Prognosis of women with pelvic pain during pregnancy: a long-term follow-up study

Transitional pain services updates and a novel service for the obstetric population

PURPOSE OF REVIEW

This paper is an update of the publications on Transitional Pain Services and explores the viability of a dedicated transitional pain service for women.

RECENT FINDINGS

We address common pain pathologies establishing referral criteria, pathways, and effective strategies to decrease chronification of pain during pregnancy.

SUMMARY

This review highlights the importance establishing transitional pain service models at every institution and in particular in obstetric population as pain is normalized by Society during pregnancy.

Physical job demands in pregnancy and associated musculoskeletal health and employment outcomes: a systematic review

OBJECTIVE

A decline in musculoskeletal health during pregnancy is an underappreciated adverse outcome of pregnancy that can have immediate and long-term health consequences. High physical job demands are known risk factors for nontraumatic musculoskeletal disorders in the general working population. Evidence from meta-analyses suggest that occupational lifting and prolonged standing during pregnancy may increase risk of adverse pregnancy outcomes. This systematic review examined associations between occupational lifting or postural load in pregnancy and associated musculoskeletal disorders and related sequalae.

DATA SOURCES

Five electronic databases (Medline, Embase, CINAHL, NIOSHTIC-2, and Ergonomic Abstracts) were searched from 1990 to July 2022 for studies in any language. A Web of Science snowball search was performed in December 2022. Reference lists were manually reviewed.

STUDY ELIGIBILITY CRITERIA

Eligible studies reported associations between occupational lifting or postural load and musculoskeletal health or sequelae (eg, employment outcomes) among pregnant and postpartum workers.

METHODS

Data were extracted using a customized form to document study and sample characteristics; and details of exposures, outcomes, covariates, and analyses. Investigators independently assessed study quality for 7 risk-of-bias domains and overall utility, with discrepant ratings resolved through discussion. A narrative synthesis was conducted due to heterogeneity.

RESULTS

Sixteen studies (11 cohort studies, 2 nested case-control studies, and 3 cross-sectional studies) from 8 countries were included (N=142,320 pregnant and N=1744 postpartum workers). Limited but consistent evidence with variable quality ratings, ranging from critical concern to high, suggests that pregnant workers exposed to heavy lifting (usually defined as ≥22 lbs or ≥10 kg) may be at increased risk of functionally limiting pelvic girdle pain and antenatal leave. Moreover, reports of dose-response relationships suggest graded risk levels according to lifting frequency, ranging from 21% to 45% for pelvic girdle pain and 58% to 202% for antenatal leave. Limited but consistent evidence also suggests that postural load increases the risk of employment cessation.

CONCLUSION

Limited but consistent evidence suggests that pregnant workers exposed to heavy lifting and postural load are at increased risk of pelvic girdle pain and employment cessation. Job accommodations to reduce exposure levels may promote safe sustainable employment for pregnant workers.

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.

Gap between the prevalence of and consultation rate for lumbopelvic pain in postnatal Japanese women

BACKGROUND

We aimed to assess the prevalence of lumbopelvic pain (LPP), including low back pain (LBP) and/or pelvic girdle pain (PGP), consultation rate, and desire for treatment of postnatal Japanese women.

METHODS

We performed a cross-sectional study of 98 postnatal Japanese women within 1 year of childbirth. We retrospectively evaluated the prevalence of LBP before and during pregnancy and the prevalence of LPP after childbirth using a self-administered questionnaire. We used the distribution of pain to differentiate LBP and/or PGP after childbirth and its intensity was assessed using a visual analogue scale. The effects of LPP on daily life were assessed using the Oswestry disability index (ODI). In addition, we assessed the consultation rate for LPP and the desire to consult a healthcare professional, using self-administered questionnaires.

RESULTS

The prevalence of LPP after childbirth was 66%. Women with a history of LBP before and during pregnancy were more likely to have LPP following childbirth (both P < 0.001). The consultation rate among the postnatal women with LPP was 9%, but 56% of the women wished to consult a healthcare professional. The ODI score was significantly higher in postnatal women who wanted to consult a healthcare professional than in those who did not (P < 0.01).

CONCLUSIONS

Two thirds of the postnatal Japanese women who participated in this study had LPP, but the consultation rate was low. However, more than half of these women had the desire to consult a healthcare professional.

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.

Differences in balance control despite self-reported resolution of pregnancy-related pelvic girdle pain. A cross-sectional study

BACKGROUND

Motor control patterns are altered when women with pregnancy-related pelvic girdle pain (PGP) experience pain. In low back pain, these adaptations can persist after recovery.

OBJECTIVES

This study aimed to assess balance control in postpartum women with and without a history of PGP during pregnancy.

DESIGN

Cross-sectional study.

METHOD

Eighteen postpartum women who reported to be recovered from PGP, and twelve postpartum women without a history of PGP during pregnancy performed two clinical tests: the single leg stance and active straight leg raise test. Primary outcomes were ground reaction forces measured with a force platform.

RESULTS

Multiple linear regression analyses showed smaller lateral displacement (β = -11cm; 95%CI: 19 to -3; p = 0.008) and lower displacement velocity of the Centre of Pressure (COP) (Ratio of Geometric Means (RGM) 0.76; 95%CI: 0.59 to 0.99; p = 0.043) during single leg stance in the participants with a history of PGP compared to participants without a history of PGP. Push-off force (β = -4.8 N; 95%CI: 22.0 to 12.5; p = 0.57) and asymmetry of push-off force (RGM 1.77; 95%CI: 0.62 to 5.04; p = 0.27) did not differ between groups. During the active straight leg raise test, no differences in lateral displacement (β = 3 cm; 95%CI: 3 to 8; p = 0.30) and COP displacement velocity (RGM 1.03; 95%CI: 0.70 to 1.52; p = 0.87) were observed.

CONCLUSIONS

Although the women with a history of PGP considered themselves recovered, their balance control during single leg stance was poorer compared to those without a history of PGP. No differences were found during the active straight leg raise test.

Sacroiliac Joint and Pelvic Dysfunction Due to Symphysiolysis in Postpartum Women

Pregnancy-related pain in the sacroiliac joint (SIJ), lumbosacral region, pubic symphysis, or in any combination of these joints has been coined as pelvic girdle pain (PGP) and has been estimated to affect almost half of all pregnant women. SIJ dysfunction in pregnancy is due to multiple biomechanical mechanisms, such as increased weight, change in posture, increased abdominal and intrauterine pressure, and laxity of the spine and pelvic structures. Moreover, when compared to men, women have increased SIJ mobility due to increased pubic angle and decreased SIJ curvature. These differences may assist in parturition where hormones, such as relaxin and estrogen, cause symphysiolysis. A retrospective review of the literature was conducted in the PubMed database using the search term “pregnancy-related sacroiliac joint pain.” All peer-reviewed studies were included. Around 8%-10% of women with PGP continue to have pain for one to two years postpartum. Patients that were treated with SIJ fusion show statistically significant improvement in pain scores when compared to patients that had non-operative treatment. Although we have a number of studies following patients after sacroiliac (SI) joint fusion for pelvic pain with SI joint dysfunction, further research is needed to study sacroiliac fusion for SI joint dysfunction in postpartum women to better tailor and optimize surgical outcomes for this patient population.

Women's Experience of Pelvic Girdle Pain After Childbirth: A Meta-Synthesis

INTRODUCTION

Persistent pelvic girdle pain (PGP) and the resulting consequences may occur for more than 10 years after birth. The purpose of this meta-synthesis is to provide a new interpretation and deeper understanding of women's experience of living with PGP postpartum.

METHODS

A literature review of CINAHL, PsycINFO, PubMed, Scopus, and ProQuest dissertations was conducted for any qualitative study addressing PGP after birth and published in English from 2000 to 2019. A meta-synthesis using Noblit and Hare's meta-ethnography approach was performed.

RESULTS

Seven studies were found describing the experiences of women living with PGP from birth to 13 years after birth. Six themes emerged that represented women's experience: invisible pain, life being restrained, failure to perform the maternal role, experiencing downward emotional spiral, need for active social support, and adaptation to a new conditional life.

DISCUSSION

The experiences of women living with PGP after birth highlight the need for holistic care. Interventions by health care providers should support the ability of women to perform daily functions and adapt to their new reality instead of a disease-focused intervention. In addition, women with PGP emphasize the importance of active social support from family members and health care providers. Future research that examines the differences between PGP during the first 3 months postpartum versus that which persists later is needed to develop targeted interventions.

Adult female patient with osteitis pubis and pelvic instability requiring surgery: A case report

Background

Osteitis pubis (OP) is an inflammatory condition of the symphysis pubis (SP) characterized by focal pain and local tenderness. Pelvic instability (PI) is commonly associated with this condition. It is still not clear if OP leads to PI or it is PI that leads to OP. The exact cause of osteitis pubis is not yet known, although several predisposing factors have been suggested to contribute to this condition. In most cases, it is self-remitting and rarely needs surgical intervention.

Case presentation

A 63-year old woman presented with a 12-month history of persistent pain at the symphysis pubis and non-responsive to analgesics. The pain was aggravated by physical activity such as standing and walking. Physical examination showed focal tenderness at the symphysis pubis with no tenderness over the sacroiliac joints or lumbar region. The diagnosis was confirmed by characteristic findings on radiographs, CT and MRI. Surgery was considered after all conservative measures failed. The patient underwent a wedge-shaped resection of the symphysis pubis; the bone defect was filled autologous tri-cortical bone and fixed with dual plating. The outcome was satisfactory with radiologic union and symptom resolution postoperatively.

Conclusions

Osteitis pubis due to pelvic instability can cause chronic and persistent pain. In cases where conservative treatment fails, surgery should be considered. We recommend wide surgical resection of all non-viable bone at the symphysis pubis with the addition of tri-cortical iliac bone graft. Double plating should be considered in order to maximize the rate of fusion and further stabilize the fixation.

Effect of Sedentary Time on the Risk of Orthopaedic Problems in People Aged 50 Years and Older

OBJECTIVE

Many people experience orthopaedic problems (OPPs), such as knee joint pain, hip joint pain, low back pain, and knee stiffness in their lifetimes. OPPs can impair lower extremity function, cause depression, and worsen quality of life. The aim of this study was to investigate the association between sedentary time (SDT) and OPPs.

DESIGN

Retrospective cross-sectional study.

SETTING

This study used data from the 2014-2015 Korea National Health and Nutrition Examination Survey. Survey participants with previous or current osteoarthritis or rheumatoid arthritis, as diagnosed by a doctor, were excluded. OPPs were defined as knee joint pain, hip joint pain, low back pain, and knee stiffness. The cut-off value for SDT was 7.5 hours/day. The study population comprised 3,671 people (1,856 men and 1,815 women), all of whom were ≥50 years-old. Multiple logistic regression analyses were performed.

RESULTS

A total of 328 men (17.7%) and 519 women (28.6%) had OPPs. Men with SDTs ≥7.5 hours had a greater risk of OPPs than did men with SDTs <7.5 hours (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.08-1.93). A pink-collar job, physical inactivity during leisure time, and passive (e.g. riding in a car or train) versus active (e.g. walking or riding a bicycle) transportation predicted OPPs in men with SDTs ≥7.5 hours. SDT was a risk factor for knee joint pain in men (OR, 1.80; 95% CI, 1.11-2.92) and hip joint pain in women (OR, 2.05; 95% CI, 1.35-3.11).

CONCLUSIONS

In men, prolonged SDT is a risk factor for OPPs. More physical activity programmes should be launched at the community level for people ≥50 years-old to reduce the occurrence of OPPs.

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.

Nausea and vomiting in pregnancy - association with pelvic girdle pain during pregnancy and 4-6 months post-partum

Background

To better understand previous associations reported regarding nausea and vomiting in pregnancy (NVP) and pelvic girdle pain (PGP), an investigation into timing of symptom onset for NVP and PGP in pregnancy, as well as the association of NVP with PGP 4-6 months post-partum was performed. We hypothesised that women with NVP symptoms would be most susceptible to experiencing persistence of PGP post-partum.

Methods

Fifty two thousand six hundred seventy-eight pregnancies from the Norwegian Mother and Child Cohort Study were analysed regarding nausea, vomiting, pelvic girdle pain, and health outcome data collected from questionnaires answered between gestation weeks 15, 20, 30, and 6 months post-partum. Logistic regression was used.

Results

Women experiencing NVP and PGP together (6.9%) were heaviest in the sample, youngest at menarche and had highest proportion with education ≤12 years. The primiparous women in this group had the lowest timespan from menarche to pregnancy. Women with nausea alone (NP) and NVP had higher odds of PGP 4-6 months post-partum (adjusted odds ratio, aOR = 2.14, 95% CI 1.70–2.71, and aOR = 2.83, 95% CI 2.25–3.57, respectively), compared to symptom-free women. NP/NVP symptoms appeared early in the first trimester, while PGP symptoms appeared later in pregnancy. Women with longer durations of nausea and/or vomiting had a higher proportion of PGP compared to shorter duration women.

Conclusions

Women with NP and NVP had increased odds of PGP 4-6 months post-partum, and women with a long duration of nausea and/or vomiting had a higher proportion of PGP than women with shorter duration, both during pregnancy and 4-6 months post-partum. This finding suggests a synergistic relationship between NP/NVP and PGP.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1764-7) contains supplementary material, which is available to authorized users.

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.

Chronic pelvic pain in an interdisciplinary setting: 1-year prospective cohort

BACKGROUND

Chronic pelvic pain affects ∼15% of women, and presents a challenging problem for gynecologists due to its complex etiology involving multiple comorbidities. Thus, an interdisciplinary approach has been proposed for chronic pelvic pain, where these multifactorial comorbidities can be addressed by different interventions at a single integrated center. Moreover, while cross-sectional studies can provide some insight into the association between these comorbidities and chronic pelvic pain severity, prospective longitudinal cohorts can identify comorbidities associated with changes in chronic pelvic pain severity over time.

OBJECTIVE

We sought to describe trends and factors associated with chronic pelvic pain severity over a 1-year prospective cohort at an interdisciplinary center, with a focus on the role of comorbidities and controlling for baseline pain, demographic factors, and treatment effects.

STUDY DESIGN

This was a prospective 1-year cohort study at an interdisciplinary tertiary referral center for pelvic pain and endometriosis, which provides minimally invasive surgery, medical management, pain education, physiotherapy, and psychological therapies. Exclusion criteria included menopause or age >50 years. Sample size was 296 (57% response rate at 1 year; 296/525). Primary outcome was chronic pelvic pain severity at 1 year on an 11-point numeric rating scale (0-10), which was categorized for ordinal regression (none-mild 0-3, moderate 4-6, severe 7-10). Secondary outcomes included functional quality of life and health utilization. Baseline comorbidities were endometriosis, irritable bowel syndrome, painful bladder syndrome, abdominal wall pain, pelvic floor myalgia, and validated questionnaires for depression, anxiety, and catastrophizing. Multivariable ordinal regression was used to identify baseline comorbidities associated with the primary outcome at 1 year.

RESULTS

Chronic pelvic pain severity decreased by a median 2 points from baseline to 1 year (6/10-4/10, P < .001). There was also an improvement in functional quality of life (42-29% on the pain subscale of the Endometriosis Health Profile-30, P < .001), and a reduction in subjects requiring a physician visit (73-36%, P < .001) or emergency visit (24-11%, P < .001) in the last 3 months. On multivariable ordinal regression for the primary outcome, chronic pelvic pain severity at 1 year was independently associated with a higher score on the Pain Catastrophizing Scale at baseline (odds ratio, 1.10; 95% confidence interval, 1.00-1.21, P = .04), controlling for baseline pain, treatment effects (surgery), age, and referral status.

CONCLUSION

Improvements in chronic pelvic pain severity, quality of life, and health care utilization were observed in a 1-year cohort in an interdisciplinary setting. Higher pain catastrophizing at baseline was associated with greater chronic pelvic pain severity at 1 year. Consideration should be given to stratifying pelvic pain patients by catastrophizing level (rumination, magnification, helplessness) in research studies and in clinical practice.

An Interdisciplinary Approach to Endometriosis-associated Persistent Pelvic Pain

Endometriosis-associated pelvic pain is a common and often challenging problem. For certain patients, pain persists or recurs despite adequate medical or surgical therapy targeted to endometriosis. In this patient population, there is often the presence of coexisting pain conditions such as irritable bowel syndrome, painful bladder syndrome and myofascial pain as well central sensitisation. An interdisciplinary approach where both peripheral pain triggers and central sensitization are addressed is likely to lead to improved pain and quality of life. The approach to the evaluation and treatment of the patients with persistent/chronic pelvic pain and endometriosis is outlined in this article.

Pregnancy-related lumbopelvic pain: classification and diagnostics according to European guidelines and a review of literature

Lumbopelvic pain associated with pregnancy may originate from the lumbar spine, the pelvic girdle or may be mixed. According to European guidelines, individual subtypes of pain require different procedures, for which a detailed differential diagnosis is necessary. These ailments arouse a lot of controversy. The aim of the work was to present the current state of knowledge on the aforementioned ailments, including European guidelines and the latest trends in foreign literature. The diagnosis of lumbopelvic pain, with particular emphasis on the pathophysiology and methods of differentiation of both pain syndromes, was discussed. Lumbar spine pain is mainly related to the mechanical load caused by a pregnant uterus. In the case of pelvic girdle pain, the main cause is the disorder of optimal stability, which depends on the correct mechanisms of force and form closure. Pelvic girdle pain is characterized by other clinical symptoms and risk factors, it also often remains after pregnancy, having negative impact on the daily functioning of a woman even years after giving birth. Depending on the location (one or both sacroiliac joints, pubic symphysis), several types of this pain syndrome are distinguished. The worst prognosis is pelvic pain associated with the involvement of all three joints at the same time. Until now, this term has not been more widely used in the Polish-language literature. The complexity of chronic pain syndromes, in which the discomforts of the pregnancy period may develop, entails the necessity of early identifi cation and deliberate action. Knowledge of the etiopathogenesis of these ailments is a prerequisite for therapeutic success. Introduction of terminology popular in foreign literature will improve treatment of these diseases, adapting it to current standards and will also enable better exchange of experience between professionals. pelvic girdle pain, lumbar pain, pregnancy

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.

Chiropractic Management of Pregnancy-Related Lumbopelvic Pain: A Case Study

OBJECTIVE

The purpose of this case report is to describe chiropractic management of a patient with pregnancy-related lumbopelvic pain.

CLINICAL FEATURES

A pregnant 35-year-old woman experienced insidious moderate to severe pregnancy-related lumbopelvic pain and leg pain at 32 weeks' gestation. Pain limited her endurance capacity for walking and sitting. Clinical testing revealed a left sacroiliac joint functional disturbance and myofascial trigger points reproducing back and leg pain.

INTERVENTION AND OUTCOME

A diagnosis of pregnancy-related low back pain and pregnancy-related pelvic girdle pain was made. The patient was treated with chiropractic spinal manipulation, soft tissue therapy, exercises, and ergonomic advice in 13 visits over 6 weeks. She consulted her obstetrician for her weekly obstetric visits. At the end of treatment, her low back pain reduced from 7 to 2 on a 0-10 numeric pain scale rating. Functional activities reported such as walking, sitting, and traveling comfortably in a car had improved.

CONCLUSION

This patient with pregnancy-related lumbopelvic pain improved in pain and function after chiropractic treatment and usual obstetric management.

Interventions for preventing and treating low-back and pelvic pain during pregnancy

BACKGROUND

More than two-thirds of pregnant women experience low-back pain and almost one-fifth experience pelvic pain. The two conditions may occur separately or together (low-back and pelvic pain) and typically increase with advancing pregnancy, interfering with work, daily activities and sleep.

OBJECTIVES

To update the evidence assessing the effects of any intervention used to prevent and treat low-back pain, pelvic pain or both during pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth (to 19 January 2015), and the Cochrane Back Review Groups' (to 19 January 2015) Trials Registers, identified relevant studies and reviews and checked their reference lists.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of any treatment, or combination of treatments, to prevent or reduce the incidence or severity of low-back pain, pelvic pain or both, related functional disability, sick leave and adverse effects during pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

We included 34 RCTs examining 5121 pregnant women, aged 16 to 45 years and, when reported, from 12 to 38 weeks' gestation. Fifteen RCTs examined women with low-back pain (participants = 1847); six examined pelvic pain (participants = 889); and 13 examined women with both low-back and pelvic pain (participants = 2385). Two studies also investigated low-back pain prevention and four, low-back and pelvic pain prevention. Diagnoses ranged from self-reported symptoms to clinicians' interpretation of specific tests. All interventions were added to usual prenatal care and, unless noted, were compared with usual prenatal care. The quality of the evidence ranged from moderate to low, raising concerns about the confidence we could put in the estimates of effect. For low-back painResults from meta-analyses provided low-quality evidence (study design limitations, inconsistency) that any land-based exercise significantly reduced pain (standardised mean difference (SMD) -0.64; 95% confidence interval (CI) -1.03 to -0.25; participants = 645; studies = seven) and functional disability (SMD -0.56; 95% CI -0.89 to -0.23; participants = 146; studies = two). Low-quality evidence (study design limitations, imprecision) also suggested no significant differences in the number of women reporting low-back pain between group exercise, added to information about managing pain, versus usual prenatal care (risk ratio (RR) 0.97; 95% CI 0.80 to 1.17; participants = 374; studies = two). For pelvic painResults from a meta-analysis provided low-quality evidence (study design limitations, imprecision) of no significant difference in the number of women reporting pelvic pain between group exercise, added to information about managing pain, and usual prenatal care (RR 0.97; 95% CI 0.77 to 1.23; participants = 374; studies = two). For low-back and pelvic painResults from meta-analyses provided moderate-quality evidence (study design limitations) that: an eight- to 12-week exercise program reduced the number of women who reported low-back and pelvic pain (RR 0.66; 95% CI 0.45 to 0.97; participants = 1176; studies = four); land-based exercise, in a variety of formats, significantly reduced low-back and pelvic pain-related sick leave (RR 0.76; 95% CI 0.62 to 0.94; participants = 1062; studies = two).The results from a number of individual studies, incorporating various other interventions, could not be pooled due to clinical heterogeneity. There was moderate-quality evidence (study design limitations or imprecision) from individual studies suggesting that osteomanipulative therapy significantly reduced low-back pain and functional disability, and acupuncture or craniosacral therapy improved pelvic pain more than usual prenatal care. Evidence from individual studies was largely of low quality (study design limitations, imprecision), and suggested that pain and functional disability, but not sick leave, were significantly reduced following a multi-modal intervention (manual therapy, exercise and education) for low-back and pelvic pain.When reported, adverse effects were minor and transient.

AUTHORS' CONCLUSIONS

There is low-quality evidence that exercise (any exercise on land or in water), may reduce pregnancy-related low-back pain and moderate- to low-quality evidence suggesting that any exercise improves functional disability and reduces sick leave more than usual prenatal care. Evidence from single studies suggests that acupuncture or craniosacral therapy improves pregnancy-related pelvic pain, and osteomanipulative therapy or a multi-modal intervention (manual therapy, exercise and education) may also be of benefit.Clinical heterogeneity precluded pooling of results in many cases. Statistical heterogeneity was substantial in all but three meta-analyses, which did not improve following sensitivity analyses. Publication bias and selective reporting cannot be ruled out.Further evidence is very likely to have an important impact on our confidence in the estimates of effect and change the estimates. Studies would benefit from the introduction of an agreed classification system that can be used to categorise women according to their presenting symptoms, so that treatment can be tailored accordingly.

The health-seeking behaviours of first-time mothers with persistent pelvic girdle pain after childbirth in Ireland: A descriptive qualitative study

OBJECTIVE

to explore the health-seeking behaviours of primiparous women with pelvic girdle pain persisting for more than three months post partum.

DESIGN

a descriptive qualitative design involving face-to-face semi-structured interviews following institutional ethical approval. Transcripts were analysed using thematic analysis.

SETTING

an urban hospital in Ireland.

PARTICIPANTS

a purposive sample of 23 consenting first-time mothers with pelvic girdle pain persisting for at least three months post partum.

FINDINGS

'they didn't ask, I didn't tell' was a key theme, which included emerging categories of a perceived lack of follow-up post partum, and feeling ignored by healthcare professionals. The theme 'Seeking advice and support' describes women's role of talking to others, and triggers and barriers to getting help. 'Coping strategies' was the third theme emerging from the interviews, whereby participants described different strategies they used to deal with their symptoms, although many expressed uncertainty about what to do or who to see.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

our findings show the importance of appropriate information and follow-up care for women with pelvic girdle pain and highlight barriers they encounter in seeking help. They also question the duration of postnatal care as participants felt that postnatal care was stopped too early. The findings may assist maternity care providers in addressing mothers' expectations and needs related to persistent pelvic girdle pain.

Asymmetric pelvic bracing and altered kinematics in patients with posterior pelvic pain who present with postural muscle delay

BACKGROUND

The purpose of the study was to examine the muscle activity and hip-spine kinematics in a group of individuals diagnosed with posterior pelvic girdle pain and confirmed postural muscle delay during a repeated fast hip flexion task.

METHODS

Twenty-four (12 pain and 12 control) age and sex matched participants performed a repeated fast hip flexion task to auditory signal. Surface EMG activity in the external and internal oblique, the multifidus, the gluteus maximus and biceps femoris in the stance-limb was examined for onset timing and EMG integral. Sagittal plane hip (swing limb) and spine kinematics were examined for group and side differences over the repeated trials.

FINDINGS

While the pain group lacked significant feedforward muscle activity they displayed higher muscle activity at movement onset in the biceps femoris bilaterally (p<0.05) as well as the external oblique (p<0.05) during motion of the symptomatic side. Furthermore, the pain group experienced asymmetrical spinal range of motion with increased motion on the contralateral side (p<0.001) and reduced flexion velocity on the symptomatic side (p<0.001).

INTERPRETATION

The findings support previous hypotheses regarding the effect of increased biceps activity on pelvic control during lumbo-pelvic rotation. Further, there appears to be a symptom led strategy for bracing the innominate through opposing tension in the biceps and external oblique during movement of the painful side. Such asymmetrical pelvic girdle bracing may be a strategy to increase the stability of the pelvis in light of the failed load transfer mechanism. Putatively, this strategy may increase the mechanical stress on the sacroiliac joint exacerbating pain complaints.

Prevalence and predictors of genito-pelvic pain in pregnancy and postpartum: the prospective impact of fear avoidance

INTRODUCTION

There is limited knowledge regarding the symptom profile of genito-pelvic pain in pregnancy and postpartum, and potential psychosocial predictors of this pain. Prior studies have reported a positive association between prepregnancy pain and postpartum genito-pelvic pain. Greater fear avoidance has been associated with increased genital pain intensity in women, unrelated to childbirth. This relationship has not been examined prospectively in a postpartum population.

AIMS

The study aims were to examine the symptom profile of genito-pelvic pain during pregnancy and at 3 months postpartum, and the impact of prepregnancy nongenito-pelvic pain and fear avoidance in pregnancy on genito-pelvic pain at 3 months postpartum.

METHODS

First-time expectant mothers (N = 150) completed measures of fear avoidance (pain-related anxiety, catastrophizing, hypervigilance to pain), prepregnancy nongenito-pelvic pain, childbirth-related risk factors (e.g., episiotomy), and breastfeeding.

MAIN OUTCOME MEASURES

Those reporting genito-pelvic pain in pregnancy and/or at 3 months postpartum answered questions about the onset (prepregnancy, during pregnancy, postpartum) and location (genital, pelvic, or both) of the pain and rated the intensity and unpleasantness of the pain on numerical rating scales.

RESULTS

Of 150 women, 49% reported genito-pelvic pain in pregnancy. The pain resolved for 59% of women, persisted for 41%, and 7% of women reported a new onset of genito-pelvic pain after childbirth. Prepregnancy nongenito-pelvic pain was associated with an increased likelihood of postpartum onset of genito-pelvic pain. Greater pain-related anxiety was associated with greater average genito-pelvic pain intensity at 3 months postpartum.

CONCLUSIONS

Results suggest that about half of women may develop genito-pelvic pain during pregnancy, which will persist for about a third, and a subset will develop this pain after childbirth. Prior recurrent nongenito-pelvic pain may enhance the risk of developing genito-pelvic pain postpartum, while greater pain-related anxiety in pregnancy may increase the risk for greater intensity of postpartum genito-pelvic pain.

Evaluation of self-administered tests for pelvic girdle pain in pregnancy

BACKGROUND

Different tests are used in order to classify women with pelvic girdle pain (PGP). One limitation of the tests is that they need to be performed by an examiner. Self-administered tests have previously been described and evaluated by women who performed the tests directly before the examiner performed the original tests. Thus, an evaluation of the self-administered tests performed in a more natural setting, such as the women's home is needed.The purpose of this study was to investigate the agreement between self-administered tests performed at home and tests performed by an examiner on women with suspected PGP. Additionally to compare the classification made by an examiner and classification based on results of the self-administered tests and questionnaire.

METHODS

One hundred and twenty three pregnant women with suspected PGP participated. Before the appointment at the clinic the women performed the self-administered tests and filled in a questionnaire. During the appointment one specialized physiotherapist performed the tests. Result of the two different sets of tests and the classifications made by the examiner and the self-administered tests including questionnaires were compared concerning percentage of agreement (POA), sensitivity and positive predicted value (PPV).

RESULTS

The P4 and the bridging test had the highest POA (≥ 74.8%), sensitivity (≥ 75.5%) and PPV (≥ 91.2%) for posterior PGP. For anterior PGP the MAT test had highest POA (76.4%), and PPV (69.5%), and the modified Trendelenburg test the highest sensitivity (93.0%). Agreement between the two classifications was 87%.A significantly higher number of positive P4 and bridging tests (p<0.01) and a significantly lower number of positive Trendelenburg tests, Active Straight Leg raise and Straight Leg Raise (p<0.05) were recorded by the examiner compared to the self-administered ones.

CONCLUSIONS

Our results indicate that self-administered test and questionnaires are possible to use for testing and classification of women with suspected PGP.

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.

Clinical guidelines for occupational lifting in pregnancy: evidence summary and provisional recommendations

Empirically based lifting criteria established by the National Institute for Occupational Safety and Health (NIOSH) to reduce the risk of overexertion injuries in the general US working population were evaluated for application to pregnant workers. This report proposes criteria to guide decisions by medical providers about permissible weights for lifting tasks performed at work over the course of an uncomplicated pregnancy. Our evaluation included an extensive review of the literature linking occupational lifting to maternal and fetal health. Although it has been 29 years since the American Medical Association's Council on Scientific Affairs published its report on the Effects of Pregnancy on Work Performance, these guidelines continue to influence clinical decisions and workplace policies. Provisional clinical guidelines derived from the NIOSH lifting criteria that account for recent evidence for maternal and fetal health are presented and aim to improve the standard of care for pregnant workers.

Interventions for preventing and treating pelvic and back pain in pregnancy

BACKGROUND

More than two-thirds of pregnant women experience low-back pain (LBP) and almost one-fifth experience pelvic pain. Pain increases with advancing pregnancy and interferes with work, daily activities and sleep.

OBJECTIVES

To assess the effects of interventions for preventing and treating pelvic and back pain in pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (18 July 2012), identified related studies and reviews from the Cochrane Back Review Group search strategy to July 2012, and checked reference lists from identified reviews and studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of any treatment to prevent or reduce the incidence or severity of pelvic or back pain in pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias and extracted data. Quality of the evidence for outcomes was assessed using the five criteria outlined by the GRADE Working Group.

MAIN RESULTS

We included 26 randomised trials examining 4093 pregnant women in this updated review. Eleven trials examined LBP (N = 1312), four examined pelvic pain (N = 661), and 11 trials examined lumbo-pelvic (LBP and pelvic) pain (N = 2120). Diagnoses ranged from self-reported symptoms to the results of specific tests. All interventions were added to usual prenatal care and unless noted, were compared to usual prenatal care. For LBP, there was low-quality evidence that in general, the addition of exercise significantly reduced pain (standardised mean difference (SMD) -0.80; 95% confidence interval (CI) -1.07 to -0.53; six RCTs, N = 543), and disability (SMD -0.56; 95% CI -0.89 to -0.23; two RCTs, N = 146); and water-based exercise significantly reduced LBP-related sick leave (risk ratio (RR) 0.40; 95% CI 0.17 to 0.92; one RCT, N = 241). Low-quality evidence from single trials suggested no significant difference in pain or function between two types of pelvic support belt, between osteopathic manipulation (OMT) and usual care or sham ultrasound (sham US). Very low-quality evidence suggested that a specially-designed pillow may relieve night pain better than a regular pillow. For pelvic pain, there was moderate-quality evidence that acupuncture significantly reduced evening pain better than exercise; both were better than usual care. Low-quality evidence from single trials suggested that adding a rigid belt to exercise improved average pain but not function; acupuncture was significantly better than sham acupuncture for improving evening pain and function, but not average pain; and evening pain relief was the same following either deep or superficial acupuncture. For lumbo-pelvic pain, there was moderate-quality evidence that an eight- to 20-week exercise program reduced the risk of women reporting lumbo-pelvic pain (RR 0.85; 95% CI 0.73 to 1.00; four RCTs, N = 1344); but a 16- to 20-week training program was no more successful than usual care at preventing pelvic pain (one RCT, N = 257). Low-quality evidence suggested that exercise significantly reduced lumbo-pelvic-related sick leave (RR 0.76; 95% CI 0.62 to 0.94, two RCTs, N = 1062), and improved function. Low-quality evidence from single trials suggested that OMT significantly reduced pain and improved function; either a multi-modal intervention that included manual therapy, exercise and education (MOM) or usual care significantly reduced disability, but only MOM improved pain and physical function; acupuncture improved pain and function more than usual care or physiotherapy; pain and function improved more when acupuncture was started at 26- rather than 20- weeks' gestation; and auricular (ear) acupuncture significantly improved these outcomes more than sham acupuncture.When reported, adverse events were minor and transient.

AUTHORS' CONCLUSIONS

Moderate-quality evidence suggested that acupuncture or exercise, tailored to the stage of pregnancy, significantly reduced evening pelvic pain or lumbo-pelvic pain more than usual care alone, acupuncture was significantly more effective than exercise for reducing evening pelvic pain, and a 16- to 20-week training program was no more successful than usual prenatal care at preventing pelvic or LBP. Low-quality evidence suggested that exercise significantly reduced pain and disability from LBP.There was low-quality evidence from single trials for other outcomes because of high risk of bias and sparse data; clinical heterogeneity precluded pooling. Publication bias and selective reporting cannot be ruled out.Physiotherapy, OMT, acupuncture, a multi-modal intervention, or the addition of a rigid pelvic belt to exercise seemed to relieve pelvic or back pain more than usual care alone. Acupuncture was more effective than physiotherapy at relieving evening lumbo-pelvic pain and disability and improving pain and function when it was started at 26- rather than 20-weeks' gestation, although the effects were small.There was no significant difference in LBP and function for different support belts, exercise, neuro emotional technique or spinal manipulation (SMT), or in evening pelvic pain between deep and superficial acupuncture.Very low-quality evidence suggested a specially-designed pillow may reduce night-time LBP.Further research is very likely to have an important impact on our confidence in the estimates of effect and is likely to change the estimates.  Future research would benefit from the introduction of an agreed classification system that can be used to categorise women according to presenting symptoms.

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.

Predictors for postpartum pelvic girdle pain in working women: the Mom@Work cohort study

The objective of this study was to examine which factors during pregnancy and postpartum predict pelvic girdle pain (PGP) at 12 weeks postpartum among working women. A total of 548 Dutch pregnant employees were recruited in 15 companies, mainly health care, child care, and supermarkets. The definition of PGP was any pain felt in the pelvic girdle region at 12 weeks postpartum. Participants received questionnaires at 30 weeks of pregnancy and at 6 and 12 weeks postpartum with demographic, work-related, pregnancy-related, fatigue, psychosocial, PGP-related and delivery-related questions. Univariate and multiple logistic regression analyses were performed. Almost half of the women experienced pain in their pelvic girdle at 12 weeks postpartum. However, the level of pain and the degree of disability due to postpartum PGP was low. Pregnancy-related predictors for PGP at 12 weeks were history of low back pain, higher somatisation, more than 8 hours of sleep or rest per day, and uncomfortable postures at work. The pregnancy and postpartum-related predictors were: more disability at 6 weeks, having PGP at 6 weeks, higher mean pain at 6 weeks, higher somatisation during pregnancy and at 6 weeks postpartum, higher birth weight of the baby, uncomfortable postures at work and number of days of bed rest. Based on these results, it is concluded that extra attention should be given to women who experience PGP during pregnancy to prevent serious PGP during late pregnancy and postpartum. More research is needed to confirm the roles of hours of sleep, somatisation, and bed rest in relation to PGP.

Mode of delivery and persistence of pelvic girdle syndrome 6 months postpartum

OBJECTIVE

We sought to study the association between mode of delivery and persistent pelvic girdle syndrome (PGS) (pain in anterior and bilateral posterior pelvis) 6 months postpartum.

STUDY DESIGN

We followed up 10,400 women with singleton deliveries in the Norwegian Mother and Child Cohort Study who reported PGS in pregnancy week 30 (1999 through 2008). Data were obtained by 3 self-administered questionnaires and linked to the Medical Birth Registry of Norway.

RESULTS

Planned cesarean section was associated with the presence of severe PGS 6 months postpartum (adjusted odds ratio [OR], 2.3; 95% confidence interval [CI], 1.4-3.9). In women who used crutches during pregnancy, emergency (adjusted OR, 2.0; 95% CI, 1.0-4.0) and planned (adjusted OR, 3.3; 95% CI, 1.9-5.9) cesarean section were each associated with severe PGS.

CONCLUSION

The results suggest an increased risk of severe PGS 6 months postpartum in women who underwent a cesarean section vs women who had an unassisted vaginal delivery.

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.

Pregnancy related back pain, is it related to aerobic fitness? A longitudinal cohort study

Background

Low back pain with onset during pregnancy is common and approximately one out of three women have disabling pain. The pathogenesis of the pain condition is uncertain and there is no information on the role of physical fitness. Whether poorer physical conditioning is a cause or effect of back pain is also disputed and information from prospective studies needed.

Methods

A cohort of pregnant women, recruited from maternal health care centers in central Sweden, were examined regarding estimated peak oxygen uptake by cycle ergometer test in early pregnancy, reported physical activity prior to pregnancy, basic characteristics, back pain during pregnancy and back pain postpartum.

Results

Back pain during the current pregnancy was reported by nearly 80% of the women. At the postpartum appointment this prevalence was 40%. No association was displayed between estimated peak oxygen uptake and incidence of back pain during and after pregnancy, adjusted for physical activity, back pain before present pregnancy, previous deliveries, age and weight. A significant inverse association was found between estimated peak oxygen uptake and back pain intensity during pregnancy and a direct association post partum, in a fully adjusted multiple linear regression analysis.

Conclusions

Estimated peak oxygen uptake and reported physical activity in early pregnancy displayed no influence on the onset of subsequent back pain during or after pregnancy, where the time sequence support the hypothesis that poorer physical deconditioning is not a cause but a consequence of the back pain condition. The mechanism for the attenuating effect of increased oxygen uptake on back pain intensity is uncertain.

Association between the serum levels of relaxin and responses to the active straight leg raise test in pregnancy

There is a common belief that the laxity of pelvic joints increases in pregnancy. The hormone relaxin is suggested to be one of the most influential factors implementing this effect. Furthermore, increased laxity is assumed to induce pelvic girdle pain (PGP). The objectives were to examine the serum relaxin levels in pregnancy and to investigate whether relaxin levels relate to symptoms and clinical tests for PGP. Data from questionnaires, clinical tests and blood samples were collected once in pregnancy (gestation week 5-24) from 212 women. Serum from blood samples were analyzed by ELIZA to determine the concentration of relaxin. Self reported symptoms were assessed by Disability Rating Index (DRI) and pain intensity (VAS). Clinical examinations included Active Straight Leg Raise (ASLR) test and pain provocation tests. ANOVA was used to assess the effect of gestation age and multivariable statistics to examine the association between relaxin levels and the symptoms or responses to clinical tests. The serum levels of relaxin varied widely between individuals and were only marginally influenced by the gestation age. There was no association between gestation age and responses to clinical tests or pain intensity, but DRI increased with gestation age. Serum concentration of relaxin showed a significant association to positive score on the ASLR test, but no significant associations to responses to pain provocation tests, pain intensity or DRI. The results indicate that relaxin contributes to laxity of pelvic joints in pregnancy. Yet, no evidence of relaxin having an impact on symptoms or perceived disability was found.

Pelvic girdle pain: potential risk factors in pregnancy in relation to disability and pain intensity three months postpartum

The objective of this prospective cohort study was to examine how results of clinical tests on women with pelvic girdle pain (PGP) in late pregnancy were associated with disability and pain intensity 12 weeks postpartum controlling for socio-demographical and psychological factors. Out of the 283 women clinically examined in gestation week 30, 179 were considered afflicted from PGP and constituted the study sample. Potential risk factors were assessed by questionnaires (at inclusion and in gestation week 30) and clinical examination in gestation week 30. The clinical examination included pain provocation tests for the pelvis as well as the active straight leg raise test. We used pain intensity and disability (disability rating index, DRI) as response variables, derived from questionnaires 12 weeks postpartum. Using multivariable linear regression analyses, sum of pain provocation tests and pre-pregnancy low back pain (LBP) were significantly associated with DRI 12 weeks postpartum. Furthermore, sum of pain provocation tests and number of pain sites were significantly associated with pain intensity. In conclusion, we found that when including results of clinical tests as risk factors together with socio-demographical and psychological factors in multivariable regression models, the clinical risk factors are the ones that remain significant. These results are of clinical importance because they seem to have the potential to identify women with a poor prognosis.

Pregnancy-related pelvic girdle pain: an update

A large number of scientists from a wide range of medical and surgical disciplines have reported on the existence and characteristics of the clinical syndrome of pelvic girdle pain during or after pregnancy. This syndrome refers to a musculoskeletal type of persistent pain localised at the anterior and/or posterior aspect of the pelvic ring. The pain may radiate across the hip joint and the thigh bones. The symptoms may begin either during the first trimester of pregnancy, at labour or even during the postpartum period. The physiological processes characterising this clinical entity remain obscure. In this review, the definition and epidemiology, as well as a proposed diagnostic algorithm and treatment options, are presented. Ongoing research is desirable to establish clear management strategies that are based on the pathophysiologic mechanisms responsible for the escalation of the syndrome's symptoms to a fraction of the population of pregnant women.

Pelvic girdle pain and low back pain in pregnancy: a review

Pregnancy-related pelvic girdle pain (PGP) and pregnancy-related low back pain (PLBP) are common problems with significant physical, psychological, and socioeconomic implications. There are several management options that are underutilized because of lack of comprehensive knowledge by health-care professionals and fear of harmful effects of treatment on the developing fetus. Interventions such as patient education, the use of pelvic belts, acupuncture, and aquatic and tailored postpartum exercises can be of some benefit to these patients. This article will focus on the diagnosis and management of PGP and PLBP, with discussion of terminology, epidemiology, risk factors, pathophysiology, and prognosis.

Motor control patterns during an active straight leg raise in chronic pelvic girdle pain subjects

STUDY DESIGN

Repeated measures.

OBJECTIVE

To investigate motor control (MC) patterns in chronic pelvic girdle pain (PGP) subjects during an active straight leg raise (ASLR).

SUMMARY OF BACKGROUND DATA

The ASLR is a test used to assess load transference through the pelvis. Altered MC patterns have been reported in subjects with chronic PGP during this test. These patterns may impede efficient load transfer, while having the potential to impinge on respiratory function and/or to adversely affect the control of continence.

METHODS

Twelve female subjects with chronic PGP were examined. Electromyography of the anterior abdominal wall, right chest wall and the scalene, intraabdominal pressure, intrathoracic pressure, respiratory rate, pelvic floor kinematics, and downward leg pressure of the nonlifted leg were compared between an ASLR lifting the leg on the affected side of the body versus the nonaffected side.

RESULTS

Performing an ASLR lifting the leg on the affected side of the body resulted in a predominant MC pattern of bracing through the abdominal wall and the chest wall. This was associated with increased baseline shift in intraabdominal pressure and depression of the pelvic floor when compared with an ASLR lifting the leg on the nonaffected side.

CONCLUSION

This MC pattern, identified during an ASLR on the affected side of the body, has the potential to be a primary mechanism driving ongoing pain and disability in chronic PGP subjects.

Self-administered tests as a screening procedure for pregnancy-related pelvic girdle pain

The aim of this study was to investigate sensitivity and specificity of self-administrated tests aimed at pain provocation of posterior and/or anterior pelvis pain and to investigate pain intensity during and after palpation of the symphysis. A total of 175 women participated in the study, 100 pregnant women with and 25 pregnant women without lumbopelvic back pain and 50 non-pregnant women. Standard pain provocation tests were compared with self assessed tests. All women were asked to estimate pain during and after palpation of the symphysis. For posterior pelvic pain, the self-test of P4 and Bridging test had the highest sensitivity of 0.90 versus 0.97 and specificity of 0.92 and 0.87. Highest sensitivity for self-test for anterior pelvic pain was pulling a mat 0.85. Palpation of symphysis was painful and persistency of pain was the longest among women who fulfilled the criteria for symphyseal pain. There were overall significant differences between the groups concerning intensity and persistency of pain (P < 0.001). Our results indicate that pregnant women can perform a screening by provocation of posterior pelvic pain by self-tests with the new P4 self-test and the Bridging test. Palpation of the symphysis is painful and should only be used as a complement to history taking, pain drawing and pulling a MAT-test.

Prognostic factors for recovery from postpartum pelvic girdle pain

Pelvic girdle pain (PGP) has a high incidence during pregnancy and in some women pain will persist for years. Most studies have used pain as the outcome measure, and little attention is given to functioning or disability. A better understanding of prognostic factors for recovery seems important for clinical care and treatment. The aim of the present paper was to identify prognostic factors for recovery from postpartum PGP and disability, and to determine the impacts of prognostic factors when pain intensity and disability are used as outcome measures. Seventy-eight women with diagnosed PGP were included 6-16 weeks postpartum. Possible prognostic factors were obtained through clinical tests and questionnaires at baseline. The clinical tests were posterior pelvic pain provocation (P4) test, active straight leg raise (ASLR) test and pain provocation of long dorsal sacroiliac ligament (LDL). One year postpartum outcome measures were obtained by Oswestry disability index (ODI ver 2.0) and worst evening pain (VAS 0-100). Multiple linear regression and logistic regression analyses were used to identify significant prognostic factors. At baseline 60% believed they would recover and 40% were uncertain or believed they would not recover. Fifty per cent had a history of low back pain (LBP), and 20% had high emotional distress (HSCL25-item > or =1.75). About 75% had positive LDL and P4 at both sides and 24% had pain located to all three pelvic joints. Forty per cent had ASLR scores of at least 4 (sum score range 0-10). Multivariate analyses showed consistently that ASLR and belief in improvement were statistical significant predictors for both disability and pain as outcome measures. ASLR score <4 predicted 10 points lower ODI and 19 points lower evening pain compared with having ASLR score of at least 4. Pain location was a statistical significant predictor in only one analysis. History of LBP or high psychological distress was not prognostic for recovery. ASLR test and belief in improvement are predictors of clinical significance in women having PGP postpartum.

Motor control patterns during an active straight leg raise in pain-free subjects

STUDY DESIGN

Repeated measures.

OBJECTIVE

To investigate motor control (MC) patterns of normal subjects during the low level physical load of the active straight leg raise (ASLR).

SUMMARY OF BACKGROUND DATA

Aberrant MC patterns, as observed with the ASLR test, are considered to be a mechanism for ongoing pain and disability in subjects with chronic musculoskeletal pelvic girdle pain. These patterns may not only affect the provision of lumbopelvic stability, but also respiration and the control of continence. Greater understanding of MC patterns in pain-free subjects may improve the management of pelvic girdle pain. METHODS.: Fourteen pain-free nulliparous women were examined during the ASLR. Electromyography of the anterior abdominal wall, right chest wall and the anterior scaleni, intraabdominal pressure (IAP), intrathoracic pressure (ITP), respiratory rate, pelvic floor kinematics, and downward leg pressure of the nonlifted leg were compared between a left and right ASLR.

RESULTS

There was greater activation of obliquus internus abdominis and obliquus externus abdominis on the side of the ASLR. The predominant pattern of activation for the chest wall was tonic activation during an ipsilateral ASLR, and phasic respiratory activation lifting the contralateral leg. Respiratory fluctuation of both IAP and ITP did not differ lifting either leg. The baseline shifts of these pressure variables in response to the physical demand of lifting the leg was also the same either side. There was no difference in respiratory rate, pelvic floor kinematics, or downward leg pressure.

CONCLUSION

Pain-free subjects demonstrate a predominant pattern of greater ipsilateral tonic activation of the abdominal wall and chest wall on the side of the ASLR. This was achieved with minimal apparent disruption to IAP and ITP. The findings of this study demonstrate the plastic nature of the abdominal cylinder and the flexibility of the neuromuscular system in controlling load transference during an ASLR.