Clinical Practice Guidelines for Pelvic Girdle Pain in the Postpartum Population

Abstract

Background: 

Pelvic girdle pain (PGP) is defined as pain experienced between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the sacroiliac joint. Pelvic girdle pain is common postpartum, may result from pregnancy-related factors, and is a leading cause of disability postpartum. The purpose of this clinical practice guideline is to provide evidence-based recommendations for physical therapist management of PGP in the postpartum population.

Key Points: 

Postpartum individuals may experience PGP beginning during pregnancy, immediately after childbirth, or up to 2 years after delivery. Although most cases of PGP in pregnancy resolve spontaneously, a subset of postpartum individuals may experience persistent pain. Based upon critical appraisal of literature and expert opinion, 23 action statements for risk factors, systems screening, examination, diagnosis, prognosis, theoretical models of care, and intervention for postpartum individuals with PGP are linked with explicit levels of evidence.

A significant body of evidence exists to support physical therapist intervention with postpartum clients with PGP to reduce pain and disability. Emerging evidence suggests that further investigation of biopsychosocial factors is warranted, especially factors that influence the development of persistent pain in the postpartum population. Future research is needed in several areas to optimize examination and intervention strategies specific to postpartum individuals and guided by a classification system for PGP that includes elements of pain, movement, and biopsychosocial factors.

The authors provide clinical practice guidelines for providing physical therapy to postpartum individuals with PGP.

INTRODUCTION

Aim of the Guidelines

The Academy of Pelvic Health Physical Therapy (APHPT) of the American Physical Therapy Association (APTA) is committed to creating evidence-based practice guidelines for women's health physical therapy management of patients with musculoskeletal impairments. The purposes of this clinical guideline are to describe evidence-based physical therapy practice including screening, diagnosis, prognosis, intervention, and assessment of outcome for women with postpartum pelvic girdle pain (PP-PGP). Specific aims include:

• Define common terminology related to PP-PGP,
• Identify appropriate outcome measures to assess changes resulting from physical therapy interventions,
• Identify interventions supported by current best evidence to address impairments of body function and structure, activity limitations, and participation restrictions associated with common musculoskeletal conditions,
• Provide information to inform stakeholders regarding the care of women with PP-PGP, and
• Create a reference publication for physical therapist clinicians, academic instructors, clinical instructors, students, interns, residents, and fellows regarding the best current practice regarding PP-PGP.

Statement of Intent

This guideline is not intended to be interpreted or to serve as a standard of clinical care. Standards of care are determined on the basis of all clinical data available for an individual patient and are subject to change, as scientific knowledge and technology advance and patterns of care evolve. The practice framework and parameters should be considered as guidelines only. A successful outcome is not assured in every patient, nor should the guidelines be interpreted as being inclusive of all proper methods of care or exclusive of other acceptable methods of care. The clinical data presented by the patient, the diagnostic and treatment options available, and the patient's values, expectations, and preferences must be used to render a final judgment regarding a clinical procedure or treatment plan. However, we suggest that any significant departure from the accepted guidelines be documented in the patient's medical records at the time the relevant clinical decision is made.

Pelvic Girdle Pain

Pelvic girdle pain (PGP) is defined as “pain experienced between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the sacroiliac joint (SIJ). The pain can radiate into the posterior thigh and can occur in conjunction with pain in the symphysis.”¹ This operational definition of PGP was utilized in the construction of the search strategy and creation of these recommendations. Based on this definition of PGP, pubic symphysis (PS) pain was included in the guideline, as some clients with PGP will report both anterior and posterior pelvic pain.

Pelvic girdle pain is a condition common postpartum and may result from pregnancy-related factors. The etiology and pathogenesis of PP-PGP is not well-understood. Pelvic girdle pain may develop during pregnancy and continue into the postpartum period. It may also develop after childbirth and its clinical course appears independent of pain in pregnancy. These differences in onset time of PGP are important, as little is known about which individuals in pregnancy will develop pain and which individuals postpartum will develop pain.

A subset of individuals with PP-PGP develops persistent pain, which is characterized by comorbid kinesiophobia, fear-avoidance behavior, and/or the presence of psychological symptoms in addition to pain and disability.^2,3 Clinical presentation of persistent PP-PGP appears to be more complex, impacting multiple areas of physical, cognitive, emotional, and social functioning, and often requiring a multidisciplinary care approach with psychological intervention.

This is not a guideline on delivery-related trauma to the pelvis. Delivery-related trauma to the pelvis has not been correlated to PP-PGP specifically but has been linked to PS rupture/diastasis and pain, coccydynia, and pelvic fractures (which are covered in the systems screening and differential diagnosis sections of this guideline). Coccyx pain, or coccydynia, is a condition where the location and mechanism of pain differs from PP-PGP,⁴ and, therefore, was not included in this guideline. Clients with coccyx pain would need to be examined and treated differently from those with PP-PGP. Additionally, unique interventions such as intrarectal mobilization and soft tissue work are specific to the condition of coccydynia and not to the condition of PP-PGP. For these reasons, coccydynia was excluded in this guideline.

Defining the Postpartum Period

The postpartum period is often defined as the time from delivery through the first 6 to 8 weeks. However, because not all physical changes return to prepregnancy states during that time, sources identify women as postpartum for up to 12 months after delivery.^5,6 The authors completed the search strategy based on both the 6- to 8-week and 12-month operational definitions of postpartum, but too few results were identified in these searches. As a result, the authors revised the operational definition of postpartum for this guideline to refer to the period from delivery through the second postpartum year.

Medical care postpartum, including screening and knowledge of PP-PGP, is variable both internationally and domestically. The World Health Organization recommends at least 3 postnatal contacts for mother and newborn occurring on day 3, between 7 and 14 days, and at 6 weeks, including a home visit within the first week and a screening for back pain.⁷ The American College of Obstetricians and Gynecologists has redefined the postpartum period to include a fourth trimester and recommends contact with a maternal care provider within the first 3 weeks and a comprehensive visit including physical, social, and psychological health within 12 weeks.⁶ The role of lactation is potentially important, as hormone levels in nursing women are altered versus prepregnancy. Therefore, we propose that all individuals who continue to breastfeed or pump be considered within the fourth trimester.

Currently, there is no recommendation for screening for PP-PGP or the potential physical disability associated with this condition in the postpartum period. As a result, no recommendations for physical therapy referrals are listed for this condition in published maternal care guidelines. Access to physical therapists for PP-PGP evaluation is also variable.⁸

Associated Physical Changes That Occur Postpartum

Physical changes associated with the effects of pregnancy, trauma during labor and delivery, and physiological recovery processes in the postpartum period impact the clinical presentation, examination, and interventions provided to individuals with PP-PGP after delivery. The primary focus of this guideline is on the specific condition of PGP in the postpartum population. Recommendations made are based on current evidence and best practice. When literature on PP-PGP existed, recommendations were made regarding secondary postpartum physical health impairments, such as abdominal and pelvic floor muscle weakness. However, when literature was not specific to PGP postpartum, the authors generally did not make a recommendation for practice. Readers are encouraged to seek alternative sources for references on the assessment and rehabilitation of physical changes in the postpartum client associated with the effects of pregnancy, trauma during labor and delivery, and/or the normal physiological recovery processes that are independent of PP-PGP.

METHODOLOGY

Committee members for this clinical practice guideline (CPG) were selected by the APHPT based on content expertise. The committee was charged with performing a systematic review and evaluation of the literature to produce an evidence synthesis for the physical therapy evaluation and management of PP-PGP. Committee members were required to submit conflict-of-interest forms to the APHPT as a condition of authorship. Funding and support for CPG development were provided through the APTA (CPG grant) and the APHPT. These sponsors did not have any influence over the recommendations in this CPG. The development of the CPG was guided by the APTA Clinical Practice Guideline Process Manual.

Search Strategy

A comprehensive literature search was performed from May 2015 through December 2020 in the following databases: PubMed (National Center for Biotechnology Information), CINAHL (EBSCO), Cochrane Library (Wiley), Web of Science (Thomson Reuters), and PEDro (Centre for Evidence-Based Physiotherapy). A combination of keywords and subject headings were used. The primary search terms used were pelvic girdle pain, low back pain, lumbosacral region, lumbopelvic, sacroiliac joint pain, pubic symphysis pain, postpartum period, physical therapy modalities, and exercise therapy. Articles were included if they were written in English and related to risk factors, diagnosis, medical screening, examination, outcome measures, prognosis, intervention, or models of care for PGP in the postpartum population. Research designs included randomized controlled trials, cohorts, case series, and case reports. Articles were excluded if they discussed cancer-related pelvic pain or perineal pain, were not specific to postpartum individuals with PGP, or were poster or conference abstracts. Articles on pregnancy-related PGP were included only if postpartum data were provided. A reference librarian with expertise in systematic reviews verified the search.

Clinical Questions Searched

The authors designed the guideline search strategy to investigate the following clinical questions:

• What risk factors are most associated with PP-PGP?
• What should be included in a systems screening in individuals with PP-PGP?
• What physical therapy examination, outcome measures, and diagnoses are most valid, reliable, and clinically useful for PP-PGP?
• What is known about the prognosis for recovery from PP-PGP?
• What theoretical models of care are available to best guide interventions for PP-PGP?
• What physical therapy interventions are most effective and clinically useful for PP-PGP?

Evidence Appraisal, Level of Evidence Recommendations, and Grade Assignments

Once the search strategy was complete, the authors independently screened titles and abstracts based on inclusion and exclusion criteria described earlier. Titles and abstracts were screened by 2 authors independently for inclusion. Additionally, 2 authors independently appraised included articles. The level of evidence definitions and recommendation grading system outlined in the APTA Clinical Practice Guidelines Manual⁹ was utilized (Table 1). A third author was consulted to resolve discrepancies. Extracted critical elements were entered into an Excel data file. In the presence of 2 or more articles that were well done and provided consistent evidence, a strong recommendation was made. In the presence of either 1 well-done article or weaker articles that provided consistent evidence, a moderate recommendation was made. In the presence of conflicting evidence or lower quality studies, a weak recommendation was made. In the absence of evidence, expert opinion was provided. Aggregate analysis of the literature was done to determine an overall level of evidence.⁹Table 2 provides the definitions of the aggregate evidence levels.

Table 1. - Grading of Evidence^a

Letter Grade	Level of Obligation	Definition
A	Strong	A high level of certainty of moderate to substantial benefit, harm, or cost, or a moderate level of certainty for substantial benefit, harm, or cost (based on a preponderance of level 1 or 2 evidence with at least 1 level 1 study)
B	Moderate	A high level of certainty of slight to moderate benefit, harm, or cost, or a moderate level of certainty for a moderate level of benefit, harm, or cost (based on a preponderance of level 2 evidence, or a single high-quality randomized controlled trial)
C	Weak	A moderate level of certainty of slight benefit, harm, or cost, or a weak level of certainty for moderate to substantial benefit, harm, or cost (based on level 2 thru 5 evidence)
D	Theoretical/foundational	A preponderance of evidence from animal or cadaver studies, from conceptual/theoretical models/principles, or from basic science/bench research, or published expert opinion in peer-reviewed journals that supports the recommendation
P	Best practice	Recommended practice based on current clinical practice norms, exceptional situations in which validating studies have not or cannot be performed, yet there is a clear benefit, harm, or cost, expert opinion
R	Research	An absence of research on the topic or disagreement among conclusions from higher-quality studies on the topic

^aFrom APTA.⁹

Table 2. - Level of Evidence Definitions^a

Level of Evidence	Types of Studies
	Intervention/Prevention	Pathoanatomic/Risk/Clinical Course/Prognosis/Differential Diagnosis	Diagnosis/Diagnostic Accuracy	Prevalence of Condition/Disorder	Examination/Outcomes
I. Evidence obtained from high-quality systematic reviews, diagnostic studies, prospective studies, or randomized controlled trials (RCTs)	Systematic review of high-quality RCTsb High quality RCTb	Systematic review of prospective cohort studies High-quality prospective cohort studyc	Systematic review of high-quality diagnostic studies High-quality diagnostic study with validationd	Systematic review of high-quality cross-sectional studies High-quality cross-sectional studye	Systematic review of prospective cohort studies High-quality prospective cohort study
II. Evidence obtained from lesser-quality diagnostic studies, prospective studies, or RCTs (eg, weaker diagnostic criteria and reference standards, improper randomization no blinding, less than 80% follow-up)	Systematic review of high-quality cohort studies High-quality cohort studyc High-quality outcomes research High-quality quasi-experimental studyf High-quality single-subject designg Lower-quality RCTh	Systematic review of retrospective cohort studies Lower-quality prospective cohort study High-quality retrospective cohort study Consecutive cohort study Outcomes study or ecological studyi	Systematic review of exploratory diagnostic studies or consecutive cohort studies High-quality exploratory diagnostic study Consecutive retrospective cohort study	Systematic review of studies that allows relevant estimate Lower-quality cross-sectional study	Systematic review of lower-quality prospective cohort studies Lower-quality prospective cohort study
III. Case-controlled studies or retrospective studies	Systematic review of case-controlled studies High-quality case-controlled study Outcomes study or ecological studyi Lower-quality cohort study	Lower-quality retrospective cohort study High-quality cross-sectional study Case-controlled study	Lower-quality exploratory diagnostic study Nonconsecutive retrospective cohort study	Local non-random study	High-quality cross-sectional study
IV. Case series	Case series	Case series	Case-controlled study		Lower-quality cross-sectional study
V. Expert opinion	Expert opinion	Expert opinion	Expert opinion	Expert opinion	Expert opinion

^aFrom APTA.⁹

^bHigh-quality includes RCTs more than 80% follow-up; blinding; appropriate randomization procedures.

^cHigh-quality or dramatic effect cohort study includes more than 80% follow-up.

^dHigh-quality diagnostic study includes consistently applied reference standard and blinding.

^eHigh-quality prevalence study is a cross-sectional study that uses a local and current random sample or censuses.

^fHigh-quality comparative study without random assignment to groups.

^gMust have a minimum of “a” and B” phase.

^hWeaker diagnostic criteria and reference standards, improper randomization, no blinding, less than 80% follow-up may add threats to bias and validity.

ⁱHigh-quality outcome or ecological studies use instrumental variable(s) or other control for confounding factors.

RECOMMENDATIONS

Risk Factors

Aggregate evidence level I

Grade of recommendation: A

There is strong evidence that individuals are more likely to develop PP-PGP if there is a history of lumbar or PGP, including PGP during pregnancy.

There is moderate evidence that pain location in the posterior pelvis; pain with rolling in bed and with weight-bearing; multiparity; cesarean delivery; presence of depressive symptoms; higher body mass index (BMI) prepregnancy; work factors; and breastfeeding position are associated with the development of PP-PGP. There is weak evidence for the following risk factors as associated with PP-PGP: maternal age; maternal height; fetal weight; epidural anesthesia; and duration of the second stage of labor.

Systems Screening

Aggregate evidence level I

Grade of recommendation: A

There is strong evidence that mood disorders are common postpartum. Mood disorders may begin up to 4 weeks postpartum, and there is an increased incidence at 2 to 3 years after delivery. PTs should administer a depression index to screen for mood disorders postpartum; screen for suicidal ideation; refer to psychological, gynecological, or primary care providers for depressive symptoms; and refer to the emergency department in the presence of suicidal ideation. Future research should investigate further the role of fear, anxiety, and catastrophizing and the potential influence on PP-PGP.

Aggregate evidence level II

Grade of recommendation: B

There is moderate evidence that postpartum individuals (with or without PP-PGP) are at risk for muscle impairments in the pelvic floor, abdominal, hip, and back regions following pregnancy and delivery. PTs should screen for urinary and fecal incontinence; perform abdominal wall, back and hip screening; and refer to a pelvic health physical therapist should the patient report urinary and/or fecal incontinence symptoms.

Aggregate evidence level III

Grade of recommendation: C

There is weak evidence that childbirth may result in injury to the pudendal nerve resulting in denervation of the perineal muscles, abnormal sensation, and/or sexual dysfunction. Radicular symptoms (sensory and strength impairments in a lower extremity) with a history of traumatic or prolonged labor may also be present. PTs should perform a lower quarter neurologic assessment including sensory and motor assessment of the perineal region and pelvic floor and refer for medical examination of the lumbosacral plexus in the presence of distal neurologic symptoms.

Aggregate evidence level IV

Grade of recommendation: C

There is weak evidence that women with PP-PGP may present with femoral neck or sacral fractures to secondary low bone mineral density (BMD). There is weak evidence that breastfeeding is associated with reduced BMD. There is weak evidence that heparin use during pregnancy is associated with transient osteoporosis. PTs should screen for activity-associated pain that improves with rest, breastfeeding status postpartum, and heparin use in pregnancy, delivery or postpartum. PTs should perform boney palpation over site(s) of pain. PTs should refer for imaging to rule out stress fracture when a patient presents within 2 weeks of delivery with any of the following complaints: severe pain; decreased or inability to weight bear; antalgic gait or limp; sudden onset of pain located at SIJ, buttocks, low back, or PS; or pain relieved with lying down.

Examination

Aggregate evidence: I

Grade of recommendation: A

There is strong evidence for a consistent clinical presentation of PP-PGP that involves pain location in the posterior pelvis in the region of the SIJ and/or anterior pain at the PS, pain with rolling in bed, and pain with lower extremity (LE) weight-bearing. PTs should inquire about location of pain, pain with rolling, and pain with LE weight-bearing.

Aggregate evidence level: III

Grade of recommendation: C

There is moderate evidence validating the use of the Oswestry Low Back Pain Disability Questionnaire and the Pelvic Girdle Questionnaire (PGQ), and weak evidence validating the use of the Quebec Back Pain Disability Scale (QBPDS) to measure disability associated with PP-PGP. These measures are appropriate for use as part of examination of individuals with PP-PGP.

Aggregate evidence level: V

Grade of recommendation: P

Alignment testing of pelvic girdle bony landmarks is common in physical therapy practice, but has inconsistent evidence for its reliability and validity, especially in PP-PGP. PTs may perform alignment testing at pelvic landmarks to determine the presence of asymmetry during the examination; however, this should not be performed in isolation.

Aggregate evidence level: V

Grade of recommendation: P

There is no evidence specific to the postpartum population to support palpation of the PS to rule in the presence of anterior PP-PGP. PTs may palpate the PS as part of a comprehensive examination of the pelvic girdle, as both posterior and anterior pain symptoms may be present. Anterior pain at the PS warrants a different clinical decision-making process.

Aggregate evidence level: V

Grade of recommendation: P

There is limited evidence to support palpation of the long dorsal ligament (LDL) test specific to the postpartum population. The lack of agreement among the LDL, posterior pelvic pain provocation (P4), and active straight leg raise (ASLR) tests in nonsevere case presentations suggest that the tests do not assess the same structures and/or function in postpartum individuals without severe PGP. PTs may perform the LDL test, but this test should not be performed in isolation.

Aggregate evidence level: II and III

Grade of recommendation: A and B

There is strong evidence to support the use of the P4 test and moderate evidence to support the use of the flexion-abduction-external rotation (FABER) test to rule in PP-PGP. PTs should perform the P4 test. PTs may perform additional provocation tests as necessary to confirm the location of pain and irritability of the structures.

Aggregate evidence level: V

Grade of recommendation: P

The PS experiences laxity, trauma, and/or pain associated with pregnancy and delivery. PTs should not perform Gaenslen's test in the first 4 weeks postpartum or beyond 4 weeks postpartum in the presence of PS pain.

Aggregate evidence level: V

Grade of recommendation: C

There is weak evidence to support the use of the Modified Trendelenburg test for women with PP-PGP. Standing tests may reproduce symptoms in the presence of impaired loading response. Based on strong evidence for pain reproduction with limb loading, PTs should perform standing examination tests—including double-limb support, single-limb support, and transitional movements—to observe and assess the level of difficulty, presence of pain, and movement impairments during trunk and limb movements. Future research on PP-PGP should include standing single-limb loading tests for determining pain and movement impairments.

Aggregate evidence level: II

Grade of recommendation: A

There is strong evidence that the ASLR test allows for the assessment of supine limb loading. The ASLR test assesses the ability of both bony and muscle systems to provide appropriate stabilization of the pelvic girdle to allow for pain-free movement of the LEs. PTs should perform the ASLR for PP-PGP.

Aggregate evidence level: I

Grade of recommendation: A

There is strong evidence that muscle function is impaired in PP-PGP. There is evidence to suggest that, at a minimum, the following should be assessed: force production, endurance, resting muscle tone, and muscle length. Muscle function is an important element to include in the PT examination of clients with PP-PGP.

Aggregate evidence level: V

Grade of recommendation: C

There is weak evidence to support the examination of diastasis rectus abdominis (DRA) in women with PP-PGP. There is moderate evidence to suggest that the presence of DRA impacts the function of the abdominal wall and pelvic floor muscles. PTs may perform DRA assessment for PP-PGP. Future research should investigate a potential relationship between DRA and PP-PGP.

Prognosis

Aggregate evidence level: I

Grade of recommendation: A

There is strong evidence to suggest that prognosis of recovery depends on initial pain and disability scores. There is strong evidence to suggest that individuals with PP-PGP with greater disability and pain scores should be expected to recover more rapidly and return to function. There is strong evidence to suggest that those with low disability scores and low pain scores at the start of physical therapy intervention demonstrate minimal gains. PTs should assess pain level and administer a disability questionnaire to inform prognosis. Future research should investigate fear-avoidance beliefs and mental health to potentially identify women not following a “normal” course of recovery after PP-PGP.

There is strong evidence to suggest that individuals with PP-PGP who present to PT beyond 3 months after delivery may experience minimal to no gains with intervention. PTs should advocate for initiating care in early postpartum (before 3 months postpartum) to reduce likelihood of chronic PP-PGP.

Regardless of intervention, there is strong evidence to suggest that individuals with PP-PGP may continue to experience low disability and/or pain at 1 year and at 2 years postpartum. It is unclear whether this is based on preexisting or comorbid conditions or whether this is related to a natural progression of recovery from pregnancy and childbirth. Future research should investigate the implication of these confounding variables on continued pain and disability at 1 and 2 years postpartum.

Intervention

Aggregate evidence level: I

Grade of recommendation: A

There is strong evidence to support the inclusion of patient education on PP-PGP, normal changes postpartum, and body mechanics in the intervention. PTs may educate clients on pain and physiology behind PP-PGP and normal changes postpartum. PTs may instruct clients on functional movement strategies associated with activities of daily living (ADLs) and childcare tasks. Future research should explore educational methods for PP-PGP in relation to outcome.

Aggregate evidence level: I

Grade of recommendation: A

There is strong evidence to support the use of a pelvic belt for PP-PGP in conjunction with cointerventions, such as education, functional training, and exercise. PTs should not use a pelvic belt in isolation.

Aggregate evidence level: I

Grade of recommendation: A

There is strong evidence that the use of manual therapy interventions is no better than stabilization exercises for long-term, more than 6 months' improvement in outcomes. There is strong evidence for the use of manual therapy in conjunction with cointerventions to provide short-term improvements in pain and disability in PP-PGP. PTs should not apply manual therapies in isolation.

Aggregate evidence level: V

Grade of recommendation: P

Based on the wide use of patient education and ergonomic advice in intervention studies, PTs may consider functional training as an intervention for PP-PGP. Functional training has not specifically been studied in PP-PGP. Future research should implement functional training, including gait, double-limb, single-limb, transitional movements, ADLs/IADLs, and childcare tasks.

Aggregate evidence level: I

Grade of recommendation: A

There is strong evidence to support the use of exercise to improve performance of pelvic floor, back flexors, back extensors, and hip extensors. Therefore, PTs should prescribe exercise to address muscle performance impairments; however, the influence on pain and disability due to PP-PGP is not well-understood. PTs should modify exercise that is painful. PTs may also consider cointerventions, such as education, pelvic belt, an assistive device for gait, functional training, and/or manual therapy until tolerance to exercise improves.

Theoretical Models of Care

Aggregate evidence level: V

Grade of recommendation: P

There is limited evidence to support the use of a specific theoretical model for the diagnosis/classification and subsequent intervention for PP-PGP. Pathoanatomical models of care fail to direct decisions on intervention. Examination and intervention studies suggest that impaired limb loading is a primary movement impairment for PP-PGP. Biopsychosocial models of PGP capture the comorbid symptoms associated with PP-PGP, such as psychological factors. Future research should consider models that include pain location, movement impairments, and biopsychosocial factors in PP-PGP.

Summary

Please refer to online materials for details associated with each recommendation, as well as literature summary tables. The authors propose a hybrid diagnostic model that includes examination of both pain location and movement impairments to assess and classify PP-PGP. The aim of this hybrid model is to include examination for symptomatic joints as well as the specific patterns of movement that contribute to impaired load transfer of the pelvic girdle.¹⁰ The authors propose 3 classifications of PP-PGP: (1) SIJ load transfer impairment with or without asymmetry (unilateral joint involvement), (2) pelvic girdle load transfer impairment (≥2 joints involved), and (3) PS load transfer impairment. The clinical decision-making (CDM) flowchart for PP-PGP (Figure) facilitates implementation of this proposed PP-PGP classification into clinical practice. The CDM flowchart is designed to help readers select appropriate tests and measures to determine a specific diagnosis that can subsequently direct intervention strategies. Decisions are based on pain location, pain response to treatment, presence of asymmetry, and movement impairments contributing to the presenting load transfer impairments.

Figure.: Clinical decision-making flowchart for PP-PGP. jts indicates joints; PG, pelvic girdle; PS, pubic symphysis; SIJ, sacroiliac joint; STM, soft tissue mobilization. This figure is available in color online (https://journals.lww.com/jwhpt).

RISK FACTORS

Pain in pregnancy can be predictive of pain postpartum. Therefore, where applicable, studies that correlated clinical presentation during pregnancy with persistent pain postpartum are represented in this summary. There is a specific subset of individuals who develop PP-PGP who did not experience PGP during pregnancy. It is unclear what mechanisms contribute to differences in pain onset. See Table 3 for details associated with risk factors in individuals experiencing PP-PGP.

Table 3. - Factors Associated With a Higher Risk of PP-PGP

LOE	Risk Factor		Relative Risk (95% CI)	Reference
I	History of prior LBP and/or PGP	PGP in pregnancy LBP prior to pregnancy Pain in year prior to pregnancy Pain in prior pregnancy	OR = 3.57 (2.71 to 4.72) OR = 2.75 (2.08 to 3.64) OR = 2.2, P = .0001 χ2 = 6.43, P = .03 OR = 16.08 (8.47 to 30.51) OR = 2.28 (1.12 to 4.66), P = .0236 r = 0.52, P < .0001	Wiezer et al161 Wiezer et al161 Albert et al11 Simonds et al16 Elden et al13 Gutke et al12 Wu et al15
I/II	Pain location	Posterior pain only PS pain only Number of pain locations Posterior pelvis and/or deep in the gluteal region, with/without radiation into the posterior thigh but not down to the foot Combined PS and posterior pain	OR = 3.4 (−1.0 to 7.8), P = .03 OR = 11.8 (2.3 to 21.2), P = .03 OR = 8.0 (−0.03 to 16), P = .05 OR = 3.39 (1.17 to 9.81), P = .02 OR = 8.4 (−0.07 to 17), P = .03	Bergström et al20 Gausel et al19 Vøllestad and Stuge17 Gutke et al12 Albert et al11
II	High disability	High ODI (postpartum d 1) ODI (3 m postpartum)	ODI in pregnancy ODI > 20: OR = 3.3 (1.1 to 9.7), P = .034 ODI > 40: OR = 5.1 (1.7 to 15.0), P = .003 B = −1.14 (−2.04 to −0.24), t = −2.56, P < .0140	Gutke et al2 Sjödahl et al21
II	Pain with activity	When turning in bed With weight-bearing	OR = 1.47 (1.14 to 1.90), P = .003 74% reported pain 90% with pain after 30 min of standing 81% reported pain with standing on 1 leg 81% reported pain with walking for 30 min 50% with pain after 5 min of standing	Gutke et al12 Mens et al58 Mens et al58 Ronchetti et al82
II	Mode of delivery	Cesarean section higher risk of PP-PGP Vaginal delivery/twin delivery associated with PS diastasis	Adjusted OR = 2.0 (1.3 to 4.9) χ2 = 17.39; P < .001 χ2 = 4.89; P = .05 OR = 2.3 (1.4 to 3.9) OR = 12.6 (1.48 to 106.46), P = .020 (vaginal delivery) OR = 9.20 (2.52 to 33.57), P = .001 (twin delivery)	Mukkannavar et al22 Munro et al24 Simonds et al16 Bjelland et al162 Yoo et al163
II	Provocation testing of the pelvic girdle	High number of bilateral positive pain provocation tests ASLR (score 0-3) Unilateral P4 ASLR test score ≥4	OR = 1.79 (1.25 to 2.57), P = .0015 OR = 4.4 (1.1 to 17.5), P = .035 Adjusted OR = 1.8 (1.1 to 3) Adjusted OR = 2.3 (1.2 to 3.3)	Elden et al13 Vøllestad and Stuge17 Mukkannavar et al22 Mukkannavar et al22
II	Parity	Multiparous >3 pregnancies 2 pregnancies	OR = 2.2, P < .001 OR = 1.3 (0.47 to 2.24) OR = 1.42 (0.29 to 3.76) OR = 1.2 (0.6 to 2.1), P = .01 OR = 1.6 (1.1 to 2.6), P = .01 χ2 = 5.89, P = .05 χ2 = 32, P < .0001	Albert et al11 Gutke et al12 Gashaw et al164 Mukkannavar et al23 Wu et al15
	BMI	Increased BMI BMI >25	OR = 1.14 (1.04 to 1.25), P = .01 OR = 2.80 (1.14 to 6.98)	Biering et al165 Wiezer et al161
	Depressive symptoms	More depressive symptoms Depression in pregnancy	OR = 3.58 (1.39 to 9.22), P = .008 OR = 1.43 (1.04 to 1.96)	Gutke et al51 Wiezer et al161
	Work factors	Unhappy with work No work outside the home Heavy workload	OR = 10.06 (2.16 to 46.91), P = .003 χ2 = 9.81, P = .002 OR = 1.37 (1.01 to 1.88)	Gutke et al12 Mukkannavar et al23 Wiezer et al161
	Breastfeeding	Sitting position while breastfeeding Breastfeeding 0-2 mo	Adjusted OR = 1.5 (0.9 to 2.8) Adjusted OR = 1.34 (1.03 to 1.75)	Mukkannavar et al22 Bjelland et al166
	Muscle endurance	Low endurance of trunk flexors	OR = 1.18 (1.01 to 1.37), P = .04 B = −1.23 (−1.83 to −0.62), t = −4.10, P < .0002	Gutke et al12 Sjödahl et al21

Abbreviations: ASLR, active straight leg raise; BMI, body mass index; CI, confidence interval; CS, cesarean section; FABER, flexion, abduction, external rotation test; LBP, low back pain; LOE, level of evidence; ODI, Oswestry Disability Index; OR, odds ratio; PP-PGP, postpartum pelvic girdle pain; P4, posterior pelvic pain provocation test; PS, pubic symphysis; χ2, chi square statistic.

There is strong evidence that the following risk factors contribute to experiencing PP-PGP: history of prior lumbar and/or PGP,^11–16 location of pain in the posterior or anterior aspect of the pelvis during pregnancy,^{11,12,17–20} high level of disability day 1 postpartum,^2,21 cesarean section birth,^16,22–24 postpartum pain with turning in bed and weight-bearing,^2,12 and more than 2 provocative tests during pregnancy.^13,17,22,23 Modifiable risk factors that PTs may address include pain with activity during pregnancy, physical therapy care for individuals immediately postcesarean birth or for women with a high level of disability/pain immediately postpartum, positioning during breastfeeding, and higher BMI in pregnancy.

SYSTEMS SCREENING

Screening during the postpartum period has been organized to highlight system and tissue considerations for medical referrals and/or specific physical therapy examination tests to guide clinical decision-making. Pain in the lumbopelvic region in the postpartum population may be associated with conditions that warrant a medical referral, such as inflammatory, infective, traumatic, neoplastic, degenerative, or metabolic disorders. The PT should proceed with caution and consider a medical referral for any history of trauma, unexplained weight loss, history of cancer, steroid use, substance abuse, human immunodeficiency virus or immunosuppressed state, neurologic symptoms or signs, fever, and/or feelings of malaise. The PT should complete a review of systems as part of the physical therapy examination to identify signs and symptoms of medical disorders and refer as appropriate. Failure to achieve functional improvements and/or lumbopelvic pain that does not reduce with rest, and/or severe, disabling pain may also require a medical referral.

Pregnancy negatively impacts BMD, which does not immediately resolve postpartum. Studies have demonstrated average BMD decreases with loss of trabecular bone of 1.8% to 3.4% in the lumbar spine, 3.2% ± 0.5% at the hip, 4.3% in the femoral neck, 4.2% ± 0.7% at the distal forearm, and 6% at the calcaneus across trimesters in the antepartum period.²⁵ Generally, these losses in BMD resolve within 6 months of delivery²⁵ but can be prolonged in individuals who breastfeed or those who take blood thinners such as heparin.^26–28 Low BMD may increase risk of fracture when associated with unusual forces. Therefore, a complete history should include lactation status, birth history, and activity profile for a complete understanding of risk of compromised bone integrity. The hip and sacrum are the most common postpartum sites of loss of bone integrity. Symptoms associated with hip and/or sacral fracture may include groin pain, pain that radiates to the hip, severe pain with weight-bearing that is relieved when lying supine, and altered/antalgic gait. Clinical examination may reveal pain with provocation testing, palpation, and motion testing in multiple directions; however, the gold standard for diagnosis of bony compromise is magnetic resonance imaging (MRI).^29–31

The joints of the pelvic ring are particularly susceptible to injury due to the presence of abnormal forces, the laxity induced during pregnancy, and trauma associated with childbirth.³² A prospective case control study by Wurdinger et al³³ compared pelvic MRI images of 19 postpartum women 2 to 5 days post-delivery with images from 11 healthy, nulliparous women. The images revealed a larger gap in the pelvic ring joints and signal changes in the pubic cartilage in 8/13 asymptomatic and 5/6 symptomatic postpartum women as compared with the nulliparous women. Of the 6 symptomatic women, MRI revealed SIJ lesions (2/6) and PS rupture (1/6). The patients reported symptoms that included PP-PGP, pain that radiated to the hips, and waddling gait. Therefore, although PS diastasis/rupture is uncommon, all postpartum individuals should be screened for functional impairments that indicate asymmetrical loss of the integrity of the pelvic girdle (pain with rolling, single-limb stance, stairs, and asymmetrical sitting). Severe pain in the anterior PS, pain to touch, difficulty weight-bearing, and/or urinary symptoms may suggest PS diastasis.³⁴ When PS diastasis is suspected, referral for imaging is warranted.

It is important to differentiate between musculoskeletal dysfunction and systemic issues that may affect the joints associated with the pelvic girdle. Musculoskeletal dysfunctions associated with the hip can include bursitis/tendonitis, chondral damage/loose bodies, capsular laxity, femoral acetabular impingement, and labral irritations/tears. Hip pain that warrants a medical referral may include systemic issues such as infection; Paget's disease; rheumatoid, psoriatic, and septic arthritis; and/or hematoma, which have all been reported postpartum.^35–37 The clinical presentation of hip pain of a systemic origin is similar to that of hip pain of musculoskeletal origin with complaints of difficulty with gait and bilateral buttock pain within the first 2 weeks postpartum. Musculoskeletal and systemic causes can be differentiated by the presence of fever in the systemic cases.^38–42 Pain complaints in the anterior abdominal wall and/or perineum in the postpartum period may also be associated with nonmusculoskeletal conditions. It is important to consider the presence of uterine rupture, umbilical hernia, infection, obstetric fistula, and/or incomplete delivery of the placenta as possible causes. Once again, the symptoms in these more severe conditions may mimic musculoskeletal causes. For example, Tennfjord et al⁴³ reported that women with obstetric fistula commonly experienced complaints of leg pain, difficulty walking, and reduced function in the ankle and knee joints post-delivery. Differentiating factors include a greater severity of the pain, presence of associated signs/symptoms (fever, severe bleeding, ballooning of the abdominal region, and continuous stool or urine loss), and/or failure to improve. The presence of any of these symptoms would warrant an immediate physician referral.

The PT should also rule out the presence of lumbar spine dysfunctions, which may mimic PGP by the presence of pain below the posterior superior iliac spine (PSIS) with possible radiation into the buttocks and LEs. Such conditions may include spondylolisthesis, lumbar disc dysfunction, and/or other space occupying lesions around the spinal cord and/or nerve roots. If lumbar dysfunction is suspected, movement testing of the lumbar spine combined with a complete neurologic screen should be performed including screening for the presence of lower and upper motor neuron signs as well as bowel/bladder dysfunction.

The pelvic girdle musculature is at risk for impairments due to the physical changes associated with pregnancy and the trauma of childbirth. Most impairments do not require immediate medical referral and are amenable to physical therapist management. However, inability to activate the pelvic floor musculature (PFM), loss of sensation (unilateral or bilateral perineal hypoesthesia), and/or urinary or fecal incontinence should initiate a referral to a physician. Inability to activate the PFM may indicate an injury to the pudendal nerve or another branch of the lumbosacral plexus. Risk factors for nerve injury include delivery of multiple fetuses, prolonged labor, small or skeletally immature pelvis, and instrument-assisted delivery.^44–47 Symptoms such as pain in the lower back/buttock and LEs, foot drop, and gait dysfunction may also be associated with more severe nerve injury.

In addition to physical complaints, mood disorders are common during the postpartum period. Most postpartum individuals will experience the postpartum “blues'' associated with the rebalancing of hormone levels following delivery of the fetus and placenta.⁴⁸ However, some individuals will experience clinical depression and, in a limited number of severe cases, postpartum psychosis. Any suspicion of postpartum depression should warrant a referral to a physician and/or mental health practitioner. The Edinburgh Postnatal Depression Scale (EPDS) is considered the gold standard for screening of postpartum depressive symptoms.⁴⁹ Postpartum depression is likely to begin within 4 weeks of delivery but may occur as early as 1 day postdelivery.⁵⁰ It is considered clinically significant if the symptoms are present most of the day, nearly every day, for nearly 2 weeks. Symptoms are consistent with the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-V) criteria for major depression. A minimum of 5 of the following must be present to meet the criteria: depressed mood, severe anxiety, markedly diminished interest or pleasure with activity, appetite disturbance (loss with weight loss), sleep disturbance (insomnia and fragmented sleep), physical agitation, psychomotor slowing, fatigue, feelings of worthlessness or excessive guilt, decreased concentration, and/or recurrent thoughts of death or suicidal ideation.^51–53 A score of greater than or equal to 10 on the EPDS is considered to indicate the presence of depressive symptoms. However, any positive response to the suicidal ideation on item #10 (even with a score <10) should be considered a red flag and initiate an immediate referral to the emergency department. In addition, depression may result in somatization, and therefore should be considered when patients do not improve as expected. The EPDS does not capture all aspects of lower mood or heightened anxiety. PTs should consider administering additional scales measuring other aspects of biopsychosocial functioning, including lower mood, anxiety, fear, and kinesiophobia, especially for individuals with persistent PP-PGP or those who do not respond as expected to PT interventions.

EXAMINATION

This CPG provides clinicians with a core set of examination tests and measures supported by the best available evidence. The CPG will enable clinicians to:

• determine the presence of clinical findings associated with a PP-PGP diagnosis as described and
• identify changes in impairments, function, activity limitations, and participation restrictions over an episode of care in physical therapy.

Clinicians should choose the most appropriate measures based on the patient's presentation, needs, and goals.

Outcome Measures

A variety of domains need to be specifically assessed in individuals with PP-PGP. Measures of pain, general health status and disability, postpartum quality of life, and mental health including psychological and emotional status should be conducted by the clinician. Outcome measures specifically validated in individuals with PP-PGP include the Oswestry Low Back Pain Disability Questionnaire (ODQ) and the PGQ. The PGQ is the only outcome measure designed specifically to evaluate impairments and functional limitations of PGP during pregnancy and postpartum.⁵⁴ The PGQ includes questions from previously established functional outcome measures (Disability Rating Index), ODQ, and the Roland-Morris Disability Questionnaire) and functional activity questions considered clinically relevant by clinicians and a patient focus group. Specific questions are asked related to perceived disability associated with pain intensity, personal hygiene, lifting, walking, sitting, standing, sleeping, sexual activity, social activity, and traveling.

The QBPDS is a measure validated in the general population with nonspecific low back pain to measure the grade of disability.⁵⁵ It is frequently used in studies as a comparison measure in studies investigating pregnancy-related PGP.^56–61 However, the QBPDS has not been specifically validated in the postpartum population. See Table 4 for details associated with disability outcome measures utilized for PP-PGP.

Table 4. - Outcome Measures Utilized for PP-PGP

LOE	Tool	Description	Method/Units	Psychometric Properties				Reference
I	Oswestry Disability Index (ODI)	A condition-specific outcome measure designed to assess the level of disability in individuals with spinal disorders. The ODI contains 10 sections that evaluate pain and domains of daily living including personal care, lifting, walking, sitting, standing, sleeping, sexual activity, social activity, and traveling. Scores are reported on a 0%-100% scale, with 100% representing severe disability	Self-report 5-point Likert Scale 0 = no disability 5 = severe disability	ICC	0.94 (0.89-0.97)			Fairbank and Pynsent167 Grotle et al168 Ogollah et al169
				MDC	11.1; 8.68
				MCID	10 patients, 30%
				SEM	4.02
				Cronbach α	0.83
				Validity	PGQ Activity subscale (r = 0.72) PGQ Symptom subscale (r = 0.71) SF2 (r = 0.66)
	Pelvic Girdle Questionnaire (PGQ)	A condition-specific outcome measure designed to assess aspects of quality of life in the antepartum and postpartum population who experience pelvic girdle pain. The PGQ is a 25-item questionnaire with 2 subscales: 20-item Activity subscale and 5-item Symptom subscale. There are 75 possible points that are adjusted (×4/3) to a 0%-100% scale, with 100% representing the highest impact on quality of life.	Self-report 4-point Likert Scale 0 = no impairment/pain 4 = large extent/considerable pain		PGQ (Total)	Activity Sub scale	Symptom Subscale	Stuge et al54,170
				ICC (95%)	0.93 (0.87-0.96)	0.93 (0.86-0.96)	0.91 (0.84-0.95)
				MDC	14.8	14.4	19.6
				SEM	5.33	5.21	19.6
				Cronbach α	0.86
				Validity	Activity subscale (r = 0.93) Symptom subscale (r = 0.96) DRI (r = 0.76) ODI (r = 0.72) SF2 (r = 0.63)
	Quebec Back Pain Disability Scale (QBPDS)	The QBPDS is a 20-item self-administered instrument designed to assess the level of functional disability in individuals with back pain. The scale is a reliable and valid measure used for monitoring the progress of individual patients participating in treatment or rehabilitation programs. The minimum score is 20 and the maximum score is 100. Higher scores correlate to greater disability. % of maximal disability = (score – 20)/80 × 100% Minimum detectable change (90% confidence) 15 points	Self-report 5-point Likert Scale 0 = not difficult at all 5 = unable to do	ICC (95%)	0.70 to 0.99			Kopec et al55 Damen et al56 Mens et al60
				MDC	15
				SEM	5.33
				Cronbach α	0.89-0.96
				Validity	ODI (r = 0.80) RMDQ (r = 0.77)

Abbreviations: DRI, Disability Rating Index; ICC, intraclass correlation coefficient; LOE, level of evidence; MCID, minimal clinically important difference; MDC, minimal detectable change; PGQ, Pelvic Girdle Questionnaire; PP-PGP, postpartum pelvic girdle pain; QBPDS, Quebec Back Pain Disability Scale; RMDQ, Roland-Morris Disability Questionnaire; SEM, standard error of the measure; SF2, Physical Functioning dimension of the Short Form-36.

Physical Tests and Measures

Any abnormal findings identified during the screening examination should be followed up with a detailed examination. Specific recommendations for selection of procedures to rule in PP-PGP and inform the selection of interventions are detailed later. The order of physical measures presented is representative of a typical examination flow based on position. The PT should consider modification of positions based on patient mobility and tolerance.

The recommendations describe the current evidence regarding a combination of pathoanatomic (Table 5) and movement testing to confirm the location of pain and identify specific limitations that contribute to load transfer impairments. Testing for muscle performance (strength, timing/coordination, and endurance), ligament/joint integrity, and performance during limb (upright) and trunk (supine) loading tasks will be discussed. Assessment for symmetrical responses to testing (ie, agreement between testing on the right versus left sides) should be emphasized due to the association between asymmetry and the presence of PP-PGP. A gold standard test is not currently available. Therefore, the validity of the available clinical tests is difficult to assess. Most of the physical tests/measures have a high specificity, but lower sensitivity. Therefore, a combination of tests is likely necessary to rule out the presence of PP-PGP. Reliance on the results of a single test may result in a false-negative result.

Table 5. - Special Tests for PP-PGP

LOE	Test	Study Population	Psychometrics					Reference
			Sn	Sp	Re	NPV	PPV
I	PS palpation test	2269a pregnant women at wk 33 of gestation	0.60	0.99	κ = 0.89			Albert et al171
III	Long dorsal ligament palpation	178 women with PGP since pregnancy or that began within 3 wk postpartum receiving PT at OP clinic 0.5-4.8 y postpartum (median 1.7 y)	0.76	0.86				Vleeming et al69
		Mixed—both pregnant and postpartum were reported Mixed PGP/LBP group (n = 61) Controls (n = 63)	0.21	0.98	κ = 0.76 (0.64-0.88)			Njoo et al70
I/II	Posterior pelvic pain provocation (P4) test	Postpartum women who experienced PGP during pregnancy Current PGP (n = 51) No current PGP (n = 238)	0.569	0.164		0.90	0.42	Olsén et al72
		Women with persistent pelvic girdle pain after delivery (n = 32)	0.88	0.89		0.87	0.89	Gutke et al74
		Women with postpartum PGP (n = 200) Women with lumbopelvic pain (n = 50) Healthy women (n = 50)	0.69					Mens et al75
		Pregnant and postpartum women with PGP (2 and 6 mo post-delivery) (n = 38) Pregnant women without PGP (n = 14)	0.70-0.74					Hansen et al73
II	FABER test	Postpartum women who experienced PGP during pregnancy Current PGP (n = 51) No current PGP (n = 238)	0.608	0.205		0.909	0.517	Olsén et al72
I	Active straight leg raise (ASLR) test	Postpartum women who experienced PGP during pregnancy Current PGP (n = 51) No current PGP (n = 238)	0.588	0.151		0.829	1.00	Olsén et al72
		49 pairs of women at least 6 mo postpartum—with PGP and without PGP			ICC 0.886-0.955 (right leg) 0.905-0.952 (left leg)			Stuge et al79
		Patients with PGP and ≥3 on 0-10 pain score	0.58	0.97				Damen et al78
		Women with postpartum PGP (n = 200) Women with lumbopelvic pain (n = 50) Healthy women (n = 50)	0.87	0.94	r = 0.87			Mens et al75
II	Modified Trendelenburg	Postpartum women who experienced PGP during pregnancy Current PGP (n = 51) No current PGP (n = 238)	0.176 Anterior pain 0.49 Posterior pain	0.02 0.08		0.846 0.849	0.563 0.50	Olsén et al72

Abbreviations: FABER, flexion, abduction, external rotation test; LBP, low back pain; LOE, level of evidence; NPV, negative predictive value: proportion of patients with a positive test who are correctly diagnosed; OP, outpatient; PGP, pelvic girdle pain; P4, posterior pelvic pain provocation test; PP-PGP, postpartum pelvic girdle pain; PPV, positive predictive value: proportion of patients with a negative test who are correctly diagnosed; PS, pubic symphysis; Re, reliability; Sn, sensitivity; Sp, specificity.

^aNo available evidence specific to reliability/validity in the postpartum population.

Palpation

Alignment Testing

Palpation of bony landmarks has been described to assist with identification of asymmetry of the pelvic joints but generally has not been studied in the postpartum population. Palpation may be performed in seated or standing positions. Landmarks most commonly palpated for alignment include the iliac crests, anterior superior iliac spine (ASIS), PSIS, and pubic tubercles. A number of studies have shown poor intra- and intertester reliability with alignment testing through palpation. In addition, asymmetry in position was not strongly associated with the presence of PGP.⁶² Therefore, the PT may choose to perform alignment testing but should not rely on results in isolation to determine the diagnosis and/or intervention strategy.^62–65

Pubic Symphysis Palpation

Although the available evidence is limited to expert opinion, palpation of the PS is an important element to include in examination of individuals with PP-PGP. To determine PS involvement in PP-PGP, assessment begins with palpation for pain in standing or in supine with the symphysis pain palpation test (SPPT). In the SPPT, the anterior portion of the PS is palpated. If the palpation causes pain that persists more than 5 seconds after removal of the examiner's hand, it is recorded as pain. If the pain disappears within 5 seconds, it is recorded as tenderness. Pubic symphysis palpation should not be done in isolation. Joint involvement should be confirmed by provocation testing (FABER test) and standing assessment (Modified Trendelenburg test), which are described later.⁶⁶ Positive testing would indicate that the PS is involved in the anterior pain and impairments associated with limb loading should be assessed.

Long Dorsal Ligament Palpation

Vleeming et al^10,67–69 explain that the LDL becomes taut with specific motions at the SIJ and that tension across the LDL contributes to form closure at the pelvic girdle. Pain to touch in this region suggests ligamentous strain. There is weak evidence to support inclusion of palpation of the long dorsal sacroiliac ligament (LDL) in postpartum clients with posterior PP-PGP.⁶⁹ The LDL test involves palpation of the LDL directly under the caudal part of the PSIS in prone and assessment of symptom provocation. The examiner scores the pain as positive or negative on a 4-point scale: no pain = 0; mild = 1; moderate = 2; and unbearable = 3. The scores on both sides are added. The sum score ranges from 0 to 6. Palpation of the LDL should not be done in isolation. The LDL test is typically used in combination with the P4 test and the ASLR test (described later) with a patient presenting with lumbopelvic and/or SIJ pain.

Njoo et al⁷⁰ reported high intertester reliability of LDL palpation; however, the study population was not specific to postpartum individuals and did not differentiate between those with lumbar sites of pain and PGP. Vleeming et al⁶⁹ specifically evaluated the use of the LDL test in the postpartum population and demonstrated little agreement between results of LDL and ASLR or P4 testing in the absence of severe PP-PGP presentation. Specificity of the LDL test was found to be 0.98 only when severe case presentation patients were included. The lack of agreement among the LDL, P4, and ASLR tests in nonsevere case presentations suggests that the tests do not assess the same structures and/or function in PP-PGP individuals without severe symptoms. Therefore, the clinical value of a positive LDL test, the reliability of LDL palpation across a diverse postpartum population, and the relationship between presence of pain at the LDL and function remain unclear.

Provocation Testing

Provocation testing is used to rule in the presence of pain at the SIJ and/or the PS. Several provocation tests have been described in the PGP and SIJ literature. However, only 2 provocation tests—the P4 test and the FABER or Patrick's) test—have been specifically described in the postpartum population. Gaenslen's test⁷¹ should not be performed within the first 4 weeks postpartum due to the risk of injury (see later). Further research should explore the mechanisms that potentially explain variability in positive testing among palpation, provocation, and load transfer testing in relation to pelvic girdle structure and function in the postpartum population.

Posterior Pelvic Pain Provocation (P4) Test

There is strong evidence to support inclusion of the P4 test to rule in PP-PGP.^72–75 The P4 test is performed with the patient in the supine position with the hip and knee flexed to 90° on the side being tested. A light manual pressure is applied to the patient's flexed knee along the longitudinal axis of the femur while the examiner stabilizes the contralateral pelvis through a force applied over the superior anterior iliac spine. The test is considered positive when the patient reports a familiar well-localized pain deep in the gluteal area on the ipsilateral side.⁷⁴

FABER (Patrick's) Test

There is moderate evidence to suggest inclusion of the FABER test to rule in PP-PGP. The FABER test is performed with the patient in supine. The limb on the painful side is placed so that the ankle is just above the knee of the contralateral limb. The examiner provides a gentle downward pressure on the knee of the painful side while stabilizing the ASIS of the nonpainful side. The examiner assesses the presence and location of pain. Patients presenting with PP-PGP will often report pain posteriorly (at the PSIS) or anteriorly (at the PS) on the ipsilateral side during this test.

Gaenslen's Test

Although the available evidence is limited to expert opinion, Gaenslen's test^71,76 should be performed with caution in postpartum clients. The test is performed with the patient positioned in supine with the painful limb resting very near the end of the treatment table. The examiner raises the nonpainful side hip to 90°. A downward force to the painful side lower limb is applied while applying a flexion-based counterforce to the flexed limb. A positive test is described as pain with the application of the torque across the pelvic joints. Because of the risk of PS trauma during pregnancy/childbirth, it is recommended that PTs not perform Gaenslen's test for the first 4 weeks postpartum and/or beyond 4 weeks postpartum when in the presence of PS pain.

Assessment of Sacroiliac Joint Motion

Several researchers have investigated SIJ mobility and laxity in postpartum individuals using Doppler imaging.^77,78 While SIJ laxity was elevated during pregnancy, Damen et al⁷⁸ reported that mean SIJ laxity values decreased from 36 weeks pregnancy to 8 weeks postpartum and were within a normal range by 8 weeks postpartum. Asymmetric laxity of the SIJ rather than the degree of laxity was associated with PP-PGP.⁷⁸ Asymmetric laxity of SIJ in pregnancy corresponded with a 2.8 relative risk ratio for moderate to severe PGP persisting at 8 weeks postpartum.^77,78 No clinical measures were identified that were reliable and valid in the postpartum population for assessment of asymmetrical laxity of the pelvic girdle (SIJ and PS). Although the available evidence is limited to expert opinion, we recommend that functional assessment be used to determine asymmetrical responses to limb loading. PTs should use tests that assess limb loading, specifically ASLR and single-limb standing assessments, from immediately to up to 1 year postpartum. Future research should consider the use of Doppler ultrasound in clinical practice to measure laxity.

Functional Limb Loading Assessment

The ability to stabilize the pelvis to allow movement of the LEs involves adequate co-contraction of lumbopelvic muscles and is important to return to full participation in functional activities postpartum. Functional limb loading can be assessed in standing, in supine, and through observation of functional task performance.

Active Straight Leg Raise Test

There is strong evidence to support inclusion of the ASLR test in the examination of individuals with PP-PGP.^{56,57,59,60,72,75,78–80} This test assesses supine limb loading as a means to determine ability to stabilize the pelvic girdle and trunk in response to the movement of the LE.⁸¹ To perform the ASLR test, the patient is positioned in supine. The patient is asked to raise each limb approximately 6 inches while assessing for difficulty. If lifting the limb was difficult, the examiner then stabilizes the pelvis by compressing the ASIS medially or by placing a belt around the pelvis. The patient is again asked to raise the affected limb approximately 6 inches. If this movement is no longer difficult, the test is considered positive.^58–60

A positive ASLR test is suggestive of impaired coordination of the lumbopelvic muscles. A positive test suggests that the individual would benefit from exercises to improve muscle performance for stabilization to function optimally. A negative ASLR test in the presence of PP-PGP generally indicates adequate levels of co-contraction of lumbopelvic muscles and appropriate force closure of the pelvic girdle.

Standing Assessment

Standing tests for PP-PGP can be considered in 3 categories: (1) double-limb support, (2) single-limb support, and (3) transitional movements. Standing in double-limb support is unlikely to elicit symptoms (pain or difficulty with the task), except in severe case presentations.⁸² Standing in single-limb support or transitional movements, such as sit to stand, walking, and/or rolling in bed, are more likely to reproduce anterior or posterior pain and/or result in abnormal movement patterns in individuals with PP-PGP.^2,58,82,83 Although the available evidence is limited, based on common functional complaints, standing tests should be performed, including single-leg stance, transition from sitting to standing, and walking.⁵⁴ Clinicians should observe and assess the level of pain and degree of movement impairment during these 3 functional movement assessments to determine whether the individual is able to manage the transfer of the load of the trunk and pelvis over the limb. Examination that is performed solely in the seated and/or supine positions is less likely to evoke symptoms in milder dysfunction. If the individual is unable to be assessed in standing, the ASLR test may be used to determine limb loading effects on pain and trunk motion in the supine position.

Traditionally, the Modified Trendelenburg test⁷² (pain produced at the anterior or posterior region of the pelvic girdle during limb loading while the opposite hip is flexed to 90°), the Gillet (March),⁸⁴ or Stork test^85,86 (palpation for mechanical locking of the sacrum and ilium during a standing hip flexion task) has been performed to determine load transfer impairments of the PS or SIJ. These types of standing tests are used to identify the location of pain (Modified Trendelenburg test) or asymmetries in motion across the SIJ (Gillet/March or Stork). Unfortunately, the literature is silent regarding appropriateness of the Gillet (March) or Stork test in the postpartum population. Only the Modified Trendelenburg test has been reported in the PP-PGP population.^17,22,23,87 Thus, future research is needed to investigate the appropriateness of the combined testing of palpation with single-leg stance to objectively measure limb loading impairments in PP-PGP. There is also a need to identify other specific impairments/muscle performance issues that contribute to the load transfer impairment.

Muscle Function Assessment

Because of uterine enlargement combined with weight gain and hormonal changes, the abdominal, lumbar, and hip musculature are exposed to abnormal forces during pregnancy and childbirth. Postpartum individuals are at risk for: loss of fascial integrity of the abdominal and pelvic floor muscles; changes in resting length (the abdominals, pelvic floor, and thoracic back extensors muscles are lengthened while lumbar back extensors are shortened); changes in resting muscle tone; and acute inflammation associated with the trauma of childbirth. These physical changes may lead to reduced or altered muscle function/performance.

The literature investigating what changes in muscle function/performance persist in the postpartum period is evolving. There is strong evidence to support that muscle function/performance impairments are present in PP-PGP. However, there is limited evidence linking altered muscle function/performance to the presence of persistent PP-PGP. Given the lack of robust evidence to improve pain, we have assembled the available literature on muscle function/performance and operationalized this construct unique to PP-PGP.

There is strong evidence to suggest that the following should be prioritized in the specific assessment of PP-PGP:

• timing of contraction (multifidi, abdominals, and PFM)
• endurance (back extensors, trunk flexors)
• strength/force production (hip extensors, back extensors, abdominals, and PFM)
• resting tone/over-activity (multifidi, abdominals, and PFM)

The following tests have been described to assist in assessing muscle function/performance.

Timing of Contraction

Pregnancy and childbirth may result in altered timing of muscle contraction. The ASLR test is one method that has been used to assess appropriate timing of contraction in the postpartum population. Sjödahl et al²¹ demonstrated delayed onset of contraction of the PFM and abdominals during the ASLR test in women with PP-PGP as compared with those without pain. Surface electromyography (EMG) was utilized to measure abdominal and PFM activity.

Endurance Testing

Back flexor endurance test: To test isometric endurance of back flexors, McQuade et al⁸⁸ describe a supine test with arms crossed over the chest, hands on the opposite shoulders, hips bent, and knees and feet apart. Participants were asked to nod and continue to lift the head and shoulders until the inferior angle of the scapula was lifted from the surface, and maintain the position as long as possible.⁸³ The number of seconds that the position was maintained for was recorded up to a maximum of 120 seconds.

Back extensor muscle endurance test: To measure the isometric endurance of the back extensors, participants lay prone with arms crossed and the trunk horizontal off the table. The pelvis was fixed to the table by straps and the lower legs were held in place by the tester.⁸⁹ The time that this position was maintained was recorded in seconds and the test up to a maximum of 120 seconds. This test may be uncomfortable in the presence of PP-PGP. Therefore, use of this test should be used judiciously.

Resting Tone

There is moderate evidence to suggest that there may be increased resting tone in the back extensors, abdominals, and/or PFM in individuals with PP-PGP. A variety of tests/measures can be used to assess the resting tone of the musculature. Overactivation can be identified clinically with the use of palpation, EMG biofeedback, manometry, and diagnostic ultrasound. The strongest evidence suggests use of EMG biofeedback and/or manometry.

Force Production

Trunk/back flexor musculature: There is moderate evidence that force production may be impaired in trunk flexor musculature postpartum. Maximum voluntary isometric contraction of the trunk musculature has been used to measure force production capacity of the trunk flexors postpartum and found that postpartum individuals were weaker at all angles than nulliparous individuals.⁹⁰ However, the relationship between impaired force production and the presence of PP-PGP has not been established.

Hip musculature: There is moderate evidence that hip musculature, in particular, hip extensors, should be assessed (see Table 6) due to the relationship between hip extensor weakness and the presence of PP-PGP.^21,83,91 Gutke et al⁸³ reported lower hip extension strength and gait speed in those reporting PP-PGP. Maximal voluntary isometric hip extension or adduction can be measured with a dynamometer and compared between sides. However, functional assessment may also be warranted.

Table 6. - Muscle Function Assessment in PP-PGP

LOE	Muscle Function	Test/Measures	Study Population	Study Findings	Reference
II	Timing of contraction	ASLR test	Women with persistent PP-PGP (n = 28) Women without PGP (n = 13)	The PP-PGP group showed a delayed onset in both the PFM (P = .01) and muscles of the lower lateral abdominal wall (P < .01) compared with the control group).	Sjödahl et al80
II	Endurance	Trunk flexor endurance test	Women with persistent PP-PGP and PP-PGP in combination with lumbar pain at 3 mo postpartum (n = 88) and 15 mo postpartum (n = 58)	Age + trunk flexor endurance was predictive of disability 15 mo postpartum	Sjödahl et al21
		Back flexor and back extensor muscle endurance tests	Women 3 mo postpartum classified into groups no low back pain PP-PGP lumbar pain combined lumbar and PP-PGP	Women with PP-PGP have lower endurance of back flexors than women without pain (mean difference 17.9 seconds, P = .001). Back extensors (mean difference 28.3 seconds, P < .001, compared to women without LBP or PP-PGP)	Gutke et al83
II	Force production	Maximal hip ADD force using handheld dynamometry	Postpartum women with long-lasting posterior PP-PGP (n = 49) Postpartum women of the same age group without PGP (n = 37)	Women with PP-PGP demonstrated significantly reduced hip ADD force during ASLR testing (without belt) than controls (107 ± 51 N vs 211 ± 42 N) (P < .00001).	Mens and Pool-Goudzwaard91
		Hip extensor strength using handheld dynamometry	Women with persistent PGP and PGP in combination with lumbar pain at 3 mo postpartum (n = 88) and 15 mo postpartum (n = 58)	Disability + hip extensor strength was predictive of disability 15 mo postpartum	Sjödahl et al21
		Maximal voluntary isometric hip extensor strength using handheld dynamometry	Women 3 mo postpartum classified into groups no low back pain PP-PGP lumbar pain combined lumbar and PP-PGP	Max voluntary isometric hip extensor strength postpartum (mean difference 45-73 N, P = .03, compared with women without LBP or PP-PGP)	Gutke et al83
II	Resting tone	Ultrasound imaging at rest and during ASLR test	Postpartum women with ongoing PGP that started during pregnancy (n = 43) Postpartum women with no PGP (n = 39)	Increased thickness of the TrA during ASLR test in patients with PP-PGP	Mens and Pool-Goudzwaard91
		Manometry of PFM at rest, with voluntary contraction and during ASLR	49 pairs of women at least 6 mo postpartum—with PGP and without PGP	Significantly larger reduction of the muscle length during ASLR test than during voluntary PFM contraction PFMs were less contracted during ASLR test with compression compared with ASLR test without compression (P < .001)	Stuge et al79
		Manometry with a vaginal balloon catheter	Women >6 mo postpartum with PGP onset during pregnancy or within 3 mo post-delivery	Higher vaginal rest pressure in women with PGP	Stuge et al126
II	Muscle length	Ultrasound measurement of levator hiatus	49 pairs of women at least 6 mo postpartum—with PGP and without PGP	Women with PP-PGP had a significantly smaller levator hiatus at rest as compared with controls The area of levator hiatus was significantly smaller during ASLR in women with PP-PGP compared with the control group	Stuge et al79
		Ultrasound measurements of levator hiatus area	Women >6 mo postpartum with PGP onset during pregnancy or within 3 mo post-delivery	Smaller levator hiatus area in PGP groups compared with controls	Stuge et al126

Abbreviations: ADD, adductor; ASLR, active straight leg raise; FABER, flexion, abduction, external rotation test; LBP, low back pain; LOE, level of evidence; PFM, pelvic floor muscle; PGP, pelvic girdle pain; PP-PGP, postpartum pelvic girdle pain; P4, posterior pelvic pain provocation test; TrA, transverse abdominis.

Pelvic floor musculature: There is strong evidence that pelvic floor muscle function is impaired postpartum. Muscle strength assessment of the PFM through manometry has been shown to be reliable and valid.^92,93 PFM endurance has been defined as a sustained maximal contraction and was quantified during the first 10 seconds as the area under the curve.⁹⁴ Manometry measurement has demonstrated higher reliability coefficients than digital muscle testing on maximum voluntary contraction strength, endurance, and vaginal resting pressure.⁹⁵ Weakness of PFM has not been specifically associated with PP-PGP. However, further investigation is warranted. The PFM has been found to automatically contract during the ASLR test.⁷⁹ However, manual compression during the ASLR test reduced the automatic PFM contraction by 62% to 66%. There was no difference between those with PP-PGP compared with those without PP-PGP in the reduction in PFM force.⁷⁹ These results suggest that PFM performance is important in pelvic girdle stabilization, and, therefore, should be assessed and any identified impairments addressed.

Muscle length: Due to the physical stresses and hormonal changes during pregnancy and childbirth, the pelvic girdle musculature is at risk for changes in muscle length postpartum. The back extensors and hip flexors are most likely to be shortened, while the pelvic floor and abdominal muscles are most likely to be lengthened. At the time of this guideline, there was limited to no evidence describing reliable and valid measures of pelvic muscle length in this population. Future research should investigate the effect of muscle length changes in individuals with PP-PGP.

Diastasis recti abdominis assessment: A common finding postpartum is diastasis recti abdominis (DRA), in which the linea alba has been disrupted due to the lengthening of the abdominal wall during pregnancy. DRA has been associated with the presence of pelvic floor dysfunction,⁹⁶ but no studies have specifically linked the presence of DRA with the presence of PP-PGP. The clinical assessment of DRA is generally performed with the patient in supine. The clinician observes and palpates the interrecti distance during an active trunk flexion (actively lifting the head/shoulders off of the table).

There is no agreement about the degree of separation that is considered clinically significant; however, an interrecti distance greater than 2 finger widths at, above, or below the umbilicus warrants additional investigation. Because DRA can impact the integrity and function of the abdominal wall,⁹⁷ all postpartum individuals should be screened for the presence of DRA and an appropriate treatment plan be established when DRA is identified, regardless of the presence or absence of PP-PGP. Future research should consider classifying abdominal muscle performance (over- or underactive) in the presence of DRA and/or pelvic floor disorders to understand contributions to PP-PGP. (See Table 7 for a summary of the literature associated with DRA.)

Table 7. - Summary of Evidence Regarding DRA in the Postpartum Population

LOE	Study Population	DRA Findings in Postpartum	Reference
II	Women 12-14 mo postpartum with DRA (IRD ≥2.2 cm; n = 18) and without DRA (IRD <2.2 cm; n = 22)	Women with DRA demonstrated significantly lower trunk muscle rotation torque and scored lower on the sit-up test than those without DRA IRD was negatively correlated with both trunk rotation torque (ρ = −0.367) and sit-up test score (ρ = −0.514)	Hills et al172
	Postpartum women who were running a minimum of once per week (n = 507)	Among women who had given birth to a child within the past 2 y, 32% perceived RA separation Compared with primiparous women, multiparous women were more likely to report a perceived RA separation (OR, 2.11; 95% CI, 1.08-4.26) The odds of perceived RA separation were greater among women with a caesarean section delivery than women who never had a caesarean section (OR, 2.20; 95% CI, 1.05-4.70) Postpartum SUI increased the odds of perceived RA separation more than 2-fold (OR = 2.25; 95% CI, 1.02-5.08; P = .040) Antenatal weight training decreased the odds of abdominal separation (OR, 0.51; 95% CI, 0.26-0.96)	Blyholder et al173
	Primiparous postpartum women (n = 84)	The prevalence of DRA decreased from 100% at gestational week to 35%-39% at 6 mo postpartum	Fernandes da Mota et al174
	Postpartum women (n = 40) and age-matched nulliparous females (n = 20) Measurements taken 4-8 wk and 6-8 mo after childbirth	The IRD at 2.5 cm above the umbilical ring and at the upper margin of the umbilical ring decreased (P = .013 and P = .002, respectively) A negative correlation between IRD and abdominal muscle function at 7 wk and 6 mo postpartum was found (r = 0.34-0.51; P < .05, except for trunk flexion strength at 6 mo postpartum, P = .064) IRD changes between 7 wk and 6 mo postpartum were correlated with improvement in trunk flexion strength (Spearman ρ = 0.38, P = .040) At 6 mo after childbirth, postpartum women had greater mean IRDs at all 4 locations (from cranial to caudal: 1.80 ± 0.72, 2.13 ± 0.65, 1.81 ± 0.62, and 1.16 ± 0.58 cm) than those of nulliparous females (0.85 ± 0.26, 0.99 ± 0.31, 0.65 ± 0.23, and 0.43 ± 0.17 cm) (all P < .001)	Liaw et al97
	Women seeking medical care for lumbar or pelvic area diagnoses who had delivered at least 1 child (n = 39, PD) Women with a history of LAP (n = 8) CON (n = 53)	Incidence of DRA was 74.4% for the PD, 50.9% in the CON, and 100% in the LAP groups 47% of the measurements at the umbilicus showed a DRA, while 35% below the umbilicus, and 35% above was classified as DRA There was a significant difference between those with and without DRA for the VAS scores for abdominal and pelvic area pain	Parker et al128

Abbreviations: CI, confidence interval; CON, control group; DRA, diastasis recti abdominis; IRD, inter-rectus distance; LAP, laparoscopy; LOE, level of evidence; OR, odds ratio; PD, pelvic diagnosis; RA, rectus abdominis; SUI, stress urinary incontinence; VAS, Visual Analog Scale.

Diagnosis/Classification

Pelvic girdle pain in the postpartum client may resemble that of pregnancy-related PGP or pelvic girdle pain syndromes in the nonpregnant population. Several theoretical classification models—biopsychosocial,^98,99 pathoanatomic,^76,100 treatment-based,^101,102 and movement-based classifications^103–106—may be considered when applying this guideline to an individual client with PP-PGP. The challenge with choosing the appropriate model for PP-PGP is highlighted when one considers the scope of this condition. Consideration of several factors commonly present with PP-PGP is needed to classify the condition including psychological health, number of pelvic joints involved, and underlying functional impairments associated with faulty joint kinematics. Each factor needs to be considered to direct care decisions.

The biopsychosocial model⁹⁸ highlights the importance of the psychological health of the individual and may be considered when incorporating moderators that may affect intervention outcomes. This is especially important with the postpartum client who may require additional education and referrals to other medical providers because of postpartum health, independent of PP-PGP. Recent research^107,108 proposes biopsychosocial models for PGP that incorporate pain science, person-centered language, and a focus on patient beliefs. Beales et al¹⁰⁷ adapted the common illness model to PGP, although not specific to the postpartum population. A more explicit focus on patients' beliefs, emotional responses, and lifestyle behaviors related to PGP may provide a more patient-centered approach and better capture factors related to fear avoidance, kinesiophobia, and psychological distress, which are common in persistent PP-PGP.

An increased focus on the neurobiological aspects of PP-PGP, the role of inflammation, and involvement of central factors in the development of persistent PP-PGP may provide a much-needed mechanism to investigate inflammatory factors that may (1) promote physical recovery after childbirth and/or (2) contribute to PP-PGP. Meijer et al¹⁰⁸ propose inflammation (local and systemic) as a possible integrated link between the biomechanical and psychological dimensions of PGP. Biopsychosocial models of PGP have not been applied to the postpartum population and do not guide specificity for interventions beyond patient education, counseling, or referral needs. Further research should apply these approaches to PP-PGP, explore the clinical presentation of PP-PGP in relation to a pain science model, and classify pain types in relation to interventions.

Understanding of the kinematics of the pelvic girdle is an important factor when attempting to classify PP-PGP. The shape of the sacrum, ilium, PS, and supporting connective tissues are uniquely designed to create form closure, which allows a locking mechanism during limb loading.^68,109 In addition, the surrounding musculature, when activated in a coordinated fashion, reinforces the stability of the pelvic joints providing force closure.^10,110–114 Thus, using provocative testing to understand which joints are involved (SIJ and PS) is important. However, given the interaction between joint loading and muscle performance, it is important to not simply perform provocative testing in isolation. Provocative tests provide insight into the pathoanatomic location of pain, but do not provide guidance related to the specificity of the impairments needed to be addressed during intervention.

The treatment-based classification model^101,102 relies heavily on alignment to determine the need to provide a manipulative technique. However, there is strong evidence to support the lack of reliability in identifying pelvic girdle alignment and accessory motion impairments in the nonpregnant population.^115,116 Recent research by Hodges et al¹¹⁷ developed a multidisciplinary collaborative model of the construct of SIJ pain/PGP, not specific to the postpartum population. In this collaborative model, biomechanical factors were rated by a panel of international experts as most important. The 3 biomechanical aspects rated most centrally to the model of SIJ pain/PGP included “poor anatomical/structural characteristics,” “motor impairment,” and “poor posture and alignment.”¹¹⁷ Similarly, our proposed model is a hybrid framework that emphasizes a biomechanical approach and incorporates patient-specific functional activity assessment.

Clinicians should not rely solely on alignment testing to determine treatment options. Once the involved joints have been identified and the presence of asymmetry determined, movement testing of the trunk and hip is needed to determine specific patterns of movement and coexisting impairments to determine an individualized care plan. Thus, based on the evidence associated with presenting symptoms and physical limitations of women with PP-PGP, the authors propose a classification system that considers key aspects of each of the reported models noted previously including alignment, provocative testing, and movement testing. The focus of this model is associated with identification of specific load transfer impairments of the pelvic girdle. The emerging science related to the neurobiology of pain with an increased focus on patient beliefs and language is promising. However, these approaches have not been applied to the postpartum population. Therefore, we are unable to incorporate these elements into the hybrid model of PP-PGP at this time.

The authors propose 3 categories of load transfer impairments for PP-PGP:

1. Sacroiliac joint load transfer impairment with or without asymmetry,
2. Pelvic girdle load transfer impairment (≥2 more joints), and
3. Pubic symphysis load transfer impairment.

The CDM flowchart (refer to the Figure) facilitates implementation of this proposed PGP classification into clinical practice. The CDM flowchart is designed to help readers select appropriate tests and measures based on the respective theoretical models as well as develop appropriate intervention strategies for the client with PP-PGP, based on location of pain, pain response to treatment, movement-related load transfer impairments (trunk, hip, and pelvic girdle), and presence of asymmetry (alignment and muscle performance). The focus of this classification system is on nociceptive aspects of PP-PGP. Future research should investigate nociplastic PP-PGP with considerations for intervention.

Hybrid Diagnostic Model of PP-PGP

The components of the movement system^105,118 to classify PP-PGP include consideration of state of each component of the system, bone, muscle, integument (including fascia), ligament, and neural control. Individuals with PP-PGP may have persistent pregnancy-related connective tissue laxity^78,119–121 and muscle performance impairments in the supportive muscle groups of the pelvic girdle.^{21,43,79,80,83,97,122–128} The primary movement impairment that results is an inability to adequately control joint stability of the SIJ, PS, or both, during functional movements that require limb or trunk loading. In individuals with PP-PGP, there is impaired muscle function in the abdominals,^12,97 back flexors and extensors, hip adductors and extensors,^21,80,91 and pelvic floor muscles,^79,126 combined with excessive or asymmetrical accessory motion at the SIJ and/or PS.^{56,77,78,98,129} These impairments may cause pain and difficulty with functional tasks such as walking, moving from sit to stand, and rolling.^100,130

It is theorized that maladaptation of the ability to transfer the weight of the trunk over the limb occurs due to the reduction of the kinematic locking mechanism of the joints—both the structural stability of the joint and the muscle performance is impaired.^{10,81,85,86,109,122,131–133} Because directionality of movement is unique to the individual,^134–136 specific assessment of alignment and muscle performance during testing will allow individualized treatment plans to be developed. The focus of treatment is to improve muscle performance of the abdominals, back and hip extensors, and pelvic floor to improve stabilization of the pelvic girdle during functional activities and load transfer tasks. Specific attention needs to be given to movements that impose asymmetrical stresses across the SIJ or PS.^10,56 For example, excessive trunk and lumbopelvic rotation during single-leg stance occurs due to reduced performance of the abdominals, hip, and back extensors to assist in stabilization of the SIJ during this task. Impaired muscle performance of specific muscles that affect the stability of the pelvic joints may be determined during movement testing of the spine and hip, and can include bending, return from bending, standing on 1 leg, and lifting 1 leg in supine. Due to reduced reliability in the nonpregnant population^115,116 and the lack of specificity found in utilizing testing in the postpartum population,¹⁰¹ palpation should not be solely relied upon to direct treatment strategies for PP-PGP. However, in the presence of continued asymmetry of the pelvic joints combined with the presence of pain that does not reduce with increased muscle performance and/or mechanical stabilization, an attempt to correct a suspected positional impairment may be considered, followed by prescribing specific stabilization activities.¹⁰¹

Diagnostic categories: See Tables 8, 9, and 10 for details.

Table 8. - Sacroiliac Joint Load Transfer Impairment With or Without Asymmetry

History	Key Tests and Signs		Differential Diagnosis	Intervention
	Static	Dynamic
Pain and/or clicking at the region of the SIJ Unilateral pain Pain and difficulty with asymmetrical loading of LE/pelvis during functional mobility activities58 History/risk factors Prior episodes of PGP and/or LBP; SUI; PFD	Alignment: ASIS and PSIS alignment asymmetry (in more hypermobile cases changes may occur with variations of hip positions of ABD/ADD) lumbar alignment is asymmetrical Source tests: Standing compression: manual compression may aggravate until manual positional correction of asymmetry with compression is performed if pain abolishes or lessens with compression indicates need for belt stabilization or taping Provocative tests: 1/5 positive tests <8 wk postpartum Avoid Gaenslen's test within the first 4 wk postpartum. 3/5 positive tests >8 wk postpartum (FABER, thigh thrust (P4); sacral spring, ASIS distraction (supine), Sacral compression (side-lying)) Muscle length impairments Unilateral length changes shortened hip flexor, spine extensor on the anterior rotated side; shorten hamstrings, gluteal muscles on posterior rotated side	Muscle strength/performance impairments: Poor unilateral control of abdominal oblique muscles, transverse abdominis, hip extensors, lateral rotators and abductors, multifidus, and pelvic floor ASLR: Observe unilateral performance impairments: pelvic rotation with complaint of difficulty and/or SIJ pain performing ASLR Compression or positional correction with compression abolishes pain and/or increases ease of ASLR Movement tests: Standing: Forward bending: lumbar flexion > hip flexion Prone hip extension: pain along the joint line. suspect positional impairment Quadruped: increased sacral region pain with position Single-leg stance: (+) for pain (+Stork,85,86,131 Modified Trendelenburg test), unilateral + SLS testing occurs with less involved cases of hypermobility Functional mobility activities: pain with rolling, sit to stand, stair climbing, transitional positions Gait: inability to transfer load of trunk from above to LE, increased trunk shift with loading or inability to load if form closure is lost. Sits asymmetrically	Movement Impairment diagnosis106 Lumbar extension-rotation Lumbar flexion-rotation Femoral adduction femoral Adduction/medial rotation Hip posterior glide Hip anterior glide/medial rotation Visceral origin: Gastrointestinal, genitourinary, reproductive organ disease Metastatic disease/cancers: abdominal organs, uterus, bladder, Musculoskeletal Origin: Lumbar disc disease Inflammatory arthritis: ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, lupus, Reiter syndrome, compression fractures Labral tear (hip) Snapping hip syndrome (groin pain) Sacral or pubic arch stress fracture (military, high-impact activities, postpartum osteoporosis) Hormone imbalance affecting ligamentous structures	1. Bracing (belt) or taping104,120,157,158,175–178 2. Motor recruitment of gluteal, back, abdominal, and PFM)21,83,126 3. Education to minimize pain during functional activities18,99,141–149 (rolling, sit to stand, single-leg stance, walking, breast feeding/childcare) 4. Consider assistive device if functional mobility severely impaired or painful Address specific movement impairments that would cause rotational stress 5. Joint mobilization/manipulation: Consider if asymmetry does not resolve with belt, exercise, and functional training101

Abbreviations: ABD, abduction; ADD, adduction; ASIS, anterior superior iliac spine; ASLR, active straight leg raise; FABER, flexion, abduction, external rotation; LBP, low back pain; LE, lower extremity; PFD, pelvic floor dysfunction; PFM, pelvic floor muscle; PGP, pelvic girdle pain; P4, posterior pelvic pain provocation test; PSIS, posterior superior iliac spine; SIJ, sacroiliac joint; SLS, single-leg stance; SUI, stress urinary incontinence; VAS, Visual Analog Scale.

Table 9. - Pelvic Girdle Load Transfer Impairment (≥2 Joints)

History	Key Tests and Signs		Differential Diagnosis	Intervention
	Static	Dynamic
Pain and/or clicking at the region of 1 SIJ Bilateral sacral pain, simultaneous unilateral posterior and anterior pain or pain in all 3 regions is indicative of more involved case presentation Pain and difficulty with loading of lower extremity/pelvis during functional mobility activities (bilateral symptoms) History/risk factors Prior episodes of PGP and/or LBP; SUI; PFD	Alignment: Symmetrical pelvic landmarks, flat lumbar spine Source tests: Standing compression: Abolish or lessen pain indicates need to belt Provocative tests: 1/5 positive tests <8 wk postpartum; Avoid Gaenslen's test within the first 4 wk postpartum. 3/5 positive tests >8 wk postpartum: FABER/Patrick's, P4; sacral spring, ASIS distraction (supine), sacral compression (side lying) Muscle length impairments: Long abdominal muscles due to the postpartum period	Muscle strength/performance impairments: Poor control of abdominal oblique muscles, transverse abdominis, hip extensors, lateral rotators and abductors, multifidus, and pelvic floor. Bilateral presentation. ASLR: Bilateral observation of pelvic rotation with difficulty and/or SIJ pain. Compression abolishes pain and/or increases ease of ASLR. Movement tests: Standing: Forward bending: Lumbar flexion > hip flexion Prone hip extension: delayed onset of gluteals, will test weak Quadruped: increased sacral region pain with position Single-leg stance: (+) bilaterally for pain (+Stork, Modified Trendelenburg test), Bilateral +SLS testing indicates need for assistive device Functional mobility activities: Pain with rolling, sit to stand, stair climbing, transitional positions Gait: inability to transfer load of trunk from above to lower extremity, increased trunk shift with loading or inability to load if form closure is lost. Sits in lumbar flexion.	Movement differential106 Lumbar flexion Lumbar extension Femoral adduction Femoral adduction/medial rotation Hip posterior glide Hip anterior glide/medial rotation Visceral origin: gastrointestinal, genitourinary, reproductive organ disease metastatic disease/cancers: abdominal organs, uterus, bladder Musculoskeletal origin: Lumbar disc disease Inflammatory arthritis: ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, lupus, Reiter syndrome, compression fractures Labral tear (hip) Snapping hip syndrome (groin pain) Sacral or pubic arch stress fracture (military, high-impact activities, osteoporosis) Hormone imbalance affecting ligamentous structures	1. Bracing (belt)120,157,158,175–178 2. Appropriate motor recruitment of gluteal, back, abdominal, and PFM; including timing of contraction, avoiding rotational stressors across the pelvis 3. Education to minimize pain during functional activities18,99,141–149 4. Consider assistive device if functional mobility severely impaired or painful162,171 5. Joint mobilization/manipulation: not indicated in the presence of symmetrical joints Address-specific movement impairments that would cause rotational stress83,155,179

Abbreviations: ABD, abduction; ASIS, anterior superior iliac spine; ASLR, active straight leg raise; FABER, flexion, abduction, external rotation test; LBP, low back pain; PFD, pelvic floor dysfunction; PFM, pelvic floor muscle; PGP, pelvic girdle pain; P4, posterior pelvic pain provocation test; PSIS, posterior superior iliac spine; SIJ, sacroiliac joint; SLS, single-leg stance; SUI, stress urinary incontinence.

Table 10. - Pubic Symphysis Load Transfer Impairment

History	Key Tests and Signs		Differential Diagnosis	Intervention
	Static	Dynamic
Pain at the region of the PS that may or may not radiate to the groin Anterior pain and instability in unilateral stance; pain with walking; pain with prolonged sitting with legs crossed or in asymmetrical positions (side lying, stair climbing, inclines); pain with transitional movements (sit to stand and rolling) Urogenital symptoms may be present32,157,180 (dyspareunia, UI, pain with urination, vulvar pain) Activity/history History of trauma during delivery, SPD during pregnancy or excessive unilateral leg loading in postpartum (lower limb injury or history of LLD)	Alignment: Without asymmetry: symmetrical pubic rami With asymmetry: pubic rami asymmetry (changes with variations of hip positions, ABD/ADD, in more mobile cases symptoms may persist unless compression occurs) Palpation: Pain to palpate at PS63,115 Source tests: Iliac compression test: in standing or supine132 improves pain With asymmetry: positional correction with compression abolishes pain or lessens pain Provocative tests: + FABER/Patrick's test76	Muscle strength/performance impairments: Poor performance of abdominal, adductor and gluteal muscles. Movement tests: Modified Trendlenberg72: increases pain at PS Supine hip flexion: increases pain at PS Supine abduction lateral rotation from a hip flexed position (also known as bent knee fall-out): pain with leg fall out at PS or with initiation of return Gait: Increased lateral trunk shift with single-leg stance, assistive device needed in more severe cases Standing trunk motions: negative for pain	Movement impairment106 Femoral adduction Femoral adduction/medial rotation Hip anterior glide/medial rotation Lumbar rotation-extension Lumbar flexion/rotation Lumbar flexion Lumbar extension Thoracic flexion-rotation Visceral origin: gastrointestinal, genitourinary, reproductive organ disease Metastatic disease/cancers: abdominal organs, uterus, bladder Musculoskeletal origin: Osteitis PS, bone bruise, bony edema, arthritis, fracture: compression/stress, osteoporosis-related, PS stress fracture Adductor or rectus abdominis strain Cam/pincer deformity, hip impingement Hernia: inguinal, abdominal fascia Thoracic disc disease Inflammatory arthritis: ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, Reiter syndrome, lupus Hormone imbalance affecting ligamentous structures	1. Bracing (pelvic belt)149,157,175,177,178,181,182 2. Exercises of the gluteal, hip adductor, and abdominal muscles182 3. Appropriate timing for motor recruitment of gluteal, back, abdominal, PFM179 4. Treatment of movement impairments that cause rotational stress16,104 (walking, rolling in bed, stair climbing, car transfers, carrying, ADLs) 5. Education to minimize pain during functional activities18,99,141–149 (avoid end-range hip flexion and abduction) 6. Consider assistive device if functional mobility severely impaired or painful155,162 7. Joint mobilization: If poor tolerance to stabilization, correct any positional impairment183

Abbreviations: ABD, abduction; ADD, adduction; ADLs, activities of daily living; FABER, flexion, abduction, external rotation test; LLD, leg length discrepancy; PFM, pelvic floor muscle; PS, pubic symphysis; SPD, symphysis pubis dysfunction; UI, urinary incontinence.

Load transfer impairment may present with excessive and/or asymmetrical motion causing impaired stability of the joint during limb loading and with rolling when recumbent. Symptoms may present either unilaterally (sacroiliac joint load transfer impairment—Table 8) or bilaterally (pelvic girdle load transfer impairment—Table 9). Key positive tests and signs that may be present for SIJ load transfer impairment include positive LDL (in more severe cases), ASLR, Modified Trendelenburg, Stork or March test, P4, and FABER tests. Positive results will produce symptoms in the region of the posterior SIJ. Strength testing may reveal reduced performance of the gluteal muscles on the side of pain, and if unilateral in presentation, asymmetrical back and abdominal muscle performance impairments may be present. Impaired performance of the muscles that create force closure across the joint may be determined during movement testing (forward bending, single-leg stance, supine hip flexion, and prone hip extension). Focus of treatment is improving single-leg stance mechanics during functional tasks by both mechanical (belt) and/or muscle (force) stabilization of the pelvic ring reducing the motions that impose physical stresses across the SIJ. In the presence of asymmetry that does not resolve with use of a belt, functional training, and stabilization exercises, the use of joint mobilization should be considered.

Pelvic girdle load transfer impairment (Table 9) includes 2 or more joints and is considered part of a continuum of worsening impairment, indicating increased severity of the condition. Pain and functional difficulty may occur with limb loading at 2 to 3 regions. Ambulation may be severely limited for individuals, and, therefore, a pelvic belt and assistive device may be warranted to allow protection of the supportive connective tissues of the pelvic girdle and reduce pain with functional mobility. Treatment may need to consider positions of the surrounding joints, including maintaining normal lumbar lordosis to assist with locking of the SIJ posteriorly combined with reduced mechanical stress across the PS. Avoidance of excessive flexion of the lumbosacral region as well as reduction of hip range of motion for flexion and abduction may be needed during functional activities, sit to supine, sitting, and sit to stand.

Pubic symphysis load transfer impairment (Table 10) may present with anterior PGP and potential excessive motion (superior glide or rotation) at the PS during loading of the limb. Key positive tests and signs include palpation of the PS and Modified Trendelenburg or single-limb tests. Pain located at the PS may be reproduced with end-range hip flexion or abduction. Pain may improve with manual compression across the pelvis or belt stabilization. Focus of treatment is stabilization of the PS during limb loading (muscle activation and belt stabilization) as well as reduction of mechanical stress on the PS during functional activities that create either rotational stress across the pelvis (active hip flexion, walking, rolling in bed, in and out of a car) or gap the PS (leg abduction). Persistence of an asymmetry of the PS may require assessment for leg length discrepancy or a positional impairment. Correction of a positional impairment should be followed by stabilization exercises to reduce the physical stress across the tissues related to the PS (abdominal, pelvic floor, adductor, and gluteal musculature). Impaired performance of the muscles that create force closure across the joint may be determined during movement testing.

For all categories of load transfer impairment, ADLs and specific childcare activities should be assessed including positions for play and nursing the baby, carrying the baby, diaper changes, and pushing a stroller.

Prognosis

Hemingway et al¹³⁷ report that prognosis is the risk of future health-related impairments given a specific condition. Prognosis of recovery from PP-PGP appears to depend on initial pain and disability scores. Individuals with PP-PGP with greater disability and higher pain scores should be expected to recover more rapidly and return to function. Conversely, those with low disability and low pain scores should be expected to recover to a lesser extent. For this latter group, clinicians should administer measures of fear avoidance, kinesiophobia, and psychological symptoms because of the likelihood of confounding factors and the increased likelihood of minimal gains with physical therapy intervention.

Across studies, a portion of individuals with PP-PGP failed to achieve 0% disability and/or absence of pain at 6 months to 1 year^19,21,138 and at 2 years postpartum.¹²⁵ It is unclear whether the continuation of pain and disability found in these studies is directly related to unresolved PP-PGP or indicative of confounding factors, such as preexisting conditions, reduced hip extension and trunk flexion performance, psychological symptoms, and/or the development of chronic pain, kinesiophobia, and fear avoidance. The addition of fear-avoidance questionnaires and measures of mental health in future research may facilitate better identification of individuals with PP-PGP not following a “normal” course of recovery.

There is conflicting evidence that age is a nonmodifiable risk factor for poorer prognosis. Both younger age (<30) and older age (>30) have been identified as corresponding to higher rates, intensity, and/or duration of pain in PP-PGP. This finding may be attributable more to parity than maternal chronological age. Young women and older women (>30 years) have higher rates, intensity, and/or duration of pain.^12,15 In a study by Gutke et al,¹² each year older corresponded to a 1.2 increased risk for PP-PGP at 3 months after childbirth. Conversely, Wu et al¹⁵ found that younger women were more likely to have PGP than their older counterparts. Significant relationships related to the presence of PP-PGP at 1 year are associated with a combined presence of increased age and reduced muscle performance of the hip extensors and trunk flexors.²¹ Future studies should employ techniques to stratify groups based on parity, utilize age- and parity-matched controls, and perform subgroup analyses to further investigate interrelationships among parity, age, pain intensity, duration, and prevalence.

As previously noted in the risk factors for developing PP-PGP, individuals are more likely to develop PP-PGP if they have experienced pain during pregnancy and if they have more severe symptoms at the time of presentation.^11–16 However, some individuals do not have PGP during pregnancy, but develop PGP during the postpartum period.^139,140 Why PGP during pregnancy persists into the postpartum period is not well understood. See Table 11 for a summary of the prognostic factors in persisting PP-PGP from 3 months to 12 years after childbirth. Future research should investigate factors that contribute to persistent PP-PGP.

Table 11. - Prognosis for Persistent PP-PGP

LOE	Prognostic Factor Reported	Description of Participants	Prevalence of Persistent PP-PGP	Level of Disability Reported in PP-PGP	Results	Reference
II	PP-PGP prevalence with disability	n = 295 Time postpartum: 12 y Age: 43.3 (4.6)	40.3% (n = 119)	Self-reported health: fair to poor (OR: 2.62-7.26, P < .0001)	Spontaneous recovery with no recurrences is unlikely for a subgroup of women with PP-PGP	Bergström et al20
		n = 284 Time postpartum: <4 to >12 wk Age: 25 (4)	41% (n = 116)	Moderate to high levels of disability on ODI was reported in 100% (n = 116) of PP-PGP group compared with 16.7% (n = 28) of No PGP group	Pain presenting at 0-4 wk persisted at 3 mo postpartum	Mukkannavar et al22
		n = 215 Time postpartum: 12 wk to 1 y Age: 31 (4)	30% at 12 wk 31% at 1 y	Physical function at 12 wk and 1 y was unchanged	No improvement noted at 1 y postpartum	Robinson and Mengshoel184
		n = 272 Time postpartum: 3 mo Age: 30 (18, 44)	33% (n = 89) had some form of LPP 11% (n = 46): PP-PGP 17% (n = 23): LPP	40% had moderate to severe disability	One in 3 women had an LPP classification at 3 mo postpartum	Gutke et al2
		n =328 Time postpartum: 12 wk Age: 30.8	Baseline PP-PGP persisted at 12 wk in 15% of cases		All groups improved with treatment	Elden et al185
	PP-PGP predictors	n = 345 Time postpartum: 11 y Age: 30 (23, 39)	10.7% (37/345)	Decreased ability to perform daily activities (P < .001), lower self-efficacy (P = .046), decreased HRQL (P < .001), higher levels of anxiety and depression (P < .001), more prone to pain catastrophizing, and worked significantly fewer h/wk (P = .032).	Number of positive pain provocation tests (OR = 1.79), history of LBP (OR = 2.28), positive PS pressure test (OR = 2.01), positive Faber (Patrick's) test (OR = 2.22), positive Modified Trendelenburg test (OR = 2.20)	Elden et al13
		n =176 Time postpartum: 14 mo Age: 31.9 (3.8)	15.3% (n = 27) (80.7%) reported pain 115 (65.3%) reported recurrent pain 27 (15.3%) reported continuous pain	Self-reported health: poor or quite poor	Lower pain levels	Bergstrom et al186
		n =58 Time postpartum: 15 mo Age: 31 (28, 33)	62%	Disability from 3 to 15 mo postpartum: 66% reported decreased disability, while 33% reported increased disability. Median ODI score at 15 mo postpartum = minimal disability category	Increased age combined with and reduced trunk flexor endurance, and reduced hip extension strength combined with level of disability	Sjödahl et al21
		n = 273 Time postpartum: 6 mo	29% (n = 79)		Higher catastrophizing and more restrictive physical function = 2x risk	Olsson et al140
		n =464 Time postpartum: 6 mo	264 no LBPP 168 recurrent LBPP 32 continuous		PP-PGP predictors: Previous LBP	Mogren187
		n = 65 Time postpartum: 2 y	85% treatment group 47% control group		PP-PGP predictors: Minimum disability	Stuge et al138
		n = 341 Time postpartum: 2 y	8.6%		PP-PGP predictors: Combined PS and bilateral posterior pelvic pain during pregnancy had slower recovery postpartum than among women with fewer pain locations	Albert et al171

Abbreviations: HRQL, health-related quality of life; LBP, low back pain; LBPP, low back and pelvic pain; LOE, level of evidence; LPP, lumbopelvic pain; ODI, Oswestry Disability Index; OR, odds ratio; PGP, pelvic girdle pain; PP-PGP, postpartum pelvic girdle pain; PS, pubic symphysis.

Intervention

Pregnancy-related studies were excluded from the intervention recommendations unless a PT intervention was applied specifically for PP-PGP and the PT intervention was applied within the first postpartum year. For some interventions, such as therapeutic modalities, an insufficient number of studies were available upon which to make recommendations for or against the use of the intervention, including therapeutic ultrasound, infrared, and electrical stimulation. Outcome measures most commonly reported were pain and disability. Cointerventions were common across intervention studies for PP-PGP.

Education

Education interventions across PP-PGP studies included the following components: pathology, etiology, and clinical presentation of PGP; load transfer impairment; rationale for belt stabilization; and strategies to minimize pain during functional activities and instrumental activities of daily living (IADLs) using both biomedical and biopsychosocial approaches.^{18,99,141–149}

Bastiaenen et al⁹⁹ compared the effects of a biopsychosocial-tailored intervention for PP-PGP to usual care. The biopsychosocial intervention consisted primarily of self-management and fear-avoidance concepts, with education on lumbopelvic anatomy. Reduced disability after 3 months of treatment was reported in both groups, but to a greater extent in the biopsychosocial intervention group (+2 points on Roland-Morris Disability Questionnaire).⁹⁹ However, no significant differences were found between groups at 6 and 12 months post-intervention.¹⁴⁵

Exercise

Exercise intervention studies reported significant improvements in pain and disability in all groups, regardless of the type of exercise intervention delivered.^{18,127,138,141–143,146,148–156} Greater improvements have been reported in muscle performance, pain, and disability as compared with controls or usual care groups. Outcomes of exercise interventions compared with those of manual therapy interventions were consistently superior for reported long-term outcomes. Exercise interventions directed at muscle strengthening consistently report improvements in strength and disability post-intervention. The specificity of exercise does not appear to significantly impact pain or disability outcomes. Exercise intervention studies often included the use of a pelvic belt as a cointervention to reduce pain during exercise and improve function. Exercise generally did not worsen symptoms. All groups experienced reductions in pain and disability, and the use of belts may have contributed to improved outcomes. Therefore, it is our recommendation that PTs should use pelvic belts in conjunction with education and exercise interventions.

Stabilization exercises were the most common exercises prescribed and are defined as progressive strengthening of the abdominals, back extensors, and PFM. Stabilization exercises emphasize activation of the transversus abdominus (trA) and PFM prior to limb or trunk movements for adequate force closure of the pelvic girdle. Improvements in muscle function of the paraspinals,¹⁴⁸ abdominals,¹⁵⁰ hip extensors,¹⁴² hip adductors and abductors,¹⁵⁰ and pelvic floor^127,152 were reported in exercise-based intervention studies in PP-PGP. Evidence on the effectiveness of trunk stabilization exercises for the management of PP-PGP is summarized in Table 12: stabilization exercises.

Table 12. - Intervention for PP-PGP: Stabilization Exercise

LOE	Intervention Type	Description of Intervention	Description of Participants	Outcomes	Results	Reference
I	Stabilization exercises vs general exercise	3x/wk × 8 wk 2 groups: supervised stabilization exercises vs general exercise	n = 68 Time postpartum: 2-4 wk	Pain (VAS) TrA muscle thickness (ultrasound) PFMC	Significant increases in TrA muscle thickness and PFMC in stabilization exercise group compared with general exercise group. Significant decreases in pain within groups pre-to post-intervention in both stabilization and general exercise groups. No significant differences between groups for pain reduction.	Ehsani et al150
	Stabilization exercises + electrothermal modalities	3x/wk × 6 wk Individualized stabilization exercises Infrared radiation and continuous ultrasound on posterior LPP region	n = 34 Time postpartum: 3-12 mo	Pain (VAS) Disability (ODI) PPT at soft tissue 3 cm lateral to the spinous processes (L1-S5)	Significant improvements in pain, disability, and PPT in both groups. Significantly greater improvements in pain, disability, and PPT in the stabilization group compared with usual care.	Saleh et al151
	Stabilization exercises + PFMC	3 sessions/wk × 12 wk Individualized stabilization exercises targeting multifidus and transversus abdominis Intervention group received PFMC training in addition to stabilization exercises	n = 40 Time postpartum: at least 3 mo	Pain (VAS) Disability (ODI) Trunk ROM (Schober test) PFM (Kegel perineometer)	Significant differences in pain, disability, and PFM strength in favor of stabilization exercise + PFMC group than stabilization exercises alone. Both groups significantly improved in pain, disability, trunk ROM, and PFMC over time.	ElDeeb et al152
	Individualized rehabilitation + chiropractic care (spinal manipulative therapy)	12 individualized rehab sessions (with or without chiro care) over 20 wk HEP of stabilization exercises + LE stretching and strengthening, postural exercises provided to all participants	n =11 Time postpartum: 3-6 mo	Pain (NRS, PGQ) Disability (ODI) General health status	No significant differences between groups on pain, disability or general health status. Both groups improved in pain and disability over time. No change in general health status in either group.	Gausel et al18
	Stabilization exercises + PFMC, electrotherapy modalities	45-min sessions, 3x/wk × 6 wk Individualized PT, stabilization exercises with PFMC with and without electrotherapy modalities	n = 36 Time postpartum: 12 wk	Pain (VAS) Disability (ODI) PFMC at rest PFMC with MVC	Significant differences in pain, disability, and PFMC MVC in favor of intervention group (P < .05). No difference in PFMC at rest within or between groups.	Teymuri et al127
	Stabilization exercises + aerobic exercise, PFMC, stretching	60-min/wk × 12 wk Group fitness classes during pregnancy Stabilization exercises, PFMC, stretching	n = 105 nulliparous Time postpartum: 6-8 wk	Presence of PGP (questionnaire)	No differences in PP-PGP between women who exercised during pregnancy and controls (OR = 0.38, 95% CI = 0.13-1.10, P = .07).	Haakstad and Bo153
	Stabilization exercises	2 sessions/d × 3 d Intervention group: Core stabilization exercises along with postural correction in different positions (ie, supine, crook lying and half sitting position and prone position) Control group: Simple back strengthening exercises in different positions (ie, supine, crook lying)	n = 40 Time postpartum: 0-2 d	Restriction in ADLs— mobility, dressing, etc and IADL's complex tasks Muscle power of LEs (MMT) Mobility (dependent or independent)	Significant differences identified in favor of the intervention group for LE muscle power (P < .001), improved IADLs (P < .001), and improved mobility (P < .0001).	Chaudry et al154
I	Stabilization exercises	Home-based exercise, at least 2x/daily, focused on TrA, multifidus, PFM	n = 88 Time postpartum: at least 8 wk	Pain (VAS) Disability (ODI) HRQOL Muscle function: Hip EXT Back flexor endurance Back extensor endurance Pelvic floor Gait speed	No difference between groups on pain intensity, HRQOL, or ODI between groups. Significant differences in pain intensity at 3-mo, favoring intervention group (P = .011) Significant differences between groups in hip EXT strength at 3-mo follow-up (P = .047) Improvement in ODI from baseline to 6-mo follow-up within groups (P < .05).	Gutke et al142
I	Stabilization exercises	Comparison of 3 treatments: Standard treatment alone Standard treatment with acupuncture Standard treatment with stabilization exercises during pregnancy	n = 386 Time postpartum: 12 wk	Pain (VAS) Presence of PP-PGP (test battery)	3/4 women were pain-free at 12 wk postpartum. 99% of women tested negative for PGP at 12 wk postpartum. No difference in pain or PGP testing between groups.	Elden et al143
		Group training 1 (60-min session)/wk × 12 wk during pregnancy	n = 301 nulliparous Time postpartum: 12 wk	Presence of LPP Functional status (DRI) PFM strength	Significantly reduced incidence of pain (P = .056) and increased functional status (P = .011) postpartum in women who participated in group exercise intervention in pregnancy.	Morkved et al146
		Group training 1 (120-min session), 2x/wk × 4 wk during pregnancy	n = 569 with posterior PGP or PS pain Time postpartum: 6, 12 mo	Pain (VAS) Presence of PGP (P4 test)	No significant differences in pain score or presence of PGP at 6 or 12 mo postpartum between groups.	Haugland et al155
I	Stabilization exercises with manual therapy, education	PT with stabilizing exercises or PT alone Home-based with equipment in home Included mobilization, massage, education, physical activity (Per Stuge 2006 included “Emotions/Awareness” 20 wk of treatment (1 session q2 w)	n = 81 Time postpartum: 6-16 wk	Pain (VAS) Functional status (ODI) Quality of life (SF-36) Hip strength (ADD/ABD) (HHD) Endurance of back muscles (Sorensen test), ASLR test	Significant differences in pain, disability, physical QOL scale and physical tests in favor of the stabilization exercises group. Disability reduced by 50% in the intervention group. Physical testing results were significant after the Intervention only, not at the 1-y postpartum follow-up.	Stuge et al156
			n = 65 Time postpartum: 1 y, 2 y	Pain Disability QOL	Gains maintained at 2 y postpartum in the intervention group. Controls reduced disability at 2 y, without intervention.	Stuge et al138
I	Stabilization exercises with belt, education	Experimental group: Diagonal trunk exercises with educational video, ergonomics, and pelvic belt (n = 16) Control group 1: Longitudinal trunk exercises with educational video, ergonomics, and pelvic belt (n = 14) Control group 2: No exercise. Educational video, ergonomics, and pelvic belt (n = 14)	n = 44 Time postpartum: 6 wk to 6 mo	Pain (VAS, evening pain severity; morning pain severity) Fatigue (VAS, evening fatigue severity; morning fatigue severity) General Health (NHP) Global Improvement (1, 2, 3) Mobility of pelvic joints (x-ray, mm)	No significant differences between groups. Educational video and pelvic belt yielded comparable results to video-based trunk exercise intervention.	Mens et al149
III	Stabilization exercises, no belt	2 sessions/wk, total of 14 sessions over 8 wk Individualized PT Manual therapy, soft tissue mobilization, therapeutic exercise, gait training, patient education.	n = 1 Time postpartum: 4 d	Pain (VAS) Functional status (PSFS)	PP-PGP pain decreased from 10/10 to 0/10 on VAS.	Renard and Abraham-Justice141

Abbreviations: ABD, abduction; ADD, adduction; ADLs, activities of daily living; ASLR, active straight leg raise; DRA, diastasis recti abdominis; EXT, extension; HEP, home exercise program; HHD, handheld dynamometer; HRQOL, health-related quality of life; IADLs, instrumental activities of daily living, IRD, inter-rectus distance; LAP, laparoscopy; LE, lower extremity; LOE, level of evidence; L1-S5, lumbar 1 to Sacral 5; LPP, lumbopelvic pain; MMT, manual muscle test; MVC, maximal voluntary contraction; NHP; Nottingham Health Profile; NRS, Numeric Rating Scale; ODI, Oswestry Disability Index; PD, pelvic diagnosis; PFMC, pelvic floor muscle contraction; PFM, pelvic floor muscles; PGP, pelvic girdle pain; PGQ, Pelvic Girdle Questionnaire; PP-PGP, postpartum pelvic girdle pain; P4, posterior pelvic pain provocative test; PPT, pain pressure threshold; PS, pubic symphysis; PSFS, Patient Specific Functional Scale; PT, Physical Therapy; QOL, quality of life; RA, rectus abdominis; ROM, range of motion; SF-36, Short Form 36 Physical Functioning; TrA, transverse abdominis; VAS, Visual Analog Scale.

Exercise interventions have been conducted as early as within the first postpartum week,^141,154 but most frequently beginning at 6, 8, or 12 weeks postpartum. Intervention duration ranged from 4 to 20 weeks. Session time, when reported, ranged from 40 to 120 minutes. Stabilization exercises were provided most commonly with cointerventions, including modalities, stretching and therapeutic exercise, pelvic floor muscle contraction, manual therapy and soft tissue mobilization, physical activity and home exercise program, and education and functional training.

Pelvic Belt

Pelvic belts were most commonly utilized in combination with exercise intervention studies^{91,147,149,157} (see Table 13). The application of a pelvic belt has been demonstrated to reduce laxity and ASLR scores¹⁵⁸ and increase hip adductor force production.⁹¹ In combination with exercise interventions, the application of the pelvic belt has been demonstrated to improve pain.^147,149

Table 13. - Intervention for PP-PGP: Pelvic Belt

LOE	Description of Intervention	Participants	Outcomes	Results	Reference
I	Experimental group: Diagonal trunk exercises with educational video, ergonomics, and pelvic belt (n = 16) Control group 1: Longitudinal trunk exercises with educational video, ergonomics, and pelvic belt (n = 14) Control group 2: No exercise. Educational video, ergonomics, and pelvic belt (n = 14)	n = 44 Time postpartum: 6 wk to 6 mo Mean = 4.1 mo (range: 1.7-5.6 mo)	Pain (VAS, evening pain severity; morning pain severity) Fatigue (VAS, evening fatigue severity; morning fatigue severity) General Health (NHP) Global Improvement (1, 2, 3) Mobility of pelvic joints (x-ray, mm)	No significant differences between groups. Educational video and pelvic belt yielded comparable results to video-based trunk exercise intervention.	Mens et al149
I	Belt = Rehband. No specifics on tension, wear schedule, or frequency of use. Compared effectiveness of 3 different intervention programs. Belt was provided in all 3 groups. 3 groups, all received belt: Pelvic belt + info: n = 40 Home exercise, belt + info: n = 41 In clinic exercise, belt + info: n = 37	n = 118 Women tested positive in ≥3 pelvic pain provocation tests in late pregnancy Time postpartum: 3, 6, and 12 mo.	VAS Pain localization Pain type DRI	Use of a pelvic belt with information achieved comparable outcomes to use of a pelvic belt with information and either home or in-clinic exercise. No differences in pain or activity across the 3 groups. Significant reduction in pain intensity and improvements in higher activity ability from pregnancy to 12 mo postpartum (P = .000) across all 3 groups.	Nilsson-Wikmar et al147
II	2 types of belts tested: Rafys belt and Erasmus belt Investigated changes in hip ADD force with the addition of a pelvic belt in PP-PGP and controls	n = 86 Time postpartum: ≥6 mo PP-PGP confirmed with both ASLR, P4 testing (+); pain duration >6 mo	% increase in ADD force (HHD) in second ASLR attempt after tightening belt NRPS QBPDS ASLR, P4	Women with PP-PGP demonstrated significantly increased hip ADD force with addition of a belt (from 107 ± 51 N to 129 ± 59 N) (P < .00001). Women in the control group demonstrated comparable hip ADD force with and without the belt (P = .67).	Mens and Pool-Goudzwaard91
II	A belt of nonelastic material was used (model 3221/3300, Rafys, Hengelo, the Netherlands) 5 cm wide at the anterior and 7 cm at the posterior side. Tension range: 50-100 N High position: Just below the ASIS. Low position: At PS level Doppler imaging was used to measure propagation of vibratory waves through SIJ. Measurement was performed on the SIJ dorsally pre- and post-belt application to measure the change in laxity.	n = 25 Time postpartum: Within 5 y VAS >30 mm (“moderate to severe”)	VAS QBPDS SIJ laxity ASLR test	Decreased SIJ laxity and reduced ASLR scores with belt compared with without belt. High position decreased SIJ laxity to a significantly greater degree (1.3 TU, SD = 1.7 TU) than low position (0.6 TU, SD = 1.0 TU) (P = .006). Positive correlation between decrease in mean laxity value with belt in both high position (Pearson's correlation coefficient 0.54, P = .005) and low position (Pearson's correlation coefficient 0.57, P = .003) compared with no belt.	Mens et al158

Abbreviations: ADD, adduction; ASIS, anterior superior iliac spine; ASLR, active straight leg raise; DRI, Disability Rating Index; HHD, handheld dynamometry; LOE, level of evidence; NHP, Nottingham Health Profile; NPRS, Numeric Pain Rating Scale; NRS, Numeric Rating Scale; PP-PGP, postpartum pelvic girdle pain; q, every; QBPDS, Quebec Back Pain Disability Score; SIJ, sacroiliac joint; TU, threshold units; VAS, Visual Analog Scale.

The pelvic belt may be worn at either a high (at the ASIS) or low (at the PS) position. The pelvic belt in either position has been shown to reduce laxity and improve ASLR scores as compared to no belt. The pelvic belt worn in a high position decreased SIJ laxity to a significantly greater degree than the low position.¹⁵⁸

All studies that investigated effects of the pelvic belt enrolled participants with a minimum Visual Analog Scale (VAS) score of 30 mm or greater.^147,158 Therefore, the value of pelvic belt use is unclear in PP-PGP individuals with low pain severity (<30 mm on VAS). Future research should investigate the clinical value of pelvic belt use in PP-PGP individuals with pain severity less than 30 mm on the VAS and the use of a pelvic belt during the first 4 weeks postpartum.

Manual Therapy

Manual therapy intervention studies with PP-PGP were included if 2 criteria were met: (1) at least one manual therapy intervention was directed to the pelvic girdle, and (2) the pain description or inclusion criteria were consistent with PP-PGP. Studies were excluded if manual therapy was applied only to the lumbar spine and/or hip and if the pain description was consistent with lumbar pain. There is strong evidence supporting the application of manual therapy interventions in conjunction with cointerventions to provide short-term improvements in pain and disability in PP-PGP (see Table 14).^{18,101,148,159} PTs should not apply manual therapies in isolation. There is strong evidence that the use of manual therapy interventions is no better than stabilization exercises for long-term improvement (>6 months) in outcomes.^18,138

Table 14. - Intervention for PP-PGP: Manual Therapy

LOE	Intervention Type	Description of Participants	Description of Intervention	Outcomes	Results	Reference
I	Manual therapy (chiropractic spinal manipulative therapy) + individualized rehabilitation	n = 11 Time postpartum: 3-6 mo	12 sessions over 20 wk Intervention group received 12 individualized rehab sessions with spinal manipulative therapy. Control group received 12 individualized rehab sessions. Both groups received HEP of stabilization exercises + LE stretching and strengthening, postural exercises.	Pain (NRS, PGQ) Disability (ODI) General health status	No significant differences between groups on pain, disability, or general health status. Both groups improved in pain and disability over time. No change in general health status in either group.	Gausel et al18
	Manual therapy (OMT)	n = 80 Time postpartum: 3-15 mo	1x/2 wk × 6 wk Intervention group received OMT (40- to 60-min sessions) at baseline, 2, 4, and 6 wk Controls waitlisted Time to follow-up: 8 wk, 3 mo post-intervention	Pain (VAS) Disability (ODI)	Both groups significantly improved in pain over time. Larger improvements in pain (between-group difference of means, 4.8; 95% CI, 4.1-5.4; P < .001) and disability (between-group difference of means, 10.6; 95% CI, 9.9-13.2; P < .005) found in the intervention group.	Schwerla et al159
	Manual therapy with stabilization exercises, education, physical activity	n = 81 Time postpartum: 6-16 wk	PT with or without stabilizing exercises Home-based with equipment in home Included mobilization, massage, education, physical activity 20 wk of treatment	Pain (VAS) Disability (ODI) Quality of life (SF-36) Hip strength (ADD/ABD) (HHD) Endurance of back muscles (Sorensen test) ASLR test	Significant differences in pain, disability, physical QOL scale, and physical tests in favor of the stabilization exercises group. Disability reduced by 50% in the intervention group. Physical testing results were significant after the intervention only, not at the 1-y postpartum follow-up.	Stuge et al148
		n = 65 Time postpartum: 1 y, 2 y		Pain (VAS) Disability (ODI) Quality of life (SF-36)	Gains maintained at 2 y postpartum in the intervention group. Controls reduced disability at 2 y, without intervention.	Stuge et al138
	Manual therapy (HVTT)	n = 69 Time postpartum: Within 1 y	1 or 2 sessions of HVTT over maximum 1-wk HVTT (to more symptomatic innominate in supine with ipsilateral side bending and contralateral trunk rotation, grade 5), then 10 repetitions of hand-heel rock exercise in quadruped Follow-up: 2-4 d post-HVTT. Repeated up to 1 more time if ODI <50% improved	Pain (VAS, body diagram) ODI FABQ	80% of subjects experienced significant reduction in symptoms post-HVTT. Nonresponse to mobilization predicted by at least 2 of 3 variables with 87% accuracy. Variables included: age >35, VAS-Best >3, negative prone knee bend test. No subject had higher pain or disability after intervention.	Al-Sayegh et al101
	Manual therapy with stabilization exercises, education, physical activity	n = 81 Time postpartum: 6-16 wk	20 wk of treatment PT with or without stabilizing exercises Home-based with equipment in home Included mobilization, massage, education, physical activity	Pain (VAS) Disability (ODI) Quality of life (SF-36) Hip strength (ADD/ABD) (HHD) Endurance of back muscles (Sorensen test) ASLR test	Significant differences in pain, disability, physical QOL scale, and physical tests in favor of the stabilization exercises group. Disability reduced by 50% in the intervention group. Physical testing results were significant after the intervention only, not at the 1-y postpartum follow-up.	Stuge et al148
		n = 65 Time postpartum: 1 y, 2 y		Pain (VAS) Disability (ODI) Quality of life (SF-36)	Gains maintained at 2 y postpartum in the intervention group. Controls reduced disability at 2 y, without intervention.	Stuge et al138

Abbreviations: ABD, abduction; ADD, adduction; ASLR, active straight leg raise; FABQ, Fear Avoidance Behavior Questionnaire; HEP, home exercise program; HHD, handheld dynamometry; HVTT, high velocity thrust technique; LE, lower extremity; LOE, level of evidence; NRS, Numeric Rating Scale; ODI, Oswestry Disability Index; OMT, osteopathic manual therapy; PGQ, Pelvic Girdle Questionnaire; PP-PGP, postpartum pelvic girdle pain; QOL, quality of life; SF-36, Short Form 36 Physical Functioning; VAS, Visual Analog Scale.

Al-Sayegh et al¹⁰¹ reported improved Oswestry Disability Index (ODI) and VAS scores in PP-PGP utilizing a high velocity thrust technique (HVTT) mobilization to the pelvis. The population studied was within one year of giving birth. As many as 19% had delivered within the previous month. No adverse effects were reported. In the presence of asymmetry, severe disability (>40%) as measured with the ODI score and/or VAS more than 3, PTs may consider the use of HVTT if PP-PGP is nonresponsive to functional activity training and therapeutic exercise targeted to their specific load transfer impairment.¹⁰¹ In addition, nonsuccess following HVTT was defined by failure to achieve a 50% reduction in ODI score post-intervention. Nonsuccess was predicted with 75% probability when 2 of the 3 variables (age >35, VAS best >3, and negative prone knee bend test) were present. Nonsuccess was predicted with 87% probability of nonsuccess with 3 of 3 variables present. PTs may consider using a pelvic belt in combination with exercise for individuals with PP-PGP who do not respond to HVTT.

Summary of Limitations in Intervention Studies

Consistency of well-described educational interventions, patient-centered language, and instructional elements were generally lacking. Studies utilized multiple theoretical frameworks for exercise interventions and lacked true control groups. Inconsistencies in reporting of intervention parameters, including frequency, duration, and combinations of therapeutic interventions applied, made synthesis of best practice recommendations challenging. Most exercise-based intervention studies utilized pelvic belts across groups, making it difficult to investigate the effects of exercise and pelvic belts in isolation. Additionally, most intervention studies include multiple cointerventions. Cointerventions, such as medication use, involvement with additional health providers and participation in other therapies, physical activity, and description of postpartum standard of care after delivery across international studies, were identified and made it challenging to determine the impact of any one intervention. Longer follow-up (beyond completion of intervention), compliance mechanisms and proposed explanations for worsening of pain during or following intervention are needed in future intervention studies.

Results of PP-PGP belt studies may not be as generalizable to less severe cases of PGP (VAS <30 mm). High-quality biomechanical studies evaluating physical and/or functional changes following belt use and large, longitudinal studies investigating belt use with functional tasks and pain complaints in the population with PP-PGP have generally not been conducted. Future research should be performed with PP-PGP to investigate the biomechanical effects of pelvic belt use, especially during ASLR testing, standing double-limb and single-limb support testing, and functional tasks.

Research Recommendations

Based on this CPG, there are several future research recommendations that span each aspect of this review. Table 15 provides the recommendations based on each section.

Table 15. - Recommendations for Future Research on PP-PGP

Factors specific to postpartum participants	Include a comprehensive description of participants to address confounding factors unique to the postpartum population (eg, parity, delivery-related factors, postpartum mood, breastfeeding positions, and lactation status).
Prognosis for recovery and clinical course	Investigate fear-avoidance behaviors and mental health to identify women not following a “normal” course of recovery after PP-PGP. Investigate factors that contribute to persistent pain. Investigate the implication of these confounding variables on continued pain and disability at 1 and 2 y postpartum. Follow groups as a whole rather than just following painful cohorts during pregnancy into the postpartum period.
Examination	Identify a reliable test to assess symmetry in the pelvic girdle specific to the postpartum population and the relationship between asymmetry and PP-PGP. Include standing single-limb loading tests for determining pain and movement impairments. Compare the value of provocation tests to functional measures to streamline the examination. Examine the best measures of muscle performance to guide intervention, including the use of sEMG, rehabilitative ultrasound imaging, etc. Investigate the effect of muscle length changes in individuals with PP-PGP. Investigate a potential relationship between DRA and PP-PGP, including categorization of individuals with DRA based on factors such as width, depth, and ability to generate tension across the linea alba. Consider classifying abdominal muscle performance (over or under active) in the presence of DRA and/or pelvic floor disorders to understand contributions to PP-PGP. Investigate the biomechanical effects of pelvic belt use, especially during ASLR testing, standing double-limb and single-limb support testing, and functional tasks.
Diagnosis	Consider classification systems that include pain location, response to treatment, presenting movement impairments, and psychological factors in PP-PGP. Investigate theoretical frameworks for PP-PGP that incorporate biopsychosocial factors, neurobiological approaches to PGP, fear/illness perception, and central factors.
Intervention	Explore educational methods for PP-PGP in relation to outcomes. Specifically, investigate the role of a pain science approach and use of language in patient interaction. Investigate the effects of functional training, including gait, double-limb, single-limb, transitional movements, ADLs/IADLs, and childcare tasks. Include a comprehensive description of exercise interventions, patient education, specific functional activity training, and use of belt. Interventions should include frequency, duration, intensity, supervision, and compliance. Future research should investigate the biomechanical effects of pelvic belt use, especially during ASLR testing, standing double-limb and single-limb support testing, and functional tasks. Future research should investigate the use of a pelvic belt within the first 4 wk postpartum. Longer follow-up after intervention to investigate relationships between increased muscle strength postpartum, pain, and disability.

Abbreviations: ADLs, activities of daily living; ASLR, active straight leg raise; DRA, diastasis recti abdominis; IADLs, instrumental activities of daily living; PP-PGP, postpartum pelvic girdle pain; sEMG, surface electromyography.

Much emphasis has been placed on the use of provocation tests to rule in or out PP-PGP. While this type of testing helps to inform the clinician as to the location of the pain and the irritability of the tissues, this type of testing provides little information regarding specific impairments and functional limitations to guide the selection of appropriate interventions. Future research should compare the value of provocation tests to those of functional measures to streamline the diagnosis and treatment of PP-PGP.

It is common practice to measure the change in thickness of the abdominal, multifidus, and/or PFM as a means of assessing improvement in patients with lumbar and/or PGP. Currently, there is little evidence to suggest that the change in muscle thickness correlates with resolution of PP-PGP. Preliminary evidence suggests that muscle thickness is of lesser value than appropriate activation of the musculature, including appropriate timing and coordination of muscle activation with functional tasks. Future research should examine the best measures of muscle performance to guide intervention.

Standing tests have been described in the assessment of individuals with PP-PGP. However, most literature on standing tests for PGP has been performed longitudinally starting with populations who develop PGP during pregnancy and with additional assessment of the PGP groups at various time points postpartum.¹⁶⁰ Little research exists on standing tests/measures specifically for the identification of PGP in the postpartum population, regardless of the time of symptom onset. Future research should follow groups as a whole, rather than following painful cohorts during pregnancy into the postpartum period.

Emerging evidence suggests that biopsychosocial factors may have a greater influence on PP-PGP than what is currently known. Therefore, further investigation of the potential influence of patient beliefs, language, anxiety, fear, pain catastrophizing, inflammation, and other neurobiological factors should be explored in individuals with PP-PGP. In addition, intervention approaches that incorporate these factors with PP-PGP should be investigated.