Pelvic Girdle Pain During Pregnancy and as a New …...©Fitwise Physiotherapy 2013 1 Pelvic Girdle...

©Fitwise Physiotherapy 2013 1

Pelvic Girdle Pain During Pregnancy and as a New Mum: Management and Solutions by Gen McGlashan FACP*

*Specialist Continence and Women’s Health Physiotherapist

(As awarded by the Australian College of Physiotherapists in 2010). Co-Director of

Fitwise Physiotherapy, Melbourne, Australia.

2 Pelvic Girdle Pain During Pregnancy and as a New Mum: Management and Solutions. ©Fitwise Physiotherapy 2013

Pelvic Girdle Pain During Pregnancy and as a New Mum: Management and Solutionsby Gen McGlashan FACP*Specialist Continence and Women’s Health Physiotherapist (As awarded by the Australian College of Physiotherapists in 2010). Co-Director of Fitwise Physiotherapy, Melbourne, Australia.


Index: Page

Chapter 1

What is PGP? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4-5

• How common is it?

• What are the causes?

• What are the symptoms?

Chapter 2

How to manage PGP during Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6-9

Chapter 3

PGP in Labour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Chapter 4

How to manage PGP after having a baby . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

• What is the Prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Chapter 5

Tips for coping with your toddler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13-14

Chapter 6

Who can help? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

• Obstetrician

• Physio

• Midwife

• GP

• Psychologist

• Acupuncturist

• Remedial masseur / Myotherapist

• Home help agencies

• Family members

• Friends

Chapter 7

Frequently Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16-17

Recommended Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17


Chapter 1: What is PGP?

PGP stands for Pelvic Girdle Pain. It is also commonly referred to as Pelvic Instability.

Common “Google” terms for PGP are :

• PelvicInstability

• Pubicsymphysitis,pubicsymphysisdysfunction,DiastasisoftheSymphysisPubis(DSP)

• Symphysispubisdysfunction(SPD)

• PelvicJointSyndrome

• PhysiologicalPelvicGirdleRelaxation

• SymptomGivingPelvicGirdleRelaxation

• PosteriorPelvicPain

• PelvicArthropathy

• InferiorPubicShear/SuperiorPubicShear/SymphysealShear

• Symphysiolysis

• Osteitispubis(usuallypostpartum)

• Sacroiliitis

• One-sidedSacroiliacSyndrome/DoubleSidedSacroiliacSyndrome

• Hypermobility

PGPreferstopainfelteitheratthebackofthepelvis,ononeorbothsides,and/orpainoverthepubicjoint.Painisgenerallylocatedbetweenthetopofthepelvisandthebottomofthebuttocks.Painmaybereferredintothebuttockand/ordowntheleg,soit’softenconfusedwithsciatica.

PGPinvolvingthepubicsymphysisjointcanalsoreferpaintothegroin,innerthigh,lowerabdomen,andvaginalarea.

PGPcanbroadlybecategorizedaseither“Specific”or“non-specific”.Forsomepeople,PGPmayresultfromaspecificmedicalcause(eg.pelvicfracture,oraninflammatoryarthritis)whichcanbeidentifiedbydiagnostictests(eg.X-ray,bonescan,bloodtests).However,‘non-specific’PGPismorecommon,andoftenarisesduringorshortlyafterpregnancy.

Asmanyas50%ofwomenexperiencePGPduringpregnancy.Happily,90%ofwomenrecoverfromPGPwithin12monthsofhavingtheirbaby.However,upto10%ofwomencancontinuetohavesignificantPGPanddisability2yearspost-birth.

PGPisaconditionoftenmisdiagnosed,misunderstoodandpoorlymanaged.

What causes PGP during pregnancy and after having a baby?

Duringpregnancytherearemanychangesthatoccurtoyourbodythatchangethewayitworks.Therearetheobviouschangesthatinclude:

• Yourtummygrowing,whichstretchesyourabdomenandstomachmuscles

• Theweightofthebabysittingonyourpelvicfloormusclesthroughoutthepregnancy,providingaslightstretchtothemtoo.

• Yourcentreofgravity,orbalancepoint,movingforwardasyourtummygrows,whichaddsincreasedloadtoyourbackandchallengesyourbalance.

Lessobviousarethehormonalchangesthatoccur,rightfromthefirsttrimester,whichchangesthe‘stretchiness’ofyourligaments.Relaxinisoneofthehormonesresponsiblefor

Chapter 1


thisincreaseinligamentlaxity,asitchangesthecollagenstructureofyourconnectivetissue(whichmakesupligaments).Connectivetissue,includingligaments,helpscontrolyourjointsandsupportyourpelvicfloormuscles.

Jointsrelyonyourmusclestocontroltheirmovement,helpedbytheligamentsaroundthejoint.Theyhaveagood“job-sharing”arrangementtoallowworkdonebyeachcomponenttogivegoodmovementcontrolaroundthejoint.Whenyoubecomepregnant,theligamentsbecomestretchy,andthemusclesneedtoworkalittlehardertomaintaingoodcontrolofthejoints.

Thejointsofthepelvishaveverylittle,almostimperceptiblemovementinthemwhenyouarenotpregnant.Whenyouarepregnantthismovementincreasesandalthoughextremelysmall,itcanbedoublethemovementthatwaspresentpriortopregnancy.

Ifthemusclesaredoingtheirjobproperly,thentheyworkalittleharderandgoodmovementcontrolismaintained.Howeveritisverycommon

inpregnancyforthemusclesnottorecognizetheneedtochangethewaytheywork.Thisleadstopoorcontroloftheextramovementavailabletothejoints,stressingtheligamentsandresultingininflammationandpain.

Itisverysimilartowalkingoververyrocky,unevenground,withyouranklesrollingmorethantheynormallydo,pullingonyourankleligaments–thiswouldresultininflamedandsoreankleligaments.IfyouhavePGP,whenyouhavebeenwalkingaroundyourpelvicjointsmaybesore,astheyhaveexperiencedthesamekindof stress.

Thejointsofthepelvistransfertheloadofourbodyweightfromourlegstoourtrunk,andthentotheotherlegaswewalkaround.Higherloads,suchascarryingaweight(toddler,shopping)orjogging/runningsignificantlyincreasesthedifficultyforyourjointstodothisloadtransferwithgoodcontrol.Aswehavealreadydiscussed,poorcontrolgenerallyresultsinpain!

Asyourtummymusclesstretchthroughoutpregnancy,andtheweightofthebabyincreasesonyourpelvicfloormuscles,itisharderforthemusclestotightenandsupportthepelvicjoints,andthistoocancontributetopoorcontrolofthepelvicjointmovement,andincreasedpain.

What is PGP?


Chapter 2: How to manage PGP during pregnancy:

TherearetwopartstothemanagementapproachofPGPduringpregnancy.

1. Treatingthesymptoms

2. Treatingthecause

Treating the Symptoms:

Aswedescribedinthepreviouschapter,thesymptomsexperiencedwithPGPrelatetoinflammationthatispresentaroundthepelvicjoints.Theinitial(first48hoursorso)managementisthesameasifyouhadsprainedyourankle,anditwasnowsoreandinflamed:

1. Icethejoints,tosettletheinflammation.Iceisappliedoverthesorejoints(backand/orfrontofpelvis)for20minutesatatime.Initiallythisisdoneevery2hours.Youdonotneedtowakeuptoiceovernight,butifyouwakebecauseyouaresore,thenicingwillhelpsettlethepainandenableyoutogetbacktosleep.

2. Restthejointsinitially:bygettingyourbodyweightoffthejointsasmuchaspossible.Thismeanssittingorlyingdownforthe

majorityoftime,for1-3days,dependingonseverity.Positionyourselfcomfortably,withpillowsorcushionssupportingyourlegsandtummyifappropriate.Itisimportantaftertheinitialperiodofrestthatyoucommenceexercising,withspecificexercisesprescribedbyyourphysiotherapist,toensurethemusclesyouneedtohelpcontrolthepelvicjointsareworkingoptimally.Itisimportantbecause,ifyourestallthetime,withoutspecificexercises,themusclesyouneedtohelpwillgetprogressivelyweaker,andyouwillcontinuetogetsorewithlessandlessactivity.

Chapter 2


Why is it important to manage the inflammation?

Goodresearchhasshownthatifyouhavepainand/orinflammation,thebodychangeshowitusesthemusclesinthatarea.Sometimesitforgetstoswitchthemonatall.Othertimesitswitchesthemon,butmuchlaterthantheyneedtocomeonforgoodmovementcontrol.Attimesthebodyswitchesonallthebigmusclesintheareatosplintthejoint,commonlyknownasmusclespasm,creatingnewpain,andpreventinggoodmovementcontrol.

Soyoucanseethatforefficientcontrolofyourpelvicjoints,painandinflammationneedtobekeptatbay!

How is muscle spasm managed?

Musclesthatcommonlygetverytight,andmayspasmwithPGPare:glutealmuscles(yourbutt!),lowerback,innerthigh,hamstrings(backofthigh)andhipflexors(frontofhip/groinarea).

Aswehavedescribed,thereasonthatthepelvicjointsbecomesoreinpregnancyisusuallybecauseofpoormovementcontrol,duetotheeffectpregnancyhasonthebiomechanicsofyourbody.(Neverisyourbodyaschallengedbiomechanicallyaswhenyouarepregnant!)

Treating the cause:

Aswehavedescribed,thereasonthatthepelvicjointsbecomesoreinpregnancyisusuallybecauseofpoormovementcontrol,duetothe

effectpregnancyhasonthebiomechanicsofyourbody.Neverisyourbodyaschallengedbiomechanicallyaswhenyouarepregnant!

Inorderforyourjointstobewellcontrolled,itisvitalthatyouhavegoodawarenessandcontrolofyourdeep“core”muscles.Thatis,yourpelvicfloormuscles,yourdeepabdominalmuscles(TA),andyourdeepbackmuscles(Multifidus).Thesemusclesworkwiththeotherimportantmuscleofthecore,thediaphragm,toprovideastabletrunkandpelvisfromwhichyourarmsandlegscanwork.Ifyouneedtoholdyourbreathtobeabletoactivateyourother3coremuscles,thenyoudonothavegoodmovementcontrol.Youareusingyourdiaphragmto“splint”whenyouholdyourbreathtotryandcontrolyourjoints.Ifyourbodyhastomakeacallregardingwhethertobreatheorcontroljoints,asageneralrule,breathingwillwin!Thisleavesyouwithaproblem,asnowyourjointsarenolongerwellcontrolledandmaygetsore!

Thereforeitisimperativethatyoulearntousethedeepbackandabdominalmuscles,withyourpelvicfloor,whilemaintainingnormalbreathing.

Apelvic support beltmaybeprescribedbyyourphysiotherapisttoimproveyourmovementcontrol.Itisnotagoodideatojust“buyabelt”orborrowawell-meaningfriends’belt.Noteveryoneneedsabelt,andinsomecasesabeltcanmakeyourpainworse.Itisimportanttohavethebeltfittedaspartofanassessmentbyyourphysiotherapisttoensure:

a) youactuallyneedabelt-youmaynot!

b) youhavetherightsizebeltfitted

c) youareinstructedonhowandwhentowearthebelt

Thebeltmustalsobeingoodcondition(ifwornthroughoutapreviouspregnancy,itmaynolongerhavetherightqualitiestodothejobwellforyou).

Tubigripisanelastictubularbandagethatcanbefittedtoweararoundyourtummytogiveitsupport.Ithelpstotakesomeoftheloadofthebaby’sweightoffyourlowerback,andimprovesyourtummymuscles’capacitytogetyouthroughtheday.Youdostillneedtouseyourabdominalmusclestohelpsupportthebaby,butthe

Management during pregnancy


tubigripmeanstheydon’thavetoworkso hardandtheirabilitytocontractismadealittleeasier.

Ice packs are integral to managing PGP throughoutpregnancy.Asdescribedearlier,itisvitaltomanagethepainandinflammatorycomponenttothiscondition.Flexiblegelpacksthatarere-usablearethebesttouse.Itisworthpurchasingoneortwoofthesetokeepinthefreezerasyouaregoingtobeusingtheseonandoffthroughoutyourpregnancy.Althoughfrozenpeasareknowntoworkwellfortheoddinjurythatrequiresice,theyarebulkyandnotwellsuitedtorepeateduse.

Spikey ballsarefantasticforself-massage.Theyenableyoutokeeptightmusclesloose.Yourphysiotherapistcantellyouifitislikelytobeusefulforyouandshowyouhowtousethe

spikeyball.

Exercise:

Yourphysiotherapistmay initially prescribeaperiodof rest to settle yourpain.However,itisimportanttokeepyourmuscles

strong,soafterthisinitialrest,guidedexerciseshouldbeundertaken.Themaintypesofexercisethatareimportanttoaddressarespecificstabilization(movementcontrol)exercises,andcardioexercise(huffandpuffexercise).

Yourphysiotherapistwillexplainwhichformofeachexerciseisappropriateforyou.Thisishighlyindividual.

Cardio exercise:

Walking:Somepeoplewillbeabletocontinuewalkingforexercise,whereasthismaybehighlyproblematicforothers.

SwimmingworkswellformanywomenwithPGP,butgenerallybreaststrokekickshouldbeavoided.Careneedstobetakenwithgettinginandoutofthepool,andwalkingonthewetsurfacesaroundthepool,toavoidslipping.

Cycling: astationarybikeisagoodwaytoexerciseifyoucancontrolyourpelvicmotionwell.Thisinvolveshavingthecorrectseatheightandhandlebarssethigherthanyoumaybeusedto,toaccommodateforyourgrowingbaby.Itisimportantnottoturntheresistanceupsohighthatyouturnthebikeintoastairclimber.Trytokeepevenpressureonbothpedalsthroughoutthesession,makingperfectcircleswiththepedals,notjustpushingdown.

Specific stabilization exercises:

Whenyou’reassessedbyyourphysiotherapist,theywillascertainwhichmusclesyouneedtoparticularlyfocusontoimprovethemovement

Chapter 2


controlofyourpelvicjoints.Fromthis,theywillbeabletowriteyouanexerciseprogramtohelptrainthesemusclestofunctionbetter.Thisisaskillyourbodyneedstomaster.

Normallywhenwelearnanewskill,oncewehavemasteredit,ourbodyremembersexactlywhattodotoreproducethatskilleachtimeitisrequired.Duringpregnancy,becauseyourbodykeepschanging,yourbodystrugglestomastertheskillsrequired.Thepictureyourbrainhasofyourbody,andwhereyourbodyisinspace,neverreallymatchestherealityduringpregnancy.Asyourbodychangesweekly(sometimesdaily!),yourbrainisconstantlyplaying“catchup”.Itisthereforeimportanttoperformtheseexercisesregularly(atleastweekly),toenableyourbrain’spictureofyourbodytomatchupwiththerealityofyouractualpregnantbody,andenabletherightmusclestoberecruitedattherighttime,withtherightintensity.Thisiswhatisrequiredforoptimalmovementcontrol.

General daily activities:

Ifyouhavepoormovementcontrolofyourpelvicjoints,certain activities may aggravate your pain, byoverloadingyourjoints.Generallytheseareactivitiesthatrequirestandingonasingleleg,unevenlyloadingyourpelvicjoints,oroverloadingyourpelvicjoints.

Theseinclude:

1. Pushingashoppingtrolley-worsewhenitisfullyloadedand/orhasatoddlerinit;

2. Standingononelegtogetdressed;

3. Running;

4. Prolongedwalking;

5. Walkingonunevenorsoftground(eg:softsand,bushtracks);

6. Carryingatoddleronyourhip;

7. Gettingin/outofthecar;

8. Vacuuming/mopping.

Management during pregnancy

7


Chapter 3: PGP and Labour:

Ideallyyouwillarriveat“labourday”withyourpainwellmanagedratherthanhavinglimpedtothefinishline(literally!).However,evenifthisisnotthecaseforyou,itisstillpossibletolaboureffectivelywithPGP.Unlessthereisamedicalreasonforyoutohaveacaesariandelivery(adecisionforyouandyourdoctorormidwife)thereisnorequirementforyoutohaveacaesarianforPGP.Yourphysiotherapistwillbeabletoguideyouinrelationtoyourpelvicjointsandlabour/delivery.

Duringlabourtherearealwayspositionsthatwillbemorecomfortablethanothers,andthisishighlyindividual.Whichpositioniscomfortablewillchangethroughoutyourlabour.PGPmaymakesomepositionsuncomfortableforyou,andifthisisthecase,thenkeeptryingdifferentpositionsuntilyoufindonethatiscomfortable.

First Stage Labour:Ifyouareplanningavaginalbirth,thenideallyyouwillwanttostayuprightandactiveduringthefirststageofyourlabour(thedilatingstage).Ifyouhavearrivedat“labourday”withyourpainwellcontrolled,thenstandingwillbeoneofyouroptionsintermsofpositioning.Walkingbetweencontractionsisoftenrecommendedintheearlystagesoflabour,tohelplabourbecomewellestablished.Unlessyourpainhasbeenminimalwhenyoustartlabour,walkingmayovertimemakeyourjointsmoresore.Ifsoyouwouldbebettertostayuprightandmovingbysittingonafitballandleaningontoatableorbedtosupportyourupperbody.Thiswayyourjointsarewellsupported,andyoucanremainmobilebyrockingsidetoside.IfyouhavesignificantPGPatthetimeyoustartlabour,youwillbenefitfrommoresupportedpositions.

Second stage labour:

Duringsecondstageoflabour(thepushinganddeliveringthebabystage)yourlegswillneedtobeapart.Thisisnotaprobleminitself,solongasyourlegsarewellsupportedbyyourbirthassistants(partner,midwife).Itispreferablethatyourlegsarenotpushedwideapartandleanton.Itisalsopreferablethatifyouhaveanepiduralandcan’tfeelorcontrolyourlegs,thatanyonemovingthemforyoumakessuretheyarewellsupported.Thisisbecauseyouwillnotbeabletofeelanypain,andwon’tbeabletoguidethemor“catch”thelegifthepersonholdingitletsgo!

PositionsforpushingyourbabyoutshouldnotbecompromisedbyPGP.Youcanstilldeliveryourbabyinkneeling,eitheron‘all4’s’,orkneelingleaningontosomethingtosupportyourupperbody.Supportedsittingmayalsobeacomfortablepositionforyou.

Afteryourbabyisbornyouwillneedtotakecareofyourpelvicjointsuntilyouregainsensationandcontrolofyourlegsifyouhavehadanepiduraloracaesarian.

Chapter 3 PGP and labour


Chapter 4: Management of PGP after having a baby.

WomenwithPGPareoftentold,“havingthebabyisthecure”.However,thecureisnotimmediate,andrequiressomeworkonyourparttoachieve.Yoursymptoms(particularlypain)aregenerallymuchimprovedimmediatelyafterdelivery,howevertheunderlyingmechanicalchallengeofincreasedmovementavailabletothepelvicjoints,doesn’tstarttoreverseitselfuntilapproximately3weeksafterbirth.

Thehormonerelaxin,partlyresponsibleforthisincreasedmovement,isoutofyoursystemby2-3daysafterbirth.Howevertheincreasedlaxityoftheligamentsremainsforsometime.

Themusclesyouneedtohelpcontrolthisincreasedmovement(particularlyabdominalandpelvicfloormuscles),havebeenoverstretched,andarenotcapableofgoodcontractionsintheearlyweeksafterbirth.Whileyourpregnancy,overstretchedthesemuscles,thebabyheldthemtight,whichgavethemsometensiontohelpcontrolyourpelvicjoints.Thistensionisabsentafterthebirthofyourbaby,leavingyouwithcompromisedpelvicjointcontrol.

Management:

Managementduringthisperiodisprimarilyfocusedonrehabilitatingthefunctionoftheseimportantmuscles.Thepriorityoftheseexercisesistomirroractivitiesormovementsthatwedoeachday.Thiswaythereisoptimaltransferofyourhardworkintoimprovedpelvicjointfunctionthroughoutyourbusyday.

Itisvitalthattheseexercisesareprescribedforyouspecifically,aseachindividualwillhavedifferentneedsandfocustohelpthemachievegoodcontrol.Letyourphysiotherapistknowwhatyourfinalgoalsarewithrespecttoexercise,typeofwork,andphysicalfunction,asthesegoalsareimportantinsettingyourlongtermprogram.

Oftenthereislittleornopainintheearlyweeksafterbirth,whichcanbeduetothemorelimitedactivitylevelthatiscommonatthistime.Asmumsstarttogetmovingmore-exercising,andgenerallybusieroutsidethehouse-itispossibleforthepelvicjointstobecomesore.Itisimportanttostartproperrehabilitationofthecoremusclesassoonasispractical,butpreferablynolaterthan3-6weeksafterthebirthofyourbaby.Itisnevertoolatetorehabilitate

Chapter 4 Management of PGP after having a baby


thesemuscles.Theearlieryoustart,thelesstimethereistodeveloppooruseofyourmuscles,andbadhabitsthatarehardtobreak.

Theprogramprescribedgenerallyrequiresyoutoexercise2-3timesperweek,for20weekstoproperlyrehabilitateyourbody.Thisalsolaysgoodfoundationsforanotherpregnancyifthisisinyourplan.

What is the Prognosis:

Anyongoingpaincaninitiallybemanagedwithicepacks,asforduringpregnancy.Pharmaceuticaloptionsmaynowbeavailable,asyouarenotpregnant,andthesecanbediscussedwithyourGPorobstetrician.

ItiscommontobetoldthatonceyouhavehadPGPinonepregnancy,youwillgetitagainnextpregnancy,butearlierandpossiblyworse.Inour

experience,thishasgenerallynotbeenthecaseforclientswhohaveputinthehardworkaftergivingbirthandpriortothenextpregnancy.

Ifyourehabilitateandrecoverwellafteryourbabyisborn,thenresearchshowsthattheresultsgainedinthefirstsixmonthsofrehabaremaintainedoneandtwoyearslater.Thisisgoodnewsasitmeansthatitisworthdoingthejobproperly,rehabilitatingyourmusclesinthefirstsixmonthsafterbirth.Thisthenpreparesyourbodywellforthephysicalchallengesofmotherhood,aswellasprovidingagoodbaseforafurtherpregnancy.

OnlyaverysmallnumberofwomenwhohavePGPduringtheirpregnancygoontohavepersistentpainlongerterm.Thisisstillverytreatable,howeveritrequiresadifferentapproachtoacutepain.

Chapter 4 Management of PGP after having a baby


Chapter 5: Tips for coping with toddlers:

YourmainaimistoNOTliftyourtoddler.WesaythisrealizingthatitisinevitablethatyouwillhavetimeswhereyouHAVEtoliftyourtoddler,howeverifyouraimisnotto,youwillliftonlywhenthereisNOOTHERCHOICE,ratherthanfromhabit.

Itisalsogoodtogetyourtoddlerusedtonotbeinglifted,withtherationaletheyarea“biggirl/boy”or“mummyhasasoreback”.Ifyouwaitforthearrivalofyourbaby,youhaveababyinyourarmsandoftencan’tliftthem,andyourtoddlerassociatesyounotliftingthemanymorewiththearrivalofthenewbaby.

Tips to avoid lifting toddlers:

1. Always take yourself to your toddler, rather than bringing them to you. Asmothersweautomaticallyscoopupourtoddlerwhentheyaredistressedorgrizzlingandjustwantacuddle.Itismuchbetterfor

yourbodyifyousit,kneel,orevensquatdownandcuddleyourtoddlerattheirheight.Havingthemclimbintoyourlapasyousit,orevenlyingdownwiththemisalsogoodalternativetoliftingthem.Theincreasedweightofcarryingatoddler(andweknowthey’renotknownforbeingcalmandco-operative!)significantlyincreasestheloadpassingthroughyourpelvicjoints,andthisaddstothechallengeyourmuscleshavecontrollingthemovement.

2. Hold your toddler’s hands when they are climbing into and out of the bath rather thanlifttheminandout.

3. Use your toddler’s climbing skills to your advantage.

Whenclimbingintooroutof:

•Highchairs:placeachairorstoolbesidethehighchair,andholdingyourtoddler’shands,helpthemclimbupandintothehighchair.Removetheescaperoute(chair/stool)oncetheyaresafelyinthehighchair!

•Cots:havethesidedownonthecot.Placeasmallstoolorchairbesidethecot,andholdingyourtoddler’shandshelpthemclimbontothechair,thenontothesideofthecot,andjumpin.Pullupthesideofthecot,andremovethetemptationofretracingtheirroutebyremovingthechair/stoolawayfromthecot!

Chapter 5 Tips for coping with Toddlers


•Cars:Keepasmalllightplasticstepinthebootofthecarforyourtoddlertouse.Putthestepdownforyourtoddler,andthenahandundertheirbottomtohelpthemtoclimbintothecar.Youcanencouragethemtoclimbintotheircarseatforyoutodoupthebuckles.

4. Always use the stroller when out with a toddler.Yes,evenforveryquicktripsintotheshops!Carryingyourtoddler,usuallyon

onehip,isaveryprovocativeactivityforyourpelvicjoints.Itputsthenotinsignificantweightofyourtoddlerrightthroughonesideofyourpelvis,whichisveryhardforyourmusclestocontrol.Thatassumesyourtoddlerstaysstill,anddoesn’twriggle,orthrowtheirweightaroundunexpectedly,inwhichcaseitisnearlyimpossibleforyourbodytodealwiththiswell.Whetheryouarecarryingthem,orhavingtorunandchasethem,yourpelvicjointswillnotcopewellwitheitheractivity.Soit’sbettertousethestrollerandcontrolthesituation.Ifyouhavebeenusing/areusingcrutchestowalk,thenthestrollermaybeenoughsupportforyoutogettheshortdistanceyouneedtowalk,whileputtingthecrutchesacrossthetopofthestroller,sotheystillcomewithyou.

5. Rest when your toddler rests! Evenifyourtoddlerdoesn’thaveanapanymore,trytocreateatimeduringthedaywhenyoubothdo“quiettime”together.Makethisrestingtimeagoodtimetoputyouricepackonifrequired.Lyingdownreadingabooktogether,doingapuzzle,orwatchingDisney’slatestwilldoyoubothgood!

Chapter 5 Tips for coping with Toddlers


Chapter 6: Who can help?

1. YOU:Youaretheonewhoreallycontrolsallthis.Youwillbegivenlotsofhelp,toolsandtrickstohelpyoumanageandrehabilitateyourbodywithPGP,butitisYOUthathastodecidetomanagethiswellornot.Changingthewayyounormallydothingscanbefrustrating,andinitiallycanseemdifficulttoimplement.

2. Obstetricianand/orGP:CanreferyoutoaWomen’sHealthphysiotherapist,experiencedintreatingpregnantandpostnatalwomen,andPGP.Theycanhelpbyprescribinganalgesicmedicationwhenappropriate,andifyouareexperiencingsignificantdisability,theycanprovideletterstosupportyourapplicationfordisabledparkingpasses,orhomehelpfromagenciesorcouncil.

3. Physiotherapist:Youdonotneedareferraltoseeaphysiotherapist.YoushouldbookintoaWomen’sHealthphysiotherapistthathasexperiencetreatingPGP.Yourtreatmentmayinvolvemassage,exercises,andeducationaboutPGPandhowtomanageandtreatit.Youwillbeadvisedaboutwhatexerciseyoucanandcan’tdo.

4. Midwife:Yourmidwifemayreferyoutophysiotherapy.Sheorhewillalsohelpyoulabourwithinanylimitationsyoumayhavefromyourpelvicjoints.Theywillalsohelplookafteryourpelvicjointsduringlabour.

5. Psychologist:IfyouhavesignificantdisabilitywithPGP,thenapsychologistmaybeveryusefultohelpgiveyoustrategiesforcopingwithyourchangedcircumstances.

6. Acupuncturist:RecentresearchhasshownpromisingresultsformanagingpainassociatedwithPGP

7. Remedialmasseur/Myotherapist:RegularmassagecanbeveryhelpfulwhenmanagingPGP(andisagreatthingduringanypregnancyorforanynewmum!)Pregnancy

andlookingafteranewbabyareveryphysicaltimesofyourlife,puttingalargenumberofnewstrainsonareasofyourbodythatarenotnecessarilypreparedforthem.Aswithanyelitesportswoman,massagehelpswithrecoveryfromthesenewphysicalstrainsandeffortsyourbodyisundergoing.

8. Homehelpagencies:Speakwithyourlocalcounciltoseewhetheryoumayqualifyfortheirhelp.Therearealsoprivatehomehelpandnannyagenciesthatcanbeusedifyouhavelittlefamilysupportavailable.

9. Familymembers:Areinvaluable!Smallthingslikecookingmealsforthefreezer,takingyourtoddlerforanafternoonorday,vacuumingyourlivingroom…thelistisendless!Neversay“no”tofamilyoffersofhelp.Evenifyoufeelyoucandothetaskyourself,takeadvantageoftheoffertorest,ice,ordoyourexercisesession,(allthingsthatbenefityou),becausethiscreatesawin/winsituation.Youhavebeenabletotakecareofyourself,andyourfamilymember/sfeeltheyarehelpingyou.

10.Friends:Asforfamilymembers!Ifyouarenotcomfortablewithaskingyourfriendstocleanyourhouseforyou,thensometimesjustorganizingtomeetuptodoyourexercisetogethercanhelpkeepyoumotivatedandontherighttracklookingafteryourself.

Chapter 6 Management during pregnancy


Chapter 7: FAQ:

1. Is pelvic Instability the same as PGP? PGPisthenametheinternational

communityhasgiventowhatwaspreviouslycalledPelvicInstability.Partofthereasonfortherenamingoftheconditionistoreflectmoreaccuratelythecondition,inthatitreferstopainofthepelvicgirdle.ThepelvisisNOT“unstable”,infactthejointsaresomeofthemoststablejointsinthebody

2. Is my pelvis “unstable’? See question 1

3. Will tubigrip squash my baby? No.Yourbabyisbeautifullysurrounded

byfluid,itwouldbeliketryingtosquashsomethinginthemiddleofawater-filledballoon.

4. How often do I wear the tubigrip? Beguidedbyyourtherapists’instructions,

howeverusuallyitisusedprimarilyduringthedaytohelpsupporttheweightofthebabywhenyouareupandabout.Itcanbeveryusefultohelpyourollinginbedifthatisparticularlydifficultforyou,asithelps“bringyourtummywithyou”.Howeveritisoftennicetohaveabreakfromwearingit,andatnightisthelogicaltimetodothis.

5. Will the ice ‘freeze’ my baby? No.Thebabyisblissfullyunawareofthe

ice.Thecoldfromtheiceonlypenetratesacoupleofcentimetresbelowtheskin.Weareluckytheligamentswearetryingtoiceareveryshallow,justundertheskin,otherwisetheicewouldn’twork!

6. Do I need a belt? Yourphysiotherapistwilldosometestsas

partofyourassessmentthatwilldetermineifyourequireabeltornot.Remember,noteveryoneneedsabelt.Forsomepeopleitmaymakethemworse,soitisimportantyouareassessedproperly,donotjustbuyorborrowabelt.

7. Can I wear my old belt? Ifyourbeltfromapreviouspregnancywas

notwornforverylongitmaybepossibleforyoutowearitagain.However,ifyouhavechangedsize,orworeyourbeltformorethan3monthslastpregnancy,itisunlikelyyourbeltwilldotherequiredjob.Elasticstretchesandagesovertime,sothe

effectivenessofthebeltmaybediminished.Thebestthingtodoistakeyouroldbelttoyourphysioappointmentandthenyourphysiocancheckifitisstillgoingtobeeffectiveforyou.

8. Do I wear my belt under or over my clothing?

Yourbeltwilldothejobeitheroverorunderyourclothing.Considerationneedstobegiventohowmuchtimeyouaregoingtospendsittingdown,aswhilethebeltwhilstsafetositin,itmaynotbeparticularlycomfortable.Mostwomenwillundothebeltwhilstsitting,sohavingreadyaccesstothebeltmayrequireyoutowearthebeltoveryourclothing.Thereareproductsonthemarketyoucanweartohelplengthenyourtopstocoverthebeltifyourequire.

9. Do I have to lie down when I’m resting? No,youcansitifyouarecomfortablesitting.

Youaremainlytryingtoavoidsinglelegweightbearing,suchaswhenwalking,soamixoflyingandsittingisideal.Rememberthatrestisanacutepainmanagementstrategy.Relativerestiswhatisrequiredoncetheacutepainhasbeensettled,thatis,agoodmixoftherightexerciseandrest.

10. Can I still go for a walk? Walkingisoftenaprovocativeactivityfor

womenwithPGP.Manywomenwillfindthatwalkingcausestheirjointstobecomesore,eitheratthetimetheyarewalking,orsometimelater.Rememberwalkingaroundashoppingcentreisthesameasgoingfortheequivalentwalkforexercise.Yourphysiotherapistwillbeabletoguideyouastowhetheryoucanwalkforexercise,andhowmuchwalkingisappropriateforyou.

11. Should I stop exercising? Initiallyyoumayneedtostopexercising

Chapter 7


whileyourpainsettles,butitisimportantthatyoure-commenceexercisingasrecommendedbyyourphysiotherapist.DoingnoexerciseisasbadasdoingthewrongexercisewhenyouhavePGP.Youbecomedeconditioned,andthemusclesyouneedtohelpcontrolyourpelvicjointsarelessabletoworkforyou.

12. Why do I need to do Clinical Pilates? ClinicalPilatesisamethodofexercising

thattargetsyourdeepposturalmuscles,trainingthemtoworkbettertocontrolyourlumbarspineandpelvicjoints.Thisistreating“thecause”ratherthanjusttreatingthesymptomsofPGP.ClinicalPilatesisindividuallyprescribedexercises,afterafullassessment,byaphysiotherapistwithClinical Pilates training. It is not a generic Pilatesclasswhereeveryonedoesthesameexercises.

13. Is it ok to do Pilates lying on my back?

After16weeksofpregnancy,itisrecommendedbyallExerciseinPregnancyGuidelines,thatyoudonotexerciselyingonyourback.Modificationstoallexercisesusuallydonelyingonyourbackarealwayspossible,soitisnotnecessaryforyoutobeplacedonyourbackforexercisebetween16weeksofpregnancyanddeliveringyourbaby.

14. How often do I need to do Clinical Pilates?

Onceperweekistheminimumyoushoulddo Clinical Pilates initially. Clinical Pilates isa‘skill’morethana‘fitness’,justlikelearninganewtennisshotorgolfswing.Ifyouhavealessononceperweek,youwilllearntoplaytennis.Ifyouhavealessontwiceaweek,youwilllearntoplayfaster.Particularlyduringpregnancy,whenyourbodyisconstantlychanging,itisimportanttoregularlyattendyourclassorperformyourexercises.

15. Is all exercise safe to do?

No.Notallexerciseissafetodoeitherduringpregnancy,orwithPGP.Thereareguidelinesforgeneralexerciseinpregnancy,andyourWomen’sHealthphysiotherapistwillbeabletoguideyoutofindanexercisethatissafeforyoutodobothduringpregnancy,andwithPGP.

16. If I can’t walk for exercise, what exercise can I do?

Swimming,exercisebike,andspecificphysiorunpregnancyexerciseclassesareallwaysforyoutobeabletomaintainyourcardiovascularfitnessduringpregnancy,andinthepostnatalperiodifyouhavePGP.Wespecificallyrecommendphysioclassesduringthistime,asthephysiowillbeabletomodifytheclassforyouifthereareexercisesintheclassthatarenotPGP“friendly”.

17. Do I need to have a Caesarian delivery if I have PGP?

No,unlessthereisamedicalreasonforyoutohaveacaesariandelivery(whichwillbeadecisionforyouandyourdoctorormidwife)thereisnorequirementforyoutohaveacaesarianforPGP.Yourphysiotherapistwillbeabletoguideyouregardingyourpelvicjointsandlabour/delivery.

18. Will this happen again? ItiscommonforPGPtooccurinsubsequent

pregnancies.However,ifthejointcontrolissuesareaddressedbetweenpregnancies,thenourexperienceisthatourclientsdomuchbetterintheirsubsequentpregnancies.Itisnota‘given’thatifyouhavehadPGPinonepregnancy,youwillhaveitearlierandworseinthenextpregnancy.Thisisacommonstatementoftenheard,butthereisgoodevidencethatdoingthecorrectexerciseandrehabilitationafteryouhavehadyourbaby,isexcellentpreparationforyournextpregnancy.

Recommended Reading:European guidelines for the diagnosis and Treatment of pelvic girdle pain. Vleeming A et al. European Spine Journal 2008. 17(6): 794-819. Available in full text, free, on PubMed Central.

Frequently asked questions / Recommended reading


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