Physiotherapy - Pelvic Girdle Pain (PGP)

Introduction

This is the term used for all pelvic pain. This includes pain anywhere from the lumbar spine, abdomen and into the thighs. However, symptoms can vary considerably.

Pregnancy related PGP is common, around 1 in 5 pregnant ladies experience mild discomfort around the pelvis.

There are lots of contributing factors including:

• Hormone changes
• Weakness of pelvic floor and abdominal muscles prior to pregnancy
• A hard physical job or sedentary lifestyle
• Twin or more pregnancy
• Previous low back pain, and previous PGP
• Increased body weight (BMI) before or by the end of pregnancy
• Increased mobility of other joints
• Effect of pregnancy on posture

Advice

• Rest - you may need to rest more often but be as active as the pain allows
• You may be referred to a specialist physiotherapist who may see you within a group setting
• You may need to wear a maternity support belt to minimise pelvic discomfort. If the pain is severe, you may need some help with walking, e.g. crutches, or advice about pain relief
• Minimise non-essential weight bearing activities e.g. shopping, lifting and carrying. Be particularly careful if you have a young child - you should avoid carrying them on one hip
• To lift correctly, bend your knees; keep your weight evenly distributed through both legs and your back fairly straight. Try to keep the load close to your body
• Sit with your weight evenly distributed through both buttocks and stand with both feet flat on the floor, avoid shifting your weight to one side. Avoid standing on one leg e.g. to get dressed
• If possible, avoid straddle movements e.g. in and out of the bath or car and low squatting, modify your activity as necessary
• Sleeping on the top of an inside-out sleeping bag or wearing a silky nightdress may make it easier to turn over in bed and sleeping on your side with a pillow between your knees can make your pelvis more comfortable
• Consider alternative positions for intercourse e.g. lying on your side or kneeling on all fours
• If swimming take care getting in and out of the pool
• Avoid aggravating your pain, but be as active as possible. Try to pace your activities appropriately
• Accept help when you need it if available
• Climb stairs one at a time
• Use a rucksack for symmetry
• Wear cushioned flat shoes
• Do the exercises suggested by your Physiotherapist

Where possible modify activities that make the pain worse, which may include:

• Standing on one leg
• Bending or twisting, or carrying a toddler on one hip
• Crossing your legs
• Sitting or standing for long periods
• Lifting heavy weights
• Pushing heavy objects

Emotional effects of PGP

The discomfort of PGP and difficulty with normal activities may make you feel low. Do ask for help if this is affecting you.

Exercise (Guidelines from The Royal College of Obstetrics and Gynaecologists)

Regular Physical activity:

• Improves/maintains physical fitness
• Helps weight management
• Reduces the risk of gestational diabetes
• Enhances psychological well being

30 minutes of moderate intensity exercise (low impact) on most days is recommended. It is better to exercise during the day rather than the evening due to fatigue and swelling.

Exercises

It is important to work the deep supporting muscles around the abdomen and lower back.

They will have to work during different functional activities therefore it is important to practise them in different positions.

Sitting - find midway pelvis position

• Rock pelvis forward all the way
• Rock pelvis backwards all the way
• Then find the midpoint between the two positions and maintain this for good posture

Pelvic floor muscles

Whilst lying, sitting or standing, begin to tighten your pelvic floor by squeezing around the back passage, as if you are trying to stop yourself from passing wind, at the same time as lifting the muscles at the front, as if trying to stop a flow of urine.

• Squeeze for 10 seconds, 10 times
• 10 repetitions of short, strong squeezes (do both of these 3 times per day)

Try to find things during the day that remind you to do these exercises, set a alarm or download the squeezy app on your mobile phone

Lower Abdominal Muscles

This exercise can be done in lying, sitting or standing.

Place hands on the lower abdominal muscles creating a diamond shape with hands (belly button in the middle).

• Draw the tummy away from your hands, to tighten the muscles
• Hold for 10 seconds, 3 repetitions, 3 times a day
• Try to do the pelvic floor exercises at the same time. If struggling to do this, do separately

Points to Watch

Breathe normally during the exercises – do not hold your breath. If you find this difficult, try to perform the exercise as you breathe out. Try to relax your shoulders and ribcage.

If you are lying down ensure you are well supported with pillows and have your shoulders higher than your hips, or lie on your side.

• If you are sitting make sure you sit up tall, with your back supported
• If you are standing have your feet hip distance apart and parallel. Keep your shoulders back and relaxed – imagine there is a string from your head to your tailbone drawing you up to the ceiling

Pelvic tilting

This exercise is a rocking motion of the pelvis forwards and backwards.

This exercise can be done in sitting, standing or on “all fours” (See pictures below).

• Grow up as tall as you can, arching your lower back and sticking your bottom out
• Then, roll back onto your tail bone, tucking your bottom under
• Keep your upper body as still as possible, the movement should come from the pelvis
• Repeat 10 times, several times a day

During labour and delivery

• Try to have an active labour if possible, changing positions regularly and trying to use gravity assisted (upright) positions to give birth if appropriate. It may be beneficial to discuss this in further detail with your midwife
• Try to keep separation of the legs to a minimum
• Adopt a comfortable position in all stages of labour, e.g. lying on the left or right side, kneeling upright with support from cushions or a partner, or standing leaning onto a high bed
• You can also use the birthing ball during the first stage, rocking and bouncing gently

It is important to remember these points even if you have an epidural and are not aware of any pain.

Measuring your pain-free gap

• You may find it useful to measure your pain-free gap as you approach labour. Lie on your back, knees bent, feet flat
• Allow your knees to fall apart gently and measure the distance between your knees at which you are no longer comfortable
• Record this in your hand-held notes and make sure the midwife in the labour suite is aware of your condition

In severe cases caesarean section may need to be considered but this will have to be discussed with your consultant and there is no evidence to suggest that there are better outcomes than with vaginal deliveries. Most women with PGP can have a normal birth.

Following the birth

Your pain may not resolve immediately after delivery. Give it time to settle, following the advice previously detailed. If you have had no improvement six weeks postnatally you may wish to contact your physiotherapist for advice.

• Do not be afraid to ask for help. You should get as much rest as possible – recruit your partner, relatives or friends
• If you are still in pain while in hospital ask the doctor for some anti-inflammatory medication and pain killers before going home if appropriate
• If possible avoid heavy lifting and twisting for the first few months

Post Natal Exercises

(Seek further advice if you have complications or a C section)

0-6 weeks - you can start pelvic floor exercises and your lower abdominal exercise as soon as you have started passing urine. Walking and core stability exercises.

6-12 weeks - low impact exercise, swimming, gym, power walking, cycling. Progress core stability exercises e.g. Pilates.

12 weeks - slowly build up impact activities as you feel able.

If you require any further advice please speak to your doctor, midwife or specialist Physiotherapist.

Further Advice

www.pogp.co.uk
www.pelvicpartnership.org.uk
www.nhs.uk/pregnancy
www.rcog.org.uk – Physical activity guidelines for pregnant women

Acknowledgements

This leaflet has been created with thanks to Pelvic Obstetric & Gynaecology Physiotherapy (POGP).