Research Review by Dr. Shawn Thistle©

Date:

June 2007

Study Title:

Pelvic girdle pain and lumbar pain in relation to postpartum depressive symptoms

Authors:

Gutke A, Josefsson A & Oberg B

Publication Information:

Spine 2007; 32(13): 1430-1436.

Summary:

Low back pain and depression are common complications of pregnancy. An estimated 45% of women will have LBP during pregnancy, while 25% will have LBP postpartum. Depression rates also show a first peak in women during child-bearing years, with approximately 10-20% of women experiencing depressive illness during pregnancy or within one year postpartum.

Although this usually resolves, up to 25% of women who experience postpartum depression can have symptoms persist beyond one year. Further, postpartum depression can be associated with many antenatal risk factors, including psychological distress, sick leave, and financial strain. Risk for relapse in subsequent pregnancies could also be as high as 50%.

Previous research has suggested that an association may exist between postpartum LBP and depression; however these studies were low quality, or did not directly address this relationship. In non-pregnant populations, an association has been established between disabling LBP and a high level of psychological distress.

This study, part of a larger cohort project, investigated the relationship between lumbopelvic pain and postpartum depression, and the prevalence of depressive symptoms in women classified as having pelvic girdle pain (PGP) and/or lumbar pain.

A cohort of 267 postpartum women enrolled in the antenatal health care system in Sweden participated in this study. All subjects had a normal pregnancy, and were enrolled between gestational weeks 12 and 18. Women were excluded if they had a systemic locomotor system disease, previous spinal/pelvic/femur surgery, spinal problems within the 2 months prior to becoming pregnant, or a history of fracture or neoplasm.

In addition to providing comprehensive baseline data, each subject underwent a physical assessment by a physical therapist to determine the presence of any lob back or PGP. Patients were then classified into the following groups for analysis:
  1. no lumbopelvic pain
  2. pelvic girdle pain (PGP) - between gluteal fold and PSIS
  3. lumbar pain - above PSIS
  4. PGP and lumbar pain
The physical examination involved standardized tests based mainly on Mechanical Diagnosis and Therapy principles (MDT - commonly known as McKenzie), in addition to pain provocation tests for the SI joint, the Active Straight Leg Raise test, neurological examination, and hip ROM.

The Edinburgh Postnatal Depression Scale was used to measure depressive symptoms. This 10-item self-report scale has been validated, and is specifically designed to screen for depression in community samples. Each item is scored on a 4-point scale (from 0-3) with a total score range of 0-30. Although the scale cannot confirm a diagnosis of depression, a cutoff score of ≥10 has been proposed for depression screening, while a score ≥13 suggests probable depression (which thus requires more comprehensive evaluation or referral) according to existing studies.

Pertinent Results:

  • after delivery, 33% of women experienced some form of lumbopelvic pain (this is similar to findings in previous studies on postpartum LBP): 17% had PGP, 11% had lumbar pain, and 5% had combined pain
  • using a cutoff of ≥10 on the Edinburgh Scale, 16% (n=44) of women experienced depressive symptoms postpartum
  • overall, depressive symptoms were 3 times more common in women with lumbopelvic pain (subgroups had a 3 to 6-fold increase in likelihood of screening positive for depression)
  • in the group with depressive symptoms, 61% of them had some form of lumbopelvic pain - thus, 27 of 267 women (~ 10%) had both lumbopelvic pain and depressive symptoms (representing the comorbidity rate in this study)
  • the prevalence of depressive symptoms was higher in women with lumbar pain than those without any pain when both cutoff points were used on the Edinburgh Scale
  • for PGP, the prevalence of depressive symptoms was only significant when using the lower cut off score of 10

Conclusions & Practical Application:

Many pregnant women consult manual medicine providers for treatment of low back and pelvic pain during pregnancy and postpartum, with reportedly good results. It is therefore important for manual therapists to be cognizant of potential comorbidities that may accompany these conditions, in order to better manage patient cases in a holistic manner. Early recognition is the key for both of these conditions, and there are treatment options for postpartum depression (as well as postpartum LBP/PGP).

This simple, well-designed study strengthens the probable association between postpartum low back or pelvic pain and depressive symptoms.