1. To learn etiology of LBP in pregnancy. 2. To learn the role of evidence-based treatment principles: * Patient Education * Exercise

Size: px

Start display at page:

Download "1. To learn etiology of LBP in pregnancy. 2. To learn the role of evidence-based treatment principles: * Patient Education * Exercise"

Lynn Lyons
5 years ago
Views:

2 1. To learn etiology of LBP in pregnancy 2. To learn the role of evidence-based treatment principles: * Patient Education * Exercise 3. To learn the muscles of your core and how to engage them 4. To learn prenatal exercise precautions

3 Approx. 50% of pregnant women will suffer from some kind of LBP at some point during their pregnancies or postpartum [2-4]. The majority of women are affected in their first pregnancy [21]. 85% of women w/ LBP in a previous pregnancy will develop it in a subsequent pregnancy [1,34,35].

4 Considered to be the most important risk factor for postpartum LBP and the leading reason for sick leave [2-4]. Prevention: Exercise!! * Exercise on a regular basis before pregnancy seems to reduce the risk of LBP during pregnancy [2,3]. * It has been proven that a 12-week training program during pregnancy is effective in the prevention of LBP at 36 weeks of pregnancy [44].

5 Prognosis: Good - The prevalence of LBP rapidly declines during the first months after childbirth.

6 * The increase of the abdominal sagittal diameter and consequent shifting of the body gravity center anteriorly increase stress on the LB [3,8,9,11]. * Studies suggest that an anterior shift is associated with pubic symphysis problems [8]. * Postural changes may be implemented to balance this anterior shift, causing lordosis and increasing stress on the LB [24].

7 * The response of the intervertebral discs in axial loading leads to decreased height and compression of the spine [8]. * Abdominal muscles are stretched to accommodate the enlarging uterus, causing muscle fatigue and resulting in an extra load on the spine, which must support the majority of the increased weight of the torso [3,8].

8 It has been suggested that LBP may be due to hormonal changes. Relaxin increases tenfold during pregnancy, causing ligamentous laxity, generalized discomfort, BP, instability of the pelvis and misalignment of the spine. This association is under debate, however, since many studies do not confirm any correlation between relaxin serum levels and severity of LBP during pregnancy [2,3,7,8,9]. According to some initial pilot data, weakness of the gluteus medius is strongly related to the presence of LBP during pregnancy [5].

9 Conservative management is the gold standard including physical therapy, stabilization belts, nerve stimulation, acupuncture, massage, relaxation and yoga [2,3,8,19,20]. Some studies advocate that acupuncture may be a complement to a therapy program, since it helps to alleviate LBP during pregnancy while increasing the capacity for some physical activities and helps diminish the need for drugs [3,8,58]. Patients who received a 1-week continuous acupuncture treatment at specific auricular points had a significant reduction in pain compared with those of the control groups [52].

Place right above the hipbone or greater trochanter. Make sure it is snug.

11 For best results apply SI Belt while lying down on your back, on the floor or bed. Wear it under clothing, over your underwear or directly on skin. Place right above the hipbone or greater trochanter. Make sure it is snug. For best results it is recommended that the SI Belt be worn at least 23 hours per day.

12 Research has shown patient education plays a key role in treating LBP in pregnancy, including standing, walking and bending techniques without causing additional stress on the spine or muscle fatigue [3,8]. New moms are at the greatest risk of injury from the load of lifting and carrying a new baby and childcare equipment, thus instruction in proper body mechanics and ergonomics is recommended [59].

13 The use of a footstool & back support while sitting is recommended, as well as avoiding work that increases muscle fatigue [3,8]. Avoid prolonged walking or standing [3,8].

14 5-Part Patient Education Series: 1) Pain neuroscience education 2) Cardiovascular exercise and graded return to activity/pacing techniques 3) Postural retraining/ergonomics with * Sitting active vs. passive posture, car, while feeding/nursing moms * Standing * Sleeping * Work station

15 Enter the car by sitting down facing the door. Swing legs into the car at the same time. Shoulders and hips should move together. Never twist. Reverse the process while getting out of the car. Use a foam stress wedge to elevate your pelvis and a lumbar roll to add extra support.

Use good posture, keeping chest up and shoulders back, ear-shoulderhip aligned Keep a wide base of support with your knees slightly bent or stand with feet in a staggered position.

16 Use good posture, keeping chest up and shoulders back, ear-shoulderhip aligned Keep a wide base of support with your knees slightly bent or stand with feet in a staggered position. If available, place one foot on a low stool or lower shelf. Use DLC core contraction to maintain correct posture Wear supportive soft-soled shoes and avoid hard-soled or highheeled shoes. Avoid bending, reaching, and straining

17 Pillow should support the head and neck. A neck roll may be added for extra support Keep head and shoulders in line with hips Keep hips bent to less than 90 degrees or bend the top leg and keep the lower leg straight Pillow used between the knees to align the hip and knee If you have arm pain, painful arm should be on top with pillow(s) propped between bent arm and rib cage to support in a neutral shoulder position

18 Forward ready position: perch on the edge of the chair, lean into desk while maintaining low back arch and avoid rounding shoulders forward. This position works especially well for writing. Upright functional ready position: the typical upright posture with the back supported or, if the seat is tilted, sitting for short periods of time without using the backrest to work on postural endurance.

19 4) Proper body mechanics bending & reaching techniques * HH chores - cleaning, laundry * Childcare bathing, floor positioning 5) Proper lifting techniques * Lifting, carrying, pushing, pulling * Groceries, laundry * Childcare - crib/car seat transfers

20 Laundry Keep basket at waist height when sorting laundry Squat or half kneel to get clothes in and out of front loading washer or dryer, avoid bending at waist Use golfer s lift to get clothes out of top loading washer Use squat or power position to lift laundry basket from floor.

21 Sweeping and Vacuuming Use long handle equipment to avoid stooping Keep broom or vacuum close to your body Stay upright, step or lunge with your legs to push the vacuum Avoid bending at the waist or reaching with your arm Pivot with your feet, don t twist your trunk

22 Lifting and Carrying Children Squat or half kneel to pick up child from the floor Use golfer s lift or mini squat to lift from crib Keep your child close to you Carry child or carrier in front of you whenever possible Avoid holding baby or carrier on your hip Hook arm through carrier to carry it in front of you.

23 Bathing & Diapering Diapering should be done on a changing table or bed while avoiding waist bending. Diapering may also be done on the floor with attention to proper bending techniques. Squat or half kneel to lift child in and out of tub. Sit on edge of tub with one or both feet in the tub, or kneel in front of the tub Bend forward at the hips

24 Feeding Sit in a chair with good support and feet supported on the floor or stool Prop child on a pillow or boppy pillow when bottle or breast feeding Keep upper back against the backrest. Bring the child close to you instead of leaning forward Use power lift when picking up child and placing in highchair. Have child sit in highchair for spoon feeding. Sit in a forward perch position while feeding baby

25 Car Transfer Bend at the hips not at the waist Keep the child close to you Support with your foot on the floor of the car or knee on the seat as you place child into the car seat.

26 Carrying Carry child in front of you instead of on your hip Keep the child or a carrier very close to you You may hook your arm through the carrier handle to hold in front of you

27 DiDiaDiapering Diaper changing Use a changing table or bed to avoid waist bending Sit on your knees or on the edge of a pillow if you are sitting on the floor

28 Ffeeding Feeding Use a Boppy pillow or other pillow on your lap for baby positioning Have baby sit in a highchair for spoon feeding

29 Bathing Kneel or sit on edge of tub or stool May place one or both feet into the tub and lean forward from your hips

30 Lifting Lift and lower baby from floor with a half-kneel, keeping baby very close to you.

31 Transfer baby from crib with a golfer s lift or mini-squat.

32 DO DON T

33 Stand with feet wide, as close to the object as possible Keep head and shoulders retracted back Stick out buttocks Keep your knees over your feet

34 The most common practice in managing LBP is exercising. Many relevant studies have been published, describing several fitness activities such as individualized PT, group PT classes, yoga and water aerobics [7,53,54]. Stretching has been shown to reduce LBP and maintain correct posture and body alignment (Hyatt, 2003) American Congress of Obstetricians and Gynecologists recommends 30 min or more of moderate cardiovascular exercise on most, if not all, days of the week [59].

35 Generally safe to begin an exercise program during pregnancy, even if no exercise prior. Supine exercises not to exceed 5 minutes after the 4 th month. Can place a rolled towel under the right hip to lessen the effects of uterine compression on vessels. Never exercise to exhaustion. Stop any exercise that causes vaginal bleeding. Heart rate not to exceed 140 bpm during cardiovascular exercise.

36 Ultrasound, estim, ionto, mechanical lumbar traction & heat are contraindicated. Can use ice except on abdomen. Encourage DLC during and after pregnancy. Listen to your body. It it s painful or doesn t feel right, stop that exercise [59].

37 Stretch program * Recommend 1-2x/day, hold seconds each, repeat 2-3x each * For pain reduction, it s best to stretch just before going to bed * Primary tool for pain management, esp. during flare-ups (followed by icing)

TRUNK ELONGATION/SIDEBEND Sitting on floor or chair, reach up overhead to

38 MODIFIED CHILD POSE Start with your hips/knees spread apart and let your hips drop back and stretch out your arms in front of you. 30 second hold 2-3 reps. TRUNK ELONGATION/SIDEBEND Sitting on floor or chair, reach up overhead to lengthen spine and bend trunk slightly to the opposite side. 30 second hold 2-3 reps.

39 CAT BACK On hands and knees, slowly round pelvis and hips up towards ceiling to arch back like a cat. Drop pelvis and hips toward the floor. Avoid rocking forward and backward on knees. Hold each position, or gently repeat movement several repetitions. PIRIFORMIS Pull knee toward opposite shoulder in seated position and hold. Repeat on the other side.

40 Cardiovascular program * 150 minutes/week (10 min bouts also beneficial) * Heart rate not to exceed 140 bpm * Pain reduction benefits * Motivational Interviewing Specific MedX lumbar strengthening utilizing Pregnancy, Post-partum and Post-C-section protocols

42 Core training * Deep Layer Core Contraction * Lower abdominals * Alternate arm leg lift in quadriped * Bridging Pelvic stability (gluteus medius strengthening) * Clamshells * Sidelying leg raises

43 Muscle 1: Pelvic Floor Contraction (Kegel Exercise) Lightly contract the muscle as if you were going to cut off the flow of urine midstream. Do not perform a maximal contraction, lightly contract drawing up 50% Avoid squeezing your buttocks together, squeezing your legs, tilting your pelvis, or holding breath. Muscle 2: Lower Abdominal (Transversus Abdominis) Contraction While maintaining your pelvic floor contraction, draw in or pull your lower abdomen in and up toward your spine (bringing your belly button toward your spine) To locate, place one hand on your stomach. Inhale deeply and expand your ribs. Then forcefully exhale as if you are blowing up a balloon or fogging a mirror. When the TA contracts you should feel your abdominals draw away from your hand.. Avoid tilting your pelvis, holding your breath, using your upper abs, or sucking in your stomach.

44 Muscle 3: Spinal (Multifidus) Contraction While maintaining your pelvic floor contraction and your lower abdominal contraction, swell your back muscles by squeezing them together. You can feel this contraction by wrapping your hands around your rib cage with your thumbs placed on either side of your spine. If you are having difficulty, you can lightly push your fingertips into your thighs to assist Avoid extending your back (leaning back), tilting pelvis, or holding your breath.

45 Lower Abdominal Exercise Alternate Arm and Leg Lift Bring one leg up to 90 degrees, and then bring the other one up to meet it. Straighten one leg out and drop slightly (less than 45 degree angle). Return to starting position. Alternate and repeat. Maintaining a deep core contraction, simultaneously raise one arm out in front of you, and raise the opposite leg. Hold this position for 10 seconds. Alternate sides, and keep your pelvis level. Repeat up to 12 repetitions (2 minutes).

46 BRIDGING QUADRUPED GLUTE SET WITH LEG LIFT Position lying on back with legs bent, and arms at sides. Placing palms up aids in facilitation, so do this if able. Engage your DLC, and lift hips off floor using hips and buttock muscles, rolling up one vertebra at a time. Hold 10 seconds. Lower hips slightly and lift again using buttocks to push hips up. Return to start position as needed to reengage DLC. Repeat up to 12 repetitions ( 2 minutes). Position on your hands and knees or over Swiss ball. Squeeze buttocks, lift leg up while keeping knee bent 90 degrees and foot flexed. Push heel toward ceiling. Make sure not to arch the low back. Pause, and then slowly lower leg down.

47 CLAMSHELLS Lie on your side with hips and knees stacked and bent between degrees. Keeping heels together, slowly lift top leg and rotate outwards in a clamshell fashion without rotating pelvis backward. Maintain DLC, move slowly, and pause at top of motion. SIDELYING LEG RAISE Lie on side, hips stacked. Bend your bottom knee to about 45 degrees for support. Rotate toes down. Leading with the heel, raise the top leg. Maintain DLC, move slowly and pause at top of motion.

48 Exercise may be resumed as soon as physically and medically safe, as soon as within days of delivery. Exercise after pregnancy has been associated with decreased incidence of post-partum depression. Start with 20 min brisk walks, increasing 5-10 min each week as tolerated [59].

Hippokratia (Quarterly Medical Journal): 2011 Jul-Sept; 15(3):205-210.

49 Hippokratia (Quarterly Medical Journal): 2011 Jul-Sept; 15(3): Faculty of Medicine at the University of Crete in Greece The aim of this article is to present a current review of the literature concerning pregnancy related LBP. By using PubMed database and LPB and pregnancy as key words, abstracts and original articles investigating the diagnosis and treatment of LBP during pregnancy were searched and analyzed.

50 1. Bastiaanssen JM, de Bie RA, Bastiaenen CH, Essed GG, van den Brandt PA. A historical perspective on pregnancy-related LB &/or pelvic girdle pain. Eur J Obstet Gynecol Reprod Biol. 2005;120: Vleeming A, Albert HB, Ostgaard HC, Sturesson B, Stuge B. European guidelines for the Dx and treatment of pelvic girdle pain. Eur Spine J. 2008;17; Perkins J, Hammer RL, Loubert PV. Identification and management of pregnancy-related LBP. J Nurse Midwifery. 1998;43: Sihvonen T, Huttunen M, Makkonen M, Airaksinen O. Functional changes in back muscle activity correlate with pain intensity and prediction of LBP during pregnancy. Arch Phys Med Rehabil. 1998;79:

51 5. Bewyer KJ, Bewyer DC, Messenger D, Kennedy CM. Pilot data: association between gluteus medius weakness and LBP during pregnancy. Iowa Orthop J. 2009;29: Stuge B, Hilde G, Vollestad N. Physical therapy for pregnancyrelated LB and pelvic pain: A systematic review. Acta Obstet Gynecol Scand. 2003;82: Sabino J, Grauer JN. Pregnancy and LBP. Curr Rev Musculoskelet Med. 2008;1: To WW, Wong MW. Factors associated with back pain symptoms in pregnancy and the persistence of pain 2 years after pregnancy. Acta Obstet Gynecol Scand. 2003;82: Ostgaard HC, Andersson GB, Schultz AB, Miller JA. Influence of some biomechanical factors on LBP in pregnancy. Spine (Phila Pa 1976) 1993;18:61-65.

52 19. Fogarty V. Intradermal sterile water injections for the relief of LBP in labour a systematic review of the literature. Women Birth. 2008;21: Bailey A. Risk factors for LBP in women: still more questions to be answered. Menopause. 2009;16: Wang SM, Dezinno P, Maranets I, Berman MR, Caldwell-Andrews AA, Kain ZN. LBP during pregnancy: prevalence, risk factors, and outcomes. Obstet Gynecol. 2004;104; Sandler SE. The management of LBP in pregnancy. Man Ther. 1996;1: Stapleton DB, MacLennan AH, Kristiansson P. The prevalence of recalled LBP during and after pregnancy: a South Australian population survey. Aust NZJ Obstet Gynaecol. 2002;42:

53 35. Mens JM, Damen L, Snijders CJ, Stam HJ. The mechanical effect of a pelvic belt in patients with pregnancy-related pelvic pain. Clin Biomech (Bristol, Avon) 2006; 21: Morkved S, Salvesen KA, Schei B, Lydersen S, Bo K. Does group training during pregnancy prevent lumbopelvic pain? A randomized clinical trial. Acta Obstet Gynecol Scand. 2007;86: Wang SM, Dezinno P, Lin EC, Lin H, Yue JJ, Berman MR, et al. Auricular acupuncture as a treatment for pregnant women who have LBP and posterior pelvic pain: a pilot study. Am J Obstet Gynecol. 2009; 201:271-e Ostgaard HC, Zetherstrom G, Roos-Hansson E. Back pain in relation to pregnancy: a 6-year follow-up. Spine (Phila Pa 1976) 1997;22:

54 54. Bastiaenen CH, de Bie RA, Vlaeyen JW, Goossens ME, Leffers P, Wolters PM, et al. Longterm effectiveness and costs of a brief selfmanagement intervention in women with pregnancy-related LBP after delivery. BMC Pregnancy Childbirth. 2008;8: Kvorning N, Holmberg C, Grennert L, Aberg A, Akeson J. Acupuncture relieves pelvic and LBP in late pregnancy. Acta Obstet Gynecol Scand. 2004;83: ACOG Committee Opinion for Exercise during Pregnancy-Postpartum

Expecting Straighten Up Backs and Bellies

Expecting Straighten Up Backs and Bellies Pregnancy is often associated with spine and pelvis discomfort and postural changes. (references 1-13) As the baby grows and the uterus expands, your abdominal