Pregnancy-induced Pelvic Girdle Pain: The ICF Framework

Mini Review

By Bilen Mekonnen Araya

Pregnant women experience pregnancy-related bodily changes that are accompanied by bodily pains due to the physical demand of the growing fetus, the extra weight, and hormonal variations. The pelvic girdle—made up of four bones: right and left hip bones, the sacrum, and the coccyx—bears the bulk of the body’s weight (1). Pregnancy-related hormonal changes cause the pelvic ligaments, muscles, and joints to stretch so that the pelvic girdle can accommodate the weight of the growing fetus. Unfortunately, such changes during pregnancy are also accompanied by musculoskeletal pain such as pelvic girdle pain (2).

Pelvic girdle pain is defined as the pain experienced between the posterior iliac crest and the gluteal fold particularly in the vicinity of the sacroiliac joints (3). Pregnancy-induced Pelvic Girdle Pain (PPGP) is one of the common complaints during pregnancy that needs to be discussed by disability and rehabilitation related models for a better understanding and management of the condition. This paper discusses how the International Classification of Functioning, Disability, and Health (ICF) framework can be used to describe the condition.

The incidence of PPGP ranges from 4% to 86% (2,4-7). PPGP begins in the first trimester—the first 3 months of pregnancy—and the pain’s severity gradually increases as the pregnancy progresses. In some conditions, the pain might persist into the postpartum period, which is not very well studied in the field of rehabilitation (8). PPGP impairs the ability to accomplish daily functions such as sitting, bending, squatting, lying on the back, walking, climbing stairs, and standing (2,9,10). Moreover, it is a disabling condition that can result in a significant loss in the physiological well-being, social functioning, and employability of pregnant women (11). For instance, an estimated 37-72% of pregnant women globally reported taking a 12-15 week sick leave due to pelvic girdle pain throughout their pregnancy (5,12,13). The cause of PPGP is multi-factorial, relating to hormonal, biomechanical, and other predisposing pre-pregnancy factors (14). These factors add to the varying degree of pain-related disability among pregnant women.

PPGP can potentially be disabling for women living with the condition, yet there is a lack of adequate description and explanation of the condition using relevant disability and rehabilitation-related frameworks. Incorporating such frameworks in clinical and rehabilitation settings advances the understanding of such a complex health condition and guides clinical professionals to design appropriate rehabilitation services for women experiencing PPGP. Rehabilitation science aims to maximize functioning, increase participation, and enhance the quality of life (15). The ICF framework can be used to describe and explain PPGP and to design rehabilitation services for PPGP.

..an estimated 37-72% of pregnant women globally reported taking a 12-15 week sick leave due to pelvic girdle pain throughout their pregnancy.

The ICF, developed by the World Health Organization, is a comprehensive framework for health and disability that focuses on health components rather than disability to create a common language for understanding health conditions (16) and describing the human function (17). One of the distinct aspects of the ICF is its ability to be implemented at the body, individual, and societal levels. Other traditional models of disability (e.g., the medical model) fail to capture more than the biological aspects of a person’s life, and instead focus on ‘fixing’ the problem. On the other hand, the ICF looks beyond the obvious biological problem and provides a holistic perspective. The ICF has four domains: the body structure and function, activity, participation, and contextual (environmental and individual) factors (16). Applying the ICF framework to PPGP allows us to address the physical, psychological, and social impacts of the condition.

Image source: wavebreakmedia_micr (freepik)

At the body function and structural level, the pelvic floor muscles and ligaments are overstretched to accommodate the fetus and bear the extra weight of the pregnancy leading to changes in body posture and pain. At the individual level, the functional limitations of PPGP restrict the woman’s ability to perform meaningful daily activities like standing or sitting for long periods, walking, and completing household or employment-related activities that require pelvic joint movement (11). The pain also creates a problem in intimate partner relationships (17). At the participation level, PPGP impedes women from participating in meaningful social activities resulting in social isolation and loneliness, yet no functional capacity evaluations measure these subsequent outcomes (17). Furthermore, the debilitating effects of PPGP may force women to take sick-leaves, where absence from work put women living with the condition at a socio-economic disadvantage (12). Lastly, the ICF assists healthcare providers and rehabilitation professionals to identify the environmental and personal factors that facilitate or hinder the disability caused by PPGP. For instance, the healthcare professionals’ perception of PPGP as an accepted and expected symptom of pregnancy may make women feel dismissed (18).

The ICF can be used to create a common platform to facilitate cooperation among healthcare providers to design targeted rehabilitation services for women with PPGP. While the medical model is limited as it only addresses the impairment (e.g., the pain component), the ICF can be used to design a comprehensive and multi-factorial care plan that addresses not only the impairment but other personal and environmental factors that target PPGP. On the contrary, when implementing the medical model of disability, health professionals have the responsibility and authority to implement a treatment plan to “fix” the problem (19). The therapies for PPGP informed by the medical model include—but are not limited to—water gymnastics, yoga, pelvic stabilizing exercises, nerve stimulation, and anesthetic injections to reduce pain (20,21). Studies show that the treatments alone are not bringing the outcome intended—managing the pain—due to the changes in regular functioning during pregnancy and the fact that the women are not being included in their management plan (22,23). Currently, only 25% of providers recommend any management plan for PPGP (24) and with this in mind, it needs to be emphasized that recommending sick-leaves is not a management plan and tends to have unforeseen consequences.

Image source: Waewkidja (freepik)

In contrast, the ICF can be applied to inform rehabilitation goal-setting, intervention, and evaluation of management outcomes for the women in clinical or community settings. By using ICF, healthcare providers include clients in the management plan, which increases exercise adherence for the pain. Also, to maximize the day to day functioning of the women, ICF can be used to create an alternative plan for their household activities and employment by sharing responsibilities and involving family members in the treatment plan to make the household environment more accommodating. At the individual and community level, rehabilitation service providers can work on building the woman’s self-esteem by counseling and creating community awareness and advocacy on PPGP, respectively. ICF can also be used to monitor and evaluate the effectiveness of the current treatment plans and give recommendations based on its four domains.

…only 25% of providers recommend any management plan for pelvic girdle pain and with this in mind, it needs to be emphasized that recommending sick-leaves is not a management plan…

Involving the clients and family members in the management plan provides a complete picture into aspects of the person’s life including their social interactions and how they can manage the condition effectively. The medical model is focused on treating the pain, which can be considered the cause for everything, but treating pain during pregnancy is difficult due to the physiological and anatomical changes that occur at the time of pregnancy. The ICF, goes beyond “fixing” the problem, which addresses the aim of rehabilitation practice: to achieve and maintain optimal functioning and interaction with their environment.

Acknowledgements

Featured illustration by Alexandra Ho for rehabINK.

To refer to this article, it can be cited as:

Araya, B.M. Pregnancy-induced Pelvic Girdle Pain: The ICF framework. rehabINK. 2021:10. Available from: https://rehabinkmag.com

References

  1. Rice University. Anatomy and Physiology: The Pelvic Girdle and Pelvis [Available from: https://opentextbc.ca/anatomyandphysiology/chapter/8-3-the-pelvic-girdle-and-pelvis/#:~:text=The%20pelvic%20girdle%20is%20formed,coccyx%2C%20together%20form%20the%20pelvis.
  2. Gutke A, Boissonnault J, Brook G, Stuge B. The Severity and Impact of Pelvic Girdle Pain and Low-Back Pain in Pregnancy: A Multinational Study. Journal of Women’s Health. 2018;27(4):510-7.
  3. 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(6):794-819.
  4. Kanakaris NK, Roberts CS, Giannoudis PV. Pregnancy-related pelvic girdle pain: an update. BMC Medicine. 2011;9(1):15.
  5. Malmqvist S, Kjaermann I, Andersen K, Okland I, Larsen JP, Bronnick K. The association between pelvic girdle pain and sick leave during pregnancy; a retrospective study of a Norwegian population. BMC Pregnancy Childbirth. 2015;15:237.
  6. Weis CA, Barrett J, Tavares P, Draper C, Ngo K, Leung J, et al. Prevalence of Low Back Pain, Pelvic Girdle Pain, and Combination Pain in a Pregnant Ontario Population. J Obstet Gynaecol Can. 2018;40(8):1038-43.
  7. Dunn G, Egger MJ, Shaw JM, Yang J, Bardsley T, Powers E, et al. Trajectories of lower back, upper back, and pelvic girdle pain during pregnancy and early postpartum in primiparous women. Womens Health (Lond). 2019;15:1745506519842757.
  8. Wuytack F, Daly D, Curtis E, Begley C. Prognostic factors for pregnancy-related pelvic girdle pain, a systematic review. Midwifery. 2018;66:70-8.
  9. Borkar S, Mahishale A. Determining the prevalence of patterns of pregnancy-induced pelvic girdle pain and low back pain in urban and rural populations: A cross-sectional study. Journal of the Scientific Society. 2016;43(2).
  10. Ceprnja D, Chipchase L, Gupta A. Prevalence of pregnancy-related pelvic girdle pain and associated factors in Australia: a cross-sectional study protocol. BMJ Open. 2017;7(11):e018334.
  11. Gutke A, Bullington J, Lund M, Lundberg M. Adaptation to a changed body. Experiences of living with long-term pelvic girdle pain after childbirth. Disabil Rehabil. 2018;40(25):3054-60.
  12. Vermani E, Mittal R, Weeks A. Pelvic girdle pain and low back pain in pregnancy: a review. Pain Pract. 2010;10(1):60-71.
  13. Gutke A, Olsson CB, Vollestad N, Oberg B, Wikmar LN, Robinson HS. Association between lumbopelvic pain, disability and sick leave during pregnancy – a comparison of three Scandinavian cohorts. J Rehabil Med. 2014;46(5):468-74.
  14. Hodges PW, Cholewicki J, Popovich Jr JM, Lee AS, Aminpour P, Gray SA, et al. Building a collaborative model of sacroiliac joint dysfunction and pelvic girdle pain to understand the diverse perspectives of experts. PM&R. 2019;11:S11-S23.
  15. World Health Organization. Rehabilitation 2020 [Available from: https://www.who.int/news-room/fact-sheets/detail/rehabilitation.
  16. WHO. Towards a common language for functioning, disability, and health. ICF. 2002.
  17. Clinton SC, Newell A, Downey PA, Ferreira K. Pelvic girdle pain in the antepartum population: physical therapy clinical practice guidelines linked to the international classification of functioning, disability, and health from the section on women’s health and the orthopaedic section of the American Physical Therapy Association. Journal of Women’s Health Physical Therapy. 2017;41(2):102-25.
  18. Wuytack F, Curtis E, Begley C. The health-seeking behaviours of first-time mothers with persistent pelvic girdle pain after childbirth in Ireland: A descriptive qualitative study. Midwifery. 2015;31(11):1104-9.
  19. Hodges PW, Cholewicki J, Popovich JM, Jr., Lee AS, Aminpour P, Gray SA, et al. Building a Collaborative Model of Sacroiliac Joint Dysfunction and Pelvic Girdle Pain to Understand the Diverse Perspectives of Experts. PM R. 2019;11 Suppl 1:S11-S23.
  20. Casagrande D, Gugala Z, Clark SM, Lindsey RW. Low Back Pain and Pelvic Girdle Pain in Pregnancy. J Am Acad Orthop Surg. 2015;23(9):539-49.
  21. Stuge B. Evidence of stabilizing exercises for low back- and pelvic girdle pain – a critical review. Braz J Phys Ther. 2019;23(2):181-6.
  22. Shiri R, Coggon D, Falah-Hassani K. Exercise for the prevention of low back and pelvic girdle pain in pregnancy: A meta-analysis of randomized controlled trials. Eur J Pain. 2018;22(1):19-27.
  23. Martins RF, Pinto e Silva JL. Treatment of pregnancy-related lumbar and pelvic girdle pain by the yoga method: a randomized controlled study. J Altern Complement Med. 2014;20(1):24-31.
  24. Hughes CM, Liddle SD, Sinclair M, McCullough JEM. The use of complementary and alternative medicine (CAM) for pregnancy related low back and/ or pelvic girdle pain: An online survey. Complement Ther Clin Pract. 2018;31:379-83.