I’m pregnant and in pain: Is my pelvis is out of alignment? Is it unstable?   What is pelvic girdle pain in pregnancy? Do we actually know?

Both pelvic girdle pain (PGP) and low back pain (LBP) are commonly report by pregnant women (Vleeming, Albert, Ostgaard, Sturesson, & Stuge, 2008). Although pregnancy related low back pain (PLBP) and pregnancy related pelvic girdle pain (PPGP) can be defined separately, they are often combined in much of the research on pelvic pain in pregnancy. PLBP has been defined as being between the 12th rib and the gluteal fold and PPGP has been defined as being felt between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the sacroiliac joints and /or in the symphysis pubis (Vleeming et al., 2008).

Prevalence data on PLBP and PPGP is varied however recent data suggests a prevalence as high as 70-86% (Gutke, Boissonnault, Brook, & Stuge, 2018; Liddle & Pennick, 2015).

A recent multinational sample study from the US, UK, Norway and Sweden found that women in the UK demonstrated highest pain intensity sores and highest scores on the Pelvic Girdle Questionnaire (PGQ) and they also reporting the greatest concerns about PPGP / PLBP as compared to cohorts in the US, Norway and Sweden. Only 69% of women in the UK thought their pain would disappear after delivery (Gutke et al., 2018)

It has been identified that belief in improvement is a statistically significant predictor of persistent pelvic girdle pain and disability (Vollestad & Stuge, 2009).

Women with PPGP also have reported physical, psychosocial and work-related challenges, with changes to family relationships, altered sleep patterns, impaired mobility and sick leave from work (Elden, Gutke, Kjellby-Wendt, Fagevik-Olsen, & Ostgaard, 2016; Elden, Lundgren, & Robertson, 2013; Persson, Winkvist, Dahlgren, & Mogren, 2013; Van De Pol, Van Brummen, Bruinse, Heintz, & Van Der Vaart, 2007). Perhaps unsurprising, coincidental or causative, studies have identified that postpartum women reporting the worst symptoms of PPGP also report to have poorer general health status compared to those with less symptoms (Bergstrom, Persson, & Mogren, 2014; Bergström, Persson, & Mogren, 2016). Given the poor sleep, social disruption and presence of pain, it is not surprising that there are significantly higher rates of anxiety and depression in women with PPGP than non PPGP pregnant women (Elden et al., 2016). It is not known if the anxiety and depression is caused by the PPGP or if the PPGP is a causative factor for the anxiety and depression.

One of the first papers to identify that maternal depression can have a direct impact on the offspring's neural function and subsequent mental health health later in life was by Pratt et al (2019). This rather tragically highlights that this prevalent psychiatric disorder, (Marcus, 2009; Gold et al., 2008), has a significant domino effect. Priel et al., (2019) reported on a longitudinal study on children from birth and across the first decade of life to examine risk and resilience in the context of maternal depression, focusing on middle childhood. They found that the relationship between maternal depression and childhood physical health was observed even in children with no history of early childhood chronic illness, indicating that maternal depression can lead to more general health problems early in life. They concluded that exposure to maternal depression carries measurable consequences for children's well‐being beyond infancy.

The aetiology of PPGP / PLBP are complex and multifactorial (Vleeming et al., 2008; (Kanakaris, Roberts, & Giannoudis, 2011) and arguably not fully understood. In the absence of clear aetiology, risk factors for the development of PGP have been used to facilitate a better understanding. In accordance with a thorough systematic review, there is strong evidence that the following are risk factors for developing PPGP / PLBP: prior history of pregnancy; orthopaedic dysfunctions; increased BMI, smoker, dissatisfaction and a lack of leave of improvement in the prognosis of PGP (Clinton & LaCross, 2017)

Evidence has shown that there is an alteration in motor control and biomechanics in all pregnant women but that women with PPGP have greater altered kinematics to pregnant women without PPGP (Aldabe, Milosavljevic, & Bussey, 2012). As such treatment and management paradigms for PPGP/PLBP have focussed around biomechanical adaptation and manual therapies, starting with correcting posture first and then using passive manual therapy / motor control techniques to address the neuromuscular adaptations (Jones et al., 2017).

Such treatment paradigms and manual therapy modalities may have been based on the premise that 1) motor control patterns are the cause of the PPGP and PLBP and subsequent reduced function 2) that we have valid and reliable tests for establishing altered kinematics in the clinical environment 3) that manual therapy treatment methods influence and restore the kinematics and that finally 4) as a result of the restored kinematics that pain and function improve.

Validity and reliability exists for pain provocation tests to establish that nociceptive input may be elicited in and round the pelvic joints (Vleeming et al., 2008) and also that some manual therapy techniques specific to PPGP may reduce pain (Khorsan, Hawk, Lisi, & Kizhakkeveettil, 2009). However, this does not confirm that biomechanics is the primary cause of pain and disability or that manual therapy changes the biomechanics. Validity and reliability of palpation of the pelvis and pelvic joints and identification of asymmetry with such palpation have been poor (Robinson et al., 2008; Cooperstein & Hickey, 2016; Stovall & Kumar, 2010) and this may be in part due to a high degree of natural variance in the bony palpation landmarks of the sacroiliac joints (Preece et al., 2008). The mechanism by which manual therapy techniques reduce pain, regardless of type, may be considered as being through neurophysiological response or contextual factors rather than the biomechanical elements of a specific treatment (Menke, 2014; Bialosky, Bishop, George & Robinson, 2011).

Education aimed at addressing biomechanical changes and exercises to potentially prevent the neuromuscular changes during pregnancy from causing PPGP/PLBP have not been proven to make a difference to prevalence and severity of PPGP / PLBP (Eggen, Stuge, Mowinckel, Jensen, & Hagen, 2012).

It is also worthy to note that the postural, motor control and biomechanical changes are evident in all pregnant women and are not indicative of severity of PPGP / PLBP (Clinton et al., 2017). The implication has been that manual therapy, as a ‘treatment’ is addressing these biomechanical changes and motor control changes, which appear to exist in all women, however the research outcomes cannot substantiate that there have been biomechanical changes before and after treatments and there is limited evidence to suggest any benefit on reported pain reduction (Hall et al., 2016).

In light of a wider understanding of PPGP what is becoming more apparent is that the risk factor for developing persistent PPGP and maybe even the presence of acute PPGP is less to do with biomechanical but perhaps linked to belief structure and more to do with biochemical or neurophysiological mechanisms (Bergström et al., 2016; Clinton & LaCross, 2017; Smith, Galbraith, & Blumer, 2018; Feliz et al., 2015), and that underlying knowledge of the context dependent nature of the produced pain influences this output and subsequently a person’s experience.

References 

Bergstrom, C., Persson, M., & Mogren, I. (2014). Pregnancy-related low back pain and pelvic girdle pain approximately 14 months after pregnancy - pain status, self-rated health and family situation. BMC Pregnancy Childbirth, 14. https://doi.org/10.1186/1471-2393-14-48

Bergström, C., Persson, M., & Mogren, I. (2016). Sick leave and healthcare utilisation in women reporting pregnancy related low back pain and/or pelvic girdle pain at 14 months postpartum. Chiropractic & Manual Therapies, 24, 1–11. https://doi.org/10.1186/s12998-016-0088-

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