Chapter OneWhat Is Pelvic Instability?
Janet, whose daughter was a year old when she wrote the following account, underwent nine treatments for pelvic pain.
On April 10, 1996, my healthy, beautiful daughter, Heather, was born. Before the birth I had experienced some pain in my lower back and pelvis but thought it was a normal part of pregnancy and paid little attention to it. After the birth, I spent the first few months in a happy daze, ignoring all the pain. Then I had to go back to work in August, and the pain became worse. I went to the doctor and he recommended physiotherapy, but the therapy just made the pain even worse. After several treatments I felt that I was regressing. Then I went to a therapist who used chiropractic techniques. He saw right away that it was not my back but my pelvis that was the problem.
He suggested a pelvic sling and contacted my doctor about sending me to the hospital. There, after undergoing many X rays, scans, and other tests, I spent four weeks in a cast. It was pure hell because you can't do anything-you can't even sit or lie down comfortably. The cast didn't fit well: When I did lie down, there was enough room between my body and my cast to prop a towel in. With the support gone, the pain became unbearable.
After two weeks, a groove was sawed in the cast and I was given a pelvic sling so I could turn over in the evening. After four weeks, nothing that had been done had had any effect at all, and the pain continued.
I reached the point where I could only hobble around the house. I could only go outside in a wheelchair. I could not care for my own daughter and had to have someone in the house day and night to do everything. My husband not only took care of Heather and me, but he was also there for me emotionally. He cheered me up after all my crying spells.
Finally I went to see Cecile, who had a program for treating pelvic pain. Two days after the first exercise session, I noticed an improvement. I had not seen any improvement for months. In fact, I had only seen things get worse. One week after beginning the exercises, I could already walk better. I didn't need my pelvic sling anymore; nor did I need the wheelchair. Now, after nine treatments (three and a half months later), I can climb stairs again, walk for a while, ride my bike for a while, take care of my daughter, and do some light housework. Sitting up straight for more than a half hour or standing for long isn't quite possible yet, but I am so happy that I have gotten this far.
Yvonne had experienced pelvic pain for several years. When she first saw me for treatment she still walked with crutches. She noticed significant improvement after only four sessions.
It's hard to believe that it could take six years of seeking treatment for pain and dysfunction before finally meeting someone who knows what's going on in your body and can really help you. After all this time, it's great to be pain free!
As you can see from the stories of Janet and Yvonne, pelvic pain can be debilitating and frustrating-even agonizing. What is it, and what causes it?
First, let's deal with terminology. The term "pelvic instability" is nowadays often replaced by the term "pregnancy-related pelvic (or pelvic girdle) pain," which is a much better description of this symptomatic disorder. It has also been called "peripartum pelvic pain"-pelvic pain that occurs around the time of delivery. The term "pelvic instability" is best used once a formal diagnosis of such is made by a physiotherapist or doctor. In Parts I through IV of this book I've used the terms "pelvic pain," "pregnancy-related pelvic pain," and "pelvic instability" somewhat interchangeably. If you're interested in a slightly more clinical discussion of terminology, see Chapter 12.
Pelvic pain involves the bones, joints, nervous system, and muscles of the pelvic and lower-back area. Although the pelvis appears to be a fixed circle of bone, it is actually made up of three separate bones joined together (see Figure 1.1 on the next page):
the two hipbones (the ilia)
the backbone in the lower spine (the sacrum), wedged between the hipbones
A fourth bone, the tailbone (coccyx), is involved in some cases of pregnancy-related pelvic pain.
There are also three joints:
the pubic joint (the pubic symphysis, connecting both hipbones on the front side)
two joints in the lower back area on either side of the sacrum, known as the sacroiliac (SI) joints
The bones form a ring that is held together with ligaments and cartilage, which relax and stretch in response to hormonal changes during pregnancy in order to expand the birth canal area during delivery. This results in the lengthening and weakening of the ligaments of the pelvic joints, the connective fascia, and the surrounding muscles, which all provide stability to the pelvic ring. As a result, the bones may shift and become misaligned, causing pain and interfering with the ability to move properly. Since the musculoskeletal system is inter related, this misalignment may ultimately affect the entire body. Functional movements that were once taken for granted, such as moving from sitting to standing, reaching to put things away, or simply getting out of bed in the morning, may all become difficult and painful.
Who Experiences Pregnancy-Related Pelvic Pain?
Having an unstable pelvis is a normal condition in pregnancy and doesn't necessarily lead to pain; in fact, it is a useful condition that facilitates giving birth. The research of Leonie Damen has shown that pregnant women who experience pelvic pain have differing amounts of laxity between their right and left sacroiliac joints as compared to other pregnant women. A large difference in laxity may cause a displacement of the ilium or the portion of the sacrum that has the most freedom to move. Thus, it is thought that pain arises from the misalignment that occurs as a result of a slightly shifted ilium and/or sacrum into a badly recognized position. As a result of the "new" position in the sacroiliac joint, one will unconsciously try to restore the situation, and muscles will tense and pull within or around the pelvis. This will cause pelvic pain if the wrong muscles try to do the correcting. Tension in the pelvic-floor muscles or in the muscles of the inside of the leg (adductor muscles) will worsen the misaligment and provoke pain.
Women who swam a lot during their youth have significantly more complaints than other patients. I think one of the reasons behind this is that these women have developed a motor pattern that involves a strong use of the pelvic- floor and adductor muscles.
Women who experienced low-back pain before pregnancy or who have demanding jobs that require them to stand for much of the day, such as nurses or physical therapists, are at greater risk of experiencing pelvic pain while pregnant and also of having to endure a prolonged recovery. This could be because the muscle system that should be used in forward-bending or lifting activities has not been sufficiently trained. In other words, poor posture can lead not only to low-back pain but also to pelvic pain!
You can compare pregnancy-related pelvic pain with a train derailment. The train is the ilium, which has derailed from the sacrum. The railway system (the body) is paralyzed at once, and the railway workers (nerves and muscles) panic. Transportation (body movement) must continue, so buses are called in (muscles that would normally carry out other functions), sent by the railroad's central administration (the brain). Once the train is put back on track (via symmetry exercises) and the damage is repaired (during the postpregnancy period), the panic subsides. Traffic returns to normal, and slowly the malfunctions (pain complaints) disappear.
The derailment between the sacrum and the ilium causes the muscles and joints to send the wrong signals, which makes a patient incapable of instinctively feeling or sensing how she should move. The loss of contact between the surfaces of the joints results in unnatural movement patterns and forces the muscles into inappropriate positions. The result is that some muscles tense up while others become weakened. This displacement of the pelvis may have already occurred before a woman became pregnant, but it usually takes place during the pregnancy or delivery.
A derailment doesn't just confuse train traffic; it affects the entire system, which can become overwhelmed when certain parts of the body must accommodate jobs normally done by other areas of the body. Other people may have to take over some of the woman's daily functions.
How Pelvic Pain Can Affect Your Life
Having a child always prompts many life changes, and it is even more difficult to make the required adjustments when the new mother is in constant pain and cannot function; she is not able to take care of her child, cannot enjoy physical intimacy, and requires a great deal of help.
Fortunately, most of my patients tell me that their relationships with their partners improve rapidly once they regain control of their bodies. If it doesn't look like a couple is going to be able to overcome this setback, it may be a good idea for them to discuss the problem with a doctor or a marriage counselor.
Take heart. This book will help you to prevent big trouble and regain normal functioning whenever your pelvis slips out of order.
Chapter TwoHow Do You Recognize Pelvic Dysfunction?
Ellen is another patient for whom it took several years to pinpoint the cause of her problems, which shows how difficult it can be to define these conditions, particularly when they develop over time. She underwent three treatments for pelvic pain; therapy started in the second year following her second pregnancy.
After my first delivery I had problems with my right hip. I primarily had trouble getting up after lying down or sitting. I was really tired and had a lot of trouble handling everyday chores. It took me six years to realize that I had developed chronic problems with my pelvis.
Catherine, who experienced problems for a number of years after her first delivery, underwent conventional treatment throughout that time. She started my therapy program a year after her third delivery and received seven treatments for pelvic instability. She wrote the following when her third child was fifteen months old:
After having my first son I hobbled around with pain in my back and legs. Now, after eight years of pain and therapy, I realized that I had developed pelvic instability. Ironically, that realization occurred when no one was taking me seriously anymore and people were telling me I shouldn't exaggerate so much. In the last three months I've had more positive results than in all the years before. I have the feeling that I can live an almost painless, reasonably normal life. For eight years the specialists told me I had a hernia, but it turns out that's not what was causing the pain.
Francine had three treatments after the delivery of her third child. This excerpt was written when her third child was three months old:
I had problems during my last pregnancy, but I thought it was the baby pressing against my pelvis. Despite a lot of pain I kept walking and working. After the delivery the pain went away, but a week later it came back. After a month I finally called my doctor for help and was referred to Cecile for physiotherapy. The exercises she had me do really made a difference and helped a great deal more than simply resting.
Characteristics of Pelvic Dysfunction
Most women who have this syndrome report continuous pain. Sometimes the pain is sharp, sometimes burning or sore. It seems to focus in and around the pelvic area: in the lower back, the tailbone, the stomach, the sides or back of the thighs, the groin, or the pelvic bone. The pain can radiate downward into the legs, upward into the back, and even into the neck. One of the most annoying things about the pain is that it's so changeable; sometimes it is intense, yet at other times it may disappear suddenly, making the patient feel confused and unsure.
Once this syndrome develops, activities of daily living may become more difficult, including:
turning over in bed
standing for a long time
sitting for a long time
getting up from a couch or chair, especially a low one
walking up and down stairs
lying in the same position for a long time
taking care of a child
vacuuming, ironing, washing dishes, cooking
getting into and out of a car
Besides the general pain that can stem from the activities described above, other symptoms can include:
pain while urinating or defecating
Are your symptoms caused by pelvic instability? A patient with pregnancy-related pelvic pain due to misalignment of the pelvis may have problems with the following exercises. For easy reference, this section is reproduced at the back of the book.
Test Exercise 1
Lie down on your back and stretch out your legs.
Try to lift one leg and then lower it.
Then try lifting the other leg.
If this exercise is difficult, if it hurts, or if you can't even lift your leg in this position, try to lift your leg while pressing against your hips with your hands. Use your hands to exert pressure on both sides of your hips, as if you were pushing your hips together.
If you notice that it is easier to lift your leg when you press your hands into your hips, your symptoms are probably caused by pelvic instability. If applying pressure to both sides of your hips does not help you to lift your leg, it may be a good idea to consult your doctor.
Test Exercise 2
Standing, try to move a light object, such as a piece of paper, forward along the floor with your foot. When pelvic instability or injury is present, this exercise will often be easier with one leg than the other.
Test Exercise 3
Lie on your back with your legs outstretched.
Bend your knees but keep your feet flat on the floor.
Try to move your knees apart while keeping the sides or soles of your feet together.
For someone with pelvic pain, this exercise can range from uncomfortable to extremely painful. You may experience the pain in the pubic bone or on the inside of the thighs near the groin. You may also feel pain in the lower back on either side, at one of your sacroiliac joints (due to joint compression or resistance to normal sacroiliac or lumbar movement). If you frequently experience pain in the tailbone area (the coccyx, see Figure 1.1 on page 8), this exercise may cause you to feel tension in the bottom of the pelvis.
Test Exercise 4
Sit on a hard chair for a while. If you experience pain in your tailbone, it could be caused by tension in the bottom of your pelvis. Most pelvic pain patients can only sit for a limited period of time.
Chapter ThreeWhat Causes Pregnancy-Related Pelvic Pain? A Closer Look
Janice developed pelvic pain following the birth of her first child; she required three treatments approximately two months after her second pregnancy.
The delivery of my first child in 1995 was prolonged and intense; it was an assisted labor, lying down, pushing with my legs up.
The six weeks following my second delivery went badly. I definitely attempted far too much, thinking, I can do this all by myself. I really don't need any help. So, with a baby in a baby carrier and my older son (eighteen months old) in my arms, we took the train to visit Grandma, who was in intensive care. After that I took the kids to the zoo, and, of course, I was carrying far too much. I also did lots of housework soon after my delivery. There was no time to heal and recover my strength. Finally my back and pelvis gave out.