Pregnancy-related Pelvic Girdle Pain (PPGP)

• What is Pregnancy-related Pelvic Girdle Pain (PPGP)?
• What causes PPGP?
• How to improve symptoms of PPGP
• Need more help?

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What is Pregnancy-related Pelvic Girdle Pain (PPGP)?

Unfortunately, PPGP is very common during pregnancy. Approximately one third of people will experience PPGP at some point in their pregnancy.

PPGP normally presents as persistent discomfort anywhere in the region of the pelvis:

• Lower Back
• Buttocks
• Pubic Bone
• Groin
• Hips
• Thighs

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What causes PPGP?

We USED to think that PPGP was caused by:

• hormonal changes causing a slight softening of the tissues in preparation for growing bump and birth
• changes in the biomechanics (body weight, centre of gravity, the way you move)
• change in the load placed on your muscles and ligaments around your pelvis

These changes do happen but we now know they do not directly cause pain.

Because of recent research we NOW KNOW that PPGP is caused by:

• an increase in sensitivity or ‘up-regulation’ in the nervous system (brain, spinal cord, nerves)

PPGP has very little to do with the changes in your biomechanics at all!

This up-regulation is normally driven by the addition of the many stressors that commonly come with pregnancy such as:

Remember, pregnancy related stressors, such as those listed above, are experienced in addition to any ongoing stressors that we already have. These stressors may not be obvious or what we would normally identify as ‘stress’. They may be low level stressors that typically come with living a high energy, busy, constantly ‘switched on’ life (that most of us live in the 21st century!)

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How to improve symptoms of PPGP

The good news is there are lots of ways you can improve your symptoms of PPGP.

Many women are able to significantly improve their symptoms by changing the way they think about their pain and by making a few small modifications in their day.

The most effective way to improve PPGP is to reduce the sensitivity of your nervous system. There are many ways you can do this:

• Understand Pain
• Understand Your Body
• Evoke The Relaxation Response
• Exercise
• Modify Your Daily Activities
• Pain Relief

Understand Pain

Think of pain like your brain’s alarm system going off or like a communication between your brain and body. Your alarm system goes off when your brain feels under threat. Your brain needs a way to communicate this to you and that is pain.

Your brain may feel under threat when it is trying to cope with too many stressors and becomes overwhelmed.

What you are feeling is very real but it is important to understand that, in the absence of injury, pain is 100% created in the brain and does NOT equal tissue damage.

Watch this video for more information about pain.

Understand your Body

Hormonal changes in pregnancy create a slight softening of the tissues in preparation for growing bump and birth. This is completely NORMAL and research shows that this does NOT have a link with developing PPGP.

Many people have been given outdated information about their bodies which have caused beliefs such as:

• ‘My pelvis is misaligned’
• ‘My pelvis is unstable’
• ‘The joints in my back are of place’
• ‘The discs in my back have slipped’

If you have been given this information by a health professional, unless you have had a traumatic injury, it is likely INACCURATE.

These beliefs only drive worry about the structural integrity of your body and create fear of movement.

Your back and pelvis are made up of the strongest joints in your body and do not become unstable or misaligned in pregnancy. They are also not supposed to be 100% symmetrical!

Understand your Energy System

It is well known that growing a human can feel exhausting from early on in pregnancy. Try to be mindful of your energy levels during your day as this directly contributes to the sensitivity of your nervous system.

When your energy levels are running low, your alarm system is more likely to go off and create pain and fatigue (remember this is your body’s way of communicating with you).

Try to modify your daily activities so you are not draining your energy too quickly. There are many ways you can do this:

• try to slow down as much as possible
• avoid having too much planned in one day
• avoid being on your feet for long periods
• take regular breaks if possible
• be kind to yourself!
• prioritise sleep and rest
• arrange a meeting at work to complete your risk assessment and discuss modification of work duties

Exercise

Exercise is one of the best ways to decrease the sensitivity of your nervous system and therefore help to decrease your PPGP!

Many people are anxious about exercising in pregnancy however there is no evidence that exercise is harmful!

It is also perfectly safe to continue exercises from pre-pregnancy, although some modifications may need to be made such as reducing the intensity or impact of your chosen exercise.

Although there are no absolute restrictions to exercising in low-risk pregnancy it is recommended that you:

• Don’t bump the bump – avoid contact, high risk, and extreme sports
• Avoid lying flat for long periods on your back after 19 weeks
• Keep hydrated and avoid overheating
• Listen to your body and adapt exercise if causing discomfort
• Avoid temperatures that are too hot or too cold
• Avoid high altitudes or low depths
• Try not to get too breathless – you should be able to still have a conversation

If you are having a high risk pregnancy, or are not keeping well please discuss exercise with your obstetric team.

We recommend if struggling with symptoms of PPGP you consider doing some:

• pregnancy yoga
• swimming

Both these type of exercises are low impact, calming and great for reducing sensitivity in your nervous system (the best way to reduce pain).

See this infographic for further information regarding recommended exercise in pregnancy.

Modify Daily Activities

Plan ahead / Modify timing of tasks

• Aim to complete larger activities (e.g. walking the dog, supermarket shopping) at a time of day when your energy levels are higher (i.e. not after a long day at work, as this tends to be when your nervous is more sensitive).

TIP: for most people, the morning (if you have had good quality sleep) tends to be when the nervous system is less sensitive.

Sleep

• Aim for 8-10 hours of sleep within 24hrs. If your sleep is broken due to discomfort or/and frequent toilet trips overnight, try to catch up on sleep during the day having naps where possible.

Accept help

• Pregnancy can be tough especially if you already have young children.
• Accept help with childcare, nursery/school drop offs/pick- ups.
• Delegate housework and other household chores which will help you to slow down and prioritise others activities that may help you to calm your nervous system like rest and sleep!

Other advice (only applicable if you are finding difficult)

• Sit down when getting dressed
• When sleeping, place a pillow in between your legs
• Try getting in/out of bed and turning in bed via your hands and knees (try not to hold your breath or brace)
• If sitting for long periods, take regular breaks and try sitting on a gym ball

Nutrition & Hydration

Ensure you are eating plenty of nutrient dense foods like fruit and veggies! If you are struggling with nausea or vomiting try small snacks throughout the day instead of large meals. If your calorie intake is low this will affect your energy levels which will affect your pain!

Keep well hydrated by drinking between 1.5 -2L of fluids per day.

Visit NHS Inform for more information.

Evoke the Relaxation Response

Finding moments of calm throughout the day will help to desensitize your nervous system. Set time aside (can be as little as 10 minutes) and practise:

• Deep diaphragmatic breathing
• Gentle, fluid, mindful exercise – think yoga or swimming
• Meditation / Mindfulness

Other ways to evoke the relaxation response:

• Anything that helps you to relax
• Do something that you enjoy
• Meet with friends and/or family who make you laugh
• Take regular baths
• Spend more time in nature or with pets

Pain relief

There is a variety of pain relief options available in the community for you to consider if you are struggling to cope with your PPGP symptoms:

• Analgesic medication
• Heat/Cold therapy
• TENS machine
• Manual therapy such as massage
• Acupuncture

Please discuss pain relief options with your GP, Pharmacist, midwife, or obstetric consultant.

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Need more help?

If you are finding it difficult to manage your PPGP after reading (and following) the information above please self-refer to Pelvic Health Physiotherapy.

You will be given a telephone or Near Me appointment (normally within 2 weeks) where you can discuss your symptoms and management strategies with a specialist physiotherapist.

It may be appropriate to ask you to attend the clinic for a face to face appointment.

• Complete this form to self refer to Pelvic Health Physiotherapy.