Pain in the pelvic region of the body is common among pregnant women and can be experienced well into the postpartum period.  The traditional thinking that has dominated implicates the hormone relaxin as a key culprit.  Surely the release of a pregnancy-related hormone that has a job to soften ligaments would result in increased motion of the pelvic structures is the reason for the pain, right?  Actually, we now know this is wrong.  We now understand that pregnancy-related pelvic girdle pain (PPGP) – that is pain anywhere in the pelvic region, including the joints at the back and the front – has much more to do with factors outside of the pelvic tissues.  Factors that actually make the pelvic tissue more sensitive or reactive to stimulus.  This happens due to factors that evoke automated protective responses in the nervous system   Understanding PP-PGP from the perspective of “more sensitive tissue” not only fits with evolved pain science but also helps to explain why only half of women struggle with this problem.  If the problem was really related to something inherent in all pregnancies, then all women and all pregnancies would demonstrate PGP.  Well, we know that is simply not the case so like everything else in life, it means the tissue is more complex, but it is not complicated.

What makes tissues more sensitive or protective?  There are many, but the top 3 I target include:

 1. Fear

There is so much fear related to pregnancy and birth particularly if there have been any difficult situations related to conception, a previous pregnancy, a previous birth and so on.  There is also a great deal of fear related to the INCORRECT assumption that discomfort in the pregnant pelvis means the pelvis is “dysfunctional” or “unstable”.  We see consistently that those who have incorrect beliefs about the structural integrity of their pelvis are the ones who have lasting persistent pain postpartum.  Sadly, many well-meaning care providers induce harm by perpetuating this incorrect narrative.

2. Low Energy Reserve

A basic tenant of our biological protection mechanisms is to trigger alarm when resources are low.  One such alarm output is pain. The energy demands of pregnancy are huge and we are currently living in a biological mismatch.  That is to say, in the 21^st century, our lives are really not organized to match what is optimal for our biological systems.  Mamas who experience PGP are consistently those who are depleted, spread thin and not sleeping well.  The resulting tissue sensitively is a call for help and attempting to communicate the needs for self-care, rest and restoration.

3. Altered Inflammatory Processing

As with every health state that deviates from optimal, inflammation is a key modulator and should always be an aspect of physiology we are prioritizing to correct.  Many of the established risk factors for PGP such as smoking, increased body mass index and low engagement in exercise all have the common underpinning of systemic inflammation.

*Note that NONE of the established risk factors for PGP have anything to do with the structures of the pelvis

So, what do we do to dial down the protection response to foster ease with movement and a renewed sense of empowerment through pregnancy and into birth and beyond?

We do many things, use many tools and consider all the systems at play, but we should always ensure our care is grounded in the following:

1. Ensure mama understands how the pain systems works and how all the biological systems (including thoughts, expectations, sleep status, perceptive of social support and so on), impact the threat-response systems.

2. Where unhelpful health beliefs exist, work to help reframe these perspectives through a combination of cogitative and mindfulness strategies.

3. Promote reassurance regarding structural integrity of the pelvis through using traditional strategies such as manual therapy, exercise and physical supports.

*Consider this list your litmus test to know if you are engaging in evolved evidence-informed care

If you are a healthcare provider who wants to learn more and evolve your approach to pregnancy-related PGP, visit Reframe Rehab to register for Reframe Pelvic Girdle Pain: A 21st Century Approach.