Trial for the Treatment of Pelvic and Back Pain in Pregnancy
Trial for the Treatment of Pelvic and Back Pain in Pregnancy
The investigators aim to conduct a prospective open label randomized controlled trial to test
 the hypothesis that following initial assessment by a physiotherapist, group care exercise
 class is as effective in reducing pain as individual physiotherapy care.
Back pain is reported to affect at least 75% of women at some stage during their pregnancy.
 In the United States one review found that approximately a third of women find back pain in
 pregnancy a severe problem. It has been reported that 20% of all pregnant women suffer from
 the condition to such an extent that they require medical help. Six years after pregnancy,
 problems remain in about 7% of women with PGP, causing severe disability and reducing ability
 to work. The increase in back pain in pregnancy occurs most likely as a result of the natural
 underlying posture deviations been accentuated in pregnancy. Anterior displacement of the
 sacrum, posterior displacement of the trunk and a significant increase in the anterior tilt
 of the pelvis results in exaggerated lordosis of the lower back.

 Stretching, weakness, and separation of abdominal muscles further impede neutral posture and
 place even more strain on paraspinal muscles. Joint laxity in the anterior and posterior
 longitudinal ligaments of the lumbar spine puts strain on the lumbar spine and there is
 widening and increased mobility of the sacroiliac joints and pubic symphysis to facilitate
 the baby's passage through the birth canal.

 A significant cause of back pain in pregnancy appears to result from pelvic girdle pain
 (PGP). Back pain in pregnancy is more common in women with pre-existing back pain, back pain
 in a previous pregnancy, advanced maternal age and multiparity. Despite the high incidence of
 back pain in pregnancy (75% of women attending antenatal clinics at Cork University Maternity
 Hospital) only a fraction of women (25% in the same audit) report back pain to their health
 care providers presumably due to their perception that there are minimal interventions for
 the safe treatment of back pain in pregnancy. Similar results have been shown in other
 studies.

 A Cochrane review on interventions for preventing and treating pelvic and back pain in
 pregnancy republished in October 2008 found no studies dealing specifically with prevention
 of back or pelvic pain in pregnancy. They included eight studies (1305 participants) that
 examined the effects of adding various pregnancy-specific exercises, physiotherapy,
 acupuncture and pillows compared with usual prenatal care. They concluded that all but one
 study had moderate to high potential for bias. Adding pregnancy specific exercises,
 physiotherapy or acupuncture to usual prenatal care appears to relieve back or pelvic pain
 more than usual prenatal care alone, although the effects appear small. Recent trials
 investigating the effect of acupuncture on PGP concluded that acupuncture and stabilising
 exercises constitute efficient complements to standard treatment for the management of PGP in
 pregnancy but acupuncture alone has no significant effect on pain or on the degree of sick
 leave compared with non penetrating sham acupuncture.

 The pain of PGP is experienced between the posterior iliac crest and the gluteal fold,
 particularly in the vicinity of the sacroiliac joints. The endurance capacity for standing,
 walking and sitting is diminished. Diagnosis can only be reached after exclusion of lumbar
 causes and this diagnosis should be based on a medical history, a physical standardised
 examination with specific clinical tests that reproduce pain in the pelvic girdle.

 The European guidelines state that available evidence is insufficient to recommend any
 particular treatment modality.
Inclusion Criteria:

 -  Pregnant women (primigravida and multigravida) from 20-35 weeks of gestation attending
 Cork University Maternity Hospital (CUMH) low risk antenatal clinics who are referred
 to the physiotherapy department by their health care provider or following self
 referral with back pain or pelvic pain will be assessed for inclusion in the trial.

 -  Women referred to the physiotherapy department with symptoms of PGP will be assessed
 on presentation by a one of six departmental physiotherapists specializing in women's
 health.

 -  To make the diagnosis of PGP the following tests will be performed as per the European
 Guidelines on the diagnosis and treatment of Pelvic Girdle Pain and a pain history
 taken as detailed.

 -  Sacroiliac joint assessment

 1. Posterior pelvic pain provocation test (P4)

 2. Gaenslen´s test.

 3. Compression of ASIS

 4. Distraction SIJ pain provocation test

 5. Assessment of Sulci depth in lumbar spine in neutral and extension

 -  Functional pelvic test 6.Active straight leg raise test (ASLR).

 -  Pain history (according to the criteria of Ostgaard)

 7.It is recommended that a pain history be taken with specific attention paid to pain
 patterns and irritability of PGP.

 8.There must be no nerve root syndrome. 9.The severity of pain must be related to
 motion.

 -  The diagnosis of PGP will be made if the patient has 2 or more of criteria 1-4
 (Laslett's criteria) in combination with a negative McKenzie and negative neurological
 examination. Criteria 5-9 will be performed and assessed to try and improve diagnostic
 sensitivity and specificity as well as help exclude other pathologies that may cause
 pelvic and back pain.

 Exclusion Criteria:

 1. Women with other pain conditions, history of orthopaedic disease or surgery in the
 spine or pelvic girdle systemic disorders or if attending the high risk antenatal
 clinic in CUMH will be excluded from the study.

 2. If women volunteered a history of sexual abuse at any point of the study they would be
 excluded from the trial.

 3. Women who do not speak English fluently.

 4. Women with non viable pregnancies.

 5. Women who have already received treatment for PGP outside of this trial.

 6. Pregnant women who present who will not be booking at CUMH for their pregnancy or are
 not resident in the South West of Ireland

 7. Women with a history of severe PGP in previous pregnancies. Severe PGP will be defined
 as occurring less than 20 weeks gestation in a previous pregnancy or requiring
 crutches in a previous pregnancy or women with a history of PGP in 2 or more previous
 pregnancies.