Rajiv Gandhi University of Health Sciences, Karnataka
Curriculum Development Cell
CONFIRMATION FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
Registration Number :Name of the Candidate : / Ms. DAIWAJNA SNEHA ASHOK
Address : / C/O Shivram N. Palankar, “Draupadi Sadan”, Shivapur colony, Near NTTF, Dharwad.
Name of the Institution : / SDM COLLEGE OF PHYSIOTHERAPY, DHARWAD.
Course of study and subject : / MASTERS IN PHYSIOTHERAPY
Date of Admission to course : / July 1st 2011
Title of the Topic : / “PELVIC GIRDLE PAIN AND LOW BACK PAIN DURING PREGNANCY AND POSTPARTUM IN INDIAN WOMEN: A PROSPECTIVE COHORT STUDY OF PREVALENCE AND RISK FACTORS IN RELATION TO PAIN INTENSITY AND DISABILITY.”
Brief resume of the intended work : / Attached
Signature of the student :
Name of the guide : / Dr. PRASHANT MUKKANNAVAR
Remarks of the guide : / Recommended for registration
Signature of the guide :
Co-guide name :
Signature of the co-guide :
Name of the HOD : / Dr. RAVI SAVADATTI
Signature of the HOD :
Principal name : / Dr. RAVI SAVADATTI
Principal mobile number : / 9845051209
Principal Address :
Remarks of the principal :
A) / BRIEF RESUME OF THE STUDY
INTRODUCTION:
About 50% of the pregnant women experience low back pain and/or pelvic pain at some point during pregnancy and postpartum. Most recover spontaneously within months after delivery, but in around 25% of cases, the pain is persistent.1
A large number of terms have been used in the literature to indicate lumbopelvic pain during pregnancy and postpartum. They include pregnancy related pelvic pain,2 pelvic insufficiency,3 pelvic girdle pain (PGP),4 pregnancy related low back pain,5 pelvic girdle relaxation,6 peripartum pelvic pain,7 posterior pelvic pain after pregnancy,8 pelvic instability,9 symphysis pubis dysfunction.10 Few studies11,12 classified pelvic girdle pain into five subgroups such as pelvic girdle syndrome, symphysiolysis, one sided sacroiliac syndrome, double sided sacroiliac syndrome, miscellaneous. Most of the literature did not uniformly classify pelvic girdle pain and low back pain during pregnancy and postpartum.13 Recently, European Guidelines on the diagnosis and treatment of pelvic girdle pain, have suggested pregnancy related pelvic girdle pain to refer to pain in the pelvic area, pregnancy related low back pain to refer to pain in the low back region, and pregnancy related lumbopelvic pain when no distinction is made between pelvic girdle pain and low back pain.14
Many different pelvic pain provocation tests and criteria have been used for classifying pelvic girdle pain for diagnostic purposes and the results have seldom been evaluated as risk factors for sustained pelvic girdle pain.15 A number of tests for pain provocation of different tissues and locations in the pelvis are recommended,16 which include palpation of the pubic symphysis (sensitivity: 0.59; specificity: 0.50), active straight leg raise (ASLR) test (sensitivity: 0.53; specificity: 0.83), gaenslen’s test (sensitivity: 0.47; specificity: 1.0), sacroiliac compression test(sensitivity: 0.59; specificity: 0.50-1.0), sacroiliac distraction test (sensitivity: 0.53; specificity: 0.67-1.0), posterior pelvic pain provocation test (P4 test) (sensitivity: 0.84-0.93; specificity: 0.80-0.98), long dorsal ligament (LDL) test (sensitivity: 0.11-0.49; specificity: 1.0), modified trendelenburg test (sensitivity: 0.60-0.62; specificity: 0.99).14,17
Classification of pelvic girdle pain requires exclusion of lumbar causes.14 Several tests for examination of the lumbar spine in pregnancy have been described such as pain provocation by spinal movements, palpation of the lumbosacral spine and straight leg raise test.18-20 Many classification systems exist for patients with low back pain, the strengths and weaknesses have been discussed in few reviews.21,22 Several classification systems for low back pain patients have been identified, which are relevant for physiotherapists.23-26 The Mechanical Diagnosis and Therapy (MDT) has been identified as a well described classification system. It is commonly used and includes a standardised history, neurological examination, and evaluation of red flags. Within the protocol, symptom response during and after repeated movements is evaluated, and this procedure has shown promising results in reliability studies.27-29 Few studies evaluated pain provocation tests by MDT protocol and reported good validity30 and reliability31 of the classification system for pregnancy related lumbopelvic pain. Based on current knowledge and existing guidelines, clinical evaluation of pregnancy-related low back pain should include pelvic pain provocation tests and neurological examination, take known characteristics of pelvic girdle pain and lumbar pain into account, and be sufficient to identify discogenic pain and signs of serious pathology.14,32
Studies3,19,33 report a wide range of prevalence (4% to 76%) of pelvic girdle pain and/or pregnancy related low back pain. In Western countries, the point prevalence of lumbopelvic pain during pregnancy was reported as 58.5%34 and 51%.20 The period prevalence was reported as 28.9%,8 76.5%,35 44.6%,36 69.7%37 and 72%38 in prospective studies, and 77%,39 58%,40 48%,41 24%42 in retrospective studies. In non-Western countries, the reported prevalence of lumbopelvic pain during pregnancy was 54.4%,43 76%,44 89.9%,45 49.5%13 and 60%.39
For low back pain in pregnant women, the point prevalence was found to be 25% and 16% of women with pregnancy related low back pain reported persistent pain 6 years after childbirth.32 In Western countries, the reported prevalence of pelvic girdle pain during pregnancy was 23.6%,17 22.6%,2 36.2%,20 14.2%,6 31.2%46 and 34%36 in prospective studies, and 42.4%47 and 9.8%48 in retrospective studies. The point prevalence of pelvic girdle pain in pregnant women was found to be 20%.14,49 The prevalence of pelvic girdle pain postpartum was reported as 8.5%, 2 years postpartum2 and 5%, 4%, 2%, 2, 6, 12 months postpartum.6
Several risk factors have been associated with postpartum low back pain or pelvic pain such as low endurance of back flexors,50 work dissatisfaction,51 older age,1 higher body mass index (BMI),52 previous history of low back pain,51 previous lumbopelvic pain during or after pregnancy,53 strenuous work,21 hypermobility,52 smoking,6,21,47 parity,51 trauma to the pelvis during pregnancy,51 breastfeeding54 and type of delivery.55
Previous studies of pelvic girdle pain during and after pregnancy had reported that positive scores on the P4 test and functional ASLR test were associated with disability and pain.16 In a study by Mens et al56 it was revealed that there is an association between the ASLR test and mobility in the pelvic joints. ASLR test helps in transferring weight between the spine and the legs which would in turn help to assess disease severity in patients with pelvic girdle pain postpartum.15,57 P4 test is a pain provocation test of the posterior parts of the pelvis, described to elicit a well-known and distinctly located pain, situated deep in the gluteal region of the side being tested.57 A study by Robinson et al15 showed that P4 test was not associated with either disability or pain intensity at 12 weeks postpartum but it was considered as a risk factor for the development of pelvic girdle pain during pregnancy. The P4 test and the ASLR test thus seemed to differ in their ability to predict the development of pelvic girdle pain in pregnancy and prognosis postpartum. This suggests that P4 test and ASLR test reflect different aspects of pelvic girdle pain.
Apart from P4 test and ASLR test, few studies explored psychological factors such as catastrophizing and fear-avoidance beliefs as risk factors in the development and maintenance of low back pain and/or pelvic girdle pain and related disability during pregnancy and postpartum.1 As a consequence of pelvic girdle pain and/or pregnancy related low back pain, many women find difficulty in day to day functional activities which is the most likely cause of disability. Hence, evaluation of the consequences of pelvic girdle pain and/or low back pain in terms of disability is important in the rehabilitation process for identifying target areas in the treatment strategies.49
For adequate evaluation of low back pain and/or pelvic girdle pain, reliable and valid outcome measures are necessary.58 To date, most of the self-report outcome measures such as Oswestry Disability Index (ODI),59-62 Fear-Avoidance Beliefs Questionnaire (FABQ)1,63-65 and Visual Analogue Scale (VAS)66.67 have frequently been used in clinical studies with women who have pelvic girdle pain and/or low back pain. The Oswestry Disability Index (ODI) assesses activities of daily living that might be disrupted by low back pain and/or pelvic girdle pain and is found to have a good validity and reliability. The Fear-Avoidance Beliefs Questionnaire (FABQ) focuses on respondents’ beliefs about how physical activity and work affect their low back pain and is found to be valid and reliable during and after pregnancy. Visual Analogue Scale (VAS) is usually a horizontal line of 100mm length with the ends labelled as the extremes of pain i.e. “no pain” to the “worst imaginable pain”. It was found to be valid and reliable in case of pelvic girdle pain and/or low back pain during and after pregnancy. Pelvic girdle Questionnaire (PGQ)58,68 is the first condition-specific measure assessing activity limitations and symptoms for people with pelvic girdle pain both during pregnancy and postpartum. Recently, the PGQ is found to have a good reliability and construct validity during pregnancy and postpartum.
NEED FOR THE STUDY:
Pregnancy related back pain and pelvic girdle pain are common across countries, irrespective of socioeconomic factors.58 Most studies do not differentiate between pelvic girdle pain and lumbar pain, neither during pregnancy nor postpartum, or exclude women with lumbar pain.61,69 However, a clinical classification is important in order to evaluate possible differences in subgroup prevalence, potential risk factors, consequences in terms of pain intensity and disability, and predictors of persistency, and thereby possible differences in management. Pregnancy itself may interfere with studied factors. Therefore it is important to follow all pregnant women in a cohort, including women with all types of low back pain and/or pelvic girdle pain.
Most of the information about pelvic girdle pain has been obtained in Western countries, especially in the European population.49 Very few studies investigated pregnancy related lumbopelvic pain, and especially pelvic girdle pain and low back pain in non-Western countries.39,43-45 In India, there is little information about the prevalence, incidence and potential risk factors for pelvic girdle pain and/or low back pain during pregnancy and postpartum. Thereby a need arises to evaluate the consequences of pelvic girdle pain and/ low back pain during pregnancy and postpartum in Indian women.
RESEARCH HYPOTHESIS:
NULL HYPOTHESIS (H0): There will not be a relation between risk factors of pelvic girdle
pain and/or low back pain in terms of pain intensity and disability
during pregnancy and postpartum in Indian women.
ALTERNATE HYPOTHESIS (H1): There will be a relation between risk factors of pelvic girdle pain and/or low back pain in terms of pain intensity and disability
during pregnancy and postpartum in Indian women.
REVIEW OF LITERATURE:
Recently, European Guidelines on the diagnosis and treatment of pelvic girdle pain, the Working Group 4 (WG4) proposed the term pelvic girdle pain with the following definition: ‘‘Pelvic girdle pain generally arises in relation to pregnancy, trauma, arthritis and osteoarthritis. Pain is experienced between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the SIJ. The pain may radiate in the posterior thigh and can also occur in conjunction with/or separately in the symphysis. The endurance capacity for standing, walking, and sitting is diminished. The diagnosis of PGP can be reached after exclusion of lumbar causes. The pain or functional disturbances in relation to PGP must be reproducible by specific clinical tests.”14
According to the European guidelines, Low back pain is defined by pain between the 12th rib and the gluteal fold.14 In a study done by Ostgaard et al,17,49,70 it was stated that lumbar pain during pregnancy originates in the lumbar spine region with or without radiation to the leg, and without a specifically defined pain structure. It is a different syndrome than pregnancy related pelvic girdle pain. Pregnancy related low back pain is dull in character and is experienced when the patient is in forward flexion. There is restriction of spine movement in the lumbar region, and palpation of the erector spinae muscles exacerbates pain. The pain resembles the back pain that occurs in the non-pregnant state.
The exact mechanisms that lead to the development of pregnancy related pelvic girdle pain remain uncertain. A variety of approaches have been proposed that suggest hormonal, biomechanical, traumatic, metabolic, genetic and degenerative etiologic implications.4 Pregnancy related low back pain, seems to be a result of quite a few factors such as mechanical, hormonal and others.5
Several classification systems for low back pain patients have been identified, which are relevant for physiotherapists.23-26 The Mechanical Diagnosis and Therapy (MDT) has been identified as a well described classification system. It is commonly used and includes a standardised history, neurological examination, and evaluation of red flags. Within the protocol, symptom response during and after repeated movements is evaluated, and this procedure has shown promising results in reliability studies.27-29 Few studies evaluated pain provocation tests by MDT protocol and reported good validity30 and reliability31 of the classification system for pregnancy related lumbopelvic pain.
Studies3,19,33 report a wide range of prevalence (4% to 76%) of pelvic girdle pain and/or pregnancy related low back pain. In Western countries, the point prevalence of lumbopelvic pain during pregnancy was reported as 58.5%34 and 51%.20 The period prevalence was reported as 28.9%,8 76.5%,35 44.6%,36 69.7%37 and 72%38 in prospective studies, and 77%,39 58%,40 48%,41 24%42 in retrospective studies. In non-Western countries, the reported prevalence of lumbopelvic pain during pregnancy was 54.4%,43 76%,44 89.9%,45 49.5%13 and 60%.39
In a study31 done to evaluate the inter-rater reliability of a standardised classification system for pregnancy-related lumbopelvic pain, 31 consecutive pregnant women with non-specific lumbopelvic pain were evaluated by two examiners and classified into lumbar pain, PGP, or combined pelvic girdle and lumbar pain. A standard history about different positions/activities of daily life such as bending, sitting, standing, walking, and lying, was analysed by a standardised mechanical assessment of the lumbar spine (Mechanical Diagnosis and Therapy), including tests of repeated end-range movements to standing and lying, pelvic pain provocation tests (distraction test, posterior pelvic pain provocation test, Gaenslen’s test, compression test, and sacral thrust) a hip-rotation range-of-motion test, the active straight-leg-raising test, and a neurological examination. The study showed that agreement for the three syndromes (lumbar pain, PGP, or combined pelvic girdle and lumbar pain) was 87%, with a kappa coefficient of 0.79 (95% CI 0.60–0.98). It was possible to perform the classification procedure throughout pregnancy. There was substantial agreement between the two examiners for the classification of non-specific lumbopelvic pain into lumbar pain and PGP in pregnant women.