Pelvic Girdle Pain During Pregnancy

Lumbo-pelvic pain, which can be defined as, pregnancy related low back pain or pregnancy related pelvic girdle pain, occurs in 24%-90% of women while they are pregnant (Van Benten et al., 2014). Although this usually goes away after birth over 1/3rd of women still have pain 1-year post pregnancy (JOSPT, 2014).

What is Pelvic Girdle Pain?

Your pelvis is made up of your hip bones (ilium, ischium, pubis bones), your tailbone (sacrum/coccyx) and various muscles, tendons and nerves which all work together to support your pelvis and internal organs. When these bones, tendons and muscles do not work together as they should this is when you feel pain. Pain can be in the posterior pelvic girdle (below your lower back) most often caused by an unstable sacral iliac (SI joint), or in the anterior pelvic girdle (in your groin) due to instability in the symphysis pubis. These ‘joints’ are not meant to move, but due to the lovely relaxin hormone floating through your pregnant body they can easily become unstable and extremely painful!    pelvic girdle pain

Pelvic girdle pain (PGP) increases with everyday activities such as walking, standing, sitting and lying down. It can increase drastically after only 30 minutes of activity (Fagevik Olsen, Elden & Gutke, 2014). Sounds pretty annoying right?

Why is it important to identify and treat pelvic girdle pain?

This persistent and awful pain not only effects women physically but also puts them at an increased risk of depression and decreased quality of life. Lumbo-pelvic pain is responsible for a large percentage of sick leave costs for pregnant women as well (Fagevik Olsen, Elden & Gutke, 2014). I laugh because my doctor wrote me a note to have modified work due to pelvic pain and my restrictions were “no standing, no walking, no sitting, or lying down for more than 25% of the day”…Uh, so what exactly could I do? Obviously this resulted in me going off on maternity leave a little earlier than planned.

Identification of women with severe PGP is also important since they are at the “highest risk of persistent pain both during and after pregnancy…and have the greatest consequences in terms of pain, intensity, disability and health related quality of life” (Olsen, Elden & Gutke, 2014). As a sufferer of PGP I can attest that it absolutely affected my quality of life and overall mood since some days even walking around the house was intolerable.

How can I tell if I have PGP?

A recent study by Fagevik Olsen, Elden & Gutke (2014) looked at the effectiveness of self-tests for pregnant women to screen for pelvic girdle pain so that they can be referred to a doctor or physical therapist for evaluation. Here are some of the tests I pulled from this study and this study !  Now, just a warning, if you do have Sacroiliac (SI) joint pain or Symphysis Pubis Dysfunction (SPD) you will know within SECONDS of attempting any of these tests.

SI joint pain is felt beside your tailbone and is often a sharp, deep pain that occurs with certain movements. It can even feel like your hip or tailbone is ‘out of place’. Symphysis Pubis pain is a sharp, lightning bolt type pain that feels like it is often deep in your pelvis. These pains can range from a dull ache or nothing at rest to constant excruciating pain all the time.

Please note all the images and descriptions for these tests were taken directly from the two articles cited above. (Fagevik Olsen M et al, 2009) and (Fagevik Olsen, Elden & Gutke, 2014)

1) P4 Test

Lying in the supine position with 90-degree flexion at the hip the patient presses on the flexed knee, along the longitudinal axis of the femur.

Positive test = reproducing the pain in the SI area
POSH test self adminstered

http://www.thestudentphysicaltherapist.com/posh-test.html <– see more info on this test here

Patrick Faber Test

Lying in the supine position with one hip flexed, abducted and rotated so that the heel rests on the opposite kneecap. Positive test = reproducing the pain in the SI area

faber test self administered

http://www.thestudentphysicaltherapist.com/faber-test1.html <– see more info on this test here

Trendelenberg Test

Standing on one leg, flexing the other with the hip and knee at 90. Positive test = reproducing the pain in the SI area

trelenberg test

http://www.thestudentphysicaltherapist.com/trendelenburg-test.html

Bridging Test

The patient lifts the buttock and extended one leg. Positive test = reproducing the pain in the SI area

bridging test pelvic pain

Mat Test

The patient performed a movement of hip abduction and adduction simulating the movement to pull a mat across the floor. Positive test = pain in the symphysis
mat sliding test

Straight Leg Raise Test

Tests for disc involvement, see more info here.

straight leg raise test

Per (Fagevik Olsen, Elden & Gutke, 2014) , in order to be classified as PGP the following criteria had to be fulfilled…

  • Pain experienced between the hip bones and the gluteal fold particularly in the area of the SI joint in the symphysis.
  • Reports by the women of weight-bearing related pain and its duration in the pelvic girdle.
  • Diminished capacity to stand, walk and sit.
  • Positive clinical diagnostic tests, which reproduced pain in the pelvic girdle.
  • No nerve root syndrome (Negative SLR test).

Be sure to quantify your pain on a scale if you are bringing it to the attention of a doctor or therapist! It really helps them establish a baseline and help rule out other problems.

pain scale

What can I do about it?

Physical and Occupational Therapy during and after pregnancy can help decrease low back and pelvic pain and increase mobility and quality of life.

Van Benten et. al (2014) concluded “according to the literature there is moderate evidence for the positive effect of exercise therapy on pain, disability, and/or sick leave for the treatment of lumbo-pelvic pain during pregnancy. Moreover, data shows that patient education seems to be a helpful intervention”.

Talk to you doctor about a referral to therapy or seek out a therapist near you. A physical therapist who specializes in orthopedic rehabilitation or women’s health will be able to do a proper assessment and prescribe exercises for you to continue at home which can provide some relief! They can also recommend appropriate braces or taping techniques that may help decrease the pain and provide increased stability to those poor overstretched joints. If you are able to see an Occupational Therapist (usually covered by insurance with a doctors order) be sure to take advantage, a home visit will help identify the daily activities that are most difficult and how you can modify the activity or the environment to be able to complete them with as little pain as possible! Also, chiropractic care is fantastic for helping to realign your pelvic bones and spine. This can decrease pain due to nerve irritation and  inflammation. This is what helped me the MOST during my pregnancy and I always recommend chiropractic care to other pregnant mamas out there. As always please comment below or send me an email if you have any questions!

Hope this helps!

In fitness & good health,

Natasha

 

References

JOSPT (2014). “Pregnancy and Low Back Pain: Physical Therapy can Reduce Back and Pelvic Pain During and After Pregnancy”. J Orthop Sports Phys Ther 2014;44(7):474. doi:10.2519/jospt.2014.0505

Fagevik Olsen et al. (2009). “Self Adminstered Tests as a Screening Procedure for Pregnancy Related Pelvic Girdle Pain”. Eur Spine J (2009) 18:1121–1129 DOI 10.1007/s00586-009-0948-2

Fagevik Olsen, Elden, & Gutke. (2014) “Evaluation of Self-adminstered Tests for Pelvic Girdle Pain in Pregnancy”. BMC Musculoskelet Disord. 15(138)

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Pregnancy Core Strength Exercises

As promised here are some core exercises that I started while I was pregnant and am still continuing today!

Transverse Abdominis (TA) Activation

  • Sitting against the wall, best to sit on a ball for beginners
  • Take a deep breath and while slowly exhaling pull your belly button to your spine keeping everything tight. Hold for 3 seconds and relax.
  • Repeat this 5-10 times increasing the amount of time spent in a static hold.
  • VISUALIZATION TIP – I think of a string attached from the inside of my bellybutton to the wall, I imagine this string shortening, pulling on my bellybutton and getting my stomach as flat as possible WITHOUT moving my ribs. This will ensure that you are working the right muscles!
  • Maintain good posture, shoulders back, head up.
  • FOR MORE OF A CHALLENGE – do this without a ball under you, in a sitting position supported by your legs.

Core strength wall sit

Kegels

  • Start by doing these in sitting, then try lying on the ground, side lying, or standing as I find the different positions activate different areas.
  • Feel as if you are trying to stop the flow of urine, pulling that pelvic floor up as high as possible, hold for 10 seconds then relax.
  • It is just as important to be able to completely relax these muscles (feeling almost as if you are going to go to the bathroom) as it is to tense them. Muscles only function properly if there is a good balance between tension and relaxation, therefore muscles that are too tight don’t work very well!
  • VISUALIZATION TIP – Think of a string going through the midline of your body out the top of your head. As this string shortens it pulls up on your pelvic floor. Try to activate this area without using any other muscles like your buttock or thighs!

kegel exercises

These exercises and daily walking and squats are the key to an easy and successful labor and delivery! Make time for exercise now before baby and you will reap the benefits later.

 

After Pregnancy… Exercises to rebuild that core and heal your diastasis!

 

TA Activation, Lying Down
  • Lying on the ground have your legs bent at a 90 degree angle
  • Take a deep breathe, as you exhale pull your stomach flat into the ground. Feel like your bellybutton is sinking.
  • I like to keep my hands on my stomach to make sure im working the right muscles, you should feel yourself ‘get skinnier’ without sticking your ribs out, or arching your back.
  • Back and shoulders should be flat on the ground with a slight neutral curve in your lumbar spine.

This is your starting position for the following exercises.

core strength activation

 

Heel Slides
  • From your starting position rest both heels on the ground. Slowly slide one heel out being careful not to not move anything other than your leg.
  • Do 5 on each side, rest, repeat 3 times.

core strength exercises

Leg lifts – Knees bent

  • From your starting position, take a deep breath, then as you exhale lower one leg down to the ground, touch your foot to the ground without resting and return to starting position. Try to not let your abdominals relax or arch your back.
  • If you cannot maintain a strong core position while doing this, start with going halfway to the ground.
  • Alternate legs, do 10 repetitions, rest, repeat 3 sets.

core strength exercises

Only when the above feels too easy, move on to the next exercise

Leg Lifts – Legs straight

  • From starting position straighten you legs. Keep your core tight and don’t let your back arch while doing this.
  • Take a deep breath in, as you exhale  lower one leg to the ground, bring back to starting position, repeat on other side.
  • Alternate legs, 10 repetitions,rest, complete 3 sets.

core strength exercises leg lifts

Hope you get the chance to try some of these ! The great thing is that they can be done in your bedroom with no equipment so they are easy to sneak in during nap time!

On another note, it’s really challenging to find pictures to demonstrate these exercises without infringing on some copyrights so I just took these myself after the gym really quick while the baby was still sleeping in her carseat!! So no judgement please! I am still getting my own body back and I have a long way to go,  but I am definitely feeling pretty great about where I am with my core strength right now. I was hoping to make a video but quite honestly between the baby crying and the dog barking I think it would take about 100 takes.

Take home points – key things to remember to do these correctly…

  • Never lift your head off the ground, keep a neutral neck, chin slightly tucked
  • Keep your core tight, as soon as your hips, lower back or anything else lifts off the ground or shifts in the wrong direction you are no longer working the right muscles.
  • BREATHE, it is important to breathe through these exercises as holding your breath doesn’t help much, and as much as that’s common sense its surprisingly hard to do sometimes!

See this picture for the WRONG way to do these exercises. By lifting your head up off the ground you are putting a lot of outward stress on your abdominals which can actually make your tummy look worse!

bad core exercises after baby

If you have any questions about any of these exercises please comment below or send me an email at natasha@fitmamasb.com and I will be happy to help!

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Diastasis Recti

Do you have a diastasis? I DO! Surprisingly, being in the medical field I had never heard much of this before becoming pregnant. When I was about 20 weeks along I noticed this strange ‘ridge’ forming in the middle of my stomach every time I leaned backwards or got out of bed. Naturally, I freaked out. I did some research and this is what I learned.

“Diastasis recti is a separation between the left and right side of the rectus abdominis muscle. This muscle covers the front surface of the belly area… Pregnant women may develop the condition because of increased tension on the abdominal wall. The risk is higher if with multiple births or many pregnancies.” (source). “A diastasis recti looks like a ridge, which runs down the middle of the belly area. It stretches from the bottom of the breastbone to the belly button. It increases with muscle straining” (source).


So what to do? First I realized that a lot of what I was doing was all wrong, and had probably made my condition worse, hence why I noticed it so early on in my pregnancy. Being a first time mom I wasn’t showing much at all in my first trimester and therefore decided it would be beneficial to continue an abdominal and core strengthening routine throughout the first trimester. Well, this was a mistake.

There are many exercises that are contraindicated for diastasis recti, including crunches, planks, V sits, and pretty much all your standard ab exercises! Also, I realized that I had an very tight rectus abdominus, that was out of balance with the rest of my core muscles, putting extra strain and pressure on my linea alba (the connective tissue between the two sides of your abdominals), which in turn increased my risk of developing a diastasis.

So first thing I did, I stopped working out my abs. Second thing I did was cry a little, haha kidding, but really I was pretty upset and feeling a little stupid. Lastly, I pulled out my old therapy books and look up what I can do to be proactive about healing this diastasis both before and after this baby is born.

During pregnancy there are a few things you can do in order to prevent this, or in my case prevent it from getting worse. It is important to be aware of how you are moving and how much strain you are putting on your abdominal muscles. For example, the way I would normally get out of bed (simply by sitting up) puts an excessive amount of force on my abs and literally tears them further apart every single time. By using a log rolling technique, where you lie on your side and use your arms and the help of gravity to get up helps to decrease this strain and tension. Also, being aware to engage your transverse abdominus (TA) when doing any lifting or bending also helps protect your abs and distributes the force evenly across your entire core.

What is your TA?

It is the muscle that acts like a corset, supporting your torso and core muscles from the front around to the back. Now, being in my last trimester I am focusing on strengthening my TA and pelvic floor muscles not only to prevent further diastasis but also to aid with labor and delivery. After birth, the same principles still apply. Doing 100 crunches a day will do nothing for your mummy tummy except make it worse! There are many exercises that can hurt a diastasis and cause it to never heal properly, and others that encourage the muscles to heal the way they were before.

Kinesiotaping for Diastasis Recti

The last thing I would like to share with you on this topic is the power of Kinesiotaping. If you haven’t heard of this, it’s a fairly new concept that uses fabric elastic tape applied to the skin in order to aid with recovery and the healing process. A more in depth explanation is supplied below, from here

“The Kinesio Taping® Method is a definitive rehabilitative taping technique that is designed to facilitate the body’s natural healing process while providing support and stability to muscles and joints without restricting the body’s range of motion as well as providing extended soft tissue manipulation to prolong the benefits of manual therapy administered within the clinical setting. Latex-free and wearable for days at a time, Kinesio® Tex Tape is safe for populations ranging from pediatric to geriatric, and successfully treats a variety of orthopedic, neuromuscular, neurological and other medical conditions. The Kinesio® Taping Method is a therapeutic taping technique not only offering your patient the support they are looking for, but also rehabilitating the affected condition as well. By targeting different receptors within the somatosensory system, Kinesio® Tex Tape alleviates pain and facilitates lymphatic drainage by microscopically lifting the skin.  This lifting affect forms convolutions in the skin thus increasing interstitial space and allowing for a decrease in inflammation of the affected areas”.

After reviewing various coursewares from my past and reviewing the application and proper use of Kinesiotape I discovered that this could also be used during and after pregnancy! So here I go, trying anything I can to be proactive about healing my diastasis.

This is me in the picture below, I think I’m around 31 or 32 weeks here, and I have been applying the tape for approximately a month leaving it on for 3 days, then taking it off for one, then back on for 3, etc. By placing the tape in this formation using proper technique, it essentially ‘reminds’ my muscles that they are meant to be together and not pull apart, encouraging proper alignment and decreasing tension on the linea alba.

IMG_3318IMG_3319Yes, I look silly, and I get alot of attention in the pool change room! But it’s a small price to pay for something that really works. When I take off the tape I usually check the status of my diastasis, and after using the tape for 2 months it has not gotten any worse! This is shocking to me considered how much larger my stomach has gotten, and I also have not had any pain associated with it. I also feel it serves as a proprioceptive reminder to keep my core in proper alignment and reminds me to engage my other muscles during activities to protect this fragile connective tissue.

I hope you learned something from this article! Please don’t hesitate to contact me with any questions about my own personal experience so far. I am so pleased with the outcome thus far that I have signed up for a hands on course on how to use Kinesiotape for a multitude of different conditions, so look forward to future posts on this subject!

Read more on some new posts I wrote here and here! Do you have a diastasis and don’t know what to do about it? Contact me today, I can help!

In fitness and good health,
Natasha

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Pregnancy

IMG_3342
So, I’m currently 33 ½ weeks pregnant. Getting down to the home stretch! This has been such an overwhelming experience that I don’t even know where to start. I have learned so much about myself, the human body, and the miracle of creating a human being! Most importantly I feel this has been a life changing experience as it has given me a different perspective on health, beauty, and fitness, as well as the struggles that others go through mentally and physically dealing with weight gain, injuries, and accepting things that are out of your control. So far I have gained nearly 40 pounds, 40 POUNDS and I still have 6 weeks left! By 20 weeks pregnant I had already gained over 20, and this was a very hard reality for me. I have a type A personality, which in many ways is a positive thing! I am organized, detail oriented, strong willed, and dedicated to whatever I put my mind to. But when faced with things that are out of my control (which in this case was weight gain during pregnancy) it took me some time to sort out the feelings in my head and see the positives instead of dwelling on the negatives. The weight gain was due to a few things, 1) due to my nausea I felt terrible if I didn’t snack on something all day, I could only stomach crackers, soup, and toast, which obviously weren’t the healthiest choices, but you do what you have to do in order to not throw up all day at work! 2) I had some minor complications early on so my doctor put me on activity restrictions. I was obviously concerned about the health of my baby so I listened and followed her every word! Going from working out 5x a week to not being able to do more than a brisk walk was a huge adjustment. At first I thought, why even bother, I might as well sit around and do nothing! Then I decided to see the positive side and use this as a time to explore different opportunities and adapt to these changes. I began swimming again and realized how much I missed it! I also continued with yoga, but instead of going to the studio I practiced at home which allowed me to modify and adapt the moves without feeling like everyone in the class was watching me. I started Pilates, which is awesome. A perfect combination of all the things I love, stretching, strengthening, postural control and body alignment. I began seeing a chiropractor for my low back and hip pain and committed myself to doing my therapy exercises every night. All of these things made me happier, healthier, and brought me to the realization that there is no point to sit around and think about all the things that I can’t do, but rather enjoy doing the things I can! I was desperately in need of those feel good endorphins at the time and exercise, no matter in what form, made me feel like myself again and less like I was living in another persons body. Today, I am continuing to exercise 4 days a week, I feel great, I have lots of energy, my joint pain is gone, and I am very focused on training my body to get ready for labor. I am so blessed to be carrying this little girl and we just cant wait to meet her!
In fitness and good health,
Natasha

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