Comparing a Multimodal Intervention and Standard Obstetrics Care for Low Back and Pelvic Pain in Pregnancy
Monday, March 02, 2015 01:37 PM

Musculoskeletal pain in pregnant women commonly is viewed as transient, physiologic, and self-limited. However, most women report either low back pain (LBP) or pelvic pain (PP) during pregnancy and the morbidity that is associated with such complaints. Moreover, up to 40% of patients report musculoskeletal pain during the 18 months after delivery, and one-fifth of these women have severe LBP that leads to major personal, social, or economic problems. Pregnancy-related LBP contributes substantially to health care costs.

In this study a prospective, randomized trial of 169 women was conducted to examine whether a multimodal approach of musculoskeletal and obstetric management (MOM) was superior to standard obstetric care (STOB) to reduce pain, impairment, and disability in the antepartum period.  The results suggest that the multimodal approach in the MOM treatment in pregnancy reduces pain and discomfort, while improving the quality of daily activities for pregnant women who experience LBP/PP. The study authors conclude that a multimodal approach to low back and pelvic pain in mid pregnancy benefits patients more than standard obstetric care.  

Baseline evaluation occurred at 24-28 weeks’ gestation, with follow-up at 33 weeks’ gestation. Primary outcomes were the Numerical Rating Scale (NRS) for pain and the Quebec Disability Questionnaire (QDQ). Both groups received routine obstetric care. Chiropractic specialists provided manual therapy, stabilization exercises, and patient education to MOM participants.

The MOM group demonstrated significant mean reductions in Numerical Rating Scale scores and Quebec Disability Questionnaire scores from baseline to follow-up evaluation. The group that received standard obstetric care demonstrated no significant improvements.

Patients in the STOB group received total care from a self-chosen obstetric provider who had the discretion to recommend one or more of the following remedies: rest, aerobic exercise, heating pad application for a maximum length of 10 minutes, use of acetaminophen for mild pain, or narcotics for discomfort unrelieved by other measures. Referral to orthopedic or neurologic services was used for cases in which pain was debilitating or unresponsive to standard modalities.

Like the STOB group, the frequency of obstetrics visits for patients in the MOM group was also dictated by their self-chosen obstetrics providers. The MOM group additionally had weekly visits with a chiropractic specialist who provided education, manual therapy, and stabilization exercises, based on the biopsychosocial model.  The biopsychosocial model explains that a patient’s pain syndrome is not comprised solely of the injured body structure but also includes psychologic and social components, such as fear of movement and high pain expectancy. Patients were reassured the pain experienced was unlikely pathologic and that reactivation of joint and muscle mobility by exercise would likely improve symptoms and signs without posing risk to the patient or her fetus.

The goal of manual therapy was to restore joint motion and reduce muscle tension. Hypomobile joints were assessed with the long dorsal ligament test, posterior PP provocation test, and clinical palpation and were treated with routine joint mobilization. Joint mobilization techniques were performed by gently moving hypomobile joints in their restricted directions to help restore proper range of motion. Muscle tension was evaluated by clinical palpation and was treated with postisometric relaxation and myofascial release.

We have shown that a combination of manual therapy, exercise, and patient education reduces pain and disability when applied at 24-33 weeks’ gestation. The benefits derived are both subjective and objective. Patients perceived less pain and disability and an overall global improvement in daily activities. Their physical examinations revealed improved range of motion, stability, and less irritation at the lumbar and pelvic joints. Notably, no adverse events were reported in either group. We conclude that a multimodal approach to musculoskeletal LBP/PP that is instituted in the late second and early third trimesters of pregnancy benefits patients above and beyond standard obstetrics provider care.

Chiropractic interventions and education, meshed with standard prenatal practice, led to an improvement in the MOM group that were not observed in the STOB group between 24 and 33 weeks’ gestation.