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| <div class="noeditbox">Welcome to [[ Vrije Universiteit Brussel Evidence-based Practice Project| Vrije Universiteit Brussel's Evidence-based Practice project]]. This space was created by and for the students in the Rehabilitation Sciences and Physiotherapy program of the Vrije Universiteit Brussel, Brussels, Belgium. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div><div class="editorbox"> | | <div class="noeditbox">Welcome to [[ Texas State University Evidence-based Practice Project| Texas State University's Evidence-based Practice project space]]. This is a wiki created by and for the students in the Doctor of Physical Therapy program at Texas State University - San Marcos. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div> <div class="editorbox"> |
| '''Original Editors '''- [[User:Timothy Assi|Timothy Assi]] | | '''Original Editors ''' |
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| '''Lead Editors''' - Your name will be added here if you are a lead editor on this page. [[Physiopedia:Editors|Read more.]] | | '''Lead Editors''' - Your name will be added here if you are a lead editor on this page. [[Physiopedia:Editors|Read more.]] |
| </div> | | </div> |
| == Search Strategy == | | == Search Strategy == |
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| 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.
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| == Definition/Description == | | == Definition/Description == |
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| 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>
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| == 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> ==
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| 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]].
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| == Epidemiology /Etiology == | | == Epidemiology /Etiology == |
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| 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> 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>
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| == Characteristics/Clinical Presentation == | | == Characteristics/Clinical Presentation == |
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| 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> 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> 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" />
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| == <br>Differential Diagnosis == | | == Differential Diagnosis == |
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| == Diagnostic Procedures ==
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| 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" />
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| 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).
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| == Examination == | | == Examination == |
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| add text here related to physical examination and assessment | | add text here <br> |
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| == <br>Medical Management == | | == Medical Management (current best evidence) == |
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| == <br>Physical Therapy Management == | | == Physical Therapy Management (current best evidence) == |
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| 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]] <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" />
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| == Key Research == | | == Key Research == |
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| add links and reviews of high quality evidence here (case studies should be added on new pages using the case study template) | | add links and reviews of high quality evidence here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br> |
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| == <br>Resources == | | == Resources <br> == |
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| == <br>Clinical Bottom Line == | | == Clinical Bottom Line == |
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| == <br>Recent Related Research (from Pubmed) == | | == Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed]) == |
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| | see tutorial on [[Adding PubMed Feed|Adding PubMed Feed]] |
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| == References == | | == References == |
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