So what is PGP and why is manual therapy important?
Written by Madeleine Speed, the Pelvic Partnership, June 2015
Have you noticed any pregnant women using crutches to get around?
Once you are aware of a relationship between pregnancy and the use of crutches, you are more likely to spot examples on the high street. I saw a pregnant mum coming out of the supermarket last week who was hobbling around on crutches and looked to be in the first few months of pregnancy. As pregnancy-related Pelvic Girdle Pain (PGP) can affect one in five pregnant women* (to a greater or lesser degree), it is likely that this woman’s reduced mobility was one of the symptoms of PGP. Like others involved in the Pelvic Partnership charity, I do carry information about pregnancy-related PGP for just this situation! Unfortunately, I was going through the checkout and couldn’t rush after the woman to talk to her and ask about PGP.
Although pregnancy-related PGP has a NICE guideline for healthcare professionals about how best to assess and treat it, there are still many women who contact the Pelvic Partnership’s helpline whose symptoms have not been assessed or diagnosed. My concern about the mum in the supermarket, has prompted this blog.
Those who have been reading Pelvic Partnership information on the charity’s website for several years may be tempted to skip this blog and get a cup of tea. That’s fine! However, if you are a newcomer to this subject and think that you or someone close to you has the symptoms of pregnancy-related Pelvic Girdle Pain, some basic information may be very helpful to you. So here is a short review of what pregnancy-related PGP is, what causes it (as well as what doesn’t) and why manual therapy has proved more effective to bring about recovery than simply advocating exercises.
A biomechanical problem
I may have been correct in assuming that the pregnant woman was using crutches because of PGP but not every woman with PGP will have such severe symptoms. Some women may be aware of only slight pain and discomfort with PGP while a small minority will find that pain and reduced mobility requires crutches or a wheelchair to get about.
The key and fundamental message about PGP is that it’s a biomechanical problem and not caused by hormones. The causes of PGP are usually down to:
- a stiff or stuck pelvic joint, so the ring of bones making up the pelvis no longer functions properly
- muscles becoming tight and painful to compensate for the stuck joint or joints
If you think you may have pregnancy-related PGP, the most obvious symptoms are pain and inflammation in the pelvic joints which in turn can mean that it is hard for you to sit comfortably for any length of time, to stand for a while, walk, drive a car, climb stairs, or turn over in bed. In fact, PGP can make it hard to do many of the everyday tasks that previously you’ve taken for granted – at work or at home.
Your symptoms of PGP may not be identical to someone else’s
Although the causes of PGP are common to all cases, your symptoms may not be exactly the same as someone else’s. Some women have very little pain or discomfort and can get around fairly easily while others may find they can barely take a steps without feeling that stabbing or burning pain. Your pain may be at the front of the pelvis or it may be at the back; you may be less aware of it during the day but feel much more pain at night. Some women are aware of a severe pain for most of the time but whether your pain is mild or very pronounced, you are probably also finding that your mobility has decreased so your ability to move around, walk or manage stairs is considerably compromised. Even when you are sitting still, you may not be able to move your legs freely to the extent that you cannot open your knees any further apart than three or four centimetres (which can make it very difficult to dress, get in or out of bed or to get into the car). All this can make it very hard to function as you did before the symptoms arrived and to cope with all the tasks needed to manage in pregnancy or care for a new baby and a young family.
About asymmetry and stiff or stuck joints
In general, if we are healthy and well, we all start out with wonderful posture and symmetrically mobile joints. Toddlers are amazingly flexible and when they have mastered walking, they naturally hold themselves erect when they move around or sit. Unfortunately, this ideal state may not last throughout our lives and our natural, balanced and symmetrical mobility can be altered as a result of injury, poor posture, straining to pull or push objects or through carrying too heavy weights. Over time, the pelvic joints that were once moving symmetrically can become stuck and asymmetrical.
Even if you were previously unaware of pelvic asymmetry you may find that this changes when you become pregnant. During pregnancy, this misalignment can mean that when you try to carry out your normal activities, the joints that are not stuck have to move more to compensate for the stuck one, and they get irritated and painful. The pain can also start suddenly as a result of stepping awkwardly, a trip or fall, or even just getting out of the bath awkwardly or picking up a toddler. If this is not treated, the pain often increases as the pregnancy progresses because as the baby grows, this also changes how the pelvis functions because of the shape and size of your bump.
Current best practice therefore shows that the key to full recovery is to get good manual therapy from someone experienced in treating PGP and preferably as soon as the symptoms first occur. Once the pelvis is realigned and stiff and stuck joints work freely again, and the pain has settled, exercises can help to strengthen supporting muscles to keep the pelvis functioning efficiently.In the past, women were told it was all down to their hormones which made the joints loose. The treatment offered at that time included crutches, support belts and exercises to ‘strengthen the core muscles’, but this tends not to be effective for most people as it does not address the underlying problems of stuck, asymmetrical pelvic joints. Pain inhibits muscles and stops them from working normally, so most women report that it doesn’t matter how much they exercise, the underlying pain doesn’t go away, and in some cases gets worse with the exercises.
Stamping out myths
Unfortunately, women often tell us that they see healthcare professionals who are not aware of the biomechanical causes of pregnancy-related PGP. As a result, there are still myths circulating about PGP which really do not help. Although PGP is common during pregnancy, it is not a normal part of being pregnant and you should not be expected to just put up with it. In fact, those professionals who say that pain and limited mobility are a natural part of pregnancy are doing women a real disservice and condemning them to unnecessary hardship. The symptoms should not be tolerated and if you have them, you should be encouraged to seek and receive help as soon as the symptoms arise. The sooner you get the joints treated, the sooner you can get the pain under control, and in many cases, feel completely better.
Another myth is that PGP is caused by pregnancy hormones and that the pain and difficulties of walking, sitting, etc, will go away as soon as the baby is born. As mentioned above, PGP is not caused by hormones and rarely goes away without appropriate treatment (although some women find that after birth the symptoms are less obvious, although they seem to be in the minority). If the symptoms are not treated during and after the pregnancy, the symptoms reoccur early in the next pregnancy. However, the symptoms are still treatable, so do not worry if this is your situation as you should benefit from treatment at whatever stage you receive it after the PGP starts. Sometimes healthcare professionals are reluctant to treat pregnant women and this is probably because traditionally it was thought that it was not safe to treat pregnant women, but this is not based on any research evidence. the current national advice is that it is safe to receive treatment for PGP when you are pregnant (treatment does not impact adversely on the baby at all). So in summary, it is important to look for manual therapy as soon as the symptoms occur, but if you don’t manage to get treatment straight away, it is still safe at any time in pregnancy even if you are nearing birth.
Women are sometimes told that they can overcome PGP symptoms by stopping breastfeeding. The idea is that there is a relationship between hormones and PGP such that stopping breastfeeding will reduce some of the pregnancy hormones and therefore minimise PGP symptoms. This is untrue; PGP is a mechanical, and not a hormonal problem, so stopping breastfeeding will not aid recovery. The Pelvic Partnership’s first blog features a recent study of PGP symptoms and breastfeeding. The study suggests that far from breastfeeding prolonging recovery from PGP, it is actually beneficial in overcoming PGP symptoms (you can read more about this study via the Wiley Library website). Of course, it is your choice about whether you want to bottle feed or breastfeed your baby but as breastfeeding is widely recognised to bring health benefits to both mother and baby (e.g. UNICEF, the NHS, NICE, and the NCT, promote the importance of breastfeeding), it is sad that a myth is persuading women to give it up. The findings of the recent study show that women should never be encouraged to stop breastfeeding in order to reduce PGP symptoms. What’s more, it can be very upsetting to discover that the symptoms of PGP do not disappear as soon as breastfeeding stops.
Although we have tried to dispel the myth that hormones are the cause of PGP, it would be untrue to say that there is no relationship between the role of hormones and the amount of pain experienced in PGP. For example, women who have had their babies but still experience PGP symptoms have said that these symptoms can become worse when they are about to have their periods or during menstruation. This is usually a sign that there is still an alignment problem which becomes more evident with slight hormonal changes. Therefore if this is you, it is a sign that some further manual therapy is probably needed.
What is manual therapy?
‘Manual therapy’ is usually a term used to describe treatment that involves the use of the therapist’s hands as opposed to treatment with a machine or device (e.g. an ultrasound machine). A manual therapist such as a physiotherapist, chiropractor or osteopath will use their hands to restore the function of the pelvic and back joints and reduce associated pain while ensuring that muscles are working properly.
A trained and experienced physiotherapist, osteopath or chiropractor will use a range of techniques to overcome the symptoms of PGP. These can include:
- Mobilisation – the hands move limbs, bones and joints by gently pulling or pushing them back into position and allowing release of tight tissues around a joint.
- Manipulation – uses more rapid, forceful movements than mobilisation and often uses the weight of the therapist to move the bones and joints into a better/natural position.
- Muscle energy techniques – these include encouraging the patient to take an active part by contracting the muscle around a joint which allows the therapist move a targeted joint back into the correct alignment where it will function normally again.
- Trigger points – treating any tight points in muscles which may arise from the body compensating for a joint that is not moving properly, often using trigger point techniques or acupuncture.
- Massage – where pressure from the hands is applied to the soft tissue and joints to help muscles relax, improve circulation and reduce pain once the joints are back in alignment.
The end result should be a return to free and efficient movement without pain.
Individuals have individual bodies
We are all different and our bodies will be unique to us. However, the joints are cleverly designed to work in specific ways and any treatment will involve knowledge of how to restore this movement. Although different practitioners use a different ‘language’ to describe their treatment, the principles are broadly similar, and a good practitioner from any discipline will expect to produce results quickly. So the role of any manual therapist, whether a physiotherapist, osteopath or chiropractor, will be to understand why an individual’s body is not working properly and why it is experiencing problems. Although there may be certain features in common, it is unlikely that you will experience the symptoms of PGP in exactly the same way as another women. So the manual therapist will need to examine each woman who presents with PGP as an individual.
If you are considering manual therapy for the first time to treat your PGP symptoms, do contact the Pelvic Partnership for information to help you. Ahead of seeing a manual therapist, it is worth ringing to ask questions about whether the physiotherapist, osteopath or chiropractor has successfully treated pregnancy-related PGP before. You can ask how they would treat PGP and you would expect an answer which mentions manual therapy (rather than offering a series of exercises without manual therapy). If the answers you receive reassure you, then it is worth making an appointment, if you are not sure, you might want to make further enquiries.
At your first appointment, the manual therapist will need to start with a brief series of questions about past health history, any illnesses, any operations and about the progress of your pregnancy. Next, you should receive a thorough examination (carried out with you in your underwear), to identify which pelvic joint or joints are not functioning properly. If the focus is entirely on the pain experienced as a result of PGP symptoms, this may miss the underlying cause of the pain, which is the stuck joint. Usually, the stiff or stuck joint is in the back of the pelvis at the sacro-iliac joints, but the pain is often felt at the front because this is a smaller, less stable joint. Therefore treatment should focus on the joint that is not functioning properly, rather than on the site of the pain, as concentrating on the pain alone can be misleading. After fully examining you, the therapist should clearly explain why you have the pain and outline a treatment plan that should relieve the symptoms. The duration of treatment is very much dependent on your symptoms but you should expect to feel an improvement in your function (and hopefully pain as well) after each treatment session, even if you have had pain for a long time. You may need to have a few more sessions to really help you to feel better, but it should be obvious after a couple of sessions whether the treatment is working. If not, do talk with your therapist to discuss why this might be and whether you need another opinion on what the problem is and why it is not getting better.
As everyone is different it is difficult to give an outline of how long treatment might continue. Some women find that about two or three treatment sessions can provide significant results but for others this may take longer. You may be surprised at how few treatment sessions you may need before the symptoms reduce or disappear all together.
* Albert H (2001)