinia, pubis dysfunction, diastasis symphysis pubis

Movement of pelvic joints during childbirth •20mm inferior & 7mm anterior movement of the ilium on the sacrum; •Forceps may cause a grade 5 posterior movement of the sacrum, •Possible rupture of pubic ligaments •Bleeding into Palastanga, Field & Soames fig. 4.56, p. 397 → sacroiliitis Fascia, pregnancy and birth • Linea alba: complex CT that connects left & right abdominal muscles • Average inter‐recti distance = 0.9 ‐ 1cm , diastasis occurs when distance is > 1‐2cm

• Trauma to the linea alba &/or endopelvic fascia → • “Non optimal strategies for posture & movement &/or breathing create failed load transfer that can lead to pain, incontinence & breathing disorders” (Lee et al, 2008)

Pregnancy‐related Low Back &/or Pelvic Girdle Pain • Historical perspective: literature difficult to evaluate & draw conclusions due to variation in terminologies & classification methods: • Pelvic instability • Posterior • Pelvic joint/girdle syndrome • Symptomatic pelvic girdle relaxation • Symphysiolysis • Symphysis pubis dysfunction/diastasis • Often not differentiated from LBP • Reported prevalence rates of the condition vary

Pregnancy‐related Low back and Pelvic Girdle Pain

• Pain of musculoskeletal origin that is experienced in the lumbar and/or sacro‐ iliac area during pregnancy or in the immediate . Pain may occur in conjunction with or separately in the symphysis pubis (Vleeming, Albert, Ostgaard, Sturesson, & Stuge, 2008) Symphysis pubis dysfunction

• ? Increased mobility of the pubic joint • Normal gap in pregnancy up to 9mm, can be > 10mm, no relationship between degree of separation & clinical symptoms • Symptoms range from mild‐intermittent groin/ pubic pain to severe disabling pain • Often audible click or crunch of the joint • Onset can be insidious or traumatic • ? Surgical fixation if diastasis > 4cm • ‘Diastasis of symphysis pubis’: different condition? Low back and pelvic girdle pain

• ~ 50% women experience % pregnant women with back and/or pelvic girdle back &/or pelvic pain

pain (PGP) during 60 pregnancy (? Severity) pregnancy • Important to differentiate 50 after birth LBP and PGP 40

• Incidence (point activities effected prevalence) of PGP is ~ % 30 20‐ 42% • ? Functional impairment 20 long term ↑ with combined LBP/PGP 10 pain

(Bastiaanssen, de Bie, Bastiaenen, Essed, & van den Brandt, 2005; Vleeming et al., 2008; 0 Wu et al., 2004)

Morbidity of pregnancy‐related LBP &/or PGP

• Reduced ability to maintain an active lifestyle during pregnancy (Olsson & Nilsson‐Wikmar, 2004) • Severe cases require mobility aids eg walking stick/crutches/wheelchair • Venous thrombosis is possible complications of bed rest or reduced mobility (Babarinsa, Adewole, Fatade, & Ajayi, 1999) • Risk of condition (Robinson, Eskild, Heiberg, & Eberhard‐Gran, 2006) Morbidity of pregnancy‐related LBP &/or PGP • Risk to psychological health, (Brown & Lumley, 2000; Gutke, Josefsson, & Oberg, 2007; Mogren, 2006). • Increased sick leave (Olsson & Nilsson‐Wikmar, 2004) • ? Associated with urinary incontinence (Lee, Lee, & McLaughlin, 2008; Pool‐Goudzwaard et al., 2005; Smith et al., 2008). • ? Increased use of analgesics during pregnancy • ? Influence on mobility in labour and mode of birth Aetiology

• Hormonal factors? Can have increase mobility of pelvic joints but not correlated pain • /alteration in relaxin receptors: evidence inconclusive • Oral contraceptives may influence metabolism • Asymmetrical movement or positioning of pelvic joints/altered pelvic girdle biomechanics secondary to altered neuro‐muscular control • Diet/ diabetes/ other ?

Risks for developing back/pelvic pain during pregnancy • Previous history of back pain • Previous trauma to the pelvis Conflicting evidence: • physically demanding work

• multiparity • hyper ‐mobile joints (connective tissue insufficiency) • Obesity/ BMI (European Guidelines on diagnosis and treatment of pelvic girdle pain, 2008)

Management

• There is evidence of a reduced understanding of the significance of pregnancy‐related LBP and PGP amongst caregivers (Fredriksen, Moland, & Sundby, 2008; Owens, Pearson, & Mason, 2002; Wellock & Crichton, 2007) • The condition is often described as a “minor disorder’’ or “common discomfort” that must be endured until after the baby is born What can we do to help?

• Acknowledge • Antenatal /postnatal referral • Advice for back/pelvic girdle pain: – Avoid activities that cause uneven weight on legs or twisting the body eg: standing on one leg, sitting cross legged, vacuuming/sweeping, stairs – Avoid bending, lifting & carrying heavy things – Reduce stride length – Use stability strategies for postural change • Anticipate : Mobility and positioning in labour

Treatment of LBP &/or PGP Cochrane Review (Pennick and Young, 2007)

• Individualised programme focusing on specific stabilising/strengthening exercises and pelvic tilts • Pelvic belt for symptomatic relief • ‘Water gymnastics’: 2x RCTs • Special pillows: low level evidence • Information (education): no evidence • / stretches/ physiotherapy appear to relieve pain more than ‘usual’ care alone (ie analgesics, physical modalities, belt) • All studies have moderate to high bias • European Guidelines (2008)

References

• Babarinsa, I. A., Adewole, I. F., Fatade, A. O., & Ajayi, A. B. (1999). Obstetric arthropathy: a study of nine cases. Journal of Obstetrics and Gynaecology., 19(6), 620‐622. • Bastiaanssen, J. M., de Bie, R. A., Bastiaenen, C. H. G., Essed, G. G. M., & van den Brandt, P. A. (2005). A historical perspective on pregnancy‐ related low back and/or pelvic girdle pain. European Journal of Obstetrics and Gynecology and Reproductive Biology, 120(1), 3‐14. • Bastiaenen, C. H. G., de Bie, R. A., Wolters, P. M. J. C., Vlaeyen, J. W. S., Leffers, P., Stelma, F., et al. (2006). Effectiveness of a tailor‐made intervention for pregnancy‐related pelvic girdle and/or after delivery: short‐term results of a randomized clinical trial [ISRCTN08477490]. BMC Musculoskeletal Disorders, 7, 19. • Brown, S., & Lumley, J. (2000). Physical health problems after childbirth and maternal depression at six to seven months postpartum. British Journal of Obstetrics and Gynaecology 107, 1194‐1201.

• Eberhard‐Gran, M., & Eskild, A. (2008). Diabetes mellitus and pelvic girdle syndrome in pregnancy‐‐is there an association? Acta Obstetricia et Gynecologica Scandinavica, 87(10), 1015‐1019. • Granath, A. B., Hellgren, M. S. E., & Gunnarsson, R. K. (2006). Water aerobics reduces sick leave due to low back pain during pregnancy. JOGNN: Journal of Obstetric, Gynecologic, & Neonatal Nursing, 35(4), 465‐ 471. • Gutke, A., Östgaard, H. C., & Öberg, B. (2006). Pelvic girdle pain and lumbar pain in pregnancy: a cohort study of the consequences in terms of health and functioning. Spine, 31(5), E149‐155. • Gutke, A., Josefsson, A., & Oberg, B. (2007). Pelvic girdle pain and lumbar pain in relation to postpartum depressive symptoms. Spine, 32(13), 1430‐ 1436. • Henderson, C., & MacDonald, S. (Eds.). (2004). Mayes’ Midwifery: A textbook for midwives. (13th ed.). Edinburgh: Bailliere Tindall. • Heuther, S. & McCance, K.(Eds), (2004). Understanding pathophysiology (3rd ed). Missouri: Mosby. • Lee, D. G. (1996). Instability of the sacroliliac joint & consequences to gait. Journal of Manual and Manipulative Therapy, 4(1), 22 ‐29. • Lee, D. & Vleeming, A. (2000). Current concepts on pelvic impairment. Proceedings of the 7th Scientific Conference of the IFOMT, Perth, Australia, p 188‐123. • Lee, D. G., Lee, L. J., & McLaughlin, L. (2008). Stability, continence and breathing: the role of fascia following pregnancy and delivery. Journal of Bodywork & Movement Therapies, 12(4), 333‐348. • Magee, D.J. (1997) Orthopedic Physical Assessment (3rd ed) Philadelphia: W.B. Saunders Company. • Marieb, E. & Hoehn, K. (2007) Human Anatomy & Physiology (7th ed.) San Fransisco: Pearson Benjamin Cummings • Mogren, I. M. (2006). BMI, pain and hyper‐mobility are determinants of long‐ term outcome for women with low back pain and pelvic pain during pregnancy. Eur Spine J, 15, 1093‐1102. • Mogren, I. M. (2006). Percieved health, sick leave, psychosocial situation, and sexual life in women with low‐back pain and pelvic pain during pregnancy. Acta Obstetricia et Gynecologica Scandinavica, 85, 647‐656. • Olsson, C., & Nilsson‐Wikmar, L. (2004). Health related quality of life and physical ability among pregnant women with and without back pain in late pregnancy. Acta Obstetricia et Gynecologica Scandinavica, 83, 351‐357.

• Palastanga, N., Field, D., Soames, R. (2000) Anatomy & Human Movement: Structure & Function. Oxford: Butterworth Heinemann • Panjabi, M. M. (1992). The stabilising system of the spine. Part 1: Function, dysfunction, adaptation & enhancement. Journal of Spine Disorders, 5(4), 383‐389. • Owens, K., Pearson, A., & Mason, G. (2002). Symphysis pubis dysfunction ‐ a cause of significant obstetric morbidity. European Journal of Obstetrics and Gynecology and Reproductive Biology., 105( 2), 143‐146. • Pennick, V. E., & Young, G. (2008). Interventions for preventing and treating pelvic and back pain in pregnancy. Cochrane Database of Systematic Reviews (2 ). • Robinson, H. S., Eskild, A., Heiberg, E., & Eberhard‐Gran, M. (2006). Pelvic girdle pain in pregnancy: the impact on function. Acta Obstetricia et Gynecologica Scandinavica, 85(2), 160‐164. • Smith, M., Russell, A., & Hodges, P. (2008). Is there a relationship between parity, pregnancy, back pain and incontinence? Int Urogynecol J, 19(205‐ 211). • Stables, D. & Rankin, J. (Eds) (2005). Physiology in Childbearing: with anatomy & related biosciences (2nd ed). Edinburgh: Elsevier.

• Vleeming, A., Albert, H., Ostgaard, H. C., Sturesson, B., & Stuge, B. (2008). European guidelines for the diagnosis and treatment of pelvic girdle pain. Eur Spine J, 17, 794‐819. • Wellock, V. K., & Crichton, M. A. (2007). Understanding pregnant women's experiences of symphysis pubis dysfunction: the effect of pain. Evidence Based Midwifery, 5(2), 40‐46. • Wu, W. H., Meijer, O. G., Uegaki, K., Mens, J. M. A., van Diee¨ n, J. H., Wuisman, P. I. J. M., et al. (2004). Pregnancy‐related pelvic girdle pain (PPP) I: Terminology, clinical presentation and prevalence. Eur Spine J 13, 575‐589.