The prevalence, implications, and clinical course of pregnancy-related pelvic girdle pain
Keywords:pelvic girdle pain, PGP, pregnancy
Pelvic girdle pain (PGP) during pregnancy is common and, indeed, has always been considered normal. It is commonly associated with moderate to severe pain that impairs everyday activities such as getting up from a chair, bending, walking, working in the home and caring for children, as well as, of course, paid employment. Also, PGP is a frequent cause of sick leave during pregnancy. The aetiology of PGP is poorly understood and there is no official nomenclature, no effective evidence- based preventive measures or treatment, known risk factors or detailed knowledge of the clinical course of the various subgroups of this condition.Objectives
The objectives for this project were to determine the prevalence of PGP during pregnancy in a random population of women, detect factors associated with the development of this condition, explore what influences taking sick leave due to PGP, and examine whether pregnant women with PGP, who have been sub-grouped on the basis of two clinical tests, differ with regards to demographic characteristics and/or the clinical course of PGP during the second half of their pregnancy.Methods
The thesis consists of three papers, based on two separate data collections at Stavanger University Hospital. Paper I and II originate from a retrospective cohort study conducted in 2009, in which women giving birth at Stavanger University hospital in a 4-month period were asked to fill in a questionnaire on demographic features, pain, disability, PGP, pain-related activities of daily living, sick leave in general and for PGP, frequency of exercising before and during pregnancy, and Oswestry Disability Index.
Inclusion criteria were singleton pregnancy of at least 36 weeks and competence in the Norwegian language. Drawings of the pelvic and low back area were used for the localization of pain. PGP intensity was then rated retrospectively on a numerical rating scale. Non-parametric tests, multinomial logistic regression and sequential linear regression analysis were used in the statistical analysis.
Paper III originate from a prospective longitudinal cohort study carried out in 2010. Inclusion criteria were the as for the retrospective data collection and took place at the second-trimester routine ultrasound examination. All eligible women (n=503) filled in questionnaires and answered a weekly SMS question during pregnancy until delivery. Women with pain in the pelvic area underwent a clinical examination following a test procedure recommended in the European guidelines for the diagnosis and treatment of PGP.Results
Paper I report that nearly 50% of the women experienced moderate and severe PGP during pregnancy. Approximately half of them had PGP syndrome, whereas the other half experienced lumbopelvic pain. Ten percent of the women experienced moderate and severe LBP alone. These pain syndromes increased sick leave and impaired general level of function during pregnancy. Approximately 50% of women with PGP had pain in the area of the symphysis pubis. The analysis of risk factors did not present a unidirectional and clear picture.
In Paper II PGP is reported to be a frequent and major cause of sick leave during pregnancy among Norwegian women, which is also reflected in activities of daily living as measured with scores on all Oswestry disability index items. In the multivariate analysis of factors related to sick leave and PGP were work satisfaction, problems with lifting and sleeping, and pain intensity risk factors for sick leave. Also, women with longer education, higher work satisfaction and fewer problems with sitting, walking, and standing, were less likely to take sick leave in pregnancy, despite the same pain intensity as women being on sick leave. In Paper III, 42% (212/503) reported pain in the lumbopelvic region and 39% (196/503) fulfilled the criteria for a probable PGP diagnosis. 27% (137/503) reported both the posterior pelvic pain provocation (P4) and the active straight leg raise (ASLR) tests positive at baseline in week 18, revealing 7.55 (95% CI 5.54 to 10.29) times higher mean number of days with bothersome pelvic pain compared with women with both tests negative. They presented the highest scores for workload, depressed mood, pain level, body mass index, Oswestry Disability Index and the number of previous pregnancies. Exercising regularly before and during pregnancy was more common in women with negative tests.Conclusions
Pelvic pain in pregnancy is a health care challenge in which moderate and severe pain develops rather early and has important implications for society. The observed associations between possible causative factors and moderate and severe LBP and PGP in the analysis of the retrospective data may, together with results from other studies, bring some valuable insights into their multifactorial influences and provide background information for future studies.
Some pregnant women with PGP show a higher pain tolerance, most likely dependant on education, associated with work situation and/or work posture, which decreases sick leave. These issues are recommended to be further examined in a prospective longitudinal study since they may have important implications for sick leave frequency during pregnancy.
If both P4 and ASLR tests were positive mid-pregnancy, a persistent bothersome pelvic pain of more than 5 days per week throughout the remainder of pregnancy could be predicted. Increased individual control over work situation and an active lifestyle, including regular exercise before and during pregnancy, may serve as a PGP prophylactic.
2. Wu WH, Meijer OG, Uegaki K, Mens JM, van Dieen JH, Wuisman PI, et al. Pregnancy-related pelvic girdle pain (PPP), I: Terminology, clinical presentation, and prevalence. Eur Spine J. 2004;13(7):575-89.
3. Vermani E, Mittal R, Weeks A. Pelvic girdle pain and low back pain in pregnancy: a review. Pain Pract. 2010;10(1):60-71.
4. Abramson D, Roberts SM, Wilson PD. Relaxation of the pelvic joints in pregnancy. Surg Gynecol Obstet. 1934;58:595-613.
5. Melzack R. The McGill Pain Questionnaire: major properties and scoring methods. Pain. 1975;1(3):277-99.
6. Mantle MJ, Greenwood RM, Currey HL. Backache in pregnancy. Rheumatol Rehabil. 1977;16(2):95-101.
7. 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.
8. Kristiansson P, Svardsudd K, von Schoultz B. Back pain during pregnancy: a prospective study. Spine (Phila Pa 1976). 1996;21(6):702- 9.
9. 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.
10. MacLennan AH, MacLennan SC. Symptom-giving pelvic girdle relaxation of pregnancy, postnatal pelvic joint syndrome and developmental dysplasia of the hip. The Norwegian Association for Women with Pelvic Girdle Relaxation (Landforeningen for Kvinner Med Bekkenlosningsplager). Acta Obstet Gynecol Scand. 1997;76(8):760-4.
11. Mens JM, Vleeming A, Stoeckart R, Stam HJ, Snijders CJ. Understanding peripartum pelvic pain. Implications of a patient survey. Spine (Phila Pa 1976). 1996;21(11):1363-9; discussion 9-70.
12. Saugstad LF. Persistent pelvic pain and pelvic joint instability. Eur J Obstet Gynecol Reprod Biol. 1991;41(3):197-201.
13. Vas J, Aranda-Regules JM, Modesto M, Aguilar I, Baron-Crespo M, Ramos-Monserrat M, et al. Auricular acupuncture for primary care treatment of low back pain and posterior pelvic pain in pregnancy: study protocol for a multicentre randomised placebo-controlled trial. Trials. 2014;15:288.
14. Gutke A, Kjellby-Wendt G, Oberg B. The inter-rater reliability of a standardised classification system for pregnancy-related lumbopelvic pain. Man Ther. 2010;15(1):13-8.
15. Gutke A, Ostgaard HC, Oberg B. Predicting persistent pregnancy-related low back pain. Spine (Phila Pa 1976). 2008;33(12):E386-93.
16. Kanakaris N, Roberts C, Giannoudis P. Pregnancy-related pelvic girdle pain: An update. BMC medicine. 2011;9:15.
17. Albert H, Godskesen M, Westergaard J. Prognosis in four syndromes of pregnancy-related pelvic pain. Acta Obstet Gynecol Scand. 2001;80(6):505-10.
18. van Kessel-Cobelens AM, Verhagen AP, Mens JM, Snijders CJ, Koes BW. Pregnancy-related pelvic girdle pain: intertester reliability of 3 tests to determine asymmetric mobility of the sacroiliac joints. J Manipulative Physiol Ther. 2008;31(2):130-6.
19. 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(1):33-43.
20. 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.
21. Van De Pol G, Van Brummen HJ, Bruinse HW, Heintz AP, Van Der Vaart CH. Pregnancy-related pelvic girdle pain in the Netherlands. Acta Obstet Gynecol Scand. 2007;86(4):416-22.
22. Albert H, Godskesen M, Westergaard J. Evaluation of clinical tests used in classification procedures in pregnancy-related pelvic joint pain. Eur Spine J. 2000;9(2):161-6.
23. Bastiaanssen JM, de Bie RA, Bastiaenen CH, Heuts A, Kroese ME, Essed GG, et al. Etiology and prognosis of pregnancy-related pelvic girdle pain; design of a longitudinal study. BMC Public Health. 2005;5:1.
24. Gutke A, Ostgaard HC, Oberg B. Pelvic girdle pain and lumbar pain in pregnancy: a cohort study of the consequences in terms of health and functioning. Spine (Phila Pa 1976). 2006;31(5):E149-55.
25. Bjelland EK, Eskild A, Johansen R, Eberhard-Gran M. Pelvic girdle pain in pregnancy: the impact of parity. Am J Obstet Gynecol. 2010;203(2):146 e1-6.
26. Kovacs FM, Garcia E, Royuela A, Gonzalez L, Abraira V, Spanish Back Pain Research N. 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(17):1516-33.
27. Larsen EC, Wilken-Jensen C, Hansen A, Jensen DV, Johansen S, Minck H, et al. Symptom-giving pelvic girdle relaxation in pregnancy. I: Prevalence and risk factors. Acta Obstet Gynecol Scand. 1999;78(2):105-10.
28. Malmqvist S, Kjaermann I, Andersen K, Okland I, Bronnick K, Larsen JP. Prevalence of low back and pelvic pain during pregnancy in a Norwegian population. J Manipulative Physiol Ther. 2012;35(4):272- 8.
29. Mousavi SJ, Parnianpour M, Vleeming A. Pregnancy related pelvic girdle pain and low back pain in an Iranian population. Spine (Phila Pa 1976). 2007;32(3):E100-4.
30. Ostgaard HC, Andersson GB, Karlsson K. Prevalence of back pain in pregnancy. Spine (Phila Pa 1976). 1991;16(5):549-52.
31. Pierce H, Homer CS, Dahlen HG, King J. Pregnancy-related lumbopelvic pain: listening to Australian women. Nurs Res Pract. 2012;2012:387428.
32. Robinson HS, Veierod MB, Mengshoel AM, Vollestad NK. Pelvic girdle pain--associations between risk factors in early pregnancy and disability or pain intensity in late pregnancy: a prospective cohort study. BMC Musculoskelet Disord. 2010;11:91.
33. Gashaw M, Gedlu S, Janakiraman B. Burden of pelvic girdle pain during pregnancy among women attending ante-natal clinic, Ethiopia:a cross-sectional study. BMC Pregnancy Childbirth. 2020;20(1):494.
34. Starzec M, Truszczynska-Baszak A, Tarnowski A, Rongies W. Pregnancy-Related Pelvic Girdle Pain in Polish and Norwegian Women. J Manipulative Physiol Ther. 2019;42(2):117-24.
35. 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.
36. Bakilan F ZD. Musculoskeletal problems during pregnancy. J Clin Med Kaz. 2020;60(6):53-5.
37. Ramachandra P, Maiya AG, Kumar P, Kamath A. Prevalence of musculoskeletal dysfunctions among Indian pregnant women. J Pregnancy. 2015;2015:437105.
38. Hassan E. Recall Bias can be a Threat to Retrospective and Prospective Research Designs. The Internet Journal of Epidemiology. 2005;3(2)
39. Bastiaanssen JM, de Bie RA, Bastiaenen CH, Essed GG, van den Brandt PA. A historical perspective on pregnancy-related low back and/or pelvic girdle pain. Eur J Obstet Gynecol Reprod Biol. 2005;120:3- 14.
40. Mogren IM, Pohjanen AI. Low back pain and pelvic pain during pregnancy: prevalence and risk factors. Spine (Phila Pa 1976). 2005;30(8):983-91.
41. Robinson HS, Eskild A, Heiberg E, Eberhard-Gran M. Pelvic girdle pain in pregnancy: the impact on function. Acta Obstet Gynecol Scand. 2006;85(2):160-4.
42. Leadbetter RE, Mawer D, Lindow SW. Symphysis pubis dysfunction: a review of the literature. J Matern Fetal Neonatal Med. 2004;16(6):349-54.
43. Mens JM, Vleeming A, Snijders CJ, Stam HJ, Ginai AZ. The active straight leg raising test and mobility of the pelvic joints. Eur Spine J. 1999;8(6):468-73.
44. Ostgaard HC, Andersson GB, Schultz AB, Miller JA. Influence of some biomechanical factors on low-back pain in pregnancy. Spine (Phila Pa 1976). 1993;18(1):61-5.
45. O'Sullivan PB, Beales DJ, Beetham JA, Cripps J, Graf F, Lin IB, et al. Altered motor control strategies in subjects with sacroiliac joint pain during the active straight-leg-raise test. Spine (Phila Pa 1976). 2002;27(1):E1-8.
46. Albert H, Godskesen M, Westergaard JG, Chard T, Gunn L. Circulating levels of relaxin are normal in pregnant women with pelvic pain. Eur J Obstet Gynecol Reprod Biol. 1997;74(1):19-22.
47. Bjelland EK, Eberhard-Gran M, Nielsen CS, Eskild A. Age at menarche and pelvic girdle syndrome in pregnancy: a population study of 74 973 women. BJOG. 2011;118(13):1646-52.
48. Hansen A, Jensen DV, Wormslev M, Minck H, Johansen S, Larsen EC, et al. Symptom-giving pelvic girdle relaxation in pregnancy. II: Symptoms and clinical signs. Acta Obstet Gynecol Scand. 1999;78(2):111-5.
49. MacLennan AH, Nicolson R, Green RC, Bath M. Serum relaxin and pelvic pain of pregnancy. Lancet. 1986;2(8501):243-5.
50. Cusi M, Saunders J, Van der Wall H, Fogelman I. Metabolic disturbances identified by SPECT-CT in patients with a clinical diagnosis of sacroiliac joint incompetence. Eur Spine J. 2013;22(7):1674-82.
51. Foulkes JF. Hereditary pelvic arthropathy of pregnancy. J Obstet Gynaecol Br Emp. 1957;64(1):131.
52. O'Sullivan PB, Beales DJ. Diagnosis and classification of pelvic girdle pain disorders--Part 1: a mechanism based approach within a biopsychosocial framework. Man Ther. 2007;12(2):86-97.
53. O'Sullivan PB, Beales DJ. Diagnosis and classification of pelvic girdle pain disorders, Part 2: illustration of the utility of a classification system via case studies. Man Ther. 2007;12(2):e1-12.
54. Saunders J CM, Hackett L,Van der Wall H. A comparison of ultrasound guided PRP injection and prolotherapy for mechanical dysfunction of the sacroiliac joint. . Journal of Prolotherapy. 2018;10:e992-e9.
55. Vleeming A, Schuenke M. Form and Force Closure of the Sacroiliac Joints. PM R. 2019;11 Suppl 1:S24-S31.
56. Mens JM, Pool-Goudzwaard A, Stam HJ. Mobility of the pelvic joints in pregnancy-related lumbopelvic pain: a systematic review. Obstet Gynecol Surv. 2009;64(3):200-8.
57. 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.
58. Aldabe D, Milosavljevic S, Bussey MD. Is pregnancy related pelvic girdle pain associated with altered kinematic, kinetic and motor control of the pelvis? A systematic review. Eur Spine J. 2012;21(9):1777-87.
59. Arumugam A, Milosavljevic S, Woodley S, Sole G. Effects of external pelvic compression on form closure, force closure, and neuromotor control of the lumbopelvic spine--a systematic review. Man Ther. 2012;17(4):275-84.
60. Gutke A, Ostgaard HC, Oberg B. Association between muscle function and low back pain in relation to pregnancy. J Rehabil Med. 2008;40(4):304-11.
61. Beales DJ, O'Sullivan PB, Briffa NK. The effects of manual pelvic compression on trunk motor control during an active straight leg raise in chronic pelvic girdle pain subjects. Man Ther. 2010;15(2):190- 9.
62. Katonis P, Kampouroglou A, Aggelopoulos A, Kakavelakis K, Lykoudis S, Makrigiannakis A, et al. Pregnancy-related low back pain. Hippokratia. 2011;15(3):205-10.
63. Lee DG, Lee LJ, McLaughlin L. Stability, continence and breathing: the role of fascia following pregnancy and delivery. J Bodyw Mov Ther. 2008;12(4):333-48.
64. Fortin JD, Aprill CN, Ponthieux B, Pier J. Sacroiliac joint: pain referral maps upon applying a new injection/arthrography technique. Part II: Clinical evaluation. Spine (Phila Pa 1976). 1994;19(13):1483-9.
65. Fortin JD, Kissling RO, O'Connor BL, Vilensky JA. Sacroiliac joint innervation and pain. Am J Orthop (Belle Mead NJ). 1999;28(12):687-90.
66. Laslett M. Evidence-based diagnosis and treatment of the painful sacroiliac joint. J Man Manip Ther. 2008;16(3):142-52.
67. Palsson TS, Beales D, Slater H, O'Sullivan P, Graven-Nielsen T. Pregnancy is characterized by widespread deep-tissue hypersensitivity independent of lumbopelvic pain intensity, a facilitated response to manual orthopedic tests, and poorer self-reported health. J Pain. 2015;16(3):270-82.
68. Szpunar MJ, Parry BL. A systematic review of cortisol, thyroid- stimulating hormone, and prolactin in peripartum women with major depression. Arch Womens Ment Health. 2018;21(2):149-61.
69. Shnaekel KL, Magann EF, Ahmadi S. Pubic Symphysis Rupture and Separation During Pregnancy. Obstet Gynecol Surv. 2015;70(11):713-8.
70. Wang Y, Li YQ, Tian MR, Wang N, Zheng ZC. Role of relaxin in diastasis of the pubic symphysis peripartum. World J Clin Cases. 2021;9(1):91-101.
71. Bjorklund K, Bergstrom S, Nordstrom ML, Ulmsten U. Symphyseal distention in relation to serum relaxin levels and pelvic pain in pregnancy. Acta Obstet Gynecol Scand. 2000;79(4):269-75.
72. Clark J, Nijs J, Yeowell G, Goodwin PC. What Are the Predictors of Altered Central Pain Modulation in Chronic Musculoskeletal Pain Populations? A Systematic Review. Pain Physician. 2017;20(6):487- 500.
73. Bulgakov AV. Specific features of psycho-emotional states of working women during pregnancy. Electron J Gen Med 2018;6(15):1-8
74. Gatchel R, Turk, DC. Psychosocial factors in pain : critical perspectives. New York: Guildford Press; 1999.
75. Burton AK, Tillotson KM, Main CJ, Hollis S. Psychosocial predictors of outcome in acute and subchronic low back trouble. Spine (Phila Pa 1976). 1995;20(6):722-8.
76. Hoogendoorn WE, van Poppel MN, Bongers PM, Koes BW, Bouter LM. Systematic review of psychosocial factors at work and private life as risk factors for back pain. Spine (Phila Pa 1976). 2000;25(16):2114-25.
77. Macfarlane GJ, Thomas E, Croft PR, Papageorgiou AC, Jayson MI, Silman AJ. Predictors of early improvement in low back pain amongst consulters to general practice: the influence of pre-morbid and episode-related factors. Pain. 1999;80(1-2):113-9.
78. Linton SJ. A review of psychological risk factors in back and neck pain. Spine (Phila Pa 1976). 2000;25(9):1148-56.
79. Pincus T, Burton AK, Vogel S, Field AP. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine (Phila Pa 1976). 2002;27(5):E109-20.
80. Hill JC, Fritz JM. Psychosocial influences on low back pain, disability, and response to treatment. Phys Ther. 2011;91(5):712-21.
81. Kamper SJ, Maher CG, Herbert RD, Hancock MJ, Hush JM, Smeets RJ. How little pain and disability do patients with low back pain have to experience to feel that they have recovered? Eur Spine J. 2010;19(9):1495-501.
82. Grotle M, Foster NE, Dunn KM, Croft P. Are prognostic indicators for poor outcome different for acute and chronic low back pain consulters in primary care? Pain. 2010;151(3):790-7.
83. Hill JC, Dunn KM, Lewis M, Mullis R, Main CJ, Foster NE, et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum. 2008;59(5):632-41.
84. Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, et al. Comparison of stratified primary care management for low back pain with current best practice (STarT Back): a randomised controlled trial. Lancet. 2011;378(9802):1560-71.
85. Robinson PS BA, Vollestad NK, Robinson HS. . The association between pregnancy, pelvic girdle pain and health-related quality of life - a comparison of two instruments. J Patient Rep Outcomes 2018;2(45).
86. Mackenzie J, Murray E, Lusher J. Women's experiences of pregnancy related pelvic girdle pain: A systematic review. Midwifery. 2018;56:102-11.
87. Albert HB, Godskesen M, Korsholm L, Westergaard JG. Risk factors in developing pregnancy-related pelvic girdle pain. Acta Obstet Gynecol Scand. 2006;85(5):539-44.
88. Gutke A, Josefsson A, Oberg B. Pelvic girdle pain and lumbar pain in relation to postpartum depressive symptoms. Spine (Phila Pa 1976). 2007;32(13):1430-6.
89. Eberhard-Gran M, Eskild A. Diabetes mellitus and pelvic girdle syndrome in pregnancy--is there an association? Acta Obstet Gynecol Scand. 2008;87(10):1015-9.
90. Robinson HS, Dagfinrud H. Reliability and screening ability of the StarT Back screening tool in patients with low back pain in physiotherapy practice, a cohort study. BMC Musculoskelet Disord. 2017;18(1):232.
91. Mens JM, Huis In 't Veld YH, Pool-Goudzwaard A. The Active Straight Leg Raise test in lumbopelvic pain during pregnancy. Man Ther. 2012;17(4):364-8.
92. Vleeming A, Schuenke MD, Masi AT, Carreiro JE, Danneels L, Willard FH. The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. J Anat. 2012;221(6):537-67.
93. O'Sullivan PB, Beales DJ. Changes in pelvic floor and diaphragm kinematics and respiratory patterns in subjects with sacroiliac joint pain following a motor learning intervention: a case series. Man Ther. 2007;12(3):209-18.
94. Ceprnja D, Chipchase L, Fahey P, Liamputtong P, Gupta A. Prevalence and Factors Associated With Pelvic Girdle Pain During Pregnancy in Australian Women: A Cross-Sectional Study. Spine (Phila Pa 1976). 2021.
95. Gaenslen F. Sacro-iliac arthrodesis: indications, author's technic and end-results. JAMA. 1927;89(24):2031-5.
96. Bhardwaj A, Nagandla K. Musculoskeletal symptoms and orthopaedic complications in pregnancy: pathophysiology, diagnostic approaches and modern management. Postgrad Med J. 2014;90(1066):450-60.
97. Ahlqvist K, Bjelland EK, Pingel R, Schlager A, Nilsson-Wikmar L, Kristiansson P. The Association of Self-Reported Generalized Joint Hypermobility with pelvic girdle pain during pregnancy: a retrospective cohort study. BMC Musculoskelet Disord. 2020;21(1):474.
98. Ali A, Andrzejowski P, Kanakaris NK, Giannoudis PV. Pelvic Girdle Pain, Hypermobility Spectrum Disorder and Hypermobility-Type Ehlers-Danlos Syndrome: A Narrative Literature Review. J Clin Med. 2020;9(12).
99. Rost CC, Jacqueline J, Kaiser A, Verhagen AP, Koes BW. Prognosis of women with pelvic pain during pregnancy: a long-term follow-up study. Acta Obstet Gynecol Scand. 2006;85(7):771-7.
100. Owe KM, Bjelland EK, Stuge B, Orsini N, Eberhard-Gran M, Vangen S. Exercise level before pregnancy and engaging in high-impact sports reduce the risk of pelvic girdle pain: a population-based cohort study of 39 184 women. Br J Sports Med. 2016;50(13):817-22.
101. Vollestad NK, Stuge B. Prognostic factors for recovery from postpartum pelvic girdle pain. Eur Spine J. 2009;18(5):718-26.
102. Robinson HS, Mengshoel AM, Bjelland EK, Vollestad NK. Pelvic girdle pain, clinical tests and disability in late pregnancy. Man Ther. 2010;15(3):280-5.
103. Wuytack F, Daly D, Curtis E, Begley C. Prognostic factors for pregnancy-related pelvic girdle pain, a systematic review. Midwifery. 2018;66:70-8.
104. Bjelland EK, Stuge B, Engdahl B, Eberhard-Gran M. The effect of emotional distress on persistent pelvic girdle pain after delivery: a longitudinal population study. BJOG. 2013;120(1):32-40.
105. Gausel AM, Malmqvist S, Andersen K, Kjaermann I, Larsen JP, Dalen I, et al. Subjective recovery from pregnancy-related pelvic girdle pain the first 6 weeks after delivery: a prospective longitudinal cohort study. Eur Spine J. 2020;29(3):556-63.
106. Beales DJ, Gaynor O, Harris J, Fary R, O'Sullivan PB, Slater H, et al. Correlations between the active straight leg raise, sleep and somatosensory sensitivity during pregnancy with post-partum lumbopelvic pain: an initial exploration. Scand J Pain. 2019;19(1):53- 60.
107. Engeset J, Stuge B, Fegran L. Pelvic girdle pain affects the whole life--a qualitative interview study in Norway on women's experiences with pelvic girdle pain after delivery. BMC Res Notes. 2014;7:686.
108. Elden H, Gutke A, Kjellby-Wendt G, Fagevik-Olsen M, Ostgaard HC. Predictors and consequences of long-term pregnancy-related pelvic girdle pain: a longitudinal follow-up study. BMC Musculoskelet Disord. 2016;17:276.
109. Persson M, Winkvist A, Dahlgren L, Mogren I. "Struggling with daily life and enduring pain": a qualitative study of the experiences of pregnant women living with pelvic girdle pain. BMC Pregnancy Childbirth. 2013;13:111.
110. Noren L, Ostgaard S, Johansson G, Ostgaard HC. Lumbar back and posterior pelvic pain during pregnancy: a 3-year follow-up. Eur Spine J. 2002;11(3):267-71.
111. Orvieto R, Achiron A, Ben-Rafael Z, Gelernter I, Achiron R. Low-back pain of pregnancy. Acta Obstet Gynecol Scand. 1994;73(3):209-14.
112. Dorheim SK, Bjorvatn B, Eberhard-Gran M. Sick leave during pregnancy: a longitudinal study of rates and risk factors in a Norwegian population. BJOG. 2013;120(5):521-30.
113. Truong BT, Lupattelli A, Kristensen P, Nordeng H. Sick leave and medication use in pregnancy: a European web-based study. BMJ Open. 2017;7(8):e014934.
114. Rieck KME, Telle K. Sick leave before, during and after pregnancy. Acta Sociologica. 2013;56(2):117-37.
115. Backhausen M, Damm P, Bendix J, Tabor A, Hegaard H. The prevalence of sick leave: Reasons and associated predictors - A survey among employed pregnant women. Sex Reprod Healthc. 2018;15:54-61.
116. Ariansen AM. Age, occupational class and sickness absence during pregnancy: a retrospective analysis study of the Norwegian population registry. BMJ Open. 2014;4(5):e004381.
117. 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.
118. Robinson HS, Mengshoel AM, Veierod MB, Vollestad N. Pelvic girdle pain: potential risk factors in pregnancy in relation to disability and pain intensity three months postpartum. Man Ther. 2010;15(6):522- 8.
119. Robinson HS, Vollestad NK, Veierod MB. Clinical course of pelvic girdle pain postpartum - impact of clinical findings in late pregnancy. Man Ther. 2014;19(3):190-6.
120. Malmqvist S, Kjaermann I, Andersen K, Gausel AM, Økland I, Larsen JP, et al. Can a bothersome course of pelvic pain from mid- pregnancy to birth be predicted? A Norwegian prospective longitudinal SMS-Track study. BMJ Open. 2018;8(7):e021378.
121. Williamson A, Hoggart B. Pain: a review of three commonly used pain rating scales. J Clin Nurs. 2005;14(7):798-804.
122. Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976). 2000;25(22):2940-52; discussion 52.
123. Leijon O, Wiktorin C, Harenstam A, Karlqvist L, Group MOAR. Validity of a self-administered questionnaire for assessing physical work loads in a general population. J Occup Environ Med. 2002;44(8):724-35.
124. Lorber M, Skela Savic B. Job satisfaction of nurses and identifying factors of job satisfaction in Slovenian Hospitals. Croat Med J. 2012;53(3):263-70.
125. Bhatnagar K, Srivastava K, Singh A, Jadav SL. A preliminary study to measure and develop job satisfaction scale for medical teachers. Ind Psychiatry J. 2011;20(2):91-6.
126. Linton SJ, Melin L. The accuracy of remembering chronic pain. Pain. 1982;13(3):281-5.
127. Mogren I. Perceived health, sick leave, psychosocial situation, and sexual life in women with low-back pain and pelvic pain during pregnancy. Acta Obstet Gynecol Scand. 2006;85(6):647-56.
128. Nilsson-Wikmar L, Holm K, Oijerstedt R, Harms-Ringdahl K. Effect of three different physical therapy treatments on pain and activity in pregnant women with pelvic girdle pain: a randomized clinical trial with 3, 6, and 12 months follow-up postpartum. Spine (Phila Pa 1976). 2005;30(8):850-6.
129. Ostgaard HC. Assessment and treatment of low back pain in working pregnant women. Semin Perinatol. 1996;20(1):61-9.
130. Axen I, Bodin L, Bergstrom G, Halasz L, Lange F, Lovgren PW, et al. The use of weekly text messaging over 6 months was a feasible method for monitoring the clinical course of low back pain in patients seeking chiropractic care. J Clin Epidemiol. 2012;65(4):454-61.
131. Spielberger CD, Gorsuch, R. L., Lushene, R., Vagg, P. R., Jacobs, G. A. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press; 1983.
132. 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 (Phila Pa 1976). 2001;26(10):1167- 71.
133. Laslett M, Williams M. The reliability of selected pain provocation tests for sacroiliac joint pathology. Spine (Phila Pa 1976). 1994;19(11):1243-9.
134. Mogren IM. BMI, pain and hyper-mobility are determinants of long-term outcome for women with low back pain and pelvic pain during pregnancy. Eur Spine J. 2006;15(7):1093-102.
135. Mogren IM. Previous physical activity decreases the risk of low back pain and pelvic pain during pregnancy. Scand J Public Health. 2005;33(4):300-6.
136. Haakstad LAH, Voldner N, Bo K. Pregnancy and advanced maternal age-The associations between regular exercise and maternal and newborn health variables. Acta Obstet Gynecol Scand. 2020;99(2):240-8.
137. Katz N, Borenstein DG, Birbara C, Bramson C, Nemeth MA, Smith MD, et al. Efficacy and safety of tanezumab in the treatment of chronic low back pain. Pain. 2011;152(10):2248-58.
138. Sheahan PJ, Diesbourg TL, Fischer SL. The effect of rest break schedule on acute low back pain development in pain and non-pain developers during seated work. Appl Ergon. 2016;53 Pt A:64-70.
139. Stuart EA. Matching methods for causal inference: A review and a look forward. Stat Sci. 2010;25(1):1-21.
140. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, NJ: Erlbaum; 1988.
141. Bjelland EK, Stuge B, Vangen S, Stray-Pedersen B, Eberhard- Gran M. Mode of delivery and persistence of pelvic girdle syndrome 6 months postpartum. Am J Obstet Gynecol. 2013;208(4):298 e1-7.
142. Howell E. Pregnancy-related symphysis pubis dysfunction management and postpartum rehabilitation: two case reports. J Can Chiropr Assoc 2012;56(2):102-11.
143. OZDEMIR S. BH, ORTABAG T. ACIKEL C. Evaluation of the efficacy of an exercise program for pregnant women with low back and pelvic pain: a prospective randomized controlled trial. Journal of Advanced Nursing. 2015;71(8):1926-39.
144. Saxena AK, Chilkoti GT, Singh A, Yadav G. Pregnancy-induced Low Back Pain in Indian Women: Prevalence, Risk Factors, and Correlation with Serum Calcium Levels. Anesth Essays Res. 2019;13(2):395-402.
145. Meucci RD, Perceval AH, Lima DR, Cousin E, Marmitt LP, Pizzato P, et al. Occurrence of combined pain in the lumbar spine, pelvic girdle and pubic symphysis among pregnant women in the extreme south of Brazil. Rev Bras Epidemiol. 2020;23:e200037.
146. Kuciel N, Sutkowska E, Cienska A, Markowska D, Wrzosek Z. Myoelectrical activity of muscles stabilizing the sacroiliac joints before and after the use of elastic tapes in women suffering from Pregnancy- related Pelvic Girdle Pain. Ginekol Pol. 2020;91(4):223-30.
147. Dawson EG, Kanim LE, Sra P, Dorey FJ, Goldstein TB, Delamarter RB, et al. Low back pain recollection versus concurrent accounts: outcomes analysis. Spine (Phila Pa 1976). 2002;27(9):984-93; discussion 94.
148. Linton SJ. Memory for chronic pain intensity: correlates of accuracy. Percept Mot Skills. 1991;72(3 Pt 2):1091-5.
149. Bolton JE. Accuracy of recall of usual pain intensity in back pain patients. Pain. 1999;83(3):533-9.
150. Von Korff M, Jensen MP, Karoly P. Assessing global pain severity by self-report in clinical and health services research. Spine (Phila Pa 1976). 2000;25(24):3140-51.
151. Bryant RA. Memory for pain and affect in chronic pain patients. Pain. 1993;54(3):347-51.
152. Haas M, Nyiendo J, Aickin M. One-year trend in pain and disability relief recall in acute and chronic ambulatory low back pain patients. Pain. 2002;95(1-2):83-91.
153. Rasmussen CDN, Holtermann A, Jorgensen MB. Recall Bias in Low Back Pain Among Workers: Effects of Recall Period and Individual and Work-Related Factors. Spine (Phila Pa 1976). 2018;43(12):E727- E33.
154. Davies SJ, Lum JA, Skouteris H, Byrne LK, Hayden MJ. Cognitive impairment during pregnancy: a meta-analysis. Med J Aust. 2018;208(1):35-40.
155. Ouellette SJ, Hampson E. Memory and affective changes during the antepartum: A narrative review and integrative hypothesis. J Clin Exp Neuropsychol. 2019;41(1):87-107.
156. Visser PS KJ, Marquette J, Curtin M. Mail surveys for election forecasting? An evaluation of the Columbus Dispatch poll. Public Opinion Quarterly. 1996;60(2):181-227.
157. Holbrook AL KJ, Moore D, Tourangeau R Response Order Effects in Dichotomous Categorical Questions Presented Orally: The Impact of Question and Respondent Attributes. Public Opinion Quarterly. 2007;71(3):325-48.
158. Mealing NM, Banks E, Jorm LR, Steel DG, Clements MS, Rogers KD. Investigation of relative risk estimates from studies of the same population with contrasting response rates and designs. BMC Med Res Methodol. 2010;10:26.
159. Curtin R, Presser S, Singer E. The effects of response rate changes on the index of consumer sentiment. Public Opin Q. 2000;64(4):413-28.
160. Salen BA, Spangfort EV, Nygren AL, Nordemar R. The Disability Rating Index: an instrument for the assessment of disability in clinical settings. J Clin Epidemiol. 1994;47(12):1423-35.
161. 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(7):1096-108.
162. Rejano-Campo M, Ferrer-Pena R, Urraca-Gesto MA, Gallego- Izquierdo T, Pecos-Martin D, Stuge B, et al. Transcultural adaptation and psychometric validation of a Spanish-language version of the "Pelvic Girdle Questionnaire". Health Qual Life Outcomes. 2017;15(1):30.
163. Acharya RS, Tveter AT, Grotle M, Khadgi B, Koju R, Eberhard- Gran M, et al. Cross-Cultural Adaptation and Validation of the Nepali Version of the Pelvic Girdle Questionnaire. J Manipulative Physiol Ther. 2020;43(3):257-65.
164. Gutke A, Stuge B, Elden H, Sandell C, Asplin G, Fagevik Olsen M. The Swedish version of the pelvic girdle questionnaire, cross-cultural adaptation and validation. Disabil Rehabil. 2020;42(7):1013-20.
165. Dunn KM CP. Classification of Low Back Pain in Primary Care: Using "Bothersomeness" to Identify the Most Severe Cases. Spine. 2005;30(15):1887-92.
166. Bo K, Backe-Hansen KL. Do elite athletes experience low back, pelvic girdle and pelvic floor complaints during and after pregnancy? Scand J Med Sci Sports. 2007;17(5):480-7.
167. Naugle KM, Fillingim RB, Riley JL, 3rd. A meta-analytic review of the hypoalgesic effects of exercise. J Pain. 2012;13(12):1139-50.
168. Owe KM, Nystad W, Bo K. Correlates of regular exercise during pregnancy: the Norwegian Mother and Child Cohort Study. Scand J Med Sci Sports. 2009;19(5):637-45.
169. Madeira HG, Garcia JB, Lima MV, Serra HO. [Disability and factors associated with gestational low back pain]. Rev Bras Ginecol Obstet. 2013;35(12):541-8.
170. Olsson C, Nilsson-Wikmar L. Health-related quality of life and physical ability among pregnant women with and without back pain in late pregnancy. Acta Obstet Gynecol Scand. 2004;83(4):351-7.
171. Hansen ML, Thulstrup AM, Juhl M, Kristensen JK, Ramlau- Hansen CH. Occupational exposures and sick leave during pregnancy: results from a Danish cohort study. Scand J Work Environ Health. 2015;41(4):397-406.
172. Henrotin JB, Vaissiere M, Etaix M, Dziurla M, Malard S, Lafon D. Exposure to occupational hazards for pregnancy and sick leave in pregnant workers: a cross-sectional study. Ann Occup Environ Med. 2017;29:12.
173. Juhl M, Andersen PK, Olsen J, Andersen AM. Psychosocial and physical work environment, and risk of pelvic pain in pregnancy. A study within the Danish national birth cohort. J Epidemiol Community Health. 2005;59(7):580-5.
174. Hammer PEC, Garde AH, Begtrup LM, Flachs EM, Hansen J, Hansen AM, et al. Night work and sick leave during pregnancy: a national register-based within-worker cohort study. Occup Environ Med. 2019;76(3):163-8.
175. Murakami E. Sacroiliac Joint Disorder. Singapore: Springer Nature Singapore Pte Ltd.; 2019.
176. Gilleard W, Crosbie J, Smith R. Effect of pregnancy on trunk range of motion when sitting and standing. Acta Obstet Gynecol Scand. 2002;81(11):1011-20.
177. Gilleard WL, Crosbie J, Smith R. Static trunk posture in sitting and standing during pregnancy and early postpartum. Arch Phys Med Rehabil. 2002;83(12):1739-44.
178. Byrd-Craven J, Massey AR. Lean on me: effects of social support on low socioeconomic-status pregnant women. Nurs Health Sci. 2013;15(3):374-8.
179. Ozturk G, Geler Kulcu D, Aydog E, Kaspar C, Ugurel B. Effects of lower back pain on postural equilibrium and fall risk during the third trimester of pregnancy. J Matern Fetal Neonatal Med. 2016;29(8):1358- 62.
180. Davenport MH, Ruchat SM, Poitras VJ, Jaramillo Garcia A, Gray CE, Barrowman N, et al. Prenatal exercise for the prevention of gestational diabetes mellitus and hypertensive disorders of pregnancy: a systematic review and meta-analysis. Br J Sports Med. 2018;52(21):1367-75.
181. 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.
182. Koukhan S, Rahimi, A., Ghasemi, M., Naimi, S. S.,Akbarzadeh Baghban, A. Postural Changes during First Pregnancy. Br J Med Med Res. 2015;7(9):744-53.
183. Rainville J, Hartigan C, Martinez E, Limke J, Jouve C, Finno M. Exercise as a treatment for chronic low back pain. Spine J. 2004;4(1):106-15.
184. Rasmussen M-LH SM, Wohlfahrt J, Videbech P, Melbye M. Risk, treatment duration, and recurrence risk of postpartum affective disorder in women with no prior psychiatric history: A population-based cohort study. . PLoS Med. 2017;14(9).
185. Dipietro L, Evenson KR, Bloodgood B, Sprow K, Troiano RP, Piercy KL, et al. Benefits of Physical Activity during Pregnancy and Postpartum: An Umbrella Review. Med Sci Sports Exerc. 2019;51(6):1292-302.
186. Karoly P, Ruehlman LS. Psychological "resilience" and its correlates in chronic pain: findings from a national community sample. Pain. 2006;123(1-2):90-7.
187. Stendal Robinson H, Lindgren A, Bjelland EK. Generalized joint hypermobility and risk of pelvic girdle pain in pregnancy: does body mass index matter? Physiotherapy Theory and Practice. 2021:1-8.
188. Wergeland E, Strand K. Work pace control and pregnancy health in a population-based sample of employed women in Norway. Scand J Work Environ Health. 1998;24(3):206-12.
189. Andersen LK, Backhausen M, Hegaard HK, Juhl M. Physical exercise and pelvic girdle pain in pregnancy: A nested case-control study within the Danish National Birth Cohort. Sex Reprod Healthc. 2015;6(4):198-203.
190. Committee Opinion No. 650 Summary: Physical Activity and Exercise During Pregnancy and the Postpartum Period. Obstet Gynecol. 2015;126(6):1326-7.