PAIN AND YOU
Before we get to talking about the commonly experienced pregnancy complaint of “Pelvic Girdle Pain”, I want you to view pain through a different lens - one that you may not be used to. There can be many scary symptoms and stories that women are given about pregnancy, labour and the “after baby body”, so let’s start by calling this a normal process and focus on what is within your control when experiencing and managing it.
But first, what are we talking about? Pelvic Girdle Discomfort describes a collection of signs and symptoms of dull or sharp aches and pains experienced anywhere around the front (most commonly the pubic joint) or back of the pelvis (commonly the lumbopelvic or sacroiliac area), and can be on one, or both sides. Symptoms vary from mild discomfort to severe pain that, when acute, can make you freeze mid-stride.
It is most commonly brought on during pregnancy and in the months after birth, but there are other lifestyle and health conditions that it can also be commonly seen in, such as impact injuries, or inflammatory conditions.
In pregnancy, some of the reasons and causes for pelvic pain are thought to include:
Stretch related signals and increases in downward pressure on the pelvic floor muscles, ligaments and other structures around the abdominal area as the belly grows with baby.
A change in the centre of gravity or balance point, which moves forward with baby growing.
And to a less extent, relaxation of ligaments and connective tissue (a natural process to make way for baby) through the action of hormones such as ‘relaxin’.
A WORD ABOUT YOUR PELVIS
The pelvis is a pretty solid and strong structure. It's role is to support the load of the trunk whilst stationary, as well as a support and transfer weight during movement.
The joints of the body rely on many muscles and ligaments to support and control their movement, and the joints of the pelvis usually have very little movement. Whilst pelvic joint movement during pregnancy increases, the extra mobility is still very small. As a structure, the pelvis is extremely durable, and won’t just ‘fall apart’ as a result of pregnancy – as I hear many women fearfully describe.
From infant-hood, movement is learnt in a way most optimal to control the body. In preparation for movement, when there is an expected change in position body segments (both voluntarily,like when choosing to take a step, and involuntarily, like when falling), muscles should switch on to stabilise and protect the body before movement. However, due to the constant changes during pregnancy and the dynamic movements of everyday life, muscles around this area have a lot to keep up with. Occasionally, poor control leads to extra stress being placed on the ligaments, and can lead to inflammation as a response. Kind of like when you roll your ankle - the ligaments are stretched and stressed as a result of the muscles not supporting the joint in time.
How common is it?
The estimated incidence of low back and pelvic girdle pain in pregnancy highly variable, between 4–84%. This is probably because there are so many names and ambiguous diagnostic criteria. Some that you may hear about include pelvic instability, pubic symphysis dysfunction, pubic symphysitis, pelvic Joint syndrome, symphysis pubis dysfunction (SPD), physiological pelvic girdle relaxation, symptom giving pelvic girdle relaxation, posterior pelvic pain, pelvic arthropathy, Inferior Pubic Shear/ Superior Pubic Shear / Symphyseal Shear, symphysiolysis, Sacroiliitis - just to name a few - thanks Wiki.
Basically, a lot of ways to describe something wrong with an area of the that is constantly changing throughout pregnancy. But is this experience of pain, just like many others, just another adaptive response?
We have many threat detection systems that pick-up on changes (I.e. our eyes, ears etc) and allow us to act on information gathered to help us to survive. When it comes to pelvic pain in pregnancy, it can been seen as a survival mechanism where our body aims to protect the life growing within. A signal that there is change, and that we should pay attention.
MANAGING PELVIC PAIN:
The acute phase:
1. Managing the symptoms – pain and inflammation.
Initial symptoms are thought to be related to inflammation and, at the musculoskeletal level, this can often lead to changes in how muscles are recruited and used around the affected area to prevent further damage. If not properly managed, compensatory movement patterns can develop and lead to more long-term challenges.
Here, simple steps such as the well-known RICE (rest, ice, compression, elevation) protocol can apply, like when you sprain an ankle. For the pelvis: Rest and use an ice pack, especially in the first day or two, and book in to see your doctor or physiotherapist. They may be able to provide you with other options for managing inflammation and can recommend treatment options and items such as support belts.
2. Managing the (potential) causes - adjusting your movements.
Initially rest may be necessary to minimise further inflammation and pain, however after a few days, movement is essential. Specific and targeted exercises, as well as modifying common activities in pregnancy, can ensure that movement patterns are learned in the most efficient way possible. Here are some examples:
Moving with your knees together in common activities such as getting in and out of the car, or rolling over in bed.
Find comfortable sleeping positions, and adding props like a pillow between your legs.
Modifying daily tasks – like taking half the washing load out at a time, picking up items (or other children), or getting help with any of these, and generally moving slowly, especially for sideways movements or tasks that involve changing direction.
Your women’s health physiotherapist or exercise physiologist can test for pain or functional disturbances through clinical test and help modify the activities that may be aggravating problem areas for you. They can also teach you targeted exercises for lengthening and strengthening the right muscles.
Long-term and chronic pain:
Around 90% of pelvic discomfort often resolves within three months postpartum. For acute back pain, only 8-15% can be explained by a pathoanatomical (physical) cause and cannot be explained by structural anomalies identified through imaging (such as x-rays or MRI). When it comes to chronic pain (more than 3-6 months) there is even more of a mismatch between the pain signal and tissue damage.
When exploring chronic pain, our words and values around "pain" is much more important than the reasons why pain presented in the first place. I hear so many women talk about their body being 'out of whack' or 'completely ruined' after having a baby, and this is so far from the truth. It is change, and this change brings a whole new life. Words and perception of ourselves have so much more of an impact on our capabilities, both physically and mentally.
As we’ve already said, it is so normal to become more sensitive to the pelvis, and we can see it as an evolutionary and protective mechanism as this is the area that baby is carried in. Your body protecting life... makes sense. Pain is a signal - to stop or modify what you are doing, or maybe just slow down, which is not a bad thing for pregnancy.
If you are being treated for pelvic pain many months after birth, one of the main things to remember is that tests for mobility and instability do no align with levels of pain, and likewise tests for the sensitivity of tissue (provocation tests) does relate to the "instability" of your pelvis. Other than the physiological, hormonal and postural changes, there many other predictors of pelvic pain in pregnancy, which tells us that there is something more than just the physical aspects that cause pain to persist. Some include:
A depressed mood,
Lack of sleep,
Increased life stress factors,
A history of lower back or pelvic girdle pain,
previous injury to the pelvis (like from a fall or accident),
having pelvic girdle pain in a previous pregnancy,
a physically demanding job, but also lack of regular exercise,
increased body mass index,
emotional distress and smoking,
...just to name a few.
There are many health care practitioners who treat pain – your GP, physiotherapist, massage therapist, acupuncturist, chiropractor, or psychologist - to name but a few. Learning to move effectively can therefore come through several different approaches, depending on what works best for you.
Keep in mind that there are plenty of things that take priority post-natally. The best thing you can do is remember that it will simply be a matter of time before you feel like you start to have control of the changes your body goes through. Confidence in your ability is everything, and all you can do is get the right support and give yourself the permission of time. Remember that your body has amazing capabilities, but I don't need to tell you what you already know!
For more on understanding Pelvic Girdle Pain in pregnancy and labour, and therapies that help to manage it effectively see Pregnancy Birth and Baby.