|Year : 2016 | Volume
| Issue : 2 | Page : 70-74
Determining the prevalence of patterns of pregnancy-induced pelvic girdle pain and low back pain in urban and rural populations: A cross-sectional study
Arati Mahishale, Sudini Santosh Borkar
Department of OBG Physiotherapy, KLEU Institute of Physiotherapy, Belagavi, Karnataka, India
|Date of Web Publication||18-May-2016|
Sudini Santosh Borkar
MIG-18, Vidhyanagar Housing Board, Margao, Goa - 403 601
Source of Support: None, Conflict of Interest: None
Background: Biomechanical changes during pregnancy impose postural deviations, leading to various musculoskeletal pain syndromes. Commonly noted pain syndromes are the pelvic girdle pain (PGP) and low back pain (LBP), which were experienced by pregnant women globally. There is a prevalence of pregnancy-related PGP (PPGP) and pregnancy-related LBP (PLBP) in Western population. Data of the same in Indian pregnant population lack evidence. Objective: To find the rates of incidence and prevalence of different patterns of PPGP and PLBP in the urban and rural pregnant women. Materials and Methods: A total of 580 pregnant women were screened for inclusion criteria. Confirmation of diagnosis of PGP and LBP was done for 457 subjects using Modified Oswestry Disability Index (MODI) questionnaire and the pelvic girdle questionnaire (PGQ). Once diagnosed, all participants were subjected to nine clinical tests to differentiate the site of pain and to classify them accordingly into three different groups, namely group A (LBP), group B [posterior pelvic pain (PPP)], and group C [anterior pelvic pain (APP)]. Results: The point prevalence of pain in group A (LBP) was 31%, in group B (PPP) was 65%, and in group C (APP) was 15%. The prevalence of PGP and LBP was 75% in the urban pregnant population and 25% in the rural pregnant population. Conclusion: The prevalence rate of PPP (65%) is higher than that of LBP (31%) and APP (15%). Also PPP is reported to be highest in primiparous with gestational age of 38 weeks. The urban population showed 75% and rural population showed 25% of PGP and LBP.
Keywords: Low back pain (LBP), Modified Oswestry Disability Index (MODI) questionnaire, pelvic girdle pain (PGP), pelvic girdle questionnaire (PGQ), pregnancy
|How to cite this article:|
Mahishale A, Borkar SS. Determining the prevalence of patterns of pregnancy-induced pelvic girdle pain and low back pain in urban and rural populations: A cross-sectional study. J Sci Soc 2016;43:70-4
|How to cite this URL:|
Mahishale A, Borkar SS. Determining the prevalence of patterns of pregnancy-induced pelvic girdle pain and low back pain in urban and rural populations: A cross-sectional study. J Sci Soc [serial online] 2016 [cited 2021 Apr 20];43:70-4. Available from: https://www.jscisociety.com/text.asp?2016/43/2/70/182597
| Introduction|| |
Pregnancy-related pelvic girdle pain (PPGP) and pregnancy-related low back pain (PLBP) are the most common problems reported in the pregnant women in the Indian society.  According to the European guidelines of Vleeming et al., PGP can be defined as follows: "Pelvic girdle pain that generally arises in relation to pregnancy, trauma, arthritis and osteoarthritis. Pain is experienced between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the sacroiliac joints (SIJ). The pain may radiate in the posterior thigh and can also occur in conjunction with/or separately in the symphysis pubis."  Low back pain is characterized as an axial or parasagittal discomfort in the lower lumbar region and it is musculoskeletal in nature. 
Reported prevalence rates of PPGP in Western countries are 23.6%, 22.6%, 36.2%, 14.2%, 31.2%, and 34% in various prospective studies, and 42.4% and 9.8% in retrospective studies. Similarly for PLBP, the point prevalence in the Western countries was found to be 25% and 16%.  The etiological factors of PGP include hormonal changes, biomechanical changes, trauma, metabolic factors, inadequate motor control, and stress of the ligamentous structures.  The hormone relaxin affects the laxity of ligaments of the pelvic girdle as well as ligaments in the rest of the body. The effect of increased ligament laxity is a slightly larger range of movement in the pelvic joints. If this is not compensated by altered neuromotor control, pain may occur and also lead to the widening and separation of the symphysis pubis.  The studies have reported an association with metabolic comorbidities, such as diabetes, but the underlying etiologic mechanism is not clear. Studies elucidate that cases with PGP are more likely to have a mother or sister with PGP.  LBP during pregnancy that is generally ascribed to the many changes in load and body mechanics that occur during the carrying of a child. Increase of the weight during pregnancy clearly shifts the body's center of gravity anteriorly and increase the moment arm of forces applied to the lumbar spine. Studies suggest that an anterior shift is associated with pubic symphysis problems. Postural changes may be implemented to balance the anterior shift, leading to lordosis, and increase in the natural inward curvature of the spine, further increasing stress on the lower back. Also the intervertebral discs respond to axial loading by expelling fluid, resulting in decreased height and an overall compression of the spine. 
PPGP is classified into five subgroups depending on the symptoms  such as pelvic girdle syndrome that includes symptoms of anterior and posterior pelvic girdle, symphysis pubis, and bilateral joints. Symphysiolysis includes symptoms of the anterior pelvic girdle and pubic symphysis. Symptoms of the posterior pelvic girdle and unilateral sacroiliac joint are called one-sided sacroiliac syndrome. Double-sided sacroiliac syndrome includes symptoms such as posterior pelvic girdle and bilateral sacroiliac joint. Inconsistent findings of the pelvic girdle are included in the miscellaneous group. PPGP often starts during the 18 th week of pregnancy and it often reaches peak intensity between the 24 th week and 36 th week or begin shortly after postpartum. Women with PGP experience stabbing, shooting, or burning type of deep unilateral or bilateral pain in the gluteal region, between the iliac crest and the gluteal fold, near the sacroiliac joints and distal to the lumbar spine that may radiate to the posterior thigh and can be associated with or without symphysis pain. It limits ability to maintain prolonged positions and activities, especially endurance is diminished for standing, walking, and sitting.  Various clinical tests are performed to confirm the diagnoses of sacroiliac joint pain that are as follows: PPP provocation test (P4), Patrick's Faber test, palpation of the long dorsal sacroiliac joint ligament, Gaenslen's test, distraction, compression, and Menell's tests. Palpation of symphysis and modified Trendelenburg's test of the pelvic girdle are the tests used for symphysis pain and active straight leg raise test (ASLR test) is the functional pelvic test used for LBP. 
The point prevalence of PGP in pregnant women was found to be 20% in the Western countries. Similarly, the point prevalence of PLBP was found to be 25%, and 16% of women with PLBP reported persistent pain 6 years after childbirth in the Western countries.  Indian data of the same in Indian pregnant population lack evidence hence the present study intends to find the prevalence of patterns of PPGP and PLBP in Indian pregnant population and to create an Indian database for pregnancy so that emphases on treatment measures are implemented.
| Materials and methods|| |
Source of data
Inpatient and outpatient departments of obstetrics and gynecology at a tertiary care center.
The present study was designed as a cross-sectional study to find the prevalence of patterns of PPGP and PLBP at a tertiary care center.
Sampling design and sampling allocation
Sample of convenience/nonprobability sampling.
- The study was endorsed by the Institutional Ethical Committee. A total of 580 pregnant women were screened based on the inclusion criteria that included:
The women were excluded if they have a
- Pregnant women with complaints of LBP and PPGP,
- Subjects with gestation age of 16-40 weeks,
- Subjects willing to participate in the study.
All participants signed an informed consent form that declared their voluntary agreement to participate in the study. Demographic details were taken and confirmation of diagnosis of PGP and LBP was done in 457 women using Modified Oswestry Disability Index (MODI) questionnaire and the pelvic girdle questionnaire (PGQ).Participants were then subjected to nine clinical tests to differentiate the site of pain and to classify them accordingly into three different groups, namely group A (LBP), group B (PPP), and group C [anterior pelvic pain (APP)], respectively.Outcome measures
- History of neoplasm, trauma or previous spinal, pelvic or femur surgery;
- Gynecological problem where the women is advised for complete bed rest;
- Women with verified diagnosis of spinal problems, such as spondylosis and spinal fracture;
- Women on analgesic for the LBP; and
- Noncooperative subjects.
- Modified Oswestry Disability Index (MODI):  It is a subjective assessment of the level of function (disability) in activities of daily living in those suffering from acute or chronic LBP. The questionnaire examines perceived level of disability in 10 everyday activities of daily living questions.
- Pelvic girdle questionnaire (PGQ):  It is a self-reported questionnaire consisting of 20 activity items and 5 symptom items that are scored on a 4-point response scale and item score are summed and transformed to yield a score of 0-100 where 100 is the worst possible score.
| Results|| |
A total of 457 pregnant women were included in the study between the gestational ages of 16-40 weeks. Nine clinical tests were used to differentiate the pain and group the subjects into LBP, PPP, and APP accordingly, and the percentage of each group was evaluated.
The mean age of all the participants with PPP and LBP was 23 years and the mean age of all the participants with APP was 24.5 years. Similarly, the mean gestational age of all the participants with PPP, APP, and LBP was reported to be 38 weeks. The data also showed that 70% of the primiparous women, 26% of the multiparous women, and 4% of the grand multipara women complained of PPP. Also, 55% of the primiparous women, 13% of the multiparous women, and 4% of the grand multiparous women complained of LBP. A total of 86% of the primiparous women and 14% of the multiparous women were diagnosed with APP [Table 1].
|Table 1: Mean age, gestational age, and parity of posterior pelvic pain (PPP), anterior pelvic pain (APP), and low back pain (LBP)|
Click here to view
The PPP had a prevalence of 65%, LBP had a prevalence of 31%, and APP had a prevalence of 15% [Figure 1]. PGP and LBP had prevalence of 75% in the urban population and 25% in the rural pregnant population. Urban pregnant women showed higher prevalence (75%) than the rural population [Figure 2].
|Figure 1: Prevalence of posterior pelvic pain (PPP), low back pain (LBP), and anterior pelvic pain (APP)|
Click here to view
| Discussion|| |
The present study shows that the prevalence of PPP is more as compared to that of LBP and APP.
The point prevalence of LBP was found to be 31% in the present study. A similar study was conducted by Wang et al. who concluded that the prevalence of LBP during pregnancy in the New Haven Country, Connecticut is 68.5%.  The study also stated that there is no association between gestational age and LBP. Contradicting, the present study found that LBP is more common in women with gestational age 38 weeks. This could be due to the effect of relaxin and other hormones along with an increase in the lordosis curvature of the lumbar spine. The present study participants with LBP had mean age of 23 + 1 which is in consistent with the findings of Wang et al., which stated that pregnant women in the age group of 25-27 years have more LBP.  Morgen et al. reported a mean gestation age at onset of LBP to be 22.1 weeks,  whereas Jennifer S stated that up to 20% of women claimed that pain started as early as 16 weeks with some claiming pain within the first month.  The present study had inclusion criteria of gestational age of 16-40 weeks, which is the beginning of LBP during pregnancy.
The prevalence of PPP was reported to be 65% and that of APP was reported to be 15% in the present study. Fransico M stated that the pelvic pain in the Spanish women attending the antenatal classes was diagnosed to be 64.7%.  None amongst the 341 pregnant women included by Albert et al. in their study reported to have APP symptoms during pregnancy and even in the postpartum period which is in contrast to the present study which reported that out of 225 pregnant women 15% of women complained of APP.  This is due to the activities and postures adopted by the Indian women as compared to the western population. Albert et al. states that multiparity is the main factor for developing pelvic pain but the present study states that primiparous women have more chances of developing LBP, PPP, and APP.  This could be due to the sudden hormonal changes, undue stretch of the pelvic soft tissue structure, and biomechanical changes that occur during the pregnancy. Mens et al. is of the same opinion as that of the present study which states that primiparity is more associated with the pelvic pain.  Bejland et al. also reported that the risk of developing PGP increases with previous pregnancy.  The results of the present study show more PPP, APP, and LBP in primiparous women which could be due to more primiparous women included in the study as compared to the multiparous or grand multiparous. The PPP and APP is diagnosed to be severe in 38 weeks, which is almost similar to the findings of Mens et al.'s study. Also, Stefan M in his study has proved that the pregnancy relates pelvic pain is more in 36 weeks of pregnancy.  The women of age group of 23-24.5 years were reported to be positive for PPP and APP, which could be due to the biomechanical changes occurring during pregnancy.
The urban population showed 75% and rural population showed 25% of PGP and LBP in the present. The prevalence could be less in rural population as compared to the urban population due the ground level of activities more in them in which the gravity assists in the easy movements of the pelvic and the lumbar spine. Urban pregnant population are mostly prevented from doing heavy activities and encouraged to lead a more sedentary lifestyle. The activity level is also more in rural pregnant women as compared to the urban pregnant women.
A study was done by Britt et al. which reported that pelvic girdle questionnaire is the first condition-specific measure developed for people with PGP and is high reliable and valid in people with PGP both during pregnancy and postpartum.  The present study has also used the same questionnaire to administer the women with PGP. Davidson M and Keating JL studied the comparison of five low back disability questionnaires, namely the MODI questionnaire, the Quebec Back Pain Disability Scale, the Roland-Morris Disability Questionnaire, the Waddell Disability Index, and the physical health scales of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) in LBP patients.  Same questionnaire has been used in the present study. European Guidelines (2008) are recommended for the diagnosis of PGP. The tests have high intertester reliability. The present study used standardized tests for the classification. 
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Verstraete EH, Vanderstraeten G, Parewijck W. Pelvic girdle pain during or after pregnancy: A review of recent evidence and a clinical care path proposal. Facts Views Vis Obgyn 2013;5:33-43.
Vleeming A, Albert HB, Ostgaard HC, Sturesson B, Stuge B. European guidelines for the diagnosis and treatment of pelvic girdle pain. Eur Spine J 2008;17:794-819.
Jeniffer S, Jonathan NG. Pregnancy and low back pain. Curr Rev Musculoskeletal Med 2008;1:137-41.
Ashok ds. Pelvic girdle pain and low back pain during pregnancy and postpartum in Indian women: a prospective cohort study of prevalence and risk factors in relation to pain intensity and disability (doctoral dissertation, Rajiv Gandhi university of health sciences).
Pelvic girdle pain in pregnancy and post-partum. Clinical practice guideline. 2014; guideline no 16:3-27.
Sjödahl J. Pregnancy-related pelvic girdle pain and its relation to muscle function: Linköping: Linköping University Electronic Press, 2010; p. 79.
Strand LI, Moe-Nilssen R, Ljunggren AE. Back performance scale for the assessment of mobility-related activities in people with back pain. Phys Ther 2002;82:1213-23.
Stuge B, Garratt A, Krogstad Jenssen H, Grotle M. The pelvic girdle questionnaire: A condition-specific instrument for assessing activity limitations and symptoms in people with pelvic girdle pain. Phys Ther 2011;91:1096-108.
Wang SM, Dezinno P, Maranets I, Berman MR, Caldwell-Andrews AA, Kain ZN. Low back pain during pregnancy: Prevalence, risk factor and outcomes. Obstet Gynecol 2004;104:65-70.
Mogren IM, Pohjanen AI. Low back pain and pelvic pain during pregnancy: Prevalence and risk factors. Spine (Phila Pa 1976) 2005;30:983-91.
Kovacs FM, Garcia E, Royuela A, González L, Abraira V; Spanish Back Pain Research Network. Prevalence and factors associated with low back pain and pelvic girdle pain during pregnancy: A multicenter study conducted in the Spanish National Health Service. Spine (Phila Pa 1976) 2012;37:1516-33.
Albert H, Godskesen M, Westergaard J. Prognosis in four syndromes of pregnancy-related pelvic pain. Acta Obstet Gynecol Scand 2001;80:505-10.
Mens JM, Vleeming A, Snijders CJ, Koes BW, Stam HJ. Reliability and validity of the active straight leg raise test in posterior pelvic pain since pregnancy. Spine 2001;26:1167-71.
Davidson M, Keating JL. A comparison of five low back disability questionnaires: Reliability and responsiveness. Phys Ther 2002;82:8-24.
[Figure 1], [Figure 2]