Pelvic Girdle Pain in Pregnancy: A Review.

Importance: Pelvic girdle pain is often thought to be a recent phenomenon, but this condition was described as early as 400 BC by Hippocrates. Despite being identified for years, confusion continues about the definition and management of this ailment affecting many pregnancies. Objective: The purpose of the review is to assess the incidence, etiology, pathophysiology, risk factors, diagnosis, management, and pregnancy outcomes/recovery of current pregnancies, and outcomes of future pregnancies complicated by pelvic girdle pain. Evidence Acquisition: Electronic databases (PubMed and Embase) were searched from 1980 to 2021 with the only limitation being that the articles were in English. Studies were selected that examined associations between pelvic pain/pelvic girdle pain and pregnancy. Results: There were 343 articles identified. After reviewing the abstracts, 88 were used in this review. Pelvic girdle pain is a common condition of pregnancy, affecting a reported 20% of pregnant women. The pathophysiology is poorly understood and likely multifactorial, involving both hormonal and biomechanical changes that occur during pregnancy. Several risk factors have been identified. This diagnosis is most commonly made based on symptoms related to pelvic pain during pregnancy. Treatment should be multimodal, including pelvic girdle support, stabilizing exercises, analgesia, and potentially complementary therapies. The effects on future pregnancies are uncertain, although some limited information suggests an increased risk of recurrent PGP in subsequent pregnancies. Conclusions: Pelvic girdle pain in pregnancy is a common condition that is often overlooked as a normal part of pregnancy but has a significant impact on quality of life during, after, and in subsequent pregnancies. Multimodal therapies are available and are largely low cost and noninvasive. Relevance: Our aim is to increase the awareness of pelvic girdle pain in pregnancy as a common but often underdiagnosed and undertreated condition.

Self efficacy associated with regression from pregnancy-related pelvic girdle pain and low back pain following pregnancy.

BACKGROUND: Self-efficacy, one's ability to deal with pain, disability, and other symptoms through self-management techniques, positively affect the quality of life in patients with chronic diseases. Pregnancy-related back pain is a common musculoskeletal disorder pre- and postnatally. Hence, the study aimed to determine whether self-efficacy is associated with the development of back pain during pregnancy. METHODS: Between February 2020 and February 2021, a prospective case-control study was performed. Women with back pain were included. The self efficacy was assessed by the Chinese version of the General Self-efficacy Scale (GSES). Pregnancy-related back pain was measured using a self-reported scale. No regression from pregnancy-related back pain is defined as a recurrent or persistent pain score ≥ 3 over a week around 6 months postpartum. Women experiencing back pain during pregnancy are classified according to whether having a regression. This problem can be divided into pregnancy-related low back pain (LBP) and posterior girdle pain (PGP). The differences in variables were compared between groups. RESULTS: A total of 112 subjects have completed the study finally. These patients were followed up with an average of 7.2 months after childbirth ranging from six to 8 months. 31 subjects (27.7%) of the included women did not report regression 6 months postpartum. The mean self efficacy was 25.2 (SD:10.6). Patients with no regression tended to be older (LBP:25.9 ± 7.2 vs.31.8 ± 7.9, P = 0.023; PGP: 27.2 ± 7.9 vs. 35.9 ± 11.6, P < 0.001*), have a lower self efficacy (LBP:24.2 ± 6.6 vs.17.7 ± 7.1, P = 0.007; PGP: 27.6 ± 6.8 vs. 22.5 ± 7.0, P = 0.010), and need high daily physical demand in their vocations (LBP:17.4% vs. 60.0%, P = 0.019; PGP: 10.3% vs. 43.8%, P = 0.006) when compared to those with regression. Multivariate logistic analysis shows that risk factors for no regression from pregnancy-related back pain included LBP (OR = 2.36, 95%CI = 1.67-5.52, P < 0.001), pain ratings of the onset of back pain during pregnancy≥3(OR = 2.23, 95%CI = 1.56-6.24, P = 0.004), low self efficacy (OR = 2.19, 95%CI = 1.47-6.01, P < 0.001), and high daily physical demand in their vocations (OR = 2.01, 95%CI = 1.25-6.87, P = 0.001). CONCLUSIONS: Low self efficacy makes the women experience about two-fold risk to experience no regression from pregnancy-related back pain. Evaluation for self efficacy is simple enough to be used to improve perinatal health.

The effect of gestational diabetes mellitus on occurrence of the pelvic girdle pain and symptom severity in pregnant women.

The primary objective of this study was to examine the effect of gestational diabetes mellitus (GDM) on pelvic girdle pain (PGP) occurrence and symptom severity. Pregnant women who were with/without GDM, 20-40 years of age, and also in the second and third trimesters of pregnancy were included in the study. PGP provocation tests were administered to 187 pregnant women to determine the presence and severity of PGP. Based on the test results, the study subjects were divided into two groups; Group 1 (GDM+, PGP+; n:32) and Group 2 (GDM-, PGP+; n:35). Both groups were asked to fill in the Pelvic Girdle Questionnaire (PGQ). The relationship between the presence of GDM and the presence of PGP was found to be significant (p = .043). It was found the groups were similar in view of pain, and also in PGQ total/subscale scores (p > .05). Although GDM has no effect on symptom severity, it has been determined that it may relate to the development of PGP. Therefore, early interventions (nutrition, exercise, belt using, etc.) are recommended to prevent the development of PGP in pregnant women with a family history of diabetes, with a previous diagnosis of diabetes and/or with GDM detected in their previous pregnancies. Clinical Trial Number: 04769375Impact of StatementWhat is already known on this subject? Gestational diabetes mellitus and pelvic girdle pain are pathologies that develops secondary to pregnancy-related systemic and biomechanical changes.What do results on this study add? GDM may related the development of PGP.What are the implications of these findings for clinical practice and/or further research? Early interventions (nutrition, exercise, belt using, etc.) and strict control of pregnant women in view of PGP is recommended to prevent the development of PGP in pregnant women with a family history of diabetes, with previous diagnosis of diabetes and/or with GDM detected in their previous pregnancies. The evaluation of pregnant women for PGP before administering interventions, such as exercise and diet (both decrease the pro-inflammatory markers), following the diagnosis of GDM and the measurement of plasma anti- and pro-inflammatory marker values in the same time period will further reveal the relationship between GDM and PGP.

Postpartum septic symphysitis, a rare condition with possible long-term consequences: a cohort study with long-term follow-up.

BACKGROUND: Postpartum septic symphysitis (PPSS) is defined as acute onset of severe pain around the symphysis, restricted movement, fever, and elevated inflammatory parameters. It is a rare but serious condition requiring urgent diagnosis and treatment. The aim of this study was to describe the incidence, symptoms, diagnosis, treatment, and long-term follow-up of PPSS. METHODS: This follow-up study included 19 out of 21 women diagnosed with PPSS from 1989 to 2017 at one tertiary care hospital in Sweden. Clinical data were retrieved from hospital records and compared to those retrieved from a regional registry. Women completed a postal questionnaire, and those who reported lumbopelvic pain (LPP) were offered a clinical examination. RESULTS: 1) PPSS was diagnosed after a normal postpartum period of 24 to 50 h by blood tests (n = 19/19), ultrasonography (n = 9 /19), computer tomography (n = 8/19) or magnetic resonance imaging (n = 16/19) Treatment included aspiration of symphyseal abscesses, i.v. antibiotics and different physiotherapeutic interventions. Women with PPSS more frequently were primiparous (n = 14/19, p = 0.001), had an instrumental delivery (n = 14/19, p = 0.003), longer time of active labour (p = 0.01) and second stage of labour (p = 0.001) than women in the regional registry. 2) Ten out of 19 (52%) women reported LPP at follow-up. These women more often suffered impaired function related to LPP (Pelvic Girdle Questionnaire, 27 versus 0, p < 0.0001), a poorer health-related quality of life (EuroQol-5 dimensions p = 0.001 and EuroQol-visual analogue scale, 65 mm versus 84 mm, p = 0.022) and higher levels of anxiety and depression (Hospital Anxiety Depression Scale (HADS) HADS-Anxiety, 7 versus 2, p = 0.010; and HADS-Depression, 1 versus 0, p = 0.028) than women with no pain. 3). Of the eight women who were clinically assessed, one had lumbar pain and seven had pelvic girdle pain (PGP). CONCLUSIONS: In the largest cohort of patients with PPSS to date, primiparas and women with instrumental vaginal delivery were overrepresented, indicating that first and complicated deliveries might be risk factors. Approximately half of the women reported PGP at follow-up, with considerable consequences affecting health-related quality of life and function decades after delivery. Prospective multicentre studies are needed to establish risk factors, long-term consequences, and adequate treatment for this rare pregnancy complication.

Nódulos de Copeman, una causa frecuente pero poco conocida de dolor lumbar: presentación de un caso / Copeman nodules, a frequent but little known cause of low back pain; case report

Los nódulos de Copeman o lipomas episacrales son una entidad muy prevalente en la población general. Consisten en herniaciones de la grasa subfascial en la región episacral, a través de zonas debilitadas de la fascia toracodorsal suprayacente. Generalmente son bilaterales y simétricos, y solo en raras ocasiones dan manifestaciones clínicas. Presentamos el caso de una mujer de 63 años que acude por dolor lumbar refractario a los tratamientos convencionales. La exploración ecográfica sugiere el diagnóstico de nódulos de Copeman. Se aborda el tratamiento de la paciente desde una perspectiva multidisciplinar, decidiendo finalmente intervenirla quirúrgicamente. Tras la intervención la clínica remitió al poco tiempo, permitiendo a la paciente seguir una vida normal sin molestias ni tratamiento analgésico (AU)

Copeman nodules or episacral lipomas are a very prevalent entity in the general population. They consist of subfascial fat herniations at the episacral region, through weakened areas of the overlying thoracodorsal fascia. They are usually bilateral and symmetric. Only in rare cases they are the cause of clinical manifestations. We present the case of a 63-year-old woman who presents with lumbar pain refractory to conventional treatments. Ultrasound examination suggests the diagnosis of Copeman nodules. The treatment of the patient is approached from a multidisciplinary perspective, finally deciding to operate the patient. After the intervention, the symptoms remitted shortly, allowing the patient to continue a normal life without discomfort or analgesic treatment (AU)

Risk factors for pregnancy-related pelvic girdle pain: a scoping review.

BACKGROUND: Pregnancy-related Pelvic Girdle Pain (PPGP) is a common complaint. The aetiology remains unclear and reports on risk factors for PPGP provide conflicting accounts. The aim of this scoping review was to map the body of literature on risk factors for experiencing PPGP. METHODS: We searched the databases PubMed, Embase, CINAHL, PsycINFO, MIDIRS, and ClinicalTrial.gov (3 August 2020). We selected studies with two reviewers independently. Observational studies assessing risk factors for PPGP were included. Studies examining specific diagnostic tests or interventions were excluded. RESULTS: We identified 5090 records from databases and 1077 from ClinicalTrial.gov. Twenty-four records met the inclusion criteria. A total of 148 factors were examined of which only 14 factors were examined in more than one study. Factors that were positively associated with PPGP included a history of low back or pelvic girdle pain, being overweight/obese, already having a child, younger age, lower educational level, no pre-pregnancy exercise, physically demanding work, previous back trauma/disease, progestin-intrauterine device use, stress, depression and anxiety. CONCLUSIONS: A large number of factors have been examined as potential risk factors for PPGP, but there is a lack of repetition to be able to draw stronger conclusions and pool studies in systematic reviews. Factors that have been examined in more than five studies include age, body mass index, parity and smoking. We suggest a systematic review be conducted to assess the role of these factors further in the development of PPGP.

Occurrence of combined pain in the lumbar spine, pelvic girdle and pubic symphysis among pregnant women in the extreme south of Brazil. / Ocorrência de dor combinada na coluna lombar, cintura pélvica e sínfise púbica entre gestantes do extremo sul do Brasil.

OBJECTIVES: To estimate the prevalence and characterize the occurrence of low back pain (LBP), posterior pelvic girdle pain (PPGP) and pubic symphysis pain (PSP) among pregnant women resident in Rio Grande, RS. METHODS: This was a cross-sectional study of all postpartum women who gave birth in 2016. Two pictures were used to investigate the presence of LBP, PPGP and PSP, both isolated and combined. Multinomial logistic regression was used to evaluate the factors associated with each symptom. RESULTS: LBP was reported by 42.2%, PSP by 4.9%, and PPGP by 2%, while LBP + PSP was reported by 9%, LBP and PPGP by 2.8% and PPGP + PSP by 1.1%, and pain in all three regions was reported by 3.9% of the sample. The more advanced the age of the pregnant women, the risk for LBP and of LBP combined with one of the pelvic girdle regions was reduced, while the risk for PPGP + PSP was increased. Depression during pregnancy increased the risk for all symptom combinations. CONCLUSION: This study provided a detailed description of the occurrence of the evaluated outcomes and its associated factors. Studies like this are rare in Brazil, especially a census with low rates of losses and refusals. The high prevalence of the evaluated symptoms suggests that it should be investigated routinely in prenatal care, taking into account the age of the pregnant women, depressive symptoms and those experiencing combined or intense pain.

Arcuate Pubic Ligament Injury-An Unknown Cause of Athletic Pubalgia.

A case report is presented that gives new insight into a very rare cause of athletic pubalgia. Up till now, no case has been published in literature about the relevance of an arcuate pubic ligament (APL) injury in athletic pubalgia. The APL or inferior pubic ligament is a thick triangular arch of ligamentous fibers connecting the 2 pubic bones below. The main function of the APL is to stabilize the symphysis pubis. The rupture of this ligament can lead to groin pain due to lack of stabilization of the symphysis pubis. Despite the importance of the anatomical and clinical function of the APL, very limited research is available about injuries of this ligament. This report describes a case of a traumatic left APL rupture, confirmed by magnetic resonance imaging, causing longstanding left groin pain in an amateur athlete.

Ocorrência de dor combinada na coluna lombar, cintura pélvica e sínfise púbica entre gestantes do extremo sul do Brasil / Occurrence of combined pain in the lumbar spine, pelvic girdle and pubic symphysis among pregnant women in the extreme south of Brazil

RESUMO: Objetivos: Estimar a prevalência e caracterizar a ocorrência de dor lombar gestacional (DLG), dor na cintura pélvica posterior (DCPP) e dor na sínfise púbica (DSP) entre gestantes residentes em Rio Grande, RS. Métodos: Estudo transversal realizado com todas as puérperas com parto em 2016. Foram utilizadas duas figuras para investigar a presença de DLG, DCPP e DSP de forma isolada ou combinada. Regressão logística multinomial foi usada para avaliar os fatores associados a cada sintoma. Resultados: DLG foi referida por 42,2% das entrevistadas, DSP por 4,9%, e DCPP por 2%, enquanto DLG + DSP por 9%, DLG + DCPP por 2,8%, DCPP + DSP por 1,1% e dor nas três regiões por 3,9% delas. Quanto maior era a idade da gestante, menor foi o risco de DLG e de DLG combinada a uma das regiões da cintura pélvica e maior o risco de DCPP + DSP. Depressão na gestação aumentou o risco de todas as combinações dos sintomas. Conclusão: Este estudo realizou uma descrição mais detalhada da ocorrência dos desfechos avaliados e de seus fatores associados. Estudos como este são raros no país, sobretudo com baixas taxas de perdas e recusas. A elevada prevalência dos sintomas avaliados sugere que sua investigação seja rotineira nas consultas de pré-natal, atendo-se a idade das gestantes, sintomas depressivos e a dores combinadas e intensas.

ABSTRACT: Objectives: To estimate the prevalence and characterize the occurrence of low back pain (LBP), posterior pelvic girdle pain (PPGP) and pubic symphysis pain (PSP) among pregnant women resident in Rio Grande, RS. Methods: This was a cross-sectional study of all postpartum women who gave birth in 2016. Two pictures were used to investigate the presence of LBP, PPGP and PSP, both isolated and combined. Multinomial logistic regression was used to evaluate the factors associated with each symptom. Results: LBP was reported by 42.2%, PSP by 4.9%, and PPGP by 2%, while LBP + PSP was reported by 9%, LBP and PPGP by 2.8% and PPGP + PSP by 1.1%, and pain in all three regions was reported by 3.9% of the sample. The more advanced the age of the pregnant women, the risk for LBP and of LBP combined with one of the pelvic girdle regions was reduced, while the risk for PPGP + PSP was increased. Depression during pregnancy increased the risk for all symptom combinations. Conclusion: This study provided a detailed description of the occurrence of the evaluated outcomes and its associated factors. Studies like this are rare in Brazil, especially a census with low rates of losses and refusals. The high prevalence of the evaluated symptoms suggests that it should be investigated routinely in prenatal care, taking into account the age of the pregnant women, depressive symptoms and those experiencing combined or intense pain.

The effects of pelvic belt use on pelvic alignment during and after pregnancy: a prospective longitudinal cohort study.

BACKGROUND: Pelvic alignment changes during pregnancy and post-childbirth. Pelvic belts exert external forces that compress and stabilize the joints, and therefore, could influence pelvic alignment. However, limited information is available regarding this potential effect. Therefore, the purpose of this study is to investigate the influence of pelvic belt use on pelvic alignment during and after pregnancy. METHODS: Data of 201 pregnant women in late pregnancy and 1 month after childbirth were used. Pelvic alignment measurements, including anterior and posterior pelvic width, pelvic asymmetry, and pelvic belt use during and after pregnancy were investigated. Participants were divided into four groups according to pelvic belt use: before and after childbirth (BAC), before childbirth only (BC), after childbirth only (AC), and non-use (NU). Then, an initial one-way ANOVA was conducted to compare the amount of change in pelvic alignment from late pregnancy to post-childbirth between the groups. After the initial analysis, a multivariate regression analysis was performed to determine the statistically significant differences between the groups to consider other factors that influenced pelvic alignment such as age, BMI, number of previous childbirths, vaginal delivery and pelvic asymmetry in late pregnancy. Next, a cutoff point for subgroup stratification based on the weekly duration of pelvic belt use and inter-group changes in pelvic alignment were compared. RESULTS: As the result of the initial one-way ANOVA, the decrease in pelvic asymmetry from during pregnancy to postpartum for BAC was greater than that for AC. Moreover, multiple regression analysis showed that the effect of pelvic belt that was revealed in the initial analysis was statistical significance even after adjustment for other factors. Moreover, pelvic asymmetry in the BAC group decreased, compared to being increased or unchanged in the NU and AC groups when the group cutoff time was 7 h per week. CONCLUSIONS: Continuous and extended use of pelvic belts during and after pregnancy might be related to modifications of pelvic asymmetry in the perinatal period. Therefore, the instruction of correct and comfortable usage and the recommendation of continuous use of pelvic belt especially during pregnancy are required for prevention of some discomforts related to pelvic malalignment.

Building a Collaborative Model of Sacroiliac Joint Dysfunction and Pelvic Girdle Pain to Understand the Diverse Perspectives of Experts.

BACKGROUND: Pelvic girdle pain (PGP) and sacroiliac joint (SIJ) dysfunction/pain are considered frequent contributors to low back pain (LBP). Like other persistent pain conditions, PGP is increasingly recognized as a multifactorial problem involving biological, psychological, and social factors. Perspectives differ between experts and a diversity of treatments (with variable degrees of evidence) have been utilized. OBJECTIVE: To develop a collaborative model of PGP that represents the collective view of a group of experts. Specific goals were to analyze structure and composition of conceptual models contributed by participants, to aggregate them into a metamodel, to analyze the metamodel's composition, and to consider predicted efficacy of treatments. DESIGN: To develop a collaborative model of PGP, models were generated by invited individuals to represent their understanding of PGP using fuzzy cognitive mapping (FCM). FCMs involved proposal of components related to causes, outcomes, and treatments for pain, disability, and quality of life, and their connections. Components were classified into thematic categories. Weighting of connections was summed for components to judge their relative importance. FCMs were aggregated into a metamodel for analysis of the collective opinion it represented and to evaluate expected efficacy of treatments. RESULTS: From 21 potential contributors, 14 (67%) agreed to participate (representing six disciplines and seven countries). Participants' models included a mean (SD) of 22 (5) components each. FCMs were refined to combine similar terms, leaving 89 components in 10 categories. Biomechanical factors were the most important in individual FCMs. The collective opinion from the metamodel predicted greatest efficacy for injection, exercise therapy, and surgery for pain relief. CONCLUSIONS: The collaborative model of PGP showed a bias toward biomechanical factors. Most efficacious treatments predicted by the model have modest to no evidence from clinical trials, suggesting a mismatch between opinion and evidence. The model enables integration and communication of the collection of opinions on PGP.

Form and Force Closure of the Sacroiliac Joints.

The principles of form and force closure were introduced to describe the complex mechanism of sacroiliac joint (SIJ) stability. Form closure refers to a theoretical stable state of a joint with close fitting articular surfaces, where no extra forces are needed to maintain the stable state of the system during loading and unloading situations. If the sacrum would fit in the pelvis with perfect form closure, no lateral compressional forces would be needed to maintain stability. However, such a construction would make mobility practically impossible. Force closure is the theoretical state where lateral force and friction resulting in joint compression, are required for the joint to withstand a vertical load. Structures that contribute to SIJ stability via "form closure" include (1) the configuration of the interfacing joint surfaces, along with dorsocranial "wedging" of the sacrum into the ilia; (2) the corresponding ridges and grooves of the articular surfaces of the SIJs and resultant high coefficient of friction; and (3) the integrity of the binding ligaments, which are among the strongest in the body. Shearing forces absorbed in the SIJ occur because of a combination of person-specific anatomical features. This results in unique form and force closure situations that provide effective and tailored joint accommodation that balance both friction and compression in the joint. Force closure occurs because of altered joint reaction force via taut ligaments, fascia, muscles, and the ground reaction force they are reacting to at the moment. In the ideal state, force closure creates a perpendicular compressive reaction force to the SIJ to adapt and overcome the forces of gravity. In order for force closure to be effective, sacral nutation must occur and is considered to be anticipatory for joint loading. Sacral nutation results in tensing all of the dorsal SIJ ligaments (interosseous, dorsal sacroiliac) with the exception of one, the long dorsal ligament (LDL). This prepares the pelvis to absorb and increase in load. As a result, the posterior ilium are pressed together causing an increase in SIJ compression. This review will discuss the importance of understanding form and force closure principles because they are related to understanding the relationship of anatomy and function of the SIJ.

Prevalence of Low Back Pain, Pelvic Girdle Pain, and Combination Pain in a Pregnant Ontario Population.

OBJECTIVE: The purpose of the current pilot study is to determine the point and period prevalence of site-specific back pain, low back pain (LBP), pelvic girdle pain (PGP), and combined pain (Combo Pain) in pregnant women at a large urban centre in Ontario. METHODS: Point and period prevalence for LBP, PGP, and Combo Pain were determined using a questionnaire and accompanying pain diagram. Women were included in the study if they were healthy, of child-bearing age (18-45 years), currently experiencing a singleton pregnancy (any trimester), and proficient in the English language. RESULTS: Data collected from 287 women were included in the analysis. Three-quarters of women suffered from some sort of pregnancy-related back pain. The point and period prevalences for women who were experiencing LBP, PGP, and Combo Pain were 15.7%, 17.8%, and 15.3% and 33.4%, 27.9%, and 30.7%, respectively. Secondary analyses demonstrated that increasing GA and suffering from both pains at some point prior to pregnancy (Prior Both) increased the risk of experiencing PGP and Combo Pain during pregnancy, respectively. CONCLUSION: The current study demonstrates that 76% of sampled women experienced pregnancy-related back pain and the prevalence of site-specific pain (LBP, PGP, and Combo Pain) increases with increased gestation. Risk factors include advanced GA and experiencing both types of pain prior to pregnancy (Prior Both). Furthermore, it is suggested that a standard definition of pain by location should be developed and employed so that future studies can elucidate appropriate prevention strategies and treatment options for each.

Prognostic factors for pregnancy-related pelvic girdle pain, a systematic review.

BACKGROUND: Pregnancy-related Pelvic Girdle Pain (PPGP) is a very common complaint. Although many women recover after a birth, about a third continue to have symptoms three months postpartum and 8.5% of women still have persistent symptoms two years afterwards. Knowledge of prognostic factors may help understand the course of PPGP and inform management. OBJECTIVES: To determine the prognostic factors for PPGP by systematically reviewing the literature. DESIGN: Systematic review. METHODS: We searched PubMed, Embase, CINAHL, PsycINFO, MIDIRS, and ClinicalTrial.gov (15 April 2017) with no filters. Only studies reported in English were included. Two review authors independently selected studies. Any factors that might affect the course of PPGP up to one year postpartum were of interest. We excluded interventions and diagnostic studies. We conducted double independent data extraction, risk of bias and quality of evidence (GRADE) assessment. FINDINGS: We identified 4374 citations of which three studies were included in our analysis. Previous low back pain, pain in three to four pelvic locations, and being overweight/obese made recovery 12 weeks postpartum less likely. Six months postpartum, Pelvic Girdle Syndrome (PGS) was more likely to persist in women who used crutches or had severe pain in three pelvic locations during pregnancy, had other pain conditions, a younger age of menarche, previous low back pain or a high co-morbidity index, were obese, or experienced emotional distress during pregnancy. For women who used crutches during pregnancy, an instrumental birth or caesarean section was associated with persistent PGS. However, the quality of evidence (GRADE) was low to very low for all factors, hence, findings are uncertain. KEY CONCLUSIONS: The limited number of studies and lack of replication prevents us from drawing definitive conclusions. IMPLICATIONS FOR PRACTICE: Potentially modifiable factors during pregnancy seem to impact the prognosis of PPGP postpartum.

[Relationship between perineal characteristics and symptoms and pelvic girdle pain: A literature review]. / Caractéristiques et symptômes pelvi-périnéaux dans les douleurs de la ceinture pelvienne : une revue de la littérature.

INTRODUCTION: Pelvic girdle pain (PGP) is characterized by the presence of pain in the posterior pelvic area, distally and laterally to the fifth lumbar vertebra, and/or at the pubic symphysis. PGP is a very common pain condition in women, especially during pregnancy and postpartum. After delivery, pain prevalence decreases to 7 % in the first three months. The current literature describes an association between pelvic girdle pain and different perineal characteristics and symptoms. OBJECTIVES: A better understanding of perineal structures influence on PGP could assist towards the management of this condition. The aim of this review is to describe the peer-reviewed literature about perineal function in patients with PGP. METHODS: A bibliographic search on PubMed was conducted. The key words used were: pelvic girdle pain, pregnacy-related low back pain, lumbopelvic pain, posterior pelvic pain, peripartum pelvic pain, pelvic girdle relaxation, pelvic joint instability, peripartum pelvic pain, sacroiliac joint pain, sacroiliac joint dysfunction, sacroiliac-joint related pelvic pain and pelvic floor. Two hundred and twenty-one (221) articles were identified. Out of them, a total of nine articles were selected. The level of evidence was determined using Oxford's scale. RESULTS: Patients with PGP showed increased activity of the pelvic floor muscles (P=0.05) (LE3), decreased urogenital hiatus area (PGP 12.4 cm2±2.7, control 13.7 cm2±2.8, P=0.015) (LE3), shorter endurance time (PGP 17.8 s; control 54.0 s, P=0.00) (LE3), significantly later onset time during affected side leg elevation (PGP 25ms, control -129ms, P=0.01) (LE3), levator ani and obturator internus tenderness (PGP 25/26; control 5/25, P<0.001) (LE3) and a higher prevalence of vesico-sphincteric disorders compared to asymptomatic subjects (LE3). CONCLUSION: This review confirms that subjects suffering PGP present particular perineal characteristics regarding morphology and biomechanics. It would be interesting to develop clinical research concerning pelvic floor release effect in PGP.

The Severity and Impact of Pelvic Girdle Pain and Low-Back Pain in Pregnancy: A Multinational Study.

BACKGROUND: Pelvic girdle pain (PGP) and low-back pain (LBP) are the most common musculoskeletal disorders experienced during pregnancy, yet they are not familiar to healthcare providers in some countries. The objective was to compare prevalence, severity, and impact of PGP and LBP among pregnant women in the United States, the United Kingdom, Norway, and Sweden. Women's desires for, access to, and experience of treatment were also examined. MATERIALS AND METHODS: This is a cross-sectional self-reported questionnaire study of pregnant women, recruited at maternity care units in gestational weeks 30-38. Main outcome measures were presence and impact of PGP and/or LBP. RESULTS: A total of 869 pregnant women from the United States (n = 214), the United Kingdom (n = 220), Norway (n = 220), and Sweden (n = 215) were included. PGP and/or LBP were reported by 70%-86%, with lowest prevalence in Scandinavia. Severity and impact differed significantly across countries (p < 0.001), with U.K. women reporting the highest pain intensity (Numeric Rating Scale [NRS] 7/10) and highest mean total score on the Pelvic Girdle Questionnaire (PGQ) (46/100). U.S. women were significantly less afflicted, with mean PGQ total score 35/100 (p ≤ 0.001). The countries differed regarding concern about PGP and/or LBP (p < 0.001), with U.K. women being most affected (NRS 5/10). Norwegian women were most likely to receive treatment (53%) and U.S. women least likely (24%) (p < 0.001). Among women receiving treatment, 68%-87% reported a positive effect. CONCLUSIONS: PGP and/or LBP during pregnancy are common in the United States, the United Kingdom, Norway, and Sweden. Severity, concern, and treatment experiences differed across countries. The majority of women who received treatment reported a positive effect.

Adaptation to a changed body. Experiences of living with long-term pelvic girdle pain after childbirth.

PURPOSE: To explore how women experience living with long-term pregnancy-related pelvic girdle pain. MATERIALS AND METHODS: Nine women with persistent pregnancy-related pelvic girdle pain of 2-13 years were recruited by means of purposive sampling from long-term follow-up studies. The women were 28-42 years of age and had given birth to 2-3 children. Audio-taped in-depth interview with open-ended questions were used with the guiding question 'How do you experience living with pregnancy-related pelvic girdle pain?'. The Empirical Phenomenological Psychological method was chosen for analysis. RESULTS: The pregnancy-related pelvic girdle pain syndrome has a profound impact on everyday life for many years after pregnancy. Three constituents were identified as central to the experience of living with pregnancy-related pelvic girdle pain: (1) the importance of the body for identity, (2) the understanding of pain, and (3) stages of change. The manner in which the women experienced their pain was interpreted in terms of two typologies: the ongoing struggle against the pain, and adaptation and acceptance. CONCLUSION: The participants' narratives highlighted that the pain led to severe functional limitations that threatened their capability to perform meaningful daily activities, and interfered with their sense of identity. It appears essential to meet with each patient individually and to manage long-term pregnancy-related pelvic girdle pain as a pain syndrome. IMPLICATIONS FOR REHABILITATION Chronic pregnancy-related pelvic girdle pain • Pregnancy-related pelvic girdle pain impairs women's capacity to perform meaningful activities of daily life for many years after pregnancy. • The participants' narratives highlighted that the pain interfered with their sense of identity. • It appears essential to meet with each patient individually and to manage long-term pregnancy-related pelvic girdle pain as a pain syndrome.

Low Back Pain and Pelvic Girdle Pain in Pregnancy.

Pregnancy has a profound effect on the human body, particularly the musculoskeletal system. Hormonal changes cause ligamentous joint laxity, weight gain, and a shift in the center of gravity that leads to lumbar spine hyperlordosis and anterior tilting of the pelvis. In addition, vascular changes may lead to compromised metabolic supply in the low back. The most common musculoskeletal complaints in pregnancy are low back pain and/or pelvic girdle pain. They can be diagnosed and differentiated from each other by history taking, clinical examination, provocative test maneuvers, and imaging. Management ranges from conservative and pharmacologic measures to surgical treatment. Depending on the situation, and given the unique challenges pregnancy places on the human body and the special consideration that must be given to the fetus, an orthopaedic surgeon and the obstetrician may have to develop a plan of care together regarding labor and delivery or when surgical interventions are indicated.

Adherence, tolerance and effectiveness of two different pelvic support belts as a treatment for pregnancy-related symphyseal pain - a pilot randomized trial.

BACKGROUND: Pregnancy-related pubic symphysis pain is relatively common and can significantly interfere with daily activities. Physiotherapist-prescribed pelvic support belts are a treatment option, but little evidence exists to support their use. This pilot compared two pelvic belts to determine effectiveness (symptomatic relief), tolerance (comfort) and adherence (frequency, duration of use). METHODS: Unblinded, 2-arm, single-center, randomized (1:1) parallel-group trial. Twenty pregnant women recruited from the community (Dunedin, New Zealand), with physiotherapist-diagnosed symphyseal pain, were randomly allocated to wear either a flexible or rigid belt for three weeks. One author, not involved in data collection, randomized the allocation to trial group. The unblinded primary outcome was the Patient Specific Functional Scale (PSFS). Secondary outcomes were pain intensity during the preceding 24 hours and preceding week (visual analogue scale [VAS]), and disability (Modified Oswestry Disability Questionnaire [MODQ]). Duration of use (hours) was recorded daily by text messaging. Participants were assessed at baseline, by weekly phone interviews and at intervention completion (three weeks). To assess comfort, women wore the alternate belt in the fourth week. RESULTS: Twenty pregnant women (mean ± SD age, 29.4 ± 6.5 years; mean gestation at baseline, 30.8 ± 5.2 weeks) were randomized to treatment groups (flexible = 10, rigid =10) and all were included in analysis. When adjusted for baseline, PSFS scores were not significantly different between groups at follow up (mean difference -0.1; 95% CI: -2.5 to 2.3; p =0.94). Pain in the preceding 24 hours reached statistical significance in favor of the flexible belt (VAS, p = 0.049). Combining both groups' data, function and pain were significantly improved at three weeks (mean difference -2.3; 95% CI: 1.2 to 3.5; p< 0.001). Belts were worn for an average of 4.9 ± 2.9 hours per day; women preferred the flexible belt. No adverse events were reported. CONCLUSION: These preliminary results suggest the flexible pelvic support belt may be more effective in reducing pain and is potentially better tolerated than a rigid belt. Based on these data, a larger trial is both feasible and clinically useful. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12614000898651 , 25th August, 2014.