Effects of Progressive Muscle Relaxation Exercises Accompanied by Music on Low Back Pain and Quality of Life During Pregnancy

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1 Journal of Midwifery & Women s Health Original Research Effects of Progressive Muscle Relaxation Exercises Accompanied by Music on Low Back Pain and Quality of Life During Pregnancy Zehra Baykal Akmeşe, RM, MSc, Nazan Tuna Oran, PhD, RN Introduction: Back pain is commonly experienced by pregnant women. Evidence suggests that progressive muscle relaxation (PMR) therapy, a complementary therapy widely used by pregnant women, may improve the physical and psychological outcomes of pregnancy. The aim of this study was to investigate the effects of PMR training accompanied by music on perceived pain and quality of life (QOL) in pregnant women with low back pain (LBP). Methods: This was a prospective randomized controlled trial. The study was designed to examine the effects of PMR accompanied by music on pregnant women with LBP. In total, 66 pregnant women were assigned randomly to a PMR group or a control group (33 women in each). A personal information form was used as a data collection tool; a visual analog scale was used for measuring pain; and the Short Form-36 was used to evaluate QOL. Results: The control and intervention groups were comparable at baseline. Significant differences were observed between the 2 groups after 4 and 8 weeks of intervention. The intervention group showed significant improvement in all QOL subscales after the intervention. The intervention group, but not the control group, showed significant improvement in perceived pain after the intervention. The intervention group experienced a greater decrease in perceived pain and improved QOL than the control group. Discussion: Our findings show that PMR accompanied by music may be an effective therapy for improving pain and QOL in pregnant women with LBP. Large randomized studies are recommended to confirm these results. JMidwiferyWomens Health 2014;59: c 2014 by the American College of Nurse-Midwives. Keywords: muscle relaxation, pain management, patient education, pregnancy, preventive health care, quality of life INTRODUCTION Back pain during pregnancy is a common condition often regarded as an unavoidable issue in a normal pregnancy. It is the most common musculoskeletal problem that affects pregnant women; 50% to 70% of pregnant women experience some form of low back pain (LBP) during pregnancy. 1 5 In one systematic review of 106 articles from around the world, the average prevalence of pregnancy-related pelvic-girdle pain was 45%. It was described as severe in 25% of pregnant women, moderate in 30%, and mild in 45%. 6 The average prevalence of pain was 56.7% in the 5 articles from North America in this review, 6 and was 67% in another study of an underserved US pregnant population. 7 One study reported the prevalence of LBP in pregnant Turkish women as 54%. 8 Thus, pregnancyrelated LBP is a relatively common problem encountered by clinicians. Variousexplanationsofthepathophysiologythatleadsto back pain in the antenatal period have been proposed, including the increase in load on the back as a result of the total weight gained during pregnancy and the weight of the fetus; hormonal changes in the pregnant woman, which destabilize thespineandsacroiliacjoints;andconnectivetissuemicrotrauma in the sacroiliac joints, resulting from trunk extensor Address correspondence to Zehra Baykal Akmeşe, RM, Msc, Ege University Izmir Ataturk School of Health, Bornova, Izmir, Turkey. zehra.baykal@ege.edu.tr muscle forces to balance the anterior flexion moment caused by the growing fetus. 5 The symptoms of LBP during pregnancy are severe enough to affect activities of daily living and reduce quality of life (QOL), leading to frequent periods of bed rest and absence from work. 9,10 More than 80% of pregnant women with back pain experience discomfort during daily activities and have difficulties with housework, child care, and job performance. 11 Relaxation therapy has recently become an integral part ofthecareofindividualswithchronicdisease,duetobenefits such as reducing anxiety and stress, distracting attention away from the pain, relieving muscle strain and contractions, facilitating sleep, and reducing sensitivity to fatigue and pain. 12 A recent systematic review concluded that there are numerous positive effects of relaxation techniques during pregnancy, including maternal, fetal, and neonatal outcomes. 13 Some examples are fewer admissions to hospital, fewer obstetric complications, longer gestation, reduced cesarean births, fewer postpartum complications, higher birth weight, and improved neonatal behavioral performance. One of the most simple and easily learned relaxation techniques is progressive muscle relaxation (PMR), a widely used procedure originally developed in 1938 by Jacobson. 14 The PMR technique involves deep breathing and progressive relaxation (tense release) of major muscle groups. The techniquepromotessystematicrelaxationofthemajormuscle groups of the body with the goal of physical and mental /09/$36.00 doi: /jmwh c 2014 by the American College of Nurse-Midwives 503

2 Relaxation therapy and progressive muscle relaxation (PMR) are forms of complementary and alternative medicine often used in pregnancy. PMR induces both physiologic and psychological relaxation and decreases pain sensation in pregnant women with low back pain. PMR training is a potentially effective midwifery intervention to reduce pain while increasing quality of life in pregnant women with low back pain. relaxation, reducing the response to stress, reducing skeletal muscle contractions, and decreasing pain sensations. 12 Although PMR has been documented to reduce pain and lessen mobility difficulties due to other causes, such as osteoarthritis, it has not been evaluated in pregnancy-related LBP. 15 This study was conducted to determine the effectiveness of PMR accompanied by music in reducing perceived pain and improving QOL in pregnant women with LBP. METHODS Study Design This study was an 8-week prospective randomized controlled trial conducted from January 2007 through September Pregnant women who presented at the Antenatal Care Unit of the Department of Obstetrics and Gynecology, Faculty of Medicine, Ege University for routine antenatal care and reported back pain were eligible to enroll. The study was approved by the institutional ethics committee of Ege University. All participating women provided informed consent before enrolling in the study. Study Subjects and Setting All women at the beginning of their second trimester were informed by researchers at the hospital clinic of the possibility of taking part in the study if they had a physician diagnosis of back pain. The inclusion criteria were as follows: 1) presence of LBP diagnosed by a physician; 2) aged 20 to 35 years; 3) 12 to 24 weeks gestation; 4) no history of LBP or lumbar pathology before pregnancy; 5) visual analog scale (VAS) score (to assess the degree of pain at the time of diagnosis) of 4 or greater on a scale of 10; 6) no other contraindication, such as heart disease, chronic obstructive lung disease, diabetes mellitus, incompetent cervix/cerclage, multiple gestation, risk of premature labor, preeclampsia/pregnancy-induced hypertension, thrombophlebitis, pulmonary embolism, intrauterine growth restriction, or serious blood disease; 7) no history of abortion or curettage; 8) resident in the city of Izmir, Turkey; 9) own a compact disc (CD) player at home; 10) a primary school graduate; and 11) no hearing deficit. Participants were assigned randomly to the intervention or control groups using a random number table. Assessment Tools A3-partsurveywasusedfordatacollection.Thequestionnaires included a personal information form, a visual analog scale for measuring pain, and the Short Form-36 (SF-36) for evaluating QOL. Personal Information Form The personal information form (PIF), an investigatordeveloped survey, consisted of 37 questions divided into 3 sections: demographic characteristics, pregnancy and obstetric history,andpersonalhabits(table1). Visual Analog Scale The VAS is a common, simple method with established validity and reliability. 16 The VAS rating system consists of a 100- mm line that represents pain along a continuum of 2 extremes, from no pain (a score of 0) to extreme pain (a score of 10). Short Form-36 The general purpose SF-36 is one of the best-known scales used to measure health-related QOL, a subjective concept based on self-perception. The scale was developed by the RAND Corporation (Santa Monica, CA). 17 TheSF-36isa sensitive measure of treatment success in people with LBP 18 and has been used in studies of pregnant and postpartum women and in longitudinal studies that followed women from pregnancy into the postnatal period. 19 It has been translated into Turkish, and a validity and reliability study has been reported. 20 The test consists of 36 items assigned to 8 subscalesphysical functioning (10 items), role-physical (4 items), bodily pain (2 items), general health (5 items), vitality (4 items), social functioning (2 items), role-emotional (3 items), and mental health (5 items). These 8 scales are further clustered into the physical component summary (physical function, rolephysical, bodily pain, and general health) and the mental component summary (vitality, social function, role-emotional, and mental health). For each question, the participants were asked to mark the choice that was most appropriate for them. Each subscale was scored between 0 and 100. High scores on all subscales indicate deterioration in QOL. Data Collection Intervention Group Women who enrolled and were randomized to the intervention group completed the PIF, SF-36, and VAS at the first 504 Volume 59, No. 5, September/October 2014

3 Table 1. Sociodemographic and Obstetric Characteristics of Women Enrolled in a Study of Progressive Muscle Relaxation for Treatment of Low Back Pain in Pregnancy PMR,n(%) Control,n(%) Characteristic (n = 33) a (n = 33) b P value a Age, y (33.4) 9 (27.3) (42.4) 15 (45.4) 30 8 (24.2) 9 (27.3) Education level High school 24 (72.7) 21 (63.6) Graduate school/faculty 9 (27.3) 12 (26.4) Economic status c Fair 21(63.6) 14 (42.4) Good 12 (36.4) 19 (57.6) Occupational activity Housewife 20 (60.6) 18 (54.5) Sedentaryjob 7(21.2) 10(30.3) Active job 6 (18.2) 5 (15.2) Body mass index, kg/m (72.7) 20 (60.6) (27.3) 13 (39.4) Gestational age at entry to study weeks 13 (39.4) 13 (39.4) weeks 9 (27.3) 12 (36.4) weeks 11 (33.3) 8 (24.2) Gravidity 1 24 (72.7) 20 (60.6) (27.3) 13 (39.4) Exercise before pregnancy d Yes 11 (33.3) 13 (39.4) No 22 (66.7) 20 (60.6) Frequency of exercise before pregnancy e Every day 6 (54.5) 7 (53.8) timesperweek 5(45.5) 6(46.2) Abbreviation: PMR, progressive muscle relaxation. a Chi-squared P value. b Includes only those women who completed the 8-week study. c Economic status was defined as good when total income was higher than the national minimum wage, and fair whentotalincomewasequaltoorlessthanthenational minimum wage. d Including only walking and/or Pilates. e PMR group n = 11, control group n = 13. study visit. The PMR technique was explained with the aid of a handbook that included relaxation exercises, including information about how to perform the progressive relaxation exercises, and breathing techniques. Women also received a relaxation exercise CD prepared by the Turkish Psychological Association, 21 which contained instructions for relaxation exercises and background low-level music. The CD instructions advise women to lie on a comfortable bed. The therapist s voice then instructs them to contract and release different muscle groups. They practice tensing a muscle group until they feel the slight contraction and then release it, simultaneously relaxing all other muscle groups. Practice progresses in the same manner, starting with the muscles in the feet, then the calf, thigh, gluteal muscles, abdomen, chest, hands, forearms,shoulders,neck,face,andfinallytheforehead.atypical CD session lasts about 20 minutes. Women in the intervention group were first educated about the PMR technique in a quiet room in the obstetrics polyclinic and were then allowed to listen to the CD about the relaxation exercises. Later, the researchers demonstrated the exercises and women were asked to perform them. This education was provided once for each pregnant woman and lasted Journal of Midwifery & Women s Health 505

4 approximately 2 hours. The aim was to help women learn and perform the exercises properly. Care was taken to ensure that the exercises were the only content of the practice sessions. After the education session, each pregnant woman was giventhehandbookandcdandwasaskedtolistentoand perform the PMR exercises at home, following the instructions on the CD, twice per day (morning and evening) for 8 weeks. At 4 weeks after the first meeting, women returned to the obstetrics polyclinic for another visit and were asked to perform the PMR exercises under the supervision of the researcher to identify any errors in performance. They completed the SF-36 and VAS scale. Women returned again to the obstetrics polyclinic 4 weeks later, after the completion of their 8-week PMR program, and completed the SF-36 and VAS scale one more time. Participants recorded their performance of the exercises on a standard calendar and were encouraged not to skip more than 2 exercise sessions per week. They were also warned not to use other complementary therapies, such as acupuncture, massage, and other mind body techniques, during the study period. They were questioned about this at each visit and at the end of the study. Routine daily activity was not restricted. Control Group Women who enrolled and were randomized to the control group also completed the PIF, SF-36, and VAS at the first study visit. Then they were instructed to simply lie down and do nothing for 20 minutes twice per day (morning and evening). This was to help equalize the activities of the control and intervention groups. Participants recorded their performance of this activity on a standard calendar and were encouraged not toskipmorethan2sessionsperweek.theyvisitedtheclinicat weeks 4 and 8 and rated their pain and QOL on the SF-36 and VAS scales. They were also warned not to use any complementary treatment for LBP during this period; this was questioned ateachvisitandagainattheendofthestudy.routinedailyactivitywasnotrestricted.attheendofthe8-weekperiodafter completion of the study, women in the control group then received the same CD and handbook as did participants in the intervention group. All women completed the surveys and questionnaires without assistance from study staff. Completed forms were sealed in a large envelope and collected by the study coordinator at the end of the study. After completion of the study, forms were submitted for scoring, blinded to both the group (intervention or control) and the timing of the visit (initial, middle, or last visit). Data Processing and Analysis Theprimaryaimofthisstudywastocompare8-weekchanges in pain scores measured by the VAS in each group and between the 2 groups. A secondary aim was to compare 8-week changes in QOL in each group and between the groups. The results were analyzed using the SPSS software (SPSS for Windows; SPSS, Inc., Chicago, IL). The level of significance in all analyses was set at P less than.05. Figure 1. ChangesintheVASScoresinthePMRandControl Groups Over Time Abbreviations: PMR, progressive muscle relaxation; VAS, visual analog scale. Note:VAS1atbaseline,VAS2at1month,VAS3at2months. The means of the parametric data for the groups were compared using the unpaired t test. The chi-squared test was used for categorical data. A repeated-measures analysis of variance was used to identify differences between the PMR and control groups in terms of the changes in the VAS and SF-36 QOL scores over time. RESULTS We contacted 97 healthy pregnant women; 24 were excluded due to either failure to meet the inclusion criteria or declining to participate. We randomly assigned the remaining 73 pregnant women (aged years) to the PMR group (n = 37) or the control group (n = 36). At the end of the study (8 weeks later), 66 women (33 per group) had completed the program. No significant differences in sociodemographic or obstetric characteristics were observed between the groups (Table 1). All 66 women from both groups were asked about their use of any complementary therapies (other than PMR in the intervention group), and we did not detect any use of any other complementary therapy. Additionally, the performance of the assigned practice was similar in both groups. All women in both groups assessed their pain on the VAS scaleatthebeginningofthestudyandthenagainatweeks4 and 8. There was no statistically significant difference between the initial VAS scores related to LBP between the groups. There was a statistically significant difference between the 2 groups in the change in pain scores experienced over the 8 weeks (F = ; df = 2; P.001). The 33 participants in the PMR group reported a significant reduction in pain scores at week 8 (P. 005). In contrast, those in the control group exhibited increased pain scores at week 8; the increases reached statistical significance (Table 2, Fig. 1). Significant differences between the control and PMR groups were observed on all SF-36 subscales. The initial (T1) scores showed a significant difference between the groups in 7 of the 8 SF-36 subscales (scores on physical function,bodypain,generalhealth,vitality,socialfunction,and 506 Volume 59, No. 5, September/October 2014

5 Table 2. ChangesintheVASScoresintheInterventionandControlGroups Baseline VAS 1-month VAS 2-month VAS Pain Mean (SD) Mean (SD) Mean (SD) F P PMR Group 7.78 (1.61) 5.21 (1.53) 3.72 (1.25) Control Group 7.69 (1.75) 8.42 (1.03) 9.03 (0.98) Abbreviations: PMR, progressive muscle relaxation intervention group; SD, standard deviation; VAS, visual analog scale. Table 3. Effects of the 8-week Progressive Muscle Relaxation Training on SF-36 Subscale Scores in the Intervention and Control Groups PMR Group Control Group Subscales Time Mean (SD) Mean (SD) F P Physical function baseline (9.10) (9.84) 1-month (5.85) (8.70) month (8.04) (7.15) Role physical baseline (12.54) (24.80) 1-month (50.56) (24.42) month (50.56) (20.75) Body pain baseline (9.18) (14.73) 1-month (5.05) (8.75) month (5.05) (11.97) General health baseline (5.64) (9.19) 1-month (2.17) (9.30) month (1.77) (7.33) Vitality baseline (6.61) (11.83) 1-month (4.33) (7.30) month (4.50) (9.43) Social function baseline 83.33!14.87) (16.27) 1-month (11.88) (13.98) month (11.88) (9.62) Role emotional baseline (50.56) (25.16) 1-month (50.56) (33.07) month (50.56) (25.03) Mental health baseline (4.12) (8.46) 1-month (2.46) (8.23) month (2.47) (6.93) Abbreviations: PMR, progressive muscle relaxation intervention group; SD, standard deviation; SF, short form. Note:Comparingthebaselineand2-monthscores,apositiveeffectofPMRisseenbetweenthegroupsinallSF-36domains.Thegreatestdifferencewasin the role physical, followed by physical function, general health, social function, and body pain. The smallest difference was in role emotional, followed by mental health. mental health were higher in the PMR group at baseline; scores on the role physical subscale were lower at baseline in the PMR group). Over the 8-week period, the scores on all SF- 36 subscales increased gradually in the PMR group, while the scores decreased in the control group (Table 3). DISCUSSION This study is one of the first to evaluate the effectiveness of PMR in reducing symptoms of LBP and improving QOL in pregnancy. In the control group of the present study, pregnant women with LBP had significant progressive worsening of QOL(measuredbySF-36)andLBP(measuredbyVAS)during a 2-month period. However women who received PMR training and practiced it regularly experienced significant improvement in perceived pain as well as significant positive effects in all 8 QOL domains, as measured by the SF-36. Thus, our findings demonstrate that PMR may be an effective therapy for improving LBP and QOL in pregnant women. There are several reasons why this therapy might produce the observed benefit. In the autonomic nervous system, tension and relaxation involve the firing of sympathetic and parasympathetic nerve fibers, respectively. Because muscle relaxation constitutes the major dominant component of PMR, the parasympathetic system dominates during and after PMR, resulting in subsequent reductions in heart rate, respiratory rate, and blood pressure. It has also been suggested that deep somatic restfulness, together with parasympathetic dominance, reduces anxiety. The relaxation response generally may also reduce pain by decreasing tissue oxygen Journal of Midwifery & Women s Health 507

6 demand, lowering levels of chemicals such as lactic acid, and releasing endorphins. 22 Thus, a PMR-induced reduction in anxiety, along with the decreased perception of pain, may eventually improve QOL status in pregnant women. A systematic review concerning nonpharmacologic therapies for acute and chronic LBP revealed that cognitivebehavioral therapy, PMR, exercise, interdisciplinary rehabilitation, functional restoration, and spinal manipulation were effective for chronic or subacute ( 4 weeks duration) LBP. 25 AlthoughPMRhasbeenusedbypregnantwomenforvarious reasons, few studies have addressed its specific use in pregnancy for managing LBP. In one study, PMR intervention was compared with massage in pregnant women with leg and back pain. 26 Inthatstudy,legpaindecreasedsignificantlyafter the first and last treatments in both the PMR and massage groups, but back pain decreased only in the massage group. 26 In our study, PMR training accompanied by music improved LBP significantly. Pain decreased over time during the study in the intervention group, whereas the pain scores (and perceived pain) in the control group increased gradually. Given that in one survey a majority of pregnant women reported that they would use complementary and alternative medicine such as massage, relaxation, hypnosis, yoga, or acupuncture during pregnancy, 23 andinanothersurveymore than 90% of prenatal health care providers recommend nonpharmacologic treatment and alternative therapy, 24 PMR accompanied by music may be an acceptable and effective therapy to recommend for improving pain and QOL in pregnant women with LBP. Inaddition,ourstudyisthefirsttoassesstheeffectsofsupervised PMR training on QOL in pregnant women with LBP. In this investigation, the PMR group improved significantly on 8 QOL subscales, whereas the same 8 subscale scores decreased gradually in the control group. Pregnant women with back pain have some difficulties with daily activities, which canaffectthempsychologicallyanddecreaseqol The SF-36 is a suitable tool for assessing QOL in pregnant women. 27 Hueston and Kasik-Miller studied the 8 subscale scores of the SF-36 during a normal pregnancy period. They found that 3 subscales associated with physical health status changed significantly with gestational age. Physical functioning, role limitation due to physical problems, and body pain scales all decreased as pregnancy progressed. 31 Scores on the vitality subscale of the SF-36 also decreased with the deterioration in physical functioning during the later phase of a normal pregnancy. 29,32 Thesefindingswereveryclosetothoseof our control group. In addition to the obvious outward physical changes that accompany pregnancy, there may also be increases in mental health issues, including depression, anxiety, and stress. 33 Bastani et al reported beneficial effects of relaxation in reducing anxiety and perceived stress in pregnant women. 34 Musical therapy is a type of complementary and alternative medicine that may be beneficial for decreasing stress, preventing depression, and improving pain. Music makes a person calm and optimistic. 35 Kimber et al reported a pain-lowering effect of music and relaxing techniques during labor. 36 In our study, the mental health subscale scores decreased in the control group but increased in the intervention group. Such increases in mental health scores may have been due to the further relaxing effect of the background music on the exercise CD. This study has some limitations. The first is the small sample size. Future research on the effects of PMR would obviously be strengthened by use of a larger number of pregnant women. Second, many complementary and alternative medicine techniques are used together. Our intervention group received PMR together with music. Because music itself is another complementary and alternative medicine technique, it is difficult to know whether it was the PMR with the music, the PMR alone, or possibly both individually that might have been effective. The beneficial effects of PMR and music should be further explored in a 3-intervention study. It is also unknown how PMR works as an adjunctive therapy to standard medical treatment. Randomized controlled trials are needed to assess analgesic dose and/or pattern needed in conjunction with PMR. Another limitation is the lack of absolute blinding after establishment of the groups. The participants in the experimental group comprehended, at the beginning of the study, the possiblebeneficialeffectoftheexerciseprogramontheirlbp; this expectation could have further ameliorated their pain. The women of the control group, however, underwent no extra treatment (medication, exercise, etc.) even though they were aware of participating in a prospective study; this disappointment may have inhibited coping strategies with pain. Although women in the control group were also advised to simply lie down for 20 minutes twice per day to equalize the 2 groups, the lack of absolute blinding might have introduced some bias into the results. We also note the initial nonhomogeneous (T1) scores of subscales of SF-36, suggesting that the groups differed prior to the intervention. How this could have influenced the outcome is unknown. This might be due to the relatively small number of participants in each group. During the initial selection of subjects, the exclusion of women with VAS less than 4 might have further reduced the homogeneity of the groups initial scores. CONCLUSION LBP is one of the most common musculoskeletal conditions experienced by pregnant women. We conclude that PMR training and practice can reduce LBP and improve QOL in pregnant women. AUTHORS Zehra Baykal Akmeşe, RM, MSc, is Research Assistant at Ege University Izmir Ataturk School of Health, Department of Midwifery, Bornova, Izmir, Turkey. NazanTunaOran,PhD,RN,isAssociateProfessoratEge University Izmir Ataturk School of Health, Department of Midwifery, Bornova, Izmir, Turkey. CONFLICT OF INTEREST The authors have no conflicts of interest to disclose. 508 Volume 59, No. 5, September/October 2014

7 ACKNOWLEDGMENTS Financial support for this study was provided by Ege University Scientific Research Project (No. 2007/ASYO/004). REFERENCES 1.Östgaard HC, Andersson GB. Previous back pain and risk of developingbackpaininafuturepregnancy.spine 1991;16(4): Wang SH, Dezzinno P, Maranets I, Berman MR, Caldwell-Andrews AA, Kain ZN. Low back pain during pregnancy: Prevalence, risk factors, and outcomes. Obstet Gynecol 2004;104(1): Mogren IM, Pohjanen A. Low back pain and pelvic pain during pregnancy: Prevalence and risk factors. Spine 2005;30(8): Garshasbi A, Zadeh SF. The effect of exercise on the intensity of low back pain in pregnant woman. Int J Gynaecol Obstet 2005;88(3): Vermani E, Mittal R, Weeks A. Pelvic girdle pain and low back pain in pregnancy: A review. Pain Pract 2010;10(1): Wu WH, Meijer OG, Uegaki K, et al. Pregnancy-related pelvic girdle pain (PPP), I: Terminology, clinical presentation, and prevalence. Eur Spine J 2004;13(7): SkaggsCD,PratherH,GrossG,GeorgeJW,ThompsonPA,Nelson DM. Back and pelvic pain in an underserved United States pregnant population: A preliminary descriptive survey. JManipulativePhysiol Ther 2007;30(2): Mazicioglu M, Tucer B, Ozturk A, et al. Low back pain prevalence in Turkish pregnant women. JBackMusculoskeletRehabil 2006;19(2): Östgaard HC. Assessment and treatment of low back pain in working pregnant women. Semin Perinatol 1996;20(1): Mens JMA, Vleeming A, Stoeckart R, Stam HJ, Snijders CJ. Understanding peripartum pelvic pain. Implications of a patient survey. Spine 1996;21: Ansari NN, Hasson S, Naghdi S, Keyhani S, Jalaie S. Low back pain during pregnancy in Iranian women: Prevalence and risk factors. Physiother Theory Pract 2010;26(1): McGuigan FJ, Lehrer PM. Progressive relaxation: Origins, principles, and clinical applications. In Lehrer PM, Woolfolk RL, Sime WE, eds. Principles and Practice of Stress Management.Thirded.NewYork, NY: The Guilford Press; 2007: Fink NS, Urech C, Cavelti M, Alder J. Relaxation during pregnancy: What are the benefits for mother, fetus, and the newborn? A systematic review of the literature. J Perinat Neonatal Nurs 2012;26(4): Snyder M. Progressive relaxation. In Snyder M, ed., Independent Nursing Interventions, 2nded.NewYork,NY:DelmarPublishers Inc.; 1992: Baird CL, Sands L. A pilot study of the effectiveness of guided imagery withprogressivemusclerelaxationtoreducechronicpainandmobility difficulties of osteoarthritis. Pain Manag Nurs 2004;5: Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res 2011;63(11): Ware JE Jr, Sherbourne CD. The MOS 36- item short-form health survey (SF-36). I. Conceptual framework and item selection. Medical Care 1992;30(6): Ware JE, Kosinski M. SF-36 Physical & Mental Health Summary Scales: A Manual for Users of Version 1.2nded.Lincoln,RI:QualityMetric, Inc; Jomeen J, Martin C. Perinatal quality of life: Is it important for childbearing women? Pract Midwife 2012;15(4): KocyigitH,AydemirO,FisekG,OlmezN,MemisA.Reliabilityand validity of the Turkish version of the Short Form 36 (SF-36). (in Turkish). İlaç vetedavidergisi. 1999;12, Turkish Psychological Association Publications. Relaxation Exercises CD. Ankara, Turkey; Conrad A, Roth WT. Muscle relaxation therapy for anxiety disorders: It works but how? JAnxietyDisord2007;21(3): Sabino J, Grauer JN. Pregnancy and low back pain. Curr Rev Musculoskelel Med 2008;1(2): Wang MS, Dezinno P, Fermo L, et al. Complementary and alternative medicine for low-back pain in pregnancy: A cross-sectional survey. J Altern Complement Med 2005;11(3): Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low back pain: A review of the evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline. Ann Intern Med 2007;147: Field T, Hernandez-Reif M, Hart S, Theakston H, Schanberg S, Kuhn C. Pregnant women benefit from massage therapy. JPsychosomObstet Gynaecol 1999;20(1): van de Pol G, de Leeuw JR, van Brummen HJ, van der Vaart CH, Bruinse HW, Heintz AP. The Pregnancy Mobility Index: A mobility scale during and after pregnancy. Acta Obstet Gynecol Scand 2006;85(7): Greenwood CJ, Stainton MC. Back pain/discomfort in pregnancy: Invisible and forgotten. JPerinatEduc. 2001;10(1): Nicholson WK, Setse R, Hill-Briggs F, Cooper LA, Strobino D, Powe NR. Depressive symptoms and health-related quality of life in early pregnancy. Obstet Gynecol 2006;107(4): Haas JS, Jackson RA, Fuentes-Afflick E, et al. Changes in the health status of women during and after pregnancy. JGenInternMed 2005;20(1): Hueston WJ, Kasik-Miller S. Changes in functional health status during normal pregnancy. J Fam Pract 1998;47(3): Otchet F, Carey MS, Adam L. General health and psychological symptom status in pregnancy and the puerperium: What is normal? Obstet Gynecol 1999;94(6): WatsonJP,ElliotSA,RuggAJ,BroughDI.Psychiatricdisorderin pregnancy and the first postnatal year. Br J Psychiatry 1984;144: Bastani F, Hidarnia A, Kazemnejad A, Vafaei M, Kashanian M. A randomized controlled trial of the effects of applied relaxation training on reducing the effects of anxiety and perceived stress in pregnant women. JMidwiferyWomensHealth2005;50(4):e Nilsson U. The anxiety-and pain-reducing effects of music interventions: A systematic review. AORN J 2008;87(4): Kimber L, McNabb M, Mc Court C, Haines A, Brocklehurst P. Massage or music for pain relief in labour: a pilot randomised placebo controlled trial. Eur J Pain 2008;12(8): Journal of Midwifery & Women s Health 509