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Health Professionals

Pelvic Girdle Pain (formerly Symphysis Pubis Dysfunction/SPD)

Please note that throughout this website we have referred to the new umbrella term "Pelvic Girdle Pain " for this collection of symptoms following the publication of new guidelines for its management in 2007.  The terms Symphysis Pubis Dysfunction or SPD are still commonly used.

 

Key Facts about Pelvic Girdle Pain

Affects 1 in 5 pregnant women to some degree 1 in 20 have significant pain and mobility problems Can occur at any stage of pregnancy or post natally  When untreated around  1 in 14 women  may still have symptoms persisting for 2 years Risk Factors include previous low back pain and/or trauma to the pelvis  Exact cause unknown but hormonal changes in pregnancy, altered muscle activity in the lumbo pelvic hip region and asymmetrical pelvic joint laxity known to be associated Can be safely treated at any stage of pregnancy or post natally by an appropriately trained physiotherapist In women with severe symptoms consider  a multidisciplinary approach which may include OT referral, social work input and pain clinic referral. Advise re birth planning, suitable birthing positions and measure the  pain free gap (if applicable)  Care should be taken to move the legs symmetrically during any intervention during labour or during any gynaecological procedure e.g D &C  and to avoid excessive hip abduction  Research in post natal women has shown that an individualised treatment programme of exercises is effective4 The Association of Chartered Physiotherapists in Women's Health have recently published new guidelines

 

 

A bit of anatomy - The Pelvic Girdle

One of the main functions of the pelvis is to transfer load from the trunk to the lower limbs during all day to day activities such as standing, walking  and running and to do this effectively there has to be adequate stability.

This stability is achieved by a combination of factors:

• The  bones - the shape of the bones and how they fit together. The sacrum is wedge shaped and provides a large, flat surface for articulation with the ilia on either side.
• The ligaments - strong ligaments provide support to the sacro iliac and symphysis pubis joints.
• Muscles - both the core and global muscle slings.
• Neural control.
• Emotions can affect neural control

During load  transfer the sacrum tilts forward (nutates) between the ilia and combined  with the factors above, a self locking mechanism is produced which provides  optimal stability of the pelvis.

There also has to be  flexibility and shock absorption  during activities such as walking and other weight bearing activities so  there is also normally a small amount of movement  at the sacro iliac joints.

Who gets Pelvic Girdle Pain?

Pregnant women are by far  the most commonly affected group but it  can however affect women who are not pregnant and men too sometimes as a result of injury or trauma.

What is the incidence?

When Pelvic Girdle Pain is studied separately rather than being included with low back pain several studies have shown the incidence to be around 20% of all pregnant women with around 5% of women having serious problems with pain and disability (Larsen et al 1999¹Ostgaard et al 1994b²)

The incidence of pelvic girdle pain in the non pregnant population is not known but studies on post natal women have shown that untreated around 7% of women continue to experience symptoms 2 years post natally³

What are the symptoms of Pelvic Girdle Pain?

Symptoms vary widely from one person to another  from mild occassional discomfort when walking to severe debilitating pain requiring crutches or a wheel chair.

Not all women have the classically described  pain in the Symphysis Pubis Joint. Pain may be felt only in the sacro iliac joint/s

Symptoms may include:

• Pain in one or more joints of the pelvis, often affecting the pubic bone at the front or one or both sacro iliac joints at the back
• Pain in the lower back, hip joints, groin, lower abdomen or inner thighs
• Pain and difficulty with walking sometimes walking with a waddling gait
• Difficulty with activities which involve standing on one leg such as dressing and climbing stairs
• Difficulties with activities of daily living including getting in and out of a car/turning over in bed and getting in and out of a bath
• Difficulties with household activities such as hoovering, lifting and carrying small children and pushing shopping trolleys.
• Clicking or grinding in the pelvic joints which may be heard or felt.
• Stress urinary incontinenece
• upper back stiffness
• knee pain
• Feeling that the hip is out of place or has to pop into place before walking

What causes Pelvic Girdle Pain?

 The exact cause is not clear  but a number of different factors have been identified which include:

Hormonal Effects

 In pregnancy there is an Increase in the amount of the hormone relaxin which  causes softening of the ligaments throughout the body.

However research  by Bjorklund et al (1999) concluded that hormone levels alone had no relevance to the development of symptoms in the women in the study.

 Altered activity in the lumbo pelvic hip muscles

In pregnancy the muscles which normally provide support and stability  to the pelvis and back are put under stress by the growing size and weight of the baby which also causes postural changes.

The pelvic floor muscles are affected by the weight of the baby sitting on the pelvic floor and the abdominal and rib cage muscles are  stretched by the growing bump.

To cope with the increased joint laxity caused by the hormonal effects above the muscles have to work harder and sometimes they either  overwork or work ineffectively which can result in pain.

Optimal stability of the pelvic girdle depends on  the bones, joints, muscles and nerves working efficiently  so ineffective muscle control can affect the function  of the pelvic girdle  and pain can result.

Asymmetric joint laxity

Studies have shown that there is no linear correlation between the amount of joint laxity and pain  but there is a link between asymmetrical joint laxity and pain. As the pelvis is a closed ring of bone if one joint becomes stiff or stuck this will alter the function of all the other joints.

 During load transfer the sacrum tillts forward (nutates) between the two ilia and together with the ligaments and muscles  produces a self locking mechanism which provides optimal stability. If the sacro iliac joints don't move together  this nutation of the sacrum will fail to work properly and this self locking mechanism will not be effective.

Interestingly no correlation has been found  between the degree of widening of the symphysis pubis joint and pelvic pain either during pregnancy or in the post partum period

How is the diagnosis made?

History

History from patient especially of pain and where and when it occurs. Pain turning over in bed, going up and down stairs and getting in and out of a car are commonly reported symptoms.

Physiotherapy Referral

After  exclusion of other condtions - e.g. Urinary tract infection, Braxton Hicks contractions, a referral should be made to a physiotherapist  with experience of managing pelvic girdle pain

 A  thorough assessment of the lumbo pelvic hip region will be performed  to decide which structures are causing pain and to work out an appropriate  treatment plan.

Pelvic Girdle Pain is a diagnosis of exclusion after other causes of lumbo pelvic hip pain have been ruled out and  people develop pelvic girdle pain for a variety of very individual reasons.

One test for effective load transfer between the trunk and lower limbs is  the supine Active Straight Leg Raising Test (ASLR) which has been found to be reliable, sensitive and specific for pelvic girdle pain (Mens et al 1999, 2001, 2002)

 Treatment of Pelvic Girdle Pain

A treatment plan will be recommended  tailored to the individual patient which may include:

• Mobilising joints which have become stiff or "stuck"
• Correcting the alignment of the joints within  and between the lumbar spine, pelvic girdle and hip
• Soft tissue work/treating muscles which have become over active or tight
• *Restoring the best possible function  of the "core" or "deep stabilising" muscles. 
• Improving the function of the "global muscle slings" which move and stabilise joints  e.g gluteal muscles 
• Rehabilitation in functional/activities of daily living

*This  involves "hands on " manual techniques which may vary according to the preference of the therapist  and which may include muscle release techniques, joint mobilisation, massage and muscle energy techniques. 

Taping or a pelvic belt may  be used as an adjunct along with core stability training.

In a study of post natal women with pelvic girdle pain  an individualised treatment programme comprising of specific stabilisng exercises was shown to be effective⁴

Pain Management

Options to consider include:

Use of TENS machine

TENS may be a good option to consider for pain relief in people with Pelvic girdle pain/Symphysis Pubis Dysfunction.

New Guidelines have been issued regarding the safe use of TENS in pregnancy for musculoskeletal pain. Click here to access the guidelines.

Acupuncture

Evidence is increasing that acupuncture reduces pain in pregnant women with pelvic girdle pain.  Research was published in 2005 of a  single blind  controlled trial⁵ with three groups: a control group who were offered advice, a pelvic belt and muscle strengthening exercises, a group who were given stabilising exercises and the third group who were given acupuncture.

 After treatment pelvic pain was reduced significantly in the group who had stabilising exercises compared with controls but interestingly  the reduction was greatest in the group who had acupuncture.

 

Review of Mangement of Non-Obstetric Pain in Pregnancy 2008 British Pain Society.

Click here to access the review (starting on page 10 of the document)

 

 Managing Birth with Pelvic Girdle Pain/Symphysis Pubis Dysfunction(SPD)

One of the greatest concerns that women with pelvic girdle pain/symphysis pubis dysfunction(SPD) who contact us  have is how the birth of their baby will be managed.

Articles in popular press and women's magazines with headlines such as "my pelvis split in two when giving birth" only heighten this anxiety. Added to this is often the fear  that giving birth will "damage" their pelvis and  that they won't be able to have any pain relief in case it masks the symptoms of "damage".

The ACPWH guidelines discuss the issues around managing birth with pelvic girdle pain/symphysis pubis dysfunction(SPD) and the guidelines include advice regarding recording  the pain free gap(if applicable), suggestions regarding suitable birthing positions and discuss the pros and cons of  C-section and pain management.

 Click here to access the Guidelines.

Useful Links:

 European Guidelines on the Diagnosis and Treatment of Pelvic Girdle Pain.

 Diane Lee - The Evolution of Myths and Facts Regarding Function and Dysfunction of the Pelvic Girdle

BIMM Presentation on Prolotherapy by Dr John Tanner

References

1.Larsen EC, Wilken-Jensen C, Hansen A, Jensen DV, Johansen S, Minck H, Wormslev M, Davidsen M, Hansen TM (1999) Symptom-giving pelvic girdle relaxation in pregnancy I Prevalence and risk factors. Acta Obstet Gynecol Scand 78: 105-110

2..Ostgaard HC, Zetherstrom G, Roos-Hansson E, Svanberg B (1994b) Reduction of back and Posterior Pelvic Pain in Pregnancy Spine 19: 894-900

3.Albert H, Godskesen M, Westergaard J (2001) Prognosis in four syndromes of Pregnancy Related Pelvic Pain Acta Obstet Gynecol Scand 80: 505-510

4.Stuge B, Laerum E, Kirkesola G, Vollestad N 2004  The efficacy of a treatment program focusing on specific stabilising exercises for Pelvic Girdle Pain after pregnancy. Spine 29 (4) : 351

5.Elden H, Ladfors L,Olsen MF, Ostgaard HC, Hagberg H. Effects of acupuncture and stabilising exercises as adjunct to standard treatment in pregnant women with pelvic girdle pain randomised single blind controlled trial. BMJ 2005: 330: 761

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