The Impact of Physical Therapy on Peripartum Females with Low Back/ Pelvic Pain Mary E. Bono
December 13, 2004
Critical Literature Review and Scientific Writing, IDST 6400 University of Medicine and Dentistry of New Jersey
"Peripartum pelvic pain is defined as pain in the pelvic region (with or without radiation) that started during pregnancy or within three weeks after delivery and for which no clear diagnosis is available to explain the symptoms." (Mens, Vleeming, Stoeckart, Stam, & Snijders, 1996, p. 1363). Forty-nine percent of women who are pregnant experience some type of back pain, including pain that is experienced above the lumbar region, in the lumbar region and pain over the sacroiliac joints, sometimes with radiation into the thighs (Ostgaard, Andersson, & Karlsson, 1991). Heckman and Sassard (1994) reported that women with a history of back pain prior to becoming pregnant are twice as likely to develop back pain while pregnant, as well as women who have been previously pregnant. Although low back pain and pelvic pain are extremely common in women, the exact etiology is unknown. A woman's body undergoes many changes during pregnancy. First, there is a change in the center of gravity due to weight gain. The average weight gain during a single-fetus pregnancy is twelve kg. As the uterus begins to enlarge and ascend into the abdominal cavity, the center of gravity is displaced upward, forward and laterally, during the twelfth week of pregnancy (LaBan & Rapp, 1996). This change in the center of gravity leads to a change in the degree of lordosis of the spine, although there are conflicting views in the literature whether there is an increase or decrease in lumbar lordosis. There is agreement however, that this change in lordosis affects the paraspinal musculature. Furthermore, the abdominal muscles become overstretched and weakened as the expanding uterus separates the rectus abdominis (Fast, Weiss, Ducommun, Medina & Butler 1990). This lack of abdominal strength, as well as the change in the paraspinal musculature decreases lumbopelvic stability. One must also take into consideration that low back and posterior pelvic pain begins on average during the eighteenth week of pregnancy, prior to significant weight gain. Many researchers have hypothesized this may be due to hormonal changes that occur during pregnancy causing an imbalance between the ligaments, muscles and joints in the posterior aspect of the pelvis (Vleeming, Mooney, Dorman, Snijders, & Stoeckart, 1997). Pregnancy related hormones cause an increased laxity in collagen tissue within the symphysis pubis and sacroiliac joints in preparation for delivery (Damen, Buyruk, Guler-Uysal, Lotgering, Snijders & Stam, 2001). Specifically, relaxin, a polypeptide hormone, decreases the intrinsic strength and rigidity of collagen in both the joint capsules and ligaments (Walker, 1992). As ligamentous relaxation occurs, the stability between the paired sacroiliac joints and pubic symphysis decreases, leading to increased range of motion between the pelvic joints, further decreasing lumbopelvic stability. As the lumbopelvic instability occurs, muscles in the lumbar and pelvic region contract stronger in an attempt to reestablish stability. However, this increased muscle tension may cause pain, which contributes to muscle insufficiency further weakening the lumbopelvic region (Vleeming, et al. ,1997). Up until recently back and posterior pelvic pain in pregnancy has been thought to be a self-healing condition, therefore there is limited research done in this area. Due to the alterations in the biomechanics that occur as a result of pregnancy research is now beginning to examine the effects of stabilization exercises on the lumbopelvic region. These exercises are based on the theoretical model of a self-locking mechanism of the sacroiliac joints. Within this model are the principles of form closure and force...
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