Pubic Symphysis Dysfunction: Difference between revisions
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== Key Evidence == | == Key Evidence == | ||
In the next table you can find some information of the levels of evidence of the used information to create this page on physio-pedia. In the first column you can see the name of the author of the resource, in the next you can read the level of evidence and in the last you can find the grades of evidence.<br> | |||
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! scope="col" | Name Author | |||
! scope="col" | levels of evidence | |||
! scope="col" | grades of evidence | |||
|- | |||
| Aslan E. et al. | |||
| 1A | |||
| A | |||
|- | |||
| Allsop J.R. | |||
| 5 | |||
| F | |||
|- | |||
| Bjorklund K. et al. | |||
| 1C | |||
| B | |||
|- | |||
| Coldron Y.<span class="Apple-tab-span" style="white-space:pre"> </span> | |||
| 1A | |||
| A | |||
|- | |||
| Depledge J. et al. | |||
| 1B | |||
| B | |||
|- | |||
| Elden H. et al. | |||
| 1C | |||
| B | |||
|- | |||
| Guthrie L. | |||
| 5 | |||
| F | |||
|- | |||
| Jain S. et al. | |||
| 1A | |||
| A | |||
|- | |||
| Lennard F. | |||
| 1C | |||
| B | |||
|- | |||
| Lohman A.H.M. | |||
| 5 | |||
| F | |||
|- | |||
| MacLennan A.H. et al. | |||
| 2B | |||
| C | |||
|- | |||
| Moore K.L. et al. | |||
| 5 | |||
| F | |||
|- | |||
| Ohtera K.L. et al. | |||
| 5 | |||
| F | |||
|- | |||
| Owens K. et al. | |||
| 2C | |||
| C | |||
|- | |||
| Robson S.E. et al. | |||
| 5 | |||
| F | |||
|- | |||
| Schünke M. et al. | |||
| 5 | |||
| F | |||
|- | |||
| Versprille-Fischer E.S. | |||
| 5 | |||
| F | |||
|- | |||
| Welsh H. | |||
| 1A | |||
| A | |||
|- | |||
| Whitby P. | |||
| 5 | |||
| F | |||
|- | |||
| Young G. et al. | |||
| 1A | |||
| A | |||
|} | |||
== Resources <br> == | == Resources <br> == | ||
Revision as of 18:57, 22 December 2011
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Search Strategy
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To get some information about this topic search in (universital) libraries and on internet (Pubmed en Pedro). keywords:
• Pubic symphysis dysfunction
• Pelvic girdle pain
• Symphysis pubic
Introduction[edit | edit source]
Jain S. et al. says that: “A symphysis pubis dysfunction is a common and debilitating condition affecting woman. It’s painful and it can have a significant impact on quality of life, which can lead to complications as depression.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleIn British population we can see an incidence of 1:36 to 1:300.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title A study of Owens K. et al. shows that this injury arises in the first trimester of pregnancy for 9% of women, in the second for 44%, in the third for 15% and postnatal for 2%.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Symphysis pubis dysfunction has been described as a collection of signs and symptoms of discomfort and pain in the pelvic area, including pelvic pain radiating to the upper thighs and perineum.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Clinically Relevant Anatomy
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We can find the symphysis pubic on the anterior side of the pelvis. It’s also the anterior boundary of the perineum.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title In cooperation with the illio-sacral joints the symphysis forms a stable pelvic ring. This ring allows only some small mobility.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title The pubic symphysis is a cartilagenous joint which consists of a fibrocartilagneous interpubic disc Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title(which had transversal and helical fibers) and the surrounding ligaments uniting the bodies of the pubic bones in the median plane. With children this disc is very small and the hyaline cartilage is very wide. But it evolves conversely.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title With men the disc is higher, smaller and narrower.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Normally with women the symphysis pubic gap is 4-5 mm wide and it widens 2-3 mm during the last trimester of pregnancy. This is necessary to facilitate the delivery of the fetus.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title In symphysis pubis dysfunction the joints become more relaxed and allow instability in the pelvic girdle. When the gap is equal to or more than 10 mm there’s a diastasis of the symphysis pubic.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Mechanism of Injury / Pathological Process
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Aslan et al. say that the aetology of SPD is unknown.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Pregnancy leads to an altered pelvic load, lax ligaments and weaker musculature. This leads to spino-pelvic instability, which manifest itself as symphysis pubic dysfunction.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
In early stages of the pregnancy the corpus luteum secretes a lot of relaxin and progesteron.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title From the 12th week of the pregnancy this function is continued by the placenta and decidua.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Relaxin breaks down collagen in the pelvic joint and causes laity and softening. Progesterone has a similar effect. But relaxin has no correlation with the degree of symptoms of symphysis pubic dysfunction.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title A Norwegian study showed that genetic susceptibility to joint dysfunction is possibly caused by an aberration of relaxine.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title It would seem that the presence of laxity as the result of a hormonal link is undisputed.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title However there is no full disclosure for this.
Clinical Presentation[edit | edit source]
Symphysis pubic dysfunction is a condition that causes excessive movement of the pubic symphysis in the anterior or lateral direction and causes pain.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Both factors are possibly due to a misalignment of the pelvis. It’s frequently associated with pregnancy and childbirth. Therefore the mid-wife is the first who gets to know the complaints.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleIn recent years we can see an increased level of cases of pubic symphysis dysfunction. This is possibly due to the increased age of getting a child.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
As previously stated, pain is a symptom of this disease. It can be a burning, shooting, grinding or stabbing pain.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title This can be a mild pain, but his can progress to a severe and prolonged pain. The pain is usually relieved by rest.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleThe pain often radiates to the back, abdomen, groin, perineum and leg.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title The pain disappears commonly after giving birth, but this is not the case for everyone. This emphasizes the importance of an individual treatment.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title There are many other symptoms like a discomfort sense onto the front of the joint. Another symptom is the ability to hear some click of the lower back, hip joints and saccroillial joints if the patients position changes.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Another symptom is the difficulty in some movements like the ab- and adduction. It limits people in their daily lives. There’s a typical gait, like the difficulty to climb stairs and problems with weight-bearing activities.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Some people say there is a link between a depression and this dysfunction.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title This is possibly due to the physical discomfort.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleSymphysis pubic dysfunction can be the result of a diastasis, a rupture, an osteomy or a fracture.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleSome causes of symphysis pubic dysfunction are: pregnancy/ partus, a sports injury and prostatectomy. In a sport accident this is caused by falling with the legs in hyper abduction, like in horse-riding.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Diagnostic Procedures[edit | edit source]
Like in each dysfunction an early diagnosis is important, to minimize the possibility of a long term problem. But not all healthcare practioners know this problem. A diagnosis is often made symptomatically (after a pregnancy). But imaging is the only way to confirm the dysfunction(level of evidence A)Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, sometimes an MRI, x-ray, CT or ultrasoundCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title are also used for diagnosis(level of evidence A).Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title But the main thing in the diagnose is a good physical examination, this way you can rule out some other problems like lumbar spine problems, prolapsed discs,...(level of evidence 1A)Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Tenderness over the symphysis pubis and the sacro-illiacal joints are the commonest clinical signs. The range of hip motions (abduction and exorotation) could be limited in function of the pain.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleThis loss of abduction function can give a waddling gait. Fry and Wellock et al. say:” Clinicians are able to palpate the symphysis but the woman’s own description of discomfort is sufficient to diagnose.”Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
No test is diagnostic. On palpation anterior posterior/ superior inferior displacement of the upper border of the symphysis pubis or tuberculum pubicum can be felt. An active straight leg raise test may be limited or impossible to do. Bilateral trochanter compression can cause pain(level of evindence 1A).Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title But the next test for symhyseal pain in pregnancy have a high sensitivity (se), specificity (sp) and inter-examiner reliability (i-er):Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
- Palpate the anterior surface of the symphysis pubis, when the woman lies on her back, the test is positive when the pain persists for more than 5 seconds after removal of the hand.Cite error: Invalid
<ref>tag; name cannot be a simple integer. Use a descriptive title(se=60%, sp=99%and i-er=0,89 Kappa coefficient). - When standing on one leg the woman isn’t able to maintain the pelvis in a horizontal plane and the opposite buttocks drops. This is also known as Trendlenburg’s sign.Cite error: Invalid
<ref>tag; name cannot be a simple integer. Use a descriptive title (se=60%, sp=99% and i-er= 0,63 kappa coefficient). - A Patrick’s fabere sign: the examiner held one illiac spine in a flexed position, the woman is in a supine position, then she places her heel on the heterolateral knee with the leg falling passively outwards. This test is positive when there is a pain in the sacro-illiacal joint.Cite error: Invalid
<ref>tag; name cannot be a simple integer. Use a descriptive title(se=40%, sp=99%, i-er= 0,54 kappa coefficient).
Management / Interventions
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There is no evidence in literature to support any particular treatment.3 People with pubic symphysis dysfunction use elbow crutches(level of evidence 1A)Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title, pelvic-support devices(level of evidence A)Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title (although often used there is no published evidence for their efficacy)Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title and prescribed pain reliefs (But be careful taking NSAIDS while pregnant)Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title. In very severe cases a wheelchair and eventually social services are recommended(level of evindence 1A).Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
The intervention of a physio-therapist can be as useful as other treatments. He can prescribe some exercises for core and pelvic stability. Women can also discuss their birth planning with an obstetrician/ midwife/ ergo therapist to get some information about using the body in daily life and during childbirth. In severe cases surgery is indicated after the childbirth.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
A good birth planning is important. Women with pubic symphysis dysfunction should give birth in an upright position, with knees slightly open. But it’s also important that the gap never exceeds the maximal comfort zone, that’s why it’s suggested that the patient wear a ribbon to both legs(level of evidence 1A).Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Practices such as placing the feet on the midwife's hips during birth, stirrups, and interventions such as forceps should be avoided in the delivery room if possible because they can strain ligaments further(level of evidence 1A).Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title This causes long term problems. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
As physiotherapist you can give some advice to use the body in daily life, back care and to avoid activities that put undue strain on the pelvis. Here are some tips (level of evindence 1 A)Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title:
- Avoid squatting, strenuous exercises, prolonged standing, lifting and carrying, stepping over things, twisting movements of the body, vacuum cleaning and stretching exercises!
- Sit down while doing things if possible.
- Sleep with a pillow between the legs. Keeps legs flexed and together to get in/ out of bed.
Yound and Jewell found there was a measurable reduction in back and pelvic pain in pregnancy with physiotherapy and acupuncture(level of evindence 1A).Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Also Eden et al. showed a reduction in pelvic pain in combination with stabilizing exercises.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title The personal care given by the ancupunturist could have caused this.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Water gymnastics from week 22 of the gestation reduced back pain and reduced the rate of absence from work(level of evindence 1A).Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Swimming is safe but the patient should avoid the breaststroke as the action of kicking the legs apart will put the symphysis pubis on strain. Front crawl or using a float and kicking the legs straight diminishes this problem says Guthrie L.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title An Ozzlo Pilow for the support of the pregnant abdomen provided better pain relief and improved sleep.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Lennard F. et al. found the efficacy of physiotherapy antenatal back pain.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Pelvic floor exercises from early pregnancy are supposed to reduce the risk to develop symphysis pubic dysfunction. Deep-abdominal (m. transversus abdominis) exercises increase the core stability and this prevents women to develop pelvic- or back pain in pregnancy (level of evindence 1A). Pelvic muscle floor exercises can be progressed by starting off with a small number of repitions and gradually increasing the seconds to hold on a contraction. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleWhen the transversus abdominis muscle contracts, we can see a synergistic activation of the pelvic floor. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
The next therapies can also be of value: TENS, ice, external heat and massage, but their efficacy isn’t jet proved (level of evidence A).Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title The effects of a treatment of a chiropractor or the effects of talking to “hands on experts” can be useful.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
There is no evidence that caesarean is beneficial for women with symphysis pubic dysfunction, however when hip abduction is severely restricted this can be necessary (level of evidence A).Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title During labour and delivery leg abduction(=separation) should be kept to a minimum.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title Use of epidural and spinal anesthesia have been discouraged on account of masking pubic symphysis dysfunction pain, however there is no evidence for this. Women with symphysis pubic dysfunction require longer hospital stays.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Differential Diagnosis
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Jain S. et al sayCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title: “The differential diagnosis includes lumbago, sciata, urinary tract infection osteitis pubis and osteomyelitis. These need to be firmly excluded to ensure the diagnosis of symphysis pubic dysfunction.”Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
Key Evidence[edit | edit source]
In the next table you can find some information of the levels of evidence of the used information to create this page on physio-pedia. In the first column you can see the name of the author of the resource, in the next you can read the level of evidence and in the last you can find the grades of evidence.
| Name Author | levels of evidence | grades of evidence |
|---|---|---|
| Aslan E. et al. | 1A | A |
| Allsop J.R. | 5 | F |
| Bjorklund K. et al. | 1C | B |
| Coldron Y. | 1A | A |
| Depledge J. et al. | 1B | B |
| Elden H. et al. | 1C | B |
| Guthrie L. | 5 | F |
| Jain S. et al. | 1A | A |
| Lennard F. | 1C | B |
| Lohman A.H.M. | 5 | F |
| MacLennan A.H. et al. | 2B | C |
| Moore K.L. et al. | 5 | F |
| Ohtera K.L. et al. | 5 | F |
| Owens K. et al. | 2C | C |
| Robson S.E. et al. | 5 | F |
| Schünke M. et al. | 5 | F |
| Versprille-Fischer E.S. | 5 | F |
| Welsh H. | 1A | A |
| Whitby P. | 5 | F |
| Young G. et al. | 1A | A |
Resources
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add appropriate resources here
Case Studies[edit | edit source]
add links to case studies here (case studies should be added on new pages using the case study template)
References[edit | edit source]
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