Classification of pregnancy related non-specific low back pain and pelvic girdle pain: a systematic review

Background: Pregnancy related non-specific low back pain (PNSLBP) and pelvic girdle pain (PGP) affect almost half of pregnant women, causing substantial disability for some. These diagnoses, which may represent several possible individual or co-occurring conditions, lack the specificity required to guide personalized treatment decisions. A reliable and valid classification is needed to direct effectiveness research and inform treatment strategies.

Objectives: To describe the psychometric properties of pathoanatomic classifications of PNSLBP and PGP as well as to assess the risk of bias of supporting evidence.

Methods: Two independent reviewers systematically searched PubMed, Embase, Cochrane and PEDro databases and conducted a manual search of reference list of eligible articles reporting office-based examination for classifying PNSLBP/PGP. QUADAS-2 tool was used to assess the risk of bias and applicability of reviewed studies.

Results: Ten studies were eligible. Inter-rater reliability was 87% for PNSLBP and 84.6% for PGP. Major sources of potential bias included the lack of reference standard diagnostic tests, insufficient blinding, non-systematic order of index test application, and unclear participant selection procedures. Patient flow throughout studies and the interval between testing (flow and timing) showed the lowest risk of bias. The applicability of the reference standard had the highest concern, while participant selection and index test had the lowest.

Conclusion: Although acceptable inter-rater reliability has been demonstrated, there is no current evidence to support the validity of PNSLBP and PGP classification systems. Future studies should consider including reference standard diagnostic tests, random order sequencing of index tests, rigorous selection criteria, and blinded assessors.     

Pregnancy and pelvic girdle pain: Analysis of pelvic belt on pain

Aims and objectives

To analyse pain and functional capacity in women with pelvic girdle pain and to evaluate the effect of pelvic belt on these parameters. Two types of belts were to compare.

Background

Pelvic girdle pain is very common during pregnancy. To prevent and relieve pelvic pain, women can use a set of techniques and tools such as a pelvic belt. While scientific evidence is lacking, commercial industries suggest the effectiveness of pelvic belts.

Design

Randomised control trial.

Methods

Forty‐six pregnant women with pelvic girdle pain were evaluated. Pain analysis included a quantitative and a qualitative assessment. A daily activities questionnaire was used for functional capacity evaluation. Women were tested at two times during the pregnancy for a longitudinal evaluation, and they used one of the two belt models during their pregnancy.

Results

Pelvic pain started between the 14th–21st week of pregnancy. Pain intensity was 60 ± 20 mm. Daily activities could increase pain. The use of belts reduced pain. The intensity of pain decreased by 20 mm on a visual analogue scale. The daily activities were also easier. However, all these conclusions are valid only if pregnant women used belts regularly on short periods.

Conclusions

The belts appear to be interesting tools to reduce pelvic pain and improve comfort of pregnant women. This effect might be explained by an analgesic effect with proprioceptive and biomechanical effect. The different types of belts could have differential effects on global, sacroiliac joint and back pain during pregnancy, but this hypothesis requires confirmation.

Relevance to clinical practice

Relevant for patient: to use an easy and validated tool. Relevant for clinical practice: to suggest a tool scientifically validated for patient. Relevant to economic issues: belts decrease pelvic pain and increase comfort of pregnant women. Sick leave could decrease.     

Using the posterior pelvic pain provocation test in pregnant Japanese women

This study investigated the usefulness of the posterior pelvic pain provocation (PPPP) test for differentiating between pelvic pain and low back pain because of the different prognoses and treatment strategies. We recruited 263 Japanese women who were > 36 weeks' gestation and 213 were included. The PPPP test was applied to 154 women with self‐reported lumbopelvic pain. The participants were divided into three groups: the PPPP test positive (PPPP+, n = 60) subgroup, PPPP test negative (PPPP?, n = 94) subgroup, and no pain group (n = 59). The disability scores of the PPPP+ subgroup were significantly higher than the scores of the PPPP? subgroup and no pain group. In the PPPP+ subgroup, the intensity of pelvic pain was significantly correlated with the disability scores, but that of low back pain was not. The PPPP test could be carried out by a midwife without side‐effects and could detect pregnant women with impaired ability in daily life due to lumbopelvic pain.     

妊娠晚期下腰及骨盆痛影响因素分析

目的了解妊娠晚期孕妇下腰及骨盆痛发生率及其影响因素。方法采用问卷调查对1 254例妊娠晚期孕妇进行下腰、骨盆痛及其相关因素调查、分析。1 254例妇女在孕36周常规产前检查时接受问卷调查,包括:年龄,身高,肥胖指数,受教育程度,是否失业,城市或农村人口,有无保姆,孕前有否腰痛,前次妊娠有否腰痛,疼痛部位、程度、性质、加重及缓解方法,孕妇活动能力(日常活动,家务劳动,户外活动)等。结果妊娠晚期孕妇下腰及骨盆痛发生率为48.96%。身高,受教育程度,是否失业及有无保姆与疼痛无明显关系。低龄、高龄孕妇较适龄孕妇更易腰痛。超重孕妇更易腰痛。孕前有腰痛及前次妊娠有腰痛者在本次妊娠中发生腰痛比例增大。城乡孕妇腰痛发生率有较大差异。久站最易加重腰痛,卧位可以明显减轻疼痛。下腰及骨盆痛对妊娠晚期孕妇的活动影响较大。结论妊娠晚期孕妇下腰及骨盆痛发生率高,对于某些影响因素有必要采取相应的有效干预措施以提高孕妇的生活质量。     

The behavior of pain in response to sit-stand workstations: a systematic review

Abstract

Background: Chronic neck and/or low back pain (LBP) is the most common musculoskeletal complaint among individuals employed in sedentary jobs. Literature is available on the behavior of chronic neck and LBP in response to sit-stand workstations (SSW) but lacks a clinically significant consensus.

Objective: The purpose of this systematic review is to report the clinical significance of the behavior of pain in response to SSW in comparison to traditional desks.

Methods: Articles were retrieved from electronic databases. Inclusion criteria were 1) employees in work environments that entail prolonged sitting time and with chronic neck and/or LBP, 2) intervention of SSW, and 3) the report on pain as an outcome. Exclusion criteria included 1) children or students, 2) intervention of mobility desks (i.e. treadmill, cycling), and 3) absence of pain prior to the study. Risk of bias was assessed using the PEDro scale.

Results: 3 studies were reported as Cohen’s d and revealed alleviation of neck and/or LBP with small to trivial clinical effect sizes. 1 study was calculated as odds ratio; its participants were more likely to report neck pain but less likely to report LBP with SSW compared to traditional desks. Another study reported results in p-values and were statistically significant for neck pain and insignificant for LBP.

Conclusion: Overall, findings suggest SSW may not absolutely relieve chronic neck or LBP but should not be excluded from pain management recommendations due to potential of positive impact.     

Adaptation to a changed body. Experiences of living with long-term pelvic girdle pain after childbirth

Abstract

Purpose: To explore how women experience living with long-term pregnancy-related pelvic girdle pain.

Materials and methods: Nine women with persistent pregnancy-related pelvic girdle pain of 2–13 years were recruited by means of purposive sampling from long-term follow-up studies. The women were 28–42 years of age and had given birth to 2–3 children. Audio-taped in-depth interview with open-ended questions were used with the guiding question 'How do you experience living with pregnancy-related pelvic girdle pain?'. The Empirical Phenomenological Psychological method was chosen for analysis.

Results: The pregnancy-related pelvic girdle pain syndrome has a profound impact on everyday life for many years after pregnancy. Three constituents were identified as central to the experience of living with pregnancy-related pelvic girdle pain: (1) the importance of the body for identity, (2) the understanding of pain, and (3) stages of change. The manner in which the women experienced their pain was interpreted in terms of two typologies: the ongoing struggle against the pain, and adaptation and acceptance.

Conclusion: The participants’ narratives highlighted that the pain led to severe functional limitations that threatened their capability to perform meaningful daily activities, and interfered with their sense of identity. It appears essential to meet with each patient individually and to manage long-term pregnancy-related pelvic girdle pain as a pain syndrome.

• IMPLICATIONS FOR REHABILITATION

• Chronic pregnancy-related pelvic girdle pain

• ??Pregnancy-related pelvic girdle pain impairs women’s capacity to perform meaningful activities of daily life for many years after pregnancy.

• ??The participants’ narratives highlighted that the pain interfered with their sense of identity.

• ??It appears essential to meet with each patient individually and to manage long-term pregnancy-related pelvic girdle pain as a pain syndrome.

     

The effectiveness of stabilising exercises in pelvic girdle pain during pregnancy and after delivery: A systematic review

Background

Pelvic girdle pain is a common musculoskeletal disorder which affects women during pregnancy and the postpartum period. In previous years, physiotherapists have focused on managing pelvic girdle pain through stabilizing exercises.

Purpose

The aim of this study was to systematically review studies investigating the effectiveness of the stabilizing exercises for pelvic girdle pain during pregnancy and the postpartum period.

Methods

The following electronic databases were utilized to search for eligible studies: MEDLINE, EMBASE, CINAHL, Physiotherapy Evidence Database, and Cochrane Library. Inclusion and exclusion criteria were defined a priori. The quality assessment was performed by the two reviewers independently using the PEDro scale (Physiotherapy Evidence‐based Database).

Results

Six studies were identified as eligible with the inclusion and exclusion criteria. All studies evaluated the pain as an outcome measure. The evidence conflicted between the studies. Two studies showed that stabilizing exercises decrease pain and improve the quality of life for pregnant women when they are carried out on a regular basis. There is some limited evidence that stabilizing exercises decrease pain for postpartum women too.

Conclusion

In summary, there is limited evidence for the clinician to conclude on the effectiveness of stabilizing exercises in treating pelvic girdle pain during pregnancy and the postpartum periods.     

Physiotherapy management of patients with chronic pelvic pain (CPP): A systematic review

Introduction: Chronic pelvic pain (CPP) is a common pain condition. However, treatment remains challenging. Musculoskeletal findings are frequent; therefore physiotherapy might be helpful. The purpose of this review was to evaluate the current evidence on physiotherapy in patients with CPP (PROSPERO registration number CRD42016037516). Methods: Six databases were searched and additional hand searches were performed. Two reviewers independently conducted the database search and selected studies using a two-step approach. The methodological quality was assessed applying the Critical Review Form – Quantitative Studies. Results: A total of eight studies were included. Trigger point therapy was examined in four studies; two of which were randomized controlled trials. All studies indicate a significant change in pain measurement. The other four studies evaluated the effect of biofeedback, Thiele massage, Mensendieck somatocognitive therapy and aerobic exercises, whereas the last two were tested in controlled trials. All studies showed significant improvements in pain assessment. Conclusions: The evidence currently available is sparse with methodological flaws, making it difficult to recommend a specific physiotherapy option. There is an urgent need for high-quality randomized controlled trials to identify the most effective physiotherapy management strategy for patients with CPP.     

Effects of external pelvic compression on trunk and hip muscle EMG activity during prone hip extension in females with chronic low back pain

Many studies have reported higher trunk and hip muscle activity in patients with chronic low back pain (CLBP). Increased trunk and hip muscle activity could contribute to pain. Previous studies have shown that external pelvic compression (EPC) decreased back and hip muscle activity during physical tasks.In this study, we assessed the effects of EPC on the electromyography (EMG) activity of the latissimus dorsi (LD), elector spinae (ES), gluteus maximus (GM), and biceps femoris (BF) in a CLBP group and a healthy group during prone hip extension (PHE).Forty female volunteers (20 non-specific CLBP, 20 healthy) were recruited. Surface EMG data were collected from the LD, ES, GM, and BF muscles during a PHE task. Normalized EMG values were analyzed by separate repeated-measures analysis of variance (ANOVA) for each muscle.The normalized EMG activity in the left LD, bilateral ES, and right GM was significantly higher in the CLBP group than in the healthy group during PHE. In the CLBP group, the normalized EMG activity in the left LD, bilateral ES, and right GM was significantly lower with EPC than without (p < 0.05). This suggests that the application of EPC decreased trunk and hip extensor EMG activity in the CLBP group during PHE.     

Abdominal and pelvic floor muscle function in women with and without long lasting pelvic girdle pain

Approximately 5-20% of postpartum women suffer from long-lasting pelvic girdle pain (PGP). The etiology and pathogenesis of PGP are still unclear. The aim of this study was to examine whether subjects with and without persisting PGP and disability differed with respect to their ability to voluntarily contract the deep abdominals (TrA and IO) and to the strength of the pelvic floor muscles (PFM). Twenty subjects (12 with persisting PGP, 8 recovered from PGP) were examined. Contractions of the deep abdominal muscles (TrA and IO) were imaged by real-time ultrasound. Vaginal palpation and observation were used to assess the women's ability to perform correct a PFM contraction. PFM strength was measured by a vaginal balloon catheter connected to a pressure transducer. The active straight leg raise test was used to assess the ability of load transfer. The results showed no statistical significant difference between the groups in increase of muscle thickness of the deep abdominal muscles (TrA; P = 0.87 and IO; P = 0.51) or regarding PFM strength (P = 0.94). The ability to voluntarily contract the deep abdominal muscles and the strength of the PFMs are apparently not associated to PGP. However, the results are based on a small sample and additional studies are needed.     

Analyzing chronic low back pain: the relative contribution of pain coping strategies

Sixty-two chronic low back pain patients were administered the Coping Strategies Questionnaire (CSQ) to assess the frequency of use and perceived effectiveness of a variety of cognitive and behavioral pain coping strategies. Analysis of individual variables revealed that CSQ factors, gender, physical examination findings, and chronicity of pain had significant effects on one or more of a series of pain, psychological distress or behavioral measures. To assess the relative contribution of each of these variables hierarchical stepwise regression analyses were carried out. These analyses revealed that the Helplessness factor of the CSQ explained 50% of the variance in psychological distress (Global Severity Index of the SCL-90R), and 46% of the variance in depression (Beck Depression Inventory). Patients scoring high on this CSQ factor had significantly higher levels of psychological distress. None of the demographic or medical status variables explained a significant proportion of variance in the psychological distress measures. The Diverting Attention and Praying factor of the CSQ explained a moderate (9%), but significant amount of variance in pain report. Patients scoring high on this factor had higher scores on the McGill Pain Questionnaire. Coping strategies were not strongly related to pain behavior measures such as guarding or uptime. A consideration of pain coping strategies may allow one to design pain coping skills training interventions so as to fit the needs of the individual low back pain patient.     

Perceived health six months after delivery in women who have experienced low back pain and pelvic pain during pregnancy

BACKGROUND AND OBJECTIVES: A majority of women suffer from low back pain and pelvic pain (LBPP) during pregnancy. The aim of the study was to investigate perceived health, sexual life, social situation, sick leave and use of medical services 6 months after pregnancy in women with LBPP during pregnancy. RESEARCH METHODS: In a previous questionnaire study, 72% (n = 639) of the respondents had reported LBPP during pregnancy. These respondents were sent a second questionnaire approximately 6 months after delivery. The respondents were divided into three groups: 'no pain', 'recurrent pain' and 'continuous pain'. Pearson's chi-squared test was used to test the difference between groups. RESULTS: Perceived health status 6 months after pregnancy was less favourable for women with persistent LBPP compared to women with remission of LBPP. Family situation, change of relationship and sexual life did not differ among women with remission of LBPP or persistent LBPP after pregnancy. Four of 10 women with persistent LBPP had sought medical care, and two of 10 had been on sick leave because of LBPP after pregnancy. CONCLUSIONS: Perceived health status was less favourable for women with persistent LBPP after pregnancy. Use of medical services among women with persistent LBPP was prevalent.     

Differential diagnosis of endometriosis in patient with nonspecific low back pain: A case report

BackgroundEndometriosis is one of the most widespread gynecological disorders and a very common condition amongst fertile women, thus it has to be considered one of the possible sources of lumbopelvic pain. Endometriosis is commonly related to low back pain (LBP) and therefore often mistaken for a musculoskeletal disorder.The purpose of this case report is to underline the primary role of clinical reasoning and assessment process, which led the physiotherapist to the differential diagnosis, considering endometriosis among the possible causes of low back pain.Case presentationS.C, 45 years old, complained to physiotherapist of lumbar spine and left buttock pain, spreading to the hypogastric, inguinal and left pubic areas. The patient's past medical history included gynecological visceral disorders, regularly monitored. Functional evaluation and clinical tests revealed a disorder referred to the lumbar spine and sacroiliac region. Initial physical therapy management included education, manual therapy and therapeutic exercise. Nevertheless, after five treatment sessions, the symptoms remained unchanged, and therefore the patient was referred to a gynecologist for a consultation. The patient underwent a laparoscopy for endometriosis eradication and the intervention resulted in complete abolition of symptoms, enabling the patient to return to work and to do physical activities.Conclusionsthis case report highlights the importance of a thorough clinical assessment and the identification of relevant findings from patient's medical history to be carried out by the physiotherapist. Those are of crucial importance to make an appropriate differential diagnosis and to screen amongst the possible causes of lumbopelvic pain also visceral ones as endometriosis, which often manifests with associated symptoms such as nonspecific LBP.     

Pelvic musculoskeletal dysfunctions in women with and without chronic pelvic pain

Aim

This study aimed to compare the prevalence of pelvic musculoskeletal dysfunctions in women with and without Chronic Pelvic Pain (CPP).

Effects of Qigong practice in office workers with chronic non-specific low back pain: A randomized control trial

ObjectiveTo investigate the effects of Qigong practice, Guan Yin Zi Zai Gong level 1, compared with a waiting list control group among office workers with chronic nonspecific low back pain (CNLBP).MethodsA randomized controlled trial was conducted at offices in the Bangkok Metropolitan Region. Seventy-two office workers with CNLBP were screened for inclusion/exclusion criteria (age 20–40 years; sitting period more than 4 h per day) and were allocated randomly into two groups: the Qigong and waiting list groups (n = 36 each). The participants in the Qigong group took a Qigong practice class (Guan Yin Zi Zai Gong level 1) for one hour per week for six weeks at their workstation. The participants were encouraged to conduct the Qigong exercise at home every day. The waiting list group received general advice regarding low back pain management. The primary outcomes were pain intensity, measured by the visual analog scale, and back functional disability, measured by the Roland and Morris Disability Questionnaire. The secondary outcomes were back range of motion, core stability performance index, heart rate, respiratory rate, the Srithanya Stress Scale (ST-5), and the global perceived effect (GPE) questionnaire.ResultsCompared to the baseline, participants in the Qigong group experienced significantly decreased pain intensity and back functional disability. No statistically significant difference in these parameters was found in the waiting list group. Comparing the two groups, Qigong exercise significantly improved pain intensity, back functional impairment, range of motion, core muscle strength, heart rate, respiratory rate, and mental status. The Qigong group also had a significantly higher global outcome satisfaction than the waiting list group.ConclusionQigong practice is an option for treatment of CNLBP in office workers.     

Prostatitis and chronic pelvic pain syndrome in men

Primary care physicians can and should diagnose, classify, and treat patients?presenting with acute and chronic prostatitis syndromes. Although the chronic syndromes are a challenge to manage, this review article provides the necessary background to allow primary care physicians to take on this task. Patients who are unfortunate to be diagnosed with a prostatitis syndrome have the best chance for successful therapy at initial presentation. Those patients will ultimately benefit from an informed and educated physician.     

Pain neurophysiology education for the management of individuals with chronic low back pain: systematic review and meta-analysis

Pain neurophysiology education (PNE) is a form of education for patients with chronic low back pain (CLBP). The purpose of this systematic review was to investigate the evidence for PNE in the management of pateints with CLBP. A literature search of MEDLINE, CINAHL and AMED was performed from 1996(01)–2010(09). RCT appraisal and synthesis was assessed using the Cochrane Back Review Group (CBRG) guidelines. The main outcome measures were pain, physical-function, psychological-function, and social-function. Two moderate quality RCTs (n = 122) were included in the final review. According to the CBRG criteria there was very low quality evidence that PNE is beneficial for pain, physical-function, psychological-function, and social-function. Meta-analysis found PNE produced statistically significant but clinically small improvements in short-term pain of 5 mm (0, 10.0 mm) [mean difference (95%CI)] on the 100 mm VAS. This review was limited by the small number of studies (n = 2) that met the inclusion criteria and by the fact that both studies were produced by the same group that published the PNE manual. These factors contributed to the relatively low grading of the evidence. There is a need for more studies investigating PNE by different research groups to support early promising findings. Until then firm clinical recommendations cannot be made.