Low Back Pain and Pregnancy: Difference between revisions

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'''Original Editors '''- [[User:Timothy Assi|Timothy Assi]]
'''Original Editors '''  


'''Lead Editors''' - Your name will be added here if you are a lead editor on this page.&nbsp; [[Physiopedia:Editors|Read more.]]  
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== Search Strategy  ==
== Search Strategy  ==


Using PubMed, I combined various terms for searching articles regarding the subject. At first, I found some articles giving specific information concerning low back pain in pregnancy and the epidemiology, risk factors, cause. Later on, I searched for articles including physiotherapy and its treatment. Because there was an overload of information with contradictory studies, it was difficult to exclude some information. I searched for new articles in the references for other relevant studies and visited many libraries for a book on this subject. Eventually I found a few books about low back pain itself, but not really in relation to pregnancy.
'''Databases''':PubMed, CINAHL, Cochrane, JOSPT


== Definition/Description  ==
<br>
 
'''Key words''': Pregnancy, Manual Therapy, Physical Therapy, Low Back Pain, Exercise


Pregnancy-related low back pain and/or [[Pregnancy Related Pelvic Pain|pregnancy-related pelvic girdle pain]] (PPGP) are two different common complaints that can occur separately or combined.<ref name="Endresen">Endresen EH. Pelvic pain and low back pain in pregnant women – an epidemiological study. Scan J Rheumatol. 1995; 24: 135–41.</ref> Ostgaard et al. created criteria defining the differences between [[Low Back Pain|low back pain]] and posterior pelvic pain – although it is unclear why a distinction is made. Low back pain is situated above the [[Sacrum|sacrum]] and mostly provoked when a patient was asked to bend over (forward flexion). He observed decreased motion in the [[Lumbar spine|lumbar spine]] and pain by palpation of the [[Erector spinae|erector spinae]]. Ostgaard also developed the [[Pelvic pain provocation test|pelvic pain provocation test]] to exclude pregnancy-related low back pain from PPGP.<ref name="Bastiaanssen">Bastiaanssen JM, de Bie RA, Bastiaenen CH, Essed GG, van den Brandt PA.A historical perspective on pregnancy-related low back and/or pelvic girdle pain. Eur J Obstet Gynecol Reprod Biol. Maastricht. 2005 (D)</ref><ref name="Ostgaard, Reduction of back and posterior pelvic pain in pregnancy">H.C. Ostgaard, G. Zetherstrom, E. Roos-Hansson and B. Svanberg.Reduction of back and posterior pelvic pain in pregnancy . Spine 19. 1994; pp. 894–900 (B)</ref><ref name="Ostgaard, The posterior pelvic pain provocation test in pregnant women">Ostgaard HC, Zetherstrom G, Roos-Hansson E. The posterior pelvic pain provocation test in pregnant women. Spine . 1994;3:258–60.(B)</ref>
'''Search Timeline''': April 12th 2011-May 1st 2011


== Clinically Relevant Anatomy<ref name="Kapandji, deel 3">I.A. Kapandji. Bewegingsleer deel III de romp en wervelkolom. Bohn Stafleu van Loghum. Houten. 2009; 257 pages.</ref>  ==
== Definition/Description<br>  ==


The lower back region – also called the [[Lumbar|lumbar]] region – is part of the spine and consists of five[[Vertebrae|vertebrae]]. This region has his own specific curvature - the lumbar [[Lordosis|lordosis]], different from the upper [[Thoracic|thoracic]] and [[Cervical|cervical]] region. These five lumbar vertebrae are also larger and wider because of their weight-bearing properties. The sacrum and [[Coccyx|coccyx]] are situated below the lumbar region. Two important [[Ligament|ligaments]] connect the vertebral bodies of the spine: [[Longitudinale ligament|lig. longitudinale]] anterior and posterior. These long ligaments are attached to an [[Intervertebral disc|intervertebral disc]] between two consecutive vertebrae. [[Ligament flavum|Lig. flavum]], [[Ligament interspinale|lig. interspinale]], [[Ligament intertransversarium|lig. intertransversarium]], lig. anterius and posterius are other ligaments that provide stability due to the firm connection between the vertebrae. Furthermore, it is important to observe the functionality of some muscles related to low back pain: [[Muscles of back|back muscles]], [[Pelvic muscles|pelvic muscles]] and [[Abdominal muscles|abdominal muscles]].  
Low back pain is a common complaint that occurs in 60-70% of pregnancies. (1) It can begin at any point during pregnancy, and approximately one third of these women suffer from severe pain. (2) This is know as either Low Back Pain (LBP) or Peripartum Posterior Pelvic Pain (PPPP). There is limited research available regarding Physical Therapy intervention for pregnant women suffering from Low Back Pain, and for this reason, a homogenous approach tends to be used. As we know, Low Back Pain is not homogenous, and special considerations and precautions should be taken when treating this population. Pregnancy-related Low Back Pain can be defined as pain that is anywhere between the 12th rib and the gluteal folds/pubic symphysis during the course of pregnancy that is not the result of a known pathology such as disc herniation. (3) (4) <br><br>


== Epidemiology /Etiology  ==
== Epidemiology /Etiology  ==


Previous studies (or reviews) investigated the prevalence of low-back pain during pregnancy in various populations. The results seemed very variable, ranging from 24% to more than 89,8%.<ref name="Endresen" /><ref name="Bastiaanssen" /><ref name="Mogren">Mogren IM, Pohjanen AI. Low back pain and pelvic pain during pregnancy: prevalence and risk factors. Spine . 2005 Apr 15;30(8);983-91.(C)</ref><ref name="Ostgaard, Prevalence of back pain in pregnancy">Ostgaard HC, Andersson GBJ, Karlsson K. Prevalence of back pain in pregnancy. Spine 1991; 16: 549–52.(C)</ref><ref name="Orvieto">Orvieto R, Achiron A, Ben-Rafael Z, Gelernter I, Achiron R. Low back pain of pregnancy. Acta Obstet Gynaecol Scand. 1994; 73: 209–14.(C)</ref><ref name="Ansari">Ansari NN, Hasson S, Naghdi S, Keyhani S, Jalaie S. Low back pain during pregnancy in Iranian women: Prevalence and risk factors. Physiotherapy Theory and Practice, 26(1):40–48, 2010(C)</ref>&nbsp;The international reported prevalence of PPGP - and/or low back pain - in the Netherlands was between 45% and 89%.<ref name="Bastiaenen">C.H.G. Bastiaenen, E.J.M. Hendriks,A.L. Pool-Goudzwaard,N.T.M. Bernards,M.L. van Engelenburg-van Lonkhuyzen, C.P. Albers-Heitner,J. van der Meij,M.H.M. Grupping-Morel,R.A. de Bie. KNGF-richtlijn, Zwangerschapsgerelateerde bekkenpijn, Nederlands Tijdschrift voor Fysiotherapie,Jaargang 119 · Nummer 1; 2009 (D)</ref>  
The exact etiology of LBP during pregnancy is unknown, but there are known factors that are believed to be contributers. During pregnancy, hormonal changes occur, specifically the release of the hormone Relaxin, which is thought to contribute to ligament laxity, softening of cartilage, and the proliferation of synovium. (2) This causes ligament laxity specifically in the Sacro-Iliac Joint, and the Pubic Symphysis.  
 
Another contributer is the increase in weight which is an average of 25-35 pounds gained during&nbsp;pregnancy. The weight gain&nbsp;increases the amount of force placed across joints, changes the center of gravity, and forces the patient into an anterior pelvic tilt. The anterior displacement of the center of gravity will cause women to shift their heads and upper body posteriorly over the pelvis, causing hyperlordosis of the lumbar spine, which places additional stress on the intervertebral discs, ligaments, and facet joints that can lead to joint inflammation. In addition, abdominal muscles are stretched and weakened, and the added weight can compress on the lumbosacral plexus. There are additional theories that vascular changes&nbsp;may occur during pregnancy, including pressure changes in the vena cava and aorta that lead to water retention, cause hypervolemia, decreased cardiac output, lower the blood pressure and raise heart rate, which can lead to ischemia and metabolic changes, inducing low back pain.  
 
<br>Risk factors for Low Back Pain during pregnancy include a history of LBP during pregnancy, multiple abortions, and smoking. (4)
 
Also another&nbsp;condition which may occur during pregnancy is called Diastasis Rectus Abominis, which is the separation of the Rectus Abdominis at the Linea Alba,&nbsp;leading to poor posture and LBP. (5)
 
While values are not known in the United States, in a single year in Sweden, sick leave associated with LBP in pregnancy accounted for $2.5 billion. (9)  
 
<br><br>  


== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==


There is a lack of scientific clarity to the mechanism of this injury, yet there are several possible reasons. During pregnancy, changes occur in the facet joints, back muscles, ligaments and disc, which can affect the stability of the spine and lead to back pain. Increasing weight of the fetus causes a larger abdominal volume, allowing the abdominal muscles to be stretched and impaired.<ref name="Dequeker">J. Dequeker. Chronische lage rugpijn en invaliditeit – rugpijn in gynaecologie. Acco Leuven. 1979; 141 pages</ref><ref name="Gilleard">Wendy L Gilleard, J Mark M Brow.Structure and function of the abdominal muscles in primigravid subjects during pregnancy and the immediate postbirth period. Physical Therapy, 1996; 750-62(C)</ref> Static equilibrium interruption of the back and abdomen changes the center of gravity, resulting in posture adjustments and extra mechanical stress on the back.<ref name="Dequeker" /><ref name="Russell">R Russell, F Reynolds. Back pain, pregnancy, and childbirth. British medical journal. 1997;1059-1064.</ref><ref name="Wong">W. W. K. To, M. W. N. Wong. Factors associated with back pain symptoms in pregnancy and the persistence of pain 2 years after pregnancy. Acta Obstetricia et Gynecologica Scandinavica. 2003; 1086-91.(C)</ref>&nbsp;As pregnancy progresses, [[Relaxine|relaxine]] concentration rises causing laxity of the lig. longitudinalis and weakening this strong ligament. The concentration of relaxin in women with severe pelvic girdle pain in pregnancy is significantly higher than woman without back pain.<ref name="Russell" /><ref name="MacLennan">MacLennan AH, Nicolson R, Green RC, Bath M. Serum relaxin and pelvic pain of pregnancy. Lancet 1986;243-5.(B)</ref>&nbsp;Risk factors that increase the complaints were similar in some studies<ref name="Mogren" /><ref name="Ostgaard, Prevalence of back pain in pregnancy">HC, Andersson GBJ, Karlsson K. . Spine 1991; 16: 549–52</ref><ref name="Bastiaenen" /><ref name="Ostgaard, Previous back pain and risk of developing back pain in a future pregnancy">Ostgaard HC, Andersson GBJ. Previous back pain and risk of developing back pain in a future pregnancy. Spine 1991; 16: 433–6.(C)</ref>: previous backpain history before pregnancy and [[Multiparity|multiparity]]. Some authors<ref name="Orvieto" /><ref name="Meeusen">R. Meeusen. Praktijkgids Rug-en nekletsels deel1. Kluwer. 2001;154-56pages</ref> believe that age, weight and height of the mother, fetal weight, the number of pregnancies, etc. are not risk factors, but this stays unclear since there are many studies with contradictory results.<ref name="Bastiaanssen" /> The prevalence of low-back pain during pregnancy also depends on the moment of pregnancy, which is measured the highest during the third trimester of the pregnancy.<ref name="Ansari" /><ref name="Bastiaenen" />
The most common onset tends to be during the 5th and 6th month of gestation, and the pain is usually worse later on in the day. 67% of women suffer from pain at night. Factors that aggravate the pain include: standing, sitting, coughing or sneezing, walking, and straining during a bowel movement. During the physical exam, the paravertebral muscles are tender to palpation, the muscles of the back are weak during testing, and there is possible decreased ROM in flexion. The description of the pain is not localized at times, and may be intermittent. It is possible for the pain to radiate down as far as the calf. (4)<br><br>
 
== Differential Diagnosis  ==
 
There are other musculoskeletal disorders to consider, including Sciatica, Meralgia Paresthetica, Thoracic/Rib pain, Hip pain, coccodynia, spontaneous abortions, osteomyelitis, osteoarthritis, osteitis condensans ilii, metastatic cancers, and Diastasis Recti.  


== <br>Differential Diagnosis ==
Differential Diagnosis for Disc Disease (7)


add text here
Morning pain and stiffness, weight bearing, age of the patient, increased abdominal pressure provokes pain, sleep not usually disturbed, eases as day progresses and then gets worse again, history of repeated micro trauma, movement eases pain but not for long (e.g. fidgets), going up hill provokes pain, sitting too long provokes pain especially in low chairs, getting out of a chair provokes pain


== Diagnostic Procedures  ==
Facet Joint Involvement


To formulate a diagnosis, the patient her history ([[Anamnesis|anamnesis]]), movement possibilities / limitations and [[Help-request|help-request]] must be known. This will help the physiotherapist understand the patient her health problem and needs. Knowledge of the anatomical and functional disorders, activity limitations and restriction of participation will help the physiotherapist to estimate his role within the physiotherapy. It is important to recognize specific complaints – known as [[Red flags|red flags]]. And if present, contact a doctor.<ref name="Bastiaenen" />
Non weight bearing, related to movement specifically rotation, pain increased by lateral compression, history of minor injury, pain is not usually referred to an extremity, eases with rest, not affected by coughing or sneezing


Different measure instruments can be used in the diagnosis to estimate the complaints more objectively: [[Visual analogue scale|Visual Analogue Scale]] (VAS)<ref name="Ronald">M. Ronald, J.R. Jenner. Back pain New approaches to rehabilitation and education. Manchester university press. 1989;258 pages</ref>, [[Roland‐Morris Disability Questionnaire|Roland Disability Questionnaire]] (RDQ), [[Impact on Participation and Autonomy|Impact on Participation and Autonomy]] (IPA), [[PHotograph series Of Daily Activities|PHotograph series Of Daily Activities]] (PHODA), [http://www.physio-pedia.com/extensions/FCKeditor/fckeditor/editor/Pain%20Behavior%20Scale Pain Behavior Scale] (PBS).
Sacroiliac Involvement<br>There is a definite laterality to pain, pain does not midline, can refer pain to the leg, turning in bed provokes pain, getting out of the car provokes pain, pain is referred to the groin or genitals, pain is related to menstruation prior to pregnancy because of the effects of cyclic hormones on pre-pregnant SIJ ligaments. <br>  


== Examination  ==
== Examination  ==


add text here related to physical examination and assessment
'''History'''
 
Subjective questions:
 
Have you experienced any complications with prior or the current pregnancy(s)?<br>Has the physician given any precautions for therapy or exercise?<br>Do you experience dizziness when lying on your back?<br>Any lightheadedness?<br>Is there anything you do that aggravates or eases the pain?
 
'''Physical Exam'''
 
During an examination of a patient who is pregnant, positioning is a key&nbsp;consideration.&nbsp;Excessive time in supine is not recommended due to the weight of the uterus on the vena cava and vital structures. (7) Examination&nbsp;should include observation of posture and&nbsp; gait, neurologic screen to rule out underlying pathology, range of motion, muscle tests, palpation, muscle length tests, and assessment of joint mobility. Special tests can include FABER and Trendelenberg.
 
Due to the level of pain and disability of the patient, and potentially the size of the pregnant abdomen, certain tests and measures may need to be modified for this population.
 
Modified Tests: (6)
 
Hip Flexor Length: To modify the test position, have the patient sit on the edge of a table or mat, and extend the test leg as much as possible, while maintaining slight knee flexion. The pelvis should be kept in a neutral alignment. The examiner in one case study assumed that if the patient had normal flexibility, she would able to extend her hip perpendicular to the floor.
 
<br>
 
[[Image:Modified Hip Flexor Assessment small.jpg|Image:Modified_Hip_Flexor_Assessment_small.jpg]]<br>
 
Modified Hip Flexor Assessment<br>
 
<br>
 
[[Image:Thomas Test small.jpg|Image:Thomas_Test_small.jpg]]<br>
 
Thomas Test
 
<br>
 
SI Joint Examination: The reliable test for measuring symmetry of the ASIS’ is in standing, but if the patient is unable to stand, a modification is to have the patient lying in supine, and have them perform a pelvic bridge. The purpose of the bridge is to align the pelvis in neutral, and then the ASIS’ can be palpated for symmetry in supine.
 
Innominate Torsion: The modification for this test is done in long-sitting. First, the patient was positioned in supine, and the medial malleoli are palpated, looking for discrepancies in length. Then, the medial malleoli are examined again in long-sitting, to see if there is any shortening of either leg .
 
Diastasis Recti Test: Position patient in hooklying, and have the patient lift the head and shoulders, and reach for their feet. Palpate the patient’s linea alba, and measure width of separation with fingers. One to 1.5 finger width separation is normal. Either two to 2.5 fingers or observation of a bulge at midline is considered abnormal, and the PT should exhibit caution with any intervention.<br><br>
 
== Medical Management (current best evidence)  ==
 
As a physical therapist, it&nbsp;is important to ask the patient if they are having regular check ups by their obstetrician, and if they have any&nbsp;contraindications regarding exercise. A variety of precautions should be taken to manage LBP during pregnancy. Some interventions include: encouraging sidelying while sleeping (can be assisted by using a wedge-shaped pillow), using compression socks to promote venous return to the heart and reduce edema, support belts, soft tissue massage, acetaminophen use if approved by MD (NSAIDs are contraindicated).
 
While further researcher is needed, the use of support belts has preliminarily been shown to be an effective tool for decreasing pain intensity, duration and effect on ADLs. One such belt is The Loving Comfort support belt which is covered by Medicaid. (7)
 
Precautions include: Avoiding heavy lifting, holding breath while performing exercises, no moist heat on lower back, ultrasound, and electrical-stimulation.
 
According to the American College of Obstetricians and Gynecologists, exercise should be avoided if the following signs or symptoms are experienced:
 
Vaginal bleeding, dizziness or feeling faint, increased shortness of breath, chest pain, headache, muscle weakness, calf pain or swelling, uterine contractions, decreased fetal movement, fluid leaking from the vagina. (4)<br>&nbsp;<br>
 
== Physical Therapy Management (current best evidence)  ==
 
Managment includes specific interventions to address pain, weakness,&nbsp;and mobilty in the pelvic girdle and low back region. After reviewing the research, common interventions that were found to be effective&nbsp;included: two maual therapy techniques and three therapeutic exercises.
 
<br>
 
Manual Interventions:
 
<br>
 
[[Image:Modified PA Mob small.jpg|Image:Modified_PA_Mob_small.jpg]]


== <br>Medical Management  ==
Posterior/Anterior Mobilizations in Sidelying to address pain and mobility&nbsp;(Grades 1-4).


add text here
<br>


== <br>Physical Therapy Management  ==
[[Image:Sidelying MET small.jpg|Image:Sidelying_MET_small.jpg]]


The way of treatment depends on the diagnosis and timing of pregnancy (before or after childbirth). Firstly, the patient should understand her own symptoms and be motivated to remain active. [[Back care advice|Back care advice]]&nbsp;<ref name="Orvieto" /> and exercise during second half of the pregnancy <ref name="Garshasbi">A. Garshasbi, S. Faghih Zadeh.The effect of exercise on the intensity of low back pain in pregnant women. International Journal of Gynecology and Obstetrics.2005; 88, 271—275(B)</ref> significantly reduces LBP. [[Postural education|Postural education]] can prevent unnecessary mechanical stress on the back <ref name="Sabino">J Sabino, Jonathan N. Grauer. Pregnancy and low back pain. Curr Rev Musculoskelet Med. 2008; 1:137–141(D)</ref>, therefore neutral postures during ADL and physical activities are recommended. Stability, coordination and functional preservation should be trained with [[Back exercise|active back exercises]] - endurance training for back muscles stabilization.<ref name="Meeusen" /> Pelvic tilts, knee pull, straight leg raising, curl up, lateral straight leg raising and water aerobics are recommended because it relieves lumbar pain in pregnancy.<ref name="Sabino" />
Muscle Energy Technique&nbsp;by resisting hip flexion&nbsp;while stabilizing the sacrum&nbsp;(to correct anterior innominate rotation)  


== Key Research  ==
<br>Exercises:


add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template)
<br>


== <br>Resources  ==
[[Image:Clams.JPG]]


add appropriate resources here
Strengthening gluteus medius with clams in sidelying position.


== <br>Clinical Bottom Line  ==
<br>  


add text here
&nbsp;<br>


== <br>Recent Related Research (from Pubmed)  ==
[[Image:Marching with ADIM small.jpg|Image:Marching_with_ADIM_small.jpg]]


see tutorial on Adding PubMed Feed
Abdominal Drawing in Maneuver&nbsp;sitting on physioball. Can progress exercise&nbsp;by combining&nbsp;ADIM&nbsp;with lower extremity marching.


<br>  
<br>  


[[Image:Lat Pull Down small.jpg|Image:Lat_Pull_Down_small.jpg]]
Latissimus dorsi pull-downs with glute sets to increase the strength of the posterior oblique sling mucles, which compress the SIJ.
<br>
Aerobic exercise: Walking, swimming, recumbent bicycle (or nustep), at a low to moderate intensity. The stress on the back should be minimal. <br><br>
== Resources <br>  ==
-See Recent Related Research
[[Low Back Pain in Pregnancy|Here]] is another page concerning lower back pain in pregnancy.
== Clinical Bottom Line  ==
Many pregnant women experience low back pain.&nbsp;Key questions must be asked and special modifications must be made with physical exam and treatment. Therefore, as&nbsp;patient centered&nbsp;practitioners, it is our job to research&nbsp;and implement evidence based practice to increase outcomes with minimal number of treatments with this special&nbsp;population.
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]]
<div class="researchbox">
<rss>http://eutils.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=14MpKbWO9zvFebubT4UTZKZm_0Q0VJ_VKdfcgw_JcJ0AWU29XI|charset=UTF-8|short|max=10</rss>
<br>
</div>
== References  ==
== References  ==


<references />
Special thanks to Jennifer Stone, PT


see adding references tutorial.
<references />


<br>  
1. Mogren IM, Pohjanen AI. Low back pain and pelvic pain during pregnancy.&nbsp;''Spine''. 2005;30:983-991.<br>2. Hall J, Cleland J, Palmer J. The Effects of Manual Physical Therapy and Therapeutic Exercise on Peripartum Posterior Pelvic Pain: Two Case Reports. ''Journal of Manual and Manipulative Therapy''. 2005;13(2): 94-102<br>3. Gutke A, Kjellby-Wendt G, Oberg B. The inter-rater reliability of a standardised classification system for pregnancy-related lumbopelvic pain. ''Manual Therapy''. 2010; 15: 13-18.<br>4. Sneag D, Bendo J. Pregnancy-related low back pain. ''Orthopedics''. 2007; 30: 839-845.&nbsp;<br>5. Jeffcoat H. Exercises for low back pain in pregnancy. ''Int J Childbirth Educ. ''2008; 23: 9-12.&nbsp;<br>6. Cullaty M. Suspected Sacroiliac Joint Dysfunction: Modifying Examination and Intervention During Pregnancy. ''Journal of Women's Health Physical Therapy''. 2006; 30(2): 18-24<br>7. Sandler SE. The Management of Low Back Pain in Pregnancy. ''Manual Therapy''. 1996; 1(4):178-185<br>8. Carr C. Use of a maternity support binder for relief of pregnancy-related back pain. ''JOGNN''. 2003; 32: 495-502.<br>9. Noren L, Ostgaard S, Nielsen TF &amp; Ostgaard HC. Reduction of sick leave for lumbar back and posterior pelvic pain in pregnancy. ''Spine''. 1997; 22: 2157-2160.<br>10. Huber L. Pelvic Pain in Pregnancy. ''Cinahl Information Systems''. 2009.<br>11. Freyder SC. Exercising While Pregnant. ''JOSPT''. 1989; 3: 358-365
 
<br><br><br>  


Template:VUB
[[Category:Texas_State_University_EBP_Project]]

Revision as of 10:25, 12 October 2012

Original Editors

Lead Editors - Your name will be added here if you are a lead editor on this page.  Read more.

Search Strategy[edit | edit source]

Databases:PubMed, CINAHL, Cochrane, JOSPT


Key words: Pregnancy, Manual Therapy, Physical Therapy, Low Back Pain, Exercise

Search Timeline: April 12th 2011-May 1st 2011

Definition/Description
[edit | edit source]

Low back pain is a common complaint that occurs in 60-70% of pregnancies. (1) It can begin at any point during pregnancy, and approximately one third of these women suffer from severe pain. (2) This is know as either Low Back Pain (LBP) or Peripartum Posterior Pelvic Pain (PPPP). There is limited research available regarding Physical Therapy intervention for pregnant women suffering from Low Back Pain, and for this reason, a homogenous approach tends to be used. As we know, Low Back Pain is not homogenous, and special considerations and precautions should be taken when treating this population. Pregnancy-related Low Back Pain can be defined as pain that is anywhere between the 12th rib and the gluteal folds/pubic symphysis during the course of pregnancy that is not the result of a known pathology such as disc herniation. (3) (4)

Epidemiology /Etiology[edit | edit source]

The exact etiology of LBP during pregnancy is unknown, but there are known factors that are believed to be contributers. During pregnancy, hormonal changes occur, specifically the release of the hormone Relaxin, which is thought to contribute to ligament laxity, softening of cartilage, and the proliferation of synovium. (2) This causes ligament laxity specifically in the Sacro-Iliac Joint, and the Pubic Symphysis.

Another contributer is the increase in weight which is an average of 25-35 pounds gained during pregnancy. The weight gain increases the amount of force placed across joints, changes the center of gravity, and forces the patient into an anterior pelvic tilt. The anterior displacement of the center of gravity will cause women to shift their heads and upper body posteriorly over the pelvis, causing hyperlordosis of the lumbar spine, which places additional stress on the intervertebral discs, ligaments, and facet joints that can lead to joint inflammation. In addition, abdominal muscles are stretched and weakened, and the added weight can compress on the lumbosacral plexus. There are additional theories that vascular changes may occur during pregnancy, including pressure changes in the vena cava and aorta that lead to water retention, cause hypervolemia, decreased cardiac output, lower the blood pressure and raise heart rate, which can lead to ischemia and metabolic changes, inducing low back pain.


Risk factors for Low Back Pain during pregnancy include a history of LBP during pregnancy, multiple abortions, and smoking. (4)

Also another condition which may occur during pregnancy is called Diastasis Rectus Abominis, which is the separation of the Rectus Abdominis at the Linea Alba, leading to poor posture and LBP. (5)

While values are not known in the United States, in a single year in Sweden, sick leave associated with LBP in pregnancy accounted for $2.5 billion. (9)



Characteristics/Clinical Presentation[edit | edit source]

The most common onset tends to be during the 5th and 6th month of gestation, and the pain is usually worse later on in the day. 67% of women suffer from pain at night. Factors that aggravate the pain include: standing, sitting, coughing or sneezing, walking, and straining during a bowel movement. During the physical exam, the paravertebral muscles are tender to palpation, the muscles of the back are weak during testing, and there is possible decreased ROM in flexion. The description of the pain is not localized at times, and may be intermittent. It is possible for the pain to radiate down as far as the calf. (4)

Differential Diagnosis[edit | edit source]

There are other musculoskeletal disorders to consider, including Sciatica, Meralgia Paresthetica, Thoracic/Rib pain, Hip pain, coccodynia, spontaneous abortions, osteomyelitis, osteoarthritis, osteitis condensans ilii, metastatic cancers, and Diastasis Recti.

Differential Diagnosis for Disc Disease (7)

Morning pain and stiffness, weight bearing, age of the patient, increased abdominal pressure provokes pain, sleep not usually disturbed, eases as day progresses and then gets worse again, history of repeated micro trauma, movement eases pain but not for long (e.g. fidgets), going up hill provokes pain, sitting too long provokes pain especially in low chairs, getting out of a chair provokes pain

Facet Joint Involvement

Non weight bearing, related to movement specifically rotation, pain increased by lateral compression, history of minor injury, pain is not usually referred to an extremity, eases with rest, not affected by coughing or sneezing

Sacroiliac Involvement
There is a definite laterality to pain, pain does not midline, can refer pain to the leg, turning in bed provokes pain, getting out of the car provokes pain, pain is referred to the groin or genitals, pain is related to menstruation prior to pregnancy because of the effects of cyclic hormones on pre-pregnant SIJ ligaments.

Examination[edit | edit source]

History

Subjective questions:

Have you experienced any complications with prior or the current pregnancy(s)?
Has the physician given any precautions for therapy or exercise?
Do you experience dizziness when lying on your back?
Any lightheadedness?
Is there anything you do that aggravates or eases the pain?

Physical Exam

During an examination of a patient who is pregnant, positioning is a key consideration. Excessive time in supine is not recommended due to the weight of the uterus on the vena cava and vital structures. (7) Examination should include observation of posture and  gait, neurologic screen to rule out underlying pathology, range of motion, muscle tests, palpation, muscle length tests, and assessment of joint mobility. Special tests can include FABER and Trendelenberg.

Due to the level of pain and disability of the patient, and potentially the size of the pregnant abdomen, certain tests and measures may need to be modified for this population.

Modified Tests: (6)

Hip Flexor Length: To modify the test position, have the patient sit on the edge of a table or mat, and extend the test leg as much as possible, while maintaining slight knee flexion. The pelvis should be kept in a neutral alignment. The examiner in one case study assumed that if the patient had normal flexibility, she would able to extend her hip perpendicular to the floor.


Image:Modified_Hip_Flexor_Assessment_small.jpg

Modified Hip Flexor Assessment


Image:Thomas_Test_small.jpg

Thomas Test


SI Joint Examination: The reliable test for measuring symmetry of the ASIS’ is in standing, but if the patient is unable to stand, a modification is to have the patient lying in supine, and have them perform a pelvic bridge. The purpose of the bridge is to align the pelvis in neutral, and then the ASIS’ can be palpated for symmetry in supine.

Innominate Torsion: The modification for this test is done in long-sitting. First, the patient was positioned in supine, and the medial malleoli are palpated, looking for discrepancies in length. Then, the medial malleoli are examined again in long-sitting, to see if there is any shortening of either leg .

Diastasis Recti Test: Position patient in hooklying, and have the patient lift the head and shoulders, and reach for their feet. Palpate the patient’s linea alba, and measure width of separation with fingers. One to 1.5 finger width separation is normal. Either two to 2.5 fingers or observation of a bulge at midline is considered abnormal, and the PT should exhibit caution with any intervention.

Medical Management (current best evidence)[edit | edit source]

As a physical therapist, it is important to ask the patient if they are having regular check ups by their obstetrician, and if they have any contraindications regarding exercise. A variety of precautions should be taken to manage LBP during pregnancy. Some interventions include: encouraging sidelying while sleeping (can be assisted by using a wedge-shaped pillow), using compression socks to promote venous return to the heart and reduce edema, support belts, soft tissue massage, acetaminophen use if approved by MD (NSAIDs are contraindicated).

While further researcher is needed, the use of support belts has preliminarily been shown to be an effective tool for decreasing pain intensity, duration and effect on ADLs. One such belt is The Loving Comfort support belt which is covered by Medicaid. (7)

Precautions include: Avoiding heavy lifting, holding breath while performing exercises, no moist heat on lower back, ultrasound, and electrical-stimulation.

According to the American College of Obstetricians and Gynecologists, exercise should be avoided if the following signs or symptoms are experienced:

Vaginal bleeding, dizziness or feeling faint, increased shortness of breath, chest pain, headache, muscle weakness, calf pain or swelling, uterine contractions, decreased fetal movement, fluid leaking from the vagina. (4)
 

Physical Therapy Management (current best evidence)[edit | edit source]

Managment includes specific interventions to address pain, weakness, and mobilty in the pelvic girdle and low back region. After reviewing the research, common interventions that were found to be effective included: two maual therapy techniques and three therapeutic exercises.


Manual Interventions:


Image:Modified_PA_Mob_small.jpg

Posterior/Anterior Mobilizations in Sidelying to address pain and mobility (Grades 1-4).


Image:Sidelying_MET_small.jpg

Muscle Energy Technique by resisting hip flexion while stabilizing the sacrum (to correct anterior innominate rotation)


Exercises:


File:Clams.JPG

Strengthening gluteus medius with clams in sidelying position.


 

Image:Marching_with_ADIM_small.jpg

Abdominal Drawing in Maneuver sitting on physioball. Can progress exercise by combining ADIM with lower extremity marching.


Image:Lat_Pull_Down_small.jpg

Latissimus dorsi pull-downs with glute sets to increase the strength of the posterior oblique sling mucles, which compress the SIJ.


Aerobic exercise: Walking, swimming, recumbent bicycle (or nustep), at a low to moderate intensity. The stress on the back should be minimal.

Resources
[edit | edit source]

-See Recent Related Research

Here is another page concerning lower back pain in pregnancy.

Clinical Bottom Line[edit | edit source]

Many pregnant women experience low back pain. Key questions must be asked and special modifications must be made with physical exam and treatment. Therefore, as patient centered practitioners, it is our job to research and implement evidence based practice to increase outcomes with minimal number of treatments with this special population.

Recent Related Research (from Pubmed)[edit | edit source]

see tutorial on Adding PubMed Feed

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References[edit | edit source]

Special thanks to Jennifer Stone, PT


1. Mogren IM, Pohjanen AI. Low back pain and pelvic pain during pregnancy. Spine. 2005;30:983-991.
2. Hall J, Cleland J, Palmer J. The Effects of Manual Physical Therapy and Therapeutic Exercise on Peripartum Posterior Pelvic Pain: Two Case Reports. Journal of Manual and Manipulative Therapy. 2005;13(2): 94-102
3. Gutke A, Kjellby-Wendt G, Oberg B. The inter-rater reliability of a standardised classification system for pregnancy-related lumbopelvic pain. Manual Therapy. 2010; 15: 13-18.
4. Sneag D, Bendo J. Pregnancy-related low back pain. Orthopedics. 2007; 30: 839-845. 
5. Jeffcoat H. Exercises for low back pain in pregnancy. Int J Childbirth Educ. 2008; 23: 9-12. 
6. Cullaty M. Suspected Sacroiliac Joint Dysfunction: Modifying Examination and Intervention During Pregnancy. Journal of Women's Health Physical Therapy. 2006; 30(2): 18-24
7. Sandler SE. The Management of Low Back Pain in Pregnancy. Manual Therapy. 1996; 1(4):178-185
8. Carr C. Use of a maternity support binder for relief of pregnancy-related back pain. JOGNN. 2003; 32: 495-502.
9. Noren L, Ostgaard S, Nielsen TF & Ostgaard HC. Reduction of sick leave for lumbar back and posterior pelvic pain in pregnancy. Spine. 1997; 22: 2157-2160.
10. Huber L. Pelvic Pain in Pregnancy. Cinahl Information Systems. 2009.
11. Freyder SC. Exercising While Pregnant. JOSPT. 1989; 3: 358-365