PGP BY Sinéad Dufour
Imagine you are 32 weeks pregnant with your first child and you start to have pain in the low back and pubic area when you change position, sit or stand for longer periods. The pain makes it very difficult for you to function and you worry about whether you can continue to work. You are also concerned about the upcoming birth of your baby and whether you will be able to care for your baby, an often seemingly overwhelming task without having to deal with pain. Now imagine you have seen your health care provider and have been told that your pelvis is separating because of the “pregnancy hormones” and that you need to put up with this until after you have your baby, as “it will probably get better afterwards”. Imagine you are also told, to be careful because “your pelvis is unstable”. These are common words of advice or explanations pregnant women receive from their healthcare providers, including physiotherapists. These words are not substantiated and do more harm than good.
In chapter, weather you are a mama to be, a mama or someone who cares for mama, you will be inspired with respect to all that can be done to address persisting pain in the pelvis and lower back. This pain presentation is referred to as pregnancy-related pelvic girdle pain (PPGP) and includes as an umbrella term previous deceptions of pain in the symphysis pubis joint (the front of the pelvis) and the sacroiliac joints (at the back of the pelvis).
Know that despite this issue being common, and for some very debilitating, once you understand what the pain system is trying to communicate, you hold the power to radically improve your situation. Know that the term “PPGP” does not refer to minor aches and pains through the lower back and pelvis that are self-limiting. These minor issues are to be expected through pregnancy and the post-partum period and are in fact rather benign. What we are referring to with “PPPGP” is a pain process that is more centrally driven and that translates to the the tissues and structures around the pelvis feeling sensitive and very sore. It is not because structures are unstable or that there is “dysfunction” of any pelvic structures. Rather one’s pervious exposures, current health status, and state of mind are key when it comes to driving sensitivity in the pelvic structures.
PPGP has and continues to be addressed as a biomechanical issue when it should be addressed as a neurophysiological issue. For many, the burden on the biological systems does ease enough off when baby is born and thus the pain really eases. But for people whose systems are really taxed, the systems remain threated after baby is born and thus the pain continues.
To understand this better, it can help to look at the PPGP risk factors, remember it is not an issue that affects everyone:
Parity – meaning having had a baby (this issues does not often happen in a first pregnancy).
Previous trauma – any form of trauma (note that a very high proportion of women experience trauma birthing their first baby).
Previous history of lower back or pelvic pain (a situation which will alter sensory distribution and lower the threat threshold).
Increased body mass index – the mechanism of which is understood to be systemic inflammation which contributes to structures being more sensitive.
Smoking – again the mechanism of systematic inflammation is implicated.
Lack of belief of improvement – this one is huge as ones understanding of their symptom will dictate the course of their recovery (many women are led to believe PPPGP is related to the pregnancy itself when it isn’t, it is related to the context of the person beyond the pregnancy).
This list really highlights that the issue really is not biomechanical in nature. If we understand that all pain is contextually driven and that the status of someone’s biology contributes to the the brain’s analysis of the sensory input then PPGP is easy to understand. The brain is always tasked with making a sensible story of the sensory information coming in. For those who had a difficult first birth or very challenging time in the post-partum period and whose systems are not recharged well and fear related to birth is lingering, than, it is understandable that the pain alarm system will start going off in a subsequent pregnancy.
Fear related to aspects of pregnancy, birth and postpartum and fear related to movement are key targets. It is important that people understand the pain for what it is, so incorrect assumptions about the pain are not being made. A common misunderstanding is that pain with movement, means the movement is “damaging”, which of course if very far from the truth. Mamas need to move. There are lots of ways to adapt movement and to training the nervous system to be in a less threatened state. Working with someone to assist you to move in novel and pain free, in a way that sends your body a signal of safety and surrender, is a critical step to reclaiming function. Beliefs about pain are really important to achieved this. Look for clinician who use a psychologically informed perspective, using multimodal approaches including education, counselling, exercise and others supportive modalities that foster trust and confidence rather than dependence and disability.
PPGP is usually characterized by tension and guarding in the structures around the pelvis including the pelvic floor. Gentle strategies guided by a pelvic health physiotherapist can be very helpful. One of the worse things to do it thing you need to brace and tighten your legs and tummy to “hold everything thing together”. Those behaviours will make things worse. The take home message is that the pelvis is strong and robust and sensitive tissues can be addressed by considering fears, the nervous system, the state of and the state of inflammation. With guidance PPGP can be resolved easily and self-managed.
Sinéad Dufour PT, PhD
Instagram: @dr.sinead
References
Pulsifer J, Britnell S, Sim A, Adaszynski J, Dufour S. Reframing beliefs and instiling facts for contemporary management of pregnancy-related pelvic girdle pain. Br J Sports Med. 2022 Nov;56(22):1262-1265. doi: 10.1136/bjsports-2022-105724. Epub 2022 Aug 10. PMID: 35948414.
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