Pubic Pain During Pregnancy: Multifaceted Problem, Requiring Comprehensive Treatment.

Women with pubic symphysis dysfunction and pain during pregnancy often face major functional difficulties resulting in a considerable decrease in quality of life. What causes this pain and how can it be treated?

Symptoms of Pubic Symphysis dysfunction:

- Widening begins at 10^th-12^th week of pregnancy (usually hormonally related at this stage)

- Mild to severe pain in pubic region, groin and inside of thigh (one side or both)

- Frequently accompanied by SacroIliac Joint, Low Back and Suprapubic pain

- Pain worst during weight bearing activities especially those involving lifting one leg (like climbing stairs), or straining

- May hear or feel a clicking or grinding sensation in joint

- "Waddling" when walking

- Rarely ruptures, or widens more than 10mm during pregnancy.

The pubic joint as well as the other joints of the pelvis must become more mobile to facilitate the passage of the fetus through the birth canal. Mother nature has taken care of that for us by releasing reproductive hormones that cause the supporting connective tissues that stabilize joints to lengthen and weaken. During labour the pubic symphysis can widen up to 2cm from the normal motion of 1mm in men and 5mm in women who have given birth. The increased movement, although necessary, can lead to joint irritation and inflammation as well as increase the risk of injury of the “other” supporting structures of the joints.

This common pregnancy related pain is traditionally treated using stabilization belts, rest and ice. But there are many other factors to consider in the treatment of pubic pain during pregnancy to ensure we are not simply treating the symptom of pain but also addressing the cause. Pelvic stabilization belts have been shown to have a mechanical stabilizing effect on the joints of the pelvis. However, there is not a big difference in pain relief during pregnancy, between women who preform core rehab exercises and those who ware belts and do the rehab. This tells us that there are more pieces of the puzzle than simply increasing in mechanical stability of the joints.

Other structures that provide stability to the joints of the pelvis include: thoracolumbar fascia, gluteal muscles and core muscles (a deep group of stabilizing muscles that include: pelvic floor, transverses abdominals, multifidi and diaphragm ). These structures are affected by changes in joint movement and biomechanical changes in the body like the shift in the center of gravity as pregnancy progresses.

When treating any pelvic pain (especially during pregnancy) both the mechanical cause of the pain as well as the dynamic changes to all the other stabilizing structures must be considered when developing comprehensive treatment plan.

There is no ONE cause of joint pain during pregnancy, rather a combination of many factors: Hormones (Estrogen, Relaxin), weak stabilizing muscles, biomechanical changes, shift in center of gravity. Individually designed treatment programs are most effective as they will consider occupation, physical demands of a patient. A comprehensive treatment plan for pubic symphasis dysfunction during pregnancy should be multifaceted and include:

- An exercise plan that activates and progressively strengthens the deep core stabilizing muscles
- soft tissue techniques to help balance the length of the supporting musculature
- joint manipulation, when necessary, to promote equal and symmetrical movement of all joints of the pelvis
- modalities that will aid in decreasing pain and discomfort
- patient education and training in self-help (modifications in daily activities for comfort, sleep posture pillow placement, how to roll over in bed, activating pelvic floor, ergonomic changes).

So, BELTS OR NO BELTS?
I say if it helps it helps, but research shows that you MUST teach and train muscles to provide pelvic stability from within rather than solely relying on external aids!

PATIENTS- Make sure you are doing your exercises under the guidance and expertise of your practitioner!

References:
1. Depledge J, McNair P, Keal-Smith S et al. Management of Symphysis Pubis Dysfunction During Pregnancy Using Exercise and... Physical Therapy; Dec 2005; 85, 12; pg. 1290
2. Garras DN, Carothers JT, Olson SA. Single-Leg stance (flamingo) radiographs to assess pelvic instability: how much motion is normal? J Bone Joint Surg Am. 2008; 90(10):2114-8.

3. Mens JMA, Vleeming A, Stoeckart R, et al. Understanding peripartum pelvic pain. Implications of a Patient Survey. Spine 1996;21:1363–9.

4. Nilsson-Wikmar L, Holm K.et al.Effect of Three Different Physical Therapy Treatments on Pain and Activity in Pregnant Women With Pelvic Girdle Pain: A Randomized Clinical Trial With 3, 6, and 12 Months Follow-up postpartum. SPINE, 2005; 30 (8), 850–856.

5. Pool-Goudzwaard A.L, Vleeming A, et al. Insufficient lumbopelvic stability: a Clinical, Anatomical and Biomechanical approach to ‘a-specific’ low back pain. Manual Therapy, 1998; 3(1), 12-20.
6. Rustamova S, Predanic M, et al. Changes in Symphysis Pubis Width During Labor. J. Perinat. Medicine. 2009; 37: 370–373.

Your Body & Changes During Menopause

What is happening in your body?

Menopause is defined as not having a menstrual period for 1 year. During menopausal Transition (usually between the ages of 47-52) hormones begin to fluctuate leading to a permanent decrease in the production of estrogen and progesterone.

Estrogen and Progesterone are regulated by the anterior pituitary gland in the brain. The anterior pituitary gland is controlled by the hypothalamus portion of the brain which is the "Master Control" for your body. The HYPOTHALAMUS receives information from other sections of your brain that control delicate functions in your body like: emotions, sexual desire, thirst, hunger, body temperature, sleep patterns and regulates them through the NERVOUS SYSTEM.

How do hormone changes affect the body and cause physical symptoms?

JOINT PAIN:

Among its many jobs, estrogen works to decrease inflammation. Decreasing estrogen levels can contribute to pain in the joints common joint affected are: knees, elbows, hips, low back, shoulders and neck.

HEADACHE:

Many women suffer from headaches due to fluctuations in estrogen and progesterone. Estrogen causes blood vessels to dilate and Progesterone causes them to constrict.

Migraine: It can occur on one side or both sides of head. Other symptoms include nausea, vomiting, sensitivity to light and noises often accompany migraines.

Tension Headaches: Generally produces a diffuse, mild to moderate pain throughout the head like having a tight band around your head. This kind of headache may also cause pain at the back of neck and base of scull.

Sinus Headaches: Caused by inflammation and blockage of the sinus cavities

MUSCLE TENSION/ CRAMPING/ SPASMS

The feeling that muscles are always tight or under strain can cause persistent and ongoing pain. These symptoms are closely related to stress and anxiety.

Low estrogen causes an increase in cortisol levels (stress hormone), high levels of cortisol and low estrogen cause the muscles in the body to tighten and fatigue. Progesterone has a calming effect on the body and mind. When levels of progesterone begin to drop prior to menopause, muscle tension tends to increase.

TREATMENT OPTIONS:
Lifestyle changes including physical activity (walking, swimming, yoga flexibility and muscle strengthening) can help alleviate joint pain, bone loss and stress.

Complementary & Alternative Medicines: Herbal supplements (under the care of Naturopathic Doctor), Chiropractic, Massage Therapy and Acupuncture can help keep joints moving and pain free, as well as treat existing joint pain, headache and muscle tension.

Chiropractic treatment as part of CAM (Complementary & Alternative Medicine)

Chiropractic treatment can help treat both the symptoms and the cause of the pain. By treating the muscles and joints associated with tension and constriction of blood vessels, both sooths symptoms during a headache and helps prevent them from returning. Your Chiropractor at Dynamic Health & Performance will develop a well rounded treatment plan specifically designed to give you the best results.

We also screen for other causes of pain (posture, overuse injury) recognizing and avoiding dietary triggers for headache, screening and recognizing risk factors that may require further medical investigation or referral back to family doctor, as well as guidance to other CAM therapists when necessary.