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PrintExercise therapy: Coping with pregnancy related discomforts
Introduction
Most of the musculoskeletal problems that arise during pregnancy can be prevented and treated by physiotherapy. Individualized physical therapy programs have been found more effective than group sessions for the reduction of pain and sick leave due to back pain in pregnancy.
Pregnancy related problems: Physiotherapy and exercises
The most common, pregnancy related problems which benefit from physiotherapy are musculoskeletal problems like back pain; pelvic girdle pain (approx. 50% prevalence in pregnancy(Britt et al)), thoracic pain, nerve compression syndromes (e.g. carpel tunnel), stress incontinence and diastasis rectus abdominus.
Pelvic girdle pain and back pain
According to an article published by Artal et al most of the musculoskeletal problems that pregnant women experience are related to the altered postures with women getting heavier, while ligaments and muscles relax and stretch respectively. Whilst it may not be possible to stop this process from occurring, it is possible to minimize these maladaptive postures. With posture advise and through strengthening the core muscles the weakened structural integrity can be somewhat restored. This can help reduce or eliminate many of the common discomforts associated with pregnancy and improve postpartum recovery, particularly those associated with back problems (Artal et a and Hammer et al).
In addition to changes in posture, development of abnormal movement patterns is also very commonly seen, in particular during the second and third trimester. The resultant effect of abnormal movement will be pain during bed and car transfers, sit-stands and with walking. Gentle exercises to strengthen the core muscles, hamstrings and deep gluteal muscles combined with soft tissue release of the overactive piriformis, and advice of normal movements is often all that is required to reduce or completely eliminate pain.
Nerve Pathologies
Exercises to mobilize the nerves within nervous system can also be advised for women with nerve compression.
Incontinence
Incontinence (urine more so but faecal too) is a very common problem that may affect women during pregnancy. Neglecting the importance of pelvic floor muscles may result in women going on to develop incontinence during the pregnancy and at a later stage in life. Strengthening these muscles during pregnancy can also help develop the ability to relax and control the muscles in preparation for labor and delivery.
Ongoing strengthening post-delivery is highly recommended to promote the healing of perineal tissues, increase the strength of the pelvic floor muscles, and help these muscles return to a healthy state, including increased urinary control. Incontinence at any stage, can also be affected by a person’s lifestyle, occupation and diet and therefore advise must be provided in addition to exercise for such women.
Diastasis rectus abdominus
Traditional stomach crunches and sit-ups have actually been found to do more harm than good by increasing the separation of the rectus abdominus sheath. This is due to excessive exertion of tummy muscles that are stretching during the natural course of pregnancy. A study done by C. Cynthia et al at the Columbia University School of Physical Therapy showed that pregnant women who did not exercise had a 90% incidence of diastasis recti as compared with 12.5% in the exercising group who used their transverse abdominis during exercise. What this study highlights is the importance of exercise, but that too the correct form of exercise.
Not only antenatally but pilates based exercises to reduce the separation of these muscles postnatally is also often prescribed.
Additional benefits of exercise
Exercise also helps to ease the process of labor by training breathing control and strengthening the muscles required for labor. Exercise helps combat pregnancy related depression by improving body image and increasing self-esteem. It also aids in a faster recovery following delivery.
Considerations for Exercise prescription and physiotherapy intervention
Prior to exercise prescription knowledge regarding potential risks, awareness of baseline norms (e.g. in BP) and the assessment of the physical ability of the individual to engage in various activities is required. Given the potential risks, albeit rare, thorough physical evaluation of each pregnant woman should be conducted before any exercise programme is recommended. Individualized evaluation and exercise prescription by physiotherapists which includes intensity, frequency, and duration of the exercise seem to be important determinants of its beneficial effects. A women’s health physiotherapist specializing in issues associated with pregnancy can recommend exercises for pregnant and post-partum women after an assessment which generally consists of an analysis of the following:
- Joint mobility and symmetry
- Muscle imbalances and strengths
- Neurological evaluation
- Evaluation of functional limitations
Physiotherapy treatment techniques in addition to exercise commonly include:
- Pain management.
Techniques to aid joint and soft tissue flexibility.
Stress relief and relaxation training.
Recommendations for sleeping and birth positions
Posture correction and ergonomic advice
Postpartum rehabilitation
It is also very important to provide women with knowledge of instances where exercise is detrimental to their health and the babies.
EXERCISES
Aerobic activities and activities that promote musculoskeletal fitness are part of an overall exercise prescription. Typically, aerobic exercise can consist of any activities that use large muscle groups in a continuous rhythmic manner and the intensity veryimportantly should be based on scales which measure rate of perceived exertion. Exercises for musculoskeletal fitness include strength training and ?exibility exercises.
The 2003 Canadian clinical practice guidelines for exercise in pregnancy and the postpartum period, issued jointly by the Society of Obstetricians and Gynecologists of Canada and the Canadian Society for Exercise Physiology, provide more speci?c recommendation. Previously sedentary women should be counseled to begin with 15 mins of continuous exercise three times per week and work toward a goal of 30 mins four times per week.
SPECIFIC STABILITY EXERCISES
- Kegel Exercises
Kegel exercises, also called pelvic floor exercises, help strengthen the muscles especially the levator ani that support the bladder, uterus, and bowels
Intensive training of the pelvic floor muscles during pregnancy seems to facilitate rather than to obstruct labour. It could prevent a prolonged second stage in one in eight women. (7)A Cochrane review of 43 randomized trials concluded that PFM exercise was consistently better than no treatment or placebo and should be offered as first-line treatment for women with stress incontinence.
- Abdominal bracing exercise
This exercise requires the co-contraction of the transversus abdominis and multifidus that wrap right around the abdomen like a corset. It helps protect the spine which is under constant stress of the growing uterus, postural changes and reduced ligamentous stability. A study was done to compare the effects of the contraction of the transversus abdominis, independently of the other abdominals; with the bracing action that used all the lateral abdominal muscles on sacroiliac joint laxity. Joint laxity values decreased significantly in all individuals during both muscle patterns (P < 0.001). However interestingly isolating transversus abdominis contraction decreased sacroiliac joint laxity (or rather increased sacroiliac joint stability) to a significantly greater degree than the general abdominal exercise pattern (P < 0.0260) Richardson et al)
Pelvic titling combined with abdominal bracing are essential exercises for maintaining good posture and to prevent back ache that is due to bad posture.
MOBILITY EXERCISES
- Pelvic tilt
Pelvic tilts strengthen the muscles of the abdomen and lower back, increase hip mobility. Pelvic tilts are particularly effective in relieving lumbar pain.(J. Sabino et al)
- Stretching
Sub occipital extensors, pectorals, hip flexors and back extensors are tight due to an increased kyphosis, cervical and lumbar lordosis in pregnancy and can be the source of thoracic and posterior pelvic pain. In a study by Yeo et al that compared walking and stretching exercise, it was found that regular stretching exercises may promote endogenous antioxidants among women at risk for preeclampsia. The incidence of preeclampsia was 14.6% (95% CI, 5.6 to 29.2) among the walkers and 2.6% (95% CI; 0.07 to 13.8) among the stretchers
Warning signs to terminate exercise while pregnant
• Vaginal bleeding
• Dyspnoea before exertion
• Dizziness
• Headache
• Chest painMuscle weakness
• Calf pain or swelling (need to rule
out thrombophlebitis)
• Preterm labour
• Decreased fetal movement
• Amniotic fluid leakage
SUMMARY
Pregnancy should not be a state of confinement, and pregnant women with uncomplicated pregnancies should be encouraged to continue and engage in physical activities. Despite the fact that pregnancy is associated with profound anatomical and physiological changes, exercise can help prevent and combat many of the complications.
If your suffering from any of the above problems, or wish to seek further advice about excerise, consult a womens health physiotherapist
REFRENCES
- S. Snyder, B. Pendergraph. Exercise During Pregnancy: What do we really know? American Family Physician 2004;69(5)
- Borg-Stein J, Dugan S, Gruber J: Musculoskeletal aspects of pregnancy. Am J Phys Med Rehabil 2005;84:180 –192.
- Kramer MS. Aerobic exercise for women during pregnancy. Cochrane Database Syst Rev. 2004;(1):CD000180
- W Brown .The benefits of physical activity during pregnancy Journal of Science and Medicine in Sport2002;5(1):37-45
- Gavard, Jeffrey A; Artal, Raul.Effect of Exercise on Pregnancy Outcome; Clinical Obstetrics & Gynecology: 2008;5( 2)467-480
- Britt Stuge, Even Lærum, Gitle Kirkesola, Nina Vøllestad. The Efficacy of a Treatment Program Focusing on Specific Stabilizing Exercises for Pelvic Girdle Pain After Pregnancy-A Randomized Controlled Trial; Spine 2004;29:351–359
- R Artal, M O’Toole.Guidelines of the American College of Obstetricians and Gynecologists for exercise during pregnancy and the postpartum period Br. J. Sports Med.2003;37;6-12
- R. L. Hammer, J. Perkins, R. Parr. Exercise During the Childbearing Year; The Journal of Perinatal Education2000:9(1)
- Chiarello Cynthia, Falzone Laura A., McCaslin Kristin, Patel Mita N, Ulery Kristen R. The Effects of an Exercise Program on Diastasis Recti Abdominis in Pregnant Women;Journal of Women’s Health Physical Therapy 2005:29 (1)11–16
- Kjell Å Salvesen, Siv Mørkved. Randomised controlled trial of pelvic floor muscle training during pregnancy:BMJ 2004;329:378–803
- Hay-Smith EJ, Bo K, Berghmans LC, Hendriks HJ, de Bie RA, van Waalwijk van Doorm ES. Pelvic floor muscle training for urinary incontinence in women. The Cochrane Library,Issue 1, 2001.
- Richardson, Carolyn A.; Snijders, Chris J.; Hides, Julie A.; Damen, Léonie; Pas, Martij; Storm, Joop. The Relation Between the Transversus Abdominis Muscles, Sacroiliac Joint Mechanics, and Low Back Pain: Spine 2002; 27(4) 399-405
- SeonAe Yeo, Sandra Davidge, David L. Ronis, Cathy L. Antonakos, Robert Hayashi, Sharon O’Leary A Comparison of Walking versus Stretching Exercises to Reduce the Incidence of Preeclampsia: A Randomized Clinical Trial: Hypertension in Pregnancy 2008; Vol. 27, No. 2 , 113-130
New mums: Pain in the thumb?
Its common knowledge, that pregnant women and new mothers are prone to experience low back pain. Lots have been said to why, and such women have successfully been treated with strengthening exercises to stabilise the pelvis.
However did you know that pregnant women and new born mothers were also prone to wrist and thumb problems?
Carpel tunnel is widely recognised as a problem experienced by women antenatally and postnatally. This condition arises due to an increase in the blood volume circulation and swelling commonly experienced during pregnancy.
The carpel tunnel itself comprises of the bones and ligaments that form a canal at the base of the hand and as the median nerve passes through this, it can be compressed and impinged.
The median nerve gives sensation to the thumb, the index, middle, and half of the ring finger and is responsible for movement of a muscle at the base of the thumb. Pressure on this nerve can therefore cause a loss of either sensation or strength in these areas.
In addition Deqeurvain tendonitis is also seen during the last trimester of pregnancy and in new mothers. In fact some statistics have suggested that 50% of new mothers will experience these symptoms and the older the new mother (40 plus) the more likely. An increase in the incidence of dequervain also relates to the increase in the weight of new born babies over the last 30 years.
This condition involves irritation to 2 muscle tendons that mobilise the thumb causing pain with pinching, grasping, lifting and other movements of the thumb and wrist.
The root cause of this problem in the pregnant clientale is believed to be due to the repetitive and frequent improper lifting and cradling of the child.
Improper lifting and cradling
As a mother bends down to lift her child she often places her thumb under the child’s armpit. In doing so she put a lot of strain on the thumb joint and muscles. This is a movement that is often done repetitively and for a long period and from various heights (floor to standing, cot to standing). As the child continues to grow and gets heavier the strain may potentially worsen, causing inflammation, waekening and scarring to the tendon.
Also whilst cradling the child, some mother will use an L shape index finger and thumb to cradle and support the child’s head. Again overstraining the tendons of the thumb leading to the above problems.
Save your thumbs
New mothers could place their hand around the ribcage of their child and gently squeeze as they lift the child. This will alleviate the pressure exerted on the muscles of the thumb.
Alternatively supporting the child from the bottom and behind the head to lift the child can also reduce the pressure on thumbs.
Have a read of the carpel tunnel and Deqeurvain tendonitis articles for more informarmation about these conditions and physiotherapy treatment options to help your hands.
Pilates and Physiotherapy
What is Pilates?
Pilates is a unique body conditioning exercise designed to rebalance the body, bringing it, into its correct neutral alignment whilst targeting the deep postural muscles (Transverse abdominals and muscles of the pelvic diaphragm). In essence pilates challenges the core muscles and builds strength from the inside out, helping a person to reshape their body, adding to a leaner and more toned figure. It boasts of a perfect balance between strength and flexibility, whilst relieving unwanted stress and tension. The phenomena of pilates is a popular and growing trend in western countries amongst athletes and celebrities, as well as in the treatment of peripheral and spinal musculoskeletal dysfunction. Today pilates is evolving and is taught worldwide in gyms and hospital, benefiting millions of people. The aim of this article is a brief introduction to pilates and its clinical benefits in physiotherapy.
Background
Pilates was first discovered in Germany in the early 20th century by a keen diver, gymnast and boxer by the name of Joseph Pilates. Joseph Pilates had spent the majority of his childhood fighting rickets, asthma and rheumatic fever and this fuelled his desire to become physically immune to these ailments. Through studying a variety of different disciplines (yoga, Zen) he brought about this new notion of exercise. During the war he practised his theory of exercise, and became involved in the rehabilitation of war victims. Once the war ended, Joseph Pilates relocated to New York and soon went on to open the first pilates studio attracting elite actors, dancers and athletes.
Clinical Pilates vs Pilates
Clinical pilates is used to treat people with musculoskeletal injuries and is conducted by a physiotherapist certified with Clinical pilates certification. If a person experiences an injury or repetitive injuries, they may have joint stiffness, muscle spasms, poor posture or abnormal movement patterns as a cause or a result of the injury. It is therefore important to first treat the above complaints before commencing pilates.
In addition certain pilates exercises may aggravate the symptoms. An example is someone who may experience a back strain, due to too much extension in the lower back. Such individuals may have an exaggerated lordotic postures and therefore extension pilates exercises may not be advisable. This is something that would not be picked up if a person was to attend a routine pilates class, which does a combination of both flexion and extension exercises.
Not only is it important to select the right type of pilates exercise, it is also necessary to ensure that the correct and appropriate level is prescribed. Routine pilates may be too challenging for a person with back pain. This will cause the individual to compensate and utilise stronger global muscles as opposed to the core muscles, therefore negating the benefits of the pilates exercise. As a secondary result, a person may start to experience muscle spasm in the global muscles due to the increased exertion. The physiotherapist having tested your muscle strength and range of movement, will be able to ensure that the exercises are appropriate and although challenging not detrimental to recovery.
The added benefit of clinical pilates to routine pilates is not only is it more individualised to the person and their problem, it can also be more functional. If the person for example is keen to return to an activity or a sport (swimmer, footballer, dancer) the standard exercises can be modified by the physiotherapist to strengthen the core muscles whilst carrying out the aggravating movement. This could mean that the core muscles of a footballer is challenged as he kicks, dribbles a football and not just in static postures.
Peripheral injuries
When dealing with peripheral joint/ muscular injuries e.g. ankle instabilities the ankle is the main focus of the treatment. This makes sense and is always a good place to start to strengthen and rehabilitate local structures. However the research is beginning to move towards looking at the whole picture. Improving an individual dynamic control of their movements, will mean that person is less likely to sustain injuries. There is a growing trend to rehabilitate athletes whilst incorporating Pilates based exercises to teach a person to move more efficiently. Pilates can be used to treat hip, shoulder, knee and ankle injuries.
Spinal Injuries
Pilates in conjunction with manual joint mobilisations and soft tissue release is an effective way to treat back pain.
Time and time again the research has shown that any form of back pain leads to a loss of function of the deep muscles (multifidus) of the spine at that level. Unfortunately these muscles do not have the capacity to turn back on again, once the initial episode of back pain has resolved, and therefore these muscles require specific training to reactivate and stabilise the spine. In the long term these muscles without exercise will continue to waste further and subsequent muscle spasm in the global and more superficial muscles is experienced. This predominately occurs as a mean to stabilise the back in the absence of the deep muscle activity. Such individuals will report recurrent flare ups of back pain in the year due to the ongoing weakness of the spine.
In addition to weakness, back injuries usually occur after an extended period of time, in a bad posture, excessively loading the joint.
Clinical pilates is a form of exercise that both facilitates the strengthening of these deep muscles whilst educating a person where a neutral spine lies. In time a person will feel that there back is stronger, as they become more aware of what sitting or standing in a good posture entails.
In the long term they will also have the endurance to sustain these better postures for longer periods, through conducting the exercises.
If a person is new to pilates one- to one sessions with a physiotherapist or very small classes is initially strongly recommended, this is to ensure a person can be taught the correct techniques and the 5 concepts of pilates accurately (breathing, neck, rib pelvis position and stabilizing). Pilates can be a little tricky and can easily be done incorrectly and therefore close supervision is required to prevent faulty patterns learnt.
The benefits of Pilates
• General fitness and body awareness greater strength and muscle tone
• Improved flexibility
• A flatter stomach
• Improved efficiency of the respiratory, lymphatic and circulatory systems
• Better posture and awareness
• Less incidence of back pain
• Increased joint mobility
• Lower stress level
Which clients would benefit from Pilates?
• Males and females
• Pregnant: Pre and post natal
• Athletes and dancers
• Amputee and stroke rehabilitation clients
• Elderly
• Children 12 years-old +
Clinical pilates therefore targets the musculoskeletal injury more specifically. The physiotherapist is able to identify your posture type, establish the mechanism of injury, understand what the peron is aiming to return to and work out which exercises would be of more benefit to the individual. Clinical pilates therefore looks at treating the cause as well as selecting the appropriate repertoire of exercises to strengthen the injured areas and even be done for injury prevention.
If your suffering from recurrent episodes of back pain or peripheral injuries – Clinical Pilates may be just what you need!
Hard Core Muscles for Mummies (Part 2)
In the previous article on "Hard Core Muscles for Mummies (part 1)", we have touched on the importance of strong core muscles. Now let us look at some simple exercises (that do not require equipment) people can do at home to help strengthen their core muscles.
Exercises should be done daily for 3 -4 weeks to see results.
Understanding changes to an expectant woman’s body
Extensive physical and physiological changes take place in an expectant woman through the actions of the hormones, oestrogen, progesterone and relaxin. These changes create challenges, which should never be undermined, and hence it is important to understand the effects on the woman’s body during pregnancy to learn to cope with the challenges.
Respiratory system
The demand of oxygen is increased because the basal metabolic rate and the mass of the expectant woman increase as well. It is estimated that a woman will require about 20% more oxygen than normal at term. She also exhales more carbon dioxide which triggers the already sensitive respiratory system to increase the respiratory rate slightly. Hence, it is this lowering of the carbon dioxide that leads to pregnant women to become breathless on activity. Also, many expectant women will experience the ascending uterus which progressively obstructs the descent of the diaphragm, which is needed for deep breathing. It can force the diaphragm upwards by at least 4cm towards the end of pregnancy. Hence this rising pressure pushes the rib cage out sideways and forwards, resulting in pain in the front of the lower ribs, also known as ribflare. Furthermore, rib-flaring make expectant women breathe with the top part of her chest, thereby causing breathlessness even during mild exertion during pregnany but especially so, towards the end of term.
The cardiovascular system
During pregnancy, a woman’s blood volume increases by at least 40%. However, the plasma volume increases more than the red cells, hence possibly resulted in dilution anaemia, leading to tiredness in the early weeks of pregnancy. She may also feel faint when lying on her back. This is due to enlarging fetus compressing the aorta and inferior vena cava against the lumbar spine, thereby restricting blood flow. This condition is known as pregnancy supine hypotensive syndrome and can be relieved by turning onto her side. Such a condition tend to happen more in the 3rd trimester, though it can occur any time after the 4th month of pregnancy.
Varicose veins of the legs may occur during pregnancy or worsen during this period. This is due to reduction in vascular tone and changes in collagen structure in the body (due to progesterone and relaxin) .
For the same reason, “water retention” or swelling in ankles, feet and hands in late pregnancy may lead to joint stiffness and nerve compression syndromes, such as carpal tunnel syndrome.
The musculoskeletal system
The hormone, relaxin, is produced about 2 weeks into pregnancy. Relaxin alters the composition of collagen, which exist in joints, ligaments and connective tissues. As a result, the modified collagen is more elastic and flexible, leading to more movement in joints, and thus less stability of the system. The weight bearing joints, such as the pelvis, bear the brunt of the increased stress and loading during pregnancy, and with the instability that relaxin cause, the pelvis is susceptible to injury and pain, one of the conditions known as symphysis pubis diastasis. Also, ligaments of feet become lax and with the additional weight of pregnancy, causes discomfort. This results in aching and flat feet. Hence, comfortable yet supportive foot wear is strongly recommended during this period.
Posture-wise, her centre of gravity will move forward, leading to increased lower back curvature, compensatory curving of the upper back, rounding of shoulders and forward chin position. This incorrect posture exerts excessive strain and fatigue on her body, particularly in the spine, pelvis and other weight bearing joints (i.e. knees), resulting in aches and pains, such as lower back, with the pain spreading to the buttocks, thighs and down the legs.
Other muscular changes, such as the separation of the abdominal muscle, known as rectii diastasis, is associated with low back strain, as the abdominals are no longer able to support core and the spine as efficiently as before.
Therefore, with all the extensive changes in the expectant woman’s body, it is obvious that the healtier and fitter she is both before and during pregnancy, the more easily she can cope with pregnancy. If possible, she should prepare to be fit physically and emotionally before each pregnancy and maintain the fitness during the pregnancy, thereby enhancing recovery after delivery. In the next article in this series, we will look at the common physical problems affecting women during pregnancy and it’s solutions.
Breastfeeding postural related aches and pain
"I am a recent mother. And I have been breastfeeding my 3-month old baby daughter. Since about 2 months ago, I have started have neck aches and around my upper back. I think this is related to my breastfeeding posture. Is there anything I can do about it? Thanks in advance! – Melinda Q."
Does Labour Epidural Cause Chronic Backache?
After childbirth with an epidural, one may experience short-term back soreness at the catheter site where the medication was injected. As such, most women tend to associate labour epidural analgesia with chronic or long-term back pain. But is there really a connection between labour epidural and chronic backache?
Belt Up Your Unstable SIJ
An unstable Sacro-illiac Joint (SIJ) can cause pain in the lower back and pelvic region. This happens when the core muscles surrounding it are too weak to support the SIJ. A sacroiliac support belt can help to provide support and stability to the joints during the initial stages of core stability training. (more…)
Posterior Pelvic Pain (Sacroiliac Joint Pain) in Pregnant Women
Posterior pelvic pain (PPP) is pain felt at or near the sacroiliac joints of your pelvis as a result of sacroiliac joint dysfunction.
These are joints located at the 2 dimples of the lower back. The pain often feels deep within your lower back and can occur on one or both sides of your back. In some cases, pain radiates down to the buttock and the back of the thigh.
While pain may begin at any time during pregnancy, PPP on average begins in the 18th week of pregnancy and becomes more intense as the pregnancy progresses. The pain usually spontaneously resolves within 3 months post delivery. But in some cases it can become chronic and disabling.
What are the Sacroiliac joints?
The sacroiliac joints (SIJ) are formed between the sacrum, a triangular-shaped bone in the lower portion of the spine, and the right and left ilium of the pelvis. The SIJ is a strong and stable weight-bearing joint that permits very little movement due to its natural structure. The main role of the SIJ is to allow forces to be transmitted effectively through the body, absorbing impact from the legs to the spine during activities such as walking, running and jumping.
The SIJ is kept stable through two mechanisms:
- Firstly, the rough, groove-like connecting surfaces of the sacrum and ilium interlock and help stabilise the joint, like two pieces of Lego together.
- Secondly, the SIJ is further strengthened by a complex mesh of ligaments and muscles such as the core stabilizers. These core muscles, such as the transversus abdominis and multifidus which surround the SIJ, act as active stabilizers by actively contracting to create a compressive force over the SIJ, gripping the joint firmly together. They act as a natural corset by providing that compression around the lower back and pelvic region -much like wrapping your fingers around the two Lego pieces, keeping them firm and tight.
Posterior pelvic pain arises from sacroiliac joint dysfunction, in other words, when the stability of SIJ is compromised.
Why does it happen?
During pregnancy, mechanisms stabilising the SIJ is affected. This instability allows for increased motion, stressing the SIJ.
- Hormones released during pregnancy relax the ligaments of the body to allow the pelvis to enlarge, in preparation for childbirth
- Due to the growing uterus, some of the core muscles around the pelvis get ‘stretched’ and weakened.
Moreover, the additional weight and altered walking pattern associated with pregnancy can cause significant mechanical strain on the sacroiliac joints, which may result in SIJ inflammation, giving a deep ache in the posterior pelvis.
What are the symptoms?
Of all the back pains experienced during pregnancy, posterior pelvic pain is the most common – you are four times more likely to experience PPP than lumbar pain.
You may have posterior pelvic pain / sacroiliac joint dysfunction if you have:
- Deep, boring pain in the back of the pelvis (around the sacroiliac joints)
- Pain may occasionally radiate to the groin and thighs.
- The pain is typically worse with standing, walking, climbing stairs, resting on one leg, getting in and out of a low chair, rolling over and twisting in bed, and lifting. The pain improved when lying down.
- If there is inflammation and arthritis in the SI joint, you may experience stiffness and a burning sensation in the pelvis.
Diagnosing Sacroiliac Joint Dysfunction in pregnancy
Your doctor and/or physiotherapist will conduct a thorough history and physical examination to determine the underlying disorders for your pain. That includes your description of symptoms, a series of tests designed to look at the stability, movement, and pain in the sacroiliac joints and surrounding structures. Imaging, such as computed tomography (CT) scan and X-ray may also help in the diagnosis. Another reliable diagnostic method involves injecting an anesthetic agent into the SI joint, guided by an X-ray machine, numbing the irritated area, thereby identifying the pain source. However, due to the concerns of fetal exposure to radiation, diagnostic procedures involving radiation is generally avoided.
Treatment and Management
The first-line treatment of pregnancy-related sacroiliac joint dysfunction is physiotherapy and exercises that focuses on core stability of the trunk and pelvic girdle. Sometimes, a sacro-iliac belt is prescribed to complement the core stability exercises and to give quick pain relief. Exercises will form a large part of the treatment and in some cases, mobilisation (a gentler form of manipulation) of your hip, back or pelvis may be used to correct any underlying movement dysfunction. Other manual techniques include muscle energy technique (MET) and myofascial release. It is vital to engage a physiotherapist who is skilled in treating pregnancy-related pain as she is aware of the studies that support the use of specific stabilizing exercises and other treatment techniques, thereby preventing the dysfunction from escalating into a chronic condition.
Other alternative treatments include anesthetic and steroidal injections into the SIJ that can help in pain relief, which lasts from one day or much more long-term. Oral anti-inflammatory medications are often effective in pain relief as well. However, these two treatments may be contra-indicated during pregnancy.
Posterior Pelvic Pain Home Advice
Here are some tips for expectant women with posterior pelvic pain..
Lying down
- Avoid lying on your back for long periods of time, particularly after the 19th week of your pregnancy.
- Try lying on your side (preferably your left) with a pillow placed between your knees and another under your tummy.
- If your waist sags down into the bed, try placing a small rolled up towel under your waist.
Turning over in bed
- To turn to your right while lying on your back, arch your lower back, tighten your pelvic floor muscles and lower abdominal muscles and bend both knees one by one.
- Turn your head to the right and take your left arm over to the right of your body. Hold onto the side of your bed if you can.
- To turn, pull with your left hand and take both knees over to the right so that you roll to the right. As soon as possible, bend your knees up as high as they will go – this helps to lock out your pelvis and lessen pain.
- Reverse this to turn to the left.
Getting out of bed
- Roll onto your side with your knees bent up, move your feet over the edge of the bed and push yourself up sideways with your arms.
- Reverse the process when you lie down.
Standing from a sitting position.
- Sit on the edge of the chair.
- Keeping your knees apart slightly and lean forwards till your head is directly over your knees, keeping your back straight.
- Stand up by pushing up with your arms, with your back straight and tummy tucked in. This helps to hold your pelvic joints in their most stable position and may reduce your pain significantly.
Reference:
- Fitzgerald CM and Le J. Back pain in pregnancy requires practitioner creativity. Biomechanics. 2007 November
- Ostgaard HC, Andersson GB, Karlsson K. Prevalence of back pain in pregnancy. Spine. 1991; 16:549-552.
- Ostgaard HC, Zetherstrom G, Roos-Hansson E, Svanberg B. Reduction of back and posterior pelvic pain in pregnancy. Spine. 1994; 19:894-900.
- http://www.sidysfunction.com/articles/lumbarbackandposteriorpelvicpain.html
What is Symphysis Pubis Dysfunction (SPD)
If you are pregnant and experience pain in groin and inner thighs around the start of your second trimester, there is a chance that you are suffering from Symphysis Pubis Dysfunction (SPD). In one study1of the British population, the incidence of SPD varies from 1:360.3% to 2.77%. Thankfully, the pain goes away after delivery.
What is Symphysis Pubis Dysfunction?
The symphysis pubisis a fibrocartilaginous (a mixture of fibrous tissue and cartilaginous tissues) joint that connects the two halves of the pelvis together and keeps them steady during activity (see image). This joint is supported by a network of muscles and ligaments that allow very little movement to occur under normal circumstances. During pregnancy, the symphysis pubis widens an average of 2-3 mm from the usual 4-5mm gap. The average gap is about 7.7mm. This widening of the pelvic ring helps facilitate the delivery of baby.
Symphysis Pubis Dysfunction is when this joint becomes overly relaxed, allowing the pelvic girdle to become unstable. This leads to pain and inflammation.
In severe cases, the symphysis pubis partially or fully ruptures, increasing the gap to more than 10mm. This is known as the diastasis of the symphysis pubis (DSP).
SPD typically starts in the second trimester. The start of pain is usually gradual and can be very intense. It is usually relieved by rest. The good news is that symptoms commonly disappear shortly after delivery. A small percentage of women however, continue to experience pain for several months after delivery.
Why does it happen?
SPD is a result of a combination of factors; an altered pelvic load, hormonal and biochemical alterations causing ligament laxity and a weakening of pelvic and core musculature during pregnancy, leading to instability.
Symptoms
You may have SPD if you have one or more of the following:
- Pain localised to your symphysis pubis, including shooting, stabbing and burning pains, grinding and audible clicking sensations and/or persistent discomfort.
Source: e-radiography.net - Pain radiating to lower abdomen, groin, perineum, thigh, leg and back
- Difficulty in walking, climbing up or down stairs, rising up from a chair, impaired weight bearing activities, e.g. standing on one leg or lifting/parting the legs, turning in bed.
Diagnosing SPD
SPD today is becoming more widely understood by GPs, obstetricians and midwives. It is diagnosed by a combination of your own description of symptoms and a battery of tests designed to look at the stability, movement and pain in the pelvic joints and structures surrounding it. Imaging, such as X-rays, is the only way to confirm the misalignment of the pelvic bones. However, due to the concerns of fetal exposure to radiation, ultrasound is the preferred modality for assessing symphyseal widening in pregnancy.
Your doctor or midwife may refer you to a physiotherapist who has experience in treating this condition.
Management
A specialist physiotherapy assessment and review should be arranged. The physiotherapist can advise on back care and strategies to avoid activities that put unnecessary strain on the pelvis and on safe exercise during pregnancy.
Exercises for the pelvic girdle and core stabilizers of the trunk will form a large part of the treatment and are aimed at improving the stability of the pelvis and back. In some cases, mobilisation (a gentler form of manipulation) of your hip, back or pelvis may be used to correct any underlying movement dysfunction. Other manual techniques include muscle energy technique (MET) and myofascial release. The physiotherapist may also prescribe a pelvic support belt to give quick relief.
Other alternative treatments include hydrotherapy (exercise in water) and acupuncture which sometimes can be useful.
SPD Home Advice
Here are some things pregnant women with SPD can do to minimize their discomfort.
- A void activities which cause discomfort, e.g. lifting, carrying, prolonged standing, walking and strenuous exercise
- Rest more frequently in a position which is comfortable, such as:
- lying with your knees bent and supported
- lying on your side with a pillow between your knees
- sitting with your knees slightly apart
- avoid sitting with legs crossed.
- Mild to moderate exercise, including abdominal wall and pelvic floor exercises, is acceptable.
- Avoid straddling and squatting movements, which means moving with knees apart (hip abduction), when:
- getting in and out of car. Try to keep knees together.
- getting in and out of bed. When moving in bed, try to keep legs together particularly when moving from side to side. Do not push with one foot as this will worsen the pain. Push equally with both feet to move about the bed.
- Adopt good posture, avoid bending and twisting.
- If swimming, avoid the breast-stroke with the legs kicking outwards.
- Ice packs can be used for five minutes at a time or an ice cube can be rubbed on the symphysis pubis for 20–30 seconds
Reference:
- Owens K, Pearson A, Mason G. Symphysis pubis dysfunction – a cause of significant obstetric morbidity.Eur J Obstet Gynecol Reprod Biol 2002;105:143–46.
- MacLennan AH, MacLennan SC. Symptom-giving pelvic girdle relaxation of pregnancy, postnatal pelvic joint syndrome and development dysplasia of the hip.Acta Obstet Gynecol Scand1997;76:760–64.
- Jain S, Eedarapalli P, Jamjute P, Sawdy R. Symphysis pubis dysfunction: a practical approach to management.The Obstetrician & Gynaecologist 2006;8:153–158.
