Pelvic girdle pain, clinical tests and disability in late pregnancy

Associations of physical activity and weight gain during pregnancy with pregnancy-related pelvic girdle pain intensity - A retrospective cohort study

OBJECTIVE

The aims of this study were first, to explore pain trajectories of pelvic girdle pain, and second, to explore if weight gain during pregnancy and/or physical activity before and during pregnancy were associated with the severity of pelvic girdle pain.

METHODS

The study included data from a retrospective cohort study in 2009, with data collection performed via questionnaires. Group-based trajectory modelling was performed on the reported intensity of pelvic girdle pain in each pregnancy month, and associations between the latent classes and physical activity and/or weight gain were assessed.

RESULTS

A total of 569 women were included in the analyses. Five distinct trajectory classes for the course of pelvic girdle pain were identified. A higher body mass index (BMI) increase during pregnancy was negatively associated with the probability of being pain free, with -3.2 percentage points per unit increase in BMI (95 % CI -5.3 to -1.1; p = 0.003), and positively associated with the probability of experiencing early onset moderate to severe pain, +1.1 percentage points per unit increase in BMI (95 % CI 0.2 to 2.1; p = 0.022). Weight gain below recommendations was negatively associated with early onset moderate to severe pain; -10.6 percentage points per unit increase in BMI (95 % CI -18.8to-2.4;p = 0.011). Physical activity in pregnancy was not significantly associated with pain trajectory classes when adjusting for pre-pregnancy variables.

CONCLUSIONS

Our findings suggest that pelvic girdle pain intensity during pregnancy can take multiple courses and is associated with weight gain during pregnancy.

Pelvic girdle pain in pregnancy and early postpartum - prevalence and risk factors in a multi-ethnic cohort

BACKGROUND

Pelvic girdle pain (PGP) is common during and after pregnancy. It has been assumed that Scandinavian women report more PGP than women of other ethnicities. However, there are few population-based studies on ethnic differences and few with ethnicity as risk factor for PGP. The purposes of the present study were: To examine the prevalence of self-reported PGP through pregnancy and early postpartum in a multi-ethnic cohort. To investigate how ethnicity and patient characteristics were associated with risk of PGP during pregnancy and early postpartum. To investigate if clinical and personal factors obtained in gestation week (GW) 15 were associated with PGP in GW28 and postpartum week (PPW) 14.

METHODS

This study analyzed questionnaire data from 823 women from the Stork - Groruddalen mult-iethnic cohort study in Norway. Chi-square tests were used to investigate ethnic differences in prevalence of self-reported PGP, and logistic regression analyses to identify factors associated with self-reported PGP.

RESULTS

Women from South-Asia and Middle East reported 10-20% higher prevalence of self-reported PGP at all time points compared with Western women. Ethnicity was associated with PGP in GW15 and PPW14, adjusted for parity. Pain locations in pelvic area (PGP locations) in GW15, especially combined symphysis and posterior PGP, gave the highest risk (OR=7.4) for PGP in GW28 and in PPW14 (OR = 3.9). Being multiparous was a risk for PGP in PPW14 (OR=1.9).

CONCLUSIONS

Women of South Asian and Middle Eastern background had higher risk of self-reported PGP than Western women. Ethnicity was associated with PGP in GW15 and PPW14, after adjustments for parity. PGP locations in GW15 was the most prominent risk factor for PGP in GW28 and PPW14, whilst ethnicity was not significant in multivariable analyses.

Predictive Factors for Pregnancy-Related Persistent Pelvic Girdle Pain (PPGP): A Systematic Review

Background and Objectives: To identify the most frequently reported predictive factors for the persistency of pregnancy-related pelvic girdle pain (PPGP) at 3-6 months after childbirth in women with PPGP alone or PPGP in association with pregnancy-related lower back pain (PLBP). Methods: Eligibility criteria: Two authors independently selected studies excluding PPGP determined by a specific, traumatic, gynecological/urological cause or isolated PLBP and studies that did not include the presence/absence of PPGP as the the primary outcome. We, instead, included studies with an initial assessment in pregnancy (within 1 month of delivery) and with a follow-up of at least 3 months after delivery. Data sources: The research was performed using the databases of Medline, Cochrane, Pedro, Scopus, Web of Science and Cinahl from December 2018 to January 2022, following the indications of the PRISMA statement 2021 and the MOOSE checklist. It includes observational cohort studies in which data were often collected through prospective questionnaires (all in English). Study appraisal and risk of bias: Two independent authors performed evaluations of the risk of bias (ROB) using the quality in prognostic studies (QUIPS) tool. Synthesis of results: An in-depth qualitative analysis was conducted because, due to a high degree of heterogeneity in the data collection of the included studies and a lack of raw data suitable for quantitative analysis, it was not possible to carry out the originally planned meta-analyses for the subgroups. Results: The research process led to the inclusion of 10 articles which were evaluated using the QUIPS tool: 5 studies were evaluated as low ROB and 5 were evaluated as moderate ROB. High levels of pain in pregnancy, a large number of positive provocation tests, a history of lower back pain and lumbo-pelvic pain, high levels of disability in pregnancy, neurotic behavior and high levels of fear-avoidance belief were identified as strong predictors of long-term PPGP, while there was weak or contradictory evidence regarding predictions of emotional distress, catastrophizing and sleep disturbances. Discussion: The impossibility of carrying out the meta-analysis by subgroups suggests the need for further research with greater methodological rigor in the acquisition of measures based on an already existing PPGP core predictors/outcome sets.

Generalized joint hypermobility and the risk of pregnancy-related pelvic girdle pain: Is body mass index of importance?-A prospective cohort study

INTRODUCTION

Pelvic girdle pain (PGP) affects approximately 50% of pregnant women. The mechanisms are multifactorial but not fully understood. Women with generalized joint hypermobility (GJH) may be vulnerable to load in the pelvic joints during pregnancy. Our aim was to investigate if women with GJH had an increased risk of PGP and higher pain intensity during and after pregnancy, compared with women with normal joint mobility. We also studied if body mass index (BMI) in early pregnancy influenced that risk.

MATERIAL AND METHODS

A prospective cohort study of 356 women, whose data were collected by self-reports and clinical examinations in early and in late pregnancy and 9 months after childbirth. GJH was present with ≥5/9 points on the Beighton score. PGP was defined by a pain drawing and ≥1 positive test. Pain intensity was measured with a visual analogue scale (0-100 mm). We adjusted for age and origin in logistic regression and ordinal logistic regression analysis.

RESULTS

In early pregnancy, 47.1% of the women with GJH had PGP vs 32.6% of women with normal joint mobility (adjusted odds ratio [aOR] 1.76; 95% confidence interval [CI] 0.86-3.62) and had higher odds of reporting higher pain intensity (aOR 2.04; 95% CI 1.02-4.07). The odds of PGP were highest for women with GJH and BMI ≥25 kg/m2 (aOR 6.88; 95% CI 1.34-35.27) compared with women with normal joint mobility and BMI <25 kg/m2 . The estimated associations were weaker and not statistically significant in late pregnancy or after childbirth.

CONCLUSIONS

Women with GJH did not have an increased risk of PGP during or after pregnancy but reported higher pain intensity in early pregnancy compared with women with normal joint mobility. Since women with combined GJH and BMI ≥25 kg/m2 had the highest odds of PGP in early pregnancy, our results may suggest that health care needs to pay attention to and develop methods to reduce the risk of PGP and delay the onset of pain during pregnancy in women with this combination.

Effects of Conventional Exercises on Lower Back Pain and/or Pelvic Girdle Pain in Pregnancy: A Systematic Review and Meta-Analysis

Pregnant women frequently complain of low back discomfort associated with their pregnancies. On their quality of life, it could have a detrimental effect. Pregnancy-related low back pain (LBP) and pelvic girdle pain (PGP) are associated with substantial direct and indirect expenditures. Evidence addressing strategies to treat and prevent these illnesses needs to be clarified. This review aimed to examine the connection between exercise, LBP, and PGP. To find relevant studies (in the English language) that matched the inclusion and exclusion criteria, a systematic search of peer-reviewed literature was carried out using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, Scopus, the Web of Science, Pub Med, and ClinicalTrials.Gov. The publishing window was limited to the previous 10 years (2012-2022). Utilizing Review Manager version 5.4 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen), the results were examined. JADAD ratings were used to evaluate the quality of the included studies. To analyze the endpoints, the mean, standard mean difference (SMD), and 95% confidence intervals (CI) were determined. We chose 16 randomized controlled trials (RCTs) that included 1885 pregnant individuals with pelvic girdle and/or lower back discomfort. The combined data showed that the exercise group had lower VAS scores than the control group. The final result, however, did not significantly differ. Most of the studies had high JADAD scores, ranging from 3 to 5 points. Lower back pain and/or pelvic girdle discomfort during pregnancy are not influenced by exercise; however, women who are provided with a regular exercise program appear to manage the condition effectively with improved functional status.

Lumbopelvic pain and sick leave during pregnancy: A comparison of Italy and Norway

BACKGROUND

Pregnancy-related lumbopelvic pain is a frequently reported musculoskeletal disorder, but few studies have compared data between countries.

OBJECTIVES

Examine prevalence, severity, and sick leave and explore potential risk factors associated with pregnancy-related lumbopelvic pain in Italian women and compare the results to a similar study in Norway, utilizing the same questionnaire.

DESIGN

Cross-sectional.

METHODS

Italian (n = 481) and Norwegian women (n = 435) were allocated from two public hospitals in Rome (Fatebenefratelli San Giovanni Calibita-Isola Tiberina) and Oslo (Oslo University Hospital), as well as four antenatal clinics in Modena (Italy). The questionnaire was completed between gestation weeks 32 and 36, addressing women's experiences of pregnancy-related lumbopelvic pain and sick leave in current week, and retrospectively for prepregnancy, first and second trimesters.

RESULTS

In Italy and Norway, 39% and 57% of pregnant women reported pregnancy-related lumbopelvic pain, respectively, with 11% and 25% experiencing severe pregnancy-related lumbopelvic pain. Pregnancy-related lumbopelvic pain was associated with sick leave in Norway (p < 0.01), but not in Italy (p = 0.66) at late gestation. In both countries, women with pregnancy-related lumbopelvic pain versus those with no pregnancy-related lumbopelvic pain were more likely to be multiparous (Italy: 40% versus 31%, p = 0.06 and Norway: 53% versus 38%, p < 0.01), and have gestational weight gain above guidelines (Italy: 21% versus 13%, p = 0.02% and Norway: 27% versus 14%, p < 0.01) and previous experience of pregnancy-related lumbopelvic pain (Italy: 15% versus 2%, p < 0.01 and Norway: 31% versus 4%, p < 0.01). Maternal exercise (⩾2 times weekly) was associated with less pregnancy-related lumbopelvic pain (Italy: odds ratio = 0.33, 95% confidence interval = 0.11-1.0, p = 0.05 and Norway: odds ratio = 0.55, 95% confidence interval = 0.29-1.0, p = 0.06).

CONCLUSION

We observed high rates of pregnancy-related lumbopelvic pain in Italy and Norway, with Norwegian women reporting the highest prevalence and severity level. While both countries had similar rates of sick leave in late gestation, an association between pregnancy-related lumbopelvic pain and sick leave was observed among Norwegian women only. Health care providers should be proactive in addressing pregnancy-related lumbopelvic pain through open communication and seeking input from pregnant individuals. However, it is essential to acknowledge that the current evidence on effective treatments remains limited and inconclusive, highlighting the need for further research in this field.

Outcome Measurement Instruments and Evidence-based Recommendations for Measurement of the Pelvic Girdle Pain Core Outcome Set (PGP-COS): A Systematic Review and Consensus Process

This study provides evidence- and consensus-based recommendations for the instruments to measure the five Pelvic Girdle Pain Core Outcome Set (PGP-COS): pain frequency, pain intensity/severity, function/disability/activity limitation, health-related quality of life and fear avoidance. Studies evaluating measurement properties of instruments measuring any PGP-COS outcome in women with PGP were identified through a systematic search of MEDLINE, EMBASE and PEDro databases (inception-July 2021). The methodological quality of studies and quality of measurement properties were evaluated using the COnsensus-based Standards for the selection of health status Measurement Instruments (COSMIN) checklist. Quality criteria and the synthesized evidence were graded using the modified grading of recommendations, assessment, development, and evaluation (GRADE) approach. A consensus meeting with PGP stakeholders was then held to establish recommendations, based on the evidence, for the instruments that should be used to measure the PGP-COS. Ten instruments were identified from 17 studies. No instrument showed high quality evidence for all measurement properties and/or measured all PGP-COS outcomes. Based on current evidence and consensus, the Pelvic Girdle Questionnaire (PGQ), the Short Form-8 (SF-8) and the Fear Avoidance Beliefs Questionnaire (FABQ) are recommended for measuring the PGP-COS. Future research should establish additional measurement properties of instruments and to substantiate these recommendations.

Prevalence and factors associated with postpartum pelvic girdle pain among women in Poland: a prospective, observational study

Background

Pelvic girdle pain (PGP) is a type of pregnancy-related lumbopelvic pain. This study aimed to examine the prevalence, severity, and factors associated with postpartum PGP in a selected group of postpartum women in Poland.

Methods

This was a prospective, observational study. In phase 1, 411 women were recruited 24–72 h postpartum. The prevalence of PGP was assessed by a physiotherapist using a series of dedicated tests. Pelvic floor muscle function and presence of diastasis recti were assessed via palpation examination. Age, education, parity, mode of delivery, infant body mass, body mass gain during pregnancy, the use of anesthesia during delivery and were recorded. In a phase 2, 6 weeks postpartum, the prevalence of PGP and its severity were assessed via a self-report.

Results

In phase 1 (shortly postpartum), PGP was diagnosed in 9% (n = 37) of women. In phase 2 (6 weeks postpartum), PGP was reported by 15.70% of women (n = 42). The univariable analyses showed a higher likelihood of PGP shortly postpartum in women who declared PGP during pregnancy (OR 14.67, 95% CI 4.43–48.61) and among women with abdominal midline doming (OR 2.05, 95% CI 1.04–4.06). The multivariable regression analysis showed significant associations in women with increased age (OR 1.12, 95% CI 1.01–1.21) and declaring PGP during pregnancy (OR 14.83, 95% CI 4.34–48.72).

Conclusion

Although the prevalence of postpartum PGP among women in Poland is lower than reported in other countries, it is experienced by almost every tenth women shortly postpartum and every sixth can report similar symptoms 6 weeks later. Age, PGP during pregnancy and abdominal midline doming were associated with experiencing PGP shortly postpartum.

Association Among Pelvic Girdle Pain, Diastasis Recti Abdominis, Pubic Symphysis Width, and Pain Catastrophizing: A Matched Case-Control Study

OBJECTIVE

Pregnancy-related pelvic girdle pain (PGP) may persist or occur postpartum and negatively affects women's lives. There is uncertainty regarding the association between the structures of the bony pelvis, diastasis recti abdominis (DRA), pain processing, and PGP and to what extent these factors should be considered during physical therapy. This study aimed to evaluate the differences between women with and without PGP shortly after delivery regarding the separation of a pubic symphysis, DRA, and pain catastrophizing.

METHODS

Women diagnosed with PGP 24 to 72 hours after vaginal delivery were matched to pain-free controls according to age and parity. Ultrasound evaluations of diastasis recti (interrecti distance [IRD]) during rest and curl-up task and pubic symphysis (interpubic width) were performed. The Pain Catastrophizing Scale was used to assess the level of catastrophizing. A special Cox regression model was used to fit a conditional logistic regression for a 1:2 matched case-control study.

RESULTS

Thirty-five women with clinically diagnosed PGP and 70 matched controls were included in the study. The PGP group had a significantly higher pre-pregnancy body mass index than the control group. After adjusting for body mass index in multiple conditional logistic regression, the interpubic distance (odds ratio = 1.64; 95% CI = 1.22 to 2.20) and IRD during curl-up (odds ratio = 2.01; 95% CI = 1.08 to 3.74) were significantly associated with PGP. Pain catastrophizing and IRD at rest were not associated with PGP in univariable or multivariable analysis.

CONCLUSIONS

Pain catastrophizing is similar for women with and without PGP early postpartum. However, the degree of the pubic symphysis and rectus abdominis separation during the curl-up task are positively associated with PGP shortly after delivery.

IMPACT

This study indicates that a reconsideration of the way we look at DRA is warranted. The development of a more comprehensive assessment including objective measurements and a biopsychosocial understanding is needed to inform directions for further postpartum physical therapy.

Generalized joint hypermobility and risk of pelvic girdle pain in pregnancy: does body mass index matter?

Background: Women with generalized joint hypermobility may be at increased risk of pregnancy-related pelvic girdle pain, but evidence is inconclusive. Objectives: In this prospective cohort study of 283 pregnant women in Norway, we aimed to study the association of generalized joint mobility with pelvic girdle pain, and to evaluate if pre-pregnancy body mass index was a modifier of the association. Methods: Generalized joint hypermobility was defined as a score of ≥5/9 positive tests on the Beighton score measured in early pregnancy. Primary outcome was evening pain intensity in gestation week 30, measured by a 100 mm visual analogue scale. We applied linear regression analyses to estimate age-adjusted unstandardized beta coefficients. Results: Evening pain intensity was similar among women with Beighton score ≥ 5/9 and women with Beighton score < 5/9 (age-adjusted mean difference 2.8 mm; 95% CI: -9.2 to 14.9 mm). Women with Beighton score ≥ 5/9 and pre-pregnancy body mass index ≥ 25 kg/m², reported higher evening pain than women with Beighton score < 5/9 and pre-pregnancy body mass index <25 kg/m² (age-adjusted mean difference 28.7 mm; 95% CI: 14.3-43.1 mm). Conclusions: Overall, evening pain intensity was similar among pregnant women with and without generalized joint hypermobility. However, women with a combination of generalized joint hypermobility and body mass index ≥25 kg/m² reported higher evening pain compared to women with normal joint mobility and body mass index <25 kg/m², suggesting that body mass index may modify the association. The estimates could be imprecise due to the small study sample, and our findings should be interpreted with caution.

Telerehabilitation for pelvic girdle dysfunction in pregnancy during COVID-19 pandemic crisis: A case report

Background: Pelvic girdle dysfunction is a common musculoskeletal disorder among pregnant women. It is a disabling condition affecting the ability of a pregnant woman to perform her daily functional activities. The scope of digital health in delivering rehabilitation services is growing exponentially, especially in the present COVID -19 pandemic crisis.Case description: A 29-year-old primigravida, at 32 weeks of gestation with severe pelvic girdle pain during bed transitions, sought physiotherapy consultation via video call, as she expressed difficulty in accessing Physiotherapy services due to the present pandemic crisis. Physiotherapy consultation was provided in 4 weekly sessions using a real-time video-based telerehabilitation program and the patient performed unsupervised exercise sessions for 30 minutes for 5 days per week for 4 weeks. The plan of care included muscle energy techniques, pelvic cloth belt, strengthening, stabilization exercises and stretching.Outcomes: The patient completed four sessions including evaluation and treatment and there was a reduction of pain scores for bed transitions from NPRS 8/10 during session one to NPRS 0/10 during session four. The Pelvic girdle dysfunction questionnaire showed a decrease in percentage scores from 54.6 to 4 at the end of physiotherapy sessions.Conclusion: Telerehabilitation was successfully used to manage a pregnant woman with pelvic girdle dysfunction.

Trunk, pelvic and hip kinematics during the Stork test in pregnant women with pelvic girdle pain, asymptomatic pregnant and non-pregnant women

BACKGROUND

Pelvic girdle pain is prevalent during pregnancy, and women affected report weight-bearing activities to be their main disability. The Stork test is a commonly used single-leg-stance test. As clinicians report specific movement patterns in those with pelvic girdle pain, we aimed to investigate the influence of both pregnancy and pelvic girdle pain on performance of the Stork test.

METHODS

In this cross-sectional study, 25 pregnant women with pelvic girdle pain, 23 asymptomatic pregnant and 24 asymptomatic non-pregnant women underwent three-dimensional kinematic analysis of the Stork test. Linear mixed models were used to investigate between-group differences in trunk, pelvic and hip kinematics during neutral stance, weight shift, leg lift and single leg stance.

FINDINGS

Few and small significant between-group differences were found. Pregnant women with pelvic girdle pain had significantly less hip adduction during single leg stance compared to asymptomatic pregnant women (estimated marginal means (95% confidence intervals) -1.1° (-2.4°, 0.3°) and 1.0° (-0.4°, 2.4°), respectively; P = 0.03). Asymptomatic pregnant women had significantly less hip internal rotation compared to non-pregnant women 4.1° (1.6°, 6.7°) and 7.9° (5.4°, 10.4°), respectively (P = 0.04) and greater peak hip flexion angle of the lifted leg in single leg stance 80.4° (77.0°, 83.9°) and 74.1° (70.8°, 77.5°), respectively (P = 0.01). Variation in key kinematic variables was large across participants in all three groups.

INTERPRETATION

Our findings indicate that trunk, pelvic and hip movements during the Stork test are not specific to pregnancy and/or pelvic girdle pain in the 2nd trimester. Instead, movement strategies appear unique to each individual.

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.

Burden of pelvic girdle pain during pregnancy among women attending ante-natal clinic, Ethiopia:a cross-sectional study

Background

Pelvic girdle pain (PGP) is a commonly reported maternal morbidity that negatively impacts the well-being of women during pregnancy and extends long term into the post-partum period. The burden of maternal morbidity; including pregnancy-related PGP; has been overlooked in Ethiopia to date. This study aimed to determine the prevalence and identify factors associated with pelvic girdle pain during pregnancy in North West Ethiopia.

Methods

A hospital-based cross-sectional study was conducted among pregnant women visiting the antenatal care clinic in Obstetrics ‘outpatient department at the University of Gondar comprehensive specialized hospital in Gondar. Data were collected by interview method using structured questionnaires, patient medical record reviews, and physical measurements. Univariate and multivariable logistic regression model analyses were used to identify factors associated with PGP.

Results

A total of 424 participants with gestational ages ranging from 6 to 39 weeks participated in this study. The age of the study participants ranged from 18 to 44 years with a mean age of (27 ± 4.6 years). The overall cumulative prevalence of pelvic girdle pain among pregnant women was 103 (24.3%),95% CI (20.3, 28.8). The major associated factors with pelvic girdle pain were previous history of pelvic girdle pain (AOR 16.08; 95% CI, 8.47–30.51), previous history of back pain (AOR 1.66; 95% CI, 1.5–4.24) and having children (AOR 1.42; 95% CI, 1.29–3.76).

Conclusion

One-quarter of pregnant Ethiopian women reported pelvic girdle pain. PGP must be considered as major pregnancy-related morbidity, and progress in the intervention of PGP is vital to enhance the quality of life in this population.

A self-report questionnaire for pregnancy-related symphyseal pain

BACKGROUND

Symphyseal pain (SP) experienced during pregnancy is a common condition that can negatively influence function and wellbeing. Despite its adverse impact on quality of life, standardised diagnostic criteria for SP as a distinct type of pelvic girdle pain (PGP) are lacking.

OBJECTIVES

To develop a reliable self-administered instrument that could differentiate SP from posterior PGP in pregnant women, and ultimately be used for epidemiological or clinical purposes.

METHOD

Qualitative data from 17 women (four focus groups) were used to develop a questionnaire. The questionnaire was tested against physical therapy diagnoses based on clinical assessment in 122 pregnant women with SP (n = 41), posterior PGP (n = 41) or no PGP (n = 40); 30 women repeated the questionnaire a day later to assess reliability. Multinomial logistic regression models were used to assess the performance of candidate items in distinguishing between the groups.

RESULTS/FINDINGS

The single questionnaire item relating to location of worst pain (diagrammatic form) is useful for differentiating SP from posterior PGP and individuals with no PGP. The worst pain location question with the addition of the Pelvic Girdle Questionnaire provides a measure of "SP with impact", and is the best combination for distinguishing SP and posterior PGP. Test-retest reliability scores were excellent.

CONCLUSION

These findings provide new opportunities for diagnosing pregnancy-related SP, and highlight questionnaire items which best differentiate SP from posterior PGP. These items could be used in future epidemiological research, and in clinical settings as a quick, effective screening tool.

Subjective recovery from pregnancy-related pelvic girdle pain the first 6 weeks after delivery: a prospective longitudinal cohort study

PURPOSE

The purpose of this study was to investigate the subjective recovery from pregnancy-related pelvic girdle pain (PGP) during the first 6 weeks after delivery and to detect possible risk factors for a poor recovery.

METHODS

The participants were included in this study at the routine ultrasound examination at 18 weeks of pregnancy. The women received a weekly SMS with the question "How many days during the last week has your PGP been bothersome?" The SMS-track from the final 10 weeks of pregnancy and first 6 weeks after delivery were assessed and sorted, based on individual graphs. A total of 130 women who reported PGP during pregnancy and met for clinical examination 6 weeks after delivery were included in the study.

RESULTS

In all, 83% of the women experienced substantial recovery from severe or moderate PGP within 6 weeks after delivery. Of these, 44% reported a substantial recovery already within 2 weeks after delivery. More multiparous women, women reporting PGP the year before pregnancy, and women with high pain intensity during pregnancy had a poor recovery.

CONCLUSIONS

The prognosis following PGP in pregnancy is good and the majority of women recovered substantially from severe and moderate pregnancy-related PGP within 6 weeks after delivery. For many women, a subjective substantial recovery occurred within 2 weeks after delivery. Predictors for a poor recovery were multiparity, PGP the year before pregnancy and a high pain intensity during pregnancy. These slides can be retrieved under Electronic Supplementary Material.

The Timed Up & Go test in pregnant women with pelvic girdle pain compared to asymptomatic pregnant and non-pregnant women

BACKGROUND

The Timed Up and Go (TUG) test, a standardized functional mobility test, has been proposed as a physical performance-based measure in pregnant women with pelvic girdle pain (PGP).

OBJECTIVES

This cross-sectional study aimed to investigate physical function by the use of TUG in pregnant women with PGP compared to asymptomatic pregnant and non-pregnant women, and to identify factors associated with increased TUG.

METHODS

In total, 25 pregnant women with PGP, 24 asymptomatic pregnant and 25 asymptomatic non-pregnant women participated. One-way analysis of variance was used to explore difference in TUG between the groups and multiple linear regression analyses to explore associations between TUG and potential explanatory variables.

RESULTS

The time on TUG varied among pregnant women with PGP, and was significantly higher (mean (95% CI) 6.9 (6.5, 7.3) seconds) than for asymptomatic pregnant (5.8 (5.5, 6.0), p < 0.001) and non-pregnant (5.5 (5.4, 5.6), p < 0.001) women. In the total study sample, group, increased BMI and sick leave were significantly associated with increased TUG (p-values≤0.02). In pregnant women with PGP, pain intensity was the only significant clinical factor associated with increased TUG (p = 0.002).

CONCLUSION

Pregnant women with PGP used longer time and showed larger variation in TUG than asymptomatic pregnant and non-pregnant women, this underpins that TUG targets activities relevant to PGP. Our results provide new knowledge about factors influencing TUG time. Importantly, multivariable analyses suggest that pain intensity should be considered when interpreting TUG time in pregnant women with PGP.

Impact of job adjustment, pain location and exercise on sick leave due to lumbopelvic pain in pregnancy: a longitudinal study

Objective: To identify factors associated with sick leave due to lumbopelvic pain (LPP) in pregnancy. Design: Prospective cohort study using participants from a randomized controlled trial (RCT) designed to study the effect of exercise during pregnancy on pregnancy related diseases. Setting: St. Olavs Hospital, Trondheim University Hospital and Stavanger University Hospital, April 2007 to December 2009. Subjects: Healthy pregnant women. Main outcome measures: Self-reported sick leave due to LPP in late pregnancy (gestation week 32-36). Results: In total, 532/716 (74%) women reported LPP at 32-36 weeks of pregnancy, and 197/716 (28%) reported sick leave due to LPP. Not receiving job adjustments when needed (Odds ratio, OR with 95% confidence interval, CI, was 3.0 (1.7-5.4)) and having any pain in the pelvic girdle versus no pain (OR 2.7 (1.3-5.6), OR 2.7 (1.4-5.2) and OR 2.2 (1.04-4.8)) for anterior, posterior and combined anterior and posterior pain in the pelvis respectively, were associated with sick leave due to LPP in late pregnancy. Also higher disability, sick listed due to LPP at inclusion and lower education, were significant explanatory variables. There was a trend of reduced risk for sick leave due to LPP when allocated to the exercise group in the original RCT (OR 0.7 (0.4-1.0)). Conclusion: Facilitating job adjustments when required might keep more pregnant women in employment. Furthermore, pain locations in pelvic area, disability, lower education and being sick listed due to LPP in mid pregnancy are important risk factors for sick leave in late pregnancy. Key points Current awareness: More than half of pregnant women are on sick leave during pregnancy and the most frequently reported cause is lumbopelvic pain. This paper adds: Inability to make job adjustments, pain locations in pelvic area, disability and lower education level were the most important risk factors for sick leave in late pregnancy. Facilitating early job adjustment might be a precaution to keep more pregnant women in work. Allocation to an exercise group tended to reduce the risk of sick leave in late pregnancy.Registration number: Clinical trial gov (NCT00476567).

Pregnancy-Related Pelvic Girdle Pain in Polish and Norwegian Women

OBJECTIVES

The aim of the study was to assess prevalence of pelvic girdle pain (PGP) in Polish and Norwegian pregnant women.

METHODS

We enrolled 189 Polish and 75 Norwegian randomly selected pregnant women. The participants were 12 to 36 weeks pregnant. They filled in a self-administered questionnaire concerning their demographic data, pregnancy parameters, and the character and location of pain. To differentiate between various kinds of pain, pain maps were used. The participants could mark lumbar pain, PGP, or combined pain (PGP + lumbar pain). Based on pain locations, different subgroups of PGP were recognized. To assess the intensity and functional limitations related to PGP, the pain scale and the Pelvic Girdle Questionnaire were used.

RESULTS

The prevalence of isolated PGP did not differ statistically between the groups, being declared by 17% of Polish women and 19% of Norwegian women (P = .074). Overall prevalence of PGP (together with combined pain) was reported more often by Norwegian women (56%) than Polish women (42%) (P = .043). The pain in all 3 pelvic joints was statistically more common in Norwegian women as well (P = .037). There were no other statistical differences in PGP subgroups between the participants. Mean values of the numeric pain scale were 4.87 for Poles and 4.88 for Norwegians, and of the Pelvic Girdle Questionnaire 32.67% and 41.76% for Poles and Norwegians, respectively. These differences were not statistically significant.

CONCLUSIONS

Isolated PGP has been reported by a similar percentage of Polish and Norwegian women. The severity of signs and symptoms of PGP is similar in both study groups.

Evidence of stabilizing exercises for low back- and pelvic girdle pain - a critical review

BACKGROUND

Pregnancy-related low back pain (LBP) and pelvic girdle pain (PGP) have been associated with an alteration in the strategy for lumbopelvic stabilization. Different core stabilization approaches exist, the evidence is however controversial.

METHODS

This paper discusses how to improve the evidence of exercises for women suffering from LBP and PGP during and after pregnancy. Exercises should be understood in a context, where the bio-psycho-social perspective directs the prescription of exercises, targeting both psychological and physical factors. The type of exercise probably should be individually tailored to the needs and capability of the individual and it is not only about the most appropriate exercise, it is about dosage and delivery of the exercises, and it is about performance. To promote adherence the use of patient preferences, with self-defined movement goals, may be a motivational basis for behavior change. Communication skills may facilitate positive beliefs and provide a motivational foundation for empowerment, self-efficacy and for self-management. To learn by discovery where the patient learns through their own experiences, might motivate the patients to active engagement and to behavioral change. Adherence probably will increase when the patients understand the aim and the rationale behind the exercises they are prescribed. However, with high adherence to exercises that maintains an inappropriate motor pattern, LBP and PGP possibly could proceed into chronicity.

CONCLUSION

Exercises need to be meaningful to the patient, relevant for daily activities, individualized according to patient preferences, guided and supervised to secure performance and quality.

Cross-cultural adaptation of the Pelvic Girdle Questionnaire (PGQ) into Brazilian Portuguese and clinimetric testing of the PGQ and Roland Morris questionnaire in pregnancy pelvic pain

OBJECTIVE

To translate and cross-culturally adapt the Pelvic Girdle Questionnaire (PGQ) into Brazilian Portuguese and test the measurement properties of the PGQ and the Roland Morris Disability Questionnaire (RMDQ) in women with pelvic pain during pregnancy.

METHODS

Thirty pregnant women were included in the assessment of the pre-test of the final version of the PGQ and 100 were included in the assessment of the measurement properties. In the initial assessment, the PGQ, RMDQ, pain numerical rating scale, and WHOQOL-BREF were applied to test the internal consistency and construct validity. In the 48-hour assessment, only the PGQ and RMDQ were applied to test reliability and measurement error; in the reassessment after one month, the PGQ, RMDQ, and global perceived effect scale were applied to evaluate responsiveness.

RESULTS

The PGQ showed adequate internal consistency (Cronbach's alpha=0.83), substantial reliability (ICC2,1=0.85), very good measurement error (5%), and good responsiveness (r=-0.62). We also observed good correlation with disability and quality of life in the physical health domain, moderate correlation with pain and quality of life in the psychological domain, and poor correlation with quality of life in the domains social relationships and environment. The RMDQ showed adequate internal consistency (Cronbach's alpha=0.80), substantial reliability (ICC2,1=0.76), good measurement error (9%), moderate responsiveness (r=-0.51), moderate correlation with quality of life in the physical health and psychological domains, and weak correlation with pain and quality of life in the social relationships and environment domains.

CONCLUSION

The Brazilian Portuguese version of the PGQ showed superior measurement properties compared to the RMDQ, being a valid, reliable, and responsive instrument for assessing patients with pelvic pain during pregnancy.

The Swedish version of the pelvic girdle questionnaire, cross-cultural adaptation and validation

Purpose: The aims of this study were to translate and culturally adapt The Pelvic Girdle Questionnaire to Swedish, and to evaluate the construct and discriminative validity.Materials and methods: A translation and cultural adaptation process was performed according to international guidelines. Pilot tests were conducted among 16 women during pregnancy and post-partum. Analysis of the construct and discriminative validity of the Swedish version of the Pelvic Girdle Questionnaire was performed in a sample of 177 pregnant women suffering from pain in the lumbo-pelvic area. Participants completed the Pelvic Girdle Questionnaire along with Oswestry Disability Index, numeric rating scales for pain intensity and for pelvic girdle pain concerns.Results: The Swedish version of the Pelvic Girdle Questionnaire showed high internal consistency with Cronbach's alphas between 0.82 and 0.96, good convergent validity with high correlations with the Oswestry Disability Index and the pain intensity numeric rating scale, whereas moderate correlation was shown between the concerns numeric rating scale and the other instruments as hypothesized. Receiver operating characteristic curves showed good discriminatory capacity for women in need of treatment.Conclusions: The Swedish version of the Pelvic Girdle Questionnaire has patient acceptability. It has good construct and discriminative validity for measurements of consequences of pregnancy-related pelvic girdle pain among Swedish speaking women.IMPLICATIONS FOR REHABILITATIONPregnancy-related pelvic girdle pain may be disabling and long-lasting, however treatable when identified.The Pelvic Girdle Questionnaire is the only condition-specific, reliability tested and validated questionnaire for pelvic girdle pain.The Swedish version of the Pelvic Girdle Questionnaire has patient acceptability, good construct validity for pelvic girdle pain among Swedish speaking women, and shows good discriminative capacity for women in need of treatment.

Cross-cultural Adaptation of the Pelvic Girdle Questionnaire for the Polish Population

OBJECTIVE

The purpose of this study was to translate and culturally adapt the Pelvic Girdle Questionnaire (PGQ) into Polish to allow pelvic girdle pain (PGP) assessment in Polish women.

METHODS

The translation process comprised 4 stages: forward translation, backward translation, committee review, and pretest. We then conducted a pilot study of the final version of the questionnaire in 49 women (mean age: 31.2 years, standard deviation: 3.74 years) who had PGP when pregnant or within a year postpartum.

RESULTS

The internal consistency of the newly created questionnaire assessed with Cronbach's α was 0.916.

CONCLUSION

The internal consistency of the process of translation and cross-cultural adaptation of the Polish version of the PGQ was satisfactory. The Polish version of the PGQ may be used both in clinical practice and for research among Polish women with PGP.

Protocol for the development of a core outcome set for pelvic girdle pain, including methods for measuring the outcomes: the PGP-COS study

Background

Pelvic Girdle Pain (PGP) is an important cause of disability and economic cost worldwide. There is a need for effective preventative and management strategies. Emerging studies measure a variety of outcomes rendering synthesis and translation to clinical practice difficult. A Core Outcome Set (COS) can address this problem by ensuring that data are relevant, useful and usable for making well-informed healthcare choices. The aim of this study is to develop a consensus-based PGP-COS, including agreement on methods (e.g. instruments) for measuring the construct outcomes in the COS for use in research and clinical practice. Furthermore, as there is uncertainty as to whether incorporating stakeholder interviews in addition to conducting a systematic review to determine an initial list of outcomes for the Delphi survey, or, whether using different rating scales in a Delphi survey impacts on the final COS, we propose to embed two methodological studies within the PGP-COS development process to address these questions.

Methods

The PGP-COS study will include five phases: (1) A systematic review of the literature and semi-structured interviews with 15 patients (three countries) to form the initial list of outcomes for the Delphi survey; (2) A 3-round Delphi including patients, clinicians, researchers and service providers; (3) A systematic review of methods for measuring the outcomes in the preliminary PGP-COS identified in the Delphi survey; (4) A face-to-face consensus meeting to agree on the final PGP-COS and methods for measuring the COS; (5) Global dissemination.

To address the methodological questions, we will assess the number and type of outcomes, in the final PGP-COS, that were exclusively derived from the interviews. Secondly, we will randomise Delphi survey participants to either a 5-point or 9-point importance rating scale, and examine potential differences in ‘important’ ratings between the groups.

Discussion

There is currently no COS for measuring/monitoring PGP in trials and clinical practice. A PGP-COS will ensure that relevant outcomes are measured using appropriate measurement instruments for patients with PGP globally.

Core outcome set registration

This PGP-COS was registered with COMET (Core Outcome Measures for Effectiveness Trials) in January 2017 (http://www.comet-initiative.org/studies/details/958).

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0624-5) contains supplementary material, which is available to authorized users.

Factors associated with pain in the pelvic girdle in pregnant adolescents: A case-control study

BACKGROUND

Due to biological immaturity and unfavorable psychosocial conditions, it is conjectured that teenage pregnancy may be associated with disorders such as pelvic girdle pain. The evidence for risk factors for pelvic girdle pain in pregnant adolescents remains unclear.

OBJECTIVES

To evaluate the factors associated with pelvic girdle pain related to pregnancy in adolescents.

DESIGN

Case-control study.

METHOD

Seventy three pregnant women with presence of pelvic girdle pain (case group) and 331 pregnant women without pelvic girdle pain (control group) aged between 10 and 19 years, with gestational age between 28 and 40 weeks were included.

RESULTS/FINDINGS

A logistic regression model was used to identify factors associated with the occurrence of pelvic girdle pain. The following aspects were considered for the model: sociodemographic, anthropometric, gynecological and obstetrical, related to lifestyle, musculoskeletal and psychosocial factors. The results showed that suspected common mental disorder (OR: 2.27; 95% CI: 1.23 to 4.18), low back pain during menstruation (OR: 2.10; 95% CI: 1.16 to 3.80) and strenuous work (OR: 1.95; 95% CI: 1.13 to 3.35) were associated with pelvic girdle pain among pregnant adolescents.

CONCLUSIONS

Attention must be given to pregnant adolescents with suspected common mental disorder, low back pain during menstruation and strenuous work in order to ensure referral to the appropriate healthcare professional for early prevention of pelvic girdle pain.

The association between pregnancy, pelvic girdle pain and health-related quality of life - a comparison of two instruments

Background

The main purposes in this cross-sectional study were to study the impact of pregnancy and pelvic girdle pain (PGP) on health related quality of life (HRQoL), by comparing the scores on different domains of two HRQoL instruments in pregnant women with population norms as well as in women with severe and less severe PGP. Further, to explore the association between PGP and HRQoL and whether the two instruments differ in the way they assess the influence of PGP on HRQoL.

Methods

Pregnant women in gestation week 30 completed questionnaires containing the Short Form Health Survey (SF-36) and the Nottingham Health Profile (NHP). Additional variables, self-reported PGP, pain location in the pelvis and response on clinical tests were also collected. HRQoL scores were compared with expected age adjusted mean scores and comparisons between groups with different severity of PGP were made, using Mann-Whitney U, t-tests and Hodges-Lehman method.

Results

Two hundred eighty-three pregnant women, mean age 31.3 (SD 4.2) years, participated. We found statistical significant differences in all domains of both HRQoL instruments in late pregnancy compared to the expected age-adjusted means of the reference populations (p ≤ 0.003) except for Social isolation (p = 0.775). Women with PGP had lower HRQoL than women without, and the most affected women scored lowest. SF-36 detected a deficit in Social Function compared to norms whereas the NHP showed no evidence of Social Isolation.

Conclusions

Both instruments revealed changes in HRQoL in pregnant women compared with population norms. Pregnancy itself influences HRQoL and having PGP gave an additional impact. The consistency of the correlations between SF-36 and NHP domains across the sub-groups found in this study suggests convergent validity across levels of impairment. The results in social domains vary between SF-36 and NHP in pregnant women and might be due to the basic design (construction) of the tools.

Can a bothersome course of pelvic pain from mid-pregnancy to birth be predicted? A Norwegian prospective longitudinal SMS-Track study

OBJECTIVE

To explore if pregnant women with pelvic girdle pain (PGP), subgrouped following the results from two clinical tests with high validity and reliability, differ in demographic characteristics and weekly amount of days with bothersome symptoms through the second half of pregnancy.

DESIGN

A prospective longitudinal cohort study.

PARTICIPANTS

Pregnant women with pelvic and lumbopelvic pain due for their second-trimester routine ultrasound examination.

SETTING

Obstetric outpatient clinic at Stavanger University Hospital, Norway.

METHODS

Women reporting pelvic and lumbopelvic pain completed a questionnaire on demographic and clinical features. They were clinically examined following a test procedure recommended in the European guidelines for the diagnosis and treatment of PGP. Women without pain symptoms completed a questionnaire on demographic data. All women were followed weekly through an SMS-Track survey until delivery.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcome measures were the results from clinical diagnostic tests for PGP and the number of days per week with bothersome pelvic pain.

RESULTS

503 women participated. 42% (212/503) reported pain in the lumbopelvic region and 39% (196/503) fulfilled the criteria for a probable PGP diagnosis. 27% (137/503) reported both the posterior pelvic pain provocation (P4) and the active straight leg raise (ASLR) tests positive at baseline in week 18, revealing 7.55 (95% CI 5.54 to 10.29) times higher mean number of days with bothersome pelvic pain compared with women with both tests negative. They presented the highest scores for workload, depressed mood, pain level, body mass index, Oswestry Disability Index and the number of previous pregnancies. Exercising regularly before and during pregnancy was more common in women with negative tests.

CONCLUSION

If both P4 and ASLR tests were positive mid-pregnancy, a persistent bothersome pelvic pain of more than 5 days per week throughout the remainder of pregnancy could be predicted. Increased individual control over work situation and an active lifestyle, including regular exercise before and during pregnancy, may serve as a PGP prophylactic.

Evaluating Acupuncture and Standard carE for pregnant women with Back pain (EASE Back): a feasibility study and pilot randomised trial

BACKGROUND

Many pregnant women experience low back pain. Acupuncture appears to be a safe, promising intervention but evidence is needed about its clinical effectiveness and cost-effectiveness.

OBJECTIVES

To assess the feasibility of a future large randomised controlled trial (RCT) testing the additional benefit of adding acupuncture to standard care (SC) for pregnancy-related back pain.

DESIGN

Phase 1: a questionnaire survey described current care for pregnancy-related back pain. Focus groups and interviews with midwives, physiotherapists and pregnant women explored acceptability and feasibility of acupuncture and the proposed RCT. Phase 2: a single-centre pilot RCT. Participants were identified using six methods and randomised to SC, SC plus true acupuncture or SC plus non-penetrating acupuncture.

PARTICIPANTS

Phase 1: 1093 physiotherapists were surveyed and 15 midwives, 21 physiotherapists and 17 pregnant women participated in five focus groups and 20 individual interviews. Phase 2: 125 women with pregnancy-related back pain participated.

INTERVENTIONS

SC: a self-management booklet and onward referral for one-to-one physiotherapy (two to four sessions) for those who needed it. SC plus true acupuncture: the self-management booklet and six to eight treatments with a physiotherapist comprising true (penetrating) acupuncture, advice and exercise. SC plus non-penetrating acupuncture: the self-management booklet and six to eight treatments with a physiotherapist comprising non-penetrating acupuncture, advice and exercise.

MAIN OUTCOME MEASURES

Pilot RCT outcomes included recruitment rates, treatment fidelity, follow-up rate, patient-reported pain and function, quality of life and health-care resource use. Birth and neonatal outcomes were also assessed. Staff overseeing outcome data collection were blind to treatment allocation.

RESULTS

Phase 1: 629 (57.5%) physiotherapists responded to the survey, 499 were experienced in treating pregnancy-related back pain and reported 16 advice and 18 treatment options. Typical treatment comprised two to four individual sessions of advice and exercise over 6 weeks. Acupuncture was reported by 24%. Interviews highlighted the impact of back pain and paucity of effective interventions. Women and midwives strongly supported a RCT and expressed few concerns. Physiotherapists' concerns about acupuncture in pregnancy informed a training programme prior to the pilot RCT. Phase 2: We recruited 125 of 280 potentially eligible women (45%) in 6 months and randomised 41 to SC and 42 each to the SC plus true acupuncture and SC plus non-penetrating acupuncture arms. Analysis was conducted with 124 participants (41, 42 and 41, respectively) as one participant was randomised in error. Three of six recruitment methods were the most successful. In total, 10% of women (n = 4) randomised to SC alone accessed one-to-one physiotherapy and received an average of two treatments. The average number of treatments was six for both SC plus true acupuncture and SC plus non-penetrating acupuncture. Treatments were in line with protocols. Eight-week follow-up was 74%. Patient-reported outcomes (pain, function and quality of life) favoured the addition of acupuncture. There was no evidence of serious adverse events on mothers or birth and neonatal outcomes. The Pelvic Girdle Questionnaire was found to be an appropriate outcome measure for a future trial.

CONCLUSIONS

A future main RCT is feasible and would be welcomed by women and clinicians. Longer-term follow-up and further follow-up efforts are recommended for a main trial.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN49955124.

FUNDING

This project was funded by the National Institute of Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 33. See the NIHR Journals Library website for further project information.

The MMP9 rs17576 A>G polymorphism is associated with increased lumbopelvic pain-intensity in pregnant women

BACKGROUND AND AIMS

Matrix metalloproteinase 9 (MMP9) is an enzyme that may affect degradation of several extracellular matrix (ECM) components in the pelvic ligaments during pregnancy. Previous studies indicate that genetic variations in the gene encoding MMP9 may affect the enzymatic activity. One such genetic variant is a single nucleotide polymorphism (SNP), rs17576 A>G. In this study we investigated whether the MMP9 SNP rs17576 A>G may be associated with increased lumbopelvic pain in 838 pregnant woman. The study was registered with ClinicalTrials.gov (NCT 00476567) on May 21, 2007.

METHODS

Lumbopelvic pain-intensity was measured by visual analog scale (VAS) at two time points during pregnancy, T1 (18-22 weeks), T2 (32-36 weeks) and 3 months after delivery. Blood samples were collected at each point and SNP genotyping was carried out using predesigned TaqMan SNP genotyping assays.

RESULTS

The results showed a significant association between the number of G alleles and pain-intensity in the evening at T2. The pain among G/G carriers was higher than among A/G carriers, which in turn was higher than among the A/A carriers. The most pronounced association between the G allele and pain-intensity was observed in primiparae.

CONCLUSIONS

We conclude that the MMP9 rs17576 A>G polymorphism is associated with increased lumbopelvic pain-intensity during pregnancy. The present data support the hypothesis that lumbopelvic pain during pregnancy may be related to a relaxin - MMP9 - tissue remodeling mechanism.

IMPLICATIONS

The present findings may be important for future mechanistic studies on how MMP9 rs17576 A>G may affect changes in the ECM components in pelvic ligaments and lumbopelvic pain-intensity during pregnancy.

The Pelvic Girdle Questionnaire: Responsiveness and Minimal Important Change in Women With Pregnancy-Related Pelvic Girdle Pain, Low Back Pain, or Both

BACKGROUND

The Pelvic Girdle Questionnaire (PGQ) is a condition-specific measure for women with pelvic girdle pain (PGP). The PGQ includes items relating to activity/participation and bodily symptoms and has reliability, validity, and feasibility for use in research and clinical practice.

OBJECTIVE

The purposes of this study were to examine the responsiveness of the PGQ, to determine the minimal important change (MIC) for the PGQ, and to compare the PGQ with other outcome measures.

DESIGN

This study used a prospective cohort design.

METHODS

A total of 801 women responded to a booklet of questionnaires in the last trimester of their pregnancy and within 3 months post partum. Responsiveness analyses followed recommendations from the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist. The responsiveness of the PGQ was tested by examining correlations between the change scores of the total PGQ and the other patient-reported outcome measures.

RESULTS

A total of 606 women (76%) reported PGP, low back pain, or both. Of these women, 441 (73%) responded to the follow-up questionnaire post partum. The PGQ (both subscale and total scores) discriminated most accurately between participants who improved and those who did not improve, with an area under the receiver operator characteristic curve of 72%. The MIC values indicated that a change score smaller than 25 for the total score and activity subscale score and a change score of 20 for the symptom subscale score should be regarded as insignificant. Baseline PGQ scores had a large impact on the MIC estimates for the absolute change scores but not on the relative percentage change scores. Five of 6 hypotheses were supported (83%).

LIMITATIONS

The type of anchor and definition of important change used might be weaknesses in women whose status is changing from pregnant to post partum.

CONCLUSIONS

The PGQ showed acceptable responsiveness in women with PGP, low back pain, or both.

Low back pain and causative movements in pregnancy: a prospective cohort study

Background

Low back pain (LBP) during pregnancy might be strongly related to posture and movements of the body, and its management is a clinically important issue. The purpose of this study was to investigate the activities related to LBP during pregnancy.

Methods

Participants included 275 women before 12 weeks of pregnancy. The women were evaluated at 12, 24, 30, and 36 weeks of pregnancy. The intensity of LBP was assessed using the Numerical Rating Scale (NRS). Movements related to LBP were investigated by free descriptive answers. Descriptive statistics were used to compile the movements that pregnant women thought induced LBP at each evaluation. Subsequently, a linear regression analysis was performed to evaluate the degree of association of certain movements with LBP using the data of participants who had LBP. The intensity of LBP (NRS score) was specified as the dependent variable, the movements that were related to pain were specified as the independent variables at the analysis. A significance threshold was set at 0.05.

Results

The final sample used in the analyses was 254, 249, 258, and 245 women at 12, 24, 30, and 36 weeks of pregnancy, respectively. There were 16 kinds of movements that induced LBP and all of them were daily activities rather than special movements that require extra task or effort. As pregnancy progressed, less number of participants attributed pain to a specific movement. At all evaluations, movements, especially sitting up, standing up from a chair, and tossing and turning were thought to be related to LBP. Furthermore, standing up from a chair and tossing and turning were significantly related to LBP throughout the pregnancy. In contrast, lying down and sitting up were significantly related to LBP but the relationship did not continue till late pregnancy.

Conclusions

Daily routine activity is related to LBP during pregnancy. These results suggest that recommendations for pregnant women about basic physical movements, such as ways of standing up that reduce the load on the body might be useful in the management of LBP.

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.

Predictors and consequences of long-term pregnancy-related pelvic girdle pain: a longitudinal follow-up study

Background

Pelvic girdle pain (PGP) is a multifactorial condition, which can be mentally and physically compromising both during and after pregnancy. However, long-term pregnancy-related PGP has been poorly investigated. This longitudinal follow-up study uniquely aimed to describe prevalence and predictors of PGP and its consequences on women’s health and function up to 11 years after pregnancy.

Methods/Design

A postal questionnaire was sent to 530 women who participated in 1 of 3 randomized controlled studies for PGP in pregnancy. Women who reported experiencing lumbopelvic pain were offered a clinical examination. Main outcome measure was the presence of long term PGP as assessed by an independent examiner. Secondary outcomes were: working hours/week, function (the Disability Rating Index, and Oswestry Disability Index), self-efficacy (the General Self-Efficacy Scale), HRQL (Euro-Qol 5D and EQ-Visual scale), anxiety and depression, (Hospital anxiety and depression scale,) and pain-catastrophizing (Pain Catastrophizing Scale), in women with PGP compared to women with no PGP.

Results

A total of 371/530 (70 %) women responded and 37/ 371 (10 %) were classified with long-term PGP. Pregnancy-related predictors for long-term PGP were number of positive pain provocation tests (OR = 1.79), history of low back pain (LBP) (OR = 2.28), positive symphysis pressure test (OR = 2.01), positive Faber (Patrick’s) test (OR = 2.22), and positive modified Trendelenburg test (OR = 2.20). Women with PGP had significantly decreased ability to perform daily activities (p < .001), lower self-efficacy (p = 0.046), decreased HRQL (p < .001), higher levels of anxiety and depression (p < .001), were more prone to pain catastrophizing, and worked significantly fewer hours/week (p = 0.032) compared to women with no PGP.

Conclusions

This unique long-term follow up of PGP highlights the importance of assessment of pain in the lumbopelvic area early in pregnancy and postpartum in order to identify women with risk of long term pain. One of 10 women with PGP in pregnancy has severe consequences up to 11 years later. They could be identified by number of positive pain provocation tests and experience of previous LBP. Access to evidence based treatments are important for individual and socioeconomic reasons.

Sick leave and healthcare utilisation in women reporting pregnancy related low back pain and/or pelvic girdle pain at 14 months postpartum

BACKGROUND

Pregnancy related low back pain (PLBP) and pelvic girdle pain (PGP) are considered common complications of pregnancy. The long-term consequences for women with persistent PLBP/PGP postpartum are under-investigated. The main objective was to investigate the prevalence, pattern and degree of sick leave as well as healthcare utilisation and its perceived effect in women with persistent PLBP/PGP at 12 months postpartum.

METHOD

This is a follow-up study of a cohort involving of a sample of women, who delivered from January 1(st) 2002 to April 30(th) in 2002 at Umeå University Hospital and Sunderby Hospital, and who reported PLBP/PGP during pregnancy. A total of 639 women were followed-up by a second questionnaire (Q2) at approximately 6 months postpartum. Women with persistent PLBP/PGP at the second questionnaire (N = 200) were sent a third questionnaire (Q3) at approximately 12 months postpartum.

RESULTS

The final study sample consisted of 176 women reporting PLBP/PGP postpartum where N = 34 (19.3 %) reported 'no' pain, N = 115 (65.3 %) 'recurrent' pain, and N = 27 (15.3 %) 'continuous' pain. The vast majority (92.4 %) of women reported that they had neither been on sick leave nor sought any healthcare services (64.1 %) during the past 6 months at Q3. Women with 'continuous' pain at Q3 reported a higher extent of sick leave and healthcare seeking behaviour compared to women with 'recurrent' pain at Q3. Most women with persistent PLBP/PGP had been on sick leave on a full-time basis. The most commonly sought healthcare was physiotherapy, followed by consultation with a medical doctor, acupuncture and chiropractic.

CONCLUSION

Most women did not report any sick leave or sought any healthcare due to PLBP/PGP the past 6 months at Q3. However, women with 'continuous' PLBP/PGP 14 months postpartum did report a higher prevalence and degree of sick leave and sought healthcare to a higher extent compared to women with 'recurrent' PLBP/PGP at Q3. Women with more pronounced symptoms might constitute a specific subgroup of patients with a less favourable long-term outcome, thus PLBP/PGP needs to be addressed early in pregnancy to reduce both individual suffering and the risk of transition into chronicity.

Experiences of First-Time Mothers With Persistent Pelvic Girdle Pain After Childbirth: Descriptive Qualitative Study

BACKGROUND

Pelvic girdle pain (PGP) is common during pregnancy and negatively affects women's lives. When PGP persists after the birth, the way it affects women's lives may change, particularly for first-time mothers as they adjust to motherhood, yet the experiences of women with persistent PGP remain largely unexplored.

OBJECTIVES

The objective of this study was to explore primiparous women's experiences of persistent PGP and its impact on their lives postpartum, including caring for their infant and their parental role.

DESIGN

This was a descriptive qualitative study.

METHODS

Following institution ethical approval, 23 consenting primiparous women with PGP that had started during pregnancy and persisted for at least 3 months postpartum participated in individual interviews. These interviews were recorded, transcribed, and analyzed using thematic analysis.

RESULTS

Four themes emerged: (1) "Putting up with the pain: coping with everyday life," in which women put up with the pain but had to balance activities and were grateful for support from family and friends to face everyday challenges; (2) "I don't feel back to normal," in which women's feelings of physical limitations, frustration, and a negative impact on their mood were described; (3) "Unexpected," in which persistent symptoms were unexpected for women due to a lack of information given about PGP; and (4) "What next?," in which the future of women's symptoms was met with great uncertainty, and they expressed worry about having another baby.

CONCLUSION

For first-time mothers, having persistent PGP postpartum affects their daily lives in many ways. These findings provide important information for health care providers, which will improve their understanding of these women's experiences, will enhance rapport, and can be used to provide information and address concerns to optimize maternity care during pregnancy and beyond.

Reliability of the Timed Up and Go test and Ten-Metre Timed Walk Test in Pregnant Women with Pelvic Girdle Pain

BACKGROUND AND PURPOSE

There is a lack of functional objective tests available to measure functional status in women with pelvic girdle pain (PGP). The purpose of this study was to establish test-retest and intertester reliability of the Timed Up and Go (TUG) test and Ten-metre Timed Walk Test (10mTWT) in pregnant women with PGP.

METHODS

A convenience sample of women was recruited over a 4-month period and tested on two occasions, 1 week apart to determine test-retest reliability. Intertester reliability was established between two assessors at the first testing session. Subjects were instructed to undertake the TUG and 10mTWT at maximum speed. One practise trial and two timed trials for each walking test was undertaken on Day 1 and one practise trial and one timed trial on Day 2.

RESULTS

Seventeen women with PGP aged 31.1 years (SD [standard deviation] = 2.3) and 28.7 weeks pregnant (SD = 7.4) completed gait testing. Test-retest reliability using the intraclass correlation coefficient (ICC) was excellent for the TUG (0.88) and good for the 10mTWT (0.74). Intertester reliability was determined in the first 13 participants with excellent ICC values being found for both walking tests (TUG: 0.95; 10mTWT: 0.94).

CONCLUSION

This study demonstrated that the TUG and 10mTWT undertaken at fast pace are reliable, objective functional tests in pregnant women with PGP. While both tests are suitable for use in the clinical and research settings, we would recommend the TUG given the findings of higher test-retest reliability and as this test requires less space and time to set up and score. Future studies in a larger sample size are warranted to confirm the results of this study.

Pregnancy-related low back pain and pelvic girdle pain approximately 14 months after pregnancy - pain status, self-rated health and family situation

Background

Pelvic girdle pain (PGP) in pregnancy is distinct from pregnancy-related low back pain (PLBP). However, women with combined PLBP and PGP report more serious consequences in terms of health and function. PGP has been estimated to affect about half of pregnant women, where 25% experience serious pain and 8% experience severe disability. To date there are relatively few studies regarding persistent PLBP/PGP postpartum of more than 3 months, thus the main objective was to identify the prevalence of persistent PLBP and PGP as well as the differences over time in regard to pain status, self-rated health (SRH) and family situation at 12 months postpartum.

Methods

The study is a 12 month follow-up of a cohort of pregnant women developing PLBP and PGP during pregnancy, and who experienced persistent pain at 6 month follow-up after pregnancy. Women reporting PLBP/PGP (n = 639) during pregnancy were followed up with a second questionnaire at approximately six month after delivery. Women reporting recurrent or persistent LBP/PGP at the second questionnaire (n = 200) were sent a third questionnaire at 12 month postpartum.

Results

A total of 176 women responded to the questionnaire. Thirty-four women (19.3%) reported remission of LBP/PGP, whereas 65.3% (n = 115) and 15.3% (n = 27), reported recurrent LBP/PGP or continuous LBP/PGP, respectively. The time between base line and the 12 months follow-up was in actuality 14 months. Women with previous LBP before pregnancy had an increased odds ratio (OR) of reporting ‘recurrent pain’ (OR = 2.47) or ‘continuous pain’ (OR = 3.35) postpartum compared to women who reported ‘no pain’ at the follow-up. Women with ‘continuous pain’ reported statistically significant higher level of pain at all measure points (0, 6 and 12 months postpartum). Non-responders were found to report a statistically significant less positive scoring regarding relationship satisfaction compared to responders.

Conclusions

The results from this study demonstrate that persistent PLBP/PGP is a major individual and public health issue among women 14 months postpartum, negatively affecting their self-reported health. However, the perceived relationship satisfaction seems to be stable between the groups.

Clinical course of pelvic girdle pain postpartum - impact of clinical findings in late pregnancy

The aims were to study: prevalence of pelvic girdle pain (PGP) one year postpartum; clinical course of PGP, physical functioning (PF) and bodily pain (BP) (from SF-36, 0 (worst) to 100 (best)) from gestation week (GW) 30 to one year postpartum; and whether findings at GW30 were associated with development of PF and BP from GW30 to one year postpartum. 215 pregnant women were followed from GW30 to one year postpartum. Clinical examination and questionnaire were used at GW30, questionnaire only were used at 12 weeks and one year postpartum. The women were categorised by GW30 clinical variables: self-reported PGP, pain locations in the pelvis and response to two clinical tests. Linear mixed models for repeated measures were used to study PF and BP during follow-up, within the categories of clinical variables. PGP prevalence remained unchanged from 12 weeks to one year postpartum (31-30%). PF and BP scores improved markedly from GW30 to 12 weeks postpartum, and marginally thereafter. Median PF scores were 70, 95 and 100 at GW30, 12 weeks and one year postpartum, respectively. Corresponding median BP scores were 52, 84 and 84. We found significant interactions between each clinical variable and time (P ≤ 0.01) for PF and BP. The most afflicted women at GW30 experienced largest improvement. Despite high PGP prevalence one year postpartum, most women recovered in terms of PF and BP scores. Unfavourable clinical course postpartum did not appear to depend on self-reported PGP, pain locations in the pelvis, or response to clinical tests at GW30.

Pelvic girdle pain in Indian postpartum women: a cross-sectional study

During pregnancy or postpartum period many women will experience some degree of pelvic girdle pain (PGP). In India, there is no information about the PGP prevalence and its associated factors evaluated during postpartum period.

PURPOSE

To reveal the prevalence of PGP postpartum in Indian women and identify associated factors with PGP postpartum.

METHODS

In this cross-sectional study, 284 postpartum women completed a questionnaire and underwent clinical examinations. The clinical examination included pain provocation tests for the pelvic as well as the active straight leg raise (ASLR) test. Possible associating factors were studied by using nonparametric tests and logistic regression analysis.

RESULTS

A total of 116 postpartum women (41%) had reported PGP at the time of the examination. A stepwise logistic regression analysis was performed to reveal associated factors. In the final model, factors such as (1) Caesarean delivery (adjusted OR, 2.0; 95% CI, 1.3-4.9); (2) ASLR test score ≥4 (adjusted OR, 2.3; 95% CI, 1.2-3.3); (3) Unilateral P4 test (adjusted OR, 1.8; 95% CI, 1.1-3.0); and (4) Sitting position during feeding (adjusted OR, 1.5; 95% CI, 0.9-2.8) were associated with the PGP.

CONCLUSION

We found a high prevalence of PGP in Indian women during the first three months of postpartum period. Our finding suggests that unilateral posterior pelvic pain provocation test (P4), ASLR test score ≥4, caesarean section delivery and sitting in breast-feeding posture were associated with increased risk of PGP during postpartum.

The effect of emotional distress on persistent pelvic girdle pain after delivery: a longitudinal population study

OBJECTIVE

To study the prognosis for pelvic girdle pain, and to explore the association between presence of emotional distress during pregnancy and pelvic girdle syndrome 6 months after delivery.

DESIGN

Longitudinal population study.

SETTING

Norway, for the period 1999-2008.

POPULATION

A follow-up of 41 421 women in the Norwegian Mother and Child Cohort who reported pelvic girdle pain at 30 weeks of gestation.

METHODS

Data were obtained by self-administered questionnaires in weeks 17 and 30 of gestation, and 6 months after delivery.

MAIN OUTCOME MEASURE

Pelvic girdle syndrome 6 months after delivery, defined as pain in the anterior pelvis and on both sides in the posterior pelvis.

RESULTS

Six months after delivery, 78.0% of the women had recovered, 18.5% reported persistent pain in one or two pelvic locations, 3.0% reported pelvic girdle syndrome and 0.5% reported severe pelvic girdle syndrome. The recovery rates decreased with increasing levels of pain severity in pregnancy. Being emotionally distressed at two time points during pregnancy was associated with the presence of pelvic girdle syndrome (adjusted OR 1.5, 95% CI 1.2-1.9) and severe pelvic girdle syndrome (adjusted OR 1.9, 95% CI 1.1-3.1), after adjustment for pain severity in pregnancy, other medical conditions, body mass index, age at menarche, previous low back pain, and smoking during pregnancy.

CONCLUSIONS

In this follow-up of women with pelvic girdle pain in pregnancy, the recovery rates after delivery were high. Our findings suggest that the presence of emotional distress during pregnancy is independently associated with the persistence of pelvic girdle pain after delivery.

Can supervised group exercises including ergonomic advice reduce the prevalence and severity of low back pain and pelvic girdle pain in pregnancy? A randomized controlled trial

BACKGROUND

Many women have low back pain (LBP) or pelvic girdle pain (PGP) during pregnancy, but there is limited evidence of effective primary and secondary preventive strategies.

OBJECTIVE

The purpose of this study was to investigate whether a group-based exercise program can reduce the prevalence and severity of LBP and PGP in pregnant women.

DESIGN

An observer-blinded randomized controlled trial with equal assignments to a training group and a control group was conducted.

SETTING

The study was conducted in primary care maternity units in 2 suburban municipalities in the southeastern part of Norway.

PATIENTS

The participants were 257 pregnant women who were healthy and between 18 and 40 years of age before gestation week 20.

INTERVENTION

The training group received supervised exercises in groups once a week, and the control group received standard care.

MEASUREMENTS

The main outcome measures were self-reported LBP and self-reported PGP. Secondary outcome measures were pain intensity in the morning and evening, disability, and 8-Item Short-Form Health Survey (SF-8) Physical Component Summary (PCS) and Mental Component Summary (MCS) scores. Follow-up measurements were performed at gestation weeks 24, 28, 32, and 36.

RESULTS

Overall, there was no effect of the program on the prevalence of PGP (odds ratio = 1.03, 95% confidence interval [CI] = 0.66 to 1.59) or LBP (odds ratio = 0.77, 95% CI = 0.50 to 1.19). For the secondary outcomes, the estimated mean differences between the groups were -0.4 (95% CI = -0.8 to 0.1) for pain intensity in the morning, -0.4 (95% CI = -1.0 to 0.2) for pain intensity in the evening, -1.0 (95% CI = -2.2 to 0.0) for disability, 1.8 (95% CI = 0.0 to 3.7) for the SF-8 PCS, and -0.6 (95% CI = -2.2 to 1.4) for the SF-8 MCS.

LIMITATIONS

Due to low statistical power, the estimates for the primary outcomes are imprecise.

CONCLUSIONS

Supervised group exercise did not reduce the prevalence of LBP or PGP in pregnancy.

Pregnancy-related lumbopelvic pain: listening to Australian women

Objective. To investigate the prevalence and nature of lumbo-pelvic pain (LPP), that is experienced by women in the lumbar and/or sacro-iliac area and/or symphysis pubis during pregnancy. Design. Cross-sectional, descriptive study. Setting. An Australian public hospital antenatal clinic. Sample population: Women in their third trimester of pregnancy. Method. Women were recruited to the study as they presented for their antenatal appointment. A survey collected demographic data and was used to self report LPP. A pain diagram differentiated low back, pelvic girdle or combined pain. Closed and open ended questions explored the experiences of the women. Main Outcome Measures. The Visual Analogue Scale and the Oswestry Disability Index (Version 2.1a). Results. There was a high prevalence of self reported LPP during the pregnancy (71%). An association was found between the reporting of LPP, multiparity, and a previous history of LPP. The mean intensity score for usual pain was 6/10 and four out of five women reported disability associated with the condition. Most women (71%) had reported their symptoms to their maternity carer however only a small proportion of these women received intervention. Conclusion. LPP is a potentially significant health issue during pregnancy.