Pregnancy-related low back pain is an unfortunately common occurrence, affecting many women. More than 2/3 of pregnant women experience low-back pain (LBP) and almost 1/5 experience pelvic pain. Symptoms usually start around the 18th week of pregnancy, but can also begin in the first trimester or as late as three weeks after delivery.1 Pain increases with advancing pregnancy and interferes with work, daily activities and sleep.2 The most frequent pain location and the most severe pain are related to the pelvic girdle. Posterior pelvic girdle pain (PGP) has been defined as pain localized between the iliac crests and the gluteal folds with or without radiation down the leg. Anterior PGP is experienced in the symphysis and can occur in addition to posterior PGP or as a separate syndrome, previously referred to as SPD or symphysis pubis dysfunction.
Diagnosing Pelvic Girdle Pain
The diagnosis of pelvic girdle pain has been a contentious issue, with both poor inter- and intra-rater reliability demonstrated in using bony landmarks, asymmetry and misalignment theories. But as all skilled therapists know, accurate diagnosis is the key to successful treatment outcomes. The publication of the European guidelines for the diagnosis and treatment of pelvic girdle pain by Vleeming et al 2 set down the questions:
- What is the most optimal diagnostic process for patients with PGP?
- What is the most effective treatment for reducing pain and improving disability in patients with PGP?
Despite the popular theory that relaxin levels are to blame for increased pelvic joint laxity and therefore pelvic girdle pain, Vleeming et al found that there is no linear relationship between pain and increased range of motion in the pelvic joints; thus, apparently, some women can handle increased range of motion caused by ligament laxity while other women cannot. This indicates that decreased joint stability may be compensated for by changed muscle function, postural patterns and ergonomic modifications.
The following tests are recommended by Vleeming et al (2008)3 for clinical examination of PGP:
- Posterior Pelvic Pain Provocation Test (P4/thigh thrust)
- Patrick’s Faber Test
- Palpation of the Long Dorsal SIJ Ligament
- Gaenslen’s Test
- Palpation of the Symphysis
- Modified Trendelenburg Test of the Pelvic Girdle
- Functional Pelvic Test (also know as the Active Straight Leg Raise Test or ASLR)
Access to therapists specializing in the treatment of pregnancy-related musculoskeletal dysfunction may be limited, especially in rural locations. A recent paper from Olsen in 20144 looked at the accuracy of self-testing for diagnosis of pelvic girdle pain. The participants in the study had to fulfill the criteria laid down by the European Guidelines:3
- A pain drawing with well-defined markings of pain over the gluteal area or the symphyseal joint
- A history of weight-bearing related pain in the pelvic girdle
- Positive self-administered tests, which reproduced pain in the pelvic girdle
- No nerve root syndrome judged by a negative self-administered modified straight leg raise
Among the tests for identification of posterior PGP, the highest percentage of agreement and sensitivity was seen for the self-administered P4 test as compared to a clinically-administered P4. The single leg bridging test was another assessment for identifying posterior PGP that was shown to have a high sensitivity and high percentage of agreement compared to tests performed by an examiner. There was poorer correlation between self-testing and clinical testing using the ASLR and the SLR. It’s both important and possible to identify women at risk for persistent PGP in the postpartum as early as possible.4 The self-administered tests could further contribute to specific identification of PGP and thereby provide the basis for an early intervention. In addition, they can be used in perinatal care units as a ground for timely referral to specialist physical therapy for treatment.
Final Note of Caution
Be careful with testing when using the pain provocation tests. These women are already in pain, so be judicious in provoking further pain without offering resolution! Part 2 of this post will look at the treatment options for pregnancy-related PGP.
- Pregnancy related pelvic girdle pain (PPP), (1): Terminology, clinical presentation and prevalence. Wu W, Meijer O., Uegaki K et al European Spine Journal 13 (7), 575-589
- Interventions for preventing and treating pelvic and back pain in pregnancy (Review) Pennick V, Liddle SD Cochrane Database Syst Rev. 2013
- European guidelines for the diagnosis and treatment of pelvic girdle pain, Vleeming A et al 2008
- Evaluation of self-administered tests for pelvic girdle pain in pregnancy, Olsen M, Elden H, Gutke A. BMC Musculoskeletal Disorders 2014, 15:138
- Impact of postpartum lumbopelvic pain on disability, pain intensity, health-related quality of life, activity level, kinesiophobia, and depressive symptoms. Gutke A, Lundberg M, Ostgaard HC, Oberg B: Eur Spine J 2011, 20:440-448