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Management of pelvic girdle pain in pregnancy
Evidence review U
NICE Guideline, No. 201
National Guideline Alliance (UK).
Management of pelvic girdle pain in pregnancy
Review question
What interventions are effective in treating mild to moderate pelvic girdle pain during pregnancy?
Introduction
It is estimated that 1 in 5 women experience pain in the pelvic girdle region during pregnancy. Pelvic girdle pain can make daily activities during pregnancy difficult for women and may have an effect on pain intensity felt during labour or birth. The question aims to identify which treatment options are the most effective for pelvic girdle pain during pregnancy.
Summary of the protocol
Please see Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.
Table 1
Summary of the protocol (PICO table).
For further details, see the review protocol in appendix A.
Methods and process
This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual 2014. Methods specific to this review question are described in the review protocol in appendix A.
Declarations of interest were recorded according to NICE’s conflicts of interest policy.
Clinical evidence
Included studies
Eleven articles reporting 10 randomised controlled trials (RCTs) in pregnant women with pelvic girdle pain were included in this review (Elden 2005, Elden 2008a, Elden 2013, Gausel 2017, Kordi 2013, Melkersson 2017, Mirmolaei 2018, Nicolian 2019, Nilsson-Wikmar 2005 and Wedenberg 2000, with Elden 2008b reporting additional outcomes from the same study as Elden 2005).
The included studies are summarised in Table 2.
Four RCTs examined the effectiveness of acupuncture: 1 study compared an 8-week course of traditional body acupuncture and standard treatment to sham acupuncture and standard treatment (Elden 2008a); 1 study with 3-arms was reported in two articles and compared a 6-week course of body acupuncture and standard treatment, and physiotherapy-delivered in-home stabilising exercise and standard treatment, to standard treatment only (Elden 2005, Elden 2008b); 1 study compared a 4-week acupuncture course and standard treatment (Nicolian 2019); 1 study compared a 1-month course of traditional ear and body acupuncture to physiotherapy-delivered in-home exercise advice (Wedenberg 2000).
Three RCTs examined various forms of manual therapy: 1 study compared an 8-week course of craniosacral therapy and standard treatment to standard treatment only (Elden 2013); 1 study compared chiropractic treatment provided for the duration of the pregnancy to standard treatment (Gausel 2017); and 1 study compared a 6-week course of foot manipulation and physiotherapy-delivered in-home exercise advice to sham foot manipulation and physiotherapy-delivered in-home exercise advice (Melkersson 2017).
One 3-arm RCT compared a 6-week course of pelvic girdle support belt (a non-rigid lumbopelvic belt) and information to a combination of physiotherapy-delivered in-home exercise advice and information or information only (Kordi 2013).
Two RCTs assessed the effectiveness of physiotherapy-delivered exercise advice: 1 study with 3-arms compared physiotherapy-delivered in-home or in-clinic exercise advice, a pelvic girdle support belt (a non-elastic sacroiliac belt), and information provided from recruitment until gestation week 38 to a combination of pelvic girdle support belt and information (Nilsson-Wikmar 2005); 1 quasi-RCT compared a 12-week course of physiotherapy-delivered exercise advice to standard treatment (Mirmolaei 2018).
Five studies were conducted in Sweden (Elden 2005, Elden 2008a, Elden 2013, Melkersson 2017 and Nilsson-Wikmar 2005). One study conducted in France (Nicolian 2019), 2 studies conducted in Iran (Kordi 2013, Mirmolaei 2018) and 1 study in Norway (Gausel 2017).
One additional study (Scott 2018) was identified in final update searches for the review that met the protocol inclusion criteria but did not affect the evidence base or draft recommendations. The searches were initially updated in May 2020 but due to the atypical prolongation of guideline development to due COVID-19 pandemic, the searches were updated again in September 2020. New evidence identified in this final update search which did not impact on the conclusions was not fully included in the report but is referenced in appendix M.
See the literature search strategy in appendix B and study selection flow chart in appendix C.
Excluded studies
Studies not included in this review are listed, and reasons for their exclusion are provided in appendix K.
Summary of studies included in the evidence review
Summaries of the studies that were included in this review are presented in Table 2.
Table 2
Summary of included studies.
See the full evidence tables in appendix D. No meta-analysis was conducted and there are thus no forest plots presented in appendix E.
Quality assessment of clinical outcomes included in the evidence review
See the evidence profiles in appendix F.
Economic evidence
Included studies
A systematic review of the economic literature was conducted but no economic studies were identified which were applicable to this review question.
Excluded studies
A global search of the economic evidence was undertaken for all review questions in this guideline. See Supplement 2 for further information.
Summary of studies included in the economic evidence review
No economic evidence was identified for this review question, therefore, there are no economic evidence profiles
Economic model
An economic analysis was undertaken to estimate the cost-effectiveness of use of a lumbopelvic support belt versus usual cares set as information only or exercise advice. (See Appendix J – Economic analysis for the full report).
Overview of methods
The economic evaluation was conducted in the form of a cost-utility analysis (CUA), with outcomes expressed in terms of cost per quality adjusted life year (QALY) gained. The model setting was for the NHS. The studied population were pregnant women with mild to moderate pelvic girdle pain.
The interventions, population and the clinical inputs were informed entirely from 1 RCT (Kordi 2013) that was included in the accompanying clinical evidence review. This study assigned women to one of three groups; information only, a home based exercise programme and a non-rigid, lumbopelvic support belt (referred to as ‘belt’).
In accordance with NICE methodology, a NHS and Personal Social Services (PSS) perspective was adopted for this analysis. Costs were based on a 2017/18 price year, reflecting the most recently available NHS Reference Costs at the time of writing. Costs were not discounted as all relevant costs occurred within the relatively short time horizon of the model.
EQ-5D utilities were used in the model which were mapped from health-related quality of life scores reported in the Kordi study. Utility measurements at base, week 3 and week 6 were weighted against the time between each measurement to compute total QALYs. This method was followed for each intervention, with the intervention with the most QALYs being the most effective.
The belt was a clear intervention as this is not typically offered by the NHS. The clinical study, Kordi 2013, upon which this analysis is based also assessed information advice and exercise as treatment strategies. As there was ambiguity as to what constituted standard care in the UK context, the belt was compared to each of the interventions in separate pairwise analyses.
Main findings
Both deterministic and probabilistic sensitivity analysis (PSA) were conducted for when the belt is i) compared with information only and ii) exercise. A deterministic analysis computes the results from the reported point estimates of each input parameter. PSA calculates the results by accounting for uncertainty inherent in the model input values. This involved sampling model inputs from pre-specified probability distributions that reflected the uncertainty around the point estimates for the model values.
With both comparisons in the deterministic analysis, the belt was cost effective with an incremental cost effectiveness ratio between £1900 and £2930 per QALY gained – a large distance from a threshold of £20000 per QALY. PSA demonstrated that the belt was 93% likely to be cost effective when compared to information only and 96% likely to be cost effective when compared to exercise.
Numerous one-way sensitivity analysis showed the model output was robust to low/high values, with the exception of the cost of a belt. This was because the one-way sensitivity analysis set an arbitrarily high unit cost of a belt at an extreme value to test robustness. There was some uncertainty as to which would be the correct costing of a belt, though all seemingly appropriate inputs were between £16-20. A threshold analysis indicated that the unit cost of a belt would have to increase from £17 to £164 for it not to be cost effective when compared with information only. When compared with exercise, the threshold analysis indicated that the belt would have to increase from £17 to £113 for the belt intervention to not be cost effective. The results of the base case analysis also held when subjected to various scenario analyses such as where treatment is hypothetically extended to 9 weeks.
There were some views among the committee that the cost of a physio might be included in the belt group only, but standard practice in the UK would see mild analgesics more commonly offered to women. However, even at this assumption, the incremental cost effectiveness ratios (ICERs) of the belt versus information only and the belt versus exercise were £9473 and £13816 respectively – still someway of a £20000 per QALY threshold.
Strengths/limitations
One key strength of this analysis is that it is the only known cost utility analysis in this topic area, applicable to the NICE decision making context.
The results show that the belt is likely to be a cost effective intervention when compared to standard care and be an efficient use of NHS resources. In both comparisons, the results of the deterministic and probabilistic analysis pointed towards the belt being cost effective. There was some uncertainty as to the correct unit cost of a lumbopelvic belt. However, a threshold analysis indicated that the belt would need to cost more than £100 per person for the belt intervention to not be cost effective. Given that all possible cost inputs fall some way under this figure, this key area of uncertainty is greatly minimised. The interpretation of the cost effectiveness of the belt was also robust to scenario analysis whereby those receiving the belt would also receive a single physio appointment.
The model has a number of limitations and, in particular, the health-related quality of life (HRQoL) inputs used to calculate QALYs are mapped into EQ-5D-5L data. Whilst mapping is a conventional method for deriving utilities, the 5 level version of the EQ-5D has not been validated by NICE. Nevertheless, in the absence of any other evidence, the estimates had face validity with the reported quality of life scores in the clinical evidence review and proved robust when subject to a probabilistic and deterministic sensitivity analysis. Furthermore, another limitation is that the model was informed by one RCT and did not include other interventions included in the clinical review. As this model estimates QALYs directly from Kordi 2013 however, it would be difficult to incorporate these other interventions within the same model.
Evidence statements
Clinical evidence statements
Comparison 1. Acupuncture + standard treatment versus standard treatment
Critical outcomes
Pain intensity during pregnancy
- Low quality evidence from 1 RCT (N=386) showed that there is a statistically significant difference favouring acupuncture plus standard treatment over standard treatment on pain intensity in the morning as assessed by a visual analogue scale one week after the treatment in pregnant women with pelvic girdle pain: difference between medians 13, p<0.0001.
- Low quality evidence from 1 RCT (N=386) showed that there is a statistically significant difference favouring acupuncture plus standard treatment over standard treatment on pain intensity in the evening as assessed by a visual analogue scale one week after the treatment in pregnant women with pelvic girdle pain: difference between medians 27, p<0.001.
- Low quality evidence from 1 RCT (N=199) showed that there is no clinically important difference between acupuncture plus standard treatment and standard treatment on pain intensity, assessed with the numerical rating scale: MD −0.9 (95% CI −1.56 to −0.24).
Pelvic-related functional disability/functional status during pregnancy
- Moderate quality evidence from 1 RCT (N=199) showed that there is no clinically important difference between acupuncture plus standard treatment and standard treatment on disability, assessed with Oswestry disability index: MD −3.5 (95% CI −7.27 to 0.27).
Important outcomes
Adverse effects during pregnancy
- Moderate quality evidence from 1 RCT (N=255) showed that there is a clinically important difference favouring standard treatment over acupuncture plus standard treatment on the number of women who experience adverse effects during pregnancy in women with pelvic girdle pain: RR 5.59 (95% CI 2.74 to 11.41).
- High quality evidence from 1 RCT (N=199) showed that there is a clinically important difference favouring standard treatment over acupuncture plus standard treatment on the number of women who experience acupuncture specific adverse effects during pregnancy: POR 11.68 (95% CI 5.49 to 24.85).
- Low quality evidence from 1 RCT (N=199) showed that there is no clinically important difference between acupuncture plus standard treatment and standard treatment on non-specific adverse effects during pregnancy: RR 1.04 (95% CI 0.86 to 1.59).
Days off work/sick leave
No evidence was identified to inform this outcome.
Days in hospital admitted to antenatal ward for treatment of pelvic girdle pain
No evidence was identified to inform this outcome.
Women’s experience and satisfaction of care
- Very low quality evidence from 1 RCT (N=215) showed that there is no clinically important difference between acupuncture plus standard treatment and standard treatment on the number of pregnant women with pelvic girdle pain who reported no pain relief within one week of treatment: RR 0.62 (95% CI 0.11 to 3.62).
- Low quality evidence from 1 RCT (N=215) showed that there is no clinically important difference between acupuncture plus standard treatment and standard treatment on the number of pregnant women with pelvic girdle pain who reported that the treatments were harmful within one week of treatment: RR 0.78 (95% CI 0.58 to 1.05).
- Moderate quality evidence from 1 RCT (N=215) showed that there is a clinically important difference favouring acupuncture plus standard treatment over standard treatment on the number of pregnant women with pelvic girdle pain who reported that the treatment was not helpful within one week of treatment: RR 0.15 (95% CI 0.05 to 0.41).
- Moderate quality evidence from 1 RCT (N=215) showed that there is a clinically important difference favouring acupuncture plus standard treatment over acupuncture on the number of pregnant women with pelvic girdle pain who reported that the treatment was of good or very good help within one week of treatment: RR 3.92 (95% CI 2.63 to 5.86).
Admission at birth to the neonatal unit
- Very low quality evidence from 2 RCTs (N=452) showed that there is no clinically important difference between acupuncture plus standard treatment and standard treatment on the number of babies who are admitted to the neonatal unit: RR 0.81 (95% CI 0.36 to 1.82).
Comparison 2. Acupuncture + standard treatment versus non-penetrating sham acupuncture + standard treatment
Critical outcomes
Pain intensity during pregnancy
- Very low quality evidence from 1 RCT (N=115) showed that there is no statistically significant difference between acupuncture plus standard treatment and sham acupuncture plus standard treatment on pain intensity in the morning as assessed by a visual analogue scale during the last treatment week in pregnant women with pelvic girdle pain: difference between medians 1, p=0.29.
- Very low quality evidence from 1 RCT (N=115) showed that there is no statistically significant difference between acupuncture plus standard treatment and sham acupuncture plus standard treatment on pain intensity in the evening as assessed by a visual analogue scale during the last treatment week in pregnant women with pelvic girdle pain: difference between medians 5, p=0.48.
- Very low quality evidence from 1 RCT (N=115) showed that there is no statistically significant difference between acupuncture plus standard treatment and sham acupuncture plus standard treatment on the number of pregnant women with pelvic girdle pain who report discomfort during the last treatment week: difference between medians 5, p=0.15.
Pelvic-related functional disability/functional status during pregnancy
- Very low quality evidence from 1 RCT (N=115) showed that there is a statistically significant difference favouring acupuncture plus standard treatment over sham acupuncture plus standard treatment on pelvic-related functional disability/functional status during pregnancy as assessed by the disability rating index within 1 week after end of treatment in pregnant women with pelvic girdle pain: difference between medians 11, p<0.001.
- Very low quality evidence from 1 RCT (N=115) showed that there is no statistically significant difference between acupuncture plus standard treatment and sham acupuncture plus standard treatment on pelvic-related functional disability/functional status during pregnancy as assessed by the Oswestry disability index within 1 week after end of treatment in pregnant women with pelvic girdle pain: difference between medians 2, p=0.47.
Important outcomes
Adverse effects during pregnancy
- Low quality evidence from 1 RCT (N=115) showed that there is a clinically important difference favouring sham acupuncture plus standard treatment over acupuncture plus standard treatment on the number of women who experience a de qi sensation in pregnant women with pelvic girdle pain: RR 3.32 (95% CI 2.18 to 5.06).
- Very low quality evidence from 1 RCT (N=115) showed that there is no clinically important difference between acupuncture plus standard treatment and sham acupuncture plus standard treatment on the number of women who experience fainting in pregnant women with pelvic girdle pain: RR 1.23 (95% CI 0.35 to 4.34).
- Very low quality evidence from 1 RCT (N=115) showed that there is no clinically important difference between acupuncture plus standard treatment and sham acupuncture plus standard treatment on the number of women who experience haematoma in pregnant women with pelvic girdle pain: RR 0.98 (95% CI 0.56 to 1.73).
- Very low quality evidence from 1 RCT (N=115) showed that there is no clinically important difference between acupuncture plus standard treatment and sham acupuncture plus standard treatment on the number of women who experience needle pain in pregnant women with pelvic girdle pain: RR 0.91 (95% CI 0.45 to 1.82).
- Very low quality evidence from 1 RCT (N=115) showed that there is no clinically important difference between acupuncture plus standard treatment and sham acupuncture plus standard treatment on the number of women who experience sleepiness in pregnant women with pelvic girdle pain: RR 1.47 (95% CI 0.26 to 8.50).
- Very low quality evidence from 1 RCT (N=115) showed that there is no clinically important difference between acupuncture plus standard treatment and sham acupuncture plus standard treatment on the number of women who experience slight bleeding in pregnant women with pelvic girdle pain: RR 1.01 (95% CI 0.75 to 1.36).
Days off work/sick leave
No evidence was identified to inform this outcome.
Days in hospital admitted to antenatal ward for treatment of pelvic girdle pain
No evidence was identified to inform this outcome.
Women’s experience and satisfaction of care
No evidence was identified to inform this outcome.
Admission at birth to the neonatal unit
No evidence was identified to inform this outcome.
Comparison 3. Acupuncture versus physiotherapy-delivered in-home exercise advice
Critical outcomes
Pain intensity during pregnancy
No evidence was identified to inform this outcome.
Pelvic-related functional disability/functional status during pregnancy
No evidence was identified to inform this outcome.
Important outcomes
Adverse effects during pregnancy
- Very low quality evidence from 1 RCT (N=46) showed that there is no clinically important difference between acupuncture and physiotherapy-delivery in-home exercise advice on the number of serious adverse effects during pregnancy in women with pelvic girdle pain: RD 0 (95% CI −0.09 to 0.09).
- Very low quality evidence from 1 RCT (N=46) showed that there is no clinically important difference between acupuncture and physiotherapy-delivered in-home exercise advice on the number of minor adverse effects during pregnancy in women with pelvic girdle pain: RR 0.26 (95% CI 0.06 to 1.19).
Days off work/sick leave
No evidence was identified to inform this outcome.
Days in hospital admitted to antenatal ward for treatment of pelvic girdle pain
No evidence was identified to inform this outcome.
Women’s experience and satisfaction
- Very low quality evidence from 1 RCT (N=46) showed that there is no clinically important difference between acupuncture and physiotherapy-delivered in-home exercise advice on the number of pregnant women with pelvic girdle pain who reported that the treatments were good or excellent: RR 1.24 (95% CI 0.96 to 1.6).
Admission at birth to the neonatal unit
- Very low quality evidence from 1 RCT (N=60) showed that there is no clinically important difference between acupuncture and physiotherapy-delivered in-home exercise advice on the number of admissions at birth to the neonatal unit: RD 0 (95% CI −0.09 to 0.09).
Comparison 4. Acupuncture + standard treatment versus physiotherapy-delivered in-home exercise advice + standard treatment
Critical outcomes
Pain intensity during pregnancy
- Low quality evidence from 1 RCT (N=386) showed that there is no statistically significant difference between acupuncture and physiotherapy-delivered in-home exercise on morning pain intensity in the morning as assessed by a visual analogue scale one week after the treatment in pregnant women with pelvic girdle pain: difference between medians 3, p=not significant.
- Low quality evidence from 1 RCT (N=386) showed that there is a statistically significant difference favouring acupuncture over physiotherapy-delivered in-home exercise on evening pain intensity in the evening as assessed by a visual analogue scale one week after the treatment in pregnant women with pelvic girdle pain: difference between medians 14, p=0.01.
Pelvic-related functional disability/functional status during pregnancy
No evidence was identified to inform this outcome.
Important outcomes
Adverse effects during pregnancy
- Moderate quality evidence from 1 RCT (N=256) showed that there is a clinically important difference favouring physiotherapy-delivered in-home exercise over acupuncture on the number of women who experience adverse effects during pregnancy in women with pelvic girdle pain: RR 2.05 (95% CI 1.30 to 3.22).
Days off work/sick leave
No evidence was identified to inform this outcome.
Days in hospital admitted to antenatal ward for treatment of pelvic girdle pain
No evidence was identified to inform this outcome.
Women’s experience and satisfaction of care
- Very low quality evidence from 1 RCT (N=219) showed that there is no clinically important difference between acupuncture and physiotherapy-delivered in-home exercise on the number of pregnant women with pelvic girdle pain who report pain relief within one week of treatment: RR 0.41 (95% CI 0.08 to 2.07).
- Moderate quality evidence from 1 RCT (N=219) showed that there is a clinically important difference favouring physiotherapy-delivered in-home exercise over acupuncture on the number of pregnant women with pelvic girdle pain who report that the treatments were harmful within one week of treatment: RR 2.01 (95% CI 1.29 to 3.12).
- Very low quality evidence from 1 RCT (N=219) showed that there is no clinically important difference between acupuncture and physiotherapy-delivered in-home exercise on the number of pregnant women with pelvic girdle pain who reported that the treatment was not helpful within one week of treatment l: RR 2.06 (95% CI 0.38 to 10.99).
- Very low quality evidence from 1 RCT (N=219) showed that there is no clinically important difference between acupuncture and physiotherapy-delivered in-home exercise on the number of pregnant women with pelvic girdle pain who the treatment was of good or very good help within one week of treatment: RR 1.05 (95% CI 0.9 to 1.22).
Admission at birth to the neonatal unit
- Very low quality evidence from 1 RCT (N=256) showed that there is no clinically important difference between acupuncture and physiotherapy-delivered in-home exercise on the number of babies admitted to the neonatal unit at birth: RR 0.70 (95% CI 0.26 to 1.91).
Comparison 5. Manual therapy (chiropractic treatment) versus standard treatment
Critical outcomes
Pain intensity during pregnancy
- Very low quality evidence from 1 RCT (N=56) showed that there is no clinically important difference between chiropractic therapy and standard treatment on pain intensity as assessed by a visual analogue scale between weeks 21 and 30 in pregnant women with pelvic girdle pain: MD −3.70 (95% CI −15.92 to 8.52).
- Very low quality evidence from 1 RCT (N=56) showed that there is no clinically important difference between chiropractic therapy and standard treatment on pain intensity as assessed by a visual analogue scale between weeks 33 and 40 in pregnant women with pelvic girdle pain: MD −3.90 (95% CI −21.81 to 14.01).
Pelvic-related functional disability/functional status during pregnancy
- Very low quality evidence from 1 RCT (N=56) showed that there is no clinically important difference between chiropractic therapy and standard treatment on pelvic-related functional disability/functional status during pregnancy as assessed by the disability rating index in pregnant women with pelvic girdle pain: MD 2.60 (95% CI −6.58 to 11.78).
Important outcomes
Adverse effects during pregnancy
No evidence was identified to inform this outcome.
Days off work/sick leave
- Very low quality evidence from 1 RCT (N=56) showed that there is no clinically important difference between chiropractic therapy and no treatment on number of sick leaves between week 19 and 30 in pregnant women with pelvic girdle pain: RR 0.88 (95% CI 0.37 to 2.09).
- Very low quality evidence from 1 RCT (N=56) showed that there is no clinically important difference between chiropractic therapy and no treatment on number of sick leaves between week 31 and 36 in pregnant women with pelvic girdle pain: RR 0.80 (95% CI 0.37 to 1.72).
Days in hospital admitted to antenatal ward for treatment of pelvic girdle pain
No evidence was identified to inform this outcome.
Women’s experience and satisfaction
No evidence was identified to inform this outcome.
Admission at birth to the neonatal unit
No evidence was identified to inform this outcome.
Comparison 6. Manual therapy (craniosacral therapy) + standard treatment versus standard treatment
Critical outcomes
Pain intensity during pregnancy
- Very low quality evidence from 1 RCT (N=123) showed that there is a statistically significant difference favouring craniosacral therapy over standard treatment on pain intensity in the morning as assessed by a visual analogue scale during the treatment in pregnant women with pelvic girdle pain: difference between medians 8, p=0.02.
- Very low quality evidence from 1 RCT (N=123) showed that there is no statistically significant difference between craniosacral therapy and standard treatment on pain intensity in the evening as assessed by a visual analogue scale during the treatment in pregnant women with pelvic girdle pain: difference between medians 8, p=0.08.
- Very low quality evidence from 1 RCT (N=123) showed that there is no statistically significant difference between craniosacral therapy and standard treatment on pain discomfort within one week after end of treatment in pregnant women with pelvic girdle pain: difference between medians 0.5, p= 0.43.
Pelvic-related functional disability/functional status during pregnancy
- Very low quality evidence from 1 RCT (N=123) showed that there is no statistically significant difference between craniosacral therapy and standard treatment on pelvic-related functional disability/functional status during pregnancy as assessed by the disability rating index within one week after end of treatment in pregnant women with pelvic girdle pain: difference between medians 3.5, p=0.30.
- Very low quality evidence from 1 RCT (N=123) showed that there is a statistically significant difference favouring craniosacral therapy over standard treatment on pelvic-related functional disability/functional status during pregnancy as assessed by the Oswestry disability index within one week after end of treatment in pregnant women with pelvic girdle pain: difference between medians 8, p=0.02.
Important outcomes
Adverse effects during pregnancy
No evidence was identified to inform this outcome.
Days off work/sick leave
- Very low quality evidence from 1 RCT (N=123) showed that there is no clinically important difference between craniosacral therapy and standard treatment on number of pregnant women with pelvic girdle pain who take sick leave: RR 1.43 (95% CI 0.70 to 2.93).
Days in hospital admitted to antenatal ward for treatment of pelvic girdle pain
No evidence was identified to inform this outcome.
Women’s experience and satisfaction
No evidence was identified to inform this outcome.
Admission at birth to the neonatal unit
No evidence was identified to inform this outcome.
Comparison 7. Manual therapy (foot manipulation) + physiotherapy-delivered in-home exercise advice versus sham manual therapy (sham foot manipulation) + physiotherapy-delivered in-home exercises
Critical outcomes
Pain intensity during pregnancy
- Low quality evidence from 1 RCT (N=97) showed that there is no clinically important difference favouring foot manipulation over sham foot manipulation on morning pain intensity in the pelvic region as assessed by a visual analogue scale after 6 weeks of treatment in pregnant women with pelvic girdle pain: MD −9.00 (95% CI −19.78 to 1.78).
- Low quality evidence from 1 RCT (N=97) showed that there is a clinically important difference favouring foot manipulation over sham foot manipulation on evening pain intensity in the pelvic region as assessed by a visual analogue scale after 6 weeks of treatment in pregnant women with pelvic girdle pain: MD −18.00 (95% CI −29.97 to −6.03).
- Low quality evidence from 1 RCT (N=97) showed that there is no clinically important difference between foot manipulation and sham foot manipulation on pain intensity in the symphysis as assessed by a visual analogue scale after 6 weeks of treatment in pregnant women with pelvic girdle pain: MD −3.00 (95% CI −11.54 to 5.54).
Pelvic-related functional disability/functional status during pregnancy
No evidence was identified to inform this outcome.
Important outcomes
Adverse effects during pregnancy
No evidence was identified to inform this outcome.
Days off work/sick leave
No evidence was identified to inform this outcome.
Days in hospital admitted to antenatal ward for treatment of pelvic girdle pain
No evidence was identified to inform this outcome.
Women’s experience and satisfaction
No evidence was identified to inform this outcome.
Admission at birth to the neonatal unit
No evidence was identified to inform this outcome.
Comparison 8. Pelvic girdle support belt + information versus information
Critical outcomes
Pain intensity during pregnancy
- Low quality evidence from 1 RCT (N=105) showed that there is a clinically important difference favouring non-rigid pelvic girdle support belt and information over information only on pain intensity after 6 weeks of treatment as assessed by a visual analogue scale in pregnant women with pelvic girdle pain: MD −34.20 (95% CI −41.62 to −26.78).
Pelvic-related functional disability/functional status during pregnancy
- Very low quality evidence from 1 RCT (N=105) showed that there is no clinically important difference between non-rigid pelvic girdle support belt and information and information only on Pelvic-related functional disability/functional status during pregnancy after 6 weeks of treatment as assessed by the Oswestry disability index in pregnant women with pelvic girdle pain: MD −5.60 (95% CI −9.86 to −1.34).
Important outcomes
Adverse effects during pregnancy
No evidence was identified to inform this outcome.
Days off work/sick leave
No evidence was identified to inform this outcome.
Days in hospital admitted to antenatal ward for treatment of pelvic girdle pain
No evidence was identified to inform this outcome.
Women’s experience and satisfaction
No evidence was identified to inform this outcome.
Admission at birth to the neonatal unit
No evidence was identified to inform this outcome.
Comparison 9. Pelvic girdle support belt + information versus physiotherapy-delivered in-home exercise advice + information
Critical outcomes
Pain intensity during pregnancy
- Low quality evidence from 1 RCT (N=105) showed that there is a clinically important difference favouring non-rigid pelvic girdle support belt plus information over physiotherapy-delivered in-home exercise advice plus information on pain intensity after 6 weeks of treatment as assessed by a visual analogue scale in pregnant women with pelvic girdle pain: MD −20.10 (95% CI −28.29 to −11.91).
Pelvic-related functional disability
- Low quality evidence from 1 RCT (N=105) showed that there is no clinically important difference between non-rigid pelvic girdle support belt plus information and physiotherapy-delivered in-home exercise advice plus information on pelvic-related functional disability after 6 weeks of treatment as assessed by the Oswestry disability index in pregnant women with pelvic girdle pain in pregnant women with pelvic girdle pain: MD −1.40 (95% CI −5.13 to 2.33).
Important outcomes
Adverse effects during pregnancy
No evidence was identified to inform this outcome.
Days off work/sick leave
No evidence was identified to inform this outcome.
Days in hospital admitted to antenatal ward for treatment of pelvic girdle pain
No evidence was identified to inform this outcome.
Women’s experience and satisfaction
No evidence was identified to inform this outcome.
Admission at birth to the neonatal unit
No evidence was identified to inform this outcome.
Comparison 10. Physiotherapy-delivered in-home exercise advice versus standard treatment
Critical outcomes
Pain intensity during pregnancy
- Very low quality evidence from 1 RCT (N=171) showed that there is a clinically important difference favouring physiotherapy-delivered in-home advice over standard treatment on pain intensity after 12 weeks of treatment as assessed by a visual analogue scale in pregnant women with pelvic girdle pain: MD −2.07 (95% CI −2.90 to −1.24).
Pelvic-related functional disability/functional status during pregnancy
- Very low quality evidence from 1 RCT (N=171) showed that there is a clinically important difference favouring physiotherapy-delivered in-home advice over standard treatment on pelvic-related functional disability/functional status during pregnancy after 12 weeks of treatment as assessed by the Oswestry disability rating index in pregnant women with pelvic girdle pain: MD −9.94 (95% CI −14.71 to −5.17).
Important outcomes
Adverse effects during pregnancy
No evidence was identified to inform this outcome.
Days off work/sick leave
No evidence was identified to inform this outcome.
Days in hospital admitted to antenatal ward for treatment of pelvic girdle pain
No evidence was identified to inform this outcome.
Women’s experience and satisfaction
No evidence was identified to inform this outcome.
Admission at birth to the neonatal unit
No evidence was identified to inform this outcome.
Comparison 11. Physiotherapy-delivered in-home exercise advice + standard treatment versus standard treatment
Critical outcomes
Pain intensity during pregnancy
- Low quality evidence from 1 RCT (N=386) showed that there is a statistically significant difference favouring physiotherapy-delivered in-home exercise advice plus standard treatment over standard treatment only on pain intensity in the morning as assessed by a visual analogue scale one week after the treatment in pregnant women with pelvic girdle pain: difference between medians 9, p=0.03.
- Low quality evidence from 1 RCT (N=386) showed that there is a statistically significant difference favouring physiotherapy-delivered in-home exercise advice plus standard treatment over standard treatment only on pain intensity in the evening as assessed by a visual analogue scale one week after the treatment in pregnant women with pelvic girdle pain: difference between medians 13, p=0.02.
Pelvic-related functional disability/functional status during pregnancy
No evidence was identified to inform this outcome.
Important outcomes
Adverse effects during pregnancy
- Moderate quality evidence from 1 RCT (N=261) showed that there is a clinically important difference favouring standard treatment over physiotherapy-delivered in-home exercise advice plus standard treatment on the number of women who experience adverse effects during pregnancy in pregnant women with pelvic girdle pain: RR 2.73 (95% CI 1.26 to 5.91).
Days off work/sick leave
No evidence was identified to inform this outcome.
Days in hospital admitted to antenatal ward for treatment of pelvic girdle pain
No evidence was identified to inform this outcome.
Women’s experience and satisfaction of care
- Very low quality evidence from 1 RCT (N=211) showed that there is no clinically important difference between physiotherapy-delivered in-home exercise advice plus standard treatment and standard treatment only on the number of pregnant women with pelvic girdle pain who reported no pain relief within one week of treatment: RR 1.5 (95% CI 0.37 to 6.12).
- Moderate quality evidence from 1 RCT (N=211) showed that there is a clinically important difference favouring physiotherapy-delivered in-home exercise advice plus standard treatment over standard treatment only on the number of pregnant women with pelvic girdle pain who reported that the treatments were harmful within one week of treatment: RR 0.39 (95% CI 0.26 to 0.59).
- Moderate quality evidence from 1 RCT (N=211) showed that there is a clinically important difference favouring physiotherapy-delivered in-home exercise advice plus standard treatment over standard treatment only on the number of pregnant women with pelvic girdle pain who reported that the treatment was not helpful within one week of treatment: RR 0.07 (95% CI 0.02 to 0.3).
- Moderate quality evidence from 1 RCT (N=211) showed that there is a clinically important difference favouring physiotherapy-delivered in-home exercise advice plus standard treatment over standard treatment only on the number of pregnant women with pelvic girdle pain who reported the treatment was of good or very good help within one week of treatment: RR 3.32 (95% CI 2.25 to 4.88).
Admission at birth to the neonatal unit
- Very low quality evidence from 1 RCT (N=259) showed that there is no clinically important difference between physiotherapy-delivered in-home exercise advice plus standard treatment and standard treatment only on the number of babies admitted at birth to the neonatal unit: RR 1.49 (95% CI 0.55 to 4.06).
Comparison 12. Physiotherapy-delivered in-home exercise advice + information versus information
Critical outcomes
Pain intensity during pregnancy
- Very low quality evidence from 1 RCT (N=105) showed that there is a clinically important difference favouring physiotherapy-delivered in-home exercise advice plus information over information only on pain intensity after 6 weeks of treatment as assessed by a visual analogue scale in pregnant women with pelvic girdle pain: MD −14.10 (95% CI −22.14 to −6.06).
Pelvic-related functional disability/functional status during pregnancy
- Very low quality evidence from 1 RCT (N=105) showed that there is no clinically important difference between physiotherapy-delivered in-home exercise advice plus information and information only on pelvic-related functional disability/functional status during pregnancy after 6 weeks of treatment as assessed by the Oswestry disability index in pregnant women with pelvic girdle pain: MD −4.20 (95% CI −8.55 to 0.15).
Important outcomes
Adverse effects during pregnancy
No evidence was identified to inform this outcome.
Days off work/sick leave
No evidence was identified to inform this outcome.
Days in hospital admitted to antenatal ward for treatment of pelvic girdle pain
No evidence was identified to inform this outcome.
Women’s experience and satisfaction
No evidence was identified to inform this outcome.
Admission at birth to the neonatal unit
No evidence was identified to inform this outcome.
Comparison 13. Physiotherapy-delivered in-home exercise advice + information + pelvic girdle support belt versus information + pelvic girdle support belt
Critical outcomes
Pain intensity during pregnancy
- Low quality evidence from 1 RCT (N=118) reported that there was no group effect at gestation week 38 on pain intensity during pregnancy between physiotherapy-delivered in-home exercise advice or in-clinic exercise advice combined with information and pelvic girdle support belt and information and pelvic girdle support belt only, in pregnant women with pelvic girdle pain as assessed by a visual analogue scale: difference between medians 1, p=not reported.
Pelvic-related functional disability/functional status during pregnancy
- Low quality evidence from 1 RCT (N=118) reported that there was no group effect at gestation week 38 on pelvic-related functional disability/functional status during pregnancy between physiotherapy-delivered in-home or in-clinic exercise advice combined with information and pelvic girdle support belt, and information and pelvic girdle support belt only in pregnant women with pelvic girdle pain as assessed by the disability rating index: difference between medians 1, p=not reported.
Important outcomes
Adverse effects during pregnancy
No evidence was identified to inform this outcome.
Days off work/sick leave
No evidence was identified to inform this outcome.
Days in hospital admitted to antenatal ward for treatment of pelvic girdle pain
No evidence was identified to inform this outcome.
Women’s experience and satisfaction
No evidence was identified to inform this outcome.
Admission at birth to the neonatal unit
No evidence was identified to inform this outcome.
Comparison 14. Physiotherapy-delivered in-home exercise advice, + information + pelvic girdle support belt versus physiotherapy-delivered in-clinic exercise + information + pelvic girdle support belt
Critical outcomes
Pain intensity during pregnancy
- Low quality evidence from 1 RCT (N=118) reported that there was no group effect at gestation week 38 on pain intensity during pregnancy as assessed by a visual analogue scale between physiotherapy-delivered in-home or in-clinic exercise advice combined with information and pelvic girdle support belt and information and pelvic girdle support belt only in pregnant women with pelvic girdle pain: difference between medians 12, p=not reported.
Pelvic-related functional disability/functional status during pregnancy
- Low quality evidence from 1 RCT (N=118) reported that there was no group effect at gestation week 38 on pelvic-related functional disability/functional status during pregnancy as assessed by the disability rating index between physiotherapy-delivered in-home or in-clinic exercise advice combined with information and pelvic girdle support belt and information and pelvic girdle support belt only in pregnant women with pelvic girdle pain: difference between medians 7, p=not reported.
Important outcomes
Adverse effects during pregnancy
No evidence was identified to inform this outcome.
Days off work/sick leave
No evidence was identified to inform this outcome.
Days in hospital admitted to antenatal ward for treatment of pelvic girdle pain
No evidence was identified to inform this outcome.
Women’s experience and satisfaction
No evidence was identified to inform this outcome.
Admission at birth to the neonatal unit
No evidence was identified to inform this outcome.
Comparison 15. Physiotherapy-delivered in-clinic exercise advice + information + pelvic girdle support belt versus information + pelvic girdle support
Critical outcomes
Pain intensity during pregnancy
- Low quality evidence from 1 RCT (N=118) reported that there was no group effect at gestation week 38 on pain intensity during pregnancy as assessed by a visual analogue scale between physiotherapy-delivered in-home or in-clinic exercise advice combined with pelvic girdle support belt, and information and pelvic girdle support belt only in pregnant women with pelvic girdle pain: difference between medians 13, p=not reported.
Pelvic-related functional disability/functional status during pregnancy
- Low quality evidence from 1 RCT (N=118) reported that there was no group effect at gestation week 38 on pelvic-related functional disability/functional status during pregnancy as assessed by the disability rating index between physiotherapy-delivered in-home or in-clinic exercise advice combined with information and pelvic girdle support belt, and information and pelvic girdle support belt only in pregnant women with pelvic girdle pain: difference between medians 6, p=not reported.
Important outcomes
Adverse effects during pregnancy
No evidence was identified to inform this outcome.
Days off work/sick leave
No evidence was identified to inform this outcome.
Days in hospital admitted to antenatal ward for treatment of pelvic girdle pain
No evidence was identified to inform this outcome.
Women’s experience and satisfaction
No evidence was identified to inform this outcome.
Admission at birth to the neonatal unit
No evidence was identified to inform this outcome.
Economic evidence statements
Evidence from the guideline economic analysis suggested that use of a non-rigid lumbopelvic support belt may be a cost effective option when compared with either information only, or exercise. The economic analysis is directly applicable to the NICE decision-making context.
The committee’s discussion of the evidence
Interpreting the evidence
The outcomes that matter most
The committee agreed that pain intensity during pregnancy and pelvic-related functional disability/functional status during pregnancy were critical as these demonstrate effectiveness of the interventions. The following were considered to be important outcomes: adverse effects during pregnancy, days off work/sick leave, days in hospital admitted to antenatal ward for treatment of pelvic girdle pain, women’s experience and satisfaction of care, and admission of baby at birth to the neonatal unit.
The quality of the evidence
The quality of the evidence ranged from very low to high, with most of the evidence being of very low quality. This was predominately due to serious overall risk of bias in some outcomes; imprecision around the effect estimate in many outcomes; and indirectness in a few outcomes.
Reasons for serious risk of bias was due to concerns around randomisation as little information was provided around the process of randomisation and allocation concealment in a few outcomes. Other reasons for serious risk of bias included deviations from intended interventions due to not blinding participants in some outcomes, and high missing outcome data for a few outcomes. Some outcomes were also downgraded for risk of bias as they are subjective.
Some outcomes were downgraded for indirectness as there were some studies where a high percentage of the women had pain in regions other than the pelvic girdle.
There was no evidence identified for the use of analgesics or the use of ice or heat packs to treat pelvic girdle pain. No evidence was identified for the outcome days in hospital admitted to antenatal ward for pelvic girdle pain.
Benefits and harms
Referral to physiotherapy
Several studies compared physiotherapy-delivered exercise advice – that is, advice provided by a physiotherapist to perform specific exercises - with other interventions or combinations thereof. Although there was insufficient data to permit meta-analysis for any of the outcomes of interest and some evidence to suggest that there is an increased risk of experiencing adverse events (typically mild and related to the back pain itself) compared to standard treatment, the results suggest that engaging in physiotherapy-recommended exercise may ameliorate intensity of pelvic girdle pain and pelvic-related functional disability compared to standard treatment alone.
The committee discussed the evidence which they agreed was consistent overall with a benefit of physiotherapy-delivered exercise advice in women with pelvic girdle pain. However they noted the limited quality of the evidence and the fact that some outcomes, for example pelvic-related functional disability, were not universally improved by exercise advice and agreed that on this basis the recommendation should be weak (‘consider’).
Non-rigid pelvic girdle support belt
The committee also discussed the evidence which showed that a non-rigid lumbopelvic belt reduced pain intensity in women with pelvic girdle pain. One RCT of pregnant women with pelvic girdle pain compared non-rigid pelvic girdle support belt and information for 6 weeks, to physiotherapy-delivered in-home exercise advice and information, and information (concerning anatomy, body posture, and ergonomic advice about sitting, walking and lying down) only. This trial showed that there is a clinically important difference favouring a non-rigid pelvic girdle support belt and information over either physiotherapy-delivered in-home exercise advice and information or information only on the outcome of pain intensity during pregnancy. Although the same trial showed no clinically important difference between wearing a non-rigid pelvic girdle support belt and receiving either physiotherapy-delivered in-home exercise advice and information, or information only on the outcome of pelvic-related functional disability/functional status during pregnancy.
The committee used the evidence together with the economic model (see details in appendix J) to make a recommendation for referral to physiotherapy services for a non-rigid lumbopelvic belt. The committee discussed the economic evidence that supports a non-rigid lumbopelvic belt, but agreed not to make a strong recommendation. They highlighted some of the limitations of the study used to inform the economic analysis, such as a small sample size and the differences in the context of the study to the UK. They also discussed the implications of a strong recommendation on current practice. Current wait times for physiotherapy services on the NHS are long, and a strong recommendation may have a negative impact on wait times for all physiotherapy services. The committee discussed that not making a strong recommendation may mean women will purchase a non-rigid lumbopelvic belt without consulting physiotherapy services. They discussed whether there was potential for harm if women do not receive appropriate advice on how to wear a belt, however on balance the committee felt that risk was small.
The committee specified that referral for exercise advice or a belt should be to physiotherapy services rather than a physiotherapist, as neither of these interventions necessarily have to be delivered in person and can be, for example, via a telephone consultation.
Other interventions
Three RCTs on traditional body acupuncture or ear and body acupuncture, and 3 RCTs each examining a type of manual therapy, were identified. However, there was insufficient data to permit meta-analysis for any of the outcomes of interest for any comparison.
Acupuncture
The committee discussed the evidence on acupuncture that showed some improvements on pain intensity, and on women’s experience and satisfaction. They agreed that the resources needed to implement a recommendation for acupuncture in the NHS are not currently adequate (for example, there may not be enough trained practitioners) and that it is therefore likely that such a recommendation would entail a substantial cost.. The committee felt that because the evidence was mixed regarding the benefits and harms of acupuncture, and the quality of the evidence was poor, they could not justify a recommendation that would have a substantial resource impact.
Manual therapy
The evidence on manual therapy for the treatment of pelvic girdle pain during pregnancy was sparse, with only 3 studies identified, and on disparate interventions. The committee discussed the importance of only 1 of these studies having investigated the effects of manual therapy alone, and not in combination with any other intervention. The evidence for this study showed that there were no important benefits on the outcomes of interest. Therefore, the committee agreed that there was insufficient evidence to show that manual therapy alone had any important benefits on the outcomes of interest, and agreed not to make a recommendation. They discussed the 2 other studies which showed some benefit of manual therapy, however they highlighted that manual therapy was delivered in combination with physiotherapy delivered advice. The committee felt that although they were not able to make a judgement on the benefits and harms of manual therapy, they had considered the benefits of physiotherapy delivered advice from other available evidence and felt the recommendation they had agreed for this intervention was sufficient, and better supported with other evidence.
Cost effectiveness and resource use
The committee noted that no relevant published economic evaluations had been identified for this topic. They also deemed that the evidence presented in the clinical review was not of sufficient quality to allow for recommendations on acupuncture or manual therapy. These treatments are not routinely offered by the NHS, and the committee acknowledged there would be a significant resource impact were they to make such recommendations.
The committee also acknowledged the potential resource implications from recommending that women be offered a non-rigid lumbobelvic support. Given the relatively high proportion of women who experience mild to moderate pelvic girdle pain, the committee were mindful of that a recommendation could entail a significant national resource impact, despite the likelihood of the unit cost of a belt being relatively minimal in comparison to other interventions. An economic analysis developed for this guideline suggested that offering women use of a non-rigid lumbopelvic support belt was a cost effective option from an NHS perspective.
The recommendation to refer to physiotherapy services partly reflect current practice, though the committee acknowledged there is a significant degree of regional variation and take up in practice. Hence, an increase in resources may be required to provide services where they are not routinely available.
References
Elden 2008a
Elden, H., Fagevik-Olsen, M., Ostgaard, H. C., Stener-Victorin, E., Hagberg, H., Acupuncture as an adjunct to standard treatment for pelvic girdle pain in pregnant women: Randomised double-blinded controlled trial comparing acupuncture with non-penetrating sham acupuncture, BJOG: An International Journal of Obstetrics and Gynaecology, 115, 1655–1668, 2008a [PubMed: 18947338]Elden 2005
Elden, H., Ladfors, L., Olsen, M. F., Ostgaard, H. C., Hagberg, H., Effects of acupuncture and stabilising exercises as adjunct to standard treatment in pregnant women with pelvic girdle pain: randomised single blind controlled trial, BMJ (Clinical research ed.), 330, 761, 2005 [PMC free article: PMC555879] [PubMed: 15778231]Elden 2008b
Elden,H., Ostgaard,H.C., Fagevik-Olsen,M., Ladfors,L., Hagberg,H., Treatments of pelvic girdle pain in pregnant women: adverse effects of standard treatment, acupuncture and stabilising exercises on the pregnancy, mother, delivery and the fetus/neonate, BMC Complementary and Alternative Medicine, 8, 34, 2008b [PMC free article: PMC2467402] [PubMed: 18582370]Elden 2013
Elden, H., Ostgaard, H. C., Glantz, A., Marciniak, P., Linner, A. C., Olsen, M. F., Effects of craniosacral therapy as adjunct to standard treatment for pelvic girdle pain in pregnant women: A multicenter, single blind, randomized controlled trial, Acta Obstetricia et Gynecologica Scandinavica, 92, 775–782, 2013 [PubMed: 23369067]Gausel 2017
Gausel, A. M., Kjaermann, I., Malmqvist, S., Andersen, K., Dalen, I., Larsen, J. P., Okland, I., Chiropractic management of dominating one-sided pelvic girdle pain in pregnant women; a randomized controlled trial, BMC Pregnancy and Childbirth, 17 (1) (no pagination), 2017 [PMC free article: PMC5622492] [PubMed: 28962596]Kordi 2013
Kordi, R., Abolhasani, M., Rostami, M., Hantoushzadeh, S., Mansournia, M. A., Vasheghani-Farahani, F., Comparison between the effect of lumbopelvic belt and home based pelvic stabilizing exercise on pregnant women with pelvic girdle pain; A randomized controlled trial, Journal of Back and Musculoskeletal Rehabilitation, 26, 133–139, 2013 [PubMed: 23640314]Melkersson 2017
Melkersson, C., Nasic, S., Starzmann, K., Bengtsson Bostrom, K., Effect of Foot Manipulation on Pregnancy-Related Pelvic Girdle Pain: A Feasibility Study, Journal of Chiropractic medicine, 16, 211–219, 2017 [PMC free article: PMC5659811] [PubMed: 29097951]Mirmolaei 2018
Mirmolaei, S. T., Ansari, N. N., Mahmoudi, M., Ranjbar, F., Efficacy of a physical training program on pregnancy related lumbopelvic pain, International Journal of Women’s Health and Reproduction Sciences, 6, 161–166, 2018Nicolian 2019
Nicolian, S., Butel, T., Gambotti, L., et al., Cost-effectiveness of acupuncture versus standard care for pelvic and low back pain in pregnancy: A randomized controlled trial, PLoS ONE, 14, e0214195. 2019 [PMC free article: PMC6476478] [PubMed: 31009470]Nilsson-Wikmar 2005
Nilsson-Wikmar, L., Holm, K., Oijerstedt, R., Harms-Ringdahl, K., Effect of three different physical therapy treatments on pain and activity in pregnant women with pelvic girdle pain: A randomized clinical trial with 3, 6, and 12 months follow-up postpartum, Spine, 30, 850–856, 2005 [PubMed: 15834325]Scott 2018
Scott, K.L., Hellawell, M.Effects of water and land based exercise programmes on women experiencing pregnancy-related pelvic girdle pain: a randomized controlled feasibility study, Journal of Pelvic, Obstetric and Gynaecological Physiotherapy, 122, 21–29, 2018Wedenberg 2000
Wedenberg, K., Moen, B., Norling, A., A prospective randomized study comparing acupuncture with physiotherapy for low-back and pelvic pain in pregnancy, Acta Obstet Gynecol ScandActa obstetricia et gynecologica Scandinavica, 79, 331–5, 2000 [PubMed: 10830757]
Appendices
Appendix A. Review protocols
Appendix B. Literature search strategies
Appendix C. Clinical evidence study selection
Appendix D. Clinical evidence tables
Appendix E. Forest plots
Appendix F. GRADE tables
Appendix G. Economic evidence study selection
Economic evidence study selection for review question: What interventions are effective in treating mild to moderate pelvic girdle pain during pregnancy?
A single economic search was undertaken for all topics included in the scope of this guideline. No economic studies were identified which were applicable to this review question. See supplementary material 2 for details.
Appendix H. Economic evidence tables
Economic evidence tables for review question: What interventions are effective in treating mild to moderate pelvic girdle pain during pregnancy?
No economic evidence was identified which was applicable to this review question.
Appendix I. Economic evidence profiles
Economic evidence profiles for review question: What interventions are effective in treating mild to moderate pelvic girdle pain during pregnancy?
No economic evidence was identified which was applicable to this review question.
Appendix J. Economic analysis
Appendix K. Excluded studies
Excluded clinical and economic studies for review question: What interventions are effective in treating mild to moderate pelvic girdle pain during pregnancy?
Clinical studies
Table 35Excluded studies
| Study | Reason for exclusion |
|---|---|
| A Pilot Randomized Controlled Trial Evaluating Three Treatments for Pregnancy-Related Low Back Pain: Exercise, Spinal Manipulation, and Neuroemotional Technique, Journal of midwifery & women’s health, 57, 537–537, 2012 | Conference abstract. Published results have been considered separately, see reason for exclusion for Peterson 2014. |
| Abbasi, Osman Z., Zito, Patrick M., Osteopathic Manipulative Treatments for Common Pain Issues Encountered in Pregnancy, International Journal of Childbirth Education, 28, 76–78, 2013 | Non-systematic review |
| Almousa, S., Lamprianidou, E., Kitsoulis, G., The effectiveness of stabilising exercises in pelvic girdle pain during pregnancy and after delivery: A systematic review, Physiotherapy research international : the journal for researchers and clinicians in physical therapy, 23, 2018 [PubMed: 29115735] | Systematic review. Included studies checked. No additional studies matching out protocol |
| Barfoot, C., Tudor, R., D’Almeida, I., Joice, D., Staples, S., Smith, R., Bateman, A., Mercer, C., Koulouglioti, C., A pilot randomised trial of 4 physiotherapy interventions for pregnancy related pelvic girdle pain, Physiotherapy (United Kingdom), 1), eS111, 2015 | Conference abstract |
| Barkatsa, V., Wozniak, G., Syrmos, N., Iliadis, C., Roupa, Z., Intervetions for pelvic girdle pain in pregnant women, Bone, 1), S237, 2010 | Conference abstract |
| Bergamo, T. R., Latorraca, C. O. C., Pachito, D. V., Martimbianco, A. L. C., Riera, R., Findings and methodological quality of systematic reviews focusing on acupuncture for pregnancy-related acute conditions, Acupuncture in Medicine, 36, 146–152, 2018 [PubMed: 29559431] | Systematic review. Included studies checked. No additional studies matching out protocol |
| Bertuit, J., Leyh, C., Feipel, V., Center of plantar pressure during gait in pregnancy-related pelvic girdle pain and the effect of pelvic belts, Acta of Bioengineering & Biomechanics, 20, 69–76, 2018 [PubMed: 30520454] | No outcomes of interest matching our protocol |
| Bhandiwad, A., Vaisravanath, S., Sujatha, M. S., Role of short term exercise intervention in pelvic girdle pain in pregnancy, Physiotherapy (United Kingdom), 1), eS147–eS148, 2015 | Conference abstract |
| Buchberger, B., Krabbe, L., Evaluation of outpatient acupuncture for relief of pregnancy-related conditions, International Journal of Gynecology and Obstetrics, 141, 151–158, 2018 [PubMed: 29355951] | Systematic review. Included studies checked. No additional studies matching out protocol |
| Butel, T., Nicolian, S., Durand, M., Filipovic-Pierucci, A., Kone, M., Gambotti, L., Mallet, A., Durand-Zaleski, I., Dommergues, M., Cost-effectiveness of acupuncture versus standard care for pelvic and low back pain in pregnancy: An analysis of the game randomized trial, Value in Health, 19 (7), A588, 2016 | Conference abstract |
| Cameron, L., Marsden, J., Watkins, K., Freeman, J., Management of antenatal pelvic-girdle pain study (MAPS): A single centred blinded randomised trial evaluating the effectiveness of two pelvic orthoses, Prosthetics and Orthotics International, 39, 447, 2015 | Conference abstract |
| Ceprnja, D., Gupta, A., Does muscle energy technique have an immediate benefit for women with pregnancy-related pelvic girdle pain?, Physiotherapy Research International, 24, e1746, 2019 [PubMed: 30209851] | Crossover study design |
| Clarkson, C., Korean hand acupuncture for pregnancy-related pelvic girdle pain: a feasibility study, Journal of Pelvic, Obstetric & Gynaecological Physiotherapy, 36–41, 2017 | Feasibility study - not looking at the outcomes specified in the protocol. |
| Close, C., Sinclair, M., Cullough, J. M., Liddle, D., Hughes, C., A pilot randomised controlled trial (RCT) investigating the effectiveness of reflexology for managing pregnancy low back and/or pelvic pain, Complementary therapies in clinical practice, 23, 117–124, 2016 [PubMed: 26021213] | Mixed sample <50% have pelvic pain (3% pelvic pain only; 44% pelvic and lower back pain; 53% lower back pain only) |
| Close, C., Sinclair, M., Liddle, S. D., Madden, E., McCullough, J. E., Hughes, C., A systematic review investigating the effectiveness of Complementary and Alternative Medicine (CAM) for the management of low back and/or pelvic pain (LBPP) in pregnancy, Journal of Advanced Nursing, 70, 1702–16, 2014 [PubMed: 24605910] | Systematic review. Included studies checked. No additional studies matching out protocol |
| Davenport, M. H., Marchand, A. A., Mottola, M. F., Poitras, V. J., Gray, C. E., Jaramillo Garcia, A., Barrowman, N., Sobierajski, F., James, M., Meah, V. L., Skow, R. J., Riske, L., Nuspl, M., Nagpal, T. S., Courbalay, A., Slater, L. G., Adamo, K. B., Davies, G. A., Barakat, R., Ruchat, S. M., Exercise for the prevention and treatment of low back, pelvic girdle and lumbopelvic pain during pregnancy: a systematic review and meta-analysis, British journal of sports medicine, 53, 90–98, 2019 [PubMed: 30337344] | Systematic review. Included studies checked. No additional studies matching our protocol. |
| Delshad, B., Zarean, E., Yeowell, G., Sadeghi-Demneh, E., The immediate effects of pelvic compression belt with a textured sacral pad on the sacroiliac function in pregnant women with lumbopelvic pain: A cross-over study, Musculoskeletal Science and Practice, (no pagination), 2020 [PubMed: 32560872] | Study design not a randomised controlled trial |
| Depledge, J., McNair, P. J., Keal-Smith, C., Williams, M., Management of symphysis pubis dysfunction during pregnancy using exercise and pelvic support belts, Physical therapy, 85, 1290–1300, 2005 [PubMed: 16305268] | No useful data reported |
| Ee, C. C., Manheimer, E., Pirotta, M. V., White, A. R., Acupuncture for pelvic and back pain in pregnancy: a systematic review, American Journal of Obstetrics and Gynecology, 198, 254–259, 2008 [PubMed: 18313444] | Systematic review. Included studies checked. No additional studies matching out protocol |
| Eggen,M.H., Stuge,B., Mowinckel,P., Jensen,K.S., Hagen,K.B., Can supervised group exercises including ergonomic advice reduce the prevalence and severity of low back pain and pelvic girdle pain in pregnancy? A randomized controlled trial, Physical Therapy, 92, 781–790, 2012 [PubMed: 22282770] | Study population does not meet protocol eligibility criteria - <50% women with pelvic girdle pain at baseline. |
| Ekdahl, L., Petersson, K., Acupuncture treatment of pregnant women with low back and pelvic pain--an intervention study, Scandinavian journal of caring sciences, 24, 175–182, 2010 [PubMed: 20102541] | No population of interest - Mixed sample including women with lower back pain, only 4 (10%) women with pelvic girdle pain. |
| Fisseha, B., Mishra, P. K., The effect of group training on pregnancy-induced lumbopelvic pain: systematic review and meta-analysis of randomized control trials, Journal of Exercise Rehabilitation, 12, 15–20, 2016 [PMC free article: PMC4771147] [PubMed: 26933655] | Systematic review - effective in improving lower back pain after pregnancy not during pregnancy. |
| Flack, N. A. M. S., Hay-Smith, E. J. C., Stringer, M. D., Gray, A. R., Woodley, S. J., Adherence, tolerance and effectiveness of two different pelvic support belts as a treatment for pregnancy-related symphyseal pain - A pilot randomized trial, BMC Pregnancy and Childbirth, 15 (1) (no pagination), 2015 [PMC free article: PMC4339641] [PubMed: 25885585] | No comparison of interest - Compares two different pelvic support belts |
| Fontana Carvalho, A. P., Dufresne, S. S., Rogerio de Oliveira, M., Couto Furlanetto, K., Dubois, M., Dallaire, M., Ngomo, S., da Silva, R. A., Effects of lumbar stabilization and muscular stretching on pain, disabilities, postural control and muscle activation in pregnant woman with low back pain, European journal of physical and rehabilitation medicine, 56, 297–306, 2020 [PubMed: 32072792] | Exclude on population. Low back pain only, not specific to pelvic girdle pain. |
| Franke, H., Franke, J. D., Belz, S., Fryer, G., Osteopathic manipulative treatment for low back and pelvic girdle pain during and after pregnancy: A systematic review and meta-analysis, Journal of Clinical Chiropractic Pediatrics, 17, 1468–1468, 2018 [PubMed: 29037623] | Journal Abstract |
| Franke, H., Franke, J. D., Belz, S., Fryer, G., Osteopathy in low back pain and pelvic girdle pain during and after pregnancy: Systematic review and meta-analysis, Osteopathische Medizin, 19, 11–19, 2018 | Non-English study |
| George, J. W., Skaggs, C. D., Thompson, P. A., Nelson, D. M., Gavard, J. A., Gross, G. A., A randomized controlled trial comparing a multimodal intervention and standard obstetrics care for low back and pelvic pain in pregnancy, American Journal of Obstetrics and Gynecology, 208, 295.e1–295.e7, 2013 [PubMed: 23123166] | No population of interest - Mixed sample including women with lower back pain, percentage of women with pelvic pain not reported. |
| Guerreiro da Silva, J. B., Nakamura, M. U., Cordeiro, J. A., Kulay, L., Jr., Acupuncture for low back pain in pregnancy--a prospective, quasi-randomised, controlled study, Acupunct MedAcupuncture in medicine : journal of the British Medical Acupuncture Society, 22, 60–7, 2004 [PubMed: 15253580] | Mixed sample includes women with back pain or pelvic pain, percentage of women with pelvic pain is not reported. |
| Gutke, A., Betten, C., Degerskar, K., Pousette, S., Fagevik Olsen, M., Treatments for pregnancy-related lumbopelvic pain: A systematic review of physiotherapy modalities, Acta Obstetricia et Gynecologica Scandinavica, 94, 1156–1167, 2015 [PubMed: 26018758] | Systematic review - 1 additional study not identified in search (Guerreiro da Silva 2004) but not of interest. |
| Gutke, A., Sjodahl, J., Oberg, B., Specific muscle stabilizing as home exercises for persistent pelvic girdle pain after pregnancy: A randomized, controlled clinical trial, Physiotherapy (United Kingdom), 1), eS440–eS441, 2011 [PubMed: 21031289] | No outcome of interest - outcomes assessed after delivery |
| Haakstad, L. A., Bo, K., Effect of a regular exercise programme on pelvic girdle and low back pain in previously inactive pregnant women: A randomized controlled trial, Journal of Rehabilitation MedicineJ Rehabil Med, 47, 229–234, 2015 [PubMed: 25385408] | Study population does not meet protocol eligibility criteria - <50% women with pelvic girdle pain. |
| Hall, H., Cramer, H., Sundberg, T., Ward, L., Adams, J., Moore, C., Sibbritt, D., Lauche, R., The effectiveness of complementary manual therapies for pregnancy-related back and pelvic pain A systematic review with meta-analysis, Medicine (United States), 95 (38) (no pagination), 2016 [PMC free article: PMC5044890] [PubMed: 27661020] | Systematic review. Included studies checked. No additional studies matching out protocol |
| Haugland, K. S., Rasmussen, S., Daltveit, A. K., Group intervention for women with pelvic girdle pain in pregnancy. A randomized controlled trial, Acta Obstetricia et Gynecologica Scandinavica, 85, 1320–1326, 2006 [PubMed: 17091411] | No outcome of interest - examines outcomes after pregnancy not during pregnancy. |
| Jiang, Q., Wu, Z., Zhou, L., Dunlop, J., Chen, P., Effects of Yoga Intervention during Pregnancy: A Review for Current Status, American Journal of Perinatology, 32, 503–514, 2015 [PubMed: 25535930] | Systematic review. Included studies checked. No additional studies matching out protocol |
| Jorge, C., Santos-Rocha, R., Bento, T., Can group exercise programs improve health outcomes in pregnant women? A systematic review, Current Women’s Health Reviews, 11, 75–87, 2015 | Systematic review. Included studies checked. No additional studies matching out protocol |
| Kalus, S. M., Kornman, L. H., Quinlivan, J. A., Managing back pain in pregnancy using a support garment: A randomised trial, BJOG: An International Journal of Obstetrics and Gynaecology, 115, 68–75, 2008 [PubMed: 17999695] | No population of interest - Mixed sample including women with lower back pain, percentage of women with pelvic pain not reported. |
| Kinser, P. A., Pauli, J., Jallo, N., Shall, M., Karst, K., Hoekstra, M., Starkweather, A., Physical Activity and Yoga-Based Approaches for Pregnancy-Related Low Back and Pelvic Pain, Journal of obstetric, gynecologic, and neonatal nursing : JOGNN, 46, 334–346, 2017 [PubMed: 28302455] | Systematic review. Included studies checked. No additional studies matching out protocol |
| Koch, W., Acupuncture and its use in the management of low back and, pelvic girdle pain in pregnancy, Journal of the acupuncture association of chartered physiotherapists, 37–47, 2008 | Literature review (not systematic) |
| Kuciel, N., Sutkowska, E., Cienska, A., Markowska, D., Wrzosek, Z., Myoelectrical activity of muscles stabilizing the sacroiliac joints before and after the use of elastic tapes in women suffering from Pregnancy-related Pelvic Girdle Pain, Ginekologia PolskaGinekol Pol, 91, 223–230, 2020 [PubMed: 32374023] | This is a non-randomised study. As there is randomised controlled trial data available this study is excluded. |
| Kvorning,N., Holmberg,C., Grennert,L., Aberg,A., Akeson,J., Acupuncture relieves pelvic and low-back pain in late pregnancy, Acta Obstetricia et Gynecologica Scandinavica, 83, 246–250, 2004 [PubMed: 14995919] | Mixed sample includes women with back pain and pelvic pain, percentage of women with pelvic pain was not reported. |
| Liddle, S. D., Pennick, V., A systematic review of interventions for preventing and treating low-back and/or pelvic pain during pregnancy, European Spine Journal, 1), S128, 2014 | Conference abstract |
| Liddle, S. D., Pennick, V., Interventions for preventing and treating low–back and pelvic pain during pregnancy, Cochrane Database of Systematic Reviews, 2015 [PMC free article: PMC7053516] [PubMed: 26422811] | Systematic review - 3 studies not included in search (Elden 2005; Kvoring 2004; Wedenberg 2000). Elden 2005 and Wedenberg 2000 included in the review, whilst Kvoring 2004 does not match criteria set out in the protocol. |
| Lillios, S., Young, J., The effects of core and lower extremity strengthening on pregnancy-related low back and pelvic girdle pain: a systematic review, Journal of Women’s Health Physical Therapy, 36, 116–124, 2012 | Systematic review. Included studies checked. No additional studies matching our protocol. |
| Lund, I., Lundeberg, T., Lonnberg, L., Svensson, E., Decrease of pregnant women’s pelvic pain after acupuncture: A randomized controlled single-blind study, Acta Obstetricia et Gynecologica Scandinavica, 85, 12–19, 2006 [PubMed: 16521674] | No comparison of interest - compares two type of acupuncture. |
| Martins, R. F., Pinto, E. Silva J. L., Treatment of pregnancy-related lumbar and pelvic girdle pain by the yoga method: A randomized controlled study, Journal of Alternative and Complementary Medicine, 20, 24–31, 2014 [PubMed: 23506189] | No intervention of interest - yoga |
| Melkersson, C., Nasic, S., Starzmann, K., Bengtsson Boström, K., Effect of Foot Manipulation on Pregnancy-Related Pelvic Girdle Pain: A Feasibility Study, Journal of Clinical Chiropractic Pediatrics, 17, 1470–1470, 2018 [PMC free article: PMC5659811] [PubMed: 29097951] | Journal abstract |
| Miquelutti, M. A., Cecatti, J. G., Makuch, M. Y., Evaluation of a birth preparation program on lumbopelvic pain, urinary incontinence, anxiety and exercise: a randomized controlled trial, BMC Pregnancy & Childbirth, 13, 154, 2013 [PMC free article: PMC3750492] [PubMed: 23895188] | No population of interest - includes all pregnant women with or without pelvic girdle pain |
| Monaghan, C., Haywood, A., Pelvic girdle pain - part 1: quantitative results from a mixed-methods service evaluation introducing a manual therapy treatment approach to usual care, Journal of Pelvic, Obstetric & Gynaecological Physiotherapy, 47–55, 2016 | As there is randomised controlled trial data available, this study has been excluded. |
| Morkved, S., Salvesen, K. A., Schei, B., Lydersen, S., Bo, K., Does group training during pregnancy prevent lumbopelvic pain? A randomized clinical trial, Acta Obstetricia et Gynecologica Scandinavica, 86, 276–82, 2007 [PubMed: 17364300] | Study does not meet protocol eligibility criteria - Prevention of lumbopelvic pain - 43% had low back and/or pelvic girdle pain at baseline (unclear what proportion with pelvic pain). |
|
Nct,, Effects of Specific Pelvic Stabilization Exercise With Transabdominal Ultrasonography-guided Biofeedback in Postpartum Women Suffering From Pregnancy-related Pelvic Girdle Pain, https: | Clinical trial entry, full results not published however intervention does not meet the interventions specified in the protocol. |
|
Nct,, Foot Manipulation for Pregnancy Related Pelvic Girdle Pain, Https: | Clinical trial record |
|
Nct,, Laser Acupuncture and Acupressure for Low Back Pain, https: | Clinical trial entry, full results not published however, population is not specific to pelvic girdle pain. |
|
Nct,, Pelvic Girdle Pain in a Pregnant Population in Western Norway, Https: | Clinical trial record |
|
Nct,, Ultrasound Guided Posterior Sacroiliac Ligament Corticosteroid Injection in Pregnancy-Related Pelvic Girdle Pain, Https: | Clinical trial record |
|
Nct,, Trial for the Treatment of Pelvic and Back Pain in Pregnancy, Https: | Clinical trial record |
|
Nct,, The Effects of a Water Based Exercise Programme and a Land Based Exercise Programme on Women Experiencing Pregnancy Related Pelvic Girdle Pain, Https: | Clinical trial record |
| Oduola, O., McDonagh, T., O’Leary, M., Pelvic Girdle Pain Survey in Pregnancy: A Maternity Hospital Experience, Irish Medical Journal, 111, 1–2, 2018 [PubMed: 30556677] | Study design not a randomised controlled trial. |
| Ostgaard, H. C., Zetherstrom, G., Roos-Hansson, E., Svanberg, B., Reduction of back and posterior pelvic pain in pregnancy, Spine, 19, 894–900, 1994 [PubMed: 8009346] | Study does not meet protocol eligibility criteria - unclear proportion of women with pelvic pain only; no useable outcome data. |
| Ozdemir, S., Bebis, H., Ortabag, T., Acikel, C., Evaluation of the efficacy of an exercise program for pregnant women with low back and pelvic pain: a prospective randomized controlled trial, Journal of advanced nursing, 71, 1926–1939, 2015 [PubMed: 25823561] | Study population does not meet protocol eligibility criteria - women with low back and pelvic pain. |
| Peng, Yueh-Chu, Chou, Fan-Hao, Different Exercise Intensities for Relieving Lumbopelvic Pain in Pregnant Women, Journal for Nurse Practitioners, 15, 249–249, 2019 | Systematic review. Included studies checked. No additional studies matching our protocol. |
| Peters, R., van der Linde, M., Osteopathic treatment of women with back pain during pregnancy. A randomised controlled study, Osteopathische Medizin, 8, 26, 2007 | Non-English study |
| Peterson, C. K., Muhlemann, D., Humphreys, B. K., Outcomes of pregnant patients with low back pain undergoing chiropractic treatment: A prospective cohort study with short term, medium term and 1 year follow-up, Chiropractic and Manual Therapies, 22 (1) (no pagination), 2014 [PMC free article: PMC3994225] [PubMed: 24690125] | As there is randomised controlled trial data available, this study has been excluded. |
| Quintero Rodriguez, C., Troynikov, O., The Effect of Maternity Support Garments on Alleviation of Pains and Discomforts during Pregnancy: A Systematic Review, Journal of PregnancyJ Pregnancy, 2019, 2163790, 2019 [PMC free article: PMC6699320] [PubMed: 31467715] | Systematic review. Included studies checked. No additional studies matching our protocol. |
| Ribnikar, N., Scepanovic, D., Verdenik, I., Zgur, L., Effect of pelvic belt and physiotherapy advice on pain in pregnant women with pelvic girdle pain, Physiotherapy (United Kingdom), 1), eS1306–eS1307, 2015 | Conference abstract |
| Richards, E., Van Kessel, G., Virgara, R., Harris, P., Does antenatal physical therapy for pregnant women with low back pain or pelvic pain improve functional outcomes? A systematic review, Acta Obstetricia et Gynecologica Scandinavica, 91, 1038–1045, 2012 [PubMed: 22583125] | Systematic review. Included studies checked. No additional studies matching out protocol. |
| Rodrigues, P., Yamada, E., Simmer, C., Santos, K., Rangel, K., Prudente, L., Efficacy of therapeutic exercises and superficial heat in the posterior lumbar pelvic pain during pregnancy, Physiotherapy (United Kingdom), 97, eS1050–eS1051, 2011 | No comparator of interest |
| Schiff Boissonnault, J., Klestinski, J. U., Pearcy,, The role of exercise in the management of pelvic girdle and low back pain in pregnancy: a systematic review of the literature, Journal of Women’s Health Physical Therapy, 36, 69–77, 2012 | Systematic review. Included studies checked. No additional studies matching our protocol. |
| Shafiee, M., Rostami, M., Comparison between the effect of lumbopelvic belt and home based pelvic stabilizing exercise on pregnant women with pelvic girdle pain; A randomized controlled trial, European Journal of Medical Research, 1), 35, 2011 [PubMed: 23640314] | Conference abstract |
| Shiri, R., Coggon, D., Falah-Hassani, K., Exercise for the prevention of low back and pelvic girdle pain in pregnancy: A meta-analysis of randomized controlled trials, European Journal of Pain (United Kingdom), 22, 19–27, 2018 [PubMed: 28869318] | Systematic review on prevention of pregnancy related pain - no additional relevant studies matching our protocol |
| Sklempe Kokic, I., Ivanisevic, M., Uremovic, M., Kokic, T., Pisot, R., Simunic, B., Effect of therapeutic exercises on pregnancy-related low back pain and pelvic girdle pain: Secondary analysis of a randomized controlled trial, Journal of Rehabilitation MedicineJ Rehabil Med, 49, 251–257, 2017 [PubMed: 28233012] | Study does not meet protocol eligibility criteria - Approximately 50% women had pre-pregnancy lumbopelvic pain; not clear how many had pelvic girdle pain - mix of women with low back and pelvic pain; outcome - occurrence of lumbopelvic pain. |
| Stafne, S. N., Salvesen, K. A., Romundstad, P. R., Stuge, B., Morkved, S., Does regular exercise during pregnancy influence lumbopelvic pain? A randomized controlled trial, Acta Obstetricia et Gynecologica Scandinavica, 91, 552–559, 2012 [PubMed: 22364387] | Study population does not meet protocol eligibility criteria - <50% women with lower back pain at baseline. |
| Upadhyay, K., Hoare, Z., Gholkar, N., A randomised controlled pilot analysis to assess a new flexible pelvic harness (harness gravidarum) for management of pelvic girdle pain in pregnancy, BJOG: An International Journal of Obstetrics and Gynaecology, 126 (Supplement 2), 167–168, 2019 | Conference abstract |
| van Benten, E., Pool, J., Mens, J., Pool-Goudzwaard, A., Recommendations for physical therapists on the treatment of lumbopelvic pain during pregnancy: a systematic review, Journal of Orthopaedic & Sports Physical TherapyJ Orthop Sports Phys Ther, 44, 464–73, A1–15, 2014 [PubMed: 24816503] | Systematic review. Included studies checked. No additional studies matching out protocol |
| Vas, J., Cintado, M. C., Aranda-Regules, J. M., Aguilar, I., Rivas Ruiz, F., Effect of ear acupuncture on pregnancy-related pain in the lower back and posterior pelvic girdle: A multicenter randomized clinical trial, Acta Obstetricia et Gynecologica Scandinavica, 98, 1307–1317, 2019 [PubMed: 31034580] | Less than 50% of sample have pelvic pain |
| Vesentini, G., Prior, J., Ferreira, P. H., Hodges, P. W., Rudge, M., Ferreira, M. L., Pelvic floor muscle training for women with lumbopelvic pain: a systematic review and meta-analysis, European journal of pain, 31, 2020 [PubMed: 32735717] | Systematic review. Included studies checked. No additional studies matching out protocol |
| Wang, S. M., DeZinno, P., Lin, E. C., Lin, H., Yue, J. J., Berman, M. R., Braveman, F., Kain, Z. N., Auricular acupuncture as a treatment for pregnant women who have low back and posterior pelvic pain: a pilot study, American Journal of Obstetrics and Gynecology, 201, 271.e1–271.e9, 2009 [PMC free article: PMC2768290] [PubMed: 19560110] | Mixed sample <50% have pelvic pain (36% posterior pelvic pain only; 8% posterior pelvic pain lower back pain; 56% lower back pain only). |
| Wang, S. M., Lin, E., Braveman, F., Kain, Z., Auricular acupuncture as a treatment for posterior pelvic pain during pregnancy: a RCT, AnesthesiologyAnesthesiology, 107, Abstract no: A277, 2007 | Conference abstract |
| Wuytack, F., O’Donovan, M., Outcomes and outcomes measurements used in intervention studies of pelvic girdle pain and lumbopelvic pain: A systematic review, Chiropractic and Manual Therapies, 27, 2019 [PMC free article: PMC6829811] [PubMed: 31700607] | Systematic review. Included studies checked. No additional studies matching our protocol. |
Economic studies
A single economic search was undertaken for all topics included in the scope of this guideline. No economic studies were identified which were applicable to this review question. See supplementary material 2 for details.
Appendix L. Research recommendations
Research recommendations for review question: What interventions are effective in treating mild to moderate pelvic girdle pain during pregnancy
No research recommendations were made for this review question.
Appendix M. Additional studies in update searches
Table 36. Summary of studies identified but not extracted (PDF, 112K)
Final
Evidence reviews underpinning recommendation 1.4.15
These evidence reviews were developed by the National Guideline Alliance which is a part of the Royal College of Obstetricians and Gynaecologists
Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.
NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.
- Adaptation to a changed body. Experiences of living with long-term pelvic girdle pain after childbirth.[Disabil Rehabil. 2018]Adaptation to a changed body. Experiences of living with long-term pelvic girdle pain after childbirth.Gutke A, Bullington J, Lund M, Lundberg M. Disabil Rehabil. 2018 Dec; 40(25):3054-3060. Epub 2017 Aug 23.
- Pregnancy and pelvic girdle pain: Analysis of pelvic belt on pain.[J Clin Nurs. 2018]Pregnancy and pelvic girdle pain: Analysis of pelvic belt on pain.Bertuit J, Van Lint CE, Rooze M, Feipel V. J Clin Nurs. 2018 Jan; 27(1-2):e129-e137. Epub 2017 Nov 3.
- Physical exercise and pelvic girdle pain in pregnancy: A nested case-control study within the Danish National Birth Cohort.[Sex Reprod Healthc. 2015]Physical exercise and pelvic girdle pain in pregnancy: A nested case-control study within the Danish National Birth Cohort.Andersen LK, Backhausen M, Hegaard HK, Juhl M. Sex Reprod Healthc. 2015 Dec; 6(4):198-203. Epub 2015 Apr 24.
- Review Women's experiences of pregnancy related pelvic girdle pain: A systematic review.[Midwifery. 2018]Review Women's experiences of pregnancy related pelvic girdle pain: A systematic review.Mackenzie J, Murray E, Lusher J. Midwifery. 2018 Jan; 56:102-111. Epub 2017 Oct 16.
- Review Musculoskeletal symptoms and orthopaedic complications in pregnancy: pathophysiology, diagnostic approaches and modern management.[Postgrad Med J. 2014]Review Musculoskeletal symptoms and orthopaedic complications in pregnancy: pathophysiology, diagnostic approaches and modern management.Bhardwaj A, Nagandla K. Postgrad Med J. 2014 Aug; 90(1066):450-60. Epub 2014 Jun 5.
- Management of pelvic girdle pain in pregnancyManagement of pelvic girdle pain in pregnancy
- LOC120902144 [Anopheles arabiensis]LOC120902144 [Anopheles arabiensis]Gene ID:120902144Gene
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