Research Review By Dr. Ceara Higgins ©

Audio:

Download MP3

Date Posted:

October 2014

Study Title:

Recommendations for physical therapists on the treatment of lumbopelvic pain during pregnancy: a systematic review

Authors:

Van Benten E, Pool J, Mens J & Pool-Goudzwaard A

Author's Affiliations:

University of Applied Sciences Utrecht, Utrecht, the Netherlands; M-Visio, Barneveld; IMPACT Medical Centre, Zoetermeer; Erasmus MC, University Medical Centre, Rotterdam; VU University Amsterdam, Amsterdam, all in the Netherlands.

Publication Information:

Journal of Orthopaedic & Sports Physical Therapy 2014; 44(7): 464-473.

Background Information:

The prevalence of pregnancy-related low back pain (LBP) and pelvic girdle pain (PGP) has been reported to vary from 24%-90%. This extreme range is primarily due to a lack of a clear definition and classification criteria for these conditions. Previous reviews have used a variety of different definitions. In addition, previous reviews have failed to consider patient education (including functional training in self-care, home management, work, and patient-related instruction) as part of any given intervention. The current review considered LBP & PGP as a single category and did consider patient education as an intervention.

Patient education is generally regarded as very safe and it is commonly employed by manual medicine providers for patients with many different conditions. Exercise therapy has been more widely studied for pregnancy with varying results, however, no consensus has been reached with regard to the type or frequency of exercise that is most useful. Manual therapy is also widely used by physiotherapists, chiropractors, and other manual practitioners. While the efficacy has not been firmly established, it has been well established as a safe form of therapy for pregnant patients (22). These treatment approaches could all be valuable for patients with LBP/PGP during pregnancy. The aim of this systematic review was to assess the peer-reviewed literature on the effectiveness of physical therapy interventions in treating lumbopelvic pain during pregnancy.

Pertinent Results:

  • Of the 22 RCTs included, 3 looked at women with PGP, 1 focused on LBP (confirmed by palpation), 5 focused on women with both LBP and PGP or did not differentiate, and 13 did not focus on lumbopelvic pain specifically.
  • The majority of studies used pain or disability as the main outcome measure. Most commonly, the visual analog scale (VAS) and the Roland-Morris Disability Questionnaire were utilized. Other outcome measures used included physical tests, anxiety, and overall treatment experience.
  • 4 categories of interventions were identified in the studies reviewed. These included exercise therapy, manual therapy, material support, and combinations of interventions. Most studies included a control group, which received standard antenatal care.
Combined Intervention Studies (n = 7):

Seven studies utilized a combination of intervention and of these, 6 showed a positive effect on pain, disability, and/or sick leave. Depledge and colleagues (1) investigated the effect of muscle-training exercises with and without the use of a pelvic belt on improvement in pain and disability during activities of daily living (ADLs) and showed that training had a positive effect, which was not affected by the use of the pelvic belt. Meanwhile, Kordi and colleagues (13) utilized similar interventions but found that the use of a pelvic belt, when combined with muscle-training exercises, showed greater improvements than exercises alone. Eggen and colleagues (2) looked at the use of supervised exercise combined with ergonomic advice and found that the combination did not influence prevalence and severity of lumbopelvic pain. All other combination studies (7, 16-18) looked at a combination of education on a variety of topics (anatomy, pathology, posture physiology, changes during pregnancy, relaxation, and modification and advice on ADLs) and either exercise therapy, manual therapy, or use of a pelvic belt. All of these studies showed positive effects on pain, disability, and sick leave.

Exercise Studies (n = 9):

Nine studies investigated the use of exercise therapy alone. All of these reported a positive effect on pain, disability and sick leave. Four were considered to be of relatively high quality and showed positive effects on functional status (16) and sick leave (8, 11, 21). Six studies showed decreases in pain (6, 8, 10-12, 15) while one study (11) showed increased pain as pregnancy progressed in all groups. Finally, one study (21) showed no significant between group differences in pain levels, but significantly less sick leave in the exercise group.

Manual Therapy Studies (n = 5):

Five studies looked at the use of manual therapy during pregnancy and all showed positive effects on back pain and disability. They type of manual therapy used varied, with two studies (14, 19) looking at joint mobilization and three (3-5) looking at massage therapy. All were of relatively poor quality. Of the studies looking a joint mobilization, one (14) explored the use of osteopathy alongside usual obstetric care and showed a significantly better decrease in pain and disability with osteopathic manipulation combined with obstetric care, compared with obstetric care alone. The other (19) looked at chiropractic mobilization and stabilization techniques and showed positive effects on pain and disability, but no significant difference between treatment groups.

Material Support Studies (n = 1):

One study (9) looked at the use of material support in the form of wearing a BellyBra or Tubigrip and showed positive effects on pain intensity but no significant between group differences.

Clinical Application & Conclusions:

Moderate evidence was found to support the use of exercise therapy to reduce pain, disability, and/or sick leave in patients with lumbopelvic pain during pregnancy. Studies support a training frequency of 1-2 times per week, with a focus on improving balance, active stabilization, muscle strength in the lower back, pelvis, and pelvic floor, and co-contraction of the transverse abdominal muscles, pelvic floor muscles, and other muscle groups.

Studies including extensive patient education – provided verbally or in writing, on a one-on-one basis or in groups – showed positive effects on pain, disability, and/or sick leave. As the education was not provided separately from other interventions we cannot conclusively state that education was solely responsible for observed improvements. However, providing education is an easy and safe way to treat patients and could be considered a useful tool to include in the treatment of pregnant patients with lumbopelvic pain.

There is little research into the use of manual therapy and material support, despite a positive trend in studies that have been published. Higher quality studies are needed in these areas before more conclusive recommendations can be made.

Study Methods:

The authors searched PubMed, PEDro, Scopus, and CINAHL for English studies published in peer-reviewed journals between January 1992 and November 2013. An additional search was conducted on the reference lists of the articles found.

Inclusion Criteria:
  • RCTs studying pregnant women with or without lumbopelvic pain; and
  • use of non-pharmacological interventions performed by physical and manual therapists, osteopaths, or chiropractors.
Exclusion criteria:
  • Full-text article could not be found/retrieved
  • Either medical or invasive interventions utilized
  • Interventions that only addressed gynaecological or obstetric issues
All selected articles were independently assessed by two of the authors for relevance and eligibility. Study quality was assessed using the Cochrane Back Review Group Internal Validity Checklist. All articles scoring 5 or less were considered to be of relatively poor quality, while those scoring 6 or higher were considered to be of relatively good quality. 22 RCTs were included in the review. The median score for quality was 6/11, indicating overall moderate quality for this body of evidence.

No restrictions were placed on articles selected based on outcome measure used, however, for the purpose of this review, pain, disability, and sick leave were considered the primary variables of interest.

Study Strengths / Weaknesses

Strengths:
  • Two separate authors extracted data from the articles and a third reviewer was consulted if no consensus was reached.
  • The Cochrane Back Review Group criteria were utilized – they have been shown to have good interrater agreement.
  • The study utilized a broad and thorough literature search strategy.
Weaknesses:
  • The quality of the data reporting was mostly deemed to be poor, even in included studies.
  • Appropriate information regarding obstetric complications was lacking in the articles, making it difficult to make any significant conclusions about these types of adverse events.
  • Due to the variety of inclusion criteria and outcome measures used in the reviewed articles, it was not possible to pool the data for meta-analysis.
  • Categorizing the interventions into four intervention groups was helpful for analysis, but it was not always possible to clearly identify and separate specific interventions.
  • Many authors did not report all of the data, which often precluded calculating effect sizes.
  • Most studies lacked adequate blinding.
  • Many studies did not report compliance and drop-out rates

Additional References:

  1. Depledge J, McNair PJ, Keal-Smith C, & Williams M. Management of symphysis pubis dysfunction during pregnancy using exercise and pelvic support belts. Physical Therapy. 2005; 85:1290-1300
  2. Eggen MH, Stuge B, Mowinckel P et al. Can supervised group exercises including ergonomic advice reduce the prevalence and severity of low back pain and pelvic girdle pain in pregnancy? A randomized controlled trial. Physical Therapy. 2012; 92: 781-790
  3. Field T, Diego MA, Hernandez-Reif M et al. Massage therapy effects on depressed pregnant women. Journal of Psychosomatic Obstetrics & Gynecology 2004; 25: 115-122.
  4. Field T, Figueiredo B, Hernandez-Reif M et al. Massage therapy reduces pain in pregnant women, alleviates prenatal depression in both parents and improves their relationships. Journal of Bodywork & Movement Therapies 2008; 12: 146-150
  5. Field T, Hernandez-Reif M, Hart S et al. Pregnant women benefit from massage therapy. Journal of Psychosomatic Obstetrics & Gynecology 1999; 20: 31-38.
  6. Garshasbi A & Faghih Zadeh S. The effect of exercise on the intensity of low back pain in pregnant women. International Journal of Gynecology & Obstetrics 2005; 88: 271-275.
  7. George JW, Skaggs CD, Thompson PA et al. A randomized controlled trial comparing a multimodal intervention and standard obstetrics care for low back and pelvic pain in pregnancy. American Journal of Obstetrics & Gynecology 2013; 208: 295.
  8. Granath AB, Hellgren MS, Gunnarsson, RK. Water aerobics reduces sick leave due to low back pain during pregnancy. Journal of Obstetric, Gynecological & Neonatal Nursing 2006; 35: 465-471.
  9. Kalus SM, Kornman LH, Quinlivan JA. Managing back pain in pregnancy using a support garment: a randomized trial. BJOG 2008; 115: 68-75.
  10. Kashanian M, Akbari Z, Alizadeh MH. The effect of exercise on back pain and lordosis in pregnant women. International Journal of Gynecology & Obstetrics 2009; 107: 160-161.
  11. Kihlstrand M, Stenman B, Nilsson S, Axelsson O. Water-gymnastics reduced the intensity of back/low back pain in pregnant women. Acta Obstetricia et Gynecologia Scandinavica 1999; 78: 180-185.
  12. Kluge J, Hall D, Louw Q et al. Specific exercises to treat pregnancy-related low back pain in a South African population. International Journal of Gynecology & Obstetrics 2011; 113: 187-191.
  13. Kordi R, Abolhasani M, Rostami M et al. Comparison between the effect of lumbopelvic belt and home based pelvic stabilizing exercise on pregnant women with pelvic girdle pain: a randomized controlled trail. Journal of Back & Musculoskeletal Rehabilitation 2013; 26: 113-139.
  14. Licciardone JC, Buchanan S, Hensel KL et al. Osteopathic manipulative treatment of back pain and related symptoms during pregnancy: a randomized controlled trial. American Journal of Obstetrics & Gynecology 2010; 202: 43.
  15. Martins RF, Pinto e Silva JL. Treatment of pregnancy-related lumbar and pelvic girdle pain by the yoga method: a randomized controlled study. Journal of Alternative & Complementary Medicine 2014; 20: 24-31.
  16. Morkved S, Salvesen KA, Schei B et al. Does group training during pregnancy prevent lumbopelvic pain? A randomized clinical trial. Acta Obstetricia et Gynecologia Scandinavica 2007; 86: 276-282.
  17. Nilsson-Wikmar L, Holm K, Oijerstedt R, Harms-Ringdahl K. Effect of three different physical therapy treatments on pain and activity in pregnant women with pelvic girdle pain: a randomized clinical trial with 3,4, and 12 months follow-up postpartum. Spine 2005; 30: 850-856.
  18. Ostgaard HC, Zetherstrom G, Roos-Hansson E, Svanberg B. Reduction of back and posterior pelvic pain in pregnancy. Spine 1994; 19: 894-900.
  19. Peterson CD, Haas M, Gregory WT. A pilot randomized controlled trial comparing the efficacy of exercise, spinal manipulation, and neuro emotional technique for the treatment of pregnancy-related low back pain. Chiropractic & Manual Therapies 2012; 20: 18.
  20. Shim MJ, Lee YS, Oh HE, Kim JS. Effects of a back-pain-reducing program during pregnancy for Korean women: a non-equivalent control-group pretest-posttest study. International Journal of Nursing Studies 2007; 44: 19-28.
  21. Stafne SN, Salvesen KA, Romundstad PR et al. Does regular exercise during pregnancy influence lumbopelvic pain? A randomized controlled trial. Acta Obstetricia et Gynecologia Scandinavica 2012; 91: 552-559.
  22. Stuber KJ, Wynd S, Weis CA. Adverse events from spinal manipulation in the pregnant and postpartum periods: A critical review of the literature. Chiropractic & Manual Therapies 2012; 20: 8.