Susannah Britnell, PSD Communications Committee member
Imagine you are 32 weeks pregnant with your first child (even you men out there!) and you start to have pain in the low back and pubic area when you change position, sit or stand for longer periods or when you walk. The pain makes it very difficult for you to function and you worry about whether you can continue to work and manage your household. You are also concerned about the upcoming delivery and whether you will be even be able to care for your baby, an often seemingly overwhelming task without having to deal with pain.
Now imagine you have seen your health care provider and have been told that your pelvis is separating because of the hormone Relaxin and that you need to put up with this until after you have your baby, as “it will probably get better afterwards”. “Be careful” “If it hurts, don’t do it”, “ Your pubic bone is splitting”, “ Your pelvis is unstable”. These are common words of advice or explanations pregnant women with pelvic girdle pain (PGP) receive from their healthcare providers, including physiotherapists. As physiotherapists, we understand that our sacroiliac or pubic joints can’t fall apart while we are walking around or turning over in bed, and most, if not all of us, have kept moving while experiencing some pain, but if we really take time to think about it, our patients often don’t have this education, knowledge or experience; they may worry that moving with pain could be dangerous and could make them worse. Naturally, the words we choose to use with our patients can reinforce these misconceptions.
As physiotherapists, we are inspired to help our patients, and to give them the best information and advice we possibly can. However, when we are treating pregnant women with PGP, too many of us are off the mark, so to speak. Perhaps this is because there is the thought that PGP is temporary, merely a result of hormonal change and that treatment is not needed or helpful in pregnancy. Perhaps there is a fear or lack of confidence in treating pregnant women. Too many times, pregnant women are told that there is nothing that can be done and are given a hot pack and told to “take it easy”.
Pelvic girdle pain is characterized by pain around the pubic and sacroiliac joints, and can present as pain in the inner groin and adductor area, the buttocks and the sides of the hips and is aggravated most commonly by maintaining sustained postures or changing position. PGP affects approximately 16-25% (Kanakaris 2011) of pregnant women, although it is very likely underreported and dismissed as a normal consequence of pregnancy. Prognosis is very good, with a majority of women improving within a few months after delivery and only approximately 5-8.5% (Kanakaris 2011) going on to have persistent symptoms. A combination of hormonal, mechanical, and motor control factors are believed to be factors involved in PGP (Vleeming 2007), contrary to a previous belief that the hormone Relaxin, alone, was responsible. Education and exercise therapy are recommended to manage PGP in pregnancy (Rost 2006, 2004, Vleeming 2007), contrary to the old concept of needing to wait until after delivery to gain any symptomatic improvement.
More recently, we are realizing the importance of central factors and their role in perpetuating pain and impacting prognosis. Lumbopelvic pain in pregnancy is also associated with excessive negative thinking and fear avoidance beliefs (Olsson 2009) and pregnant women with lumbopelvic pain are three times more likely to experience depression (Gutke 2007). Catastrophizing during and after pregnancy has been associated with postpartum lumbopelvic pain and decreased function, as well as more persistent symptoms (Olsson 2012, Olsson 2012). Vollestad (2009) found that ASLR and belief in improvement were statistical significant predictors for both disability and pain as outcome measures. Those who believed they would get better were more likely to improve; amazing but true!
We all have had patients who have voiced fear of pain and moving while experiencing pain, with concerns that this may make their condition worse. You may also, as I have, treated women who worried that their babies could also feel their pain. This helped me realize how differently my patients thought about pain and their condition, and this discovery allowed me to address beliefs that were perpetuating fear and pain avoidance.
One of the most important roles we can play as physiotherapists is as an educator; to correct inaccurate beliefs: our own and our patient’s. In order to educate our patients well, we need to have clear understanding of what we are trying to say. Identifying inaccurate thoughts, particularly if they lead to catastrophizing, can make a significant difference to a woman’s pain experience, even before any other treatment/management strategies are implemented. Before and in addition to any manual therapy and or exercises we give to our patients, we should make clear accurate communication a priority. Urban myths regarding breastfeeding being associated with laxity-related musculoskeletal pain should be put to rest. Suggestions to “be careful” (suggesting fragility), restrict function (reinforcing disability), to rest more and avoid activity (usually makes symptoms worse) should be set aside. Too many women have weaned their babies early, in hopes this would alleviate their PGP, a decision based upon “helpful” advice, often from their physiotherapist, despite the fact that there is no evidence to support this. Many women are sadly advised not to lift their babies for several weeks after delivery in order to not aggravate their PGP. Imagine the logistics with that, let alone the heartache.
The good news is that PGP can be managed very successfully, and women can be shown effective self management programs which allow them to take control of their own care and become more confident, comfortable and active during their pregnancies. Women can be shown how to integrate good strategies into daily activities so that they can manage work, daily activities and child/baby care independently during pregnancy and postpartum.
Studies have also shown that vaginal deliveries are not only safe for women with PGP, they are even preferable. Bjelland (2012) found a 2-3 fold increased risk of severe PGP postpartum in women with PGP after a planned Cesarean Section. It is interesting that association between breastfeeding and persistent pain has not been established despite the insidious myth that breastfeeding causes laxity and musculoskeletal pain; in fact, a new study shows that those who breastfed for a shorter period were more likely to have PGP rather than the reverse (Bjelland 2014).
If the prognosis is so good for pregnant women with PGP, why should we be concerned? Two answers come to light. Firstly, pregnant women deserve to have as pleasant an experience of pregnancy as possible, and if we can help them to reduce pain and improve their function, then it’s our duty to do so. Secondly, that small percentage of women who develop persistent symptoms most likely make up a large proportion of women coming in to see us for treatment with long standing back pain which never improved after a pregnancy or delivery years ago. Most women do not make a connection between the PGP they experienced in a past pregnancy and the daily back pain they now experience. Along the way, these women may have developed poor coping patterns, anxiety, catastrophizing, and experienced many losses which accompany persistent pain, all which will perpetuate pain and dysfunction. At the Centre for Pelvic Pain and Endometriosis at BC Women’s Health Centre in Vancouver, where I am very grateful to be working, early research shows a very high percentage of our persistent pelvic pain patients have unresolved PGP and addressing this can make a significant positive impact on their pain and function.
I believe physiotherapists have a privileged role in helping to shape the experience of pregnant women with PGP. Misguided statements such as, “You need to be careful”, “Your pelvis is unstable”, “Your pubic joint is splitting”, “You must keep your legs together” are not only inaccurate, they are harmful. Physiotherapists are in the ideal position to calm anxiety, correct misconceptions and educate our patients about their condition in a way that decreases the threat of their pain and gives them permission to move. Our management approach should always include education that is clear, accurate and presented in a way that reduces the threat and therefore the fear of pain. What could be better than instilling confidence, promoting freedom to move and reducing anxiety in this special group of women? When it comes down to it, isn’t that what working as a physiotherapist is all about?
Susannah Britnell, Registered Physiotherapist
Centre for Pelvic Pain and Endometriosis
Women’s Hospital and Health Centre
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