Acta Obstetricia et Gynecologica. 2010; 89: 1187 1191 SHORT REPORT Clinical findings, pain descriptions and physical complaints reported by women with post-natal pregnancy-related pelvic girdle pain LARS-LENNART NIELSEN Section for Physiotherapy Science, Department of Public Health and Primary Health Care, University of Bergen, Norway Abstract The objective was to describe clinical findings and pain patterns following the provocation by activities of daily living (ADL) in women suffering from pregnancy-related post-natal pelvic pain 6 12 months after delivery. Forty-one informants answered questionnaires regarding pain characteristics in respect to 14 different ADL. All informants had bilateral pain, and typically it was described as an aching pain in the areas of the posterior superior iliac spines and in the symphyseal region. Running was the most provocative activity, followed by domestic work and by activities involving pushing and pulling. Duration of the activity had a great impact on the tolerance for all activities, and for the majority of the women, menstruation and ovulation caused an exacerbation of the symptoms. Key words: Post-natal complications, pelvic girdle pain, functional impairment, pain description Introduction It is estimated that 20% of pregnant women in Scandinavia suffer from pelvic pain. Although the great majority get well after delivery, with or without treatment, recovery from pain after delivery may be slow and incomplete, resulting in residual pain and impairment, even after several years (1). The pathogenesis is still unclear. In the European guidelines (1) pelvic girdle pain (PGP) is defined as a specific form of low back pain (LBP) that can occur separately or in conjunction with LBP, in both pregnant and non-pregnant women, as well as in males. Pain during pregnancy that originates in the lumbar spine (LBP) is considered as having a different etiology and clinical presentation compared to pregnancyrelated pelvic girdle pain (PPGP) (1,2). The signs and symptoms of post-natal PPGP are described as pain localized to the structures around the pelvic joints, provoked by movements straining the sacroiliac joints or the pubic symphysis (i.e. abduction, climbing stairs, long strides) (3) or activities putting these joints on prolonged stress (i.e. sitting, standing, walking) (3 5). It is not fully comprehended to what degree the different activities provoke pain, and in which order they impair activities of daily living (ADL). Three retrospective studies have been published based on self-reported medical histories of patients with postnatal PPGP (4,6), but diagnoses were not confirmed by clinical examination. Results from an exploratory study based on self-reported medical histories of 401 women with post-natal PPGP attending physiotherapy practices in Norway, where diagnoses were confirmed, were reported by Hansen and Nielsen (3). Nilsson-Wikmar (7) and Haugland et al. (8) described signs and symptoms in patients with post-natal PPGP, based on structural interviews and Correspondence: Lars-Lennart Nielsen, ISF, University of Bergen, Kalfarveien 31, N-4018 Bergen, Norway. E-mail: Lars.Lennart.Nielsen@fys.no (Received 28 February 2009; accepted 3 February 2010) ISSN 0001-6349 print/issn 1600-0412 online Ó 2010 Informa Healthcare DOI: 10.3109/00016349.2010.501853
1188 L.-L. Nielsen clinical tests. In the latter study, pain intensity was quantified for four activities. The present study aimed to investigate how pain, resulting from PPGP, affected a number of ADL typical for women on maternity leave. Material and methods Seventy-two women with pain in the pelvic region that had started during the previous pregnancy, and was still present 6 12 months after delivery, were recruited to a multi-center study by nationwide announcements and written requests to medical practitioners in 12 counties. Ten manual therapists in seven different counties were responsible for the examination. The principles of the interview and the clinical procedures were explained to the clinicians by written instructions and video, and a standardized protocol for recording their findings was applied. The women were examined by the manual therapist practicing nearest to their home address. The clinical examination consisted of an evaluation of known characteristics of PGP and lumbar pain, tests to identify and exclude discogenic pain and red flag conditions. Three sacroiliac provocation tests were included: the transverse anterior distraction/ posterior compression test, the transverse posterior distraction/anterior compression test, and the shearing test for the interosseous ligaments (9). The superinferior translation test was applied as provocation test for the pubic symphysis (9). As there is no diagnostic procedure that is considered as Gold standard for the condition, the final diagnosis of post-natal PPGP was founded on all parts of the examination by experienced clinicians. After the examination, 41 women were included according to inclusion and exclusion criteria. By a posted author-generated survey, informants were asked about the general pain intensity, pain localization and pain quality, symptoms in respect to 14 different ADL, the consistency of symptom variation, symptom change in relation to ovulation and menstruation, need for rest periods during the day, and physical fitness. Pain intensity was marked on a 100-mm horizontal visual analog scale (VAS). Pain drawings were used to sample information about pain localization and pain character. The drawings were scored with a transparency template. The ADL were measured with respect to frequency, pain level and duration. The study was approved by the Committee for Medical Research Ethics and the National Data Inspectorate of Norway. Results The mean age of the informants was 30 years (range 21 40). Nearly one-third (29%) were 27 years or younger, 83% were 33 years or younger. A third of the women were primiparous (13 women), 13 women had two, 12 women had three, and three women had four children or more. Most of the multiparous women had a child under the age of five in addition to their baby. Fifty-one percent had a college or university degree. There was no typical co-morbidity for the informants. The clinical examination revealed a muscular weakening in the lower extremities for 39% of the women. By active lumbar mobility tests in standing, most informants experienced pain provocation by lateral flexion (78%) and hyperextension (61%). Palpation provoked pain in the posterior part of the pelvis and at the symphysis pubis. One or more of the pelvic provocation tests were positive for all informants but one. The two provocation tests for the ventral and dorsal sacroiliac ligaments were positive for 68% of the women, the sacral shearing test was positive for 71%, and the symphyseal shearing test was positive for 63% of the women. The general pain level ( How strong do you rate your average daily Pelvic Girdle Pain? with No pain/ intolerable pain as anchors) was assessed by the informants to be 42 at the VAS. All informants had bilateral pain. The two areas most frequently marked were the posterior superior iliac spine (73%) and the symphyseal/inguinal region (71%) (Table 1). Concurrent pain in the lower extremities was frequent, but was always rated as lower than the pain intensity in the pelvic region. Eighty-three percent of the informants described the pain localization as deep. Pain character varied according to anatomical area, but an aching pain was the most frequently used description. In the pelvic region, the mean pain intensity was 61 mm (SD 21 mm), in the lower extremity 33 mm (SD 26 mm). Table 1. Self-reported pain distribution and localization (n = 41). % N Pain distribution Pelvic areas only 22 9 Bilateral pain 100 41 Lower extremities only 0 0 Pain localization reported by >40% Sacroiliac joints 73 30 Pubic symphysis 71 29 Gluteal regions 63 26 Throcanterial region 49 20 Posterior thigh 46 19 Lumbo-sacral transition 42 17
Clinical findings and physical impairments by post-natal pelvic girdle pain 1189 Most of the informants reported a deep bilateral pain in the pelvic region, and that the pain was radiating into the lower extremity. Running was the most provocative activity (VAS score of 75), followed by domestic work (vacuum cleaning, washing floors and tidying up), and pushing/pulling. To generate the scorings for the worst affected women, the results from the VAS of the item general pain level were dichotomized according to whether the score was 1 49 or 50 100 (Table 2). For the latter group (n = 24), all activities that were asked for resulted in a mean pain level of 56 or higher at the VAS, including the activities lying, dressing, driving a car, and intercourse. The number of responders of each intensity level varied with the duration of the provocative activities (Table 3). Pelvic pain was provoked for 71% of the women within 5 minutes of domestic work, and for nearly all (98%) after 15 minutes. Other activities related to domestic work, as lifting, carrying and nursing, also showed high values, even after a short time. Standing, walking, sitting and taking care of the infant were all provocative activities for more than 71% of the informants when they were doing the activities for 15 minutes or more. One-third of the women reported that they would experience pain by walking 100 meters, 58% by walking a few hundred meters, and 95% by walking 2 km. All but one stated a need for rest from their daily duties during the day. On a visual analog scale from 1 to 100, the amount of help they needed from another person during the day to cope was quantified Table 2. Pain provoking activities ranked according to: (left side) mean VAS values (0 100) for all responders (n = 41); and (right side) mean VAS values for the informants with a VAS score of 50 or higher at the item general pain level (n = 24). VAS 1 100 VAS 50 100 n % VAS SD n % VAS SD Running 36 88 75 25 31 76 83 17 Domestic work 40 98 65 21 34 83 72 14 Pushing or pulling 40 98 64 25 31 76 74 16 Carrying 38 93 58 23 24 59 73 14 Lifting 38 93 55 24 22 54 73 14 Walking stairs 36 88 54 29 22 54 74 14 Standing 39 98 51 22 25 61 65 13 Sitting 37 90 48 23 22 54 65 12 Stooping 38 93 48 24 20 49 66 15 Intercourse 38 93 46 22 21 51 63 11 Walking 39 98 45 23 22 54 62 12 Driving car 31 76 40 23 11 27 66 14 Lying 33 80 39 21 13 32 60 13 Dressing 33 80 31 18 8 20 56 5 Table 3. Pain provoking activities ranked by degree of pain provocation after 15 minutes (n = 41). Activity to a mean score of 43 (SE 3.8), with six persons scoring 75 or higher. Twenty-nine informants reported that their menstrual cycle had returned, and for 25 (86%) this caused an exacerbation of the symptoms. One-third of the women were severely affected by the cyclic changes. Sixteen women felt the exacerbation of symptoms both premenstrually and around ovulation. Discussion Duration >15 minutes 5 15 minutes <5 minutes Domestic work 98% 93% 71% Standing 78% 68% 32% Lifting/carry/nursing 73% 68% 42% Walking 71% 61% 22% Sitting 71% 44% 15% Cooking 59% 34% 20% Nearly all patients (90%) had pain by palpation in the interspinous region of L5/S1 as well as at the posterior superior iliac spines. This could indicate that palpation alone does not differentiate between PPGP patients and patients with lumbar pathology. Also, although the term aching pain was used by 75% of the material, previous studies have shown that this terminology is used by most patients with LBP due to disc herniation (10). Accordingly, pain characteristics seem to be of limited value in the discrimination between LBP and PGP. Each of the provocation tests of the SI joints was positive for 68 71% of the material, and combined the tests were positive for all but one participant. Reliability studies on each of the three provocation tests included in this study have shown only moderate inter-tester agreement (11). The results support the view that multi-test regimens may prove a reliable method to differentiate PGP from other clinical conditions in the region (1,2). Most informants who had regained their menstrual periods after childbirth reported that pain was influenced negatively by menstruation and/or ovulation. This complicates the estimation of pain intensity, as symptoms will get worse every fortnight regardless of the activity level. Evaluating provocative activities by postnatal PPGP is difficult, as the pain intensity for the various activities is influenced by previous provocation as well as the duration of the particular activity (3). Mens et al. (4) found that standing for 30 minutes
1190 L.-L. Nielsen was the single activity that provoked pain for 90% of women, which was close to our results. Ronchetti et al. (5) showed in a study of severely affected women with PGP that more than 50% of the informants had problems within 5 minutes on standing, and that represented the greatest disability for the total group. Our findings show that as many as two-thirds of the women reported pain provocation after 5 minutes standing. Standing is usually combined with other physical activities, like cooking or nursing the child, and may indicate that it is difficult to manage the household and care-taking without any form for assistance for the severely affected patients with postnatal PPGP. Walking provoked pain among 83%. According to Gutke et al. (2), women with PPGP walked at a slower speed in a test situation compared to healthy women. This could indicate either a reluctance to walk faster to avoid provoking pain, or be due to muscular insufficiency in the pelvic muscles (2,12). Running was the most provocative activity reported. Biomechanically, running is a combination of weight-bearing and long strides, performed as fast movements. Combining these three factors, or failing to control these movements, probably explains the high pain intensity. Domestic work, as well as activities related to being a mother of an infant (lifting, carrying and nursing), showed high VAS values, even after a short time. According to Norén et al. (12), housework is more troublesome for women with post-natal PPGP than for women with LBP. The study of MacLennan and MacLennan (6) showed that the women spent averagely 5 hours a day in a chair. It is then alarming to find that in our study most informants (71%) experienced pain provocation after sitting for 15 minutes, the worst affected within 5 minutes of sitting. This discomfort may partly be explained by an increased sensitivity to direct pressure or tension on tender structures in the gluteal region. In the study of Hansen and Nielsen (3), 67 87% of the informants with PPGP reported that the tolerance for sitting depended on the characteristics of the seat. In our study 25 56% used a seat cushion, implying discomfort by sitting on hard surfaces. Pain when lying has previously been regarded as primarily a consequence of getting in and out of bed (3), or activities performed while lying, particularly when turning in bed (3,4). MacLennan and MacLennan found that 55% experienced an increase of pain within 4 hours of lying down (6). Our study confirms that pain in the pelvic region during lying is common. By contrast, a great majority (88%) also reported that they needed to rest during the day by lying down in order to reduce pain. The results from this study reflect the signs and symptoms of women with PPGP 6 12 months after delivery. Typically, the women suffer from a bilateral aching pain located in the areas of the sacroiliac joints and at the pubic symphysis. Concurrent pain in the central lower back is common. The pain is provoked during typical domestic work and core activities for women with young children. The pain during activities tends to appear after a relatively short time (5 15 minutes), and when it appears, it is rated as rather intense by the patient. Pain is, however, also experienced by sitting and standing, and even after some hours of lying. The pain may tend to get worse during menstruation and/or ovulation. Provocation of a specific activity depended on the duration of the activity. That should be appreciated when testing patients with post-natal PPGP. This may imply that new studies aiming at refining the diagnostic procedures for post-natal PPGP should investigate the combination of activities that relate both to straining the pelvic ligaments and the duration of the procedure. Acknowledgements The author acknowledges the late Jon Helge Hansen, Tromsø, for dedicated contribution to the planning and data collection of the project, and valuable advice on the results. Professor Anna Elisabeth Ljunggren, University of Bergen, contributed to writing of the article. Landsforeningen for Kvinner med Bekkenløsningsplager (the Norwegian patient organization for PGP) provided the financial founding, logistics and human resources for the project. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. References 1. Vleeming A, Albert H, Östgaard HC, Stuge B, Sturesson B. European guidelines on the diagnosis and treatment of pelvic girdle pain. Cost action B13 low back pain: guidelines for its management. The European Commission, Research Directorate-General, Department of Policy, Coordination and Strategy, 2004. 2. Gutke A, Ostgaard HC, Oberg B. Association between muscle function and low back pain in relation to pregnancy. J Rehabil Med. 2008;40:304 11. 3. Hansen JH, Nielsen LL. Rygg-og bekkenrelaterte plager blant kvinner som følge av svangerskap og/eller fødsel [Post-natal low back and pelvic complaints. Report from a survey of 401 women with PPGP]. Oslo: The Norwegian Fund for Post-Graduate Training in Physiotherapy, 1995.
Clinical findings and physical impairments by post-natal pelvic girdle pain 1191 4. Mens JM, Vleeming A, Stoeckart R, Stam HJ, Snijders CJ. Understanding peripartum pelvic pain. Implications of a patient survey. J Manipulative Physiol Ther. 1996;21: 1363 9. 5. Ronchetti I, Vleeming A, Van Wingerden JP. Physical characteristics of women with severe pelvic girdle pain after pregnancy: a descriptive cohort study. J Manipulative Physiol Ther. 2008;33:E145 51. 6. MacLennan AH, MacLennan SC. Symptom-giving pelvic girdle relaxation of pregnancy, postnatal pelvic joint syndrome and developmental dysplasia of the hip. The Norwegian Association for Women with Pelvic Girdle Relaxation. Acta Obstet Gynecol Scand. 1997;76:760 4. 7. Nilsson-Wikmar L. Back pain post partum: clinical and experimental studies. Sweden: Karolinska Institutet, 2003. 8. Haugland KS, Rasmussen S, Daltveit AK. Group intervention for women with pelvic girdle pain in pregnancy. A randomized controlled trial. Acta Obstet Gynecol Scand. 2006;85:1320 6. 9. Lee D. The pelvic girdle, 2nd edn. Toronto: Churchill Livingstone, 1999. 10. Nielsen LL. Smertebilde ved bekkenløsningsplager og lumbalt skiveprolaps [Pain characteristics by post-natal pelvic girdle pain and lumbar disc herniation]. Master Thesis. University of Bergen, 1996. 11. Robinson HS. Pelvic girdle pain in pregnancy: the impact on function. Acta Obstet Gynecol Scand. 2006;85: 160 4. 12. Norén L, Östgaard S, Johansson G, Östgaard HC. Lumbar back and posterior pelvic pain during pregnancy: a 3-year follow-up. Eur Spine J. 2002;11:267 71.