Annelie Gutke

Pelvic Girdle Pain and Lumbar Pain in Pregnancy : A Cohort Study of the Consequences in terms of Health and Functioning

Study Design. A cohort study in pregnancy. Objectives. To differentiate between pregnancy-related pelvic girdle pain (PPGP) and lumbar pain, and to study the prevalence of each syndrome and its consequences in terms of pain, functioning, and health. Summary of Background Data. When studying prevalence, etiology, and consequences, differentiation between PPGP and lumbar pain is important, and, to our knowledge, its consequences for functioning and health during pregnancy have not previously been studied. Methods. All women answered questionnaires (demographic data, EuroQol). Women with lumbopelvic pain completed the Oswestry Disability Index, pain intensity measures, in addition to undergoing a mechanical assessment of the lumbar spine, pain provocation tests, and active straight leg raising test. Results. Of 313 women, 194 had lumbopelvic pain. The PPGP subgroup comprised 54% of those women with lumbopelvic pain, lumbar pain 17%, and combined PPGP and lumbar pain 29%. Women having both PPGP and lumbar pain reported the highest consequences in terms of health and functioning. Conclusions. Pain intensity, disability, and health measurements differentiate subgroups of lumbopelvic pain in pregnancy.

Predicting persistent pregnancy-related low back pain.

Study Design. A cohort study. Objective. To examine the course of subtypes of low back pain (LBP) experienced [no LBP, pelvic girdle pain (PGP), lumbar pain, and combined PGP and lumbar pain (combined pain)] during gestational weeks 12 to 18 and 3 months postpartum, and to explore potential predictors for persistent PGP or combined pain postpartum. Summary of Background Data. LBP is more prevalent in pregnant women (25%) than in the general population (6.3%). Persistent LBP postpartum (16%) is usually studied as a single entity. However, only one subgroup of LBP, pelvic girdle pain (PGP), is associated with pregnancy. Several studies have suggested an association between muscular dysfunction and pregnancy-related LBP, however, muscle dysfunction has not been evaluated as potential predictor of persistent LBP postpartum. Possible subgroup differences in the course and predictors of persistent LBP are unknown. Methods. Pregnant women (n = 308) were classified into LBP subgroups by mechanical assessment of the lumbar spine, pelvic pain provocation tests, standard history, and pain drawings. Trunk muscle endurance, hip muscle strength (dynamometer) and gait speed were evaluated. Multiple logistic regression was used to identify predictors from self-reports and clinical examination. Results. Women with combined pain recovered to a lower degree 33% (17 of 51) than those with PGP 66% (56 of 85) or lumbar pain 72% (21 of 29). Predictors for having persistent PGP or combined pain after delivery were low endurance of back flexors, older age, combined pain in early pregnancy and work dissatisfaction (explained variance 30%). Conclusion. Women with combined pain were identified to be a target group since they had the most unfavorable course and since the classification of combined pain was found to be a predictor for persistent pain postpartum. Identification of women at risk for persistent pain postpartum seems possible in early pregnancy and requires physical examination and self-reports. Pregnancy had low impact on the course of lumbar pain.

ASSocIAtIoN BEtWEEN MuScLE FuNctIoN AND LoW BAcK PAIN IN RELAtIoN to PREGNANcY

OBJECTIVE To investigate the association of muscle function and subgroups of low back pain (no low back pain, pelvic girdle pain, lumbar pain and combined pelvic girdle pain and lumbar pain) in relation to pregnancy. DESIGN Prospective cohort study. SUBJECTS Consecutively enrolled pregnant women seen in gestational weeks 12-18 (n = 301) and 3 months postpartum (n = 262). METHODS Classification into subgroups by means of mechanical assessment of the lumbar spine, pelvic pain provocation tests, standard history and a pain drawing. Trunk muscle endurance, hip muscle strength (dynamometer) and gait speed were investigated. RESULTS In pregnancy 116 women had no low back pain, 33% (n = 99) had pelvic girdle pain, 11% (n = 32) had lumbar pain and 18% (n = 54) had combined pelvic girdle pain and lumbar pain. The prevalence of pelvic girdle pain/combined pelvic girdle pain and lumbar pain decreased postpartum, whereas the prevalence of lumbar pain remained stable. Women with pelvic girdle pain and/or combined pelvic girdle pain and lumbar pain had lower values for trunk muscle endurance, hip extension and gait speed as compared to women without low back pain in pregnancy and postpartum (p < 0.001-0.04). Women with pelvic girdle pain throughout the study had lower values of back flexor endurance compared with women without low back pain. CONCLUSION Muscle dysfunction was associated with pelvic girdle pain, which should be taken into consideration when developing treatment strategies and preventive measures.

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

Study Design. A cohort study. Objective. To investigate the possible association of lumbopelvic pain and postpartum depression and differences in the prevalence of depressive symptoms among women without lumbopelvic pain and women classified as having pelvic girdle pain (PGP) and/or lumbar pain. Summary of Background Data. Lumbopelvic pain and depression are common pregnancy complications, but their comorbidity has rarely been evaluated and has not been studied in relation to subgroups of lumbopelvic pain. Methods. In a cohort of consecutively enrolled pregnant women, the Edinburgh Postnatal Depression Scale was used to evaluate depressive symptoms at 3 months postpartum, applying a primary screening cutoff of ≥10 and a cutoff of ≥13 for probable depression. Women were classified into lumbopelvic pain subgroups by means of mechanical assessment of the lumbar spine, standard history, pelvic pain provocation tests, a pain drawing, and the active straight leg raising test. Results. The postpartum cohort (n = 267) comprised 180 (67%) women without lumbopelvic pain, 44 (16%) with PGP, 29 (11%) with lumbar pain, and 14 (5%) with combined PGP and lumbar pain. Applying a cutoff of ≥10, postpartum depressive symptoms were more prevalent in women with lumbopelvic pain (27 of 87, 31%; 95% confidence interval, 26%–36%) than in women without lumbopelvic pain (17 of 180, 9%; 95% confidence interval, 5%–13%; P < 0.001). The comorbidity of lumbopelvic pain and depressive symptoms was 10%. Depressive symptoms were more prevalent in women with lumbar pain versus women without lumbopelvic pain when applying cutoffs of ≥10 or ≥13 (P ≤ 0.002); whereas for women with PGP, this comparison was significant only at the screening level of ≥10 (P = 0.01). Conclusions. Postpartum depressive symptoms were 3 times more prevalent in women having lumbopelvic pain than in those without. This comorbidity highlights the need to consider both symptoms in treatment strategies.

The inter-rater reliability of a standardised classification system for pregnancy-related lumbopelvic pain

Pregnancy-related lumbopelvic pain has varying clinical presentations and effects among subgroups. Different lumbopelvic pain subgroups require different specific management approaches which require the differentiation between lumbar and pelvic girdle pain (PGP). Thirty-one consecutive pregnant women with non-specific lumbopelvic pain were evaluated by two examiners and classified into lumbar pain, PGP, or combined pelvic girdle and lumbar pain. A standard history about different positions/activities of daily life such as bending, sitting, standing, walking, and lying, was followed by a standardised mechanical assessment of the lumbar spine (Mechanical Diagnosis and Therapy), including tests of repeated end-range movements to standing and lying, pelvic pain provocation tests (distraction test, posterior pelvic pain provocation test, Gaenslens test, compression test, and sacral thrust) a hip-rotation range-of-motion test, the active straight-leg-raising test, and a neurological examination. Agreement for the three syndromes (lumbar pain, PGP, or combined pelvic girdle and lumbar pain) was 87% (27/31), with a kappa coefficient of 0.79 (95% CI 0.60-0.98). It was possible to perform the classification procedure throughout pregnancy. There was substantial agreement between the two examiners for the classification of non-specific lumbopelvic pain into lumbar pain and PGP in pregnant women.

Specific muscle stabilizing as home exercises for persistent pelvic girdle pain after pregnancy: a randomized, controlled clinical trial.

OBJECTIVE To investigate the efficacy of home-based specific stabilizing exercises focusing on the local stabilizing muscles as the only intervention in the treatment of persistent postpartum pelvic girdle pain. DESIGN A prospective, randomized, single-blinded, clinically controlled study. SUBJECTS Eighty-eight women with pelvic girdle pain were recruited 3 months after delivery. METHODS The treatment consisted of specific stabilizing exercises targeting the local trunk muscles. The reference group had a single telephone contact with a physiotherapist. Primary outcome was disability measured with Oswestry Disability Index. Secondary outcomes were pain, health-related quality of life (EQ-5D), symptom satisfaction, and muscle function. RESULTS No significant differences between groups could be found at 3- or 6-month follow-up regarding primary outcome in disability. Within-group comparisons showed some improvement in both groups in terms of disability, pain, symptom satisfaction and muscle function compared with baseline, although the majority still experienced pelvic girdle pain. CONCLUSION Treatment with this home-training concept of specific stabilizing exercises targeting the local muscles was no more effective in improving consequences of persistent postpartum pelvic girdle pain than the clinically natural course. Regardless of whether treatment with specific stabilizing exercises was carried out, the majority of women still experienced some back pain almost one year after pregnancy.

The postural response of the pelvic floor muscles during limb movements : A methodological electromyography study in parous women without lumbopelvic pain

BACKGROUND Pregnancy-related lumbopelvic pain is common. More than 30% of women have persistent pain 3 months after giving birth. There is no consensus regarding the pathology. However, coordination of muscle activity by appropriate timing and amplitude is necessary for maintaining adequate stability in the lumbopelvic area. The aim was to develop a method using surface electromyography to detect a feed-forward response in the pelvic floor muscles during limb movements performed at a comfortable speed applicable in future studies for women with lumbopelvic pain. METHODS Ten parous women with no lumbopelvic pain in the past 12 months were included. Surface electromyographic activity was recorded from the pelvic floor muscles and unilaterally from transversus abdominis/internal oblique, rectus abdominis, erector spinae, hip adductors, rectus femoris and deltoid. The subjects performed leg lift in supine and arm lift from standing. The electromyographic onset was related to the initiation of the movement. FINDINGS In the majority of the women the electromyographic onsets of the pelvic floor muscles occurred before the movement was initiated, regardless of whether it was a leg or an arm lift. In addition, electromyographic onsets for the other muscles, except the rectus abdominis during the arm lift, also occurred prior to the movements. INTERPRETATION The findings suggest a feed-forward response in the pelvic floor muscles during leg and arm lifts in women who had previously given birth and were without lumbopelvic pain. Movements performed at a comfortable speed seem to be useful in order to detect such a response.

Treatments for pregnancy‐related lumbopelvic pain: a systematic review of physiotherapy modalities

To explore the effect of physiotherapeutic interventions on pregnancy‐related lumbopelvic pain.

Association between lumbopelvic pain, disability and sick leave during pregnancy – a comparison of three Scandinavian cohorts.

OBJECTIVE To explore the association between disability and sick leave due to lumbopelvic pain in pregnant women in 3 cohorts in Sweden and Norway and to explore possible factors of importance to sick leave. A further aim was to compare the prevalence of sick leave due to lumbopelvic pain. DESIGN/SUBJECTS Pregnant women (n = 898) from two cohorts in Sweden and one in Norway answered to questionnaires in gestational weeks 10–24; two of the cohorts additionally in weeks 28–38. METHODS Logistic regression models were performed with sick leave due to lumbopelvic pain as dependent factor. Disability, pain, age, parity, cohort, civilian status, and occupational classification were independents factors. RESULTS In gestational weeks 10–24 the regression model included 895 cases; 38 on sick leave due to lumbopelvic pain. Disability, pain and cohort affiliation were associated with sick leave. In weeks 28–38, disability, pain and occupation classification were the significant factors. The prevalence of lumbopelvic pain was higher in Norway than in Sweden (65%, vs 58% and 44%; p < 0.001). CONCLUSION Disability, pain intensity and occupation were associated to sick leave due to lumbopelvic pain. Yet, there were significant variations between associated factors among the cohorts, suggesting that other factors than workability and the social security system are also of importance.

Response of the muscles in the pelvic floor and the lower lateral abdominal wall during the Active Straight Leg Raise in women with and without pelvic girdle pain: An experimental study

BACKGROUND The relationship between activation of the stabilizing muscles of the lumbopelvic region during the Active Straight Leg Raise test and pelvic girdle pain remains unknown. Therefore, the aim was to examine automatic contractions in relation to pre-activation in the muscles of the pelvic floor and the lower lateral abdominal wall during leg lifts, performed as the Active Straight Leg Raise test, in women with and without persistent postpartum pelvic girdle pain. METHODS Sixteen women with pelvic girdle pain and eleven pain-free women performed contralateral and ipsilateral leg lifts, while surface electromyographic activity was recorded from the pelvic floor and unilaterally from the lower lateral abdominal wall. As participants performed leg lifts onset time was calculated as the time from increased muscle activity to leg lift initiation. FINDINGS No significant differences were observed between the groups during the contralateral leg lift. During the subsequent ipsilateral leg lift, pre-activation in the pelvic floor muscles was observed in 36% of women with pelvic girdle pain and in 91% of pain-free women (P=0.01). Compared to pain-free women, women with pelvic girdle pain also showed significantly later onset time in both the pelvic floor muscles (P=0.01) and the muscles of the lower lateral abdominal wall (P<0.01). INTERPRETATION We suggest that disturbed motor activation patterns influence womens ability to stabilize the pelvis during leg lifts. This could be linked to provocation of pain during repeated movements.