Created by the authors for the APHPT, the new document presents evidence-based recommendations for physical therapy management of clients with PGP-PP. The lead author is Adrienne H. Simonds, PT, PhD, of Rutgers, The State University of New Jersey, Blackwood, N.J. An executive summary appears in the journal’s January/February issue. The complete guideline recommendations are available online at the JWHPT and APHPT websites.
Postpartum pelvic girdle pain: Guidelines and clinical practice for physical therapy management.
PGP-PP appears to be distinct from the common condition of pelvic girdle pain developing during pregnancy (antepartum PGP). For some women with PGP-PP, pain becomes a persistent problem, accompanied by fear of movement and physical activity and sometimes by psychological symptoms beyond pain and disability.
Persistent PGP-PP presents a “more complex” problem that “impact[s] multiple areas of physical, cognitive, emotional, and social functioning, and often requiring a multidisciplinary care approach,” according to the guideline document. Physical therapists are a key part of the professional team involved in managing this potentially debilitating condition.
Dr. Simonds and the guideline team followed a formal process to develop the first evidence-based clinical practice guideline for physical therapy management of PGP-PP. The guideline presents a total of 23 recommendations in six key areas, ranked by strength of supporting evidence:
Risk Factors – Strong evidence suggests that women with previous low back pain or PGP, including PGP during pregnancy, are at higher risk of developing PP-PGP. A wide range of other symptoms and pregnancy-related risk factors are possible, with varying levels of evidence.
Systems Screening – Physical therapists should screen for mood disorders in postpartum women, as depression is a possible risk factor for PP-PGP. There is also strong evidence to support screening for muscle impairments in the pelvic floor, abdominal, hip, and back regions.
Examination – Women with PP-PGP have consistent patterns of pain in the posterior and anterior pelvis, pain with rolling in bed, and pain with weight-bearing. Recommendations address specific, evidence-based tests and examinations to assess levels of pain and muscle function.
Prognosis – The prognosis of PP-PGP is greatly affected by the initial symptoms: clients with initially high pain and disability scores are expected to recover more rapidly and return to function, while those with less-severe symptoms have “minimal gains.” Evidence suggests that women with PP-PGP may experience continued pain and disability, even with physical therapy and other treatments.
Intervention – Recommendations address specific physical therapy interventions for clients with PP-PGP. Interventions with strong evidence of benefit include patient education and, combined with other physical therapy interventions, the use of a pelvic belt. Manual therapy appears to be no more effective than exercise to stabilize and improve the performance of the pelvic floor, back, and hip muscles.
Theoretical Models of Care – Recommendations call for further research to support the use of a “specific theoretical model” for diagnosis, classification, and physical therapy intervention for PP-PGP.
The full guideline document presents a thorough review and discussion of each recommendation, linked to the supporting evidence. The guideline team also proposes a new “hybrid” diagnostic model and classification system for PP-PGP, identifying three categories of load transfer impairment. An accompanying Clinical Decision-Making flowchart facilitates the selection of appropriate tests and intervention strategies for individual clients with PP-PGP.
The authors emphasize the limitations of the available evidence, pointing out recommendations for further research in each aspect of their review. “There is much work to be done to elevate postpartum health, and we believe physical therapists are important member of an interdisciplinary team,” Dr. Simonds comments. “We hope these guidelines streamline what is known about PP-PGP and provide a jumping off point for more advancements in physical therapy care for the postpartum population.”