Predicting Bothersome Pelvic Pain from Mid-Pregnancy to Birth

Research Review By Dr. Ceara Higgins

Date Posted: December 2018

Study Title: Can a bothersome course of pelvic pain from mid-pregnancy to birth be predicted? A Norwegian prospective longitudinal SMS-Track study

Authors: Malmqvist S, Kjaermann I, Andersen K, et al.

Author’s Affiliations:

University of Stavanger; Stavanger University Hospital, Norway.

Publication Information:

BMJ Open 2018; 8: e021378. doi:10.1136/bmjopen-2017-021378.

Background Information:

Approximately half of pregnant women will experience pelvic girdle pain (PGP) during their pregnancy, with 25-30% experiencing severe pain. The exact etiology of PGP is unknown; however, it is known to lead to pain-related restrictions on physical activity during and after childbirth, and to have a psychological impact on their perceived health, sexual life and general quality of life. PGP is classified as specific (caused by trauma) or non-specific (multifactorial) and is diagnosed through physical examination. To date, no gold-standard testing exists for the diagnosis of PGP, although the posterior pelvic pain provocation test (P4) for sacroiliac joint dysfunction and the active straight leg raise test (ASLR) for detecting failing force closure have both shown high levels of validity and reliability (both described in methods section below) (1).

Existing prospective studies on PGP have generally collected data at baseline and at 1 or 2 follow-up points, limiting the total amount of data available for analysis. More frequent data collection may allow for a more accurate description of the clinical course of PGP during pregnancy. Collection of longitudinal data through text messages has been shown to be feasible in clinical settings (3) and allows for the collection of a much greater data pool. The authors of this study aimed to explore the differences in demographics and clinical characteristics at mid-pregnancy and the weekly amount of days with bothersome symptoms throughout the second half of pregnancy in women sub-grouped based on the results of two valid and reliable clinical tests (P4 and ASLR) at 18 weeks of pregnancy. The authors hypothesized that sacroiliac dysfunction and failing force closure diagnosed at mid-pregnancy could be used to predict a course of bothersome symptoms throughout the second half of pregnancy.

Pertinent Results:

503 women were included in the study. Of these, 42% reported pain in the lumbopelvic region. On clinical examination, 39% fulfilled the criteria for a probable PGP diagnosis and 27% had positive findings on both the ASLR and P4 tests. Those women reporting pelvic pain but having no positive clinical findings were placed in the ASLR and P4 negative group.

Demographically, women with positive ASLR and P4 tests had a heavier workload, higher BMI at week 18 and exercised less both before and during pregnancy. Further, just over 1/3 of these women reported feeling of depression during their pregnancy, and almost half had required sick leave during their pregnancy. These women also showed higher levels of physical disability and pain at week 18 than women reporting pain but having negative ASLR and P4 tests. Women with positive ASLR and negative P4 had the highest number of previous pregnancies.

The SMS-Track response rate was 75%, with a decline in response seen at the end of the pregnancy. As a result, the authors stopped their data analysis at week 38 (it would have been very interesting if they were able to collect data after delivery!).

Women who showed both positive P4 and ASLR tests reported a high weekly average number of days (5 days/week) with bothersome pelvic pain throughout their pregnancies. Women who had both tests negative showed a steady rise in the number of bothersome days, from 0.5 days/week at week 18 to 2 days/week in week 37. The group with a positive P4 and negative ASLR only showed 3 bothersome days/week at week 18, but this rapidly increased to match the group with both positive tests from week 29 onward. The group with a positive ASLR and negative P4 also showed 3 bothersome days/week at 18 weeks, but never reached the level of the group with both tests positive.

Overall, the estimated rate for experiencing bothersome days was 7.5 times higher in women with both ASLR and P4 positive and 1.5 times higher in women with either a positive ASLR or positive P4 when compared to women with both tests negative. For every additional previous pregnancy, the mean number of bothersome days increased by 13.5% and even slight increases in BMI significantly increased the number of bothersome days, while age had no impact.

Demographic data also showed that women with the highest number of previous pregnancies and highest mean rate of PGP in previous pregnancies also exercised more frequently, both before and during the current pregnancy, than women in the other positive test groups. This may be because they have found exercise to be beneficial for improving muscle activation, recovering function, and decreasing pain (4) during previous pregnancies. Finally, women who were able to control their work situation showed better health overall during their pregnancy than women without any ability to control their work situation.

Clinical Application & Conclusions:

This study suggests that a comprehensive, conservative training program including clinician instruction and supervision of exercises, manual therapy (including SMT) and a cognitive behavioural approach may be an effective and safe option for patients with neurogenic claudication due to LSS. Statistically significant and clinically important improvements in walking distance were found, with results favouring a structured, six-week comprehensive program (remember, the natural history of LSS is normally NO improvement in walking ability). This is therefore a highly meaningful outcome for patients with neurogenic claudication due to LSS!

Considering both groups received the same educational materials, exercises and self-management strategies, the role of supervised and individualized education and instruction, interactions with clinicians, manual therapy and/or cognitive behavioral interventions may be related to the superior improvements in the comprehensive group. Given these are evidence-based treatments for chronic low back pain (11), this study further supports their use for patients with neurogenic claudication due to LSS, specifically.

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