Differential Diagnosis of Peri-partum Pubic Symphysis ... · Frank separation is considered 10 mm...
Transcript of Differential Diagnosis of Peri-partum Pubic Symphysis ... · Frank separation is considered 10 mm...
8/21/2014
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Jil l Schif f
Boissonnault
PT, PhD, WCS
DIFFERENTIAL DIAGNOSIS
AND MANAGEMENT OF
PUBIC SYMPHYSIS
DYSFUNCTION IN THE
OBSTETRIC CLIENT
By the end of this session the attendee will :
1 . Understand and apply to patient care the pathophysiology of peripartum pubic symphysis dysfunction
2. Select treatment interventions for the above- mentioned musculoskeletal dysfunction in the pregnant and postpartum client .
3. Consider appropriate home programs for clients with such musculoskeletal dysfunction.
4. Appreciate current evidence for the interventions the participants discuss.
OBJECTIVES
Anatomy review and differential diagnosis of
PSD in the perinatal period
Case of “Pubic Instability” or Pelvic Girdle
Pain in pregnancy
Case of Peripartum pubic symphysis
separation
Considerations for labor and delivery for the
woman with PSD
CONTENT PUBIC SYMPHYSIS
Joined by a fibrocartilaginous disc; fibrocartilaginous amphiarthroiss jt. Lined with hyaline cartilege.
Supported superiorly and inferiorly by ligaments
Motion occurs in sagital and frontal planes
Pathology includes
Separation
Instability with potential
‘unleveling’
Osteitis pubis
PATHOLOGY DURING THE CHILDBEARING
YEAR
PERI-PARTUM SEPARATED SYMPHYSIS
PUBIS (OR SYMPHYSOLYSIS OR DIASTASIS
SYMPHYSIS PUBIS)
www.e-radiography.net
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Frank separation is considered 10 mm or >
Pain does not seem to coincide with the degree of separation
Some mild separation (not necessarily painful) is considered normal in pregnancy and during contractions ( Boland 1933, Bjorklund 1997)
Can occur during pregnancy or postpartum Separation related to delivery seems most common, though
stats are unknown
DEFINITION AND PHYSIOLOGY
Prevalence: about 1/600 (range1/30-1/30,000!)
(Bolland 1933, Cappiello 1995, Snow, 1997, Dunivan 2009)
Peri-partum vs. pre-natal incidence-Unknown, but
literature discusses MOI related to delivery
Theoretical MOI
Fetal size
Maternal Position
Stiffness of pubic connective tissue
Rapid fetal descent (Snow 1997)
EPIDEMIOLOGY/PATHOPHYSIOLOGY OF
PERI-PARTUM PUBIC SYMPHYSIS
SEPARATION
Pathology to the pubic symphysis may be the
norm or quite common ( B r a n d o n 2 0 1 2 , H e r m a n n 2 0 0 7 , W u r d i ng e r 2 0 0 2 )
Bone marrow edema (76-86% in Hermann
study)
Fx (27% in Brandon study)
Capsular dysruption (rare)
Separation (rare)
Levator ani tears at the symphysis (common)
EPIDEMIOLOGY/PATHOPHYSIOLOGY OF
PERI-PARTUM PUBIC SYMPHYSIS
SEPARATION, CONT.
Pain management strategies
Post-partum pain medication
Referral to PT
Imaging (Scr iven, 1995)
CT
MRI
US
Radiograph
Surgical stabilization-internal or external (Luger 1995, Dunivan
2009, Osterhof f 2012)
Injections (Schwar tz, 1985)
Spinal cord Stimulator -1 Case ( Idrees 2012)
MEDICAL MANAGEMENT OF PERI-PARTUM
PUBIC SYMPHYSIS SEPARATION
Patient Interview Findings
Aggravation:
Transitional movements
Bed mobility
Hip abduction
Alleviation
Rest, Ice, Pain Relievers, Support belt, avoidance of weight shift (rolling walker)
Pain: Intense
Location at pubis with radiation into thighs, groin, perineum
COMMON SYMPTOM PRESENTATION
Frontal Plane Movement
that goes beyond physiologic
expectations
Superior of Inferior Shears
PUBIC SHEARS
www.docstoc.com
quizlet.com
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Patient Interview Findings
Aggravation:
Transitional movements
Bed mobility
Alleviation
Rest, Ice, Pain Relievers, Support belt, avoidance of
weight shift
Pain: Not as intense as with a separation
Location at pubis with radiation into thighs, groin,
perineum
COMMON SYMPTOM PRESENTATION-
SHEARS
• Painful, non-
infectious
inflammatory
condition of the
pubic bone and
symphysis
• Etiology: most
l ikely periosteal
trauma is initiating
factor
• Seen in athletes
and postpartum
women and after
urogynecological
surgical procedures
OSTEITIS
PUBIS
www.radpod.org
Present with: • Pain
• “Waddling” gait
• May be accompanied with low grade fever, elevated sed rate,
and mild leukocytosis
Radiographic findings • Reactive Sclerosis
• Rarefaction
• Osteolytic changes
OSTEITIS PUBIS, SIGNS AND SYMPTOMS DIFFERENTIAL DIAGNOSIS OF PERI-PARTUM
GROIN PAIN
Consider osseous, joint and
soft-tissues in the region
&
Obstetric Complications
Ouch!
SI joint
Illium/Ischium
Pubic Symphysis
Low lumbar spine
Hip
Ligaments and discs
Musculature of the
region
ANATOMICAL CONSIDERATIONS SACROILIAC JOINT DYSFUNCTION AS A
SOURCE OF PERI-PARTUM PUBIC/GROIN PAIN
The sacral-iliac joint
can refer pain into
the groin and hip
Positional
dysfunction there
can disrupt the
normal anatomical
structure of the
pubic symphysis
en.wikipedia.org
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ILIUM AS A SOURCE OF SYMPTOMS
Positional
pathology (Ilial
rotations, upslips,
downslips)
www.eorthopod.com
LUMBAR SPINE AND DISC AS A SOURCE OF
SYMPTOMS
Upper lumbar
spine pathology
as pain referral
or radicular
symptoms into
the groin
www.medscape.org
HIP AS A SOURCE OF SYMPTOMS
OA of the hip
Labral tears
Bone Density Issues
Stress Fx
Bursitis
Femoral Acetabular
impingement
Separated Symphysis Pubis
Pubic Shear or unleveling of the
pubis 2◦ hormonally mediated joint instability
Osteitis Pubis
PUBIC SYMPHYSIS PATHOLOGY
Abruption of the placenta
Round ligament pain
Transient Osteoporosis of the Hip
in Pregnancy/Post-Partum
OTHER POTENTIAL OBSTETRIC SOURCES OF
SX
• Definition: placenta peels
away from the inner wal l of
the uterus before del ivery —
either par tial ly or completely
— i t 's known as placental
abruption
• Symptoms:
• Vaginal bleeding
• Abdominal/groin pain
• Back pain
• Uterine tenderness
• Rapid uterine contractions,
often coming one right after
another
ABRUPTION OF THE PLACENTA
www.moondragon.org
http://www.mayoclinic.com/health/placental-
abruption
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• Round ligament pain is sharp or jabbing, often felt in the lower belly or groin area on one or both sides.
• Intermittent in nature
• considered a normal part of pregnancy
• Exercise may cause the pain, as will rapid movements
• Round ligament has contractile tissue running through it; allows for “rebound”
ROUND LIGAMENT PAIN
tummytime.onslow.org
• Self - l imiting nature and
spontaneous recovery
• Fractures are infrequent
• True incidence during
pregnancy is unknown
• Onset: General ly in 3rd
tr imester
• TOH Pain locale: inguinal or
greater trochanteric regions
with referral to anter ior thigh .
• ROM: l imited at the hip
• Functionally restr icted weight
bearing ( B o i s s o n n a u l t , 2 0 0 1 )
TRANSIENT OSTEOPOROSIS OF THE HIP
(TOH) IN PREGNANCY/POSTPARTUM
MUSCLE PATHOLOGY AS A
SOURCE OF SYMPTOMS
Adductors
Iliopsoas
Abdominal obliques
TRIGGER POINTS
ILIUM, ISCHIUM AND MUSCULAR
INFLUENCES AND, CANNOT FORGET THE PELVIC FLOOR AS
A PAIN GENERATOR!
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Perform assessment in positions that the pt. can
tolerate (commonly supine only, if pp)
Goal of R/O structures above and below the CC (i.e.,
pubis)
Clear L-S, SI jts, Hips, Ilia
Use pt. report to R/O abruption, round ligament
Assess for muscle pathology if Hx and Physical Exam
lead you that way
Perform an internal assessment of PF if needed
PERFORM A LOWER QUARTER SCREENING
EXAM WITH SOME SPECIAL TESTS
Physical Exam
ASLR (Mens 2012): Research shows it to be better to detect
SI-jt pain, but can be sensitive to this
Palpation of symphysis (Vleeming 2008, Albert2001, 2002)
Modified Trendelenburg (Vleeming 2008, Albert2001, 2002)
SPECIAL TESTS AT THE PUBIC SYMPHYSIS
As a provocation
test
Clearing the Sacrum
Includes
Springing the
Sacrum in Sitting,
P4 test supine
PATELLAR PUBIC PERCUSSION TEST
TO R/O STRESS FX, BONE DENSITY ISSUES
Pt. Hx and possible MOI lead you there
R/O all other potential sources of Sx
Springing the pubis or palpation there very
tender
Trendellenburg painful
Bed mobility painful
Hip Abduction painful at Pubis
ASLR may be painful
May be unable to weight bear
AFTER CONSIDERATION/ASSESSMENT OF
VARIOUS PAIN GENERATORS; SETTLING ON
PUBIC SYMPHYSIS
Palpatory assymmetry absent
Attempt to “level out” pubis makes no
change
Essentially a “Rule-Out” Dx
DETERMINATION OF SEPARATION VS. SHEAR
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CASE 1: PUBIC INSTABILITY IN PREGNANCY;
PART OF PELVIC GIRDLE PAIN IN
PREGNANCY
www.aylesburyosteopath.co.uk
EPIDEMIOLOGY OF PELVIC GIRDLE PAIN IN
PREGNANCY
1460 women who formed incidence cohort, assessed at 33 wks gestation
1. Women who reported daily pain that could be objectively confirmed was 20.1%
Sub-grouped as follows:
Pelvic girdle syndrome (pain in all 3 joints) (6.0%)
Symphysioloysis (2.3%)
One-sided a sacroiliac syndrome (5.5%)
Double-sided sacroiliac syndrome (6.3%)
Misc (sx not objectively confirmed)
(Albert, 2002)
Parity ↑ Odds Ratio of having PGP in pregnancy
(Bjelland, 2010)
PROGNOSIS FOR OBSTETRIC PELVIC GIRDLE
PAIN
(Albert et al, 2001)
Cohort of 1789 women initially assessed at 33 wks
These women were re -examined (questionnaire and physical
exam) at regular
intervals for 2 years after delivery or until sx disappeared
At 2 yr postpartum, 21% with pelvic girdle syndrome (pain in
all 3 joints) stil l had pain
Indicators of highest relative risk for long term pain
High number of positive tests
Low mobility index
Conclusion: women with pelvic girdle syndrome or pain in all 3
joints, had poorest prognosis
MEDICAL MANAGEMENT OF PELVIC GIRDLE
PAIN IN PREGNANCY ’
Pain Medications
Belts and Supports-off the
shelf type
Referral to PT
PATIENT HX/INTERVIEW - PGP IN
PREGNANCY
Typical order of difficult ADLs for severe PGP listing most to
least:
standing still,
cycling,
walking,
sitting,
and lying
(Ronchett i , 2008)
Pelvic Girdle Pain Questionnaire : Self-
reported questionnaire that is condition specific for PGP
util iz ing 2 scales (activit ies/participation and symptoms);
highly reliable and valid in women with PGP during and after
pregnancy
(Stuge, 2011)
:
Ronchetti, 2008
P4 (Posterior pelvic
pain provocation test)
ASLR
Long dorsal ligament
tests
Quebec Back Pain
Disability Scale)
European Guidelines for PGP
SIJ Pain :
P4/thigh thrust
Patrick’s Faber test,
Palpation of the long dorsal SIJ ligament,
Gaenslen´s test.
Symphysis Palpation of the symphysis
Modified Trendelenburg test of the pelvic girdle
Functional pelvic test Active straight leg raise test
(V leeming, 2008)
PHYSICAL EXAM ASSESSMENT- PGP
IN PREGNANCY
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EBP FOR PT INTERVENTIONS- PGP/PUBIC
SHEAR IN PREGNANCY
Contraction of TRa ↓ laxity of SI-jt;
drawing-in maneuver ↓ laxity of SI-jt
(Richardson, 2002)
Systematic Reviews support use of
exercise for treatment or prevention of
PGP either alone or in combination with
acupuncture, advice and/or belts
(Boissonnault 2012, Stuge 2003)
EXERCISE FOR THE PGP/PUBIC SHEAR
CASE
Isolated activation of deep, local muscle system with
integration into all transitional movements: abdominal
drawing-in
Spine stabilization exercises in various positions: sidelying,
quadruped, Upright kneel
Functional Lower extremity strengthening with equal -
bilateral weight bearing: E.G., sit to stand, Rising and
lowering to half-kneel
Trunk/Pelvic girdle strengthening: anterior-posterior t i lt ing
standing, gluteus maximus, gluteus medius, back extensors
Fitness advice: which activit ies or machines?
EDUCATION FOR PGP/PUBIC SHEAR CASE
To ↓ catastrophizing and fear beliefs
use of FABQ and other self-administered
questionnaires can provide evidence for
the intervention
To empower self-management of the
condition
ADVICE FOR PGP/PUBIC SHEAR CASE
Postural alignment
Body mechanics
sleeping positions
ADLs (e.g., laundry, grocery-shopping)
Symmetrical movement
Sit-to-stand
Bed mobility
Isometric use of Adductors or Abductors in transitional activities (rolling, shifting)
Use of heat/ice (ice, especially over symphysis pubis)
MANUAL THERAPY OPTIONS FOR
PGP/PUBIC SHEAR CASE
Muscle Energy Rx
Direct Jt-mob to Sacral bases, ILAs
STM about posterior pelvis
(Murphy 2009, Licciardone 2010, George
2012)
BELTS/SUPPORTS AND GAIT AIDS
Support garments for Pelvic Girdle Pain: some
evidence for use
(Carr 2003, Mens 2006 , Ho 2009)
Consider assistive gait aid if gait continues to
be aggravating
Forearm crutches
Rolling walker
scooter
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THE CASE
30 yr old Gravida 2, para 1, @ 14 weeks gestation.
Has a 3-yr old dtr., and is a University professor
CC: pubic pain with occasional Left and Right SI-jt
pain
Hx of CC: Began @ 8 weeks and has worsened. Has
similar pain (less intense) in first pregnancy that
abated between pregnancies.
Pt. Goals: To continue working and exercising as
she does now.
FINDINGS OF PT. INTERVIEW: PGP/PUBIC
SHEAR
Rates pain 2/10-7/10
Location: “my groin, my left upper thigh and buttock and
sometimes after a really long day with lots of t ime on my feet
my left rear-end dimple and sometimes the same place on the
right”
Nature: Can be sharp (intermittent) or achey (can be constant
once it comes on).
Agg: climbing hill from parking ramp to office, roll ing over in
bed, walking > 10 min, sit -to-stand after sitt ing > 45 min
Alev: NWB rest, ice, Tylenol
PHYSICAL EXAM FINDINGS IN
PGP/PUBIC SHEAR CASE
Gait: antalgic and waddling a bit
Standing posture: unremarkable
Position testing in sitting: a superior left pubic
shear & Left on Left Sacral torsion
Palpation: painful over pubis. Painful also at Left
and Right SI jts over sacral sulci; Left dorsal
ligament painful
ASLR and P4+ on the left; weight shift onto L LE
provokes sharp groin pain and a duller, L -sided
posterior pain
Pubis Palpation
(or Springing)
for Tenderness
Asymmetric
Straight Leg
Raise Test-In
this Case, for
Trunk
Instability
MET to correct pubic shear
and sacral torsion; Direct
mobilization in sitt ing @
Left ILA
Exercise
Stabilization: trunk ex in 4
point
Strengthening ex: standing
pelvic tilts, TRa in 4-point
& sitting, glut medius
strengthening with
theraband, glut max
strengthening in 4-point
Body mechanics instruction
Sleep: get soft mattress pad and squeeze pillow between legs to roll and shift
Lifting 3-yr old
Postural alignment
Sleep with pillow between knees and avoid assymmetric sleeping postures
Sitting @ desk: avoid crossing LE’s; got her a foot rest and a work chair back support
PT INTERVENTIONS FOR PGP/PUBIC
SHEAR CASE
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MET: SUPERIOR PUBIC SHEAR CORRECTION
Greenman, PE. Principles of Manual Medicine
ASSESSMENT OF SACRAL BASE POSITION
IN SITTING
ASSESSMENT OF SACRAL BASE POSITION IN
4-POINT
MET: FORWARD SACRAL TORSION
CORRECTION
DIRECT MOBILIZATION IN SITTING FOR A
‘R ON R’ FORWARD SACRAL TORSION
Symmetrical movement
instruction
Sit-to-stand: symmetry
and/or with isometric
adduction or abduction
Ice to SI-jts and/or pubis
at home, prn
SI-belt: Found it helpful if
doing chores requiring
WB > 15 min. Preferred
Serola Belt (Serola.net)
Discussed fitness
program:
encouraged her to move
to aqua class/exercise
vs. land-based running
and zumba classes.
Self-mobilization for
pubic shear (supine)
and SI-Jt pain (seated
and standing)
PT INTERVENTIONS FOR PGP/PUBIC SHEAR
CASE, CONT.
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Self-
Mobilization
Of Pubis in
Sitting
SELF-MOBILIZATION OF A RIGHT SUPERIOR
PUBIC SHEAR (ALSO OF A POSTERIORLY
ROTATED RIGHT ILIUM)
SELF MOBILIZATION OF THE SACRUM PELVIC STABILIZATION VIA ADDUCTOR
SQUEEZE TO ASSIST IN ↓ PAIN WITH ROLLING
ROLLING WITH ISOMETRIC HIP ABDUCTION
SUPPORT BELT FOR PGP
IEM Maternity Sacroilic (SI) Support
iemortho.com
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CASE 2: SEPARATED SYMPHYSIS PUBIS (OR
SYMPHYSOLYSIS OR DIASTASIS SYMPHYSIS
PUBIS) DURING DELIVERY
www.e-radiography.net
28 yr old Gr 1 para 1, 26 hours postpartum, S/P vaginal delivery. Pt is a hospital RN
CC: excruciating pubic and groin pain, 9-10/10
Hx of CC: Pain began pp when pt attempted to stand to use toilet. Unsuccessful. Was catheterized and put on bedrest. PT referral initialized by nursing staff
In 2nd stage, spouse reported hearing a gun-shot-like pop as pt. pulled forward on squat bar while she was in semi-reclining & instructed to put feet on squat bar
MD ordered radiograph: 3 cm separation seen
Past Hx: no previous c/o pubic pain in pregnancy or prior to pregnancy
Pt lives with spouse in a two-story home
THE CASE
PATIENT INTERVIEW FINDINGS- MEDICAL
MANAGEMENT OF PERI-PARTUM PUBIC
SYMPHYSIS SEPARATION
Pain Location: at Pubis and up into groin bilaterally
with some ache in Left SI -jt
Nature: Sharp
Agg: Any bed mobility or attempt at WB or to move
legs
Alev: lying still, pain meds
Pt. Goals: able to return home, use stairs, care for
newborn, perform IADLs, RTW in 6 weeks as RN.
Pain management.
PHYSICAL EXAM FINDINGS- SEPARATED
SYMPHYSIS PUBIS DURING DELIVERY
Movement Assessment: Pt. could not roll, scoot or shift
in bed without pain > 6/10
Posture: WB unsuccessful without trochanteric belt
Mobility: with rolling walker and belt Pt. able to
ambulate for short distances with <4/10 pain
Palpation: exquisite pain at pubis -could not assess
position
Did not attempt additional physical assessment
IN-HOSPITAL PT INTERVENTIONS- SEPARATED
SYMPHYSIS PUBIS DURING DELIVERY
Gait: Rolling walker (parameters given); stairs -none if
possible; if necessary, consider going up and down on bottom
or at least foot -to-foot.
Pelvic support belt (parameters given)
Bed mobility training (log roll , use of adductor squeeze -gentle-
with pil low)
Soft mattress pad
Discussion on activity level:
With spouse present
Minimize WB; baby brought to her; no IADLs
3 weeks need for assistance
Appt. made for 6 wk FU in PT
OP PT PHYSICAL EXAM FINDINGS- SEPARATED
SYMPHYSIS PUBIS DURING DELIVERY
Palpation:
Left inferior sacral shear
Left superior pube
Tenderness still at pubis and at left SI-Jt
Pain with weight shift in standing
ASLR +
Did not attempt P4
Some fear avoidance (not formally assessed)
(Waddell 1993)
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OP PT INTERVENTIONS- SEPARATED
SYMPHYSIS PUBIS DURING DELIVERY
MET to correct pubic shear
MET to correct sacral shear
Self-mobilization for pubis and sacrum
HEP for Pelvic stabilization exercises
Seated
Standing on step
Glut, abdominal and back extensor strengthening
Encouraged continued use of pelvic belt, especially
when out of the house
Pubis Palpation
(or Springing)
for Tenderness
Asymmetric
Straight Leg
Raise Test-In
this Case, for
Trunk
Instability
MET: SUPERIOR PUBIC SHEAR CORRECTION
Greenman, PE. Principles of Manual Medicine
SELF-MOBILIZATION OF A RIGHT SUPERIOR
PUBIC SHEAR (ALSO OF A POSTERIORLY
ROTATED RIGHT ILIUM)
SELF MOBILIZATION OF THE SACRUM
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POST PUBIC SYMPHYSIS SEPARATION
BEGINNING STABILIZATION EXERCISE PT RECOMMENDATIONS FOR L&D- PELVIC
GIRDLE PAIN IN PREGNANCY
First Stage
Minimize walking
Avoid asymetric postures
Second Stage
Support LE’s, if semi-reclining, with pillows
folded under knees
Avoid WB postures if these provoke Sx (e.g., 4-
point, upright kneel)
Avoid squatting, especially if pain is @ pubis
PERI-PARTUM SEPARATED SYMPHYSIS PUBIS
REFERENCES
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D e p l e d g e J , M c N a i r P J , K e a l - S m i t h C , W i l l i a m s M . M a n a g e m e n t o f s y m p h y s i s p u b i s d y s f u n c t i o n d u r i n g p r e g n a n c y u s i n g e x e r c i s e a n d p e l v i c s u p p o r t b e l t s . P h y s T h e r . 2 0 0 5 D e c ; 8 5 ( 1 2 ) : 1 2 9 0 - 3 0 0 .
G a r a g i o l a D , T a r v e r R , G i b s o n L , R o g e r s R , W a s s J . A n a t o m i c c h a n g e i n t h e p e l v i s a f t e r u n c o m p l i c a t e d v a g i n a l d e l i v e r y : a C T s t u d y o n 1 4 w o m e n . A J R A m J R o e n t g e n o l 1 9 8 9 ; 1 5 3 : 1 2 3 9 – 1 2 4 1 .
H e r m a n n K G , H a l l e H , R e i s s h a u e r A , S c h i n k T , V s i a n s k a L , M u ¨ h l e r M R , L e m b c k e A , H a m m B , B o l l o w M . P e r i p a r t u m c h a n g e s o f t h e p e l v i c r i n g : u s e f u l n e s s o f m a g n e t i c r e s o n a n c e i m a g i n g . R o f o 2 0 0 7 ; 1 7 9 : 1 2 4 3 – 1 2 5 0 .
I d r e e s A . M a n a g e m e n t o f c h r o n i c s y m p h y s i s p u b i s p a i n f o l l o w i n g c h i l d b i r t h w i t h s p i n a l c o r d s t i m u l a t o r . J o u r n a l o f t h e P a k i s t a n M e d i c a l A s s o c i a t i o n 2 0 1 2 ; 6 2 ( 1 ) : 7 1 - 7 3 .
L e a d b e t t e r R E , M a w e r D , L i n d o w S . S y m p h y s i s p u b i s d y s f u n c t i o n : a r e v i e w o f t h e l i t e r a t u r e . J M a t e r n F e t a l N e o n a t a l M e d 2 0 0 4 ; 1 6 : 3 4 9 –3 5 4 .
L u g e r E , E l c h a n a n J , A r b e l R , D e k e l S . T r a u m a t i c S e p a r a t i o n o f t h e S y m p h y s i s P u b i s d u r i n g P r e g n a n c y : A C a s e R e p o r t . T h e J o u r n a l o f T r a u m a : I n j u r y , I n f e c t i o n , a n d C r i t i c a l C a r e 3 8 ( 2 ) : 1 9 9 5 , 2 5 5 - 2 5 6 .
M e n s J M , H u i s I n ' t V e l d Y H , P o o l - G o u d z w a a r d A . T h e A c t i v e S t r a i g h t L e g R a i s e t e s t i n l u m b o p e l v i c p a i n d u r i n g p r e g n a n c y . M a n T h e r . 2 0 1 2 A u g ; 1 7 ( 4 ) : 3 6 4 - 8 .
O s t e r h o f f G , O s s e n d o r f C , O s s e n d o r f - K i m m i c h N , Z i m m e r m a n n R , W a n n e r G A , S i m m e n H P , W e r n e r C M . S u r g i c a l s t a b i l i z a t i o n o f p o s t p a r t u m s y m p h y s e a l i n s t a b i l i t y : t w o c a s e s a n d a r e v i e w o f t h e l i t e r a t u r e . G y n e c o l O b s t e t I n v e s t . 2 0 1 2 ; 7 3 ( 1 ) : 1 - 7 .
S c h w a r t z Z , K a t z Z , L a n c e t M : M a n a g e m e n t o f p u e r p e r a l s e p a r a t i o n o f t h e s y m p h y s i s p u b i s . I n t J G y n e c o l O b s t e t 2 3 : 1 2 5 , 1 9 8 5
S c r i v e n M W , J o n e s D A , M c K n i g h t L . T h e i m p o r t a n c e o f p u b i c p a i n f o l l o w i n g c h i l d b i r t h : a c l i n i c a l a n d u l t r a s o n o g r a p h i c s t u d y o f d i a s t a s i s o f t h e p u b i c s y m p h y s i s . J R S o c M e d 1 9 9 5 ; 8 8 : 2 8 - 3 0 .
S n o w R E , N e u b e r t A G . P e r i p a r t u m p u b i c s y m p h y s i s s e p a r a t i o n : b o x s e r i e s a n d r e v i e w o f l i t e r a t u r e . O b s t e t G y n e c o l S u r v 1 9 9 7 ; 5 2 : 4 3 8 - 4 3 .
S t u g e B , H i l d e G , V o l l e s t a d N . P h y s i c a l t h e r a p y f o r p r e g n a n c y - r e l a t e d l o w b a c k a n d p e l v i c p a i n : a s y s t e m a t i c r e v i e w . A c t a O b s t e t G y n e c o l S c a n d . 2 0 0 3 ; 8 2 : 9 8 3 - 9 9 0 .
V l e e m i n g A , A l b e r t H B , O s t g a a r d H C , S t u r e s s o n B , S t u g e B . E u r o p e a n g u i d e l i n e s f o r t h e d i a g n o s i s a n d t r e a t m e n t o f p e l v i c g i r d l e p a i n . E u r S p i n e J . 2 0 0 8 ; 1 7 : 7 9 4 - 8 1 9 .
W a d d e l l G , N e w t o n M , H e n d e r s o n I , e t a l . A F e a r - A v o i d a n c e B e l i e f s Q u e s t i o n n a i r e ( F A B Q ) a n d t h e r o l e o f f e a r - a v o i d a n c e b e l i e f s i n c h r o n i c l o w b a c k p a i n a n d d i s a b i l i t y . P a i n . 1 9 9 3 ; 5 2 : 1 5 7 – 1 6 8 .
W u r d i n g e r S , H u m b s c h K , R e i c h e n b a c h J R , P e l k e r G , S e e w a l d H J , K a i s e r W A . M R I o f t h e p e l v i c r i n g j o i n t s p o s t p a r t u m : n o r m a l a n d p a t h o l o g i c a l f i n d i n g s . J M a g n R e s o n I m a g i n g 2 0 0 2 ; 1 5 : 3 2 4 – 3 2 9 .
A s s o c i at i on o f t h e C h a r t e r e d S o c i e t y o f P h y s i o t he r ap i s t s i n W o m e n ’ s H e a l t h : P r e g n an cy R e l a t e d P e l v i c
g i r d l e P a i n , L o n d on , 2 0 0 7 , A s s o c i at i on o f C h a r t e r e d P h y s i o t he r ap i s t s i n W o m e n ’s H e a l t h .
A l b e r t H , G o d s k e se n M , W e s t e r g a ar d J . P r o g n os i s i n f o u r s y n d r om e s o f p r e g n a nc y - r e l at e d p e l v i c p a i n .
A c t a O b s t e t G y n e c o l S c a n d . 2 0 0 1 ; 8 0 ( 6) :5 0 5 - 1 0.
A l b e r t H B , G o d s k e se n M , W e s t e r g aa r d J G . I n c i d e nc e o f f o u r s y n d r om e s o f p r e g n an cy r e l a t e d p e l v i c
j o i n t p a i n . S p i n e . 2 0 0 2 ; 2 7 ( 2 4 ) : 2 8 31 - 4
B j o r k l a nd K , L i n d g r e n P G , B e r g s t r om S , U l m s t e n U . s o n o g r aph i c a s s e ss m e nt o f s y m p h y s e al j o i n t
d i s t e n s i on i n t r a p a r t u m . A c t a O b s t e t G y n e c o l s c a n d i n av i c a 1 9 9 7 . 7 6 ( 3 ) : 2 2 7 - 3 2 .
B o i s s on nau l t W G , B o i s s on na ul t J S . T r a n s i e n t O s t e op or os i s o f t h e H i p A s s o c i at e d w i t h P r e g n a nc y
J O S P T . 2 0 0 1 ; 3 1 ( 7) :3 5 9 - 3 67
B o i s s on nau l t J S , K l e s t i n s k i J U , P e a r c y K . T h e r o l e o f e x e r c i se i n t h e m a n a g e m e nt o f p e l v i c g i r d l e a n d
l o w b a c k p a i n i n p r e g n a nc y : a s y s t e m a t i c r e v i e w o f t h e l i t e r a t u r e . J o f W o m H e a l t h P T . 2 0 1 2 ; 3 6 ( 2 ) : 6 9 -
7 7 .
B o l a n d B F : S e p a r a t i on o f s y m p h y s i s p u b i s : r e p o r t o f t e n c a s e s o c c u r r i ng d u r i n g d e l i v e r y , N E n g l J M e d
2 0 8 : 4 3 1 - 4 3 8, 1 9 3 3 .
B r a n d on C , J a c o b son J A , L o w L K , P a r k L , D e L a n c e y J , M i l l e r J . P u b i c b o n e i n j u r i e s i n p r i m i p a r ous
w o m e n: m a g n e t i c r e s o nan ce i m a g i n g i n d e t e c t i o n a n d d i f f e r e n t i a l d i a g n o s i s o f s t r u c t ur a l i n j u r y .
U l t r a s o un d O b s t e t G y n e c o l . 2 0 1 2 A p r ; 3 9 ( 4 ) : 4 44 - 51
C a p p i e l l o G A , O l i v e r B C : R u p t u r e o f s y m p h y s i s p u b i s c a u s e d b y f o r c e fu l a n d e x c e s s i v e a b d u c t i on o f t h e
t h i g h s w i t h l a b o r e p i d u r a l a n e s t h e s i a , J F l o r i d a M e d A s s o c 8 2 : 4 3 8 - 4 4 3, 1 9 9 5 .
D e S t e f an o L , G r e e nm a n P . G r e e nm an ’ s p r i n c i p l e s o f m a n u a l m e d i c i ne . B a l t i m o r e , M D : L i p p i n c o tt
W i l l i a m s & W i l k i n s / W ol l t e r s K l u w e r , 2 0 1 1 .
D u n i v a n G C , H i c k m a n A M , C o n n o l l y A . S e v e r e s e p a r at i on o f t h e p u b i c s y m p h y s i s a n d p r o m pt
o r t h o p e di c s u r g i c a l i n t e r v e nt i on . O b s t e t G y n e c o l . 2 0 0 9 A u g ; 1 1 4 ( 2 P t 2 ) : 4 7 3 - 5 .
D e p l e d g e J , M c N a i r P J , K e a l - S m i t h C , W i l l i a m s M . M a n a g e m e n t o f s y m p h y s i s p u b i s d y s f u n c t i on d u r i n g
p r e g n a nc y u s i n g e x e r c i s e a n d p e l v i c s u p p o r t b e l t s . P h y s T h e r . 2 0 0 5 D e c ; 8 5 ( 1 2) : 12 90 - 3 00 .
G a r a g i o l a D , T a r v e r R , G i b s o n L , R o g e r s R , W a s s J . A n a t o m i c c h a n g e i n t h e p e l v i s a f t e r u n c o m pl i c a te d
v a g i n a l d e l i v e r y : a C T s t u d y o n 1 4 w o m e n. A J R A m J R o e n t ge no l 1 9 8 9 ; 1 5 3 : 1 2 3 9 – 1 2 4 1 .
PERI-PARTUM PUBIC SYMPHYSIS
REFERENCES
H e r m a n n K G , H a l l e H , R e i s s h a u e r A , S c h i n k T , V s i a n s k a L , M u ¨ h l er M R , L e m b c k e A , H a m m B , B o l l o w M . P e r i p a r tu m c h a n g es o f t h e p e l v i c r i n g : u s e f u ln es s o f m a g n e t i c r e s o n a n c e i m a g i n g . R o f o 2 0 0 7 ; 1 7 9 : 1 2 4 3 – 1 2 5 0.
I d r e e s A . M a n a g e m e nt o f c h r o n i c s y m p h ys i s p u b is p a i n f o l l o w i ng c h i l d b i r t h w i t h s p i n a l c o r d s t i m u la t o r . J o u r n a l o f t h e P a k i s t a n M e d i c a l A s s o c i a t io n 2 0 1 2 ; 6 2 ( 1 ) : 7 1 - 7 3 .
L e a d b e t te r R E , M a w e r D , L i n d o w S . S y m p h ys i s p u b i s d y s f u nc t i o n : a r e v i e w o f t h e l i t e r a tu r e. J M a t e r n F e t a l N e o n a t a l M e d 2 0 0 4 ; 1 6 : 3 4 9 – 3 5 4 .
L u g e r E , E l c h a n an J , A r b e l R , D e k e l S . T r a u m a t i c S e p a r a t io n o f t h e S y m p h y s i s P u b i s d u r i n g P r e g n a n c y : A C a s e R e p o r t . T h e J o u r n a l o f T r a u m a: I n j u r y , I n f e c t io n , a n d C r i t i c a l C a r e 3 8 ( 2 ) : 1 9 9 5 , 2 5 5 - 25 6 .
L e n t z S . O s t e i t i s P u b i s : a R e v i e w . O b s t e t a n d G y n e c o l S u r v e y 1 9 9 5 ; 5 0 ( 4 ) : 3 1 0 - 3 1 5 .
M e n s J M , H u i s I n ' t V e l d Y H , P o o l - G o u d z waa rd A . T h e A c t i v e S t r a i g h t L e g R a i s e t e s t i n l u m b o p el v i c p a i n d u r i n g p r e g n a nc y . M a n T h e r . 2 0 1 2 A u g ; 1 7 ( 4) : 36 4 - 8 .
O s t e r h o f f G , O s s e n d o r f C , O s s e n d o r f - K im m ic h N , Z i m m e r m an n R , W a n n e r G A , S i m m e n H P , W e r n e r C M . S u r g i c a l s t a b i l i z a t io n o f p o s t p ar tu m s y m p h ys e a l i n s t a b i l i t y : t w o c a s e s a n d a r e v i e w o f t h e l i t e r a t u re . G y n e c o l O b s t e t I n v e s t . 2 0 1 2 ; 7 3 (1 ) : 1 - 7 .
S c h w a r t z Z , K a t z Z , L a n c e t M : M a n a g e m e nt o f p u e r p e r a l s e p a r a t io n o f t h e s y m p h y s i s p u b is . I n t J G y n e c o l O b s t e t 2 3 : 1 2 5 , 1 9 8 5
S c r i v e n M W , J o n e s D A , M c K n ig h t L . T h e i m p o r tan c e o f p u b ic p a i n f o l l o w i ng c h i l d b i r th : a c l i n i c a l a n d u l t r a so n o g rap h ic s t u d y o f d i a s t a s i s o f t h e p u b ic s y m p h ys i s . J R S o c M e d 1 9 9 5 ; 8 8 : 2 8 - 3 0 .
S n o w R E , N e u b e r t A G . P e r i p a r tu m p u b ic s y m p h y s i s s e p a r a t i o n : b o x s e r i e s a n d r e v i e w o f l i t e r a tu r e. O b s t e t G y n e c o l S u r v 1 9 9 7 ; 5 2 : 4 3 8 - 4 3 .
V l e e m i ng A , A l b e r t H B , O s t g a a r d H C , S t u r e s s o n B , S t u g e B . E u r o p e a n g u i d e l i ne s f o r t h e d i a g n o si s a n d t r e a t m e nt o f p e l v i c g i r d l e p a i n . E u r S p i n e J . 2 0 0 8 ; 1 7: 7 9 4 - 8 19 .
W a d d e l l G , N e w t o n M , H e n d e r s o n I , e t a l . A F e a r - A vo i d anc e B e l i e f s Q u e s t i o n na i re ( F A B Q ) a n d t h e r o l e o f f e a r - avo i d an c e b e l i e f s i n c h r o n i c l o w b a c k p a i n a n d d i s a b i l i t y . P a i n . 1 9 9 3 ; 5 2: 1 57 – 1 68 .
W u r d in g er S , H u m b s c h K , R e i c h e n b ac h J R , P e l k e r G , S e e w a l d H J , K a i s e r W A . M R I o f t h e p e l v i c r i n g j o i n t s p o s t p ar tu m : n o r m a l a n d p a t h o lo g ic a l f i n d ing s . J M a g n R e s o n I m a g i n g 2 0 0 2 ; 1 5 : 3 2 4 – 3 2 9 .
PERI-PARTUM PUBIC SYMPHYSIS
REFERENCES, CONT.
PELVIC GIRDLE PAIN IN PREGNANCY
REFERENCES
A l b e r t H , G o d s k e s e n M , W e s t e r g a a r d J . P r o g n o s i s i n f o u r s y n d r o m e s o f p r e g n a n c y - r e l a t e d p e l v i c p a i n . A c t a O b s t e t G y n e c o l S c a n d . 2 0 0 1 ; 8 0 ( 6 ) : 5 0 5 -1 0 .
A l b e r t H B , G o d s k e s e n M , W e s t e r g a a r d J G . I n c i d e n c e o f f o u r s y n d r o m e s o f p r e g n a n c y r e l a t e d p e l v i c j o i n t p a i n . S p i n e . 2 0 0 2 ; 2 7 ( 2 4 ) : 2 8 3 1 - 4 .
B j e l l a n d E K , A s k i l d A , J o h a n s e n R , E b e r h a r d - G r a n M . P e l v i c g i r d l e p a i n i n p r e g n a n c y : t h e i m p a c t o f p a r i t y . A m J o f O b s t e t G y n e c o l . 2 0 1 0 ; 2 0 3 : 1 4 6 . e 1 - 6 .
B o i s s o n n a u l t J S , K l e s t i n s k i J U , P e a r c y K . T h e r o l e o f e x e r c i s e i n t h e m a n a g e m e n t o f p e l v i c g i r d l e a n d l o w b a c k p a i n i n p r e g n a n c y : a s y s t e m a t i c r e v i e w o f t h e l i t e r a t u r e . J o f W o m H e a l t h P T . 2 0 1 2 ; 3 6 ( 2 ) : 6 9 - 7 7 .
C a r r C A ( 2 0 0 3 ) U s e o f a m a t e r n i t y s u p p o r t b i n d e r f o r r e l i e f o f p r e g n a n c y - r e l a t e d b a c k p a i n . J o u r n a l o f O b s t e t r i c , G y n e c o l o g i c , a n d N e o n a t a l N u r s i n g 3 2 , 4 9 5 – 5 0 2 .
G e o r g e J W , S k a g g s C D , T h o m p s o n P A , N e l s o n D M , G a v a r d J A , G r o s s G A . A r a n d o m i z e d c o n t r o l l e d t r i a l c o m p a r i n g a m u l t i m o d a l i n t e r v e n t i o n a n d s t a n d a r d o b s t e t r i c s c a r e f o r l o w b a c k a n d p e l v i c p a i n i n p r e g n a n c y . A m J O b s t e t G y n e c o l . 2 0 1 2 O c t 2 3 . p i i : S 0 0 0 2 - 9 3 7 8 ( 1 2 ) 0 1 9 6 9 - 2 . d o i : 1 0 . 1 0 1 6 / j . a j o g . 2 0 1 2 . 1 0 . 8 6 9 . [ E p u b a h e a d o f p r i n t ]
H o S S , Y u W W , L a o T T , C h o w D H , C h u n g J W , L i Y . E f f e c t i v e n e s s o f m a t e r n i t y s u p p o r t b e l t s i n r e d u c i n g l o w b a c k p a i n d u r i n g p r e g n a n c y : a r e v i e w . J C l i n N u r s . 2 0 0 9 J u n ; 1 8 ( 1 1 ) : 1 5 2 3 - 3 2 .
L i c c i a r d o n e J C , B u c h a n a n S , H e n s e l K , K i n g H H , F u l d a K G , S t o l l S T . O s t e o p a t h i c m a n i p u l a t i v e t r e a t m e n t o f b a c k p a i n a n d r e l a t e d s y m p t o m s d u r i n g p r e g n a n c y : a r a n d o m i z e d c o n t r o l l e d t r i a l . A m J O b s t e t G y n e c o l 2 0 1 0 ; 2 0 2 : 4 3 . e 1 – 8 .
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j o i n t s . E u r . S p i n e J . 8 , 4 6 8 – 4 7 3 .
M e n s J M , D a m e n L , S n i j d e r s C J , S t a m H J . T h e m e c h a n i c a l e f f e c t o f a p e l v i c b e l t i n p a t i e n t s w i t h p r e g n a n c y - r e l a t e d p e l v i c p a i n . C l i n B i o m e c h 2 0 0 6 ; 2 1 : 1 2 2 - 7 .
M u r p h y D R , H u r w i t z E L , M c G o v e r n E E . O u t c o m e o f p r e g n a n c y - r e l a t e d l u m b o p e l v i c p a i n t r e a t e d a c c o r d i n g t o a d i a g n o s i s - b a s e d d e c i s i o n r u l e : a p r o s p e c t i v e o b s e r v a t i o n a l c o h o r t s t u d y . J M a n i p u l a t i v e P h y s i o l T h e r 2 0 0 9 ; 3 2 :6 1 6 -2 4 .
R o n c h e t t i I , V l e e m i n g A , v a n W i n g e r d e n J P . P h y s i c a l c h a r a c t e r i s t i c s o f w o m e n w i t h s e v e r e p e l v i c g i r d l e p a i n a f t e r p r e g n a n c y : a d e s c r i p t i v e c o h o r t s t u d y . S p i n e , 2 0 0 8 M a r 1 ; 3 3 ( 5 ) : E 1 4 5 - 5 1 .
R i c h a r d s o n C A , S n i j d e r s C J , H i d e s J A , D a m e n L , P a s M S , S t o r m J . T h e r e l a t i o n b e t w e e n t h e t r a n s v e r s u s a b d o m i n i s m u s c l e s , s a c r o i l i a c j o i n t m e c h a n i c s , a n d l o w b a c k p a i n . S p i n e , 2 0 0 2 F e b 1 5 ; 2 7 ( 4 ) : 3 9 9 - 4 0 5 .
S t u g e B , H i l d e G , V o l l e s t a d N . P h y s i c a l t h e r a p y f o r p r e g n a n c y - r e l a t e d l o w b a c k a n d p e l v i c p a i n : a s y s t e m a t i c r e v i e w . A c t a O b s t e t G y n e c o l S c a n d . 2 0 0 3 ; 8 2 : 9 8 3 - 9 9 0 .
S t u g e B , B e r g l a n d A : E v i d e n c e a n d i n d i v i d u a l i z a t i o n : i m p o r t a n t e l e m e n t s i n t r e a t m e n t f o r w o m e n w i t h p o s t p a r t u m p e l v i c g i r d l e p a i n . P h y s i o t h e r T h e o r y a n d P r a c t i c e . 2 0 1 1 ; 2 7 ( 8 ) : 5 5 7 - 5 6 5 .
S t u g e B , G a r r a t t A , K r o g s t a d J e n s s e n H , G r o t l e M . T h e p e l v i c g i r d l e q u e s t i o n n a i r e : a c o n d i t i o n s p e c i f i c i n s t r u m e n t f o r a s s e s s i n g a c t i v i t y l i m i t a t i o n s a n d s y m p t o m s i n p e o p l e w i t h p e l v i c g i r d l e p a i n . P h y s T h e r . 2 0 1 1 ; 9 1 : 1 0 9 6 -1 1 0 8 .
V l e e m i n g A , A l b e r t H B , O s t g a a r d H C , S t u r e s s o n B , S t u g e B . E u r o p e a n g u i d e l i n e s f o r t h e d i a g n o s i s a n d t r e a t m e n t o f p e l v i c g i r d l e p a i n . E u r S p i n e J . 2 0 0 8 ; 1 7 : 7 9 4 -8 1 9 .