Research Review By Dr. Ceara Higgins©

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Date Posted:

January 2021

Study Title:

Chiropractic Care of Adults with Postpartum-Related Low Back, Pelvic Girdle, or Combination Pain: A Systematic Review

Authors:

Weis CA, Pohlman K, Draper C da Silva-Oolup S, Stuber K & Hawk C

Author's Affiliations:

Canadian Memorial Chiropractic College, Toronto, Canada; Parker University, Dallas, Texas; Texas Chiropractic College, Pasadena, Texas, USA

Publication Information:

Journal of Manipulative and Physiological Therapeutics 2020 Aug 29: S0161-4754(20)30127-5. doi: 10.1016/j.jmpt.2020.05.006.

Background Information:

Low back pain (LBP), pelvic girdle pain (PGP), or a combination of the two has been reported to occur in up to 90% of pregnant women (1) and is the first instance of back pain in over 30% of women. Unresolved back pain during pregnancy can lead to chronic pain by 3 to 6 months postpartum and can affect the mother’s activities of daily living, including taking care of her newborn (1).

One prior survey showed that 60% of chiropractors continued to see at least 80% of pregnant patients after delivery, providing treatment for musculoskeletal dysfunction and education on the physical and mental challenges of being a new mother (4). Treatment generally included manual therapy, including mobilization, spinal manipulative therapy (SMT), soft tissue techniques, and active therapies such as exercise and self-management approaches (4).

Managing pain in this population can be a challenge for primary care physicians, due to a belief that the condition is normal and transient, a lack of knowledge on how to best treat these patients and discomfort in treating this population. Therefore, identifying professions which may have effective treatment modalities is important to ensure appropriate referrals and care. This review aimed to assess the effectiveness of treatments within the chiropractic scope of practice for LBP, PGP, or combination pain during the postpartum period.

Pertinent Results:

Literature Search Results:
5 systematic reviews (SRs), 10 RCTs, and 1 cohort study were included in this review. This included 4 acceptable quality SRs and 1 low quality SR. Only a qualitative analysis could be performed on the SRs due to a lack of heterogeneity between the trials, limited methodological quality, and variation among individual studies.
 
Post-Partum Low Back Pain:
 
Spinal Manipulative Therapy (SMT)/Mobilization:
One study of acceptable quality randomized 45 postpartum women into either posterior to anterior (PA) lumbar mobilization plus ultrasound and infrared treatment, placebo mobilization plus ultrasound and infrared, or a control group of ultrasound and infrared treatment alone. Patients received treatment 3 times a week for 4 weeks. Those receiving PA lumbar mobilizations showed decreased pain intensity and surface electromyography and increased functional ability as compared to the other groups.

Pelvic Girdle Pain:
 
Multimodal Care:
A low-quality SR suggested that after delivery, treatment should focus on multidimensional strategies, as single-treatment strategies are not generally effective. Bed rest, pelvic binders/casting/braces, bilateral traction, TENS, intra-symphyseal injections, physiotherapy, and occupational therapy were all suggested in some combination.

Exercise:
2 SRs of acceptable quality showed no clear evidence to suggest exercise as a treatment for, or for prevention of, PGP in postpartum women. The method of therapy delivery, type of exercise, duration of the program, and sample sizes were too heterogenous to be able to make solid recommendations.

A high-quality RCT randomized 386 women into 3 groups: 1) specific stabilizing exercises and standard treatment; 2) acupuncture plus standard treatment; or 3) standard treatment alone (information, pelvic belt, and exercises). Regression of PGP was seen in almost all participants at 12 weeks post-delivery regardless of their treatment group, however, the authors considered a VAS < 10mm to be pain free. Using a VAS = 0 as pain free could have altered their results. These authors also noted that women in the specific stabilizing exercise group showed less frequency of pain during pain provocation tests and suggested that the continuous daily exercise strengthened their pelvic muscles and decreased their sensitivity to the tests. A second, acceptable quality RCT showed similar results in women randomized into either a diagonal trunk muscle exercise group, longitudinal trunk muscle exercise group, or an information only group. Neither type of exercise appeared to have any benefit over information alone. A third, acceptable quality RCT showed no additional benefit of adding exercise to a program including exercise and the use of a nonspecific elastic belt. The authors also noted that training the hip flexor muscles may actually worsen PGP. A final acceptable quality RCT focused on an 18-20 week specific stabilizing exercise program and showed statistically and clinically significant decreases in pain and disability as well as a higher quality of life when compared to controls at 1 week and 1 year postpartum. The authors suggested that the individual treatment approach with functionally integrated stabilization exercises is more effective. In a follow-up study, it was found that the benefits of this program continued for 2 years after delivery and suggested that this was a result of: 1) focusing on particular muscles for their stabilizing functions in rehabilitation; 2) integrating specific stabilizing exercises into daily activities so that patterns of co-contraction would eventually occur automatically; and 3) giving the exercises early enough that they may not provoke pain leading to increased or enhanced dynamic stability of the lumbopelvic region and reducing fear-avoidance behaviours.
 
Patient Education/Information:
One acceptable SR was found, which included 2 high-quality RCTs. Both RCTs focused on the patient-therapist relationship, education, and active lifestyle and found functional improvements at 12 weeks postpartum. However, in a follow-up study, there were equal improvements in both a group receiving general anatomical information, exercise, pain management, and advice on lifestyle, orthoses, and delivery and a group receiving only UOBC (usual obstetric care) at 6 and 12 months postpartum.

Post-Partum Low Back Pain and Pelvic Girdle Pain:
 
Spinal Manipulation Therapy/Mobilizations:
A single cohort study of acceptable quality looked at 69 postpartum women within a year of giving birth. Subjects received a high-velocity thrust technique (HVTT) to the most symptomatic side. If no “pop” was heard on the first attempt a second attempt was allowed. Subjects were then instructed to perform range of motion exercises and return 2-4 days later for a follow-up where those who showed an improvement of 50% or less on ODI were asked to repeat the examination and treatment. Eighty percent of the subjects reported a greater than 50% improvement on the ODI 24-72 hours following treatment, leading the authors to conclude that 1 treatment of HVTT was effective for this population.

Exercise:
An acceptable quality SR, including 2 high quality RCTs, showed that core stabilization and postural correction initiated immediately after giving birth reduced back pain better than strengthening. However, a second acceptable quality SR, including 3 good quality and 1 fair quality RCTs, suggested that while there was some evidence indicating that an individually tailored and supervised program involving all relevant muscles with high compliance was effective, there was so much variability in methodology that no firm conclusions could be made.

In the 1 high quality RCT, 88 postpartum women were randomized into either a group receiving a home program consisting of specific stabilizing exercises (focusing on the transverse abdominis, multifidus, and pelvic floor) or a group receiving information only for 10 weeks. The exercise program was no more effective in improving back related disability or reducing pain than information at 3 or 6 months postpartum. The authors suggested that the home-based approach may not be optimal, as it makes it more difficult to control for compliance and exercise frequency. As well, they suggested that the dose and length of the training period may have been too low to reach any significant changes. A low quality RCT showed that both a group receiving group exercise and a group given individual exercise showed significant reductions in pain intensity at 3 months postpartum. However, the change was not statistically significant. They suggested that individualized treatment was more effective than a general program.
 
Osteopathic Manipulative Therapy:
An acceptable quality RCT randomized patients into an OMT group which received direct and indirect visceral and cranial techniques, or a 2-month wait list for the same treatment. They found that OMT reduced pain intensity and improved functional disability at 3 months postpartum.

Physiotherapy:
One SR of acceptable quality included 4 studies of good quality, all of which examined some type of stabilizing exercises for motor control and stability of the lumbopelvic region. They suggested that individually adjusted and guided exercises that were supervised by a physiotherapist lead to the best results.
 
Self-Management:
A single, high quality RCT randomized 126 women who were recruited during pregnancy or within 2 weeks after delivery into a self-management group based around biopsychosocial factors (including education, goals, action plans and problem solving, fear avoidance of intervention, and exercise), or a usual care group (where they could self-select their care). They found that a 12-week, tailor-made program was more beneficial than usual care as measured with the Roland Morris Disability Questionnaire.

Clinical Application & Conclusions:

This review focused on interventions that are within the chiropractic scope of practice and do not require additional certification. The evidence is as follows:
 
Post-Partum Low Back Pain:
 
Favorable outcomes were found with moderate strength evidence for PA lumbar mobilizations plus ultrasound and infrared laser used 3 times per week for 4 weeks, with both pain intensity and disability improving in the treatment group. The authors concluded that PA lumbar mobilizations should be considered for a postpartum population with LBP as a result of the impact of pregnancy and labour and the physical demands associated with caring for a newborn.
 
Post-Partum Pelvic Girdle Pain:
 
Unclear outcomes were found with inconclusive strength evidence for the use of a multimodal treatment plan. The one SR concluded that single treatment strategies are not effective, and care should include multidisciplinary management, individualized to the patient. The authors further suggested that TENS, intra-symphyseal injections, and physical and occupational therapy could be considered as part of this plan.

Unclear outcomes with moderate strength evidence were found for the use of exercise. The high and acceptable quality RCTs showed a mix of unclear, non-favorable, and favorable results, with some RCTs showing improved pain and disability scores in all participants regardless of the exercise intervention.

Unclear outcomes from inconclusive strength evidence were found for patient education. An RCT was reviewed which provided an educational program, including general anatomical information, exercise, pain management, and advice on activities of daily living, orthoses, and delivery, in small groups once a week for 4 weeks. No statistical difference in pain scores was seen between groups, although all groups showed the biggest reductions in pain at 6 months postpartum. However, it is worth noting that the study was done in Norway, where women are entitled to free physiotherapy and sick leave with a PGP diagnosis, and 60% of the control group searched for treatment. This may explain the similar outcomes.
 
Post-Partum Low Back Pain and Pelvic Girdle Pain
 
Spinal Manipulation (SMT)/Mobilizations:
No overall outcome was determined for the single cohort study reviewed. However, the authors concluded that a single treatment of a high-velocity thrust technique (HVTT) on the symptomatic side seems to reduce the ODI by 50% in the first 24-72 hours. Thus, HVTT is considered to be a low-risk treatment, can be performed quickly, and appears to be effective in this population.

Exercise:
No firm conclusions were possible due to conflicting evidence and the high amount of variability in exercise programs, modes of delivery, follow-up times, etc. in the studies. However, there was some evidence to suggest that exercises may help relieve LBP and PGP and that individually tailored programs of appropriate stability exercises given under the guidance of a trained therapist were most effective.
 
Osteopathic Manipulative Therapy:
Favorable outcomes were found from evidence of inconclusive strength, suggesting that there was a significant difference in pain and disability following 4 treatments of OMT over 8 weeks when compared to no intervention.
 
Physiotherapy:
Unclear outcomes were found from evidence of inconclusive strength. Overall, there was not enough evidence to determine the effectiveness of physiotherapy. However, the authors suggested that supervised, individually guided, and adjustable exercise may be more beneficial than no information or exercise.

Self-Management:
Unclear outcomes were found from evidence of inconclusive strength. A single RCT looking at a 12-week, tailor-made, self-management program regarding biopsychosocial factors vs usual care found that while the subjects still experienced pain at 12 weeks postpartum, they showed clinically and statistically significant improvements in disability.

Research in this area is limited and further high-quality studies need to be undertaken. Further, the authors of this review suggest that a “model curriculum” should be developed for chiropractic colleges to reflect the recommendations of this and future reviews.

Overall, no treatment option was found to have enough evidence to make a clear recommendation. Manual therapies showed favorable outcomes, but that was based on evidence of inconclusive strength, highlighting the need for more rigorous study in this area.

Study Methods:

This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (6) (PRISMA) guidelines and the search strategy was developed in conjunction with a health sciences librarian. Titles were screened by 2 independent reviewers with disagreements resolved by discussion and a third reviewer.
 
Inclusion Criteria:
  • Studies published (in English) before November 2016 in a peer-reviewed journal.
  • Studies including women who were postpartum (up to 2 years) who had lumbar spine or pelvic girdle musculoskeletal complaints
  • Interventions included in the chiropractic scope of care, such as manual therapy, SMT, and modalities commonly used by chiropractors which do not require additional certifications
  • Outcomes including pain, disability, and patient-centered outcomes such as global impression of change, and prevalence of LBP and PGP
  • Randomized control trials, cohort studies, or systematic reviews
Exclusion Criteria:
  • Non-peer-reviewed publications
  • Commentaries, editorials, letters, case reports or case series, or non-clinical studies
  • Studies with no treatment outcomes
  • Studies on any treatment that requires an additional certification
  • Studies which received a score of “unacceptable” by the SIGN criteria for SRs, RCTs, and cohort studies
  • SRs where the research question was not clearly defined, the inclusion/exclusion criteria were not clearly defined, and/or a comprehensive literature search was not carried out
Systematic reviews/meta-analyses (SR/MA), RCTs, and cohort studies were evaluated with a modified version of the Scottish Intercollegiate Guideline Network (SIGN) checklist (7) and scored as “high quality, low risk of bias”, “acceptable quality, moderate risk of bias”, “low quality, high risk of bias”, or “unacceptable”. No data was extracted from “unacceptable” articles. An adapted version of the US Preventative Services Task Force criteria from the UK report (8) was used to determine strength of evidence, rated as “high”, “moderate”, or “inconclusive”. Finally, a description of the outcomes was included. If all articles showed improvement, outcomes were classified as “favorable”; if all articles failed to show improvement, outcomes were classified as “non-favorable”; and if all articles showed a mix of improvement, a lack of improvement, or no difference, outcomes were classified as “unclear”.

Data from SRs was extracted by 2 investigators and included time of parturition, type of back pain experienced, type of treatment/intervention, quality of the review, author and published year, number of studies, number of participants, type of studies, grading used and quality assessment of studies, and conclusions. 3 teams extracted data from the RCTs/cohort studies, including location of pain, treatment type, time of parturition, type of back pain, author and year of publications, quality score, patient population information, intervention and treatment dosage, comparison group and dosage, outcome and timeline of measures, outcome measures, VAS between groups mean change difference, conclusions, and limitations.

Study Strengths / Weaknesses:

Strengths:
  • A strong search strategy was employed.
  • The authors employed appropriate methodology for this topic in accordance with PRISMA guidelines, in addition to employing the SIGN criteria to assess risk of bias of the included studies.
Weaknesses:
  • Due to difficulties in discerning the conditions covered in post-partum populations it is possible relevant studies were missed.
  • The area examined in the studies was not always clear. Therefore, it is possible that the studies may have been separated into incorrect categories which could have skewed the results.

Additional References:

  1. Stapleton DB, ManLannan AH, Kristiansson P. The prevalence of recalled low back pain during and after pregnancy: a South Australian population survey. Aust N Z J Obstet Gynaecol 2002; 42(5): 482-485.
  2. Weis C, Barrett J, Tavares, et al. Prevalence of low back pain, pelvic girdle pain, and combination pain in a pregnant Ontario population. J Obstet Gynaecol Can 2018; 40(8): 1038-1043.
  3. Bastiaanssen J, de Bie R, Bastiaenen C, et al. Etiology and prognosis of pregnancy-related pelvic girdle pain; design of a longitudinal study. BMC Public Health 2005; 5: 1.
  4. Yuen T, Wells K, Benoit S, et al. Therapeutic interventions employed by Greater Toronto Area chiropractors on pregnant patients: results of a cross-sectional online survey. J Can Chiro Assoc 2013; 57(2): 132-142.
  5. Weis CA, Stuber K, Barrett J, et al. Attitudes toward chiropractic: a survey of Canadian obstetricians. J Evid Based Complementary Altern Med 2016; 21(2): 92-104.
  6. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Br Med J 2009; 339: b2535.
  7. Hawk C, Minkalis A, Khorsan R, et al. Systematic review of nondrug, nonsurgical treatment of shoulder conditions. J Manipulative Physiol Ther 2017; 40(5): 293-319.
  8. Bronfort G, Haas M, Evans R, et al. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat 2010; 18: 3.

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