Expert / 8 December, 2020 / Dr Lucy Tinning
Pelvic Girdle Pain is a common condition affecting one in five pregnant women. Previously it was known as Symphysis Pubis Dysfunction (SPD) but this term indicates that only the symphysis pubis is affected, when in fact this is not usually the case. PGP can be experienced in different areas around the pelvic ring, including the hips thighs; sacroiliac joints at the back and the symphysis pubis at the front.
There are several possible reasons why women get PGP, including strenuous work (twisting and bending the back many times in an hour), a history of low back pain or pelvic girdle pain or previous injury to the pelvis. Because PGP is often due to the joints in the pelvis moving unevenly, it can make the pelvis less stable and as such, painful. As the baby grows in the womb, the extra weight can change the way you sit or stand and this puts more strain on the pelvis.
Pregnant mums who experience pain in the pelvic area might learn that their symptoms are PGP related, as opposed to “typical” pregnancy aches and pains. Some doctors and midwives who are aware of PGP will assess and diagnose PGP and follow the guidelines on treatment as laid out but the Royal College of Obstetricians and Gynaecologists. However, research suggests that this is not always the case for many women. PGP is often normalised and women’s pains are misunderstood, with many mums not receiving the treatment they desperately need. Currently, the treatment includes manual therapy from a physiotherapist, osteopath or chiropractor as well as some practical advice about certain positions and activities to avoid or employ to help manage the pain.
Because the research shows that only 25% of women are offered treatment, many women do not get referred for the support they need. If they can afford it, they can seek a diagnosis privately from a physiotherapist, osteopath or chiropractor. A clinical measure does exist for assessing PGP, The Pelvic Girdle Questionnaire (Stuge et al, 2011), which those reading this may find useful to know and understand when seeking a diagnosis. It is a self-report questionnaire that women complete during pregnancy and post-partum so that their clinician can get a sense of their physical symptoms and how best to treat them.
Pelvic Girdle Pain can start and continue as early as the first trimester, and/or any time after. It can also persist postnatally. Studies show that up to 17.5% of women experience PGP three months postnatally and approximately 5% to 8% of women still have symptoms two years after giving birth.
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PGP Symptoms vary in range and severity and affect women both mentally and physically. The experience of pain can be very challenging to manage and cope with. For some women, their mobility is significantly affected and they experience pain when walking, climbing stairs and turning over in bed, as well as other functional activities of daily living such as getting dressed, stepping into the shower, sitting and lifting.
The extent to which PGP distresses women cannot be underestimated. The research suggests that mums with PGP are more likely to feel anxious and/or depressed. This has been linked to the fact that they are more likely to struggle with activities of daily living than pregnant women who do not have PGP and that they tend to be very fearful of these activities so avoid them altogether. PGP is also linked with sleep disturbance and it is a major cause of sick leave from work (up to 72% of sick leave) as women cannot function in the work-place. Some women require crutches and/or a wheelchair and in extreme cases, they may become housebound. Their quality of life is significantly impacted and their sense of identity is wrapped up in this too.
In my work, I hear a lot from women about how their PGP has discouraged them from having more children because the pain has been so hard to cope with. Their pain experience is referred to as “torture”, that their “body has failed” and that being dependent on others for support leaves them with feelings of shame and embarrassment. They also believe that having PGP impacts their relationship with their other children, as they cannot care for them in the way they want to. Guilt is a strong feeling for these mums. The research supports this, with women reporting feeling unprepared for the pain, powerless and out of control as they struggle to find ways to manage it daily.
First, understand the pain…….
Managing persistent pain requires a mind-body approach. A common framework to understanding pain and identifying ways to manage it is the biopsychosocial perspective. This model captures the mind-body connection as it identifies pain as an experience that results from a deep, complex and dynamic interaction among three domains, biological (genetics, biochemistry), psychological (emotions, beliefs about pain, memories, behaviour) and social (culture, family, socio-economics). We all have different biological and genetic make-ups, this coupled with our different life experiences and influences determines how we manage and cope with our world. Pain can feel worse when the domains are not balanced, and achieving this balance will be different for everyone. We are all unique individuals with our own history and experiences (for example, how was pain viewed in your family growing up? Was it validated or dismissed? What did you learn about being in pain?).
If we go a little deeper into our domains, we can get a sense of how to manage PGP better. We know that pain is a condition of the nervous system and is located in the brain. We also understand that the nervous system has two pain pathways, both of which can stimulate the release of different pain-relieving chemicals. They include: “The Bottom-Up Pathway” and the “Top-Down Pathway”, and are both mind and body processes).
The “Bottom-Up Pathway” concerns your five senses which identify the sensation of pain and send that information up the spinal cord to the brain (biological). The “Top-Down Pathway” is activated when the brain has received this information that your senses have provided, it interprets it and makes an appropriate response. This pathway is driven by your knowledge within your brain and is based on thoughts, feelings and memories of life experiences (psychological, social) – THIS IS YOUR MIND.
These top-down and bottom-up pathways are vital in our experience of pain especially because they are also responsible for releasing pain-relieving chemicals. Being the amazing humans we are, we have the power to influence these pathways using both our mind and body!
Then you can use mind-body strategies to manage the pain…
Both pathways need attention and may mean that you need some additional support. I would certainly recommend seeking help from a range of practitioners, family and close friends. Asking your doctor and/or midwife for further information is a good start, seeking a referral to a physiotherapist, osteopath or chiropractor who has experience of treating PGP is vital.
Experiment with these strategies, what works for some people does not work for others but they are ideas to help calm the nervous system and release pain-relieving chemicals.
Try and take steps to better understand your feelings – how do you feel? If you sit with your thoughts and resist blocking them out, what comes up? Fear, anger, guilt, shame, sadness? Write them down and honour them. Share them with loved ones or work through them with a therapist so you feel understood and supported. PGP can be a rocky ride with good days and bad days and you need people on your side to support you.
Use mindfulness strategies to support you. Look to incorporate some mindfulness strategies – try and remain present in the moment, without judging yourself or anything for that matter. Just noticing what is happening around you can help, and this can be done from the comfort of your garden or on the couch with a cup of tea. Ask yourself, what do you see, hear, taste and smell? Whilst it may be tricky, try and resist those fearful or distracting thoughts and just focus on the now.
Feeling safe is vital to help keep your anxiety down. You might feel vulnerable at times and so making sure you’re in an environment that feels comfortable and gives you some control will help. Breathwork is an amazing way to let your body know that it is safe, as are relaxing body scan exercises. The breath is a very powerful way to activate your parasympathetic nervous system.
Spiritual practices are a fantastic way to bring calmness into your life. Guided meditations, being in nature and accessing your spiritual community are also great for calming the nervous system.
Manual treatment, so “hands-on” therapy from a physiotherapist, osteopath or chiropractor with experience of treating women with PGP is a vital tool in your kit. Ask your doctor to refer you and to also help you get seen at the earliest possible stage in your pregnancy. We know that manual treatment works for PGP.
A massage or a healing touch (such as a hug) from either yourself or your partner can work wonders. Touch is a very powerful way of communicating with the human nervous system and is deeply ingrained in our mind and body as a way to soothe ourselves. It may not be for everyone, so make sure you feel comfortable and do what feels right for you.
Hot or cold sensations can aid pain relief, such as a hot/warm water bottle, cold pack or damp towel if placed on the affected area for a short period. Other sensory experiences such as being in a pool or bath can help too.
Try and act on your feelings and give yourself a chance to express your feelings rather than squashing them down. This way you may hold this tension in your body otherwise, leading to tight sore muscles.
Sleeping can be a constant struggle for women with PGP and is often disturbed due to pain. If it is possible, I recommend making time to have a nap during the day. Being pregnant and experiencing pain is hard on the body and so resting is crucial.
Gentle movement and exercises suggested by your manual therapy practitioner may help. It is important to do exercises that are designed for your body and your symptoms, rather than a generic plan.
The more you practice these strategies, both bottom-up and top-down, the stronger your neural pathways to calming your nervous system will be. Connecting to the parts of your body that feel pain and focusing on relaxing and soothing them will also be of benefit during birth and postnatally.
Many women worry about giving birth with PGP. The most important thing to do is speak with your midwife and explore your options so that you understand fully the different choices available to you and at what stages you can change your mind if your initial choice does not feel right. Birthrights.org is an organisation where you can gain some good information about what your rights are during the birth of your baby. Just because you have PGP, it does not mean that certain birth wishes cannot be fulfilled (unless other medical reasons arise). This includes water births, which mums with PGP often ask about.
Women who have taken the time to practice the top-down/bottom-up pain pathway management strategies may find they can more easily settle their nervous system during birth. Calm breathing techniques will remind your body it is safe, and mind-body connections using body scanning can help relax the pelvis during labour and birth.
If PGP has not been treated and if you have not had the opportunity to follow a personalised rehabilitation plan, it is more likely that the condition will return in subsequent pregnancies.
PGP is pretty common which makes the lack of awareness about it surprising. Things are improving though, and many NHS Trusts offer support. This does tend to focus on the physical symptoms and, like any condition that causes pain, a broader more holistic approach is needed which includes the mental health component. If you believe you are experiencing PGP, do not understate it or allow anyone else to. We know the impact it can have on women, particularly at a time when women can feel vulnerable already. We also know it needs to be treated. Ask your doctor and midwife for advice, if they cannot help, then perhaps seek a second opinion. Do request a referral for manual treatment and mental health support. Importantly, have compassion for yourself and do not try to struggle through it alone.
Article by Clinical Psychologist, Dr Lucy Tinning, www.drlucytinning.com
Dr Lucy Tinning is an expert in pain management for Pelvic Girdle Pain. Dr. Lucy has a number of resources for women with PGP, including a Facebook support group for women with PGP (Supporting you Through Pelvic Girdle Pain), an online mini-course for understanding and managing PGP, as well as free online Masterclasses and resources on her website. Dr. Lucy can be contacted for further information and support for one-off individual sessions focusing on a PGP concern or for ongoing therapy.
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