A Paradigm Shift In Pregnancy-Related Pelvic Girdle Pain

The need for a biopsychosocial, whole person framework to manage low back pain and persistent pelvic pain has a strong evidence base and this is also slowly being acknowledged for Pregnancy Pelvic Girdle Pain1.  Based on this, at WMHP we have changed our approach to PPGP, however we are aware a strong biomedical bias in the diagnosis, language and management advice regarding PPGP persists.
The European guidelines for the diagnosis and treatment of pelvic girdle pain (PGP) define PGP as pain arising in relation to pregnancy, trauma, arthritis and osteoarthritis2. Pain is experienced between the posterior iliac crest and the gluteals fold, particularly in the vicinity of the sacroiliac joint. The pain may radiate in the posterior thigh and can also occur in conjunction with/or separately in the symphysis2.
Pregnancy Related Pelvic Girdle Pain (PPGP) is estimated to occur in 56-72% of pregnant women, with 33%–50% reporting symptoms before 20 weeks gestation and 20% reporting severe symptoms from 20–30 weeks gestation3.  It can have a significant impact on quality of life, ability to work throughout pregnancy and can also cause substantial disability and loss of function3
In 2022, a group of Canadian researchers and clinicians published a wonderful infographic that reframes beliefs about PPGP for patients and clinicians4.  They acknowledge that there are many commonly held beliefs about PPGP that actually have no evidence to support them, and in fact, can contribute to PPGP worsening, or persisting for longer periods of time. 
The authors of the infographic have proposed three key concepts to reframe beliefs and management of PPGP4 :
  • Stable: The pelvis is resilient and adaptable to the demands of pregnancy, childbirth and childcare while maintaining its stable structure. 
  • Safe: Postural and pelvic structural changes are normal, safe and necessary to support the growing demands of pregnancy and childbirth. 
  • Self Manageable: Pain education, emotional wellbeing, sleep optimization, exercise and external supports that promote independence are the most helpful strategies to reduce pelvic girdle pain. 
Everyone involved in the care of women during the childbearing year must adopt this evidence-based change in understanding and approach to the diagnosis and management of PPGP and ensure they are not contributing to unhelpful narratives.  We should all consider contemporary pain science and reframe beliefs to promote self-efficacy for those experiencing PPGP.  We at WMHP wholeheartedly agree with the perfectly articulated conclusion drawn by Pulsifer et al:
Early intervention for PPGP is essential to help pregnant 
people make sense of their pain experience, believe in the possibility 
of change and adopt positive lifestyle habits throughout their 
pregnancy for improved health and birth outcomes.

1. Beales D, Slater H, Palsson T, O’Sullivan P. Understanding and managing pelvic girdle pain from a person-centred biopsychosocial perspective Musculoskeletal Science and Practice 2020; 48:102-152

2. Vleeming A, Albert HB, Ostgaard HC, Sturesson B, Stuge B. European guidelines for the diagnosis and treatment of pelvic girdle pain. Eur Spine J. 2008;17(6):794–819.

3. Clinton S, Newell A, Downey P, Ferreira K. Clinical Practice Guidelines Pelvic Girdle Pain in the Antepartum Population: Physical Therapy Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Section on Women's Healthand the Orthopaedic Section of the American Physical Therapy Association Journal of Women's Health Physical Therapy. 2017; ¬ 41(2)¬ p 102–125

4. Pulsifer J, Britnell S, Sim A, et al.  Reframing beliefs and instiling facts for contemporary management of pregnancy- related pelvic girdle pain Br J Sports Med 2022;0:1–2. doi:10.1136/bjsports-2022-105724 

5. Aldabe D, Ribeiro DC, Milosavljevic S and Bussy MD.  Pregnancy-related pelvic girdle pain and its relationship with relaxin levels during pregnancy: a systematic review Eur Spine J. 2012 Sep;21(9):1769-76.

6. Snijders CJ, Vleeming, and Stoeckart R. Transfer of lumbosacral load to iliac bones and legs: Part 1: Biomechanics of self-bracing of the sacroiliac joints and its significance for treatment and exercise. Clinical Biomechanics. 1993; 8(6):285-294

7. Margie H Davenport MH, Andree-Anne Marchand A-A, Michelle F Mottola MF, Veronica J Poitras VJ, Casey E Gray CE, Alejandra Jaramillo Garcia AJ et al. Exercise for the prevention and treatment of low back, pelvic girdle and lumbopelvic pain during pregnancy: a systematic review and meta-analysis. Br J Sports Med. 2019;53(2):90-98. doi: 10.1136/bjsports-2018-099400.  

8. Bjelland EK, Owe KM, Stuge B, Vangen S and Eberhard-Gran M. Breastfeeding and pelvic girdle pain: a follow-up study of 10,603 women 18 months after delivery. BJOG. 2015;122(13):1765-71

9. Bjelland EK, Stuge B, Vangen S, et al. Mode of delivery and persistence of pelvic girdle syndrome 6 months postpartum. Am J Obstet Gynecol. 2013 Apr;208(4):298.e1-

September 2023