8/21/2014 1 Jill Schiff 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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8/21/2014
1
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
8/21/2014
2
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
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
8/21/2014
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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
8/21/2014
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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
A s s o c i a t i o n 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 h e r a p i s t s i n W o m e n ’ s H e a l t h : P r e g n a n c y 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 o n , 2 0 0 7 , A s s o c i a t i o n o f C h a r t e r e d P h y s i o t h e r a p 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 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 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 .
B o l a n d B F : S e p a r a t i o n 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 n g 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 o n C , J a c o b s o n 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 o u s w o m e n : m a g n e t i c r e s o n a n c e 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 u r a l i n j u r y . U l t r a s o u n 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 4 4 - 5 1
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 f u l a n d e x c e s s i v e a b d u c t i o n 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 a n o L , G r e e n m a n P . G r e e n m a n ’ 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 n e . B a l t i m o r e , M D : L i p p i n c o t t W i l l i a m s & W i l k i n s / W o l 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 a t i o n 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 p t o r t h o p e d i c s u r g i c a l i n t e r v e n t i o n . 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 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 .
M e n s , J . M . A . , V l e e m i n g , A . , S n i j d e r s , C . J . , S t a m , H . J . , G i n a i , A . Z . , 1 9 9 9 . T h e a c t i v e s t r a i g h t l e g r a i s i n g t e s t a n d m o b i l i t y o f t h e p e l v i c
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 .