P H Y S I O T H E R A P Y d ia s t a s is o f t h e p u b i c s y m p h y s i s w it h s p e c i a l CONSIDERATION OF PREGNANCY AND PARTURITION p ECEMBER 1978 13 G A IL W IL SO N B.Sc. (Physio.) W itw atersrand hum an sym physis p ubis undergoes a variety of es under the influence of age an d function, and c h a n g e 5 u n der th e special ho rm o n al influence of in 1 ncv and the m echanical tra u m a o f p artu ritio n , pregna^ a Synchondrosis w hich usually changes into I* ^ j j r t h r o s i s an d occasionally develops into a real a - t h r o d i a l joint. A t b irth , th e connection betw een the d'a . bones is u n in terru p ted , consisting p o sterio rly and 'riorly of cartilage, a n te rio rly and in ferio rly of SU*36 l a r i z e d ligam entous connective tissue. T h e m edian SSCU . _ 4. ^ in th#» s p r n n H v p n r n f l i f p a n d h coincides w ith th e increased shearing stresses on the llnhvsis due to th e assu m ption o f th e u p rig h t gait, o n e survey, (Putschar, 1971) 97% o f ad u lt fem ales lowed these p rim ary clefts Secondary tr a u m a tic clefts in the c a rtila g e a re m ore freauent in fem ales, due to o v arian an d placental h o r m o n e s in pregnancy. R elaxin has a rem arkable effect on collagen tissues, causing h y p ertro p h y o f the in d i­ vidual cells. It is m ost m arked w here collagen cells are very tightly packed together, e.g. in th e dense ligaments o f the pelvis. T hese effects occur w ithin hours of the ad m in istratio n of relaxin (V an R ooyen, 1974). Oestrogen, progesterone, pregnenolone, p regnan­ diol and other horm ones have th e sam e effect, b u t take longer to produce the changes. D elivery of a m atu re infant produces tra u m a tic changes in the sym physis pubis, leading to extrusion o f to m fibrocartilage in any pre-existing cleft, so th a t com plete clefts a re m uch m ore common in fem ales a fte r p a rtu ritio n . T h e m argins of these various cartilage tears undergo degenerative changes and, although the h aem orrhage is resorbed, the cartilage tears do n o t heal. In m u ltip aro u s w omen, one observes additional tears fro m th e m ost recent preg­ nancy, superim posed an old unhealed tears and each pregnancy and delivery leaves the p u b ic sym physis permanently som ew hat loosened. A roentgenographic survey (Vix, 1971) show ed an average width o f 7,1 m m in a large n u m b er o f pregnant subjects, com pared to an average o f 4,1 m m in non- sregnant women. iESULTS OF A LOCAL ST U D Y The following tab le indicates the incidence o f this problem in a local study of 409 patients seen regularly during the last trim ester o f pregnancy. T otal N u m b er % 409 100 318 77,8 79 19,3 12 2,9 16 3.9 7 2,2 8 10,1 1 8,3 Total num ber o f Pregnancies P rim ig ra v id a Para 1 Para 2 + Total no. w ith P u b ic Symph. Prob. P rim ig rav . w ith P u b ic Symph. Prob. Para. 1 w ith P u b ic Symph. Prob. Para. 2 + w ith P u b ic Symph. P rob. These results confirm th e ea rlie r discussion. O f the patients seen 3,9% h ad p u b ic sym physis problem s; the Pnmigravida has a 2,2% incidence an d the m u ltip ara snowed a much h ig h er incidence. O f the patients com ­ plaining o f pubic sym physis problem s 56% were m ulti- Parous women. SIG NS A N D SYMPTOMS OF PUBIC SYM PHYSIS PROBLEM Pregnancy Age seem ed to have no bearing o n the situation. On average, th e signs an d sym ptom s w ere noted from the 30th week of pregnancy. T hey w ere m ost m arked betw een 34 - 36 weeks, a stage at w hich the horm onal level is presum ably very high. A t this stage in som e p rim ig rav id a trau m atic dam age m ay arise as the head engages in the pelvic inlet. Some m u ltip aro u s patients rep o rted problem s starting at 24 weeks o r even earlier. Pain was localised at th e sym physis pubis. A ching occurred in the groin eith er b ilaterally o r unilaterally. T hese sym ptom s w ere reproduced b y passive m o b ilisa­ tio n of th e sym physis pubis, by resisted tru n k flexion and by pressure on the iliac crests w hich forced them laterally. All patients com plained o f extrem e stiffness an d p a in in the groin and o f difficulty w ith am b u latio n follow ing bedrest. Prolonged standing, w alking and w eight transferance, e.g. stepping off a kerb, caused pain. In severe cases a w addling g ait developed. E x e r­ cises in th e ante-natal class involving ab d u ctio n o f th e hip, often provided the first indication th a t the problem was arising; the p atien t experienced pain and was unable to carry out the exercise. In som e subjects there was associated p a in over the sacro-iliac joints, w ith o u t the disabling sym ptom s described above. Puerperium Tw o cases, b o th follow ing the b irth of th e ir second baby, who h ad not received an y ante-natal therapy, w ere referred fo r treatm en t on th e 3rd day post partum . T h e diagnosis o f diastasis of the sym physis pubis was m ade as am b u latio n h a d becom e im possible. T hese w ere the m ost severe cases in the study, and also took th e longest tim e to reh ab ilitate. M arked p ain was present over th e p u b ic sym physis, pain was experienced on tru n k m ovem ents an d they were u n ­ able to attem p t straig h t leg raising. T ransference of w eight, as in a n orm al gait p attern , was initially severely lim ited by pain. TREA TM EN T Pregnancy O bstetric textbooks advocate bedrest an d a supporting b in d e r fo r patients exhibiting this condition. E xperience w ith these cases indicated th at bedrest produced m ore pain, stiffness an d gross im m obility. A n exercise p ro ­ gram m e, m ob ilisatio n an d the w earing of a m atern ity corset fo r the bin d in g effect produced good results. T reatm en t was as follow s: As soon as signs an d sym ptom s o f loosening o f the pu b ic sym physis w ere noted, th e patients w ere given a n exercise routine sim ilar to th at used in a back class, b u t obviously these exercises did not involve any strong tru n k flexion o r h ip ab d u ctio n w hich w ould aggravate the sep aratio n o f the sym physis pubis. Leg m ovem ents using patterns of hip flexion, ad duction and internal ro ta tio n w ith knee flexion w ere also used. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 14 F I S I O T E R A P I E DESEMBER 1978 In m ild cases this exercise p rogram m e p rovided relief fro m the stiffness. P atien ts w ho m issed ante-natal p h y sio th erap y sessions o r h ad been confined to bed fo r o th er m edical reasons, im m ediately rep o rted m arked stiffness an d pain on am b u latio n . T hose p atien ts who w ere im proving an d w ere overkeen and did an excessive am o u n t o f w alking o r standing also presented w ith m ore pain. T h e m ore severe cases, m ostly m u ltip aro u s m others, follow ed an a d ap te d exercise program m e. T hey req u ired local heat, e.g. in fra-red p rio r to the m o b ilisatio n p ro ­ cedures w hich gave m arked relief o f pain. T h e m o b ilisa­ tio n was done w ith the p atien t in th e supine position. T h e th e ra p ist flexed the h ip and knee, in terlocked the fingers o f both hands and cupped them over th e to p o f the knee. T h e h ip w as then adducted and internally rotated, w ith as m uch flexion as the p regnant uterus w ill allow (M aitlan d 1977). A n o scillating dow nw ard force w as then applied, w orking short o f th e pain in i­ tially. T h e dosage o f m o b ilisatio n depended on the severity o f the pain. T h e pro ced u re w as in itially carried o u t on th e m ost p ainful side and then on th e opposite side. T h e side ex h ib itin g th e m ost pain and resistance can be likened to a tig h t bow -string. R elief fro m the p ain and stiffness follow ed this m o bilisin g p rocedure and am b u latio n an d m ovem ent becam e easier. A m atern ity corset was advocated fo r the bin d in g effect to ap p ro x im ate th e sym physial ends and was used fo r prolonged w alking o r standing. A d d u ctio n of the thighs was also encouraged to correct the w addling gait. Post-parturition G re a t care m ust be taken when tre a tin g these patients as p o st-p artu m avulsion can occur very easily up to th e tenth day. • T h e reason fo r possible sym physial avulsion is the result o f the ra p id fall in the horm one levels, causing an o x ic changes in the collagen fibres due to throm boses, and th e sym physial ligam ent is extrem ely w eakened. Strong tru n k flexion is co n tra-in d icated as this can increase the sym physial w idth by up to 7,1 mm and the sudden strong m uscular action of tru n k flexion can result in a total te a r o f the sym physial ligam ent and total sep aratio n o f the p u b ic sym physis (Van R ooyen, 1974). B earing these points in m ind, an exercise plan fo r m o b ility w as given, avoiding prone kneeling positions w hich could lead to a ir em bolus. M o b ilisatio n p ro ­ cedures and in fra-red irra d ia tio n w ere also used. A tight corset o r b in d e r was then applied to facilitate w alking. P atien ts g rad u ally im proved over th e first six weeks, a fte r w hich they joined a post-natal exercise gro u p w here tru n k flexion and h ip ab d u ctio n w ere slowly progressed. RESULTS T w o to th ree m onths p o st-p artu m the patients were pain -free and ab le to do all th e exercises. O ne case re-in ju red th ree m onths a fte r her delivery due to a fall on a tennis court. She presented w ith a chronic sym­ physiolysis and im proved g rad u ally on regular exercise treatm ent. O rth o p aed ic advice w as to continue pro­ longed conservative treatm ent. T h e use of hydrocortisone injection, as m entioned in som e of the lite ra tu re (Sharp, 1973) was n o t suggested in any o f the cases, and open reduction w ith plate fixation, as fo r d isru p ted pubic sym physis resulting from tra u m a tic injuries, obviously did not apply in these cases. References 1. M aitland, G. D. (1977): V ertebral M anipulation, 4th ed. B utterw orths, London. 2. Putschar, W. G . J. (1976): T h e S tructure of the. H um an Symphysis Pubis w ith Special C o n sid eratio n o f P artu ritio n and its Sequelae. A m . J. o f A nthropol., 45, 589 - 594. 3. S harp, I. K. (1973): P late F ix atio n of Disrupted Symphysis. J. Bone Jo in t Surg., 55 (B), 6 1 8 -6 2 0 . 4. Van R ooyen, A. J. L. (1974): Pelvic Joint Movements in Pregnancy. P ap er read to S.A.S.P. O bstetric Asso­ ciation Sym posium . 5. Vix, V. A. and R yu, C Y. (1971): T he A dult Sym­ physis Pubis: N orm al and A bnorm al. A m . J. R o en t­ genol R adium Ther. N ncl. M ed., 112, 5 1 7 -5 2 5 . Bibliography 1. H arris, N . H . (1974): Lesions o f Pubic Symphysis in W om en. Brit. M ed. J., 4, 209 -211. 2 H aw kins, D. F . (1974): O bstetric T herapeutics, 1st Ed. Bailliere T indall, London. 3. Lewis, M. M. (1977): P u b ic Sym physis D iastasis treated by Open R eduction and In tern al Fixation. Clin. O rthop., 123, 37 - 39. 4. M aitland, G. D. (1970): P eripheral M anipulation, 1st Ed. B utterw orths, L ondon. 5. O lerud, S. and G revsten, S. (1974): C hronic Pubis Symphysiolysis. J. Bone Jo in t Surg., 56A, 799 - 802. 6. R ovinsky, J. J. and G uttm acher, A. F . (1971): M edi­ cal, Surgical and G ynecologic C om plications o f Preft«" nancy. 2nd Ed. W illiam s and W ilkins, Baltim ore, ffl 7. W ah, L. M. (1977): E ffect o f H orm ones on C ollageff M etabolism and C ollagenase A ctivity in the pubic sym physis ligam en of th e guinea pig. E ndocrinology, vl 100, 571 - 5799. D IV ISIO N OF C O N T IN U IN G M EDICA L E D U C A T IO N U N IV E R SIT Y O F T H E W IT W A TE R SRA ND T el.: 725-2915/75 1 - 3 M arch 1979: C ivil D efence C onference an d W o rk ­ shop. 7 M arch 1979: F in a n c ia l M anagem ent. 9 - 1 0 M arch 1979: L earn in g a b o u t T erm in al Care. 17 M arch 1979: T h e M entally H an d icap p ed P re-school Child. 9 - 1 3 July 1979: L earn in g D isab ilities. JO U R N A L OLD COPIES T h e E d ito rial B oard plans to bind two sets o f back copies o f the Jo u rn a l and need the follow ing issues to com plete the two sets: M arch, July and O ctober 1949. A pril, July and O ctober 1950. A p ril 1951. Ja n u a ry an d O ctober 1952. Ja n u a ry an d July 1953. A pril 1954. M arch 1960. D ecem ber 1968. Ju n e 1974. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )