Posted by Madeleine Speed, the Pelvic Partnership, July 2017
"I'm so relieved," Mandy said. "I finally had a reason for the pain I’ve been experiencing; I was worrying about all sorts of ailments but my GP is sure that I have pelvic girdle pain." Mandy lent in closer and confided, "Thing is, she said it was to do with my hormones and that it will get better when I have my baby. She didn't suggest a way forward to help with my pain other than pain medication, a list of exercises and general advice but these aren't helping and I’m not sure how much longer I can put up with this."
If this sounds familiar and you've had a diagnosis of pregnancy-related Pelvic Girdle Pain (PGP), you may be relieved to hear that PGP is a mechanical joint problem (so it's not caused by hormones) and usually responds well to treatment from a physiotherapist, osteopath or chiropractor experienced in using 'hands on' manual therapy to treat PGP or pelvic joint problems. Treatment is safe at any stage during pregnancy as well as postnatally, the sooner the better.
Recognising the real cause of PGP
The cause of PGP symptoms is usually down to stiff or 'stuck' pelvic joints which stop the pelvis from functioning correctly. A skilled manual therapist should assess which joint or joints in the pelvis are causing the problem and use their hands to restore normal movement again, which should help relieve pain in the joints and surrounding muscles.You will need to find a manual therapist who can demonstrate that they really address the cause of PGP and not simply relieve the symptoms. For example, medication, mobility aids and exercises are all available to help you manage the pain and immobility that can result from PGP symptoms. Some women find acupuncture or dry needling can help with muscle spasm and pain relief while others find that pain medication (particularly at night) helps them to manage because they get a good night's sleep. While these can all be very useful for controlling uncomfortable symptoms, they are very unlikely to address the underlying cause of your pain which is usually down to pelvic joint dysfunction. So it's important to find a skilful manual therapist who can treat the cause even if you also look for additional help to manage painful symptoms in between treatment sessions.
Accessing the right treatment for PGP
Once you know what you are looking for, how do you go about gaining access to manual therapy?
- Ask your GP or midwife to refer you to an experienced physiotherapist who has undertaken extra training to learn to treat PGP using hands-on techniques. They will refer you to an outpatient or musculoskeletal physiotherapist, or a women’s health physiotherapist at your local hospital or health centre.
- Don't give up if the first physiotherapist you see doesn't seem to be able to help you or you are encouraged to join a group without immediate one-to-one treatment. It sometimes takes persistence to see a physiotherapist on an individual basis and to find someone who is experienced in treating PGP and seems to be helping you to make progress. Ask to speak to a senior physiotherapist or head of physiotherapy.
- If you find it difficult to explain what you want from your GP, midwife or when you see the physiotherapist, take a copy of our 'Stickmum' leaflet with you so you can show the physiotherapist what you are expecting from them. You might also want to take a copy of the relevant National guidelines which summarise the key information about treating PGP effectively including manual therapy.
- In the UK, a midwife or GP referral to a physiotherapist is free within the NHS and the best way to access a manual therapist on your first attempt. If you have to wait more than a month for an appointment and you have not had any luck speaking to a senior physiotherapist, you might want to try a private manual therapist. We hold a list of recommended practitioners on our website (NB each manual therapist has to provide two or more separate recommendations from women with PGP whom the have treated successfully). There will be a charge for a private practitioner but you may feel it is worth finding treatment quickly so you avoid the symptoms getting worse and less easy to manage.
If you are unable to find a recommended practitioner in your area you could try:
- your local sports injury clinic where you can ask to speak to a sports physiotherapist, who ideally specialises in pelvic joint problems, to discuss whether they have relevant experience. They do not have to have specific experience of treating pregnant women. It is most important that they are confident at manually treating the pelvic joints and getting their patients back to playing sport and doing all the normal activities of daily life, rather than just coping with pain and avoiding normal activities. To find a manual or sports physiotherapist in your area visit the Physio First website.
- a local osteopath or chiropractor – again, check that they have experience in treating pelvic joint problems. You may find these websites helpful: General Osteopathic Council, British Chiropractic Association and McTimoney Chiropractic Association.
So how do you know if you have found a 'good' manual therapist?
Once you have obtained a referral to see a physiotherapist or spoken to a local sports physiotherapist (or osteopath or chiropractor) who has experience of PGP, how do you know what 'manual therapy' entails and what should you expect from the first appointment?
The aim of manual therapy treatment is to assess the position and the symmetry of movement of your pelvic joints, especially the sacroiliac joints at the back of the pelvis. The joints in the pelvis should work together as a team and if one or more is not functioning correctly, the manual therapist will need to find out which one or ones are causing the problem, and then treat it or them and the surrounding muscles which often go into spasm and cause pain because they are trying to compensate for the incorrectly functioning joints.
Here are a few pointers about what to expect at your first appointment:
- Your first appointment should be for a longer session than usual so that the therapist can ask you about your general health and health background (including illnesses and any accidents, breaks and problems you may have experienced). They should also ask you about your PGP and how it affects you.
- They should ask to examine you so they can make an assessment of your PGP symptoms - they will look at how your pelvis is working and how the joints and muscles are moving (so they should ask you to undress down to your underwear).
- They will look at and feel how the joints at the back and front of your pelvis move when you move (e.g. standing on one leg, bending forwards etc).
- They will feel how symmetrically the joints move when you are lying down on your back and your front (or your side if you are very pregnant).
- They should discuss their findings and agree a plan of treatment with you, explaining what they are going to do.
And what should you expect from the actual treatment?
Although approaches vary between therapists, manual therapy is usually offered as a treatment by physiotherapists, chiropractors or osteopaths with training and experience in treating PGP. From each manual therapist you should expect the following:
- Gentle hands-on techniques to treat PGP, ensuring that the joints are moving symmetrically and normally, rather than focusing on treating pain.
- Treatment that usually involves a combination of joint realignment or mobilisation and soft-tissue or muscle treatment. This might include myofascial release, muscle energy techniques and trigger point release with or without the use of acupuncture or dry needling. Joints will need to be mobilised if they are stiff or 'stuck' and are not working symmetrically. Muscles supporting the pelvis are also likely to become tight or go into spasm if they are trying to compensate for the pain in one or more of your pelvic joints. This muscle tightness will often need to be released as part of the treatment to allow the joint/s to move normally and prevent the problem from occurring again. This may need to be done at each visit, until your muscles become strong enough to keep them in place without treatment.
- To leave each treatment session feeling better, following the initial 'treatment soreness', with either improved function such as being able to walk without your crutches or stand on one leg, or reduced pain (or hopefully both).
- You may be given a pelvic/sacroiliac support belt or crutches to use between treatments particularly in the later stages of pregnancy. These can help you to move more comfortably and are likely to be removed as you get stronger and more stable between treatment sessions. They are usually unhelpful without treatment to correct your joint dysfunction.
- You are likely to be given gentle exercises to help your pelvic stability once your pain has reduced. If you have a lot of pain, exercises on their own are not usually effective because the pain stops the muscles from working properly. As you recover, your exercise programme will be adapted to suit your individual needs until you get back to normal. For more information about exercise and PGP please click here.
Sadly, it is often the case that some NHS and private manual therapists are not experienced in treating PGP effectively using manual therapy techniques. It may take you a while to find the right manual therapist that works for you. Charlene had first-hand experience of this and tried three manual therapists before finding the one that helped her to recover: “The biggest lesson I have learnt from having PGP is to keep seeking another opinion, and to never presume that simply because someone is specialised in their field, looks and acts like a professional or are being sympathetic, that they are giving you the best service. If you are not truly improving, I would encourage you to seek another opinion!.”
If your PGP does not improve after each treatment, then visit our 'What to do if treatment is not helping' web page.