Low back and pelvic girdle pain during pregnancy  Afsaneh Azari, Women’s Physiotherapy research group, ACECR  Roxana Bazaz Behbahani, Women’s Physiotherapy research group, ACECR

Kinds of Low back pain  Lumbar Pain (L.B.P)  Posterior Pelvic Pain (P.P.P) Or Pelvic Girdle Pain (P.G.P)

 PGP is a combination of mechanical, hormonal, circulatory and psychosocial factors.  A sedentary life style increases risk of back pain compared to patients who engage in a more active life style.

Epidemiology of pelvic and low back pain in pregnancy:  Back pain is very common complaint in pregnant women  2/3 of pregnant women  80% of pregnant women  4%- 76/4% (Ansari etal. 2003, Berget al. 1988, Diakow et al. 7991, Endpesen 1995, fast et al, 1990, Golighty 1982, Kogstad 1988, Kristsson et al. 1996, et al. 1999, Mantle et al. 1977, moon et al. 2000, Mousavi 2003)

 20% PGP in pregnant women ( European Guidelines on the diagnosis of PGP )  % of all pregnant women have serious PGP with 5-8 % of them having severe problems with pain and disability ( Daly et al 1991, broadhurst 1996 )

Reasons for this large variation:  Prospective and retrospective studies  Diagnostic procedure (in some studies the women diagnose their own condition, in others a history of pelvic pain is declared sufficient to propose a diagnosis, in others both a pain history and clinical examination)  Location of pain (Some studies specify LBP, some p.p.p, some don’t specify the area and some describe both)

Etiology:  The causes of PGP are multifactorial and often there is an obvious explanation  PGP is more likely to be a combination of factors that include: The pelvic girdle joints moving asymmetrically Abnormal pelvic girdle biomechanics from altered activity in the spinal, abdominal, pelvic girdle, hip and pelvic floor muscles A small member of women may have non biomechanical but hormonally- induced pain in the pelvic girdle. Occasionally the position of the baby may produce PGP.

Risk factors  History of previous LBP  History of previous trauma to the pelvis  multiparity  Poor work place ergonomics and awkward working conditions  General joint hyper mobility

Factors not associated with PGP include:  Contraceptive pills  Time interval since last pregnancy  Smoking  Height  Weight  Probably age (one study reports that young age is a risk factor)  Breast feeding (European Guidelines on the diagnosis and treatment of PGP)

. Diagnosis of PGP:  The diagnosis can be reached from signs and symptoms experienced and described by a women during the pregnancy or in the postnatal period  All women should be asked whether they have any problems with their back or pelvis  Signs and symptoms should not be ignored or dismissed as aches and pains of pregnancy

Common signs and symptoms include:  Difficulty walking (waddling gait)  Pain on weight bearing on one leg e.g Climbing stairs, dressing.  Pain and/or difficulty in straddle movements e.g getting in and out of bath, turning in bed.

 Clicking or grinding in pelvic area may be audible or pulpable.  Limited and pain full hip abduction  difficulty lying in some positions e.g. supine – side lying.  Pain during normal activities of daily life.  Pain and difficulty during sexual intercourse.

Clinical examination of PGP:  Active S.L.R (ASLR, mens 2001)  Gaenslen test (Gaenslen 1927)  Long dorsal sacroiliac lig. Test (LDL test uleeming 2002)  Pain provocation of the symphysis by modified trendlenburgs test (Albert 2000)  Patrik’s faber test (Albert 2000)  Posterior pelvic pain provocation test (ostgaard 1994)  Symphysis pain palpation test (Albert 2000)  A pain drawing with well- defined markings of stabbing in the L50s, area, but not in to the foot.

The posterior pelvic pain provocation test: (H.C.ostgaard et al)  The test is easy to learn  It’s applicable throughout pregnancy  There is a strong correlation between a positive test answer and history of p.p.p (p< 0/01)  There is no side effects  Test is high specific and had a high negative prediction value for L.B.P among pregnant women.

Diagnostic imaging:  Poor sensitivity of conventional radiography in detecting early. stages of SIJ arthritis and degeneration.  MRI only for (AS) patients.  Do not use scintigrapy for PGP.  Do not use local SIJ injections as a diagnostic tool for PGP.

Treatment of P.G.P  First line treatment of pregnancy related PGP is physiotherapy and exercise.  Physiotherapists offer a holistic approach in the management of antenatal and post natal.  Physiotherapy aims to improve spinal and pelvic girdle biomechanics and stability, improving strength of trunk and pelvic muscle, improving range of hip mobility, controlling pain and improving function.

 Core stabilizing exe of the trunk and pelvic girdle.  Gentle mobilization ( a gentle form of manipulation of hip, back or pelvis)  Muscle energy technique and myofacial release.  Exercise to retain motor control and strength of abdominal, spinal, pelvic girdle, hip and pelvic floor muscle.  Educating correct posture and lifestyle including: back care,ergonomics, lifting, looking after baby and toddlers and position for sexual intercorse.

 Pain control modalities like acupuncture, and TENS.  Exercise in water.  Provision of equipment as an adjunct to treatment e,g. crutches, pelvic girdle support belts,….

Counter Indications:  Anesthetic and steroidal injections into SIJ  Oral anti inflammatory medications

Thanks for your attention