During Massage Pregnancy
During Massage Pregnancy
Pregnancy related Pelvic Girdle Pain (PGP) causes pain, instability and limitation of mobility and functioning in any of the three pelvic joints. PGP has a long history of recognition, mentioned by Hippocrates. and later described in medical literature by Snelling.
"The affection appears to consist of relaxation of the pelvic articulations, becoming apparent suddenly after parturition or gradually during pregnancy and permitting a degree of mobility of the pelvic bones which effectively hinders locomotion and gives rise to the most peculiar and alarming sensations". Snelling (1870) .
Anatomy
The pelvis is the largest bony part of the skeleton. There are three joints, the symphysis pubis (SP), and two sacroiliac joints. A highly durable network of ligaments surrounds these joints giving them tremendous strength.
The pubic symphysis has a fibrocartilage joint which may contain a fluid filled cavity and is avascular; it is supported by the superior and arcuate ligaments. The sacroiliac joints are synovial, but their movement is restricted throughout life and they are progressively obliterated by adhesions. The nature of the bony pelvic ring with its three joints determines that no one joint can move independently of the other two.
Classification
Prior to the 20th century many Physicians who specialized in this field of pregnancy related PGP used varying terminologies. It is now referred to as Pregnancy Related Pelvic Girdle Pain that may incorporate the following conditions:
- Diastasis of the Symphysis Pubis(DSP)
- Symphysis pubis dysfunction(SPD)
- Pelvic Joint Syndrome
- Physiological Pelvic Girdle Relaxation
- Symptom Giving Pelvic Girdle Relaxation
- Posterior Pelvic Pain
- Pelvic Arthropathy
- Inferior Pubic Shear/ Superior Pubic Shear /Symphyseal Shear
- Symphysiolysis
- Osteitis pubis (usually postpartum)
- Sacroiliitis
- One-sided Sacroiliac Syndrome /Double Sided Sacroiliac Syndrome
- Hypermobility
"The classification between hormonal and mechanical pelvic girdle instability is no longer used. For treatment and/or prognosis it makes no difference whether the complaints started during pregnancy or after childbirth." Mens (2005)
Symptoms
A combination of postural changes, the growing baby, unstable pelvic joints under the influence of pregnancy hormones and changes in the centre of gravity can all add to the varying degrees of pain or discomfort. In some cases it can come on suddenly or following a fall, sudden abduction of the thighs (opening to wide too quickly)or an action that has strained the joint.
PGP can begin as early as the first trimester of pregnancy. Pain is usually felt low down over the symphyseal joint, this area may be extremely tender to the touch. Pain may also be felt in the hips, groin and lower abdomen and can radiate down the inner thighs. You may waddle or shuffle, and may be aware of an audible clicking sound coming from the pelvis. PGP can develop slowly during pregnancy, gradually gaining in severity as the pregnancy progresses.
During pregnancy and postpartum, the symphyseal can gap can be felt moving and/or straining when walking, climbing stairs and turning over in bed. These activities can be difficult or even impossible. Pain may remain static, i.e. in one place such as the front of the pelvis producing the feeling of having been kicked, in other cases it may start in one area and move to other areas, you may even experience a combination of symptoms. Any weight bearing activity has the potential of aggravating an already unstable pelvis producing symptoms that may limit the ability for the woman to carry out many daily activities. She will experience pain involving movements such as dressing, getting in and out of the bath, rolling in bed, climbing the stairs and sexual activity. Pain will also be present when lifting, carrying, pushing or pulling.
The symptoms (and their severity) experienced by women with PGP vary, but include:
- Present swelling and/or inflammation over joint.
- Difficulty lifting leg.
- Pain pulling legs apart.
- Unable to stand on one leg.
- Unable to transfer weight through pelvis and legs.
- Pain in hips and/or restriction of hip movement.
- Transferred nerve pain down leg.
- Can be associated with bladder and/or bowel dysfunction.
- A feeling of symphysis pubis giving way.
- Stand with a stooped over back.
- Malalignment of pelvic and/or back joints.
- Struggle to sit or stand.
- Pain may also radiate down the inner thighs.
- You may waddle or shuffle.
- Aware of an audible ‘clicking’ sound coming from the pelvis.
Severity
The severity and instability of the pelvis can be measured on a three level scale.
Pelvic type 1: The pelvic ligaments support the pelvis sufficiently. Even when the muscles are used incorrectly, no complaints will occur when performing everyday activities. This is the most common situation in persons who have never been pregnant, who have never been in an accident, and who are not hyperactive.
Pelvic type 2: The ligaments alone do not support the joint sufficiently. A coordinated use of muscles around the joint will compensate for ligament weakness. In case the muscles around the joint do not function, the patient will experience pain and weakness when performing everyday activities. This kind of pelvic often occurs after giving birth to a child weighing 3000 grams or more, in case of hyperactivity, and sometimes after an accident involving the pelvis. Type 2 is the most common form of pelvic instability. Treatment is based on learning how to use the muscles around the pelvis more efficiently.
Pelvic type 3: The ligaments do not support the joint sufficiently. This is a serious situation whereby the muscles around the joint are unable to compensate for ligament weakness. This type of pelvic instability usually only occurs after an accident, or occasionally after a (small) accident in combination with giving birth. Sometimes a small accident occurring long before giving birth is forgotten so that the pelvic instability is attributed only to the childbirth. Although the difference between Type 2 and 3 is often difficult to establish, in case of doubt an exercise program may help the patient. However, if Pelvic Type 3 has been diagnosed then invasive treatment is the only option: in this case parts of the pelvic are screwed together. (Mens 2005)
Psychosocial impact
PGP in pregnancy seriously interferes with participation in society and activities of daily life; the average sick leave due to posterior pelvic pain during pregnancy is 7 to 12 weeks.
In some cases women with PGP may also experience emotional problems such as anxiety over the cause of pain, resentment, anger, lack of self-esteem, frustration and depression; she is three times more likely to suffer postpartum depressive symptoms. Other psychosocial risk factors associated with woman experiencing PGP include higher level of stress, low job satisfaction and poorer relationship with spouse.
Causes
Sometimes there is no obvious explanation for the cause of PGP but usually there is a combination of factors such as:
- The pelvic joints moving unevenly.
- A change in the activity of the muscles in the pelvis, hip, abdomen, back and pelvic floor.
- A history of pelvic trauma.
- The position of the baby altering the loading stresses on the pelvic ligaments and joints.
- Strenuous work.
- Previous lower back pain.
- Previous pelvic girdle pain during pregnancy.
- Hypermobility, genetical ability to stretch joints beyond normal range.
- An event during the pregnancy or birth that caused injury or strain to the pelvic joints or rupture of the fibrocartilage.
- The occurrence of PGP is associated with twin pregnancy, first pregnancy and a higher age at first pregnancy.
Mechanism
Pregnancy related Pelvic Girdle Pain (PGP) can be either specific (trauma or injury to pelvic joints or genetical i.e. connective tissue disease) and non-specific. PGP disorder is complex and multi-factorial and likely to be also represented by a series of sub-groups driven by pain varying from peripheral or central nervous system, altered laxity/stiffness of muscles, laxity to injury of tendinous/ligamentous structures to ‘mal-adaptive’ body mechanics.
Pregnancy begins the physiological changes through a pattern of hormonal secretion and signal transduction thus initiating the remodelling of soft tissues, cartilage and ligaments. Over time, the ligaments could be stretched either by injury or excess strain and in turn may cause PGP.
Relaxin hormone
Relaxin is a hormone produced mainly by the corpus luteum of the ovary and breast, in both pregnant and non-pregnant females. During pregnancy it is also produced by the placenta, chorion, and decidua. The body produces relaxin during menstruation that rises to a peak within approximately 14 days of ovulation and then declines. In pregnant cycles, rather than subsiding, relaxin secretion continues to rise during the first trimester and then again in the final weeks. During pregnancy relaxin has a diverse range of effects, including the production and remodelling of collagen thus increasing the elasticity of muscles, tendons, ligaments and tissues of the birth canal
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