Santé musculo-squelettique pendant la grossesse et le post-partum

• Use culturally safe, trauma- and violence-informed care. Explain why sensitive questions matter, ask permission, provide choices and account for previous healthcare, reproductive, pregnancy, birth, loss or interpersonal trauma (Public Health Agency of Canada, 2018).
• Patient and contextual information: age; sex and gender when clinically relevant; pronouns and preferred terms; language and communication needs; occupation or school; caregiving; activities and roles important to the patient; cultural practices; and community connections.
• Contexte de grossesse ou de post-partum : gestational age and estimated due date; date and outcome of the pregnancy; time since birth or pregnancy loss; gravidity and parity; multiple pregnancy; prenatal and postpartum care providers; and whether routine maternity follow-up is in place.
• Pregnancy, birth and recovery history: previous pregnancy-related musculoskeletal symptoms; current or previous pregnancy complications; mode of birth; labour duration and positioning; assisted birth; caesarean, perineal or abdominal wound; perineal tear or episiotomy; postpartum haemorrhage; infection; anaemia; infant feeding; and any activity or medical restrictions with their reason and review plan.
• Primary musculoskeletal concerns: onset, location, quality, intensity, irritability and pattern of pain, stiffness, swelling, weakness, numbness or tingling; trauma or sudden load; relationship to pregnancy or birth; and whether symptoms are improving, stable, fluctuating or worsening.
• Functioning and participation: effects on walking, transfers, turning in bed, stairs, self-care, household tasks, work or school, sleep, exercise, sexual activity, infant feeding, lifting, carrying, floor care, stroller use, caregiving and community participation.
• Pelvic and abdominal symptoms: pelvic pressure or heaviness; urinary or faecal leakage, urgency or retention; constipation; prolapse symptoms; pelvic or perineal pain; pain with sexual activity; abdominal-wall concern; wound pain; and the patient’s goals for pelvic health or abdominal recovery.
• Revue des systèmes corporels : constitutional symptoms; neurological; cardiovascular and peripheral vascular; respiratory; genitourinary and gastrointestinal; reproductive and obstetric; breast or chest; musculoskeletal and bone health; immune, infectious or inflammatory; endocrine or metabolic; skin and wound; haematologic or bleeding; sleep; cognition; and mood symptoms that may change safety, the differential diagnosis, exercise participation, medication decisions or referral.
• Health and safety context: hypertension or pre-eclampsia; diabetes; cardiac, respiratory or thromboembolic disease; bleeding disorder; inflammatory or autoimmune disease; cancer; osteoporosis or fracture risk; hypermobility; migraine; anaemia; infection; recent surgery, immobilization or trauma; and current medicines and supplements, including anticoagulants and medicines that affect alertness, balance or exercise response.
• Physical activity and recovery context: activity before and during pregnancy; current walking, aerobic, resistance and pelvic-floor activity; changes in load tolerance; fear or uncertainty about movement; access to rest and recovery; nutrition and hydration; sleep and fatigue; smoking; alcohol or substance use; and goals for return to work, exercise, running, sport or other valued activity.
• Psychological and social context: mood, anxiety, intrusive thoughts, birth or loss experience, body-image concerns, confidence, social support, caregiving load, partner or family support, safety at home, employment or leave, income, housing, food security, transportation, discrimination and access to maternity, rehabilitation, pelvic health, mental-health or lactation care.
• Soins et interventions antérieurs : education, activity change, exercise, pelvic health care, hands-on care, medication, braces or supports, mental-health care, obstetric or other medical care, and culturally grounded approaches tried; benefits, adverse effects, burden and reasons care was difficult to use or continue.
• Patient perspective: understanding of the symptoms; concerns about pregnancy, birth, healing, damage, infant safety, feeding or exercise; priorities, preferences, cultural context, expectations, strengths and what a meaningful improvement would look like.
• Flag review: check Red Flags and refer to the separate fixed Orange Flags and Yellow Flags modules when relevant. Reassess when pain, bleeding, fluid loss, neurological status, breathing, blood pressure, fetal movement, mood or general health changes.

Outcome measures

• Choose a small set that reflects the patient’s goals and can be repeated. Add a region- or symptom-specific measure only when it helps answer a clinical question.
• Patient-specific functioning: Patient-Specific Functional Scale (PSFS).
• Disability and participation: WHO Disability Assessment Schedule 2.0 (WHODAS 2.0).
• Qualité de vie : WHOQOL-BREF or another suitable validated quality-of-life measure.
• Pelvic girdle symptoms and activity: Pelvic Girdle Questionnaire (PGQ) when pelvic girdle pain is the working presentation (Stuge et al., 2011).
• Pelvic-floor symptoms: a validated measure matched to the concern can be added when it will guide pelvic health care. Check current access and licensing requirements before distributing a questionnaire.
• Physical performance: a repeatable task such as walking, sit-to-stand, stairs, carrying, balance or a patient-prioritized caregiving task can be added. Record the conditions and symptom response.
• Individual goals and recovery: agree on patient-defined goals and how progress will be recognized. A global rating of change or recovery can support review when useful.

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

• Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
• Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
• Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

• Suicide or self-harm thoughts: thoughts without immediate danger.
• Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
• Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

• Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
• Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
• Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
• Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

• Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
• Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
• Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
• Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
• Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
• Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

• Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
• Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
• Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
• Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
• Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.

Select examination elements that answer a clinical question or may change safety, the working presentation, care or referral. Adapt pace, positioning, exposure and loading to gestational or postpartum stage, symptoms, healing, fatigue, feeding needs, trauma history, mobility and patient preference.

• Ongoing consent, dignity and comfort: explain each step, offer choices, ask permission before touch or exposure, provide draping, offer a chaperone according to policy and preference, and stop or modify the examination when requested. Internal pelvic examination is not routine and is completed only by a clinician with appropriate competence, consent and scope.
• Immediate safety and general observation: observe general appearance, breathing, posture, gait, transfers and spontaneous movement. Record blood pressure and other vital signs when obstetric, cardiovascular, respiratory, infectious or systemic concern is present, and act on abnormal findings within local protocols.
• Positioning: use comfortable alternatives and frequent position changes. Avoid prolonged supine positioning when it causes light-headedness, nausea, pallor or other symptoms of aortocaval compression, particularly later in pregnancy.
• Regional musculoskeletal examination: examine the symptomatic spine, pelvic girdle, hip, thorax or upper limb with active and passive movement, resisted testing, palpation and focused tests only when results may change care. Use the least provocative approach needed and record symptom response, strength, movement quality and capacity.
• Pelvic girdle examination: assess walking, rolling, transfers, stairs, single-leg loading and other relevant tasks. A small cluster of pain-provocation and functional tests can support a pelvic girdle pain presentation after lumbar, hip and serious causes are considered; no single test establishes the diagnosis.
• Neurological and vascular examination: assess strength, sensation, reflexes, coordination, neural tension or upper motor neuron findings when indicated. Assess limb swelling, tenderness, perfusion and pulses when vascular concern is plausible without using a musculoskeletal test to rule out thrombosis.
• Abdominal wall and wound context: inspect and assess the abdominal wall, linea alba behaviour, breathing, pressure management and function when relevant. Inter-recti distance can be recorded consistently when it will change care, but width alone does not define disability or treatment need. Inspect caesarean or perineal healing only within scope and with explicit consent (Gluppe et al., 2024).
• Pelvic-floor context: ask permission to screen bladder, bowel, prolapse, pain and sexual symptoms. When within competence and scope, assess the ability to contract, relax and coordinate the pelvic floor with breathing and functional tasks; otherwise arrange pelvic health assessment.
• Physical performance and caregiving tasks: select meaningful measures of walking, sit-to-stand, stairs, balance, lifting, carrying, feeding position, floor transfer or return-to-activity capacity. Record symptoms, confidence, quality, assistance and test conditions.
• Investigations and imaging: tests are not routine solely because a patient is pregnant or postpartum. Imaging and medical investigation follow Red Flags, the working differential and whether the result is likely to change care. Pregnancy status and radiation or medication exposure are communicated to the imaging or medical team.
• Reassessment: repeat the findings and tasks needed to review progress, revisit the working presentation, identify adverse effects and decide whether further assessment or shared care is appropriate.

Working clinical presentations

Use these as working clinical descriptions rather than fixed stages. Presentations can overlap or change, and a serious obstetric, medical or psychiatric condition can coexist.

• Pregnancy-related low back or pelvic girdle pain: pain is located between the posterior iliac crest and gluteal fold, at the pubic symphysis, or in the lumbar region and is influenced by walking, stairs, rolling, standing, single-leg loading or other activities. Examination supports a mechanical lumbopelvic presentation after serious, hip, neurological and obstetric causes are considered.
• Postpartum low back or pelvic girdle pain: symptoms continue or begin after the pregnancy and affect mobility, sleep, caregiving, work or return to activity. Birth recovery, previous pain, symptom severity, mood, sleep and access to support can influence the course (Wiezer et al., 2020).
• Pelvic-floor presentation: urinary or faecal leakage, urgency, prolapse symptoms, pelvic pressure, pelvic or perineal pain, sexual pain, poor pelvic-floor coordination or reduced confidence affects activity and participation.
• Abdominal-wall or diastasis-related presentation: concern about abdominal separation, pressure control, trunk function, appearance or task capacity is present. Inter-recti distance is one finding and does not by itself establish impairment severity or the need for treatment (Gluppe et al., 2024).
• Upper-limb or cervicothoracic presentation: wrist, thumb, hand, shoulder, neck or thoracic symptoms relate to local loading, fluid-related nerve symptoms, feeding, lifting, carrying, sleep position, equipment or work. Use the relevant regional pathway when appropriate.
• Hip, coccyx or other regional presentation: symptoms fit a local musculoskeletal condition after obstetric, fracture, inflammatory, neurological and referred causes are considered. Use the relevant regional pathway and retain pregnancy or postpartum factors that change positioning, loading or shared care.
• Deconditioning or return-to-activity presentation: reduced strength, endurance, balance, confidence or load tolerance affects daily activity, work, running, sport or recreation, with or without regional pain or pelvic-floor symptoms.
• Alternative or systemic presentation: the pattern fits an obstetric, vascular, hypertensive, infectious, inflammatory, neurological, traumatic, gynaecologic, cardiopulmonary or psychiatric condition better than a musculoskeletal presentation. Revisit Red Flags and arrange appropriate assessment.

Develop care with the patient and coordinate with maternity, primary care and other providers when needed. Choices reflect gestational or postpartum stage, the working presentation, safety, healing, goals, preferences, culture, access, infant feeding, caregiving, other health conditions, previous responses and treatment burden. Respect the patient’s right to accept, decline, limit or stop any part of care.

Education, self-management and participation

• Understanding symptoms: validate the patient’s experience and explain the working presentation without describing symptoms as inevitable, harmless or caused by a single structural change. Discuss reasons for reassessment and shared care.
• Daily activity and caregiving: pacing, task variation, brief recovery periods, comfortable sleep and feeding positions, changes to lifting or carrying, help with caregiving, and gradual return to valued activity can reduce avoidable disruption without making rest the main strategy.
• Protection and optimal loading: temporary support, an aid, task modification or reduced loading can help after injury, during a marked flare or while tissue healing or a serious condition is clarified. Progress toward tolerable, meaningful loading as safety, healing and symptoms allow; routine immobilization is not needed for uncomplicated musculoskeletal symptoms.

Physical activity and exercise

• Pregnancy physical activity: in an uncomplicated pregnancy, options can work toward at least 150 minutes of moderate-intensity activity each week over at least three days, using aerobic and resistance activity and daily pelvic-floor muscle training. Type, dose and progression reflect previous activity, symptoms, gestational stage, medical guidance and patient preference (Mottola et al., 2018).
• Postpartum physical activity: early light-intensity activity can begin as tolerated, followed by an individualized, gradual and symptom-based progression. Options can work toward at least 120 minutes of moderate-to-vigorous activity over four or more days each week, combining aerobic and resistance activity. Progression to moderate-to-vigorous activity follows sufficient healing of incisions and perineal tears and no increase in vaginal bleeding (Davenport et al., 2025).
• Exercise screening and modification: the Get Active Questionnaire for Pregnancy ou Get Active Questionnaire for Postpartum can support identification of medical guidance needs. Exercise is paused and the appropriate maternity or medical team contacted for vaginal bleeding, possible amniotic fluid leakage, regular painful contractions, dizziness, headache, chest pain, unusual shortness of breath, calf pain or swelling, or muscle weakness affecting balance (American College of Obstetricians and Gynecologists, 2020).
• Lumbopelvic rehabilitation: individualized aerobic, resistance, mobility, trunk and hip exercise can be graded around symptoms and goals. Movement and task strategies, walking or other preferred activity, and a trial of a pelvic support belt can be combined when they improve a specific activity; response determines continuation.
• Pelvic-floor rehabilitation: training can include awareness, coordination, strengthening, endurance, relaxation and integration with breathing and functional tasks according to the examination. Daily pelvic-floor muscle training is part of the Canadian postpartum guideline, while pain or an overactive presentation can require relaxation and down-training rather than repeated strengthening alone (Davenport et al., 2025; Woodley et al., 2020).
• Abdominal-wall rehabilitation: progressive abdominal and whole-body exercise can target trunk capacity and meaningful tasks. There is no established single best program for diastasis recti, and changes in inter-recti distance are interpreted alongside symptoms, confidence and functioning (Gluppe et al., 2024).
• Return to running, impact, heavy lifting or sport: progression is based on healing, symptoms, pelvic-floor and abdominal response, strength, balance, impact tolerance, sleep and recovery, previous activity and the demands of the goal. A single universal postpartum date or test does not establish readiness.

Hands-on, supportive and comfort strategies

• Hands-on care: regional mobilization, spinal manipulation, soft-tissue techniques or massage can accompany active care when a short-term goal is to improve comfortable movement or participation. The evidence does not establish one individual hands-on intervention as consistently effective for pregnancy- or postpartum-related lumbopelvic pain. Positioning, pressure, consent and response are reviewed at each visit; hands-on care is not used as the sole approach (Weis et al., 2020a; Weis et al., 2020b; Weis et al., 2022).
• Safety and informed consent: published adverse-event evidence for spinal manipulation during pregnancy and postpartum is limited and does not allow incidence or relative risk to be estimated. Technique and positioning reflect gestational or postpartum stage, comfort, hypermobility, symptoms and contraindications, with discussion of expected benefits, uncertainty, alternatives and the option to decline or stop care (Weis et al., 2021; Weis et al., 2022).
• Supports and equipment: a short trial of a pelvic belt, wrist or thumb support, pillow, feeding support, mobility aid or task-specific equipment can be used when it improves a defined activity. Fit, skin, circulation, dependence and continued need are reviewed.
• Comfort strategies: heat, cold, breathing, relaxation, water-based activity or another acceptable strategy can support movement, rest or participation when safe. Avoid overheating in pregnancy, protect skin and circulation, and review whether the strategy helps the agreed goal.

Psychological, social and interdisciplinary support

• Sleep, mood and coping: practical sleep support, pain-coping skills, relaxation, psychological care and perinatal mental-health services can be integrated when sleep, anxiety, depression, trauma, intrusive thoughts or distress affects functioning and these options match the patient’s priorities.
• Caregiving, work and access: partner or family support, workplace changes, community services, lactation support, occupational therapy, social care and culturally grounded supports can be combined according to identified barriers and patient preference.
• Pelvic, obstetric and medical shared care: coordinate with pelvic health, midwifery, obstetric, primary care, lactation, mental-health or other services when the presentation crosses scopes or an exercise precaution, wound, bleeding, pelvic health, feeding or medical issue needs follow-through.

Medication and supplement shared care

• Médicament : decisions about pain medicines or other drugs during pregnancy or lactation sit with an authorized prescriber or pharmacist. Review indication, benefits, adverse effects, interactions, pregnancy or infant-feeding context and effects on alertness, balance or exercise.
• Supplements and natural health products: questions are reviewed with an authorized prescriber or pharmacist. Discuss evidence, product authorization, dose, interactions, duplication, adverse effects and cost rather than assuming that a product labelled natural is safe in pregnancy or lactation.

Not part of routine care

• Prolonged bed rest or broad activity restriction for uncomplicated musculoskeletal symptoms.
• Passive physical modalities, hands-on care, taping, bracing or support garments used as stand-alone care in place of active care and self-management.
• A one-size-fits-all six-week clearance, a fixed return-to-running date or pressure to return to pre-pregnancy appearance or performance on a preset timeline.
• Using pain, posture, joint sounds, pelvic alignment or inter-recti distance alone to claim damage, instability or treatment need.
• Internal pelvic examination, perineal or breast or chest examination, or exposure without explicit informed consent, appropriate competence and clinical need.

Monitoring and reassessment

• Agree on a reassessment point based on gestational or postpartum stage, symptom course, safety, healing, goals, the options being tried, patient needs and access rather than a fixed visit schedule.
• Repeat the small outcome set recorded at baseline and review pain, bleeding or wound change, activity tolerance, strength, pelvic-floor and abdominal symptoms, task performance, functioning, participation, confidence, benefits, adverse effects, treatment burden and progress toward patient-defined goals.
• Continue what is useful and acceptable; adapt or stop what is not; and revisit Red Flags, the working presentation, differential diagnosis, investigation, referral or shared care when progress differs from expectations or new safety concerns emerge.

• Expected course: many pregnancy-related musculoskeletal symptoms improve after birth, but recovery varies by presentation, symptom severity, pregnancy or birth events, sleep, caregiving and access to care. Pelvic girdle, low back, pelvic-floor or abdominal symptoms can persist, and there is no single postpartum recovery timeline (Wiezer et al., 2020).
• Factors associated with a less favourable course: previous low back or pelvic girdle pain, more severe or multisite pelvic pain in pregnancy, greater limitation in functioning, other pain conditions, depressive symptoms, higher physical workload and relevant comorbidity have been associated with persistent postpartum lumbopelvic symptoms. These are group-level associations, not certain causes or individual predictions (Wiezer et al., 2020).
• Potential supports for recovery: validating information, feasible activity and exercise, gradual loading, pelvic-floor and abdominal rehabilitation when indicated, sleep and mental-health support, help with caregiving and work demands, timely medical or pelvic health shared care, and access to preferred services may support functioning and participation.
• Discussing prognosis: describe uncertainty in plain language, ask what the patient wants to know, and update the outlook using goals, repeated outcomes and the observed response over time. Do not use mode of birth, postpartum week, pain intensity, inter-recti distance or one examination finding as a fixed prediction.