Due to the few RCTs on the effect of treatment for PGP also CCTs were searched for and assessed. In order to be included the studies had to meet the following criteria:
prospective controlled clinical trials (randomized and non-randomized) which studied pregnant women or women in the postpartum period (within 1 year after giving birth), with or without pelvic pain or low back pain. Studies were excluded if they included women with obstetric complications, inflammatory joint diseases, rheumatoid arthritis, ankylosing spondylitis, fractures, osteoporosis, neoplasm with or without metastasis, or other severe pathology related to the spinal column. Interventions evaluated were physical therapy; such as exercise, back school, massage, mobilization/manipulation, use of sacroiliac belt, water gymnastics, electrotherapy and acupuncture; in addition, external fixation, surgery and injection therapy were evaluated.
Studies with at least one of the following outcome measures were included: pain, functional status, sick leave, or with more general outcomes, such as generic health status, well being, overall improvement and patient satisfaction.
One systematic review (searching until 2000) evaluated the effectiveness of physical therapy interventions for pregnancy-related LBP [121
]. Of the 17 studies found, 9 were controlled clinical trials, 4 were randomised and 3 were considered to be of high methodological quality [59
]. One study investigated postpartum women [79
]. Because of the heterogeneity and the varying quality of the studies included in the systematic review, there is no strong evidence concerning the effect of physical therapy interventions on the prevention and treatment of back and pelvic pain related to pregnancy. Evidence was often related to multifactor programs, which include a variety of modalities, such as information, specific exercises, ergonomic advice and mobilisation. The effectiveness of the various components of these programs remains unclear. An updated search (2000–2004) revealed 5 additional studies [17
Exercises for PGP in pregnancy Evidence
(level C): Six studies have examined the effect of exercises on PGP and low back pain in pregnancy with conflicting results [31
]. One RCT of high methodological quality compared water gymnastics with a control group receiving no treatment, and showed a significant positive effect of water gymnastics on sick leave and on pain intensity [59
]. There were no specific inclusion criteria, apart from being pregnant. Only one study [86
] used specific inclusion criteria for PGP. The patients were randomized into three different treatment groups; information, home exercises, and an in-clinic exercise group. There was no significant difference between the groups during pregnancy or at the follow-up (3, 6 and 12 months postpartum) regarding pain intensity and activity. Two trials of moderate to low methodological quality studying individualized physical therapy with exercises show significant positive effects on pain intensity and sick leave [88
]. Another study shows significant decrease in pain intensity after pelvic tilt exercises during pregnancy [127
Discussion: The interventions were heterogeneous with regard to type and duration of exercises, whether performed individually or in groups. The group consider the current scientific evidence sufficient to recommend exercises in pregnancy. Exercises should focus on adequate advice concerning activities of daily living and to avoid maladaptive movement patterns.
Recommendation: We recommend exercises in pregnancy.
Exercises for PGP postpartum Evidence
(level C): Two RCTs with high methodological quality have studied PGP postpartum [79
]; specific inclusion criteria for PGP were used in both studies. Mens et al. [79
] compared video instructed exercises for the diagonal trunk muscle system with placebo exercises and no exercises. No significant differences were found between the groups after 8 weeks of intervention. The exercises were not individualized and not supervised. In the study of Stuge et al. [122
], a treatment program focusing on specific stabilising exercises was compared with physical therapy without specific stabilizing exercises. A stabilizing exercise is meant to dynamically control the lumbar segments and the pelvic joints by activating the local muscles in coordination with the global muscles. These exercises are effective when the pelvic girdle is adequately compressed at the moment of loading, as a result of forces acting across the joint, to ensure stability.
The anatomical structures responsible for stabilization are the ligaments and mono- and polyarticular muscles and fascia [78
A treatment program focusing on specific stabilising exercises [122
] had both statistically and clinically a significantly better effect on pain, functional status, health-related quality of life and physical tests than physical therapy without specific stabilizing exercises, measured after 20 weeks of intervention and 1 year postpartum. A 2-year follow-up study showed persisting low levels of pain and disability in the exercise group and significant differences between the comparison groups [123
: These two studies [79
] differ in type of intervention, individualization, dosage, duration and guidance, and in the number of subjects studied. In the study of Mens et al. [79
], 25% of the subjects terminated their exercise program due to pain, probably because the exercises were too heavy. A treatment program with specific exercises that include local and global muscle systems, individually adapted and guided by a physical therapist show best effects. Further investigation is needed to identify the most effective elements in this type of individual intervention program.
Recommendation: We recommend the use of an individualized treatment program focusing on specific stabilizing exercises as part of a multifactorial treatment for PGP postpartum.
Exercises for PGP based on ankylosing spondylitis Evidence
(level C): One systematic review with sufficient quality was found [20
] (higher than 60 on the quality score). On the basis of this review there are indications that exercise therapy, (consisting of functional, mobilizing and muscle strengthening and exercises for aerobic endurance, and proprioceptive neuromuscular facilitation), is effective. This recommendation is however based on one small RCT of good methodological quality [63
] and there is insufficient evidence about the effectivity in relation to other forms of therapy.
Dagfinrud et al. [20
] stated that a home exercise program is better than no intervention, supervised group physiotherapy is better than home exercises, and that a combined inpatient spa-exercise therapy followed by supervised outpatient weekly group physiotherapy is better than weekly group physiotherapy alone [132
Recommendation: We recommend the use of an individualized exercise program for PGP based on ankylosing spondylitis.
(level C): Two moderate to low methodological quality studies investigated individualized physical therapy [88
]. The two studies had no specific inclusion criteria, apart from being pregnant. Östgaard et al. [97
] compared individual physical therapy with two classes of modified back-school education with training and a control group. They found that individual physical therapy resulted in significantly higher reduction in sick leave and lower pain intensity 8 weeks postpartum compared to the control group. Noren et al. [88
] compared individualized physical therapy with no specific treatment. Pain intensity and sick leave was significantly reduced. However, no comparison between the groups was performed for pain intensity.
Discussion: Based on these findings individually tailored programs are more effective than general group training or no treatment. In our opinion, treatment should be based on the findings from an individual examination.
Recommendation: We recommend the use of individualized physical therapy for PGP.
(level C): One quasi-randomized controlled trial studying pregnant women, compared massage therapy with progressive muscle relaxation therapy and found significantly less back pain intensity, reduced anxiety, improved mood and better sleep in the massage group. However, no comparisons between the groups were made [40
]. There were no specific inclusion criteria, apart from being pregnant.
Discussion: Massage might be helpful. The working group agrees that massage could be given as part of a multifactorial individualized treatment program.
Recommendation: There is no evidence to recommend massage as a stand-alone treatment for PGP.
Modified back school classes
(level C): Two moderate to low methodological quality studies investigated back school classes [74
]. There were no specific inclusion criteria, apart being pregnant. No significant effect was found on pain intensity or sick leave [97
]. A significantly higher proportion of the control group experienced “troublesome” or “severe” backache, compared with the treated group; however, compliance was very low [74
Discussion: Both studies examined an intervention with only two classes of modified back school education with training and ergonomic back care advice. The amount of therapy may have been too small to expect a realistic change, or group treatment may not be sufficient for effective treatment.
Recommendation: There is no evidence to recommend back school classes as a treatment for PGP in pregnancy.
Special pillows to reduce back pain
(level C): One crossover trial compared the use of a specially shaped pillow to fit under the woman’s abdomen (Ozzlo pillow) with a standard pillow [128
]. There were no specific inclusion criteria, apart from being pregnant. Lower scores for backache at night were recorded during the week that women used the Ozzlo pillow; there were no differences in sleeping scores.
Discussion: A crossover study with no separate control group is considered to be a weaker design than an RCT. Moreover, because there is no theoretical rationale behind this intervention, and because the tested pillow is not commercially available, the results of this study are of minor interest here.
Recommendation: We do not recommend a specific pillow as a treatment for PGP during pregnancy.
Evidence (level D): No RCTs or CCTs have studied the effect of information as a single treatment.
Discussion: Several studies have included information as part of their interventions (79, 86, 88, 97, 122). The group agree that the purpose of information is mainly to reduce fear and to encourage/help patients to take an active part in their treatment and/or rehabilitation. It is essential that the information and treatment are consistent across professions to preclude unnecessary anxiety about the condition. General information on PGP needs to be presented (anatomy, biomechanics, motor control) and the patient reassured that their problems are not dangerous to them or their child and that they will probably improve/recover. The patient needs to be encouraged to enjoy physical activity and manage and combine this with periods of rest in order to recuperate. To provide adequate information and ergonomic advice is considered useful.
Recommendation: There is no evidence to recommend information as a single treatment; however, providing adequate information is considered useful.
Manipulation and joint-mobilization
Evidence (level D): No RCTs or CCTs have studied the effect of manipulation or joint mobilization for PGP.
: However, four studies have examined manipulation [21
] or mobilisation for PGP in pregnancy [10
]. The results of the studies indicate that manipulation and mobilisation might be a possible treatment for PGP. The studies had, however, few participants and no control group. Manipulation of the SIJ has been shown to normalize clinical test results without altering the position of the SIJ [130
]. The results of these studies may be based on a positive soft tissue response.
Recommendation: There is no evidence to recommend manipulation or mobilisation for PGP. However, manipulation or joint mobilisation may be used to test for symptomatic relief, but should only be applied for a few treatments.
(level D): No RCTs or CCTs have studied the effect of a pelvic belt for PGP. Discussion
: Several studies have included the use of a pelvic belt as part of their interventions but without investigating it as a single treatment [10
]. The results show that a pelvic belt may reduce mobility/laxity of the SIJ [23
]. Effective load transfer through the pelvis, measured by active straight leg raising (ASLR) has been improved by application of a pelvic belt [78
]. One pilot study using a prospective, two-group design showed a positive effect in pain scores and on daily activities after using a maternity support binder for relief of pregnancy-related back pain [17
Recommendation: There is no evidence to recommend the use of a pelvic belt as a single treatment for PGP. A pelvic belt may be fitted to test for symptomatic relief, but should only be applied for short periods.
Evidence (level D): There is no evidence to recommend the use of electrotherapy, because no studies on this modality were found.
Rest evidence (level D): There is no specific evidence to recommend rest.
(level B): Three RCTs investigated acupuncture in the treatment of PGP and LBP during pregnancy [47
]. There were no specific inclusion criteria, apart from being pregnant. One study of moderate to low methodological quality compared acupuncture with physical therapy [148
]. A significant effect on pain and functional status, in favour of acupuncture, was found. The results may be biased by high drop-out rates and because the groups differed with regard to pain location (LBP and PGP). Furthermore, individual acupuncture treatment was compared to physical therapy given mainly as group treatment. The second study [67
] compared acupuncture with no treatment. Acupuncture patients were significantly less bothered by pain compared with the control group. However, the study was of moderate to low methodological quality because of high drop-out and no intention-to-treat analysis. Also lack of attention given to the control group might have influenced the results. The third study showed significant decrease in pain intensity in the group receiving acupuncture compared to the control group [47
]; also, the capacity to perform general activities improved significantly in the acupuncture group. Another study [33
] shows that acupuncture together with stabilising exercises constitute efficient complements to standard treatment for PGP. The results show significant effect of acupuncture on pain; however, effect on function was not measured.
Discussion: Despite the moderate to low quality of some of the studies, there is evidence that acupuncture seems to alleviate LBP and pelvic pain during pregnancy.
Recommendation: There are indications that acupuncture during pregnancy may reduce pain, but high quality studies are needed.
SIJ therapeutic injection therapy
(level B): In two RCTs [70
], local anaesthetics in combination with corticosteroids were applied to the SIJ in patients suffering predominantly from non-specific spondyloarthropathies and ankylosing spondylitis; the procedure led to pain relief after 1–6 months in 60–88% of the patients.
Discussion: Different guiding techniques for intra-articular injections in the SIJ were used either under fluoroscopy or with CT or MRI guidance. All studies showed immediate pain relief with decreasing effects over time. The therapeutic effect in inflammatory diseases is longer compared with osteoarthritis. Local injection appears promising in patients with inflammatory diseases. However, more studies are needed to clarify whether additional SIJ injections are required besides medication for ankylosing spondylitis.
Recommendation: We recommend intra-articular SIJ injections (under imaging guidance) for ankylosing spondylitis.
(level C): Two CCTs [39
] reported that after application of local anaesthetics and radiofrequency denervation of nerve endings in the posterior ligaments and the posterior capsule [39
] and in the posterior capsule [44
], respectively, between 36 to 65% of the patients had pain relief after 3–12 month.
Discussion: Radiofrequency denervation needs further research before recommendations can be made.
Recommendation: There is no evidence to support the use of radiofrequency denervation.
(level C): One RCT (n
= 110) [154
] reported that after lumbopelvic ligament injection of 20% glucose plus 0.2% lidocaine or normal saline injection, both groups reported sustained reductions in pain and disability, irrespective of the injected substance.
Discussion: There is a substantial effect of injection therapy independent of the used injection. Prolotherapy showed no benefit compared with local saline injections. Further studies are needed to confirm that intra-articular injections are essential, besides general medication. There is no evidence for non-ankylosing spondylitis PGP patients to use local injections as treatment.
Recommendation: There is no evidence to support the use of prolotherapy
Evidence: No studies are available on PGP and pharmacological treatment.
: In clinical practice the medication for PGP should not differ from the medication for acute non-specific LBP [36
], and should generally be restrictive until scientific studies may demonstrate otherwise.
: Pharmacological treatment should follow the guidelines of acute non-specific LBP. Prescribe medication, if necessary, for pain relief (preferably to be taken at regular intervals); first choice paracetamol, second choice NSAIDs [36
(level D). No RCTs or CCTs were identified. Eleven cohort studies on fusion surgery of the SIJ have been found [9
]. In most studies intra-articular SIJ anaesthetic blocks were used as a preoperative inclusion criterion. Three studies advocate an external preoperative test, before surgery [112
Surgery could be applied for severe traumatic cases of PGP as an exception to this recommendation, but only when other non-operative treatment modalities have failed when performed by professionals with expert knowledge of the condition. In that case, preoperative assessment with an external fixator for 3 weeks to evaluate longer lasting effects of fixation, is recommended.
Both clinical and biomechanical data support the use of an external fixator prior to surgery [112
In all mentioned reports of fusion surgery, preoperative evaluation was thorough and an operation took place only on patients in whom non-operative treatment had been unsuccessful.
The studies included 2 up to 77 patients and the results were assessed by the authors as fair to excellent in 50–89% of the patients. In a case report by Berthelot et al. [11
] two patients were operated and had total pain relief. Different techniques are described, but the transiliac technique described by Smith-Petersen and Rogers [115
] with some modifications was most widely used.
Intra-articular sacroiliac injections may also be a useful preoperative tool, but will probably only be an indicator in patients with intra-articular pathology.
In two studies additional symphysiodesis is advocated [90
]; however, from a biomechanical viewpoint this is highly questionable. Van Zwienen et al. [137
] reported that 15% of pseudarthrosis in the symphysis and 9% of nerve root injury was due to posterior instrumentation.
No evidence-based criteria exist for surgery of PGP and it is strongly recommended that physicians with extensive knowledge of the condition perform sacroiliac fusions within a scientific protocol.
Recommendation: There is no evidence to recommend sacroiliac fusion.
: Two RCTs of moderate to low quality investigated the effect of treatment aimed at preventing PGP and LBP during pregnancy [31
]. No effect was found on prevention of the incidence of PGP or LBP. No specific prevention study has been identified.
Discussion: The interventions studied aimed both at prevention and treatment of pregnant women with or without PGP or LBP.
Recommendation: We cannot recommend any specific preventive measure.