Adapted Physical Activity and Pelvic Floor Function for Pelvic Girdle Pain During Pregnancy

Background and Rationale

Pregnancy induces substantial morphological, hormonal, and biomechanical changes that increase the risk of musculoskeletal pain, particularly pelvic girdle pain (PGP). Up to 63% of pregnant women experience PGP, which may significantly affect mobility, quality of life, and psychological well-being. Although international guidelines, including those of the American College of Obstetricians and Gynecologists (ACOG), recommend physical activity during pregnancy, few interventions specifically target PGP, and the role of pelvic floor function has been largely overlooked.

The pelvic floor contributes to lumbopelvic stability through myofascial connections and motor control. Dysfunction of the pelvic floor muscles is frequently observed in women with PGP, with symptoms such as hypertonicity, poor endurance, and ineffective contractions. Evidence suggests an association between pelvic floor dysfunction and pelvic pain, but no trial to date has combined adapted physical activity with targeted pelvic floor rehabilitation in pregnant women with PGP.

Objectives

The primary objective of this exploratory randomized controlled trial is to evaluate the effect of a combined intervention (adapted physical activity with optional individualized pelvic floor rehabilitation) on pain intensity and functional impact of PGP during pregnancy.

Secondary objectives include:

• To assess the effect of the intervention on pelvic symptoms and pelvic floor functionality.
• To explore the relationship between pelvic floor dysfunction and the course of PGP.
• To evaluate adherence and acceptability of the intervention program.

Study Design

This is a monocentric, randomized, controlled, open-label exploratory trial conducted at Hospital La Tour in Geneva, Switzerland. Forty pregnant women with clinically confirmed PGP will be randomly assigned (1:1) to an intervention group or a control group. Randomization will be stratified by gestational age and baseline pain intensity.

Intervention group: Weekly adapted physical activity sessions in group format (minimum 9 sessions, 60 minutes each), from enrollment until 36-38 weeks of gestation. Sessions alternate between land and pool settings and include lumbopelvic stabilization, core and multifidus strengthening, mobility, and cardiorespiratory training. Women identified with pelvic floor dysfunction at baseline (via the Pelvic Floor Distress Inventory, PFDI-20) will also be offered up to 9 sessions of individualized pelvic floor rehabilitation.

Control group: Standard prenatal follow-up and a flyer with evidence-based recommendations on safe physical activity during pregnancy. No supervised sessions are provided.

Study Population

Eligible participants are pregnant women ≤27 weeks of gestation with clinically confirmed PGP of moderate to severe intensity (VAS ≥3/10). Diagnosis requires typical pain localization and at least 3 positive clinical tests (e.g., P4 test, Patrick FABER, Menell, ASLR). Exclusion criteria include isolated low back pain without pelvic involvement or any medical contraindication to exercise during pregnancy.

Outcomes

• Primary outcomes:

• Pain intensity measured by the Visual Analog Scale (VAS, 0-10 cm).
• Functional impact of PGP measured by the Pelvic Girdle Questionnaire (PGQ, 25 items, score 0-100).
• Secondary outcomes:

• Physical activity (Pregnancy Physical Activity Questionnaire, PPAQ).
• Pelvic symptoms (Pelvic Floor Distress Inventory, PFDI-20).
• Pelvic floor function (PERFECT scheme by digital palpation).
• Adherence to intervention (≥75% of sessions attended).
• Acceptability (post-intervention questionnaire with Likert scales).

Assessments occur at baseline (≤27 weeks), late pregnancy (36-38 weeks), and 3 months postpartum.

Sample Size and Statistical Considerations

Sample size (n=40, 20 per group) was determined based on detecting a clinically meaningful reduction in VAS pain scores, with α=0.05, 95% power, and an expected large effect size (d=0.8). Data will be analyzed on an intention-to-treat basis using descriptive statistics, parametric or non-parametric tests as appropriate, and mixed linear models including relevant covariates (e.g., parity, baseline scores).

Duration and Timeline

The project will last 27 months in total. Enrollment will begin in September 2025 and end in December 2026. The last postpartum follow-up will occur in March 2027, and the study will close in October 2027. Individual participation lasts approximately 6-8 months.

Ethical Considerations

The study is categorized as minimal risk (Category A under Swiss ClinO). All interventions are non-invasive, adapted to pregnancy, and consistent with international standards for prenatal physiotherapy. Approval will be obtained from the Commission Cantonale d'Éthique de la Recherche sur l'être humain (CCER), affiliated with swissethics. Participation is voluntary, and women may withdraw at any time without affecting their standard care. Data will be managed securely in REDCap with strict confidentiality measures.

Significance

This trial will generate new evidence on a comprehensive approach integrating adapted physical activity with pelvic floor rehabilitation for managing pelvic girdle pain in pregnancy. If effective, it could inform physiotherapy practice and contribute to international guidelines, ultimately improving maternal health and quality of life.

Inclusion criteria

• Pregnant women aged ≥18 years
• Gestational age ≤27 weeks at enrollment
• Clinically confirmed pelvic girdle pain, defined as:
• Pain localized between the posterior iliac crest and the gluteal fold, particularly around the sacroiliac joints and/or pubic symphysis, Pain intensity ≥3/10 on Visual Analog Scale (VAS), At least 3 positive clinical tests among: Posterior Pelvic Pain Provocation (P4) test, Patrick's FABER, Menell's test, Active Straight Leg Raise (ASLR), and palpation of long dorsal sacroiliac ligament or symphysis pubis
• Ability to understand and provide written informed consent

Exclusion criteria

• Isolated low back pain without pelvic involvement
• Contraindications to exercise during pregnancy (e.g., severe preeclampsia, placenta previa after 26 weeks, risk of preterm labor, ruptured membranes, significant cardiac or pulmonary disease)
• Neurological, rheumatologic, or orthopedic conditions that may interfere with participation
• Insufficient French language proficiency to understand questionnaires and instructions
• Participation in another interventional study that could affect outcomes