Original article

Clinical course of pelvic girdle pain postpartum e Impact of clinical

ndings in late pregnancy
Hilde Stendal Robinson
a,
*
, Nina K. Vllestad
a
, Marit B. Veierd
b
a
Department of Health Sciences, Institute of Health and Society, University of Oslo, P.O. Box 1089, Blindern, 0317 Oslo, Norway
b
Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, P.O. Box 1122, Blindern, 0317 Oslo, Norway
a r t i c l e i n f o
Article history:
Received 12 June 2013
Received in revised form
6 January 2014
Accepted 13 January 2014
Keywords:
Lumbopelvic pain
Low back pain
Postpartum
Clinical tests
a b s t r a c t
The aims were to study: prevalence of pelvic girdle pain (PGP) one year postpartum; clinical course of
PGP, physical functioning (PF) and bodily pain (BP) (from SF-36, 0 (worst) to 100 (best)) from gestation
week (GW) 30 to one year postpartum; and whether ndings at GW30 were associated with develop-
ment of PF and BP from GW30 to one year postpartum.
215 pregnant women were followed from GW30 to one year postpartum. Clinical examination and
questionnaire were used at GW30, questionnaire only were used at 12 weeks and one year postpartum.
The women were categorised by GW30 clinical variables: self-reported PGP, pain locations in the pelvis
and response to two clinical tests. Linear mixed models for repeated measures were used to study PF and
BP during follow-up, within the categories of clinical variables.
PGP prevalence remained unchanged from 12 weeks to one year postpartum (31e30%). PF and BP
scores improved markedly from GW30 to 12 weeks postpartum, and marginally thereafter. Median PF
scores were 70, 95 and 100 at GW30, 12 weeks and one year postpartum, respectively. Corresponding
median BP scores were 52, 84 and 84. We found signicant interactions between each clinical variable
and time (P 0.01) for PF and BP. The most aficted women at GW30 experienced largest improvement.
Despite high PGP prevalence one year postpartum, most women recovered in terms of PF and BP
scores. Unfavourable clinical course postpartum did not appear to depend on self-reported PGP, pain
locations in the pelvis, or response to clinical tests at GW30.
2014 Elsevier Ltd. All rights reserved.
1. Introduction
Pelvic girdle pain (PGP) is common during pregnancy, with a
reported prevalence from 20% to above 50% depending on the case
denition (Olsson and Nilsson-Wikmar, 2004; Gutke et al., 2006;
Mogren, 2006; Robinson et al., 2006; Vleeming et al., 2008; Bjel-
land et al., 2010; Robinson et al., 2010a). Pain is usually located
between the posterior iliac crest and the gluteal fold, predomi-
nantly around the sacroiliac joints and may also include pain in the
symphysis (Vleeming et al., 2008). PGP has been associated with
reduced capacity for weight-bearing activities such as walking and
standing (Rost et al., 2006; Robinson et al., 2006, 2010c). Although
the severity of PGP, in terms of disability or pain is modest in most
women, a considerable fraction does report severe disability
(Olsson and Nilsson-Wikmar, 2004; Gutke et al., 2006; Robinson
et al., 2010a; Mens et al., 2012b). Several studies have also reported
that PGP prevalence declines markedly in the rst months
postpartum (Albert et al., 2001; Mogren, 2006; Gutke et al., 2008;
Robinson et al., 2010b), but the clinical course of PGP in longer
follow-up has been the object of few studies. One study found that
8.5% of the women with PGP in late pregnancy reported PGP two
years postpartum (Albert et al., 2001).
Previous studies on the clinical course of PGP in the rst weeks
postpartum have used slightly different criteria, but were based
mostly on PGP prevalence (Albert et al., 2001; Mogren, 2006; Gutke
et al., 2008). It has been reported that pain locations and responses
to clinical tests are associated with PGP prevalence, disability and
pain intensity postpartum (Albert et al., 2001; Gutke et al., 2008;
Robinson et al., 2010b). Albert et al. (2001) found that women
with combined pain in the symphysis and posterior parts of the
pelvis during pregnancy recovered to a lesser extent two years after
delivery than women with fewer pain locations. Gutke et al. (2008)
found that women with combined low back pain and PGP in
pregnancy had a less favourable course till three months post-
partum. We previously reported a low level of disability and pain
intensity 12 weeks postpartum, despite a PGP prevalence of 31%
(Robinson et al., 2010b). However, 25% of these women had higher
* Corresponding author. Tel.: 47 22 84 53 94; fax: 47 22 84 50 91.
E-mail address: h.s.robinson@medisin.uio.no (H.S. Robinson).
Contents lists available at ScienceDirect
Manual Therapy
j ournal homepage: www. el sevi er. com/ mat h
1356-689X/$ e see front matter 2014 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.math.2014.01.004
Manual Therapy 19 (2014) 190e196
disability scores compared to healthy women of the same age with
minor ailments (Salen et al., 1994), and 25% reported moderate pain
intensity. Based on these results it is of interest to explore the
clinical course of PGP postpartum in the same cohort with a longer
follow-up time, in order to examine both long-term PGP preva-
lence, and the degree of afiction (disability) as determined by
physical functioning and pain. Moreover, physical functioning and
pain in the study sample one year after delivery should be
compared with normative data from the general population.
The aims of this study were: 1) to determine the prevalence of
self-reported PGP one year postpartum, 2) to examine the clinical
course from gestation week (GW) 30 to one year postpartum in
terms of prevalence of PGP, physical functioning and bodily pain
and 3) to examine whether presence of self-reported PGP, pain
locations in the pelvis or responses to clinical tests at GW30 are
associated with the development of physical functioning and bodily
pain over time from GW30 to one year postpartum.
2. Materials and methods
This paper is based on a prospective cohort study of pregnant
women who were followed up from early pregnancy to one year
postpartum (Robinson et al., 2010b, 2010c). The Regional Com-
mittee for Medical Research Ethics and the Norwegian Social
Fig. 1. Flow chart of the study sample.
H.S. Robinson et al. / Manual Therapy 19 (2014) 190e196 191
Science Data Services gave formal approval of the study (reference
number: S-05284, approved on 20 December 2005). All partici-
pants gave written informed consent.
2.1. Procedures
Most women in Norway attend maternity care units (MCUs) for
health services during pregnancy. Midwives and staff at four MCUs
located in, and nearby the capital Oslo handled the recruitment
process. All eligible Norwegian-speaking pregnant women
(n385), were invited to participate in the study at their rst
contact with the MCUs, between January 2006 and June 2007.
Women not expected to have a normal pregnancy (as determined
by the midwife) were excluded from participation. A total of 326
women agreed to participate. Mean age at study enrolment was 31
years (range 18e45 years) and 60% of participants were nulliparous.
Data used in the present paper were collected by questionnaires
and clinical examinations at GW30, and by questionnaires alone at
12 weeks and one year postpartum. Out of the 326 women
recruited to the cohort, 283 were examined in GW30 and 233 of
these returned the questionnaire at one year postpartum. However,
18 of these were excluded due to a new pregnancy and 215 women
constituted the study sample (Fig. 1).
2.1.1. Outcome variables
Presence of PGP was assessed at GW30, 12 weeks and one year
postpartumbya simple question in the questionnaire: Do you have
pain inyour pelvic girdle? (yes, no). The Short Form-36 (SF-36) was
also lled in at GW30, 12 weeks and one year postpartum (Norwe-
gian version 1.1) (Loge and Kaasa, 1998; Loge et al., 1998). This
generic instrument covers central healthaspects and canbe usedfor
healthy as well as patient groups (Ware, 2000). Disability and pain
are complaints associated with PGP (Vleeming et al., 2008), thus we
applied the subscales of physical functioning and bodily pain in this
study. These scales range from0 (worst physical functioning/bodily
pain) to 100 (best physical functioning/bodily pain).
2.1.2. Other variables
Age, education, employment and parity were recorded at study
enrolment (mean GW15). Pain locations in the pelvis were derived
from pain drawings. The active straight leg raise (ASLR) test and
posterior pelvic pain provocation (P4) test were performed at clin-
ical examinations at GW30. Active lifting of one extended leg at a
time was performed and scored by the participant on a 6-point
Likert scale (0 not difcult to lift to 5 impossible to lift the
leg). The scores for the two legs were added, thus the ASLR score
ranges from0 to 10. Asumscore over 0 was dened as a positive test
(Mens et al., 2001, 2002). High sensitivity and specicity have been
reportedfor the ASLRtest inpregnancy withthis cut-off value (Mens
et al., 2012a). The P4test was performedwiththewomansupine and
the hip and knee exed to 90

. Once in this position, the examiner

applied pressure, pushing the knee into the pelvis through the
longitudinal axis of the femur (Ostgaardet al., 1994). The participant
reported whether this provoked a familiar pain in the posterior
pelvis (yes, no). Both sides were tested and the response to the P4
test could thus be negative, unilateral positive or bilateral positive.
The P4 test is reportedto be reliable andhave highvalidity for PGP in
pregnancy (Ostgaard et al., 1994) Both the ASLR test and the P4 test
are widely used in clinical practice to examine potential PGP pa-
tients as well as in research (Ostgaard et al., 1994; Mens et al., 2001,
2002; Robinson et al., 2007; Gutke et al., 2009; Mens et al., 2010,
2012a). Both tests are reported to distinguish between PGP and
LBP (Ostgaard et al., 1994; Gutke et al., 2009; Mens et al., 2012a).
2.1.3. Statistical analyses
Missing in SF36 was handled according to the standard proce-
dure for SF36 (Loge et al., 1998). A total of 17 participants had
missing items on SF36: 4 at GW30, 7 at 12 weeks postpartum and 7
oneyear postpartum(11of these participants missedonlyone item).
Descriptive data are presented as frequencies, percentages,
means with standard deviations and medians with rst (Q1) and
third (Q3) quartiles. Expected age-adjusted mean scores of physical
functioning and bodily pain for the study sample were estimated as
described by Fayers and Machin (2007, page 436) using the Nor-
wegian population norms for women in the age groups 19e29, 30e
39 and 40e49 years (Loge and Kaasa, 1998) (corresponding to the
age groups 18e29, 30e39 and 40e45 years in our study sample).
Study women were categorised according to clinical variables at
GW30: 1) presence of PGP (yes, no), 2) painlocations inthe pelvis (no
pain, symphysis pain only, posterior pain only, combined symphysis
and posterior pain), 3) P4 response (negative, unilateral positive,
bilateral positive) and 4) ASLR score (negative 0, positive >0).
A linear mixed model for repeated measures (unstructured
covariance matrix) was used to study the evolution of physical
functioning and bodily pain scores, within the categories of clinical
variables over the three time points considered. Physical func-
tioning and bodily pain scores were log
e
transformed in these an-
alyses, while trends over time are illustrated by box plots on the
original scale.
All analyses were performed using SPSS (version 19) and a 5%
level of signicance was used.
3. Results
The study sample was similar to the total cohort and the women
being examined at GW30 in terms of age, education, marital status,
employment and parity (Table 1), and in terms of the prevalence of
self-reported PGP and median physical functioning and bodily pain
scores at GW30 (Table 2). As compared to the study sample, drop-
outs tended to have similar age, similar length of education and
similar parity, while some discrepancies were found for marital
status, smoking and employment (Table 1).
Prevalence of self-reported PGP in the study sample declined
from 63% at GW30 to 31% and 30% 12 weeks and one year post-
partum, respectively (Table 2). Sixty-nine percent of the women
who reported PGP at 12 weeks postpartumalso reported PGP at one
year postpartum, and 6 of the women (3%) who reported PGP at one
year postpartum had not reported PGP either in pregnancy or 12
weeks postpartum. These 6 women had comparable scores on
physical function with the rest of the study sample at 12 weeks
(median 92 and 95, respectively) and one year postpartum (98 and
100, respectively), but they reported less bodily pain compared
with the rest of the study sample (92 and 84, respectively). Com-
bined symphysis pain and bilateral posterior pain were reported by
53, 12 and 5 women at GW30, 12 weeks and one year postpartum,
respectively.
Physical functioning and bodily pain scores improved markedly
between GW30 and 12 weeks postpartum, and remained high at
one year postpartum. The observed means of these scores one year
postpartumwere slightly higher (95 for physical functioning and 83
for bodily pain) than those reported for women aged 19e49 years
in the general Norwegian population (Table 2), and slightly higher
than the expected age-adjusted mean scores for the study sample,
based on the norms for the general Norwegian population (92 and
77, respectively).
The linear mixed model analyses of physical functioning and
bodily pain scores showed signicant interactions between the
clinical variable and time for all four considered clinical variables
(p 0.01). The women with the lowest scores (highest afiction) at
H.S. Robinson et al. / Manual Therapy 19 (2014) 190e196 192
GW30 showed the largest changes across the time periods. The
difference in scores across the categories of clinical variables nar-
rowed 12 weeks postpartum, with small changes observed be-
tween 12 weeks and one year postpartum (Figs. 2 and 3).
Some differences between categories of clinical ndings were
seen at GW30. Women that reported PGP or some pain locations in
the pelvis had lower median physical functioning and bodily pain
scores (were more aficted) compared to those without pain
(Figs. 2 and 3). Similar differences in physical functioning and
bodily pain scores were seen in women with and without positive
response to the P4 and ASLR tests.
At 12 weeks postpartum, the median scores for physical func-
tioning and bodily pain were quite similar in all categories of
clinical variables, except for bodily pain scores in the variable pain
locations in the pelvis (Figs. 2 and 3). The women with combined
symphysis and posterior pain had a median bodily pain score of 72
(Q1 62, Q3 84) whereas for those with no pain locations in the
pelvis the corresponding value was 100, i.e. no pain (Q1 84,
Q3 100).
At one year postpartum, the median (Q1, Q3) scores across the
categories of clinical variables for physical functioning were very
similar (Fig. 2). Median bodily pain scores were lowest (i.e. highest
afiction) for women reporting PGP, pain locations in the pelvis or
having positive responses to the P4 and ASLR tests (Fig. 3).
4. Discussion
We found large improvements in physical functioning and
bodily pain across the three time points considered in our analysis
(GW30, 12 weeks and one year postpartum) in this sample of
women. In general, physical functioning and bodily pain scores
were high one year postpartum, irrespective of the clinical variables
considered, i.e., pain locations in the pelvis, or responses to clinical
tests at GW30. Importantly, the signicant interaction effects be-
tween the clinical variables and time indicated that the largest
improvements postpartum were seen among the women who re-
ported the highest afiction in late pregnancy.
The observed mean scores for physical functioning and bodily
pain postpartumwere slightly higher than mean scores for women
of the same age in the general Norwegian population (Loge and
Kaasa, 1998). One explanation for the higher scores (i.e. less pain
and better physical function) in our study sample than in the
general population might be the different age distribution within
the age groups. For instance, compared to the general population
age group of 40e49 years, the corresponding age group in our
sample was in the young range (40e45 years). Moreover, it has
been shown that physical functioning and pain reported by patients
tend to be more favourable than those reported by the general
population (Fayers and Machin, 2007). The same response shift
may also exist among the aficted women in our sample. However,
the differences between the observed and the estimated means (3
for physical functioning and 6 for bodily pain) were small when the
variability in responses was taken into account.
We have previously reported that 62% of the women in this
same cohort reported PGP at GW30 (Robinson, 2010), and impor-
tantly, only 31% reported PGP at 12 weeks postpartum (Robinson
et al., 2010b). These results are in concordance with previous
studies, showing that the PGP prevalence declines most markedly
in the rst months postpartum (Albert et al., 2001; Noren et al.,
2002; Rost et al., 2006). Only 5 women reported combined sym-
physis pain and bilateral posterior pelvic pain, which is in agree-
ment with the results reported in a large Norwegian population
based study (Bjelland et al., 2013). Having pain in all these three
locations has previously been termed pelvic girdle syndrome and
used to identify those with a severe condition (Albert et al., 2001;
Robinson et al., 2006). Hence, our data indicate that 2e3% of the
Table 2
The clinical course of pelvic girdle pain (PGP) prevalence, and physical functioning (PF) and bodily pain (BP) scores at gestationweek 30, and 12 weeks and one year postpartum
in the study sample. Data at gestation week 30 for the entire cohort and the general Norwegian population data (Loge and Kaasa, 1998) for women are given for comparison.
Study sample (n215) Total cohort (n326) General Norwegian population (women)
Gestation
week 30
12 weeks
postpartum
One year
postpartum
Gestation week 30 19e29 years
a
30e39 years
a
40e49 years
a
Expected age-adjusted
mean scores
PGP, yes n (%) 136 (63) 66 (31) 64 (30) 193 (62) 94 (11) 92 (13) 89 (17) 92
PF score Mean (SD) 67 (20) 92 (13) 95 (9) 100 67 (21)
Median (Q1,Q3) 70 (55, 85) 95 (90, 100) (95,100) 70 (55, 80)
BP score Mean (SD) 57 (23) 78 (22) 83 (20) 57 (23) 80 (23) 77 (25) 74 (26) 77
Median (Q1,Q3) 52 (41, 74) 84 (62, 100) 84 (72, 100) 52 (41, 74)
PGP: pelvic girdle pain, PF score: physical functioning score, BP score: bodily pain score from Short form 36.
PF and BP, 0e100 scales; 0 worst physical functioning/bodily pain, 100 best physical functioning/bodily pain.
a
Loge and Kaasa (1998).
Table 1
Selected characteristics of the study sample, the total cohort, the women examined at GW30 and missing women (drop-outs) at one year postpartum.
Study sample n215 Total cohort n326 Women examined at
GW30 n283
Drop-outs from GW 30 till
1 year postpartum n47
Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Age (years) 31 (4) 31 (4) 31 (4) 31 (4)
Education (years) 16 (3) 16 (2) 16 (3) 16 (2)
n (%) n (%) n (%) n (%)
Married/cohabitant (yes) 211 (98) 316 (97) 275 (97) 44 (94)
Smoking (yes) 6 (3) 15 (5) 12 (4) 4 (9)
Employed, yes 203 (94) 393 (93) 261 (92) 38 (81)
Parity 0 121 (56) 196 (60) 167 (59) 28 (60)
1 75 (35) 103 (32) 92 (33) 15 (32)
2 20 (9) 27 (8) 24 (8) 4 (9)
GW: gestation week, SD: standard deviation.
H.S. Robinson et al. / Manual Therapy 19 (2014) 190e196 193
women have severe PGP one year postpartum. Since the proportion
of women with PGP is stable from 12 weeks till one year post-
partum, a transition to a more chronic PGP status seems to occur
around or before 12 weeks postpartum. This is in accordance with
studies on low back pain that dened 3 months as the limit for
the condition to be dened as chronic (Frank et al., 1996; Waddell,
2004). However, the proportion of women with PGP seems sur-
prisingly high one year postpartum. The lack of decline in preva-
lence of PGP might be due to altered demands when the women
shift from being in early postpartum period to a life combining
work, leisure time and family.
A different pattern is seen when using data on physical func-
tioning and bodily pain. Both scores improved markedly and were
comparable with expected age-adjusted mean scores within the
rst 12 weeks postpartum. The scores remained high until one year
postpartumand only small changes were observed. Relatively large
variations in physical functioning and bodily pain scores were
found in categories of clinical variables, but 75% of the women had
physical functioning scores above 95 (Q1 95) and 75% had bodily
pain scores above 72 (Q1 72). Furthermore, clinical variables in
late pregnancy do not seemto be associated with the clinical course
of PGP postpartum. There were few women in each of the
categories of clinical variables scoring lower than population norms
of physical functioning and bodily pain one year postpartum, but
some of these women scored markedly lower.
The results indicated that most women did recover from PGP,
even though 30% still reported having the condition one year
postpartum. One possible explanation for this is that women did
not experience their pain as bothersome anymore, but instead
experienced it more like discomfort. Yet, when asked specically,
they reported discomfort as pain. Hence, the dichotomous question
about having PGP could be less sensitive than a continuous mea-
sure as the SF-36. It might also be explained as an adaptation to the
situation or a change in reporting behaviour. Both explanations
imply that the afiction becomes less important to the person.
According to Schwartz et al. (2005), adaptation to PGP can suggest
an experienced alteration in health during and after pregnancy,
which changed the womans internal standards and values, and
thus their reporting behaviour. Furthermore, physical functioning
and bodily pain may interact. For example, a reduction in physical
functioning scores may inuence, and thus reduce bodily pain
scores or vice versa. Length of pregnancy and personal experience
of pregnancy and birth may also recalibrate a womans pain
threshold, or idea of pain, and result in an adjustment to the
Fig. 2. Box-plots of physical functioning as reported in the SF-36 at gestation week 30, 12 weeks and one year postpartum. The study sample (n215) was categorised according to
presence of pelvic girdle pain, pain locations in the pelvis, posterior pelvic pain provocation (P4) test and active straight leg raise (ASLR) test at gestation week 30. Median, quartiles
and range are presented. The length of the box is the distance between the rst (Q1) and third (Q3) quartile, i.e., the interquartile range (IQR). Circles and asterisks represent outliers
(>1.5 IQR and >3 IQR above the third quartile, respectively).
H.S. Robinson et al. / Manual Therapy 19 (2014) 190e196 194
situation. The results underpin the importance of evaluating
afiction together with the prevalence of PGP.
The prevalence of PGP one year postpartum in this study was
close to the point prevalence reported for LBP in general pop-
ulations (Waddell, 2004), indicating that this could be the same
entity. However, previous studies have reported that the response
on the clinical tests used here, are different in patients with LBP and
PGP (Ostgaard et al., 1994; Gutke et al., 2009; Mens et al., 2012a).
Furthermore, we have previously found that response on the P4
and ASLR tests contributed independently to disability in multi-
variable analysis during pregnancy (Robinson et al., 2010a). Thus, it
seems more likely that PGP and LBP are different entities in
connection to pregnancy. However, retrospective studies on LBP
have reported that several women with chronic LBP identify
pregnancy as an initial appearance of the pain (Biering-Sorensen,
1983; Svensson et al., 1990). Knowledge of the association be-
tween PGP and LBP in women throughout life is lacking.
Six of the womenwho reported PGP at one year postpartum(3%)
did not report PGP at any of the previous follow-ups in the study,
indicating that they developed PGP from 12 weeks till one year
postpartum. Their scores on physical function were comparable
with the total cohort at 12 weeks and one year postpartum, but
they reported less bodily pain. Since no responses on clinical tests
are available at one year follow up, we cannot exclude LBP in this
group.
The prospective design and long follow-up is an important
strength of this study. Furthermore, the use of pain drawings and
clinical examinations at GW30 allowed us to examine the impact of
clinical ndings in late pregnancy on the course until one year
postpartum. As compared to the study sample, drop-outs were
similar in most aspects, however, slightly fewer women among the
drop-outs were married/cohabitant, non-smokers and employed.
These ndings are consistent with non-compliance present in other
studies (Galea and Tracy, 2007; Tough et al., 2009; Stacey et al.,
2011). Self-reporting of physical functioning is a potential weak-
ness. We do not knowwhether the reported physical functioning is
real, an adaptation to the situation, or a result of reporting behav-
iour. This could have been explored further by use of tests for
physical function. Likewise, bodily pain is also self-reported and
might suffer from similar weakness.
5. Conclusion
Thirty percent of the women in this cohort reported PGP one
year postpartum. Yet the validity of the single question for assess-
ment of PGP one year postpartum may be questioned since most
Fig. 3. Box-plots of bodily pain at gestation week 30, 12 weeks and one year postpartum. The study sample (n215) was categorised according to presence of pelvic girdle pain, pain
locations in the pelvis, posterior pelvic pain provocation (P4) test and active straight leg raise (ASLR) test at gestation week 30. Median, quartiles and range are presented. The length
of the box is the distance between the rst (Q1) and third (Q3) quartile, i.e., the interquartile range (IQR). Circles and asterisks represent outliers (>1.5 IQR and >3 IQR above the
third quartile, respectively).
H.S. Robinson et al. / Manual Therapy 19 (2014) 190e196 195
women were fully recovered with regard to physical functioning
and bodily pain. Difference between groups dened by PGP, pain
locations in the pelvis and responses to clinical tests in late preg-
nancy seemto have little inuence on the clinical course of physical
functioning and bodily pain postpartum.
Acknowledgements
This study has been supported by the EXTRA funds from the
Norwegian Foundation for Health and Rehabilitation, The Norwe-
gian Fund for Post-Graduate Training in Physiotherapy and the
University of Oslo.
We thank Hans and Olaf Physiotherapy clinic and the Maternity
Care Units (MCU) for kindly making it possible to collect the data in
this study. In particular we want to thank Professor Anne Marit
Mengshoel for valuable contribution in planning the study and
Elisabeth K Bjelland, PhD, RPT for valuable help with the clinical
examinations of the participating women. Furthermore we want to
thank Anne Karine Bergva, Sigrunn Anmarkrud, Grete Kristiansen,
Hege Kaspersen, Astrid Stormoen, Eva Marie Flaathen, Heidi
Arnesen, Tove Mols and Wenche Sjberg at the MCU for help with
recruiting the pregnant women. We also thank Trudy Perdrix-
Thoma for language review.
References
Albert H, Godskesen M, Westergaard J. Prognosis in four syndromes of pregnancy-
related pelvic pain. Acta Obstet Gynecol Scand 2001;80(6):505e10.
Biering-Sorensen F. A prospective study of low back pain in a general population. II.
Location, character, aggravating and relieving factors. Scand J Rehabil Med
1983;15(2):81e8.
Bjelland EK, Eskild A, Johansen R, Eberhard-Gran M. Pelvic girdle pain in pregnancy:
the impact of parity. Am J Obstet Gynecol 2010;203(2):146.
Bjelland EK, Stuge B, Vangen S, Stray-Pedersen B, Eberhard-Gran M. Mode of de-
livery and persistence of pelvic girdle syndrome 6 months postpartum. Am J
Obstet Gynecol 2013;208(4):298e307.
Fayers PM, David Machin. Quality of Life. The assessment, analysis and interpre-
tation of patient-reported outcomes. Chichester, England: John Wiley & Sons
Ltd; 2007.
Frank JW, Brooker AS, DeMaio SE, Kerr MS, Maetzel A, Shannon HS, et al. Disability
resulting from occupational low back pain. Part II: what do we know about
secondary prevention? A review of the scientic evidence on prevention after
disability begins. Spine (Phila Pa 1976) 1996;21(24):2918e29.
Galea S, Tracy M. Participation rates in epidemiologic studies. Ann Epidemiol
2007;17:643e53.
Gutke A, Ostgaard HC, Oberg B. Pelvic girdle pain and lumbar pain in pregnancy: a
cohort study of the consequences in terms of health and functioning. Spine
2006;31(5):E149e55.
Gutke A, Ostgaard HC, Oberg B. Predicting persistent pregnancy-related low back
pain. Spine 2008;33(12):E386e93.
Gutke A, Hansson ER, Zetherstrom G, Ostgaard HC. Posterior pelvic pain provoca-
tion test is negative in patients with lumbar herniated discs. Eur Spine J 2009
Jul;18(7):1008e12.
Loge JH, Kaasa S. Short form 36 (SF-36) health survey: normative data from the
general Norwegian population. Scand J Soc Med 1998;26(4):250e8.
Loge JH, Kaasa S, Hjermstad MJ, Kvien TK. Translation and performance of the
Norwegian SF-36 Health Survey in patients with rheumatoid arthritis. I. Data
quality, scaling assumptions, reliability, and construct validity. J Clin Epidemiol
1998;51(11):1069e76.
Mens JM, Vleeming A, Snijders CJ, Koes BW, Stam HJ. Reliability and validity of the
active straight leg raise test in posterior pelvic pain since pregnancy. Spine
2001;26(10):1167e71.
Mens JM, Vleeming A, Snijders CJ, Koes BW, Stam HJ. Validity of the active straight
leg raise test for measuring disease severity in patients with posterior pelvic
pain after pregnancy. Spine 2002;27(2):196e200.
Mens JM, Pool-Goudzwaard A, Beekmans RE, Tijhuis MT. Relation between sub-
jective and objective scores on the active straight leg raising test. Spine (Phila Pa
1976) 2010;35(3):336e9.
Mens JM, Huis In t Veld YH, Pool-Goudzwaard A. The Active Straight Leg Raise test
in lumbopelvic pain during pregnancy. Man Ther 2012a;17(4):364e8.
Mens JM, Huis In t Veld YH, Pool-Goudzwaard A. Severity of signs and symptoms in
lumbopelvic pain during pregnancy. Man Ther 2012b;17:175e9.
Mogren IM. BMI, pain and hyper-mobility are determinants of long-term outcome
for women with low back pain and pelvic pain during pregnancy. Eur Spine J
2006;15(7):1093e102.
Noren L, Ostgaard S, Johansson G, Ostgaard HC. Lumbar back and posterior
pelvic pain during pregnancy: a 3-year follow-up. Eur Spine J 2002;11(3):
267e71.
Olsson C, Nilsson-Wikmar L. Health-related quality of life and physical ability
among pregnant women with and without back pain in late pregnancy. Acta
Obstet Gynecol Scand 2004;83(4):351e7.
Ostgaard HC, Zetherstrom G, Roos-Hansson E. The posterior pelvic pain provocation
test in pregnant women. Eur Spine J 1994;3(5):258e60.
Robinson HS, Eskild A, Heiberg E, Eberhard-Gran M. Pelvic girdle pain in pregnancy:
the impact on function. Acta Obstet Gynecol Scand 2006;85(2):160e4.
Robinson HS, Brox JI, Robinson R, Bjelland E, Solem S, Telje T. The reliability of
selected motion- and pain provocation tests for the sacroiliac joint. Man Ther
2007;12(1):72e9.
Robinson HS, Mengshoel AM, Bjelland EK, Vollestad NK. Pelvic girdle pain, clinical
tests and disability in late pregnancy. Man Ther 2010a;15(3):280e5.
Robinson HS, Mengshoel AM, Veierod MB, Vollestad N. Pelvic girdle pain: potential
risk factors in pregnancy in relation to disability and pain intensity three
months postpartum. Man Ther 2010b;15(6):522e8.
Robinson HS, Veierod MB, Mengshoel AM, Vollestad NK. Pelvic girdle pain - asso-
ciations between risk factors in early pregnancy and disability or pain intensity
in late pregnancy: a prospective cohort study. BMC Musculoskelet Disord
2010c;11(1):91.
Robinson HS. Pelvic girdle pain and disability during and after pregnancy. The
University of Oslo; 2010.
Rost CC, Jacqueline J, Kaiser A, Verhagen AP, Koes BW. Prognosis of women with
pelvic pain during pregnancy: a long-term follow-up study. Acta Obstet
Gynecol Scand 2006;85(7):771e7.
Salen BA, Spangfortke L, Nordemar R. The disability rating index: an instrument for
the assessment of disability in clinical settings. J Clin Epidemiol 1994;47(12):
1423e35.
Schwartz C, Sprangers M, Fayers P. Response shift: you know its there but how do
you capture it? Challenges for the next phase of research. In: Fayers P, Hays R,
editors. Assessing quality of life in clinical trials, vol. 2. Oxford: Oxford Uni-
versity Press; 2005. pp. 275e90.
Stacey T, Thompson JM, Mitchell EA, Ekeroma AJ, Zuccollo JM, McCowan LM. The
Auckland Stillbirth study, a case-control study exploring modiable risk factors
for third trimester stillbirth: methods and rationale. Aust N Z J Obstet Gynaecol
2011;51:3e8.
Svensson HO, Andersson GB, Hagstad A, Jansson PO. The relationship of low-back
pain to pregnancy and gynecologic factors. Spine 1990;15(5):371e5.
Tough SC, Siever JE, Benzies K, Leew S, Johnstom DW. Maternal well-being and its
association to risk of developmental problems in children at school entry. BMC
Pediatr 2010;10:19.
Vleeming A, Albert HB, Ostgaard HC, Sturesson B, Stuge B. European guidelines for
the diagnosis and treatment of pelvic girdle pain. Eur Spine J 2008;17(6):794e
819.
Waddell G. The back pain revolution. Edinburgh: Churchill Livingstone; 2004.
Ware JE. Using generic measures of functional health and well-being to increase
understanding of disease burden. Spine 2000;25(12):1467.
H.S. Robinson et al. / Manual Therapy 19 (2014) 190e196 196