Lumbopelvic pain pregnancy

Dr D. Muller

Family chiropractor at Yonge & Eglinton

How does pregnancy affect low back pain? What about epidural?

How does pregnancy affect low back pain? What about epidural?

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During pregnancy, serious pain affect about 25%, and severe disability in about 8% of women. During the post partum nearly 7% of all women develop serious problems. The mechanisms that cause disabilities remain unclear. Modifications in muscle activity, abnormal perceptions of the leg with movement, and altered motor coordination were observed but are still poorly understood.

In general, around 45% of all pregnant women and 25% of all postpartum women suffer from pregnancy-related pelvic girdle pain and pregnancy-related low back pain (LBP). Contrary to low back pain in pregnancy, the prevalence of pelvic pain in pregnancy was found to be higher in second and later pregnancies. Vigorous work, previous episodes of low back pain, previous lumbopelvic pain during or after pregnancy are risk factors that are strongly correlated with low back pain during and after pregnancy.

Study indicates weak evidence linking epidural anesthesia with low back pain after pregnancy. Low back pain during the post-partum was reported to naturally improve in 3 months in 93% of cases, whereas the 7% who did not get better turned out to be at high risk for persistent severe pain. The general descriptions of pregnancy-related low back pain are: pelvic girdle pain usually presents as “stabbing”; pain located in the lower back is described as a “dull ache”, and pain in the thoracic spine is usually reported as “burning”.

In a group of pregnant women with lumbopelvic and/or thoracic pain, the examiners reported “shooting pain” in 80% of patients, a “feeling of oppression” in 65%, and both “a sharp twinge” and “dull pain” in 50%. Pelvic girdle pain has been reported to be more severe than LBP during pregnancy, while the reverse situation was observed postpartum. Prolonged standing and walking were the most common triggers of pain.

Chiropractic care helps the patients improving pain, discomfort, stiffness and even the baby’s optimal position and the progression of labour.

Dr. D Muller, BSc, DC, Webster Certified, ICPA Member

APA 2017 Momentum Conference Lumbopelvic Summary

Three weeks ago, I attended the Australia Physiotherapy Association Momentum 2017 conference in Sydney. It was my first time attending a conference, and it was amazing! I expected to feel brain-dead and be sick of research and statistics by the end of the conference. Instead, I learnt something from every presentation, caught up with a lot of colleagues and friends, and challenged my current understanding of physiotherapy.

So I thought I would give a summary of my conference, the interesting tid-bits I learnt, or journal articles which piqued my interest.

1) Low Back Pain

Tim Mitchell, Specialist Musculoskeletal Physio

Tim Mitchell

A Clinical Framework for Identifying Modifiable & Non-modifiable Contributors to Disabling Low Back Pain

Tim works at Curtin University with Darren Beales, Peter O’Sullivan and Helen Slater, coordinating and presenting on the undergraduate and Masters physiotherapy programs. They have developed a framework to “demystify” the lumbar spine, effectively summing up all aspects of assessing and managing a lumbar spine injury.

It is continuing to be updated, with feedback from clinicians, so feel free to critique the framework. I believe the framework provides a lovely base to then work from, especially in your first 10 years of physiotherapy. It addresses joint factors, movement patterning impairments, psychological contributors, motivations and barriers to recovery.

The framework is available for purchase on iBooks, titled Musculoskeletal Clinical Translation Framework, by Tim Mitchell, Darren Beales, Helen Slater and Peter O’Sullivan, for $19.99 with proceeds donated back to Curtin University physiotherapy program. The framework gives clinical examples and case studies to work through, using the framework. For those undergoing, or planning on undertaking, Masters post-graduate studies, this would be a great resource.

Images courtesy of Tim Mitchell, APA 2017

Peter O’Sullivan, Specialist Musculoskeletal Physiotherapist

Peter O’Sullivan

Cognitive Functional Therapy for Disabling Low Back Pain

Peter followed Tim, discussing the cognitive functional therapy model which Peter developed to treat low back pain.

I have had many discussions in the past few years about Peter’s approach to treating lumbar pain. To clarify, Peter is a manual therapist, he puts his hands on every patient he assesses and treats. However, due to Peter’s skill set and reputation, he sees predominantly chronic low back pain patients with pain lasting at least 6 months who haven’t responded to manual therapy with previous therapists. His clientele often aren’t appropriate for extensive manual therapy, as this hasn’t been effective, however Peter will always put his hands on the patient to assess muscle tone, muscle activation, joint mobility etc.

There is the tendency to assume that Peter utilises exercise therapy with every patient, and avoids manual therapy, however again this is appropriate to his clientele. The cognitive functional therapy approach includes manual therapy, exercise therapy, education, psychology and referral for additional services if required, addressing the individual aspects of a patient’s condition, individualised to each patient. The moral of the story is assess the patient’s mobility, motor patterning, habits, behaviours and then address them, using a multi-faceted program, relevant to each individual patient.

So after all that, what did Peter actually talk about at the conference?

  • Peter used this word to describe the cumulative factors that sensitise a patient’s pain system
  • This could include poor sleep, increased work hours, stressful life events (moving house, death in family), increased training load, illness (ongoing cold symptoms), reduced exercise/meditation
  • Individually each situation is a stressor, but the cumulative effect or “context” can have much greater implications on their pain system
  • STrong therapeutic alliance

    • The role of the physiotherapist is to form a team with the patient
    • The therapist should facilitate however the patient should be an active member of their rehabilitation
    • Treatment/management should consist of techniques aimed at making the patient independent and able to self-manage, not rely on the therapist for regular passive intervention
  • Decrease sympathetic wind-up

    • Desensitise the painful region with pain-free exposure
    • Manual therapy and exercise prescription should be used to reduce local pain, to then allow pain-free movement
    • You must then integrate these new behaviours into previously painful movements, to develop new memories and reduce fear
    • E. g. squatting brings on multisegmental lumbar pain, as the patient maintains lumbar hyperextension throughout the movement, treatment to regain lumbar flexion (e. g. lumbar muscle release in sidelying progressing into greater hip/lumbar flexion, anterior/posterior lumbar mobilisations, lumbar flexion physiological mobilisation, diaphragmatic breathing in Child’s pose position etc) must be followed with retraining the squatting technique out of hyperextension
    • By reinforcing a pain-free squat with new technique, after desensitising the local painful tissue, the patient forms new memories of squatting and breaking old habits
  • For more information on Peter’s Cognitive Functional Therapy approach to treating lumbar pain, the following articles are excellent!

    O’Sullivan 2015, in Physical Therapy 95:11

    Bunzli 2016, in Physical Therapy 96:9

    Vibe Fersum 2013, in European Journal of Pain 17

    O’Keeffe 2015, in British Medical Journal 5

    Darren Beales, Specialist Musculoskeletal Physiotherapist

    2) Pelvic Girdle Pain

    Darren Beales

    The Influence of Pain & Other Factors on Motor Function

    Following in the Curtin University vein, Darren Beales is world-renowned for his articles on Pelvic Girdle Pain in 2009, with Peter O’Sullivan. He presented on pain causing motor patterning issues and altered muscle function, rather than motor patterning and altered muscle function causing pain.

    Darren discussed the recent study by Helen Slater and colleagues (2016), which found females tested at 20 and 22 years of age, who Reported severe menstrual pain had heightened sensitivity to cold (at an area distant to their menstrual pain region) and heightened pressure sensitivity (at the area of menstrual pain). This suggests those who report higher menstrual pain have altered central and peripheral neurophysiological processing, giving greater pain sensitivity.

    Paananen, in 2015, utilising the same Raine Study (a Western Australian pregnancy cohort study following females from birth) found those females with low cortisol levels in response to stress, had greater musculoskeletal pain levels. Those with combined lower cortisol levels and lower thresholds on pressure testing had even higher pain levels.

    Another study by Palsson (2015) looked at tissue sensitivity in pregnant females. They compared pregnant females to non-pregnant female controls, assessing sensitivity to light touch, pin-prick and pressure testing, along with active straight leg raise (ASLR) and SIJ pain provocation tests. They also completed questionnaires regarding sleep, wellbeing and disability. The pregnant females were divided into high or low pain groups, with the High pain group reporting greater difficulty on ASLR and both pregnant groups reporting greater pain on provocation testing. Both pregnant groups reported much lower pain pressure thresholds (pressure became painful at a much lower level than those non-pregnant). Those in the high pain group had poorer sleep and wellbeing than the low pain group, but there was no difference between pressure thresholds and disability.

    So if all pregnant females have a sensitised pain system, but those with higher pain levels have poorer sleep and wellbeing, should we try address sleep and stress levels, rather than motor control?

    Should the ASLR only be used as a reassessment tool, to determine which strategies improve heaviness, rather than just as a positive/negative test (see Sian’s previous ASLR post)?

    Tricountychiropractor's Blog

    Chiropractic

    Neck Curve and Quality of Life Improved Under Chiropractic Care

    On December 7, 2015, the Annals of Vertebral Subluxation Research published a study documenting the case of a patient with an arthritic reversed neck curve being helped with chiropractic.

    The authors of the study begin by noting the importance of proper curvatures in the spine. As viewed from the side, the spine should have a forward curve, known as lordosis in the neck; a rearward curve, known as kyphosis, in the middle back; and another lordosis curve in the lower back. These normal curvatures are essential to properly distribute forces through the body.

    Without a proper curvature in the neck, forces of daily activity can create multiple structural and functional problems in the neck including subluxations. According to research, a number of conditions and symptoms have been linked to the loss of neck curvature. These include mechanical neck pain, cervical-brachial neuralgia, vascular headaches, migraine headaches, cervicogenic headache, numbness, vertigo, nausea, airway obstruction, suboccipital pain, occipital neuralgia, numbness or tingling, muscle spasms, and decreased neck range of motion.

    In this case, a 31-year-old man went to the chiropractor seeking relief. His complaints included arthritis in his neck, stabbing pain in ribs, and numbness/tingling in both hands. He reported that his neck problems had started 8 years earlier and caused a sharp stabbing pain. He reported that rotating and popping his neck gave him some temporary relief. He was also suffering from sleep issues and fatigue as well as shortness of breath, heartburn, and depression.

    A chiropractic examination was performed that included palpation, range of motion, heart rate variability testing, surface electromyography, thermal scans and spinal x-rays. The tests were performed to detect the presence of subluxation as well as to monitor the body’s response to care.

    Specific chiropractic care was started at the rate of three visits per week for the first month. After 7 weeks of care, the patient reported improvement in his symptoms with an overall decrease in his symptoms. He felt his posture had improved and he was holding his head higher, slouching less, and he found it easier to keep straight up.

    Follow up testing showed improvement in all the objective tests that were performed. Neck x-rays showed a return to normal of the man’s neck curvature, demonstrating that his spinal and neural integrity had improved.

    In their discussion, the authors of this study note the importance of a proper neck curvature by stating, “Improvement in cervical lordosis or restoration of the cervical curve has been associated with various outcomes in the literature. It has been suggested that restoration of normal spinal curves leads to improved health outcomes, pain reduction, increased function, and improved quality of life.”

    MRI Shows Subluxation in Whiplash Case Study

    In the December 19, 2007 issue of the scientific journal Chiropractic & Osteopathy, is a case study that clearly documented the presence of a subluxation on MRI and showed how chiropractic helped in this case when medical care had previously failed.

    This case documented the plight of a 21 year old woman who was involved in an automobile accident. The accident was so severe the woman was unconscious and had to be cut out of her car by rescue teams. She was taken to the emergency room where she suffered a seizure and regained consciousness.

    In the hospital, the 21 year old had x-rays and a CT scan. In spite of the severity of the accident, the doctors interpreted these x-ray studies as normal. She was treated for her cuts and released with the advice to return for a neurological evaluation. The neurologists recommended medications for the headaches that the young girl had now developed.

    When she finally sought out chiropractic care, she was suffering from chronic neck pain, headaches, and dizziness. Her pain was so severe that she rated it as the worst pain of her life. Her neck range of motion was severely limited and created pain when she moved her head or neck.

    Because of the severity of her case, an MRI was ordered. Upon chiropractic evaluation, this study showed that the top bone in the neck (atlas) had shifted to the left. Re-evaluation by the Neuroradiologist concurred with the chiropractor’s opinions.

    Chiropractic care was initiated utilizing specific adjustments targeted to vertebral subluxations of the upper cervical spine. The care initially was three times per week for six weeks. During this time, the woman showed a 75% reduction of symptoms. In the next four weeks of care, she reported a 100% reduction of her pain.

    Neck Curve and Quality of Life Improved Under Chiropractic Care

    On December 7, 2015, the Annals of Vertebral Subluxation Research published a study documenting the case of a patient with an arthritic reversed neck curve being helped with chiropractic.

    The authors of the study begin by noting the importance of proper curvatures in the spine. As viewed from the side, the spine should have a forward curve, known as lordosis in the neck; a rearward curve, known as kyphosis, in the middle back; and another lordosis curve in the lower back. These normal curvatures are essential to properly distribute forces through the body.

    Without a proper curvature in the neck, forces of daily activity can create multiple structural and functional problems in the neck including subluxations. According to research, a number of conditions and symptoms have been linked to the loss of neck curvature. These include mechanical neck pain, cervical-brachial neuralgia, vascular headaches, migraine headaches, cervicogenic headache, numbness, vertigo, nausea, airway obstruction, suboccipital pain, occipital neuralgia, numbness or tingling, muscle spasms, and decreased neck range of motion.

    In this case, a 31-year-old man went to the chiropractor seeking relief. His complaints included arthritis in his neck, stabbing pain in ribs, and numbness/tingling in both hands. He reported that his neck problems had started 8 years earlier and caused a sharp stabbing pain. He reported that rotating and popping his neck gave him some temporary relief. He was also suffering from sleep issues and fatigue as well as shortness of breath, heartburn, and depression.

    A chiropractic examination was performed that included palpation, range of motion, heart rate variability testing, surface electromyography, thermal scans and spinal x-rays. The tests were performed to detect the presence of subluxation as well as to monitor the body’s response to care.

    Specific chiropractic care was started at the rate of three visits per week for the first month. After 7 weeks of care, the patient reported improvement in his symptoms with an overall decrease in his symptoms. He felt his posture had improved and he was holding his head higher, slouching less, and he found it easier to keep straight up.

    Follow up testing showed improvement in all the objective tests that were performed. Neck x-rays showed a return to normal of the man’s neck curvature, demonstrating that his spinal and neural integrity had improved.

    In their discussion, the authors of this study note the importance of a proper neck curvature by stating, “Improvement in cervical lordosis or restoration of the cervical curve has been associated with various outcomes in the literature. It has been suggested that restoration of normal spinal curves leads to improved health outcomes, pain reduction, increased function, and improved quality of life.”

    Pregnancy-Related Lumbopelvic Pain Improved with Chiropractic

    The June 2016 issue of the Journal of Chiropractic Medicine published a case study involving a pregnant woman suffering from pregnancy-related lumbopelvic pain (PR LPP) being helped by chiropractic care.

    The study authors note that women suffering with lumbopelvic pain only see care in about 25% of the cases because many believe that the pain is normal during pregnancy. Those who do not gain relief are more likely to continue to have pain after their pregnancy. A previous randomized chiropractic clinical trial showed that chiropractic care given in conjunction with the normal obstetric care was more effective in eliminating pregnancy-related lumbopelvic pain than just obstetric care by itself.

    In this case, a 35-year-old pregnant woman presented herself for chiropractic care. She was suffering with moderate pregnancy-related lumbopelvic pain and leg pain. The pain was over both pelvic bones across her lower back. She also reported having an “uncomfortable” tension in her neck and shoulders.

    She rated her back and leg pain as a 7 out of 10, with 10 being the worst. The pain started at about the 20th week of her pregnancy and was now radiating down her leg. She reported that standing or sitting for more than 30 minutes, or walking for more than 10 minutes, made her condition worse.

    Her history noted that this pregnancy was the result of her fourth in vitro fertilization in a time period of less than 5 years. A previous attempt resulted in the birth of her son. However, two additional attempts to become pregnant resulted in complications and terminated pregnancies.

    After an examination, chiropractic care was initiated. The woman was also given some stretching exercises and advised to slowly increase the amount of walking she was doing. Within one week of starting chiropractic care, the woman reported a reduction in the severity and duration of her low back and leg pain. She noted that she was able to sit and walk for longer periods of time.

    After 13 visits, she was able to walk or stand for longer than 30 minutes, and sit and travel for more than one hour in the car. This made her daily activities much easier and she reported a decrease in her stress and anxiety. Her overall pain rating dropped from a 7 to a 2 out of 10.

    Pregnancy-Related Low Back Pain Helped with Chiropractic

    A review of previous studies on the effectiveness of chiropractic for pregnant women with lower back pain was published in the July 2008 edition of the Journal of Manipulative and Physiological Therapeutics (JMPT). This study looked at previously published works on this subject to review the body of evidence for the effectiveness of chiropractic care.

    The JMPT report starts off by noting that between 50% and 80% of pregnant women suffer from low back pain (LBP) during their pregnancy. They noted that a review of previous work showed that from 68% to 85% of pregnant women with back pain during pregnancy do not look for any care for their lower back pain. The authors theorize that this is because most pregnant women consider back pain to be a normal part of the pregnancy.

    In reviewing all the scientific literature on the subject of chiropractic for low back pain in pregnancy, the authors of the JMPT review narrowed their selection down to 6 studies that met their specific criteria. The results of the various studies showed a high percentage of pregnant women did get relief from their lower back pain through chiropractic.

    In one reviewed study 84% of the 25 subjects reported relief of their lower back pain. In a larger study of 103 patients who received chiropractic care during their pregnancy, all of the women reported greater than 50% decrease in back pain on a questionnaire. In yet another case series where 120 pregnant women with LBP underwent an average of 15 chiropractic treatments, the results showed that 25% had complete remission of their back pain, 50% reported feeling very well, 15% were feeling better, and 10% noted no change in condition.

    Interestingly, none of the studies reviewed for the JMPT report indicated any adverse effects or evidence of harm to either the pregnant woman or unborn child from the chiropractic care. The authors of the JMPT report noted that there was a need for more comprehensive studies involving control groups, but they did note that all studies they included reported positive results for the subject under chiropractic care. They noted in their conclusion, “Results from the 6 included studies showed that chiropractic care is associated with improved outcome in pregnancy-related LBP.” (article taken from http://www. chirocentral. net/article/1767.html)

    If you or a loved one is pregnant, this is a fantastic time to be checked for spinal misalignments (subluxations). Call our clinic to set up a consultation with the doctors. Vidalia: (912) 538-0708 Baxley: (912) 705-4321.

    BMC Pregnancy and Childbirth

    Table of Contents

    This article has Open Peer Review reports available.

    A systematic review of randomised controlled trials on the effectiveness of exercise programs on Lumbo Pelvic Pain among postnatal women

    • Pei-Ching Tseng 1 ,
    • Shuby Puthussery 2Email author,
    • Yannis Pappas 1 and
    • Meei-Ling Gau 3

    © Tseng et al. 2015

    Accepted: 10 November 2015

    Published: 26 November 2015

    Background

    A substantial number of women tend to be affected by Lumbo Pelvic Pain (LPP) following child birth. Physical exercise is indicated as a beneficial method to relieve LPP, but individual studies appear to suggest mixed findings about its effectiveness. This systematic review aimed to synthesise evidence from randomised controlled trials on the effectiveness of exercise on LPP among postnatal women to inform policy, practice and future research.

    A systematic review was conducted of all randomised controlled trials published between January 1990 and July 2014, identified through a comprehensive search of following databases: PubMed, PEDro, Embase, Cinahl, Medline, SPORTDiscus, Cochrane Pregnancy and Childbirth Group’s Trials Register, and electronic libraries of authors’institutions. Randomised controlled trials were eligible for inclusion if the intervention comprised of postnatal exercise for women with LPP onset during pregnancy or within 3 months after delivery and the outcome measures included changes in LPP. Selected articles were assessed using the PEDro Scale for methodological quality and findings were synthesised narratively as meta-analysis was found to be inappropriate due to heterogeneity among included studies.

    Four randomised controlled trials were included, involving 251 postnatal women. Three trials were rated as of ‘good’ methodological quality. All trials, except one, were at low risk of bias. The trials included physical exercise programs with varying components, differing modes of delivery, follow up times and outcome measures. Intervention in one trial, involving physical therapy with specific stabilising exercises, proved to be effective in reducing LPP intensity. An improvement in gluteal pain on the right side was reported in another trial and a significant difference in pain frequency in another.

    Conclusion

    Our review indicates that only few randomised controlled trials have evaluated the effectiveness of exercise on LPP among postnatal women. There is also a great amount of variability across existing trials in the components of exercise programs, modes of delivery, follow up times and outcome measures. While there is some evidence to indicate the effectiveness of exercise for relieving LPP, further good quality trials are needed to ascertain the most effective elements of postnatal exercise programs suited for LPP treatment.

    Background

    Pain in the lower back and pelvic regions, collectively known as Lumbo Pelvic Pain (LPP), tends to be commonly reported among pregnant and postnatal women with varying prevalence rates. Lumbo Pelvic Pain (LPP) refers to self-reported pain in areas of lower back, anterior pelvis, posterior pelvis, or any combination of these locations [ 1 , 2 ]. Majority of women report LPP in pregnancy with prevalence rates ranging from 26.5 % to 91 % [ 3 – 12 ]. A substantial number of women continue to experience the pain in the postnatal period with varying intensity and duration [ 13 , 14 ]. A higher range of variation is reported in LPP prevalence in the postnatal period compared to its prevalence in pregnancy due to apparent differences in follow-up times, methods of measurement and definitions [ 12 , 14 – 20 ]. For instance, using a self-rated Visual Analogue Scale (VAS), Líndal et al., [ 16 ] reported prevalence rates of 75 % at 3 days after delivery among women who had lower back pain in pregnancy, and 54 % at 90-days after delivery. In a population based survey, Stapleton et al., [ 18 ] found that 8 % of women reported the onset of recurrent low back pain soon after pregnancy whereas the figures rose to 13 % at 1 year after child birth. In another prospective cohort study of pregnant women, 28.9 % of all pregnant women had some type of back pain during the index pregnancy and 5 % had pain 3 years after birth [ 17 ].

    The presence of LPP is often identified and confirmed by diagrammatic representations of self-reported pain location alone or in combination with clinical tests [ 3 , 12 , 21 – 26 ]. Most LPP is reported in and around the lumbar area, which is responsible for supporting the majority of the upper body weight [ 27 ]. Factors associated with LPP occurrence in pregnancy and in the postnatal period include maternal age, parity, high Body Mass Index (BMI), smoking, oral contraceptives, previous history of LPP, uncomfortable working conditions, and lack of exercise [ 4 , 10 , 15 , 26 , 28 – 31 ].

    Persistent LPP can negatively impact women’s ability to perform daily activities and quality of life. Among postnatal women it has been shown that LPP leads to sleep problems, depression, fatigue, anxiety, and a general inability to doing activities that involve carrying or lifting [ 25 , 32 – 35 ]. For instance, Gutke et al., [ 35 ] found that women suffering from LPP are three times more likely to experience symptoms of postnatal depression compared to those without. In another study [ 25 ], 40 % of women with postnatal LPP reported moderate to severe disability with pain intensity being the major explanatory variable for disability level. The same study also found that the impact of having pelvic girdle pain, combined pain, or lumbar pain were equivalent in terms of disability, pain intensity, health-related quality of life, activity level and kinesiophobia [ 25 ].

    Different interventions have been used to reduce LPP in general including exercise acupuncture, drugs, therapies using heat/cold, traction, laser, ultrasound, short wave, massage, and corsets [ 36 , 37 ]. A systematic review of randomised controlled trials of treatment methods to prevent or reduce the incidence or severity of pelvic or back pain in pregnancy have indicated moderate quality evidence suggesting the effectiveness of acupuncture or exercise tailored to the stage of pregnancy, in significantly reducing evening pelvic pain or lumbo-pelvic pain more than usual care alone [ 38 ]. The same review also suggested acupuncture as significantly more effective than exercise for reducing evening pelvic pain. Clinical approaches for LPP management have specified the importance of activation of muscles for motor control and stability of the lumbopelvic region [ 39 ] and physical exercise has been indicated as a beneficial method to relieve LPP during pregnancy and after child birth [ 22 , 40 – 42 ]. Emerging studies on the effectiveness of exercise on LPP among postnatal women, however, appear to indicate mixed findings and do not provide sufficient evidence on their own to inform clinical practice in this area. A systematic synthesis of the existing evidence on the effectiveness of physical exercise on postnatal LPP is yet to be conducted. This review aimed to synthesise findings from randomised controlled trials on the effectiveness of exercise on LPP among postnatal women to inform policy, practice and future research in the area.

    This review follows the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guidelines ( http://www. prisma-statement. org/PRISMAStatement/Checklist. aspx ). The review question was framed using Population, Intervention, Comparator, Outcome, and Study design (PICOS) framework. The population comprised of postnatal women who reported LPP onset either in pregnancy or within 3 months after delivery. The interventions comprised of physical therapy with a suite of exercise programs specifically designed to strengthen deep local muscles and global muscles in the lumpopelvic region. The comparators included no therapy; or physical therapy using other methods such as massage relaxation, joint mobilization, manipulation, electrotherapy, hot packs, and simple back strengthening exercises. The primary outcome measure was changes in LPP. This review considered randomised controlled trials published between 1990 and 2014. Randomised controlled trials were eligible for inclusion if the reported intervention comprised of postnatal exercise for women who reported LPP onset during pregnancy or within 3 months after delivery, and the outcome measures included changes in LPP. The review protocol was agreed between the four authors.

    Key search terms

    Postpartum women OR “postnatal women” OR “after delivery” OR “postpartum period” OR “postpartum females” OR “birth” OR “after birth” OR “natal” OR “perinatal” OR “puerperium”

    Exercise OR “postpartum exercise” OR “postnatal exercise” OR “postpartum training” OR “postpartum practices” OR “abdominal training” OR “exercise prescription” OR “abdominal training “OR “female athlete” OR “physical activities” OR “physical fitness”

    Back pain OR “backache” OR “low back pain “OR “lower back pain “OR “upper back pain” OR “high back pain” OR “anterior pelvic pain” OR “posterior pelvic pain” OR “buttocks pain” OR “pelvic pain” OR “symphysis pain” OR “sacroiliac joint pain” OR “pelvic girdle pain” OR “lumbar pelvic pain” OR “lumbosacral pain” OR “lumbar pain” OR “postpartum-related LBP” OR “self management of LBP” OR “vertebrogenic pain”

    Core muscles OR “trunk muscles” OR “core stabilisation” OR “transverses abdominis” OR “lumbar multifidus” OR “musculoskeletal” OR “musculoskeletal conditions” OR “musculoskeletal disorders”

    Physical endurance OR “endurance” OR “core muscle strength”

    1 AND 2 AND 3 AND 4 AND 5 AND 6

    Methodological quality assessment and data analysis

    Summary of study characteristics

    Mens et al., [ 46 ] 2000 Netherlands

    Diagonal Trunk Muscle Exercises in Peripartum Pelvic Pain: A Randomised Clinical Trial

    Randomised controlled trial

    Intervention group: 16

    Control group 1: 14

    Control group 2: 14

    Stuge et al., [ 47 ] a 2004

    The Efficacy of a Treatment Program Focusing on Specific Stabilising Exercises for Pelvic Girdle Pain After Pregnancy: A Randomised Controlled Trial

    Randomised, single-blind, clinically controlled study with a stratified group design

    Intervention group: 40

    Control group: 41

    One year postpartum:

    Intervention group: 39

    Stuge et al., [ 51 ] a

    The Efficacy of a Treatment Program Focusing on Specific Stabilising Exercises for Pelvic Girdle Pain After Pregnancy: A Two-Year Follow-up of a Randomised Clinical Trial

    Control group: 39

    Two year postpartum:

    Intervention group: 30

    Control group: 35

    Specific muscle stabilising as home exercises for persistent pelvic girdle pain after pregnancy: a Randomised, Controlled Clinical Trial

    Prospective, randomised, single-blinded clinically controlled study

    Intervention group: 32

    3-month follow-up analysis (n = 26)

    6-month follow-up analysis (n = 24)

    Control group: 54

    3-month follow-up analysis (n = 39)

    6-month follow-up analysis (n = 36)

    Effectiveness of core stabilisation exercises along with postural correction in postpartum back pain

    A randomised controlled trial with non-probability sampling

    Intervention group: 20

    Control group: 20

    A Both publications originated from the same trial

    Study selection

    Flowchart of study selection process

    Stuge et al. [ 47 ] a & [ 51 ] a

    Random sequence generation

    Low risk of bias

    Low risk of bias

    Low risk of bias

    Low risk of bias

    Low risk of bias

    Low risk of bias

    Low risk of bias

    Unclear risk of bias

    Blinding of participants and personnel

    Unclear risk of bias

    Low risk of bias

    Low risk of bias

    Unclear risk of bias

    Incomplete outcome data

    Low risk of bias

    Low risk of bias

    Low risk of bias

    Unclear risk of bias

    Low risk of bias

    Low risk of bias

    Low risk of bias

    Unclear risk of bias

    Other sources of bias

    Low risk of bias

    Low risk of bias

    Low risk of bias

    Unclear risk of bias

    A Both publications originated from the same trial

    Although the interventions included exercise programs, the components of the intervention, outcome measures, and follow up times were too diverse to allow a meta-analysis of the study findings. This was further confirmed by testing homogeneity with the Meta-Analysis Add-In for Microsoft Excel software package [ 50 ] and hence a narrative synthesis was undertaken.

    Study characteristics

    The study participants included 251 postnatal women reported in four trials who experienced LPP onset either in pregnancy or within 3 months after child birth as described in Table 2 . The overall sample size in individual trials ranged from 40 to 86 [ 48 , 49 ] with the size of the intervention group varying between 16 and 41 women [ 46 , 51 ]. Two articles had originated from the same trial reporting outcome measures at different intervals such as the week after the 18–20 week intervention, 1-year, and 2-years postpartum [ 47 , 51 ]. One study divided participants into three groups: an experimental group with 16 postnatal women and two control groups with 14 each [ 46 ]. The included trials were from different countries: Netherlands [ 46 ], Norway [ 47 , 51 ], Sweden [ 48 ] and Pakistan [ 49 ].

    The assessment data were collected at different time points such as baseline [ 46 – 49 , 51 ]; soon after intervention [ 46 ]; at 3- and 6- months follow up [ 48 ]; and at 1- and 2- years after delivery [ 47 , 51 ]. Only one trial assessed the long term effect of the intervention with outcomes reported at 1- and 2 – year follow-up periods [ 47 , 51 ]. One trial did not clearly report the time points when the assessment data was collected [ 49 ].

    Interventions and comparators

    The interventions consisted of various exercise programs as presented in Table 2 . Three trials used stabilisation exercise programs as the intervention – either specific [ 48 ] or core [ 47 , 49 , 51 ], while the third trial used diagonal trunk muscle systems training program [ 46 ]. The core stabilisation exercise program used by Stuge et al., [ 47 , 51 ] was focused on training the deep local muscles (the transverse abdominal wall muscles with co-activation of the lumbar multifidus in the lumbosacral region) and global muscles (m. gluteus maximus, m. latissimus dorsi, the oblique abdominal muscles, m. erector spinae, m. quadratus lumborum, and hip adductors and abductors). The initial focus of this exercise was on specific contraction of the transverse abdominal muscles. In addtion to stabilisation exercises, postural correction techniques in different positions such as supine, crook lying, half sitting and prone were also employed for the intervention group in another trial [ 49 ]. The specific stabilising exercises reported by Gutke et al., [ 48 ] focused on strengthening the transversely oriented abdominal, lumbar multifidus, and the pelvic floor muscles, and on improving motor control and stability.

    The interventions were varied in their frequency and duration. The frequency of the exercise ranged from ≥ 2 times per day [ 48 ] to three days per week [ 46 , 47 , 51 ]. The exact frequency of the exercise was not reported in one trial [ 49 ]. In this trial, women in the treatment group were were given three exercise sessions of half an hour during their stay in the hospital after birth. After discharge from the hospital, these women were called back for follow up sessions of 30 to 40 min treatment [ 49 ]. The total reported duration of the intervention was between 8 weeks [ 46 ] and 20 weeks [ 47 , 51 ] although this information was not available in the case of two trials [ 48 , 49 ]. Co-interventions such as the use of a pelvic belt and pain medication were reported to be used for the experimental and control group in one trial [ 46 ]. The methods of delivering the interventions differed across trials and included a videotape with instruction of exercises to be performed at home without supervision [ 46 ]; individualized exercise program performed mainly at home with guidance by the physical therapist with adjustments performed once a week or fortnightly [ 47 , 51 ]; home training with individual guidance and adjustment of the exercise program every two weeks by one of two treating physiotherapists [ 48 ]; and treatment sessions at the hospital [ 49 ]. Compliance was measured using a training diary in two trials [ 47 , 48 , 51 ] and a designated form in another one [ 46 ]. This information was not available in one trial [ 49 ]. The home-based approach in one trial was reported to be a barrier to control for compliance with diaries not handed in as expected [ 48 ]. One trial reported high compliance with the treatment [ 47 , 51 ]. Compliance was less optimal in two trials [ 46 , 48 ]. In one trial, 25 % of the subjects in the experimental group stopped their exercise programme before the end of the study because of increase in pain [ 46 ] and only 78 % of the women in the treatment group reached stage 3 of the treatment programme in the other [ 48 ]. No compliance information was reported in one trial [ 49 ].

    The comparators included longitudinal trunk muscle systems training [ 46 ]; physical therapy using ergonomics massage, joint mobilization, manipulation, electrotherapy, hot packs [ 47 , 51 ]; simple back strengthening exercises [ 49 ]; or no exercise [ 46 , 48 ]. Mens et al. [ 46 ] included two comparison groups – one group with instructions to train the longitudinal trunk muscle system involving rectus abdominis muscle, longitudinal parts of the erector spinae muscle, and quadratus lumborum muscle, and the other instructed to refrain from exercise.

    Primary outcome: Changes in LPP

    Summary of findings

    Intervention duration and frequency

    Effectiveness of the intervention (P<05)

    Mens et al., [ 46 ] 2000

    Instructions given by videotape with training of the diagonal trunk muscles (n=16).

    Comparator 1: Instructions given by videotape with training of the longitudinal trunk muscles (n=14).

    Intensity of pain and fatigue in the morning and evening based on Visual Analogue Scale (VAS).

    No significant differences in pain intensity, fatigue, HQRL, or mobility measures between the experimental group and both control groups.

    Light exercises to be performed 3 times per day and heavy exercises 3 times per week

    Health-related quality of life (HQRL) based on Nottingham Health Profile (NHP).

    Comparator 2: Instructions given by videotape without exercises (n=14).

    Gluteal pain provoked by the Posterior Pelvic Pain Provocation (PPPP) test on the left and right sides.

    Experimental group scored better than the control groups with repect to gluteal pain provoked by the PPPP test on the right side.

    Mobility of pubic symphysis (radiographic examination).

    Stuge et al., [ 47 ] a 2004 & Stuge et al., [ 51 ] a 2004

    Physical therapy with specific stabilising exercises (n=40).

    Physical therapy without specific stabilising exercises (n=41).

    18 to 20 weeks duration.

    Pain intensity in the morning and evening based on VAS.

    After the intervention and 1 year follow up:

    Functional status (Oswestry LBP Disability Questionnaire). Health-related quality of life (SF-36 Health survey).

    Pain intensity in the morning and evening was significantly reduced in the intervention group. Functional status in the intervention group significantly better than the control group.

    Physical endurance (Sӧrensen Test, ASLR test).

    Health-related quality of life shows significant improvement in the intervention group with largest effect in physical function, role physical and bodily pain.

    3 days a week with a daily duration of 30 to 60 min

    Significant differences in functional status, evening pain, and morning pain between the groups were maintained 2 years after delivery.

    Health-Related Quality of Life at 2 years after delivery revealed that significant differences persisted between the groups in physical functioning, role physical, and bodily pain.

    No significant differences between the 2 groups were seen for the other 5 subscales (general health, vitality, social functioning, role emotional, and mental health).

    Gutke et al., [ 48 ] 2010

    Specific stabilising exercises focused on the transversely Oriented abdominal, the lumbar multifidus, and the pelvic floor muscles.

    Total duration not reported ≥ 2 times per day and to perform each exercise with 10 repetitions.

    Disability based on the Oswestry Disability Index (ODI) version 2.0.

    For ODI, no difference could be demonstrated between the intervention and control groups at 3- or 6-month follow-up. Significant difference in pain frequency was demonstrated between the two groups at the 3-month follow-up in favour of the intervention group.

    Instructed to resume normal activities.

    Pain intensity measured with VAS (0–100 mm) for current pain and average pain during the previous week.

    Pain frequency (always, day and night to several times per week, or occasionally to never).

    Health related quality of life (HRQL) measured using EuroQol instrument (EQ-5D and EQ-VAS).

    No differences could be found between the groups regarding pain intensity,

    Wellbeing measured with VAS (0–100 mm) with defined end-points (low value indicating high wellbeing).

    HRQL or wellbeing.

    Chaudry et al., [ 49 ] 2013

    Core stabilisation exercises along with postural correction in different positions.

    Simple back strengthening exercises in different positions.

    Total duration not reported.

    Back pain (Visual analogue scale VAS).

    Significant improvement in ADLs and IADLs in intervention group compared to control group.

    3 sessions of half an hour during the stay in hospital.

    Activities of Daily Livings (ADLs) and Instrumental Activities of Daily Livings (IADLs)

    Significant improvement in muscle power in intervention group compared to control group.

    Mobility (dependent and independent).

    Muscles power. Manual Muscle Testing (MMT).

    Significant improvement in mobility in intervention group compared to control group.

    Intervention group showed improvement in edema compared to control group, but p-value was insignificant.

    A Both publications originated from the same trial

    In terms of the effectiveness of the exercise program on LPP, one trial [ 47 , 51 ] reported significant positive effect on pelvic pain intensity as a result of the exercise. This trial found significant reductions in pain intensity in the morning and evening during the intervention period and at 1- and 2-year follow-ups, with a better reduction of pelvic girdle pain in the intervention group compared to the control group [ 47 , 51 ]. The authors observed biggest improvements in pain intensity during the intervention period of 20 weeks, with a further but slow improvement over the 6 months following treatment, which was also maintained 2 years after delivery. However, low levels of pain sustained in the intervention group 2 years after delivery [ 47 , 51 ]. Although another trial reported significant improvements in back pain related variables such as restriction in Activities of Daily Livings (ADLs), and Instrumental Activities of Daily Livings (IADLs), changes in pain intensity was not reported as such [ 49 ]. Gutke et al., [ 48 ] reported significant difference in pain frequency between the intervention and control groups at 3-month follow-up in favour of the intervention group, but did not find any differences between the groups with respect to pain intensity, or other related variables such as health related quality of life (HRQDL) and wellbeing. Mens et al., [ 46 ] did not find any significant difference with respect to the severity of pain in the morning and evening or related fatigue between the experimental group and both control groups. However, the intervention group scored better than the control groups with respect to changes in the gluteal pain provoked by the PPPP test scores on the right side [ 46 ]. Within-group comparisons in three trials showed a decrease in LPP intensity and associated variables in both experimental and control groups at different follow-up intervals compared to baseline [ 46 – 48 , 51 ].

    Other LPP related outcomes

    A number of other LPP related outcome measures were also reported as shown in Table 4 . Two trials reported changes in functional status or disability measured using Oswestry Lower Back Pain Disability Questionnaire (ODI) [ 47 , 48 , 51 ] and Disability Rating Index (DRI) [ 51 ]. Stuge et al. [ 47 , 51 ] reported significant improvements in functional status in the intervention group compared to the control group at one week after the intervention and at 1-and 2-year follow ups. However, Gutke et al., [ 48 ] could not find any difference with respect to functional status between the 2 groups at 3- or 6-month follow-ups.

    Changes in health related quality of life in the intervention and control groups were reported in three trials using instruments such as SF-36 Health Survey [ 47 , 51 ], EuroQol instrument (EQ-5D and EQ-VAS) [ 48 ], and Nottingham Health Profile (NHP) [ 46 ]. Using SF-36 Health Survey, Stuge et al., [ 47 , 51 ] assessed health related quality of life at the time of entry, within one week after intervention, 1- and 2-years postnatal. On health related quality of life measurements, the same trial reported significant differences between the experimental and control groups in physical functioning, role physical, and body pain following the intervention and at 1- and 2-years after delivery [ 47 , 51 ]. Using NHP, Mens et al., [ 46 ] reported overall improvement among study participants on NHP pain scale at 8 weeks of intervention compared to baseline, but could not find any statistically significant difference between the intervention and control groups. No differences were detected between the groups by Gutke et al., [ 48 ] on EuroQol instrument (EQ-5D and EQ-VAS) on health related quality of life or wellbeing measured with VAS with defined end-points (low value indicating high wellbeing).

    Changes in physical mobility was reported by Mens et al. [ 46 ] using radiographic examination to assess mobility of the pubic symphysis on left and right lower extremities at 8 weeks after the intervention [ 46 ]. Although there was an overall improvement in physical mobility among participants at 8 weeks of intervention compared to baseline, there was no statistically significant difference between the experimental and comparison groups [ 46 ]. Another study reported marked improvement in mobility dependence among the experimental group compared to control group after following core stabilisation exercises and postural correction [ 49 ].

    Changes in physical endurance was reported based on physical examinations and tests such as Sorensen Test and Active Straight Leg Raising (ASLR) test [ 47 ] and muscle function test [ 48 ]. Stuge et al., [ 47 ] used Sorensen Test and ASLR test at the time of entry, within one week after intervention and one year after delivery and found improvements in physical endurance with statistically significant differences between the groups in favour of the intervention. Gutke et al., [ 48 ] found significant difference between the intervention and control groups for the mean hip extension remaining at 3-month follow up. Within-group comparisons in the same study also showed improvements in both groups in several global muscles, but not in the pelvic floor muscles at 3- and 6-months follow up compared to baseline [ 48 ].

    Discussion

    The current review was undertaken to synthesise the evidence from randomised controlled trials on the effectiveness of physical exercise on LPP among postnatal women. Despite a comprehensive search, the authors did not find any other systematic reviews focusing on the effectiveness of exercise on LPP among women after child birth. Our review indicates that only a small number of randomised controlled trials have evaluated the effectiveness of exercise on LPP among postnatal women either as a primary or secondary outcome. Further, existing trials appear to suggest inconsistent findings and do not adequately allow estimates of effect in either direction. Among the four trials included in our review, involving 251 post natal women, three were rated as of ‘good’ methodological quality, with a score of 6–8 on a 10 point assessment scale, indicating fairly good methodological rigor. Among these, one trial that involved physical therapy with specific stabilising exercises proved to be effective in terms of reducing LPP intensity both after the intervention and at 1- and 2- year follow ups [ 47 , 51 ]. The same trial also showed significant positive effect of the exercise program on other related variables such as functional status, health related quality of life and physical endurance [ 47 , 51 ]. The remaining two trials that were rated as of ‘good’ quality did not show any beneficial impact with respect to LPP intensity [ 46 , 48 ]. However, improvements in gluteal pain on the right side was found in the intervention group in one trial [ 46 ], and a significant difference in pain frequency between the two groups at 3-month follow-up in the other [ 48 ]. Reportedly, many participants in the treatment group in one trial complained of increasing pain during the exercises with the majority attributing the pain to the exercise aimed at strengthening the hip extensors [ 46 ].

    The inconsistent findings found in our review may be attributed to methodological factors, variability in the intervention elements and the way the intervention was administered. Previous research has highlighted the importance of activation of muscles for motor control and stability of the lumbo pelvic region [ 39 , 53 ], and a recent pre and post experimental study using convenient sampling has suggested lumbo-pelvic stabilisation exercises to be beneficial for improving trunk muscle endurance, pain and functional ability in women with postnatal lumbo-pelvic pain [ 54 ]. Among the trials included in our review, only one included thoroughly instructed regularly supervised high quality exercises designed to involve all relevant muscles of the pelvic girdle [ 47 , 51 ]. There were also marked differences across trials with respect to type of exercises, frequency and duration, and the way the exercises and instructions were administered. Compliance to the intervention is also likely to significantly influence the outcomes and is an important indicator of an intervention’s feasibility for future implementation. Among the trials included in our review, only one trial reported good compliance [ 47 , 51 ]. The ability to exercise without provoking pain, possibility of training at home under the guidance of a therapist, use of a training diary, the ability to gradually increase the resistance of individually adapted exercises and the integration of muscle control into functional tasks were all found to be important to encourage compliance [ 47 , 51 ]. Although VAS was used as measure of pain intensity in all the trials, a range of pain related outcome measures were reported across trials. As evident in our review and as has been indicated by other researchers, a standardised set of outcome measures to accurately capture LPP is yet to be developed [ 46 ].

    The rigorous methodological approach based on a well-defined research question with a comprehensive search strategy, clear inclusion and exclusion criteria, standardised quality assessment techniques, and structured data extraction make our findings valid and reliable. The review has certain limitations, however. Although the narrative synthesis allowed for a thorough discussion on the effectiveness of the interventions, a meta-analysis was not feasible for making estimates of strength of effect due to variations in intervention components, outcome measures, follow up times and study quality among the selected studies. The restriction to randomised controlled trials as inclusion criteria might have resulted in the exclusion of non-randomised and other experimental studies that have yielded useful findings. However, randomised controlled trials are deemed to be the most rigorous method to determine the presence of a cause-effect relationship between an intervention and outcome, and therefore the highest quality of evidence for a systematic review [ 55 , 56 ]. In spite of a comprehensive search, we were able to identify only four randomised controlled trials that met our inclusion criteria. However, three of the four selected trials were of fairly good methodological quality with blinded assessments and standardised and validated data collection tools to ensure internal validity and the robustness of the findings. Although the authors of one trial [ 49 ] were contacted for additional information about methodological aspects, this information could not be obtained. We were also unable to explore any potential publication bias resulting from exclusion of unpublished randomised controlled trials or findings reported in grey literature.

    Conclusion

    Although postnatal exercise is routinely recommended to women, our review indicates a paucity of methodologically rigorous research studies to make reliable conclusions with respect to the effectiveness of physical exercise on LPP amongst postnatal women. An individually tailored program reported in a fairly good quality trial, with stabilising exercises involving all relevant muscles, delivered under the guidance of a therapist with high treatment compliance was shown to be effective on LPP and other related variables. Further high quality randomised trials with controlled co-interventions and standardised outcome measures are needed to identify the most effective combination of exercise elements that can have an effect on reducing LPP and the associated health and well-being factors.

    As a substantial number of women tend to be affected by LPP following pregnancy and birth with significant potential implications for the women, their families, and the society as a whole, effectively managing LPP is an issue for all stakeholders concerned with maternal and women’s health. While physical therapy involving exercise programs tends to be one of the treatment approaches used to relieve LPP, ascertaining its effectiveness is a matter of importance to policy, practice and research in the area.

    По материалам:

    Http://drmuller. ca/how-does-pregnancy-affect-low-back-pain-what-about-epidural/

    Http://www. raynersmale. com/blog/2017/11/1/apa-conference-summary

    Http://tricountychiropractors. wordpress. com/

    Http://bmcpregnancychildbirth. biomedcentral. com/articles/10.1186/s12884-015-0736-4

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