Luck's Yard Clinic

Anterior Pelvic Girdle - February 2008

Chiropractic management on Pelvic girdle pain (PGP) and Symphysis pubis dysfunction (SPD)

By: Tone Tellefsen DC. BSc. FCC. (paeds)

ABSTRACT

Anterior pelvic girdle instability is a condition, which is often difficult to recognise, diagnose and manage in the medical and chiropractic field. The author builds on her own clinical experience by using a case study and discussing her theories on the osseous and myo-fascial stabilisation factors acting on the pregnant pelvic girdle. The author discusses the need for clinical guidelines in any medical and caring profession to aid in the assessment, treatment and appropriate advice on daily living for pregnant women suffering with this debilitating condition.

Keywords: Chiropractic care, pelvic girdle pain (PGP), pelvic girdle instability (PGI), pregnancy-related pregnant girdle pain (PRPP), pregnancy, symhysis pubis joint (SPJ) symphysis pubis joint dysfunction (SPD).

Introduction

Back and pelvic pain in pregnancy has historically been considered to be an almost inevitable consequence of the biomechanical stresses occurring in pregnancy (Nilsson-Wikmar 2005; Wu et al. 2004). It has also has been viewed as one condition, but this attitude has changed in the last 10-20 years (Albert et al 2002). Pelvic girdle pain (PGP) may occur separately or in conjunction with low back pain and it is the aim of this article to focus on the anterior aspect of the pelvic girdle. The difficulty in defining pelvic girdle pain comes from a lack of definition of locating the pain.

It is now widely established that approximately 48%-56% of women may suffer with low back and pelvic pain during pregnancy (Berg et al. 1988; Fast et al 1987; Kristiansson 1996; Ostgaard 1991). Albert et al (2002) performed the largest study to date, including 2269 pregnant women. Of these pregnant women 20,1 % were found to have PGP. The actual incidence of pain in the symphysis pubis during pregnancy is also widely disputed and Albert et al. found it to be, 2,3% (2002) were as Ostgaard et al found the incidence to be 8% (1991) and Rost et al: 57%,(2004) in their respective studies.

Nomenclature of anterior pelvic girdle pain has been also been varied and is reflected by the lack of clear definition on this syndrome (Albert et al 2002). It has thus been described and involves: Osteitis pubis (Borgstein et al. 2005; Stern et al. 1993), pelvic insufficiency (Albert et al. 2002), symphysiolisis (Albert et al. 2002), rupture of the symphysis pubis (Borgstein et al.2005), or symphysis pubis separation, also defined as a diastasis (Albert et al. 2002; Berg et al. 1998; Borgstein et al. 2005; Stern et al. 1993). The SPJ must be separated at least 10 mm to be defined as a diastasis (Lindsey 1988; Schriven 1995; Stern 1993).

Anterior pelvic girdle pain has in the literature most commonly been described as symphysis pubis dysfunction (SPD) (Fry 1999), but has lately been included in the description of pelvic girdle pain (PGP) or pregnancy related pelvic pain (PRPP or PPP) (Damen et al. 2002; Wu et al. 2004; Vleeming et al. 2004). Anterior pelvic girdle pain or SPD may give pain locally or radiate to the groin and hips as well as one or both sacro-iliac joints (Wu et al. 2004). Usually it makes movement difficult (Albert et al. 2002; Wu et al. 2004) and many women feel a sense of instability or the pelvis "not holding together very well". . Some women may also experience a clicking sensation in the pelvic joints during pregnancy. This may either be in the sacroiliac joints or the symphysis pubis region.

The pelvic girdle is a complicated ring structure, which is anatomically designed for weight bearing, ambulation, movement and stability of the trunk. It has been said that the pelvis in humans works as a platform with three large levers acting on it: the spine and each leg (Vleeming et al. 2004). The sacro iliac joints (SIJ) are synovial with strong posterior and interosseous sacro iliac ligaments connecting the sacrum to the ilium (Borgstein et al. 2005; Kapanji 1994; Lee 2004). See picture 1. The SPJ is a cartilaginous joint between the two pubic bones and a thin layer of fibro cartilage is covering the articular surfaces of the joint These surfaces are separated by a fibro cartilaginous inter pubic disc (Lindsey et al. 1988; Stern 1993) The SPJ is supported by four ligaments namely the anterior pubic, posterior pubic, superior arcuate and inferior arcuate ligaments (Lindsey 1988; Stern et al. 1993).

Picture 1) Ligaments of the pelvic girdle viewed from the anterior aspect. (Adapted from Lee 2005)

Vleeming and his colleagues formed a concept to try to explain the function of pelvic stabilising factors, which was termed form and force closure (Vleeming et al. 1990a, b, Vleeming et al. 1997). Form closure relies on the anatomical shape of the sacrum fitting onto the grooves of the iliae, shaping a keystone effect for passive stability. (See picture 2) Force closure entails the local muscle forces acting on the ligaments and fascia to compress the joint and aid in creating a shear to allow for adequate movement. (See picture 3) When these two work in synchronicity they provide a "self bracing mechanism" of the pelvic girdle. Stability of the SIJ is further achieved by forward nutation of the sacrum causing tightening of the SIJ ligaments such as the interosseous ligaments (Vleeming 2004). This will cause the posterior parts of the iliac bones to press together and therefore increase the SIJ compression needed for stability.

Picture 2) Scematic picture of form closure - Vleeming et al 1990a, Snijders et al 1990a

Picture 3) Schematic picture of force closure - Vleeming et al 1990a, Snijders et al 1993)

Form closure may be disrupted during pregnancy due to the added weight gain compressing onto the sacrum and potentially affecting it's positional alignment within the pelvis with regards to the iliae. The author believes this may cause an open wedge effect of the SIJ's, especially if the sacrum is forced to counter nutate such as in an alordotic situation.

There are several muscle groups acting in an anterior and posterior sling to enhance the force closure effect of the pelvic girdle (Lee 2004). The posterior oblique sling will cause force closure of the SIJ with help of the latissimus dorsi and opposite gluteus maximus (Lee 2004). Force closure of the SPJ, is proposed to be achieved by the anterior oblique sling via the external and internal oblique and the transverse abdominal muscles in association with the adductor/abdominal fascia. The pelvic floor muscles and thoracic diaphragm are also found to be of importance in controlling form and force closure (Lee 2004) The author believes that the normal force closure acting on the SPJ may be reduced during pregnancy due to the enlarged abdomen affecting the force vectors working on the anterior muscle sling.

In 2004, a scientific committee in Melbourne (Vleeming et al. 2004) drew together the European guidelines on the most recent and up to date research on pelvic girdle pain (PGP) including its' examination, diagnosis and management. Medical approach to this condition has traditionally been bed rest, using a walker or a walking stick for ambulation, anti-inflammatory agents after parturition or in severe cases surgery to stabilise the joint (Borg-Stein et al. 2005). From this congress it was concluded that there is no substantial evidence yet for physical therapy, exercise, massage, back school classes, water gymnastics, acupuncture or using a specialized supportive pillow in bed (Vleeming et al. 2004). All the approaches mentioned above may have a positive effect but there is so far insufficient evidence to support it. A pelvic belt may be fitted for symptomatic relief but should only be fitted for short periods (Damen et al. 2002; Vleeming et al. 2004). It is also possible that manipulation and mobilization may help but this needs further studies as well. The strongest recommendation at this point was to use an individualized treatment including stabilising exercises as part of a multi factorial treatment programme (Wikmar et al. 2005; Vleeming et al. 2004).

In chiropractic it is traditional to look at the combination of structural and functional alignment of the pelvic girdle, hip joints and the lower extremities. for a holistic assessment of pelvic girdle dysfunction. Joan Fallon wrote about the chiropractic treatment of SPD in her textbook on pregnancy and described the superior-inferior mal alignment of the symphysis pubis as a common occurrence in pregnancy (Fallon 1994). She felt this was attributed to a ligamentous laxity causing a loosening of the SPJ as well as a superior-inferior strain on the joint alignment. (See picture 4) Studying the movements of the pelvic girdle, (Kapanji 1994; Lee 2004) it would also be possible to assume that a rotational aspect of this mal alignment or strain may occur both anteriorly (SPJ) and posteriorly (SIJ). (See picture 5)

Picture 4) Superior-inferior strain of the symphysis pubis joint. (Adapted from Kapanji, The Physiology of the joints 1985)

Picture 5) Rotation of the iliae affecting the symphysis pubis joint. (Adapted from Kapanji, The physiology of the joints 1985)

De Jarnette, The founder of the chiropractic philosophy and treatment system known as the sacro occipital technique, (SOT)(1984) divided lumbo pelvic conditions into three categories. The second category concerns pelvic instability where the interosseous ligaments of the sacro iliac joints have stretched so that the weight bearing part of the SIJ is affected. This in turn causes friction and inflammation as well as rotation of the pelvic girdle, involving the SPD. This usually occurs on one side. It has also been found by Damen et al (2002) that asymmetric laxity of the sacroiliac joints has been identified as a possible predictive indicator of those who suffer moderate to severe postpartum back pain. It was not the magnitude of pelvic laxity, which seemed most painful but the asymmetry between both SI joints.

Added to this is the still debated antenatal hormonal influence of the ligaments of the pelvic girdle. For many years the belief has been that serum relaxin and or progesterone has been responsible for relaxing the ligaments of the pelvis in order to make room and thus facilitate for childbirth (Borgstein et al. 2005; Kristianson 1996; Mac Lennan 1986). However the most recent studies are still in dispute as to the significance of hormone related instability and the relationship with joint pain and dysfunction (Albert et al. 1997; Hansen et al. 1996; Vleeming et al. 2004). Further research is indeed needed in this area. The following case history aims to show how chiropractic examination and management was able to help a nulli parous woman suffering from anterior PGP from early on in pregnancy with a combination of specific, gentle chiropractic SOT techniques, postural advice and stabilising exercises.

Case history

A 36 year old, primi gravid woman, who was an existing patient consulted the author due to pre existing low back and shoulder pain at 17 weeks gestation. She reported anterior pelvic girdle pain in the symphysis pubis region from 11-12 weeks gestation. It had progressively worsened in the last week. There was no history of obvious injury or trauma to the lumbo-pelvic spine during this period. She had never experienced this pain before. She reported of being involved in a rear end car accident in the past, suffering with "whole body whiplash". There was also a previous snowboard accident 5 years earlier, causing low back and shoulder stiffness. She was a very fit woman with a history of constipation and frequent bouts of cystitis. On the chiropractors' advice she had taken up pilates exercises which had helped her considerably. Her hobbies included gardening, reading, snowboarding and mountain biking. She worked in front of the computer screen as a systems tester. She travelled to work by car or train and this would take up to 1-1 1/2 hours each way.

Chiropractic Examination

Examination revealed an alordotic lumbar spine with the pelvis in flexion. She had good and symptom free active range of movement of the lumbar spine. On supine examination the pelvic girdle was rotated, with the left pubic ramus higher in relationship to the right and the left anterior superior iliac spine (ASIS) were higher and more posterior. Pain was elicited over the SPJ, especially inferiorly at the adductor muscle insertion as well as over the rectus abdominal insertion, superiorly. The pelvic floor muscles close to the SPJ were also very tender as well as the gluteus maximus, medius and piriformis bilaterally. She had restricted movement of the right hip in internal rotation and a short and tight iliopsoas on the right. The anterior hip muscles and ligaments were restricted and taut on palpation and mobility assessment. (See picture 6)

Picture 6) Ligaments of the anterior aspect of the hip joint. (Adapted from Lee 2005)

Chiropractic Care Due to the clinical picture with the symptomatology described above it was deduced that she presented with a mal-aligned pelvic girdle aggravated by pregnancy-induced instability, causing shear, strain and inflammation of the SPJ. Having been involved in the care and management of women with similar unstable conditions it was decided she would be treated with low force techniques such as using SOT blocks (Byfield 2000; DeJarnette 1984; Howatt 1999, Williams S. 2005) in the supine position. This was aimed to reduce the rotational aspect of the pelvis in order to correct the SPJ alignment as well as reducing the open wedge effect of the sacrum, often seen in sacroiliac instability. (See picture 7). The blocks were positioned under the pelvis in such a way to reduce the rotational strain of the whole pelvic girdle and thus level the SPJ and ASIS bilaterally.

Picture 7. Supine blocking. (Tone Tellefsen)

It was felt that a direct adjustment to the SPJ would be contraindicated in this situation as it might further shear the mal-aligned SPJ. It might also be too painful with a direct contact to the SPJ. The authour deemed t this procedure might aggravate the pregnancy-induced form/force closure imbalance. Additionally the patient was treated with gentle mobilisation and myofascial techniques to the sacrum and hips and lower abdominal and uterine fasciae to reduce any other mechanical strain upon the SPJ. The treatment was also correlated with localised muscle work (soft tissue work, trigger point therapy and stretching) to the appropriate pelvic girdle muscles such as the piriformis, glutei group, adductors and ilio-psoas muscles. This was provided either in the lateral recumbent position, leaning over the treatment bench or prone on a pregnancy "doughnut cushion". (See picture 8)

Picture 8) "Doughnut" cushion for pregnant patients. (Tone Tellefsen)

The patient was also adviced to use local cryo-therapy over the SPJ to reduce the inflammation in the area. For home care, she was gently instructed in exercises suitable in pregnancy to improve lumbo-pelvic and lower abdominal strength and stability (Lee 2004; Hyman & Liebenson 1996; Stuge et al. 2004). Some of these exercises were done on the Swiss ball as well as lying over it at home whilst resting.

The patient was given verbal pre natal advice, pregnancy books, and brochures on home care and postural support in relation to pelvic girdle instability. This included: the necessity to stand straight, from feet up to pelvis, reduce lateral movements of the legs and sleeping in the lateral recumbent position with a pillow between her knees at night. The standing Alexander Technique stance was introduced with "soft" knees, relaxed gluteal tension and lumbar lordosis, with weight bearing emphasis on the heels. It is the authors' experience that women suffering with SPD may often be recommended additional pain relief during natural labour or even be offered a Caesarean section as she may experience a higher degree of pain from the descent of the foetal head passing close to the joint during a vaginal delivery. It was therefore essential to educate the patient as much as possible about the anatomy of her lumbo-pelvic spine and how changing positions and posture may encourage an easier labour and birth process and possible reduce the need for medical intervention (Common knowledge charitable trust 2001; Northruup 1998; Sutton & Scott 1997; Tellefsen 2000).

Outcome The patient was treated every week to two weeks initially and made a good and steady progress up until 27 weeks when she reported of left sided leg pain making her leg feeling numb. Discal neurology was not present on examination. On this visit, it was felt that the left sacro-iliac joint was locked and inflamed and indeed needed a gentle side posture adjustment with minimal rotation. This was performed with the lesion side down reducing unwanted shear on the whole pelvic girdle.

She re-injured herself at 29 weeks when she tried to move a heavy mattress on the floor with her foot and thus strained the hip and SPJ again. She was now using crutches, and it was hard for her to ambulate and weight-bear without their help. At this point she also had to do a longer journey in the car, which made her symptoms worse. She now had treatment twice a week using the blocks in the supine position and mobilisation and myofascial release techniques as before. She quickly regained mobility, felt better in the SPJ and did not need the crutches anymore for ambulation. There was also less evidence of swelling over the joint.

During these last ten weeks she had two sessions with two chiropractors working on her together. During these sessions she would lie kneeling over the couch with the abdomen unsupported. The chiropractors would focus on the sacrum, sacro tuberous ligament and SPJ as well as thoraco lumbar junction and L2-3. After these treatments she would feel very much better and find it easier to walk. Her husband was also instructed in massage techniques to release the sacrum in order to prepare for labour and this also helped her general pelvic alignment. The patient went into labour at 38,5 weeks' gestation, 12 hours after her last chiropractic treatment. She had a 6 1/2 hour vaginal delivery with no medical pain relief or intervention. Her pelvis and SPJ was asymptomatic throughout the labour. The patient was monitored over the next six months for general spinal and pelvic alignment. The SPJ remained symptom free during most of this time and would only give her minor discomfort during her monthly periods. During this time she started pilates classes again and felt this helped her to feel stronger in her back and pelvis.

Discussion

The case above is but one of many seen in the practice of the author on a daily basis. As the symptoms started early on in her pregnancy it is possible to assume the pain may be linked with hormonal laxity of the pelvic stabilising ligaments, aggravated by a pre-existing rotational strain of the SPJ. When the abdomen and uterus grew it may also have reduced the supporting effect of the anterior sling muscles acting to stabilise the SPJ. The author believes it would be feasible to see how a mal aligned SPJ due to both rotation of the pelvic girdle and loss of form/force closure due to ligamentous laxity and weight gain could cause pain, dysfunction and the feeling of instability in this region.

Pregnancy is a time of considerable physiological and postural changes within the space of 40 weeks. The localized weight gain of the abdomen and the enlarged breasts will often move the pelvic centre of gravity anterior (Cascioli & Webster 2005; Tellefsen 2000). This may cause lumbo sacral strain and back pain due to the compression of the posterior facet joints and imbalance of the lumbar spine muscles (Tellefsen 2000). Some women may find it hard to stand upright for any length of time and would most likely start to favour leaning on one leg and weight-bear more than the other. This may cause rotation and malalignment of the pelvic girdle. Women with older sibling may also rotate their pelvis by lifting their toddler on their hip. The life of a pregnant woman suffering with SPD and PGP is not necessarily easy. The pain and discomfort varies from low-grade dull ache to acute crippling pain and inability to move about. Women may have difficulty walking upstairs or even on flat surfaces. Stepping into a bath or indeed a car is very hard. Lifting shopping or an older toddler is also very difficult, as is housework. Many women feel almost imprisoned in their own homes as they find it very hard to get out and maintain a normal level of daily life.

As Chiropractors we have found the general public awareness of this condition increasing over the last ten years, but many women are still not getting the appropriate advice or treatment for this. Coupled with the fear of the possible enhanced pain and difficulty in labour this is not a desirable situation for women and one we should try to prevent at the outset.

With the exception of the principles of SOT there was little in the chiropractic literature, which addressed how to manage hyper-mobility of the pelvic girdle. Andrews (2003) used the treatment cases of the author in her Masters research to assess patient response to this type of management. Questionnaires were sent to 23 women suffering from SPD who had been diagnosed and treated with chiropractic care by the author. These women had suffered with SPD during pregnancy and after. The symptoms had started at 16-28 weeks in 62% of the group and at 28-36 weeks in 18,75%. The patients were treated with a combination of pregnancy specific adjustments (if indicated), SOT wedges in the supine position, gentle hip and lumbar spine mobilisation, soft tissue work, advice on stabilising and group exercises, ice packs and posture. The response rate to the questionnaire was 70%. Out of the group, 25% stated that they had complete recovery after treatment and 62,5 % reported moderate recovery. 12,5 % of the group reported a sight recovery whilst no one felt it had made no difference or made it worse. This is the largest group of patients so far which have been assessed for chiropractic treatment with pelvic girdle pain. It may of course have it's limitations since the group was purposive and for convenience chosen from the sample of the one chiropractor.

Conclusion

Pelvic girdle pain is sometimes a crippling and life affecting condition which merits more research and understanding. Much research has already been done into the anatomical and biomechanical properties of the pelvic girdle in pregnancy (Lee 2005; Snijders 1993a; Vleeming et al. 2004) but little has been done scientifically looking at large cohort groups having manual versus sham therapy. Scant research has been done in this arena of chiropractic and osteopathic care and there has only been a few cases presented previously in this way (Andrew and Pedersen 2003; Cassidy 2002; Panarello 2005; Stern 1993). The author proposes a theory to try to explain why some women may suffer with anterior pelvic girdle pain and instability in pregnancy. This is based on the theory of SOT and the research on form and force closure. (Snijders et al 1993a; Vleeming1993 a,b).

The author discusses how she believes that the "self bracing" mechanism seen in normal or optimal pelvic girdle stability may be disrupted in pregnancy and further aggravated by functional and structural mal alignment of the pelvic girdle. This may explain how some women may suffer more than others and furthermore be resistant to traditional management such as using a crutch or a pelvic belt. With this in mind she discusses the management of such a case using the combined principles of SOT as well as education of posture and rehabilitative exercises to strengthen core stability (DeJarnette 1984; Nilsson-Wikmar 2003; Stuge 2004). Perhaps the key is to understand that each pregnant woman has her own individual biomechanical structure and function as well as previous history concerning possible injuries, sports activities, occupation and children just to mention a few. Each woman should therefore be managed and treated individually given her different set of circumstances.

Many chiropractors manage women with this condition on a daily basis but are due to time restraint unable to perform studies into the efficacy of their treatment. There is also the question of how easy it is to study such a diverse group as pregnant women when they may have pain experienced in the same region due to different aetiologies. It would be helpful to undertake further studies looking at co-management of different strategies including: manual therapies, the use of pelvic support belts, postural education and strengthening exercises just to mention a few. This paper has not focused on the examination procedures found specific and effective for assessing pelvic joint stability, but this would be of utmost importance in the Chiropractic field to do in the future. It is also time for the different manual therapy disciplines to come together as in the International Joint committee in Melbourne (Vleeming 2004) and work towards future strategies for better diagnosis and management of this condition.

References