Differential Diagnosis of Peri-partum Pubic Symphysis Separation

Transcription

8/21/2014
OBJECTIVES
DIFFERENTIAL DIAGNOSIS
AND MANAGEMENT OF
PUBIC SYMPHYSIS
DYSFUNCTION IN THE
OBSTETRIC CLIENT
Jill Schif f
Boissonnault
PT, PhD, WCS
By the end of this session the attendee will:
1 . Understand and apply to patient care the
pathophysiology of peripartum pubic symphysis
dysfunction
2. Select treatment interventions for the abovementioned musculoskeletal dysfunction in the pregnant
and postpartum client .
3. Consider appropriate home programs for clients with
such musculoskeletal dysfunction.
4. Appreciate current evidence for the interventions the
participants discuss.
CONTENT
Anatomy review and differential diagnosis of
PSD in the perinatal period
Case of “Pubic Instability” or Pelvic Girdle
Pain in pregnancy
Case of Peripartum pubic symphysis
separation
Considerations for labor and delivery for the
woman with PSD
PATHOLOGY DURING THE CHILDBEARING
YEAR
PUBIC SYMPHYSIS
 Joined by a
fibrocartilaginous disc;
fibrocartilaginous
amphiarthroiss jt.
Lined with hyaline
cartilege.
 Supported superiorly
and inferiorly by
ligaments
 Motion occurs in
sagital and frontal
planes
PERI-PARTUM SEPARATED SYMPHYSIS
PUBIS (OR SYMPHYSOLYSIS OR DIASTASIS
SYMPHYSIS PUBIS)
Pathology includes
Separation
Instability with potential
‘unleveling’
Osteitis pubis
www.e-radiography.net
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EPIDEMIOLOGY/PATHOPHYSIOLOGY OF
PERI-PARTUM PUBIC SYMPHYSIS
SEPARATION
DEFINITION AND PHYSIOLOGY
Frank separation is considered 10 mm or >
Pain does not seem to coincide with the
degree of separation
Some mild separation (not necessarily
painful) is considered normal in pregnancy
and during contractions ( Boland 1933,
Bjorklund 1997)
Can occur during pregnancy or postpartum
 Separation related to delivery seems most common, though
stats are unknown
EPIDEMIOLOGY/PATHOPHYSIOLOGY OF
SEPARATION, CONT.
Pathology to the pubic symphysis may be the
norm or quite common
Bone marrow edema (76-86% in Hermann
study)
Fx (27% in Brandon study)
Capsular dysruption (rare)
Separation (rare)
Levator ani tears at the symphysis (common)
(Bra nd on 2012, Herm a nn 2007, Wu rd inger 2002 )
 Prevalence: about 1/600 (range1/30 -1/30,000!)
(Bolland 1933, Cappiello 1995, Snow, 1997, Dunivan 2009)
 Peri-partum vs. pre-natal incidence-Unknown, but
literature discusses MOI related to delivery
 Theoretical MOI
 Fetal size
 Maternal Position
 Stiffness of pubic connective tissue
 Rapid fetal descent
(Snow 1997)
MEDICAL MANAGEMENT OF PERI-PARTUM
PUBIC SYMPHYSIS SEPARATION
 Pain management strategies
 Post-partum pain medication
 Referral to PT
 Imaging (Scr i ven ,




 Surgical stabilization-internal or external
( Lu g er 1 9 9 5 , D u n i va n
2 0 0 9, O s terh of f 2 01 2 )
 Injections ( S c h w a r t z, 1 9 8 5)
 Spinal cord Stimulator -1 Case
COMMON SYMPTOM PRESENTATION
Patient Interview Findings
 Aggravation:
 Transitional movements
 Bed mobility
 Hip abduction
 Alleviation
 Rest, Ice, Pain Relievers, Support belt, avoidance of
weight shift (rolling walker)
 Pain: Intense
 Location at pubis with radiation into thighs, groin,
perineum
1995)
CT
MRI
US
Radiograph
(Id r ees 2 01 2 )
PUBIC SHEARS
quizlet.com
 Frontal Plane Movement
that goes beyond physiologic
expectations
 Superior of Inferior Shears
www.docstoc.com
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COMMON SYMPTOM PRESENTATIONSHEARS
Patient Interview Findings
 Aggravation:
 Transitional movements
 Bed mobility
 Alleviation
 Rest, Ice, Pain Relievers, Support belt, avoidance of
weight shift
 Pain: Not as intense as with a separation
 Location at pubis with radiation into thighs, groin,
perineum
OSTEITIS PUBIS, SIGNS AND SYMPTOMS
OSTEITIS
PUBIS
• Painful, non infectious
inflammatory
condition of the
pubic bone and
symphysis
• Etiology: most
likely periosteal
trauma is initiating
factor
• Seen in athletes
and postpartum
women and after
urogynecological
surgical procedures
www.radpod.org
DIFFERENTIAL DIAGNOSIS OF PERI-PARTUM
GROIN PAIN
 Present with:
• Pain
• “Waddling” gait
• May be accompanied with low grade fever, elevated sed rate,
and mild leukocytosis
 Radiographic findings
• Reactive Sclerosis
• Rarefaction
• Osteolytic changes
ANATOMICAL CONSIDERATIONS
 SI joint
 Illium/Ischium
 Pubic Symphysis
 Low lumbar spine
 Hip
 Ligaments and
discs
 Musculature of the
region
Consider osseous, joint and
soft-tissues in the region
&
Obstetric Complications
Ouch!
SACROILIAC JOINT DYSFUNCTION AS A
SOURCE OF PERI-PARTUM PUBIC/GROIN PAIN
The sacral-iliac joint
can refer pain into
the groin and hip
Positional
dysfunction there
can disrupt the
normal anatomical
structure of the
pubic symphysis
en.wikipedia.org
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ILIUM AS A SOURCE OF SYMPTOMS
LUMBAR SPINE AND DISC AS A SOURCE OF
SYMPTOMS
Upper lumbar
spine pathology
as pain referral
or radicular
symptoms into
the groin
Positional
pathology (Ilial
rotations, upslips,
downslips)
www.eorthopod.com
www.medscape.org
HIP AS A SOURCE OF SYMPTOMS
OA of the hip
Labral tears
Bone Density Issues
Stress Fx
Bursitis
Femoral Acetabular
impingement
OTHER POTENTIAL OBSTETRIC SOURCES OF
SX
Abruption of the placenta
Round ligament pain
Transient Osteoporosis of the Hip
in Pregnancy/Post-Partum
PUBIC SYMPHYSIS PATHOLOGY
Separated Symphysis Pubis
Pubic Shear or unleveling of the
pubis 2 ◦ hormonally mediated joint
instability
Osteitis Pubis
ABRUPTION OF THE PLACENTA
• Definition: plac enta peels
away from the inner wall of
the uterus before deliv er y —
either par tially or c ompletely
— it's known as plac ental
abruption
• Symptoms:
• Vaginal bleeding
• Abdominal/groin pain
• Back pain
• Uterine tenderness
• Rapid uterine contractions,
often coming one right after
another
www.moondragon.org
http://www.mayoclinic.com/health/placentalabruption
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ROUND LIGAMENT PAIN
TRANSIENT OSTEOPOROSIS OF THE HIP
(TOH) IN PREGNANCY/POSTPARTUM
• Round ligament pain is
sharp or jabbing, often
felt in the lower belly or
groin area on one or both
sides.
• Intermittent in nature
• considered a normal part
of pregnancy
• Exercise may cause the
pain, as will rapid
movements
• Round ligament has
contractile tissue running
through it; allows for
“rebound”
• Self-limiting nature and
spontaneous rec ov ery
• Frac tures are infrequent
• True inc idenc e during
pregnancy is unknown
• Onset: Generally in 3rd
trimester
• TOH Pain loc ale: i nguinal or
greater troc hanteric regions
with referral to a n terior t high .
• ROM: limited at the hip
• Func tionally restricted weight
bearing

(Boi sson n a ult, 2001)
tummytime.onslow.org
TRIGGER POINTS
MUSCLE PATHOLOGY AS A
SOURCE OF SYMPTOMS
ILIUM, ISCHIUM AND MUSCULAR
INFLUENCES
 Adductors
 Iliopsoas
 Abdominal obliques
AND, CANNOT FORGET THE PELVIC FLOOR AS
A PAIN GENERATOR!
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PERFORM A LOWER QUARTER SCREENING
EXAM WITH SOME SPECIAL TESTS
 Perform assessment in positions that the pt. can
tolerate (commonly supine only, if pp)
 Goal of R/O structures above and below the CC (i.e.,
pubis)
 Clear L-S, SI jts, Hips, Ilia
 Use pt. report to R/O abruption, round ligament
 Assess for muscle pathology if Hx and Physical Exam
lead you that way
 Perform an internal assessment of PF if needed
SPECIAL TESTS AT THE PUBIC SYMPHYSIS
 Physical Exam
(Mens 2012): Research shows it to be better to detect
SI-jt pain, but can be sensitive to this
 Palpation of symphysis (Vleeming 2008, Albert2001, 2002)
 Modified Trendelenburg (Vleeming 2008, Albert2001 , 2002)
 ASLR
As a provocation
test
PATELLAR PUBIC PERCUSSION TEST
TO R/O STRESS FX, BONE DENSIT Y ISSUES
Clearing the Sacrum
Includes
Springing the
Sacrum in Sitting,
P4 test supine
AFTER CONSIDERATION/ASSESSMENT OF
VARIOUS PAIN GENERATORS; SETTLING ON
PUBIC SYMPHYSIS
Pt. Hx and possible MOI lead you there
R/O all other potential sources of Sx
Springing the pubis or palpation there very
tender
Trendellenburg painful
Bed mobility painful
Hip Abduction painful at Pubis
ASLR may be painful
May be unable to weight bear
DETERMINATION OF SEPARATION VS. SHEAR
Palpatory assymmetry absent
Attempt to “level out” pubis makes no
change
Essentially a “Rule-Out” Dx
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CASE 1: PUBIC INSTABILIT Y IN PREGNANCY;
PART OF PELVIC GIRDLE PAIN IN
PREGNANCY
EPIDEMIOLOGY OF PELVIC GIRDLE PAIN IN
PREGNANCY
1460 women who formed incidence cohor t, assessed at 33 wks
gestation
 1 . Women who repor ted daily pain that could be objectively
confirmed was 20.1 %
 Sub-grouped as follows:





Pelvic girdle syndrome (pain in all 3 joints) (6.0%)
Symphysioloysis (2.3%)
One-sided a sacroiliac syndrome (5.5%)
Double-sided sacroiliac syndrome (6.3%)
Misc (sx not objectively confirmed)
(Albert, 2002)
 Parity ↑ Odds Ratio of having PGP in pregnancy
(Bjelland , 2010)
www.aylesburyosteopath.co.uk
PROGNOSIS FOR OBSTETRIC PELVIC GIRDLE
PAIN
(Albert et al, 2001 )
 Cohort of 1789 women initially assessed at 33 wks
 These women were re -examined (questionnaire and physical
exam) at regular
 intervals for 2 years after delivery or until sx disappeared
 At 2 yr postpartum, 21% with pelvic girdle syndrome (pain in
all 3 joints) still had pain
 Indicators of highest relative risk for long term pain
 High number of positive tests
 Low mobility index
MEDICAL MANAGEMENT OF PELVIC GIRDLE
PAIN IN PREGNANCY’
Pain Medications
Belts and Supports-off the
shelf type
Referral to PT
 Conclusion: women with pelvic girdle syndrome or pain in all 3
joints, had poorest prognosis
PATIENT HX/INTERVIEW - PGP IN
PREGNANCY
 Typical order of difficult ADLs for severe PGP listing most to
least:





standing still,
cycling,
walking,
sitting,
and lying
( R o n ch ett i, 2 0 0 8)
Pelvic Girdle Pain Questionnaire: Selfreported questionnaire that is condition specific for PGP
utilizing 2 scales (activities/participation and symptoms);
highly reliable and valid in women with PGP during and after
pregnancy
(St u ge, 2 01 1 )
PHYSICAL EXAM ASSESSMENT- PGP
IN PREGNANCY
:
Ronchetti, 2008
 P4 (Posterior pelvic
pain provocation test)
 ASLR
 Long dorsal ligament
tests
 Quebec Back Pain
Disability Scale)
European Guidelines for
PGP
 SIJ Pain :
 P4/thigh thrust
 Patrick’s Faber test,
 Palpation of the long dorsal
SIJ ligament,
 Gaenslen´s test.
 S ymphysis
 Palpation of the symphysis
 Modified Trendelenburg test
of the pelvic girdle
 Functional pelvic test Active
straight leg raise test
(V leeming, 2 0 0 8 )
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EBP FOR PT INTERVENTIONS- PGP/PUBIC
SHEAR IN PREGNANCY
EXERCISE FOR THE PGP/PUBIC SHEAR
CASE
Contraction of TRa ↓ laxity of SI-jt;
drawing-in maneuver  ↓ laxity of SI-jt
(Richardson, 2002)
Systematic Reviews support use of
exercise for treatment or prevention of
PGP either alone or in combination with
acupuncture, advice and/or belts
(Boissonnault 2012, Stuge 2003)
 Isolated activation of deep, local muscle system with
integration into all transitional movements: abdominal
drawing-in
 Spine stabilization exercises in various positions: sidelying,
quadruped, Upright kneel
 Functional Lower extremity strengthening with equal bilateral weight bearing: E.G., sit to stand, Rising and
lowering to half-kneel
 Trunk/Pelvic girdle strengthening: anterior-posterior tilting
standing, gluteus maximus, gluteus medius, back extensors
 Fitness advice: which activities or machines?
EDUCATION FOR PGP/PUBIC SHEAR CASE
ADVICE FOR PGP/PUBIC SHEAR CASE
To ↓ catastrophizing and fear beliefs
use of FABQ and other self-administered
questionnaires can provide evidence for
the intervention
To empower self-management of the
condition
MANUAL THERAPY OPTIONS FOR
PGP/PUBIC SHEAR CASE
Muscle Energy Rx
Direct Jt-mob to Sacral bases, ILAs
STM about posterior pelvis
(Murphy 2009, Licciardone 2010, George
2012)
 Postural alignment
 Body mechanics
 sleeping positions
 ADLs (e.g., laundry, grocery-shopping)
 Symmetrical movement
 Sit-to-stand
 Bed mobility
 Isometric use of Adductors or Abductors in
transitional activities (rolling, shifting)
 Use of heat/ice (ice, especially over symphysis
pubis)
BELTS/SUPPORTS AND GAIT AIDS
Support garments for Pelvic Girdle Pain: some
evidence for use
(Carr 2003, Mens 2006 , Ho 2009)
Consider assistive gait aid if gait continues to
be aggravating
Forearm crutches
Rolling walker
scooter
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THE CASE
 30 yr old Gravida 2, para 1, @ 14 weeks gestation.
Has a 3-yr old dtr., and is a University professor
 CC: pubic pain with occasional Left and Right SI-jt
pain
 Hx of CC: Began @ 8 weeks and has worsened. Has
similar pain (less intense) in first pregnancy that
abated between pregnancies.
 Pt. Goals: To continue working and exercising as
she does now.
FINDINGS OF PT. INTERVIEW: PGP/PUBIC
SHEAR
 Rates pain 2/10 -7/10
 Location: “my groin, my left upper thigh and buttock and
sometimes after a really long day with lots of time on my feet
my left rear-end dimple and sometimes the same place on the
right”
 Nature: Can be sharp (intermittent) or achey (can be constant
once it comes on).
 A gg: climbing hill from parking ramp to office, rolling over in
bed, walking > 10 min, sit -to-stand after sitting > 45 min
 Alev: NWB rest, ice, Tylenol
PHYSICAL EXAM FINDINGS IN
PGP/PUBIC SHEAR CASE
 Gait: antalgic and waddling a bit
 Standing posture: unremarkable
 Position testing in sitting: a superior left pubic
shear & Left on Left Sacral torsion
 Palpation: painful over pubis. Painful also at Left
and Right SI jts over sacral sulci; Left dorsal
ligament painful
 ASLR and P4 + on the left; weight shift onto L LE
provokes sharp groin pain and a duller, L -sided
posterior pain
Pubis Palpation
(or Springing)
for Tenderness
PT INTERVENTIONS FOR PGP/PUBIC
SHEAR CASE
Asymmetric
Straight Leg
Raise Test-In
this Case, for
Trunk
Instability
 MET to correct pubic shear
and sacral torsion; Direct
mobilization in sitting @
Left ILA
 Exercise
 Stabilization: trunk ex in 4
point
 Strengthening ex: standing
pelvic tilts, TRa in 4-point
& sitting, glut medius
strengthening with
theraband, glut max
strengthening in 4-point
 Body mechanics instruction
 Sleep: get soft mattress pad
and squeeze pillow between
legs to roll and shift
 Lifting 3-yr old
 Postural alignment
 Sleep with pillow between
knees and avoid
assymmetric sleeping
postures
 Sitting @ desk: avoid
crossing LE’s; got her a foot
rest and a work chair back
support
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MET: SUPERIOR PUBIC SHEAR CORRECTION
ASSESSMENT OF SACRAL BASE POSITION
IN SITTING
Greenman, PE. Principles of Manual Medicine
ASSESSMENT OF SACRAL BASE POSITION IN
4-POINT
MET: FORWARD SACRAL TORSION
CORRECTION
DIRECT MOBILIZATION IN SITTING FOR A
‘R ON R’ FORWARD SACRAL TORSION
PT INTERVENTIONS FOR PGP/PUBIC SHEAR
CASE, CONT.
 Symmetrical movement
instruction
 Sit-to-stand: symmetry
and/or with isometric
adduction or abduction
 Ice to SI-jts and/or pubis
at home, prn
 SI-belt: Found it helpful if
doing chores requiring
WB > 15 min. Preferred
Serola Belt (Serola.net)
 Discussed fitness
program:
 encouraged her to move
to aqua class/exercise
vs. land-based running
and zumba classes.
 Self-mobilization for
pubic shear (supine)
and SI-Jt pain (seated
and standing)
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SELF-MOBILIZATION OF A RIGHT SUPERIOR
PUBIC SHEAR (ALSO OF A POSTERIORLY
ROTATED RIGHT ILIUM)
SelfMobilization
Of Pubis in
Sitting
SELF MOBILIZATION OF THE SACRUM
PELVIC STABILIZATION VIA ADDUCTOR
SQUEEZE TO ASSIST IN ↓ PAIN WITH ROLLING
ROLLING WITH ISOMETRIC HIP ABDUCTION
SUPPORT BELT FOR PGP
IEM Maternity Sacroilic (SI) Support
iemortho.com
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CASE 2: SEPARATED SYMPHYSIS PUBIS (OR
SYMPHYSOLYSIS OR DIASTASIS SYMPHYSIS
PUBIS) DURING DELIVERY
THE CASE
 28 yr old Gr 1 para 1, 26
hours postpartum, S/P
vaginal delivery. Pt is a
hospital RN
 CC: excruciating pubic
and groin pain, 9-10/10
 Hx of CC: Pain began pp
when pt attempted to
stand to use toilet.
Unsuccessful. Was
catheterized and put on
bedrest. PT referral
initialized by nursing
staff
 In 2 nd stage, spouse
reported hearing a gunshot-like pop as pt. pulled
forward on squat bar
while she was in semireclining & instructed to
put feet on squat bar
 MD ordered radiograph: 3
cm separation seen
 Past Hx: no previous c/o
pubic pain in pregnancy
or prior to pregnancy
 Pt lives with spouse in a
two-story home
www.e-radiography.net
PATIENT INTERVIEW FINDINGS- MEDICAL
MANAGEMENT OF PERI-PARTUM PUBIC
SYMPHYSIS SEPARATION
PHYSICAL EXAM FINDINGS - SEPARATED
SYMPHYSIS PUBIS DURING DELIVERY
 Pain Location: at Pubis and up into groin bilaterally
with some ache in Left SI-jt
 Nature: Sharp
 Agg: Any bed mobility or attempt at WB or to move
legs
 Alev: lying still, pain meds
 Pt. Goals: able to return home, use stairs, care for
newborn, perform IADLs, RT W in 6 weeks as RN.
Pain management.
 Movement Assessment: Pt. could not roll, scoot or shift
in bed without pain > 6/10
 Posture: WB unsuccessful without trochanteric belt
 Mobility: with rolling walker and belt Pt. able to
ambulate for short distances with <4/10 pain
 Palpation: exquisite pain at pubis -could not assess
position
 Did not attempt additional physical assessment
IN-HOSPITAL PT INTERVENTIONS - SEPARATED
OP PT PHYSICAL EXAM FINDINGS - SEPARATED
 Gait: Rolling walker (parameters given); stairs -none if
possible; if necessary, consider going up and down on bottom
or at least foot -to-foot.
 Pelvic support belt (parameters given)
 Bed mobility training (log roll, use of adductor squeeze -gentlewith pillow)
 Soft mattress pad
 Discussion on activity level:
 Palpation:
 Left inferior sacral shear
 Left superior pube
 Tenderness still at pubis and at left SI-Jt
 Pain with weight shift in standing
 ASLR +
 Did not attempt P4
 Some fear avoidance (not formally assessed)
(Waddell 1993)
 With spouse present
 Minimize WB; baby brought to her; no IADLs
 3 weeks need for assistance
 Appt. made for 6 wk FU in PT
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OP PT INTERVENTIONS- SEPARATED
 MET to correct pubic shear
 MET to correct sacral shear
 Self-mobilization for pubis and sacrum
 HEP for Pelvic stabilization exercises
 Seated
 Standing on step
 Glut, abdominal and back extensor strengthening
 Encouraged continued use of pelvic belt, especially
when out of the house
Pubis Palpation
(or Springing)
for Tenderness
MET: SUPERIOR PUBIC SHEAR CORRECTION
Asymmetric
Straight Leg
Raise Test-In
this Case, for
Trunk
Instability
Greenman, PE. Principles of Manual Medicine
SELF-MOBILIZATION OF A RIGHT SUPERIOR
PUBIC SHEAR (ALSO OF A POSTERIORLY
ROTATED RIGHT ILIUM)
SELF MOBILIZATION OF THE SACRUM
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POST PUBIC SYMPHYSIS SEPARATION
BEGINNING STABILIZATION EXERCISE
PT RECOMMENDATIONS FOR L&D- PELVIC
GIRDLE PAIN IN PREGNANCY
First Stage
Minimize walking
Avoid asymetric postures
Second Stage
Support LE’s, if semi-reclining, with pillows
folded under knees
Avoid WB postures if these provoke Sx (e.g., 4point, upright kneel)
Avoid squatting, especially if pain is @ pubis
REFERENCES
PERI-PARTUM SEPARATED SYMPHYSIS PUBIS
REFERENCES
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Differential Diagnosis of Peri-partum Pubic Symphysis Separation

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