Tuesday 24 February 2004
Physiotherapy Management of Symphysis Pubis Dysfunction
Lucy Townsend MSc MCSP SRP
The diagnosis of symphysis pubis dysfunction (SPD) is a broad differential diagnosis, only achieved by consideration of symptoms and clinical assessment (Owens et al 2002). No objective criteria exist to confirm the diagnosis, which is therefore one of exclusion (Larsen et al 1999). If examination confirms pelvic problems with no signs of another causative disease the diagnosis of SPD is made (Hansen et al 1999).
Therefore SPD is a description of symptoms, or a syndrome, rather than a disease entity. SPD presents with varying problems leading to diagnostic confusion, and this increases the likelihood of inappropriate treatment (Albert et al 2000).
The hormonal effect of pregnancy on the pelvis has traditionally been cited as the cause of SPD, and has lead to the predominantly conservative management seen today. The assumption that manual treatment is unlikely to be effective whilst hormones are exerting their influence means that management is aimed at activity avoidance rather than active treatment of the pelvis, an assumption unsupported by the literature . For this approach to be justified the role of hormones must be proved.
When joint mobility is directly investigated with respect to pain, the findings are also less than conclusive. Bjorkland et al (2000) comment that pelvic girdle relaxation is commonly cited as an underlying cause of pelvic pain during pregnancy, but no such relationship has been proved.
In recent studies alteration in symmetrical mobility has shown the strongest relationship to pain. Asymmetrical mobility through the pelvis will result in pathological joint stresses and so pain.
Therefore it is not the hormones or the laxity alone that directly cause pain, but the hormones or laxity may in some women result in a dysfunctional pelvic mechanism, and this will cause pain.
This understanding of the condition has major implications for our management of these patients. Manual techniques that correct the asymmetrical mobility at the pelvic joints should allow us to treat the condition and not merely manage the symptoms.