Rebalance Physical Therapy Case Study

Peripartum Pubic Symphysis Dysfunction

Case Study by Hina Sheth MS, PT, OCS, MTC

Hello Fellow Colleagues! I am happy to send you our first official case study with patient experience. The format I used is to get the patient perspective after evaluation and during treatment first, then the case study and then their experience after the treatment sequence and after affects. I would love to receive any feedback or question you might have after you read this one. Thank you for all of you wanting to be a part of this group.

 

Patient Testimonial and Experience after evaluation and during treatment:

After giving birth to my son in 2013, I was in extreme pubic/pelvic pain, to the point where I could not walk. I was told by my OBGYN that I just needed to rest and give myself time to heal. With time and exercise, the pain eventually decreased, but it never went away. Two years later and pregnant with baby #2, I found myself with the same severe pubic pain again. My OBGYN chalked it up to typical “pregnancy pain” and said that once the baby was born, I would be ok. That was not ok with me. That is when I found Rebalance Physical Therapy. Hina Sheth was really the first healthcare practitioner that took my pain seriously. After just two visits with her, I had significantly decreased pubic and pelvic pain and my mobility improved. I was able to sleep better and even keep up with my very active two year old! Most importantly, I felt more informed about my injury. Hina also took the time to talk to me about labor and delivery positioning to avoid further injury. She reached out to my doula to discuss this as well, and even wrote a letter for me to give to my OBGYN and the hospital staff. I am going into this next delivery with confidence that my injury will not be worsened. The level of attention and care Hina has provided me are second to none. I truly feel fortunate to be her patient and am so grateful to have found her and Rebalance Physical Therapy.

 

Patient Exam and Asessment

Hx: Patient is a 32-year-old female with a 2.5 year hx of pubic symphysis /groin pain starting after vaginally birth of her first child in October of 2013. This pain became more manageable with incorporating running into her exercise regiment however the pain never completely resolved.

In September of 2015 she became pregnant again and ran a 5K in November 2015 and her pain returned. Her pain significantly increased, affecting her ability to carry, lift, walk without limping. She reports pain as 7-8/10 on pain scale localized to her groin and pubic symphysis.

She is seeking my help to reduce pain so that she can get comfortable these last few weeks as well as seek guidance for this upcoming delivery.

PMH: sacroiliac joint pain/coccyx pain, low back pain, TMJ/Neck pain

Medications: Tylenol and Prenatals

Objective Findings:

Posture: L transverse pelvic rotation, L intrapelvic torsion

External Trigger Points: B/L hip adductors, obturator externus

Functional Movement testing: pain with one legged standing and up and down stairs

Palpation: 2+/5 for pubic symphysis, 2+/5 for iliococcygeus, adductors, gluteals, coccygeus

Impression:

Patient presents to physical therapy with signs and symptoms consistent with pubic symphysis hypermobility and strain. Contributing factors include a malpositioned pelvic bone, muscular spasming of the adductors, gluteals, iliococygeus and coccygeus and increased joint laxity. Today we were able to treat her and improve pelvic positioning through joint mobilization, we also fitted her for a belt to compress her pubic cone to improve stability. She was advised to ice and take Tylenol as well as avoid exercises that would further stretch the joint.

She will benefit from treatment consisting of manual therapy (which may include soft tissue and joint mobilization, selected strengthening and stretching, home exercise program and education.

We also discussed the importance of her hip positioning during this next delivery to reduce further joint strain. It was discussed that the likelihood of her continuing to have pubic symphysis pain post partum was highly probable. It was also discussed that delivery itself could strain the pubic symphysis further. Delivery in a side-lying or quadraped position could reduce strain on the joint. If she does have to delivery in the lithotomy position then limiting excess hip abduction and flexion would be strongly advised.

All of the findings and treatment sequence were discussed with the patient.

Goals: In 2-3 visits

1. Reduce pubic symphysis pain to 3/10 at most

2. Restore and maintain pelvic symmetry with use of belt

3. Independent with a HEP

Treatment sequence

1. Manual therapy to decrease muscular spasming around pelvic floor and hip musculature

2. Muscle energy techniques to balance pelvis and sacrum

3. Fitted for sacroiliac support with appropriate strap positioning for ultimate hip/pelvic/lumbar support

4. Therapeutic exercises and stretches to balance out pelvic muscles

5. Wrote detailed note to doula and OB/GYN for positioning during delivery to reduce pubic separation

Patient experience after treatment and delivery

Yes, delivery went SO well! I ended up (accidentally?) laboring at home for almost the entire thing – by the time we got to the hospital, I was already 8cm! We got there a little after midnight, and he was born at 1:50AM! 9lbs 3oz and 21″ long. NO MEDS!! I am feeling really good as far as my PSD goes. My tailbone still gets pretty sore, but my pubic bone seems to be in pretty good shape. Thank you so much for helping me. You helped make this delivery was so much different than my first, and it was exactly how I wanted it to be 🙂

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