Pelvic girdle pain: The Stickmum project 3 years forward

Manual therapy

Studies are moving into researching treatment for PGP. Traditional treatments (rest, exercise, support belts) are still advocated in many countries, particularly during pregnancy. Schwerta et al (2015) conducted a randomised controlled trial of 80 women in Germany who were treated with osteopathic techniques postpartum (pregnant women were specifically excluded from their study), and reported clinically significant improvements in outcomes in the treatment. Franke et al (2017: 760) concluded from their meta-analysis of the effectiveness of osteopathic manipulative treatment that there was a ‘significant medium-sized effect on decreasing pain and increasing functional status’ in pregnant women with PGP, and also a positive effect in postpartum women.

Hilde et al (2016), in a proposal for a Cochrane review, suggested reviewing randomised controlled trials comparing traditional PGP management, including exercise, physical conditioning, manual therapy, belts, massage, transcutaneous electrical nerve stimulation (TENS) and patient education. These are new and welcome developments in the care of women with PGP, who have previously often been told that the problem is due to hormonal changes or weak core muscles. These theories no longer hold much sway (Albert et al, 1997; Mens et al, 2009), and a recent study (Almousa et al, 2018) found that the effect of exercise varied between studies, with only some finding a statistically significant improvement. Hydrotherapy, also often advocated, was studied in a randomised controlled trial of 516 pregnant women (Backhausen et al, 2017) that found that, although the intensity of the women's back pain was lower, this was not clinically significant and the treatment did not reduce women's time on sick leave, their level of disability or their self-rated general health and quality of life.

Guidelines from the National Institute of Health and Care Excellence (NICE) (2016) on lower back pain and sciatica recommend that exercise is not used alone and should be complemented by manual therapy. While back pain has some different symptoms from PGP, the pelvis is attached to the spine and the systems are integral to each other, so such advice is relevant to women with PGP. NICE recommends clinicians to:

NICE also makes a strong recommendation not to use belts for back pain management and, given the similarities in the reasons for using belts to stabilise the lumbar and pelvic joints, this should also apply to PGP. Use of belts should not be a treatment modality, but may occasionally be used alongside manual therapy as part of a treatment package.

Caesarean section

Studies in India (Joshi et al, 2016), Norway (Bjelland et al, 2013) and Sweden (Mogren, 2007) into caesearean section outcomes showed that women who have caesarean sections have more persistent PGP pain than women who have an unassisted vaginal birth. This finding should be interpreted with care, however: these were not randomised controlled trials, so it is possible that the women who had caesearean section had more severe PGP antenatally, and that this was the reason for undertaking the caesearean section. An unassisted vaginal birth is very different from an assisted birth, where additional trauma may be experienced due to the use of the lithotomy position and the consequent biomechanical stress to the pelvic joints. Consequently, particularly without manual therapy treatment, it would be expected that women with more severe PGP symptoms antenatally would have a slower recovery postnatally.

Women who have good manual therapy treatment during pregnancy report to the Pelvic Partnership that they remain mobile with minimal pain towards the end of their pregnancy—this is particularly noted by women who have had severe symptoms that were not treated in a previous pregnancy, who report how different their experiences had been. Anecdotal evidence shows that women are less likely to request induction or caesearean section, and are therefore less likely to experience the associated morbidity. Consequently, they are more likely to recover quickly after giving birth. Antenatal manual therapy therefore has an important role to play in reducing intervention.

Breastfeeding

In a large Norwegian study of 10 603 women (18.5% of the respondents to a cohort study) 18 months postnatally, Bjelland et al (2015) found a small beneficial effect on recovery from PGP with breastfeeding, saying that women at 18 months postnatally reported more pain if they had breastfed for a shorter time. The authors found that the result was statistically significant (P<0.001) and was evident in women with a body mass index ≥25 kg/m². The authors concluded that women with PGP should be encouraged to breastfeed. This differs from advice that women in the UK are often given to stop breastfeeding on the assumption that PGP is associated with breastfeeding hormones, and with increased duration and severity of pain. The findings of the Norwegian study are consistent with the mechanical nature of PGP, and anecdotal evidence reports that advice to stop breastfeeding tends to be given by clinicians who believe that PGP is caused by hormones that produce ligamentous laxity. This has been repeatedly shown not to be the case (MacLennan et al, 1986; Hansen et al, 1996; Albert et al, 1997; Marnach et al, 2003). Therefore a possible explanation of Bjelland et al's (2015) findings is that the physical activity required in making up formula is greater than simply picking up a baby to breastfeed. As with other normal physical activities such as walking, climbing stairs and turning over in bed, which aggravate PGP symptoms, the physical aspects of formula preparation and feeding may be causing an increase in physical symptoms (or at least preventing improvements).

The long-term effect of not treating PGP

Women who do not receive manual therapy can report months or years of pain and further physical and psychological effects (Gutke et al, 2017).

A longitudinal study of women 12 years postpartum (Bergström et al, 2017) reported that severity of pain was closely related to women's emotional wellbeing. A previous cohort study was followed up 12 years postnatally through follow-up questionnaires to 639 women, 295 of whom consented to participate.

The results showed that 19% of women still had pain 12 years postpartum, 1 in 5 had taken sick leave, and 11% had a disability pension due to their PGP. More than half of the women had not sought further treatment for their PGP since the birth, some despite continuing symptoms, and of those who had, 44% had sought physiotherapy.

Elden et al (2016) reported similar findings in their study, where the authors contacted women who had participated in a previous randomised controlled trial 11 years postnatally using a postal questionnaire and telephone interview, inviting some women for a physical assessment. Overall, 10% of women who had PGP in pregnancy had ‘considerable consequences on health and function in daily life up to a decade later’ (Elden et al, 2016:4).

These findings are stark indications that the myths women are told about PGP resolving as soon as their baby is born—that it is merely a pregnancy-related condition—are not borne out by the evidence. Clinicians who refer women to manual therapists, who can address the underlying causes of PGP and the asymmetry of movement at the pelvic joints, can avert significant morbidity. Treatment enables women to recover and take up their roles as mothers and in wider society, without unnecessary, preventable and treatable pain, disability and psychological distress.

Can prevention work?

Prevention is unlikely to be effective across the population, as it is difficult to predict who will develop PGP, which is why studies reviewing predictive factors contribute less to improving outcomes. Studies showing that PGP is not a hormonal issue have been crucial, and understanding the need to focus treatment on asymmetrical movement has developed treatment options. However, what will have the greatest impact for women and for health services is recognising symptoms early, and treating with a full assessment of the symmetry of movement of the pelvic girdle joints. The key focus, often then neglected, is restoration of the normal symmetrical function of these joints.

Access to treatment

Access to manual therapy is very variable across the country. Some NHS physiotherapy services provide excellent manual therapy treatment, and the Pelvic Partnership is rarely contacted by women in these parts of the country as they can access timely and effective treatment. Women may have the resources to pay for a sports physiotherapist to assess and treat their pelvic alignment, but many have not. Where NHS physiotherapy services do not have resources to provide manual therapy and only offer group advice or exercise sessions, women in these areas are the ones who seek information from the Pelvic Partnership and treatment from the private sector. This creates a two-tier system where women who can afford treatment can access it and recover, and those who cannot may form that 10-19% of women who experience symptoms 12 years postnatally and beyond (Elden et al, 2016; Bergström et al, 2017). In addition to the physical and psychological consequences, this is a significant strain on personal and NHS finances. However, the cost of providing a small number of manual therapy assessments and treatments to a larger number of women, resulting in improved outcomes, is likely to be significantly less than the cost of providing ongoing support. This support is likely to include more midwifery, GP and obstetric appointments during pregnancy; increased interventions, and ongoing additional GP appointments, pain medication, psychological and psychiatric support and physiotherapy for months or years postnatally.

Introduction

Most helpline calls and online information requests to the Pelvic Partnership (around 300 annually) describe a pattern of care, which continues for weeks and months during and after pregnancy. Women are first (falsely) told that because the problem is hormonal, nothing can be done. Alternatively, women say that clinicians will assess them fully, identify that one (or more) of the pelvic joints is not moving normally, and then tell them that their core muscles or pelvic floor are weak and they need to strengthen them. They are then given exercises, a belt or crutches and told to rest, avoid painful movements or exercise more, and they continue to try to function as normal with a dysfunctional joint. The joint then becomes more irritated (often revealed on later MRI scans), the core does not strengthen as the muscles are inhibited by pain, and the woman's mobility and function deteriorate. Women are also told that the pain will go when the baby arrives. When this does not happen, they are offered further exercises, and eventually told that they ‘just have to put up with it’.

In 2015 the Pelvic Partnership published a leaflet for health professionals and women that included a cartoon ‘Stickmum’ character. It told two stories: the first detailing the account we often hear from women with PGP who are unable to access effective ‘hands-on’ treatment for their symptoms, leading to long-term pain and disability; and the second showing how easy PGP is to treat, resulting in reduction and, often, resolution of symptoms (Figures 1 and 2). The aim of the leaflet was to encourage health professionals to offer manual therapy treatment as soon as symptoms appear.

The response was very positive and we receive requests from midwives and physiotherapists every week for more information. These contacts illustrate a shift in practice and a greater awareness of PGP since Stickmum appeared. Women more frequently tell us that their midwife identified that they had PGP and that they should seek treatment and information about their options, rather than telling them it was hormonal and nothing could be done. Both women and midwives are more aware that manual therapy treatment is available and have higher expectations of treatment during pregnancy; however, there is still variability across the country, both in awareness and in the access to manual therapy treatment. There is also variability in responses from obstetricians supporting women with birth options such as a birthing pool to help with mobility and pain relief, or caesarean section if severely incapacitated by PGP. Caesarean section is most likely to occur when they have not had access to effective manual therapy during pregnancy and their symptoms have not been reduced.

Women who contact the Pelvic Partnership tell us that they are often discouraged from continuing breastfeeding, despite the known benefits. Those who do stop breastfeeding do not usually experience an improvement in symptoms, and in fact often identify how much more difficult life becomes when having to manage the practical elements of formula feeding. Stopping breastfeeding can result in feelings of guilt, as the benefits of breastfeeding are clear, and breastfeeding may be the one thing that women can do even when immobile. For some women, taking the baby out in a pram, changing or bathing the baby may cause increased pain or be physically impossible for women on crutches or in a wheelchair.

Results

Since the publication of Stickmum, midwives, women and other clinicians have responded to the leaflet with comments, some of which (anonymised using pseudonyms) have been included here.

The impact of the Stickmum leaflet has been outstanding. Women previously used to contact the Pelvic Partnership towards the end of a pregnancy when they were on crutches, often housebound, and very anxious about birth. They would have been told that nothing more could be done to treat their pain, that it was ‘too late’ and so wanted to discuss their birth options. More women are contacting us earlier in pregnancy telling us that their midwife has recognised that they have PGP and that they know treatment is available. The effect of not receiving timely treatment continues to be researched (Gutke et al, 2017, Wuytack et al, 2015), and findings show that women try to cope with the condition and not be demanding, but feel helpless when they are told that there is nothing that can be done. Women who have visited the website tell us that they were able to access good treatment without needing to speak directly to us. The Pelvic Partnership website received 70 000 hits to last year, indicating that a significant number of women and health professionals are accessing this information.

These findings support the experience of the women contacting the Pelvic Partnership, who are often offered exercise groups or exercise sheets by their physiotherapist, or attend hydrotherapy sessions. They tell us that these treatments are either not effective, or make the symptoms worse, leading them to seek manual therapy treatment either from another NHS clinician or from private practitioners to improve their symptoms. This in turn supports the theory that an asymmetry of movement at the sacroiliac joints is responsible for the dysfunction and pain experienced in PGP, and the finding of the manual therapy studies that treating this asymmetry leads to a clinically significant improvement in symptoms.