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The role of physiotherapy in managing pregnancy related pelvic girdle pain.

Pregnancy related pelvic girdle pain (PPGP) is a common musculoskeletal condition with a prevalence ranging from 23% to 33% in New Zealand and Australia (Ashby & Johnson, 2015, Pierce, Homer, Dahlen, & King, 2012). Most women with PPGP report moderate to severe pain (Pierce et al., 2012). In addition, the ability to perform everyday activities such as getting up from a chair, bending and walking is affected (Elden, Ladfors, Olsen, Ostgaard, & Hagberg, 2005). Furthermore, a significant proportion of women report a persistence of symptoms following childbirth suggesting that the condition is not self-resolving (Elden, Gutke, Kjellby-Wendt, Fagevik-Olsen, & Ostgaard, 2016). With the pain and functional restrictions during and following pregnancy, PPGP is now considered a major public health issue (Elden, Lundgren, & Robertson, 2014).

Generally, women with PPGP report beneficial effects following physiotherapy management (Chang, Jensen, & Lai, 2015, Fishburn & Cooper, 2015, Pierce et al., 2012). For example, an Australian study reported that 75% of women had improvement in symptoms following physiotherapy (Pierce et al., 2012). Similarly, a recent clinical trial found a statistically significant and clinically meaningful effect on pain and function following a single physiotherapy treatment session (Ceprnja & Gupta, submitted for publication). In this study, pain reduced from an average (SD) of 5.6 (2.7) before treatment to 2.8 (2.2) after physiotherapy when measured using a visual analogue scale (Ceprnja & Gupta, submitted for publication). Importantly, no adverse events have been reported following physiotherapy management indicating that physiotherapy is a very safe treatment option for PPGP (Gutke, Betten, Degerskar, Pousette, & Olsen, 2015).

Unfortunately, however, not all women with PPGP are offered physiotherapy as a treatment option. This is an anecdotal observation that is supported by research findings. An Australian study reported that only 16 of 45 (35%) women reporting pain to a healthcare provider received treatment (Pierce et al., 2012). The number of women who received treatment for PPGP was even lower in a study conducted in China, with only 9% receiving physiotherapy (Chang et al., 2015). Unfortunately, little is known about the reasons for the disparity between the number of women affected by PPGP and the number that receive treatment. It is possible that health care providers, such as doctors, midwives and nurses, may not be referring women to physiotherapy due to a lack of knowledge about the effectiveness and safety of physiotherapy treatment for PPGP Further, it is plausible that women with PPGP may also be unaware of the available treatment options. There needs to be a greater awareness that physiotherapy in PPGP is a safe and effective treatment strategy in order to reduce the missed opportunities for women to receive care.

Education is the key to informing pregnant women and their healthcare providers about physiotherapy in PPGP Many pregnant women report that they "were unprepared for PPGP", "did not know much about the condition" and "received little recognition and support" (Elden et al., 2014, Persson, Winkvist, Dahlgren, & Mogren, 2013). Indeed, the growth in web-based discussion forums among pregnant women suggests that they seek education, information and support (Fredriksen, Harris, & Moland, 2016). Information about PPGP and how they can access physiotherapy for treatment must be provided to all pregnant women by their health care providers early in pregnancy. In a digitally literate world, there are many opportunities for appropriate evidence-based information to be disseminated to health care providers and pregnant women.

There is also an important role for physiotherapy in PPGP beyond pregnancy. Persistent pain is common following pregnancy with up to 10% of women reporting severe consequences 11 years later (Elden et al., 2016). Managing a greater proportion of women with PPGP may identify those at risk of developing chronic pain and hence prevent persistence of symptoms post-partum. Considering persistent PPGP, as other chronic pain conditions, is associated with reduced health related quality of life (Elden et al., 2016), early assessment and treatment of all women with PPGP must be a health priority.

The way forward to better care for women with PPGP is through education and collaboration. Physiotherapy has an integral role within the multidisciplinary team to advocate for recognition of PPGP as a treatable condition. Information about the safety and effectiveness of physiotherapy management must be widely available to reassure all women with PPGP that pain and disability can be minimised. Physiotherapists are well placed to advocate for improvements in health pathways and closer collaborations between health care providers to ensure women with PPGP receive the best care available in order to meet their health needs and expectations. Such changes in health care practice have the potential to increase the number of women receiving physiotherapy and, in doing so, improve the experiences of women with PPGP during pregnancy and beyond.

Dragana Ceprnja B. Phty (Hons) PhD student, School of Science and Health, Western Sydney University, Sydney, Australia Health Professional Educator, Physiotherapy Department, Westmead Hospital, Sydney, Australia

Lucy Chipchase M App Sc (Physio), PhD Professor of Physiotherapy, School of Science and Health, Western Sydney University, Sydney, Australia

Amitabh Gupta B Phty, M Sports Phty, PhD Lecturer, Physiotherapy, School of Science and Health, Western Sydney University, Sydney, Australia Senior Physiotherapist, Physiotherapy Department, Westmead Hospital, Sydney, Australia

doi: 10.15619/NZJP/45.2.01


Dragana Ceprnja, Physiotherapy Department, Westmead Hospital, PO Box 533, Wentworthville, NSW, Australia 2145, Telephone: +61 29845 6502, Email:


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Ceprnja D., & Gupta, A. (2016). Therapist assisted exercise in the treatment of pregnancy related pelvic girdle pain: a randomized controlled trial. Submitted for publication.

Chang H., Jensen M. P., & Lai Y. (2015). How do pregnant women manage lumbopelvic pain? Pain management and their perceived effectiveness. Journal of Clinical Nursing, 24: 1338-1346. doi: 10.1111/jocn.12742.

Elden H., Gutke A., Kjellby-Wendt G., Fagevik-Olsen M., & Ostgaard H. (2016). Predictors and consequences of long-term pregnancy-related pelvic girdle pain: a longitudinal follow up study. BMC Musculoskeletal Disorders, 17: 276. doi 10.1186/s12891-016-1 154-0.

Elden H., Ladfors L., Olsen M. F., Ostgaard H. C., & Hagberg H. (2005). Effects of acupuncture and stabilising exercises as adjunct to standard treatment in pregnant women with pelvic girdle pain: randomised single blind controlled trial. BMJ, 330(7494):761-764. doi: 10.1136/ bmj.38397.507014.E0.

Elden H., Lundgren I., & Robertson E. (2014). The pelvic ring of pain: Pregnant women's experiences of severe pelvic girdle pain: An interview study. Clinical Nursing Studies, 2(2): 30-41. doi: 10.5430/cns.v2n2p30.

Fishburn S., & Cooper T. (2015). Pelvic girdle pain: Are we missing opportunities to make this a problem of the past? British Journal of Midwifery, 23(11): 774-778.

Fredriksen E. H., Harris J., & Moland K. M. (2016). Web-based discussion forums on pregnancy complaints and maternal health literacy in Norway: a qualitiative study. Journal of Medical Internet Research, 18(5): e113. doi 10.2196/jmir. 5270.

Gutke A., Betten C., Degerskar K., Pousette S., & Olsen M. F. (2015). Treatments for pregnancy-related lumbopelvic pain: a systematic review of physiotherapy modalities. Acta Obstetrica Gynecologica Scandinavica, 94(11), 1156-1167. doi: 10.1111/aogs.12681.

Persson M., Winkvist A., Dahlgren L., & Mogren I. (2013). "Struggling with daily life and enduring pain": a qualitative study of the experiences of pregnant women living with pelvic girdle pain. BMC Pregnancy & Childbirth, 13: 111. doi: 10.1186/1471-2393-13-111.

Pierce H., Homer C. S. E., Dahlen H. D., & King J. (2012). Pregnancy-related lumbopelvic pain: listening to Australian women. Nursing Research and Practice. doi: 10.1 155/2012/387428.
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Title Annotation:GUEST EDITORIAL
Author:Ceprnja, Dragana; Chipchase, Lucy; Gupta, Amitabh
Publication:New Zealand Journal of Physiotherapy
Article Type:Editorial
Date:Jul 1, 2017
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