Are you experiencing persistent pelvic or low back pain in your pregnancy that limits your ability to be active, perform daily tasks, or produces fear of movement? Have you been told that your pelvis is unstable and possibly separating due to the relaxin hormone? Has this made you fearful to move or give birth? Did you know that these claims are not backed up by evidence and can be quite harmful to your health.
If you have persistent pelvic pain, you may be experiencing Pregnancy Related Pelvic Girdle Pain (PPGP). PPGP is a specific category of pelvic girdle pain experienced in both pregnancy and postpartum that affects approximately 50% of the population. PPGP is caused by biological, psychological and social factors.
You may be experiencing pain at the front of your pelvis in the pubic symphysis region, pain at the level of your sacroiliac joints, diffused pain throughout your pelvis and/or radiating pain into your lower back or the fronts and backs of your legs. This is ongoing pain that may result in altered or limited movement and possible disability. This is not pain that is relieved by a good stretch, a warm bath or a soothing massage.
We used to think that the hormone relaxin was specifically to blame for this pain. We now know that increased levels of relaxin do not corelate to increased levels of pain or disability. There are however hormones that can make a pregnant pelvis more sensitive and heighten or increase pain responses.
Fear and fear responses can be an underlying driver of PPGP. There may be a history of trauma and specifically a history of birth trauma. There is a high correlation with anxiety and depression.
When clinical misinformation (such as your pelvis is unstable), a history of trauma and a sensitized pelvis align, the response may be guarding of both the pelvis and the pelvic floor due to fear. Individuals may become scared to move as they fear their pelvis will not be strong enough to withstand loading. They fear the process of birth due to a traumatic past history, pain and a lack of perceived pelvic stability. This cycle continues to increase their pain and decrease both their mobility and feelings of safety in their bodies. When an individual experiences persistent pain, their nervous system can wind up making them more susceptible to pain. A minimal pain experience can affect the nervous system as a tremendous threat. Their tolerance and resilience to pain is compromised.
Please know that your pelvis is one of the strongest structures in your body! Your pubic symphysis is designed with the intention to form a stable pelvic ring. It is solidly built and robust in nature. It would take a massive blunt force trauma to produce significant disruptions to the pubic symphysis.
Although orthopedic assessment should be performed as best practices to rule out any conditions that may be causing pain, be wary of clinicians who attest they can “fix” your PPGP through the re-alignment of your pelvic bones. We all have natural asymmetries to our pelvic structures. These asymmetries are not the cause of PPGP.
So, what does evidence-based treatment of Pregnancy Related Pelvic Girdle Pain look like?
If you’re seeing a manual therapist, any manual therapy should be performed from the position of calming the nervous system rather than manipulating pelvic alignment. Treatment should not stop there. A case-by-case treatment plan can be developed through a relational therapeutic alliance where both the clinician and the client are active participants. The clinician is engaged in the client’s history, their current beliefs about their pain, and their therapeutic goals.
The clinician can challenge unhelpful beliefs, provide pain related education, and offer referrals for psychotherapy, nutrition and lifestyle coaching. Any other modality that can calm and soothe the nervous system, is helpful at reinforcing a comprehensive treatment plan. Some examples would be yoga, Qi Gong or breathing and meditation practices.
Novel (new) movement has been proven to be one of the most helpful interventions for PPGP. A novel movement sequence developed by Dr. Sinead Dufour (see instructions below) can be very helpful at decreasing the sensitivity of the pelvis, specifically at the joint structures of the pelvis.
This is done through developing symmetry in the pelvis, balancing any structures that may be pulling to one side and providing equilibrium through the soft tissue. Although this is a symmetry sequence, the real benefit to this sequence is that it teaches individuals to find ease in pelvic and core structures that are used to bracing and guarding. It makes movement feel safe once again and therefore has the potential to rewire the brain and challenge unhelpful beliefs.
Please know that there is treatment for PPGP beyond “waiting for the baby to be born”. Being an active participant in your own care is very important. Developing mindful practices that work for you can provide you with tools that can help you develop agency, empowerment and resilience.
The evidence-based information provided in this article is from the research and teaching of Dr. Sinead Dufour PT, PhD, specifically from her course on Pregnancy Related Pelvic Girdle Pain titled: “Reframe Pelvic Girdle Pain: A 21st Century Approach” offered through Reframe Rehab.
Novel Movement Sequence for Pregnancy Related Pelvic Girdle Pain
Developed by Dr. Sinead Dufour
This sequence works best when you are inviting comfort and ease into each exercises, allowing yourself to be light and free. Notice if you have a tendency to either brace or grip your abdomen or pelvis when you are performing the sequence. Give your body permission to let go of this gripping. This includes when you are moving from pose to pose.
For more information, see a step by step written description following these photos.
Begin by lying down on your back.
Bend your knees, placing the soles of your feet on the ground. Slowly bring the soles of your feet together allowing your knees to move out to the sides into butterfly position.
You can place comfortable supports under your knees to decrease the amount of stretch if needed.
Bring your awareness to your breath.
Allow your breath to gently fill your lower rib cage, abdomen and pelvic floor.
See if you can feel a gentle swelling of your perineum on your inhale and a gentle lifting of your perineum on your exhale.
Spend approximately 5 breaths here, or until you feel your pelvic floor release.
From butterfly position, on your exhale, push the pinky toe sides of your feet into the ground. Notice if there is any bracing in your abdominals or pelvis as you do this. Keep your belly and pelvis soft.
On your inhale fully release.
On your inhale, slowly begin to float your knees back together so that the soles of your feet are resting into the floor, knees are bent, feet and knees are touching.
On your exhale, gently kiss the knees together. Notice if there is any bracing or gripping in your abdominals or pelvis while you do this. Keep your belly and pelvis soft.
Inhale to release.
Begin to set up for bridge pose: keep your knees bent, soles of your feet into the ground, and place your feet hip width distance apart, toes are facing forward.
Take your arms down by your side and make sure you can graze your heels with your fingertips.
On your exhale, slowly lift into bridge position. Push your heels into the ground. Glutes should engage.
Inhale to release back down.
See if you can move with ease and comfort, trying not to brace or grip your muscles as you do this. Keep your belly and pelvic soft.
It can be helpful to imagine you are as light as a feather as you lift your pelvis off the ground.