Chiropractic Care for Postpartum Pelvic Girdle Pain
and Low Back Pain: A Case ReportThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: J Clinical Chiropractic Pediatrics 2011 (Dec); 12 (2): 910–914 ~ FULL TEXT
Karen Gregory, BAppSc(Chiro) and Robert Rowell, DC, MS
Private practice,
Blackburn, Victoria, Australia
kazgregory@yahoo.com
Background: It has been documented that between 50% to 80% of pregnant women suffer from low back pain. While pregnancy related pelvic girdle pain may be considered a “normal” part of pregnancy, it does not mean that there are no options for the patient both during and after pregnancy to help alleviate any discomfort.
Objective: This case describes the chiropractic care of a postpartum woman with pelvic girdle / low back pain.
Clinical Features: A 33-year-old, 3-month postpartum female presented for chiropractic care to help resolve her pelvic girdle / low back pain which she had suffered from since the birth of her daughter. She experienced pain in the left hip daily which was aggravated by bathing and lifting her daughter.
Intervention: A thorough physical and neurological examination was performed. Chiropractic adjustments consisting of Thompson, Activator, and Diversified techniques along with myofascial release of both round ligaments were given.
Outcome: Complete resolution of her pelvic girdle/low back pain.
Conclusion: There have been many risk factors documented for the cause of pregnancy related pelvic girdle or low back pain, and a number of quality of life consequences as a result. This paper illustrates the case of a patient who experienced resolution of her discomfort while under chiropractic care.
Key words: chiropractic, postpartum, pregnancy related, low back pain, pelvic girdle pain
From the FULL TEXT Article
Introduction
Between 50% to 80% of pregnant women suffer from low back pain (LBP). [1] While back/pelvic girdle pain is often considered to be a normal consequence of pregnancy, it can have a significant impact on the quality of life of the patient as it can “disturb sleep, prevent women from going to work and interfere with ordinary daily activities such as carrying, cleaning, even sitting and walking.” [2]
A study conducted by Stepleton et al reported that over two-thirds (68%) of the subjects they reviewed continued to experience recurrent LBP after completing their pregnancies. [3] To and Wong reported that the “incidence of persistent back pain symptoms after pregnancy varied, from the disappearance of pain within 2 days of delivery for over 60%, to as high as 82% experiencing persistent pain at 18 months and that there was an overall incidence of around 21% still with pain at 2 years after delivery.” [4] Ostgaard et al noted that postpartum pregnancy related pelvic girdle pain (PPP) spontaneously disappeared within 3 months in 93% of cases, and that 7% who do not recover have a greater risk of prolonged serious pain. [5]
A study by Albert et al found that 6 months after delivery all the women with symphysial pain were better, and that 2 years after giving birth 4.2% and 6.5% of women who had experienced unilateral and bilateral sacro-iliac pain respectively continued to have pain, while 18% of the women who suffered from anterior and posterior pelvic pain were still having pain. [6]
Bastianseen et al, state that “pregnancy-related pelvic girdle pain (PPGP) is a complex phenomenon, and that previous studies could not convincingly distinguish low back pain from PPGP” therefore suggesting that pregnancy-related “back pain” form a specific syndrome. [7]
According to the European guidelines for the diagnosis and treatment of pelvic girdle pain, PGP is defined as “pain experienced between the posterior iliac crest and the gluteal fold, particularly within the vicinity of the SI joints,” while low back pain is “defined as pain between the 12th rib and the gluteal fold,” [8] and that PGP is diagnosed once lumbar causes are excluded. These guidelines concluded that PGP is a “specific form of low back pain (LBP) that can occur separately or in conjunction with LBP.” [8] The European guidelines also noted that PGP most commonly arises from pregnancy, trauma, arthritis and/or osteoarthritis. Regarding the diagnosis of PGP they recommend the use of pain provocation tests such as P4/thigh thrust, Patrick Fabere, Gaenslen’s Test and modified Trendelenberg’s test, and pain palpation tests using the long dorsal sacroiliac ligament and palpation of the symphysis. The functional test recommended is the active straight leg raise (ASLR).
A report published by Noren et al found that women with pelvic pain had “greater functional impairments than those with lumbar pain, and that women who had a combination of the types of pain were more severely disabled than either of the two groups alone”. [9] The European Guidelines for the diagnosis and treatment of pelvic girdle pain, document that pain can radiate to the posterior thigh, and diminishes the patient’s capacity for standing, walking and sitting.
There are numerous causes given for the increased incidence of back pain in pregnancy which can include:previous history of low back pain,
heavy work,
smoking,
contraceptive pills,
increased weight during pregnancy,
pluripara,
increased stress levels,
maternal age when pregnant and hormonal changes,
altered posture due to the increased lumbar lordosis required to balance the anterior weight of the womb,
ligamentous laxity caused by the hormone relaxin produced by the corpus luteum, and fluid retention within the connective tissue. [2, 10]The review of 34 relevant studies conducted by Wu et al, Pregnancy related pelvic girdle pain (PPP), found that there was a total of 15 possible risk factors for PPP and of those 15 there was strong evidence pointing toward
strenuous work,
previous low back pain
and previous PPP,while weak evidence was found for
maternal height and weight,
the use of oral contraceptives,
smoking,
epidural anaesthesia
and prolonged second stage labour. [10]While pregnancy related pelvic girdle pain may be a “normal” part of pregnancy, it does not mean that there are no options for the patient both during and after pregnancy to help alleviate any discomfort. According to Lisi, while this pain can be quite disabling, as few as 32% of women report their symptoms to their prenatal provider and of these providers, only 25% recommend treatment. [11] The South Australian population survey conducted by Stapleton et al found that 48.9% of the 397 women surveyed did not receive any treatment for their pregnancy related back pain. Of those who did receive treatment
35% were recommended bed rest,
27% used pain-killing medication,
21% used physiotherapy treatment,
11% used chiropractic treatment,
while the remaining 6% stated using other means. [3]Chiropractic is a natural modality of choice used by many women during and after pregnancy to assist them in the birth process and the recovery. Chiropractic care has shown to have improved outcomes in pregnancy related LBP. [1] A review of the literature performed by Borggren concluded that chiropractic care during pregnancy may be a “safe and effective means of treating common musculoskeletal symptoms that patients may encounter,” [12] they also reported that studies have shown that “chiropractic manipulation may significantly decrease the incidence of “back labour”” and that, “women who seek chiropractic care throughout gestation have shorter labour times.” [12]
The purpose of this paper is to present the case of a woman with postpartum PPP who experienced relief of symptoms with chiropractic care. The key words used for the search of supporting evidence for this paper include:chiropractic,
postpartum,
low back pain,
pelvic girdle pain,
pregnancy related.
Clinical Presentation
A 33-year-old 3-months postpartum female complaining of left low back pain, just above her hip which she had suffered from since the delivery of her daughter sought chiropractic care. The patient experienced the pain daily and noted that it radiated down the leg to above the knee. The pain was not excruciating, but was “not right” and was exacerbated by lifting and bending (especially for baths). The pain was subjectively reported by the patient. There was no noted change in sensory or motor function.
In reviewing her history it was found that she had been hospitalized for 4 days during the pregnancy due to mid back pain that radiated to the ribs, but there had been no recurrence of this pain since giving birth. The patient did receive chiropractic care in another office during her pregnancy from 23 weeks yet she felt “very uncomfortable” during her whole pregnancy. The patient experienced a degree of stress throughout her pregnancy journey due to renovating and selling their home and changing jobs.
The patient noted that she had experienced a tobogganing accident in 2006 where she had a bad fall onto the buttock which resulted in back issues, but did not have any treatment or radiographs taken at this time.
The patient’s labor went over 2 days and concluded in a natural birth of a healthy baby girl; however, the recovery was delayed as the patient was torn badly and she suffered from a uterine infection requiring antibiotics.
Physical examination findings demonstrated a high right iliac crest, increased lumbar lordosis and forward head carriage with her posture. Her thoracolumbar range of motion was decreased in flexion and left lateral flexion. All thoracolumbar motion caused tension in the right sacroiliac (SI) joint. Seated Kemps test was positive for local pain in the right SI and L5 area when the patient was taken into right lateral flexion and extension. Nachlas test was negative, however local pain was noted in the L4/5 region with flexion of the right knee i.e. bringing the foot to the buttock. Fabere test was positive for local right SI pain and the patient was found to have a tight left psoas muscle group. Using Thompson leg length analysis it was found that she had a short right leg going long on flexion of the knees to 90 degrees indicating a positive Derefield and therefore a SI subluxation.
Palpatory examination found increased muscle tone and decreased spinal joint motion with mild edema in the areas of C1, C2, C4, T7-9, L1, L5, right ilium and coccyx. As the patient was still breastfeeding it was decided that radiographs would not be obtained.
Interventions and Outcomes
The patient was adjusted using numerous techniques. The right ilium was adjusted using Thompson technique. The patient was prone on the table and the right posterior ilium was contacted by the practitioner using the right hypothenar eminence over the posterior superior iliac spine while the left hand supported the left ischium and three posterior to anterior with slight inferior to superior directional thrusts were applied. Thompson drop table technique was also used to adjust the L5 where the practitioner used a broad thumb contact over the right body of L5 and applied a medial to lateral posterior to anterior thrust three times. An Activator II instrument was used on the coccyx, placing it gently to the right lateral and inferior side of the coccyx and applying one impulse on a setting of two rings. Diversified manual technique was used to adjust T7-9, C1 and C4.
For the adjustment of T7-9 the patient was initially seated and relaxed with the chin tucked in slightly while the practitioner contacted the T9 vertebrae with a loose fist contact and then instructed the patient to allow herself to be layed back on the table by the practitioner. The thrust is a body drop impulse along the facet joints of T8. C1 and C4 were adjusted, contacting the left and the right respectively, using the lateral index finger contact over the neural arches while the patient was relaxed and supine. A high-velocity, low-amplitude (HVLA) thrust was applied in a lateral to medial and posterior to anterior direction.
Myofascial release was performed on both round ligaments while the patient was relaxed in the supine position with her knees flexed to 45 degrees and feet resting flat on the table. The round ligaments were addressed individually with a broad 5-finger contact over the superior aspect of the ligament while a broad 5-finger contact was under the posterior flank, directly opposite to the superior hand, a gentle torque was then used while the posterior hand held the torque in the opposite direction until a release was felt between the 2 contact hands.
The patient returned for a follow-up visit three days later and noted that she had had complete resolution of her left low back pain within 24 hours after her adjustment. The resolution of her pain was a subjective finding by the patient, and not noted by questionnaire. The patient was then not able to return for a further follow up for 18 days and on this visit noted that the pain had returned. The pain decreased subjectively in intensity again immediately after an adjustment. After a total of five chiropractic adjustments within a 4 week period, her pain had resolved and has continued to be resolved the past 4 months. The patient has continued with fortnightly wellness chiropractic care over the past 4 months. During the course of chiropractic care, the patient did not receive any other form of treatment. As she was breastfeeding over the counter medications were only very occasionally used and this was limited to acetaminophen.
A physical reassessment was conducted one month after initially presenting and objectively the patient demonstrated significant change. Her posture was balanced, her thoracolumbar range of motion was full, however, extension did cause some discomfort in the right SI joint. Fabere, Nachlas and Seated Kemp's were negative and without local pain. Leg lengths were balanced and subluxations were found at C1, C5, T8, T12, T10, L5 and right Sacrum.
Discussion
As can be seen from the patient's presentation, her symptomatology is mixed. The patient presented with left low back pain above the hip, yet during physical assessment it was noted that her right SI joint was the cause of her discomfort. This mixed presentation can be common in the pregnant and post-partum patient as described above.
As stated in The European Guidelines for the diagnosis and treatment of pelvic girdle pain, pain does not have to be local but can radiate to the posterior thigh, which can affect the patient’s ability to easily conduct everyday activities such as walking, standing or even sitting. This patient noticed that the pain was starting to have an impact on her quality of life as it was becoming painful to bathe and even lift her daughter.
This patient presented to the practice at 3-months post partum, this is the time frame specified by Ostgaard et al that PPP can spontaneously resolve. However, as stated previously, pain can persist for up to at least 2 years postpartum. This patient could have possibly had spontaneous resolution of her PPP if no treatment was sought, however when referring to the collection of data, she may still have experienced discomfort for a longer period of time. Also, given that the patient had the recurrence of her PPP 18 days after the initial chiropractic adjustment, this decreases the chance that her pain spontaneously resolved, but rather was a consequence of her chiropractic treatment.
The patient in this case did not have an occupation that involved strenuous work nor have a previous pregnancy. However, the patient had experienced previous low back pain which started five years earlier caused by a tobogganing accident where she landed badly on her buttock, putting her in a high risk category for experiencing PPP as described by Wu et al.
From a chiropractic point of view, during pregnancy the “entire pelvis is capable of substantial fluidity of movement due to hormonal changes that occur to allow the pelvis to open enough for the passage of the baby.” [13] Biomechanically, with an increase in the lumbar lordosis to account for the increased weight anteriorly and the softening of the ligamentous and connective tissue, a woman’s centre of gravity changes over the nine months of pregnancy. Because of these postural changes and the softening of the ligamentous and connective tissue around the sacroiliac joints, pelvis, pubic symphysis and spine, pregnant women are predisposed to strains in supporting structures. [14] These changes can be a cause of vertebral subluxation and myofascial system tension and pain. Myofascial release of the round ligaments of the uterus may help to decrease the overall myofascial tension in the pelvis complementing the adjustive care the patient received.
The Vertebral Subluxation Complex, as defined by the Association of Chiropractic Colleges (ACC), is a “complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health.” [15] Subluxation involving the lumbar plexus can result in “irritability and pain into the buttocks and down the leg.” [13] This case may demonstrate the sort of changes described in the ACC definition of subluxation.
Limitations
During the assessment of this patient the chiropractor used the recommended diagnostic tests of Patrick Fabere, passive and active straight leg raises, while other SI/low back tests (Nachlas and Seated Kemp's) were also used. Pain and disability questionnaires are documented throughout the literature as a method of testing and assessing a patients subjective level of pain. Ronchetti et al, use the Quebec Back Pain Disability Scale as one of the methods to help determine the severity of pelvic girdle pain. [16] A pain and disability or quality of life questionnaire was not used as a means of assessing the severity of the condition in this case therefore only the patient’s subjective complaints are reported. This is a limitation of this case report. Future research should use objective measures to attempt to quantify patient improvement.
Conclusion
While it is considered to be a “normal” consequence of pregnancy, many women experience and suffer from pelvic girdle or low back pain both during and after pregnancy. There have been many risk factors documented for the cause of pregnancy related pelvic girdle or low back pain, and a number of quality of life consequences as a result of this PPP. Numerous treatment suggestions have been described to help provide pregnant women with options and this paper illustrates the case of a patient who experienced resolution of her discomfort while under chiropractic care. Currently there is a lack of literature on the effects of chiropractic care on PPP. This paper illustrates a positive outcome for a patient with PPP. Although more research is needed, chiropractic care should be considered for pregnant women with PPP.
References:
Stuber KJ, Smith DL.
Chiropractic Treatment of Pregnancy-Related Low Back Pain: A Systematic Review of the Evidence.
J Manipulative Physiol Thera 2008; 31(6):447-454Young G, Jewell D.
Interventions for preventing and treating pelvic and back pain in pregnancy.
Cochrane Database of Systematic Reviews, 2002 Issue 1.
Art. No.: CD00139. DOI: 10.1002/14651858.CD001139Stepleton DB, MacLennan AH, Kristiansson P.
The prevalence of recalled low back pain during and after pregnancy: a South Australian population survey.
Australian and New Zealand J Obstetrics and Gynecol 2002; 43:482-485To WWK, Wong MWN.
Persistence of back pain symptoms after pregnancy and bone mineral density changes as measured by quantitative ultrasound — A two year longitudinal follow up study.
BMC Musculoskeletal Disorders 2011,12:55Ostgaard HC, Andersson GB, Wennergren M.
The impact of low back and pelvic pain in pregnancy on the pregnancy outcome.
Acta Obstetric and Gynecol Scandinavia 1991; 70:21-24Albert H, Godskesen M, Westergaard J.
Prognosis in four syndromes of pregnancy-related pelvic pain.
Acta Obstetrica et Gynecol Scandinavia 2001; 80:505-10Bastiaanssen JM, de Bie RA, Bastiaenen CHG, Essed GGM, de Brandt PA.
A historical perspective on pregnancy-related low back and/or pelvic girdle pain.
European J Obstetrics and Gynecol and Reprod Biology 2005; (120):3-15Vleeming A, Albert HB, Ostgaard HC, Sturesson B, Stuge B.
European Guidelines for the diagnosis and treament of pelvic girdle pain.
European Spine J 2008, (17):794-819Noren L, Ostgaard S, Johansson G, Ostgaard HC.
Lumbar back and posterior pelvic pain during pregnancy: A 3-year follow-up.
European Spine J 2002; 11(3): 267-271Wu WH, Meijer OG, Uegaki K, Mens JMA, van Dieen JH, Wuisman PIJM, Ostgaard HC.
Pregnancy-related pelvic girdle pain (PPP), I: Terminology, clinical presentation and prevalence.
European Spine J 2004; 13: 575-589Lisi AJ,
Chiropractic Spinal Manipulation for Low Back Pain of Pregnancy:
A Retrospective Case Series
J Midwifery Womens Health 2006 (Jan); 51 (1): e7-10Borggren CL,
Pregnancy and chiropractic: a narrative review of the literature.
J Chiropractic Med 2007; (6): 70-74Fallon J.
Chiropractic & Pregnancy.
Virginia: International Chiropractors Association; 1994Levangie PK, Norkin CC.
Joint Structure and Function: A Comprehensive Analysis.
Sydney: Maclennan and Petty; 2001Association of Chiropractic Colleges.
The Chiropractic Paradigm
Position Paper 1 (July 1996).Ronchetti I, Vleeming A, van Wingerden JP.
Physical Characteristics of women with severe pelvic girdle pain after pregnancy: A descriptive cohort study.
Spine 2008; 33(5):E145-51
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