A sports physiotherapist’s approach to treating pregnancy-related PGP
Lucy Walmsley MSc MCSP qualified from St Mary’s Hospital, London in 1994. Having worked in NHS hospitals, both a large London teaching hospital, and a local district general, she then went on to complete a Masters Degree in Sports Medicine and Rehabilitation. Lucy worked for some time in professional sports settings including Gloucester Rugby Club and with UK Athletics. As well as being expert in the management of sports injuries, Lucy has also specialised in the management of spinal and pelvic problems, including those associated with pregnancy. Lucy says that she gathered a large amount of experience in treating pregnancy-related PGP after our chair, Sarah Fishburn, consulted her about PGP back in the late 1990s! In the course of her clinic work she has treated numerous pregnant and post-natal women with pregnancy related pelvic dysfunctions using the same approach and found it to be effective. This led her to investigate the area further and discover that manual treatment and management of this condition offers a much better outcome for these patients. Lucy has been a great supporter of the Pelvic Partnership and provided workshops and presentations for women with PGP and also for healthcare professionals.
The history of PGP
Pelvic pain with poor mobility during pregnancy is not well recognised or diagnosed by healthcare professionals within the UK and sadly it is often dismissed as something ‘new’ as if it’s been invented by the most recent generation of young mothers. However, pain and discomfort within the pelvis during pregnancy has historically caused difficulties for women over a very long period. Some experts have found references to it within the writings of ancient Greeks but if we avoid the pitfalls of looking back that far, there are references to Symphysis Pubis Dysfunction in the work of Snelling in 1872 which suggest that the symptoms are far from ‘new’. Subsequent research confirms that awareness and recognition of pelvic pain by the medical profession remains poor (Fry 1999). This probably isn’t helped by a vast number of names used to describe the connection with the pelvis including ‘pelvic girdle relaxation’, ‘pain provoking pelvic syndrome’, ‘Osteitis Pubis’, etc. The name is still changing, most recently becoming ‘Pelvic Girdle Pain’ (PGP). PGP is certainly an improvement, given that the condition is not just confined to problems with the Symphysis Pubis as some of the former names might imply. Before we think that the new name indicates greater understanding, sadly, this doesn’t seem supported by more recent research. In fact in 2007, Asian and Fynes commented that there was still no international consensus on definition, diagnostic criteria or treatment protocols, which can certainly pose a problem for current women with the characteristic symptoms.
So where does this leave us today?
Well, as healthcare professionals, we need to keep sharing information about PGP gained from real experience of treating women and finding out more about how the condition is affecting them. Over the years, I have seen many women who have presented with PGP symptoms and I like to work out exactly what the problem is for each woman and find ways that help them to overcome or, at very least, manage the symptoms so that they can resume activities that were easy for them before the PGP started. In addition, it is helpful to keep an eye on recent research and particularly to use it to clear up some modern myths about it. One traditional view is that having PGP is “all down to your hormones”. Yet there are a good number of more recent research papers that show how, for the majority of women, the problem is down to a biomechanical problem and not due to hormones at all. It is usually due to an asymmetrical movement at the sacro-illiac joints and a failure of one or more of the pelvic joints to move smoothly and in harmony with the others. Hormones may play a part, in terms of both the severity and the timing of the pain, but key research papers demonstrate that hormones are not the cause.
We are also better informed from recent research observation about the pelvis. For example, in the past women may not have been offered treatment because of misinformation around the sacro-iliac joints which traditionally were thought not to move, but have now been proven to do so.
How I treat PGP
Before talking about my approach to treating PGP (which is in keeping with current best practice), I think it is helpful to look at how the key systems within the body operate, enabling it to function normally. There are three different systems that all need to work together to maintain efficient functioning so that a person can stand without falling and move around freely in a chosen direction. These systems are the active (muscles), passive (joints and ligaments) and control (nerves and communication with the brain and the muscles) systems and they all need to work harmoniously to allow controlled balance and movement. When something goes wrong with one of these systems, the others work hard to try and compensate so that the body can still function. When PGP occurs this is often what happens; it can interfere with how efficiently these three systems work together and can mean an over-reliance on one system over time at the expense of another, resulting in restricted movement and pain. For example, with the passive system of joints and ligaments, if these are not moving freely or smoothly, the active system might struggle and start to draw on different muscles to allow movement forward. This may cause strain and difficulty over time and in women with PGP, I often observe the adoption of peculiar crab-like walking techniques as the three systems work hard to propel the body forward while keeping it upright.
So when I treat women who come to see me with pain and difficulty walking, sitting for periods, driving or turning over in bed, etc, I try to learn more about which of the three systems has a problem and try to address and resolve the difficulties through manual therapy. With PGP, it is usually the case that the body is struggling to compensate for stiff and inflexible pelvic joints that aren’t working together anymore linking to a slight asymmetry in the pelvis. Over time, this struggle can result in pain and inflammation in surrounding soft tissue. Often the muscles, joint, ligaments and nervous system have moved out of their natural position. I try to resolve the joint and muscle problems so the body can return to its natural and optimum mode of movement again. So the aim of the treatment is to produce an objective change to patients at each session, so that they can walk out feeling a bit better – maybe not particularly with less pain (subjective improvement), but with better function and able to move more easily (objective improvement).
Remembering each person is an individual
I find that much depends on each individual’s own symptoms and how the three systems are working or failing to work together. Trying to generalise about women with PGP or without PGP is dangerous! Women’s bodies have so much in common and yet when you look at them in depth, there are so many characteristics that are unique to each individual: how the veins lie, the exact size and shape of the pelvis, position of key joints, etc so that it is easy to find as much variety between women as there are variations in hair colour. Of course science is at the heart of physiotherapy but it is as much an art as a science. I might use my knowledge of anatomy to inform me about how a woman’s body might fail to function efficiently and to isolate which areas I may need to treat with manual therapy. However, even though my training will be very similar to the next sports physiotherapist’s, no two practitioners will approach the same patient in exactly the same way. But this doesn’t mean it is a dark art! I am sure many physiotherapists give the importance I give to carrying out a systematic approach when individually assessing each woman I see with PGP, working out which joints and muscles are not working as well as they might and finding ways to encourage them to release and function normally again. I think it is also very important to take a proper medical background with each new patient as it is vital to understand if there are any past illnesses, accidents or surgery that might need to be considered ahead of offering a treatment plan.
Pain and PGP
Many of the women I see have been prompted to look for help because they find the amount of pain they are experiencing is intolerable. Of course pain is going to play a big role in the everyday life of a woman with PGP. However, I do try to encourage patients to put their pain to one side during a treatment session so I can concentrate instead on how their joints, muscles and limbs work together and where problems are occurring. This to me is vital because focusing on pain and how it is experienced can be very misleading. For example, a patient can experience a pain in one part of their pelvis but the site of the pain may not necessarily indicate the source of the problem – this phenomenon is known as ‘referred pain’. The joint causing the pain may be different from where the pain is experienced.
By this, I don’t mean that I dismiss pain as being unimportant – this is very far from the case. Controlling pain can be really vital to helping someone to feel better because sometimes experiencing pain can prevent the body from responding to treatment properly. Although we often have an aversion to taking medication (and particularly when pregnant), it seems that sometimes for manual treatment to be really effective, over-active pain receptors have to be soothed so that the body can accept the changes brought about through the manual, ‘hands-on’ techniques and doesn’t block the benefits. It sounds odd when you first hear it, but some of the women I see with PGP who seem very sensitive to pain, take a suitable pain killer just before they come in for their manual therapy with me and/or I use dry needling as part of their treatment session to reduce the pain produced by tight muscles before starting any ‘hands-on’ treatment. If you think this might help you, talk to your GP and discuss this approach with your manual therapist before your treatment begins.
I think it is also important to highlight that although some women do not feel discomfort in the few days folllowing treatment, some do. This shouldn’t be an indication that the manual therapy hasn’t worked. In fact, on the contrary it can suggest that there have been some beneficial changes and the body is getting used to functioning naturally again (after a spate of compensating for PGP symptoms, which, as mentioned above can lead to pain and problems). If you are very sensitive to pain and have experienced PGP symptoms for some time, it may be that providing manual therapy does cause some discomfort initially but this should subside after just a couple of days (and in some women the treatment soreness is gone in a few hours).
Communication is vital
Take a note of any movements that might cause you more pain or difficulty with your PGP. For example, some women find that bending and twisting can increase the pain and that pushing a trolley around the supermarket or using the vacuum cleaner can make the symptoms of PGP worse. The more you know your limits while you are recovering, the better you can avoid movements, positions and everyday tasks that increase the painful symptoms. Passing this information on to your physiotherapist can also help them to identify biomechanical difficulties preventing you from moving freely and address them in your treatment sessions.
Good communication between you and your physiotherapist can be really useful in helping you towards your recovery or the best management of your symptoms. Ask questions about your PGP, which pelvic joint or joints are causing the problem so you start to understand your body better. Find out what exercises may help you build core strength and assist you in keeping your pelvis aligned. Talk to your physiotherapist if you don’t feel you are getting better or if you notice any additional symptoms. If your physiotherapist understands your concerns and you still don’t seem to be responding to the treatment sessions, ask for some feedback on why and see if there is senior physiotherapist available to offer other ideas and a way forward. Be prepared to ask for a second opinion if you don’t feel that you walk out after each treatment session aware of at least some improvements, however small.
Lucy has a physiotherapy practice in Bourton-on-the-Water in the Cotswolds.