Advertisement

Management of women with pregnancy-related pelvic girdle pain: an international Delphi study

Published:September 22, 2021DOI:https://doi.org/10.1016/j.physio.2021.09.002

      Abstract

      Objectives

      Pregnancy-related pelvic girdle pain (PPGP) contributes to significant prenatal and postpartum impairments; however, various clinical practices exist around the conservative treatment of this condition. This study sought to reach a consensus on the essential components of PPGP management through an international Delphi survey of experts in women's health.

      Design and participants

      Eighty-seven international experts in the field of PPGP were invited to participate and surveyed over three rounds. Round 1 of the survey utilised open-ended questions to gain feedback on 16 components of PPGP management previously identified by a focus group. Feedback from panel members guided modification and refinement of questions for Rounds 2 and 3. A 5-point Likert scale was used to rate level of agreement, with a minimum threshold for consensus of ≥75% agreement set across all survey rounds.

      Results

      Forty four of the 87 (50%) invited professionals agreed to participate in the panel, with 77% (34/44) of panellists contributing to all three rounds. Of the 16 initial components, 15 were included in Round 2. The final consensus was reached on 10 important components of assessment and management after Round 3: pain education; postural and ergonomic advice; social and lifestyle factors; psychological factors, cultural considerations, strengthening exercise, other exercise, exercise precautions, manual therapy and the use of crutches.

      Conclusion

      This study identified 10 key components that should be considered in the management of PPGP. In addition, these components provide a potential framework for future research around the conservative management of PPGP.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Physiotherapy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Ronchetti I
        • Vleeming A
        • van Wingerden JP
        Physical characteristics of women with severe pelvic girdle pain after pregnancy: a descriptive cohort study.
        Spine. 2008; 33: E145-E151https://doi.org/10.1097/BRS.0b013e3181657f03
        • Albert H.
        • Godskesen M.
        • Westergaard J.
        Evaluation of clinical tests used in classification procedures in pregnancy-related pelvic joint pain.
        E Spine J. 2000; 9: 161-166https://doi.org/10.1007/s005860050228
        • Gutke A.
        • Östgaard H.C.
        • Öberg B.
        Pelvic girdle pain and lumbar pain in pregnancy: a cohort study of the consequences in terms of health and functioning.
        Spine. 2006; 31: E149-E155https://doi.org/10.1097/01.brs.0000201259.63363.e1
        • Elden H.
        • Gutke A.
        • Kjellby-Wendt G.
        • Fagevik-Olsen M.
        • Ostgaard H.C.
        Predictors and consequences of long-term pregnancy-related pelvic girdle pain: a longitudinal follow-up study.
        BMC Musculoskelet Dis. 2016; 17: 276https://doi.org/10.1186/s12891-016-1154-0
        • Vleeming A.
        • Albert H.B.
        • Östgaard H.C.
        • Sturesson B.
        • Stuge B.
        European guidelines for the diagnosis and treatment of pelvic girdle pain.
        E Spine J. 2008; 17: 794-819https://doi.org/10.1007/s00586-008-0602-4
        • Robinson H.S.
        • Veierød M.B.
        • Mengshoel A.M.
        • Vøllestad N.K.
        Pelvic girdle pain-associations between risk factors in early pregnancy and disability or pain intensity in late pregnancy: a prospective cohort study.
        BMC Musculoskelet Dis. 2010; 11: 91https://doi.org/10.1186/1471-2474-11-91
        • Virgara R.
        • Maher C.
        • Van Kessel G.
        The comorbidity of low back pelvic pain and risk of depression and anxiety in pregnancy in primiparous women.
        BMC Pregnancy Childb. 2018; 18: 288https://doi.org/10.1186/s12884-018-1929-4
        • Gutke A.
        • Olsson C.B.
        • Völlestad N.
        • Öberg B.
        • Wikmar L.N.
        • Robinson H.S.
        Association between lumbopelvic pain, disability and sick leave during pregnancy–a comparison of three Scandinavian cohorts.
        J Rehabil Med. 2014; 46: 468-474https://doi.org/10.2340/16501977-1801
        • Stuge B.
        • Bergland A.
        Evidence and individualisation: important elements in treatment for women with postpartum pelvic girdle pain.
        Physiotherapy Theor Pr. 2011; 27: 557-565https://doi.org/10.3109/09593985.2010.551802
        • Gausel A.M.
        • Kjærmann I.
        • Malmqvist S.
        • Andersen K.
        • Dalen I.
        • Larsen J.P.
        • et al.
        Chiropractic management of dominating one-sided pelvic girdle pain in pregnant women; a randomised controlled trial.
        BMC Pregnancy Childb. 2017; 17: 331https://doi.org/10.1186/s12884-017-1528-9
        • Hughes C.M.
        • Liddle S.
        • Sinclair M.
        • McCullough J.E.
        The use of complementary and alternative medicine (CAM) for pregnancy related low back and/or pelvic girdle pain: an online survey.
        Complement Ther Clin. 2018; 31: 379-383https://doi.org/10.1016/j.ctcp.2018.01.015
        • Liddle S.D.
        • Pennick V.
        Interventions for preventing and treating low-back and pelvic pain during pregnancy.
        Cochrane Db Syst Rev. 2015; CD001139https://doi.org/10.1002/14651858.CD001139.pub4
        • Bishop A.
        • Holden M.
        • Ogollah R.
        • Foster N.
        Current management of pregnancy-related low back pain: a national cross-sectional survey of UK physiotherapists.
        Physiotherapy. 2016; 102: 78-85https://doi.org/10.1016/j.physio.2015.02.003
        • Beales D.
        • Hope J.B.
        • Hoff T.S.
        • Sandvik H.
        • Wergeland O.
        • Fary R.
        Current practice in management of pelvic girdle pain amongst physiotherapists in Norway and Australia.
        Man Ther. 2015; 20: 109-116https://doi.org/10.1016/j.math.2014.07.005
        • Gibbins A.K.
        • Wood P.J.
        • Spark M.J.
        Managing inappropriate use of non-prescription combination analgesics containing codeine: A modified Delphi study.
        Res Soc Admin Pharm. 2017; 13: 369-377https://doi.org/10.1016/j.sapharm.2016.02.015
        • Ferguson F.C.
        • Brownlee M.
        • Webster V.
        A Delphi study investigating consensus among expert physiotherapists in relation to the management of low back pain.
        Musculoskeletal Care. 2008; 6: 197-210
        • Keeney S.
        • Hasson F.
        • McKenna H.P.
        A critical review of the Delphi technique as a research methodology for nursing.
        International journal of nursing studies. 2001; 38: 195-200
        • Keeney S.
        • McKenna H.
        • Hasson F.
        The Delphi technique in nursing and health research.
        John Wiley & Sons, United Kingdom2011
        • Hsu C-C
        • Sandford BA
        The Delphi technique: making sense of consensus.
        Practical Assessment, Research, and Evaluation. 2007; 12: 10https://doi.org/10.7275/pdz9-th90
        • Keeney S.
        • Hasson F.
        • McKenna H.
        Consulting the oracle: ten lessons from using the Delphi technique in nursing research.
        J Adv Nurs. 2006; 53: 205-212https://doi.org/10.1111/j.1365-2648.2006.03716.x
        • Louw A.
        • Diener I.
        • Butler D.S.
        • Puentedura E.J.
        The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain.
        Arch Phys Med Rehab. 2011; 92: 2041-2056https://doi.org/10.1016/j.apmr.2011.07.198
        • Wood L
        • Hendrick PA
        A systematic review and meta‐analysis of pain neuroscience education for chronic low back pain: Short‐and long‐term outcomes of pain and disability.
        Eur J Pain. 2019; 23: 234-249https://doi.org/10.1002/ejp.1314
        • Watson J.A.
        • Ryan C.G.
        • Cooper L.
        • Ellington D.
        • Whittle R.
        • Lavender M.
        • et al.
        Pain neuroscience education for adults with chronic musculoskeletal pain: a mixed-methods systematic review and meta-analysis.
        J Pain. 2019; https://doi.org/10.1016/j.jpain.2019.02.011
        • Moseley GL
        • Butler DS
        Fifteen years of explaining pain: the past, present, and future.
        J Pain. 2015; 16: 807-813https://doi.org/10.1016/j.jpain.2015.05.005
        • Lee H.
        • McAuley J.H.
        • Hübscher M.
        • Kamper S.J.
        • Traeger A.C.
        • Moseley G.L.
        Does changing pain-related knowledge reduce pain and improve function through changes in catastrophising?.
        Pain. 2016; 157: 922-930https://doi.org/10.1097/j.pain.0000000000000472
        • Traeger Ac
        • Lee H
        • Hübscher M
        • Skinner Iw
        • Moseley Gl
        • Nicholas Mk
        • et al.
        Effect of intensive patient education vs placebo patient education on outcomes in patients with acute low back pain: a randomised clinical trial.
        JAMA Neurol. 2019; 76: 161-169https://doi.org/10.1001/jamaneurol.2018.3376
        • Eggen M.H.
        • Stuge B.
        • Mowinckel P.
        • Jensen K.S.
        • Hagen K.B.
        Can supervised group exercises including ergonomic advice reduce the prevalence and severity of low back pain and pelvic girdle pain in pregnancy? A randomised controlled trial.
        Phys Ther. 2012; 92: 781https://doi.org/10.2522/ptj.20110119
        • Kordi R.
        • Abolhasani M.
        • Rostami M.
        • Hantoushzadeh S.
        • Mansournia M.A.
        • Vasheghani-Farahani F.
        Comparison between the effect of lumbopelvic belt and home based pelvic stabilising exercise on pregnant women with pelvic girdle pain; a randomised controlled trial.
        J Back Musculoskelet. 2013; 26: 133-139https://doi.org/10.3233/BMR-2012-00357
        • Persson M.
        • Winkvist A.
        • Dahlgren L.
        • Mogren I.
        Struggling with daily life and enduring pain": a qualitative study of the experiences of pregnant women living with pelvic girdle pain.
        BMC Pregnancy Childb. 2013; 13: 111https://doi.org/10.1186/1471-2393-13-111
        • Doğru H.Y.
        • Özsoy F.
        • Doğru S.
        • Karaman T.
        • Şahin A.
        • Özsoy A.Z.
        • et al.
        Catastrophizing, Depression and Anxiety During Pregnancy: Relation Between Lumbopelvic Pain and Physical/Social Functioning.
        J Ration-Emot Cogn-B. 2018; 36: 119-136https://doi.org/10.1007/s10942-017-0277-z
        • Olsson C.B.
        • Grooten W.J.
        • Nilsson-Wikmar L.
        • Harms-Ringdahl K.
        • Lundberg M.
        Catastrophizing during and after pregnancy: associations with lumbopelvic pain and postpartum physical ability.
        Phys Ther. 2012; 92: 49-57https://doi.org/10.2522/ptj.20100293
        • Bjelland E.
        • Stuge B.
        • Engdahl B.
        • Eberhard‐Gran M.
        The effect of emotional distress on persistent pelvic girdle pain after delivery: a longitudinal population study.
        Int J Gynaecol Obst. 2013; 120: 32-40https://doi.org/10.1111/1471-0528.12029
        • Albert H.B.
        • Godskesen M.
        • Korsholm L.
        • Westergaard J.G.
        Risk factors in developing pregnancy‐related pelvic girdle pain.
        Acta Obstet Gyn Scan. 2006; 85: 539-544https://doi.org/10.1080/00016340600578415
        • Olsson C.
        • Buer N.
        • Holm K.
        • Nilsson-Wikmar L.
        Lumbopelvic pain associated with catastrophising and fear‐avoidance beliefs in early pregnancy.
        Acta Obstet Gyn Scan. 2009; 88: 378-385https://doi.org/10.1080/00016340902763210
        • Beales D.
        • Lutz A.
        • Thompson J.
        • Wand B.M.
        • O’Sullivan P.
        Disturbed body perception, reduced sleep, and kinesiophobia in subjects with pregnancy-related persistent lumbopelvic pain and moderate levels of disability: an exploratory study.
        Man Ther. 2016; 21: 69-75https://doi.org/10.1016/j.math.2015.04.016
        • Bakker E.C.
        • van Nimwegen‐Matzinger C.W.
        • Ekkel‐van der Voorden W.
        • Nijkamp M.D.
        • Völlink T.
        Psychological determinants of pregnancy‐related lumbopelvic pain: a prospective cohort study.
        Acta Obstet Gyn Scan. 2013; 92: 797-803https://doi.org/10.1111/aogs.12131
        • Rowelll L.N.
        • Mechlinl B.
        • Jil E.
        • Addamol M.
        • Girdlerl S.S.
        Asians differ from non‐Hispanic Whites in experimental pain sensitivity.
        Eur J Pain. 2011; 15: 764-771https://doi.org/10.1016/j.ejpain.2010.11.016
        • Acharya R.S.
        • Tveter A.T.
        • Grotle M.
        • Eberhard-Gran M.
        • Stuge B.
        Prevalence and severity of low back-and pelvic girdle pain in pregnant Nepalese women.
        BMC Pregnancy Childb. 2019; 19: 247https://doi.org/10.1186/s12884-019-2398-0
        • Gutke A.
        • Boissonnault J.
        • Brook G.
        • Stuge B.
        The severity and impact of pelvic girdle pain and low-back pain in pregnancy: a multinational study.
        J Women’s Health. 2018; 27: 510-517https://doi.org/10.1089/jwh.2017.6342
        • Depledge J.
        • McNair P.J.
        • Keal-Smith C.
        • Williams M.
        Management of symphysis pubis dysfunction during pregnancy using exercise and pelvic support belts.
        Phys Ther. 2005; 85: 1290-1300https://doi.org/10.1093/ptj/85.12.1290
        • Stuge B.
        • Lærum E.
        • Kirkesola G.
        • Vøllestad N.
        The efficacy of a treatment program focusing on specific stabilising exercises for pelvic girdle pain after pregnancy: a randomised controlled trial.
        Spine. 2004; 29: 351-359https://doi.org/10.1097/01.BRS.0000090827.16926.1D
        • Ehsani F.
        • Sahebi N.
        • Shanbehzadeh S.
        • Arab A.M.
        • ShahAli S.
        Stabilization exercise affects function of transverse abdominis and pelvic floor muscles in women with postpartum lumbo-pelvic pain: a double-blinded randomised clinical trial study.
        Int Urogynecol J. 2019; : 1-8https://doi.org/10.1007/s00192-019-03877-1
        • Granath A.B.
        • Hellgren M.S.
        • Gunnarsson R.K.
        Water aerobics reduces sick leave due to low back pain during pregnancy.
        JOGNN. 2006; 35: 465-471https://doi.org/10.1111/j.1552-6909.2006.00066.x
        • Stafne S.N.
        • Salvesen K.A.
        • Romundstad P.R.
        • Stuge B.
        • Morkved S.
        Does regular exercise during pregnancy influence lumbopelvic pain? A randomised controlled trial.
        Acta Obstet Gyn Scan. 2012; 91: 552-559https://doi.org/10.1111/j.1600-0412.2012.01382.x
        • Steiner W.A.
        • Ryser L.
        • Huber E.
        • Uebelhart D.
        • Aeschlimann A.
        • Stucki G.
        Use of the ICF model as a clinical problem-solving tool in physical therapy and rehabilitation medicine.
        Phys Ther. 2002; 82: 1098-1107https://doi.org/10.1093/ptj/82.11.1098
        • Gutke A.
        • Betten C.
        • Degerskär K.
        • Pousette S.
        • Fagevik Olsén M.
        Treatments for pregnancy‐related lumbopelvic pain: a systematic review of physiotherapy modalities.
        Acta Obstet Gyn Scan. 2015; 94: 1156-1167https://doi.org/10.1111/aogs.12681
        • Bjelland E.K.
        • Stuge B.
        • Vangen S.
        • Stray-Pedersen B.
        • Eberhard-Gran M.
        Mode of delivery and persistence of pelvic girdle syndrome 6 months postpartum.
        Am J Obstet Gynecol. 2013; 208 (298.e1–.e7)https://doi.org/10.1016/j.ajog.2012.12.002