ArticlePDF AvailableLiterature Review

Recommendations for Physical Therapists on the Treatment of Lumbopelvic Pain During Pregnancy: A Systematic Review

May 2014
Journal of Orthopaedic and Sports Physical Therapy 44(7)

DOI: 10.2519/jospt.2014.5098

Source
PubMed

Authors:

Esther van Benten

Vrije Universiteit Amsterdam

Jan J M Pool

Hogeschool Utrecht

Annelies Pool-Goudzwaard

Vrije Universiteit Amsterdam

Study design: Systematic review of the literature. Objectives: To review and assess the peer-reviewed literature on the effectiveness of physical therapy interventions in treating lumbopelvic pain during pregnancy. Background: Current guidelines on interventions for lumbopelvic pain during pregnancy differ in their recommendations for assessment and intervention. Recent publications may allow revising current recommendations for the treatment of this complex problem. Methods: An electronic search strategy was conducted in PubMed, PEDro, Scopus, and CINAHL of literature published from January 1992 to November 2013. Two authors independently assessed all abstracts for eligibility. Articles were independently rated for quality by 2 authors, using the Cochrane Back Review Group criteria for methodological quality. Where possible, effect sizes were calculated for the different interventions. Results: A total of 22 articles (all randomized controlled trials) reporting on 22 independent studies were included. Overall, the methodological quality of the studies was moderate. Data for 4 types of interventions were considered: a combination of interventions (7 studies, n = 1202), exercise therapy (9 studies, n = 2149), manual therapy (5 studies, n = 360), and material support (1 study, n = 115). Conclusion: All included studies on exercise therapy, and most of the studies on interventions combined with patient education, reported a positive effect on pain, disability, and/or sick leave. Evidence-based recommendations can be made for the use of exercise therapy for the treatment of lumbopelvic pain during pregnancy. Level of evidence: Therapy, level 1a-. J Orthop Sports Phys Ther 2014;44(7):464-473. Epub 10 May 2014. doi:10.2519/jospt.2014.5098.

Description of the 7 Studies (n = 1202) Using a Combination of Interventions

…

Levels of Evidence According to the Cochrane Back Review Group

…

Summary of Results of Exercise Therapy

…

FIGURE. PRISMA flow diagram of literature search.

…

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464 | july 2014 | volume 44 | number 7 | journal of orthopaedic & sports physical therapy

[ research report ]

Lumbopelvic pain during pregnancy, deﬁned as

pregnancy-related low back pain (LBP) and/

or pregnancy-related pelvic girdle pain (PGP),

is a complex problem, with both a physical and

psychological burden.46 The prevalence is reported to

range from 24% to 90%, mainly due to the lack of a clear deﬁnition and

classiﬁcation of the condition.45,46 In the

Netherlands, 20% of all pregnant women

with lumbopelvic pain seek medical help

between weeks 34 and 40 of pregnancy.3

Guidelines for physical therapists would

be helpful for optimal evidence-based

assessment, as well as

for intervention. How-

ever, the Dutch national

guidelines4 and the Eu-

ropean guidelines46 on

lumbopelvic pain for

physical therapists dier in regard to rec-

ommendations for both assessment and

intervention. In the European guidelines,

various assessments and interventions

are discussed and recommended. In con-

trast, the Dutch national guidelines rec-

ommend very limited or no intervention

in the majority of patients with lumbo-

pelvic pain with an uncomplicated preg-

nancy, with the main focus of the limited

intervention being to provide information

and improve the patient’s physical condi-

tion. Because physical therapists in the

Netherlands can follow both the Dutch

national and the European guidelines, in-

consistencies in treatment approach exist

and there is lack of transparency. Given

the most recently published literature

on the treatment of lumbopelvic pain, it

is necessary to update the guidelines for

physical therapists, with the aim to reach

consensus.

Recently, a systematic review of the

Cochrane Collaboration by Pennick and

Liddle33 discussed a variety of interven-

tions for lumbopelvic pain during preg-

STUDY DESIGN: Systematic review of the

literature.

OBJECTIVES: To review and assess the peer-

reviewed literature on the eectiveness of physical

therapy interventions in treating lumbopelvic pain

during pregnancy.

BACKGROUND: Current guidelines on interven-

tions for lumbopelvic pain during pregnancy dier

in their recommendations for assessment and

intervention. Recent publications may allow revis-

ing current recommendations for the treatment of

this complex problem.

METHODS: An electronic search strategy

was conducted in PubMed, PEDro, Scopus, and

CINAHL of literature published from January 1992

to November 2013. Two authors independently

assessed all abstracts for eligibility. Articles were

independently rated for quality by 2 authors, using

the Cochrane Back Review Group criteria for meth-

odological quality. Where possible, eect sizes

were calculated for the dierent interventions.

RESULTS: A total of 22 articles (all randomized

controlled trials) reporting on 22 independent

studies were included. Overall, the methodological

quality of the studies was moderate. Data for 4

types of interventions were considered: a combina-

tion of interventions (7 studies, n = 1202), exercise

therapy (9 studies, n = 2149), manual therapy (5

studies, n = 360), and material support (1 study,

n = 115).

CONCLUSION: All included studies on exercise

therapy, and most of the studies on interventions

combined with patient education, reported a

positive eect on pain, disability, and/or sick leave.

Evidence-based recommendations can be made

for the use of exercise therapy for the treatment of

lumbopelvic pain during pregnancy.

LEVEL OF EVIDENCE: Therapy, level 1a–. J Or-

thop Sports Phys Ther 2014;44(7):464-473. Epub

10 May 2014. doi:10.2519/jospt.2014.5098

KEY WORDS: back pain, gravida, intervention,

pelvis

1University of Applied Sciences Utrecht, Utrecht, the Netherlands. 2M-Visio, Barneveld, the Netherlands. 3Institute of Human Movement Studies, Faculty of Health Care, University

of Applied Sciences Utrecht, Utrecht, the Netherlands. 4IMPACT Medical Centre, Zoetermeer, the Netherlands. 5Department of Rehabilitation Medicine and Physical Therapy,

Erasmus MC, University Medical Centre, Rotterdam, the Netherlands. 6Department of Movement Studies, Musculoskeletal Physical Therapy, VU University Amsterdam,

Amsterdam, the Netherlands. The authors certify that they have no aliations with or ﬁnancial involvement in any organization or entity with a direct ﬁnancial interest in the

subject matter or materials discussed in the article. Address correspondence to Esther van Benten, Anthonie Fokkerstraat 5, 3772 MP Barneveld, the Netherlands. E-mail:

ESTHER VAN BENTEN, PT, MPT1,2 • JAN POOL, PT, PhD3,4 • JAN MENS, MD, PhD5 • ANNELIES POOL-GOUDZWAARD, PT, PhD4,6

Recommendations for Physical Therapists

on the Treatment of Lumbopelvic Pain

During Pregnancy: A Systematic Review

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journal of orthopaedic & sports physical therapy | volume 44 | number 7 | july 2014 | 465

nancy. However, that review did not

consider patient education and providing

information to the patient to be part of

the intervention, though many of the in-

cluded studies did. Providing information

to the patient is an important part of the

therapeutic process. Patient information

is not only recommended by the Dutch

national guidelines for lumbopelvic pain

but is also deﬁned for physical therapy in

general by the World Confederation for

Physical Therapy. “Functional training in

self-care,” “home management,” “work,”

and “patient-related instruction” are all

components of an intervention that can

be included in the category “patient edu-

cation.” The present review also consid-

ers providing information to be part of an

intervention to be provided by physical

therapists; therefore, this review adds

valuable information to earlier reviews

and provides new recommendations for

future research.

The aim of this review was to deter-

mine the level of evidence of the treat-

ment of lumbopelvic pain that has been

reached using methods established by the

Cochrane Back Review Group (CBRG).44

All treatment approaches considered are

listed in the policy statement “Descrip-

tion of Physical Therapy” by the World

Confederation for Physical Therapy.

METHODS

Literature Search

systematic electronic search

strategy was conducted using

PubMed, PEDro, Scopus, and

CINAHL (APPENDIX, available online).

Studies were limited to those published

in English in peer-reviewed journals be-

tween January 1992 and November 2013.

An additional search of the reference lists

of the included articles was conducted,

and all systematic reviews published on

the treatment of pregnancy-related lum-

bopelvic pain were carefully read. The

reference lists of these earlier reviews

were compared with the reference list

of the present review. Randomized con-

trolled trials (RCTs) that were not iden-

tiﬁed in the search but met the inclusion

criteria were included. Studies for which

the full-text article could not be obtained

were excluded (FIGURE).

Study Selection

Two authors (E.B. and A.P.) indepen-

dently assessed the selected articles for

relevance and eligibility. All articles were

assessed with regard to the inclusion cri-

teria for design, study sample, interven-

tions, and relevant outcome measures.

Any disagreement was resolved by dis-

cussion and consensus.

Eligibility of the Studies

Inclusion Criteria Only RCTs studying

pregnant women with or without lumbo-

pelvic pain were included. All nonphar-

macological interventions performed by

physical and manual therapists, osteo-

paths, or chiropractors were considered

for inclusion. Although there were no

restrictions for the outcome measures,

pain, disability, and sick leave were con-

sidered to be the primary variables of

interest.

Exclusion Criteria Studies were excluded

if the intervention was either medical or

invasive (eg, drug use, surgery, acupunc-

ture) or addressed gynecological or ob-

stetric issues only (eg, condition of the

fetus or labor-related items).

Quality Assessment

Included RCTs were independently rated

for quality by 2 authors (E.B. and A.P.)

using the CBRG Internal Validity Check-

list, which consists of 11 items related to

methodology in clinical trials.44 This as-

sessment tool has been shown to have

good interrater agreement.16,44 Any dis-

agreement in rating was resolved by dis-

cussion and consensus; a third assessor

(J.P.) was consulted if no consensus was

reached. No cuto point was used as an

exclusion criterion to include the study in

the review. The score for each study was

used as an indication of the quality of evi-

dence for the results and conclusions of

the study. A score of 5 or less was consid-

ered relatively poor, and a score of 6 or

greater relatively good. All decisions were

made according to the recommendations

of the CBRG.44

Data Extraction and Synthesis

A standardized template was used to

extract data from the included RCTs

(study design, population, interventions,

Records identiﬁed through

database search, n = 1298

Records after duplicates removed,

n = 1284

Records screened by title and

abstract, n = 1284

Additional records identiﬁed

through other sources, n = 8

Full-text articles assessed for

eligibility, n = 28

Studies included in qualitative

synthesis, n = 22

Eligibility Screening Identiﬁcation

Records excluded, n = 1256

Full-text articles excluded, n = 6

• Nonrandomized, n = 1

• Follow-up data, n = 1

• Outcome measures not relevant,

n = 1

• Not published in English, n = 3

Included

FIGURE. PRISMA ﬂow diagram of literature search.

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466 | july 2014 | volume 44 | number 7 | journal of orthopaedic & sports physical therapy

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outcome measures, results, and conclu-

sions). For the readability of the tables,

outcome measures were reported in the

same order: pain, disability, sick leave,

and other outcome measures. If pos-

sible, eect size was calculated to assess

the magnitude of the change in scores

within groups. Eect size was deﬁned as

the mean change score in a group of pa-

tients, divided by the standard deviation

of the baseline scores of that same group

(TABLES 1 through 4, available online).36

Due to dierent inclusion criteria, inter-

ventions, and outcome measures, it was

not possible to pool the data and perform

a meta-analysis. Qualitative conclusions

on the level of evidence are based on the

deﬁnitions from the CBRG (TABLE 5).44

RESULTS

Search Results

The FIGURE shows the process of

study selection and inclusion. In the

initial database search, 1298 poten-

tially relevant articles were identiﬁed. A

hand search of the reference lists of the

other systematic reviews yielded 8 addi-

tional potentially relevant articles. After

removing duplicate studies, 1284 articles

remained. After screening by title and ab-

stract, 1256 articles were excluded, leav-

ing 28 articles for full-text assessment. Of

these, 6 articles were excluded because

the study design was not randomized (n

= 1), only postpartum follow-up data of

an RCT that was already included were

presented (n = 1), the measured outcomes

were hemodynamics of mother and fe-

tus (n = 1), and the manuscript was not

published in English (n = 3). This left 22

RCTs to be included in the review.

Methodological Quality

Overall, the methodological quality of

the included RCTs was moderate. Of the

22 studies, the median score on method-

ological quality according to the CBRG

was 6/11 (mean, 6; range, 2-10). TABLES

1 through 4 (available online) present the

scores per study and TABLE 6 the calcula-

tion of the scores.

Study Characteristics

Study Population and Type of Lumbo-

pelvic Pain All studies focused primar-

ily on a sample population of pregnant

women, mostly recruited from antenatal

health care centers. However, the stud-

ies diered in their inclusion and exclu-

sion criteria. Of the 22 RCTs, 3 examined

women with PGP.5,24,31 One study focused

on LBP, conﬁrmed by palpation.35 Five

studies examined women with a com-

bination of both or did not distinguish

between LBP and PGP.14,19,23,28,39 Thir-

teen studies did not speciﬁcally focus on

lumbopelvic pain and included pregnant

women.6,10-13,17,21,22,26,29,32,38,40

Outcome Measures The eectiveness of

treatment was measured by a variety of

outcome measures, but most studies used

pain or disability. For pain, the visual

analog scale19,22,24,28,31,39,40 and numeric

pain rating scale5,6,14,23,26,35 were the most

commonly used measurement tools. For

disability, the Roland-Morris Disability

Questionnaire5,6,21,23,26,35 and the Disabil-

ity Rating Index31,40 were the most often

used instruments. Other outcome mea-

sures included physical tests, anxiety,

and overall treatment experience (TABLES

1 through 4, available online).

Interventions for Lumbopelvic Pain The

interventions included in the studies were

divided into 4 categories that ﬁt the inter-

ventions, as recommended by the World

Confederation for Physical Therapy: a

combination of interventions (often with

educational programs), exercise therapy,

manual therapy, and material support.

Only studies with a methodological qual-

ity score of 6 or greater, according to the

CBRG,44 are described here in more de-

tail (TABLE 6). Eect sizes were calculated

(if possible) and are reported in the cor-

responding tables. It should be noted that

all included studies were pragmatic trials

and, therefore, all control groups received

standard antenatal care, unless otherwise

indicated.

Combination of Interventions Seven

studies (n = 1202) assessed the eect of

combinations of interventions (TABLE 1,

available online).5,6,14,24,31,32,39 With the

exception of the study by Eggen et al,6

all studies showed a positive eect on

pain, disability, or sick leave. Three stud-

ies scored 6 or better for methodologi-

cal quality,5,14,31 and 4 had a score less

than 6.6,24,32,39 Depledge et al5 presented

evidence for the eect of muscle-train-

ing exercises on improvement of pain

and disability in activities of daily living

(ADL) with the use of a pelvic belt com-

pared to no belt, and found that use of

the pelvic belt did not increase the eect

of training. This ﬁnding contrasts that of

Kordi et al,24 who showed that the group

wearing a pelvic belt had a signiﬁcantly

greater reduction in pain and disability

than the group that only performed ex-

ercises. The study by Eggen et al6 showed

that supervised exercises in combination

with ergonomic advice did not inﬂuence

the prevalence and severity of lumbopel-

vic pain. However, all studies that investi-

gated multimodal programs that included

education about anatomy, pathology,

posture physiology, changes during preg-

nancy, relaxation, and modiﬁcation and

advice on ADL showed positive eects on

pain, disability, and sick leave. Positive

TABLE 5 Levels of Evidence According to the

Cochrane Back Review Group

Abbreviations: CCT, controlled clinical trial; RCT, randomized controlled trial.

Level of Evidence Description

Strong Consistent ﬁndings among multiple high-quality RCTs

Moderate Consistent ﬁndings among multiple low-quality RCTs and/or CCTs and/or 1 high-quality RCT

Limited One low-quality RCT and/or CCT

Conﬂicting Inconsistent ﬁndings among multiple trials (RCTs and/or CCTs)

No evidence from trials No RCTs or CCTs

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eects were shown for a combination of

education and exercise therapy,5,24,31,32,39

the use of a pelvic belt,24,31 and manual

therapy14 during pregnancy (TABLE 7).

Exercise Therapy Nine studies (n = 2149)

assessed the eect of exercise therapy in

dierent forms (TABLE 2, available on-

line).13,17,21-23,28,29,38,40 All studies reported a

positive eect on pain, disability, and sick

leave (TABLE 8). Studies of relatively high

methodological quality demonstrated a

positive eect on functional status29 and

sick leave.17,22,40 There were dierences

in pain outcomes. Six studies reported a

decrease in pain intensity in the interven-

tion group13,17,21-23,28 ; however, 1 study also

reported an increase in pain with advanc-

ing pregnancy in all groups.22 Stafne et

al40 found no signiﬁcant between-group

dierence in self-reported pain but sig-

niﬁcantly less sick leave in the inter-

vention group compared to the control

group.

Manual Therapy Five studies (n = 360)

assessed the eect of manual therapy (TA-

BLE 3, available online). All 5 studies pre-

sented positive eects on back pain and

disability; however, the speciﬁc interven-

tions varied. Only 2 of the studies investi-

gated manual therapy performed as joint

mobilization26,35; the other 3 studies in-

vestigated massage therapy10-12 and were

of relatively poor quality. Licciardone

et al26 demonstrated that osteopathic

manual therapy in combination with

usual obstetric care, compared to usual

TABLE 6 Methodological Quality Scores According

to the Cochrane Back Review Group

Study Risk of Bias 1 2 3 4 5 6 7 8 9 10 11

Depledge et al510/11 11111101111

Eggen et al65/11 1 1 0 0 0 0 0 1 0 1 1

Field et al12 3/11 0 0 1 0 0 0 0 0 0 1 1

Field et al11 2/11 0 0 0 0 0 0 0 0 0 1 1

Field et al10 4/11 0 0 1 0 0 1 0 0 0 1 1

Garshasbi and Faghih Zadeh13 5/11 1 0 1 0 1 0 0 0 0 1 1

George et al14 6/11 1 1 1 0 0 0 0 0 1 1 1

Granath et al17 6/11 0 1 1 0 1 0 1 0 0 1 1

Kalus et al19 6/11 1 1 1 1 0 0 0 0 1 1 0

Kashanian et al21 3/11 0 0 1 0 0 0 0 0 0 1 1

Kihlstrand et al22 7/11 1 1 1 0 0 0 0 1 1 1 1

Kluge et al23 7/11 1 1 1 0 0 0 1 0 1 1 1

Kordi et al24 5/11 1 0 1 0 0 0 0 0 1 1 1

Licciardone et al26 8/11 1 1 0 1 0 1 1 1 1 1 0

Martins and Pinto e Silva28 7/11 1 1 1 0 0 1 0 1 0 1 1

Mørkved et al29 8/11 1 1 1 0 0 1 0 1 1 1 1

Nilsson-Wikmar et al31 7/11 1 0 1 0 1 1 1 0 0 1 1

Östgaard et al32 5/11 0 0 1 0 0 0 1 0 1 1 1

Peterson et al35 6/11 1 1 0 0 0 1 1 1 1 0 0

Sedaghati et al38 2/11 0 0 1 0 0 0 0 0 0 1 0

Shim et al39 3/11 0 0 1 0 0 0 0 0 1 0 1

Stafne et al40 8/11 1 1 1 0 0 1 0 1 1 1 1

*Items:

1. Was the method of randomization adequate?

2. Was the treatment allocation concealed?

3. Were the groups similar at baseline regarding the most important prognostic indicators?

4. Was the patient blinded to the intervention?

5. Was the care provider blinded to the intervention?

6. Was the outcome assessor blinded to the intervention?

7. Were cointerventions avoided or similar?

8. Was the compliance acceptable in all groups?

9. Was the dropout rate described and acceptable?

10. Was the timing of the outcome assessment similar in all groups?

11. Did the analysis include an intention-to-treat analysis?

Items*

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obstetric care or a sham intervention, led

to signiﬁcantly better decrease of pain

and regression of disability. Peterson et

al35 reported positive eects on disability

and pain as a result of chiropractic mo-

bilization and stabilization techniques;

however, no signiﬁcant dierences be-

tween groups were found.

Material Support One study19 (n = 115)

of moderate quality assessed the eect of

material support on PGP, and found that

wearing a BellyBra or a Tubigrip had a

positive eect on pain intensity. The in-

tervention group using a BellyBra had a

signiﬁcantly decreased impact of pain on

sleeping and some daily activities com-

pared with the group using the Tubigrip.

Although no signiﬁcant dierence be-

tween groups was found for pain reduc-

tion, both groups reported signiﬁcantly

less pain.

Level of Evidence There is moderate evi-

dence for the ecacy of several types of

exercise training, such as daily training of

the pelvic ﬂoor, weekly training of mus-

cle strength, aerobic training, and water

aerobics.17,22,23,28,29 Training should be

performed at a frequency of 1 to 2 times

a week17,22,28,29 and focus on improving

balance; active stability; strength of the

muscles of the lower back, pelvis, and pel-

vic ﬂoor; and cocontraction of the trans-

verse abdominal and pelvic ﬂoor muscles

with other muscle groups.13,17,22,23,28,29

Data for the other interventions did not

achieve a moderate level of evidence.

DISCUSSION

The aim of this systematic review

was to evaluate the evidence provid-

ed by the literature on the treatment

of lumbopelvic pain during pregnancy

and to inform physical therapists about

the best available evidence for interven-

tion in this population. The primary

ﬁnding was moderate evidence for the

ability of exercise therapy to reduce pain

intensity,5,22-24,28,29,35 disability,5,24,29,35 and

sick leave.17,22,40 This is of importance for

future guidelines and is likely to improve

consistency across guidelines.

The main strength of this systematic

review was its broad and thorough litera-

ture search. In addition, where possible,

eect sizes were calculated and P values

reported, which improved the ability to

draw conclusions and make comparisons.

The primary limitation of this review

is that the heterogeneous study popula-

tions and variety of interventions and

outcome measures precluded pooling the

data. This was also a limitation reported

in previous systematic reviews by Stuge et

al41 and Pennick and Liddle.33 Although

categorizing the interventions into 4 in-

tervention groups helped the analysis, al-

location to speciﬁc interventions was not

always clear. Nevertheless, the advantag-

es of this categorization seem to outweigh

the disadvantages. Furthermore, many

authors did not report all of the data, for

example, baseline measurements and

variance in the data (ie, standard devia-

tions), which often precluded calculation

of eect sizes.

Methodological Quality

The methodological quality of the in-

cluded studies was moderate. As shown

in TABLE 6, most studies had adequate

randomization, treatment allocation,

and timing of measurements. In regard to

data reporting, most studies had groups

with similar characteristics at baseline

and used intention-to-treat analysis

to account for missing data. However,

most studies lacked adequate blinding.

Blinding patients is a dicult process in

nonpharmacological trials, but blinding

outcome assessors and care providers

may be possible and could improve meth-

odological quality. The methodological

quality of several trials could have been

TABLE 8 Summary of Results of Exercise Therapy

Abbreviations: =, no signiﬁcant dierence between groups; +, signiﬁcant dierence between groups in

favor of the study group.

Study Risk of Bias Pain Disability Sick Leave

Stafne et al40 8/11 = = +

Mørkved et al29 8/11 … + =

Kihlstrand et al22 7/11 + … +

Kluge et al23 7/11 + + …

Martins and Pinto e Silva28 7/11 + … …

Granath et al17 6/11 + … +

Garshasbi and Faghih Zadeh13 5/11 + … …

Kashanian et al21 3/11 + … …

Sedaghati et al38 2/11 = … …

TABLE 7 Summary of Positive Results of

Interventions Combined With Education

Abbreviations: =, no signiﬁcant dierence between groups; +, signiﬁcant dierence between groups in

favor of the study group.

Study Risk of Bias Pain Disability Sick Leave

Depledge et al510/11 + … …

Nilsson-Wikmar et al31 7/11 = … …

George et al14 6/11 + + …

Kordi et al24 5/11 + + …

Östgaard et al32 5/11 = … =

Shim et al39 3/11 + … …

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higher if the authors had reported their

data more thoroughly and/or eectively.

In many studies, compliance and drop-

out rates were not reported. Surprisingly,

little attention was given to describing or

avoiding cointerventions. These meth-

odological ﬂaws were present for all

therapeutic interventions. In summary,

improvement can be achieved in the

methodology of the studies.

Combination of Interventions

All studies that included extensive edu-

cation (in terms of anatomy, pathology,

changes during pregnancy, posture physi-

ology, self-management, modiﬁcation

of and advice on ADL, and relaxation)

showed positive results on pain, disabil-

ity, and/or sick leave (TABLE 7).5,14,24,31,32,39

In those studies, this information was

provided verbally or in writing, or indi-

vidually or in groups. TABLE 1 (available

online) presents details on all studies us-

ing a combination of interventions.

It cannot be determined whether the

positive results were due to the multidi-

mensional nature of these treatment pro-

grams or whether education added value

to the interventions, because the RCTs

did not include groups receiving the same

intervention but without education. The

European guideline46 states that there is

no evidence for the eect of providing

information as a standalone treatment.

Nevertheless, Vleeming et al46 consider it

useful to reduce fear and allow patients

to take an active part in their rehabilita-

tion, a recommendation that appears to

be based on opinion. In contrast, Basti-

aenen et al4 stated that no intervention is

needed except for advice (giving informa-

tion and encouraging physical activity),

because pregnancy-related lumbopelvic

pain is a self-limiting disease, with most

women recovering postpartum. Based on

the results of this review, advice and edu-

cation seem to be important components

of treatment, resulting in positive eects

on pain and disability.5,14,24,32,39 However,

the self-limiting aspect of this condition

is debatable, given that a considerable

number of women do not recover after

delivery. Throughout pregnancy, 73% of

the cohort reported pain in the lumbo-

pelvic area, decreasing to 35.9% 3 weeks

after delivery and to 34.4% 1 year after

delivery.2 If it is possible to reduce com-

plaints of lumbopelvic pain during preg-

nancy, as demonstrated by studies in the

present review,5,32,39 this prognosis could

be improved.

Exercise Therapy

Exercise therapy has a positive eect on

pain, disability, and/or sick leave in those

with LBP. The evidence was less robust

and the eect sizes were smaller for those

with PGP (TABLE 2, available online).

Seven of 9 RCTs, all of moderate qual-

ity, investigated exercise therapy alone

and showed a positive eect of exercise

on pain and/or disability.13,17,21,23,28,29,38

In contrast, 2 RCTs reported no eect

on pain but a positive eect on disabil-

ity and/or sick leave.22,40 In these RCTs,

a potential explanation for the lack of

eect on pain is that, in all studies, the

control groups received usual antenatal

care; this can also be seen as a form of

treatment or at least an important inﬂu-

ence. Education seems to be an impor-

tant factor of treatment.5,31,32,39 Midwives

are likely to give relatively speciﬁc infor-

mation and advice on anatomy, postural

changes, and, perhaps, home exercises

for pregnant women with lumbopelvic

pain. This does not justify the assump-

tion that usual antenatal care is the same

as “doing nothing”; however, this issue is

not discussed in these studies. This may

not be a study ﬂaw but, rather, a result of

being a pragmatic trial. To overcome the

considerable amount of advice given dur-

ing usual antenatal care, the eect size of

the exercise group should be larger than

that of the control group. In one study the

eect sizes could not be calculated,22 and

in another the dierence was relatively

small40 (TABLE 2, available online), which

might have inﬂuenced the outcomes.

Stafne et al40 reported no positive eect

of exercise on pain. However, it should be

noted that lumbopelvic pain was not the

primary outcome measure of that study,

as it focused on gestational diabetes and

glucose metabolism, and the reduction of

lumbopelvic pain was included as 1 of 6

possible eects. Prevalence of lumbopel-

vic pain was measured by asking the sub-

jects, “Do you have pain in the pelvic and/

or lumbar area? Yes/No.” It is not surpris-

ing that pregnant women occasionally

experience pain in the pelvic or lumbar

area. This seems to be the case, because

no dierence between the groups was

found for prevalence. The lack of a proper

deﬁnition for the condition seems to be a

limitation of this study.40 No dierences

between the groups were found for dis-

ability, pain intensity, and fear-avoidance

beliefs; however, there was a dierence in

sick leave, which was signiﬁcantly lower

among the women who exercised. Exer-

cise had a positive inﬂuence of some kind,

because women in the study of Stafne et

al40 seemed to handle the disorder better

when they exercised regularly.

As stated above, there was moderate

evidence for the positive eect of several

types of exercise therapy.13,17,22,23,29,35 TABLE

2 (available online) provides detailed

information on exercise therapy for all

studies, and TABLE 7 provides the detailed

outcomes showing that 8 of 9 studies had

a positive eect on pain, disability, or sick

leave. These outcomes are consistent with

the European guideline,46 which recom-

mends individualized exercises focusing

on advice for ADL and avoiding maladap-

tive movements. However, an important

dierence is that, in the European guide-

line, stabilization exercises were recom-

mended only for the postpartum period.

Several studies included in the present

review demonstrated that stabilization

exercises are eective to reduce pain and

disability in the prepartum period.5,23,28,40

Manual Therapy

Limited research has focused on the use

of manual therapy techniques for the

treatment of lumbopelvic pain during

pregnancy. There is relatively high-qual-

ity evidence for the positive eect of os-

teopathic manual therapy in combination

with usual obstetric care on improvement

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470 | july 2014 | volume 44 | number 7 | journal of orthopaedic & sports physical therapy

[ research report ]

of pain and disability.26 In the study by

George et al,14 although manual therapy

seemed to add to the positive ﬁndings,

no conclusions can be drawn because

manual therapy treatment was part of a

multimodal therapeutic approach. Lic-

ciardone et al26 performed the only study

that investigated osteopathic joint mo-

bilization and soft tissue techniques and

showed a signiﬁcant dierence in disabil-

ity between the groups; however, this be-

tween-group dierence was not found for

back pain. The study by Peterson et al35

showed improvement in pain and disabil-

ity in all 3 groups, but, again, no signiﬁ-

cant dierences were found between the

groups. Studies that investigated massage

therapy did not have pain as a primary

outcome measure and were of relatively

poor quality.10-12

Consistent with both previously men-

tioned guidelines, based on the current

evidence, there is no evidence that man-

ual therapy should be recommended for

the treatment of lumbopelvic pain during

pregnancy. Additional RCTs investigating

manual therapy treatment approaches

for lumbopelvic pain in this population

are needed.

Material Support

The present review provides no sub-

stantial evidence for the use of material

support. Although this is consistent with

the recommendation of the European

guidelines,46 the guidelines nevertheless

advise that a pelvic belt may be ﬁtted to

test for symptomatic relief. Bastiaenen et

al4 did not advise against the use of a belt

or crutches, but left it up to the patient to

decide on the usefulness of these devices.

The present review included 1 RCT that

compared the eect of 2 dierent sup-

ports,19 with promising results related

to pain. However, the use of a pelvic belt

in combination with other treatment in-

terventions has more often been investi-

gated.5,24,31 Conﬂicting evidence, ranging

from a positive eect on pain and disabil-

ity5,24,32 to no added beneﬁts, was found

for exercises and advice.5 The present

evidence is insucient to recommend the

use of any material support. More stud-

ies focusing on the eects of the use of a

pelvic belt are needed.

Comparison With Other

Systematic Reviews

Six other systematic reviews studied in-

terventions for lumbopelvic pain during

pregnancy.18,20,33,37,41,45 The reviews by Stuge

et al41 and Pennick and Liddle33 included

mostly clinical trials, whereas the reviews

by Vermani et al45 and Kanakaris et al20

also included other study designs. The

authors of the last 2 reviews mentioned

studies of high and low methodological

quality, but did not explain if and how

this was objectively determined. In con-

trast, both Stuge et al41 and Pennick and

Liddle33 assessed methodological quality

using clearly deﬁned criteria. The present

review adds to the strength of both these

studies by also applying these criteria in

more detail, in accordance with the CBRG

Internal Validity Checklist44 (TABLE 6).

Five of these reviews included articles

on LBP and/or PGP in both the prepar-

tum and postpartum stages; only Pennick

and Liddle33 did not. It may be useful to

distinguish between these 2 stages to es-

timate dierent practical implications.

With regard to the inclusion of the RCTs,

estimating the methodological quality,

and reporting on the interventions dur-

ing the prepartum stage alone, the great-

est similarity exists between the design of

the present review and that of the most

recent review of Pennick and Liddle.33

Therefore, comparison of only these 2

reviews is discussed in more detail below.

Pennick and Liddle33 assessed 26

RCTs and the present review included 22

RCTs. Of these studies, 14 are discussed

in both reviews.5,6,13,14,19,21-23,26,28,29,35,38,40

Twelve RCTs included by Pennick and

Liddle33 were not included in our review,

because 4 were not published in an Eng-

lish peer-reviewed journal,1,15,34,42 1 was

published prior to 1992,43 and another

7 investigated acupuncture.7-9,25,27,47,48 On

the other hand, our review assessed 8

studies10-12,17,24,31,32,39 that were not includ-

ed in the review by Pennick and Liddle.33

Although Pennick and Liddle33 also

calculated eect sizes, no comparison can

be made between our calculations and

theirs because of missing data. We be-

lieve that the calculations we made have

added value to the reported results. Large

to medium eect sizes were calculated for

the eect of the combination of exercise

and information on disability and pain5

(TABLE 1, available online), ﬂexibility of the

spine13 (TABLE 2, available online), mas-

sage on anxiety and leg and back pain10-12

(TABLE 3, available online), and the use of

a support garment on pain during ADL

(TABLE 4, available online). However, we

should mention that, for most of the in-

cluded RCTs, the eect sizes could not be

calculated due to missing data.

Pennick and Liddle33 concluded that

there is moderate evidence for the eect

of physical therapy in treating lumbopel-

vic pain. There was some indication that

adding acupuncture, physical therapy,

or exercise therapy to standard antena-

tal care seemed to relieve lumbopelvic

pain to a greater extent than standard

antenatal care alone. The present re-

view supports that conclusion and pro-

vides additional information regarding

education and information. Adding

information and advice to other treat-

ment interventions (eg, exercise therapy)

seems to have a positive eect in treating

lumbopelvic pain.5,31,32,39 However, more

research on the inﬂuence of education

is needed. Education is not speciﬁcally

mentioned in the review by Pennick and

Liddle,33 but is only referred to as a part

of a multimodal approach in 1 of the in-

cluded RCTs.14 However, patient educa-

tion during early pregnancy is mentioned

as a possible focus for future research.

The present review included 7 RCTs that

speciﬁcally mentioned education as a

part of the treatment provided. Four of

these RCTs24,31,32,39 were not included in

the review by Pennick and Liddle,33 and

of the 3 RCTs that were included,5,6,14 no

speciﬁc mention of education was made

in the discussion of results.

Pennick and Liddle33 presented their

results according to the condition. Thus,

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journal of orthopaedic & sports physical therapy | volume 44 | number 7 | july 2014 | 471

the eect of treatment of LBP, pelvic

pain, or lumbopelvic pain is presented

and calculated. Although a number of

tests are validated to distinguish between

LBP and PGP,45 not all of the included

studies in their study sample used these

tests as inclusion or exclusion criteria.

Thus, various studies ended up in the

same category, even though they used

dierent criteria for diagnosing a condi-

tion, or did not distinguish between LBP

and PGP. Until a universally recognized

classiﬁcation system for these conditions

is available, it may be more useful to fo-

cus on dierent treatment interventions

and not to distinguish between LBP and

PGP when presenting conclusions. From

this perspective, the moderate evidence

for exercise therapy and patient educa-

tion seems promising. Exercise combined

with education, when added to usual an-

tenatal care, had a positive eect on the

rehabilitation (pain, disability, and/or

sick leave) of these patients as a whole.

However, when analyzing these condi-

tions separately, this ﬁnding is more ro-

bust for LBP than for PGP.

Although it seems that there is no

strong evidence for any of the interven-

tions provided by physical therapists, we

would like to put this conclusion into

perspective. Moderate evidence is pres-

ent for exercise therapy. Treating lumbo-

pelvic pain during pregnancy with this

form of therapy generally yielded better

results on pain, disability, and sick leave

than use of standard antenatal care alone.

Therefore, physical therapists can play an

important role in the rehabilitation of pa-

tients with lumbopelvic pain by provid-

ing exercise. Providing patient education

also seems to be a promising option, but

requires further research.

In their systematic review, Nasci-

mento et al30 discussed dierent forms

of exercise during pregnancy and found

them to be associated with control of

gestational weight gain, gestational dia-

betes, and prevention of urinary incon-

tinence and LBP. No contraindications

were found, and exercise at moderate

intensity was safe for both mother and

fetus. Their recommendation to encour-

age pregnant women to participate in

aerobic and strength training at moder-

ate intensity (at least 3 times a week for

30 minutes or more) is, for the most part,

consistent with our ﬁndings of eective-

ness of aerobic and strength training at

moderate intensity.17,22,23,28,29 Our review

adds to this point by specifying training

goals, such as improving balance; active

stability; strengthening the muscles of

the lower back, pelvis, and pelvic ﬂoor;

and cocontraction of the transverse ab-

dominal and pelvic ﬂoor muscles with

other muscle groups.13,17,22,23,28,29 For this,

we recommend a frequency of 1 to 2

times a week.17,22,28,29 This dierence be-

tween reviews may be attributed to the

inclusion of dierent trials. For example,

Nascimento et al30 based their conclu-

sions on trials that not only included pain

as an outcome but also outcomes such as

depression, blood pressure, excessive ges-

tational weight gain, gestational diabetes,

urinary incontinence, quality of life, and

birth weight.

Future Research

The present review shows that positive

results are reached with various forms of

exercise therapy. In addition, patient edu-

cation seems promising as an adjunct to

other interventions. Therefore, it may be

warranted to perform an RCT in which

precisely described exercise therapy

and structured education on LBP and

PGP (anatomy, pathology, changes dur-

ing pregnancy, posture physiology, self-

management, modiﬁcation and advice

on ADL, and relaxation) are investigated

as both separate and combined inter-

ventions in 3 groups, compared with a

control group. Moreover, a classiﬁcation

system for LBP and PGP is required to

establish whether the same or dierent

types of treatment should be applied in

these 2 conditions.

For future research, considerable

improvement in study methodology is

required. Similar inclusion criteria and

outcome tools should be used in high-

quality RCTs to enable pooling of data

and proper comparison of the dierent

treatment interventions. Also, attention

should be paid to report all data, such as

the dropout rate, compliance rate, and

cointerventions provided. Researchers

should also try to achieve better blind-

ing. When it is impossible to blind the

patients, which is often the case in physi-

cal therapy treatment, it would be beneﬁ-

cial to blind care providers and outcome

assessors. The present systematic review

indicates that there is evidence to sup-

port exercise therapy and providing in-

formation; however, the development of

a template, based on consensus in out-

come measures (eg, which study sample

to choose and which results and data to

report), would enable one to deﬁne and

specify such a statement and to calculate

eect sizes properly.

CONCLUSION

According to the available lit-

erature, there is moderate evidence

for the positive eect of exercise

therapy on pain, disability, and/or sick

leave for the treatment of lumbopelvic

pain during pregnancy. Moreover, data

show that patient education seems to

also be a helpful intervention. Physical

therapists can apply these interventions

and thereby improve treatment of this

condition. All included studies on exer-

cise therapy (all of moderate quality) re-

ported a positive eect on 1 or more of

the 3 outcomes in rehabilitation: pain,

disability, and sick leave. Six of 7 stud-

ies on interventions combined with edu-

cation showed a positive eect on pain

and/or disability or sick leave. There is

limited evidence for the eect of mate-

rial support and manual therapy, and

the studies involved have methodological

limitations. For future research, more ho-

mogeneous populations, as well as stan-

dardization of methods and reporting of

data, are required. t

KEY POINTS

FINDINGS: Exercise therapy is effective in

treating pregnancy-related lumbopelvic

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472 | july 2014 | volume 44 | number 7 | journal of orthopaedic & sports physical therapy

[ research report ]

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30. Nascimento SL, Surita FG, Cecatti JG.

pain. The evidence is more robust for

treating pregnancy-related LBP than for

pregnancy-related PGP. Patient educa-

tion seems to be a promising option.

IMPLICATIONS: Physical therapists can

implement active exercise in their treat-

ment strategy.

CAUTION: In the current literature, strong

evidence is lacking for the use of mate-

rial support, manual therapy, and for

combining interventions, due to the

small number of studies and meth-

odological limitations. However, this

does not imply that these interventions

should not be further investigated. More

transparency and homogeneity are re-

quired.

ACKNOWLEDGEMENTS: We are thankful to the

authors who provided their articles that could

not be retrieved in full text. We are grateful to

Dr Britt Stuge for reviewing this article and

giving her useful comments and support.

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MORE INFORMATION

WWW.JOSPT.ORG

Physical exercise during pregnancy: a sys-

tematic review. Curr Opin Obstet Gynecol.

2012;24:387-394. http://dx.doi.org/10.1097/

GCO.0b013e328359f131

31. Nilsson-Wikmar L, Holm K, Oijerstedt R, Harms-

Ringdahl K. Eect of three dierent physical

therapy treatments on pain and activity in

pregnant women with pelvic girdle pain: a ran-

domized clinical trial with 3, 6, and 12 months

follow-up postpartum. Spine (Phila Pa 1976).

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32. Östgaard HC, Zetherström G, Roos-Hansson

E, Svanberg B. Reduction of back and

posterior pelvic pain in pregnancy. Spine

(Phila Pa 1976). 1994;19:894-900. http://dx.doi.

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33. Pennick V, Liddle SD. Interventions for

preventing and treating pelvic and back

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org/10.1002/14651858.CD001139.pub3

34. Peters R, van der Linde M. Osteopathic Treat-

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Pregnancy. A Randomized Controlled Trial

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35. Peterson CD, Haas M, Gregory WT. A pilot

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ecacy of exercise, spinal manipulation,

and neuro emotional technique for the treat-

ment of pregnancy-related low back pain.

Chiropr Man Therap. 2012;20:18. http://dx.doi.

org/10.1186/2045-709X-20-18

36. Portney LG, Watkins MP. Foundations of Clinical

Research: Applications to Practice. 2nd ed. Up-

per Saddle River, NJ: Prentice Hall Health; 2000.

37. Richards E, van Kessel G, Virgara R, Har-

ris P. Does antenatal physical therapy for

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38. Sedaghati P, Ziaee V, Ardjmand A. The eect of

an ergometric training program on pregnants

weight gain and low back pain. Gazz Med Ital

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39. Shim MJ, Lee YS, Oh HE, Kim JS. Eects of a

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ijnurstu.2005.11.016

40. Stafne SN, Salvesen KA, Romundstad PR,

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during pregnancy inﬂuence lumbopelvic pain?

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41. Stuge B, Hilde G, Vøllestad N. Physical therapy

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org/10.1034/j.1600-0412.2003.00125.x

42. Suputtitada A, Wacharapreechanont T, Chai-

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back pain. J Med Assoc Thai. 2002;85 suppl

1:S170-S179.

43. Thomas IL, Nicklin J, Pollock H, Faulkner K.

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44. van Tulder M, Furlan A, Bombardier C,

Bouter L. Updated method guidelines for

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org/10.1097/01.BRS.0000065484.95996.AF

45. Vermani E, Mittal R, Weeks A. Pelvic girdle

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view. Pain Pract. 2010;10:60-71. http://dx.doi.

org/10.1111/j.1533-2500.2009.00327.x

46. Vleeming A, Albert HB, Östgaard HC, Sturesson

B, Stuge B. European guidelines for the diagno-

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s00586-008-0602-4

47. Wang SM, DeZinno P, Lin EC, et al. Auricular

acupuncture as a treatment for pregnant women

who have low back and posterior pelvic pain: a

pilot study. Am J Obstet Gynecol. 2009;201:271.

e1-271.e9. http://dx.doi.org/10.1016/j.

ajog.2009.04.028

48. Wedenberg K, Moen B, Norling A. A prospec-

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pelvic pain in pregnancy. Acta Obstet Gynecol

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org/10.1034/j.1600-0412.2000.079005331.x

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journal of orthopaedic & sports physical therapy | volume 44 | number 7 | july 2014 | A1

ONLINE TABLES

TABLE 1 Description of the 7 Studies (n = 1202) Using

a Combination of Interventions

Study

Risk of Bias

(CBRG) Study Sample Intervention Groups Outcome Measures Eect Size

Within-Group

Dierences

Between-Group

Dierences Conclusion

Depledge

et al5

10/11 90 pregnant

women

with

symphysis

pubis dys-

function

EX: speciﬁc muscle-

strengthening

exercises; verbal

and written educa-

tion about anatomy

and pathology of

symphysis pubis

dysfunction and

self-help manage-

ment, including

the modiﬁcation of

daily activities

EX+RB: EX plus rigid

pelvic belt

EX+NRB: EX plus

nonrigid pelvic belt

All during 1 wk.

How many times

exercises were

performed and

how long the belts

were worn were not

speciﬁed

Pain (NRS for maxi-

mum pain over

preceding wk)

Pain (NRS for

average pain over

preceding wk)

Disability (RMDQ)

Disability (PSFS)

Pain (NRS for maximum

pain over preceding

wk): EX, –1.65; EX+RB,

–0.41; EX+NRB, –0.51

Pain (NRS for average

pain over preceding

wk): EX, –1.07; EX+RB,

–0.27; EX+NRB, –0.79

Disability (RMDQ): EX,

–1.06; EX+RB, –0.49;

EX+NRB, –0.65

Disability (PSFS): EX,

–2.45; EX+RB, –1.06;

EX+NRB, –1.50

Signiﬁcant

reduction in

RMDQ score

(P<.001),

PSFS score

(P<.001), and

NRS scores

(average

and worst)

(P<.001) in all

3 groups

Average pain was

signiﬁcantly

reduced in the EX

and EX+RB, but

not for EX+NRB

No signiﬁcant

dierences

between groups

for disability and

maximum pain

Use of pelvic belts

did not add to the

eects provided

by a muscle-

strengthening

program and

advice

It would seem ben-

eﬁcial in the long

term for women

to use their

muscles to pro-

vide stability to

the pelvis rather

than to rely on an

external device

Nilsson-

Wikmar

et al31

7/11 118 women

with PPP

EG (n = 40): use

of a nonelastic

sacroiliac belt,

information and

education about

PPP

HEG (n = 41): EG,

home exercises

(muscle strength-

ening and stretch-

ing) not speciﬁed

how often

CEG (n = 37): EG,

training program

with equipment

in clinic (muscle

strengthening and

stabilization) twice

per wk

Pain (VAS)

Pain (marked

squares in pain

drawing)

Disability (DRI)

Pain (VAS), NC

Pain (marked squares in

pain drawing), NC

Disability (DRI), NC

Pain decreased in

all groups

Disability

decreased

between

gestation 38

wk and 12 mo

postpartum

No signiﬁcant

dierence among

groups during

pregnancy or at

the follow-ups

postpartum

Women with PPP

seemed to

improve in all

groups

Neither exercises at

home nor in the

clinic had any

additional value

above giving

a nonelastic

sacroiliac belt

and information

Table continues on page A2.

Results

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A2 | july 2014 | volume 44 | number 7 | journal of orthopaedic & sports physical therapy

ONLINE TABLES

TABLE 1 Description of the 7 Studies (n = 1202) Using

a Combination of Interventions (continued)

Study

Risk of Bias

(CBRG) Study Sample Intervention Groups Outcome Measures Eect Size

Within-Group

Dierences

Between-Group

Dierences Conclusion

George

et al14

6/11 169 pregnant

women

with PPP or

LBP or both

(gestation

weeks

24-28)

MOM (n = 87): weekly

visits for an indi-

vidually designed

combination of

education, manual

therapy, stabilization

exercises, home

exercise program,

twice daily

STOB (n = 82): possi-

bility of rest, aerobic

exercise, heating

pad application,

acetaminophen,

narcotics, or referral

to orthopaedic or

neurologic services

Actual number of visits

was not recorded

for either group

Pain (NRS)

Pain (QDQ for

impact of pain)

Pain (NRS): MOM, 1.32;

STOB, 0.05

Pain (QDQ for impact

of pain): MOM, 0.45;

STOB, –0.32

STOB: no

signiﬁcant

improvements

MOM: signiﬁcantly

more reduction

in NRS and QDQ

scores than in

STOB (P<.001)

A multimodal

approach to low

back and pelvic

pain in mid preg-

nancy beneﬁts

patients more

than STOB

Eggen et

al6

5/11 257 healthy

pregnant

women

(gestation

week, less

than 20)

SG (n = 129): super-

vised exercises in

groups once per wk,

ergonomic advice,

advice to do home

exercises

CG (n = 128): standard

care

Pain (prevalence:

% women with

self-reported

PGP)

Pain (prevalence: %

women with self-

reported LBP)

Pain (NRS for worst

pain in morning)

Pain (NRS for worst

pain in evening)

Disability (RMDQ)

Physical health

(SF-36 PCS)

Mental health (SF-

36 MCS)

Pain (prevalence: %

women with self-

reported PGP): NC

Pain (prevalence: %

women with self-

reported LBP): NC

Pain (NRS for worst pain

in morning): NC

Pain (NRS for worst pain

in evening): NC

Disability (RMDQ): NC

Physical health (SF-36

PCS): SG, 0.70; CG,

0.49

Mental health (SF-36

MCS): SG, –0.25; CG,

–0.29

The main analy-

ses showed

no eect of

the training on

prevalence of

LBP or PGP

For the secondary

outcomes, no

signiﬁcant dif-

ferences were

found

Mean dierences

between the

groups: pain

intensity morning,

–0.4 (95% CI:

–0.8, 0.1); pain in-

tensity in evening,

–0.4 (95% CI:

–1.0, 0.2); disabil-

ity, –1.0 (95% CI:

–2.2, 0.0); SF-36

PCS, 1.8 (95% CI:

0.0, 3.7); SF-36

MCS, –0.6 (95%

CI: –2.2, 1.4)

Supervised group

exercises had

no inﬂuence on

the prevalence

and severity of

LBP and PGP in

pregnancy

Table continues on page A3.

Results

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journal of orthopaedic & sports physical therapy | volume 44 | number 7 | july 2014 | A3

ONLINE TABLES

TABLE 1 Description of the 7 Studies (n = 1202) Using

a Combination of Interventions (continued)

Study

Risk of Bias

(CBRG) Study Sample Intervention Groups Outcome Measures Eect Size

Within-Group

Dierences

Between-Group

Dierences Conclusion

Kordi et

al24

5/11 105 pregnant

women with

PGP (gesta-

tion weeks,

20-32)

CG (n = 35): general in-

formation (anatomy,

body posture, and

ergonomic advice

regarding sitting,

walking, and lying)

EG (n = 35): general in-

formation, exercises

at home: (1) aerobic

exercises (25 min,

3 times per wk); (2)

stretching exercises

for hamstrings,

inner thigh, side

waist, quadriceps,

and back (3

times per wk); (3)

strengthening exer-

cises for the pelvis

(3-5 times each

exercise session, 2

exercise bouts per d

and 3 d per wk)

BG (n = 35):

general informa-

tion, constantly

wearing a nonrigid

lumbopelvic belt

(only removed while

sleeping)

Pain (VAS at 3 wk)

Pain (VAS at 6 wk)

Disability (ODQ at

3 wk)

Disability (ODQ at

6 wk)

QoL (WHOQOL-

BREF PH at

3 wk)

QoL (WHOQOL-

BREF PH at

6 wk)

QoL (WHOQOL-

BREF PsH at

3 wk)

QoL (WHOQOL-

BREF PsH at

6 wk)

QoL (WHOQOL-

BREF SR at

3 wk)

QoL (WHOQOL-

BREF SR at 6 wk)

QoL (WHOQOL-

BREF EH at 3 wk)

QoL (WHOQOL-

BREF EH at 6 wk)

Pain (VAS at 3 wk): CG,

0.49; EG, 1.00; BG,

3.27

Pain (VAS at 6 wk): CG,

0.42; EG, 1.95; BG,

3.83

Disability (ODQ at 3 wk):

CG, 0.58; EG, 1.05;

BG, 1.52

Disability (ODQ at 6 wk):

CG, 0.56; EG, 1.37;

BG, 1.86

QoL (WHOQOL-BREF PH

at 3 wk): CG, 0.34; EG,

0.25; BG, 1.02

QoL (WHOQOL-BREF PH

at 6 wk): CG, 0.31; EG,

0.63; BG, 1.34

QoL (WHOQOL-BREF PsH

at 3 wk): CG, 0.04; EG,

0.13; BG, 0.37

QoL (WHOQOL-BREF PsH

at 6 wk): CG, 0.06; EG,

0.25; BG, 0.45

QoL (WHOQOL-BREF SR

at 3 wk): CG, 0.03; EG,

0.08; BG, 0.12

QoL (WHOQOL-BREF SR

at 6 wk): CG, 0.03; EG,

0.08; BG, 0.13

QoL (WHOQOL-BREF EH

at 3 wk): CG, 0.01; EG,

0.06; BG, 0.10

QoL (WHOQOL-BREF EH

at 6 wk): CG, 0.03; EG,

0.06; BG, 0.12

Pain intensity

decreased in

all groups

Disability

decreased in

all groups

Quality of life

increased in all

groups

Pain intensity

decreased sig-

niﬁcantly more

in BG compared

to EG and CG at

both 3 wk and 6

wk (P<.001)

Pain intensity in

EG decreased

signiﬁcantly more

than CG at 6 wk

(P<.001)

Decrease of ODQ

scores in BG

signiﬁcantly more

than CG (P<.001)

at 3 wk and 6 wk

and signiﬁcantly

more than EG at

3 wk (P = .005)

and 6 wk (P =

.008)

Decrease of mean

ODQ scores in

EG signiﬁcantly

more than in CG

(P<.001) at 6 wk

In all but social rela-

tion component

of the WHOQOL-

BREF, scores in

BG signiﬁcantly

increased more

than EG and CG

at 3 wk and 6 wk

(P<.05)

In short term, use of

a lumbopelvic belt

and information

in treatment of

PGP is superior

to exercise plus

information or

information alone

Table continues on page A4.

Results

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A4 | july 2014 | volume 44 | number 7 | journal of orthopaedic & sports physical therapy

TABLE 1 Description of the 7 Studies (n = 1202) Using

a Combination of Interventions (continued)

Results

Abbreviations: BG, belt group; CBRG, Cochrane Back Review Group; CEG, clinic exercise group; CG, control group; CI, conﬁdence interval; DRI, Disability

Rating Index; EG, education group; EH, environmental health; EX, exercise group; EX+NRB, exercise plus nonrigid belt group; EX+RB, exercise plus rigid

belt group; HEG, home exercise group; LBP, pregnancy-related low back pain; MOM, multimodal musculoskeletal and obstetric treatment; NC, not able to

calculate eect sizes due to missing data; NRS, numeric rating scale; ODQ, Oswestry Disability Questionnaire; PGP, pregnancy-related pelvic girdle pain; PH,

physical health; PPP, posterior pelvic pain; PSFS, Patient-Speciﬁc Functional Scale; PsH, psychological health; QDQ, Quebec Disability Questionnaire; QoL,

quality of life; RMDQ, Roland-Morris Disability Questionnaire; SAS, State Anxiety Scale; SF-36 MCS, 8-item Short-Form Health Survey mental component

summary; SF-36 PCS, 8-item Short-Form Health Survey physical component summary; SG, study group; SR, social relation; ST, standard treatment; ST+AC,

standard treatment plus acupuncture; ST+EX, standard treatment plus speciﬁc stabilizing exercises; STOB, standard obstetric care; VAS, visual analog scale;

WHOQOL-BREF, World Health Organization Quality of Life Questionnaire brief version.

Study

Risk of Bias

(CBRG) Study Sample Intervention Groups Outcome Measures Eect Size

Within-Group

Dierences

Between-Group

Dierences Conclusion

Östgaard

et al32

5/11 407 pregnant

women,

with or

without

PPP and/or

LBP

Group A: controls (n =

145): standard care

maternity-care unit

Group B (n = 123):

back school

education and

training program: 2

group-wise lessons

of 45 min before

gestation week 20:

simple anatomy,

posture physiology,

lifting and working

technique, muscle

training, relaxation

training. Nonelastic

sacroiliac belt in PGP

Group C (n = 139): 5

individual lessons

of 30 min between

gestation weeks

18-32. Content of

lessons same as

group B, but training

and education

were speciﬁed for

individual situation.

Nonelastic sacroiliac

belt in PGP

Pain (VAS)

Pain (drawing for

location)

Sick leave

Standardized physi-

cal examination

Pain (VAS): NC

Pain (drawing for loca-

tion): NC

Sick leave: NC

Standardized physical

examination: NC

Serious LBP or

PGP developed

in 47% of all

women

PGP was more

common than

LBP

Muscular and body

posture train-

ing reduced

subjective pain

problems in

groups B and C

(P<.05)

Ergonomic and

vocational tech-

niques were

found useful in

group C

Objective pain

intensity did

not signiﬁcantly

decrease in any

of the groups

Sick leave was

signiﬁcantly re-

duced in group

C (P<.01)

Reduction of PGP

by a nonelastic

pelvic belt in

82% of the

women with

PGP (mainly

walking)

No statistics about

dierences

between groups

mentioned

An individually

designed program

seems beneﬁcial to

reduce sick leave

because of LBP in

pregnancy

Groupwise lessons

were less eective

The program was

not eective for

reducing sick leave

or pain for patients

with PGP

A pelvic belt partly

reduced pain-

more in SG than

in CG (P<.01)

A speciﬁc exercise

program de-

creased back

pain intensity

and increased

functional ability

during pregnancy

in women with

LBP and PGP

Martins

and

Pinto e

Silva28

7/11 60 pregnant

women

with LBP

and/or PGP

(gestation

weeks

12-32)

SG (n = 30): 10

group sessions

of supervised

Hatha yoga, once

per wk (34 poses

to stimulate and

improve breathing,

range of motion

of joints, ﬂexibility,

strengthening, bal-

ance, stimulation

of introspection,

self-conﬁdence,

self-control,

concentration, and

mental relaxation).

CG (n = 30): unsu-

pervised individual

postural orientation

on daily activity,

according to an in-

struction pamphlet,

during 10 wk

Pain (VAS per

session)

Lumbar pain

provocation tests

(ﬂexion of trunk,

palpation of

spinal muscles,

decreased

circular motion

of trunk, pain

on circular

motion of trunk,

conﬁrmation of

pain site)

Posterior pelvic

pain provocation

tests (femoral

compression,

pain while

turning in bed

at night, feelings

of weight in the

posterior pelvis,

conﬁrmation of

pain site)

Pain (VAS): NC

Lumbar pain provocation

tests: NC

Posterior pelvic pain

provocation tests: NC

Lumbar pain

provocation

tests showed

signiﬁcantly

decreased

response at

the end of the

intervention in

both groups

Clinical poste-

rior pelvic pain

provocation

tests did not

show any

signiﬁcant

modiﬁcation in

either group at

the end of the

intervention

Mean pain in-

tensity scores

per session

progressively

decreased in

SG (P<.024)

Pain intensity was

signiﬁcantly lower

in SG than in CG

(P = .0058)

Yoga exercises were

more eective

at reducing

lumbopelvic pain

intensity than

postural orienta-

tion

Table continues on page A7.

Results

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journal of orthopaedic & sports physical therapy | volume 44 | number 7 | july 2014 | A7

ONLINE TABLES

TABLE 2 Description of the 9 Studies (n = 2149) Using Exercise Therapy (continued)

Results

Study

Risk of Bias

(CBRG) Study Sample Intervention Outcome Measures Eect Size

Within-Group

Dierences

Between-Group

Dierences Conclusion

Granath

et al17

6/11 390 healthy

pregnant

women

45 min of exercise and

15 min of relaxation

of dierent muscle

groups, once per

wk from 11-12 wk of

gestation through-

out pregnancy in 2

dierent forms

LBPE (n = 198): set of

exercises developed

by physiotherapists

for ﬁtness during

pregnancy. Focus

was on improving

aerobic and

movement capac-

ity, including light

jogging, sit-ups,

and pelvic mobility

exercises

WA (n = 192): WA had

the same focus

on aerobic and

movement capacity

as LBPE, but with

considerably less

risk for unwanted

weight-bearing

loading of anatomic

structures

Both interventions

focused on

strength, ﬂexibility,

and ﬁtness, and

included warming

up, stretching,

and relaxation at

the end of each

session. Speciﬁcs

about exercises/

targeted muscle

groups were not

mentioned

Pain (presence of

LBP or PPP or

both)

Sick leave

Pain: NC

Sick leave: NC

WA signiﬁcantly

diminished

LBP (P = .04)

Signiﬁcantly fewer

women on sick

leave (P = .03) in

WA than in LBPE

WA can be recom-

mended for treat-

ing LBP during

pregnancy

Table continues on page A8.

Results

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A8 | july 2014 | volume 44 | number 7 | journal of orthopaedic & sports physical therapy

ONLINE TABLES

TABLE 2 Description of the 9 Studies (n = 2149) Using Exercise Therapy (continued)

Results

Study

Risk of Bias

(CBRG) Study Sample Intervention Outcome Measures Eect Size

Within-Group

Dierences

Between-Group

Dierences Conclusion

Garshasbi

and

Faghih

Zadeh13

5/11 212 pregnant,

primigravid

women

(gestation

weeks

17-22)

SG (n = 107): for 12 wk,

60 min of exercise

3 times per wk,

supervised by a

midwife (muscle

strengthening for

abdominal and

hamstring muscles

and to increase

traction of iliopsoas

and paravertebral

muscles)

The exercises were

recommended by

Tarbiat Modares

Faculty of Sport

and tested for

pregnant women by

physiotherapists

CG (n = 105): no

intervention

Pain (KEBK)

Flexibility of spine

(sidebending test

right)

Flexibility of spine

(sidebending

test left)

Lordosis angle of

lumbar spine

Pain (KEBK): SG, –0.38;

CG, – 0.07

Flexibility of spine (side-

bending test right): SG,

1.95; CG, 1.83

Flexibility of spine (side-

bending test left): SG,

2.04; CG, 1.25

Lordosis angle of lumbar

spine: SG, 2.13; CG,

–1.66

Back pain

signiﬁcantly

decreased in

SG (P<.001)

and increased

in CG (P<.001)

Flexibility of spine

signiﬁcantly

increased in

both groups

(P<.001)

Lordosis

signiﬁcantly

increased in

both groups

(P<.001)

No major dierences

between groups

Exercise during

second and

beginning of third

trimester could

reduce back pain

and increase

ﬂexibility of the

spine

Kashanian

et al21

3/11 30 pregnant

nulliparous

women

SG (n = 15): exercise

sessions, 3 times

per wk during 8 wk

from gestational

weeks 16-24

Exercise sessions

consist of 4.5 min of

preparation (shoul-

der muscles, hands,

stretching the neck

and arm muscles)

followed by walk-

ing, stretching

(spine extensors,

hamstrings, thigh

adductor muscles,

and lumbar

paravertebral),

and strengthening

exercises (thigh

extensor muscles

and abdominal

oblique muscles)

for 21 min, then

relaxation (relax the

shoulders, arms,

hands, knees, and

legs) for 4.5 min

CG (n = 15): no

intervention

Disability (RMDQ)

Lordosis angle

Disability (RMDQ): SG,

0.32; CG, –1.57

Lordosis angle: SG, –0.27;

CG, –0.44

Increase of dis-

ability in SG (P

= .035)

Decrease of dis-

ability in CG (P

= .001)

Increased lordosis

angle in both

groups, but

greater in CG

Not speciﬁcally

mentioned in

article

Table continues on page A9.

Results

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journal of orthopaedic & sports physical therapy | volume 44 | number 7 | july 2014 | A9

ONLINE TABLES

TABLE 2 Description of the 9 Studies (n = 2149) Using Exercise Therapy (continued)

Results

Study

Risk of Bias

(CBRG) Study Sample Intervention Outcome Measures Eect Size

Within-Group

Dierences

Between-Group

Dierences Conclusion

Sedaghati

et al38

2/11 90 pregnant

women

(gestation

weeks

20-22)

SG (n = 40): 60-min

exercise program, 3

times per wk for 8

wk (15 min warming

up, 30 min cycling,

15 min cooling

down)

CG (n = 50): interven-

tion not speciﬁed

Disability (QBPDS) Disability (QBPDS): NC No signiﬁcant in-

crease of pain

intensity in

SG (P = .109);

signiﬁcant

increase in CG

(P<.001)

No between-group

dierences

calculated with

respect to LBP

Exercise during the

second half of

the pregnancy

prevented the

increase of pain

intensity

Results

Abbreviations: ADL, activities of daily living; CBRG, Cochrane Back Review Group; CG, control group; DRI, Disability Rating Index; FABQ, Fear-Avoidance

Beliefs Questionnaire; KEBK, pain questionnaire; LBP, pregnancy-related low back pain; LBPE, land-based physical exercise program; NC, not able to

calculate eect sizes due to missing data; NRS, numeric rating scale; PGP, pregnancy-related pelvic girdle pain; PPP, pregnancy-related pelvic pain; QBPDS,

Quebec Back Pain Disability Scale; RMDQ, Roland-Morris Disability Questionnaire; SG, study group; VAS, visual analog scale; WA, water aerobics.

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A10 | july 2014 | volume 44 | number 7 | journal of orthopaedic & sports physical therapy

ONLINE TABLES

TABLE 3 Description of the 5 Studies (n = 360) Using Manual Therapy

Results

Study

Risk of Bias

(CBRG)

Study

Sample Intervention

Outcome

Measure/Group Eect Size

Within-Group

Dierences

Between-Group

Dierences Conclusion

Licciardone

et al26

8/11 146 pregnant

women

(gestation

weeks

30-39)

UOBC+OMT (n =

49): soft tissue

techniques;

myofascial release;

muscle energy;

range-of-motion

mobilization; no

high-velocity, low-

amplitude thrusts,

for 7 visits between

gestation weeks

30-39

UOBC+SUT (n = 48):

sham ultrasound

treatment, for 7

visits between

gestation weeks

30-39

UOBC only (n = 49)

Pain (NRS)

Disability (RMDQ)

Pain (NRS): UOBC+OMT,

0.14; UOBC+SUT, 0.00;

UOBC only, –0.13

Disability (RMDQ):

UOBC+OMT, –0.13;

UOBC+SUT, –0.34;

UOBC only, –0.98

Back pain de-

creased with

UOBC+OMT

Back pain

remained un-

changed with

UOBC+SUT

Back pain

increased with

UOBC only

RMDQ score

increased in all

groups

Back pain: between-

group dierences

were not statisti-

cally signiﬁcant

RMDQ score

increased to

a signiﬁcantly

lesser extent

with UOBC+OMT

(P<.01)

OMT slows or halts

the deterioration

of back-speciﬁc

functioning

during third

trimester of

pregnancy

Evidence for reduc-

tion of back pain

by OMT is not as

conclusive as it is

for back-speciﬁc

functioning

Table continues on page A11.

Results

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journal of orthopaedic & sports physical therapy | volume 44 | number 7 | july 2014 | A11

ONLINE TABLES

TABLE 3 Description of the 5 Studies (n = 360) Using Manual Therapy (continued)

Results

Study

Risk of Bias

(CBRG)

Study

Sample Intervention

Outcome

Measure/Group Eect Size

Within-Group

Dierences

Between-Group

Dierences Conclusion

Peterson et

al35

6/11 57 pregnant

women

with LBP

NET (n = 20):

combination of

desensitization

procedures, ele-

ments of 5-element

Chinese medicine,

and chiropractic

medicine to

address cognitive

distortions

SMT (n = 15):

high-velocity, low-

amplitude thrusts

for hypomobile

joints; stabilizing by

creating a fulcrum

with patient lying on

padded blocks for

hypermobile joints

EX (as control) (n =

22): 15 min of home

exercises, 5 times

per wk for low back

stability, ﬂexibility,

and strength of pel-

vic ﬂoor, according

to a booklet);

instruction on pos-

tural and movement

patterns (booklet);

additional individu-

alized stretching

and strengthening

exercises

The treatment

schedule paralleled

the prenatal care

schedule (once

monthly until 28 wk

of gestation; twice

monthly until 36 wk

of gestation; and

weekly thereafter)

Pain (NRS)

Disability (RMDQ)

Pain (NRS): NET, 0.57;

SMT, 1.45; EX, 1.00

Disability (RMDQ): NET,

0.97; SMT, 1.12; EX,

0.94

Clinically mean-

ingful improve-

ment in NET,

SMT, and EX in

function and

pain intensity

No between-group

dierences

detected as

statistically

signiﬁcant

SMT and EX gener-

ally performed

slightly better

than NET for im-

proving function

and decreasing

pain

All 3 interventions

need further

investigation

Table continues on page A12.

Results

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A12 | july 2014 | volume 44 | number 7 | journal of orthopaedic & sports physical therapy

ONLINE TABLES

TABLE 3 Description of the 5 Studies (n = 360) Using Manual Therapy (continued)

Results

Study

Risk of Bias

(CBRG)

Study

Sample Intervention

Outcome

Measure/Group Eect Size

Within-Group

Dierences

Between-Group

Dierences Conclusion

Field et al10 4/11 84 depressed

pregnant

women

(gestation

weeks

18-24)

MT (n = 28): 20 min of

massage twice per

wk during 16 wk

PMR (n = 28): instruc-

tion on progressive

muscle relaxation,

twice per wk at

home for 16 wk

SPC (n = 28): standard

prenatal care only

CG (n = 28): nonde-

pressed women

Pain (VITAS for back

pain)

Pain (VITAS for leg

pain)

Anxiety (STAI)

Mood states

(POMS)

Pain (VITAS for back

pain): NC

Pain (VITAS for leg pain):

Anxiety (STAI): NC

Mood states (POMS): NC

MT decreased leg

and back pain

(P<.001)

MT signiﬁcantly

increased

serotonin and

dopamine

levels and

decreased

cortisol and

norepineph-

rine levels

(P<.05)

Lower levels of

anxiety and

depression in

MT (P<.001)

No statistics about

dierences

between groups

mentioned

MT is eective for

reducing preg-

nant women’s

stress hormones,

stressful mood

states, leg pain,

and back pain

Field et al12 3/11 26 pregnant

women

(gestation

weeks

14-30)

MT (n = 14): 20 min

of massage, twice

per wk during 5 wk

(head, neck, back,

arms, hands, legs,

and feet in sidelying

position)

PMR (n = 12): instruc-

tion on progressive

muscle relaxation in

sidelying position.

Conducted by

participants at

home, twice per wk

during 5 wk

Pain (VITAS for back

pain)

Pain (VITAS for leg

pain)

Anxiety (STAI)

Mood (POMS-D)

Sleep scale

Stress hormone

levels (urine

samples)

Pain (VITAS for back

pain): NC

Pain (VITAS for leg pain):

Anxiety (STAI): NC

Mood (POMS-D): NC

Sleep scale: NC

Stress hormone levels

(urine samples): NC

Signiﬁcant

improvement

of mood

(P<.05), sleep

disturbance

(P<.05), and

back pain

(P<.01) and

signiﬁcantly

decreased nor-

epinephrine

levels (P<.01)

in MT

Signiﬁcant

decrease of

anxiety (P<.01)

and leg pain

(P<.05) after

ﬁrst session in

both groups

Signiﬁcant

dopamine-

level increase

in both groups

(P<.01 in MT,

P<.05 in PMR)

No statistics about

dierences

between groups

mentioned

MT is eective

for reduc-

ing pregnant

women’s anxiety

levels, stress

hormones, sleep

disturbance, and

back pain

Table continues on page A13.

Results

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journal of orthopaedic & sports physical therapy | volume 44 | number 7 | july 2014 | A13

ONLINE TABLES

TABLE 3 Description of the 5 Studies (n = 360) Using Manual Therapy (continued)

Results

Study

Risk of Bias

(CBRG)

Study

Sample Intervention

Outcome

Measure/Group Eect Size

Within-Group

Dierences

Between-Group

Dierences Conclusion

Field et al11 2/11 47 depressed

pregnant

women

(gestation

weeks

14-27)

MG (n = 47): 20 min

of massage, twice

weekly from part-

ners, from 20 wk of

gestation until the

end of pregnancy

CG: no intervention

Pain (VITAS for back

pain)

Pain (VITAS for leg

pain)

Anxiety (STAI)

Anger (STAXI)

Depression (CES-D)

Relationship with

partner

Pain (VITAS for back

pain): MG, 1.24; CG,

0.53

Pain (VITAS for leg pain):

MG, 0.83; CG, 0.31

Anxiety (STAI): MG, 1.24;

CG, 0.36

Anger (STAXI): MG, 0.38;

CG, 0.17

Depression (CES-D): MG,

0.52; CG, 0.27

Relationship with partner:

MG, –0.37; CG, 0.05

Women in MG:

signiﬁcantly

decreased leg

and back pain

(both, P<.001);

signiﬁcantly

decreased

depression,

anxiety, and

anger (all,

P<.001); and

signiﬁcantly

improved

relationship

with partner

(P<.01)

All outcomes

decreased and

improved more

than in CG, but

no statistics

about dierences

between groups

were mentioned

Not only mood

states but also

relationships im-

proved mutually

when depressed

pregnant women

were massaged

by their partners

Results

Abbreviations: CBRG, Cochrane Back Review Group; CES-D, Centre for Epidemiological Studies-Depression Scale; CG, control group; EX, exercise; MG,

massage group; MT, massage treatment; NC, not able to calculate eect sizes due to missing data; NET, neuro-emotional technique; NRS, numeric rating scale;

OMT, osteopathic manipulative treatment; PMR, progressive muscle relaxation; POMS, Proﬁle of Mood States Scale; POMS-D, Proﬁle of Mood States

Depression Scale; RMDQ, Roland-Morris Disability Questionnaire; SMT, spinal manipulative therapy; SPC, standard prenatal care; STAI, State-Trait

Anxiety Inventory; STAXI, State-Trait Anger Expression Inventory; SUT, sham ultrasound treatment; UOBC, usual obstetric care; VITAS, visual analog scale

anchored with 5 faces.

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A14 | july 2014 | volume 44 | number 7 | journal of orthopaedic & sports physical therapy

ONLINE TABLES

TABLE 4 Description of the Study (n = 115) Using Material Support

Results

Study

Risk of Bias

(CBRG)

Study

Sample Intervention Outcome Measures Eect Size

Within-Group

Dierences

Between-Group

Dierences Conclusion

Kalus

et al19

6/11 115 pregnant

women

SG (n = 55): wearing

a BellyBra for 3

wk (frequency

not speciﬁed). A

BellyBra is a nylon/

spandex undergar-

ment, worn like a

vest. It has a 1-way

stretch panel across

the thoracolumbar

back, designed to

provide support

and assisted by

the involvement of

shoulder straps, to

improve posture. A

wide elastic band

sits below the abdo-

men, supporting

the uterus and

lifting weight o the

pelvis

CG (n = 60): wearing

a Tubigrip for 3

wk (frequency

not speciﬁed). A

Tubigrip is a more

generic form of

support, worn as

a double layer,

extending from the

midthoracic spine

to the sacral spine

and pelvis

Pain (VAS)

Disability, physical

activity (Likert

scores where 0

is never aected

and 10 is always

aected)

SWLS

Pain (VAS): SG, 0.73;

Tubigrip CG, 0.65

Disability: SG sleeping,

1.13; CG sleeping, 0.35;

SG getting up, 0.89;

CG getting up, 0.55;

SG sitting down, 0.83;

CG sitting down, 0.54;

SG sitting, 0.52; CG sit-

ting, 0.22; SG walking,

0.82; CG walking, 0.38;

SG working, 0.96; CG

working, 0.43; SG

overall impact on daily

activities, 0.78; CG

overall impact on daily

activities, 0.47

SWLS: SG, 0.31; CG, 0.47

In both groups,

signiﬁcantly

less pain

(P = .001 and

P = .003). No

signiﬁcant

change in

SWLS

No dierence

between groups

regarding pain

reduction. In the

SG, pain had

signiﬁcantly

less impact on

sleeping (P =

.007), getting up

from sitting (P =

.02), sitting down

(P = .04), walking

(P = .001), and

working (P = .04)

than in the CG

BellyBra can be

recommended

as a method of

treatment for

PGP

Results

Abbreviations: CBRG, Cochrane Back Review Group; CG, control group; PGP, pregnancy-related pelvic girdle pain; SG, study group; SWLS, satisfaction with

life scale; VAS, visual analog scale.

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journal of orthopaedic & sports physical therapy | volume 44 | number 7 | july 2014 | A15

SEARCH STRATEGY

1. pregnancy or gestation or gravidity or expecting or pregnant or prepartum [Text Word]

2. low back pain or back pain or posterior pelvic pain or peripartum posterior pelvic pain or pregnancy-related pelvic joint pain or pregnancy-related

pelvic girdle pain or peripartum pelvic pain or pelvic girdle relaxation

3. SI-joint or sacroiliac or pubic symphysis or sacroiliac or lumbar or lumbopelvic or lumbosacral [Text Word]

4. SI-joint or pubic symphysis or pelvic ring or pelvis or lumbar or lumbopelvic or lumbosacral or sacroiliac or pelvic capsule or pelvic ligaments or

lumbar vertebrae

5. #1 AND (#2 OR #3 OR #4)

6. randomized controlled trial [Publication Type]

7. double blind

8. single blind

9. placebo

10. clinical trial [Publication Type]

11. controlled clinical trial [Publication Type]

12. cohort OR survey [Publication Type]

13. ((((((#6) OR #7) OR #8) OR #9 OR #10) OR #11) OR #12)

14. intervention OR treatment OR manipulation OR manipulative OR mobilisation OR mobilization

15. manual therapy OR physical therapy OR manipulative therapy OR manual physical therapy OR treatment OR spinal manipulation OR passive move-

ment OR chiropractic OR osteopathic

16. exercise OR training OR relaxation OR stabilisation OR stabilization OR strength OR stabilising exercise OR stabilizing exercise OR stretching OR

coordination

17. ((#14) OR #15) OR #16

18. (#5) AND #17

19. (#13) AND #18

(Last performed on November 28, 2013.)

APPENDIX

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Effects of Exercise on Lumbopelvic Pain During Pregnancy: A Systematic Review and Meta-analysis

Article

Jan 2023
J Womens Health Phys Therap

At least 50% of women experience lumbopelvic pain during pregnancy. Physical activity has moderate health benefits and no adverse outcomes for women with uncomplicated pregnancies. Physically active pregnant women have lower pain intensities than sedentary women. It is not clear whether common exercise types are equally beneficial for the management of lumbopelvic pain during pregnancy. The aim of this systematic review is to determine the effect of exercise on reducing lumbopelvic pain intensity in pregnant women. A systematic review and meta-analysis. Seven databases (CINAHL, Medline, ScienceDirect, SportDiscus, ProQuest, Google Scholar, and Cochrane) were searched in October 2020 and again in February 2022. Studies investigating the effect of exercise on low back or pelvic pain in pregnant women were included, with no limitation on publication date. Primary data collected for quantitative analysis included pain intensity. Bias was assessed using the Cochrane bias tool. A meta-analysis was performed using individual study effect sizes (ES) using a random-effects model. Initial search yielded 1,771 results and 21 articles were identified as meeting the inclusion criteria. One article utilized 2 intervention groups and was counted as separate studies. Meta-analysis on 22 studies yielded a statistically significant and large ES, indicating exercise intervention during pregnancy results in significantly lower pain reports compared with usual prenatal care (overall ES = 2.07; 95% confidence interval = 1.35-2.78; P < .001). Exercise is beneficial in the management of lumbopelvic pain in pregnant women.

Community-based non-pharmacological interventions for improving pain, disability, and quality of life in pregnant women with musculoskeletal conditions: a systematic review

Preprint

Full-text available

Feb 2023

Background Majority of pregnant women experience pain and discomfort due to musculoskeletal conditions; with over a quarter experiencing some disability; all of which reduce quality of life during pregnancy. Community-based non-pharmacological interventions are more affordable, accessible, and acceptable, and have the capacity to reduce inequalities. Objectives To summarise community-based non-pharmacological interventions and determine their effectiveness for improving pain, disability, and quality of life amongst pregnant women with musculoskeletal conditions. Search Strategy Twelve bibliographic databases (and reference list of relevant systematic reviews) were searched from inception until March 2022. Selection Criteria All primary studies of community-based non-pharmacological interventions for pregnant women with musculoskeletal conditions reported in English which investigated pain, disability and quality of life were included. Data Collection and Analysis Data were extracted using modified Cochrane’s data extraction template. Studies were appraised using Cochrane Collaboration’s risk of bias tool. Narrative synthesis was used to summarise findings. This review registration number with PROSPERO is CRD42020189535. Main Results 33 studies involving 4,930 pregnant women with low back pain, pelvic pain, and lumbopelvic pain. Osteopathic manipulation plus standard obstetric care produced significantly superior reduction in pain intensity and disability than sham ultrasound therapy plus standard obstetric care amongst pregnant women with low back pain (moderate level of evidence). There was limited or conflicting evidence for other results. Acupuncture was more effective than placebo in reducing disability/sick leave but not pain intensity and quality of life. There was little or no added benefit of craniosacral therapy to standard obstetric care. Exercise and spinal manipulative therapy were equally effective, and better than no treatment. Home versus in-clinic exercise and aquatic versus land-based exercise were similar in effectiveness with conflicting evidence when compared with standard obstetric care. Wide flexible lumbopelvic belts or the addition of textured sacral pad was better than thin rigid lumbopelvic belts, belts without padding, or no belt. Kinesiotaping may not be better than placebo. Effectiveness of self-management programmes was inconsistent. Conclusions Community-based non-pharmacological interventions were better than no treatment and were better or as effective as standard obstetric care in improving pain intensity, disability, and quality of life.

Cognizance Amongphysiotherapy Clinicians and Students in Pelvic Girdle Dysfunction-Qualitative Analysis

Article

Full-text available

Feb 2023

Low back pain of pelvic girdle dysfunction origin is most prevalent among all age group,hence there is constant need of updates in diagnosis and therapeutic approaches,manual physiotherapy gained an adequate importance in addressing pelvic girdle dysfunctions,with an objective of understanding the awareness of pelvic girdle dysfunctions among the clinicians and students, a self-administered questionnaire was designed and administered in pre-conference workshop pelvic girdle dysfunction dogmas in diagnosis and approach at SRM college of physiotherapy SRM Institute of Science and technology Chennai India,based on the response and through the statistical analysis it was found that the awareness was lacking and there was also need to focus on the clinicians and student community towards pelvic girdle dysfunctions and its basics, this may be beneficial in enhancing better patient care services and evidence in framing up clinical practice.

Lifestyle and Chronic Pain in the Pelvis: State of the Art and Future Directions

Article

Full-text available

Nov 2021

During their lifespan, many women are exposed to pain in the pelvis in relation to menstruation and pregnancy. Such pelvic pain is often considered normal and inherently linked to being a woman, which in turn leads to insufficiently offered treatment for treatable aspects related to their pain experience. Nonetheless, severe dysmenorrhea (pain during menstruation) as seen in endometriosis and pregnancy-related pelvic girdle pain, have a high impact on daily activities, school attendance and work ability. In the context of any type of chronic pain, accumulating evidence shows that an unhealthy lifestyle is associated with pain development and pain severity. Furthermore, unhealthy lifestyle habits are a suggested perpetuating factor of chronic pain. This is of specific relevance during lifespan, since a low physical activity level, poor sleep, or periods of (di)stress are all common in challenging periods of women’s lives (e.g., during menstruation, during pregnancy, in the postpartum period). This state-of-the-art paper aims to review the role of lifestyle factors on pain in the pelvis, and the added value of a lifestyle intervention on pain in women with pelvic pain. Based on the current evidence, the benefits of physical activity and exercise for women with pain in the pelvis are supported to some extent. The available evidence on lifestyle factors such as sleep, (di)stress, diet, and tobacco/alcohol use is, however, inconclusive. Very few studies are available, and the studies which are available are of general low quality. Since the role of lifestyle on the development and maintenance of pain in the pelvis, and the value of lifestyle interventions for women with pain in the pelvis are currently poorly studied, a research agenda is presented. There are a number of rationales to study the effect of promoting a healthy lifestyle (early) in a woman’s life with regard to the prevention and management of pain in the pelvis. Indeed, lifestyle interventions might have, amongst others, anti-inflammatory, stress-reducing and/or sleep-improving effects, which might positively affect the experience of pain. Research to disentangle the relationship between lifestyle factors, such as physical activity level, sleep, diet, smoking, and psychological distress, and the experience of pain in the pelvis is, therefore, needed. Studies which address the development of management strategies for adapting lifestyles that are specifically tailored to women with pain in the pelvis, and as such take hormonal status, life events and context, into account, are required. Towards clinicians, we suggest making use of the window of opportunity to prevent a potential transition from localized or periodic pain in the pelvis (e.g., dysmenorrhea or pain during pregnancy and after delivery) towards persistent chronic pain, by promoting a healthy lifestyle and applying appropriate pain management.

The Effect of Pregnancy Exercises on Low Back Pain in Pregnant Women

Article

Full-text available

May 2022

Low back pain is common in pregnancy with varying reported incidences. Low back pain is back pain that occurs in the lumbosacral region. In general, back pain that occurs in pregnant women is influenced by several factors, namely changes in body posture during pregnancy, low back pain usually increases with parity. The risk of back pain in pregnancy is increased in women who have previously had back pain and are overweight. National guidelines recommend that healthy pregnant women should do light physical exercise every day. Most women reduce physical activity during pregnancy and only a few studies have found that pregnant women are physically active during pregnancy.The purpose of this study was to determine the effect of Pregnancy Exercises on Back Pain in Pregnant Women. The method in this study is a literature review, which tries to explore how the effect. The results in this study indicate that the results of 8 previous studies indicate that there is a significant effect of Pregnancy Exercises on Back Pain in Pregnant Women. The conclusion in this study is that of Pregnancy Exercises can reduce Back Pain in Pregnant Women. Pregnancy exercise or exercise can provide benefits to maintain and improve the physical health of pregnant women, improve blood circulation, reduce complaints of cramps or aches, and prepare for breathing, muscle and pelvic activity to face the labor process. Pregnancy exercise has very important benefits for pregnant women.

Therapeutic Exercise Regarding Musculoskeletal Health of the Pregnant Exerciser and Athlete

Chapter

Oct 2022

Physical activity during pregnancy is recommended and has been shown to benefit most women. However, some modifications to exercise routines may be necessary due to normal anatomic and physiologic changes and fetal requirements. Therefore, knowledge about the systemic changes of pregnancy should be considered when counseling women who wish to exercise through their pregnancy and should be complemented by the knowledge about the potential effect of exercise (therapeutic exercise) for the prevention and resolution of some common pregnancy-related musculoskeletal conditions. Therapeutic exercise is the systematic and planned performance of exercises that aims to improve and restore physical function.This chapter presents the scientific evidence foundation on the effect of therapeutic exercises on the prevention and resolution of three commonly pregnancy-related musculoskeletal conditions: pelvic floor dysfunction, diastasis recti abdominis, and low back and pelvic girdle pain. The chapter emphasizes the potential effect of exercise on the prevention and resolution of these musculoskeletal conditions and provides useful information when tailoring therapeutic exercise programs for pregnant women.KeywordsPregnancyDiastasis recti abdominisLow back painPelvic girdle painPelvic floor musclesUrinary incontinence

Effectiveness of Physical Therapy for the Correction of Limitation of Life Activity due to Combined Low Back Pain and Pelvic Girdle Pain in Women with Dorsopathy of Pregnancy in the Postpartum Period

Article

Mar 2022

The purpose of the study was to evaluate the effectiveness of the developed program of physical therapy in terms of the dynamics of clinical indicators characterizing the limitation of life activity due to the syndrome of combined lower back pain and pelvic girdle pain in women with dorsopathy of pregnancy in the postpartum period. Materials and methods. 29 women in the postpartum period with combined pain syndrome in the lumbar region and pelvis were examined. They were divided into 2 groups. The control group consisted of 14 women who corrected pain with non-steroidal anti-inflammatory drugs orally and locally. The comparison group consisted of 15 women who underwent a developed program of physical therapy (therapeutic exercises, massage, proprioceptive neuromuscular facilitation, kinesio taping, patient education). The intensity of pain was determined on a visual analog scale at rest and on movements, the degree of disability was determined according to the Oswestry Disability Index, Pelvic Girdle Questionnaire, Pregnancy Mobility Index. Results and discussion. The study showed that in both study groups, after the correction at rest, women actually did not experience pain. However, movement loading revealed that the women in the control group had pain, albeit mild. At the same time, in the group of women who underwent active functional rehabilitation, pain during movements was not actually noted. Improvement in life activity, limited due to lower back pain, according to the Oswestry Disability Index in the control group was 17% compared with the initial result, in the comparison group – 60% (p<0.05). Under the influence of treatment and rehabilitation measures, a statistically significant decrease in the limitation of self-service caused by pelvic girdle pain, according to the Pelvic Girdle Questionnaire, was noted compared with the baseline: in women in the control group it was 31.5%, in the comparison group – 68%. The dynamics of the results of the Pregnancy Mobility Index showed a statistically significant improvement relative to the initial result in both groups of women on the subscales of daily mobility (in the control group – by 34.2%, in the comparison group – by 51.4%), household activity (respectively 21.2 % and 52.9%), mobility outdoors (respectively 20.6% and 58%). Conclusion. It is advisable to prescribe physical therapy means in the complex recovery of women with combined low back pain and pelvic girdle pain in the postpartum period to reduce the limitation of the degree of vital activity

Technical Report

Full-text available

Jan 2015

The aims of this booklet are to increase awareness among all relevant healthcare professionals of Pregnancy-Related Pelvic Girdle Pain (PGP), provide recommendations for a seamless care pathway for women affected by PGP, and to describe the aetiology, risk factors, signs and symptoms with management options throughout pregancy, birth, the postnatal period and beyond.

Myofascial pelvic pain syndrome - Douleurs myofasciales pelvi-périnéales

Chapter

Full-text available

Dec 2021

Jan De Laere

RÉSUMÉ - La douleur pelvienne chronique est un problème en pelvi-périnéologie, qui semble toucher la femme plus que l´homme. Elle est définie par «The American College of Obstetricians and Gynecologists» comme une douleur localisée au niveau de l'abdomen au-dessous de l'ombilic, ainsi que dans les régions pelvienne, lombo-sacrale et fessière, durant depuis au moins 6 mois, qui n'est ni cyclique, ni associée à une lésion organique. Les diagnostics souvent posés sont l'endométriose, le syndrome vésical douloureux (cystite interstitielle), la prostatite chronique, ainsi que les syndromes du muscle élévateur de l'anus et du colon, ou de l'intestin irritable. Le syndrome myofascial pelvien douloureux est caractérisé par une hypertonie musculaire associée à des cordons myalgiques et à des points trigger myofasciaux et se manifeste par une douleur des muscles du plancher pelvien, du périnée et des fascias pelviens voisins. Les points trigger myofasciaux peuvent se développer dans tous les muscles du corps humain, y compris au niveau de la région pelvienne. Ils semblent ici engendrer des sensations référées au niveau de la vessie, de la prostate, du vagin, du rectum, du coccyx, du sacrum, de toute la région pelvienne, du bas du dos, du bas de l'abdomen et de la région postérieure de la cuisse. ABSTRACT - Chronic pelvic pain is a problem in perineology, which seems to affect women more than men. It is defined by "The American College of Obstetricians and Gynecologists" as pain localized in the abdomen below the umbilicus, as well as in the pelvic, lumbosacral, and gluteal regions, lasting for at least 6 months, which is neither cyclic nor associated with an organic lesion. Common diagnoses include endometriosis, painful bladder syndrome (interstitial cystitis), chronic prostatitis, and anal and colonic elevator muscle or irritable bowel syndromes. Painful pelvic myofascial syndrome is characterized by muscle hypertonicity associated with myalgic cords and myofascial trigger points and manifests as pain in the pelvic floor muscles, perineum, and surrounding pelvic fascias. Myofascial trigger points can develop in all muscles of the human body, including the pelvic region. Here they appear to generate referred sensations in the bladder, prostate, vagina, rectum, coccyx, sacrum, entire pelvic region, lower back, lower abdomen, and posterior thigh region.

Best-Practice Recommendations for Chiropractic Care for Pregnant and Postpartum Patients: Results of a Consensus Process

Article

Nov 2021
J MANIP PHYSIOL THER

Objective The purpose of this project was to develop a best-practices document on chiropractic care for pregnant and postpartum patients with low back pain (LBP), pelvic girdle pain (PGP), or a combination. Methods A modified Delphi consensus process was conducted. A multidisciplinary steering committee of 11 health care professionals developed 71 seed statements based on their clinical experience and relevant literature. A total of 78 panelists from 7 countries were asked to rate the recommendations (70 chiropractors and representatives from 4 other health professions). Consensus was reached when at least 80% of the panelists deemed the statement to be appropriate along with a median response of at least 7 on a 9-point scale. Results Consensus was reached on 71 statements after 3 rounds of distribution. Statements included informed consent and risks, multidisciplinary care, key components regarding LBP during pregnancy, PGP during pregnancy and combined pain during pregnancy, as well as key components regarding postpartum LBP, PGP, and combined pain. Examination, diagnostic imaging, interventions, and lifestyle factors statements are included. Conclusion An expert panel convened to develop the first best-practice consensus document on chiropractic care for pregnant and postpartum patients with LBP or PGP. The document consists of 71 statements on chiropractic care for pregnant and postpartum patients with LBP and PGP.

The effect of an exercise program and ergonomic advices in the treatment of pregnancy related low back pain: A randomised controlled clinical trial

Article

Full-text available

Sep 2010

Background and purpose: Low back pain is a common and costly problem in pregnancy. It is one of the main reasons of disability and absence from work with extremly direct and indirect economical impact. Women are more prone to low back pain and pregnancy is one of the predisposition. The purpose of this study was to assess the effect of an exercise program and ergonomic advices on the treatment of low back pain in pregnant women. Materials and methods: Following ethical approval and through a randomized controlled clinical trial, 120 pregnant women with low back pain were recruited into experimental and control groups. The experimental group (n=60) received therapeutic exercise combined with ergonomic advices and the control group (n=60) was given no intervention. Pain experienced by patients was assessed using Visual Analogue Scale and functional disability on Oswestry Low Back Disability Questionnaire after the planned intervention within three months follow-up. Results: Intra-group changes indicated that there was a significant reduction on pain intensity and functional disability in the experimental group (P<0.01 in both instances) but no such difference was found in the control group (P>0.05). Inter-groups changes showed significant improvements in both pain intensity and functional disability following intervention (P<0.01) in the experimental group in comparison with the control group (P<0.01 in both instances). The significance of differences held up within three months follow-up between the two groups (P<0.01 in both instances). Conclusion: Our results demonstrate that therapeutic exercise and ergonomic advices could be considered as effective approaches in the treatment of low back pain during pregnancy. Therefore, we offer regular exercise and ergonomic advices during pregnancy and afterwards in order to prevent and to control low back pain.

Lumbar pain during pregnancy: efficacy of Global Postural Reeducation (GPR) treatment

Article

Full-text available

Jun 2011

A clinical comparative study was carried out to evaluate the effectiveness of Global Postural Reeducation (GPR) in low back pain treatment during pregnancy, and its association with pregnant women functional limitations. The subjects were 34 nulliparous women attended in 3 public health units and 1 private hospital in Campinas. All women were at 20-25 weeks gestation and experiencing low back pain. Seventeen women were submitted to 8 GPR weekly consecutive sessions and 17 followed the routine recommendations for treating lumbar pain. In each GPR session the low back pain severity was assessed, before and after procedures. The control group had 3 low back pain intensity and treatment evaluation sessions (at admission, 4 and 8 weeks). Roland Morris questionnaire was applied in order to assess functional limitations in the beginning and at the end of the study. Women in the GPR group had a significant decrease of low back pain severity, before and after each session. Throughout the study, women in the GPR group had significantly lower pain medians and lower functional limitations score means than women in the control group. Covariance analysis pointed out that GPR treatment was associated to lower perceived pain intensity at the end of the follow-up. It is concluded that GPR can be an important contribution to the low back pain treatment during pregnancy and also it would help to reduce the damage caused by functional limitations. This will certainly has a positive influence upon women's quality of life.

Comparison between the effect of lumbopelvic belt and home based pelvic stabilizing exercise on pregnant women with pelvic girdle pain; A randomized controlled trial

Article

Full-text available

May 2013

Pelvic girdle pain is a common complaint of pregnant women. There are limited data on comparison between the effectiveness of stabilizing exercises and lumbopelvic belt on the treatment of these patients. The objective of this study was to compare the effect of lumbopelvic belt plus information, home based pelvic girdle stabilizing exercises plus information and information alone on pain intensity, functional status and quality of life of pregnant women with pelvic girdle pain. In this randomized clinical trial pregnant women with pelvic girdle pain (n=105) were randomly allocated to three groups; Control group (n=35) that received general information, exercise group (n=31) that in addition to general information were asked to perform specific pelvic stabilizing exercises at home and belt group (n=31) that received non-rigid lumbopelvic belt and the information. The primary outcome variables were pain intensity and functional status of the participants which were measured using visual analogue scale and Oswestry Disability Index (ODI) respectively. Quality of life of participants was measured using WHOQOL-BREF questionnaire. All measurements were performed at baseline, 3 and 6 weeks after the study conduction. The pain intensity of patients in belt group in comparison to other groups was decreased significantly at both 3 and 6 weeks follow-ups. The mean score of ODI of patients in belt group was also improved more than exercise and control groups significantly. On base of our results, it can be found that in short term lumbopelvic belt and information in treatment of pregnant women with pelvic girdle pain is superior to exercise plus information or information alone.

Physical exercise during pregnancy: A systematic review

Article

Full-text available

Sep 2012

Purpose of review: This review aims to provide an update on the recent evidence concerning exercise during pregnancy including effects for mother and fetus and the types, frequency, intensity, duration and rate of progression of exercise performed. Recent findings: Exercises during pregnancy are associated with higher cardiorespiratory fitness, prevention of urinary incontinence and low back pain, reduced symptoms of depression, gestational weight gain control, and for cases of gestational diabetes, reduced number of women who required insulin. There is no association with reduction in birth weight or preterm birth rate. The type of exercise shows no difference on results, and its intensity should be mild or moderate for previous sedentary women and moderate to high for active women. The exercise recommendations still are based on the current guidelines on moderate-intensity, low-impact, aerobic exercise at least three times a week. Yet, new guidelines propose increasing weekly physical-activity expenditure while incorporating vigorous exercise and adding light strength training to the exercise routine of healthy pregnant women. In the case of other chronic diseases like hypertension, there are still few data, and therefore more studies should be performed to assess the safety of the intervention. Summary: Physical exercise is beneficial for women during pregnancy and also in the postpartum period; it is not associated with risks for the newborn and can lead to changes in lifestyle that imply long-term benefits.

A pilot randomized controlled trial comparing the efficacy of exercise, spinal manipulation, and neuro emotional technique for the treatment of pregnancy-related low back pain

Article

Full-text available

Jun 2012

This pilot randomized controlled trial evaluated the feasibility of conducting a full scale study and compared the efficacy of exercise, spinal manipulation, and a mind-body therapy called Neuro Emotional Technique for the treatment of pregnancy-related low back pain, a common morbidity of pregnancy. Healthy pregnant women with low back pain of insidious onset were eligible to enroll in the study at any point in their pregnancy. Once enrolled, they remained in the study until they had their babies. Women were randomly allocated into one of three treatment groups using opaque envelopes. The treatment schedule paralleled the prenatal care schedule and women received individualized intervention. Our null hypothesis was that spinal manipulation and Neuro Emotional Technique would perform no better than exercise in enhancing function and decreasing pain. Our primary outcome measure was the Roland Morris Disability Questionnaire and our secondary outcome measure was the Numeric Pain Rating Scale. Intention to treat analysis was conducted. For the primary analysis, regression was conducted to compare groups on the outcome measure scores. In a secondary responder analysis, difference in proportions of participants in attaining 30% and 50% improvement were calculated. Feasibility factors for conducting a future larger trial were also evaluated such as recruitment, compliance to study protocols, cost, and adverse events. Fifty-seven participants were randomized into the exercise (n = 22), spinal manipulation (n = 15), and Neuro Emotional Technique (n = 20) treatment arms. At least 50% of participants in each treatment group experienced clinically meaningful improvement in symptoms for the Roland Morris Disability Questionnaire. At least 50% of the exercise and spinal manipulation participants also experienced clinically meaningful improvement for the Numeric Pain Rating Scale. There were no clinically meaningful or statistically significant differences between groups in any analysis. This pilot study demonstrated feasibility for recruitment, compliance, safety, and affordability for conducting a larger study in the future. Spinal manipulation and exercise generally performed slightly better than did Neuro Emotional Technique for improving function and decreasing pain, but the study was not powered to detect the between-group differences as statistically significant. Trial registration ClinicalTrials.gov (Identifier: NCT00937365).

Lombalgia durante a gestação: eficácia do tratamento com Reeducação Postural Global (YOGA)

Article

Jan 2011

Validity of measurements. In: Foundations of clinical research. Applications to practice

Article

Jan 1993

Interventions for preventing and treating pelvic and back pain in pregnancy

Article

Aug 2013

More than two-thirds of pregnant women experience low-back pain (LBP) and almost one-fifth experience pelvic pain. Pain increases with advancing pregnancy and interferes with work, daily activities and sleep. To assess the effects of interventions for preventing and treating pelvic and back pain in pregnancy. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (18 July 2012), identified related studies and reviews from the Cochrane Back Review Group search strategy to July 2012, and checked reference lists from identified reviews and studies. Randomised controlled trials (RCTs) of any treatment to prevent or reduce the incidence or severity of pelvic or back pain in pregnancy. Two review authors independently assessed risk of bias and extracted data. Quality of the evidence for outcomes was assessed using the five criteria outlined by the GRADE Working Group. We included 26 randomised trials examining 4093 pregnant women in this updated review. Eleven trials examined LBP (N = 1312), four examined pelvic pain (N = 661), and 11 trials examined lumbo-pelvic (LBP and pelvic) pain (N = 2120). Diagnoses ranged from self-reported symptoms to the results of specific tests. All interventions were added to usual prenatal care and unless noted, were compared to usual prenatal care. For LBP, there was low-quality evidence that in general, the addition of exercise significantly reduced pain (standardised mean difference (SMD) -0.80; 95% confidence interval (CI) -1.07 to -0.53; six RCTs, N = 543), and disability (SMD -0.56; 95% CI -0.89 to -0.23; two RCTs, N = 146); and water-based exercise significantly reduced LBP-related sick leave (risk ratio (RR) 0.40; 95% CI 0.17 to 0.92; one RCT, N = 241). Low-quality evidence from single trials suggested no significant difference in pain or function between two types of pelvic support belt, between osteopathic manipulation (OMT) and usual care or sham ultrasound (sham US). Very low-quality evidence suggested that a specially-designed pillow may relieve night pain better than a regular pillow. For pelvic pain, there was moderate-quality evidence that acupuncture significantly reduced evening pain better than exercise; both were better than usual care. Low-quality evidence from single trials suggested that adding a rigid belt to exercise improved average pain but not function; acupuncture was significantly better than sham acupuncture for improving evening pain and function, but not average pain; and evening pain relief was the same following either deep or superficial acupuncture. For lumbo-pelvic pain, there was moderate-quality evidence that an eight- to 20-week exercise program reduced the risk of women reporting lumbo-pelvic pain (RR 0.85; 95% CI 0.73 to 1.00; four RCTs, N = 1344); but a 16- to 20-week training program was no more successful than usual care at preventing pelvic pain (one RCT, N = 257). Low-quality evidence suggested that exercise significantly reduced lumbo-pelvic-related sick leave (RR 0.76; 95% CI 0.62 to 0.94, two RCTs, N = 1062), and improved function. Low-quality evidence from single trials suggested that OMT significantly reduced pain and improved function; either a multi-modal intervention that included manual therapy, exercise and education (MOM) or usual care significantly reduced disability, but only MOM improved pain and physical function; acupuncture improved pain and function more than usual care or physiotherapy; pain and function improved more when acupuncture was started at 26- rather than 20- weeks' gestation; and auricular (ear) acupuncture significantly improved these outcomes more than sham acupuncture.When reported, adverse events were minor and transient. Moderate-quality evidence suggested that acupuncture or exercise, tailored to the stage of pregnancy, significantly reduced evening pelvic pain or lumbo-pelvic pain more than usual care alone, acupuncture was significantly more effective than exercise for reducing evening pelvic pain, and a 16- to 20-week training program was no more successful than usual prenatal care at preventing pelvic or LBP. Low-quality evidence suggested that exercise significantly reduced pain and disability from LBP.There was low-quality evidence from single trials for other outcomes because of high risk of bias and sparse data; clinical heterogeneity precluded pooling. Publication bias and selective reporting cannot be ruled out.Physiotherapy, OMT, acupuncture, a multi-modal intervention, or the addition of a rigid pelvic belt to exercise seemed to relieve pelvic or back pain more than usual care alone. Acupuncture was more effective than physiotherapy at relieving evening lumbo-pelvic pain and disability and improving pain and function when it was started at 26- rather than 20-weeks' gestation, although the effects were small.There was no significant difference in LBP and function for different support belts, exercise, neuro emotional technique or spinal manipulation (SMT), or in evening pelvic pain between deep and superficial acupuncture.Very low-quality evidence suggested a specially-designed pillow may reduce night-time LBP.Further research is very likely to have an important impact on our confidence in the estimates of effect and is likely to change the estimates. Future research would benefit from the introduction of an agreed classification system that can be used to categorise women according to presenting symptoms.

Treatment of Pregnancy-Related Lumbar and Pelvic Girdle Pain by the Yoga Method: A Randomized Controlled Study

Article

Mar 2013
J ALTERN COMPLEM MED

Objective: Pregnancy-related lumbopelvic pain is a major problem for the majority of pregnant women. Complementary medicine has been used to alleviate pain, and yoga is one of the most commonly chosen alternative methods. The objective of this study was to assess the effectiveness of Hatha yoga in the reduction of lumbopelvic pain in pregnancy. Methods: A randomized controlled trial with 60 pregnant women (age range, 14-40 years) who reported lumbopelvic pain at 12 to 32 weeks of gestation was conducted from June 2009 to June 2011. Pregnant women who had twin pregnancies, had medical restrictions for exercise, used analgesics, and participated in physical therapy were excluded from the study. Pregnant women were divided into two groups: the yoga group, practicing exercises guided by this method, and the postural orientation group, performing standardized posture orientation according to instructions provided in a pamphlet. Treatment in each group lasted 10 weeks. A visual analog scale (VAS) was used to measure pain intensity. Lumbar pain and posterior pelvic pain provocation tests were used to confirm the presence of pain. Statistical analysis included the Mann-Whitney test, the McNemar test, a paired Wilcoxon test, and analysis of covariance. Results: The median pain score was lower in the yoga group (p<.0058) than the postural orientation group. Lumbar pain provocation tests showed a decreased response in relation to posterior pelvic pain provocation tests and a gradual reduction in pain intensity during 10 yoga sessions (p<.024). Conclusions: The yoga method was more effective at reducing lumbopelvic pain intensity compared with postural orientation.

A randomized controlled trial comparing a multimodal intervention and standard obstetrics care for low back and pelvic pain in pregnancy

Article

Oct 2012

Objective: Women commonly experience low back pain during pregnancy. We examined whether a multimodal approach of musculoskeletal and obstetric management (MOM) was superior to standard obstetric care to reduce pain, impairment, and disability in the antepartum period. Study design: A prospective, randomized trial of 169 women was conducted. 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. Results: The MOM group demonstrated significant mean reductions in Numerical Rating Scale scores (5.8 ± 2.2 vs 2.9 ± 2.5; P < .001) and Quebec Disability Questionnaire scores (4.9 ± 2.2 vs 3.9 ± 2.4; P < .001) from baseline to follow-up evaluation. The group that received standard obstetric care demonstrated no significant improvements. Conclusion: A multimodal approach to low back and pelvic pain in mid pregnancy benefits patients more than standard obstetric care.

Recommendations for Physical Therapists on the Treatment of Lumbopelvic Pain During Pregnancy: A Systematic Review

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