Hans Christian Östgaard

European guidelines for the diagnosis and treatment of pelvic girdle pain

A guideline on pelvic girdle pain (PGP) was developed by “Working Group 4” within the framework of the COST ACTION B13 “Low back pain: guidelines for its management”, issued by the European Commission, Research Directorate-General, Department of Policy, Coordination and Strategy. To ensure an evidence-based approach, three subgroups were formed to explore: (a) basic information, (b) diagnostics and epidemiology, and (c) therapeutical interventions. The progress of the subgroups was discussed at each meeting and the final report is based on group consensus. A grading system was used to denote the strength of the evidence, based on the AHCPR Guidelines (1994) and levels of evidence recommended in the method guidelines of the Cochrane Back Review group. It is concluded that PGP is a specific form of low back pain (LBP) that can occur separately or in conjunction with LBP. PGP generally arises in relation to pregnancy, trauma, arthritis and/or osteoarthritis. Uniform definitions are proposed for PGP as well as for joint stability. The point prevalence of pregnant women suffering from PGP is about 20%. Risk factors for developing PGP during pregnancy are most probably a history of previous LBP, and previous trauma to the pelvis. There is agreement that non risk factors are: contraceptive pills, time interval since last pregnancy, height, weight, smoking, and most probably age. PGP can be diagnosed by pain provocation tests (P4/thigh thrust, Patrick’s Faber, Gaenslen’s test, and modified Trendelenburg’s test) and pain palpation tests (long dorsal ligament test and palpation of the symphysis). As a functional test, the active straight leg raise (ASLR) test is recommended. Mobility (palpation) tests, X-rays, CT, scintigraphy, diagnostic injections and diagnostic external pelvic fixation are not recommended. MRI may be used to exclude ankylosing spondylitis and in the case of positive red flags. The recommended treatment includes adequate information and reassurance of the patient, individualized exercises for pregnant women and an individualized multifactorial treatment program for other patients. We recommend medication (excluding pregnant women), if necessary, for pain relief. Recommendations are made for future research on PGP.

Effects of acupuncture and stabilising exercises as adjunct to standard treatment in pregnant women with pelvic girdle pain: randomised single blind controlled trial.

Abstract Objectives To compare the efficacy of standard treatment, standard treatment plus acupuncture, and standard treatment plus stabilising exercises for pelvic girdle pain during pregnancy. Design Randomised single blind controlled trial. Settings East Hospital, Gothenburg, and 27 maternity care centres in Sweden. Participants 386 pregnant women with pelvic girdle pain. Interventions Treatment for six weeks with standard treatment (n = 130), standard treatment plus acupuncture (n = 125), or standard treatment plus stabilising exercises (n = 131). Main outcome measures Primary outcome measure was pain (visual analogue scale); secondary outcome measure was assessment of severity of pelvic girdle pain by an independent examiner before and after treatment. Results After treatment the stabilising exercise group had less pain than the standard group in the morning (median difference = 9, 95% confidence interval 1.7 to 12.8; P = 0.0312) and in the evening (13, 2.7 to 17.5; P = 0.0245). The acupuncture group, in turn, had less pain in the evening than the stabilising exercise group (−14, −18.1 to −3.3; P = 0.0130). Furthermore, the acupuncture group had less pain than the standard treatment group in the morning (12, 5.9 to 17.3; P < 0.001) and in the evening (27, 13.3 to 29.5; P < 0.001). Attenuation of pelvic girdle pain as assessed by the independent examiner was greatest in the acupuncture group. Conclusion Acupuncture and stabilising exercises constitute efficient complements to standard treatment for the management of pelvic girdle pain during pregnancy. Acupuncture was superior to stabilising exercises in this study.

Pelvic Girdle Pain and Lumbar Pain in Pregnancy : A Cohort Study of the Consequences in terms of Health and Functioning

Study Design. A cohort study in pregnancy. Objectives. To differentiate between pregnancy-related pelvic girdle pain (PPGP) and lumbar pain, and to study the prevalence of each syndrome and its consequences in terms of pain, functioning, and health. Summary of Background Data. When studying prevalence, etiology, and consequences, differentiation between PPGP and lumbar pain is important, and, to our knowledge, its consequences for functioning and health during pregnancy have not previously been studied. Methods. All women answered questionnaires (demographic data, EuroQol). Women with lumbopelvic pain completed the Oswestry Disability Index, pain intensity measures, in addition to undergoing a mechanical assessment of the lumbar spine, pain provocation tests, and active straight leg raising test. Results. Of 313 women, 194 had lumbopelvic pain. The PPGP subgroup comprised 54% of those women with lumbopelvic pain, lumbar pain 17%, and combined PPGP and lumbar pain 29%. Women having both PPGP and lumbar pain reported the highest consequences in terms of health and functioning. Conclusions. Pain intensity, disability, and health measurements differentiate subgroups of lumbopelvic pain in pregnancy.

Previous Back Pain and Risk of Developing Back Pain in a Future Pregnancy

Four hundred twenty-nine pregnant women who had back pain before pregnancy and 375 pregnant women with no previous back pain were followed at regular intervals from the 12th week of pregnancy until delivery; back-pain complaints were recorded. Overall, back pain occurred twice as often in the group with a back-pain history (period prevalence) (P < 0.001). The point prevalence of back pain in weeks 12, 24, 30, and 36 was three times higher in the group who had had back pain before pregnancy indicating that pain was not only more prevalent but also lasted longer in that group. Women who had been pregnant previously tended to have an increased risk of back pain, and there was a statistically significant correlation between multiparity and longer periods of back pain (P < 0.001). Young age increased the risk of back pain (P < 0.001). Pain intensity was higher in the younger women during the first part of their pregnancies but not later on (P < 0.05).

Predicting persistent pregnancy-related low back pain.

Study Design. A cohort study. Objective. To examine the course of subtypes of low back pain (LBP) experienced [no LBP, pelvic girdle pain (PGP), lumbar pain, and combined PGP and lumbar pain (combined pain)] during gestational weeks 12 to 18 and 3 months postpartum, and to explore potential predictors for persistent PGP or combined pain postpartum. Summary of Background Data. LBP is more prevalent in pregnant women (25%) than in the general population (6.3%). Persistent LBP postpartum (16%) is usually studied as a single entity. However, only one subgroup of LBP, pelvic girdle pain (PGP), is associated with pregnancy. Several studies have suggested an association between muscular dysfunction and pregnancy-related LBP, however, muscle dysfunction has not been evaluated as potential predictor of persistent LBP postpartum. Possible subgroup differences in the course and predictors of persistent LBP are unknown. Methods. Pregnant women (n = 308) were classified into LBP subgroups by mechanical assessment of the lumbar spine, pelvic pain provocation tests, standard history, and pain drawings. Trunk muscle endurance, hip muscle strength (dynamometer) and gait speed were evaluated. Multiple logistic regression was used to identify predictors from self-reports and clinical examination. Results. Women with combined pain recovered to a lower degree 33% (17 of 51) than those with PGP 66% (56 of 85) or lumbar pain 72% (21 of 29). Predictors for having persistent PGP or combined pain after delivery were low endurance of back flexors, older age, combined pain in early pregnancy and work dissatisfaction (explained variance 30%). Conclusion. Women with combined pain were identified to be a target group since they had the most unfavorable course and since the classification of combined pain was found to be a predictor for persistent pain postpartum. Identification of women at risk for persistent pain postpartum seems possible in early pregnancy and requires physical examination and self-reports. Pregnancy had low impact on the course of lumbar pain.

ASSocIAtIoN BEtWEEN MuScLE FuNctIoN AND LoW BAcK PAIN IN RELAtIoN to PREGNANcY

OBJECTIVE To investigate the association of muscle function and subgroups of low back pain (no low back pain, pelvic girdle pain, lumbar pain and combined pelvic girdle pain and lumbar pain) in relation to pregnancy. DESIGN Prospective cohort study. SUBJECTS Consecutively enrolled pregnant women seen in gestational weeks 12-18 (n = 301) and 3 months postpartum (n = 262). METHODS Classification into subgroups by means of mechanical assessment of the lumbar spine, pelvic pain provocation tests, standard history and a pain drawing. Trunk muscle endurance, hip muscle strength (dynamometer) and gait speed were investigated. RESULTS In pregnancy 116 women had no low back pain, 33% (n = 99) had pelvic girdle pain, 11% (n = 32) had lumbar pain and 18% (n = 54) had combined pelvic girdle pain and lumbar pain. The prevalence of pelvic girdle pain/combined pelvic girdle pain and lumbar pain decreased postpartum, whereas the prevalence of lumbar pain remained stable. Women with pelvic girdle pain and/or combined pelvic girdle pain and lumbar pain had lower values for trunk muscle endurance, hip extension and gait speed as compared to women without low back pain in pregnancy and postpartum (p < 0.001-0.04). Women with pelvic girdle pain throughout the study had lower values of back flexor endurance compared with women without low back pain. CONCLUSION Muscle dysfunction was associated with pelvic girdle pain, which should be taken into consideration when developing treatment strategies and preventive measures.

Treatments of pelvic girdle pain in pregnant women: adverse effects of standard treatment, acupuncture and stabilising exercises on the pregnancy, mother, delivery and the fetus/neonate.

BackgroundPrevious publications indicate that acupuncture is efficient for the treatment of pelvic girdle pain, PGP, in pregnant women. However, the use of acupuncture for PGP is rare due to insufficient documentation of adverse effects of this treatment in this specific condition. The aim of the present work was to assess adverse effects of acupuncture on the pregnancy, mother, delivery and the fetus/neonate in comparison with women that received stabilising exercises as adjunct to standard treatment or standard treatment alone.MethodsIn all, 386 women with PGP entered this controlled, single-blind trial. They were randomly assigned to standard treatment plus acupuncture (n = 125), standard treatment plus specific stabilising exercises (n = 131) or to standard treatment alone (n = 130) for 6 weeks. Acupuncture that may be considered strong was used and treatment was started as early as in the second trimester of pregnancy. Adverse effects were recorded during treatment and throughout the pregnancy. Influence on the fetus was measured with cardiotocography (CTG) before-during and after 43 acupuncture sessions in 43 women. A standardised computerized method to analyze the CTG reading numerically (Oxford 8000, Oxford, England) was used. After treatment, the women rated their overall experience of the treatment and listed adverse events if any in a questionnaire. Data of analgesia and oxytocin augmentation during labour, duration of labour, frequency of preterm birth, operative delivery, Apgar score, cord-blood gas/acid base balance and birth weight were also recorded.ResultsThere were no serious adverse events after any of the treatments. Minor adverse events were common in the acupuncture group but women rated acupuncture favourably even despite this. The computerized or visually assessed CTG analyses of antenatal recordings in connection with acupuncture were all normal.ConclusionThis study shows that acupuncture administered with a stimulation that may be considered strong led to minor adverse complaints from the mothers but had no observable severe adverse influences on the pregnancy, mother, delivery or the fetus/neonate.

Acupuncture as an adjunct to standard treatment for pelvic girdle pain in pregnant women: randomised double‐blinded controlled trial comparing acupuncture with non‐penetrating sham acupuncture

Objective  To investigate whether acupuncture has a greater treatment effect than non‐penetrating sham acupuncture in women with pelvic girdle pain (PGP) during pregnancy.

Regression of pelvic girdle pain after delivery: follow-up of a randomised single blind controlled trial with different treatment modalities.

Objective. An earlier publication showed that acupuncture and stabilising exercises as an adjunct to standard treatment was effective for pelvic girdle pain during pregnancy, but the post‐pregnancy effects of these treatment modalities are unknown. The aim of this follow‐up study was to describe regression of pelvic girdle pain after delivery in these women. Design. A randomised, single blind, controlled trial. Setting. East Hospital and 27 maternity care centres in Göteborg, Sweden. Population. Some 386 pregnant women with pelvic girdle pain. Methods. Participants were randomly assigned to standard treatment plus acupuncture (n = 125), standard treatment plus specific stabilising exercises (n = 131) or to standard treatment alone (n = 130). Main outcome measures. Primary outcome measures: pain intensity (Visual Analogue Scale). Secondary outcome measure: assessment of the severity of pelvic girdle pain by an independent examiner 12 weeks after delivery. Results. Approximately three‐quarters of all the women were free of pain 3 weeks after delivery. There were no differences in recovery between the 3 treatment groups. According to the detailed physical examination, pelvic girdle pain had resolved in 99% of the women 12 weeks after delivery. Conclusions. This study shows that irrespective of treatment modality, regression of pelvic girdle pain occurs in the great majority of women within 12 weeks after delivery.

Effects of craniosacral therapy as adjunct to standard treatment for pelvic girdle pain in pregnant women: a multicenter, single blind, randomized controlled trial

Pelvic girdle pain (PGP) is a disabling condition affecting 30% of pregnant women. The aim of this study was to investigate the efficacy of craniosacral therapy as an adjunct to standard treatment compared with standard treatment alone for PGP during pregnancy.